New Professional Challenges for Physicians in the 21st Century

COLLÈGE DES MÉDECINSDU QUÉBEC

Commission on the Practiceof Medicine in the 21st Century

New Professional Challengesfor Physicians in the 21st Century

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COLLÈGE DES MÉDECINSDU QUÉBEC

New Professional Challengesfor Physicians in the 21st Century

Report and recommendationsof the Commission on the Practiceof Medicine in the 21st Century,together with commitments madeby the Collège des médecinsdu Québec

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NOTE TO READERS

The following document is an abridged version ofthe 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 WestMontréal, QuébecH3H 2T8

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

By fax: (514) 933-3112

By E-mail: [email protected]

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FOREWORD

In the spring of 1996, the health care system wasstruggling with unprecedented budget constraints which resulted in extremelydifficult organizational decisions, including the closure of many hospitals, themerging of various establishments and the vaunted shift to ambulatory care.This situation led sometimes perturbed physicians to question the Collège aboutthe 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 inthis 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 duringmy 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 healthcare 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, aswell as other health care professionals to build a composite of what medicinewill be tomorrow. The Commission’s final report received an enthusiastic wel-come from Bureau members and, on October 15, 1997, they unanimouslyadopted 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 formduring the coming months and years, working together with its partners andthe various bodies and/or groups concerned.

We trust that the reference points contained in this document will bring togetherthose 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 challengeslooming on the horizon, so that we may continue to provide Quebecers withquality service.

Roch Bernier, M.D.President

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

Dr. Joseph AyoubOncologistHôpital Notre-Dame, MontréalPresident of the Commission

Dr. Claude BélisleFamily PhysicianCentre de santéDrummondville

Dr. Josée CaronGeneral SurgeonCentre hospitalier Jeffery HaleQuébec City

Dr. Pierre DuplessisAssistant General SecretaryCollège des médecins du QuébecSecretary to the Commission

Ms. Julie GermainMedical StudentUniversity of Sherbrooke

Dr. Paul Grand’MaisonFamily PhysicianDirector, Health Sciences Education CentreUniversity of Sherbrooke

Dr. Charles GuertinSurgery Resident IFédération des médecins résidentsdu Québec

Mr. Benoît LauzièreRepresentative of the public appointedto the Bureau of the Collège des médecinsdu QuébecSchool executive

Dr. Paule LebelCommunity Health Medical SpecialistCentre hospitalier Côte-des-NeigesMontréal

Dr. Sandra PalmieriCommunity Health Resident V

Ms. Odette Plante MarotNurseHôpital Saint-Luc, Montréal

Ms. Céline PlourdePharmacistPharmacie Céline PlourdeSaint-Léonard-d’Aston

With the collaboration of:Ms. Monique ChaputAdult Education ExpertCollège des médecins du QuébecCoordinator and facilitator ofthe Commission’s work, authorof the report

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ACKNOWLEDGMENTS

EXPERTS WHO MET WITHCOMMISSION MEMBERS

Docteur Renaldo N. BattistaProfesseur titulaireFaculté de médecine, Université McGillPrésident du Conseil d’évaluationdes technologies de la santé

Monsieur le juge Jean-Louis BaudouinCour d’appel du Québec

Monsieur Gilles DussaultProfesseur titulaireDépartement d’administration de la santéFaculté de médecine, Université de Montréal

Monsieur Claude ForgetConseillerCEF Ganesh Corporation

Docteur André MungerMédecin de familleCLSC SOC, Sherbrooke

Monsieur Jean ParéPrésident et rédacteur en chefL’actualité (magazine mensuel, Montréal)

Monsieur Norbert RodriguePrésidentConseil de la santé et du bien-être du Québec

Monsieur David J. RoyDirecteurCentre de bioéthiqueInstitut de recherches cliniques de Montréal

Monsieur Yves SéguinDirecteur général délégué aux affairescanadiennesCompagnie générale des eaux

ORGANIZATIONS WHICH MET WITHCOMMISSION MEMBERS

Conseil médical du Québec

Fédération des médecins omnipraticiensdu Québec

Fédération des médecins spécialistesdu Québec

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

The Commission also wishes to thank all the directors and executive physicians ofthe Collège des médecins du Québec who assisted during the consultation phase.Particular thanks also go to Dr. Chantal Archer and Ms. Lorraine Locas, researchagents, and Mesdames Céline Bastien, Christiane Beaudoin, Denise Chrétien, HélèneLandry 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 documenttexts and drawing up the final report.

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PERSONS CONSULTED WHEN THEMESWERE BEING STUDIED OR TEXTS WRITTEN

Docteur Marie-Dominique BeaulieuMédecin de familleHôpital Notre-Dame, Montréal

Monsieur Jean-Pierre BélangerConseillerConseil de la santé et du bien-être du Québec

Docteur Howard BergmanChef de la division de gériatrieHôpital général juif Sir M.B. Daviset Université McGill, Montréal

Docteur Roch BernierPrésidentCollège des médecins du Québec

Docteur Lucie Brazeau-LamontagneSecrétaire et vice-doyenneFaculté de médecineUniversité de Sherbrooke

Docteur Suzanne BrissetteMédecin de familleHôpital Saint-Luc, Montréal

Docteur Julie BruneauMédecin de familleHôpital Saint-Luc, Montréal

Monsieur Yvon BrunelleAgent de rechercheDirection générale de la rechercheet de l’évaluationMinistère de la Santé et des Services sociaux

Monsieur Claude CastonguayVice-président du ConseilBanque Laurentienne

Docteur Louise CharbonneauMicrobiologiste médicaleCLSC des Faubourgs, Montréal

Docteur Réal CloutierMédecin-conseilRégie régionale de la santé et des servicessociaux Chaudière-Appalaches

Docteur Christine CollinSous-ministre adjointeDirection générale de la santé publiqueMinistère de la Santé et des Services sociaux

Docteur Michel CôtéCardiologueCentre universitaire de santé de l’EstrieSherbrooke

Docteur Adrien DandavinoDirecteurDirection des études médicalesCollège des médecins du Québec

Docteur Serge DaneaultMédecin-conseilDirection de la santé publiqueRégie régionale de la santé et des servicessociaux de Montréal-Centre

Docteur Geneviève DechêneMédecin de familleClinique médicale de l’Ouest, Verdun

Docteur Jocelyn DemersHématologue-oncologueHôpital Sainte-Justine, Montréal

Maître Pierre DeschampsDirecteur de la rechercheCentre de recherche en droit privéet comparé de l’Université McGill

Monsieur Jean-Claude DeschênesConseiller en administration et en formationMinistère de la Santé et des Services sociaux

Docteur Gilles DesrosiersMédecin-conseilRégie régionale de la santé et des servicessociaux de l’Estrie

Madame Sylvie DillardSous-ministre adjointeDirection générale de la planificationet de l’évaluationMinistère de la Santé et des Services sociaux

Monsieur Hubert DoucetProfesseur invitéFacultés de médecine et de théologieUniversité de Montréal

Monsieur Guy DurandProfesseur et directeur du DESS en bioéthiqueFaculté de théologie, Université de Montréal

Monsieur Jacques GagnéPharmacienLaboratoire de recherchepharmaceutique inc., Laval

Docteur André GaronMédecin-conseilConseil de la santé et du bien-être du Québec

Madame Marjolaine GobeilDirectricePlanification et développement professionnelOrdre des infirmières et infirmiers du Québec

Père Robert Hivon, jésuiteExpert en bioéthique, Montréal

NOUVEAUX DÉFIS PROFESSIONNELS POUR LE MÉDECIN DES ANNÉES 2000

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Docteur Gilles HudonPrésidentAssociation des radiologistes du Québec

Docteur Juan Roberto IglesiasPrésidentConseil médical du Québec

Monsieur Roger Jacob, ing., M.Sc.A.Directeur-adjointDirection des ressources financièreset des services techniquesHôpital du Sacré-Cœur de Montréal

Docteur André JacquesDirecteurDirection de l’amélioration de l’exerciceCollège des médecins du Québec

Docteur Denis LabergeDirecteur adjointDirection de l’amélioration de l’exerciceCollège des médecins du Québec

Monsieur Daniel LacasseDirecteur régional de la santé physiqueRégie régionale de la santé et des servicessociaux de l’Outaouais

Madame Michèle Lamquin-ÉthierDirectrice généraleComité provincial des malades

Docteur Bernard LapointeMédecin de familleSoins palliatifs, Hôpital Royal VictoriaMontréal

Docteur Yvon-Jacques LavalléePsychiatreCentre universitaire de santé de l’EstrieSherbrooke

Docteur Guy LegrosDirecteur adjointDirection des études médicalesCollège des médecins du Québec

