Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


5 records – page 1 of 1.

Rural and remote practice issues

https://policybase.cma.ca/en/permalink/policy211
Last Reviewed
2020-02-29
Date
2000-05-09
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2000-05-09
Replaces
Promoting medicine as a career for rural high school students (Resolution BD88-03-78)
Topics
Physician practice/ compensation/ forms
Text
CMA Policy : Rural and Remote Practice Issues The Canadian Medical Association (CMA) believes that all Canadians should have reasonable access to uniform, high quality medical care. The CMA is concerned, however, that the health care infrastructure and level of professional support in rural and remote areas are insufficient to provide quality care and retain and recruit physicians relative to community needs. The CMA has developed this policy to outline specific issues and recommendations that may help retain and recruit physicians to rural and remote areas of Canada and thereby improve the health status of rural and remote populations. The following 3 key issue areas are addressed in this policy: training, compensation and work/lifestyle support. Commitment and action by all stakeholders, including governments, medical schools, professional associations and others, are urgently required. Preamble Canadian physicians and other health care professionals are greatly frustrated by the impact that health care budget cuts and reorganization have had, and continue to have, on the timely provision of quality care to patients and general working conditions. For many physicians who practise in rural and remote communities, the impact is exacerbated by the breadth of their practice, as well as long working hours, geographic isolation, and lack of professional backup and access to specialist services. This policy has been prepared to help governments, policy-makers, communities and others involved in the retention and recruitment of physicians understand the various professional and personal factors that must be addressed to retain and recruit physicians to rural and remote areas of Canada. This policy applies to both general practitioners/family physicians as well as specialists. The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to Physician Health and Wellbeing, Physician Compensation, Physician Resource Planning, Principles for a Re-entry System in Canadian Postgraduate Medical Education and Charter for Physicians. In addition, any strategies that are developed should not be coercive and must include community and physician input; they must also be comprehensive, flexible and varied to meet and respond to local needs and interests. Definitions Rural and remote There are no standard, broadly accepted terms or definitions for "rural" and "remote" since they cannot be sufficiently defined to reflect the unique and dynamic nature of the various regions and communities that could presumably be labelled as such. The terms "rural" or "remote" medicine may be applied to many things: the physicians themselves, the population they serve, the geography of the community or access to medical services. For each of these factors, there are a number of ways to define and measure rurality. For example, a 1999 CMA survey of rural physicians showed that the most frequently mentioned characteristics of a rural community were (1) high level of on-call responsibilities, (2) long distance to a secondary referral centre, (3) lack of specialist services and (4) insufficient family physicians. As another example, Statistics Canada defines rural and small town residents for some analyses as those living in communities outside Census Metropolitan Areas (population of at least 100 000) or Census Agglomerations (population between 10 000 and 99 999), and where less than 50% of the workforce commute to a larger urban centre. Medical school For the purposes of this policy, a medical school is understood to encompass the entire continuum of medical education, i.e., undergraduate, postgraduate, continuing medical education and maintenance of competence. Training Some Canadian studies have shown that medical trainees who were raised in rural communities have a greater tendency to return to these or similar communities to practise medicine. Some studies also show that individuals who do clerkships in rural or remote communities, or have some exposure to the rural practice environment during residency training, have a greater tendency to consider practising in rural or remote communities upon graduation. The CMA applauds those medical schools that promote careers in medicine to individuals from rural and remote areas and provide medical students and residents with exposure to rural practice during their training. Regular collaboration and communication among training directors for rural and remote programs, as well as rural medical educators and leaders from other health disciplines, are strongly encouraged so that rural training issues and possible linkages may be discussed. The benefits of rural training extend not only to those physicians who ultimately end up in rural practice; those who remain in urban areas also benefit by having an enhanced understanding of the challenges of rural and remote practice. As outlined in the CMA’s 1992 Report of the Advisory Panel on the Provision of Medical Services in Underserviced Regions, the CMA believes that partnerships among medical schools, the practising profession and communities need to be formalized, particularly since medical schools have a crucial role in helping to recruit and retain physicians for rural and remote communities. The medical school’s role in such a partnership takes the form of a social contract. This contract begins with the admission of students who demonstrate a prior interest in working in rural or remote communities and may come from these communities. It also includes the exposure of students to rural practice during their undergraduate and postgraduate training. It is followed by the provision of specialized training for the conditions in which they will work and ongoing educational support during their rural and remote practice. For these reasons, the CMA strongly encourages academic health science centres (AHSCs), provincial governments, professional associations and rural communities to work together to formally define the geographic regions for which each AHSC is responsible. The AHSCs are also encouraged to include within their mission a social contract to contribute to meeting the health needs of their rural or remote populations. Practising physicians are committed to lifelong learning. In order to preserve a high standard of quality care to their patients, they must be knowledgeable about new clinical and technological advances in medicine; they must also continually develop advanced or additional clinical skills in, for example, obstetrics, general surgery and anaesthesia, to better serve the patients in their communities, especially when specialist services are not readily available. There are many practical and financial barriers that physicians in rural and remote communities face in obtaining and maintaining additional skills training, including housing, practice and other costs (e.g., locum tenens replacement expenses) while they are away from work. The CMA strongly encourages governments to develop and maintain mechanisms, such as compensation or additional tax relief, to reduce the barriers associated with obtaining advanced or additional skills training. In light of these issues, the CMA recommends that 1. Universities, governments and others encourage and fund research into criteria that predispose students to select and succeed in rural practice. 2. All medical students, as early as possible at the undergraduate level, be exposed to appropriately funded and accredited rural practice environments. 3. Medical schools develop training programs that encourage and promote the selection of rural practice as a career. 4. Universities work with professional associations, governments and rural communities to determine the barriers that prevent rural students from entering the profession, and take appropriate action to eliminate or reduce these barriers. 5. A Web site based compendium of rural experiences and electives for medical students be developed, maintained and adequately funded. 6. Advanced skills acquisition and maintenance opportunities be provided to physicians practising in or going to rural and remote areas. 7. CMA divisions and provincial/territorial governments ensure that physicians who work in rural and remote areas receive full remuneration while obtaining advanced skills, including support for the locum tenens who will replace them. 8. Any individual formally enrolled in a Royal College of Physicians of Surgeons of Canada or College of Family Physicians of Canada program be covered by the collective agreement of their housestaff organization. 9. Providers, funders and accreditors of continuing medical education for rural physicians ensure that the continuing medical education is developed in close collaboration with rural physicians and is accessible, needs-based and reflective of rural physicians’ scope of practice. 10. Physicians who practise in rural or remote areas be given reasonable opportunities to re-enter training in a postgraduate program without any return-in-service obligations. 