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CMA Members' Forum 2013 - questions and responses

Monday, Aug. 19, 2013
2:15-3:30 p.m.
Calgary, Alberta

1. Question from the Floor (AB)

There are lab tests to determine whether certain drugs will be effective for certain cancers. Yet, there is currently no funding for these tests. Would the CMA consider lobbying the federal government for funding of lab tests that help determine whether a particular drug is good for a patient? Otherwise, patients must pay for this $1,000 lab work out-of- pocket. There is a role for talking to the federal government about this.

Response: CMA President, Dr. Anna Reid
An additional issue is the availability of expensive drugs for some patients. The work CMA has done is starting to have an impact on these pharmaceutical issues. What is needed is a national program to help fund these drugs and lab work. Your question ties into entire pharmaceutical issue which the CMA is working on.

2. Question from the floor (AB)

The CMA has been asked about its view on physician-assisted death and it is clear that members are being consulted. Is there a current official CMA position on this issue?

Response: CMA President, Dr. Anna Reid The CMA has a policy on euthanasia and physician-assisted suicide. The policy states that we should not engage in these practices. However, the policy is 6 years old. This has now become an evolving societal issue, with the pending legislation in Quebec. For this reason, the CMA is revisiting the issue and starting the discussion.

3. Question from the floor (BC)

The Therapeutics Initiative is of great value and may not be well known. It is an academic pharmaceutical oversight organization that reviews evidence and advises government on BC's provincial pharmacare formulary. It also produces amazing CME and provides an alternative based on statistics and risk-reduction for newer drugs. Unfortunately, the provincial government has cut funding of the Therapeutics Initiative and has defaulted on the contract it had agreed upon. Any comment from members of the panel on their vision or what we physicians can do to speak up in terms of appropriateness and what our role is when existing institutions such as this one, with an international reputation, are threatened for funding?

Response: CMA President, Dr. Anna Reid
The CMA has been involved with the health care innovation group in the Council of the Federation, which has identified appropriateness of care as a major focus. The CMA has been forceful in these meetings that appropriateness should be about quality of care, not cost-cutting. This is certainly an issue that the CMA can take forward through the Health Care Innovation Working Group and the BC minister at that point.

4. Question received in advance (MB)

Will CMA's discussion on end-of-life care include how to address and understand patient wishes for organ and tissue donation in the process?

Response: CMA President, Dr. Anna Reid
Although the issue of organ and tissue donation is not part of the General Council discussion this year, the CMA is currently reviewing its policy on patient wishes for organ and tissue donation.

5. Question from the floor (ON)

When General Council met in Niagara Falls a few years ago, there was a motion regarding physicians getting a pension plan. Has the CMA Board followed up on this motion since then?

Response: CMA Treasurer, Dr. Brian Brodie
The issue of pensions is a complex one. Clearly, the CMA is interested in ensuring physicians' financial well-being. Members will be interested to know that the CMA is leading a coalition of 11 associations that represent over 1 million self-employed professionals. Various options are being looked at - some of which would require changes to the Income Tax Act and regulations. The coalition has looked at pooled retirement pension plans as a retirement vehicle for physicians, deferred income tax and increased RSP deduction limits for all Canadians, but particularly for physicians. Also looking at a requirement that registration for all retirement savings be voluntary rather than mandatory. Although progress is slow, the CMA and the coalition are active on the issue.

6. Question from the floor (NB)

In the past year, the NB Ministry of Health imposed a 4.55% cut in fee-for service pay, despite the existing contract in place. The NBMS was required to go to court to fight a battle, which was won. There are implications for other provinces and societies with what occurred in NB. What is the CMA's opinion regarding what could be done or their opinion regarding what happened in NB?

Response: CMA President, Dr. Anna Reid
Although the CMA is not involved in individual provincial negotiations, we wrote a letter of support for NB, indicating that physicians needed to be dealt with fairly in their negotiation process . The CMA wrote similar letters of support for OMA and the AMA, some of which were signed off by all PTMAs. The CMA has been active, as a move of principle and support.

7. Question from the floor (NB)

As a long-standing member, I believe the medical profession is better united than splintered. What is your strategy for communicating the fee increase to individual members who do not participate in this meeting to let them know and appreciate the value of CMA?

