Some family doctors in Montreal are going private, with burnout and Quebec meddling to blame

MONTREAL -

The Quebec government’s latest attempt at telling Montreal’s family doctors they should be seeing more patients has landed with a thud, according to two general practitioners who said they are demoralized and tired of being micromanaged by the province.

The mental fatigue is so great, one family doctor said he knows of two colleagues in the city who have recently decided to leave the public health care system permanently and work in private medicine.

“What I hear on the ground is the burnout is palpable between physicians, between nurses, it is palpable,” said Dr. Mark Buch, 38, who runs a family medicine group (GMF) in Town of Mount-Royal and also works as a part-time emergency physician at the Jewish General Hospital.

• READ MORE: Quebec tables bill that would force family doctors to take appointments from patients on waiting list

Another GP even questions if the government’s actions of late: tabling Bill 11 that contains new regulations and recent disparaging comments about doctors’ work ethic are all part of a plan to allow more privatization to creep into Quebec’s health care system.

“Is that the intent of this manoeuvre, to make it so bad in Montreal that we start going to private doctors?" said Dr. Mark Roper, a family doctor who’s been practising in Montreal for the last 32 years.

After 11 years in practice, Buch has decided to stick it out in the public system but said he understands why two of his peers are opting out instead.

“Doctors are so frustrated and fed up with the disrespect that some are saying, forget it, I’m done, and I'm delisting off of RAMQ, I'm going to go private,” he said.

“And those physicians who go off RAMQ, I can tell you with 100 per cent certainty, they make less money than in the public system.”

Buch said that’s because they can decide to see fewer patients per day allowing them to spend the time needed with each patient.

“They can practise medicine with dignity. And that is not the case right now,” he added.

Roper, who is currently investing a lot of time and energy into fighting for a strong public health care system agrees.

“It takes a lot to succeed in a private practice,” he said.

He also lamented that with so many Montreal residents doctor-less and in need of care “nowadays it is more possible to have a successful private practice, unfortunately.”

The vast majority of GP’s have not plunged into the private sector, but Buch said he does know some who are considering it or who are going to work at hospital-based practices or at private businesses to get away from the pressures of primary care.

Taking early retirement is also now seen as a viable option, and may become a more palatable idea each time the government floats a new plan to change doctors’ workflow.

In addition, there is the cohort of female family doctors, who are starting families of their own and are placed in a no-win situation, Buch said.

“This entire concept is very anti-feminine,” he said referring to the province’s repeated theme that GPs don’t work hard enough.

Not all doctors can work six days a week as he usually does, he said, “because they have a family, they have to raise children… that's their personal choice, and their right as a professional to do that.”

“We see the mass exodus of nurses from the healthcare system. I can foresee the same thing happening with family physicians,” said Buch. 

MORE DOCS NEEDED IN MONTREAL

Does Montreal need more doctors?

Roper, also the director of the primary care division at the McGill University Health Centre's (MUHC) department of family medicine, answers this question with a resounding, yes - though the health minister disagrees.

The province sends doctors to regions that ostensibly need them through a permit system known as PREM --a regional physician resource plan. Roper would like to see the system suspended.

The PREM plan for 2022 was released in October.

In a few months, he’ll be voicing his critique on the record. Aside from running a busy GMF, he has initiated a legal challenge against the government, with a first court date scheduled for Feb. 22.

What’s his main quarrel?

Roper said he plans to argue that the government used flawed logic when it made its decision about how many doctors need to be allocated to each region to serve the local population.

Roper said he’s analyzed all the same health insurance board (RAMQ) data the health minister has access to --data which is publicly available.

He concluded that it makes more sense to figure out how many doctors are needed in a certain area, based on how many residents don't have their own doctor yet, while health minister Christian Dube, “is looking at the number of doctors working in an area,” Roper said.

Roper said that is a “flawed indicator” because it doesn’t take into account who the doctors’ patients are - more precisely, where they live.

He provided a few examples to bolster his argument, taking into account that the stated goal of the government is to register at least 85 per cent of the population in each territory.

Some regions are doing well in that regard. The Bas-St-Laurent region has a patient registration rate of 89 per cent. The Gaspesie-Iles-de-la-Madelaine is at 90 per cent.

