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Policies that advocate for the medical profession and Canadians


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Breast-feeding mothers

https://policybase.cma.ca/en/permalink/policy1748
Last Reviewed
2020-02-29
Date
1983-10-01
Topics
Health care and patient safety
Resolution
GC83-30
Be it resolved that the Canadian Medical Association recommend that breast-feeding mothers consult their physician two weeks post partum especially if they are breast-feeding for the first time; and be it further resolved that the CMA support: a) the provision of a physical environment in maternity units favourable to the initiation and continuation of successful breast-feeding; and b) the adoption of measures to facilitate the continuation of breast-feeding for women working outside the home.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1983-10-01
Topics
Health care and patient safety
Resolution
GC83-30
Be it resolved that the Canadian Medical Association recommend that breast-feeding mothers consult their physician two weeks post partum especially if they are breast-feeding for the first time; and be it further resolved that the CMA support: a) the provision of a physical environment in maternity units favourable to the initiation and continuation of successful breast-feeding; and b) the adoption of measures to facilitate the continuation of breast-feeding for women working outside the home.
Text
Be it resolved that the Canadian Medical Association recommend that breast-feeding mothers consult their physician two weeks post partum especially if they are breast-feeding for the first time; and be it further resolved that the CMA support: a) the provision of a physical environment in maternity units favourable to the initiation and continuation of successful breast-feeding; and b) the adoption of measures to facilitate the continuation of breast-feeding for women working outside the home.
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Streamlining patient flow from primary to specialty care: a critical requirement for improved access to specialty care

https://policybase.cma.ca/en/permalink/policy11299
Last Reviewed
2020-02-29
Date
2014-10-25
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-10-25
Topics
Health systems, system funding and performance
Text
When physicians believe their patients may require the expertise of another physician, effective, timely and informative communication between all physicians is essential to ensure appropriate use of specialty care services. The results of physician surveys indicate a lack of informative referral communication exists in Canada. Significant variation exists in referral request processes*. This is contributing to the poor access to specialty care that many patients are experiencing. Some of this variation is necessary, however, which means that a single, standardized solution to improve the entire referral and consultation process is not feasible. Nonetheless, while communication processes and information requirements for referral requests vary considerably, the communication and information needs in consultant responses is essentially the same for all referring physicians. Unfortunately, provision of this information is often lacking. This problem can be addressed through standard communication protocols because all referring physicians benefit from receiving the same types of information in response to referral requests; for example, acknowledgement of referral receipt or patient consult reports. Furthermore, when referrals are initiated, specific types of requests can benefit from standardization of communication methods and information requirements. Such activities are already underway in Canada in select areas. These successful initiatives, used together as complementary approaches to address the varying needs of referral requests, should be adopted throughout the country. Visit CMA's Referral and Consultation Process Toolbox1 for examples. Recognition, in the form of appropriate compensation, must also be given to the time spent preparing and analyzing referral requests as well as conducting consultations. Support for the use of information technology infrastructure, where available, will also facilitate efforts to streamline referral and consultation processes. It should be noted that, while the language of this policy statement has a focus on primary to specialty care referrals, the concepts and recommendations apply to referrals between all specialties. RECOMMENDATIONS * All stakeholders, especially physicians, but also, where appropriate, office assistants, nurses, other health care providers as well as patients, must be engaged in an early and meaningful way regarding any initiative that has a goal to improve referral or consultation processes. * There is no single best way to access specialist expertise; as a result, a combination of complementary initiatives (e.g., formal consultation systems, standardized referral processes with central intake systems and/or physician directories) should be implemented to reduce variation in the approaches that are used and to facilitate more timely access to specialty care for patients. * While acknowledging the referring physician's ability to interpret certain test results, the referral must be accompanied by appropriate information to allow the consulting specialist to fully assess the request, and the referring physician must be informed of what is "appropriate". * The referring physician (and family physician if different), as well as the patient, should be kept informed, in a timely fashion, of the status of the referral request, using standardized procedures, minimum information requirements and timelines. * Physician and/or physician practices should receive compensation and support in recognition of the time and effort undertaken to communicate appropriate information regarding referral requests as well as to conduct electronic or real-time consultations. Introduction When a physician decides that a patient requires the expertise of another specialist, the most appropriate next step can range from the specialist answering a question to assessing the need for a particular procedure or treatment. No matter how simple or complex the specialist's involvement may be, successful communication between all physicians is critical. Unfortunately, this does not occur as often as it should. In October 2012, a survey of physicians on the topic of referrals found that while over half of both family physicians (52%) and other specialists (69%) agree that referral communication is effective, two-thirds of family physicians noted that some kind of communication problem was a main source of frustration for them; for example not being informed about: referral receipt, the patient's appointment, a treatment plan, or that the specialist does not do the service requested. A similar proportion of specialists noted a lack of basic or supporting information (e.g., reason for referral or lab test results) as a main frustration with referral requests.2 The most appropriate method of communication differs depending on the degree of specialist involvement that is required. There are no standards about which method of communication is the most appropriate or effective, or what information is required, for each situation. Referral request processes† vary significantly; not only across specialties but among specialists within a particular specialty and even within a geographic region. Examples of this variation include: some consulting specialists will accept referrals only if the referring physician has used their specific referral form; others accept referrals using only one particular communication method (e.g., by fax); and others accept referrals on just one day each month. Such variation creates inefficiencies because referring physicians must familiarize themselves with each request process that is required by each consulting specialist. The range and quality of information provided in a referral request also varies considerably; for example, too little information (i.e. no reason for referral provided), insufficient information (i.e. out-of-date or a lack of lab or imaging tests), or to too much information (i.e. non-contributory family history). This lack of standardization is problematic. In this context, standardization means simplification rather than obligation. Standardized processes facilitate communications for referrals by removing ambiguities about which method is most appropriate for each situation. Communication methods and the types of information that are transferred between referring physicians and consulting specialists vary based on numerous factors, ranging from those beyond the control of physicians such as regulations and available technology, to those completely within their control such as their own individual preferences. An effective way to facilitate appropriate and timely access to specialty care that is within the control of the health care profession is to explore the rationale behind these varying communication and information preferences and address these variations by developing, with meaningful participation and approval from physicians and their administrative staff, standard processes for requesting a specialist referral and for communicating back to the referring physician. Some of the provincial Colleges of Physicians and Surgeons have guidelines or standards of practice specifically about referrals and consultations. The most comprehensive of these are the College of Physicians & Surgeons of Nova Scotia's (CPSNS) Guidelines for Physicians Regarding Referral and Consultation3 and the College of Physicians and Surgeons of Alberta's (CPSA) Standard for Practice on The Referral Consultation Process.4 In addition, the College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (Royal College) developed collaboratively a guide to enhancing referrals and consultations between physicians.5 While these documents do not discuss which method of communication should be used for each referral request scenario, they do provide guidance in a number of areas, including: * minimum requirements for information that should be provided with all referral requests * information that should be conveyed to patients (e.g., why they are being referred, information about the specialist appointment, etc) as well as who should be providing this information * processes that should be followed for patients requiring ongoing care from the consulting physician While standardization of the minimum information requirements that should be included in communications between referring and consulting physicians is essential for finding efficiencies with referral processes, these efficiencies will not be fully realized without proper consideration of the information technology infrastructure that is used to convey this information. The way in which the information is provided should not require additional effort for either the sender or the receiver. Electronic referral systems, where all data necessary for an informative referral can be easily obtained by the appropriate physician from the patient's electronic health record, would be the best way to ensure that this occurs. However, until this becomes a reality, a suitable compromise can be found by allowing flexibility in the format in which the information is provided. Communication from Primary Care to Specialty Care When the extent of a specialist's involvement in patient care is simply providing a second opinion or advice about appropriate next steps, standardizing the process for this kind of communication is relatively straightforward. This is because the variation that exists in this situation is primarily due to the availability of the consulting specialist and the methods of communication that each referring physician can use to contact the specialist. Certain regions of the country have established consultation services whereby specialists participating in the program must respond to consult requests within a specified time frame. Examples of effective consultation systems include the telephone advice line known as Rapid Access to Consultative Expertise (RACE)6 in BC or the secure electronic consultation system known as Building Access to Specialist Care through e-Consultation (BASE)7 in the Champlain Local Health Integration Network (LHIN) in Ontario. Such services have proven quite effective at reducing the number of unnecessary referrals8,9; thereby ensuring more appropriate use of specialty care and helping to reduce wait times for this care. Through both of these systems, specialists ensure that they are available to respond to the consult question in a timely manner and each system uses only one form of communication. At the other end of the spectrum of specialist involvement in patient care, when the patient sees the specialist, there is a much greater degree of variation in what is required of the specialist - from one-time interventions such as surgical procedures, to chronic care. The best approach for streamlining the referral process in these more complex situations varies, depending on the type of specialist care that is required. Central Intake With central intake referral systems, the referring physician sends a referral request to one location. This central location can be organized in two ways; central triage or pooled referrals. With central triage, referrals are assigned to specialists based on their level of urgency. With pooled referrals, each referral is allocated to the next available specialist, who then does the triaging. The differences in where the triaging occurs exist due to a number of factors; including the type of care the specialty provides as well as the number of specialists in the geographic region. However, for both types of central intake systems, the referring physician follows a standard process regardless of the specialist who assumes care of the patient. Regardless of the type of central intake method that is used, the option to choose a particular specialist must always be available. However, even with this option in place, a central intake system of any kind is not necessarily the most appropriate solution for all specialties. This is often the case when ongoing patient-specialist relationships are quite common. For example, a woman might prefer that the same obstetrician cares for her during all of her pregnancies, or patients with chronic conditions such as arthritis or diabetes and require continuous care throughout their lifetime. In these situations, coordinating a central intake program where a significant proportion of specialist appointments are repeat visits is difficult. Physician Directory A physician directory might be a more useful referral tool in situations where specialties do not have sufficient numbers of specialists in one geographic region or for those that have a high degree of sub-specialization. Such directories provide, at a minimum, details of the services each specialist provides and does not provide. Those that provide information regarding wait times, especially those with information on the wait for the first specialist visit, are extremely useful for referring physicians as it allows them to select a specialist with the most appropriate wait time for their patient and, where relevant, it also allows the referring physician to develop an appropriate care plan based on the time the patient must wait for specialty care. Despite the fact that the complexities with specialty referrals mean that there is no one solution that is appropriate for all types of specialties, the extreme variation in processes that currently exists is also unnecessary. Standard referral information requirements for specialty groups with similar needs, such as most surgical specialties, have been effectively established in some areas of the country. For example, in Calgary, Alberta, a major initiative known as Medical Access to Service10, has, among other things, successfully developed a standard referral form and process for central intake for multiple specialties. While most of these specialties also request additional information, each specialty has agreed on a standard set of minimum requirements. These standards were developed collaboratively with physicians and could be expanded nationwide, while taking regulatory and technological differences into account. When establishing the requirements for an informative referral, consulting specialists must acknowledge that the referring physician may not have the expertise necessary to appropriately interpret certain test results. In such cases it is the consulting specialists who should order these tests. Communication from Specialty Care to Primary Care What must not be overlooked is that referral communication is bilateral. Informative and timely communication from the consulting specialist to the referring physician is also critical for a successful referral. Such a referral can be defined as one where the patient receives appropriate and timely specialty care where all parties - patient, specialist(s), referring physician and family physician (when the referring physician is not the patient's family physician) - are aware of all of the patient's relevant interactions with the health care system as well as any follow-up care that may be required. To ensure this occurs, after the referral request is initiated, the referring physician (and family physician if different) should be informed, in a timely manner, of the status of the referral at all stages: * referral receipt * request for more information * referral acceptance/rejection (with explanation and suggested alternatives) * patient appointment has been scheduled * patient consult notes (including recommended treatment plan and follow-up) A definition of what is considered "timely" is required. Standards must be established based on what is considered to be an acceptable response time at each stage. The patient must also be promptly informed of the status of the referral request throughout the entire process. Examples of the types of information that should be conveyed include (where appropriate): * how the referral request will be processed; e.g., pooled referral or central triage * expected wait time or when the appointment has been scheduled * whether another specialist has been contacted * whether a repeat visit is required * whether the patient has been contacted about anything that is relevant to them; e.g., referred elsewhere, wait time, appointment(s) scheduled The information and communication that the referring physician requires from the consulting specialist for all referrals is much more homogeneous. In addition, there are no regulatory or technological barriers preventing the provision of this information at the appropriate stages of the referral process. This is one area where communication between physicians is within their control. Therefore, improved communication for responses to referral requests through standardized processes can be much more easily established. Unfortunately this is not the case, causing considerable effort to be undertaken by referring physicians and/or their office staff to track the status of referrals. Considerably less attention has been given to this part of the process; however, some activities described in the CMA's Referral and Consultation Process Toolbox1 do address problems regarding the referral response. Central Intake systems are an example. These often include standard response times for at least the first three stages noted above, as well as information about the specialist who has received the referral request. The previously cited guidelines developed by the CPSNS 3, the standard of practice by the CPSA4 and the guide to enhancing referrals and consultations between physicians developed by the CFPC and the Royal College5 also have recommendations for consulting specialist responses to referral requests (including information requirements and timelines). These resources can be used as a starting point for establishing referral communication standards in both directions and with patients. As an important example, the guidelines for both provincial colleges specifically indicate that the consulting specialist is responsible for arranging appointments with the patient and notifying the referring physician of the date(s). Compensation and Support Another aspect of the referral process that is not given sufficient consideration is the time and effort that is involved in preparing and responding to a referral request. Both preparing an informative referral request and responding to one is time-consuming; very little recognition is given towards this work. In some areas of the country, physicians receive compensation for participating in electronic or telephone consultation programs. This form of recognition has successfully helped avoid unnecessary referrals and should be expanded nation-wide; however, much more should be done to acknowledge this effort, especially when a specialist visit is necessary. The time referring physicians spend gathering the necessary data for a referral request, or the time consulting specialists spend analyzing this data, triaging the referrals accordingly and preparing patient consult notes, is almost never acknowledged as part of a physician compensation package. In most jurisdictions this work is considered to be just a component of a typical patient visit. Since many primary care group practices employ administrative staff who are "referral coordinators"; whose main role is to assist physicians in the data gathering and preparation that is required for an informative referral request, as well as following up on referral requests; the process of referring a patient to specialty care is much more than "just a component of a typical patient visit". Support for widespread implementation of effective information technology infrastructure can facilitate the preparation of appropriate referral requests and responses and can also encourage timely and informative communication between referring physicians and consulting specialists. Conclusion The high degree of variability in both the methods of communication and the information transferred between physicians is a significant barrier to timely access to specialty care for patients. Significant effort by physicians and their office staff is expended unnecessarily in the referral process, not only in initiating or responding to the request, but also in tracking and follow-up. While there is no single solution that will address all referral communication problems, several complementary solutions exist that can reduce this variability and wasted effort, thereby simplifying the process and facilitating appropriate, timely and informative communication between referring physicians and consulting specialists. Examples of such initiatives can be found in the CMA's Referral and Consultation Process Toolbox.1 * For the purposes of this policy statement, this term applies to all situations where another physician is contacted regarding patient care. † For the purposes of this policy statement, this term applies to all situations where another physician is contacted regarding patient care. References 1 Canadian Medical Association. Referral/Consultation Process. Available at: http://www.cma.ca/referrals. Accessed 29 Nov 2013. 2 Canadian Medical Association. Challenges with patient referrals - a survey of family physicians and other specialists; October 2012 (Unpublished). 3 College of Physicians and Surgeons of Nova Scotia. Guidelines for Physicians Regarding Referral and Consultation. Available at: http://www.cpsns.ns.ca/Portals/0/Guidelines-policies/guidelines-referral-consultation.pdf. Accessed 15 Nov 2013. 4 College of Physicians & Surgeons of Alberta. The Referral Consultation Process. Available at: http://www.cpsa.ab.ca/Libraries/standards-of-practice/the-referral-consultation-process.pdf?sfvrsn=0. Accessed 16 Sep 2014. 5 College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada. Guide to enhancing referrals and consultations between physicians. Available at: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=3448. Accessed 27 Nov 2013. 6 Rapid Access to Specialist Expertise. Available at: www.raceconnect.ca. Accessed 27 Nov 2013. 7 Liddy C, Rowan MS, Afkham A, Maranger J, Keely E. Building access to specialist care through e-consultation. Open Med. 2013 Jan 8;7(1):e1-8. Available at: http://www.openmedicine.ca/article/view/551/492. Accessed 27 Nov 2013. 8 Wilson M. Rapid Access to Consultative Expertise: An innovative model for shared care. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/RACE-Overview-March-2014.pdf. Accessed 16 Sep 2014. 9Afkham A. Champlain BASE project: Building Access to Specialists Through e-Consultation. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Champlain-BASE-Dec2013-e.pdf. Accessed 16 Sep 2014. 10 Alberta Health Services, University of Calgary Department of Medicine. Medical Access to Service (MAS). Available at: http://www.departmentofmedicine.com/MAS/ Accessed 15 Nov 2013.
Documents
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Early childhood development

