Authorizing Cannabis for Medical Purposes
The legalization of cannabis for recreational purposes came into effect with the Cannabis Act in October 2018, and patients continue to have access to cannabis for therapeutic purposes. The Cannabis Regulations have replaced the Access to Cannabis for Medical Purposes Regulations. Patients can obtain cannabis for medical purposes when a physician or nurse practitioner provides a “medical document” , authorizing its use, and determining the daily dried cannabis dose in grams.
With the authorization, patients have the choice whether to (a) buy directly from a federally licensed producer; (b) register with Health Canada to produce a limited amount for personal consumption; (c) designate someone to produce it for them; or (d) buy cannabis at provincial or territorial authorized retail outlets or online sales platforms, if above the legal age limit.
While acknowledging the unique requirements of patients suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief, physicians remain concerned about the serious lack of clinical research, guidance and regulatory oversight for cannabis as a medical treatment. There is insufficient clinical information on safety and efficacy for most therapeutic claims. There is little information around therapeutic and toxic dosages and knowledge on interactions with medications. Besides the need for appropriate research, health practitioners would benefit from unbiased, accredited educational modules and decision support tools based on the best available evidence.
The Canadian Medical Association has consistently expressed concern with the role of gatekeeper that physicians have been asked to take as a result of court decisions. Physicians should not feel obligated to authorize cannabis for medical purposes.
Physicians who choose to authorize cannabis for their patients must comply with their provincial or territorial regulatory College's relevant guideline or policy. They should also be familiar with regulations and guidance, particularly:
Health Canada’s Information for Health Care Practitioners – Medical Use of Cannabis (monograph, summary and daily dose fact sheet),
the Canadian Medical Protective Association’s guidance;
the College of Family Physicians of Canada’s preliminary guidance Authorizing Dried Cannabis for Chronic Pain or Anxiety; and
the Simplified guideline for prescribing medical cannabinoids in primary care, published in the Canadian Family Physician.
The CMA recommends that physicians should:
Ensure that there is no conflict of interest, such as direct or indirect economic interest in a licensed cannabis producer or be involved in dispensing cannabis;
Treat the authorization as an insured service, similar to a prescription, and not charge patients or the licensed producer for this service;
Until such time as there is compelling evidence of its efficacy and safety for specific indications, consider authorizing cannabis only after conventional therapies are proven ineffective in treating patients’ conditions;
Have the necessary clinical knowledge to authorize cannabis for medical purposes;
Only authorize in the context of an established patient-physician relationship;
Assess the patient’s medical history, conduct a physical examination and assess for the risk of addiction and diversion, using available clinical support tools and tests;
Engage in a consent discussion with patients which includes information about the known benefits and adverse health effects of cannabis in its various forms (e.g., edibles), including the risk of impairment to activities such as driving and work;
Advise the patient regarding harm reduction strategies and the prevention of accidental exposure for children and other people;
Document all consent discussions in patients' medical records;
Reassess the patient on a regular basis for its effectiveness to address the medical condition for which cannabis was authorized, as well as for addiction and diversion, to support maintenance, adjustment or discontinuation of treatment; and
Record the authorization of cannabis for medical purposes similar to when prescribing a controlled medication.
The Cannabis Regulations provide some consistency with many established provincial and territorial prescription monitoring programs for controlled substances. Licensed producers of cannabis for medical purposes are required to provide information to provincial and territorial medical licensing bodies upon request, including healthcare practitioner information, daily quantity of dried cannabis supported, period of use, date of document and basic patient information. The Minister of Health can also report physicians to their College should there be reasonable grounds that there has been a contravention of the Narcotic Control Regulations or the Cannabis Regulations.
Approved by CMA Board February 2015
Latest update approved by CMA Board in February 2020
COMPLEMENTARY AND ALTERNATIVE MEDICINE
This statement discusses the Canadian Medical Association's (CMA) position on complementary and alternative medicine (CAM). CAM, widely used in Canada, is increasingly being subject to regulation. The CMA's position is based on the fundamental premise that decisions about health care interventions used in Canada should be based on sound scientific evidence as to their safety, efficacy and effectiveness - the same standard by which physicians and all other elements of the health care system should be assessed. Patients deserve the highest standard of treatment available, and physicians, other health practitioners, manufacturers, regulators and researchers should all work toward this end. All elements of the health care system should "consider first the well-being of the patient."1 The ethical principle of non-maleficence obliges physicians to reduce their patient's risks of harm. Physicians must constantly strive to balance the potential benefits of an intervention against its potential side effects, harms or burdens. To help physicians meet this obligation, patients should inform their physician if the patient uses CAM.
CAM in Canada
CAM has been defined as "a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine."i This definition comprises a great many different, otherwise unrelated products, therapies and devices, with varying origins and levels of supporting scientific evidence. For the purpose of this analysis, the CMA divides CAM into four general categories:
* Diagnostic Tests: Provided by CAM practitioners. Unknown are the toxicity levels or the source of test material, e.g., purity. Clinical sensitivity, specificity, and predictive value should be evidence-based.
* Products: Herbal and other remedies are widely available over-the-counter at pharmacies and health food stores. In Canada these are regulated at the federal level under the term Natural Health Products.
* Interventions: Treatments such as spinal manipulation and electromagnetic field therapy may be offered by a variety of providers, regulated or otherwise.
* Practitioners: There are a large variety of practitioners whose fields include chiropractic, naturopathy, traditional Chinese and Ayurvedic medicine, and many others. Many are unregulated or regulated only in some provinces/territories of Canada.
Many Canadians have used, or are currently using, at least one CAM modality. A variety of reasons has been cited for CAM use, including: tradition; curiosity; distrust of mainstream medicine; and belief in the "holistic" concept of health which CAM practitioners and users believe they provide. For most Canadians the use is complementary (in addition to conventional medicine) rather than alternative (as a replacement). Many patients do not tell their physicians that they are using CAM.
Toward Evidence-Informed Health Care
Use of CAM carries risks, of which its users may be unaware. Indiscriminate use and undiscriminating acceptance of CAM could lead to misinformation, false expectations, and diversion from more appropriate care, as well as adverse health effects, some of them serious.
The CMA recommends that federal, provincial and territorial governments respond to the health care needs of Canadians by ensuring the provision of clinical care that continually incorporates evidence-informed technological advances in information, prevention, and diagnostic and therapeutic services.2 Physicians take seriously their duty to advocate for quality health care and help their patients choose the most beneficial interventions. Physicians strongly support the right of patients to make informed decisions about their medical care. However, the CMA's Code of Ethics requires physicians to recommend only those diagnostic and therapeutic procedures that they consider to be beneficial to the patient or to others.3 Until CAM interventions are supported by scientifically-valid evidence, physicians should not recommend them. Unless proven beneficial, CAM services should not be publicly funded. To help ensure that Canadians receive the highest-quality health care, the CMA recommends that CAM be subject to rigorous research on its effects, that it be strictly regulated, and that health professionals and the public have access to reliable, accurate, evidence-informed information on CAM products and therapies. Specific recommendations are provided below:
a) Research: Building an Evidence Base
To date, much of the public's information on CAM has been anecdotal, or founded on exaggerated claims of benefit based on few or low-quality studies. The CMA is committed to the principle that, before any new treatment is adopted and applied by the medical profession, it must first be rigorously tested and recognized as evidence-informed.4 Increasingly, good-quality, well-controlled studies are being conducted on CAM products and therapies. The CMA supports this development. Research into promising therapies is always welcome and should be encouraged, provided that it is subject to the same standards for proof and efficacy as those for conventional medical and pharmaceutical treatments. The knowledge thus obtained should be widely disseminated to health professionals and the public.
b) An Appropriate Regulatory Framework
Regulatory frameworks governing CAM, like those governing any health intervention, should enshrine the concept that therapies should have a proven benefit before being represented to Canadians as effective health treatments.
i) Natural Health Products. Natural health products are regulated at the federal level through the Natural Health Products Directorate of Health Canada.
