Across Canada, under a number of provincial health systems, a spate of closures of emergency departments (EDs)—whether for hours at a time, a day, several days, or indefinitely—raises serious questions about how the health care system is coping with an existential crisis and what can be done about it. Largely, but not exclusively, in hospitals serving small towns and remote rural communities, these closures sometimes get announced with a handwritten sign taped to the hospital’s door, leaving patients and families who show up with emergencies to drive to the closest alternative facility.

Canadian EDs face many of the same overcrowding issues seen in the U.S. and other countries: long wait times and treatment delays; patients in need of emergency care piling up in waiting rooms; others boarding for days in ER bays—or hallways—often because there’s no bed available upstairs; ambulances “ramping” in the parking lot, unable to unload patients or respond to other emergencies in their communities. But closing the ED entirely, even just for a day, as has happened thousands of times in Canada in recent years, reflects a serious breakdown of the system.

Canadian emergency medicine advocates say the problem has been brewing for a long time, with warning signs that went largely unheeded by the provincial health authorities responsible for planning and budgeting health services in Canada. Then the COVID-19 pandemic hit, making everything worse.

“It’s a long-standing human resource problem that is now manifesting in what we could consider the most extreme form, which is ED closures in rural and remote areas of Canada, but also now in more suburban regions,” said Catherine Varner, MD, an emergency physician in Toronto and deputy editor of the Canadian Medical Association Journal.¹

Dr. Varner sees a confluence of issues coming to a head, presenting big challenges going forward. “We in emergency medicine on the ground are seeing the increasing complexity of our patient populations as they age,” she said. Canada also has a large and growing number of patients who lack a primary care physician and thus look to the ED for their primary care.

“What’s been surprising, both to people who work in health care, but also to the public, is that we’re seeing these closures more frequently, in higher numbers, in all regions across Canada,” she said. “Rural hospitals are saying, ‘We don’t have anybody to work tomorrow. We don’t have the professionals to provide the emergency care.’”

What’s Going On?

Examples of this epidemic of Canadian ED closures are not hard to find. Manitoba’s rural EDs collectively closed for 80,000 hours in 2023, four of them indefinitely.² In that same year, Ontario reported 1,200 closures of hospital EDs and other departments due to staff shortages. The Ontario Health Coalition of community grassroots organizations has been working to mobilize physicians willing to travel to different sites in need.

In British Columbia, CTV News reported on June 6, some hospitals are offering qualified doctors bonuses of hundreds of dollars, up to $4,000—per shift—to pick up some extra ED shifts in hospitals that need it.³ Northern British Columbia has been hit by ED service disruptions again this summer, prompting public rallies calling attention to the closures.⁴

A Domino Effect?

Ken Milne, MD, MSc, CCFP-EM, is a staff physician at Strathroy Middlesex General Hospital in Strathroy, Ontario, and the creator of a podcast called “The Skeptics’ Guide to Emergency Medicine.” He said every Canadian deserves timely and appropriate access to emergency medicine, but the system is not currently meeting that need.

“In Canada, most of our country is rural, and the ED closures are almost always in rural areas,” Dr. Milne explained. If staff call in sick, there’s no one to replace them. “But the closure of an ED can impact surrounding facilities, with their own fixed number of staff, turning into a domino effect and making it harder for people with emergency needs to get the help they need.”

In addition, he said, physicians are getting older and withdrawing from night work and high-intensity shifts. Meanwhile, medicine has gotten more complex for general practitioners, and patients’ expectations have also changed. “So how do we micro-allocate scarce resources? You’ll always have a challenge in rural areas. But people coming into the field now rightly want a team-based work environment where they can also have a life away from work.”

Emergency medicine is a heterogenous specialty in Canada. Some emergency physicians are board-certified after completing a five-year emergency medicine residency. Others do a one-year emergency medicine fellowship following family medicine training. And some family physicians in rural settings serve as generalists, combining clinic work, hospital wards, and ED shifts, possibly also doing anesthesiology and visiting patients in long-term care facilities. They may seek additional training in advanced trauma life support, advanced cardiac life support, pediatric advanced life support, and neonatal resuscitation, along with self-directed learning.

