New Professional Challenges For Physicians in The 21st Century

Commission on the Practice of Medicine in the 21st Century
New Professional Challenges for Physicians in the 21st Century
COLLGE DES MDECINS DU QUBEC
New Professional Challenges for Physicians in the 21st Century

Report and recommendations of the Commission on the Practice of Medicine in the 21st Century, together with commitments made by the Collge des mdecins du Qubec
COLLGE DES MDECINS DU QUBEC

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NOTE TO READERS
he following document is an abridged version of the original French text. The complete version, entitled Nouveaux dfis professionnels pour le mdecin des annes 2000, which contains 280 pages, can be obtained by contacting the Collges Communications Department: By mail: 2170 Ren-Lvesque Boulevard West Montral, Qubec H3H 2T8
By telephone: (514) 933-4441 or 1-888-MDECIN (local 206) By fax: By E-mail: (514) 933-3112 info@cmq.org
FOREWORD
n the spring of 1996, the health care system was struggling with unprecedented budget constraints which resulted in extremely difficult organizational decisions, including the closure of many hospitals, the merging of various establishments and the vaunted shift to ambulatory care. This situation led sometimes perturbed physicians to question the Collge about the consequences that these measures would have on their professional practice. Some expressed their concern about the very future of medicine in Qubec. The Collge was also dealing with the proposed reform of the professional system, which advocates the elimination of exclusive practice and the determination of activities reserved to various types of professional. It was therefore in this ambiance of constraints and expected reform that the idea of a Commission on the Practice of Medicine in the 21st Century began to develop during my annual regional tour of Qubec. It became imperative for us to set up a special group that would study and reflect on what lay ahead for medical practice, and define the roles of family physicians, medical specialists and other health care professionals at the dawn of the third millenium. In June 1996, the Collge challenged a group of physicians from various disciplines and with various types of expertise, residents and medical students, as well as other health care professionals to build a composite of what medicine will be tomorrow. The Commissions final report received an enthusiastic welcome from Bureau members and, on October 15, 1997, they unanimously adopted the 10 priority commitments made by the Collge based on the Commissions recommendations. Now, it is time to act. The Collge intends to give its commitments concrete form during the coming months and years, working together with its partners and the various bodies and/or groups concerned. We trust that the reference points contained in this document will bring together those who believe in adjusting to the inescapable changes that affect us as professionals. And, above all, that they will help us all meet the many challenges looming on the horizon, so that we may continue to provide Quebecers with quality service.
Roch Bernier, M.D. President

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MEMBERS OF THE COMMISSION ON THE PRACTICE

OF MEDICINE IN THE 21ST CENTURY
Dr. Joseph Ayoub

Oncologist Hpital Notre-Dame, Montral President of the Commission
Dr. Paule Lebel

Community Health Medical Specialist Centre hospitalier Cte-des-Neiges Montral
Dr. Claude Blisle

Family Physician Centre de sant Drummondville
Dr. Sandra Palmieri

Community Health Resident V
Ms. Odette Plante Marot

Nurse Hpital Saint-Luc, Montral
Dr. Jose Caron

General Surgeon Centre hospitalier Jeffery Hale Qubec City
Ms. Cline Plourde

Pharmacist Pharmacie Cline Plourde Saint-Lonard-dAston With the collaboration of:
Dr. Pierre Duplessis

Assistant General Secretary Collge des mdecins du Qubec Secretary to the Commission
Ms. Monique Chaput Ms. Julie Germain

Medical Student University of Sherbrooke Adult Education Expert Collge des mdecins du Qubec Coordinator and facilitator of the Commissions work, author of the report
Dr. Paul GrandMaison

Family Physician Director, Health Sciences Education Centre University of Sherbrooke
Dr. Charles Guertin

