Final Report of the Federal Advisor on Wait Times

Chapter 5: Professional Roles and Responsibilities

In the foregoing chapters I have made a number of recommendations on how to substantially improve wait times in health care systems. The recommendations so far have fallen into two major categories. First is the research that will help us to understand the effect of benchmarks and their utility in health care systems. Health systems research will permit us to continuously improve our ability to move patients smoothly through the health care system. Second are the management techniques and innovations, including information technology, that will sort out lingering system problems that we have inherited from generations of clinical and managerial predecessors.

I believe that the problem of wait times is a problem not just of "being made to wait" or "making someone wait". It is a problem of the focus of the system and the processes and machinery that support it. Over many years our health care systems have been pushed and pulled to accommodate many different goals, interests, and needs of professionals and administrators. The issues associated with wait times can be addressed if we are able to refocus the system to put the patient at the centre of our attention and problem solving.

The issue of wait times is a systemic problem that requires a systemic solution. Moreover, specific measures that make up this solution must be supported by a general cultural shift within the health system and among professionals. Without a movement that changes attitudes, assumptions and patterns of behaviour of the leaders, managers and providers of care, concrete measures are unlikely to succeed.

The discussion in this chapter will centre around the role and responsibility of health care professionals, illustrated largely through a discussion of the roles of physicians in our current health care systems. Much of what I will say reflects my own experience in medicine, my experience of working in and later leading health care delivery institutions of various sizes and more recently my discussions with fellow administrators, physicians and provincial and territorial colleagues.

With respect to the issue of wait times it is important to note that physicians, regardless of their area of practice, represent only one set of many different health care professionals involved in the totality of health care. Other groups, including but not limited to nurses, health care aides, technicians of many disciplines, administrators and managers, and increasingly social workers and therapists, all play important roles in the continuum of modern health care. These professionals organize and deliver care across facilities, in and out of acute care and in the home, in private offices and in community settings. All of us would be hard pressed to decide which member of the health care team could be eliminated without the team and patient losing out in some way.

5.1 The unique role of physicians in health care systems

Canadians for the most part feel that as patients, or as the family or friends of patients, they can be justifiably grateful to physicians and surgeons, family practice doctors, specialists and medical researchers, for the commitment and caring that these professionals demonstrate to their patients. Many Canadians will likely be able to recount an instance in which he or she, a child or parent, received a physician's careful attention, guidance through a medical problem or the maze of medical infrastructure, to benefit from an intervention or support that our health system affords Canadians. I believe that most Canadians feel this way, as do I. I have had the opportunity to witness this sentiment expressed frequently and I share with my colleagues the pride of esteem with which physicians are held in Canada.

All health care professionals have roles and responsibilities that are unique to their own profession. What makes physicians and surgeons unique, and therefore important to address directly, is the degree of influence that they are able to exercise over health care systems. This is either as a consequence of their ability to control systems of care (processes, organization and efficiencies) or to shape them through collective strength, individual participation and cooperation, or lack thereof. It is also a consequence of their relative independence. Other professionals or care providers are employees of the system or contracted to the system, while physicians are most often self-employed, may work in an entrepreneurial model and are most often paid on a fee-for-service basis.

Physicians as the "Gatekeepers"

Physicians are known as the "gatekeepers" of patients and patient care. This is a feature both of the traditions of medical care prior to the development of large health care systems and of institutional processes and administration that have traditionally centred on the role of physicians as the decision-maker. As gatekeepers, physicians have the ability to direct patient care and advance a patient to the next step of care. It is the physician who determines whether diagnostics are to be undertaken, prescriptions provided, medical and surgical interventions performed, and so forth. Additionally, physicians have autonomy as independent professionals to assign their time commitments and organize their practices.

Most physicians receive public money according to a schedule negotiated by provincial governments with provincial medical associations. Although there has been some change in the employment status profile of physicians over the last several decades, with physician's increasingly choosing salary-based roles (in a parallel stream in which funding allocations accrue to regional health authorities, hospitals or clinics), the fee-for-service arrangement remains predominant. Additionally, physician institutions, medical associations and specialist societies continue to reflect the autonomous organization of physician functions. Medical associations often reflect the values of independent business and clinical autonomy in exclusive relationship with the patients. Most physicians do not "work for the hospital". Most do not have a contractual or business arrangement in place with that institution that describes the responsibility of the physician and the facility. The relationship of the physician to the institution is defined typically by medical staff by-laws, which reflect the "rules of engagement" for physician functions within an RHA or hospital. There is seldom an agreement that binds practitioners to a prescribed level of service of volume, quality or efficiency. There is for most physicians and specialists in private practice no obligation to participate in change processes at the level of the facility or to cooperate with the procedural changes that others have adopted.

Because of their autonomy and their role in directing patient care, physicians are in a powerful position to support or resist system change. It is imperative that physicians are engaged effectively in system transformations that will support improved patient access to care.

In many provinces and health care institutions physicians are already contributing to great change processes with the issue of wait times central to their efforts. There is not a province that has made substantial progress on wait times without clinical leaders championing improved standards of care, greater efficiencies and the meaningful involvement of physicians that care. These clinical leaders cannot, however, accomplish these changes on their own, and cannot ensure that the efforts will endure without systemic supports around them. It has been my experience that the forces of change are seldom as strong as the forces against change. All participants in the health care system have a duty to promote system change that contributes to quality care.

