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Avis Favaro

What do you do if you’re sick with symptoms that worry you, but you don’t have a family doctor or there’s no walk-in clinic to turn to? People need health care from a doctor or nurse practitioner, but some turn to this: the local emergency department.

Each year, there are over 15 million visits to ERs across Canada, but new data is showing that about 15% of these — 1 in 7 — are for health conditions that could potentially have been treated in primary care.

We’re going to talk about how to interpret this new data with ER physician Howard Ovens.

Howard Ovens

The most important thing is what we don’t do. We don’t misinterpret the data and blame patients for coming to the emergency department, causing emergency department overcrowding. If you think you have an emergency, come to the emergency department. We want to see you.

Avis Favaro

We’ll also talk to a patient who says she had no choice but to go to emerg. Her doctor wasn’t around, and Shelley Petit says she actually felt ashamed to take up a spot in a crowded New Brunswick emergency unit.

Shelley Petit

I was in so much pain. I knew there was something severely wrong. But at the same time, I felt guilty being there, that — what if I took the place of one of these babies? They’re in so much pain. Or, you know, a senior?

Avis Favaro

Welcome to the Canadian ������ϱ� Information Podcast. We call it the CHIP for short. I’m Avis Favaro, the host of this conversation.

A note: the opinions expressed here don’t necessarily reflect those of the Canadian Institute for ������ϱ� Information. But it is an open discussion, and this episode is about how the national crisis in primary care is showing up in emergency rooms across the country.

We now welcome Dr. Howard Ovens, a long-time ER physician in Toronto. Thanks for coming on the show to explain the data, Dr. Ovens.

Howard Ovens

Pleasure to be with you, Avis.

Avis Favaro

Okay. So the key question, or the key point in the data, is that ������ϱ�surveyed over 1.2 million ER visits in 6 provinces. And when they look at the analysis according to why they went to ER, about 1 in 7 people who were there potentially could have been seen and helped by a family physician or a nurse practitioner. When you saw the data, were you surprised by that 1 in 7?

Howard Ovens

So there are 2 groups of people buried in that statistic. The first group thought they had an emergency. They were concerned, anxious and presented to an emergency department and, luckily, turned out that their final diagnosis was one that was not particularly serious. They were discharged, and the diagnosis on their chart is one that you could see in a family doctor’s office regularly.

To me, those people belong in the emergency department. They thought they had an emergency. We’re all glad that it wasn’t in the end, but it took some thinking and assessment by an emergency physician to make that determination.

There are other people who didn’t really want to come to the emergency department. They just couldn’t find an alternative. They don’t have a family doctor. And those people, in frustration, come to the emergency department. And ideally, in a well-designed health care system, those people could have accessed their alternatives.

Avis Favaro

Let me share part of our interview with one woman, Shelley Petit from Fredericton. She actually has a family doctor, but he wasn’t available. Have a listen.

Shelley Petit

I was in so much pain. I felt like I couldn’t stand, but I couldn’t sit or lie down. It was just all-consuming. And to the point, it was really, really scaring me. So I thought, “okay, there’s something really, really wrong. I need to go get checked.”

Avis Favaro

You’re one of the lucky Canadians who does have a family doctor.

Shelley Petit

Yep.

Avis Favaro

Where was your physician? Could you go see him or her?

Shelley Petit

He was working at another hospital at the time because in New Brunswick, family doctors have to do a couple weeks within the ER at all times. And so called the office. No, he’s working at the other hospital. But it was not the acute care hospital, which is where I had to go. So I couldn’t even potentially see my family doctor. And we’re so short on doctors.

Avis Favaro

And so then you turned to virtual care. I mean, you were doing your best to avoid —

Shelley Petit

Yeah.

Avis Favaro

— the ER. I give you points —

Shelley Petit

Yeah.

Avis Favaro

— for this.

Shelley Petit

Yeah. I called virtual care. I called the system, did the online, and they told me, “no, you have to go in. We can’t help you with this.”

Avis Favaro

Why?

Shelley Petit

Because they thought I would need labs done. I might need an X-ray done. So I had to go into the hospital. I was trying with everything to avoid it, but to no luck.

Avis Favaro

So, Dr. Ovens, do you see these sorts of cases? They have no doctor or, like Shelley, they just don’t have another option?

Howard Ovens

Every single shift.

Avis Favaro

Really? Tell me why they’re there. Why are they coming to emerg?

Howard Ovens

Well, the total range of health care concerns — from things like my family doctor retired and I don’t have anyone to prescribe my blood pressure medication for me, to I’ve got a fever, sore throat, I’m not feeling well, I’ve got abdominal pain, and the full gamut of reasons that people come to emergency departments.

Avis Favaro

How do you feel when you hear that?

