As Quebec tweaks doctor permits, family medicine bleeds

Last year the province lost more physicians than it produced. Are the government’s adjustments too little, too late?

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It’s that time of year again for Quebec medical students who will be finishing up their residencies come spring.

The dreaded application process for the permits the government hands out to control where family doctors practise is about to kick off — something no other province does and something Quebec physicians have come to loathe.

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There’s a lot at stake — not only for the new graduates, but for the roughly one million Quebecers who have found themselves without a physician in recent years.

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This has always been a stressful time for residents, since obtaining permission to work in the geographical area where they want to serve can have huge repercussions on their professional trajectories, not to mention their personal lives.

It is also a critical moment for Quebec’s ailing public health system. Amid a worsening doctor shortage and lengthening wait times, the government is tweaking the procedure for allocating the permits in 2024 to make it a little less onerous.

Residents will be able to apply to work in two regions instead of one, which means they won’t have to put all their eggs in one basket. And they can find out what additional medical duties they’ll be assigned up front, like working in long-term care or ERs, rather than having them imposed after the fact.

Will these incremental measures be enough to turn the tide?

Quebec desperately needs these graduates to take patients off the waiting list and relieve pressure on crowded emergency rooms. Yet last year Quebec lost more physicians than it produced — despite the government ramping up admissions to medical faculties over four years by more than 600 spots.

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According to the Fédération des médecins omnipraticiens du Québec, 49 more doctors retired, quit the profession, went to the private system or left the province than entered into service as family doctors in 2022.

“Last year we should have had an additional 160 (newly graduated family doctors),” said Dr. Marc-André Amyot, the president of the FMOQ. “But exceptionally this year, and to a very worrying extent, when we looked at the arrival of new doctors minus the departures, we were at minus 49. So we’re not going in the right direction.”

This deficit arose as a growing number of medical students have been shunning family practice.

“Every year we have between 160, 170, 180 training positions in family medicine that go unfilled,” explained Amyot. “In the past few years, there were about 50 students who, rather than put family medicine as their second choice, preferred to take a sabbatical year. Can you imagine, 50 students a year prefer to do additional specialty internships and then reapply for a residency in a different specialty the year after. This year, it wasn’t 50, it was 75.”

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Dr. Marc-Andre Amyot, president of the FMOQ
“Every year we have between 160, 170, 180 training positions in family medicine that go unfilled,” said Dr. Marc-André Amyot, president of the FMOQ. Photo by Dave Sidaway /Montreal Gazette

There are many reasons for this trend, including the requirement that family doctors commit to Activités médicales particuliers, which are additional duties in long-term care homes, birthing centres, emergency rooms or mental health facilities. But the complicated hoops new graduates have to jump through for a permit dictating where they can work is the biggest bone of contention.

These Plans régionaux d’effectifs médicaux, or PREMs as they are known, were instituted two decades ago to ensure an equitable distribution of family doctors across Quebec. But they have now become a deterrent to choosing family medicine — especially given specialists like surgeons or oncologists are exempt.

“It has had an off-putting effect for young doctors who would rather choose another speciality rather than choose family medicine simply because of the PREM,” said Amyot. “We’re dealing with the negative consequences of this method because it’s one of the main elements that makes family medicine unattractive.”

Now, however, the aversion to PREMs isn’t just dissuading residents from choosing family medicine, it is driving newly minted family doctors out of the public system.

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“We know that young residents are opting out of the PREM process altogether now. They’re signing to private clinics, rather than going through this procedure,” said Dr. Michael Kalin, a member of the Départment régional de médecine générale for Cavendish, which handles recruitment for that part of Montreal.

Even though he is intimately involved in choosing who gets the permits, Kalin, a family doctor in Côte-St-Luc, is a fierce critic of this system.

All doctors working in the public system must have a PREM and conduct 55 per cent of their practice in the region or district where it was granted — otherwise they are docked 30 per cent of their pay and prevented from reapplying for three years.

Not to be confused with a medical licence, the PREMs are allotted by region. But in Montreal they are also handed out by sub-region to ensure equitable coverage across the city. Until this year, doctors completing their residencies could only submit one application to the hiring committee in the district or region where they hope to work by the next summer.

Since there are usually more applicants than PREMs in Montreal, every year, some new doctors don’t get permission to practise while some positions in certain areas remain vacant. Not every doctor is willing or able to relocate to where the permits are — so they go elsewhere.

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On top of that, Kalin noted, PREMs are distributed assuming that a doctor will carry a full patient load while fulfilling their additional duties. However, if a physican takes parental leave or gets sick or scales back their hours for any reason, there is no mechanism to pick up the slack.

“One PREM does not mean one full-time doctor. One PREM means one licence,” said Kalin. “So if a doctor works one day a week, the government doesn’t provide for us to fill in the other four days. This is a big concern.”