https://policybase.cma.ca/en/permalink/policy11476
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
Text
Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.1,2 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.3,4 Negative experiences such as poverty or family or parental violence can have significant impacts on this important period of development. Even for those children who don't encounter these types of barriers, there can be problems in the early years. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.5 Just as children are susceptible to negative influences in early life, the period of rapid development means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.6 At the government and national level there are four main areas of action: Early childhood learning and care; Support for parents; Poverty reduction; and Data collection for early childhood development. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. While most of what is necessary for early childhood development will be done by governments and stakeholders outside of the health care system, there are opportunities for physicians to influence this important social determinant both through medical education, and clinical practice. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Background Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. The early childhood period is the most important development period in life.7 Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.8,9 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.10,11 According to research done by the Centers for Disease Control and Prevention in the adverse childhood event (ACE)a study, child maltreatment, neglect, and exposure to violence can significantly impact childhood development. The study involved a retrospective look at the early childhood experiences of 17,000 US adults and the impact of these events on later life and behaviour issues. An increased number of ACEs was linked to increases in risky behaviour in childhood and adolescence12 and to a number of adult health conditions including alcoholism, drug abuse, depression, diabetes, hypertension, stroke, obesity, heart disease, and some forms of cancer.13,14 The greater the number of adverse experiences in childhood the greater the likelihood of health problems in adulthood.15 A high level of ACEs was linked to language, cognitive and emotional impairment; factors which impact on school success and adult functioning.16 Finally, the study found a correlation between experiencing ACEs, suicide, and being the victim of or perpetrating intimate partner violence.17 Poverty is a significant barrier to healthy child development. Children who grow up in poor families or disadvantaged communities are especially susceptible to the physiological and biological changes associated with disease risk.18 Poverty is associated with a number of risk factors for healthy development including: unsupportive parenting, inadequate nutrition and education, high levels of traumatic and stressful events19, including higher rates of traumatic injuries20, poorer housing, lack of services, and limited access to physical activity.21 Children from low-income families score lower than children from high-income families on various measures of school readiness, cognitive development and school achievement22,23, and this gap increases over time with children of low-income families being less likely to attend post-secondary education and gain meaningful employment.24 Children who grow up in poverty are more likely to be poor as adults25,26 and to pass this disadvantage on to their own children.27,28 Children living in poverty have more problem behaviours such as drug abuse, early pregnancy, and increased criminal behaviour.29 Finally, economic hardship in childhood has been linked to premature mortality and chronic disease in adulthood.30 Early adverse events and poverty are serious impediments to healthy development, however, it is not just disadvantaged children that need attention. The early years are critical for all children regardless of socio-economic status. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.31 By 2030, 90% of morbidity in high income countries will be related to chronic diseases.32 These diseases are due in large part to risk factors such as smoking, poor nutrition, alcohol and drug abuse, and inadequate physical activity.33 These risk factors can be heavily influenced by the environment in which people live and can be increased by poor early childhood experiences.34,35 Health promotion and disease/injury prevention programs targeted at adults would be more effective if investments were made early in life on the origins of those diseases and conditions.36,37 Areas for Action While there is reason for concern regarding early childhood development, there is positive news as well. Just as children are susceptible to negative influences in early life, the period of rapid development also means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.38 Government and National: Early Childhood Learning and Care Research suggests that 90% of a child's brain capacity is developed by age five, before many children have any access to formal education.39 More than one quarter of Canadian children start kindergarten vulnerable in at least one area of development.40 Approximately two thirds of these deficiencies can be considered preventable. Evidence suggests that each 1% of excess vulnerability in school readiness leads to a reduction in GDP of 1% over the course of that child's life.41 Children who aren't ready for kindergarten are half as likely to read by the third grade, a factor that increases the risk of high school drop-out significantly. 42 While it is possible to intervene later to address these learning deficiencies, these interventions are less effective and much more costly.43 High quality early childhood programs including programs to nurture and stimulate children and educate parents are highly correlated with the amelioration of the effects of disadvantage on cognitive, emotional and physical development among children.44,45 A recent analysis of 84 preschool programs in the United States concluded that children participating in effective pre-school programs can acquire about a third of a year of additional learning in math, language and reading skills.46 Since the implementation of the universal childcare program in Quebec, students in that province have moved from below the national average on standardized tests to above the average.47 In addition, effective early childhood learning programs offer a significant return on investment. Research done on US preschool programs found a return on investment of between four and seventeen dollars for every dollar spent on the program. Evidence from the Quebec universal child care program indicates that the program costs are more than covered by the increased tax revenues generated as a result of increased employment among Quebec mothers. For every dollar spent on the Quebec program, $1.05 is received by the provincial government with the federal government receiving $0.44.48 In terms of early childhood learning and care, Canada is lagging far behind - tied for last place among 25 countries in Organization for Economic Cooperation and Development (OECD) early childhood development indicators.b,49 Canada spends the least amount of money on early childhood learning and care of all countries in the OECD (0.25% of GDP)50, or one quarter of the recommended benchmark. Of this money, fully 65% is attributable to Quebec's universal daycare program.51 Canadian families face great pressures in finding affordable and accessible quality early childhood learning and care spots across the country. In Quebec 69% of children 2-4 regularly attend early childhood learning programs; outside of Quebec the number falls to 38.6%. The challenges for low-income families are even more pronounced with almost 65% of poor children 0-5 receiving no out-of home care.52 The federal government and the provinces and territories must work to bring Canada in line with other OECD countries on early childhood learning and care. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. Support for Parents A supportive nurturing caregiver is associated with better physical and mental health, fewer behavioural problems, higher educational achievement, more productive employment, and less involvement with the justice system and social services.53 Studies have demonstrated that improved parental-child relationships can minimize the effects of strong, prolonged and frequent stress, referred to as toxic stress54,55, and that the effects of poverty can be minimized with appropriate nurturing and supportive parenting.56 Parental support programs can act as a buffer for children at the same time as strengthening the ability of parents to meet their children's developmental needs.57 Caregivers who struggle with problems such as depression or poverty may be unable to provide adequate attention to their children undermining the attachment relationships that develop in early life. The relatively limited attention that is focused on addressing the deficiencies in time and resources of parents across all socio-economic groups can undermine healthy childhood development.58 One approach that has been shown to improve parental functioning and decrease neglect and child abuse is early childhood home visiting programs, sometimes referred to as Nurse Family partnerships. These programs provide nursing visits to vulnerable young mothers from conception until the children are between two and six depending on the program. The home visits provide prenatal support, educate parents about early childhood development, promote positive parenting, connect parents with resources, and monitor for signs of child-abuse and neglect.59 Results from several randomized controlled trials of these programs in the United States have shown that the program reduces abuse and injury, and improves cognitive and social and emotional outcomes in children. A 15 year follow-up study found lower levels of crime and antisocial behaviour in both the mothers and the children that participated in these programs.60 In Canada Nurse Family Partnerships were first piloted in Hamilton, Ontario. They are now undergoing a broader implementation and review in the Province of British Columbia. These programs should continue to be supported and expanded to all families who would benefit from this proven early childhood intervention. Many Canadian provinces have established community resources for parents. Alberta has recently announced plans to establish parent link centres across the province. These will deliver parenting programs, and be home to community resources and programs.61 Similar programs exist in other provinces such as the early years centres in Ontario62, and family resource centres in Manitoba.63 Early Childhood Development Centres in Atlantic Canada are combining child care, kindergarten and family supports into early childhood centres that are aligned with schools.64 While these programs can go a long way in reducing abuse and neglect, there is still a need for an overarching strategy to reduce neglect and child abuse across the country. As the ACE study in the United States clearly demonstrated, exposure to early adverse events such as family violence or neglect have troubling implications for adult health and behaviours.65 Action must be taken to ensure that avoidable adverse events are eliminated. The CMA Recommends that: 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. Poverty reduction In 1989 the Canadian government made a commitment to end child poverty by 2000. As of 2011, more Canadian children and their families lived in poverty than when the original declaration was made.66 Canada ranks 15th out of 17 peer countries with more than one in seven children living in poverty (15.1%).67 Canada is one of the only wealthy nations with a child poverty rate that is actually higher than the overall poverty rate.68 Child poverty is a provincial and territorial responsibility as well. As of 2012, only four provinces had child poverty strategies that met the guidelines put forward by the Canadian Paediatric Society.c,69 Poor children grow up in the context of poor families which means that solutions for child poverty must necessarily minimize the poverty of their parents.70 Efforts to increase the income as well as employment opportunities for parents, in particular single parents, must be part of any poverty reduction strategy.71 Programs, such as affordable child care, that allows parents to be active participants in the work force represent one approach72,73 Quebec's program of early childhood care has increased female workforce participation by 70,000 and reduced the child poverty rate by 50%.74 Addressing poverty could minimize problem areas in child development. According to a 2009 report by the Chief Public Health Officer of Canada, of 27 factors seen as having an impact on child development, 80% of these showed improvement as family income increased.75 Increasing income has the greatest impact on cognitive outcomes for children the earlier in life the reduction in poverty takes place.76 The federal government and the provinces and territories must work to ensure that poverty does not continue to be a barrier to the healthy development of Canadian children. The CMA Recommends that: 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. Data Collection for Early Childhood Development The evidence shows the importance of early childhood development for later success and health. In order to properly design effective interventions to mitigate developmental concerns, there is a need for appropriate data on early childhood health indicators and interventions. Given the variation in outcomes of children among different communities and demographic groups, there is a need for individual level data which is linked to the community level. This will allow providers and governments to develop appropriate interventions. Such an approach is being used by the Manitoba Centre for Health Policy, the Human Early Learning Partnership in British Columbia, and Health Data Nova Scotia. Researchers at these centres are creating a longitudinal data set by linking administrative data from a range of sources.77 Such data sets should be supported in all provinces and territories. Another tool being used to measure the progress of Canadian children is the Early Development Instrument (EDI). This tool is a 104 item checklist completed by teachers for every child around the middle of the first year of schooling. The checklist measures five core areas of early child development that are known to be good predictors of adult health, education and social outcomes. These include: physical health and well-being; language and cognitive development; social competence; emotional maturity; and communication skills and general knowledge.78,79 This tool has been used at least once in most of the provinces and territories with a commitment from most jurisdictions to continue this monitoring.80 While this is a good start, it gives only a snapshot of development. Ideally a monitoring system plots several points of time in development to identify trajectories of children. Ontario has introduced an enhanced well baby visit at 18 months. This clinical intervention could allow for the capture of development data at an earlier time. There is a need for more comprehensive information at the 18-month and middle childhood phases.81 The CMA Recommends that: 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. Medical Education: Given the importance of early childhood experiences on adult health there is a need for a greater understanding of the biological basis of adult diseases. The medical community needs to focus more attention on the roots of adult diseases and disabilities and focus prevention efforts on disrupting or minimizing these early links to later poor health outcomes.82 The science of early brain development and biology is rapidly evolving. There is a need to ensure that future and current physicians are up to date on this information and its implications for clinical practice.83 The Association of Faculties of Medicine and the Norlien foundation have partnered to provide funding and support for a series of e-learning tools on early brain and biological development.84 Continuing medical education does exist for some components of early childhood development and more work is underway. The Ontario College of Family Physicians has developed a CME that explores early childhood development for practitioners.85 These initiatives must be supported and expanded to all physicians who provide primary care to children and their families. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. Clinical Practice: While many of the threats to early childhood development lie outside of the hospital or medical clinic, there are a number of ways that physicians can help to address this important determinant of health within their practices. Primary care practitioners are uniquely qualified to address this fundamental population health issue,86 and can provide one important component in a multi-sectoral approach to healthy early childhood development.87 Screening and support for parents The health care system is the primary contact for many child-bearing mothers, and for many families, health-care providers are the only professionals with whom they have regular contact during the early years.88,89 According to data from the Institute for Clinical Evaluative Sciences, 97% of Ontario children aged zero to two are seen by a family physician.90 Within a patient-centred medical home, health-care providers can give support and information to parents about issues such as parenting, safety, and nutrition, and can link them to early childhood resourcesd, and other supports such as housing and food security programs. 91,92 Primary-care providers can help patients connect with public health departments who have many healthy baby and healthy child programs.93 Primary-care providers can ensure that screening takes place to identify risk factors to appropriate development.94 This screening should take place as early as the prenatal stage and continue throughout childhood. Screening should include regular assessments of physical milestones such as height, weight and vision and hearing etc. In addition, providers can identify risk factors such as maternal depression, substance abuse, and potential neglect or abuse.95 Given the negative consequences of early violence and neglect on childhood development96, this is a key role for primary-care providers. Screening for social issues such as poverty, poor housing and food insecurity should also be completed.97 A significant time for screening occurs at 18 months. This is the time for the last set of immunizations and in many cases the last time a child will have a regularly scheduled physician visit before the start of school.98 The 18 month well baby visit provides an opportunity to screen for not only medical concerns but child development as well. The enhanced 18 month well baby visite developed in Ontario combines parental observations and clinical judgment to screen for any risks a child might have.99 In Ontario, parental observation is captured through the Nipissing District Developmental Screen (NDDS). The parents complete this standardized tool and report the results to their physicians or other primary-care providers. The NDDS checklist is not meant to be a diagnostic tool but instead helps to highlight any potential areas of concern while also providing information to parents about childhood development. The 'activities for your child' section which accompanies the tool can also help reinforce the importance of development.100 As part of the visit primary-care providers fill out a standardized tool known as the Rourke Baby Record. This tool is an evidence based guide which helps professionals deliver the enhanced visit. This combined with the parental report through the NDDS, allows for a complete picture of the physical as well as the development health of the child at 18 months. Primary-care providers can use the results to discuss parenting and development and link children to specialized services, as necessary, and other community supports and resources. In Ontario early child development and parenting resource system pathways have been developed in many communities to help ensure that primary care providers can be aware of the resources and supports available for their patients.101 As was already noted, almost two thirds of vulnerabilities in readiness for school can be prevented.102 Appropriate identification through screening is a first step in correcting these issues. While the expansion of this approach is currently being reviewed in Nova Scotia, it should be implemented in all provinces and territories with appropriate compensation mechanisms and community based supports. Additionally, consideration should be made to developing screening tools for physicians outside of primary care, ie. emergency departments, who see children who might not have regular primary care physicians. The CMA Recommends that: 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. Literacy By 18 months disparities in language acquisition begin to develop.103 According to US research, by age four, children of families on welfare will hear 30 million less words than children from families with professional parents.104 This can lead to ongoing disparities in childhood learning as evidence suggests that exposure to reading and language from parents is fundamental for success in reading by children.105 Physicians and other primary-care providers can play a role in helping to reduce these disparities. They can encourage reading, speaking, singing and telling stories as part of a daily routine.f Studies have demonstrated that when physicians discuss literacy with parents and provide them with appropriate resources, such as developmentally appropriate children's books, increases in reading frequency and preschool language scores have been found.106 One program which has integrated reading and literacy into clinical practice is the 'Reach out and Read' program in the United States. This program partners with physicians, paediatricians, and nurse practitioners to provide new developmentally appropriate books to children ages 6 months through 5 years, as well as guidance for parents about the importance of reading.107,108 The success of this program has been significant with parents in the program being four to ten times more likely to read frequently with their children, and children scoring much higher on receptive and expressive language scores on standardized tests.109 Given the success of this program for American children, a similar program should be explored in the Canadian context. The CMA Recommends that: 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Conclusion The early years represent the most important time of development. The first five years can 'get under the skin' and influence outcomes throughout the life course. Negative experiences such as poverty, violence, poor nutrition, and inadequate parenting can determine behaviours as well as adult health outcomes. Effective early interventions can help to minimize or capitalize on these experiences. Government actions and supports to reduce poverty, child abuse, violence and to enable parents to care for their children are necessary. In addition, appropriate high quality early childhood learning and care programs are required for all Canadians regardless of socio-economic status. Finally, health care providers can play a role in identifying children at risk, supporting their parents to encourage healthy childhood development, and advocating for communities that ensure all Canadian children have the opportunity to grow up happy and healthy. References a The adverse childhood events are: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, mother treated violently, household substance abuse, household mental illness, parental separation or divorce, incarcerated household member. http://www.cdc.gov/ace/prevalence.htm#ACED b The indicators used for the comparison include: Parental leave of one year with 50% of salary; a national plan with priority for disadvantaged children; subsidized and regulated child care services for 25% of children under 3; subsidized and accredited early education services for 80% of 4 year-olds; 80% of all child care staff trained; 50% of staff in accredited early education services tertiary educated with relevant qualification (this is the only indicator that Canada met); minimum staff-to-children ratio of 1:15 in pre-school education; 1.0% of GDP spent on early childhood services; child poverty rate less than 10%; near-universal outreach of essential child health services. UNICEF (2008) The child care transition: A league table of early childhood education and care in economically advanced countries. Available at: http://www.unicef-irc.org/publications/pdf/rc8_eng.pdf c To meet the CPS guidelines a province/territory requires anti-poverty legislation promoting long-term action and government accountability for at least three years, and has a poverty reduction strategy with specific targets. d For a list of some of the resources available for early childhood development across the country please see the Canadian Paediatric Society Resource Page: http://www.cps.ca/en/first-debut/map/community-resources e For more detailed information on the enhanced 18 month well baby visit please see the Canadian Paediatric Society Position statement- Williams R & J Clinton. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa, ON; 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (Accessed 2014 Jan 24). For resources available to Ontario primary-care providers please visit: http://machealth.ca/programs/18-month/default.aspx f For information and resources on early literacy please see the Canadian Paediatric Society at: http://www.cps.ca/issues-questions/literacy 1 Williams R et.al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21) 2 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 3 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. 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Starting Early, Starting Strong: Manitoba's Early Childhood Development Framework. Government of Manitoba, Winnipeg (MB); 2013. Available: http://www.gov.mb.ca/cyo/pdfs/sess_ECD_framework.pdf (accessed 2014 Jan 10). 64 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 65 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 66 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 67 Conference Board of Canada. Child Poverty. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/child-poverty.aspx (accessed 2013 Jun 20). 68 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 69 Ibid. 70 APA Task Force on Childhood Poverty. A Strategic Road-Map: Committed to Bringing the Voice of Pediatricians to the Most Important Problem Facing Children in the US Today. The American Academy of Pediatrics. Elk Grove Village (IL); 2013. Available: http://www.academicpeds.org/public_policy/pdf/APA_Task_Force_Strategic_Road_Mapver3.pdf (accessed 2013 Dec 9). 71 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 72 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 73 Fauth B, Renton Z & Solomon E. Tackling child poverty and promoting children's well-being: lessons from abroad. National Children's Bureau. London (UK); 2013. Available: http://www.ncb.org.uk/media/892335/tackling_child_poverty_1302013_final.pdf (accessed 2014 Jan 10). 74 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 75 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 76 Cooper K & Stewart K. Does Money Affect Children's Outcomes? Joseph Rowntree Foundation. London(UK); 2013. Available: http://www.jrf.org.uk/sites/files/jrf/money-children-outcomes-full.pdf (accessed 2014 Feb 20). 77 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 78 Human Early Learning Partnership. Early Development Instrument. N.D. Available: http://earlylearning.ubc.ca/edi/ (accessed 2014 Oct 8). 79 Adamson P. Child well-being in rich countries: A comparative overview: Innocenti Report Card 11. UNICEF, Florrence, Italy; 2013. Available: http://www.unicef-irc.org/publications/pdf/rc11_eng.pdf (accessed 2014 Jan 10). 80 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://firstwords.ca/wp-content/uploads/2014/05/Early-Years-Study-3.pdf (accessed 2014 Feb 11). 81 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 82 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 83 Garner AS et al. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics 2012;129;e224. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2662.full.pdf+html (accessed 2014 Feb 11). 84 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 85 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 86 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 87 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 88 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 89 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 90 The Minister of Children and Youth announces that every child will receive and enhanced 18-month visit: Family Physicians Play Key Roles in Healthy Child Development. Toronto(ON). Available: http://ocfp.on.ca/docs/cme/enhanced-18-month-well-baby-visit-key-messages-for-family-physicians.pdf?sfvrsn=1 (accessed 2012 Feb 20). 91 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 92 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 93 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 94 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 95 Williams R et al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21). 96 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 97 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 98 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 99 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 100 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 101 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 102 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 103 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 104 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 105 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10). 106 Ibid. 107 Reach out and Read. Reach Out And Read: The Evidence. Boston (MA); 2013. Available: https://www.reachoutandread.org/FileRepository/Research_Summary.pdf (accessed 2014 Mar 5). 108 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 109 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10).
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Appropriateness in health care

https://policybase.cma.ca/en/permalink/policy11516
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Health care and patient safety
Text
CMA POLICY Appropriateness in Health Care Summary This paper discusses the concept of appropriateness in health care and advances the following definition: The Canadian Medical Association adopts the following definition for appropriateness in health care: It is the right care, provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care. Building on that definition it makes the following policy recommendations: * Provinces and territories should work with providers to develop a comprehensive framework by which to assess the appropriateness of health care. * Provinces and territories should work with providers to develop robust educational products on appropriateness in health care and to disseminate evidence-informed strategies for necessary changes in care processes. * Provinces and territories should work with providers to put in place incentives to decrease the provision of marginally useful or unnecessary care. Introduction As health systems struggle with the issue of sustainability and evidence that the quality of care is often sub-optimal, increasing attention is focused on the concept of appropriateness. A World Health Organization study published in 2000 described appropriateness as "a complex, fuzzy issue"1. Yet if the term is to be applied with benefit to health care systems, it demands definitional clarity. This policy document presents the Canadian Medical Association definition of appropriateness which addresses both quality and value. The roots of the definition are anchored in the evolution of Canadian health care over the last two decades. The document then considers the many issues confronting the operationalization of the term. It concludes that appropriateness can play a central role in positive health system transformation. Definition At the Canadian Medical Association General Council in 2013 the following resolution was adopted: The Canadian Medical Association adopts the following definition for appropriateness in health care: It is the right care, provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care. This definition has five key components: * right care is based on evidence for effectiveness and efficacy in the clinical literature and covers not only use but failure to use; * right provider is based on ensuring the provider's scope of practice adequately meets but does not far exceed the skills and knowledge to deliver the care; * right patient acknowledges that care choices must be matched to individual patient characteristics and preferences and must recognize the potential challenge of reconciling patient and practitioner perceptions; * right venue emphasizes that some settings are better suited in terms of safety and efficiency to delivering a specific type of care than others; * right time indicates care is delivered in a timely manner consistent with agreed upon bench marks. It is essential to appreciate that the "right cost" is a consequence of providing the right care, that it is an outcome rather than an input. In other words, if all five components above are present, high quality care will have been delivered with the appropriate use of resources, that is, at the right cost. Equally, however, it should be cautioned that right cost may not necessarily be the affordable cost. For example, a new drug or imaging technology may offer small but demonstrable advantages over older practices, but at an enormous increase in cost. Some might argue that right care includes the use of the newer drug or technology, while others would contend the excessive opportunity costs must be taken into consideration such that the older practices remain the right care. An Evolving Canadian Perspective from 1996 to 2013 In a pioneering paper from 1996 Lavis and Anderson wrote: ...there are two distinct types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided. The differences between the two parallel the differences between two other concepts in health care: effectiveness and cost-containment...An appropriate service is one that is expected to do more good than harm for a patient with a given indication...The appropriateness of the setting in which care is provided is related to cost effectiveness2. This very serviceable definition moved beyond a narrow clinical conception based solely on the therapeutic impact of an intervention on a patient, to broader contextual consideration focused on venue. Thus, for example, the care provided appropriately in a home-care setting might not be at all appropriate if given in a tertiary care hospital. Significantly, the authors added this important observation: "Setting is a proxy measure of the resources used to provide care"2. This sentence is an invitation to expand the original Lavis and Anderson definition to encompass other resources and inputs identified over the ensuing decades. Three elements are especially important. Timeliness became an issue in Canadian health care just as the Lavis and Anderson paper appeared. In 1997 almost two-thirds of polled Canadians felt surgical wait times were excessive, up from just over half of respondents a year earlier3. By 2004 concern with wait times was sufficiently pervasive that when the federal government and the provinces concluded the First Ministers' Agreement, it included obligations to provide timely access to cancer care, cardiac care, diagnostic imaging, joint replacement and sight restoration4. These rapid developments indicate that timeliness was now considered an essential element in determining the appropriateness of care. A second theme that became prominent in health care over the last two decades was the concept of patient-centredness. When the Canadian Medical Association released its widely endorsed Health Care Transformation in Canada in 2010, the first principle for reform was building a culture of patient-centred care. Succinctly put, this meant that "health care services are provided in a manner that works best for patients"5. To begin the process of operationalizing this concept CMA proposed a Charter for Patient-centred Care. Organized across seven domains, it included the importance of: allowing patients to participate fully in decisions about their care; respecting confidentiality of health records; and ensuring care provided is safe and appropriate. This sweeping vision underscores the fact that care which is not matched to the individual patient cannot be considered appropriate care. A third significant development over the last two decades was heightened awareness of the importance of scopes of practice. This awareness arose in part from the emphasis placed on a team approach in newer models of primary care6, but also from the emergence of new professions such as physician assistants, and the expansion of scopes of practice for other professionals such as pharmacists7. As the same health care activity could increasingly be done by a wider range of health professionals, ensuring the best match between competence required and the service provided became an essential element to consider when defining appropriateness. Under-qualified practitioners could not deliver quality care, while overly-qualified providers were a poor use of scarce resources. To summarize, as a recent scoping review suggested, for a complete conceptualization of appropriateness in 2013 it is necessary to add the right time, right patient and right provider to the previously articulated right care and right setting8. Why Appropriateness Matters The most frequent argument used to justify policy attention to appropriateness is health system cost. There is a wealth of evidence that inappropriate care - avoidable hospitalizations, for example, or alternative level of care patients in acute care beds - is wide spread in Canada9; eliminating this waste is critical to system sustainability. In Saskatchewan, for example, Regina and Saskatoon contracted in 2011 with private clinics to provide a list of 34 surgical procedures. Not only were wait times reduced, but costs were 26% lower in the surgical clinics than in hospitals for doing the same procedures10. There is, however, an equally important issue pointing to the importance of ensuring appropriate care: sub-optimal health care quality. In the United States, for example, a study evaluated performance on 439 quality indicators for 30 acute and chronic conditions. Patients received 54.9% of recommended care, ranging from a high of 78.7% for senile cataracts to 10.5% for alcohol dependence11. A more recent Australian study used 522 quality indicators to assess care for 22 common conditions. Patients received clinically appropriate care in 57% of encounters, with a range from 90% for coronary artery disease to 13% for alcohol dependence12. While no comparable comprehensive data exist for Canada, it is unlikely the practices in our system depart significantly from peer nations. Focusing on appropriateness of care, then, is justified by both fiscal and quality concerns. Methodology: the Challenge of Identifying Appropriateness While there is a clear need to address appropriateness - in all its dimensions - the methods by which to assess the appropriateness of care are limited and, to date, have largely focused on the clinical aspect. The most frequently used approach is the Rand/University of California Los Angeles (Rand) method. It provides panels of experts with relevant literature about a particular practice and facilitates iterative discussion and ranking of the possible indications for using the practice. Practices are labeled appropriate, equivocal or inappropriate13. A systematic review in 2012 found that for use on surgical procedures the method had good test-retest reliability, interpanel reliability and construct validity14. However, the method has been criticized for other short-comings: panels in different countries may reach different conclusions when reviewing the same evidence; validity can only be tested against instruments such as clinical practice guidelines that themselves may have a large expert opinion component2; Rand appropriateness ratings apply to an "average" patient, which cannot account for differences across individuals; and, finally, Rand ratings focus on appropriateness when a service is provided but does not encompass underuse, that is, failure to provide a service that would have been appropriate9. The Rand method, while not perfect, is the most rigorous approach to determining clinical appropriateness yet devised. It has recently been suggested that a method based on extensive literature review can identify potentially ineffective or harmful practices; when applied to almost 6000 items in the Australian Medical Benefits Schedule, 156 were identified that may be inappropriate15. This method also presents challenges. For example, the authors of a study using Cochrane reviews to identify low-value practices note that the low-value label resulted mainly from a lack of randomized evidence for effectiveness16. Assessing the appropriateness of care setting has focused almost exclusively on hospitals. Some diagnoses are known to be manageable in a community setting by primary care or specialty clinics. The rate of admissions for these ambulatory care sensitive conditions (ACSCs) - which fell from 459 per 100,000 population in 2001-02 to 320 per 100,00 in 2008-09 - is one way of gauging the appropriateness of the hospital as a care venue9. A second measure is the number of hospital patients who do not require either initial or prolonged treatment in an acute care setting. Proprietorial instruments such as the Appropriateness Evaluation Protocol (AEP)17or the InterQual Intensity of Service, Severity of Illness and Discharge Screen for Acute Care (ISD-AC)18 have been used to assess the appropriateness of hospital care for individual patients. While these instruments have been applied to Canadian hospital data19,20, there is a lack of consensus in the literature as to the reliability and utility of such tools21-23. Benchmarks exist for appropriate wait times for some types of care in Canada through the work of the Wait Time Alliance4. These include: chronic pain, cancer care, cardiac care, digestive health care, emergency rooms, joint replacement, nuclear medicine, radiology, obstetrics and gynecology, pediatric surgery, plastic surgery, psychiatric illness, and sight restoration. The recommendations are based on evidence-informed expert opinion. The other two domains of appropriateness - right patient, right provider - as yet have no objective tools by which to assess appropriateness. Barriers Determining appropriateness demands a complex and time-consuming approach, and its operationalization faces a number of barriers. The availability of some health care services may be subject to political influence which will over-ride appropriateness criteria. For example, recommendations to close smaller hospitals deemed to be redundant or inefficient may not be implemented for political reasons. Patient expectations can challenge evidence-based appropriateness criteria. In a primary care setting, for instance, it may be difficult to persuade a patient with an ankle sprain that an x-ray is unlikely to be helpful. The insistence by the patient is compounded by an awareness of potential legal liability in the event that clinical judgment subsequently proves incorrect. Choosing Wisely Canada recommends physicians and patients become comfortable with evidence-informed conversations about potentially necessary care24. Traditional clinical roles are difficult to revise in order to ensure that care is provided by the most appropriate health professional. This is especially true if existing funding silos are not realigned to reflect the desired change in practice patterns. Finally, and perhaps most importantly, even if agreed upon appropriateness criteria are developed, holding practitioners accountable for their application in clinical practice is extremely difficult due to data issues25. Chart audits could be conducted to determine whether appropriateness criteria were met when specific practices were deployed, but this is not feasible on a large scale. Rates of use of some practices could be compared among peers from administrative data; however, variation in practice population might legitimately sustain practice variation. For diagnostic procedures it has been suggested that the percentage of negative results is an indicator of inappropriate use; however, most administrative claim databases would not include positive or negative test result data26. This data deficit must be addressed with health departments and regional health authorities. Important Caveats There are several additional constraints on the use of the concept by health system managers. First, the vast majority of practices have never been subject to the Rand or any other appropriateness assessment. Even for surgical procedures clinical appropriateness criteria exist for only 10 of the top 25 most common inpatient procedures and for 6 of the top 15 ambulatory procedures in the United States. Most studies are more than 5 years old27. Second, while the notion is perhaps appealing to policy makers, it is incorrect to assume that high use of a practice equates with misuse: when high-use areas are compared to low use areas, the proportion of inappropriate use has consistently been shown to be no greater in the high-use regions28,29. Finally, it is uncertain how large a saving can be realized from eliminating problematic clinical care. For example, a US study modeling the implementation of recommendations for primary care found that while a switch to preferentially prescribing generic drugs would save considerable resources, most of the other items on the list of questionable activities "are not major contributors to health care costs"30. What is important to emphasize is that even if dollars are not saved, by reducing inappropriate care better value will be realized for each dollar spent. Policy Recommendations These methodological and other challenges31 notwithstanding, the Canadian Medical Association puts forward the following recommendations for operationalizing the concept of appropriateness and of clinical practice. 1. Provinces and territories should work with providers to develop a comprehensive framework by which to assess the appropriateness of health care. Jurisdictions should develop a framework32 for identifying potentially inappropriate care, including under-use. This involves selecting criteria by which to identify and prioritize candidates for assessment; developing and applying a robust assessment methodology; and creating mechanisms to disseminate and apply the results. Frameworks must also include meaningful consideration of care venue, timeliness, patient preferences and provider scope of practice. International examples exist for some aspects of this exercise and should be adapted to jurisdictional circumstances. Necessarily, a framework will demand the collection of supporting data in a manner consistent with the following 2013 General Council resolution: The Canadian Medical Association supports the development of data on health care delivery and patient outcomes to help the medical profession develop an appropriateness framework and associated accountability standards provided that patient and physician confidentiality is maintained. 2. Provinces and territories should work with providers to develop robust educational products on appropriateness in health care and to disseminate evidence-informed strategies for necessary changes in care processes. Both trainees and practicing physicians should have access to education and guidance on the topic of appropriateness and on practices that are misused, under-used, or over-used. Appropriately designed continuing education has been shown to alter physician practice. Point of care guidance via the electronic medical record offers a further opportunity to alert clinicians to practices that should or should not be done in the course of a patient encounter33. An initiative co-led by the Canadian Medical Association that is designed to educate the profession about the inappropriate over use of diagnostic and therapeutic interventions is Choosing Wisely Canada. The goal is to enhance quality of care and only secondarily to reduce unnecessary expenditures. It is an initiative consistent with the intent of two resolutions from the 2013 General Council: The Canadian Medical Association will form a collaborative working group to develop specialty-specific lists of clinical tests/interventions and procedures for which benefits have generally not been shown to exceed the risks. The Canadian Medical Association believes that fiscal benefits and cost savings of exercises in accountability and appropriateness in clinical care are a by-product rather than the primary focus of these exercises. 3. Provinces and territories should work with providers to put in place incentives to decrease the provision of marginally useful or unnecessary care. Practitioners should be provided with incentives to eliminate inappropriate care. These incentives may be financial - delisting marginal activities or providing bonuses for achieving utilization targets for appropriate but under-used care. Any notional savings could also be flagged for reinvestment in the health system, for example, to enhance access. Giving physicians the capacity to participate in audit and feedback on their use of marginal practices in comparison to peers generally creates a personal incentive to avoid outlier status. Public reporting by group or institution may also move practice towards the mean30. In any such undertakings to address quality or costs through changes in practice behaviour it is essential that the medical profession play a key role. This critical point was captured in a 2013 General Council resolution: The Canadian Medical Association will advocate for adequate physician input in the selection of evidence used to address costs and quality related to clinical practice variation. Conclusion When appropriateness is defined solely in terms of assessing the clinical benefit of care activities it can provide a plausible rational for "disinvestment in" or "delisting of" individual diagnostic or therapeutic interventions. However, such a narrow conceptualization of appropriateness cannot ensure that high quality care is provided with the optimal use of resources. To be truly useful in promoting quality and value appropriateness must be understood to mean the right care, provided by the right provider, to the right patient, in the right venue, at the right time. Achieving these five components of health care will not be without significant challenges, beginning with definitions and moving on to complex discussions on methods of measurement. Indeed, it may prove an aspirational goal rather than a completely attainable reality. But if every encounter in the health system - a hospitalization, a visit to a primary care provider, an admission to home care - attempted to meet or approximate each of the five criteria for appropriateness, a major step towards optimal care and value will have been achieved across the continuum. Viewed in this way, appropriateness has the capacity to become an extraordinarily useful organizing concept for positive health care transformation in Canada. Approved by CMA Board on December 06, 2014 References 1. World Health Organization. Appropriateness in Health Care Services, Report on a WHO Workshop. Copenhagen: WHO; 2000. 2. Lavis JN, Anderson GM. Appropriateness in health care delivery: definitions, measurement and policy implications. CMAJ. 1996;154(3):321-8. 3. Sanmartin C, Shortt SE, Barer ML, Sheps S, Lewis S, McDonald PW. Waiting for medical services in Canada: lots of heat, but little light. CMAJ. 2000;162(9):1305-10. 4. Wait Time Alliance. Working to Improve Wait Times Across Canada. Toronto: Wait Time Alliance; 2014. Available: http://www.waittimealliance.ca. (accessed April 18, 2013) 5. Canadian Medical Association. Health Care Transformation in Canada. Ottawa: Canadian Medical Association; 2010. 6. Canadian Medical Association. CMA Policy: Achieving Patient-centred Collaborative Care. Ottawa: Canadian Medical Association; 2008. 7. Maxwell-Alleyne A, Farber A. Pharmacists' expanded scope of practice: Professional obligations for physicians and pharmacists working collaboratively. Ont Med Rev. 2013;80(4):17-9. 8. Sanmartin C, Murphy K, Choptain N, et al. Appropriateness of healthcare interventions: concepts and scoping of the published literature. Int J Technol Assess Health Care. 2008;24(3)342-9. 9. Canadian Institute for Health Information. Health Care in Canada 2010. Ottawa: CIHI; 2010. 10. MacKinnon J. Health Care Reform from the Cradle of Medicare. Ottawa: Macdonald-Laurier Institute; 2013. 11. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. NEJM. 2003;348(26):2635-45. 12. Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100-5. 13. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care. 1986;2(1):53-63. 14. Lawson EH, Gibbons MM, Ko CY, Shekelle PG. The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol. 2012;65(11):1133-43. 15. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. Med J Aust. 2012;197(10):556-60. 16. Garner S, Docherty M, Somner J, et al. Reducing ineffective practice: challenges in identifying low-value health care using Cochrane systematic reviews. J Health Serv Res Policy. 2013;18(1):6-12. 17. Gertman PM, Restuccia JD. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care. 1981;19(8):855-71. 18. Mitus AJ. The birth of InterQual: evidence-based decision support criteria that helped change healthcare. Prof Case Manag. 2008;13(4):228-33. 19. DeCoster C, Roos NP, Carriere KC, Peterson S. Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review. CMAJ. 1997;157(7):889-96. 20. Flintoft VF, Williams JI, Williams RC, Basinski AS, Blackstien-Hirsch P, Naylor CD. The need for acute, subacute and nonacute care at 105 general hospital sites in Ontario. Joint Policy and Planning Committee Non-Acute Hospitalization Project Working Group. CMAJ . 1998;158(10):1289-96. 21. Kalant N, Berlinguet M, Diodati JG, Dragatakis L, Marcotte F. How valid are utilization review tools in assessing appropriate use of acute care beds? CMAJ. 2000;162(13):1809-13. 22. McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds. A systematic review of methods and results. Health policy. 2000;53(3):157-84. 23. Vetter N. Inappropriately delayed discharge from hospital: what do we know? BMJ. 2003;326(7395):927-8. 24. Choosing Wisely Canada. Recent News. Ottawa: Choosing Wisely Canada; 2015. Available: www.choosingwiselycanada.org. (accessed Dec 2014) 25. Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ. 2011;343:d4519. 26. Baker DW, Qaseem A, Reynolds PP, Gardner LA, Schneider EC. Design and use of performance measures to decrease low-value services and achieve cost-conscious care. Ann Intern Med. 2013;158(1):55-9. 27. Lawson EH, Gibbons MM, Ingraham AM, Shekelle PG, Ko CY. Appropriateness criteria to assess variations in surgical procedure use in the United States. Arch Surg. 2011;146(12):1433-40. 28. Chassin MR, Kosecoff J, Park RE, et al. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA. 1987;258(18):2533-7. 29. Keyhani S, Falk R, Bishop T, Howell E, Korenstein D. The relationship between geographic variations and overuse of healthcare services: a systematic review. Med care. 2012;50(3):257-61. 30. Kale MS, Bishop TF, Federman AD, Keyhani S. "Top 5" lists top $5 billion. Arch Intern Med. 2011;171(20):1856-8. 31. Elshaug AG, Hiller JE, Tunis SR, Moss JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Aust New Zealand Health Policy. 2007;4:23. 32. Elshaug AG, Moss JR, Littlejohns P, Karnon J, Merlin TL, Hiller JE. Identifying existing health care services that do not provide value for money. Med J Aust. 2009;190(5):269-73. 33. Shortt S GM, Gorbet S. Making medical practice safer: the role of public policy. Int J Risk Saf Med. 2010;22(3):159-68.
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Socially responsible investing

