text:
"PD19-03" OR "BR2019-03" OR "PD18-03" OR "PD18-01" OR "PD16-04" OR "PD15-07" OR "PD14-09" OR "BD14-04-84" OR "GC13-29" OR "BR2010-06" OR "PD09-05" OR "BR2009-02" OR "GC05-43" OR "GC04-48" OR "BR2004-07" OR "BR2004-10" OR "GC03-068" OR "GC03-37" OR "BR2001-04" OR "PD00-08"
Needs of retired physicians
That Canadian Medical Association, in collaboration with the divisions, address specific needs of retired physicians in the Canadian Medical Association's physician health and well-being program.
Physician health and well-being
The Canadian Medical Association supports the educational needs of physician leaders with respect to physician health and well-being through the creation of professional development opportunities and programs.
Presentation to The Standing Committee on the Status of Women
Good afternoon. As was said in my introduction, my name is Anne Doig and like the chair, I am a family physician. I practice as a "full service" family physician, which means that I provide care in hospital as well as in my office, including obstetrical services. I have practiced in Saskatoon for almost 32 years. It is my pleasure to be here today. As President of the Canadian Medical Association, I represent all physicians, but today, I am proud to represent women participating in what is now a traditional occupation for them, that is, medicine. Joining me today is Dr. Mamta Gautam, a specialist and champion of physician health and well-being. For 20 years, she worked as a psychiatrist treating physicians exclusively in her private practice in Ottawa, and has been hailed as "the Doctor's Doctor." The Association of Universities and Colleges of Canada has reported full-time university enrolment increased by more than 190,000, or 31%, between 2000 and 2006 and now stands at record levels. Full-time male enrolment has passed 350,000 students and full-time female enrolment has passed 460,000. Women account for two-thirds of full-time enrolment growth since 1971, a surge driven by the rapid increase in women's participation in the professions, including medicine. As it stands now, the males outnumber females among practicing physicians by 67%-33%. While there are still more men than women in practice, the percentage of female first-year residents in 2008 was 57%. This is a reversal of the percentage when I graduated, and an increase from 44% fifteen years ago. This means that a significant majority of physicians close to the beginning of their medical careers, are women. Not surprisingly, given those figures, there are many medical disciplines where the proportion of females is much higher than it was even just a few years ago. For instance, in general surgery - long held to be a bastion of male physicians - females comprised 18% of the 1993 first year residents compared to 40% in 2008. Just over half of first-year family medicine residents in 1993 were female compared to 64% today. However, women medical graduates still tend to choose to pursue residency training in family medicine, pediatrics, and obstetrics/gynecology in greater proportions than their male counterparts. As has always been the case, males continue to have a stronger preference for surgery - 23% compared to 11% of females - although that gap is narrowing. So, the overall numbers of women physicians are increasing as are the percentages of those going into what one might call non-traditional specialties, albeit at a slower rate. The so-called feminization of medicine brings with it several other issues and I will touch on two major ones. First, work-life balance. The rise in the number of women physicians is bringing a positive shift in the way physicians practice and the hours that they keep. Very few of today's young physicians - male or female - are willing to work the long hours that physicians of previous generations did. That said, data from the 2007 National Physician Survey, which included responses from over 18,000 physicians across the country, show that, on average, male doctors still work nearly 54 hours per week, while female doctors work 48 - although many work more than that. These figures do not include time on call, nor time spent on child care or other family responsibilities. Many members of the Committee can empathize with this level of commitment. In contrast, the European Union Work Time Directive has said that the maximum work week must be 48 hours. If Canada were to try to apply that directive to physicians our health care system would grind to a halt. The number of physicians opting to be paid by a means other than pure fee-for-service has dramatically increased. FFS rewards the doctor financially for seeing more patients. Female physicians typically spend more time in each patient encounter, a trait that is valued by patients but not rewarded by FFS remuneration. The second issue is stress. In spite of their increasing numbers, women in medicine still report higher rates of incidents of intimidation, sexual harassment and abuse than their male colleagues. As well, many female physicians continue to assume primary responsibility for home and family commitments in addition to their practice workload, thus compounding their stress levels. Female physicians are more likely to work flexible hours; flexibility in work schedules has been the method by which female physicians balance their professional and personal lives. Yet, as they take on more and strive to be more flexible that in itself creates more stress as they battle to be "all things to all people". The CMA identified the need to address and mitigate the unique demands on women physicians in its 1998 policy on Physician Health and Well-Being. I have brought copies to be shared with you today. As I mentioned at the start, I am joined today by Dr. Gautam who has considerable expertise in the stressors faced by physicians - and women physicians in particular - and in managing them. We will be happy to discuss the participation of women in medicine and to answer questions that you may have. Thank you.