Surgery Resident I Fdration des mdecins rsidents du Qubec
Mr. Benot Lauzire

Representative of the public appointed to the Bureau of the Collge des mdecins du Qubec School executive
ACKNOWLEDGMENTS
he members of the Commission wish to thank all those persons and organizations who agreed to meet with them, and also all those who directly contributed to the study of the various themes or writing the texts. They also acknowledge the approximately 150 persons and organizations who answered the consultation questionnaires or sent notes, comments, documents, etc. The Commission also wishes to thank all the directors and executive physicians of the Collge des mdecins du Qubec who assisted during the consultation phase. Particular thanks also go to Dr. Chantal Archer and Ms. Lorraine Locas, research agents, and Mesdames Cline Bastien, Christiane Beaudoin, Denise Chrtien, Hlne Landry and Nicole Leduc Crte who, in their various capacities, supported the Commission so efficiently during its work. Finally, the members of the Commission wish to express their most sincere gratitude to Ms. Monique Chaput for her work in coordinating operations and facilitating the Commissions meetings, as well as for writing the consultation document texts and drawing up the final report.
EXPERTS WHO MET WITH COMMISSION MEMBERS
Docteur Renaldo N. Battista Professeur titulaire Facult de mdecine, Universit McGill Prsident du Conseil dvaluation des technologies de la sant Monsieur le juge Jean-Louis Baudouin Cour dappel du Qubec Monsieur Gilles Dussault Professeur titulaire Dpartement dadministration de la sant Facult de mdecine, Universit de Montral Monsieur Claude Forget Conseiller CEF Ganesh Corporation Docteur Andr Munger Mdecin de famille CLSC SOC, Sherbrooke Monsieur Jean Par Prsident et rdacteur en chef Lactualit (magazine mensuel, Montral)
Monsieur Norbert Rodrigue Prsident Conseil de la sant et du bien-tre du Qubec Monsieur David J. Roy Directeur Centre de biothique Institut de recherches cliniques de Montral Monsieur Yves Sguin Directeur gnral dlgu aux affaires canadiennes Compagnie gnrale des eaux
ORGANIZATIONS WHICH MET WITH COMMISSION MEMBERS
Conseil mdical du Qubec Fdration des mdecins omnipraticiens du Qubec Fdration des mdecins spcialistes du Qubec
NOUVEAUX DFIS PROFESSIONNELS POUR LE MDECIN DES ANNES 2000
PERSONS CONSULTED WHEN THEMES WERE BEING STUDIED OR TEXTS WRITTEN
Docteur Marie-Dominique Beaulieu Mdecin de famille Hpital Notre-Dame, Montral Monsieur Jean-Pierre Blanger Conseiller Conseil de la sant et du bien-tre du Qubec Docteur Howard Bergman Chef de la division de griatrie Hpital gnral juif Sir M.B. Davis et Universit McGill, Montral Docteur Roch Bernier Prsident Collge des mdecins du Qubec Docteur Lucie Brazeau-Lamontagne Secrtaire et vice-doyenne Facult de mdecine Universit de Sherbrooke Docteur Suzanne Brissette Mdecin de famille Hpital Saint-Luc, Montral Docteur Julie Bruneau Mdecin de famille Hpital Saint-Luc, Montral Monsieur Yvon Brunelle Agent de recherche Direction gnrale de la recherche et de lvaluation Ministre de la Sant et des Services sociaux Monsieur Claude Castonguay Vice-prsident du Conseil Banque Laurentienne Docteur Louise Charbonneau Microbiologiste mdicale CLSC des Faubourgs, Montral Docteur Ral Cloutier Mdecin-conseil Rgie rgionale de la sant et des services sociaux Chaudire-Appalaches Docteur Christine Collin Sous-ministre adjointe Direction gnrale de la sant publique Ministre de la Sant et des Services sociaux Docteur Michel Ct Cardiologue Centre universitaire de sant de lEstrie Sherbrooke
Docteur Adrien Dandavino Directeur Direction des tudes mdicales Collge des mdecins du Qubec Docteur Serge Daneault Mdecin-conseil Direction de la sant publique Rgie rgionale de la sant et des services sociaux de Montral-Centre Docteur Genevive Dechne Mdecin de famille Clinique mdicale de lOuest, Verdun Docteur Jocelyn Demers Hmatologue-oncologue Hpital Sainte-Justine, Montral Matre Pierre Deschamps Directeur de la recherche Centre de recherche en droit priv et compar de lUniversit McGill Monsieur Jean-Claude Deschnes Conseiller en administration et en formation Ministre de la Sant et des Services sociaux Docteur Gilles Desrosiers Mdecin-conseil Rgie rgionale de la sant et des services sociaux de lEstrie Madame Sylvie Dillard Sous-ministre adjointe Direction gnrale de la planification et de lvaluation Ministre de la Sant et des Services sociaux Monsieur Hubert Doucet Professeur invit Facults de mdecine et de thologie Universit de Montral Monsieur Guy Durand Professeur et directeur du DESS en biothique Facult de thologie, Universit de Montral Monsieur Jacques Gagn Pharmacien Laboratoire de recherche pharmaceutique inc., Laval Docteur Andr Garon Mdecin-conseil Conseil de la sant et du bien-tre du Qubec Madame Marjolaine Gobeil Directrice Planification et dveloppement professionnel Ordre des infirmires et infirmiers du Qubec Pre Robert Hivon, jsuite Expert en biothique, Montral
Docteur Gilles Hudon Prsident Association des radiologistes du Qubec Docteur Juan Roberto Iglesias Prsident Conseil mdical du Qubec Monsieur Roger Jacob, ing., M.Sc.A. Directeur-adjoint Direction des ressources financires et des services techniques Hpital du Sacr-Cur de Montral Docteur Andr Jacques Directeur Direction de lamlioration de lexercice Collge des mdecins du Qubec Docteur Denis Laberge Directeur adjoint Direction de lamlioration de lexercice Collge des mdecins du Qubec Monsieur Daniel Lacasse Directeur rgional de la sant physique Rgie rgionale de la sant et des services sociaux de lOutaouais Madame Michle Lamquin-thier Directrice gnrale Comit provincial des malades Docteur Bernard Lapointe Mdecin de famille Soins palliatifs, Hpital Royal Victoria Montral Docteur Yvon-Jacques Lavalle Psychiatre Centre universitaire de sant de lEstrie Sherbrooke Docteur Guy Legros Directeur adjoint Direction des tudes mdicales Collge des mdecins du Qubec Docteur Richard Lemieux Mdecin-conseil Confrence des rgies rgionales de la sant et des services sociaux du Qubec Docteur Pauline Lesage-Jarjoura Sant communautaire, Facult de mdecine Universit de Sherbrooke Docteur Jolle Lescop Secrtaire gnrale Collge des mdecins du Qubec Docteur Georges LEsprance Neurochirurgien Centre mdical Ren-Lannec, Montral
Docteur Richard Lessard Directeur Direction de la sant publique Rgie rgionale de la sant et des services sociaux de Montral-Centre Docteur Laurent Marcoux Mdecin de famille Centre mdical Saint-Denis Saint-Denis Docteur Claude Mercure Directeur Direction des enqutes Collge des mdecins du Qubec Docteur Clment Olivier Mdecin de famille Saint-Hippolyte Docteur Marie-France Raynault Mdecin-conseil Rgie rgionale de la sant et des services sociaux de Montral-Centre Docteur Nicolas Steinmetz Directeur gnral associ Groupe de planification, Centre universitaire de sant de lUniversit McGill Docteur Michel Ttreault Prsident Groupe tactique dintervention Ministre de la Sant et des Services sociaux Docteur Jean-Bernard Trudeau Directeur des services professionnels Centre hospitalier Pierre-Janet, Hull
REGIONAL BOARDS, REGIONAL MEDICAL COMMISSIONS AND PHYSICIANS GROUPS MET DURING THE VISIT BY THE PRESIDENT OF THE COLLGE TO THE FOLLOWING REGIONS:
Abitibi-Tmiscamingue Bas-Saint-Laurent Chaudire-Appalaches Cte-Nord Estrie Gaspsieles-de-la-Madeleine Lanaudire Laurentides Laval MauricieBois-Francs Montrgie Montral-Centre Outaouais Qubec SaguenayLac-Saint-Jean
PERSONS AND ORGANIZATIONS WHO MADE WRITTEN CONTRIBUTIONS DURING THE CONSULTATION PHASE1
Docteur Youssef Ainmelk Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Diane Amyot Directrice des services professionnels Centre Frdrick-George-Hriot Drummondville Docteur Christiane Arbour Coordonnatrice du programme en sant physique et des services prhospitaliers durgence Rgie rgionale de la sant et des services sociaux des Laurentides Docteur Jean-Louis Bard Prsident Association des conseils des mdecins, dentistes et pharmaciens du Qubec Docteur Jacques Beaudry Mdecin de famille Trois-Rivires Monsieur Claude Beauregard Directeur gnral Conseil interprofessionnel du Qubec Docteur Marc Bellemare Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Charles Bernard Vice-prsident Collge des mdecins du Qubec Docteur Louis Bernard Directeur Dpartement de mdecine sociale et prventive, Universit Laval Docteur Harold Bernatchez Prsident Association des mdecins microbiologistes infectiologues du Qubec Docteur Sylvie Bernier Directrice Services professionnels Htel-Dieu de Lvis Docteur Gilbert Blain Directeur des services professionnels Institut de radaptation de Montral
Docteur Francine Blais Obsttricienne-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Luc Boileau Mdecin-conseil Rgie rgionale de la sant et des services sociaux de la Montrgie Docteur Robert Boileau Prsident Association des pneumologues de la province de Qubec Docteur Myriam Boillat Directrice du programme de rsidence Dpartement de mdecine familiale, Universit McGill Docteur Henri-Louis Bouchard Chirurgien orthopdique Centre hospitalier universitaire de Qubec Docteur Laurier Bouchard Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Monsieur Laurier Boucher Prsident Ordre professionnel des travailleurs sociaux du Qubec Docteur Claude Brire Anesthsiste Victoriaville Docteur Placide Caron Mdecin de famille Val-Brillant Docteur Aurlien Carr Administrateur Bureau du Collge des mdecins du Qubec Docteur Pierre Carrier Directeur des services professionnels Centre hospitalier Saint-Joseph de la Malbaie Docteur Simon Carrier Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Monsieur Franois Charbonneau Secrtaire et directeur gnral Ordre des optomtristes du Qubec Madame Louise Chartier Directrice Dpartement des sciences infirmires Facult de mdecine Universit de Sherbrooke Docteur Hlne Chnard Obsttricienne-gyncologue Association des obsttriciens et gyncologues du Qubec Monsieur Lionel Chouinard Directeur gnral Rgie rgionale de la sant et des services sociaux Chaudire-Appalaches
Docteur Pierre Ct Mdecine de famille Clinique mdicale du Quartier latin Montral Docteur Jean-Pierre Courteau Mdecin-conseil Rgie rgionale de la sant et des services sociaux de lOutaouais Docteur Linda Daigneault Mdecin de famille Montral Docteur Michelle Dallaire Professeur Programme de mdecine de famille Facult de mdecine Universit de Montral Docteur Wilber Deck Mdecin-conseil Rgie rgionale de la sant et des services sociaux Gaspsieles-de-la-Madeleine Docteur Donald Delisle Mdecin de famille Bromptonville Docteur Michel Desjardins Directeur des services professionnels Htel-Dieu de Gasp Docteur Jean De Serres Mdecin de famille Chelsea Docteur Jean-Pierre Despins Prsident Association des mdecins omnipraticiens des Bois-Francs Monsieur Denis Drouin Administrateur Bureau du Collge des mdecins du Qubec Madame Anne Du Sault Agente de programme en sant physique Rgie rgionale de la sant et des services sociaux de lOutaouais Docteur Claude Duguay Administrateur Bureau du Collge des mdecins du Qubec Docteur Louise Duperron Administratrice Bureau du Collge des mdecins du Qubec Monsieur Jean-Pierre Duplantie Directeur gnral Rgie rgionale de la sant et des services sociaux de lEstrie Docteur Louise Duranceau Prsidente Association des spcialistes en chirurgie plastique et esthtique du Qubec Docteur Renald Dutil Prsident Fdration des mdecins omnipraticiens du Qubec
1. A number of people who helped with the Commissions study of the various themes or the writing of texts also forwarded their written comments. Their names are not repeated here.
Docteur Alex Ferenczy Administrateur Bureau du Collge des mdecins du Qubec Docteur Raynald Ferland Prsident Association doto-rhino-laryngologie et de chirurgie cervico-faciale du Qubec Docteur France-Laurent Forest Prsident Commission mdicale rgionale Rgie rgionale de la sant et des services sociaux Gaspsieles-de-la-Madeleine Docteur Claude Fortin Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Jean-Claude Gagn Directeur gnral Centre hospitalier de la rgion de lAmiante Docteur Jeannine Gagn Mdecin de famille Centre hospitalier Saint-Eustache Docteur Richard Gagn Administrateur Bureau du Collge des mdecins du Qubec Monsieur Gilbert Gagnon Prsident Ordre des technologues en radiologie du Qubec Docteur Louis Gagnon Secrtaire Programme sant Acti-Menu Monsieur Claude Garon Directeur gnral CLSC de Jonquire Docteur Pierre Gaudreault Prsident Association des pdiatres du Qubec Docteur Pierre Gauthier Prsident Fdration des mdecins spcialistes du Qubec Docteur Pierre Gfeller Mdecin de famille Centre hospitalier et Centre de radaptation Antoine-Labelle Madame Laurie Gottlieb Directrice cole des sciences infirmires Universit McGill Docteur Jean Grgoire Mdecin-conseil Rgie rgionale de la sant et des services sociaux Chaudire-Appalaches Docteur Yves Grenier Interniste Beauport
Docteur Yves Grenier Mdecin de famille Montral Docteur Jean-Pierre Jannelle Mdecin de famille CLSC de La Pommeraie Docteur Claude Laberge Mdecin de famille Ville-Marie Docteur Philippe Laberge Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Rene Lafrenire Omnipraticienne quipe de sant mentale CLSC Huntingdon Docteur Yves Lamontagne Administrateur Bureau du Collge des mdecins du Qubec Docteur Joris Lapointe Mdecin de famille Mini-Urgences, Jonquire Monsieur Raymond Leblanc Directeur scientifique Fonds de la recherche en sant du Qubec Docteur Hlne Leclre Directrice Bureau de pdagogie des sciences de la sant, Universit Laval Docteur Yolande Leduc Vice-prsidente Association des omnipraticiens en prinatalit du Qubec Docteur Francine Lger Prsidente Collge qubcois des mdecins de famille du Canada Monsieur Michel Lger Directeur gnral Rgie rgionale de la sant et des services sociaux des Laurentides Docteur Franois Lemieux Prsident Association des omnipraticiens en prinatalit du Qubec Docteur Denis Lepage Administrateur Bureau du Collge des mdecins du Qubec Docteur Pierre Loiselle Mdecin de famille Clinique mdicale Monte de la Baie Docteur France Lussier Mdecin-conseil Rgie rgionale de la sant et des services sociaux de Lanaudire Docteur Michelle Lussier-Montplaisir Administratrice Bureau du Collge des mdecins du Qubec
Docteur Pierre Mailloux Psychiatre Trois-Rivires Docteur Lucie Marchand Mdecin de famille Magog Docteur Hubert Marcoux Responsable du programme dthique tudes postgradues, Facult de mdecine, Universit Laval Docteur Andr Mass Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Yvon Mnard Mdecin de famille Longueuil Monsieur Franois Mercier Directeur gnral Rgie rgionale de la sant et des services sociaux de lAbitibiTmiscamingue Madame Lucie Merola Secrtaire Chambre des huissiers de justice du Qubec Docteur Bernard Millette Mdecin de famille Cit de la Sant de Laval Monsieur Magella Morasse Prsident Ordre des ingnieurs forestiers du Qubec Docteur Claude Morin Mdecin de famille Havre-Aubert Docteur Louise Nasmith Directrice Dpartement de mdecine familiale Universit McGill Ordre des acupuncteurs du Qubec Docteur Michel Paquin Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Pierre Paquin Anesthsiste Sainte-Agathe-des-Monts Docteur Krystyna Pecko Directrice du secrtariat aux affaires mdicales Rgie rgionale de la sant et des services sociaux de la Montrgie Docteur Michle Pelletier Mdecin de famille Saint-Jrme Docteur Sonia Ploquin Mdecin de famille CLSC de La Pommeraie Docteur France Perron Mdecin de famille Lac-Mgantic
Docteur Gilles Pineau Prsident Programme sant Acti-Menu Docteur Benot Poulin Mdecin de famille Hpital Louis-H.-Lafontaine Madame Maya Raic Administratrice Bureau du Collge des mdecins du Qubec Docteur Gilles P. Raymond Professeur titulaire de clinique Facult de mdecine Universit de Montral Docteur Michel Rheault Chirurgien Trois-Rivires Docteur Jean Rochon Ministre de la Sant et des Services sociaux Gouvernement du Qubec Docteur Jean Rodrigue Directeur de la planification et de la rgionalisation Fdration des mdecins omnipraticiens du Qubec Docteur Peter Roper Psychiatre Montral Docteur Claude Roy Pdiatre et gastroentrologue Hpital Sainte-Justine, Montral Monsieur Jean-Marc Roy Prsident Fdration qubcoise des centres dhbergement et de soins de longue dure Monsieur Jean-Franois Snchal Rgie rgionale de la sant et des services sociaux Gaspsieles-de-la-Madeleine Monsieur Marcel Snchal Directeur gnral Conseil qubcois dagrment dtablissement de sant et des services sociaux Docteur Vyta Senikas Prsidente Association des obsttriciens et gyncologues du Qubec Docteur Pierre Shebib Mdecin de famille CLSC J.-Octave-Roussin Docteur Grald Stanimir Obsttricien-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Andr Tanguay Mdecin de famille Laval Docteur Lorraine Therrien-Saillant Directrice des services professionnels Centre hospitalier de lArchipel
Docteur Jean-Bernard Trudeau Vice-prsident Conseil de la sant et du bien-tre du Qubec Docteur Manon Turbide Obsttricienne-gyncologue Association des obsttriciens et gyncologues du Qubec Docteur Michel Turgeon Mdecin de famille Rouyn-Noranda Docteur Raymonde Vaillancourt Prsidente Sous-comit de prinatalit de la Fdration des mdecins omnipraticiens du Qubec Docteur Julien R. Veilleux Directeur Services professionnels Hpital Laval, Qubec Docteur Patrick Vinay Doyen Facult de mdecine Universit de Montral Docteur Natacha Vincent Mdecin de famille CLSC du Val-Saint-Franois Docteur Karl Weiss Secrtaire Association des mdecins microbiologistes infectiologues du Qubec
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.............................................................................................................................................................................................................................................. TO READERS ..................................................................................................................................................................................................................... 2 .............................................................................................................................................................................................................................................. WORD ............................................................................................................................................................................................................................ 3 .............................................................................................................................................................................................................................................. BERS OF THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY ............................................................................................................................... 4 .............................................................................................................................................................................................................................................. KNOWLEDGMENTS .............................................................................................................................................................................................................. 5 .............................................................................................................................................................................................................................................. OF CONTENTS ................................................................................................................................................................................................................ 11 .............................................................................................................................................................................................................................................. DUCTION ....................................................................................................................................................................................................................... 13 Report of the Commission on the Practice of Medicine in the 21st Century ........................................................................................................................ 18 .............................................................................................................................................................................................................................................. AMBLE .......................................................................................................................................................................................................................... 19 .............................................................................................................................................................................................................................................. Professional Roles for Physicians in the 21st Century .................................................................................................................................................. 20 INTRODUCTION .............................................................................................................................................................................................................................................. DUCTION ....................................................................................................................................................................................................................... 21 .............................................................................................................................................................................................................................................. THE EVOLUTION OF MEDICAL PRACTICE .................................................................................................................................................................. 22 .............................................................................................................................................................................................................................................. REPORT OF THE COMMISSION ON THE PRACTICE OF MEDICINE PANDING BODY OF KNOWLEDGE AND THE EXPLOSION OF TECHNOLOGY ............................................................................................................ 22 .............................................................................................................................................................................................................................................. IN THE 21ST CENTURY CHANGING SOCIOCULTURAL AND POLITICAL CLIMATE ........................................................................................................................................... 22 .............................................................................................................................................................................................................................................. CHANGING THE ORGANIZATIONAL FRAMEWORK OF PREAMBLE HEALTH CARE DELIVERY ......................................................................................................... 24 .............................................................................................................................................................................................................................................. ROLES, DUTIES AND ORGANIZATION OF WORK FOR PHYSICIANS IN THE 21ST CENTURY ........................................................................................................................ 25 .............................................................................................................................................................................................................................................. ORGANIZATIONS DEFINE THE ROLES OF 21ST-CENTURY PHYSICIANS ...................................................................................................................... 26 CHAPTER 1 .............................................................................................................................................................................................................................................. PHYSICIANS ROLES AS SEEN BY THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY ........................................................ 27 Evolving Professional Roles for Physicians in the 21st Century .............................................................................................................................................................................................................................................. .................................................................................................................................................................................. EFFECTIVE SCIENTIFIC CLINICIAN Introduction .............................................................................................................................................................................................................................................. ......................................................................................................................................................................................... HUMANISTIC PROFESSIONAL .............................................................................................................................................................................................................................................. 1. The Evolution of Medical Practice ......................................................................................................................................................................................................................... LEARNER I Expanding Body of Knowledge and the Explosion of Technology .............................................................................................................................................................................................................................................. .......................................................................................................................................................................................................... COMMUNICATOR I The Changing Sociocultural and Political Climate .............................................................................................................................................................................................................................................. ................................................................................................................................................................................................................. PLAYER I Changing the Organizational Framework of Health CareTEAM Delivery .............................................................................................................................................................................................................................................. ...................................................................................................................................................................................................................... MANAGER 2. Roles, Duties and Organization of Work for Physicians .............................................................................................................................................................................................................................................. ........................................................................................................................................................................................ LEADER IN THE COMMUNITY in the 21st Century .............................................................................................................................................................................................................................................. ........................................................................................................................................................................................... RESEARCHER AND TEACHER I Key Organizations Define the Roles of 21st-Century Physicians .............................................................................................................................................................................................................................................. I The Physicians Roles as seen by The Commission on the Practice COMPLEMENTARITY OF PROFESSIONAL ROLES ............................................................................................................................................................................ 33 .............................................................................................................................................................................................................................................. of Medicine in the 21st Century FAMILY PHYSICIAN ........................................................................................................................................................................................................ .............................................................................................................................................................................................................................................. Effective Scientific Clinician MEDICAL SPECIALIST ..................................................................................................................................................................................................... Humanistic Professional .............................................................................................................................................................................................................................................. TIONS BETWEEN FAMILY PHYSICIANS AND MEDICAL SPECIALISTS ........................................................................................................................... 35 Learner .............................................................................................................................................................................................................................................. TIONS WITH OTHER PROFESSIONALS ....................................................................................................................................................................... 36 Communicator .............................................................................................................................................................................................................................................. Team Player CLUSION ....................................................................................................................................................................................................................... 37 .............................................................................................................................................................................................................................................. Manager OGRAPHY ....................................................................................................................................................................................................................... 38 .............................................................................................................................................................................................................................................. Researcher and Teacher and Recommendations .............................................................................................................................................................................................. 39 .............................................................................................................................................................................................................................................. Chapter 1: Evolving Professional Roles for Physicians in3. theComplementarity 21st Century ................................................................................................................... 40 of Professional Roles .............................................................................................................................................................................................................................................. I The Family Physician OMMENDATIONS .............................................................................................................................................................................................................. 42 .............................................................................................................................................................................................................................................. The Medical Specialist Chapter 2: Toward an Ethic of Shared Responsibility inI a Pluralistic Society ................................................................................................................ 45 .............................................................................................................................................................................................................................................. I Relations Between Family Physicians and Medical Specialists OMMENDATIONS .............................................................................................................................................................................................................. 47 I Relations with Other Professionals .............................................................................................................................................................................................................................................. Chapter 3: Vulnerable Clienteles: Modes of Support and Care .................................................................................................................................... 48 .............................................................................................................................................................................................................................................. Conclusion OMMENDATIONS .............................................................................................................................................................................................................. 50 .............................................................................................................................................................................................................................................. Bibliography Chapter 4: Prevention and Health Promotion: Its Importance and Impact on 21st-Century Medicine ......................................................................... 52 .............................................................................................................................................................................................................................................. OMMENDATIONS .............................................................................................................................................................................................................. 54 .............................................................................................................................................................................................................................................. Chapter 5: The Organization of Health Care and Health Services ............................................................................................................................... 55 .............................................................................................................................................................................................................................................. OMMENDATIONS .............................................................................................................................................................................................................. 57 .............................................................................................................................................................................................................................................. Chapter 6: Funding the Health Care System .................................................................................................................................................................. .............................................................................................................................................................................................................................................. OMMENDATIONS .............................................................................................................................................................................................................. 61 .............................................................................................................................................................................................................................................. Chapter 7: The Impact of Technology on 21st-Century Medicine ............................................................................................................................... 63 .............................................................................................................................................................................................................................................. OMMENDATIONS .............................................................................................................................................................................................................. 65 Commitments of the Collge des mdecins du Qubec ..................................................................................................................................................... 66 Chapter 1: Evolving
NOTE FOREMEMA CTABLE INTRO-
TABLE OF CONTENTS
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INTRO1. EX-
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THE
2. KEY THE
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27 28 29 29 30 31 31 32
21 22 22 22 24 25 26
3.
Leader in the Community
THE 27 THE 27 35 28 RELA29 RELA29 CON30 BIBLI31 31 Summaries of the Chapters 32 34
33 33 34 35 36 37 38
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TABLE OF CONTENTS
SUMMARIES OF THE CHAPTERS AND RECOMMENDATIONS
39
Chapter 1 Evolving Professional Roles for Physicians in the 21st Century

