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Active Transportation

https://policybase.cma.ca/en/permalink/policy9483
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
Text
The major diseases affecting the quality and quantity of life of Canadians, which include obesity, diabetes, coronary artery disease, depression and cancer, are all linked to physical inactivity. In Canada, 69% of women and 68% of men in Canada are considered physically inactive.(1) The cost of this inactivity and obesity was estimated at $4.3 billion in 2001.(2) A 10% increase in physical activity could potentially reduce direct health care expenditures by $150 million a year. This does not include indirect costs such as lost productivity due to illness, premature death or a range of other factors, including mental illness and poor quality of life.(3) Thus far, efforts to increase physical activity by changing the behaviour of individuals have had limited success. One reason is that many people have difficulty sustaining behaviours that involve additional time commitments. That is one reason for the increasing emphasis being placed on active transportation, which is any human-powered form of transportation, such as walking and cycling. Walking and cycling can be efficient alternatives to automobile travel. Cycling is usually the fastest mode of travel door to door for distances under five km, and for up to 10 km in city cores. Walking is simpler and nearly as fast for distances up to two km. When travel times are similar for active and motorized transportation, physical activity is gained with no net time lost, and at much lower cost. The cost of operating a motor vehicle is typically $10,000 per year,(4) while operating costs for a bicycle are much lower. Communities that have sidewalks, enjoyable scenery, street lights and nearby stores have improved levels of active transportation and physical activity. However, in recent decades communities have often been designed around the automobile. Street design, parking space, sidewalks and distance to retail destinations have all been planned assuming motorized transportation, and this often makes it difficult to move around communities by walking or cycling. Although individual decision-making remains important in any strategy for increasing active transportation, there is an essential role for communities and governments to play. Major improvements in the health of Canadians in the past 200 years have been due to improved sanitation, access to clean water and injury prevention. The role of individual decision-making in effecting these changes is dwarfed by the impact of the public health measures and infrastructure involved. Just as potable tap water is a health issue, so are decisions about land use, transportation policy and infrastructure. Community design is a major determinant of whether people use active transportation, whether they are physically active and whether they are obese. Canadians need communities that make it easy to be physically active in their daily living. Communities can create an environment in which the physically active choice is the easy choice. They can do this via sidewalks, trails, bicycle lanes and bicycle paths, and by providing pedestrian-friendly intersections, parks and green spaces, and safe bicycle parking spaces. They can also arrange zoning so that retail destinations are within walking or cycling distance of residential areas. This process also includes dedicating a sufficient portion of their street maintenance budget (including snow clearing) to maintaining active transportation routes as well as routes for motorized vehicles. It may include redesigning intersections, giving up vehicle lanes or parking spaces, or increasing the price of parking. Additional benefits to designing communities for pedestrians and cyclists. * a stronger sense of community with greater civic involvement by citizens * increased property values and retail activity * less noise pollution * lower crime rates * less smog and other air pollution * less greenhouse gas production * decreased risk of injury to pedestrians and cyclists * decreased costs of roadway and parking construction. A role for everyone Other sectors can support communities in making active transportation choices easy choices: * Businesses can create a work environment friendly to active transportation, including a corporate culture friendly to physical activity. They can incorporate active transportation planning into building design and create an environment friendly to physical activity. These steps could include making bicycle parking, showers and lockers available, and providing stairs that are pleasant and easier to access than elevators. They can also incorporate a culture of physical activity in decisions about where and how to hold meetings, and what people are allowed to wear to work. * School boards can develop policies to promote active transportation to and from school. These include building and maintaining secure bicycle parking, ensuring safe walking routes within communities, and assisting parents in walking their children to school. * Citizens can use active transportation themselves and treat with respect those who are already making active transportation choices. They can also lobby governments to make their community safer and easier places for cycling and walking. * Physicians can encourage patients to use active transportation as a way to boost their physical activity levels and improving their health. They can also lead by example and use active transportation themselves. Recommendations The CMA recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation. The CMA urges governments to: * Commit to long-term plans for active transportation networks that are in keeping with these goals and that include specific benchmarks to measure progress. * Require that active transportation be part of all infrastructure renewal projects, with investment in active transportation vs. motorized transportation in proportion to targeted active transportation use. (Some cities have achieved active transportation rates of up to 15%.) * Develop an awareness campaign to help Canadians to recognize the value of active transportation in their communities. * Require public health impact assessments for all land-use and transportation decisions, including the impact on the chemical environment and on physical activity. * Assess the impact that changes in the "built" environment can have on public health, and which interventions are most safe and effective. 1 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43. 2 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J App Phys 2004;29(1):104. 3 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ 2000;163(11): 1435-40. 4 Canadian Automobile Association. Driving Costs: 2005 Edition. Available: www.carpool.ca/pdf/CAA-driving-costs-05.pdf (accessed 2007 Feb. 2).
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Flexibility in Medical Training (Update 2009)

https://policybase.cma.ca/en/permalink/policy9485
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Replaces
Flexibility in Medical Training
Topics
Health human resources
Text
Flexibility in Medical Training (Update 2009) The Canadian Medical Association (CMA) believes that the medical training system must be sufficiently flexible to enable medical students to make informed career choices, accommodate resident program changes, and allow practising physicians the opportunity to re-enter training to enhance their skills and knowledge, or to enter a new sphere of practice. The system must also be able to accommodate international medical graduates (IMGs) to provide them with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. For physicians-in-training, effective career guidance and positive influences on career options (e.g., role modelling, early clinical exposure, etc.) may foster confidence with career path selection and minimize program changes during residency. A flexible and well-designed re-entry postgraduate system would be characterized by: long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability. The CMA believes that, ultimately, society benefits from a flexible medical training system. These benefits may include enhanced patient care, improved access to physician services, as well as physician retention, particularly in rural and remote communities. A flexible system may also improve morale and satisfaction among students, residents and physicians, and facilitate better career choices. This policy outlines specific recommendations to help create and maintain a well-designed system for flexibility in physician training in Canada. Commitment and action by all stakeholders, including governments, medical schools, regulatory authorities and others, is required. The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to the CMA's policies on physician resource planning, physician health and well-being, physician workforce issues and others. Definitions - Postgraduate trainee - Also known as a "resident," an individual who has received his/her MD degree and is currently enrolled in an accredited program in a Canadian school of medicine that would lead to certification by either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada. - Medical student - An individual enrolled in an undergraduate program in a Canadian school of medicine that would lead to an MD degree. - International medical graduate - An individual who received his/her MD degree from a training program other than from one of Canada's undergraduate schools of medicine. - Designated positions - Postgraduate positions within the determined complement of residency positions that are identified to meet a need other than that of accommodating the annual number of new graduates of Canadian medical schools to complete the usual training for certification and licensure. Designated positions may be identified for a variety of purposes. The need for informed career decision-making and positive influences Choice of practice discipline as lifelong career can be one of the most difficult aspects of physician training. Exacerbating this challenge are the vast array of available specialties, timing of choices, as well as practice considerations in terms of lifestyle and physician resource needs. The rapidly changing face of medical practice as well as the limited amount of information and time available to consider options, are also contributing factors. A number of other forces, both positive and negative, may affect students' choices of practice specialty. These can include financial considerations in light of student debt incurred by high tuition fees and insufficient financial support. 12 The biases of faculty, family and others may also impact decisions. In addition, limited training opportunities in general, as well as a lack of flexibility to switch training programs, may also restrict choice of practice specialty. While a myriad of personal factors are acknowledged to also play contributing roles in influencing program selection, these issues are too complex to discuss here. Ultimately, students need to have access to financial support so as to reduce stress and the influence of debt on specialty choice. They also need objective information and guidance and broad clinical experiences early in their medical training as this has been identified as a critical factor in making decisions about their future careers.3 The rotating internship, abolished in the early 1990s, used to permit residency selection at a later stage in medical training. The residency program match now takes place during the final year of undergraduate studies. As a consequence of this earlier timing, some students feel pressured to make their specialty choice too early in their medical education and often before their clerkship has even begun. This can include focusing research and program electives4 in one specific area, rather than sampling a broad range of disciplines, to demonstrate conviction of choice to residency program directors at the time of the match. Fifty-nine percent of respondents to the Canadian Resident Matching Service's (CaRMS) 2006 post-match survey indicated they completed more than half of their electives in their first-choice discipline.5 This, combined with the early timing of the residency match, can lead to an uninformed choice of residency program and the realization, at a later date, that a different training program would be more suitable. Eighty percent of medical leader respondents to the 2008 Core Competency Project survey indicated that timing of career choice was the biggest challenge for career decision-making.6 Those residents who wish to change to new training programs may not believe they have the opportunity to do so. Thirty-seven percent of resident respondents to the Core Competency Project survey considered switching disciplines during their residency training7 and 39% had spoken to a faculty member about switching programs.8 Others who do change programs are ultimately delayed entry into the workforce as a result of their prolonged training. This problem is exacerbated by an insufficient number of re-entry postgraduate training positions and large debt that confine trainees to a single career path. Lack of student confidence and preparedness in choosing a postgraduate training program, or lack of success in achieving a first choice in the postgraduate match, may predict subsequent program changes. A broad range of strategies must be available to help medical students make informed career choices. These include a wider choice of electives at an earlier stage of training, positive and unbiased mentoring experiences, improved access to career information from residents, as well as career seminars and other resources. In light of the above, the CMA recommends that: 1. the undergraduate medical school curriculum be re-designed to facilitate informed career choice and, in particular, to ensure that students enjoy a broad range of clinical experiences before they have to choose a specific discipline (i.e., via CaRMS match); 2. national career counselling curricula for both medical students and residents be developed and include the following components: national standardization; stakeholder input (students, residents and others); positive and fair role modelling by both residents and practising physicians/faculty, with appropriate professional respect among medical disciplines; and formal and informal mentorship programs; 3. a wide-range of elective opportunities be developed and communicated at a national level; 4. electives reflect a broad spectrum of experiences, including community-based opportunities; 5. clinical experiences be introduced at the earliest possible stage of undergraduate learning; 6. a national policy be implemented to ensure mandatory diversification of student elective experiences; and 7. medical schools be permitted and encouraged to model alternate systems of postgraduate learning. The need for broad-based medical education In order to provide medical students with the greatest options for flexibility in medical training, they should be actively encouraged to pursue a broad-based medical education. Previously, CMA advocated for a common postgraduate year (PGY1). In the 2008 Core Competency Project survey, 77% of physician respondents, 70% of medical student respondents and 67% of program director respondents expressed support for first year residents to do a broad-based common PGY1-like rotating internship.9 The rationale for and importance of ensuring flexibility has been outlined in the previous sections. Capacity of the postgraduate training system An essential component in ensuring flexibility within the medical training system is to establish and maintain sufficient capacity at the postgraduate training level. This is necessary for the following reasons: * Sufficient capacity may prevent highly-skilled and well-trained Canadian physicians from being forced to seek postgraduate training in the U.S. and remain there to practise medicine. * It is necessary to provide IMGs with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. This reflects the CMA's recognition of the important contribution that IMGs have made, and continue to make, in the provision of medical services, teaching and research in Canada. Opportunities for IMGs will also permit Canadians who study medicine abroad to pursue their medical careers in Canada. * It is essential to provide students with sufficient choice to seek the training that best matches their skills and interests as well as societal demands. * It is crucial to provide sufficient re-entry positions to allow practising physicians to seek training in other areas of medicine to meet the demands of their communities. [Please refer to the "Re-entry" section of this policy for more details.] In light of the above, the CMA recommends that: 8. mechanisms be developed to permit reasonable movement of residents within the overall residency structure and career counselling supports be made available to residents considering such a change; 9. the capacity of the postgraduate training system be sufficiently large to accommodate the needs of the graduating cohort, the re-entry cohort, and the training needs of international medical graduates; 10. there be a clearly defined pool of re-entry postgraduate positions and positions for international medical graduates; 11. government match and maintain undergraduate medical enrolment with a target of at least 120 ministry-funded postgraduate training positions per 100 Canadian medical graduates, to accommodate the training needs of the graduating cohort, the re-entry cohort and international medical graduates; and 12. options be explored for influencing governments to support a flexible postgraduate medical education system that also meets societal needs. Re-entry medical training system Note: This section addresses only one kind of designated position, specifically, those for licensed physicians wishing to re-enter training after a period in practice (also known as "re-entry positions"). The re-entry positions addressed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry. Increased opportunity for exposure to the breadth of medical fields in undergraduate training, improved undergraduate career counselling and a postgraduate system that makes the changing of disciplines easier are some of the many aspects that should facilitate residents' satisfaction with career choice. There will, however, inevitably be individual cases where issues of societal need, personal health, lifestyle or personal choice necessitate a change in career direction after postgraduate training. This requires the availability of additional postgraduate positions allotted specifically to this sub-set. A sufficient and stable supply of re-entry positions is needed within the postgraduate training system to enable practising physicians to enhance their skills or re-enter training in another discipline. While this may apply mostly to family physicians and general practitioners wishing to train in a specialty discipline, it can also include practising specialists wanting to sub-specialize or train in another area, which could be Family Medicine. The additional or new training of primary care physicians, particularly in obstetrics, emergency medicine, anaesthesia, surgery, psychiatry and general internal medicine, will be of benefit to smaller communities lacking regular access to these specialty medical services. In addition, the availability of adequate re-entry positions may encourage new physicians to accept locum tenens, thus relieving overworked physicians in underserviced communities. Potentially, it could help to increase a community's long-term retention rate of established physicians. The CMA believes that a well-designed re-entry system for Canadian postgraduate medical education would be characterized by an accessible national registry, long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability. Stability Medical students need reassurance that re-entry positions will be available if they wish to re-enter training after a period in practice. This will enable them to better plan their careers, reduce anxieties about career selection and ultimately help to meet the health care needs of society. For physicians re-entering the postgraduate training system, there must also be the guarantee that sufficient program funding will be available to ensure completion of training. The CMA therefore recommends that: 13. a complement of clearly defined, permanent re-entry positions with stable funding be a basic component of the Canadian postgraduate training system and that the availability of these positions be effectively communicated to potential candidates; and 14. funding for re-entry positions be specifically allocated for the entire training period. Capacity The CMA believes that the capacity of the postgraduate training system must be sufficiently large to accommodate the needs of the re-entry cohort and that postgraduate re-entry positions should be supernumerary to the numbers required for the graduating cohort. [Please refer to the "Capacity of the Postgraduate Training System" section of this policy for specific recommendations.] Accessibility The CMA believes that re-entry physicians should not be restricted to competing for particular disciplines for which there is an identified need in their jurisdiction. Re-entry physicians should also be able to compete for any available disciplines across all training programs. Not every discipline will be available for re-entry each year but all should be accessible over the course of a three-year period. The CMA therefore recommends that: 15. there be accessibility within re-entry postgraduate training positions including: * open and fair competition at the national level among all re-entry candidates for the clearly defined pool of re-entry positions, * that the mix of positions available reflect the overall mix of positions in the postgraduate training system, and * recognizing the limited size of the re-entry pool, access to all specialties be available over a three-year period rather than on an annual basis; and 16. access to entry should be possible through both national and regional pools of re-entry positions, with a process comparable to that currently used for the postgraduate training system. Flexibility in the Workforce As previously mentioned, the re-entry positions discussed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry. The CMA therefore recommends that: 17. physicians who have retrained through the re-entry system have the same practice opportunities as physicians entering the workforce for the first time. Accountability The CMA recognizes the importance of public accountability and sound fiscal management and therefore recommends that: 18. there be on-going evaluation of the re-entry system in Canadian postgraduate medical education. 1 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8. 2 2007 National Physician Survey Data. 3 Directions for Residency Education, 2009 - A final report of the Core Competency Project. February 2009. Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada. 4 Ibid, page 23. 5 Ibid. 6 Ibid, page 59. 7 Ibid, page 27. 8 Ibid, page 60. 9 Ibid.
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Tuition fee escalation and deregulation in undergraduate programs in medicine (Update 2009)

