Skip header and navigation

11 records – page 1 of 2.

Clinical care for physician administrators/executives

https://policybase.cma.ca/en/permalink/policy13701
Date
2017-08-23
Topics
Physician practice/ compensation/ forms
Health human resources
Resolution
GC17-15
The Canadian Medical Association recognizes the importance of continued involvement in the provision of clinical care for physician administrators/executives, and encourages organizations employing these physicians to provide clinical practice opportunities.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Physician practice/ compensation/ forms
Health human resources
Resolution
GC17-15
The Canadian Medical Association recognizes the importance of continued involvement in the provision of clinical care for physician administrators/executives, and encourages organizations employing these physicians to provide clinical practice opportunities.
Text
The Canadian Medical Association recognizes the importance of continued involvement in the provision of clinical care for physician administrators/executives, and encourages organizations employing these physicians to provide clinical practice opportunities.
Less detail

Physician health

https://policybase.cma.ca/en/permalink/policy13739
Date
2017-10-21
Topics
Health human resources
Ethics and medical professionalism
  3 documents  
Policy Type
Policy document
Date
2017-10-21
Replaces
PD98-04 Physician health and well-being
Topics
Health human resources
Ethics and medical professionalism
Text
The term physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of interconnected physical, mental and social factors to support health and wellness.1 Attributable to a range of personal, occupational and system-level factors, physicians and learners alike are increasingly voicing distress and calling for resources and support. As a central issue for Canadian physicians, and a growing concern within the medical profession, physician ill-health is being increasingly understood as a set of risk-management practices,2 including the use of strategies rooted in organizational psychology and occupational medicine, as well as intensified oversight by professional bodies, and the integration of maintaining personal health as a core medical competency.3 Physician health, is important to the long-term sustainability of the physician workforce and health systems.4 As a quality indicator5-6 addressing the complex array of related issues is a shared responsibility of individual physicians and the systems in which they work.2,4,5 This involves efforts from individuals as well as system-level influencers, such as stakeholder groups from areas including academic medicine, medical education, practice environments, accrediting and regulatory bodies, provincial and territorial medical associations, regional and local health authorities, national medical associations and their affiliates, governments and other decision-making bodies. Meaningful, system-wide change can only occur via deliberate and concerted efforts on a national scale5 to address personal, workplace, and cultural barriers and normalize the promotion of opportunities and conditions for optimizing health and wellness. Although considerable progress has been made, it is necessary to continue working towards a more coordinated and sustained system of health promotion, illness prevention and tertiary care to build on these successes.4-5 This policy aims to provide broad, aspirational recommendations to help guide stakeholders at all levels of the health system to promote a healthy, vibrant, and engaged profession - including a healthy practice and training culture, and work environment. RECOMMENDATIONS Individual level The CMA recommends that physicians and learners: * demonstrate a commitment to physician health and well-being as part of their responsibilities under the CanMEDS Professional Role, including: Exhibiting self-awareness and managing influences on personal well-being (e.g., self-regulation and assessment, mindfulness, resilience); managing personal and professional demands for a sustainable practice throughout the career life cycle; and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need;3 * actively engage in fostering supportive work and training environments; * assume responsibility for individual actions and behaviours that may contribute to negative culture and stigma;5 * foster relationships with family and friends, as well as interests outside of medicine, and ensure sufficient rest (including time-off); and * have a family physician and visit him or her regularly for comprehensive and objective care. System level The CMA recommends that: * national-level advocacy be undertaken to address issues related to physician and learner health; * efforts to address physician health incorporate individually targeted initiatives and optimize learning and practice environments, including cultivating a healthy culture,6-7 and that stakeholders collaborate (including input from physicians and learners) to develop and promote initiatives that strengthen physician health at both the individual and system levels; * health systems adopt an understanding of their obligation to the health of physicians that is similar to the obligation of other Canadian employers to their workers (e.g., psychological safety, work hours, employee resources, standards and expectations); * policies aiming to cultivate a healthy culture be modelled, and behaviours not conducive to supporting and enabling a healthy culture dealt with in an effective manner; * physician and health system leaders acknowledge and demonstrate that physician health is a priority, and continually assess whether actions and policies align with desired values and culture;4 * physician and health system leaders be better equipped to identify and address behaviours that are symptomatic of distress (e.g., psychological) and receive more comprehensive training to address with colleagues, including within teams; * mechanisms and opportunities for physicians and learners to access existing services and programs (e.g., provincial, institutional) are maximized, and that these resources are regularly promoted and barriers to access addressed in a timely manner;5,8 * standards, processes and strategies be developed to address occupational barriers to positive health8 (at a minimum, these should address the meaningful integration of occupational and personal life, provision of resources to enhance self-care skills,4 and prioritization of opportunities for adequate rest, exercise, healthy diet and leisure;8 * wellness (including enhancement of meaning, enjoyment and engagement) be promoted, instead of an exclusive focus on reduction of harm;5 * physicians and learners be encouraged to have a family physician, and that barriers to access such care be identified and addressed; * physicians, particularly those providing primary care to other physicians, have access to training in treating physician colleagues; * physicians and learners