11. In order to promote mutual understanding, universities encourage teaching faculty to work in rural practices and that rural physicians be invited to teach in academic health science centres. 12. Medical schools develop training programs for both students and residents that encourage and promote the provision of skills appropriate to rural practice needs. 13. Medical schools support rural faculty development and provide full faculty status to these individuals. Compensation The CMA believes that compensation for physicians who practise in rural and remote areas must be flexible and reflect the full spectrum of professional and personal factors that are often inherent to practising and living in such a setting. These professional factors may include long working hours and the need for additional competencies to meet community needs, such as advanced obstetrics, anaesthesia and general surgery, as well as psychotherapy and chemotherapy. They may also include a high level of on-call responsibilities as well as a lack or total absence of backup from specialists, nurses and other complementary services that are usually available in an urban environment. Other challenges are professional isolation, limited opportunities for education or training, and high practice start-up costs. Also, if for a number of reasons a physician wishes to relocate to an urban setting, he or she may face billing restrictions as well as challenges in finding a replacement physician. Compensation for these factors is necessary to help retain physicians and recruit new ones. In addition, compensation should guarantee protected time off, paid continuing medical education or additional skills training, and locum tenens coverage. Any pool of locum tenens for rural and remote practice should be adequately funded and cross-jurisdictional licensure issues should be minimized. Living in a rural or remote community can be very satisfying for many physicians and their families; however, they must usually forgo — often for an extended period of time— a number of urban advantages and amenities. These include educational, cultural, recreational and social opportunities for their spouse or partner, their children and themselves. They may also face altered family dynamics due to a decrease or significant loss of family income if there are limited or no suitable employment opportunities for their spouse or partner. The CMA believes that all physicians should have a choice of payment options and service delivery models to reflect their needs as well as those of their patients. Physicians must receive fair and equitable remuneration and have a practice environment that allows for a reasonable quality of life. Although the CMA does not advocate one payment system for urban physicians and another for rural physicians, it believes that enhanced total compensation should be provided to physicians who work and live in rural and remote communities. In recognition of these issues, the CMA recommends that 14. Additional compensation to physicians working in rural and remote areas reflect the following areas: degree of isolation, level of responsibility, frequency of on-call, breadth of practice and additional skills. 15. In recognition of the differences among communities, payment modalities retain flexibility and reflect community needs and physician choice. 16. Financial incentives focus on retaining physicians currently practising in rural or remote areas and include a retention bonus based on duration of service. 17. Factors affecting the social and professional isolation of physicians and their families be considered in the development of compensation packages and working conditions. 18. Eligibility criteria for including physicians in a pool of locum tenens for rural or remote practice be developed in consultation with rural physicians. 19. Provincial/territorial licensing bodies establish portability of licensure for locum tenens and ensure that any fees or processes associated with licensure do not serve as barriers to interprovincial mobility. 20. Rural locum tenens programs be funded by provincial/territorial governments and include adequate compensation for accommodation, transportation and remuneration. As previously noted, some studies show that exposure to rural and remote areas during training influences students’ decision to practise in those communities upon graduation. The CMA is concerned, however, that travel and accommodation costs relating to these experiences place an undue financial burden on students. In addition, most physicians in rural and remote areas are already burdened with significant patient loads and find that they have limited time and resources to act as preceptors. The CMA believes that, to ensure the ongoing viability of student rural experiences, physician preceptors should be compensated for their participation and should not incur any additional expenses, such as student or resident accommodation costs. The CMA recommends that 21. Costs for accommodation and travel for student and resident rural training experiences in Canada not be borne by the trainees or the preceptors. 22. Training programs assume responsibility for adequately remunerating preceptors in rural or remote areas. Work and lifestyle support issues To retain and recruit physicians in rural and remote communities, there are issues beyond fair and adequate compensation that must be considered. It is crucial that the aforementioned working conditions, professional issues and array of personal and family-related issues be addressed. The ultimate goal should be to promote physician retention and implement measures that reduce the possibility of physician burnout. Like most people, physicians want to balance their professional and personal responsibilities to allow for a reasonable quality of life. Physicians in rural and remote areas practise in high stress environments that can negatively affect their health and well-being; as a consequence, the standard of care to their patients can suffer. The stress is intensified by excessive work hours, limited professional backup or support (including locum tenens), limited access to specialists, inadequate diagnostic and treatment resources, and limited or no opportunity for vacation or personal leave. At particular risk for burnout is the physician who practises in isolation. For these reasons many physicians, when considering practice opportunities, tend to seek working conditions that will not generate an excessive toll on their non-working lives. This reinforces the need for rural and remote practice environments that facilitate a balance between physicians’ professional and personal lives. In light of these issues, the CMA recommends that 23. Regardless of community size, there should always be at least 2 physicians available to serve the needs of the community. 24. Ideally, the on-call requirement for weekends never exceed 1 in 5 in any Canadian practice. (This is consistent with current CMA policy.) 25. Provincial/territorial governments have professional support and other mechanisms readily available to physicians who practise in rural and remote areas, such as sabbaticals and locum tenens. 26. Governments recognize the service of rural and remote physicians by ensuring that mechanisms exist to allow future access to practise in an urban area of their choice. The CMA believes that rural and remote physician retention and recruitment initiatives must address matters relating to professional isolation as well as social isolation for physicians and their families. This sense of isolation can increase when there are cultural, religious or other differences. For unattached physicians, zero tolerance and unreasonable restrictions with regard to relationships with potential patients can be disincentives to practise in rural or remote communities. Although the CMA believes that such policies and restrictions should be reviewed, the CMA encourages physicians to refer to the CMA policy on The Patient-Physician Relationship and the Sexual Abuse of Patients and the Code of Ethics of the Canadian Medical Association. Also, the CMA recommends that physicians abide by any provincial/territorial policies or legislation that may currently be in place. The medical services infrastructure in rural and remote areas is usually very different from that in urban settings. In addition to a lack of specialist services, physicians in these areas may often have to cope with a number of other factors such as limited or no appropriate diagnostic equipment or limited hospital beds. Physicians and their patients expect and deserve quality care. The diversity and needs of the populations, as well as the needs of the physicians who practise in rural and remote areas, must also be recognized and reflected in the infrastructure (e.g., demographic and geographical considerations). The CMA recommends that 27. A basic medical services infrastructure for rural and remote areas be defined, such as hospital beds, paramedical staff, diagnostic equipment, transportation, ready access to secondary and tertiary services, as well as information technology tools and support. 28. Provincial/territorial governments recognize that physicians who work in rural and remote areas need an environment that appropriately supports them in providing service to the local population.