https://policybase.cma.ca/en/permalink/policy9487
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Replaces
Tuition fee escalation and deregulation in undergraduate programs in medicine
Topics
Health human resources
Text
TUITION FEE ESCALATION AND DEREGULATION IN UNDERGRADUATE PROGRAMS IN MEDICINE (Update 2009) The Canadian Medical Association (CMA) is very concerned about high and rapidly escalating, undergraduate medical school tuition fees across Canada. Ontario set a precedent for the deregulation of tuition fees in May 1998 and many provinces have since followed. This policy gives universities, including medical schools, the discretion to set fees for training in those areas that lead to professional careers, such as medicine. For the 2008-2009 academic year, first-year tuition fees at most Ontario medical schools were triple the tuition fees in 1997-1998 at an average of $16,550 per year;1 this figure does not include compulsory "other fees" that can be as much as $1,700 per year.2 Irrespective of whether tuition fees have been regulated, some medical schools outside of Ontario have doubled their tuition fees within the same time period. Decreased government funding to universities is increasing the fiscal pressures on institutions and is driving these dramatic tuition fee increases. The CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant and detrimental impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. Broad Effects of High Tuition Fees Lack of Diversity Medical education in Canada has traditionally been affordable and accessible to individuals from a range of socioeconomic and ethnic groups who later serve an equally diverse population. Unfortunately, the introduction of high tuition fees may close the door to individuals who either cannot afford the high costs of a medical education or wish to avoid the prospect of significant debt load upon graduation. High tuition fees may therefore create an imbalance in admissions to medical school by favouring those who represent the affluent segment of society and not the variety of groups reflected in the Canadian population. The proportion of medical students from lower income families is already extremely low and decreasing further.3 Paradoxically, funds that should be injected to making tuition fees reasonable - and therefore more accessible by a broader range of society - may soon need to be allocated to creating career promotion and special financial support programs that target those groups that have been alienated by high tuition fees. Influence on Practice Choice and Practice Location ("Brain Drain") It is likely that paying off debts as quickly as possible will become a key consideration when determining practice location and specialty. For instance, more students may feel compelled to maximize their earning potential by pursuing those specialties that generate high incomes; others may choose those specialties with short training periods so they can enter the workforce and start to pay off debts sooner. Debt load may also influence where graduating physicians choose to practise medicine. The increasing willingness of American recruiters to pay off the debts of new graduates provides tremendous incentive to practise in the U.S. and explore research opportunities; unfortunately, it only aggravates the ongoing problem of the "brain drain" of Canadian physicians.4 While we have been enjoying a net gain of physicians from the U.S., we may experience net loss with physician shortages expected in the U.S. More physician retention and recruitment initiatives are needed to encourage physicians to remain in or return to Canada. This is especially true for rural and remote communities. Urban areas are often in a better financial position to offer incentives to new graduates than rural and remote communities where physician shortages are most pronounced. Effects on Rural and Remote Areas The CMA believes that governments must be made aware of the potentially negative impact of high tuition fees and student debt on physician workforce supply for the rural and remote areas of Canada. Research shows that medical students from rural and remote areas have a greater likelihood of returning to these communities to practise medicine.5 Research also shows that students of rural origin have higher student debts6 and are underrepresented in Canadian medical schools.7 Students from rural and remote communities face the challenge of not being able to live at home while they attend university. They must assume high relocation expenses and travel costs, as well as separation from their families while they are away at school. Of student respondents to the 2007 National Physician Survey, 53.1% of rural students compared with 67.4% of urban medical students had no debt upon entering medical school. When asked to predict their expected debt upon completion of medical school, 33.2% of rural students compared with 23% of urban students expected their debtload to exceed $100,000.8 Unfortunately, the introduction of high tuition fees might make both the personal and financial costs of pursuing a medical education too significant for students from rural and remote areas to even consider. As a result, this may generate fewer physicians willing to practise in these areas and exacerbate the problem most rural and remote communities already face in attracting and retaining physicians. High tuition fees might also further increase the reliance on international medical graduates in rural and remote communities. While the CMA values the contributions of international medical graduates in alleviating shortages in physician supply, it believes that Canadian governments must adopt the guiding principle of self-sufficiency in the production and retention of physicians to meet population needs. Effects on New and Potential Medical Students Medical students affected by high and escalating tuition fees will graduate with unprecedented debt loads. Enormous education costs, already a reality in some provinces, are a growing trend. In 2007, over one third (36%) of students said they expected debtloads of $80,000 or more upon completion of medical school.9 A number of factors, as highlighted below, contribute to students' financial burden and may affect their ability to pay off debts and meet financial obligations. This, in turn, may influence their choice of medical discipline and practice location. Exorbitant education costs may also result in students considering dropping out of, or taking longer to complete, their medical studies because they cannot afford the ongoing costs, or are too overwhelmed with the combined stress of their medical studies and trying to make financial ends meet. The CMA is very concerned that excessive debt loads will exacerbate the stress already experienced by medical students during their training and will have a significant and negative impact on their health and well-being. Previous Education Debt and Accumulative Debt Most Canadian medical schools make an undergraduate degree a prerequisite to application. As such, by the time most students are accepted into medical school, they may have already accumulated debt from a previous undergraduate degree. Many students have also completed postgraduate degrees before entering medical school.10 This debt continues to accumulate during the undergraduate years of medical school and into the postgraduate training period, which is anywhere from two years to seven years in duration. This does not include additional time spent doing fellowships. It may be very useful to establish a national clearinghouse of public and private financial assistance programs to help students in their search for financial support. Limited or No Employment Opportunities during Undergraduate Training Tuition fees, along with ongoing increases in living expenses, are already making it very difficult for some students to make ends meet. It makes matters worse that there are limited or no opportunities to generate income through employment during the academic year and the summer months. Given the intensity of the medical school program, some schools strongly advise against working part time. To further compound the problem, some schools have very short summer breaks. For those schools that do provide summer holidays, the holidays often start later than other university programs, by which time employment opportunities are scarce or low paying. There is also the common expectation that medical students will undertake unpaid clinical or research elective experiences during the summer to enhance their desirability for postgraduate medical programs. Limited or No Remuneration for the Clinical Clerkship During the clerkship years, there are no summertime breaks because students spend these years working in hospitals and other clinical settings. All Canadian medical students (outside of Québec) receive a relatively small stipend during their clerkship varying from $2,808 to $6,000;11 however, the stipend had previously been abolished in medical schools in Ontario and Québec in the early 1990s. Fortunately Ontario reinstated the stipend as the Final Year Medical Student Bursary in 2004.12 Unique Expenses In addition to very limited or no opportunities to generate employment income, medical students must bear a number of unique and significant costs. These include very high textbook and instrument costs, as well as a variety of expenses associated with their clerkship, such as travel to and from the clinical setting and the need for professional attire. The introduction of distributed medical education including satellite campuses, co-campuses and rural learning sites has increased the amount of travel required of medical students as well as the associated costs. Off-site electives also generate many additional expenses, including the cost for travel to the site - which may be in a different province - as well as accommodation and other living expenses. A 1999 survey of graduating medical students revealed that more than half took an off-site elective at a specific institution in order to increase their chances of being matched to that site.13 As postgraduate training becomes even more competitive, the number of students taking off-site electives may increase and so will the number of students who are adding this expense to their overall debt load. Medical students must also assume considerable costs related to interviews for residency training, including the high costs for travel to various interview sites, accommodation expenses, application fees for the resident matching service and other miscellaneous expenses. There is also a considerable fee for the qualifying examination that is written at the end of medical school. Insufficient Public Funding and Increasing Reliance on Bank Loans Government financial support programs (bursaries and loans) are not increasing to meet students' needs due to rising tuition costs and living expenses. As a consequence, the number of students who must rely on interest-bearing bank loans to help support themselves while they are in school may increase. Unlike some government programs, repayment of bank loans often cannot be postponed until after graduation and interest payment is required during the course of study; this further exacerbates students' financial stress. Residency Costs Upon graduation from medical school, students must pursue two to seven years of postgraduate training to obtain a licence to practise medicine. This training period is marked with fees for examinations as well as an annual tuition and/or registration fee. During 2008-2009, the tuition fee was as much as $3,900 in some provinces.14 Residents are also required to work long hours in hospitals and other clinical settings and have frequent on-call responsibilities. Although residents do receive a salary for this work, the remuneration is relatively modest when these factors and debt servicing payments are considered. In fact, mandatory debt maintenance can consume a very significant proportion of a resident's pay.15 The CMA opposes tuition fees for residents. While the CMA's opposition to residency tuition is based on a number of factors not limited to its financial impact, clearly, tuition fees exacerbate debt. High Practice Start-up Costs and Decreased Pay Potential Licensed physicians wanting to establish a clinical practice currently face start-up costs estimated between $30,000 and $50,000, depending on their practice specialty and type (e.g., solo versus group practice).16 Some specialties require capital investment over and above the basic start-up costs. These expenses will add to the significant debt that new physicians will bear in the next few years. Other Factors In addition to significantly higher debt load than the previous generation of new physicians, a number of factors may influence the net income of physicians and their ability to pay off debts. These include billing caps, stagnant fees for services, high malpractice insurance fees, overhead expenses and increasing non-remunerative administrative responsibilities. Summary In summary, the CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. This impact includes: * creating socioeconomic barriers to application to medical school and threatening the diversity of future physicians serving the public * exacerbating the physician brain drain to the U.S. where new physicians can pay off their huge debts more quickly * generating fewer physicians available or interested in practising in rural and remote areas of Canada Recommendations In response to its concerns regarding the deregulation of tuition fees and high tuition fee increases, the CMA recommends that: 1 governments increase funding to medical schools to alleviate the pressures driving tuition increases 2 any tuition increase should be regulated and reasonable 3 financial support systems for students be developed concomitantly or in advance of any tuition increase, be in direct proportion to the tuition fee increase and provided at levels that meet the needs of students. Appendix Glossary of Terms Undergraduate Program in Medicine, also known as "Medical School" Medical school is the period of study, usually four years in duration that leads to the doctor of medicine or "MD" degree upon graduation. Most Canadian universities require applicants to the undergraduate medicine program to have at least a three-year degree (e.g., Bachelor of Science degree) before they are eligible to apply. Although the title "Doctor" is conferred upon successful completion of the undergraduate program, an additional two to seven years or more of residency training is required before these individuals can apply for a licence to practise medicine in Canada. Clerkship The clerkship is the period during the last one to two years of undergraduate studies in medicine during which medical students work in hospitals, clinics and physicians' offices. Off-site Elective Many students take off-site electives during their clerkship. An "elective" is a course or training that is not mandatory to the curriculum, but may be elected or chosen by the student. An "off-site" elective means that the training is being provided at a location different from the medical school where the student is enrolled; for example, the elective may be in a different city, province, or even a different country. Resident Matching During the last year of undergraduate training, most graduating medical students participate in a national process that matches them with available residency training positions in Canada. Residency/Postgraduate Training Period After earning his/her MD degree and receiving the title "Doctor," additional training is required in a specific area before an individual may practise medicine in Canada. This period of training is referred to as "residency" or "postgraduate training;" the individuals undergoing the training are called "residents." Residents usually work in hospitals (also called "teaching hospitals") under the supervision of a licensed physician. Depending on the field of study, residency training may range from two to seven years or longer if subspecialty training is pursued (e.g., pediatric cardiology). At the end of residency training, individuals must pass a number of examinations to practise medicine in Canada. Fellowship A fellowship is training sought by individuals who wish to obtain expertise in a specific area of medicine above and beyond basic residency requirements. References 1 Tuition Fees in Canadian Faculties of Medicine: Session Commencing Fall 2008. Office of Research and Information Services, Association of Faculties of Medicine of Canada, November 2008. 2 Ibid. 3 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8. 4 "Are We Losing Our Minds? Trends, Determinants and the Role of Taxation in Brain Drain to the United States," The Conference Board of Canada, July 1999. 5 Advisory Panel Report on the Provision of Medical Services in Underserviced Regions. Canadian Medical Association, 1992. 6 2007 National Physician Survey. 7 Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL, et al. Characteristics of first-year students in Canadian medical schools. CMAJ 2002;166(8):1029-35. [0] 8 2007 National Physician Survey. 9 2007 National Physician Survey. 10 "Educational Attainment at Time of Application of Registered and Not Registered Applicants to Canadian Faculties of Medicine - 2006-2007 (Table 105)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p154. 11 "Duration of Clinical Clerkship and Amount of Stipend in Canadian Faculties of Medicine 2008-2009 (Table 7)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p9. 12 Clinical Clerkship Stipends by Faculty of Medicine, 1995-1996 to 1999-2000, Canadian Medical Association Research Directorate, January 2000. 13 Results of the Post-Match Survey of Students Graduating 1999, Canadian Resident Matching Service. 14 "Post-MD Clinical Trainee Fees in Canadian Faculties of Medicine - 2008-2009 (Table 6)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p8. 15 2007 National Physician Survey. 16 Practice Management, MD Management Ltd.
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Household antibacterial products