Response: CMA President, Dr. Anna Reid
The CMA has been reaching out to members to learn what they want. Certainly, the value of CMA will be enhanced by the rebuild that is currently under way. With the future customer relationship management system, your experience will be personalized on the new CMA website. This will definitely facilitate communications with our members.

Supplementary response: CMA President-elect, Dr. Louis H. Francescutti
In my inaugural speech on Wednesday, I will be sharing my communications map, which I plan to follow as your official spokesperson. I will subsequently be asking General Council to evaluate this presentation and roadmap. If members are agreeable, It will become the message that I and the other presidents will be taking forward to the CMA membership, as one unified message. This presentation will be available on the CMA website and available for downloading to members. As a profession, we have to look at CMA and value it. Many grassroots members don't value CMA for what it's worth. As your President, I plan to go on the road to talk about three main themes: Health Care Transformation (HCT), health equity and advocacy and three subthemes within each of those.

Supplementary response: CMA Treasurer, Dr. Brian Brodie
This is a great challenge. Many members struggle with articulating the value of membership. The CMA has a responsibility to resharpen the focus. Part of the messaging is to ensure synergy with MD Physician Services (MDPS). The two CEOs (CMA and MDPS) will be going out to meet with the members to discuss the value proposition.

Supplementary response: CMA Secretary General and CEO, Mr. Paul-Émile Cloutier
To supplement the responses already provided, all GC proceedings and a daily summary are posted on for those unable to attend General Council in person. There is a plan this year to improve engaging and communicating with our members. A lot going is going on at the moment with the Presidents' tour, but we will be doing a lot more going forward.

8. Question from the floor (ON)

Today at a Canadian Medical Foundation (CMF) luncheon, we heard about the importance of physicians being well and about the new Canadian Physician Health Institute (CPHI). Why is it that we haven't heard much about physician health and well-being in GC chambers? We are very proud of CMA for its leadership on physician health and wellness. The fact that we hear nothing, is it because it goes without saying or is there a change of direction or commitment from the CMA?

Response: CMA Board member, Dr. Gail Beck
In the past year, the thought of physician health and well-being was never far from the Board's mind and CMA is proud that Dr. Derek Puddester now heads up the CPHI initiative. "Walk the Doc" which is held at 6:00 a.m. at General Council, is another initiative to remind everyone to take care of themselves. Thank you for reminding us of its importance.

Supplementary response: CMA Past-President, Dr. John Haggie
The Newfoundland and Labrador Medical Association (NLMA) AGM was the rollout for the new CPHI; the fact that it isn't part of GC this year is no reflection of a lack of enthusiasm. It is an initiative which is being rolled out to all PTMAs. CMF is looking for a push in funds for the CPHI. Matters of the moment have simply pushed themselves to the front of the agenda.

Supplementary response: CMA President, Dr. Anna Reid
There certainly are plans for the CMA to further promote the CPHI and physician wellness. It is up to all of us in this room to keep this as a front conversation. Many of us may have struggled with this issue. CMA can take a leadership role. I personally challenge everyone in this room to look after their colleagues and themselves and their families.

9. Question from the floor (ON)

Today we heard about the proposed fee increase and how the physical infrastructure of the CMA building and computers require updating. Reserve funds were spent last year. Does CMA have a plan/timetable on how it will address the update of these tangible assets?
Response: CMA Treasurer, Dr. Brian Brodie
The issue was touched upon this morning during the treasurer's report. The pension liability will be better known next year. However, regarding the physical structure or refit, that discussion hasn't taken place yet. We estimate the cost to be around $250k per floor. The Finance Committee has attempted to take a 5-10 year strategic view on these expenses and it wants to be proactive. The costs will be funded out of operating expenses. The CMA does own significant assets, including two buildings which are mortgage free, but both need to be maintained.

10. Question received in advance (AB)

Would the CMA consider working on changing the CRA rules for expensing conferences? Currently, the Act says that we are only allowed to deduct two meetings a year as a business expense.
Response: CMA Treasurer, Dr. Brian Brodie

This limit of two conferences is concerning, given the requirements to remain accredited.

Many physicians are able to obtain CME credits close to home. In addition, there are many free CME courses available (e.g. CMA's online courses) and many physicians do readily acquire what they need within the limit of two deductible meetings a year, as imposed by CRA.