Toward a National Strategy on Mental Illness and Mental Health : CMA Presentation to the Senate Standing Committee on Social Affairs, Science and Technology
Population health/ health equity/ public health
Thank you, honourable Senators, for the opportunity to speak on the critical need to address mental health and mental illness in Canada. In my remarks today I want to talk briefly about the dimensions of the issues, the instruments available to government to address them, and the CMA's specific thoughts and recommendations on moving forward. Dimensions of the problem As the members of this committee know, the economic toll exacted by mental health disorders, including stress and distress topped 14 billion dollars in 1998. The human cost, however, extends far beyond dollars and cents. Estimates show that about one in five Canadians — close to six million people — will be affected by mental illness at some point in their life. This problem climbs still higher if one includes the serious problem of addiction to illicit drugs, alcohol, prescription drugs and the increasingly serious emerging problem of gambling addiction. Yet our society and health care system remains woefully inadequate in promoting mental health and in delivering care and treatment where and when needed. These systemic shortcomings have been exacerbated by the twin barriers of stigma and discrimination. These barriers have a detrimental effect on recovery from mental illness and addictions by hindering access to services, treatment and acceptance in the community. This is especially unfortunate because effective treatment exists for most mental illnesses and addictions. Poor mental health affects all aspects of a person's life and requires a collaborative approach. Family physicians, psychiatrists, psychologists, social workers, nurses and other counselors can be involved in one patient's mental health care. While family physicians can deal with a number of mental illnesses, most are not trained in the complicated medical management of severe mental illness. Many family physicians' offices are also not sufficiently resourced to deal with family counseling, or related issues such as housing, educational and occupational problems often associated with mental illness. As a family physician myself I should be assured that, when a patient's mental health care requires additional expertise, the appropriate resources are available for my patients and their families. Physicians are striving to ensure that the care is provided by the appropriate caregiver at the appropriate time. For example the Shared Mental Health Care initiative of the College of Family Physicians of Canada and the Canadian Psychiatric Association is designed to lead to better outcomes for patients. I know the committee will hear more about this initiative from the Canadian Psychiatric Association. I mention it now simply as a reminder that progress is being made and even more could be gained with the establishment of a national strategy to address mental illness and mental health. Canada is the only G8 nation without such a national strategy. This oversight has contributed significantly to fragmented mental health services, chronic problems such as lengthy waiting lists for children's mental health services and dire health human resource shortages. Case in point, there are no child psychiatrists in the northern territories, where such care is so desperately needed. Planning to correct the problem The fragmented state of mental health services in Canada did not develop overnight and it would be overly simplistic to say problems can be solved immediately. However, it is important to understand that there are means available to the federal government to better meet its obligations with respect to surveillance, prevention of mental illness and promotion of mental health. The way forward has been clearly described by the Canadian Alliance for Mental Illness and Mental Health, and the October 2002 National Summit on Mental Health and Mental Illness hosted by the CMA, and the Canadian Psychological and Psychiatric Associations. This gathering helped define the form that a national strategy should take. Participants recommended a focus on national mental health goals, a policy framework that includes research, surveillance, education, mental health promotion and a health resources plan, adequate and sustained funding; and an accountability mechanism. In addition to a national strategy, the CMA believes it is also important to recognize the deleterious effect of the exclusion of a "hospital or institution primarily for the mentally disordered" from the application of the Canada Health Act. Simply put, how are we to overcome stigma and discrimination if we validate these sentiments in our federal legislation? The CMA firmly believes that the development of a national strategy and action plan on mental health and mental illness is the single most important step that can be taken on this issue. The plan also requires support, wheels if you will, to overcome the inertia that has foiled attempts thus far. Those wheels come in the form of five specific actions that are listed at the back of the presentation. But, to summarize, they would include: * Amending the Canada Health Act to include psychiatric hospitals. * Adjusting the Canada Health Transfer to provide for these additional insured services. * Re-establishing an adequately-resourced federal organizational unit focused on Mental Illness and Mental Health and addictions. * The review of federal health policies and programs to ensure that mental illness is on par in terms of benefits with other chronic diseases and disabilities. * An effective national public awareness strategy to reduce the stigma associated