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Advance care planning

https://policybase.cma.ca/en/permalink/policy13694

Date
2017-05-27
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Date
2017-05-27
Replaces
Advance care planning (2015)
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Text
With the advent of technology allowing for the extension of life, and as a result of the increasing importance of personal autonomy, decisional capacity, and informed consent and the growing awareness of issues related to quality of life and dying, Canadians have become increasingly interested in expressing their wishes regarding their health care and having more input into decisions about their care should they become incapable. Advance care planning (ACP) can help patients to achieve these goals. The CMA supports development of a strategy for ACP1 in all provinces and territories. ACP leads to better concordance between patients' wishes and treatments provided,2,3 decreased anxiety for families,4 decreased moral distress for health care providers,5 decreased hospitalization rates of nursing home residents3 and fewer unnecessary medical treatments.3,6,7 ACP is at the intersection of the provision of health care, ethical values and legal rights and duties. In particular, it involves the acknowledgement of essential aspects of autonomy, informed consent, and respect of patients' care wishes now and in the future, and their intentions if they become incapable.8,9 The balancing of the need to obtain informed consent for a treatment option in the present with the need to respect health care preferences that were stated in the past has been addressed using various clinical, legal and institutional approaches across Canadian jurisdictions." Physicians10 can play a significant role in ACP throughout the course of the patient-physician relationship, including in the pediatric setting. At any time, outcomes of the planning process can be documented and/or the patient can appoint a substitute decision-maker in writing. These documents can be identified as advance directives, personal directives or powers of attorney for personal care11 (hereinafter all will be referred to as advance directives). An advance directive does not remove the need for a physician to obtain consent before providing a treatment to a patient, except in an emergency. As stated in the Canadian Medical Protective Association's consent guide: "[U]nder medical emergency situations, treatments should be limited to those necessary to prevent prolonged suffering or to deal with imminent threats to life, limb or health. Even when unable to communicate in medical emergency situations, the known wishes of the patient must be respected."12 While much of the focus of ACP is on making care decisions and nominating proxy decision-makers in case the patient becomes incapable of making decisions in the future, ACP has much more utility. ACP conversations13 can assist patients in determining treatment trajectories and making decisions about the intensity level of interventions in their current care. Providers can have discussions with patients and their families about proposed treatments in the context of the patient's communicated goals and wishes. The process of ACP also helps patients and their families to become familiar with the language and processes used to make cooperative health care decisions. SCOPE OF POLICY This policy aims to provide guidance on key considerations pertinent to ACP in a way that is consistent with a physician's ethical, professional and legal obligations. This is a complex subject: physicians should be aware of the legislation in the jurisdiction in which they practise, the standards and expectations specified by their respective regulatory authority, as well as the policies and procedures of the setting(s) in which they practise (e.g., regional health authority, hospital). GENERAL PRINCIPLES 1. ACP is a process of (a) respecting patients' wishes through reflection and communication, (b) planning for when the patient cannot make health care decisions and (c) discussion with friends, family and professionals; (d) it may result in a written document.5 It informs the substitute decision-maker and provides information for the clinician to consider in the provision of care within the bounds of the law. 2. Although often associated with the end of life, ACP represents the expression of a patient's wishes for any future health care when the patient is incapable. It expresses the patient's values and beliefs regarding current care decisions and provides information that can inform any decisions that must be made during an emergency when the patient's consent cannot be obtained. For these reasons, ACP should occur throughout a person's lifetime. 3. Respect for patients' dignity and autonomy is a cornerstone of the therapeutic physician-patient relationship. Patients' right to autonomous decision-making has become embedded in ethical frameworks, consent legislation and case law.14 Respect for the wishes of an incapable patient constitutes a preservation of autonomy and promotes trust between the physician and patient.15 4. The way in which the act of obtaining consent is weighed against the patient's stated wishes as outlined during the ACP process varies according to the jurisdiction in which the patient and physician are located. EDUCATION 1. Given the practical, ethical and legal complexities of ACP, physicians, medical learners should be supported in becoming familiar with ACP and comfortable in engaging in the process with their patients. To this end, CMA supports the development of training in ACP and efforts to make it available to all physicians and medical learners.16 For practising physicians and residents, many resources are available, for example: a. Advance Care Planning in Canada: A National Framework b. Facilitating Advance Care Planning: An Interprofessional Educational Program c. Information from the Health Law Institute of Dalhousie University on the regulatory policies and legislation of individual provinces and territories d. A comprehensive collection of Canadian resources compiled by the Speak Up campaign of the Advance Care Planning in Canada initiative e. Pallium Canada's Learning Essential Approaches to Palliative Care module on ACP In the case of medical students, the CMA supports the position of the Canadian Federation of Medical Students that end-of-life training is an essential facet of undergraduate medical education. 2. The issue of the supervision of medical learners practising ACP should be clarified, as considerable ambiguity currently exists.17 Medical learners would benefit from unified national guidelines concerning the nature of their participation in ACP, especially regarding end-of-life care. In the case of medical students, the CMA agrees with the recommendation of the Canadian Federation of Medical Students that supervision be mandatory during conversations about end-of-life care. 3. The CMA calls for more research on the outcomes associated with the provision of ACP training to physicians and medical learners. 4. The CMA recommends that governments and institutions promote information and education on ACP to patients and their substitute decision-makers. PROFESSIONAL AND LEGAL RESPONSIBILITY 1. While respecting patients' values, all physicians are expected to encourage their patients to engage in ACP with them. ACP is not a one-time event. The nature of the conversation between the physician and the patient and the regularity with which they discuss the subject will depend on the patient's health status. Family physicians and physicians have ongoing care relationships with chronically ill patients are particularly well placed to have regular discussions with their patients about their beliefs, values and wishes. An effective exchange of information between family physicians (and other physicians who work in the community with outpatients) and acute or tertiary care physicians would assist in ensuring patient's wishes are considered. 2. ACP, in particular advance directives, are at the intersection of medicine and the law. Physicians should recognize this and ask patients whether they have an advance directive or have done any ACP. 3. There is wide variation across jurisdictions in terms of the requirements and procedures for ACP; therefore, physicians should inform themselves about any relevant legislation and the scope of the requirement to obtain consent within that jurisdiction when carrying out ACP. INSTITUTIONS 1. The CMA supports institutional processes that recognize and support ACP. Support for ACP includes developing a consistent process for the exchange of information about patients' wishes and advance directives among health care providers, as patients traverse sectors and locations of care. Patients with a written advance directive must be identified and the advance directive integrated fully within the patient's records18 so that it is available across the institution (and ideally the health care system). The CMA advocates for the inclusion of advance care directive functionality as a conformance and usability requirement for electronic medical record vendors.19 Provinces and territories should be encouraged to establish robust organizational processes and resources for patients in all locations of care and strong province- or territory-wide policy, such as in Alberta.20 2. Institutions and other organizations should encourage health care providers to ask patients to bring their advance directive to appointments at the same time they ask them to bring a list of their medications or other medical information. 3. The CMA supports institutional/organizational audits of structures, processes and outcomes related to ACP as an important step in improving the quality and frequency of ACP activities. ROLE FOR GOVERNMENTS 1. The CMA supports infrastructures enabling ACP, including funding that will support ACP and other end-of-life discussions. 2. The CMA promotes the incorporation of ACP into future federal and provincial/territorial senior strategies and dementia and/or frailty strategies. 3. The CMA supports the development of ACP metrics and their future inclusion in Accreditation Canada standards. GLOSSARY Advance care planning (ACP) Advance care planning is a term used to describe a process of reflection, communication, conversation and planning by a capable individual with family, friends and professionals about their beliefs, values and wishes for a time when they no longer have the mental capacity to make decisions about their health care. ACP can also involve the naming of a substitute decision-maker.8 Advance directive The legislated term "advance directive" has different names, definitions and legal authority across the country. For example, in British Columbia an advance directive is a written legal document that provides a mechanism for capable patients to give directions about their future health care once they are no longer capable. 21 As such, in BC an advance directive may, under certain circumstances, be considered "equivalent to consent to treatment and may be acted upon directly by a health care provider without consultation with an SDM [substitute decision-maker]." 8 In Alberta it is called a personal directive. In Ontario, "advance directive" is a generic non-legal term and refers to communications that may be oral, written or in other forms.8 In Quebec, advance care directives are legally binding, as set out in the Act respecting end-of-life care, which recognizes "the primacy of freely and clearly expressed wishes with respect to care. . ."22 Current legislation does not allow for medical assistance in dying to be requested by an advance directive.23 The CMA acknowledges that considerable public, expert and legal debate exists around the issue. Informed consent To obtain informed consent, physicians must provide adequate information to the patient or capable decision-maker about the proposed procedure or treatment; the anticipated outcome; the potential risks, benefits and complications; and reasonable available alternatives, including not having the treatment; and they must answer questions posed by the patient. Consent is only informed if there is disclosure of matters that a reasonable person in the same circumstances would want to know.24 Consent must be given voluntarily, must not be obtained through misrepresentation or fraud, must relate to the treatment and must be informed. Substitute decision-maker (SDM or agent or proxy) A substitute decision-maker is a capable person who will make health care decisions on behalf of an incapable individual. In all jurisdictions the health care provider must take reasonable steps to become aware of whether or not there is a substitute decision-maker before providing health treatment to an incapable patient. Legally there are implementation differences across the country. For example, in BC a substitute decision-maker is appointed through a representation agreement, in Alberta through a personal directive and in Ontario through a power of attorney for personal care. Approved by the CMA Board of Directors May 2017 1 Canadian Medical Association. Policy resolution GC14-25 - strategy for advance care planning, palliative and end-of-life care. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 Oct 17) 2 Houben CHM, Spruit MA, Groenen MTJ, et al. Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc 2014;15:477-89. 3 Martin RS, Hayes B, Gregorevic K, et al. The effects of advance care planning interventions on nursing home residents: a systematic review. J Am Med Dir Assoc 2016;7:284-93. 4 Mack JW, Weeks JC, Wright AA, et al. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol 2010;28(7):1203-8. 5 Canadian Hospice Palliative Care Association. Advance care planning in Canada: national framework. Ottawa; The Association; 2010. 6 Teo WSK, Raj AG, Tan WS, et al. Economic impact analysis of an end-of-life programme for nursing home residents. Palliat Med 2014;28(5):430-7. 7 Zhang B, Wright AA, Huskamp HA, et al. Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med 2009;169(5):480-8. 8 Wahl J, Dykeman MJ, Gray B. Health care consent and advance care planning in Ontario. Toronto (ON): Law Commission of Ontario; 2014. 9 Canadian Medical Association. CMA Code of Ethics (update 2004). Ottawa: The Association; 2004. 10 Physician involvement is not mandatory in the process. However, it is important for physicians to engage with their patients in ACP as this can facilitate change in patients' ACP behaviour and understanding. 11 Wahl JA, Dykeman MJ, Walton T. Health care consent, advance care planning, and goals of care practice tools: the challenge to get it right. Improving the last stages of life. Toronto (ON): Law Commission of Ontario; 2016. 12www.med.uottawa.ca/sim/data/Images/CMPA_Consent_guide_e.pdf 13 Frank C, Puxty J. Facilitating effective end-of-life communication - helping people decide. CJS Journal of CME 2016;6(2). Available: http://canadiangeriatrics.ca/wp-content/uploads/2017/02/Facilitating-Effective-End-of-Life-Communication---Helping-People-Decide.pdf (accessed 2017 April 25). 14 Fleming v Reid (1991) 82 DLR (4th) 298 (CA ON); Cuthbertson v Rasouli, 2013 SCC 53; Malette v Shulman (1990), 72 OR (2d) 417; Starson v Swayze (2003) 1 SCR 722. 15 Harmon SHE. Consent and conflict in medico-legal decision-making at the end of life: a critical issue in the Canadian context. University of New Brunswick Law Journal 2010;60(1):208-29. 16 Canadian Medical Association. Policy resolution GC13-69 - training in advance care planning. Ottawa (ON): The Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 17 Touchie C, De Champlain A, Pugh D, et al. Supervising incoming first-year residents: faculty expectations versus residents' experiences. Med Educ 2014;48(9):921-9. 18 Canadian Medical Association. Policy resolution GC14-19 - advance care plans. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 19 Canadian Medical Association. BD14-05-163 Advance care directive functionality. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 20 Conversations matter. Edmonton (AB): Alberta Health Services. Available: http://goals.conversationsmatter.ca.s3-website-us-east-1.amazonaws.com/ (accessed 2017 May 19). 21 Health Care (Consent) and Care Facility (Admission) Act, RSBC 1996, c 181, s.3 22 Act respecting end-of-life care, S-32.0001. Government of Quebec. Available : http://legisquebec.gouv.qc.ca/en/ShowDoc/cs/S-32.0001 23 An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) S.C. 2016, c.3. Ottawa: Government of Canada; 2016. Available: http://canlii.ca/t/52rs0 (accessed 2016 Oct 17) 24 Riebl v Hughes, [1980] 2 SCR 880; Hopp v Lepp, [1980] 2 SCR 192.

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Charter of Shared Values: A vision for intra-professionalism for physicians

https://policybase.cma.ca/en/permalink/policy13858

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

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Corporate privacy policy respecting the collection, use and disclosure of personal information (Update 2012)

https://policybase.cma.ca/en/permalink/policy10633

Last Reviewed
2017-03-04
Date
2012-10-20
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2017-03-04
Date
2012-10-20
Replaces
Corporate Privacy Policy Respecting the Collection, Use and Disclosure of Personal Information (Update 2007)
Topics
Ethics and medical professionalism
Text
Corporate Privacy Policy Respecting the Collection, Use and Disclosure of Personal Information (Update 2012) Why a Corporate Privacy Policy? The CMA has always valued your privacy and acted to ensure that it is protected. The CMA has enacted this Corporate Privacy Policy to put into writing its current practices and to conform to legislative requirements requiring organizations to have written privacy policies. We have looked to the 10 principles of the Canadian Standards Association's (CSA) Model Code, which has been incorporated into federal privacy legislation, to formulate this policy. This Privacy Policy applies to all personal information, excluding CMA employee information and information in the public domain, that has been and will be collected, used and disclosed by the CMA. The CMA has a separate but consistent online privacy policy for the cma.ca Web site (www.cma.ca). What do we mean by "personal information"? Throughout this policy, we discuss "personal information," and it is important from the outset to set out what we mean by this term. "Personal information" is information that reveals a distinctive trait about yourself and helps others identify you. Some personal information such as your business address may be found in the public domain by accessing publications like telephone or professional directories. The focus of this policy is personal information collected, used and disclosed by the CMA that is NOT in the public domain. What types of personal information does the CMA collect and use? Primarily, the CMA collects and uses personal information about its members. CMA also has personal information about individuals who purchase CMA products and services, attend CMA sponsored events and seminars and submit manuscripts to CMA publications. The CMA assigns a personal identifier called a "CMA ID" to each member or purchaser of a CMA product or service so that you can use this number when contacting the CMA, ordering CMA products and publications or registering for the cma.ca Web site. The CMA collects personal information directly from individuals or receives it from one of its provincial or territorial medical associations ("PTMAs") or subsidiaries, the CMA group of subsidiary companies, including our primary financial services company, MD Physician Services Inc. For instance: -If you are a CMA member, you might have provided on an application form or will provide to the CMA or a PTMA or a CMA subsidiary, personal information like your home address, date of birth and gender. If you are both a client of one or more of CMA's financial subsidiaries and a CMA member, the fact of your client status, but not detailed financial information, will be known to CMA. A circumscribed and limited number of CMA employees, all of whom receive enhanced privacy training and sign specific undertakings, will have access to more detailed MD PS information such as frequency of meetings about your MD client status (but still not specific financial transactional details) in order to perform statistical analysis. - If you have attended an event organized through CMA's Meetings and Travel Department, you might have provided us with credit card data as well as information about certain travel preferences and food sensitivities. - If you have purchased a CMA product (e.g., classified advertising) or attended a CMA seminar (e.g., Physician Manager Institute), you provided us with personal contact information such as your name and address. We might also have collected credit card information if you chose to pay for the product or service by this method. - If you have submitted a manuscript for publication in a CMA journal, you provided us with contact information, financial disclosure and competing interests data and the manuscript itself. Why does the CMA collect and use personal information? The CMA will collect and use only the personal information necessary to achieve the following purposes or one consistent with them: 1. to determine an individual's eligibility for membership in the CMA or to serve as a potential contributor to a CMA publication 2. to determine an individual's eligibility to benefit from the services of one of CMA's subsidiaries or its preferred third-party suppliers 3. to provide and to communicate information about CMA member benefits and services (e.g., the delivery of publications and travel reservations, financial services, advocacy, etc.) 4. to develop and to market products and services tailored to the interests of CMA members and the purchasers of CMA products and services 5. to update contact information in the CMA database 6. to assist the CMA PTMAs and CMA's subsidiaries with the maintenance of their membership and client contact information 7. to provide individuals with the opportunity to benefit from supporting the Canadian Medical Foundation which provides CMA members and others with valuable educational programs and services 8. to conduct surveys and research studies of the physician population in order to analyze for statistical and research purposes such issues as the demographics of physician human resources 9.to engage members and physicians in CMA's policy development process 10.to broadcast urgent health alerts of national significance When and to whom does the CMA disclose personal information? The CMA does not sell personal information. The CMA will only disclose your personal information to an organization for a purpose outlined in this policy, unless we obtain your consent for a new purpose. For example, one purpose identified above is maintaining up-to-date membership and client contact information. The CMA and its subsidiariesshare a core data field for the purposes of updating addresses and confirming membership status. In addition to a core data field for the purposes of updating addresses and confirming membership status, CMA shares with its wholly owned subsidiary, MDPS, information about a member's participation in CMA activities and products such as Physician Manager Institute events. MDPS, as the most highly rated provider of CMA products and services, is seeking to have a better understanding and appreciation of physicians' relationship and interaction with CMA. Knowledge of an individual's participation in CMA events and activities provides this complete or "integrated" picture. If a CMA member objects, a note will be entered in the database. If you are both a CMA member and a client of a CMA subsidiary company, when you inform us of an address change, with your permission, this information will be changed for both organizations. The CMA might also disclose personal information to third parties or to organizations or companies that are not CMA-affiliated companies or Divisions if these organizations have contracted or partnered with the CMA to help us provide products and services or do research. For example, the CMA might out-source the mailing list function for one of its publications or work with the Canadian Post-MD Education Registry to study physician resource planning. We may, in certain instances, contract with a third party service provider located in other countries such as the United States. Your information may be processed and stored in the United States and the United States governments, courts or law enforcement or regulatory agencies may be able to obtain disclosure of your information under a lawful order made in that country. If you would like more information about the jurisdictions in which we our service providers may operate please contact us as noted in the What if you have a question... section of this policy. Within the CMA itself, your personal information in the form of interactions with the CMA will be shared amongst CMA departments. This will enable CMA to have a better understanding of your interests and activities such that CMA might tailor its product and service offerings to your interests. For example, if a member has completed a number of Physician Manager Institute courses, we might send him or her information about our Physician Leadership Credential Program. If a member objects to a particular disclosure of an activity, for instance a particular CME course, a note will be entered into the database What if you object to CMA's collection, use or disclosure of personal information? The CMA seeks to respect and honour your privacy and communication preferences. For instance, if you indicate to the CMA that you do not wish to receive certain publications, participate in surveys or receive information about new or specific benefits and services such as communications from CMA's subsidiaries, your preference will be noted and you will no longer receive correspondence from us on these issues. Please contact the CMA Member Service Centre at 888-855-2555 to make such a request. You may also at any time, subject to restrictions required by law, object to the CMA's collection, use or disclosure of personal information. You need only provide the CMA with reasonable notice in writing of your intention and the details of your objection. For instance, if you do not wish to have contact and demographic information shared with the Canadian Medical Foundation, we will respect your choice. Please note, however, that your objection to the disclosure of other information might mean that the CMA is unable to continue to provide you with some products or services. For example, if you object to the sharing of your CMA membership status with CMA's financial subsidiaries, then you will not be eligible to benefit from their products or services. MD Physician Services has to confirm your CMA membership status in order to offer you financial services. It is your responsibility to contact the CMA in order to determine how an objection to the collection, use and disclosure of personal information might affect the services supplied. How accurate is the personal information held by the CMA? The CMA makes every reasonable effort to ensure the accuracy and currency of your personal information so that we might fulfill the purposes for which it was first collected. Your personal information is subject to change so please advise us accordingly of such changes so that we might better meet your needs. How do you access the personal information held by the CMA? You may send a written request to the attention of the Chief Privacy Officer at 1867 Alta Vista Drive, Ottawa, Ontario, K1G 5W8or to privacy@cma.ca to obtain the personal information held about you by the CMA. Within a reasonable time frame, the CMA will then advise you in writing whether it has such personal information and the nature of this information unless there is the rare occurrence that the release of such information is legally prohibited. If the CMA cannot release the personal information, we will provide you with the reasons for denying access. You may challenge the accuracy and completeness of the personal information that is maintained by the CMA. The CMA will amend personal information when an individual successfully demonstrates inaccuracy or incompleteness. How secure is your personal information? The CMA makes every reasonable effort to protect your personal information by implementing security safeguards against loss or theft, as well as unauthorized access, disclosure, copying, use or modification. The CMA uses physical, organizational and technological measures as methods of protection. For instance, only a limited number of staff have access to such sensitive information as credit card numbers. Moreover, the CMA will ensure that employees are aware of the importance of maintaining the confidentiality of personal information. How long does the CMA retain personal information? The CMA keeps personal information as long as it is needed to fulfill the purposes identified above. When personal information is no longer required to fulfill the identified purposes, it will be safely and securely destroyed. Moreover, the CMA will retain personal information that is the subject of an access request for as long as is necessary to allow an individual to exhaust any legal remedy that is provided for in applicable federal or provincial/territorial privacy legislation. What if you have a question or concern about this privacy policy or CMA privacy practices?

