Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


4 records – page 1 of 1.

Guiding principles for physicians recommending mobile health applications to patients

https://policybase.cma.ca/en/permalink/policy11521
Date
2015-05-30
Topics
Health information and e-health
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Date
2015-05-30
Topics
Health information and e-health
Physician practice/ compensation/ forms
Text
GUIDING PRINCIPLES FOR PHYSICIANS RECOMMENDING MOBILE HEALTH APPLICATIONS TO PATIENTS This document is designed to provide basic information for physicians about how to assess a mobile health application for recommendation to a patient in the management of that patient's health, health care, and health care information. These guiding principles build on the Canadian Medical Association's (CMA) Physician Guidelines for Online Communication with Patients.1 Background * Mobile health applications, distinct from regulated medical devices, may be defined as an application on a mobile device that is intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. The functions of these applications may include: o The ability to store and track information about an individual or group's health or the social determinants thereof; o Periodic educational information, reminders, or motivational guidance; o GPS location information to direct or alert patients; o Standardized checklists or questionnaires.2 * Mobile health applications can enhance health outcomes while mitigating health care costs because of their potential to improve a patient's access to information and care providers.3 * Mobile health applications are most commonly used on a smart phone and/or tablet. Some may also interface with medical devices. * The use of mobile health applications reflects an emerging trend towards personalized medicine and patient involvement in the management of their health information. By 2016, 142 million health apps will have been downloaded.4 According to some industry estimates, by 2018, 50 percent of the more than 3.4 billion smartphone and tablet users worldwide will have downloaded at least one mobile health application.5 * While mobile health application downloads are increasing, there is little information about usage and adherence by patients. It is believed that many patients cease to use a mobile health application soon after downloading it. * Distributers of mobile health applications do not currently assess content provided by mobile health applications for accuracy, comprehensiveness, reliability, timeliness, or conformity to clinical practice guidelines.6 However, mobile applications may be subjected to certain standards to ensure critical technical requirements such as accessibility, reachability, adaptability, operational reliability, and universality. * Increasingly there are independent websites providing reviews of medical apps and checklists for health care professionals. However, the quality criteria used by these sites, potential conflicts of interest, and the scope and number of mobile apps assessed are not always declared by these groups. To date, randomized controlled trials are not usually employed to assess the effectiveness of mobile health applications. Some believe that the rigorousness of this type of assessment may impede the timeliness of a mobile health application's availability.7 * Some examples of the uses of mobile health applications include tracking fitness activities to supplement a healthy lifestyle; supported self-management of health and health information; post-procedure follow up; viewing of test results; and the virtualization of interaction between patients and providers, such as remote patient monitoring for chronic disease management. Some mobile health applications may be linked to a patient profile or patient portal associated with a professional or recognized association or medical society or health care organization. * Some mobile health applications may be an extension of an electronic medical records (EMR) platform. Guiding principles * The objective of recommending a mobile health application to a patient must be to enhance the safety and/or effectiveness of patient care or otherwise for the purpose of health promotion. * A mobile health application is one approach in health service delivery. Mobile health applications should complement, rather than replace, the relationship between a physician and patient. * No one mobile health application is appropriate for every patient. Physicians may wish to understand a patient's abilities, comfort level, access to technology, and