with mental illnesses and addictions in Canadian society. Looking inward While my remarks have focused on the broad status of mental health initiatives in Canada, the mental health status of Canadian health care providers is also of concern to the CMA. In recent years, evidence has shown that physician stress and dissatisfaction is rising and morale is low. The CMA's 2003 Physician Resource Questionnaire found that 45.7% of physicians are in an advanced state of burnout. Physicians, particularly women physicians, appear to be at a higher risk of suicide than the general population. The CMA has been involved in a number of activities to address this situation, including last year's launch of the Centre for Physician Health and Well-Being. The Centre functions as a clearinghouse and coordinating body to support research and provide trusted information to physicians, physicians in training and their families. A first activity of the Centre was to provide, through partnership with the CIHR's Institute of Neurosciences, Mental Health and Addiction, $100,000 in physician health research funding. This funding is currently supporting two research projects. One will develop a guide of common indicators for Canadian physician health programs. This will generate a national profile of the physicians who use the programs, the services provided, and their outcomes. The second will study the psychodynamics of physicians' work to allow for a better understanding of the dynamics of problems such as stress, burnout, addiction and violence in the workplace. These efforts must be bolstered - other health providers are also impacted by mental illness and need support. The health care provider community needs help in terms of the reduction of stigma, access to resources and supportive environments. Conclusion I know some of what I have said today will have been familiar to members of the committee given the impressive list of roundtables, witness testimony and submissions you have reviewed already as part of your study on mental health. I only hope my comments will be of help in your important efforts and lead to real progress on addressing the largely unmet mental health and mental illness needs in Canada. Recommendations for Action CMA Submission to the Senate Social Affairs, Science and Technology 1. That the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act. 2. That, in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services. 3. That the federal government re-establishes an adequately resourced organizational unit focused on Mental Illness and Mental Health and addictions within Health Canada or the new Canadian Agency for Public Health. This new unit will coordinate mental health and mental illness program planning, policy coordination and delivery of mental health services in areas of federal jurisdiction. The unit would also work with provinces and territories, and the Canada Health Council to enact the National Action Plan endorsed at the National Summit on Mental Illness and Mental Health. Specific responsibilities would include fostering research through federal bodies such as the Canadian Institute for Health Research (CIHR), and disseminating best practices in the provision of mental health programs and services in Canada. 4. That the federal government review federal policies such as disability policy, tax policy, income support policy to ensure that mental illness is on par in terms of benefits with other chronic diseases and disabilities. 5. That the federal government work with the provinces and territories and the Canadian Alliance on Mental Illness and Mental Health to develop an effective national public awareness strategy to reduce the stigma associated with mental illnesses and addictions in Canadian society.
Letter to the Honourable Pierre Pettigrew on mandatory retirement
Dear Minister: On behalf of the Canadian Medical Association, I am writing to highlight the concerns of our members regarding the issue of mandatory retirement for physicians practicing medicine in Canada. The sustained interest in this subject follows as a result of a resolution adopted by the CMA General Council on August 20, 2003. This resolution reads "that CMA, its divisions and affiliates advocate for the enactment of regulations and/or legislation that will prevent mandatory retirement of physicians based on age." Your predecessor, the Honourable Anne McLellan, requested further information from the CMA with regard to the aforementioned legislation, for the purposes of further discussion with provincial counterparts. Currently, rules governing mandatory retirement of physicians are complex and vary across jurisdictions. Nationally, the Canadian Human Rights Act governs mandatory retirement only insofar as physicians are considered employees of a federally regulated sector. The Act states that mandatory retirement is not discriminatory when a person has "reached the normal age of retirement for employees performing similar types of work." Provincially/territorially, human rights legislation varies from jurisdiction to jurisdiction. In general, employers are not allowed to discriminate on the basis of age, although some provinces and territories only protect employees to the age of 65. Most physicians however, operate as self-employed business persons, billing provincial Medicare plans on a fee-for-service basis, according to tariffs agreed upon by provincial medical associations. This means that human rights legislation does not protect most physicians. Therefore, while physicians are still free to practice medicine after they reach the age of 65 (i.e. contract to provide medical care to patients, and bill the provincial insurer for insured services), renewal of their admitting privileges depends