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Direct-to-consumer genetic testing

https://policybase.cma.ca/en/permalink/policy13696

Date
2017-05-27
Topics
Ethics and medical professionalism
  2 documents  
Policy Type
Policy document
Date
2017-05-27
Topics
Ethics and medical professionalism
Text
While genetic testing is typically provided in a clinical setting through the referral of a health care professional (HCP) or a regulated research project, a number of private companies now offer genetic testing services directly to consumers over the Internet. Direct-to-consumer (DTC) genetic testing is distinguished from clinical genetic testing ordered by a HCP in several ways: 1. DTC genetic tests are not regulated in Canada. The clinical validity and reliability of these tests varies widely, but DTC genetic testing companies make them available to consumers without distinguishing between those that may be useful to the management of one's health, those that have some limited health value, and those that are meant purely for recreational use. 2. Many of the tests advertised and sold via the Internet have not undergone clinical evaluation. 3. Marketing materials for these tests often imply that they have health value, but the terms of reference of some of the companies that offer them state that the tests are to be used for recreational purposes and many vendors do not guarantee the validity or reliability of their results. 4. Resale of personal health information and/or DNA samples is often an important part of the business model of companies that offer DTC genetic testing, raising concerns about patient privacy and insufficient or unclear disclosure of privacy terms. 5. Unlike genetic tests ordered and administered by HCPs, DTC genetic tests are ordered directly by the consumer, who most often has not consulted with a HCP as part of a clinical assessment, and the testing may not be clinically indicated. Some companies only agree to do testing if it has been ordered by a physician, but they will provide a phone conversation with one of their physicians (not based in Canada) if a consumer does not have access to a physician. When the testing is ordered by a physician, it will sometimes be ordered by the patient's personal physician. In such cases, this does not truly represent DTC genetic testing. 6. Without appropriate pre- and post-testing counselling by a HCP, consumers are left to interpret and act upon their results on their own. They might suffer psychological consequences if they overestimate their disease risk as a result of DTC. 7. As access to DTC genetic testing increases, Canadian HCPs (specifically primary care physicians) are faced with the challenge of appropriately counselling patients when they receive their test results. However, few physicians feel they have the necessary training and knowledge in genomics to provide adequate care in this area. Furthermore, these tests may have no clinical indication, produce uncertain results with ambiguous clinical applicability and have tenuous legal status, but they can potentially influence a patient's sense of well-being. GENERAL PRINCIPLES 1. The CMA is concerned with understanding, raising awareness of, and mitigating potential patient and societal harms that may arise from DTC genetic testing. 2. The CMA emphasizes the importance of the principle of protection of patient privacy and supports the right of Canadians to understand how their health information is being used by third parties, including insurance and DTC genetic testing companies. 3. The CMA believes that patients have the right to be fully informed about what a DTC genetic test can and cannot say about their health and that the scientific evidence on which a test is based should be clearly stated and easy to understand. 4. The CMA recommends regulation of both DTC genetic tests and the marketing of these tests through the development of a national framework that would include a combination of government and industry regulation with input from medical experts. 5. The CMA believes that unnecessary genetic testing should be avoided to ensure more appropriate use of health care resources. Even if a consumer pays directly for testing, any test result, even an incidental finding from a DTC genetic testing laboratory without clinical certification, may trigger a cascade of clinical investigations and lead to further unnecessary testing and inappropriate use of resources. 6. The CMA supports educational initiatives on DTC genetic testing for physicians practising in all specialties so that they can respond to patient queries about these tests and, when necessary, their results. PROTECTION OF PRIVACY * Privacy and confidentiality of patients' personal health information must be maintained. * Before a patient submits a sample to a DTC genetic testing company, the company should obtain express informed consent from the patient concerning the way in which their data will be collected and used, who will have access to the data and the interpreted results, what safeguards are in place to protect it, and how it will be disposed of in the event of a company/laboratory closure. * Patients have the right to a clear understanding of who owns the sample and the generated data, in particular whether their data will be sold or shared with third parties. If resale of personal health information and/or DNA samples is an important part of the business model of DTC-GC companies, this should be stated explicitly in terms understandable by the consumer. * DTC-GC companies that solicit Canadian consumers should be subject to the Personal Information Protection and Electronic Documents Act (PIPEDA). * The CMA encourages physicians to become familiar with privacy legislation affecting the use of DTC genetic tests by insurance companies and employers. ROLE OF PHYSICIAN * Physicians should generally avoid using DTC genetic tests unless they have been clinically and empirically validated. * Physicians who are presented with a patient's DTC genetic test results should take the following actions: o They should explain to their patient the limits of the specific test the patient used. If a physician does not know this information he/she should discuss with the patient the fact that DTC genetic test results are not necessarily obtained from an accredited laboratory or interpreted in a standardized way; therefore, the validity and clinical utility of the results may be highly variable for certain tests. o They should disclose their level of comfort in providing an accurate interpretation of the results. o They should assess whether the test results are clinically significant in the context of that patient's symptoms, signs, medical history and family history before deciding whether it is appropriate to formally consult a specialty provider such as a medical geneticist. o If a physician wishes to use the results of a test in their clinical assessment, they should ensure that the laboratory performing the test guarantees analytical reliability and validity. * Physicians should adhere to the following principles related to medically indicated genetic testing: o Physicians should generally avoid recommending and/or ordering DTC genetic tests if they do not have a clear understanding of the validity and limitations of the tests they select. o Physicians should follow best practice guidelines and make use of clinically valid tests, accredited laboratories and specialist referral(s), when appropriate. o Physicians must obtain informed consent from the patient before ordering any genetic test, assist the patient in interpreting the results, support the individual with respect to psychological and biological implications of the results, and refer the patient to appropriate resources. o Many genetic tests require pre- and post-test counselling, particularly (but not limited to) tests involving children, tests establishing carrier status or tests considered to be predictive. If a provider decides to order such testing, they also accept the responsibility for facilitating access to pre- and post-test counselling. ROLE OF GOVERNMENT * The CMA calls on the government to enact regulations based on Bill S-201 (An Act to prohibit and prevent genetic discrimination) that establish clear boundaries for the marketing, distribution, accreditation and third-party use of DTC genetic tests. * The CMA believes that it is the government's responsibility to ensure that Canadians are only offered reliable, accurate and medically relevant genetic testing services. * The CMA encourages the development of national standards for the reliability and validity of DTC genetic tests by relevant federal government agencies, in conjunction with interested stakeholders (e.g., geneticists and laboratory scientists, genetic counsellors, physicians, private and public laboratories, industry, and patient groups). * The CMA encourages the government to enact standards that can keep pace with the rapid development of technological innovation in genetic testing and genetics more generally. * The CMA encourages the government to enact standards that hold companies accountable for being transparent about their uses of data/DNA and the potential resale of such material. * The CMA encourages the government to enact standards that mandate that the type of testing (e.g., single-nucleotide polymorphism [SNP] analysis, targeted mutation testing, sequencing) be clearly labelled and that a clear explanation be provided of the type of information that can (or cannot) be obtained from such testing. SYSTEMS INFRASTRUCTURE * Genetic testing and the interpretation of the results of such testing are highly technical and complex processes. For this reason, the CMA believes that clinical testing laboratories that are used by DTC genetic testing companies must be accredited if the companies are to claim that their testing is valid. * The CMA believes that scientific evidence describing the validity and utility of a DTC genetic test should be clearly stated in language that is easy to understand. This information should include a clear statement of what a test can or cannot diagnose or infer, and statements about the validity of a specific test should be supported with references. A company that does not guarantee the reliability or validity of its test should not be allowed to make any (implicit or explicit) claims about the potential medical utility of its test and/or its potential to improve health. EDUCATION AND PUBLIC ENGAGEMENT * The CMA supports public education initiatives to increase patient awareness of the potential implications and limitations of DTC genetic testing for health purposes. The CMA supports increased genetics training for physicians to help them to further appreciate the complex issues involved and keep pace with the rapid changes in molecular genetics. Such training would support physicians to counsel patients who seek follow-up for their DTC genetic test results. Approved by the CMA Board of Directors May 2017 See also Background to CMA Policy on Direct-to-Consumer Genetic Testing BACKGROUND TO CMA POLICY DIRECT-TO-CONSUMER GENETIC TESTING See also CMA Policy PD17-05 Direct-to-Consumer Genetic Testing Some direct-to-consumer (DTC) genetic tests, such as "compatibility testing" for online dating, are purely recreational. Other tests, however, are marketed both as being for recreational use and as producing results that are useful to the management of one's health. This document concerns this second category of tests. The characteristics of these tests differ widely, and some of the companies that offer them clearly state that they do not guarantee the validity and reliability of their tests. As of January 2016, 246 companies offered some form of DNA test online.1 Many DTC genetic tests have started to penetrate the Canadian market, especially after the U.S. Food and Drug Administration issued a warning letter instructing some companies in the U.S. to cease providing unreliable health information that could potentially lead consumers to make misinformed decisions about their health, which caused some of these companies to seek out alternative markets.2 The increasing availability of DTC genetic tests in Canada presents several challenges, as the predictive value of most of the DTC genetic tests currently on the market is very low. Moreover, there is no standard model for the delivery and interpretation of the results of these tests. Greater regulatory guidance and protection is needed to ensure that individuals who choose to submit samples to DTC genetic testing companies are not adversely affected by information that is not necessarily predictive or even accurate. Survey research indicates that the general public is overwhelmingly interested in genetic testing technologies.3 Researchers predict that an increasing number of individuals will use DTC genetic testing as testing technologies continue to become more affordable and efficient.3 Since genetic issues tend to cross medical specialties, it often falls on primary care physicians to understand the role of genetics in clinical care.4 In fact, genetic testing companies often direct patients to discuss their results with their primary care physician.5 Patients not only seek out their primary care providers to discuss their genetic test results and obtain appropriate follow-up but also expect them to be able to answer questions about personal genome test results.6 Despite these expectations, health professionals' awareness and knowledge of DTC genetic tests remains low.7 Although DTC genetic tests are marketed under similar names, the genetic tests available in Canada have very different characteristics. Three types of tests are offered: (1) single-nucleotide polymorphism (SNPs) analysis, which assesses an individual's risk for common multifactorial diseases (e.g., diabetes, myocardial infarction), (2) targeted mutation analysis and (3) sequencing. Some are ordered directly by the consumer while others are pre-ordered by the consumer and the order is co-signed by a physician (the patient's physician or a physician who has never met the patient and whose services are provided by the company). SNP testing assesses for a number of genetic variants that are common in the general population and that have been identified in association studies to modify (increase or decrease) the risk of a given disease. Some DTC genetic testing companies explicitly state in their terms of service that they do not guarantee the accuracy or reliability of the test. This is due in part to deficiencies in the science underlying the tests and their interpretation. For example, the interpretation of SNPs analysis for common multifactorial diseases can only be as good as the science behind it. The scientific community has a long way to go before it will have identified all of the significant genetic risk factors and protective factors for these diseases. Because of this, a given consumer could receive greatly divergent risk interpretations.3 In the case of targeted mutation analysis and sequencing, the specific panels offered by DTC genetic testing companies may not include all of the clinically relevant genes and mutations. This could result in a consumer receiving harmful false reassurance. Test results may include information on genetic changes that are only weakly associated with disease, leading to undue anxiety. As such, the clinical and health value of DTC genetic testing continues to be debated despite consumer uptake of, and enthusiasm for, DTC genetic testing offered online. Currently, most DTC genetic testing services exist in regulatory limbo, benefiting from laws that tend to lag behind technological innovation. Questions about access to the information yielded by these tests have emerged as a particular concern. For some companies, an important part of the business model is to sell consumers' DNA along with the clinical information that the consumers provide via their interactive websites. Most Canadians are unaware of this: they pay for a test and do not expect that their data will later be sold. ISSUES ARISING IN CLINICAL CONTEXTS Studies have shown that physicians see a number of benefits with DTC genetic testing, but they also have concerns. The benefits physicians have identified include convenience, promotion of preventive medicine and the provision of personalized services.5 They are concerned about the reliability of test results, the provision of adequate information/counselling, patient anxiety if the results are misunderstood, inappropriateness of advertising, discrimination with respect to employment and insurance, the possible spread of beliefs such as genetic determinism, and the inappropriate disclosure of patients' genetic information.5 The following sections will address primary concerns identified by research and in practice. 1. Patient privacy Privacy is one of the top concerns of the general public about genetic testing.8 According to a 2010 report commissioned by the Office of the Privacy Commissioner of Canada, approximately 60% of patients indicated that privacy and discrimination fears would influence their decision to undergo genetic testing.9 The average Canadian consumer is not adequately informed that an important part of the business model of many DTC genetic testing companies is to build and sell their database of phenotypic information and DNA accumulated from their clients to third parties, such as biobanks or pharmaceutical companies. 1.1 Informed consent The increasing quantity, complexity and diversity of DTC genetic testing services pose challenges for informed consent because both specific and generic models do not meet ethical standards when applied to this type of service.10 Many companies bind their consumers to contracts that are activated once the website is viewed, a practice that challenges the adequacy of consent, as it is common for people to view a website without reading or even seeing its terms of reference.1 Consumers who present to genetic clinics tend not to question the validity of the results they have received from DTC genetic testing,11 which can be interpreted as an indication that consumers give their consent without reading or understanding the disclaimers made by the companies.11 Physicians are concerned that this lack of informed consent could compromise the confidentiality of personal health information, encourage requests for unnecessary medical tests and potentially cause distress to patients. 1.2 Insurance The insurance industry is of particular concern in the context of privacy and DTC genetic tests. A study of patients' perceptions of DTC genetic tests found that participants were concerned that genetic results could affect their health insurance premiums or lead to denial of coverage.12 Private insurance is fundamentally rooted in the practice of discriminating between clients on the basis of risk. While insurers have generally been entitled to request genetic information in the form of family history, to access medical files and to conduct medical tests,13 consumers have expressed the view that the rules governing access to genetic information should be stricter than for access to other forms of personal information.3 While there are studies that report cases of genetic discrimination, it is often unclear whether such treatment is perceived or actual.14. Thus, the consequences of genetic testing remain uncertain. Of particular concern is the potential for discrimination on the basis of results that may not be accurate and/or reliable. Although there is presently no evidence of widespread use of genetic testing by insurance companies,14experts agree that in the next 10 years public acceptance of the use of information from genetic testing will increase and it will become possible to more accurately interpret data from genetic tests (K. Boycott, J. Davies and K. Morin, CIHR Café Scientifique, unpublished remarks), threatening to alter the currently limited role that genetic testing plays in insurance company decision-making. Before policy-makers tackle the potential issues related to the use of DTC genetic testing, it is imperative that they start at ground level and explore options to regulate insurance companies' access to such tests. 2. Patient response 2.1 Interpretation of results and changes in behaviour Proponents of DTC genetic testing point to the potential for patients to make positive changes to their health as a result of learning about their genetic susceptibility to certain diseases. Findings of studies in this area, however, are inconsistent to date. While some studies have reported that there are some behaviour changes, it is important to keep in mind that early adopters of these services are likely to also be among those most motivated to make health-related changes.15 Recent evidence suggests the opposite response: the general population has a tendency to decrease healthy practices upon learning about a lower health risk, and they do not increase healthy practices when they learn that they have an increased health risk.15 Indeed, patients may make poorer health decisions if they are under the impression that they are not at risk for developing a certain disease; for example, they may avoid routine screening for breast or prostate cancer, or they may not follow exercise and diet advice. 16 These variations in behaviour can be largely attributed to the fact that there is an overarching risk that patients will misinterpret the data they receive from the testing companies. The problem with susceptibility tests in the context of DTC genetic testing is not only that the test results may cause psychological or physical harm but also that there is a possibility that patients will over-interpret their disease risk.10 Without expert guidance, the patient may not be able to evaluate their test results accurately enough to make informed health decisions.14 There is very little evidence to suggest that receipt of a DTC genetic test result produces sustained behavioural change.17 In fact, studies on psychological theories related to motivation do not consider disease risk information a useful tool for motivating patients to change their behaviour.15 Therefore, while receipt of DTC genetic test results may encourage patients to see their family physician and possibly undergo further consultation, the health care resources invested in interpreting results with limited clinical validity may not produce sustained behavioural changes, good or bad. 3. Resource allocation One of the stated goals of personalized medicine is to save health care systems money by facilitating the use of fewer but more effective treatments.18 However, greater demand for genetic testing, whether public or private, could produce the opposite effect: consumption of health care resources may increase as patients consult with their regular physician about results they obtained through a DTC company.16 Furthermore, physicians who are presented with DTC genetic test results by their patients have a legal and ethical obligation to do their due diligence and carry out a complete, clinically valid investigation, which may ultimately negate the cost savings that personalized medicine is expected to produce.16 Patients who participate in DTC genetic testing are likely to drive up the utilization of health care providers, as they seek out their primary care provider to discuss their results and they obtain follow-up care from a genetic counsellor.19,5 At least one study has suggested that there is an expectation that physicians will help patients to interpret their DTC genetic test results, and DTC genetic testing companies frequently direct patients to discuss their results with their physicians before acting upon their testing information.5 Consequently, the responsibility falls on primary care providers to discuss this technology with their patients.5 Primary care providers, however, believe that genetic specialists are the most appropriate providers of counselling for DTC genetic tests.14 While they acknowledge the benefits of DTC genetic tests, including the potential for test results to encourage patients to be more involved in their care and take responsibility for their health, they also agree that test results may encourage patients to seek unnecessary and potentially expensive follow-up tests.14 As a result, additional health care resources may be required to cope with the increased demand for medical follow-up.20 4. Physician education Although DTC genetic testing companies have been around since the early 2000s, levels of awareness among health care professionals vary, and knowledge and understanding of the services generally remain low.21 Research suggests that few physicians feel they have the necessary training and knowledge in genomics to provide adequate care in this area.17 A perceived lack of clinical utility appears to be a barrier to learning more about DTC genetic testing.6 Increased genetics training and awareness may allow physicians to better appreciate the complex issues involved and help them to better counsel patients who seek follow-up for their DTC genetic test results. 4.1 Topics that physicians want to learn about Most physicians are concerned about the privacy implications of DTC genetic testing, specifically health insurance and employment discrimination, which may affect their patients who present with a DTC genetic test.5 Therefore, important discussion points to include in a physician education program would be information on the risks of insurance and employment discrimination, legislation currently in place to protect against genetic discrimination, and guidelines for managing risk.6 Given the ease with which patients can access DTC genetic testing, it is essential to provide health professionals with appropriate education on the potential benefits and risks of DTC genetic testing and help them develop an approach to interpreting the results of such testing, so that they can protect their patients from harm and arrange follow-up appropriately.19 5. Legislative landscape in Canada Before May 2017, Canada did not have a law to specifically protect against genetic discrimination. Existing human rights and privacy law could only be ambiguously and tenuously applied to DTC genetic testing issues, including genetic discrimination and information collection, use and disclosure.14 The laws that regulate medical devices, such as the Food and Drugs Act, did not clearly apply in the context of DTC genetic tests either,2 because consumers are not purchasing genetic testing kits but rather they are purchasing testing services, which fall outside the scope of that legislation.22 As a result, there was limited evidence to form the regulations necessary to ensure the validity and utility of these tests. Fortunately, on May 4, 2017, Bill S-201 (hereinafter termed S-201), An Act to prohibit and prevent genetic discrimination,23 received Royal Assent and will soon become law. S-201 provides a basis for the creation of regulations concerning the validity and utility of DTC genetic tests. The bill prohibits the requirement that an individual submit to genetic testing or disclose the results of genetic tests in order to receive goods or services or in order to enter into or continue a contract or agreement, and it prohibits submission to genetic testing or disclosure of test results from being used as the basis of any specific conditions in a contract or agreement. S-201 amends the Canada Labour Code to protect employees from being required to undergo or disclose the results of genetic testing and amends the Canadian Human Rights Act to prohibit discrimination on the grounds of genetic characteristics.21 Legislation at a provincial level, however, may still be required. Private Member's Bill 127, An Act to amend the Human Rights Code with respect to genetic characteristics,24 was presented to the Legislative Assembly of the Province of Ontario in 2013 but did not move past the first reading. Federal and provincial privacy legislation (such as the federal Personal Information Protection and Electronic Documents Act, or PIPEDA) also plays a role in protecting against genetic discrimination by requiring an individual to consent to the collection, use or disclosure of personal information.25 Currently, the Office of the Privacy Commissioner of Canada does not support amending the Privacy Act or PIPEDA, on the grounds that these laws sufficiently apply to genetic information.23 While this legislative framework might provide some protection against genetic discrimination, there is a lack of clarity as to whether it strikes the appropriate balance between consumers' rights to privacy and the interests of insurers. Furthermore, the courts have yet to provide an opinion regarding the constitutionality of S-201 or to assist in the interpretation of privacy legislation in the context of DTC testing, because of the novelty of the service. It is uncertain if and how Bill S-201 will inform future regulations placed upon employers and insurers. Significant gaps in the legislative framework remain; in particular, privacy protection in Canada has yet to counterbalance the lack of consumer protection in Canadian insurance laws.22 While existing legislation may offer some protection, the absence of legal precedents creates uncertainty and leaves consumers to engage in DTC testing services at their own risk. May 2017 See also CMA Policy PD17-05 Direct-to-Consumer Genetic Testing REFERENCES 1 Phillips AM. Only a click away - DTC genetics for ancestry, health, love ... and more: a view of the business and regulatory landscape. Appl Transl Genom 2016;8:16-22. 2 US Food and Drug Administration. Warning letter. Silver Spring (MD): The Administration; 22 Nov 2013. Available: www.fda.gov/iceci/enforcementactions/warningletters/2013/ucm376296.htm (accessed 2017 May 19). 3 Caulfield T. Direct-to-consumer testing: if consumers are not anxious, why are policy makers? Hum Genet 2011;130:23-5. 4 Delaney SK, Christman MF. Direct-to-consumer genetic testing: perspectives on its value in healthcare. Clin Pharmacol Ther 2016; 99(2):146-8. 5 Powell KP, Cogswell WA, Christianson CA, et al. Primary care physicians' awareness, experience and opinions of direct-to-consumer genetic testing. J Genet Couns 2012;21(1):113-26. 6 Powell KP, Christianson CA, Cogswell WA, et al. Educational needs of primary care physicians regarding direct-to-consumer genetic testing. J Genet Couns 2012;21(3):469-78. 7 Jackson L, Goldsmith L, Skirton H. Guidance for patients considering direct-to-consumer genetic testing and health professionals involved in their care: development of a practical decision tool. Fam Pract 2014;31(3): 341-8. 8 Caulfield T, McGuire AL. Direct-to-consumer genetic testing: perception, problems, and policy responses. Annu Rev Med 2012; 63:23-33. 9 Office of the Privacy Commissioner of Canada. Analysis of privacy policies and practices of direct-to-consumer genetic testing companies: private sector databanks and privacy protection norms. Ottawa: The Office; March 2010. p. 6. 10 Bunnik EM, Janssens AC, Schermer MH. Informed consent in direct-to-consumer personal genome testing: the outline of a model between specific and generic consent. Bioethics 2014;28(7):343-51. 11 Brett GR, Metcalfe SA, Amor DJ, et al. An exploration of genetic health professionals' experience with direct-to-consumer genetic testing in their clinical practice. Eur J Hum Genet 2012;20(8):825-30. 12 Wasson K, Sanders TN, Hogan NS, Cherny S, Helzlsouer KJ. Primary care patients' views and decisions about, experience of and reactions to direct-to-consumer genetic testing: a longitudinal study. J Community Genet. 2013;4:495-505 13 Lemmens T, Pullman D, Rodal R. Revisiting genetic discrimination issues in 2010: policy options for Canada [PowerPoint presentation]. Ottawa: Genome Canada; 15 June 2010. Available: www.genomecanada.ca/sites/default/files/pdf/en/gps_speakers_presentation/trudo-lemmens-daryl-pullman.pdf 14 Zinatelli F. Industry Code: Genetic testing information for insurance underwriting [Internet]. Toronto, ON: CLHIA; 2017 Jan 11. Available from https://www.clhia.ca/domino/html/clhia/CLHIA_LP4W_LND_Webstation.nsf/page/E79687482615DFA485257D5D00682400/$file/Industry%20Code%20Genetic%20Testing%20-%20Updated.pdf 15 Adams SD, Evans JP, Aylsworth AS. Direct-to-consumer genomic testing offers little clinical utility but appears to cause minimal harm. N C Med J 2013;74(6): 494-8. 16 Ram S, Russell B, Gubb M, et al. General practitioner attitudes to direct-to-consumer genetic testing in New Zealand. N Z Med J 2012;125(1364):14-26. 17 Caulfield T. Obesity genes, personalized medicine and public health policy. Curr Obes Rep 2015;4(3):319-23. 18 Caulfield T, Zarzeczny A. Defining 'medical necessity' in an age of personalised medicine: a view from Canada. Bioessays 2014;36(9):813-7. 19 Bloss CS, Schork NJ, Topol EJ. Direct-to-consumer pharmacogenomic testing is associated with increased physician utilisation. J Med Genet 2014;51(2):83-9. 20 Daly AK. Direct-to-consumer pharmacogenomic testing assessed in a US-based study. J R Coll Physicans Edinb 2014;44:212-3. 21 Jackson L, Goldsmith L, Skirton H. Guidance for patients considering direct-to-consumer genetic testing and health professionals involved in their care: development of a practical decision tool. Fam Pract 2014;31(3):341-8. 22 Mykitiuk R. Caveat emptor: direct-to-consumer supply and advertising of genetic testing. Clin Invest Med 2004;27(1):23-32. 23Parliament of Canada. Legislative summary of Bill S-201: An Act to prohibit and prevent genetic discrimination. Ottawa: Parliament of Canada; 2016 24 Parliament of Canada. Bill 127: An Act to amend the Human Rights Code with respect to genetic characteristics, 2nd Sess, 40th Leg, Ontario, 2013. 25 Personal Information Protection and Electronic Document Act (PIPEDA), S.C. 2000, C.5, para 5(3).