https://policybase.cma.ca/en/permalink/policy9565
Last Reviewed
2020-02-29
Date
2009-08-19
Topics
Health care and patient safety
Resolution
GC09-90
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2009-08-19
Topics
Health care and patient safety
Resolution
GC09-90
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
Text
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
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Joint position statement: The role of health professionals in tobacco cessation

https://policybase.cma.ca/en/permalink/policy10090
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-03-05
Replaces
Tobacco : the role of the health professional in smoking cessation : joint statement (2001)
Topics
Population health/ health equity/ public health
Text
The Role of Health Professionals in Tobacco Cessation - Joint position statement This statement was developed cooperatively by the Canadian Association of Occupational Therapists, Canadian Counselling and Psychotherapy Association, Canadain Dental Hygienists Association, Canadian Medical Association, Canadian Nurses Association, and Canadian Physiotherapy Association. POSITION There is a role for every Canadian health professional in tobacco-use cessation.1 Tobacco use2 inflicts a heavy burden on Canadians' health and on the Canadian health-care system, and health professionals can advocate effectively for tobacco-use cessation at the clinical and public health levels. As providers of client and patient-centered services, health professionals are involved in tobacco cessation by: * assessing and documenting all forms of tobacco use, willingness to quit and risk of exposure to second-hand smoke; * discussing with clients and patients the negative health effects of tobacco use and exposure to second-hand smoke, and the health and other benefits (e.g., financial) of becoming tobacco free; * offering to help, and helping, tobacco users to quit; * offering a variety of tobacco-cessation strategies (e.g., counselling, behavioural therapy, self-help materials, pharmacotherapy) as appropriate to their knowledge, skills and tools; * providing strategies for non-smokers to help them reduce their exposure to second-hand smoke; * being knowledgeable about and providing referrals to community-based initiatives and resources; * recognizing that relapse occurs frequently, and conducting follow-up assessment and intervention; * tailoring interventions to the needs of specific populations (e.g., age, gender, ethnicity, diagnosis, socio-economic status); and * using a collaborative, multidisciplinary approach. As educators and researchers, health professionals are involved in tobacco cessation by: * including education on tobacco-cessation strategies and strategies for resisting tobacco use in basic education programs for health professionals; * providing professional development programs for health professionals on tobacco cessation; * conducting research to encourage and improve health professionals' knowledge and provision of tobacco cessation; and * communicating research evidence about tobacco-cessation strategies. As administrators of health-care organizations, health professionals are involved in tobacco cessation by: * offering training on tobacco cessation as part of employee orientation; * providing access to professional education on tobacco cessation for employees; * enforcing applicable bans on tobacco wherever health professionals are employed (e.g., health-care facilities, private homes); and * ensuring that tobacco-cessation programs and tobacco-free workplaces are included in accreditation standards. As public health advocates, health professionals are involved in tobacco cessation by: * increasing public awareness that health professionals can help people remain tobacco free or stop using tobacco; and * advocating for federal, provincial and territorial governments' investment in comprehensive tobacco control that includes programs, legislation and policies to prevent the uptake of tobacco and reduce tobacco use (e.g., bans on tobacco advertising). Programs must focus on health promotion and include community-based initiatives. BACKGROUND Tobacco is an addictive and harmful product, and its use is the leading cause of preventable death in Canada.3 Each year in Canada, more than 37,000 people die prematurely due to tobacco use.4 Approximately 17 per cent of the population 15 years of age and older (about 4.8 million Canadians) smoke.5 Strong evidence has revealed that smoking is associated with more than two dozen diseases and conditions.6 The economic costs of tobacco use are estimated at $17 billion annually ($4.4 billion in direct health-care costs and $12.5 billion in indirect costs such as lost productivity).7 Second-hand smoke is also harmful. Each year, more than 1,000 non-smoking Canadians die due to second-hand smoke.8 Exposure to second-hand smoke is the number two cause of lung cancer (smoking is the number one cause).9 Second-hand smoke can also aggravate allergies, bring about asthma attacks and increase the risk of bronchitis and pneumonia.10 Research also suggests that there may be a link between second-hand smoke and the risk of breast cancer.11 Tobacco use is the result of the complex interaction of individual and social factors, such as socio-economic status, having family members who smoke and exposure to marketing tactics of the tobacco industry. Reduction and elimination of tobacco use requires comprehensive, multi-faceted strategies addressing both physical dependence and social context. Such strategies will include: * prevention - helping to keep non-users from starting to use tobacco; * cessation - helping current smokers to quit, and helping prevent relapse; and * protection - protecting all Canadians from the harmful effects of tobacco use and from the influences of tobacco industry marketing. Prevention is the most important strategy of the three; being tobacco-free is a vital element of a healthy active life. Thus, for current tobacco users, quitting is the single most effective action they can take to enhance the quality and length of their lives. Most tobacco users would like to improve their health, and in a Canadian survey 30 per cent of all smokers stated that they intended to quit as means of doing so.12 Indeed, in studies in Canada, the U.K. and Germany, smokers rated health concerns and current health problems as the primary reason for wanting to quit;13 other reasons why smokers quit include the cost of cigarettes14 and persistent advice to quit from family15 and health professionals.16 However, the relapse rate is very high because of the addictive nature of tobacco.17 Most smokers attempt to quit several times before they finally succeed. Smoking cessation counselling is widely recognized as an effective clinical strategy. Even a brief intervention by a health professional significantly increases the cessation rate.18 Furthermore, counselling programs that initiate follow-up calls to smokers as a "proactive" measure have been found to increase smoking-cessation rates by 50 per cent.19 The majority of Canadians consult a health professional at least once a year,20 creating several "teachable moments" when they may be more motivated than usual to change unhealthy behaviours.21 A smoker's likelihood of quitting increases when he or she hears the message from a number of health-care providers from a variety of disciplines.22 However, health professionals encounter barriers that require solutions, notably: - the need for better education for health professionals (e.g., how to identify smokers quickly and easily, which treatments are most effective, how such treatments can be delivered); - the need to allow for sufficient time to provide counselling; - the need to focus on preventive care by * increasing funding for preventive care (e.g., providing reimbursement for smoking cessation interventions, follow-up or support); and * encouraging health-care settings to facilitate preventive care (e.g., access to quick reference guides or tools to identify people with specific risk factors); - the need to increase public awareness of the smoking cessation services a health professional can provide; and - the need to recognize the frustration associated with the high rate of relapse. Because of the powerful nature of tobacco dependence, smokers often go through a long period of reaching readiness before they finally quit. References Bao Y., Duan N., & Fox S. A. (2006). Is some provider advice on smoking cessation better than no advice? An instrument variable analysis of the 2001 National Health Interview Survey. Health Services Research, 41(6), 2114-2135 Breitling, L. P., Rothenbacher, D., Stegmaier, C., Raum, E., & Brenner, H. (2009). Older smokers' motivation and attempts to quit smoking. Deutsches Arzteblatt International, 106(27), 451-455. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment. (2008). Dynamic guidelines for tobacco control in Canada Version 1.0 [Wiki clinical practice guidelines]. Toronto: Author. Canadian Cancer Society. (2010). Second-hand smoke is dangerous. Toronto: Author. Retrieved May 19, 2010, from http://www.cancer.ca/canada-wide/prevention/quit%20smoking/second-hand%20smoke.aspx Canadian Centre on Substance Abuse, (2006). The costs of substance abuse in Canada in 2002. Ottawa: Author. Canadian Lung Association. (2006). Smoking and tobacco: Second-hand smoke. Retrieved June 14, 2010, from http://www.lung.ca/protect-protegez/tobacco-tabagisme/second-secondaire/hurts-nuit_e.php Canadian Dental Hygienists Association. (2004). Tobacco use cessation services and the role of the dental hygienist - a CDHA position paper. Canadian Journal of Dental Hygiene, 38(6), 260-279. Canadian Medical Association. (2008). Tobacco control [Policy statement]. Ottawa: Author. Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., & Curry, S. J. (2008). Treating tobacco use and dependence: 2008 update [Clinical practice guideline]. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Health Canada. (2009). Smoking and your body: Health effects of smoking. Ottawa: Author. Retrieved June 17, 2010, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/body-corps/index-eng.php Health Canada. (2007). Overview of health risks of smoking. Ottawa: Author. Retrieved June 17, 2010, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/res/news-nouvelles/risks-risques-eng.php Nabalamba, A, & Millar, W. J. (2007). Going to the doctor [Statistics Canada, catalogue 82-003]. Health Reports, 18(1), 23-35. Retrieved January 26, 2011, from http://www.statcan.gc.ca/pub/82-003-x/2006002/article/doctor-medecin/9569-eng.pdf Physicians for a Smoke-Free Canada. (2005). Smoking in Canada: A statistical snapshot of Canadian smokers. Ottawa: Author. Retrieved May 14, 2010, from http://www.smoke-free.ca/pdf_1/SmokinginCanada-2005.pdf Registered Nurses' Association of Ontario. (2007). Integrating smoking cessation into daily nursing practice [Nursing best practice guideline]. Toronto: Author. Ross, H., Blecher, E., Yan, L., & Hyland, A. (2010) Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction, November 2010. Shields, M. (2004). A step forward, a step back: Smoking cessation and relapse. National Population Health Survey, Vol. 1, No. 1. Ottawa: Statistics Canada. Statistics Canada. (2009). Canadian tobacco use monitoring survey (CTUMS): CTUMS 2009 wave 1 survey results. Ottawa: Author. Retrieved January 25, 2011, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_ctums-esutc_2009/w-p-1_sum-som-eng.php Stead, L. F., Lancaster, T., & Perera, R. (2006). Telephone counselling for smoking cessation (review). Cochrane Database of Systematic Reviews, Issue 3. Vangeli, E., & West, R. (2008). Sociodemographic differences in triggers to quit smoking: findings from a national survey. Tobacco Control, 17(6), 410-415. Young, R.P., Hopkins, R.J., Smith, M., & Hogarth, D.K. (2010). Smoking cessation: The potential role of risk assessment tools as motivational triggers. Post Graduate Medical Journal, 86(1011), 26-33. Replaces: Tobacco: The role of health professionals in smoking cessation [Joint position statement]. (2001) 1 For detailed recommendations and guidelines for tobacco treatment related to health professionals, see Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, (2008); Registered Nurses' Association of Ontario, (2007); and Canadian Dental Hygienists Association, (2004). 2 For the purpose of this position statement, tobacco includes products that can be inhaled, sniffed, sucked or chewed (e.g., flavoured cigarillos, kreteks, chewing tobacco, moist snuff, betel or qat, hookah or shisha, bidis, cigars and pipes). 3 (Health Canada, 2009) 4 (Health Canada, 2007) 5 (Statistics Canada, 2009) 6 (Health Canada, 2007) 7 (Canadian Centre on Substance Abuse, 2006) 8 (Canadian Cancer Society, 2010) 9 (Canadian Lung Association, 2006) 10 (Canadian Cancer Society, 2010) 11 (Canadian Cancer Society, 2010) 12 (Physicians for a Smoke-Free Canada, 2005) 13 (Vangeli & West, 2008; Ontario Tobacco Research Unit - Tobacco Informatics Monitoring System (TIMS), 2008; Breitling, Rothenbacher, Stegmaier, Raum & Brenner, 2009) 14 (Ross, Blecher, Yan & Hyland, 2010) 15 (Young, Hopkins, Smith & Hogarth, 2010) 16 (Bao, Duan & Fox, 2006) 17 (Fiore et al., 2008; Shields, 2004) 18 (Fiore et al., 2008) 19 (Stead, Lancaster & Perera, 2006) 20 (Nabalamba & Millar, 2007) 21 (Canadian Medical Association, 2008) 22 (Fiore et al., 2008)
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Recommended guidelines for low-risk drinking