Docteur Richard LemieuxMédecin-conseilConférence des régies régionales de la santéet des services sociaux du Québec

Docteur Pauline Lesage-JarjouraSanté communautaire, Faculté de médecineUniversité de Sherbrooke

Docteur Joëlle LescopSecrétaire généraleCollège des médecins du Québec

Docteur Georges L’EspéranceNeurochirurgienCentre médical René-Laënnec, Montréal

Docteur Richard LessardDirecteurDirection de la santé publiqueRégie régionale de la santé et des servicessociaux de Montréal-Centre

Docteur Laurent MarcouxMédecin de familleCentre médical Saint-DenisSaint-Denis

Docteur Claude MercureDirecteurDirection des enquêtesCollège des médecins du Québec

Docteur Clément OlivierMédecin de familleSaint-Hippolyte

Docteur Marie-France RaynaultMédecin-conseilRégie régionale de la santé et des servicessociaux de Montréal-Centre

Docteur Nicolas SteinmetzDirecteur général associéGroupe de planification, Centre universitairede santé de l’Université McGill

Docteur Michel TétreaultPrésidentGroupe tactique d’interventionMinistère de la Santé et des Services sociaux

Docteur Jean-Bernard TrudeauDirecteur des services professionnelsCentre hospitalier Pierre-Janet, Hull

REGIONAL BOARDS, REGIONAL MEDICALCOMMISSIONS AND PHYSICIANS GROUPSMET DURING THE VISIT BY THE PRESIDENTOF THE COLLÈGE TO THE FOLLOWINGREGIONS:

– 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


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PERSONS AND ORGANIZA-TIONS WHO MADE WRITTENCONTRIBUTIONS DURINGTHE CONSULTATION PHASE1

Docteur Youssef AinmelkObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur Diane AmyotDirectrice des servicesprofessionnelsCentre Frédérick-George-HériotDrummondville

Docteur Christiane ArbourCoordonnatrice du programmeen santé physique et des servicespréhospitaliers d’urgenceRégie régionale de la santé et desservices sociaux des Laurentides

Docteur Jean-Louis BardPrésidentAssociation des conseils desmédecins, dentistes et pharmaciensdu Québec

Docteur Jacques BeaudryMédecin de familleTrois-Rivières

Monsieur Claude BeauregardDirecteur généralConseil interprofessionneldu Québec

Docteur Marc BellemareObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur Charles BernardVice-présidentCollège des médecins du Québec

Docteur Louis BernardDirecteurDépartement de médecine socialeet préventive, Université Laval

Docteur Harold BernatchezPrésidentAssociation des médecinsmicrobiologistes infectiologuesdu Québec

Docteur Sylvie BernierDirectriceServices professionnelsHôtel-Dieu de Lévis

Docteur Gilbert BlainDirecteur des services professionnelsInstitut de réadaptationde Montréal

Docteur Francine BlaisObstétricienne-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur Luc BoileauMédecin-conseilRégie régionale de la santé et desservices sociaux de la Montérégie

Docteur Robert BoileauPrésidentAssociation des pneumologuesde la province de Québec

Docteur Myriam BoillatDirectrice du programmede résidenceDépartement de médecinefamiliale, Université McGill

Docteur Henri-Louis BouchardChirurgien orthopédiqueCentre hospitalier universitairede Québec

Docteur Laurier BouchardObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Monsieur Laurier BoucherPrésidentOrdre professionnel des travailleurssociaux du Québec

Docteur Claude BrièreAnesthésisteVictoriaville

Docteur Placide CaronMédecin de familleVal-Brillant

Docteur Aurélien CarréAdministrateurBureau du Collège des médecinsdu Québec

Docteur Pierre CarrierDirecteur des services professionnelsCentre hospitalier Saint-Josephde la Malbaie

Docteur Simon CarrierObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Monsieur François CharbonneauSecrétaire et directeur généralOrdre des optométristes du Québec

Madame Louise ChartierDirectriceDépartement des sciencesinfirmièresFaculté de médecineUniversité de Sherbrooke

Docteur Hélène ChénardObstétricienne-gynécologueAssociation des obstétricienset gynécologues du Québec

Monsieur Lionel ChouinardDirecteur généralRégie régionale de la santéet des services sociauxChaudière-Appalaches

1. A number of people who helpedwith the Commission’s study ofthe various themes or the writingof texts also forwarded their writtencomments. Their names are notrepeated here.

Docteur Pierre CôtéMédecine de familleClinique médicale du Quartier latinMontréal

Docteur Jean-Pierre CourteauMédecin-conseilRégie régionale de la santé et desservices sociaux de l’Outaouais

Docteur Linda DaigneaultMédecin de familleMontréal

Docteur Michelle DallaireProfesseurProgramme de médecine de familleFaculté de médecineUniversité de Montréal

Docteur Wilber DeckMédecin-conseilRégie régionale de la santéet des services sociauxGaspésie–Îles-de-la-Madeleine

Docteur Donald DelisleMédecin de familleBromptonville

Docteur Michel DesjardinsDirecteur des services professionnelsHôtel-Dieu de Gaspé

Docteur Jean De SerresMédecin de familleChelsea

Docteur Jean-Pierre DespinsPrésidentAssociation des médecinsomnipraticiens des Bois-Francs

Monsieur Denis DrouinAdministrateurBureau du Collège des médecinsdu Québec

Madame Anne Du SaultAgente de programme en santéphysiqueRégie régionale de la santé et desservices sociaux de l’Outaouais

Docteur Claude DuguayAdministrateurBureau du Collège des médecinsdu Québec

Docteur Louise DuperronAdministratriceBureau du Collège des médecinsdu Québec

Monsieur Jean-Pierre DuplantieDirecteur généralRégie régionale de la santé et desservices sociaux de l’Estrie

Docteur Louise DuranceauPrésidenteAssociation des spécialistes enchirurgie plastique et esthétiquedu Québec

Docteur Renald DutilPrésidentFédération des médecinsomnipraticiens du Québec


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Docteur Alex FerenczyAdministrateurBureau du Collège des médecinsdu Québec

Docteur Raynald FerlandPrésidentAssociation d’oto-rhino-laryngologieet de chirurgie cervico-facialedu Québec

Docteur France-Laurent ForestPrésidentCommission médicale régionaleRégie régionale de la santéet des services sociauxGaspésie–Îles-de-la-Madeleine

Docteur Claude FortinObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur Jean-Claude GagnéDirecteur généralCentre hospitalier de la régionde l’Amiante

Docteur Jeannine GagnéMédecin de familleCentre hospitalier Saint-Eustache

Docteur Richard GagnéAdministrateurBureau du Collège des médecinsdu Québec

Monsieur Gilbert GagnonPrésidentOrdre des technologuesen radiologie du Québec

Docteur Louis GagnonSecrétaireProgramme santé – Acti-Menu

Monsieur Claude GaronDirecteur généralCLSC de Jonquière

Docteur Pierre GaudreaultPrésidentAssociation des pédiatresdu Québec

Docteur Pierre GauthierPrésidentFédération des médecinsspécialistes du Québec

Docteur Pierre GfellerMédecin de familleCentre hospitalier et Centre deréadaptation Antoine-Labelle

Madame Laurie GottliebDirectriceÉcole des sciences infirmièresUniversité McGill

Docteur Jean GrégoireMédecin-conseilRégie régionale de la santéet des services sociauxChaudière-Appalaches

Docteur Yves GrenierInternisteBeauport

Docteur Yves GrenierMédecin de familleMontréal

Docteur Jean-Pierre JannelleMédecin de familleCLSC de La Pommeraie

Docteur Claude LabergeMédecin de familleVille-Marie

Docteur Philippe LabergeObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur Renée LafrenièreOmnipraticienneÉquipe de santé mentaleCLSC Huntingdon

Docteur Yves LamontagneAdministrateurBureau du Collège des médecinsdu Québec

Docteur Joris LapointeMédecin de familleMini-Urgences, Jonquière

Monsieur Raymond LeblancDirecteur scientifiqueFonds de la recherche en santédu Québec

Docteur Hélène LeclèreDirectriceBureau de pédagogie des sciencesde la santé, Université Laval

Docteur Yolande LeducVice-présidenteAssociation des omnipraticiensen périnatalité du Québec

Docteur Francine LégerPrésidenteCollège québécois des médecinsde famille du Canada

Monsieur Michel LégerDirecteur généralRégie régionale de la santé et desservices sociaux des Laurentides

Docteur François LemieuxPrésidentAssociation des omnipraticiensen périnatalité du Québec