“I’ve been doing this work for 30 years,” Dr. Milne said. “I love rural medicine. I was raised on a farm. I’ve worked in 30 rural Ontario hospitals via Health Force Ontario. I also love practicing up to the limit of my skill set,” he said. “But the job certainly has changed. People are living longer, and medicine is much more complex. It’s getting harder to stay up to date on all the advances.”

What Are the Answers?

One solution to chronic staff shortages, Dr. Milne said, is to grow your own—drawing on people born and raised in the community. That involves decentralized training, ideally combining nurses and physicians together, and placing doctors-in-training back in their home communities. Northern Ontario School of Medicine University and the Centre for Rural Health Studies at Memorial University of Newfoundland have both developed programs aiming to entice more doctors to choose rural careers by exposing them to rural medical practice.

Other efforts have included provincial locums programs in Ontario and British Columbia to connect physicians with departments in need; the growing availability of on-demand virtual clinical support from remote physicians; and the greater use of nurse practitioners, physician assistants, and community paramedics in the ED. The Canadian Association of Emergency Physicians (CAEP)’s EM-POWER, a comprehensive task force report on the future of emergency care in Canada issued in March, proposes a roadmap to a redesigned, integrated framework for emergency care.⁵

A regionalization strategy for utilizing scarce rural emergency services, which has been explored by CAEP as well as by groups in Nova Scotia and Alberta, could link facilities and services in a more systematic way, pooling the resources of several rural hospitals located not too far from each other and struggling to stay open. Depending on driving distances, they could designate one as the center of excellence in emergency medicine for the region, said Alan Drummond, MD, a family physician who has practiced emergency medicine in Perth, Ontario (population: 6,000) for 40 years.

Dr. Drummond has been president and public affairs committee chair for CAEP, actively involved in provincial and national politics, and a widely published and outspoken voice trying to bring attention to this brewing crisis in Canadian emergency medicine. A decade ago, CAEP put out a position paper predicting a shortage of 1,500 emergency physicians in Canada by 2025, “if we didn’t start planning for the near future, which is now on us,” he said.⁶ In Canadian politics, health care is a vote loser. “So, the alternative is keep doing what we’re doing now, which is precisely nothing,” he said.

“When I started this work, my vision for myself and my country was that every Canadian would not just have access to emergency medical care, but quality access. I dedicated 34 years of my life to that goal,” Dr. Drummond said. “Let’s declare this to be the crisis it is. Let’s admit the obvious threat to services for millions of Canadians.”

The system has particularly failed to nurture its emergency medicine nurse colleagues, Dr. Drummond added. “We tell them to shut up and work, never paying a dime more than necessary, not treating emergency nursing as a specialty. If they get punched by a patient, we say: ‘What did you do to deserve it?’” Historical wrongs like this have permeated nursing, he said, and then along came COVID-19. Nurses, realizing that they were just cogs in the wheel, said they were done with it and found other jobs. But Dr. Drummond believes they might come back if they sensed that their working conditions would be improved, because practicing emergency medicine can get in your blood.

Larry Beresford is a freelance medical journalist based in Oakland, Calif., with a specialty in hospice and palliative care and thorough experience covering hospital medicine.

References

1. Varner C. Emergency departments are in crisis now and for the foreseeable future. CMAJ. 2023; 195(24): E851-E852.
2. Crabb J. Manitoba‘s rural emergency departments closed for 80,000 hours in 2023. CBC News. Published April 16, 2024. Accessed October 26, 2024.
3. Daflos P. Health authority offers $4,100 for doctors to work in B.C. emergency department. CTV News. Published June 6, 2024. Accessed October 26, 2024.
4. Pelley L. Canadian ERs keep closing this summer — but there‘s no easy fix. CBC News. Published August 17, 2024. Accessed October 26, 2024.
5. Canadian Association of Emergency Physicians. EM:POWER: The Future of Emergency Care. Published March 2024. Accessed October 26, 2024.
6. Collier R. Canada’s emergency medicine shortfall. CMAJ. 2016;188(11): E246.