 It is my privilege to introduce Dr. and Dr. Crois who are going to be giving this afternoon's lecture on professionalism and medicine social contract with society. So I'm going to introduce both because they both have really impressive credentials. So Dr. Richard Crois is a professor of orthopedic surgery and a member of the Center for Medical Education at McGill University. He served as chair of orthopedics from 1976 to 1981 directing a basic science lab and publishing extensively in the field. He was dean of the Faculty of Medicine McGill University from 1981 to 1995, during which time they started issues of cutting back on residents and the whole issue of work hours. If you stay late we might be able to ask him some more questions. He was the president of the Canadian Orthopedic Association, the American Orthopedic Research Society, the Association of Canadian Medical Colleges and he is an officer of the Order of Canada and of Lotera Nacional de Quebec and it would really not be lainly introducing him if I didn't mention that he is Princeton class of 1951. Dr. Sylvia Crois is an endocrinologist, professor of medicine and also a member of the Center for Medical Education at McGill University. Dr. Crois has served as director of the Metabolic Day Center from 1968 to 1978 and medical director of the Royal Victoria Hospital from 1978 to 1995 in Montreal. She was a member of the Dachamp Commission on the Conduct of Research on Humans and Establishments and she also holds a position of officer of the Order of Canada. Together they have taught and conducted independent research on professionalism and health professions and medicine social contract with society since 1995. They continue to travel internationally speaking on this topic at universities, hospitals and professional organizations. McGill University has established the Richard and Sylvia Crois Chair in Medical Education and I actually bought their book which I've used with a course recently. It was co-authored with one of their colleagues Yvonne Steiner and it's called Teaching Medical Professionalism and I recommend it highly. On that note I'm going to turn it over to the Croisers. Thank you very much for coming to visit us. Okay. Thank you. Thank you very, very much. It really is wonderful to be here. We are so impressed with the series on professionalism that you're giving it. We're just so pleased to be a part of it. It includes virtually everybody who's contributed to our current understanding of the field. We're old enough so we actually took Latin several years and Crescatciencia vita ex colator is translated by your scholars in a very awkward way. It says let knowledge grow from more to more and so be human life enriched. We quote Osler a lot and that's sort of late 19th, early 20th century rhetoric I think. We consulted one of our Latin scholars at McGill from the Classics Department and he suggested that let knowledge grow that life may be enriched was a little simpler and a little more contemporary. We actually think this is so appropriate for your series on professionalism. Professionalism is very important to society and I think you're contributing actually to the dissemination of knowledge around it and that society will be better if people understand in some way the relationship of medicine to society. We're going to talk about professionalism and medicine social contract. We understand, we're a little intimidated because there are some philosophers around here who probably understand social contract theory better than we do. And they will know that social contract theory is not immediately applicable. It suggests that social contract is not immediately applicable to contemporary society and we've had a discourse with other people on this. We've got to have some means of fraving our discourse with society by our I mean medicines. And social contract theory has a history. It is understood by many, many people and as we'll see later on it is part of that discourse. So with a caveat that we understand there's some limitations to using social contract to describe our relationship, we will start. So why professionalism? Why now and why the social contract? We thought we'd start with a few vignettes just to sort of describe the situations. You are a patient in the emergency room with chest pain. You have a personal cardiologist who has treated you for a heart attack in the past. You ask that he be called and be informed that he is unavailable as he is about to go to a basketball game. Second vignette and I'm sure this will relate to many of you in practice. A long-standing patient of yours has developed a life-threatening condition whose optimal treatment is not covered under his health care plan. You are asked to endorse his insurance claim using a diagnosis for which the specific treatment is covered. So where are we right now? Well, society is better informed than it ever was. It's asking for accountability, transparency and a sound professional standards. And we in medicine feel that our autonomy is severely restricted by budgets, by bureaucracy, by guidelines and by peer review. The result is actually that our relationship with society is under very intense scrutiny. Most call lists a social contract which is a term going back 300 years, as Dick said. In medicine the concept is frequently, talk to you here, talk to you, read about it. It's rarely analyzed. And it really, most don't understand that there are reciprocal rights and obligations for really what the concept is all about. So what's a social contract? 18th century concept, Hobbes, Locke, Rousseau, Montesquieu straight-line back to them. Philosophers, political scientists who have used it. The concept obviously has evolved over time. It was originally developed to try and describe the relationship when there were hereditary monarchies and citizens had very few rights. It's still used to describe the organization of contemporary society and medicine. Rawls did not classify healthcare as a primary social good, but he certainly referred to healthcare frequently in his works and said that healthcare was necessary for citizens to enjoy all of the benefits of contemporary life. And Norman Daniels, of course, is a contractualist, as is William Sullivan, and they both approach healthcare within the context of the social contract. So we aren't just an orthopedic surgeon and an endocrinologist who are invoking this concept. It stresses, as Sylvia said, mutual privileges and obligations, and we think that this is important. We use a definition from Goff, who published this in 1957, that the rights and duties of the state and its citizens are reciprocal, and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract. By