The permits are also non-transferrable. So if a physician leaves the province, moves to the private system or even dies, it’s simply gone forever, something Kalin calls “nonsensical.”

“We gave a PREM to a doctor two years ago. That doctor went private. The public system cannot reclaim that PREM. We cannot replace that doctor who went private with another doctor. It’s lost,” he said. “If this doctor voluntarily relinquishes this PREM, we should at least be allowed to replace it. We’re not even given that.”

Dr. Michael Kalin at his practice
“We know that young residents are opting out of the PREM (permit) process altogether now. They’re signing to private clinics, rather than going through this procedure,” said Dr. Michael Kalin.  Photo by Allen McInnis /Montreal Gazette

Over the years, successive governments have given more PREMs to the regions at the expense of Montreal. This artificial gerrymandering has left the city — and some neighbourhoods in particular — badly underserved. For instance, according to 2022 figures, 76 per cent of all Quebecers are assigned to a family doctor, but only 66 per cent of Montrealers. Worse, only 57 per cent of the population in the Faubourgs–Plateau-Mont-Royal–St-Louis-du-Parc administrative district and 59 per cent in Côte-des–Neiges–Métro–Parc-Extension have GPs.

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Montreal will receive 143 PREMs this year (including 112 for new graduates, plus more for academic positions and transfers). Across the province, Quebec has signed off on 591 PREMs for 2024, up from 527 last year. But Kalin said that doesn’t even begin to make up for the shortfall.

“The DRMG has calculated that Montreal is short 386 full-time family doctors to meet the needs. We have huge institutional needs right now. By my count, we have 340 unfilled or closed CHSLD beds right now as of today. And of course, we talk about emergency rooms being understaffed, patients on waiting lists for a family doctor, and so on,” he said. “There’s a general feeling that the number of PREMs do not even replace the number of doctors who are retiring or leaving each year and that we are in a chronic negative state of loss.”

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As discontent has grown among doctors over their punitive working conditions in public health care, the private system has quietly expanded.

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A Globe and Mail analysis recently found that there were 642 doctors working outside of the Régie de l’assurance maladie this past spring, more than double the number a decade earlier.

According to Le Devoir, 446 family doctors were working outside RAMQ as of July, out of about 10,300 in the province. That’s an increase since 2018-19, when there were 333.

Even if it’s a small fraction of the total number, the government is starting to take notice. The federation of medical residents didn’t invite any private clinics to its annual career day this year, apparently at the behest of the ministry, for fear even more of the young doctors Quebec has invested in educating will be poached away.

Quebec took steps last spring to repatriate some of those practitioners, setting up a fast track for physicians in private medicine or working out of province to obtain PREMs.

Speaking to medical students last May, Health Minister Christian Dubé vowed to make adjustments.

And so, with PREM applications set to get underway for 2024, a little more red tape has been snipped. Doctors can now seek a permit in two regions to better their chances. They will be able to find out their extra responsibilities at the outset. And local health authorities get more say in divvying up the number of licences granted within their region.

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Dr. Cédric Lacombe, president of the Fédération des médécins résidents du Québec, is circumspect about how much difference this will make.

“It’s a first step,” he said. “I think it’s too early to tell one way or another what real impact it will have. But that said, this first step is something that can’t hurt.”

Amyot, at the FMOQ, is skeptical, but trying to be constructive.

“The slight loosening that the minister is proposing — I’m not saying it’s bad, it’s a step in a right direction — but it’s totally insufficient,” he said.

The FMOQ has provided the ministry with more than 20 suggestions for attracting more doctors to family medicine with carrots instead of sticks. These include giving medical school applicants from remote regions more weight, paid internships at far-flung hospitals and scholarships contingent on returning to their place of origin to work later.

Kalin is blunt in his assessment that the health ministry’s tinkering with the process will make “no practical difference.”

“This second choice of PREMs has no impact on Montreal because we have more applicants that positions,” he said. “So if you put Montreal as a second choice, you’re never going to get it. And even if you put Montreal as a first choice, you may not get it.”

Determining extra medical duties this fall is also “a double-edged sword” in Kalin’s view, because doctors will commit in November to responsibilities they will not perform until next summer, at best.

“We still have a shortage in the CHSLD today,” he said. “That posting is removed, but that need is in limbo until that doctor is able to fill it — if they ever do.”

In the face of a flawed and arcane system that most doctors “despise,” Kalin believes the permits should simply be abolished.

“PREMs limit mobility,” he said. “And I find it incredibly discouraging and counterproductive. Maybe 20 years ago there was an argument to help out the regions. The initial argument no longer is relevant. And I think we need to update our policy to real-time realities.”

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