https://policybase.cma.ca/en/permalink/policy10143
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
Text
Note: These Guidelines are not intended to encourage people who choose to abstain for cultural, spiritual or other reasons to drink, nor are they intended to encourage people to commence drinking to achieve health benefits. People of low bodyweight or who are not accustomed to alcohol are advised to consume below these maximum limits. Guideline 1 Do not drink in these situations: When operating any kind of vehicle, tools or machinery; using medications or other drugs that interact with alcohol; engaging in sports or other potentially dangerous physical activities; working; making important decisions; if pregnant or planning to be pregnant; before breastfeeding; while responsible for the care or supervision of others; if suffering from serious physical illness, mental illness or alcohol dependence. Guideline 2 If you drink, reduce long- term health risks by staying within these average levels: Women Men 0–2 standard drinks* per day 0–3 standard drinks* per day No more than 10 standard drinks per week No more than 15 standard drinks per week Always have some non-drinking days per week to minimize tolerance and habit formation. Do not increase drinking to the upper limits as health benefits are greatest at up to one drink per day. Do not exceed the daily limits specified in Guideline 3. Guideline 3 If you drink, reduce short- term risks by choosing safe situations and restricting your alcohol intake: Risk of injury increases with each additional drink in many situations. For both health and safety reasons, it is important not to drink more than: Three standard drinks* in one day for a woman Four standard drinks* in one day for a man Drinking at these upper levels should only happen occasionally and always be consistent with the weekly limits specified in Guideline 2. It is especially important on these occasions to drink with meals and not on an empty stomach; to have no more than two standard drinks in any three-hour period; to alternate with caffeine-free, non-alcoholic drinks; and to avoid risky situations and activities. Individuals with reduced tolerance, whether due to low bodyweight, being under the age of 25 or over 65 years old, are advised to never exceed Guideline 2 upper levels. Guideline 4 When pregnant or planning to be pregnant: The safest option during pregnancy or when planning to become pregnant is to not drink alcohol at all. Alcohol in the mother's bloodstream can harm the developing fetus. While the risk from light consumption during pregnancy appears very low, there is no threshold of alcohol use in pregnancy that has been definitively proven to be safe. Guideline 5 Alcohol and young people: Alcohol can harm healthy physical and mental development of children and adolescents. Uptake of drinking by youth should be delayed at least until the late teens and be consistent with local legal drinking age laws. Once a decision to start drinking is made, drinking should occur in a safe environment, under parental guidance and at low levels (i.e., one or two standard drinks* once or twice per week). From legal drinking age to 24 years, it is recommended women never exceed two drinks per day and men never exceed three drinks in one day. 2 Approved by the CMA Board in March 2011 Last reviewed and approved by the CMA Board in March 2019. The above is excerpted from the report, Alcohol and Health in Canada: A Summary of Evidence and Guidelines for Low-Risk Drinking Available: https://www.ccsa.ca/sites/default/files/2019-04/2011-Summary-of-Evidence-and-Guidelines-for-Low-Risk%20Drinking-en.pdf (accessed 2019 March 01).
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Determining the impact of chemical contamination on human health

