The following document presents the Medical Council of Canada’s (MCC) Considerations for Cultural-Communication, Legal, Ethical and Organizational Aspects of the Practice of Medicine (C2LEO) in a classification based on the proficiency at competencies that comprise the physician roles identified by CanMEDS.
Important notice: We will begin to incorporate the new C2LEO content in to the MCC examinations starting in 2008 and beyond.
Please note that at this time, no attempt has been made to identify which C2LEO Objectives are issues relating to MCC QE Part I but all are subject to evaluation in the Part II examination. This separation was originally completed for CLEO in recognition of the fact that some of the legal, ethical, and organizational objectives are best learned during graduate clinical education. This separation will be extended in the near future to the new Cultural-Communication objectives and all reclassified objectives, as applicable.
November 2005
© The Medical Council of Canada, 2005
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The CLEO (Considerations for the Legal, Ethical and Organizational Aspects of Practice) Objectives were first published in 1999 and incorporated into the Qualifying Examinations Part I and II in 2000-01. The most recent version, called C2LEO, incorporates all of the material from the earlier version in a reclassification based on the proficiency at competencies that comprise the physician roles identified by CanMEDS. This framework identifies six roles for the medical practitioner: communicator, collaborator, health advocate, manager, scholar and professional. This framework is now extensively implemented in Canada, and recognized worldwide.
The C2LEO Objectives, as the name implies, include an additional component outlining the cultural-communication aspects of medical practice. The purpose of this addition is to identify behavioural bench marks that assess a physician’s ability to practice in a Canadian context. Of necessity, this includes consideration of Canadian cultural and regional diversity. Although sensitivity to all cultures and regions is an essential skill for Canadian physicians, a special relation with people of First Nations is acknowledged.
Opportunities to discuss and understand values and mores are critical to the intent of cultural-communication objectives. Such values and mores may differ from those of a physician’s personal circumstances and experiences. Thus, enhancement of one’s generic knowledge and skills must be demonstrated by one’s ability to adapt those skills to certain contexts. They must demonstrate the ability to:
The other three components of C2LEO, namely ethical, legal and organizational, are also addressed in the reclassification:
Medical ethics arise from the traditions of the profession, philosophy, and our social standards. They are expressed as principles and concepts, which lead to more specific guidelines or codes for particular situations. Ethical problems tend to be resolved through prolonged public debate and discussion. Breaches of the ethical guidelines are generally dealt with within the profession, but may also be the concern of health care institutions as well.
The legal section is based on the statutory and case laws relevant to the practice of medicine. Laws are specific, not conceptual. Legal requirements may be set out by the Provincial and Federal legislatures or determined by the courts as they make rulings on particular cases. This document tries to cover the area of law that is in effect in most provinces, although occasional reference is made to notable laws that may only apply in identified provinces. The physician entering practice will want to be sure of the specific legal requirements of the Province in which they are licensed. A breach of a relevant law would be dealt with legally.
The third section is on organizational aspects of the practice of medicine. Physicians in Canada are practising in a complex health care system. They have numerous professional obligations, and interact with many other groups responsible for all aspects of health care. This section is written from the point of view of what the physician entering practice will need to know. Breaches of expected standards in these aspects may be the concern of the college, the courts, or the health care institutions, or may simply result in inefficiencies and frustrations.
Rationale
To provide care that is high in quality, physicians establish an effective relationship with patients and other health care professionals. In order to establish such a relationship, it is essential that physicians possess communications skills that elicit patients’ beliefs, concerns, and expectations about their illness. There are three types of patient-related communication skills: content, process, and perceptual.
Detailed Objectives: Patients
1. Content skills (not content of clinical situations, but history segments such as history of present problem, past and family history, personal and social history, drug and allergy history, review of systems, etc.)
1.1. Specific information requested
1.1.1. Provide ample time for the interview so that patients are not feeling rushed, yet attend to daily schedule and keep interview on task.
1.1.2. Explain the reason for the session and establish the sequence of events.
1.1.3. Explain rationale for each segment of the interview; explain the logic of the questions and their sequence.
1.1.4. Obtain information accurately and efficiently, so that the clinical situation is clearly identified.
1.1.5. Communicate in simple, non-medical terms.
1.1.6. Tailor patient-centered interview to the clinical setting (e.g. emergency room, ambulatory, in-patient).
1.2. Specific follow-up questions and cultural issues
1.2.1. Elicit the patient’s perspective of their illness, including beliefs, values, attitudes, thoughts, dreams, apprehensions, aspirations, wishes, and way of thinking whenever appropriate.
1.2.2. Respect and seek assistance when uncertain about local parlance, idioms, and expressions.
1.3. Material reported in the written record
1.3.1. Maintain and retain accurate, legible, and comprehensive records and fill required forms, referral notes, and any legally required reports. The law (and good practice) obliges the physician to maintain an adequate medical record, which includes:
1.3.1.1. ensuring adequate, continuous, and comprehensive care;
1.3.1.2. quality control;
1.3.1.3. evidence in the context of alleged malpractice; and
1.3.1.4. provision of medical-legal reports
1.3.2. Determine the minimum time-frames for the preservation of medical records specified by law (10 years in most jurisdictions, and possibly permanently).
1.3.3. Contrast levels of entitlement to patient’s medical records by different interested parties. While patients and their representatives are fully entitled to access upon written request, third parties may only have such access with the consent of the patient, by provision of law (e.g., post-mortem insurance company access; post-mortem family access concerning inheritable diseases), or by order of a court.
1.3.4. Determine the statutes that provide for the compulsory disclosure of part or all of a medical record under certain defined circumstances.
1.3.5. Determine the very limited circumstances under which a physician may refuse to permit access to a medical record where the physician believes that such disclosure would harm the patient or a third party. Such refusal may however be challenged, including in court.
1.3.6. Provide patients full access to the content of the medical record on request, despite the medical record being the property of the physician or institution.
1.3.7. Provide a copy of the medical record to another physician at the patient’s (written) request. The physician may charge the patient a reasonable fee for copying and delivering the record. The record may not be unreasonably withheld, even where the fee has not been paid (e.g., in the case of financial hardship).
1.3.8. Provide a medical record on the patient’s (written) request to a patient’s lawyer or insurer.
1.3.9. Construct appropriate written legal communications such as prescriptions and learn about possible special requirements associated with narcotic prescriptions.
1.3.10. Conduct discharge planning, referrals to outside services, and the patient’s family doctor where appropriate to do so.
1.3.11. Learn about and respond to pertinent provincial privacy legislation.
1.3.12. Describe reasonable precautions taken to maintain confidentiality, not only of verbal/telephone communication, but fax or e-mail communication. Legal requirements apply equally to electronic records, so that particular care must be taken with respect to preservation and confidentiality.
1.3.13. Describe reasonable precautions taken to maintain confidentiality of charts, written or computer stored records, and educational or research rounds or presentations.
1.3.14. Determine the particular legal requirement in some provinces relating to medical records of which physicians in certain specialties need to be aware (e.g., statutorily specified authorization form for disclosure of psychiatric records in Ontario).
2. Process skills: good medical practice depends on mutual understanding and positive relationship between the physician, the patient, and the family along with respect for patient’s welfare, cultural diversity, beliefs, and autonomy.
2.1. Manner information gathered: culturally sensitive
2.1.1. Initiate interview in a manner that is reassuring and comforting because it is respectful of the patient’s culture.
2.1.2. Provide support to patients during the interview by not passing judgment in questions asked and comments made, not assigning blame, nor questioning motives or values.
2.1.3. Provide patient with the opportunity to narrate own medical problem with as little interruption as possible.
2.1.4. Gather information using both open and closed questions.
2.1.5. Listen attentively to elicit and synthesize relevant information about all problems and understanding of their content.
2.1.6. Assist patients with their questions.
2.1.7. Elucidate the meaning of questions or statements if cues taken in indicate a lack of understanding.
2.1.8. Evaluate the most appropriate language to be used (either but not necessarily both of Canada’s official languages), including respect for the patient’s language preference.
