Expectations of physicians and of the medical profession are undergoing significant change. Some of these changes call into question the unwritten compact between physicians and society known as the social contract of medicine. Although, in some ways, these changes represent threats to the profession, they are also a unique opportunity. Physician leaders can play a role in addressing issues at the system level: by unifying the profession, improving relations between physicians, and ensuring greater focus on patient-centred care. None of these solutions is easy. However, determined action can ensure that physicians reclaim their role as health system leaders and contribute to a system that provides high-quality care for patients and a rewarding career for physicians.

 

KEY WORDS: medical professionalism, physician leadership, accountability, quality, profession-led regulation, intra-professionalism, unity, patient-centred care

 

The concept of professionalism is not unique to medicine.  However, medical professionalism has endured in its centrality to the identity of physicians. From the Hippocratic oath to more recent codes of ethics, medical professionalism is rooted in the well-being of the patient. Beyond this, physicians are expected to consider their actions vis-à-vis society and the systems in which they practise. These expectations are often referred to as the “social contract of medicine,” whereby physicians act in the best interests of their patients and society in exchange for privileges, such as professionally led regulation. Changes in practice and expectations of the public, of governments, and within the profession have begun to call into question the nature and scope of the social contract. Increasingly, there are suggestions that physicians may not always be holding up their end of the bargain.

Recent evidence shows that patients no longer trust physicians the way they once did. An Ipsos poll commissioned by the Canadian Medical Association in 2013 found that less than half (46%) of Canadians view their physicians as trustworthy — a decrease of 24% in 10 years.1 The same poll found a decrease in the proportion of physicians perceived as up to date on current developments (from 60% to 36%) and compassionate (from 61% to 35%). Physicians themselves agree, with 85% reporting a threat to their reputation and role in Canada.1 Top

 

Physicians have not necessarily failed to uphold their side of the agreement. Rather, changing expectations are beginning to redefine the social contract. There is a need to ensure that the professional values and roles that physicians have always adhered to still reflect the realities of 21st century medicine. These new realities offer both a threat and an opportunity. If physicians and their representative organizations do not rise to the challenge, then other parties, such as governments and regulatory bodies, will step in and make changes that may not benefit patients or the health care system. On the flip side, physicians have a unique opportunity to reclaim their role as health system leaders.

 

In this article, we present some of the challenges facing the medical profession. We examine issues at the system level, the impact of strained relations between physicians, and the need to increase care that is truly patient-centred. This analysis is intended to provide physician leaders with an impetus for change. We believe that changes will ultimately lead to better patient outcomes as well as a more rewarding practice for physicians. Top

 

Leadership for health system improvement

 

As the Ipsos data1 show, the reputation of physicians collectively in society has decreased in recent years. Research on medical investigations/interventions has demonstrated gaps in knowledge as well as practices that have little benefit and are even sometimes harmful.2 A recent study in the British Medical Journal found that medical errors are now the third leading cause of death in the United States.3 Although there are questions about the reliability of these data, and many errors are due to systemic issues, patients are more likely to question medical decisions as the number of serious injuries and deaths increases. This can challenge the trust relationship between physicians and their patients.

 

Patients are not the only ones questioning medical professionals. The public is increasingly calling on governments to be accountable for taxpayer dollars. As a result, governments are looking at spending as a way to demonstrate accountability to taxpayers. In 2014, the British Columbia auditor general’s report, “Oversight of Physician Services,”4 included three main findings. First, government is not ensuring that physician services achieve value for money. Second, government is unable to demonstrate whether physician services are high quality and compensation is best value. Third, systemic barriers limit the government’s ability to achieve value for money. Top

 

Further, at least three provinces have questioned the system of professionally led regulatory oversight of medical practice. From 2010 to 2011, a series of problems with the quality of diagnostic imaging reports was identified in health authorities in British Columbia. A resulting report recommended improvements in licensing, credentialing, privileging, and performance management.5 In October 2014, Ontario Health Minister Eric Hoskins issued a letter to all college presidents and registrars/executive directors calling for increased public reporting and transparency.6 He cited his responsibility under the Regulated Health Professions Act, 19917 to regulate in the public interest, including ensuring relevant, timely, useful, and accurate public access to information. Finally, in November 2015, the Quebec National Assembly passed Bill 208 to address the province’s concerns about access by establishing minimum requirements for general practitioners and specialists for the provision of patient care. Before its passage, Quebec Health Minister Gaétan Barrette reached an agreement with physicians to delay implementation until December 2017 in exchange for a commitment to ensure that 85% of the province’s population would have a family physician.9 This conversation is ongoing, and the challenge to physician autonomy remains.

