Thank you Madam Chair and Committee members for the opportunity to speak to you today. I am Briane Scharfstein, Associate Secretary General at the Canadian Medical Association (CMA) and a family physician by training. I am speaking on behalf of the CMA and our 67,000 physician members across the country.
We commend the Senate for striking this Committee. We are concerned that the aging population has not received sufficient national policy attention. With regard to today's discussion I would note that the CMA has advocated for the elimination of mandatory retirement and we are pleased to see that in general, provincial jurisdictions have eliminated mandatory retirement based on what has become an arbitrary age cutoff. With some obvious exceptions, such as athletics, competence is not related to age per se for most areas of human endeavour. Where human activity may pose risk to the safety of others we believe that the best approach is to develop evidence-based tools and procedures that can be used to assess competence on an ongoing basis.
While physicians play a significant role on a variety of fronts related to aging, I am going to focus my remarks on two specific areas:
* Ensuring the competence of physicians; and
* Fitness to operate motor vehicles and the role of physicians.
Turning first to the competence of the medical workforce, physicians are making diagnoses and performing procedures on a daily basis, both of which may entail a significant amount of risk for our patients. I would add that this is being done in an era where medical knowledge is rapidly increasing.
As a profession that continues to enjoy a high degree of delegated self-regulation, we recognize the importance of ensuring that physicians are and remain competent across the medical career lifecycle. This entails both an individual and collective obligation to:
* engage in lifelong learning;
* recognize and report issues of competence in one's self and one's peers; and
* participate in peer review processes to assure ongoing competence.
First and foremost, physicians have an individual ethical and professional obligation to maintain their competence throughout their career lifecycle. The CMA Code of Ethics calls on physicians to:
* practise the art and science of medicine competently, with integrity and without impairment;
* engage in lifelong learning to maintain and improve professional knowledge skills and attitudes;
* report to the appropriate authority any unprofessional conduct by colleagues; and
* be willing to participate in peer review of other physicians and to undergo review by your peers1
I would stress the importance of peer review in medicine, which is one of the defining characteristics of a self-regulating profession. Simply put, physicians are expected to hold themselves and their colleagues accountable for their behaviour and for the outcomes they achieve on behalf of their patients.2
The individual accountability that physicians have to themselves and to each other is reinforced by a collective accountability for lifelong learning and peer review that is mandated by the national credentialing bodies and by the province/territorial licensing bodies.
With regard to lifelong learning, both national credentialing bodies require evidence of ongoing continuing professional development as a condition of maintaining credentials. The College of Family Physicians of Canada operates a Maintenance of Proficiency program that requires its certificants to earn 250 credits over five years.3 The Royal College of Physicians and Surgeons of Canada operates a Maintenance of Certification Program that requires its Fellows to achieve 400 credits over a five year period with a minimum 40 in any single year.4
The Canadian Medical Protective Association, the mutual defence organization that provides liability coverage for the vast majority of physicians in Canada also plays a role in identifying high risk areas of medical practice and providing a range of educational materials and programs designed to mitigate such risk.5
Each province and territory has a licensing body - usually known as a College of Physicians and Surgeons that is established to protect the public interest. These colleges operate mandatory peer review programs that ensure that physician's practices are reviewed at regular intervals. These programs typically involve a review of the physician's practice profile based on administrative data, a visit to the physician's office by a medical colleague in a similar type of practice and an audit of a sample of patient charts, followed by a report with recommendations.
In addition, most jurisdictions now have or will soon have in place a program pioneered in Alberta that provides a 360o assessment by administering questionnaires to a sample of a physician's patients, colleagues, and co-worker health professionals. These probe several aspects of competence and reports are provided back to the physician.6
Peer review is even more rigorous in the health care institutions where physicians carry out practices and procedures that involve the greatest potential risk to patients. Physicians are initially required to apply for hospital privileges that are reviewed annually by a credentials committee. These committees have the authority to renew, modify or cancel a physician's privileges. In between annual reviews a physician's day-to-day performance is subject to review by a variety of quality assurance processes and audit/review committees such as morbidity and mortality. Health care institutions in turn are subject to regular scrutiny by the Canadian Council on Health Services Accreditation which would include the oversight of physician practice among its review parameters.
