Opinion: Time to push back on health crisis in Quebec


As a physician, I fear for the worst as baby boomers age and increase the demand for services that are among the worst in the country.

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A major report by Accreditation Canada, whose team of inspectors visits hospitals across the country, “adds to the growing body of research highlighting the reality that Montreal’s ERs are in crisis,” the Gazette reported this month in an article on dismal wait-time statistics, with a specific focus on the McGill University Health Centre.

Though similar problems exist across various hospitals, the single most important underlying cause common to all is overlooked, in my view: The vast majority of ER problems are not the fault of the hospitals but of over-centralized planning.

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The Ministry of Health and Social Services has for several decades dictated hospital policies throughout Quebec. This micromanagement approach will continue to grow under the proposed rules of Bill 15 now being discussed in the National Assembly. How long will our political leaders, suffering patients and unengaged voters allow this to continue before demanding a new way forward?

The ER situation is not new. In 2016 the Gazette reported wait times across Quebec were among the worst in the Western world. The proportion of adults who reported waiting five hours or more during their last visit to an ER was 35 per cent in Quebec versus 15 per cent in Ontario and 13 per cent in Alberta.

These were the findings of a comprehensive study by Dr. Robert Salois, then the provincial health commissioner. Since the report, ER wait times in the country have generally become longer. Quebec in general and Montreal in particular remain among the worst.

As an attending physician and researcher at the Montreal General Hospital who has been in practice for 37 years, I believe that health care indicators in general —  including ER wait times — will continue to deteriorate unless thoughtful, data-driven decisions are made by the provincial health care leadership.

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When my wife (a respirologist) and I came on staff in 1986, we had trained and worked at the Royal Victoria Hospital, rural community hospitals in northern and eastern Quebec, and academic hospitals associated with the medical schools at UCLA and Harvard. We accepted faculty and staff positions in Montreal as the quality of hospital care at that time was highly competitive with the best we had seen in the United States.

When we arrived, we knew there was increasing interest in encouraging physicians to practise in rural settings but did not realize how coercive and dysfunctional medical manpower allocation was about to become.

Initially, young physicians were attracted to rural practice with financial incentives, including a substantial premium. However, this carrot was replaced with a made-in-Quebec solution. The stick was the adoption of the “plan effectifs medicaux” (PEMs and PREMs) to restrict the number of new clinical practice positions available each year in specific communities.

The underlying goal was to force young physicians to practise in rural communities by limiting the number of positions in urban centres that were fully supported by  public health insurance billing (RAMQ). This program, unique to Quebec, has yielded no objective data to demonstrate the benefits of this approach compared to the rest of the country.

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Access to primary care and specialty care in urban centres like Montreal has declined steadily since then Parti Québécois health minister François Legault  introduced these practice restrictions 20 years ago.

In all fairness, it is difficult to believe that any elected health minister could conceive of such legislation after only a short time in the position, and one must assume that the Health Ministry was primarily responsible for these new rules and the increased centralization of health care planning.

It is also worth noting that no provincial government since then has chosen to remove these regulations given the abysmal health statistics that clearly place Quebec at the bottom of many critical provincial health care indicators.

Before examining the health indicators, a few reflections from my years of practice at the Montreal General Hospital:

During the first few years I was in practice, one could still get a patient admitted to the hospital directly from one’s office without sending them down to the ER. We knew our patients, and after examining them in our offices, could reliably determine who was too sick to go home.

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This changed rapidly as beds became scarcer, but typically a call down to the ER, a consultation by the ER physician, some selective testing, and nearly all our patients were admitted to the hospital the same day or within 24 hours.

Last month, I spent two weeks attending on the in-patient internal medicine service where between 20-24 patients were under my care while supervising the medical students and residents. The wait time — from arriving at the ER to being transferred upstairs to an in-patient bed — averaged five days.

Imagine being sick enough to require hospitalization but spending the first 120 hours in the emergency room, sometimes in a hallway if no ER rooms were available and/or on a gurney if no bed was free.

Given that the ER was always over capacity, sometimes up to 200 per cent, the patient experience was necessarily less than humane. Not much better for the nursing staff who were often missing personnel in an ER handling far too many patients given its limited capacity.

