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CMA PolicyBase

Policies that advocate for the medical profession and Canadians


37 records – page 1 of 4.

Aboriginal peoples and mental illness

https://policybase.cma.ca/en/permalink/policy9210
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC08-21
The Canadian Medical Association urges Canadian medical schools to include in their curricula material related to the deleterious effect of negative stereotyping of Aboriginal peoples suffering from mental illnesses and substance use disorders.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC08-21
The Canadian Medical Association urges Canadian medical schools to include in their curricula material related to the deleterious effect of negative stereotyping of Aboriginal peoples suffering from mental illnesses and substance use disorders.
Text
The Canadian Medical Association urges Canadian medical schools to include in their curricula material related to the deleterious effect of negative stereotyping of Aboriginal peoples suffering from mental illnesses and substance use disorders.
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Access to a family physician

https://policybase.cma.ca/en/permalink/policy9534
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health human resources
Health systems, system funding and performance
Physician practice/ compensation/ forms
Population health/ health equity/ public health
Resolution
GC09-29
The Canadian Medical Association will work with provincial/territorial medical associations (PTMAs) to urge governments to collaborate with PTMAs in the implementation of a program that will identify and manage "orphan" patients who do not have access to a family physician.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health human resources
Health systems, system funding and performance
Physician practice/ compensation/ forms
Population health/ health equity/ public health
Resolution
GC09-29
The Canadian Medical Association will work with provincial/territorial medical associations (PTMAs) to urge governments to collaborate with PTMAs in the implementation of a program that will identify and manage "orphan" patients who do not have access to a family physician.
Text
The Canadian Medical Association will work with provincial/territorial medical associations (PTMAs) to urge governments to collaborate with PTMAs in the implementation of a program that will identify and manage "orphan" patients who do not have access to a family physician.
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Access to long-term care

https://policybase.cma.ca/en/permalink/policy9500
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC09-19
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, affiliates and associates, will communicate to governments that insufficient access to long-term care at all ages is an obstacle to improving the health care system.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC09-19
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, affiliates and associates, will communicate to governments that insufficient access to long-term care at all ages is an obstacle to improving the health care system.
Text
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, affiliates and associates, will communicate to governments that insufficient access to long-term care at all ages is an obstacle to improving the health care system.
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Active Transportation