In summary, the medical profession subscribes to the notion that competence is something that must regularly be reviewed and enhanced across the medical career life cycle, and that such reviews and assessments must be grounded in evidence that is gathered from peers and other validated tools.
Turning to our patients, one area that our members are regularly called on to assess competence is the determination of medical fitness to operate motor vehicles. To assist physicians in carrying out this societal responsibility, the CMA recently released our 7th edition of the Driver's Guide.7 What you will note about this 134 page guide is that the section on aging is only 3 pages long. The focus of the guide is on how substances such as alcohol and medications and a range of disease conditions such as cardiovascular and cerebrovascular disease may impose risks on fitness to operate a range of motor vehicles including automobiles, off-road vehicles, planes and trains. It provides graduated guidelines that relate to the severity and stage of the condition. As is noted in the section on aging, while the guide acknowledges the greater prevalence of health conditions in older age groups and hence the higher crash rates among the 65 and over age group, it states that the high crash rates in older people cannot be explained by age-related changes alone. In fact, by avoiding unnecessary risk and possessing the most experience, healthy senior drivers are among the safest drivers on the road. Rather, it is the presence and accumulation of health-related impairments that affect driving that is the major cause of crashes for older people. Because older age per se does not lead to higher crash rates, age-based restrictions on driving are not supportable.
Rather than focusing on arbitrary age cutoffs what are required are evidence-based tools such as the Driver's Guide that can be used to detect and assess conditions that may present at any point in the life cycle.
I would like to return to the physician workforce and the practical implications of arbitrary age cutoffs. As you may know Canada is experiencing a growing shortage of physicians - the effects of which are about to be compounded as the first of the baby boomers turn 65 in 2011. Currently we rank 24th out of the 30 OECD countries in terms of physician supply per 1,000 population - our level of 2.2 physicians per 1,000 is one third below the OECD average of 3.0.
As of January 2008, according to the CMA physician Master File there are just over 8,200 licensed physicians in Canada who are aged 65 or older. They represent more than 1 in 10 (13%) of all licensed physicians. Moreover, they are very active; they work on average more than 40 hours per week and in addition more than 40% of them still have on-call responsibilities each month. These doctors make vital contributions to our health care system.
In conclusion, the CMA believes that the public interest is best served by ensuring that all competent physicians, regardless of age, are able to practice medicine. Artificial barriers to practice based on age are simply discriminatory and counter productive in an era of health human resource shortages.
Finally Madam Chair, we hope that the CMA will be invited back to appear before your committee. We have long been concerned with the access of the senior population to health care services and I will leave you with a copy of our policy on principles of medical care of older persons.8 We also hope you will examine the issue of long-term care which has had little if any national policy attention. I will also leave you with a copy of our recent technical background report on pre-funding of long-term care that we tabled at the Federal Minister of Finance's Roundtable in November 2007.9
Thank you again for this opportunity and I would be pleased to answer any questions.
1 Canadian Medical Association. CMA Code of ethics.(Update 2004). http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed 01/23/08.
2 Canadian Medical Association. Medical professionalism (Update 2005). http://policybase.cma.ca/dbtw-wpd/Policypdf/PD06-02.pdf. Accessed 01/23/08.
3 College of Family Physicians of Canada. Mainpro(r)Maintenance of Proficiency. http://www.cfpc.ca/English/cfpc/cme/mainpro/maintenance%20of%20proficiency/default.asp?s=1. Accessed 01/23/08.
4 Royal College of Physicians and Surgeons of Canada. Maintenance of Certification Program. http://rcpsc.medical.org/opd/moc-program/index.php. accessed 01/23/08.
