Instead of boosting GP ranks, the Legault government’s health reforms have undermined family practice and made the profession less and less attractive.
![McMedicine fuels Quebec's family doctor crisis](https://topnews.media/wp-content/uploads/2024/05/gettyimages-939383994.jpg)
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During his 2022 re-election campaign, Premier François Legault levelled with Quebecers when he admitted that the government could no longer promise everyone a family doctor.
It was a rare moment of political honesty, if a risky strategic move. The writing had been on the wall for years, though few leaders dared admit it. As the ranks of aging physicians depleted due to retirement, medical students turned their backs on family medicine in increasing numbers. More and more patients found themselves searching for an elusive new general practitioner — or enduring long waits in emergency rooms to deal with acute health issues because they had nowhere else to turn.
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What Legault did promise on that sunny September day was “one-stop shopping” for access through new web and telephone portals.
Since the Coalition Avenir Québec won a second mandate, Health Minister Christian Dubé has undertaken seismic reforms to health care that he vowed would “shake” the system. Gradually, some of those changes are starting to take shape.
But the remedies the Legault government has prescribed have weakened one of the already crumbling pillars of health care: family medicine. Instead of finding ways to fill the ranks of missing general practitioners by loosening restrictions and improving conditions, Quebec is changing the way family doctors practise in ways that are ultimately making the profession less attractive.
In the bleak assessment of one physician: “Family medicine as we teach it, as I wanted to practise it, no longer exists in Quebec.”
Dr. Michael Kalin is a family doctor in Côte-St-Luc and a member of the Département régional de médecine générale (DRMG) for Cavendish, a body that helps recruit new physicians. He made the striking comments in a recent interview about why 70 of the 75 vacant residencies in family medicine in all of Canada are in Quebec this year. And we have spoken many times in the past about how Quebec’s Plans régionaux d’effectifs médicaux — permits that dictate where new doctors can offer their services to ensure an even distribution of care across the province — are driving physicians out of family medicine, the public health system — or even the province. This year, 116 of the 479 PREMs for “new billers” were unfilled at the end of April.
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But his remarks about the demise of family medicine indicate a new level of demoralization among primary caregivers.
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Family medicine, Kalin explained, is based on four principles: being a skilled clinician; practising in a community setting; serving a defined patient population; and establishing a doctor-patient relationship.
“Three are gone. They no longer exist in Quebec,” he lamented.
Only the first, being a skilled clinician, is still intact.
A family doctor is meant to be “a resource for a defined patient population. …. That’s gone. The government has now embraced populational walk-in clinics, where you get collective registrations. You don’t have a practice anymore. You see a more complex and difficult, random population base,” Kalin said. “The heart and soul of family medicine is that you want to build a doctor-patient relationship. You can’t do that anymore because you’re being sent patients from 811 with complex, difficult issues that you need to resolve and then you may never see the patient again.”
In a new promotional video last week, Dubé appeared alongside Legault to boast about how ER visits have fallen by 1.5 million now that the more than 640,000 Quebecers without a family doctor can now book a consultation through the “guichet d’accès à la première ligne (GAP),” by calling 811.
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This may take pressure off crowded ERs and offer relief to patients who desperately need help. But it runs counter to how family medicine is traditionally practised.
“There’s no more personal touch to this, there’s no more relationship. They provide you with the list, the government wants access to this, they want to see how many (patients) you’ve seen, how fast you’re going, what your productivity is. It’s no longer about personal health care, it’s about McMedicine,” Kalin lamented. “It’s how fast and how quickly you can get through consumers. It’s not about prevention. It’s not about that personal touch. It’s about solving the problem and moving on. That is not what family medicine is supposed to be and that is why students are not choosing to go into family medicine. It does not exist in Quebec as it does elsewhere in Canada.”
The government’s strategy is not only discouraging young doctors to get into family practice at a time when they are most needed, Kalin said it is doing patients a disservice.
“As a family doctor, I feel like patients have unfortunately suffered as a result of this approach. There is merit in group multi-disciplinary care. But this is not what is being offered now,” Kalin said.
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“When they give you that patient who arrives in your clinic, and you say ‘Hi, how can I help you today?’ it can be anything from ‘I am a cancer patient who hasn’t see a doctor in two years’ to ‘I need a referral to see a gynecologist.’ We don’t know what we’re getting. We’re doing our best and I commend my entire profession, who I think are doing an exceptional job under really, really difficult circumstances. But it’s not family medicine.”
The grievances of family doctors continue to pile up. According to the Fédération des médecins omnipraticiens du Québec, they include: needless paperwork; supplemental duties in birthing centres and nursing homes known as Activités médicales particulières (AMPs), PREMs constraining where doctors can work, pay disparities with specialists, increased pressure to do more to make up the slack in an ailing health system and a devaluing of family medicine.
A new bone of contention is Bill 11, which removes a family doctor’s discretion in deciding to take on new patients. While this may be intended to facilitate equity and fairness to people waiting to be assigned to a GP, Kalin said the policy also gives rise to absurdities.
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“The latest measure, Bill 11, will now take away physicians’ choice in selecting patients. So again, why would you want to become a new doctor when you have lost the choice over who you can select as patients? That doesn’t mean that people who are on the waiting list should be passed over, I’m not suggesting that whatsoever. But what I’m saying is, if I have two out of three siblings in a family, why can’t I take the third as a patient to keep the family unit whole, in one office? But I can’t anymore,” Kalin said. “This is another slap to family doctors and our autonomy.”
The other shoe has yet to drop in terms of the centralization of control of the health system under the newly created Santé Québec.
The Legault government recently announced that it will be opening 200 more places in Quebec’s medical schools next fall to train more doctors.
But will it convince more of the applicants to eventually practise family medicine?
The way things are going, Kalin is not particularly hopeful.
“I’m very pessimistic about the future and when young doctors come in, I will support them as well as I possibly can. I think that they’re courageous and they’re noble, because I think it’s a hard field to go into now,” he said. “Because honestly, if I was choosing my career, today, I don’t know if I would select family medicine. And I love family medicine.”
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