Practice Outside an Institution


Under review

Traditionally in Québec, we distinguish two ways of practicing medicine — practice inside an institution and private practice.  However, the dividing line between private office and public institution has become more and more permeable for a variety of reasons which are not pertinent for discussion here.

Family physicians do not only work from their office. They are being called upon to provide various forms of care and services in medical institutions to a greater and greater extent. In addition, increasingly specialized care is migrating outside of institutions and into treatment facilities that can no longer be simply qualified as doctors’ offices. New organizational models somewhere between institutions and private offices have been growing in number for several years, with their sole common characteristic being that the care is being dispensed outside of the institutional setting.

In this section, we will strive to present a global vision of medicine being practiced outside of institutions in Québec and to offer a clear interpretation of its evolution. In so doing, we will emphasize certain aspects that, regardless of the organizational model, we believe raise various issues with respect to the quality of physicians’ professional practice. 

In the face of these issues, current laws and regulations do not always offer the coherent answers we would hope for. As we will see in  the following pages, the requirements of the Code of Ethics of Physicians apply to all physicians regardless of their place of practice (see Duties and Obligations of Physicians). Moreover, new administrative rules were adopted in 2007 with respect to the types of associations possible for physicians, whether they practice within or outside of an institution. In addition, the rules pertaining to advertising were also revised in 2010. The new Regulation respecting records, places of practice and the cessation of practice by a physician, which was updated in 2012, now applies to all physicians, irrespective of whether they practice within an institution or outside an institution. In modifying certain provisions of the Act Respecting Health Services and Social Services (LSSSS) and the Act Respecting Health Insurance (LAM) in 2006 and 2009, the Québec government established a governing framework for two new bodies — specialized medical centres (CMS) and associated medical clinics (CMA). However, now that a number of interventions previously restricted to institutions can be carried out outside of these settings, several questions have emerged and remain unanswered. 

Among all the requirements imposed within an institution, which are still pertinent? For example, do we need to obtain written consent before embarking on any surgery, invasive procedure or research project? By calling for written consent when treatment is not medically required, the Civil Code only offers a partial response (see The Physician’s Obligations under Certain Laws). Practice outside an institution raises numerous new questions which the Collège is attempting to answer, be it in the Code of Ethics, in its regulations,in the guidelines, or in the practice guides COLLÈGE DES MÉDECINS DU QUÉBEC. La rédaction et la tenue des dossiers par le médecin en milieu extrahospitalier : guide d'exercice, Montréal, Collège des médecins du Québec, April 2013.
COLLÈGE DES MÉDECINS DU QUÉBEC. La tenue des dossiers par le médecin en centre hospitalier de soins généraux et spécialisés : guide d'exercice, Montréal, Collège des médecins du Québec, December 2005.
As you will see in this section, vigilance must always be the order of the day for physicians.  
With respect to the more practical aspects of practice outside of institutions, we recommend consulting the documents published by medical federations (FMOQ and FMSQ) and medical associations (CMA, CFPC, RCPSC). The Québec Federation of General Practitioners (FMOQ) Web site offers several training modules designed for medical residents and focused on such subjects as the choice of a location to practice, possible modes of compensation, billing,  financial planning and insurance, specific medical activities (AMP) and required medical manpower plans (PREM). For more information about the new organizational models, it would be useful to consult the Ministère de la Santé et des Services sociaux (MSSS) and  Régie de l’assurance maladie du Québec (RAMQ) Web sites. However, given the extremely rapid pace with which this area is evolving, the best way to remain informed is often to follow the news.