analogy. It's not a written contract. And the Oxford Dictionary of Philosophy has something which is quite similar, actually. The social contract in healthcare. This is cited frequently in the literature by physicians, healthcare planners, and non-physicians. That the social contract in healthcare hinges on professionalism, that it is the basis for the expectations of both medicine and society. It isn't constant. It's constantly being renegotiated as medicine and society evolve. In our lifetime, the social contract in healthcare and the nature of professionalism have changed dramatically. Professionalism has got to evolve as the contract changes. So, where did we start? Well, we started with what Fred Haferty, who's a wonderful sociologist, calls nostalgic professionalism. At that time, most physicians were, and surgeons were solo practitioners. They were accountable only to the patient, very little to society. The patient paid them directly and there was sort of a, what has been called a covenant between the patient and the physician. Now, at that time, we had unquestioned authority and autonomy. It sometimes was a little frightening when we first went into practice that you would tell a patient to do something and they did. And there were lots of opportunities to demonstrate altruism using the Robin Hood principle of asking the rich to pay a little bit more and serving those who couldn't pay without cost. And physicians and surgeons were highly trusted. The reason we start there is because that's a lot of what we believe today, both society and individual physicians. This is what people think is what practice is all about. But a lot has changed since that time. First, healthcare is much more effective than it used to be. It's much more complex and therefore it costs a lot more. The result is there is a high financial risk and most people can't pay directly for the care they get. And third party payers who've come in, whether it's the state, as it is somewhat north of you, or the corporate sector, the insurance companies and the HMOs, this has changed the contract. But society also changed. Starting somewhere in about the 60s was the questioning society. They questioned why they gave trust to our profession blindly and thought that we better get down and earn it. They looked at our altruism, thought we paid more attention to our own finances and to our own self-interests. And they said that we allowed incompetent, unethical people to continue in practice without doing anything about it, mainly that we did not self-regulate well. We also, along with this, had new levels of accountability. It was no longer just to the patient. It was to the payers and also to society. This changed the contract, too. Now, there are tensions in the contract and this relationship with society. In the first place, is the practice of medicine a job? Or is it more than that? Is it a calling? And I think most people, even the Marxists, agree that it is more than just a job. The problem of altruism versus self-interest, we all, that is a very hard line to draw between what I get pleasure out of and being altruistic and what I can do for the patient. Art versus science and technology, we are increasingly surrounded by science and wonderful developments in technology. Where has the art of medicine gone? Sometimes this is partly humanism. And autonomy versus accountability. The more accountable you are, the less autonomy you really have. There are new ones. The question of whether the practice of medicine is a moral act or whether it's something to be sold. And I think you have much more of that down here than we do, whether it's a commodity. What is our duty to our patients, the fiduciary duty, versus our responsibility to society in a place with limited resources? Not everybody can get at everything and who's responsible for that? The reality versus competition. The more competitive you are, the less collegial you are, the less collegial you are, the harder it is to self-regulate. And the less self-regulate is done because you're competing with somebody. And there's also the employee, many are now employees of some company or whatever, versus the independent professional and nostalgic professionalism. If you look at those tensions and clump them, and we're sort of clumpers, our threats come from two sources. The first are internal, within our areas of jurisdiction, things that we must do in some areas which we have failed to do. The others, of course, come from outside. Generally the nature of the healthcare system within which we must function, within which the people we are trying to help learn must function. And those we see no alternative to some form of negotiations to try and alter that. So that will be a theme throughout this. Professional status is important to us. Certainly the sociologists, if you read most of them, you will, I think it won't do much for your ego, but I think they're absolutely correct. They point out that it confers prestige and respect. Everybody wants their child to become a professional. We are generally trusted. We have autonomy in practice, less than we used to, but it's still there. We do enjoy the privilege of self-regulation. And, of course, there are substantial financial rewards. So it's important to us to try and maintain aspects of professionalism. But I think that in the last 10 to 15 years, outside observers, generally from the social sciences, have concluded that professionalism, professions are actually a benefit to society, unlike George Bernard Shaw who said that professions were a conspiracy against the society. Eliot Freidson wrote a series of books through the years. I see that Andrew Abbott is going to discuss his contributions. It was interesting. He went from being highly critical of the medical profession to, in his last two books, he returned to a sense almost of despair pointing out that professionals weren't beneficial to society. And Bill Sullivan, a friend of ours, stated that neither economic incentives nor technology nor administrative control has proved an effective surrogate for the commitment to integrity invoked in the ideal of professionalism. I think that's probably why we're all here today. Somehow we have to inculcate professionalism in the medical profession so that it comes from within because you can't impose those types of standards. And it's also important, I think, to point out to society that we are not just pursuing our own self-interest one and elite status, which we have, as we're trying to defend professionalism. There are observers in society who feel that the survival of functioning professionalism is important