PRACTICE IN INSTITUTIONS
INTRODUCTION
Under review
Medical practice in institutions represents a considerable portion of the clinical activities of physicians in Québec. Many factors explain this situation: the complexity of health problems; the sophisticated technologies used in modern medicine; the necessary input of other health and social services professionals; the need to bring these professionals and resources together into functioning entities; and the need to hospitalize and provide accommodation for a great many patients so as to ensure the continuity and quality of their care.
One can expect that, in future, an even greater number of physicians will practice in a variety of health care facilities. Under a new provision of the Act respecting health services and social services (LSSSS), all family physicians must commit themselves to devoting part of their practice to special medical activities (AMP), notably in the emergency room or with patients admitted to a hospital centre or to a residential and long-term care centre (LSSSS, ss. 360 and 361). Physicians who do not make this commitment could see a reduction in pay imposed upon them. The Act respecting health services and social services has an equivalent provision for all medical specialists who do not have privileges in an institution operating a hospital centre and whose specialty is stipulated in an agreement concluded to this effect (sec. 361.1). The terms and conditions of a physician’s participation in special medical activities (AMP) are specified by agreement with the Federation of General Practitioners of Québec (FMOQ) or the Federation of Medical Specialists of Quebec (FMSQ), whichever is applicable.
Almost all health care institutions in Québec are public. Professional medical practice in these institutions is governed by several pieces of legislation, notably:
An Act respecting health services and social services (LSSSS) and the ensuing Organization and Management of Establishments Regulation (ROAE);
The Professional Code and the various regulations ensuing from it, among them The Code of Ethics of Physicians;
The Medical Act;
The Health Insurance Act and the agreements concluded with the medical federations pursuant to this law.
In their relations with health institutions, physicians enjoy a special position because of their status as independent workers. They  are neither members of the personnel of these institutions (LSSSS, sec. 236); nor executives, nor employees. Physicians are not subject to the provisions of the Labour Code or the Labour Standards Act, which apply to other health workers (Health Insurance Act, sec.19).  Medical residents are considered employees of the institution and are subject to the above laws. But they still maintain their professional independence as medical doctors and are thus subject to the Code of Ethics of Physicians of Québec.
Physicians are independent professionals, and the agreements concluded between the ministère de la Santé et des Services sociaux (MSSS) and the Quebec Federation of General Practitioners, and the Quebec Federation of Medical Specialists reaffirm this independence, notably by ensuring the freedom to provide therapy and freedom to choose their place of practice, as well as respecting the personal and private nature of the physician-patient relationship, an important aspect of which is professional secrecy. The freedom to provide therapy means that physicians have the right to decide on the medical care required, to prescribe the appropriate treatments and their mode of administration (Agreement on health and hospital insurance between the MSSS and the FMOQ, Art. 7.04). Institutions must respect this professional independence, within the framework of their mission and their resources (Agreement on health and hospital insurance between the MSSS and the FMOQ, Art 8.01).
While the special status enjoyed by physicians has its guarantees, it also has its obligations. Physicians must respect the rules  in effect in the institution, provide the professional services attached to their functions and assume on-call duties in their department or service. In choosing to practice in an institution, physicians also agree to be part of a health care team with constant concern for the quality of care given to their patients. When physicians practice in institutions, they, of necessity, have close relations with the health care network. Hence, the importance of knowing its structures, the internal organization of its institutions and the elements creating an even more specific framework for medical practice.
PRACTICE IN INSTITUTIONS
THE INSTITUTIONS
Under review
Since 1991, the Act respecting health services and social services (LSSSS) has distinguished between an institution and a centre. An institution refers to the legal entity engaging in the activities inherent in the mission of one or many centres. “The function of institutions is to ensure the provision of continuous and accessible quality health and social services which respect the rights and spiritual needs of individuals and which aim at reducing or solving health and welfare problems and responding to the needs of the various population groups. To that end, institutions must manage their human, material and financial resources effectively and efficiently and cooperate with other key players.” (LSSSS, sec. 100).
To summarize, the institution assumes the functions of planning, management and provision of services within the scope of one or several missions defined in an operating permit issued by the MSSS.
The notion of centre refers to the mission of an institution and not to a physical place-- for which the term, facility, is used. The Act respecting health services and social services establishes five types or categories of centers, whose names are rather explicit in terms of the services offered or the populations served:
the local community service centre (CLSC);
the hospital centre (CH);
the child and youth protection centre (CPEJ);
the residential and long-term care centre (CHSLD);
the rehabilitation centre (CR).
Each type of centre has a specific mission, which defines and limits the kind of services offered there (LSSSS, ss. 79-93. See also Section on General Organization).
A new type of institution was created in 2005: the health and social services centre (LSSSS, s. 99.4). As an institution, the CSSS must offer a certain range of services. But its main responsibility is to ensure that all of the needs of a population are covered. The CSSS is responsible for bringing together the resources in the territory, coordinating their activities, and establishing partnerships essential to the operation of each services network.
Physicians’ private offices are not institutions within the meaning of the Act (LSSSS, sec. 95). They are, however, one of the partners with which the CSSS can conclude agreements to better meet the needs of the population.
A new legal framework has in fact been created so that resources outside of institutions can be called upon in order to increase access to certain services without compromising the quality of these services (See Section 3.2.5 on the subject of specialized medical centers and associated medical clinics).
PRACTICE IN INSTITUTIONS
THE INTERNAL ORGANIZATION OF INSTITUTIONS
Under review
Every institution must establish its own organization plan, but all institutions have a similar organizational structure, which  includes a board of directors, an executive director, management personnel (which includes a director of professional services), a council of physicians, dentists and pharmacists, a council of nurses, a multidisciplinary council, a users’ committee, and a council of midwives, if need be. Each of these bodies performs its functions in all centers operated by the institution.
The following organization chart shows more specifically the organizational structure of a CSSS. In a hospital centre, each department may comprise several services headed by a department head.
The Board of Directors
Until recently, a board of directors was formed to administer the affairs of a particular centre or institution. But to improve the continuity of care and integration of services, legislative amendments were made whereby one board of directors could administer several centers, even several institutions, within a given territory (LSSSS, sec. 119-128).
The composition of this one board of directors may vary, depending on whether the institutions concerned provide rehabilitation or residential services, community health services, or operate a hospital centre. Essentially, it is composed of:
representatives elected by the population;
one or two representatives of the users’ committee; 
a representative of physicians, dentists and pharmacists;
a representative of the nursing staff;
a representative of the multidisciplinary council;
one or two representatives of the remaining personnel members;
persons representing foundations and landlords of premises, if applicable, or faculties of medicine, if applicable;
persons designated by the agency to represent the other institutions in the region and appointed by the Minister to represent the other regions served, if applicable;
persons designated by the above-mentioned, one of whom  will represent the community organizations in the territory;
the executive director of the institution (LSSSS, sec. 129-133). 
A specific board of directors must, however, be formed to administer an institution which operates a university hospital centre, a university institute or an affiliated university centre (LSSSS, sec. 126).
The board of directors manages the affairs of all the institutions it administers and exercises all powers within these, as designated in the list of principal powers of the board (LSSSS, ss. 170–181).
The principal powers of the board of directors of an institution
The principal powers of the board of directors of an institution are as follows:
Manages the affairs of every institution it administers.
Establishes the priorities and orientations of the institution.
Ensures that these priorities and orientations are respected and are in compliance with the staffing plans approved by the agency.
Ensures the pertinence, quality and effectiveness of the services provided.
Ensures respect for users’ rights and promptness in processing their complaints.
Ensures economical and efficient use of human, material and financial resources.
Ensures the participation, motivation,  enrichment, maintenance of professional standards and development of human resources.
Appoints the executive director and senior management officers.
Appoints physicians and dentists, assigns a status and grants privileges to them and determines the obligations attached to such privileges.
Allocates financial resources to each of the institutions it administers.
Concludes service contracts.
Appoints the local service quality and complaints commissioner and creates a watchdog committee responsible for ensuring follow-up on complaints and recommendations. 
The Executive Director
The executive director of a public institution, under the authority of the board of directors, is responsible for the administration and operation of all institutions which the board administers (LSSSS, sec. 194). In addition to his or her other functions, he or she must “see that the clinical activity taking place in the centre is coordinated and supervised.” (LSSSS, sec. 195).
Organization Plan
“Every institution must prepare an administrative and scientific organization plan. This plan describes the administrative structures of the institution, its divisions, services and departments as well as its clinical programs.” (LSSSS, sec. 183).
As for medical activities, the organization plan of the institution must:
indicate, on the recommendation of the council of physicians, dentists and pharmacists or the medical service, which department or service is responsible for the medical acts of a clinical program (LSSSS, sec. 183);
provide for a risk management committee charged with identifying, analyzing and preventing the risk of care-related incidents or accidents (including nosocomial infections) as well as providing support to victims and their close relatives (LSSSS, sec. 183.1-183.4);
provide for the creation of clinical departments and services in hospital centres (LSSSS, sec. 184), among them, a clinical department of general medicine which must be under the responsibility of a family physician (LSSSS, sec.185);
provide for, in CLSCs, CRs and CHSLDs, the creation of a medical service, or the appointment of a physician in charge of medical care, if at least one physician practices in the centre (LSSSS, sec. 186);
must specify the family physician staffing plan; another part must specify the specialist staffing plan. Each of these parts must indicate respectively the number of family physicians and specialists, by specialty, who may practice their profession in each department or service. Once approved by the ASSS, these parts of the organization plan will constitute the medical staffing plan of the institution (LSSSS, ss. 184  and 186). The CPDP, including the university concerned, if applicable, must be consulted on the part of the organization plan pertaining to the creation of clinical departments and services, and the part pertaining to medical staffing plans; 
provide for a central mechanism to manage access to specialized and superspecialized services in the institution’s clinical departments (LSSSS, sec. 185.1)
The organization plan must be reviewed every three years.
The Director of Professional Services
In institutions operating a hospital centre or a health centre, the board of directors must appoint a director of professional services (DPS) after consultation with the CPDP. The DPS, who must be a physician, holds a management position in the institution and is paid by the institution. A DPS may be  appointed by any other institution (LSSSS, sec. 202). Under the authority of the executive director, the DPS is mandated to coordinate, “with the other directors concerned, the professional and scientific activity of any centre operated by the institution.” (LSSSS, sec. 203). In performing his duties (see box), he supervises the activities of clinical department heads and acts as interface between the administration and the medical organization of the institution.