The CMA believes that the principle of fairness must be applied to the regulatory process so that natural health products are treated fairly in comparison with other health products.5 The same regulatory standards should apply to both natural health products and pharmaceutical health products. These standards should be applied to natural health products regardless of whether a health claim is made for the product. This framework must facilitate the entry of products onto the market that are known to be safe and effective, and impede the entry of products that are not known to be safe and effective until they are better understood. It should also ensure high manufacturing standards to assure consumers of the products' safety, quality and purity. The CMA also recommends that a series of standards be developed for each natural health product. These standards should include:
* manufacturing processes that ensure the purity, safety and quality of the product;
* labelling standards that include standards for consumer advice, cautions and claims, and explanations for the safe use of the product to the consumer.6
The CMA recommends that safety and efficacy claims for natural health products be evaluated by an arm's length scientific panel, and claims for the therapeutic value of natural health products should be prohibited when the supportive evidence does not meet the evidentiary standard required of medications regulated by Health Canada.7 Claims of medical benefit should only be permitted when compelling scientific evidence of their safety and efficacy exists.8
The Canadian Medical Association advocates that foods fortified with "natural health" ingredients should be regulated as food products and not as natural health products
The CMA recommends that the regulatory system for natural health products be applied to post-marketing surveillance as well as pre-marketing regulatory review. Health Canada's MedEffect adverse reaction reporting system now collects safety reports on Natural Health Products. Consumers, health professionals and manufacturers are encouraged to report adverse reactions to Health Canada.
ii) CAM Practitioners. Regulation of CAM practitioners is at different stages. The CMA believes that this regulation should: ensure that the services CAM practitioners offer are truly efficacious; establish quality control mechanisms and appropriate standards of practice; and work to develop an evidence-informed body of competence that develops with evolving knowledge.
Just as the CMA believes that natural health products should be treated fairly in comparison with other health products, it recommends that CAM practitioners be held to the same standards as other health professionals. All CAM practitioners should develop Codes of Ethics that insure practitioners consider first the best interests of their patients.
Among other things, associations representing CAM practitioners should develop and adhere to conflict of interest guidelines that require their members to:
* Resist any influence or interference that could undermine their professional integrity;9
* Recognize and disclose conflicts of interest that arise in the course of their professional duties and activities, and resolve them in the best interests of patients;10
* Refrain, for the most part, from dispensing the products they prescribe. Engaging in both prescribing and dispensing , whether for financial benefit or not, constitutes a conflict of interest where the provider's own interests conflict with their duty to act in the best interests of the patient.
c) Information and Promotion
Canadians have the right to reliable, accurate information on CAM products and therapies to help ensure that the treatment choices they make are informed. The CMA recommends that governments, manufacturers, health care providers and other stakeholders work together to ensure that Canadians have access to this information. The CMA believes that all natural health products should be labeled so as to include a qualitative list of all ingredients. 11 Information on CAM should be user-friendly and easy to access, and should include:
* Instructions for use;
* Indications that the product or therapy has been convincingly proven to treat;
* Contraindications, side effects and interactions with other medications;
* Should advise the consumer to inform their health care provider during any encounter that they are using this product.12
This information should be provided in such a way as to minimize the impact of vested commercial interests on its content.
In general, brand-specific advertising is a less than optimal way of providing information about any health product or therapy. In view of our limited knowledge of their effectiveness and the risks they may contain risks, the advertising of health claims for natural health products should be severely restricted. The CMA recommends that health claims be promoted only if they have been established with sound scientific evidence. This restriction should apply not only to advertising, but also to all statements made in product or company Web sites and communications to distributors and the public. Advertisements should be pre-cleared to ensure that they contain no deceptive messages. Sanctions against deceptive advertising must be rigidly enforced, with Health Canada devoting adequate resources to monitor and correct misleading claims.
The CMA recommends that product labels include approved health claims, cautions and contraindications, instructions for the safe use of the product, and a recommendation that patients tell physicians that they are using the products. If no health claims are approved for a particular natural health product, the label should include a prominent notice that there is no evidence the product contributes to health or alleviates disease.
The Role of Health Professionals
Whether or not physicians and other health professionals support the use of CAM, it is important that they have access to reliable information on CAM products and therapies, so that they can discuss them with their patients.
Patients should be encouraged to report use of all health products, including natural health products, to health care providers during consultations. The CMA encourages Canadians to become educated about their own health and health care, and to appraise all health information critically.
The CMA will continue to advocate for evidence-informed assessment of all methods of health care in Canada, and for the provision of accurate, timely and reliable health information to Canadian health care providers and patients.
i Working definition used by the National Center for Complementary and Alternative Medicine of the U.S. National Institutes of Health.
1 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004.
2 Canadian Medical Association. Policy resolution GC00-196 - Clinical care to incorporate evidence-based technological advances. Ottawa (ON): The Association; 2000. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
3 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
4 Canadian Medical Association. CMA statement on emerging therapies [media release]. Ottawa (ON): The Association; 2010. Available: www.facturation.net/advocacy/emerging-therapies.
5 Canadian Medical Association. CMA statement on emerging therapies [media release]. Available: www.facturation.net/advocacy/emerging-therapies.
6 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa (ON): The Association; 1998.
7 Canadian Medical Association. Policy resolution GC08-86 - Natural health products. Ottawa (ON): The Association; 2008.
8 Canadian Medical Association. Policy resolution GC10-100 - Foods fortified with "natural health" ingredients. Ottawa (ON): The Association; 2010. Available:
9 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Paragraph 7. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
10 Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: The Association; 2004. Paragraph 11. Available: http://policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm.
11 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa: The Association; 1998.
12 Canadian Medical Association. Brief BR1998-02 - Regulatory framework for natural health products. Ottawa: The Association; 1998.
The harms associated with psychoactive prescription medicinesi including sedatives and tranquilizers1, stimulants2, and analgesics, particularly opioids3, such as oxycodone, hydromorphone and fentanyl, are a significant public health and patient safety issue.