Thank you for your suggestion. CMA would like to see this suggestion incorporated into a package of tax changes that CMA can include in its next submission to the Pre-budget Finance Committee. We can include this and make sure the governments and CRA know that a maximum of 2 conferences per year is inadequate.

11. Question from the floor (BC)

How much does the average member know about the Value Proposition of the CMA? As a suggestion for a sales force: PTMA delegates should be funded and have a role to take the message on the road to meet with grassroots members.

Response: CMA Board Chair, Dr. Michael Golbey
This is an excellent suggestion and a terrific opportunity. Thank you for raising it.

12. Question/comment from the floor (ON)

Regarding scopes of practice - specifically reversing what I see occurring: There are currently positions posted for midwives only - some family physicians or Ob/Gyns might be interested in competing for this role which is more narrow and which may provide them with a better life balance. Yet, it seems physicians are being restricted for some of these positions.

Response: CMA Past-President, Dr. John Haggie
This question is timely. Many years ago, the CMA, in collaboration with the pharmacists, developed a document on scopes of practice. Attempts since then have failed. There are discussions about expanding scopes of practice for rural areas and narrowing down the scope in urban areas. CMA is looking at revisiting its policy and is interested in knowing what members think about the issue of scope of practice. Some feel the CMA has been too quiet on the issue.

13. Question from the floor (AB)

Is my understanding correct that dividends paid to CMA by MD Physician Services make up 20% of CMA revenue?

Response: CMA Treasurer, Dr. Brian Brodie
The dividends received from MDPS account of under $6 million, which represents about 15% of CMA revenue.

Supplementary comment: It is also my understanding that staff of medical clinic are eligible to access MD Physician Services. CMA could do a better job of promoting this, which could result in increased revenue. Most physicians in the room are probably unaware that their employees are eligible for this benefit.

Response: CMA Treasurer, Dr. Brian Brodie
The best we can be as ambassadors for our professional association is to talk about the products and services that are of value. MD Physician Services would be thrilled if we could be more vocal in telling others about the great offering. They totally understand what we physicians are about. They provide a great level of personalized service at a great rate.

14. Question from the floor (AB)

In response to Dr. Haggie's question about scope of practice: We as physicians have neglected to be responsive to the needs of society. We need to be more understanding of our patients' needs and less focused on the physician's rights and privileges. We need to keep in balance what's expected of us. We have known about the aging population and yet it has taken us 20 years to bring it to the stage. Why is that? The time has come to look at our scope of practice and change and/or preserve it, i.e., preserve family practice. Do we not want to stop and think? Have we not allowed our scope of practice to respond to the needs of society?

15. Supplementary question from the floor (AB)

Regarding End of life: it is encouraging to hear terms like late life care and terms like terminal care versus palliative care. However, some terms also lead to confusion. I hope CMA can help clarify terms such as euthanasia versus end-of-life care, versus palliative care versus physician assisted suicide and versus physician assisted death. I can only see more confusion down the road.

Response: CMA President, Dr. Anna Reid
The role of CMA General Council is to hear what delegates have to say from the floor and through motions directing us to make policy. If we are directed through a motion, we proceed and do so.

16. Question from the floor (NS)

Regarding the for-profit plasma clinics that are poised to open in Canada: Should they be allowed to open, there would be a change in policy following the Krever inquiry as well as a change in practice to allow for-profit companies to pay people for their plasma - without a clear benefit to Canadians. Given the national implication of whether there needs to be federal then provincial approval, has the CMA taken a position on the opening of these for-profit plasma clinics?

Response: CMA President, Dr. Anna Reid
The CMA hasn't yet begun that discussion, but thank you, as we will keep it in mind.

17. Question from the floor (NB)

Where do we stand currently with the government's plan to change federal government money transfers to per capita funding. NB has the most chronic disease rate, the oldest population and the highest chronic disease rate.

Response: CMA Secretary General and CEO, Mr. Paul-Émile Cloutier
This issue was recently discussed at the Presidents' Forum that brings together presidents of provincial and territorial medical associations [PTMAs]. A draft document has been prepared, but hasn't yet been finalized. If there is a consensus among PTMAs, CMA will certainly push forward with recommendations to the federal government, but the document first needs to come back to PTMAs for agreement.

Supplementary response: CMA President, Dr. Anna Reid
This issue came up informally through the Council of the Federation. It is difficult to get consensus as it affects all of us in all provinces, but we are working on it.

