le SpécialiSte A KEY ROLE IN THE NETWORK FOUNDATIONS Drug Insurance: How to Control its Cost (Page 44) AFTER BILL 130 DR SERGE GAUTHIER

Transcription

1 le SpécialiSte Drug Insurance: How to Control its Cost (Page 44) Vol. 19, no. 4 December 2017 FOUNDATIONS A KEY ROLE IN THE NETWORK EXCLUSIVE AFTER BILL 130 DR SERGE GAUTHIER PAGE 7 PAGE 22 DECODING CONSCIENTIOUS OBJECTION PAGE 36

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3 Galerie Claude Lafitte Depuis 1975 PUBLICITÉ PLEINE PAGE Galerie Claude Lafitte Marc-Aurèle Fortin «La Vieille Forge», v. 1945, aquarelle, 22'' x 28'' Oeuvres de grands maîtres canadiens et européens recherchées. Haute valeur offerte. Évaluation gratuite sur rendez-vous pour les oeuvres de Borduas Ferron Fortin Gagnon Krieghoff Lemieux Letendre McEwen Pellan Riopelle Suzor-Côté Groupe des Sept et autres Claude Lafitte, votre spécialiste expert-conseil

4 RÉCHAUFFEZ VOTRE HIVER GRÂCE À VOS POINTS. PUBLICITÉ LA COMPAGNIE AÉRIENNE, LE DÉPART ET LE VOL DE VOTRE CHOIX. LES VOYAGEURS MC ONT LE CHOIX. PLEINE PAGE Vivez l Expérience Voyages MC dès aujourd hui grâce à points en prime à l adhésion. Allez à rbc.com/voyages pour présenter RBC Banque une demande. Royale Photo prise au Jardin botanique de Montréal Sous réserve des disponibilités. Certaines restrictions peuvent s appliquer. Pour consulter toutes les conditions, allez à rbc.com/primesvoyages. Pour que vous receviez la prime de points RBC Récompenses, nous devons avoir approuvé votre demande. Les points RBC Récompenses offerts en prime à l adhésion figureront sur votre premier relevé mensuel. Cette offre ne peut être combinée à aucune autre offre. La Banque Royale du Canada se réserve le droit de retirer cette offre à tout moment, même après que vous l avez acceptée. / MC Marque(s) de commerce de Banque Royale du Canada. RBC et Banque Royale sont des marques déposées de Banque Royale du Canada. Toutes les autres marques de commerce appartiennent à leur propriétaire respectif.

5 Contents 24 DOSSIER Le Spécialiste is published 4 times per year by the Fédération des médecins spécialistes du Québec. EDITORIAL COMMITTEE Dr Sylviane Forget Dr J. Marc Girard Dr Karine Tousignant Maître Sylvain Bellavance Nicole Pelletier, APR Patricia Kéroack, CW DELEGATED PUBLISHER Nicole Pelletier, APR Director, Public Affairs and Communications RESPONSIBLE FOR PUBLICATIONS Patricia Kéroack, CW Communications consultant REVISION Angèle L Heureux Françoise Pontbriand GRAPHIC DESIGNER Dominic Armand ADVERTISING France Cadieux ENGLISH VERSION INTERNET ONLY TO CONTACT US EDITORIAL CONTENT communications@fmsq.org ADVERTISING fcadieux@fmsq.org magazinelespecialiste.org Fédération des médecins spécialistes du Québec 2, Complexe Desjardins, Suite 3000 PO Box 216, succ. Desjardins Montréal (Québec) H5B 1G PUBLICATIONS MAIL Postal Indicia LEGAL DEPOSIT 4th quarter 2017 Bibliothèque nationale du Québec ISSN The President s Editorial After Bill 130: Mind the Boomerang! 08 In The News 10 Continuing Professional Development 13 Medical Practice 15 About Billing 17 Legal Issues 20 Did You Know Great Names In Quebec Medicine FOUNDATIONS: A KEY ROLE IN THE NETWORK 25 A Matter of Necessity 28 A Tribute to Serious Commitments The mission of the Fédération des médecins spécialistes du Québec is to defend and promote the economic, professional, scientific and social interests of the medical specialists who are members of its affiliated associations. The Fédération des médecins spécialistes du Québec represents the following medical specialties: Adolescent Medicine; Anatomical Pathology; Anesthesiology; Cardiac Surgery; Cardiology (adult or pediatric); Child and Adolescent Psychiatry; Clinical Immunology and Allergy; Colorectal Surgery; Critical Care Medicine (adult or pediatric); Dermatology; Developmental Pediatrics; Diagnostic Radiology; Emergency Medicine; Endocrinology and Metabolism; Forensic Pathology; Forensic Psychiatry; Gastroenterology; General Internal Medicine; General Pathology; General Surgery; General Surgical Oncology; Geriatric Medicine; Geriatric Psychiatry; Gynecologic Oncology; Gynecologic Reproductive Endocrinology and Infertility; Hematological Pathology; Hematology; Infectious Diseases; Internal Medicine; Maternal-Fetal Medicine; Medical Biochemistry; Medical Genetics; Medical microbiology and infectious diseases; Medical Oncology; Neonatal- Perinatal Medicine; Nephrology; Neurology; Neuropathology; Neurosurgery; Nuclear Medicine; Obstetrics and Gynecology; Occupational Medicine; Ophtalmology; Orthopedic Surgery; Otolaryngology-Head and Neck Surgery; Pediatric Emergency Medicine; Pediatric Hematology/ Oncology; Pediatric Surgery; Pediatrics; Physical Medicine and Rehabilitation; Plastic Surgery; Psychiatry; Public Health and Preventive Medicine; Radiation Oncology; Respirology (adult or pediatric); Rheumatology; Thoracic Surgery, Urology and Vascular Surgery. All pharmaceutical product advertisements are previously approved by the Pharmaceutical Advertising Advisory Board (PAAB). The authors of signed articles are solely responsible for the opinions expressed therein. No reproduction without previous authorization from the publisher. THIS ISSUE S ADVERTISERS Desjardins 2 Galerie Claude Lafitte 3 RBC Royal Bank 4 Professionals' Financial 6 Sogemec Assurances 12 and 45 TELUS 16 Dr Serge Gauthier, Neurologist 36 In the World of Medicine 41 Federation Affairs 43 Professionals' Financial 44 Sogemec Assurances 46 L éditorial de la présidente L après 130 : attention au boomerang! 47 Member Services Commercial Benefits 32 A Small Region's Battle 34 Mont-Tremblant 30 MultiD 48 5

6 The President s Editorial fprofessionnels.com Actionnaire de Financière des professionnels depuis 1978 UNE POLYARTHRITE FINANCIÈRE VOUS ANKYLOSE? DEMANDEZ À VOTRE CONSEILLER QUEL TRAITEMENT VOUS REMETTRA SUR PIED. CONSULTEZ DES EXPERTS QUI VOUS COMPRENNENT Financière des professionnels inc. détient la propriété exclusive de Financière des professionnels Fonds d investissement inc. et de Financière des professionnels Gestion privée inc. Financière des professionnels Fonds d investissement inc. est un gestionnaire de portefeuille et un gestionnaire de fonds d investissement qui gère les fonds de sa gamme de fonds et offre des services-conseils en planification financière. Financière des professionnels Gestion privée inc. est un courtier en placement membre de l Organisme canadien de réglementation du commerce des valeurs mobilières (OCRCVM) et du Fonds canadien de protection des épargnants (FCPE) qui offre des services de gestion de portefeuille.

7 Dr Diane Francœur The President s Editorial AFTER BILL 130: MIND THE BOOMERANG! We predicted a nightmare, but it was obviously denied by the Minister. Which is it then? Who's right? In my opinion, it's the tip of the iceberg which, instead of melting, becomes more and more visible. Some of you wrongly believe that in denouncing this menace, we are milking it for "political gain." I would answer that the enemy is among us! By minimizing the effects of a Bill that has not yet been applied, we let it infiltrate and insinuate itself quietly into our practice. And when the moment comes, it will hit hard! For some unhappy victims of Bill 130, it will be the end of a career. Think, in particular, of physicians who, after decades of very loyal services in our public health system, will be shown the door because they no longer meet the criteria of "full-time equivalent" which are set unilaterally by the Assistant Deputy Minister, Michel Bureau. In a Hospital Close to You Like any other profession or craft, it is also true that in our Federation there are disruptive physicians. They are a minority and we will not defend the indefensible. And yet, to control them, the DSPs, the heads of departments or services will not find a magical and rapid solution in Bill 130. They will have to compile dossiers, collect proof, meet the physician, document an action plan, before confirming failure. Just as it's always been done... It isn't a law they need, but rather support and training. This being said, the renewal of our Agreement, expired since March 31, 2015, is still not signed because the Minister refuses to negotiate the issue of our conditions of practice. Meanwhile, the heads of departments and services are neither paid nor trained because these terms are indeed part of the clauses to be renewed. The heads need to know how to manage certain difficult colleagues who are, in a way, the consequence of failing to apply rules already in effect. The Reign of Terror and Top Down Violence It is well known that Gaétan Barrette terrorizes (the word is appropriate!) his presidents and executive directors who, in turn, terrorize their managers and staff. Assistant Deputy Minister Bureau terrorizes DSPs and encourages them to do the same with their physicians. This climate of terror, menace, manipulation has one aim only: weaken the rights of the medical specialist and force him to give in to inappropriate decisions. And what can we say about the internal omerta! Each day, physicians tell us of unacceptable situations they experience in their institutions. These cases should be denounced publicly, because citizens and patients need to be informed. And yet, physicians don't dare speak publicly for fear of retribution. Some have done so and were severely reprimanded. We are in 2017, soon to be Dictators don't belong here, not in the healthcare network nor elsewhere. Worse, autocracy undermines people's morale. For proof, the Quebec Physicians' Health Program has registered an increase of 38% in new cases last year. These are colleagues who can't take it anymore and doesn't include those who have chosen to end it permanently. It's not a fantasy. Your Patients First and Foremost! More than ever, I ask you to fight to preserve your professional independence in the name of your patients. They are the ones you owe your loyalty to. As medical specialists, you cannot back down when faced with what must be defended in their name. You are not employees of the DSPs nor of the presidents and executive directors. Don't accept the unacceptable. Don't make your patients endure what you wouldn't want to suffer, because of potential contracts being imposed This is my last editorial of the year A year that is closing with either an open negotiation or by a blockage that is quite involuntary on our part. All year, we have worked hard, in particular to renew our Agreement in a realistic and responsible fashion. We cannot back down, because negotiating our conditions of practice is part of our intrinsic values. And, as you indicated in our survey last spring, conditions of practice worry you more than does the financial aspect. I wish to sincerely thank our directors, our staff, the members of our Board of directors, and the presidents of our medical associations. Without them all, we wouldn't have a Federation. Together, we can do a lot! While we wait for 2018, I wish all of you my very best for the Holiday period. Rest well. Another difficult year is ahead of us, but let's maintain our morale and find professional satisfaction in caring for our patients! LS 7

8 In The News By Sylviane Forget, MD* Centre for International Cooperation in Health and Development (CCISD) THE FMSQ IS ACTIVELY COOPERATING The Centre for International Cooperation in Health and Development (CCISD) is celebrating 30 years of existence this year. Founded in 1987, under the aegis of the Faculty of Medicine of Laval University, then becoming an independent non-profit organization in 1996, the CCISD designs and manages international health projects in developing countries, in particular within the Francophonie. The CCISD's expertise covers a wide spectrum of health issues, including maternal and infant health; primary health care; sexual and reproductive health, as well as the rights attached to them; a healthy environment and governance. All of these projects are structured along crosscutting principles that include equality between the sexes, community participation, respect for and protection of the environment. For example, the CCISD acted as leader in the context of projects supporting faculties of medicine and research institutes in order to establish epidemiological monitoring centres in several countries in West Africa, from the early 1990s until The CCISD also distinguished itself at the start of the 1990s and the first years of the new century in the fight against AIDS in French-speaking Africa with its projects SIDA 1, 2 and 3, which earned it the UNAIDS Best Practices award. Thanks to its expertise in project management and in strengthening local capabilities, the Centre also managed infrastructure and primary health care service support projects in the Kinshasa province of the Democratic Republic of Congo between 2003 and 2017, as well as the training of high-quality medical and paramedical personnel in community health centres in Mali, in cooperation with the Cégep de Saint-Jérôme and the Université de Sherbrooke. Over the years, its activities and projects have been extended to other healthcare areas and other countries, in particular those of maternal and infant health and food safety in Haiti; epidemiological monitoring in 15 countries in West Africa; prevention and treatment of sexually-transmitted infections in Niger; and improving living conditions in rural areas of Bolivia. Since its beginnings in 1976, the CCISD has completed more than 100 projects, and managed a budget of close to a quarter billion dollars in interventions in 41 countries affecting 12 million direct and indirect beneficiaries. New Partnerships Over recent years, the CCISD involved itself in exploration work to identify other countries with a potential for intervention, including Nigeria, the Ivory Coast, Myanmar and Colombia. In Quebec, the CCISD has a long history of collaborating with partners from the cooperation sector, such as the Société de coopération pour le développement international (SOCODEVI) and the LÉGER FOUNDATION, as well as with various collegiate and university teaching facilities, including the Cégep de Saint-Jérôme, Laval University, the Université de Sherbrooke and the International Health Unit (IHU) of the Université de Montréal. Also, over the last two years, the CCISD has been looking for new partnerships in Quebec, by increasing the number of its member institutions in order to showcase Quebec's health expertise on the international stage. It was in this context in 2015, when I was a new counsellor on the FMSQ's Board of Directors, that I was nominated a member of the Board of Directors of the CCISD as representative of the Federation. It was with pleasure that I accepted this mandate. In meetings and during study days, I discovered with interest all the mechanics involved in international cooperation activities, updated in medicine under the title of "global health." Diversity in expertise is an essential component of project success. Indeed, the spectrum of needs is vast and includes efficient project management; healthy governance; knowledge of financial principles, microcredit and accounting; the evaluation of healthcare needs and epidemiological monitoring; communications and adaptation to various cultural realities; engineering and the management of a healthy environment; in addition to basic medical, paramedical and pharmaceutical knowledge, and more. My First Mission In November 2015, I had the opportunity to accompany the CCISD mission to the Democratic Republic of the Congo (DRC) for the mid-mandate evaluation of the PASSKIN project (Projet Appui au système de santé de la province de Kinshasa). Even though I had been careful to prepare myself mentally to be shocked, there are few words to describe the conditions I observed in the field and the immensity of the healthcare needs of this population: a "clinic" for ambulatory care located in an old container, rusty and overheated; a space the size of a large closet, squalid and equipped with cardboard walls behind which women gave birth; and a "hospital centre" without electricity, toilets or running water. In the middle of all this, I met obstetrical nurses who had just finished 36 unpaid hours on call and who had delivered patients during the night with a flashlight as sole source of light. I also met competent and dedicated physicians trying their best to resuscitate newborns in distress with whatever they had at their disposal. 8 * The author is a pediatric gastroenterologist at the MUHC and a member of the Board of Directors of the FMSQ.

