Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


16 records – page 1 of 2.

Assisted reproduction (Update 2001)

https://policybase.cma.ca/en/permalink/policy197
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Ethics and medical professionalism
Text
Like all scientific and medical procedures, assisted human reproduction has the potential for both benefit and harm. It is in the interests of individual Canadians and Canadian society in general that these practices be regulated so as to maximize their benefits and minimize their harms. To help achieve this goal, the Canadian Medical Association (CMA) has developed this policy on regulating these practices. It replaces previous CMA policy on assisted reproduction. Objectives The objectives of any Canadian regulatory regime for assisted reproduction should include the following: (a) to protect the health and safety of Canadians in the use of human reproductive materials for assisted reproduction, other medical procedures and medical research; (b) to ensure the appropriate treatment of human reproductive materials outside the body in recognition of their potential to form human life; and (c) to protect the dignity of all persons, in particular children and women, in relation to uses of human reproductive materials. Principles When a Canadian regulatory regime for assisted reproduction is developed, it should incorporate the following principles: For the regulation of assisted reproduction, existing organizations such as medical licensing authorities, accreditation bodies and specialist societies should be involved to the greatest extent possible. If the legislation establishing the regulatory regime is to include prohibitions as well as regulation, the prohibition of specific medical and scientific acts must be justified on explicit scientific and/or ethical grounds. If criminal sanctions are to be invoked, they should apply only in cases of deliberate contravention of the directives of the regulatory agency and not to specific medical and scientific acts. Whatever regulatory agency is created should include significant membership of scientists and clinicians working in the area of assisted reproduction. Elements of a Regulatory Regime The regulation of assisted reproduction in Canada should include the following elements: Legislation to create a national regulatory body with appropriate responsibilities and accountability for coordinating the activities of organizations that are working in the area of assisted reproduction and for carrying out functions that other organizations cannot perform. The development and monitoring of national standards for research related to human subjects including genetics and reproduction. The regulatory body would work closely with the Canadian Institutes of Health Research, other federal and provincial research granting councils, the National Council on Ethics in Human Research and other such organizations. The development and monitoring of national standards for training and certifying physicians in those reproductive technologies deemed acceptable. As is the case for all post-graduate medical training in Canada, this is appropriately done through bodies such as the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. The licensing and monitoring of individual physicians. This task is the responsibility of the provincial and territorial medical licensing authorities which could regulate physician behaviour in respect to the reproductive technologies, just as they do for other areas of medical practice. The development of guidelines for medical procedures. This should be done by medical specialty societies such as the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Canadian Fertility and Andrology Society (CFAS). The accreditation of facilities where assisted reproduction is practised. There is already in Canada a well functioning accreditation system, run by the Canadian Council on Health Services Accreditation, which may be suitable for assisted reproduction facitilies. Whatever regulatory body is established to deal with assisted reproduction should utilize, not duplicate, the work of these organizations. In order to maximize the effectiveness of these organizations, the regulatory body could provide them with additional resources and delegated powers. Criminalization The CMA is opposed to the criminalization of scientific and medical procedures. Criminalization represents an unjustified intrusion of government into the patient-physician relationship. Previous attempts to criminalize medical procedures (for example, abortion) were ultimately self-defeating. If the federal government wishes to use its criminal law power to regulate assisted reproduction, criminal sanctions should apply only in cases of deliberate contravention of the directives of the regulatory agency and not to specific medical and scientific acts.
Documents
Less detail

Best practices for smartphone and smart-device clinical photo taking and sharing

https://policybase.cma.ca/en/permalink/policy13860
Date
2018-03-03
Topics
Health information and e-health
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Date
2018-03-03
Topics
Health information and e-health
Ethics and medical professionalism
Text
Clinical photography is a valuable tool for physicians. Smartphones, as well as other devices supporting network connectivity, offer a convenient, efficient method to take and share images. However, due to the private nature of the information contained in clinical photographs there are concerns as to the appropriate storage, dissemination, and documentation of clinical images. Confidentiality of image data must be considered and the dissemination of these images onto servers must respect the privacy and rights of the patient. Importantly, patient information should be considered as any information deriving from a patient, and the concepts outlined therefore apply to any media that can be collected on, or transmitted with, a smart-device. Clinical photography can aid in documenting form and function, in tracking conditions and wound healing, in planning surgical operations, and in clinical decision-making. Additionally, clinical photographs can provide physicians with a valuable tool for patient communication and education. Due to the convenience of this type of technology it is not appropriate to expect physicians to forego their use in providing their patients with the best care available. The technology and software required for secure transfer, communication, and storage of clinical media is presently available, but many devices have non-secure storage/dissemination options enabled and lack user-control for permanently deleting digital files. In addition, data uploaded onto server systems commonly cross legal jurisdictions. Many physicians are not comfortable with the practice, citing security, privacy, and confidentiality concerns as well as uncertainty in regards to regional regulations governing this practice.1 Due to concern for patient privacy and confidentiality it is therefore incredibly important to limit the unsecure or undocumented acquisition or dissemination of clinical photographs. To assess the current state of this topic, Heyns et al. have reviewed the accessibility and completeness of provincial and territorial medical regulatory college guidelines.2 Categories identified as vital and explored in this review included: Consent; Storage; Retention; Audit; Transmission; and Breach. While each regulatory body has addressed limited aspects of the overall issue, the authors found a general lack of available information and call for a unified document outlining pertinent instructions for conducting clinical photography using a smartphone and the electronic transmission of patient information.2 The discussion of this topic will need to be ongoing and it is important that physicians are aware of applicable regulations, both at the federal and provincial levels, and how these regulations may impact the use of personal devices. The best practices supported here aim to provide physicians and healthcare providers with an understanding of the scope and gravity of the current environment, as well as the information needed to ensure patient privacy and confidentiality is assessed and protected while physicians utilize accessible clinical photography to advance patient care. Importantly, this document only focusses on medical use (clinical, academic, and educational) of clinical photography and, while discussing many core concepts of patient privacy and confidentiality of information, should not be perceived as a complete or binding framework. Additionally, it is recommended that physicians understand the core competencies of clinical photography, which are not described here. The Canadian Medical Association (CMA) suggests that the following recommendations be implemented, as thoroughly as possible, to best align with the CMA policy on the Principles for the Protection of Patient Privacy (CMA Policy PD2018-02). These key recommendations represent a non-exhaustive set of best practices - physicians should seek additional information as needed to gain a thorough understanding and to stay current in this rapidly changing field. KEY RECOMMENDATIONS 1. CONSENT * Informed consent must be obtained, preferably prior, to photography with a mobile device. This applies for each and any such encounter and the purpose made clear (i.e. clinical, research, education, publication, etc.). Patients should also be made aware that they may request a copy of a picture or for a picture to be deleted. * A patient's consent to use electronic transmission does not relieve a physician of their duty to protect the confidentiality of patient information. Also, a patient's consent cannot override other jurisdictionally mandated security requirements. * All patient consents (including verbal) should be documented. The acquisition and recording of patient consent for medical photography/dissemination may be held to a high standard of accountability due to the patient privacy and confidentiality issues inherent in the use of this technology. Written and signed consent is encouraged. * Consent should be considered as necessary for any and all photography involving a patient, whether or not that patient can be directly recognized, due to the possibility of linked information and the potential for breach of privacy. The definition of non-identifiable photos must be carefully considered. Current technologies such as face recognition and pattern matching (e.g. skin markers, physical structure, etc.), especially in combination with identifying information, have the potential to create a privacy breach. * Unsecure text and email messaging requires explicit patient consent and should not be used unless the current gold standards of security are not accessible. For a patient-initiated unsecure transmission, consent should be clarified and not assumed. 2. TRANSMISSION * Transmission of photos and patient information should be encrypted as per current-day gold standards (presently, end-to-end encryption (E2EE)) and use only secure servers that are subject to Canadian laws. Explicit, informed consent is required otherwise due to privacy concerns or standards for servers in other jurisdictions. Generally, free internet-based communication services and public internet access are unsecure technologies and often operate on servers outside of Canadian jurisdiction. * Efforts should be made to use the most secure transmission method possible. For data security purposes, identifying information should never be included in the image, any frame of a video, the file name, or linked messages. * The sender should always ensure that each recipient is intended and appropriate and, if possible, receipt of transmission should be confirmed by the recipient. 3. STORAGE * Storing images and data on a smart-device should be limited as much as possible for data protection purposes. * Clinical photos, as well as messages or other patient-related information, should be completely segregated from the device's personal storage. This can be accomplished by using an app that creates a secure, password-protected folder on the device. * All information stored (on internal memory or cloud) must be strongly encrypted and password protected. The security measures must be more substantial than the general password unlock feature on mobile devices. * Efforts should be made to dissociate identifying information from images when images are exported from a secure server. Media should not be uploaded to platforms without an option for securely deleting information without consent from the patient, and only if there are no better options. Automatic back-up of photos to unsecure cloud servers should be deactivated. Further, other back-up or syncing options that could lead to unsecure server involvement should be ascertained and the risks mitigated. 4. Cloud storage should be on a Canadian and SOCII certified server. Explicit, informed consent is required otherwise due to privacy concerns for servers in other jurisdictions. 5. AUDIT & RETENTION * It is important to create an audit trail for the purposes of transparency and medical best practice. Key information includes patient and health information, consent type and details, pertinent information regarding the photography (date, circumstance, photographer), and any other important facts such as access granted/deletion requests. * Access to the stored information must be by the authorized physician or health care provider and for the intended purpose, as per the consent given. Records should be stored such that it is possible to print/transfer as necessary. * Original photos should be retained and not overwritten. * All photos and associated messages may be considered part of the patient's clinical records and should be maintained for at least 10 years or 10 years after the age of majority, whichever is longer. When possible, patient information (including photos and message histories between health professionals) should be retained and amalgamated with a patient's medical record. Provincial regulations regarding retention of clinical records may vary and other regulations may apply to other entities - e.g. 90 years from date of birth applies to records at the federal level. * It may not be allowable to erase a picture if it is integral to a clinical decision or provincial, federal, or other applicable regulations require their retention. 6. BREACH * Any breach should be taken seriously and should be reviewed. All reasonable efforts must be made to prevent a breach before one occurs. A breach occurs when personal information, communication, or photos of patients are stolen, lost, or mistakenly disclosed. This includes loss or theft of one's mobile device, texting to the wrong number or emailing/messaging to the wrong person(s), or accidentally showing a clinical photo that exists in the phone's personal photo album. * It should be noted that non-identifying information, when combined with other available information (e.g. a text message with identifiers or another image with identifiers), can lead to highly accurate re-identification. * At present, apps downloaded to a smart-device for personal use may be capable of collecting and sharing information - the rapidly changing nature of this technology and the inherent privacy concerns requires regular attention. Use of specialized apps designed for health-information sharing that help safeguard patient information in this context is worth careful consideration. * Having remote wipe (i.e. device reformatting) capabilities is an asset and can help contain a breach. However, inappropriate access may take place before reformatting occurs. * If a smartphone is strongly encrypted and has no clinical photos stored locally then its loss may not be considered a breach. * In the event of a breach any patient potentially involved must be notified as soon as possible. The CMPA, the organization/hospital, and the Provincial licensing College should also be contacted immediately. Provincial regulations regarding notification of breach may vary. Approved by the CMA Board of Directors March 2018 References i Heyns M†, Steve A‡, Dumestre DO‡, Fraulin FO‡, Yeung JK‡ † University of Calgary, Canada ‡ Section of Plastic Surgery, Department of Surgery, University of Calgary, Canada 1 Chan N, Charette J, Dumestre DO, Fraulin FO. Should 'smart phones' be used for patient photography? Plast Surg (Oakv). 2016;24(1):32-4. 2 Unpublished - Heyns M, Steve A, Dumestre DO, Fraulin FO, Yeung J. Canadian Guidelines on Smartphone Clinical Photography.
Documents
Less detail

Boxing (Update 2001)

https://policybase.cma.ca/en/permalink/policy192
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Replaces
Boxing (1986)
Topics
Population health/ health equity/ public health
Text
The CMA recommends to the appropriate government authorities that all boxing be banned in Canada. Until such time, strategies to prevent injury should be pursued. Background The CMA considers boxing a dangerous sport. While most sports involve risk of injury, boxing is distinct in that the basic intent of the boxer is to harm and incapacitate his or her opponent. Boxers are at significant risk of injuries resulting in brain damage. Boxers are susceptible not only to acute life-threatening brain trauma, but also to the chronic and debilitating effects of gradual cerebral atrophy. Studies demonstrate a correlation between the number of bouts fought and the presence of cerebral abnormalities in boxers. There is also a risk of eye injury including long-term damage such as retinal tears and detachments. Recommendations: - CMA supports a ban on professional and amateur boxing in Canada. - Until boxing is banned in this country, the following preventive strategies should be pursued to reduce brain and eye injuries in boxers: - Head blows should be prohibited. CMA encourages universal use of protective garb such as headgear and thumbless, impact-absorbing gloves - The World Boxing Council, World Boxing Association and other regulatory bodies should develop and enforce objective brain injury risk assessment tools to exclude individual boxers from sparring or fighting. - The World Boxing Council, World Boxing Association and other regulatory bodies should develop and enforce standard criteria for referees, ringside officials and ringside physicians to halt sparring or boxing bouts when a boxer has experienced blows that place him or her at imminent risk of serious injury. - The World Boxing Council, World Boxing Association and other regulatory bodies should encourage implementation of measures advocated by the World Medical Boxing Congress to reduce the incidence of brain and eye injuries. - CMA believes that the professional responsibility of the physician who serves in a medical capacity in a boxing contest is to protect the health and safety of the contestants. The desire of spectators, promoters of the event, or even injured athletes that they not be removed from the contest should not influence the physician’s medical judgment. - Further long term outcome data should be obtained from boxers in order to more accurately establish successful preventive interventions. CMA encourages ongoing research into the causes and treatments of boxing-related injuries, and into the effects of preventive strategies.
Documents
Less detail

