Family doctors warn private medicine is becoming a 'trend' in Quebec

Trend in Que. towards private medicine Family doctors in Quebec see private health care as a viable way to practise medicine without government interference.

Family doctors in Quebec are warning that the health ministry's latest attempt to legislate how primary care is delivered will only help drive more general practitioners out of the public system and into private health care.

"I think it's something to worry about. I think it's a bit of a trend," said Dr. Isabelle Leblanc, a GP at St. Mary's Hospital who's also the president of the group Quebec Doctors for a Public System.

"We teach family medicine residents. It's only been a few years that people actually graduate thinking that they're going to go work in the private system because they feel that's what's best for them," said Leblanc.

That is, when they choose to specialize in family medicine at all.

"There are 75 residency posts that were left vacant in family medicine last year. It will be catastrophic this year," the president of the province's federation of family doctors (FMOQ) said candidly in an interview.

Dr. Marc-Andre Amyot who only took over as head of the FMOQ in December 2021, said a colleague who is interviewing students for residency slots in family medicine reported to him that many "try to find a post elsewhere in Canada."

"And, yes, it preoccupies me that doctors leave for the private system," he said.

"It's an enormous problem. It's sad. We favour a strong public system and we have to attack the problem in a big way," said the GP of 30 years.

Unfortunately, some say the private sector option became even more attractive following remarks made by Quebec's health minister and premier last October about how "they're going to find the lazy doctors and punish them," Leblanc said.

"I think that is a reason why so many people are considering going private," she said, describing a culture of disrespect that "drives some people away."

"We have to stop the doctor-bullying, value family medicine, and make the practice attractive," along with providing doctors with key support from other professionals, according to Amyot who is based in Joliette.

He describes a vicious circle where the government has promised investments in mental health services, while at the same time telling the federation "we're missing psychologists, we're missing personnel."

But the province is also short 1,000 family doctors, said Amyot, and "we can't keep assuming the entirety of first-line services."

None of this comes as a shock to long-time Montreal family doctor Mark Roper -- who also had a trainee doctor at his family medicine group -- who chose to remain in the city but start a practice outside the medicare system.

"One of the reasons he's going into private was the restrictions…he just didn't like the government's interference in his practice," Roper said.

There's a sense that the government is not interested in knowing what is happening on the ground, Leblanc said.

"It's not by imposing top-down decisions without talking to us, it's going to work," and access to primary care will be improved, Leblanc said adding a one-size-fits-all approach won't work.

"You can't treat people in Montreal the same way you treat them in Baie Comeau or Ormstown," because there are different needs and demands in each region.

So the government's plan to further manage their workflow in one broad stroke in Bill 11, the subject of a parliamentary commission in February, was seen by some doctors as excess meddling.

Some elements of Bill 11 even create ethical issues when it comes to their mission to provide family care, doctors suggest.

That concern revolves around a new primary care access hub that's being quietly rolled out in Montreal and is already functioning in other parts of the province.

The doctors don't have any quibble with improved access to health care, they say, on the contrary.

However, they don't think it makes sense that they would have to take on patients from the waiting list in their region, but wouldn't be permitted to sign up the family members of the patients they already have.

"Bill 11, in its current form, won't fix anything," Amyot said.

Roper takes the same stance." I don't see any redeeming factors in it," he said.

"I'm for ease of access for people booking appointments with doctors who are available of course," he said, but "this is planning gone crazy."

He said the government already tells GPs where to work and for how many hours, in the emergency room or long-term care home for example, in addition to their regular office hours for patients.

Above all, Roper doesn't think the new legislation will do anything to solve what he sees as a persistent problem of inequitable distribution of doctors around the province, a result of the government's system of handing out permits to practice (PREMS).

To that end, Roper and a lawyer will face off against health ministry civil servants in court on March 7 and 8 and his lawyer Julius Grey is expected to use ministry data to show why Montreal in particular needs more family doctors.

"What I see happening is a private system developing in the areas close to 60 per cent [patient] registration rates that are not getting any increases...and I see patients being pushed back to their home territories for primary care," he said.

'EVERYBODY SHOULD HAVE ACCESS TO HEALTH CARE'

A registered nurse and manager who worked for decades at most of Montreal's major hospitals made the switch to the private sector - and has no regrets.

John-David Couturier now runs the Canada College Health Centre, a private clinic downtown that offers appointments with family doctors and urgent care, all for a price.

"I want people to understand that I left the public health sector, not because I wanted to," said Couturier, but because he felt he had no choice.

He was "convinced that the public health-care system cannot offer me what I need," which is better working conditions, he said.

Given the shortage of human resources in the province, he believes that public and private services "need to be side by side."

The clinic opened in the fall, at first to provide care for the private college's many international students but it's now growing in popularity with the local population, he said.

So far, they employ two part-time family doctors and are looking for specialists.

And he said there is interest from doctors who "want to quit and come with us now, quit the public, because we're brand new, all new equipment. It's like we're family," he said.

