Originally published October 2012
Physicians assume key responsibilities in healthcare including the provision of much needed medical care, research into new treatments, teaching the future generation of doctors, and managing healthcare facilities, centres, or clinics. In all of these roles, physicians are expected to embody professionalism and to fulfill the obligations expected of the profession.
Physicians as advocates
In support of quality care, physicians may struggle to find the appropriate balance between meeting the needs of individual patients and the wider needs of society. Obligations placed on doctors vary depending on whether they are advocating for a patient or, more broadly, for societal good. Physicians should clearly understand on whose behalf they are speaking, the extent to which they are authorized to speak for an organization or individual, what their message is, and how best to communicate that message. When advocating for an individual patient, physicians should consider the implications on others, including society and the healthcare system overall. Professionalism in this context extends beyond the one-to-one relationship between a doctor and an individual patient, and recognizes interdependencies within the healthcare system.
A recent policy paper by the Canadian Medical Association offers a framework for physician advocacy.1 This framework includes questions for doctors considering advocacy initiatives, such as whether the issue impacts patient care, whether partners should be consulted, and whether the physician has all the relevant facts. Physicians may find this framework helpful.
At the system level, physicians are leaders in advocating for quality care and patient safety. At times, advocacy can bring a physician into conflict with a colleague, a hospital administrator, a health authority, or policy makers. Conflict can sometimes lead to positive change, but it can also be difficult to manage and must be dealt with constructively by all parties.
Doctors must be mindful there is a distinction between appropriate advocacy and what can be seen by others as disruptive behaviour. Even when advocating for an individual patient or for system improvement, physicians have a responsibility to act professionally for the benefit of their patients, colleagues, other healthcare professionals, and the institutions in which they practise. Doctors are well-positioned to identify areas for change that may lead to improvements in quality and safety, and their recommendations should be welcomed by hospitals and health authorities. Medical regulatory authorities (Colleges) have said it is appropriate for physicians to advocate in a responsible manner; however physicians must be aware that overzealous advocacy may disrupt the provision of care.
The CMPA suggests physicians consider the following when voicing their concerns and suggestions to their institutions:
Present concerns and arguments clearly and calmly.
To the greatest extent reasonable, work within the approved channels of communication.
Offer multiple options for consideration or possible solutions.
Use positive persuasion rather than an authoritative tone and disposition.
Develop proposals that are comprehensive, understandable, measurable, and accountable.
When appropriate include the perspective of other healthcare providers to help explain the issues and recommend options and solutions.
Approach the issue with transparency.
Identify and build on areas of consensus that unite parties, contributing to a collective process.
Remain open to dialogue and discussion, as solutions are often achieved through constructive exchanges.
As providers and champions of quality and safety, physicians can and should advance responsible solutions that result in tangible system improvements. Indeed, physicians have a professional obligation to support the effective delivery of care.
Physicians who have a leadership role in a healthcare organization, such as a chief of staff or clinical department leader, have duties that differ from those of a practising physician. As head of a department or chief of staff, a physician functions as an officer of the institution, carrying out the broad duties owed by the institution to patients. When dealing with medico-legal situations, the courts view a physician-leader as a representative of the institution.
Liability is engaged if officers fail to act reasonably in carrying out the duties assigned to them by legislation and hospital bylaws, or if they fail to intervene when they know, or ought to know, that a patient may come to harm without intervention.
Physician leaders also set the tone for quality improvement and show leadership by promoting safer patient care. Many physicians are seen as thought leaders in important quality and safety advances. Certainly, medical professionalism is demonstrated when physicians champion or participate in quality or safety improvement efforts. Physician leaders should assess their strengths and limitations and seek relevant training and professional development opportunities.
Physicians as champions of a just culture of safety and quality improvement
Physicians can advance and contribute to a just culture of safety (see the CMPA's Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and health care institutions), making the provision of safe care a core value in the practice environment. Physicians should champion a just culture, so that quality improvement becomes part of the healthcare organization's way of operating. A just culture encourages learning from adverse events and close calls to strengthen the system of care, and abandoning a "name and blame" mentality.
Where appropriate, physicians should also take part in systems-oriented quality improvement activities and encourage the sharing of lessons learned — both within and among healthcare institutions. Involvement in these activities will help to meet physicians' professional responsibilities to contribute to improved care and set the example for other healthcare providers to follow.
Professionalism and privacy in the electronic age
Physicians have administrative duties associated with their practice. This requires that they comply with privacy legislation, as it applies to print or electronic health records. In all cases, patient health information must be appropriately protected. While sharing information within the circle of care — that is the group of healthcare workers providing care to the patient — is generally permissible based on implied consent, disclosing information to individuals or organizations outside the circle of care often requires the patient's express consent, unless the disclosure is permitted by law.
Doctors who are unclear on whether they should access patient information should ask themselves whether they need the information to provide care to the patient, and whether they have the patient's implied or express consent to access the information. Generally, if the patient information is needed to provide care or the patient has expressly consented, it is reasonable for the provider to access and use that information.
