Hanes: Doctor has job offers in Montreal, but is blocked by ‘rigid’ permit system

Quebec’s PREM process not only undermines efforts to recruit doctors, it is actively driving some away from the province.

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It should be a no-brainer.

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Dr. Stan Joseph (not his real name) grew up in Notre-Dame-de-Grâce. He went to medical school at McGill University. After graduating three years ago, Joseph and his wife, also a doctor, moved to Iqaluit, Nunavut, to practise where they believed they could be of greatest service. They thought they’d stay in the North for a long time to come.

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But life factors are now luring them back to Montreal. Aging parents and wanting their young children to grow up close to their grandparents are the two biggest pulls. However, when he accompanied his mother to a Montreal emergency room recently, Joseph’s eyes were opened about where their skills could be put to the best use.

“Waiting 16 hours without being seen, you end up just getting up and walking out, thinking you’ll try again somewhere else. … We have polar bears up here, but that just wouldn’t happen (in Iqaluit),” Joseph said in an interview. “It was this funny realization like, ‘Actually, the place that’s really underserved right now is the place where I grew up, where my family lives.’ ”

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More than a million Quebecers don’t have family doctors, including 800,000 in Montreal. In some parts of the city, up to 65 per cent of the population has no general practitioner. Montreal badly needs physicians. And here are two McGill-trained doctors ready to roll up their sleeves and pitch in. They both even have job offers in Montreal.

If this were any other province, the couple would already be packing their boxes. But Joseph is missing one thing: a PREM.

Short for Plans régionaux d’effectifs médicaux, these are permits that dictate where physicians can practise in Quebec, not to be confused with the medical licences granted by the Collège des médecins authorizing them to work.

Getting one is an extra hoop to jump through for new medical school graduates and physicians who want to come here from outside Quebec. Without one, doctors face penalties and restrictions — although they are allowed to work in the private system.

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To many physicians, PREMs have long been a source of frustration as well as a bureaucratic nightmare. But a policy originally put in place two decades ago to address a shortage of doctors in rural regions and ensure equitable coverage across Quebec has now become counterproductive.

This is the first of two columns about how PREMs are not only undermining efforts to recruit doctors, but actively driving some away.

It focuses on Joseph, who was willing to share his experience applying for a PREM, but didn’t want to be identified because his future and job prospects are up in the air. The next column will examine McGill’s cohort of new med school grads and how many have received PREMs in 2023.

Each year, the Health Ministry allots a certain number of PREMs to each region. There is a once-a-year, two-week window to vie for a PREM, which closed in October.

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While applying, Joseph and his wife found out there was a separate process for academic PREMs, for which the deadline had already passed. But luckily, there was one vacant PREM, which his wife put in for and was granted, allowing her to accept a post at the McGill University Health Centre.

“At this point, we were very happy, because it’s a job description that’s consistent with what she wants to do,” Joseph said. “And so we’re thinking, ‘OK, this is good. We’re 50 per cent of the way there. Surely now there’s a good chance that I will get this PREM.’ ”

Although applicants are advised to focus on getting a PREM first, Joseph said he was encouraged by friends and colleagues who had gone through the rigamarole to seek out work opportunities anyway. He has managed to secure offers that are right up his alley, including a pilot project on Indigenous health care at the Queen Elizabeth Health Complex in N.D.G. and working in the ER at Lachine Hospital, which is turning away ambulances to deal with large patient volumes and staffing shortages.

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But a job is not to be confused with a PREM — and those doing the hiring don’t have any say over whether Joseph gets permission to practise.

Making matters even more complicated, there are 12 sub-regions within Montreal, so applicants must seek a PREM in the area of the city where they want to work and later bill the RAMQ for at least 55 per cent of their services in that zone.

For the sake of fairness, the doctors who conduct the interviews for PREMs aren’t from the district where the applicant wants to practise. The needs of each of Montreal’s 12 districts are defined by a local Département régional de médecine générale. The heads of the DRMGs meet regularly to share their recruitment goals and then interview the PREM candidates for one another’s sub-regions.

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There were 15 candidates for seven PREMs in the DRMG that includes N.D.G. this year. And in the end, Joseph didn’t get one.

He and his wife are now weighing their options.

If Joseph were to take one of the jobs he’s found here, he would take a 30 per cent hit when he bills RAMQ. He would also be barred from reapplying for a PREM for five years and be denied hospital privileges. Aside from the unfairness of getting docked pay, Joseph wants to maintain the acute care skills he’s honed.

He could do what many doctors are increasingly doing and go work in the private system.

“Nothing against the private clinics per se, but that’s not why I went into family medicine,” Joseph said.

Or he could go practise in Ontario, where no PREMs are needed.

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“I’ve currently applied to five jobs total within a 300-kilometre radius of Montreal, and I’ve had offers in four of them,” he said.

In this case, Quebec would not only lose Joseph, but his wife as well — not to mention her PREM, which, once awarded, cannot be transferred to another doctor.

Joseph has not given up hope of practising in Montreal, but he is discouraged by a confusing and “rigid” process that is turning away doctors — even ones with jobs.

Orphan patients should be just as disheartened.



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