SUPER CLINICS: A CHECKUP
‘Lineups galore’ by walk-in patients. A detrimental impact on smaller clinics and CLSCs. The disincentive to take on more complex medical dossiers. For critics, these are some of the troubling symptoms of super clinics. But proponents say the plan is work
In 2014, an election promise touted a solution to Quebec’s perennial crisis in ER overcrowding: the creation of 50 super clinics by the end of 2018. But the 31 inaugurated so far are ‘a drop in the bucket,’ critics say. ‘It’s all smoke and mirrors.’ Others insist the plan is working. Aaron Derfel investigates.
It’s become an almost weekly ritual for Gaétan Barrette. The health minister strides before a podium at a newly inaugurated super clinic and declares in front of the TV cameras that thousands more patients will soon have access to a family doctor.
And that’s not all, he tells reporters. The super clinics will finally solve Quebec’s perennial crisis in emergency-room overcrowding.
“For the first time in history — and it’s never been seen before — there is a reduction in the number of patients presenting to the ER,” Barrette said on Feb. 23 in Côtedes-Neiges without providing any figures to back up that assertion.
Less than two weeks later in Pointe-Claire, Barrette predicted that the Stillview super clinic will attract 40,000 walk-in patients per year. “This is a very, very significant milestone,” he added in what sounded like a pre-electoral speech.
But a close examination of the super clinics raises questions about many of Barrette’s claims, chief among them, that the minister is fulfilling a 2014 election promise to “create” 50 super clinics by the end of this year. In fact, the Montreal Gazette has confirmed that every one of the 31 super clinics announced to date was longestablished as a family medicine group, and all were already open seven days a week before Barrette rechristened them.
In 2014, the provincial Liberals pledged in their English-language electoral platform that the super clinics would be“true agents of health that will be open 24/7.” Instead, Barrette is keeping the super clinics open four hours longer on Saturdays and Sundays than those family medicine groups that are open on weekends, too.
A key distinction is that the super clinics have three or four more nurses and other professionals so they can carry out at least 20,000 medical consultations a year among walk-in patients who are not registered with a family doctor. But existing family medicine groups — known in French as groupes de médecine de famille (GMF) — accept walk-ins, too.
Health Ministry officials did not respond to a query by the Montreal Gazette asking for the total investment thus far in super clinics. Parti Québécois health critic Diane Lamarre — who has filed numerous access-to-information requests on the subject — cited a figure of $1.8 million in start-up costs for the first 19 super clinics. That works out to an average of nearly $100,000 per super clinic, a tiny fraction of the nearly $38.5-billion health- and social-services budget.
“It’s all smoke and mirrors,” Lamarre said of the re-branded super clinics. “The public is being misled.”
When Barrette launched the Pierre Boucher super clinic in Longueuil in November, he vowed that it would offer at least 40,000 consultations for walk-in patients each year. But the previously named Pierre Boucher Family Medicine Group had already surpassed that goal in 2016, reporting 47,000 consultations for walk-in patients that year, according to documents obtained by Lamarre.
What’s more, the operator of one super clinic and the chief executive of a large medical centre that will be granted super clinic status on Sunday told the Gazette that it’s not unusual for their receptionists to turn away walk-in patients on busy days.
“Sometimes we have lineups galore in the morning,” said Vince Trevisonno, CEO of the Brunswick Medical Centre in Pointe-Claire. The clinic on St-John’s Blvd. extended its weekend hours in October in anticipation of its super-clinic designation, effective Sunday.
During a tour of his clinic in February, Trevisonno declined to allow a reporter to interview any of the patients in the waiting rooms of the sprawling clinic, citing the need to protect their privacy. Two hours later, medical director Barbara Hogenbirk arranged for a patient she has been following for at least 20 years to phone the reporter to share her positive experience.
Dr. Mark Roper, chief physician of the Queen Elizabeth super clinic in Notre-Dame-de-Grâce, acknowledged the difficulties in being able to treat all walk-ins despite hiring two more nurses. The clinic extended its weekend hours on Sept. 11, 2017.
“Some mornings we have 100 patients registered by noon,” he said. “We try to avoid closing early but when you have 80 people waiting, it’s a dangerous situation.”
When a reporter called the Centre de médecine familiale StLaurent on Feb. 13 at 9 a.m., a prerecorded message noted the date that day, stating the clinic was already full: “The admission is presently closed. The doctors’ schedule ... is available on our website.” Barrette inaugurated that super clinic last April.
Paul Saba, a family physician who runs a small practice and who also works at Lachine Hospital, criticized Barrette for promoting super clinics at the expense of government-run CLSC clinics and private doctors’ offices.
“I think the government is taking the wrong approach in just trying to build these super clinics,” Saba said. “They’re not a one-size-fitsall solution.”
“Those super clinics are not going to solve the problem with the ERs,” added Saba, who works in the emergency at Lachine Hospital. “They ’re like a drop in the bucket.”
