As he entered his 60s, Tony D’Apice and his wife realized it was unwise for him to continue putting off being followed by a family doctor, especially since he had a lingering issue with his pituitary gland. So it came as a relief to him when the Quebec government announced what it touted as a quick way to register for a GP online.That was nearly two years ago. In mid-July, when the 62-year-old Kirkland resident went online to verify his status, he was shocked to discover that his estimated wait time for a doctor had nearly doubled to more than 500 days.In a Kafkaesque twist, D’Apice has found that every few months when he logs onto the government website to check his wait time, it goes up instead of down.“It’s very bad,” D’Apice said of the online system, known in French as the Guichet d’accès aux médecins de famille, or GAMF.“What’s the use of being on a waiting list when every time you check, it gets longer? It’s supposed to go down.”“What am I supposed to do if I have something?” asked D’Apice, who runs a digital marketing business. “I should be going to a family doctor regularly to get some tests.” As a stopgap measure, D’Apice will drop by a local CLSC walk-in clinic if he needs a blood test, but he confesses that’s far from ideal.D’Apice’s ordeal is frustratingly common — and increasingly so — on the island of Montreal. Since the government launched the GAMF system in April 2016, the number of people waiting for a family doctor in Montreal has jumped by more than 35 per cent. As of May this year (the latest month for which complete figures are available), almost 137,000 people in Montreal who registered online were still waiting for a general practitioner, according to the Régie de l’assurance-maladie du Québec, which manages the system.
Dr. Mark Roper, chief of the Queen Elizabeth super clinic in N.D.G., attributes the flagrant disparity between Montreal and the regions to poor planning and politics.
Allen McInnis /
Average wait times for a family doctor in Montreal vary from a low of 205 days on the West Island for so-called vulnerable patients (those with chronic conditions like heart disease) to a high of 499 days for non-vulnerable patients in the north end of the city. In D’Apice’s case, he has already waited more than 560 days.What’s startling about the Montreal figures is how far they lag behind those in regions outside the city. In Saguenay—Lac-St-Jean, the registration rate is 91.6 per cent, the highest in the province. Other outlying regions fare nearly as well, like Chaudière-Appalaches (89.3 per cent) and Mauricie—Centre-du-Québec (89.2 per cent). That means that in those regions, nearly nine out of 10 people who want a family doctor have one.By comparison, the registration rate in the centre-west of Montreal is the lowest in the province at 65.8 per cent as of May 31. It gets worse when one drills down deeper to examine the rates of city districts like Parc-Extension (61 per cent). In effect, in a multi-ethnic district where more than 43 per cent of the population is considered poor, only one of two people who need a family doctor can get one. Provincially, the overall registration rate under the GAMF system inched up to 81 per cent in 2019 from 80 per cent last year. Had Montreal’s rates increased, the province would have succeeded in reaching its 85 per-cent goal — the target that former health minister Gaétan Barrette pledged would be achieved by Jan. 1, 2018.Dr. Mark Roper, chief of the Queen Elizabeth super clinic in Notre-Dame-de-Grâce, attributed the flagrant disparity between Montreal and the regions to poor planning and politics.“I have lobbied three health ministers over the last number of years, and I have come to the conclusion that no politician will change the present system because they’re worried about consequences politically from off-island ridings,” Roper said. “They may be perceived as favouring Montreal.”The prospect of that disparity disappearing under the Coalition Avenir Québec government is illusory to non-existent, say observers. This is the same government that soon after it was elected last October took steps to adopt its secularism law, Bill 21, against the objections of Montreal Mayor Valérie Plante.
Health Minister Danielle McCann. During the last provincial election campaign, she promised that a CAQ government would implement a 36-hour maximum wait time for Quebecers to consult a family doctor or so-called super nurse.
