The impasse over the physician services agreement continues between Ontario’s Ministry of Health and Long-Term Care, and the Ontario Medical Association, which represents about 30,000 physicians in Ontario.
Much has been written about this, in medical literature and in the mainstream media. Most of the conversation revolves around dollars and cents; there is not much talk about the social contract between the physicians and citizens of Ontario.
What does the social contract between physicians and the public look like? Has it changed, in this era of government austerity and finite health care dollars (particularly when physician billing alone makes up about 10 percent of Ontario’s budget)?
In Western medicine, the social contract between physicians and society is tacit. Society affords physicians a certain respect, status and financial remuneration. This is in return for services rendered, professional autonomy and self-regulation, and a health care system within which to work. It is understood that physicians are to be ethical, competent, accountable, and empathetic to patients, society, their colleagues and themselves.
The social contract took on this form for a variety of reasons. With the growing value accorded to scientific knowledge in the late 19th and early 20th centuries, physicians gained more influence and importance in society. Paul Starr, an American sociologist, has noted that as health care became commoditized and moved from the home into the market during this period, physicians used the cultural authority of science and higher knowledge to control the supply of health care. They achieved this by becoming a more unified profession, and by limiting entry into the profession through restricted admission into training programs, licensing laws, and controlling the provision of medications. In Canada, things unfolded in a similar way. Canadian physicians have played a central role in the development and regulation of the medical profession — particularly its independence — and more broadly in the health care systems we know today.
A thorough understanding of this evolving social contract can help health care stakeholders make sense of challenges the medical profession currently faces.
In Canada, the Royal College of Physicians and Surgeons of Canada’s CanMEDS framework outlines the promises physicians make according to the social contract. Medical trainees and physicians are expected to adhere to these roles to improve patient care. According to this framework, the professional role (one of seven roles) “reflects contemporary society’s expectations of physicians” in return for privileges granted. Professionalism is therefore the foundation of the social contract, because society and physicians have agreed to use the construct of “the profession” to organize the provision of health care services.
Presently, the medical profession, particularly in Ontario, faces the challenge of redefining its role as a leader in the transformation of health care. The evolving nature of the social contract means society’s expectations of the medical profession are in a state of flux. One expectation that is gaining traction is the need to strike the right balance between physicians’ autonomy and their accountability. An ideal balance would enable physicians to provide optimal patient care as the population continues to grow and age, while acting as stewards of scarce health care resources. The public is demanding that health care workers and institutions demonstrate they are getting good value for its money.
Naturally, physicians are cautious about the dangers accountability may pose to the profession. Many have pushed back against government-mandated accountability in health policy, because it might threaten the part of the social contract that allowed doctors to assess the value of their own work. Some fear that this accountability will make physicians responsible for repairing a flawed health care system that they did not create.
Accountability will inevitably be more important in the practice of medicine going forward, as this practice exists within the framework of increasingly complex publicly funded health care systems and limited government resources. Darren Larsen, Chief Medical Information Officer for Ontario MD, writes in his blog that “accountability means new work. It means exposing parts of our practices that may not be effective and in fact commits us to improving them…accountability is simply about matching the desire to do the right thing, with showing that the right thing is actually happening.”
The medical profession can lead the reform of health care by taking ownership of accountability and determining what it will look like. Accountability must be meaningful but, most importantly, it must be measurable, and it must be quantified and studied. Its measurement should be clinically relevant – informed by patients’ real needs rather than by billing and administrative data or the unending drive for more bar graphs. When it is wasteful, measurement does not help anyone, and it becomes more of a distraction than a benefit.
Ultimately, accountability can and should force us, as physicians and medical trainees, to confront what we don’t know in order to improve patient care. To achieve accountability in our public system, many players have to be involved. We know that patients’ health is impacted only in part by clinical care; governments are equally accountable for it, with their role in the modernization of outmoded hospital infrastructures and the development of preventative health care policies to keep patients from getting sick in the first place.
For years, collaboration between physicians and governments has produced programs that work for everyone. There is no reason why accountability cannot be modernized in the same collaborative way. It is only a matter of time before accountability becomes a fundamental part of the good practice of medicine.
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