be given reasonable access to confidential assistance in dealing with personal and professional difficulties, provided in a climate free of stigmatization; * programs and services be accessible to physicians and learners at every stage of their diagnosis and treatment, and that seeking treatment should not feel punitive or result in punitive consequences; * physicians and learners have supportive learning and work environments free of discrimination, and for processes which provide reasonable accommodations to physicians and learners with existing disabilities, while allowing for safe patient care, to be bolstered; and * practices which enable safe and effective patient care, and support workflow and efficient capture of information (e.g., electronic medical records), do not create excessive work and time burdens on physicians. Physician organizations, professional associations and health authorities The CMA recommends that: * all physicians and learners have access to a robust and effective provincial physician health program (PHP), and for long-term, sustained efforts to be made to maintain and enhance physician health, including a commitment to resourcing PHPs5 via the provision of stable funding through provincial and territorial medical associations, or the negotiation of such funding from provincial governments; * training programs, hospitals, and other workplaces ensure appropriate programs, services, and policies are developed, in-place, and enforced for physicians and learners to get help to manage health and behavioural issues, support the need for treatment, and facilitate return to work or training while protecting individual confidentiality, privacy, as well helping the institution manage risk; * the range of continuing medical education offerings aimed at personal health be expanded (content should develop individual skills and extend to training for leaders and administrators that targets improved training and practice environments and culture); * continuing education credits for physicians' efforts to enhance their personal wellness or that of colleagues be established and promoted, free of conditions requiring links to patient care; * emerging champions from learner and early-career segments be identified and supported; and * the unique health and wellness challenges faced by physicians and learners in rural, remote, or otherwise under-serviced regions (including the Canadian territories) be recognized, and for access to services and other resources to be enhanced. Medical schools, residency training programs, and accreditation bodies The CMA calls for: * accreditation standards for health and wellness programs and initiatives for medical faculties and training programs, and health authorities to be raised, reviewed in an ongoing manner and that standards and competencies be enforced; * action to bring meaningful change to the 'hidden curriculum' by aligning formal and 'hidden' curriculums that promote and reinforce positive conduct, and for accreditation bodies to consider this in their review and enforcement of standards for training programs; and * formal health and wellness curricula to be integrated and prioritized at the undergraduate and postgraduate levels, including but not limited to training around how to recognize and respond to distress or illness in oneself and colleagues, as well as self-management strategies (e.g., resilience and mindfulness). Medical regulatory authorities The CMA calls for medical regulatory authorities to: * work with provincial and territorial medical associations, PHPs, governments and other key stakeholders to; (a) create a regulatory environment that protects the public (their explicit duty) while limiting barriers for physicians seeking diagnosis and treatment,5 and (b) promote resources for early self-identification of potential health issues; and * while maintaining their duty to protect the public, review their approach to mental health challenges to ensure that focus is placed on the existence of impairment (illness interferes with ability to engage safely in professional activities,9 and not the mere presence of a diagnostic label or act of seeking of care5 (in order to ensure that physicians and learners who are appropriately caring for their health not be impacted in their ability to work). Governments The CMA calls for: * governments to acknowledge the adverse impact their policies and processes can have on the health of physicians, and to adopt and enforce health and wellness standards through a lens of occupational health for physicians that are similar to those afforded to other Canadian workers; * governments to work with employers and key stakeholders to create more effective systems that provide better practice and training conditions;5 and * enhanced support for provincial PHPs, institutions (e.g., medical schools, training programs), and other providers of physician health services.5 Researchers The CMA recommends that: * national and regional data for major health and wellness indicators be assessed at regular intervals to establish and compare norms and to better target and assess initiatives; * a national research strategy be developed through collaboration among relevant stakeholders to identify priorities, coordinate efforts, and promote innovation (consider the specific recommendations from a 2016 research summit to improve wellness and reduce burnout,10 including: Estimating economic impacts; using common metrics; developing a comprehensive framework for interventions with individual and organizational components; and sharing the best available evidence); and * further research in a range of areas including, but not limited to: efficacy of programs, strategies, and systems for promoting and managing health and wellness; examination of the factors exerting the greatest influence on physician health; and system-level interventions.5 Approved by the CMA Board of Directors October 2017 See also Background to CMA Policy on Physician Health REFERENCES 1 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 2 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 3 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 4 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-6. Available: https://doi.org/10.1016/j.mayocp.2016.10.004 (accessed 2017 Oct 30). 5 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. Available: https://doi.org/10.1016/S0140-6736(09)61424-0 (accessed 2017 Oct 30). 7 Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205. Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 8 Ruotsalainen JH, Verbeek JH, Mariné A, Serra C, Ruotsalainen JH, Verbeek JH, et al. Preventing occupational stress in healthcare workers. Sao Paulo Medical Journal 2016;134:92-92. Available: https://doi.org/10.1590/1516-3180.20161341T1 (accessed 2017 Oct 30). 9 Rondinelli RD, Genovese E, Brigham CR, American Medical Association (AMA). Guides to the evaluation of permanent impairment. Chicago: AMA; 2008. Available: https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1160002 (accessed 2017 Oct 30). 