https://policybase.cma.ca/en/permalink/policy10149
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Population health/ health equity/ public health
Text
Industrialization and manufacturing have had enormous positive benefits for humankind, but the consequences of hazardous by-products (chemical contamination) to human health and the environment are less well recognized. A major incident such as Bhopal is an unequivocal example of catastrophic poisoning caused by industry. However, more subtle human health impacts can result from low levels of exposure to chemical and industrial by-products from agriculture, consumer products, manufacturing, and even medical sources. Chemicals from industrial sources have been found in the soil, water, air, food and human tissue. Due to improving technology, even minuscule amounts of potentially noxious substances can be detected. Some exposures warrant remedial action, but in others the health impact may be negligible: the toxin, dose, route and duration of exposure must be considered. Of course, there are potentially toxic substances that have been found to pose little or no harm to human health, but there are many more for which the health effects are unknown. A substantial knowledge gap exists in that the effects of many chemical agents have not been fully studied. As a result, rigorous surveillance and assessment to ensure potential health impacts are reduced or avoided is necessary. Chemicals like dichlorodiphenyltrichloroethane (DDT) can persist in the environment or in living beings long after the product was pulled from the market, making it essential that full and rigorous testing of new and existing chemicals is undertaken. Finally, research is needed to determine whether emerging issues, such as the presence of pharmaceuticals in drinking water, pose a legitimate threat to human health. Chemicals, properly managed, can and will continue to provide enormous benefits to society, but caution is warranted because of the potential health consequences. Provided below is a discussion of certain classes of chemicals that need to be regulated, monitored and properly researched. Agriculture Agriculture represents the largest component of the global economy. Rising pressures to meet the needs of a growing population have resulted in the mechanization of farming, and the widespread use of fertilizers and pesticides.1 Fertilizer and pesticide run-off has been found in soil, water and the human food supply.2 Approximately 40 chemicals classified by the International Agency for Research on Cancer (IARC) as known, probable, or possible human carcinogens, are EPA registered pesticides available on the open market.3 Long-term low dose pesticide exposure has been linked to various cancers, immune suppression, hormonal disruption, reproductive abnormalities, birth defects, and developmental and behavioural problems.4 Certain pesticides are also known to be persistent in the human body.5 While many individual pesticides can be safely used, there is a lack of research on the effect of certain pesticides when used in combination. Consumer Products Modern technologies have led to advances with a positive impact on the quality of human life. While newer consumer products have benefits over earlier materials, their use is not without side effects. Both the chemicals used to make these products and those that form key components of the products themselves may be harmful. Bisphenol A (BPA) is an industrial chemical added to many hard plastic bottles and to metal based food and beverage cans since the 1960s.6 In August 2010, Statistics Canada reported that measurable levels of BPA were found in the urine of 91 per cent of Canadians aged six to 79.7 Concerns have been raised about effects on the brain, behaviour, and prostate gland from exposure to this chemical, particularly in fetuses, infants, and children.8 In 2008, Canada banned BPA in infant bottles.9 In October 2010, Canada went a step further by becoming the first jurisdiction in the world to declare BPA toxic.10 Manufacturing With the growing demand for consumer products, there has been a corresponding growth in manufacturing. Manufacturing is one of the biggest contributors to outdoor air pollution, and contributes to soil and water pollution.11 In 2004, US industry released 1.8 billion pounds of potentially toxic chemicals. Exposure to some of these chemicals has been linked to severe health effects, including cancer. 12 One of the released chemicals, dioxin, can be harmful at very low levels. Dioxins accumulate in fats and break down slowly. This leads to contamination of the food supply, and human exposure through the consumption of meat, dairy, fish and shellfish.13 Even in the far north, animals have been found to contain dioxins.14 The EPA estimates that the cancer risk from dioxins already present in the general public is 1-per-1,000.15 In most cases the emissions pose minimal risk to human health. However, chemicals, and chemical combinations which remain unstudied should be properly assessed.16 Medical Practices Advancements in medical science and the use of pharmaceuticals, diagnostic equipment and other medical treatments have prolonged life expectancy. However, these interventions can also contribute to environmental contamination. In 2008, the Associated Press reported pharmaceuticals in the water of 24 major metropolitan areas in the United States, serving 41 million people.17 There is a concern that these pharmaceuticals could negatively impact male fertility, lead to birth defects, cause breast and testicular cancer in humans, and lead to antibiotic resistance.18 For many pharmaceuticals found in water sources, no concerted environmental impact surveys have been carried out.19 Mercury is used in fever thermometers, sphygmomanometers, gastrointestinal tubes, and oesophageal dilators20. Reports indicate that medical waste incinerators are among the largest sources of anthropogenic mercury emissions in both the United States and Canada.21 Medical waste, while not the principle source of mercury poisoning, contributes to the mercury levels present in the environment. In fetuses, infants and children, low-dose exposure to mercury can cause severe and lifelong behavioural and cognitive problems.22 At higher exposure levels, mercury may adversely affect the kidneys, the immune, neurological, respiratory, cardiovascular, gastrointestinal, and haematological systems of adults.23 It has also been linked to cancer.24 These examples highlight the major categories of human exposure to chemicals. As the review suggests, some of these chemicals have been linked to harmful human health impacts. What is important to keep in mind, however, is that the harm is conditional on the level and lengths of exposure. For most people, these chemicals pose no harm because the exposure is so low. In some cases, such as BPA, it has been determined that the potential harm is not worth the risk: the Canadian government has decided to declare BPA toxic and regulate it accordingly. In other cases, such as pharmaceuticals, the evidence simply warrants further study and surveillance. Given the potential harm to human health, surveillance and research are vitally important in all categories. The more information that is available to policy makers and health care professionals, the better the chance of limiting human health impacts. What has been done? International Action Concerns regarding chemical contamination and human health have led to numerous interventions from the international community. These include the International Programme on Chemical Safety (1980), the Inter-Organization Programme for the Sound Management of Chemicals (1995), the Globally Harmonized System of Classification and Labelling (2002), and the Strategic Approach to International Chemicals Management, which was adopted by governments and stakeholders at the first International Conference on Chemicals held in Dubai in 2006. 25 Various conventions have also been passed, including the Stockholm Convention (2004) on persistent organic pollutants such as DDT, and the Rotterdam Convention (2004) which applies to pesticides and industrial chemicals.26 There is some concern about the continued effectiveness of the Rotterdam convention. In 2006, the Canadian government was instrumental in preventing the listing of asbestos as a toxic chemical. Given the persuasive evidence of the harm caused by asbestos, this action undermines the legitimacy of voluntary international conventions.27 Canadian Action In addition to being a signatory to all international agreements listed above, the Canadian government has programs for chemical management domestically. The main tool is the Canadian Environmental Protection Act (CEPA) 1999. Jointly administered by Environment Canada and Health Canada, it is intended to prevent pollution and address the potentially dangerous chemical substances to which Canadians are exposed.28 The plan calls for increased surveillance of certain chemicals to monitor exposure and health effects, and will increase focus on the management of the health and environmental risks of pharmaceuticals, personal care products, and chemical contamination in food.29 There were 23,000 chemical substances on the Domestic Substances List (DSL) in Canada in 1999. To date, only about 1,000 of these chemicals have been fully assessed. Of the remaining 22,000, 85% have been categorized as not requiring any additional action.30The most recent Canadian Chemicals Management Plan states that full assessments will be done on 550 substances identified as potentially harmful. Even with these additional assessments, more than 3,000 chemicals will not have been assessed. Canadian Medical Association In 2009, the Canadian Medical Association and the Canadian Nurses Association released a joint position statement on environmentally responsible activity for the health-care sector. Recommendations included the proper handling and disposal of toxic chemicals and the reduction of products using these substances. An adapted version of this position statement was then endorsed by a coalition of 12 national healthcare organizations and the David Suzuki Foundation. In October 2010, the World Medical Association, of which CMA is a member, adopted a policy statement on environmental degradation and the management of chemicals. The statement calls for mercury-free health care, support for international efforts to restrict chemical pollution and to monitor harmful chemicals in humans and the environment, and mitigation of the health effects of toxic exposure to chemicals. What needs to be done? Research and Surveillance Research on chemicals produced through man-made activities remains insufficient. While some of the more toxic chemicals have been reviewed and are now more closely regulated, thousands remain that have had neither health nor environmental assessments. The Domestic Substances List in Canada has 3,300 chemicals of concern that have not been assessed. There is limited research on the effect of these chemicals in combination or in different mediums. Finally, work must be done to ensure environmental and human surveillance of potential chemical exposure threats. The CMA: 1. Urges the government to complete the health and environmental assessment of the chemicals on the Domestic Substances List. 2. Encourages research on the health impacts of chemical substances, as well as the combinations of these substances in different products (e.g. pesticides), and in different mediums (e.g. pharmaceuticals in drinking water). Long-term research programs are required to determine health impacts from prolonged low-dose exposures. 