The future of medicine
In 1997 the Canadian Medical Association (CMA) embarked on a study of the future of medicine. Two premises guided this activity: (1) the pace of change in the practice of medicine that physicians experienced in the last quarter of the 20th century is bound to increase in the 21st century; and (2) it is essential that the medical profession position itself to influence future developments in medical practice.
In order to prepare the profession to anticipate and meet the challenges of the future, the CMA is engaged in a medium- to long-term (5–20 years) planning exercise. This policy statement summarizes the results of the first part of this exercise: working definitions of health, health care and medicine; a vision for the future of the medical profession; and the implications of this vision for the roles of physicians. This work was conducted by an expert project advisory group, which developed background papers on these topics and prepared this statement for approval by the CMA Board of Directors.
Health: is a state of physical, mental, emotional and spiritual well-being. It is characterized in part by an absence of illness (a subjective experience) and disease (a pathological abnormality) that enables one to pursue major life goals and to function in personal, social and work contexts.
Health care: is any activity that has as its primary objective the improvement, maintenance or support of physical, mental, emotional and spiritual well-being, as characterized by the absence of illness and disease.
Medicine: is the art and science of healing. It is based on a body of knowledge, skills and practices concerned with the health and pathology of individuals and populations. The practice of medicine encompasses those health care activities that are performed by or under the direction of physicians in the service of patients, including health promotion, disease prevention, diagnosis, treatment, rehabilitation, palliation, education and research.
A vision for the future of the medical profession
Medicine will continue to be a healing profession dedicated to serving humanity. Its cornerstone will continue to be the relationship of trust between the patient and the
physician. It will uphold with integrity the values of respect for persons, compassion, beneficence and justice. It will strive for excellence and incorporate progress in its art and science. It will maintain high standards of ethics, clinical practice, education and research in order to serve patients. It will encourage the development of healthy communities and of practices and policies that promote the well-being of the public. It will demonstrate its capacity for societal responsibility through self-regulation and accountability. It will actively participate in decision-making regarding health and health care policy. It will guard against forces and events that may compromise its primary commitment to the well-being of patients.
The roles of physicians in the future1
Although the vision and values of medicine are enduring and will remain stable, the practice environment of physicians will change as the medical profession responds to health system and societal influences. This in turn will have implications for the roles of physicians.
The traditional role of physicians has been medical expert and healer. This has involved diagnosing and treating disease and other forms of illness, comforting those who cannot be cured and preventing illness through patient counselling and public-health measures. While this role will remain at the core of medical practice, the evolving context of health care requires physicians to assume additional roles to support their primary role.
The CMA proposes the following roles as essential to the future practice of medicine (cf. Fig. 1 for their interrelationship). Although no physician will function in all roles simultaneously, they should all have the fundamental competencies to participate in each of these roles.
-Medical expert and healer: Physicians have always been recognized for their role as medical expert and healer; it is the defining nature of their practice and derives from the broad knowledge base of medicine and its application through a combination of art and science. This is the foundation for continued physician leadership in the provision of medical and health care in the future.
-Professional: There must be renewed efforts to reaffirm the principles of the medical profession, including upholding its unique body of knowledge and skills; maintenance of high standards of practice; and commitment to the underlying values of caring, service and compassion. The medical profession of the future must continue to develop standards of care with ongoing opportunities for continued assessment of competency in order to remain a credible, self-regulated discipline worthy of public respect and trust.
-Communicator: Increasing emphasis will be placed upon the ability to gather and communicate medical information in a compassionate and caring fashion, to enter into a partnership with patients when organizing care plans and to provide important information through counselling and the promotion of health. As always, the patient–physician relationship will remain paramount, with its essential features of compassion, confidentiality, honesty and respect.
-Scholar: Scholarship involves the creation of new knowledge (research), its uniform application (clinical practice) and its transfer to others (education). It is this strong association with the science of medicine and physicians’ willingness to embrace the scholarship of their practice that is closely linked to their roles of
medical experts and professionals.
-Collaborator: Health care services will increasingly be provided by interdisciplinary teams throughout the continuum of care from health promotion activities to the management of acute life-threatening disorders to the delivery of palliative care. In the role of collaborator, physicians recognize the essential functions of other health care workers and respect unique provider contributions in patient-centred health care delivery.