“In Montreal, we’re at a 69 per cent registration rate overall,” Roper said, before zeroing in on a few areas to make his point about the doctor shortage:

• The Plateau Mont-Royal-St-Louis-du-Parc area of Montreal has only a 61 per cent patient registration rate.
• There are 68, 844 residents there who still need a family doctor.
• Next year the area is slated to receive 10 new GPs - however, it’s expected to lose seven doctors to retirement, for a net gain of only three doctors.

On the other hand, the Saguenay-Lac-St-Jean region, with a 92 per cent registration rate, and only 20,897 residents without a family doctor, is getting 17 new doctors, according to the PREM plan. With seven GPs expected to retire, that’s still a net gain of ten new doctors in the region.

That doesn't make sense to Roper.

“My argument is that the distribution of PREMS is flawed,” he said. “That’s resulted in this disparity, inequality of access to a family doctor.”

He also lays out the case and the need for more doctors in an area of Montreal called Cotes-des-Neiges-Metro-Parc-Extension, which includes the western part of the downtown core.

Here, according to his calculation is the most “extreme” example of what he called the government’s flawed analysis that highlights a different issue entirely.

That territory has a population of 252,334 people, 94,405 of whom are not registered with a family doctor.

Roper said the health ministry claims there are enough doctors in the area, it’s just that they aren’t working hard enough to sign up new patients.

"But the numbers on record show just the opposite," he said. "Doctors in the area have registered 270, 000 patients."

"So how come they registered 270,000 patients and there are only 250,000 people living in the area and there are still 94,000 people in the area who are unregistered?”

The answer he said, is that more than 50 per cent of the people who are signed up with a family doctor there live outside the region.

They could be people who work in that part of the city or who used to live there, for example - but they don't reside there now. Meanwhile, current residents are crowded out.

This is because of the concept of portability in Quebec, which means the right to seek health care wherever one chooses, is built into the province's health care system.

"You can’t take away portability of health care, but it’s not even appearing on Mr. Dube’s radar," Roper concluded.

His suggestion?

“If your [registration] target is 85 per cent and you want equity just throw all the doctors where you’re below 85 per cent,” and revamp the system as we know it.

The family physician’s arguments against the Quebec government’s PREM system will be tested in court over two days starting on February 22.

Constitutional and civil rights lawyer Julius Grey has taken on the case. .

‘ONLY SO MANY HOURS IN THE DAY’

Neither Roper nor Buch are optimistic Bill 11 will improve the system in any way.

The proposed legislation tabled by Dube on Thursday appears to be an effort to temporarily appease doctors by holding off on imposing financial penalties or on fixing specific targets for the minimum number of patients per physician.

Once again, it is being viewed largely as an example of government interference, that doesn’t address the real problems.

If the legislation passes, among other requirements, GPs would have to make appointment times available for people who are on the waiting list, likely some doctors said, at the expense of their patients.

"I don't think any doctor has difficulty contributing… but there are only so many hours in the day,” said Buch.

"I think it's quite insulting to sort of make a broad statement that we don't work hard enough.” he said, referring to Premier Legault’s pronouncement in late October, an idea later propped up in the National Assembly by Dube.

The accusation also rankles Roper, as someone who has been on the front lines of the doctor shortage battle in Montreal, with successive governments.

"It’s galling to see the mismanagement of the medical manpower situation by the health ministries and then they blame the physicians for their own shortcomings," said the general practitioner.

“A lot of these doctors are working in their private offices, working in long-term care institutions, in emergencies, exposing themselves to the COVID virus, and someone says, 'oh you only have 700 patients you should have 15 hundred.' No,” said Roper.

For the first 15 years of their practice family doctors are assigned various other jobs by their local health authority, Buch explained. If they decline, they get a 30 per cent pay cut.

“So there is no such thing as a full-time family doctor for the first 15 years of practice. That's just the system that we're in,” said Buch.

The assignments take them out of their offices from 6-12 hours per week. Each job comes with more paperwork and added responsibilities, he said.

“Contrary to what he [Dube] says, the doctors are working hard. He is just not measuring the right information,” said Roper.