10 Dyrbye LN, Trockel M, Frank E, Olson K, Linzer M, Lemaire J, et al. Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Ann Intern Med 2017;166:743-4. Available: https://doi.org/10.7326/M16-2956 (accessed 2017 Oct 30). BACKGROUND TO CMA POLICY PHYSICIAN HEALTH See also CMA Policy on Physician Health In recent decades there has been growing recognition of the impact of physician health on systemic outcomes and patient-care.1,2 Physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of of interconnected physical, mental and social factors to support health and wellness.3 It is also being increasingly understood as a set of risk-management practices aimed at shifting perceptions of health from being an individual (private) matter to more of a shared resource.4 In Canada evidence for this includes the use of strategies adapted from organizational psychology and occupational medicine to change physician behaviour, as well as intensified oversight by professional bodies, and the inclusion of maintaining personal health as a core competency for physicians.4,5 Despite concerted efforts to promote and protect the health and wellness of physicians, the collective state of physician health remains a significant threat to the viability of Canada's health system.1 Physician distress is emerging as an important quality indicator in medical practice,4,6 and both individual- and system-level factors are well-established contributors to compromised physician health.2,7 As such, the advancement of a model of shared responsibility - targeting the relative roles of individual physicians and system-level influencers8 - represents a robust response to this reality. 1. The state of learner and physician health Poor health may develop before or during training and persist into medical practice. Medical school and residency training are particularly challenging times, when a myriad of competing personal and professional demands threaten learner health. In Canada, it has been reported that most students suffer from at least one form of distress over the course of their training9,10 and recent national data point to higher rates compared to their age and education-matched peers. With respect to burnout, characterized by a high level of emotional exhaustion and/or high level of depersonalization (at least weekly), overall rates are reportedly 37%.11,12 Similarly higher levels of depression, anxiety and burnout are reported among American medical students than in the general population.13 While both residents and physicians are reported to be physically healthier than the general population, their mental and social health are cause for concern.1,14 Compared with the general population, physicians are at a higher risk of experiencing adverse outcomes such as depression and burnout15,16 - the latter of which is nearly twice as common among physicians compared with workers in other fields, even after adjusting for age, sex, education level, relationship status, and work hours.17 Results from the 2017 CMA National Physician Health Survey18 showed that 49% of residents and 33% of physicians screened positive for depression, and high burnout rates were reported in 38% of residents 29% of physicians. Furthermore, although the mental health, addiction and substance-use problems, including alcohol, among physicians are not dissimilar to those in the general population, the abuse of prescription drugs (e.g., opioids) is reportedly higher.1,19 Although most physicians referred to monitoring programs have been diagnosed with substance use disorders, an increasing number are being referred for recurrent mood disorders, often stemming from workplace concerns.20,21 1.1 Contributing factors Adverse health outcomes among learners and physicians are linked to a range of contributing factors, including intrinsic ones (e.g., personality characteristics22 and other personal vulnerabilities) and extrinsic ones (e.g., excessive workloads, excessive standards of training and practice, excessive duty hours, lack of autonomy, disruptive behaviour, poor work-life integration, increasing demands with diminishing resources, systemic failures, financial issues, and the practice and training environment).2,15,23 Moreover, the management of risk that many physicians are involved with as it relates to the treatment and management of their patients can be challenging and impacts their health4. A dearth of recent data on the health status of physicians in Canada represents a critical gap in knowledge and limits future efforts to refine, select and assess initiatives. 2. Consequences 2.1. Impact on learners and physicians Compromised physician health can result in decreased personal and professional satisfaction, dysfunctional personal and professional relationships, increased attrition and increased rates of suicide and suicidal ideation.6,24,25 Perhaps most troubling, completed suicide rates among physicians are 1.4-2.3 times higher than in the general population - between 300 and 400 physicians annually in the United States.26 In Canada, suicidal ideation among physicians (including residents) has been recently reported at 19% (lifetime) and 9% (in the last year)18, while Canadian medical student data report 14% (lifetime) and 6% (in the last year).11 Overall, ideation rates are higher among both physicians and learners than in the general population.27 2.2. Impact on patient care The impact of the mental and physical health of physicians extends to the quality of care provided to patients.16,28,29 For instance, physicians suffering from burnout are reportedly two to three times more likely to report their conduct with their patients as sub-optimal.24 Indeed, physicians remain a primary source of health information for patients, and they act as both role models and health advocates.15 Characteristics of burnout (e.g., poor communication and reduced empathy) run counter to the core principles of patient-centred care,30 and physicians who maintain healthy lifestyles are more likely to focus on preventive strategies with their patients.31,32 Although deficits in physician health can negatively affect patient care, it is notable that evidence linking the health of physicians to medical errors is incomplete, if not difficult to establish. Nevertheless, studies have reported a relationship between medical error and specific adverse outcomes such as burnout.17,33 2.3 Impact on health system Issues that are associated with compromised physician health, such as reduced productivity, increased turnover, absenteeism and the likelihood of early retirement,25,34 contribute to the strained state of the health system. Given that physicians represent a significant proportion of the Canadian medical workforce, more attention must be paid to physician health if the health system is to be sustainable.2 Encouragingly, studies have shown that resources and services such as workplace wellness programs produce investment returns,35,36 