Four years ago, the Avenir Quebec Alliance promised everyone a family doctor.
To reach this goal, the government took the offensive, engaging in often heated debate with doctors with the goal of forcing them to take in more patients.
Less than a week into the CAQ re-election campaign, the party He gave up on the 2018 election promiseadmittedly not feasible.
“finally!” said Dr. Ariane Murray, MD, a family physician and chief of regional general medicine in Montreal. “Not everyone needs a family doctor. They need to get care when they need it.”
Clearly, CAQ shares his sentiments. If re-elected, she has promised to launch a new digital platform to help patients make appointments with the right health professional when they need care.
Murray agrees that the idea that family physicians should be the gatekeepers of primary health care is outdated. She said it was inactive and disrupted the system.
Unless a patient has a chronic medical condition that requires regular checkups and tests, most people will be better served by a physical therapist, psychiatrist, nurse or even a pharmacist, depending on their needs, Murray said.
But for this system to work, there must be enough healthcare professionals to meet the demand, and their services must be covered by public health insurance.
“Many patients come to visit us and we tell them, ‘You know, this should be treated by a psychiatrist.’ “And they say, ‘You know? You’re free, and a psychiatrist isn’t. I don’t have insurance,'” said Murray, who works at the family clinic at Verdun Hospital.
Murray hopes that free and easy access to other health professionals will free up family physicians to see patients who need a doctor’s care.
According to official estimates, there are now at least 834,000 Quebecers on the family doctor’s waiting list. This waiting is especially evident in the Montreal region, where an increasing number of general practitioners are approaching retirement age.
To improve access to medical care, both Québec Solidaire and Parti Québécois say they will invest more in CLSCs.
The Conservative Party of Quebec will increase the number of medical school admissions at Quebec universities and allow doctors to work in both the public and private systems, while encouraging Quebecers to purchase supplemental insurance for treatment in private clinics.
The liberals pledge once again that every Quebec has a family doctor. Over the next five years, they will add 1,000 places to medical schools in Quebec. They say they would also prefer to distribute the doctors geographically.
However, recruiting new medical students and persuading them to choose family medicine is not so simple, warns Murray.
In recent years, dozens of family medicine residencies have disappeared. Murray believes that medical students are influenced by negative political discourse about family physicians, who are often accused of not working hard enough.
It also did not help all of the CAQ, with Bill 11And the liberals before them with Bell 20passed legislation – against doctors’ wishes – forcing general practitioners to take in more patients.
“It’s very important that the messages change,” Murray said. “We need to make this job attractive again.”
More flexibility required
Another problem that discourages family physicians is the rings they need to join a clinic in the area where they want to work. The county determines where doctors are assigned to work through a permit system, known as PREM – the Provincial Physician Resource Plan.
Despite the shortage of family physicians in some parts of the island, in recent years CAQ has reduced the number of permits in Montreal in order to create new jobs in booming suburbs, including Montérégie, Lanaudière and Laval. The Montreal Regional Department of General Medicine estimates that there is a shortfall of 372 full-time physicians.
Not only does PREM restrict where doctors can practice, but general practitioners are also required to perform additional activities, such as shifts in long-term care homes or emergency rooms. These are moving targets that also affect the balance of a physician’s work and scope of practice.
“There are different rules every year,” said Dr. Neboisa Kovacina, a family physician at St. Mary’s Hospital. “It is unpredictable.”
Watch | A doctor and a nurse put their hopes in the elections:
He says the uncertainty has discouraged many qualified bilingual family physicians, who have decided it is easier to find a job outside the province than to fight to stay in Montreal.
“For me, this is a failure of the system,” Kovacina said.
He doesn’t think PREM should be scrapped entirely, but said he hopes the government will take steps to make it more flexible.
An increasing number of physicians have abandoned the general system entirely. In the past five years, nearly 400 family physicians have chosen to opt out of Régie de l’assurance maladie du Québec.
Murray said easing some of the public order work restrictions could persuade some of them to return.
The same is true for physicians who trained in Quebec and made residencies in the province, but left due to the difficulty of establishing their practice in Quebec.