Canada has one of the highest per capita consumption of prescription opioids in the world.4 Dispensing of medications has substantially increased in Canada, although patterns vary considerably between provinces.5 In 2011, while opioid consumption for medical purposes in morphine equivalence (ME)ii was 62mg per person globally, Canada's ME was 812mg per person.6 When comparing to other developed countries, Australia's ME was 427 and Denmark's 483. In North America, about 5% of the adult population, and substantially higher rates for teens and young adults, reported non-medical opioid use in the previous year. This rate is higher than all other illegal drugs, with the exception of marijuana.7
Psychoactive medications pose significant health and safety risks. The harms include overdoses, suicides, motor vehicle accidents, relationship and employment problems, workplace accidents and exposure to blood borne pathogens and other infections when used by injection, besides addiction.
Data are not collected systematically in Canada, making it difficult to assess the harms and track the trends and impact of the introduction of policy changes. However, practitioners have seen the significant impact of these prescription drugs on their patients and to public health. Studies in Ontario show that the number of people enrolled in methadone maintenance treatment rose from about 7,800 in 2001 to over 35,000 in 2011, where opioids have surpassed heroin as the drug used.8 Opioid-related deaths nearly tripled from 2002 to 2010, according to the Office of the Chief Coroner of Ontario.9 Another study showed that other non-opioid depressants (sedatives), such as benzodiazepines, were involved in 92% of the opioid-related deaths.10
The impact is felt particularly among vulnerable populations, such as youth, seniors, First Nations and those living in poverty. In 2013, opioids were reported as the third most common drug used by students in Ontario (after alcohol and marijuana).11 Opioid addiction rates anywhere from 43% to 85% have been reported in some Indigenous communities.12 13 While accurate data on the harms of prescription medication among seniors is lacking, it is well known that the prevalence of pain is higher among older adults and that they account for a significant proportion of prescriptions.
The "high" they produce also leads to these medications being sought after for recreational purposes and, as they are legal products, they are often more easily accessible than street drugs. Surveys with youth have shown that as much as 70% of opioids have been obtained from legitimate prescriptions to family and friends (55% were shared at no cost).14 As well, because opioids have high abuse liability and addiction potential, people have resorted to illegal behaviour to obtain them, such as doctor-shopping, forging prescribers' signatures, or buying from street dealers.
Of great concern, opioid dispensing levels are strongly correlated with increased mortality, morbidity and treatment admissions for substance use.15 16 Studies in Ontario and British Columbia have replicated similar findings in the US. Many patients were prescribed these medications and developed dependence.17
Psychoactive medications are important therapeutic tools and serve legitimate purposes, when prescribed in an appropriate manner with proper assessment, and as part of a comprehensive therapeutic strategy and monitoring. Medications, such as opioids, have been essential in areas such as palliative and cancer care and have contributed to the alleviation of suffering.
Since the 1990s, opioids have been recommended for longer-term treatment of chronic non-cancer pain, and have become widely used due in part to aggressive promotion and marketing for this indication.18 19 However, there is evidence for significant pain relief in the short term but a need for more evidence regarding maintenance of pain relief over longer periods of time, or for improved physical function.20 21 22
Important contributing factors for the increase in prescriptions are also the lack of supports and incentives for the treatment of complex cases, including availability and funding for treatment options for pain and addictions. Alternate approaches to pain management require more time with the patient. In addition, there are new highly potent opioid drugs available.23 24
Canada's physicians are deeply concerned about the harms of opioids and other psychoactive prescription medications. As prescribers, they have a fundamental role in helping to ensure safe and effective use of these drugs, and the deterrence of abuse. 25 26 27 Physicians assess patients and consider whether a prescription is clinically indicated according to best practices, as well as consider whether the benefits outweigh the risks, while screening for risk factors for substance dependence and diversion. This area can be a source of tension with patients who might seek to obtain drugs through fraudulent means.28 It is also an area which causes concern to many physicians, and this could be affecting access to adequate pain management where it is needed.29
The challenge for physicians and public policymakers is how to mitigate the harms of psychoactive prescription drug use, while ensuring that patients have access to the appropriate treatment for their clinical conditions.
Comprehensive National Strategy
Canada's physicians believe that this challenge requires a complex and multifaceted solution; and to further such a solution, the CMA recommends that Canada have a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based, complementing existing strategies to address the harms associated with the two legal drugs - alcohol and tobacco. This comprehensive approach is necessary, as isolated measures can have unintended consequences, such as under-medicating people that require a medical treatment or constraining people to seek illegal drugs as an option when medications are made tamper-resistant.
The federal government has created the National Advisory Council on Prescription Drug Misuse, co-chaired by the Canadian Centre on Substance Abuse, the Coalition on Prescription Drug Misuse (Alberta) and the Nova Scotia Department of Health and Wellness, in partnership with Health Canada's First Nations and Inuit Health Branch's Prescription Drug Abuse Coordinating Committee. In its 2013 report First Do No Harm: Responding to Canada's Prescription Drug Crisis30, there are nearly 60 recommendations toward the development of a strategy to combat the harms associated with psychoactive prescription medications. However, there is much still to be done.
The CMA supports collaborative efforts by the federal and provincial/territorial governments, and by health professionals and other stakeholders, to develop and implement a comprehensive national strategy. Such a strategy should include the following:
1. Improvement of Drug Safety
Health Canada, as the agency that approves prescription drugs for use and monitors their safety once on the market, has several levers by which it can control Canadians' access to drugs. One of these is the Controlled Drugs and Substances Act (CDSA) and its regulations, which govern access to illegal products and recently has included psychoactive prescription drugs.
Because of their health and safety risks, it is important that Health Canada ensures that the CDSA subjects psychoactive substances to high levels of regulatory scrutiny during both the approval process and post-approval surveillance. The Act should require manufacturers to:
* Meet stringent pre-approval requirements. For example, Health Canada could require intensive review of pre-approval clinical trial results and of product monographs by an expert impartial review committee (including addiction, pain and public health expertise); or require that the manufacturer fulfill special conditions, such as formal post-market studies, as a condition of the drugs' approval; or even require larger sample sizes or longer study periods to assess harms;
* Adhere to restrictions on the marketing of controlled medications to health professionals and the general public. The adequacy of regulations needs to be assessed in this regard.
* Develop and cover tamper-resistant formulations of psychoactive drugs of concern. Although not a standalone solution, tamper-resistant formulations can reduce the potential for manipulation to be able to use through snorting, chewing or intravenously.
2. Enhancement of Optimal Prescribing through Evidence-Based Guidance, Education and Support for Prescribers
CMA recommends that appropriate prescribing of psychoactive medications should be addressed through evidence-based guidance and education. A strategy to support optimal therapy might include:
* Support for models of care that allow a physician to spend time with complex patients.
* Ongoing development and dissemination of clinical guidance. The Canadian Guideline for Use of Opioids to Treat Chronic Non-Cancer Pain was published in the CMAJ in 2010. CMA has co-sponsored an online CME module based on this guideline. There is interest in similar guidelines for sedatives and stimulants.
* Evaluative research to support the critical review of guidelines periodically. It is essential to review data on chronic conditions for which risks might outweigh benefits.
* Relevant, unbiased and easily accessible information for prescribers, which can readily be incorporated into everyday practice. This should include clinical decision-support tools for use at the point of care, inclusive of dosing guidelines and guidance on when to seek consultation with experts. Physicians also require tools, including those that facilitate: monitoring of effectiveness and tolerance by tracking pain and physical function; screening for past and current substance use; screening for depression; tapering of problematic or ineffective doses; among others.
