The CFPC’s role in self-regulation

We can get public support only if we can be seen as serving the public good.

Harold C. Sox¹

Dear Colleagues,

I recently had the privilege of participating in a reflection exercise organized by the Quebec Medical Association, in collaboration with the Quebec College of Family Physicians, regarding medicine’s contract with society. Drs Richard and Sylvia Cruess gave an excellent “stage setting” presentation to remind us of the dynamic nature of this reciprocal relationship. Several points of tension were covered: the ethical obligations of physicians to their patients and society; physicians’ roles as healers and professionals (which both overlap and are distinct); the evolving nature of the social contract; and the risk of loss of respect, trust, and autonomy for the medical profession should society perceive that the social contract is not respected. Recent events in Quebec (Bill 20) and Manitoba (statement on 24/7 coverage) have generated some concern about the infringement of government on medicine as a self-regulated profession.

In the United States, the American Board of Medical Specialties (through the American Board of Family Medicine for our discipline), an independent physician-led body, sets the standards for certification and recertification of physicians and manages the process that includes continuing professional development (CPD), practice improvement initiatives, and examinations at regular intervals.^2,3

In the United Kingdom, inquiries into recent serious adverse events have led to greater involvement of the government and employers in regulation, mandatory participation by physicians in recertification, and annual appraisal with revalidation every 5 years. Greater transparency and accountability are now required of physicians. There is a sense that the changes being imposed have had negative, unintended consequences on professional freedom and on medicine as a calling (as opposed to a job).^2,3

In Canada, the responsibility for self-regulation is assumed by provincial licensing authorities. Their prime objective is protection of the public, and they are accountable to their respective provincial governments. The Royal College and the CFPC contribute to maintenance of competence through our accredited CPD programs. Both organizations help physicians track and validate their learning, and build in incentives to make this learning targeted and productive. The CFPC and the Royal College are collaborating with the Federation of Medical Regulatory Authorities to develop a framework to affirm, enhance, and monitor physicians’ performance in all aspects of practice. We aim for the enhancements of Mainpro+ to be well aligned with this framework. The CFPC, Royal College, Federation of Medical Regulatory Authorities, Canadian Medical Protective Association, Canadian medical schools, Canadian Medical Association, and Medical Council of Canada are also embarking on the Future of Medical Education in Canada–Continuing Professional Development initiative, examining the evolution of CPD and asking and responding to important questions to support the medical profession in maintaining competence and improving practice in the future. Are these developments enough for the profession to continue to regulate itself and maintain the trust of patients and the public? Is participation in Mainpro+ a sufficient requirement for maintaining Certification? Should our process be more robust and include recertification as well? What would or should the requirements for recertification be? Is a form of 360 review, such as the Physician Achievement Review in Alberta and Nova Scotia, a sufficient addition? How would we measure the effects of such processes on access and quality of care?

The reflection exercise, review of some literature on the subject, and discussions with medical regulatory authorities bring me to the following initial conclusions.

• The Canadian system up to now has been mostly collaborative, involving the certifying Colleges and licensing authorities, enabling the beginnings of a model of shared accountability. We need to build on this foundation.³

• No single tool can reliably paint an accurate picture of “quality work,” nor will a single approach cover the range of activities characterizing the work of family physicians.³

• As a physician, I prefer a “bottom up” approach.³ I prefer to be “nudged” toward activities and feedback opportunities by my professional association and the regulatory authority, rather than mandated by government to demonstrate performance or maintenance of competence.

Governments face financial and political pressures that influence their view of the social contract. Most physicians see their profession as a calling and aim to best meet the needs of their patients; however, we work in a system that does not always facilitate access and integration. To retain the privilege of self-regulation, we must engage patients, the public, regulatory authorities, governments, and—possibly most important—one another, in providing and ensuring the best care for everyone. I invite you to share your thoughts and comments by e-mailing info{at}cfpc.ca.

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