Functions of the DPS
(LSSSS, sec. 204) 
Directs, coordinates and supervises the activities of the department heads.
Obtains the opinion of the clinical department heads on the administrative and financial consequences of the activities of the physicians and dentists in the various clinical departments.
Applies the administrative sanctions provided for in cases of non-compliance with rules for the use of resources, and informs the CPDP and clinical department heads of such.
Supervises the operation of the committees of the CPDP and ensures that the council monitors and assesses adequately the medical, dental and pharmaceutical acts performed in all centres operated by the institution.
Takes all necessary steps to ensure that any examination, autopsy or expertise required under the Act respecting the determination of the causes and circumstances of death is carried out.
Carries out any other function provided for in the organization plan of the institution.
Transmits the necessary information concerning organ and tissue donors, if need be. 
The Institution’s Resources: Striving for Efficiency
Every institution has a certain quantity of human and material resources to help it accomplish the missions of the centres it operates. The MSSS, through the ASSS, allocates its overall budget for this purpose. The extent of an institution’s resources and the budget at its disposal have an effect on the kind of medical services physicians can provide there. For example, a CLSC has no operating room, and CHs do not, as a rule, provide home care. Capital and operating budgets, which determine the total expenses authorized, restrict the sphere of activity of institutions.
Given the government’s limited financial capacity and out of a concern for equity in resources allocation, the government authorities and administrators of the health and social services network must reconcile the  search for efficiency in the use of its resources with the quality of services,  accessibility being one  aspect. As medical activities have a direct effect on the effectiveness and quality of services offered in a health institution, physicians are being asked by the board of directors where they practice, through the CPDP and the DPS, to take part in improving the system’s efficiency. 
PRACTICE IN INSTITUTIONS
MEDICAL-ADMINISTRATIVE ORGANIZATION
Under review
The medical-administrative organization of an institution comprises the council of physicians, dentists and pharmacists (CPDP), its committees, and the clinical departments and services. Thus, it includes all physicians, dentists and pharmacists practicing in an institution. The lines of authority are established by the Act respecting health services and social services and its applicable regulations, which impose obligations on physicians and on the medical-administrative organization, as well as on the institution’s administration.
The Council of Physicians, Dentists and Pharmacists
Every institution operating one or more centers where at least five physicians, dentists or pharmacists practice must form a CPDP (LSSSS, sec. 213).
The CPDP includes all physicians, dentists and pharmacists practicing in all centres operated by an institution. Its  essential function is to ensure the quality of services provided by its members and, in this capacity, it is directly responsible to the board of directors. The CPDP also has responsibilities with respect to medical activities (see box).
THE RESPONSIBILITIES OF THE CPDP
(LSSSS, sec. 214) 
Control and assess the quality and pertinence of the medical, dental and pharmaceutical acts performed in the centre.
Assess and maintain the professional standards of the physicians, dentists and pharmacists practicing in the centre.
Make recommendations on the qualifications and competence of a physician or dentist who applies for appointment or the renewal of an appointment and on the privileges and status to be granted to him or her.
Make recommendations on the qualifications and competence of a pharmacist who applies for appointment and on the status to be granted to him or her.
Give its opinion on the disciplinary measures the board of directors should impose on physicians, dentists or pharmacists.
Make recommendations on the rules governing medical and dental care and on the rules governing the use of medicines applicable in the centre and formulated by each clinical department head.
Make recommendations on the obligations which may be attached to the enjoyment of the privileges granted to a physician or a dentist by the board of directors, in relation to the specific requirements of the centre, particularly those concerning:
a) the participation of a physician or dentist in the clinical activities of the centre, including on-call duty;
b) the participation of a physician or dentist in teaching and research activities, where the case arises;
c) the participation of a physician or dentist in professional, scientific, medical or administrative committees;
d) the participation of a physician or dentist in medical activities pursuant to an agreement referred to in sections 108 and 109.
Develop the terms and conditions of a duty roster system ensuring, on a permanent basis, the availability of physicians, dentists and, where the case arises, pharmacists and clinical biochemists, according to the needs of the centre.
Give its opinion on the professional aspects of the following questions:
a) the technical and scientific organization of the centre;
b) the rules governing the utilization of the resources and the administrative sanctions to be included therein.
Make recommendations on the professional aspects of the appropriate distribution of medical and dental care and pharmaceutical services, and on the medical organization of the centre;
Carry out any other function entrusted to it by the board of directors. 
The CPDP must perform its functions in accordance with its mission and the institution’s resources. “In exercising its functions, the council of physicians, dentists and pharmacists shall take into account the necessity of providing adequate and efficient services to users and the organization and available resources of the institution.” (LSSSS, sec. 214). It must submit an annual report of its activities to the board of directors.
In addition to its responsibilities to the board of directors with respect to the quality of services provided and the competence of  its members, the CPDP must assist the executive director of the institution by giving its opinion on the administrative aspects of various questions (see box) concerning the organization and provision of care.
MATTERS ON WHICH THE CPDP ADVISES THE EXECUTIVE DIRECTOR 
(LSSSS, sec. 215) 
The measures to be taken to ensure that the medical, dental and pharmaceutical services provided in the centre are complementary to those provided in a centre operated by another institution of the region and respond to the needs of the population to be served, taking into account the resources available and the necessity of providing adequate services.
The rules governing the utilization of resources and the administrative sanctions to be included therein.
The technical and scientific organization of the centre.
The appropriate distribution of medical and dental care and pharmaceutical services, and the medical organization of the centre.
Any other questions brought to its attention by the executive director.
“The council of physicians, dentists and pharmacists may adopt by-laws concerning its internal management, the creation and operation of committees and the pursuit of its objects. The by-laws come into force after having been approved by the board of directors.” (LSSSS, sec. 216).
In hospital centers the CPDP must create, in addition to an executive committee, a committee on professional qualifications, a committee on medical, dental and pharmaceutical evaluation, a committee of pharmacology, and a disciplinary committee when necessary (ROAE, ss. 97 and 106; LSSSS, ss. 46 and 48. Committees of this kind, which are not obligatory in other institution categories, make for a better distribution of CPDP tasks.
The executive committee exercises all the powers of the CPDP and reports on its activities at least once a year at the general meeting of the council’s members. Its responsibilities encompass all medical activities performed in the institution as well as the activities specific to the CPDP (ROAE,  sec. 98). It is composed of at least five physicians, dentists and pharmacists designated by the CPDP, the executive director and the DPS of the institution or, when  no DPS has been appointed, a physician designated by the executive director (LSSSS, sec. 217).
The qualifications committee is responsible for studying the applications for the appointment of physicians, dentists and  pharmacists and recommending to the executive committee the granting of status and practice privileges, as well as renewing them or not every two years. It is responsible for opening and keeping a professional file on each member of the CPDP (ROAE, sec. 100).
The  committee on medical, dental and pharmaceutical evaluation assesses the quality of care and makes recommendations to the executive committee in this regard. More specifically, it ensures that the content of patients’ records complies with the various regulations; it makes judgments  on the quality and appropriateness of the medical, dental and pharmaceutical care given to users; it studies preoperative and postoperative diagnoses, as well as surgical procedure cases where there was no excision; it examines the records of patients who presented with complications and cases of death that have occurred in the  hospital centre. It reviews periodically the treatment prescribed for nosocomial infections and for the centre’s most common ailments (ROAE, sec. 103).
The pharmacology committee sees to it that medications are properly used in the institution and makes recommendations to the executive committee in this regard. It ensures that control mechanisms are put in place, among them, the retrospective study of records, notably records of patients having presented with adverse reactions or allergies. It advises the department head on the selection of medications to be prescribed in the institution and on the rules concerning their use. It assesses requests to use medications for research purposes  or for situations of particular medical necessity (ROAE, sec. 105).
The disciplinary committee is an  ad hoc committee formed by the executive committee to examine a complaint made against a physician, dentist or pharmacist concerning the quality of services provided, his or her competence, diligence, conduct or compliance with the rules or by-laws of the institution or the CPDP. As required, this committee follows the accepted procedure for the study of complaints concerning physicians, dentists and pharmacists. Essentially, the disciplinary committee hears the professional concerned, as well as his or her counsel, if there is one. After examining the complaint, the disciplinary committee  presents its report to the executive committee, which then takes the appropriate measures. When it recommends that a disciplinary measure be applied, the executive committee forwards the file to the board of directors (ROAE, ss. 106-109).
Given the nature of the activities of the  various committees of the CPDP, the files and minutes of the meetings of the CPDP and each of its committees are confidential. Thus, nobody may read them except those duly authorized to do so (LSSSS, sec. 218).
Clinical Departments
The organization plan of an institution, in addition to outlining the clinical departments, services and programs, must provide for their formation (LSSSS, sec. 183-184).
In a hospital centre, physicians are grouped together in various departments according to their specialty or type of work, and each department may include several services, each with a specific area of activity. Thus, the department of general medicine may include an emergency service, an extended care service, a family medicine service and a geriatric service. The department of surgery may include a general surgery service, an orthopedic service and a urology service. A physician is usually attached to one department only, but he or she may practice in several services in the same or different department. All hospital centers,  except for those designated by regulation, must have a clinical department of general medicine under the responsibility of a general practitioner (LSSSS, sec. 185).
A clinical program generally encompasses a group of multidisciplinary activities geared to a defined clientele or specific health problem, such as a palliative care program, a pulmonary disease program or a home care program. It should be noted that many health facilities have now adopted a program-based mode of management, meaning that all of their clinical activities are grouped according to subject matter. Finally, the organization plan must indicate which department or service is responsible for the medical, dental and pharmaceutical acts performed in the context of a program (LSSSS, sec. 183).
In CLSCs, CHSLDs and CRs, the plan must provide for the creation of a medical service or the appointment of a physician in  charge of medical care, if at least one physician practices in the centre (LSSSS, sec. 186). This service is equivalent in a sense to the department of general medicine in a hospital centre, and the physician’s duties are the same as those of a department head (ROAE, ss. 78.1-81).
All medical activities carried out in institutions are therefore supervised either by the departments and services in a hospital centre or by medical services in other types of centers. Hence the importance attributed to the role of department head.