The built environment and health

https://policybase.cma.ca/en/permalink/policy11063
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Population health/ health equity/ public health
Text
The Built Environment is part of the overall ecosystem of our earth. It encompasses all the buildings, spaces and products that are created, or at least significantly modified by people. It includes our homes, schools and workplaces, parks, business areas and roads. It extends overhead in the form of electric transmission lines, underground in the form of waste disposal sites and subway trains and across the country in the form of highways (Health Canada, 1997)." The built environment affects every one of us every day, and mounting evidence suggests that it can play a significant role in our state of health and well-being. This policy statement provides the perspective of the Canadian Medical Association on how the built environment can influence health, and what all sectors in society might do to ensure that community design and development takes the health of residents into consideration. Background In the 19th century, the industrial revolution attracted hordes of people into cities. Congestion, squalid living conditions, and lack of clean water, clean air, and proper sewage systems led to outbreaks of diseases such as cholera and tuberculosis. These events, coupled with the development of the germ theory, served as a catalyst for public and professional awareness of how the built environment has direct health impacts; clean water, fresh air, uncongested living conditions, and proper housing were all recognized as constituents of good health. During the past three decades, the 'Healthy Cities' movement has brought a renewed interest to the health implications of the built environment by focusing on disease prevention through community design. Over the years this idea has proliferated, and a body of literature has grown revealing the large scope of health risk factors that may be influenced by the built environment. The literature indicates that the following connections between the built environment and public health are possible: o Decreased physical activity o Increased prevalence of obesity o Increased prevalence of asthma and other respiratory diseases o Injuries and unintended fatalities o Heat exposure. (Frank , Kavage S, & Devlin A, 2012) (Franks, Kavage & Devlin, 2012; Health Canada 2013) There is also mounting evidence that these factors may be compounded for vulnerable populations such as children, the elderly, and those living in poverty. Smart Growth is an urban planning and transportation theory that became popular almost two decades ago. Though different organizations may differ slightly in their view of what smart growth means, its general aims are to build compact accessible cities that avoid urban sprawl and mitigate auto-dependence. The 'Smart Growth' movement contains tenets that research supports in creating healthy built environments such as mixed land uses, providing transportation alternatives like walking and bicycle infrastructure and public transit, and creating walkable neighbourhoods. (Smart Growth BC, 2012)(See definitions) What the Research Is Telling Us Physical Activity Canada's physical activity guidelines recommend that children from 5 to 11 should be active for at least 60 minutes a day; those 18 and over should be active for at least 150 minutes per week. (Canadian Society of Exercise Physiology, 2011). Participation in regular physical activity bestows substantial health benefits; it can lengthen and improve quality of life and reduce the risk for many physical and mental health conditions. Physical activity can improve overall fitness, lower risk for heart disease, stroke, and high blood pressure, lower risk for non-insulin dependent diabetes and the risk of overweight. (Dannenberg, Frumkin, & Jackson, 2011) Physical activity includes more than exercise and leisure time activity, it also includes active transportation such as walking to school, work or errands as part of daily living. One of the most important determinants of physical activity is a person's neighbourhood. (Jackson & Kochtotzky) Research shows that urban sprawl, access to parks and recreation/fitness facilities, and neighbourhood walkability all may have an impact on physical activity levels (Cutts, Darby, Boone, & Brewis, 2009; Ewing, Schmid, Killingsworth, Zlot, & Raudenbush, 2003). Individuals living in walkable neighbourhood with a mix of land uses and interconnected street networks were found to be 2-4 times more likely to achieve 30 minutes moderate physical activity a day. Urban design characteristics associated with higher physical activity rates include pedestrian-oriented street and site design, parks, trails, playgrounds and other recreational facilities within walking distance and sidewalks. (Frank , Kavage S, & Devlin A, 2012) A barrier to physical activity can be the perception of the lack of a safe place to be active. Safety concerns keep 1 in 5 Canadians from walking or bicycling. Urban design that encourages walking and cycling can improve perceived neighbourhood safety. (Heart and Stroke Foundation of Canada, 2011) There are unique barriers to active modes of transportation in rural communities. Rural environments often lack pedestrian facilities and bike lanes; stores, schools, jobs, and services are sometimes located far apart from homes; and parks and recreation facilities are rare. Understanding these barriers is the first step towards finding opportunities to remove them. (Active Living Research and the Public Health Institute, 2013) CMA' policy on Active Transportation recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation and physical activity. Increased prevalence of obesity Obesity has almost doubled in the past 3 decades; in 1978 the measured obesity rate was 13.8% and in 2008 the measured obesity rate was 25.4% (PHAC/CIHI, 2011). Obesity is associated with high blood pressure, stroke, and heart disease, which are among the leading causes of disability and death (Statistics Canada, 2008). Mental health conditions, type II diabetes, several types of cancer, among many other diseases, are also linked to obesity (Guh, Zhang, Bansback, Amarsi, Birmingham, & Anis, 2009). The combined cost of obesity and these related conditions was estimated to be $4.3 billion dollars in 2005 (Public Health Agency of Canada, 2012). There are many factors involved in this increase, but a causal indicator is the decline in physical activity among Canadians: In 2005, 47% of Canadians were reported as being 'inactive' (Human Resource and Skills Development Canada, 2006). Urban design that encourages sedentary living habits such as work, home, school and shopping separated by distances that discourage walking, parking lots built as close as possible to final destinations not only discourage walking but encourage automobile usage. (Jackson, Kochtitzky, CDC) Less walkable, auto dependent built environments have been correlated with higher body weights and obesity. (Frank , Kavage S, & Devlin A, 2012) Furthermore, research indicates that the food environment that we live in, and the amount of healthy food choices we have access to, can affect the chance of becoming obese as well. For example, neighbourhoods with a high density of fast food restaurants or neighbourhoods with poor access to grocery stores (food deserts) have both been correlated with obesity (Larsen & Gilliland, 2008; Cummins & Macintyre, 2006; Frank L. D., 2009). Increased prevalence of asthma and other respiratory diseases In August 2008, the CMA released a report estimating that the effects of air pollution would result in 11,000 hospital admissions and 21,000 deaths Canada wide, totaling a financial cost of close to $8.1 billion dollar (Canadian Medical Association, 2008). Carbon monoxide, sulfur and nitrogen oxides, volatile organic compounds, ozone, and lead, among other toxins, are emitted into the air every day from industrial processes and car exhaust. These air-borne chemicals are associated with heart disease, cancer, acute respiratory illness, and the aggravation of other respiratory illnesses such as asthma (Frank L. D., 2009). While the built environment does not directly produce these chemicals, it has a role to play in where those chemicals are emitted, where they are concentrated, and, in the case of vehicles, how much of them are produced. Urban sprawl has been tied to longer commute times and higher total vehicle miles traveled per person. Neighbourhood design and walkability have been identified as factors that can affect number of vehicle trips taken and transportation mode choice, and increased mixed land use has been identified as a factor that could further decrease emission rates (Newman & Kenworthy, 1989; Frank, Sallis, Conway, Chapman, Saelens, & Bachman, 2006). Injuries and unintentional fatalities Transport-related injuries accounted for a total of $3.7 billion dollars in healthcare costs in Canada in 2009 (SmartRisk, 2009). The majority of this financial burden was related to motor vehicle, pedestrian, and cycling accidents. Death and injuries from these types of incidents typically happen at a younger age which both increases the years of life lost due to death or disability and the financial burden of continuing care (SmartRisk, 2009). The built environment perhaps has the most identifiable and direct correlation to this category of impacts. Designs of auto-oriented environments that promote high traffic volume, high traffic speed, and low accessibility for pedestrians and cyclists lead to increased incidence of injuries and fatalities (Surface Transportation Policy Partnership, 2002). Increased prevalence of illness and death related to heat exposure The 'urban heat island effect' is a phenomenon correlated with urban environments that are primarily asphalt and concrete and lack vegetation and green space. Such environments have been estimated to have anywhere from 1oC to 12oC higher surface level temperatures in comparison to rural areas (United States Environmental Protection Agency, 2012). This can be especially dangerous for elderly individuals in the summertime and studies have demonstrated increased mortality amongst these populations during hot summers (Centers for Disease Control and Prevention, 2009). This is not only an issue of building materials and the balance of green space but has to do with isolation as well: If elderly residents have poor access to public transportation they may not be able to reach air-conditioned facilities. Noise Exposure Noise - be it from transport, industry, neighbours, or construction - is a prominent feature of the urban environment. Prolonged exposure to environmental noise has been directly linked to physical and psychosocial health outcomes, including hypertension, high blood pressure and heart disease, hearing impairment, stress levels, and sleep. There is some evidence linking noise to reduced ability to concentrate and more aggressive behavior. (Stansfeld SA, 2003) In general, denser neighbourhoods have higher levels of ambient noise through the concentration of more people, traffic, and activities. However, as with air pollution, noise exposure is extremely site-specific and not necessarily exclusive to walkable or auto-oriented neighbourhoods. (Frank , Kavage S, & Devlin A, 2012) Canadian noise mapping data would assist researchers in assessing how environmental noise affects health and assist communities to proactively manage noise pollution. Vulnerable populations The research shows that certain built environment characteristics may affect specific populations such as children, the elderly, low-income populations. Children: Overweight and obesity is an issue for Canadians nationwide, but particularly so for children. Between 1978 to 2004 there was a 70% increase in overweight and obese children aged 12-17 (Statistics Canada, 2006). Obesity in children can lead to health issues such as hypertension, glucose intolerance, and orthopedic complications (Statistics Canada, 2006). Furthermore obesity in childhood has a high likelihood of carrying over into adulthood and may result in further health problems such as diabetes and heart disease (Statistics Canada, 2006). With this in mind, environments that promote physical activity are especially important for this segment of the population. Living in mixed use communities with walkable destinations, parks and recreational facilities is related to greater physical activity. (Dannenburg, Frumkin & Jackson, 2011) Elderly: The elderly population is generally less physically robust and more prone to chronic illnesses, which make them especially vulnerable to air pollution and heat exposure. Physical activity is an important aspect of daily life for this age group as it has been shown to reduce the negative health impacts of aging (Vogel, Brechat, Lepetre, Kaltenbach, Berthel, & Lonsdorfer, 2009). Being physically active however, requires accessible and safe streets that cater to the needs of individuals with mobility issues. Special consideration is required when constructing the built environment to ensure the needs of this growing population. CMA's policy on Health and Health Care Principles for an Aging Population recommends that communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems or other aspects of the built environment. Low Income Populations: Low income populations are at higher risk for chronic illnesses such as high blood pressure and diabetes, and have a lower overall survivability for major heart attacks (Centre for Chronic Disease Prevention and Control. , 2002; Statistics Canada, 1996-97). They are also more likely to smoke, be overweight or obese, and are less likely to be physically active (Creatore, Gozdyra, Booth, & Glazier, 2007). Many of these factors may be due to limited access to stable housing, housing