* Educational programs in optimal prescribing, pain management and in the management of addictions, as part of the curriculum in medical school, and residency training as well as in continuing education. Particular support is needed for those in primary care.
* Guidance for prescribers about how to deal with conflict in their practice. This would include guidance for patient-centred educational discussions on safe opiate prescribing and use and management of addictions.
* Access to expert advice if required through such means as:
o Policies or standards of practice developed by provincial regulatory colleges of physicians, which can include limitations on prescription volume, treatment period and indications.
o Communities of practice, knowledge hubs and clinical support networks that link practitioners with experts in the field, facilitating triage and supporting front line generalists. Experts can not only provide clinical information, but can provide mentorship and personal advice about best practices.
o Feedback to practitioners about their prescribing practices, particularly if potentially concerning patterns are identified. This initiative should be facilitated by collaborative work between health care professionals and their respective provincial regulatory colleges.
o Academic detailing programs, which use personalized, one-on-one techniques to deliver impartial prescribing information to practitioners.
3. Enhancement of Optimal Prescribing through Physician Regulation and Prescription Monitoring Programs
Medicine is a regulated profession, and the provincial colleges of physicians have ultimate authority and responsibility for the oversight of physician practice. The colleges have taken a leading role in educating their members about appropriate prescribing, in monitoring prescribing practices to ensure their appropriateness and taking disciplinary action when required, and through collaborating with law enforcement agencies to detect and halt criminal diversion.
The CMA recommends that federal and provincial regulations regarding controlled substances recognize the established authority of physician regulatory colleges for the oversight of the medical profession.
While prescription monitoring programs (PMPs) exist in most provinces, they vary considerably in terms of quality, the nature of the information they require, whether health care practitioners have real-time access, and the purpose for which the data are collected. Standardization of monitoring systems across Canada according to best practices can contribute to addressing the harms associated with psychoactive prescription medication by:
* Allowing health care practitioners to identify previous or concomitant prescriptions of controlled medications with more than one practitioner at the time the prescription is requested or filled;
* Deterring interprovincial or jurisdictional fraud, by allowing health care practitioners to identify other prescriptions at the time the prescription is requested or filled; and
* Improving professional regulatory bodies' capacity for oversight and intervention by establishing a mechanism for real-time monitoring.
The CMA recommends that all levels of government work with one another and with health professional regulatory agencies to develop a pan-Canadian system of real-time prescription monitoring. As a first step, the CMA recommends the establishment of consistent national standards for prescription monitoring.
PMPs should be compatible with existing electronic medical and pharmacy record systems and with provincial pharmaceutical databases. Participation in prescription monitoring programs should not impose an onerous administrative burden on health care providers. PMPs should not deter physicians from using controlled medications when necessary.
CMA also recommends that Health Canada ensure that its legislative framework be used to facilitate and support the advancement of e-health, specifically e-prescribing. Electronic health records can help individual physicians or pharmacists identify potential diversion and double prescriptions, at the point where a prescription is written or filled. The electronic health record also facilitates the sharing of information among health professionals, and could minimize the potential administrative burden.
PMPs should conform to privacy laws, protecting patient confidentiality while enabling the sharing of necessary information. The CMA strongly recommends that Health Canada undertake a privacy impact assessment of the regulatory framework for controlled prescription drugs, and share the results with stakeholders.
4. Increase in Access to Treatment for Pain
Chronic pain affects many aspects of a person's life including their ability to work, their emotional, mental and physical health, and their quality of life. Pain costs Canada an estimated $60 Billion dollars per year; more than the cost of heart disease, cancer and diabetes.31 CMA has endorsed a national strategy for pain, developed and proposed by the Canadian Pain Coalition and Canadian Pain Society,32 which addresses four target areas: awareness and education; access; research; and ongoing monitoring.
Experts believe that improved access to specialized pain treatment could reduce inappropriate use of pain medications. Current best practices in pain management include:
* Care by an interprofessional team that could include physiotherapists, occupational therapists, psychologists and other health professionals;
* Recommendation of non-pharmaceutical interventions such as therapy for trauma and social pain, social supports and coping strategies;
* Appropriate pharmaceutical prescription options, covered by provincial formularies; and
* A focus on patient participation and empowerment.
However, specialized pain treatment programs are in short supply. Wait times are greater than one year at more than one third of publicly funded inter-professional treatment programs.33 In many parts of Canada, particularly rural and remote areas, such programs are not available. In addition, while physician visits are covered by the public health care system, services provided by other health professionals are more likely to be either covered by private health benefits or paid out of pocket, and are therefore beyond the means of many Canadians. These factors may result in heavier reliance on prescription medication as treatment for chronic pain.
The CMA recommends that all partners work to improve and promote access to specialized treatment programs for pain management, and that investments be made in research about options for treatment.
5. Increase in Access to Treatment for Addiction
Access to addiction treatment is very limited and, when available, is primarily comprised of detox or the substitution treatments with methadone or Suboxone(r) (buprenorphine and naloxone). As addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry by definition, which manifests along biological, psychological, social and spiritual dimensions, treatment must address all those areas rather than just one or another.34
The CMA supports the enhancement of access to options for addiction treatment that address different needs. Treatment programs must be coordinated and patient-centred, and address physical, psychological, social and spiritual circumstances. For example, it is important that addiction programs be culturally relevant for Indigenous communities.
Treatment programs must also be integrated within the health care system and be adequately funded to meet evidence based, best-practice guidelines.
CMA also supports the development and dissemination of practice tools and guidelines to help physicians assess the addiction potential of a patient receiving psychoactive medications, and to assist in managing patients who have addiction and related problems and complications.
6. Increase in Information through Epidemiological Surveillance
One of the challenges in dealing with prescription drug abuse, which can reflect hazardous (episodic) use, harmful (regular) use or addiction, is the incompleteness of our knowledge of the extent of the problem. Countries, such as the US and France, are able to monitor psychoactive drug use, while in Canada we still rely on unsystematically collected or locally limited data. The creation of a national surveillance system that supports the collection of systematic, standardized information would:
* Permit the thorough assessment of the problem, with the development and monitoring of indicators;
* Support the early detection of diversion or inappropriate prescribing behaviour;
* Support the establishment of best practices to address crucial issues;
* Identify research priorities; and
* Evaluate the impact of the implementation of strategies.
Sources of information should include PMPs, coroner's investigations, emergency room admissions, and poison control data, among others.
7. Prevention of Deaths due to Overdose
Overdose deaths have increased dramatically over the past ten years. The risk of harm from overdose may be compounded if recreational users are afraid to call for emergency assistance for fear of facing criminal charges. Opioid death and complications overdoses can be prevented with appropriate medication and prompt emergency response. The CMA recommends the:
* Creation and scaling up of community-based programs that offer access to naloxone and other opioid overdose prevention tools and services. Training should be made available to health workers, first responders, as well as opioid users, families and peers about the prevention of overdose fatalities.35
* Improvement of access to naloxone to reverse opioid overdoses. This should include the prescription of naloxone to high risk individuals and third parties who can assist a victim experiencing an opiate-related overdose.