 

Physician accountability in Canada is currently governed primarily by the profession. Legislative authority over health professionals is the purview of provincial and territorial governments, which have delegated authority to the provincial medical regulatory colleges. Regulators are responsible for public protection through the licensure of physicians and the development and enforcement of regulations, standards of practice, policies, and guidelines governing medical practice.10 Concern is growing that colleges may not be sufficiently protecting the public from incompetent or even criminal physicians.11 Top

 

Professionally led regulation is a privilege, not a right, and one that can be removed. Regulatory failings in the United Kingdom led to the removal of professionally led regulation through the creation of the Professional Standards Authority for Health and Social Care, an umbrella regulatory body governing the activities of regulatory bodies.11 Composition of the General Medical Council is no longer determined by physicians. In addition, all UK physicians are required to renew their license every five years through a process of revalidation.11

 

Further, the alignment of incentives/payments for performance and quality of medical care is an issue of concern. In Canada, fee-for-service (FFS) remains the second most popular payment method, accounting for 37.2% of physician payments.12 FFS is a volume-based system that rewards physicians for providing services regardless of whether they are necessary or delivered with high quality. This is not to say that a FFS system cannot be successful in achieving desired outcomes, but, as the Canadian system is currently designed, it may limit opportunities to promote quality of care and practitioner accountability.13 Top

 

A number of issues face physicians at the system level: (1) calls for increasing accountability to patients and the system; (2) a need to demonstrate value and quality; (3) the need for a regulatory system that does a better job of protecting the public; and (4) a need to examine the systems of incentives that have made health care improvements difficult for many years. None of these challenges has an easy solution; they require a reconsideration of the way physicians interact with the system. However, they also represent an opportunity for physician leaders to work with stakeholders to ensure a health system that meets the needs of Canadians.

 

Unifying the profession

 

At a recent gathering of Canadian physician thought leaders, participants noted a lack of unity among physicians.14 They noted divides between family physicians and specialists, between students/residents and practising physicians, and between medical leaders/administrators and front-line physicians.

 

There are many systemic challenges to effective intra-professional relationships in Canadian health care.15 One of these is the hidden curriculum in medical education; the peer and educator influences that function within the organizational and cultural structure of the institution. It is these unwritten rules and behaviours that work alongside formal training to determine how physicians will practise.15 Top

 

Perhaps one of the more difficult realities is the denigration of colleagues that sometimes occurs between specialties.16 This can be especially true for trainees considering family medicine or psychiatry. Research in Canada and internationally has demonstrated that many specialties see family physicians as less skilled and not as worthy of respect.17 Medical students also report the negative attitudes of colleagues and family as a deterrent to choosing psychiatry as a specialty.18

 

In his 2014 book, The Secret Language of Doctors, Dr. Brian Goldman devotes an entire chapter to the terminology that doctors use to refer to other specialities.16 Goldman suggests that much of the slang is merely a way to deal with the stresses of medicine; language such as this, however, has the potential to reinforce negative stereotypes and could result in significant strains on intra-professional relationships.

 

Another potential barrier is the issue of pay relativity. Specialists with similar education, training, and responsibility are sometimes paid vastly different amounts depending on whether they provide procedures or rely on direct patient encounters with no procedures.19 Annual compensation can differ by hundreds of thousands of dollars between specialities.16 These pay differentials may lead to conflict, with greater pay being seen as synonymous with greater respect.16 Although there are no easy answers to this issue, some provinces have begun the difficult process of revising and modernizing their fee codes to address such inequities. This is a good example of the challenging but ultimately necessary conversations that lie ahead for physician leaders in Canada. Top

 

There are also serious issues in the relationship between practising physicians and medical learners. Studies conducted with medical students and residents have found that intimidation and harassment are still issues of concern in Canadian medical training. According to a 2012 survey, 72.9% of respondents reported experiencing inappropriate behaviour from others during residency.20 Of these, half came from attending physicians or nursing staff. Further, 45–93% of residents or junior doctors experienced some form of negative encounter at least once during residency. Verbal abuse was the most common form. Sexual harassment was also documented by 25–60% of residents.

 

During summer 2016, physician contract negotiations in Ontario presented a stark example of this difficult challenge. Although there was disagreement among physicians at all levels, medical learners seemed to face particularly harsh criticism for their views. Although thankfully small in number, threats to end careers as well as threats of actual physical violence were reported by medical students and residents and were in clear public view in many cases on social media.21 The medical profession has an obligation to denounce this sort of behaviour in clear and unmistakable terms.