SUMMARY RECOMMENDATIONS
40 40 42
Chapter 2 Toward an Ethic of Shared Responsibility in a Pluralistic Society

45 45 47
Chapter 3 Vulnerable Clienteles: Modes of Support and Care

48 48 50
Chapter 4 Prevention and Health Promotion: Its Importance and Impact on 21st-Century Medicine
52 52 54
Chapter 5 The Organization of Health Care and Health Services

55 55 57
Chapter 6 Funding the Health Care System

59 59 61
Chapter 7 The Impact of Technology on 21st-Century Medicine

63 63 65
COMMITMENTS OF THE COLLGE DES MDECINS DU QUBEC
66
12
INTRODUCTION
n June 1996, the Collge des mdecins du Qubec set up a task force to reflect upon what might comprise the practice of medicine in the 21st century. The members of the Bureau wanted to see an examination of the prospects for the practice of medicine in Qubec, the major changes the profession might expect and the measures that might be taken immediately to contend with tomorrows realities.
TERMS OF REFERENCE
he Commission on the Practice of Medicine in the 21st Century was entrusted with a mandate to: I review the role and functions of the general practitioner, notably medical management and follow-up care in the context of the transformation of health care; I review the role and functions of the medical specialist, particularly as a consultant, and to define the conditions of practice specific to them; I identify more clearly the collaboration of other health professionals in health care delivery within the context of medicine in the 21st century.
THEMES
he commissioners were faced with an ambitious task. Taking stock of the content, the scope, and the variety of topics related to their mandate, they decided to define the topics they wished to study in depth, and then determine the course to follow in documenting each of them. The members of the Commission split into small working committees, each corresponding to one of the topics selected. Each committee then developed an inventory of the relevant literature, and met with different experts and representatives of various agencies. Eleven experts were heard and questioned at plenary sessions of the commissioners1. Given the speed of change, indeed of veritable transformation, and the difficulty of extrapolating beyond certain limits, the Commissions forecasts, while at first
1. The experts met with by all members of the Commission are listed on page 5.
13
INTRODUCTION
extending 15 to 20 years into the future, were soon narrowed down to five or ten years. At the beginning of 1997, each working committee summarized its work in a text, and the major issues and various statements were discussed at plenary sessions by all members of the Commission. Finally, the reflections of the committees, coupled with the wide range of opinions and positions adopted during the plenary sessions, became the raw material for the texts written in the spring of 1997 and circulated during the consultation phase. The Commission therefore discharged its mandate by translating it into seven topics for study, which are the subjects of the seven chapters in this report: 1. Evolving professional roles for physicians in the 21st century; 2. Toward an ethic of shared responsibility in a pluralistic society; 3. Vulnerable clienteles: modes of support and care; 4. Prevention and health promotion: its importance and impact on 21stcentury 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
n important consultation phase took place between February and August 1997. Over 3000 copies of the Commissions consultation paper were circulated. A questionnaire for each text in the document allowed those consulted to express their level of agreement with the main assertions and make comments. These seven questionnaires, as well as the seven consultation texts, were also available on the Internet at the Collge des mdecins du Qubecs address. As the president of the Collge conducted his annual tour into virtually all regions of Qubec, he was joined by the members of the Commission, in turn. This gave them an opportunity to speak to regional board representatives and to regional medical commissions and, above all, to listen to them. Furthermore, in every region visited, all physicians were invited to attend a meeting organized especially for them. Opinions and reactions were registered on site, while written comments from regional authorities and physicians were also solicited to be submitted by mail.
14
INTRODUCTION
Added to the Qubec-wide tour were meetings with key organizations, and internal consultations with the physicians who make up each of the three Divisions of the Collge des mdecins du Qubec. In addition, requests for written comments were addressed to persons designated as selected discussants. Overall, more than 300 organizations, dozens of experts and numerous members of the medical profession were heard during the consultation phase, and they did indeed considerably expand the thinking of the Commission. Two subsequent meetings enabled the Commissioners to review, confirm or modify their positions with a view to writing the final text of their report and formulating recommendations relative to each topic.
FINAL REPORT Seven Topics, Seven Chapters

The Commission received its mandate from the Bureau of the Collge des mdecins du Qubec whose mission is to promote quality medicine in order to protect the public and improve the health of Quebecers. This is the perspective from which the Commission examined certain hotly debated issues, such as the funding of health care and services. The viewpoints from which they were analysed are in keeping with the mission of the Collge des mdecins and the mandate of the Commission. Each topic, given its complexity and importance, could have been the subject of a detailed and voluminous monograph. The Commission therefore decided to address what it felt were the most sensitive aspects from the viewpoint of evolving medical practice in the coming years, and to develop the topics in succinct fashion only, limiting each chapter to 15 or 20 pages. Thus, it wishes to make available to the clinician, who is often very busy, a summary of present thinking on topics relevant to the practice of the profession and an overview of foreseeable trends in the medium term, all of it linked to brief historical elements. With a bibliography at the end of every chapter (French version only), readers, if they so wish, may consult the documents which inspired the thinking in the report. It quickly became evident, as the commissioners held their meetings, that the patient and the patient-physician relationship were the prime reference points essential to the issue of medical practice in the 21st century. This is
15
INTRODUCTION
why in this report, after the evolving roles of physicians are examined, attention is focused on ethics, vulnerable clienteles and prevention and health promotion activities. These are followed by reflections on the organization of health care and health services, funding and technology, which in fact are ways and means of creating a framework and support system for patient care and the patient-physician relationship.
Appendix: An Overview of Certain Health Problems

In addition to their reflections and recommendations on the seven topics, the commissioners have included in their report a document entitled A Brief Look at Certain Health Problems in the 21st century (French version only). This document was prepared very differently. As the commissioners carried out their mandate, they constantly searched for identifiable trends in the evolution of certain major health problems in the years ahead; these would then serve as a context for their prospective work. For every problem listed, they called upon expert physicians, sometimes bringing together the clinician and the community health physician, from whom they requested a quick-reference sheet on the question. Here again, the Commission did not wish to publish an exhaustive treatise on any given health problem, but a summary of the main points concerning anticipated developments five to eight years down the road, the effects of the disease, its prevalence, and the diagnostic, therapeutic and rehabilitation means used, if applicable. This quick-reference approach, while it allows one to absorb a lot of information at a glance, is admittedly not gratifying and does not do justice to the knowledge and reputation of the authors. 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 removed, since the texts were too long.
COMMISSIONS RECOMMENDATIONS
or each topic, the members of the Commission developed a number of recommendations addressed to the Collge des mdecins du Qubec. With these recommendations, the commissioners address the Collge directly, and propose concrete courses of action to effect the changes to be made in the coming years.
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INTRODUCTION
COMMITMENTS OF THE COLLGE

