At least two dozen Ontario hospitals have turned to a privately run company for temporary physicians, as a growing shortage of doctors threatens to close small and mid-sized hospital emergency rooms across the province.
Med-Emerg International Inc. - which operates as a temporary staffing agency for health-care professionals based in Mississauga - currently supplies doctors to 24 Ontario hospitals, says company founder Dr. Ramesh Zacharias.
"The reality is that this isn't the worst yet," says Zacharias. "It's going to get worse before it gets better. If you have a problem with your health-care system, it will show up first in the emergency department. All of these factors within the past 20 years are coming together."
The physician shortage almost forced hospital emergency departments to close this summer in Sudbury, Kirkland Lake, Guelph, Belleville, Collingwood and Kitchener-Waterloo, according to local newspaper reports.
Officials with the Niagara Health System (NHS) issued a press release late last month saying they were developing a contingency plan in case the continuing shortage of physicians "forces the NHS to temporarily shut down an (emergency department), as other Ontario hospitals facing similar pressures have done over the last several months."
The Niagara Health System is responsible for five emergency departments throughout the region and one walk-in clinic in St. Catharines.
"In the last several months, as the shortage of physicians has become more acute in emergency departments across the province, it has become increasingly difficult to secure physicians from the agency for our emergency departments in Niagara," Tracy MacDonald, vice-president of patient services, said in the press release.
Emergency department doctors at two of the Niagara region's hospitals - Port Colborne General and Douglas Memorial - also act as the community's family doctors and must juggle busy family practices, the NHS press release notes.
Speaking off the record, officials at Ontario hospitals say the long hours, high stress and relatively low pay make it difficult to attract emergency-room physicians for their staff. Some larger hospitals are also believed to be "topping up" doctors' wages in other departments, making emergency-room work even more unattractive.
The Canadian Association of Emergency Physicians (CAEP) first went public about the situation in June 2005, with an awareness campaign called, "Canada's ERs: We Can't Afford to Wait Any Longer.”
At the time, a group spokesman said the public must understand the situation is unnecessary and solvable.
It appears as if the problem has continued. Two Alberta women suffered miscarriages this summer while in a hospital emergency waiting room with dozens of strangers watching.
In Vancouver, a study released last spring showed 15 of the region's hospital emergency departments were found to have waiting times that were higher than national standards.
A level-three triage patient requiring urgent critical care, for example, is supposed to be seen by a doctor in 30 minutes or less. But at Surrey Memorial Hospital, statistics showed a typical level-three patient has to wait 113 minutes to see a doctor.
Back in Ontario, the issue made headlines in the Kitchener-Waterloo region earlier this month when officials at the Grand River Hospital were hours away from locking their doors to emergency patients and sending away ambulances.
Hospital administrators finally went outside the region to bring in other doctors who could cover the needed shifts. The hospital's roster of ER physicians was used up after working extra shifts for almost a year to keep the emergency department open, one doctor told the Kitchener-Waterloo Record newspaper in a story published on Oct. 14.
Closing the emergency department at Grand River Hospital would have meant ambulances and patients would have been diverted to the area's other medical facilities, including Cambridge Memorial Hospital.
But Cambridge Memorial was already struggling with staffing problems of its own.
The board of directors announced late last month it was hiring a Med-Emerg executive on a six-month contract to run its emergency department.
Med-Emerg's vice-president of medical services, Dr. James Ducharme, would be responsible for recruiting new emergency physicians and his eventual replacement. His mandate would also include "developing new protocols and policies to deliver emergency medicine," according to a hospital press release.
Cambridge Memorial had been searching for someone since the departure of its chief of emergency last June. He had quit after being in the position for less than a year.
A report in the National Review of Medicine last January said 12 out of 14 emergency physicians and "many senior nurses" quit their jobs at Cambridge Memorial during a few months last year because of high stress and management urging them to see patients more quickly.
But the hospital also had its high-profile admirers.
Earlier this spring, the Toronto-based Registered Nurses' Association of Ontario (RNAO) recognized Cambridge Memorial Hospital as one of 12 "spotlight health-care organizations for best practices across Canada."