Docteur Denis LepageAdministrateurBureau du Collège des médecinsdu Québec

Docteur Pierre LoiselleMédecin de familleClinique médicale Montéede la Baie

Docteur France LussierMédecin-conseilRégie régionale de la santé et desservices sociaux de Lanaudière

Docteur Michelle Lussier-MontplaisirAdministratriceBureau du Collège des médecinsdu Québec

Docteur Pierre MaillouxPsychiatreTrois-Rivières

Docteur Lucie MarchandMédecin de familleMagog

Docteur Hubert MarcouxResponsable du programmed’éthiqueÉtudes postgraduées, Facultéde médecine, Université Laval

Docteur André MasséObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur Yvon MénardMédecin de familleLongueuil

Monsieur François MercierDirecteur généralRégie régionale de la santé etdes services sociaux de l’Abitibi-Témiscamingue

Madame Lucie MerolaSecrétaireChambre des huissiers de justicedu Québec

Docteur Bernard MilletteMédecin de familleCité de la Santé de Laval

Monsieur Magella MorassePrésidentOrdre des ingénieurs forestiersdu Québec

Docteur Claude MorinMédecin de familleHavre-Aubert

Docteur Louise NasmithDirectriceDépartement de médecine familialeUniversité McGill

Ordre des acupuncteursdu Québec

Docteur Michel PaquinObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur Pierre PaquinAnesthésisteSainte-Agathe-des-Monts

Docteur Krystyna PeckoDirectrice du secrétariataux affaires médicalesRégie régionale de la santé et desservices sociaux de la Montérégie

Docteur Michèle PelletierMédecin de familleSaint-Jérôme

Docteur Sonia PéloquinMédecin de familleCLSC de La Pommeraie

Docteur France PerronMédecin de familleLac-Mégantic


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Docteur Gilles PineauPrésidentProgramme santé – Acti-Menu

Docteur Benoît PoulinMédecin de familleHôpital Louis-H.-Lafontaine

Madame Maya RaicAdministratriceBureau du Collège des médecinsdu Québec

Docteur Gilles P. RaymondProfesseur titulaire de cliniqueFaculté de médecineUniversité de Montréal

Docteur Michel RheaultChirurgienTrois-Rivières

Docteur Jean RochonMinistre de la Santéet des Services sociauxGouvernement du Québec

Docteur Jean RodrigueDirecteur de la planificationet de la régionalisationFédération des médecinsomnipraticiens du Québec

Docteur Peter RoperPsychiatreMontréal

Docteur Claude RoyPédiatre et gastroentérologueHôpital Sainte-Justine, Montréal

Monsieur Jean-Marc RoyPrésidentFédération québécoise des centresd’hébergement et de soins delongue durée

Monsieur Jean-François SénéchalRégie régionale de la santéet des services sociauxGaspésie–Îles-de-la-Madeleine

Monsieur Marcel SénéchalDirecteur généralConseil québécois d’agrémentd’établissement de santéet des services sociaux

Docteur Vyta SenikasPrésidenteAssociation des obstétricienset gynécologues du Québec

Docteur Pierre ShebibMédecin de familleCLSC J.-Octave-Roussin

Docteur Gérald StanimirObstétricien-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur André TanguayMédecin de familleLaval

Docteur Lorraine Therrien-SaillantDirectrice des services professionnelsCentre hospitalier de l’Archipel

Docteur Jean-Bernard TrudeauVice-présidentConseil de la santé et du bien-êtredu Québec

Docteur Manon TurbideObstétricienne-gynécologueAssociation des obstétricienset gynécologues du Québec

Docteur Michel TurgeonMédecin de familleRouyn-Noranda

Docteur Raymonde VaillancourtPrésidenteSous-comité de périnatalitéde la Fédération des médecinsomnipraticiens du Québec

Docteur Julien R. VeilleuxDirecteurServices professionnelsHôpital Laval, Québec

Docteur Patrick VinayDoyenFaculté de médecineUniversité de Montréal

Docteur Natacha VincentMédecin de familleCLSC du Val-Saint-François

Docteur Karl WeissSecrétaireAssociation des médecinsmicrobiologistes infectiologuesdu Québec


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.............................................................................................................................................................................................................................................. NOTETO READERS ..................................................................................................................................................................................................................... 2

.............................................................................................................................................................................................................................................. FORE-WORD ............................................................................................................................................................................................................................ 3

.............................................................................................................................................................................................................................................. MEM-BERS OF THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY ............................................................................................................................... 4

.............................................................................................................................................................................................................................................. AC-KNOWLEDGMENTS .............................................................................................................................................................................................................. 5

.............................................................................................................................................................................................................................................. TABLEOF CONTENTS ................................................................................................................................................................................................................ 11

.............................................................................................................................................................................................................................................. INTRO-DUCTION ....................................................................................................................................................................................................................... 13

Report of the Commission on the Practice of Medicine in the 21st Century ........................................................................................................................ 18.............................................................................................................................................................................................................................................. PRE-

AMBLE .......................................................................................................................................................................................................................... 19

.............................................................................................................................................................................................................................................. Chapter 1: EvolvingProfessional Roles for Physicians in the 21st Century .................................................................................................................................................. 20

.............................................................................................................................................................................................................................................. INTRO-DUCTION ....................................................................................................................................................................................................................... 21

.............................................................................................................................................................................................................................................. 1.THE EVOLUTION OF MEDICAL PRACTICE .................................................................................................................................................................. 22

.............................................................................................................................................................................................................................................. EX-PANDING BODY OF KNOWLEDGE AND THE EXPLOSION OF TECHNOLOGY ............................................................................................................ 22

.............................................................................................................................................................................................................................................. THECHANGING SOCIOCULTURAL AND POLITICAL CLIMATE ........................................................................................................................................... 22

..............................................................................................................................................................................................................................................CHANGING THE ORGANIZATIONAL FRAMEWORK OF HEALTH CARE DELIVERY ......................................................................................................... 24

.............................................................................................................................................................................................................................................. 2.ROLES, DUTIES AND ORGANIZATION OF WORK FOR PHYSICIANS IN THE 21ST CENTURY ........................................................................................................................ 25

.............................................................................................................................................................................................................................................. KEYORGANIZATIONS DEFINE THE ROLES OF 21ST-CENTURY PHYSICIANS ...................................................................................................................... 26

.............................................................................................................................................................................................................................................. THEPHYSICIAN’S ROLES AS SEEN BY THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY ........................................................ 27

................................................................................................................................................................................................................................................................................................................................................................................................................................ EFFECTIVE SCIENTIFIC CLINICIAN 27

....................................................................................................................................................................................................................................................................................................................................................................................................................................... HUMANISTIC PROFESSIONAL 28

....................................................................................................................................................................................................................................................................................................................................................................................................................................................................... LEARNER 29

........................................................................................................................................................................................................................................................................................................................................................................................................................................................ COMMUNICATOR 29

............................................................................................................................................................................................................................................................................................................................................................................................................................................................... TEAM PLAYER 30

.................................................................................................................................................................................................................................................................................................................................................................................................................................................................... MANAGER 31

...................................................................................................................................................................................................................................................................................................................................................................................................................................... LEADER IN THE COMMUNITY 31

......................................................................................................................................................................................................................................................................................................................................................................................................................................... RESEARCHER AND TEACHER 32

.............................................................................................................................................................................................................................................. 3.COMPLEMENTARITY OF PROFESSIONAL ROLES ............................................................................................................................................................................ 33

.............................................................................................................................................................................................................................................. THEFAMILY PHYSICIAN ........................................................................................................................................................................................................ 34

.............................................................................................................................................................................................................................................. THEMEDICAL SPECIALIST ..................................................................................................................................................................................................... 35

.............................................................................................................................................................................................................................................. RELA-TIONS BETWEEN FAMILY PHYSICIANS AND MEDICAL SPECIALISTS ........................................................................................................................... 35

.............................................................................................................................................................................................................................................. RELA-TIONS WITH OTHER PROFESSIONALS ....................................................................................................................................................................... 36

.............................................................................................................................................................................................................................................. CON-CLUSION ....................................................................................................................................................................................................................... 37

.............................................................................................................................................................................................................................................. BIBLI-OGRAPHY ....................................................................................................................................................................................................................... 38

.............................................................................................................................................................................................................................................. Summaries of the Chaptersand Recommendations .............................................................................................................................................................................................. 39

..............................................................................................................................................................................................................................................Chapter 1: Evolving Professional Roles for Physicians in the 21st Century ................................................................................................................... 40

.............................................................................................................................................................................................................................................. REC-OMMENDATIONS .............................................................................................................................................................................................................. 42