he Commissions recommendations were tabled with the Bureau, and a day of reflection which brought together the executive members of the Collge and the Bureaus directors enabled everyone to discuss them carefully and prepare the commitments to be made by the Collge in their regard. Entitled Commitments of the Collge des mdecins du Qubec, the text resulting from this process and officially approved by the Bureau makes up the last section of this document. The Collge is now in a position to develop an action plan for the next three years as a follow-up to the work of the Commission on the Practice of Medicine in the 21st Century. Thus, the Commissions in-depth reflection process will have a logical and concrete outcome.
17
eport
of the Commission on the Practice of Medicine in the 21st Century
18
REAMBLE
he Commission on the Practice of Medicine in the 21st Century will have a tangible impact on this 150th anniversary year of the Collge des mdecins du Qubec thanks to the texts and quick-reference sheets contained in this report. We believe that these should be considered as reference points which should be revisited from time to time during the coming years. We hope that they will clarify some of the new professional challenges that physicians will have to face in the 21st century, stimulate and guide the search for solutions, instill the courage to deal with change, measure the divide between today and tomorrow and, maybe, provide an element of continuity. We believe that the various texts stand by themselves, independently of the recommendations to which our work has given rise, and that, for the Collge des mdecins du Qubec and all members of the medical profession, they represent modest yet solid, stimulating markers on the road to the future. The conclusions we reached during this exciting work are now submitted to our readers for consideration. It is our sincere hope that they will prove useful to physicians, other health care professionals and administrators, and will enable them to form the partnerships that are necessary to us as we stand on the threshold of a new century if we are to ensure that Quebecers receive the very best in health care and services. Commissioners,
Joseph Ayoub, M.D. President of the Commission
Pierre Duplessis, M.D. Secretary to the Commission
Claude Blisle, M.D.
Benot Lauzire
Jose Caron, M.D.
Paule Lebel, M.D.
Julie Germain, M.D.
Sandra Palmieri, M.D.
Paul GrandMaison, M.D.
Odette Plante Marot
Charles Guertin, M.D.
Cline Plourde, B.Ph. 19
CHAPTER 1
volving Professional Roles for Physicians in the 21st Century
20
CHAPTER 1 Evolving
Professional Roles for Physicians in the 21st Century
INTRODUCTION
hysicians practise a science and an art, the purpose of which is to maintain or restore health by preventing, diagnosing and treating illness. An interest and passion for science and humanity all come together in the physician. Indeed, the role of physicians materializes first and foremost in the therapeutic relationship with their patients, and it is to these patients that physicians are primarily accountable and responsible. This patient-physician relationship is fundamental. Given our changing health care system, the Commission on the Practice of Medicine in the 21st Century thought it important to take a close look at the dynamics current in the medical profession, which are also likely to change considerably. Its reflections are supported by a firm belief in the fundamental values and characteristics of the health care services provided in Qubec, namely equity, accessibility, respect for personal dignity, effectiveness, comprehensiveness and continuity. Its thinking is also based on a respect for the public nature of our health care system. Through the centuries, medicine and surgery made enormous strides in their development and merged into one profession, its scope broadening with the advances in knowledge about humans and their ailments, and the availability of a growing list of pharmaceutical products. The profession became more complex and more specialized. Other paramedical professions developed at the same time, and individuals progressively played a greater part in maintaining and recovering their own health. In short, medicine is a dynamic, multifaceted profession, constantly interacting with the population and other allied professions; it enriches itself by drawing upon different areas of knowledge and competence in all the scientific disciplines that now form part of it. The text that follows begins by tracing the evolution of medical practice. It then presents an overview of the roles to be played by 21st-century physicians, and the skills required of them. It also briefly describes how professional roles may complement one another in the area of health care and services.
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CHAPTER 1 Evolving
1. THE EVOLUTION OF MEDICAL PRACTICE
XPANDING BODY OF KNOWLEDGE AND THE EXPLOSION OF TECHNOLOGY
dvances in science and technology are now disseminated almost instantaneously. They are becoming increasingly numerous and spectacular, presenting possibilities for today and promises for tomorrow that were previously undreamed of1. With this phenomenon of continuously expanding knowledge and technical possibilities, physicians are faced with one of the greatest challenges to professional practice in the 21st centurythe challenge to make proper use of information. Physicians must keep themselves informedand ceaselessly continue to do soto bring their knowledge and technical skills up to date, and to perfect their capacity for judgment, which will be increasingly needed to deal with difficult situations. They will also have to inform others, and do it well, concerning themselves with the content of the information as well as the manner in which it is communicated. Physicians will have to inform patients, who, being more autonomous, will increasingly question the relevance and consequences of acts performed. They will have to inform a public that is worried about equity, costs, and the future of the health care system. They will have to be ready to inform local and regional authorities and governments, which must make decisions and answer for choices made in disbursing public funds.
Science and technology are not alone in exerting influence on the changing practice profile of physicians. Changing needs and values, new levels of awareness and sensitivity, social demand and political choices are also elements that will continue to transform traditional medical practice in the 21st century. One cannot deny that Qubecs public health and social services system has greatly contributed not only to broadening access to services but also to improving the quality of care. Physicians and their patients have gone from private offices to better equipped hospitals. Little by little, the increased use of these services has led to hypertrophy of these special centres, where demand has grown more quickly than supply. Medicine was free, so they were told, and people jostled one another at the door, waiting to get in.
HE CHANGING SOCIOCULTURAL AND POLITICAL CLIMATE
1. On this subject, see Chapter 7, The Impact of Technology on Medicine in the 21st Century.
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CHAPTER 1 Evolving
Physicians therefore had to be productive. This phenomenon, combined with technological progress and an effective pharmaceutical armamentarium, transformed medical practice, particularly in certain specialties, replacing traditional medicine centred mostly on observation and treatment, with medicine based on diagnostic and therapeutic intervention. Paradoxically, in circumstances where quality and access to care have greatly improved, and in a context where improvement in treatment techniques is unequalled, physicians risk becoming, often despite themselves, volume care providers rather than professionals who provide care and ensure its continuity to single individuals and whole persons. Parallel to the qualitative and quantitative development of health care, a new cultural relationship to health has emerged in Qubec. Not only did health become an increasingly important concern, even an obsession for some, but its very definition broadened considerably. The subject of health was gradually transformed into a social, collective project with lasting consequences; among them, conscious, growing citizen participation, the establishment of an organization that was certainly productive, but enormous and complex, creating an increasing number of professional fields and new approaches in a constant state of change. Thus, Qubecs health care system, which was private, became public. According to the Commission, this system is based on three fundamental values:2 I equity for every citizen who is ill, that is, unrestricted access to the same quality of care for all; I solidarity, that is, a collective effort to share resources, so that the sick person is not alone to shoulder the financial burden; I respect for a persons human dignity, which, in the area of health, finds its expression in the sacred and fundamental nature of the patient-physician relationship, which includes the patients free choice of a physician, on the one hand, and the obligation to maintain confidentiality, on the other. In a climate of new values and social pressures, government intervention has increased in the last decades. To realize how much, one need only look at how far we have come from the Hospital Insurance Act of 1960, to the Act respecting health services and social services and amending various legislation of 1991. Adopted in 1992, health and social welfare policy consolidated the systems reorganization in terms of efficiency and effectiveness.
2. See Chapter 5, The Organization of Health Care and Health Services.
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CHAPTER 1 Evolving
What followed was the accentuation of a trend that was already becoming a reality. While often poorly understood, it has become known as the ambulatory shift and seems destined to be the order of the day for medical practice for the coming years.
The ambulatory shift is the logical follow-up to

what preceded it. Health services, particularly medical services, had to be adapted and made more accessible, the inefficient use of hospital services had to be corrected using more appropriate resources, and oft-neglected prevention and health promotion activities had to be revived. New trends in health and social services (new techniques, particularly those that make day surgery possible, changes in treatment concepts that favour home care, de-institutionalization and the greater role played by the user in the care-giving process) are leading to major changes in medical practice. Furthermore, we must not forget that, despite politicized discussions, and a few bureaucratic mishaps, health and social services objectives are inspired by a philosophy centred around the health of individuals and the community, and not on the delivery of individual services. Achieving these objectives therefore requires a more concerted organization and more productive delivery of care and services for the benefit of as many people as possible considered on a community basis. This collective vision underlying current reforms is not foreign to the medical ideal; it ranks first under the rights and obligations of physicians to the public. The physicians paramount duty [...] is to protect the health and well-being of the persons he takes care of, both individually and collectively, reads the Code of ethics of physicians. We are, as it were, rediscovering in Qubec that physicians also have a responsibility to the community and not only to individuals. The expression ambulatory shift covers a multitude of practices which, thanks to new technologies and new work organization methods, facilitate the maximal use of alternative resources when it comes to hospitalization. In real terms, this shift in direction involves many different kinds of action, among them, transferring traditional resources to the community, developing group medical practice supported by increased home care resources, decompartmentalizing professional practices, strengthening psychosocial support, and capitalizing fully on the latest breakthroughs in information technology.
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HANGING THE ORGANIZATIONAL FRAMEWORK OF HEALTH CARE DELIVERY
CHAPTER 1 Evolving
Of course, accumulated delays, budget restrictions, sudden unforeseen disruptions, uncertainties do not make things easier. These provide new professional challenges for physicians. They force them to look for the real meaning behind the current transition, and to espouse its deep-seated goals, namely, its community-based orientation in the gestational phase, as some have described it. This socially desirable, economically necessary and politically resolute orientation asks physicians to review their commitment to the community and to revive an ancient mode of practice where support and treatment of the sick take place in their living environment. This way of practising medicine, which predominated for a long time, focuses on the individual; it must now, without relinquishing its first focus, broaden itself to include a community perspective. To summarize, the 21st century will make great demands on the practice of medicine, despite the fact that the profession no longer has a monopoly on health care. Nonetheless, and for good reason, physicians will be asked to keep exercising leadership by their presence and their competence. They will be asked not only to put aside any reticence about the new organizational framework, but to resolutely involve themselves in the process and to direct it, by occupying a central place in it, one that is warranted by their training and the responsibilities they assume. From this point of view, the roles and professional competence of physicians take on paramount importance.
2. ROLES, DUTIES AND ORGANIZATION OF WORK

FOR PHYSICIANS IN THE 21ST CENTURY
he day-to-day work of physicians has substantially changed in recent years, and their duties have increased considerably. Major technological changes have occurred, health problems have become more complex, the population has aged, and the chronically ill live longer while presenting more complex profiles. Organizations want more efficiency, resources are shrinking, information in all its forms increases possibilities, but demands more. Thus, the patient-physician relationship is more important than ever, and is even more demanding. From these changes come many new tasks to be assumed by physicians, tasks that are not recognized financially or considered when dealing with the medical workforce. Medical specialists, while playing the role of expert clinicians in looking after their patients, must increasingly act as expert consultants vis--vis
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CHAPTER 1 Evolving
other physicians and health professionals. They must set aside time to interact with the latter, give them the information they need, support them in patient follow-up, often coordinate teams in specialized fields, involve themselves in medical-administrative work, teach, and take on certain research obligations, as the case may be. As for family physicians, they must increase the time they spend with families, the elderly, and chronically ill patients; they must devote the necessary time to coordinating their work with that of the nurse and specialist colleagues. Their work with respect to medical record-keeping, medicaladministrative tasks and teaching, if applicable, will become ever more demanding. Family practitioners will often act as ombudsmen for their patients vis--vis certain agencies and health professionals, so that their patients have ready access to the care their condition requires. These duties will in future be part and parcel of the practice of medicine, calling for new professional roles and hence, new skills. Above all, they will demand time, energy and availability on the part of physicians, who, in the midst of these new everyday realities, must continue to honour the unique patient-physician relationship and the tacit contract that links the physician to the patient, notably as the one ultimately responsible for the medical care given to the latter.
Many organizations have come up with their

own definition of the roles of the physician. We think it important to present these briefly, then to describe the physicians role as seen by the Commission on the Practice of Medicine in the 21st Century.
EY ORGANIZATIONS DEFINE THE ROLES OF 21ST-CENTURY PHYSICIANS
In its definition, the World Health Organization (WHO) presents the fivestar physician (WHO-WONCA Conference 1994: London, Ont., 1995; World Health Organization, 1996) as an effective clinician, a decision-maker, a communicator, a leader in the community and a team worker. These elements are repeated in most of the other definitions of the physicians role. The College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada (1993) refine this definition by adding dimensions that apply particularly to the family physician. They highlight the importance of the patient-physician relationship, the physicians position as advocate and coordinator of care, as well as provider of primary care to the patient and the entire community.
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CHAPTER 1 Evolving
CanMEDS 2000 clarifies the WHO definition of medical specialists (Royal College of Physicians and Surgeons of Canada, 1996). To the elements already cited, it adds the role of manager of information, treatment and resources, as well as advocate-defender of health, scholar and professional. Medical specialists are also resource persons for their colleagues and other workers in the health care system. The position put forward in the document Overview and Synthesis : What People of Ontario Need and Expect from Physicians Part 2 (Educating Future Physicians for Ontario [EFPO], 1993 : 22-52) assembles several of these roles and describes the physician as a medical expert, a communicator, a means of access to the health care system and a manager of resources and care, a scholar, a competent scientist and a human being with a private life and personal aspirations. Regardless of the organization, the importance of ethics, professional attitudes and behaviour are emphasized.
The Commission began by considering the fact

that physicians are first and foremost persons with legitimate aspirations who wish to fulfil themselves as individuals. They have rights and obligations as individuals and citizens. They live in a society to which they bring their personal and professional skills, both human and scientific. Given this fact, they also have rights and obligations as physicians. Their roles hinge on these realities. Furthermore, given all the roles of the physician recognized by the various key organizations, the Commission set out to extract those that seemed most pertinent and that represented the most outstanding challenges for the 21st century. It is of course impossible for one individual to completely master all of the skills required to execute each of these roles. The Commission still wishes to present them as avenues to be explored by 21st-century physicians, who must constantly upgrade their skills.
HE PHYSICIANS ROLES AS SEEN BY THE COMMISSION ON THE PRACTICE OF MEDICINE IN THE 21ST CENTURY
EFFECTIVE SCIENTIFIC CLINICIAN

