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Citizenship: The 5% that makes all the difference

It falls to each of us to be those anxious, jealous guardians of our democracy; to embrace the joyous task we’ve been given to continually try to improve this great nation of ours. Because for all our outward differences, we, in fact, all share the same proud title, the most important office in a democracy: Citizen. Barack Obama 44th President of the United States of America, January 10th 2017

Obama Speech

https://www.whitehouse.gov/farewell

It’s the time of year when faculty members in the Department of Medicine (DOM) complete their annual report. This is a process of reflection through which faculty members review their year’s achievements. We all complete a reporting template summarizing our achievements for review and evaluation by the Division Chair and Department Head (or in my case the Dean). The annual report provides metrics that reflect personal productivity, which is a way of saying it quantifies deliverables. The annual report also offers a stage upon which the faculty member and their supervisor can engage in a discussion around progress to promotion and foster strategic career planning. Although annual reports are seen by some as a daunting task (especially if one views it as receiving a report card) the resulting conversations and planning are worth the effort. Properly conducted the exercise shapes careers, deepens relationships, acknowledges achievement, reveals stresses and strains and allows the Department Head to help guide mid-course corrections when needed.

The annual report process is guided by a document called the role description. This document is customized to each faculty member and is refreshed each year. It provides a rough guide as to what the faculty member’s role is within the Department outlining time allocations to various service domains (clinical work, research and education). The time allocation in a given domain determines the expectations for deliverables in that domain (i.e. more time for education equals more educational services that are expected to be rendered). The composition of the domains varies depending on the type of physician involved (clinician-scholar, clinician-scientist, clinician-educator).

At the time I joined the Department of Medicine in 2012 we were creating an accountability framework that matched deliverables to a physician’s role description. The general spirit of the accountability framework and role description is to ensure productive and accountable use of the public funds provided to our alternative-funding plan (SEAMO) by the Ontario Ministry of Health and Long Term Care (MOHLTC) to pay physicians. Under this accountability program, chaired by Dr. Bill Paterson, a clinician-scholar would largely be evaluated on clinical productivity, innovation and excellence whereas the success of a clinician-educator would be based on creativity, leadership and service in undergraduate or postgraduate education. A clinician scientist’s metrics of achievement would include publications, grants, and trainees. To these standard metrics of success was added citizenship-short hand for participating in the life of the Department of Medicine (that’s Life with a capital “L”). With the encouragement and advice of the Deputy Head, Dr. Stephen Vanner, the head of the finance and resource committee, Dr. Mike Fitzpatrick, and the Division Chairs we allotted 5% of the totality of a faculty member’s efforts (and income) to being a good citizen. The formal recognition of citizenship’s importance was intended to make manifest the value we place on faculty members giving of their time and talent to support the many and diverse needs of the Department. Over the past 4 years citizenship has become engrained in the role description, and in my opinion, is one of the most important aspects of a well-run Department.

Citizenship activities may be clustered as serving two broad categories of the higher good. They may serve to “provide service” or they may serve to “creating a better community”. Examples of DOM citizens providing service include serving on university and hospital committees, interviewing medical students and residents, engaging the medical community through continuing professional development activities and engaging the community through volunteerism. Equally important is the role of good citizenship in enhancing our community and thereby enriching the lives of our faculty (a form of self-centered altruism). We chose to value the participation of faculty in the rounds and retreats that create a sense of community. In fact, we stipulated the need to attend 60% of certain rounds (like morbidity and mortality rounds and medical grand rounds).

Why should one incentivize faculty to attend rounds and retreats? It’s not for the CME; it’s for the development of a community. In Medicine, as in broader life, people tend to associate with small groups of colleagues that are like-minded. In Medicine, it is common to see selective association between individuals within the same specialty or subspecialty. Unchecked this attraction to the similar results in balkanization. This can lead to social isolation (not knowing one’s colleagues) and impairs the Department’s ability to successfully achieve its holistic mission of education, research, and clinical care in a manner that best serves our patients and learners. Organ-specific institutes (Heart Institutes, Neurosciences Institutes) have a role but do not, in my view, optimally serve the holistic needs of patients or trainees as well as a well-run Department of Medicine, home to 14, interconnected specialty Divisions comprised of engaged citizens.

In principle, failure to participate as a citizen would cause the faculty member to forfeit a sum of money aligned with the 5% of the role description allotted to citizenship. In reality, highlighting the benefits of attending rounds and retreats and participating in selecting medical students and residents, by placing a metrics on the activity has been all about enhanced quality and not at all about money at risk. Citizenship activities have not only improved the attendance at rounds, but also dramatically improved their quality. Faculty members now enjoy both the educational and socialization aspect of these events, and recognize the sense of community they have engendered within the Department of Medicine. Faculty express pride in the improved quality of their Department’s offerings. Interestingly, in 3 years the citizenship metric has existed no faculty member has been penalized by having the aligned funding withheld.

I have outlined a few of the activities we count as citizenship (there are many more). That said, it is perhaps more interesting to consider the attributes of a good citizen. I have thought about this a lot in the past few years and offer a list of core traits that I believe makes a good citizen, whether one is considering a government or an academic Department. I have included some illustrative quotes to reinforce the fact that many before me have come to similar conclusions.

I) Principled:

There were, unfortunately, no great principles on which parties were divided – politics became a mere struggle for office. Sir John A Macdonald

II) Altruistic:

Every man must decide whether he will walk in the light of creative altruism or in the darkness of destructive selfishness. Martin Luther King, Jr

III) Engaged:

The tyranny of a prince in an oligarchy is not so dangerous to the public welfare as the apathy of a citizen in a democracy (Charles de Montesquieu, author of the L’Esprit des lois which helped inform the rhetoric of the US constitution).

IV) Empowered:

“You can, you should, and if you’re brave enough to start, you will.” Stephen King

 V) Empathetic:

“No one cares how much you know, until they know how much you care.” Theodore Roosevelt

 VI) Informed:

“We can easily forgive a child who is afraid of the dark; the real tragedy of life is when men are afraid of the light.” Plato

VII) Tolerant:

The best thing to give to your enemy is forgiveness; to an opponent, tolerance. Benjamin Franklin

In Mr. Obama’s eloquent wrap-up speech he used the term citizen or citizenship no fewer than 7 times. He concluded that “citizen” is a democracy’s highest office. This is also true in the DOM. In my view, our Departmental leaders are the servants of their fellow citizens (we are their DOM-inions!). To these leaders, Division Chairs and Program Directors, I offer the following thought. You serve your fellow citizens and in so doing make the DOM better and enrich the lives of your colleagues. One day, when your term is done, you will be able to put down your heavy load and be elevated once again to the simpler and less encumbered rank of Citizen of the Department of Medicine.

So remember, when you engage in citizenship you shape and improve our collective destiny. The changes you want and the solutions you envision require your full engagement. Thank you for attending rounds, for coming to retreats, for interviewing students and residents. Thank you for making our DOM one of the most democratic structures I have had the privilege to work in during my career. When we meet during the upcoming year to review your goals and achievements I encourage all faculty to celebrate the great acts of citizenship they have achieved.

Citizenship activities are the 5% of your time that changes us from a good Department to a great one!

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Dr. Archer, Dept. Head
Dr. Archer, Dept. Head