2.1.9. Assess the need for interpreter/other communication aids.
2.2. Manner information given: culturally sensitive, ethically correct
2.2.1. To patient
2.2.1.1. Respect patients’ autonomy, the ethical and legal basis for truth telling.
2.2.1.2. Provide the truthful information requested by patient, both with respect to nature and quantity of information.
2.2.1.3. In certain circumstances, respect patients’ right to not know, after ascertaining wishes.
2.2.1.3.1. Respect and identify valid exceptions to truth telling.
2.2.1.3.2. Seek consent for disclosure.
2.2.1.3.3. Identify the personal and cultural context and the manner in which it may influence a patient’s choice.
2.2.1.3.4. Respect a patient’s choice above that of family members.
2.2.1.3.5. Discuss with the patient the extent of the family’s involvement in health issues.
2.2.1.4. Seek guidance in situations of conflict (e.g. ethical duties, particularly the duty to do no harm and family involvement)
2.2.1.5. Identify situations of inevitable disclosure.
2.2.1.6. Ensure that there exists a common insight and awareness of the information provided and that the patient’s point of view has been taken into consideration.
2.2.1.7. Provide support to patients during counseling by sharing the decision-making process rather than telling patients what to do.
2.2.1.8. Discuss alternatives, beliefs, and future plans.
2.2.1.9. In providing difficult news, respect cultural differences, be open-minded and willing to explore alternative points of view, avoid being dogmatic.
2.2.1.10. Respect patient’s need to make realistic life decisions.
2.2.1.11. Explain to patients the basis for the physician’s obligation to maintain confidentiality.
2.2.2. To family
2.2.2.1. Facilitate understanding with patients and their families in order to enable them to undertake decisions as equal partners.
2.2.2.2. Respect patients’ privacy in discussing health issues.
2.2.2.3. In transmitting difficult news, provide it by identifying with the patient and/or family, without “hidden agendas” or deceptions, and with respect, acceptance, and understanding.
2.2.2.4. In transmitting difficult news (e.g. end of life decisions, chronic illness, homecare, long-term placement or disability), learn the patient’s situation first, and be willing to participate with patients and/or family in mutually defining and solving problems without arousing in them feelings of inadequacy.
2.2.2.5. Maintain patient confidentiality while engaging family in a collaborative role; differentiate between collaborative roles in differing cultures, especially in the context of First Nations.
2.2.2.6. Interact with family and/or community members (including First Nations context) either individually or in a team meeting.
2.2.3. To 3rd parties
2.2.3.1. Synthesize and present information appropriate to the needs of the audience, and discuss achievable and acceptable plans of action that address issues of priority to the individual and community.
2.2.3.2. Demonstrate sensitivity to cultural and personal factors that improve interactions with patients and the community.
2.2.3.3. Communicate effectively with colleagues, faculty, the community, the media, and other sectors.
2.2.3.4. Identify situations in which third parties have a legitimate interest and right to information and advise patients of obligatory disclosure of information in situations such as
2.2.3.4.1. Legal requirements in the interest of public health. Physicians are legally required under certain provisions of various provincial and federal laws to report to the appropriate authorities confidential information concerning the health, well-being, morbidity, or mortality of a patient.
2.2.3.4.2. Reporting requirements vary from province to province, and often include areas such as:
2.2.3.4.2.1. fitness to work in the field of aeronautics;
2.2.3.4.2.2. reports to coroners regarding death through violence, misconduct, negligence, malpractice, pregnancy, or unknown cause(s);
2.2.3.4.2.3. suspected child abuse or abandonment;
2.2.3.4.2.4. fitness to drive a vehicle on public highways;
2.2.3.4.2.5. pre-marital health;
2.2.3.4.2.6. communicable/infectious and certain environmental/occupational diseases;
2.2.3.4.2.7. details of births and deaths (vital statistics legislation);
2.2.3.4.2.8. occupational illness and injury;
2.2.3.4.2.9. the conduct of other physicians or regulated health professionals;
2.2.3.4.2.10. conditions in health care institutions; and
2.2.3.4.2.11. neglected persons.
2.2.3.4.3. Failure to make such a statutorily-required report can incur penal sanction (e.g. charge, fines) or civil liability on the part of the physician concerned. These obligations to report constitute legal exceptions to the duty of confidentiality and physicians making such reports are shielded from any liability for doing so. In certain cases (e.g. certain provisions of legislation relating to highway safety and motor vehicles in Quebec and Nova Scotia respectively) physicians are authorized (as opposed to being required) to report certain information concerning a patient, and are shielded from liability for doing so.
2.2.3.4.4. legitimate interest of 3rd parties such as insurance companies, and
2.2.3.4.5. duty to warn threatened individuals
2.2.3.5. Select reasonable limits to disclosure, and reveal only the relevant and necessary information, in a situation requiring disclosure to a third party.
2.2.3.6. State the duty to advise patients of known risks of voluntary disclosure (e.g., risks of disclosure of HIV status).
2.2.3.7. Transmit required information in a timely fashion.
2.2.3.8. Transmit information provided to third parties (e.g. Medical Plan, Insurance Company, welfare, and other government departments) with honesty and integrity.
2.2.3.9. Evaluate and seek guidance where harm from disclosure balances harm from maintaining confidentiality.
2.3. Manner of relationship building: culturally sensitive, ethically correct.
2.3.1. Establish an early rapport.
2.3.2. Interact with the patient in a manner that establishes a secure relationship in which the patient feels content to share concerns. In the Canadian medical model, the patient is central to health care, and this approach begins with the interview.
2.3.2.1. Greet the patient with respect, obtain the patient’s name and introduce yourself.
2.3.2.2. Explain the interview process, obtain consent if necessary, and attend to patient’s comfort.
2.3.2.3. Negotiate the agenda of the interview so that both the physician’s and patient’s perspectives are considered.
2.3.3. Act according to current codes defining the doctor-patient relationship.
2.3.4. Place the best interest of the patient first; this is the primary goal of each member of the health care team.
2.3.5. Establish a relationship of trust by following through on undertakings made to the patient in good faith.
2.3.6. Identify changes in patient’s feelings and motives related to passage of time, or clinical setting and address them during the interview.
2.4. How interview is terminated
2.4.1. Make certain that the conclusion of the interview is appropriate in both timing and manner.
2.4.2. Plan together with patient the manner in which follow-up will occur.
3. Perceptual skills
3.1. Underlying thought processes
3.1.1. Medical problem solving & decision making
3.1.1.1. Demonstrate an organized approach to medical problem solving by identifying, formulating, and solving patients’ problems using scientific thinking and based on obtained and correlated information from different sources.
3.1.1.2. Differentiate between competing conditions by collecting and critically evaluating relevant data for the solution of problems.
3.1.1.3. Apply the principles of critical appraisal to sources of medical information that affect medical decision making.
3.1.2. Synthesizing information
3.1.2.1. Summarize information for patient at end of segments of the interview to ensure accuracy and comprehensiveness.
3.1.2.1.1. Take into account patient’s expectations.
3.1.2.1.2. Invite patient corrections.
3.1.2.2. Give information in portions that can be digested and check for comprehension, using the patient’s responses as a guide.
3.1.2.3. Ask patient what other information would be helpful and explain.
3.1.2.4. Organize explanation, divide it into discrete sections, and develop a logical sequence.
3.1.2.5. Use concise, easily understood statements and avoid jargon.
3.1.2.6. Relate explanations to patient’s illness framework such as previously elicited beliefs, concerns, and expectations.
3.1.3. Considering investigation and treatment alternatives
3.1.3.1. Discuss with patient purpose and implications of investigations as well as investigation alternatives.
3.1.3.2. Elicit patient’s understanding, reactions, and concerns about investigative plans including acceptability.
3.1.3.3. Discuss diagnosis and prognosis of medical condition.
3.1.3.4. Discuss with patient treatment alternatives including no intervention, medication or surgery, non-drug treatments (e.g. diet, exercise, physiotherapy, counseling), risks and benefits.
3.1.4. Monitoring process and content skills: own and others
3.1.4.1.1. Disclose the limitations to the patient where personal beliefs or inclinations limit the treatment a physician is able to offer.
3.1.4.1.2. Obtain patient’s view of need for action, benefits, barriers, motivation, and accept alternative viewpoint as appropriate.