hysicians are scientists working on behalf of human beings. They possess the competence that makes them experts in the diagnosis and treatment of disease. They help facilitate access to quality
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CHAPTER 1 Evolving
health care services for the population they serve. They encourage healthy living habits in their patients, practise preventive clinical medicine with them, give them the necessary care, and show concern for the health goals of the community in which they work. To fully assume their role, 21st-century physicians must, more than ever before, find ways and means to maintain their sound scientific training and to keep learning new technical skills. Furthermore, they will need to have their skills increasingly recognized and respected. Being responsible for the care of their patients, they must be accountable for their acts and be free to make the necessary decisions.
HUMANISTIC PROFESSIONAL
ow and even more so in the future, the fluid and ever-evolving context of real medical practice will demand a high level of professionalism from physicians. Much as the competent and skilful scientist will be called upon to diagnose and treat disease, so will the humanist and person with good judgment be needed to analyse and understand the new issues and imagine future solutions, objectively discussing and lucidly envisaging their consequences. While acquired competence and a general education are a prerequisite for the right to practise in a context of extended responsibilities, a humanistic attitude and mind-set are equally essential. We are not speaking here of an outward show of humanism to compensate for deficient training, but of one that is clearly rooted in an awareness of the fact that the patient is a unique individual whose integrity, autonomy and dignity must be acknowledged. Such humanism enlightens practitioners in their decision-making and imbues the patient-physician relationship with the sensitivity, empathy and compassion needed to put the illness to be treated into perspective. Finally, it is on this brand of humanism that one lays and maintains the twofold foundation of the patient-physician relationship: an egalitarian relationship in human terms, and a helping relationship from the patients point of view. Convinced that the professional and human aspects of medical practice will take on new importance in the 21st century, the Commission firmly believes that the selection criteria for candidates applying to medical school,
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CHAPTER 1 Evolving
the training programs and the examinations leading to a permit to practise must be reviewed to include these attendant skills.
LEARNER
hysicians strive to maintain and increase their competence so as to achieve a high level of excellence throughout their years of practice. They have a duty to keep abreast of scientific and technological developments as well as major social changes that impact on the practice of medicine. The moment their training begins, they must develop sound self-learning habits, enabling them to master precise, complex skills. Throughout their entire lives, physicians will improve their capacity to learn, to classify and build up their body of knowledge, and to have easy access to their store of information, which they must constantly update. Physicians must also develop the habit of self-evaluation, assessing the true measure of their knowledge and skills from the results of their work. Thus, everyday practice will constantly nourish their motivation for selfimprovement. This self-evaluating capacity will touch on all aspects of their work, from clinical decisions to different facets of their relations with patients and other health professionals.
COMMUNICATOR
hysicians spend more and more time producing information to be transmitted to patients and their families, colleagues, other health care workers as well as to the public. The new health care and social services structure implies that citizens take responsibility for their state of health. Developments in information and monitoring techniques, in the treatment and relief of pain, reinforce their ability to assume this responsibility. As communicators with their patients, physicians must make an effort to help them make decisions and take full responsibility for their own health. They must speak to the patient or family, successfully communicating the information needed to understand the disease and treatment, so that the necessary decisions can be made, as much as possible, with the patient or next of kin.
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CHAPTER 1 Evolving
To successfully play the role of communicator, which is becoming a more and more important part of medical practice, physicians must keep honing their communication skills. These skills will display themselves in the ability to be clear and precise, and to use language suited to the person being addressed. They must make sure the person has understood them and learn how to listen themselves, so that real communication can take place.
TEAM PLAYER
he reorganization now under way requires a much stronger sense of team-work between first-line physicians and second and third-line physicians, so that together they can discharge their duties in the community, and ensure continuous and comprehensive care. It is also clear that future physicians will frequently have to work as members of interdisciplinary teams. The growth of new social phenomena such as marginalization, itinerancy, violence, emotional problems and poverty, to name but a few, will increasingly require intervention by various professionals, who will have to work together to ensure better treatment for patients, appropriate follow-up and support in keeping with their situation. The interdisciplinary approach also opens the way to collaboration with patients and their milieu. In this context, tomorrows physicians will have to face up to many demands, such as developing the ability to cooperate, mastering the principles of team-work and adopting its behaviour, learning to better acknowledge and respect the fields of expertise of other professionals and, in the midst of all this, be active participants who use their own competence for the greater good of patients and their families, while remaining the ones ultimately responsible for the medical care delivered. Historically, all professions have evolved with a storehouse of knowledge and techniques that define them as unique. The professions were juxtaposed, as it were, when they were formed. But this division between fields of practice, or exclusivity, no longer suits the needs of the present health care system. With a view to protecting the public, the Office des professions is attempting to redefine the fields of practice so as to cut down on interprofessional conflict and modernize the professional system, making it more adaptable to the changing needs of the population and the professions themselves and appropriately responsive to these needs.
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Are we moving toward a professional system based on the classification of acts (Office des professions du Qubec, 1996)? Will we move more toward fields of practice in which a certain number of acts and activities are shared, as the Collge des mdecins du Qubec suggests? Further developments on this subject are expected in the coming months. With this in view, the Commission is interested in the present attempts at a rapprochement between the various professional orders working in the health care field. It encourages mixed committees working on subjects of common concern, so that protectionist mentalities may evolve even further. Thus, professionals, physicians in particular, will one day be able to work together in a naturally harmonious and concerted way.
MANAGER
he community orientation which, it seems, will characterize medicine in the 21st century adds to and broadens the responsibilities of physicians. They can no longer work in isolation in an office. They must become involved in the organization of care given to the community, in the very place where the activities of daily life take place. At the local or regional level, as the case may be, physicians will have to take on more responsibility for managing the medical practice component of the health care system. They will have to take part in the organization, coordination, control and evaluation of care delivery structures. To do so, they will have to develop the skills required for effective management. Allowing for exceptions, they will not necessarily become career managers. Rather, they will act as professionals with a unique expertise that enables them to be part of decisions involving resource allocation.
LEADER IN THE COMMUNITY

hysicians act in deference to the values of Qubec society and its health care system. As members of a community, they take part in efforts to improve the health and well-being of its other members. They stand up for their patients and intervene at a decisionmaking level to defend their interests. They do their best to ensure the wellbeing of individuals without neglecting the pursuit of the common good.
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Physicians have a duty to be open-minded and level-headed in their judgments. They will also have to show intellectual discipline, moral rectitude and coherence when they take a position, so as to positively influence the thinking and decisions of their fellow-citizens.
RESEARCHER AND TEACHER

linical research and basic research are also missions of the medical profession. With the advent of information technology, clinical research can now extend to different practice settings. In the future, research will become even richer and more diverse, thanks to the formidable amount of information contained in data banks. Physicians will have to realize this and take more interest in research. Physicians also have a responsibility to teach. Becoming a physician involves a long learning process and to get through it successfully, they must rely on their elders to impart the knowledge and clinical skills they themselves have acquired. In addition, physicians who are called upon by colleagues as experts and consultants are indeed acting as teachers in the way they write their reports or answer questions. On this point, the Commission reiterates its conviction on the importance of family physicians being able to practise in a hospital centre, including a university hospital centre, since the training of physicians is a process that continues throughout all their years of practice, both on the treatment sites themselves and through direct contact with patients and colleagues. * * *
iven all the roles selected by the Commission, some will say it is unrealistic to think that a physician could play all these roles. But the Commission believes that the attributes of a scientific and effective clinician, humanistic professional, learner, communicator and team player, are fundamental and essential to the practice of medicine in the 21st century. The abilities of manager, community leader and researcher-teacher are also fundamental, but in varying degrees depending on the interests of each and the practice setting. Often, excellence in all of the skills required by these roles will be shared among members of a group of physicians, each having developed a number of specific abilities to play these roles, without mastering all to the same degree.
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3. COMPLEMENTARITY OF PROFESSIONAL ROLES

hysicians perform the roles described above in one of two fields of activityfamily medicine or specialized medicine. The medical community and society in general have corresponding expectations of each. Relations between the two groups and between physicians and other professionals working in health care are changing quickly. Considerable professional challenges await physicians, and they must be faced, not only in the 21st century, but as of now, for the good of patients and the communities to which they belong. The following paragraphs address the question of complementarity of roles and the challenges it raises.
Family physicians are called upon to play a particular role in first-line care. Indeed, they are responsible for the primary care of their patients and, in an overall way, of their community. They provide most of the firstline care and a certain amount of second-line care. They use the other resources in the health care system as needed. The first-line care they provide corresponds to primary medical care as defined by WHO. It includes preventive, curative, rehabilitative and palliative care. It is characterized by its accessibility 24 hours a day, seven days a week. Thus, it is comprehensive and continuous and includes long-term management of the person (Conseil mdical du Qubec, 1995). Family physicians practise in a setting as close as possible to the area in which their patients live. For these patients, they are the principal means of access to the health care system. Indeed, the family physician is the keystone on which all other medical care depends. The Commission believes that the practice context for family physicians, already in a state of flux, will have to change again considerably in years to come. First-line physicians will work mostly in an ambulatory and community setting. Every physician will be accountable to a given clientele for the health care and services for which they have accepted responsibility; this will include longitudinal follow-up for that particular group of clients, who will depend upon firstly their own physicians services, then on those of the group to which their physician belongs. Many will have to deliver services to particular populations such as the elderly who are no longer selfsufficient. In addition, family physicians will continue to have a place in the hospitals, including the university hospitals; this place is particularly
HE FAMILY PHYSICIAN
33
CHAPTER 1 Evolving
important in outlying areas, where they very often ensure continuity of care to hospitalized patients. To ensure the total care of their patients, family physicians will almost never practise solo, but in a group practice setting. Using information technology to make their interventions more effective, these groups will form real networks, communicating regularly among themselves by computer. Family physicians will also work more and more in an interdisciplinary setting, while remaining ultimately responsible for medical care. Finally, they will collaborate in the organization of first-line medical services at the local, regional and provincial level, according to population needs.
While they perform the roles common to all physicians, specialists have also acquired a more indepth 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 problems. On the other hand, they are expert consultants for first-line practitioners, physicians in other specialties, other professionals in the health care sector, as well as patients and their families. Certain specialties require a highly technical facility, leading the specialist to master often very complex technologies. The Commission foresees that, given technological advances in particular, future specialists will work in ambulatory specialized settings, in out-patient facilities, or in superspecialized hospital settings where a small number of patients require special care. They will be called upon, even more than they are now, to be part of an interdisciplinary team. At times, they may even have to leave their usual workplace to go and see certain patients. In other cases, medical specialists will go to community settings, acting as consultants to the teams in place, discussing individual cases. Examples of such practices now exist in psychiatry and geriatrics. Finally, it is foreseeable that in the 21st century the development of telemedicine will considerably alter the role of specialist-consultants, giving the very diversified milieus in Qubec and elsewhere greater access to their expertise. Medical specialists will be responsible for second and third-line care and will also have to involve themselves in the planning and management of these medical services at local, regional and provincial levels. Given the expertise for which medical specialists are recognized, they will occupy a preponderant place in the area of clinical research, while ensur34
HE MEDICAL SPECIALIST
CHAPTER 1 Evolving
ing the participation of family physicians when feasible. Finally, with their in-depth knowledge comes the duty to teach family physicians, a duty that goes beyond the simple individual consultation process and takes place in the context of continuing medical education.
Family physicians are the principal players in our

health care system. Medical specialists tie their practice to that of the family practitioner, thereby increasing the possibilities for intervention in more specialized areas of medicine. In many specialties, however, specialists cannot provide a global view of the patients situation. Hence the importance of first-line services coming under the responsibility of the family physician, with the specialist acting mainly as a consultant. The hierarchical structuring of medical services 3 is a major issue, and this concept is part of the current line of thinking of many national and international groups of experts. Many organizations have in fact stressed how important it is that the patient have his own family physician, and before seeking out specialized care, that he obtain a request for a consultation from the latter. This is what was proposed by the Conseil mdical du Qubec (1995), the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada (1993) and the Qubec Federation 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 different areas of medical competence, making the care more relevant, effective and efficient. The Commission adheres completely to the principles underlying this hierarchical structuring. It encourages an orientation whereby every patient would be followed by one family physician and would receive a first assessment from the latter before calling on a specialist. But the Commission is not in favour of mechanisms that would make this way of doing things obligatory or coercive4. Rather it believes that efforts to educate patients and physicians, coupled with standards applying to the remuneration of the latter, would serve the same purpose while maintaining a necessary flexibility in certain cases and safeguarding personal responsibility.
ELATIONS BETWEEN FAMILY PHYSICIANS AND MEDICAL SPECIALISTS
3. See Chapter 5 on this subject, The Organization of Health Care and Health Services. 4. For more information, please refer to chapters 5 and 6 dealing with the organization of health care services and funding, respectively.
35
CHAPTER 1 Evolving
Our health care system is undergoing profound