-Advocate: As the health sector becomes increasingly complex and interdependent with other sectors of society, it will be essential for physicians to play a greater role as health advocates. This may pertain to advocacy for individual and family health promotion in the practice environment; it may also relate to the promotion of improved health at the broader community level.
-Manager: In order to provide quality care, physicians of the future must be effective resource managers at the individual practice level, at the health care facility level and as part of the wider health care system.
In order to fulfil these roles and participate in communities as integral members of society, physicians need to lead balanced lives.
Physicians may sometimes experience conflicts among these roles. The CMA Code of Ethics specifies the basic principles of professional ethics for dealing with such conflicts.
The CMA has developed this vision for the future of medicine and the future roles of physicians to assist individual physicians and medical organizations to anticipate and prepare for the challenges of the next 20 years. The vision provides the profession with criteria for evaluating proposed changes in how medicine is practised and reaffirms the core values of medicine that must be upheld in whatever system emerges.
The CMA invites other organizations, nonmedical as well as medical, to comment on the contents of this statement and its implications for health and health care. The CMA welcomes opportunities to dialogue with others on how the health care system can be improved for the benefit of future patients and society in general.
1The section is indebted to the work of the Educating Future Physicians for Ontario (EFPO) project supported by the Associated Medical Services group, the Ontario faculties of medicine and the Ontario Ministry of Health, and the Canadian Medical Education Directions for Specialists 2000 (CanMEDs 2000) project of the Royal College of Physicians and Surgeons of Canada.
Guidelines for Assessing Health Care System Performance
In recent years, Canadians have expressed a loss of confidence in the ability of the health care system to meet their needs. At the same time, governments, health professionals, patients and the public are demanding greater accountability from the system and those responsible for how it currently functions. Attempts to respond to these concerns have highlighted the fact that the development and evolution of the system have not been based on assessment of performance or outcome measurements.
Through proper assessment, the capacity and performance of the health care system can be evaluated to identify opportunities for improvements in quality of care, health outcomes or both. These improvements should be based on sound decision-making using the best available information. The following guidelines have been created by the CMA in consultation with a broad group of stakeholders to serve as guiding principles for those involved in the establishment and ongoing development of health care system performance processes.
1) Recognizing that the ultimate goal of the health care system is to improve health, assessment of the system's performance and capacity must address structure, process and outcomes in the following domains: clinical services; governance; management; finances; human, intellectual and physical capital; and stakeholder perception and satisfaction.
2) Assessment of health care system performance must be comprehensive throughout the continuum of care at all levels(f1) and involving all activities related to providing care.
3) The issues of privacy and confidentiality of patient information must be addressed at all levels as outlined in the Principles for the Protection of Patients' Personal Health Information.
4) Assessment of health care system performance must enhance accountability (f2) among administrators, patients, payers, providers and the public.
5) Assessing the performance of the health care system requires information that is reliable, valid, complete, comprehensive and timely. The information used for the purpose of assessing health care system performance must be continually evaluated and audited in a transparent process.
6) An independent group (f3) (f4) working with an advisory body (or bodies) composed of representative stakeholders should be responsible for overseeing the definition, collection and custodianship of data and the interpretation and dissemination of health care system performance assessment.
7) The advisory body (or bodies) must rely on the best available evidence, which may include or be limited to expert opinion in the areas of data definition and collection, privacy, analysis and interpretation (f5) in assessment of health care system performance.
8) In the assessment of health care system performance, and in particular with respect to the interpretation of information, the advisory body (or bodies) should place heavy emphasis on the viewpoints of relevant peer groups.
9) The processes of data collection, analysis, interpretation and communication to administrators, patients, payers, providers and the public should be systematic and ongoing.
10) The process of assessing health care system performance should be evaluated on an ongoing basis to determine whether it is achieving the desired effects on quality of care and health outcomes.
1-Provider, institutional, regional, provincial and national levels.
2-Accountability entails the procedures and processes by which one party justifies and takes responsibility for its activities (Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med 1996;124:229).
3-Without ownership or equity in the group being evaluated and without financial incentives related to the content of the evaluation.
4-Chosen through a transparent process.
5-Must include consideration of relevant legislation and regulations.