..............................................................................................................................................................................................................................................Chapter 2: Toward an Ethic of Shared Responsibility in a Pluralistic Society ................................................................................................................ 45


..............................................................................................................................................................................................................................................Chapter 3: Vulnerable Clienteles: Modes of Support and Care .................................................................................................................................... 48


..............................................................................................................................................................................................................................................Chapter 4: Prevention and Health Promotion: Its Importance and Impact on 21st-Century Medicine ......................................................................... 52


..............................................................................................................................................................................................................................................Chapter 5: The Organization of Health Care and Health Services ............................................................................................................................... 55


..............................................................................................................................................................................................................................................Chapter 6: Funding the Health Care System .................................................................................................................................................................. 59


..............................................................................................................................................................................................................................................Chapter 7: The Impact of Technology on 21st-Century Medicine ............................................................................................................................... 63


Commitments of the Collège des médecins du Québec ..................................................................................................................................................... 66

INTRODUCTION 13

REPORT OF THE COMMISSION ON THE PRACTICE OF MEDICINEIN THE 21ST CENTURY 18

PREAMBLE 19

CHAPTER 1Evolving Professional Roles for Physicians in the 21st Century 20

Introduction 21

1. The Evolution of Medical Practice 22■ Expanding Body of Knowledge and the Explosion of Technology 22■ The Changing Sociocultural and Political Climate 22■ Changing the Organizational Framework of Health Care Delivery 24

2. Roles, Duties and Organization of Work for Physiciansin the 21st Century 25

■ Key Organizations Define the Roles of 21st-Century Physicians 26■ The Physician’s Roles as seen by The Commission on the Practice

of Medicine in the 21st Century 27Effective Scientific Clinician 27Humanistic Professional 28Learner 29Communicator 29Team Player 30Manager 31Leader in the Community 31Researcher and Teacher 32

3. Complementarity of Professional Roles 33■ The Family Physician 33■ The Medical Specialist 34■ Relations Between Family Physicians and Medical Specialists 35■ Relations with Other Professionals 36

Conclusion 37

Bibliography 38

TABLE OF CONTENTS

12

SUMMARIES OF THE CHAPTERS AND RECOMMENDATIONS 39

Chapter 1Evolving Professional Roles for Physicians in the 21st Century 40

SUMMARY 40RECOMMENDATIONS 42

Chapter 2Toward an Ethic of Shared Responsibility in a Pluralistic Society 45


Chapter 3Vulnerable Clienteles: Modes of Support and Care 48


Chapter 4Prevention and Health Promotion: Its Importance and Impacton 21st-Century Medicine 52


Chapter 5The Organization of Health Care and Health Services 55


Chapter 6Funding the Health Care System 59


Chapter 7The Impact of Technology on 21st-Century Medicine 63


COMMITMENTS OF THE COLLÈGE DES MÉDECINS DU QUÉBEC 66

TABLE OF CONTENTS

13

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

INTRODUCTION

In June 1996, the Collège des médecins duQuébec 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 tosee an examination of the prospects for the practice of medicine in Québec,the major changes the profession might expect and the measures that mightbe taken immediately to contend with tomorrow’s realities.

TERMS OF REFERENCE

The Commission on the Practice of Medicine inthe 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 aconsultant, and to define the conditions of practice specific to them;

■ identify more clearly the collaboration of other health professionals inhealth 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 topicsrelated to their mandate, they decided to define the topics they wished tostudy in depth, and then determine the course to follow in documentingeach of them.

The members of the Commission split into small working committees, eachcorresponding to one of the topics selected. Each committee then devel-oped an inventory of the relevant literature, and met with different expertsand representatives of various agencies. Eleven experts were heard andquestioned at plenary sessions of the commissioners1. Given the speed ofchange, indeed of veritable transformation, and the difficulty of extrapo-lating beyond certain limits, the Commission’s forecasts, while at first

14

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

At the beginning of 1997, each working committee summarized its workin a text, and the major issues and various statements were discussed atplenary sessions by all members of the Commission. Finally, the reflectionsof the committees, coupled with the wide range of opinions and positionsadopted during the plenary sessions, became the raw material for the textswritten in the spring of 1997 and circulated during the consultation phase.

The Commission therefore discharged its mandate by translating it intoseven topics for study, which are the subjects of the seven chapters in thisreport: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’sconsultation paper were circulated. A questionnaire for each text in thedocument allowed those consulted to express their level of agreement withthe main assertions and make comments. These seven questionnaires, aswell as the seven consultation texts, were also available on the Internet atthe Collège des médecins du Québec’s address.

As the president of the Collège conducted his annual tour into virtually allregions of Québec, he was joined by the members of the Commission, inturn. 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 ameeting 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

15

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

Overall, more than 300 organizations, dozens of experts and numerousmembers of the medical profession were heard during the consultationphase, 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 theirreport and formulating recommendations relative to each topic.

FINAL REPORT

Seven Topics, Seven Chapters

The Commission received its mandate from the Bureau of the Collège desmédecins du Québec whose mission is to promote quality medicine in orderto protect the public and improve the health of Quebecers. This is the per-spective from which the Commission examined certain hotly debatedissues, such as the funding of health care and services. The viewpoints fromwhich they were analysed are in keeping with the mission of the Collègedes 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 thereforedecided to address what it felt were the most sensitive aspects from theviewpoint of evolving medical practice in the coming years, and to developthe 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, asummary of present thinking on topics relevant to the practice of the pro-fession and an overview of foreseeable trends in the medium term, all ofit linked to brief historical elements. With a bibliography at the end ofevery chapter (French version only), readers, if they so wish, may consultthe documents which inspired the thinking in the report.

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

INTRODUCTION

16

why in this report, after the evolving roles of physicians are examined, at-tention is focused on ethics, vulnerable clienteles and prevention and healthpromotion activities. These are followed by reflections on the organizationof health care and health services, funding and technology, which in factare 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 BriefLook 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 searchedfor identifiable trends in the evolution of certain major health problems inthe years ahead; these would then serve as a context for their prospectivework. 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 treatiseon any given health problem, but a summary of the main points concerninganticipated developments five to eight years down the road, the effects ofthe disease, its prevalence, and the diagnostic, therapeutic and rehabili-tation means used, if applicable. This quick-reference approach, while itallows 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 Commissiondeveloped a number of recommendations addressed to the Collège desmédecins du Québec. With these recommendations, the commissionersaddress the Collège directly, and propose concrete courses of action toeffect the changes to be made in the coming years.

INTRODUCTION

17

COMMITMENTS OF THE COLLÈGE

The Commission’s recommendations were ta-bled with the Bureau, and a day of reflection which brought together theexecutive members of the Collège and the Bureau’s directors enabled eve-ryone to discuss them carefully and prepare the commitments to be madeby the Collège in their regard. Entitled “Commitments of the Collège desmédecins du Québec”, the text resulting from this process and officiallyapproved by the Bureau makes up the last section of this document. TheCollège is now in a position to develop an action plan for the next threeyears 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.

INTRODUCTION

18

Reportof the Commissionon the Practice of Medicinein the 21st Century

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PREAMBLE

The Commission on the Practice of Medicine in the21st Century will have a tangible impact on this 150th anniversary year of theCollège des médecins du Québec thanks to the texts and quick-reference sheetscontained 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 thatphysicians will have to face in the 21st century, stimulate and guide the searchfor 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 desmédecins 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 toour readers for consideration. It is our sincere hope that they will prove usefulto 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 thethreshold of a new century if we are to ensure that Quebecers receive the verybest in health care and services.

Commissioners,

Joseph Ayoub, M.D. Pierre Duplessis, M.D.President of the Commission Secretary to the Commission

Claude Bélisle, M.D. Benoît Lauzière

Josée Caron, M.D. Paule Lebel, M.D.

Julie Germain, M.D. Sandra Palmieri, M.D.

Paul Grand’Maison, M.D. Odette Plante Marot

Charles Guertin, M.D. Céline Plourde, B.Ph.

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Evolving Professional Rolesfor Physicians in the 21st Century

CHAPTER 1

21

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, diagnosingand treating illness. An interest and passion for science and humanity allcome together in the physician. Indeed, the role of physicians materializesfirst and foremost in the therapeutic relationship with their patients, and itis 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 ofMedicine in the 21st Century thought it important to take a close look atthe dynamics current in the medical profession, which are also likely tochange considerably. Its reflections are supported by a firm belief in the fun-damental values and characteristics of the health care services provided inQuébec, 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 theirdevelopment and merged into one profession, its scope broadening withthe advances in knowledge about humans and their ailments, and the avail-ability of a growing list of pharmaceutical products. The profession becamemore complex and more specialized. Other paramedical professions devel-oped at the same time, and individuals progressively played a greater partin maintaining and recovering their own health. In short, medicine is a dy-namic, multifaceted profession, constantly interacting with the populationand other allied professions; it enriches itself by drawing upon different ar-eas of knowledge and competence in all the scientific disciplines that nowform part of it.

