Enough is enough: An exasperated plea from family doctors
By: Dr Laura Sang
Access to primary care for
patients without a family doctor is about to get even harder as of May 31 when
the government is shutting down the program "Projet de loi 11". This
program was instated in 2022, allowing family doctors to open walk-in
appointments to the public for patients without a family doctor. During its
operation over 900,000 patients (many of whom were vulnerable) were seen by
family doctors participating in this program according to FMOQ statistics.
Approximately 138,000 of them were individually rostered by a family doctor as
a result. While this was not a perfect solution for patients and family doctors
alike, it allowed for increased access to frontline care which ultimately
decreased the number of non-urgent visits to the ER.
We are currently short of about
1200-1500 family doctors in Quebec and have about 100 less practicing in the
public system compared to 2019 as per FMOQ statistics. What is the driving
force of the exodus to the private system and early retirement? It mostly boils
down to poor working conditions. Firstly, family doctors practicing in the
public sector are highly regulated unlike anywhere else in the country. PREMs
(regional physician resource plans) force physicians to practice predominantly
in a specific region - i.e. 55% of your billing must be completed within that
given region. Inasmuch, family doctors are held to 12 hours of AMPs
(specific medical activities) per week for the first 15 years of practice. A
physician can change AMPs every 2 years and must select their AMPs from the
list of available options, which can change every few weeks. Many physicians
are obliged to work mixed AMPs meaning they are forced to work in multiple
locations, which by default limits their availability for patient emergencies.
Any failure to comply with the PREMs and AMPs results in a 30% cutback on
physician billings to RAMQ. This is important as between licensure and overhead
costs in office (family doctors must pay clinic rent to work) it costs about 50,000$
a year just to be a family doctor. There is no paid vacation, no paid sick
days, no pension so we need to plan accordingly to secure our futures. We are
subject to similar restrictions as would be a salaried government employee
without any of the benefits. No wonder the private system may appear so
attractive to many, especially to new family doctors fresh out of
residency.
However, throwing more money at
family doctors isn't what is needed. Many people are leaving the public sector
because they have no other choice as they can no longer cope with the demands
in the public system. A national survey of physicians conducted by the CMA in
2021 showed that 48% of physicians tested positive on depression screening, 53%
signaled high levels of professional burnout, 49% were planning on reducing
their clinical hours or stopping working altogether over the next 2 years, and
79% had a low score for personal fulfilment. This is in part due to the
increasing patient complexity and lack of support from allied resources. Wait
times for imaging and specialist consultations are increasing. Many specialists
now act as consultants to be able to see a higher volume of patients. This means
that they cannot follow up their patients but instead will provide family
doctors with a list of recommendations of investigations and treatments. Family
doctors must then order imaging and trial medications before being able to refer
to the specialist. Another burden faced by family physicians is the
administrative burden, most of which is unpaid. Insurance forms, following up
test results and other various administrative tasks amount on average to
an extra 10 hours of work per week according to a recent CMA survey.
We have known about this
looming healthcare crisis for decades. It was never a question of if, only a
question of when. Its arrival is merely hastened by the COVID-19 pandemic and a
variety of other socio-political factors. It is time for action and
accountability on the part of our government. Primary care is the backbone of
our healthcare system. Without it, people will experience unnecessary morbidity
and mortality, and our healthcare system will pay more for it. Let us treat and
manage peoples' high cholesterol to prevent a future debilitating stroke. Let
us diagnose and control peoples' diabetes to prevent a foot amputation thirty
years down the road.
The proposed changes would
likely save the healthcare system money in the long run. We know what we need, but
we are waiting for a government that is willing to listen. We need to do away
with the PREM and AMP systems or at the very least be more flexible with
them. We need financial incentives instead of fines. We need compensation
for unpaid administrative tasks. We need safe workplace environments and reasonable
work hours for physicians, nurses, and all other allied healthcare professionals
to keep people from burning out. We need officials to stop making decisions for
us without us.
References:
https://www.cma.ca/latest-stories/profession-under-pressure-results-cmas-2021-national-physician-health-survey
FMOQ
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