Howard Ovens

First of all, it’s challenging and, at times, almost sad for patients who really have some problems that require continuity of care, that they don’t have that service when they’re entitled to it. They’ve paid taxes for it.

And of course, it’s frustrating because it adds a further degree of complexity to our work, which is already, by its very nature, challenging and complex. And now, you’ve got another layer, which is: I’ve taken care of today’s problem, but what are they going to do next?

Avis Favaro

Do you feel that group of patients is growing? Or the severity of their problems that they’re bringing to the ER is increasing?

Howard Ovens

Both. Because of the crisis in access to primary care, the duration of time since people who previously had a family doctor have gone without an annual checkup or screening exams that are recommended by our best evidence — they haven’t had these things done in some time, so other problems have developed or progressed.

Avis Favaro

So you’re seeing, for example, people show up with advanced diabetes?

Howard Ovens

All kinds of problems that have been left to fester: diabetes, hypertension, in some cases early symptoms that we’ve done some research here at Sinai — one of my colleagues — on, unfortunately, how frequently we diagnose cancer in the emergency department.

Avis Favaro

I’ve heard that. It must be so hard because in a lot of cases, these can be detected early or prevented, like colon cancer. How do you feel when you see a case like that? What does that do to the morale of your, you know —

Howard Ovens

Well, there’s always complexity in health care, but we are seeing, unfortunately, a bit of an increase in prevalence of colon cancer in very young people, 20s and 30s. And I have made that diagnosis myself a few times. Very memorable, very sad because usually, when we’re making the diagnosis, it’s not an early diagnosis. And of course, this can be very devastating.

Avis Favaro

So in the context of this report, it’s really a sign that the primary care system is not working the way it should be. Can we put it that way? How would you phrase it?

Howard Ovens

This data is not directly measuring access to primary care. It’s a proxy for that because we don’t have — ������ϱ�— when I say we, the health care system — ������ϱ�doesn’t have data on primary care access, primary care visits. We don’t have a number that tells you, even of those people who have family doctors, how many can get an appointment within 24 or 48 hours when they need it. We don’t have that data. So we try to squeeze some of information implied out of the emergency department data. So it’s a proxy for what we’re talking about.

Avis Favaro

And so what does the data tell you?

Howard Ovens

There is a signal here, which can be most appropriately measured against itself over time and between jurisdictions to give us information about trends across the country, by community and over time about access to primary care.

When we take that data and combine it with what we both know from health care system data more broadly, as well as our personal experience working in emergency departments, we know that there is a crisis in access to primary care.

Avis Favaro

So here’s a bit more of our interview with Shelley. Not only was she desperately trying to avoid going to an ER, she says she actually felt terrible about sitting in this packed waiting room, despite being in severe pain.

Shelley Petit

A war zone. Honest to god, this is what I think it looks like in the hospitals in Palestine and Israel right now. It’s just so many bodies everywhere, begging for help. Begging for help.

Avis Favaro

Really? That —

Shelley Petit

Yeah. Yeah. “Help me.” They’re in pain. People are crying. The worst is when the children are there crying. And it’s heartbreaking. You know? And we’ve had people that are dying in waiting rooms here in New Brunswick. And this should not be happening. I don’t understand it.

Avis Favaro

Did you feel guilty?

Shelley Petit

Yes. I knew I was in excruciating pain. I knew there was something severely wrong. But at the same time, I felt guilty being there, that — what if I took the place of one of these babies? They’re in so much pain. Or, you know, a senior? Because I think of my mom, who’s been going through stroke issues. And it, you know, how can you feel okay being there when you know so many other people might need the same bed you do?

Avis Favaro

Guilty about going to the ER. That’s pretty powerful. Dr. Ovens, do you hear patients say that?

Howard Ovens

Yes.

Avis Favaro

What does that tell you? Or what concerns you about stories like that?

Howard Ovens

I don’t want any patient to feel guilty when they are seeking help for a problem that they are worried about or suffering with. So I’m very sorry that the deficiencies in our health care system made anyone feel guilty for seeking help.

She’s also not the main problem causing ED crowding and long waits. That’s much more related to seriously ill people who need to be in the hospital but are waiting for a bed in the emergency department for many hours and, in many cases, many days and using up limited resources of nursing time and bed space, stretcher space. And so our efficiency in seeing new patients is severely compromised.

And so she shouldn’t feel guilty. We’re very grateful if people like that are patient and polite to the staff. People get very frustrated and angry with us at times, but she should not feel guilty.

Avis Favaro

Other patients have told us that they try to avoid going to the ER by using virtual care, the virtual care services. But several of them told us that they are often told to go to emerg because the doctor on the other side of the Zoom call doesn’t have the skill. So is virtual care helping or hindering care?