location (normally close to highways or industrial zones with high pollution exposure), neighbourhood safety, and lack of access to or affordability of healthy food options. Recommendations Planning and public health combined efforts in the 19th century to improve living conditions. Today there is a need for health care practitioners, particularly those in the public health field, and community planners to work together, to share their expertise and efforts, to improve the health and well-being of Canadians. By designing communities that encourage and support healthy living - physical activity, healthy weights, access to healthy foods - we can address some of the risk factors for many chronic diseases and create supportive, active communities. Health Care Associations can: o Advocate for health supportive environments by increasing the public and policy makers' understanding of the impact of the built environment on health. o Advocate for the contribution that public health professionals can make to urban planning and development to ensure that population health impacts are recognized and mitigated. o Provide community planners with strong public health arguments and health data to support healthy communities. Health Care Professionals can: o Incorporate an awareness of a patient's built environment (such as housing, access to transportation and healthy foods) into treatment programs and health counseling. o Encourage your community to adopt policies and design principles that build healthy supportive environments. Federal, Provincial and Local Governments can: o Integrate concepts of population health into urban planning. o Promote multidisciplinary planning teams, including professionals in medicine, public health and community design to ensure that all stakeholders take health impacts into account. o Incorporate health impact assessments into community planning and development initiatives in the public sector. o Encourage the private sector to provide infrastructure and amenities in developments that promote healthy living. The Public can: o Learn more about the connection between the built environment and health and advocate for positive change. o Become involved in public consultations regarding local community planning and development. Further Research o Develop research projects at the Federal level on the impact of the built environment on health to inform and help coordinate programs and initiatives at the provincial and local levels. o Focus on creating a standardized set of health indicators that can be uniformly applied to assess the status of a community's built environment. o Research into the effectiveness of policy options on various communities (urban, suburban, rural). Conclusion It is important that we acknowledge how our surroundings can affect our lives and health, and work together to create positive change. The CMA is willing to work with other people and organizations to ensure that the influence of the built environment on health receives the attention that it warrants with the ultimate goal of building or re-inventing healthy communities for all Canadians. Definitions In order of appearance Inactive: "Respondents are classified as active, moderately active or inactive based on an index of average daily physical activity over the past 3 months. For each leisure time physical activity engaged in by the respondent, an average daily energy expenditure is calculated by multiplying the number of times the activity was performed by the average duration of the activity by the energy cost (kilocalories per kilogram of body weight per hour) of the activity. The index is calculated as the sum of the average daily energy expenditures of all activities. Respondents are classified as follows: 3.0 kcal/kg/day or more = physically active; 1.5 to 2.9 kcal/kg/day = moderately active; less than 1.5 kcal/kg/day = inactive". (Human Resource and Skills Development Canada, 2006). Urban Sprawl: "A particular type of suburban development characterized by very low-density settlements, both residential and non-residential; dominance of movement by use of private automobiles, unlimited outward expansion of new subdivisions and leap-frog developments of these subdivisions; and segregation of land uses by activity." (United States Department of Housing and Urban Development, 1999) Walkability: Walkability refers to the ease with which pedestrians can move within and between environments. The literature gives varied definitions but the main variable to consider are the following: mixed land use (defined below), proximity to destinations (accessibility and convenience), pedestrian facilities (sidewalks, urban furniture etc...), street connectivity (short block lengths, availability of multiple alternate routes etc...), aesthetics (landscape, vegetation, architecture), presences of public spaces (parks, plazas, etc...), presence of traffic calming measures (lower speed limits, street narrowing, speed bumps etc...), and access to transit. (Shay, Spoon, & Khattak, 2003) Transportation Mode Choice: Transportation mode choice refers to an individuals decision regarding how to get from one destination to another. The theory behind mode choice is complex and involves characteristics of the built environment, socio-demographic and socioeconomic variables, benefit-cost analysis, and personal preference. (Cervero, Built Environments and Mode Choice: Toward a Normative Framework, 2002) Mixed Land Use: "Land use mix is the composition of uses within a given geographic area." (Cervero, Land Use Mixing and Suburban Mobility, 1998) The uses referred to can be restaurants, offices, studios, shops, or any variety of business, institution, natural space, or recreation site. In the literature there are various indices and equations used to measure the degree of 'mixed land use' in an area. Urban Heat Island Effect: The urban heat island effect occurs when the sun significantly heats urban surfaces (concrete, asphalt, etc...) to significantly higher temperatures than the surroundings air (can be upwards of 27-50oC). Comparatively shaded or more moist regions (such as rural areas with lots of vegetation) stay much closer to the surrounding air temperature. This heat imbalance between urban surfaces and surrounding air causes heat to transfer from those surfaces to the air, elevated the temperature above what it normally would be. This happens both at a surface and an atmospheric level. (United States Environmental Protection Agency, 2012) Smart Growth: Smart Growth is an urban planning and transportation theory that became popular almost two decades ago. Though different organization's may differ slightly in their view of what smart growth means, it's general aims are to build compact accessible cities that avoid urban sprawl and mitigate auto-dependence. Some of the principles of this movement are as follows: 1). Incorporate mixed land uses into community designs 2). Build compact, accessible neighbourhoods close to jobs and amenities 3). Provide alternative modes of public transportation 4). Diversify housing to meet the needs of people from all socioeconomic classes 5). Maintain and protect natural open spaces 6). Build within existing communities instead of developing beyond community boundaries 7). Preserve agricultural land 8). Use new, sustainable technology in infrastructure and buildings 9). Develop community identity 10). Encourage active citizens to remain engaged in their communities (Smart Growth BC, 2012) Bibliography Human Resource and Skills Development Canada. (2006). Retrieved July 15, 2012, from Indicators of Well-Being in Canada: Physical Activity: http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=8 Active Living Research and the Public Health Institute. (2013). Where the Rubber Meets the Road: Promoting Active Transportation in Rural Areas.. Retrieved September 2013, from Active Living Research : http://activelivingresearch.org/where-rubber-meets-road-promoting-active-transportation-rural-areas Canadian Medical Association. (2008). No Breathing Room: National Illness Cost of Air Pollution. Ottawa: CMA. Canadian Society of Exercise Physiology. (2011). Canadian Physical Activity Guidelines. Canadian Society of Exercise Physiology. Centers for Disease Control and Prevention. (2009, May 31). Extreme Heat: A Prevention Guide to Promote Your Personal Health and Safety. Retrieved July 15, 2012, from CDC: http://www.bt.cdc.gov/disasters/extremeheat/heat_guide.asp Centre for Chronic Disease Prevention and Control. . (2002). Diabetes in Canada, 2nd Edition. Ottawa: Health Canada. Cervero, R. (1998). Land Use Mixing and Suburban Mobility. Transportation Quarterly, 42(3). Cervero, R. (2002). Built Environments and Mode Choice: Toward a Normative Framework. Transportation Research Part D: Transport and Environment , 7(4), 265-284. Creatore, M., Gozdyra, P., Booth, G., & Glazier, R. (2007). Chapter 1: Setting the Context. In M. Creatore, P. Gozdyra, G. Booth, R. Glazier, & M. Tynan, Neighbourhood Environments and Resources for Healthy Living - A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences. Cummins, S., & Macintyre, S. (2006). Food Environments and Obesity - Neighbourhood or Nation. International Journal of Epidemiology, 35(1), 100-104. Cutts, B., Darby, K., Boone, C., & Brewis, A. (2009). City Structure, Obesity, and Environmental Justice: An Integrated Analysis of Physical and Social Barriers to Walkable Streets and Park Access. Social Science and Medicine, 69(9), 1314-1322. Dennenberg, A. L., Howard, F., & J, J. R. (Eds.). (2011). Making Healthy Places Designing and Building for Health, Well-being and Sustainability . Washington: Island Press. Department of Health and Human Resources. (2004, August 20). National Institute of Health. Retrieved July 30, 2012, from Obesity and the Built Environment: http://grants.nih.gov/grants/guide/rfa-files/rfa-es-04-003.html Ewing, R., Schmid, T., Killingsworth, R., Zlot, A., & Raudenbush, S. (2003). Relationship Between Urban Sprawl and Physical Activity, Obesity, and Morbidity. The Science of Health Promotion, 18(1), 47-57. Frank , L., Kavage S, & Devlin A. (2012). Health and the Built Environment: A Review. World Medical Association. Frank, L. D. (2009, January). Final Report on Health Assessment Tool Development for Peel Region by Larry Frank. Retrieved July 15, 2012, from Peel Region: http://www.peelregion.ca/health/urban/pdf/Peel-Lit-Review-Final-11072008-submitted.pdf Frank, L., Sallis, J., Conway, T., Chapman, J., Saelens, B., & Bachman, W. (2006). Many Pathways from Land Use to Health: Associations Between Neighborhood Walkability and Active Tranportation, Body Mass Index, and Air Quality. Journal of the American Planning Association, 72(1), 75-87. Guh, D., Zhang, W., Bansback, N., Amarsi, Z., Birmingham, C., & Anis, A. (2009). The Incidence of Co-morbidities Related to Obesity and Overweight: A Systematic Review and Meta-Analysis. Public Health, 9(88), 1-20. Heart and Stroke Foundation of Canada. (2011). Position Statements: Community Design,Physical Activity, Heart Disease and Stroke. Retrieved June 2012, from Heart and Stroke Foundation of Canada: http://www.heartandstroke.com/site/c.iklQLcMWJtE/b.3820627/ Jackson, R. J., & Kochtotzky, C. (n.d.). Creating a Healthy Enviroment: The Impact of the Built Environment on Public Health. Retrieved April 2012, from Sprawl Watch Clearinghouse Monograph Series: http://www.sprawlwatch.org/health.pdf Larsen, K., & Gilliland, J. (2008). Mapping the Evolution of 'Food Deserts" in a Canadian City: Supermarket Accessibility in London, Ontario, 1961-2005. International Journal of Health Geographics, 7(16), 1-16. Newman, P., & Kenworthy, J. (1989). Gasoline Consumption and Cities. Journal of the American Planning Association , 55(1), 24-37. PHAC/CIHI. (2011). Obesity in Canada. Ottawa: Public Health Agency of Canada. Public Health Agency of Canada. (2012, July 18). Obestiy in Canada: Snapshot. Retrieved July 29, 2012, from Public Health Agency of Canada: http://www.phac-aspc.gc.ca/publicat/2009/oc/index-eng.php Shay, E., Spoon, S., & Khattak, A. (2003). Walkable Environments and Walking Activity. Carolina Transportation Program, Department of City and Regional Planning. North Carolina: Carolina Transportation Program. Smart Growth BC. (2012). 10 Smart Growth Principles. Retrieved 30 July, 2012, from Smart Growth BC: http://www.smartgrowth.bc.ca/Default.aspx?tabid=133 SmartRisk. (2009). The Economic Burden of Injury in Canada. Toronto: SmartRisk. Stansfeld SA, M. M. (2003). Noise pollution: non-auditory effects on health. . British Medical Bulletin,, 68, 243-257. Statistics Canada. (1996-97, May 29). National Population Health Survey, Cycle 2. Canada: The Daily. Statistics Canada. (2006, June 28). Childhood Obesity: A Troubling Situation. Retrieved July 15, 2012, from StatsCan: http://www41.statcan.ca/2006/2966/ceb2966_004-eng.htm Statistics Canada. (2008). Mortality, Summary List of Causes. Health Statistics Division . Ottawa: Statistics Canada. Surface Transportation Policy Partnership. (2002). Mean Streets 2002. Washington, DC: STPP. United States Department of Housing and Urban Development. (1999). The State of the cities 1999: Third Annual Report. Washington, DC: USHUD. United States Environmental Protection Agency. (2012, July 13). Heat Island Effect. Retrieved July 29, 2012, from United States Environmental Protection Agency: http://www.epa.gov/hiri/ United States Environmental Protection Agency. (2012, June 21). Heat Island Effect: Basic Information. Retrieved July 15, 2012, from United States Environmental Protection Agency: http://www.epa.gov/hiri/resources/pdf/BasicsCompendium.pdf Vogel, T., Brechat, P., Lepetre, P., Kaltenbach, G., Berthel, M., & Lonsdorfer, J. (2009). Health Benefits of Physical Activity in Older Patients: A Review. The International Journal of Clinical Practice, 63(2), 303-320.
Documents
Less detail