on the policies or regulations of individual hospitals. In light of the evidence supporting an existing shortage of physicians, federal and provincial/territorial decision makers should be acutely aware of the detrimental effect mandatory retirement has with regard to health human resource planning initiatives. Currently, 10.7% of practising Canadian physicians are over the age of 65. Many of these physicians practice quite actively. In 2003, a CMA survey indicated that physicians over 65 reported working on average 46 hours per week, excluding on-call responsibilities. To remove this experienced cohort of practitioners from the practice setting would be to further exacerbate the growing medical professional shortage. It is shortsighted to uphold restrictions on the practice of medicine by physicians, solely on the basis of age. Continuing professional development for practicing physicians throughout their medical careers is mandated by both the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada as a requirement of maintenance of certification. In a system which self-regulates based on competency, barriers to practice that are age-based are both unnecessary and discriminatory. The CMA respectfully requests you to follow the lead of your predecessor and raise the issue of mandatory retirement with your provincial/territorial counterparts. There should be no disparity nation wide; age-based barriers to practicing medicine should not be tolerated for physician employees or independent contractors alike. In some cases, federal, provincial and territorial human rights legislation may need to be amended. Equally as important, these concerns must be factored into discussions around health human resource planning. Thank you for your time and interest in this very important matter. We look forward with anticipation to your response. For your information, a more detailed account of mandatory retirement follows in the addendum to this letter. Should you have any further questions, I would be pleased to discuss this issue in further detail with you and your staff. Sincerely, Dr. Sunil Patel President, Canadian Medical Association cc: Presidents, Provincial / Territorial Medical Associations BACKGROUNDER: MANDATORY RETIREMENT Preface: Since its introduction in 1884 by German Chancellor Otto von Bismarck, the age of 65 has become firmly entrenched as "retirement age". Mandatory retirement can be considered a form of discrimination or bias, insofar as scientific data does not support the principle of retirement on the basis of attainment of a specific chronological age. While human rights legislation governs the mandatory age of retirement for employees (including some physicians) with variations from province to province, the extent to which provincial human rights legislation applies to the mandatory retirement of physicians varies, depending on whether the physician is an employee of the hospital or an independent contractor. Legislative and regulatory framework: Human Rights Legislation vis-à-vis Mandatory Retirement Federal and provincial/territorial human rights legislation govern mandatory retirement for physician employees, depending on whether their employers are under federal or provincial jurisdiction. As most health institutions are under provincial jurisdiction, the vast majority of physician employees are protected by provincial human rights legislation. Each province and territory has enacted human rights legislation that governs in their respective areas of jurisdiction. The legislation tends to be analogous from one province to the next, but there are differences worth noting. Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of seven provinces and territories. Four provinces do not consider mandatory retirement to be discrimination if the employee is 65 years or older. In two provinces, if mandatory retirement is provided for in a retirement or pension plan, it does not amount to discrimination. Jurisdiction Provisions governing mandatory retirement age Canada Mandatory retirement is not a discriminatory practice when a person has reached the normal retirement age for employees performing the same type of work. Consequently, in that case, the Act allows for mandatory retirement. Alberta Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this province. British Columbia Older employees are protected until the age of 65 against discrimination based on age. Consequently, employees aged 65 or over cannot file a complaint if they are obliged to retire for that reason. Manitoba Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this province. New Brunswick Termination of employment provided for in a retirement or pension plan does not constitute a discriminatory measure. In the absence of such a plan, however, employees who are obliged to retire may file a complaint for discrimination based on age, under the legislation on human rights. Newfoundland and Labrador Termination of employment provided for in a retirement or pension plan does not constitute a discriminatory measure. In the absence of such a plan, however, employees who are obliged to retire may file a complaint for discrimination based on age. They may use this recourse until the age of 65. Jurisdiction Provisions governing mandatory retirement age Northwest Territories Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this territory. Nova Scotia Mandatory retirement at age 65 does not constitute a discriminatory measure if it is standard in the workplace in question. However, the Human Rights Commission of this province investigates when an employee aged 65 or over is not treated in the same manner as others of the same age where retirement is concerned. Nunavut Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this