Hanes: We should be outraged by idea for solving family-doctor crisis

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Having a family doctor to call when you’re sick or have nagging health concerns feels a bit like winning the lottery these days in Quebec.

The shortage of general practitioners gets worse by the year, as more and more older doctors retire, too few new graduates arrive to fill their shoes, and the private sector lures increasing numbers of physicians away from the public system.

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It is estimated the province is lacking 1,500 family doctors, while more than two million Quebecers are orphans, dependent for all their health needs on walk-in clinics, emergency rooms or a new triaging hotline that will find you a one-time appointment with a random physician.

Losing your GP is stressful and the long wait to find a new care provider is frustratingly long. But all Quebecers should be extremely worried about the plan in the works to resolve the scarcity of family physicians once and for all: cutting loose all the people in decent health and assigning only vulnerable patients with chronic conditions to dedicated doctors.

The news trickled out last week with the release of a study by the Institut national d’excellence en santé et services sociaux, which suggested that 1.5 million medical appointments a year used up by Quebecers in decent shape visiting their physicians could be reallocated to some 500,000 stray patients with moderate to serious health problems. Everybody else would just book an exam as needed through the Guichet d’accès à la première ligne (GAP), the new central booking service that matches unattached patients with vacant appointments.

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This drastic and draconian idea ought to be nothing more than a trial balloon that sparks some discussion before it floats away forever. But the terrifying reality is that this is getting serious consideration from the Quebec government and the Fédération des médecins omnipraticiens du Québec (FMOQ), which represents family doctors.

The study was ordered up by the government in the course of negotiations for a new contract with GPs. And a former FMOQ vice-president wrote a glowing article describing just this kind of redistribution in June in the organization’s newsletter.

But don’t be fooled by the moralizing about “equity” for the sick or the guilt-tripping of Quebecers lucky enough to have a family physician. After years of successive policy failures, the government is now so desperate to staunch the hemorrhaging that it’s going to rob Peter to pay Paul. Instead of aiming for the highest standard of care for everyone, it is ready to downgrade the offering for all but the sickest. If it can’t manage to strengthen the backbone of the system, it’s prepared to gut it altogether. If it can’t ensure the weakest patients are taken care of, it’s poised to sacrifice the well-being of the general population.

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Whether you have a family doctor or are hoping to find one, all Quebecers should be outraged.

The abrupt severing of the relationship between six million Quebecers and their trusted physicians will not help those on waiting lists. The inconvenience of having to see a different primary care provider at a different clinic each time you have a medical problem will not improve anyone’s health — just ask those stuck in limbo right now. The complete abandonment of preventive medicine will lead to more sick people in the long run.

Dr. Michael Kalin, a physician in Côte-St-Luc, is an ardent defender of family medicine and one of the rare outspoken critics of the botched policies and bureaucratic red tape that have debilitated the profession he loves. Kalin, who sees walk-ins who are referred through the GAP in addition to his usual longtime patient load, warned the central booking service is no substitute for having a regular family doctor.

“The idea that the GAP is equipped to replace care for healthy adults is false. The GAP is a glorified walk-in clinic. That’s it. It is meant to deal with people with acute problems. And the premise that doctors will take that opportunity to screen patients for other issues at that time is really short-sighted,” Kalin said.

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“If you come in with a flu, it’s not the best time for me to talk about breast screening, colon screening, women’s health issues, your blood pressure, smoking cessation, financial security and on and on. It’s not conducive to those types of interventions. The GAP is designed for an acute problem and a quick fix. It is not the place for preventive health and to do the interventions that will lead to the long-term improvements.”

Beyond the obvious ramifications for patients, there are many less apparent consequences that make this proposal even more ludicrous.

For starters, appointments made through the GAP cost the Quebec government more than visits from regularly assigned patients, thanks to the lucrative agreement signed with the FMOQ to encourage physicians to open up time slots for walk-in patients.

“The GAP costs three times the amount for every intervention. We know this. It is money poorly delegated,” Kalin explained. “Why are we paying three times the amount for the individual with the simple problem and one-third the amount for a patient who needs complex care? Because that’s what the government is proposing: healthy people go through the GAP. So financially it doesn’t make sense, medically it doesn’t make sense, ethically I think it’s dubious.”

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The Quebec government seems ready to pay more money for less comprehensive care in order to provide the illusion of quicker access. But this further erodes the bedrock principle of family medicine, which is that one doctor should be responsible for a dedicated population. If doctors can bill more to see a stranger once for a single issue, it disincentivizes the hard work of taking on patients and caring for them throughout their lifetime. This might make the work of physicians easier — and it might explain why the FMOQ is even tempted by such an overhaul. But this model is upside-down and backwards.

“It is destroying the fabric of family medicine, because family medicine is built on relationships,” Kalin said. “The GAP is the antithesis of that. The GAP is McMedicine. It’s about fast-food delivery.”

Adding insult to injury, the lack of continuity for patients and physicians also risks wasting money, scarce resources and precious time.

“The patients belong to no one. No one takes ownership. It’s never anybody’s responsibility. It’s always pushed off to the next person. It’s always somebody else’s problem,” he said. “We’re making this impersonal system where everybody is going to be calling call centres to be seen for problems that the agents don’t understand and can’t prioritize, sent to different sites each time where doctors don’t have the ability to access previous notes or records. We’re going to have redundancy, unnecessary testing, over-treatment, and I would say any study would suggest that the outcomes from this will be poor.”

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The GAP was only supposed to be a stopgap measure to give orphan patients a place to turn and take the pressure off overburdened emergency rooms. Now, due to a total lack of vision and a failure to address the root causes of the family doctor crisis, it’s set to become the subpar default. It’s as if Quebec has thrown up its hands about the prospect of ever having a health system that functions the way it should.

Are Quebecers going to stand for this?

Having a family doctor is not a luxury. Of course the most vulnerable patients need and deserve a family doctor to follow them. But so do all Quebecers. So the notion that anything will be solved by taking doctors away from the haves to allot them to the have-nots is disingenuous. It’s also a Band-Aid on a gaping wound and a prescription for a sicker society.

Quebecers who care about their own health, the health of others and the health system as a whole need to speak out before it’s too late.

ahanes@postmedia.com

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