Howard Ovens

So I’ll have to choose my words carefully. We do feel, me and my colleagues who work in emergency departments, that there are areas in the health care system that have been designed for the advantage of providers rather than patients, and where they are mostly focused on doing quick assessments of relatively simple problems and where, if you’re going to take up more time or resources or expose them to more liability, they will refer you pretty quickly to an emergency department, whether you think you have an emergency or not.

Avis Favaro

You’re —

Howard Ovens

And —

Avis Favaro

— referring to walk-in clinics and virtual care in some cases?

Howard Ovens

Yes. So to me, virtual care, it is fantastic that a patient who didn’t really want to see their doctor in person — maybe they, again, need a prescription renewal. Maybe they want to discuss the results of a test they just had or follow up on a problem with a physician they know, who knows about that problem. And saving them time and parking and travel expense and treating them virtually is fantastic.

But as the initial assessment of an undifferentiated problem, it’s challenging and it’s very unhelpful if the service that’s provided is not connected to the rest of the health care system so that proper continuity of care can be observed, warm handover referrals can be made, records can be kept which are accessible to other members of the health care team.

And we do have a lot of providers, both individual physicians’ groups and corporations, who have designed a system that is profitable but does not — you know, does not meet, holistically, the needs of these patients and relies a lot on emergency departments to be their safety net.

Avis Favaro

You know, interesting. That’s a question that Shelley, the patient in New Brunswick, actually asks herself. Did the virtual service help her avoid the ER? No, it didn’t, she says. Here’s part of her interview.

Shelley Petit

I think it was a cover-your-butt situation. “We don’t know quite what’s going on. We can’t really tell. You probably need labs or an X-ray. So you go because we don’t want to be responsible if we tell you, ‘well, no, just take some extra Tylenol and try to deal with it,’ in case it was something more severe and you have a worse response down the line.”

Avis Favaro

So you went reluctantly?

Shelley Petit

Yes. I avoid the hospital with everything I can.

Avis Favaro

So, Dr. Ovens, what do we do with the data that ������ϱ�has collected here?

Howard Ovens

So the most important thing to me and my colleagues is what we don’t do. We don’t misinterpret the data and blame patients for coming to the emergency department or blame people without family doctors or without access to them for causing ED overcrowding.

What we do is use it as one of a number of measures over time to tell us if we are finally starting to address the access to primary care crisis. Are we creating more capacity for comprehensive primary care, more ability of groups of family doctors to see people in a timely way for urgent, unscheduled types of problems?

Avis Favaro

So you would want to see this 1 in 7 decrease over time?

Howard Ovens

Absolutely. Yes.

Avis Favaro

That’s a marker you would like to see. So, I guess, to sum up then, people may be confused, and I have a sense that a lot of people don’t even go to emergency. Does that worry you when data comes out and it’s misinterpreted?

Howard Ovens

Yes. So we are always seeing and we’re always afraid of very responsible people who read about long wait times in emergency departments or hear people in leadership positions talk about inappropriate use of the emergency department, and they decide that they better tough it out at home and they’re actually losing precious time with a time-sensitive issue. And we see them when their appendix is already burst or their stroke or heart attack can no longer be reversed, et cetera.

Avis Favaro

So the data, when it’s not appropriately framed, can scare people away and cost lives?

Howard Ovens

Absolutely.

Avis Favaro

Interestingly, the patient, Shelley, feels exactly the same way. And she had this message.

Shelley Petit

It’s your body. Listen to your body. We know our bodies. You know, sometimes you get an ache or pain that, oh! But you know it’s going to go away in 5 minutes, and it’s going to be bad, but, you know, we’ve been through all this in our bodies. But when you know, like, this is not normal. This is not a natural pain. This — whoa, like, this is bad, and it’s staying and getting worse, you gotta go. Go. Just bring a well-charged phone and a book and some snacks.

Avis Favaro

So to sum up, Dr. Ovens, we’ve got to be careful with the data.

Howard Ovens

I think this data is more useful to health care system leaders than to individuals. Again, this is an important signal among many that can give us a scorecard on how we’re doing in rebuilding the primary care system, which is the foundation of our health care.

My message to individuals and their families who may be experiencing a concern is if you think you have an emergency, come to the emergency department. We want to see you.

Avis Favaro

All right. Thank you very much, Dr. Ovens. Appreciate it.

Howard Ovens

My pleasure.

Avis Favaro

There’s much, much more data on this report, including provincial differences in ER visits by patients who could potentially have been taken care of in primary care but weren’t. It’s all posted at cihi.ca.

Thank you so much for listening, and please subscribe to the CHIP wherever you get your podcasts.

I’m Avis Favaro. Talk to you next time.