the context of the application of care before recommending a mobile health application. * Should a physician recommend a mobile health application to a patient, it is the responsibility of the physician to do so in a way that adheres to legislation and regulation (if existing) and/or professional obligations. * If the mobile health application will be used to monitor the patient's condition in an ongoing manner, the physician may wish to discuss with the patient what they should watch for and the steps they should take in response to information provided. * Physicians are encouraged to share information about applications they have found effective with colleagues. * Physicians who require additional information about the competencies associated with eHealth and the use of health information technologies may wish to consult The Royal College of Physicians and Surgeons of Canada's (RCPSC) framework of medical competencies, CanMEDS.8 * Physicians may wish to enter into and document a consent discussion with their patient, which can include the electronic management of health information or information printed out from electronic management platforms like mobile health applications. This agreement may include a one-time conveyance of information and recommendations to cover the elements common to many mobile health applications, such as the general risk to privacy associated with storing health information on a mobile device. Characteristics of a safe and effective mobile health application A mobile health application does not need to have all of the following characteristics to be safe and effective. However, the more of the following characteristics a mobile health application has, the likelier it will be appropriate for recommendation to a patient: 1. Endorsement by a professional or recognized association or medical society or health care organization As recommended by the Canadian Medical Protective Association (CMPA), it is best to select mobile health applications that have been created or endorsed by a professional or recognized association or medical society.9 Some health care organizations, such as hospitals, may also develop or endorse applications for use in their clinical environments. There may also be mobile health applications associated with an EMR platform used by an organization or practice. Finally, some mobile health applications may have been subject to a peer review process distinct from endorsement by an association or organization. 2. Usability There are a number of usability factors than can complicate the use of mobile applications, including interface and design deficiencies, technological restrictions, and device and infrastructure malfunction. Many developers will release periodic updates and software patches to enhance the stability and usability of their applications. Therefore, it would be prudent for the physician recommending the mobile health application to also recommend to the patient that they determine if the application has been updated within the last year. Physicians considering recommending a mobile health application to a patient may wish to ask about the patient's level of comfort with mobile health technologies, their degree of computer literacy, whether or not the patient owns a mobile device capable of running the application, and whether or not the patient is able to bear potential one-time or ongoing costs associated with use of the application. Physicians may consider testing the application themselves beforehand to understand whether its functionality and interface make it easy to use. 3. Reliability of information Physicians considering recommending a mobile health application may wish to understand how the patient intends to use the information, and/or review the information with the patient to understand whether it is current and appropriate. Information presented by the mobile health application should be appropriately referenced and time-stamped with the last update by the application developer. 