It is essential that all physicians practicing in Québec understand how the health care system functions. This is not necessarily an easy task, for health care systems throughout the world, whether public, private or mixed, have become imposing, complex structures. The Québec system differs from those in other Canadian provinces because of the integration of health services and social services thus adding its complexity.
The first section sketches the broad outlines of the health and social services system—“Québec-style”. A brief history will illustrate how the Québec health care system compares to other public systems, where needs increasingly exceed resources. This overview will also show how the Québec system differs from others in that its general organization is very centralized, a rather paradoxical feature given that services are essentially provided at the local level. It is evident that the multiple formulas applied to promote decentralization of the system have not managed to eliminate this contradiction. Reorganization on a regional and then local basis now seems to be the advocated solution for better integrating medical and other activities.
The second section attempts to precisely situate the professional practice of physicians within the health care system. The manner in which the medical practice of physicians is integrated has not always been clear in Québec. This is still the case, and the various types of current practice bear this out. To date, the two principal forms of medical practice have been practice in institutions and private practice. However, other formulas situated somewhere between these two are on the rise. These include family medicine groups (GMF), specialized medical centers (CMS), and associated medical clinics (CMA). Once again, these new developments point to the difficulties inherent in wanting to integrate independent professionals into an essentially public system.
The practice of medicine in an institution is an independent type of practice. But as it is linked to institutions in the public system, this type of practice obliges physicians to reconcile their ethical obligations with the medical and administrative constraints of institutions as stipulated in the Act respecting Health Services and Social Services (LSSSS).
In contrast, medical practice outside public institutions is often designated as “private practice”. However, barring a few exceptions, it also is an integral part of the public health care system, if only because medically required services are publicly funded. Here again, many formulas from CLSCs to family medicine groups (GMF), from regional medical manpower plans (PREM) to special medical activities (AMP), have been put in place to better integrate this type of practice into the public network. To date, the results have been mitigated, so much so that one can rightly ask whether a healthy tension between the professional independence of physicians and the very centralized organization of the health care system is not just another characteristic of the “Québec way”.
The organizational aspects of medical practice in Québec pose an additional challenge to physicians. Indeed, what we see is that physicians are working in increasingly varied spheres. Clinical research, medico-legal assessment, occupational medicine, public health, as well as administrative and commercial types of practice, are all areas of activity in which the professional independence of physicians is constantly being put to the test.