CMA Code of Ethics and Professionalism

https://policybase.cma.ca/en/permalink/policy13937
Date
2018-12-08
Topics
Population health/ health equity/ public health
  3 documents  
Policy Type
Policy document
Date
2018-12-08
Replaces
Code of ethics of the Canadian Medical Association (Update 2004)
Topics
Population health/ health equity/ public health
Text
CMA CODE OF ETHICS AND PROFESSIONALISM Compassion A compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances of each patient and to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient. Honesty An honest physician is forthright, respects the truth, and does their best to seek, preserve, and communicate that truth sensitively and respectfully. Humility A humble physician acknowledges and is cautious not to overstep the limits of their knowledge and skills or the limits of medicine, seeks advice and support from colleagues in challenging circumstances, and recognizes the patient’s knowledge of their own circumstances. Integrity A physician who acts with integrity demonstrates consistency in their intentions and actions and acts in a truthful manner in accordance with professional expectations, even in the face of adversity. Prudence A prudent physician uses clinical and moral reasoning and judgement, considers all relevant knowledge and circumstances, and makes decisions carefully, in good conscience, and with due regard for principles of exemplary medical care. The CMA Code of Ethics and Professionalism articulates the ethical and professional commitments and responsibilities of the medical profession. The Code provides standards of ethical practice to guide physicians in fulfilling their obligation to provide the highest standard of care and to foster patient and public trust in physicians and the profession. The Code is founded on and affirms the core values and commitments of the profession and outlines responsibilities related to contemporary medical practice. In this Code, ethical practice is understood as a process of active inquiry, reflection, and decision-making concerning what a physician’s actions should be and the reasons for these actions. The Code informs ethical decision-making, especially in situations where existing guidelines are insufficient or where values and principles are in tension. The Code is not exhaustive; it is intended to provide standards of ethical practice that can be interpreted and applied in particular situations. The Code and other CMA policies constitute guidelines that provide a common ethical framework for physicians in Canada. In this Code, medical ethics concerns the virtues, values, and principles that should guide the medical profession, while professionalism is the embodiment or enactment of responsibilities arising from those norms through standards, competencies, and behaviours. Together, the virtues and commitments outlined in the Code are fundamental to the ethical practice of medicine. Physicians should aspire to uphold the virtues and commitments in the Code, and they are expected to enact the professional responsibilities outlined in it. Physicians should be aware of the legal and regulatory requirements that govern medical practice in their jurisdictions. Trust is the cornerstone of the patient–physician relationship and of medical professionalism. Trust is therefore central to providing the highest standard of care and to the ethical practice of medicine. Physicians enhance trustworthiness in the profession by striving to uphold the following interdependent virtues: A. VIRTUES EXEMPLIFIED BY THE ETHICAL PHYSICIAN 2 B. FUNDAMENTAL COMMITMENTS OF THE MEDICAL PROFESSION Consider first the well-being of the patient; always act to benefit the patient and promote the good of the patient. Provide appropriate care and management across the care continuum. Take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a risk of harm or if harm has occurred. Recognize the balance of potential benefits and harms associated with any medical act; act to bring about a positive balance of benefits over harms. Commitment to the well-being of the patient Promote the well-being of communities and populations by striving to improve health outcomes and access to care, reduce health inequities and disparities in care, and promote social accountability. Commitment to justice Practise medicine competently, safely, and with integrity; avoid any influence that could undermine your professional integrity. Develop and advance your professional knowledge, skills, and competencies through lifelong learning. Commitment to professional integrity and competence Always treat the patient with dignity and respect the equal and intrinsic worth of all persons. Always respect the autonomy of the patient. Never exploit the patient for personal advantage. Never participate in or support practices that violate basic human rights. Commitment to respect for persons Contribute to the development and innovation in medicine through clinical practice, research, teaching, mentorship, leadership, quality improvement, administration, or advocacy on behalf of the profession or the public. Participate in establishing and maintaining professional standards and engage in processes that support the institutions involved in the regulation of the profession. Cultivate collaborative and respectful relationships with physicians and learners in all areas of medicine and with other colleagues and partners in health care. Commitment to professional excellence Value personal health and wellness and strive to model self-care; take steps to optimize meaningful co-existence of professional and personal life. Value and promote a training and practice culture that supports and responds effectively to colleagues in need and empowers them to seek help to improve their physical, mental, and social well-being. Recognize and act on the understanding that physician health and wellness needs to be addressed at individual and systemic levels, in a model of shared responsibility. Commitment to self-care and peer support Value and foster individual and collective inquiry and reflection to further medical science and to facilitate ethical decision-making. Foster curiosity and exploration to further your personal and professional development and insight; be open to new knowledge, technologies, ways of practising, and learning from others. Commitment to inquiry and reflection 3 C. PROFESSIONAL RESPONSIBILITIES The patient–physician relationship is at the heart of the practice of medicine. It is a relationship of trust that recognizes the inherent vulnerability of the patient even as the patient is an active participant in their own care. The physician owes a duty of loyalty to protect and further the patient’s best interests and goals of care by using the physician’s expertise, knowledge, and prudent clinical judgment. In the context of the patient–physician relationship: 1. Accept the patient without discrimination (such as on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation, or socioeconomic status). This does not abrogate the right of the physician to refuse to accept a patient for legitimate reasons. 2. Having accepted professional responsibility for the patient, continue to provide services until these services are no longer required or wanted, or until another suitable physician has assumed responsibility for the patient, or until after the patient has been given reasonable notice that you intend to terminate the relationship. 3. Act according to your conscience and respect differences of conscience among your colleagues; however, meet your duty of non-abandonment to the patient by always acknowledging and responding to the patient’s medical concerns and requests whatever your moral commitments may be. 4. Inform the patient when your moral commitments may influence your recommendation concerning provision of, or practice of any medical procedure or intervention as it pertains to the patient’s needs or requests. 5. Communicate information accurately and honestly with the patient in a manner that the patient understands and can apply, and confirm the patient’s understanding. 6. Recommend evidence-informed treatment options; recognize that inappropriate use or overuse of treatments or resources can lead to ineffective, and at times harmful, patient care and seek to avoid or mitigate this. 7. Limit treatment of yourself, your immediate family, or anyone with whom you have a similarly close relationship to minor or emergency interventions and only when another physician is not readily available; there should be no fee for such treatment. 8. Provide whatever appropriate assistance you can to any person who needs emergency medical care. 9. Ensure that any research to which you contribute is evaluated both scientifically and ethically and is approved by a research ethics board that adheres to current standards of practice. When involved in research, obtain the informed consent of the research participant and advise prospective participants that they have the right to decline to participate or withdraw from the study at any time, without negatively affecting their ongoing care. 10. Never participate in or condone the practice of torture or any form of cruel, inhuman, or degrading procedure. Physicians and patients Patient-physician relationship 4 11. Empower the patient to make informed decisions regarding their health by communicating with and helping the patient (or, where appropriate, their substitute decision-maker) navigate reasonable therapeutic options to determine the best course of action consistent with their goals of care; communicate with and help the patient assess material risks and benefits before consenting to any treatment or intervention. 12. Respect the decisions of the competent patient to accept or reject any recommended assessment, treatment, or plan of care. 13. Recognize the need to balance the developing competency of minors and the role of families and caregivers in medical decision-making for minors, while respecting a mature minor’s right to consent to treatment and manage their personal health information. 14. Accommodate a patient with cognitive impairments to participate, as much as possible, in decisions that affect them; in such cases, acknowledge and support the positive roles of families and caregivers in medical decision-making and collaborate with them, where authorized by the patient’s substitute decision-maker, in discerning and making decisions about the patient’s goals of care and best interests. 15. Respect the values and intentions of a patient deemed incompetent as they were expressed previously through advance care planning discussions when competent, or via a substitute decision-maker. 16. When the specific intentions of an incompetent patient are unknown and in the absence of a formal mechanism for making treatment decisions, act consistently with the patient’s discernable values and goals of care or, if these are unknown, act in the patient’s best interests. 17. Respect the patient’s reasonable request for a second opinion from a recognized medical expert. Physicians and the practice of medicine Patient privacy and the duty of confidentiality 18. Fulfill your duty of confidentiality to the patient by keeping identifiable patient information confidential; collecting, using, and disclosing only as much health information as necessary to benefit the patient; and sharing information only to benefit the patient and within the patient’s circle of care. Exceptions include situations where the informed consent of the patient has been obtained for disclosure or as provided for by law. 19. Provide the patient or a third party with a copy of their medical record upon the patient’s request, unless there is a compelling reason to believe that information contained in the record will result in substantial harm to the patient or others. 20. Recognize and manage privacy requirements within training and practice environments and quality improvement initiatives, in the context of secondary uses of data for health system management, and when using new technologies in clinical settings. 21. Avoid health care discussions, including in personal, public, or virtual conversations, that could reasonably be seen as revealing confidential or identifying information or as being disrespectful to patients, their families, or caregivers. Medical decision-making is ideally a deliberative process that engages the patient in shared decision-making and is informed by the patient’s experience and values and the physician’s clinical judgment. This deliberation involves discussion with the patient and, with consent, others central to the patient’s care (families, caregivers, other health professionals) to support patient-centred care. In the process of shared decision-making: Decision-making 5 22. Recognize that conflicts of interest may arise as a result of competing roles (such as financial, clinical, research, organizational, administrative, or leadership). 23. Enter into associations, contracts, and agreements that maintain your professional integrity, consistent with evidenceinformed decision-making, and safeguard the interests of the patient or public. 24. Avoid, minimize, or manage and always disclose conflicts of interest that arise, or are perceived to arise, as a result of any professional relationships or transactions in practice, education, and research; avoid using your role as a physician to promote services (except your own) or products to the patient or public for commercial gain outside of your treatment role. 25. Take reasonable steps to ensure that the patient understands the nature and extent of your responsibility to a third party when acting on behalf of a third party. 26. Discuss professional fees for non-insured services with the patient and consider their ability to pay in determining fees. 27. When conducting research, inform potential research participants about anything that may give rise to a conflict of interest, especially the source of funding and any compensation or benefits. 28. Be aware of and promote health and wellness services, and other resources, available to you and colleagues in need. 29. Seek help from colleagues and appropriate medical care from qualified professionals for personal and professional problems that might adversely affect your health and your services to patients. 30. Cultivate training and practice environments that provide physical and psychological safety and encourage help-seeking behaviours. 31. Treat your colleagues with dignity and as persons worthy of respect. Colleagues include all learners, health care partners, and members of the health care team. 32. Engage in respectful communications in all media. 33. Take responsibility for promoting civility, and confronting incivility, within and beyond the profession. Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues. 34. Assume responsibility for your personal actions and behaviours and espouse behaviours that contribute to a positive training and practice culture. 35. Promote and enable formal and informal mentorship and leadership opportunities across all levels of training, practice, and health system delivery. 36. Support interdisciplinary team-based practices; foster team collaboration and a shared accountability for patient care. Physicians and self Physicians and colleagues Managing and minimizing conflicts of interest 6 38. Recognize that social determinants of health, the environment, and other fundamental considerations that extend beyond medical practice and health systems are important factors that affect the health of the patient and of populations. 39. Support the profession’s responsibility to act in matters relating to public and population health, health education, environmental determinants of health, legislation affecting public and population health, and judicial testimony. 40. Support the profession’s responsibility to promote equitable access to health care resources and to promote resource stewardship. 41. Provide opinions consistent with the current and widely accepted views of the profession when interpreting scientific knowledge to the public; clearly indicate when you present an opinion that is contrary to the accepted views of the profession. 42. Contribute, where appropriate, to the development of a more cohesive and integrated health system through interprofessional collaboration and, when possible, collaborative models of care. 43. Commit to collaborative and respectful relationships with Indigenous patients and communities through efforts to understand and implement the recommendations relevant to health care made in the report of the Truth and Reconciliation Commission of Canada. 44. Contribute, individually and in collaboration with others, to improving health care services and delivery to address systemic issues that affect the health of the patient and of populations, with particular attention to disadvantaged, vulnerable, or underserved communities. Approved by the CMA Board of Directors Dec 2018 37. Commit to ensuring the quality of medical services offered to patients and society through the establishment and maintenance of professional standards. Physicians and society
Documents
Less detail

