On the evening of June 18, 2002, paramedics were called to respond to an emergency. A man suffered a cardiac arrest and needed to be rushed to hospital. The man, who lived 300 meters from the Shawinigan hospital, needed resuscitation maneuvers.
However, when they arrived at the emergency room, the rescuers came up against closed doors, for lack of an available doctor. The paramedics then turned back and headed for the Trois-Rivières hospital, located 43 km away. During transport, half an hour later, the man died.
The media reported the tragedy and the news quickly spread across Quebec. The bereaved family later filed a $1.2 million lawsuit against the Shawinigan doctor and hospital.
In response to the discontent, the Minister of Health at the time then gave himself the power to assign general practitioners by way of bailiffs to emergencies that were understaffed. The minister’s decision had created an outcry within the medical profession, many seeing it as an abuse of power.
Law 142
Following this event, the Minister of Health was to impose Bill 142. This law made it possible to enforce the staffing plans of each region and to ensure that family doctors were directed to hospitals thanks to this called special medical activities (AMP).
Twenty years later, ART is still part of medical jargon. AMPs are an obligation for the family doctor to carry out a minimum of 12 hours of practice in certain sectors such as hospital emergencies, care and follow-up of vulnerable patients, short-term care, obstetrics in institutions, and care in CHSLDs and rehabilitation centres. Sharp observers will have noted that three of the first four sectors are in the hospital.
However, if initially the AMPs were imposed on all general practitioners, the Minister of Health would subsequently introduce a disparity clause for new family doctors with less than 15 years of practice. These are the only ones who have to contribute to MPAs.
side effects
We collectively paid a very high price for this decision by the Minister of Health to impose AMP on new family physicians. Now, many doctors prefer to work in an environment like a hospital where there is quick access to technical platforms, laboratory services, radiography and various specialists for consultation. And with AMP, some have come to give only 25% of their time in the clinic for the care and follow-up of patients.
Yet it’s an open secret that health systems that are heavily frontline oriented are more efficient and cost less.
Primary care is the first contact citizens, families and the community have with the healthcare system. The goal is to bring health care close to where people live and work. Thus, we want to create a privileged link between the patient and the clinician, to offer health services according to needs, to carry out prevention and to direct patients towards more specialized levels of care when the situation requires it.
It seems to us that instead of imposing disparity clauses on new family doctors, we should rather train more of them, incorporate them into dynamic teams, assign them mentors, associate them with medical assistants so that they see more patients, equip clinics well to attract and retain them, and create care networks with other professionals.
The constraints imposed on family physicians have led many medical students to avoid family medicine residency. Since 2014, an estimated 425 family medicine training positions have remained vacant. However, as said the Dr Louis Godin, former president of the Fédération des médecins omnipraticiens du Québec, it is not by waving the stick that we are going to ensure that medical students choose family medicine.
A “GAP” with reality
The percentage of patients registered with a family doctor has stagnated for several years at around 80% in Quebec. Regions like Gaspésie have rates of access to a family doctor of 90%, but in Montreal, this percentage is close to 70%.
To solve the problem, the Minister of Health launched in June 2022 the first line access window (GAP). The goal of the GAP is to help people without a family doctor to obtain a medical appointment. To do this, GAP users are referred to doctors, nurses, pharmacists and other professionals according to their particular health needs. With the GAP, Quebec says that 89% of the population would now have access to primary care.
But having access to primary care without seeing a family doctor or a specialized nurse practitioner can pose a real risk of falling through the cracks if there is no care or follow-up. And this lack of frontline access invariably leads to overuse of the emergency department.
In addition, the realities of large cities are very different from those of the regions. Hence the importance of consulting local authorities to find out what the needs are and to seek solutions specific to each region.
A horse remedy
Claude Castonguay, former Minister of Health, sounded the alarm in 2016, saying that AMPs had had their day: “This system must be finished so that doctors can practice within their communities, close to their patients. In return, specialists will necessarily have to become more involved in the proper functioning of emergencies. »
Although Mr. Castonguay’s remedy may seem drastic with the current shortage of doctors, he is still somewhat right. Family physicians must not bear the brunt of disorganization in hospitals, bureaucratic heaviness, union intransigence and the disengagement of certain professionals.
Currently, new family physicians do everything, and not enough of each task. However, the first line must be the strongest element of the network precisely to try to prevent patients from ending up in hospitals.
Young people are the next generation, they have the energy and the ideas to help make their clinics innovative and enjoyable places. We must reduce the organizational and bureaucratic barriers that deter them from choosing family medicine and give priority to the first line of health care.