such as decreases in medical leave and absenteeism2,36,37 Implementing strategies from occupational medicine are also being increasingly employed to ensure patient safety when doctors return to work after illness.4 This contributes to helping balance the need of institutions and medical regulatory agencies to minimize the risk while maximizing quality of patient care, with the desire of individual physicians to help their patients while leading healthy, fulfilling lives.4 Although there are moral grounds for addressing physician and learner ill-health, an economic case can also be made to support and guide initial and ongoing investment to address the problem.7,18 In navigating the many external challenges facing the Canadian the health system, it is critical that system-level leaders not neglect internal threats, including physician distress and dissatisfaction6,7, and challenges in navigating complex work environments.24 To this end, although there are many positive and supportive elements within medical culture, it is also important to acknowledge aspects that contribute to poor health. 2.4 Impact on the culture of medical practice and training and on the workplace Enduring norms within the culture of medicine are directly contributing to the deterioration of the health of Canadian learners and physicians.2 Culturally rooted impediments, such as the reluctance to share personal issues or admit vulnerability, discourage the medical profession from acknowledging, identifying and addressing physician health issues.7 Physicians and learners alike face pressure not to be ill, to care for patients regardless of their personal health and even to attempt to control their own illness and treatment by self-medicating.1,38 Indeed, physicians are often portrayed as being invincible professionals who put patient needs above all else, including their own needs.39,40 Although the CMA Code of Ethics encourages physicians to seek help from colleagues and qualified professionals when personal or workplace challenges compromise patient care41 physicians tend to delay or avoid seeking treatment, especially for psychosocial or psychiatric concerns. Moreover, nearly 33% of Canadian physicians are not registered with a family physician.42 which means they are among the lowest users of health services.43 Providing care to physician colleagues is both complex and challenging, yet this is an area where formal training has not been explicitly or systematically provided on a national scale.1 There is a need to identify physicians willing to treat colleagues, to develop or adapt existing approaches that encourage help-seeking and to help physicians to navigate the treatment of colleagues. Stigma around mental health within medical practice and training acts as a significant barrier to early intervention.1,44 In a localized study of Canadian physicians, 18% reported distress, but only 25% considered getting help and only 2% actually did.39 Similarly, national CMA data reported that 'feeling ashamed to seek help' was identified (76%) as a major reason for physicians not wanting to contact a physician health program.18 Indeed, common concerns include not wanting to let colleagues or patients down, believing seeking help is acknowledging weakness, being apprehensive about confidentiality, and fearing negative reprisals (e.g., from colleagues, supervisors, regulatory bodies, other licence-granting bodies, insurers)1,45 Fear of retribution is also a frequent reason why physicians may feel hesitant to report impaired colleagues, even if supportive of the concept.46 From the outset of training, medical learners are introduced to system-wide cultural aspects and values of the medical profession, which they then internalize and pass on to others.2 Extensive literature on the "hidden curriculum" points to a performance culture that includes norms such as the view that adversity is character building and the valorization of emotional repression (e.g., mental toughness).2,47 Culture-related issues are being increasingly addressed as a function of medical professionalism. For instance, commitment to physician health, collegiality and support have been established as key competencies within the Professional Role of the CanMEDS Framework,5 the most widely accepted and applied physician competency framework in the world.48 This involves a commitment to exhibiting self-awareness and managing influences on personal well-being and professional performance; managing personal and professional demands for a sustainable practice throughout the physician life cycle, and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need. In support of these commitments to personal care, physicians must develop their capacity for self-assessment and monitoring, mindfulness and reflection, and resilience for sustainable practice.5 Intra-professionalism, characterized by effective clinical and personal communication among physicians,49 significantly influence job satisfaction, which in turn has been shown to predict physician health outcomes.50 Furthermore, peer support can buffer the negative effects of work demands;39 collegial, professional environments are known to be healthier for both providers and patients.51 Conversely, unprofessional behaviour is associated with physician dissatisfaction,50 and dysfunctional workplaces and poor collegiality are linked to burnout.52 Unprofessional workplace behaviour is tolerated, and in fact is often customary, within medical training and practice environments.53 Of particular concern, such behaviour carried out by more senior physicians has been shown to encourage similar conduct among learners,54 highlighting the importance of promoting effective professional role modelling.55 Unfortunately, poor supervisory behaviour, and even mistreatment of learners, is common within the medical training environment.56 Although expectations for professional behaviour are increasingly being incorporated into both undergraduate and postgraduate teaching, issues related to a lack of professionalism persist in both training and practice.51 System-wide efforts are needed to counter what is perceived to be an eroding sense of collegiality and to promote professionalism as a way to address physician burnout and enhance engagement.7,39 3. Treatment and preventive approaches 3.1 Physician health services The scope of physician health services has expanded from focusing primary focus on identifying treating and monitoring physicians with substance abuse issues to more recent efforts to de-stigmatize poor physician health and integrate proactive resources to complement tertiary approaches.1 In Canada, there are multiple services to support the health needs of learners and physicians. These can be conceptualized along a continuum of approaches,1 including the following: health-promoting environments (e.g., efforts to ensure balanced workloads, provide more support staff, and encourage physicians to make sure they get adequate exercise, nutrition and sleep in