9 In The News These are the people in the field who need support, equipment, training and encouragement. And that is where the CCISD's approach makes the most sense, in establishing renewable resources and reinforcing local capabilities. It is thanks to this partnership and appropriation approach by local communities that it will be possible to perpetuate projects to improve healthcare in developing countries. The relationship between the FMSQ and the CCISD is called upon to develop bidirectionally. On the one hand, the FMSQ can supply great medical expertise for projects the CCISD is called to manage. On the other, cooperating with the CCISD can represent a unique possibility for Quebec's medical specialists who are concerned about social equity and who wish to do their part in international healthcare. If adventure calls to you, please don't hesitate to get in touch with me. Long life to the CCISD! (ccisd.org) LS ON THE POLITICAL SCENE From the National Assembly Bill 130, An Act to amend certain provisions regarding the clinical organization and management of health and social services institutions, was adopted on October 25th, two minutes before the session was adjourned, before an almost-deserted National Assembly, in a climate of indifference and without a roll call of MNAs. As was the case with Bill 20, the initial text of Bill 130 was modified through the adoption of 64 amendments tabled by the Minister during its detailed study by the members of the Committee on Health and Social Services, spread over 16 sessions and totalling 61 hours of work. The controversial Bill 62, An Act to foster adherence to State religious neutrality and, in particular, to provide a framework for religious accommodation requests in certain bodies, was adopted on October 18th. The Federation commented on this piece of legislation and submitted a white paper during special consultations which were held in the fall of Please note, opposition parties voted against this Bill's adoption. A new bill was presented by the Minister on October 5th: Bill 148, An Act to regulate generic medication procurement by owner pharmacists and to amend various legislative provisions. Special consultations and public hearings took place on November 7th and 8th, while a dozen groups or individuals were heard by the Committee. Still among the Committee's active mandates, Bill 118, An Act respecting medical laboratories, orthopedic service centres and respiratory physiology centres operated by an entity other than a health and social services institution, has not advanced since February 23rd. It is impossible to know whether this Bill will be adopted or not by the end of the current session, scheduled for December 8th. Finally, the long-awaited Bill 157, An Act to constitute the Société québécoise du cannabis, to enact the Cannabis Regulation Act and to amend various highway safety-related provisions, was presented on November 16th by the Minister for Rehabilitation, Youth Protection, Public Health and Healthy Living, Madam Lucie Charlebois. At the time of writing this, no date had yet been announced for the special consultations and public hearings that will be held by the Committee on Health and Social Services. From the House of Commons On October 5th, Bill C-45, An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, passed the detailed study stage by the Standing Committee on Health. Some 115 white papers, including that of the FMSQ, were provided to the members of the Committee who heard 114 witnesses. This Bill was the subject of a report with amendments. It will thus move to the House of Commons for its third reading, before being submitted to the Senate. Faced with an outcry of protests resulting from his project to modify taxation rules and after a process of consultations initiated on July 18th and ending on October 2nd, the Minister of Finance, Bill Morneau, finally announced he would review certain provisions initially contemplated by his reform. LS 9

10 Continuing Professional Development By Sam J. Daniel, MD Director, Continuing Professional Development FMSQ THE PERSONALIZED PRACTICE FEEDBACK PROGRAM As medical specialists, we know perfectly well that our training continues throughout our professional lives and that we have to keep ourselves up to date on the progress of medicine and on advances in healthcare. Several studies have in fact shown that evaluating a medical practice with the help of multisource feedback supports one's continuing professional development (CPD) and that it can have significant repercussions on one's practice. The most remarkable of these studies, the Physician Achievement Review (PAR), was led by the College of Physicians and Surgeons of Alberta in cooperation with the universities of Calgary and Alberta. Their team designed questionnaires to evaluate a set of performance criteria. Within the framework of their pilot project, 308 physicians distributed questionnaires to their patients and colleagues. At the end of the project, their comments proved to be very positive. Two out of three physicians indicated they planned to make, or had already made, changes to their medical practice by basing themselves on the data obtained from the PAR evaluation. Up to now, physicians had very few tools to evaluate their performance and their practice, and Quebec physicians did not have a tool like PAR, in French and online. Moreover, with the coming into effect of the CMQ regulation regarding CPD, which requires 10 hours of evaluation during each 5-year cycle, it became imperative for us to equip medical specialists in the field. To accomplish our mission, which consists of optimizing and supporting the continuing improvement of our members' competence, performance and practice, we tried to create a tool that would allow for multisource feedback with the help of an extremely user-friendly online platform. We have called it Programme de rétroaction personnalisé sur la pratique or PRPP (Personalized Practice Feedback Program). In summary, the PRPP is a 360-degree online evaluation tool, which allows medical specialists in Quebec to receive feedback on their practice. The PRPP proposes three questionnaires aimed at each physician's colleagues or patients. A first questionnaire, aimed at colleagues, whether physicians or not, allows the medical specialist to obtain the opinion of work colleagues on the way he or she assumes certain CanMEDS roles. A second questionnaire, aimed at patients, allows the medical specialist to obtain their opinion of the relationship with him or her, as a physician. The last questionnaire, also aimed at patients, provides for an evaluation of the relationships they have with his or her staff, as well as the management and organization of his or her clinic. According to our calculations, it takes less than five minutes to fill out each questionnaire. In summary, the PRPP is a 360-degree online evaluation tool, which allows medical specialists in Quebec to receive feedback on their practice. The results of the evaluations are confidential and only the physician can access the data pertaining to his or her practice. The program also allows the various persons interrogated to fill out the questionnaires anonymously, in French or in English, thanks to a unique identifier. Please note that all the information obtained within the framework of this program remains strictly confidential and anonymous. In order to ensure the protection of privacy and the confidentiality of data regarding physicians evaluated and the persons having filled out the questionnaire, no data identifying the respondents is collected (i.e. postal code, city, physician's medical specialty, age, etc.). And to protect even more the confidentiality of the information obtained, only consolidated and anonymous data is subsequently communicated to the physician evaluated. It is important to note that this tool is being offered on a strictly voluntary basis to medical specialists who wish to evaluate their practice and design a continuing professional development plan based on their needs. This is a Section 3 activity within the meaning assigned to it by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. 10

11 Continuing Professional Development Another interesting aspect of this tool for the physician evaluated, and only for him or her, is that he or she can obtain the answers to questionnaires in real time because the feedback is generated dynamically in the form of a personalized report. As soon as four persons or more have completed one of the questionnaires, an up-to-date summary is generated; this summary is modified each time new responses are obtained. It contains an average of grades and respondents' written comments. of several pilot studies performed throughout the province of Quebec, physicians indicated that the tool was easy to use as well as useful. Patients also stated they were satisfied with the tool, that the questionnaires were easy to understand and that they could be filled out rapidly. The information collected within the framework of this program aims to encourage an enlightened reflection on the practice habits of healthcare professionals in a given sphere so that they can improve them by way of interactive training activities which are incorporated into their daily lives. Consolidated and anonymous results are sent to the FMSQ to help it identify continuing professional development needs and then to propose targeted training courses. These reports do not contain any information identifying anyone, whether the patient or a physician. During the program's trial phase, the physician who so desires can request the help of a personal coach to support him or her in reflecting on the evaluation. Within the framework The information collected within the framework of this program aims to encourage an enlightened reflection on the practice habits of healthcare professionals in a given sphere so that they can improve them by way of interactive training activities which are incorporated into their daily lives Connect to the FMSQ portal, using your address and password, then select FMSQ.O G P PP. Click on Aller sur le site du P PP Go to the P PP site. Select the questionnaire that meets your needs. Fill out the self-evaluation form. Print, cut and give one of the business cards to those you asked to fill out a questionnaire. ach business card includes a) instructions b) a unique D number that associates the answers obtained with your account. esponders have one month to fill out the online feedback questionnaire same questionnaire used for self-evaluation. See on line for more information on this subject. Consult the personalized feedback report on your practice. Section available only if at least four persons filled out a feedback questionnaire. Feedback report generated dynamically and comparing your self-evaluation to the consolidated answers from patients, colleagues or physicians who responded to a questionnaire. Fill out the program s evaluation form. For more information, contact P PP fmsq.org. This is a Section 3 multisource evaluation activity as defined by the Royal College of Physicians and Surgeons of Canada in the Maintenance of Certification Program. It has been approved by the Continuing Professional Development Directorate of the Fédération des médecins spécialistes du Québec. Do not forget to login to the MAINPORT electronic portfolio to record your learning activities and the results you have obtained. You can declare the number of hours you needed to complete them and your accumulated credits are automatically calculated. We are anxiously awaiting your comments on this new program (dpc@fmsq.org). And, if you believe you are capable of acting as a personal coach, know that we are on the lookout for champions who will be fully trained by the FMSQ to act in such a capacity. At the end of this training, we will provide you with a certificate recognizing your expertise and allowing you to coach your medical specialist colleagues. LS 11

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13 Medical Practice By Michèle Drouin, MD, FRCP Director, Professional Affairs FMSQ THE USEFULNESS OF JOINT PROCUREMENT Every medical specialist uses medical supplies and equipment every day, whether it's a small piece of tubing or a robotized operating room. Historically, purchasing policies and the choice of various products took place locally, without a formal mechanism for consulting the physicians involved. A weak purchasing power did not always generate the best price, but it was sometimes possible to negotiate with suppliers. In such a case, hospital centres were at times able to acquire without charge supplies or small related devices for which they had little or no budget. A few years ago, our government entities realized there were considerable savings if they opted for joint procurement for several institutions or even for the province as a whole. These savings could represent several million dollars that could be reinvested in the network to meet other needs. By virtue of the Management framework regarding the preservation of the health and social services network's assets and the Management framework regarding the addition of medical equipment, non-medical equipment, and furniture in Quebec's sociosanitary network, institutions are now responsible for complying with the obligation of taking part in joint procurement. The rules of acquisition, under the coordination of the MSSS, are part of management rules and practices. These are explained in detail in the Ministry's circular (October 2015), which also contains definitions of certain guidelines with which to prepare a procurement file, such as: maximizing investments by grouping acquisitions; maintaining healthy competition between suppliers throughout the process; allowing a choice of supplies and equipment among those that have qualified by virtue of authorized adjudication provisions; implicating the medical associations involved and experts from the institutions whose mission specifically concerns the area targeted by the process; following up on the savings achieved through the process. In addition, the MSSS has set up and leads a coordination and follow-up committee which is charged with ensuring guidelines and various terms associated with the acquisition process are respected. This committee is made up, among others, of representatives of the MSSS, the three directors general of joint procurement groups (also called purchasing groups) and two representatives from the FMSQ, including the President. Procurement Groups and Their Territories Sigma Santé GACOQ (Joint Procurement Group for Western Quebec) GACEQ (Joint Procurement Group for Eastern Quebec) Montréal, Laval Outaouais, Abitibi-Témiscamingue, Laurentides et Lanaudière, Montérégie Bas-Saint-Laurent/Gaspésie/ Îles-de-la-Madeleine, Saguenay Lac-St-Jean, Côte-Nord/ Nord-du-Québec, Québec/ Chaudière-Appalaches, Mauricie/ Centre-du-Québec, Estrie The Role of Joint Procurement Groups Procurement Groups are required to issue various calls for tenders that are delegated to them by an institution or by the MSSS. They support institutions in their procurement activities. Throughout the process, they support users in order to clearly identify their needs and coordinate the work of partners (institutions, physicians and other users). Their work contributes to standardizing the call for tenders process and to supporting the implementation of negotiated contracts. The Role of the Federation While it is clear to the MSSS that acquisitions must be effected via a process of joint procurement, it is essential in the FMSQ's opinion that medical specialists be directly involved in the evaluation and choice of supplies and equipment being acquired, since in essence these are their work tools! The Federation is thus not only present on the coordination and follow-up committees, but in addition it has the responsibility of choosing the medical specialists who will take part in the various expert committees. The Professional Affairs Directorate has been mandated with coordinating and following up on the process of designating physicians. The Designation Process A procurement group needing to go ahead with a call for tenders sends the Federation a standard form which contains all the data associated with the mandate (technical specifications), the list of institutions, users and medical specialties involved, as well as the number of physicians needed for each specialty's tasks. All of these details are then sent on to the various associations in order to choose the medical experts. In our communications with the associations, we remind them that the choice of physicians must be based on three main principles: The physician's technological expertise or experience with the equipment in question; The importance of users being represented. Thus, physicians in the institutions affected by the call for tenders must be chosen; The absence of conflicts of interest. 13

14 Medical Practice 14 The Role of Medical Experts The designated physicians are involved from the very start of the call for tenders process. They thus take part in identifying needs; then they decide upon the quality standards and characteristics of the products to be acquired; and finally, they undertake the evaluation of each of the products proposed. Legal Responsibilities It must be noted that the procurement group needs to obtain the signature of each designated physician on a "formal commitment" which was adopted by the coordination and follow-up committee in May This commitment has two parts. The first deals with the confidentiality of the process: the physician must undertake not to reveal any information capable of providing any advantage to a tenderer to the detriment of others. The second involves the independence of the physician, who must attest he or she is not in a conflict of interest, or that there is no appearance of a conflict of interest, with any of the companies tendering. A statement regarding conflicts of interest is appended to each form and physicians are duty-bound to declare any activities which could place them in an apparent or potential conflict of interest. This second part has generated numerous questions from our medical experts, to the point that we have asked for a legal opinion regarding the definition of a conflict of interest for medical specialists who participate in a selection committee. Here are a few aspects quoted from the legal opinion to help you reflect on the matter: Nature of association Is this an activity aimed at advancing science, the profession, research, etc.? Remuneration Is the activity remunerated and, if so, who benefits? The physician directly, a research project, the hospital foundation? Does it involve the payment of a purely recreational activity, like a trip? Date When did the activity take place? Was it concurrently or before the committee's work or its preparations? Recurrence Does the physician take part recurrently in some of activities with the same supplier? Other suppliers Has the physician taken part in comparable activities with other suppliers, thus establishing that the relationship was not "exclusive" in nature? Finally, even if the physician is not performing a medical act per se, according to the same legal opinion, he or she remains subject to his or her ethical obligations, in particular provisions no 63 and 80 of the Code of Ethics: 63. A physician must safeguard his professional independence at all times and avoid any situation in which he would be in conflict of interest ( ). 80. A physician may not be party to any agreement or accept any benefit that could jeopardize his professional independence, particularly in the context of continuing medical education activities. The Repercussions of this Issue In May 2016, in a message sent to all association presidents during the implementation of the process of designating medical experts, our President reminded us of the importance of the issue of joint procurement: "The FMSQ is aiming for a better performance by the public healthcare system. All of the actors involved have been able to profit from the openness of medical specialists to harmonize as much as possible their medical practices and to allow for recourse to a diversified and controlled selection of contractual suppliers. We firmly believe in any form of shared management, which implies an active participation by medical specialists in the decision-making process of joint procurements. It is important to remember that this initiative allows the government to save millions of dollars annually. Thus, we must all cooperate actively and respect our commitments regarding contracts for equipment and specialized supplies." According to the MSSS, the target insofar as potential savings are concerned for the period 2015 to 2018 is around 100 million dollars. In addition to these financial repercussions, we have made sure that medical specialists would participate in all selection committees, these experts being chosen by your medical associations according to a disciplined and uniform process. In addition, we have to underline the importance of the partnership contribution clause. 10% and 12% One of the significant repercussions of the joint procurement process is the partnership clause that commits suppliers to make a contribution to the clinical activities of participating institutions. The partnership contribution is credited as a volume discount representing 10% of the total value of purchases by each institution or 12% in the case of institutions dedicated to research. These contributions must be paid on an annual basis to the institution and must be allocated to clinical activities, to research, to the trial of new technologies, to the acquisition of equipment and to education support associated with the specialty involved and contributing to the issue. Conclusion Since May 2016, several dozen calls for tenders have been issued and many of your colleagues have actively participated in the evaluation and choice of your work tools. We have identified more than a hundred potential files in all fields and all regions in the Plan. We are counting on your participation and cooperation in this respect! LS