4. Privacy and security There are inherent security risks when a patient uses mobile health applications or enters sensitive information into their mobile device. Mobile devices can be stolen, and the terms of use for mobile health applications may include provisions for the sharing of information with the application developer and other third-parties, identified or un-identified, for commercial purposes. In 2014, the Officer of the Information and Privacy Commissioner of Alberta assessed approximately 1200 mobile applications and found nearly one-third of them required access to personal information beyond what should be required relative to their functionality and purpose, and that basic privacy information was not always made available.10 Physicians entering into and documenting a consent discussion with their patients may wish to include the electronic management of health information in the scope of these discussions, and make a notation of the discussion in the patient's health record. If physicians have not entered into and documented a general consent discussion, they may wish to indicate to the patient that there are security risks associated with mobile health applications, and recommend that the patient avail themselves of existing security features on their device. Physicians may wish to recommend to the patient that they determine whether a privacy policy has been made available which discloses how data is collected by the application and used by the developer, or a privacy impact assessment, which demonstrates the risks associated with the use of the application. Some mobile health applications may feature additional levels of authentication for use, such as an additional password or encryption protocols. If all other factors between applications are equal, physicians may wish to recommend that patients use mobile health applications adhering to this higher standard of security. 5. Avoids conflict-of-interest Physicians may wish to recommend that patients learn more about the company or organization responsible for the development of the application and their mandate. There is a risk of secondary gains by mobile health application developers and providers where information about patients and/or usage is gathered and sold to third parties. A standardized conflict of interest statement may be made available through the mobile health application or on the developer's website. If so, physicians may wish to refer the patient to this resource. Physicians who develop mobile applications for commercial gain or have a stake in those who develop applications for commercial gain may risk a complaint being made to the College on the basis that the physician engaged in unprofessional conduct if they recommend mobile health applications to their patients in the course of patient care. 6. Does not contribute to fragmentation of health information Some mobile health applications may link directly to an EMR, patient portal, or government data repository. These data resources may be standardized, linked, and cross-referenced. However, health information entered into an application may also be stored on a mobile device and/or the patient's home computer, or developers of mobile health applications may store information collected by their application separately. While there may be short-term benefits to using a particular mobile health application, the range of applications and developers may contribute to the overall fragmentation of health information. If all other factors between applications are considered equal, physicians may wish to recommend mobile health applications which contribute to robust existing data repositories, especially an existing EMR. 7. Demonstrates its impact on patient health outcomes While not all mobile health applications will have an appropriate scale of use and not all developers will have the capacity to collect and analyze data, physicians may wish to recommend mobile health applications that have undergone validation testing to demonstrate impact of use on patient health outcomes. If mobile health applications are claiming a direct therapeutic impact on patient populations, physicians may wish to recommend that their patients seek out or request resources to validate this claim. References 1 Canadian Medical Association. Physician guidelines for online communication with patients. Ottawa: The Association; 2005. Available: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD05-03.pdf?_ga=1.32127742.1313872127.1393248073 2 US Food and Drug Administration, Center for Devices and Radiological Health, Center for Biologics Evaluation and Research. Mobile medical applications: guidance for industry and Food and Drug Administration staff. Rockville (MD): The Administration; 2015. Available: www.fda.gov/downloads/MedicalDevices/.../UCM263366.pdf 3 Canada Health Infoway. Mobile health computing between clinicians and patients. White paper. Toronto: The Infoway; 2014 Apr. Available: www.infoway-inforoute.ca/index.php/resources/video-gallery/doc_download/2081-mobile-health-computing-between-clinicians-and-patients-white-paper-full-report 4 iHealthBeat. 