Clinical Department Head
The head of a clinical department of medicine must be a physician. He or she is appointed by the board of directors after consultation with the physicians practicing in the department, with the DPS and the CPDP (LSSSS, sec. 188). The clinical department head, under  the authority of the DPS (LSSSS, sec. 189), directs the activities of all physicians in the department. Furthermore, he or she is accountable to the CPDP, for supervising the manner in which medicine is practiced in his or her department and for establishing the rules for medical care (sec. 190). In CLSCs and CHSLDs where there is no DPS, the head of the medical service reports to the executive director. According to the responsibilities he or she assumes, the clinical department head is accountable to the DPS or the CPDP (see box). The legislator has also entrusted the department head with the task of supervising, in collaboration with the director of nursing services, the  medical activities of nurses and other professionals in his or her department who are competent to perform these by regulation of the Collège des médecins du Québec (sec. 190-1.1).
RESPONSIBILITIES OF THE CLINICAL DEPARTMENT HEAD, DEPENDING ON THE AUTHORITY UNDER WHICH HE ACTS:
Under the authority of the DPS (LSSSS, sec. 189): 
Coordinates, subject to the responsibilities discharged by  the CPDP, the professional activities of physicians in his or her department.
Manages medical resources.
Draws up, for his or her department, rules governing the use of medical resources and material resources used by physicians, and ensures that the central access management mechanism operates as it should.
In the case of the clinical head of the radiology department, the clinical head of the medical biology laboratories department,  and the clinical head of the pharmacy department, manages the resources of his or her department.
Draws up a duty roster.
Ensures an appropriate distribution of medical services in his or her department.
Ensures compliance with the rules governing the use of resources.  
Under the authority of the CPDP (LSSSS, sec. 190):
Supervises the manner in which medicine is practiced in the department.
Supervises, subject to the responsibilities discharged by the director of nursing services, the medical activities performed  by nurses and other professionals in the department who are competent to perform them.
Draws up, for his or her department, rules governing medical care and rules governing the use of medication, taking into account the necessity of providing adequate services to users and the organization and available resources of the institution.
Gives his or her opinion on the privileges and status to be granted to a physician upon an application for appointment or renewal of appointment and on the obligations attached to the enjoyment of such privileges. 
The head of a service generally performs the duties of his or her department head vis-à-vis the physicians in the service; nonetheless, he or she still answers directly to the department head for all duties performed as head of the service.
In all matters, a physician practicing in an institution is first accountable to the head of the service and to the head of the department. 
PRACTICE IN INSTITUTIONS
CONDITIONS OF PRACTICE IN AN INSTITUTION
Under review
To practice in an institution, a physician must meet the following conditions:
be appointed by a resolution of the board  of directors of the institution (LSSSS, ss. 237-243 and 251);
produce a document in which he or she acknowledges having read the resolution (LSSSS, sec. 243);
hold a valid professional liability insurance policy (LSSSS, sec. 258);
fulfill the obligations attached to his or her appointment (LSSSS, sec. 242);
observe the by-laws of the institution and the CPDP (LSSSS, ss. 242 and 249).
Appointment
The conditions for the appointment of a physician to an institution are set out in the LSSSS (ss. 237-248). The steps leading to the appointment are the same in all institution categories (see box below).
STEPS LEADING TO A PHYSICIAN’S APPOINTMENT TO PRACTICE IN AN INSTITUTION 
(LSSSS, ss. 237-248)
The physician makes an application for appointment to the executive director of the institution.
The executive director informs the candidate, in writing, of the state of the medical staffing plan of the institution.
The qualifications committee of the CPDP studies the application for appointment.
The CPDP makes a recommendation to the board of directors.
The board of directors checks with the Agency to ensure that the appointment complies with the regional medical staffing plan (PREM).
The board of directors approves or refuses the application for appointment. It then communicates its decision in writing to the physician, giving its reasons.
The physician whose appointment has been approved attests in writing to having read the content of the resolution. 
When approving the appointment of a physician, the board of directors must set out the status and privileges of this physician, the period for which they are granted, and the nature and scope of the medical activities he  or she may engage in at the centre. In addition, the resolution of the board of directors must ensure that the physician makes a commitment to fulfill the obligations attached to the enjoyment of his or her privileges, which are determined following the recommendations of the CPDP (LSSSS, sec. 242).
All appointments must comply with the medical and dental staffing plan defined in the institution’s organization plan. The board of directors must, before accepting a physician’s application for appointment, receive the approval of the agency. The latter ensures that the medical staffing plan of the institution justifies the appointment. An appointment granted when the complement  of the medical staffing plan has already been reached may be withdrawn (LSSSS, ss. 239, 240, 240.1 and 240.2).
The board of directors must transmit its decision in writing to the candidate within 90 days of the executive director’s receipt of the application. The reasons for any refusal must be given in writing. A physician who is not satisfied with a decision rendered in his or her regard on the basis of criteria of qualification, scientific competence or conduct, may contest the decision before the Administrative Tribunal of Québec (LSSSS, sec. 252).
The physician’s status determines his or her membership and level of participation in the CPDP (active member, associate member, advisory member, honorary member). A physician, dentist or pharmacist is granted a status based on the extent of the activities he or she performs for the institution (ROAE, ss. 87-96).
Privileges are granted to a physician or dentist  in terms of the hospital centre’s organization and manpower plan. Privileges determine the nature and scope of
medical acts that a physician may perform in a department (ROAE, s. 86).
The obligations attached to the enjoyment of privileges concern the physician’s participation in activities related to the centre’s requirements, notably (LSSSS, sec. 214):
participation in clinical activities, including on-call duties;
participation in teaching and research activities, as necessary;
participation in professional, scientific, medical or administrative committees;
participation in medical activities pursuant to an agreement between institutions (LSSSS, ss. 108-109). In this case, the agreement must be made known to the physician and be valid at the time of his or her application for appointment or renewal of appointment.
The privileges granted to a physician are usually for a period of two to three years. Except on notice to the contrary, the application for renewal of the appointment is made automatically and on the same terms as the last application (LSSSS, sec. 237). An application for renewal “may be refused by the board of directors only on the basis of criteria of qualifications, scientific competence or the conduct of the physician […], having regard to the specific requirements  of the institution and fulfilment of the obligations attached to the enjoyment of privileges” (LSSSS, sec. 238).
Regulations and By-laws
The regulations and by-laws a physician must observe in an institution are notably as follows:
The regulations of the Act respecting health services and social services;
The regulations of the Professional Code, among them, the Code of Ethics of Physicians;
The Regulation respecting the standards relating to prescriptions made by a physician;
The rules of the institution;
The regulations of the CPDP.
The CPDP regulations govern the functioning of the council itself and member participation in its activities. The rules of an institution are adopted by the board of directors. These generally concern the administrative aspects of everyday activities in the institution and medical practice. This applies to rules governing the use of the institution’s resources, which are drawn up by the department head and approved by the board of directors, after consultation with the CPDP (LSSSS, sec 189).  
Among these rules, two of them are also fundamental to medical practice in an institution.
Rules governing the use of medical resources and material resources in a centre. These are established by each department head, under the authority of the DPS. Before coming into effect, these rules must be approved by the board of directors, acting on prior advice received from the CPDP on the subject. They must also provide for administrative  sanctions in cases of non-compliance (LSSSS, ss. 189, 191-192, 214 and 215).
Rules governing medical care and the use of medicines. These rules must take into account the necessity of providing adequate services to users, as well as the organization and available resources of the institution.
These are usually drawn up by the clinical department head, under the authority of the CPDP (LSSSS, sec. 190). The pharmacy department head or the pharmacist may also, under the authority of the CPDP, draw up rules for the use of medications (ROAE, sec. 77). When these rules concern nurses authorized to engage in the medical activities referred to in section 36.1 of the Nurses Act, the director of nursing care must cooperate in determining these (LSSSS, sec. 207), and the council of nurses (CN) must make recommendations concerning such rules (LSSSS, sec. 192).
These rules come into effect after having been approved by the board of directors, on the recommendation of the CPDP (LSSSS, ss. 189, 192, 214). The LSSSS also stipulates that physicians practicing in the various departments must be subject to the same set of rules. Thus, in identical clinical situations, two departments may not adopt two different rules. It is up to the CPDP to recommend a single set of rules (LSSSS, sec. 190). Note that certain of these rules may concern specialized nurse practitioners.
The rules of an institution are adopted by  the board of directors. These generally concern the administrative aspects of everyday activities in the institution and medical practice. This applies to rules governing the use of the institution’s resources, which are drawn up by the department head and approved by the board of directors, after consultation with the CPDP (LSSSS, sec. 189).
Non-compliance with Rules
A physician who does not comply with certain rules and regulations is liable to disciplinary measures or administrative sanctions (ss. 189, 205 and 249). “The board of directors may take disciplinary measures with respect to a physician or dentist. The disciplinary measures that may be taken include a reprimand, a change in status, the withdrawal of privileges, the suspension of status or privileges for a specific period and the cancellation of status or privileges. They may also include a recommendation that the physician or dentist serve a period of refresher training, take a refresher course or both, and may, if necessary, restrict or  suspend some or all of the physician’s or dentist’s privileges for the duration of the refresher period. Every disciplinary measure taken against a physician or a dentist must give reasons and be based solely on lack of qualifications, scientific incompetence, negligence, misconduct, non-compliance with the by-laws of the institution, having regard to the  specific requirements of the institution, or non-compliance with the  [conditions of his or her appointment]. The disciplinary measures must be imposed in accordance with the procedure prescribed by regulation […]. The executive director must send a copy of the decision to the professional order concerned” (LSSSS, sec. 249).
When the board of directors decides to apply a disciplinary measure against a physician, it must communicate its decision to the latter, to the executive committee of the CPDP and to the Collège des médecins. It must also have given the physician in question the opportunity to be heard beforehand (ROAE, sec. 109). The physician concerned by the disciplinary measure may contest the decision before the Administrative Tribunal of Québec (LSSSS, sec. 252).
The administrative sanctions provided for in cases of non-compliance with the rules governing the use of resources “may have the effect of limiting or suspending the right of a physician to use the resources of the institution” (LSSSS,  sec. 189). However, they cannot be considered as affecting the privileges granted to the physician by the board of directors. When an administrative sanction must be applied, the DPS informs the physician concerned of the reasons justifying the decision and ensures that it is applied. The physician concerned by such a decision may contest the decision before the Administrative Tribunal of Québec (LSSSS, sec. 205).