15 About Billing By Jacques Ouellet, MD Director, Economic Affairs - FMSQ HAVE YOU HEARD ABOUT OUR "ACCOUNT BY ACCOUNT" ANALYSIS? Since my arrival at the Federation and even if I had just left the executive of my own medical association, I quickly realized that the meaning of the term account-by-account analysis (compte à compte), which we have been using, varied according to the person I was speaking to. As this is a very important subject that bears a quickly-approaching deadline, I wanted to review it with you and explain the mandate attached to it and how we intend to complete it. The renewal of the Agreement for the period April 1, 2010 to March 31, 2015 included supplementary sums which were supposed to allow us to reach parity with the Canadian average as regards to remuneration. The Delegates' Assembly approved a plan aimed at filling existing gaps between medical associations on two levels: to reset the balance within the Federation to start with, then to compare their positions with those of their colleagues throughout Canada. This purely mathematical exercise needed the development of a powerful calculation tool. It is with the help of this tool, accepted by the Delegates, that we have been able to calculate the target Average Gross Remuneration (AGR) that each association should have reached by the end of the period. Thus, since 2012 and according to the various work deadlines established, medical associations obtained the information regarding the sums they would receive to reach their target AGR. Modifications 64 to 67, which came into effect in May 2013 and January 2014, gave the start signal to the sequence of planned payments. In 2013, the distribution was reviewed in order to reflect the positioning of each medical association. Modification 71, which came into effect in April 2015 (along with associated sums), marked the end of this sequence. However, because of the spreading out contained in the 2014 Agreement, other sums are still to come. Since everything leads us to believe that these latter sums (if they are realized) will be parametric and would result in few variations to the targets aimed for, we felt the final account-by-account analysis could begin. Major Project A colossal project to compile data began in the summer of 2016 to validate and explain the positioning of the AGR of each medical association compared to the initial targets. As the data needed to complete the exercise has only been available since April 2017, the work will have to extend at least until the end of this year. To date, close to three quarters of the account-by-account analysis is complete. To date, close to three quarters of the account-by-account analysis is complete. An ad hoc committee for this exercise, set up at the request of the Board of Directors, has met several times to review the results of the preliminary analysis performed by the Economic Affairs Directorate. Each of the medical associations, whose data has been reviewed, has its own characteristics and, at the Federation, our efforts have allowed us to adjust our evaluations and to put the finishing touches to them. This process will only be finished when all the medical association files have been analyzed. Important Reminder The aim of the account-by-account analysis is not to change the distribution tool (nor redo all our calculations), but to verify three fundamental aspects: 1. Has the initial target been reached and, if not, must it be corrected? 2. Has the initial target been exceeded and, if so, must it be adjusted? 3. Are we sure that the medical associations that have reached their initial targets, or that are close to reaching them, have maintained their level of productivity? This comprehensive exercise will be done in great part by the Federation's actuarial team. However, taking into account the extent of the task and always with the aim of respecting the planned deadlines, we have retained the services of external experts for some of these activities. At the end of the exercise, the ad hoc committee will meet with each medical association in order to bring them up to date. Equipped with all the comments emanating from the medical associations, the Federation's negotiating committee will conclude its work and make a final proposal that will be presented to the Delegates' Assembly. Rest assured that this exercise has been, and is being, undertaken with as much rigour as possible and constant attention to transparency. LS 15

16

17 Legal Issues By Maître Sylvain Bellavance et Maître Laurence Le Guillou Legal Affairs and Negotiations FMSQ BILL 130: ANOTHER HEINOUS LAW October 26th was a dark day for specialized medicine in Quebec: this was the day that Bill 130, An Act to amend certain provisions regarding the clinical organization and management of health and social services institutions, was sanctioned. Although certain sections aren't in effect yet, most of the sections of Bill 130 came into effect on November 10, Last February, the Federation was provided with the opportunity to express its opposition to this law before the parliamentary committee because it aims to control medical practice and silence medical specialists. On that day, the Federation was not able to comment on the numerous unacceptable aspects of the Act, because as usual the Minister of Health tabled at the last minute more than sixty amendments which could not be subjected to any analysis or debate. Bill 130 is heinous: it provides for more obligations of every kind for medical specialists; gives increased control to Directors of Professional Services (DSPs) while reducing the crucial role of the CMDPs; grants various powers of coercion with regards to physicians, under the threat of penalties; increases the Minister's omnipotence and provides for other dictates or constraints. This constantly renewed attitude of the Minister's, who seeks to impose his point of view rather than look for the cooperation of physicians and other professionals and stakeholders in the healthcare network, will again have no new positive effect for the people of Quebec. Bill 130 can be succinctly summarized along the following themes: Obligations Bill 130 adds even more obligations of all kinds for medical specialists, including the following: The Act makes it mandatory to establish obligations to be associated with the privileges granted to the physician. These obligations must aim to ensure the physician's participation in the institution's responsibilities, in particular access to services, as well as their quality and pertinence. The physician will be responsible from now on, collectively with the other physicians practising within the institution, for ensuring there is no interruption in access to the institution's services. The Board of Directors of any institution will have to, at the latest six months after the law comes into effect, modify any resolution by which it accepted a request for appointment or for the renewal of the appointment of a physician in order to render it compliant with the new requirements of the law. Powers Bill 130 adds to the powers and responsibilities of the government, the president and executive director, and the DSP, while reducing the powers of the CMDP. For example, The government will be empowered to name the assistant president and executive director, up to now appointed by the Board of Directors. In certain circumstances, the president and executive director will be able to develop rules for the use of resources, for medical and dental care as well as for the use of medications. From now on, the DSP will be consulted on the obligations that must be associated with privileges and, in the case of a request for renewal, he or she will need to provide his or her opinion to the president and executive director regarding how the physician has met the requirements listed in the Board of Directors' resolution. The CMDP will only be consulted regarding the obligations to be associated with privileges and, when preparing the institution's organizational plan, on the question of which department or service the medical acts of a clinical program depend upon. Control Bill 130 creates increased control over the practice of medicine through the modifications it brings to the process of granting hospital privileges. Thus: The physician will no longer be considered to have made a request to renew his or her appointment, according to the terms of his or her last request, which supposes that he or she will be obliged to present a request to renew his or her appointment. Privileges which are currently granted for a maximum period of 3 years, will from now be granted for a period of 18 to 24 months. While the current law provides that they be renewed, barring exception, for a minimum period of 2 years, privileges will from now on be renewed for a minimum period of one year and a maximum period of 3 years. The resolution by virtue of which the Board of Directors accepts a request for appointment or for the renewal of an appointment of a physician will be considered null and void if it does not respect the requirements of the Bill. The Board of Directors' resolution will from now on provide for privileges to be granted to a physician for all the facilities of the institution and will specify in which ones his or her profession will mainly be practised. The status of associate member or consulting member should not be granted or renewed when the needs of the institution can be fulfilled by an active member. 17

18 Legal Issues 18 A request for the renewal of an appointment can be refused if the renewal cannot be effected without respecting the conditions of attribution of a status as provided for by a regulation. Coercion and Penalties Bill 130 grants various powers of coercion with regards to medical specialists, under threat of penalties: The Minister can implement a temporary support system for access to specialized services in which all public institutions operating a general and specialized care hospital centre would have to take part. This system would allow for the drawing up of an on-call list of medical specialists, for a specialty targeted by a regulation, in order to call upon them to provide services to an institution that is experiencing significant problems of access to services. The physician would be deemed to hold the needed privileges to practise his or her profession within the institution. The Minister must declare the operating terms of this system via regulation. Any medical specialist, whose specialty is targeted by regulation and who practises his or her profession in a general and specialized care hospital centre will have to participate in the temporary support system put into place by the Minister. Unless he or she is exempted, the physician who does not respect this obligation will be declared in default and his or her remuneration will be reduced as a result according to the provisions of the regulation. Any medical specialist, subject to an agreement by virtue of the Health Insurance Act and within the limits provided for in a regulation, will need to make himself or herself available to insured persons by using the appointment system put in place by the RAMQ. Unless he or she is exempted, the physician who does not respect this obligation will be declared in default and his or her remuneration will be reduced as a result according to the provisions in the regulation. The All-Powerful Minister Bill 130 creates an omnipotence that grows ceaselessly with the addition of new excessive powers in the hands of the Minister, including the following: The Minister will now be able to refuse the request for privileges from a physician if it does not comply with the institution's organizational plan or with ministerial directions regarding the management of medical manpower. In order to meet needs in family medicine or in specialized medicine, the Minister will be able to require the addition of certain obligations to a physician's privileges when he gives the required approval before a request is accepted. The Minister will now be able to authorize any proposed regulation emanating from various entities, including the Board of Directors of public institutions and CMDPs, and require that modifications be made to them. The distribution of an institution's medical manpower will now need to take into account the requirements associated with the maintenance of competence of physicians and dentists and, as the case may be, to respect the ministerial directions regarding the management of medical manpower. The Minister will be able to recommend to the government any person of his choice for the position of president and executive director or assistant president and executive director if a list is not provided within a reasonable delay. Bill 130 grants more extensive powers to the Minister to approve institutional organization plans. The Minister's powers regarding services associated with informational resources are widened. The Minister will establish a minimum percentage of beds that will need to be reserved in the departments capable of taking charge of users from the emergency department who need to be hospitalized. And Many More Other dictates or constraints are provided for in the Bill, whether this concerns determining institutional organization plans, the length of stay in emergency, registering users on the list of access to services, the organization of public health, the confinement of individuals, joint procurement groups, etc. For a more complete analysis of the main modifications brought in via Bill 130 that concern medical specialists, we refer you to the document available in the secure portion of the FMSQ portal. This first analysis of the Bill allows us to conclude that many portions remain extremely vague, some obligations imposed on physicians being very extensive and other details which need to be covered by regulations to be edicted by the Minister or the government. The Federation has, indeed, heard various echoes according to which the Minister wishes to define physician workloads or require they sign contracts by mutual agreement with their institutions. For the Federation, this way of proceeding is unacceptable. The Federation has clearly indicated to the Minister and other government representatives that the conditions of practice of physicians must be negotiated and cannot therefore be unilaterally imposed in a law, a regulation or a directive of any kind. At the moment of writing these lines, our discussions are ongoing, but the Federation does not intend of abdicate on this fundamental principle. Until we advise you of further developments, we invite you all to be vigilant and to report to us any measure which is contrary to this principle and this, by communicating with us at coderouge@fmsq.org. For its part, the Federation will continue to support and vigorously defend the interests of medical specialists. LS

19 AFTER BILL 130 This Affects You EACH AND EVERY ONE! Since the Opération CODE ROUGE Grand Assembly on May 13, 2017, at the Olympic Stadium, the FMSQ has received hundreds of inquiries or support requests from medical specialists. These requests deal with various subjects, including Bills 10, 20 and, the newest one, 130, as well as the medical manpower management rules and the PEMs, status and privileges within institutions, obligations and rights of physicians, professional independence, parental and other leaves of absence, the workload, the rules of care in the emergency room or in other units, the resources needed to practise the profession, OPTILAB, the powers of the RAMQ, etc. Are you experiencing a situation that prevents you from providing the care you want to your patients? Write to us. Each request received is studied with extreme attention and as quickly as possible. According to each situation, we can help you with legal, media or personal advice. You are not alone. The FMSQ is there to defend your rights. coderouge@fmsq.org 19

20 Did You Know... AWARDS AND NOMINATIONS ANQ Prize The Association des neurologues du Québec presented its Hommage ANQ 2017 prize to Dr Jean Mathieu, a neurologist working in Saguenay. This prize highlights a neurologist's overall career and contribution to advancing neurology in Quebec. Dr Mathieu's work is internationally recognized and deals with myotonic dystrophy, a disease that is prevalent in the Saguenay Lac-Saint-Jean Region. Association des physiatres du Québec Prize During its conference held at Lac Beauport, the Association des physiatres du Québec presented its Michel-Dupuis Prize to Dr Pierre Béliveau, a pioneer of sports medicine in Quebec, now retired. This prize, presented every two years, recognizes and highlights the remarkable career of a physiatrist with a marked interest for the musculoskeletal system. SRQ Prize The Société de radiologie du Québec presented its annual prizes on November 14th: Royal College Awards Two medical specialists from the McGill University Health Centre were honoured by the Royal College of Physicians and Surgeons of Canada. Dr Donald Sheppard, a medical microbiologist and infectious disease specialist, was named Mentor of the Year for Region 4. Dr Devinder Paul Cheema, an ophthalmologist, received the Prize for Excellence Specialist of the Year for Region 4. UBC Prizes Dr Stanley Nattel, a cardiologist and researcher at the Montreal Heart Institute, has received one of the Margolese Prizes given out by the University of British Columbia. This prize recognizes Canadian researchers who have contributed to advancing the treatment of cardiovascular diseases. Dr Nattel was our Great Name in Medicine in December Canadian Anesthesiologists Annual Meeting Dr Christina Lamontagne, an anesthesiologist currently on a Fellowship at the CHU Sainte-Justine, has won first prize in the Resident s Oral Competition during the 2017 Annual Meeting of the Canadian Anesthesiologists' Society. The title of Dr Lamontagne's presentation was "Intravenous Dexmedetomidine for Treatment of Shivering During Cesarian Section Delivery Under Neuraxial Anesthesia." The Montreal Women's Y Foundation Award Dr Marie Laberge-Malo, a pediatrician and specialist in physical medicine and rehabilitation at the CHU Sainte-Justine, received the Woman of Distinction 2017 Award from the Montreal Women's Y Foundation. This award is given to women who bring about positive and lasting change in society and whose personal contribution in the community has been important in building a better world for women and girls. 20 Dr Rachel Del Carpio, a radiologist at the MUHC Montreal General Hospital, received the Albert-Jutras 2017 prize. This prize is the most prestigious recognition given out by the Société; it highlights the overall career of a Quebec radiologist. Dr Julie Déry, a radiologist at the CHU Sainte-Justine, received the Bernadette- Nogrady 2017 prize, which highlights the remarkable contribution of a radiologist through research, teaching and high-quality patient care, while totalling less than 11 years of practice. Professor of the Year Dr Louiselle Leblanc, a medical microbiologist and infectious disease specialist at Montreal's Hôpital du Sacré-Coeur, was named "Professor of the Year" by residents in the Medical Microbiology and Infectious Diseases and the Adult Infectious Diseases programs. New Emeritus Professors Photo credit: Laval University Dr Yvon Cormier, a respirologist, Dr Jean Talbot, a medical biochemist, and Dr Bernard Têtu, an anatomical pathologist, were named Emeritus Professors by Laval University.