to society. So what is medical professionalism? And we'll just very briefly go through how we have approached it at McGill. We find it easier to divide the roles that a physician has into two. Not of the healer and not of the professional. Now, you don't wake up at 8 and become a professional and decide at 11 you're going to be a healer. You always are combining together. But we have found that it is much easier to analyze them separately. And the reason we do this is because the history is very different. There have always been healers in society. The medicine men and women, the shamans and so forth have always had a role in society and a respected role. The professions arose in the Middle Ages, in the guilds and the universities in medieval Europe and England. The learned professions were the law, clergy medicine and the military. We won't go into why that happened. They served an elite. They were not very impressive in society. And there was some question, if you think of George III of why you would ever go to a physician, you sometimes were worse off than if you just let nature take its course. Until science came along. And science came along at the same time of the industrial revolution. The industrial revolution gave people enough money to buy health care. And science, of course, was made it worth buying. Because of science, the linkages to universities became very strong. And most medical schools are university based and most residency programs, Canada, but some of them here are university based. And this brings us to the present. Two very strong links between the two are the codes of ethics which describe the behaviors of both the healer and the professional. And, of course, science which empowers both. Professionalism, as you read about it, as the word is used usually, is both roles. We have chosen to separate them. You can justify this by going to the literature and you can tease out the aspects of professionalism and of the healer. Obviously, these things, as Sylvia said, go back generations caring and compassion, listening to the patient, insight, openness, respect for the healing function. We actually heal very few people. They heal themselves. We try and facilitate that. The fact that you're there for your patient. Those things are traditionally associated in the literature with the healer. Autonomy, self-regulation and the presence of associations and institutions that carry out our business for us are characteristic of professions. We weren't... Hippocrates wasn't responsible to society. He was responsible to patients and students. That's a new concept and, of course, teamwork is something that's been added. In the middle are a host of activities which are common to both. Competence, of course, being the outstanding one. Confidentiality, altruism and a trustworthiness and a constellation of attributes that make you trustworthy. Integrity, honesty, morality and ethical behavior as expressed in codes of ethics and responsibility to the profession. Now, profession, professionalism are generic terms applied to different occupations in this world. Change this to lawyer. Change this to adjudicator of disputes. You change this, but these stay relatively similar. That's one of the reasons why we think there's some logic to taking this approach. But and it's a very big but society doesn't need a lawyer. They need an adjudicator of disputes. Society doesn't need a professional. They need a healer. Professionalism is a means to an end. So we can't remember the definition that we wrote and published and certainly don't expect anybody else to. When you create, we believe that if you're going to teach and evaluate something in current medical education, you have to be very careful in outlining what you're going to teach. So definitions really are important. We've traveled a lot and the most common failing I believe amongst those people trying to teach professionalism is that they don't agree on a common definition which serves as the basis of teaching and learning and evaluation. This was designed to serve medical educators. It is all encompassing, which is why you can't remember it. I'll read it, but it's certainly available in the literature. It doesn't matter which definition you pick if you're going to teach and evaluate professionalism. There are a half dozen very good ones in the literature. Pick one and use it. This is ours. An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or the practice of an art founded upon it is used in the service of others. That's straight out of the Oxford English Dictionary so we didn't make it up. Its members are governed by codes of ethics and profess. That's what we do when we recite the modern version of the Hippocratic Oath. A commitment to competence, integrity and morality, altruism and the promotion of the public good within their domain. These commitments form the basis of the social contract between a profession and society and society in turn grants. We don't have a God given right to our professional status. The profession a monopoly over the use of its knowledge base. That's our license. The right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served, to their colleagues and to society. That's our concept of what profession consists of. Now when you look at this the role of the healer is really universal. You can go around the world and talk to fellow physicians or surgeons and you can relate to them because of the healer role. But the professionalism will vary between countries because of the culture and their social contract will vary because of their cultures and their traditions. So why invoke the social contract? Well in the first place we need to communicate with the society and professionalism provides a basis for this dialogue which we must put we can no longer not listen to what society is telling what we did for about 30 years. It supplies the rationale for our obligations, for our professional obligations that we must do and it implies consequences if we don't meet them. Others reasonable expectations. Rudolph Klein who's a sociologist in England I think gives a very nice definition of today's social contract where he calls it a bargain. He said it's a bargain where we're given prestige, autonomy, the privilege of self regulation and rewards on the understanding that will be altruistic, self regulate well, be trustworthy and address the concerns of society. Now the social contract is not like GM and the auto workers and it is really a mix of written and unwritten the licensing laws, healthcare information, codes of ethics all are written available to the public and there are some legal obligations that arise out of this but