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andré picard

Care is shifting out of hospitals, the traditional power base for specialist physicians, and into the community.

"I don't think there's ever been a greater time for our profession to shine than right now," Louis Francescutti, the new president of the Canadian Medical Association, said at the outset of his inaugural address at the 146th annual meeting of the CMA.

But nor has there been a time when there was more angst in the profession of medicine, and that unease bubbled just under the surface throughout the deliberations of the self-proclaimed "Parliament of Medicine." There are 78,000 doctors in Canada; that is more than there ever has been, in raw numbers and per capita. Physician income has climbed steadily in recent years; in some parts of the profession, gross income is up 30 per cent over the past decade.

Yet there was little celebration at the physicians' gathering in Calgary this week. There were long discussions about a troubling new trend: Unemployed and underemployed doctors, and concerns – expressed explicitly and implicitly – about health professionals such as pharmacists and nurse-practitioners assuming roles that were once the exclusive purview of physicians.

There were many hallway chats about the tough labour environment: the numerous contract squabbles of the past year, the even more difficult talks that lie ahead as governments try to move away from fee-for-service payments and impose more restrictions on physicians and demand more accountability. But beyond physician supply and income – the hot button issues that always get the most attention – there is a much more fundamental upheaval taking place.

Medicine has long been synonymous with health care. Doctors were the masters of hospitals and they dominated primary care with private practices, all the while remaining fiercely independent. But all that is changing.

Health-care systems in Canada and elsewhere are moving away from the traditional medical model. Patients (and payers) are demanding more patient- and family-centred care and a lot less paternalism. Care is shifting out of hospitals, the traditional power base for specialist physicians, and into the community. The traditional family physician in solo practice is disappearing and being replaced by clinics staffed by multidisciplinary teams. (Where doctors will still play an essential role, let's not forget.)

Along with the recognition that the sands are shifting is a fair bit of grumbling, especially from older docs (there is a striking generation gap in the practice of medicine that is rarely talked about).

Dr. Francescutti told his colleagues to embrace rather than resist change, for the good of patients. He even urged them to consider some radical ideas.

"Wouldn't it be great if there were no patients?" the CMA president said. "We need to have that conversation."

By this, he means that physicians should not just sit back and treat disease; they have to put much more effort into prevention and, in particular, use their influence to get governments and the public to address the root causes of disease, the so-called socio-economic determinants of health. (His predecessor as CMA president, Anna Reid, also made this her rallying cry.) That means advocating for early childhood education, social housing, decent wages and the like, not just more health spending.

Dr. Francescutti referred, at length, to the "wake-up call to the profession" delivered last year by Governor-General David Johnston.

In a memorable speech to the Royal College of Physicians and Surgeons, Mr. Johnston reminded doctors that they are a party to a social contract, one that grants them status and privilege, but in return entails an obligation to serve the public good.

In 2013, the public good requires that Canadian physicians embrace a fundamental transformation of the health system and that they advocate passionately for the changes – patient-centred care, a shift to the community and tackling social inequities – even if they will, as a profession, pay a price for doing so.

That may be a bitter pill to swallow, but it's better than the alternative.

As Dr. Francescutti said: "Embrace new ideas or have them imposed." If Canada's doctors respect the social contract, the medical profession will indeed shine, and we will all be healthier for it.