21 Did You Know... ASE Council on Pediatric and Congenital Heart Disease Founder s Award Dr Jean-Claude Fouron, a pediatric cardiologist who recently retired from the CHU Sainte-Justine, has received the prestigious ASE Council on Pediatric & Congenital Heart Disease Founder s Award. This award was given to him to highlight, as a whole, his work and his accomplishments which have changed how cardiologists, obstetricians and other specialists work, when they are called upon to look after patients presenting with various fetal-maternal diseases. Prix Galien Award Dr Ernesto Schiffrin, an internist at Montreal's Jewish General Hospital and holder of the Canada Research Chair in Hypertension and Vascular Research, was presented with the Prix Galien Canada - Research award for 2017 to highlight his important contribution to pharmaceutical research. The Prix Galien is the most prestigious recognition in the field of pharmaceutical research and innovation in Canada. Prix Hippocrate Dr Gilles Julien, a pediatrician, along with his team have received the Prix Hippocrate. This recognition, awarded by the publication Le Patient, highlights the interdisciplinary work of physicians with other healthcare professionals for the benefit of patients. Two honourable mentions have also been awarded. The first was given to the team of Dr Charles Frenette, a microbiologist and infectious disease specialist at the MUHC, for reducing infections on surgical sites of Solid Organ Transplantation and Hepatobiliary Surgery and in Cardiac Surgery. The second one was awarded to the team of Dr Lionel Carmant, a pediatric neurologist, at the CHU Sainte-Justine, for the Neuro-Cardiac Investigation Clinic (CINC). NEW RELEASES Dr Jean-François Bélanger, a psychiatrist at the CSSS du Haut-Saint-Maurice, a composer and a multi-instrumentalist, has just had a new album come out, Les entrailles de la montagne. After Les vents orfèvres, this album completes his diptych dedicated to Scandinavian influences and instruments. Fearful Asymmetry Dr Richard Leblanc, a neurosurgeon at the Montreal Neurological Institute and Hospital (MNI), has published "Fearful Asymmetry," which relates the history of research on the brain and on localizing language functions in 19th century France. Dr Leblanc is the co-author, with the late Dr Willam Feindel, also a neurosurgeon, of the book "The Wounded Brain Healed" covering the history of the MNI from 1934 to L asthme chez l athlète Dr Louis-Philippe Boulet, a respirologist, and Mme Julie Turmel, a research professional at the Centre de recherche de l Institut universitaire en cardiologie et pneumologie de Québec, have published L asthme chez l athlète : comment devenir expert dans la prise en charge de son asthme. This book, which is aimed at Olympic athletes and all those who practise competition-level sports, supplies simplified information to allow athlete patients to better manage their asthma, to reduce its effects on their health and athletic performances, and to have the best quality of life possible. A Trio of Textbooks on Urology The 3rd edition of the "Textbook of the Neurogenic Bladder," written by Dr Jacques Corcos, a urologist at the Montreal Jewish General Hospital, in cooperation with Dr David Ginsberg, from the University of South Carolina, and Dr Gilles Karsenty, from the Aix-Marseille University provides an update of current knowledge on the neurogenic bladder. "Overactive Bladder: Practical Management" was written and edited by Dr Jacques Corcos, a urologist at the Montreal Jewish General Hospital, in cooperation with Dr Scott McDiarmid, Director of the Bladder Control and Pelvic Pain Center in Greensboro, North Carolina, and Dr John Heesakkers, of Radboud University Nijmegen in the Netherlands. This book is also available in Chinese. "Consultation in Neurourology: A Practical Evidence- Based Guide" was written by Dr Jacques Corcos and Dr Mikolaj Przydacz, both urologists at the Montreal Jewish General Hospital. This guide covers in a practical way all the aspects of diagnosing and taking charge in neurourology. LS 21

22 22 Great Names In Quebec Medicine SO AS TO NEVER FORGET As a neurologist at the Douglas Mental Health University Institute, Serge Gauthier remembers that, when he was a young man, he had the right profile, school results, and needed aptitudes to become a physician. And yet, he says he just wanted to make his mother's wish for a doctor in the family come true. In fact, she would have been an excellent physician herself, but at that time women didn't have as many "opportunities" as they do today. He also remembers large family get-togethers during which he never tired of listening to the serious conversations headed by his uncle, a pathologist and researcher. After his bachelor's degree in biochemistry, he opted for medicine and received his diploma at the age of 24. He then immediately signed up for neurology at McGill, a completely natural choice that reminded him of accompanying a family member to see a neurologist. Those visits gave him the opportunity to get to know Dr Francis McNaughton, who would eventually become his mentor and teach him the rudiments of a warm bedside manner with patients and the desire to practice an empathetic kind of medicine. Dr Gauthier then decided to undertake complementary training in neurochemistry at the Allen Memorial Institute. He applied for a position that had opened up at the Montreal Neurological Institute and Hospital and was successful in getting it. His first years in clinical work were full and fascinating: he divided his time between university teaching, consulting, various committees inside and outside the hospital, his research and the administration of the department. He wanted to advance knowledge of the brain and its illnesses and learn how to cure all his patients; but to get there he would have to pursue research activities. By Patricia Kéroack, C.W. In the context of his clinical activities, Dr Gauthier dealt with cases of Alzheimer's disease, which was discovered in 1906, but was still little known at the time. We know today that Alzheimer's presents under several forms. Before the age of 50, it is referred to as the familial form of the disease since it is hereditary, with the dominant gene being transmitted before birth. Another form of the disease manifests between the ages of 60 and 70 and is also hereditary but the gene in question is recessive (this was discovered simultaneously in Montreal and in New York, but the credit was given to the American team). Finally, after the age of 80, advanced age is the only factor explaining the development of the disease, affecting one individual out of three. Dr Serge Gauthier Neurologist On the Traces of Alzheimer's One patient changed the course of his career. "This 33-year-old woman had the familial form of Alzheimer's disease. I still remember our first meeting. She came in from Trois-Rivières, accompanied by her two teenage sons and her husband, and arrived at my office an hour late. I quickly understood the difficulties she and her family had to deal with because of the disease and I promised myself I would find a way of helping her and other people suffering from Alzheimer's." Completely by chance, he met a colleague psychiatrist who had just received a barrel of lecithin, a natural product which was said to have positive effects on memory, similar to the action of L-dopa on Parkinson's. The moment was perfect to undertake research on the effects of lecithin and other molecules on the progression of the disease, etc. Over the years, multicentre clinical studies followed one another. Dr Gauthier's work and the expertise of his team were rapidly recognized world-wide and he was invited to take part in major international studies. It was already known that cerebral atherosclerosis was the main risk factor for Alzheimer's, but it was only in 1980 that British studies showed that a deficit in acetylcholine was also involved. During a dozen years in Montreal, Dr Gauthier and his team repeatedly took on studies and clinical trials of acetylcholinesterase inhibitors. The team took part in developing practice guidelines for this type of medication. Dr Gauthier and his team carried on their work by also studying the effects of molecules that reduce the quantity of plaques of amyloid beta proteins, as well as aggregation inhibitors for tau proteins that accumulate in nerve cells. "Our centre tested modified methylene blue against hyperphosphorylated tau protein. We undertook numerous trials at different doses with good results at times, but also with errors. Today, I would do this research over again by adding a placebo group, which we didn't do the first time," he explains, adding that in research everything is a question of patience. Dr Gauthier is of the opinion that widespread cooperation is what advances knowledge; interdisciplinarity, cooperation, the exchange and sharing of information all contribute to accelerating the work in all major areas of research.

23 Great Names In Quebec Medicine Imaging Changes Everything Dr Gauthier quickly realized that the only way to observe the effects of these molecules was to be able to see them with the help of neuroimaging. At the beginning, the technique was very recent and results were not probative. Today, the technique has proven itself and is widely used; research has consequently evolved. "We recently published the first images of the brain's cholinergic cells, which we had been trying to do for 20 years," he says, referring to the study published in Molecular Psychiatry (2017;22:306-11). Today, Dr Gauthier is working on a research project dealing with the analysis of neurological interactions due to amyloid beta proteins and tau proteins thanks to positron emission tomography (PET scans). Many people have volunteered for this study. They are over 60, do not have memory problems, but are worried about a possible loss of memory or the development of the disease in years to come. Dr Gauthier is of the opinion that the next generation of imaging techniques will allow for personalized treatments thanks to targeted screening. From Screening to Personalizing Treatment Research on Alzheimer's is progressing on exponentially, but there is still a lot to do. Genetics today allow screening for the Alzheimer gene. Since this gene could modify response to treatment, it is essential its presence be screened for before undertaking randomized studies. At present, to protect patients' personal data, the information obtained is stored in the research file and not in their medical file. Even if there is still a lot to do, Dr Gauthier is very optimistic: "Lately, we performed triple PET scans. This way of doing allows us to personalize the biological diagnoses of the illness in people who are either at risk or who have mild symptoms of the disease." For the last three years, in cooperation with researchers in St. Louis (Missouri), he has been performing clinical trials with young patients affected with familial Alzheimer's. To gather an interesting population of subjects, he invited people from all regions of Quebec and Ontario to register with him. As a result, he can then suggest they either take part in studies or try preventative treatments. Alzheimer's and Related Diseases In a great many patients, Alzheimer's does not occur in isolation. Elderly people also present with vascular forms of dementia (or cerebral atherosclerosis), mixed dementias, Parkinson's, etc. This is why Dr Gauthier has multiplied his research projects and has looked for possible links with other diseases. Among others, he has collaborated with Dr Jacques Montplaisir's team, from the Centre d'étude du sommeil, to see if there could be links between sleep disorders and Alzheimer's. This cooperation allowed him to use medical imaging and EEGs during sleep. Recently, they undertook to establish if sleep apnea was one of the risk factors. Other collaborations deal with Parkinson's disease which is often concomitant with Alzheimer's. The first biological tests that will identify the Parkinsonian component of Alzheimer's will be available shortly and uses medical imaging or a lumbar puncture to detect the levels of the alpha-synuclein protein in the cerebrospinal liquid, specific to Parkinson's. In addition, Lewy-body dementia, which combines the characteristics of Parkinson's and Alzheimer's, is another major subject of research for which his colleague neurologists in Quebec send him their patients, knowing that his team is working on the disease and that the therapeutic response of these patients is distinctive. With close to 50 million people affected in the world, Alzheimer's disease remains a great challenge. And the Future? The whole world recognizes the contribution of Dr Gauthier to research: in addition to professional awards, he is a Knight of the Order of Canada and of the Ordre national du Québec. Dr Gauthier knows, moreover, that he has to take the time to prepare the next generation of researchers so that his work can continue, since there is still a lot to do. Too many researchers have left their work suspended when they disappeared. He is also the founder of the Réseau des cliniques de la mémoire du Québec. Every two years, this conference summarizes the advancement of science. Then, with his residents and fellows, he discusses the importance of humanism in medicine. He wants to infect them with the desire to work empathetically with the elderly: they need to be reassured, to have what is happening to them explained honestly and exactly. In Montreal's multicultural context, one sometimes needs to modify the questions and reinterpret the answers, since patients from other cultures than our own can interpret things in a different way. According to Dr Gauthier, the next decade will witness the arrival of tests that will allow Alzheimer patients to be treated according to their specific genetic profile. It will probably be possible to draw a biological balance sheet at a given age (say 55) and predict the risk of developing the disease. A preventative treatment that is adapted and personalized for patients in whom silent markers are detected could be prescribed. But, will we have perfected a treatment for people with Alzheimer's? Dr Gauthier doesn't know and prefers to continue prescribing a healthy lifestyle as a prevention method. There can't be a miracle cure for such a complex and multi-factorial disease, no more than a treatment can be perfected in a few short years. LS 23

24 DOSSIER FOUNDATIONS A KEY ROLE IN THE NETWORK W hether they deal with general or specialized care, our healthcare institutions benefit from the financial support generated by foundations, precious allies in delivering our offer of services to the population. Foundations have become the key to success for hospitals, of course, but also for schools, universities and museums. And let's not forget the foundations created by groups, families or corporations that are often associated with one cause in particular. According to information published by the federal government, there are currently more than 86,000 charitable organizations registered with the Canada Revenue Agency. Of these, more than 10,000 are foundations (public or private). They all want the same thing: to raise as much money as possible for their institution or their clientele. Of course, the more money they raise, the more they want to raise... because new projects are launched, because needs continuously increase. 24 The face of philanthropy has changed profoundly. We now talk of a philanthropic culture, of financing packages, of a solicitation industry, of investments, of commitments, of a competitive market, of fiscal advantages, etc. To meet their obligations, foundations today have to compete with audacity, creativity and ingenuity to solicit current and potential donors. A sign of the times or a problem in our society? There are more and more needs to meet and budgets to balance. We can question such a phenomenon. For example, is it normal for a hospital to count on such a source of financing? Can this type of financial contribution be integrated in a regular operating budget, thus reducing the contribution from the official paying agent? What kind of performance can we hope for from a foundation? In this dossier, Le Spécialiste has p ro v i d e d a v e n u e f o r m e d i c a l specialists who have decided to invest themselves in their foundation, those who have had to fight for their project to be accepted, and those who work there on a daily basis. Beyond all the questions surrounding the "philanthropy market", there are those who want to give back to their community, those who want to thank the people who helped them become better persons or, quite simply, those who are concerned with the welfare of others. The timing is well-chosen because December is the month when everyone's generosity is visible.

25 A MATTER OF NECESSITY TO DEVELOP THE HEALTHCARE NETWORK FOUNDATIONS A KEY ROLE IN THE NETWORK By Alain Demers, Director General Association des fondations d établissements de santé du Québec In Quebec, philanthropy has grown very significantly over the last 20 years. Over time, the government has been faced with many budgetary constraints and backed out of many programs it had supported until then. In such circumstances, numerous foundations and non-profit organizations (NPOs) were born, in order to meet the various financial needs that were no longer taken on by the government. The foundations in our healthcare network thus became increasingly important, even essential. At the beginning, their mission was directly linked to the development of the network, while operating expenses were looked after in the government's budget. A Portrait of Foundations Associated with a Healthcare Institution Quebec currently has some 230 foundations associated with a healthcare institution. Their importance varies considerably, with the funds they amass each year ranging from a few thousand to several tens, if not hundreds of millions of dollars. In all, 63 of these foundations amassed more than $1 million in and To these 230 foundations, we can add many other charitable organizations working in the health sector, like Leucan, Opération Enfant Soleil or the Quebec Cancer Foundation. The monies collected by these organizations and foundations are added to the amounts reinvested in the Quebec healthcare network, but are not included in the following tables. These contain the data and figures of 218 foundations associated with a healthcare institution as at September 21, The comparison over eight years clearly illustrates the growth in foundation revenues, i.e. an increase of close to 53%. The amounts remitted to institutions for their part increased by 67%. Administration expenses and the various costs associated with the campaigns and the fund-raising activities are deducted from gross revenues and vary from one foundation to another. The amounts remitted to various institutions thus represent Quebec Foundations Associated with a Healthcare Institution Gross revenues in Number of foundations % More than $5 million 18 8% From $1 to $5 million 39 18% From $500,000 to $1 million 27 12% From $100,000 to $500, % Less than $100, % Total Gross Revenues $441,631,143 $289,287,191 Total Amounts Remitted to Various Institutions Source: CRA, Forms T3010 $255,627,827 $153,056,401 part of the monies amassed. In addition, since acquisitions and projects financed thanks to foundation contributions are not always completed the same year that the sums are amassed, the gap between gross revenues and amounts remitted the same year is often affected. Whether they are associated with a hospital or with another network institution, such as a CLSC, a palliative care institution or a CHSLD, to name but a few, these institutional foundations play an essential role in the development of the network. The donations amassed generally serve to meet the four following needs: acquisition of medical equipment; support for research and teaching; support for the development of employee competencies in CISSSs and CIUSSSs; carrying out isolated projects of various types that are not financed by the institution's current budget. Within the context of major campaigns or projects, it can happen that the installation of new infrastructures is partly financed by foundations, for example the building of a specialized wing for the treatment of cancer. Do you known the AFÉSAQ? The Association des fondations d'établissements de santé du Québec (AFÉSAQ) plays an essential role for the various foundations, whether the people working in the latter are volunteers or professionals in philanthropic management. Its mission is to unite its members, defend their interests, encourage networking and promote the best practices of philanthropic management in the area of health and social services. 25

26 26 In order to fulfill this mission, each year the AFÉSAQ organizes a seminar and proposes new training sessions via webinars. It also offers its members consulting services dealing with strategy, operations or again the best practices in philanthropic management or governance. It also plays an important representation role. It organizes exchange circles between its members (general managers, communications and marketing resources), thus encouraging a sharing of best practices, real experiences and innovative ideas. It also offers many reference tools to its members, for example a table of remuneration recommendations for their employees. The AFÉSAQ has 93 foundation members who amass more than 72% of funds collected by all the foundations associated with a healthcare institution. Among the 63 healthcare institution foundations in Quebec who amassed more than $1 million over the last two years (average revenues of $6.46 million), 42 are members of the AFÉSAQ. According to the Canada Revenue Agency's forms T3010, the 42 members accumulated 79.7% of gross revenues of the 63 foundations. Philanthropic Trends in Quebec and in Canada Several trends are evolving in the philanthropic habits of Quebeckers and Canadians. First, let's look at some numbers (Statistics Canada): Between 2011 and 2015, the number of donations has gone down each year in Canada, but the amount of the average donation has increased. In Canada, the total amount of donations exceeded $9 billion in In 2016, Quebeckers gave an average of $252 while Canadians elsewhere gave $484. The good news is that the trend in Quebec has been on the rise for 5 years, contrary to the rest of Canada where it has been decreasing. One number clearly illustrates how important foundations in the healthcare sector have become: 56% of donations amassed in Quebec in 2016 were directed to organizations and foundations in this sector. (Épisode and Léger Marketing, 2017). 56% of donations amassed in Quebec in 2016 were directed to organizations and foundations [in the healthcare sector]. Insofar as major trends are concerned, a few years ago benefit activities still occupied an important place in fund raising, whether these involved golf tournaments, suppers or benefit shows. New activities were organized, in particular numerous sports challenges. Overall, however, this type of activity is decreasing, giving way to other modes of fund raising, in particular because the activities generally involve expense ratios that are quite high and the mobilization of many resources. In more recent years, a great number of foundations have set up planned donation programs and instituted committees or groups of young philanthropists. They have also perfected several of their practices, whether this involves solicitations by mail or the basic practices of philanthropy, such as developing relationships and recognizing donors. Of course, the evolution of communication methods has meant that these now occupy a prominent place in foundation strategies. The foundations associated with the healthcare network have of course followed these trends. The AFÉSAQ considers it essential to transmit a culture of excellence, ethics and integrity in everything that touches philanthropic management. Administrative Costs and Expenses In an evolving and developing philanthropic context, the professionalization of resources and best practices in fund raising are indispensable. Just like benefit activities that often involve important expenses, foundations have various administrative expenses, whether these involve salaries, communication methods (telephones, website, etc.) or administration (office supplies, post office, etc.). They must also shoulder the expenses associated with the various solicitation campaigns. Finally, they must equip themselves with essential tools, such as a database, search tools and digital platforms created specifically for fund raising. These various expenses are often still the subject of debate. Foundation leaders shoulder all management responsibilities and want to offer good results while maintaining the ratio of expenses as low as possible, just like in a private corporation. Donors and the public in general often expect foundations to have very low administrative expenses, if not none at all. "This is often the sign of a philanthropic culture that is not yet well developed" (Lapointe, AFÉSAQ Conference, 2016). Can one imagine that a hospital foundation succeeds in amassing $5 million each year without any expenses at all and possibly only through the contribution of volunteers? To ask the question is to answer it.