https://policybase.cma.ca/en/permalink/policy13718
Last Reviewed
2020-02-29
Date
2017-08-23
Topics
Physician practice/ compensation/ forms
Resolution
GC17-20
The Canadian Medical Association recommends that MD Financial Management Inc. provide information regarding socially responsible investing when marketing and advising on its investment portfolios.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2017-08-23
Topics
Physician practice/ compensation/ forms
Resolution
GC17-20
The Canadian Medical Association recommends that MD Financial Management Inc. provide information regarding socially responsible investing when marketing and advising on its investment portfolios.
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The Canadian Medical Association recommends that MD Financial Management Inc. provide information regarding socially responsible investing when marketing and advising on its investment portfolios.
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Management of physician fatigue

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

Medical assistance fund

https://policybase.cma.ca/en/permalink/policy11699
Last Reviewed
2019-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC14-85
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC14-85
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
Text
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
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National advance care planning toolkit website

https://policybase.cma.ca/en/permalink/policy11190
Last Reviewed
2018-03-03
Date
2014-03-01
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Resolution
BD14-05-162
The Canadian Medical Association recommends the use of a national advance care planning toolkit website with references to provincial and territorial resources to assist physicians in conversations about advanced care planning with their patients.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2014-03-01
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Resolution
BD14-05-162
The Canadian Medical Association recommends the use of a national advance care planning toolkit website with references to provincial and territorial resources to assist physicians in conversations about advanced care planning with their patients.
Text
The Canadian Medical Association recommends the use of a national advance care planning toolkit website with references to provincial and territorial resources to assist physicians in conversations about advanced care planning with their patients.
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Advanced care directive functionality

https://policybase.cma.ca/en/permalink/policy11191
Last Reviewed
2018-03-03
Date
2014-03-01
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
BD14-05-163
The Canadian Medical Association advocates for the inclusion of advanced care directive functionality as an electronic medical record vendor conformance and usability requirement.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2014-03-01
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
BD14-05-163
The Canadian Medical Association advocates for the inclusion of advanced care directive functionality as an electronic medical record vendor conformance and usability requirement.
Text
The Canadian Medical Association advocates for the inclusion of advanced care directive functionality as an electronic medical record vendor conformance and usability requirement.
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Advance care plans

https://policybase.cma.ca/en/permalink/policy11215
Last Reviewed
2018-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
GC14-19
The Canadian Medical Association supports the integration of advance care plans within patient records.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
GC14-19
The Canadian Medical Association supports the integration of advance care plans within patient records.
Text
The Canadian Medical Association supports the integration of advance care plans within patient records.
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CMA supports all physicians in CMA's policy on euthanasia and assisted suicide.

https://policybase.cma.ca/en/permalink/policy11220
Last Reviewed
2018-03-03
Date
2014-08-20
Topics
Ethics and medical professionalism
Resolution
GC14-24
The Canadian Medical Association (CMA) supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying as defined in CMA's policy on euthanasia and assisted suicide.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2014-08-20
Topics
Ethics and medical professionalism
Resolution
GC14-24
The Canadian Medical Association (CMA) supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying as defined in CMA's policy on euthanasia and assisted suicide.
Text
The Canadian Medical Association (CMA) supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying as defined in CMA's policy on euthanasia and assisted suicide.
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Principles for the protection of patient privacy

