Quebec physicians and gulag (part 2)

News 8 July, 2017
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    Guillaume Hébert

    Saturday, July 8, 2017 10:02

    Saturday, July 8, 2017 10:27

    Look at this article

    Two weeks ago, I wrote a post that focused on a clinic in Montreal-Nord that are having difficulty recruiting family physicians and a representative of the general practitioners who invoked the spectre of the soviet Union to illustrate what would be the situation of quebec physicians if one had to assign them to certain areas where the needs are greatest. This text has done much to respond and I want to push the reflection a bit further in this second post.

    I was first accused of not having mentioned the “PREM” and ” PEM “, or regional Plans staffing and medical staffing Plans medical.

    It is in both cases the mechanisms established by the Ministry of Health and social Services (MSSS) in 2004 to ensure – at least theoretically – that the doctors are working in areas or institutions where the needs are greatest.

    To practice in a given region, a family physician must obtain a “notice of compliance in the PREM” or in simpler language : “PREM “). The EMP mainly relate to the medical specialists and are awarded based on institutions, rather than of regions.

    If a family physician practice without having previously obtained a PREM for the region where it is installed, it will be punished. Conversely, physicians may be exempt from the requirement of obtaining a PREM in some cases (ex : three years of practice in an isolated region or even 20 years of practice in the public network).

    In view of these constraints, some doctors argue that the responsibility of the regions underserved returns to the DHSS, and not to the doctors.

    It must be admitted with the doctors as a part of the responsibility lies well and truly at the ministry, and now even more directly to the minister, since he has undertaken to arrogate to themselves powers constantly growing. This power, and this responsibility is observed, for example, when the minister Barrette announced 35 PREM-additional – after the registration period as usual and that these new positions will be granted to physicians who decide to join a super-clinic. Thus, rather than responding to the needs of the population, the current mechanism seems to respond to the whims of the minister. Remember also, that the minister Barrette had back in January of this year after having wanted to promote arbitrarily the installation of doctors in his constituency.

    Moreover, the allocation of the PREM by region is opaque. We know that the regional departments of general medicine (DRMG) are responsible for the needs assessment, that the Fédération des médecins omnipraticiens (FMOQ) is consulted, that a joint committee of management of the medical workforce (COGEM) decides on possible waivers, then the last word rests with the minister of Health. But we don’t know much else of which guide these negotiations.

    It would seem that these powers of the positions and appointments of doctors are so hazardous that some doctors have dubbed the whole process ” Loto-PREM “…

    But at present the doctors as victims or actors of the network and without liability vis-à-vis the regional distribution of the workforce, there is a very big step not to be crossed.

    First, note that the PREM does not exist since 2004. If we created them, it is that there was a problem, and that it was understood that we could not rely on a division of “natural” doctors, which will be appropriate to the needs of the population. In other words, past experience has shown that when we let the doctors be free to choose their place of practice, some regions – notably the most deprived regions – are not sufficiently part of the preferences of doctors.

    Then, it is useless to seek the intervention of the College of Physicians – which is supposed to protect the public – or even at a major medical federations to denounce the people are being neglected by the current operation. Clearly, these groups of doctors does not move much and their demands are rather to simply escape the constraints.

    The medical Federations do indigneront not the fact that the transfer of resources from the CLSC to the GMF will greatly reduce the capacity of the public system to provide overall care to the disadvantaged populations.

    As my colleague Anne Plourde has been shown in a note recently published, the mission of a CLSC has a range population while the GMF is limited to its members. The current transition of the CLSC to the GMF affects disadvantaged neighbourhoods and serves the interests of physicians who find themselves at the head of the new private facilities.

    Interestingly, Physicians for a public plan (MQRP) have also dedicated their annual report this year to the study of this model of ” medicine entrepreneurial “.

    Finally, note that

    The notice of compliance in the PREM does for the doctor only one requirement : respect a minimum threshold of 55 % of his days (and not revenues) billing completed in this region. The remaining 45% may be charged in one or more other regions without the family doctor has to undertake steps with the other DMRG to obtain a notice of compliance. (from “the Guides to Residents 2014” canadian medical Association)

    In other words, doctors would be able to devote a portion of their hours outside of their ” home port “. It would perhaps not be to a doctor in Abitibi to complete his hours in the Gaspé region, but may be they could see doctors attached to the Crown of montreal come in to complete their hours by giving a thumbs up in disadvantaged neighbourhoods ?

    A physician has also made me notice that it may be relevant to more select students in medicine based on the neighbourhoods where they come from. By doing this, you could increase the chances that once trained, the doctor is disinterested in areas that are less affluent, if it is itself the result.

    It remains that we go back to the same point as in the first post : all these scaffolds bureaucratic have been created with the objective to better respond to the needs of the people without calling into question the status of self-employed physicians.

    So, I insist again on this idea : the doctors do not belong to a species of upper caste and they should accept the same status as the other workers and health care workers (and most of the workers and of workers in general, for that matter).

    Fun fact, this little controversy will have had the merit of making me explore more of the medicine of the soviet union. I stumbled on this account highly interesting of various works on medicine as it was practiced in a country like the USSR.

    Although all is not dark, we learn, for example, that under Brejev, a young psychiatrist

    Semën Gluzman, challenged the diagnosis of irresponsibility issued by the institute Serbskij about Pëtr Grigorenko, general, gradient, interned in a psychiatric hospital, because he supported the civil rights movement and the claims of the Crimean Tatars. For having denounced the expertise fallacy of his colleagues, Guzman was arrested in 1972 and sentenced to several years of camp.

    You believe that I insist too much on a simple joke ?

    It is that doctors have the annoying habit of often imagine the gates of the gulag. Two years prior to the arrest of Guzman by Brezhnev, in Quebec, the eminent cardiologist Peter Grondin threatens to leave the province if it establishes a public health insurance and universal. As you can hear it in this episode everyone was talking about (12 minutes), it states that the law proposed by the quebec government is more rigid than the soviet regime “.

    The excerpt is definitely worth a visit, if only for the look of Claude Castonguay…

    By the way, I did some calculations and conversions, and I realized that in the 80’s, a doctor in the soviet earned on average the equivalent of… 7000$ in canadian dollars today. In the USSR, the blue-collar workers earned more than professionals, it seems.

    In sum, this is not very clever nor very helpful to the debate to compare the quebec health care system of the USSR. Perhaps it is time that the doctors break with this habit.

    It is obvious that, like anyone else, doctors have their say on the organisation of health and social services system in quebec. But it is urgent that they release the ballast, and that they recognise that they are among workers who are the most privileged in our society in terms of status, power and remuneration. Some doctors destroy the credibility of the profession as a whole when they express themselves as if they were being persecuted.

    Those should see how a little bit of humility will cost them in the end much less expensive than a proletarian revolution….

    (This text has been written in collaboration with Anne Plourde)