Cessation of Practice in Institutions
A physician’s cessation of practice must  not in any way compromise the quality of patient follow-up, since all physicians are bound by their code of ethics to ensure that the patients they examine, investigate or treat receive the medical follow-up required by their condition (Code of Ethics of Physicians,  ss. 32 and 35). Provisions for supervising the cessation of practice in an institution are also in place.
A physician may cease to practice in an institution by choice or if his or her appointment is not renewed. If a physician decides to cease practicing in a centre, he or she must give prior notice of at least 60 days to the board of directors. Once received by the board of directors, this notice is irrevocable (LSSSS, sec. 254). However, the board may authorize the departure of a physician before the 60 days have expired (LSSSS, sec. 255).
When a physician ceases to practice in a centre without the authorization of the board of directors or before the 60 days have expired, the institution may ask the Régie de l’assurance maladie du Québec (RAMQ) to issue an order cancelling the physician’s participation in the Health Insurance Plan. In other words, the physician would no longer be authorized, for a given period,  to bill for the insured services he had rendered. The non-participating period is fixed by the RAMQ and is equal to twice the number of days remaining in the 60-day period (LSSSS, sec. 257). Furthermore, the Collège des médecins is notified in writing if the board of directors judges that the departure affects the quality or accessibility of medical services.
In cases where the board of directors decides not to renew the appointment, the cessation is determined by the board. This decision must be based solely on criteria of qualification, scientific competence or conduct, as they pertain to the specific requirements of the institution, and fulfillment of the obligations attached to the enjoyment of the privileges granted (LSSSS, sec. 238). The physician may contest this decision before the Administrative Tribunal of Québec (LSSSS, sec. 252).
Remuneration
Like the LSSSS and its regulations, the agreements and their appendices with medical federations fix the conditions of medical practice relative to health insurance and hospitalization insurance. Thus, the agreements prescribe payment methods and payscales in institutions and elsewhere. They also determine certain conditions of practice in institutions for physicians paid a fixed honorarium or a salary and for physicians paid a per diem payment. Physicians and institutions are bound by these agreements.
The methods of remuneration are specified in the agreements. Fee-for-service, flat rate, mixed payment, hourly rate, fixed honorarium and salary are the main methods of payment of physicians. The conditions for applying each of these payment methods are also defined in the agreements, depending on the institution in which the physician practices, his or her appointment, and the medical activities performed. Except in a measure provided by government regulation, no individual agreement may be concluded between a physician and an institution concerning remuneration for the provision of insured services (LSSSS, sec. 259 and 505).
PRACTICE IN INSTITUTIONS
EXAMINING A COMPLAINT CONCERNING A PHYSICIAN
Under review
Every institution must establish a procedure for examining complaints filed by users (LSSSS, ss. 29-59). A special procedure applies for the examination of a complaint filed by a user against a physician or a medical resident (LSSSS, ss. 41-59).
After consultation with the CPDP, the board of directors must appoint a medical examiner, who may or may not practice in a centre operated by the institution, but who will be responsible for applying this procedure. Note that this physician may also examine a complaint filed by someone other than a user (LSSSS, sec. 44).
The medical examiner assigned with a complaint filed against a physician or a medical resident must choose the appropriate steps to be taken from among the following possibilities:
examine the complaint pursuant to the LSSSS (ss. 45-50);
forward it to the CPDP for “study for disciplinary reasons by a committee formed for this purpose”;
forward it to the authority determined by regulation, if it concerns a medical resident;
dismiss it if he judges it frivolous, vexatious or in bad faith.
In cases of examination of a complaint  concerning a physician, the latter must collaborate with the medical examiner and the members of the disciplinary committee, if there is one.
The medical examiner must “transmit his or her conclusions in writing to the user and the physician concerned, together with the appropriate recommendations, and inform the user of the conditions and procedures” at his or her disposal (LSSSS, sec. 47).
The user who does not agree with the conclusions sent to him by the medical examiner or said to have been sent to  him by the medical examiner may make a written or verbal request for a review of his complaint before the review committee (LSSSS, sec. 53). The review committee is composed of three members appointed by the board of directors of the local authority. The committee chairperson is chosen from among the elected or co-opted members of  the board of directors. The two other members are appointed from among the  physicians, dentists and pharmacists practicing in the same network, on the recommendation of the CPDP, the local authority or other institutions in the territory or, in the absence of such council, after consultation with the physicians, dentists and pharmacists concerned (LSSSS, sec. 51).
When the medical examiner sends a complaint to the CPDP to be examined for purposes of discipline, the latter must form a disciplinary committee. The disciplinary committee must then follow the stipulated procedure, which is to hear the professional concerned and report on its evaluation to the CPDP. Should it decide to recommend the application of a disciplinary measure, the executive committee of the CPDP must then send the file to the board of directors (ROAE, ss. 106-109).
If the user’s complaint concerns administrative or organizational problems that involve medical, dental or pharmaceutical services, it must be examined by the local service quality and complaints commissioner (LSSSS, sec. 45).
PRACTICE IN INSTITUTIONS
PHYSICIANS: ESSENTIAL CARE PROVIDERS IN INSTITUTIONS
Under review
This section presents the medical and administrative structures and the obligations inherent in medical practice in institutions, since physicians are essential care providers in most institutions of the health care network. They enjoy a special status there as independent professionals, but they must also meet many requirements, among them, those of working as part of a medical team and discharging the duties they have undertaken. 
PRACTICE OUTSIDE AN INSTITUTION
INTRODUCTION
Under review
Traditionally in Québec, we distinguish two ways of practicing medicine — practice inside an institution and private practice.  However, the dividing line between private office and public institution has become more and more permeable for a variety of reasons which are not pertinent for discussion here.
Family physicians do not only work from their office. They are being called upon to provide various forms of care and services in medical institutions to a greater and greater extent. In addition, increasingly specialized care is migrating outside of institutions and into treatment facilities that can no longer be simply qualified as doctors’ offices. New organizational models somewhere between institutions and private offices have been growing in number for several years, with their sole common characteristic being that the care is being dispensed outside of the institutional setting.
In this section, we will strive to present a global vision of medicine being practiced outside of institutions in Québec and to offer a clear interpretation of its evolution. In so doing, we will emphasize certain aspects that, regardless of the organizational model, we believe raise various issues with respect to the quality of physicians’ professional practice. 
In the face of these issues, current laws and regulations do not always offer the coherent answers we would hope for. As we will see in  the following pages, the requirements of the Code of Ethics of Physicians apply to all physicians regardless of their place of practice (see Duties and Obligations of Physicians). Moreover, new administrative rules were adopted in 2007 with respect to the types of associations possible for physicians, whether they practice within or outside of an institution. In addition, the rules pertaining to advertising were also revised in 2010. The new Regulation respecting records, places of practice and the cessation of practice by a physician, which was updated in 2012, now applies to all physicians, irrespective of whether they practice within an institution or outside an institution. In modifying certain provisions of the Act Respecting Health Services and Social Services (LSSSS) and the Act Respecting Health Insurance (LAM) in 2006 and 2009, the Québec government established a governing framework for two new bodies — specialized medical centres (CMS) and associated medical clinics (CMA). However, now that a number of interventions previously restricted to institutions can be carried out outside of these settings, several questions have emerged and remain unanswered. 
Among all the requirements imposed within an institution, which are still pertinent? For example, do we need to obtain written consent before embarking on any surgery, invasive procedure or research project? By calling for written consent when treatment is not medically required, the Civil Code only offers a partial response (see The Physician’s Obligations under Certain Laws). Practice outside an institution raises numerous new questions which the Collège is attempting to answer, be it in the Code of Ethics, in its regulations,in the guidelines, or in the practice guides  As you will see in this section, vigilance must always be the order of the day for physicians.
With respect to the more practical aspects of practice outside of institutions, we recommend consulting the documents published by medical federations (FMOQ and FMSQ) and medical associations (CMA, CFPC, RCPSC). The Québec Federation of General Practitioners (FMOQ) Web site offers several training modules designed for medical residents and focused on such subjects as the choice of a location to practice, possible modes of compensation, billing,  financial planning and insurance, specific medical activities (AMP) and required medical manpower plans (PREM). For more information about the new organizational models, it would be useful to consult the Ministère de la Santé et des Services sociaux (MSSS) and  Régie de l’assurance maladie du Québec (RAMQ) Web sites. However, given the extremely rapid pace with which this area is evolving, the best way to remain informed is often to follow the news.
PRACTICE OUTSIDE AN INSTITUTION
PRACTICE OUTSIDE AN INSTITUTION AND THE HEALTH CARE SYSTEM
Under review
We often draw a distinction between practice within and outside of an institution as if these two forms of medical practice were totally different. In actual fact, according to the terms of the Act Respecting Health Services and Social Services (LSSSS, Section 95), private doctors’ offices are not considered to be institutions. Nevertheless, the care offered therein constitutes an essential component of the health care system. Most of the medical services offered outside of an institutional setting are covered by the health insurance plan because they are medically required. They are often needed prior or subsequent to the provision of care in institutions that are part of the public network, which makes private offices, and other resources, indispensable partners of the health care system in Québec. Indeed, these resources are increasingly perceived as collaborators with which network institutions should be forging agreements in order to better meet the growing needs of the population.
Private Practice
Over the past few decades, the position of physicians who practice outside of institutions has changed considerably vis-à-vis the health care system. Compared to working in an institutional setting, private practice is always considered to offer more benefits both for patients and physicians, including theoretically greater accessibility, more direct doctor-patient contact and simplified administrative formalities. Doctors in private practice enjoy more professional freedom and manage all aspects of their practice, such as the booking of appointments, keeping of files, work schedule, personnel management, organization of office materials, not to mention assuring the quality of equipment and professional services.
However, we know that private practice also has its disadvantages. First of all, management costs can be relatively substantial. These costs vary depending on the particular discipline, type of activities and  place of practice. In order to partially compensate for the inherent costs of private practice, provision has been made for differential remuneration for interventions based on whether they are carried out in institutional or private settings. Within the  context of certain organizational models, such as family medicine groups (GMF) and network clinics, additional support is now offered for time-consuming administrative tasks and technical matters. In the case of private practice, this support is usually more limited, particularly for doctors practicing alone, which, in turn, reduces the range of services they can provide.