https://policybase.cma.ca/en/permalink/policy9483
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
Text
The major diseases affecting the quality and quantity of life of Canadians, which include obesity, diabetes, coronary artery disease, depression and cancer, are all linked to physical inactivity. In Canada, 69% of women and 68% of men in Canada are considered physically inactive.(1) The cost of this inactivity and obesity was estimated at $4.3 billion in 2001.(2) A 10% increase in physical activity could potentially reduce direct health care expenditures by $150 million a year. This does not include indirect costs such as lost productivity due to illness, premature death or a range of other factors, including mental illness and poor quality of life.(3) Thus far, efforts to increase physical activity by changing the behaviour of individuals have had limited success. One reason is that many people have difficulty sustaining behaviours that involve additional time commitments. That is one reason for the increasing emphasis being placed on active transportation, which is any human-powered form of transportation, such as walking and cycling. Walking and cycling can be efficient alternatives to automobile travel. Cycling is usually the fastest mode of travel door to door for distances under five km, and for up to 10 km in city cores. Walking is simpler and nearly as fast for distances up to two km. When travel times are similar for active and motorized transportation, physical activity is gained with no net time lost, and at much lower cost. The cost of operating a motor vehicle is typically $10,000 per year,(4) while operating costs for a bicycle are much lower. Communities that have sidewalks, enjoyable scenery, street lights and nearby stores have improved levels of active transportation and physical activity. However, in recent decades communities have often been designed around the automobile. Street design, parking space, sidewalks and distance to retail destinations have all been planned assuming motorized transportation, and this often makes it difficult to move around communities by walking or cycling. Although individual decision-making remains important in any strategy for increasing active transportation, there is an essential role for communities and governments to play. Major improvements in the health of Canadians in the past 200 years have been due to improved sanitation, access to clean water and injury prevention. The role of individual decision-making in effecting these changes is dwarfed by the impact of the public health measures and infrastructure involved. Just as potable tap water is a health issue, so are decisions about land use, transportation policy and infrastructure. Community design is a major determinant of whether people use active transportation, whether they are physically active and whether they are obese. Canadians need communities that make it easy to be physically active in their daily living. Communities can create an environment in which the physically active choice is the easy choice. They can do this via sidewalks, trails, bicycle lanes and bicycle paths, and by providing pedestrian-friendly intersections, parks and green spaces, and safe bicycle parking spaces. They can also arrange zoning so that retail destinations are within walking or cycling distance of residential areas. This process also includes dedicating a sufficient portion of their street maintenance budget (including snow clearing) to maintaining active transportation routes as well as routes for motorized vehicles. It may include redesigning intersections, giving up vehicle lanes or parking spaces, or increasing the price of parking. Additional benefits to designing communities for pedestrians and cyclists. * a stronger sense of community with greater civic involvement by citizens * increased property values and retail activity * less noise pollution * lower crime rates * less smog and other air pollution * less greenhouse gas production * decreased risk of injury to pedestrians and cyclists * decreased costs of roadway and parking construction. A role for everyone Other sectors can support communities in making active transportation choices easy choices: * Businesses can create a work environment friendly to active transportation, including a corporate culture friendly to physical activity. They can incorporate active transportation planning into building design and create an environment friendly to physical activity. These steps could include making bicycle parking, showers and lockers available, and providing stairs that are pleasant and easier to access than elevators. They can also incorporate a culture of physical activity in decisions about where and how to hold meetings, and what people are allowed to wear to work. * School boards can develop policies to promote active transportation to and from school. These include building and maintaining secure bicycle parking, ensuring safe walking routes within communities, and assisting parents in walking their children to school. * Citizens can use active transportation themselves and treat with respect those who are already making active transportation choices. They can also lobby governments to make their community safer and easier places for cycling and walking. * Physicians can encourage patients to use active transportation as a way to boost their physical activity levels and improving their health. They can also lead by example and use active transportation themselves. Recommendations The CMA recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation. The CMA urges governments to: * Commit to long-term plans for active transportation networks that are in keeping with these goals and that include specific benchmarks to measure progress. * Require that active transportation be part of all infrastructure renewal projects, with investment in active transportation vs. motorized transportation in proportion to targeted active transportation use. (Some cities have achieved active transportation rates of up to 15%.) * Develop an awareness campaign to help Canadians to recognize the value of active transportation in their communities. * Require public health impact assessments for all land-use and transportation decisions, including the impact on the chemical environment and on physical activity. * Assess the impact that changes in the "built" environment can have on public health, and which interventions are most safe and effective. 1 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43. 2 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J App Phys 2004;29(1):104. 3 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ 2000;163(11): 1435-40. 4 Canadian Automobile Association. Driving Costs: 2005 Edition. Available: www.carpool.ca/pdf/CAA-driving-costs-05.pdf (accessed 2007 Feb. 2).
Documents
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Acute care beds

https://policybase.cma.ca/en/permalink/policy9224
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC08-43
The Canadian Medical Association and provincial/territorial medical associations will work with governments to implement transparent and publicly available principles for the supply and effective management of functional acute care beds.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC08-43
The Canadian Medical Association and provincial/territorial medical associations will work with governments to implement transparent and publicly available principles for the supply and effective management of functional acute care beds.
Text
The Canadian Medical Association and provincial/territorial medical associations will work with governments to implement transparent and publicly available principles for the supply and effective management of functional acute care beds.
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Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health care and patient safety
Population health/ health equity/ public health
Resolution
GC09-92
The Canadian Medical Association recognizes addiction as a chronic, treatable disease and urges that it be included in national and provincial/territorial efforts to improve chronic disease management.
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2009-08-19
Topics
Health care and patient safety
Population health/ health equity/ public health
Resolution
GC09-92
The Canadian Medical Association recognizes addiction as a chronic, treatable disease and urges that it be included in national and provincial/territorial efforts to improve chronic disease management.
Text
The Canadian Medical Association recognizes addiction as a chronic, treatable disease and urges that it be included in national and provincial/territorial efforts to improve chronic disease management.
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Canadian tuberculosis control programs

https://policybase.cma.ca/en/permalink/policy9260
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health care and patient safety
Resolution
GC08-91
The Canadian Medical Association advocates for mobilization of federal resources to facilitate Canadian tuberculosis control programs to screen refugees and immigrants new to Canada in accordance with current health policy.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health care and patient safety
Resolution
GC08-91
The Canadian Medical Association advocates for mobilization of federal resources to facilitate Canadian tuberculosis control programs to screen refugees and immigrants new to Canada in accordance with current health policy.
Text
The Canadian Medical Association advocates for mobilization of federal resources to facilitate Canadian tuberculosis control programs to screen refugees and immigrants new to Canada in accordance with current health policy.
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Caring in a Crisis: The Ethical Obligations of Physicians and Society During a Pandemic