44M mobile health apps will be downloaded in 2012, report predicts. Available: www.ihealthbeat.org/articles/2011/12/1/44m-mobile-health-apps-will-be-downloaded-in-2012-report-predicts 5 Jahns R-G. 500m people will be using healthcare mobile applications in 2015. Research2guidance. Available: www.research2guidance.com/500m-people-will -be-using-healthcare-mobile-applications-in-2015/ 6 Lyver, M. Standards: a call to action. Future Practice. 2013 Nov. Available: www.cma.ca/Assets/assets-library/document/en/about-us/FP-November2013-e.pdf 7 Rich P. Medical apps: current status. Future Practice 2013 Nov. Available: www.cma.ca/Assets/assets-library/document/en/about-us/FP-November2013-e.pdf 8 Royal College of Physicians and Surgeons of Canada. The CanMEDS 2015 eHealth Expert Working Group report. Ottawa: The College; 2014. Available: www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/ehealth_ewg_report_e.pdf 9 Canadian Medical Protective Association. Managing information to delivery safer care. Ottawa: The Association; 2013. Available: https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/managing-information-to-deliver-safer-care 10 Office of the Information and Privacy Commissioner of Alberta. Global privacy sweep rasies concerns about mobile apps [news release]. Available: www.oipc.ab.ca/downloads/documentloader.ashx?id=3482
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. Available: https://doi.org/10.1016/S0140-6736(09)61424-0 (accessed 2017 Oct 30). 7 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-6. Available: https://doi.org/10.1016/j.mayocp.2016.10.004 (accessed 2017 Oct 30). 8 Lemaire JB, Wallace JE. Burnout among doctors. BMJ 2017;358:j3360. 9 Tepper J, Champion C, Johnston T, Rodin D, White A, Bastrash M, et al. Medical student health and wellbeing. Ottawa: Canadian Federation of Medical Students (CFMS); 2015. 10 Dyrbye LN, Harper W, Durning SJ, Moutier C, Thomas MR, Massie FS, et al. Patterns of distress in US medical students. Med Teach 2011;33:834-9. Available: https://doi.org/10.3109/0142159X.2010.531158 (accessed 2017 Oct 30). 11 Canadian Federation of Medical Students (CFMS). CFMS-FMEQ national health and wellbeing survey - Student research position. International Conference on Physician Health; 2016 Sep 18-20; Boston. Ottawa: CFMS; 2016. 12 Maser B, Houlton R. CFMS-FMEQ national health and wellbeing survey: Prevalence and predictors of mental health in Canadian medical students. Canadian Conference on Physician Health; 2017 Sep 7-9; Ottawa. Ottawa: CFMS; 2017. 13 Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among US medical students. Ann of Intern Med 2008;149:334-41. Available: https://doi.org/10.7326/0003-4819-149-5-200809020-00008 (accessed 2017 Oct 30). 14 George S, Hanson J, Jackson JL. Physician, heal thyself: a qualitative study of physician health behaviors. Acad Psychiatry 2014;38:19-25. Available: https://doi.org/10.1007/s40596-013-0014-6 (accessed 2017 Oct 30). 15 Roman S, Prévost C. Physician health: state of knowledge and preventive approaches. Montreal: Programme d'aide aux médecins du Québec (PAMQ); 2015. Available: http://catalogue.cssslaval.qc.ca/GEIDEFile/Doc_224290_ang.pdf?Archive=102463592064&File=Doc_224290_Ang_pdf (accessed 2017 Oct 30). 16 West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-81. Available: https://doi.org/10.1016/S0140-6736(16)31279-X (accessed 2017 Oct 30). 17 Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med 2017 Sep 25 [epub ahead of print]. Available: https://doi.org/10.1001/jamainternmed.2017.4340 (accessed 2017 Oct 30). 18 Simon C, McFadden T, Canadian Medical Association (CMA). National Physician Health Survey: The Process, Preliminary Data, and Future Directions 2017. Canadian Conference on Physician Health; 2017 Sep 7-9; Ottawa. Ottawa: CMA; 2017. 19 Lefebvre LG, Kaufmann IM. The identification and management of substance use disorders in anesthesiologists. Can J Anaesth 2017;64:211-8. Available: https://doi.org/10.1007/s12630-016-0775-y (accessed 2017 Oct 30). 20 Albuquerque J, Deshauer D, Fergusson D, Doucette S, MacWilliam C, Kaufmann IM. Recurrence rates in Ontario physicians monitored for major depression and bipolar disorder. Can J Psychiatry 2009;54:777-82. Available: https://doi.org/10.1177/070674370905401108 (accessed 2017 Oct 30). 21 Brewster JM, Kaufmann IM, Hutchison S, MacWilliam C. Characteristics and outcomes of doctors in a substance dependence monitoring programme in Canada: prospective descriptive study. BMJ 2008;337:a2098. 