CMA guidelines on judicial advocacy

https://policybase.cma.ca/en/permalink/policy14018
Policy Type
Policy document
Date
2018-12-08
Replaces
CMA Guidelines on Court Interventions
Text
The CMA’s stance on intervention and judicial advocacy is to bring an evidence-based perspective to assist in relation to the decision-making of issues at hand. CMA’s strategic plan and guiding principles opens the possibility that there may be circumstances when legal advocacy, and in particular judicial advocacy, may be leveraged strategically and proactively as a further tool in CMA’s advocacy toolbox to bring a non-partisan, evidence-based perspective to the courtroom that would further the organization’s vision for “a vibrant professional and a healthy population”. Purpose and Scope of Policy Given CMA 2020, and informed by knowledge of past experiences, the purpose of this policy is to provide guidelines to assist with decision making as to whether CMA should use legal action, as part of its advocacy toolbox, to move CMA’s work forward on a cause or issue. Cases Deemed Appropriate for CMA Judicial Advocacy – General Principles 1. Stage and Venue of Proceedings a) Generally, CMA will only engage in a proposed case at an appellate level or in the highest forum in which a matter is likely to be finally decided. b) Exceptionally, the CMA may engage in a proposed case at a lower court or a court of first instance where: i) circumstances justify engagement, such as an invitation from the court or where physicians’ expertise is necessary to create a trial record that supports the CMA’s policy position(s) or provides added relevant information that is not otherwise being provided or would highlight a critical issue that requires attention or would attract the attention of relevant parties. c) Exceptionally, CMA may leverage international fora (e.g., United Nations treaty bodies) where involvement could help advance a specific cause or issue being championed by the CMA. 2. CMA’s Role in Proceedings With some rare exceptions , , the CMA will only assume the role of intervener in a proposed case. The CMA will intervene where the CMA may bring a non-partisan, evidence-based analysis to an issue and where there are compelling reasons for doing so, considering the evaluation criteria contained in the Reference Guide in Appendix 1 of this policy. 3. Relevance to Existing CMA Policy a) The CMA may engage in a proposed case where engagement would constitute a significant contribution to the consideration of the issue or issues involved and only when the position sought to be advanced is: i. supported by and consistent with previously adopted policy of CMA; or ii. a matter of compelling public or professional interest which the Board of Directors then adopts as CMA policy following appropriate consultation. b) Where there is CMA policy that is clear, relevant to the proposed case and a matter of record, the policy should be cited and explained (e.g., in factum or affidavit). c) If the CMA’s proposed stance in a case proceeding supports a position which the CMA has not previously adopted as policy, the CMA Board of Directors must adopt the position as policy before authorizing the activity. 4. Issue of National, Special and/or Unifying Significance to Profession a) The CMA will generally only engage in a proposed case of special and unifying significance to the medical profession. b) The CMA will not engage in a proposed case where the matter is only of local or regional concern or of a private nature with no public interest or compelling professional or public policy component. 5. Potential Case Outcome(s) and Effect(s) Prior to engagement, the CMA must consider the potential impact(s) (both favourable and unfavourable) of the legal precedent that may set by the proposed case on members of the medical profession and patients. 6. Collaboration with Provincial/Territorial Associations, Affiliates and other Organizations a) In the spirit of community building and collaborating with those who share our vision, the CMA welcomes opportunities to collaborate with provincial or territorial associations, affiliates and other organizations provided that these Guidelines are followed and that the other organizations i. share positions on the issues at stake in the case that are consistent with CMA policy. ii. can follow through on tasks, deadlines and communication needs related to collaboration. b) While not mandatory, CMA would expect mutual assistance in funds and in kind when it collaborates with another organization (in relation to a judicial proceeding) or is asked to intervene. 7. Reputational Risk and Stakeholder Relations Implications The CMA will consider as a general principle whether involvement in a proposed case: a) may present the CMA with reputational risk(s) (e.g., inconsistent with mission and values, controversial, too political). b) may impact relations with other stakeholders, including provincial/territorial medical associations, associates, affiliates and other organizations. 8. Financial and Resource Implications The CMA will consider as a general principle the financial and resource implications of involvement in a proposed case such as the affordability of the proceeding, or competing demands for limited resources and staff availability. To the extent possible, the CMA will seek pro bono external legal assistance. Authorization to Engage in Judicial Advocacy CMA’s Senior Management Team will generally perform a preliminary analysis of the proposal to engage in a proposed case and may use the Reference Guide appended to these guidelines as a decision-making tool (see Appendix 1). The decision to engage in a proposed case must be ultimately authorized by the CMA Board of Directors. Once the Board has authorized the application, CMA staff will follow established internal protocol and procedures in the preparation of the required documentation according to the appended Working Draft Protocol (see Appendix 3). CMA staff will regularly provide the CMA Board with updates of the Court proceeding. Appendix 1: Reference guide for determining if appropriate for CMA to engage in judicial advocacy on a matter, in accordance with CMA Guidelines on Judicial Advocacy Degree to which criterion favours proposed judicial advocacy initiative (please provide reasons for choice) Strongly favours Somewhat favours Mildly favours Does not favour Stage and venue of proceedings Court of highest level? If yes, mark as “strongly favours” Appellate level? If yes, mark as “somewhat favours” If not court of highest level or other appellate court, indicate jurisdiction Relevance of matter to existing CMA policy Is matter consistent with previously adopted policy? Is matter of compelling public interest that may be adopted as policy? Is matter of compelling professional interest that may be adopted as policy? Issue of National, Special or Unifying Significance to the Profession Does matter have impact beyond local/regional level? Does matter have special or unifying significance for medical profession? Collaboration or Request for Involvement Co-intervention? Other request for involvement? Practical Considerations Financial implications Reputational risk Stakeholder relations implications Appendix 2: Contents of Request for CMA to Intervene 1. Requests for CMA to intervene in court proceedings can arrive from multiple sources (internally – CMA Board, CMA provincial or territorial associations, affiliates, another organization, an individual member, etc.). CMA’s Legal Services Department may also monitor judicial developments and identify cases of special interest to CMA. 2. Unless there are exceptional circumstances, the request for CMA to intervene in a court proceeding shall contain the following: (i) The style or caption of the case, identification of the last court to render a decision in the case and the court in which it is proposed to intervene. A copy of the decision or order appealed from, any accompanying reasons and other relevant documentation must be attached to (or linked from) the proposal; (ii) The date by which the proposed application for leave to intervene and factum must be filed; (iii) The issues before the Court and potential outcomes, dissenting views and likelihood of success, including policy implications for CMA depending on the various outcomes; (iv) The position sought to be advanced on CMA’s behalf and how this position is consistent with existing CMA policy. If there is no existing CMA policy, the request should state why CMA should adopt the policy prior to intervention; (v) If the request relates to a local or regional matter, an explanation of how the position to be taken is not inconsistent with CMA policy and the broader interests and concerns of CMA; (vi) Consultations undertaken, if any, on why the matter warrants CMA intervention as a compelling issue of public policy and special interest to the medical profession; (vii) A list of other organizations that might have an interest in the intervention or co-intervening with CMA; (viii) Disclosure of any personal or professional interest, in the matter on the part of any individual or organization participating in the decision to seek the Board of Directors’ authorization to intervene; and (ix) Budget development. 3. Where the request to intervene arises in a case where there is no existing CMA policy on the issue, the party making the request should demonstrate the urgency and importance of adopting the policy position to be advanced. Appendix 3: Working Draft Protocol and Procedures for Court Intervention Document Preparation
CMA staff will prepare the application documents for leave to intervene in concert with expert litigation legal counsel.
Depending on the issues before the Court, the President or Chair or the CMA Board may review the contents of the application documents for leave to intervene and the actual factum prior to filing with the Court. Alternatively, the application documents and factum will be shared as information items with the CMA President and Board after filing. The decision to obtain the President and/or Chair and/or Board approval or not prior to filing lies with the CMA CEO.
CMA staff may also consult with the President and Chair on the choice of individual filing the affidavit (called the “affiant”) on CMA’s behalf. The affiant will in most circumstances be a physician, usually at the elected level, with experience and expertise on the issues before the Court.
All CMA Departments will consult with and co-ordinate with the CMA Legal Department. For example, the content of any Communication Strategy documents (e.g. press releases, media alerts, news articles, etc.) as part of the court proceeding must be consistent with the contents of CMA’s application for leave to intervene documents and factum. Approved by the CMA Board of Directors Dec 2018
Documents
Less detail

CMA Policy Endorsement Guidelines

https://policybase.cma.ca/en/permalink/policy14021
Date
2018-03-03
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Date
2018-03-03
Topics
Ethics and medical professionalism
Text
These Guidelines constitute an implementation tool of seven recommendations and are informed by Guidelines for CMA’s Activities and Relationships with Other Parties (aka CMA’s Corporate Relationships Policy) and CMA’s Advertising and Sponsorship Policy. 1. Scope These Guidelines apply to the Canadian Medical Association (and not to its subsidiaries). As these are Guidelines, exceptions may be necessary from time to time wherein staff may use their discretion and judgment. 2. Definition Endorsement is an umbrella term encompassing “policy endorsement”, “sponsorship1” and “branding”. Policy endorsement includes: (a) CMA considering upon request, non-pecuniary public approval, which may include the use of CMA’s name and/or logo, of an organization’s written policy, on an issue that aligns with CMA policy, where there is no immediate expectation of return; or, (b) CMA adopting the policy of another organization as our policy; or (c) CMA asking another organization to publicly support our policy. 3. Process (a) Criteria: For policy endorsement requests from another organization to endorse their policy2 the following criteria shall be applied: i) we have a policy on the subject-matter and ii) we are actively working on advancing that policy position and iii) the organization has a follow-up action plan associated with its request. (b) Approval: Where policy exists, approval requires a policy staff member (with portfolio responsibility) and the VP of Medical Professionalism, or the policy staff member (with portfolio responsibility) and the Chief Policy Advisor. Where no policy exists, approval of the Board of Directors is required. (c) Annual confirmation: Where CMA adopts the policy of another organization3, CMA staff shall confirm annually, or more frequently if circumstances dictate, that the policy has not been altered by the other organization. (d) Requests: Pursuit of personal endorsement requests are not appropriate. Wherever possible, requests should come from an organization and not an individual. 4. Results (a) Where CMA adopts the policy of another organization, the adopted policy shall become CMA policy, and will include a notation on the document as being an adopted policy of [organization]. (b) All adopted policies will be housed in an accessible searchable database. (c) All requests by organizations for CMA to endorse their policy will be tracked in a central location, along with any response. 1 Sponsorship means, to consider upon request, pecuniary public approval, which may include the use of CMA’s name and/or logo, of an organization’s event (eg., conference), on an issue that is supported by CMA policy or that promotes CMA brand awareness, where there is an immediate expectation of return. 2 That is, part (a) of the definition in Section 2. 3 That is, part (b) of the definition in Section 2.
Documents
Less detail

Drug testing in the workplace (Update 2001)

https://policybase.cma.ca/en/permalink/policy194
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Replaces
Drug testing in the workplace (1992)
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Health and safety in the workplace continue to be areas of concern to the CMA. The CMA recommends that educational programs on the risks of drug-related impairment to health and safety in the workplace be directed toward labour, management and the public in general. Occupations for which impairment resulting from drug use may constitute a serious hazard should be identified and designated as such. The association recommends that supervisors be trained to refer a worker in a safety-sensitive job for a health assessment if the supervisor has reasonable grounds to suspect impairment of the worker. Workers holding safety-sensitive jobs should be educated to report any departure from their usual state of health as well as any drugs (prescribed or otherwise) being taken to the occupational health physician or, in the absence of such, to the physician of the worker's choice. The CMA is opposed to routine pre-employment drug testing. It recommends that random drug testing among employees be restricted to safety-sensitive positions and undertaken only when measures of performance and effective peer or supervisory observation are unavailable. Drug testing should always be conducted in such a way as to protect confidentiality and should be undertaken with the subject's informed consent (except when otherwise required by law). The idea of drug testing among workers has developed from society's concern over the relation between drug use and impairment, with resultant risks to the worker, fellow workers and the public. Education: Since prevention is the principal and ultimate objective the association recommends that educational programs on the risks of impairment to health and safety in the workplace be directed toward labour, management and the public in general. Illicit drugs are not the only ones that may cause impairment. Certain prescription drugs and even some over-the-counter medications may affect a person's ability to carry out professional functions safely; such effects may vary considerably from one person to another. Alcohol is by far the most common impairing drug implicated in accidents; in addition, the scientific literature contains a growing body of information on impairment and dangers resulting from the use and misuse of various therapeutic medications. Far less is documented or known about the role of illicit drugs in work-related accidents. Safety-sensitive occupations: In most workplaces there are occupations for which impairment may constitute a serious hazard. Such occupations should be identified and designated as such. Workers who hold such safety-sensitive jobs must accept the fact that other workers and the public need to be protected from the hazards of impairment, whether from physical or psychologic ill health or from the use of drugs (over-the-counter, prescription or illicit). Performance assessment of safety-sensitive occupations: The CMA recommends that supervisors be trained to refer a worker in a safety-sensitive job for a health assessment if the supervisor has reasonable grounds (e.g., unsatisfactory performance or observed unusual behaviour) to suspect impairment of the worker. The examining physician may recommend that some tests (including tests for the presence of certain drugs) be carried out under pre-agreed protocols. Workers holding safety-sensitive jobs must be educated to report any departure from their usual state of health as well as any drugs (prescribed or otherwise) they may be taking to the occupational health physician or, in the absence of such, to the physician of the worker's choice. Testing: Any discussion of drug testing must take the following into account: If a quantitative test is to be used to determine impairment a limit must be established beyond which a person is deemed to be impaired. However, since the threshold of impairment varies from one person to another this variation should be taken into account when a worker is being assessed. The tests must be valid and reliable. They must be performed only in laboratories accredited for drug testing. The tests must provide results rapidly enough to be useful in deciding whether the person should continue to work. If different testing procedures are available and the differences between the validity and reliability are not significant the least intrusive alternative should be chosen. The test should be conducted in such a way as to ensure confidentiality and should be undertaken with the subject's informed consent (except when otherwise required by law). Pre-employment testing: The CMA opposes routine pre-employment drug testing for the following reasons: Routine pre-employment drug screening may not objectively identify those people who constitute a risk to society. The mass, low-cost screening tests may not be reliable or valid. The circumstances may not justify possible human rights violations. Random testing: The CMA believes that random drug testing among employees has a limited role, if any, in the workplace. Such testing should be restricted to employees in safety-sensitive positions and undertaken only when measures of performance and effective peer or supervisory observation are unavailable. Role of occupational health services: Occupational health physicians must not be involved in a policing or disciplinary role with respect to employee testing. CMA recommends that employers provide a safe environment for all workers. With the help of experts such as those from national and provincial agencies dedicated to dealing with substance abuse occupational health departments should develop lists of drugs known to cause short-term or long-term impairment, including alcohol. These lists should be posted prominently in the workplace, and workers should be advised that in the event of obvious impairment those involved in safety-sensitive occupations will be asked to undergo medical assessment. If testing for drugs is indicated refusal to submit to testing may result in a presumption of noncompliance with the health requirements of the job. Alcohol impairment should not be tolerated, and legislation should be considered that would set a legal blood alcohol level for safety-sensitive occupations. Breathalyzers or other detection methods could be used if alcohol impairment is suspected in a person holding safety-sensitive occupation. As stated previously, refusal to submit to testing may result in a presumption of noncompliance with the health requirements of the job. These measures should be discussed with labour and management. Labour should be expected to recognize drug-related impairment as a serious health and safety issue, and management should demonstrate its concern by ensuring access to treatment, prevention and educational programs such as employee assistance programs.
Documents
Less detail

