Support urged for physicians who speak out on health care issues
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* Lauren Vogel

Powerless, passed over and pushed out of the decision-making of a system they once ruled. Physicians painted a bleak self-portrait of themselves as the exiled kings of Canada’s health care system during discussions on physician advocacy and apathy at the Canadian Medical Association 144th annual general meeting and the Canadian Medical Protective Association (CMPA) annual meetings, both of which were held in St. John’s, Newfoundland and Labrador in August.

But while ongoing changes to the physician–hospital relationship are making it more difficult for physicians to speak up on behalf of their patients or participate in administration, panelists at both events urged physicians to consider the extent to which the marginalization of physicians may actually be self-generated.

Lower thresholds for both internal and external disclosure of physician performance, limited or nonexistent protections for physicians practicing outside the hospital privileges model, and increasing use of confidentiality agreements or physician “gag orders” by institutions are all realities of Canada’s changing health care landscape, and pose real barriers to physician advocacy, CMPA Chief Executive Officer Dr. John Gray told delegates.

“Unfortunately, you do hear physicians saying that things are changing too fast and I just don’t want to be bothered any more,” he later told reporters. “Physicians have to stay engaged and define a changed role for themselves, not just give up and let the health authorities tell them what their new role will be.”

While experts at a CMA panel on advocacy earlier urged delegates to become the voice of patients, some delegates expressed skepticism, noting that physicians are often unwilling to advocate for themselves, let alone their patients, for fear of recrimination.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/183/13/E1005/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/183/13/E1005/F1)

The increasing use of confidentiality agreements or physician “gag orders” are among reasons that Canadian physicians are feeling ever-more muzzled.

Image courtesy of © 2011 Thinkstock

“There’s a role here [for CMA] to support those physicians who do speak out, because as patient advocates it’s a huge obstacle when physicians will not partner with us on sound, evidence-based issues,” argued panelist Deb Maskens, founder of Kidney Cancer Canada.

“They say government advocacy is not something they do, that they don’t have the time, that it’s not something they’re good at,” Maskens added. “But that’s hugely underestimating your value.”

A physician and patient standing together and “fervently presenting a case is very powerful,” panelist and former federal cabinet minister Chuck Strahl said, adding that such a relationship is one in which each partner lends credibility to the other.

The biggest part of the fight in advocating for a better health care system remains “getting someone from the medical profession to back up and give credibility to what the patient is saying,” said session moderator and journalist Dale Goldhawk. “That’s a tough row to hoe.”

CMPA released a spate of recommendations in support of physician advocacy. Those included calls for physicians to:

*   Remain engaged in health care administrative decision making, including at the health authority and hospital levels, in part by seeking formal and informal leadership roles that advance quality care.

*   Actively participate in efforts to resolve conflicts at the local level and, to the extent feasible, avoid unnecessary and inappropriate escalation of these concerns.

*   Avoid forming or communicating hasty or partially informed opinions about the performance of colleagues or other care providers.

*   Carefully consider the medico-legal protections specified in any agreement before entering into it, including protections related to procedural fairness and natural justice.

Gray also called on medical professional associations to support physicians with advocacy tools and training, and to work with physicians, health authorities and institutions to define the “fine line” between what is appropriate advocacy and disruptive behaviour.

“The CMA can’t just say you’ve got to be an advocate, a leader, without giving people the training, the tools and supports for them to do that,” Gray added.