there are moral obligations. You cannot legislate someone to be compassionate you cannot legislate somebody to have presence so that there are moral obligations to this and there are the ones that are universal mainly the healer and those that are local as society changes and as medicine changes it's constantly evolving, being renegotiated if you will. So who are the parties to the contract? Klein, you know, you really don't need what we're about to say because we think Rudolf Klein's is lovely and elegant and simple. We're not going to goof it all up for you by making it too complex. The social contract takes place between medicine and society and neither medicine nor society are monolithic. They both are extraordinarily complex. Medicine of course consists of individual physicians primarily and our institutions that represent us. Those include licensing bodies, professional associations medical schools and so forth and so on and the American Medical Association of course is important. The stance which we take when we address society depends on the interaction between us and our institutions, those chosen to represent us and there's clearly tension at that level. We are actually in Canada, I think it's interesting 85-90% of Canadian physicians are strongly supportive of our healthcare system. So when we address governments we're in a different situation from those of you who live in this country where you've got a much more complex system and I think there isn't agreement as to where, what direction medicine should take. Society in the developed and democratic world of course consists of governments and citizens. Now within the healthcare field we start with patients but there's also the general public and patients will have wishes and desires which are different from those of the general public. It includes how much taxes you wish to pay it includes whether you think that expensive treatment should be covered or should not be covered but eventually generally at the time of elections in most countries some type of stance is taken to develop a consensus. Government consists of politicians and civil servants and certainly nationalized systems like the UK and Europe and our country to an increasing degree managers who are in the field. They all have their own vested interests they all have their own opinions. This overall relationship is intensely political you should know that the most dangerous job in Canada is not a NASCAR racing driver it's being a minister of health in any of the Canadian provinces. The half-life is very short because health care has now into the political arena so this is a political relationship health care is either the first or the second issue in every federal and provincial election in Canada. It's either the economy or health care and of course they're pretty tightly linked. The importance of professionalism to this is that for us on this side the rules of the game are outlined by what it means to be a professional as we renegotiate our contract we cannot do it like the United Auto Workers do. When you look at that diagram you will see that there are some things that are not there because we believe these we along with Rosen and Dewar in the UK believe that these are modifiers of the contract the health care system the nature of the health care system it may also be an expression of the contract but it's not in there the regulatory framework is very important we'll talk a little bit about the UK in a couple of minutes that outlines the nature of the contract the commercial sector has a huge impact in some countries much less than ours great here other stakeholders other health care professionals any organized group in society and of course finally the media the media doesn't just reflect public opinion the media particularly in the health care field directs public opinion to a very great degree so what are the expectations that we have and here's where we could put this all on one slide but it tends to oversimplify a very complex relationship so if you start with what are the patients in the public want of us of medicine well they obviously need the healer and they expect that when they go to a physician or surgeon that they're competent they are they want to be able to get the care they need when they need it and their problems on both side of the border on that they want altruistic service where their needs will come before that of the individual physician they expect that the practitioner will be moral will have integrity and be honest and therefore trustworthy and will follow the things that are laid out in their codes of ethics and at this point we usually ask our student how many people have read the recent code of ethics of either here or of the AMA raise your hands that's about right that's just about what we find and yet that is a public document the public can read it and that's what they expect you to follow so just as a side they expect accountability and openness they manage our affairs and for a long time they didn't care they now do how do we self-regulate how do we handle conflicts of interest they expect us to become be partners with them it's no longer paternalistic and they want to they expect us to be a source of objective advice especially in times of bio-terrorism and epidemics and so forth and the sociologists will tell you that there is no purpose for a profession unless it promotes the public good so one should always look at actions in the way of does it promote the public good now on our side this is a contract what do we expect from our patients in the public we expect to be trusted because we know that if we aren't trusted that we cannot do for the patients the things that we need to you can't do invasive procedures if somebody doesn't trust you with a knife we need autonomy enough to be able to make decisions for the patient that best fit their needs doesn't mean you can do anything anytime anywhere but it does mean that we have the freedom nobody there are guidelines but we can apply them as they seem appropriate we expect a role in public policy and we've had some instances where our role has been ignored and disasters have occurred we expect the public and the individual patient to share some responsibility for their health if their problems are related to obesity and they refuse to lose weight if their problems are related to smoking and they refuse to stop we expect them to help let them help us we increasingly in the modern generation expect to maintain a reasonable lifestyle where we can have a reasonable family life and where we can follow some of our own hobbies and this sometimes interferes with altruism and we do expect rewards and