The text that follows begins by tracing the evolution of medical practice. Itthen 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 andservices.

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EXPANDING BODY OF KNOWLEDGEAND THE EXPLOSION OF TECHNOLOGY

THE CHANGING SOCIOCULTURALAND POLITICAL CLIMATE

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

1. THE EVOLUTION OF MEDICAL PRACTICE

Advances in science and technology are nowdisseminated almost instantaneously. They arebecoming increasingly numerous and specta-cular, presenting possibilities for today and prom-

ises for tomorrow that were previously undreamed of1. 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 doso—to bring their knowledge and technical skills up to date, and to perfecttheir capacity for judgment, which will be increasingly needed to deal withdifficult 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 andconsequences of acts performed. They will have to inform a public that isworried about equity, costs, and the future of the health care system. Theywill 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.

Science and technology are not alone in exert-ing influence on the changing practice profile ofphysicians. 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 systemhas greatly contributed not only to broadening access to services but alsoto improving the quality of care. Physicians and their patients have gonefrom private offices to better equipped hospitals. Little by little, the increaseduse of these services has led to hypertrophy of these special centres, wheredemand has grown more quickly than supply. Medicine was “free”, so theywere told, and people jostled one another at the door, waiting to get in.


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

Physicians therefore had to be productive. This phenomenon, combinedwith 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 greatlyimproved, and in a context where improvement in treatment techniquesis unequalled, physicians risk becoming, often despite themselves, “volume”care providers rather than professionals who provide care and ensure itscontinuity to single individuals and whole persons.

Parallel to the qualitative and quantitative development of health care, anew cultural relationship to health has emerged in Québec. Not only didhealth become an increasingly important concern, even an obsession forsome, but its very definition broadened considerably. The subject of healthwas 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 enormousand complex, creating an increasing number of professional fields and newapproaches 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 samequality of care for all;

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

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

In a climate of new values and social pressures, government interventionhas increased in the last decades. To realize how much, one need only lookat how far we have come from the Hospital Insurance Act of 1960, to theAct 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.


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CHANGING THE ORGANIZATIONAL FRAMEWORK OF HEALTH CARE DELIVERY

What followed was the accentuation of a trend that was already becominga 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.

The ambulatory shift is the logical follow-up towhat preceded it. Health services, particularlymedical services, had to be adapted and mademore accessible, the inefficient use of hospitalservices had to be corrected using more appro-

priate resources, and oft-neglected prevention and health promotionactivities had to be revived. New trends in health and social services (newtechniques, particularly those that make day surgery possible, changes intreatment concepts that favour home care, de-institutionalization and thegreater role played by the user in the care-giving process) are leading tomajor changes in medical practice.

Furthermore, we must not forget that, despite politicized discussions, and afew bureaucratic mishaps, health and social services objectives are inspiredby 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 aspossible 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 thepublic. “The physician’s paramount duty [...] is to protect the health andwell-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.

The expression “ambulatory shift” covers a multitude of practices which,thanks to new technologies and new work organization methods, facilitatethe 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 psychosocialsupport, and capitalizing fully on the latest breakthroughs in informationtechnology.


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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 realmeaning behind the current transition, and to espouse its deep-seatedgoals, namely, its community-based orientation “in the gestational phase”,as some have described it. This socially desirable, economically necessaryand politically resolute orientation asks physicians to review their commit-ment to the community and to revive an ancient mode of practice wheresupport 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 practiceof medicine, despite the fact that the profession no longer has a monopolyon health care. Nonetheless, and for good reason, physicians will be askedto keep exercising leadership by their presence and their competence. Theywill be asked not only to put aside any reticence about the new organiza-tional framework, but to resolutely involve themselves in the process andto direct it, by occupying a central place in it, one that is warranted by theirtraining and the responsibilities they assume. From this point of view, theroles and professional competence of physicians take on paramount im-portance.

2. ROLES, DUTIES AND ORGANIZATION OF WORKFOR 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 becomemore complex, the population has aged, and the chronically ill live longerwhile 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 comemany new tasks to be assumed by physicians, tasks that are not recognizedfinancially or considered when dealing with the medical workforce.

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


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K EY ORGANIZATIONS DEFINE THEROLES OF 21ST-CENTURY PHYSICIANS

other physicians and health professionals. They must set aside time to in-teract with the latter, give them the information they need, support themin patient follow-up, often coordinate teams in specialized fields, involvethemselves 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 specialistcolleagues. Their work with respect to medical record-keeping, medical-administrative tasks and teaching, if applicable, will become ever moredemanding. 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 willdemand time, energy and availability on the part of physicians, who, in themidst of these new everyday realities, must continue to honour the uniquepatient-physician relationship and the tacit contract that links the physicianto the patient, notably as the one ultimately responsible for the medical caregiven to the latter.

Many organizations have come up with theirown definition of the roles of the physician. We

¨ think it important to present these briefly, thento 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; WorldHealth Organization, 1996) as an effective clinician, a decision-maker, a com-municator, a leader in the community and a team worker. These elementsare 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 theimportance of the patient-physician relationship, the physician’s positionas advocate and coordinator of care, as well as provider of primary care tothe patient and the entire community.


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THE PHYSICIAN’S ROLES AS SEENBY THE COMMISSION ON THE PRACTICEOF MEDICINE IN THE 21ST CENTURY

CanMEDS 2000 clarifies the WHO definition of medical specialists (RoyalCollege 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 otherworkers in the health care system.

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

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

The Commission began by considering the factthat physicians are first and foremost persons withlegitimate 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 asphysicians. Their roles hinge on these realities.

Furthermore, given all the roles of the physician recognized by the variouskey organizations, the Commission set out to extract those that seemed mostpertinent and that represented the most outstanding challenges for the21st century. It is of course impossible for one individual to completelymaster 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-centuryphysicians, 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 thediagnosis and treatment of disease. They help facilitate access to quality


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

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

HUMANISTIC PROFESSIONAL

Now and even more so in the future, the fluidand ever-evolving context of real medical practice will demand a high levelof 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 understandthe new issues and imagine future solutions, objectively discussing and lu-cidly envisaging their consequences.

While acquired competence and a general education are a prerequisite forthe right to practise in a context of extended responsibilities, a humanisticattitude and mind-set are equally essential. We are not speaking here of anoutward show of humanism to compensate for deficient training, but ofone that is clearly rooted in an awareness of the fact that the patient is aunique 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 andcompassion 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 ofview.

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


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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 theircompetence so as to achieve a high level of excellence throughout theiryears of practice. They have a duty to keep abreast of scientific and techno-logical developments as well as major social changes that impact on thepractice of medicine.

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

Physicians must also develop the habit of self-evaluation, assessing thetrue 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 theirwork, 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 takeresponsibility for their state of health. Developments in information andmonitoring techniques, in the treatment and relief of pain, reinforce theirability to assume this responsibility. As communicators with their patients,physicians must make an effort to help them make decisions and take fullresponsibility for their own health. They must speak to the patient or fam-ily, successfully communicating the information needed to understand thedisease and treatment, so that the necessary decisions can be made, as muchas possible, with the patient or next of kin.


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

TEAM PLAYER

The reorganization now under way requires amuch stronger sense of team-work between first-line physicians and sec-ond and third-line physicians, so that together they can discharge theirduties 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 worktogether to ensure better treatment for patients, appropriate follow-up andsupport in keeping with their situation. The interdisciplinary approach alsoopens 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 principlesof team-work and adopting its behaviour, learning to better acknowledgeand respect the fields of expertise of other professionals and, in the midstof all this, be active participants who use their own competence for thegreater 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 knowledgeand techniques that define them as unique. The professions were juxta-posed, as it were, when they were formed. But this division between fieldsof practice, or “exclusivity”, no longer suits the needs of the present healthcare 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 oninterprofessional conflict and modernize the professional system, makingit more adaptable to the changing needs of the population and the profes-sions themselves and appropriately responsive to these needs.


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

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

MANAGER

The community orientation which, it seems, willcharacterize medicine in the 21st century adds to and broadens the responsi-bilities of physicians. They can no longer work in isolation in an office. Theymust 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 totake on more responsibility for managing the medical practice componentof 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 enablesthem to be part of decisions involving resource allocation.

LEADER IN THE COMMUNITY

Physicians act in deference to the values ofQuébec 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 othermembers. 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.