In general, basic services in family medicine include consultations with or without appointment, minor surgery, home visits and, occasionally, specimen collection. For specialties, the variety of services offered varies with the discipline. If the size of the office and its location in a polyclinic allow, laboratory imaging and specialized consultation services may be offered. The location of the practice and the proximity of a medical centre are factors that also have an influence on the types of care offered. It is important to note that an increasing number of clinics are complementing the skills of physicians with those of other health professionals, most notably in the areas of nutrition, psychology, social work and physiotherapy. Of course, physicians must not collaborate with any individuals practicing medicine illegally (Code of Ethics of Physicians, Section 62).
Networks of Primary Care Services
Since the introduction of health insurance, numerous efforts have been made to further integrate private doctors’ offices into the public network. The most significant initiative is unquestionably the creation of Centres locaux de services communautaires (CLSC). Over the past few years, a number of health and social service agencies have established integrated primary care service networks, with the principal objective being to increase accessibility in given territories. Private offices  that voluntarily join these networks must meet specific criteria with respect to the services offered and hours of availablity. In certain cases, they are part of an on-call system that operates 24 hours a day, 7 days a week and that is established within their territory to offer home care services to clients in collaboration with  Centres de santé et de services sociaux (CSSS). Since the fusion of health care institutions in 2005, CSSSs are obliged to assume responsibility for the public within the  territory of their local health networks (RLS). Furthermore, in order to meet all  of the publics’ needs,  they must establish agreements with medical clinics and GMFs.
For their part, regional departments of general medicine (DRMG) established within agencies are responsible for defining primary care service needs in their territory. They also advise agencies and the Ministry with respect to their respective regions’ medical manpower plans (PREM) and ensure that physicians participate in particular medical activities (AMP) they deem to be priorities in their regions. In various areas of Québec, there are CSSS and DRMG committees in place to see that private practice offices work increasingly as part of this network.
As we will see further on, other organizational models, such as specialized medical centres (CMS) and associated medical clinics (CMA), are striving to concretize the desired complementarity.
PRACTICE OUTSIDE AN INSTITUTION
PRACTICE OUTSIDE AN INSTITUTION AND THE HEALTH INSURANCE PLAN
Under review
For most of their interventions, the vast majority of physicians are remunerated by the Régie de l’assurance maladie du Québec (RAMQ). Although it is always possible for physicians who practice outside of institutions not to participate in the public health insurance plan or to opt out, such doctors are relatively rare in Québec.
Consequently, it is difficult to understand the current situation and its issues without being cognizant of the fundamental aspects of the provincial health insurance plan as it presently operates. In that regard, we  consulted the information presented on the Régie de l’assurance maladie Web site. RAMQ is the organization that administers the province’s public health and drug insurance plans. In so doing, it informs the population, determines the eligibility of individuals, compensates health professionals (doctors, pharmacists, dentists) and assures the secure circulation of information.
Persons Insured Under the Plan
Since November 1, 1970, all residents or visitors to Québec who meet the conditions stipulated in the law are covered by the provincial health insurance plan. To be eligible for insured health care services, individuals must present their valid health insurance card. If the card has expired, they must  pay for any services rendered and claim a reimbursement from the Régie. Generally, individuals originating from outside Canada, even if they are Canadian citizens, are eligible for Québec health insurance after a waiting period, of up to three months, subsequent to their registration. This waiting period is also known as the “délai de carence”.
However, certain health care services could be rendered without charge depending on an individual’s particular situation. These could include services for victims of conjugal or family violence or sexual assault, services related to pregnancy, childbirth or abortion, or care provided to people with health problems of an infectious nature that could have repercussions from a public health standpoint. Québec has also signed social security agreements with certain countries exempting citizens of these countries from the usual waiting period.
Natives of another province who settle in Québec are eligible for coverage under the provincial health insurance plan as soon as they are no longer covered by their province of origin’s plan. Coverage under the Québec plan generally begins on the first day of the third month following their arrival in the province. The individual receives the health insurance card within two weeks of the effective date of coverage. While the person remains covered under their province  of origin’s health insurance plan, they must present the health insurance card issued to them by that province to the physician when they require health care in Québec. As such, their province of origin’s health insurance plan will assume the costs incurred. However, if the physician refuses the card, the individual must pay the doctor directly and then request a reimbursement from the body administering the plan in their province of origin.
Services Covered in Québec
Insured individuals can take advantage of a number of free services covered under the health insurance plan. In addition to medical services, the plan covers a range of other more specific health care needs, such as dental treatments for children under the age of 10.
With respect to medical services, regardless of where they were rendered, the health insurance plan was initially designed to cover required care provided by a family physician or specialist. These services included examinations, consultations, diagnostics, therapeutic interventions, psychiatric treatments, surgery, radiology and
anaesthesiology. Health care systems have since undergone numerous changes, and it is not always easy to determine what is now part of the “basket of services” covered in Québec.
Since the beginning, health care services deemed by the plan to be unnecessary from a medical standpoint have not been covered, even though they are, in fact, being rendered by physicians. The health insurance card cannot be presented for these services, whatever physician is providing them, and the cost of such care must be assumed by the recipient. Treatments rendered for purely aesthetic purposes are a classic example of these types of services.
Some services are not covered because they are not related to the prevention or treatment of an illness. These include visits to a doctor and, if applicable, tests passed to obtain an insurance policy or its reinstatement, to obtain or retain a job (unless the test is required by Québec  legislation other than the Act Respecting Collective Agreement Decrees), to obtain a passport or visa, or to be admitted to an academic institution, association, organization, summer camp, fitness centre, athletic club, daycare centre or recreation department. 
When an individual sees a doctor and undergoes tests for the sole purpose of obtaining a health certificate, they must  also assume the costs. Moreover, although certain exceptions may apply, tests required for legal purposes are also not covered.
Coverage of certain services may vary  depending on where they are rendered. For example, some services are only covered if dispensed within an institution. This applies to most laboratory services and certain medical imaging procedures such as computed axial tomography, magnetic resonance imaging and ultrasound outside of pregnancy.
Certain services are covered upon special authorization only. As no treatments rendered for aesthetic reasons are covered under the health insurance plan, a physician must determine if the service is requested for such purposes alone, or if it is necessary from a medical standpoint. Services for which a medical consult is required to determine if they are covered by  the RAMQ include mammaplasty, abdominal lipectomy, blepharoplasty, electrolysis in the event of hirsutism, treatment of a scar in a location other than the face or neck, and skin grafts required subsequent to a trauma. 
Coverage can also be more or less comprehensive. Even if an individual presents their health insurance card for health care services that are covered under the plan, certain costs could be billed to them. In that regard, the term “incidental fees” designates costs billable to patients for some services, even if they are associated with insured services. For example, physicians are entitled to request financial compensation for medications and aesthetic agents used in private practice, for the completion of certain medically related administrative forms, as well as for copies and summaries of files prepared and transmitted upon the request of patients. 
Physicians Participating, Opting Out or Not Participating in the Plan
According to the terms of the Act Respecting Health Insurance, health care professionals authorized to provide insured services are distinguished based on whether or not they participate in the  public health insurance plan. Most Québec physicians participate in the plan. In other words, they accept the health insurance card. Consequently, insured individuals do not generally have to pay for covered services. The Régie pays these participating doctors directly for services rendered in accordance with the agreements negotiated between the government and the medical federations (FMOQ, FMSQ).
Although they are few in number, some physicians who have so-called “opted out” do not accept the card but respect the fee structure as per the agreements. They bill their services to their patients, who can then request a reimbursement from the Régie using the form obtained during their visit. Of course, these physicians must advise their patients of this situation in advance.
Another small percentage of doctors, referred to as “non-participants”, do not adhere to the health insurance plan in any way whatsoever. They bill their services directly to patients, establishing their fees entirely on their own. Barring certain exceptions, the Régie does not reimburse the cost of any services rendered by these physicians, even in the case of covered services. A non-participating physician who renders an insured service in accordance with the law in an emergency situation may bill the Régie for the amount of fees payable by virtue of the agreeement. Non-participating physicians are also obliged to advise people who consult them of their mode of operation before any services are rendered.
Unless otherwise indicated, all physicians participate in the health insurance plan. If they opt out or decide not to participate,  they must advise the Régie in accordance with certain terms and conditions prescribed in the agreements. A physician who has opted out or chosen not to take part in the plan can re-adhere to it by filing a formal request. Although it is always possible for physicians to choose not to participate or to opt out of the health insurance plan, a number of the provisions of the Act Respecting Health Insurance serve to prevent them from both participating and not participating in the plan (“mixed practice”). The Régie has a list available of  physicians who have opted out or do not participate in the health insurance plan. While this list is growing, the number of physicians concerned remains relatively low. Moreover, the government reserves the right to intervene if the Minister deems this number to be too high so that insured services can continue to be rendered in accordance with standardized conditions throughout Québec or within any of its regions (Act Respecting Health Insurance, Section 30).
With all the combinations of these three variables being possible (persons insured by the plan, services covered under the plan, and physicians who do or do not participate in the plan), situations can vary considerably outside of institutions. Most of the time, physicians who participate in the plan offer covered services to insured individuals. However, a participating physician may also  offer services that are not covered. As well, they could provide covered services, but to individuals who are not insured. At the same time, an insured person could also decide to consult a non-participating doctor to obtain services that would be insured if the physician participated in the plan. And so on, and so forth…..
Despite this great diversity, the fundamental issues remain essentially the same from a doctor’s professional ethics standpoint. The physician may only claim the fees that are warranted by the nature and circumstances of the professional services rendered. When certain costs are billable to the patient, the physician must notify them of such in a very clear and timely fashion. Whether the physician participates in the plan, whether the patient is eligible for coverage under the plan or whether the services are insured,  this rule remains unchanged. The cost of certain services, materials or other expenses must clearly be displayed in the physician’s waiting room. Furthermore, if a  patient believes that a doctor’s fees are unjust and wishes to contest a bill, they can contact the Collège’s Investigation Department to obtain information and request an account resolution.
PRACTICE OUTSIDE AN INSTITUTION
PROVISION OF CARE OUTSIDE INSTITUTIONS
Under review
How medical practice is positioned vis-à-vis the health insurance plan and the health care system, makes it easier to understand  that this form of practice complements various organizational models. Moreover, the health care system that prevails in Canada and Québec is often described as a “mixed system”, with the financing of the plan and management of the system being essentially public, while the provision of care is far from being limited to public institutions. Since the beginning, it was established that all health care institutions had to be publicly managed and funded in Canada and Québec. However, the modes of financing and management could always vary for other organizations providing health care.