https://policybase.cma.ca/en/permalink/policy13833
Date
2017-12-09
Topics
Health information and e-health
Ethics and medical professionalism
  2 documents  
Policy Type
Policy document
Date
2017-12-09
Replaces
PD11-03 Principles for the Protection of Patients' Personal Health Information
Topics
Health information and e-health
Ethics and medical professionalism
Text
Patients have a right to privacy and physicians have a duty of confidentiality arising from the patient-physician relationship to protect patient privacy. The right to privacy flows from the principle of respect for patient autonomy, based on the individual's right to conduct and control their lives as they choose.1 When approaching any ethical question around privacy, the principle of respect for patient autonomy must be balanced against other competing principles (e.g. beneficence, non-maleficence). The protection of privacy and the concomitant duty of confidentiality are essential to foster trust in the patient-physician-relationship, the delivery of good patient care and a positive patient care experience. Privacy protection is an important issue for Canadians,2 and research suggests that patients may withhold critical health information from their health care providers because of privacy concerns.3 Patients will be more willing to share complete and accurate information if they have a relationship of trust with their physician and are confident that their information will be protected.4 In today's ever-evolving technological environment and due to the shift away from the traditional (paternalistic) physician-patient relationship, patients, physicians and other public and private stakeholders are using and sharing personal health information in new and innovative ways. This raises new challenges for clinical practice and, crucially, how to navigate expanded uses of data via the use of new technologies and the requirements of patient privacy. Institutions, clinics, and physician-group practices may share responsibility with the physician for the protection of patient information. There is thus a tension between physician and institutional responsibilities to protect patient information, challenged by the rapidly changing use and adoption of new technologies. While this will continue to redefine expectations of privacy and confidentiality, there are several foundational principles that remain unchanged. SCOPE OF POLICY The Canadian Medical Association (CMA) Principles for the Protection of Patients' Personal Health Information aim to provide guidance on key ethical considerations pertinent to the protection of patient information in a way that takes into account a physician's (including medical learner) ethical, professional, and legal obligations. The Principles are not designed to serve as a tool for legislative compliance in a particular jurisdiction or to provide a standard of care. Physicians should be aware of privacy legislation in the jurisdiction in which they practice, the standards and expectations specified by their respective regulatory authorities (including Privacy Commissioners), publications and risk management education provided by the CMPA as well as policies and procedures of any given setting (e.g., a regional health authority or a hospital). SUBSTANTIVE PRINCIPLES THAT GUIDE THE OBLIGATIONS OF THE PHYSICIAN TO PROTECT PATIENT PRIVACY 1. Trust * Trust is the cornerstone of the patient-physician relationship and plays a central role in providing the highest standard of care. * Physicians and their patients build relationships of trust that enable open and honest dialogue and foster patients' willingness to share deeply personal information (often) in conditions of vulnerability. * Physicians can cultivate and maintain patient trust by, unless the consent of the patient has been obtained to do otherwise, collecting health information only to benefit the patient, by sharing information only for that purpose, and by keeping patient information confidential; patient trust has been found to be the most powerful determinant of the level of control patients want over their medical records.5 * To maintain trust, physicians must consider the duty to care and the duty not to harm the patient in evaluating privacy requirements. * The extent to which a patient expects (and may tolerate a loss of) privacy and confidentiality is culturally and individually relative.6 2. Confidentiality * Physicians owe a duty of confidentiality to their patients; there is both an ethical (respect for autonomy) and a legal basis imposed by privacy legislation) for this duty. * The duty to maintain patient confidentiality, like trust, is fundamental to the therapeutic nature of the patient-physician relationship; it creates conditions that allow patients to openly and confidently share complete health information, resulting in a stronger physician-patient relationship and better delivery of care.7 * The duty to maintain patient confidentiality means that physicians do not share the health information with anyone outside of the patient's circle of care, unless authorized to do so by the patient.1,8 There are varying interpretations of what constitutes the patient's circle of care; this depends on the facts of the situation and the jurisdiction.9 * Privacy requirements raise complex issues in learning environments and quality improvement initiatives. It is desirable that any of the patient's physicians who will have ongoing care interactions with the patient can remain included in information-sharing about the patient. * Shared electronic health records present challenges to confidentiality. For example, patients may wish to limit some aspects of their record to only some providers within their circle of care.10 * In practice, respecting privacy and the duty of confidentiality govern the physician's role as data steward, responsible for controlling the extent to which information about the person is protected, used or disclosed.11 A central rule to balancing a patient's right to privacy and the duty of confidentiality is the "minimum necessary" use and disclosure of personal health information, whereby a data steward should use or disclose only the minimum amount of information necessary to fulfil the intended purpose. In some circumstances, de-identifying or aggregating personal health information before use or disclosure can minimize the amount of information disclosed.12 * The duty to maintain patient confidentiality is not absolute and is subject to exceptions in limited circumstances,13 i.e., when required or permitted by law to disclose information (see below in Data Stewardship: Collection, use and disclosure of personal health information). 3. Consent * Patient consent is an important mechanism for respecting patient autonomy; obtaining voluntary and informed consent to share patient information is fundamental to the protection of privacy and the duty of confidentiality. * Physicians are generally required to obtain informed consent from the patient before they can disclose the patient's personal health information. Consent is only informed if there is disclosure of matters that a reasonable person in the same circumstances would want to know, including 1) to whom the patient information will be disclosed, 2) whether it could be disclosed to other third parties, and 3) the purpose for which it could be used or disclosed. * While informed consent is required as a general rule, physicians may infer that they have the patient's implied consent to collect, use, disclose and access personal health information 1) for the purpose of providing or assisting in providing care (i.e., share only the necessary information with those involved within the patient's circle of care); and 2) to store personal health information in a medical record (i.e., paper, electronic, or hospital-based). Physicians will want to consider if it is appropriate in the circumstances to advise the patient when a disclosure has been made. * When the patient is a minor, the physician must consider whether it is the parent or the child who determines the use and disclosure of the minor's personal health information. A young person who is deemed to understand fully the implications of a decision regarding proposed collection, use or disclosure of personal health information is generally deemed to have control over their personal health information with respect to the decision. * Where the patient is not capable to provide the required consent (e.g. is deemed to be incompetent), physicians must seek consent from the patient's substitute decision-maker. 4. Physician as data steward * As data stewards, physicians have the responsibility to understand their role in protecting patient privacy and appropriate access to patient information. * The information contained in the medical record belongs to the patient who has a general right of access to their personal health information, and the right to control the use and further disclosure and to the continued confidentiality of that information. * A data steward (e.g., physician, institution or clinic) holds the physical medical record in trust for the care and benefit of the patient.14 * Physicians should provide their patients access to their medical record, if requested.15 (See below in Data Stewardship: Access to personal information). * Physicians ought to have appropriate access to personal health information and have the ability to provide their patients with access to their medical record. Appropriate access should be interpreted to include access for patient follow up (as part of the duty to care) and review for the purpose of improving patient care. * Physicians should consider consulting available resources to assist them in fulfilling their duties as data stewards. PROCEDURAL PRINCIPLES THAT GUIDE THE APPLICATION OF PHYSICIAN OBLIGATIONS Physicians must manage personal health information in compliance with relevant legislation that establishes rules governing the access, collection, use, disclosure, and retention of personal health information, provincial privacy laws, and professional expectations and regulations specified by their respective regulatory authorities. 1. Data Stewardship: Access to personal information * Patients have a right of reasonable access to the personal health information in their medical record (i.e., paper, electronic, or hospital-based) under the control or in the custody of a physician, institution, or clinic. * In exceptional situations, physicians can refuse to release the information in the patient's medical record. 2. Data Stewardship: Collection, use and disclosure of personal health information * There are circumstances where there are required (e.g., monitoring of claims for payment, subpoenas) and permitted disclosures of personal health information without patient consent (e.g., where the maintenance of confidentiality would result in a significant risk of substantial harm to the patient or to others). * Security safeguards must be in place to protect personal health information in order to ensure that only authorized collection, use, disclosure or access occurs. * Physicians play an important role in educating patients about possible consensual and non-consensual uses and disclosures that may be made with their personal health information, including secondary uses of data for, e.g., epidemiological studies, research, education, and quality assurance, that may or may not be used with explicit consent. 3. Data Stewardship: Retention of personal health information * Personal health information should be retained for the period required by any applicable legislation and as specified by their respective regulatory authorities. It may be necessary to maintain personal health information beyond the applicable period where there is a pending or anticipated legal proceeding related to the care provided to the patient. * Likewise, physicians should transfer and dispose of personal health information in compliance with any applicable legislation and professional expectations outlined by their respective regulatory authorities. * Physicians are encouraged to seek technical assistance and advice on the secure transfer, disposal, and/or selling of electronic records.15 4. Data Stewardship: Use of technology * Physicians should obtain patient consent to use electronic means and/or devices for patient care (e.g., sending digital photographs) and for communicating patient information (e.g., the use of email). To obtain informed consent, physicians should explain to patients that there are necessary benefits and risks in using technologies in clinical contexts. The CMPA has provided a written consent form to that effect that can be included in the patient's medical record. * As a general practice, physicians are encouraged to make use of technological innovations and must evaluate whether the technology is appropriate for patient care and has reasonable safeguards to protect patient privacy. Approved by the CMA Board of Directors December 2017 See also Background to CMA Policy Principles for the Protection of Patient Privacy REFERENCES 1 Martin JF. Privacy and confidentiality. In: ten Have H, Gordijn B (Eds). Handbook of global bioethics. New York: Springer, Dordrecht; 2014. p.119-37. 2 Office of the Privacy Commissioner of Canada. Canadians and privacy final report. Gatineau: Office of the Privacy Commissioner of Canada; 2009. Available: https://www.priv.gc.ca/information/por-rop/2009/ekos_2009_01_e.asp (accessed 2017 Nov 17). 3 Canadian Medical Protective Association (CMPA). Privacy and a wired world - Protecting patient health information. Ottawa: CMPA; 2011 Dec. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2011/privacy-and-a-wired-world-protecting-patient-health-information (accessed 2017 Nov 17). 4 Royal College of Physicians and Surgeons of Canada (RCPSC). Duty of confidentiality. Ottawa: RCPSC; 2017. Available: http://www.royalcollege.ca/rcsite/bioethics/cases/section-3/duty-confidentiality-e (accessed 2017 Dec 15). 5 Damschroder LJ, Pritts JL, Neblo MA, Kalarickal RJ, Creswell JW, Hayward RA. Patients, privacy and trust: patients' willingness to allow researchers to access their medical records. Soc Sci Med 2007;64:223-35. 6 Campbell JI, Eyal N, Musiimenta A, Haberer JE. Ethical questions in medical electronic adherence monitoring. J Gen Intern Med 2016;31:338-42. Available: https://link.springer.com/content/pdf/10.1007%2Fs11606-015-3502-4.pdf (accessed 2017 Nov 17). 7 Crook MA. The risks of absolute medical confidentiality. Sci Eng Ethics 2013;19:107-22. 8 Cohen I, Hoffman A, Sage W (Eds). The Oxford Handbook of U.S. Health Law. New York: Oxford University Press; 2015. 9 Canadian Medical Protective Association (CMPA). The voice of professionalism within the system of care. Ottawa: CMPA; 2012 Oct. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2012/the-voice-of-professionalism-within-the-system-of-care (accessed 2017 Nov 17). 10 Canadian Medical Protective Association (CMPA). Did you know? Patients can restrict access to their health information. Ottawa: CMPA; 2017 Nov. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2017/did-you-know-patients-can-restrict-access-to-their-health-information (accessed 2017 Nov 17). 11 Francis JG, Francis LP. Privacy, confidentiality, and justice. J Soc Philos 2014;45:408-31. 12 Burkle CM, Cascino GD. Medicine and the media: balancing the public's right to know with the privacy of the patient. Mayo Clin Proc 2011;86:1192-6. 13 Canadian Medical Protective Association (CMPA). When to disclose confidential information. Ottawa: CMPA; 2015 Mar. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/when-to-disclose-confidential-information (accessed 2017 Nov 17). 14 Canadian Medical Protective Association (CMPA). Releasing a patient's personal health information: What are the obligations of the physician? Ottawa: CMPA; 2012 Oct. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2012/releasing-a-patient-s-personal-health-information-what-are-the-obligations-of-the-physician (accessed 2017 Nov 17). 15 Canadian Medical Protective Association (CMPA). Protecting patient health information in electronic records. Ottawa: CMPA; 2013 Oct. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2013/protecting-patient-health-information-in-electronic-records (accessed 2017 Nov 17). (c) 2017 Canadian Medical Association. You may, for your non-commercial use, reproduce, in whole or in part and in any form or manner, unlimited copies of CMA Policy Statements provided that credit is given to Canadian Medical Association. BACKGROUND TO CMA POLICY PRINCIPLES FOR THE PROTECTION OF PATIENT PRIVACY See also CMA Policy on Principles for the Protection of Patient Privacy Context The advent of Electronic Medical Records, the rapid spread of mobile health apps, and the increasing use of social media within the health care community, have each created new challenges to maintaining a duty of confidentiality within the physician-patient relationship. These technologies present both opportunities and challenges with respect to medical professionalism.1 The permeation of these types of interactions into everyday life now places physicians in new situations that some find difficult to navigate.2 These challenges will only increase in the coming years, as the use of online technologies in health care is continuously growing.3 Canada is only in the early stages of managing the emerging issues of technology-induced errors that compromise privacy in the health care setting.4 Therefore, this paper will briefly discuss the importance of protecting privacy, followed by an overview of the main challenges to maintaining privacy as the physician-patient relationship evolves at the backdrop of emerging technologies. Privacy and Confidentiality The overlapping, but not identical, principles of the protection of privacy and the duty of confidentiality are essential to the physician-patient relationship. These principles not only foster trust, but also the delivery of effective and lasting care. Rooted in the Hippocratic Oath, the modern-day right to privacy flows from the principle of autonomy, which attributes to individuals the right to conduct and control their lives as they choose.5 Privacy protection is an important issue to Canadians,6 with research suggesting that patients may even withhold critical health information because of privacy concerns.7 Health care professionals are bound by legal and ethical standards to maintain privacy and confidentiality of patient information.8 Physicians must therefore be aware of the implications of privacy legislation specific to their jurisdiction.7 The duty to protect patient privacy is important to uphold, as health information can potentially be identifiable and sensitive; the confidentiality of this information must therefore be protected to ensure that patient privacy is not breached. 9 While the traditional, and largely obsolete, models of the physician-patient relationship involve a unidirectional flow of information, the ease at which patients can now access medical information through the Internet, and the use of social media within the health care community, have reinterpreted how information is communicated from physician to patient, and vice versa.10 We must therefore re-define expectations of privacy and confidentiality, first by distinguishing one from the other. The terms "privacy" and "confidentiality" are often used interchangeably by both researchers and clinicians. Several bioethics discussions on the distinction between these terms places confidentiality under the umbrella of privacy.11 While confidentiality involves the information itself, which is disclosed or not, privacy is about the impact of that disclosure on the person.9 Privacy seems to be more intimately linked to the individual, focusing on the circumstances under which the information is used.12-13 Confidentiality, on the other hand, is a duty that health professionals have towards their patients to not share the information exchanged during their encounter, unless authorized by the patient.5,12 In practice, the duty of confidentiality governs the physician's role as data stewards, responsible for controlling the extent to which information about the person is protected, used or disclosed.14 As one paper describes, "privacy is invaded, confidentiality is breached."13 From a patient perspective, it is important to respect and protect privacy because it allows individuals time and space to share their concerns without feeling judged or misunderstood,11 resulting in a stronger physician-patient relationship and better delivery of care. However, from a research perspective, a fine balance must be struck between using accurate information while still upholding the privacy rights of individuals.11 As such, the argument for absolute confidentiality puts a near impossible burden on research clinicians.11 Moreover, from a public safety perspective, a physician may be morally and legally required to break confidentiality in order to protect both the patient and others who may be involved. The challenge is to balance the traditional goal of confidentiality - to protect patient privacy and interest - with that of third parties and public health.5 Therefore, a central rule to balancing confidentiality with a patients' right to privacy is the "minimum necessary" use and disclosure of personal health information, whereby a data steward should use or disclose only the minimum amount of information necessary to fulfil the intended purpose.8 It is equally important to recognize that the extent to which a patient may tolerate a loss of privacy is culturally and individually relative.15 Health care providers have a legal and ethical obligation to keep patient health information private, sharing it only with the authorization of the patient.16 Informed consent, therefore, appears to be a fundamental requirement to upholding confidentiality and patient privacy rights. Issues While emerging privacy issues touch many areas of practice, this section will emphasize three of the most prominent issues in recent literature: access and use of information, electronic medical and health records and, online communication and social media. 1. Technological change and institutional data stewardship In today's ever-evolving technological environment, including the emergence of shared electronic health records, online communication, social media, mobile applications, and big data, physicians, patients and other public and private stakeholders are using and sharing personal health information in new and innovative ways. The traditional (paternalistic) model of the physician-patient relationship involved a bidirectional flow of information. However, the ease at which patients can now access medical information from alternative sources via the Internet, and the use of social media within the health care community, has redefined how information is communicated from physician to patient, and vice versa.10 This raises new challenges for clinical practice, specifically how to navigate expanded access of data via the use of new technologies and the requirements of patient privacy by effectively managing security concerns. In many situations, the physician may not be the sole or primary custodian of (i.e., control access to) the patient's records once the health information is collected. Institutions, clinics, and physician-group practices may also have responsibility for patient information and therefore play an important role in ensuring it is protected. There is thus a grey area between physician and institutional responsibilities to protect patient information, challenged by the rapidly changing use and adoption of new technologies, such as electronic health and medical records. While this will continue to redefine expectations of privacy and confidentiality, there are several foundational principles that remain unchanged. 2. Electronic medical and health records Medical records are compiled primarily to assist physicians and other health care providers in treating patients.16 Yet, they are particularly vulnerable to privacy breaches when this information is exposed to secondary uses, including epidemiological studies, research, education and quality assurance. As contemporary information management and stewardship have had to evolve in response to emerging technology, the parameters of the "medical record" have grown increasingly ambiguous.17 With the proliferation of a wide variety of new health information technology (including electronic health and medical records), concerns about quality and safety have been raised.4 There is evidence that if such technology is not designed, implemented and maintained effectively, it may result in unintended consequences, including technology-induced errors and breaches of patient privacy.4 Reports involving Canada Health Infoway have even pointed to health information technology as a tool that may sometimes reduce rather than enhance patient safety, most often due to human factors. 4 As a result, recommendations have been made to develop a reporting system that would allow health professionals to anonymously report human errors resulting from the use of health information technology - a challenge in itself, as the distinction between human and technological error is often blurred.4 In Canada, a number of efforts have been undertaken by several organizations, including Health Canada and Canada's Health Informatics Organization.4 Yet, services aimed at improving health information technology safety, from a national level, remain poor.4 As a result, organizations like Canada Health Infoway have promoted the need for collaborative efforts to improve health information technology safety standards in Canada, 4 so to ensure that the current and future uses of "medical record" data are accurate and respectful of patient privacy. 3. Access and use of personal health information for research The courts have long established that health information belongs to the patient.18 As a result, privacy ownership refers to the belief that patients own their private information as well as the right to control access to this information.19 As in other jurisdictions, the overarching challenge in Canada is to strike a balance between enabling access to health and health-related data for research while still respecting Canadians' right to privacy and control over the confidentiality of their information.20 The integrity of healthcare information is fundamental, given that it is the basis on which treatment decisions are made both in research and in clinic. 9 There are three principles upon which information security is based: 9 1) only authorized people have access to confidential information; 2) information must be accurate and consistent, may only be modified by authorized people in ways that are appropriate; 3) information must be accessible by authorized users when needed. Canadian research ethics have demonstrated that beneficial work can be done while maintaining confidentiality to sensitive personal health information.21 Yet, the challenge remains to create a uniform system for accessing data and performing data-based research due to 1) the lack of consistency and clarity in Canada's ethical and legal framework and, 2) varied interpretations of key terms and issues across the country.21 For example, the term "non-identifiable data" remains ambiguous across provinces and is subject to interpretation by data custodians, who may consider their legal duty to protect privacy as precluding access to data.21 This lack of legal clarity has contributed to varied cautious and conservative interpretations of data access legislation.21 National uniform guidelines on the appropriate access, disclosure and use of personal health data would allow data stewards to advance their research while respecting their patients' right to privacy. 4. Online communication with patients and social media Social media and online communication is pervasive in Canadian society; from Facebook to Twitter, social media has changed the way people interact and disseminate information.21 There is currently widespread discussion among health care professionals and academics regarding the role that social media and online communication should play in the physician-patient relationship.22 A growing number of physicians have embraced the opportunities of interconnectivity that social media affords, implementing their own privacy procedures to reflect this new type of data collection, use and storage.7 While evidence has been lacking on whether the use of social media does improve patient outcomes,22 there is no denying that patients are seeking health care information from online platforms, including social media.22 This type of communication poses a unique set of opportunities and challenges for physicians: while the use of social media could increase physician reach and patient engagement, it can also blur boundaries between one's personal and professional life.22 Although patient-physician online communication is currently limited, physicians still feel that they are encountering an ethical dilemma, especially when they find themselves in boundary crossing situations, like a friend request from a patient.2 Physicians are particularly concerned that, through online communication, they may be exposed to medico-legal and disciplinary issues, especially with respect to patient privacy.2 Given different studies have suggested that unprofessional uses of social media are not uncommon,23 physicians who choose to communicate with patients online or through social media must remember that they are still governed by the same ethical and professional standards that remain paramount.22 As technology continues to evolve, so too will the traditional parameters of the patient-physician relationship. The physician's ethical and professional obligation to protect patient privacy, however, must remain paramount at the backdrop of technology use. Simply banning social media and online communication would neither eliminate risk, nor benefit patient care outcomes. 24 Instead, institutions should establish stringent policies that outline how to prevent or minimize the effects of privacy breaches associated with social media and online communication.25 This should also include a tracking mechanism to help balance the obligation to privacy with evolving technology.25 December 2017 See also CMA Policy on Principles for the Protection of Patient Privacy REFERENCES 1 Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 2013;158(8):620-627. 2 Brown J, Ryan C. How doctors view and use social media: a national survey. J Med Internet Res 2014;16:e267. Available: https://doi.org/10.2196/jmir.3589 (accessed 2017 Nov 17). 3 Lambert KM, Barry P, Stokes G. Risk management and legal issues with the use of social media in the healthcare setting. J Healthc Risk Manag 2012;31(4):41-47. 4 Kushniruk AW, Bates DW, Bainbridge M, Househ MS, Borycki EM. National efforts to improve health information system safety in Canada, the United States of America and England. Int J Med Inform 2013;82(5):e149-160. 5 Martin JF. Privacy and confidentiality. In: ten Have H, Gordijn B (Eds). Handbook of global bioethics. New York: Springer, Dordrecht; 2014. p.120-1. 6 Office of the Privacy Commissioner of Canada. Canadians and privacy final report. Gatineau: Office of the Privacy Commissioner of Canada; 2009. Available: https://www.priv.gc.ca/information/por-rop/2009/ekos_2009_01_e.asp (accessed 2017 Nov 17). 7 Canadian Medical Protective Association (CMPA). Privacy and a wired world - Protecting patient health information. Ottawa: CMPA; 2011 Dec. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2011/privacy-and-a-wired-world-protecting-patient-health-information (accessed 2017 Nov 17). 8 Burkle CM, Cascino GD. Medicine and the media: balancing the public's right to know with the privacy of the patient. Mayo Clin Proc 2011;86:1192-6. 9 Williams PA. Information security governance: a risk assessment approach to health information systems protection. Stud Health Techol Inform 2013;193:186-206. 10 Borza LR, Gavrilovici C, Stockman R. Ethical models of physician-patient relationship revisited with regard to patient autonomy, values and patient education. Rev Med Chir Soc Med Nat Iasi 2015;119(2):496-501. 11 Crook MA. The risks of absolute medical confidentiality. Sci Eng Ethics 2013;19(1):107-122. 12 Cohen I, Hoffman A, Sage W (Eds). The Oxford handbook of U.S. health law. New York: Oxford University Press; 2015. 13 Francis L. Privacy and confidentiality: the importance of context. The Monist; 91(1);2008:52-67. 14 Francis JG, Francis LP. Privacy, confidentiality, and justice. J Soc Philos 2014;45:408-31. 15 Campbell JI, Eyal N, Musiimenta A, Haberer JE. Ethical questions in medical electronic adherence monitoring. J Gen Intern Med 2016;31:338-42. Available: https://link.springer.com/content/pdf/10.1007%2Fs11606-015-3502-4.pdf (accessed 2017 Nov 17). 16 Canadian Medical Association (CMA). Medical record confidentiality, access and disclosure. Ottawa: CMA; 2000. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_The_medical_record_confidentiality_access_and_disclosure_Update_2000_PD00-06-e.pdf (accessed 2017 Oct 30). 17 Fenton SH, Manion F, Hsieh K, Harris M. Informed Consent: Does anyone really understand what is contained in the medical record? Appl Clin Inform 2015;6(3):466-477. 18 Canada. Supreme Court. McInerney v MacDonald. Dom Law Rep. 1992 Jun 11;93:415-31. 19 Petronio S, Dicorcia MJ, Duggan A. Navigating ethics of physician-patient confidentiality: a communication privacy management analysis. Perm J 2012;16(4):41-45. 20 Council of Canadian Academies (CCA). Accessing health and health-related data in Canada. Ottawa: The Expert Panel on Timely Access to Health and Social Data for Health Research and Health System Innovation, Council of Canadian Academies; 2015. Available: http://www.scienceadvice.ca/uploads/eng/assessments%20and%20publications%20and%20news%20releases/Health-data/HealthDataFullReportEn.pdf (accessed 2017 Nov 17). 21 Canadian Medical Association (CMA). Social media and Canadian physician: Issues and rules of engagement. Ottawa: CMA; 2011. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/CMA_Policy_Social_Media_Canadian_Physicians_Rules_Engagement_PD12-03-e.pdf (accessed 2017 Oct 30). 22 Eysenbach G. Medicine 2.0: Social networking, collaboration, participation, apomediation, and openness J Med Internet Res 2008;10(3):e22. 23 Mayer MA, Leis A, Mayer A, Rodriguez-Gonzalez A. How medical doctors and students should use social media: A review of the main guidelines for proposing practical recommendations. Stud Health Technol Info 2012;180:853-857. 24 Moses RE, McNeese LG, Feld LD, Feld AD. Social media in the health-care setting: Benefits but also a minefield of compliance and other legal issues. Am J Gastroenterol 2014;109(8):1128-1132. 25 Yang YT, Silverman RD. Mobile health applications: The patchwork of legal and liability issues suggests strategies to improve oversight. Health Aff (Millwood) 2014;33(2):222-227.
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Charter of Shared Values: A vision for intra-professionalism for physicians

https://policybase.cma.ca/en/permalink/policy13858
Date
2017-12-09
Topics
Ethics and medical professionalism
  2 documents  
Policy Type
Policy document
Date
2017-12-09
Replaces
CMA Charter for Physicians (Update 1999)
Topics
Ethics and medical professionalism
Text
What is it? The CMA Charter of Shared Values aims to identify shared values and commitments to each other and to the profession to which physicians and learners can commit to promote trust and respect within the profession and for each other, and identify opportunities for engagement and leadership to promote civility and confront incivility within the profession. Why does it matter? The Charter is intended to further strengthen professional responsibilities in support of a unified and aligned profession. We achieve the highest degree of both individual and collective success when we work together, commit together and believe together; when we share a clearly articulated set of common values, virtues and principles; and when we subscribe to the same explicit and implicit understandings. Commitments to Each Other: Our most important shared values RESPECT As a physician, I will strive to be respectful; I will recognize that everyone has inherent worth, is worthy of dignity, and has the right to be valued and respected, and to be treated ethically; I will respect others and their personal and professional dignity; and I will aim to promote and model respect through collaborative training and practice. INTEGRITY As a physician, I will strive to act with integrity; I will act in an honest and truthful manner, with consistency of intentions and actions; and I will act with moral concern to promote and model effective leadership and to achieve a good outcome for patients. RECIPROCITY As a physician, I will strive to cultivate reciprocal relationships; I will be kind with my physician colleagues, and expect them to respond similarly; I will share and exchange my knowledge and experience with them; and I will be generous with them in spirit and in time. CIVILITY As a physician, I will strive to be civil; I will respect myself and others, regardless of their role, even those with whom I may not agree; I will enter into communication with my physician colleagues with an attitude of active and open listening, whether it be in person, in writing, or virtually; and I will accept personal accountability. Commitments to the Profession 1. Commitment to promoting a culture of respect and collegiality As a physician, I will strive to build a culture based on mutual respect and collegiality where physicians treat each other as people in a shared endeavor, and promote civility. I will strive to:
Cultivate respectful, open, and transparent dialogue and relationships
Take responsibility for promoting civility and confronting incivility within the profession
Recognize the relative value among family medicine and specialties and across the educational spectrum, and of the profession’s shared contributions within health systems
Model healthy and supportive training and practice environments 2. Commitment to promoting a culture of self-care and support As a physician, I will strive to build a culture of self-care and support where physicians are empowered to ask for help and are supported to care for their own physical, mental, and social well-being. I will strive to:
Value physician health and wellness and promote a professional culture that recognizes, supports, and responds effectively to your needs and colleagues in-need
Cultivate an environment of physical and psychological safety, conducive to challenging the status quo, as well as encouraging help-seeking behaviours, without fear of negative reprisal
Recognize that both individual and system-level barriers contribute to health and wellness-related issues and advocate for cultural and systemic change to remove barriers 3. Commitment to promoting a culture of leadership and mentorship As a physician, I will strive to foster a culture of leadership and mentorship across the career life cycle. I will strive to:
Encourage and enable opportunities and participation in leadership roles across all levels of training, practice, and health system delivery
Promote and enable formal and informal mentorship opportunities and leadership training across all levels of training and practice
Value the exchange of knowledge and experience and encourage reflective relationships (bi-directional) across all levels of training and practice 4. Commitment to promoting a culture of inquiry and reflection As a physician, I will strive to foster a culture of inquiry and reflection that values and enables reflective practice, individually and collectively. I will strive to:
Value and enable collective inquiry and self-reflection to effect meaningful change
Foster curiosity and exploration to identify strengths and capabilities of teams and health systems to generate new possibilities for action
Cultivate strong connections and relationships between, and meaningful interactions with, colleagues 5. Commitment to promoting a culture of quality As a physician, I will strive to foster a culture of quality and quality improvement. I will strive to:
Foster intra- and inter-professional collaborations and promote collaborative models of care
Provide high quality patient care and have a view to continuous improvement at the practice and system level, and commit to developing and applying the skills and techniques of quality improvement
Understand that quality improvement is a critical and life-long part of education and practice; participate in maintaining professional standards in myself and my colleagues
Engage patients, families, and caregivers in the process of improvement 6. Commitment to valuing a culture of diversity As a physician, I will strive to foster a community of practitioners that reflects the diversity of the communities they serve. I will strive to:
Promote diversity within the profession to be receptive and responsive to the evolving (physical, emotional, cultural, socioeconomic) needs of our patient populations
Foster a training and practice environment where diverse and unique perspectives, across generations, cultures and abilities, are heard and appreciated
Foster diversity in leadership across the full spectrum of leadership roles within the profession and health systems
Value the importance of these perspectives within the medical profession, even when they may not be my own patients, families, and caregivers in the process of improvement cma.ca/medicalprofessionalism
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Excise duty framework for cannabis products

https://policybase.cma.ca/en/permalink/policy13799
Date
2017-12-07
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Response to consultation
Date
2017-12-07
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) is pleased to provide its comments with respect to the Government of Canada's consultation on the Proposed Excise Duty Framework for Cannabis Products published November 10.1 In the move towards the legalization and regulation of cannabis, there are many economic interests at play; private corporations and different levels of government stand to benefit greatly with sales and considerable tax revenue.2 It is essential that the federal and provincial/territorial governments be held accountable to the public health and safety objectives set out for the new regime for legal access to cannabis, particularly that of protecting children and youth.3 It is fundamental that commercialization is rigorously controlled through taxation, regulation, monitoring and advertising controls. Final pricing must be such as to discourage the illegal production and trafficking of cannabis. However, a balance must be found with the use of taxation and pricing levers to discourage use. Revenues need to be clearly earmarked to cover the health and social costs of legalization. In some U.S. jurisdictions, for example, some of the revenue is directed to recovering the costs of regulatory programs as well as in substance use treatment programs, and for social programs. Most of the future tax revenues should be redistributed to the provinces and territories. This is because they have jurisdiction over services that will likely feel the impact with legalization, such as health care, education, social and other services, as well as enforcement of legislation and regulations. A public health approach to legalization will emphasize prevention, education and treatment initiatives which require adequate and reliable funding. It will also require strong surveillance and monitoring activities to adjust measures should unintended harms be detected. Resources need to be promptly available to address potential negative impacts. CMA recommends that the revenue resulting from the taxation of cannabis production and sales be earmarked to address health and social harms of cannabis use and its commercialization, in line with a public health approach to the legalization of cannabis. The proposal states that "Any cannabis products sold under the proposed Cannabis Act for medical purposes will be subject to the duty rates and conditions of the excise duty framework, which will become applicable as per the transitional rules (...) Cannabis products that are produced by an individual (or a designated person) for the individual's own medical purposes in accordance with the proposed Cannabis Act will not be subject to the excise duty. Seeds and seedlings used in this production will be subject to duty."1 The CMA is supportive of similar taxation treatment of cannabis products, regardless of whether they are used for medical or non-medical purposes. The CMA has long called for more research to better understand potential therapeutic indications of cannabis, as well as its risks.4 5 Physicians recognize that some individuals suffering from terminal illness or chronic disease for which conventional therapies have not been effective may obtain relief with cannabis used for medical purposes. However, clinical evidence of medical benefits is limited and there is very limited guidance for the therapeutic use, including indications, potency, interactions with medications and adverse effects. Health Canada does not approve of cannabis as a medicine, as it has not gone through the approvals required by the regulatory process to be a pharmaceutical. It is important that there be support for cannabis research in order to develop products that can be held to pharmaceutical standards, as is the case with dronabinol (Marinol(r)), nabilone (Cesamet(r)) and THC/CBD (Sativex(r)). The experience of legalization for non-medical use in Colorado and Washington has shown that two separate regimes with distinct regulations can be very difficult to enforce given the different standards.6 A lower tax rate on cannabis for medical use could potentially provide an incentive for people to seek a medical authorization, and that was observed initially in Colorado.7 The CMA recommends that the same tax rates be applied to the production and sales of both the medical and the non-medical use of cannabis products. The move towards the legalization and regulation of cannabis will require a balanced approach to discourage the illegal production and trafficking of cannabis while also using taxation and pricing levers to discourage use. Much of the revenues raised should be redistributed to the provinces and territories to enable them to cover the health and social costs of legalization. A public health approach to legalization will emphasize prevention, education, treatment and surveillance initiatives which requires adequate and reliable funding. 1 Department of Finance Canada. Proposed excise duty framework for cannabis products. Ottawa: Department of Finance Canada; 2017. Available: http://www.fin.gc.ca/n17/data/17-114_1-eng.asp (accessed 2017 Dec 05). 2 Sen A, Wyonch R. Don't (over) tax that joint, my friend. Intelligence MEMOS. Ottawa: CD Howe Institute; 2017 Jul 19. Available: https://www.cdhowe.org/sites/default/files/blog_Anindya%20and%20Rosalie_0719.pdf (accessed 2017 Dec 06). 3 Task Force on Marijuana Legalization and Regulation. Ministry of Justice, Ministry of Public Safety and Emergency Preparedness and Ministry of Health. Toward the legalization, regulation and restriction of access to marijuana. Discussion paper. Ottawa: Cannabis Legalization and Regulation Secretariat; 2016. Available: http://www.healthycanadians.gc.ca/health-system-systeme-sante/consultations/legalization-marijuana-legalisation/alt/legalization-marijuana-legalisation-eng.pdf (accessed 2017 Dec 05). 4 Canadian Medical Association (CMA). A public health perspective on cannabis and other illegal drugs. CMA Submission to the Special Senate Committee on Illegal Drugs. Ottawa: CMA; 2002. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/cannabis.pdf (accessed 2017 Dec 05). 5 Canadian Medical Association (CMA). Medical Marijuana. CMA Policy. Ottawa: CMA; 2011. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/PD11-02-e.pdf (accessed 2017 Dec 05). 6 Canadian Centre on Substance Use and Addiction (CCSA). Cannabis regulation: Lessons learned in Colorado and Washington State. Ottawa: CCSA; 2015. Available: http://www.ccsa.ca/Resource%20Library/CCSA-Cannabis-Regulation-Lessons-Learned-Report-2015-en.pdf (accessed 2017 Dec 05). 7 Office of the Parliamentary Budget Officer. Legalized cannabis: Fiscal considerations. Ottawa: Office of the Parliamentary Budget Officer; 2016. Available: http://www.pbo-dpb.gc.ca/web/default/files/Documents/Reports/2016/Legalized%20Cannabis/Legalized%20Canabis%20Fiscal%20Considerations_EN.pdf (accessed 2017 Dec 05).
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Review of Pan-Canadian health organizations