Documents
Less detail

Management of physician fatigue

https://policybase.cma.ca/en/permalink/policy11127
Last Reviewed
2019-03-03
Date
2014-05-24
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2014-05-24
Topics
Health human resources
Text
Health systems around the world are struggling with how to best meet the health needs of their populations. Health leaders speak with urgency about the need to improve the individual experience of care, improve the health of populations, and maximize return on investments. Physicians concur - they are continually focused on providing better care to their patients. Concurrently, concerns over patient safety have arisen over the last two decades, rooted in studies of adverse events. The incidence of adverse events (AEs) in acute care hospitals has been reported in the United States (US),1,2,3 Australia,4 United Kingdom,5 and Canada.6 Between 5% and 20% of patients admitted to hospital experience one or more AEs; between 36.9% - 51% of these AEs are preventable; and AEs contribute billions of dollars through additional hospital stays as well as other costs to the system, patients and the broader society.7 Leape et al. maintain that more than two-thirds of AEs are preventable.8 These outcomes have prompted decision makers, policy makers and healthcare providers to examine contributing factors, including the increasingly complex health system and its impact on the well-being of providers. Patient safety and physician well-being are the key drivers leading to restrictions on resident and/or physician duty hours aimed at reducing their fatigue. The European Working Time Directive (EWTD) was first established in 1993 to place limits on all workers' hours throughout Europe under the umbrella of health and safety legislation. That directive included physicians but excluded doctors in training. In 2000, a new directive passed to include the "junior doctor" constituency accompanied by a requirement that by 2009 all health systems in the European Union limit resident work to a maximum of 48 hours averaged per week. The intention was to improve the working lives of doctors in training and to increase patient safety. A systematic review on the impact of the EWTD on postgraduate medical training, patient safety, or clinical outcomes found studies to be of poor quality with conflicting results.9 In 2003, the Accreditation Council for Graduate Medical Education (ACGME) in the US adopted a set of duty hour regulations for physicians in training. The ACGME issued revised regulations that went into effect in July 2011, reflecting the recommendations of a 2008 Institute of Medicine report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, calling for elimination of extended duty shifts (more than 16 hours) for first year residents, increasing days off, improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks, and increasing oversight by more senior physicians.10 The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error. In 2013, the National Steering Committee on Resident Duty Hours released Canada's first comprehensive, collaborative and evidence-based report on fatigue and duty hours for Canada's approximately 12,000 residents. The Committee stresses that a comprehensive approach is necessary in order to enhance safety and wellness outcomes. Fatigue risk management is a predominant theme in the recommendations. Fatigue management systems are in place in other sectors/industries that have a low threshold for adverse outcomes including aviation, transportation, and the Department of National Defence. In 2010, the Canadian Nurses Association released a position statement Taking Action on Nurse Fatigue that speaks to system, organizational and individual level responsibilities of registered nurses. There are currently no specific policies in Canada for physicians in practice with respect to fatigue management. Given the heterogeneity of medical practice (i.e. various specialties) and of the practice settings (i.e. rural and remote versus urban, clinic versus hospital, etc.), the solutions emanating from a fatigue management policy may be different - one size will not fit all. Impact of Physician Fatigue Patient Safety Sleep deprivation is the condition of not having enough sleep and can be either chronic or acute. It impairs cognitive and behavioural performance. "Sleep is required for the consolidation of learning and for the optimal performance of cognitive tasks. Studies of sleep deprivation have shown that one night without sleep negatively affects the performance of specific higher cognitive functions of the prefrontal cortex and can cause impairment in attention, memory, judgment, and problem solving."(p. 1841)11 A seminal study by Williamson and Feyer found that after 17-19 hours without sleep, performance on some cognitive and motor performance tests was equivalent or worse than that at a blood alcohol concentration (BAC) of 0.05%.12 Wakefulness for 24 hours is equivalent to a blood alcohol level of 0.10%.13 A chronic sleep-restricted state can cause fatigue, which is a subjective feeling of tiredness, lack of energy and motivation. A large body of research exists linking sleep deprivation/fatigue, performance and adverse patient outcomes, particularly for medical residents. 14,15,16,17,18,19, 20, 21,22, 23,24 However, literature on the impact on performance varies based on a number of factors. There are significant inter-individual differences in the global response to sleep loss, as well as significant intra-individual variations in the degree to which different domains of neurobehavioral function (e.g., vigilance, subjective sleepiness, and cognitive performance) are affected. Inter-individual differences are not merely a consequence of variations in sleep history. Rather, they involve trait-like differential vulnerability to impairment from sleep loss. 25 Evidence suggests an inconclusive relationship between duty hour reductions (primarily those implemented in the US) and patient safety, suggesting that restrictions on consecutive duty hours have not had the anticipated impact on this crucial outcome as anticipated.26 Several large studies have revealed only neutral or slightly improved patient mortality and other clinical parameters since implementation of the ACGME work hour limits in the US.27,28, 29,30 In complex and ever changing health systems, it is difficult to isolate the impact of restricted duty hours alone. Research on the effects of practicing physician sleep deprivation and extended work shifts on clinical outcomes is limited and inconclusive.31, 32 The issue of physician fatigue is complex, and is affected by much more than duty hours. Other contributing factors affect performance including work patterns, individual response to sleep loss, experience of the worker, the context of which sleep deprivation is necessary, hours of actual sleep, patient volume, patient turnover and patient acuity, environmental factors, personal stressors, workload, etc. Limiting work hours alone is not sufficient to address sleep deprivation among physicians. Reduced or disturbed periods of sleep, more consecutive days or nights of work, shift variability, and the volume of work all increase fatigue and thus can contribute to errors. One of the biggest concerns with a fatigue management strategy is continuity of care, linked to the number of transfers of care (handover) among providers. Transfers of care inevitably increase in an environment of work hour limitations.33, 34 Handovers are considered critical moments in the continuity of patient care and have been identified as a significant source of hospital errors, often related to poor communication. There is a growing body of literature on how to do these well and how to teach this well. This is an important skill for physicians in the context of a fatigue management strategy: "Standardization of the handover process has been linked to a reduction in the number of errors related to information transfers. In addition, effective mechanisms for the transfer of information at transition points have been recognized as patient safety enablers."35 Provider Well-being Provider well-being (physical, mental, occupational) is linked to system performance and patient outcomes. It is affected by fatigue and work patterns including night shift and extended hours. Comprehensive, systematic reviews of the health effects of on-call work in 2004 showed that nighttime work interrupted sleep patterns, aggravated underlying medical conditions, and increased the risk of cardiovascular, gastrointestinal, and reproductive dysfunction.36,37.38 Other research suggests an elevated risk of breast cancer,39,40 prostate cancer,41 colorectal cancer,42 asthma43, diabetes,44 and epilepsy45 for shift workers. Disruption of the body's circadian rhythms is thought to be one of the main pathways for adverse health effects from shift work, particularly for work schedules that involve night work. Given that 24-hour work is unavoidable in various industries, including healthcare, researchers have evaluated different shift schedules designed to reduce some of the negative health effects of working at night. Optimal shift schedules are aligned as much as possible with the circadian rhythm, promote adaptation of the circadian rhythm with shift