https://policybase.cma.ca/en/permalink/policy9109
Last Reviewed
2019-03-03
Date
2008-02-23
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2008-02-23
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Text
Inherent in all health care professional Codes of Ethics is the duty to provide care to patients and to relieve suffering whenever possible. However, this duty does not exist in a vacuum, and depends on the provision of goods and services referred to as reciprocal obligations, which must be provided by governments, health care institutions and other relevant bodies and agencies. The obligation of government and society to physicians can be seen as comparable to the obligations of physicians to their patients. The recent experience of Canadian physicians during the SARS epidemic in Toronto has heightened the sensitivities of the medical profession to several issues that arose during the course of dealing with that illness. Many of the lessons learned (and the unanswered questions that arose) also apply to the looming threat of an avian flu (or other) pandemic. Canadian physicians may be in a relatively unique position to consider these issues given their experience and insight. The intent of this working paper is to highlight the ethical issues of greatest concern to practicing Canadian physicians which must be considered during a pandemic. In order to address these issues before they arise, the CMA presents this paper for consideration by individual physicians, physician organizations, governments, policy makers and interested bodies and stakeholders. Although many of the principles and concepts could readily be applied to other health care workers, the focus of this paper will be on physicians. Policies regarding physicians in training, including medical students and residents, should be clarified in advance by the relevant bodies involved in their oversight and training. Issues of concern would include the responsibilities of trainees to provide care during a pandemic and the potential effect of such an outbreak on their education and training. A. Physician obligations during a pandemic The professional obligations of physicians are well spelled out in the CMA Code of Ethics and other documents and publications and are not the main focus of this paper. However, they will be reviewed and discussed as follows. Several important principles of medical ethics will be of particular relevance in considering this issue. Physicians have an obligation to be beneficent to their patients and to consider what is in the patient's best interest. According to the first paragraph of the CMA Code of Ethics (2004), "Consider first the well-being of the patient". Traditionally, physicians have also respected the principle of altruism, whereby they set aside concern for their own health and well-being in order to serve their patients. While this has often manifested itself primarily as long hours away from home and family, and a benign neglect of personal health issues, at times more drastic sacrifices have been required. During previous pandemics, many physicians have served selflessly in the public interest, often at great risk to their own well-being. The principle of justice requires physicians to consider what is owed to whom and why, including what resources are needed, and how these resources would best be employed during a pandemic. These resources might include physician services but could also include access to vaccines and medications, as well as access to equipment such as ventilators or to a bed in the intensive care unit. According to paragraph 43 of the CMA Code of Ethics, physicians have an obligation to "Recognize the responsibility of physicians to promote equitable access to health care resources". In addition, physicians can reasonably be expected to participate in the process of planning for a pandemic or other medical disaster. According to paragraph 42 of the CMA Code of Ethics, physicians should "Recognize the profession's responsibility to society in matters relating to public health, health education, environmental protection, legislation affecting the health and well-being of the community and the need for testimony at judicial proceedings". This responsibility could reasonably be seen to apply both to individual physicians as well as the various bodies and organizations that represent them. Physicians also have an ethical obligation to recognize their limitations and the extent of the services they are able to provide. During a pandemic, physicians may be asked to assume roles or responsibilities with which they are not comfortable, nor prepared. Paragraph 15 of the CMA Code of Ethics reminds physicians to "Recognize your limitations and, when indicated, recommend or seek additional opinions or services". However, physicians have moral rights as well as obligations. The concept of personal autonomy allows physicians some discretion in determining where, how and when they will practice medicine. They also have an obligation to safeguard their own health. As stated in paragraph 10 of the CMA Code of Ethics, physicians should "Promote and maintain your own health and well-being". The SARS epidemic has served to reopen the ethical debate. Health care practitioners have been forced to reconsider their obligations during a pandemic, including whether they must provide care to all those in need regardless of the level of personal risk. As well, they have been re-examining the obligation of governments and others to provide reciprocal services to physicians, and the relationship between these obligations. B. Reciprocal obligations towards physicians While there has been much debate historically (and especially more recently) about the ethical obligations of physicians towards their patients and society in general, the consideration of reciprocal obligations towards physicians is a relatively recent phenomenon. During the SARS epidemic, a large number of Canadian physicians unselfishly volunteered to assist their colleagues in trying to bring the epidemic under control. They did so, in many cases, in spite of significant personal risk, and with very little information about the nature of the illness, particularly early in the course of the outbreak. Retrospective analysis has cast significant doubt and concern on the amount of support and assistance provided to physicians during the crisis. Communication and infrastructure support was poor at best. Equipment was often lacking and not always up to standard when it was available. Psychological support and counselling was not readily available at the point of care, nor was financial compensation for those who missed work due to illness or quarantine. Although the Ontario government did provide retrospective compensation for many