It is important to properly distinguish between the financing of organizations providing care and the funding of services themselves, which is or is not assumed by the health insurance plan depending on whether or not the patient and service are covered and whether or not the physician is participating in the plan. Since the creation of the health insurance plan in Québec, the principal sources of financing for organizations other than public institutions have been the professional fees claimed from the RAMQ by physicians, and the management of these organizations has been, more often than not, handled by these doctors. However, the financing may also originate from another government body like the Commission de la santé et sécurité du travail (CSST), a private insurer, or from fees and expenses billed directly to patients.
When physicians adopt certain newer organizational models, other sources of funding specific to each model are added to the so-called “private” financing we have just described. A public subsidy can be granted in return for a commitment to offer a defined service. This is the case for GMFs and what is expected for CMAs. Various combinations are thereby possible, even if some of these remain newly emerging phenomena for the time being. Presently, there are only a few specialized medical center projects, but these are already posing new financing and management challenges because they involve considerable private investments out of all proportion to what has been required to date by private doctors’ offices.
PRACTICE OUTSIDE AN INSTITUTION
DIFFERENT ORGANIZATIONAL MODELS
Under review
There have been several formulas applied, be it to develop medical services offered outside of institutions by physicians practicing alone or in groups, or to promote their integration into the public network. Such  endeavours are family medicine groups (GMF), network clinics, specialized medical centers (CMS), associated medical clinics (CMA) and health care cooperatives. These  different modes of organization will be summarily described in the sections that follow.
Individual and Group Practice
In the case of independent private practice, the family physician or other specialist practices alone in their own office or individually at a private polyclinic. A minority of doctors are now opting for this type of practice.  Although a model that is less and less commonplace, it does offer some advantages, including a more personalized physician-patient relationship.
In group practice, a certain number of doctors join together in an organized and autonomously managed clinic, or they associate with an already established larger group, such as a private polyclinic. In accordance with the Regulation respecting records, places of practice and the cessation of practice by a physician, physicians who practice in a group can maintain one single medical file per patient and per place of practice. This type of practice is increasingly becoming a favoured option among physicians.
Family Physician Groups
In 2000, the Commission examining health and social services in Québec (Clair Commission) recommended the establishment of family medicine groups (GMF). The purpose of creating this new structure for  the provision of services was to improve accessibility, dispensation and continuity of care, as well as to entrust clients with greater responsibility. The MSSS estimates  that, with 300 average-sized GMFs in place catering to between 15,000 and 24,000 individuals, a total of 75% of the Québec population could be registered with a physician who is a member of a GMF. There are currently both small and large GMFs in place. The first such groups appeared in November 2002. In November 2012, there were 250 accredited FMGs in Québec.
GMFs are comprised of a sufficient number of physicians to assure the equivalent of six to 12 full-time family doctors (ETC) who  agree to perform activities specific to GMFs — consultations with or without appointment and home care. These physicians work as a group in an office, CLSC or out of family medicine units (UMF) in close collaboration with nurses and other health professionals. Recognized as a functional body, the GMF defines the services it offers in accordance with those expected of it. In return, it enjoys the benefits of agency and MSSS support. One physician in each GMF takes care of allocating tasks, assigning responsibilities to members of the group, and managing the allotted budget with the personnel who have been designated for that purpose.
Doctors who belong to a GMF sign an agreement among themselves that establishes the decision making procedures within the group, particularly the distribution of tasks and responsibilities. In addition, the group must conclude an agreement with the CLSC in their territory in order to integrate  a psychosocial component into its service offerings. As part of a written agreement with the agency, the GMF defines its commitment to the specific services that are to be offered, and in return, the agency agrees to offer specific technical and financial support. 
Registration with a physician member of the group is voluntary, free, without territorial limit, and serves as a fundamental element of this organizational model. From an administrative standpoint, the subsidy will be granted based on a  progressive scale that takes the weighted number of individuals registered with all members of the GMF into account. The number and  type of patients registered with an ETC physician in a GMF normally varies between 1,000 and 2,000. What physicians appreciate most in this model from a clinical standpoint is the important complementary role played by nurses.
Associated Medical Clinics and Specialized Medical Centres
As noted in the previous chapter, a new legal framework was created subsequent to the decision rendered by the Supreme Court in the Chaoulli-Zéliotis case in 2005 (Chapter 1, Section 2.2). This framework, outlined in Bill 33 (Act to Amend the Act Respecting Health Services and Social Services and Other Legislative Provisions) adopted in December 2006 and clarified in Bill 34 (Act to Amend Various Legislative Provisions Concerning Specialized Medical Centre and Medical Imaging Laboratories) adopted in June 2009, is aimed at using resources outside of institutions so as to increase access to certain specialized services without compromising the quality of these services. 
Specialized medical centres (CMS) were defined as places outside of institutions where physicians can, under certain conditions, provide a number of specialized medical services specified by law or regulation that were heretofore provided in institutions. The conditions include obtaining an operating permit issued by the government, appointing a medical director responsible for assuring the quality of the medical services offered, and certification by a recognized organization within three years of obtaining the operating permit. The services specified in the regulation subsequently adopted, and in effect since March 31, 2010, presently consist of surgical interventions that were determined based on the length of stay and the type of anesthesia required, as well as the risks involved.  The law recognizes two types of CMS — those where exclusively physicians who participate in Québec’s health insurance plan practice, and those with only non-participating physicians. For their part, associated medical clinics (CMA) — whether or not they are specialized medical clinics or laboratories — were defined as places where physicians who participate in the health insurance plan offer certain services as part of a partnership agreement with an institution operating a hospital centre and with the agency concerned.
Network clinics possess certain characteristics of associated medical clinics. In this model, which is widespread today in the Montréal and Québec City regions, a large number of full-time equivalent (ETC) physicians (generally more than 10) form a group and establish an agreement with a CSSS to offer an extensive range of services with and without appointment (a proportion of  approximately 50%). In Montréal, the framework is defined by the agency and the Regional Department of General Medicine. These network clinics operate day and night, on weekends, and on legal holidays. They are mandated to accept so-called orphan clients with no family doctor and those deemed as being vulnerable. In addition to enjoying benefits with respect to remuneration, network clinics have the support of the agency and the use of service corridors to access secondary care medical services. They must have rapid access to basic imaging services and ultrasound, and they are also responsible for helping to find a family doctor using a primary care network they maintain with nearby private practices. It is estimated that a network clinic typically offers services to approximately 50,000 clients. 
Health Care Cooperatives
Over the past few years, another health  care services organizational model has developed. There are now several health care co-operatives in place for citizens in Québec, generally in locations where there was a scarcity or risk of losing medical resources or health care services. The formula rests on the leadership of people engaged in their milieu, working in collaboration with health care professionals. The members, who must make a contribution, establish structures that support professionals and make the specific services offered by the cooperative accessible. 
This model has some unique and interesting characteristics, but it also raises several questions. For example, the physician  may enjoy certain benefits from an administrative standpoint, including reduced  or even free rent, which, in another context, could be considered to be an unacceptable advantage. At the same time, it must be clear that the fact a patient does not join the cooperative or does not renew their membership cannot in any way whatsoever constitute a hindrance to the accessibility and continuity of care, nor influence the quality of care. It remains to be seen how this formula can respect the ethical obligations of physicians, coexist with a public health care system, and work harmoniously with other organizational models.
PRACTICE OUTSIDE AN INSTITUTION
COMMON PROFESSIONAL ISSUES
Under review
The framework for medical practice has been designed for the institutional model on the one hand and private practice on the other. What happens in the case of all these situations where physicians practice their profession in settings that are neither institutional nor private in the classic sense of the term? The question is pertinent and does not have any easy answers.
Some of these situations probably require a framework that resembles what exists in institutions for the same types of medical interventions and  which we have discussed in the previous section. Others  are more similar to private practice and should meet its requirements, which we will address in the following section. In fact, the Regulation respecting records, places of practice and the cessation of practice by a physician establishes standards for the organization of a private practice. The regulation clearly outlines the rules regarding the keeping of records, doctors’ rooms or offices and other effects. It also stipulates the procedure to follow in the event of a cessation or reorientation of the practice. 
Fortunately, certain reference points are common to all situations. Regardless of the location or type of practice, whatever the circumstance, physicians remain autonomous professionals responsible for their  actions. Whether in an institution, a private setting or elsewhere, the practice of the profession is governed in Québec by the Professional Code, the Medical Act and its ensuing regulations, and the Code of Ethics of Physicians. The doctor is always bound by the same obligations with respect to competence, providing assistance, respecting professional secrecy or maintaining their professional independence. Moreover, some provisions offer detailed stipulations to better guide physicians faced with situations of greater concern. For example, it has been clearly specified that the physician cannot exhibit “interventionism”, which is to say, the doctor must respect the patient’s freedom of choice to have prescriptions filled in the location of their choice. Provisions that could apply to the leasing of premises have also been stipulated, and rules governing incorporated practice were updated and are much more explicit with respect  to acceptable practices. As well, rules pertaining to physician advertising have been defined. The new Regulation respecting records, places of practice and the cessation of practice by a physician, adopted in May 2012, is now addressed to all physicians. In very clear terms, it sets forth the rules concerning records and places of practice and specifies the procedure to follow in the event of cessation or reorientation of practice. 
Furthermore, there are some specifications with regard to the billing of medical interventions. Billing is subject to the  agreements concluded with the MSSS, the Québec Federation of General Practitioners (FMOQ), or the Québec Federation of Medical Specialists (FMSQ), as applicable. For reference purposes, the various medical associations also publish fee schedules for the costs charged to patients. The MSSS exercises a certain degree of control via the issuance of permits that are mandatory for the new organizational models. In short, the formal framework is in the process of adjusting itself to this evolution in medical practice. Until this process is complete, however, physicians must remain vigilant, as this evolution is giving rise to new challenges on a daily basis.
