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Commission on the Practice of Medicine in the 21st Century

New Professional Challenges for Physicians in the 21st Century

COLLÈGE DES MÉDECINS DU QUÉBEC

New Professional Challenges for Physicians in the 21st Century

Report and recommendations of the Commission on the Practice of Medicine in the 21st Century, together with commitments made by the Collège des médecins du Québec

21st Century, together with commitments made by the Collège des médecins du Québec COLLÈGE DES MÉDECINS

COLLÈGE DES MÉDECINS DU QUÉBEC

NOTE TO READERS

The following document is an abridged version of the original French text. The complete version, entitled Nouveaux défis pro- fessionnels pour le médecin des années 2000, which contains 280 pages, can be obtained by contacting the Collège’s Communications Department:

By mail:

2170 René-Lévesque Boulevard West Montréal, Québec H3H 2T8

By telephone: (514) 933-4441 or 1-888-MÉDECIN (local 206)

By fax:

(514) 933-3112

By E-mail:

info @ cmq.org

FOREWORD

In the spring of 1996, the health care system was struggling with unprecedented budget constraints which resulted in extremely difficult organizational decisions, including the closure of many hospitals, the merging of various establishments and the vaunted shift to ambulatory care. This situation led sometimes perturbed physicians to question the Collège about the consequences that these measures would have on their professional prac- tice. Some expressed their concern about the very future of medicine in Québec. The Collège was also dealing with the proposed reform of the professional sys- tem, which advocates the elimination of exclusive practice and the determina- tion of activities reserved to various types of professional. It was therefore in this ambiance of constraints and expected reform that the idea of a Commis- sion on the Practice of Medicine in the 21st Century began to develop during my annual regional tour of Québec. It became imperative for us to set up a spe- cial group that would study and reflect on what lay ahead for medical practice, and define the roles of family physicians, medical specialists and other health care professionals at the dawn of the third millenium.

In June 1996, the Collège challenged a group of physicians from various disci- plines and with various types of expertise, residents and medical students, as well as other health care professionals to build a composite of what medicine will be tomorrow. The Commission’s final report received an enthusiastic wel- come from Bureau members and, on October 15, 1997, they unanimously adopted the 10 priority commitments made by the Collège based on the Com- mission’s recommendations.

Now, it is time to act. The Collège intends to give its commitments concrete form during the coming months and years, working together with its partners and the various bodies and/or groups concerned.

We trust that the reference points contained in this document will bring together those who believe in adjusting to the inescapable changes that affect us as pro- fessionals. And, above all, that they will help us all meet the many challenges looming on the horizon, so that we may continue to provide Quebecers with quality service.

the horizon, so that we may continue to provide Quebecers with quality service. Roch Bernier, M

Roch Bernier, M.D. President

MEMBERS OF THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY

Dr. Joseph Ayoub

Oncologist Hôpital Notre-Dame, Montréal President of the Commission

Dr. Claude Bélisle

Family Physician Centre de santé Drummondville

Dr. Josée Caron

General Surgeon Centre hospitalier Jeffery Hale Québec City

Dr. Pierre Duplessis

Assistant General Secretary Collège des médecins du Québec Secretary to the Commission

Ms. Julie Germain

Medical Student University of Sherbrooke

Dr. Paul Grand’Maison

Family Physician Director, Health Sciences Education Centre University of Sherbrooke

Dr. Charles Guertin

Surgery Resident I Fédération des médecins résidents du Québec

Mr. Benoît Lauzière

Representative of the public appointed to the Bureau of the Collège des médecins du Québec School executive

Dr. Paule Lebel

Community Health Medical Specialist Centre hospitalier Côte-des-Neiges Montréal

Dr. Sandra Palmieri

Community Health Resident V

Ms. Odette Plante Marot

Nurse Hôpital Saint-Luc, Montréal

Ms. Céline Plourde

Pharmacist Pharmacie Céline Plourde Saint-Léonard-d’Aston

With the collaboration of:

Ms. Monique Chaput

Adult Education Expert Collège des médecins du Québec Coordinator and facilitator of the Commission’s work, author of the report

ACKNOWLEDGMENTS

The members of the Commission wish to thank all those persons and organizations who agreed to meet with them, and also all those who directly contributed to the study of the various themes or writing the texts. They also acknowledge the approximately 150 persons and organizations who answered the consultation questionnaires or sent notes, comments, documents, etc.

The Commission also wishes to thank all the directors and executive physicians of the Collège des médecins du Québec who assisted during the consultation phase. Particular thanks also go to Dr. Chantal Archer and Ms. Lorraine Locas, research agents, and Mesdames Céline Bastien, Christiane Beaudoin, Denise Chrétien, Hélène Landry and Nicole Leduc Crête who, in their various capacities, supported the Com- mission so efficiently during its work.

Finally, the members of the Commission wish to express their most sincere grati- tude to Ms. Monique Chaput for her work in coordinating operations and facilitat- ing the Commission’s meetings, as well as for writing the consultation document texts and drawing up the final report.

EXPERTS WHO MET WITH COMMISSION MEMBERS

Docteur Renaldo N. Battista Professeur titulaire Faculté de médecine, Université McGill Président du Conseil d’évaluation des technologies de la santé

Monsieur le juge Jean-Louis Baudouin Cour d’appel du Québec

Monsieur Gilles Dussault Professeur titulaire Département d’administration de la santé Faculté de médecine, Université de Montréal

Monsieur Claude Forget Conseiller CEF Ganesh Corporation

Docteur André Munger Médecin de famille CLSC SOC, Sherbrooke

Monsieur Jean Paré Président et rédacteur en chef L’actualité (magazine mensuel, Montréal)

Monsieur Norbert Rodrigue Président Conseil de la santé et du bien-être du Québec

Monsieur David J. Roy Directeur Centre de bioéthique Institut de recherches cliniques de Montréal

Monsieur Yves Séguin Directeur général délégué aux affaires canadiennes Compagnie générale des eaux

ORGANIZATIONS WHICH MET WITH COMMISSION MEMBERS

Conseil médical du Québec

Fédération des médecins omnipraticiens du Québec

Fédération des médecins spécialistes du Québec

NOUVEAUX DÉFIS PROFESSIONNELS POUR LE MÉDECIN DES ANNÉES 2000

PERSONS CONSULTED WHEN THEMES WERE BEING STUDIED OR TEXTS WRITTEN

Docteur Marie-Dominique Beaulieu Médecin de famille Hôpital Notre-Dame, Montréal

Monsieur Jean-Pierre Bélanger Conseiller Conseil de la santé et du bien-être du Québec

Docteur Howard Bergman Chef de la division de gériatrie Hôpital général juif Sir M.B. Davis et Université McGill, Montréal

Docteur Roch Bernier Président Collège des médecins du Québec

Docteur Lucie Brazeau-Lamontagne Secrétaire et vice-doyenne Faculté de médecine Université de Sherbrooke

Docteur Suzanne Brissette Médecin de famille Hôpital Saint-Luc, Montréal

Docteur Julie Bruneau Médecin de famille Hôpital Saint-Luc, Montréal

Monsieur Yvon Brunelle Agent de recherche Direction générale de la recherche et de l’évaluation Ministère de la Santé et des Services sociaux

Monsieur Claude Castonguay Vice-président du Conseil Banque Laurentienne

Docteur Louise Charbonneau Microbiologiste médicale CLSC des Faubourgs, Montréal

Docteur Réal Cloutier Médecin-conseil Régie régionale de la santé et des services sociaux Chaudière-Appalaches

Docteur Christine Collin Sous-ministre adjointe Direction générale de la santé publique Ministère de la Santé et des Services sociaux

Docteur Michel Côté Cardiologue Centre universitaire de santé de l’Estrie Sherbrooke

Docteur Adrien Dandavino Directeur Direction des études médicales Collège des médecins du Québec

Docteur Serge Daneault Médecin-conseil Direction de la santé publique Régie régionale de la santé et des services sociaux de Montréal-Centre

Docteur Geneviève Dechêne Médecin de famille Clinique médicale de l’Ouest, Verdun

Docteur Jocelyn Demers Hématologue-oncologue Hôpital Sainte-Justine, Montréal

Maître Pierre Deschamps Directeur de la recherche Centre de recherche en droit privé et comparé de l’Université McGill

Monsieur Jean-Claude Deschênes Conseiller en administration et en formation Ministère de la Santé et des Services sociaux

Docteur Gilles Desrosiers Médecin-conseil Régie régionale de la santé et des services sociaux de l’Estrie

Madame Sylvie Dillard Sous-ministre adjointe Direction générale de la planification et de l’évaluation Ministère de la Santé et des Services sociaux

Monsieur Hubert Doucet Professeur invité Facultés de médecine et de théologie Université de Montréal

Monsieur Guy Durand Professeur et directeur du DESS en bioéthique Faculté de théologie, Université de Montréal

Monsieur Jacques Gagné Pharmacien Laboratoire de recherche pharmaceutique inc., Laval

Docteur André Garon Médecin-conseil Conseil de la santé et du bien-être du Québec

Madame Marjolaine Gobeil Directrice Planification et développement professionnel Ordre des infirmières et infirmiers du Québec

Père Robert Hivon, jésuite Expert en bioéthique, Montréal

NOUVEAUX DÉFIS PROFESSIONNELS POUR LE MÉDECIN DES ANNÉES 2000

Docteur Gilles Hudon Président Association des radiologistes du Québec

Docteur Juan Roberto Iglesias Président Conseil médical du Québec

Monsieur Roger Jacob, ing., M.Sc.A. Directeur-adjoint Direction des ressources financières et des services techniques Hôpital du Sacré-Cœur de Montréal

Docteur André Jacques Directeur Direction de l’amélioration de l’exercice Collège des médecins du Québec

Docteur Denis Laberge Directeur adjoint Direction de l’amélioration de l’exercice Collège des médecins du Québec

Monsieur Daniel Lacasse Directeur régional de la santé physique Régie régionale de la santé et des services sociaux de l’Outaouais

Madame Michèle Lamquin-Éthier Directrice générale Comité provincial des malades

Docteur Bernard Lapointe Médecin de famille Soins palliatifs, Hôpital Royal Victoria Montréal

Docteur Yvon-Jacques Lavallée Psychiatre Centre universitaire de santé de l’Estrie Sherbrooke

Docteur Guy Legros Directeur adjoint Direction des études médicales Collège des médecins du Québec

Docteur Richard Lemieux Médecin-conseil Conférence des régies régionales de la santé et des services sociaux du Québec

Docteur Pauline Lesage-Jarjoura Santé communautaire, Faculté de médecine Université de Sherbrooke

Docteur Joëlle Lescop Secrétaire générale Collège des médecins du Québec

Docteur Georges L’Espérance Neurochirurgien Centre médical René-Laënnec, Montréal

Docteur Richard Lessard Directeur Direction de la santé publique Régie régionale de la santé et des services sociaux de Montréal-Centre

Docteur Laurent Marcoux Médecin de famille Centre médical Saint-Denis Saint-Denis

Docteur Claude Mercure Directeur Direction des enquêtes Collège des médecins du Québec

Docteur Clément Olivier Médecin de famille Saint-Hippolyte

Docteur Marie-France Raynault Médecin-conseil Régie régionale de la santé et des services sociaux de Montréal-Centre

Docteur Nicolas Steinmetz Directeur général associé Groupe de planification, Centre universitaire de santé de l’Université McGill

Docteur Michel Tétreault Président Groupe tactique d’intervention Ministère de la Santé et des Services sociaux

Docteur Jean-Bernard Trudeau Directeur des services professionnels Centre hospitalier Pierre-Janet, Hull

REGIONAL BOARDS, REGIONAL MEDICAL COMMISSIONS AND PHYSICIANS GROUPS MET DURING THE VISIT BY THE PRESIDENT OF THE COLLÈGE TO THE FOLLOWING REGIONS:

– Abitibi-Témiscamingue

– Bas-Saint-Laurent

– Chaudière-Appalaches

– Côte-Nord

– Estrie

– Gaspésie–Îles-de-la-Madeleine

– Lanaudière

– Laurentides

– Laval

– Mauricie–Bois-Francs

– Montérégie

– Montréal-Centre

– Outaouais

– Québec

– Saguenay–Lac-Saint-Jean

NOUVEAUX DÉFIS PROFESSIONNELS POUR LE MÉDECIN DES ANNÉES 2000

PERSONS AND ORGANIZA- TIONS WHO MADE WRITTEN CONTRIBUTIONS DURING THE CONSULTATION PHASE 1

Docteur Youssef Ainmelk Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur Diane Amyot Directrice des services professionnels Centre Frédérick-George-Hériot Drummondville

Docteur Christiane Arbour Coordonnatrice du programme en santé physique et des services préhospitaliers d’urgence Régie régionale de la santé et des services sociaux des Laurentides

Docteur Jean-Louis Bard Président Association des conseils des médecins, dentistes et pharmaciens du Québec

Docteur Jacques Beaudry Médecin de famille Trois-Rivières

Monsieur Claude Beauregard Directeur général Conseil interprofessionnel du Québec

Docteur Marc Bellemare Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur Charles Bernard Vice-président Collège des médecins du Québec

Docteur Louis Bernard Directeur Département de médecine sociale et préventive, Université Laval

Docteur Harold Bernatchez Président Association des médecins microbiologistes infectiologues du Québec

Docteur Sylvie Bernier Directrice Services professionnels Hôtel-Dieu de Lévis

Docteur Gilbert Blain Directeur des services professionnels Institut de réadaptation de Montréal

1. A number of people who helped with the Commission’s study of the various themes or the writing of texts also forwarded their written comments. Their names are not repeated here.