32

Physicians have a duty to be open-minded and level-headed in their judg-ments. They will also have to show intellectual discipline, moral rectitudeand coherence when they take a position, so as to positively influence thethinking 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 thefuture, research will become even richer and more diverse, thanks to theformidable amount of information contained in data banks. Physicians willhave to realize this and take more interest in research.

Physicians also have a responsibility to teach. Becoming a physician involvesa long learning process and to get through it successfully, they must relyon their elders to impart the knowledge and clinical skills they themselveshave acquired. In addition, physicians who are called upon by colleaguesas experts and consultants are indeed acting as teachers in the way theywrite their reports or answer questions. On this point, the Commission re-iterates its conviction on the importance of family physicians being able topractise in a hospital centre, including a university hospital centre, since thetraining of physicians is a process that continues throughout all their yearsof 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 theseroles. 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 alsofundamental, but in varying degrees depending on the interests of each andthe practice setting. Often, excellence in all of the skills required by these roleswill 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 tothe same degree.


33

THE FAMILY PHYSICIAN

3. COMPLEMENTARITY OF PROFESSIONAL ROLES

Physicians perform the roles described above inone of two fields of activity—family medicine or specialized medicine. Themedical community and society in general have corresponding expecta-tions of each. Relations between the two groups and between physiciansand 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 andthe communities to which they belong. The following paragraphs addressthe question of complementarity of roles and the challenges it raises.

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 includespreventive, curative, rehabilitative and palliative care. It is characterized byits 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 settingas 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 caredepends.

The Commission believes that the practice context for family physicians,already in a state of flux, will have to change again considerably in years tocome. First-line physicians will work mostly in an ambulatory and commu-nity setting. Every physician will be accountable to a given clientele for thehealth care and services for which they have accepted responsibility; thiswill include longitudinal follow-up for that particular group of clients, whowill depend upon firstly their own physician’s services, then on those ofthe 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 inthe hospitals, including the university hospitals; this place is particularly


34

THE MEDICAL SPECIALIST

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

To ensure the total care of their patients, family physicians will almost neverpractise solo, but in a group practice setting. Using information technol-ogy to make their interventions more effective, these groups will form realnetworks, 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 willcollaborate in the organization of first-line medical services at the local, re-gional and provincial level, according to population needs.

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 caresector, as well as patients and their families. Certain specialties require ahighly technical facility, leading the specialist to master often very complextechnologies.

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

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

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


35

R ELATIONS BETWEEN FAMILYPHYSICIANS AND MEDICAL SPECIALISTS

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

Family physicians are the principal players in ourhealth care system. Medical specialists tie theirpractice to that of the family practitioner, therebyincreasing 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 familyphysician, with the specialist acting mainly as a consultant.

The hierarchical structuring of medical services3 is a major issue, and thisconcept is part of the current line of thinking of many national and inter-national groups of experts. Many organizations have in fact stressed howimportant 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 duQuébec (1995), the College of Family Physicians of Canada and the RoyalCollege 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 wherebyevery patient would be followed by one family physician and would receivea 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 doingthings obligatory or coercive4. 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 careservices and funding, respectively.


36

R ELATIONS WITH OTHERPROFESSIONALS

Our health care system is undergoing profoundchange, 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 certainactivities that do not necessarily demand their competence. And, given theexpanding roles of other professionals, it is pertinent that we take anotherlook at how duties can be shared, both in the workplace and at the level ofthe professional orders. It will be up to the Collège des médecins du Québecto define the field of practice and acts that come within the competence ofthe physician, as well as those that can be shared, for the greater good ofpatients and in deference to the professional roles of each.

The nurse clinician, to cite an example, will intervene more in emergencyroom settings, in first-line prevention, geriatrics, chronic and palliative care,whereas the surgical assistant will play a role in the operating room, andthe 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 tofree-up physicians and make their medical practice more dynamic, whileenabling them to give their patients more comprehensive care. All of thesechanges 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 anopenness to the possible roles to be played by other professionals, will helpmake professional practice more dynamic. The basic principles governingthese 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.


37

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 physiciansand 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, andfrom our particular point of view, for physicians. Their special position associal actors places them at the crossroads of every major change. It is clearthat they will have to combine forces to innovate, adapt and continue togive their patients the best possible care. As they cope with technologicalchange and the shift to ambulatory and community care, they will be calledupon as never before to revive a deep-seated humanism, which will enablethem to weather the storms that will certainly still beset the health and so-cial services system in which they work every day.


38

BIBLIOGRAPHY

Association of American Medical Colleges. 1993 – «AAMC policyon the generalist physician as adopted October 8, 1992». – Vol. 68,no 1␣ (Jan.). – P. 1-6

Barondess, J.A. 1993 – «The future of generalism». – Annals of Inter-nal Medicine. – Vol. 119, no 2 (July 15). – P. 153-160

Becker-Reems, E.D. 1994 – Self-managed work teams in healthcare organizations. – Chicago : American Publishing. – 245 p. – ISBN1-55648-122-5

Berwick, D.M. 1994 – «Eleven whorthy aims for clinical leadershipof health system reform». – JAMA. – Vol. 272, no 10 (Sept. 14). –P. 797-802

Braunwald, E. 1991 – «Subspecialists and internal medicine : a per-spective». – Annals of Internal Medicine.␣ – Vol. 114, no 1 (Jan. 1). –P. 76-78

Collège des médecins de famille du Canada. 1995 – Gérer le chan-gement : un modèle de pratique de groupe en médecine familiale␣ :Livre vert : document de discussion sur la réforme des soins de santéde première ligne. – Ottawa : CMFC. – 54 p.

Collège des médecins de famille du Canada. 1997 – Agrément desprogrammes de résidence et certification. – Ottawa : CMFC. – 47 p.– ISBN 1-896014-21-6

Collège des médecins de famille du Canada ; Collège royal des mé-decins et chirurgiens du Canada. 1993␣ – Relations entre le médecinde famille et le spécialiste consultant dans la prestation des soins desanté : rapport du Groupe de travail. – Ottawa : CMFC ; CRMCC.␣ –42 p. – ISBN 0-921413-91-2

Conseil médical du Québec. 1995 – Avis sur une nouvelle dyna-mique organisationnelle à implanter : la hiérarchisation des ser-vices médicaux. – Québec : le Conseil. – 47, [13]␣ p. –␣ Avis 95-03. –ISBN 2-550-24786-8

Contandriopoulos, André-Pierre. 1994 – «Réformer le système desanté : une utopie pour sortir d’un statu quo impossible». – Rup-tures, revue transdisciplinaire en santé. – Vol. 1, no 1. – P. 8-26

Cruess, Sylvia R. ; Cruess, Richard L. 1997 – «Teaching medicine as aprofession in the service of healing». – Academic Medicine. – Vol. 72,no 11 (Nov.). – P. 941-952

Dussault, Gilles. 1986 – «La collaboration interprofessionnelle : uneutopie?». – Artère.␣ – Vol.␣ 4 , no 3 (avril). – P. 17-18

Dussault, Gilles. 1990 – «Les déterminants de l’efficacité du travailmultidisciplinaire». – Le Gérontophile.␣ – Vol. 12, no 2 (printemps). –P. 3-6

Educating future physicians for Ontario (EFPO). 1993 – Overviewand synthesis : What people of Ontario need and expect from phy-sicians – Part 2. – Associated Medical Services, The Ministry of Healthof Ontario, and the five medical school or academic health sci-ences centres of Ontario

Forum national sur la santé. 1997 a – La santé au Canada : un héri-tage à faire␣ fructifier␣ :␣ Volume I : rapport final du Forum national surla santé. – Ottawa : le Forum.␣ –␣ 36 p.␣ – ISBN 0-662-81718-4

Forum national sur la santé. 1997 b – La santé au Canada : un héri-tage à faire fructifier : Volume II : rapports de synthèses et documentsde référence. – Ottawa : le Forum.␣ –␣ 1v. en pag. multiple. – ISBN0-662-81719-2

Friedman, E. 1995 – «The power of physicians : autonomy andbalance in a changing system». – American Journal of Medicine. –Vol. 99, no 6 (Dec.). – P. 579-586

«Future of medicine (The)». 1994 – The Economist. – March 19. –P. 3-18

Gaucher, Ellen M. ; Coffey, Richard J. 1993 – Total quality in health-care : from theory to practice. – San Francisco : Jossey-Bass. – 651 p.– (Jossey-Bass Health Ser.)␣ –␣ ISBN 1-55542-534-8

Greenfield, S. et al. 1992 – «Variations in resource utilization amongmedical specialties and systems of care : results from the medicaloutcomes study». – JAMA. – Vol. 267, no 12 (March 25). – P. 1624-1630

Mechanic, D. 1996 – «Changing medical organization and the ero-sion of trust». – Milbank Quarterly. – Vol. 74, no 2. – P. 171-189

Office des professions du Québec. 1996 – Approche à l’égard de laréserve et du partage d’actes professionnels : vers un système profes-sionnel plus souple et mieux adapté␣ :␣ cadre de référence. – Québec :l’Office. – 22 p.