https://policybase.cma.ca/en/permalink/policy13737
Date
2017-11-24
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-11-24
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) welcomes this opportunity to provide input to the review of the Pan-Canadian health organizations (PCHOs). The CMA has had the opportunity to interact with all of them at one time or another. This review is timely, as there is a burning issue: Canada continues to languish near the bottom of the Commonwealth Fund's 11-country rankings, and the leading edge of the baby boom will reach age 75 in 2021, at which point per capita health care costs in Canada will escalate. We will discuss major unmet needs, make some general observations and offer two recommendations. References are provided in the bibliography. Unmet needs National focal point for quality: Our impression is that none of the PCHOs is pursuing a comprehensive approach to quality improvement (QI) consistent with the framework set out by the Institute of Medicine (IOM) in its 2001 report Crossing the Quality Chasm. The framework is built around the need for health care to be safe, effective, patient-centred, timely, efficient and equitable. To our knowledge Accreditation Canada is the only national organization that has adopted such a framework, but their QI mandate is to set standards and accredit health care organizations although it could potentially play an expanded role. The Canadian Patient Safety Institute has done an excellent job of highlighting the importance of patient safety, but that is only one of the six dimensions outlined in the IOM framework. Work needs to be done in Canada to address each of the other five dimensions. In terms of effective care, although the concept of evidence-based medicine was pioneered in Canada, we do not have a national developer of guidance to clinicians like the United Kingdom's National Institute for Health and Care Excellence (NICE). It is noted that there are some localized efforts in this area, such as Alberta's Toward Optimized Practice program, and the CMA Infobase maintained by CMA Joule contains some 1,200 clinical practice guidelines. Patient-centred care will be discussed below. Since the expiry of the 2004 Health Accord and the Wait Times Reduction Fund (WTRF), which the CMA spent years trying to get on the policy agenda, timely access to care has fallen out of the spotlight. The Wait Time Alliance did its best to promote the expansion and adoption of wait time benchmarks beyond the five treatments initially included in the WTRF, with very limited success. It is no surprise that according to the Commonwealth Fund's 2016 survey of 11 countries, Canadians faced the longest waiting times for a specialist appointment. In terms of efficiency there has been a rapid uptake of the Choosing Wisely Canada initiative by medical organizations, but the campaign could benefit from resources to conduct a thorough evaluation of its impact. The dimension of equitable care will be considered below as part of the discussion of social determinants of health. At least six provinces have established health quality councils, and if they had a national focal point for their efforts they could cross-pollinate their expertise and learnings with respect to all six of the Institute of Medicine's dimensions of care. National patient voice - While it is encouraging to see the emphasis on patient and family-centred care among the PCHOs, the lack of an organized national patient voice is a key gap. Previously the Consumers' Association of Canada provided an articulate patient/consumer voice on health issues, and indeed it was one of the seven charter members of the Health Action Lobby in 1991. However, the association's ability to speak in this capacity was greatly diminished after its federal funding dried up in the 1990s. At present there are various patient groups sponsored by health charities and industry but they tend to focus on specific interests. Patients Canada, an organization established in 2011, is showing promise, but with annual expenditures of just under $130,000 in 2014 it is insufficiently resourced to function as a national patient voice representing all regions of the country. There is a need for an independent go-to focal point that can speak on behalf of patients on national issues and that can help national health organizations with their advocacy and policy development initiatives. With better resources, Patients Canada might be able to play this role. Health equity - Given the impact of health inequalities in Canada they have a relatively low profile on the national scene, aside from the inequity between the health status of Canada's Indigenous Peoples and that of the general population. For example, Mackenbach and colleagues estimated that socio-economic inequalities accounted for 20% of health care costs in the European Union in 2004. There is little reason to imagine that the situation in Canada would be much different, but health inequalities have not been a preoccupation of the PCHOs. The Public Health Agency of Canada (PHAC) has done some good work in helping the federal government to meet its commitments in regard to the World Health Organization's 2011 Rio Political Declaration on Social Determinants of Health and it also funds the National Collaborating Centre for Determinants of Health, but these efforts have little profile outside of the public health community. The pronounced socio-economic gradient across virtually all causes of morbidity and mortality tends to be overlooked in the pursuit of strategies to address individual diseases. PHAC's Health Inequalities Data Tool shows that that the Canadian crude mortality rates for circulatory system disease and lung cancer in the lowest income quintile for census metropolitan areas are 1.6 and 1.7 times the rates in the highest income quintile, respectively. There are groups in Canada such as the Wellesley Institute and Health Providers Against Poverty that focus on health equity issues, and Canada should look at the leadership role being played by Sir Michael Marmot's Institute of Health Equity at University College London in England. Driving innovation - The Canadian Agency for Drugs and Technologies in Health is widely recognized for its work evaluating drugs and technologies but it is not in the business of promoting system-wide implementation. The Advisory Panel on Healthcare Innovation (David Naylor, Chair) recommended the establishment of a Healthcare Innovation Agency and a Healthcare Innovation Fund with the objective of effecting "sustainable and systemic changes in the delivery of health services to Canadians." More recently, the Standing Senate Committee on Social Affairs, Science and Technology called for a national conference on robotics, artificial intelligence and 3D printing that would give rise to working groups and a secretariat with a view to integrating these technologies into health care systems across Canada. One can cite examples where Canada has developed innovative technologies but has not made them mainstream. For example, telemedicine was pioneered by the late Dr. Maxwell House in Newfoundland in the mid-1970s. It is now being used regularly for clinical sessions, but the logical extension to telehome monitoring is barely in its infancy. According to the 2015 Canadian Telehealth Report there were 411,778 telehealth clinical sessions in 2014, but there were just 3,803 patients being monitored through telehomecare. Furthermore. the number of telehealth clinical sessions represents just 0.15% of the 270.3 million physician services reported by the Canadian Institute for Health Information (CIHI) in 2015-16. In contrast, Kaiser Permanente reported in 2016 that 52% of the 110 million physician-member interactions in the previous year took place through virtual means. One example of the use of a fund to bring about sustainable change was the two-step process that began with the establishment of the $150 million Health Transition Fund following the 1997 report of the National Forum on Health and the $800 million Primary Health Care Transition Fund that was part of the 2000 Health Accord. These resulted in the sustained adoption of new models of primary care delivery in Ontario and Alberta. It is noteworthy that the Canadian Foundation for Healthcare Improvement is doing interesting work in spreading and scaling up innovative treatment for patients with chronic obstructive pulmonary disease. The need for a dedicated entity to drive innovation is illustrated by the experience of the Health Care Innovation Working Group, which was struck by the premiers in 2012 and which included the unprecedented participation of professional associations including the CMA. The group released an ambitious report in the summer of 2012, but the effort was run by senior bureaucrats and association staff "off the sides of their desks" and has essentially stalled. Such a body could also play a role in sharing innovations across jurisdictions. Enhanced analytical capability - Since the demise of the Economic Council of Canada (ECC) in the 1990s Canada's national analytical capability in health care has diminished. The ECC employed health economists like the late Ludwig Auer who undertook detailed analysis of health sector data to examine issues like hospital productivity. CIHI does an excellent job of turning out reports such National Health Expenditure (NHEX) Trends in Canada, but these are not sufficient for an in-depth examination of a $242 billion industry. As journalist André Picard commented on the 2017 NHEX release, "We don't actually know how much we spend on administration, because it is hidden in places like hospital spending ... nor do we know the cost of labour ... we should certainly have a better idea of how much we spend on nurses, physician assistants, personal support workers, laboratory technologists and technicians and so on." Looking ahead, the widespread adoption of electronic medical records is going to present a major analytical opportunity and challenge. In 2008 PHAC provided a grant to the College of Family Physicians of Canada to establish the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and subsequently provided additional funding until 2015. The goal of CPCSSN was to establish a database on eight chronic diseases and neurologic conditions by extracting de-identified patient information from electronic medical records. As of the last update, in October 2016, CPCSSN now includes 11 university-affiliated primary care research networks and almost 1,200 physicians contributing data from 1.5 million patients. A recent report concludes that CPCSSN's diagnostic algorithms show excellent sensitivity and specificity for hypertension, diabetes, epilepsy and parkinsonism. The CMA highlighted CPCSSN in its submission to the Advisory Panel on Healthcare Innovation as being worthy of ongoing federal support. General observations We would like to make three general observations. First, the future of the PHCOs should not be decided in isolation. Instead, we believe that the big picture of federal funding for the advancement of health and health care should be considered, including the investments that the federal government is making in the Canadian Institutes of Health Research and the Strategy for Patient-Oriented Research. Second, the CMA's engagement with the PCHOs has been haphazard. While we have had the opportunity to participate in consultations and technical and working groups with the PCHOs, these interactions have generally fallen short of what we would consider to be early, meaningful and ongoing engagement. Third, the PCHOs have developed considerable expertise within their mandates and spheres of activity. They could almost certainly harness their potential to mount a synergistic effort to successfully address pressing national issues that might otherwise seem almost impossible to confront, such as seniors care. Recommendations The CMA respectfully offers two recommendations: 1. That the government's implementation plan following the PCHO review include mechanisms to address the following needs: * for a national focal point that promotes a comprehensive approach to quality health care; * for a well-resourced national patient voice that advocates for patient- and family-centred health care; * for greater recognition of the importance of the social determinants of health and health equity; * for a national mechanism to drive the sustainable adoption of innovative technologies in health care across Canada; and * for advanced analytical capabilities to conduct in-depth assessments of funding mechanisms and advance the collection and analysis of data generated by electronic medical records. 2. That the federal government challenge the PCHOs and other federal agencies to work with the provincial/territorial governments and stakeholders to develop and implement a national action plan to address the health and health care of Canada's seniors. Bibliography Accreditation Canada. Client- and family-centred care in the Qmentum program. Ottawa: Accreditation Canada; 2015. Advisory Board. A milestone: Kaiser now interacts more with patients virtually than in-person. Washington, DC: Advisory Board; 2016 Oct 13. Available: www.advisory.com/daily-briefing/2016/10/13/kaiser-telehealth (accessed 2017 Nov 10). Advisory Panel on Healthcare Innovation. Unleashing innovation: excellent healthcare for Canada. Ottawa: Minister of Health; 2015. Available: http://healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/alt/report-healthcare-innovation-rapport-soins-eng.pdf (accessed 2017 Nov 10). Birtwhistle R. Update from CPCSSN. Can Fam Physician 2016;62(10):851. Canadian Institute for Health Information. National Physician Database. Table B.1 Number of services, by physician specialty, national groupin system strata and province/territory, 2015-2016. Ottawa: The Institute; 2017. Canadian Medical Association. CPG Infobase: clinical practice guidelines. Ottawa: The Association; 2017. Available: www.cma.ca/En/Pages/clinical-practice-guidelines.aspx (accessed 2017 Nov 10). Canadian Medical Association. Submission to Advisory Panel on Healthcare Innovation. Ottawa: The Association; 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA-Submission-Adv-Panel-on-HC-Innovation.pdf (accessed 2017 Nov 10). Canada's Health Informatics Association. 2015 Canadian telehealth report. Toronto: The Association; 2015. Available: https://livecare.ca/sites/default/files/2015%20TeleHealth-Public-eBook-Final-10-9-15-secured.pdf (accessed 2017 Nov 10). Health Providers Against Poverty(HPAP). Canada: HPAP; 2017. Available: https://healthprovidersagainstpoverty.ca (accessed 2017 Nov 10). Institute of Health Equity. London: Institute of Health Equity; 2017. Available: www.instituteofhealthequity.org (accessed 2017 Nov 10). Mackenbach J, Meerding W, Kunst A. Economic costs of health inequalities in the European Union. J Epidemiol Community Health 2011;65(5):412-9. National Academy of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press; 2001. The National Institute for Health and Care Excellence (NICE). Improving health and social care through evidence-based guidance. London: NICE; 2017. Available: https://www.nice.org.uk/ (Accessed 24 November 2017). Osborn R, Squires D, Doty M, Sarnak S, Schneider E. In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Aff (Millwood) 2016;35(12):2327-6. Patients Canada. Toronto: Patients Canada, 2017. Available: www.patientscanada.ca/ (accessed 2017 Nov 10). Picard A. It's time for a data-driven approach to health care. Globe and Mail 2017 Nov 7. https://beta.theglobeandmail.com/opinion/its-time-for-a-data-driven-approach-to-health-care/article36858079/?ref=http://www.theglobeandmail.com& (accessed 2017 Nov 10). National Collaborating Centre for Determinants of Health (NCCDH). Antigonish, NS: NCCDH; 2017. Available: /www.nccdh.ca/ (accessed 2017 Nov 10). Public Health Agency of Canada. Health inequalities data tool - public health infobase. Ottawa: Public Health Agency of Canada; 2017. Available: https://infobase.phac-aspc.gc.ca/health-inequalities/ (accessed 2017 Nov 10). Schneider E, Sarnak D, Squires D, Shah A, Doty M. Mirror, mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. New York, NY: Commonwealth Fund; 2017. Available: www.commonwealthfund.org/~/media/files/publications/fund-report/2017/jul/schneider_mirror_mirror_2017.pdf (accessed 2017 Nov 13). Standing Senate Committee on Social Affairs, Science and Technology. Challenge ahead: integrating robotics, artificial intelligence and 3D printing technologies into Canada's healthcare systems. Ottawa: The Senate; 2017. Available: https://sencanada.ca/content/sen/committee/421/SOCI/reports/RoboticsAI3DFinal_Web_e.pdf (accessed 2017 Nov 10). Tinkham & Associates LLP. Financial statements of Patients Canada. Toronto: Tinkham & Associates LLP; 31 Dec 2014. Available: www.patientscanada.ca/site/patients_canada/assets/pdf/patientscanada-financialstatements-2014.pdf (accessed 2017 Nov 10). Toward Optimized Practice (TOP). Edmonton, AB: TOP; 2017. Available: www.topalbertadoctors.org/home/ (accessed 2017 Nov 13). Wellesley Institute. Toronto: Wellesley Institute; 2017. Available: www.wellesleyinstitute.com/about (accessed 2017 Nov 10). Williamson T, Green M, Birtwhistle R, Khan S, Garies S, Wong S, Natarajan N, Manca D, Drummond N. Validating the 8 CPCSSN case definitions for chronic disease surveillance in a primary care database of electronic health records. Ann Fam Med 2014;12(4):367-72. World Health Organization. Rio political declaration on social determinants of health. Geneva: The Organization; 2011. Available: www.who.int/sdhconference/declaration/Rio_political_declaration.pdf?ua=1 (accessed 2017 Nov 10).
Documents
Less detail