Saba had considered an offer to join a super clinic but ultimately decided to stay where he is because he said he can spend more time with his patients.
“I just felt that I didn’t want to be involved in the whole politics of having to see a patient every so many minutes. I take the time that the patients need. Some patients take 15 minutes, some a half hour, some a full hour.”
Dr. Hélène Boyer, the medical director of a family medicine group in the Saint-Louis du Parc CSLC, expressed concern that her clinic might have to “abandon” as many as 3,500 patients because it isn’t receiving the resources from the government as Barrette gives priority to super clinics.
“This reorganization is having a detrimental effect on us,” Boyer said, referring to her CLSC in the Plateau Mont-Royal borough. “We had a clinic that was functioning well, that was following patients for 25 to 30 years, and all of a sudden what do we do? What do I tell these patients?”
Boyer explained that two of her doctors will be retiring soon, but the government has not allocated positions at her clinics for replacements — something it used to do automatically before the advent of the super clinics. Boyer suspects that’s the case because the health ministry is granting new positions at the super clinics instead.
The result is that 3,500 patients who were being followed by the two doctors will have to look elsewhere — a process that can easily take months, if not more than a year. Indeed, Lamarre discovered through an access-to-information request that 12,000 patients across the province who are at least 80 years old are languishing on a wait list for a family doctor.
Lamarre contends that many family doctors are reluctant to take on elderly patients and those with chronic diseases because they often have to go to the hospital. Among Barrette’s reforms is the requirement that family doctors post an attendance rate (“taux d’assiduité”) of at least 80 per cent among their patients or they ’ll face financial penalties.
Barrette imposed the attendance rate to boost the number of return visits by a patient to a super clinic. If a patient ends up having to go to the hospital several times in a year, the super clinic’s attendance rate drops.
“This requirement creates a disincentive to take the more complex patients,” she said. “This means that they take care of patients who are less sick rather than patients who are very sick.”
Although Barrette set the goal of having 85 per cent of all Quebecers signed up with a family doctor by Jan. 1, 2017, more than 1.6 million Quebecers still didn’t have one at the end of January, according to the government’s own statistics.
Yet Barrette appears convinced that the magic solution is simply to set up his promised 50 super clinics by the end of the year, Boyer said.
“It makes no sense,” she added. “Since we want to create these super clinics, we’re in the process of hollowing out clinics that used to function well, clinics like mine.”
The operators of the Medistat Clinic in Pierrefonds share similar concerns, warning that they might have to close their emergency walk-in practice because the health ministry intends to cut off funding to pay its nurses full time. The reason? Medistat does not have enough doctors to convert into a super clinic so it can stay open 12 hours a day, seven days a week. Although Medistat is normally open on weekends, it closes at 5 p.m. on Saturday and Sunday.
This weekend, faced with the prospect of reduced government funding, the clinic will not open at all on Sunday.
“I feel as if we are being punished because, in a nutshell, we are too small to expand into a super clinic,” said Dr. Orly Hermon, one of the directors at Medistat. “It’s super clinic or nothing.”
Although Barrette promised to look into Medistat’s predicament, he remained non-committal. Asked why the minister has chosen to convert super clinics from existing family medicine groups rather than setting them up from scratch, Barrette’s press attaché sidestepped the question.
“The decision by a network clinic (which was Medistat’s status) or a family medicine group to adopt the super clinic model is not mandatory,” Catherine W. Audet replied by email. “It’s the choice of the doctors.
“With the super clinics, our goal is to improve access to front-line services. We also want to provide supplementary services that the network clinics have not been able to offer.”
During the 2014 election campaign, Barrette and then-candidate-for-premier Philippe Couillard spoke repeatedly about super clinics. What they didn’t share with voters was their plans for a cost-cutting administrative overhaul of the health system that would eliminate more than 1,300 managerial positions.
Those reforms commanded all of Barrette’s attention for the first two years of the Liberal government’s mandate, and during this period the minister did not set up a single super clinic. Instead, the McGill University Health Centre complained that it had to chop tens of millions of dollars from its operating budget as Barrette pursued his fiscal austerity agenda.
In retrospect, say experts, the super clinic plan was hobbled from the start. Yet during this same period, the province’s medical specialists saw their incomes catch up with and even surpass those of their counterparts in Ontario following an agreement that Barrette, a former radiologist, had negotiated with the government years earlier when he served as president of the province’s federation of medical specialists. On the other side of the negotiating table at the time was a former brain surgeon and then-health minister, Couillard.
Despite having to turn away walk-in patients, especially during the flu season, the operators of super clinics insist that the concept behind them is sound, and they praised Barrette for providing them with additional funds.
“I think this is a project the government should be proud of,” said Roper, head of the Queen Elizabeth super clinic.