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The evolving professional relationship between Canadian physicians and our health care system: Where do we stand?

https://policybase.cma.ca/en/permalink/policy10389

Last Reviewed
2019-03-03
Date
2012-05-26
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2012-05-26
Topics
Ethics and medical professionalism
Text
This paper discusses the current state of the professional relationship between physicians and the health care system. A review of the concept of medical professionalism, and the tensions that can arise between the care of individual patients and a consideration of the broader needs of society, provides some basic groundwork. Our understanding of what it means to be a physician has evolved significantly over the years, and the medical profession is now being challenged to clarify the role it is willing to play in order to achieve transformation of our health care system. We have arrived at this point due to a convergence of several factors. Regionalization of health care has led to a change in the leadership roles played by practising physicians and to the opportunities they have for meaningful input into system change. Physicians are now also less likely to be involved in hospital-based care, which has resulted in a loss of collegiality and interactions with peers. Changing models of physician engagement status and changing physician demographics have also presented new and unique issues and challenges over the past few years. The Canadian Medical Association (CMA) suggests that its physician members and other stakeholders employ a "AAA" lens to examine the challenges and opportunities currently facing Canadian physicians as they attempt to engage with the health care system: Autonomy, Advocacy and Accountability. These important concepts are all underpinned by strong physician leadership. Leadership skills are fundamentally necessary to allow physicians to be able to participate actively in conversations aimed at meaningful system transformation. KEY CMA RECOMMENDATIONS ARE AS FOLLOWS: Physicians should be provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system. Physicians need to be provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and must be included as valued collaborators in the decision-making process. Physicians have to recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society. Physicians must be able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system. Physicians should participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes. Patient care should be team based and interdisciplinary with smooth transition from one care setting to the next and funding and other models need to be in place to allow physicians and other health care providers to practise within the full scope of their professional activities. INTRODUCTION The concept of medical professionalism, at its core, has always been defined by the nature and primacy of the individual doctor-patient relationship, and the fiduciary obligation of physicians within this relationship. The central obligation of the physician is succinctly stated in the first tenet of the CMA Code of Ethics: Consider first the well-being of the patient.1 Since the latter half of the 20th century, however, there has been a growing emphasis on the need for physicians to also consider the collective needs of society, in addition to those of their individual patients. As stated in the CMA Code of Ethics: Consider the well-being of society in matters affecting health. This shift in thinking has happened for at least two reasons. First, there have been tremendous advances in medical science that now enable physicians to do much more to extend the length and quality of life of their patients, but these advances inevitably come at a cost which is ultimately borne by society as a whole. Second, since World War II, Canadian governments have been increasingly involved in the financing of health care through taxation revenues. As a result, there have been growing calls for physicians to be prudent in their use of health care resources, and to be increasingly accountable in the way these resources are employed. The 2002 American Board of Internal Medicine (ABIM) Foundation Charter on Medical Professionalism calls for physician commitment to a just distribution of finite resources: "While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."2 This has also been described as civic professionalism. Lesser et al have put forward a systems view of professionalism that radiates out from the patient-physician relationship to broader interactions with members of the health care team, the training environment and to the external environment, dealing with payers and regulators and also addressing the socio-economic determinants of health.3 Understandably, given that the resources available for health care are finite, tensions will arise between the care of individual patients and the collective needs of society, and these tensions can at times be very difficult to resolve for individual medical practitioners. As stated in the CMA policy Medical Professionalism (Update 2005): Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit. 4 Over time the delivery, management and governance of health care have become more complex, and as a result the health care sector now accounts for roughly one in 10 jobs in Canada. There are more than two dozen regulated health professions across Canada, as well as numerous professional managers employed in various capacities, many of whom have had little or no exposure to the everyday realities of the practice of clinical medicine. Notwithstanding the acknowledgement of the very real and important need for inter-professional collaboration and teamwork, inevitably this creates competition for influence in the health care system. The CMA 2005 update of its policy on medical professionalism acknowledges the need for change. While maintaining responsibility for care of the patient as a whole, physicians must be able to interact constructively with other health care providers within an interdisciplinary team setting. The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality. Now, physicians are being challenged to clarify exactly what it is that they are prepared to do in order to advance the much-needed transformation of our health care system, and how they will partner with patients, other care providers and the system in order to achieve this common goal. This provides a significant opportunity for physicians to continue their leadership role in the health care transformation initiative in the interests of their patients, while at the same time redefining their relationship with the system (understood in this context as health care administrators, governments and their representatives, health districts, health care facilities and similar organizations) in order to ensure that they have a meaningful and valued seat at the decision-making table, now and in the future. BACKGROUND The common refrain among health administrators, health ministry officials and health policy analysts for the past decade and longer has been that physicians are "not part of the health care system", that they are independent contractors and not employees, and that they are too often part of the problem and not the solution. Over this period of time, several developments have resulted in a diminished role of physicians in clinical governance in Canada and have, to varying degrees, transformed the professional and collegial relationship between physicians and their health regions, health care facilities and communities to one that is increasingly governed by legislative fiat or regulation. Regionalization Beginning with New Brunswick in 1992, all jurisdictions except Ontario, the Yukon Territory and Nunavut have adopted a regional governance model. This change has eliminated all hospital and community services boards within a geographic region and replaced them with a single regional board. Clinical governance is now administered through a regional medical advisory committee (MAC). Some provinces such as Saskatchewan recognize the role of the district (regional) medical staff association. This has had a profound impact in reducing the number of physicians engaged in the clinical governance of health care institutions. Another by-product of regionalization is that in virtually all jurisdictions, physicians no longer sit on governing boards. While physicians continue to serve as department heads and section chiefs within regions and/or individual hospital facilities, the level of support and financial compensation to do so varies greatly, particularly outside major regions and institutions, and there has been a lack of physician interest in such positions in some places. Practice environment In addition to a diminished presence in clinical governance, physicians are less likely to be actively involved in hospitals than they were previously. Anecdotally, many physicians, particularly in larger urban communities, describe having been "pushed out" of the hospital setting, and of feeling increasingly marginalized from the decision-making process in these institutions. Another result of the diminished engagement with hospitals has been the loss of the professional collegiality that used to be fostered through interaction in the medical staff lounge or through informal corridor consultations. In the community setting, there have been some positive developments in terms of physician leadership and clinical governance. Ontario and Alberta have implemented new primary care funding and delivery models that promote physician leadership of multidisciplinary teams, and at least two-thirds of the family physicians in each of these jurisdictions have signed on. British Columbia has established Divisions of Family Practice, an initiative of the General Practice Services Committee (a joint committee of the BC Ministry of Health and the BC Medical Association), in which groups of family physicians organize at the local and regional levels and work in partnership with the Health Authority and the Ministry of Health to address common health care goals. Looking ahead, regionalization is also likely to affect physicians in community-based practice. There is a clear trend across Canada to require all physicians within a region to have an appointment with the health region if they want to access public resources such as laboratory and radiology services. In the future this may also result in actions such as mandated quality improvement activities which may be of variable effectiveness and will not necessarily be aligned with the learning needs of physicians. Physician engagement status Traditionally physicians have interfaced with hospitals through a privileges model. This model, which has generally worked well, aims to provide the physician with the freedom to reasonably advocate for the interests of the patient.5 In this model, legislation and regulations also require that there are minimum procedures in place for renewing, restricting, and terminating privileges, and that procedures are set out to ensure that this takes place within a fair and structured framework. The hospital's MAC generally reviews physician privileges applications and recommends appointment and reappointment. The MAC thus plays an integral role in ensuring the safety of care within the region or hospital.5 There has been increasing attention recently on engaging in other types of physician-hospital relationships, including employment or contractual arrangements. This type of arrangement can vary from an employment contract, similar to that used by other professional staff such as nurses and therapists, to a services agreement whereby the physician provides medical services to the hospital as an independent contractor.5 However, there are concerns, expressed by the Canadian Medical Protective Association (CMPA) and others, that many of the procedural frameworks and safeguards found in hospital bylaws pertaining to the privileges model may not necessarily extend to other arrangements, and that physicians entering into these contractual agreements may, in some cases, find their appointment at the hospital or facility terminated without recourse. Under such arrangements the procedural fairness and the right of appeal available under the privilege model may not be available to physicians. One relatively new approach is the appointment model, which aims to combine many of the protections associated with the privileges model with the advantages of predictability and specificity of the employment model. It generally applies the processes used to grant or renew privileges to the resolution of physician performance-related issues.5 It has been argued that changes in appointment status and relationship models can have a detrimental impact on the relationship between practitioners and health care facilities.6 While this has been reported specifically within the context of Diagnostic Imaging, the same may hold true for other specialties as well. It should also be noted that the issues raised in this paper are applicable to all members of the profession, regardless of their current or future practice arrangements or locations. Changing physician demographics and practice patterns It is well recognized that physician demographics and practice patterns have changed significantly over the past several years. Much has been written about the potential impact of these changes on medicine, and their impact on patient care, on waiting lists and on the ability of patients to access clinical services.7 It is also acknowledged that "lifestyle factors," that is to say the attempt by many physicians to achieve a healthier work-life balance, may play a role in determining the type and nature of clinical practice chosen by new medical graduates, the hours they will work and the number of patients they will see. All of these changes mean that clinical practices may have smaller numbers of patients and may be open shorter hours than in the past. Physicians are being increasingly challenged to outline their understanding of their commitment to ensuring that all patients have timely access to high quality health care within the Canadian public system, while balancing this with their ability to make personal choices that are in their best interests. Put another way, how can we assist physicians in adjusting their clinical practices, at least to some extent, based on the needs of the population? DISCUSSION While there are clearly challenges and barriers to physician participation in meaningful transformation of the health care system, there are also opportunities for engagement and dialogue, particularly when the doctors of Canada show themselves to be willing and committed partners in the process. Health care transformation cannot be deferred just because it involves difficult decisions and changes to the status quo. Regardless of how we have reached the current situation, relationships between physicians and other parties must evolve to meet future needs. Physicians need to be assisted in their efforts in this regard, both by local health boards and facilities, and by organizations such as the CMA and its provincial and territorial counterparts. Physicians, individually and collectively, need to demonstrate what they are willing to do to assist in the process and what they are willing to contribute as we move forward, and they need to commit to having the medical profession be an important part of the solution to the challenges currently facing the Canadian system. We examine some of these challenges through the "AAA" lens of Autonomy, Advocacy and Accountability, which are underpinned by the concept of Physician Leadership. Autonomy To a large extent, physicians continue to enjoy a significant degree of what is commonly termed clinical or professional autonomy, meaning that they are able to make decisions for their individual patients based on the specific facts of the clinical encounter. In order to ensure that this autonomy is maintained, physicians need to continue to embrace the concept of clinical standards and minimization of inter-practice variations, where appropriate, while also recognizing the absolute need to allow for individual differences in care based on the requirements of specific patients. Professional autonomy plays a vital role in clinical decision-making, and it is at the heart of the physician-patient relationship. Patients need to feel that physicians are making decisions that are in the best interest of the patient, and that physicians are not unduly limited by external or system constraints. As part of this decision-making, physicians may also need to consider carefully the appropriate balance between individual patient needs and the broader societal good. In recent years, governments have sometimes made use of the "legislative hammer" to force physicians to conform to the needs of the health system, thus undermining physicians' individual or personal autonomy. Historically, physicians have organized themselves to provide 24-hour coverage of the emergency room and other critical hospital services. This has proven increasingly challenging in recent years, particularly in the case of small hospitals that serve sparsely populated areas where there are few physicians. Physicians need to continue to make sure that they do not confuse personal with professional autonomy and that they continue to ensure that health care is truly patient-centred. Physicians have rights but also obligations in this regard and they need to make sure that they continue to use a collaborative approach to leadership and decision-making. This includes an ongoing commitment to the concept of professionally-led regulation and meaningful physician engagement and participation in this system. While physicians will continue to value and protect their clinical and professional autonomy, and rightly so as it is also in the best interests of their patients, they may need to consider which aspects of personal and individual autonomy they may be willing to concede for the greater good. For example, physicians may need to work together and collaboratively with administrators and with the system to ensure that call coverage is arranged and maintained so that it need not be legislatively mandated, or imposed by regions or institutions. They may need to consider changing the way they practice in order to serve a larger patient population so that patients in need of a primary care physician do not go wanting, and so that the overall patient care load is more evenly balanced amongst colleagues. New primary care models established in Ontario and Alberta over the past decade that provide greater out-of-hours coverage are one example of such an initiative. By working collaboratively, both individually and collectively, physicians are finding creative ways to balance their very important personal autonomy with the needs of the system and of their patients. These efforts provide a solid foundation upon which to build as the profession demonstrates its willingness to substantively engage with others to transform the system. To paraphrase from the discussion at the CMA's General Council meeting in August 2011: Physicians need to carefully examine their individual and collective consciences and show governments and other partners that we are willing to play our part in system reform and that we are credible partners in the process. All parties in the discussion, not only physicians, must be able to agree upon an appropriate understanding of professional autonomy if the health care system is to meet the current and future needs of Canadians. Advocacy Physician advocacy has been defined as follows: Action by a physician to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.8 This can consist of advocacy for a single patient to assist them in accessing needed funding for medications, or lobbying the government for changes at a system level. How and when individual physicians choose to undertake advocacy initiatives depends entirely on that individual practitioner, but physicians as a collective have long recognized their obligation to advocate on behalf of their individual patients, on behalf of groups of patients, and at a societal level for changes such as fairer distribution of resources and adequate pandemic planning. Traditionally, physicians have served as advocates for their patients in a number of arenas; however, various factors such as provincial/territorial legislation, regulatory authorities, and hospital contracts have combined to make them more reluctant to take on this important role and as a result overall patient care may suffer and the patient-physician relationship may be threatened. Increasingly, hospital bylaws urge or require physicians to consult with their institution or health region before going public with any advocacy statements, and in at least one health region physicians are required to sign a confidentiality agreement. Because of this, many physicians fear reprisal when they decide to act as an advocate. The ability to undertake advocacy initiatives is a fundamental concept and principle for Canadian physicians. Indeed, the CMA Code of Ethics encourages physicians to advocate on behalf of the profession and the public. Patients need to feel that their concerns are heard, and physicians need to feel safe from retribution in bringing those concerns forward. A well-functioning and respectful advocacy environment is essential to health care planning. Health care is about making choices every day. Governments struggling to balance budgets should be aware that the public can accept that hard choices must and will get made - but they are less likely to be supportive if physicians and their patients do not feel that their opinions are sought and considered as part of the process. Frontline health care providers, many of whom work in relative isolation in an office or community setting, also need to feel that they have a voice. The CMA supports the need for a forum where primary care physicians can speak with one voice (and make sure that this voice is heard and respected) in a community setting. In addition to advocating for issues related directly to patient care, physicians, as community leaders, may also be called upon to advocate for other issues of societal importance, such as protection of the environment or social determinants of health. These advocacy undertakings can also be of great importance. There can be a fine line between advocacy that is appropriate and is likely to affect important and meaningful change, and advocacy that others will perceive as being obstructive or counterproductive in nature. To further complicate matters, what might be seen as appropriate advocacy in one circumstance might not be in a different setting. Physicians should be clear on whose behalf they are speaking and whether they have been authorized to do so. If they have any questions about the possible medicolegal implications of their advocacy activities, they may also wish to contact their professional liability protection provider (e.g., CMPA) for advice in these instances. Depending on the facts of the individual circumstances, physicians may need to consider other factors as well when deciding if, when and how to undertake advocacy activities. They should also be aware that their representative medical organizations, such as national specialty societies, provincial and territorial medical associations and the CMA, may be able to assist them with their initiatives in certain situations. Physicians should not feel alone when advocating for their patients, particularly when this is done in a reasonable manner and in a way that is likely to effect meaningful and important change. Accountability Physician accountability can be seen to occur at three levels: accountability to the patients they serve, to society and the health care system and to colleagues and peers. Accountability to patients The physician-patient relationship is a unique one. Based on, optimally, absolute trust and openness, this relationship allows for a free exchange of information from patient to physician and back again. Physicians often see patients at their most vulnerable, when they are struggling with illness and disease. While other health care providers make essential contributions to patient care, none maintain the unique fiduciary relationships that are at the heart of the physician's role and which are recognized by law. Physicians are accountable to their individual patients in a number of important ways. They provide clinical services to their patients and optimize their availability so that patients can be seen and their needs addressed in a timely fashion. They follow up on test results. They facilitate consultations with other physicians and care providers and follow up on the results of these consultations when needed. They ensure that patients have access to after hours and emergency care when they are not personally available. Physicians can also fulfill their obligation to be accountable to patients in other ways. They can participate in accreditation undertakings to ensure that their practices meet accepted standards. They can ensure, through lifelong learning and maintenance of competency activities, that they are making clinical decisions based on the best available evidence. They can undertake reviews of their prescribing profiles to ensure that they are consistent with best current standards. All of these activities can also be used to maximize consistencies within and between practices and minimize inter-practice variability where appropriate. Accountability to society and the health care system Physician accountability at this level is understandably more complex. In general, society and the health care system in Canada provide physicians with financial compensation, with a significant degree of clinical autonomy as reflected by professionally-led regulation, and with a high level of trust. In some cases, physicians are also provided with a facility in which to practice and with access to necessary resources such as MRIs and operating rooms. In return, physicians agree to make their own individual interests secondary in order to focus on those of their patients, and they agree to provide necessary medical services. Accountability then can be examined based on the extent that these necessary services are provided (i.e. patients have reasonable access to these services) and also the level of quality of those services. Clearly, neither access nor quality can be considered in isolation of the system as a whole, but for the purposes of this paper the focus will be on the role of the physician. The issue of level and comprehensiveness of service provision has been considered to some extent above under the concept of physician autonomy. Physicians as individuals and as a collective need to ensure that patients have access to timely medical care and follow up. They also need to make sure that the transition from one type of care to another (for example, from the hospital to the community setting) is as seamless as possible, within the current limitations of the system. Collectively and individually, physicians also have an obligation to make sure that the quality of the care they provide is of the highest standard possible. They should strive for a "just culture of safety", which encourages learning from adverse events and close calls to strengthen the system, and where appropriate, supports and educates health care providers and patients to help prevent similar events in the future.9 Thousands of articles and hundreds of books have been published on the subjects of quality assurance and quality improvement. From a physician perspective, we want to be able to have access to processes and resources that will provide us with timely feedback on the level of quality of our clinical care in a way that will help us optimize patient outcomes and will be seen as educational in nature rather than punitive. As a self-regulated profession, medicine already has strong accountability mechanisms in place to ensure the appropriate standards of care are maintained. To ensure that physicians are able to meet their obligation to be accountable to the health care system for high quality care, the CMA has developed a series of recommendations for Continuous Quality Improvement (CQI) activities (see box below). Physicians need to take ownership of the quality agenda. New medical graduates are entering practice having come from training systems where they have access to constant feedback on their performance, only to find themselves in a situation where feedback is non-existent or of insufficient quality to assist them in caring for their patients. While regulators and health care facilities have a legitimate interest in measuring and improving physician performance, ultimately physicians themselves must take responsibility for ensuring that they are providing their patients with the highest possible standard of care, and that mechanisms are in place to ensure that this is in fact the case. Accountability to colleagues Physicians are also accountable to their physician peers and to other health care providers. While much of this accountability is captured by the concept of "collegiality," or the cooperative relationship of colleagues, there are other aspects as well. Anecdotal evidence suggests strongly that many physician leaders find themselves marginalized by their peers. They describe being seen as having "gone over to the other side" when they decide to curtail or forego their clinical practices in order to participate in administrative and leadership activities. Physicians should instead value, encourage and support their peers who are dedicating their time to important undertakings such as these. As well, physicians should actively engage with their administrative colleagues when they have concerns or suggestions for improvement. Collaboration is absolutely vital to the delivery of safe and quality care. Physicians also need to make sure that they do everything they can to contribute to a "safe" environment where advocacy and CQI activities can be undertaken. This can mean encouraging physician colleagues to participate in these initiatives, as well as serving as a role model to peers by participating voluntarily in CQI undertakings. Physicians are also accountable to ensure that transition of care from one physician to another occurs in as seamless a manner as possible. This includes participating in initiatives to improve the quality and timeliness of both consultation requests and results, as well as ensuring professional and collegial communications with other physicians and with all team members. Finally, physicians need to support each other in matters of individual health and well-being. This can include support and care for colleagues suffering from physical or psychological illness, as well as assisting with accommodation and coverage for duty hours and professional responsibilities for physicians who are no longer able to meet the demands of full-time practice for whatever reason. Physician Leadership "You will not find a high performing health system anywhere in the world that does not have strong physician leadership." Dan Florizone, Deputy Minister of Saskatchewan Health As we can see from the discussion above, having strong physician leaders is absolutely critical to ensuring that the relationship between physicians and the health care system is one of mutual benefit. Physicians as a collective have an obligation to make sure that they support both the training required to produce strong physician leaders, as well as providing support for their colleagues who elect to undertake this increasingly important role. Physicians are well-positioned to assume leadership positions within the health care system. They have a unique expertise and experience with both the individual care of patients, as well as with the system as a whole. As a profession, they have committed to placing the needs of their patients above those of their own, and this enhances the credibility of physicians at the leadership level as long as they stay committed to this important value. Leadership is not just about enhancing the working life of physicians, but is about helping to ensure the highest possible standard of patient care within an efficient and well-functioning system. As part of their leadership activities, physicians need to ensure that they are consistently engaged with high quality and reliable partners, who will deliver on their promises and commitments, and that their input is carefully considered and used in the decision-making process. These partners can include those at the highest level of government, and must also include others such as medical regulators and senior managers. Without ensuring that they are speaking with the right people, physicians cannot optimize their leadership initiatives. Physician leadership activities must be properly supported and encouraged. Many physicians feel increasingly marginalized when important meetings or training opportunities are scheduled when they are engaged in direct patient care activities. Non-clinician administrators have time set aside for these activities and are paid to participate, but physicians must either miss these discussions in order to attend to the needs of their patients, or cancel clinics or operating room times. This means that patient care is negatively impacted, and it presents a (sometimes significant) financial disincentive for physicians to participate. Some jurisdictions have recognized this as a concern and are ensuring that physicians are compensated for their participation. Patients want their physicians to be more involved in policy-making decisions and this must be enabled through the use of proper funding mechanisms, reflective learning activities, continuing professional development credits for administrative training and participation, assisting in the appropriate selection of spokespersons including guidelines on how to select them, and guidelines for spokespersons on how to provide meaningful representation of the profession's views. Physician leadership training must take place throughout the continuum of medical education, from the early days of medical school through to continuing professional development activities for those in clinical practice. Physicians with an interest in and aptitude for leadership positions should ideally be identified early on in their careers and encouraged to pursue leadership activities and training through means such as mentorship programs and support from their institutions to attend training courses and meetings where they will be able to enhance and refine their leadership skills. There has been action on several fronts to support the organized professional development of physicians in leadership roles. Since the 1990s the Royal College of Physicians and Surgeons of Canada (RCPSC) has been implementing its CanMEDs framework of roles and competencies in the postgraduate medical training programs across Canada, and this has also been adopted by the College of Family Physicians of Canada (CFPC). The CanMEDs framework sets out seven core roles for physicians. Two that are most pertinent to the relationship between physicians and the health care system are those of manager and health advocate.10 These roles highlight the importance of physician involvement in leadership and system engagement activities, and are relevant for physicians in training as well as those in practice. As managers, physicians are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system. As health advocates, physicians responsibly use their expertise and influence to advance the health of individual patients, communities and populations. A number of key enabling competencies have been identified for each role, and the RCPSC has developed a variety of resource materials to support the framework. For almost 30 years, the CMA has been offering the Physician Manager Institute (PMI) program in order to provide training for physicians pursuing leadership and management positions. PMI is offered in "open enrolment" format in major cities across Canada, and also "in house" through longstanding associations with hospitals and health regions (e.g., Calgary zone of Alberta Health Services [AHS]). In 2010 the CMA and the Canadian Society of Physician Executives introduced the Canadian Certified Physician Executive (CCPE) Program. The CCPE is a peer-assessed credential that can be attained either through an academic route that is based on completion of PMI courses or through a practice-eligibility route based on formal leadership experience.11 The CMA also partners with several provincial and territorial medical associations to provide leadership training. Currently CMA has agreements with the Saskatchewan, Ontario and Quebec medical associations and this will extend to the four Atlantic medical associations and the Alberta Medical Association/AHS in 2012. In addition, a number of university business schools have developed executive program offerings for health leaders. During the past decade, a number of physicians have taken up CEO positions in Canada's major academic health organizations. Internationally, it has been recognized that physician leadership is critical to the success of efforts to improve health services.12, 13 Having well trained and qualified physicians in leadership roles is critical in making sure that physicians continue to play a central role in the transformation of the Canadian health care system. The CMA and its membership unreservedly support our physician colleagues who dedicate their time and energies to these leadership activities and the CMA will continue to play an integral part in supporting and training the physician leaders of the future. CONCLUSION: THE CMA'S VISION OF THE NEW PROFESSIONAL RELATIONSHIP BETWEEN CANADIAN PHYSICIANS AND OUR HEALTH CARE SYSTEM We have explored the factors that have brought us to this point, as well as the issues that must be examined and addressed to enable us to move forward. It is now time for the physicians of Canada to commit to meaningful participation in the process of transforming our health care system. This can only be achieved through the concerted efforts of all parties, including governments, health authorities, health care facilities, physicians and other health care providers. It will not be easy, and it is not likely that this transformation will take place without commitment and sacrifice on our part. However, now is the time for physicians to demonstrate to their patients, to their colleagues and to society that they are willing to do their share and play their role in this critically important process, at this critically important time. Doing so will help them to achieve the CMA's vision of the new professional relationship between Canadian physicians and the health care system. In this vision: Physicians are provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system. Physicians are provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and are included as valued collaborators in the decision-making process. Physicians recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society. Physicians are able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system. Physicians participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes. Patient care is team based and interdisciplinary with seamless transition from one care setting to the next and funding and other models are in place to allow physicians and other health care providers to practise within the full scope of their professional activities. REFERENCES __________________________ 1. Canadian Medical Association. CMA Code of Ethics. http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed 05/20/11. 2. ABIM Foundation. Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine 2002; 136(3): 243-6. 3. Lesser C, Lucey C, Egener B, Braddock C, Linas S, Levinson W. A behavioral and systems view of professionalism. JAMA 2010; 304(24): 2732-7. 4. Canadian Medical Association. Medical professionalism 2005 update. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD06-02.pdf. Accessed 06/03/11. 5. Canadian Medical Protective Association. Changing physician : hospital relationships. Managing the medico-legal implications of change. 2011. https://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_2011_changing_physician-e.cfm. Accessed 02/07/12. 6. Thrall JH. Changing relationship between radiologists and hospitals Part 1: Background and major issues. Radiology 2007; 245: 633-637. 7. Reichenbach L, Brown H. Gender and academic medicine: impact on the health workforce. BMJ. 2004; 329: 792-795. 8. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: what is it and how do we do it? Acad Med 2010 Jan; 85(1): 63-7. 9. Canadian Medical Protective Association. Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and health care institutions. 2009. http://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_learning_from_adverse_events-e.cfm. Accessed 02/07/12. 10. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework. http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf. Accessed 05/20/11. 11. Canadian Society of Physician Executives and Canadian Medical Association. Canadian Certifies Physician Executive. Candidate Handbook. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Leadership/CCPE/2012CCPE-Handbook_en.pdf. Accessed 05/20/11. 12. Ham C. Improving the performance of health services: the role of clinical leadership. Lancet 2003; 361: 1978-80. 13. Imison C, Giordano R. Doctors as leaders. BMJ 2009; 338: 979-80.