5 Canadian Medical Protective Association. Risk management @ a glance. http://www.cmpa-acpm.ca/cmpapd03/pub_index.cfm?FILE=MLRISK_MAIN&LANG=E. Accessed 01/23/08.
6 College of Physicians and Surgeons of Alberta. Physician Achievement Review Program. http://www.cpsa.ab.ca/collegeprograms/par_program.asp. Accessed 01/23/08.
7Canadian Medical Association. Determining medical fitness to operate motor vehicles. CMA Driver's Guide 7th edition.Ottawa, 2006.
8 Canadian Medical Association. Principles for medical care of older persons. http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD00-03.pdf. Accessed 01/23/08.
9 Canadian Medical Association. Pre-funding long-term care in Canada: technical backgrounder. Presentation to the Federal Minister of Finance's roundtable, Oshawa, ON, November 23, 2007.
Medical professionalism (Update 2005)
The environment in which medicine is practised in Canada is undergoing rapid and profound change. There are now continued opportunities for the medical profession to provide leadership for our patients, our communities and our colleagues through strengthened professionalism. The Canadian Medical Association (CMA) is strongly committed to medical professionalism and has developed this policy both to inform physicians and others about its meaning and value and to promote its preservation and enhancement. This document outlines the major features of medical professionalism, the opportunities which exist in this area and the challenges which lie before us.
Why Medical Professionalism?
The medical profession is characterized by a strong commitment to the well-being of patients, high standards of ethical conduct, mastery of an ever-expanding body of knowledge and skills, and a high level of clinical independence. As individuals, physicians' personal values may vary, but as members of the medical profession they are expected to share and uphold those values that characterize the practice of medicine and the care of patients.
Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit. Three major features of medical professionalism - the ethic of care, clinical independence and self-regulation - benefit physicians, their patients and society:
Ethic of care: This is characterized by the values of compassion, beneficence, nonmaleficence, respect for persons and justice (CMA's Code of Ethics). Society benefits from the ethic of care whereby, in the provision of medical services, physicians put the interests of others ahead of their own. Dedication and commitment to the well-being of others is clearly in the interests of patients, who are the primary beneficiaries.
Clinical independence: Medicine is a highly complex art and science. Through lengthy training and experience, physicians become medical experts and healers. Whereas patients have the right to decide to a large extent which medical interventions they will undergo, they expect their physicians to be free to make clinically appropriate recommendations. Although physicians recognize that they are accountable to patients, funding agencies and their peers for their recommendations, unreasonable restraints on clinical autonomy imposed by governments and administrators, whether public or private, are not in the best interests of patients, not least because they can damage the trust that is an essential component of the patient-physician relationship. Conversely, physicians are not morally obliged to provide inappropriate medical services when requested by patients despite their respect for patient autonomy.
Self-regulation: Physicians have traditionally been granted this privilege by society. It includes the control of entrance into the profession by establishing educational standards and setting examinations, the licensing of physicians, and the establishment and ongoing review of standards of medical practice. In return for this privilege, physicians are expected to hold each other accountable for their behaviour and for the outcomes they achieve on behalf of their patients. Self-regulation is exercised by many different professional organizations, from medical practice partnerships to the statutory provincial/territorial licensing bodies. It has evolved into a partnership with the public. Self-regulation benefits society by taking the best advantage of the professional expertise needed to appropriately set and maintain standards of training and practice, while providing suitable accountability in matters of professional behaviour. The profession's commitment to the maintenance of those standards is demonstrated by its willingness to participate in outcomes review at many levels, from institutional quality assurance activities to formal prospective peer review, and to actively support their statutory and legislated licensing authorities.
Opportunities in Medical Professionalism
Over the past few years much has been written about the issue of medical professionalism in both the lay and scientific media. The practice of medicine has changed considerably, and with these changes have come challenges but also opportunities. The medical profession continues to be a greatly respected one, and it is still generally seen as being distinct from many others because of the unique nature of the physician-patient relationship. There exists now an opportunity to reinforce the professional values and priorities that have sustained medicine for so long, and to embrace new approaches which will serve it well in the years to come.
