Industrialization and manufacturing have had enormous positive benefits for humankind, but the consequences of hazardous by-products (chemical contamination) to human health and the environment are less well recognized. A major incident such as Bhopal is an unequivocal example of catastrophic poisoning caused by industry. However, more subtle human health impacts can result from low levels of exposure to chemical and industrial by-products from agriculture, consumer products, manufacturing, and even medical sources. Chemicals from industrial sources have been found in the soil, water, air, food and human tissue. Due to improving technology, even minuscule amounts of potentially noxious substances can be detected.
Some exposures warrant remedial action, but in others the health impact may be negligible: the toxin, dose, route and duration of exposure must be considered. Of course, there are potentially toxic substances that have been found to pose little or no harm to human health, but there are many more for which the health effects are unknown. A substantial knowledge gap exists in that the effects of many chemical agents have not been fully studied. As a result, rigorous surveillance and assessment to ensure potential health impacts are reduced or avoided is necessary. Chemicals like dichlorodiphenyltrichloroethane (DDT) can persist in the environment or in living beings long after the product was pulled from the market, making it essential that full and rigorous testing of new and existing chemicals is undertaken. Finally, research is needed to determine whether emerging issues, such as the presence of pharmaceuticals in drinking water, pose a legitimate threat to human health.
Chemicals, properly managed, can and will continue to provide enormous benefits to society, but caution is warranted because of the potential health consequences. Provided below is a discussion of certain classes of chemicals that need to be regulated, monitored and properly researched.
Agriculture represents the largest component of the global economy. Rising pressures to meet the needs of a growing population have resulted in the mechanization of farming, and the widespread use of fertilizers and pesticides.1 Fertilizer and pesticide run-off has been found in soil, water and the human food supply.2 Approximately 40 chemicals classified by the International Agency for Research on Cancer (IARC) as known, probable, or possible human carcinogens, are EPA registered pesticides available on the open market.3 Long-term low dose pesticide exposure has been linked to various cancers, immune suppression, hormonal disruption, reproductive abnormalities, birth defects, and developmental and behavioural problems.4 Certain pesticides are also known to be persistent in the human body.5 While many individual pesticides can be safely used, there is a lack of research on the effect of certain pesticides when used in combination.
Modern technologies have led to advances with a positive impact on the quality of human life. While newer consumer products have benefits over earlier materials, their use is not without side effects. Both the chemicals used to make these products and those that form key components of the products themselves may be harmful. Bisphenol A (BPA) is an industrial chemical added to many hard plastic bottles and to metal based food and beverage cans since the 1960s.6 In August 2010, Statistics Canada reported that measurable levels of BPA were found in the urine of 91 per cent of Canadians aged six to 79.7 Concerns have been raised about effects on the brain, behaviour, and prostate gland from exposure to this chemical, particularly in fetuses, infants, and children.8 In 2008, Canada banned BPA in infant bottles.9 In October 2010, Canada went a step further by becoming the first jurisdiction in the world to declare BPA toxic.10
With the growing demand for consumer products, there has been a corresponding growth in manufacturing. Manufacturing is one of the biggest contributors to outdoor air pollution, and contributes to soil and water pollution.11 In 2004, US industry released 1.8 billion pounds of potentially toxic chemicals. Exposure to some of these chemicals has been linked to severe health effects, including cancer. 12 One of the released chemicals, dioxin, can be harmful at very low levels. Dioxins accumulate in fats and break down slowly. This leads to contamination of the food supply, and human exposure through the consumption of meat, dairy, fish and shellfish.13 Even in the far north, animals have been found to contain dioxins.14 The EPA estimates that the cancer risk from dioxins already present in the general public is 1-per-1,000.15 In most cases the emissions pose minimal risk to human health. However, chemicals, and chemical combinations which remain unstudied should be properly assessed.16
Advancements in medical science and the use of pharmaceuticals, diagnostic equipment and other medical treatments have prolonged life expectancy. However, these interventions can also contribute to environmental contamination. In 2008, the Associated Press reported pharmaceuticals in the water of 24 major metropolitan areas in the United States, serving 41 million people.17 There is a concern that these pharmaceuticals could negatively impact male fertility, lead to birth defects, cause breast and testicular cancer in humans, and lead to antibiotic resistance.18 For many pharmaceuticals found in water sources, no concerted environmental impact surveys have been carried out.19
Mercury is used in fever thermometers, sphygmomanometers, gastrointestinal tubes, and oesophageal dilators20. Reports indicate that medical waste incinerators are among the largest sources of anthropogenic mercury emissions in both the United States and Canada.21 Medical waste, while not the principle source of mercury poisoning, contributes to the mercury levels present in the environment. In fetuses, infants and children, low-dose exposure to mercury can cause severe and lifelong behavioural and cognitive problems.22 At higher exposure levels, mercury may adversely affect the kidneys, the immune, neurological, respiratory, cardiovascular, gastrointestinal, and haematological systems of adults.23 It has also been linked to cancer.24
These examples highlight the major categories of human exposure to chemicals. As the review suggests, some of these chemicals have been linked to harmful human health impacts. What is important to keep in mind, however, is that the harm is conditional on the level and lengths of exposure. For most people, these chemicals pose no harm because the exposure is so low. In some cases, such as BPA, it has been determined that the potential harm is not worth the risk: the Canadian government has decided to declare BPA toxic and regulate it accordingly. In other cases, such as pharmaceuticals, the evidence simply warrants further study and surveillance. Given the potential harm to human health, surveillance and research are vitally important in all categories. The more information that is available to policy makers and health care professionals, the better the chance of limiting human health impacts.
What has been done?
Concerns regarding chemical contamination and human health have led to numerous interventions from the international community. These include the International Programme on Chemical Safety (1980), the Inter-Organization Programme for the Sound Management of Chemicals (1995), the Globally Harmonized System of Classification and Labelling (2002), and the Strategic Approach to International Chemicals Management, which was adopted by governments and stakeholders at the first International Conference on Chemicals held in Dubai in 2006. 25
Various conventions have also been passed, including the Stockholm Convention (2004) on persistent organic pollutants such as DDT, and the Rotterdam Convention (2004) which applies to pesticides and industrial chemicals.26 There is some concern about the continued effectiveness of the Rotterdam convention. In 2006, the Canadian government was instrumental in preventing the listing of asbestos as a toxic chemical. Given the persuasive evidence of the harm caused by asbestos, this action undermines the legitimacy of voluntary international conventions.27
In addition to being a signatory to all international agreements listed above, the Canadian government has programs for chemical management domestically. The main tool is the Canadian Environmental Protection Act (CEPA) 1999. Jointly administered by Environment Canada and Health Canada, it is intended to prevent pollution and address the potentially dangerous chemical substances to which Canadians are exposed.28 The plan calls for increased surveillance of certain chemicals to monitor exposure and health effects, and will increase focus on the management of the health and environmental risks of pharmaceuticals, personal care products, and chemical contamination in food.29
There were 23,000 chemical substances on the Domestic Substances List (DSL) in Canada in 1999. To date, only about 1,000 of these chemicals have been fully assessed. Of the remaining 22,000, 85% have been categorized as not requiring any additional action.30The most recent Canadian Chemicals Management Plan states that full assessments will be done on 550 substances identified as potentially harmful. Even with these additional assessments, more than 3,000 chemicals will not have been assessed.
Canadian Medical Association
In 2009, the Canadian Medical Association and the Canadian Nurses Association released a joint position statement on environmentally responsible activity for the health-care sector. Recommendations included the proper handling and disposal of toxic chemicals and the reduction of products using these substances. An adapted version of this position statement was then endorsed by a coalition of 12 national healthcare organizations and the David Suzuki Foundation.
In October 2010, the World Medical Association, of which CMA is a member, adopted a policy statement on environmental degradation and the management of chemicals. The statement calls for mercury-free health care, support for international efforts to restrict chemical pollution and to monitor harmful chemicals in humans and the environment, and mitigation of the health effects of toxic exposure to chemicals.