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Health equity and the social determinants of health: A role for the medical profession

https://policybase.cma.ca/en/permalink/policy10672

Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
Text
Health equity is created when individuals have the opportunity to achieve their full health potential; equity is undermined when preventable and avoidable systematic conditions constrain life choices.1 These conditions are known as the social determinants of health. The World Health Organization (WHO) defines the social determinants of health as the circumstances in which people are born, develop, live and age.2 In 2002, researchers and policy experts at a York University conference identified the following list: income and income distribution; early life; education; housing; food security; employment and working conditions; unemployment and job security; social safety net; social inclusion/exclusion; and health services. 3 Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.4 Any actions to improve health and tackle health inequity must address the social determinants and their impact on daily life.5 THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH STATUS Social status is one of the strongest predictors of health at the population level. There is a social gradient of health such that those with higher social status experience greater health than those with lower social status. The social gradient is evident not only when comparing the most disadvantaged to the most advantaged; within each strata, even among those holding stable middle-class jobs, those at the lowest end fare less well than those at the higher end. The Whitehall study of civil servants in the United Kingdom found that lower ranking staff have a greater disease burden and shorter life expectancy than higher-ranking staff.6 Differences in medical care did not account for the differences in mortality.7 This gradient has been demonstrated for just about any health condition.8 Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.9 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods (four years for men; two years for women).10 Dietary deficiencies, common in food insecure households, can lead to an increased chance of chronic disease and greater difficulty in disease management. It is estimated that about 1.1 million households in Canada experience food insecurity, with the risk increasing in single-parent households and in families on social assistance.11 Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.12 Effective early childhood development offers the best opportunity to reduce the social gradient and improve the social determinants of health,13 and offers the greatest return on investment.14 Low income contributes not only to material deprivation but social isolation as well. Without financial resources, it is more difficult for individuals to participate in cultural, educational and recreational activities or to benefit from tax incentives. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.15 This social isolation and its effects are most striking in Canada's homeless population. Being homeless is correlated with higher rates of physical and mental illness. In Canada, premature death is eight to 10 times higher among the homeless.16 The gradient in other social determinants can have an adverse impact as well. A study conducted in the Netherlands estimated that average morbidity and mortality in the overall population could be reduced 25-50% if men with lower levels of education had the same mortality and morbidity levels as those men with a university education.17 Employment status also follows this gradient, such that having a job is better than being unemployed. 18 Unemployment is correlated with increased blood pressure, self-reported ill health, drug abuse, and reductions in normal activity due to illness or injury.19 Unemployment is associated with increases in domestic violence, family breakups and crime. Finally, job security is relevant.20 Mortality rates are higher among temporary rather than permanent workers.21 Canada's Aboriginal people face the greatest health consequences as a result of the social determinants of health. Poverty, inadequate or substandard housing, unemployment, lack of access to health services, and low levels of education characterize a disproportionately large number of Aboriginal peoples.22 The crude mortality rate for First Nations is higher and life expectancy lower than the Canadian average.23 Aboriginal peoples experience higher rates of chronic disease, addictions, mental illness and childhood abuse.24 Aboriginal peoples have higher rates of suicide, with suicide being the leading cause of potential years of life lost in both the First Nations and Inuit populations.25 THE SOCIAL DETERMINANTS OF HEALTH AND CANADA'S HEALTH SYSTEM These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.26 Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.27 Chronic diseases such as diabetes account for 67% of direct health care costs and 60% indirect costs.28 Research has shown that Canadians with low incomes are higher users of general practitioner, mental health, and hospital services.29 People in the lowest income group were almost twice as likely as those in the highest income group to visit the emergency department for treatment. 30 Part of this may be caused by differences in access to care. Low-income Canadians are more likely to report that they have not received needed health care in the past 12 months.31 Those in the lowest income groups are 50% less likely than those in the highest income group to see a specialist or get care in the evenings or on weekends, and 40% more likely to wait more than five days for a doctor's appointment.32 Barriers to health care access are not the only issue. Research in the U.K.33 and U.S.34 has found that compliance with medical treatment tends to be lower in disadvantaged groups, leading to pain, missed appointments, increased use of family practice services and increased emergency department visits, and corresponding increases in cost. In the U.S., non-adherence has been attributed to 100,000 deaths annually.35 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.36 These differences have financial costs. In Manitoba for example, research conducted in 1994 showed that those in the lowest income decile used services totaling $216 million (12.2%). In the same year, those in the highest income decile consumed $97 million (5.5%) of expenditures. If expenditures for the bottom half of the population by income had been the same as the median, Manitoba would have saved $319 million or 23.1% of their health care budget. 37 According to a 2011 report, low-income residents in Saskatoon consume an additional $179 million in health care costs than middle income earners.38 To reduce the burden of illness and therefore system costs, Canada needs to improve the underlying social and economic determinants of health of Canadians. However, until these changes have time to improve the health status of the population, there will still be a large burden of illness correlated to these underlying deficiencies. As a result, the health system will need to be adequately resourced to address the consequences of the social determinants of health. AREAS FOR ACTION The WHO Commission on the Social Determinants of Health identified four categories through which actions on social determinants can be taken. These include: * reducing social stratification by reducing inequalities in power, prestige, and income linked to socio-economic position; * decreasing the exposure of individuals and populations to the health-damaging factors they may face; * reducing the vulnerability of people to the health damaging conditions they face; and * intervening through health care to reduce the consequences of ill health caused by the underlying determinants.39 All of these areas offer possibilities for action by the physician community. The following section provides suggestions for action by the medical profession through: CMA and national level initiatives; medical education; leadership and research; and clinical practice. CMA and national level initiatives Despite the strong relationship between the social determinants of health and health, little in the way of effective action has resulted. CMA and its partners can and should, advocate for research and push for informed healthy public policy, including health impact assessments for government policies. Additionally, targeted population health programs aimed at addressing the underlying determinants should be supported. All Canadians need a better understanding of the health trends and the impacts of various social and economic indicators. Information about the differences in specific health indicators, collected over time,40 is essential to the task of describing underlying health trends and the impacts of social and economic interventions. Data within primary care practices could be assembled into (anonymous) community-wide health information databases, to address this need. CMA recommends that: 1. The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment. 2. Options be examined for minimizing financial barriers to necessary medical care including pharmaceuticals and medical devices necessary for health. 3. Federal and provincial/territorial governments examine ways to improve the social and economic circumstances of all Canadians. 4. Efforts be made to educate the public about the effect of social determinants on individual and population health. 5. Appropriate data be collected and reported on annually. This data should be locally usable, nationally comparable and based on milestones across the life course. Medical education Medical education is an effective means to provide physicians with the information and tools they require to understand the impact of social determinants on the health of their patients and deal with them accordingly.41 In 2001, Health Canada published a report in which they stated that the primary goal of medical education should be the preparation of graduates who know how to reduce the burden of illness and improve the health of the communities in which they practice.42 Among the report's recommendations was a call for greater integration of the social determinants in medical curricula.43 Although the CanMEDS framework has been a part of the Royal College of Physicians and Surgeons of Canada's accreditation process since 2005, challenges to the integration of these competencies remain.44 The report called for a greater emphasis on providing medical students with firsthand experiences in the community and with distinct populations (service learning),45 which addresses the difficulties in teaching the social aspects of medicine within a traditional classroom or hospital setting.46 Many such programs exist across the country.47 However, these programs are still limited and there is a need to increase the availability of longitudinal programs which allow students to build on the skills they develop throughout medical school. Increasingly residency programs which focus on the social determinants of health are being offered.48 These programs are a means of providing physicians with the proper tools to communicate with patients from diverse backgrounds49 and reduce behaviours that marginalized patients have identified as barriers to health services.50 It also provides residents with physician role models who are active in the community. However, medical residents note a lack of opportunities to participate in advocacy during residency.51 Further, while experiential programs are effective in helping to reduce barriers between physicians and patients from disadvantaged backgrounds, greater recruitment of medical students from these marginalized populations should also be explored and encouraged. Finally, physicians in practice need to be kept up to date on new literature and interventions regarding the social determinants. Innovations which help address health equity in practice should be shared with interested physicians. In particular, there is a need for accredited continuing medical education (CME) and a means to encourage uptake.52 CMA recommends that: 6. Greater integration of information on the social determinants and health inequity be provided in medical school to support the CanMEDS health advocate role 7. All medical schools and residency programs offer service learning programs, to provide students with an opportunity to work with diverse populations in inner city, rural and remote settings, and to improve their skills in managing the impact of the social determinants on their patients. 8. CME on the social determinants of health and the physician role in health equity be offered and incentivized for practising physicians. Leadership and research Within many communities in Canada, there are physicians who are working to address social determinants and health equity within the patient populations they serve. This is done in many cases through collaboration with partners within and outside of the health care system. Providing these local physician leaders with the tools they need to build these partnerships, and influence the policies and programs that affect their communities is a strategy that needs to be explored. Evidence-based research about health equity, the clinical setting and the role of physicians is underdeveloped. Interested physicians may wish to participate in research about practice level innovations, as a means of contributing to the evidence base for 'health equity' interventions or simply to share best practices with interested colleagues. Further, physicians can provide the medical support to encourage the adoption of early childhood development practices for example, which support later adult health. In time, research will contribute to training, continuing medical education and potentially to clinical practice guidelines. Physicians can provide leadership in health impact assessments and equity audits within the health care system as well. Data is essential to identify health equity challenges within a program, to propose and test measures that address the issues underlying the disparities. Formal audits and good measurement are essential to develop evidence-based policy improvements.53 Innovative programs such as those within the Saskatoon Health Region and the Centre for Addiction and Mental Health in Toronto are examples of using these tools to improve access and reduce inequities. CMA recommends that: 9. Physicians who undertake leadership and advocacy roles should be protected from repercussions in the workplace, e.g., the loss of hospital privileges. 10. Physician leaders explore opportunities to strengthen the primary care public health interface within their communities by working with existing agencies and community resources. 11. Physician leaders work with their local health organizations and systems to conduct health equity impact assessments in order to identify challenges and find solutions to improve access and quality of care. 12. Physicians be encouraged to participate in or support research on best practices for the social determinants of health and health equity. Once identified, information sharing should be established in Canada and internationally. Clinical practice In consultation with identified health equity physician champions, a number of clinical interventions have been identified which are being undertaken by physicians across the country. These interventions could be undertaken in many practice settings given the right supports, and could be carried out by various members of the collaborative care team.1 First, a comprehensive social history is essential to understand how to provide care for each patient in the context of their life.54 There are a number of tools that can be used for such a consultation and more are in development.55 However, consolidation of the best ideas into a tool that is suitable for the majority of health care settings is needed. There is some concern that asking these questions is outside of the physician role. The CanMEDS health advocate role clearly sees these types of activities as part of the physician role.56 The 'Four Principles of Family Medicine' defined by the College of Family Physicians of Canada, affirms this role for physicians as well.57 Community knowledge was identified as a strategy for helping patients. Physicians who were aware of community programs and services were able to refer patients if/when social issues arose.58 Many communities and some health providers have developed community resource guides.59 For some physicians, developing a network of community resources was the best way to understand the supports available. As a corollary, physicians noted their work in helping their patients become aware of and apply for the various social programs to which they are entitled. The programs vary by community and province/territory, and include disability, nutritional supports and many others. Most if not all of these programs require physicians to complete a form in order for the individual to qualify. Resources are available for some of these programs,60 but more centralized supports for physicians regardless of practice location or province/territory are needed. Physicians advocate on behalf of their patients by writing letters confirming the medical limitations of various health conditions or the medical harm of certain exposures.61 For example, a letter confirming the role of mold in triggering asthma may lead to improvements in the community housing of an asthmatic. Additionally, letters might help patients get the health care services and referrals that they require. As identified leaders within the community, support from a physician may be a 'game-changer' for patients. Finally, the design of the clinic, such as hours of operation or location, will influence the ability of people to reach care.62 CMA recommends that: 13. Tools be provided for physicians to assess their patients for social and economic causes of ill health and to determine the impact of these factors on treatment design. 14. Local databases of community services and programs (health and social) be developed and provided to physicians. Where possible, targeted guides should be developed for the health sector. 15. Collaborative team-based practice be supported and encouraged. 16. Resources or services be made available to physicians so that they can help their patients identify the provincial/territorial and federal programs for which they may qualify. 17. Physicians be cognizant of equity considerations when considering their practice design and patient resources. 18. All patients be treated equitably and have reasonable access to appropriate care, regardless of the funding model of their physician. CONCLUSION Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative. Physicians as clinicians, learners, teachers, leaders and as a profession can take steps to address the problems on behalf of their patients. REFERENCES 1 A full review of the consultations is provided in the companion paper The Physician and Health Equity: Opportunities in Practice. 1 Khalema, N. Ernest (2005) Who's Healthy? Who's Not? A Social Justice Perspective on Health Inequities. Available at: http://www.uofaweb.ualberta.ca/chps/crosslinks_march05.cfm 2 World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Available at: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf 3 Public Health Agency of Canada (N.D.) The Social Determinants of Health: An Overview of the Implications for Policy and the Role of the Health Sector. Available at: http://www.phac-aspc.gc.ca/ph-sp/oi-ar/pdf/01_overview_e.pdf 4 Keon, Wilbert J. & Lucie Pépin (2008) Population Health Policy: Issues and Options. Available at: http://www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf 5 Friel, Sharon (2009) Health equity in Australia: A policy framework based on action on the social determinants of obesity, alcohol and tobacco. The National Preventative Health Taskforce. Available at: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-hlth-equity-friel.pdf 6 Wilkinson, Richard & Michael Marmot eds. (2003) Social Determinants of Health: The Solid Facts: Second Edition. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf 7 Khalema, N. Ernest (2005) Who's Healthy?... 8 Dunn, James R. (2002) The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Available at: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf 9 Ibid 10 Wilkins, Russ; Berthelot, Jean-Marie; and Ng E. [2002]. Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Health Reports 13 [Supplement]: pp. 45-71 11 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health: The Canadian Facts. Available at: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf 12 Raphael, Dennis (2003) "Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy." Policy Options. March 2003 pp.35-40. 13 World Health Organization (2008) Closing the gap in a generation... 14 Hay, David I. (2006) Economic Arguments for Action on the Social Determinants of Health. Canadian Policy Research Networks. Available at: http://www.cprn.org/documents/46128_en.pdf 15 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health... 16 Ibid. 17 Whitehead, Margaret & Goran Dahlgren (2006) Concepts and principles for tackling social inequities in health: Levelling up Part 1. World Health Organization Europe. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf 18 Wilkinson, Richard & Michael Marmot eds. (2003) "Social Determinants of Health... 19 Ferrie, Jane E. (1999) "Health consequences of job insecurity." In Labour Market Changes and Job Security: A Challenge for Social Welfare and Health Promotion. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98411/E66205.pdf 20 Marmot, Michael (2010) Fair Society Healthy Lives: The Marmot Review: Executive Summary. Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf 21 World Health Organization (2008) Closing the gap in a generation... 22 Aboriginal Healing Foundation, Frequently Asked Questions (Ottawa: Canadian Government Publishing Directorate, 2009) Available at: http://www.ahf.ca/faq 23Health Council of Canada, "The Health Status Of Canada's First Nations, Métis And Inuit Peoples", 2005, Available at:http://healthcouncilcanada.ca.c9.previewyoursite.com/docs/papers/2005/BkgrdHealthyCdnsENG.pdf 24 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health... 25Health Council of Canada, (2005)"The Health Status Of Canada's First Nations, Métis And Inuit Peoples... 26 Dunn, James R. (2002) The Health Determinants Partnership... 27 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf 28 Munro, Daniel (2008) "Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health." The Conference Board of Canada. Available at: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb 29 Williamson, Deanna L. et.al. (2006) "Low-income Canadians' experiences with health-related services: Implications for health care reform." Health Policy. 76(2006) pp. 106-121. 30 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians... 31 Williamson, Deanna L. et.al. (2006) "Low-income Canadians'... 32 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health... 33 Neal, Richard D. et.al. (2001) "Missed appointments in general practice: retrospective data analysis from four practices." British Journal of General Practice. 51 pp.830-832. 34 Kennedy, Jae & Christopher Erb (2002) "Prescription Noncompliance due to Cost Among Adults with Disabilities in the United States." American Journal of Public Health. Vol.92 No.7 pp. 1120-1124. 35 Bibbins-Domingo, Kirsten & M. Robin DiMatteo. Chapter 8: Assessing and Promoting Medication Adherence. pp. 81-90 in King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients... 36 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health... 37 Dunn, James R. (2002) The Health Determinants Partnership... 38 Saskatoon Poverty Reduction Partnership (2011) from poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Available at: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf 39 World Health Organization (2005) Action On The Social Determinants Of Health: Learning From Previous Experiences. Available at: http://www.who.int/social_determinants/resources/action_sd.pdf 40 Braveman, Paula (2003) "Monitoring Equity in Health and Healthcare: A Conceptual Framework."Journal of Health, Population and Nutrition. Sep;21(3):181-192. 41 Royal College of Physicians (2010) How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education. Available at: http://www.marmotreview.org/AssetLibrary/resources/new%20external%20reports/RCP-report-how-doctors-can-close-the-gap.pdf 42 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools. Available at: http://www.medicine.usask.ca/leadership/social-accountability/pdfs%20and%20powerpoint/SA%20-%20A%20vision%20for%20Canadian%20Medical%20Schools%20-%20Health%20Canada.pdf 43 Ibid. 44 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate: Translating the Quest for Social Responsibility into Medical Education and Practice." Academic Medicine. Vol.86 No.9 pp.1108-1113. 45 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools... 46 Meili, Ryan; Fuller, Daniel; & Jessica Lydiate. (2011) "Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project." Medical Teacher. 33; 659-666. 47 Ford-Jones, Lee; Levin, Leo; Schneider, Rayfel; & Denis Daneman (2012) "A New Social Pediatrics Elective-A Tool for Moving to Life Course Developmental Health." The Journal of Pediatrics. V.160 Iss. 3 pp.357-358; Meili, Ryan; Ganem-Cuenca, Alejandra; Wing-sea Leung, Jannie; & Donna Zaleschuk (2011) "The CARE Model of Social Accountability: Promoting Cultural Change." Academic Medicine. Vol.86 No.9 pp.1114-1119. 48 Cuthbertson, Lana "U of A helps doctors understand way of life in the inner city." Edmonton Journal Dec 22, 2010. Available at: http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=943d7dc3-927b-4429-878b-09b6e00595e1 49 Willems, S.; Maesschalck De, S.; Deveugele, M.; Derese, A. & J. De Maeseneer (2005) "Socio-economic status of the patient and doctor-patient communication: does it make a difference?" Patient Education and Counseling. 56 pp. 139-146. 50 Bloch, Gary; Rozmovits, Linda & Broden Giambone (2011) "Barriers to primary care responsiveness to poverty as a risk factor for health." BioMed Central Family Practice. Available at: http://www.biomedcentral.com/content/pdf/1471-2296-12-62.pdf; Schillinger, Dean; Villela, Theresa J. & George William Saba. Chapter 6: Creating a Context for Effective Intervention in the Clinical Care of Vulnerable Patients. pp.59-67. In King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients. 51 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate... 52 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities... 53 Meili, Ryan (2012) A Healthy Society: How A Focus On Health Can Revive Canadian Democracy. Saskatoon: Canada. Purich Publishing Limited. pp.36 54 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities... 55 Bloch, Gary (2011) "Poverty: A clinical tool for primary care "Family & Community Medicine, University of Toronto. Available at: http://www.healthprovidersagainstpoverty.ca/system/files/Poverty%20A%20Clinical%20Tool%20for%20Primary%20Care%20%28version%20with%20References%29_0.pdf ; Bricic, Vanessa; Eberdt, Caroline & Janusz Kaczorowski (2011) "Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study." International Journal of Family Medicine. Available at: http://www.hindawi.com/journals/ijfm/2011/812182/ ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, female health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, male health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders 56 Frank, Dr. Jason R. ed. (2005) "The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better Care." Office of Education: The Royal College of Physicians and Surgeons of Canada. Available at: http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf 57 Tannenbaum, David et.al. (2011) "Triple C Competency-based Curriculum: Report of the Working Group on Postgraduate Curriculum Review-Part 1 58 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities... 59 Doyle-Trace L, Labuda S. Community Resources in Cote-des-Neiges. Montreal: St Mary's Hospital Family Medicine Centre, 2011. (This guide was developed by medical residents Lara Doyle-Trace and Suzan Labuda at McGill University.); Mobile Outreach Street Health (N.D.) Pocket MOSH: a little MOSH for your pocket: A Practitioners Guide to MOSH and the Community We Serve. Available at: http://www.cdha.nshealth.ca/mobile-outreach-street-health 60 Health Providers Against Poverty (N.D.) Tools and Resources. Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders 61 Meili, Ryan (2012) A Healthy Society: How A Focus...pp.61; UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities... 62 Rachlis, Michael (2008) Operationalizing Health Equity: How Ontario's Health Services Can Contribute to Reducing Health Disparities. Wellesley Institute. Available at: http://wellesleyinstitute.com/files/OperationalizingHealthEquity.pdf