If the doctor is not authorized to work in a particular area, he is punished with a reduction in his salary. For some clinicians, working outside their preferred area is not an option – for example, if a spouse cannot find a job elsewhere.
Murray said that if the requirements for getting PREM were relaxed, she believes some of those doctors who left the county could also co-opt some of the doctors who left the county.
One of the ways the CAQ wants to improve access to a family doctor is through the primary care portal, the Guichet d’accès à la première ligne (difference). When a health problem arises, patients should call a number where the nurse directs them to a doctor or other health professional.
Covasina believes the idea has potential and is optimistic that it will save time on family doctors by eliminating unnecessary appointments. But he said there must be continuity of care. For example, if someone receives an abnormal test result, that person should be reported.
“If a physician is not primarily responsible for a particular patient, who will it be, and how will that person be assigned?” Kovacina said.
The patient should also know who the point of contact is.
Kovacina said quick one-off visits might work for younger, healthier patients who don’t need follow-up — but that won’t work for frail or older groups with chronic problems who may have more complex complaints. He said these patients should be prepared with the appropriate specialist for follow-up care.
One of the biggest challenges facing the Family Medicine (GMF) group, Kovacina said, is consistent and stable employment. With the high turnover of nurses and administrative staff, it is difficult to establish continuity when people are being replaced frequently.
He said improving wages and working conditions could help make these jobs more attractive.
Kovacina said technological improvements could also help simplify medical records, telephones and communication systems.
Dr. George Zaarour is proud of his clinic’s modern approach.
Zaarour is the medical director of District Medical, a GMF in Ahuntsic, which has a large number of clients on both ends of the demographic spectrum – young families and seniors.
A team of 30 family physicians and 10 part-time specialists supervise 24,000 registered patients.
“We have the bell station fully registered,” Zarour jokes.
It is impossible to manage such a large patient load over the phone, so patients are encouraged to schedule their appointments online. The clinic also runs Facebook and Instagram pages to inform patients of its various services.
The Hawthorn Clinic is located in a culturally diverse neighborhood. Many of her patients are newcomers to the county, so the administrative staff is trained in how to help them use the health care system.
There is also a mentoring program for new doctors, to teach them how to fill out documents and share lab applications online, which saves a lot of time.
“We are a group of recent graduates,” Zaarour said. “Our average age is probably 34, 35. We practice differently than anyone who has been in practice for 20 years.”
He would like the county to give family physicians more freedom to decide what’s best for their clinic and their clients. Hawthorn, he said, is open to meeting whatever standards the county sets, but “stop stopping me from being creative, and give me flexibility.”
Consult community clinics
A good starting point, Zaarour said, is to give individual regional health boards — in his case, CIUSSS du Nord-de-l’Île-de-Montréal — more autonomy over how they set their budget.
For a clinic the size of a medical district, there would have to be eight nurses, but to have only one, the doctors at the GMF had to hire themselves. They were about to hire four more but couldn’t get the regional health board to pay the first nurse’s salary.
“How would one nurse want to meet the needs of 24,000 patients?” Zaarour said. “It is an impossible task.”
He would also like to see the Ministry of Health consult doctors extensively, to find out what works and what doesn’t.
In Montreal, Zaarour suggests that the county sit down with medical directors in 10 large, well-managed groups to talk about best practices, ways to improve certain programs, and how to address labor shortages.
“If the rules and financing [are] Zaarour said, “One size fits all approach, it will always fail. Let’s work on funding the nurses. Why don’t we find nurses? Why can’t we keep our nurses?”
The three CBC family physicians spoke with hope that no matter who wins the election, the outcome will be the start of an open conversation about how best to provide front-line services to Quebecers.
“This is how we are going to make it more transparent,” Kovacina said.
Murray would like to see a more collaborative approach to care. She says family medicine is not about putting patients through a regimen as quickly as possible, but about taking the time to listen to patients and assess their true needs.
“No one would benefit from having a family doctor who should be forced to do that job,” Murray said. “Patients will notice, which is bad for everyone.”