System Challenges and their solutions. How Belgians do it.

By Dr Marc Sabbe.

Click here for the video summary.

Read the review by Dr. Mohammad Ali Merchant.

Consultant Emergency Medicine and Treasurer

European Society of Emergency Medicine

(Leadership Resilience in Emergency Care Workshop, Leeds)

Reviewed by Dr. Mohammad Ali Merchant, Clinical Fellow Leeds Teaching Hospitals


About the Speaker

Marc SABBE is a Consultant in Emergency Medicine and is a Professor in Emergency and Disaster Medicine at the University of Leuven, Belgium. He is one of the founders of the Belgian and European society of Emergency Medicine, where he has actively fulfilled several tasks.


  • Understanding the Belgian healthcare system
  • Belgian experiences
  • Leadership skills required in developing a speciality
  • Taking Emergency Medicine forwards.

Marc starts of on a lighter note and mentions he will talk about development of emergency medicine connected to leadership rather than systemic challenges as it is a very broad term and we need to be more clear about which systems do we focus on, i.e. Health care systems, Hospital systems or ED systems??


Healthcare systems

As he sent a few residents for a year of training, to London, and observed that he felt that most of the time we were over regulating the health care systems. We tend to complicate the healthcare system more than required. The residents on return also felt that there were no less regulations in UK than in Belgium. Although regulations are good but have their own limitations. They are well known in the fast food industry in maintaining the same standards internationally, but the balance between the regulations and the personal abilities is more important, and also that it all boils down to the individual efforts to make it slightly better.

Development of the Healthcare system in Belgium

He then talked about the development of emergency medicine in Belgium, and starts with a delivering an overview of the Belgian health care system. The system was founded less than a couple of centuries ago, and finalised in1963.It has multicultural influence embedded in to the system. He mentions that their paradigm was cultured more towards a survival one rather than having a chauvinistic approach. They never hesitated to compromise on the right thing to do, and have always looked towards a win-win situation. There exists a language barrier between the north and the south of Belgium, hence, not only did they have to learn from the European world but also from each other, therefore had to rely on this approach for survival.


Need for developing Emergency Medicine Belgium

He explains further as to why would there be a need to develop Emergency medicine as a speciality? According to him there were a few main reasons;

  1. Either there is a New Pathology born which needs special attention. Gives an example of when tuberculosis was discovered and Thoracic medicine developed a pulmonary tuberculosis as a branch.
  2. New knowledge surfaces, which demands individual attention e.g., Radiology was not there as specialty as far back as he can remember. Physicians and Cardiologists interpreted their own findings
  3. Specific demands of society e.g. In the 60’s road traffic accidents prompted them to come up and address unplanned medical care. In the 70’s ED nurses were responsible for the patients involved in accidents.

Later in 80’s two professors, both from two different universities, went to USA and UK for several months on a prospection in order to cater to this problem. At return both of these professors had very different views. One of them felt the need for developing a separate specialty whereas the other thought it was politically not possible and that they should make a supra-speciality.

But one of them couldn’t wait to be a REBEL. One of the Professors started an informal training in Emergency medicine. He continued this till 1993, when after an immense amount of effort, persistence and re-regulating the specialities, Emergency medicine became a supra speciality, which more than a decade later in, 2005, matured further and was recognized as a basic specialty.


Types of Leaderships required to attain the Goals

How did this happen? He felt that, it actually required different kinds of leadership. Firstly, it required an Operational leadership, which means that there had to be an emergency specialist on the shop floor at all times. Secondly, during the night on calls and on weekends, when other speciality doctors were unavailable at site, Emergency physicians were there, that gave an extra support to the specialties as well as the patients being admitted to the wards. It made a great difference. Thirdly, they were not only developing a team, but also an integrated team approach. And finally the need to explore a new field that not many were willing to develop was of crucial significance.


The French Model

The lack of Paramedics and quality of ambulances also influenced them to develop these Emergency department teams in order to improve patient safety. They copied the French as they acquired this approach. They later went on to develop clinical toxicology and observational emergency medicine. They also paid great emphasis on the 4 hour rule as it can be detrimental to the observational medicine if they lagged.


Operational Leadership

Marc, then explains that beside operational leadership and the importance of having scientific leaderships at different levels in this healthcare system was also very important in taking ED forwards. Developing scholars and professors in different universities helped. At the moment they have 12 professors in 7 medical schools, and 2 of the Deans are primarily Emergency physicians. This puts emergency medicine into a better position as compared to the rest of the specialities.


The Belgian Society of Emergency Medicine

The Belgian society of emergency medicine was set up in 1990, which was even prior to emergency medicine being recognized as a speciality in Belgium. In addition, International courses on Concept and developments in emergency medicine, which had two doctors attend from each European country, provided insights in how to develop International leadership. It was to bring them together and understand how to develop emergency medicine as a speciality. From this group was born the Club of Leuven, which later on developed into the European Society of Emergency Medicine.


The Role of Political Leadership

Political Leadership is optimally important in developing a new speciality. It is vital to understand the difference between decision makers and decision takers. First and foremost, the decision makers are the one who need to be influenced in order to achieve the desired goals. If the decision bypasses the decision makers and reaches the decision takers first, the objectives are not achieved. Political influences are needed at every level e.g. Universities, Hospitals and at the National healthcare levels.

To begin with, they wanted to bring in cheap affordable care to the society, which was an excellent slogan for the politicians. It took for them to develop a system in which the decision was taken and implemented after discussions between the Political and the Professional leaderships, which are more less were the same people. Secondly there is also an administration of the health care system headed by the ministers who also have advisors as an integral part. All of these steps help in improved decision making.

Marc gave an example of them developing the National or Federal council of pre-hospital care. By creating this they also developed their own decision makers within the administrative system. Hence the Emergency physicians became the scientific advisors for the healthcare system. They now have influence on the decision makers which helps developing the speciality further.


Achieving through collaboration

He goes on to explain the process to influence the decision takers through the collaboration of all the emergency physicians was essential. He gives another example of a process in which a key advisor to the health minister was a qualified emergency physician, which helped in the smoother flow in the development of the

Emergency medicine in Belgium.

Marc finally concludes his talk by delivering the take home messages. He summarises that developing Emergency medicine doesn’t just require clinical expertise and scientific knowledge, rather it is an adapted social functioning. So it is a must for us to adapt in order to grow and function optimally, regardless of whether it’s at a local or a universal society level. Our goals should be crystal clear and well defined, which can also be dispersed and shared via the social media.

Last, he invites all the participants to join him in a conference next year in Vienna for a further discussion and in order to understand this topic better.


Take home Message and what I enjoyed

I thoroughly enjoyed the talk and felt it was up to the mark as he eloquently delivered his experiences efficiently. Dr. SABBE clearly delivered the cross cultural experience. He highlighted the steps required with all the vast leadership qualities necessary in developing and taking the Emergency speciality forward. He highlighted the importance on developing leadership skill and various levels. In order to take the speciality to newer heights these leadership abilities play a key role. The power point presentation, although simple, delivered the message well.

He summed up his European experience in developing emergency medicine as speciality and leaderships required for the smooth flow of system changes in precise take home points, which were helpful to understand how different cultures manage their emergency department differently. Although there were some difference, but I also felt that Emergency departments broadly remain the same and it is the system implementation that differ.


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