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Perceived shortage of family doctors in Quebec

Can we do something about it?

Correspondence to: Dr F.P. Gladu, Institut de gériatrie de Montréal, 4565 Queen Mary, Montreal, QC H3W 1W5; telephone 514 340-2800; e-mail fpgmd{at}yahoo.fr

While the public health care system is suffering from underfunding, this is not the only source of its problems. Current reforms, such as the computerization of patient files, the rationalization of drug consumption, and the integration of medical points of service, will have a negligible effect on service delivery as long as there continues to be too few family physicians to care for the population of Quebec. There is consensus in the media that the shortage of physicians is, to a large extent, responsible for the problems in Quebec’s health care system. But is this perception correct?

The Canadian Institute for Health Information has published 2005 data on the percentage of people in each province who do not have a regular physician (Table 1).¹ These data show the following.

• Quebec has by far the worst situation (25% of its people are without a regular physician), despite the fact that it ranks third in terms of the number of general practitioners per 100 000 people. Quebec has 16% more family physicians per 100 000 people than the rest of Canada does. In spite of this, more than twice as many of its residents do not have physicians.
  
• Quebec also has the highest percentage of specialist physicians per 100 000 residents—20% more than elsewhere in Canada. With more specialists, family physicians should be able to focus on their primary care duties.
  
• Nova Scotia is the only province with significantly more GPs per 100 000 people than Quebec. But while it has only 8% more primary care physicians, it offers far superior family medicine services: only 5.4% of Nova Scotians do not have access to family physicians.
  
• The 2 other densely populated provinces have far less difficulty providing their taxpayers with family physicians. While British Columbia has a slightly higher proportion of general practitioners per 100 000 people and fewer specialists than Quebec, only 11% of its population does not have access to family physicians. In Ontario, which has a real shortage of general practitioners (at least compared with Quebec, which has 28% more), only 9% of the population do not have their own physicians (ie, a third the number who do not have physicians in Quebec).
  

The situation is even worse in Montreal than it is in Quebec as a whole, and this is contributing to overcrowded emergency rooms. Where only 9.4% of Toronto, Ont, residents do not have family physicians, which is similar to the average for Ontario, the percentage of patients with no physicians in Montreal is 32.4%, much higher than the average for Quebec.

Between 1999 and 2004, at least 200 000 Quebec residents lost their family physicians, and during the same period, at least 900 000 others could have been treated by new family physicians but were not because none were available. Altogether, nearly 2 million Quebec residents have no family physicians.

Patients who do not have family physicians are often forced to go to emergency rooms for care, which explains why more than half of emergency consultations are not for true emergencies.² These visits cost taxpayers 5 to 10 times more^3,4 than the same consultations in family physicians’ offices. In addition, patients who are cared for by family physicians have better survival rates, are less expensive to care for, are hospitalized less often, and consume fewer drugs than other patients.^5–11 Not surprisingly, Quebec spends more per capita on drugs than any other province.¹² It all adds up to the biggest waste of public funds of our generation.

Why does Quebec rank so poorly?

With such a large pool of physicians, why does Quebec rank so poorly? The average number of hours worked per week is 10% lower for female physicians,¹³ but the fact that the percentage of female family physicians is 6% higher in Quebec only explains a 15-minute-per-week gap with the rest of Canada. Clearly, the effect of the more rapid increase in the proportion of female family physicians in Quebec has been minimal.

There is only 1 other factor that sets Quebec apart from the rest of Canada. Since 1993, at the expense of their regular patients, all new general practitioners have been required to take on special medical activities (SMAs) in hospitals during their first 20 years of practice. If they do not, they are fined 30% of their income. Special medical activities are activities that are essential but less popular among physicians because they are paid for at a lower rate or performed at less attractive times of day: 24-hour on-call shifts, elder care, and obstetric and emergency services. In practice, very few hospitals allow physicians to work fewer than 25 hours a week, so the compulsory threshold of 12 hours a week is purely theoretical.

As a result, the physicians concerned limit themselves to hospital practice or complete their work week with walk-in clinics. All other physicians, who represent more than half the work force, are not under any obligation to take on SMAs.

During the past 15 years, while the population has aged, physicians retiring and leaving private practice have not been replaced, and many clinics have had to close. A full-time family physician in private practice is usually able to care for more than 1500 patients. While general practitioners in the rest of Canada care for an average of 950 patients, general practitioners in Quebec care for an average of only 685 patients. In both instances, general practitioners provide some secondary care, but in Quebec, less than half of this clinical time is spent caring for regular patients. Is this well advised?

In all the other provinces, all physicians do SMAs through targeted incentives. All have pitched in with hospital duties and care of regular patients in their private practices. The results are both clear and convincing. In Quebec, however, physicians are remunerated from within a closed budget. Tying hospital SMAs to pay bonuses would mean a freeze or drop in income for general practitioners in private practice who choose not to participate in SMAs. It is clear that the technocrats’ dogma and the physicians’ silence on the crucial issue of a closed budget for remunerating general practitioners is partly responsible for the system’s current problems. For the past 15 years, both the public and physicians have suffered the consequences of this lack of long-term vision.