"The RNAO chose spotlight organizations for their proven track record with nursing best practices and their commitment through financial and human resources to ensuring their successful implementation," a hospital press release from last March stated.
Opposition politicians at the Ontario legislature argued the province was headed down a slippery slope toward privatized health care by using Med-Emerg to essentially run the emergency department.
"You have to look beyond the politics at the real facts," Med-Emerg's Zacharias said in an interview. "Hospitals have been using a non-clinical model of outsourcing for the past 40 years, with services like laundry and dietary. The unfortunate victim here is the truth. This is not privatization."
Other hospital departments have been using doctors who provide their services as "independent contractors" for years, he adds.
Zacharias says Med-Emerg has worked with more than 60 hospitals during the past 23 years of being in business. "Our doctors have seen more than three million patients at these hospitals in Ontario and not a single patient has ever been sent a bill," he says.
But critics point out Med-Emerg still bills the hospitals and those costs are paid by the provincial government, so it still comes out of taxpayers' pockets.
"There is a cost to having us at the table, but the hospitals would have these costs anyways. They have to staff the emergency departments with doctors and set up billing and administration systems," Zacharias says.
Doctors under contract with Med-Emerg are paid the same as their emergency department colleagues under provincial guidelines, he adds.
Zacharias says as part of the contract, each hospital is charged an "administration fee," based on what services it would like Med-Emerg to provide.
He would not say how much Cambridge Memorial Hospital was paying Ducharme and Med-Emerg for its services.
Cambridge Memorial CEO Julia Dumanian declined an interview request from Business Edge, saying she had a full schedule of other appointments.
Hospital spokesman Chris Sellers, however, did respond to questions about the cost of hiring Med-Emerg. "As this is a private contract, it is not appropriate to identify the amount. However, we have a set and approved budget and the contract is within our budget," he wrote in an e-mail.
Zacharias says the solution is for Ontario to use more of a "collaborative team-based health-care model.”
For example, a cast technician could look after someone with a broken leg or a nutritionist could counsel a patient with a dietary problem.
Zacharias adds hospitals could also use more nurse practitioners - nurses who receive extra university training to perform additional services, such as performing an annual physical or writing prescriptions.
Willi Kirenko, president of the Nurse Practitioners Association of Ontario, says her members can't replace physicians, but evidence shows they can make emergency departments run smoother.
Kirenko, who is based in Chatham, participated in a six-month experiment earlier this year where registered practical nurses and registered practical nurse assistants were used in the emergency department waiting room.
"The experiment was a resounding success," she said in an interview. "Patient-satisfaction surveys were way up. They really appreciated the extra attention while they were waiting (to see a physician)."
Kirenko said there isn't much difference in salary for nurses who decide to go for the additional nurse practitioner training. "They do it to further their own personal development and serve the local community more than anything else," she explained.
Ontario Premier Dalton McGuinty said his Liberal government would not stop Cambridge Memorial from hiring Med-Emerg to run its emergency department on a six-month basis.
"I hope it doesn't end up that way, but as an Ontarian, if I've got to choose between a privately funded doctor and no doctor, then I'd take the privately funded doctor," McGuinty told Canadian Press.
The provincial health minister warned other hospitals not to do the same as Cambridge Memorial.
Using any kind of temporary medical staff is not a good idea because they aren't used to working together as a team, says Doris Grinspun, executive director of the Registered Nurses Association of Ontario.
"Nurses in the emergency department have to make split-second decisions and be able to anticipate and respond to each other. We are against any temporary people because they would not be able to work the same as a regular full-time employee," Grinspun says.
"You have to ask why the government is suddenly having this shortage of doctors all over the place when there are practical nurses right now (that) are looking for work. They want jobs."
Zacharias says hospitals in other Canadian provinces have not directly asked about hiring Med-Emerg doctors on a temporary basis, at least for the past few years.
"I would certainly be willing to talk to them if they called, though," he says. "Something needs to be done."
(David Hatton can be reached at hatton@businessedge.ca)