3. Encourages ongoing surveillance of chemicals in the environment. 4. Encourages ongoing research on the impact of regulations and monitoring of chemicals on human health and the environment. Advocacy Regulations have been developed both internationally and domestically to undertake chemical management. However, gaps remain, largely due to the voluntary nature of the frameworks. Canada can play a lead role by respecting its commitments, seeking continued adherence to these agreements and providing leadership in developing effective domestic programs and legislation. The CMA: 5. Urges the government to continue to support international efforts to manage chemical pollution. In particular CMA urges the government to fully support the principles of the Rotterdam Convention and support the listing of Asbestos as an Annex III toxic chemical. 6. Supports government legislation and regulation which reduces dangerous chemical pollution, detects and monitors harmful chemicals in both humans and the environment, mitigates the health effects of toxic exposures, and requires an environmental and health impact assessment prior to the introduction of a new chemical. Regulatory frameworks should be favoured over voluntary frameworks in order to ensure a level playing field for all manufacturers and to secure rapid and equitable health protection for all Canadians. CMA encourages the government to advocate for similar legislation internationally. Leadership Physicians can participate in the monitoring of patients for potential health effects from chemical exposure. Additionally, physicians can be leaders in encouraging greener health care practices. Finally, physicians can support national medical organizations in developing clinical tools to assess patient risk to chemical exposure. The CMA: 7. Supports the phase out of mercury and other persistent, bio-accumulating and toxic chemicals in health care devices and products. 8. Supports the development of effective and safe systems to collect and dispose of pharmaceuticals that are not consumed. 9. Supports the development of clinical tools for physicians to help assess their patients' risk from chemical exposures. Education and Professional Development Physicians have a role to play in educating their patients, the public, and current and future colleagues about the potential human health consequences of chemical contamination. Medical education and continuing professional development in this area could have a significant impact on human health. The CMA: 10. Should assist in building professional and public awareness of the impact of the environment and global chemical pollutants on personal health. 11. Supports the development of locally appropriate continuing medical education on the clinical signs, diagnosis and treatment of diseases that are introduced into communities as a result of chemical pollution. 12. Encourages physicians to inform patients about the importance of safe disposal of pharmaceuticals that are not consumed. Conclusion National and International initiatives have substantially reduced the incidence of harmful chemical contamination, but more work is needed. Evidence of health effects (or lack thereof) may be strong for certain chemicals, but for others it remains incomplete. Given the dangers of chemicals such as dioxin, which can cause severe effects with small doses, more comprehensive research is warranted. To ensure human health consequences are identified and risks are minimized, improved surveillance is essential. Further policies and regulations are needed to ensure that chemicals utilized are as safe as possible. The Canadian BPA ban demonstrates the use of the precautionary principle in the presence of convincing if not complete evidence. While there are clear benefits associated with the use of chemicals, it is necessary to ensure that potential harmful effects are considered.' Finally, public and health care provider information is sorely lacking. Physicians can play a role in correcting some of these deficiencies through their actions to support research and surveillance, advocacy, leadership, education, and professional development. References 1 Ongley, Edwin D. (1996) Control of water pollution from agriculture- FAO irrigation and drainage paper 55.Chapter 1: Introduction to agricultural water pollution Food and Agriculture Organization of the United Nations. Available at: http://www.fao.org/docrep/w2598e/w2598e00.HTM 2 Peters, Ruud J.B. (2006) Man-Made Chemicals in Food Products. TNO Built Environment and Geosciences. Available at: http://assets.panda.org/downloads/tno_report.pdf 3 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk: What We Can Do Now: 2008-2009 Annual Report. President's Cancer Panel. Available at: http://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf 4 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk...; Shah, Binod P. & Bhupendra Devkota (2009) "Obsolete Pesticides: Their Environmental and Human Health Hazards." The Journal of Agriculture and Environment. Vol:10 June 2009. Available at: http://www.nepjol.info/index.php/AEJ/article/view/2130/1961 ; Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution: Burden and Strategies for Control in Disease Control Priorities in Developing Countries. Disease Control Priorities Project. Available at: http://files.dcp2.org/pdf/DCP/DCP43.pdf 5 California Environmental Protection Agency (2002) Environmental Protection Indicators for California: Chapter 3: Environmental Exposure Impacts Upon Human Health. Available at: http://oehha.ca.gov/multimedia/epic/2002reptpdf/Chapter3-7of8-HumanHealth.pdf 6 United States Food and Drug Administration (2010) Update on Bisphenol A for Use in Food Contact Applications. Available at: http://www.fda.gov/newsevents/publichealthfocus/ucm064437.htm 7 CBC News (October 13, 2010) BPA declared toxic by Canada. Available at: http://www.cbc.ca/health/story/2010/10/13/bpa-toxic.html 8 States Food and Drug Administration (2010) Update on Bisphenol A... 9 Health Canada (2008) Government of Canada Protects Families with Bisphenol A Regulations Available at: http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2008/2008_167-eng.php 10 CBC News (October 13, 2010) BPA declared toxic by Canada... 11 Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution... 12 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health: An Analysis of Toxic Chemicals Released in Communities across the United States. U.S. PIRG Education Fund. Available at: http://cdn.publicinterestnetwork.org/assets/KTfes5EXnCLOgG9eWTKU6g/ToxicPollutionandHealth2007.pdf 13 World Health Organization (2010) Dioxins and their effects on human health. Available at: http://www.who.int/mediacentre/factsheets/fs225/en/index.html 14 Woolford, Julian & Noemi Cano Ed. (2006) Killing them softly... 15 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health... 16 Ibid 17 Natural Resources Defense Council (2010) Dosed Without Prescription: Preventing Pharmaceutical Contamination of Our Nation's Drinking Water. Available at: http://www.nrdc.org/health/files/dosed4pgr.pdf 18 Wright-Walters, Maxine & Conrad Volz (2009) Municipal Wastewater Concentrations of Pharmaceutical and Xeno-Estrogens: Wildlife and Human Health Implications. Available at: http://www.chec.pitt.edu/Exposure_concentration_of_Xenoestrogen_in_pharmaceutical_and_Municipal_Wastewater__Final8-28-07%5B1%5D.pdf; Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment. Available at: www.epa.gov/osp/regions/emerpoll/daughton.ppt; Nikolaou, Anastasia; Meric, Sureyya & Despo Fatta (2007) "Occurrence patterns of pharmaceuticals in water and wastewater environments." Analytical and Bioanalytical Chemistry. 387: 1225-1234; Natural Resources Defense Council (2010) Dosed Without Prescription... 19 Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment... 20 Environment Canada. (N.D.)Mercury and the Environment. Available at: http://www.ec.gc.ca/MERCURY/SM/EN/sm-mcp.cfm#MD 21 Health Care Without Harm (2007) The Global Movement for Mercury Free Health Care. Available at: http://www.noharm.org/lib/downloads/mercury/Global_Mvmt_Mercury-Free.pdf; World Health Organization (2005) Mercury in Health Care: Policy Paper. Available at: http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpaper.pdf 22 Environmental Working Group (N.D.) Chemical Pollution: The Toll on America's Health. Available at: http://www.ewg.org/files/EWG-kid-safe-toll-on-health.pdf 23 California Environmental Protection Agency (2002) Environmental Protection Indicators... 24 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk... 25 World Health Organization (N.D.) International Programme on Chemical Safety: About us. Available at: http://www.who.int/ipcs/en/; World Health Organization (N.D.) Inter-Organization Programme for the Sound Management of Chemicals. Available at: http://www.who.int/iomc/brochure/brochure_english.pdf; United Nations Economic Commission for Europe (N.D.) Globally Harmonized System of Classification and Labelling of Chemicals (GHS). Available at: http://www.unece.org/trans/danger/publi/ghs/ghs_welcome_e.html; Weinberg, Jack (2008) An NGO Guide to SAICM: The Strategic Approach to International Chemicals Management. Available at: http://www.ipen.org/ipenweb/documents/book/saicm%20introduction%20english.pdf 26 Eskenazi, Brenda et.al. (2009) "The Pine River Statement: Human Health Consequences of DDT Use." Environmental Health Perspectives. 117:1359-1367 Available at: http://www.eoearth.org/article/Human_Health_Consequences_of_DDT_Use#gen4; World Health Organization (N.D.) Rotterdam Convention: Share Responsibility. Available at: http://www.pic.int/home.php?type=t&id=5&sid=16 27 Kazan-Allen, Laurie (2007) Rotterdam Treaty Killed by Chrysotile Asbestos! International Ban Asbestos Secretariat. Available at: http://www.ibasecretariat.org/lka_rott_meet_geneva_oct_06.php 28 Government of Canada (2007) The Canadian Environmental Protection Act, 1999 (CEPA 1999). Available at: http://www.chemicalsubstanceschimiques.gc.ca/about-apropos/cepa-lcpe-eng.php 29 Government of Canada (2010) Chemicals Management Plan. Available at: http://www.chemicalsubstanceschimiques.gc.ca/plan/index-eng.php 30 Ibid.
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Medication use and seniors (Update 2017)

