Written by Denise Felsztyna

for Prof. Jeffrey Gandell

Since trying herbal teas, applying creams and lotions, and alternating between hot and cold showers were not efficient techniques, I figured that visiting Dr. Kalin was the next move to deal with my sore throat. Contrary to implication, walk-in clinics require an appointment. The process is like survival of the fittest, in which your opponent is an answering machine. The battle was tight during my thirty-minute phone call with the automated system, but I somehow managed to steal a consultation slot. I arrived at the clinic fifteen minutes early on the day of my appointment to avoid missing my turn; one round with that machine had been sufficient. The anesthetic smell of rubbing alcohol stunk and the yellow wallpaper on the corner of the room had started to peel off. I could only hear the sound of the receptionist typing on her computer. I went over to her office and she took my medicare card. She never removed her sight from her computer, except when she barked at me, saying: “sit in the waiting room until the doctor calls for you”. An hour and a half later, I heard a squeaky, high-pitched voice massacre my family name.

Despite the complicated process, I am one of the fortunate Quebecers to have access to a family doctor. The 6800 full–time family physicians cover six million Quebecers, leaving 25 percent of the nation without a doctor (CMAJ Medical Knowledge). Due to this lack of coverage, emergency rooms are transformed into seas of people in which waves of coughing cause currents of germs. According to the College of Canadian Physicians, “these visits cost taxpayers five to ten times more than the same consultations in family physicians’ offices” (Canadian Institute of Health). Not only would it decongest the emergency rooms if the ratio of doctors was proportionate to the population, but it would be fair. Two million Quebecers are paying for services they are not receiving. Although this dearth of doctors might seem like an innocent accident, it did not develop on its own. On the contrary, a human touch subtly interfered with our health system, causing a shortage of doctors.

Being a powerhouse, the professional order of Québec’s doctors holds the upper hand when negotiating its members’ salaries, which impacts the number of doctors that enter the system. Since the state cannot speculate with citizens’ health, it succumbs to the salary standards demanded by the Collège des Médecins who use the possible exodus of physicians or of strikes as threats. The professional order of Quebec’s doctors has become like a mother whose nurturing ways have protected doctors’ wages, with the exception that its relationship with doctors is strictly professional. Dr. Gaétan Barette, previous mother figure of the professional order, had negotiated a wage increase of 67 percent for specialist doctors making their incomes rise from 240 500 dollars in 2008 to 350 000 dollars in 2014 (Radio-Canada). While the provincial government has historically allocated the biggest portion of its budget to the health sector, it has not prevented the shortage of doctors. Money is at the root of most problems, but its distribution is a bigger issue in this social stake. In light of this reality, the ministry’s motto in terms of the health system follows the economic principle by which supply decreases as demand increases.

The government inevitably has to restrict the number of doctors that enter the work market to sustain the salary benchmark requested by the professional order. Quebec’s bureaucratic culture has enabled health ministers to filter the number of physicians’ positions available for each region and for each establishment in Québec through the stingy PREM system. Introduced during the liberal era, it was expected to improve the old punitive system, but according to Dr. Kalin, “the PREMS have proven to be much worse”. Like a funnel, it restricts the entrance of doctors into the work market by making the access to PREM licenses harder than stealing a consultation from an answering machine. Dr. Kalin said that, in 2013, there were only three PREM licenses given to medical graduates for the sector of Westmount, Montreal West, Côte-St-Luc, and Hampstead. Those left out of the boat can work, but only earn 70 percent of a doctor’s regular salary (Dr. Kalin). While medical graduates have passed all their exams to become members of the Collège des Médecins, they cannot find employment because the government cannot pay their wages. It has reached a point where “16 percent of new specialist and sub-specialist physicians cannot find work, and 31 percent pursue further training to become more employable,” according to the College of Canadian Physicians (The Gazette).

