QMA Annual Day
On April 20, the QMA held its Annual Day around the theme of professionalism. On the agenda: the conclusions from the Québec/Canadian tours on professionalism, a presentation on the similarities between professional issues in the medical and legal fields, and an account of the Alberta medical community’s recent experiences.
Dr. Isabelle Samson opened by presenting the report from the consultations conducted during the QMA’s Medical Professionalism Tour. Two observations emerged from the many comments made by physicians, the first being that the dual role of caregiver and professional required by the medical profession seems to have been poorly integrated by many physicians.
Second, while most physicians consider the status quo to be untenable, few see themselves as part of the solution or as agents of change. For more information, consult a summary of the report or read the full report here.
Following Dr. Samson’s presentation, Dr. Laurent Marcoux, president of the Canadian Medical Association (CMA), discussed some related initiatives taking place within his organization.
Canada-wide initiatives to foster medical professionalism
According to Dr. Marcoux, professionalism is a fundamental value that “defines who we are and what we do, as well as our relationships with our colleagues and patients.” It is therefore not surprising that professionalism is top of mind in provincial and territorial medical associations across the country.
It is also what prompted the CMA to take steps to better define and promote medical professionalism. Last December, the CMA’s board of directors adopted a Charter of Shared Values that redefines the commitment of physicians to one another. The charter focuses on four key elements: respect, integrity, reciprocity and civility. “We achieve a higher degree of success when we work together and mutually believe in our work, when we make a common commitment and share a set of values, virtues and principles,” explained Dr. Marcoux.
Before the end of the year, the CMA will also present its Code of Ethics and Professionalism, based on its Code of Ethics, which itself is undergoing a major revision to reflect the realities of today’s society. The new code will highlight the virtues that are embodied by the medical profession and put into practice by physicians every day: compassion, honesty, humility, integrity, a moral conscience and trust.
The third element in the CMA’s professionalism platform is an accountability framework that will be unveiled later this year. It will remind physicians of the commitment they made to the medical system.
Dr. Marcoux made use of his visit to Montréal to remind all physicians of the importance of caring for their own health. According to the preliminary results of the CMA’s National Physician Survey:
- No less than 30% of practising and resident physicians report a high level of burnout;
- Almost 35% have been diagnosed with depression;
- The rate of suicidal ideation is close to 19%.
“We must support them in creating an environment where overwork can be avoided, and we also need to develop prevention tools,” explained Dr. Marcoux, with a reminder that the CMA’s very first Physician Health Policy was made public last fall. To conclude, the president called on physicians to commit to improving the network by acting as agents of renewal.
Physicians and lawyers: Facing the same challenges!
Associate professor in the Faculty of Law at Université Laval and lead researcher of the Axe Droit et politiques de la santé at the Centre de recherche en gestion des services de santé FSA-ULaval-CHU in Québec City, lawyer Anne-Marie Savard highlighted the similarities between the medical and legal professions.
Like physicians, lawyers are subject to a tacit social contract with the public. However, the model of the lawyer working alone or with partners and being accountable to no one but the client has had its day. In the past few years, we have witnessed the diversification of the legal profession and a bottleneck in the judicial system, which has been marked by a decline in judicial activity. Meanwhile, the number of lawyers has increased.
It should be mentioned that the judicial system no longer meets the needs of justiciables due to the length and cost of proceedings and to dissatisfaction with outcomes, “which has led to a loss of public confidence in judicial institutions and lawyers,” said Savard. Lawyers took note of this fact. Recognizing that justice is a public service, they accepted that they must do their part to apply sound management to legal proceedings, given that the institutions have limited resources.
Collectively, they took the necessary steps to regain the public’s trust. The Bar association lobbied to amend the Code of Civil Procedure in 2014, and a new version came into effect on January 1, 2016. The Code of Professional Conduct of Lawyers was also revised in 2015.
A cultural shift
Savard describes these changes as a cultural shift, within which lawyers had to change their way of working. By adopting the principle of proportionality in the Code of Civil Procedure, “they committed to informing their clients that there are other ways of resolving disputes than litigation (for example, negotiation, mediation and arbitration),” explained the professor. As a result, lawyers are less frequently in court. The new Code of Civil Procedure also incites lawyers to limit proceedings to what is necessary for the purposes of litigation and to work together under the principle of cooperation.
Under the new code of ethics, lawyers are no longer accountable only to their clients; they are also “servants of justice.” They must take into account accessibility to justice, they must facilitate cooperation for the effective administration of justice and to support the authority of the courts, and they must consider the social context within which the law operates. They must also “foster a relationship of trust between the public and the administration of justice.”
In Savard’s view, the context and the means employed to further the legal profession are comparable to those of physicians and the evolution of medical professionalism. As stated in the new Code of Ethics of Physicians, “A physician must collaborate with other physicians to maintain and improve the availability and quality of the medical services to which a clientele or a population must have access.” In other words, a cultural shift toward a more social role is required.