3.1.4.1.3. Consider patient’s lifestyle, beliefs, cultural background, and abilities.
3.1.5. Attitudes that influence communication
3.1.5.1. Emotions
3.1.5.1.1. The physician will not exploit the relationship for personal advantage, be it financial, academic, or otherwise.
3.1.5.1.2. Maintain and respect professional boundaries at all times including physical, emotional, and sexual boundaries.
3.1.5.1.3. Maintain and respect professional boundaries with regard to treatment of themselves, families, and at times friends, an inappropriate practice in most circumstances.
3.1.5.2. Preconceived assumptions
3.1.5.2.1. Apply principles of gender equality in relationships with patients, co-workers, and colleagues.
3.1.5.3. Prejudices
3.1.5.3.1. Accept or refuse patients requesting care
3.1.5.3.1.1. without consideration of race, gender, age, sexual orientation, financial means, religion, or nationality.
3.1.5.3.1.2. without arbitrary exclusion of any particular group of patients, such as those known to be difficult or afflicted with serious diseases; in emergency situations, care must be given regardless.
3.1.5.3.2. Once having accepted a patient into care, the physician may terminate the relationship, providing
3.1.5.3.2.1. care has been transferred or
3.1.5.3.2.2. adequate notice has been given to allow the patient to make alternative arrangements.
Rationale
Medical care requires the involvement of diverse health care professionals. This necessity means that inter-professional relations with these health care professionals and workers be based on respect for all members of the team. It is essential to identify the roles, competencies, and lines of responsibility of each.
Detailed objectives
1. Communicate effectively with other health care professionals in the team context.<
2. Together with other health care workers who are self-regulated, acknowledge the equality of roles and skills of practice, and define these roles and skills of each profession.
3. Conduct yourself in inter-professional relationships with respect and establish clear communication.
4. Delegate tasks and acts to physicians and other healthcare workers according to expertise.
5. Work in a collegial way within a team structure involving other physicians and health care workers.
6. Maintain respect for the role of the other health professions at all times.
Rationale
Much of the work of physicians occurs within various institutions and requires collaboration with many other individuals. To be a valuable member and collaborator of a health care team it is essential to understand the workings of hospitals and other institutions – their organization (governance/management/ medical staff/other health care) and interrelationships. Physicians-to-be should be aware that within a hospital or other health institutions they have a contractual arrangement and cannot view themselves as independent operators. They need to understand the duties and obligations of the Chief of Staff, Chief of Department/Service, and the individual staff/medical staff member. They must understand the accountability of physicians for medical care rendered and their mandate to review and continuously improve care. They need to understand that the granting of appointment to the staff of a hospital/ institution with privileges is accompanied by rights, responsibilities, and obligations. They need to understand the process and sanctions that may be brought to bear for incompetence, incapacity, or misconduct as a member of the medical staff.
Detailed Objectives
1. Consult effectively
1.1. Effectively consult with other physicians to develop investigations, prevention, treatment, and continuing care plans for individuals, communities, and populations.
1.1.1. Identify limits of personal expertise.
1.1.2. Identify and describe the role, expertise, and limitations of other medical consultants.
1.1.3. Explicitly integrate consultants’ opinions into management plans.
1.1.4. Once adequate consultation has been sought and received, commit to a decision based on best available evidence, even when the evidence leaves room for uncertainty.
1.1.5. Respect colleagues and establish clear lines of communication.
1.1.6. Foster a positive collaborative relationship with colleagues without regard to ethnic origin, cultural background, gender, religion, etc.
1.1.7. Express thoughts, and share feelings with colleagues toward improving quality of care delivered as well as reducing stress and improving quality of life for self and/or for colleagues.
1.2. Effectively consult with health care professionals to develop investigations, prevention, treatment, and continuing care plans for individuals, communities, and populations.
1.2.1. Identify and describe the role, responsibilities, expertise, and limitations of other health care professionals.
1.2.2. Delegate activities to other health care workers if the activity resides within their area of responsibility and/or expertise and if delegation is your responsibility.
1.2.3. Develop, lead, and/or participate in partnerships with multidisciplinary teams of health care professionals, as well as inter-section collaboration toward collective responsibility for health promotion interventions.
1.2.4. Participate/work in an interdisciplinary team and accept, consider, and respect the opinions of other team members, while contributing in your area of special expertise.
1.2.5. Respect other health care professionals and establish clear lines of communication with them.
1.2.6. Foster a positive collaborative relationship with other health care professionals without regard to ethnic origin, cultural background, gender, religion, etc.
1.3. Effectively consult with patients and families as well as the population served to develop investigations, prevention, treatment, and continuing care plans.
1.3.1. Identify the roles of patients and their family.
1.3.2. Inform and involve the patient and family in decision-making.
1.3.3. Explicitly integrate the opinions of the patient into management plans.
1.3.4. Develop, lead, and/or participate in partnerships with the population served, toward collective responsibility for health promotion interventions.
2. Contribute effectively to interdisciplinary team activities
2.1. Hospitals/Medical Care Institutions/Medical Schools
2.1.1. Governance: while physicians are mostly not employed by hospitals, physicians’ practice in hospitals is regulated by common law and a number of statutory provisions.
2.1.1.1. Outline the statutory authority for public hospitals/institutions, and the nature and powers of governance.
2.1.1.2. Explain how governance influences patient care, research, and educational activities at a local level (regional differences expected).
2.1.1.3. Collaborate with such health care systems and jointly work toward equity in access to health care, effectiveness, and quality.
2.1.2. Management: hospitals may regulate physician admission to hospital practice and physician conduct and compliance with hospital requirements through the issue and withdrawal of hospital privileges.
2.1.2.1. Outline the nature and power of management in public hospitals.
2.1.2.2. Outline the nature of by-laws or regulations of institutions/hospitals.
2.1.2.3. Legal provisions concerning medical practice in hospitals include physicians’ duty to
2.1.2.3.1. ensure their own ongoing competence;
2.1.2.3.2. respect hospital by-laws and regulations;
2.1.2.3.3. practice within the limits of privileges granted; and
2.1.2.3.4. cooperate with other physicians and hospital personnel.
2.1.2.4. Maintain adequate hospital records, including ongoing care and discharge treatment.
2.1.3. Medical staff organization/Departments/Committees
2.1.3.1. Outline the nature and power of medical advisory committee or equivalent and medical staff association.
2.1.3.2. Outline the duties of the Chief of Staff or equivalent (e.g. Director of Professional Services or Vice President Medical Affairs), Chief of Department/Service. The titles may vary among different hospitals and provinces.
2.1.3.3. If part of an interdisciplinary team in charge of an administrative responsibility, identify and describe the role, expertise, and limitations of other members of the team.
2.1.3.4. Participate in interdisciplinary team meetings and accept, consider, and respect the opinions of other team members, while contributing in your area of special expertise.
2.1.3.5. Communicate with members of an interdisciplinary team in the resolution of conflicts, provision of feedback, and where appropriate, assume a leadership role.
2.1.3.6. Appointments/Privileges/Obligations
2.1.3.6.1. Outline the duties and lines of reporting of the individual medical staff.
2.1.3.6.2. Outline the nature of obligations such as on-call for individual medical staff.
2.1.3.6.3. Outline the accountability of medical staff members and the process and sanctions for professional misconduct or failure to maintain medical standards.
2.1.3.6.4. Outline the notion of professional self-regulation as it applies to medical staff appointees.
2.1.4. Teaching and learning
2.1.4.1. Devote part of the working day to the teaching of others.
2.1.4.2. Request feedback about the quality of teaching provided.
2.1.4.3. Improve teaching through advice from experts and your own continuing medical education.
2.1.4.4. Seek assistance from others even if expert in a given field, since no one can be an expert in everything.
2.1.4.5. Accept supervision and feedback.
2.1.4.6. Identify and describe the role, expertise, and limitations of members of an interdisciplinary team (e.g. anatomists, pathologists, pharmacologists, pediatricians, nurses, pharmacists, etc) in an educational task.