training and practice); primary prevention (e.g., resilience training, stress-reduction groups, fatigue management programs, strategies to enhance teamwork and collaborative care); secondary prevention (e.g., access to assessment and counselling; services and workshops on coping with adverse events, litigation and career transitions and on managing difficult behaviour); and tertiary prevention (e.g., more intensive outpatient counselling, inpatient treatment). Many of these approaches, including those at the system level, focus on assisting the individual physician rather than addressing more contextual issues. Most jurisdictions in Canada have consolidated a number of services under the banner of a provincial physician health program (PHP).These range from counselling, treatment and/or peer support to fitness-to-practice and return-to-work assessments, workplace behaviour management and relationship management. The services available to physicians in a given area vary greatly.1,15 More established and resourced programs often offer services across the continuum, while less established programs tend to focus on secondary and tertiary services.2 Provincial PHPs have been shown to produce positive outcomes1,20,21,48 and are generally considered to be effective in addressing user issues,57 however but many physicians remain reluctant to access them.58 In addition to provincial programs, many learners and physicians in Canada can access support and treatment from other sources, including medical school and faculty wellness programs, employee assistance or workplace programs, and more individual-led options such as physician coaches.1 There has been a steady accumulation of evidence on the positive returns of workplace health and wellness programs,35 as well as indications that even modest investments in physician health can make a difference.17 In response to challenges posed by the considerable diversity in the organizational structure of provincial PHPs, the ways in which PHPs classify information, the range of services they offer, the mechanisms of accountability to stakeholders and the manner in which they pursue non-tertiary activities (e.g., education and prevention work)59 a consortium of PHPs released a preliminary Descriptive Framework for Physician Health Services in Canada in 2016. Through this framework a series of core services (and modes of activity within each) were defined.59 Potential users of the framework include PHPs, academic institutions, medical regulators, national associations, hospitals and health authorities, as well as other local groups. The framework may serve a range of purposes, including program reviews and planning, quality improvement, resource allocation, advocacy, stakeholder consultation and standards development.59 Initiatives such as this framework help address a persistent gap in Canada around equity of and access to services. Overall, fulfilling the needs of all learners and physicians through enhanced service quality and functional equivalence is an ongoing challenge for provincial PHPs and other service providers, and it must be a priority moving forward. 3.2 Individual primary prevention Prevention and promotion activities can help mitigate the severity and decrease the incidence of adverse outcomes associated with physician health issues among learners and physicians.3 Although secondary and tertiary services are critical components of any health strategy, complementary, proactive, preventive initiatives promote a more comprehensive approach. Some of the best-documented strategies include attuning to physical health (e.g., diet, exercise, rest), psychosocial and mental health (e.g., mindfulness and self-awareness, resilience training, protecting and maintaining cultural and recreational interests outside of medicine, and protecting time and relationships with family and friends).60 For instance, resilience has been identified as an indicator of physician wellness61 and as a critical skill for individuals working in health care environments.39 Innovative, coordinated approaches such as resilience and mindfulness training are instrumental in helping physicians overcome both anticipated and unexpected difficulties, to position them for a sustainable career in medicine. Many internal (e.g., personal) and external (e.g., occupational) factors can interfere with a physician's capacity to consistently maintain healthy lifestyle behaviours and objectively attend to personal health needs. Although the emergence of individually targeted proactive and preventive activities is encouraging, a greater focus on system-level initiatives to complement both proactive and tertiary approaches is needed. This also aligns with recent CMA member data indicating that medical students (61%), residents (55%), physicians (43%) and retired physicians (41%) want more access to resources to ensure their emotional, social and psychological well-being.62 Such an approach is increasingly important in light of physicians' professional responsibility to demonstrate a commitment to personal health.5 4. Physician health as a shared responsibility Although physicians are a critical component of Canadian health systems, those systems do not necessarily promote health in the physician community. It cannot be overstated that many health challenges facing learners and physicians are increasingly systemic in nature.1 Despite increasing challenges to the cultural norm that health-related issues are an individual-physician problem,2 system-level factors are often ignored.1,7 Although solutions targeted at the individual level (e.g., mindfulness and resilience training) are important proactive approaches and are a common focus, they often do not address occupational and organizational factors.7 Intervention exclusively at the individual level is unlikely to have meaningful and sustainable impacts. Interventions targeting individual physicians are likely most effective when paired with efforts to address more systemic (e.g., structural and occupational) issues.63 Moreover, organization-directed interventions have been shown to be more effective in reducing physician burnout than individual-directed interventions, and meaningful reductions in negative outcomes have been linked to system-level interventions.22,34 Concerted efforts at the system level will ultimately drive substantive, meaningful and sustainable change. This includes coordination among leaders from national, provincial and local stakeholders as well as individual physicians.16,22,64 Potential influencers include medical schools and other training programs, regulatory bodies, researchers (and funding bodies), professional associations and other health care organizations, as well as insurers.1 Indeed, addressing the complex array of issues related to physician health is a shared responsibility. A clear mandate exists to guide individuals and leaders in promoting and protecting the health of learners and physicians.1,7 5. Conclusion Physician health is a growing