Over-crowded waiting rooms, long wait times up to 10-12 hours. The headlines have been in the news for years. Staff do the best with the knowledge and training they have along with systems available to them. But the issues of overcrowding and perceived slow response times continue. Why is that? And what do the health authorities need to do to fix it?
The issues will not go away by simply trying to change a few policies or hire more staff. In my July 22 commentary, I developed the need for strong leadership to deal with some challenging issues. Not until those at the top understand that the “fix” requires more than just talk and more than mere motions and political positioning. It requires a “deep dive” to get to the real core issues, as challenging as that will be.
In 1962, Dr. Malcolm McEachern, the father of modern hospital administration, described emergency departments in his classic text, Hospital Organization and Management. In it he listed 8 critical elements that are required to make an emergency department function and, in the narrative, there was not even a hint that the Emergency Department would be used as a replacement for the doctor’s office! Originally the department was developed for the care of patients presenting with fractures, trauma and other life/limb-threatening conditions. Consequently, he emphasized the basics such as the visible presence of an involvement by specialists, proximity to the operating room and much more. It was a place where those conditions that could not be dealt with in the family doctors’ office could be managed effectively.
So what has happened in the meantime? It is said that at least 80% of the visits to emergency are not life-threatening; serious, important, but not fitting the traditional definition of emergency. They arrive, as has been stated on numerous occasions, because they cannot get access to a provider of primary care services who can deal with the problem. In the old days, they call their doctor. Not so in 2021 for many reasons described in earlier commentaries.
But, Emergency Medicine is not Family Medicine or just Primary Care in another location. Emergency Medicine is as much a Medical Specialty as Neurosurgery, Cardiology, or Paediatrics for it requires skills that are seen but not perfected in Family Medicine training or general medical practice. Professionally trained Emergency Room Physicians, or “Emerg Docs”, need to be quick on their feet, quick to run through differential diagnosis on the fly, adept at using the skills of diagnosis by listening and observing. They need to have skills developed to the level that blood work and x-rays mostly confirm what their eyes, hands and ears have already told them.
They must also be able to organize staff so that the skills of the trained Emergency Room Physician are utilized in ways that apply clinical skills to defined problems. Other staff can see that paperwork is done, procedures followed, chart studied for history relevance. In many modern Emergency Rooms, other staff order diagnostic tests and initiate therapy based on approved clinical protocols. To cope with the volume and to ensure that sick people are treated efficiently and with quality, a true team approach needs to be taken to Emergency Medicine. In some facilities, some of the backbone of the Emergency Room are physicians with battlefield training where they have learned to make decisions quickly and engage the entire team.
When the busy emergency room, staffed with professionals trained in that specialty, is inundated with urgent but not emergent cases, the system then begins to unravel; patients get testy, staff get frustrated. Urgent care cases have no place in the professional emergency department but they arrive because they have no other options for getting attention for what they believe to be a serious health problem. It may be a laceration; it may be recurrent abdominal pain; or it may be influenza or bronchitis. These will not kill but do need care at 3 p.m. on Saturday or 9 p.m. on Sunday. Having been directed to Emergency by the doctors office answering machine does not justify compromising the integrity of the Emergency Department.
Professional Emergency Room physicians, faced with this dilemma, need to go further than complain in the doctors lounge. Yet if they make an issue at the Medical Staff meeting it will generate push-back from family doctors. But it is the hospital governing authority who owns the problem and the onus is ultimately on the CEO and the Board to initiate action to provide essential care for those non-emergent patients. There are many options and physicians have not discharged their obligation until they make a formal presentation to the governing authority with the demand for action. Short of that, the reports of 12 hour waits continue.
In 1991 I interviewed, at length, the Physician in Charge of a large Emergency Department in a major community and he told me flat out: “the crowding and long waits that you describe will not happen in my department.” He then proceeded to explain how the organization of his emergency department was based on training, protocols, engagement of a team of staff at full scope of practice, the segregation of Urgent Cases to a separate Urgent Care Centre.
That is the type of Emergency Medicine that fully trained Emerg Docs love to practice, not having their time diverted to chest colds and the many conditions that need help but not his/her help.
This model, while based upon physicians with certification in Emergency Medicine, needs support of the local physician community. It has to be a team effort in which local family doctors with demonstrated skill in Emergency medicine, come alongside to support and help cover some of the busy shifts. But it cannot be the place where physicians with no demonstrated aptitude or passion for Emergency Medicine get to take shifts to supplement their income.
So, fixing the system will require some very difficult conversations, some of which may not be too pleasant. But real progress is never achieved with everyone feeling the need to keep everyone happy. Creating an efficient service for the public is essential; under the Canada Health Act, every Canadian is entitled to timely care, not sitting 9 hours in agony waiting to be seen.
I do not profess to have all the answers. What I do know is that we have some wonderful physicians and nurse practitioners in New Brunswick. We also should be able to deliver a much higher standard of urgent and emergency care than is the case; we have the talent but have not had the organizational or political will to do the Deep Dive.
We should take no pride at all in being ranked, in Canada, as health system number 9 out of 10 developed countries. Let’s fix this with a renewed sense of pride and optimism.
Ken McGeorge is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News and is the author of Health Care Reform in New Brunswick, available at www.kenmcgeorge.com; His email address is firstname.lastname@example.org.
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.