All this after three years of a pandemic that has left staff feeling generally burnt out, while struggling to maintain services across a hospital dealing with closed beds, significantly lower numbers of health care professionals, and reduced access to diagnostic services (radiology, blood tests, pathology, etc.) given technician shortages.

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With a general strike looming by unionized health care workers, the next few months look particularly worrisome.

My personal impressions from the past few weeks are supported by health care indicators at the hospital and regional and provincial levels.

The situation in Montreal is the worst in the province, and the provincial data are among the worst in the country. Access to a regular family physician is lowest in Quebec — and at around 69 per cent in Montreal, it is the lowest in the country.

Wait times in Montreal ERs are the longest in the country and significantly longer than cities like Toronto where approximately 90 per cent of the population has a family physician. Makes sense; if you don’t have access to medical care, where is the one place a doctor is always available?

Some colleagues have correctly noted that one cannot conclusively prove that the extended ER wait times are the direct effect of limited access to a family physician. A few weeks ago, a few colleagues and I completed a quick analysis at the MGH:

First, we reviewed charts of the ambulatory patients seen for outpatient problems typically seen in a doctor’s office. During a typical 24-hour period in the middle of the week, 47 patients were seen, each spending many hours in the ER waiting to be seen. Among these patients, only 17 per cent could provide their doctor’s name, indicating that at least 83 per cent did not have access to a doctor in a timely fashion.

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To confirm these findings, based on a limited one-day survey, we then used the MUHC computer system to review all hospital records during the past year, from both the MGH and the Royal Victoria Hospital at the Glen site. Among just over 42,000 ambulatory visits, about 12,000 (29 per cent) had a family physician’s name in their ER record while 30,000 (71 per cent) did not.

Clearly, individuals without family doctors are disproportionally seen in the ER for ambulatory problems. Imagine how much less crowded the ER might be if a significant proportion of these 30,000 visits could have been seen in a doctor’s office in a timely fashion. Imagine how much faster patients might have been evaluated and admitted when necessary.

Other statistics confirm that health care in Quebec requires a major overhaul:

During the pandemic we had the worst mortality rate in our nursing homes of any province. Unfortunately, the health care workers in nursing homes were the lowest paid before the pandemic, resulting in many having to hold more than one job to make ends meet. COIVD had no trouble spreading among nursing homes with many workers assigned to more than one.

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The number of long-term care beds as of March 2021, per 10,000 individuals 65 years of age and older, was among lowest in the country at 24 versus 29 on average, with only Nunavut having poorer access than Quebec.

While around 90 per cent of Canadians had access to a regular health care provider in 2019-’20, only 80 per cent did in Quebec, with Montreal at the bottom of the province at 69 per cent.

Compared to Toronto, Montreal has nine per cent fewer nurses per 10,000 population (181 versus 165), 28 per cent fewer specialist physicians (32 versus 23), and 30 per cent fewer family physicians (20 versus 14).

First-year wages for our nurses are among the lowest in the country.

Quebec also leads other provinces in the number of doctors who work outside of medicare. By a lot. The most recent report estimated 642 “non-participating” physicians in Quebec versus 12 in the rest of the country!

Despite all these shortcomings, the per capita health care spending in Quebec remains above that in Ontario (in 2022-’23, hospital spending per capita was $1,980 versus $1,742) while that province’s ER wait times, and access to primary care physicians, have been consistently superior to ours.

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It is time to push back at all levels.

The administrative leadership in our hospitals and regional health authorities must push back when faced with humiliating articles in the media that expose our unacceptable wait times.

The regional health authorities must insist that access to short- and long-term care be improved.

The professional colleges must demand a re-examination of the PEMs, PREMs and low wages paid to many categories of health professionals.

In the short term, nurses and other health care professionals will need to be recruited in a highly competitive market across North America.

The physician shortage could be alleviated starting next spring by removing the PREMs and PEMs and encouraging new physicians to stay in the province while they enjoy full RAMQ coverage in the region of their choice to keep them in the public system.

The media must continue covering these stories until the situation improves substantially.

Bill 15 should be put to rest until these medical staffing issues are addressed.

And, finally, voters must hold our elected officials responsible for the Health Ministry regulations they support.

Otherwise, the situation will only get worse as baby boomers age and increase the demand for health care services that are insufficient and among the worst in the country.

Steven Grover is a senior attending physician at the MUHC and a professor of medicine at McGill University.

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