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Visiting Professorship in Medical Citizenship

2017 dates: March 20-24
Dr. Nadine Caron

 

Please note: The Department of Bioethics is hosting this information as a courtesy. The Bioethics secretary does not have any further information than is posted in this website. For more information, please email vpmc@dal.ca. Thank you.

See the 2017 Schedule

See the Call for Proposals

For information on previous schedules of events, choose a year below:


What is medical citizenship?

Every doctor's voice matters.

Medical citizenship means every doctor should have a voice and should use it, and every doctor’s voice matters. If doctors cannot speak out, we have a problem.

• Have you ever wanted to speak your mind on a difficult topic but felt peer pressure not to be seen as ‘stirring the pot’?
• Have you ever stayed silent on an issue because you felt that speaking your mind might result in making enemies with the administration of your institution?
• Do you work in a group with a dynamic such that raising ethical concerns or expressing honest dissent can result in you, a colleague or another doctor being marginalized?
• Do you feel that the person you report to has seemingly unchecked power over your working life, such that you would not want to cross them by expressing an unpopular opinion?

If any of these applies to you, it suggests you are actively struggling with issues central to medical citizenship in your daily work. If you do not have an opportunity to discuss these issues in your workplace, it suggests these issues are not being acknowledged, and if they are not acknowledged they cannot be addressed.

At the broadest, medical citizenship is meant to encompass the range of activities that doctors may take to improve patient care, contribute to their communities in their professional capacity, and effect changes within the medical profession itself. It is about the quandaries that doctors can find themselves in during the course of simply doing their job, taking care of patients, working in hospitals, managing limited resources, teaching students and participating in research. Medical citizenship is about how you respond to the ethical challenges that individual doctors can expect to encounter during their working careers. It is also about what you do with the preconceptions, concerns and fears that many doctors have when they recognize they are involved in an ethically difficult situation and they contemplate what next steps might be appropriate, as well as what might happen if they voice their concerns.

Current context for medical citizenship

The loss of doctors' voices in health care

Doctors are expected to advocate for patients and quality healthcare. The importance of physician advocacy is enshrined in the CMA Code of Ethics, as well as being one of the seven roles in the CanMEDS framework. As a profession each of us is required and expected to embed advocacy into our practice of medicine. However, we also work in hospital and university environments that are undergoing increasing corporatization. Furthermore, health care in Canada is publicly funded, resulting in politicization of the process of resource allocation. Corporations, universities, government and elected officials play key roles in the leadership and functioning of the health care system, and yet each of them – like doctors - is vulnerable to conflicts of interests. Doctors interface with patients, as well as each of these other entities, in the process of delivering care to their patients. Doctors also have a duty to advocate for their patients and if necessary ‘blow the whistle’ on conduct of individuals or institutions/corporate bodies that are not acting in their patients’ best interests. Doctors often learn that in trying to 'do the right thing' or even 'just do their job', they may run afoul of those in positions of power in their working environment. In addition, post hoc examination of health care scandals often reveals that a significant number of doctors and health care professionals would have had to ‘turn a blind eye’ to troubling occurrences and events, for the situation to have escalated to the status of a public scandal.

Examples of such events in Canada in recent years include the Newfoundland breast cancer scandal, the case of the forensic pathologist Dr Charles Smith in Toronto, the abuse of power against doctor whistleblowers in Alberta, and the case of Dr Nancy Olivieri in Toronto (recent recipient of an honorary degree from Dalhousie University).

So what are doctors to do when they identify an ethics issue and become concerned that those in authority in their hospital or university or government cannot be counted on to act ethically or enforce good ethical standards? What supports can they access if they find themselves in conflict with administrators, politicians or colleagues? What should a doctor do when they see an individual or group being treated unjustly by the hospital or university?

Adding further complexity, how should a doctor address and work through situations where colleagues have differing opinions and perspectives on ‘the right thing to do’? How might this influence and shape how doctors work together in the organizational context? How should a doctor analyze, understand and act on conflicts of interest in the health care environment where power imbalances are also at play? How does a doctor balance conflicts in their role as a health care professional versus their role in a health care organization (hospital or university)? These are issues that are not traditionally acknowledged, aired or addressed in medical training or continuing medical education.
 