priority for the medical profession. Medical practice and training present complex occupational environments34, in which leaders play a central role in shaping training, practice and organizational culture through the implicit and explicit ways in which they communicate core values.2 When promoting physician health across the career lifecycle it is also important to consider the unique challenges and experiences of physicians who are not actively practicing (e.g., on leave; have non-clinical roles) as well as those who are retired. Notwithstanding the impact on patient care or health systems, promoting the health of individual physicians and learners is in and of itself worthy of attention. Indeed, leaders in the health system have a vested interest in helping physicians to meet the personal and professional challenges inherent in medical training and practice as well as in promoting positive concepts such as wellness and engagement.7 The increasingly blurred lines between physician health, professionalism and the functioning of health systems40 suggest that leaders at all levels must promote a unified and progressive vision of a healthy, vibrant and engaged physician workforce. This involves championing health across the career life cycle through advocacy as well as promoting solutions and outcomes through a lens of shared responsibility at both individual and system levels. Broad solutions skewed towards one level, without requisite attention given to the other level, are unikely to result in meaningful change. Moving from rhetoric to action, this next frontier integrates the promotion of self-care among individuals, support for healthy and supportive training and practice environments - both physical and cultural - as well as continued innovation and development of (and support for) physician health services. This constellation of efforts will ultimately contribute to the success of these actions. October 2017 See also CMA Policy on Physician Health REFERENCES 1 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 2 Montgomery AJ. The relationship between leadership and physician well-being; A scoping review. Journal of Healthcare Leadership 2016;55:71-80. Available: http://www.ingentaconnect.com/content/doaj/11793201/2016/00000055/00000001/art00010 (accessed 2017 Oct 30). 3 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 4 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 5 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. Available: https://doi.org/10.1016/S0140-6736(09)61424-0 (accessed 2017 Oct 30). 7 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-6. Available: https://doi.org/10.1016/j.mayocp.2016.10.004 (accessed 2017 Oct 30). 8 Lemaire JB, Wallace JE. Burnout among doctors. BMJ 2017;358:j3360. 9 Tepper J, Champion C, Johnston T, Rodin D, White A, Bastrash M, et al. Medical student health and wellbeing. Ottawa: Canadian Federation of Medical Students (CFMS); 2015. 10 Dyrbye LN, Harper W, Durning SJ, Moutier C, Thomas MR, Massie FS, et al. Patterns of distress in US medical students. Med Teach 2011;33:834-9. Available: https://doi.org/10.3109/0142159X.2010.531158 (accessed 2017 Oct 30). 11 Canadian Federation of Medical Students (CFMS). CFMS-FMEQ national health and wellbeing survey - Student research position. International Conference on Physician Health; 2016 Sep 18-20; Boston. Ottawa: CFMS; 2016. 12 Maser B, Houlton R. CFMS-FMEQ national health and wellbeing survey: Prevalence and predictors of mental health in Canadian medical students. Canadian Conference on Physician Health; 2017 Sep 7-9; Ottawa. Ottawa: CFMS; 2017. 13 Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among US medical students. Ann of Intern Med 2008;149:334-41. Available: https://doi.org/10.7326/0003-4819-149-5-200809020-00008 (accessed 2017 Oct 30). 14 George S, Hanson J, Jackson JL. Physician, heal thyself: a qualitative study of physician health behaviors. Acad Psychiatry 2014;38:19-25. Available: https://doi.org/10.1007/s40596-013-0014-6 (accessed 2017 Oct 30). 15 Roman S, Prévost C. Physician health: state of knowledge and preventive approaches. Montreal: Programme d'aide aux médecins du Québec (PAMQ); 2015. Available: http://catalogue.cssslaval.qc.ca/GEIDEFile/Doc_224290_ang.pdf?Archive=102463592064&File=Doc_224290_Ang_pdf (accessed 2017 Oct 30). 16 West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-81. Available: https://doi.org/10.1016/S0140-6736(16)31279-X (accessed 2017 Oct 30). 17 Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med 2017 Sep 25 [epub ahead of print]. Available: https://doi.org/10.1001/jamainternmed.2017.4340 (accessed 2017 Oct 30). 18 Simon C, McFadden T, Canadian Medical Association (CMA). National Physician Health Survey: The Process, Preliminary Data, and Future Directions 2017. Canadian Conference on Physician Health; 2017 Sep 7-9; Ottawa. Ottawa: CMA; 2017. 19 Lefebvre LG, Kaufmann IM. The identification and management of substance use disorders in anesthesiologists. Can J Anaesth 2017;64:211-8. Available: https://doi.org/10.1007/s12630-016-0775-y (accessed 2017 Oct 30). 20 Albuquerque J, Deshauer D, Fergusson D, Doucette S, MacWilliam C, Kaufmann IM. Recurrence rates in Ontario physicians monitored for major depression and bipolar disorder. Can J Psychiatry 2009;54:777-82. Available: https://doi.org/10.1177/070674370905401108 (accessed 2017 Oct 30). 21 Brewster JM, Kaufmann IM, Hutchison S, MacWilliam C. Characteristics and outcomes of doctors in a substance dependence monitoring programme in Canada: prospective descriptive study. BMJ 2008;337:a2098. 22 Lemaire JB, Wallace JE, Sargious PM, Bacchus M, Zarnke K, Ward DR, et al. How attending physician preceptors negotiate their complex work environment: A collective ethnography. Acad Med 2017 Jun 20 [epub ahead of print]. Available: http://journals.lww.com/academicmedicine/Abstract/publishahead/How_Attending_Physician_Preceptors_Negotiate_Their.98194.aspx (accessed 2017 Oct 30). 23 Lemaire JB, Wallace JE. How physicians identify with predetermined personalities and links to perceived performance and wellness outcomes: a cross-sectional study. BMC Health Serv Res 2014;14:616. Available: https://doi.org/10.1186/s12913-014-0616-z (accessed 2017 Oct 30). 24 Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med 2003;114:513-9. 25 Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014;14:254. Available: https://doi.org/10.1186/1472-6963-14-254 (accessed 2017 Oct 30). 26 Andrew LB. Physician suicide: Overview, depression in physicians, problems with treating physician depression. New York: Medscape; 2017 Jun 12. Available: https://emedicine.medscape.com/article/806779-overview#a3 (accessed 2017 Oct 30). 27 Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med 2014;89:443-51. Available: https://doi.org/10.1097/ACM.0000000000000134 (accessed 2017 Oct 30). 28 de Oliveira GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesth Analg 2013;117:182-93. Available: https://doi.org/10.1213/ANE.0b013e3182917da9 (accessed 2017 Oct 30). 