Freeing doctors from their role of gatekeeper

Want to go into a bar? You will first have to go through the doorman. While he scans you to see if you are worthy of the place, the other customers wait in line.

In our vast health care system, the family doctor plays the role of gatekeeper. He is the key, the one you have to go through to access other professionals.

And there too, there is queue. No less than 880,000 Quebecers are currently waiting for a family doctor. Without it, they are too often condemned to follow the walls of the network without succeeding in entering it. Or to go overcrowding emergencies.

The Legault government is impatient with this expectation, which violates its promise to offer “a family doctor for every Quebecer”. Hence the standoff between him and general practitioners.

We wrote it before: GPs will need to find a way to follow more patients. But we must also broaden the discussion beyond the simple equation “1000 patients per family doctor”.

Several health management experts believe that the current debate must affect the organization of care and the distribution of tasks between family physicians and other actors in the network.

We know that great progress has been made in recent years to give more responsibilities to nurses and pharmacists. However, very recent research from CIRANO shows that the distribution of tasks is not yet optimal between doctors, the different types of nurses and patient attendants.

It mentions concrete examples of tasks that could be shared between doctors and nurses. Depending on their training, this ranges from back pain assessment and postoperative wound management to medication review.

Consult CIRANO’s research

This is without counting health professionals such as physiotherapists, psychologists, nutritionists, occupational therapists, etc. Even within the public network, a referral from a physician is often requested before referring patients to these services. And still too many private insurers require this reference to reimburse the treatments of their clients.

It seems normal to have to consult a general practitioner before a specialist doctor. But could patients be taken care of by multidisciplinary teams of which the general practitioner would not always be the point of entry? This is the spirit of family physician groups (FMGs), but it is far from optimal everywhere. And with the electronic medical record and advancements that make information easier to share, is it absolutely necessary that there is only one conductor per patient?

Some of these questions are not new. They are complex and we do not claim to have the expertise to answer them. But the time seems right to go into them further.

Another taboo question: does every Quebecer really need a family doctor? Is this the case, for example, of a young 25-year-old who is bursting with health? In an ideal world, no doubt. In our dysfunctional system, is this a priority? We will not find an answer if we do not ask the question.

Finally, there is the fact that family physicians spend 40% of their time not in the office, but in the hospital. In doing so, they provide essential second-line care. But they weaken the first. And a weak first line exposes everything else in the network.

There is obviously no simple solution. Every weight that is removed from general practitioners invariably falls on other stakeholders – medical specialists on one side or nurses on the other. However, they are not precisely in surplus. This does not prevent researchers like Réjean Hébert, former Minister of Health, from believing that we could give back a role of attending physician to specialists rather than using them as “consultants”.

François Legault asks a legitimate question when he wonders if some family doctors could follow more patients. But the reflection must go beyond squeezing 1000 Quebecers per family doctor to fulfill an electoral commitment.

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