How is our health system, exhausted by two years of pandemic, and on the eve of a “Dubé reform”? The emergency physician Alain Vadeboncoeur examines the Quebec medical profession in his new essay, to be published this week.
In To take care. At the bedside of the health system (Lux, 139 pages, to be published on August 18), the militant doctor enamels his beginnings of chapter by clinical cases, illustrating each time a bad fold.
In this 139-page review, we understand that the “nerve of the war” is stuck, that is to say the money and the remuneration of the doctors. The scans that once took an hour are now done in minutes. The invoice price did not decrease accordingly. Faced with them, psychiatrists cannot make their patient speak any faster. This is followed by salaries increased “a lot” and above all in an unequal way, with no benefit for the patient.
What prescriptions for an ossified model, doctor? “Pay by result. »
In the United States in particular, “they don’t look at how often you see your patient, they look at the health indicators and see if it improves”.
“If we leave the emergency room and come back after three days… You haven’t done anything”, concludes the Dr Vadeboncoeur. “We are quite hesitant to change the model to see if there are other things. We lack audacity in this area. »
Heal in the void
Another plague in health centers: “unnecessary” acts.
“Useless” for a medical specialist to treat patients in good health while a nurse could take care of them, observes the emergency doctor. However, this waste of specialized expertise is observed among gynecologists, psychiatrists, dermatologists…
The remedy, however, is progressing. Since 2020, the Institute for the relevance of medical acts has been flushing out unnecessary acts and tedious duplicates. Their most recent decision was to prevent pediatricians from caring for healthy children.
Amputating these “unnecessary” services will not be smooth, he warns. “A patient has been taking his annual blood test for twenty years, and overnight, he is told that he does not need it. There will be resistance. »
The hour of half-choices
Recent history shows that, faced with decision-making, Quebec has often opted for “half-choices”.
Family physicians, for example, are on both fronts. They spend a large part of their time in hospitals, while nearly a million Quebecers are waiting in line to be matched with one of them. “We have roughly the same number of doctors as elsewhere, but their task is more focused on the hospital. So on the front line, we are discovered. »
But some evils do not wait. Quebecers thus visit emergency rooms more than any other society in the world. “There are reasons for that, and it is the weakness of the first line”, observes the emergency physician for nearly 30 years. “We have always remained on half-choices. If it is family physicians who do hospitalizations, their number must be increased, that is clear. The same indecision strikes the construction site of the computerization of the network. However, Quebec had developed software capable of digitizing medical data in the early 2000s.
“In 2016, the government even signed a mutual agreement contract to acquire it and extend it throughout Quebec, which would have represented a major step forward,” he says in his book. “Except that due to legislative pressure, this contract was cancelled, and a call for tenders was then launched, but was not won by the same firm. »
This change of direction saddens the doctor. “If we had continued on the same path, the pandemic could have been a little different. »
The waltz-hesitation of Quebec around the privatization of the care seems however to have come to an end. “Ten or 12 years ago, there were several fronts at the same time,” recalls the ardent defender of the public system.
Who remembers the fevered enthusiasm around “PPPs”? “Most people understand that this is not the solution”, and the place of the private sector is no longer confined to “particular niches”, according to him.
Private initiatives often arise from the lack of flexibility of the public network, as the essayist doctor writes in his book. “The orthopedist Nicolas Duval, founder of the first private orthopedic surgery clinic in Quebec, has already told me that he had nurtured the project of creating a public clinic, affiliated with a hospital, and devoted to extra-medical orthopedic surgery. hospital, as there are successful models in other places. Faced with a refusal from the authorities, he then decided, out of spite, to leave the RAMQ to found his own clinic. »
The decision to open one of the first large private clinics in Quebec is therefore based on “expertise, volume, complications”, says Vadeboncoeur, rather than on “the method of remuneration”.
The more it changes…
The pandemic emergency will have shaken the columns of the temple to the point where the changes have taken place at high speed.
“It reminded me that the health network can move very quickly in a very coherent way”, notes the Dr Vadeboncoeur. The acute crisis over, the great liner that is the health system has resumed its cruising speed. It is now a question of knowing if the reform wanted by the minister Christian Dubé will refocus again the trajectory of the ministry to the budget of 54.2 billion dollars.
It is ultimately a kind of peer review of the “Dubé plan” that Alain Vadeboncoeur delivers to us in his new opus. The ministerial orientations presented this spring are “pretty cold, quite drab”, as usual. “But it corresponds to very living realities, which I have experienced, it corresponds to care, to patients. […] I wanted to come back to all these questions on which I reflected. »
“Stimulating”, therefore, this Dubé plan, but impressive in its magnitude. “Am I convinced that we can do all this? I have a small doubt. I don’t know if we’re strong enough. But, do we have a choice? It’s more that we have no choice, we have to do what, ”slices the one who was emergency chief for 27 years.