Quebec wants to force family doctors to see more patients. Is that the way to fix primary care?

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Quebec Premier François Legault is exasperated with the province’s family doctors.

Back in 2018, when his Coalition Avenir Québec was running for office, they promised that every citizen would have a family doctor by the end of their mandate. The “chicken in every pot” promise was a popular one, helping propel the CAQ to victory.

Back then, there were 400,000 Quebeckers without a family doc. Today the number is 857,000. (The province has a centralized Guichet d’accès à un médecin de famille, or GAMF, where residents can register and be assigned a doctor, at least theoretically.)

So Mr. Legault is on the warpath.

At a news conference last week, he thundered “my patience has run out” and threatened legislation if the province’s 10,000 family physicians don’t put a big dent in the waiting list by accepting more patients.

The Premier even brandished a blacklist of physicians he said were not pulling their weight – a binder full of laggards, if you will. He said they could expect big pay cuts if they don’t pull up their socks.

The CAQ government wants every family doctor to have a roster of at least 1,000 patients. According to provincial data, 52 per cent have fewer than that magic (read: random) number and 14 per cent have fewer than 500 patients, and/or work less than 150 days a year.

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Mr. Legault has had this bee in his bonnet for a long time. Two decades ago, when he was health minister in a Parti Québécois government, he introduced legislation that would cut the pay of physicians by 30 per cent if they did not meet productivity standards. The Liberal government eventually passed similar legislation but it was never enforced.

A lot of what the Premier says on this issue is complete nonsense and his ham-fisted solution is ridiculous.

The vast majority of family physicians work full-time hours, and then some.

But 70 per cent of family docs are women, many of them of child-bearing age, and they choose family medicine and part-time work specifically to have a better family life. Punishing them for doing so – which is what the threatened legislation would do – is preposterous and counter-productive.

Quebec, unlike most provinces, forces family physicians to work at least 12 hours a week proffering care in “priority areas” such as emergency rooms, hospitals or long-term care homes. This law takes them away from their clinics one to two days a week and forces them to have fewer patients.

The province also severely restricts where physicians can practise, a rule that is supposed to ensure care in rural and remote areas but whose unintended consequence is that it is virtually impossible to get a family doctor if you live in a big city such as Montreal.

Access to primary care is a serious issue in Quebec and all of Canada. That millions of Canadians do not have a primary care practitioner (a family doc, nurse practitioner or multidisciplinary care team) is a travesty.

The system is completely dysfunctional from the way we train family doctors through to the way we pay them.

Mr. Legault, in a back-handed manner, has drawn attention to this reality. But the solution is not to bash doctors, it’s to fix the system so doctors can work more efficiently, and we can get more bang for our health care bucks.

Quebec’s Premier is right when he says that doctors have little or no accountability within our public system. Most doctors are independent contractors with only the vaguest of contracts.

We pay family physicians on a fee-for-service basis, for treating one thing at a time, when we should pay them to treat people with complex chronic conditions, not specific ailments.

The big unspoken question in this political drama is: What are the metrics for measuring the performance of family physicians?

Having 1,000 patients on a roster is one potential metric, but a crude one, especially since “having a doctor” does not guarantee getting an appointment. (Only 43 per cent of Canadians can get a same-day appointment with their doctor.)

We actually have very little idea what doctors do, and almost no data on outcomes. As the adage goes, you can’t manage what you don’t measure.

We need to fundamentally rethink how primary care is delivered and paid for. That’s going to take collaboration, co-operation and political risk-taking.

Mr. Legault is right about one thing: We need a profound change in health care culture. But waving around blacklists and issuing threats is not going to improve access to care, or quality of care, for anyone.

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