 

This treatment of learners is problematic for a number of reasons. Harassment and intimidation can lead to burnout and cynicism.22 Affected learners face isolation, self-blame, and loss of confidence, all of which can lead to deteriorating physical and mental health.20 Witnessing unprofessional behaviour has been shown to have negative effects on the learner’s own personal code of ethics and can become part of the hidden curriculum as outlined above.23 Finally, witnessing this type of behaviour threatens to work at cross purposes with the values of professionalism being taught in the formal curriculum.  Top

 

Increasing unity within the profession presents the biggest opportunity for physician leaders. Although burnout and stress from larger system issues can cause negative and disruptive behaviour, physicians are the only ones who can address and improve these relationships. Leaders must be proactive in bridging the divide with front-line physicians. Further, physician leadership should be developed at the clinical level. Finally, efforts should be made to connect system leaders and academics, clinical leaders, and front-line practitioners in addressing the important challenges facing health care in Canada.

 

Increasing patient-centred care

 

Another important challenge rests with improving the overall health care experience for our patients. Research demonstrates that achieving patient-centred care leads to greater patient satisfaction, improved patient outcomes, and a reduction in both underuse and overuse of health care services.24 Research has also demonstrated associated reductions in mortality, hospital acquired infections, and improved patient functional status.25 These results make it clear that increasing patient-centred care will have benefits for physicians as well. Despite this evidence, very few health systems are managing to achieve this objective. Top

 

There are a number of challenges to integrating the principles of patient-centred care into medical practice. One is the lack of effective communication between physicians and their patients. Patients are often unsatisfied with communication, even when physicians think they have done a good job.26 Surveys have shown that better communication from physicians is a key desire for patients.26 Researchers have linked poor communication with misdiagnoses, ordering unnecessary tests, and low patient compliance. Poor communication is the root cause of 40% of malpractice suits due to medical errors.27 Conversely, effective communication increases self-management of chronic disease.28

 

Another barrier is the way that systems are currently designed: putting providers rather than patients at the centre of system planning and delivery. According to data from a 2013 Commonwealth Fund survey, 62% of Canadians find it difficult to access medical care in the evenings, on weekends, or during holidays.29 Nearly half of respondents (47%) said they had recently used an emergency department for a problem that could have been treated by their family doctor. Fewer than half (41%) can get same-day or next-day access to their family physician.

 

The relationship between physicians and their patients is fundamental to the practice of high-quality medicine. Bolstering trust should be a primary goal for physician leaders. Improvements will lead to patients who are more engaged in managing their own care. These activated patients often use resources more effectively, take more preventative health steps, and may in fact reduce pressures on the system.30 Reducing pressures on the system, in turn, could translate into reductions in demand for all members of the system, including physicians. Top

 

Conclusion: a vision for medicine in the 21st century

 

The practice of medicine in Canada is facing challenges that are different from those at any other time in recent history. Pressure from patients and society, from governments and from within the profession is contributing to an era of change and uncertainty.

 

These challenges also represent tremendous opportunities. The delivery of high-quality patient-centred care and enhanced accountability for clinical outcomes should be promoted by all physician leaders.

 

Further, there is a need to take action to help unify the medical profession. Leaders should demonstrate to their colleagues that there is much more that unites the profession than divides it and create safe spaces for colleagues to interact with civility.

 

Finally, leaders need to work together to help restore the trust that is so necessary for effective patient–physician relationships. By demonstrating leadership in health system improvements, physician leaders can ensure a health system that works for their patients, for funders, and for all health care providers. Top

 

References

1.Ipsos Reid. Physicians’ unique value in changing times. Ottawa: Canadian Medical Association; 2013.

2.Tallis RC. Doctors in society: medical professionalism in a changing world (editorial). Clin Med 2006;6(1):7-12. Available: https://tinyurl.com/hjbwxx8

3.Makary MA, Daniel M. Medical error — the third leading cause of death in the US. BMJ 2016; 353 :i2139.

4.Oversight of physician services. Victoria: Office of the Auditor General of British Columbia; 2014. Available: https://tinyurl.com/z94hepx

5.KPMG. British Columbia Ministry of Health — provincial review of licensure, credentialing, privileging, monitoring and enhancement of performance. Victoria: Ministry of Health; 2012. Available: https://tinyurl.com/h5t7chx

6.Hoskins E. Minister Hoskins’ letter to college presidents and registrars (health bulletin). Toronto: Ministry of Health and Long-Term Care; 2014. Available: https://tinyurl.com/zkvfxnc

7.Regulated health professions act, 1991. S.O. 1991, c. 18. Toronto: Government of Ontario; 1991. Available: https://tinyurl.com/zhedcol

8.Bill 20: an act to enact the act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation. Québec: Assemblée nationale Québec; 2015. Available: https://tinyurl.com/he574kk

9.Fidelman C. Barrette backtracks on Bill 20, on condition 85% of Quebecers have family doctor by 2017. Montreal Gazette 2015; May 25. Available: https://tinyurl.com/gs8she8

10.Naylor CD, Gerace R, Redelmeier DA. Maintaining physician competence and professionalism: Canada’s fine balance. JAMA 2015;313(18):1825-6.