Docteur Francine Blais Obstétricienne-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur Luc Boileau Médecin-conseil Régie régionale de la santé et des services sociaux de la Montérégie

Docteur Robert Boileau Président Association des pneumologues de la province de Québec

Docteur Myriam Boillat Directrice du programme de résidence Département de médecine familiale, Université McGill

Docteur Henri-Louis Bouchard Chirurgien orthopédique Centre hospitalier universitaire de Québec

Docteur Laurier Bouchard Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Monsieur Laurier Boucher Président Ordre professionnel des travailleurs sociaux du Québec

Docteur Claude Brière Anesthésiste Victoriaville

Docteur Placide Caron Médecin de famille Val-Brillant

Docteur Aurélien Carré Administrateur Bureau du Collège des médecins du Québec

Docteur Pierre Carrier Directeur des services professionnels Centre hospitalier Saint-Joseph de la Malbaie

Docteur Simon Carrier Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Monsieur François Charbonneau Secrétaire et directeur général Ordre des optométristes du Québec

Madame Louise Chartier Directrice Département des sciences infirmières Faculté de médecine Université de Sherbrooke

Docteur Hélène Chénard Obstétricienne-gynécologue Association des obstétriciens et gynécologues du Québec

Monsieur Lionel Chouinard Directeur général Régie régionale de la santé et des services sociaux Chaudière-Appalaches

Docteur Pierre Côté Médecine de famille Clinique médicale du Quartier latin Montréal

Docteur Jean-Pierre Courteau Médecin-conseil Régie régionale de la santé et des services sociaux de l’Outaouais

Docteur Linda Daigneault Médecin de famille Montréal

Docteur Michelle Dallaire Professeur Programme de médecine de famille Faculté de médecine Université de Montréal

Docteur Wilber Deck Médecin-conseil Régie régionale de la santé et des services sociaux Gaspésie–Îles-de-la-Madeleine

Docteur Donald Delisle Médecin de famille Bromptonville

Docteur Michel Desjardins Directeur des services professionnels Hôtel-Dieu de Gaspé

Docteur Jean De Serres Médecin de famille Chelsea

Docteur Jean-Pierre Despins Président Association des médecins omnipraticiens des Bois-Francs

Monsieur Denis Drouin Administrateur Bureau du Collège des médecins du Québec

Madame Anne Du Sault Agente de programme en santé physique Régie régionale de la santé et des services sociaux de l’Outaouais

Docteur Claude Duguay Administrateur Bureau du Collège des médecins du Québec

Docteur Louise Duperron Administratrice Bureau du Collège des médecins du Québec

Monsieur Jean-Pierre Duplantie Directeur général Régie régionale de la santé et des services sociaux de l’Estrie

Docteur Louise Duranceau Présidente Association des spécialistes en chirurgie plastique et esthétique du Québec

Docteur Renald Dutil Président Fédération des médecins omnipraticiens du Québec

NOUVEAUX DÉFIS PROFESSIONNELS POUR LE MÉDECIN DES ANNÉES 2000

Docteur Alex Ferenczy Administrateur Bureau du Collège des médecins du Québec

Docteur Raynald Ferland Président Association d’oto-rhino-laryngologie et de chirurgie cervico-faciale du Québec

Docteur France-Laurent Forest Président Commission médicale régionale Régie régionale de la santé et des services sociaux Gaspésie–Îles-de-la-Madeleine

Docteur Claude Fortin Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur Jean-Claude Gagné Directeur général Centre hospitalier de la région de l’Amiante

Docteur Jeannine Gagné Médecin de famille Centre hospitalier Saint-Eustache

Docteur Richard Gagné Administrateur Bureau du Collège des médecins du Québec

Monsieur Gilbert Gagnon Président Ordre des technologues en radiologie du Québec

Docteur Louis Gagnon Secrétaire Programme santé – Acti-Menu

Monsieur Claude Garon Directeur général CLSC de Jonquière

Docteur Pierre Gaudreault Président Association des pédiatres du Québec

Docteur Pierre Gauthier Président Fédération des médecins spécialistes du Québec

Docteur Pierre Gfeller Médecin de famille Centre hospitalier et Centre de réadaptation Antoine-Labelle

Madame Laurie Gottlieb Directrice École des sciences infirmières Université McGill

Docteur Jean Grégoire Médecin-conseil Régie régionale de la santé et des services sociaux Chaudière-Appalaches

Docteur Yves Grenier Interniste Beauport

Docteur Yves Grenier Médecin de famille Montréal

Docteur Jean-Pierre Jannelle Médecin de famille CLSC de La Pommeraie

Docteur Claude Laberge Médecin de famille Ville-Marie

Docteur Philippe Laberge Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur Renée Lafrenière Omnipraticienne Équipe de santé mentale CLSC Huntingdon

Docteur Yves Lamontagne Administrateur Bureau du Collège des médecins du Québec

Docteur Joris Lapointe Médecin de famille Mini-Urgences, Jonquière

Monsieur Raymond Leblanc Directeur scientifique Fonds de la recherche en santé du Québec

Docteur Hélène Leclère Directrice Bureau de pédagogie des sciences de la santé, Université Laval

Docteur Yolande Leduc Vice-présidente Association des omnipraticiens en périnatalité du Québec

Docteur Francine Léger Présidente Collège québécois des médecins de famille du Canada

Monsieur Michel Léger Directeur général Régie régionale de la santé et des services sociaux des Laurentides

Docteur François Lemieux Président Association des omnipraticiens en périnatalité du Québec

Docteur Denis Lepage Administrateur Bureau du Collège des médecins du Québec

Docteur Pierre Loiselle Médecin de famille Clinique médicale Montée de la Baie

Docteur France Lussier Médecin-conseil Régie régionale de la santé et des services sociaux de Lanaudière

Docteur Michelle Lussier-Montplaisir Administratrice Bureau du Collège des médecins du Québec

Docteur Pierre Mailloux Psychiatre Trois-Rivières

Docteur Lucie Marchand Médecin de famille Magog

Docteur Hubert Marcoux Responsable du programme d’éthique Études postgraduées, Faculté de médecine, Université Laval

Docteur André Massé Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur Yvon Ménard Médecin de famille Longueuil

Monsieur François Mercier Directeur général Régie régionale de la santé et des services sociaux de l’Abitibi- Témiscamingue

Madame Lucie Merola Secrétaire Chambre des huissiers de justice du Québec

Docteur Bernard Millette Médecin de famille Cité de la Santé de Laval

Monsieur Magella Morasse Président Ordre des ingénieurs forestiers du Québec

Docteur Claude Morin Médecin de famille Havre-Aubert

Docteur Louise Nasmith Directrice Département de médecine familiale Université McGill

Ordre des acupuncteurs du Québec

Docteur Michel Paquin Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur Pierre Paquin Anesthésiste Sainte-Agathe-des-Monts

Docteur Krystyna Pecko Directrice du secrétariat aux affaires médicales Régie régionale de la santé et des services sociaux de la Montérégie

Docteur Michèle Pelletier Médecin de famille Saint-Jérôme

Docteur Sonia Péloquin Médecin de famille CLSC de La Pommeraie

Docteur France Perron Médecin de famille Lac-Mégantic

NOUVEAUX DÉFIS PROFESSIONNELS POUR LE MÉDECIN DES ANNÉES 2000

Docteur Gilles Pineau Président Programme santé – Acti-Menu

Docteur Benoît Poulin Médecin de famille Hôpital Louis-H.-Lafontaine

Madame Maya Raic Administratrice Bureau du Collège des médecins du Québec

Docteur Gilles P. Raymond Professeur titulaire de clinique Faculté de médecine Université de Montréal

Docteur Michel Rheault Chirurgien Trois-Rivières

Docteur Jean Rochon Ministre de la Santé et des Services sociaux Gouvernement du Québec

Docteur Jean Rodrigue Directeur de la planification et de la régionalisation Fédération des médecins omnipraticiens du Québec

Docteur Peter Roper Psychiatre Montréal

Docteur Claude Roy Pédiatre et gastroentérologue Hôpital Sainte-Justine, Montréal

Monsieur Jean-Marc Roy Président Fédération québécoise des centres d’hébergement et de soins de longue durée

Monsieur Jean-François Sénéchal Régie régionale de la santé et des services sociaux Gaspésie–Îles-de-la-Madeleine

Monsieur Marcel Sénéchal Directeur général Conseil québécois d’agrément d’établissement de santé et des services sociaux

Docteur Vyta Senikas Présidente Association des obstétriciens et gynécologues du Québec

Docteur Pierre Shebib Médecin de famille CLSC J.-Octave-Roussin

Docteur Gérald Stanimir Obstétricien-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur André Tanguay Médecin de famille Laval

Docteur Lorraine Therrien-Saillant Directrice des services professionnels Centre hospitalier de l’Archipel

Docteur Jean-Bernard Trudeau Vice-président Conseil de la santé et du bien-être du Québec

Docteur Manon Turbide Obstétricienne-gynécologue Association des obstétriciens et gynécologues du Québec

Docteur Michel Turgeon Médecin de famille Rouyn-Noranda

Docteur Raymonde Vaillancourt Présidente Sous-comité de périnatalité de la Fédération des médecins omnipraticiens du Québec

Docteur Julien R. Veilleux Directeur Services professionnels Hôpital Laval, Québec

Docteur Patrick Vinay Doyen Faculté de médecine Université de Montréal

Docteur Natacha Vincent Médecin de famille CLSC du Val-Saint-François

Docteur Karl Weiss Secrétaire Association des médecins microbiologistes infectiologues du Québec

NOTE

TO READERS

WORD

 

2

3

4

5

11

TABLE OF CONTENTS

13

18

 

19

INTRODUCTION

20

13

21

22

REPORT OF THE COMMISSION ON THE PRACTICE OF MEDICINE

22

 

IN THE 21ST CENTURY

 

18

22

PREAMBLE

24

19

25

CHAPTER 1

26

Evolving Professional Roles for Physicians in the 21st Century

27

20

Introduction

EFFECTIVE SCIENTIFIC CLINICIAN 27

21

1.

The Evolution of Medical Practice

22

HUMANISTIC PROFESSIONAL 28 LEARNER 29

Expanding Body of Knowledge and the Explosion of Technology

22

The Changing Sociocultural and Political Climate

COMMUNICATOR 29

22

Changing the Organizational Framework of Health Care Delivery

TEAM PLAYER 30

24

2.

Roles, Duties and Organization of Work for Physicians

MANAGER 31

in the 21st Century

LEADER IN THE COMMUNITY 31

25

Key Organizations Define the Roles of 21st-Century Physicians

RESEARCHER AND TEACHER 32

26

The Physician’s Roles as seen by The Commission on the Practice of Medicine in the 21st Century Effective Scientific Clinician Humanistic Professional

33

34

35

27

27

28

 

Learner Communicator Team Player Manager Leader in the Community Researcher and Teacher

35

29

36

29

37

30

38

31

31

39

32

3.

Complementarity of Professional Roles

40

33

The Family Physician

42

33

The Medical Specialist

45

34

Relations Between Family Physicians and Medical Specialists

47

35

Relations with Other Professionals

 

36

48

Conclusion

50

37

Bibliography

52

38

54

55

57

 

59

 

61

63

65

66

FORE-

MEM-

AC-

TABLE

INTRO-

PRE-

INTRO-

1.