What needs to be done?
Research and Surveillance
Research on chemicals produced through man-made activities remains insufficient. While some of the more toxic chemicals have been reviewed and are now more closely regulated, thousands remain that have had neither health nor environmental assessments. The Domestic Substances List in Canada has 3,300 chemicals of concern that have not been assessed. There is limited research on the effect of these chemicals in combination or in different mediums. Finally, work must be done to ensure environmental and human surveillance of potential chemical exposure threats.
1. Urges the government to complete the health and environmental assessment of the chemicals on the Domestic Substances List.
2. Encourages research on the health impacts of chemical substances, as well as the combinations of these substances in different products (e.g. pesticides), and in different mediums (e.g. pharmaceuticals in drinking water). Long-term research programs are required to determine health impacts from prolonged low-dose exposures.
3. Encourages ongoing surveillance of chemicals in the environment.
4. Encourages ongoing research on the impact of regulations and monitoring of chemicals on human health and the environment.
Regulations have been developed both internationally and domestically to undertake chemical management. However, gaps remain, largely due to the voluntary nature of the frameworks. Canada can play a lead role by respecting its commitments, seeking continued adherence to these agreements and providing leadership in developing effective domestic programs and legislation.
5. Urges the government to continue to support international efforts to manage chemical pollution. In particular CMA urges the government to fully support the principles of the Rotterdam Convention and support the listing of Asbestos as an Annex III toxic chemical.
6. Supports government legislation and regulation which reduces dangerous chemical pollution, detects and monitors harmful chemicals in both humans and the environment, mitigates the health effects of toxic exposures, and requires an environmental and health impact assessment prior to the introduction of a new chemical. Regulatory frameworks should be favoured over voluntary frameworks in order to ensure a level playing field for all manufacturers and to secure rapid and equitable health protection for all Canadians. CMA encourages the government to advocate for similar legislation internationally.
Physicians can participate in the monitoring of patients for potential health effects from chemical exposure. Additionally, physicians can be leaders in encouraging greener health care practices. Finally, physicians can support national medical organizations in developing clinical tools to assess patient risk to chemical exposure.
7. Supports the phase out of mercury and other persistent, bio-accumulating and toxic chemicals in health care devices and products.
8. Supports the development of effective and safe systems to collect and dispose of pharmaceuticals that are not consumed.
9. Supports the development of clinical tools for physicians to help assess their patients' risk from chemical exposures.
Education and Professional Development
Physicians have a role to play in educating their patients, the public, and current and future colleagues about the potential human health consequences of chemical contamination. Medical education and continuing professional development in this area could have a significant impact on human health.
10. Should assist in building professional and public awareness of the impact of the environment and global chemical pollutants on personal health.
11. Supports the development of locally appropriate continuing medical education on the clinical signs, diagnosis and treatment of diseases that are introduced into communities as a result of chemical pollution.
12. Encourages physicians to inform patients about the importance of safe disposal of pharmaceuticals that are not consumed.
National and International initiatives have substantially reduced the incidence of harmful chemical contamination, but more work is needed. Evidence of health effects (or lack thereof) may be strong for certain chemicals, but for others it remains incomplete. Given the dangers of chemicals such as dioxin, which can cause severe effects with small doses, more comprehensive research is warranted. To ensure human health consequences are identified and risks are minimized, improved surveillance is essential.
Further policies and regulations are needed to ensure that chemicals utilized are as safe as possible. The Canadian BPA ban demonstrates the use of the precautionary principle in the presence of convincing if not complete evidence. While there are clear benefits associated with the use of chemicals, it is necessary to ensure that potential harmful effects are considered.'
Finally, public and health care provider information is sorely lacking. Physicians can play a role in correcting some of these deficiencies through their actions to support research and surveillance, advocacy, leadership, education, and professional development.
1 Ongley, Edwin D. (1996) Control of water pollution from agriculture- FAO irrigation and drainage paper 55.Chapter 1: Introduction to agricultural water pollution Food and Agriculture Organization of the United Nations. Available at: http://www.fao.org/docrep/w2598e/w2598e00.HTM
2 Peters, Ruud J.B. (2006) Man-Made Chemicals in Food Products. TNO Built Environment and Geosciences. Available at: http://assets.panda.org/downloads/tno_report.pdf
3 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk: What We Can Do Now: 2008-2009 Annual Report. President's Cancer Panel. Available at: http://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf
4 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk...; Shah, Binod P. & Bhupendra Devkota (2009) "Obsolete Pesticides: Their Environmental and Human Health Hazards." The Journal of Agriculture and Environment. Vol:10 June 2009. Available at: http://www.nepjol.info/index.php/AEJ/article/view/2130/1961 ; Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution: Burden and Strategies for Control in Disease Control Priorities in Developing Countries. Disease Control Priorities Project. Available at: http://files.dcp2.org/pdf/DCP/DCP43.pdf
5 California Environmental Protection Agency (2002) Environmental Protection Indicators for California: Chapter 3: Environmental Exposure Impacts Upon Human Health. Available at: http://oehha.ca.gov/multimedia/epic/2002reptpdf/Chapter3-7of8-HumanHealth.pdf
6 United States Food and Drug Administration (2010) Update on Bisphenol A for Use in Food Contact Applications. Available at: http://www.fda.gov/newsevents/publichealthfocus/ucm064437.htm
7 CBC News (October 13, 2010) BPA declared toxic by Canada. Available at: http://www.cbc.ca/health/story/2010/10/13/bpa-toxic.html
8 States Food and Drug Administration (2010) Update on Bisphenol A...
9 Health Canada (2008) Government of Canada Protects Families with Bisphenol A Regulations Available at: http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2008/2008_167-eng.php
10 CBC News (October 13, 2010) BPA declared toxic by Canada...
11 Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution...
12 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health: An Analysis of Toxic Chemicals Released in Communities across the United States. U.S. PIRG Education Fund. Available at: http://cdn.publicinterestnetwork.org/assets/KTfes5EXnCLOgG9eWTKU6g/ToxicPollutionandHealth2007.pdf
13 World Health Organization (2010) Dioxins and their effects on human health. Available at: http://www.who.int/mediacentre/factsheets/fs225/en/index.html
14 Woolford, Julian & Noemi Cano Ed. (2006) Killing them softly...
15 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health...
17 Natural Resources Defense Council (2010) Dosed Without Prescription: Preventing Pharmaceutical Contamination of Our Nation's Drinking Water. Available at: http://www.nrdc.org/health/files/dosed4pgr.pdf
18 Wright-Walters, Maxine & Conrad Volz (2009) Municipal Wastewater Concentrations of Pharmaceutical and Xeno-Estrogens: Wildlife and Human Health Implications. Available at: http://www.chec.pitt.edu/Exposure_concentration_of_Xenoestrogen_in_pharmaceutical_and_Municipal_Wastewater__Final8-28-07%5B1%5D.pdf; Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment. Available at: www.epa.gov/osp/regions/emerpoll/daughton.ppt; Nikolaou, Anastasia; Meric, Sureyya & Despo Fatta (2007) "Occurrence patterns of pharmaceuticals in water and wastewater environments." Analytical and Bioanalytical Chemistry. 387: 1225-1234; Natural Resources Defense Council (2010) Dosed Without Prescription...
19 Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment...
20 Environment Canada. (N.D.)Mercury and the Environment. Available at: http://www.ec.gc.ca/MERCURY/SM/EN/sm-mcp.cfm#MD
21 Health Care Without Harm (2007) The Global Movement for Mercury Free Health Care. Available at: http://www.noharm.org/lib/downloads/mercury/Global_Mvmt_Mercury-Free.pdf; World Health Organization (2005) Mercury in Health Care: Policy Paper. Available at: http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpaper.pdf
22 Environmental Working Group (N.D.) Chemical Pollution: The Toll on America's Health. Available at: http://www.ewg.org/files/EWG-kid-safe-toll-on-health.pdf
23 California Environmental Protection Agency (2002) Environmental Protection Indicators...
24 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk...