Medical professionals must recognize that patients have a wide variety of resources available for their health care needs, from traditional physician services to paramedical practitioners, to complementary medicine and to information obtained from the internet. While maintaining responsibility for care of the patient as a whole, physicians must be able to interact constructively with other health care providers within an interdisciplinary team setting, and must be able to interpret information for patients and direct them to appropriate and accurate resources.
The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality.
Although there are some challenges to professionalism, as outlined below, the greatest opportunity before us may be to remind physicians of the reasons they chose a career in medicine to begin with - for many, it is a calling rather than a job. In spite of the numerous recent changes in the health care system and the practice of medicine, the primary reason most physicians entered the field remains the same - the sanctity of the fiduciary relationship between physicians and their patients. The renewal of medical professionalism must be led from within the profession itself, and the CMA and its members are in a unique position to take advantage of the many opportunities which exist and to respond to the challenges we face.
Challenges to Medical Professionalism
Medical professionalism is being challenged from within and without. These challenges arise from pressures that may serve to undermine the ethic of care, clinical independence and self-regulation and may result, for individual physicians and the medical profession, in diminished morale and changes in lifestyle and practice patterns. These changes may have a detrimental impact on the health of physicians, and also on the quality of patient care.
Resource restraints: The CMA has identified scarcity of resources, whether human or material, as undermining the ability of physicians to maintain excellence in clinical care, research and teaching. Although much attention has been paid recently to the insufficient number of physicians in Canada, and although recent developments indicate some limited cause for optimism, much work remains to be done. Issues of access to continuing professional development, workforce sustainability, inadequate numbers of training positions for new doctors, the integration of foreign-trained physicians into the workforce and the apparent inability of governments to resolve inadequacies in health care funding continue to frustrate physicians' attempts to achieve their professional goals and care for their patients. These factors all have the potential for contributing to the decline of professional morale.
Bureaucratic challenges: This refers to the introduction of layers of management and policy directives between the physician and the patient. It is a result of changes that have taken place in the organization and delivery of medical care, especially the involvement of governments in all aspects of health care. The traditional one-on-one relationship of physician and patient is now set within a context of government and corporate interests, in which the physician may sometimes assume the status of an employee, that pose considerable challenges to the exercise of the professional values of clinical autonomy and self-regulation. Moreover, while the responsibility for organizing the delivery of scarce resources has been increasingly transferred from physicians to managers, physicians are still ultimately responsible, both morally and legally, for providing quality care. Although the increasing complexity of health care delivery requires recourse to sophisticated management systems, there is a danger that as physicians become increasingly answerable to or constrained by third parties, their ability to fulfill their commitment to their individual patients can be seriously compromised.
Unprofessional conduct: Some physicians do not uphold the values of the profession. A few put their interests or the interests of third parties ahead of the interests of their patients. The profession needs to meet this challenge by demonstrating its ability to uphold its values and its commitment to doing so. Supporting strong and transparent self-regulatory systems will be a key component of this endeavor.
Commercialism: In recent years the market mentality has expanded its influence to many areas formerly outside its domain, including governments, universities and the professions. Health care has become a major industry, one in which physicians play a central role, and commercial interests, whether private or public, may pressure physicians to compromise their responsibilities to their patients, research subjects and society. The potential for physicians and medical associations to become drawn into conflict-of-interest situations is increasing. Commercialism may compromise both the ethic of care and clinical independence by its reinterpretation of medical care as a commodity and the patient-physician relationship as something less than a fiduciary relationship. There is an inherent opportunity for the profession to address the issue of conflict of interest and to re-affirm its primary obligation and dedication to the patients it cares for.