2.1.5. Research, QA/QI
2.1.5.1. Identify and describe the role, expertise, and limitations of members of an interdisciplinary team (e.g. molecular biologists, integrational physiologists, pathologists, statisticians, epidemiologists, laboratory technologists, etc) in a research problem.
2.1.5.2. Outline the requirement for continuous quality of care review.
2.1.6. Hospital/Institution support groups
2.1.6.1. List some of the groups available for the support of patients in hospitals/institutions or upon leaving hospitals/institutions.
2.1.6.2. Outline some of the potential benefits available to patients who seek the assistance of such groups.
2.1.7. Hospital – Family Liaison Committees
2.1.7.1. Outline the role of family liaison committees.
2.2. Practice settings
2.2.1. Institutional practice
2.2.1.1. List various types of medical practice and delivery systems and how they differ from each other; outline advantages/ disadvantages of different practice situations.
2.2.1.2. Describe different remuneration models available in fee-for-service, salaried practice, and capitation (including managed care).
2.2.1.3. Describe some methods for controlling health care costs and allocating resources.
2.2.2. Private office practice
2.2.2.1. Outline the obligations/responsibilities in the general administration and management of an office.
2.2.2.2. Outline the responsibility and obligation to meet medical regulatory requirements for a medical office practice (medical records, advertising, narcotic and drug control, quality assurance, infection control).
2.2.2.3. Outline some strategies for practicing cost-effective health care and resource allocation that doe not compromise quality of care.
2.2.2.4. Describe the requirement for advertising of services not to be false or misleading, to be in good taste, not creating unjustified expectations, and not impugning the reputation of other physicians or services.
2.2.2.5. Describe principles underlying billing policies for uninsured services recommended by the provincial licensing authority and/or provincial medical association/federation (nature of service, patient’s ability to pay, notification of fee prior to treatment).
2.2.2.6. Discuss the special requirements for billing for uninsured services, including prior disclosure of fees to patients, opportunities to discuss fees, and fees to be determined by the nature of service.
2.2.3. Medical records in Office Practice: medical records document the nature and continuity of care for each patient and must meet a statutory requirement for their development, maintenance, and security. Patient’s right of access has recently been clarified and extended by the courts. Physicians must demonstrate an understanding of who else has access to these records or their copies, and under what circumstances, such as patient consent to release or when other physicians are providing concurrent or consultative care (see Communicator role).
2.2.3.1. Outline the physicians’ duty to maintain adequate records on each patient.
2.2.3.2. Determine what basic elements must be included in that record.
2.2.3.3. Explain that the records must be secure and they are the property of the physician and patient.
2.2.3.4. Outline the length of time records must be maintained.
2.2.3.5. Describe the right of access of patients and authorized representatives to their records/copies at reasonable times.
2.2.3.6. Communicate that the patient may request transfer of the medical information to another physician, but a fee may be charged for this transfer or copying of records.
2.2.3.7. Explain that physicians may only deny patients access to their own medical record when they believe on reasonable grounds that such disclosure may lead to harm to the patient or violate a confidence.
2.3. Support Services in the Community
2.3.1. Outline strategies to partner with health care support services in the community to assess, coordinate, and improve health care.
2.3.2. Identify/access the health systems along with their respective policies, organization, financing, cost-containment measures of rising health care costs, toward the effective management of health care delivery
2.3.3. Outline the coordination of services (ambulatory, in-patient, chronic care, rehabilitation) and identify individuals able to assist with access to community services (home care coordinators, etc).
2.3.3.1. Federal programs and services (e.g. Health Protection Branch, Bureau of Drugs and Devices, Bureau of Radiation and Medical Devices)
2.3.3.2. Provincial programs and services (e.g. Provincial Laboratories, Public Health Departments, Social Service Agencies, District or regional health councils/boards/ agencies, Worker’s Compensation Board or equivalent).
2.3.3.3. Non-governmental agencies: There exists a large informal network of volunteer and other groups that exist to assist or advocate in the community of behalf of institutions, specific disease states, or patient groups.
2.3.3.3.1. Describe the major role volunteer support groups play in fundraising and in providing direct support for patients in or out of institutions.
2.3.3.3.2. Describe the role some advocacy groups play in promoting the interest of sufferers of specific disease states through public awareness, fundraising activities, and direct patient care.
2.3.3.3.3. Outline the role and benefit of non-profit organizations in providing health care out of hospital.
2.3.3.3.4. Outline the role of some advocacy groups in challenging current healthcare and care by physicians.
2.3.3.3.5. Discuss the role of non-government agencies in fundraising for health services, program support, and research.
2.3.3.3.5.1. Volunteer support and non-profit organizations
2.3.3.3.5.1.1. Home care - VON, AIDS organizations
2.3.3.3.5.1.2. Disease-specific groups (e.g. Arthritis society)
2.3.3.3.5.1.3. Community groups (e.g. St. John’s Ambulance)
2.3.3.3.5.1.4. Religious groups (e.g. Salvation Army)
2.3.3.3.5.1.5. Community health centers
2.3.3.3.5.1.6. Social and counseling services
2.3.3.3.5.1.7. Child’s Aid Society
2.3.3.3.5.1.8. Facilities and services for the aged
2.3.3.3.5.1.9. Co-ordination of services (ambulatory – inpatient – chronic care – rehabilitation), home care coordinators
2.3.3.3.5.2. Advocacy groups
2.3.3.3.5.2.1. Patient advocacy
2.3.3.3.5.2.1.1. Consumers Association of Canada
2.3.3.3.5.2.1.2. Psychiatric patient survivor’s group
2.3.3.3.5.2.2. Disease advocacy (e.g. AIDS groups, Canadian Cancer Society)
2.3.3.3.5.3. Foundations for fundraising
2.3.3.3.5.4. Services provided by institutions (nursing homes, chronic care facilities, mental health facilities, ambulatory services, in-patient services, etc.)
2.3.3.3.5.5. Other services (physiotherapy, occupational therapy)
2.4. Self-regulation of the Profession: medical self-regulation implies that society grants certain privileges and obligations to the profession and in turn requires the profession to act in the public interest through licensing authorities, certifying bodies, and medical associations.
2.4.1. Describe how health care governance influences patient care, research, and educational activities at a provincial and national level.
2.4.1.1. Licensing authorities
2.4.1.1.1. Determine the role and authority of provincial licensing authorities to regulate and govern all members of the profession in the public interest by setting and maintaining standards.
2.4.1.1.2. Outline your role and obligations as members of the licensing authority.
2.4.1.1.3. Describe the requirement for cooperation with the licensing authority (e.g. access to records, the office, etc).
2.4.1.1.4. List the standards for entry to practice (licensing requirements).
2.4.1.1.5. Outline the requirements for ethical and mandatory reporting to the licensing authority (code of ethics, public hospitals act, province-specific health care legislation).
2.4.1.1.6. Describe the system for processing complaints/allegation about physicians’ performance/conduct.
2.4.1.2. Certifying bodies (MCC, RCPSC, CFPC)
2.4.1.2.1. Describe the difference between the licensing authority and the certifying bodies (MCC, RCPSC, CFPC).
2.4.1.3. Medical Associations (CMA, Specialty societies)
2.4.1.3.1. Outline the requirements for continuing competence (MAINPRO, MOC).
2.4.1.3.2. Describe the difference between the licensing authority and the various medical professional associations).
2.5. Professional Associations (CMA, Provincial divisions of CMA, Resident/Student associations, CMPA): Professional medical associations have a distinctive role from the role of the provincial Licensing Authorities with which they have a statutory and mandatory relationship.
2.5.1. Describe the role and voluntary nature of CMA and other professional associations. (e.g. advocating for and representing the interests of the medical profession in health care and health education.)
2.5.2. Describe the role and function of the certifying/evaluating bodies (RCPSC, CFPC, and MCC) and the AFMC in evaluating candidates and the advocacy role of the RCPSC and CFPC for specialists and family physicians, in dealing with the areas of educational standards.
2.5.3. Outline the role of specialty and other professional associations in providing educational and professional development, as well as being advocates for their disciplines.
2.5.4. Outline the role of student and resident associations in promoting and protecting their members’ interests.
2.5.5. Describe the role of the CMPA as a medical defense association representing the interest of individual physicians.