Reinvention is possible
Dr. Carl Nohr, past president of the Alberta Medical Association (AMA) and board member of the CMA, gave a presentation on the experience of the Alberta medical community, which has recently undergone a profound change in its relationship with the government and the public.
Having obtained an analysis of the breakdown of the social contract that closely resembled the QMA’s analysis, Dr. Nohr asked Annual Day attendees if there was a future for physicians, given the health network’s current challenges.
In his view, the medical profession cannot be separated from the society it serves, which grants it its “professional” status. Unfortunately, in recent years there has been a loss of compassion, availability, accountability, interest in public health and altruism—all of which form the basis of professionalism—by physicians.
This has led to a change in the way physicians are viewed by the public. Alberta faces the same access and availability issues as Québec. And while Alberta’s physicians may not have received the same pay increases as Québec’s physicians in recent years, the province’s annual health budget has risen by as much as 7.5% “for the sole reason that physicians kept increasing their workload,” which the province was no longer able to sustain. There has also been a flagrant lack of services in rural regions because growing numbers of physicians wish to practise in urban centres. Yet, “it is the responsibility of physicians to ensure physicians are available throughout the province,” stated Nohr.
“Out of basic compassion, they should adopt a ‘what’s good for the goose is good for the gander’ approach,” he stressed.
Understanding the value of productivity to the common good
In his former role of president of the AMA, Nohr took steps to explain to both physicians and the government that the status quo was not sustainable and that they had to work together to improve the situation. In his view, “trust is the basis of a productive relationship.” This applies to colleagues as well as patients. For the medical profession, this will have to begin with the realization that it cannot “remain a monopoly focused on its own interests.”
The solution is to go back to basics and provide inspiration rather than impose a particular viewpoint. For this to happen, there must be a common understanding that healthcare should revolve around the patient. Physicians must let go of the notions of providing care to and for the patient, and instead adopt an approach of working with the patient.
This type of awareness would be impossible without the understanding that productivity should not be measured in terms of the volume of patients that a physician can manage, but rather, the value of the care provided.
To achieve this, physicians must participate in the “judicious and conscientious” management of the resources entrusted to them.
Responsible management through collaboration
This is the responsible management approach Nohr attempted to implement during his presidency. It is an approach wherein the success of one depends on the success of the others and within which the individual is inseparable from the collective. It is one that is achieved through collaboration, not confrontation.
The AMA eventually came to an agreement with the government to resolve the two main issues in Alberta: (1) finding “the physicians we need to practise in rural regions and being able to send them there,” and (2) relying on appropriateness of care as a way to limit the increase in the healthcare budget, which physicians committed to reducing from 7.5% to 4%.
In response to a question from one of the Annual Day attendees, who wanted to know how Dr. Nohr had managed to convince 78% of AMA members that these reforms were necessary, Nohr explained, “I did my best to persuade them that it was in our best interests. When it comes down to it, if we can share a vision of what is possible, we can get everyone on board.”
To close the day, QMA president Dr. Hugo Viens stated that the report stemming from the consultations undertaken during the professionalism tour marked the beginning of a new process. “It’s clear that more than ever, physicians must develop a shared vision of their profession and commit to renewing the social contract,” he emphasized. Results from the tour indicated that physicians support the four avenues for action proposed by the QMA: leadership, professionalism, clinical governance and medical organization.
And although it is not yet clear to many physicians what form these actions will take, the fact that they believe in the process is “a step in the right direction,” according to Viens. It also signals to the QMA that it must continue to be proactive in facilitating the implementation of solutions and supporting the physicians who commit to them.
Developing a performance-oriented medical organization
Through its interactions with the other provinces, the QMA has recognized that the stakeholders who succeed in moving things in the right direction are those who take control of their medical organizations with a view to performance. Recent studies on the compensation of physicians have reached the same conclusions. Viens pointed out that “if we ignore the sociopolitical noise that surrounds them, these studies clearly demonstrate that performance within health networks is most strongly influenced by medical organization, not by our pay scales or misunderstood bonus systems, which are what get talked about the most!”
The QMA is already very committed to the development of medical leadership and will continue in this direction. Along with its members, it also intends to pursue its campaign against overdiagnosis and overmedication, which was initiated several years ago. Viens stressed the importance of continuing to educate physicians, decision makers and patients through training and tools, and of assisting local leaders who are taking steps to implement changes in practice that encourage relevance in their respective settings.
The role of physician executives—which is one of leadership—must be recognized as such by their physician colleagues and by the various clinical, administrative and governmental authorities. The QMA’s Physician Executives Group is an effective instrument in their continued promotion.
At present, however, the main focus is medical organization. Current frameworks do not allow physicians to work together. The medical community must learn to collaborate and the QMA intends to further this issue. The challenge is a real one and it may push the association to reinvent itself in order to mobilize the resources required to carry out the task.