physicians whose practices were affected by the outbreak, the issue was addressed late, and not at all in some cases. It is clear that Canadian physicians have learned greatly from this experience. The likelihood of individuals again volunteering "blindly" has been reduced to the point where it may never happen again. There are expectations that certain conditions and obligations will be met in order to optimize patient care and outcomes and to protect health care workers and their families. Because physicians and other health care providers will be expected to put themselves directly in harm's way, and to bear a disproportionate burden of the personal hardships associated with a pandemic, the argument has been made that society has a reciprocal obligation to support and compensate these individuals. According to the University of Toronto Joint Centre for Bioethics report We stand on guard for thee, "(The substantive value of) reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients and their families." Therefore, in order to provide adequate care for patients, the reciprocal obligation to physicians requires providing some or all of the following: Prior to a pandemic - Physicians and the organizations that represent them should be more involved in planning and decision making at the local, national and international levels. In turn, physicians and the organizations that represent them have an obligation to participate as well. - Physicians should be made aware of a clear plan for resource utilization, including: - how physicians will be relieved of duties after a certain time; - clearly defined roles and expectations, especially for those practicing outside of their area of expertise; - vaccination/treatment plans - will physicians (and their families) have preferential access based on the need to keep caregivers healthy and on the job; - triage plans, including how the triage model might be altered and plans to inform the public of such. - Physicians should have access to the best equipment needed and should be able to undergo extra training in its use if required. - Politicians and leaders should provide reassurances that satisfy physicians that they will not be "conscripted" by legislation. During a pandemic - Physicians should have access to up-to-date, real time information. - Physicians should be kept informed about developments in Canada and globally. - Communication channels should be opened with other countries (e.g. Canada should participate in WHO initiatives to identify the threats before they arrive on our doorstep). - Resources should be provided for backup and relief of physicians and health care workers. - Arrangements should be made for timely provision of necessary equipment in an ongoing fashion. - Physicians should be compensated for lost clinical earnings and to cover expenses such as lost wages, lost group earnings, overhead, medical care, medications, rehabilitative therapy and other relevant expenses in case of quarantine, clinic cancellations or illness (recognizing that determining exactly when or where an infection was acquired may be difficult). - Families should receive financial compensation in the case of a physician family member who dies as a result of providing care during a pandemic. - In the event that physicians may be called upon in a pandemic to practice outside of their area of expertise or outside their jurisdiction, they should to contact their professional liability protection provider for information on their eligibility for protection in these circumstances. - Interprovincial or national licensing programs should be developed to provide physicians with back-up and relief and ensure experts can move from place to place in a timely fashion without undue burden. - Psychological and emotional counselling and support should be provided in a timely fashion for physicians, their staff and family members. - Accommodation (i.e. a place to stay) should be provided for physicians who have to travel to another locale to provide care; or who don't want to go home and put their family at risk, when this is applicable, i.e. the epidemiology of the infectious disease causing the pandemic indicates substantially greater risk of acquiring infection in the health care setting than in the community. - Billing and compensation arrangements should ensure physicians are properly compensated for the services they are providing, including those who may not have an active billing number in the province where the services are being provided. After a pandemic - Physicians should receive assistance in restarting their practice (replacing staff, restocking overhead, communicating with patients, and any other costs related to restarting the practice). - Physicians should receive ongoing psychological support and counselling as required. C. How are physician obligations and reciprocal obligations related? Beyond a simple statement of the various obligations, it is clear that there must be some link between these different obligations. This is particularly important since there is now some time to plan for the next pandemic and to ensure that reciprocal obligations can be met prior to its onset. Physicians have always provided care in emergency situations without questioning what they are owed. According to paragraph 18 of the CMA Code of Ethics, physicians should "Provide whatever appropriate assistance you can to any person with an urgent need for medical care". However, in situations where obligations can be anticipated and met in advance, it is reasonable to expect that they will be addressed. Whereas a physician who encounters an emergency situation at the site of a car crash will act without concern for personal gain or motivation, a physician caring for the same patient in an emergency department will rightly expect the availability of proper equipment and personnel. In order to ensure proper patient care and physician safety, and to ensure physicians are able to meet their professional obligations and standards, the reciprocal obligations outlined above should be addressed by the appropriate body or organization. Conclusion If patient and physician well-being is not optimized by clarifying the obligations of physicians and society prior to the next pandemic, in spite of available time and resources necessary to do so, there are many who would call into question the ethical duty of physicians to provide care. However, the CMA believes that, in the very best and most honourable traditions of the medical profession, its members will provide care and compassion to those in need. We call on governments and society to assist us in optimizing this care for all Canadians.
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Children's health and environmental toxins

