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The Elephant, the Rider and the Path:

A Time of Transition in the Department

David Latter
David Latter

Three months ago Richard Reznick announced that he had accepted the position of Dean of Health Sciences at Queen's University. This ended his term as Chair of the Department two years earlier than expected. During Richard's eight year term the Department underwent significant changes. I would like to highlight some of the accomplishments that Richard Reznick championed.

The number of faculty members steadily grew over the last 8 years and now numbers 250 full time surgeons. In particular the number of surgeon scientists grew the most and this is reflected in the increased "footprint" of scientific productivity that Ben Alman, our Vice Chair of Research, has so eloquently described (1).Our rate of successful grant capture continues to be one of the highest of all surgical departments in North America.

The Surgeon Scientist Program is flourishing. A few years ago there were serious concerns about the financial viability of the program With thoughtful restructuring of the program's method of revenue collection, improved support from the Ministry of Health, effective lobbying for industry support, and the incredibly inspiring 25th Surgeon Scientist Program Gala held this past spring, the SSP financial health is strong.

Surgical education became much more rigorous under Richard's watch. The Department now has over 30 surgeons with Masters of Education degrees. Our residency programs are the strongest in the country and as a result our residency training programs almost always fill their entry positions completely on the first round of the CaRMS match. An organized, more education - based clinical fellowship program has been implemented across the Department. The results of these changes in our Department's clinical fellowships have been noticed by other departments in the Faculty of Medicine, and many have been copied. The surgical skills lab continues to grow in its scope of student users and teaching activities. Our surgeons significantly outperform in terms of number of teaching awards captured at the university level as well as nationally and internationally. Integrated medical education at partially affiliated community hospitals started in the Department years ago and continues to grow. Competency Based Curriculum, a novel concept in medical education is actually happening here in the Division of Orthopedics. Many have written about competency based medical education, but few had the determination to begin to use it. For sure it is still a concept being explored but indications to date point to success. (See the CBC article on pg 12). The Department (mainly Richard) felt that the recent PAIRO agreement that included a provision of "home by 2 hours post call" would negatively affect the surgical education of our residents. Based on this belief the Department requested and was granted an exemption to this provision. We were the only department in the province that objected and received this exemption.

Critical care illness insurance was introduced. The Department holds a policy that covers all of our full time faculty for $60,000 of critical care insurance, a vital link before disability insurance payments start.

Day care for all of our full time faculty was introduced to help busy surgeons, usually our younger recruits, manage the difficulties and costs of obtaining quality day care for their children.

Perhaps Richard's most significant accomplishment during his eight year term was to be the glue that binds us all together for the greater good. He always tried to promote the feeling that we all have a role to play for the Department. That message was effectively delivered.

When Richard Reznick announced that he was accepting the position of Dean of Health Sciences at Queen's University it was clear that the Department of Surgery was about to undergo a period of transition. This change will be valuable, not because we are deficient, but because it will give us an opportunity to review and enhance our strengths, and improve in any areas of weakness.

This summer I have been reading an interesting book - Switch. How to Change Things When Change is Hard by Chip and Dan Heath. It is about the mechanics of change and how to make change work. They use an analogy developed by University of Virginia psychologist Jonathan Haidt. Haidt states that our emotional behaviour is like an Elephant and our rational behaviour is like a Rider that sits atop our Elephant trying to direct decisions and behaviour. For any given task the Rider can do a pretty good job of controlling the Elephant, but over time if the Elephant and the Rider do not agree, there will be a problem. And not surprisingly, the Elephant will win. The Heath brothers add a third element to the analogy called the Path. The Path helps both the Rider and the Elephant to know where they are going. If the Path to effective change is not clear then there is great likelihood that eventually the Rider and the Elephant will get confused at a fork in the road and disagree on their next move. Progress - effective change- will be stopped.

The authors of Switch discuss numerous strategies that include: identifying "bright spots", carefully describe the critical steps, clearly define the destination, use many small changes to add up to a large effect, like growing your people, etc. The strength of the book lies in the many real life examples of exactly how effective change was successfully accomplished. Particularly germane to our environment, many of the examples are medical. I recommend this book to anyone who has a vision of how our Department might improve for the future. We should be ready for our next Chair and be ready for some changes in our path. While the path may not yet be entirely clear to anyone, I think we can all agree that our destination ought to be recognition as the best surgical department in the world.

For the next 3-6 months I have the honour as serving as the Interim Chair of the Department. My duty is to make sure that the day to day mechanics of the Department continue without interruption. As in any organization of this size, new issues arise continuously and I will endeavour to make sure they are handled appropriately. In many ways, I can thank Richard Reznick for having developed a departmental culture of including many in the essential dealings of the Department. As a result, as Vice Chair Education for the Department, I was well informed and well prepared to accept the interim position. More importantly, numerous other surgeons play vital roles in the management of the department and all of these able colleagues have stepped up to assist me.

We all look forward to the search committee's selection for our next Chair. This individual will be given an incredible responsibility to continue the legacy of the Department of Surgery at The University of Toronto. We are strong but undoubtedly we can be better. The next Chair will have an opportunity to reflect and build on our status. He or she will likely consult far and wide, inside and outside of the Department. With judgment, knowledge, and input from all members of the Department, the new Chair will begin to determine our new path toward our destination. And then the Riders and the Elephants in all of us will start a trip down this new Path to an even better Department of Surgery.

David Latter

(1) See also The Surgical Spotlight, 2009, Fall, Our Department's Global Footprint

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