27 FOUNDATIONS A KEY ROLE IN THE NETWORK Bill 10 The Stakes in the Context of the CISSSs and the CIUSSSs Where Are We After 30 months? With the coming into effect of Bill 10, foundations were faced with several challenges. Important changes inherent in the creation of the CISSSs and the CIUSSSs, as much in the structures as in the personnel, have had repercussions on all fronts. With the coming into effect of Bill 10, foundations were faced with several challenges. Foundations are independent organizations with their own governance structures. The new act modified the structure of CSSSs, but not that of foundations. It thus had numerous indirect repercussions, sometimes major ones, which forced boards of directors and permanent employees to display resilience and especially... creativity. We have to admit there was a period of uncertainty and hesitation. Several hospitals had been regrouped within one CISSS and foundations had to react. They thus had to modify certain ways of working, to establish relations with the new stakeholders, reassure donors, create new partnerships and work in cooperation with the other foundations which were now also a part of the new CISSS. Most foundations that existed before the reform still exist. There were a few mergers and some foundations chose to change their names, as these were sometimes associated with a structure that no longer existed, like the CSSSs. Slow-downs, Interruptions and Lost Revenues Among the effects of Bill 10 that are still being felt, there is the slow-down in the implementation and execution of the various projects financed by foundations in several regions. These delays are perhaps normal within the framework of a major restructuring, but in such a case, foundations need to speak with their donors in order to reassure them, because the latter had agreed to make a donation for a specific project that is slow to produce tangible results. There are also repercussions on the administrative side that need to be managed. Several foundations were lucky enough to benefit from accessory revenues (parking fees, coffee shops, television sets in rooms, etc.). For some of them, the loss of these revenues, especially those generated by parking fees, have had a major effect on their balance sheets. Soliciting users has slowed down in some areas, or even completely stopped for a certain period. Solicitation methods are not yet optimal in all regions. These interruptions and slow-downs have meant a loss of revenues and a decrease in the number of donors in the database of some foundations, a loss of revenue not only in the short-term, but also in the medium-term, because donors often donate again after a first donation. The reform has also resulted in changes for the various CMDPs, whose activities have slowed down, or even been paralyzed in certain regions. Some CISSSs and CIUSSSs now regroup several hospitals and parameters have had to be redefined regarding the entity representing physicians, dentists and pharmacists in the new organizations. Cooperation with the foundations has at times been negatively impacted. CMDPs were, and still are, very important allies for foundations as many physicians recognize the essential contribution of foundations and are among their donors. A Winning New Start Certain regions have rapidly mobilized, encouraged by the president and executive director of the CISSS or the CIUSSS and of various foundation stakeholders. This mobilization has given rise to the creation of committees bringing together various foundations, thus developing better communications and promoting work in closer cooperation and ensuring complementarity between various foundations and their CISSS or their CIUSSS. This was the case in particular in the Mauricie Centre-du-Québec region where, under the encouragement of the President and Executive Director, Mr. Martin Beaumont, a philanthropic committee bringing together the 18 foundations was set up. This committee meets 4 to 5 times per year. This is a privileged venue for exchanges and cooperation between the management team at the CIUSSS and the foundations in the territory. Among the objectives of this committee, we must highlight the harmonization of solicitation practices in each of the foundations and a dialogue based on their operational and developmental aspects. New partnership agreements are also on the point of being signed between the CISSSs and their foundations. These agreements will establish milestones for several elements in a wide range, in particular the representation of the CISSS with the foundation in a spirit of cooperation and partnership, the analysis and the treatment of requests emanating from the foundation and the participation of various CISSS employees being involved in the activities of the foundation(s). These two examples, among many others, will serve as catalysts for other regions. In this respect, the AFÉSAQ plays a significant role and supports its members in their search for solutions to different problems. Even if all these challenges are not resolved, we see in the various initiatives both the resilience and the capacity to adapt of our foundations, always with a view to continuing to develop and to continuing to play one of the most important roles in the development of the healthcare network in Quebec. References are available on the FMSQ portal (fmsq.org). 27

28 A TRIBUTE TO SERIOUS COMMITMENTS FROM THE STARTING LINE In 1974, as a member of the Santa Cabrini Hospital CMDP, I learnt from the hospital's executive that there was no budget for the purchase of medical equipment integrating new technologies. Even worse, there was very little money available to allow us to replace the equipment we already had. In 1975, I accepted the position of president of the CMDP. The position of DSP being vacant at the same time, the hospital's director asked me to help by taking on the duties of the position temporarily. I agreed to do so part-time, but the "temporarily" finally lasted 14 years. Albert Chiricosta Urologist Santa Cabrini Foundation It was apparent that the hospital's financial situation was not going to improve. In cooperation with a member of the Board of Directors and the hospital's director, we thought that a foundation could be the solution. The Santa Cabrini Foundation (SCF) was incorporated in That year, there were only three of us to solicit funds. From 7:00 p.m. to 11:00 p.m., during approximately three weeks, we filled out countless requests to obtain funds... with pen and paper. The thousand or so letters we sent out allowed us to raise... a bit more than $1,000. By 1977, we had started to better determine what we wanted the Foundation to become and established our strategy. Our hospital's main mission being to serve the Italian community, we started by drawing up a list of the presidents of the various associations and companies as well as the names of the organizers of golf tournaments to get to know our clientele. From this list, we recruited a few members who were well-known in the community to form a Board of Directors, whose members then became our first ambassadors. Then, each Chairman of the Board brought in new members; and each member, new contacts... All of this allowed us to rapidly widen our field of action, whether with the public or with institutions. Learning to Distinguish Ourselves A community hospital centre like ours doesn't have the same advantages as a specialized centre does to solicit funds. We cannot compete with hospital centres who have treatment units in cardiology, cancer, mental health or others. That is why it is very important, even essential, that the members of the Board of Directors take part, personally, in fund raising. We have to know how to invite their new ideas and, especially, how to draw advantage from their numerous contacts. Since its creation in 1976, the Santa Cabrini Foundation has given some 16 million dollars to the hospital and the Dante Senior Centre so that the services offered can be more human and of the highest quality. The aim of the Foundation has always been to help the Dante Senior Center and the Santa Cabrini Hospital maintain themselves at the cutting edge of technology as well as provide their clients with the best care possible. Since its beginnings, the Foundation has been responsible, in whole or with the government's contribution, for setting up new services, such as ultrasound, CAT scans and magnetic resonance imaging, as well as for replacing equipment, in particular in nuclear medicine. Since its creation in 1976, the Santa Cabrini Foundation has given some 16 million dollars to the hospital and the Dante Senior Centre so that the services offered can be more human and of the highest quality. Recently, the Foundation inaugurated the Centre de lutte contre le cancer which it financed on its own: a bill that reached $2 million! Today, it continues its excellent work because the needs of the community it serves are in constant evolution. Fortunately, we can always count on the support and energy of the members of our Board of Directors to carry on with our annual fund-raising campaigns, such as our Great Ball, our golf tournament, our gift-wrapping counter at Christmas time, without forgetting the very popular lottery with the chance to win a car! 28

29 FOUNDATIONS A KEY ROLE IN THE NETWORK THE GLORIES AND MISERIES OF REGIONAL FOUNDATIONS I am a member of our hospital's Foundation since From the beginning, a member of the Council of Physicians, Dentists and Pharmacists (CMDP) sits on the Foundation's Board of Directors. Insofar as I am concerned, the selection process was very simple since I was the only one to tender my candidacy when my predecessor left. Afterwards, I was coopted to sit on the Board. Our mandates are for two years and, according to the Foundation's statutes, a member cannot sit for more than eight years on the Board. This year marks the end of my fourth two-year mandate and I will have to make room for another member of the CMDP whom I've already recruited... François Gagnon Internist Fondation de la santé de Rivière-du-Loup At the beginning, I took on the roles of representative of the CMDP and Director. For the last four years, however, I have also been acting as Vice-President, which means that I also sit on the Financial Audit Committee. As well, I have always been active on the organizing committee for the Foundation's annual golf tournament, for which I was once Honorary President just like other members of the Board of Directors. I have also been Honorary President of one of our annual fund-raising campaigns. It is difficult at the beginning to understand all the workings of such an organization and to analyze all the subtleties of its financial statements. Fortunately, there have always been accountants or people from the world of finance to help me understand the finer details. I am the only physician on the Board of Directors of the Foundation and my role is important, if only to explain to the other members the operation of medical equipment, for which financing requests have been made to the Foundation. Thanks to my explanations, the Board members can make an informed decision and I admit that I have certainly had an influence as subject matter expert. The Foundation finances the purchase of medical equipment that allows the hospital to offer investigations and treatments in our region. Such a contribution is very satisfying, because the Foundation finances the purchase of medical equipment that allows the hospital to offer investigations and treatments in our region, thus minimizing travel for our patients while facilitating the retention of physicians and other healthcare professionals or by remaining attractive to them. I am particularly proud that I convinced my colleagues on the Board to finance the purchase of a repetitive transcranial magnetic stimulation (rtms) device to treat resistant non psychotic depression. I am always impressed by the quality of the other members of the Board who invest so much time and energy in their role. We have to attend the Foundation's monthly meetings in addition to taking part in various committee meetings and fund-raising activities. However, I am disappointed by the meager commitment of certain physicians. It seems inconceivable to me that a physician fails to make a donation each year to his foundation. The rate of participation in fund-raising activities (golf tournament) is also very low. And yet, the Foundation receives a lot of requests from physicians and it would seem logical to me that they should take an active part in financing the purchase of the said equipment. I must admit that the merger of hospitals has resulted in a certain level of confusion, as many of my colleagues thought that the foundations had also merged and that the money raised would not necessarily be invested in their location. For the moment, the Ministry guarantees that the foundations will remain independent and that the money raised will be used to finance projects specific to each installation to which the foundation is attached. In order to get physicians to donate, I think we will have to include a mandatory contribution when we renew CMDP dues. I know that this policy is already in effect in certain hospitals. Does the Fact of Being in a Region make a Medical Foundation's Work Easier? "We can see it in two ways. Being in a region opens doors more easily: since everyone known everyone else, we can easily get the help of a restaurant owner to organize an evening, or solicit that of a car dealer or a personality in the region. On the other hand, the population remains the same; it can't be stretched, no more than its pockets can! The more a person is solicited, the more he or she has to make a choice. We have to take that into consideration." 29

30 30 Emmène-moi au sommet Épargnez 39 % sur vos billets SkiMax 56 $ / billet En vente jusqu au 7 décembre SERVICES AUX MEMBRES AVANTAGES COMMERCIAUX Nos annonceurs et nos partenaires commerciaux vous offrent des produits ou des services pour répondre à vos besoins. ENCOURAGEZ-LES Voir à la page 47 THE PHILANTHROPIC COMMITMENT Aware of the privileged role of the physician in our society, I decided to get involved in philanthropic work at the start of my practice in As a member of the Board of Directors and President of the Fondation de l'hôpital du Saint-Sacrement, then later Vice-President of the Fondation des hôpitaux Enfant-Jésus Saint-Sacrement, I put a lot of energy in soliciting my colleagues and had some extraordinary meetings with business people, the members of the staff of the Foundation and the hospital environment, the volunteers and hospital directors. I was thus able to admire the charitable commitment of all these people who give back to others. Pierre Hallé Gastroenterologist Fondation du CHU de Québec Within the context of my work, my best win will have been, on the one hand, to have the Foundation rapidly invest more than a million dollars for the renewal of our technical capacity in 1995 in order to be able to maintain the offer of quality care, but especially to prevent the closure of the Hôpital du Saint-Sacrement. On the other hand, my biggest success has been to contribute to the merger of the foundations attached to the Centre hospitalier affilié universitaire and the Centre universitaire de Québec while retaining the best of each of these foundations which allowed us to set up the Fondation du CHU de Québec which took off. Today, it is without a doubt a great hospital foundation. Within the Foundation, I have the privilege of chairing the Comité d'attribution des fonds and of being able to rapidly authorize requests for research grants, technological development, the humanization of care and professional development, while keeping in mind that the objective is to improve the quality of care as well as the patient's experience. The healthcare network's reform has not changed my vision nor that of a third of my colleagues at the CHU de Québec-Université Laval who are regularly involved as philanthropic physician, guardian, partner and ambassador. Each of them enthusiastically supports the Fondation du CHU de Québec. My major challenge remains to convince all my other colleagues at the CHU de Québec-Université Laval to contribute financially and invest themselves personally in all the causes we support, in particular regarding the $60 million contribution that the Fondation du CHU de Québec has committed itself to donating to the opening of the new hospital complex in Quebec in 2025 on the site of the Hôpital de l'enfant-jésus. Thus, my more than 30 years of involvement in hospital foundations have allowed me to realize that by giving we do a good thing, we do ourselves good and we feel better.

