Quebec's Bill 114

When 51-year-old Claude Dufresne, experiencing his second myocardial infarction, arrived at the emergency department (ED) of the 142-bed Centre hospitalier du Centre-de-la-Mauricie in Shawinigan-Sud, he was 6 minutes too late; the ED had closed for the night because none of the hospital's 60 family physicians or internists were available to staff it. He died while being transported to the next nearest ED, some 30 minutes away.

With provincial elections around the corner, Health Minister François Legault responded not by creating another task force but by introducing and passing new legislation.¹ Under Bill 114, chief hospital administrators faced with an ED staffing problem must create a list of all family physicians and emergency specialists who, during the preceding 4 years, worked at least 1 ED shift. A physician so listed must “report to the [ED] to which he or she is assigned [for the] periods of duty [specified by the administrator].” There are fines for noncompliance or encouraging noncompliance.

The physician–patient relationship is based on trust, the physician–government relationship on necessity. Physicians broke that trust by not staffing the ED of such an important regional hospital. Re-establishing trust will require patience, determination and perhaps some sacrifice. But the damage done by Bill 114 to the physician–government relationship will be permanent, at least for the remainder of the government's mandate. Already, some physicians are notching up the rhetoric and speaking, perhaps unfairly (for this is not war), of conscription (see News, p. 681). We have heard that some medical students in Quebec have already started to avoid elective rotations in the ED for fear of being placed on the government lists.

The difficulties in attracting skilled physicians and nurses to work in our crowded, chaotic, underresourced and frustrating EDs are of course not new. The current Quebec government had been working with physicians to try to solve the problems in Shawinigan for at least 2 years. Previous governments have struggled with ED staffing problems and waiting lists for decades.

The problems in the EDs have their roots in the lack of adequate home care, which stalls patients in hospital beds, in the sluggish response of the government to its own Clair Commission recommendation to reform primary care,² in cuts to medical school enrolment, in incentive plans to get physicians to retire and, perhaps most importantly, in the changing face of emergency medicine. Much acute medical care that was once provided in abundant hospital beds is now done in the ED. Training requirements for ED physicians have lengthened to 3 years for family physicians and 5 years for specialists. It is not surprising that physicians facing ED duty in deplorably overcrowded departments, with inadequate numbers of support staff and facing increasingly complex diagnostic and management problems without having received adequate postgraduate training, are opting out.

Acute solutions to chronic problems by governments in distress are apt to fail, as this one will. But this one will also severely damage the medical profession in Quebec. There is a fine but very distinct line between propelling physicians through incentives and disincentives and compelling them through legislation. It is a line that should not have been crossed. — CMAJ