18. Advance question (ON)

Could you list the last three innovative changes that occurred directly due to CMA Leadership?

Response: CMA President, Dr. Anna Reid
Among others, the CMA is currently working with the Council of the Federation on the issue of clinical appropriateness, and exploring the potential for initiatives such as Choosing Wisely in the Canadian context. There have also been a number of initiatives to address the social determinants of health, such as a physician guide for addressing health inequalities in practice, launched earlier this year, as well as the 2012 launch of a referral tool kit for physician members with the goal of improving the patient's experience.

CMA also created the wait time agenda in 2004 and has contributed significantly to sustaining it through the Taming of the Queue conferences and our participation in the Wait Time Alliance. These are a few of the highlights.

19. Question from the floor (AB)

Regarding scopes of practice, there are certain changes that would significantly decline the quality of patient care. Specifically, optometrists in Alberta who have applied to do surgery. This could be a great detriment to patients. The Canadian Association of Optometrists is working toward an Alberta test case to be fanned out across the country. This is great cause for concern for patients and the medical profession. I feel the CMA needs to do something different. We are far too polite. It's time to jump on the issue that allowing a non-physician to do surgery is a bad idea. We need political activism and a voice. This is not just turf issue. There is evidence in the US of adverse outcomes when optometrists are permitted to perform surgery. Yet, there is an ear from government. for this. We need less politeness and more fighting.

Response: CMA President, Dr. Anna Reid
The GP Forum has had discussions about scopes of practice. Not a turf war, but about quality and how to provide that quality to patients. We always have to bring it back to quality for the patient. We will keep your comments in mind. It's always a delicate balance about how strident we are.

20. Question from the floor (ON)

Regarding scopes of practice: It is necessary to distinguish between individual scopes of practice and team scopes of practice. A lot of concern is about people setting up their own shop - not practising as a health care treatment team. Somewhere along the way, we will have to talk about our own scopes of practice. Some physicians have a very limited scope of practice. The FPs are looking at developing sub-specialties. We need to be transparent about qualifications, by having an open discussion.

Response: CMA Board member, Dr.Gail Beck
The present debate shows the importance of having the discussion about the physicians' unique value proposition. It is timely. Scopes of practice are important in the profession itself, especially when health human resources are so very important.

21. Question from the floor

Regarding scopes of practice, every year on our college renewal form, we have to indicate whether there is a change in our scope of practice. The assumption is that you're working within the scope of practice for which you were trained. It is something that the colleges are taking an interest in.

Regarding consecutive hours of work, there has been work by residents who have researched the number of hours that it is safe for them to work. Since then, there has been policy based on this research. Is the CMA starting to look at any of that with respect to practising physicians, as opposed to just residents?

Response: CMA President, Dr. Anna Reid
This discussion has started at the CMA, but hasn't been concluded.

Supplementary response: CMA Past-President, Dr.John Haggie
A CMA draft document is being prepared by the Committee on Education and Professional Development. The draft has been circulated to the PTMAs for comment. It is a well-researched paper. However, there is Less literature around practising physicians working long hours, versus residents - some work from the Canadian Armed Forces has been referenced . However, as a policy statement, it is still in early stages.

22. Question/comment from the floor (ON)

I have some negative feedback regarding today's lunch time video, in which a man's right hand is on a woman's right shoulder. Not sure what the relationship or the context is, but this would be considered an inappropriate boundary relationship if the doctor was supervising.

Response: CMA Board Chair, Dr. Michael Golbey
Unfortunately, the CMA Executive Committee did not attend the lunch and therefore hasn't viewed the video, but it will certainly be looked at.

23. Question from the floor (ON)

Regarding scopes of practice in rural practice. The issue in rural Canada has a different look. If you are a small town of five doctors and want to establish a hospitalist route for those doctors, or a route for those physicians wanting to be administrators, for example, you suddenly need 12 physicians for that community. What is really needed is physicians with comprehensive skills, i.e., a combination of anesthesia, OB/GYN and psychiatry. We need to be able to support that kind of care. Rural communities need those services. There is no viable model that can be sustained in those communities that doesn't involve GPs. Any thoughts on that level of generalism at the CMA?