“There’s no doubt that the super clinics prevent people from going to the ER. I would say that if our super clinic was not open, we’d have another 40 (patients a day) going to the emergency for their problems.”
With the extra government funds, the Queen Elizabeth super clinic has hired two more nurses. The N.D.G. centre is remarkable by even super clinic standards, as its doctors can treat patients with intravenous antibiotics, fix some broken limbs in casts and perform minor suturing. That has earned the facility the added designation of “urgent care.”
At the Herzl super clinic in Côtedes-Neiges, doctors there concede that they must still sometimes turn away patients, but a survey of its services “found that 97 per cent of patients would recommend us to their friends and family.”
Meanwhile, the Brunswick Medical Centre in Pointe-Claire is forging ahead with an expansion of at least $20 million as it erects a new office building next door, more than doubling its space. The clinic boasts more than 40 family doctors on staff as well as 60 specialists, including pediatricians.
A tour of the Brunswick centre revealed that it’s a model of efficiency. Trevisonno, the CEO, has arranged to cater gourmet lunches for the doctors every day so they don’t have to leave the clinic. Since medical specialists practise at the clinic as well, patients don’t have to leave the building for a referral.
All the waiting rooms have window views and Trevisonno has commissioned a local artist to adorn the walls with colourful paintings. The parking is free, while the public Lakeshore General Hospital nearby charges up to $14 a day.
“It’s been a wonderful experience,” said Monique Bissonnette, a longtime patient. “I honestly don’t have one negative thing to say.”
Still, Bissonnette considers herself fortunate to be followed by Brunswick’s medical director as she realizes that many people on the West Island don’t have a family doctor.
“I think it’s a horror show,” the Saint-Lazare resident said of the province’s health-care system. “I count myself very lucky.”
Trevisonno welcomed the additional funds from the government to operate a super clinic, saying this will allow Brunswick to hire two more nurses. He predicted that the additional resources and funding will boost the clinic’s volume of walk-in patients from 40,000 to 55,000 a year.
Hogenbirk, the medical director and Bissonnette’s physician, defended Barrette’s decision to convert large centres like hers into super clinics rather than setting them up from scratch.
“Don’t you think it’s wiser to rehabilitate an existing clinic to become a super clinic rather than spending a heck of a lot of money building from scratch a brandnew building with a new parking lot and try to recruit new doctors from who knows where that don’t exist?” she asked. “I think it’s very smart to adapt a current large clinic and get those doctors to do the evening shifts.”
Despite the differences between the administrators of super clinics and those in charge of smaller centres, they agree that the health ministry has not granted enough family-medicine positions for new doctors in the Montreal area. And that might explain why, more than anything else, super clinics continue to turn away patients and ERs remain overcrowded.
“We have doctors applying to work with us, but they are not permitted to work with us because of the government restrictions,” Roper said, alluding to the Plans régionaux d’effectifs médicaux or PREMs, a system the ministry manages to determine how many family doctors are given a permit to practise in a specific area.
The PREMs, Roper argues, have tended to favour the outlying regions to the detriment of Montreal. Montreal doctors treat both local residents and those from the off-island suburbs who commute to the city, yet both Liberal and PQ governments have resisted allocating more permits to what is known bureaucratically as Region 6. Politically, more votes are up for grabs off island than in Montreal.
The city’s ERs also lack a sufficient number of family doctors to handle an aging population with increasingly complex medical needs, say emergency specialists. Although a scarcity of nurse practitioners and Barrette’s reluctance to fund hospital beds have contributed to the ER crisis, emergency specialists contend that more family doctors in the city would make the single greatest difference.
Which brings us to Barrette’s assertion: that the super clinics have led to a drop in ER congestion. In the absence of any figures by Barrette, one can only turn to the daily provincial registry that keeps track of the number of patients in the city ’s ERs. For the past month, the registry has shown that ER overcrowding has not dropped, and in fact, some hospitals like the Lakeshore General are reporting higher rates than a few years ago.
Two Montreal ER doctors, who spoke to the Gazette on condition that their names not be published for fear of professional reprisals, said the situation has worsened despite the super clinics.
“Our volumes at St. Mary ’s (Hospital) have increased significantly,” one doctor said. “We’re routinely running over 150 per cent. Over the last month, we’ve had 35 to 37 patients in the ER overnight when normally we have 20 to 25.”
At Jean Talon Hospital, five ER physicians have quit in the last two years because of burnout, said one doctor who’s considering leaving, too.
“Good people are leaving because the government is not letting the hospital hire more doctors,” he said. “They’re just giving more work to the same number of doctors.”
“I’m thinking of going to work in a super clinic,” he added, fully aware of the irony. “But that’s just a reshuffling of the cards, isn’t it?”
Our volumes at St. Mary’s have increased significantly. We’re routinely running over 150 per cent. Over the last month, we’ve had 35 to 37 patients in the ER overnight when normally we have 20 to 25.