Advancing Inclusion and quality of life for seniors

https://policybase.cma.ca/en/permalink/policy13729
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. The number of seniors expected to need help or care in the next 30 years will double, placing an unprecedented challenge on Canada’s health care system. That we face this challenge speaks to the immense success story that is modern medicine, but it doesn’t in any way minimize the task ahead. Publicly funded health care was created about 50 years ago when Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. People 85 and older make up the fastest growing age group in our country, and the growth in the number of centenarians is also expected to continue. The Canadian Medical Association is pleased that the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is studying ways Canada can respond to these challenges. Here, for your consideration, we present 15 comprehensive recommendations that would help our seniors remain active, contributing citizens of their communities while improving the quality of their lives. These range from increasing capital investment in residential care infrastructure, to enhancing assistance for caregivers, to improving the senior-friendliness of our neighbourhoods. The task faced by this committee, indeed the task faced by all of Canada, is daunting. That said, it is manageable and great advances can be made on behalf of seniors. By doing so, we will ultimately deliver both health and financial benefits to all Canadians. Dr. Laurent Marcoux, CMA President The Canadian Medical Association (CMA) is pleased to submit this brief to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its study regarding how the Government can support vulnerable seniors today while preparing for the diverse and growing seniors population of tomorrow. This brief directly addresses the three themes considered by this Committee:
How the Government can improve access to housing for seniors including aging in place and affordable and accessible housing;
How the Government can improve income security for vulnerable seniors; and
How the Government can improve the overall quality of life and well-being for seniors including community programming, social inclusivity, and social determinants of health. Improving access to housing for seniors As part of a new National Housing Strategy, the federal government announced in the 2017 Budget that it will invest more than $11.2 billion in a range of initiatives designed to build, renew, and repair Canada’s stock of affordable housing and help to ensure that Canadians have adequate and affordable housing that meets their needs. While a welcome step, physicians continue to see the problems facing seniors in relation to a lack of housing options and supports — problems that cascade across the entire health care system. A major hindrance to social equity in health care delivery and a serious cause of wait times is the inappropriate placement of patients, particularly seniors, in hospitals. Alternate level of care (ALC) beds are often used in acute care hospitals to accommodate patients — most of whom are medically stable seniors — waiting for appropriate levels of home care or access to a residential care home/facility. High rates of ALC patients in hospitals affect all patients by contributing to hospital overcrowding, lengthy waits in emergency departments, delayed hospital admissions, cancelled elective surgeries, and sidelined ambulance services waiting to offload new arrivals (often referred to as code gridlock).1 Moreover, unnecessarily long hospital stays can leave patients vulnerable to hospital-acquired illnesses and disabilities such as delirium, deconditioning, and falls. Daily costs - Ontario $842: acute care hospital, per patient $126: long-term care residence, per patient $42: home care, per patient # of acute care hospital beds = 18,571 14% waiting for placement = 2,600 beds Providing more cost-effective and appropriate solutions will optimize the use of health care resources. It has been estimated that it costs $842 per day for a hospital bed versus $126 per day for a long-term care bed and $42 per day for care at home.2 An investment in appropriate home or residential care, which can take many forms, will alleviate inappropriate hospital admissions and facilitate timely discharges. The residential care sector is facing significant challenges because of the rising numbers of older seniors with increasingly complex care needs. The demand for residential care will increase significantly over the next several years because of the growing number of frail elderly seniors requiring this service. New facilities will need to be constructed and existing facilities will need to be upgraded to comply with enhanced regulatory requirements and respond to residents’ higher care needs. The Conference Board of Canada has produced a residential care bed forecast tied to population growth of age cohorts. It is estimated that Canada will require an average of 10,500 new beds per year over the next 19 years, for a total of 199,000 new beds by 2035. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes.3 A recent report by the Canadian Institute for Health Information indicated that residential care capacity must double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided across the continuum of care.4 These findings provide a sense of the immense challenges Canada faces in addressing the residential care needs of older seniors. Investments in residential care infrastructure and continuing care will improve care for seniors while significantly reducing wait times in hospitals and across the system, benefiting all patients. Efforts to de-hospitalize the system and address the housing and residential care options for Canada’s aging population are key. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure. RECOMMENDATION 1 The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Improving income security for vulnerable seniors Income is a key factor impacting the health of individuals and communities. Higher income and social status are linked to better health.5 Adequate Income: Poverty among seniors in Canada dropped sharply in the 1970s and 1980s but it has been rising in recent years. In 2012, the incidence of low income among people aged 65 years and over was 12.1%. This rate was considerably higher for single seniors at 28.5%.6 Incidence of low income (2012) Seniors overall: 12.1% Single seniors: 28.5% Most older Canadians rely on Old Age Security (OAS), the Canada Pension Plan (CPP), and their personal pensions or investments to maintain their basic standard of living in retirement. Some seniors are also eligible for a Guaranteed Income Supplement (GIS) to improve their financial security. The CMA recognizes the federal government’s actions to strengthen these programs and initiatives to ensure their viability and to provide sustainable tax relief. These measures must continue and evolve to support aging Canadians so they can afford to live at home or in age-friendly communities as they get older. The government’s actions to ensure adequate income support will also assist aging Canadians to take care of their health, maintain independence, and continue living safely without the need for institutional care. On the topic of seniors’ income security, the financial abuse of seniors cannot be overlooked. Elder abuse can take many forms: financial, physical, psychological, sexual, and neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported. The CMA supports public awareness initiatives that bring attention to elder abuse, as well as programs to intervene with seniors who are abused and with their abusers. RECOMMENDATION 2 The CMA recommends that the federal government take steps to provide adequate income support for older Canadians, as well as education and protection from financial abuse. Improving the overall quality of life and well-being for seniors Improving how we support and care for Canada’s growing seniors population has been a priority for CMA over the past several years. For the first time in Canada’s history, persons aged 65 years and older outnumber those under the age of 15 years.7 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.8 People aged 85 years and over make up the fastest growing age group in Canada — this portion of the population grew by 127% between 1993 and 2013.9 Statistics Canada projects, on the basis of a medium-growth scenario, that there will be over 11,100 Canadians aged 100 years and older by 2021, 14,800 by 2026 and 20,300 by 2036.7 Though age does not automatically mean ill health or disability, the risk of both increases with age. Approximately 75 to 80% of Canadian seniors report having one or more chronic conditions.10 Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada’s population ages. The Conference Board of Canada has estimated 2.4 million Canadians 65 years and older will need continuing care, both paid and unpaid, by 2026 — a 71% increase since 2011.11 When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. The aging of our population is both a success story and a pressing health policy issue. National seniors strategy Canada needs a new approach to ensure that both our aging population and the rest of Canadians can get the care they need, when and where they need it. The CMA believes that the federal government should invest in seniors care now, guided by a pan-Canadian seniors strategy. In doing so, it can help aging Canadians be as productive as possible — at work, in their communities, and in their homes. The CMA is pleased with the June 2017 Report of the Standing Senate Committee on National Finance that called for the federal government to develop, in collaboration with the provinces and territories and Indigenous partners, a national seniors strategy in order to control spending growth while ensuring appropriate and accessible care.12 The CMA is also pleased that MP Marc Serré (Nickel Belt) secured support for his private members’ motion calling for the development of a national seniors strategy. Over 50,000 Canadians have already lent their support to this cause (see www.DemandaPlan.ca). RECOMMENDATION 3 The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. Improving assistance for home care and Canada’s caregivers Many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding for these services varies widely from province to province. The disparity among the provinces in terms of their fiscal capacity in the current economic climate will mean improvements in seniors care will advance at an uneven pace. The funding and delivery of accessible home care services will help more aging Canadians to recover from illness, live at home longer, and contribute to their families and communities. Multi-year funding arrangements to reinforce commitment to and financial investment in home care should be carefully considered.13 The development of innovative partnerships and models to help ensure services and resources for seniors’ seamless transition across the continuum of care are also important. RECOMMENDATION 4 The CMA recommends governments work with the health and social services sectors, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Family and friend caregivers are an extremely important part of the health care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend, and 62% of caregivers helping seniors said that the care receiver lived in a private residence separate from their own.14 According to a report by Carers Canada, the Canadian Home Care Association, and the Canadian Cancer Action Network, caregivers provide an array of services including personal and medical care, housekeeping, advocacy, financial management, and social/emotional support. The report also indicated that caregivers contribute $25 billion in unpaid labour to our health system.15 Given their enormous contributions, Canada’s caregivers need support in the form of financial assistance, education, peer support, and respite care. A pan-Canadian caregiver strategy is needed to ensure caregivers are provided with the support they require.15 Caregivers provide... Personal and Medical Care Housekeeping worth $25 billion in Advocacy unpaid labour Financial Managemen Social-emo ional Suppor RECOMMENDATION 5 The CMA recommends that the federal government and other stakeholders work together to develop and implement a pan-Canadian caregiver strategy, and expand the support programs currently offered to informal caregivers. Canadians want governments to do more to help seniors and their family caregivers.16 The federal government’s new combined Canada Caregiver Credit (CCC) is a non-refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit would result in a refund payment to provide further financial support for low-income families. RECOMMENDATION 6 The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s recent commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcome step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it is important to establish clear operating principles between the parties to oversee the funding implementation and for the development of clear metrics to measure performance. RECOMMENDATION 7 The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investments in home care and mental health recognize the importance of these aspects of the health care system. They also signal that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. RECOMMENDATION 8 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. Programs and supports to promote healthy aging The CMA believes that governments at all levels should invest in programs and supports to promote healthy aging, a comprehensive continuum of health services to provide optimal care and support to older Canadians, and an environment and society that is “age friendly”.17 The Public Health Agency of Canada (PHAC) defines healthy aging as “the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life.”18 It is believed that initiatives to promote healthy aging and enable older Canadians to maintain their health will help lower health care costs by reducing the overall burden of disability and chronic disease. Such initiatives should focus on physical activity, good nutrition, injury (e.g. falls) prevention, and seniors’ mental health (including depression). RECOMMENDATION 9 The CMA recommends that governments at all levels support programs to promote physical activity, nutrition, injury prevention, and mental health among older Canadians. For seniors who have multiple chronic diseases or disabilities, care needs can be complex, and they may vary greatly from one person to another and involve many health care providers. Complex care needs demand a flexible and responsive health system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community-based health care (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and foot care), to long-term care and palliative care. Ideally, this continuum should be managed so that the senior can remain at home and out of emergency departments, hospitals, and long-term care unless appropriate; easily access necessary care; and make a smooth transition from one level of care to another when necessary. RECOMMENDATION 10 The CMA recommends governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. Every senior should have the opportunity to have a family physician or to be part of a family practice that serves as a medical home. This provides a central hub for the timely provision and coordination of the comprehensive menu of health and medical services. A medical home should provide patients with access to medical advice and the provision of, or direction to, needed care 24 hours a day, seven days a week, 365 days a year. Research in 2014 by the Commonwealth Fund found that the percentage of Canadian seniors who have a regular family physician or place of care is very high (98%); however, their ability to get timely access based on same-day or next-day appointments was among the lowest of 11 nations.19 Compared to seniors in most other countries surveyed, Canadian seniors were also more likely to use the emergency department and experience problems with care coordination. RECOMMENDATION 11 The CMA recommends governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. Prescription drugs represent the fastest-growing item in the health budget and the second-largest category of health expenditure. As the population of seniors grows, there will be an ongoing need for detailed information regarding seniors’ drug use and expenditure to support the overall management of public drug programs.20 Despite some level of drug coverage for seniors in all provinces and territories, some seniors still skip doses or avoid filling prescriptions due to cost, and more research into the extent of this problem is required.21 The CMA supports the development of an equitable and comprehensive pan-Canadian pharmacare program. As a step toward comprehensive, universal coverage, the CMA has repeatedly called on the federal government to implement a system of catastrophic coverage for prescription medication to reduce cost barriers of treatment and ensure Canadians do not experience undue financial hardship. Moreover, with more drugs available to treat a large number of complex and chronic health conditions, the CMA supports the development of a coordinated national approach to reduce polypharmacy among the elderly. RECOMMENDATION 12 The CMA recommends governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. Optimal care and support for older Canadians also depends on identifying, adapting, and implementing best practices in the care of seniors. PHAC’s Best Practices Portal22 is one noteworthy initiative, and the system needs to spread and scale best practices by leveraging and enhancing pan-Canadian resources that build capacity and improve performance in home care and other sectors.13 RECOMMENDATION 13 The CMA recommends that governments and other stakeholders support ongoing research to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and costs. An environment and society that is “age friendly” One of the primary goals of seniors policy in Canada is to promote the independence of older Canadians, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, governments and society must keep the social determinants of health in mind when developing and implementing policy that affects seniors. It is also important to eliminate discrimination against seniors and promote positive messaging around aging. An age-friendly society respects the experience, knowledge, and capabilities of its older members and accords them the same worth and dignity as it does other citizens. Employment is also important for seniors who need or desire it. Many seniors are choosing to remain active in the workplace for a variety of reasons, such as adding to their financial resources or staying connected to a social network.23 The CMA recognizes the federal government’s support for seniors who opt to continue working. And, while many employers encourage older workers and accommodate their needs, employment may be difficult to find in workplaces that are unwilling to hire older workers. RECOMMENDATION 14 The CMA recommends that governments at all levels and other partners give older Canadians access to opportunities for meaningful employment if they desire. The physical environment, including the built environment, can help to promote seniors’ independence and successful, healthy aging. The World Health Organization defines an “age-friendly environment” as one that fosters health and well-being and the participation of people as they age.24 Age-friendly environments are accessible, equitable, inclusive, safe and secure, and supportive. They promote health and prevent or delay the onset of disease and functional decline. They provide people-centered services and support to enable recovery or to compensate for the loss of function so that people can continue to do the things that are important to them.24 These factors should be taken into consideration by those who design and build communities. For example, buildings should be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation should be provided in neighbourhoods with large concentrations of seniors. RECOMMENDATION 15 The CMA recommends that governments and communities take the needs of older Canadians into account when designing buildings, walkways, transportation systems, and other aspects of the built environment. Conclusion The CMA recognizes the federal government’s commitment to support vulnerable seniors today while preparing for the diverse and growing seniors’ population of tomorrow. The CMA’s recommendations in this submission can assist the government as it seeks to improve access to housing for seniors, enhance income security for vulnerable seniors, and improve the overall quality of life for seniors in ways that will help to advance inclusion, well-being, and the health of Canada’s aging population. To maximize the health and well-being of older Canadians, and ensure their active engagement and independence for as long as possible, the CMA believes that the health care system, governments, and society should work with older Canadians to promote healthy aging, provide quality patient-centred health care and support services, and build communities that value Canadians of all ages. References 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_final. pdf#search=code%20gridlock (accessed 2016 Sep 22). 2 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare (accessed 2016 Sep 22). 3 Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; Manuscript submitted for publication. 4 Canadian Institute for Health Information (CIHI). Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi.ca/sites/default/files/document/seniors-in-transition-report-2017-en.pdf (accessed 2017 Jun 30). 5 World Health Organization. Health Impact Assessment (HIA). The determinants of health. Available: http://www.who.int/hia/evidence/doh/en/ (accessed 2017 Oct 23). 6 Statistics Canada. Persons in low income (after-tax low income measure), 2012. The Daily. Ottawa: Statistics Canada; 2014 Dec 10. Available: http://www.statcan.gc.ca/daily-quotidien/141210/t141210a003-eng.htm (accessed 2017 Oct 17). 7 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.pdf (accessed 2016 Sep 19). 8 Statistics Canada. Canada Year Book 2012, seniors. Ottawa: Statistics Canada; 2012. Available: https://www.statcan.gc.ca/pub/11­ 402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm (accessed 2017 Oct 18). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Canadian Institute for Health Information (CIHI). Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: The Institute; 2014 Nov. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf (accessed 2016 Sept 19). 11 Stonebridge C, Hermus G, Edenhoffer K. Future care for Canadian seniors: a status quo forecast. Ottawa: Conference Board of Canada; 2015. Available: http://www.conferenceboard.ca/e-library/abstract.aspx?did=7374 (accessed 2016 Sep 20). 12 Report of the Standing Senate Committee on National Finance. Getting ready: For a new generation of active seniors. Ottawa: The Committee; 2017 Jun. Available: https://sencanada.ca/content/sen/committee/421/NFFN/Reports/NFFN_Final19th_Aging_e.pdf (accessed 2017 Oct 18). 13 Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association. Better Home Care in Canada: A National Action Plan. 2016. Ottawa: Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association; 2016. Available: http://www.thehomecareplan.ca/wp-content/uploads/2016/10/Better-Home-Care-Report-Oct-web.pdf (accessed 2017 Oct 23). 14 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006-X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/article/14142-eng.pdf (accessed 2016 Sep 22). 15 Carers Canada, Canadian Home Care Association, Canadian Cancer Action Network. Advancing Collective Priorities: A Canadian Carer Strategy. 2017. Mississauga: Canadian Home Care Association, Canadian Cancer Action Network; 2017. Available: http://www.cdnhomecare.ca/media. php?mid=4918 (accessed 2017 Oct 23). 16 Ipsos Public Affairs, HealthCareCAN, Canadian College of Health Leaders. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 06). 17 Canadian Medical Association. Health and Health Care for an Aging Population. Ottawa: The Association; December 2013. Available: https:// www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Health_and_Health_Care_for_an_Aging-Population_ PD14-03-e.pdf (accessed 2017 Oct 20). 18 Government of Canada. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2010 – Canada’s experience in setting the stage for healthy aging. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/annual-report-on-state-public-health-canada-2010/chapter-2.html (accessed 2017 Oct 23). 19 Commonwealth Fund. 2014 International Health Policy Survey of Older Adults in Eleven Countries. 2014. New York: Commonweath Fund; 2014. Available: http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2014/nov/pdf_1787_commonwealth_fund_2014_intl_ survey_chartpack.pdf (accessed 2017 Oct 23). 20 Canadian Institute for Health Information. Drug Use among Seniors on Public Drug Programs in Canada, 2002 to 2008. (2010). Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/drug_use_in_seniors_2002-2008_e.pdf (accessed 2017 Oct 23). 21 Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. CMAJ. 2012 Feb21;184(3):297-302. Available: http://www.cmaj.ca/content/184/3/297.short. (accessed 2017 Oct 23). 22 Public Health Agency of Canada. Canadian Best Practices Portal. Ottawa: Public Health Agency of Canada; 2016. Available: http://cbpp-pcpe. phac-aspc.gc.ca/public-health-topics/seniors/ (accessed 2017 Oct 23). 23 Government of Canada. Action for Seniors report. 2014. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/ employment-social-development/programs/seniors-action-report.html (accessed 2017 Oct 23). 24 World Health Organization (WHO). Age-friendly environments. Geneva: WHO; 2017. Available: http://www.who.int/ageing/projects/age­ friendly-environments/en/ (accessed 2017 Oct 23).
Documents
Less detail

Physician health

https://policybase.cma.ca/en/permalink/policy13739
Date
2017-10-21
Topics
Health human resources
Ethics and medical professionalism
  3 documents  
Policy Type
Policy document
Date
2017-10-21
Replaces
PD98-04 Physician health and well-being
Topics
Health human resources
Ethics and medical professionalism
Text
The term physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of interconnected physical, mental and social factors to support health and wellness.1 Attributable to a range of personal, occupational and system-level factors, physicians and learners alike are increasingly voicing distress and calling for resources and support. As a central issue for Canadian physicians, and a growing concern within the medical profession, physician ill-health is being increasingly understood as a set of risk-management practices,2 including the use of strategies rooted in organizational psychology and occupational medicine, as well as intensified oversight by professional bodies, and the integration of maintaining personal health as a core medical competency.3 Physician health, is important to the long-term sustainability of the physician workforce and health systems.4 As a quality indicator5-6 addressing the complex array of related issues is a shared responsibility of individual physicians and the systems in which they work.2,4,5 This involves efforts from individuals as well as system-level influencers, such as stakeholder groups from areas including academic medicine, medical education, practice environments, accrediting and regulatory bodies, provincial and territorial medical associations, regional and local health authorities, national medical associations and their affiliates, governments and other decision-making bodies. Meaningful, system-wide change can only occur via deliberate and concerted efforts on a national scale5 to address personal, workplace, and cultural barriers and normalize the promotion of opportunities and conditions for optimizing health and wellness. Although considerable progress has been made, it is necessary to continue working towards a more coordinated and sustained system of health promotion, illness prevention and tertiary care to build on these successes.4-5 This policy aims to provide broad, aspirational recommendations to help guide stakeholders at all levels of the health system to promote a healthy, vibrant, and engaged profession - including a healthy practice and training culture, and work environment. RECOMMENDATIONS Individual level The CMA recommends that physicians and learners: * demonstrate a commitment to physician health and well-being as part of their responsibilities under the CanMEDS Professional Role, including: Exhibiting self-awareness and managing influences on personal well-being (e.g., self-regulation and assessment, mindfulness, resilience); managing personal and professional demands for a sustainable practice throughout the career life cycle; and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need;3 * actively engage in fostering supportive work and training environments; * assume responsibility for individual actions and behaviours that may contribute to negative culture and stigma;5 * foster relationships with family and friends, as well as interests outside of medicine, and ensure sufficient rest (including time-off); and * have a family physician and visit him or her regularly for comprehensive and objective care. System level The CMA recommends that: * national-level advocacy be undertaken to address issues related to physician and learner health; * efforts to address physician health incorporate individually targeted initiatives and optimize learning and practice environments, including cultivating a healthy culture,6-7 and that stakeholders collaborate (including input from physicians and learners) to develop and promote initiatives that strengthen physician health at both the individual and system levels; * health systems adopt an understanding of their obligation to the health of physicians that is similar to the obligation of other Canadian employers to their workers (e.g., psychological safety, work hours, employee resources, standards and expectations); * policies aiming to cultivate a healthy culture be modelled, and behaviours not conducive to supporting and enabling a healthy culture dealt with in an effective manner; * physician and health system leaders acknowledge and demonstrate that physician health is a priority, and continually assess whether actions and policies align with desired values and culture;4 * physician and health system leaders be better equipped to identify and address behaviours that are symptomatic of distress (e.g., psychological) and receive more comprehensive training to address with colleagues, including within teams; * mechanisms and opportunities for physicians and learners to access existing services and programs (e.g., provincial, institutional) are maximized, and that these resources are regularly promoted and barriers to access addressed in a timely manner;5,8 * standards, processes and strategies be developed to address occupational barriers to positive health8 (at a minimum, these should address the meaningful integration of occupational and personal life, provision of resources to enhance self-care skills,4 and prioritization of opportunities for adequate rest, exercise, healthy diet and leisure;8 * wellness (including enhancement of meaning, enjoyment and engagement) be promoted, instead of an exclusive focus on reduction of harm;5 * physicians and learners be encouraged to have a family physician, and that barriers to access such care be identified and addressed; * physicians, particularly those providing primary care to other physicians, have access to training in treating physician colleagues; * physicians and learners be given reasonable access to confidential assistance in dealing with personal and professional difficulties, provided in a climate free of stigmatization; * programs and services be accessible to physicians and learners at every stage of their diagnosis and treatment, and that seeking treatment should not feel punitive or result in punitive consequences; * physicians and learners have supportive learning and work environments free of discrimination, and for processes which provide reasonable accommodations to physicians and learners with existing disabilities, while allowing for safe patient care, to be bolstered; and * practices which enable safe and effective patient care, and support workflow and efficient capture of information (e.g., electronic medical records), do not create excessive work and time burdens on physicians. Physician organizations, professional associations and health authorities The CMA recommends that: * all physicians and learners have access to a robust and effective provincial physician health program (PHP), and for long-term, sustained efforts to be made to maintain and enhance physician health, including a commitment to resourcing PHPs5 via the provision of stable funding through provincial and territorial medical associations, or the negotiation of such funding from provincial governments; * training programs, hospitals, and other workplaces ensure appropriate programs, services, and policies are developed, in-place, and enforced for physicians and learners to get help to manage health and behavioural issues, support the need for treatment, and facilitate return to work or training while protecting individual confidentiality, privacy, as well helping the institution manage risk; * the range of continuing medical education offerings aimed at personal health be expanded (content should develop individual skills and extend to training for leaders and administrators that targets improved training and practice environments and culture); * continuing education credits for physicians' efforts to enhance their personal wellness or that of colleagues be established and promoted, free of conditions requiring links to patient care; * emerging champions from learner and early-career segments be identified and supported; and * the unique health and wellness challenges faced by physicians and learners in rural, remote, or otherwise under-serviced regions (including the Canadian territories) be recognized, and for access to services and other resources to be enhanced. Medical schools, residency training programs, and accreditation bodies The CMA calls for: * accreditation standards for health and wellness programs and initiatives for medical faculties and training programs, and health authorities to be raised, reviewed in an ongoing manner and that standards and competencies be enforced; * action to bring meaningful change to the 'hidden curriculum' by aligning formal and 'hidden' curriculums that promote and reinforce positive conduct, and for accreditation bodies to consider this in their review and enforcement of standards for training programs; and * formal health and wellness curricula to be integrated and prioritized at the undergraduate and postgraduate levels, including but not limited to training around how to recognize and respond to distress or illness in oneself and colleagues, as well as self-management strategies (e.g., resilience and mindfulness). Medical regulatory authorities The CMA calls for medical regulatory authorities to: * work with provincial and territorial medical associations, PHPs, governments and other key stakeholders to; (a) create a regulatory environment that protects the public (their explicit duty) while limiting barriers for physicians seeking diagnosis and treatment,5 and (b) promote resources for early self-identification of potential health issues; and * while maintaining their duty to protect the public, review their approach to mental health challenges to ensure that focus is placed on the existence of impairment (illness interferes with ability to engage safely in professional activities,9 and not the mere presence of a diagnostic label or act of seeking of care5 (in order to ensure that physicians and learners who are appropriately caring for their health not be impacted in their ability to work). Governments The CMA calls for: * governments to acknowledge the adverse impact their policies and processes can have on the health of physicians, and to adopt and enforce health and wellness standards through a lens of occupational health for physicians that are similar to those afforded to other Canadian workers; * governments to work with employers and key stakeholders to create more effective systems that provide better practice and training conditions;5 and * enhanced support for provincial PHPs, institutions (e.g., medical schools, training programs), and other providers of physician health services.5 Researchers The CMA recommends that: * national and regional data for major health and wellness indicators be assessed at regular intervals to establish and compare norms and to better target and assess initiatives; * a national research strategy be developed through collaboration among relevant stakeholders to identify priorities, coordinate efforts, and promote innovation (consider the specific recommendations from a 2016 research summit to improve wellness and reduce burnout,10 including: Estimating economic impacts; using common metrics; developing a comprehensive framework for interventions with individual and organizational components; and sharing the best available evidence); and * further research in a range of areas including, but not limited to: efficacy of programs, strategies, and systems for promoting and managing health and wellness; examination of the factors exerting the greatest influence on physician health; and system-level interventions.5 Approved by the CMA Board of Directors October 2017 See also Background to CMA Policy on Physician Health REFERENCES 1 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 2 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 3 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 4 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-6. Available: https://doi.org/10.1016/j.mayocp.2016.10.004 (accessed 2017 Oct 30). 5 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. Available: https://doi.org/10.1016/S0140-6736(09)61424-0 (accessed 2017 Oct 30). 7 Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205. Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 8 Ruotsalainen JH, Verbeek JH, Mariné A, Serra C, Ruotsalainen JH, Verbeek JH, et al. Preventing occupational stress in healthcare workers. Sao Paulo Medical Journal 2016;134:92-92. Available: https://doi.org/10.1590/1516-3180.20161341T1 (accessed 2017 Oct 30). 9 Rondinelli RD, Genovese E, Brigham CR, American Medical Association (AMA). Guides to the evaluation of permanent impairment. Chicago: AMA; 2008. Available: https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1160002 (accessed 2017 Oct 30). 10 Dyrbye LN, Trockel M, Frank E, Olson K, Linzer M, Lemaire J, et al. Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Ann Intern Med 2017;166:743-4. Available: https://doi.org/10.7326/M16-2956 (accessed 2017 Oct 30). BACKGROUND TO CMA POLICY PHYSICIAN HEALTH See also CMA Policy on Physician Health In recent decades there has been growing recognition of the impact of physician health on systemic outcomes and patient-care.1,2 Physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of of interconnected physical, mental and social factors to support health and wellness.3 It is also being increasingly understood as a set of risk-management practices aimed at shifting perceptions of health from being an individual (private) matter to more of a shared resource.4 In Canada evidence for this includes the use of strategies adapted from organizational psychology and occupational medicine to change physician behaviour, as well as intensified oversight by professional bodies, and the inclusion of maintaining personal health as a core competency for physicians.4,5 Despite concerted efforts to promote and protect the health and wellness of physicians, the collective state of physician health remains a significant threat to the viability of Canada's health system.1 Physician distress is emerging as an important quality indicator in medical practice,4,6 and both individual- and system-level factors are well-established contributors to compromised physician health.2,7 As such, the advancement of a model of shared responsibility - targeting the relative roles of individual physicians and system-level influencers8 - represents a robust response to this reality. 1. The state of learner and physician health Poor health may develop before or during training and persist into medical practice. Medical school and residency training are particularly challenging times, when a myriad of competing personal and professional demands threaten learner health. In Canada, it has been reported that most students suffer from at least one form of distress over the course of their training9,10 and recent national data point to higher rates compared to their age and education-matched peers. With respect to burnout, characterized by a high level of emotional exhaustion and/or high level of depersonalization (at least weekly), overall rates are reportedly 37%.11,12 Similarly higher levels of depression, anxiety and burnout are reported among American medical students than in the general population.13 While both residents and physicians are reported to be physically healthier than the general population, their mental and social health are cause for concern.1,14 Compared with the general population, physicians are at a higher risk of experiencing adverse outcomes such as depression and burnout15,16 - the latter of which is nearly twice as common among physicians compared with workers in other fields, even after adjusting for age, sex, education level, relationship status, and work hours.17 Results from the 2017 CMA National Physician Health Survey18 showed that 49% of residents and 33% of physicians screened positive for depression, and high burnout rates were reported in 38% of residents 29% of physicians. Furthermore, although the mental health, addiction and substance-use problems, including alcohol, among physicians are not dissimilar to those in the general population, the abuse of prescription drugs (e.g., opioids) is reportedly higher.1,19 Although most physicians referred to monitoring programs have been diagnosed with substance use disorders, an increasing number are being referred for recurrent mood disorders, often stemming from workplace concerns.20,21 1.1 Contributing factors Adverse health outcomes among learners and physicians are linked to a range of contributing factors, including intrinsic ones (e.g., personality characteristics22 and other personal vulnerabilities) and extrinsic ones (e.g., excessive workloads, excessive standards of training and practice, excessive duty hours, lack of autonomy, disruptive behaviour, poor work-life integration, increasing demands with diminishing resources, systemic failures, financial issues, and the practice and training environment).2,15,23 Moreover, the management of risk that many physicians are involved with as it relates to the treatment and management of their patients can be challenging and impacts their health4. A dearth of recent data on the health status of physicians in Canada represents a critical gap in knowledge and limits future efforts to refine, select and assess initiatives. 2. Consequences 2.1. Impact on learners and physicians Compromised physician health can result in decreased personal and professional satisfaction, dysfunctional personal and professional relationships, increased attrition and increased rates of suicide and suicidal ideation.6,24,25 Perhaps most troubling, completed suicide rates among physicians are 1.4-2.3 times higher than in the general population - between 300 and 400 physicians annually in the United States.26 In Canada, suicidal ideation among physicians (including residents) has been recently reported at 19% (lifetime) and 9% (in the last year)18, while Canadian medical student data report 14% (lifetime) and 6% (in the last year).11 Overall, ideation rates are higher among both physicians and learners than in the general population.27 2.2. Impact on patient care The impact of the mental and physical health of physicians extends to the quality of care provided to patients.16,28,29 For instance, physicians suffering from burnout are reportedly two to three times more likely to report their conduct with their patients as sub-optimal.24 Indeed, physicians remain a primary source of health information for patients, and they act as both role models and health advocates.15 Characteristics of burnout (e.g., poor communication and reduced empathy) run counter to the core principles of patient-centred care,30 and physicians who maintain healthy lifestyles are more likely to focus on preventive strategies with their patients.31,32 Although deficits in physician health can negatively affect patient care, it is notable that evidence linking the health of physicians to medical errors is incomplete, if not difficult to establish. Nevertheless, studies have reported a relationship between medical error and specific adverse outcomes such as burnout.17,33 2.3 Impact on health system Issues that are associated with compromised physician health, such as reduced productivity, increased turnover, absenteeism and the likelihood of early retirement,25,34 contribute to the strained state of the health system. Given that physicians represent a significant proportion of the Canadian medical workforce, more attention must be paid to physician health if the health system is to be sustainable.2 Encouragingly, studies have shown that resources and services such as workplace wellness programs produce investment returns,35,36 such as decreases in medical leave and absenteeism2,36,37 Implementing strategies from occupational medicine are also being increasingly employed to ensure patient safety when doctors return to work after illness.4 This contributes to helping balance the need of institutions and medical regulatory agencies to minimize the risk while maximizing quality of patient care, with the desire of individual physicians to help their patients while leading healthy, fulfilling lives.4 Although there are moral grounds for addressing physician and learner ill-health, an economic case can also be made to support and guide initial and ongoing investment to address the problem.7,18 In navigating the many external challenges facing the Canadian the health system, it is critical that system-level leaders not neglect internal threats, including physician distress and dissatisfaction6,7, and challenges in navigating complex work environments.24 To this end, although there are many positive and supportive elements within medical culture, it is also important to acknowledge aspects that contribute to poor health. 2.4 Impact on the culture of medical practice and training and on the workplace Enduring norms within the culture of medicine are directly contributing to the deterioration of the health of Canadian learners and physicians.2 Culturally rooted impediments, such as the reluctance to share personal issues or admit vulnerability, discourage the medical profession from acknowledging, identifying and addressing physician health issues.7 Physicians and learners alike face pressure not to be ill, to care for patients regardless of their personal health and even to attempt to control their own illness and treatment by self-medicating.1,38 Indeed, physicians are often portrayed as being invincible professionals who put patient needs above all else, including their own needs.39,40 Although the CMA Code of Ethics encourages physicians to seek help from colleagues and qualified professionals when personal or workplace challenges compromise patient care41 physicians tend to delay or avoid seeking treatment, especially for psychosocial or psychiatric concerns. Moreover, nearly 33% of Canadian physicians are not registered with a family physician.42 which means they are among the lowest users of health services.43 Providing care to physician colleagues is both complex and challenging, yet this is an area where formal training has not been explicitly or systematically provided on a national scale.1 There is a need to identify physicians willing to treat colleagues, to develop or adapt existing approaches that encourage help-seeking and to help physicians to navigate the treatment of colleagues. Stigma around mental health within medical practice and training acts as a significant barrier to early intervention.1,44 In a localized study of Canadian physicians, 18% reported distress, but only 25% considered getting help and only 2% actually did.39 Similarly, national CMA data reported that 'feeling ashamed to seek help' was identified (76%) as a major reason for physicians not wanting to contact a physician health program.18 Indeed, common concerns include not wanting to let colleagues or patients down, believing seeking help is acknowledging weakness, being apprehensive about confidentiality, and fearing negative reprisals (e.g., from colleagues, supervisors, regulatory bodies, other licence-granting bodies, insurers)1,45 Fear of retribution is also a frequent reason why physicians may feel hesitant to report impaired colleagues, even if supportive of the concept.46 From the outset of training, medical learners are introduced to system-wide cultural aspects and values of the medical profession, which they then internalize and pass on to others.2 Extensive literature on the "hidden curriculum" points to a performance culture that includes norms such as the view that adversity is character building and the valorization of emotional repression (e.g., mental toughness).2,47 Culture-related issues are being increasingly addressed as a function of medical professionalism. For instance, commitment to physician health, collegiality and support have been established as key competencies within the Professional Role of the CanMEDS Framework,5 the most widely accepted and applied physician competency framework in the world.48 This involves a commitment to exhibiting self-awareness and managing influences on personal well-being and professional performance; managing personal and professional demands for a sustainable practice throughout the physician life cycle, and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need. In support of these commitments to personal care, physicians must develop their capacity for self-assessment and monitoring, mindfulness and reflection, and resilience for sustainable practice.5 Intra-professionalism, characterized by effective clinical and personal communication among physicians,49 significantly influence job satisfaction, which in turn has been shown to predict physician health outcomes.50 Furthermore, peer support can buffer the negative effects of work demands;39 collegial, professional environments are known to be healthier for both providers and patients.51 Conversely, unprofessional behaviour is associated with physician dissatisfaction,50 and dysfunctional workplaces and poor collegiality are linked to burnout.52 Unprofessional workplace behaviour is tolerated, and in fact is often customary, within medical training and practice environments.53 Of particular concern, such behaviour carried out by more senior physicians has been shown to encourage similar conduct among learners,54 highlighting the importance of promoting effective professional role modelling.55 Unfortunately, poor supervisory behaviour, and even mistreatment of learners, is common within the medical training environment.56 Although expectations for professional behaviour are increasingly being incorporated into both undergraduate and postgraduate teaching, issues related to a lack of professionalism persist in both training and practice.51 System-wide efforts are needed to counter what is perceived to be an eroding sense of collegiality and to promote professionalism as a way to address physician burnout and enhance engagement.7,39 3. Treatment and preventive approaches 3.1 Physician health services The scope of physician health services has expanded from focusing primary focus on identifying treating and monitoring physicians with substance abuse issues to more recent efforts to de-stigmatize poor physician health and integrate proactive resources to complement tertiary approaches.1 In Canada, there are multiple services to support the health needs of learners and physicians. These can be conceptualized along a continuum of approaches,1 including the following: health-promoting environments (e.g., efforts to ensure balanced workloads, provide more support staff, and encourage physicians to make sure they get adequate exercise, nutrition and sleep in training and practice); primary prevention (e.g., resilience training, stress-reduction groups, fatigue management programs, strategies to enhance teamwork and collaborative care); secondary prevention (e.g., access to assessment and counselling; services and workshops on coping with adverse events, litigation and career transitions and on managing difficult behaviour); and tertiary prevention (e.g., more intensive outpatient counselling, inpatient treatment). Many of these approaches, including those at the system level, focus on assisting the individual physician rather than addressing more contextual issues. Most jurisdictions in Canada have consolidated a number of services under the banner of a provincial physician health program (PHP).These range from counselling, treatment and/or peer support to fitness-to-practice and return-to-work assessments, workplace behaviour management and relationship management. The services available to physicians in a given area vary greatly.1,15 More established and resourced programs often offer services across the continuum, while less established programs tend to focus on secondary and tertiary services.2 Provincial PHPs have been shown to produce positive outcomes1,20,21,48 and are generally considered to be effective in addressing user issues,57 however but many physicians remain reluctant to access them.58 In addition to provincial programs, many learners and physicians in Canada can access support and treatment from other sources, including medical school and faculty wellness programs, employee assistance or workplace programs, and more individual-led options such as physician coaches.1 There has been a steady accumulation of evidence on the positive returns of workplace health and wellness programs,35 as well as indications that even modest investments in physician health can make a difference.17 In response to challenges posed by the considerable diversity in the organizational structure of provincial PHPs, the ways in which PHPs classify information, the range of services they offer, the mechanisms of accountability to stakeholders and the manner in which they pursue non-tertiary activities (e.g., education and prevention work)59 a consortium of PHPs released a preliminary Descriptive Framework for Physician Health Services in Canada in 2016. Through this framework a series of core services (and modes of activity within each) were defined.59 Potential users of the framework include PHPs, academic institutions, medical regulators, national associations, hospitals and health authorities, as well as other local groups. The framework may serve a range of purposes, including program reviews and planning, quality improvement, resource allocation, advocacy, stakeholder consultation and standards development.59 Initiatives such as this framework help address a persistent gap in Canada around equity of and access to services. Overall, fulfilling the needs of all learners and physicians through enhanced service quality and functional equivalence is an ongoing challenge for provincial PHPs and other service providers, and it must be a priority moving forward. 3.2 Individual primary prevention Prevention and promotion activities can help mitigate the severity and decrease the incidence of adverse outcomes associated with physician health issues among learners and physicians.3 Although secondary and tertiary services are critical components of any health strategy, complementary, proactive, preventive initiatives promote a more comprehensive approach. Some of the best-documented strategies include attuning to physical health (e.g., diet, exercise, rest), psychosocial and mental health (e.g., mindfulness and self-awareness, resilience training, protecting and maintaining cultural and recreational interests outside of medicine, and protecting time and relationships with family and friends).60 For instance, resilience has been identified as an indicator of physician wellness61 and as a critical skill for individuals working in health care environments.39 Innovative, coordinated approaches such as resilience and mindfulness training are instrumental in helping physicians overcome both anticipated and unexpected difficulties, to position them for a sustainable career in medicine. Many internal (e.g., personal) and external (e.g., occupational) factors can interfere with a physician's capacity to consistently maintain healthy lifestyle behaviours and objectively attend to personal health needs. Although the emergence of individually targeted proactive and preventive activities is encouraging, a greater focus on system-level initiatives to complement both proactive and tertiary approaches is needed. This also aligns with recent CMA member data indicating that medical students (61%), residents (55%), physicians (43%) and retired physicians (41%) want more access to resources to ensure their emotional, social and psychological well-being.62 Such an approach is increasingly important in light of physicians' professional responsibility to demonstrate a commitment to personal health.5 4. Physician health as a shared responsibility Although physicians are a critical component of Canadian health systems, those systems do not necessarily promote health in the physician community. It cannot be overstated that many health challenges facing learners and physicians are increasingly systemic in nature.1 Despite increasing challenges to the cultural norm that health-related issues are an individual-physician problem,2 system-level factors are often ignored.1,7 Although solutions targeted at the individual level (e.g., mindfulness and resilience training) are important proactive approaches and are a common focus, they often do not address occupational and organizational factors.7 Intervention exclusively at the individual level is unlikely to have meaningful and sustainable impacts. Interventions targeting individual physicians are likely most effective when paired with efforts to address more systemic (e.g., structural and occupational) issues.63 Moreover, organization-directed interventions have been shown to be more effective in reducing physician burnout than individual-directed interventions, and meaningful reductions in negative outcomes have been linked to system-level interventions.22,34 Concerted efforts at the system level will ultimately drive substantive, meaningful and sustainable change. This includes coordination among leaders from national, provincial and local stakeholders as well as individual physicians.16,22,64 Potential influencers include medical schools and other training programs, regulatory bodies, researchers (and funding bodies), professional associations and other health care organizations, as well as insurers.1 Indeed, addressing the complex array of issues related to physician health is a shared responsibility. A clear mandate exists to guide individuals and leaders in promoting and protecting the health of learners and physicians.1,7 5. Conclusion Physician health is a growing priority for the medical profession. Medical practice and training present complex occupational environments34, in which leaders play a central role in shaping training, practice and organizational culture through the implicit and explicit ways in which they communicate core values.2 When promoting physician health across the career lifecycle it is also important to consider the unique challenges and experiences of physicians who are not actively practicing (e.g., on leave; have non-clinical roles) as well as those who are retired. Notwithstanding the impact on patient care or health systems, promoting the health of individual physicians and learners is in and of itself worthy of attention. Indeed, leaders in the health system have a vested interest in helping physicians to meet the personal and professional challenges inherent in medical training and practice as well as in promoting positive concepts such as wellness and engagement.7 The increasingly blurred lines between physician health, professionalism and the functioning of health systems40 suggest that leaders at all levels must promote a unified and progressive vision of a healthy, vibrant and engaged physician workforce. This involves championing health across the career life cycle through advocacy as well as promoting solutions and outcomes through a lens of shared responsibility at both individual and system levels. Broad solutions skewed towards one level, without requisite attention given to the other level, are unikely to result in meaningful change. Moving from rhetoric to action, this next frontier integrates the promotion of self-care among individuals, support for healthy and supportive training and practice environments - both physical and cultural - as well as continued innovation and development of (and support for) physician health services. This constellation of efforts will ultimately contribute to the success of these actions. October 2017 See also CMA Policy on Physician Health REFERENCES 1 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 2 Montgomery AJ. The relationship between leadership and physician well-being; A scoping review. Journal of Healthcare Leadership 2016;55:71-80. Available: http://www.ingentaconnect.com/content/doaj/11793201/2016/00000055/00000001/art00010 (accessed 2017 Oct 30). 3 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 4 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 5 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. 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International Conference on Physician Health; 2016 Sep 18-20; Boston. Ottawa: CFMS; 2016. 12 Maser B, Houlton R. CFMS-FMEQ national health and wellbeing survey: Prevalence and predictors of mental health in Canadian medical students. Canadian Conference on Physician Health; 2017 Sep 7-9; Ottawa. Ottawa: CFMS; 2017. 13 Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among US medical students. Ann of Intern Med 2008;149:334-41. Available: https://doi.org/10.7326/0003-4819-149-5-200809020-00008 (accessed 2017 Oct 30). 14 George S, Hanson J, Jackson JL. Physician, heal thyself: a qualitative study of physician health behaviors. Acad Psychiatry 2014;38:19-25. Available: https://doi.org/10.1007/s40596-013-0014-6 (accessed 2017 Oct 30). 15 Roman S, Prévost C. Physician health: state of knowledge and preventive approaches. Montreal: Programme d'aide aux médecins du Québec (PAMQ); 2015. 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A medical industry perspective – supporting small business, the economic engine of Canada

