Jill Rafuse is associate editor in CMAJ's news and features section.
Canadian Medical Association Journal 1995; 153: 978-979
[résumé]
No decisions were made -- the purpose was to get the views of members of General Council -- but at least two clear opinions emerged from a lively session about the CMA's governing structure held during the August annual meeting in Winnipeg.
The first was that the CMA needs to find a way to represent its diverse membership better, giving a stronger voice to affiliates, students, women and young physicians. The second was: don't mess with the authority of General Council.
More than 80 physicians attended the session, which was held by the Committee on Structure before the opening of General Council. Committee chair Dr. Rob Bartlett, a family physician from Sussex, NB, made it clear from the outset that although the committee has explored options that could fundamentally change the governance and policy-development structure of the CMA, it wants much of the report's details to represent "your opinion."
The challenge, he suggested, is to mould an effective CMA that will have a governing body that represents members and has clearly delineated lines of authority, autonomy and accountability. It will also create value for members, divisions and affiliates, be flexible and make decisions quickly when dealing with issues.
Many doctors at the special session said the CMA is driven too much by medicopolitical issues, particularly when its mandate includes professional and educational representation for physicians.
Currently, the CMA represents its membership -- individual physicians -- through other organizations and their representatives. The model is neither a federation, which represents organizations, nor republican, which represents individuals. Although it is often called the Parliament of Canadian medicine, one speaker said somewhat disparagingly that it more closely resembles the Senate in its response time.
The CMA's governing authority is General Council, which meets once a year. Approximately 235 voting delegates are members, chosen primarily by the 12 divisions according to population. Each of the 38 affiliate societies also has a vote.
Between General Councils, work is carried out by a 26-member Board of Directors. Its voting members represent the 12 CMA divisions on a representation-by-population basis; other members include the chair, president, president-elect, past president and honorary treasurer. Many physicians consider the large board unwieldy and too politically driven.
"Up to now the CMA has been flying on only one wing, the medicopolitical one," said Dr. William Pryse-Phillips, who attends board meetings as an observer for the Committee of Affiliate Societies. He said the other wing should be added by giving voice to educational and professional issues through the affiliate societies.
"We are a very diverse profession with a large number of diverse issues," agreed Dr. Marjorie Keymer, a Toronto physician who sits on the Committee on Structure.
Other physicians supported formalized interaction with the affiliate societies, particularly because this would bring added expertise to the CMA councils and committees where policy is developed. There was also interest in increasing the profile of young physicians, students and women.
However, the committee's suggestion that General Council could become the senior policy-advisory body to a smaller Board of Directors -- which would be responsible for policy-making and strategic planning -- met with opposition that later spilled from the information session into General Council.
"We have to make a statement that we [General Council] are the governing body," Dr. Derryck Smith told General Council. "This is an extremely important issue and we should let the committee know what we think."
Similar sentiment was expressed during the information session. "General Council is the only forum for all physicians," one physician said. "The board can't represent all viewpoints, but they can be aired at General Council." Even though the board sets policy when General Council is not sitting, he added, its actions can be ratified or rejected by the assembly.
"Membership in the CMA is voluntary," added another doctor. "You have to make members feel they belong. General Council has to be the policy-setting body."
Ultimately, delegates decided that it would be inappropriate to restrict the Committee on Structure's work by refusing to let it consider alternatives. A motion to confirm the authority of General Council was referred to the committee for consideration.
During the information session, the question of changing the method of electing the president was also raised, although it appeared to draw little support. Currently, the president-elect is nominated by the divisions on a rotating basis and elected by General Council. Dr. Barbara Kane, a Prince George, BC, psychiatrist who sits on the committee, suggested this rotation disenfranchises a lot of potentially excellent candidates. Perhaps the president should be chosen by merit, not geography, with divisions nominating candidates for election each year. Considering the example offered by the chair of the Board of Directors, there is no reason to presume that the presidency would be dominated by the larger divisions: the last two chairs have been from the Maritimes. Most speakers on this subject, however, offered no criticism of the existing practice.
One physician said that with the current model, a doctor must devote many years of service at the divisional level to gain the experience and political expertise to work at a national level. "We need to fast-track young physicians into being involved with the CMA," he suggested. There is value in gaining experience in the divisions, he added, but there also must be other ways for younger physicians to gain political expertise.
Others noted that most health care "action" in Canada is found at the provincial, not the federal, level. "Political battles are fought in the divisions where we live," one physician said. "I'd hate for the CMA to lose the political expertise we have in the divisions."
At the conclusion of the annual meeting, Bartlett called the 2-hour information session a success. "I was pleased with the debate," he said. "It gives us a lot of direction and a clear sense of the areas where we can build consensus. My only regret is that the issue [of governance] is so big that we couldn't touch on all aspects of it."
Bartlett said the debate over who should be responsible for setting policy is not finished, although "General Council has certainly expressed a clear opinion" of the role it wants to continue to play. "Clearly there are choices," he said, "and we want to explore these choices to find what will suit us best for the future."
Bartlett said he sensed consensus on the need for gender balance, a voice for affiliates, representation that allows for diversity of opinion, and a dedicated forum for students and young physicians. However, significant issues still require discussion, including the need for improved two-way communication with members.
The Committee on Structure, which has been consulting broadly with members, students, divisions and others, will present a discussion paper to the Board of Directors by early next year, Bartlett said. "The members of the committee do not have a preconceived plan," he added. "This feedback from General Council is just one of many consultations with we've had with the people interested in having a strong CMA."
Besides Bartlett, Kane and Keymer, other members of the committee are Drs. Raymond Carignan, Montreal, David Hambly, Montague, PEI, and Lionel Lavoie, Melfort, Sask. Members are invited to send written comments or suggestions to the Committee on Structure, Attn. Joe Chouinard, Director of Corporate Affairs, CMA, PO Box 8650, Ottawa On K1G 0G8; fax 613 731-7314.