Maintenance of Competency
The obligation of maintaining competency is inherent to the practice of all professions, and medicine is no exception. Personal needs and practical and organizational contexts vary a great deal from one individual to another, and all physicians are considered to be responsible for their own approach. Several programs exist to support physicians in their individual continuing professional development (DPC) efforts. For instance, the Collège des médecins du Québec’s self-management plan offers its members a simple and straightforward approach to carrying out their individual DPC plan. In fact, there are  multiple opportunities for professional development. Group practice and exercising the profession within milieus where there is a concentration of health care professionals favour such programs. Clinical contacts also constitute learning opportunities for physicians, and today, the possibilities for discussing cases are multiplying with the use of new information technologies like telemedicine, telecourses and easier access to practice guides, to name but a few.
Respect for patients: scheduling appointments and communication
As a professional, it is also important to possess tangible means with which to adequately serve patients. When practicing outside of institutions, physicians have prime responsibility in that regard. Appointment taking and communication systems also merit attention.
There is no doubt that an inadequate appointment system serves to alienate clients, while an efficient system attracts them. There are numerous different formulas in this regard, and each has its advantages and disadvantages. What is important is that the physician adopts and adapts a system so that it best responds to the expectations of patients and to their own requirements and work habits. In the case of group practice, it can be advantageous to select a method common to everyone so as to avoid confusion and error.
Following are some examples of appointment systems:
Without appointment  — Although increasingly rare, some physicians receive their patients on a “first come, first served” basis. Except in emergency cases, this method of operating may engender dissatisfaction and frustration among the doctor, office staff and patients alike.
Patient flow  — Definitely the most commonplace, this system spaces out appointments into segments of 10, 15, 30, 45 or 60 minutes. In theory, this is the ideal formula, provided the physician and patients are punctual and each visit does not exceed its scheduled time. However, the everyday reality is that this system is far from reliable.
Patient concentration — This method calls for a certain number of patients to arrive at the same time. If the physician plans to see four patients in an hour, they will all arrive at the office at the same time. Inevitably, the concentration of patients at the beginning of the hour leads to frustration among patients who must wait.
Open period — Another way to regulate patient flow is to leave open periods to be able to respond to emergencies or special cases. At the same time, physicians can allow for a few minutes of respite at the end of each hour to make up for lost time if necessary.
It is also possible to schedule appointments several months in advance. The disadvantage of this practice is that appointments must sometimes be cancelled or changed because of an emergency or personal activity like a conference or impromptu vacations. 
Appointments must be listed in an appointment register, which needs to be kept for a minimum of 12 months. For group practices comprised of several doctors, it can be advantageous to use a computerized system that can be integrated with a local electronic clinic file. In that case, it is important to always ensure that patient data is protected and used confidentially.
Within the current context, where the demand for medical services far exceeds the supply capacity, particularly when it comes to primary care, the challenge for physicians actually runs in the reverse direction. Doctors must learn to contain the demand within certain acceptable limits. The means being used to do so are more often than not improvised, but the fact is, the results are more or less satisfactory. In order to be able to continue to effectively follow up on their patients, many doctors are simply refusing to accept any new patients. Others are choosing not to conduct followups in favour of dedicating themselves exclusively to the “no appointment” system. In some cases, coupons are distributed to make waiting times more predictable. In that regard, one basic rule should always apply — provide service that is consistent with what was announced. This rule helps assure respect for patients, even if it is impossible to satisfy all their needs. Certain ethical provisions also allow for the establishment of priorities, such as the obligation to assure emergency care and the required follow-up based on the patient’s condition.
What ever the solution envisaged, communication systems play a pivotal role. The key element here is the direct contact that must be established with patients who use the clinic’s services. Two principal factors promote such positive contact and patient loyalty — a satisfactory doctor-patient relationship and a cordial attitude on the part of staff.
Of all the tools available to physicians, the telephone is undoubtedly among the most valuable. In most cases, it is via telephone that initial contacts are made with patients. Because they serve as a reflection of the organization, receptionists should be amiable and courteous individuals capable of exercising sound judgement. In addition, it is important to establish a clear and uniform policy with respect to how telephone calls are directed and managed. In that regard, a rigorous and coherent procedure has a favourable impact on the efficiency of a physician’s work. For example, it is advisable that one telephone line be reserved for communication with consultants, pharmacists and laboratories. The criterion for determining how many phone lines are required is simple — the optimal number is that which will reduce waiting to a minimum.
Among the other means of communication available to physicians are computer systems, which can be very useful, particularly when it comes to RAMQ billing and the use of e-mail. A large-scale project to computerize the health care network is currently underway in Québec. This initiative will enable professionals to gain access to certain valuable information for the treatment of patients, including medication lists, laboratory results, medical imaging, data required in  emergency situations like susceptibility to allergies, etc.
For its part, e-mail already offers a range of interesting benefits — from quick access to information and reduced paper consumption, to simultaneous communication with several individuals, the transmission of graphic documents, and soon, the transmission of diagnostic examination results as well. However, since the security of information is not always guaranteed, its utilization demands the utmost prudence (see section The Obligations of Physicians under other Regulations) . Nevertheless, there is no doubt that the evolution of communications is in the process of changing the way medicine is practiced, as confirmed by “telemedicine”, the practice of medicine from a distance. Given a proper framework, telemedicine can significantly contribute to improving access to quality health care. Finally, there are other indispensable tools  available to physicians and their staff to help them serve their patients adequately, such as fax machines, information leaflets and pamphlets, and answering machines or telephone answering services offered by private companies. However, rigorous mechanisms must always be put into place to guarantee the confidentiality of records and communications, whether via telephone, fax or the Internet.   
Access to Care and Follow-Up
Access to care and follow-up currently pose a number of challenges for physicians, particularly when combined. Doctors are well aware that, if they accept new patients, they will have to monitor their status. In recognition of that fact, many of them believe that the only solution is teamwork. It is important to note, however, that working in groups or teams must not have a negative impact on the care patients receive. On the contrary, regardless of the difficulties this can represent, doctors must always ensure that patients are being adequately taken care of before personally withdrawing from a situation.
Professional Independence and Administrative Aspects
A number of observers believe that the greatest challenges today relate to the professional independence of physicians, with certain business and administrative aspects creating situations of potentialconflict of interest. This is certainly a subject that also merits more detailed discussion.
Purchase, Rental and Keeping of Premises
According to various studies, approximately half of private practice offices actually belong to physicians and the remaining half to financial promoters or others. The decision to rent or buy is, first and foremost, a business decision.
Nevertheless, whatever physicians decide in this regard, they must ensure that their agreements allow them to respect the Code of Ethics and to organize and keep a space that meets the standards outlined in the Regulation respecting records, places of practice and the cessation of practice by a physician.
With respect to rental agreements, physicians must ensure that they do not compromise either their professional independence or the right of patients to choose freely.
Although the Québec Code of Ethics of Physicians already contained several provisions aimed at controlling conflicts of interest and preserving the physician’s professional independence,  it was amended on March 1, 2008 to establish new rules pertaining to leases. More specifically, it is now stipulated that, in their capacity as physicians or in using their title of physicians, doctors must refrain from accepting any commission, rebate or other material benefit, with the exception of customary tokens of appreciation and gifts of modest value (Section 73.3).
Any agreement entered into by a physician regarding the use of a building or space to exercise their profession must be entirely recorded in writing. Such agreement must also indicate its compliance with the Code of Ethics of Physicians, and it must be released to the Collège des médecins du Québec upon request (Section 72). Moreover, the Code stipulates that the use of a building or space at no charge or at a reduced rate constitutes a material benefit that is prohibited if granted by a pharmacist or corporation in which the pharmacist is a partner or shareholder, a person whose activities are associated directly or indirectly with a pharmaceutical practice, or any other person within a context that may present a real or apparent conflict of interest (Section 73.1).
To gauge the scope of these amendments and concretely illustrate the behaviour expected of physicians in this regard, it should first be made clear that all agreements or leases must be free of any conditions that could have an effect on a physician’s professional independence, in particular, by governing the act of prescribing medication or directing patients after a prescription is written. In addition, the lease entered into by a physician with a professional or an individual or legal entity leading to the sale of goods, products, medications or apparatus prescribed by the physician must call for a just and reasonable rent so as not to be deemed a material benefit prohibited by the  Code. Just and reasonable signifies that the rent is in line with the area’s socio-economic conditions and with the nature and intensity of the services rendered. The rent calculation could be based on an hourly rate or the surface area to be utilized.
There are certain situations in which  a physician may enter into a lease under advantageous conditions or even accept  free rent. In such cases, these agreements, which are made in keeping  with various specific socio-economic conditions, allow physicians to practice their profession in a region where there is a shortage of doctors, while in other cases, they assure the dispensation of medical care and favour interdisciplinarity. One example of such a situation is a doctor who has the benefit of free or discounted rent and the services of a nurse in a private residence for seniors with reduced mobility. Another example could be a physician who makes premises available free of charge a few days per month to a consulting physician in order to offer patients a range of integrated services. Similarly, a physician may agree to practice a few days each month in a remote region within premises made available free of charge by the local municipality. It is important to note in all of these cases that the party  with which the physician established an agreement is not linked directly or indirectly to a pharmaceutical practice or the sale of medications, products, apparatus or other goods the physician may prescribe.  
In sum, since December 4, 2008, all physicians who have concluded an agreement pertaining to the use of a property or space for the practice of medicine must ensure that this agreement is entirely recorded in writing and that it includes a statement by the parties that the obligations arising from the agreement comply with the Code of Ethics of Physicians, as well as a clause authorizing release of the agreement to the Collège des médecins upon request. There  are certain rental agreement models available for consultation on the Web sites of the various medical federations.
Types of Association and Partnership
A physician working in private practice or within an institutional setting may enter into a partnership contract governed by the  Civil Code of Québec. Under this contract, which is established within a spirit of cooperation, the physician and his/her associates agree to conduct their  activities and contribute to the effective operation of the enterprise in accordance with certain terms and conditions. These could include the pooling of property and knowledge and the sharing of monetary benefits generated by their activities. 
—  Partnerships: An Intense Relationship
When a partnership between individuals is established, it must combine three essential elements — an investment, profit-sharing, and the intention to form the partnership. In this case, all professional fees are pooled and shared. As of recently, physicians can incorporate to form a limited liability partnership or a joint stock company. The general partnership (GP) offers certain advantages, but it also calls for various conditions to be met, such as the partners having to share a common philosophy, a high level of trust in each other, and similar financial needs. Moreover, unlike a partnership for expenses, the general partnership presumes mutual responsibility in proportion to each individual’s share as established in the contract.