What are the appropriate mechanisms for addressing these issues?

What if these avenues don't work?

Hospital and university administrations have undergone rapid corporatization and commercialization over the last decade or so. As a result the old collegial, consensus style of governance has been replaced by a corporate model. Corporate governance typically places high value on loyalty to the administration. Doctors have a relatively limited voice in these new governance structures, and the doctors who become administrators are under pressure to conform to the administration’s values. A local (Capital Health) survey points to concerning levels of distrust and cynicism on the part of doctors towards hospital administrators.

One would think that medical staff associations and our provincial and national advocacy groups would be the natural place for doctors to turn for assistance in dealing with ethical dilemmas. However, local experience has shown that participation in the work of these organizations is not what it could be, and the central issues of medical citizenship have not been taken up by these organizations. For some reason we as doctors often do not come together effectively in supporting our patients and each other through established advocacy groups. Perhaps the reason for this lies in the fact that the full range of advocacy for all doctors in a complex healthcare system cannot be undertaken by one or two centralized groups. Perhaps the important voices of doctors often cannot be represented as one voice, and doctors concerns cannot easily be distilled into a few key issues. While we certainly have commonalities, perhaps institutions, decision makers and society need access to the views, passion and knowledgeable input of the full breadth and depth of our profession. Overall, while it is acknowledged that important changes are being made in our communities and in patient care as a result of centralized physician advocacy, it is not clear that doctors are always able to find appropriate and/or receptive ways to address their concerns. It would seem that the input of all members of our profession, in large ways and small, is needed for our healthcare system to optimally serve our patients.
 

What could be done to change all this?

A core principal of medical citizenship is that each of us has an important part to play in advocacy. As doctors, we should all have a role in shaping and improving our health care system. We all have a key responsibility in creating processes, frameworks, and opportunities for all health care professionals to feel comfortable in voicing concerns and considerations about our health care system. In some ways, change will need to involve grassroots efforts based on professional codes of conduct and values. A grassroots effort will be needed to restore a healthy balance between centralized and individual physician advocacy.

The issues and challenges of medical citizenship are simply not discussed among doctors. As a group we do not acknowledge or study the barriers to medical citizenship. We are not well educated in organizational ethics, organizational psychology, the manifestations of workplace bullying and the procedural and legal issues around managing conflicts of interest in health care. Most of us do not have the vocabulary or theoretical framework to assess and call attention to these issues.

If we can educate ourselves and our students in these important areas, if we can create a culture where doctors are openly cognizant of barriers to medical citizenship, and have a theoretical framework to apply to these barriers, as well as a vocabulary to identify them, and knowledge on effective ways to call attention to and overcome them, we would have the skillsets to better advocate for our patients and the public interest. Shining a spotlight on medical citizenship will also challenge administrators and managers to acknowledge the problems engendered by constricting physician advocacy with respect to conflicts of interest in healthcare institutions. Public and frank discussions of the importance of medical citizenship would challenge administrators, managers and politician leaders to make space for the breadth and depth of doctors’ voices to be heard in healthcare debate.

The visiting professorship in medical citizenship is a place to start.

It's not just about doctors

Now more than ever, health care professionals work in teams. Advocacy is enshrined in the expected competencies of all health care professionals, and most if not all the issues of medical citizenship affect us all. Additionally, health care researchers of all professional backgrounds struggle with the conflicts of interest that arise in the institutions in which they work.

What you can do

• Let your colleagues know about this, start a discussion
• Support the Visiting Professorship by sending a donation either as an individual or group (email vpmc@dal.ca for details)
• Organize an event (see below)
• If you would like to help with an event but do not feel able to be a team leader, contact us and we will try to put you in touch with an established team (email vpmc@dal.ca)

Would you like to help sponsor the VPMC?

If you or a group you are part of (division, department or other organization) would like to help sponsor this event please email us at vpmc@dal.ca. We are entirely dependent on donations to fund travel and accommodation for our visiting professor.
 

Would you like to be a member of the VPMC steering committee?

Please email us at vpmc@dal.ca and let us know why you are interested on serving on this committee.

Any questions?
Email us at vpmc@dal.ca