EX-

THE

2.

KEY

THE

BERS OF THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY

KNOWLEDGMENTS

OF CONTENTS

DUCTION

Report of the Commission on the Practice of Medicine in the 21st Century

AMBLE

Chapter 1: Evolving

Professional Roles for Physicians in the 21st Century

DUCTION

THE EVOLUTION OF MEDICAL PRACTICE

PANDING BODY OF KNOWLEDGE AND THE EXPLOSION OF TECHNOLOGY

CHANGING SOCIOCULTURAL AND POLITICAL CLIMATE CHANGING THE ORGANIZATIONAL FRAMEWORK OF HEALTH CARE DELIVERY

ROLES, DUTIES AND ORGANIZATION OF WORK FOR PHYSICIANS IN THE 21ST CENTURY

ORGANIZATIONS DEFINE THE ROLES OF 21ST-CENTURY PHYSICIANS

PHYSICIAN’S ROLES AS SEEN BY THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY

3.

THE

THE

RELA-

RELA-

CON-

BIBLI-

COMPLEMENTARITY OF PROFESSIONAL ROLES

FAMILY PHYSICIAN

MEDICAL SPECIALIST

TIONS BETWEEN FAMILY PHYSICIANS AND MEDICAL SPECIALISTS

TIONS WITH OTHER PROFESSIONALS

CLUSION

OGRAPHY

Summaries of the Chapters

REC-

REC-

REC-

REC-

REC-

REC-

REC-

and Recommendations

Chapter 1: Evolving Professional Roles for Physicians in the 21st Century

OMMENDATIONS

Chapter 2: Toward an Ethic of Shared Responsibility in a Pluralistic Society

OMMENDATIONS

Chapter 3: Vulnerable Clienteles: Modes of Support and Care

OMMENDATIONS

Chapter 4: Prevention and Health Promotion: Its Importance and Impact on 21st-Century Medicine

OMMENDATIONS

Chapter 5: The Organization of Health Care and Health Services

OMMENDATIONS

Chapter 6: Funding the Health Care System

OMMENDATIONS

Chapter 7: The Impact of Technology on 21st-Century Medicine

OMMENDATIONS

Commitments of the Collège des médecins du Québec

TABLE OF CONTENTS

SUMMARIES OF THE CHAPTERS AND RECOMMENDATIONS

39

Chapter 1 Evolving Professional Roles for Physicians in the 21st Century

40

SUMMARY

40

RECOMMENDATIONS

42

Chapter 2 Toward an Ethic of Shared Responsibility in a Pluralistic Society

45

SUMMARY

45

RECOMMENDATIONS

47

Chapter 3 Vulnerable Clienteles: Modes of Support and Care

48

SUMMARY

48

RECOMMENDATIONS

50

Chapter 4 Prevention and Health Promotion: Its Importance and Impact on 21st-Century Medicine

52

SUMMARY

52

RECOMMENDATIONS

54

Chapter 5 The Organization of Health Care and Health Services

55

SUMMARY

55

RECOMMENDATIONS

57

Chapter 6 Funding the Health Care System

59

SUMMARY

59

RECOMMENDATIONS

61

Chapter 7 The Impact of Technology on 21st-Century Medicine

63

SUMMARY

63

RECOMMENDATIONS

65

COMMITMENTS OF THE COLLÈGE DES MÉDECINS DU QUÉBEC

66

INTRODUCTION

In June 1996, the Collège des médecins du Québec set up a task force to reflect upon what might comprise the prac- tice of medicine in the 21st century. The members of the Bureau wanted to see an examination of the prospects for the practice of medicine in Québec, the major changes the profession might expect and the measures that might be taken immediately to contend with tomorrow’s realities.

TERMS OF REFERENCE

The Commission on the Practice of Medicine in the 21st Century was entrusted with a mandate to:

review the role and functions of the general practitioner, notably medi- cal management and follow-up care in the context of the transforma- tion of health care;

review the role and functions of the medical specialist, particularly as a consultant, and to define the conditions of practice specific to them;

identify more clearly the collaboration of other health professionals in health care delivery within the context of medicine in the 21st century.

THEMES

The commissioners were faced with an ambi- tious task. Taking stock of the content, the scope, and the variety of topics related to their mandate, they decided to define the topics they wished to study in depth, and then determine the course to follow in documenting each of them.

The members of the Commission split into small working committees, each corresponding to one of the topics selected. Each committee then devel- oped an inventory of the relevant literature, and met with different experts and representatives of various agencies. Eleven experts were heard and questioned at plenary sessions of the commissioners 1 . Given the speed of change, indeed of veritable transformation, and the difficulty of extrapo- lating beyond certain limits, the Commission’s forecasts, while at first

1. The experts met with by all members of the Commission are listed on page 5.

INTRODUCTION

extending 15 to 20 years into the future, were soon narrowed down to five or ten years.

At the beginning of 1997, each working committee summarized its work in a text, and the major issues and various statements were discussed at plenary sessions by all members of the Commission. Finally, the reflections of the committees, coupled with the wide range of opinions and positions adopted during the plenary sessions, became the raw material for the texts written in the spring of 1997 and circulated during the consultation phase.

The Commission therefore discharged its mandate by translating it into

seven topics for study, which are the subjects of the seven chapters in this report:

1. Evolving professional roles for physicians in the 21st century;

2. Toward an ethic of shared responsibility in a pluralistic society;

3. Vulnerable clienteles: modes of support and care;

4. Prevention and health promotion: its importance and impact on 21st- century medicine;

5. The organization of health care and health services;

6. Funding the health care system;

7. The impact of technology on 21st-century medicine.

CONSULTATION

An important consultation phase took place be- tween February and August 1997. Over 3000 copies of the Commission’s consultation paper were circulated. A questionnaire for each text in the document allowed those consulted to express their level of agreement with the main assertions and make comments. These seven questionnaires, as well as the seven consultation texts, were also available on the Internet at the Collège des médecins du Québec’s address.

As the president of the Collège conducted his annual tour into virtually all regions of Québec, he was joined by the members of the Commission, in turn. This gave them an opportunity to speak to regional board represen- tatives and to regional medical commissions and, above all, to listen to them. Furthermore, in every region visited, all physicians were invited to attend a meeting organized especially for them. Opinions and reactions were regis- tered on site, while written comments from regional authorities and physi- cians were also solicited to be submitted by mail.

INTRODUCTION

Added to the Québec-wide tour were meetings with key organizations, and internal consultations with the physicians who make up each of the three Divisions of the Collège des médecins du Québec. In addition, requests for written comments were addressed to persons designated as “selected dis- cussants”.

Overall, more than 300 organizations, dozens of experts and numerous members of the medical profession were heard during the consultation phase, and they did indeed considerably expand the thinking of the Com- mission. Two subsequent meetings enabled the Commissioners to review, confirm or modify their positions with a view to writing the final text of their report and formulating recommendations relative to each topic.

FINAL REPORT

Seven Topics, Seven Chapters

The Commission received its mandate from the Bureau of the Collège des médecins du Québec whose mission is to promote quality medicine in order to protect the public and improve the health of Quebecers. This is the per- spective from which the Commission examined certain hotly debated issues, such as the funding of health care and services. The viewpoints from which they were analysed are in keeping with the mission of the Collège des médecins and the mandate of the Commission.

Each topic, given its complexity and importance, could have been the sub- ject of a detailed and voluminous monograph. The Commission therefore decided to address what it felt were the most sensitive aspects from the viewpoint of evolving medical practice in the coming years, and to develop the topics in succinct fashion only, limiting each chapter to 15 or 20 pages. Thus, it wishes to make available to the clinician, who is often very busy, a summary of present thinking on topics relevant to the practice of the pro- fession and an overview of foreseeable trends in the medium term, all of it linked to brief historical elements. With a bibliography at the end of every chapter (French version only), readers, if they so wish, may consult the documents which inspired the thinking in the report.

It quickly became evident, as the commissioners held their meetings, that the patient and the patient-physician relationship were the prime reference points essential to the issue of medical practice in the 21st century. This is

INTRODUCTION

why in this report, after the evolving roles of physicians are examined, at- tention is focused on ethics, vulnerable clienteles and prevention and health promotion activities. These are followed by reflections on the organization of health care and health services, funding and technology, which in fact are ways and means of creating a framework and support system for pa- tient care and the patient-physician relationship.

Appendix: An Overview of Certain Health Problems

In addition to their reflections and recommendations on the seven topics, the commissioners have included in their report a document entitled “A Brief Look at Certain Health Problems in the 21st century” (French version only). This document was prepared very differently.

As the commissioners carried out their mandate, they constantly searched for identifiable trends in the evolution of certain major health problems in the years ahead; these would then serve as a context for their prospective work. For every problem listed, they called upon expert physicians, some- times bringing together the clinician and the community health physician, from whom they requested a quick-reference sheet on the question.

Here again, the Commission did not wish to publish an exhaustive treatise on any given health problem, but a summary of the main points concerning anticipated developments five to eight years down the road, the effects of the disease, its prevalence, and the diagnostic, therapeutic and rehabili- tation means used, if applicable. This quick-reference approach, while it allows one to absorb a lot of information at a glance, is admittedly not grati- fying and does not do justice to the knowledge and reputation of the au- thors. As a matter of fact, when the report was prepared for publication, some of the material, as well as the bibliographic references, had to be re- moved, since the texts were too long.

COMMISSION’S RECOMMENDATIONS

For each topic, the members of the Commission developed a number of recommendations addressed to the Collège des médecins du Québec. With these recommendations, the commissioners address the Collège directly, and propose concrete courses of action to effect the changes to be made in the coming years.

INTRODUCTION

COMMITMENTS OF THE COLLÈGE

The Commission’s recommendations were ta- bled with the Bureau, and a day of reflection which brought together the executive members of the Collège and the Bureau’s directors enabled eve- ryone to discuss them carefully and prepare the commitments to be made by the Collège in their regard. Entitled “Commitments of the Collège des médecins du Québec”, the text resulting from this process and officially approved by the Bureau makes up the last section of this document. The Collège is now in a position to develop an action plan for the next three years as a follow-up to the work of the Commission on the Practice of Medi- cine in the 21st Century. Thus, the Commission’s in-depth reflection pro- cess will have a logical and concrete outcome.

R eport

of the Commission on the Practice of Medicine in the 21st Century

PREAMBLE

The Commission on the Practice of Medicine in the 21st Century will have a tangible impact on this 150th anniversary year of the Collège des médecins du Québec thanks to the texts and quick-reference sheets contained in this report. We believe that these should be considered as refer- ence points which should be revisited from time to time during the coming years. We hope that they will clarify some of the new professional challenges that physicians will have to face in the 21st century, stimulate and guide the search for solutions, instill the courage to deal with change, measure the divide be- tween today and tomorrow and, maybe, provide an element of continuity.

We believe that the various texts stand by themselves, independently of the rec- ommendations to which our work has given rise, and that, for the Collège des médecins du Québec and all members of the medical profession, they repre- sent modest yet solid, stimulating markers on the road to the future.

The conclusions we reached during this exciting work are now submitted to our readers for consideration. It is our sincere hope that they will prove useful to physicians, other health care professionals and administrators, and will en- able them to form the partnerships that are necessary to us as we stand on the threshold of a new century if we are to ensure that Quebecers receive the very best in health care and services.

Commissioners,

the very best in health care and services. Commissioners, Joseph Ayoub, M.D. President of the Commission

Joseph Ayoub, M.D. President of the Commission

Claude Bélisle, M.D.
Claude Bélisle, M.D.
M.D. President of the Commission Claude Bélisle, M.D. Josée Caron, M.D. Julie Germain, M.D. Paul

Josée Caron, M.D.

of the Commission Claude Bélisle, M.D. Josée Caron, M.D. Julie Germain, M.D. Paul Grand’Maison, M.D. Charles

Julie Germain, M.D.

Bélisle, M.D. Josée Caron, M.D. Julie Germain, M.D. Paul Grand’Maison, M.D. Charles Guertin, M.D. Pierre

Paul Grand’Maison, M.D.

Charles Guertin, M.D.
Charles Guertin, M.D.