29 Shanafelt TD, Mungo M, Schmitgen J, Storz KA, Reeves D, Hayes SN, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc 2016;91:422-31. Available: https://doi.org/10.1016/j.mayocp.2016.02.001 (accessed 2017 Oct 30). 30 Kitson A, Marshall A, Bassett K, Zeitz K. What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. J Adv Nurs 2013;69:4-15. Available: https://doi.org/10.1111/j.1365-2648.2012.06064.x (accessed 2017 Oct 30). 31 Cameron D, Katch E, Anderson P, Furlong MA. Healthy doctors, healthy communities. J Ambul Care Manage 2004;27:328-38. 32 Lobelo F, de Quevedo IG. The evidence in support of physicians and health care providers as physical activity role models. Am J Lifestyle Med 2016;10:36-52. 33 Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995-1000. Available: https://doi.org/10.1097/SLA.0b013e3181bfdab3 (accessed 2017 Oct 30). 34 Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205. Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 35 Chenevert D, Tremblay MC. Analyse de l'efficacité des programmes d'aide aux employés : Le cas du PAMQ. Montreal: HEC Montreal; 2016. Available: http://www.professionsante.ca/files/2016/07/Rapport-Chenevert-VF.pdf (accessed 2017 Oct 30). 36 Morneau Shepell Ltd. Workplace mental health priorities report 2015. Toronto: Morneau Shepell Ltd.; 2015. Available: https://www.morneaushepell.com/ca-en/insights/workplace-mental-health-priorities-report (accessed 2017 Oct 30). 37 Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff (Millwood) 2010;29:304-11. Available: https://doi.org/10.1377/hlthaff.2009.0626 (accessed 2017 Oct 30). 38 Harrison J. Doctors' health and fitness to practise: The need for a bespoke model of assessment. Occup Med (Lond) 2008;58:323-7. Available: https://doi.org/10.1093/occmed/kqn079 (accessed 2017 Oct 30). 39 Wallace JE, Lemaire J. On physician well being-you'll get by with a little help from your friends. Soc Sci Med 2007;64:2565-77. Available: https://doi.org/10.1016/j.socscimed.2007.03.016 (accessed 2017 Oct 30). 40 Lesser CS, Lucey CR, Egener B, Braddock CH, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA 2010;304:2732-7. Available: https://doi.org/10.1001/jama.2010.1864 (accessed 2017 Oct 30). 41 Canadian Medical Association (CMA). CMA code of ethics. Ottawa: CMA; 2004. Available: https://www.cma.ca/Assets/assets-library/document/en/PD04-06-e.pdf (accessed 2017 Oct 30). 42 ePhysician Health. Primary care: Physician patient module. Ottawa: ePhysician Health; 2017. Available: http://ephysicianhealth.com/ (accessed 2017 Oct 30). 43 Sibbald B, Bojke C, Gravelle H. National survey of job satisfaction and retirement intentions among general practitioners in England. BMJ 2003;326:22. 44 Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T. Challenge of culture, conscience, and contract to general practitioners' care of their own health: qualitative study. BMJ 2001;323:728-31. 45 Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA 2010;304:1181-90. Available: https://doi.org/10.1001/jama.2010.1300 (accessed 2017 Oct 30). 46 DesRoches CM, Rao SR, Fromson JA, Birnbaum RJ, Iezzoni L, Vogeli C, et al. Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA 2010;304:187-93. Available: https://doi.org/10.1001/jama.2010.921 (accessed 2017 Oct 30). 47 Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum: what can we learn from third-year medical student narrative reflections? Acad Med 2010;85:1709-16. Available: https://doi.org/10.1097/ACM.0b013e3181f57899 (accessed 2017 Oct 30). 48 Dupont RL, Skipper GE. Six lessons from state physician health programs to promote long-term recovery. J Psychoactive Drugs 2012;44:72-8. Available: https://doi.org/10.1080/02791072.2012.660106 (accessed 2017 Oct 30). 49 Beaulieu M-D, Samson L, Rocher G, Rioux M, Boucher L, Del Grande C. Investigating the barriers to teaching family physicians' and specialists' collaboration in the training environment: a qualitative study. BMC Med Educ 2009;9:31. Available: https://doi.org/10.1186/1472-6920-9-31 (accessed 2017 Oct 30). 50 Van Ham I, Verhoeven AAH, Groenier KH, Groothoff JW, De Haan J. Job satisfaction among general practitioners: a systematic literature review. Eur J Gen Pract 2006;12:174-80. Available: https://doi.org/10.1080/13814780600994376 (accessed 2017 Oct 30). 51 Bahaziq W, Crosby E. Physician professional behaviour affects outcomes: a framework for teaching professionalism during anesthesia residency. Can J Anaesth 2011;58:1039-50. Available: https://doi.org/10.1007/s12630-011-9579-2 (accessed 2017 Oct 30). 52 Cydulka RK, Korte R. Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med 2008;51:714-722.e1. Available: https://doi.org/10.1016/j.annemergmed.2008.01.005 (accessed 2017 Oct 30). 53 Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: A cross-sectional qualitative study. Med Teach 2016;38:410-8. Available: https://doi.org/10.3109/0142159X.2015.1073241 (accessed 2017 Oct 30). 54 Case GA. Performance and the hidden curriculum in Medicine. Performance Research 2014;19:6-13. Available: https://doi.org/10.1080/13528165.2014.947120 (accessed 2017 Oct 30). 55 Schneider B, Barbera KM. The Oxford handbook of organizational climate and culture. Oxford: Oxford University Press; 2014. 56 Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The prevalence of medical student mistreatment and its association with burnout. Acad Med 2014;89:749-54. Available: https://doi.org/10.1097/ACM.0000000000000204 (accessed 2017 Oct 30). 57 Canadian Medical Protective Association (CMPA). Physician health: Putting yourself first. Ottawa: CMPA; 2015 Sep. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/physician-health-putting-yourself-first (accessed 2017 Oct 30). 58 Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med 2002;77:918-21. 59 Canadian Medical Foundation (CMF). A descriptive framework for physician health services in Canada: A report prepared by the tricoastal consortium for the Canadian Medical Foundation. Ottawa, CMF, 2016 May. Available: http://medicalfoundation.ca/wp-content/uploads/2016/09/7.b-TCC-Descriptive-Framework-Survey-Companion-FINAL-May-24-2016.pdf (accessed 2017 Oct 30). 60 Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med 2013;88:301-3. Available: https://doi.org/10.1097/ACM.0b013e318280cff0 (accessed 2017 Oct 30). 61 Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med 2013;88:382-9. Available: https://doi.org/10.1097/ACM.0b013e318281696b (accessed 2017 Oct 30). 62 Canadian Medical Association (CMA). CMA Baseline 2014: Overall findings report. Ottawa: CMA; 2014. 63 Ruotsalainen JH, Verbeek JH, Mariné A, Serra C, et al. Preventing occupational stress in healthcare workers. Sao Paulo Medical Journal 2016;134:92-92. Available: https://doi.org/10.1590/1516-3180.20161341T1 (accessed 2017 Oct 30). 64 Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: The way forward. JAMA 2017;317:901-2. Available: https://doi.org/10.1001/jama.2017.0076 (accessed 2017 Oct 30).
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

