The College of Physicians and Surgeons of Alberta has released Advice to the Profession on Professional Courtesy, following up on the recommendations of the Vertes Report. You can find it here: http://www.cpsa.ca/wp-content/uploads/2017/01/AP_Professional-Courtesy.pdf?x91570
I’ve written the College an open letter (Open Letter to CPSA Professional Courtesy Advice), because they seem to imply that my report to the Vertes Inquiry was influential on their advice. I don’t really see that my views had any influence on them at all. Perhaps they worked with the idea of “conflict of interest” from my report, but they didn’t really put it in the context of everything else I said or in the context of what I think about conflict of interest in medicine (that the profession should do more avoiding of conflict of interest and less “managing”). I’m quite ethically skeptical of the practice of professional courtesy, as Vertes notes in his final report.
Here are my specific concerns about the College’s Advice:
1) The College expands the definition of professional courtesy beyond the traditional one of colleagues and their families to include also friends and contacts of colleagues. It is not clear what justifies expanding the definition in this way. It sounds like an invitation to the people of Alberta to get on the phone and start working their “contacts.”
Justice Vertes in the Inquiry Report said that he thought there was some scope for professional courtesy, but he explicitly denied it should extend this far. He said:
I accept that physicians are under an ethical duty preventing them from treating themselves or their family members. They must get care from others. So I can also accept that professional courtesy can and should encompass services by one physician to another. In practical terms, that usually means a direct and personal referral. I do not consider this to be improper. I would include in this professional colleagues, such as nurses. But the real question is how widely this practice should apply. I see no justification in labelling as professional courtesy consultations conducted as favours for friends or other contacts. That does beg the question of a two-tiered system (particularly since those services are still charged to the public system). There is no ethical rationale, as in the case of physicians, for extending preferential accommodation to others – at least not under the pretext of professional courtesy. Furthermore, while personal and professional loyalties may be positive values in some contexts, requests for preferential access can pose an ethical dilemma for the health care provider and even create a conflict of interest. (pp. 126-127 of https://www.assembly.ab.ca/pub/PDF/HealthServicesPreferentialAccess_Inquiry_Volume1.pdf)
2) The practice is a holdover from the days when physicians themselves might have been unable to afford care. Not everyone in the profession was prosperous and health insurance was not yet widespread. It is unclear if there is any justification for it in the contemporary world.
3) I take very seriously the stewardship responsibilities of the profession with regard to the citizens and taxpayers of Canada, and so I consider the practice akin to anyone else who is a gatekeeper for services paid for by the public purse using that position to benefit their personal contacts. That is, I see it as a clear conflict of interest that should be avoided, not “managed” as the College Advice recommends.
4) I find it doubtful that the queue-jumping issue can be resolved by saying follow-up care should be on the basis of need, like everyone else. Once the consult or second opinion is in hand, everyone has to act on it—you can’t go back in the queue where you would have been without the special treatment.
5) One might hope that advocacy and going the extra mile to make that phone call or add an extra appointment at the end of the day would be focussed on need (advancing health equity) and not on getting even better access to care for those who already have good access to care. I’ve been calling this “equity-promoting” vs. “equity degrading” differential access since I wrote the report for the Inquiry.
6) There is a whole dimension of boundaries and self-care at stake here, which we often ignore when we focus on the queue-jumping, stewardship, and equity concerns. I think it’s important, but when I talk to the media we don’t always get this far! The Colleges would use agreeing to see a patient outside of office hours as an example of a “boundary crossing”—not yet a violation, but something to pay attention to, as a possible warning sign. There’s a good literature on problems with VIP care—care to anyone influential enough to persuade you to vary your normal approach to practice. (When I talk to physicians about these issues they often link professional courtesy and VIP care.) I like this recent Guzman article: http://www.mdedge.com/ccjm/article/95473/practice-management/caring-vips-nine-principles. Also, relying on professional courtesy can be a warning sign of a deficit in self-care—health care providers avoid seeking care for all sorts of unhealthy reasons, and then they seek care informally under the guise of professional courtesy.
With respect, I think Vertes in the quote above was somewhat unclear about this–he seemed to confuse the idea that people shouldn’t get care from their own physician family members with the idea that they should get their own physician family members to secure them access to care (instead of getting access to care like everyone else does).
To be clear, I don’t think that the existence of professional courtesy is the biggest threat to health equity in the Canadian health care system. Lack of pharmacare has a strong claim for that title. Running neck and neck is the simple fact that we assume that our single-payer “single-tier” system will deliver equity, when we need to track it and act on what we find, which we don’t do very well. Furthermore, an approach to queue-jumping in health care should probably be part and parcel of addressing problems in access to care, and not an isolated punitive policy issue. But the topic does raise the question whether physicians and colleagues are stakeholders in the system like the rest of us, or able to use their insider access to avoid the problems that other Canadians live with.
Even if you think it’s more of a grey area than I think it is, I worry that the College’s advice steers people in one direction rather than giving them an understanding of all the dimensions of the issue to help them fit their approach to their own professional conscience.