"They won't have the pressure. They don't have a number of patients to see per day."

The head of the FMOQ understands the appeal. "You see all the ads?"

Amyot is referring to ads for a large network of private clinics around Quebec that have been airing frequently in both languages throughout the pandemic.

Its website boasts the private enterprise is expanding its reach, with new operating rooms already open in Quebec City and another opening in Laval in March.

"The environment appears to be agreeable so it's attractive for doctors," Amyot said, to perhaps ditch what he describes as layers of imposed government rules, that he said don't do anything to improve patient care.

But he and others like Leblanc who are monitoring the creep of such clinics say it's "bad for the population."

"I personally profoundly think that everybody should have access to health care and I think it's troubling that some people cannot have the health care they deserve because they can't pay."

"As a rich society as we are, we can make sure that people can have medicare for all," she said.

Roper takes it a step further. "Send the bill to the government and say you couldn't find me a doctor in the public system. I had to go to a private system, here's the bill," he said.

IS THE GOVERNMENT PAYING ATTENTION?

Leblanc does not get the impression the Quebec government understands the impact on the network when even a few general practitioners leave medicare to set up shop on their own.

"I don't think they realize the harm it's going to do," she said especially since there has been a parallel private system in place for so long, and because it's a system successive governments have relied upon to a certain extent to pick up the slack, especially when it comes to surgeries.

But she points out that the private sector can't do all the heavy lifting.

"Those GPs see patients in the private system but the moment the patient gets a tiny bit sick, they're back into the public system, right? This is not a real private system," she said.

"There are issues. People are jumping the queue by doing that," since the majority of the population can't afford regular private consultations and are left to wait for care.

CTV News has emailed the health ministry twice to ask if they monitor how many family doctors are leaving to work in private practices but has not received a reply.

As for exactly how many family doctors go private permanently, that's difficult to determine because doctors in Quebec are permitted to go back and forth between public and private.

They simply have to give Quebec's health insurance board (RAMQ) 30 days' notice before they disconnect from medicare to work in the private sector for any length of time. They are then deemed ‘non-participants,' by RAMQ.

Physicians are required to give eight days' notice when they want to return.

So any doctor who is now on the very long and publicly available list of non-participants may very well return after a few weeks or months.

However, according to data RAMQ provided to CTV News, between 2011 and Nov.15, 2021, a total of 389 doctors left the public medical system and haven't returned.

That breaks down to 124 specialists and 265 general practitioners.

The numbers fluctuate from year to year. Eight GPs unlisted from RAMQ in 2014, for example. That jumped to 30 in 2015 and fell to 23 in 2016.

The highest number of GPs who became non-participants over the last decade, 51, was in 2021.

It's also hard to know for certain why they cut ties with RAMQ and if indeed they went private, though it appears likely, because RAMQ spokesperson Caroline Dupont said they can eliminate a few other reasons they disconnect.

"Physicians whose permit to practice is not valid are excluded from the numbers if, for example, they are deceased or if their licence was suspended, and RAMQ was advised," Dupont explained in an email.

Likewise, doctors who notify RAMQ they've retired, or who move out of province and change their address online aren't placed in the non-participant category.

They're simply considered to be doctors who can no longer bill them for services rendered.

While the absolute number of non-participants is low given that Quebec's College of Physicians had 11,799 family doctors listed on its registry as of March 1, 2022, when just one family doctor leaves the public system hundreds of patients can find themselves without primary care.

"If all of these people [GPs] came back in the public system and had an appropriate amount of patients, the waiting lists would be much shorter," said Leblanc.

SOME HELP ON THE HORIZON?

The government has slowly started rolling out a new program in Montreal that with one phone call is supposed to connect people who do not have a family doctor with a limited number of primary care services.

It is set to begin officially in Montreal in April after having been tested first in the Bas-St-Laurent, Saguenay-Lac-Saint-Jean region and the Monteregie.

Complete details on how the new gateway is expected to work, and which services will be available are here:

There will be a central number and all five of Montreal's health authorities, the CIUSSS as they're known, will refer people who call with a health issue to appropriate help where possible.

It will be called the Guichet d'acces a la premiere ligne in French, or GAP for short.

Amyot said he received assurances from Health Minister Christian Dube, that the GAP will be implemented.

It's a type of support, albeit at a preliminary stage, that his federation and other groups, including Quebec's College of Physicians have been asking for.

"It's about the work conditions rather than about the remuneration aspect," Amyot said.

"The minister told me they asked the establishments to put all the resources necessary so that other professionals can address the issues that don't require the expertise of a family doctor," Amyot said.

It will take time before it has any impact. The province is short of nurses and other professionals like psychologists who are most in-demand and so GAP offerings will be rather narrow for months, likely years, to come.

But it's a start.

"We agree with that and yes, it will help," Amyot said, adding they'll "take anything that will help," as long as it doesn't come in the form of new unnecessary legislation.

GPs need "the tools to allow them to treat their patients properly, and efficiently," he said, or the "exodus" may continue.