What can be done?

Recently, the Collège des médecins du Québec, which is the professional body dedicated to protecting the public in the area of health care outside of the union demands of physicians, issued a position paper in the context of the parliamentary consultation on the response of th Charest government to the Supreme Court’s decision in Chaouilli. The College stated [freely translated]:

"We cannot emphasize enough that access to a family physician is an urgent problem and that resolving this issue would have a substantial effect on the entire health care system .... In the area of family medicine, easing the restrictions imposed on physicians, in particular young physicians just starting to practise medicine, such as special medical activities ... is one avenue to explore."¹⁴

The Quebec government has made access to health care a central commitment, and in 2006, the Minister of Health acknowledged that the imposition of SMAs had had the perverse effect of decreasing the number of medical practices and restricting patients’ access to family physicians. And yet these harmful measures still have not been eliminated. In light of the effect that they are having on access and on quality of care, the best course of action would be to follow the more liberal approach of the other provinces.

In particular, making all family physicians in Quebec share responsibility for SMAs and thus easing the weekly workload of physicians with less than 20 years’ practice would enable them to care for regular patients in family practices and resolve the so-called shortage of family physicians. In light of the relative abundance of general practitioners in Quebec compared with the rest of Canada, this alone would enable Quebec to match the clinical care ratios found in the rest of the country and to ensure that more than 96% of Quebec residents had family physicians. By unclogging our emergency rooms and redirecting patients to family physicians, we would improve the health of the population and reap substantial savings.

Footnotes

Competing interests

None declared

The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

References

1. Canadian Institute for Health Information. Supply, distribution and migration of Canadian physicians, 2005. Ottawa, ON: Canadian Institute for Health Information; 2005. Available from: http://secure.cihi.ca/cihiweb/products/supply_distribution_migration_canadian_physicians_2005_e.pdf. Accessed 2007 August 22.
2. Canadian Institute for Health Information. Understanding emergency department wait times. Ottawa, ON: Canadian Institute for Health Information; 2005. Available from: http://secure.cihi.ca/cihiweb/products/Wait_times_e.pdf. Accessed 2007 August 22.
3. Association Québécoise des établissements de santé et de services sociaux. Statistiques de l’année financière 2005–2006 tirées du Rapport 2005 sur la méthodologie SIAP. Quebec, QC: Direction de la vigie, du financement et des systèmes, Association Québécoise des établissements de santé et de services sociaux; 2006.
4. Association Québécoisedes établissements de santé et de services sociaux. Rapport 2005 sur la méthodologie SIAP. Quebec, QC: Association Québécoise d’établissements de santé et de services sociaux;; 2006.
5. Starfield B. Primary care and health: a cross-national comparison. JAMA 1991;266:2268-71.[Abstract/Free Full Text]
6. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians: health care expenditures and mortality experience. J Fam Pract 1998;47:105-9.[Medline]
7. Chin MH, Zhang JX, Merrell K. Specialty differences in the care of older patients with diabetes. Med Care 2000;38(2):131-40.[Medline]
8. Starfield B. The effectiveness of primary health care. In: Lakhani M. A celebration of general practice. Abingdon, UK: Radcliffe Publishing; 2003.
9. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations’ health: assessing the evidence. Health Aff (Millwood) 2005;Suppl Web Exclusives:W5-97-107.
10. Greenfield S, Nelson EC, Zubkoff M, Manning W, Rogers W, Kravitz RL, et al. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcome Study. JAMA 1992;267:1624-30.[Abstract/Free Full Text]
11. Mark DH, Gottlieb MS, Zellner BB, Chetty VK, Midtling JE. Medicare costs in urban areas and the supply of primary care physicians. J Fam Pract 1996;43:33-9.[Medline]
12. Canadian Institute for Health Information. Dépenses par habitant de médicaments prescrits assumées par les secteurs public et privé, 2005. Ottawa, ON: Canadian Institute for Health Information; 2006. Accessible from: http://secure.cihi.ca/cihiweb/fr/media_10may2006_fig5_f.html. Accessed 2007 August 22.
13. Collège des médecins du Québec. Rapport sur les effectifs médicaux 2006–2007. Montréal, QC: Collège des médecins du Québec; 2007.
14. Collège des médecins du Québec, Consultation relative au document intitulé Garantir l’accès: un défi d’équité, d’efficience et de qualité. Mémoire présenté à la Commission des affaires sociales. Montreal, QC: Collège des médecins du Québec; 2006. p. 3-4.

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La pénurie réelle ou ressentie de médecins de famille au Québec: Peux-t-on y remédier?

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