https://policybase.cma.ca/en/permalink/policy10151
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-05-28
Replaces
Medication use and seniors
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Older Canadians represent the fastest-growing segment of our population and are the largest users of prescription drugs. Seniors take more drugs than younger Canadians because, on average, they have a higher number of chronic conditions. According to the Canadian Institute for Health Information, in 2012, nearly two-thirds of seniors had claims for 5 or more drug classes, and more than one-quarter of seniors had claims for 10 or more drug classes. The number of drugs used by seniors increased with age. The use of multiple medications, or polypharmacy, is of concern in the senior population. The risk of drug interactions and adverse drug reactions is several-fold higher for seniors than for younger people. This phenomenon is associated with pharmacokinetic and pharmacodynamics factors in seniors, including changes in renal and hepatic function, increased sensitivity to drugs and, potentially, multiple medical problems. In older persons, adverse drug reactions are often complex and may be the direct cause of hospital admissions for acute care. Cognitive and affective disorders, for example, may be due to adverse reactions to sedatives or hypnotic drugs. Chronic pain is a common issue, and it is important to carry out research into and education for health care providers concerning the unique challenges of managing pain in older adults. The CMA supports the development of a coordinated national approach to reduce polypharmacy and prevent adverse drug reactions. Prescribers must be vigilant to optimize pharmacotherapy and in reconciling medications, taking into consideration physiological changes as a person ages. Deprescribing should be considered, reducing or stopping medications that may be harmful or no longer be of benefit, seeking to improve quality of life. There has been considerable interest in determining which factors affect prescribing behavior and how best to influence these factors. Strategies that improve prescribing practices include evidence-based drug information provided through academic detailing; objective continuing medical education; accessible, user-friendly decision support tools available at point of care; and electronic prescribing systems that allow physicians access to their patient's treatment and medication profiles. The following principles define the basic steps to appropriate prescribing for seniors.
Know the patient.
Know the diagnosis.
Know the drug history. Keep a medication list for each patient and review, update, reconcile and evaluate adherence at each visit. Instruct the patient to bring all prescription and over-the-counter medications, including medications prescribed by other physicians, and natural health products, to each appointment. In some provinces, pharmacists conduct medication use reviews for patients on public drug benefit programs.
Know the history of use of other substances such as alcohol, tobacco, cannabis, opioids and caffeine.
Consider non-pharmacologic therapy, including diet, exercise, psychotherapy or community resources. Continuing medical education in specific non-pharmacologic therapies is valuable. For example, evaluation and management of behavioural and psychological symptoms of dementia should be considered before anti-psychotic therapy. As well, Canadian standardized non-pharmacologic order sets should be developed for the treatment of delirium.
Know the drugs. Critically evaluate all sources of drug information and use multiple sources such as clinical practice guidelines, medical journals and databases, continuing medical education and regional drug information centres. Monitor patients continually for adverse drug reactions. Appropriate drug dosage depends on factors such as age, sex, body size, general health, concurrent illnesses and medications, and hepatic, renal and cognitive function (for example, older people are particularly sensitive to drugs that affect the central nervous system).
Keep drug regimens simple. Avoid mixed-frequency schedules when possible. Try to keep the number of drugs used for long-term therapy under five to minimize the chance of drug interactions and improve adherence.
Establish treatment goals. Determine how the achievement of goals will be assessed. Regularly re-evaluate goals, adequacy of response and justification for continuing therapy. Time to benefit of prescribed medications should be a key consideration when providing care to seniors at end of life.
Encourage patients to be responsible medication users. Verify that the patient and, if necessary, the caregiver, understands the methods and need for medication. Recommend the use of daily or weekly medication containers, calendars, diaries or other reminders, as appropriate, and monitor regularly for compliance. Encourage the use of one dispensary. The Institute for Safe Medication Practices Canada has developed a program, Knowledge is the best medicine (https://www.knowledgeisthebestmedicine.org), that can be helpful to seniors and their healthcare team manage medicines safely and appropriately. Approved by the Board on May 28, 2011 Update approved by the Board on March 02, 2019
Documents
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Principles for health system governance

https://policybase.cma.ca/en/permalink/policy10320
Last Reviewed
2019-03-03
Date
2011-10-23
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-10-23
Replaces
Regionalization (Update 2001)
Topics
Health systems, system funding and performance
Text
Principles for Health System Governance This policy provides principles and recommendations for developing, implementing and evaluating health system governance models such as regionalized health care for the purposes of delivering high quality care to patients. Since the 1990s, health care systems in many countries including Canada have been searching for more effective health system governance models to accomplish a variety of health policy objectives. These objectives include funding health care based on population health needs and improving service delivery integration. In Canada, most provinces and territories moved to a regionalized model of health system governance during the 1990s. This "regionalization" approach involved both decentralizing and centralizing specific elements of the health care system. Decentralizing involved moving planning, budgeting and decision making authority from the provincial or territorial level to certain regional bodies. Centralizing involved moving the planning and governance of health care and medical services from individual institutions or agencies to a regional body. In terms of the delivery of health care services, centralization often occurred through the consolidation of several programs into a single program for a region and through the merger and closure of individual institutions. Since 2003, several provincial governments initiated new changes to their approach to health system governance ranging from vertical integration involving a range of health agencies under a single board (e.g., Quebec) to the creation of boards that oversee the delivery of care for larger portions of a jurisdiction or even the entire jurisdiction itself (e.g., Alberta Health Services). Many of these new models involve an arm's length authority governed by an appointed board that is mandated to manage and integrate the operations of the health system across the province/territory while leaving the ministry of health to set the overall plan and priorities for the health system as well as set standards and monitor outcomes. No doubt, governments will continue to search for an ideal health system governance and delivery model as part of an effort to develop "high performing health systems". Examples of high performing health systems exist at all levels such as at regional levels within countries (e.g., Jonkoping, Sweden) or at the client group level (e.g., US Veterans Health Administration). Health system governance models, such as health regions or health agencies, must have an overall goal of ensuring the delivery of high quality, timely and accessible care to its citizens. The Institute for Healthcare Improvement's (IHI) Triple Aim concept identifies three objectives for health systems: improve the health of the population; improve the health care experience for patients; and improve the value for money spent on health and health care. Many previous health system reforms have not resulted in improved care for patients. The CMA's 2010 action plan, Health Care Transformation in Canada: Change that Works. Care that Lasts, calls for patient-centred health care that puts the patients and their families' interests first. From the health provider perspective, previous regionalization efforts have raised several issues of concern, including whether these models translate into improved delivery of care for patients. There is also concern with the prospect that new models will limit provider involvement in health system governance and that health human resource planning will be localized when mobility of labour transcends local borders. The CMA is committed to playing a positive role in the debate on the future of health care reform in Canada. It recognizes that health system governance models are subject to change. However, this CMA policy on health system governance identifies fundamental principles that should guide any model under consideration. These guiding principles draw upon previous CMA work starting in 1991 with its Working Group on Regionalization, leading to its Language of Health System Reform report. Guiding principles Patient-centred: Any consideration of governance models must begin with an overall goal of providing patient-centred care-seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity. Defined objectives: The development and implementation of health system governance models/strategies must begin with a clear statement of objectives. The objectives should reflect the changes that need to be made to the health care system to address specific problems and, whenever possible, must be defined in measurable terms so that health system governance policies can be evaluated. Accountability/authority: Aligning accountability and authority is essential to effective and sustainable high performing health systems. Accountability is affected by the degree of authority and the scope of responsibilities (i.e., planning, administration, organization and funding of health care services) transferred to the governing units (e.g., regions). Who is accountable, and for what, need to be defined. There needs to be a clear statement of the roles of government, governing boards, physicians and all health care stakeholders. Physicians have a unique contribution to make and their views should be taken into account in any restructuring of the health care delivery system. Needs based planning/Responsive to regional needs: The definition of the region(s) or sub-regions should reflect the natural, socio-political and geographic divisions of the population. Once regions are defined, the health care needs of the population served by regional units should be determined through epidemiological studies, input from communities and other needs assessment. In addition to local planning, there is also the need for broader based planning to address medical and scientific research, new technologies and procedures. Regional health needs can vary requiring flexible delivery models. Credentialing that meets jurisdictional standards should be maintained at the regional level in order to effectively respond to regional needs and issues. Informed choice: Any form of health system governance should not restrict patients' mobility between providers or regions, physicians' mobility between and within regions, or physicians' choice of practice setting by limiting employment to community health centres or other forms of group practice. Participatory democracy Both patients/public and providers should be involved in determining governance models and participating in the ongoing governance of health systems. If providers are to be encouraged to get involved, they need to have ready access to the planning and administrative skills needed to participate effectively and make a valuable contribution to management and leadership. Three key areas in which providers must become knowledgeable and involved include governance and credentialing, health care needs assessment and health economics. Clinical autonomy: Physicians have a responsibility to advocate on behalf of their patients to ensure the availability of needed care. This responsibility should not be hindered by a physician's practice setting, mode of remuneration or paying agency. Evaluation: Evaluation protocols must be built into health system governance models at the outset, and the results of evaluation must be used to "fine tune" and improve the strategies. These protocols should address cost effectiveness, population health status, patient access to health care services and the interests of government, the profession and the public. Standards for reasonable access: Certain areas and cultural groups do not have the same level of access to health care services as the national norm. All health system governance models should address these shortcomings to ensure that the entire population of any given region has reasonable access to primary, secondary and tertiary care. Balancing access and affordability: One of the implicit objectives of new models of health system governance appears to be achieving both control over health care costs and redirecting expenditures from health care to community and social services. Governing authorities must be careful to maintain a balance between access to health care services and affordability allowing for a variety of methods to achieve this (e.g., internal markets). They must also maintain a comprehensive accounting of the cost of implementing any new model. Balancing curative with preventive and sustaining care: All health system governance models must support not only the system's ability to provide curative care but also an ability to provide effective preventive and sustaining care. Governance models should ensure funds can be allocated toward a comprehensive approach to care as well as allow for models of care that support all three functions. Support for medical education and research: Policies and structures of health system governance models need to acknowledge and foster the role of medical education and research in the health care system. Governance of medical teaching and research should reside within the academic health sciences centres. These centres should be assured of adequate financial and human resources and of access to cross regional patient populations and to community teaching sites in order to provide adequate learning and research opportunities. Recommendations With regard to the development, implementation and evaluation of health system governance models, the CMA recommends that: * advocacy on behalf of patients and physicians be maintained irrespective of any regional administrative boundaries; * governments ensure that the introduction of new models of health system governance do not interfere with clinical autonomy and professional freedom in the context of the physician/patient relationship; * governments, health governing authorities and institutions ensure that physicians, through their professional associations, are included in the development and revision of practitioner/medical staff bylaws and appointment policies; * family physicians, on the basis of their education, training and skills, are reaffirmed as the preferred point of entry into Canada's health care system; * governments ensure that catchment area under the governing authority be defined in a way that is sensitive to the political, cultural and geographic circumstances of the population and recognizes established patterns of the demand for, and the provision of, health care; * governments ensure that the introduction of new governance models does not interfere with reasonable access by the population to medical services at the primary, secondary and tertiary levels; * leadership be provided to help ensure that the development, implementation and evaluation of health system governance models are based on clear, measurable objectives; * governments develop and maintain national standards for access to high quality health care, medical education and research, irrespective of regional boundaries; * governments ensure that programs and policies under any form of health system governance be designed and implemented in a manner that supports key principles of medical education and research, including: - the governance and resources required for medical teaching, both in the academic health sciences centres and in appropriate community based sites throughout the province or territory, - academic health sciences centres' responsibilities for providing secondary and tertiary care to catchment populations that cut across regional boundaries, and - the need for academic physician resource plans to ensure a critical mass for teaching and research; * governments give priority to mechanisms to protect the mobility of patients and physicians when developing and implementing programs under any new health system governance model; and * the medical profession work with governments to develop: - clear role, responsibility and accountability statements for government, health system governing boards, health care providers and consumers, - mechanisms to ensure that governing boards have broad representation and meaningful input from the community, including physicians, and that regional boards be recruited through a clearly specified appointment or electoral process, - guidelines for use by communities to assess their health care needs and to provide assistance, as required, with the conduct of such assessments, - protocols and procedures for evaluating health system governance initiatives, - mechanisms to ensure adequate and appropriate physician input into operational aspects of regional planning and coordination of health care services, and - processes under any health system governance model ensure adequate opportunities for research, education (including continuing medical education) and training of physicians consistent with national standards.
Documents
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Operational principles for the measurement and management of wait lists (Update 2011)