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Healthy behaviours - promoting physical activity and healthy eating

https://policybase.cma.ca/en/permalink/policy11523

Date
2015-05-30
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Date
2015-05-30
Replaces
Promoting Physical Activity and Healthy Weights
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) supports the promotion of healthy lifestyles in order to improve individual health and well-being and the overall health status of the population. Healthy lifestyles refer to patterns of individual practices and personal behavioural choices that are associated with optimal health. Two of the most important behaviours to create or maintain optimum health are healthy eating and physical activity. For many Canadians, their diet and physical activity levels can have a negative rather than positive impact on their overall health. There is a particular concern for children and youth who are growing up in increasingly obesogenic environments that reinforce practices that work against a healthy lifestyle.1 Childhood obesity research tells us that overweight and obese children are more likely to stay the same into adulthood.2 To reverse this trend, determined action is required for children and youth to learn and acquire healthy behaviours that they will maintain throughout their life. Healthy lifestyles are central to successful aging and improving the likelihood of recovery after poor health.3 This policy paper discusses the importance of physical activity and healthy eating, and the role that individuals and families, schools, workplaces, communities, the food industry and all levels of governments can play in promoting healthy lifestyles. We know that collaborative action is required to make it easier for Canadians to incorporate healthy eating and physical activity into their daily lives - to make the healthy choice the easy choice. What are the health impacts of unhealthy diets and physical inactivity Diet is the leading risk factor for death, disability and life-years lost; being estimated to cause over 65,000 deaths and 864,000 life years lost in Canada in 2010.4 Unhealthy diet has been consistently linked with cardiovascular diseases (heart disease, stroke, hypertension, diabetes, dyslipidemia) and some cancers,5 which constitutes the majority of the disease burden in Canada. An estimated 80% of hypertension, which affects over 7 million Canadians, is directly or indirectly attributed to unhealthy diet.6 An estimated 60% of Canadian adults and close to one-third of children are overweight or obese, largely caused by unhealthy diets.7 Overweight and obesity (and the lifestyle choices associated with them) are contributors to more than 18 chronic conditions.8 This includes diabetes, cardiovascular disease, hypertension and liver disease, as well as breast, colon and prostate cancer. Obesity is a public health issue not unique to Canada as the rates are increasing worldwide. Obesity is generally attributed to the fact that, as a society, we are increasing our calorie intake while at the same time burning less energy in physical activity. While it is difficult to determine how many deaths are directly attributable to obesity, we know that obesity often co-exists with other risk factors such as the lack of physical activity. Exercise is one of the top modifiable risk factor for chronic disease.9 Regular physical activity is associated with a reduced risk of cardiovascular disease, some types of cancer, diabetes, obesity, hypertension, bone and joint diseases, and depression.10 The risk for many of these conditions is reduced by 20 - 40% in adults with the highest levels of physical activity compared to those with the lowest levels of physical activity. Recent research has shown that a sedentary lifestyle is associated with higher risk for chronic conditions such as obesity, diabetes and cancer independent of physical activity levels.11 According to the most recent Canadian Health Measures Study physical activity levels for children and youth are low with 6 out of 10 waking hours devoted to sedentary pursuits. Obesity is rising and physical fitness is declining.12 Canadians who do not achieve adequate levels of physical activity or eat unhealthy foods are vulnerable to preventable chronic diseases, premature death, and contribute to high health care costs. For instance, in 1999, $2.1 billion or 2.5% of the total direct health care costs were attributable to physical inactivity.13 To understand why the rates of obesity and overweight are rising, it may be helpful to look at what we already know about healthy eating and physical activity. What we know about healthy eating While modern science has allowed us to expand our knowledge of the impact of nutrients and food on human health we continue to be beset with illness and disease caused by the foods we consume. Having the right amount and type of food recommended in Canada's Food Guide is a first step towards healthy eating. But Canadians self-reported dietary intakes do not meet national dietary recommendations despite high reliance on public education concerning healthy eating and healthy diets. Children and adults are under-consuming the recommended servings of vegetables and fruits, an established proxy for healthy eating habits, and exceeding daily recommended intakes of sodium.14,15 As the links between nutrition and disease, and the impact on the health of our society are revealed it is more important than ever to understand what influences healthy eating behaviours. Food choices are structured by a variety of individual determinants of behaviour, ranging from one's physiological state, food preferences, nutritional knowledge, perceptions of healthy eating and psychological factors. Many processed foods have become popular due to their accessibility and 'convenience factor', but these features have changed the way food and in particular these products are consumed compared to unprocessed foods: increased 'grazing', eating alone or eating while carrying out other activities such as work or driving. In addition, many calories consumed come in liquid form.16 Growth in the production and consumption of ultra-processed foods has increased drastically in the last decades in both higher and lower-income countries.17 A number of studies have shown that because less healthy foods are cheaper than healthier food, individuals from lower socioeconomic classes tend to be more dependent on unhealthy foods for nourishment.18 Other determinants for healthy eating include a wide range of contextual factors, such as the interpersonal environment created by family and peers, the physical environment, which determines food availability and accessibility, the economic environment, in which food is a commodity to be marketed for profit, and the social environment. Within the social environment, social status (income, education and gender) and cultural milieu are determinants of healthy eating that may be working "invisibly" to structure food choice.19 What we know about physical activity Canada's Physical Activity Guidelines recommend that children and youth aged 5 to 17 get at least 60 minutes of moderate-to-vigorous physical activity (MVPA) per day; and adults get 150 minutes of physical activity per week.20 In fact, about 94% of Canadian children and youth do not meet minimum physical activity guidelines.21 Furthermore, about 85% of Canadian adults do not meet the minimum guidelines. Physical activity includes but is not limited to sports and recreation. Using active transportation to get to work as well as being active at work is an alternative form of MVPA and can also lead to improved health. For most Canadians, the average day is spent on passive activities such as TV viewing, computer and game-console use, workplace sitting, and time spent in automobiles. Moreover, the sprawling suburban communities, in which many live, do not encourage physical activity. Emerging research suggests that prolonged sitting time is associated with an increased health risk.22 These findings mean that one can meet the minimum physical activity guidelines and still not engage in a healthy lifestyle. Spending a few hours a week at the gym or otherwise engaged in moderate or vigorous activity doesn't seem to significantly offset the risk. Hence too much sitting is a risk distinct from too little exercise. While further research is required to identify which methods of exercise promotions work best for individuals,23 it is clear that supportive environments and infrastructures are essential for Canadians to make physical activity part of their daily lives. CMA's policies about the Built Environment and Active Transportation support the role of the environment on our physical activity patterns. How we can promote physical activity and healthy eating A sedentary lifestyle is a cue for physician advice.24 Physical activity is a vital sign that may require as much attention as other traditional vital signs25 - weight, blood pressure, or smoking history. Physicians are eager to initiate these conversations, especially with patients living with chronic diseases. A message must be repeated many times in order to effect a change in lifestyle. Physicians can reiterate the medical importance of physical activity and healthy eating by reinforcing this message during each office visit, and writing the recommendation on a prescription pad.26 For instance, in British Columbia, physicians are prescribing exercise on specially-designed pads, distributing free pedometers, and hosting free walking events for their patients and the public. In the Edmonton area, Primary Care Networks are prescribing free access passes or a free month of access at local municipal recreation facilities. And in Nova Scotia, physicians have been running a free provincial running program for over 10 years that benefits thousands of kids in elementary school. Nonetheless these clinical interventions alone cannot shape healthier food consumption patterns and lifestyle choices. An obvious starting point to develop a comprehensive policy is to understand the interplay between individual and environmental determinants that influence our behaviours. In this regard, CMA has developed policies on Active Transportation and the Built Environment and Health which recognize the role of neighborhood design and alternative modes for transportation for an active lifestyle. This approach is also at the heart of the Integrated Pan-Canadian Healthy Living Strategy (PCHLS)27, approved in 2005 by all levels of government. CMA commends the efforts put in the PCHLS to prioritize healthy eating and physical activity. What we recommend CMA looks forward to working with others in making options for physical activity and healthy eating more available and accessible to all Canadians. The following recommendations highlight the potential contributions of the following sectors: health professionals, all levels of government, communities, workplaces, schools, the food industry and individuals and families. Health Professionals CMA encourages physicians to promote healthy eating and physical activity inside and outside their office. Physicians are lifestyle change agents and remain the preferred source of information about health for many people. Physicians, who are committed to physical activity, are role models whose advice on healthy living is more likely to be adopted.28 CMA encourages physicians to address any work-imposed limitations - such as the lack of time, motivation, or tiredness - that could also influence their own exercise and eating habits. In clinical practice, physicians can help patients start or maintain a healthy lifestyle by: * assessing nutrition and physical activity as part of routine assessments; * determining the factors that influence individual patient's nutrition and physical activity levels; * assessing patient's readiness to change and tailoring interventions and support to their current situation; * providing an exercise prescription to encourage physical activity to maintain or improve health status, and * working in inter-professional teams to provide patient education with other health care providers such as dieticians. Medical students and residents, while reporting a high level of importance for exercise prescription concede a low level of expertise in this area upon graduation.29,30,31 As knowledge develops, physicians and other health professionals should be kept updated and encouraged to incorporate the most effective interventions into their practices. The CMA encourages the development of continuing medical education courses on issues related to physical activity and healthy eating. Within the healthy living approach, there are multiple opportunities to extend the role of physicians into the community as observed in Nova Scotia, British Columbia and Edmonton area. Physicians can establish strong community norms for a healthy lifestyle by: * establishing and reinforcing healthy food policies in hospital cafeterias or at health-related meetings and conferences * using, facilitating and advocating for the use of active transportation in their communities * working within the community to ensure that recreation centres and other facilities are available and patients can be referred to the services most appropriate to their needs Federal, Provincial, and Territorial Governments CMA calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015. In 2005, Canada's federal, provincial, and territorial governments endorsed a 10-year Healthy Living Strategy Framework, whose initial priorities included the promotion of healthy eating and physical activity. The national strategy addressed information and support for Canadians to help them make healthy choices; support for physicians and other health professionals in counselling patients on healthy weight and in treating existing obesity; community infrastructures that make healthy living easier; and public policies that encourage healthy eating and physical activity. The federal and provincial / territorial governments have undertaken a number of activities in the intervening years to promote physical activity and healthy eating but much remains to be done. CMA believes that all levels of governments have a continuous obligation to provide public guidance on healthy eating and to promulgate policies, standards, regulations and legislations that support the availability and accessibility of healthy and affordable food and beverage choices. CMA calls on governments to improve access to nutritious food at affordable prices for all Canadians. The price of milk, fresh produce and other healthy foods can vary greatly across Canada. In many remote areas, they are often more expensive than processed, nutrition-poor foods because of high transportation costs. Governments should implement effective programs to offset the impact of transportation costs on food prices in northern and remote communities. Even in urban areas, nutritious food may be unaffordable for people on low incomes. School meal programs, social assistance rates that take into account the cost of purchasing healthy food, access to urban farmers' markets can help to ensure that all Canadians have access to healthy foods at a reasonable price. CMA calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. The typical Canadian child may be exposed to as many as 40,000 advertisements for food a year.32 This does not include point-of-sale promotions, such as displays of candy bars at convenience-store counters. CMA's policy on marketing of unhealthy foods and beverages to children and youth calls for a ban on marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. CMA calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food. Brand-specific advertising is a less than optimal way to provide health information to consumers, who should be encouraged to seek out objective information sources for answers to their questions about physical activity and healthy eating. To improve the quality of information received through commercial channels, the CMA recommends that health claims made for foods be strictly regulated to ensure that they are based on the best available scientific evidence and that they are accurately communicated to consumers. Food advertisements should be pre-cleared before airing in the media, and the provisions against deceptive advertising in the Food and Drug Act should be strengthened. CMA recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians. CMA encourages all levels of governments to continue to fund and support research for healthy lifestyles. There is a clear need to invest in research to strengthen the evidence base about physical activity and healthy eating, particularly on:
best measures for assessing overweight and obesity;
the effectiveness of weight management and treatment programs; and
the effect of policy interventions on healthy eating and physical activity on rates of obesity and obesity-related disease. Food Industry CMA encourages governments to continue to work with the food industry to improve the food environment in Canada. The partnership and collaboration of food manufacturers is needed to help Canadians make healthier food choices. The food industry can work with governments to:
reduce the salt, sugar, saturated fat, trans fat and calorie content of processed foods and pre-prepared meals;
provide information about the calorie and nutrition content on restaurant menus;
restrict advertising and in-store promotion of high-sugar, high-salt, high-fat foods, particularly those aimed at children;
provide user-friendly consumer information about their products, including and accurate health and advertising claims;
improve the nutrition fact table to make it more user friendly and increase the amount of information for example, by identifying the amount of free sugars. Communities CMA calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour. Communities have an important role to play to promote healthy behaviours for children, youth, and adults. They shape how many Canadians decide to live, work and play in their daily life. Through mixed-use land planning and building design, communities can create walking-friendly environments, and reduce the time people spend in cars. To achieve this, communities should consider:
developing and maintaining a community-wide network of walking and cycling paths;
zoning communities in such a way that amenities are within walking distance of homes; and
revising building codes to make stairs accessible, pleasant and safe, so that people have an alternative to taking the elevator. Canadians are considerably more physically active in the summer than in the winter and this could have an impact on obesity trends.33 Communities could improve pathways to healthy lifestyles year-round by improving access to indoor sport and recreation facilities, especially during winter. Where possible, communities should consider partnering with schools to share the use of gymnasiums, playgrounds, fields, courts, and tracks with the public after school hours and on weekends. In doing so, communities are ensuring the best use of time and resources, but also sharing liability for the development, operation, and maintenance of the facilities. Community food security can happen if local residents have equal access to safe, affordable and nutritious food. Communities have a role to play in advocating for healthier food options in schools and workplaces, encouraging community kitchens to teach cooking skills, and supporting local agriculture and farmers markets. This, in turn, would encourage individuals to eat more healthy foods. Workplaces CMA encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias. Prolonged, unbroken time spent sitting in front of a screen is very common in the workplace. In addition, four out of five commuters sit daily in their private vehicles to go to work.34 As Canadians spend most of their adult life at work, it is important to reduce workplace sitting. CMA encourages employers, especially in sedentary occupational groups, to increase opportunities for physical activity. For example, employers can promote healthy behaviours by:
Building on-site fitness facilities or entering into agreements with off-site fitness centres to provide programs for their employees
Providing showers, bike racks and other amenities for employees for those who want to commute to work on foot or by bike. Healthier food options in cafeteria and vending machines can promote and encourage healthy eating by employees. Schools Schools, where children spend most of their time outside of home, present an excellent opportunity to instil healthy behaviours at an early age. They could, for example, provide comprehensive nutrition education, serve nutritious food in their cafeterias and promote physical activity by providing formal instruction and informal recreation time. Schools can provide the most effective and efficient way to reach not only the children themselves, but their parents, teachers, and other community members.35 CMA encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades. Only 26% of Canadian schools reported that they had implemented daily physical education classes for their students.36 There is some evidence that school-based physical activity can increase physical activity levels and reduce time spent watching television at home. 37 For instance, schools can promote physical activity through unstructured out-of-home play, structured sports, or active transportation (e.g. walking to school). Children who are physically active and spend less time watching television after school are less likely to become overweight before age 12.38 CMA recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch. CMA calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people. Fast food restaurants and convenience stores can be an important influence on children's eating habits and food choices.39 Children attending schools within a short distance of fast food restaurants eat fewer fruits and vegetable servings, and drink more soft drinks than others who did not have similar establishments within proximity.40 To encourage effective school-based nutrition interventions, it is therefore important to educate students about the nutrition value of foods, healthy food choices, and provide healthy canteens or cafeterias. Individuals and families CMA recommends that all Canadians work toward achieving and maintaining health by:
educating themselves about their dietary needs and about the caloric and nutrition content of foods; and
engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults. Ultimately, healthy eating and physical activity require that individuals take action to make healthy choices in their lives. To inform these choices, Canadians should be supported with appropriate resource materials with consistent information about healthy eating and physical activity. For instance, many young children do not choose what they consume; their parents buy and prepare the food for them. Research suggests that mothers and children appear to have divergent attitudes towards food and mealtimes.41 In this regard, it is important for parents to be well-informed and able to explain the tangible benefits of foods and their nutritional components to their children before they reach adulthood. What we conclude Healthy behaviours are easier to maintain through life if acquired in childhood and encouraged by the family. Therefore Canadian families should be supported in efforts to ensure that both children and adults eat nutritiously and exercise daily. We believe there is a role for everyone in promoting healthy behaviours - including health professionals, individuals, families, schools, workplaces, communities, the food industry and all levels of governments. Popular approaches seek to provide individuals with information and options about healthy lifestyles choices. However, individual choice is not sufficient to ensure healthy behaviours. Many barriers to the adoption of healthy behaviours and lifestyle choices can be met through a targeted population health approach, and evidence-based policy and regulatory controls. A comprehensive change in culture and mindset, political endorsement and multifaceted strategies are needed to promote and facilitate change to improve the dietary practices and physical activity levels of Canadians. Summary of Recommendations 1. The Canadian Medical Association encourages physicians to promote healthy eating and physical activity inside and outside their office. 2. The Canadian Medical Association calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015. 3. The Canadian Medical Association calls on governments to improve access to nutritious food at affordable prices for all Canadians. 4. The Canadian Medical Association calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. 5. The Canadian Medical Association calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food. 6. The Canadian Medical Association recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians. 7. The Canadian Medical Association encourages governments to continue to work with the food industry to improve the food environment in Canada. 8. The Canadian Medical Association calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour. 9. The Canadian Medical Association encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias. 10. The Canadian Medical Association encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades. 11. The Canadian Medical Association recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch. 12. The Canadian Medical Association calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people. 13. The Canadian Medical Association recommends that all Canadians work toward achieving and maintaining health by: * educating themselves about their dietary needs and about the caloric and nutrition content of foods; and * engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults. References 1 Swinburn B, Egger G. The runaway weight gain train: too many accelerators, not enough brakes. BMJ. 2007;329:736-9. 2 Waters E, de Silva-Sanigorski A, Hall BJ, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011;(12): CD001871. 3 Shields M, Martel L. (2006). Healthy living among seniors. Ottawa: Statistics Canada; 2005. Available: www5.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno=82-003-S20050009086&lang=eng (accessed 2014 Jan 20). 4 Institute for Health Metrics and Evaluation. Global burden of disease arrow diagram. Seattle (WA): The Institute; 2013. Available: www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram (accessed 2010 Mar 15) 5Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population, Institute of Medicine of the National Academies. A population-based policy and systems change approach to prevent and control hypertension. Report, v-173. Washington (DC): National Academies Press; 2010. 6 Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet 2011;377(9775):1438-47. 7 Roberts KC, Shields M, de Groh M, et al. Overweight and obesity in children and adolescents: results from the 2009 to 2011 Canadian Health Measures Survey. Health Rep. 2012;23(3):37-41. 8 Canadian Institute for Health Information, Public Health Agency of Canada. Obesity in Canada. Ottawa: The Agency; 2011. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/index-eng.php (accessed 2014 Jan 20). 9 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease study 2010. Lancet. 2012;380:2224-60. 10Colley, R, Garriguet D, Janssen I, et al. Physical activity of Canadian adults: accelerometer results from the 2007 to 2009 Canadian Health Measures Study. Statistics Canada Cat. No. 82-003 XPE. Health Rep. 2011 Mar;22(1). 11 Statistics Canada. Directly measured physical activity of Canadian adults, 2007-2011. Health fact sheets. Ottawa: Statistics Canada; 2013. 12 Colley R, Garriguet D, Janssen I, et al. Physical activity of Canadian children and youth: accelerometer results from the 2007 to 2009 Canadian Health Measures Study. Statistics Canada Cat. No. 82-003 XPE. Health Rep. 2011 Mar;22(1). 13 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada CMAJ. 2000;163(11):1435-40. 14 Statistics Canada. Fruit and vegetable consumption. Health fact sheets. Statistics Canada Cat. No. 82-625-XWE. Ottawa: Statistics Canada; 2012. Available: www.statcan.gc.ca/pub/82-625-x/2013001/article/11837-eng.htm (accessed 2013 Nov 8). 15 Garriguet D. Canadians' eating habits. Statistics Canada Cat. No. 82-003. Health Rep. 2007;18(2):17-32. Available: www.statcan.gc.ca/pub/82-003-x/2006004/article/habit/9609-eng.pdf (accessed 2013 Jul 10). 16 Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. DOI:10.1017/S1368980009005291. 17 Monteiro CA, Levy RB. A new classification of foods based on the extent and purpose of their processing. Uma nova classifi cação de alimentos baseada na extensão e propósito do seu processamento. Cad Saude Publica. 2010;26(11):2039-49. 18 World Health Organization. Obesity the "new norm": day 1 of nutrition and NCDs conference. 2013. Available: www.euro.who.int/en/health-topics/health-policy/pages/news/news/2013/07/obesity-the-new-norm-day-1-of-nutrition-and-ncds-conference 19 Raine KD. Determinants of healthy eating in Canada: an overview and synthesis. Can J Public Health. 2005;96(Suppl 3):S8-14, s18-15. 20 Canadian Society for Exercise Physiology. Canadian physical activity guidelines. Ottawa: The Society; 2011. Available: www.csep.ca/guidelines (accessed 2014 Jan 20). 21 Statistics Canada. Canadian health measures survey: directly measured physical activity of Canadians, 2007 to 2011. The Daily. Ottawa: Statistics Canada; 2013 May 30. Available: www.statcan.gc.ca/daily-quotidien/130530/dq130530d-eng.pdf (accessed 2014 Jan 20). 22 Owen N, Healy GN, Matthews CE, et al. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev. 2010;38(3):105-13. 23 Foster C, Hillsdon M, Thorogood M, Kaur A, Wedatilake T. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2013 (1). Review. 24 Glasgow RE, Eakin EG, Fisher EB, et al. Physician advice and support for physical activity results from a national survey. Am J Prev Med. 2001;21(3):189-96. 25 Salis R. Developing healthcare systems to support exercise: exercise as the fifth vital signs. Br J Sports Med. 2011;45(6):473-4. 26 Andersen RE, Blair SN, Cheskin LJ, et al. Encouraging patients to become more physically active: the physician's role. Ann Intern Med. 1997;127(5):395-400. 27 Public Health Agency of Canada. Overview of the Pan-Canadian Healthy Living Strategy. 2010. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/ipchls-spimmvs-eng.php (accessed 2014 Jan 20). 28 Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89-92. 29 Rogers LQ, Gutin B, Humphries MC, et al. Evaluation of internal medicine residents as exercise role models and associations with self-reported counseling behavior, confidence, and perceived Success. Teach Learn Med. 2006;18(3):215-21. 30 Connaughton AV, Weiler RM, Connaughton DP. (May-June 2001). Graduating medical students' exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep. 2001;116:226-34. 31 Vallance JK, Wylie M, MacDonald R. Medical students' self-perceived competence and prescription of patient-centered physical activity. Prev Med. 2009;48(2):164-6. DOI: 10.1016/j.ypmed.2008.12.006 32 The Kaiser Family Foundation. The role of media in childhood obesity. Menlo Park (CA): The Foundation; 2004 Feb. Available: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/the-role-of-media-in-childhood-obesity.pdf (accessed 2014 Mar 19). 33 Merchant AT, Dehghan M, Akhtar-Danesh N. Seasonal variation in leisure-time physical activity among Canadians Can J Public Health. 2007;98(3):203-8. 34 Statistics Canada. Commuting to work. National Household Survey. 2011. Available: https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-012-x/99-012-x2011003_1-eng.cfm (accessed 2014 Jan 20). 35 Perez-Rodrigo C. School-based nutrition education: lessons learned and new perspectives. Public Health Nutr. 2001;4(1A):131-9. 36 Canadian Fitness and Lifestyle Research Institute. Policies related to physical activities. 2011 opportunities for physical activity at school survey. 2012 Aug 14. Available: http://www.cflri.ca/sites/default/files/node/1054/files/Schools%202011%20Bulletin%2012%20-%20Policy%20EN.pdf (accessed 2013 Sep 15). 37 Dobbins M, Husson H, DeCorby K, et al. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst Rev. 2013;2:CD007651. 38 O'Brien M, Nader PR, Houts RM, et al. The ecology of childhood overweight: a 12-year longitudinal analysis. Int J Obes (Lond). 2007;31(9):1469-78. 39 Howard PH, Fitzpatrick M, Fulfrost B Proximity of food retailers to schools and rates of overweight ninth grade students: an ecological study in California. BMC Public Health. 2011;11(68). 40 Davis B, Carpenter C. Proximity of fast-food restaurants to schools and adolescent obesity. Am J Public Health. 2009;99(3):505-10. 41 Le Bigot Macaux A. Eat to live or live to eat? Do parents and children agree? Public Health Nutr. 2001;4(1A):141-6.