25 World Health Organization (N.D.) International Programme on Chemical Safety: About us. Available at: http://www.who.int/ipcs/en/; World Health Organization (N.D.) Inter-Organization Programme for the Sound Management of Chemicals. Available at: http://www.who.int/iomc/brochure/brochure_english.pdf; United Nations Economic Commission for Europe (N.D.) Globally Harmonized System of Classification and Labelling of Chemicals (GHS). Available at: http://www.unece.org/trans/danger/publi/ghs/ghs_welcome_e.html; Weinberg, Jack (2008) An NGO Guide to SAICM: The Strategic Approach to International Chemicals Management. Available at: http://www.ipen.org/ipenweb/documents/book/saicm%20introduction%20english.pdf
26 Eskenazi, Brenda et.al. (2009) "The Pine River Statement: Human Health Consequences of DDT Use." Environmental Health Perspectives. 117:1359-1367 Available at: http://www.eoearth.org/article/Human_Health_Consequences_of_DDT_Use#gen4; World Health Organization (N.D.) Rotterdam Convention: Share Responsibility. Available at: http://www.pic.int/home.php?type=t&id=5&sid=16
27 Kazan-Allen, Laurie (2007) Rotterdam Treaty Killed by Chrysotile Asbestos! International Ban Asbestos Secretariat. Available at: http://www.ibasecretariat.org/lka_rott_meet_geneva_oct_06.php
28 Government of Canada (2007) The Canadian Environmental Protection Act, 1999 (CEPA 1999). Available at: http://www.chemicalsubstanceschimiques.gc.ca/about-apropos/cepa-lcpe-eng.php
29 Government of Canada (2010) Chemicals Management Plan. Available at: http://www.chemicalsubstanceschimiques.gc.ca/plan/index-eng.php
The Canadian Medical Association and the Canadian Nurses Association put forward the following principles to guide the transformation of the health care system in Canada toward one that is sustainable and adequately resourced, and provides universal access to quality, patient-centred care delivered along the full continuum of care in a timely and cost-effective manner. Such a system promotes health, effectively manages illness and focuses on outcomes, thereby contributing to a country's social and economic development and well-being.1
Canada's health care system is in need of transformation to better meet the health needs of Canadians. First, while it is recognized that elements of transformation are already taking place across the country, it is important that regional or jurisdictional change be guided by a common framework. Second, health care transformation must build on the five principles of the Canada Health Act (universality, accessibility, portability, comprehensiveness and public administration) that currently apply only to hospital and physician services. Moving beyond these services, a common set of principles is required to guide a national transformation toward a more effective and comprehensive medicare system. A transformed Canadian health care system demands national standards for service quality and outcomes, for which both federal and provincial/territorial governments share responsibility.
The principles below have been organized according to the Institute for Healthcare Improvement's (IHI) Triple Aim Framework, which describes the three goals of "better care for individuals, better health for populations and lower per capita costs."2 It has been IHI's experience that all three must be addressed; where organizations address only one or two, results may be achieved to the detriment of the other(s).
ENHANCE THE HEALTH CARE EXPERIENCE
The patient must be at the centre of health care. Patient-centred care is seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity.3 Improving the patient experience and the health of Canadians must be at the heart of any reforms.
A strong primary health care foundation as well as collaboration and communication within and between health professional disciplines along the continuum are essential to achieving patient-centred care.
Canadians deserve quality services that are appropriate for patient needs, respect individual choice and are delivered in a manner that is timely, safe, effective and according to the most currently available scientific knowledge. Services should also be provided in a manner that ensures continuity of care. Quality must encompass both the processes and the outcomes of care. More attention needs to be given to ensuring a system-wide approach to quality.
IMPROVE POPULATION HEALTH
HEALTH PROMOTION AND ILLNESS PREVENTION
The health system must support Canadians in the prevention of illness and the enhancement of their well-being. The broader social determinants of health (e.g., income, education level, housing, employment status) affect the ability of individuals to assume personal responsibility for adopting and maintaining healthy lifestyles and minimizing exposure to avoidable health risks. Coordinated investments in health promotion and disease prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system. This is a responsibility that must be shared among health care providers, governments and patients, who must be actively engaged in optimizing their health and be involved in decisions that affect their overall health.
The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and multi-sectoral policies to address the social determinants of health.4 In all societies, good health is directly related to the socio-economic gradient - the lower a person's social position, the worse his or her health. The relationship is so strong that it is measurable within any single socio-economic group, even the most privileged.
It is due to the sum of all parts of inequity in society - material circumstances, the social environment, behaviour, biology and psychosocial factors, all of which are shaped by the social determinants of health.5
Some health inequities are preventable; failure to address them will result in poorer health and higher health care costs than necessary. Improved health literacy (defined as the ability to access, understand and act on information for health) would help to mitigate these inequalities.
IMPROVE VALUE FOR MONEY
Sustainable health care requires universal access to quality health services that are adequately resourced and delivered along the full continuum in a timely and cost-effective manner. Canada's health care system must be sustainable in the following areas:
* Resourcing: Health services must be properly resourced based upon population needs, with appropriate consideration for the principles of interprovincial and intergenerational equity and pan-Canadian comparability of coverage for and access to appropriate health services.
- Financing: The health care system needs predictability, certainty and transparency of funding within the multi-year fiscal realities of taxpayers and governments, and funding options that promote risk-pooling, inter-provincial and inter-generational equity and administrative simplicity.
- Health human resources: Health care will be delivered within collaborative practice models; pan-Canadian standards/licensure will support inter-provincial portability of all health care providers; health human resource planning will adjust for local needs and conditions.
- Infrastructure: Health care in the 21st century demands a fully functional health care information technology system as well as buildings and capital equipment.
* Research: Health research in Canada will inform adjustments to health service delivery and to the resourcing of health services.
* Measuring and reporting: Outcome data are linked to cost data; comparable and meaningful performance measures are developed and publicly reported; outcomes are benchmarked to high-performing, comparable jurisdictions.
* Public support: The health care system must earn the support and confidence of the users and citizens of Canada, who ultimately pay for the system.
All stakeholders - the public/patients/families, providers and funders - have a responsibility for ensuring the system is effective and accountable. This includes:
* Good governance: Clear roles, lines of authority and responsibilities are necessary for the funding, regulation and delivery of health care services, even where these may be shared between levels of government and among health care providers. Patients, families and providers must be partners in the governance of the system.
* Responsible use: Services should be funded, offered and used responsibly.
* Strong public reporting: Timely, transparent reporting at the system level on both processes and outcomes that can be used and understood by stakeholders and the public are necessary.
* Enforceability and redress: Mechanisms are in place to enforce accountability and provide redress when the system does not fulfill its obligations.
* Leadership/stewardship: Long-term strategic planning and monitoring is necessary to ensure the system will be sustainable.
* Responsive/innovative: The system is able to adapt based on reporting results.
APPLICATION OF PRINCIPLES AND NEXT STEPS
Over the next several months, a number of health care initiatives will be considered at both the provincial/territorial and federal levels. This will include discussions aimed at signing a new health care accord between the federal government and the provinces/territories. Any such agreements or initiatives must be consistent with the principles set out in this document.
Approved by the CMA and CNA Boards of Directors, June 2011
1 World Health Organization. Regional Office for Europe. The Tallinn Charter: Health systems for health and wealth. Copenhagen, Denmark, 2008. http://www.euro.who.int/__data/assets/pdf_file/0008/88613/E91438.pdf.
2 See http://www.ihi.org/IHI/Programs/StrategicInitiatives/IHITripleAim.htm.
3 Canadian Medical Association. Health care transformation in Canada: Change that works. Care that lasts. Ottawa, 2010. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/HCT/HCT-2010report_en.pdf.
4 Canadian Nurses Association. Social justice: A means to an end; an end in itself. Ottawa, 2010.
5 The Marmot Review. Fair Society, Healthy Lives, February, 2010. http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf.