Pierre Duplessis, M.D. Secretary to the Commission M.D. Secretary to the Commission

Benoît LauzièreM.D. Pierre Duplessis, M.D. Secretary to the Commission Paule Lebel, M.D. Sandra Palmieri, M.D. Odette Plante

Paule Lebel, M.D. M.D.

to the Commission Benoît Lauzière Paule Lebel, M.D. Sandra Palmieri, M.D. Odette Plante Marot Céline Plourde,

Sandra Palmieri, M.D.

the Commission Benoît Lauzière Paule Lebel, M.D. Sandra Palmieri, M.D. Odette Plante Marot Céline Plourde, B.Ph.

Odette Plante Marot

the Commission Benoît Lauzière Paule Lebel, M.D. Sandra Palmieri, M.D. Odette Plante Marot Céline Plourde, B.Ph.

Céline Plourde, B.Ph.

CHAPTER 1

Evolving Professional Roles for Physicians in the 21st Century

C HAPTER 1 E volving Professional Roles for Physicians in the 21st Century

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

INTRODUCTION

Physicians practise a science and an art, the pur- pose of which is to maintain or restore health by preventing, diagnosing and treating illness. An interest and passion for science and humanity all come together in the physician. Indeed, the role of physicians materializes first and foremost in the therapeutic relationship with their patients, and it is to these patients that physicians are primarily accountable and respon- sible. This patient-physician relationship is fundamental.

Given our changing health care system, the Commission on the Practice of Medicine in the 21st Century thought it important to take a close look at the dynamics current in the medical profession, which are also likely to change considerably. Its reflections are supported by a firm belief in the fun- damental values and characteristics of the health care services provided in Québec, namely equity, accessibility, respect for personal dignity, effective- ness, comprehensiveness and continuity. Its thinking is also based on a re- spect for the public nature of our health care system.

Through the centuries, medicine and surgery made enormous strides in their development and merged into one profession, its scope broadening with the advances in knowledge about humans and their ailments, and the avail- ability of a growing list of pharmaceutical products. The profession became more complex and more specialized. Other paramedical professions devel- oped at the same time, and individuals progressively played a greater part in maintaining and recovering their own health. In short, medicine is a dy- namic, multifaceted profession, constantly interacting with the population and other allied professions; it enriches itself by drawing upon different ar- eas of knowledge and competence in all the scientific disciplines that now form part of it.

The text that follows begins by tracing the evolution of medical practice. It then presents an overview of the roles to be played by 21st-century physi- cians, and the skills required of them. It also briefly describes how profes- sional roles may complement one another in the area of health care and services.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

1. THE EVOLUTION OF MEDICAL PRACTICE

EXPANDING BODY OF KNOWLEDGE AND THE EXPLOSION OF TECHNOLOGY

E XPANDING BODY OF KNOWLEDGE AND THE EXPLOSION OF TECHNOLOGY A dvances in science and technology

Advances in science and technology are now disseminated almost instantaneously. They are becoming increasingly numerous and specta-

cular, presenting possibilities for today and prom- ises for tomorrow that were previously undreamed of 1 . With this phenom- enon of continuously expanding knowledge and technical possibilities, physicians are faced with one of the greatest challenges to professional prac- tice in the 21st century—the challenge to make proper use of information. Physicians must keep themselves informed—and ceaselessly continue to do so—to bring their knowledge and technical skills up to date, and to perfect their capacity for judgment, which will be increasingly needed to deal with difficult situations. They will also have to inform others, and do it well, con- cerning themselves with the content of the information as well as the man- ner in which it is communicated. Physicians will have to inform patients, who, being more autonomous, will increasingly question the relevance and consequences of acts performed. They will have to inform a public that is worried about equity, costs, and the future of the health care system. They will have to be ready to inform local and regional authorities and govern- ments, which must make decisions and answer for choices made in disburs- ing public funds.

THE CHANGING SOCIOCULTURAL AND POLITICAL CLIMATE

funds. T HE CHANGING SOCIOCULTURAL AND POLITICAL CLIMATE S cience and technology are not alone in

Science and technology are not alone in exert- ing influence on the changing practice profile of physicians. Changing needs and values, new lev-

els of awareness and sensitivity, social demand and political choices are also elements that will continue to transform tra- ditional medical practice in the 21st century.

One cannot deny that Québec’s public health and social services system has greatly contributed not only to broadening access to services but also to improving the quality of care. Physicians and their patients have gone from private offices to better equipped hospitals. Little by little, the increased use of these services has led to hypertrophy of these special centres, where demand has grown more quickly than supply. Medicine was “free”, so they were told, and people jostled one another at the door, waiting to get in.

1. On this subject, see Chapter 7, “The Impact of Technology on Medicine in the 21st Century.”

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

Physicians therefore had to be productive. This phenomenon, combined with technological progress and an effective pharmaceutical armamen- tarium, transformed medical practice, particularly in certain specialties, re- placing traditional medicine centred mostly on observation and treatment, with medicine based on diagnostic and therapeutic intervention.

Paradoxically, in circumstances where quality and access to care have greatly improved, and in a context where improvement in treatment techniques is unequalled, physicians risk becoming, often despite themselves, “volume” care providers rather than professionals who provide care and ensure its continuity to single individuals and whole persons.

Parallel to the qualitative and quantitative development of health care, a new cultural relationship to health has emerged in Québec. Not only did health become an increasingly important concern, even an obsession for some, but its very definition broadened considerably. The subject of health was gradually transformed into a social, collective project with lasting con- sequences; among them, conscious, growing citizen participation, the es- tablishment of an organization that was certainly productive, but enormous and complex, creating an increasing number of professional fields and new approaches in a constant state of change.

Thus, Québec’s health care system, which was private, became public. Ac- cording to the Commission, this system is based on three fundamental val- ues: 2

equity for every citizen who is ill, that is, unrestricted access to the same quality of care for all;

solidarity, that is, a collective effort to share resources, so that the sick person is not alone to shoulder the financial burden;

respect for a person’s human dignity, which, in the area of health, finds its expression in the sacred and fundamental nature of the patient-physician relationship, which includes the patient’s free choice of a physician, on the one hand, and the obligation to maintain confidentiality, on the other.

In a climate of new values and social pressures, government intervention has increased in the last decades. To realize how much, one need only look at how far we have come from the Hospital Insurance Act of 1960, to the Act respecting health services and social services and amending various leg- islation of 1991. Adopted in 1992, health and social welfare policy consoli- dated the system’s reorganization in terms of efficiency and effectiveness.

2. See Chapter 5, “The Organization of Health Care and Health Services.”

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

What followed was the accentuation of a trend that was already becoming a reality. While often poorly understood, it has become known as the “ambulatory shift” and seems destined to be the order of the day for medi- cal practice for the coming years.

CHANGING THE ORGANIZATIONAL FRAMEWORK OF HEALTH CARE

DELIVERY

The ambulatory shift is the logical follow-up to what preceded it. Health services, particularly medical services, had to be adapted and made

more accessible, the inefficient use of hospital services had to be corrected using more appro- priate resources, and oft-neglected prevention and health promotion activities had to be revived. New trends in health and social services (new techniques, particularly those that make day surgery possible, changes in treatment concepts that favour home care, de-institutionalization and the greater role played by the user in the care-giving process) are leading to major changes in medical practice.

Furthermore, we must not forget that, despite politicized discussions, and a few bureaucratic mishaps, health and social services objectives are inspired by a philosophy centred around the health of individuals and the com- munity, and not on the delivery of individual services. Achieving these ob- jectives therefore requires a more concerted organization and more pro- ductive delivery of care and services for the benefit of as many people as possible considered on a community basis.

This collective vision underlying current reforms is not foreign to the medi- cal ideal; it ranks first under the rights and obligations of physicians to the

public. “The physician’s paramount duty [

well-being of the persons he takes care of, both individually and collec- tively,” reads the Code of ethics of physicians. We are, as it were, rediscov- ering in Québec that physicians also have a responsibility to the commu- nity and not only to individuals.

is to protect the health and

]

The expression “ambulatory shift” covers a multitude of practices which, thanks to new technologies and new work organization methods, facilitate the maximal use of alternative resources when it comes to hospitalization. In real terms, this shift in direction involves many different kinds of action, among them, transferring traditional resources to the community, devel- oping group medical practice supported by increased home care resources, decompartmentalizing professional practices, strengthening psychosocial support, and capitalizing fully on the latest breakthroughs in information technology.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

Of course, accumulated delays, budget restrictions, sudden unforeseen dis- ruptions, uncertainties do not make things easier. These provide new pro- fessional challenges for physicians. They force them to look for the real meaning behind the current transition, and to espouse its deep-seated goals, namely, its community-based orientation “in the gestational phase”, as some have described it. This socially desirable, economically necessary and politically resolute orientation asks physicians to review their commit- ment to the community and to revive an ancient mode of practice where support and treatment of the sick take place in their living environment. This way of practising medicine, which predominated for a long time, fo- cuses on the individual; it must now, without relinquishing its first focus, broaden itself to include a community perspective.

To summarize, the 21st century will make great demands on the practice of medicine, despite the fact that the profession no longer has a monopoly on health care. Nonetheless, and for good reason, physicians will be asked to keep exercising leadership by their presence and their competence. They will be asked not only to put aside any reticence about the new organiza- tional framework, but to resolutely involve themselves in the process and to direct it, by occupying a central place in it, one that is warranted by their training and the responsibilities they assume. From this point of view, the roles and professional competence of physicians take on paramount im- portance.

2. ROLES, DUTIES AND ORGANIZATION OF WORK FOR PHYSICIANS IN THE 21ST CENTURY

The day-to-day work of physicians has substan- tially changed in recent years, and their duties have increased considerably. Major technological changes have occurred, health problems have become more complex, the population has aged, and the chronically ill live longer while presenting more complex profiles. Organizations want more efficiency, resources are shrinking, information in all its forms increases possibilities, but demands more. Thus, the patient-physician relationship is more impor- tant than ever, and is even more demanding. From these changes come many new tasks to be assumed by physicians, tasks that are not recognized financially or considered when dealing with the medical workforce.

Medical specialists, while playing the role of expert clinicians in looking after their patients, must increasingly act as expert consultants vis-à-vis

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

other physicians and health professionals. They must set aside time to in- teract with the latter, give them the information they need, support them in patient follow-up, often coordinate teams in specialized fields, involve themselves in medical-administrative work, teach, and take on certain re- search obligations, as the case may be.

As for family physicians, they must increase the time they spend with fam- ilies, the elderly, and chronically ill patients; they must devote the neces- sary time to coordinating their work with that of the nurse and specialist colleagues. Their work with respect to medical record-keeping, medical- administrative tasks and teaching, if applicable, will become ever more demanding. Family practitioners will often act as ombudsmen for their pa- tients vis-à-vis certain agencies and health professionals, so that their pa- tients have ready access to the care their condition requires.

These duties will in future be part and parcel of the practice of medicine, calling for new professional roles and hence, new skills. Above all, they will demand time, energy and availability on the part of physicians, who, in the midst of these new everyday realities, must continue to honour the unique patient-physician relationship and the tacit contract that links the physician to the patient, notably as the one ultimately responsible for the medical care given to the latter.

K EY ORGANIZATIONS DEFINE THE ROLES OF 21ST-CENTURY PHYSICIANS

¨

Many organizations have come up with their

own definition of the roles of the physician. We

think it important to present these briefly, then

to describe the physician’s role as seen by the Commission on the Practice of Medicine in the 21st Century.

In its definition, the World Health Organization (WHO) presents the “five- star physician” (WHO-WONCA Conference 1994: London, Ont., 1995; World Health Organization, 1996) as an effective clinician, a decision-maker, a com- municator, a leader in the community and a team worker. These elements are repeated in most of the other definitions of the physician’s role.

The College of Family Physicians of Canada and the Royal College of Phy- sicians and Surgeons of Canada (1993) refine this definition by adding di- mensions that apply particularly to the family physician. They highlight the importance of the patient-physician relationship, the physician’s position as advocate and coordinator of care, as well as provider of primary care to the patient and the entire community.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

CanMEDS 2000 clarifies the WHO definition of medical specialists (Royal College of Physicians and Surgeons of Canada, 1996). To the elements al- ready cited, it adds the role of manager of information, treatment and re- sources, as well as advocate-defender of health, scholar and professional. Medical specialists are also resource persons for their colleagues and other workers in the health care system.