2.5.6. Outline the unique role and authority of the licensing authority in the self-regulation and governance of the medical profession.
2.5.7. Outline the roles played by other associations and special interest groups in delineating health care, educational, and research policies in Canada.
2.5.8. Outline the roles played by other health professions’ associations in developing health policy.
Rationale
Physicians have a role in protecting and promoting the health of a whole population. The appropriate action for this role is to express health advocacy individually as well as collectively (as responses of representative groups). The goal of this advocacy is to influence public health and policy that affects public health. To achieve this goal, physicians need to understand the principles of health system organization and their economic and legislative foundations.
Acting in the patients’ best interest, physicians are obliged to make appropriate health care available to their patient in a fair and equitable manner (distributive justice). There is an expanding number of treatable patients, an increasing array of expensive technology, but a finite health care resource. This leads to inevitable conflict between the best interest of the patient and the interest of society at large. Ethical principles should guide the resolution of such conflicts.
Detailed Objectives
1. Identify the determinants of health:
1.1. Identify important determinants and risk factors of health and illnesses and of interaction between humans and their physical and social environment.
1.1.1. Social environment: Assess and respond to social environment.
1.1.1.1. Employment
1.1.1.2. Income
1.1.1.3. Social status
1.1.1.4. Culture
1.1.1.5. Social support system
1.1.1.6. Education
1.1.2. Physical environment: Assess and respond to physical environment.
1.1.2.1. Housing
1.1.2.1.1. Advocate for patients with sensitivity to their cultural background for adequate housing and safe water.
1.1.2.2. Working conditions
1.1.2.2.1. Advocate for patients with sensitivity to their cultural background for safe working conditions.
1.1.2.3. Peace and security (Including security from exposures to things such as pollutants.)
1.1.3. Biology and personal health practices/behavior:
1.1.3.1. Assess and respond to health practice and behavior by adapting patient management and education so as to promote health, enhance understanding, and enhance active participation in informed decision-making.
1.1.3.1.1. Coping skills
1.1.3.1.2. Diet and exercise
1.1.3.1.3. Smoking, substance abuse
1.1.4. Genetic endowment and gender:
1.1.4.1. Assess and respond to issues related to genetics and gender.
1.1.5. Health services and access/barriers to access
1.1.5.1. Advocate for patients if there are barriers to health care services whether with physicians or other health care services.
1.1.5.2. Advocate for the individual but in the context of societal needs when monitoring an allocating needed resources.
1.2. Advocate and contribute to improving individual and societal health in Canada.
2. Identify public policies that affect health:
2.1. Identify key issues in the development of the Canadian Health Care system, including government structure and the enabling legislation applicable to health care in Canada (BNA Act, Canada Health Act).
2.1.1. The federal authority (laws)
2.1.2. The provincial authority (laws)
2.1.3. Public funding/administration of the system (federal & provincial)
2.1.4. The components of the health care system
2.1.5. The key principles of the Canada Health Act
2.1.6. Eligibility to use the health system (residents, immigrants, & visitors)
2.2. Government agencies (e.g. communicable diseases, tobacco, substance abuse, etc)
2.2.1. Advocate action in disease, injury, and accident prevention.
2.2.2. Advocate action in protecting, maintaining, and promoting the health of individuals, families, and community.
2.2.2.1. Federal (e.g. health protection branch, medical devices): Inform oneself about international health status, global trends in morbidity and mortality of chronic diseases of social significance, the impact of population movement, trade, and environmental factors on health and the roles of national and international health organizations.
2.2.2.2. Provincial (e.g. provincial laboratories)
2.2.2.3. Public health systems and departments
2.2.2.3.1. Advocate for patients and provide documents in support of justified needs from social services; identify ethical and medical issues in patient documentation and confidentiality.
2.2.2.3.2. Advocate for patients with long-term/short-term disabilities and provide documents in support of health needs; identify ethical and medical issues in patient documentation and confidentiality.
2.2.2.4. Regional health districts/agencies
2.2.2.4.1. Identify situations in which allocation of resources is unfair, and seek resolution.
2.2.2.5. Worker’s Compensation Boards or equivalents
2.2.2.5.1. Advocate for patients and provide required documents in support of justified health problems; identify ethical and medical issues in patient documentation and confidentiality.
2.3. Non-government agencies
2.3.1. Advocate for patients and provide required documents in support of applications to insurance agencies; identify ethical and medical issues in patient documentation and confidentiality.
2.3.2. Accept leadership when needed and as appropriate for level of learning, expertise, and involvement in health issues.
3. Advocacy:
3.1. Apply the principles of moral reasoning and decision-making to conflicts within and between ethical, legal, and professional issues including those raised by economic constrains, commercialization of health care, and scientific advances.
3.2. Improve health of patients
3.2.1. Identify patient’s status with respect to one or more determinants of health (e.g. employment status) and adapt the assessment and management accordingly (i.e. the medical intervention to the patient’s social circumstances).
3.2.2. Assess the patient’s ability to access various services in the health and social system.
3.2.3. Make health resources available to patients in a manner which is fair and equitable, without bias or discrimination.
3.2.4. Identify and propose fair means of resolving disputes for resources:
3.2.4.1. primary obligation to patient;
3.2.4.2. rank known patients ahead of unknown or future patients;
3.2.4.3. use morally relevant criteria in allocating resource; and
3.2.4.4. consult hospital ethics committees or other responsible bodies.
3.3. Improve health of practice population
3.3.1. Contribute to the work of physicians’ groups, specialty societies, and other associations to identify current “at risk” groups within a given domain of medicine and apply available knowledge about prevention to “at risk” group.
3.3.2. Contribute “group data” for better understanding of health problems within the population.
3.3.3. Select interventions on the basis of best available evidence:
3.3.3.1. known to be effective;
3.3.3.2. anticipated cost benefit; and
3.3.3.3. avoid marginally beneficial investigations and treatments.
3.4. Improve health of general population
3.4.1. Outline the role of epidemiology and health economics in health management.
3.4.2. Inform patients of impact of cost restraint in a supportive way.
3.4.3. Avoid waste and be prudent in the utilization of scarce or costly resources.
Rationale
During the course of any given day, physicians are required to make choices that concern their practice, work, colleagues, and personal lives. In other words, they must learn to behave and act as managers. This function demands prioritization, health resource allocation, cooperation, and joint effort.
Detailed Objectives
1. Time Management
1.1.1. Patient Care
1.1.1.1. Manage patients in an effective, efficient, and ethical manner including health promotion and disease prevention.
1.1.1.2. Evaluate health problems and advise patients taking into account physical, psychological, social, and cultural issues.
1.1.2. Learning Needs
1.1.2.1. Regulate schedule so that time is available to address the need for continuous self-improvement as well as personal limitations including limitations of one's medical knowledge are addressed.
1.1.2.2. Plan effectively and manage own time efficiently in order to cope with uncertainty and develop the ability to adapt to change.
1.1.3. Outside activities
1.1.3.1. Identify strategies that promote care in oneself and one's colleagues.
1.1.3.2. Identify potential stressful situations and analyze their effect on the functioning of a physician.
1.1.3.3. Describe effective and ineffective ways of coping with stress.
1.1.3.4. Describe strategies to balancing lifestyle, family responsibilities, and medical practice.
1.1.3.5. Identify the circumstances under which a physician's ability to self heal should be supplemented.
1.1.3.6. List resources available to physicians in need of assistance and explain the obstacles to seeking assistance.
2. Health Resources Allocation
2.1.1. Individual
2.1.1.1. Appropriately utilize human resources, diagnostic interventions, therapeutic modalities, and health care facilities.
2.1.1.2. Generate a clinical question, search for best evidence, critically appraise the medical evidence, and apply the evidence to the individual's clinical problem.
2.1.1.3. Inform patients of impact of cost reduction in a supportive way.
2.1.2. Population
2.1.2.1. Outline population-based approaches to health care services and their implication for medical practice.
2.1.2.2. Utilize national, regional, and local surveillance data as well as demography and epidemiology in health decisions.