Documents

Less detail

Medical assistance in dying

https://policybase.cma.ca/en/permalink/policy13698

Date
2017-05-27
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Date
2017-05-27
Replaces
EUTHANASIA AND ASSISTED DEATH (UPDATE 2014)
Topics
Ethics and medical professionalism
Text
The legalization of medical assistance in dying (MAiD) raises a host of complex ethical and practical challenges that have implications for both policy and practice. The CMA supports maintaining the balance between three equally legitimate considerations: respecting decisional autonomy for those eligible Canadians who are seeking access, protecting vulnerable persons through careful attention to safeguards, and creating an environment in which practitioners are able to adhere to their moral commitments. Recognizing the educational, legislative, regulatory and practice changes that will result, the CMA recommends that legislative and regulatory processes be coordinated at the federal and provincial/territorial levels to consistently guide health systems, practitioners and patients. To that end, the CMA calls for rigorous information gathering at all levels and for experience with and research on the impacts of this new practice to be reported as it unfolds. The CMA encourages medical schools to incorporate reflective training opportunities at the undergraduate and postgraduate levels that address all aspects of medical practice that might be affected by this new intervention. Further, CMA recognizes the opportunity that exists for all health systems and practitioners to facilitate effective patient access to information about all end-of-life care options. The CMA acknowledges the importance of understanding that other acts within the realm of end-of-life care are distinct from the practice of medical assistance in dying. Further, the provision of specific assessments for eligibility to access medical assistance in dying is a distinct service unrelated to consultations for general palliative end-of-life care. It is important that physicians be aware of this distinction and the relationship between legal, medical and ethical norms with respect to medical assistance in dying. The judicial and legislative branches of government have made changes to Canadian law in this area. Society has placed assistance in dying within the realm of regulated medical practitioners. Physicians' ethical norms and duties, arising from long-standing traditions that entail moral commitments to preserve and protect life, have not changed. The CMA supports the right of all physicians to follow their conscience when deciding whether to provide or otherwise participate in assistance in dying as per the legislation governing medical assistance in dying. The CMA equally supports conscientious participation in and conscientious objection to assistance in dying by physicians. SCOPE OF POLICY This policy aims to provide guidance on key considerations in a way that is consistent with a physician's ethical, professional and legal obligations. Physicians should be aware of the federal and provincial laws in the jurisdiction in which they practise, the standards and expectations outlined by their respective regulatory authority, advice from the Canadian Medical Protective Association as well as the policies and procedures of the setting(s) in which they practise (e.g., regional health authority or hospital). RELEVANT FOUNDATIONAL CONSIDERATIONS The following considerations underpin the CMA's position on what ought to constitute the basis of any evolving legislation, regulation or guideline on the implementation of medical assistance in dying. These considerations are not ranked according to priority or importance. As with any foundational considerations, they provide a starting point for ethical reflection, and their application requires further thought and interpretation when conflicts arise. 1. Respect for autonomy: The CMA upholds the importance of respect for decisional autonomy by competent patients - such persons are free to make informed choices and autonomous decisions about their bodily integrity, their personal aims and their care that are consistent with their personal values and beliefs. CMA also asserts that persons have inherent dignity regardless of their circumstances. Services ought to be delivered, and processes and treatments ought to be applied, in ways that strive to preserve and enhance dignity. End-of-life care strives to maintain the integrity of personhood even as bodily functions deteriorate in advance of death. 2. Respect for vulnerability: In consideration of the importance of a patient's decision regarding medical assistance in dying, and the permanence of death if medical assistance in dying is chosen by a patient, the CMA believes that careful and non-judgmental exploration with patients of the reasons they are seeking assistance in dying is always warranted. Care in this regard assists physicians to fulfill the duty to ensure that conditions of vulnerability have been identified and addressed satisfactorily. Physicians should maintain diligent attention to identifying undue coercive influences on the patient. Legislation and regulations, through a carefully designed and monitored system of safeguards, should aim to minimize harm to all patients and should also address issues of vulnerability and potential coercion. 3. Respect for freedom of conscience: The CMA believes that physicians must be able to follow their conscience without discrimination when deciding whether or not to provide or participate in assistance in dying. The CMA supports physicians who, for reasons of moral commitments to patients and for any other reasons of conscience, will not participate in decisional guidance about, eligibility assessments for, or provision of medical assistance in dying. To enable physicians to adhere to such moral commitments without causing undue delay for patients pursuing this intervention, health systems will need to implement an easily accessible mechanism to which patients can have direct access. Further, the CMA believes that physicians' general employment or contract opportunities should not be influenced by their decisions to participate in, or not participate in, any or all aspects of medical assistance in dying with patients. The right of patients to seek medical assistance in dying does not compel individual physicians to provide it. Learners should be equally free to follow their conscience without risk to their evaluations and training advancement. 4. Accountability: Physicians providing or otherwise participating in assistance in dying must ensure they have the requisite training and the appropriate competencies, and the ability to assess a patient's decisional capacity or the ability to consult with a colleague to assess capacity in more complex situations. Physicians are expected to use appropriate medical judgment to make a determination of eligibility by (1) assessing the capacity of an adult to consent to the termination of life and (2) determining whether the patient has explored their options (and the putative impacts of any of the options). If the patient wishes to continue seeking medical assistance in dying, physicians are expected to use appropriate medical judgment to determine whether s/he meets the eligibility criteria as per the legislation governing medical assistance in dying. This ought to be a shared decision, and it should be made as part of a deliberative process in the context of the patient-physician relationship. The CMA encourages physicians to participate in accountability processes within their jurisdictions that ensure equitable access to all end-of-life options, including palliative and end-of-life care provided by skilled practitioners, in service of their patients' needs and values. To that end, the CMA believes that a federal oversight body and reporting regime should be established to ensure that all processes are followed. ADDITIONAL CONSIDERATIONS: PHYSICIAN DUTIES 5. Duty of non-abandonment: Physicians have an obligation to respond to a request for assistance in dying, regardless of how their moral commitment is expressed. Patients should never be abandoned and must always be supported by their physician and other members of their care team. The patient's physician ought to explore the reasons motivating the request and be sensitive to issues of culture and background throughout the dying process, regardless of the decisions the patient makes with respect to assistance in dying. There should be no undue delay in providing access to assistance in dying and all other end-of-life options, either from a clinical, system or facility perspective. For those who choose to provide assistance in dying, the duty of non-abandonment means that physicians have a duty to be available to patients during the act of ending their life. Physicians should be present or immediately available to manage any unexpected complications during the medical procedure, whether the chemical administration is done by the patient or by a regulated practitioner. 6. Duty to support interdisciplinary teams: The CMA advocates that physicians work within, and support other members of, interdisciplinary teams, pay close attention to the impacts of participation and non-participation in medical assistance in dying on their non-physician colleagues, and demonstrate solidarity with their team members as they navigate new legal and ethical territory together. 7. Duty to learners: The CMA recognizes the importance of unique moral considerations within learning environments. Learners are encouraged to reflect on their moral understanding of and views about assistance in dying and to seek a wide range of views and experiences from their patients and from their teachers and colleagues. ADDRESSING ADHERENCE TO MORAL COMMITMENTS CMA's position on conscientious participation and conscientious objection aims to harmonize two legitimate considerations: (1) effective patient access to a legally permissible medical service and (2) protection of physicians' freedom of conscience (or moral integrity) in a way that respects differences of conscience. a. The CMA believes that physicians are not obligated to fulfill a patient's request for assistance in dying but that all physicians are obligated to respond to a patient's request. This means that physicians who choose not to provide or otherwise participate in assistance in dying are: i. not required to provide it, or to otherwise participate in it, or to refer the patient to a physician or a medical administrator who will provide assistance in dying to the patient; but ii. are still required to fulfill their duty of non-abandonment by responding to a patient's request for assistance in dying. There should be no discrimination against a physician who chooses not to provide or otherwise participate in assistance in dying. b. The CMA believes that physicians are obligated to respond to a patient's request for assistance in dying in a timely fashion. This means that physicians are obligated to, regardless of their beliefs: i. provide the patient with complete information on all options available, including assistance in dying; ii. advise the patient on how to access any separate central information, counselling and referral service; and iii. transfer care of the patient to another physician or another institution, if the patient requests it, for the assessment and treatment of the patient's medical condition and exploration of relevant options. If relevant, such options may include palliative care, mental health care and, if the patient meets the eligibility criteria, provision of assistance in dying. The duty of non-abandonment still applies in all other aspects of the patient's care. c. Physicians are expected to make available relevant medical records (i.e., diagnosis, pathology, treatment and consults) to the physician accepting care of the patient when authorized by the patient to do so. d. Physicians are expected to act in good faith. They are expected to never abandon or discriminate against a patient requesting assistance in dying and to not impede or block access to a request for assistance in dying. Physicians should inform their patients of the fact and implications of their conscientious objection. No physician may require a patient to make a commitment not to seek assistance in dying as a condition of acceptance or retention of the patient. GLOSSARY WHAT MEDICAL ASSISTANCE IN DYING (MAID) ENCOMPASSES 1. Medical assistance in dying encompasses the assessment of a patient for eligibility for assistance in dying, deliberation with the patient, accompaniment of the patient through the process of deciding and, if so chosen by the patient, the provision of assistance in dying, which refers to: a. The administering by a medical practitioner or nurse of a substance to a person, at their request, that causes their death; or b. The prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their death. 2. The Supreme Court of Canada in Carter used the terms physician-assisted dying and physician-assisted death. These terms refer to both of the following: a. Voluntary euthanasia, or physician-administered assistance in dying: The physician takes the final act that will end the individual's life via, usually, the intravenous administration of a lethal substance, at the request and with the consent of a patient b. Assisted suicide, or physician-prescribed, self-administered assistance in dying: An individual performs the final act to end their life by, usually, ingesting a lethal substance prescribed or provided by the physician, at the request and with the consent of the patient. 3. Other commonly used terms are hastened death, physician-administered hastened death and physician-prescribed, patient-administered hastened death. a. These terms are proposed to make a clear distinction between palliative care and other practices that hasten or bring about death, such as through the legitimate removal of life-sustaining interventions or via the provision or administration of chemicals. 4. Medical aid in dying has a distinct technical and legal meaning within Quebec, described in Bill 52, and is limited to physicians administering the lethal substance at the request of the individual. WHAT IT DOES NOT ENCOMPASS 1. Palliative care is an integrated approach that aims to relieve suffering and improve the quality of life of those facing life-limiting acute or chronic conditions by means of early identification, assessment and treatment of pain and other symptoms. 2. Continuous palliative sedation therapy1 refers to complete sedation, with the intent of rendering the patient unable to experience the environment, sensation or thoughts, until the patient dies naturally from the underlying illness. 3. Withdrawing or withholding treatment or treatment cessation refers to withdrawing or withholding life-prolonging treatment where it is no longer indicated or desired. 4. Voluntary refusal of hydration and nutrition is the conscious and active choice to refuse and to discontinue food and fluid, orally or parenterally, with the intention of hastening death. Approved by the CMA Board of Directors May 2017 1 Consensus statement on continuous palliative sedation therapy: www.chpca.net/media/343120/final_cpst_framework.pdf. ---------------