https://policybase.cma.ca/en/permalink/policy13731
Date
2017-10-02
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2017-10-02
Topics
Physician practice/ compensation/ forms
Text
The changes announced on July 18, 2017, are the most significant change to the private corporation tax structure in 45 years and will have a negative impact on doctors and also convenience store operators, electrical contractors and family farmers. In short, these proposals will negatively affect all small business owners, most of whom are squarely in the middle class and are the engine of the Canadian economy. We believe a 75-day consultation is inadequate to assess the scope of these changes and the ramifications for not only our members but also the 1.1 million other small business operators as well as the impacts of the proposals on Canada's prospects for future economic growth. The Canadian Medical Association (CMA) strongly urges the federal government to: 1) suspend the current proposals; 2) conduct a comprehensive review of these proposals to ensure that legislation can meet policy objectives without significant unintended consequences; and 3) engage all Canadians in a comprehensive review of the tax system considering unique aspects of all sectors, including safety net provisions. Economic considerations of the tax proposals: Small business in Canada Most Canadian businesses are small. As of December 2015, there were 1.17 million employer businesses in the Canadian economy. Of these, 1.14 million (97.9%) were small-sized businesses, 21,415 (1.8%) were medium-sized businesses and 2,933 (0.3%) were large-sized businesses. Small- and medium-sized enterprise s (SMEs) are critical contributors to the Canadian economy. They generate the majority of Canadian jobs. Across the country, an estimated 10.6 million people (66.8% of the labour force) work in small-sized businesses and another 3.3 million (20.4%) are employed in medium-sized businesses. Only 2.0 million (12.8%) work in large-sized businesses. In addition to generating jobs, SMEs make a significant contribution to gross domestic product (GDP). Notably, small businesses with fewer than 50 employees will contribute on average 30% to national GDP. SMEs also make sizable contributions to research and development. Between 2011 and 2013, SMEs accounted for 27% of the research and development expenditures in this country. Medical industry Physicians' offices are an important component of the Canadian economy, employing people and supporting suppliers in their communities. The majority of physicians (66% or 54,000) own and operate a private corporation. The direct GDP contribution produced by physicians' offices in Canada in 2016 was $22.3 billion. They paid $6.2 billion in wages and salaries, employed 137,000 people and contributed $643 million in tax revenues to governments. Including the supply chain and induced effects of this economic activity, the total GDP supported by the economic footprint of physicians' offices was $33.4 billion and the total number of jobs supported was 250,000. Physicians' medical practices, in addition to providing essential health care services to Canadians, also provide a noticeable contribution to Canada's economy. The total economic footprint of physicians' practices in 2016 - directly, through their supply chain and through induced effects - accounted for 1.6% of Canada's total GDP in 2016. Making Canada an attractive place to practise medicine Physicians and small business owners across the country believe that the proposals are complex and will ultimately lead to unintended consequences that will affect all Canadians. With so many underserviced regions of Canada and 5.3 million orphan patients, it behooves government to establish conditions that facilitate recruitment and retention of highly skilled professionals, such as physicians. Physicians are more mobile than many other small business owners. Between 2014 and 2015, for instance, approximately 740 physicians (about 1% of all physicians) moved from one province or territory to another. In the CMA's recent member survey, 22% of practising physicians stated they would consider relocating their practice to another country as a result of the proposed federal tax changes. Of the medical residents who participated in the survey, 39% would consider moving their practice to another country if the proposed federal tax changes are implemented. The experience of the 1990s provides evidence that this is a real possibility. In 1992, health ministers agreed to reduce medical school enrolment, and shortly afterward provincial governments began to put restrictions in place, such as a two-year moratorium on new billing numbers in Ontario for physicians who had not completed their undergraduate or postgraduate training there. These measures sent a clear message that doctors were not welcome in Canada and it was no surprise that they left in large numbers. From 1995 to 1997 Canada experienced an annual average net loss of 454 physicians to migration, the equivalent of four medical school classes. The United States continues to face a shortage of physicians, and it may be an attractive alternative for Canadian physicians to practise. Projections released earlier this year for the American Association of Medical Colleges indicate that the United States will have a shortage of between 40,800 and 104,900 physicians by 2030. The path to becoming a physician is a long one, which includes 10 or more years of postsecondary education. As a result, physicians start their careers later than other workers. Average student debt ranges from $160,000 to $180,000. This represents a large personal investment of time and money. We want to ensure that Canada establishes the public policy conditions necessary to retain and attract the next generation of physicians. Thriving medical practices are the best medicine for patients Public policy should strive to promote economic growth, innovation and quality of life for all Canadians. Thriving medical practices are a key ingredient in ensuring that Canadians have access to medical care when and where they need it. Any changes to the existing tax regimen can have the unintended consequences of forcing owners of medical practices to curtail their operations, reduce availability of care and stifle expansions of much-needed medical services. The CMA asked physicians whether they would consider reducing the number of hours they worked if the government eliminated any or all of the benefits of incorporation. Over half of the practising physicians who responded to the survey (54%) indicated they would consider reducing their number of hours worked, and 24% indicated they would consider retirement. In addition, 31% of the respondents stated they would consider closing their practice and moving to another practice setting (such as a hospital-based or salaried position). Of particular note, 64% of the medical residents who responded to the survey indicated that they would avoid independent practice. If fewer physicians opt to stay in or enter into independent practice there could be important implications for physician supply and patient accessibility. This may be particularly important in rural and remote regions, where independent practice is the most common means for delivery of physician services. In some rural and remote communities across Canada, there is already a shortage of physicians. According to Statistics Canada, about 19% of the Canadian population lives in rural and remote communities, but only about 14% of family physicians and 2% of specialists practise in such communities. The ratio of physicians to patients is also much lower in rural than in urban Canada (0.8 versus 2.1 per 1,000 in 2013). Some of the challenges in recruiting and retaining physicians to rural and especially to remote communities include the reality that physicians in these regions often have to work long hours, have a high level of on-call responsibilities and need additional competencies to meet their community's needs. Unlike most physicians working in urban environments, they may also experience insufficient backup or a total absence of backup from other physicians, nurses and complementary services. There are typically fewer professional education opportunities in rural and remote communities. Finally, physicians sometimes find it difficult to travel long distances to visit their families in urban regions or to convince their spouses and children to relocate from urban to rural and remote communities because of limited job prospects and educational opportunities for their families. Promoting gender equality in small- and medium-sized businesses and in medical practices The current federal government has advanced a feminist agenda with a view to ensuring that all public policy aligns with and supports gender equality. It is therefore perplexing to see the tax proposals being considered, as these may further deter women from entering the medical profession. It is worth noting that female physicians now account for 40% of all Canadian physicians and they represent 60% of physicians under the age of 35. This statistic represents a significant achievement in promoting gender equality in the profession. While the potential indirect effects of the federal tax proposals apply to all physicians regardless of gender, female physicians will likely see an incrementally larger decrease in income at all career stages and particularly as they start a family. This is coupled with the fact that there are already fewer female physicians over the age of 50. Many female physicians may choose to stay at home if the current financial and entrepreneurial incentives are no longer available. In addition to the direct impact of the proposed tax measures on female physicians, any practice consolidations or closures resulting from these measures will also impact women currently employed in physician practices, including nurses and administrative support staff. This is significant for occupations such as medical administrative assistants and other health services support staff; 98% and 80% of total employees in these occupations are women, respectively. Inspiring innovation as the cornerstone of Canada's future A significant portion of medical research in Canada is funded by physician donations of cash and unpaid physician labour. This is especially true for physicians working in academic health science centres (AHSCs). AHSCs are vital to ensuring that leading-edge medical research continues in Canada. Since most AHSCs are structured as partnerships of incorporated physicians, they will also be affected by the federal tax proposals, and donations to fund medical research will be compromised as physicians make financial decisions to reduce their spending to make up for their increased tax burden. This is significant, as the CMA estimates that physicians provide $340 million from their gross earnings to fund medical research and teaching in AHSCs. Furthermore, if physicians are facing a reduction in after-tax income from their practices, they will likely favour paid labour over unpaid labour to offset the reduction, which would result in fewer physician hours spent on medical research. There would be little financial incentive for physicians to continue with medical research, which would significantly impede medical innovation in Canada. Technical considerations of the proposals: In reviewing the specifics of the proposals, the CMA wishes to provide its perspective on several of the elements being considered, including fairness, complexity, passive income of a small business corporation, anti-avoidance rules and income splitting. Fairness The tax rules for private corporations are available to everyone should they wish to start and run their own business. They have been supported and even promoted by various governments to encourage entrepreneurship and those who are willing to take the risk of starting up a small business, entering independent practice or taking over the family business. Seeking to compare a salaried employee to someone who works through a private corporation where the corporation earns an equivalent amount of income fails to take into account all the factors necessary to operate a successful business through a corporate structure. For example, private corporations reinvest in the business and save funds to weather adverse economic events and to offset the lack of employment provisions and benefits. Physicians start their medical practice with significant debt and enter their career in their 30s. Private corporations in different sectors face their own unique set of challenges and the existing policies provide certainty that enables them to make plans. The CMA is aware that in 2011 an Employment Insurance (EI) program was established for self-employed individuals whereby they could register and pay for benefits including maternity and parental leave. We understand that there has been low uptake; we suspect that is because many self-employed people cannot take a full year off for maternity/parental leave and therefore do not receive the full value of what they put into the program. Other considerations include the fact that the program is not topped up by an employer, the program does not factor in expenses related to replacement costs, and there is loss of flexibility to cover lifestyle costs. Although well-intentioned, it seems that the enhancements to the EI program may not address the realities of running a business (regardless of incorporation) and that is why we need a more comprehensive review of the tax system that considers unique sector conditions and safety net provisions. Corporations are legitimate business vehicles that facilitate compliance and administration, and they have been sanctioned and encouraged by successive governments for decades. Changing the rules now will be highly destabilizing for small business owners who have chosen to organize their affairs in this way, many of whom also do not have the resources to adjust to these changes. In some cases, provisions for physician incorporation have been part of a negotiated settlement with provincial governments. The proposed changes will drive up medical costs, increase pressure on provincial and territorial governments and worsen fee-schedule negotiations between physicians and their provincial and territorial governments, causing yet more unnecessary disruption. The use of corporations has to a certain extent kept the underground economy at bay because of mandatory reporting requirements and registration both for income tax and GST/HST purposes and for corporate governance. Complexity The Canadian tax system and in particular the rules governing both big and small corporations are complex, and successive governments have strived to simplify them over time. The proposed tax changes have a level of complexity that is counter to what the present government has been promoting by eliminating boutique tax provisions. The proposals create a bigger disparity between small business corporations eligible for the small business deduction and small public corporations that provide many of the same benefits to family shareholders. Passive investments Passive income is already taxed at higher levels than active business income. Working capital is just as necessary in a small business corporation as it is in a public corporation. Investing passively in a private corporation has been a legitimate practice for many generations of Canadian business owners. The method of taxing passive income has been in effect since 1972. Investing passively within a corporation accommodates business owners who assume risk and responsibility not otherwise assumed by employees. A few important accommodations are noted below: * Investing passively provides a business owner with efficient access to capital so that opportunities can be seized, creating growth and employment for our economy. * Business owners are more likely to accept the risk associated with making investments if they have access to more capital. * Investing passively allows a business owner to manage risks assumed when one goes into business for oneself. These risks are not otherwise assumed by employees. * Investing passively allows a business owner to diversify risk by investing in assets that are very different than private corporation shares. * Investing passively allows a business owner to provide for retirement and unforeseen circumstances that may need to be self-funded. Physicians, like other small business owners, retain capital in their corporations to weather the financial ups and downs that are inherent in self-employment. Because physicians do not have employer-sponsored pension plans or health, disability or maternity benefits or statutory vacation leave, they rely on retained earnings and make passive investments to build up the capital to fund these eventualities. Similar to other businesses, medical practices have to respond to the ups and downs of the business cycle - in the medical practice context, provincial and territorial governments will implement expenditure caps and cuts that will affect the medical practice's bottom line. Fair, simple and efficient tax system As noted by CPA Canada, fairness in our tax system is an essential principle and it is doubtful that the recent proposals will improve this. Investing passively in a private corporation has in some cases been a mechanism available to business owners of all sizes since 1972. It will be important to consider the fact that many small business owners have legitimately organized their affairs by investing passively in their corporation and have not contributed to registered retirement savings plans (RRSPs), tax free savings accounts (TFSAs) and registered education savings plans (RESPs). Fundamentally changing the tax system will in some cases require physicians to: * work for more years to save for retirement with after tax dollars; * evaluate whether Canada's tax system is competitive with that of other economies; and * alter practice decisions, such as opting to retire completely versus easing into retirement or reducing hours of work in favour of other career pursuits. Applying a 50% permanent income tax rate in the corporation to passive income assumes that all small business owners are high-rate taxpayers. This is not the case, and this assumption would inadvertently punish many small business owners who are not subject to the highest rates of income tax. In some cases, applying a high rate of personal income tax to corporate income that has already been subject to tax at 50% will result in a combined income tax rate of approximately 71%. Canada's tax system is already complex and the proposed methods of accounting for passive income will in all cases add further complexity, reducing taxpayer compliance. Tracking and pooling sources of income to account for investments will be both time consuming and costly. There will need to be simple mechanisms for both grandfathered investments and those impacted by the new rules. Lastly, making significant changes to legitimate tax structures that have been in use for 45 years requires careful consideration, material stakeholder involvement, carefully considered grandfathering provisions and the appropriate amount of time to plan and implement. The proposals concerning passive income in a private corporation represent a significant change in tax policy. If implemented as proposed by the government, the changes could act as a disincentive for those looking to invest in small business, decreasing job creation. Furthermore, the tax policy changes as proposed could make it difficult for Canada to attract, recruit and retain highly skilled professionals, which will significantly impact the quality and availability of health care in the short and long term. For consideration - prescribed allowable assets for passive investment A fair tax system accommodates taxpayers who assume different levels of risk and is flexible enough to allow taxpayers to manage various circumstances. From a policy perspective, there are many examples of accommodation or incentive, such as the lifetime capital gains exemption (LCGE) and the small business deduction (SBD), which accommodate a self-employed individual's realities when compared with an employee. In the CMA's view, passive income is already taxed at rates of almost 50% to discourage investing passively in a corporation, and when passive income is distributed to individual shareholders, investment income is appropriately taxed. Existing passive assets and any income or related capital gain thereon should not be impacted by any new system that is implemented. Regarding a transition, a taxpayer should have the ability to elect to have existing or substituted assets and the related income or capital gains taxed under the current regime resulting in no change. On a prospective basis, passive assets accumulated over and above a prescribed threshold could be subject to new investment income rules. The prescribed threshold would allow business owners to accumulate passive assets commensurate with the amount of risk they accept or assume. Alternatively, the prescribed threshold would allow a taxpayer to opt out of the onerous and costly rules that are not conducive to small business. Business owners have raised the concern that they need to retain capital in their corporations for valid business purposes. These include saving for economic downturns, future growth and contingencies such as an illness of the principal business owner. Allowing a prescribed amount of passive investments to be held by private corporations will permit them to save for these valid business reasons without facing excessive tax rates, while still meeting the government's policy objective of preventing individuals from using corporations to save beyond government tolerance. A prescribed threshold provides greater certainty for planning and ease of administration. These ideas are worth exploring but require time and the engagement of small businesses to ensure that the changes do not produce unintended consequences while meeting public policy objectives. Converting income to capital Anti-tax avoidance rules We are in support of targeted measures to curtail abuse. Non-arm's length manipulations of cost base to reduce or eliminate capital gains are not appropriate, and such abuses should be curtailed. Use of mechanisms to avoid double taxation such as the so-called pipeline strategy that has been accepted by the Canada Revenue Agency (CRA) to avoid double taxation should be encouraged, not legislated against. Estate planning CRA has issued numerous favourable advanced income tax rulings with respect to pipeline planning. The proposed changes in ITA section 84.1 are especially troublesome for those nearing retirement and those who have planned for their final estate tax liability under the current income tax regime. For example, assume an owner of a private corporation dies in Ontario and the shares are not inherited by a spouse. If the private company shares have a fair market value of $2,000,000 with minimal adjusted cost base, the estate's final income tax liability will increase by approximately $360,000 if the fair market value of the private corporation must be realized as a dividend rather than as a capital gain, as contemplated by proposed subsection 84.1(2). In addition, there would be limited opportunities for retired or near-retirement business owners to acquire life insurance or otherwise reorganize their affairs. Lastly, the proposed changes would effectively require each estate to wind up the affairs of a private corporation within a very short period of time (12 months) to avoid double taxation. For consideration Subsection 164(6) of the Act should be extended to coincide with the graduated rate estate rules that were recently introduced. On this basis, an estate would have three years to properly wind up the affairs of a private company, realize a capital loss and carry it back to the terminal return of the shareholder to avoid paying income tax twice. Income sprinkling The practice of income sprinkling within the use of a professional corporation has been supported by judgments issued by the Supreme Court of Canada. It is also true that in some cases provincial governments have amended legislation governing professionals to allow a professional to introduce family members as shareholders of their professional corporations. Such amendments were made in the context of negotiating contracts for service deliverables and remuneration and in recognition of the family involvement in running a small business, such as a medical office in the case of physicians. Upon incorporation the entity that has been created in support of a specific business activity has nominal value. The corporation builds and expands through bank borrowing, expenditures and the sweat capital of spouses/partners. The value of that sweat capital is difficult to quantify but in many respects is no different than the sweat capital provided by unrelated entrepreneurs in developing a high technology idea into a working venture. The proposed changes could result in more stringent requirements for a family shareholder to demonstrate their contribution of capital or value to an entity than would be required of a non-family member shareholder. Spouses/partners are integral to the risk and development of a business enterprise that, as a family, they have an interest in: pension income splitting recognizes the family unit and similar considerations apply here. Tax policy reflected in the ITA has always permitted a certain level of income based on the personal amount and the dividend tax credit to be received without tax cost. In 2017 the amount was approximately $32,000.00. There is no abuse in using those provisions just as there is no abuse in pension income splitting to share the tax obligation within a family. Subjectivity of reasonability criteria Regarding the application of tax on split income (TOSI) and the "reasonableness test," the CMA is concerned that in practice, the proposed rules will result in inconsistent application, as the reasonableness test requires a subjective self-assessment after considering labour and capital contributions. Consider the practical difficulties that will arise in the following situations: * Both spouses are involved in the business on a regular and continuous basis. However, at different points during their life, their involvement is limited because of health or maternity reasons. * All family members (adult children and parents) are involved on a regular and continuous basis in the business. Similar to the example above, each family member has differing levels of involvement at different times and each family member makes unique contributions. * In some cases, a household will be required to decide on the division of labour. The division of labour would consider both inside and outside duties, resulting in one family member being less active in the business for a period of time or permanently because he/she is directly supporting inside duties so that the other spouse's involvement can exceed what would normally be required of an employee. . When assessing the reasonability of a dividend paid, both the taxpayer and CRA are required to evaluate a proper rate of return and assess the risk assumed. Independent data or proxies are not readily available when assessing risk assumed with respect to a private company investment. In the case where a spouse and/or all family members are involved with the business on a regular and continuous basis, practical difficulty will constantly arise when attempting to ascertain with any degree of precision or certainty reasonable compensation in the circumstances. In some cases, a physician's spouse will deliberately choose not to enter the workforce as a second income earner because it is not economically viable to do so given the day-to-day realities of managing a business, raising a family and planning for the future. Constraining income splitting will in some cases cause hardship for families who have organized their division of labour so that the family can fully support the professional's activities. This translates into physicians being more available to grow their practice and to care for patients. If the economics concerning the division of labour within and outside of the household are seriously altered, many small business owners could be motivated to work less and refocus their division of labour. For consideration - prescribed threshold on income sprinkling Dividends are paid to shareholders as a return on their investment in the corporation. Since the distribution of the dividend is not determined by the quantum of a shareholder's contribution to the corporation, it is illogical to use contribution or labour as the criterion that determines when dividend income will be subject to TOSI. A small business is dynamic, and contributions to a family business are required at different times by different people and entail different amounts of effort. Documenting and measuring the many different contributions will undoubtedly create problems because a business owner and their spouse are often inextricably linked when it comes to valuing their contributions to a business. Because of the complexity that the proposed changes would cause, the TOSI income rules should not consider a small business owner's spouse or common-law partner. In the alternative, a threshold should be contemplated that would recognize various contributions and eliminate the uncertainty and judgment required when applying the proposed rules. The implementation of a prescribed threshold of allowable dividends to be paid to family members would alleviate many of the issues with the current reasonableness test. The primary concern with the current wording of the reasonableness tests is the inherent uncertainty because of the difficulty in determining the value of contributions made by family members. A threshold of allowable dividends would inherently acknowledge that family members contribute value and assume risk with respect to a family business. This would eliminate the uncertainty about these amounts paid to family members, allowing small businesses to recognize the contributions of family members without fear of future reassessments at the top marginal rate of tax. This would also shift the focus of the proposals to higher income earners. Dividends above the prescribed threshold would still be subject to the proposed reasonableness test, preventing excessive amounts from being paid to family members where their contributions do not warrant these distributions. These ideas are worthy of consideration but require the engagement of the small business community to ensure that the changes do not produce unintended consequences while achieving their public policy objectives. Conclusion Canada's doctors are fully committed to improving health and health care by helping families, youth and women, growing the economy and ensuring we have thriving communities from coast to coast to coast. We know that these values are shared by governments. As health care providers and as owners of small businesses, Canada's doctors have been committed to these goals for decades. While the full impact of the proposed taxation changes is currently being assessed, every indication points to significant negative ramifications for frontline health care workers and the Canadian economy. Physician medical practices contribute significantly to the local and national economy by directly employing 137,000 Canadians and providing needed medical infrastructure. These entrepreneurs are also responsible for providing a self-funded safety net. These factors have, to a significant degree, been taken into account in settling fee structures for the medical professional on an overall after-tax basis. If those provisions cannot be relied on in the future, fairness would dictate that time be given for those in the relevant provinces to renegotiate their fee structures so that new factors can be taken into account. Fairness would also dictate that other self-funded safety net provisions, such as retirement savings vehicles, be adjusted or created to cover planned and unplanned events. The July 18, 2017, proposals represent the most significant tax changes since 1972. The CMA is concerned that the government may not be aware of the potential for far-reaching unintended consequences of the proposals and therefore strongly urges the government to: 1. suspend the current proposals; 2. conduct a comprehensive review of these proposals to ensure that legislation can meet policy objectives without significant unintended consequences; and 3. engage all Canadians in a comprehensive review of the tax system considering unique aspects of all sectors, including safety net provisions. Appendix A: Unintended consequences There are several potential mitigating measures physicians may apply to offset reductions in net revenue, including the following: * Physicians may decide to operate their practices on a leaner basis, offsetting their loss in net income by reducing practice spending. They may reduce their individual spending on staff and other costs, or they may elect to consolidate several practices into one. * Physicians may decide to reduce their hours worked, or change their practice setting in response to the reduction in net income. Scenario 1 provides an example. Scenario 1: Private practice Background Dr. Johns operates a private practice in rural Ontario. Understanding that there is a significant shortage of physicians in rural communities across Canada, Dr. Johns and her husband moved to their current rural community 10 years ago. Dr. Johns' husband, a teacher by trade, has been unable to secure full-time employment because of the limited number of jobs available in their community. Instead, he helps Dr. Johns by dealing with all operational matters for her clinics. This includes negotiating leases, buying equipment and hiring staff so that Dr. Johns can focus on delivering medical services. The children are involved too; they developed and maintain the clinic website. Over the last 10 years, he has also handled all matters related to the household, including raising their two children. Dr. Johns' children are now 18 and 19 years old and are both starting university in 2018. Dr. Johns, Mr. Johns and their children are shareholders of the medical professional corporation. Outcome Because of the new changes, Dr. Johns worries that she will not be able to help her children pay for university. Dr. and Mr. Johns are now trying to decide if they should close the rural practice and move back to the city, where Mr. Johns could find employment to help pay for their children's education. Scenario 2 illustrates how the proposed tax changes would affect a female pediatrician operating her practice through a corporation. Scenario 2: Retirement Background Dr. Grey is a 55-year-old pediatrician who operates her practice through a corporation. She is married and has two adult children. Her husband is a shareholder in the corporation. Her children are not. After finishing medical school and her residency, she started practising when she was 30. She spent the next three years making minimum payments on her student loans so that she could save enough to finance her maternity leave. Between ages 33 and 35, she had two children and was unable to work. When she returned to work, her husband stopped working to raise the children and manage the household. By age 40 she had finally paid off her medical school debt, but she spent the next 15 years saving to pay for her children's education and supporting the family. As a result, Dr. Grey has not been able to save any money for retirement before now. Outcome Dr. Grey has heard that her plans may be significantly impacted by the changes to both income splitting and passive investments. She has heard that existing portfolios of passive investments will be grandfathered, but she does not see how that will help her because she is only starting to save for retirement now. As Dr. Grey's fees are set by the province she cannot increase the fees she charges to her patients and will therefore have to reduce costs, including staffing costs. Otherwise, she may never be able to retire comfortably. Scenario 3: Married physician at an academic health science centre Background Dr. Ritchie is an incorporated cardiologist working in an academic health science centre. Because of her sporadic schedule her husband is not able to work a traditional job. Instead, he manages the household, and when needed he helps with any administrative activities required for managing Dr. Ritchie's corporation. As Dr. Ritchie understands that medical research is not well funded in Canada, she donates $25,000 per year to her local research institute. Dr. Ritchie currently takes an annual dividend of $135,000 out of her corporation and pays a dividend of $35,000 to her husband. Outcome Under the proposed changes to income splitting, it is unclear what would be considered a "reasonable amount" that can be paid to Dr. Ritchie's husband for his contributions; therefore, Dr. Ritchie will have to take out all funds herself. If the $35,000 typically paid to Dr. Ritchie's husband is now paid to her, the family tax liability will increase by $13,016/year. This means that if the family wants to have the same after-tax cash under the new rules, they will have to draw an additional $23,400 out of the corporation as dividends, increasing total dividends to $193,400. To fund this additional outflow while still saving for retirement, Dr. Ritchie will have to reduce her practice's expenditures by an amount roughly equal to her annual medical research donation. She is strongly considering not making donations to medical research so that she can support her family.
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Social equity and increasing productivity