John Mahoney /
As for the concept of the GAMF database, Roper welcomes online registration, which requires individuals to enter their medicare card number, home address and answer a few questions about their health. Although Roper has used the system to sign up a few patients, he cautioned it’s only as good as the number of available doctors in a given area.“Let’s look at N.D.G. They need to register 18,000 patients to get to an 85-per-cent registration rate, which was the target of the previous government, and they’re actually going to lose doctors next year to retirement,” Roper explained. “The doctors who are going to retire, they won’t be replaced, and you’re going to have 20,000 patients next year who will need to be registered.”“So your wait time on the GAMF is going to actually increase if you have net loss of doctors in your region because doctors are retiring.”Roper blamed the underlying weakness of the GAMF system on the way the government allocates positions to new doctors starting their careers. Since 2004, the Health Ministry has relied on a policy known as Plans régionaux d’effectifs, or PREMs, to address what used to be a shortage of family doctors in off-island regions.That policy has shifted the initial imbalance to the point that Montreal now lags behind the rest of the province in access to GPs. New doctors who choose to practise in Montreal without being assigned a PREM position are docked 30 per cent in their pay.Health ministry officials acknowledge that finding a family doctor is frustratingly difficult despite the GAMF database and the establishment of super clinics that are open seven days a week. But rather than concede that the PREM policy has worked to the detriment of Montreal, the government has pinned the problem mostly on other causes.“There is no one sole reason or factor that influences the number of patients who are registered,” Noémie Vanheuverzwijn, a ministry spokesperson, said in a statement. “Several elements play a role, like the remuneration of family doctors, the establishment … of super clinics, the distribution of medical personnel, the type of patients in an area, vulnerable or non-vulnerable, etc.”Easing access to GPs “is one of the priorities of the (Health Ministry), but a challenge remains: Quebec is living with a shortage of family doctors.”
Quebec’s overall ER occupancy rate increased to 104 per cent in 2018-2019 from 100 per cent the previous year, according to the Health Ministry’s own figures.
Allen McInnis /
A study this year by the non-partisan Canadian Institute for Health Information found that Quebec has more doctors per 100,000 residents than Ontario. Yet Statistics Canada observed that Ontario has the lowest percentage of residents without a primary health-care provider in the country at 9.7 per cent. Quebec had the highest percentage, 25.6, suggesting that a lack of family doctors in the province is probably not the root problem.Paul Brunet, a patient-rights advocate for the Conseil pour la protection des malades, has criticized GPs for tending to choose far more patients in good health than those with chronic conditions that require more time and effort. That tendency might explain why the GAMF system is not working, Brunet contends.“The more your condition is serious, the more you have to face delays,” he said. “There’s clear cherry-picking in there.”Radio-Canada reported last year that family doctors rejected a cumulative total of 73,844 patients under the GAMF system, which was launched at a cost of $2 million. Among the top three reasons for rejection were that a patient could not be reached, the doctor’s practice was “incompatible” with the needs of a patient and the distance between a patient’s home and a clinic.For 2018 alone, doctors rejected 15,575 requests, a RAMQ official told the Montreal Gazette. What’s more, the ministry revealed that as of June 30, 5,020 family doctors were using the GAMF system — out of a total of nearly 9,600 in the province — a sign that perhaps the online database is not wildly popular with physicians.Brunet said he’s not against the idea of going online to sign up for a family doctor, but he noted that many older Quebecers are not internet-savvy, so that option is not easily available to them.“To me, the objective of having people registered with a family doctor is not a valuable one if we don’t see a decrease in the number of walk-in patients going to the emergency room,” Brunet added. “They should have lowered dramatically the number of people entering the ERs, but they haven’t.”In fact, the province’s overall ER occupancy rate increased to 104 per cent in 2018-2019 from 100 per cent the previous year, according to the Health Ministry’s own figures. On the island of Montreal, hospitals like the Lakeshore General and the Jewish General routinely report ER occupancy rates of more than 150 per cent.
Tony D’Apice’s estimated wait time to be assigned a family doctor has grown to 521 days.