Documents

Less detail

Palliative care

https://policybase.cma.ca/en/permalink/policy11809

Last Reviewed
2020-02-29
Date
2015-10-03
Topics
Ethics and medical professionalism
: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 10 Policy Document PD10-02 - Funding
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2015-10-03
Topics
Ethics and medical professionalism
Text
Palliative care is an approach that aims to relieve suffering and improve the quality of life of those facing life-limiting acute or chronic conditions by means of early identification, assessment, treatment of pain and other symptoms and support of all physical, emotional and spiritual needs. It may coexist with other goals of care, such as prevention, treatment and management of chronic conditions, or it may be the sole focus of care. General principles Goals 1. All Canadian residents should have access to comprehensive, quality palliative care services regardless of age, care setting, diagnosis, ethnicity, language and financial status.1 2. The Canadian Medical Association (CMA) declares that its members should adhere to the principles of palliative care whereby relief of suffering and quality of living are valued equally to other goals of medicine. 3. The CMA believes that all health care professionals should have access to referral for palliative care services and expertise.2 4. The CMA supports the integration of the palliative care approach into the management of life-limiting acute and chronic disease.3 5. The CMA advocates for the integration of accessible, quality palliative care services into acute, community and chronic care service delivery models4 that align with patient and family needs. 6. The CMA supports the implementation of a shared care model, emphasizing collaboration and open communication among physicians and other health care professionals.5 7. The CMA recognizes that the practice of assisted dying as defined by the Supreme Court of Canada is distinct from the practice of palliative care. Access to palliative care services 8. The CMA believes that every person nearing the end of life who wishes to receive palliative care services at home should have access to them. 9. Comprehensive, quality palliative care services must be made available to all Canadians and efforts to broaden the availability of palliative care in Canada should be intensified.6 10. The CMA calls upon the federal government, in cooperation with provincial and territorial governments, to improve access to pediatric palliative care through enhanced funding, training and awareness campaigns.7 11. The CMA will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative care throughout Canada.8 Education 12. All physicians require basic competencies in palliative care and may require enhanced skills appropriate to their practice. 13. The CMA requests that all Canadian faculties of medicine create a training curriculum in palliative care suitable for physicians at all stages of their medical education and relevant to the settings in which they practise.9 Role of governments 14. The CMA calls on governments to work toward a common strategy for palliative care to ensure equitable access to and adequate standards for quality palliative care.10 15. The CMA recommends that all relevant legislation be amended to recognize that any person whose medical condition warrants it is entitled to receive palliative care.11 16. The CMA supports emergency funding for end-of-life care for uninsured people residing in Canada.12 BACKGROUND In Canada, the impact of end-of-life care on both individuals and the health care system is "staggering," and the demand for this care will continue to grow as the population ages.13 It is estimated that the number of Canadians dying each year will increase by 40% to 330,000 by 2026. The well-being of an average of five others will be affected by each of those deaths, or more than 1.6 million people.14 Against this backdrop, the availability of and access to palliative care is an urgent policy and practice imperative. There has been mounting support for, and mounting criticism of the lack of, a national strategy for palliative care.15 The delivery of palliative care varies greatly across Canada due to differences in regional demographics, societal needs, government involvement and funding structures. Similarly, funding and legislation supporting access to palliative care services vary significantly between jurisdictions. A recent survey of Canadian physicians who provide palliative medicine found that: (1) Canada needs an adequate palliative medicine workforce; (2) primary care providers need more support for palliative care education and training; (3) palliative medicine as a distinct discipline must be further developed to better meet the complex needs of patients; and (4) Canada must ensure minimum palliative medicine standards are met.16 In an effort to address the current challenges in palliative care and improve both the quality of care and access to care, the CMA developed recommendations for a national call to action: 1. All patients should have a primary care provider that can support them with their palliative care needs or else refer these patients earlier to a palliative care team to establish goals of care. 2. Physicians should provide leadership at local, regional, provincial/territorial and federal levels to promote the establishment of integrated models of palliative care. 3. All physicians should obtain essential palliative care skills and knowledge to provide basic palliative care services to their patients. 4. Physicians should advocate for adequate and appropriate home palliative care resources so their patients can stay in their homes as long as possible. 5. Physicians should advocate for an adequate number of palliative and/or hospice care beds to meet their communities' needs. 6. Continuing care facilities and long-term care homes should have in-house palliative care physician support on their palliative care teams. 7. Physicians should support the valuable work of hospice volunteers. 8. Medical students are encouraged to look at palliative care as a rewarding career. 9. Practising palliative care physicians are encouraged, if needed, to obtain additional certified training in palliative care from either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. 10. Physicians acknowledge the value of and support the participation of family and friends in caring for their loved ones at the end of life. Integrated palliative approach to care There are four main models of palliative care delivery in Canada: integrated palliative care programs, continuing care and long-term care facilities, residential hospices, and home-based palliative care. Palliative care was originally developed in cancer care to provide patients dying of cancer with care at the very end of life by a specialized palliative care team.17 This model has evolved significantly in response to the increasing occurrence of, and burden posed by, complex chronic disease18. Palliative care is now also provided to patients with multiple co-occurring morbidities who require multiple interventions. It is now recognized to benefit all those living with life-limiting acute or chronic conditions, including, or perhaps especially, when it is initiated earlier in the disease trajectory. Evidence shows that integrated and early provision of palliative care leads to: (1) better outcomes than those obtained with treatment alone (e.g., improvements in symptoms, quality of life and patient satisfaction; positive effects on emotional wellness; decreased suffering; and at times increased longevity) and (2) better use of resources (e.g., less burden on caregivers, more appropriate referrals to hospice palliative care, more effective use of palliative care experts, less use of emergency and intensive interventions and decreased cost of care).19-20-21-22 Taken together, these studies validate the benefits of integrating palliative care services with standard treatment and involving palliative care providers early, a collaborative approach that transcends the conventional view that palliative care is care delivered at the very end of life. At present, there is strong support for the development and implementation of an integrated palliative approach to care. Integration effectively occurs: * throughout the disease trajectory; * across care settings (primary care, acute care, long-term and complex continuing care, residential hospices, shelters, home); * across professions/disciplines and specialties; * between the health care system and communities; and * with changing needs from primary palliative care through to specialist palliative care teams. The integrated palliative approach to care focuses on meeting a person's and family's full range of physical, psychosocial and spiritual needs at all stages of frailty or chronic illness, not just at the end of life.23 It is provided in all health care settings. The palliative approach to care is not delayed until the end stages of an illness but is applied earlier to provide active comfort-focused care and a positive approach to reducing suffering. It also promotes understanding of loss and bereavement (Fig. 1). Figure 1 Specialized palliative units and hospices are essential for end-of-life care for some individuals but are not appropriate for all persons facing life-limiting chronic conditions. When a palliative approach is offered in multiple settings, people and their families can receive better care through the many transitions of chronic conditions like dementia, lung, kidney and heart diseases, and cancer. This requires that all physicians be competent in initiating a primary palliative approach: they must be able to engage in advance care planning discussions, ask about physical and emotional symptoms and make appropriate, timely referrals to other providers and resources. Primary care physicians may need to develop more expertise in palliative care. A cadre of expert palliative care physicians will be required to provide care in complex cases, engage in education and research, and provide support for health professional colleagues providing palliative care in multiple settings. All health professionals must be able to practise competently in an integrated palliative approach to care. At the heart of an integrated palliative approach to care are a patient and family surrounded by a team of multidisciplinary professionals and community providers (Fig. 2). While team members vary depending on the needs of the patients and families, the principles of whole-person care and family care do not change. This allows patients and families to have their symptoms managed, receive care in the setting of their choice, engage in ongoing discussions about their preferences for care and experience a sense of autonomy in living their lives well. Figure 2 A report on The Way Forward, a project of the Quality End-of-Life Coalition of Canada and the Canadian Hospice Palliative Care Association, summarizes the situation as follows: "Only a small proportion of Canadians will need the kind of complex, intensive or tertiary hospice palliative care provided by expert palliative care teams in institutional settings, such as residential hospices and acute care hospitals. However, everyone who is becoming frail or is faced with a chronic illness could benefit from certain key palliative care services. As our population ages, we must ensure that all Canadians have access to palliative services integrated with their other care that will help them manage symptoms, enhance their lives, give them a greater sense of control, and enable them to make informed decisions about the care they want. More equitable access to palliative care integrated with their other care will enable more Canadians to live well with their illness up to the end of life. It will also enable more people to receive care in the setting of their choice and reduce the demand on acute care resources." 24 Access to palliative care services There are currently no reliable data on the number of specialized or semi-specialized palliative care physicians in Canada. It is difficult to count these physicians because palliative care has not historically existed as a specialty. Physicians practising palliative care have a wide variety of backgrounds and training, and many provide palliative care on a part-time basis. The Canadian Society of Palliative Care Physicians is currently working with partner organizations including the CMA, the Royal College of Physicians and Surgeons and the College of Family Physicians of Canada to better define the different types of palliative care physicians to conduct a meaningful count. On the question of access, studies have found that palliative care services are not aligned with patient preferences. For example, while 70% of hospitalized elderly patients reported wanting comfort measures rather than life-prolonging treatment, more than two-thirds were admitted to intensive care units.25 Most patients and caregivers report wanting to die at home26 and in-home palliative team care is a cost-effective intervention,27 but the value of this form of care is not reflected in many provincial policies. Instead, Canadian families frequently shoulder 25% of the total cost of palliative care because they must pay for home-based services,28 such as nursing and personal care services, that are not provided by governments. With the goal of improving the congruence between patient treatment preferences for end-of-life care and the services provided, Health Quality Ontario developed an evidentiary platform to inform public policy on strategies to optimize quality end-of-life care in in-patient and outpatient (community) settings. It identified four domains in which access to end-of-life care should be optimized to align with patient preferences: (1) location (determinants of place of death); (2) communication (patient care planning discussions and end-of-life educational interventions); (3) team-based models of care; and (4) services (cardiopulmonary resuscitation [CPR] and supportive interventions for informal caregivers).29 Education It is well recognized that education in palliative care is lacking in medical school and residency training. In response, the Association of Faculties of Medicine of Canada, in partnership with the Canadian Hospice Palliative Care Association and the Canadian Society of Palliative Care Physicians, conducted the Educating Future Physicians in Palliative and End-of-Life Care Project30 to develop consensus-based competencies for undergraduate medical trainees and a core curriculum that was implemented in all 17 Canadian medical schools. Despite these efforts, a survey conducted by the Canadian Society of Palliative Care Physicians found that the competencies are not being consistently taught in medical schools, as evidenced by the fact that 10 medical schools offered less than 10 hours of teaching on palliative care and two offered none.31 Moreover, evidence suggests that Canadian physicians are not consistently or adequately trained in palliative care. There is a general lack of providers trained in palliative care for service provision, teaching, consultative support to other physicians and research. To fill the observed gap in education, the Royal College of Physicians and Surgeons of Canada is developing Palliative Medicine as a subspecialty, and the College of Family Physicians of Canada is developing a Certificate of Added Competence in Palliative Care. What is more, different levels of palliative care competencies are required for different physicians: * All physicians require basic skills in palliative care. * Palliative consultants and physicians who frequently care for patients with chronic illnesses and/or frail seniors require enhanced skills. * Palliative medicine specialists and palliative medicine educators require expert skills. More broadly, the undergraduate curricula of all health care disciplines should include instruction in the principles and practices of palliative care, including how to access specialized palliative care consultation and services. Role of governments Access to palliative care must be treated with the same consideration as access to all other medical care. Provincial/territorial and federal legislation, however, is vague in this regard and does not recognize access to palliative care as an entitlement. Government funding of community-based hospice palliative care has not increased proportionately to the number of institutionally based palliative care beds that have been cut, leaving a significant gap in the health care system.32 To address this issue, efforts to broaden the availability of and access to palliative care in Canada need to be intensified. It is imperative that governments develop a common palliative care strategy to ensure equitable access to and adequate standards for quality palliative care, including emergency funding for those who are uninsured. Glossary Integrated palliative approach to care: An approach that focuses on quality of life and reduction of suffering as a goal of care. This approach may coexist with other goals of care - prevention, cure, management of chronic illness - or be the sole focus of care. The palliative approach integrates palliative care services throughout the treatment of a person with serious life-limiting illness, not just at the very end of life. Palliative care services: Generally consists of palliative care provided by a multidisciplinary team. The team may include a primary care physician, a palliative care physician, nurses, allied health professionals (as needed), social workers, providers of pastoral care and counselling, bereavement specialists and volunteers. The team members work together in a shared care model. Shared care model: An approach to care that uses the skills and knowledge of a range of health professionals who share joint responsibility for an individual's care. This model involves monitoring and exchanging patient data and sharing skills and knowledge among disciplines.33 References 1 Policy Resolution GC99-87 - Access to end-of-life and palliative care services. Ottawa: Canadian Medical Association; 1999. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 2Policy Resolution GC14-20 - Palliative care services and expertise. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 3Policy Resolution GC13-67 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 4Policy Resolution GC13-66 - Palliative Care Services. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 5 Policy Resolution GC13-80 - Collaborative palliative care model. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 6Policy Document PD15-02 - Euthanasia And Assisted Death (Update 2014). Ottawa: Canadian Medical Association; 2015. Available: https://www.cma.ca/Assets/assetslibrary/document/en/advocacy/EOL/CMA_Policy_Euthanasia_Assisted%20Death_PD15-02-e.pdf#search=Euthanasia%20and (accessed 2015 Nov 26). 7 Policy Resolution GC06-12 - Access to pediatric palliative care. Ottawa: Canadian Medical Association; 2006. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 8Policy Resolution GC14-23 - Delivery of quality palliative end-of-life care throughout Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 9Policy Resolution GC13-71 - Training in palliative care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 10Policy Document PD10-02 - Funding the continuum of care.Ottawa: Canadian Medical Association; 2010. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 11Policy Resolution GC13-70 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 12Policy Resolution GC14-26 - Emergency funding for end-of-life care for uninsured people residing in Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 13 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework. 14 Quality End-of-Life Care Coalition of Canada. Blueprint for action 2010 to 2012. Ottawa: Quality End-of-Life Care Coalition of Canada; 2010. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf. 15 Fowler R, Hammer M. End-of-life care in Canada. Clin Invest Med. 2013;36(3):E127-E32. 16 Canadian Society of Palliative Care Physicians. Highlights from the National Palliative Medicine Survey. Surrey (BC): Canadian Society of Palliative Care Physicians, Human Resources Committee; May 2015. 17 Bacon J. The palliative approach: improving care for Canadians with life-limiting illnesses. Ottawa: Canadian Hospice Palliative Care Association; 2012. Available: http://www.hpcintegration.ca/media/38753/TWF-palliative-approach-report-English-final2.pdf. 18 Ontario Health Technology Advisory Committee OCDM Collaborative. Optimizing chronic disease management in the community (outpatient) setting (OCDM): an evidentiary framework. Toronto: Health Quality Ontario; 2013. Available: www.hqontario.ca/Portals/0/Documents/eds/ohtas/compendium-ocdm-130912-en.pdf. 19 Zimmermann C, Swami N, Krzyzanowska M, Hannon B, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-1730. 20 Klinger CA, Howell D, Marshall D, Zakus D, et al. Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West end-of-life shared-care project. Palliat Med. 2013;27(2):115-122. 21 Temel JS, Greer JA, Muzikansky MA, Gallagher ER, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM. 2010;363:733-742. 22 Bakitas M, Lyons KD, Hegel MT, Balan S, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302:741-749. 23 Quality End-of-Life Care Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for an integrated palliative approach to care. Ottawa: Quality End-of-Life Care Coalition of Canada; 2014. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf 24 Quality End-of-Life Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for the integrated palliative approach to care. Quality End-of-Life Coaltion of Canada; 2014. Available: http://www.hpcintegration.ca/media/60044/TWF-framework-doc-Eng-2015-final-April1.pdf. 25 Cook D, Rocker G. End of life care in Canada: a report from the Canadian Academy of Health Sciences Forum. Clin Invest Med. 2013;36(3):E112-E113. 26 Brazil, K, Howell D, Bedard M, Krueger P, et al. Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med. 2005;19(6):492-499. 27 Pham B, Krahn M. End-of-life care interventions: an economic analysis. Ontario Health Quality Technology Assessment Series. 2014;14(18):1-70. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf. 28 Dumont S, Jacobs P, Fassbender K, Anderson D, et al. Costs associated with resource utilization during the palliative phase of care: a Canadian perspective. Palliat Med. 2009;23(8)708-717. 29 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework 30 Association of Faculties of Medicine of Canada. Educating future physicians in palliative and end-of-life care. Ottawa: Association of Faculties of Medicine of Canada; 2004. Available: http://70.38.66.73/social-educating-physicians-e.php. 31 Daneault S. Undergraduate training in palliative care in Canada in 2011. Montreal: Soins palliatifs, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal; 2012. 32 Canadian Hospice Palliative Care Association. Fact sheet 2012: hospice palliative care in Canada. Available: http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf. 33 Moorehead, R. Sharing care between allied health professional and general practitioners. Aust Fam Physician. 1995;24(11).