work, reflect workers' needs and preferences, and meet organizational or productivity requirements. The following interventions appear to have the most beneficial effects on the health of shift workers:46 * Schedule changes including changing from backward (counterclockwise) to forward (clockwise) rotation, from eight hour to 12 hour shifts, and flexible working conditions, self-scheduling, and ergonomic shift scheduling principles * Controlled exposure to light and day; * Behavioural approaches such as physical activity, scheduled naps and education about sleep strategies; and * Use of pharmacotherapy (i.e. caffeine and melatonin) to promote sleep, wakefulness, or adaptation Sleep deprivation and on-call shifts consistently point to deterioration of mood resulting in depression, anger, anxiety, hostility, and decreased vigilance.47 ,48, 49 A Canadian study found that shift workers reported significantly higher burnout, emotional exhaustion, job stress and psychosomatic health problems (e.g. headaches, upset stomach, difficulty falling asleep) than workers on a regular day schedule.50 Prolonged duty hours by residents has been found to contribute to marital problems, pregnancy complications, depression, suicide and substance abuse,51 as well as serious conflicts with attending physicians, other residents, and nurses, in addition to increased alcohol use and instances of unethical behaviour.52 Surprisingly however, the abolishment of 24-hour continuous medical call duty for general surgery residents at one facility in Quebec was associated with self-reported poorer quality of life.53 In contrast to other recommendations on the health benefits of 8 hr shifts, the risk of a work safety incident increases markedly after more than eight hours on duty. The risk in the twelfth hour is almost double than in the eighth hour (and more than double the average risk over the first eight hours on duty).54 Extended work duration and nighttime work by interns is associated with an increased risk of reported percutaneous injuries (PIs).55 Fatigue was reported more often as a contributing factor for nighttime compared with daytime injuries. Fatigue was also more commonly reported as a contributing factor to PIs that occurred after extended work than those that occurred after non-extended work.56 Other research found that residents were most exposed to blood-borne pathogens through needle punctures or cuts during overnight duty periods.57 Health care facilities that have physicians working in them have a role in supporting and promoting provider well-being, including providing enablers of extending and continuing resiliency such as nutritious food, on call rooms, appropriate numbers of staff, locums, etc. They also have a role in working jointly and collaboratively with physicians to ensure that on-call schedules do not place work demands on individual physicians that prevent the physicians from providing safe patient care and service coverage. For example, research with emergency physicians suggests that a nap at 3 AM improves performance in physicians and nurses at 7:30 AM compared to a no-nap condition despite the fact that memory temporarily worsened immediately after the nap.58 Individual resilience, intergenerational differences, illness-related issues, as well as family commitments also need to be considered. Physicians should also be encouraged to take the necessary time to rest and recover on their time off. The obligation of physicians to provide after hour coverage and care is unavoidable and should be considered by an individual when they choose a career in medicine, and as a physician in managing their schedule/call. A review of 100 studies from around the world indicates the culture of medicine contributes to doctors ignoring the warning signs of fatigue and stress and in many cases suffering from undiagnosed ailments such as stress and depression, or from burnout.59 The authors suggest the culture of medicine is such that doctors feel they don't need help; they put their patients first. Of the 18% of Canadian doctors who were identified as depressed, only a quarter of them considered getting help and only two per cent actually did. The report suggests that burnout from working long hours and sleep deprivation because of understaffing seems to be the biggest problem worldwide.60 The Canadian Medical Protective Association (CMPA) states that physicians should consider their level of fatigue and if they are clinically fit to provide treatment or care.61 Fatigue is not a sign of weakness. All members of the health care team should support their colleagues in recognizing and managing sleep deprivation and fatigue. Physician fatigue has several ethical dimensions. The Canadian Medical Association Code of Ethics states that physicians have an ethical responsibility to self-manage their fatigue and well-being. 62 However, physicians must be trained and competent to know their own limits and evaluate their own fatigue level and well-being. The system must then support physicians in this recognition. The doctrine of informed consent is another dimension of physician fatigue. If physician fatigue is an added risk for any aspect of patient care, whether it is surgical or medical, elective or emergent, then some have argued that the doctrine of informed consent suggests that physicians have an obligation to inform patients of that risk.63 ,64 "The medico-legal considerations for physicians centre on the ethical duty to act in the best interests of their patients. This may mean that if a physician feels that his or her on-call schedule endangers or negatively impacts patient care, reasonable steps are taken to ensure patients do not suffer as a result and that the physician is able to continue providing an adequate level of care for patients."65 System Performance Addressing physician fatigue may have workforce implications. Physician workload is multifaceted comprised of clinical, research, education and administrative activities. If physician workload or duty hours are reduced, any one of these activities may be impacted. It has been suggested that implementing fatigue management strategies such as a workload ceiling for physicians may result in a greater need for physicians and thus increase system costs. However, new models of team based care delivery that incorporate technology, reduce redundancy, utilize a team based approach, and optimize the role of physicians offer an opportunity to better manage physician fatigue without necessarily requiring more physicians. Other strategies also need to be explored to improve the on-the-ground efficiency of physicians. Some of the strategies to address practicing physician sleep deprivation/fatigue such as scheduling changes and reduced workload may affect access to care, including wait times. Surgeons or others may have to cancel surgeries or other procedures because of fatigue and hours of work, forcing rescheduling of surgery/procedures and potentially increasing wait times. This is particularly relevant given Canada's large geography and varied distribution of physicians. Therefore, flexibility in strategies to address physician sleep deprivation/fatigue are needed to reflect the variety of practice types and settings in existence across the country, in particular solo practices; rural, remote and isolated sites; community locations; etc. The same holds true for smaller specialties, which has been the experience in the UK with the implementation of the EWTD. Fatigue management is a competency that needs to be taught, modelled, mentored, and evaluated across the medical education continuum, from medical student to practicing physician. Recommendations 1. Educate physicians about the effects of sleep deprivation and fatigue on the practice of medicine and physician health, and how to recognize and manage their effects. 2. Create a national tool-box of self-awareness tools and fatigue management strategies and techniques. 3. Advocate for the integration of fatigue management into the continuum of medical education. 4. Advocate for the creation of system enablers with the flexibility to: * Consider the full workload of physicians (clinical, teaching, administrative, research, etc.); * Optimize scheduling to coordinate on call and other patient care following call; and * Implement organizational/institutional level fatigue risk management plans. 5. Develop and advocate for implementation of standardized handover tools. 6. Enhance and reaffirm a culture within medicine that focuses on patient-centered care. 7. Reaffirm the culture shift within medicine that encompasses physician well-being. 8. Encourage physicians treating physicians to be aware of the aggravating effects of fatigue on their well-being and practice. Conclusion Physicians are interested in how to best meet the needs of the population, in continually improving the care provided to Canadians. To do so requires that they also care for themselves including managing the effects of sleep deprivation and fatigue. It is a complex issue that requires multifaceted solutions. Strategies must address physician fatigue at an individual, organizational/institutional and system level. References 1 Leape, LL, Brennan, TA, Laaird, N, Lawthers, AG, Logalio, AR, Barnes, BA et al. (1991).The nature of adverse events in hospitalized patients. New England Journal of Medicine 324 (6): 377-384 2 Brennan, TA, Leape, LL, Nan, M, et al. (1991). Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine 324:370-376. 3 Thomas, E., Studdert, D., Burstin, H., et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 38(3): 261-71. 4 Wilson, RL, Runciman, WB, Gibberd, RW, et al. (1995). The Quality in Australian Health Care Study. Medical Journal of Australia 163: 458-471. 5 Vincent, C, Neale, G, & Woloshynowych, M. (2001). Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal 322: 517-9. 6 Baker, G., Norton, P., Flintoft, V., Balis, R., Brown, A., Cox, J., et al. (2004). The Canadian adverse event study: the incidence of adverse events among hospitalized patients in Canada. Canadian Medical Association Journal, 170(11): 1678-1686. 7 Jeffs, L., Law, M., Baker, G., & Norton, P. (2005). Patient Safety Research in Australia, United Kingdom, United States and Canada: A Summary of Research Priority Areas, Agenda-Setting Processes And Directions for Future Research in the Context of their Patient Safety Initiatives. Retrieved from http://www.patientsafetyinstitute.ca/English/news/eventProceedings/Documents/2005%20Research%20Retreat%20-%20Patient%20Safety%20Research%20Backgrounder%20Paper.pdf 8 Leape, L., Brennan, T., Laaird, N., Lawthers, A., Logalio, A., Barnes, B. et al. (1991). The nature of adverse events in hospitalized patients. New England Journal of Medicine 324 (6): 377-384. 9 Moonesinghe, S., Lowery, J., Shahi, N., Millen, A., & Beard, L. (2011). Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review. BMJ 342:d1580. 10 Ulmer, C., Wolman, D., & Johns, M. (eds.) Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. (2008). Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press. 11 Krueger, K. & Halperin, E. (2010). Perspective: Paying Physicians to Be On Call: A Challenge for Academic Medicine. Academic Medicine 85 (12); 1840-1844. 12 Williamson, A. & Feyer, A. (2000). Moderate Sleep Deprivation Produces Impairments in Cognitive and Motor Performance Equivalent to Legally Prescribed Levels of Alcohol Intoxication. Occupational and Environmental Medicine 57: 649-655. 13 Dawson, D. & Reid, K. (1997). Fatigue, Alcohol and Performance Impairment. Nature 388: 235. 14 Arnedt, J., Owens, J., Crouch, M., et al. (2005). Neurobehavioral Performance of Residents After Heavy Night Call vs After Alcohol Ingestion. Journal of American Medical Association 294(9): 1025-33. 15 Howard, S., Gaba, D., Smoth, B., et al. (2003). Simulation Study of Rested Versus Sleep-deprived Anesthesiologists. Anesthesiology 98:1345-1355 16 Philbert, I. (2005). Sleep Loss and Performance in Residents and Nonphysicians: A Meta-analytic Examination. Sleep 28: 1392-1402. 17 Lockley, S., Barger, L., Ayas, N., Rothschild, J., Czeisler, C. et al. (2007). Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance. The Joint Commission Journal on Quality and Patient Safety 3(11): 7-18. 18 Eastridge, B., Hamilton, E., O'Keefe, G., Rege, R., Valentine, R. et al. (2003). Effect of sleep deprivation on the performance of simulated laproscopic surgical skill. The American Journal of Surgery 186: 169-174 19 Taffinder, N., McManus, I., Hul, Y., Russell, R., & Darzi, A. (1998). Effect of Sleep Deprivation on Surgeon's Dexterity on Laparsoscopy Simulator. The Lancet 352: 1191. 20 Rothschild, J., Keohane, C., Rogers, S., et al. (2009). Risks of Complications by Attending Physicians After Performing Nighttime Procedures. JAMA 302:1565-72. 21 Lockley, S., Cronin, J., Evans, E., Cade, B., Lee, C., et al. (2004). Effect of Reducing Interns' Weekly Work Hours on Sleep and Attentional Failures. N Engl J Med 351: 1829-1837. 22 Landrigan, C., Rothschild, J., Cronin, J., Kaushal, R., Burdick, E., et al. (2004). Effect of Rreducing Interns' Work Hours on Serious Medical Errors in Intensive-care Units. N Engl J Med 351: 1838-1848. 23 Barger, L., Ayas, N., Cade, B., Cronin, J., Rosner, B., et al. (2006). Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures. PLoS Med 3(12): 2440-2448. 24 Landrigan, C., Rothschild, J., Cronin, J., et al. (2004). Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units. New England Journal of Medicine 351:1838-48. 25 Van Dongen, H., Baynard, M., Maislin, G., et al. (2004). Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of a trait-like differential vulnerability. Sleep 27: 423-433. 26 Philibert,I., Nasca, T., Brigham, T., & Shapiro, J. (2013). Duty-Hour Limits and Patient Care and Resident Outcomes: Can High-Quality Studies Offer Insight into Complex Relationships? Annu. Rev. Med 64: 467-83. 27 Volpp, K., Rosen, A., Rosenbaum, PR., et al. (2007). Mortality Among Hospitalized Medicare Beneficiaries in the First 2 Years Following the ACGME Resident Duty Hour Reform. JAMA 298: 975-983. 28 Volpp, K., Rosen, A., Rosenbaum, P., et al. (2007). Mortality Among Patients in VA Hospitals in the First 2 Years Following ACGME Resident Duty Hour Reform. JAMA 298(9): 984-992. 29 Antiel, R., Reed, D., Van Arendonk, K., Wightman, S., Hall, D., Porterfield, J., et al. (2013). Effects of Duty Hour Restrictions on Core Competencies, Education, Quality of Life, and Burnout Among General Surgery Interns. JAMA Surg 148(5):448-455. 30 Drolet, B., Sangisetty, S., Tracy, T., & Cioffi, W. (2013). Surgical Residents' Perceptions of 2011 Accreditation Council for Graduate Medical Education Duty Hour Regulations. JAMA Surg 148(5): 427-433. 31 Chang, L., Mahoney, J., Raty, S., Ortiz, J., Apodaca, S., & De La Garza II, R. (2013). Neurocognitive effects following an overnight call shift on faculty anesthesiologists. Acta Anaesthesiol Scand 57: 1051-1057. 32 Sharpe, J., Weinberg, J., Magnotti, L., Nouer, S., Yoo, W., Zarzaur, B. et al. (2013). Outcomes of Operations Performed by Attending Surgeons after Overnight Trauma Shifts. J Am Coll Surg 216:791- 799. 33 Olsen, E., Drage, L., Auger, R. (2009). Sleep Deprivation, Physician Performance, and Patient Safety. Chest 136: 1389-1396. 34 Choma, N., Vasilevskis, E., Sponsler, K., Hathaway, J., & Kripalani, S. Effect of the ACGME 16-Hour Rule on Efficiency and Quality of Care: Duty Hours 2.0. JAMA INTERN MED 173 (9): 819-821. 35 Canadian Medical Protective Association. (2013). CMPA Risk Fact Sheet: Patient Handover. Retrieved January 13, 2014 from https://oplfrpd5.cmpa-acpm.ca/documents/10179/300031190/patient_handovers-e.pdf 36 Nicol, A., Botterill, J., (2004). On-call Work and Health: A Review. Environmental Health 3: 1-11. 37 Knutsson, A. & Boggild, H. (2010). Gastrointestinal disorders among shift workers. Scand J Work Environ Health 36(2): 85-95. 38 Vyas, M., Garg, A., Iansavichus, A., Costella, J., Donner, A., Laugsand, L., et al. (2012). Shift work and vascular events: systematic review and meta-analysis. British Medical Journal 345: e4800 doi: 10.1136/bmj.e4800 39 Shields, M. (2002). Shift work and health. Health Reports 13(4):11-33. 40 Fritschi, L., Glass, D., Heyworth, J., Aronson, K., Girschik, J., Boyle, T., et al. (2011). Hypotheses for mechanisms linking shiftwork and cancer. Medical Hypotheses 77:430-436. 41 Kubo, T., Ozasa, K., Mikami, K., Wakai, K., Fujino, Y., Watanabe, Y., et al. (2006). Prospective cohort study of the risk of prostate cancer among rotating-shift workers: findings from the Japan Collaborative Cohort Study. American Journal of Epidemiology 164(6): 549-555. 42 Schernhammer, E., Laden, F., Speizer, F., Willett, W., Hunter, D., Kawachi, I., et al. (2003). Night-shift work and risk of colorectal cancer in the Nurses' Health Study. Journal of the National Cancer Institute 95(11):825-828. 43 Shields, M. (2002). Shift work and health. Health Reports 13(4):11-33. 44 Ibid 45 Ibid 46 Occupational Cancer Research Centre and the Institute for Work & Health. Can the health effects of shift work be mitigated? A summary of select interventions. Retrieved March 10, 2013 from http://www.occupationalcancer.ca/wp-content/uploads/2012/09/Summary_intervention-research_FINAL.pdf 47 Eastridge, B., Hamilton, E., O'Keefe, G., Rege, R., Valentine, R. et al. (2003). Effect of Sleep Deprivation on the Performance of Simulated Laproscopic Surgical Skill. The American Journal of Surgery 186: 169-174. 48 Krueger, K. & Halperin, E. (2010). Perspective: Paying Physicians to Be On Call: A Challenge for Academic Medicine. Academic Medicine 85(12); 1840-1844. 49 Haines, V., Marchand, A., Rousseau, V., & Demers, A. (2008).The mediating role of work-to-family conflict in the relationship between shiftwork and depression. Work & Stress 22(4):341-356. 50 Jamal, M. (2004). Burnout, stress and health of employees on non-standard work schedules: a study of Canadian workers. Stress and Health 20:113-119. 51 Woodrow, S., Segouin, C., Armbruster, J., Hamstra, S., & Hodges, B. (2006). Duty Hours Reforms in the United States, France and Canada: Is It Time to Refocus our Attention on Education? Academic Medicine 81(12): 1045-1051. 52 Baldwin, D., Daugherty, S., Tsai, R., et al. (2003). A National Survey of Residents' Self-reported Work Hours: Thinking Beyond Specialty. Academic Medicine 78:1154-1163. 53 Hamadani, F., Deckelbaum, D., Sauve, D., Khwaja, K., Razek, T., & Fata, P. (2013). Abolishment of24-HourContinuousMedical Call Duty in Quebec: A Quality of Life Survey of General Surgical Residents Following Implementation of the New Work-Hour Restrictions. J Surg 70: 296-303. 