change, as we said earlier, and this is not an isolated phenomenon, it is world-wide. The Commission believes, in the light of its analyses, that the skills and knowledge required to practise medicine, either in family practice or in a specialty, will become more and more specialized. Therefore, the sharing of acts with other health professionals is necessary, so that physicians can play the exact, very specific role for which they were trained. Medicines increasing complexity will lead physicians to opt out of certain activities that do not necessarily demand their competence. And, given the expanding roles of other professionals, it is pertinent that we take another look at how duties can be shared, both in the workplace and at the level of the professional orders. It will be up to the Collge des mdecins du Qubec to define the field of practice and acts that come within the competence of the physician, as well as those that can be shared, for the greater good of patients and in deference to the professional roles of each. The nurse clinician, to cite an example, will intervene more in emergency room settings, in first-line prevention, geriatrics, chronic and palliative care, whereas the surgical assistant will play a role in the operating room, and the midwife in the delivery room. The Commission believes that this trend is irreversible and will require delicate and sometimes painful adjustments. On the other hand, it is likely to free-up physicians and make their medical practice more dynamic, while enabling them to give their patients more comprehensive care. All of these changes should occur without compromising the integrity of the patientphysician relationship or the quality of care provided. A review of the regulations with respect to activities or acts, as well as an openness to the possible roles to be played by other professionals, will help make professional practice more dynamic. The basic principles governing these changes may be defined as follows: I to respond to the needs of Quebecers; I to ensure respect for competencies; I to promote quality professional practice; I to harmonize individual and collective interests.
ELATIONS WITH OTHER PROFESSIONALS
36
CHAPTER 1 Evolving
CONCLUSION
he Commission cannot overemphasize the importance of appropriate medical education, education that is at once scientific and humanistic. This initial training, coupled with continuing education, is the only path to maintaining competence for todays physicians and ensuring that future physicians have the ability to perform the professional roles that await them. In the years to come, challenges will abound for all Qubec citizens, and from our particular point of view, for physicians. Their special position as social actors places them at the crossroads of every major change. It is clear that they will have to combine forces to innovate, adapt and continue to give their patients the best possible care. As they cope with technological change and the shift to ambulatory and community care, they will be called upon as never before to revive a deep-seated humanism, which will enable them to weather the storms that will certainly still beset the health and social services system in which they work every day.
37
CHAPTER 1 Evolving
BIBLIOGRAPHY
Association of American Medical Colleges. 1993 AAMC policy on 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 Internal Medicine. Vol. 119, no 2 (July 15). P. 153-160 Becker-Reems, E.D. 1994 Self-managed work teams in health care organizations. Chicago : American Publishing. 245 p. ISBN 1-55648-122-5 Berwick, D.M. 1994 Eleven whorthy aims for clinical leadership of health system reform. JAMA. Vol. 272, no 10 (Sept. 14). P. 797-802 Braunwald, E. 1991 Subspecialists and internal medicine : a perspective. Annals of Internal Medicine. Vol. 114, no 1 (Jan. 1). P. 76-78 Collge des mdecins de famille du Canada. 1995 Grer le changement : un modle de pratique de groupe en mdecine familiale : Livre vert : document de discussion sur la rforme des soins de sant de premire ligne. Ottawa : CMFC. 54 p. Collge des mdecins de famille du Canada. 1997 Agrment des programmes de rsidence et certification. Ottawa : CMFC. 47 p. ISBN 1-896014-21-6 Collge des mdecins de famille du Canada ; Collge royal des mdecins et chirurgiens du Canada. 1993 Relations entre le mdecin de famille et le spcialiste consultant dans la prestation des soins de sant : rapport du Groupe de travail. Ottawa : CMFC ; CRMCC. 42 p. ISBN 0-921413-91-2 Conseil mdical du Qubec. 1995 Avis sur une nouvelle dynamique organisationnelle implanter : la hirarchisation des services mdicaux. Qubec : le Conseil. 47, [13] p. Avis 95-03. ISBN 2-550-24786-8 Contandriopoulos, Andr-Pierre. 1994 Rformer le systme de sant : une utopie pour sortir dun statu quo impossible. Ruptures, revue transdisciplinaire en sant. Vol. 1, no 1. P. 8-26 Cruess, Sylvia R. ; Cruess, Richard L. 1997 Teaching medicine as a profession in the service of healing. Academic Medicine. Vol. 72, no 11 (Nov.). P. 941-952 Dussault, Gilles. 1986 La collaboration interprofessionnelle : une utopie?. Artre. Vol. 4 , n o 3 (avril). P. 17-18 Dussault, Gilles. 1990 Les dterminants de lefficacit du travail multidisciplinaire. Le Grontophile. Vol. 12, no 2 (printemps). P. 3-6 Educating future physicians for Ontario (EFPO). 1993 Overview and synthesis : What people of Ontario need and expect from physicians Part 2. Associated Medical Services, The Ministry of Health of Ontario, and the five medical school or academic health sciences centres of Ontario Forum national sur la sant. 1997 a La sant au Canada : un hritage faire fructifier : Volume I : rapport final du Forum national sur la sant. Ottawa : le Forum. 36 p. ISBN 0-662-81718-4 Forum national sur la sant. 1997 b La sant au Canada : un hritage faire fructifier : Volume II : rapports de synthses et documents de rfrence. Ottawa : le Forum. 1v. en pag. multiple. ISBN 0-662-81719-2 Friedman, E. 1995 The power of physicians : autonomy and balance 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 healthcare : 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 among medical specialties and systems of care : results from the medical outcomes study. JAMA. Vol. 267, no 12 (March 25). P. 16241630 Mechanic, D. 1996 Changing medical organization and the erosion of trust. Milbank Quarterly. Vol. 74, no 2. P. 171-189 Office des professions du Qubec. 1996 Approche lgard de la rserve et du partage dactes professionnels : vers un systme professionnel plus souple et mieux adapt : cadre de rfrence. Qubec : lOffice. 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. San Francisco : UCSF Center for the Health Professions. xvi, 60 p. Provincial Co-ordinating Committee on Community and Academic Health Science Center Relations (PCCCAR). Subcommittee on Primary Health Care. 1996 New directions in primary health care. Toronto : PCCCAR. 58, 14 p. Rosenblatt, R.A. 1992 Specialists or generalists : on whom should we 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 Skill for the new millenium : report of the societal needs working group ; CanMEDS 2000 Project (Canadian Medical Directions for Specialists 2000 Project). Ottawa : the College. 20 p. WHO-WONCA Conference (1994 : London, Ont.). 1995 Making medical practice and education more relevant to peoples needs : the contribution of the family doctor. Geneva : World Health Organization. iv, 98 p. World Health Organization. 1996 Doctors for health : a WHO global strategy for changing medical education and medical practice for health for all. Geneva : WHO. 22 p.
38
ummaries of the Chapters and Recommendations
39
CHAPTER 1
volving Professional Roles for Physicians in the 21st Century
SUMMARY
he transformation of the health care system, the evolving roles of other professionals, and the burgeoning body of knowledge and technological advances will substantially change the practice of medicine in the 21st century. Physicians are challenged by these ongoing changes and must not submit to them passively. They must involve themselves in these changes, indeed direct them, by occupying the central place warranted by their training and the responsibilities they assume as principal players in our health care system. Despite all the changes, we must keep in mind that the patientphysician relationship remains fundamental, and, in this sense, physicians remain ultimately responsible for the medical care given to their patients. In 21st-century Qubec, the Commission expects that physicians will be increasingly asked to adopt a community approach to their work, to review their commitments in this sense and, within an ambulatory care context, revive a mode of practice where support and treatment of the sick take place in their living environment. They will be called upon, not only as skilled and competent scientists to diagnose and treat disease, but as humanists and persons of good judgment who can analyse and understand new health-related issues, to imagine future solutions, discuss them objectively, and lucidly envisage their consequences. Therefore, physicians must develop their professional competence as humanists as well as scientists as of now, aware of the fact that the patient is a person whose integrity, autonomy and dignity must be respected. The Commission therefore believes that as well as working constantly to be scientific and effective clinicians, physicians must become humanistic professionals,
40
CHAPTER 1 Evolving
learners, communicators, team players, managers, leaders in their community, researchers and teachers. The complementary roles of family physician and specialist will have to be more and more coherently articulated in years to come. Family physicians, whose primary role is to give first-line care, are increasingly working in groups. They take responsibility, not only for their own patients on an individual basis, but for the entire clientele they serve by belonging to a group practice. They direct their patients to a specialist if necessary. Specialists 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 physicians, they provide first-line care in particular instances only. While family physicians practise more in an ambulatory setting, their work in the hospital remains important. Specialists, on the other hand, frequently work in the hospital, although a good part of their work (at least for certain specialties) is done in ambulatory settings. The Commission believes that physicians will work more and more as part of an interdisciplinary team composed of other physicians and other professionals. Activities that do not necessarily require their expertise will be shared with other professionals. This, in the Commissions view, is an irreversible trend, which will require sometimes difficult adjustments, but which is also likely to free physicians and make their practice more dynamic, while at the same time enabling them to provide more complete care to their clienteles.
41
CHAPTER 1 Evolving
RECOMMENDATIONS
GIVEN the evolution in medical practice brought on by a burgeoning
body of knowledge and outstanding advances in technology, a transformation in the sociocultural and political climate, and changes in the organizational framework for health care delivery;
GIVEN the expanding roles resulting from these changes, and the need for continual updating and upgrading of competence and skills; GIVEN the requirement for greater differentiation and complementa-
rity of roles between family physicians and specialists as well as other health professionals, which does not take away the family physicians place in hospital centres nor reduce the physicians ultimate legal responsibility with regard to medical care;
GIVEN that the present method of payment cannot adequately recognize and compensate for the changes in the tasks physicians must assume daily, and that it cannot facilitate the organization of work required to effectively perform them; GIVEN that the quality of medical practice cannot be dissociated from the milieu in which it takes place,
the Commission on the Practice of Medicine in the 21st Century recommends
1. 2.
That the Collge des mdecins du Qubec commit itself immediately to supporting physicians in active practice so as to enable them to better take on the roles required to practise their profession in the 21st century, notably those of scientific and effective clinician, humanistic professional, learner, communicator and team player. That the Collge des mdecins du Qubec, in concert with universities and other educational facilities, agree upon a master plan whereby medical training as a continuum (undergraduate and postgraduate training and continuing medical education) would enable todays and tomorrows physicians to acquire the competence they need to meet the medical challenges and health problems of the 21st century.
42
CHAPTER 1 Evolving
3. 4. 5. 6.
That the Collge des mdecins du Qubec, conscious of the fact that the evolving professional roles of physicians will have them attribute increasing importance to tasks such as case discussions between specialists and family physicians, interdisciplinary work, counselling the patient and the family, medical-administrative activities, etc., take position in favour of reviewing methods of payment with a view to furthering the accomplishment of such tasks. That the Collge des mdecins du Qubec implement effective means to help physicians develop habits of self-evaluation and self-learning; that it influence the heads of undergraduate and postgraduate training programs and pressure the universities to systematically develop the skills and knowledge that build these habits. That the Collge des mdecins du Qubec not only continue to evaluate the quality of medical practice in different care settings, including private practice, but that it commence immediately to support physicians in their efforts to improve the quality of care. That the Collge des mdecins du Qubec reaffirm, whenever pertinent, its vision of the family physicians role as a first-line professional who is also responsible for follow-up medical care, and its vision of the specialist as expert clinician with patients and consultant with colleagues; that it resolutely take a position in favour of the complementary roles of family physicians and specialists, and the consequent hierarchical structure of medical services this complementarity creates; that it join in the process to develop mechanisms for its realization. That the Collge des mdecins du Qubec reaffirm the family physicians place in hospitals, including university hospitals. That the Collge des mdecins du Qubec take a stand on the importance of quality second and third-line care for the population and on the need for sufficient resources, effectively and efficiently used, to sustain the development of medical specialties providing these services, ensuring notably that adequate technical facilities be available for their use.
7. 8.
43
CHAPTER 1 Evolving
9. 10. 11.
That the Collge des mdecins du Qubec, in concert with the Interprofessional Council of Qubec, the Office des professions and other professional orders, pursue its efforts to clearly define the competence and field of practice of physicians and other health professionals; in so doing, that the Collge clearly define the responsibilities of physicians and the mechanisms for their collaboration with other professionals. That the Collge des mdecins du Qubec, given the physicians legal and ultimate responsibility with regard to medical care, attribute the necessary value to the physicians special role on interdisciplinary teams and see to it that physicians acquire the necessary skills to work as part of such teams. That the Collge des mdecins du Qubec, in its relations with its membership, faculties of medicine, associations and federations of physicians, stress the need for physicians to take part in the development of knowledge by increasing their participation in research programs, within any pertinent ethical boundaries.
44
CHAPTER 2
oward an Ethic of Shared Responsibility in a Pluralistic Society
SUMMARY
oday, the ethical dilemmas physicians must face are more numerous, more complex, more controversial and are frequently debated in public. Along with the rest of society, they are confronted with many situations that call for difficult, sometimes even heartbreaking, choices. These choices involve the beginning of life (e.g. new reproductive technologies, prenatal diagnosis) as well as the end of life (e.g. euthanasia, cessation of treatment, assisted suicide) and the multiple situations involving care and procedures (e.g. organ transplants, screening for genetic diseases) that may occur over the course of a lifetime. Two factors have a particular impact on the ethical aspect of medical practicetechnoscientific advances and sociocultural changes. Their influence on the realities of the 21st century will likely be more marked. In the scientific and technological fields, the realm of possibility has expanded much more quickly than is desirable or necessary. And this is precisely where ethics comes in. Efforts will therefore have to be made to extend its boundaries in the coming years. As for the social and cultural climate, moral pluralism and the defence of individual rights appear to be irreversible features of our society. Besides, evolving attitudes on death are leading to ethical problems that were totally unforeseeable not so long ago. Finally, the upheavals in the health care system are raising new questions on the limits of the States role in the lives of citizens and the choices imposed by limited resources and financial means, particularly as regards medicine aimed at satisfying peoples desires.
45
CHAPTER 2 Toward
an Ethic of Shared Responsibility in a Pluralistic Society
Ethics is unquestionably a concern for clinicians who must daily honour their patients trust by paying attention to all the values that have the welfare of the person at their very core. They will have to protect these values in their milieu, and give them special consideration in their actions. But ethics also concerns research physicians and represents a major obligation on their part. Thus, it is important to increase ethical competence within the medical profession, during university training and in continuing medical education. This competence must extend to the ability to lead the decision-making process in matters of ethics, whether it be at a personal level or in group discussion. Medical ethics is a matter of utmost concern to the Collge des mdecins du Qubec, given its responsibility to promote quality medicine in order to protect the public. The Commission suggests that the Collge create a permanent centre where ethical issues would be addresseda place for research activities, information, and discussion on the ethical aspects of medical practice.
46
CHAPTER 2 Toward
an Ethic of Shared Responsibility in a Pluralistic Society
RECOMMENDATIONS
GIVEN the ethical grounds for medical practice, notably respect for
a persons dignity, integrity and freedom;