Documents

Less detail

Physician health

https://policybase.cma.ca/en/permalink/policy13739

Date
2017-10-21
Topics
Health human resources
Ethics and medical professionalism
  3 documents  
Policy Type
Policy document
Date
2017-10-21
Replaces
PD98-04 Physician health and well-being
Topics
Health human resources
Ethics and medical professionalism
Text
The term physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of interconnected physical, mental and social factors to support health and wellness.1 Attributable to a range of personal, occupational and system-level factors, physicians and learners alike are increasingly voicing distress and calling for resources and support. As a central issue for Canadian physicians, and a growing concern within the medical profession, physician ill-health is being increasingly understood as a set of risk-management practices,2 including the use of strategies rooted in organizational psychology and occupational medicine, as well as intensified oversight by professional bodies, and the integration of maintaining personal health as a core medical competency.3 Physician health, is important to the long-term sustainability of the physician workforce and health systems.4 As a quality indicator5-6 addressing the complex array of related issues is a shared responsibility of individual physicians and the systems in which they work.2,4,5 This involves efforts from individuals as well as system-level influencers, such as stakeholder groups from areas including academic medicine, medical education, practice environments, accrediting and regulatory bodies, provincial and territorial medical associations, regional and local health authorities, national medical associations and their affiliates, governments and other decision-making bodies. Meaningful, system-wide change can only occur via deliberate and concerted efforts on a national scale5 to address personal, workplace, and cultural barriers and normalize the promotion of opportunities and conditions for optimizing health and wellness. Although considerable progress has been made, it is necessary to continue working towards a more coordinated and sustained system of health promotion, illness prevention and tertiary care to build on these successes.4-5 This policy aims to provide broad, aspirational recommendations to help guide stakeholders at all levels of the health system to promote a healthy, vibrant, and engaged profession - including a healthy practice and training culture, and work environment. RECOMMENDATIONS Individual level The CMA recommends that physicians and learners: * demonstrate a commitment to physician health and well-being as part of their responsibilities under the CanMEDS Professional Role, including: Exhibiting self-awareness and managing influences on personal well-being (e.g., self-regulation and assessment, mindfulness, resilience); managing personal and professional demands for a sustainable practice throughout the career life cycle; and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need;3 * actively engage in fostering supportive work and training environments; * assume responsibility for individual actions and behaviours that may contribute to negative culture and stigma;5 * foster relationships with family and friends, as well as interests outside of medicine, and ensure sufficient rest (including time-off); and * have a family physician and visit him or her regularly for comprehensive and objective care. System level The CMA recommends that: * national-level advocacy be undertaken to address issues related to physician and learner health; * efforts to address physician health incorporate individually targeted initiatives and optimize learning and practice environments, including cultivating a healthy culture,6-7 and that stakeholders collaborate (including input from physicians and learners) to develop and promote initiatives that strengthen physician health at both the individual and system levels; * health systems adopt an understanding of their obligation to the health of physicians that is similar to the obligation of other Canadian employers to their workers (e.g., psychological safety, work hours, employee resources, standards and expectations); * policies aiming to cultivate a healthy culture be modelled, and behaviours not conducive to supporting and enabling a healthy culture dealt with in an effective manner; * physician and health system leaders acknowledge and demonstrate that physician health is a priority, and continually assess whether actions and policies align with desired values and culture;4 * physician and health system leaders be better equipped to identify and address behaviours that are symptomatic of distress (e.g., psychological) and receive more comprehensive training to address with colleagues, including within teams; * mechanisms and opportunities for physicians and learners to access existing services and programs (e.g., provincial, institutional) are maximized, and that these resources are regularly promoted and barriers to access addressed in a timely manner;5,8 * standards, processes and strategies be developed to address occupational barriers to positive health8 (at a minimum, these should address the meaningful integration of occupational and personal life, provision of resources to enhance self-care skills,4 and prioritization of opportunities for adequate rest, exercise, healthy diet and leisure;8 * wellness (including enhancement of meaning, enjoyment and engagement) be promoted, instead of an exclusive focus on reduction of harm;5 * physicians and learners be encouraged to have a family physician, and that barriers to access such care be identified and addressed; * physicians, particularly those providing primary care to other physicians, have access to training in treating physician colleagues; * physicians and learners be given reasonable access to confidential assistance in dealing with personal and professional difficulties, provided in a climate free of stigmatization; * programs and services be accessible to physicians and learners at every stage of their diagnosis and treatment, and that seeking treatment should not feel punitive or result in punitive consequences; * physicians and learners have supportive learning and work environments free of discrimination, and for processes which provide reasonable accommodations to physicians and learners with existing disabilities, while allowing for safe patient care, to be bolstered; and * practices which enable safe and effective patient care, and support workflow and efficient capture of information (e.g., electronic medical records), do not create excessive work and time burdens on physicians. Physician organizations, professional associations and health authorities The CMA recommends that: * all physicians and learners have access to a robust and effective provincial physician health program (PHP), and for long-term, sustained efforts to be made to maintain and enhance physician health, including a commitment to resourcing PHPs5 via the provision of stable funding through provincial and territorial medical associations, or the negotiation of such funding from provincial governments; * training programs, hospitals, and other workplaces ensure appropriate programs, services, and policies are developed, in-place, and enforced for physicians and learners to get help to manage health and behavioural issues, support the need for treatment, and facilitate return to work or training while protecting individual confidentiality, privacy, as well helping the institution manage risk; * the range of continuing medical education offerings aimed at personal health be expanded (content should develop individual skills and extend to training for leaders and administrators that targets improved training and practice environments and culture); * continuing education credits for physicians' efforts to enhance their personal wellness or that of colleagues be established and promoted, free of conditions requiring links to patient care; * emerging champions from learner and early-career segments be identified and supported; and * the unique health and wellness challenges faced by physicians and learners in rural, remote, or otherwise under-serviced regions (including the Canadian territories) be recognized, and for access to services and other resources to be enhanced. Medical schools, residency training programs, and accreditation bodies The CMA calls for: * accreditation standards for health and wellness programs and initiatives for medical faculties and training programs, and health authorities to be raised, reviewed in an ongoing manner and that standards and competencies be enforced; * action to bring meaningful change to the 'hidden curriculum' by aligning formal and 'hidden' curriculums that promote and reinforce positive conduct, and for accreditation bodies to consider this in their review and enforcement of standards for training programs; and * formal health and wellness curricula to be integrated and prioritized at the undergraduate and postgraduate levels, including but not limited to training around how to recognize and respond to distress or illness in oneself and colleagues, as well as self-management strategies (e.g., resilience and mindfulness). Medical regulatory authorities The CMA calls for medical regulatory authorities to: * work with provincial and territorial medical associations, PHPs, governments and other key stakeholders to; (a) create a regulatory environment that protects the public (their explicit duty) while limiting barriers for physicians seeking diagnosis and treatment,5 and (b) promote resources for early self-identification of potential health issues; and * while maintaining their duty to protect the public, review their approach to mental health challenges to ensure that focus is placed on the existence of impairment (illness interferes with ability to engage safely in professional activities,9 and not the mere presence of a diagnostic label or act of seeking of care5 (in order to ensure that physicians and learners who are appropriately caring for their health not be impacted in their ability to work). Governments The CMA calls for: * governments to acknowledge the adverse impact their policies and processes can have on the health of physicians, and to adopt and enforce health and wellness standards through a lens of occupational health for physicians that are similar to those afforded to other Canadian workers; * governments to work with employers and key stakeholders to create more effective systems that provide better practice and training conditions;5 and * enhanced support for provincial PHPs, institutions (e.g., medical schools, training programs), and other providers of physician health services.5 Researchers The CMA recommends that: * national and regional data for major health and wellness indicators be assessed at regular intervals to establish and compare norms and to better target and assess initiatives; * a national research strategy be developed through collaboration among relevant stakeholders to identify priorities, coordinate efforts, and promote innovation (consider the specific recommendations from a 2016 research summit to improve wellness and reduce burnout,10 including: Estimating economic impacts; using common metrics; developing a comprehensive framework for interventions with individual and organizational components; and sharing the best available evidence); and * further research in a range of areas including, but not limited to: efficacy of programs, strategies, and systems for promoting and managing health and wellness; examination of the factors exerting the greatest influence on physician health; and system-level interventions.5 Approved by the CMA Board of Directors October 2017 See also Background to CMA Policy on Physician Health REFERENCES 1 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 2 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 3 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 4 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-6. Available: https://doi.org/10.1016/j.mayocp.2016.10.004 (accessed 2017 Oct 30). 5 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. Available: https://doi.org/10.1016/S0140-6736(09)61424-0 (accessed 2017 Oct 30). 7 Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205. Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 8 Ruotsalainen JH, Verbeek JH, Mariné A, Serra C, Ruotsalainen JH, Verbeek JH, et al. Preventing occupational stress in healthcare workers. Sao Paulo Medical Journal 2016;134:92-92. Available: https://doi.org/10.1590/1516-3180.20161341T1 (accessed 2017 Oct 30). 9 Rondinelli RD, Genovese E, Brigham CR, American Medical Association (AMA). Guides to the evaluation of permanent impairment. Chicago: AMA; 2008. Available: https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1160002 (accessed 2017 Oct 30). 10 Dyrbye LN, Trockel M, Frank E, Olson K, Linzer M, Lemaire J, et al. Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Ann Intern Med 2017;166:743-4. Available: https://doi.org/10.7326/M16-2956 (accessed 2017 Oct 30). BACKGROUND TO CMA POLICY PHYSICIAN HEALTH See also CMA Policy on Physician Health In recent decades there has been growing recognition of the impact of physician health on systemic outcomes and patient-care.1,2 Physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of of interconnected physical, mental and social factors to support health and wellness.3 It is also being increasingly understood as a set of risk-management practices aimed at shifting perceptions of health from being an individual (private) matter to more of a shared resource.4 In Canada evidence for this includes the use of strategies adapted from organizational psychology and occupational medicine to change physician behaviour, as well as intensified oversight by professional bodies, and the inclusion of maintaining personal health as a core competency for physicians.4,5 Despite concerted efforts to promote and protect the health and wellness of physicians, the collective state of physician health remains a significant threat to the viability of Canada's health system.1 Physician distress is emerging as an important quality indicator in medical practice,4,6 and both individual- and system-level factors are well-established contributors to compromised physician health.2,7 As such, the advancement of a model of shared responsibility - targeting the relative roles of individual physicians and system-level influencers8 - represents a robust response to this reality. 1. The state of learner and physician health Poor health may develop before or during training and persist into medical practice. Medical school and residency training are particularly challenging times, when a myriad of competing personal and professional demands threaten learner health. In Canada, it has been reported that most students suffer from at least one form of distress over the course of their training9,10 and recent national data point to higher rates compared to their age and education-matched peers. With respect to burnout, characterized by a high level of emotional exhaustion and/or high level of depersonalization (at least weekly), overall rates are reportedly 37%.11,12 Similarly higher levels of depression, anxiety and burnout are reported among American medical students than in the general population.13 While both residents and physicians are reported to be physically healthier than the general population, their mental and social health are cause for concern.1,14 Compared with the general population, physicians are at a higher risk of experiencing adverse outcomes such as depression and burnout15,16 - the latter of which is nearly twice as common among physicians compared with workers in other fields, even after adjusting for age, sex, education level, relationship status, and work hours.17 Results from the 2017 CMA National Physician Health Survey18 showed that 49% of residents and 33% of physicians screened positive for depression, and high burnout rates were reported in 38% of residents 29% of physicians. Furthermore, although the mental health, addiction and substance-use problems, including alcohol, among physicians are not dissimilar to those in the general population, the abuse of prescription drugs (e.g., opioids) is reportedly higher.1,19 Although most physicians referred to monitoring programs have been diagnosed with substance use disorders, an increasing number are being referred for recurrent mood disorders, often stemming from workplace concerns.20,21 1.1 Contributing factors Adverse health outcomes among learners and physicians are linked to a range of contributing factors, including intrinsic ones (e.g., personality characteristics22 and other personal vulnerabilities) and extrinsic ones (e.g., excessive workloads, excessive standards of training and practice, excessive duty hours, lack of autonomy, disruptive behaviour, poor work-life integration, increasing demands with diminishing resources, systemic failures, financial issues, and the practice and training environment).2,15,23 Moreover, the management of risk that many physicians are involved with as it relates to the treatment and management of their patients can be challenging and impacts their health4. A dearth of recent data on the health status of physicians in Canada represents a critical gap in knowledge and limits future efforts to refine, select and assess initiatives. 2. Consequences 2.1. Impact on learners and physicians Compromised physician health can result in decreased personal and professional satisfaction, dysfunctional personal and professional relationships, increased attrition and increased rates of suicide and suicidal ideation.6,24,25 Perhaps most troubling, completed suicide rates among physicians are 1.4-2.3 times higher than in the general population - between 300 and 400 physicians annually in the United States.26 In Canada, suicidal ideation among physicians (including residents) has been recently reported at 19% (lifetime) and 9% (in the last year)18, while Canadian medical student data report 14% (lifetime) and 6% (in the last year).11 Overall, ideation rates are higher among both physicians and learners than in the general population.27 2.2. Impact on patient care The impact of the mental and physical health of physicians extends to the quality of care provided to patients.16,28,29 For instance, physicians suffering from burnout are reportedly two to three times more likely to report their conduct with their patients as sub-optimal.24 Indeed, physicians remain a primary source of health information for patients, and they act as both role models and health advocates.15 Characteristics of burnout (e.g., poor communication and reduced empathy) run counter to the core principles of patient-centred care,30 and physicians who maintain healthy lifestyles are more likely to focus on preventive strategies with their patients.31,32 Although deficits in physician health can negatively affect patient care, it is notable that evidence linking the health of physicians to medical errors is incomplete, if not difficult to establish. Nevertheless, studies have reported a relationship between medical error and specific adverse outcomes such as burnout.17,33 2.3 Impact on health system Issues that are associated with compromised physician health, such as reduced productivity, increased turnover, absenteeism and the likelihood of early retirement,25,34 contribute to the strained state of the health system. Given that physicians represent a significant proportion of the Canadian medical workforce, more attention must be paid to physician health if the health system is to be sustainable.2 Encouragingly, studies have shown that resources and services such as workplace wellness programs produce investment returns,35,36 such as decreases in medical leave and absenteeism2,36,37 Implementing strategies from occupational medicine are also being increasingly employed to ensure patient safety when doctors return to work after illness.4 This contributes to helping balance the need of institutions and medical regulatory agencies to minimize the risk while maximizing quality of patient care, with the desire of individual physicians to help their patients while leading healthy, fulfilling lives.4 Although there are moral grounds for addressing physician and learner ill-health, an economic case can also be made to support and guide initial and ongoing investment to address the problem.7,18 In navigating the many external challenges facing the Canadian the health system, it is critical that system-level leaders not neglect internal threats, including physician distress and dissatisfaction6,7, and challenges in navigating complex work environments.24 To this end, although there are many positive and supportive elements within medical culture, it is also important to acknowledge aspects that contribute to poor health. 2.4 Impact on the culture of medical practice and training and on the workplace Enduring norms within the culture of medicine are directly contributing to the deterioration of the health of Canadian learners and physicians.2 Culturally rooted impediments, such as the reluctance to share personal issues or admit vulnerability, discourage the medical profession from acknowledging, identifying and addressing physician health issues.7 Physicians and learners alike face pressure not to be ill, to care for patients regardless of their personal health and even to attempt to control their own illness and treatment by self-medicating.1,38 Indeed, physicians are often portrayed as being invincible professionals who put patient needs above all else, including their own needs.39,40 Although the CMA Code of Ethics encourages physicians to seek help from colleagues and qualified professionals when personal or workplace challenges compromise patient care41 physicians tend to delay or avoid seeking treatment, especially for psychosocial or psychiatric concerns. Moreover, nearly 33% of Canadian physicians are not registered with a family physician.42 which means they are among the lowest users of health services.43 Providing care to physician colleagues is both complex and challenging, yet this is an area where formal training has not been explicitly or systematically provided on a national scale.1 There is a need to identify physicians willing to treat colleagues, to develop or adapt existing approaches that encourage help-seeking and to help physicians to navigate the treatment of colleagues. Stigma around mental health within medical practice and training acts as a significant barrier to early intervention.1,44 In a localized study of Canadian physicians, 18% reported distress, but only 25% considered getting help and only 2% actually did.39 Similarly, national CMA data reported that 'feeling ashamed to seek help' was identified (76%) as a major reason for physicians not wanting to contact a physician health program.18 Indeed, common concerns include not wanting to let colleagues or patients down, believing seeking help is acknowledging weakness, being apprehensive about confidentiality, and fearing negative reprisals (e.g., from colleagues, supervisors, regulatory bodies, other licence-granting bodies, insurers)1,45 Fear of retribution is also a frequent reason why physicians may feel hesitant to report impaired colleagues, even if supportive of the concept.46 From the outset of training, medical learners are introduced to system-wide cultural aspects and values of the medical profession, which they then internalize and pass on to others.2 Extensive literature on the "hidden curriculum" points to a performance culture that includes norms such as the view that adversity is character building and the valorization of emotional repression (e.g., mental toughness).2,47 Culture-related issues are being increasingly addressed as a function of medical professionalism. For instance, commitment to physician health, collegiality and support have been established as key competencies within the Professional Role of the CanMEDS Framework,5 the most widely accepted and applied physician competency framework in the world.48 This involves a commitment to exhibiting self-awareness and managing influences on personal well-being and professional performance; managing personal and professional demands for a sustainable practice throughout the physician life cycle, and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need. In support of these commitments to personal care, physicians must develop their capacity for self-assessment and monitoring, mindfulness and reflection, and resilience for sustainable practice.5 Intra-professionalism, characterized by effective clinical and personal communication among physicians,49 significantly influence job satisfaction, which in turn has been shown to predict physician health outcomes.50 Furthermore, peer support can buffer the negative effects of work demands;39 collegial, professional environments are known to be healthier for both providers and patients.51 Conversely, unprofessional behaviour is associated with physician dissatisfaction,50 and dysfunctional workplaces and poor collegiality are linked to burnout.52 Unprofessional workplace behaviour is tolerated, and in fact is often customary, within medical training and practice environments.53 Of particular concern, such behaviour carried out by more senior physicians has been shown to encourage similar conduct among learners,54 highlighting the importance of promoting effective professional role modelling.55 Unfortunately, poor supervisory behaviour, and even mistreatment of learners, is common within the medical training environment.56 Although expectations for professional behaviour are increasingly being incorporated into both undergraduate and postgraduate teaching, issues related to a lack of professionalism persist in both training and practice.51 System-wide efforts are needed to counter what is perceived to be an eroding sense of collegiality and to promote professionalism as a way to address physician burnout and enhance engagement.7,39 3. Treatment and preventive approaches 3.1 Physician health services The scope of physician health services has expanded from focusing primary focus on identifying treating and monitoring physicians with substance abuse issues to more recent efforts to de-stigmatize poor physician health and integrate proactive resources to complement tertiary approaches.1 In Canada, there are multiple services to support the health needs of learners and physicians. These can be conceptualized along a continuum of approaches,1 including the following: health-promoting environments (e.g., efforts to ensure balanced workloads, provide more support staff, and encourage physicians to make sure they get adequate exercise, nutrition and sleep in training and practice); primary prevention (e.g., resilience training, stress-reduction groups, fatigue management programs, strategies to enhance teamwork and collaborative care); secondary prevention (e.g., access to assessment and counselling; services and workshops on coping with adverse events, litigation and career transitions and on managing difficult behaviour); and tertiary prevention (e.g., more intensive outpatient counselling, inpatient treatment). Many of these approaches, including those at the system level, focus on assisting the individual physician rather than addressing more contextual issues. Most jurisdictions in Canada have consolidated a number of services under the banner of a provincial physician health program (PHP).These range from counselling, treatment and/or peer support to fitness-to-practice and return-to-work assessments, workplace behaviour management and relationship management. The services available to physicians in a given area vary greatly.1,15 More established and resourced programs often offer services across the continuum, while less established programs tend to focus on secondary and tertiary services.2 Provincial PHPs have been shown to produce positive outcomes1,20,21,48 and are generally considered to be effective in addressing user issues,57 however but many physicians remain reluctant to access them.58 In addition to provincial programs, many learners and physicians in Canada can access support and treatment from other sources, including medical school and faculty wellness programs, employee assistance or workplace programs, and more individual-led options such as physician coaches.1 There has been a steady accumulation of evidence on the positive returns of workplace health and wellness programs,35 as well as indications that even modest investments in physician health can make a difference.17 In response to challenges posed by the considerable diversity in the organizational structure of provincial PHPs, the ways in which PHPs classify information, the range of services they offer, the mechanisms of accountability to stakeholders and the manner in which they pursue non-tertiary activities (e.g., education and prevention work)59 a consortium of PHPs released a preliminary Descriptive Framework for Physician Health Services in Canada in 2016. Through this framework a series of core services (and modes of activity within each) were defined.59 Potential users of the framework include PHPs, academic institutions, medical regulators, national associations, hospitals and health authorities, as well as other local groups. The framework may serve a range of purposes, including program reviews and planning, quality improvement, resource allocation, advocacy, stakeholder consultation and standards development.59 Initiatives such as this framework help address a persistent gap in Canada around equity of and access to services. Overall, fulfilling the needs of all learners and physicians through enhanced service quality and functional equivalence is an ongoing challenge for provincial PHPs and other service providers, and it must be a priority moving forward. 3.2 Individual primary prevention Prevention and promotion activities can help mitigate the severity and decrease the incidence of adverse outcomes associated with physician health issues among learners and physicians.3 Although secondary and tertiary services are critical components of any health strategy, complementary, proactive, preventive initiatives promote a more comprehensive approach. Some of the best-documented strategies include attuning to physical health (e.g., diet, exercise, rest), psychosocial and mental health (e.g., mindfulness and self-awareness, resilience training, protecting and maintaining cultural and recreational interests outside of medicine, and protecting time and relationships with family and friends).60 For instance, resilience has been identified as an indicator of physician wellness61 and as a critical skill for individuals working in health care environments.39 Innovative, coordinated approaches such as resilience and mindfulness training are instrumental in helping physicians overcome both anticipated and unexpected difficulties, to position them for a sustainable career in medicine. Many internal (e.g., personal) and external (e.g., occupational) factors can interfere with a physician's capacity to consistently maintain healthy lifestyle behaviours and objectively attend to personal health needs. Although the emergence of individually targeted proactive and preventive activities is encouraging, a greater focus on system-level initiatives to complement both proactive and tertiary approaches is needed. This also aligns with recent CMA member data indicating that medical students (61%), residents (55%), physicians (43%) and retired physicians (41%) want more access to resources to ensure their emotional, social and psychological well-being.62 Such an approach is increasingly important in light of physicians' professional responsibility to demonstrate a commitment to personal health.5 4. Physician health as a shared responsibility Although physicians are a critical component of Canadian health systems, those systems do not necessarily promote health in the physician community. It cannot be overstated that many health challenges facing learners and physicians are increasingly systemic in nature.1 Despite increasing challenges to the cultural norm that health-related issues are an individual-physician problem,2 system-level factors are often ignored.1,7 Although solutions targeted at the individual level (e.g., mindfulness and resilience training) are important proactive approaches and are a common focus, they often do not address occupational and organizational factors.7 Intervention exclusively at the individual level is unlikely to have meaningful and sustainable impacts. Interventions targeting individual physicians are likely most effective when paired with efforts to address more systemic (e.g., structural and occupational) issues.63 Moreover, organization-directed interventions have been shown to be more effective in reducing physician burnout than individual-directed interventions, and meaningful reductions in negative outcomes have been linked to system-level interventions.22,34 Concerted efforts at the system level will ultimately drive substantive, meaningful and sustainable change. This includes coordination among leaders from national, provincial and local stakeholders as well as individual physicians.16,22,64 Potential influencers include medical schools and other training programs, regulatory bodies, researchers (and funding bodies), professional associations and other health care organizations, as well as insurers.1 Indeed, addressing the complex array of issues related to physician health is a shared responsibility. A clear mandate exists to guide individuals and leaders in promoting and protecting the health of learners and physicians.1,7 5. Conclusion Physician health is a growing priority for the medical profession. Medical practice and training present complex occupational environments34, in which leaders play a central role in shaping training, practice and organizational culture through the implicit and explicit ways in which they communicate core values.2 When promoting physician health across the career lifecycle it is also important to consider the unique challenges and experiences of physicians who are not actively practicing (e.g., on leave; have non-clinical roles) as well as those who are retired. Notwithstanding the impact on patient care or health systems, promoting the health of individual physicians and learners is in and of itself worthy of attention. Indeed, leaders in the health system have a vested interest in helping physicians to meet the personal and professional challenges inherent in medical training and practice as well as in promoting positive concepts such as wellness and engagement.7 The increasingly blurred lines between physician health, professionalism and the functioning of health systems40 suggest that leaders at all levels must promote a unified and progressive vision of a healthy, vibrant and engaged physician workforce. This involves championing health across the career life cycle through advocacy as well as promoting solutions and outcomes through a lens of shared responsibility at both individual and system levels. Broad solutions skewed towards one level, without requisite attention given to the other level, are unikely to result in meaningful change. Moving from rhetoric to action, this next frontier integrates the promotion of self-care among individuals, support for healthy and supportive training and practice environments - both physical and cultural - as well as continued innovation and development of (and support for) physician health services. This constellation of efforts will ultimately contribute to the success of these actions. October 2017 See also CMA Policy on Physician Health REFERENCES 1 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 2 Montgomery AJ. The relationship between leadership and physician well-being; A scoping review. Journal of Healthcare Leadership 2016;55:71-80. Available: http://www.ingentaconnect.com/content/doaj/11793201/2016/00000055/00000001/art00010 (accessed 2017 Oct 30). 3 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 4 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 5 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. Available: https://doi.org/10.1016/S0140-6736(09)61424-0 (accessed 2017 Oct 30). 7 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-6. Available: https://doi.org/10.1016/j.mayocp.2016.10.004 (accessed 2017 Oct 30). 8 Lemaire JB, Wallace JE. Burnout among doctors. BMJ 2017;358:j3360. 9 Tepper J, Champion C, Johnston T, Rodin D, White A, Bastrash M, et al. Medical student health and wellbeing. Ottawa: Canadian Federation of Medical Students (CFMS); 2015. 10 Dyrbye LN, Harper W, Durning SJ, Moutier C, Thomas MR, Massie FS, et al. Patterns of distress in US medical students. Med Teach 2011;33:834-9. Available: https://doi.org/10.3109/0142159X.2010.531158 (accessed 2017 Oct 30). 11 Canadian Federation of Medical Students (CFMS). CFMS-FMEQ national health and wellbeing survey - Student research position. International Conference on Physician Health; 2016 Sep 18-20; Boston. Ottawa: CFMS; 2016. 12 Maser B, Houlton R. CFMS-FMEQ national health and wellbeing survey: Prevalence and predictors of mental health in Canadian medical students. Canadian Conference on Physician Health; 2017 Sep 7-9; Ottawa. Ottawa: CFMS; 2017. 13 Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among US medical students. Ann of Intern Med 2008;149:334-41. Available: https://doi.org/10.7326/0003-4819-149-5-200809020-00008 (accessed 2017 Oct 30). 14 George S, Hanson J, Jackson JL. Physician, heal thyself: a qualitative study of physician health behaviors. Acad Psychiatry 2014;38:19-25. Available: https://doi.org/10.1007/s40596-013-0014-6 (accessed 2017 Oct 30). 15 Roman S, Prévost C. Physician health: state of knowledge and preventive approaches. Montreal: Programme d'aide aux médecins du Québec (PAMQ); 2015. Available: http://catalogue.cssslaval.qc.ca/GEIDEFile/Doc_224290_ang.pdf?Archive=102463592064&File=Doc_224290_Ang_pdf (accessed 2017 Oct 30). 16 West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-81. Available: https://doi.org/10.1016/S0140-6736(16)31279-X (accessed 2017 Oct 30). 17 Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med 2017 Sep 25 [epub ahead of print]. Available: https://doi.org/10.1001/jamainternmed.2017.4340 (accessed 2017 Oct 30). 18 Simon C, McFadden T, Canadian Medical Association (CMA). National Physician Health Survey: The Process, Preliminary Data, and Future Directions 2017. Canadian Conference on Physician Health; 2017 Sep 7-9; Ottawa. Ottawa: CMA; 2017. 19 Lefebvre LG, Kaufmann IM. The identification and management of substance use disorders in anesthesiologists. Can J Anaesth 2017;64:211-8. 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