54 Folkard, S. & Tucker, P. (2003). Shift work, safety and productivity. Occupational Medicine 53: 95-101. 55 Ayas, N., Barger, L., Cade, B., et al. (2006). Extended Work Duration and the Risk of Self-reported Percutaneous Injuries in Interns. JAMA 296(9): 1055-62. 56 Ayas, N., Barger, L., Cade, B., et al. (2006). Extended Work Duration and the Risk of Self-reported Percutaneous Injuries in Interns. JAMA 296(9): 1055-62. 57 Parks, D., Yetman, R., McNeese, M., Burau, K., & Smolensky, M. (2000). Day-night pattern in accidental exposures to blood-borne pathogens among medical students and residents. Chronobiology International 17(1): 61-70. 58 Smith-Coggins, R., Howard, S., Mac D., Wang, C., Kwan, S., Rosekind, M., Sowb, Y., Balise, R., Levis, J., Gaba, D. (2006). Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. Ann Emerg Med, 48(5): 596-604. 59 Wallace, J., Lemaire, J., & Ghali, W. (2009). Physician wellness: a missing quality indicator. The Lancet 374 (9702): 1714-1721. 60 Wallace, J., Lemaire, J., & Ghali, W. (2009). Physician wellness: a missing quality indicator. The Lancet 374 (9702): 1714-1721. 61 Canadian Medical Protective Association. The new realities of medical care. Originally published September 2012. Retrieved January 12, 2014 from https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/the-new-realities-of-medical-care 62 Canadian Medical Association. (2011). Canadian Medical Association Code of Ethics. Ottawa: Author. 63 Mercurio. M. & Peterec, S. (2009). Attending Physician Work Hours: Ethical Considerations and the Last Doctor Standing. Pediatrics 124:758-762. 64 Czeisler, C., Pellegrini, C., & Sade, R. (2013). Should Sleep-Deprived Surgeons Be Prohibited From Operating Without Patients' Consent? Ann Thorac Surg 95:757-766. 65 Canadian Medical Protective Association. The new realities of medical care. Originally published September 2012. Retrieved January 12, 2014 from https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/the-new-realities-of-medical-care
Documents
Less detail

CMA Code of Ethics and Professionalism

https://policybase.cma.ca/en/permalink/policy13937
Date
2018-12-08
Topics
Population health/ health equity/ public health
  3 documents  
Policy Type
Policy document
Date
2018-12-08
Replaces
Code of ethics of the Canadian Medical Association (Update 2004)
Topics
Population health/ health equity/ public health
Text
CMA CODE OF ETHICS AND PROFESSIONALISM Compassion A compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances of each patient and to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient. Honesty An honest physician is forthright, respects the truth, and does their best to seek, preserve, and communicate that truth sensitively and respectfully. Humility A humble physician acknowledges and is cautious not to overstep the limits of their knowledge and skills or the limits of medicine, seeks advice and support from colleagues in challenging circumstances, and recognizes the patient’s knowledge of their own circumstances. Integrity A physician who acts with integrity demonstrates consistency in their intentions and actions and acts in a truthful manner in accordance with professional expectations, even in the face of adversity. Prudence A prudent physician uses clinical and moral reasoning and judgement, considers all relevant knowledge and circumstances, and makes decisions carefully, in good conscience, and with due regard for principles of exemplary medical care. The CMA Code of Ethics and Professionalism articulates the ethical and professional commitments and responsibilities of the medical profession. The Code provides standards of ethical practice to guide physicians in fulfilling their obligation to provide the highest standard of care and to foster patient and public trust in physicians and the profession. The Code is founded on and affirms the core values and commitments of the profession and outlines responsibilities related to contemporary medical practice. In this Code, ethical practice is understood as a process of active inquiry, reflection, and decision-making concerning what a physician’s actions should be and the reasons for these actions. The Code informs ethical decision-making, especially in situations where existing guidelines are insufficient or where values and principles are in tension. The Code is not exhaustive; it is intended to provide standards of ethical practice that can be interpreted and applied in particular situations. The Code and other CMA policies constitute guidelines that provide a common ethical framework for physicians in Canada. In this Code, medical ethics concerns the virtues, values, and principles that should guide the medical profession, while professionalism is the embodiment or enactment of responsibilities arising from those norms through standards, competencies, and behaviours. Together, the virtues and commitments outlined in the Code are fundamental to the ethical practice of medicine. Physicians should aspire to uphold the virtues and commitments in the Code, and they are expected to enact the professional responsibilities outlined in it. Physicians should be aware of the legal and regulatory requirements that govern medical practice in their jurisdictions. Trust is the cornerstone of the patient–physician relationship and of medical professionalism. Trust is therefore central to providing the highest standard of care and to the ethical practice of medicine. Physicians enhance trustworthiness in the profession by striving to uphold the following interdependent virtues: A. VIRTUES EXEMPLIFIED BY THE ETHICAL PHYSICIAN 2 B. FUNDAMENTAL COMMITMENTS OF THE MEDICAL PROFESSION Consider first the well-being of the patient; always act to benefit the patient and promote the good of the patient. Provide appropriate care and management across the care continuum. Take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a risk of harm or if harm has occurred. Recognize the balance of potential benefits and harms associated with any medical act; act to bring about a positive balance of benefits over harms. Commitment to the well-being of the patient Promote the well-being of communities and populations by striving to improve health outcomes and access to care, reduce health inequities and disparities in care, and promote social accountability. Commitment to justice Practise medicine competently, safely, and with integrity; avoid any influence that could undermine your professional integrity. Develop and advance your professional knowledge, skills, and competencies through lifelong learning. Commitment to professional integrity and competence Always treat the patient with dignity and respect the equal and intrinsic worth of all persons. Always respect the autonomy of the patient. Never exploit the patient for personal advantage. Never participate in or support practices that violate basic human rights. Commitment to respect for persons Contribute to the development and innovation in medicine through clinical practice, research, teaching, mentorship, leadership, quality improvement, administration, or advocacy on behalf of the profession or the public. Participate in establishing and maintaining professional standards and engage in processes that support the institutions involved in the regulation of the profession. Cultivate collaborative and respectful relationships with physicians and learners in all areas of medicine and with other colleagues and partners in health care. Commitment to professional excellence Value personal health and wellness and strive to model self-care; take steps to optimize meaningful co-existence of professional and personal life. Value and promote a training and practice culture that supports and responds effectively to colleagues in need and empowers them to seek help to improve their physical, mental, and social well-being. Recognize and act on the understanding that physician health and wellness needs to be addressed at individual and systemic levels, in a model of shared responsibility. Commitment to self-care and peer support Value and foster individual and collective inquiry and reflection to further medical science and to facilitate ethical decision-making. Foster curiosity and exploration to further your personal and professional development and insight; be open to new knowledge, technologies, ways of practising, and learning from others. Commitment to inquiry and reflection 3 C. PROFESSIONAL RESPONSIBILITIES The patient–physician relationship is at the heart of the practice of medicine. It is a relationship of trust that recognizes the inherent vulnerability of the patient even as the patient is an active participant in their own care. The physician owes a duty of loyalty to protect and further the patient’s best interests and goals of care by using the physician’s expertise, knowledge, and prudent clinical judgment. In the context of the patient–physician relationship: 1. Accept the patient without discrimination (such as on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation, or socioeconomic status). This does not abrogate the right of the physician to refuse to accept a patient for legitimate reasons. 