Solving the medical identity crisis

Recent trends and events are usually some indication of what is about to follow.

In the field of licensure and regulation of medical practice, it is no longer good enough to deal with bad apples when they become obvious. “Accountability,” “quality assurance,” “continuous quality improvement,” “risk management,” “pro-activity,” and “openness” have become the orders of the day. Closer monitoring of standards of education, practice performance, and maintenance of competence have grown steadily in the past 25 years.

Some medical schools, including UBC, are adopting new approaches to undergraduate education. Many are also including education on so-called “alternative/complementary” practices. It will be essential to ensure that the scientific basis of modern medicine is maintained.

All Canadian jurisdictions have increased their minimum post-graduate training requirement for licensure from 1 to 2 years, but there is still concern that emerging family physicians are often not prepared to meet some of the challenges of clinical practice, especially in outlying communities. UBC’s program has responded well by developing additional training opportunities, despite severe funding constraints. Government will have to be persuaded to adequately fund such initiatives as an important part of meeting the medical needs of remote communities.

The Canadian policy of two main streams to licensure, combined with no surplus of post-graduate training positions, and with the elimination of a PGI year that could be common to both streams, has forced premature future career choices, with adverse effects on trainees and less than optimum realization of their potential. This must be reconsidered in the near future.

Attention to maintenance of competence will continue to grow. In BC, the College has focused on monitoring and enhancement of practice performance. On-site peer assessment of office medical practices, initiated in the mid 1980s, has now looked at some 1700 practitioners. The comprehensiveness of assessments will undoubtedly increase in the future.

The triplicate prescription program began about a decade ago, mainly monitoring prescriptions of narcotic/analgesics. Development of the province’s PharmaNet system enabled this to be expanded into the prescription review program, through which prescribing of other selected drugs can be audited as well. Methadone prescribing is also monitored, and the office practices of its prescribers are periodically peer audited.

These and other existing College activities can be expected to be added to in the future, as part of a cross-Canada movement to proactively monitor and enhance practice performance and assure the public of competent, ethical care. Early attention to potential problems, with feedback directly applicable to the physician’s practice, is preferable to late imposition of severe practice restrictions. The RCPSC and the CFPC are applying similar interactive concepts in their programs for maintaining certification.

Computer programs now being installed at the College will further enhance direct interaction with members by way of a secure “extranet” pathway, which will also enable confidential electronic exchange of clinical information between members. Combined with growth of provincial telemedicine capabilities, which the College is actively promoting, continuity of medical education and maintenance of competence will be increasingly assured in ways that dedicated physicians should find rewarding rather than threatening. There will be nothing to fear from ongoing peer review, which has long existed in the hospital setting, unless a practice is way out of line. The same may not be said of intrusions by other authorities into regulation of medical practice.

Medicine has suffered much loss of trust and respect in recent times. Resentments over the perceived power, privilege, and financial status of physicians, plus growth of anti-elitist public sentiments in general, have spurred legislators and policymakers to find ways to take control of the profession. We have seen the creation of a Health Professions Council, soon followed by a Royal Commission on Health Care and Costs that made recommendations to restructure the governance of the health professions, including medicine.

It is no accident that health-policy analysts have been deeply involved in both of these bodies, nor that replacing the Medical Practitioners Act with the so-called model Health Professions Act would create authority for the government to impose rules on the profession against its will. Since the rules embrace standards of practice, the control potential of this intrusion is obvious. This contentious proposal could come to the fore in the near future, and the profession will need to decide how strongly it will defend independent self-regulation.

There are signs that politicians, faced with the current state of health services and a looming physician supply crisis, are realizing that reliance on health-policy analysts may not be wise, and that serious rifts with the medical profession are counter-productive. It is said that “the future is now.” If so, it would be timely for the profession to re-establish its leadership role now by actively exploring better ways of working with government to address a number of important issues. Positive ideas for optimal use of physician expertise should be proposed, e.g., multi-disciplinary clinics with physicians leading teams of allied health professionals and appropriate delegation protocols.

Reasons for the present serious fragmentation of medical services should be identified and solutions proposed, including ways to ensure coordination of patient care. There is suspicion that the profession’s financial interests are taking precedence over professional commitment. Medicine must confirm its commitment to the principle that nobody should be denied necessary medical care because of inability to pay for it. Associations between physicians and profit-seeking commercial enterprises also need to be re-examined more closely to ensure there are adequate safeguards against the financial exploitation of patients. Medicine will have to resolve its identity crisis, and decide whether to continue to govern itself as a profession or be governed as a trade.

Dr Handley is the registrar of the College of Physicians and Surgeons of BC.