The Role of Health Professionals in Tobacco Cessation - Joint position statement
This statement was developed cooperatively by the Canadian Association of Occupational Therapists, Canadian Counselling and Psychotherapy Association, Canadain Dental Hygienists Association, Canadian Medical Association, Canadian Nurses Association, and Canadian Physiotherapy Association.
There is a role for every Canadian health professional in tobacco-use cessation.1 Tobacco use2 inflicts a heavy burden on Canadians' health and on the Canadian health-care system, and health professionals can advocate effectively for tobacco-use cessation at the clinical and public health levels.
As providers of client and patient-centered services, health professionals are involved in tobacco cessation by:
* assessing and documenting all forms of tobacco use, willingness to quit and risk of exposure to second-hand smoke;
* discussing with clients and patients the negative health effects of tobacco use and exposure to second-hand smoke, and the health and other benefits (e.g., financial) of becoming tobacco free;
* offering to help, and helping, tobacco users to quit;
* offering a variety of tobacco-cessation strategies (e.g., counselling, behavioural therapy, self-help materials, pharmacotherapy) as appropriate to their knowledge, skills and tools;
* providing strategies for non-smokers to help them reduce their exposure to second-hand smoke;
* being knowledgeable about and providing referrals to community-based initiatives and resources;
* recognizing that relapse occurs frequently, and conducting follow-up assessment and intervention;
* tailoring interventions to the needs of specific populations (e.g., age, gender, ethnicity, diagnosis, socio-economic status); and
* using a collaborative, multidisciplinary approach.
As educators and researchers, health professionals are involved in tobacco cessation by:
* including education on tobacco-cessation strategies and strategies for resisting tobacco use in basic education programs for health professionals;
* providing professional development programs for health professionals on tobacco cessation;
* conducting research to encourage and improve health professionals' knowledge and provision of tobacco cessation; and
* communicating research evidence about tobacco-cessation strategies.
As administrators of health-care organizations, health professionals are involved in tobacco cessation by:
* offering training on tobacco cessation as part of employee orientation;
* providing access to professional education on tobacco cessation for employees;
* enforcing applicable bans on tobacco wherever health professionals are employed (e.g., health-care facilities, private homes); and
* ensuring that tobacco-cessation programs and tobacco-free workplaces are included in accreditation standards.
As public health advocates, health professionals are involved in tobacco cessation by:
* increasing public awareness that health professionals can help people remain tobacco free or stop using tobacco; and
* advocating for federal, provincial and territorial governments' investment in comprehensive tobacco control that includes programs, legislation and policies to prevent the uptake of tobacco and reduce tobacco use (e.g., bans on tobacco advertising). Programs must focus on health promotion and include community-based initiatives.
Tobacco is an addictive and harmful product, and its use is the leading cause of preventable death in Canada.3 Each year in Canada, more than 37,000 people die prematurely due to tobacco use.4 Approximately 17 per cent of the population 15 years of age and older (about 4.8 million Canadians) smoke.5 Strong evidence has revealed that smoking is associated with more than two dozen diseases and conditions.6 The economic costs of tobacco use are estimated at $17 billion annually ($4.4 billion in direct health-care costs and $12.5 billion in indirect costs such as lost productivity).7
Second-hand smoke is also harmful. Each year, more than 1,000 non-smoking Canadians die due to second-hand smoke.8 Exposure to second-hand smoke is the number two cause of lung cancer (smoking is the number one cause).9 Second-hand smoke can also aggravate allergies, bring about asthma attacks and increase the risk of bronchitis and pneumonia.10 Research also suggests that there may be a link between second-hand smoke and the risk of breast cancer.11
Tobacco use is the result of the complex interaction of individual and social factors, such as socio-economic status, having family members who smoke and exposure to marketing tactics of the tobacco industry. Reduction and elimination of tobacco use requires comprehensive, multi-faceted strategies addressing both physical dependence and social context. Such strategies will include:
* prevention - helping to keep non-users from starting to use tobacco;
* cessation - helping current smokers to quit, and helping prevent relapse; and
* protection - protecting all Canadians from the harmful effects of tobacco use and from the influences of tobacco industry marketing.
Prevention is the most important strategy of the three; being tobacco-free is a vital element of a healthy active life. Thus, for current tobacco users, quitting is the single most effective action they can take to enhance the quality and length of their lives.
Most tobacco users would like to improve their health, and in a Canadian survey 30 per cent of all smokers stated that they intended to quit as means of doing so.12 Indeed, in studies in Canada, the U.K. and Germany, smokers rated health concerns and current health problems as the primary reason for wanting to quit;13 other reasons why smokers quit include the cost of cigarettes14 and persistent advice to quit from family15 and health professionals.16 However, the relapse rate is very high because of the addictive nature of tobacco.17 Most smokers attempt to quit several times before they finally succeed.
Smoking cessation counselling is widely recognized as an effective clinical strategy. Even a brief intervention by a health professional significantly increases the cessation rate.18 Furthermore, counselling programs that initiate follow-up calls to smokers as a "proactive" measure have been found to increase smoking-cessation rates by 50 per cent.19 The majority of Canadians consult a health professional at least once a year,20 creating several "teachable moments" when they may be more motivated than usual to change unhealthy behaviours.21 A smoker's likelihood of quitting increases when he or she hears the message from a number of health-care providers from a variety of disciplines.22
However, health professionals encounter barriers that require solutions, notably:
- the need for better education for health professionals (e.g., how to identify smokers quickly and easily, which treatments are most effective, how such treatments can be delivered);
- the need to allow for sufficient time to provide counselling;
- the need to focus on preventive care by
* increasing funding for preventive care (e.g., providing reimbursement for smoking cessation interventions, follow-up or support); and
* encouraging health-care settings to facilitate preventive care (e.g., access to quick reference guides or tools to identify people with specific risk factors);
- the need to increase public awareness of the smoking cessation services a health professional can provide; and
- the need to recognize the frustration associated with the high rate of relapse. Because of the powerful nature of tobacco dependence, smokers often go through a long period of reaching readiness before they finally quit.
Bao Y., Duan N., & Fox S. A. (2006). Is some provider advice on smoking cessation better than no advice? An instrument variable analysis of the 2001 National Health Interview Survey. Health Services Research, 41(6), 2114-2135
Breitling, L. P., Rothenbacher, D., Stegmaier, C., Raum, E., & Brenner, H. (2009). Older smokers' motivation and attempts to quit smoking. Deutsches Arzteblatt International, 106(27), 451-455.
Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment. (2008). Dynamic guidelines for tobacco control in Canada Version 1.0 [Wiki clinical practice guidelines]. Toronto: Author.
Canadian Cancer Society. (2010). Second-hand smoke is dangerous. Toronto: Author. Retrieved May 19, 2010, from http://www.cancer.ca/canada-wide/prevention/quit%20smoking/second-hand%20smoke.aspx
Canadian Centre on Substance Abuse, (2006). The costs of substance abuse in Canada in 2002. Ottawa: Author.
Canadian Lung Association. (2006). Smoking and tobacco: Second-hand smoke. Retrieved June 14, 2010, from http://www.lung.ca/protect-protegez/tobacco-tabagisme/second-secondaire/hurts-nuit_e.php
Canadian Dental Hygienists Association. (2004). Tobacco use cessation services and the role of the dental hygienist - a CDHA position paper. Canadian Journal of Dental Hygiene, 38(6), 260-279.
Canadian Medical Association. (2008). Tobacco control [Policy statement]. Ottawa: Author.
Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., & Curry, S. J. (2008). Treating tobacco use and dependence: 2008 update [Clinical practice guideline]. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
Health Canada. (2009). Smoking and your body: Health effects of smoking. Ottawa: Author. Retrieved June 17, 2010, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/body-corps/index-eng.php
Health Canada. (2007). Overview of health risks of smoking. Ottawa: Author. Retrieved June 17, 2010, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/res/news-nouvelles/risks-risques-eng.php
Nabalamba, A, & Millar, W. J. (2007). Going to the doctor [Statistics Canada, catalogue 82-003]. Health Reports, 18(1), 23-35. Retrieved January 26, 2011, from http://www.statcan.gc.ca/pub/82-003-x/2006002/article/doctor-medecin/9569-eng.pdf
Physicians for a Smoke-Free Canada. (2005). Smoking in Canada: A statistical snapshot of Canadian smokers. Ottawa: Author. Retrieved May 14, 2010, from http://www.smoke-free.ca/pdf_1/SmokinginCanada-2005.pdf
Registered Nurses' Association of Ontario. (2007). Integrating smoking cessation into daily nursing practice [Nursing best practice guideline]. Toronto: Author.
Ross, H., Blecher, E., Yan, L., & Hyland, A. (2010) Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction, November 2010.
Shields, M. (2004). A step forward, a step back: Smoking cessation and relapse. National Population Health Survey, Vol. 1, No. 1. Ottawa: Statistics Canada.
Statistics Canada. (2009). Canadian tobacco use monitoring survey (CTUMS): CTUMS 2009 wave 1 survey results. Ottawa: Author. Retrieved January 25, 2011, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_ctums-esutc_2009/w-p-1_sum-som-eng.php
Stead, L. F., Lancaster, T., & Perera, R. (2006). Telephone counselling for smoking cessation (review). Cochrane Database of Systematic Reviews, Issue 3.
Vangeli, E., & West, R. (2008). Sociodemographic differences in triggers to quit smoking: findings from a national survey. Tobacco Control, 17(6), 410-415.
Young, R.P., Hopkins, R.J., Smith, M., & Hogarth, D.K. (2010). Smoking cessation: The potential role of risk assessment tools as motivational triggers. Post Graduate Medical Journal, 86(1011), 26-33.
Tobacco: The role of health professionals in smoking cessation [Joint position statement]. (2001)
1 For detailed recommendations and guidelines for tobacco treatment related to health professionals, see Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, (2008); Registered Nurses' Association of Ontario, (2007); and Canadian Dental Hygienists Association, (2004).
2 For the purpose of this position statement, tobacco includes products that can be inhaled, sniffed, sucked or chewed (e.g., flavoured cigarillos, kreteks, chewing tobacco, moist snuff, betel or qat, hookah or shisha, bidis, cigars and pipes).
3 (Health Canada, 2009)
4 (Health Canada, 2007)
5 (Statistics Canada, 2009)
6 (Health Canada, 2007)
7 (Canadian Centre on Substance Abuse, 2006)
8 (Canadian Cancer Society, 2010)
9 (Canadian Lung Association, 2006)
10 (Canadian Cancer Society, 2010)
11 (Canadian Cancer Society, 2010)
12 (Physicians for a Smoke-Free Canada, 2005)
13 (Vangeli & West, 2008; Ontario Tobacco Research Unit - Tobacco Informatics Monitoring System (TIMS), 2008; Breitling, Rothenbacher, Stegmaier, Raum & Brenner, 2009)
14 (Ross, Blecher, Yan & Hyland, 2010)
15 (Young, Hopkins, Smith & Hogarth, 2010)
16 (Bao, Duan & Fox, 2006)
17 (Fiore et al., 2008; Shields, 2004)
18 (Fiore et al., 2008)
19 (Stead, Lancaster & Perera, 2006)
20 (Nabalamba & Millar, 2007)
21 (Canadian Medical Association, 2008)
22 (Fiore et al., 2008)
Medical professionalism (Update 2005)
The environment in which medicine is practised in Canada is undergoing rapid and profound change. There are now continued opportunities for the medical profession to provide leadership for our patients, our communities and our colleagues through strengthened professionalism. The Canadian Medical Association (CMA) is strongly committed to medical professionalism and has developed this policy both to inform physicians and others about its meaning and value and to promote its preservation and enhancement. This document outlines the major features of medical professionalism, the opportunities which exist in this area and the challenges which lie before us.
Why Medical Professionalism?
The medical profession is characterized by a strong commitment to the well-being of patients, high standards of ethical conduct, mastery of an ever-expanding body of knowledge and skills, and a high level of clinical independence. As individuals, physicians' personal values may vary, but as members of the medical profession they are expected to share and uphold those values that characterize the practice of medicine and the care of patients.
Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit. Three major features of medical professionalism - the ethic of care, clinical independence and self-regulation - benefit physicians, their patients and society:
Ethic of care: This is characterized by the values of compassion, beneficence, nonmaleficence, respect for persons and justice (CMA's Code of Ethics). Society benefits from the ethic of care whereby, in the provision of medical services, physicians put the interests of others ahead of their own. Dedication and commitment to the well-being of others is clearly in the interests of patients, who are the primary beneficiaries.
Clinical independence: Medicine is a highly complex art and science. Through lengthy training and experience, physicians become medical experts and healers. Whereas patients have the right to decide to a large extent which medical interventions they will undergo, they expect their physicians to be free to make clinically appropriate recommendations. Although physicians recognize that they are accountable to patients, funding agencies and their peers for their recommendations, unreasonable restraints on clinical autonomy imposed by governments and administrators, whether public or private, are not in the best interests of patients, not least because they can damage the trust that is an essential component of the patient-physician relationship. Conversely, physicians are not morally obliged to provide inappropriate medical services when requested by patients despite their respect for patient autonomy.
Self-regulation: Physicians have traditionally been granted this privilege by society. It includes the control of entrance into the profession by establishing educational standards and setting examinations, the licensing of physicians, and the establishment and ongoing review of standards of medical practice. In return for this privilege, physicians are expected to hold each other accountable for their behaviour and for the outcomes they achieve on behalf of their patients. Self-regulation is exercised by many different professional organizations, from medical practice partnerships to the statutory provincial/territorial licensing bodies. It has evolved into a partnership with the public. Self-regulation benefits society by taking the best advantage of the professional expertise needed to appropriately set and maintain standards of training and practice, while providing suitable accountability in matters of professional behaviour. The profession's commitment to the maintenance of those standards is demonstrated by its willingness to participate in outcomes review at many levels, from institutional quality assurance activities to formal prospective peer review, and to actively support their statutory and legislated licensing authorities.
Opportunities in Medical Professionalism
Over the past few years much has been written about the issue of medical professionalism in both the lay and scientific media. The practice of medicine has changed considerably, and with these changes have come challenges but also opportunities. The medical profession continues to be a greatly respected one, and it is still generally seen as being distinct from many others because of the unique nature of the physician-patient relationship. There exists now an opportunity to reinforce the professional values and priorities that have sustained medicine for so long, and to embrace new approaches which will serve it well in the years to come.
Medical professionals must recognize that patients have a wide variety of resources available for their health care needs, from traditional physician services to paramedical practitioners, to complementary medicine and to information obtained from the internet. While maintaining responsibility for care of the patient as a whole, physicians must be able to interact constructively with other health care providers within an interdisciplinary team setting, and must be able to interpret information for patients and direct them to appropriate and accurate resources.
The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality.
Although there are some challenges to professionalism, as outlined below, the greatest opportunity before us may be to remind physicians of the reasons they chose a career in medicine to begin with - for many, it is a calling rather than a job. In spite of the numerous recent changes in the health care system and the practice of medicine, the primary reason most physicians entered the field remains the same - the sanctity of the fiduciary relationship between physicians and their patients. The renewal of medical professionalism must be led from within the profession itself, and the CMA and its members are in a unique position to take advantage of the many opportunities which exist and to respond to the challenges we face.
Challenges to Medical Professionalism
Medical professionalism is being challenged from within and without. These challenges arise from pressures that may serve to undermine the ethic of care, clinical independence and self-regulation and may result, for individual physicians and the medical profession, in diminished morale and changes in lifestyle and practice patterns. These changes may have a detrimental impact on the health of physicians, and also on the quality of patient care.