To obtain salary standards similar to our neighbors, the professional order uses the threat of doctors departing to the United States or other Canadian provinces. In reality, the Collège des Médecins is omitting that obtaining a green card is practically impossible, so the possibility of physicians leaving to the U.S.A. is not a substantial threat. Likewise, the PREM system also limits the entrance of doctors into the work market of other Canadian provinces. Dr. Kalin highlighted that the same system exists in Ontario, where he previously worked. Although the risk of doctors migrating to other provinces is more significant, the chances that they will obtain PREM licenses elsewhere are just as minimal. Besides, unlike Canadian doctors who are functionaries of the state, American doctors’ salaries follow the principle of capitalism, in which demand and supply set the prices for their medical services. When using the United States as an example, the Collège de Médecins is demanding through coercion that contributors meet the standards of the private sector within a public system. By the same token, the Collège des Médecins is not considering the differences in the cost of living or the economic situation when referencing other Canadian provinces. For instance, while doctors earn 300 000 dollars in Alberta, its GDP growth was of 3.5 percent in 2013 (RBC). In contrast, Quebec’s doctors earn on average 200 000 dollars, but the GDP growth of Quebec was a lean 1.3 percent (RBC). The economic contexts being as different as honey and butter, doctors’ salaries outside Quebec cannot be compared to our doctors’ salaries.

Quebec’s culture of complacency has demoralized people in the fight against bureaucratic systems. Just as we have accepted that Quebec has the worst road conditions in all of North America, we have become used to waiting months for medical appointments, spending hours in emergency rooms, and having only ten minute consultations during walk-in clinic hours. If we cut every physician’s salary by half, we could double the number of doctors. If they earned $100 000 dollars annually rather than $200 000, we could have 13 600 full-time physicians rather than 6800. Then again, although it is ideal, I doubt the plausibility of this solution. Dr. Kalin suggests that “more family physicians are not the answer to the shortage: Nurse practitioners are the solution”.

If family physicians’ and nurse practitioners’ duties were redistributed, 6800 family physicians would no longer constitute a shortage. According to Dr. Kalin, a nurse practitioner can perform up to 70 percent of a family physician’s work. Since they can indeed “diagnose, treat illnesses, order tests, and prescribe medications,” they could take some of family doctors’ responsibilities that could then increase their number of patients (Canadian Nurse Association). Everyone could have access to fast medical service in case of an emergency, shrinking the seas of people in the emergency rooms into ponds or small lakes. Overall, the primary caring network could be strengthened in a cost effective manner. While a family physician earns on average 200 000 dollars a year, a nurse practitioner costs the government 70 000 dollars (Canadian Nurse Association). Cleaning up the system would open the gates of opportunities to universal medical coverage in Québec.

More nurse practitioners would make Quebec’s shortage of doctors a legend, so that whenever you wanted an appointment, you would not have to fight with an answering machine. Meanwhile, my throat is still on fire. Back at the clinic, once the doctor called for me and I made it to the other side of the reception, I felt overwhelmed with a sense of achievement. Not only had I managed to beat an answering machine, but I had survived the waiting surrounded by people reeking of germs. The doctor made a sign with his hand to follow him. His office was bright and spacious, which was quite a contrast with the waiting room. He made me stick my tongue out, say “ahhhh,” and, after ten minutes of consulting, he reported that nothing was wrong with me. While walking away with my back somewhat arched and a frown on my forehead, I realized that I had not only wasted my time, but that I had prevented someone who was truly sick from consulting the doctor.

Work Cited

Fidelman, Charlie. “Quebec Doctors Earn Third-Lowest Salaries in Canada”.  Global. Global News. 23 Jan. 2013. Web. 13 Feb. 2014.

Gladu, François-Pierre. “Perceived shortage of family doctors in Quebec. Can we do something about it?” The Official Journal of the College of Family Physicians of Canada 53.11 (2007): n. pag. Web. 13 Feb 2014.

Glouberman, Noa. “Relocating? Compare cost of living and industries across Canada.” Metroland Media. Web. 2 Apr 2014.  

“Nurse Practitioners: It’s about time.” Canadian Nurses Association. Web. 2 Apr 2014.

Picard, André. “How Much Are Canadian Doctors Paid?”. The Globe and Mail. The Globe and Mail. 23 Jan. 2013. Web. 13 Feb. 2014.

Pinker, Susan. “Doctor Shortage in Quebec a Real Numbers Game”. CMAJ Medical Knowledge that Matters, Web Science 167.3 (2002): n. pag. Web. 13 Feb 2014.  

Radio Canada. “L’effet Barette: 42 pourcent de plus les Médecins Spécialistes.” Radio Canada Québec. Web. 4 Apr. 2014. Web. 9 Apr. 2014.

“RBC Economics: Research.”  Royal Bank of Canada. Web. 2 Apr 2014.