More carrots and fewer sticks will attract family doctors here
Association says red tape is encouraging potential practitioners to look elsewhere
There have been worrying signs in recent weeks that efforts to recruit more desperately needed family doctors in Quebec are not getting the desired results.
After the matching process to place graduates of medical schools in residencies for 2024, 70 of the unfilled positions in family medicine out of 75 in all of Canada, were in Quebec, although 458 candidates were matched in the province, about four per cent more than last year.
Meanwhile, the process for new doctors finishing their residencies to obtain permits stipulating where in Quebec they can practice has also wrapped up, with a high proportion of vacancies. Of 591 Plans régionaux d'effectifs médicaux authorized in 2024, 180 had no takers after the initial rounds of interviews and selections.
Health Ministry spokesperson Marie-claude Lacasse said more PREMS could still be awarded in a second wave of applications. But as of April 22, 116 of the 479 PREMS for “new billers,” or residents on the cusp of becoming full-fledged physicians, were still up for grabs.
It's creating a crisis within a crisis in Quebec's beleaguered health-care system: As more and more family doctors are retiring, the next generation of young physicians are shunning family medicine — even as more residencies and more training places are being made available to them.
In 2022, Quebec lost 49 more doctors than it gained. And there are no signs the bleeding will stop, despite more than 649,000 Quebecers who don't have a general practitioner.
Dr. Marc-andré Amyot, president of the Fédération des médecins omnipraticiens du Québec, laments “a quadruple exodus of family doctors: an exodus to the private sector; an exodus to other provinces; an exodus to other specialties and an exodus toward a premature retirement.”
“It's extremely worrying,” he said in a recent interview, noting the vacancies are spread across Quebec.
On the Côte Nord, 13 of 18 PREMS for new doctors are still available. In the Gaspé, 12 of the 13 for 2024 are unclaimed. But even in more populous areas, where the PREMS are allotted by sub-region, six of Montreal's 112 permits are still open, including three in Ahuntsic—montréal-nord, as well as 12 of the 69 PREMS in Montérégie, two of them in Vaudreuil-soulanges.
There are many reasons young doctors are turning their backs on family medicine, such as a heavier workload due to the doctor shortage, too much paperwork, a disparity in pay compared with specialists and a denigration of the profession in political discourse. But in Quebec, there are also extra duties, known as Activités médicales particulières, which require family doctors to spend a certain amount of their time delivering babies, working in long-term care homes, doing shifts in emergency rooms or administering medically assisted death.
But the restrictive PREMS, which dictate where family doctors can practice, are a particular irritant. Implemented more than 20 years ago to ensure an even distribution of physicians across the territory, PREMS add extra red tape, uncertainty and frustration to establishing a family practice. Quebec is the only province to have such a system.
The Quebec government made some tweaks to this year's PREM allocation process to make it less onerous, like allowing residents to apply in two regions and two sub-regions instead of one to bolster their chances of being able to work, and finding out their AMP responsibilities earlier. But it doesn't seem to have made much difference.
“This year, there are more unfilled PREM posts than ever. And that worries us enormously. It should worry the ministry, too,” Amyot said. “We don't know what the residents are doing if they don't apply for a PREM. Are they going to take a sabbatical year? Are they going to leave for another province? Are they going to go private?”
Dr. Michael Kalin is a family physician in Côte-st-luc and a member of the Départment régional de médecine générale for Cavendish, a body that assesses service needs, conducts interviews and selects recipients of PREMS. He is a fierce critic of the permitting system and thinks it should be abolished. The process is so absurd, it can actually result in the loss of new family doctors who are willing to roll up their sleeves.
“It's heart-wrenching. I think I had 17 applications for 10 spots. To be clear, I'm saying no to seven doctors who want to work in a region,” Kalin said. “It's mind-boggling to me that we train these doctors, that they're motivated, they're excellent. They want to come, they want to fill a need. But I'm missing seven spots for them. So are they going to go somewhere else or will they leave the province? I don't know.”
Months ago, the FMOQ presented the government with more than 20 proposals for reforming (or perhaps replacing) the PREM system to reduce the barriers for students and residents choosing family medicine.
“The FMOQ wants to revalourize family medicine and subscribes to the current thinking that PREMS have contributed to a disinterest in this specialty,” reads a copy of the document obtained by The Gazette. “We can't help but remark that, despite two decades of applying PREMS on the Quebec territory, we can now affirm that the inconveniences outweigh the advantages of maintaining PREMS. Actors in the field note that the use of this coercive measure to ensure the distribution of doctors since 2004 hurts more than it helps.”
The FMOQ lists concrete measures that can be rolled out in the short, medium and long term to ensure there is adequate access to service in all regions.
Short-term suggestions include:
■ Allowing the fulfilment of AMP duties in regions other than the one where doctors principally work.
■ Creating a new “AMP de dépannage” to allow for more nimble troubleshooting.
■ Ensuring a more equitable distribution of specialists sharing duties in institutions, even at unfavourable hours.
■ Distributing nurse practitioners more evenly across Quebec, to avoid the duplication of care provided by family doctors.
■ Improving and simplifying access to specialized services and technical platforms.
Some of the medium-term proposals are:
■ Creating a process for replacing absences among physicians.
■ Directing new doctors arriving in the country to high-needs regions and sub-regions.
■ Promoting the use of new communication tools among professionals and patients to ensure better access to information and telemedicine.
■ Fine-tuning the list of medical services offered by family doctors to eliminate non-useful tasks or tasks that can be performed by other professionals.
Quebec must offer more carrots and fewer sticks to attract students and residents to family medicine and doctors to underserved regions, Amyot said. These could include:
■ Guaranteeing a contingent of medical-school candidates from targeted areas.
■ Creating more teaching units in the regions so that all steps toward becoming a doctor are offered there.
■ Using scholarships, bursaries and internships to maintain the link between medical students and their regions during their training.
■ Offering bonuses for hanging their shingle there once they graduate.
“The most important element for a doctor to return to a region or go to an underserved region during a serious shortage of doctors is the provenance of those candidates. So we need to select more candidates from regions like Côte-nord, Bas St-laurent, Gaspé — that's an important element that is part of our numerous recommendations to the ministry. The choice of candidates — then maintaining the link between the region and the candidates with summer internships and scholarships to encourage them to return to work in a hospital or in the region,” he said. “We're in favour of incentives rather than constraints and coercive measures.”
One measure the FMOQ has proposed — facilitating the return of doctors now working outside Quebec or outside the public system — was acted on last year with Accord 774, which allows physicians from elsewhere in Canada or who are in the private sector to seek permission to practise here.
But otherwise, the proposals haven't been greeted with much urgency.
“We want to work with the ministry on those 20 recommendations, but we haven't had the opportunity,” Amyot said. “The ministry has been preoccupied by other files that they judge to be higher priorities. That's not our perception. We think a strong first line in Quebec with a sufficient number of family doctors to provide enough service is an investment in the health of Quebecers.”
The latest data on unfilled family medicine residencies and PREMS for new doctors should be an urgent wake-up call to the government that it's time to act. Stat.