* Enactment of Good Samaritan laws by all levels of government in order to protect callers from criminal charges if they call emergency services to report an overdose. 36 37
8. Provision of Information for Patients and the Public
Awareness programs that provide accurate information to patients and the general public are important, and could include:
* Information on the benefits and harms of psychoactive prescription medication use, and signs of dependence and overdose. This should include the risk of dependence and addiction associated with the use of opiates for the treatment of acute and chronic pain.
* Messages aimed at the prevention of problematic drug use among young people and other populations at risk.
* Information regarding safe medication storage and disposal, and reducing access to medications from family and friends. CMA supports national prescription drug "drop off" days, and recommends that patients be educated about the importance of routinely returning unused prescription drugs to the pharmacy.
The CMA recommends that Canada have a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based. This strategy should include:
* That Health Canada require that manufacturers meet stringent pre-approval requirements, adhere to restrictions on the marketing of controlled medications to health professionals and the general public, and develop formulations of psychoactive drugs of concern that are tamper-resistant.
* Support for optimal prescribing through evidence-based guidance, education and supports, such as clinical guidance, clinical decision-support tools, educational programs, expert advice, and supportive models of care.
* The enhancement of optimal prescribing through physician regulation and the development of a pan-Canadian system of real-time prescription monitoring programs, compatible with electronic medical and pharmacy record systems, based on national standards.
* Increased access to specialized pain management and treatment, according to best practices, with investments in research.
* The enhancement of access to options for addiction treatment that address different needs, and the support for the development and dissemination of practice tools and guidelines.
* The creation of a national surveillance system that supports the collection of systematic, standardized information to better inform and track policy changes.
* The creation and scaling up of community-based programs that
* Offer access to opioid overdose prevention tools and services, including the improvement of access to medication to reverse opioid overdoses (naloxone) and the enactment of Good Samaritan laws by all levels of government.
* The provision of accurate information to patients and the general public, including safe medication storage and disposal.
i Psychoactive drugs are substances that, when taken, have the ability to change an individual's consciousness, mood or thinking processes (WHO, 2004). Psychoactive prescription drugs include sedatives (such as benzodiazepines and barbiturates), stimulants (such as amphetamines), and opioids (such as oxycodone, hydromorphone, morphine and fentanyl). [World Health Organization (2004) Neuroscience of psychoactive substance use and dependence. Available at: http://www.who.int/substance_abuse/publications/en/Neuroscience.pdf]
ii Comprises six main opioids: fentanyl, hydromorphone, methadone, morphine, oxycodone and pethidine.
1 Canadian Centre on Substance Abuse. Prescription sedatives and tranquilizers. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Prescription-Sedatives-and-Tranquilizers-2013-en.pdf
2 Canadian Centre on Substance Abuse. Prescription stimulants. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Prescription-Stimulants-2013-en.pdf
3 Canadian Centre on Substance Abuse. Prescription opioids. Canadian drug summary. Ottawa: The Centre; 2013. Available: http://ccsa.ca/Resource%20Library/CCSA-Canadian-Drug-Summary-Prescription-Opioids-2013-en.pdf
4 International Narcotics Control Board. Narcotics drugs: estimated world requirements for 2013; statistics for 2011. New York: United Nations; 2013.
5 Fischer B, Jones W, Murray K, et al. Differences and over-time changes in levels of prescription opioid analgesic dispensing from retail pharmacies in Canada, 2005-2010. Pharmacoepidemiol Drug Saf. 2011;20:1269-77.
6 United Nations Office on Drugs and Crime. World drug report 2014. New York: The Office; 2014. Available: www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf
7 Fischer B, Keates A, Buhringer G, et al. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction. 2013;109:177-81.
8 Fischer B, Argento E. Prescription opioid related misuse, harms, diversion and interventions in Canada: a review. Pain Physician. 2012;15:ES191-ES203.
9 National Advisory Council on Prescription Drug Misuse. First do no harm: responding to Canada's prescription drug crisis. Ottawa: Canadian Centre on Substance Abuse; 2013.
10 Dhalla IA, Mamdani MM, Sivilotti MLA, et al. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone CMAJ. 2009;181(12): 891-6.
11 Centre for Addiction and Mental Health. Drug use among Ontario students, 1977-2013: results of the Ontario Student Drug Use and Health Survey. Toronto: The Centre; 2013. Available: www.camh.ca/en/research/news_and_publications/ontario-student-drug-use-and-health-survey/Documents/2013%20OSDUHS%20Docs/2013OSDUHS_Highlights_DrugUseReport.pdf
12 Chiefs of Ontario. Prescription drug abuse strategy: 'Take a stand.' Final report. Toronto: Chiefs of Ontario; 2010. Available: www.chiefs-of-ontario.org/sites/default/files/files/Final%20Draft%20Prescription%20Drug%20Abuse%20Strategy.pdf
13 Health Canada. Honouring our strengths: a renewed framework to address substance use issues among First Nations people in Canada. Ottawa: Health Canada; 2011. Available: http://nnadaprenewal.ca/wp-content/uploads/2012/01/Honouring-Our-Strengths-2011_Eng1.pdf
14 US Department of Health and Human Services Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville (MD): The Department; 2011. p. 25. Available: www.oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.pdf
15 Gomes T, Juurlink DN, Moineddin R, et al. Geographical variation in opioid prescribing and opioid-related mortality in Ontario. Healthc Q. 2011;14(1):22-4.
16 Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005-2009. Pharmacoepidemiol Drug Saf. 2013;22(4):438-42.
17 Brands B, Blake J, Sproule B, et al. Prescription opioid abuse in patients presenting for methadone maintenance treatment. Drug Alcohol Depend. 2004;73(2):199-207.
18 Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142 DOI: 10.1136/bmj.d5142.
19 Manchikanti L, Atluri S, Hansen H, et al. Opioids in chronic noncancer pain: have we reached a boiling point yet? Pain Physician. 2014;17(1):E1-10.
20 Franklin GM. Opioids for chronic noncancer pain. A position paper of the American Academy of Neurology. Neurology. 2014;83:1277-84. Available: www.neurology.org/content/83/14/1277.full.pdf+html
21 Chou R, Ballantyne JC, Fanciullo GJ, et al. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10:147-59.
22 Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;(1):CD006605.
23 Fischer B, Goldman B, Rehm J, et al. Non-medical use of prescription opioids and public health in Canada. Can J Public Health. 2008;99(3): 182-4.
24 Fischer B, Keates A, Buhringer G, et al. Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world? Addiction. 2013;109:177-81.
25 Silversides A. Opioid prescribing challenges doctors. CMAJ. 2009;181(8):E143-E144.
26 Dhalla IA, Persaud N, Juurlink DN. Facing up to the prescription opioid crisis. BMJ. 2011;343:d5142.
27 Kirschner N, Ginsburg J, Sulmasy LS. Prescription drug abuse: a policy position paper from the American College of Physicians. Ann Intern Med. 2014;160:198-213.
28 Saveland C, Hawker L, Miedema B, et al. Abuse of family physicians by patients seeking controlled substances. Can Fam Physician. 2014;60:e131-6.
29 Wenghofer EF, Wilson L, Kahan M, et al. Survey of Ontario primary care physicians' experiences with opioid prescribing. Can Fam Physician. 2011;57(3):324-32.