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

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

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

GIVEN the importance of a forum for information and discussion on
ethical questions raised by everyday medical practice;
the Commission on the Practice of Medicine in the 21st Century recommends
12. 13. 14. 15.
That the Collge des mdecins du Qubec and its representatives, take every opportunity to publicize and promote the values underlying the practice of medicine, notably the primacy of the patients well-being, a humanistic approach to the patient-physician relationship, and respect for a persons dignity, integrity and freedom. That the Collge des mdecins du Qubec ensure the development and maintenance of sound ethical competence in its members, during their university training and as part of their continuing medical education. That the Collge des mdecins du Qubec set up an information, education and exchange process on the ethical aspects of problems encountered in everyday medical practice; that this structure complement other existing agencies (networks, committees, faculty departments, associations, etc.). That the Collge des mdecins du Qubec see to the publication and widespread distribution to its members of tools and guides, particularly a clinical decision-making procedure that takes ethics into account, so as to help them shoulder their responsibilities in situations presenting complex problems in an often pluralistic moral and cultural context.
47
CHAPTER 3
ulnerable Clienteles: Modes of Support and Care
SUMMARY
he appearance of particularly vulnerable clienteles is a recent phenomenon in Qubec. It is the result of four major factors: a rapidly aging population, impoverishment, the disintegration of traditional social structures and an increase in immigration and international adoption. These realities, inevitably accompanied by a train of health and social problems, will unquestionably become more and more widespread in coming years, particularly in the Greater Montral area where over 45% of our physicians practise. The latter will have to prepare themselves to support and manage the medical needs of people subjected to these new social phenomena, since they will form an ever-growing portion of their clientele. First-line physicians will be the ones most often called upon to intervene and help these vulnerable persons. But given the complexity of the health problems on a physical, psychological and social level, and given the necessity of taking action which has a bearing on the living conditions of their patients, they should move toward an interdisciplinary mode of practice. Much work has yet to be done at this level, and a sound understanding of the complementarity of actions taken by first-line physicians, specialists and other professionals is urgently needed. Physicians are the ones best placed to appreciate the suffering of vulnerable clienteles. They could become advocates of their health needs and rights; to do so they must have the required tools. From this perspective, continuing medical education activities must focus more on the development of certain skills, such as the ability to work in an interdisciplinary context, the ability to use and coordinate community resources, and the ability to adopt modes of communication suited to certain vulnerable
48
CHAPTER 3 Vulnerable
Clienteles: Modes of Support and Care
clienteles. Is the 21st-century physician ready to play the role of defender of the vulnerable patients interests? How will 21stcentury physicians better prepare themselves to play this role? What are the most effective strategies physicians can use to defend the interests of a vulnerable individual, a vulnerable group? With whom must they ally themselves in championing these rights and interests? To sum up, the skills sought in 21st-century physicians are many, and the need to profoundly transform the way they practise medicine so as to meet the needs of vulnerable clienteles is inescapable.
49
RECOMMENDATIONS
GIVEN the specific needs of certain particularly vulnerable clienteles; GIVEN the advantages of a global, interdisciplinary approach; GIVEN that medical management of these clienteles has repercussions
on the type of task required, the need to adapt certain tools of evaluation, and medical workforce planning, the Commission on the Practice of Medicine in the 21st Century recommends
16. 17. 18. 19.
That the Collge des mdecins du Qubec, through its accreditation of training programs, examinations to obtain a permit to practise, and continuing medical education, ensure that the training of physicians prepares them to work with vulnerable clienteles, more specifically through comprehensive medical management of the patient, interdisciplinary team work and home visits. That the Collge des mdecins du Qubec devise tools to evaluate the quality of medical care given to vulnerable clienteles and ensure their application, particularly in comprehensive medical management of the patient, the work of physicians on interdisciplinary teams, and home visits. That the Collge des mdecins du Qubec, in collaboration with the bodies concerned, including other professional orders, devise tools to evaluate the quality of interdisciplinary work and ensure their application 1. That the Collge des mdecins du Qubec take the necessary steps vis-vis medical federations so that measures are taken to acknowledge the necessary tasks involved in work with vulnerable clienteles (home visits, listening, educating the patient, looking for available community resources, etc.) 2.
1. According to members of the Commission, this recommendation must be taken together with recommendations 9 and 10. 2. This recommendation must be taken together with recommendation 3.
50
20. 21.
That the Collge des mdecins du Qubec make certain that tools are developed to evaluate the effectiveness of the supportive role played by medical specialists with families grappling with the complex problems that vulnerable clienteles often present; that the Collge make certain that the tools developed are applied 3. That the Collge des mdecins du Qubec, notably through its participation in medical workforce determination, ensure that the impact of vulnerable clienteles on the practice of medicine be considered when determining medical workforce needs.
3. This recommendation must be taken together with recommendation 6.
51
CHAPTER 4
revention and Health Promotion: Its Importance and Impact on 21st-Century Medicine
SUMMARY
urative care has always occupied a preponderant place in the health care system. But it no longer plays the important role it once played in improving mortality rates, even though it still represents the lions share of costs to the health care system. It is now acknowledged that a populations state of health depends on a combination of factors that do not necessarily include curative care. In this context, prevention and health promotion would appear to provide a choice solution. Prevention attempts to prevent the onset of disease or to slow down its progress and delay its complications. The thrust of health promotion, long associated with prevention, is the adoption of healthy behaviours that maintain health and even improve it. Despite the exposure that prevention and health promotion have had over some twenty years in Qubec and elsewhere in the world, many questions are being discussed and have not yet been answered. What is the role of each different professional, of physicians in particular? Do prevention and health promotion appreciably reduce the costs associated with disease? How will society allow access to certain types of screening, while still respecting ethical standards? At a time when financial resources are shrinking considerably, where will prevention and health promotion fit in? The purpose of this chapter is to provide answers to these questions. It may be useful to point out that the roles of the various playersfamily physicians, specialists and other professionals must be defined from a perspective of complementarity and be well understood by each. The results of prevention and health
52
CHAPTER 4 Prevention
and Health Promotion: Its Importance and Impact on 21st-Century Medicine
promotion will only be optimally felt when the role of every professional is fully taken into account, and family physicians truly perform their role as principal players. The Commission anticipates greater access to information for practitioners and patients alike. It also expects that more clinical practice guidelines and guides will be published and, as a result, prevention and health promotion measures will be incorporated into all quality professional practices. Finally, it is unrealistic to think that prevention and health promotion will save substantial amounts of money, since the measures involved will necessitate the provision of funds and, in all likelihood, morbidity and mortality will be merely postponed. However, we can anticipate that life expectancy, and life expectancy in good health, will increase substantially.
53
CHAPTER 4 Prevention
and Health Promotion: Its Importance and Impact on 21st-Century Medicine
RECOMMENDATIONS
GIVEN the impact of prevention and health promotion on the general
state of health and well-being of the population;

GIVEN the importance of incorporating these elements into basic edu-
cation as well as continuing medical education, the Commission on the Practice of Medicine in the 21st Century recommends
22. 23. 24. 25.
That the Collge des mdecins du Qubec advocate prevention and health promotion as an integral part of medical care. That the Collge des mdecins du Qubec ensure that prevention and health promotion activities are an integral part of the everyday practice of medicine. That the Collge des mdecins du Qubec pay particular attention to questions concerning predictive genetic testing and accessibility to various preventive measures. That the Collge des mdecins du Qubec support the incorporation of prevention and health promotion activities into undergraduate and postgraduate training as well as continuing medical education 1.
1. According to members of the Commission, this recommendation must be taken together with recommendation 2.
54
CHAPTER 5
he Organization of Health Care and Health Services
SUMMARY
he Commission on the Practice of Medicine in the 21st Century considers the organization of health care and services to be central. It singles out three fundamental values for Qubec society: equity, solidarity and respect for personal human dignity. It also underlines certain cultural characteristics of Qubec citizens, among them, the free care and services from professionals of their choice, in the facility of their choice and in the language of their choice (French or English). The Commission recognizes the importance of the regional level in the organization of health care and services and, thus advocates regionally based models of medical practice. The Commission sees family physician group practices as an irreversible trend toward the medical management of populations and believes the tendency should also extend to specialists. To better guarantee uniformity and quality of care, it suggests the establishment of medical councils, either local or regional, as need be. For specialties with few practitioners, the Commission recommends that they form a provincial network, going beyond mere sporadic helping out. The Commission supports the idea that the ambulatory shift is necessary, that the system must be made more efficient and the number of beds reduced. However, it questions the real purpose behind the operation now under way, as well as the pace of the expenditure reductions being imposed on the system. It recalls the conditions essential to the success of the ambulatory shift.
55
CHAPTER 5 The
Organization of Health Care and Health Services
The Commission does not recommend mandatory registration with a given family physician; rather it suggests different ways and means of building patient adherence to one attending physician or group of physicians. It realizes that a large portion of first-line services are provided by specialists and does not see this situation as beneficial. It recommends a hierarchical structure of medical services, without making it mandatory to obtain a referral from a family physician before seeing a specialist. The Commission believes that formulas such as integrated service networks like those which exist in perinatal care and are being put in place for the elderly, are promising models that call for further experimentation. The Commission recommends that the Collge associate itself closely with these pilot projects. It does not believe that models such as Health Maintenance Organization (HMO) and Managed Care are applicable in their present form to Qubec.
56
CHAPTER 5 The
RECOMMENDATIONS
GIVEN the importance for the population of a judicious geographic
and functional distribution of the medical workforce throughout Qubec;