Ensuring equitable access to health care: Strategies for governments, health system planners, and the medical profession

https://policybase.cma.ca/en/permalink/policy11062
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Ensuring equitable access to effective and appropriate health care services is one strategy which can help to mitigate health inequities resulting from differences in the social and economic conditions of Canadians. Equitable access can be defined as the opportunity of patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.1 There is far ranging evidence indicating that access to care is not equitable in Canada. Those with higher socio-economic status have increased access for almost every health service available, despite having a generally higher health status and therefore a decreased need for health care. This includes insured services (such as surgery), as well as un-insured services such as pharmaceuticals and long-term care. Those from disadvantaged groups are less likely to receive appropriate health care even if access to the system is available. They are more likely to report trouble getting appointments, less testing and monitoring of chronic health conditions, and more hospitalizations for conditions that could be avoided with appropriate primary care. There is a financial cost to this disparity in equitable care. Reducing the differences in avoidable hospitalizations alone could save the system millions of dollars. Barriers to equitable access occur on both the patient and health care system or supply side. Common barriers include: (see pdf for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers To tackle barriers on the patient side there is a need to reduce barriers such as transportation and the prohibitive cost of some medically necessary services. Further, there is a need to increase the health literacy of patients and their families/caregivers as well as providing support to health care providers to ensure that all patients are able to be active participants in the management of their care. On the system side the strategies for action fall into four main categories: patient-centred primary care which focuses on chronic disease management; better care coordination and access to necessary medical services along the continuum of care; quality improvement initiatives which incorporate considerations of equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. Recommendations are provided for CMA and national level initiatives; health care planners; and physicians in practice. Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. Introduction: In Canada as in many countries around the world there are major inequities in health status across the population. Those lower on the socio-economic scale face higher burdens of disease, greater disability and even shorter life expectancies.2 Many of these disparities are caused by differences in social and economic factors such as income and education known as the social determinants of health.3,1 While many of these factors are outside of the direct control of the health care system, ensuring equitable access to effective and appropriate health care services can help to mitigate some of these disparities. The alternative can also be true. In health systems where access to care and appropriateness are unequal and skewed in favour of those of higher socio-economic status, the health system itself can create further inequities and add greater burden to those already at an increased risk of poor health. Physicians as leaders in the health care system can play a role in ensuring equitable access to care for all Canadians. Equitable Access to Health Care in Canada: Equitable access can be defined as the opportunity for patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.4 Due to burden of disease and therefore need, those with lower socio-economic status should be utilizing more services along the continuum.5 That, however, is not the case. Individuals living in lower income neighbourhoods, younger adults and men are less likely to have primary care physicians than their counterparts.6 Primary care physicians deliver the majority of mental illness treatment and they are the main source of referrals to psychiatrists or other specialists. However, much of the care for people with mental illnesses, especially on the lower socio-economic end of the scale, is delivered in emergency rooms, which is both costly and episodic. This is due not only to a lack of primary care access but to a lack of community mental health services.7 Those with higher socio-economic status are much more likely to have access to and utilize specialist services.8 Examples include greater likelihood of catheterization and shorter waits for angiography for patients with myocardial infarction9; and greater access to in-hospital physiotherapy, occupational therapy, and speech language therapy for those hospitalized with acute stroke10. Low income men and women with diabetes were just as likely to visit a specialist for treatment as high income individuals despite a significantly greater need for care.11 There is a correlation between higher income and access to day surgery.12 A Toronto study found that inpatient surgery patients were of much higher income than medical inpatients.13 Additionally, utilization of diagnostic imaging services is greater among those in higher socio-economic groups.14 Access to preventive and screening programs such as pap smears and mammography are lower among disadvantaged groups.15 Geography can cause barriers to access. In general rural Canadians have higher health care needs but less access to care.16 People in northern and rural communities typically have to travel great distances to obtain health services as many, especially specialist services, cannot be obtained in their home community.17 Those living in the most rural communities in Canada are the least likely to have a regular family doctor, or to have had a specialist physician visit.18 According to data from the Society of Rural Physicians of Canada, 21% of the Canadian population is rural while only 9.4% of family physicians and 3% of specialists are considered rural.19 This lack of access to specialists and other medically necessary services can lead to delays in treatment and harm to health including unnecessary pain and permanent disability.20 Further, travel for necessary treatment often comes with a significant financial cost.21 It is not just access to insured services that is a problem in Canada. Many Canadians do not have access to needed pharmaceuticals. Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.22 The use of appropriate diabetes preventative services, medication, and blood glucose testing, has been shown to be dependent on out of pocket expenditures.23 Rehabilitation services are difficult for some Canadians to access as well. Services such as physiotherapy and occupational therapy are often not covered unless they are provided in-hospital or to people on certain disability support programs. This leads to long wait times for services that are covered or no access at all.24 Adding to these inequities is the fact that different programs are covered in different provinces and territories.25 Access to mental health services is a major challenge for Canadians. According to data from Statistics Canada, more than half a million Canadians who had a perceived need for mental health care services, reported that their needs were unmet. Access to counselling services was the most frequent unmet need reported.26 A number of important mental health professionals - notably psychologists and counsellors - are not funded through provincial health budgets, or are funded only on a very limited basis. Access to psychologists is largely limited to people who can pay for them, through private insurance or out of their own pockets.27,2 Access to subsidized residential care, long-term care, home care and end-of-life care is problematic as well. Those with means can access high quality long-term care services within their community, while those with inadequate resources are placed in lower quality facilities sometimes hours away from family and friends.28 Even with expansions promised by governments, home care will not be able to meet the needs of underserved groups such as those living in rural and remote areas.29 Finally, only a fraction of patients have access to or receive palliative and end-of-life care. Those living in rural or remote areas or living with disabilities have severely limited access to formal palliative care.30 Difficulties in access are particularly acute for Canada's Aboriginal peoples. Many live in communities with limited access to health care services, sometimes having to travel hundreds of miles to access care.31 Additionally, there are jurisdictional challenges; many fall through the cracks between the provincial and federal health systems. While geography is a significant barrier for Aboriginal peoples, it is not the only one. Aboriginals living in Canada's urban centres also face difficulties. Poverty, social exclusion and discrimination can be barriers to needed health care. Of all federal spending on Aboriginal programs and services only 10% is allocated to urban Aboriginals. This means that Aboriginals living in urban areas are unable to access programs such as Aboriginal head start, or alcohol and drug services, which would be available if they were living on reserve.32 Further, even when care is available it may not be culturally appropriate. Finally, Canada's Aboriginal peoples tend to be over-represented in populations most at risk and with the greatest need for care, making the lack of access a much greater issue for their health status.33 However, these examples are only part of the story as accessing care which is inappropriate cannot be considered equitable access.34 Those of lower socio-economic status are more likely to use inpatient services; show an increased use of family physician services once initial contact is made;35 and have consistently higher hospitalization rates; 36 This could be due to the higher burden of need or could demonstrate that the services that are received are not addressing the health care needs of those lower on the socio-economic scale.37 Women and men from low-income neighbourhoods are more likely to report difficulties making appointments with their family doctors for urgent non-emergent health problems. They were also more likely to report unmet health care needs.38 In terms of hospitalizations, people with lower socio-economic status were much more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) and mental health39; admissions which could potentially be avoided with appropriate primary care.40 They were also found to have on average longer lengths of stay.41 According to a study of hospitals in the Toronto Central Local Health Integration Network, patients considered to be Alternate Level of Care were more likely to have a low-income profile.42 Further, people with ACSC in low-income groups, those living in rural areas, or those with multiple chronic conditions were twice as likely to report the use of emergency department services for care that could have been provided by a primary care provider.43 There is a financial cost to this disparity. According to a 2011 report, low-income residents in Saskatoon alone consume an additional $179 million in health care costs than middle income earners.44 A 2010 study by CIHI found increased costs for avoidable hospitalizations for ambulatory care sensitive conditions were $89 million for males and $71 million for females with an additional $248 million in extra costs related to excess hospitalizations for mental health reasons.45 Areas for Action: As the background suggests, equitable access is about more than just utilization of services. There are patient characteristics as well as complex factors within the health system which determine whether equitable access is achieved. Recent work has categorized access as having considerations on the supply of services and demand of patients for care. On the demand or patient side we must consider: ability to perceive; ability to seek, ability to reach, ability to pay, and ability to engage. On the supply side or health system considerations include: approachability; acceptability, availability and accommodation, affordability, and appropriateness. 46 The following table highlights some of the current barriers to equitable access. (See PDF for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers Patient based actions for improving equitable access: Low health literacy can lead to difficulties for some Canadians in perceiving a need for care.47 Evidence suggests that more than half of Canadian adults (60%), lack the capacity to obtain, understand and act upon health information and services in order to make health decisions on their own.48 Many physicians are undertaking strategies to minimize this lack of health literacy among their patients. Examples include plain language resources as well as teach-back exercises which allow physicians to determine whether patients have fully understood the information provided.49 These efforts should continue to be supported. Understanding how the health system works and where to access services can be a problem for some individuals.50 Beliefs about the need and value for certain services can also undermine the ability of patients in seeking care.51 Work needs to be done to ensure that disadvantaged groups are aware of the services that are available to them and the benefits of taking preventative steps in their health. Low-income Canadians are ten times more likely to report unmet needs of health care due to the cost of transportation.52 Other barriers include a lack of child care, and ability to get time off work to attend necessary health appointments.53 Strategies that provide patients with transportation to appointments or subsidies for such travel have seen some success. Extended office hours and evening appointments can increase access for those unable to take time off work. Additionally, programs that provide patients with home visits from health care providers can help to eliminate this barrier. Further support and expansion of these programs should be explored. There is also the inability to pay for services not covered by provincial plans such as pharmaceuticals, physiotherapy and other rehabilitation services.54 According to a 2005 report on diabetes in Canada, affordability and access to medical supplies was the biggest challenge for those Canadians living with diabetes.55 Access to services such as mental health counselling, subsidized residential care, and long-term care are also hindered by the inability to pay. Even if patients are able to obtain care they may not be able to fully engage. Language difficulties, low health literacy, cognitive challenges (ie. Dementia), cultural mores and norms, and discrimination or insensitivity of health care workers, may all act as barriers to full participation in care.56 Efforts should be made to develop teaching methods to improve engagement of patients and their families/caregivers from disadvantaged groups.57 Strategies to remove or minimize the barriers created by a lack of health literacy should be developed and shared with physicians and other health care providers. Further, programs which facilitate access to services including interpretation and translation of key health information should be supported.58 Finally, an understanding of a patient's cultural and social context is important. The Royal College of Physicians and Surgeons of Canada and the Association of Faculties of Medicine of Canada have developed training modules for physicians who will be working with Canada's Aboriginal peoples.59 Similar programs have been developed by the Canadian Paediatric Society, and the Society of Obstetricians and Gynaecologists of Canada. More of this training is needed and should focus on groups who are likely to experience disadvantage in health care access and appropriateness. Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 1. Governments develop a national strategy for improving the health literacy of Canadians which takes into account the special needs of different cultures. 2. Governments provide accessible and affordable transportation options for patients requiring medical services when such services are unavailable locally. 3. Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. 4. Governments examine methods to ensure that low-income and other disadvantaged Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care. 5. Governments explore options to provide funding for long-term care services for all Canadians. 6. Governments ensure that necessary interpretation and translation services are provided at all points of care. Physicians in Practice The CMA recommends that 7. Physicians be supported in addressing the health literacy of their patients and their families/caregivers. 8. Physician education programs continue to emphasize the important cultural and social contexts in which their patients live. System based actions for improving equitable access: On the system side there are two main areas that need to be addressed: making sure that people can access the services that they need (approachability, availability and accommodation, and affordability); and ensuring that once they have accessed the system that services are appropriate for their health needs (acceptability and appropriateness). Strategies for action include: patient-centred primary care which focuses on chronic disease management; better care coordination and greater access to necessary medical services along the continuum; quality improvement initiatives which incorporate equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. 1. Patient-centred primary care which focuses on chronic disease management and which includes programs to increase access to those most at need. Comprehensive primary care offers the biggest possibility for increasing equitable access and reducing health disparities. Data from a large population study in Ontario indicates that inequities in access to primary care and appropriate chronic disease management are much larger than inequities in the treatment of acute conditions.60 Currently many primary care services are located outside of the neighbourhoods with the greatest need for care. While some are accessible through public transportation, there is still a need for more convenient access for these communities. Community health centres (CHC) offer a good model for addressing this challenge through location in disadvantaged neighbourhoods and the provision of culturally appropriate care.61 Additionally, CHCs offer a number of different health, and sometimes social services, under one roof making access to many different types of care more convenient for patients. More work needs to be done to to reduce barriers in access to Canadians living in rural and remote communities. Telemedicine is one strategy that has increased access for rural Canadians. The Ontario Telemedicine Network is one example of this innovative approach. Patients in rural communities can have access to specialists in urban centres through their local health providers. Examples include cardiac rehab follow-up, tele-homecare to support lifestyle changes, and psychiatric or mental health consultations.62 Programs which encourage recruitment and training of health professionals from rural and disadvantaged populations have been found to increase access as these individuals are more likely to return to their home communities to practice.63 Medical schools have been attempting to increase the diversity in their schools for a number of years. However, work still needs to be done. Data from the 2012 student component of the National Physician Survey shows that 278 of the 2000 students who responded to the survey (13.9%) come from families considered to be in the top 1% of earners in Canada. This is compared to only 46 (2.3%) of students whose family incomes place them in the bottom quintile of earners. 64 One of the suggested strategies for increasing diversity in medical schools is increasing the knowledge about the medical profession among rural and disadvantaged young people. An innovative program in Alberta called Mini Docs allows children between the ages of six and 12 to learn about being a doctor and how to stay healthy. The children get to wear medical scrubs for the day and use harmless medical tools such as stethoscopes and bandages. The day long program is run by medical students.65 Strategies to remove financial barriers to access, such as scholarships, should be expanded. Further, there is a need to modify the admissions process to recognize the differences in access to programs such as MCAT preps and overseas volunteer experiences based on the availability of financial resources as well as the necessity of employment for some students while in medical school. This necessary employment may limit the time available for volunteer and community service.66 Another strategy that can be effective in increasing access is programs that seek to link primary care providers with unattached and underserved patients. Programs such as Health Care Connect in Ontario and the GP and Me program in British Columbia actively seek to link sometimes hard to serve patients to appropriate primary care. The College of Family Physicians of Canada has developed a blueprint for comprehensive primary care for Canadians. The concept, a 'patient's medical home' seeks to link Canadians with a comprehensive health care team led by a family physician. These medical homes will take many forms but will be designed to increase both access and the patient-centredness of care.67 Another barrier to access is timeliness of service. Many patients are forced to use walk in clinics or emergency departments as they cannot receive the required care from their primary care providers. Use of walk-in clinics or emergency departments for primary care may lead to lost opportunities for prevention and health promotion.68 Advanced access programs can help to improve equitable access to care by facilitating timely appointments for all patients.69 The AIM (Access improvement measures) program in Alberta uses a system designed by the Institute for Healthcare Improvement to redesign practice to focus on same day appointments and elimination of unnecessary delays.70 Primary care which prioritizes chronic disease management offers the greatest potential for increasing appropriateness of care and reducing system costs. Those most likely to have chronic diseases are also those who face the biggest barriers to equitable access.71 Currently many people with ACSC do not receive the appropriate tests to monitor their conditions, management of their medications, or supports to self-manage their disease.72 Some programs do exist to encourage more effective management of chronic disease. The Champlain Local Health Integration Network (LHIN) in Ontario has developed a cardiovascular disease prevention network to improve care through the use of evidence based practices and better integration between all areas of the health care continuum.73 Primary Care networks in Alberta have similar goals designed to connect multiple physicians, clinics and regions together to support the health needs of the population.74 Further work is necessary to expand these types of programs and to provide appropriate compensation models for complex patients. Payment models in some jurisdictions undermine access by failing to take morbidity and co-morbidity into consideration in designing rates such as equal capitation.75 Finally, there is a need to encourage greater self-management of disease. Practice support programs in British Columbia are providing training to support physicians in increasing patient self-management and health literacy.76 Additional programs of this nature are necessary in all jurisdictions. 