The position put forward in the document Overview and Synthesis : What People of Ontario Need and Expect from Physicians – Part 2 (Educating Fu- ture Physicians for Ontario [EFPO], 1993 : 22-52) assembles several of these roles and describes the physician as a medical expert, a communicator, a means of access to the health care system and a manager of resources and care, a scholar, a competent scientist and a human being with a private life and personal aspirations.

Regardless of the organization, the importance of ethics, professional atti- tudes and behaviour are emphasized.

THE PHYSICIAN’S ROLES AS SEEN BY THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY

ON THE PRACTICE OF MEDICINE IN THE 2 1 S T CENTURY T he Commission began

The Commission began by considering the fact that physicians are first and foremost persons with legitimate aspirations who wish to fulfil them- selves as individuals. They have rights and obli-

gations as individuals and citizens. They live in a society to which they bring their personal and professional skills, both hu- man and scientific. Given this fact, they also have rights and obligations as physicians. Their roles hinge on these realities.

Furthermore, given all the roles of the physician recognized by the various key organizations, the Commission set out to extract those that seemed most pertinent and that represented the most outstanding challenges for the 21st century. It is of course impossible for one individual to completely master all of the skills required to execute each of these roles. The Commis- sion still wishes to present them as avenues to be explored by 21st-century physicians, who must constantly upgrade their skills.

EFFECTIVE SCIENTIFIC CLINICIAN

Physicians are scientists working on behalf of hu- man beings. They possess the competence that makes them experts in the diagnosis and treatment of disease. They help facilitate access to quality

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

health care services for the population they serve. They encourage healthy living habits in their patients, practise preventive clinical medicine with them, give them the necessary care, and show concern for the health goals of the community in which they work.

To fully assume their role, 21st-century physicians must, more than ever before, find ways and means to maintain their sound scientific training and to keep learning new technical skills. Furthermore, they will need to have their skills increasingly recognized and respected. Being responsible for the care of their patients, they must be accountable for their acts and be free to make the necessary decisions.

HUMANISTIC PROFESSIONAL

Now and even more so in the future, the fluid and ever-evolving context of real medical practice will demand a high level of professionalism from physicians. Much as the competent and skilful sci- entist will be called upon to diagnose and treat disease, so will the human- ist and person with good judgment be needed to analyse and understand the new issues and imagine future solutions, objectively discussing and lu- cidly envisaging their consequences.

While acquired competence and a general education are a prerequisite for the right to practise in a context of extended responsibilities, a humanistic attitude and mind-set are equally essential. We are not speaking here of an outward show of humanism to compensate for deficient training, but of one that is clearly rooted in an awareness of the fact that the patient is a unique individual whose integrity, autonomy and dignity must be acknowl- edged.

Such humanism enlightens practitioners in their decision-making and im- bues the patient-physician relationship with the sensitivity, empathy and compassion needed to put the illness to be treated into perspective. Final- ly, it is on this brand of humanism that one lays and maintains the two- fold foundation of the patient-physician relationship: an egalitarian relation- ship in human terms, and a helping relationship from the patient’s point of view.

Convinced that the professional and human aspects of medical practice will take on new importance in the 21st century, the Commission firmly be- lieves that the selection criteria for candidates applying to medical school,

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

the training programs and the examinations leading to a permit to prac- tise must be reviewed to include these attendant skills.

LEARNER

Physicians strive to maintain and increase their competence so as to achieve a high level of excellence throughout their years of practice. They have a duty to keep abreast of scientific and techno- logical developments as well as major social changes that impact on the practice of medicine.

The moment their training begins, they must develop sound self-learning habits, enabling them to master precise, complex skills. Throughout their entire lives, physicians will improve their capacity to learn, to classify and build up their body of knowledge, and to have easy access to their store of information, which they must constantly update.

Physicians must also develop the habit of self-evaluation, assessing the true measure of their knowledge and skills from the results of their work. Thus, everyday practice will constantly nourish their motivation for self- improvement. This self-evaluating capacity will touch on all aspects of their work, from clinical decisions to different facets of their relations with pa- tients and other health professionals.

COMMUNICATOR

Physicians spend more and more time produc- ing information to be transmitted to patients and their families, colleagues, other health care workers as well as to the public.

The new health care and social services structure implies that citizens take responsibility for their state of health. Developments in information and monitoring techniques, in the treatment and relief of pain, reinforce their ability to assume this responsibility. As communicators with their patients, physicians must make an effort to help them make decisions and take full responsibility for their own health. They must speak to the patient or fam- ily, successfully communicating the information needed to understand the disease and treatment, so that the necessary decisions can be made, as much as possible, with the patient or next of kin.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

To successfully play the role of communicator, which is becoming a more and more important part of medical practice, physicians must keep hon- ing their communication skills. These skills will display themselves in the ability to be clear and precise, and to use language suited to the person being addressed. They must make sure the person has understood them and learn how to listen themselves, so that real communication can take place.

TEAM PLAYER

The reorganization now under way requires a much stronger sense of team-work between first-line physicians and sec- ond and third-line physicians, so that together they can discharge their duties in the community, and ensure continuous and comprehensive care. It is also clear that future physicians will frequently have to work as mem- bers of interdisciplinary teams.

The growth of new social phenomena such as marginalization, itinerancy, violence, emotional problems and poverty, to name but a few, will increas- ingly require intervention by various professionals, who will have to work together to ensure better treatment for patients, appropriate follow-up and support in keeping with their situation. The interdisciplinary approach also opens the way to collaboration with patients and their milieu.

In this context, tomorrow’s physicians will have to face up to many de- mands, such as developing the ability to cooperate, mastering the principles of team-work and adopting its behaviour, learning to better acknowledge and respect the fields of expertise of other professionals and, in the midst of all this, be active participants who use their own competence for the greater good of patients and their families, while remaining the ones ulti- mately responsible for the medical care delivered.

Historically, all professions have evolved with a storehouse of knowledge and techniques that define them as unique. The professions were juxta- posed, as it were, when they were formed. But this division between fields of practice, or “exclusivity”, no longer suits the needs of the present health care system. With a view to protecting the public, the Office des profes- sions is attempting to redefine the fields of practice so as to cut down on interprofessional conflict and modernize the professional system, making it more adaptable to the changing needs of the population and the profes- sions themselves and appropriately responsive to these needs.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

Are we moving toward a professional system based on the classification of acts (Office des professions du Québec, 1996)? Will we move more toward fields of practice in which a certain number of acts and activities are shared, as the Collège des médecins du Québec suggests? Further developments on this subject are expected in the coming months.

With this in view, the Commission is interested in the present attempts at a rapprochement between the various professional orders working in the health care field. It encourages mixed committees working on subjects of common concern, so that protectionist mentalities may evolve even further. Thus, professionals, physicians in particular, will one day be able to work together in a naturally harmonious and concerted way.

MANAGER

The community orientation which, it seems, will characterize medicine in the 21st century adds to and broadens the responsi- bilities of physicians. They can no longer work in isolation in an office. They must become involved in the organization of care given to the community, in the very place where the activities of daily life take place.

At the local or regional level, as the case may be, physicians will have to take on more responsibility for managing the medical practice component of the health care system. They will have to take part in the organization, coordination, control and evaluation of care delivery structures. To do so, they will have to develop the skills required for effective management. Al- lowing for exceptions, they will not necessarily become career managers. Rather, they will act as professionals with a unique expertise that enables them to be part of decisions involving resource allocation.

LEADER IN THE COMMUNITY

Physicians act in deference to the values of Québec society and its health care system. As members of a community, they take part in efforts to improve the health and well-being of its other members. They stand up for their patients and intervene at a decision- making level to defend their interests. They do their best to ensure the well- being of individuals without neglecting the pursuit of the common good.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

Physicians have a duty to be open-minded and level-headed in their judg- ments. They will also have to show intellectual discipline, moral rectitude and coherence when they take a position, so as to positively influence the thinking and decisions of their fellow-citizens.

RESEARCHER AND TEACHER

Clinical research and basic research are also mis- sions of the medical profession. With the advent of information technol- ogy, clinical research can now extend to different practice settings. In the future, research will become even richer and more diverse, thanks to the formidable amount of information contained in data banks. Physicians will have to realize this and take more interest in research.

Physicians also have a responsibility to teach. Becoming a physician involves a long learning process and to get through it successfully, they must rely on their elders to impart the knowledge and clinical skills they themselves have acquired. In addition, physicians who are called upon by colleagues as experts and consultants are indeed acting as teachers in the way they write their reports or answer questions. On this point, the Commission re- iterates its conviction on the importance of family physicians being able to practise in a hospital centre, including a university hospital centre, since the training of physicians is a process that continues throughout all their years of practice, both on the treatment sites themselves and through direct con- tact with patients and colleagues.

*

*

*

Given all the roles selected by the Commission, some will say it is unrealistic to think that a physician could play all these roles. But the Commission believes that the attributes of a scientific and effec- tive clinician, humanistic professional, learner, communicator and team player, are fundamental and essential to the practice of medicine in the 21st century. The abilities of manager, community leader and researcher-teacher are also fundamental, but in varying degrees depending on the interests of each and the practice setting. Often, excellence in all of the skills required by these roles will be shared among members of a group of physicians, each having devel- oped a number of specific abilities to play these roles, without mastering all to the same degree.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

3. COMPLEMENTARITY OF PROFESSIONAL ROLES

Physicians perform the roles described above in one of two fields of activity—family medicine or specialized medicine. The medical community and society in general have corresponding expecta- tions of each. Relations between the two groups and between physicians and other professionals working in health care are changing quickly. Con- siderable professional challenges await physicians, and they must be faced, not only in the 21st century, but as of now, for the good of patients and the communities to which they belong. The following paragraphs address the question of complementarity of roles and the challenges it raises.

THE FAMILY PHYSICIAN

of roles and the challenges it raises. T HE FAMILY PHYSICIAN F amily physicians are called

Family physicians are called upon to play a par- ticular role in first-line care. Indeed, they are re-

sponsible for the primary care of their patients and, in an overall way, of their community. They provide most of the first- line care and a certain amount of second-line care. They use the other re- sources in the health care system as needed. The first-line care they pro- vide corresponds to primary medical care as defined by WHO. It includes preventive, curative, rehabilitative and palliative care. It is characterized by its accessibility 24 hours a day, seven days a week. Thus, it is comprehen- sive and continuous and includes long-term management of the person (Conseil médical du Québec, 1995). Family physicians practise in a setting as close as possible to the area in which their patients live. For these pa- tients, they are the principal means of access to the health care system. In- deed, the family physician is the keystone on which all other medical care depends.

The Commission believes that the practice context for family physicians, already in a state of flux, will have to change again considerably in years to come. First-line physicians will work mostly in an ambulatory and commu- nity setting. Every physician will be accountable to a given clientele for the health care and services for which they have accepted responsibility; this will include longitudinal follow-up for that particular group of clients, who will depend upon firstly their own physician’s services, then on those of the group to which their physician belongs. Many will have to deliver serv- ices to particular populations such as the elderly who are no longer self- sufficient. In addition, family physicians will continue to have a place in the hospitals, including the university hospitals; this place is particularly

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

important in outlying areas, where they very often ensure continuity of care to hospitalized patients.

To ensure the total care of their patients, family physicians will almost never practise solo, but in a group practice setting. Using information technol- ogy to make their interventions more effective, these groups will form real networks, communicating regularly among themselves by computer. Fam- ily physicians will also work more and more in an interdisciplinary setting, while remaining ultimately responsible for medical care. Finally, they will collaborate in the organization of first-line medical services at the local, re- gional and provincial level, according to population needs.

THE MEDICAL SPECIALIST

according to population needs. T HE MEDICAL SPECIALIST W hile they perform the roles common to

While they perform the roles common to all phy- sicians, specialists have also acquired a more in-

depth knowledge of their discipline and possess additional high-level skills in their specific area of practice. On the one hand, they are experts who treat patients presenting more complex health prob- lems. On the other hand, they are expert consultants for first-line practitio- ners, physicians in other specialties, other professionals in the health care sector, as well as patients and their families. Certain specialties require a highly technical facility, leading the specialist to master often very complex technologies.

The Commission foresees that, given technological advances in particular, future specialists will work in ambulatory specialized settings, in out-patient facilities, or in superspecialized hospital settings where a small number of patients require special care. They will be called upon, even more than they are now, to be part of an interdisciplinary team. At times, they may even have to leave their usual workplace to go and see certain patients. In other cases, medical specialists will go to community settings, acting as consult- ants to the teams in place, discussing individual cases. Examples of such practices now exist in psychiatry and geriatrics. Finally, it is foreseeable that in the 21st century the development of telemedicine will considerably alter the role of specialist-consultants, giving the very diversified milieus in Québec and elsewhere greater access to their expertise.