Resource restraints: The CMA has identified scarcity of resources, whether human or material, as undermining the ability of physicians to maintain excellence in clinical care, research and teaching. Although much attention has been paid recently to the insufficient number of physicians in Canada, and although recent developments indicate some limited cause for optimism, much work remains to be done. Issues of access to continuing professional development, workforce sustainability, inadequate numbers of training positions for new doctors, the integration of foreign-trained physicians into the workforce and the apparent inability of governments to resolve inadequacies in health care funding continue to frustrate physicians' attempts to achieve their professional goals and care for their patients. These factors all have the potential for contributing to the decline of professional morale.
Bureaucratic challenges: This refers to the introduction of layers of management and policy directives between the physician and the patient. It is a result of changes that have taken place in the organization and delivery of medical care, especially the involvement of governments in all aspects of health care. The traditional one-on-one relationship of physician and patient is now set within a context of government and corporate interests, in which the physician may sometimes assume the status of an employee, that pose considerable challenges to the exercise of the professional values of clinical autonomy and self-regulation. Moreover, while the responsibility for organizing the delivery of scarce resources has been increasingly transferred from physicians to managers, physicians are still ultimately responsible, both morally and legally, for providing quality care. Although the increasing complexity of health care delivery requires recourse to sophisticated management systems, there is a danger that as physicians become increasingly answerable to or constrained by third parties, their ability to fulfill their commitment to their individual patients can be seriously compromised.
Unprofessional conduct: Some physicians do not uphold the values of the profession. A few put their interests or the interests of third parties ahead of the interests of their patients. The profession needs to meet this challenge by demonstrating its ability to uphold its values and its commitment to doing so. Supporting strong and transparent self-regulatory systems will be a key component of this endeavor.
Commercialism: In recent years the market mentality has expanded its influence to many areas formerly outside its domain, including governments, universities and the professions. Health care has become a major industry, one in which physicians play a central role, and commercial interests, whether private or public, may pressure physicians to compromise their responsibilities to their patients, research subjects and society. The potential for physicians and medical associations to become drawn into conflict-of-interest situations is increasing. Commercialism may compromise both the ethic of care and clinical independence by its reinterpretation of medical care as a commodity and the patient-physician relationship as something less than a fiduciary relationship. There is an inherent opportunity for the profession to address the issue of conflict of interest and to re-affirm its primary obligation and dedication to the patients it cares for.
Consumerism: Physicians strongly support the right of patients to make informed decisions about their medical care. However, the CMA's Code of Ethics requires physicians to recommend only those diagnostic and therapeutic procedures that they consider to be beneficial to the patient or to others. There is a proliferation of health information and advertising in the popular media and on the Internet that may be inaccurate or poorly understood. Taken to its extreme, consumerism can be detrimental not just to professionalism but to the well-being of patients and the interests of society.
Industrialization: This refers to the increased division and specialization of labour in the delivery of health care, whereby the delivery of health care may become fragmented. There is increasing pressure within medicine to improve efficiency and optimize cost savings. While these may be important goals in the broader context of health care, we must ensure that they do not impact negatively on the doctor-patient relationship.
Realizing Opportunities and Dealing with Challenges
Individual physicians should protect, enhance and promote professionalism in medicine by reflecting the values of the medical profession in their practice and by contributing to the efforts of organized medicine to maintain and enhance the ethic of care, clinical autonomy and self-regulation. These efforts require action in 3 areas: policy, education and self-regulation.
Policy: All those involved in health care - physicians, patients, other health care providers, administrators, governments and the general public (as taxpayers, potential patients, relatives of patients, etc.) - should be informed about the values of the medical profession and where it stands on issue related to accountability, clinical autonomy and self-regulation. Policies of medical associations should reflect these values and should speak clearly on topics such as conflict of interest. Policies should be reviewed frequently and updated when necessary, in order to take account of the rapidly changing environment in which medicine is practiced. The topic of professionalism should be granted increasing importance in policy discussions. Policies should be developed and updated in related areas, such as conflict of interest and physician-industry interactions.
In order to be consistent and trustworthy, medical associations should adhere to the same high standards of behaviour that they require of individual physicians. The challenges posed by resource restraints, bureaucratization, unprofessional conduct, commercialism and consumerism are no less serious for associations than for individuals and require sound harmonized policies for both. The CMA has an opportunity for leadership in this regard.
Education: However professional values and policies are established, they must be transmitted to current and future members of the profession in order to have any effect.
Like most other aspects of medical education, the values of professionalism are both taught and modeled. Professionalism should be an essential component of the formal medical curriculum at the undergraduate and postgraduate training levels. Moreover, active demonstration of professionalism such as role modeling by physicians, and in the internal culture of the medical schools and hospitals where students receive their training, should be used to advantage and challenged when necessary. Likewise for physicians in practice, formal continuing professional development programs and role modeling by other physicians are important for the maintenance of professionalism.
Physicians need to communicate and test their understanding of their professional role with others involved in patient care at numerous levels. Such initiatives, which would engage patients, other professionals and policy-makers, require further development.
The CMA and other medical organizations have taken leadership roles in assisting patients and health care providers in making informed decisions by creating numerous continuing professional development opportunities and readily available clinical information for physicians, effective patient education materials, self-help books and validated Web sites, including www.cma.ca. These efforts need to continue and be strengthened.
Self-regulation: In order to maintain self-regulation in an environment that is increasingly suspicious of such privileges, the medical profession has to demonstrate that self regulation benefits society in general. This requires, among other things, that the medical profession continue to demonstrate its commitment to the tasks required by self-regulation, including setting and enforcing high standards of behaviour for both individual physicians and medical associations.
Physicians continue to value medical professionalism highly. They believe that it benefits patients greatly and that it should be preserved and enhanced. Professionalism will continue to be based on the relationship of trust between patients and physicians, and the primacy of the physician-patient relationship. It encompasses the values of compassion, beneficence, nonmaleficence, respect for persons and justice. As professionals, physicians will strive to maintain high standards of ethics, clinical practice and education and demonstrate a capacity for social responsibility through self-regulation and accountability (see CMA Policy Statement The Future of Medicine).
The CMA welcomes opportunities to engage in dialogue with others as to how professionalism in health care can be preserved and enhanced for the benefit of patients, physicians and society in general.
Older Canadians represent the fastest-growing segment of our population and are the largest users of prescription drugs. Seniors take more drugs than younger Canadians because, on average, they have a higher number of chronic conditions. According to the Canadian Institute for Health Information, in 2012, nearly two-thirds of seniors had claims for 5 or more drug classes, and more than one-quarter of seniors had claims for 10 or more drug classes. The number of drugs used by seniors increased with age.
The use of multiple medications, or polypharmacy, is of concern in the senior population. The risk of drug interactions and adverse drug reactions is several-fold higher for seniors than for younger people. This phenomenon is associated with pharmacokinetic and pharmacodynamics factors in seniors, including changes in renal and hepatic function, increased sensitivity to drugs and, potentially, multiple medical problems. In older persons, adverse drug reactions are often complex and may be the direct cause of hospital admissions for acute care. Cognitive and affective disorders, for example, may be due to adverse reactions to sedatives or hypnotic drugs. Chronic pain is a common issue, and it is important to carry out research into and education for health care providers concerning the unique challenges of managing pain in older adults.
The CMA supports the development of a coordinated national approach to reduce polypharmacy and prevent adverse drug reactions. Prescribers must be vigilant to optimize pharmacotherapy and in reconciling medications, taking into consideration physiological changes as a person ages. Deprescribing should be considered, reducing or stopping medications that may be harmful or no longer be of benefit, seeking to improve quality of life.
There has been considerable interest in determining which factors affect prescribing behavior and how best to influence these factors. Strategies that improve prescribing practices include evidence-based drug information provided through academic detailing; objective continuing medical education; accessible, user-friendly decision support tools available at point of care; and electronic prescribing systems that allow physicians access to their patient's treatment and medication profiles.
The following principles define the basic steps to appropriate prescribing for seniors.
Know the patient.
Know the diagnosis.