30 National Advisory Council on Prescription Drug Misuse. First do no harm: responding to Canada's prescription drug crisis. Ottawa: Canadian Centre on Substance Abuse; 2013. Available: www.ccsa.ca/resource%20library/canada-strategy-prescription-drug-misuse-report-en.pdf
31 Canadian Pain Strategy Initiative. Rise up against pain: the Canadian Pain Strategy. Available: http://canadianpainstrategy.ca/en/home.aspx
32 Canadian Pain Coalition, Canadian Pain Society. Call to action: the need for a national pain strategy for Canada. 2011. Available: http://canadianpainstrategy.ca/media/11445/final%20nat%20pain%20strategy%20for%20can%20121511%20eng.pdf
33 Canadian Pain Coalition, Canadian Pain Society. Call to action: the need for a national pain strategy for Canada. 2011. Available: http://canadianpainstrategy.ca/media/11445/final%20nat%20pain%20strategy%20for%20can%20121511%20eng.pdf
34 American Society of Addiction Medicine. Public policy statement: definition of addiction. 2011. Available: www.asam.org/for-the-public/definition-of-addiction
35 Carter CI, Graham B. Opioid overdose prevention & response in Canada. Policy brief series. Vancouver: Canadian Drug Policy Coalition; 2013. Available: http://drugpolicy.ca/solutions/publications/opioid-overdose-prevention-and-response-in-canada/
36 Follett KM, Piscitelli A, Parkinson M, et al. Barriers to calling 9-1-1 during overdose emergencies in a Canadian context. Crit Social Work. 2014;15(1):18-28. Available: http://www1.uwindsor.ca/criticalsocialwork/system/files/Follett_Piscitelli_Parkinson_Munger_2014.pdf
37 Carter CI, Graham B. Opioid overdose prevention & response in Canada. Policy brief series. Vancouver: Canadian Drug Policy Coalition; 2013. Available: http://drugpolicy.ca/solutions/publications/opioid-overdose-prevention-and-response-in-canada/
PHYSICIAN RESOURCE PLANNING
The purpose of this policy statement is to identify the key elements required to properly undertake physician resource planning to support the delivery of appropriate medical care to all Canadians. A sustainable health care system requires effective physician resource planning and training that ensures an appropriate specialty mix that is responsive to population needs. CMA supports the need for the establishment of a coordinated national approach toward physician resource planning and an appropriately responsive undergraduate and postgraduate education system. CMA supports supply- and demand- projection models for health human resources using standardized approaches. National specialty societies should be actively engaged in physician resource planning for their respective discipline. Governments must work cooperatively with the medical profession to meet the needs of the population they serve in an affordable manner including funding the necessary infrastructure to support the appropriate number and mix of physicians.
1. Physician resource planning requires a pan-Canadian supply and needs-based projection model.
2. Infrastructure and resources as well as physician resources need to match the needs-based projection.
3. Strategies should be used throughout the undergraduate and postgraduate training system to address the current challenges matching physician resources to population needs.
4. Changing models of care delivery must be taken into consideration when developing physician resource projection models.
The purpose of this policy statement is to identify the key elements required to properly undertake physician resource planning to support the delivery of appropriate medical care to all Canadians.1
Ensuring an adequate supply of physician human resources is a major tenet of the Canadian Medical Association's (CMA) Health Care Transformation initiative.2 While the number of students enrolled in Canadian medical schools increased by over 60 percent between 2001-02 and 2011-12, some enrollment reductions are now occurring despite significant physician resource issues remaining, affecting patient care delivery across the country.
Currently, four to five million Canadians do not have a family physician. For older family physicians who may retire soon or wish to reduce their practice workload, there may be no colleagues able to take on new patients. Many new family physicians do not take on as large a roster of patients as those retiring. Even where overall supply has improved, recruiting and retaining physicians in underserved areas remains a challenge. Canada continues to license International Medical Graduates (IMGs) with 25% of practicing physicians receiving their medical degree from outside of the country3-the distribution of this group varies throughout Canada.
Physician disciplines in short supply vary by jurisdiction. Some new physicians (especially those dependent on hospital based resources) are finding it hard to secure employment in their discipline.4 Concern for the future has spread to postgraduate residents and medical students. Completing fellowships, to make physicians more marketable, are now commonplace. A major contributor to underemployment in some specialties is a lack of infrastructure and related human resources (e.g., operating room time, nursing care).
A sustainable health care system requires effective physician resource planning and training that ensures an appropriate specialty mix that is responsive to population needs. At present, there is no pan-Canadian system to monitor or manage the specialty mix. Few jurisdictions engage in formal health human resources planning and little cross-jurisdictional or pan-Canadian planning takes place. Currently, few Canadian jurisdictions have a long-term physician resource plan in place, particularly one that employs a supply and needs-based projection model. It has been almost four decades since the federal government has completed a needs-based projection of physician requirements in Canada.5
Physician resource planning must consider the population's health care needs over a longer term as the length of time to train a physician can be over a decade long depending on the specialty; this also means that practice opportunities can change during the period of training. The consequences of the lack of monitoring and management of the physician specialty mix can be long-lasting. A 2014 comparison of posted physician practice opportunities across Canada versus the number of post-graduate exits suggests a supply and demand mismatch for both family physicians (more positions posted than post-grad exits) and for medical and surgical specialists (more post-grad exits than available positions posted).6
Overall goal and considerations of physician resource planning
The overall goal of physician resource planning is to produce a self-sustaining workforce that will effectively serve the health needs of Canadians by providing an adequate supply of clinicians, teachers, researchers and administrators.
Physician resource planning should recognize the following considerations:
* Physicians in training have a dual role of learner and clinical care provider.7
* Shifts in service delivery can occur with the development of new technologies, the changing prevalence of some disease states, the emergence of new illnesses and shifting public expectations (see Appendix A: The impact of emerging health technologies and models of care on physician resource planning).
* Rural and remote communities possess unique challenges of not only attracting physicians but also in the nature of skills required to provide services.
* Physicians are required for services to patient populations who fall under federal jurisdiction including members of the Canadian Armed Forces, First Nations and Inuit, refugees and refugee claimants, veterans, and prisoners in federal penitentiaries; this includes consideration of how they are attracted and the skills they require.
* The full use of national medical services should be utilized instead of outsourcing to other countries. In instances where outsourcing of medical services occurs, Canadian training and certification standards must be met.
* The emphasis from governments and the public for 24/7 access to a wide scope of physician and health care services must be balanced with the possibility of more fragmented care from multiple physicians involved in the care of a single patient.
* There is a need for more clearly defined scopes of professional activity and optimal interactions among primary care physicians including family physicians who acquire enhanced/advanced skills to meet community needs, general specialists and subspecialists, particularly in the large urban areas where these three broad groups co-exist.
* It is also relevant to define the role and most appropriate interactions of physicians with other healthcare professionals, including but not limited to physician assistants, specially trained nurses, dieticians, therapists and pharmacists.
* The current shift to alternate payment plans and collaborative care models may, increase or decrease the non-clinical portion (e.g., research, teaching) of a physician's workload and thus increase the need for additional physicians.