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 organization of health care and health services;
GIVEN that the evaluation function inherent in the mission of the Col-
lge des mdecins du Qubec requires that it consider new ways of organizing health care and health services, the Commission on the Practice of Medicine in the 21st Century recommends
26. 27.
That the Collge des mdecins du Qubec pursue its activities on the determination of the medical workforce and state its position publicly on the geographic and functional distribution of physicians in Qubecs regions. That, before any decisions are made, the Collge des mdecins du Qubec highlight the importance of pilot projects having to do with any change affecting patients, and that it sit on steering committees for these projects, notably with respect to the following: I the organization of care (registration of patients, regional organization of services); I the distribution of care (e.g. integrated care and service plans for the functionally impaired elderly); I the dynamics of care (e.g. hierarchical structure of care, mandatory referral); and for each type of project, that the Collge measure its impact on the quality of care.
57
CHAPTER 5 The
28. 29. 30.
That the Collge des mdecins du Qubec monitor the changes in the system; that it rigorously evaluate the impact of these changes on the quality of care provided by physicians and received by patients; that it denounce any significant negative consequences, and suggest necessary adjustments. That the Collge des mdecins du Qubec support initiatives which group physicians together in a context that provides accessible and integrated services; more concretely, that the Collge des mdecins du Qubec involve itself in the process of evaluating pilot projects ensuing from these initiatives, and make the necessary recommendations. That the Collge des mdecins du Qubec, given the growing importance of the regional level in the organization of health care and services, promote the creation of regional and sub-regional medical councils whose essential task would be to evaluate the quality of medical acts.
58
CHAPTER 6
unding the Health Care System
SUMMARY
n Qubec, the operating costs of the health care and services system are high; they are in the order of $13 billion and represent 9.9% of GDP. Despite the present financial difficulties, the Commission concludes that, if the system operated optimally, this level of funding would be enough to ensure the necessary health care and services to the population. Indeed, many examples show that efficiency gains are still possible within the system. However, these gains will not compensate for the expected budget cutbacks to the future system. The Commission wishes to maintain a publicly funded health care system, with funding remaining at its present level. It recognizes the importance of the regions when developing mechanisms for allocating financial resources to the systems agencies. To this end, it proposes an improved weighted regional per capita formula for funding the regions. With respect to the remuneration of physicians, from the perspective of quality medicine, the Commission does not support the principle of capitation. It proposes the adoption of mixed methods, and suggests as food for thought a comprehensive remuneration package which would be given to groups of physicians, and used taking into account certain features of the practice plans. The Commission finds that the new Drug Insurance Plan is worthy of note from many points of view. It introduces a new method of public-private funding as well as elements which redefine accessibility (e.g. essential drugs in every class). But the
59
CHAPTER 6 Funding
the Health Care System
Commission also notes that this insurance plan is becoming another tax burden and, what is more, it is not sure that the plan as presently conceived can withstand the expected cost increases in the medium term. The Commission concludes by sounding the alarm and emphasizing that the budget cutbacks and pace of financial recovery imposed on the system are threatening the quality and integrity of the system itself.
60
CHAPTER 6 Funding
RECOMMENDATIONS
GIVEN the many signs of exhaustion resulting from successive budget
cuts, right at a time when major changes in the organization of care and services demand considerable efforts;
GIVEN that efficiency gains have yet to materialize, and that they will
not produce enough savings to satisfy new needs in health care and services;
GIVEN the opening debate on desirable levels and areas of public and
private funding of the health care system;

GIVEN the impact of current regionalization plans on the way services
are funded;
GIVEN the link between work organization and payment methods for
physicians, the Commission on the Practice of Medicine in the 21st Century recommends
31. 32. 33.
That the Collge des mdecins du Qubec officially demand that no new budget cuts be made to the health care system until the impact of the cutbacks already made have been evaluated in terms of their effects on sick people; that the Collge take part in such evaluation and take a public position on the subject; That the Collge des mdecins du Qubec involve itself, along with other organizations or agencies concerned by this question, in a search for ways and means of improving the health care systems efficiency; That the Collge des mdecins du Qubec assert its conviction that services essential to the health of Quebecers, as well as access to these services, must be ensured for them without additional cost within a public health care system.
61
CHAPTER 6 Funding
34. 35.
That the Collge des mdecins du Qubec actively participate in the discussions on private-public funding from the point of view of its own mission. That the Collge des mdecins du Qubec closely monitor the development of regionalized funding plans for health care and services; that it take part in the evaluation of these plans as they pertain to quality of care and their effects on the clientele.
62
CHAPTER 7
he Impact of Technology on 21st-Century Medicine
SUMMARY
echnology is now a vital component of medicine. It may be defined as all the drugs, instruments, procedures, support systems and organizational systems required to provide care*. Technologies linked to information, telemedicine and computer systems (professional assistance and patient assistance programs) are the ones that will most affect medicine in the coming years. Technologies resulting from recently acquired knowledge in biology will also have a considerable effect. They will move laboratory analysis away from central laboratories and into physicians consulting rooms and pharmacies, and to the patients bedside. The perfecting of new drugs, new vaccines and other very specific molecules through genetic engineering will also expand rapidly after a latent period of some eight to ten years. These products will lead to changes in medical practice. In this regard, the increased use of genetic testing is expected, and this will have major repercussions. Instrument and equipment miniaturization and laboratory automation will call for new ways of doing things, particularly in diagnostic practices and procedures. The Commission identifies two probable consequences of these expected innovations. The first concerns the patient-physician
* Office of Technology Assessment [1978], cited in H. David Banta, Clyde J. Behney and Jane Sisk Willems, Toward Rational Technology in Medicine : Considerations for Health Policy, New York, Springer Pub.,1981, p. 5
63
CHAPTER 7 The
Impact of Technology on 21st-Century Medicine
relationship, which will have to be redefined, and ethical issues, which will have to be examined in depth. This is particularly evident if one considers genetic testing. The second concerns the difficult choices imposed by the costs of purchasing and using the latest technology. The Commission emphasizes the fact that information seems to be the predominant factor in the technological advances of the next 10 to 15 years. It would also underscore the fact that using these new technologies or technology in general makes no sense unless it is coupled with an improved quality of life, both individual and collective, physical and psychological.
64
CHAPTER 7 The
Impact of Technology on 21st-Century Medicine
RECOMMENDATIONS
GIVEN the expanding role of technology in medical practice; GIVEN that the personal dignity and well-being of the patient take pre-
cedence;
GIVEN the benefits to the patient of optimal use of information tech-
nology, the Commission on the Practice of Medicine in the 21st Century recommends
36. 37. 38. 39.
That the Collge des mdecins du Qubec ensure that, in using technology, physicians consider ethical principles, apply criteria for their judicious use and show a concern for the cost-effectiveness ratio; That the Collge des mdecins du Qubec define strategies to optimize the incorporation of clinical practice guidelines and guides into everyday medical practice 1. That the Collge des mdecins du Qubec take part in the discussions of existing task forces and join in projects on the use of computerized information and communication technologies in daily clinical activities (computerized medical record, smart card, telemedicine, etc.); that it make the necessary recommendations to have these means promote quality medical practice; That the Collge des mdecins du Qubec adopt a strategic plan to induce the entire professionphysicians in postgraduate training as well as those in practiceto make optimal use of information technologies (expert systems to assist in decision-making and prescription, data banks providing quick access to scientific achievements and discoveries, etc.) 2.
1. This recommendation is an extension of recommendation 1; it has been placed in this group of recommendations for the simple reason that the Commission explicitly addresses the question of clinical practice guidelines in this chapter. 2. According to members of the Commission, this recommendation is closely linked to recommendation 2.
65
ommitments
of the Collge des mdecins du Qubec
66
he Collge des mdecins du Qubec followed the work of the Commission on the Practice of Medicine in the 21st Century with great interest and appreciated the care and concern with which the commissioners discharged their mandate, especially in view of the breadth and complexity of the topics examined. Indeed, the Collge des mdecins du Qubec thought it particularly positive that the work of the Commission included a phase of consultation with physicians working in all parts of Qubec, with organizations involved in health care, and with experts on the various questions addressed. An orientation day for members of the Bureau and physicians employed by the Collge enabled us to study and discuss the outcome of the Commissions reflections and its recommendations. As a follow-up to this orientation day, the Collge des mdecins du Qubec wishes to state publicly that it has favourably received the work and reflections of the Commission and strongly supports all of its recommendations to the Collge. Accordingly, the Collge des mdecins du Qubec plans to publish and widely circulate the results of the Commissions work. To better direct its actions in the coming months and years, the Collge des mdecins du Qubec has extracted ten priority commitments from the Commissions 39 recommendations. They are as follows.
67
C
1. 2. 3. 4.
OMMITMENTS
To take the necessary measures so that physicians in active practice and physicians in training can better take on the roles required to practise their profession in the 21st century. These roles comprise particularly those of scientific and effective clinician, humanistic 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 specialists as expert-clinicians with their patients and consultants with their colleagues. To pursue efforts, in concert with the Interprofessional Council of Qubec, the Office des professions du Qubec and other professional orders, to clearly define the competence and field of practice of physicians and other health professionals, as well as the responsibilities of each and the mechanisms for collaboration between them. To reaffirm, given the legal responsibility for medical care assumed by physicians, the latters essential role in interdisciplinary work, and to make sure that physicians acquire the necessary skills to work as part of such teams.
68
5.
To evaluate the quality of medical practice in different care settings, including private practice, emphasizing the comprehensiveness and continuity of medical care; to begin immediately to support Qubec physicians in their efforts to acquire, develop and maintain the competence required to provide such care, and to support practice sites in their efforts to continually improve the services they provide.
6. 7. 8. 9. 10.
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 problems 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 promoting 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.
69

New Professional Challenges For Physicians in The 21st Century

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New Professional Challenges For Physicians in The 21st Century

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Commission on the Practice of Medicine in the 21st Century

New Professional Challenges for Physicians in the 21st Century

COLLGE DES MDECINS DU QUBEC

New Professional Challenges for Physicians in the 21st Century

COLLGE DES MDECINS DU QUBEC

Roch Bernier, M.D. President

MEMBERS OF THE COMMISSION ON THE PRACTICE

Dr. Joseph Ayoub

Dr. Paule Lebel

Dr. Claude Blisle

Dr. Sandra Palmieri

Ms. Odette Plante Marot

Dr. Jose Caron

Ms. Cline Plourde

Dr. Pierre Duplessis

Ms. Monique Chaput Ms. Julie Germain

Dr. Paul GrandMaison

Dr. Charles Guertin

Mr. Benot Lauzire

EXPERTS WHO MET WITH COMMISSION MEMBERS

ORGANIZATIONS WHICH MET WITH COMMISSION MEMBERS

NOUVEAUX DFIS PROFESSIONNELS POUR LE MDECIN DES ANNES 2000

PERSONS CONSULTED WHEN THEMES WERE BEING STUDIED OR TEXTS WRITTEN

NOUVEAUX DFIS PROFESSIONNELS POUR LE MDECIN DES ANNES 2000

NOUVEAUX DFIS PROFESSIONNELS POUR LE MDECIN DES ANNES 2000

NOUVEAUX DFIS PROFESSIONNELS POUR LE MDECIN DES ANNES 2000

NOUVEAUX DFIS PROFESSIONNELS POUR LE MDECIN DES ANNES 2000

NOTE FOREMEMA CTABLE INTRO-

Leader in the Community

THE 27 THE 27 35 28 RELA29 RELA29 CON30 BIBLI31 31 Summaries of the Chapters 32 34

SUMMARIES OF THE CHAPTERS AND RECOMMENDATIONS

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

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

Chapter 3 Vulnerable Clienteles: Modes of Support and Care

Chapter 5 The Organization of Health Care and Health Services

Chapter 6 Funding the Health Care System

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

COMMITMENTS OF THE COLLGE DES MDECINS DU QUBEC

FINAL REPORT Seven Topics, Seven Chapters

Appendix: An Overview of Certain Health Problems

COMMITMENTS OF THE COLLGE

Joseph Ayoub, M.D. President of the Commission

Pierre Duplessis, M.D. Secretary to the Commission

Claude Blisle, M.D.

Jose Caron, M.D.

Paule Lebel, M.D.

Julie Germain, M.D.

Sandra Palmieri, M.D.

Paul GrandMaison, M.D.

Odette Plante Marot

Charles Guertin, M.D.

Cline Plourde, B.Ph. 19

volving Professional Roles for Physicians in the 21st Century

Professional Roles for Physicians in the 21st Century

Professional Roles for Physicians in the 21st Century

1. THE EVOLUTION OF MEDICAL PRACTICE

XPANDING BODY OF KNOWLEDGE AND THE EXPLOSION OF TECHNOLOGY

HE CHANGING SOCIOCULTURAL AND POLITICAL CLIMATE

Professional Roles for Physicians in the 21st Century

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

Professional Roles for Physicians in the 21st Century

The ambulatory shift is the logical follow-up to