Consumerism: Physicians strongly support the right of patients to make informed decisions about their medical care. However, the CMA's Code of Ethics requires physicians to recommend only those diagnostic and therapeutic procedures that they consider to be beneficial to the patient or to others. There is a proliferation of health information and advertising in the popular media and on the Internet that may be inaccurate or poorly understood. Taken to its extreme, consumerism can be detrimental not just to professionalism but to the well-being of patients and the interests of society.
Industrialization: This refers to the increased division and specialization of labour in the delivery of health care, whereby the delivery of health care may become fragmented. There is increasing pressure within medicine to improve efficiency and optimize cost savings. While these may be important goals in the broader context of health care, we must ensure that they do not impact negatively on the doctor-patient relationship.
Realizing Opportunities and Dealing with Challenges
Individual physicians should protect, enhance and promote professionalism in medicine by reflecting the values of the medical profession in their practice and by contributing to the efforts of organized medicine to maintain and enhance the ethic of care, clinical autonomy and self-regulation. These efforts require action in 3 areas: policy, education and self-regulation.
Policy: All those involved in health care - physicians, patients, other health care providers, administrators, governments and the general public (as taxpayers, potential patients, relatives of patients, etc.) - should be informed about the values of the medical profession and where it stands on issue related to accountability, clinical autonomy and self-regulation. Policies of medical associations should reflect these values and should speak clearly on topics such as conflict of interest. Policies should be reviewed frequently and updated when necessary, in order to take account of the rapidly changing environment in which medicine is practiced. The topic of professionalism should be granted increasing importance in policy discussions. Policies should be developed and updated in related areas, such as conflict of interest and physician-industry interactions.
In order to be consistent and trustworthy, medical associations should adhere to the same high standards of behaviour that they require of individual physicians. The challenges posed by resource restraints, bureaucratization, unprofessional conduct, commercialism and consumerism are no less serious for associations than for individuals and require sound harmonized policies for both. The CMA has an opportunity for leadership in this regard.
Education: However professional values and policies are established, they must be transmitted to current and future members of the profession in order to have any effect.
Like most other aspects of medical education, the values of professionalism are both taught and modeled. Professionalism should be an essential component of the formal medical curriculum at the undergraduate and postgraduate training levels. Moreover, active demonstration of professionalism such as role modeling by physicians, and in the internal culture of the medical schools and hospitals where students receive their training, should be used to advantage and challenged when necessary. Likewise for physicians in practice, formal continuing professional development programs and role modeling by other physicians are important for the maintenance of professionalism.
Physicians need to communicate and test their understanding of their professional role with others involved in patient care at numerous levels. Such initiatives, which would engage patients, other professionals and policy-makers, require further development.
The CMA and other medical organizations have taken leadership roles in assisting patients and health care providers in making informed decisions by creating numerous continuing professional development opportunities and readily available clinical information for physicians, effective patient education materials, self-help books and validated Web sites, including www.cma.ca. These efforts need to continue and be strengthened.
Self-regulation: In order to maintain self-regulation in an environment that is increasingly suspicious of such privileges, the medical profession has to demonstrate that self regulation benefits society in general. This requires, among other things, that the medical profession continue to demonstrate its commitment to the tasks required by self-regulation, including setting and enforcing high standards of behaviour for both individual physicians and medical associations.
Physicians continue to value medical professionalism highly. They believe that it benefits patients greatly and that it should be preserved and enhanced. Professionalism will continue to be based on the relationship of trust between patients and physicians, and the primacy of the physician-patient relationship. It encompasses the values of compassion, beneficence, nonmaleficence, respect for persons and justice. As professionals, physicians will strive to maintain high standards of ethics, clinical practice and education and demonstrate a capacity for social responsibility through self-regulation and accountability (see CMA Policy Statement The Future of Medicine).
The CMA welcomes opportunities to engage in dialogue with others as to how professionalism in health care can be preserved and enhanced for the benefit of patients, physicians and society in general.