This column by Armine Yalnizyan was originally published by the Toronto Star on Wednesday July 20, 2022. Armine is a Contributing Columnist to Toronto Star Business featured bi-weekly.
Exhausted, and with his N95 strap marks still etched into his face after a recent weekend shift, the emergency room doctor’s quiet desperation is palpable as we speak.
We won’t use his name because he’s not authorized to comment publicly, but emergency room care in Canada is on life support, and he believes Canadians should know why.
While you’re waiting for help, the ER doctor is waiting on someone else to do their job so the doctor can get to you. These jobs, he says, are increasingly falling to him or not getting done at all, despite the obvious, overwhelming need.
This doctor trained for 11 years to learn how to save lives in an emergency. He tells me his ER department processed 95 per cent of patients in less than four hours before the pandemic. In the past two months, it regularly takes 14 hours. The average wait time to get admitted to hospital in Ontario is currently the highest on record — roughly 20 hours.
There are many reasons for the backups — pandemic protocols, population aging, more people without family physicians, staffing burnout and illness — and plenty of solutions, all of which require more spending.
But some spending saves money.
These days, the ER doc says he increasingly finds himself cleaning rooms, doing data entry, rebooking diagnostic tests, and sterilizing and finding parts for equipment because there aren’t enough people to do these jobs.
“I go to look in your ear with the light, and the light is burned out. It’s mind-boggling how often that happens. If they just spent some money … to make sure these things are in place when needed, we could all work much harder and faster.”
He tells me he can’t understand why there aren’t more workers to provide basic supports.
“You’d think they’d spend more money to have us work more efficiently and faster. Instead, they are spending more to have us work less efficiently and slower.”
The emergency department registers about 240 patients a day on average, he says, up only slightly from the pre-pandemic average of 230 patients a day.
Typically the ER docs here see about 1.8 patients an hour. This is down from 2.2 patients an hour in pre-pandemic days, but not primarily because of COVID-19.
Much of it is due to technology, too.
Perhaps his biggest beef is the amount of time he says he’s now expected to spend interfacing with a screen instead of with patients.
The hospital laid off the clerks who used to input that data instead of repurposing them to be physicians’ assistants, and booking them on round-the-clock shifts.
“It’s now my job to put that information into the system. It used to be someone else’s job.”
The new, electronic medical record and computerized order entry system regularly malfunctions, he says.
In an emergency department.
He’s similarly baffled by a lack of cleaning staff, even as he scurries to make sure a room is opened up as fast as possible.
“A cleaner waiting to clean the room is seen as too expensive. Instead, they have a doctor waiting for the room. How is that cheaper?”
When he goes ahead and does the job — wiping things down, sanitizing — he does so at an hourly pay rate of 10 times or more that of the cleaner.
Then there’s patient care. On a recent overnight shift, he sent six patients home and rescheduled diagnostic tests for day hours because, despite a decade of ER group advocacy for full-night radiology coverage, they only handle life-threatening cases overnight.
Every time a patient who has registered to be seen in ER leaves and comes back, they have to re-register, at a system cost of roughly $400 each time — even if they receive no service.
One night, one doctor, six patients with unresolved issues, $2,400. Wasted.
This week the Financial Accountability Office revealed that Ontario underspent its budget for 2021-22 by $7.2 billion dollars (3.9 per cent), but overspent its health budget by $4.1 billion, of which $3 billion was for hospitals.
Did we get better care?
Last week, Canada’s provincial and territorial premiers demanded $28 billion more a year from the federal government for heath care, no strings attached. That is 65 per cent more than the feds are currently transferring to the provinces and territories for health care.
Not only is there no plan to fix the ER doctor’s light bulb, reboot his computer system or clean his examination room so he can do his job; there is no plan, period.
The cult of efficiency that has beset all public services since the 1990s has left the system unable to cope with surges.
We’re using the most expensive workers in the most expensive part of our health-care system to do work other types of workers could and should do, at far lower cost.
This is not a new insight. When I wrote a report for the federal government in 2006 about how to use international aid to drive better health-care outcomes, I tapped into stories about how people with no medical experience were trained to deliver simple health care to peers in their communities.
This thinking is regularly used in the distribution of malaria prevention tools around the world. We trained thousands of dental therapists to bring primary dental care to children in their schools in Saskatchewan and Manitoba in the late 1970s, using dentists only as needed. During the pandemic, we trained people with little medical experience how to become immunizers in eight to 10 hours.
Modular training, or “badging,” is used in skilled trades and the military to increase supply of particular skills and reduce bottlenecks. Why not in health care?
There’s no silver bullet for what ails us, but — as this doctor’s story shows — there are plenty of things that can be done, intentionally, systematically, to bring us back from the brink.
Hiring more lower-paid workers to help higher-paid workers put their skills to full use is a small step that could deliver big change, for patients and health-care workers alike.
More money without a plan isn’t a sustainable path forward.