Medical specialists will be responsible for second and third-line care and will also have to involve themselves in the planning and management of these medical services at local, regional and provincial levels.

Given the expertise for which medical specialists are recognized, they will occupy a preponderant place in the area of clinical research, while ensur-

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

ing the participation of family physicians when feasible. Finally, with their in-depth knowledge comes the duty to teach family physicians, a duty that goes beyond the simple individual consultation process and takes place in the context of continuing medical education.

R ELATIONS BETWEEN FAMILY PHYSICIANS AND MEDICAL SPECIALISTS

ELATIONS BETWEEN FAMILY PHYSICIANS AND MEDICAL SPECIALISTS F amily physicians are the principal players in our

Family physicians are the principal players in our health care system. Medical specialists tie their practice to that of the family practitioner, thereby

increasing the possibilities for intervention in more specialized areas of medicine. In many specialties, however, special- ists cannot provide a global view of the patient’s situation. Hence the im- portance of first-line services coming under the responsibility of the family physician, with the specialist acting mainly as a consultant.

The hierarchical structuring of medical services 3 is a major issue, and this concept is part of the current line of thinking of many national and inter- national groups of experts. Many organizations have in fact stressed how important it is that the patient have his “own” family physician, and be- fore seeking out specialized care, that he obtain a request for a consulta- tion from the latter. This is what was proposed by the Conseil médical du Québec (1995), the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada (1993) and the Québec Fed- eration of General Practitioners. Putting the process into action, however,

is still a major challenge for the medical profession.

This hierarchical structure is meant to improve the interaction between dif- ferent areas of medical competence, making the care more relevant, effec- tive and efficient. The Commission adheres completely to the principles un- derlying this hierarchical structuring. It encourages an orientation whereby every patient would be followed by one family physician and would receive

a first assessment from the latter before calling on a specialist. But the Com-

mission is not in favour of mechanisms that would make this way of doing things obligatory or coercive 4 . Rather it believes that efforts to educate pa- tients and physicians, coupled with standards applying to the remunera- tion of the latter, would serve the same purpose while maintaining a nec- essary flexibility in certain cases and safeguarding personal responsibility.

3. See Chapter 5 on this subject, “The Organization of Health Care and Health Services.”

4. For more information, please refer to chapters 5 and 6 dealing with the organization of health care services and funding, respectively.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

R ELATIONS WITH OTHER PROFESSIONALS

in the 21st Century R ELATIONS WITH OTHER PROFESSIONALS O ur health care system is undergoing

Our health care system is undergoing profound change, as we said earlier, and this is not an iso- lated phenomenon, it is world-wide. The Com- mission believes, in the light of its analyses, that

the skills and knowledge required to practise medicine, either in family prac- tice or in a specialty, will become more and more specialized. Therefore, the sharing of acts with other health professionals is necessary, so that phy- sicians can play the exact, very specific role for which they were trained. Medicine’s increasing complexity will lead physicians to opt out of certain activities that do not necessarily demand their competence. And, given the expanding roles of other professionals, it is pertinent that we take another look at how duties can be shared, both in the workplace and at the level of the professional orders. It will be up to the Collège des médecins du Québec

to define the field of practice and acts that come within the competence of

the physician, as well as those that can be shared, for the greater good of patients and in deference to the professional roles of each.

The nurse clinician, to cite an example, will intervene more in emergency room settings, in first-line prevention, geriatrics, chronic and palliative care, whereas the surgical assistant will play a role in the operating room, and the midwife in the delivery room.

The Commission believes that this trend is irreversible and will require deli- cate and sometimes painful adjustments. On the other hand, it is likely to free-up physicians and make their medical practice more dynamic, while enabling them to give their patients more comprehensive care. All of these changes should occur without compromising the integrity of the patient- physician relationship or the quality of care provided.

A review of the regulations with respect to activities or acts, as well as an

openness to the possible roles to be played by other professionals, will help make professional practice more dynamic. The basic principles governing these changes may be defined as follows:

to respond to the needs of Quebecers;

to ensure respect for competencies;

to promote quality professional practice;

to harmonize individual and collective interests.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

CONCLUSION

The Commission cannot overemphasize the im- portance of appropriate medical education, education that is at once sci- entific and humanistic. This initial training, coupled with continuing edu- cation, is the only path to maintaining competence for today’s physicians and ensuring that future physicians have the ability to perform the profes- sional roles that await them.

In the years to come, challenges will abound for all Québec citizens, and from our particular point of view, for physicians. Their special position as social actors places them at the crossroads of every major change. It is clear that they will have to combine forces to innovate, adapt and continue to give their patients the best possible care. As they cope with technological change and the shift to ambulatory and community care, they will be called upon as never before to revive a deep-seated humanism, which will enable them to weather the storms that will certainly still beset the health and so- cial services system in which they work every day.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

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Summaries of the Chapters and Recommendations

S ummaries of the Chapters and Recommendations

CHAPTER 1

Evolving Professional Roles for Physicians in the 21st Century

SUMMARY

The transformation of the health care system, the evolving roles of other professionals, and the burgeoning body of knowledge and technological advances will substantially change the practice of medicine in the 21st cen- tury. Physicians are challenged by these ongoing changes and must not submit to them passively. They must involve themselves in these changes, indeed direct them, by occupying the cen- tral place warranted by their training and the responsibilities they assume as principal players in our health care system. De- spite all the changes, we must keep in mind that the patient- physician relationship remains fundamental, and, in this sense, physicians remain ultimately responsible for the medical care given to their patients.

In 21st-century Québec, the Commission expects that physicians will be increasingly asked to adopt a community approach to their work, to review their commitments in this sense and, within an ambulatory care context, revive a mode of practice where support and treatment of the sick take place in their living envi- ronment. They will be called upon, not only as skilled and com- petent scientists to diagnose and treat disease, but as humanists and persons of good judgment who can analyse and understand new health-related issues, to imagine future solutions, discuss them objectively, and lucidly envisage their consequences.

Therefore, physicians must develop their professional compe- tence as humanists as well as scientists as of now, aware of the fact that the patient is a person whose integrity, autonomy and dignity must be respected. The Commission therefore believes

that as well as working constantly to be scientific and effective clinicians, physicians must become humanistic professionals,

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

learners, communicators, team players, managers, leaders in their community, researchers and teachers. The complementary
learners, communicators, team players, managers, leaders in
their community, researchers and teachers.
The complementary roles of family physician and specialist will
have to be more and more coherently articulated in years to
come. Family physicians, whose primary role is to give first-line
care, are increasingly working in groups. They take responsibil-
ity, not only for their own patients on an individual basis, but
for the entire clientele they serve by belonging to a group prac-
tice. They direct their patients to a specialist if necessary. Spe-
cialists perform functions more specific to their field of practice.
First, they are expert-consultants called upon by colleagues,
patients and families. As second and third-line attending phy-
sicians, they provide first-line care in particular instances only.
While family physicians practise more in an ambulatory setting,
their work in the hospital remains important. Specialists, on the
other hand, frequently work in the hospital, although a good
part of their work (at least for certain specialties) is done in am-
bulatory settings.
The Commission believes that physicians will work more and
more as part of an interdisciplinary team composed of other
physicians and other professionals. Activities that do not neces-
sarily require their expertise will be shared with other profession-
als. This, in the Commission’s view, is an irreversible trend, which
will require sometimes difficult adjustments, but which is also
likely to free physicians and make their practice more dynamic,
while at the same time enabling them to provide more complete
care to their clienteles.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

RECOMMENDATIONS

GIVEN the evolution in medical practice brought on by a burgeoning body of knowledge and outstanding advances in technology, a trans- formation in the sociocultural and political climate, and changes in the organizational framework for health care delivery;

GIVEN the expanding roles resulting from these changes, and the need for continual updating and upgrading of competence and skills;

GIVEN the requirement for greater differentiation and complementa- rity of roles between family physicians and specialists as well as other health professionals, which does not take away the family physician’s place in hospital centres nor reduce the physician’s ultimate legal re- sponsibility with regard to medical care;

GIVEN that the present method of payment cannot adequately recog- nize and compensate for the changes in the tasks physicians must assume daily, and that it cannot facilitate the organization of work required to effectively perform them;

GIVEN that the quality of medical practice cannot be dissociated from the milieu in which it takes place,

the Commission on the Practice of Medicine in the 21st Century recommends

1. That the Collège des médecins du Québec commit itself immediately to supporting physicians in active practice so as to enable them to better take on the roles required to practise their profession in the 21st century, notably those of scientific and effective clinician, human- istic professional, learner, communicator and team player.

2. That the Collège des médecins du Québec, in concert with universities and other educational facilities, agree upon a master plan whereby medical training as a continuum (undergraduate and postgraduate training and continuing medical education) would enable today’s and tomorrow’s physicians to acquire the competence they need to meet the medical challenges and health problems of the 21st century.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

3. That the Collège des médecins du Québec, conscious of the fact that the evolving professional roles of physicians will have them attribute increasing importance to tasks such as case discussions between spe- cialists and family physicians, interdisciplinary work, counselling the patient and the family, medical-administrative activities, etc., take po- sition in favour of reviewing methods of payment with a view to fur- thering the accomplishment of such tasks.

4. That the Collège des médecins du Québec implement effective means to help physicians develop habits of self-evaluation and self-learning; that it influence the heads of undergraduate and postgraduate train- ing programs and pressure the universities to systematically develop the skills and knowledge that build these habits.

5. That the Collège des médecins du Québec not only continue to evalu- ate the quality of medical practice in different care settings, including private practice, but that it commence immediately to support physi- cians in their efforts to improve the quality of care.

6. That the Collège des médecins du Québec reaffirm, whenever perti- nent, its vision of the family physician’s role as a first-line professional who is also responsible for follow-up medical care, and its vision of the specialist as expert clinician with patients and consultant with col- leagues; that it resolutely take a position in favour of the complemen- tary roles of family physicians and specialists, and the consequent hi- erarchical structure of medical services this complementarity creates; that it join in the process to develop mechanisms for its realization.

7. That the Collège des médecins du Québec reaffirm the family physi- cian’s place in hospitals, including university hospitals.

8. That the Collège des médecins du Québec take a stand on the im- portance of quality second and third-line care for the population and on the need for sufficient resources, effectively and efficiently used, to sustain the development of medical specialties providing these serv- ices, ensuring notably that adequate technical facilities be available for their use.

CHAPTER 1 Evolving Professional Roles for Physicians in the 21st Century

9.

10.

11.

That the Collège des médecins du Québec, in concert with the Inter- professional Council of Québec, the Office des professions and other professional orders, pursue its efforts to clearly define the competence and field of practice of physicians and other health professionals; in so doing, that the Collège clearly define the responsibilities of physi- cians and the mechanisms for their collaboration with other profes- sionals.

That the Collège des médecins du Québec, given the physician’s legal and ultimate responsibility with regard to medical care, attribute the necessary value to the physician’s special role on interdisciplinary teams and see to it that physicians acquire the necessary skills to work as part of such teams.

That the Collège des médecins du Québec, in its relations with its mem- bership, faculties of medicine, associations and federations of physi- cians, stress the need for physicians to take part in the development of knowledge by increasing their participation in research programs, within any pertinent ethical boundaries.

CHAPTER 2

Toward an Ethic of Shared Responsibility in a Pluralistic Society

SUMMARY

Today, the ethical dilemmas physi- cians must face are more numerous, more complex, more con- troversial and are frequently debated in public. Along with the rest of society, they are confronted with many situations that call for difficult, sometimes even heartbreaking, choices. These choices involve the beginning of life (e.g. new reproductive tech- nologies, prenatal diagnosis) as well as the end of life (e.g. euthanasia, cessation of treatment, assisted suicide) and the multiple situations involving care and procedures (e.g. organ transplants, screening for genetic diseases) that may occur over the course of a lifetime.

Two factors have a particular impact on the ethical aspect of medical practice—technoscientific advances and sociocultural changes. Their influence on the realities of the 21st century will likely be more marked.

In the scientific and technological fields, the realm of possibility has expanded much more quickly than is desirable or necessary. And this is precisely where ethics comes in. Efforts will therefore have to be made to extend its boundaries in the coming years.