Delivery of quality palliative end-of-life care throughout Canada

https://policybase.cma.ca/en/permalink/policy11219
Date
2014-08-20
Topics
Health human resources
Resolution
GC14-23
The Canadian Medical Association will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative end-of-life care throughout Canada.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health human resources
Resolution
GC14-23
The Canadian Medical Association will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative end-of-life care throughout Canada.
Text
The Canadian Medical Association will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative end-of-life care throughout Canada.
Less detail

Integration of sex/gender diversity education into medical school curricula and programs

https://policybase.cma.ca/en/permalink/policy11228
Date
2014-08-20
Topics
Health human resources
Ethics and medical professionalism
Resolution
GC14-48
The Canadian Medical Association calls for the integration of sex/gender diversity education into medical school curricula and programs.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health human resources
Ethics and medical professionalism
Resolution
GC14-48
The Canadian Medical Association calls for the integration of sex/gender diversity education into medical school curricula and programs.
Text
The Canadian Medical Association calls for the integration of sex/gender diversity education into medical school curricula and programs.
Less detail

Physician resource trends among specialties that focus on seniors’ care

https://policybase.cma.ca/en/permalink/policy11270
Date
2014-08-20
Topics
Health human resources
Resolution
GC14-73
The Canadian Medical Association will examine physician resource trends among specialties that focus on seniors’ care.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health human resources
Resolution
GC14-73
The Canadian Medical Association will examine physician resource trends among specialties that focus on seniors’ care.
Text
The Canadian Medical Association will examine physician resource trends among specialties that focus on seniors’ care.
Less detail

Educational material for students who are considering attending medical school outside Canada

https://policybase.cma.ca/en/permalink/policy11278
Date
2014-08-20
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC14-81
The Canadian Medical Association supports development of educational material for students who are considering attending medical school outside Canada.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC14-81
The Canadian Medical Association supports development of educational material for students who are considering attending medical school outside Canada.
Text
The Canadian Medical Association supports development of educational material for students who are considering attending medical school outside Canada.
Less detail

Fees for on call service

https://policybase.cma.ca/en/permalink/policy442
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC98-44
That the Canadian Medical Association support in principle that fees be paid to physicians for the service of being on call.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC98-44
That the Canadian Medical Association support in principle that fees be paid to physicians for the service of being on call.
Text
That the Canadian Medical Association support in principle that fees be paid to physicians for the service of being on call.
Less detail

Frequency of on-call services

https://policybase.cma.ca/en/permalink/policy445
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health human resources
Resolution
GC98-72
That the Canadian Medical Association recommend that in principle Canadian physicians not be required to provide on-call services more frequently than 1 night in 5.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health human resources
Resolution
GC98-72
That the Canadian Medical Association recommend that in principle Canadian physicians not be required to provide on-call services more frequently than 1 night in 5.
Text
That the Canadian Medical Association recommend that in principle Canadian physicians not be required to provide on-call services more frequently than 1 night in 5.
Less detail

Health information privacy and medical school curricula and training programs

https://policybase.cma.ca/en/permalink/policy446
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health human resources
Resolution
GC98-73
That the Canadian Medical Association encourage Canadian medical schools to incorporate the principles and details of the CMA Principles for the Protection of Patients' Personal Health Information into their undergraduate curricula and postgraduate training programs.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
1998-09-09
Topics
Health human resources
Resolution
GC98-73
That the Canadian Medical Association encourage Canadian medical schools to incorporate the principles and details of the CMA Principles for the Protection of Patients' Personal Health Information into their undergraduate curricula and postgraduate training programs.
Text
That the Canadian Medical Association encourage Canadian medical schools to incorporate the principles and details of the CMA Principles for the Protection of Patients' Personal Health Information into their undergraduate curricula and postgraduate training programs.
Less detail

11 records – page 1 of 2.