2. Better care coordination and greater access to necessary medical services along the continuum of care. Patient-centred care which integrates care across the continuum and which includes community services will be necessary to ensure not only greater access but greater acceptability of care.77 Innovative programs focused on increasing the coordination in terms of transition from hospital to home have shown some success in preventing readmissions particularly when vulnerable populations are targeted.78 Health Links in Ontario aims to reduce costs, based on the assumption that much of the utilization of high cost services, such as emergency department visits, could be prevented with better coordinated care. One of the pilot sites in Guelph aims to assign one person in primary care, likely a doctor or a nurse, to be the primary contact for patients deemed high need and to intervene on behalf of these patients to ensure better care coordination.79 Further work is needed to ensure greater coordination in speciality care. As the evidence demonstrates, access to specialist services are skewed in favour of high-income patients. To reduce this inequity it may be necessary to standardize the referral process and facilitate the coordination of care from the primary care providers' perspective.80 A new program in British Columbia is designed to reduce some of these barriers by providing funding and support to rapid access programs which allow family physicians to access specialist care through a designated hotline. If no specialist is available immediately there is a commitment that the call will be returned within two hours. Specialists available through this program include cardiology, endocrinology, nephrology, psychiatry, and internal medicine among others.81 Similar programs in other jurisdictions could help to increase coordination between primary and speciality care. Care coordination is only part of the problem, however. There is also a need to increase the access to services that are medically necessary across the care continuum. These include a lifetime prevention schedule82, diagnostic testing, specialty services, and access to appropriate rehabilitation services, mental health, long-term care and end of life care. 3. Quality improvement initiatives which incorporate considerations of equity as part of their mandate. Equity has become a key component of many quality improvement initiatives around the world. The Health Quality Council Ontario identified nine attributes of a high-performing health system: safe, effective, patient-centred, accessible, efficient, equitable, integrated, appropriately resourced, and focused on population health.83 The POWER study, a large study of Ontario residents found that where there were targeted programs for quality improvement fewer inequities were observed. In particular they referred to the actions of Cancer Care Ontario and the Ontario Stroke Network. Both of these groups had undergone large quality improvement initiatives to standardize care and increase coordination of services through evidence-based guidelines and ongoing performance measurement. Considerations of accessibility and equity were specifically included. As a result of these efforts, the POWER study found that acute cancer and stroke care in Ontario were quite equitable.84 Similar efforts are underway in other jurisdictions. The Towards Optimized Practice initiative in Alberta supports efforts in medical offices to increase the use of clinical practice guidelines for care as well as quality improvement initiatives.85 Encouraging more health services and programs to undertake such quality improvement initiatives could help to reduce the inequities in access for all Canadians. 4. Health system planning and assessment which prioritizes equitable access to care Considerations of equity must be built specifically into all planning considerations. Too often services are designed without adequate consideration of the specific needs of disadvantaged groups. Planners need to do a better job of understanding their practice populations and tailoring programs to those most in need of care.86 This planning should be done in consultation with other sectors that play a role in influencing the health of their practice populations. Further, assessments of the equity and use of services is also needed. Some services may be designed in a way that is more appropriate for some than others, resulting in higher utilization among some groups and a lack of access for others.87 Innovative work is taking place in the Saskatoon Health Region to try and understand these barriers. Health care services are undergoing specific health equity assessments to ensure that all services meet the needs of diverse populations. This includes looking at the full spectrum of services from preventative care and education programs to tertiary level care such as dialysis. In Ontario, the local health integration networks (LHIN) have now been tasked with developing equity plans for their services. Clear goals and performance measurements are part of this work.88 One of the tools available to support this work is a health equity impact assessment tool developed by the Ontario Ministry of Health and Long-Term Care. This tool is intended for use by organizations within the health system as well as those outside the system who will impact on the health of Ontarians. The main focus of the tool is to reduce inequities that result from barriers in access to quality health services. Additionally, it is designed to identify unintended health impacts, both positive and negative, before a program or policy is implemented.89 Further work is needed to ensure that equity is included in the deliverables and performance management of health care organizations and provider groups across the country.90 To support these planning programs appropriate data will need to be collected. This data needs to be comprehensive for all services and needs to include specific data points which will allow planners as well as providers to understand the composition of their populations as well as measure and report on considerations of equity.91 Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 9. Governments continue efforts to ensure that all Canadians have access to a family physician. 10. Appropriate compensation and incentive programs be established in all jurisdictions to support better management of chronic disease for all Canadians. 11. Governments provide funding and support to programs which facilitate greater integration between primary and speciality care. 12. With support from government, national medical organizations develop programs to increase standardization of care and the use of appropriate clinical practice guidelines. 13. Appropriate data collection and performance measurement systems be put in place to monitor equitable distribution of health services and greater appropriateness of care. Health System Planners The CMA recommends that: 14. Needs based planning be mandated for all health regions and health system planning. Equity impact assessment should be part of this planning to ensure that services meet the needs of all Canadians. 15. Chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system be prioritized in all health systems. 16. Quality improvement initiatives be mandated in all care programs. These programs should include a specific focus on standardization of care and continuous quality improvement and should include equity of access as part of their mandate. Physicians in Practice The CMA recommends that: 17. Physicians be supported in efforts to offer timely access in primary care settings. 18. Physicians be supported in continued efforts to include all patients in decisions about their care and management of their illnesses. 19. Physicians be supported in continued efforts to standardize care and utilize evidence based clinical practice guidelines with a particular emphasis on the management of chronic disease. 20. Physicians be encouraged and adequately supported to participate in community-based interventions that target the social determinants of health. Conclusion: Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. The strategies discussed above offer some opportunities for the health sector and the medical profession to intervene and mitigate this inequity. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. While these strategies offer some hope, these actions alone will not be sufficient to increase the overall health of the Canadian population. Action is still required to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians. References: 1 This paper represents a focus on equitable access to care. For a more general policy statement on the role of physicians in addressing the social determinants of health please see: Canadian Medical Association. Health Equity and the Social Determinants of Health: A Role for the Medical Profession. Ottawa, ON; 2012. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-03.pdf 2 The Canadian Medical Association is currently developing a policy paper on access to mental health services in Canada. It is anticipated that this policy statement will be completed in 2014. 1 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 2 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14). 3 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 4 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 5 Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health 2004; 58: 655-658. 6 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter7-AccesstoHealthCareServices.pdf (accessed 2012 Dec 10). 7 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives: The Mental Health Strategy for Canada.Ottawa (ON): Mental Health Commission of Canada; 2012. Available: http://strategy.mentalhealthcommission.ca/pdf/strategy-text-en.pdf (accessed 2013 Mar 12). 8 Allin S. Does Equity in Healthcare Use Vary...; Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg Regional Health Authority: Variations Across Areas in Relation to Health and Socioeconomic status. Winnipeg (MB) Manitoba Centre for Health Policy. Available: http://mchp-appserv.cpe.umanitoba.ca/teaching/pdfs/hcm_forum_nf.pdf (accessed 2013 Feb 6); McGrail K. Income-related inequities: Cross-sectional analyses of the use of medicare services in British Columbia in 1992 and 2002. Open Medicine 2008; 2(4): E3-10; Van Doorslaer E, Masseria C. Income-Related Inequality in the Use... Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health? J Epidemiol Community Health 2003; 57:424-428. 9 Alter DA, Naylor CD, Austin P, et al. Effects of Socioeconomic Status on Access to Invasive Cardiac Procedures And On Mortality After Acute Myocardial Infarction. NEJM 1999; 341(18):1359-1367. 10 Kapral MK, Wang H, Mamdani M, et al. Effect of socioeconomic Status on Treatment and Mortality After Stroke. JAHA 2002; 33: 268-275. 11 Booth GL, Lipscombe LL, Bhattacharyya O, et al. Ontario Women's Health Equity Report: Diabetes: Chapter 9 Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter9-Diabetes.pdf (accessed 2012 Dec 10). 12 McGrail K. Income-related inequities... Murphy K, Glazier R, Wang X, et al. Hospital Care for All: An equity report on differences in household income among patients at Toronto Central Local Health Integration Network (TC LHIN) Hospitals, 2008-2010. Toronto(ON): Centre for Research on Inner City Health. Available: http://www.stmichaelshospital.com/pdf/crich/hospital-care-for-all-report.pdf (accessed 2012 Dec 10). 13 Murphy K, Glazier R, Wang X, et al. Hospital Care for All... 14 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services...Demeter S, Reed M, Lix L, et al. Socioeconomic status and the utilization of diagnostic imaging in an urban setting. CMAJ 2005; 173(10): 1173-1177. 15 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter12-SDOHandPopsatRisk.pdf (accessed 2012 Dec 10); Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg... Wang L, Nie JX, Ross EG. Determining use of preventive health care in Ontario. Can Fam Physician 2009; 55: 178-179.e1-5; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences with health-related services: Implications for health care reform. Health Policy 2006; 76:106-121. 16 The Ontario Rural Council. TORC 2009 Rural Health Forum: Rethinking Rural Health Care: Innovations Making a Difference. Guelph, ON; 2009. Available: http://ruralontarioinstitute.ca/file.aspx?id=1fb3035d-7c0e-4bfa-a8d7-783891f5c5dc (accessed 2013 Sep 18). 17 Browne A. Issues Affecting Access to Health Services in Northern, Rural and Remote Regions of Canada. Available: http://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf (accessed 2013 Mar 13). 18 Sibley LM, Weiner JP. An evaluation of access to health care services along the rural-urban continuum in Canada. BMC Health Services Research. Toronto (ON); 2011. Available: http://www.biomedcentral.com/1472-6963/11/20 (accessed 2013 Mar 13). 19 Society of Rural Physicians of Canada. National Rural Health Strategy- summary. Shawville, QC; 2008. Available: http://www.srpc.ca/PDF/nrhsA.pdf (accessed 2013 Sep 18). 20 Health Charities Coalition of Canada. Position Statement: Access to Health Care. Ottawa, ON; 2013. Available: http://www.healthcharities.ca/media/23883/posstatement_accesshealthc_final_en.pdf (accessed 2013 Sep 18). 21 Society of Rural Physicians of Canada. Rural Canadians need and deserve equitable access to health care. Shawville, QC; 2006. Available: http://www.srpc.ca/PDF/September-20-2006.pdf (accessed 2013 Sep 18). 22 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts.... 23 Kwan J, Razzaq A, Leiter LA, et al. Low Socioeconomic Status and Absence of Supplemental Health Insurance as Barriers to Diabetes Care Access and Utilization. CJD 2008; 32(3) : 174-181. 24 Barnes S, Dolan LA, Gardner B, et al. Equitable Access to Rehabilitation : Realizing Potential, Promising Practices, and Policy Directions. Toronto (ON) Wellesley Institute; 2012. Available : http://www.wellesleyinstitute.com/wp-content/uploads/2012/06/Equitable-Access-to-Rehabilitation-Discussion-Paper1.pdf (accessed 2013 Feb 6). 25 Bowen, S. Access to Health Services for Underserved Populations in Canada. In Certain Circumstances: Issues in Equity and Responsiveness in Access to Health Care in Canada: A collection of papers and reports prepared for Health Canada. Ottawa (ON) Health Canada; 2000. Available: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2001-certain-equit-acces/2001-certain-equit-acces-eng.pdf (accessed 2013 Feb 6). 26 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. Ottawa, ON; 2013. Available: http://www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.pdf (accessed 2013 Sep 18). 27 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives... 28 EMC News. CCAC publishes long-term care waitlists monthly. Brockville (ON); 2013. Available: http://www.emcstlawrence.ca/20130404/news/CCAC+publishes+long-term+care+waitlists+monthly (accessed 2013 Apr 11). 29 Health Charities Coalition of Canada. Position Statement on Access to Home Care Revised for Approval Ottawa (ON); 2011. Available: http://www.healthcharities.ca/media/2720/HomeCarePos_statmnt_Sep22_11_Final_EN.pdf (accessed 2013 Mar 12) 30 Canadian Hospice Palliative Care Association. Fact Sheet: Hospice Palliative Care in Canada. Ottawa(ON); 2012. Available: http://www.chpca.net/media/7622/fact_sheet_hpc_in_canada_may_2012_final.pdf (accessed 2013 Mar 25). 31 Bowen, S. Access to Health Services for Underserved Populations..... 32 Place J. The Health of Aboriginal People Residing in Urban Areas. National Collaborating Centre for Aboriginal Health. Prince George, BC; 2012. Available: http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/53/Urban_Aboriginal_Health_EN_web.pdf (accessed 2013 Sep 18). 33 National Collaborating Centre for Aboriginal Health. Access to Health Services As A Social Determinant of First Nations, Inuit And Metis Health. Prince George (BC) National Collaborating Centre for Aboriginal Health; 2011. Available: http://www.nccah-ccnsa.ca/docs/fact%20sheets/social%20determinates/Access%20to%20Health%20Services_Eng%202010.pdf (accessed 2013 Feb 6). 34 Levesque JF, Harris M, Russell G. Patient-centred access to health care... 35 Allin S. Does Equity in Healthcare Use Vary...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 36 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2013 Feb 6); Van Doorslaer E, Masseria C. Income-Related Inequality... 37 Allin S. Does Equity in Healthcare Use Vary... 38 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...;Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 39 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status... 40 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status... ;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185. 41 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence: SEDAP Research Paper No. 190. Hamilton (ON) Social and Economic Dimensions of an Aging Population Research Program; 2007. Available: http://catalogue.iugm.qc.ca/GEIDEFile/23002.PDF?Archive=102297992047&File=23002_PDF (accessed 2013 Feb 14). 42 Murphy K, Glazier R, Wang X, et al. Hospital Care for All... 43 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences Among Canadians With Ambulatory Care Sensitive Conditions. Ottawa(ON); 2012. Available: https://secure.cihi.ca/free_products/PHC_Experiences_AiB2012_E.pdf (accessed 2013 Feb 14). 44 Saskatoon Poverty Reduction Partnership. From poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Saskatoon (SK): Saskatoon Poverty Reduction Partnership; 2011.Available: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf (accessed 2012 Mar 13) 45 Canadian Institute for Health Information. Hospitalization Disparities... 46 Levesque JF, Harris M, Russell G. Patient-centred access to health care... 47 Bowen, S. Access to Health Services for Underserved Populations... 48 Canadian Council on Learning. Health Literacy in Canada: Initial Results for the International Adult Literacy and Skills Survey. Ottawa (ON); 2007. Available: http://www.ccl-cca.ca/pdfs/HealthLiteracy/HealthLiteracyinCanada.pdf (accessed 2013 Apr 19). 49 Parnell TA, Turner J. IHI 14th Annual International Summit. Health Literacy: Partnering for Patient-Centred Care. April 9, 2013. 50 Bowen, S. Access to Health Services for Underserved Populations... 51 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7.... 52 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 53 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 54 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 55 Chiu S, Hwang SW. Barriers to healthcare among homeless people with diabetes. Diabetes Voice 2006; 51(4): 9-12. Available: http://www.idf.org/sites/default/files/attachments/article_473_en.pdf (2011 Feb 20), 56 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7.... Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns 2004; 56: 139-146; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 57 Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient... 58 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 59 Indigenous Physicians of Canada and the Association of Faculties of Medicine Canada, "First Nations, Inuit, Métis Health, Core Competencies: A Curriculum Framework for Undergraduate Medical Education" Updated April 2009, online: http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf (accessed October 20, 2010). 60 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2012.Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter13-AchievingHealthEquityinOntario.pdf (accessed 2013 Feb 6). 61 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... ;Bowen, S. Access to Health Services for Underserved Populations..... 62 Williams, R. Telemedicine in Ontario: Fact not Fiction: How to enhance your practice and enrich the patient experience. Ontario Telemedicine Network: Toronto, ON; 2013. Available: http://otn.ca/sites/default/files/telemedicine_in_ontario-_fact_not_fiction_02-26.pdf (accessed 2013 Sep 19). 63 Bowen, S. Access to Health Services for Underserved Populations... 64 National Physician Survey- 2012 student component 65 Alberta Medical Association. Mini Docs. Edmonton (AB); 2012. Available: https://www.albertadoctors.org/about/awards/health-promo-grant/2011-12-recipients/mini-docs (accessed 2013 Apr 18). 66 Dhalla IA, Kwong JC, Streiner DL et al. Characteristics of first-year students in Canadian... 67 The College of Family Physicians of Canada . A Vision for Canada: Family Practice: The Patient's Medical Home. Toronto, ON; 2011. Available: http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf (accessed 2012 Mar 15). 68 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 69 Ibid 70 Access Improvement Measures. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCI/RelatedPrograms/AIM/Pages/default.aspx (accessed 2013 Mar 12). 71 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 72 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences... 73 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 74 About Primary Care Networks. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCNs/Pages/default.aspx (accessed 2013 Mar 12). 75 Glazier RH. Balancing Equity Issues in Health Systems: Perspectives of Primary Healthcare. Healthcare Papers 2007; 8(Sp):35-45. 76 General Practice Services Committee. Learning Modules-Practice Management. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: http://www.gpscbc.ca/psp/learning/practice-management (accessed 2013 Mar 12). 77 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... 78 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 79 Improving Care for High-Needs Patients: McGuinty Government Linking Health Providers, Offering Patients More Co-ordinated Care. Toronto (ON) Ontario Ministry of Health and Long-Term Care; December 6, 2012. Available: http://news.ontario.ca/mohltc/en/2012/12/improving-care-for-high-needs-patients.html (accessed 2012 Dec 10). 80 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence... 81 Shared Care Partners in Care Annual Report 2011/12. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: https://www.bcma.org/files/SC_annual_report_2011-12.pdf (accessed 2013 Mar 12). 82 British Columbia Medical Association. Partners in Prevention: Implementing a Lifetime Prevention Plan. Vancouver, BC; 2010. Available: https://www.bcma.org/files/Prevention_Jun2010.pdf (accessed 2013 Sep 18). 83 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 84 Ibid. 85 Toward Optimized Practice. Edmonton (AB). Available at: http://www.topalbertadoctors.org/index.php (accessed 2013 Mar 12). 86 Ali A, Wright N, Rae M ed. Addressing Health Inequalities: A guide for general practitioners. London (UK); 2008. Available: http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Health%20Inequalities%20Text%20FINAL.ashx (accessed 2012 Jan 16); Gardner, B. Health Equity Road Map Overview. Toronto (ON): Wellesley Institute, 2012. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2012/09/HER_Systemic-Health-Inequities_Aug_2012.pdf (accessed 2013 Feb 6). 87 Bowen, S. Access to Health Services for Underserved Populations... 88 Gardner B. Health Equity Into Action: Planning and Other Resources for LHINs. Toronto(ON) Wellesley Institute; 2010. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2010/09/Health_Equity_Resources_for_LHINs_1.pdf (accessed 2013 Feb 6). 89 Ontario Ministry of Health and Long-Term Care. Health Equity Impact Assessment (HEIA) Workbook. Toronto, ON; 2012. Available: http://www.health.gov.on.ca/en/pro/programs/heia/docs/workbook.pdf (accessed 2013 Sep 30). 90 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...; Gardner, B. Health Equity Road Map...; Glazier RH. Balancing Equity Issues in Health Systems... 91 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...
Documents
Less detail