territory. Ontario Older employees are protected against age-based discrimination up to the age of 65. Consequently, employees aged 65 or over cannot file a complaint if they are obliged to retire for this reason. Prince Edward Island Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this province. Quebec Mandatory retirement constitutes a form of discrimination according to the Charter of Human Rights and Freedoms and, more explicitly, is forbidden by the Act Respecting Labour Standards. Saskatchewan Older employees are protected against age-based discrimination up to the age of 65. Consequently, employees aged 65 or over cannot file a complaint if they are obliged to retire for this reason. Yukon Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this territory. Employment Status of Practicing Physicians Most physicians operate as independent contractors, billing provincial Medicare plans on a fee-for-service basis. Human rights legislation therefore does not protect the majority of physicians because the application of the legislation is limited to certain specific relationships, such as the traditional employment relationship. In other words, since physicians are more likely to be engaged by their patients to provide care than by the hospitals in which they provide it, the relationship between physicians and hospitals is more similar to a service contract than to a traditional employment contract. As a result, physicians who are independent contractors are free to practice medicine after they reach the age of 65. Depending on the hospital specific regulatory framework however, physicians may or may not be allowed to maintain their admitting privileges. Colleges of Physicians and Surgeons Regulatory bodies that license physicians do not place any restrictions on physician practice based solely on age. The Colleges of Physicians and Surgeons are not involved in administering hospital admitting privileges. None of the provincial or territorial colleges restrict licenses to practice medicine on the basis of a physician's age. Physicians who are employed in a traditional employment or master/servant relationship are covered by applicable human rights legislation, depending on whether their employers are federally or provincially/ territorially regulated. This means that some physicians can be forced into retirement at the age of 65, while others cannot. Policy Considerations: The Changing Physician Workforce Mandatory age-based retirement for health care workers has been a contested policy for almost 25 years. The issue assumes significant value for the CMA membership. Most physicians, operating as independent contractors, are not protected by human rights legislation in terms of retirement. Hospital admitting privileges are administered by the individual institutions, and renewal of such privileges may be subject to hospital policies on mandatory retirement. As more and more physicians choose to work in a traditional employment situation, the lack of human rights protection for physicians in private practice will be thrown in sharp relief. Health Human Resources Labour shortages challenge arguments for mandatory retirement. The health sector in particular has been hit hard by human resource shortages, which are predicted to increase as the baby-boom generation begins to retire in 2012. According to a study released by the Institute for Research on Public Policy (IRPP), challenges associated with the aging workforce in Canada will require greater flexibility, by way of removing barriers to labour force participation among individuals nearing retirement.1 Physician Health and Wellbeing For many people, employment provides a fundamental sense of dignity and self-worth. Practicing medicine promotes independence, security, self-esteem and a sense of participation in the community. Involuntary termination of employment can cause psychological and emotional distress. Physician malaise is a burgeoning concern and its address has become a strategic priority for the Canadian Medical Association. Protection of physicians, be they employees or independent contractors, from mandatory retirement is a strategy which would see one dimension of physician anxiety diminished and would therefore be supported by the CMA. Mandatory retirement can have a particularly serious financial impact on physicians. Employer pension plans are often not available in employment relationships which feature part-time or provisional employees. In order to secure or maintain their standard of living upon retirement, physicians must save extensively via RRSPs or private pension plans. Those physicians with family members to support, such as young adults in post secondary education, children with disabilities, or older family members fear that they will not be able to do so if forced to leave the practice of medicine. Liability Issues While the threat of malpractice may present as one logical argument in support of a mandatory retirement age, the statistics do not support such a claim. The Canadian Medical Protective Association (CMPA) maintains that there is no significant correlation between physicians' physical age and the corresponding number of lawsuits. Dr. Norman Brown of the CMPA notes that of the over 500 new lawsuits a year, there is not a significant number involving elderly physicians. Conclusion: The public interest is best served by ensuring that all competent physicians, regardless of age, are able to practice medicine. Artificial barriers to practice based on age are simply discriminatory and counter productive in an era of health human resource shortages. 1 Merette, Marcel. (2003) "The Bright Side: A Positive View on the Economics of Aging." Institute for Research on Public Policy. Nov 18/03.