As for the social and cultural climate, moral pluralism and the defence of individual rights appear to be irreversible features of our society. Besides, evolving attitudes on death are leading to ethical problems that were totally unforeseeable not so long ago. Finally, the upheavals in the health care system are raising new questions on the limits of the State’s role in the lives of citi- zens and the choices imposed by limited resources and finan-

cial means, particularly as regards medicine aimed at satisfying people’s desires.

CHAPTER 2 Toward an Ethic of Shared Responsibility in a Pluralistic Society

Ethics is unquestionably a concern for clinicians who must daily honour their patients’ trust by
Ethics is unquestionably a concern for clinicians who must daily
honour their patients’ trust by paying attention to all the val-
ues that have the welfare of the person at their very core. They
will have to protect these values in their milieu, and give them
special consideration in their actions. But ethics also concerns
research physicians and represents a major obligation on their
part.
Thus, it is important to increase ethical competence within the
medical profession, during university training and in continuing
medical education. This competence must extend to the ability
to lead the decision-making process in matters of ethics, whether
it be at a personal level or in group discussion.
Medical ethics is a matter of utmost concern to the Collège des
médecins du Québec, given its responsibility to promote quality
medicine in order to protect the public. The Commission suggests
that the Collège create a permanent centre where ethical issues
would be addressed—a place for research activities, informa-
tion, and discussion on the ethical aspects of medical practice.

CHAPTER 2 Toward an Ethic of Shared Responsibility in a Pluralistic Society

RECOMMENDATIONS

GIVEN the ethical grounds for medical practice, notably respect for

a person’s dignity, integrity and freedom;

GIVEN the advances in science and technology, combined with irre- versible moral and cultural pluralism;

GIVEN the growing number and complexity of choices to be made with respect to everyday decisions as well as general orientations;

GIVEN the increasing need for basic education and continual updat- ing in this field, and the need for practical tools;

GIVEN the importance of a forum for information and discussion on ethical questions raised by everyday medical practice;

the Commission on the Practice of Medicine in the 21st Century recommends

12. That the Collège des médecins du Québec and its representatives, take every opportunity to publicize and promote the values underlying the

practice of medicine, notably the primacy of the patient’s well-being,

a humanistic approach to the patient-physician relationship, and re- spect for a person’s dignity, integrity and freedom.

13. That the Collège des médecins du Québec ensure the development and maintenance of sound ethical competence in its members, during their university training and as part of their continuing medical education.

14. That the Collège des médecins du Québec set up an information, edu- cation and exchange process on the ethical aspects of problems en- countered in everyday medical practice; that this structure complement other existing agencies (networks, committees, faculty departments, associations, etc.).

That the Collège des médecins du Québec see to the publication and

15. widespread distribution to its members of tools and guides, particularly

a clinical decision-making procedure that takes ethics into account, so

as to help them shoulder their responsibilities in situations presenting complex problems in an often pluralistic moral and cultural context.

CHAPTER 3

Vulnerable Clienteles: Modes of Support and Care

SUMMARY

The appearance of particularly vul- nerable clienteles is a recent phenomenon in Québec. It is the

result of four major factors: a rapidly aging population, impov- erishment, the disintegration of traditional social structures and an increase in immigration and international adoption. These realities, inevitably accompanied by a train of health and social problems, will unquestionably become more and more wide- spread in coming years, particularly in the Greater Montréal area where over 45% of our physicians practise. The latter will have

to

prepare themselves to support and manage the medical needs

of people subjected to these new social phenomena, since they will form an ever-growing portion of their clientele.

First-line physicians will be the ones most often called upon to intervene and help these vulnerable persons. But given the com- plexity of the health problems on a physical, psychological and social level, and given the necessity of taking action which has

bearing on the living conditions of their patients, they should move toward an interdisciplinary mode of practice. Much work has yet to be done at this level, and a sound understanding of the complementarity of actions taken by first-line physicians, specialists and other professionals is urgently needed.

a

Physicians are the ones best placed to appreciate the suffering of vulnerable clienteles. They could become advocates of their health needs and rights; to do so they must have the required tools. From this perspective, continuing medical education ac- tivities must focus more on the development of certain skills, such as the ability to work in an interdisciplinary context, the ability

to use and coordinate community resources, and the ability to adopt modes of communication suited to certain vulnerable

CHAPTER 3 Vulnerable Clienteles: Modes of Support and Care

clienteles. Is the 21st-century physician ready to play the role of defender of the vulnerable
clienteles. Is the 21st-century physician ready to play the role of defender of the vulnerable
clienteles. Is the 21st-century physician ready to play the role of defender of the vulnerable

clienteles. Is the 21st-century physician ready to play the role of defender of the vulnerable patient’s interests? How will 21st- century physicians better prepare themselves to play this role? What are the most effective strategies physicians can use to de- fend the interests of a vulnerable individual, a vulnerable group? With whom must they ally themselves in championing these rights and interests?

To sum up, the skills sought in 21st-century physicians are many, and the need to profoundly transform the way they practise medicine so as to meet the needs of vulnerable clienteles is ines- capable.

to profoundly transform the way they practise medicine so as to meet the needs of vulnerable
to profoundly transform the way they practise medicine so as to meet the needs of vulnerable
to profoundly transform the way they practise medicine so as to meet the needs of vulnerable

CHAPTER 3 Vulnerable Clienteles: Modes of Support and Care

RECOMMENDATIONS

GIVEN the specific needs of certain particularly vulnerable clienteles;

GIVEN the advantages of a global, interdisciplinary approach;

GIVEN that medical management of these clienteles has repercussions on the type of task required, the need to adapt certain tools of evalu- ation, and medical workforce planning,

the Commission on the Practice of Medicine in the 21st Century recommends

16. That the Collège des médecins du Québec, through its accreditation of training programs, examinations to obtain a permit to practise, and continuing medical education, ensure that the training of physicians prepares them to work with vulnerable clienteles, more specifically through comprehensive medical management of the patient, interdis- ciplinary team work and home visits.

17. That the Collège des médecins du Québec devise tools to evaluate the quality of medical care given to vulnerable clienteles and ensure their application, particularly in comprehensive medical management of the patient, the work of physicians on interdisciplinary teams, and home visits.

18. That the Collège des médecins du Québec, in collaboration with the bodies concerned, including other professional orders, devise tools to evaluate the quality of interdisciplinary work and ensure their appli- cation 1 .

19. That the Collège des médecins du Québec take the necessary steps vis- à-vis medical federations so that measures are taken to acknowledge the necessary tasks involved in work with vulnerable clienteles (home visits, listening, educating the patient, looking for available commu- nity resources, etc.) 2 .

1. According to members of the Commission, this recommendation must be taken to- gether with recommendations 9 and 10.

2. This recommendation must be taken together with recommendation 3.

CHAPTER 3 Vulnerable Clienteles: Modes of Support and Care

20. That the Collège des médecins du Québec make certain that tools are developed to evaluate the effectiveness of the supportive role played by medical specialists with families grappling with the complex prob- lems that vulnerable clienteles often present; that the Collège make certain that the tools developed are applied 3 .

21. That the Collège des médecins du Québec, notably through its par- ticipation in medical workforce determination, ensure that the impact of vulnerable clienteles on the practice of medicine be considered when determining medical workforce needs.

3. This recommendation must be taken together with recommendation 6.

CHAPTER 4

Prevention and Health Promotion:

Its Importance and Impact on 21st-Century Medicine

SUMMARY

 

Curative care has always occupied

a

preponderant place in the health care system. But it no longer

plays the important role it once played in improving mortality rates, even though it still represents the lion’s share of costs to the health care system.

It

is now acknowledged that a population’s state of health de-

pends on a combination of factors that do not necessarily in- clude curative care. In this context, prevention and health pro- motion would appear to provide a choice solution. Prevention attempts to prevent the onset of disease or to slow down its progress and delay its complications. The thrust of health pro- motion, long associated with prevention, is the adoption of healthy behaviours that maintain health and even improve it.

Despite the exposure that prevention and health promotion have had over some twenty years in Québec and elsewhere in the world, many questions are being discussed and have not yet been answered. What is the role of each different professional, of physicians in particular? Do prevention and health promo- tion appreciably reduce the costs associated with disease? How will society allow access to certain types of screening, while still respecting ethical standards? At a time when financial resources are shrinking considerably, where will prevention and health promotion fit in? The purpose of this chapter is to provide an- swers to these questions.

It

may be useful to point out that the roles of the various play-

ers—family physicians, specialists and other professionals—

must be defined from a perspective of complementarity and be well understood by each. The results of prevention and health

CHAPTER 4 Prevention and Health Promotion: Its Importance and Impact on 21st-Century Medicine

promotion will only be optimally felt when the role of every pro- fessional is fully
promotion will only be optimally felt when the role of every pro-
fessional is fully taken into account, and family physicians truly
perform their role as principal players.
The Commission anticipates greater access to information for
practitioners and patients alike. It also expects that more clini-
cal practice guidelines and guides will be published and, as a
result, prevention and health promotion measures will be in-
corporated into all quality professional practices.
Finally, it is unrealistic to think that prevention and health pro-
motion will save substantial amounts of money, since the meas-
ures involved will necessitate the provision of funds and, in all
likelihood, morbidity and mortality will be merely “postponed”.
However, we can anticipate that life expectancy, and life ex-
pectancy in good health, will increase substantially.

CHAPTER 4 Prevention and Health Promotion: Its Importance and Impact on 21st-Century Medicine

RECOMMENDATIONS

GIVEN the impact of prevention and health promotion on the general state of health and well-being of the population;

GIVEN the importance of incorporating these elements into basic edu- cation as well as continuing medical education,

the Commission on the Practice of Medicine in the 21st Century recommends

22. That the Collège des médecins du Québec advocate prevention and health promotion as an integral part of medical care.

23. That the Collège des médecins du Québec ensure that prevention and health promotion activities are an integral part of the everyday prac- tice of medicine.

24. That the Collège des médecins du Québec pay particular attention to questions concerning predictive genetic testing and accessibility to various preventive measures.

25. That the Collège des médecins du Québec support the incorporation of prevention and health promotion activities into undergraduate and postgraduate training as well as continuing medical education 1 .

1. According to members of the Commission, this recommendation must be taken to- gether with recommendation 2.

CHAPTER 5

The Organization of Health Care and Health Services

SUMMARY

The Commission on the Practice of Medicine in the 21st Century considers the organization of health care and services to be central. It singles out three fun- damental values for Québec society: equity, solidarity and re- spect for personal human dignity. It also underlines certain cul- tural characteristics of Québec citizens, among them, the free care and services from professionals of their choice, in the facil- ity of their choice and in the language of their choice (French or English).

The Commission recognizes the importance of the regional level in the organization of health care and services and, thus advo- cates regionally based models of medical practice.

The Commission sees family physician group practices as an ir- reversible trend toward the medical management of populations and believes the tendency should also extend to specialists. To better guarantee uniformity and quality of care, it suggests the establishment of medical councils, either local or regional, as need be.

For specialties with few practitioners, the Commission recom- mends that they form a provincial network, going beyond mere sporadic helping out.

The Commission supports the idea that the ambulatory shift is necessary, that the system must be made more efficient and the number of beds reduced. However, it questions the real purpose behind the operation now under way, as well as the pace of the

expenditure reductions being imposed on the system. It recalls the conditions essential to the success of the ambulatory shift.

CHAPTER 5 The Organization of Health Care and Health Services

The Commission does not recommend mandatory registration with a given family physician; rather it suggests
The Commission does not recommend mandatory registration with a given family physician; rather it suggests
The Commission does not recommend mandatory registration with a given family physician; rather it suggests

The Commission does not recommend mandatory registration with a given family physician; rather it suggests different ways and means of building patient adherence to one attending phy- sician or group of physicians. It realizes that a large portion of first-line services are provided by specialists and does not see this situation as beneficial. It recommends a “hierarchical structure of medical services”, without making it mandatory to obtain a referral from a family physician before seeing a specialist.