2.1.2.3. Work to avoid waste in the utilization of scarce or costly resources.
2.1.2.4. Work effectively as a member of a team or a collaboration (regardless whether as a team member or team leader) in order to accomplish tasks related to population health.
2.1.3. Evidence-based
2.1.3.1. Make clinical decisions based on sound evidence for the benefit of individual patients and the population served.
2.1.3.2. Utilize health care resources based on best evidence so that health care resources remain available to patients in a manner that is equitable and fair and without bias or discrimination.
2.1.3.3. Choose interventions on the basis of best available evidence:
2.1.3.3.1. Known to be effective
2.1.3.3.2. Anticipated cost benefit
2.1.3.3.3. Avoid marginally beneficial investigations or therapies
2.1.3.4. Identify situations in which allocation of resources is unfair, and seek resolution.
2.1.3.5. Propose fair means of resolving disputes for resources by keeping the primary obligation to the patient, ranking known patients ahead of unknown or future ones, use morally relevant criteria in allocating resources, and consult ethics committees and other responsible bodies.
3. Health Care Organizations
3.1. Describe advantages and disadvantages of functioning within the Canadian healthcare delivery system.
3.1.1. Outline strategies to function effectively in health care organizations ranging from individual clinical practice to organizations at the local, regional, and national level.
3.1.2. Outline the structure, financing, and operation of the Canadian health system.
3.2. Utilize community services, both governmental and non-governmental, in aid of excellent patient care.
3.2.1. Participate in planning, budgeting, evaluation, and outcome of a patient care program.
4. Informatics
4.1.1. Patient Care
4.1.1.1. Identify and retrieve patient related data from clinical data systems.
4.1.1.2. Identify and access information resources relevant for research in clinical practice.
4.1.1.3. Retrieve clinical practice guidelines from a range of biomedical information resources.
4.1.1.4. Use informatics to assist in diagnostic, therapeutic, and preventive measures, and for observation and monitoring health status.
4.1.1.5. Apply a broad base of information to the care of patients in ambulatory care, hospitals, and other health care settings.
4.1.2. Life - long Learning
4.1.2.1. Access and apply a broad base of information to the maintenance, updating, and extension of knowledge and skills.
4.1.2.2. Seek, gather, categorize, and decipher health and biomedical information from different resources.
4.1.2.3. Describe the application and limitations of informatics.
Rationale
Physicians have a unique societal role as professionals, with a distinct body of knowledge, skills, and conduct dedicated to improving the health and welfare of people. They are committed to the utmost standards of excellence in clinical care and ethical conduct, and to continuously improve their mastery over the domain of medicine.
1. Provide the utmost quality care with integrity, honesty, and compassion
1.1. Maintain and enhance competence: master and keep current knowledge & skills relevant to medical practice.
1.1.1. Assume personal responsibility for the care of individual patients.
1.1.2. Continually evaluate one’s own competence and identify its limits.
1.1.3. Participate in learning with peers and others including students, health care professionals, and community or patient groups.
1.1.4. Assist peers and others in achieving effective methods of care, in the best interests of patient well being.
1.1.5. Meet and/or exceed the standard of care that is applicable under the particular circumstance under consideration; physicians are legally liable to their patients for causing harm through a failure to do so. This liability arises from the physician’s common law duty of care to his/her patients in the doctor/patient relationship (or, in Québec, from the Civil Code provisions regarding general civil liability). Four basic elements must generally be established by a patient for an action against a physician to succeed in negligence (or civil liability):
1.1.5.1. a duty of care owed to the patient;
1.1.5.2. a breach of the duty of care;
1.1.5.3. some harm or injury to the patient; and
1.1.5.4. the harm or injury must have been caused by the breach of the duty of care.
1.1.6. Attend to the patient attentively, with continuity, and exercise reasonable care, skill, and judgment (until the relationship is ended through an appropriate process) as soon as a relationship with a patient arises; the duty of care arises out of the doctor/patient relationship (or, in Québec, the medical contract and the law of delict). The standard of care expected of a physician is one that would reasonably be expected under similar circumstance of an ordinary, prudent physician of the same training, experience, specialization, and standing. In some circumstances, physicians may be held vicariously liable (i.e., legally liable for the actions of employees or other persons under their control/delegation). Actions in negligence (or civil liability) must be launched by patients within a certain prescribed period, which may differ from province to province.
1.1.7. Provide end-of-life care, including palliation of symptoms, a moral obligation.
1.2. Alleviate patients’ distress when aware and conscious of its presence in a supportive, sympathetic manner.
1.2.1. Uninsured services: those not covered under provincial schedules of medical benefits as well as services to unregistered patients ineligible for provincial health coverage or for coverage under the reciprocal agreement among provinces.
1.2.1.1. Consider, in determining professional fees, both the nature of the service provided and the ability of the patient to pay, and be prepared to discuss the fee with the patient.
1.2.1.2. Avoid any personal profit motive in ordering drugs, appliances, or diagnostic procedures from any facility in which the physician has a financial interest.
1.2.1.3. Place the patient’s best medical interest foremost.
1.2.2. Keep all information concerning patients confidential, since it is patients’ fundamental right to security of the person, reputation, and social status, and various specific provisions in law require it.
1.2.2.1. Do not disclose patient information (whether about the existence, nature, extent of illness or any other health information) except where expressly authorized by the patient to do so, and when the law permits or requires such disclosure.
1.2.2.2. Report certain confidential information for the protection of public health and other purposes, and in some cases, failure to do so will incur penalties; these are instances of exceptions to the duty of confidentiality and the requirement of patient consent for its disclosure are provided for in various (provincial and federal) statutes.
1.2.2.3. If the legal processes involve physicians, do not disclose confidential information even in the case of service of a subpoena or police investigation, except when ordered to do so by a court or pursuant to a search warrant.
1.2.2.4. Interpret that consent may reasonably be implied, with caution, where inter-health care team communication is essential for the effective provision of care.
1.2.2.5. Exercise special care not to inadvertently disclose patient confidences; e.g. in unguarded conversation or to patients’ friends or relatives.
1.2.2.6. Do not breach the duty of confidentiality; such action will render physicians potentially liable for damages to the patient and/or open to disciplinary proceedings before provincial licensing authorities.
1.2.2.7. Physicians have a duty to warn, with limitations in law; a physician’s duty to society may in exceptional circumstances legally justify disclosure of confidential information where, for example, it becomes known to a physician that a patient is about to seriously harm or kill another person.
1.2.2.8. Seek advice from provincial licensing authorities or legal counsel when in doubt; the rule/requirement of, and exceptions to, the duty of confidentiality is complex.
1.2.2.9. Demonstrate special care with the use of fax, e-mail, or other electronic means for the transmission of patient health information, as these methods of transmission can compromise confidentiality.
1.3. Consider racial, cultural, and societal issues that have an impact of the delivery of health care
1.3.1. Identify patients’ fundamental human rights relevant to the practice of medicine, such as:
1.3.1.1. the right to security of the person and inviolability and
1.3.1.2. the right to freedom from discrimination by virtue of age, race, gender, nationality, religion, sexual orientation, financial means, or other status.
2. Exhibit appropriate personal and interpersonal professional behaviors.
2.1. Practice medicine with a license from the appropriate authority, a legal requirement. Physicians’ competence and conduct is legally (and ethically) regulated in certain respects to protect patients and society in general. Of particular concern is the physicians’ ability and willingness to:
2.1.1. Provide care and coverage with continuity and accessibility;
2.1.2. Ensure that patients have access to continuous on-call coverage and are never abandoned;
2.1.3. Respect patient-physician boundaries. Sexually suggestive or explicit conduct with patients, irrespective of apparent patient consent, is a serious transgression that could lead to criminal, civil, and disciplinary action against the physician.
2.1.4. Differentiate between healthy and unhealthy doctor patient relationships with respect to issues of power, intimacy, and trust.
2.1.5. Act with boundary issues in an effective, professional manner.
2.1.6. In some provinces, physicians are required to report certain conduct issues by other physicians, including breach of the patient-physician boundary, competency of clinical practice, and unacceptable forms of care.
2.2. Maintain and enhance professional behaviors in all interactions with patients, families, peers, and members of the health care team.