31 FOUNDATIONS A KEY ROLE IN THE NETWORK A SIGNIFICANT CONTRIBUTION TO RESEARCH My career as a respirologist, researcher and professor began in In my capacity as Director of the Unité de recherche en pneumologie, then as department head, I looked after the Fonds Alphonse-L'Espérance for research on cancer and lung disease, which was created to support the academic vocation of our department. The Fund was originally created in the early 1980's as an independent fund, then made official in 1995 in memory of Dr Alphonse L'Espérance, a visionary physician who was medical director of the Hôpital Laval from 1949 to The Fund, with a capital today of $1.5 million, has used a part of its earnings each year for the past three years to support research, education and subspecialty care in respiratory health. It is managed by the Fondation de l'institut de cardiologie et de pneumologie de Québec, previously the Fondation Hôpital Laval. Michel Laviolette Respirologist IUCPQ Foundation In 1998, along with my respirologist colleagues, I founded Innovair Ltée, a company whose mission was to support the development of research by undertaking, in particular, clinical research. Over the years, our company has financed the specialization of the endoscopy unit. A portion of Innovair's earnings has been invested in the department, to which was added the financial support from the Foundation, and which represents a significant contribution to improve the offer of services to patients. Then, an important event took place: the merger of the Corporation de l'institut de cardiologie de Québec and the Fondation Hôpital Laval which gave birth to the Fondation de l'institut universitaire de cardiologie et de pneumologie du Québec (IUCPQ Foundation), on January 1, Some of my physician colleagues and I then joined the Board of Directors of the Foundation as representatives of our respective departments: cardiology, respirology and obesity. Together, we took an active part in the meetings of the Grant Application Evaluation Committee and in fund-raising activities, but not before having solicited the members of our departments to subscribe. We also encouraged the members of the Board to support research. To illustrate the importance of this support, I would like to mention that the sums allocated to research by the IUCPQ Foundation in 2016 reached $1,196,790. Physicians Must Get Involved On the one hand, the role of the physician is essential to ensure the members of the executive and the Board of our Foundation understand the very nature of medical activities in the institution (or in a particular department) as well as the importance of the Foundation's support to these activities. On the other hand, the medical representative must also make his colleagues aware of the advantages of the Foundation. It is rare for a physician to refuse to support a foundation when he sees the tangible benefits it can have on his practice and on improving the care proffered to patients. Physicians who refuse to support their foundation have generally not been able to observe nor to profit from the results of a foundation activity (a new piece of equipment, for example). They are also people who feel little or no sense of belonging to their hospital centre. The great upheavals we have lived through in the healthcare network have imposed significant changes, ordered mergers with institutions with a far different approach, and modified the ways we had been doing things for many years. One of the great challenges for foundations is to propose original activities within the framework of their fund-raising. In 2015, I took part in the "Mont défi Parinacota" expedition, a 6,350 metre climb in Bolivia. We made our way up the volcano in extreme climate conditions. The presence of ice, snow and winds, even in the middle of summer, prevented us from reaching the top of the volcano by a few metres only, but our challenge was taken up. It was an enriching as well as a "profitable" experience since the Foundation amassed approximately $100,000 within the framework of this activity. It was so cold on the Parinacota that my camera froze in my pocket. As a result, many professionals are not yet comfortable within these new structures or have simply not yet found their place. A new culture cannot be built with the wave a hand. The Turning of a Page Today, the IUCPQ Foundation plays an indispensable role in the accomplishment of the tertiary and university vocation of the institution and its active participation grows each year. I am semi-retired professionally; I left my position on the Foundation's Board last June, but I remain totally available to help the Foundation meet potential donors or to find new members for the Board. I am proud of the work accomplished by our Foundation and optimistic regarding its future. 31

32 A SMALL REGION'S BATTLE February 2017, 4:00 p.m., Outpatient Lung Clinic, Centre hospitalier Hôtel-Dieu-de-Sorel. After having seen his family physician, Mr. Savamal (fictional alias), 58 years old, came to see me for the results of the tests he had undergone, for a pain in his shoulder that wasn't getting better in spite of physiotherapy treatments. 32 By Dr Martine Dulude in collaboration with Dr Jacques Godin Pneumologists at the Centre hospitalier Hôtel-Dieu-de-Sorel His scan showed a probable Pancoast tumour, numerous mediastinal adenopathies and probable bony metastases. Tests of his respiratory function would not allow him to undergo a transthoracic biopsy and a standard bronchoscopy didn't reach a cytological diagnosis. In addition, after discussing the case with the radiologist, it would seem the bony metastases are not accessible for biopsy. I explained that it is possible to provide palliative chemotherapy or immunotherapy, which could allow him to maintain a good quality of life for a certain time. Mr. Savamal and his wife cried. He wanted to be there at his eldest son's wedding the following year. He wanted to start treatment as quickly as possible. But, to do so, we absolutely had to have a cytological diagnosis... For this patient, there was a simple and safe way to obtain such a diagnosis: an endobronchial ultrasound (EBUS) which could be used to obtain a biopsy of the mediastinal adenopathies. However, this test is not available in our hospital centre and the patient would have to go to the Hôpital Honoré-Mercier in Saint-Hyacinthe (located an hour's drive across country). When I said as much, his response was one I unfortunately hear much too often. "Saint-Hyacinthe? But that's much too far! I don't have a car, I don't have anyone who can drive me there and I certainly don't have the $200 or more a taxi would cost. I'd prefer to die rather than go there!" I know that this may seem like an extreme reaction. I'm sure you're thinking: "It's not the end of the world to have to drive for an hour in order to get treatment. That's the case for most people!" I understand, because that's what I thought as well before coming to work in Sorel-Tracy, before I heard over and over again the same response: "I'd prefer to die rather than leave Sorel-Tracy." And, sadly, it's not just words; patients really do let themselves die rather than leave their region. Sorel-Tracy is not the only "insular" territory of its kind in Quebec; there are a lot of them. These are the regions with specific characteristics that are often similar: disadvantaged areas, whether industrial or agricultural, often with very high rates of tobacco addiction and chronic disease. Unfortunately, these regions don't receive much consideration from our politicians. They are often abandoned to their own means. For decades now, the citizens of Sorel-Tracy have learnt to expect nothing from politicians and to manage among themselves. It's like a large village. If somebody's house is destroyed by fire, everyone helps the family struck by disaster. If the Source: patrimoine-culturel.gouv.qc.ca region has the highest rate of tobacco addiction and lung cancer in the Montérégie, the people here will raise the money to obtain treatment. About three years ago, the Centre hospitalier Hôtel-Dieu-de-Sorel decided to recruit a pneumologist who was very familiar with the EBUS technique and to get the equipment needed for this examination. The hospital centre asked its Foundation to run a fund-raising campaign, after having obtained all the needed authorizations from the CSSS Pierrede-Saurel which was in charge at that moment, and making sure that the quality of the resulting exams would be sufficient, on the one hand to justify the purchase of the equipment and, on the other, to guarantee the expertise of the pneumologist on site would be maintained. The fund-raising campaign was a success, the needed funds were collected and the pneumologist was hired. In the meantime, the government changed as did the administration. With the structural reform, the CSSS Pierre-de-Saurel became the CISSS Montérégie-Est.

33 FOUNDATIONS A KEY ROLE IN THE NETWORK At the moment of going ahead with the equipment purchase, in the fall of surprise! The rules of the game had changed! Despite approval by the management of the CISSS Montérégie-Est, Quebec's Ministère de la Santé et des Services sociaux (MSSS) refused the purchase of the EBUS equipment for Sorel-Tracy, in the name of centralization. There was a moment of panic in Sorel-Tracy. This was because the fund-raising campaign was finished and we found ourselves faced with a serious ethical and legal problem. Contrary to what the authorities suggested we do, it is illegal to take this money and then simply reinvest it in another project. We would have had to call each donor, one by one, to ask if he or she agreed for the money to be used for another cause. Can you imagine what such a refusal would mean for a foundation such as that of the Centre hospitalier Hôtel-Dieu-de-Sorel? Several donors, having personal reasons to donate for the cause of lung cancer, would probably have reclaimed their donation, but even more the credibility of the Foundation would have been seriously shaken. After such an experience, how could the Foundation convince donors to give generously in the future for their cause if the latter could not be certain that the money would be used specifically for the one they had chosen? Imagine now what this situation presupposes for all the hospital foundations in Quebec. A foundation starts by obtaining all the needed authorizations, collects the funds for the purchase of a particular piece of equipment, but then finds itself unable to complete the mandate it had shouldered because the administration had changed in the meantime. We could have chosen to be discouraged. In fact, we were for a time. But our patients made us change our minds. Our patients, whom we had to urgently hospitalize, often for more than two weeks, only in order to wait for their EBUS to be performed outside of the region thanks to the hospital's disabled transport system. Our patients, who regularly asked us why we could not have the equipment if we had enough patients, the specialist needed to operate it and the money to purchase it. Our patients, who no longer had any respect for their government which once again had let them down. During medical school, we learn to care for patients, but it's often only much later than we realize that taking care of patients also means taking care of the healthcare system in order to be able to give our patients access to quality health care. In today's healthcare system, a substantial proportion of workers are exhausted and indifferent, finding their daily clinical tasks at the hospital quite heavy enough. We chose not to give up for two reasons: A. We knew that being refused this specialized piece of equipment was the beginning of the end for the region of Sorel-Tracy and that we would no longer be able to promote specialized medicine in our small institution if we could no longer have the equipment needed. B. We wanted hospital foundations to maintain their role, consisting of improving the quality of care provided to patients. We therefore chose to fight and to fight obstinately. We took part in dozens and dozens of meetings and telephone calls with all the stakeholders in the administration until the management of the CISSS Montérégie-Est informed us it was at the end of its resources after having used its contacts in the MSSS to have this decision reversed. We therefore decided to come out in the media and, believe me, it wasn't a minor affair! Even if some of us were too shy to even order a pizza over the telephone, we agreed to meet with several journalists and to take part in press briefings and in filmed interviews. We put an enormous amount of energy into this project all while continuing on with our regular work at the hospital, work that remained just as heavy. Minister Barrette finally agreed to re-evaluate the MSSS' decision and to consult the Institut national d excellence en santé et en services sociaux (INESSS). After the publication of the INESSS report, which came up with the same numbers that we had already supplied to the ministry for our request to purchase the EBUS, the Minister finally authorized us to purchase it at the start of May What a relief it was in Sorel-Tracy after so much work and so many administrative battles! In most hospitals, foundations have always been there to encourage innovation, technological developments and the human-side of healthcare. With the recent changes in the administrative processes and the significant increase in government control, it would seem to be the will of the government to modify these powers from now on, and instead direct the mission of hospital foundations to the purchase of "fixed assets." You know as well as we do that, without the support of hospital foundations, if we have to wait for government budgets to offer quality care to our patients, we'll be allocated one chair for five patients! That is why, as physicians, we must never abandon the fight to make sure our patients always receive the best healthcare possible. Our hospital foundations must be able to maintain their original mission. 33

34 Our Small Foundation Has Grown THE FFMSQ MARKS ITS 5TH BIRTHDAY! It's now been five years since the Fédération des médecins spécialistes du Québec became involved in the philanthropy adventure by supporting a cause whose aim is to serve Quebec's population in another way. 34 To create a foundation is one thing, but to find a way of operating that can win over all the medical specialties represented by the FMSQ was a challenge in itself. With the objective of helping no matter the person's age or condition, the issue of respite for caregivers quickly stood out. It was by performing a review of reports in the press that this sector of intervention seemed to be promising to us: it is a young sector and little developed, but its needs are immense. Moreover, all medical specialists understand the reality of caregivers, since they almost all have patients who have to count on someone close to them to care for them. The Fondation de la Fédération des médecins spécialistes had found ITS cause! It was on April 23, 2012, during a press conference, that the Foundation was officially launched by announcing the granting of its very first financial contribution, in the amount of $100,000, to the Brome-Missisquoi Caregivers Support Group in the presence of Chloé Sainte-Marie, well-known as the spokesperson for caregivers in Quebec. Over the years, the FFMSQ has supported all sorts of projects, and all of them had a common objective: to provide some respite to caregivers. These projects are divided into two major classes. The first, associated with services, aims to offer short-term respite to caregivers during at least 4 consecutive hours. It can involve respite at home and, in such cases, an intervener takes care of the care receiver while his or her caregiver can deal with other occupations outside of the home. It can also be a question of respite outside the home, when the care receiver takes part in an activity managed by professionals, or when the caregiver can, for example, take advantage of a weekend of rest in an institution with lodging. Finally, the respite can take the form of a camp where a group of care receivers meets under the supervision of competent personnel for a period of 2 days or more, without exceeding 14 days. The second aspect supported by the FFMSQ involves infrastructures, an area for which organizations often have difficulty obtaining financing. Taking into account the fact that an organization lacking adequate infrastructures cannot offer quality activities in a stimulating and safe environment, the FFMSQ decided Proportion of supported projects 79% 79 % 16% 55% % To date, close to half a million dollars has been contributed by the FFMSQ to the Association des proches aidants de la Capitale-Nationale, a partnership which, alone, has allowed more than 550 caregivers of the region to take advantage of close to 20,000 hours of respite. to contribute to the success of projects which would help them. Construction or renovation projects can thus be financed, just like the acquisition of specialized furniture or equipment, and so improve the respite service offered by an organization supporting caregivers. Since its creation, the Foundation has analyzed 311 requests for support, an exercise that requires discipline and that starts with exchanges with the organizations in order to better understand the reach of their projects. It is important, in fact, to make sure that the help that is financed will indeed be used to provide respite projects for care receivers, living with their caregivers, of all ages and varying conditions. Respite services Infrastructure Combining both types

35 FOUNDATIONS A KEY ROLE IN THE NETWORK Number of distinct organizations supported Number of projects supported Total of financial contributions 2012* $549, $499, $770, $1,136, $565, ** $868,428 TOTAL $4,389,013 * Period from April 23 to December 31, 2012 ** Period from January 1 to November 15, 2017 Over the last 5 years, the FFMSQ has contributed close to $4.4 million in financial support to 100 distinct organizations located in 16 regions of Quebec, which support has allowed for the success of 203 projects helping to provide respite to caregivers. In addition, to be eligible for financial support from the Foundation, the organizations asking for help must prove their credibility and integrity. Moreover, the projects that are supported must take place entirely in Quebec over a maximum period of 12 months and be offered by a non governmental organization, recognized as such in accordance with the definition in the Income Tax Act and be registered with the Canada Revenue Agency, and have a head office in Quebec. Beyond these figures, we must be proud of the numerous moments of respite that have been provided thanks to the contribution of the FFMSQ. The testimonials we receive regularly from organizations and caregivers show us what it means. Moments of rest that are offered thanks to the financial contribution of our Foundation are more than pleasant, they are essential. They allow caregivers to catch their breath in order to carry on with their commitment to their care receiver. The FFMSQ is now well established and well known, even recognized, by the organizations providing respite to caregivers. Who could have said, in 2012, when it was just learning to walk, that our Foundation would develop so quickly and would allow so many caregivers to relax a bit? There is no doubt, the FFMSQ is really reaching its objectives! For more information on the Fondation de la Fédération des médecins spécialistes: fondation.fmsq.org. DEFINITIONS Care receiver: A person with a chronic illness or a physical or intellectual disability that permanently affect his or her autonomy, no matter how old he or she is, and who needs a lot of help from a caregiver. Caregiver: Respite: A person who lives with his or her care receiver and who provides significant support, but not as a professional. Intermediary resources (e.g. CHSLDs) and family-type resources (e.g. foster families) are not considered to be caregivers. A service offered to caregivers to allow them to benefit from a moment of rest of a specific length (a block of 4 hours minimum) and for limited period (short term). 35

36 In the World of Medicine By Lucie Opatrny, internist and Marie-Ève Bouthillier, PhD* Decoding Conscientious Objection in Medical Aid in Dying FIRST RESULTS FROM A UNIQUE STUDY EXCLUSIVE The Act respecting end-of-life care came into effect in Quebec on December 10, It sets out an overall, integrated vision of palliative and end-of-life care, including medical aid in dying (MAID) for freely consenting adults meeting certain criteria. 1 There was widespread agreement in Quebec's general population that a patient should have the right to access end-of-life care, including MAID. However, physicians publicly expressed some of their concerns with these new legislative provisions and their involvement in the process. 36 Under this new Act, physicians may refuse to provide MAID (and other health professionals may refuse to take part in the practice) on the basis of conscientious objection, but they must then notify the executive director (or a designated person) of the institution. 2 In ours, the CISSS de Laval, every physician who receives a request for MAID must call the Interdisciplinary Support Group (ISG) for support or help in finding a substitute physician in the case of conscientious objection. Before providing the care allowed by the Act respecting end-of-life care, the CISSS de Laval performed a survey to better understand the points of view of physicians in its territory and to evaluate potential obstacles in anticipation of implementing the Act and respecting its spirit. For planning purposes, we have kept data on every MAID request received since the start of this new practice. After 18 months, we noticed that declarations of conscientious objection from physicians were far more frequent than we had anticipated based on our pre-act survey. We decided to analyze the motives behind the objections in order to understand conscientious objectors, to ensure continuity of care and to improve access to care for patients. The purpose of this article is therefore to analyze the debate surrounding conscientious objection in the medical ethics literature and to better understand the nature and motives behind conscientious objections by physicians working in Laval, Quebec. Defining Conscientious Objection The Debates and the Pros and Cons The term "conscientious objection" refers to a physician's refusal to proceed with an intervention for reasons of personal conscience. 3 At the beginning, this term was used by the military to designate the actions of soldiers refusing to take up arms because it went against their conscience. They claimed that killing was contrary to their fundamental values of pacifism and respect for human life. They then had to plead as to the authenticity of their convictions before a military tribunal in order to obtain an exemption or an accommodation (for example, being assigned to a support role for military activities 4 ). * D r Lucie Opatrny is an internist and the Director of Professional Services (DSP) at the CISSS de Laval Mme Marie-Ève Bouthillier, PhD, is the executive in charge of the Centre d'éthique du CISSS de Laval and a member of the Bureau de l'éthique clinique at the faculty of medicine of the Université de Montréal.