Response: CMA President-Elect, Dr. Louis H. Francescutti
Recent medical graduates in rural areas don't hesitate to say they haven't been properly trained for those positions. A lot of sub-training may be creating a shortage of properly trained individuals for those positions. These issues have been discussed at the Royal College and CFPC. There is a need to look at current training programs because physicians aren't feeling comfortable assuming those positions.

Supplementary response: CMA Past-President, Dr. John Haggie
The issue of generalism has been highlighted at the CMA Board and there have been discussions at the Canadian Medical Forum as well. In Newfoundland, in the surgical residency programs, it is difficult to get surgical residents out in rural areas for community-based training in any significant way. Therefore, they tend to be trained on a patent that relies on tertiary care centres. It is a challenge, this balance between generalism and sub-specialization. I don't know that we have found the right balance or that we have a system in place for the right balance. We have included the issue in discussions with the minister of health. Certainly, we do not have a handle on the issue now.

24. Comment from the floor (SK)

Four years ago, after finishing residency, I was terrified of rural practice. I may be one of the last of my kind to practise true general OB/GYN, especially with whispers of splitting obstetrics and gynecology. We will not be able to support a call system in a smaller centre if we really do continue to sub-specialize to the extent that we are. If such is the case, how will we be able to maintain services like they do in the bigger cities?

25. Advance question (ON)

A few years ago, Dr. Jeff Turnbull toured the country and spoke about a transformation agenda. Physicians could and should lead the transformation, whereas we have, on any significant scale, been notably silent and passive. What we need is the much larger concept of transformation.Where are we on this at the CMA? Do we have an ongoing transformation initiative? How can individual physicians or organizations get involved?

Response: CMA President, Dr. Anna Reid
The CMA's health care transformation initiative is still the main policy priority for CMA and we have looked at some of the principles of our document, including patient-centred care, sustainability and equity issues within health care transformation. We have done so by addressing the social determinants of health. We know that if we don't address the social determinants of health and deal with the upstream causes of why patients get sick, the system will not be sustainable. That initiative is very much part of the health care transformation strategy. CMA has also been working the accountability quality agenda and this is leading to our work on appropriateness of care with the Council of the Federation. In addition, CMA is working to get together with various member groups and the GP/specialist Forum on the Canadian version of Choosing Wisely. CMA has been very active, but CMA does need to find better ways of communicating this action with its members.

Supplementary response: CMA Past-President, Dr. John Haggie
The health care transformation Board Working Group has been dealing with the topics that have been described by Dr. Reid. The group is looking to produce a standard reporting format that would include: the topic, some background, a narrative and recommendations. The recommendations will include what can be done at the national level by CMA, what can be accomplished on a provincial level by the PTMAs, as well as measures and tools for individual physicians to take back and use in their own practices. Some topics lend themselves better to PTMAs, while others lend themselves better to the individual practitioner.

26. Comment from the floor (AB)

Regarding scopes of practice: As a family physician with very little work in geriatrics, I feel guilty, since I feel I should be offering that as a full-rounded physician. Recognizing that rural medicine is different, I feel that as physicians, we put a lot of guilt on ourselves. Having heard comments about the need for physicians to maintain their health and well-being, I feel we need to recognize that it isn't possible to be a jack of all trades. We need to be a master in so many areas. Students and residents are saying they can't do everything as medicine is so complex.

27. Question from the floor

I believe that, as physicians, we have not been living up to our capability. When we speak, we speak to people's heads, whereas other professionals who are looking to increase their scope of practice, are speaking to people's hearts. How does the CMA, on behalf of physicians, plan to speak to people's hearts?

Response: CMA President, Dr. Anna Reid
One such example would be the CMA's support of the interim refugee health benefits' file. The CMA has been vocal on this and attempted to meet with the Minister on the issue. This is speaking to the heart; many physicians work for free; CMA's position is that every person on Canadian soil has the right as an individual to get medical attention. That's just one example.

Supplementary response: CMA Past-President, Dr. John Haggie
The CMA has attempted to speak to the heart of physicians and to the heart of the public. The recent Innovation campaign and television spots have featured local community physicians with innovative ideas.

One thing we do badly as a profession is transitions - from medical school to residency; from residency to practising and from actively practising to reducing hours and call schedule. There is a role for mentoring people. As a profession, there are things we can do to help those transitions.

CMA Members' Forum 2013 - questions and responses