Perceived shortage of family doctors in Quebec

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.