 "I
think it's quite appropriate to use the term crisis,"
says 24-year veteran Toronto emerg physician Dr Howard
Ovens about the state of emergency medicine in Ontario.
More than 20 emergency departments (EDs) are in danger
of closing in Canada's largest province. The ED at Kitchener's
Grand River Hospital was just saved from closure —
for now — by some out-of-town docs taking extra
shifts. Some 20 more have turned to private firm Med
Emerg to staff or run their EDs.
"I think whenever you have a situation
where there's a very real possibility that patients
will show up at emergency departments and no physician
will be there to care for them — that's a crisis,"
adds Dr Ovens, who sits on the OMA's emergency medicine
executive.
So what's behind the crisis in
Ontario?
Dr Ovens blames it on two things:
overcrowding and human resources.
"I think the whole overcrowding
issue and acute care bed inventory is probably the number
one challenge in running an ED," he says. "It's not
a problem of the minor patients as CIHI suggested in
their recent report. Less acute patients require very
little resources and our contact time when we do see
them is very short."
Dr Ovens stresses that Ontario
is not alone in having troubled emergency services.
This is a national and international problem, he says,
with similar crises cropping up in Britain and the US.
And neither the current provincial Liberal regime, or
the Conservatives or New Democrats that preceded them
can fully take the blame for today's crisis.
Dr Steven Friedman, an attending
emergency physician at one of Toronto's downtown teaching
hospitals cites 'bed blockers' as a big contributor
to the current crisis. "It seems to be part of the culture
across all medicine and in politics, that's it's OK
to jam up emergency departments with inpatients but
not other units," he says. "In terms of hospital based
care, most other physicians have much more control over
their environment than the emergency department doctors.
The fact is that we don't really see anesthesiologists,
for instance, having three patients in a room designed
to hold one, or having someone in the hallway on a ventilator."
He feels the bed shortages lie
at the heart of most emerg docs' frustrations. And this
is well-known among medical students and probably discourages
them from specializing in emergency services.
"When you talk to lay people they
say 'your job must be so stressful with all the strokes
and blood and guts' but emergency doctors love that.
This is why we went into it," adds Dr Friedman. "The
stress derives largely not from treating the heart attacks
but having the heart attack patient in the waiting room
who needs a monitor, who may need a central line and
all kinds of resuscitation, but every single bed is
full. And you can't provide them the standard of care
that you've been trained to and want to give them and
the medical literature calls for you to give them —
that's stress."
He likens that feeling of powerlessness
to being a firefighter stuck in traffic, watching people
perish in a blaze, with all your skills and know-how
being squandered.
PAID
THEIR DUES
It's a nearly universal sentiment among emergency specialists
that they're underpaid relative to other physicians.
Dr Ovens cites an arm's-length report commissioned by
the OMA and the health ministry that found emergency
specialists were underpaid by 33%. "The report was thrown
in the garbage," he says.
"People vote with their feet,"
he adds. "There's a human resources crisis in emergency
medicine in Ontario. That speaks for itself in terms
of the compensations being offered."
Dr Friedman says we need to compare
emergency doctors' work to that of other physicians
when calculating compensation. "I think we are underpaid.
I think the way doctors are paid and the way different
specialities divide up the pool is anachronistic. Part
of the blame of the inequity may lie with the doctors
themselves and their leadership," he says. "Who would
you anticipate would be paid more? Someone who trained
for four or five years and works starting at 4AM nonstop
for nine hours without taking a break resuscitating
people who have heart attacks, people who've been hit
by cars, breaking bad news to their loved ones when
they don't survive? Or someone who is an office based
dermatologist, who's definitely screening for cancer
but who's spending the bulk of their day at a much more
leisurely pace, during daytime hours, treating completely
non-life-threatening skin conditions?"
"If you'd say these two doctors
are equally valued that'd be one opinion," he says.
"But if I told you the dermatologist is paid double
or sometimes triple that of the emergency physician
I think that might raise some eyebrows or at the very
least be some cause for reflection."
PRIVATE
SOLUTION
Cambridge Memorial Hospital caused a stir in late September
when it announced it had hired Dr James Ducharme, a
Med Emerg company exec, as interim chief of its troubled
ED (for a backgrounder see "Small
town ED disintegrates," NRM, Jan 30, 2006,
Vol 3, No 2). Ontario health minister George Smitherman
says the province won't block the move by the hospital,
which reportedly had a surplus of $2.5 million last
year, although he said he won't allow other hospitals
to follow suit.
Dr Ovens says this outsourcing
trend is simply wrongheaded. "I think that in general,
the model that works best is to have a director of an
ED who is committed to the institution and the community,
who's answerable to the board, and whose job it is to
ensure a quality of care is being provided," he says.
"If they're contracting out the leadership of your ED
to a third party whose primary mission is profit-oriented
— then that is a very strong barometer of failure."
He blames the difficulty in recruiting directors in
some areas on the typical stipend of $5,000 to 10,000
a year. And this is a job that takes at least two days
of a doctor's week to perform. "I'd be willing to bet
that a private firm would charge a lot more for its
services than $12-an-hour which is about what that $10,000
would work out to over a year."
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