Know the drug history. Keep a medication list for each patient and review, update, reconcile and evaluate adherence at each visit. Instruct the patient to bring all prescription and over-the-counter medications, including medications prescribed by other physicians, and natural health products, to each appointment. In some provinces, pharmacists conduct medication use reviews for patients on public drug benefit programs.
Know the history of use of other substances such as alcohol, tobacco, cannabis, opioids and caffeine.
Consider non-pharmacologic therapy, including diet, exercise, psychotherapy or community resources. Continuing medical education in specific non-pharmacologic therapies is valuable. For example, evaluation and management of behavioural and psychological symptoms of dementia should be considered before anti-psychotic therapy. As well, Canadian standardized non-pharmacologic order sets should be developed for the treatment of delirium.
Know the drugs. Critically evaluate all sources of drug information and use multiple sources such as clinical practice guidelines, medical journals and databases, continuing medical education and regional drug information centres. Monitor patients continually for adverse drug reactions. Appropriate drug dosage depends on factors such as age, sex, body size, general health, concurrent illnesses and medications, and hepatic, renal and cognitive function (for example, older people are particularly sensitive to drugs that affect the central nervous system).
Keep drug regimens simple. Avoid mixed-frequency schedules when possible. Try to keep the number of drugs used for long-term therapy under five to minimize the chance of drug interactions and improve adherence.
Establish treatment goals. Determine how the achievement of goals will be assessed. Regularly re-evaluate goals, adequacy of response and justification for continuing therapy. Time to benefit of prescribed medications should be a key consideration when providing care to seniors at end of life.
Encourage patients to be responsible medication users. Verify that the patient and, if necessary, the caregiver, understands the methods and need for medication. Recommend the use of daily or weekly medication containers, calendars, diaries or other reminders, as appropriate, and monitor regularly for compliance. Encourage the use of one dispensary.
The Institute for Safe Medication Practices Canada has developed a program, Knowledge is the best medicine (https://www.knowledgeisthebestmedicine.org), that can be helpful to seniors and their healthcare team manage medicines safely and appropriately.
Approved by the Board on May 28, 2011
Update approved by the Board on March 02, 2019
This policy statement provides operational principles for the measurement and management of wait list systems that support timely access to necessary care for patients. This statement is based on the understanding that in order for wait list systems to be effective in improving timely access to medically necessary care for patients, physicians and other providers must be centrally involved and appropriately supported to assist in their development, measurement and management.
Since the late 1990s, Canadians have become increasingly concerned over lengthening wait times to access medically necessary care. As a result, a major focus of the 2004 Health Care Accord (10-Year Agreement to Strengthen Health Care) was to improve timely access to necessary medical care. Since then, provinces and territories have taken steps to measure, monitor and manage patient wait times. However, most efforts thus far to improve wait times have been focused on the wait between the specialist consultation and the scheduled date for treatment. Patients may also experience waits in accessing a family physician (many Canadians do not have a family physician) and waiting to see a specialist following a referral by a family physician.
Canadians deserve timely access to medically necessary care. Governments must ensure that patients are treated within established wait-time benchmarks for all major diagnostic, therapeutic, and surgical services. Physicians recognize that it is desirable to minimize waits and to properly prioritize and manage patients' wait for care by accurately capturing and utilizing wait-time data.
However, there remain serious concerns over the quality of wait-time data and who has the primary responsibility for capturing the data. Physicians and other providers are increasingly being requested to input wait-time data (e.g., length of wait for consultation or for start of treatment). Yet, in many instances, they are expected to do so without the necessary resources and supports.
Outlined below are Operational Principles for the Measurement and Management of Wait Lists developed originally through CMA's Access to Quality Health Care Project(1) with input from public opinion research as well as stakeholder groups, including CMA Core Committees, Provincial-Territorial Medical Associations and CMA Affiliates.
1. To maintain or enhance patients' quality of life and health status through effective development, measurement and management of wait lists.
2. To ensure that the development, measurement and management of wait lists are based on the best available evidence of clinical appropriateness, clinical effectiveness, rational use of resources, clinical need and patient quality of life.
A. Stakeholder Involvement
1. Physicians in clinical practice must have a leadership role:
- in identifying clinically relevant data elements through consensus;
- in developing standard definitions and measures for prioritization for wait lists; and
- in developing wait-time benchmarks.
2. Health care providers and other stakeholders should be involved in the development, measurement, maintenance, monitoring, management and evaluation of wait list systems, and should be appropriately compensated for their time and effort.
B. Database Development and Management Systems
1. Systems for developing and managing wait lists must require and provide reliable, current, useful and valid data and information.
2. Database development and wait list management requires involvement of multidisciplinary panels.
3. Systems for managing wait lists should:
- provide accurate, reliable, timely, publicly accessible and real-time information in a cost-effective manner. Deadlines for inputting data should be reasonable and implemented without the use of threats or penalties;
- collect and assess data on need, quality of life and health outcomes; be flexible and dynamic so that they can adapt over time with the development of new technologies and approaches to treatment; and
- require policies and procedures on confidentiality, so that patients' and providers' privacy are protected.
1. Systems for managing wait lists require initial and sustained investment in dedicated human resources, sophisticated information systems and information technology infrastructure at all levels (e.g., medical offices, hospitals, health regions).
1. The parties involved in managing wait lists must accept their responsibilities and obligations to each other and to the public.
2. Privacy and confidentiality of patient and provider information must be respected.
3. The systems, processes and results for managing wait lists should be widely communicated to obtain stakeholder involvement and support.
1. Systems for managing wait lists must:
- be continually monitored and evaluated to identify opportunities for improvement; and
- regularly undergo independent data audits and evaluations of process and outcome.
1. An independent, stakeholder-based, non-governmental organization with an advisory committee should be responsible for overseeing and administering systems for managing wait lists.
(1) Canadian Medical Association, Access to Quality Health Care Project, January 1998. Ottawa.
Principles for Health System Governance
This policy provides principles and recommendations for developing, implementing and evaluating health system governance models such as regionalized health care for the purposes of delivering high quality care to patients.
Since the 1990s, health care systems in many countries including Canada have been searching for more effective health system governance models to accomplish a variety of health policy objectives. These objectives include funding health care based on population health needs and improving service delivery integration. In Canada, most provinces and territories moved to a regionalized model of health system governance during the 1990s.
This "regionalization" approach involved both decentralizing and centralizing specific elements of the health care system. Decentralizing involved moving planning, budgeting and decision making authority from the provincial or territorial level to certain regional bodies. Centralizing involved moving the planning and governance of health care and medical services from individual institutions or agencies to a regional body. In terms of the delivery of health care services, centralization often occurred through the consolidation of several programs into a single program for a region and through the merger and closure of individual institutions.
Since 2003, several provincial governments initiated new changes to their approach to health system governance ranging from vertical integration involving a range of health agencies under a single board (e.g., Quebec) to the creation of boards that oversee the delivery of care for larger portions of a jurisdiction or even the entire jurisdiction itself (e.g., Alberta Health Services). Many of these new models involve an arm's length authority governed by an appointed board that is mandated to manage and integrate the operations of the health system across the province/territory while leaving the ministry of health to set the overall plan and priorities for the health system as well as set standards and monitor outcomes.
No doubt, governments will continue to search for an ideal health system governance and delivery model as part of an effort to develop "high performing health systems". Examples of high performing health systems exist at all levels such as at regional levels within countries (e.g., Jonkoping, Sweden) or at the client group level (e.g., US Veterans Health Administration).
Health system governance models, such as health regions or health agencies, must have an overall goal of ensuring the delivery of high quality, timely and accessible care to its citizens. The Institute for Healthcare Improvement's (IHI) Triple Aim concept identifies three objectives for health systems: improve the health of the population; improve the health care experience for patients; and improve the value for money spent on health and health care. Many previous health system reforms have not resulted in improved care for patients. The CMA's 2010 action plan, Health Care Transformation in Canada: Change that Works. Care that Lasts, calls for patient-centred health care that puts the patients and their families' interests first.