https://policybase.cma.ca/en/permalink/policy10322
Last Reviewed
2019-03-03
Date
2011-10-23
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-10-23
Replaces
Operational principles for the measurement and management of waiting lists
Topics
Health systems, system funding and performance
Text
This policy statement provides operational principles for the measurement and management of wait list systems that support timely access to necessary care for patients. This statement is based on the understanding that in order for wait list systems to be effective in improving timely access to medically necessary care for patients, physicians and other providers must be centrally involved and appropriately supported to assist in their development, measurement and management. Since the late 1990s, Canadians have become increasingly concerned over lengthening wait times to access medically necessary care. As a result, a major focus of the 2004 Health Care Accord (10-Year Agreement to Strengthen Health Care) was to improve timely access to necessary medical care. Since then, provinces and territories have taken steps to measure, monitor and manage patient wait times. However, most efforts thus far to improve wait times have been focused on the wait between the specialist consultation and the scheduled date for treatment. Patients may also experience waits in accessing a family physician (many Canadians do not have a family physician) and waiting to see a specialist following a referral by a family physician. Canadians deserve timely access to medically necessary care. Governments must ensure that patients are treated within established wait-time benchmarks for all major diagnostic, therapeutic, and surgical services. Physicians recognize that it is desirable to minimize waits and to properly prioritize and manage patients' wait for care by accurately capturing and utilizing wait-time data. However, there remain serious concerns over the quality of wait-time data and who has the primary responsibility for capturing the data. Physicians and other providers are increasingly being requested to input wait-time data (e.g., length of wait for consultation or for start of treatment). Yet, in many instances, they are expected to do so without the necessary resources and supports. Outlined below are Operational Principles for the Measurement and Management of Wait Lists developed originally through CMA's Access to Quality Health Care Project(1) with input from public opinion research as well as stakeholder groups, including CMA Core Committees, Provincial-Territorial Medical Associations and CMA Affiliates. Goals 1. To maintain or enhance patients' quality of life and health status through effective development, measurement and management of wait lists. 2. To ensure that the development, measurement and management of wait lists are based on the best available evidence of clinical appropriateness, clinical effectiveness, rational use of resources, clinical need and patient quality of life. Principles A. Stakeholder Involvement 1. Physicians in clinical practice must have a leadership role: - in identifying clinically relevant data elements through consensus; - in developing standard definitions and measures for prioritization for wait lists; and - in developing wait-time benchmarks. 2. Health care providers and other stakeholders should be involved in the development, measurement, maintenance, monitoring, management and evaluation of wait list systems, and should be appropriately compensated for their time and effort. B. Database Development and Management Systems 1. Systems for developing and managing wait lists must require and provide reliable, current, useful and valid data and information. 2. Database development and wait list management requires involvement of multidisciplinary panels. 3. Systems for managing wait lists should: - provide accurate, reliable, timely, publicly accessible and real-time information in a cost-effective manner. Deadlines for inputting data should be reasonable and implemented without the use of threats or penalties; - collect and assess data on need, quality of life and health outcomes; be flexible and dynamic so that they can adapt over time with the development of new technologies and approaches to treatment; and - require policies and procedures on confidentiality, so that patients' and providers' privacy are protected. C. Investment 1. Systems for managing wait lists require initial and sustained investment in dedicated human resources, sophisticated information systems and information technology infrastructure at all levels (e.g., medical offices, hospitals, health regions). D. Accountability 1. The parties involved in managing wait lists must accept their responsibilities and obligations to each other and to the public. 2. Privacy and confidentiality of patient and provider information must be respected. 3. The systems, processes and results for managing wait lists should be widely communicated to obtain stakeholder involvement and support. E. Evaluation 1. Systems for managing wait lists must: - be continually monitored and evaluated to identify opportunities for improvement; and - regularly undergo independent data audits and evaluations of process and outcome. F. Governance 1. An independent, stakeholder-based, non-governmental organization with an advisory committee should be responsible for overseeing and administering systems for managing wait lists. (1) Canadian Medical Association, Access to Quality Health Care Project, January 1998. Ottawa.
Documents
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Testing of antibiotics

https://policybase.cma.ca/en/permalink/policy10157
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Resolution
GC11-69
The Canadian Medical Association supports the routine testing of antibiotics manufactured in or imported into Canada to ensure that they all comply with the labelling on the containers.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Resolution
GC11-69
The Canadian Medical Association supports the routine testing of antibiotics manufactured in or imported into Canada to ensure that they all comply with the labelling on the containers.
Text
The Canadian Medical Association supports the routine testing of antibiotics manufactured in or imported into Canada to ensure that they all comply with the labelling on the containers.
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Mentoring of early career physicians

https://policybase.cma.ca/en/permalink/policy10161
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC11-22
The Canadian Medical Association supports the development of programs that will facilitate the mentoring of early career physicians in their transition to clinical practice by experienced physicians.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC11-22
The Canadian Medical Association supports the development of programs that will facilitate the mentoring of early career physicians in their transition to clinical practice by experienced physicians.
Text
The Canadian Medical Association supports the development of programs that will facilitate the mentoring of early career physicians in their transition to clinical practice by experienced physicians.
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Scopes of practice

https://policybase.cma.ca/en/permalink/policy10162
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Physician practice/ compensation/ forms
Health human resources
Resolution
GC11-23
The Canadian Medical Association supports physicians engaging in their full scope of practice.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Physician practice/ compensation/ forms
Health human resources
Resolution
GC11-23
The Canadian Medical Association supports physicians engaging in their full scope of practice.
Text
The Canadian Medical Association supports physicians engaging in their full scope of practice.
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Physician recruitment and retention programs

https://policybase.cma.ca/en/permalink/policy10163
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC11-24
The Canadian Medical Association calls for adequate resources and coordination for the development, implementation and ongoing evaluation of physician recruitment and retention programs.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC11-24
The Canadian Medical Association calls for adequate resources and coordination for the development, implementation and ongoing evaluation of physician recruitment and retention programs.
Text
The Canadian Medical Association calls for adequate resources and coordination for the development, implementation and ongoing evaluation of physician recruitment and retention programs.
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Courses on health system operations and financing

https://policybase.cma.ca/en/permalink/policy10164
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC11-26
The Canadian Medical Association requests the faculties of medicine to include courses on health system operations and financing in the curricula.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC11-26
The Canadian Medical Association requests the faculties of medicine to include courses on health system operations and financing in the curricula.
Text
The Canadian Medical Association requests the faculties of medicine to include courses on health system operations and financing in the curricula.
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Informed career choices

https://policybase.cma.ca/en/permalink/policy10165
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Physician practice/ compensation/ forms
Health human resources
Resolution
GC11-28
The Canadian Medical Association will assist physicians during all stages of their career, with special emphasis on helping medical students and residents make informed career choices by providing job-trend data and other career-planning resources.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Physician practice/ compensation/ forms
Health human resources
Resolution
GC11-28
The Canadian Medical Association will assist physicians during all stages of their career, with special emphasis on helping medical students and residents make informed career choices by providing job-trend data and other career-planning resources.
Text
The Canadian Medical Association will assist physicians during all stages of their career, with special emphasis on helping medical students and residents make informed career choices by providing job-trend data and other career-planning resources.
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Convention on the Rights of the Child on the Involvement of Children in Armed Conflict

https://policybase.cma.ca/en/permalink/policy10173
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Ethics and medical professionalism
Health care and patient safety
Resolution
GC11-64
The Canadian Medical Association calls for federal government adherence to the United Nations’ "Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict."
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Ethics and medical professionalism
Health care and patient safety
Resolution
GC11-64
The Canadian Medical Association calls for federal government adherence to the United Nations’ "Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict."
Text
The Canadian Medical Association calls for federal government adherence to the United Nations’ "Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict."
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Compulsory use of helmets

https://policybase.cma.ca/en/permalink/policy10175
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health care and patient safety
Resolution
GC11-66
The Canadian Medical Association supports the compulsory use of helmets by people of all ages when riding all-terrain vehicles and snowmobiles.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health care and patient safety
Resolution
GC11-66
The Canadian Medical Association supports the compulsory use of helmets by people of all ages when riding all-terrain vehicles and snowmobiles.
Text
The Canadian Medical Association supports the compulsory use of helmets by people of all ages when riding all-terrain vehicles and snowmobiles.
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Sale of undergraduate training positions

https://policybase.cma.ca/en/permalink/policy10181
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Ethics and medical professionalism
Health human resources
Resolution
GC11-85
The Canadian Medical Association opposes the sale of undergraduate training positions to foreign students if this practice reduces the opportunities for Canadian applicants or negatively affects their educational experience.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Ethics and medical professionalism
Health human resources
Resolution
GC11-85
The Canadian Medical Association opposes the sale of undergraduate training positions to foreign students if this practice reduces the opportunities for Canadian applicants or negatively affects their educational experience.
Text
The Canadian Medical Association opposes the sale of undergraduate training positions to foreign students if this practice reduces the opportunities for Canadian applicants or negatively affects their educational experience.
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Techniques of advocacy and leadership

https://policybase.cma.ca/en/permalink/policy10182
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC11-86
The Canadian Medical Association actively encourages and will facilitate the incorporation of increased formal training in the techniques of advocacy and leadership in the undergraduate and postgraduate medical curricula.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC11-86
The Canadian Medical Association actively encourages and will facilitate the incorporation of increased formal training in the techniques of advocacy and leadership in the undergraduate and postgraduate medical curricula.
Text
The Canadian Medical Association actively encourages and will facilitate the incorporation of increased formal training in the techniques of advocacy and leadership in the undergraduate and postgraduate medical curricula.
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