37 In the World of Medicine In medicine, conscientious objection has mainly been raised for interventions on the reproductive capabilities of women, including emergency contraception and abortion, as well as regarding end-of-life issues, like assisted suicide and euthanasia. The people in favour of conscientious objection hold to the following arguments: Protecting the foundations of our society: freedom of thought, of conscience and of religion is a fundamental right inscribed in the charters of rights and freedoms. 5 Going against people is equivalent to a serious offence against their dignity: denying people the possibility of following the dictates of their conscience can be a serious restriction on their dignity and their integrity. 6,7,8,9,10 Even the act of referring a patient to another physician in order for the patient to obtain the service can be seen by some as being morally unacceptable. The physicians could feel complicit in the act in which they refuse to engage. 11 The possibility of making reasonable accommodations: practising medicine includes a wide range of interventions, very few of which are controversial. Reasonable accommodations must prevail just as it is impossible to perform an intervention by reason of a physical disability or a lack of skill. 12,13 Preserving diversity and humility: making the refusal to participate in certain acts impossible risks chasing away physicians who are more sensitive morally, which would generate a loss for the profession and for patients. Moreover, no one is the sole arbiter of the "moral truth." That is why we must avoid judging and instead display both humility and tolerance. 14,15 Those who oppose conscientious objection have arguments that are just as valid: Consequences for patients: the right of a physician to refuse to take part in a medical act may lead to denying access to a required service or cause delays in a person's treatment. 16,17 Costs for healthcare systems: while the possibility of referring the patient to a colleague exists, this can generate additional costs and prove to be less efficient. 18 A heavy burden on the shoulders of a reduced number of physicians: some types of medical acts engender more conscientious objections, whether they involve abortion, the prescription of an emergency contraceptive or abortion pills, or euthanasia. These medical acts come to rest on a reduced number of physicians who accept to perform them, which can constitute a heavy moral burden for the latter to carry in the long term. 19 The importance of professionalism: practising medicine means caring for patients, no matter the type of care required. In addition, being in a situation of power and monopoly regarding these services, it is the physician's moral obligation to provide them. 20 The Prevalence of Conscientious Objection Among Physicians 1. Surveys from the US and Other Countries What people believe regarding conscientious objection is still largely unknown in Quebec, and not well studied. However, there have been studies 21 aimed at assessing the prevalence of conscientious objections among physicians, residents and medical students, two of which are outlined below. A survey of Oregon doctors, conducted several months after the Death With Dignity Act was first approved by Oregon voters in November 1994, reported that approximately one third of the respondents stated that physician assisted suicide is immoral and violates the standards of professional ethics. 22 A survey of primary care physicians found that 78% of respondents agreed that a physician should never do something he or she considers to be morally wrong. More recently, a survey of primary care physicians found that 78% of respondents agreed that a physician should never do something he or she considers to be morally wrong. The majority of physicians believed they have the obligation to refer a patient to another physician in situations where it is against their conscience to perform such an act. In this survey, 68% percent of physicians objected to physician-assisted suicide Survey Among Laval Physicians Laval is the third largest city in the province of Quebec with a population of approximately 435,000 people. Since the 2015 reform of the health sector, the health and social services of this region are administered by the CISSS de Laval. The Ministère de la Santé et des Services sociaux (MSSS) of Quebec requires that each CISSS set up an interdisciplinary support group (ISG) for MAID. Before offering MAID, we performed a survey aimed at understanding the point of view of physicians and anticipating potential obstacles to the application of the law. The survey was conducted from October 20th to November 15, It included 15 multiple-choice and open-ended questions sent by to 783 physicians practicing in the Laval region. 37

38 In the World of Medicine 38 Two hundred and seven (207) physicians answered the survey, for an overall participation rate of 39%. In terms of the demographics of those answering the survey, family physicians and specialists were evenly split. A slight majority (55%) of responders were female and 53% had a hospital-based practice. The age of responders ranged from under 30 to over 60. Sixty percent of responding physicians stated they treated patients with end-of-life issues in their practice, and a large majority (89%) were aware of the new law. In answer to the question, "Are you ready to help a patient, who meets the criteria outlined in the law, with MAID?", 28% of physicians stated they would "never do this", while 48% responded that they would participate and 30% provided answers with conditions. After this survey, our institution organised several targeted learning activities, starting prior to the law coming into effect and continuing subsequent to it. Between December 10, 2015 and September 13, 2017, the Laval region recorded 113 patient-signed requests for MAID, which had been received by 61 physicians (some of whom had received multiple requests). Of these 61 physicians, only 14 (23%) participated in the treatment requested by their patients. Forty-seven of the physicians (77%) refused to actively participate in their patient's medical-aid-in-dying process, all of them using the "conscientious objection" clause, thus requiring a substitute physician be identified so as to provide the intervention required. The number of physicians invoking the "conscientious objection" clause (77%) far exceeded our expectation of the use of this kind of refusal based on our afore-mentioned physician survey. In addition, our discussions with physicians in various patient cases allowed us to understand that conscientious objection was being used for a wide variety of reasons beyond the classic definition of the term. Therefore, we devised a qualitative study using a semi-structured interview with physicians, who Decoding "Conscientious Objection" had refused to take part in their patient's request for MAID, to elucidate what they meant by "conscientious objection". Between January 2017 and September 2017, there were 47 physicians who used the "conscientious objection" clause in order to avoid providing MAID in the Laval Region of Quebec. In order to explore what "conscientious objection" meant to these physicians, we conducted the qualitative study mentioned above for which we sought and received ethics approval through our institutional review board. All 47 physicians were contacted, and we conducted semi-structured interviews with the 22 physicians who agreed to participate: there were 12 men and 10 women who ranged from 26 to 67 years old. Interviews focused on the motives for refusing to participate in a MAID request for their patients. Participants were then asked to think about the first MAID request they had received and to describe their reaction to it, including the reasons that motivated their refusal to participate. We classified the motives for refusal into two categories: 1. Refusal on religious or moral grounds: this is conscientious objection according to the definition; 2. Refusal for other reasons which do not constitute a conscientious objection according to the definition and which we separated into intrinsic and extrinsic reasons: a. Intrinsic reasons: emotional burden too high; feelings of inadequate expertise to perform the medical act; fear of stigmatization by their colleagues; fear of death. b. Extrinsic reasons: carrying a high clinical burden; lack of time; fear of medical legal repercussions.

39 In the World of Medicine Results The majority of physicians, who claimed conscientious objection and whom we met during the semi-structured interviews, were in favour of MAID (72.7% or 16/22); 13.6% (3/22) were against it and 13.6% (3/22) were neutral or ambivalent. Results from the interviews revealed that only a minority of physicians (22%) had a true moral or religious objection to MAID. Among those opposed, the most frequent concerns expressed were feelings that MAID conflicted with medicine. They declared they had been taught to save lives, not end them. They also said they viewed end-of-life care as focusing on alleviating suffering. They expressed fear over the power to end a life that was being given to them. "It would be difficult for me Results from the interviews to administer MAID to revealed that only a minority someone. Who am I to of physicians (22%) had decide to end a life? My wish a true moral or religious is to help my patient and objection to MAID. alleviate his or her suffering in the final days so they can take advantage of the life that remains. [...] If I perform MAID, I would be in conflict with [the fundamental principles of] my practice" The other 16/22 physicians (72%) used "conscientious objection" as the only reason not to participate in MAID, but their objections were issues other than a true moral refusal. Physicians were invited to discuss all contributing reasons that prevented them from providing MAID, and many mentioned more than one such reason. "The conscientious objection I declared is not a real one. It is more on an emotional level. I cannot live with performing such an act at this time. I am not capable of it right now. If a patient I've known for 30 years asked me, I would be there for him or her. I would assist, but it would affect me profoundly." References 1. Section 26. Only a patient who meets all of the following criteria may obtain medical aid in dying: 1. be an insured person within the meaning of the Health Insurance Act (chapter A-29); 2. be of full age and capable of giving consent to care; 3. be at the end of life; 4. suffer from a serious and incurable illness; 5. be in an advanced state of irreversible decline in capability; and 6. experience constant and unbearable physical or psychological suffering which cannot be relieved in a manner the patient deems tolerable. 2. Section 31. A physician practising in a centre operated by an institution who refuses a request for medical aid in dying for a reason not based on section 29 must, as soon as possible, notify the executive director of the institution or any other person designated by the executive director and forward the request form given to the physician, if that is the case, to the executive director or designated person. The executive director of the institution or designated person must then take the necessary steps to find, as soon as possible, another physician willing to deal with the request in accordance with section 29. If the physician who receives the request practises in a private health facility and does not provide medical aid in dying, the physician must, as soon as possible, notify the executive director of the local authority referred to in section 99.4 of the Act respecting health services and social services (chapter S-4.2) that serves the territory in which the patient making the request resides, or notify the person designated by the executive director. The physician forwards the request form received, if that is the case, to the executive director or designated person and the steps mentioned in the first paragraph must be taken. 3. The Code of ethics of physicians describes the physician's obligations in this respect: "24. A physician must, where his personal convictions prevent him from prescribing or providing professional services that may be appropriate, acquaint his patient with such convictions; he must also advise him of the possible consequences of not receiving such professional services. The physician must then offer to help the patient find another physician." 4. Stahl RY, Emanuel EJ. Physicians, not conscripts Conscientious objection in health care, New England Journal of Medicine 2017;376: The "freedom of thought, conscience and religion" is recognized by the Universal Declaration of Human Rights (section 18, 1948) and confirmed by subsection 2b of the Canadian Charter of Rights and Freedoms. The Supreme Court of Canada, in its ruling Carter v. Canada (Attorney General), as well as Bill C-14, An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying), confirm that the physician enjoys freedom of conscience. 6. West-Oram P, Buyx A. Conscientious Objection in Healthcare Provision: A New Dimension. Bioethics 2016 Jun;30(5): Kantymir L, McLeod C. Justification for Conscience Exemptions in Health Care. Bioethics 2014 Jan 1;28(1): Wicclair MR. Conscientious objection in medicine. Bioethics 2000 Jul 1;14(3): Wear S, LaGaipa S, Logue G. Toleration of moral diversity and the conscientious refusal by physicians to withdraw life-sustaining treatment. Journal of Medicine and Philosophy 1994;19(2): Continued on the following page. 39

40 In the World of Medicine Intrinsic Reasons The most common reason mentioned was that MAID is too much of an emotional burden to bear (13/22 or 59%), followed by a perception of lack of clinical expertise (8/22 or 36%), and a fear of being stigmatized by peers or by people in general for participating (6/22 or 27%). Only one physician mentioned being afraid of death. Extrinsic Reasons Other important factors declared were that this task could not be added to their already heavy clinical burden (9/22 or 41%); that MAID was a very time-consuming process (9/22 or 41%), and finally certain medical legal concerns (7/22 or 32%). "Nothing takes up as much time in medicine. I unfortunately don't have the time to take it on." Conclusion Physician participation in MAID is currently low, which situation, if not addressed, carries the risk of a looming crisis in access to timely MAID services. Our work sheds some light on the motives behind physician objections to MAID and how doctors view some of their ethical rights and obligations. References (continued) 10. Magelssen M. When should conscientious objection be accepted? Journal of Medical Ethics 2012;38: Minerva F. Conscientious objection, complicity in wrongdoing, and a not-so-moderate approach, Cambridge Quarterly of Healthcare Ethics 2017;26(1): Cowley C. Conscientious objection in healthcare and the duty to refer. Journal of Medical Ethics 2017;43(4): Maclure J, Dumont I. Selling conscience short: a response to Schuklenk and Smalling on conscientious objections by medical professionals, Journal of Medical Ethics 2016;43(4):234-40, publiished on line on September 28, Doi: / medethics Schuklenk U, Smalling R., Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies, Journal of Medical Ethics Published Online First: 22 April Doi: / medethics Savulescu J, Schuklenk U. Doctors have no right to refuse medical assistance in dying, abortion or contraception. Bioethics 2017;31: Doi: /bioe These studies are: Wicclair MR. Conscientious objection in medicine. Bioethics 2000 Jul 1;14(3): Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med 2007;356(6): Physicians object to participating in MAID most often for reasons other than moral or religious grounds. Major reasons cited include high emotional burden, a perception of incompetence to perform the procedure and time constraints. Using empirical evidence, we understand that the term "conscientious objection" is currently used as an opt-out mechanism in the majority of MAID situations for reasons other than conscientious objection. Physicians object to participating in MAID most often for reasons other than moral or religious grounds. Major reasons cited include high emotional burden, a perception of incompetence to perform the procedure and time constraints. This information is important in order to better plan how to support physician concerns without denying access to care for their patients. This study also raises the issue of the place of emotions and empathy in medical aid in dying, which opens the way to future research on these aspects of medical practice that cannot be overlooked. 14. Sulmasy DP. What is conscience and why is respect for it so important? Theory Med bioethics 2008;29: Fletcher J. Right to die in Canada: respecting the wishes of physician conscientious objectors. CMAJ 2015;187: Savulescu J, Schuklenk U. Doctors have no right to refuse medical assistance in dying, abortion or contraception. Bioethics 2017;31: Doi: /bioe Hughes JA. Conscientious objection in healthcare: why tribunals might be the answer, J Med Ethics 2017;43: West-Oram P, Buyx A. Conscientious objection in healthcare provision: A new dimension. Bioethics 2016 ;30(5): Lawrence RE, Curlin FA. Physicians' beliefs about conscience in medicine: a national survey. Acad Med 2009;84(9): Frank JE. Conscientious refusal in family medicine residency training. Family Medicine 2011; 43(5): Harris LF, Awoonor- Williams JK, Gerdts C, Gil Urbano L, González Vélez AC, Halpern J, et al. Development of a conceptual model and survey instrument to measure conscientious objection to abortion provision. Cameron S, editor. PLoS ONE. Public Library of Science 2016;11(10): e Wicclair MR. Conscientious objection in medicine. Bioethics 2000 Jul 1;14(3): Lawrence RE, Curlin FA. Physicians' beliefs about conscience in medicine: a national survey. Acad Med 2009;84(9): LS 40