it's interesting in the polls that are taken of physicians that the main concerns they have in the non-financial ones the question of trust autonomy and that but we also do expect to get paid now if you look at government's expectations of medicine and reciprocal these are very similar so we go over them quickly assured competence morality integrity and honesty compliance they really do expect us to comply with the details of the healthcare system very strong emphasis on accountability for performance productivity and cost effectiveness we certainly don't have to tell anybody in this room about that they expect us to be transparent and how we carry out our affairs they expect us to be a source of objective advice they certainly are free to take or ignore that advice as we've learned the hard way and they also expect us to be a force for good in society we expect of government trust autonomy we expect to be able to self-regulate that's been an important part of the contract we're going to talk a little more about that we expect a healthcare system that's value laden, equitable funded and staffed and with reasonable freedom within that particular system these things are actually very high on most physicians lists we expect a monopoly we have a long educational process we believe that we have skills which are which can only be achieved in that way and we do not think we should be competing with non-qualified people and we expect them to support us with non-financial and financial and the word respect certainly comes in in our dealings with our governments and I'd be surprised if it wasn't true here now the public also has expectations of government and this is where it's interesting how closely they mimic some of ours they do expect quality healthcare to be produced by whatever system the government has allowed to exist but their healthcare system they wish it to be accessible to be fair and to be value laden sounds very familiar to ours adequately funded and staffed more a problem north of the border than here they expect input into health policy and they feel disenfranchised in public policy the same way our profession does so that I think there are allies they expect the government to provide a system where there's a reasonable cost that it's open in how it works and to be accountable for what is put in place now the government also expects the public to not demand inappropriate use of resources and to have reasonable expectations of whatever system is in place they again expect the public to take some responsibility for their own health they will try and enforce the education that we try and give to patients on their things to do for better health but they expect that people will take that advice they expect that there is support for whatever public policy comes out and they say that they want input into public policy and management and I think sometimes take it so there are consequences when expectations are not met on either side we've chosen to call them breaches the contract it doesn't matter what you descriptive term you do what happens when we fail to meet reasonable societal expectations certainly if you look historically in the recent past you can say that there is a change in the contract there's decreased public trust in the system in the contract trust in physicians and in the profession goes down and we are as a profession much less trusted than we were a generation ago there is decreased medical influence on public policy we've seen that in Canada you can see it in the UK and I suspect it's been true here too there will be diminished if diminished self-regulation an increase in external regulation and there will be changes in autonomy and I think we can look in many countries and say that's true the Harvard Business School case study though is in the UK in the last 15 years the Bristol cases and Dr. Shipman's history the Bristol cases involve pediatric cardiac surgery on neonates that was carried out in Bristol with a mortality rate of five to six times the national average the estimate is that between 60 and 70 babies died that would have lived if they had the normal mortality rate it was due to the incompetence of the two surgeons carrying out the procedures they weren't trained to do them everybody knew the regional health authority the department chairs, the Royal College reviewed the program noted the mortality rate did nothing about it and a new anesthetist came to town from London and went through all the right steps that you should go through and finally went to the press and you can imagine the response we happened to be on sabatic and Oxford at the time and it was in the newspapers every single day forever the result three Royal Commissions later has been a profound change in the regulation of medicine in the UK by the way other professions have had changes in their regulations as well the general medical council it works in the UK as the licensing body but it also set standards for education and training it previously was a body much like our regulatory bodies made up primarily of physicians who were elected by the medical profession as of now the general medical and there were a majority of the GMC council were physicians the current general medical council is appointed by the appointments commission which is a body that makes appointments across the board in the UK on behalf of the government less than half are physicians the chairman is a non-physician and they have hived discipline off from the general medical council to a separate body that carries out discipline in the healthcare professions again totally appointed by the government this indicates that from a legal point of view the medical profession in the UK is no longer self-regulating it no longer controls the regulatory process because it doesn't have a majority other than GMC the social contract has changed and the nature of professionalism in the UK has changed as a result of the failure to self-regulate by the medical profession the failure to meet legitimate societal expectations now we frankly not being judgmental here the system may work well the system may work well it's only a year and a half since it came into effect but we will see certainly what we can say for sure is that in this instance failure of the medical profession to carry out its responsibilities within its jurisdiction there has been a profound change in the social contract and and I think if you look at that to a lesser degree we're having changes in Canada we are having that the authority of the regulatory bodies limited by the ability of ministers or governments to intervene and overrule them something which did not exist in 2017 so what