Here’s why your ER doctors are leaving
Many of us are no longer able to do what we trained to do
Canada is facing an exodus of our emergency room doctors. Smaller ERs increasingly lock their doors to the public as there are no doctors or nurses to staff them, leaving people to travel to the next closest ER in their greatest time of need. Sometimes, if that ER is too far away, they die preventable deaths.
In my group of 50 ER doctors in Victoria, B.C., nearly all of my colleagues have either considered an alternative occupation or a reduction in shifts. One freshly minted attending physician, after 13 years of gruelling education and training, is thinking about “other options.” How have we come to this? Why are so many leaving?
Moral injury pertains to the effects of perpetuating, observing or failing to prevent acts that transgress deeply held moral standards. ER doctors are leaving in droves because we can no longer do what we trained to do; we can no longer help people — our raison d’être — to the standard they deserve. In short, continual moral injury is breaking your ER doctors.
Our beloved universal health-care system can be seen as on par with a developing country’s. (The Commonwealth Fund, a health-care advocacy group, ranked Canada’s per
formance 10th among 11 high-income countries — with the U.S. last.) Heart attacks and perforated guts languish for hours in the ER wait room, directly leading to morbidity and mortality for the unfortunate patients. Only a small portion of these stories make it to the media. And universal access to our broader system is a joke when getting a GP is increasingly about who you know, faster care is awarded to those who shout the loudest, and those who can afford it pay for private imaging or fly to the U.S. to get more timely care.
Tragically, I regularly diagnose more patients with late-stage cancers than ever. These are people who should have been screened earlier, but either did not have a family doctor or had insufficient access to one, and are now sentenced to die. Perhaps worse are the cases when someone’s cancer has been caught at an early stage, but they come to our ERs seeking help as they are still waiting two months later for their first appointment with an oncologist. All I can do is offer my sympathy and send them home with the knowledge that their treatable cancer is spreading.
This is an unconscionable systemic failure. As ER doctors, we lack the tools to fix this problem, but we bear the brunt of the emotional toll because patients have nowhere else to turn. And we, rightly, never turn our patients away from at least seeing an ER physician.
In our very busy city hospitals, perhaps 15 per cent of ER patients have actual medical emergencies. The vast majority of ER patients are presenting with family medicine problems. My non-medical partner is no longer surprised to see me arrive home, invigorated, after having treated a patient that was stabbed or shot, after resuscitating a patient with septic shock, or even after giving a patient a dignified death surrounded by family when their time comes. These are true medical emergencies and it is what I’m trained to do, something that only a very few of us in society are capable of doing. And it feels so good to be of use.
But these shifts are the rarity, maybe once or twice a month. I work whole shifts without having a patient sick enough to be admitted to hospital and after those, I feel emotionally exhausted. For the vast majority of my shifts, I am plugging holes in the dam, responding to social, and often serious, chronic problems that I am not equipped to deal with. Patients are not to blame; they really have nowhere else to go.
When we do see acutely unwell patients, we are forced to compromise on our standards due to our stretched health-care system. Examination in hallways for lack of space is all too common, depriving patients of respect and dignity. Patients with alcohol or drug abuse who finally get the courage to come in for help are sent away because we lack detox beds. Or the family of an 85-year-old must be convinced that taking oral antibiotics at home for their UTI sepsis really may be the better option than languishing in an ER bed for 36 hours and developing delirium because there are no admission beds — the latter being what the patient actually needs. I walk away from these discussions feeling a deep burden of guilt for something completely out of my control. This is moral injury.
When I walk into a patient room in my ER, I usually apologize for the long wait. If I can address the anger that almost all patients experience after waiting eight hours to see me, I know that the assessment will go better. As eight-, 10-, 12-hour waits become the standard, I find myself apologizing 20 times per shift, 15 shifts a month, likely thousands of times per year, for something that is not my fault. While I’m just the face of a system that has failed, my nursing colleagues and I bear the brunt of patients’ frustration and anger.
ER doctors, leaders of highly skilled teams, are generally bighearted people who want to help those in need. It can literally be a thankless job, with our sickest patients never remembering the team who saved their lives because of the severity of their illness. The offhour and shift-work nature of the job has been proven to reduce our life expectancy by around five years. Instead of reading to my two young kids at bedtime, I am instead, on many nights, seeing those in need at the hospital. Suicide and burnout rates for ER doctors are among the highest of any profession. So why do we do it? Because, underneath the superficial visage of being the “adrenalin junkies” and “surfer dudes” of the medical world, we want to make a difference for our patients. It’s a principled choice. The people who come to see us in the ER often have nowhere else to go and we are uniquely placed to help them. We could have trained to be radiologists or dermatologists, work regular office hours, make on average twice as much and live five years longer. But we wanted to help people in their most vulnerable and sickest hour.
Long gone are the days of the early pandemic, when our neighbours banged their pots and pans in appreciation every evening. Now we are yelled at every single shift about the long wait times. We are verbally and physically assaulted so regularly that the B.C. provincial health authority recently mandated violence-prevention training. All these things, it’s just too much.
We are just at the beginning of this crisis — more doctors will leave, fewer will sign up to train in emergency medicine and governments will try to fill in the holes via physician assistants and other stopgap measures. Or they’ll try to squeeze more out of the antiquated feebased pay system designed in the 1970s that rewards ER doctors who spend less time with each patient. Further ERs will close and wait times will increase. How many people will have to die before our governments are shamed into real action, real change?
I’m not sure I’ll still be there to find out.