* The scheduling for the provision of after-hours care can have an effect on the use of physician resources (See CMA's policy statement on Management of Physician Fatigue for more information).
* High tuition fees affect the social demographic mix of those seeking medical degrees while higher debt loads and the opportunity to practice in various models of care can influence specialty choice. 8 Similarly, advice from supervising faculty role models, negative/positive experiences during training, perceived lifestyle of the discipline, personal finances and earning potentials of medical disciplines all influence a medical student's specialty choice and in turn what health services will be available to future populations. Reliable and valid information on the current and future needs of the Canadian population can help trainees to make evidence-based decisions that allow them to select careers that match the needs of their patients.
* Patterns in the transition of retiring physicians' practices need to be identified.
It is essential to project not only the number of physicians but also some measure of their likely level of professional activity. Practice patterns may vary in response to changes in lifestyle among physicians, changing health technologies, group practices, interdisciplinary care models, and increased specialization of many generalist specialists and family physicians.
The academic sector must ensure the provision of high-quality undergraduate, postgraduate and continuing education programs, and remain internationally competitive in the recruitment and retention of a first-class teaching and research community.
Structured mentorship programs and formal career counseling should be a required component of all undergraduate and postgraduate curricula in Canada.9 Teaching institutions and postgraduate accreditation authorities need to recognize the risk in requiring students to make critical career choices before exploring all the options and should develop strategies to mitigate those risks, which may include tools for assessing aptitudes. Formal career counseling throughout medical education and training can boost employment success. Results of supply projection models should also be readily available to students and advisors so an informed choice can be made.
There is a need to ensure flexibility at the undergraduate, postgraduate, and re-entry levels of medical education, with the recognition that the requirements for specialist services may change. It also allows room for standardized transfers of residents between programs and locations and for the integration of international medical graduates (IMGs). CMA recommends that a ratio of 120 postgraduate training positions per 100 medical graduates be re-established and maintained. Canadians studying medicine abroad and other IMGs who are permanent residents or citizens of Canada must be explicitly factored into the planning for the capacity of the post-MD training system. CMA supports measures to facilitate the acculturation of IMGs.
The objective of seeking reasonable self-sufficiency for the full range of physician services must be paramount.10 Self-sufficiency is defined as ensuring that the annual output of the undergraduate and postgraduate sectors of Canadian medical schools meets the medical service needs of the Canadian public. This will reduce the need to attract physicians from countries that face a higher burden of disease whose requirements for physician services exceed those of Canada. It is important to facilitate the retention of physicians who train in the Canadian postgraduate system.
There must be adequate human and physical infrastructure to support physician training. An adequate supply of clinical educators is required to prevent training bottlenecks. Strategies that utilize untapped health infrastructure resources within and outside the academic community such as satellite or distributive medical education training sites should be considered for not only training reasons but for retention purposes as well.
Effectively matching supply to societal needs
Residency training positions should reflect current and emerging population needs and if possible, job availability at the national level. Mechanisms should be in place to assist medical training programs to adjust to changing health needs in a timely manner.
Physician resource planning can benefit from enhanced evaluation of community health needs, as established by thorough determinations of health status, epidemiological studies, input from communities and other needs assessments.
In recent years, attention has been given to augmenting the provision of care to properly respond to Canada's growing seniors' population. This will require an assessment of physician resource trends among specialties that focus on seniors' care including the capacity to deliver quality palliative end-of-life care throughout Canada.
To address geographic maldistribution, programs should train physicians in the wide spectrum of practice that is required for underserved communities-both rural and urban-as well as incorporate the involvement of the communities throughout the medical trainee life cycle. Programs to attract and retain physicians, including those from rural and underservice areas, need flexible incentives to address the professional and personal needs of physicians. Financial incentives, locum support, spousal employment, children's education and support from other specialists are key factors that need to be addressed. Also, the attraction and retention of physicians to underserved areas requires the presence of adequate technical equipment and personnel.
Exposure to patterns of community practice-including generalist training-outside large urban tertiary/quaternary centres may help attract individuals into specialties best suited for rural and regional centres. CMA encourages family physicians to maintain their skills in comprehensive family medicine, while supporting their choice to acquire additional skills that will better serve the needs of their community.
It is important to strive and budget for a critical mass of physicians required to deliver basic services to given populations to permit reasonable life-style management and the avoidance of professional isolation. Coercive measures that restrict physicians' choice of location and subsequent geographic mobility are not supported.
Concentrated efforts are needed to assist new graduates of Canadian residency programs and established physicians find optimal employment in their discipline within Canada. The issue of facilitating the mobility of physicians among provinces and territories (including locum work) requires dialogue with and cooperation from individual provincial and territorial licensing authorities.
CMA supports supply- and demand- projection models for health human resources using standardized approaches. Physician human resource plans should be reviewed on an ongoing basis, examining current supply and attrition patterns to determine if new policies are required or changes are needed to the undergraduate and postgraduate complement.
Collaborative approach to physician resource planning
Physician resource planning is complex, requiring the involvement of provincial/territorial medical associations, national specialty societies, the Royal Canadian Medical Service (Canadian Armed Forces), special medical interest groups, the medical education sector, the health care facilities sectors, governments, other health care professionals and other key stakeholders.
CMA is committed to promoting a collaborative and respectful interaction among all the disciplines within the medical profession and recognition of the unique contributions of each to an efficient, high-quality and cost-effective health care delivery system. Governments must work cooperatively with the medical profession to meet the needs of the population they serve in an affordable manner including funding the necessary infrastructure to support the appropriate number and mix of physicians. National specialty societies should be actively engaged in physician resource planning for their respective discipline.
CMA supports the establishment of a coordinated national approach toward physician resource planning and an appropriately responsive undergraduate and postgraduate education system. The recruitment and retention policies available at the provincial level can play a significant role in health human resources distribution and evolution. The federal government in conjunction with the provincial Deputy Ministers and Deans of Medicine, should continue to fund a pan-Canadian supply based planning model as laid out by the Physician Resource Planning Taskforce and extend its support to the second phase which is a comprehensive needs based planning model that will be accessible to governments and the profession.
Given the importance of a planned, open and professional approach to physician resource planning, the CMA encourages all stakeholders to permit researchers, policy planners and other relevant organizations access to their physician resources database at the national and jurisdictional level while protecting the privacy of individual physicians. The CMA will continue to seek input into the design and structure of any such national databases.
The impact of emerging health technologies and models of care on physician resource planning
As in the past, a number of technological developments11 will alter the future demand for medical services and how medicine is practiced. Examples of such technological developments include: health information technologies (HITs); technologies to support distance care and self-monitoring (e.g., telemedicine, implantable or wearable sensors); surgical robotics; advanced diagnostic testing; genomic technologies; integrated care teams; and new funding models. It is important to consider how these developments will affect future supply and training (i.e., skill sets) of physicians as part of physician resource planning.