22 Lemaire JB, Wallace JE, Sargious PM, Bacchus M, Zarnke K, Ward DR, et al. How attending physician preceptors negotiate their complex work environment: A collective ethnography. Acad Med 2017 Jun 20 [epub ahead of print]. Available: http://journals.lww.com/academicmedicine/Abstract/publishahead/How_Attending_Physician_Preceptors_Negotiate_Their.98194.aspx (accessed 2017 Oct 30). 23 Lemaire JB, Wallace JE. How physicians identify with predetermined personalities and links to perceived performance and wellness outcomes: a cross-sectional study. BMC Health Serv Res 2014;14:616. Available: https://doi.org/10.1186/s12913-014-0616-z (accessed 2017 Oct 30). 24 Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med 2003;114:513-9. 25 Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014;14:254. Available: https://doi.org/10.1186/1472-6963-14-254 (accessed 2017 Oct 30). 26 Andrew LB. Physician suicide: Overview, depression in physicians, problems with treating physician depression. New York: Medscape; 2017 Jun 12. Available: https://emedicine.medscape.com/article/806779-overview#a3 (accessed 2017 Oct 30). 27 Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med 2014;89:443-51. Available: https://doi.org/10.1097/ACM.0000000000000134 (accessed 2017 Oct 30). 28 de Oliveira GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesth Analg 2013;117:182-93. Available: https://doi.org/10.1213/ANE.0b013e3182917da9 (accessed 2017 Oct 30). 29 Shanafelt TD, Mungo M, Schmitgen J, Storz KA, Reeves D, Hayes SN, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc 2016;91:422-31. Available: https://doi.org/10.1016/j.mayocp.2016.02.001 (accessed 2017 Oct 30). 30 Kitson A, Marshall A, Bassett K, Zeitz K. What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. J Adv Nurs 2013;69:4-15. Available: https://doi.org/10.1111/j.1365-2648.2012.06064.x (accessed 2017 Oct 30). 31 Cameron D, Katch E, Anderson P, Furlong MA. Healthy doctors, healthy communities. J Ambul Care Manage 2004;27:328-38. 32 Lobelo F, de Quevedo IG. The evidence in support of physicians and health care providers as physical activity role models. Am J Lifestyle Med 2016;10:36-52. 33 Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995-1000. Available: https://doi.org/10.1097/SLA.0b013e3181bfdab3 (accessed 2017 Oct 30). 34 Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205. Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 35 Chenevert D, Tremblay MC. Analyse de l'efficacité des programmes d'aide aux employés : Le cas du PAMQ. Montreal: HEC Montreal; 2016. Available: http://www.professionsante.ca/files/2016/07/Rapport-Chenevert-VF.pdf (accessed 2017 Oct 30). 36 Morneau Shepell Ltd. Workplace mental health priorities report 2015. Toronto: Morneau Shepell Ltd.; 2015. Available: https://www.morneaushepell.com/ca-en/insights/workplace-mental-health-priorities-report (accessed 2017 Oct 30). 37 Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff (Millwood) 2010;29:304-11. Available: https://doi.org/10.1377/hlthaff.2009.0626 (accessed 2017 Oct 30). 38 Harrison J. Doctors' health and fitness to practise: The need for a bespoke model of assessment. Occup Med (Lond) 2008;58:323-7. Available: https://doi.org/10.1093/occmed/kqn079 (accessed 2017 Oct 30). 39 Wallace JE, Lemaire J. On physician well being-you'll get by with a little help from your friends. Soc Sci Med 2007;64:2565-77. Available: https://doi.org/10.1016/j.socscimed.2007.03.016 (accessed 2017 Oct 30). 40 Lesser CS, Lucey CR, Egener B, Braddock CH, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA 2010;304:2732-7. Available: https://doi.org/10.1001/jama.2010.1864 (accessed 2017 Oct 30). 41 Canadian Medical Association (CMA). CMA code of ethics. Ottawa: CMA; 2004. Available: https://www.cma.ca/Assets/assets-library/document/en/PD04-06-e.pdf (accessed 2017 Oct 30). 42 ePhysician Health. Primary care: Physician patient module. Ottawa: ePhysician Health; 2017. Available: http://ephysicianhealth.com/ (accessed 2017 Oct 30). 43 Sibbald B, Bojke C, Gravelle H. National survey of job satisfaction and retirement intentions among general practitioners in England. BMJ 2003;326:22. 44 Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T. Challenge of culture, conscience, and contract to general practitioners' care of their own health: qualitative study. BMJ 2001;323:728-31. 45 Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA 2010;304:1181-90. Available: https://doi.org/10.1001/jama.2010.1300 (accessed 2017 Oct 30). 46 DesRoches CM, Rao SR, Fromson JA, Birnbaum RJ, Iezzoni L, Vogeli C, et al. Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA 2010;304:187-93. Available: https://doi.org/10.1001/jama.2010.921 (accessed 2017 Oct 30). 