2.2.1. Identify the patient (rather than the physician or the hospital for example) as a key focus and central subject of medical practice.
2.2.2. Be present for a patient without distraction and fully supportive for the patient throughout care.
2.2.3. Act in the best interest of the patient at all times; place the patient’s needs before your own self-interest.
2.2.4. Act without conflict of interest, including by virtue of direct financial interest in a pharmaceutical, therapeutic, laboratory, or other enterprise, or by virtue of a direct or indirect commission or payment for a service rendered to a patient by another person who is not a formal partner (according to the law in some provinces).
2.2.5. Listen, accept, and respond with sensitivity to the views and experiences of patients and others.
2.2.6. Acknowledge the fundamental legal rights of patients, arising under both statutory law and the rulings of the courts, that are binding on physicians.
2.2.6.1. Obtain the consent of the patient for any medical investigation, treatment, or research.
2.2.6.2. Ensure that consent is freely given by a fully informed patient.
2.2.6.3. Provide information fully, in language that the patient or involved person(s) can understand.
2.2.6.4. Include information regarding the nature of the proposed treatment or investigation, anticipated effects, material or significant risks, alternatives available, and any information regarding delegation of care; give such information according to the circumstance of each particular case.
2.2.6.5. Disclose the information personally if responsible for the procedure; in appropriate circumstances the obligation of disclosure may be delegated to another qualified physician, but responsibility lies with the delegating physician.
2.2.6.6. Accept expressed consent if implied, and given orally or in writing (according to circumstances, noting that by law in some circumstances consent must be written).
2.2.6.7. Ensure that the consenting patient has the legal capacity to consent, i.e. of a legal age to consent (different provinces specify differing ages at which a patient is deemed to be capable of giving consent). The treatment of minors often raises a number of important legal (as well as ethical and practical) issues for physicians.
2.2.6.8. Ensure that the consenting patient is competent to consent, i.e. sufficiently capable. For example, if young or mentally incapacitated, they must be able to understand the information required for consent and appreciate the reasonably foreseeable consequences. Competence is to be assessed operationally or functionally, i.e., the patient need only be competent to consent to, or refuse the particular choice in question.
2.2.6.9. Obtain consent from a court (according to the law applicable in each province and the specific circumstances), parent, or substitute decision-maker if the patient is not competent or lacks capacity to consent. The law regarding delegation of care is specific to each province and the physician should be fully aware of local requirements in this regard.
2.2.6.10. Respect a patient’s right to refuse consent, even when this may lead to the death of the patient.
2.2.6.11. Accept consent withdrawal without penalty or any other impact on the provision of care.
2.2.6.12. In a medical emergency, if necessary, treat without consent. Under certain circumstance (including pursuant to mental health legislation) where patients are a danger to the lives or health of others or themselves, or the law provides for compulsory treatment, exception is made to the requirement for consent.
2.2.6.13. Limit treatment to the scope of consent given, including the identity of the treating physician.
2.2.7. Encourage patients to become responsible, active participants in their own care, rather than assuming a paternalistic role.
2.2.8. Respect and resolve any issue surrounding advanced directives and end-of-life care.
2.2.9. Respect the patient’s right to confidentiality while acknowledging the unique role of community members in health decisions involving First Nations.
2.2.10. Respect the rights of minors in communication with parents and in involving community members of First Nations.
2.2.11. Respect Canadian ethical guidelines for the treatment of members of one’s immediate family.
2.2.12. Access information only of patients under care and with consent of the patient.
2.2.13. Practice medicine in an environment with a team approach to health care in a manner respectful of the expertise of all members of the team.
2.2.14. Work with members of the health care team in the patient’s best interest.
2.3. Accept responsibility for personal actions
2.3.1. Make independent decisions in the best interest of the patients and for the good of society.
2.3.2. Be accountable for your actions and conduct in medical practice, as well as the conduct of your colleagues and the profession.
2.3.3. Set and maintain high standards in the practice of medicine for self and the profession.
2.3.4. Possess and maintain medical expertise and practice competently without impairment by substance, ill health, or other incapacity.
2.3.5. Participate in peer review, a responsibility shared with the profession in self regulation.
2.3.6. Advertise professional services in a manner that avoids:
2.3.6.1. misrepresenting fact;
2.3.6.2. comparing either directly, indirectly, or by innuendo, services or abilities with that of any other physician or clinic, or promising or offering more effective services or better results than those available elsewhere;
2.3.6.3. deprecating another physician or clinic;
2.3.6.4. creating an unjustified expectation as to the results the physician can achieve;
2.3.6.5. taking advantage of the vulnerability of patients; and
2.3.6.6. disclosing the identity of patients.
2.4. Attain a high degree of self-awareness
2.4.1. Identify one’s own actions, motivations, and emotions that could affect the manner in which you care for patients.
2.4.2. Communicate and manage all patients in a non-judgmental manner despite behaviors that may cause discomfort such as drug abuse, teen pregnancy, etc.
2.4.3. Acknowledge patient problems; provide care or refer appropriately if a conflict exists with one’s own beliefs, values, or attitudes.
2.5. Maintain an appropriate balance between personal and professional roles, and addressing interpersonal differences in professional relations.
2.5.1. Balance personal and professional roles and responsibilities.
2.5.2. Explore and resolve interpersonal difficulties in professional relationships.
2.5.3. Adopt specific strategies to heighten personal and professional awareness and explore and resolve interpersonal difficulties in professional relationships.
2.5.4. Accept and respond to feedback as a trainee regardless of age or past experience.
2.5.5. In a learning environment, be assertive about what you know and do not know.
3. Practice medicine in an ethically responsible manner that respects the medical, legal, and professional obligations of belonging to a self-regulating body.
3.1. Medical
3.1.1. Learn and teach others the professional, legal, and ethical codes to which physicians are bound.
3.1.2. Adhere to a code of moral values that guarantees incorruptibility.
3.1.3. Act for the public good and conform to ideals of right human conduct in dealings with patients, colleagues, and society.
3.2. Legal: There is a wide range of laws that place specific duties, obligations, and/or reporting requirements (to various agencies) which fall upon the practitioner. The candidate, as a potential practitioner, will be able to apply these laws from the point of practice viewpoint rather than as a regulator. The knowledge expected at this level is general, but provincially specific laws and regulations could be evaluated at that level.
3.2.1. Identify in a clinical context that the Charter of Rights, statutes, regulations, by-laws, and rulings of courts (the “common law”) are applicable in various ways to the practice of medicine and are binding on physicians.
3.2.2. Identify in a clinical context that legal principles and provisions often reflect ethical standards; e.g., in the areas of consent, confidentiality, and the duty of care.
3.2.3. Identify in a clinical context that Canada is a federal state, in which the federal government has jurisdiction in certain areas (e.g. criminal law and the Canada Health Act) and the provincial governments in others (e.g. administration of health care and regulation of professions).1
3.2.4. Inter-provincial issues: Patient Benefits, Physician Mobility, and Medical Drugs and Devices.
3.2.4.1. Describe the extent of portability of the medical degree.
3.2.4.2. Contrast the portability of the medical degree to that of other qualifications (LMCC, certification status).
3.2.4.3. Describe the non-transferability of provincial medical licenses.
3.2.4.4. Outline the portability of patient benefits under the Canada Health Act and the Canada Medical Act.
3.2.4.5. Describe the role of the Federal Government in monitoring the health system across provincial borders, certain drugs, devices, and hazards.
3.2.4.6. Outline the need to meet local and external Licensing Authorities standards for the practice of telemedicine/ telehealth.
3.2.5. Assume responsibility and use your expertise for actions which relate to the public good, both personal and of the profession; be accountable to society for such actions.
3.2.5.1. Analyze and respond accordingly in dealing with unprofessional behaviors in clinical practice, taking into account local and provincial regulations.
3.2.5.2. Learn and apply relevant legislation that relates to the health care system in order to guide your clinical practice.
3.2.6. Outline the duty to report to specified government agencies under certain circumstances (e.g. child abuse, neglect, fitness to drive, fitness to fly, communicable diseases).