Since June 2001, the  Professional Code has allowed professional orders to adopt a regulation enabling their members to conduct their activities within a limited liability partnership (LLP) or a joint stock company (JSC). The Collège des médecins adopted such a regulation, which came into effect on March 22, 2007..   Unlike associates in a GP, physicians  in an LLP or JSC are not held jointly responsible for the professional acts of their partners if they did not participate in those acts. However, professional responsibility toward the patient remains unchanged. In fact, Section 8 of the Code of Ethics has been modified to make this clear. Physicians practicing their profession within a partnership of this kind must provide and maintain insurance protection on behalf of the partnership to cover its liabilities in the event of fault or negligence on the part of associated physicians. 
This regulation allows physicians to practice within these types of partnerships. However, they may do so only on the condition that they hold all the shares or voting rights attached to the shares and that the company’s Board of Directors is composed entirely of physicians.
Under the rules adopted by the Collège, the other shareholders or partners may only be:
- other physicians  
- the spouse, blood relatives or persons connected to the physician holding shares in the company or partnership 
- legal entities, trusts or enterprises where 100% of the voting rights attached to the shares or company  are held by physicians or a spouse, blood relative or person connected to the shareholding or partner physician
Physicians must be authorized by the Collège to practice within one of these structures. They should consult with the appropriate professionals to familiarize themselves with the steps to be taken.
—  Partnership for Expenses: A Flexible Formula
Physicians may associate to form a partnership for expenses as well, also known as a “shell company”. The partnership for expenses is formed by two or more professionals who wish to share the expenses associated with their practice while maintaining their own clientele and income. The sharing may or may not be on an equal basis, depending on the context and their choice. Oddly enough, there is very little literature available on the legal aspects of this very common type of association and its ensuing responsibilities. 
The advantages of a partnership for expenses include the rational use of human resources, the sharing of on-call duties, the assurance of finding replacements, the optimal use of premises, contact among associates, a certain autonomy, greater purchasing power for the acquisition of equipment, easier startup, and respect for everyone’s individual working pace. On the other hand, competition is greater with this type of partnership, and team spirit is less developed than in the previous partnerships discussed.
There is a formula known as “mixed division” under which fixed expenses are distinguished from variable expenses. In general, fixed expenses are those that do not vary with the volume of activity, such as rent, telephone, office equipment and part of the office staff. Some partnerships exclude various shared expenses like the purchase of books and periodicals, professional dues, attendance at conventions and conferences, as well as automobile expenses. Others set a ceiling on the sharing of expenses so as not to penalize the members who work longer hours.
— Partnership Contract
As we can see, there are many types of partnerships, none of them being better or worse than the other when it comes to the practice of medicine. The relative advantages and disadvantages are organizational, financial and, above all, fiscal in nature. Physicians who decide to work in partnership have the freedom, but also the responsibility, to define the agreements that suit them best. The first step in the establishment of a partnership contract is to decide on the terms of the agreement. These must be precise enough to avoid potential interpretation problems, and they must be flexible enough to allow the signatories a sufficient measure of autonomy. The clauses should take individual needs into account and should be reflective of the type of partnership selected. The number of clauses in a contract can vary. For reference purposes, following is a list of the most important:
- Purpose of the contract and company name
- Duration of the contract
- Investment and conditions of the partnership
- Ownership of the furnishings
- Administration of the partnership
- Professional liability
- Workload
- Division of expenses and fees, if applicable
- Obligation for maintaining competency and policy pertaining to vacations and convention or conference attendance
- Sabbatical leave
- Absence due to illness
- Maternity leave
- Methods of transmitting and keeping records in the event of the dissolution of the group or resignation of a member
- Dissolution of the company
- Departure or death of a partner
- Hiring of a family member
- Fiscal year
- Arbitration
It is strongly recommended that the services of a professional specialized in taxation be retained for the preparation of contracts.
Rules Concerning Advertising and Public Statements
The Code of Ethics of Physicians was modified to create a specific section pertaining to advertising and public statements by physicians.
The Collège recognizes the existence of new marketing practices and the emergence of new information technologies within a context where numerous forms of care and service (whether covered by the health insurance plan or not) are being publicly announced. This section echoes the Professional Code, which assigns responsibility and certain obligations to professionals with respect to advertising messages promoting their services (Section 60.1). The cornerstone of the new rules is the honesty of the message. Some practices that were formerly prohibited no longer are, unless they contribute to biasing information. However, physicians must clearly indicate their title of family doctor or other specialist (see section on Advertising).
At the same time, the Collège reiterated the rule stipulating that physicians post the costs for their services, materials and incidental expenses billable to their patients (Health Insurance Act, Section 22.0.0.1; Code of Ethics of Physicians, Section 105). 
Responsibilities of the Physician‐Employer
The Labour Standards Act governs all work relations between physician-employers and their personnel. Under the banner of their professional activities, physicians must reconcile restrictions on the use of their time and those related to the application of management standards. If they want to devote most of their time to the practice of medicine, they must surround themselves with competent and reliable personnel. In fact, efficiency demands delegation of authority and the effective distribution of tasks and responsibilities in accordance with the respective skills of staff members.
Moreover, as principals, physicians are accountable for the actions taken by their personnel. Therefore, it is important for physicians to determine those situations as precisely as possible when their staff must ask them to intervene concerning a patient, such as answering a telephone message or advising them of an incident having
occurred. It is also essential that staff members always respect the rules of confidentiality. Sound personnel management rests on good human relations. It is widely recognized that employees are most productive when they are looked upon as partners and treated with respect. Physicians have numerous obligations as employers. They must learn the art of delegating and allow their trusted personnel to take initiative, all the while supervising their work adequately and remaining responsible.
PRACTICE OUTSIDE AN INSTITUTION
CONCLUSION
Under review
The practice of medicine outside of the  health care network’s public institutions necessitates a varied range of knowledge and skills on the part of physicians.
The difficulty of integrating private medical practice with primarily public health care systems is not new. It exists everywhere, it persists in Québec, and the current shortage of material and human resources is not helping matters. The fact remains that the autonomy of physicians has its advantages for both doctors and the public, at least with respect to assigning responsibility to physicians. Despite the difficulties, we believe physicians must remain moral agents who are competent and responsible for their actions. Indeed, there are professional norms and standards in place to provide certain points of reference in that regard, and they apply everywhere.
However, these norms were developed based on a fairly classic model characterized by private doctors’ offices on the one hand, and entirely public institutions on the other. As such, the transformations currently underway in Québec are creating unprecedented situations and posing new challenges for physicians and all those who seek to preserve the quality of their professional practice. In spite of the complexity of the systems implemented to make health care accessible to all, we cannot lose sight of the ultimate objective of the practice of medicine, which is to assure each and every individual of the care they need and of the best care possible.
DIVERSIFICATION OF THE PRACTICE OF MEDICINE
Under review
Having obtained a diploma from a faculty of medicine and a permit to practice from the Collège des médecins du Québec, physicians may practice their profession in settings as varied as the roles they may play. They may also engage in clinical or non-clinical activities or divide their time between the two.
As was explained earlier, the  medical clinician  practices in institutions such as a hospital centre, a CHSLD or a CLSC, in private practice or in one of the network’s new structures, notably the family medicine group (GMF). The clinician may also practice in spheres not covered by the public plan. In this case, the patient assumes the cost of the medical services provided.
A physician may also engage in activities and assume professional responsibilities of a non-clinical nature. Albeit less known, these are essential, very varied and increasingly recognized.
Thus, a physician may be an administrator. In the public sector, he or she may be a director of professional services or department head of an institution, for example. In the private sector, he or she may be the medical director of a pharmaceutical firm or parapublic agency such as Héma-Québec.
A physician may be a researcher,  either in a university research centre, a clinical research centre or in the private sector, for a pharmaceutical firm. Without being the principal researcher of a research project, the physician may also participate as a clinician in research projects. More and more physicians practicing outside institutions are also asked to participate in research projects.
A physician may also teach, either as a university professor or as a teacher in a facility used for training purposes. He or she may  also teach in other settings, notably by giving conferences in the context of scientific activities or by taking part in continuing professional development activities.
As well, some physicians may opt to work in public health. These are physicians who are specialists in public health or family physicians who have received additional university training in the public health field and in epidemiology. For the most part, they practice in CLSCs, in regional departments of public health, at the National Institute of Public Health or at the Direction de la santé publique of the MSSS.
Others work in medico-legal assessment, as experts in the context of their medical practice, either for a third party designated as principal or as employees of agencies that call upon the expertise of physicians, such as the Société d’assurance automobile du Québec (SAAQ) or the Commission de la santé et de la sécurité au travail (CSST). Thus they may be called upon to act as expert witnesses in court and to present the conclusions of their expert assessment.
A physician may also act as a  medical consultant, using his or her clinical competence to improve the conditions and quality of medical practice in organizations such as medical federations, the Collège des médecins, or various other bodies within the  MSSS.
A physician may also be a medical evaluation officer employed in the health services of a large company or as a consultant for an insurance company. Finally, a physician may have the medico-legal skills required by the Coroner’s office for purposes of investigating the cause of death.
In all cases, the same Code of Ethics and the same laws and regulations serve as a framework for determining good medical practice. The most recent versions of the Code of Ethics of Physicians and certain regulations include sections that specify the obligations of the physician in the practice of certain professional activities, notably those of the research-physician the medico-legal expert and the public health physician.
From the very beginning of their training, medical students and medical residents in their clinical training activities are bound by the same framework of rules and regulations applicable to all medical practice.
Medical practice will continue to diversify as knowledge in the field of medicine evolves and as new social needs emerge.
ORGANIZATIONAL ASPECTS
A SOCIAL ACHIEVEMENT WORTH PRESERVING
Under review
While physicians’ links to the health care system are readily obvious to those working in institutions, all physicians most know the history, characteristics and organization of the system, still considered to be a major social achievement. Whether they work in private practice or in other settings or even outside the public system, physicians must be familiar with the system and how it functions.
Physicians have a responsibility to ensure the best possible care to patients and the population. Since most care is provided  within the health care network, physicians must take their full and rightful place within it.
Physicians who choose to provide professional services outside the public system must also take into account that they are practicing in a society that has placed the public system at the heart of its social policy. 