https://policybase.cma.ca/en/permalink/policy13725
Date
2017-09-21
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2017-09-21
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. This is due in large part to Canada’s health care system, the people working in it, research and medical school excellence, public and private investments and the many advances that have been made over the decades in medicine. However, the Canadian Medical Association (CMA) is deeply concerned that Canada’s health care system isn’t keeping up with the health care needs of older Canadians. When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 30 million and the average life expectancy is 10 years longer. The aging of our population is both an immense success story and the most pressing policy imperative of our time. Our submission and recommendations focus on seniors care. We believe the ability of our country to meet the health care needs of this segment of our population is indeed of such high priority that we have come to these consultations with this single issue in mind. While daunting, the task ahead is by no means impossible and will ultimately result in numerous health and financial benefits. By providing the means to expand long-term care and home care capacity, the Government of Canada will improve health care for seniors and others, create new jobs and add billions of dollars annually to the Gross Domestic Product. Furtherbed demand will vary over this period, peaking in 2032 and beginning to decline thereafter. The five-year projection for beds is as follows: Table 1: Projected shortage in long-term care beds, 2017–2021 Number of additional Year beds required 2017 15,740* 2018 6,940 2019 6,450 2020 6,620 2021 7,140 Projected 42,890 five-year shortage *Note: the figure for additional beds required in 2017 includes 8,420 beds’ worth of demand that is currently unmet, in the form of patients in alternate level of care beds in hospitals. The Conference Board estimated the cost to construct 10,500 beds (the average number of new beds required per year from 2017 to 2035) at $3.4 billion per year and $63.7 billion in total, on the basis of a cost estimate of $320,000 per bed (all figures in 2017 dollars). These figures include both public and private spending. This forecast does not include the significant investments required to renovate and retrofit the existing stock of residential facilities. The average number of new long-term care beds needed in Canada every year up to 2035 is 10,500. The Conference Board of Canada estimates the cost of this to be $3.4 billion per year, for a total public and private expenditure of $63.7 billion. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes. Construction of new residential care models and renovation/retrofitting of existing facilities will provide significant economic opportunities for many communities across Canada. The construction and maintenance of 10,500 new residential care beds will yield direct economic benefits that include a $1.4 billion annual average contribution to GDP supporting 14,600 jobs yearly during the capital investment phase and a $5.3 billion annual average contribution to GDP supporting an average of 58,300 jobs annually during the facility operation phase. By comparison, nursing homes and residential care facilities employed about 412,000 people in 2016. These investments would also close the significant gap between the projected residential care bed shortages and currently planned investment. When indirect economic contributions are included, the average estimated annual contribution to Canada’s GDP from the construction and operation of the new beds reaches $12.4 billion, supporting an average of 130,000 jobs annually between 2017 and 2035 (in construction, care provision and other sectors). This bed projection provides a sense of the immense challenge Canada faces in addressing the needs of a vulnerable segment of its population of older seniors. A recent report by the Canadian Institute for Health Information indicated that residential care capacity will need to double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided in Canada across the continuum of care.13 Efforts to de-hospitalize the system and deal with Canada’s aging population should be part of an overall national seniors strategy. Such a strategy was called for previously by the CMA, other organizations (e.g., the National Association of Federal Retirees), the Standing Senate Committee on National Finance14 and over 50,000 Canadians.15 Fixing seniors care will contribute to the renewal of the entire health system and will improve the productivity of health care delivery across the country. The differing fiscal capacities of the provinces in the current economic climate will mean that improvements in seniors care will advance at an uneven pace. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure models. GDP # of jobs contributions Capitalinvestment phase Operation phase 14,600 58,300 $1.4 billion $5.3 billion With indirect contributions 130,000 $12.4 billion RECOMMENDATIONS: The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Caregivers are the backbone of any care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend. While this care was most often received by a senior in their own residence, 62% of caregivers said the care recipients lived in a home separate from the caregiver’s home.16 Age-related needs are the most common reason for care requirements.17 Caregivers are of all ages; for instance, 27% of caregivers were between the ages of 15 and 29 years.18 One study has forecast that the number of Canadians requiring care will double over the next 30 years.19 Caregiver costs Work $5.5 in lost absence: productivity billion Personal upwards of or more out-of-a yearpocket: $2,000 A Statistics Canada study found that 56% of caregivers living with the care recipient provided at least 10 hours of care a week. Approximately 22% of caregivers helping a resident in a care facility also provided at least 10 hours of care a week. The chief condition for which care was provided was dementia or Alzheimer’s disease (25%).16 The cost to employers in lost productivity because of caregiving-related absenteeism is estimated at $5.5 billion annually.20 Caregivers also report high out-of-pocket expenses. This is especially true for those living with the care recipient: over 25% spend at least $2,000 annually on out-of-pocket expenses.16 Caregivers require a range of supports including education/training, peer support, respite care and financial assistance. Canadians want governments to do more to help seniors and their family caregivers.21 The federal government’s new combined Canada Caregiver Credit (CCC) is a non­refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Notwithstanding these changes and the greater flexibility for caregivers to use Employment Insurance benefits, caregivers will require more support. The CMA recommends making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit, resulting in a refund payment to provide further financial support for low-income families. RECOMMENDATION: The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcomed step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it will be important to establish clear operating principles between the parties to oversee the funding implementation including support for caregivers. RECOMMENDATION: RECOMMENDATION: The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investment in home care and mental health is a recognition that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. 5 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. T he CMA recognizes the federal government’s commitment to help Canadians be as productive as possible in their workplaces and in their communities. Implementing these recommendations as an integrated package is essential to stitching together the elements of community-based and residential care for seniors. In addition to making a meaningful contribution to meeting the future care needs of Canada’s aging population, these recommendations will mitigate the impacts of economic pressures on individuals as well as jurisdictions. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_ final.pdf (accessed 2016 Sep 22). 2 Canadian Institute for Health Information. Seniors and alternate level of care: building on our knowledge. Ottawa: The Institute; 2012 Nov. Available: https://secure.cihi.ca/ free_products/ALC_AIB_EN.pdf (accessed 2016 Sep 22). 3 Access to Care, Cancer Care Ontario. Alternate level of care (ALC) [Prepared for the Ontario Hospital Association]. Toronto: Ontario Hospital Association (OHA); 2016 May. 4 McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014 Sep 5;17(3):88–94. 5 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www. homecareontario.ca/home-care-services/facts-figures/ publiclyfundedhomecare (accessed 2016 Sep 22). 6 Sponagle J. Nunavut struggles to care for elders closer to home. CBC News. 2017 Jun 5. Available: http://www.cbc. ca/news/canada/north/nunavut-seniors-plan-1.4145757 (accessed 2017 Jun 30). 7 Health Quality Ontario. Wait times for long-term care homes. Toronto: Health Quality Ontario; 2017. Available: http://www.hqontario.ca/System-Performance/Long­ Term-Care-Home-Performance/Wait-Times (accessed 2017 Jun 22). 8 Alzheimer Society Canada. The Canadian Alzheimer’s Disease and Dementia Partnership: a collective vision for a national dementia strategy for Canada. Toronto: Alzheimer Society Canada; undated. Available: http:// www.alzheimer.ca/~/media/Files/national/Advocacy/ CADDP_Strategic_Objectives_e.pdf (accessed 2016 Sep 22). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada. ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/ dq140917a-eng.htm (accessed 2016 Sep 19). 11 The Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; forthcoming. 12 Lazurko M, Hearn B. Canadian continuing care scenarios 1999–2041. KPMG final project report to FPT Advisory Committee on Health Services. Ottawa: KPMG; 2000. Cited by Canadian Healthcare Association. New directions for facility-based long-term care. Ottawa: The Association; 2009. Available: https://www.advantageontario.ca/ oanhssdocs/Issue_Positions/External_Resources/ Sept2009_New_Directions_for_Facility_Based_LTC.pdf (accessed 2017 Jun 30). 13 Canadian Institute for Health Information. Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi. ca/sites/default/files/document/seniors-in-transition­ report-2017-en.pdf (accessed 2017 Jun 30). 14 Standing Senate Committee on National Finance. Getting ready: for a new generation of active seniors. First interim report. Ottawa: The Senate; 2017 Jun. Available: https:// sencanada.ca/content/sen/committee/421/NFFN/Reports/ NFFN_Final19th_Aging_e.pdf (accessed 2017 Jun 30). 15 Canadian Medical Association. Demand a plan. Ottawa: The Association; 2017. Available: http://www.demandaplan.ca/ (accessed 2017 Jun 30). 16 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006­ X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/ article/14142-eng.pdf (accessed 2016 Sep 22). 17 Sinha M. Portrait of caregivers, 2012. Spotlight on Canadians: results from the General Social Survey. Cat. No. 89-652-X – No. 001. Ottawa: Statistics Canada; 2013 Sep. Available: http://www.statcan.gc.ca/pub/89-652­ x/89-652-x2013001-eng.htm (accessed 2016 Sep 22). 18 Bleakney A. Young Canadians providing care. Spotlight on Canadians: results from the General Social Survey. Cat. No. 89-652-X – No. 003. Ottawa: Statistics Canada; 2014 Sep. Available: http://www.statcan.gc.ca/pub/89-652­ x/89-652-x2014003-eng.htm (accessed 2017 Jun 30). 19 Carrière Y, Keefe J, Légaré J, et al. Projecting the future availability of the informal support network of the elderly population and assessing its impact on home care services. Demography Division Research Paper Cat. No. 91F0015M – No. 009. Ottawa: Statistics Canada; 2008. Available: http://publications.gc.ca/collections/collection_2009/ statcan/91F0015M/91f0015m2008009-eng.pdf (accessed 2017 Jun 30). 20 Ceridian Canada. Double duty: the caregiving crisis in the workplace [Blog post]. Ottawa: Ceridian Canada, 2015 Nov 5. Available: http://www.ceridian.ca/blog/2015/11/ double-duty-the-caregiving-crisis-in-the-workplace/ (accessed 2016 Sep 22). 21 Ipsos Public Affairs, HealthCareCAN, National Health Leadership Conference. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20 Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 6).
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Care to new immigrants and refugees

https://policybase.cma.ca/en/permalink/policy13699
Date
2017-08-23
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC17-04
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
Policy Type
Policy resolution
Date
2017-08-23
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC17-04
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
Text
The Canadian Medical Association supports development of clinical best practice guidelines for the provision of care to new immigrants and refugees.
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