happens if society fails to meet our expectations this is a little harder and frankly there is no literature on this the literature on the Bristol cases and Shipman is extensive and it does interpret events the way we have described them as a failure of the medical profession there isn't much on what happens when there isn't anything what happens on when society fails to meet our expectations imply that when you go into the literature on physician discontent or physician's opinions on healthcare systems and we've sort of gotten to the point where we think that we are all suffering from a collective bipolar disorder and I think when we look at our response where we've had ups and downs in the implementation of our healthcare system that we vary between optimism and pessimism depending on what's happened during the last hours, days or months or so forth if things if our expectations are not being met and by the way we can talk about the Canadian healthcare system and where we feel that society has failed us a little bit if we want there's less trust in the system or the contract there's less cooperative cooperation we withdraw we don't serve on committees we look upon our work as a job rather than a calling and certainly there's less satisfaction on the other hand if all of a sudden there's been a change in ministerial policy or things are looking like they might improve then you get increased involvement in your community with your associations with other stakeholders you tend to get involved in negotiating to make the system better and we believe that there's more job satisfaction we can't point to seminal articles that would justify this but I do think that it is true so where are we well in the United States you have a market oriented system that absolutely forces physicians to become entrepreneurs within a competitive market you just have to to survive maybe not in academic medical centers but in the community there's competition the system is based upon competition and there's diminished collegiality we tried to recruit an orthopedic surgeon back to Canada who had a degree in medical education and quite a track record she was in a cooperative practice and she said that she really couldn't be away too long because she was afraid that when she got back that her so-called colleagues that her patients would be gone I mean that's not a situation that's a personal anecdote the uninsured provide a huge moral dilemma for everybody and there's no real answer to that the increased accountability has certainly been a cause of dissatisfaction and has led to decrease clinical autonomy so is there a major change in the contract certainly there's a major change in the contract in this country which was graduated from medical school in 1955 this is a totally different deal the contract is different and so is the nature of professionalism and there's decreased trust in the system and I guess uncertainty as to what the future will hold for the practice of medicine Canada a little bit different we suffer primarily from decreased funding in our system in 1990 we had the second highest per capita highest debt per GDP as a percentage of GDP in the OECD Italy was the only one that was ahead of us the big items in Canada are health and education and Willie Sutton robbed banks because that was where the money was and when people want to have major budget cuts they got to go where the money is so health and education got cut we went from the most performing health care system according to OECD to number 13 because of those cuts and it has had a profound impact on the practice of medicine as a part of those cuts they cut down on the number of health care personnel including doctors so we don't have enough there's less personal freedom in an attempt to ensure regional disparity our province not to insure it not to insure it to address regional disparity between rural areas and cities our Quebec government limits access to practice in cities you can't build a health care system unless you have permission so there's much less freedom within the system it's a major change in the contract and these changes have occurred in the last 15 years reach probably and certainly our physicians have less trust in the system so if our expectations aren't met and society by the way as we'll say again has most of the cards in these negotiations there are consequences so what should we do we're going to have to learn to live with the changes they're here to stay they're really linked to how society has changed and so we can't ignore them we have to do something and the first thing we need to do is to address the issues that are in our own control we've got to negotiate those that aren't in our control which is basically to negotiate some sort of a health care system that supports the healer role so what issues can we control and should we get at well the first is to insure that all physicians understand their obligations to society and society's expectations what are their obligations as professionals in the health care teach professionalism to the social and the social contract the concept of the social contract to medical students, residents faculty and in continuing medical education because if you don't understand what the relation is and it's interesting that the concept of the social contract in face of today's health care system they feel empowered by it because they feel they have a way to into negotiating but we also have to address what our failures are the perceived lack of altruism the fact that there is a lot of attention paid to how much money is being paid to physicians a lot of attention paid to lifestyle and some and the short duty hours the question of what is the responsibility to the patient whose well being comes first out of the patient or not we're going to have to deal with that problem and we're going to have to deal with the conflicts of interest are you doing this for me because you make more money out of it or are you doing this because that's really what's needed and we also less here but we have to look at our and their union like activities and I think even the AMA has been guilty of some corporate union like activities not necessarily in the best interests of society so have all of our associations I'm not damning them in particular and there have been some very badly managed conflicts of interest which the media is delighted to talk about and we'll have to be very careful to manage them better and to be very transparent in our relations with the other health care industries we'll have to be better in self-regulation we are our brothers and our sisters keepers we cannot allow incompetent immoral unethical