The Commission believes that formulas such as “integrated service networks” like those which exist in perinatal care and are being put in place for the elderly, are promising models that call for further experimentation. The Commission recommends that the Collège associate itself closely with these pilot pro- jects. It does not believe that models such as Health Mainte- nance Organization (HMO) and Managed Care are applicable in their present form to Québec.

models such as Health Mainte- nance Organization ( HMO ) and Managed Care are applicable in
models such as Health Mainte- nance Organization ( HMO ) and Managed Care are applicable in
models such as Health Mainte- nance Organization ( HMO ) and Managed Care are applicable in

CHAPTER 5 The Organization of Health Care and Health Services

RECOMMENDATIONS

GIVEN the importance for the population of a judicious geographic and functional distribution of the medical workforce throughout Québec;

GIVEN the relevance of pilot projects and their follow-up in the pres- ent reform of the health care system;

GIVEN the conditions essential to the success of the ambulatory shift;

GIVEN the pertinence of physicians practising in groups and the im- portance of the regional level in the effective and efficient organiza- tion of health care and health services;

GIVEN that the evaluation function inherent in the mission of the Col- lège des médecins du Québec requires that it consider new ways of organizing health care and health services,

the Commission on the Practice of Medicine in the 21st Century recommends

26. That the Collège des médecins du Québec pursue its activities on the determination of the medical workforce and state its position publicly on the geographic and functional distribution of physicians in Québec’s regions.

27. That, before any decisions are made, the Collège des médecins du Québec highlight the importance of pilot projects having to do with any change affecting patients, and that it sit on steering committees for these projects, notably with respect to the following:

the organization of care (registration of patients, regional organi- zation of services);

the distribution of care (e.g. integrated care and service plans for the functionally impaired elderly);

the dynamics of care (e.g. hierarchical structure of care, mandatory referral); and for each type of project, that the Collège measure its impact on the quality of care.

CHAPTER 5 The Organization of Health Care and Health Services

28. That the Collège des médecins du Québec monitor the changes in the system; that it rigorously evaluate the impact of these changes on the quality of care provided by physicians and received by patients; that it denounce any significant negative consequences, and suggest nec- essary adjustments.

29. That the Collège des médecins du Québec support initiatives which group physicians together in a context that provides accessible and integrated services; more concretely, that the Collège des médecins du Québec involve itself in the process of evaluating pilot projects ensuing from these initiatives, and make the necessary recommendations.

30. That the Collège des médecins du Québec, given the growing im- portance of the regional level in the organization of health care and services, promote the creation of regional and sub-regional medical councils whose essential task would be to evaluate the quality of medical acts.

CHAPTER 6

Funding the Health Care System

SUMMARY

In Québec, the operating costs of the health care and services system are high; they are in the order of $13 billion and represent 9.9% of GDP.

Despite the present financial difficulties, the Commission con- cludes that, if the system operated optimally, this level of fund- ing would be enough to ensure the necessary health care and services to the population. Indeed, many examples show that efficiency gains are still possible within the system. However, these gains will not compensate for the expected budget cut- backs to the future system.

The Commission wishes to maintain a publicly funded health care system, with funding remaining at its present level. It rec- ognizes the importance of the regions when developing mecha- nisms for allocating financial resources to the system’s agencies. To this end, it proposes an improved weighted regional per capita formula for funding the regions.

With respect to the remuneration of physicians, from the per- spective of quality medicine, the Commission does not support the principle of “capitation”. It proposes the adoption of mixed methods, and suggests as food for thought a “comprehensive remuneration package” which would be given to groups of phy- sicians, and used taking into account certain features of the prac- tice plans.

The Commission finds that the new Drug Insurance Plan is worthy of note from many points of view. It introduces a new

method of public-private funding as well as elements which re- define accessibility (e.g. essential drugs in every class). But the

CHAPTER 6 Funding the Health Care System

Commission also notes that this insurance plan is becoming another tax burden and, what is
Commission also notes that this insurance plan is becoming another tax burden and, what is
Commission also notes that this insurance plan is becoming another tax burden and, what is
Commission also notes that this insurance plan is becoming another tax burden and, what is

Commission also notes that this insurance plan is becoming another tax burden and, what is more, it is not sure that the plan as presently conceived can withstand the expected cost increases in the medium term.

The Commission concludes by sounding the alarm and empha- sizing that the budget cutbacks and pace of financial recovery imposed on the system are threatening the quality and integ- rity of the system itself.

and pace of financial recovery imposed on the system are threatening the quality and integ- rity
and pace of financial recovery imposed on the system are threatening the quality and integ- rity
and pace of financial recovery imposed on the system are threatening the quality and integ- rity
and pace of financial recovery imposed on the system are threatening the quality and integ- rity

CHAPTER 6 Funding the Health Care System

RECOMMENDATIONS

GIVEN the many signs of exhaustion resulting from successive budget cuts, right at a time when major changes in the organization of care and services demand considerable efforts;

GIVEN that efficiency gains have yet to materialize, and that they will not produce enough savings to satisfy new needs in health care and services;

GIVEN the opening debate on desirable levels and areas of public and private funding of the health care system;

GIVEN the impact of current regionalization plans on the way services are funded;

GIVEN the link between work organization and payment methods for physicians,

the Commission on the Practice of Medicine in the 21st Century recommends

31. That the Collège des médecins du Québec officially demand that no new budget cuts be made to the health care system until the impact of the cutbacks already made have been evaluated in terms of their effects on sick people; that the Collège take part in such evaluation and take a public position on the subject;

32. That the Collège des médecins du Québec involve itself, along with other organizations or agencies concerned by this question, in a search for ways and means of improving the health care system’s efficiency;

33. That the Collège des médecins du Québec assert its conviction that services essential to the health of Quebecers, as well as access to these services, must be ensured for them without additional cost within a public health care system.

CHAPTER 6 Funding the Health Care System

34. That the Collège des médecins du Québec actively participate in the discussions on private-public funding from the point of view of its own mission.

35. That the Collège des médecins du Québec closely monitor the devel- opment of regionalized funding plans for health care and services; that it take part in the evaluation of these plans as they pertain to quality of care and their effects on the clientele.

CHAPTER 7

The Impact of Technology on 21st-Century Medicine

SUMMARY

Technology is now a vital compo- nent of medicine. It may be defined as all “the drugs, instru- ments, procedures, support systems and organizational systems required to provide care”*.

Technologies linked to information, telemedicine and computer systems (professional assistance and patient assistance pro- grams) are the ones that will most affect medicine in the com- ing years. Technologies resulting from recently acquired knowl- edge in biology will also have a considerable effect. They will move laboratory analysis away from central laboratories and into physicians’ consulting rooms and pharmacies, and to the patient’s bedside.

The perfecting of new drugs, new vaccines and other very spe- cific molecules through genetic engineering will also expand rapidly after a latent period of some eight to ten years. These products will lead to changes in medical practice. In this regard, the increased use of genetic testing is expected, and this will have major repercussions.

Instrument and equipment miniaturization and laboratory au- tomation will call for new ways of doing things, particularly in diagnostic practices and procedures.

The Commission identifies two probable consequences of these expected innovations. The first concerns the patient-physician

* Office of Technology Assessment [1978], cited in H. David Banta, Clyde J. Behney

and Jane Sisk Willems, Toward Rational Technology in Medicine : Considerations for Health Policy, New York, Springer Pub.,1981, p. 5

CHAPTER 7 The Impact of Technology on 21st-Century Medicine

relationship, which will have to be redefined, and ethical issues, which will have to be
relationship, which will have to be redefined, and ethical issues, which will have to be
relationship, which will have to be redefined, and ethical issues, which will have to be

relationship, which will have to be redefined, and ethical issues, which will have to be examined in depth. This is particularly evi- dent if one considers genetic testing. The second concerns the difficult choices imposed by the costs of purchasing and using the latest technology.

The Commission emphasizes the fact that information seems to be the predominant factor in the technological advances of the next 10 to 15 years. It would also underscore the fact that using these new technologies or technology in general makes no sense unless it is coupled with an improved quality of life, both individual and collective, physical and psychological.

sense unless it is coupled with an improved quality of life, both individual and collective, physical
sense unless it is coupled with an improved quality of life, both individual and collective, physical
sense unless it is coupled with an improved quality of life, both individual and collective, physical

CHAPTER 7 The Impact of Technology on 21st-Century Medicine

RECOMMENDATIONS

GIVEN the expanding role of technology in medical practice;

GIVEN that the personal dignity and well-being of the patient take pre- cedence;

GIVEN the benefits to the patient of optimal use of information tech- nology,

the Commission on the Practice of Medicine in the 21st Century recommends

36. That the Collège des médecins du Québec ensure that, in using tech- nology, physicians consider ethical principles, apply criteria for their judicious use and show a concern for the cost-effectiveness ratio;

37. That the Collège des médecins du Québec define strategies to optimize the incorporation of clinical practice guidelines and guides into every- day medical practice 1 .

38. That the Collège des médecins du Québec take part in the discussions of existing task forces and join in projects on the use of computerized information and communication technologies in daily clinical activi- ties (computerized medical record, smart card, telemedicine, etc.); that it make the necessary recommendations to have these means pro- mote quality medical practice;

39. That the Collège des médecins du Québec adopt a strategic plan to induce the entire profession—physicians in postgraduate training as well as those in practice—to make optimal use of information tech- nologies (expert systems to assist in decision-making and prescription, data banks providing quick access to scientific achievements and dis- coveries, etc.) 2 .

1. This recommendation is an extension of recommendation 1; it has been placed in this

group of recommendations for the simple reason that the Commission explicitly addresses the question of clinical practice guidelines in this chapter.

2. According to members of the Commission, this recommendation is closely linked to

recommendation 2.

C ommitments

of the Collège des médecins du Québec

COMMITMENTS OF THE COLLÈGE DES MÉDECINS DU QUÉBEC

The Collège des médecins du Québec followed the work of the Commission on the Practice of Medicine in the 21st Cen- tury with great interest and appreciated the care and concern with which the commissioners discharged their mandate, especially in view of the breadth and complexity of the topics examined.

Indeed, the Collège des médecins du Québec thought it particularly posi- tive that the work of the Commission included a phase of consultation with physicians working in all parts of Québec, with organizations involved in health care, and with experts on the various questions addressed.

An orientation day for members of the Bureau and physicians employed by the Collège enabled us to study and discuss the outcome of the Com- mission’s reflections and its recommendations. As a follow-up to this orien- tation day, the Collège des médecins du Québec wishes to state publicly that it has favourably received the work and reflections of the Commission and strongly supports all of its recommendations to the Collège.

Accordingly, the Collège des médecins du Québec plans to publish and widely circulate the results of the Commission’s work.

To better direct its actions in the coming months and years, the Collège des médecins du Québec has extracted ten priority commitments from the Commission’s 39 recommendations. They are as follows.

COMMITMENTS OF THE COLLÈGE DES MÉDECINS DU QUÉBEC

COMMITMENTS

OF THE COLLÈGE DES MÉDECINS DU QUÉBEC C OMMITMENTS 1 . To take the necessary measures
OF THE COLLÈGE DES MÉDECINS DU QUÉBEC C OMMITMENTS 1 . To take the necessary measures

1. To take the necessary measures so that physicians in active prac- tice and physicians in training can better take on the roles required to practise their profession in the 21st century. These roles com- prise particularly those of scientific and effective clinician, human- istic professional, learner, communicator and team player.

2. To reaffirm the role of family physicians as first-line professionals also responsible for follow-up medical care, and the role of special- ists as expert-clinicians with their patients and consultants with their colleagues.

3. To pursue efforts, in concert with the Interprofessional Council of Québec, the Office des professions du Québec and other profes- sional orders, to clearly define the competence and field of prac- tice of physicians and other health professionals, as well as the responsibilities of each and the mechanisms for collaboration be- tween them.

4. To reaffirm, given the legal responsibility for medical care assumed by physicians, the latter’s essential role in interdisciplinary work, and to make sure that physicians acquire the necessary skills to work as part of such teams.

COMMITMENTS OF THE COLLÈGE DES MÉDECINS DU QUÉBEC

 

5.

To evaluate the quality of medical practice in different care set- tings, including private practice, emphasizing the comprehen- siveness and continuity of medical care; to begin immediately to support Québec physicians in their efforts to acquire, develop and maintain the competence required to provide such care, and to support practice sites in their efforts to continually improve the services they provide.

6.

To ensure that prevention and health promotion are an integral part of the everyday professional practice of physicians.

7.

To implement a process of reflection on the ethical aspects of prob- lems encountered in everyday medical practice.

8.

To implement a process of reflection on the pertinence of regional and sub-regional medical councils, and the form these would take.

9.

To implement a process of reflection on ways and means of pro- moting comprehensive medical management, interdisciplinary team work and home visits to patients who make up vulnerable clienteles.

10.

To implement a process of reflection on the use of information and communication technologies in everyday clinical activity.