47 Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum: what can we learn from third-year medical student narrative reflections? Acad Med 2010;85:1709-16. Available: https://doi.org/10.1097/ACM.0b013e3181f57899 (accessed 2017 Oct 30). 48 Dupont RL, Skipper GE. Six lessons from state physician health programs to promote long-term recovery. J Psychoactive Drugs 2012;44:72-8. Available: https://doi.org/10.1080/02791072.2012.660106 (accessed 2017 Oct 30). 49 Beaulieu M-D, Samson L, Rocher G, Rioux M, Boucher L, Del Grande C. Investigating the barriers to teaching family physicians' and specialists' collaboration in the training environment: a qualitative study. BMC Med Educ 2009;9:31. Available: https://doi.org/10.1186/1472-6920-9-31 (accessed 2017 Oct 30). 50 Van Ham I, Verhoeven AAH, Groenier KH, Groothoff JW, De Haan J. Job satisfaction among general practitioners: a systematic literature review. Eur J Gen Pract 2006;12:174-80. Available: https://doi.org/10.1080/13814780600994376 (accessed 2017 Oct 30). 51 Bahaziq W, Crosby E. Physician professional behaviour affects outcomes: a framework for teaching professionalism during anesthesia residency. Can J Anaesth 2011;58:1039-50. Available: https://doi.org/10.1007/s12630-011-9579-2 (accessed 2017 Oct 30). 52 Cydulka RK, Korte R. Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med 2008;51:714-722.e1. Available: https://doi.org/10.1016/j.annemergmed.2008.01.005 (accessed 2017 Oct 30). 53 Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: A cross-sectional qualitative study. Med Teach 2016;38:410-8. Available: https://doi.org/10.3109/0142159X.2015.1073241 (accessed 2017 Oct 30). 54 Case GA. Performance and the hidden curriculum in Medicine. Performance Research 2014;19:6-13. Available: https://doi.org/10.1080/13528165.2014.947120 (accessed 2017 Oct 30). 55 Schneider B, Barbera KM. The Oxford handbook of organizational climate and culture. Oxford: Oxford University Press; 2014. 56 Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The prevalence of medical student mistreatment and its association with burnout. Acad Med 2014;89:749-54. Available: https://doi.org/10.1097/ACM.0000000000000204 (accessed 2017 Oct 30). 57 Canadian Medical Protective Association (CMPA). Physician health: Putting yourself first. Ottawa: CMPA; 2015 Sep. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/physician-health-putting-yourself-first (accessed 2017 Oct 30). 58 Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med 2002;77:918-21. 59 Canadian Medical Foundation (CMF). A descriptive framework for physician health services in Canada: A report prepared by the tricoastal consortium for the Canadian Medical Foundation. Ottawa, CMF, 2016 May. Available: http://medicalfoundation.ca/wp-content/uploads/2016/09/7.b-TCC-Descriptive-Framework-Survey-Companion-FINAL-May-24-2016.pdf (accessed 2017 Oct 30). 60 Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med 2013;88:301-3. Available: https://doi.org/10.1097/ACM.0b013e318280cff0 (accessed 2017 Oct 30). 61 Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med 2013;88:382-9. Available: https://doi.org/10.1097/ACM.0b013e318281696b (accessed 2017 Oct 30). 62 Canadian Medical Association (CMA). CMA Baseline 2014: Overall findings report. Ottawa: CMA; 2014. 63 Ruotsalainen JH, Verbeek JH, Mariné A, Serra C, et al. Preventing occupational stress in healthcare workers. Sao Paulo Medical Journal 2016;134:92-92. Available: https://doi.org/10.1590/1516-3180.20161341T1 (accessed 2017 Oct 30). 64 Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: The way forward. JAMA 2017;317:901-2. Available: https://doi.org/10.1001/jama.2017.0076 (accessed 2017 Oct 30).
Documents
Less detail

Physician resource planning (updated 2015)

https://policybase.cma.ca/en/permalink/policy11533
Last Reviewed
2019-03-03
Date
2015-05-30
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2015-05-30
Replaces
Physician resource planning (Update 2003)
Topics
Health human resources
Text
PHYSICIAN RESOURCE PLANNING (Updated 2015) 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. Recommendations: 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. Introduction 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. Training 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. Appendix A: 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 References 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.
Documents
Less detail

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.
Documents
Less detail