Dave Sidaway /
If former health minister Barrette’s goal of registering 85 per cent of Quebecers with a family doctor was a tad ambitious, his successor has set her sights even higher. Danielle McCann promised during the last provincial election campaign that a CAQ government would implement a 36-hour maximum wait time for Quebecers to consult a family doctor or so-called super nurse.McCann doubled down on those lofty goals in June, vowing to reporters that by the end of the government’s term, the registration rate will rise to 95 per cent, as is currently the case in Ontario — remarks which her press attaché would later walk back in an interview with the Montreal Gazette.To tackle the problem of 567,000 Quebecers still waiting for a family doctor under the GAMF system, McCann announced her ministry will spend $46 million to offer general practitioners extra financial incentives to take on more patients. In the long term, the government hopes to negotiate a new way of paying doctors with the Fédérations des médecins omnipraticiens du Québec, switching from the existing fee-for-medical-act method to capitation, a system in use in Ontario.Under capitation, a doctor is paid a set amount for each enrolled patient assigned to them for a specific period of time. Alexandre Lahaie, McCann’s press attaché, predicted that capitation would result in doctors concentrating more on the so-called heavier cases, patients with multiple conditions like diabetes and heart disease.“It will improve access to a family doctor and a medical team,” Lahaie said, although he acknowledged that moving to capitation “takes time.”The current deal with the province’s GPs is set to expire in 2023, one year after the end of the CAQ government’s mandate. Thus, the odds are daunting that McCann will be able to reach a new agreement with the doctors’ federation on capitation before the next provincial election.McCann is also following Ontario’s lead when it comes to nurse practitioners. Ontario has long embraced super nurses, employing more than 3,300. Quebec, by comparison, ranks last of all provinces with just under 500.In Quebec, super nurses have the legal right to start treatment in stable patients — independently of a doctor’s say-so — for diabetes, high blood pressure, high cholesterol, asthma, hypothyroidism and chronic obstructive pulmonary disease.McCann wants to boost the number of super nurses to 2,000 within five years, and to expand their administrative powers, freeing up family doctors to see more patients.But again, such reforms will take time — time that some patients don’t have in a province with an aging population. And so for many Montrealers, their sole option will be to head straight to an overcrowded ER for what ails them.Back in Kirkland, D’Apice waits stoically to receive an email from the GAMF system to inform him that he finally has a family doctor. His latest estimated wait time? 521 days.“It’s a disgrace,” he said with a sigh.***
Constitutional lawyer Julius Grey intends to argue that Quebec’s distribution of doctors violates the Canadian Charter of Rights and Freedoms and is incompatible with the Canada Health Act.
Peter McCabe /
Legal challenge aims for fairer doctor distribution in QuebecProminent Montreal physician Mark Roper and constitutional lawyer Julius Grey are teaming up to take the Quebec government to court over the way it allocates new positions for doctors in the city versus the rest of Quebec.Roper, who runs the Queen Elizabeth super clinic in the west end, will serve as the lead plaintiff in the court case that is to include other doctors as well as patients challenging a policy known as the Plans régionaux d’effectifs médicaux, or PREMs.“What we’re arguing is that the present process of the PREMs endangers lives in Montreal, and limits patients’ access to health services,” Roper said.The Health Ministry created the PREM system in 2004 to compel new doctors to start their careers in regions across the province. The system has worked so well that Roper asserts Montreal is now woefully under-represented.Roper has also criticized the ministry for over-counting the number of family doctors in certain areas of Montreal like Notre-Dame-de-Grâce.“They think that N.D.G. has 16 too many doctors, but they count all the doctors who work in the emergency room at the MUHC superhospital,” he explained.In reality, at least 18,000 people in N.D.G. are in need of a general practitioner, a situation that will grow worse next year when two family doctors in the west end retire, Roper warned.Roper has recruited Grey to spearhead the legal challenge after giving up on persuading successive health ministers to change the system, concluding that the issue has become a political football. Grey plans to file court papers at the end of August or in early September.“I think it’s obvious that Montreal is a special problem,” Grey said, adding that the PREM system “skewers” against the city.Grey is mulling the possibility of seeking a temporary injunction against the PREM policy pending a full-blown court challenge. He intends to argue that the current distribution of doctors violates the Canadian Charter that guarantees the right to life, liberty and security of person, and is incompatible with the Canada Health Act.Grey added that jurisprudence supports his challenge, noting a ruling in British Columbia in the early 1990s that went against a similar system in effect in that province at the time.But Roper and Grey are facing a tough fight. A Health Ministry spokesperson told the Montreal Gazette that the government this year authorized 128 “supplementary” positions for family doctors in Montreal, representing nearly a quarter of all the new positions in the province. Roper disputes those numbers.***Tony D’Apice’s wait time keeps climbingThe longer he waits to be assigned a family doctor, the longer the government website says he must wait.Sept. 27, 2017: 274 daysApril 4, 2018: 399 daysSept. 29, 2018: 467 daysJune 9, 2019: 519 daysJuly 15, 2019: 521 days firstname.lastname@example.org/Aaron_Derfel