Pew Health Professions Commission. 1995 – Critical challenges :revitalizing the health professions for the twenty-first century :the third report of the Pew Health Professions Commission. – SanFrancisco : UCSF Center for the Health Professions.␣ – xvi, 60 p.

Provincial Co-ordinating Committee on Community and AcademicHealth Science Center Relations (PCCCAR). Subcommittee on Pri-mary Health Care. 1996 – New directions in primary health care. –Toronto : PCCCAR. – 58, 14 p.

Rosenblatt, R.A. 1992 – «Specialists or generalists : on whom shouldwe base the American health care system?». – JAMA. – Vol. 267,no 12 (March 25). – P. 1665-1666

Royal College of Physicians and Surgeons of Canada. 1996 – Skillfor the new millenium : report of the societal needs working group ;CanMEDS 2000 Project (Canadian Medical Directions for Specialists2000 Project). – Ottawa : the College.␣ –␣ 20␣ p.

WHO-WONCA Conference (1994 : London, Ont.). 1995 – Makingmedical practice and education more relevant to people’s needs : thecontribution of the family doctor. – Geneva␣ : World Health Organi-zation. – iv, 98 p.

World Health Organization. 1996 – Doctors for health : a WHOglobal strategy for changing medical education and medical practicefor health for all. – Geneva : WHO.␣ – 22 p.


39

Summaries of the Chaptersand Recommendations

40

SUMMARY

The transformation of the healthcare system, the evolving roles of other professionals, and theburgeoning body of knowledge and technological advances willsubstantially change the practice of medicine in the 21st cen-tury. Physicians are challenged by these ongoing changes andmust not submit to them passively. They must involve themselvesin these changes, indeed direct them, by occupying the cen-tral place warranted by their training and the responsibilitiesthey 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 caregiven to their patients.

In 21st-century Québec, the Commission expects that physicianswill be increasingly asked to adopt a community approach totheir work, to review their commitments in this sense and, withinan ambulatory care context, revive a mode of practice wheresupport 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 humanistsand persons of good judgment who can analyse and understandnew health-related issues, to imagine future solutions, discussthem 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 thefact that the patient is a person whose integrity, autonomy anddignity must be respected. The Commission therefore believesthat as well as working constantly to be scientific and effectiveclinicians, physicians must become humanistic professionals,

Evolving Professional Rolesfor Physicians in the 21st Century

CHAPTER 1

41

learners, communicators, team players, managers, leaders intheir community, researchers and teachers.

The complementary roles of family physician and specialist willhave to be more and more coherently articulated in years tocome. Family physicians, whose primary role is to give first-linecare, are increasingly working in groups. They take responsibil-ity, not only for their own patients on an individual basis, butfor 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 theother hand, frequently work in the hospital, although a goodpart of their work (at least for certain specialties) is done in am-bulatory settings.

The Commission believes that physicians will work more andmore as part of an interdisciplinary team composed of otherphysicians 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, whichwill require sometimes difficult adjustments, but which is alsolikely to free physicians and make their practice more dynamic,while at the same time enabling them to provide more completecare to their clienteles.


42


1.

2.

RECOMMENDATIONS

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

GIVEN the expanding roles resulting from these changes, and the needfor 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 otherhealth professionals, which does not take away the family physician’splace 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 mustassume daily, and that it cannot facilitate the organization of workrequired to effectively perform them;

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

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

That the Collège des médecins du Québec commit itself immediatelyto supporting physicians in active practice so as to enable them tobetter take on the roles required to practise their profession in the21st century, notably those of scientific and effective clinician, human-istic professional, learner, communicator and team player.

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

43

6.

8.7.

That the Collège des médecins du Québec, conscious of the fact thatthe evolving professional roles of physicians will have them attributeincreasing importance to tasks such as case discussions between spe-cialists and family physicians, interdisciplinary work, counselling thepatient 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.

That the Collège des médecins du Québec implement effective meansto 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 developthe skills and knowledge that build these habits.

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

That the Collège des médecins du Québec reaffirm, whenever perti-nent, its vision of the family physician’s role as a first-line professionalwho is also responsible for follow-up medical care, and its vision of thespecialist 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.

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

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

3.

4.

5.


44

9.

10.

11.

That the Collège des médecins du Québec, in concert with the Inter-professional Council of Québec, the Office des professions and otherprofessional orders, pursue its efforts to clearly define the competenceand field of practice of physicians and other health professionals; inso 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 legaland ultimate responsibility with regard to medical care, attribute thenecessary value to the physician’s special role on interdisciplinaryteams and see to it that physicians acquire the necessary skills to workas 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 developmentof knowledge by increasing their participation in research programs,within any pertinent ethical boundaries.


45

Toward an Ethic of Shared Responsibilityin a Pluralistic Society

CHAPTER 2

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 therest of society, they are confronted with many situations thatcall for difficult, sometimes even heartbreaking, choices. Thesechoices 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 themultiple situations involving care and procedures (e.g. organtransplants, screening for genetic diseases) that may occur overthe course of a lifetime.

Two factors have a particular impact on the ethical aspect ofmedical practice—technoscientific advances and socioculturalchanges. Their influence on the realities of the 21st century willlikely be more marked.

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

As for the social and cultural climate, moral pluralism and thedefence of individual rights appear to be irreversible features ofour society. Besides, evolving attitudes on death are leading toethical problems that were totally unforeseeable not so longago. Finally, the upheavals in the health care system are raisingnew 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 satisfyingpeople’s desires.

46

Ethics is unquestionably a concern for clinicians who must dailyhonour their patients’ trust by paying attention to all the val-ues that have the welfare of the person at their very core. Theywill have to protect these values in their milieu, and give themspecial consideration in their actions. But ethics also concernsresearch physicians and represents a major obligation on theirpart.

Thus, it is important to increase ethical competence within themedical profession, during university training and in continuingmedical education. This competence must extend to the abilityto lead the decision-making process in matters of ethics, whetherit be at a personal level or in group discussion.

Medical ethics is a matter of utmost concern to the Collège desmédecins du Québec, given its responsibility to promote qualitymedicine in order to protect the public. The Commission suggeststhat the Collège create a permanent centre where ethical issueswould 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

47

RECOMMENDATIONS

GIVEN the ethical grounds for medical practice, notably respect fora 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 madewith 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 onethical questions raised by everyday medical practice;


That the Collège des médecins du Québec and its representatives, takeevery opportunity to publicize and promote the values underlying thepractice 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.

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

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 complementother existing agencies (networks, committees, faculty departments,associations, etc.).

That the Collège des médecins du Québec see to the publication andwidespread distribution to its members of tools and guides, particularlya clinical decision-making procedure that takes ethics into account, soas to help them shoulder their responsibilities in situations presentingcomplex problems in an often pluralistic moral and cultural context.

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

12.

13.

14.

15.

48

SUMMARY

The appearance of particularly vul-nerable clienteles is a recent phenomenon in Québec. It is theresult of four major factors: a rapidly aging population, impov-erishment, the disintegration of traditional social structures andan increase in immigration and international adoption. Theserealities, inevitably accompanied by a train of health and socialproblems, will unquestionably become more and more wide-spread in coming years, particularly in the Greater Montréal areawhere over 45% of our physicians practise. The latter will haveto prepare themselves to support and manage the medical needsof people subjected to these new social phenomena, since theywill form an ever-growing portion of their clientele.

First-line physicians will be the ones most often called upon tointervene and help these vulnerable persons. But given the com-plexity of the health problems on a physical, psychological andsocial level, and given the necessity of taking action which hasa bearing on the living conditions of their patients, they shouldmove toward an interdisciplinary mode of practice. Much workhas yet to be done at this level, and a sound understanding ofthe complementarity of actions taken by first-line physicians,specialists and other professionals is urgently needed.

Physicians are the ones best placed to appreciate the sufferingof vulnerable clienteles. They could become advocates of theirhealth needs and rights; to do so they must have the requiredtools. From this perspective, continuing medical education ac-tivities must focus more on the development of certain skills, suchas the ability to work in an interdisciplinary context, the abilityto use and coordinate community resources, and the ability toadopt modes of communication suited to certain vulnerable

Vulnerable Clienteles: Modes of Supportand Care

CHAPTER 3

49

clienteles. Is the 21st-century physician ready to play the role ofdefender 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 theserights and interests?

