Just like Santa Claus and Richard Nixon before him, François Legault is making a list.

And while we can’t confirm if he’s checked it twice, we know that list contains the names of 4,000 doctors who aren’t working hard enough — according to Legault, at least.

Two weeks ago, the premier admitted that his government used emergency powers granted during the pandemic to circumvent privacy laws and obtain the patient lists of family doctors across Quebec. By his government’s reckoning, some 40 per cent of family physicians in the province don’t have enough patients in their practice.

He’s ready to draft legislation that would force these allegedly lazy doctors to provide care for a minimum of 1,000 patients. I suppose that’s easier than breaking into their homes and leaving a lump of coal in the sock drawer.

But who are these lazy doctors?

Last week, we decided to take a deeper look at the state of family medicine in Quebec. What we found was a lot of so-called lazy doctors who work 60 hours a week, balancing their duties as family clinicians with night shifts at the ER and days off spent catching up on paperwork.

A ‘negotiating tactic?’

Take Simon-Pierre Landry, for instance. According to our government, his 1,000 patients constitute the bare minimum workload for a family doctor. He pulled out his daily planner to show how he spends his days.

“Okay, so Thursday and Friday I did two night shifts at the emergency room and had a day off Saturday,” said Landry, a family doctor in the Laurentians. “Sunday I was at the clinic seeing patients, and Monday I was back in the ER. Tuesday as well. Wednesday I was on call for 24 hours at the ER and worked a day shift at the hospital. I had a day off Thursday but spent it doing paperwork.

“Today I’m at my clinic seeing patients. Saturday and Sunday too. Monday I’ll be at the emergency room, and Tuesday it’s back to my clinic. In the winter I try to have one day off a week to be with my kids.”

To break it down, Landry — a family doctor — spent just five of his last 12 shifts seeing patients in his clinic. He doesn’t choose to work so many hours at the hospital: he’s legally required to. Beyond work at their clinic, family doctors are required to choose an additional practice to help with Quebec’s bottlenecked healthcare system. They can do shifts in an ER, a long-term care centre, in palliative care or in home care.

When Legault and Minister of Health Christian Dubé say people like Landry need to take on a bigger workload, are they aware doctors have these additional responsibilities?

“Do they really believe what they’re saying? Because if they do, then they don’t understand how their own healthcare system works and that’s worrying,” said Landry. “Or is this a negotiating tactic? I don’t know. It’s cynical, it’s discouraging and it’s harmful. Doctors coming out of school see this witch-hunt and they’ll just avoid working in the public system altogether.”

Roughly 860,000 Quebecers are on a waiting list to get a family doctor. That’s more than twice what the number was when Legault’s Coalition Avenir Québec came to power three years ago.

Access problems are bigger than doctors

In a press conference last week, Legault said his “patience is wearing thin” with family doctors and implied there would be consequences for physicians who don’t dramatically increase their workload.

“I can see him, three months from now, making this a platform for his re-election,” said Claudel Pétrin-Desrosiers, a family doctor in Montreal. “He’ll say, ‘We forced 400 doctors to take on 1,000 new patients each. That’s 400,000 Quebecers that now have a family doctor because of us.’

“Well, good luck getting an appointment. Because even people with a family doctor know how long it takes to see them. If we all take more patients, the problem of access won’t be solved. People will wait months to see their doctor, they’ll wind up going to the ER and adding to the gridlock.”

Because family doctors have to contribute to the healthcare system outside of their own practice, their time is split between their clinics and other facilities. In other words, there are almost no full-time family doctors in Quebec.

Catherine de Montigny has been on the front lines of the worst overdose crisis in Quebec’s history. While opioid overdoses kill an average of roughly one Quebecer each day, de Montigny works with patients trying to find a pathway out of addiction.

Because she’s one of the rare doctors in the province specializing in substance use disorder, there are weeks when de Montigny is on call for the entire province. Any nurse, doctor or medical professional who needs advice on detox or rehab will reach out to de Montigny. In addition, she sees patients in her family clinic.