In addition, physicians may find themselves wondering about their role in protecting patient health information from inappropriate use by others, potentially including provincial or regional health authorities. Physicians may perceive a conflict between their legal obligations to release information in specific cases, and their professional obligations to protect patients' personal health information. The bottom line for physicians is they should protect patients' personal health information and disclose it only with patient consent or as provided for by law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm to others or to the patients themselves.2
Doctors should also address the privacy requirements for the secondary use of health information, meaning information used for health system planning, to expand disease knowledge or to support public health goals. In these situations, Colleges typically recommend the use of safeguards to maintain the balance between public health needs and patient privacy.3Unless specified by legislation or regulation, the CMPA recommends doctors obtain patient consent when their health information will be disclosed to a third party outside the circle of care or where the information will be used for a purpose other than providing healthcare to the patient. Patient information that is used for purposes other than providing healthcare should not identify individual patients.
While not new concepts, privacy and confidentiality in a digital world raise particular challenges for physicians. Members are encouraged to read the CMPA's publication, "Privacy in a wired world — Protecting patient health information" for further insights.
A shared commitment to excellence
Professionalism also calls for physicians to remain accountable to each other for the safe provision of care. In fulfilling their duty to patients and to each other, doctors may find themselves having to report a physician colleague to a College, hospital, health authority, or public health official. Physicians may want to consult their provincial and territorial legislation or College policies on reporting. Medical professionalism requires that reporting be made in a timely manner, or immediately if patient safety is at risk or if a physician's health is compromised. The physician making the report must consider the safety of the community and the welfare of the physician being reported.
If appropriate, physicians should first speak with the other doctor about why a report is being made (such as for a health issue that impacts the safety of patients). The fact is that simply ignoring reportable situations may result in disciplinary proceedings or even legal action. Doctors should keep detailed records of any relevant information leading up to the report. The CMPA is available to provide advice to members facing these difficult situations or when reporting a colleague or another healthcare professional.
Obligations of self-regulation
As the regulatory authorities for physicians, Colleges have largely defined the nature of professionalism in medical care by enunciating how they expect physicians to conduct themselves. Physicians should understand and abide by the rules, regulations, and standards outlined by their College. Whether the matter pertains to registration, assessment, education, complaints and investigations, or discipline, physicians are expected to conduct themselves responsibly and professionally, and show support for an effective system of self-governance. Members who have been made aware of a complaint to their College should contact the CMPA for advice and guidance.
As part of self- or professionally-led regulation, physicians have an obligation to ensure they are healthy and able to provide safe and competent medical care. Physicians should disclose personal health information to Colleges in circumstances where it is required by law or when the physician consents to the disclosure because it is necessary to protect patient safety. In some cases, a physician's medical condition may require significant restrictions or limitations to practice, including the worst case scenario, preclusion from practice. The CMPA maintains that decisions of this magnitude should be made using evidence-based criteria that establish an acceptable level of risk. Medical professionalism demands that doctors follow any restrictions placed on their practice as a result of a medical condition. This assists in protecting both public safety and the integrity of the medical profession.
Professionalism in legal proceedings
Professionalism extends to the legal process, whether a physician is facing a legal action or is called upon to provide expert advice. Physicians should contact the CMPA as soon as possible after learning of a legal action naming them. A CMPA medical officer and the assigned legal counsel will guide the member through the process. Despite the anxiety associated with these situations, physicians are best served when they demonstrate professionalism and integrity throughout the process.
When called to give evidence as expert consultants, physicians' conduct and testimony reflect their professionalism. Physicians should be well-prepared, truthful, maintain their composure, and refrain from arguing. Increasingly, provinces and territories are enacting legislation that specifies that the expert owes a duty to the court, not to one or more of the parties to the legal action.
Whether they wish to undertake them or not, physicians inevitably have a variety of advocacy roles and should understand on whose behalf they are speaking. Few non-clinical issues pose more decision-making challenges than identifying the appropriate balance between advocacy for the needs of an individual patient versus the broader needs of society. For example, there is no clear answer about the extent to which a family physician should or should not advocate for a patient on a specialist's waiting list. Each situation requires judgment — judgment that can be supported by the physician's understanding of his or her professional obligations.
Physicians are central to helping establish and champion a just culture of safety. From time to time, this responsibility may bring physicians into potential conflict with institutional leadership or with some of their colleagues or other healthcare professionals. Professionalism requires physicians to be accountable to their patients and to society, as well as to each other, regardless of the difficult nature of the circumstances. Applying the key tenets of medical professionalism can assist physicians in dealing with these challenging situations.
The CMPA encourages physicians to support and advance medical professionalism in all it facets. When physicians are confronted with challenges that expose them to medico-legal risk or when their integrity and professionalism is called into question, CMPA members can be comforted in the knowledge the Association is available to help.
Canadian Medical Association. "The Evolving Professional Relationship Between Physicians and the Health Care System: Where do we Stand?" 2012. Retrieved on Sept. 14, 2012 from: http://www.cma.ca/index.php?ci_id=204661&la_id=1
Canadian Medical Association, "CMA Code of Ethics," 2004
College of Physicians & Surgeons of Alberta, "Data stewardship: Secondary use of health information," December 2009, p. 11. Retrieved on March 13, 2012 from: http://www.cpsa.ab.ca/Resources/advice.aspx