2. Having accepted professional responsibility for the patient, continue to provide services until these services are no longer required or wanted, or until another suitable physician has assumed responsibility for the patient, or until after the patient has been given reasonable notice that you intend to terminate the relationship. 3. Act according to your conscience and respect differences of conscience among your colleagues; however, meet your duty of non-abandonment to the patient by always acknowledging and responding to the patient’s medical concerns and requests whatever your moral commitments may be. 4. Inform the patient when your moral commitments may influence your recommendation concerning provision of, or practice of any medical procedure or intervention as it pertains to the patient’s needs or requests. 5. Communicate information accurately and honestly with the patient in a manner that the patient understands and can apply, and confirm the patient’s understanding. 6. Recommend evidence-informed treatment options; recognize that inappropriate use or overuse of treatments or resources can lead to ineffective, and at times harmful, patient care and seek to avoid or mitigate this. 7. Limit treatment of yourself, your immediate family, or anyone with whom you have a similarly close relationship to minor or emergency interventions and only when another physician is not readily available; there should be no fee for such treatment. 8. Provide whatever appropriate assistance you can to any person who needs emergency medical care. 9. Ensure that any research to which you contribute is evaluated both scientifically and ethically and is approved by a research ethics board that adheres to current standards of practice. When involved in research, obtain the informed consent of the research participant and advise prospective participants that they have the right to decline to participate or withdraw from the study at any time, without negatively affecting their ongoing care. 10. Never participate in or condone the practice of torture or any form of cruel, inhuman, or degrading procedure. Physicians and patients Patient-physician relationship 4 11. Empower the patient to make informed decisions regarding their health by communicating with and helping the patient (or, where appropriate, their substitute decision-maker) navigate reasonable therapeutic options to determine the best course of action consistent with their goals of care; communicate with and help the patient assess material risks and benefits before consenting to any treatment or intervention. 12. Respect the decisions of the competent patient to accept or reject any recommended assessment, treatment, or plan of care. 13. Recognize the need to balance the developing competency of minors and the role of families and caregivers in medical decision-making for minors, while respecting a mature minor’s right to consent to treatment and manage their personal health information. 14. Accommodate a patient with cognitive impairments to participate, as much as possible, in decisions that affect them; in such cases, acknowledge and support the positive roles of families and caregivers in medical decision-making and collaborate with them, where authorized by the patient’s substitute decision-maker, in discerning and making decisions about the patient’s goals of care and best interests. 15. Respect the values and intentions of a patient deemed incompetent as they were expressed previously through advance care planning discussions when competent, or via a substitute decision-maker. 16. When the specific intentions of an incompetent patient are unknown and in the absence of a formal mechanism for making treatment decisions, act consistently with the patient’s discernable values and goals of care or, if these are unknown, act in the patient’s best interests. 17. Respect the patient’s reasonable request for a second opinion from a recognized medical expert. Physicians and the practice of medicine Patient privacy and the duty of confidentiality 18. Fulfill your duty of confidentiality to the patient by keeping identifiable patient information confidential; collecting, using, and disclosing only as much health information as necessary to benefit the patient; and sharing information only to benefit the patient and within the patient’s circle of care. Exceptions include situations where the informed consent of the patient has been obtained for disclosure or as provided for by law. 19. Provide the patient or a third party with a copy of their medical record upon the patient’s request, unless there is a compelling reason to believe that information contained in the record will result in substantial harm to the patient or others. 20. Recognize and manage privacy requirements within training and practice environments and quality improvement initiatives, in the context of secondary uses of data for health system management, and when using new technologies in clinical settings. 21. Avoid health care discussions, including in personal, public, or virtual conversations, that could reasonably be seen as revealing confidential or identifying information or as being disrespectful to patients, their families, or caregivers. Medical decision-making is ideally a deliberative process that engages the patient in shared decision-making and is informed by the patient’s experience and values and the physician’s clinical judgment. This deliberation involves discussion with the patient and, with consent, others central to the patient’s care (families, caregivers, other health professionals) to support patient-centred care. In the process of shared decision-making: Decision-making 5 22. Recognize that conflicts of interest may arise as a result of competing roles (such as financial, clinical, research, organizational, administrative, or leadership). 23. Enter into associations, contracts, and agreements that maintain your professional integrity, consistent with evidenceinformed decision-making, and safeguard the interests of the patient or public. 24. Avoid, minimize, or manage and always disclose conflicts of interest that arise, or are perceived to arise, as a result of any professional relationships or transactions in practice, education, and research; avoid using your role as a physician to promote services (except your own) or products to the patient or public for commercial gain outside of your treatment role. 25. Take reasonable steps to ensure that the patient understands the nature and extent of your responsibility to a third party when acting on behalf of a third party. 26. Discuss professional fees for non-insured services with the patient and consider their ability to pay in determining fees. 27. When conducting research, inform potential research participants about anything that may give rise to a conflict of interest, especially the source of funding and any compensation or benefits. 28. Be aware of and promote health and wellness services, and other resources, available to you and colleagues in need. 29. Seek help from colleagues and appropriate medical care from qualified professionals for personal and professional problems that might adversely affect your health and your services to patients. 30. Cultivate training and practice environments that provide physical and psychological safety and encourage help-seeking behaviours. 31. Treat your colleagues with dignity and as persons worthy of respect. Colleagues include all learners, health care partners, and members of the health care team. 32. Engage in respectful communications in all media. 33. Take responsibility for promoting civility, and confronting incivility, within and beyond the profession. Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues. 34. Assume responsibility for your personal actions and behaviours and espouse behaviours that contribute to a positive training and practice culture. 35. Promote and enable formal and informal mentorship and leadership opportunities across all levels of training, practice, and health system delivery. 36. Support interdisciplinary team-based practices; foster team collaboration and a shared accountability for patient care. Physicians and self Physicians and colleagues Managing and minimizing conflicts of interest 6 38. Recognize that social determinants of health, the environment, and other fundamental considerations that extend beyond medical practice and health systems are important factors that affect the health of the patient and of populations. 39. Support the profession’s responsibility to act in matters relating to public and population health, health education, environmental determinants of health, legislation affecting public and population health, and judicial testimony. 40. Support the profession’s responsibility to promote equitable access to health care resources and to promote resource stewardship. 41. Provide opinions consistent with the current and widely accepted views of the profession when interpreting scientific knowledge to the public; clearly indicate when you present an opinion that is contrary to the accepted views of the profession. 42. Contribute, where appropriate, to the development of a more cohesive and integrated health system through interprofessional collaboration and, when possible, collaborative models of care. 43. Commit to collaborative and respectful relationships with Indigenous patients and communities through efforts to understand and implement the recommendations relevant to health care made in the report of the Truth and Reconciliation Commission of Canada. 44. Contribute, individually and in collaboration with others, to improving health care services and delivery to address systemic issues that affect the health of the patient and of populations, with particular attention to disadvantaged, vulnerable, or underserved communities. Approved by the CMA Board of Directors Dec 2018 37. Commit to ensuring the quality of medical services offered to patients and society through the establishment and maintenance of professional standards. Physicians and society