Firearms control (Update 2001)

https://policybase.cma.ca/en/permalink/policy183
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Replaces
Firearms control (1993)
Topics
Population health/ health equity/ public health
Text
FIREARMS CONTROL (UPDATE 2001) Summary Firearms are a major cause of death and injury in Canada and account for nearly 1,400 deaths annually. The CMA has made several recommendations to governments and other bodies undertaking legislative review and public policy change. These recommendations relate to the regulation of firearms, education for the safe handling of firearms, broad-based violence prevention programs, and research and information provision. In addition, the CMA has produced guidelines to assist physicians in identifying and counselling patients at risk of violent behaviour and in reporting patients at risk. Firearms are a major cause of death and injury in Canada.. The cost to society of firearm-related injury, particularly spinal cord and head injuries, is considerable. Over the short term, policy should focus on firearms and the user. Applying stringent controls on firearms, however, may have little effect on the rates of death and injury if the underlying problems of violence in society are not addressed. In an effort to accommodate both short-term and long-term solutions the CMA recommends the following to governments and bodies undertaking legislative review and public policy change. Regulation The object of regulation should be to deter people at risk for violent or self-destructive behaviour from having easy access to firearms. A regulatory policy should address (a) the acquisition of firearms (e.g., licensing of firearms and/or users, processes to screen would-be purchasers who are at risk), b) secure firearm and ammunition storage methods and modifications to firearms that would render them less accessible to children or those acting on violent impulses and (c) severe penalties for offenses such as the use of a firearm in the commission of a crime or an act of violence, including family violence. Education Training in safe handling of firearms is strongly recommended, particularly for all first-time firearm users. Broader-based education programs aimed at the prevention of violence (e.g., in schools) may also be efficacious and should be evaluated for their impact in reducing violence. Research and information provision CMA encourages research in a number of areas, including the following. Firearm surveillance: the types of firearms or classes of ammunition disproportionately involved in intentional deaths and injuries, the circumstances surrounding a firearm incident (e.g., argument between friends, alcohol involvement) and data on injuries and deaths. Determination of behavioural or environmental risk factors for violent behaviour: the relative risk or benefit of keeping a firearm at home for protection i.e.. the scientific assessment of the deterrence effect): The effects of factors such as alcohol, drug use and family history of violence on the risk of violent death; and how accurately experts can identify people at risk. Case-control and cohort studies on gun control, crime and the antecedents of violent behaviour. Evaluation of education programs that discourage firearm-related violence or promote safe handling of firearms. Role of physicians The CMA recommends that physicians consider the following guidelines. Management of patients at risk It is not always possible to identify people at risk of violent or self-destructive behaviour; however, the CMA recommends that physicians be alert to warning signs that a patient may be at risk and manage that patient accordingly. For example, always ask depressed patients about suicidal and homicidal thoughts and plans (asking will not plant ideas); admit suicidal patients to hospital, even against their will, particularly if they do not have supportive families who can monitor them at home; have the family remove all firearms from the home of a patient at risk; and monitor the patient frequently, writing small prescriptions if medication is required. Good clinical judgement and close follow-up are perhaps the most effective ways of managing a self-destructive or violent patient. Reporting of patients at risk No specific guidelines exist for the reporting of patients at risk of violent behaviour. The physician should consider whether the risk of harm to society (or a third party) posed by a patient outweighs that patient's right to confidentiality. Counselling and public advocacy A physician may be asked for a reference for an applicant of a firearms acquisition certificate. Before providing the reference the physician should consider the applicant carefully for risk factors, recommend appropriate firearms training and caution against the concomitant use of firearms, alcohol and other drugs. A physician should become an advocate for nonviolent conflict resolution. As research accumulates about the most effective interventions for nonviolent conflict resolution the health sector may be able to draw on this research to work to reduce violence in society. Like motor vehicle and bicycle safety, firearm safety is a public health issue. The CMA holds that physicians, as advocates for the health of Canadians, can help reduce firearm-related damage and address the concomitant underlying problem of violence in society.
Documents
Less detail

16 records – page 1 of 2.