Why are doctors self-employed…and unionized?

The negotiations between Quebec and the doctors sound like a worn record that always hits the same discordant notes.

It’s an old tune from the 1970s.

At the time, the Minister of Health Claude Castonguay was preparing to create the universal health insurance plan. However, his project is seriously compromised by a strike of specialist doctors. Fearing losing their professional autonomy, they reject all compromises. Some even leave the province.

Suddenly: thunderclap. Labor Minister Pierre Laporte is kidnapped by the Quebec Liberation Front. He was found dead the following week. In the midst of the October crisis, public opinion is shifting against doctors who are paralyzing the health system¹.

Finally, Quebec adopts a law which imposes a return to work and specifies the contours of the brand new public plan.

But to make things easier, doctors remain independent workers paid on a fee-for-service basis, with no obligations for collective results, despite the fact that they only have one real client: the State.

Since 2007, they can even incorporate, which allows them to defer a large tax bill.

While enjoying the flexibility of their entrepreneurial status, doctors negotiate their working conditions behind the shield of powerful “unions”.

It’s the best of all worlds.

To stand up to the Minister of Health Christian Dubé, they took the liberty of going on a teaching strike which will have serious consequences for students and the population. And when the College of Physicians courageously reminded them of their duties, they had the nerve to demand the head of the head of their professional order, whose mission is the protection of the public.

All this to say that the hybrid status of doctors, which should have been temporary, has never ceased to create tensions for 55 years.

The doctors wanted to manage themselves. But their lack of integration into the health system is largely responsible for the repeated failures of the reforms we wanted to put in place. Just think of the CLSCs that doctors have shunned, refusing to be simple employees within a multidisciplinary group.

With the special law presented on Friday, Quebec will finally recover its right of management over doctors’ remuneration. This is the fundamental element of Christian Dubé’s reform, even more than the famous performance targets that we have talked about so much.

This is what will allow him to reconfigure the health system, overcoming the opposition of medical lobbies.

It remains to be seen whether the law will pass the test of the courts.

Since a Supreme Court decision (Saskatchewan decision), governments can no longer impose working conditions without negotiation. Except that doctors are not in the same context as employees subordinate to their employer. Moreover, the government of Quebec won its case when it wanted to impose Territorial Medical Workforce Plans (PTEM, formerly PREM) on them.³.

As frictions with doctors are constant, clarification of the legal issues will be welcome.

Strike, threat, special law… We are in 2025 and it’s still the same song.

We find ourselves at loggerheads, even though the reform is more consensual than we think.

Fee-for-service payment has shown its limits. It is horribly complex. It harms multidisciplinary team work. It is less effective for the management of chronic diseases and for prevention.

After substantial increases since 2010, Quebec doctors are among the best paid in Canada when taking into account the cost of living ($414,000 for omnis in full-time equivalent, $548,000 for specialists). However, this has not made it possible to increase the provision of services, on the contrary⁴.

We cannot continue like this.

Countries like the United Kingdom have imposed salary-based compensation. Quebec relies on capitation, which provides for the payment of a lump sum per patient, modulated according to the complexity of the case. This shift is necessary. The other provinces are more advanced than us.

But we can understand the anger of doctors who are asked by the government to take care of the entire population, without guaranteeing them the resources to do so. In addition, 15% of their compensation will be linked to performance targets which remain unclear.

A happy compromise would consist of linking these targets to quality of care measures (e.g.: hospital readmission, vaccination rate), focusing on value rather than the volume of care provided, as many experts recommend.

Minister Dubé wanted to go too quickly. He lacked tact. But the federations also lacked openness, rejecting the project outright. They accepted mediation reluctantly, continuing to demand arbitration, maintaining their strike.

The Federation of General Practitioners of Quebec (FMOQ) and the Federation of Specialist Physicians of Quebec (FMSQ) have always led the way. If we had a single federation, like in the other provinces, it would already be less complicated.

Today, Quebec is pulling out all the stops to force doctors to follow its instructions: disciplinary appeal, loss of years of practice, penal provisions, fines, etc.

This forced collaboration does not bode well for the implementation of a major change in the method of remuneration which is desirable. As was the implementation of the health insurance plan in 1970.

1. Pascal Mailhot, Marie-Michèle Sioui, The indomitable MammothEdition Somme Tout Le Devoir, 264 pages.

3. Consult the report “Recent developments in the supply of medical services and the remuneration of doctors in Quebec”