From the health provider perspective, previous regionalization efforts have raised several issues of concern, including whether these models translate into improved delivery of care for patients. There is also concern with the prospect that new models will limit provider involvement in health system governance and that health human resource planning will be localized when mobility of labour transcends local borders.
The CMA is committed to playing a positive role in the debate on the future of health care reform in Canada. It recognizes that health system governance models are subject to change. However, this CMA policy on health system governance identifies fundamental principles that should guide any model under consideration. These guiding principles draw upon previous CMA work starting in 1991 with its Working Group on Regionalization, leading to its Language of Health System Reform report.
Patient-centred: Any consideration of governance models must begin with an overall goal of providing patient-centred care-seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity.
Defined objectives: The development and implementation of health system governance models/strategies must begin with a clear statement of objectives. The objectives should reflect the changes that need to be made to the health care system to address specific problems and, whenever possible, must be defined in measurable terms so that health system governance policies can be evaluated.
Accountability/authority: Aligning accountability and authority is essential to effective and sustainable high performing health systems. Accountability is affected by the degree of authority and the scope of responsibilities (i.e., planning, administration, organization and funding of health care services) transferred to the governing units (e.g., regions). Who is accountable, and for what, need to be defined. There needs to be a clear statement of the roles of government, governing boards, physicians and all health care stakeholders. Physicians have a unique contribution to make and their views should be taken into account in any restructuring of the health care delivery system.
Needs based planning/Responsive to regional needs: The definition of the region(s) or sub-regions should reflect the natural, socio-political and geographic divisions of the population. Once regions are defined, the health care needs of the population served by regional units should be determined through epidemiological studies, input from communities and other needs assessment. In addition to local planning, there is also the need for broader based planning to address medical and scientific research, new technologies and procedures.
Regional health needs can vary requiring flexible delivery models. Credentialing that meets jurisdictional standards should be maintained at the regional level in order to effectively respond to regional needs and issues.
Informed choice: Any form of health system governance should not restrict patients' mobility between providers or regions, physicians' mobility between and within regions, or physicians' choice of practice setting by limiting employment to community health centres or other forms of group practice.
Participatory democracy Both patients/public and providers should be involved in determining governance models and participating in the ongoing governance of health systems. If providers are to be encouraged to get involved, they need to have ready access to the planning and administrative skills needed to participate effectively and make a valuable contribution to management and leadership. Three key areas in which providers must become knowledgeable and involved include governance and credentialing, health care needs assessment and health economics.
Clinical autonomy: Physicians have a responsibility to advocate on behalf of their patients to ensure the availability of needed care. This responsibility should not be hindered by a physician's practice setting, mode of remuneration or paying agency.
Evaluation: Evaluation protocols must be built into health system governance models at the outset, and the results of evaluation must be used to "fine tune" and improve the strategies. These protocols should address cost effectiveness, population health status, patient access to health care services and the interests of government, the profession and the public.
Standards for reasonable access: Certain areas and cultural groups do not have the same level of access to health care services as the national norm. All health system governance models should address these shortcomings to ensure that the entire population of any given region has reasonable access to primary, secondary and tertiary care.
Balancing access and affordability: One of the implicit objectives of new models of health system governance appears to be achieving both control over health care costs and redirecting expenditures from health care to community and social services. Governing authorities must be careful to maintain a balance between access to health care services and affordability allowing for a variety of methods to achieve this (e.g., internal markets). They must also maintain a comprehensive accounting of the cost of implementing any new model.
Balancing curative with preventive and sustaining care: All health system governance models must support not only the system's ability to provide curative care but also an ability to provide effective preventive and sustaining care. Governance models should ensure funds can be allocated toward a comprehensive approach to care as well as allow for models of care that support all three functions.
Support for medical education and research: Policies and structures of health system governance models need to acknowledge and foster the role of medical education and research in the health care system. Governance of medical teaching and research should reside within the academic health sciences centres. These centres should be assured of adequate financial and human resources and of access to cross regional patient populations and to community teaching sites in order to provide adequate learning and research opportunities.
With regard to the development, implementation and evaluation of health system governance models, the CMA recommends that:
* advocacy on behalf of patients and physicians be maintained irrespective of any regional administrative boundaries;
* governments ensure that the introduction of new models of health system governance do not interfere with clinical autonomy and professional freedom in the context of the physician/patient relationship;
* governments, health governing authorities and institutions ensure that physicians, through their professional associations, are included in the development and revision of practitioner/medical staff bylaws and appointment policies;
* family physicians, on the basis of their education, training and skills, are reaffirmed as the preferred point of entry into Canada's health care system;
* governments ensure that catchment area under the governing authority be defined in a way that is sensitive to the political, cultural and geographic circumstances of the population and recognizes established patterns of the demand for, and the provision of, health care;
* governments ensure that the introduction of new governance models does not interfere with reasonable access by the population to medical services at the primary, secondary and tertiary levels;
* leadership be provided to help ensure that the development, implementation and evaluation of health system governance models are based on clear, measurable objectives;
* governments develop and maintain national standards for access to high quality health care, medical education and research, irrespective of regional boundaries;
* governments ensure that programs and policies under any form of health system governance be designed and implemented in a manner that supports key principles of medical education and research, including:
- the governance and resources required for medical teaching, both in the academic health sciences centres and in appropriate community based sites throughout the province or territory,
- academic health sciences centres' responsibilities for providing secondary and tertiary care to catchment populations that cut across regional boundaries, and
- the need for academic physician resource plans to ensure a critical mass for teaching and research;
* governments give priority to mechanisms to protect the mobility of patients and physicians when developing and implementing programs under any new health system governance model; and
* the medical profession work with governments to develop:
- clear role, responsibility and accountability statements for government, health system governing boards, health care providers and consumers,
- mechanisms to ensure that governing boards have broad representation and meaningful input from the community, including physicians, and that regional boards be recruited through a clearly specified appointment or electoral process,
- guidelines for use by communities to assess their health care needs and to provide assistance, as required, with the conduct of such assessments,
- protocols and procedures for evaluating health system governance initiatives,
- mechanisms to ensure adequate and appropriate physician input into operational aspects of regional planning and coordination of health care services, and
- processes under any health system governance model ensure adequate opportunities for research, education (including continuing medical education) and training of physicians consistent with national standards.
The Role of Physicians in Recognizing and Supporting
Treatment of Gambling Addiction
(Update November 2005)
Gambling is a common activity in our society. For a small percentage, this behaviour can become pathological, affecting the well-being of gamblers as well as their families and workplaces. This disorder has been described in the "Diagnostic and Statistical Manual of Mental Disorders" Fourth Edition, (DSM IV) and is recognized as an illness by physicians.
Physicians have a role in identifying pathological gambling behaviour and being aware of the resources that exist to treat and support addicted individuals and their families. To assist them in performing this role, the CMA makes the following recommendations:
* The CMA supports the development of core curricula in gambling disorders to be offered at undergraduate and post-graduate levels and through CME programs. These could include inter-professional or interdisciplinary curricula developed in partnership with other health professionals.
* The CMA supports the development and dissemination of resources to help practising physicians screen patients to identify those with gambling addiction and to provide appropriate treatment.
* Governments should ensure the timely availability of quality treatment services appropriate to the age, culture and background of client groups.
* The CMA encourages research into gambling addiction, which could include:
identifying the biological basis for gambling;
identifying best-practice interventions to reduce the prevalence of problem gambling;
measuring the social and economic impacts of gambling on individuals and communities; and
dispelling the myths surrounding gambling addiction.
* Governments and others should work together to implement educational and policy strategies to reduce the prevalence of problem gambling. These could include:
elementary school programs to help prevent pathological gambling disorders;
limiting the number of gambling establishments, particularly video lottery terminals (VLTs) and casinos;
placing age limits on accessibility to VLTs so that children and adolescents are restricted from their use; and
promoting lower risk gambling approaches for primary prevention and harm reduction such as gambling only with a predetermined loss limit and not gambling alone.