Bill 20 could impact quality of hospital care

Protect crucial work of general practitioners,
JGH urges in brief to government

In a brief that responds to Bill 20, the JGH has commended the Ministry of Health and Social Services for setting the goal of providing Quebecers with broader, faster and easier access to health care, especially at a time when many individuals have no family doctor of their own.

However, the JGH also cautions that Bill 20 “is trying to be a one-size-fits-all solution that could have unintended consequences” for general practitioners who carry out a wide variety of critical tasks in a hospital setting.

Included in the proposed legislation, which was introduced last November, are provisions for general practitioners to take on a minimum number of patients and to see more patients per year, or else be liable to pay financial penalties.

The JGH brief, submitted in March to the Ministry of Health and Social Services, notes that some general practitioners play a crucial role in the hospital by improving the quality of non-surgical care for post-operative JGH patients—especially the elderly and/or those with multiple medical problems—in Orthopedics, as well as general care in Neurology/Neurosurgery and Oncology. Among elderly JGH patients who have had orthopedic surgery, this has substantially reduced the mortality rate and the number of transfers to Intensive Care.

The brief says that if Bill 20 is enacted in its present form, “these essential and high value-added arrangements could be substantially weakened or possibly even eliminated,” because many general practitioners would be required to spend time devoted to other tasks in order to fulfill the Bill’s requirements.

“The evolving role played by these physicians in caring for hospital in-patients needs to be acknowledged and supported,” the brief states. “Their involvement improves the quality of care, is cost-effective, and is consistent with best practices in healthcare institutions across North America. This arrangement deserves to be protected by the government for the benefit of these high-risk patients in hospitals across Quebec.”

Bill 20 also suggests that if some general practitioners are precluded from caring for patients in specialty areas, this role should be filled by specialists from various fields. However, according to the JGH brief, this proposal faces four challenges:

• Most veteran specialists at the JGH (as elsewhere) received their specialty training in an era—sometimes decades earlier— when broad-based general care of patients was part of the curriculum. Even if they excel in their own specialties, they are not properly equipped to deliver the type of acute care to the elderly and/or to those with multiple medical problems that is best provided by well-trained general practitioners and/or general internists.

• Currently and in recent years, physicians who are preparing for careers in most surgical sub‑specialties receive a narrower form of training that no longer includes the general care of patients. As a result, they lack the skills to take the place of general practitioners in tending to patients’ non-surgical needs, especially those of patients with multiple medical co-morbidities.

• The acute care of patients with complex medical problems has evolved significantly in the many years since most specialists launched their careers. Even if certain specialists were willing to provide this care, they would need remedial training to become suitable replacements for general practitioners.

• Specialists are insured for malpractice only if an adverse event occurs while they are practicing their own specialty. Given the elevated rate of morbidity among patients who are elderly and/or have multiple medical problems, specialists might well be unwilling to take the place of general practitioners in the wards, if their new duties required them to practice beyond their areas of expertise, thereby disqualifying them from coverage by their insurance plans.

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Therefore, the Jewish General Hospital recommends that general practitioners, whether hospital-based or from outside the hospital, should be allowed to continue:

• their very significant value-added care of patients in various hospital wards
• teaching medical students and/or supervising residents
• devoting the agreed-upon portion of their time to research

In addition, in order to maximize the benefits that general practitioners can deliver in a hospital setting, and in order to take the next logical step to heighten the effectiveness of Bill 10 (which took effect April 1), the JGH recommends that Bill 20 be amended so as to transform hospital-based physicians from independent entrepreneurs to salaried professionals of their respective CIUSSS, with clearly defined roles and responsibilities, and regular performance evaluations.