Why Quebec’s family doctor crisis is the worst in Canada

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Lucie Deschamps and her husband, Gaëtan Vallée, had suspected for a while that their family doctor might stop working because he was in his 70s, though he smiled and remained vague whenever they asked him.

Finally, during an appointment with Ms. Deschamps in 2021, the doctor confirmed that he was retiring. And his news came with a second blow: The two other physicians in his office, on the top floor of a medical building south of Montreal, already had full caseloads and wouldn’t take the couple.

“I felt abandoned,” Mr. Vallée recalled. He and Ms. Deschamps had joined 828,000 other Quebeckers looking for a family physician. The average wait to find a doctor in their area is one year; more than 17 months later, they are still looking.

Quebec has long had the highest rate of people in Canada without a regular physician. Part of the reason for the scarcity is that for nearly 30 years now, younger general practitioners have had to do compulsory shifts in short-staffed hospitals and other public facilities, a practice known by the French abbreviation AMP.

AMP duties made family doctors less available for primary care, leading “orphan patients” to turn to hospitals, said Maude Laberge, a health economics researcher at Laval University. “By trying to solve a problem in the ER, we created another one.”

The union representing family doctors now wants to propose a way out from the AMP. They expect to have a plan for the Health Department after the Christmas break, said Marc-André Amyot, president of Quebec’s federation of general practitioners. “We want to present the ministry with a new way of looking at the issue,” he said.

The AMP system began when the health minister in 1990, Marc-Yvan Côté, unveiled a White Paper that said too many physicians worked in personal practice in urban areas, to the detriment of hospitals and remote regions.

As a result, younger family doctors were mandated to work 12 hours per week at hospitals, nursing homes or community clinics.

“We created a culture in Quebec where family doctors do all kinds of things,” said Mathieu Pelletier, a GP in Saint-Charles-Borromée, north of Montreal. “We have family doctors who provide intensive care, who do adult hospitalizations, pediatric hospitalizations, childbirth, ERs.”

The AMP system remains in place because the understaffed health care system relies so much on it. Any change would have to be gradual, Dr. Amyot said. “It’s the twisted downside of the rules. [Family] doctors were required to work in hospitals, so they did. Then, oops, this stripped away the primary care.”

Another measure, local staffing plans (PREM in French), determines the number of family doctors who have to work for a minimum number of days in a region, to ensure that peripheral places aren’t neglected.

However, the need for GPs is now most acute in Montreal. While regions like the Lower St. Lawrence Valley and the Gaspésie have a 90-per-cent rate of access to family doctors, it’s less than 70 per cent for Montreal. In a poorer Montreal district like Côte-des-Neiges-Park Extension, the rate is only 63 per cent.

Furthermore, only a third of Quebec family doctors are even close to doing that type of medicine full-time. Based on public health insurance data, from 2000 to 2020, just 33 to 39 per cent of Quebec GPs claimed 90 per cent or more of their billings from family medicine.

Quebec’s breakdown of how much physicians bill for family medicine is the most comprehensive to be made public in Canada. A Globe and Mail examination published Saturday revealed significant gaps in data in other provinces, meaning that most Canadians don’t know how many hours family doctors are working, or how many are splitting their work between office-based primary care and practising in hospitals, nursing homes, walk-in clinics or sports-medicine clinics. The lack of information is hindering the provinces’ ability to deal with a growing crisis.

As it became clear last year that Premier François Legault couldn’t deliver on his past electoral pledge to give every Quebecker a doctor, he complained that some GPs weren’t signing up enough patients. ”My patience has hit its limit,” he said.

Family doctors like Dr. Pelletier and Sophie Bernier reject that characterization. Dr. Bernier, who works in Roberval, north of Quebec City, said local family doctors help whichever department is short-handed at the regional hospital. Two years ago, it was obstetrics; last year, emergency medicine. “It’s ridiculous to judge our workload by the number of patients,” she said.

Percentage of people in Quebec

with a family doctor

As of Feb. 28, 2021, by local services network

75

80

85

90%

N.L.

Northern

Quebec:

84.5%

QUEBEC

PEI

N.B.

Quebec City

N.S.

ONT.

U.S.

Gatineau

Montreal

Lanaudière-Nord:

80.6%

Laval:

79.6%

Nord de l’Île-

Saint-Laurent:

65%

Jardins-

Roussillon:

77.2%

MURAT YÜKSELIR AND YANG SUN /

THE GLOBE AND MAIL, SOURCE:

QUEBEC HEALTH DEPARTMENT

Percentage of people in Quebec

with a family doctor

As of Feb. 28, 2021, by local services network

75

80

85

90%

N.L.

Northern

Quebec:

84.5%

QUEBEC

PEI

N.B.