Rural and remote practice issues
Promoting medicine as a career for rural high school students (Resolution BD88-03-78)
CMA Policy : Rural and Remote Practice Issues The Canadian Medical Association (CMA) believes that all Canadians should have reasonable access to uniform, high quality medical care. The CMA is concerned, however, that the health care infrastructure and level of professional support in rural and remote areas are insufficient to provide quality care and retain and recruit physicians relative to community needs. The CMA has developed this policy to outline specific issues and recommendations that may help retain and recruit physicians to rural and remote areas of Canada and thereby improve the health status of rural and remote populations. The following 3 key issue areas are addressed in this policy: training, compensation and work/lifestyle support. Commitment and action by all stakeholders, including governments, medical schools, professional associations and others, are urgently required. Preamble Canadian physicians and other health care professionals are greatly frustrated by the impact that health care budget cuts and reorganization have had, and continue to have, on the timely provision of quality care to patients and general working conditions. For many physicians who practise in rural and remote communities, the impact is exacerbated by the breadth of their practice, as well as long working hours, geographic isolation, and lack of professional backup and access to specialist services. This policy has been prepared to help governments, policy-makers, communities and others involved in the retention and recruitment of physicians understand the various professional and personal factors that must be addressed to retain and recruit physicians to rural and remote areas of Canada. This policy applies to both general practitioners/family physicians as well as specialists. The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to Physician Health and Wellbeing, Physician Compensation, Physician Resource Planning, Principles for a Re-entry System in Canadian Postgraduate Medical Education and Charter for Physicians. In addition, any strategies that are developed should not be coercive and must include community and physician input; they must also be comprehensive, flexible and varied to meet and respond to local needs and interests. Definitions Rural and remote There are no standard, broadly accepted terms or definitions for "rural" and "remote" since they cannot be sufficiently defined to reflect the unique and dynamic nature of the various regions and communities that could presumably be labelled as such. The terms "rural" or "remote" medicine may be applied to many things: the physicians themselves, the population they serve, the geography of the community or access to medical services. For each of these factors, there are a number of ways to define and measure rurality. For example, a 1999 CMA survey of rural physicians showed that the most frequently mentioned characteristics of a rural community were (1) high level of on-call responsibilities, (2) long distance to a secondary referral centre, (3) lack of specialist services and (4) insufficient family physicians. As another example, Statistics Canada defines rural and small town residents for some analyses as those living in communities outside Census Metropolitan Areas (population of at least 100 000) or Census Agglomerations (population between 10 000 and 99 999), and where less than 50% of the workforce commute to a larger urban centre. Medical school For the purposes of this policy, a medical school is understood to encompass the entire continuum of medical education, i.e., undergraduate, postgraduate, continuing medical education and maintenance of competence. Training Some Canadian studies have shown that medical trainees who were raised in rural communities have a greater tendency to return to these or similar communities to practise medicine. Some studies also show that individuals who do clerkships in rural or remote communities, or have some exposure to the rural practice environment during residency training, have a greater tendency to consider practising in rural or remote communities upon graduation. The CMA applauds those medical schools that promote careers in medicine to individuals from rural and remote areas and provide medical students and residents with exposure to rural practice during their training. Regular collaboration and communication among training directors for rural and remote programs, as well as rural medical educators and leaders from other health disciplines, are strongly encouraged so that rural training issues and possible linkages may be discussed. The benefits of rural training extend not only to those physicians who ultimately end up in rural practice; those who remain in urban areas also benefit by having an enhanced understanding of the challenges of rural and remote practice. As outlined in the CMA's 1992 Report of the Advisory Panel on the Provision of Medical Services in Underserviced Regions, the CMA believes that partnerships among medical schools, the practising profession and communities need to be formalized, particularly since medical schools have a crucial role in helping to recruit and retain physicians for rural and remote communities. The medical school's role in such a partnership takes the form of a social contract. This contract begins with the admission of students who demonstrate a prior interest in working in rural or remote communities and may come from these communities. It also includes the exposure of students to rural practice during their undergraduate and postgraduate training. It is followed by the provision of specialized training for the conditions in which they will work and ongoing educational support during their rural and remote practice. For these reasons, the CMA strongly encourages academic health science centres (AHSCs), provincial governments, professional associations and rural communities to work together to formally define the geographic regions for which each AHSC is responsible. The AHSCs are also encouraged to