11.Dixon-Woods M, Yeung K, Bosk CL. Why is UK medicine no longer a self-regulating profession? The role of scandals involving “bad apple” doctors. Soc Sci Med 2011;73(10):1452-9.

12.National physician survey, 2013: national results by province. Ottawa: College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada; 2013. Available: https://tinyurl.com/hmee6ew

13.Davis KN. Paying for care episodes and care coordination. N Engl J Med 2007;356:1166-8.

14.Medical professionalism thought leader forum. Ottawa: Canadian Medical Association; 2  Nov. 2016.

15.Little L. System issues, policies and practices affecting physician intraprofessionalism. Ottawa: College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada; 2011. Available: https://tinyurl.com/zco7kbr

16.Goldman B. The secret language of doctors: cracking the code of hospital slang. Toronto: Harper Collins; 2014.

17.Manca D, Varnhagen S, Brett-McLean P, Allan GM, Szafran O. Respect from specialists: concerns of family physicians. Can Fam Physician 2008;54 :1434-5.e1-5. Available:

https://tinyurl.com/jno25rj

18.Wiesenfeld L, Abbey S, Takahashi S G, Abrahams C. Choosing psychiatry as a career: motivators and deterrents at a critical decision-making juncture. Can J Psychiatry 2014;59(8):450-4.

19.Wooder S. Ontario needs physician payment reform — so do doctors (blog). Stoney Creek, Ont.: drscottwooder; 21 Jul. 2015. Available: https://tinyurl.com/hbro7hg

20.Optimizing a positive work environment by addressing intimidation & harassment (position paper). Ottawa: Resident Doctors of Canada; 2015. Available: https://tinyurl.com/j5akpfp

21.Bronca T. Ontario doctors reject tentative physician services agreement in historic vote. Med Post 2016;15 Aug.

22.Billings ME, Lazarus ME, Wenrich M, Curtis JR, Engelberg RA. The effect of the hidden curriculum on resident burnout and cynicism. J Grad Med Educ 2011:3(4):503-10.

23.Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: a cross-sectional qualitative study. Med Teach 2015;Aug 14:1-9

24.Shaller D. Patient-centered care: what does it take? New York: The Commonwealth Fund; 2007. Available: https://tinyurl.com/29unw3u

25.Baxter H, Cornwell J. Using patient experience to redesign healthcare services. London: King’s Fund; 2012.

26.Fong Ha J, Longnecker N. Doctor-patient communication: a review. Ochsner J 2010;10(1):38-43. Available: https://tinyurl.com/zfdwcdg

27.Aboumatar H, Chang B, Hanna M, Siddiqui Z. Best practices in patient-centered care: conference proceedings. Baltimore: Johns Hopkins University; 2013. Available: https://tinyurl.com/gqnfzyk

28.Bauman AE, Fardy HJ, Harris PG. Getting it right: why bother with patient-centred care? Med J Aust 2003;179(5):253-6.

29.Where you live matters: Canadian views on health care quality. Toronto: Health Council of Canada; 2014. Available: https://tinyurl.com/zjxxlsy

30.Greene J, Hibbard JH. Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J Gen Intern Med 2011;27(5):520-6. Top

 

Authors

Jenny Buckley, MA, MSc, was senior advisor, Medical Professionalism, at the Canadian Medical Association and is a PhD candidate at Carleton University, Ottawa.

 

André Bernard, MD, MSc, FRCPC, is chair of the Board of Directors of Doctors Nova Scotia and an assistant professor in the Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax.

 

Emily Gruenwoldt, MHA, was director of Professional Affairs at the Canadian Medical Association, Ottawa.

 

Cécile M. Bensimon, MA, PhD, is director of Ethics and Professional Affairs at the Canadian Medical Association, Ottawa.

 

Jeff Blackmer, MD, MHSc, FRCPC, is vice-president, Medical Professionalism, at the Canadian Medical Association, Ottawa.

 

Correspondence to:  cecile.bensimon@cma.ca

 

Author attestation: JBu, EG, and JB conceptualised the manuscript. JBu drafted the initial manuscript. AB, CMB, JB contributed to revisions to the manuscript. All authors have approved the final manuscript. No authors have any conflict of interest

 

This article has been reviewed by a panel of physician leaders.

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