There is little evidence about whether new technologies increase or reduce working hours.12 However, the adoption of new technologies can lead to new roles and opportunities for physicians as well as for other staff. New technologies can also lead to a greater role for patients in taking responsibility for their own health. There is extensive evidence that new technologies can improve the quality of patient care, especially when used in addition to existing care rather than as a substitution.13
A key factor in assessing the impact of new health technologies on physician resource planning is the rate of adoption and diffusion of new technologies. The rate can vary widely depending on an extensive range of factors including ease of use, safety, cost (both in terms of acquiring the technology and to train the clinician), compatibility and culture/attitudes. Not all new technologies are successfully adopted or lead to positive outcomes. Moreover, unlike other sectors, the adoption of health care technologies does not often lead to lower costs.14 The adoption can also be influenced by broader factors such as changing patient needs and the government's fiscal resources.
One key impact of emerging health technologies is a shift in the location where care is received. For instance, less invasive surgery will lead to greater use of community services for follow up care rather than in-hospital care. Likewise, the technologies can support the provision of more specialized services in small and remote communities by family physicians with the appropriate training and support.
Emerging health technologies can also impact the type of care provided. The literature suggests the impact will be felt more in sub-specialty areas with care shifting from one subspecialty to another.15 Advances in non-invasive surgical interventions will continue to drive practice convergence such as seen with cardiac related procedures.16
The accelerated use of HITs specifically could have the greatest overall impact on health human resources due to such factors as: the need for increased training to use HITs; and an increased need for health informatics specialists (both medical and non-medical).15 Automated knowledge work tools will almost certainly extend the powers of many types of workers and help drive top-line improvements with innovations and better decision making.17
The move to more collaborative care models, particularly in primary care, can be expected in the coming years. Common characteristics of these models include comprehensive chronic disease prevention, population-based services and programs, full use of electronic medical records, quality monitoring, dedicated time to team building and collaboration, and a wide range of health care providers functioning to their full scope of practice.18 Multi-disciplinary teams could also involve a wider range of providers such as IT specialists, bio-engineers and genetic counselors. While CMA has previously called for funding models to be in place to allow physicians and other health care providers to practice within the full scope of their professional activities,19 a significant issue will be how such collaborative care models can be funded by governments on a sustained basis.
Physicians and other health care providers need to be trained to effectively adopt any new technology. The literature is clear that physicians must be engaged in any discussions regarding new and current health technologies to ensure their proper assessment and successful implementation.20 Previously, CMA has called for:
* A flexible medical training system based on informed career choice to accommodate changes in medical practice and physician resource needs;
* A sufficient and stable supply of re-entry positions within the postgraduate training system to enable practicing physicians to enhance their skills or re-enter training in another discipline.21
* Recognition that scopes of practice must reflect these changes in societal needs (including the need of the public for access to services), societal expectations, and preferences of patients and the public for certain types of health care providers to fulfill particular roles and functions, while at the same time reflecting economic realities.22
1 This policy is to be used in conjunction with CMA's policy statements on Management of Physician Fatigue (2014), Flexibility in Medical Training (Update 2009), Physician Health and Well-Being (1998), Tuition Fee Escalation and Deregulation in Undergraduate Programs in Medicine (Update 2009), and Rural and Remote Practice Issues (1998).
2 Canadian Medical Association. Health Care Transformation in Canada. Change That Works, Care That Lasts. Ottawa: The Association; 2010. Available: http://www.hpclearinghouse.ca/pdf/HCT-2010report_en.pdf (accessed 2015 May 04).
3 Canadian Institute for Health Information. Physicians in Canada, 2013: Summary Report Ottawa: The Institute; 2013 Sep.
4 College of Family Physicians of Canda, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National Physician Survey 2013. Backgrounder. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2013/10/OFFICIAL-RELEASE_NPS-2013-Backgrounder_EN.pdf
5 The last federally commissioned study, the Report of the Requirements Committee on Physician Manpower to the National Committee on Physician Manpower, was published by the Minister of National Health and Welfare in 1975.
6 Research conducted by the Canadian Medical Association. Fall 2014.
7 National Steering Committee on Resident Duty Hours. Fatigue, risk and excellence: Towards a Pan-Canadian consensus on resident duty hours. Ottawa: Royal College of Physicians and Surgeons of Canada. 2013.
8 Canadian Medical Association. Tuition fee escalation and deregulation in undergraduate programs in medicine (update 2009). Ottawa" The Association; 2003 June. Available: http://policybase.cma.ca
9 The Canadian Association of Internes and Residents. CAIR Position Paper on Mentorship. June 2013. http://residentdoctors.ca/wp-content/uploads/2014/12/CAIR-Position-Paper-on-Mentorship_June-2013_en.pdf (accessed 2015 Apr 29).
10 Self-sufficiency is a key principle of the Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources' Framework for Collaborative Pan-Canadian Health Human Resources Planning. Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources. 2009. How Many Are Enough? Redefining Self-Sufficiency for the Health Workforce: A Discussion Paper. The policy is also consistent with the World Medical Association and the World Health Organization (The WHO Global Code of Practice of the International Recruitment of Health Personnel). http://www.who.int/hrh/migration/code/code_en.pdf?ua=1
11 Definition of Health Technologies (World Health Organization): "The application of organized knowledge and skills in the form of devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of lives."
12 Evidence Centre for Skills for Health, How do technologies impact on workforce organisation? Bristol (UK): The Centre. Available: www.skillsforhealth.org.uk/index.php?option=com_mtree&task=att_download&link_id=101&cf_id=24 (accessed 2015 Feb 02).
13 Evidence Centre for Skills for Health, How do technologies impact on workforce organisation? Bristol (UK): The Centre. Available: www.skillsforhealth.org.uk/index.php?option=com_mtree&task=att_download&link_id=101&cf_id=24 (accessed 2015 Feb 2)
14 Skinner J. "The costly paradox of health-care technology". MIT Technology Review. 2013 Sep 5.
15 Anvari M. Impact of information technology on human resources in healthcare. Healthcare Quarterly, 10(4) September 2007:84-88.
16 Social Sector Metrics Inc., Health Intelligence Inc. Physician resource planning: a recommended model and implementation framework. Final report submitted to the Nova Scotia Department of Health and Wellness. 2002 Jan 31. Available: www.doctorsns.com/site/media/DoctorsNS/PhysicianResourcePlanning-finalreport.pdf (accessed 2015 Feb 2).
17 McKinsey Global Institute, Disruptive technologies: Advances that will transform life, business, and the global economy. McKinsey & Company 2013.
18 Social Sector Metrics Inc., Health Intelligence Inc. Physician resource planning: a recommended model and implementation framework. Final report submitted to the Nova Scotia Department of Health and Wellness. 2002 Jan 31. Available: www.doctorsns.com/site/media/DoctorsNS/PhysicianResourcePlanning-finalreport.pdf (accessed 2015 Feb 02).
19 Canadian Medical Association. The Evolving Professional Relationship Between Canadian Physicians and Our Health Care System: Where Do We Stand? Ottawa: The Association; 2012
20 Steven A. Olson et al., Healthcare technology: Physician collaboration in reducing the surgical cost. Clinical Orthopaedics and Related Research. (2013) 471:1854-64.
21 Canadian Medical Association. Flexibility in Medical Training (update 2009) Ottawa: The Association; 2009.
22 Canadian Medical Association. Scopes of practice. Ottawa: The Association; 2002.