Originally published October 2012
The CMPA believes that medical professionalism has never been more important, both for individual physicians and for the medical community as a whole. In addition to the daily challenges of delivering clinical care, physicians will continue to confront a number of issues which will shape the future of the profession and of medical professionalism. The CMPA believes at least 4 key considerations, anchored in the tenets of professionalism, will determine the state of the profession in the coming years:
physicians' role in advancing healthcare transformation
the evolution of quality improvement and safer medical practice
continued clinical independence
the future of self-regulation
It is evident that a transformation of healthcare is underway. We need to build on successful elements of the current system, while seeking more effective and efficient ways of delivering high quality care to patient populations whose needs are changing and whose expectations are growing. At the centre of this transformation is the need to adopt an approach that is more patient-focused and outcome-oriented.
Many medical and healthcare organizations have been advocating for such a transformation, but progress remains slow. In part, the pace of progress reflects the need to achieve consensus from many interested parties including governments, healthcare authorities, physicians, other healthcare professionals, patient groups, and others.
In keeping with the fundamental principles underlying medical professionalism, physicians have a responsibility to contribute to the deliberations that will lead to a transformed healthcare system. This responsibility reflects the profession's obligation to its patients and to society as a whole. Constructive engagement, a willingness to put societal needs above those of individuals or the profession, and a solutions-oriented approach will reinforce the trust that Canadians continue to have in doctors.
Quality improvement and the contribution to safer medical practice
This special edition has highlighted the importance of trust, integrity, and clinical competence in maintaining a vibrant and relevant medical profession. Inherent in this is the willingness to learn from adverse events (accidents in Québec) and to engage in the quality improvement process. With its primary focus on system issues, appropriately conducted quality improvement also provides a means through which the safety of care can be substantively improved.
Physicians have a vital role to play in supporting the quality improvement process, both by actively participating in reviews and by advocating for a just culture of safety. In a just culture, the emphasis is on learning, system improvement, and remediation, and a "name, blame, and shame" approach is not tolerated. This role is also directly aligned with physicians' professional responsibility to contribute to societal good. The CMPA believes active and constructive physician involvement in quality improvement remains vital to ensuring the success of the profession. In addition, this is what patients and the public expect of the medical profession. The Canadian Medical Association also maintains physicians should participate in well-designed quality-improvement initiatives.1
Continued clinical independence
Clinical independence is one of the key features of medicine and it enables physicians to make clinically appropriate recommendations without undue influence from governments, hospitals, and other organizations. Such clinical independence is crucial to the physician-patient relationship, and ensures patients have confidence their best interests are prioritized. One manner in which clinical independence has manifested itself is in the traditional role of the physician as an independent contractor whose primary responsibility is to the patient.
The traditional independent contractor role, perhaps best exemplified by the privileges model of care delivery in hospitals, is changing. More and more physicians are moving to employment-type arrangements with health authorities, hospitals, and other institutions. Provided the necessary medico-legal protections are in place, these arrangements can have certain advantages. However, the CMPA believes physicians must be wary of any loss of clinical independence and consider how such a loss might impact the tenets of medical professionalism.
In environments of fiscal restraint, medical professionalism and ethics require physicians to carefully consider costs and evidence. Physicians may question how to maintain their clinical independence while advocating for patients and serving as a steward of an organization's or society's resources. Most doctors accept that the focus should not be on limiting expensive care, but rather on the principles of evidence-based medicine.2
The future of self-regulationn
Implicit in the relative autonomy granted to the medical profession is the requirement that physicians meet specific standards of practice, and that medical regulatory authorities (Colleges) regulate the practice of medicine in order to maintain standards and protect the public interest. While self-regulation is a longstanding hallmark of the profession, it is a privilege granted by society that can be withdrawn. In many jurisdictions, the CMPA is witnessing efforts to reduce the extent to which medicine is self-regulated. The concept of professionally-led regulation is becoming more common, with increasing proportions of lay membership on the councils of Colleges.
In some provinces, government possesses the legislative authority to appoint a College supervisor if there are concerns about the quality of the College's administration or management, or about the performance of its other duties or powers. To retain the privilege of self-regulation, Canadian physicians will have to demonstrate an ongoing commitment to safe medical practice. In an age of increased accountability, mechanisms such as self-regulation will be scrutinized. Physicians should take the time to understand the benefits of this privilege, and work to ensure its continuation.
There will undoubtedly be more uncertainty in the Canadian healthcare sector over the next several years. While this dynamic environment offers a number of opportunities for doctors to contribute to substantive healthcare transformation, it also poses threats to the profession, including the undermining of key principles that have long defined medical professionalism.
The CMPA believes the next few years will be crucial in setting the future course for the profession. The Association urges its members to remain engaged on professional matters and to carefully consider individual and collective actions that might influence the medical profession's future.
Finally, it is worth remembering that the primary beneficiaries of a strong and vibrant medical profession are patients. By demonstrating medical professionalism and upholding the tenets of the profession, physicians will continue to place the interests of patients above all else.
Canadian Medical Association. "The Evolving Professional Relationship Between Physicians and the Health Care System: Where do we Stand?" 2012. Retrieved on Sept. 14, 2012
Rosenbaum, L., Lamas, D., "Cents and sensitivity – Teaching physicians to think about costs," New England Journal of Medicine (2012) Vol. 367, no. 2 p.99-101