5.2 Physician institutions

Physician organizations and professional regulatory bodies frequently provide representation in health system change processes by participating in local, regional, provincial and national discussions. Medical associations represent the goals, desires and interests of their physician membership. Provincial institutions such as Colleges of Physicians and Surgeons, which exist as a result of provincial legislation, protect the interest of the public with respect to licensing, medical practice standard setting and discipline. Colleges seldom participate in proactive consultation associated with system change and frequently find themselves exercising their legislated roles in reaction to system change that has been undertaken without their advice.

There also exists a community of professional interest, associated with the education and training of physicians, from undergraduate to specialty and sub-specialty education. This community of interest is intertwined with academic medical centres and a cadre of clinical researchers, health scientists and teachers. Medical educators and researchers bring a different perspective to the design and analysis of health care systems.

The system changes that I am proposing have the potential to improve efficiency throughout the health care system. This is especially true as it relates to the recommendations of the preceding chapter regarding the importance and impact of information technology in the health care system. The planning of the changes, the process that supports the changes and ensures that they address the needs that exist, should rely on advice from the medical community. Not only is it necessary and desirable to hear from the associations directed by physicians at large, it is necessary to hear from physician communities that are responsible for the professional conduct of physicians and their education.

5.3 Professional standards to support change

The words "system transformation" are purposefully expansive. The changes proposed throughout this final report are not only necessary but must be implemented urgently and pervasively. These changes will require careful planning, careful execution, and the cooperation and participation of many health care professionals, including but not limited to: physicians, nurses, statisticians, administrators and managers. Success will depend on ensuring that clinicians adopt new roles and responsibilities. The issue of wait times is urgent and the urgency requires that new standards of professional behaviour be developed and sustained in the long term. Expected changes in practice patterns will require the development and implementation of standards of professional conduct to be monitored and promulgated through Colleges of Physicians and Surgeons.

5.4 Educational efforts to perpetuate change

Canada's capacity for medical education is tested by many new factors that emerge on a daily basis. New demands include new conditions, changing demographics, new technology and the new expectations of students. As well public and political expectations are changing and are reflected through the media, often in a negative way. All medical schools in Canada have recently expanded medical class size to increase the number of graduating students and concomitant family physician and specialty training programs. As a result, health care systems in Canada, including educational infrastructure, must ensure that medical education incorporates emphasis on the program goals and societal values that accompany this requirement. Timely access, efficient, high quality care and fairness must be intrinsic in our delivery systems. Physicians graduating from Canadian medical schools should expect and respect the system-wide standards that Canadians support and which leaders, practitioners and employees of their health care systems can be expected to implement.

5.5 Issues of competency

The physician-patient relationship is important to physicians and patients alike. For many it is paramount in their experience of health care - an important foundation for understanding and trust.

There is already considerable variation in the physician patient relationship. Anaesthetists typically see patients only in pre-operative and operative settings and radiologists are normally service-based working either in hospital or clinic settings. In many specialty programs such as cancer care, cardiac surgery and neurosurgery physician assignments are made to patients at the point of system entry. This is referred to as service-based care. In these clinics physicians work as equal team members and provide services collaboratively.

It may be that the implementation of "service based care" and "first available slot" will result in a patient receiving surgery from a surgeon that he/she sees only in the context of that surgery. Patients need to have the confidence that whatever physician provides their care is of unquestionable competency. It is therefore incumbent on medical schools that Colleges of Physicians and Surgeons in each province, Regional Health Authorities and hospitals ensure that standards of medical education, practice and professional oversight are sufficient to guarantee that care will be undertaken by capable and competent practitioners in every instance in which care is provided.

5.6 Definition of roles

The issue of definition of professional roles has been addressed in Chapter 3. It remains in this section of the report only to emphasize that the development of professional scopes of practice, and the definition of skills and training required to assume professional responsibility, require a long and exacting effort. Professional roles and all of their accoutrements: education, licensing, regulation, competency testing, labour regulations, pay schedules and transferability, contribute to organization and to patient safety. At the same time they have the ability to create turf wars and professional stovepipes that can impede change or stifle innovation.

One means of ensuring enhanced access is to ensure that all professionals are functioning to their full scope of practice. This would ultimately free up resources at several levels that could focus on the issues of wait list management through volume increases and innovation.

5.7 Conclusion

Many of the changes that are proposed in this report have the potential to dramatically change the way we as Canadians and patients experience medical care. The recommendations not only have the ability to reduce the time that patients can expect to wait for medically necessary care but also the relationships experienced throughout the process.

Chapter 5: Professional Roles and Responsibilities Recommendations

11. That FPT governments develop a broad base for receiving advice from medical communities with respect to change in the health system and long term planning. The Canadian Medical Forum can be asked to assume this role nationally, with provinces and territories developing similar capacities locally to achieve balanced influence when medical input is deemed important;

12. That provincial Colleges of Physicians and Surgeons establish professional and ethical standards and the means to monitor professional practice with respect to physician management of wait times in provincial health care systems. The Federation of Regulatory Authorities of Canada should coordinate this effort;

13. That faculties of medicine of Canadian universities develop curricula that support changing health care systems and changing expectations regarding the competencies that physicians will require to participate in these systems led by The Association of Medical Faculties of Canada; and

14. That FPT work on health human resources initiatives focus on re-defining professional clinical roles to enable health care professionals to work at their full potential and to offer innovations in health care, which are economical and sustainable.