practitioners to continue without remediation and be followed and we'll have to think of how resources should be distributed so we're going to have to pay attention to how resources are distributed to social justice so what should we do well, Sylvia has talked about what we do for those things under our jurisdiction somehow or other we've got to address the external stresses that requires a single voice or a coordinated voice speaking for medicine I think you have a question speaking for you here we do too however our constitution gives health care to the provinces as a responsibility and at the provincial level we are universally represented by our provincial associations which are legal unions under the law I think you have some difficulty in deciding who's actually going to represent you the AMA or your association it also takes a negotiating table when you have a national health service there is a negotiating table and it's easier that's again a difficulty that we could spend a lot of time on in this country we've got to recognize that we are not the only ones at the table and in fact we're probably not the dominant players that Elliott Frydson correctly described during his lifetime but we certainly have to be at the table so we would suggest that negotiations must establish or preserve trust on the sides they're not symmetrical society has most of the cards and it's very difficult however we are not without a very, very important card every single citizen needs or will need the services of the healer and the healer remains trusted and respected and we actually do believe that if we act in a way in the negotiations that we actually have the power to influence those negotiations we can't do it by ourselves the public and medicine as we tried to point out with those three slides of expectations actually have very similar desires in health care and it would it seems logical to invoke public support in our attempt to get a system which actually supports the healer so in summary our professionalism is certainly under threat as we said earlier I think that's the reason why there are so many people in this room preserving professionalism isn't just important to us it's also important to society and professionalism does serve as the basis of our social contract and invoking this concept does provide a basis for support and a rationale for our obligations and we think it's therefore logical what we are dealing with is not inconsequential to society Vaclav Havel who is certainly one of the great statesmen of modern times says that since time immemorial a part of human culture has been man's care for himself I think if it had been translated he might have said herself that is for his own health the culture of healing may be a less visible aspect of life yet it's perhaps the most important indicator of the humanity of any society those are the issues we are dealing with and we hope we have according to your motto added to the knowledge base but perhaps some good will come out of it thank you very much for your attention I'll take the privilege of the first question so thank you for that wonderful talk you said you made a comment that we cannot negotiate like the auto workers and I guess I'm going to ask why and since we're looking at it internationally in France doctors like in Canada are unionized and in France they've actually had multiple strikes so what makes us different than the auto workers and how do we deal with strikes and then still call ourselves professionals and the obligations we have well one of the things maybe I'll give an example two examples from Canada but the Ontario obstetrics and gynecologist OB-GYN refused to deliver take on new patients because they wanted a lot more money and it was quite clear in the media that they were striking for money and they were badly tarnished by it and they lost in New Brunswick the general practitioners were earning about two thirds or half of what all the other people in Canada in the same practice were doing and they went on strike because they couldn't recruit anybody in and people were leaving and the message they gave to the public was that we need more doctors we can't get them with the current pay rate help us and the public bought it and the government gave in so it depends on whether you're striking for yourself and appearing to or whether you're striking for the public good but how is that different than the auto workers well the auto workers can totally withdraw services we cannot and in fact you haven't had problems with strikes down here you aren't organized in fact there are legal difficulties in actually creating doctors unions I believe but in most areas where doctors have the potential to strike they are classified as an essential service and are prevented from taking classical strikes where you totally withdraw services so that's why we one of the reasons why we say that it isn't you can't use the same tactics where where we use tactics which sound like they are very self-serving we lose public support and for the medical profession to exert any influence on government they absolutely have to have public support the Ontario doctor strike in 1986 that Sylvia talked about was catastrophic for physicians not just in Ontario but all across the country the medical profession remains the highest paid single occupational group in the country the press knows that the public doesn't think we're badly done by but they will support us if it looks as if as if we're being treated unfairly I have some worries about the use of the idea of a social contract and I understand you're using it loosely but still the way you've set it up it's a contract between something called medicine or the medical profession and something called society and with contracts there are bilateral obligations of various kinds but as in what you're talking about breach what usually that means is that if one party breaches the other has lower obligations some things which would have been an obligation for each now or no longer obligations and what I worry about is that really the primary obligation of a physician is not to society in some very general abstract sense but to particular patients and so the metaphor of the contract suggests that if a thing called society breaches the physician's obligations to what decrease you don't want to take it to say it's decreases but it looks as if that might follow from this particular metaphor and so that's why I'm wondering if the metaphor captures adequately the complexity of the physician situation that seems to go in the one direction towards institutions, society as a whole but in another direction towards particular patients yeah