Three reasons behind the erosion of the social contract

Étudiants en médecine et professionnalisme médical2During the training on medical professionalism organized by the QMA Students Group, participants had a chance to listen to the discussions of a very interesting panel. Dr. Alain Vadeboncoeur, head of the emergency department at the MHI, Léonard Aucoin, consultant and administrator in Québec’s health care system, and Alexandre Berkesse, senior advisor at the Direction Collaboration et Partenariat Patient (DCPP) of the Faculty of Medicine at Université de Montréal, talked about the erosion of the social contract, the consequences and the possible solutions to fix the problem.

They all agreed that the social contract was breaking down.

For Dr. Vadeboncoeur, it was clear that Quebecers today had unrealistic expectations of medicine, and perhaps also regarding accessibility. There was “quite a contrast between the apparent free provision of care and the cost of care, but also between the expectations of the population and the expectation when a lot of money is invested but without any improvement”.

Mr. Aucoin described the current disillusionment as “worrisome”. But a situation that can be explained by the purely union approach that exists in Québec. Over the years, the unions’ scope of intervention has expanded and “administrative and teaching tasks are now also in the hands of the federations”. Conversely, local institutions have been stripped of the “clinic” where “everything is in the hands of the government”. Lastly, the population no longer accepts the self-employed status of physicians, which already came without accountability, but also allowed them to incorporate when their compensation was guaranteed.


For Mr. Berkesse, it should not be forgotten that physicians and patients do not have the same expectations. While the unions referred to the legality of their agreements, the population looked at it from the humanly aspect. However, “it is shockingly aggressive for a patient to be told that it is legal,” he said. He also felt that physicians understand that although they were trained to always take action, this approach could be non-appropriate, as can be seen in the non-compliance of treatments, which is enormous in Québec and which is not talked about.

All three agree that the consequences of the current situation can be serious. For Dr. Vadeboncoeur, the population and physicians feel that no hope remains, but in his opinion, it is crucial to not simply accept that the social contract is broken: it is necessary to react and get things back on track. Mr. Aucoin feels that the danger lies in reaching a point of mistrust that could turn into complete distrust. There is also an issue regarding who will acquire the image of the medical community. Meanwhile, for Mr. Berkesse the population’s anger about physician compensation is a catalyst for challenging the very legitimacy of physicians. Patients are beginning to ask what legitimizes the gains of physicians compared with other health professionals. “Physicians will have to ask themselves why their patients are going to see the osteopath without telling them. And not fight the wave, but surf on it to use it as a driver for innovation.”

Dr. Vadeboncoeur feels we have an education issue. “We have to educate the public,” he says and review the way we finance the health care system. In his opinion, revenues should be frozen and the money redirected into the system. He also believes it is possible to recover funds by lowering the price of drugs “which cost us a lot, too much,” and by changing the way that care is provided for seniors.

Mr. Aucoin pointed out that while he may receive very good care in the Québec health care system, in contrast the service is “dismal”. His solutions? Decentralize decisions at the local level, introduce collaboration between physicians and managers, get out of the fatalism that exists in the system, and work as a team so that physicians can make voices other than those of the unions heard. Physician representation goes through the lens of negotiation. “The compensation issues must be separated from the other health issues,” he says.

Mr. Berkesse wanted to remind students that before they become future physicians, they are citizens and to never forget that what we criticize our health minister for, which is wanting to control the system, is exactly what physicians want to do because of their DNA. Somewhat like family physicians who choose to work in an emergency department rather than a family medicine practice because they feel that they have more control over what they are doing in acute care than by treating a patient over the long term. In his opinion, it is also necessary to have general assemblies on health not only to ensure that what we read about in the newspapers is not repeated, but also to discuss the redefinition of the social contract in order to redistribute the money amongst health care professionals.