include within their mission a social contract to contribute to meeting the health needs of their rural or remote populations. Practising physicians are committed to lifelong learning. In order to preserve a high standard of quality care to their patients, they must be knowledgeable about new clinical and technological advances in medicine; they must also continually develop advanced or additional clinical skills in, for example, obstetrics, general surgery and anaesthesia, to better serve the patients in their communities, especially when specialist services are not readily available. There are many practical and financial barriers that physicians in rural and remote communities face in obtaining and maintaining additional skills training, including housing, practice and other costs (e.g., locum tenens replacement expenses) while they are away from work. The CMA strongly encourages governments to develop and maintain mechanisms, such as compensation or additional tax relief, to reduce the barriers associated with obtaining advanced or additional skills training. In light of these issues, the CMA recommends that 1. Universities, governments and others encourage and fund research into criteria that predispose students to select and succeed in rural practice. 2. All medical students, as early as possible at the undergraduate level, be exposed to appropriately funded and accredited rural practice environments. 3. Medical schools develop training programs that encourage and promote the selection of rural practice as a career. 4. Universities work with professional associations, governments and rural communities to determine the barriers that prevent rural students from entering the profession, and take appropriate action to eliminate or reduce these barriers. 5. A Web site based compendium of rural experiences and electives for medical students be developed, maintained and adequately funded. 6. Advanced skills acquisition and maintenance opportunities be provided to physicians practising in or going to rural and remote areas. 7. CMA divisions and provincial/territorial governments ensure that physicians who work in rural and remote areas receive full remuneration while obtaining advanced skills, including support for the locum tenens who will replace them. 8. Any individual formally enrolled in a Royal College of Physicians of Surgeons of Canada or College of Family Physicians of Canada program be covered by the collective agreement of their housestaff organization. 9. Providers, funders and accreditors of continuing medical education for rural physicians ensure that the continuing medical education is developed in close collaboration with rural physicians and is accessible, needs-based and reflective of rural physicians' scope of practice. 10. Physicians who practise in rural or remote areas be given reasonable opportunities to re-enter training in a postgraduate program without any return-in-service obligations. 11. In order to promote mutual understanding, universities encourage teaching faculty to work in rural practices and that rural physicians be invited to teach in academic health science centres. 12. Medical schools develop training programs for both students and residents that encourage and promote the provision of skills appropriate to rural practice needs. 13. Medical schools support rural faculty development and provide full faculty status to these individuals. Compensation The CMA believes that compensation for physicians who practise in rural and remote areas must be flexible and reflect the full spectrum of professional and personal factors that are often inherent to practising and living in such a setting. These professional factors may include long working hours and the need for additional competencies to meet community needs, such as advanced obstetrics, anaesthesia and general surgery, as well as psychotherapy and chemotherapy. They may also include a high level of on-call responsibilities as well as a lack or total absence of backup from specialists, nurses and other complementary services that are usually available in an urban environment. Other challenges are professional isolation, limited opportunities for education or training, and high practice start-up costs. Also, if for a number of reasons a physician wishes to relocate to an urban setting, he or she may face billing restrictions as well as challenges in finding a replacement physician. Compensation for these factors is necessary to help retain physicians and recruit new ones. In addition, compensation should guarantee protected time off, paid continuing medical education or additional skills training, and locum tenens coverage. Any pool of locum tenens for rural and remote practice should be adequately funded and cross-jurisdictional licensure issues should be minimized. Living in a rural or remote community can be very satisfying for many physicians and their families; however, they must usually forgo — often for an extended period of time— a number of urban advantages and amenities. These include educational, cultural, recreational and social opportunities for their spouse or partner, their children and themselves. They may also face altered family dynamics due to a decrease or significant loss of family income if there are limited or no suitable employment opportunities for their spouse or partner. The CMA believes that all physicians should have a choice of payment options and service delivery models to reflect their needs as well as those of their patients. Physicians must receive fair and equitable remuneration and have a practice environment that allows for a reasonable quality of life. Although the CMA does not advocate one payment system for urban physicians and another for rural physicians, it believes that enhanced total compensation should be provided to physicians who work and live in rural and remote communities. In recognition of these issues, the CMA recommends that 14. Additional compensation to physicians working in rural and remote areas reflect the following areas: degree of isolation, level of responsibility, frequency of on-call, breadth of practice and additional skills. 