allison hanes: more constraints on doctors won't fix quebec's health-care crisis
health minister christian dubé needs to face up to the reasons for the exodus from the public to the private system.
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health minister christian dubé pulled a fresh bandage out of his first-aid kit to staunch the hemorrhaging in quebec’s ailing health system this week, the latest in a series of proposed remedies that miss the real cause of the bleeding.
before christmas, dubé intends to introduce legislation that will force newly trained doctors, both generalists and specialists, to practise in the public system to compensate for the significant investment the government makes in their medical education.
on paper, he makes a strong case. quebec desperately needs doctors; more and more physicians, including new graduates, are opting out of the régie de l’assurance maladie du québec to join private clinics; and each newly minted doctor costs the public purse between $435,000 and $790,000, according to figures provided by dubé.
the increase in physicians flocking to private health care is, of course, a serious concern. the rate has gone up 70 per cent since 2020. although the vast majority are still in the public system, about four per cent of doctors now work exclusively in the private sector, or 775 of 22,479 physicians in quebec. when two million quebecers are lacking a family doctor and wait times for a consultation with a specialist stretch beyond medically acceptable limits in some cases, every lost md hurts.
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but dubé needs to face up to the reasons for this exodus: the public health system has become more onerous to work in, while the private sector has grown unfettered. difficult working conditions are essentially driving doctors into the waiting arms of for-profit clinics.
and that’s only part of the problem.
quebec is facing a critical shortage of family physicians in particular. as more older doctors retire, too few new ones are trained to replace them. despite opening up more space in medical schools for general practitioners, more than 650 spots in family medicine over the past decade have gone unfilled. and last spring 70 of 75 vacant residency positions in family practice in all of canada were in quebec. for years now, family medicine has fallen out of favour with new graduates.
why? the causes include too much paperwork, a frustrating process to obtain a special permit (known as a prem) dictating in what region or subregion a doctor can practise, additional duties like working in nursing homes or birthing centres, and pay disparities with specialists.
but one of the biggest reasons is the devaluing of family doctors by blaming and shaming them for not doing enough to prop up the broken system.
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since the same factors that are driving doctors out of the public network are causing many to avoid family medicine in the first place, it’s hard to see how treating new graduates like military conscripts is going to make the specialty more attractive. maybe indentured servants is more like it, with premier françois legault saying he’s ready to invoke the notwithstanding clause for good measure.
legault peddled these ideas — both making doctors pay back the government for their degrees if they don’t work in the public system and using the constitutional override — in 2002, back when he was health minister in a parti québécois government.
quebec always goes for the stick — and it never seems to work. why not try the carrot? facing its own shortage of family physicians, ontario just announced it is going to offer $88 million in grants to cover tuition and other expenses for medical students who commit to staying and practising as family doctors in the province.
the fédération des médecins omnipraticiens du québec, representing gps, has proposed incentives of its own. but the government hasn’t embraced any of these alternatives.
instead, dubé is threatening unspecified penalties to get back what doctors supposedly owe quebec taxpayers for their education and legault is vowing to override their rights. that’s one heck of a recruitment campaign.
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of course, the biggest blind spot in dubé’s vision is the fact that the parallel private system that has grown so much under the legault government’s watch is luring away so many of the doctors it is trying to press into service.
the collège des médecins recently urged the government to hit the brakes on the expansion of private care. it argues that the increase in private medicine has not improved accessibility or reduced costs — quite the opposite.
since it was first elected in 2018, the coalition avenir québec government has favoured a role for the private sector, so the government has been reluctant to rein it in. but it’s clear quebec has reached a point where private medicine isn’t complementing the public system, but compromising it.
questioned about the collège’s call in the national assembly tuesday, dubé finally admitted it might be time to wean the province off private care. hey, he might even include some parameters in the forthcoming bill to restrict the flight of doctors, he added, without providing details.
it seems like more improvisation in a strained public system already reeling from disruptive reforms.
a few weeks back, dubé floated the idea of taking away family doctors from quebecers lucky enough to have a gp and reassigning physicians exclusively to 500,000 vulnerable patients with chronic health conditions. everyone else could just use the guichet d’accès à la première ligne (gap), the new central booking service that matches orphan patients with appointments, wherever they may be available.
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amid an outcry over how this would undermine preventive medicine, leave more patients without a primary care provider and potentially cost more in the long run, dubé walked back the proposal. but here’s betting we haven’t heard the last of this alarming concept. desperate times call for desperate measures.
while all this is playing out, santé québec, the new arm’s-length agency, is set to take over daily management of the public health system on dec. 1. it is led by a veteran of private medicine, geneviève biron, formerly of biron health group. in preparation, many civil servants from the health ministry are being transferred over to santé québec, promoted to management and given 10 per cent raises. meanwhile, rumours are swirling of impending budget cuts at hospitals.
a new agency … more bureaucrats … additional constraints on doctors … and less money for the institutions that actually provide health services. once again, this is the wrong prescription for fixing public health care in quebec.
correction: an earlier version of this story gave 2012 as the date when françois legault served as health minister in a parti québécois government and championed using the notwithstanding clause and financial clawbacks against doctors not working in the public system. the correct date is 2002.
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