Documents
Less detail

Maintaining Ontario’s leadership on prohibiting the use of sick notes for short medical leaves

https://policybase.cma.ca/en/permalink/policy13934
Date
2018-11-15
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2018-11-15
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) submits this brief to the Standing Committee on Finance and Economic Affairs for consideration as part of its study on Bill 47, Making Ontario Open for Business Act, 2018. The CMA unites physicians on national, pan-Canadian health and medical matters. As the national advocacy organization representing physicians and the medical profession, the CMA engages with provincial/territorial governments on pan-Canadian health and health care priorities. As outlined in this submission, the CMA supports the position of the Ontario Medical Association (OMA) in recommending that Schedule 1 of Bill 47 be amended to strike down the proposed new Section 50(6) of the Employment Standards Act, 2000. This section proposes to reinstate an employer’s ability to require an employee to provide a sick note for short leaves of absence because of personal illness, injury or medical emergency. Ontario is currently a national leader on sick notes In 2018, Ontario became the first jurisdiction in Canada to withdraw the ability of employers to require employees to provide sick notes for short medical leaves because of illnesses such as a cold or flu. This legislative change aligned with the CMA’s policy position1 and was strongly supported by the medical and health policy community. An emerging pan-Canadian concern about the use of sick notes As health systems across Canada continue to grapple with the need to be more efficient, the use of sick notes for short leaves as a human resources tool to manage employee absenteeism has drawn increasing criticism in recent years. In addition to Ontario’s leadership, here are a few recent cases that demonstrate the emerging concern about the use of sick notes for short leaves:
In 2016, proposed legislation to end the practice was tabled in the Manitoba legislature.2
The Newfoundland and Labrador Medical Association and Doctors Nova Scotia have been vocal opponents of sick notes for short leaves, characterizing them as a strain on the health care system.3,4
The University of Alberta and Queen’s University have both formally adopted “no sick note” policies for exams.5,6
The report of Ontario’s Changing Workplaces Review summarized stakeholder comments about sick notes, describing them as “costly, very often result from a telephone consultation and repeat what the physician is told by the patient, and which are of very little value to the employer.”7 Ontario’s action in 2018 to remove the ability of employers to require sick notes, in response to the real challenges posed by this practice, was meaningful and demonstrated leadership in the national context. The requirement to obtain sick notes negatively affects patients and the public By walking back this advancement, Ontario risks reintroducing a needless inefficiency and strain on the health system, health care providers, their patients and families. For patients, having to produce a sick note for an 4 employer following a short illness-related leave could represent an unfair economic impact. Individuals who do not receive paid sick days may face the added burden of covering the cost of obtaining a sick note as well as related transportation fees in addition to losing their daily wage. This scenario illustrates an unfair socioeconomic impact of the proposal to reinstate employers’ ability to require sick notes. In representing the voice of Canada’s doctors, the CMA would be remiss not to mention the need for individuals who are ill to stay home, rest and recover. In addition to adding a physical strain on patients who are ill, the requirement for employees who are ill to get a sick note, may also contribute to the spread of viruses and infection. Allowing employers to require sick notes may also contribute to the spread of illness as employees may choose to forego the personal financial impact, and difficulty to secure an appointment, and simply go to work sick. Reinstating sick notes contradicts the government’s commitment to end hallway medicine It is important to consider these potential negative consequences in the context of the government’s commitment to “end hallway medicine.” If the proposal to reintroduce the ability of employers to require sick notes for short medical leaves is adopted, the government will be introducing an impediment to meeting its core health care commitment. Reinstating sick notes would increase the administrative burden on physicians Finally, as the national organization representing the medical profession in Canada, the CMA is concerned about how this proposal, if implemented, may negatively affect physician health and wellness. The CMA recently released a new baseline survey, CMA National Physician Health Survey: A National Snapshot, that reveals physician health is a growing concern.8 While the survey found that 82% of physicians and residents reported high resilience, a concerning one in four respondents reported experiencing high levels of burnout. How are these findings relevant to the proposed new Section 50(6) of the Employment Standards Act, 2000? Paperwork and administrative burden are routinely found to rank as a key contributor to physician burnout.9 While a certain level of paperwork and administrative responsibility is to be expected, health system and policy decision-makers must avoid introducing an unnecessary burden in our health care system. Conclusion: Remove Section 50(6) from Schedule 1 of Bill 47 The CMA appreciates the opportunity to provide this submission for consideration by the committee in its study of Bill 47. The committee has an important opportunity to respond to the real challenges associated with sick notes for short medical leaves by ensuring that Section 50(6) in Schedule 1 is not implemented as part of Bill 47. 5 1 Canadian Medical Association (CMA). Third-Party Forms (Update 2017). Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD17-02.pdf (accessed 2019 Nov 13). 2 Bill 202. The Employment Standards Code Amendment Act (Sick Notes). Winnipeg: Queen’s Printer for the Province of Manitoba; 2016. Available: https://web2.gov.mb.ca/bills/40-5/pdf/b202.pdf (accessed 2019 Nov 13). 3 CBC News. Sick notes required by employers a strain on system, says NLMA. 2018 May 30. Available: www.cbc.ca/news/canada/newfoundland-labrador/employer-required-sick-notes-unnecessary-says-nlma-1.4682899 4 CBC News. No more sick notes from workers, pleads Doctors Nova Scotia. 2014 Jan 10. Available: www.cbc.ca/news/canada/nova-scotia/no-more-sick-notes-from-workers-pleads-doctors-nova-scotia-1.2491526 (accessed 2019 Nov 13). 5 University of Alberta University Health Centre. Exam deferrals. Edmonton: University of Alberta; 2018. Available: www.ualberta.ca/services/health-centre/exam-deferrals (accessed 2019 Nov 13). 6 Queen’s University Student Wellness Services. Sick notes. Kingston: Queen’s University; 2018. Available: www.queensu.ca/studentwellness/health-services/services-offered/sick-notes (accessed 2019 Nov 13). 7 Ministry of Labour. The Changing Workplaces Review: An Agenda for Workplace Rights. Final Report. Toronto: Ministry of Labour; 2017 May. Available: https://files.ontario.ca/books/mol_changing_workplace_report_eng_2_0.pdf (accessed 2019 Nov 13). 8 Canadian Medical Association (CMA). One in four Canadian physicians report burnout [media release]. Ottawa: The Association; 2018 Oct 10. Available: www.cma.ca/En/Pages/One-in-four-Canadian-physicians-report-burnout-.aspx (accessed 2019 Nov 13). 9 Leslie C. The burden of paperwork. Med Post 2018 Apr.
Documents
Less detail

Needs of retired physicians

https://policybase.cma.ca/en/permalink/policy135
Last Reviewed
2017-03-04
Date
2003-08-20
Topics
Health human resources
Resolution
GC03-37
That Canadian Medical Association, in collaboration with the divisions, address specific needs of retired physicians in the Canadian Medical Association's physician health and well-being program.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2003-08-20
Topics
Health human resources
Resolution
GC03-37
That Canadian Medical Association, in collaboration with the divisions, address specific needs of retired physicians in the Canadian Medical Association's physician health and well-being program.
Text
That Canadian Medical Association, in collaboration with the divisions, address specific needs of retired physicians in the Canadian Medical Association's physician health and well-being program.
Less detail