https://policybase.cma.ca/en/permalink/policy9239
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health care and patient safety
Resolution
GC08-71
The Canadian Medical Association urges the federal government to participate in Canadian-based research studies on children's health and environmental toxins.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health care and patient safety
Resolution
GC08-71
The Canadian Medical Association urges the federal government to participate in Canadian-based research studies on children's health and environmental toxins.
Text
The Canadian Medical Association urges the federal government to participate in Canadian-based research studies on children's health and environmental toxins.
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CMA's Presentation to the House of Commons Standing Committee on Health : H1N1 Preparedness and Response

https://policybase.cma.ca/en/permalink/policy9699
Date
2009-10-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2009-10-05
Topics
Population health/ health equity/ public health
Text
Good afternoon Madame Chair. The Canadian Medical Association is pleased to address the committee as part of its ongoing study of H1N1 planning and response. In the broad context of pandemic planning, the CMA has focused on developing information and education tools on cma.ca to ensure Canada's doctors are equipped to provide the best possible care to patients. We have also engaged in discussions with the Assembly of First Nations to address workforce shortages in First Nations and Inuit communities during a pandemic. Despite the work of governments and others, there remains much to do. To provide optimal patient care, individual physicians - primary care providers and specialists alike - require: * Regular updates on the status of H1N1 in their community; * Timely and easy access to diagnostic and treatment recommendations with clear messages tailored to their service level; * Rapid responses to questions; and * Adequate supplies of key resources such as masks, medications, diagnostic kits and vaccines. The CMA commends federal, provincial and territorial governments for creating the Canadian Pandemic Influenza Plan for the Health Care Sector. The CMA was pleased to provide feedback on elements of the plan and we are participating on the anti-viral and clinical care task groups. There are three issues that still must be addressed: First, the communications gap between public health officials and front-line providers; Second, the lack of adequate resources on the front lines; and finally, variability that exists across the country. The Communications Gap Physicians must be involved in the planning stages and must receive consistent, timely and practical plain-language information. They should not have to seek information out from various websites or other sources, or through the media. This communications gap also includes a gap between information and action. For example, we are told to keep at least a six-foot distance between an infected patient and other patients and staff. This will not be possible in a doctor's waiting room, nor will disinfecting examining and waiting rooms in-between each patient. Adequate resources Patient volumes may increase dramatically and there are serious concerns about how to manage supplies if an office is overwhelmed. There is also considerable concern over whether we can keep enough health care professionals healthy to care for patients, and whether we have enough respirators and specialty equipment to treat patients. Intensive-care units of hospitals can also expect to be severely strained as a second-wave pandemic hits. This speaks to a general lack of surge capacity within the system. Also, pandemic planning for ICUs and other hospital units must include protocols to determine which patients can benefit most when there are not enough respirators and personnel to provide the required care for all who need it. Beyond the need for more supplies, however, there is also the concern that there are only so many hours in a day. Doctors will always strive to provide care for those who need it, but if treating H1N1 cases takes all of our time, who will be available to care for patients with other conditions? Variability across the country CMA has consulted with provincial and territorial medical associations and their level of involvement in government planning as well as the general state of preparedness varies greatly. There is also marked inconsistency province-to-province around immunization schedules. We need a clear statement of recommendation to clear up this variability. In summary, there remains a great deal of uncertainty among physicians about: the vaccine, the supply of antivirals, the role of assessment centres and mass immunization clinics, delegated acts, and physicians' medico-legal obligations and protections. The bottom line is that there is still more work to do at all levels before front-line clinicians feel well prepared with information, tools and strategies they need. The CMA was pleased to meet with Dr. Butler-Jones to discuss our concerns last week and will continue to work closely with Public Health Agency of Canada to identify gaps and to prepare user-friendly information for clinicians. Thank you and I welcome any questions.
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37 records – page 1 of 4.