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

CHAPTER 3 – Vulnerable Clienteles: Modes of Support and Care

50

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 repercussionson the type of task required, the need to adapt certain tools of evalu-ation, and medical workforce planning,


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

That the Collège des médecins du Québec devise tools to evaluate thequality of medical care given to vulnerable clienteles and ensure theirapplication, particularly in comprehensive medical management of thepatient, the work of physicians on interdisciplinary teams, and homevisits.

That the Collège des médecins du Québec, in collaboration with thebodies concerned, including other professional orders, devise tools toevaluate the quality of interdisciplinary work and ensure their appli-cation1.

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


16.

17.

18.

19.

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.

51

That the Collège des médecins du Québec make certain that tools aredeveloped to evaluate the effectiveness of the supportive role playedby medical specialists with families grappling with the complex prob-lems that vulnerable clienteles often present; that the Collège makecertain that the tools developed are applied3.

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

20.

21.

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


52

Prevention and Health Promotion:Its Importance and Impact on 21st-CenturyMedicine

CHAPTER 4

SUMMARY

Curative care has always occupieda preponderant place in the health care system. But it no longerplays the important role it once played in improving mortalityrates, even though it still represents the lion’s share of costs tothe 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. Preventionattempts to prevent the onset of disease or to slow down itsprogress and delay its complications. The thrust of health pro-motion, long associated with prevention, is the adoption ofhealthy behaviours that maintain health and even improve it.

Despite the exposure that prevention and health promotionhave had over some twenty years in Québec and elsewhere inthe world, many questions are being discussed and have not yetbeen 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? Howwill society allow access to certain types of screening, while stillrespecting ethical standards? At a time when financial resourcesare shrinking considerably, where will prevention and healthpromotion 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 bewell understood by each. The results of prevention and health

53

promotion will only be optimally felt when the role of every pro-fessional is fully taken into account, and family physicians trulyperform their role as principal players.

The Commission anticipates greater access to information forpractitioners and patients alike. It also expects that more clini-cal practice guidelines and guides will be published and, as aresult, 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 alllikelihood, 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 Impacton 21st-Century Medicine

54

RECOMMENDATIONS

GIVEN the impact of prevention and health promotion on the generalstate 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,


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

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

That the Collège des médecins du Québec pay particular attention toquestions concerning predictive genetic testing and accessibility tovarious preventive measures.

That the Collège des médecins du Québec support the incorporationof prevention and health promotion activities into undergraduate andpostgraduate training as well as continuing medical education1.

CHAPTER 4 – Prevention and Health Promotion: Its Importance and Impacton 21st-Century Medicine

22.23.

24.

25.

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

55

The Organization of Health Careand Health Services

CHAPTER 5

SUMMARY

The Commission on the Practice ofMedicine in the 21st Century considers the organization ofhealth 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 freecare and services from professionals of their choice, in the facil-ity of their choice and in the language of their choice (French orEnglish).

The Commission recognizes the importance of the regional levelin 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 populationsand believes the tendency should also extend to specialists. Tobetter guarantee uniformity and quality of care, it suggests theestablishment of medical councils, either local or regional, asneed be.

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

The Commission supports the idea that the ambulatory shift isnecessary, that the system must be made more efficient and thenumber of beds reduced. However, it questions the real purposebehind the operation now under way, as well as the pace of theexpenditure reductions being imposed on the system. It recallsthe conditions essential to the success of the ambulatory shift.

56

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

The Commission believes that formulas such as “integratedservice networks” like those which exist in perinatal care andare being put in place for the elderly, are promising models thatcall for further experimentation. The Commission recommendsthat 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 applicablein their present form to Québec.

CHAPTER 5 – The Organization of Health Care and Health Services

57


RECOMMENDATIONS

GIVEN the importance for the population of a judicious geographicand functional distribution of the medical workforce throughoutQuébec;

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 oforganizing health care and health services,


That the Collège des médecins du Québec pursue its activities on thedetermination of the medical workforce and state its position publiclyon the geographic and functional distribution of physicians in Québec’sregions.

That, before any decisions are made, the Collège des médecins duQuébec highlight the importance of pilot projects having to do withany change affecting patients, and that it sit on steering committeesfor 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 onthe quality of care.

26.

27.

58

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

That the Collège des médecins du Québec support initiatives whichgroup physicians together in a context that provides accessible andintegrated services; more concretely, that the Collège des médecins duQuébec involve itself in the process of evaluating pilot projects ensuingfrom these initiatives, and make the necessary recommendations.

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

28.

29.

30.


59

Funding the Health Care System

CHAPTER 6

SUMMARY

In Québec, the operating costs ofthe health care and services system are high; they are in theorder 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 andservices to the population. Indeed, many examples show thatefficiency 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 healthcare 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 percapita formula for funding the regions.

With respect to the remuneration of physicians, from the per-spective of quality medicine, the Commission does not supportthe principle of “capitation”. It proposes the adoption of mixedmethods, and suggests as food for thought a “comprehensiveremuneration 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 isworthy of note from many points of view. It introduces a newmethod of public-private funding as well as elements which re-define accessibility (e.g. essential drugs in every class). But the

60

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

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

CHAPTER 6 – Funding the Health Care System

61


RECOMMENDATIONS

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

GIVEN that efficiency gains have yet to materialize, and that they willnot produce enough savings to satisfy new needs in health care andservices;

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

GIVEN the impact of current regionalization plans on the way servicesare funded;

GIVEN the link between work organization and payment methods forphysicians,


That the Collège des médecins du Québec officially demand that nonew budget cuts be made to the health care system until the impactof the cutbacks already made have been evaluated in terms of theireffects on sick people; that the Collège take part in such evaluationand take a public position on the subject;

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

That the Collège des médecins du Québec assert its conviction thatservices essential to the health of Quebecers, as well as access to theseservices, must be ensured for them without additional cost within apublic health care system.

31.

32.

33.

62

That the Collège des médecins du Québec actively participate in thediscussions on private-public funding from the point of view of its ownmission.

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 toquality of care and their effects on the clientele.

34.

35.


63

The Impact of Technology on21st-Century Medicine

CHAPTER 7

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 systemsrequired to provide care”*.

Technologies linked to information, telemedicine and computersystems (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 willmove laboratory analysis away from central laboratories andinto physicians’ consulting rooms and pharmacies, and to thepatient’s bedside.

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

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

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

* Office of Technology Assessment [1978], cited in H. David Banta, Clyde J. Behneyand Jane Sisk Willems, Toward Rational Technology in Medicine : Considerations forHealth Policy, New York, Springer Pub.,1981, p. 5

64

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 thedifficult choices imposed by the costs of purchasing and usingthe latest technology.

The Commission emphasizes the fact that information seemsto be the predominant factor in the technological advances ofthe next 10 to 15 years. It would also underscore the fact thatusing these new technologies or technology in general makesno sense unless it is coupled with an improved quality of life,both individual and collective, physical and psychological.

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

65

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,


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

That the Collège des médecins du Québec define strategies to optimizethe incorporation of clinical practice guidelines and guides into every-day medical practice1.

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

That the Collège des médecins du Québec adopt a strategic plan toinduce the entire profession—physicians in postgraduate training aswell 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.

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

36.

37.

38.

39.

1. This recommendation is an extension of recommendation 1; it has been placed in thisgroup of recommendations for the simple reason that the Commission explicitly addressesthe question of clinical practice guidelines in this chapter.

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

66

Commitmentsof the Collège des médecinsdu Québec

67

COMMITMENTS OF THE COLLÈGE DES MÉDECINS DU QUÉBEC

The Collège des médecins du Québec followedthe work of the Commission on the Practice of Medicine in the 21st Cen-tury with great interest and appreciated the care and concern with whichthe commissioners discharged their mandate, especially in view of thebreadth 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 withphysicians working in all parts of Québec, with organizations involved inhealth care, and with experts on the various questions addressed.

An orientation day for members of the Bureau and physicians employedby 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 publiclythat it has favourably received the work and reflections of the Commissionand strongly supports all of its recommendations to the Collège.

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

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

68

COMMITMENTS

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.

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.

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.

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.

1.

3.

2.

4.


69


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.

To ensure that prevention and health promotion are an integral part

of the everyday professional practice of physicians.

To implement a process of reflection on the ethical aspects of prob-

lems encountered in everyday medical practice.

To implement a process of reflection on the pertinence of regional

and sub-regional medical councils, and the form these would take.

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.

To implement a process of reflection on the use of information and

communication technologies in everyday clinical activity.

5.

7.

6.

8.

9.

10.

Documents

New Professional Challenges for Physicians in the 21st Century