Dual Perspective: Montrealer and Public Health Student’s Commentary on Family Doctor Shortage in Québec
By: Mariane Saroufim
Born in 1998 in the now demolished Hôpital St-Luc, I’ve been under the care of a family doctor for most of my life. I was one of the lucky ones. For some in Montréal, a family doctor isn’t guaranteed. I remember clearly when my mom learned of this new doctor, fresh out of medical school, who joined a clinic near our house. My mother, realizing the rarity of a family doctor with an unfilled practice, begged them to include my sister and I in their patient list. Growing up listening to my parent’s stories of their youth in Lebanon, I could appreciate what I had in Montréal. Living in a second-generation immigrant bubble, I believed I was lucky to live in a country with universal healthcare, a province with a solid healthcare system, and a city with healthcare accessible to all.
Or so I thought.
Even as I grew interested in public health, and learned about how Québec’s family doctor crisis is the worst in Canada, I was still optimistic. It’s not like I was oblivious to the reality. I had heard of friends with difficulty getting a simple appointment with their family physician for a prescription or a check-up. Friends and family have regaled me with their stories of long wait times or unavailable family doctors, which left patients with no option but to rely on the pricey private sector or to occupy the already crowded emergency rooms. However, the reality of the situation never hit home until I lost my own family physician. The reason? She wanted a more comfortable job with a less hectic schedule: geriatric care. Understandable. But where did that leave me?
A year and a half later, I’ve lost most of my optimism. Walk-in medical appointments are practically nonexistent. Now it seems that’s what the emergency room is for… if you can afford the long uncomfortable waiting. Otherwise, a patient has to jump through hoops to get an appointment at an urgent clinic. We’re told to login to the Québec Medical Appointment Scheduler website at 5 pm on the dot, choose a reason for an appointment and hope to find a clinic with same-day or next-day availability. No matter how fast you are, it never seems fast enough. Furthermore, with the scarcity of appointments, one can’t afford to be picky, which means accepting an appointment at any time or place, even during work hours at a clinic two districts away. Getting a follow-up is also tricky, as you are not guaranteed the same doctor at every appointment.
So what will I do now that I’ve lost my family doctor? I’ve joined the waiting list and will wait. According to the RAMQ site, the waiting time varies by region depending on the availability of doctors and the number of people on the waiting list. In 2021, the average wait time in West Island was 279 days for patients with urgent health problems such as cancer. If it was almost a year for urgent cases, what about non-urgent cases? In Verdun that same year, the average wait time for people in good health was 619 days. In most cases, waiting a few years for a family doctor is the unfortunate norm in Québec.
Once on the waiting list, I’m also assigned a Family Medicine Group (Groupe de médecine de famille) in my district. The idea is to assign you to a group of doctors to increase your chances of finding an appointment with an available doctor in your region. Another alternative measure available for people is the GAP. This proposed online triage system allows Montrealers to access critical care within 36 to 72 hours and have their less pressing needs met within two weeks, in part through Family Medicine Groups. Mr. Dubé, Québec’s health minister, believed the GAP would ensure fewer patients go to overcrowded emergency departments, thus lessening the pressure on general practitioners. While this seems like a good solution, the same downfalls apply - lack of availability and lack of follow-up. These are bandaid measures at best.
As a native Montrealer, I’ve witnessed firsthand the frustration of a lack of family doctors. As a public health student, I’ve also come to understand the crisis through a different lens.
While the precise number is unknown, most newspapers agree that more than 800 000 Quebecers are currently on a waitlist for a family doctor. According to Health Minister Christian Dubé, that number is most likely closer to 1.5 million or higher since not everyone is signed up on that list. Furthermore, compared to the national average of 14.5%, Québec had the highest proportion of residents without a regular healthcare provider at 21.5% in 2019. Not only are family doctors essential for preventative medicine and long-term follow-up, but in the Québec healthcare system, family doctors are the entry point for all other services. You cannot get an appointment with any other health service without a referral from your family doctor.
One possible explanation for the shortage of family doctors dates back to the 1990s when younger general practitioners were mandated to work compulsory shifts in short-staffed hospitals, nursing homes or community clinics for the first 15 years of their practice. This AMP system (Activités médicales particulières) is still in place today because the understaffed healthcare system relies too much on it. In today’s culture, family doctors are pulled in many different directions, filling the gaps in various healthcare sectors. In fact, according to public health insurance data, from 2000 to 2020, less than 40% of general practitioners in Québec claimed that more than 90% of their billings were from family medicine.
Many other factors contributed to the current shortage of family doctors in Québec. For example, the PREM (regional physician resource plan) restricts where doctors can practice for the first 20 years of their practice, often in favour of the underserved suburbs. Politicians making remarks about lazy doctors not working enough is just adding fuel to the fire. With the many issues they face, family doctors and new medical students feel increasingly compelled to work in another field. Many qualified bilingual family doctors have decided it’s easier to find a job outside the province or have given up on the public system entirely in favour of the private sector.
Given these challenges, many doctors are speaking up about the pressure on general practitioners to follow more patients. Many people are also questioning the role of family physicians in the healthcare landscape and wondering if people could be better served by other health professionals such as physiotherapists, nurses or even pharmacists. However, to transition from our current healthcare model to one where family physicians are not in charge of everything, two conditions need to be met: we need to have sufficient specialized healthcare professionals such as psychologists and physiotherapists, and they need to be covered by Québec’s public health insurance. Unfortunately, these conditions are not close to being met in Québec.
Many electoral parties have made promises to improve the healthcare system. Measures include investing more in CLSCs (Centre local de services communautaires), increasing the number of medical school admissions, opening private clinics in underserved areas, the GAP system, and the influx of money and commitment to train, recruit or hire more doctors, psychologists, pharmacists, nurses and administrative assistants. However, it will take a long time to implement these measures and have their effects felt by Montrealers.
We must look at the shortage of family doctors with a new, creative, and flexible eye. Doctors are speaking up with ideas such as taking a more collaborative approach to care, consulting with community clinics, starting a conversation on how to best provide front-line services to Quebecers, and hiring more human resources to reduce the administrative burden. Free and accessible access to other health professionals could also liberate family doctors. In a reality where Montréal areas like Plateau-Mont-Royal, Côtes-des-Neiges and Hochelaga have a 64% registration rate for family doctors - not including out-of-province students, refugees and homeless people, a restructuration of primary healthcare and the role of general practitioners is urgent and crucial.