“I am what François Legault considers a lazy doctor,” she said. “I have patients with dementia, patients who are homeless, older patients who are getting sicker and sicker. People are not just numbers on a spreadsheet. I’m not even close to having 1,000 patients but I’m working six days a week, some weeks, just trying to keep up with what I already have.”

Mathieu Pelletier runs a family clinic and teaches on the side. He works about 60 hours a week but, with 865 patients to his name, he doesn’t meet Legault’s minimum standards.

“Going after doctors makes for good politics,” said Pelletier. “There’s an election in one year. Do you really think they can run on their record — a healthcare system that’s collapsed, skyrocketing waiting times for surgeries, the sheer number of nurses who quit because they couldn’t take it anymore? So why not attack doctors? Why not change the conversation?

“Last year, when med students had to choose their field of expertise, there were 75 spots in the field of family medicine that remained vacant. There may have been two vacancies in the specialized medicine field. This year, I know people who have to reach out to med students and say, ‘Cover your ears, ignore what the premier is saying, it’s just politics, it’ll blow over.’ We really have to give them the hard sell because who wants to join our ranks when you’re being bullied by the government?”

From guardian angels to greedy golfers

The subtext of Legault’s frontal assault on physicians like Pelletier is that his government also happens to be renegotiating the way Quebec pays family doctors. And playing hardball is a speciality of the premier’s. When he was the Parti Québécois’ health minister at the beginning of his political career, Legault tried to impose a 30 per cent pay cut on doctors who didn’t meet certain performance requirements.

His plan never saw the light of day.

Isabelle Leblanc agrees that Quebec needs to reform the way doctors are compensated. She’s part of a group that advocates for physicians to receive less money so more funds can be transferred across our public health system. But she’s appalled by what she’s heard from the premier.

“It wasn’t so long ago that (Legault) called us guardian angels, people fighting to protect Quebecers from COVID-19,” said Leblanc, who has a clinic in Montreal’s Côte-des-Neiges district. “Now we’re lazy and greedy. What did I miss? The reality is the government doesn’t have a solution and it needs culprits to blame.

“They’re asking us to do two things at once. On the one hand they want us to take a huge increase in patients in our clinics. On the other hand, they want us to spend up to 20 hours a week not taking patients in our clinics, helping out with overflow across the health network.”

Leblanc actually meets Legault’s requirement of being a “good” doctor. She has over 1,000 patients and, since she works in one of Quebec’s most multicultural neighbourhoods, about half of them don’t speak French or English. It takes a great deal of patience and love to provide them with the care they need, she said.

“I’m in this because I believe access to healthcare is a right, not a privilege,” she said. “I think the premier is playing a dangerous game. More and more doctors will see what the government is doing and decide not to enter family medicine. There are other fields that pay far better — there is the private sector, plastic surgery, specializations. Why would someone sign up to be the government’s punching bag?”

No magic bullet solutions

Further compounding the problem, 70 per cent of family doctors under 60 years old are women. For graduates coming out of university, that number is closer to 90 per cent, Pelletier said.

“These women have the right to start a family, and that means they won’t be able to take on 2,000 patients while raising a newborn,” Pelletier said. “The government knows this but they’re choosing to play politics with it.”

There are no magic bullet solutions to Quebec’s healthcare crisis, he said. Fixing the system requires a plan that can survive if one government falls and a new one takes its place.

“When was the last time we had a health minister with vision?” Pelletier said. “They come into the job with a list of problems they want to solve in the short term. What if we invested in our front lines? If we have a strong front line, then we’ll see less need for specialized services. That’s worked in other jurisdictions.

“If you create a provincial health agency, almost like Hydro-Québec, you can start to implement plans that don’t change every time there’s an election. But then the government gives up one of its biggest weapons: the ability to politicize healthcare in an election.”

Pétrin-Desrosiers said there are days she feels the pressure of Quebec’s ailing healthcare network.

“It’s your name on the file, your signature. When you leave your patient and go home, you ask yourself, ‘Did I do everything I could for that patient?’

“And the more you’re stretched thin, the harder that question is to answer.”