Quebec City

N.S.

ONT.

U.S.

Gatineau

Montreal

Lanaudière-Nord:

80.6%

Richelieu-

Yamaska:

82.9%

Laval:

79.6%

Nord de l’Île-

Saint-Laurent:

65%

Jardins-

Roussillon:

77.2%

MURAT YÜKSELIR AND YANG SUN /

THE GLOBE AND MAIL, SOURCE:

QUEBEC HEALTH DEPARTMENT

ACCESS TO A FAMILY DOCTOR IN QUEBEC

Percentage of people with a family doctor

As of Feb. 28, 2021, by local services network

75

80

85

90%

N.L.

Minganie:

72.7%

Caniapiscau:

63.5%

Northern

Quebec:

84.5%

QUEBEC

PEI

N.B.

N.S.

Quebec City

ONT.

Montreal

U.S.

Gatineau

Laurentians:

83.2%

Lanaudière-Nord:

80.6%

Richelieu-Yamaska:

82.9%

Laval:

79.6%

Argenteuil: 85.6%

Nord de l’Île-

Saint-Laurent:

65%

Pommeraie:

89.5%

Jardins-

Roussillon:

77.2%

ONT.

U.S.

MURAT YÜKSELIR AND YANG SUN / THE GLOBE AND MAIL, SOURCE: QUEBEC HEALTH DEPARTMENT

Once they lost their doctor, Mr. Vallée and Ms. Deschamps called a dozen places without success. They found a GP but he was an hour’s drive away – if traffic is light. So they turned to a private clinic. Now, they have access to a doctor but it costs them $165 each visit.

A growing number of Quebec GPs have quit the provincial public health insurance plan, with many heading for private clinics where patients pay out of their own pockets. A decade ago, under 20 family doctors would opt out each year. In 2020, it was 32, last year 48 and so far this year, 74.

Their patients aren’t necessarily wealthier but rather are people who are unable to find a physician in the public system. Lorraine Paquette, for example, a 73-year-old cancer survivor in Sainte-Anne-des-Lacs, north of Montreal, lost her family doctor to retirement.

Her prescriptions are renewed by the surgeon who treated her cancer “but for all my other problems, my only recourse is the private sector. It goes without saying the cost of private consultations is beyond my budget,” she told The Globe. So she does her best to stay healthy with Pilates and walking, while worrying that she’s developing diabetes. “All I want is a checkup.”

And a family doctor remains the obligatory point of entry to many other services, Mr. Vallée discovered after cracking his sternum and breaking a finger in a car crash last February.

He had to see a physician for his claim under Quebec’s no-fault auto insurance plan. He needed a doctor’s referral to get physiotherapy. “The family doctor is at the heart of everything,” he said.

For GPs, this pivotal role means increased paperwork. Both Dr. Pelletier and Dr. Bernier spend at least a day a week on administrative duties.

Some of these are essential. They need for example to work the phones to help patients stuck waiting for elective surgery. But too often they are bogged down with lengthy insurance or workplace injury forms, just to reconfirm the status of people already diagnosed with permanent ailments.

Dr. Bernier has to examine workers with permanent hearing loss each time they need new hearing aids. She has to recertify that a patient whose hand was amputated still requires accommodations at his workplace. “It’s absurd. His fingers aren’t going to grow back.”

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The shortage of doctors in Quebec was compounded by other past decisions, said University of Montreal health policy professor Régis Blais. He noted for example that in the early 1990s, medical-school admissions were capped because the population wasn’t growing. Later, cost-cutting efforts under then-premier Lucien Bouchard resulted in more than 500 GPs taking buyouts and retiring early.

“It’s all interconnected,” Prof. Blais said. “If something is missing somewhere, if there’s a shortage in primary care from front-line doctors, then there are people who end up in the emergency room.”

Earlier this year, Quebec Health Minister Christian Dubé unveiled changes that included a service known as GAP, an online portal and phone line for those who need care but are still waiting to be signed up with a family doctor.

GAP users are redirected to either a physician, nurse practitioner, pharmacist, or other professionals. By counting people eligible for GAP, Quebec says 89 per cent of the population has access to primary care. Before its introduction, the rate of people registered with a doctor hovered below 80 per cent.

Easier access is not the same as being permanently signed up with a family doctor, Prof. Laberge said. “It’s not a comprehensive follow-up of their needs. It’s a workaround, but it doesn’t fix the root problem.”

With the GAP, Quebec is in effect trying to catch up with provinces like Ontario, where nurse practitioners have a broader role in primary care, Prof. Blais said.

By uncoupling access to primary care from being the sole preserve of GPs, he said, the government is acknowledging that its promise to get each Quebecker a family doctor is not realistic.

Data analysis by Yang Sun

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