that's a very that's the dilemma it's a defect in the metaphor if you will the other very strong defect is that when we were a non-secular society we could ground our relationship both with patients in society and morality and this draws it away from a moral obligation to behave in a certain way those two defects I think are very real why don't you want to go back to this idea of a moral obligation that is that there is the capacity a distinct capacity that the physician has to provide a benefit precisely as you say through training and opportunity and so forth this is a capacity to provide a benefit that no one else has why doesn't that itself generate at least some primary facial obligation well two answers to that in the first place we don't go away from it but I'm saying that it's apparent secondly we're not sure how far morality is accepted by the current generation of students, trainees, younger physicians we don't know whether whether that's actually how powerful that remains people in the room are going to have to answer that for us we're from a different generation but our observation is that that this idea of reciprocal rights and obligations is more acceptable to the current generation and I put that level up to people certainly into their 40s and I don't know whether people agree with that or not but I think you're absolutely right there is a fiduciary duty and a moral obligation to your individual patients and I think that when strikes have occurred at least in our those needs have always been met there have always been emergency service there has not been lack of contact with the patient should the need arise it's just that the elective things are sort of put off but I think we're playing games and I think the dilemma remains thank you for a wonderful talk so I particularly think it's very useful to think about as you've broken down the healer role and the professional role and you both spoke about the healer role maybe a universal across cultures or across societies so I wanted you to comment on the idea that maybe that's not quite true and maybe there are people the healer role as defined by naturopaths or other systems of care which while in our western context there is a minority of where people get their healing from but in other societies that might be the majority that they go to these other entities who can claim the healing role but yet don't have the professional role a regulation that the state might want through the social contract and even the arise of such systems even within societies like ours in certain states and certain types of education do you read that as now as a result of distrust and because of this over regulation how do you make sense of the phenomenon? I think most people and I think we would agree feel that when individuals go to alternative practitioners that it represents a failure on the part of the medical profession that we somehow have not been able to satisfy their demands now I'm not sure I understand the nature of the question so in a sense that you can claim a healing role if you're an naturopathic we do not have a monopoly over healer or the healing role I want to make that absolutely clear but we have a monopoly over our knowledge base and our skills that we have been trained nobody else can use those if you will so that's why I wanted clarification because you can say even aside from naturopaths you know healing through chaplains or other things so I want to get a sense of where this breaks down oh no no the law actually outlines the nature of our monopoly and what we are legally entitled to if you will considering that you touched on several very important themes one of which is that people feel a calling to be physicians and then also that we have an expectation especially in these modern times that we are also going to be able to have a life outside of the hospital and so my particular question is with the new hours restrictions for residents especially here how do you see going forward that professionalism can be a part of training without it being like a didactic session about professionalism how can we have people become professionals and be dedicated to the profession if they are so restricted in their hours I think one of the biggest problems that residents face in short hours and so forth face is ensuring continuity of care ensuring the patients feeling that there is presence that I know what is coming next I know who is going to provide it and I know that the person who is going to provide it knows me or knows about me and knows enough not just a bunch of numbers and I think that we have not trained very well on that and I think we are going to have to spend much more attention on how one ensures the continuity of care whether it is called transitions or whatever it is but the patient the healer needs to provide presence and you have got to do the presence if it isn't you you have got to make sure that the person to whom you are handing it off will provide that. Our first or second workshop that we gave at McGill the first year resident in family medicine came up to us and very nicely said your generation must not use professionalism as a means of imposing its lifestyle on my generation and our immediate response was a short four letter letter word like what do we do now and it is real and it is a real issue we actually have come to and by the way it is justified we are not saying that this should happen what we are telling our students and residents and presumably I am telling you is that this is your generation's obligation to work out a means whereby your patients remain satisfied with what they think is your commitment to them and you are able to have a satisfactory lifestyle and it is going to have to be it is going to have to imply working together to a much greater degree so that patients are satisfied by more than one individual but if the general public and individual patients become convinced that we work nine to five and that their needs are not going to be met after five then the nature of the relationship between you and your patient and between us and society will change profoundly and we can't do it for you guys this is something you have to work out on your own but you have to understand the consequences that is where these reciprocal rights and obligations actually do come in that there will be consequences if the public and individual patients remain dissatisfied with our response so for those who are still here if you could join me in a warm thank you to the Croisers and for those who are able and want to continue the conversation I'm going to let the Croisers sit and they can continue the conversation in that way