15. In recognition of the differences among communities, payment modalities retain flexibility and reflect community needs and physician choice. 16. Financial incentives focus on retaining physicians currently practising in rural or remote areas and include a retention bonus based on duration of service. 17. Factors affecting the social and professional isolation of physicians and their families be considered in the development of compensation packages and working conditions. 18. Eligibility criteria for including physicians in a pool of locum tenens for rural or remote practice be developed in consultation with rural physicians. 19. Provincial/territorial licensing bodies establish portability of licensure for locum tenens and ensure that any fees or processes associated with licensure do not serve as barriers to interprovincial mobility. 20. Rural locum tenens programs be funded by provincial/territorial governments and include adequate compensation for accommodation, transportation and remuneration. As previously noted, some studies show that exposure to rural and remote areas during training influences students' decision to practise in those communities upon graduation. The CMA is concerned, however, that travel and accommodation costs relating to these experiences place an undue financial burden on students. In addition, most physicians in rural and remote areas are already burdened with significant patient loads and find that they have limited time and resources to act as preceptors. The CMA believes that, to ensure the ongoing viability of student rural experiences, physician preceptors should be compensated for their participation and should not incur any additional expenses, such as student or resident accommodation costs. The CMA recommends that 21. Costs for accommodation and travel for student and resident rural training experiences in Canada not be borne by the trainees or the preceptors. 22. Training programs assume responsibility for adequately remunerating preceptors in rural or remote areas. Work and lifestyle support issues To retain and recruit physicians in rural and remote communities, there are issues beyond fair and adequate compensation that must be considered. It is crucial that the aforementioned working conditions, professional issues and array of personal and family-related issues be addressed. The ultimate goal should be to promote physician retention and implement measures that reduce the possibility of physician burnout. Like most people, physicians want to balance their professional and personal responsibilities to allow for a reasonable quality of life. Physicians in rural and remote areas practise in high stress environments that can negatively affect their health and well-being; as a consequence, the standard of care to their patients can suffer. The stress is intensified by excessive work hours, limited professional backup or support (including locum tenens), limited access to specialists, inadequate diagnostic and treatment resources, and limited or no opportunity for vacation or personal leave. At particular risk for burnout is the physician who practises in isolation. For these reasons many physicians, when considering practice opportunities, tend to seek working conditions that will not generate an excessive toll on their non-working lives. This reinforces the need for rural and remote practice environments that facilitate a balance between physicians' professional and personal lives. In light of these issues, the CMA recommends that 23. Regardless of community size, there should always be at least 2 physicians available to serve the needs of the community. 24. Ideally, the on-call requirement for weekends never exceed 1 in 5 in any Canadian practice. (This is consistent with current CMA policy.) 25. Provincial/territorial governments have professional support and other mechanisms readily available to physicians who practise in rural and remote areas, such as sabbaticals and locum tenens. 26. Governments recognize the service of rural and remote physicians by ensuring that mechanisms exist to allow future access to practise in an urban area of their choice. The CMA believes that rural and remote physician retention and recruitment initiatives must address matters relating to professional isolation as well as social isolation for physicians and their families. This sense of isolation can increase when there are cultural, religious or other differences. For unattached physicians, zero tolerance and unreasonable restrictions with regard to relationships with potential patients can be disincentives to practise in rural or remote communities. Although the CMA believes that such policies and restrictions should be reviewed, the CMA encourages physicians to refer to the CMA policy on The Patient-Physician Relationship and the Sexual Abuse of Patients and the Code of Ethics of the Canadian Medical Association. Also, the CMA recommends that physicians abide by any provincial/territorial policies or legislation that may currently be in place. The medical services infrastructure in rural and remote areas is usually very different from that in urban settings. In addition to a lack of specialist services, physicians in these areas may often have to cope with a number of other factors such as limited or no appropriate diagnostic equipment or limited hospital beds. Physicians and their patients expect and deserve quality care. The diversity and needs of the populations, as well as the needs of the physicians who practise in rural and remote areas, must also be recognized and reflected in the infrastructure (e.g., demographic and geographical considerations). The CMA recommends that 27. A basic medical services infrastructure for rural and remote areas be defined, such as hospital beds, paramedical staff, diagnostic equipment, transportation, ready access to secondary and tertiary services, as well as information technology tools and support. 28. Provincial/territorial governments recognize that physicians who work in rural and remote areas need an environment that appropriately supports them in providing service to the local population.