3.2.7. Describe the duty to comply with statutory/judicial standards for obtaining consent. Respect for patient autonomy requires the patient’s informed choice, consent, and participation. Conversely, the informed patient’s right to refuse must be respected, even when it may seem medically unwise. Individuals must be capable of understanding the relevant risks, benefits, and alternatives, and the consequences of declining. The choice should be made free of any coercion. Patients unable to give informed consent are entitled to have their interest protected through an appropriate substitute decision making procedure.
3.2.7.1. Communicate with a patient or their legitimate delegate in order to obtain their consent or refusal to a given investigation or treatment.
3.2.7.2. Explain the legal and ethical basis for consent.
3.2.7.3. Determine the process for the assessment of capacity to give consent, and conduct such an assessment.
3.2.7.4. Identify factors which can alter capacity (e.g. disease, drugs, depression).
3.2.7.5. Identify appropriate substitute decision maker, or the process to determine that individual.
3.2.7.6. Communicate clearly information relevant to informed consent (what a reasonable person would want to know in a given circumstance).
3.2.7.7. Identify reasonable steps to ensure understanding of information: can the patient explain the medical problem and the proposed treatment or test.
3.2.7.8. Determine free choice, and absence of coercion.
3.2.7.9. Accept the patient’s right to refuse or revoke consent without prejudice to subsequent treatment.
3.2.7.10. Identify ways of determining the appropriate balance between the emerging autonomy of a minor with the legitimate interests of parents or child welfare authorities.
3.2.7.11. Identify the legal requirements in such cases.
3.2.7.12. Respect the legitimacy of the intentions of impaired patients as they may have been expressed (advanced directives).
3.2.7.13. Accept the duty to provide necessary emergency care where consent is unavailable.
3.2.7.14. Accept the need to provide non-consensual treatment in the public interest: e.g., involuntary admission for patients whose condition poses an unacceptable risk to themselves or others.
3.2.7.15. Accept the role of religious belief in obtaining patient consent and the provision of treatment.
3.2.8. Describe the need to respect advanced directives or acting on behalf of the patient.
3.2.9. Describe the penalties for failing to comply with the act requiring reporting to agencies.
3.2.10. Describe the duty to report to the coroner’s office under specified circumstances.
3.2.11. Outline the duties with respect to youth and childhood protection.
3.2.12. Outline the responsibilities under the laws which regulate biomedical waste.
3.3. Professional
3.3.1. Communicate truthfully, despite possible conflict with the duty to do no harm, never transmit false information or incomplete disclosure.
3.3.2. Name and describe relevant key ethical principles relatedto unresolved and controversial ethical issues such as
3.3.2.1. euthanasia
3.3.2.2. physician assisted suicide
3.3.2.3. maternal – fetal conflict of rights
3.3.2.4. advanced reproductive technology
3.3.2.5. fetal tissue
3.3.2.6. abortion
3.3.2.7. genetic testing
3.3.3. Confronted with such situations, candidates will:
3.3.3.1. discuss in a non-judgmental manner
3.3.3.2. ensure patients’ full access to relevant and necessary information
3.3.3.3. identify whether certain options lie outside their moral boundaries and refer to another physician if appropriate
3.3.3.4. consult with appropriate ethics committees or boards
3.3.3.5. protect freedom of moral choice for students and trainees
3.3.4. Commit to maintain the integrity of the moral and collegial nature of the profession and be accountable for one’s conduct to the profession.
1. NB Canadian law applicable to the practice of medicine varies from jurisdiction to jurisdiction and evolves constantly. These objectives are therefore necessarily general and provide an overview only. Physicians, teachers, and examiners should ensure that information relied upon is up-to-date and appropriate to the applicable jurisdiction.
Rationale
Medical school is the beginning of a life-long journey of change from novice to expert physician. During and after post-graduate training, the task of mastering the domain of medicine continues. Eventually, through scholarly pursuits, physicians are able to contribute not only to one's own health care knowledge, but also to the education of others through newly found knowledge and the teaching of others.
1. Personal Continuing Medical Education
1.1. Develop and implement a personal continuing education strategy
1.1.1. Identify the essential elements of the medical profession, including not only normal/abnormal structure and function of the body as a complex of adaptive biological system, but also moral and ethical principles and legal responsibilities underlying the profession; implement a personal life-long education strategy to permit continuous learning about the profession.
1.1.2. State a commitment to scientific methods, and apply these methods to solve medical problems.
1.1.3. Incorporate a critical approach, constructive skepticism, and a research-oriented attitude in the daily professional activities.
1.1.4. Evaluate the strength and limitations of the scientific information obtained from varied sources in establishing the causation, treatment, and prevention of disease.
1.1.5. Seek out information rather than waiting for it to be given.
1.1.6. Accept complexity, uncertainty, and probability in decisions for medical practice.
1.2. Document a personal continuing education strategy
1.3. Evaluate outcome of learning
1.3.1. Seek patient evaluations.
1.3.2. Seek allied health persons evaluations.
1.3.3. Seek peer evaluations.
1.3.4. Complete available self-administered shelf examinations.
2. Apply critical appraisal principles to sources of medical information
2.1. Select appropriate question, identify knowledge gaps around the question, and formulate a plan to fill the gap.
2.1.1. Identify practice areas for research (meaning either searching for existing knowledge or adding to it).
2.2. Search literature efficiently for evidence, and assimilate newly learned material.
2.3. Assess the quality of the evidence.
2.4. Develop a system to store and retrieve the relevant information.
2.5. Consult others in a collegial manner.
2.6. Implement the solution in practice and evaluate outcome.
2.7. Keep up to date with evidence-based standard of care.
3. Facilitator in Learning of Others
3.1. Promote and enhance the learning of others for the benefit of
3.1.1. Patients
3.1.2. Students/Residents
3.1.3. Other health care professionals
4. Development of New Knowledge: Physicians have a responsibility to contribute to the advancement of medical care, which may involve research participation.
4.1. Provide the best available care to patients by participating in research if the possibility and opportunity arise.
4.2. In conducting research, contrast the need of special populations for which the rules may be different, such as children, psychiatric patients, or the cognitively impaired.
4.3. Pose a research question (clinical, basic, education, population health).
4.3.1. Determine the ethical code which regulates the relationship between the profession and the pharmaceutical industry, and identify situations which breach it.
4.3.2. Select the patient as your primary obligation in any research project. Relationships with industry are appropriate only if they do not impinge upon that responsibility.
4.3.3. Any conflicts of interest arising from a relationship with industry must be resolved in favor of the patient.
4.3.4. Preserve your professional autonomy. Any potential conflict of interest must be disclosed to the patient.
4.3.5. Determine whether institutions and organizations in which you work or hold privileges have additional requirements regarding disclosure of potential conflict of interest.
4.3.6. If a conflict of interest cannot be resolveD, the physician may recommend a second opinion, or refrain from offering an opinion.
4.4. Develop a proposal to solve a research question.
4.4.1. Conduct an appropriate literature search.
4.4.2. Identify, consult, and collaborate with appropriate content experts to conduct the research.
4.4.2.1. Identify or propose reasonable steps to ensure scientific rigor of research (peer review, expert opinion).
4.4.3. Propose methods to solve the question.
4.4.3.1. Identify reasonable criteria for ethical approval of research involving patients.
4.4.4. Carry out research outlined in the proposal.
4.4.4.1. Ensure that any research study in which your patients are involved is scientifically and ethically sound, that your patients have had full disclosure of anticipated risks and benefits, and have made an informed choice free from coercion.
4.4.4.2. Identify additional information which should be disclosed in the course of research, as opposed to clinical consent.
4.4.4.3. Acknowledge and disclose any possible conflict of interest on the part of the investigator.
4.4.4.4. Obtain ethical approval from a research ethics committee; it is the legitimate obligation of institutions to have all research approved in such a manner.
4.4.4.5. Refuse to participate or enroll your patients in research which has not been scientifically and ethically evaluated.
4.4.5. Defend and disseminate results of the research.
4.5. Collaborative research
4.5.1. If not personally engaged in research, participate in collaborative research or
4.5.2. Quality assurance or
4.5.3. Development of guidelines.
4.5.4. Maintain records of practice for analysis and improvement.
4.5.5. Contribute to institutional quality assurance.