41 Federation Affairs LOOKING BACK ON THE 10TH IED To highlight its 10th anniversary, the FMSQ's Interdisciplinary Education Day was held over two days instead of one, as had been customary. The second day was completely dedicated to practice evaluation and simulation activities. In addition to rooms in the Palais des congrès de Montréal which had been transformed for simulation exercises, certain specialized centres (the Centre d apprentissage de l Académie CHUM, the Centre d apprentissage des attitudes et habiletés cliniques at the Université de Montréal and the Steinberg Centre for Simulation and Interactive Learning at McGill University) offered a dozen simulation activities to participants, from taking charge of patients to the management of disasters and terrorist acts. Let us highlight a few important events that punctuated the first day held at the Palais des congrès de Montréal. A Motivational Speaker To highlight the tenth anniversary of the IED, a renowned speaker was added to the program. Mr Henry Mintzberg, PhD, holder of the Cleghorn Chair in Management Studies at McGill University, and author of the book "Managing the Myths of Health Care," came to present the results of his reflections on the management of our healthcare system. Dr Mintzberg evoked many incongruities between what we do and what we really want. He exhorted managers to leave their closed offices to spend more time in care units in order to see the effects of their decisions, too often theoretical and inoperable. According to Dr Mintzberg, it is impossible to manage healthcare like a business: financing according to activity is not a solution in itself since the care provided is different according to the patient and thus cannot be compared to one another. Dr Mintzberg also asked an excellent question of participants: "If the Minister of Health thinks that the best way of managing health is to cancel all management jobs in institutions and to transfer responsibilities to the CISSS-CIUSSS level, then why doesn't the Premier do the same by getting rid of all ministerial positions and managing all the ministries himself?" Excellence in CPD Award Presentation of Awards The President of the FMSQ, Dr Diane Francoeur, and the Director of Continuing Professional Development, Dr Sam Daniel, presented three awards of excellence during the lunchbreak: one in CPD and the other two to highlight interdisciplinary work. Then, at the end of the day, they presented two awards for research. Dr Paolo Costi, cardiologist at the CHUM Dr Costi is in charge of continuing professional development at the Association des cardiologues du Québec (ACQ) since His accomplishments are numerous and highly valued by his colleagues. For example, he completely modernized traditional continuing education activities in cardiology by adding online learning activities and Section 3 activities much earlier than others. During his mandate, he took on the role of veritable conductor by coordinating the ACQ's CPD activities, in addition to providing support to several members of the association who wanted to set up CPD initiatives in their own environment. He earned the respect of his peers and has become a model to emulate in the field of continuing medical education. Ensuring his replacement within his association's CPD committee will be a formidable challenge. 41

42 Federation Affairs Award of Excellence in Interdisciplinarity The Social Pediatrics in the Community Team of the Fondation du Dr Julien More than anyone else, children in a situation of vulnerability risk developing prolonged toxic stress that can have devastating effects on their cognitive, emotional, social and physical development. In 1991, realizing that these children don't always have access to the services they need, pediatrician, Dr Gilles Julien, created social pediatrics in the community, an innovative approach delivered by an interdisciplinary team: medical, psychosocial and legal. Thanks to Dr Julien's team, families benefit from coherent action plans and multidisciplinary medical, legal and psychosocial services; body-mind therapies and developmental interventions adapted to the needs of each child. Today, there are three centres in Montreal with expertise in social pediatrics in the community and more than twenty certified centres throughout Quebec. These expert centres, alone, welcome each year more than 2,000 children. Award of Excellence in Interdisciplinarity Dr Fadi Massoud This geriatrician who works at the Centre hospitalier Charles-Le Moyne and at the Institut universitaire de gériatrie de Montréal has made interdisciplinarity and teamwork unavoidable to ensure the quality and safety of care to the elderly, a frequently vulnerable population needing attention and vigilance. Dr Massoud works in close cooperation with his healthcare team to ensure patients receive high quality care. In addition to teaching interns and residents, Dr Massoud takes part in continuing education for his colleagues. He regularly organizes interdisciplinary educational activities, even interprofessional ones, in cooperation with all the members of healthcare teams and decision-makers in the social network. Awards for Research Awards for research presented by the FMSQ, a new award this year, aim to highlight the contribution of medical specialists who, thanks to their research projects, advance the practice of medicine. The winners are: Dr Rémi Rabasa-Lhoret, an endocrinologist at the CHUM, along with his team for the article:" Efficacity of single-hormone and dual-hormone artificial pancreas during continuous and interval exercise in adult patients with type-1 diabetes: randomised controlled crossover trial." This article was published in the journal Diabetologia. DOI : / s (Diabetologia Dec;59(12): ). Dr Claudia Gagnon, an endocrinologist at the CHUL Centre hospitalier de l Université Laval, along with her team for the article: "Change in fracture risk and fracture pattern after bariatric surgery: nested case-control study." This article was published in the British 42 Medical Journal. DOI : /bmj.i3794 (BMJ 2016;354:i3794). LS

43 OUR SUBSIDIARIES Professionals' Financial By François Lavoie, B.A.A., B. A., Adm.A., Pl. Fin. Senior Vice-President, Wealth Management SUPPORT THAT EVOLVES WITH YOUR NEEDS You see it in your practice: the professional environment of medical specialists is constantly getting more complex. The management of your wealth is also evolving, which can be the result of legislative modifications at the provincial or federal level, involving your personal or corporate tax situation, or it can derive from changes in your matrimonial or family situation. Tuned in to physicians, Professionals' Financial has developed targeted financial services to which you can turn in full confidence to better prepare your future, better answer the needs of your family or better manage your corporation. Your Tax Situation in Good Hands If your corporation is affected by significant legislative changes, you will need advice to know how to react and which actions to undertake. You will also try to understand the tax repercussions on your investment income. In the case of announcements from Minister Morneau regarding changes to fiscal measures affecting private corporations, we have reacted rapidly by organizing information sessions led by our tax experts and through webinars. Our support does not end there: if you are faced with a specific situation regarding your corporation, call our made-to-measure tax service. You will receive a complete analysis from our tax experts and recommendations on the best way to tackle your remuneration. They will suggest an optimal plan for cashing in at retirement, as well as strategies for donations and insurance. Various scenarios for the sale of properties or corporations can also be developed to measure their impact on your tax situation. Good Business Solutions If you own a clinic, you know that the Voluntary Retirement Savings Plans Act obligates you to set up a pension plan for your employees. However, you need to know that you are not limited to the VRSP: Professionals' Financial offers you a group RRSP that is very advantageous for you, the employer, and for your employees: administrative tasks minimized for you and the support of your advisor in all your undertakings; for your employees, putting some savings aside for their retirement, support of an advisor to choose their investments and immediate tax reduction since contributions are deducted from their basic salary. Made-to-Measure Investments Over time, you may have developed a certain interest for the financial markets. Your knowledge encourages you to concentrate your strategy in a particular class of assets rather than follow a standard investment policy. If such is the case, talk to your advisor about the possibilities of a specialized portfolio management mandate. You will benefit from the expertise of our investment managers and could even profit from a reduction in fees, in certain cases. And, if you have investments in several financial institutions, simplify your life by grouping them under a single roof, with Professionals' Financial. Thanks to our Investment Service and according to the value of your holdings, you could head towards a more personalized management of your assets and constantly maintain overall supervision of your investments, while taking advantage of very competitive management fees. Protect Your Family Even if we often prefer not to think of it, planning for your death and estate cannot be avoided. Consider the value of a family trust, which could allow you to divide revenues and reduce the tax burden on your heirs when your assets are passed on. If the liquidation of your estate risks being tiresome, look into our estate settlement services. In such difficult moments, the support of experts will provide your family with a much-appreciated peace of mind. Depending on the complexity of your estate, you could also retain the services of a qualified liquidator, who is also capable of taking on the administration of your family trust. All of these services have in common the desire to provide you with the expertise or the support you need in very specific situations, while their impact on your assets can be significant. Put your best energies in your practice where you excel and where your competence makes all the difference. Contact your advisor to discuss the expertise you are looking for: we are at your service. Professionals Financial Mutual Funds Inc. and Professionals Financial Private Management Inc. are wholly owned by Professionals Financial Inc. Professionals Financial Mutual Funds Inc. is a portfolio manager and a mutual fund dealer which manages its family of funds and which offers financial planning advisory services. Professionals Financial Private Management Inc. is an investment dealer, member of the Investment Industry Regulatory Organization of Canada (IIROC) and the Canadian Investor Protection Fund (CIPF) which offers portfolio management services. 43

44 OUR SUBSIDIARIES Sogemec Assurances By Chantal Aubin General Manager Financial Security Advisor Damage Insurance Broker My Drug Insurance HOW TO CONTROL ITS COST On January 1, 1997, the Act respecting prescription drug insurance came into force. It has now been 20 years since all Quebeckers have been obliged to have some form of drug insurance protection. Yet, by virtue of this Act, not everyone is treated equally. In fact, thanks to certain measures taken by the government to control the costs of the public plan, the premium paid by those insured under the public plan is lower than that of those insured under private plans, which are not concerned by these measures. According to the Canadian Life and Health Insurance Association (CLHIA), each year persons insured under a private insurance plan pay close to half a billion dollars 1 more than persons covered by the public portion of the general prescription drug insurance plan because the professional fees that pharmacists bill the former are higher. We thus believe it is important for you to know what you can do as an insured person under a private plan that may reduce your costs: make a greater use of generic drugs; opt for a longer renewal period for prescriptions (90 days rather than 30, if possible); compare costs. The next time you visit the pharmacy, we invite you cast a careful eye on the detailed bill that will be given to you by the pharmacist, because it now provides you with the following details: the pharmacist's fee; the price of the "molecule" (drug); the wholesaler's margin (distributor). The price of the molecule and the wholesaler's margin are set by the government; as a result, only one line varies from one pharmacy to the other, i.e. the one with the pharmacist's fee. Pharmacists' fees are also set by the government; and thus, for persons insured under the public drug prescription plan, these fees are the same, regardless of the pharmacy. This is not the case for individuals insured by private plans because, in such cases, pharmacists themselves set the amount of their fees according to the reality of their business (services offered, business hours, etc.). The amount of the bill can thus vary from one pharmacy to another. Of course, we recognize the essential role played by pharmacists within our healthcare system, as first-line providers, in particular to make sure that the drugs are used appropriately. However, it is a fact that the pharmacist's fees can vary from one pharmacy to another for a service of equal quality and that it can be advantageous to compare the cost of drugs purchased from your neighbourhood pharmacy with those purchased near your workplace. I will certainly not be teaching you, medical specialists, that increasingly costly new drugs are put on the market each year. Although this is an excellent piece of news for all of us, because previously incurable diseases like hepatitis C can now be treated, and because previously disabling conditions are no longer so thanks to new drugs, it is still a fact that the cost of these various treatments, and of those that will follow, have and will continue to have a direct impact on the cost of insurance protection. We need your cooperation to reach our two objectives, which are to avoid substantially increasing your premium as well as, and especially, to be able to continue to offer you an insurance plan that provides you with quality protection. In closing, small gestures can ensure the viability of the insurance plan we offer you and your informed choices will allow you and the other persons insured by your plan to save money. If you are not yet insured by Sogemec, we invite you to get in touch with our team of advisors without delay in order to benefit from your Federation's plan. You can reach us by dialing or by at information@sogemec.qc.ca. Reference 1. Based on figures available in

45 JE SUIS MÉDECIN SPÉCIALISTE et pour mes assurances entreprise, Sogemec Assurances est le choix qui s impose SOGEMEC et la FMSQ ont négocié pour vous un régime d assurance entreprise* qui sait répondre à vos besoins. Pour vos autres besoins en assurance, découvrez la gamme complète de protections offertes par Sogemec Auto Habitation Vie Invalidité Frais généraux Maladies graves Soins de longue durée Médicaments Maladie Dentaire Nous sommes votre référence. Faisons connaissance sogemec.qc.ca * Le régime d assurance auto, habitation et entreprise de Sogemec est souscrit par La Personnelle, assurances générales inc.

46 L éditorial de la présidente D re Diane Francœur L APRÈS 130 : ATTENTION AU BOOMERANG! Cauchemar annoncé par nous, mais évidemment nié par le ministre. Qu en est-il? Qui dit vrai? À mon avis, il s agit de la pointe de l iceberg qui, au lieu de fondre, ne cesse de se découvrir davantage. 46 Certains d entre vous croient à tort que nous faisons du «millage politique» en dénonçant cette menace. Je vous répondrai que l ennemi est parmi nous! En minimisant les effets de la Loi parce qu elle n est pas encore appliquée, nous la laissons s infiltrer et s insinuer tranquillement dans notre pratique. Et quand le moment viendra, ça va frapper fort! Pour de malheureuses victimes de la «Loi 130», ce sera la fin d une carrière. Pensons notamment aux médecins qui, après des décennies de très loyaux services dans notre système public de santé, se feront montrer la porte puisqu ils ne respecteront pas les normes de l «équivalent temps plein» défini unilatéralement par le sous-ministre adjoint, Michel Bureau. Dans un hôpital près de chez vous Comme dans toutes les professions et tous les métiers, il est vrai qu au sein de notre Fédération, il y a des médecins perturbateurs. Ils sont en minorité et nous ne défendons pas l indéfendable. Or, pour les mettre au pas, les DSP, les chefs de département et les chefs de service ne trouveront pas dans la «Loi 130» de solution magique et rapide. Il leur faudra monter des dossiers, rassembler des preuves, rencontrer le médecin, documenter un plan d action avant de confirmer l échec. Comme cela se fait depuis toujours Ce n est pas une loi dont ils ont besoin, mais bien de soutien et de formation. Cela dit, le renouvellement de notre Entente, échue depuis le 31 mars 2015, n est toujours pas signé parce que le ministre refuse de négocier nos conditions de pratique. Pendant ce temps, les chefs de service et de département ne sont ni payés ni formés puisque ces modalités font justement partie des clauses à renouveler. Les chefs ont besoin de savoir comment s y prendre avec certains collègues difficiles qui sont, d une certaine façon, le résultat d une absence d application des règles déjà en vigueur. Le régime de la terreur et la violence verticale C est connu, Gaétan Barrette terrorise (le mot est juste!) ses PDG qui, eux, terrorisent à leur tour les gestionnaires et le personnel. Le sous-ministre adjoint Bureau terrorise les DSP et les encourage à faire de même avec les médecins. Ce climat de terreur, de menace, de manipulation n a qu un seul but : affaiblir les droits du médecin spécialiste et l obliger à se plier à des décisions inappropriées. Et que dire de l omerta intramuros! Chaque jour, des médecins nous rapportent des situations inacceptables qu ils vivent dans leurs établissements. Ces cas devraient être dénoncés publiquement, car la population et les patients devraient en être informés. Or, ils n osent prendre la parole publiquement de peur des représailles. Certains l ont fait et ont eu droit à de sévères remontrances. Nous sommes en 2017, bientôt en La dictature n a pas sa place, ni dans le réseau de la Santé ni ailleurs. Pire, l autocratie mine le moral des troupes. À preuve, le Programme d aide aux médecins (PAMQ) a noté une augmentation de 38 % de nouveaux cas l an dernier. Des collègues qui n en peuvent plus, sans compter ceux qui ont choisi d en finir définitivement. Ce n est quand même pas de la fabulation. Vos patients d abord et avant tout! Plus que jamais, je vous demande de vous battre pour préserver votre autonomie professionnelle au nom de vos patients. C est à eux que vous devez votre loyauté. Comme médecins spécialistes vous ne pouvez reculer devant ce qui doit être combattu en leur nom; vous n êtes pas des employés des DSP ou des PDG. N acceptez pas l inacceptable. Ne faites pas subir à vos patients ce que vous ne voudriez pas que l on vous fasse subir à cause de l imposition d éventuels contrats Vous lisez mon dernier éditorial de l année Une année qui se termine avec une négociation ouverte ou par un blocage bien involontaire de notre part. Toute l année, nous avons travaillé fort, notamment pour renouveler notre Entente de façon réaliste et responsable. Nous ne pouvons céder, car la négociation de nos conditions de pratique fait partie de nos valeurs intrinsèques. Et comme vous nous l avez indiqué lors de notre sondage du printemps dernier, les conditions de pratique vous inquiètent davantage que l aspect financier. Je tiens à remercier très chaleureusement nos directrices et directeurs, notre personnel, les membres de notre conseil d administration, les présidents de nos associations médicales. Sans elles, sans eux, pas de Fédération. Ensemble, nous pouvons beaucoup! En attendant 2018, recevez, toutes et tous, mes meilleurs vœux du temps des fêtes. Reposez-vous. Une autre année difficile nous attend, mais gardons le moral et trouvons notre bonheur professionnel dans nos soins aux patients! LS

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