Quebec has faced a severe shortage of family physicians for years, but the government’s most recent solution may not be the answer, according to those working in the health system.

In May, Health Minister Sonia Bélanger announced that the province had achieved its goal of 500,000 new patient sign-ups to family medicine clinics. Patients signed up via the “Guichet d’accès à la première ligne” (GAP) program, which provides a primary care access point for patients who don’t have a family doctor or specialized nurse practitioner in primary care.

But most of those patients were registered collectively to a clinic and still don’t have their own doctor. Many of them still have to wait weeks or months for a clinic appointment. This situation creates difficulties for physicians, as well as patients, Nebojsa Kovacina, MD, a family physician in Montreal and assistant professor at McGill University, Montreal, told Medscape News Canada.

When collective registration was introduced, it was pitched as a “quick fix” and a “temporary measure,” he said. “The government basically made a big walk-in [clinic] for patients who are without a doctor. Patients have to call 811, which tells them where they can make an appointment, and if their clinic can take them or they need to go to a different clinic.”

Kovacina worries that this measure may not remain temporary. Quebec’s new provincial primary care policy, published in April, doesn’t specify that continuity for the patient must rest with a named provider, only that a patient be attached to a clinic. That arrangement takes a toll on physicians as well as patients.

“Physicians are caught between two fires,” he said. They’re trained to build long-term relationships, but in the new reality, they may have short appointments with patients who have no continuity. In that setting, they’re not able to properly manage complexity or chronic disease.

The mismatch weighs heaviest on new graduates who get “mixed messages” about how to practice, Kovacina said. “We’ve been trained to provide the best possible services to the patient. Collective registration doesn’t deliver that. Instead, it perpetuates two speeds in primary care, one group of patients with an assigned provider and continuity, and another cycling through whoever is available on a particular day.

“For sure, those patients without continuity are going to have more expensive care because we’re going to do more tests on them,” he said. “They’re going to have more visits, and clinicians aren’t comfortable with that.”

Tara Kiran, MD, a family physician and researcher at St. Michael’s Hospital and Fidani Chair of Improvement and Innovation at the University of Toronto, described the situation in Quebec in an episode of her Primary Focus podcast. The episode begins, “If you are a family doctor, you know one of the hardest feelings is knowing you are not seeing your own patients when they need you. You work through lunch…You squeeze in ‘just one more’...You stay late and miss dinner with your family…again. And still, patients you care about are waiting weeks for an appointment.”

Continuity: A Core Principle

Continuity is one of four pillars that evidence shows primary care needs to function well, Kovacina said. “Good relational continuity with a primary care provider will not only lead to better health outcomes but also will be better for the system and for the physician. It will cost less; we’ll be doing fewer tests and choosing more appropriate care for an individual patient because we know the patient better.”

“Primary care isn’t only an access point or a coordination function,” agreed Élise Boulanger, MD, president of the Collège québécois des médecins de famille (CQMF) and co-founder of GMF Clinique Indigo in Montreal. “Without [continuity], every encounter starts closer to zero,” she told Medscape News Canada. “You retake the history, re-establish the context, read through the file, and process all of that before you can even begin. That’s fine in urgent care, or when you’re covering for a colleague, but over the long term, patients need continuity.

“Continuity is ultimately something the patient experiences,” she said. “It must be well organized around the person. We must be able to measure continuity and genuinely value it. It can’t just be a matter of counting how many people are registered and measuring access. On the ground, many physicians are already absorbing the GAP and doing the informal continuity work the system no longer guarantees.”

Kiran agreed, noting that according to the national OurCare initiative, which she leads, about 5.8 million Canadians have no primary care at all. But she still manages to experience some satisfaction in the current system. “If I know that there’s a need and that they haven’t seen anybody in a long time, then that motivates me to want to provide care to those people,” she told Medscape News Canada. “All of us feel terrible that there are so many people out there who can’t access basic care. They’re without diagnoses and without treatment or preventive care for a long time. The opportunity to help them be healthier is a lovely part of being able to see people who haven’t had care. It can be rewarding in a different way than seeing people over time in your practice.”

Is Team Care the Answer?

“A team is essential, but it’s a complement to continuity, not a substitute for it,” Boulanger said. One difficulty is stability. “We’ve often struggled to keep the other professionals in our teams because people move on, and positions go unfilled. These professionals are hired by the system, not only by the clinic, so they have many other opportunities open to them, and turnover undermines team stability.”

There’s also a training gap, Boulanger said. Professionals like nurses often don’t arrive fully trained for primary care and must be trained on site. “Teams can carry a great deal of continuity,” she said, “but only if we invest in their stability and training. Otherwise, the team itself becomes another source of discontinuity.”

Kovacina described similar difficulties. “Some clinics have all their positions filled, while others are struggling to recruit people,” he said. “Interprofessional work takes time.” Simply adding staff doesn’t automatically translate into capacity. You can’t just put people in one room and say, ‘Work together.’”

A Clinic That’s Working

Sabrine Manoli, MD, medical director at District Medical, a large multidisciplinary practice in Montreal’s Ahuntsic district, told Medscape News Canada that her clinic has been working well as a team since before the GAP program started. The clinic includes more than 50 family doctors, roughly a dozen specialists, and about a dozen nurses, pharmacists, and other clinicians.

“When everything is on your shoulders, you’re going to crumble because it’s too much,” she said. “The team structure, with people covering for each other, is what lets the clinic absorb collectively registered patients without the fragmentation that others describe. And when a GAP patient needs ongoing care, whether for a new depression diagnosis or a complex chronic condition, physicians use their own judgment about whether to pull that patient into individual follow-up.”

Interestingly, Manoli has found that for younger, healthier GAP patients juggling work and school, the flexibility of evening and weekend appointments at the clinic can be an advantage, even without a personal physician, and the clinics can handle these patients, as well.

What frustrates the clinic about GAP isn’t the model itself, but its execution, Manoli noted. GAP-referred patients, whether healthy or chronically ill, sometimes arrive from other clinics with no chart history at all, and the clinic still doesn’t have a full list of the patients it’s responsible for. “GAP is more like a separate program,” she said. “If we were really to take charge of 100% of those patients, I think we could manage pretty well, because we really do help each other out.”

Looking Ahead

Manoli said the province has promised a complete list of the clinic’s collectively registered patients. That list could unlock a more proactive model. For example, nurses and physicians could work through the roster to identify patients over age 50 years who may be overdue for screenings that they’ve never been offered. “That would be a big step forward,” she said. “We could start a macro approach to contacting these patients and offering them preventive care.”

Kovacina said that while he doesn’t expect a mass exodus from family medicine over the current arrangement, quick fixes won’t resolve the underlying tensions. Pointing to Ontario’s primary care action plan as a model, he said that Quebec needs something similar. “Quick fixes are not going to make it. We need to have a vision for a good 10 years, work toward that, and build coalition among all professionals, so then we all know where we’re going.”

Boulanger reported being a co-owner of GMF Clinique Indigo and president of the Collège québécois des médecins de famille. Kiran reported receiving consulting fees from Ontario Health and speaker fees from several medical associations. Kovacina and Manoli declared having no relevant financial relationships. 

Marilynn Larkin, MA, is an award-winning medical writer and editor based in New York City whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.