Mini-Med at McGill: Question and Answer Corner

Mini-Med Study Corner

Professionalism and Medicine's Social Contract
Drs. Richard Cruess and Sylvia Cruess

Written Question and Answer Section:

1. While the medical professionals are doing their best to provide services to society, it appears that in Quebec and other parts of Canada, the current system is not working well. What can we as consumers do to improve this situation?

This is of course an extremely difficult issue in large part because of the complexity of health care. It is basically the continual increase in cost that creates the pressures on the system. Individuals must attempt to understand the issues and develop their own opinions. Obviously, there is an individual obligation not to overuse the health care system. Timely access to appropriate care is what the population wants and the profession wishes to deliver. Since the health care system is so tightly bound to the political process, the solutions must be political. As we said during the talk, there should be a natural alliance between the medical profession and the public which it serves on these issues. A dialog must take place on the place of the private sector in Canadian health care, something which thus far has not really occurred. An example of an issue with which the public and the profession could address together is the shortage of physicians and other health care professions, which are being controlled with excessive rigor and not enough wisdom.

2. Would you please comment on Clinical Trials and the safeguards that are in place to protect participants?

Clinical trials are a necessary part of developing new therapies, and their presence in any community brings access to the most up-to-date treatments to the population served. For those reasons, they represent an advantage to the community. However, it is essential that the public be protected and that public participation in these trials be truly voluntary. It is important that truly informed consent be obtained, and there are rules and regulations at both the hospital and university level which attempt to accomplish this as well as ensure that the trials are scientifically sound. Trials carried out outside of these domains are more difficult to control. Both hospitals and universities have review boards which must approve of all research protocols involving humans including clinical trials. There are also special rules and regulations for those who are not capable of giving consent-children, the disadvantaged, and those with mental illness. A major issue is financial conflicts of interest of health care professionals who often have a financial incentive to recruit patients. The rules are designed to force disclosure and to regulate this area. These rules have been strengthened during recent years and are much more effective now than they were. However, constant vigilance is required in order that patients be protected.

3. With the shortage of Physicians in general and Family Physicians in particular, what are your thoughts on the licensing of foreign trained doctors in Quebec?

The basic issue relates to both fairness and equity and protecting the public. Without question recent immigrants with medical degrees have a very difficult time breaking into the system. Some of some of them are well-qualified, while others have medical degrees which are not the equivalent of those in Québec and Canada. The qualifying examination is a part of the process designed to choose those who are capable and proceeding for further training. However, passing an examination does not mean that an individual is capable of practicing medicine. The examination cannot assess the personal qualifications involved in the art of medicine. For this reason, interviews and other means are used to try and select those who are deemed capable of receiving training. Obviously, neither the examination or the interviews are perfect, but they are designed to try and protect the public. Another issue relates to the difficulty involved in training individuals who often have language difficulties and different knowledge bases. The slots allocated do not come with sufficient resources to provide the extra personnel required to give the hours required for supplementary training. Our personal feeling is that there is an opportunity to accept more of these potentially valuable physicians than has occurred. However the issues are obviously complex.

* During the lecture you used the term fiduciary, would you please elaborate on the meaning of this word.

The word fiduciary has a powerful meaning in medicine. Physicians are described as having a fiduciary duty to their patients. The dictionary definitions associate fiduciary with trust, and this trust must not be betrayed. The patient has no option but to believe in the professional and to trust that the professional will act in a way that puts the patient's interests above their own. There is a legal aspect to the term, because maintaining this fiduciary duty has been found to be a professional obligation by the courts.

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