When you choose an action, you choose the consequences of that action. When you desire a consequence, you had damned well better take the action that would create it. We all make choices, but in the end our choices make us.
Today we face an unprecedented crisis in health care. Never before have so many citizens been disenfranchised from accessing a basic public service at a time when we never before had so many health practitioners. This paradox has confounded political leaders, health planners and more importantly those who need the service that is being denied, when 50,000 Nova Scotians visit an emergency department and leave without being seen because the wait is just too long.
In 1982 when I graduated, it was not uncommon for a freshly minted physician to spend some time in general practice before dedicating life to one of the many branches of medicine. As a consequence, a steady stream of physicians prepared to serve the public was available, providing much needed relief to family physicians especially in the periphery. Over the last 40 years, training requirements have changed such that medical students must choose their career path after three years of medical education and must enter that training stream immediately upon completing four years of medical school.
There is no option for a gap period before specializing. Ostensibly this change was driven by the lofty goal of improving training but a closer look would suggest that this was driven by bureaucratic determination to make the supply of clinicians more timely and predictable and provide better leverage for governments to alter the ratio of family physicians to specialists with the ultimate goal of controlling costs.
In my opinion, both family physicians and specialists are less prepared for their chosen field of practice under this model than the prior training program.
The voices in the wilderness that decried this move were silenced and so they just put their heads down and worked. Today that cohort is retiring, is burnt out, or dying and those who are present to fill the void have declared that the approach to patient care taken by those they are replacing was unsustainable, counterproductive, unsafe, and harmful; but for whom?
The actions of the bureaucrats in the early 1980s had consequences. For example, in the wake of the 1991 Barer-Stoddart re¬port (commissioned to look at physician resources in Canada), British Columbia (like many other provinces) acted to reduce enrollment in medical schools. Years later, governments began to recognize their error and increased the number of doctors in training. It was too little too late. It was true for nursing as well.
Medical schools continue to reject the vast majority of suitably qualified applicants. Thousands of young Canadians currently attend some 75 foreign medical schools. That is an inexcusable exodus of Can¬adian talent because many will not be permitted to obtain Canadian licenses.
Ten years ago the Organisation for Economic Co-operation and Development (OECD) stated that medical human resources in Canada were well short of the OECD average, and it estimated then that we needed 26,000 more doctors and yet poorly advised politicians promised the impossible like a family physician for every Nova Scotian, or an ultimate fix for health care.
For decades we have been warning of the impending health human resources crisis. In 1997 the average age of nurses was already 44, rural physician numbers had declined exponentially, and training programs for both nurses and physicians were not linked to the need of the population.
There are consequences to the inaction that accompanied those observations; 105,000 Nova Scotians do not have a family doctor, and that number is likely 10 to15 per cent higher. My age cohort will be retiring in significant numbers and the practices we leave are larger than what new physicians are prepared to accept by a factor of two, some say four. By the end of the year, it will be closer to 150,000 tracking to 200,000 people looking for a primary health care provider.
In the last 15 years, in this sector of the province, some 30 physicians have come and gone. For the last several years, residents of Richmond County have had to endure multiple days per week where the nearest emergency room was located in either Sydney or Antigonish; an 80 minute drive one way.
Ambulances are often unavailable either because they have already taken a patient to one of these departments and have long unload times, or are tied up elsewhere. The emergency department on Isle Madame has lost its status and is now an outpatient department that is by-passed by local ambulances. Some would say we have regressed to third world conditions. The consequences are dire; increased morbidity and mortality.
Recent government policy advising Nova Scotians to get out there and abandon all pandemic restrictions coupled with the low booster rate have contributed to an increased burden on an already overheated health system. The failure to appreciate that health workers would be impacted by a higher infection rate is a prime example of what happens when you choose an action, but fail to understand the consequences of that action.
Who should be held accountable for that choice? Given that we have no arms’ length body overseeing decisions in health, it begs the question where is the transparency and accountability promised to Nova Scotians?
Promises of collaborative practices and reform of primary care are laudable, but in reality, they only serve those that already are in the care of physicians and other allied health workers. Although good news that the health minister highlights that 200 nurses will soon join the system, these newly minted nurses are not ready for the hurly burly of modern ICU’s, Emergency Departments, and other demanding clinical situations. It is a false narrative to suggest otherwise.
It is time for government to recognize that we are in unprecedented times and that unless unprecedented actions are implemented more unnecessary deaths will occur. Nova Scotia had more deaths and hospitalizations since pandemic restrictions were lifted than the first two years of the pandemic. The worst may be yet to come.
The Minister of Health has a duty to the people she serves. She must lay out a clear assessment of what it will mean for people to have reduced access to diagnostic imaging, laboratory services, and primary health care in a timely manner for the next five years. She must use her power and that of the government to establish extraordinary access points where physicians and nurses can screen and triage Nova Scotians who have urgent needs.
Placing someone on a wait list for an opening to a health practitioner or using virtual care is not adequate and frankly inappropriate. People are dying on wait lists, others are suffering in physical or mental pain and all that is being proposed are platitudes.
Physicians and nurses are working very hard and some have reached their end point. There is some elasticity within the family physician and nurse practitioner community but also within the retired health worker community that is untapped. We have seen family physicians step up to help out in walk-in clinics but these are nor targeted nor funded to go after the risk groups that are sitting on wait lists or walking away from Emergency Departments.
These patients may come back with untreatable cancers, end stage congestive heart failure, or are debilitated to the point where they cannot work. It is time to entice physicians and nurses to intervene with the zeal and commitment needed in a crisis but to ask that of them means that government and professional organizations will have to think outside the box.
We should be in natural disaster mode when usual practices are adjusted to address acute health issues. We have a problem, where is the plan? Where are the actions to mitigate the suffering as it is the consequence of doing nothing for the last three decades?
Dr. Robert Martel
Arichat