We’ve heard about the shortage of family doctors in Canada and a second crisis of understaffed emergency rooms across the country. But what happens when your emergency doctor is your family doctor?
On Fogo, a tiny island with 2,200 people just off the northern coast of central Newfoundland, the family-doctor shortage and emergency-room crisis aren’t two problems — they’re one and the same.
For the first time in centuries, Fogo Island, with its 17-bed hospital, has no family doctor, leading to an urgent call for temporary doctors — known as “locums” — to help close the gap. Earlier this summer, I answered that call.
The doctor I took over for, Daniel Hewitt, looked exhausted when I arrived. In addition to keeping office hours during the day, he’d been on call for the emergency room 24/7 for the past week — and I was about to do the same.
A week might sound like a long time to be on call, but staff told me their last family doctor, Tarik Abulbida, had been on call nearly every day for an entire year before leaving in June, before Hewitt arrived.
Doing the work of many
As the only doctor on the island, I do the work of three physicians every day: I see patients in the family-medicine clinic; check on those admitted to acute-care and long-term care hospital beds; and I’m on call for the emergency room.
Emergency room shifts here can get busy.
One morning, while seeing patients in the clinic, I was called to the ER to treat a woman with chest pain — she was having a heart attack. Later, as I headed to lunch, another woman came in with one-sided weakness — a stroke.
Both patients needed emergency treatment and arrangements to transfer them to Gander — a three-hour trip by ferry and ambulance — for specialist care.
After each case, I returned to the clinic an hour behind schedule. The patients I’d abruptly left were still sitting there, waiting quietly. Emergency or not, I had to keep working until every patient in the fully booked clinic had been seen.
At 2 a.m. that night, I was called in again to treat a man with shortness of breath. After resuscitating and transferring him out to Gander, I got home at 3:30 a.m. — remembering to set an extra alarm so I’d wake up in time to run the 8:30 a.m. clinic once more.
Compromises in care
I soon learned that the practice of medicine is not the same when patients don’t have a regular doctor. I found myself having to make compromises in patient care that I’d never made before.
For example, I would write prescriptions for six to 12 months for conditions — such as poorly controlled diabetes — that are usually monitored much more frequently. The reason? The harm of running out of insulin outweighs the harm of not knowing exactly what someone should be taking.
I would order urgent tests and referrals for patients who really needed them, not knowing who was going to be able to follow up with them. For example, a potassium level check for a man whom I feared might one day need dialysis and a referral to a surgeon for a man with newly diagnosed cancer.
I wouldn’t see either of them again.
In my last two days on Fogo Island, I was shocked when staff told me I couldn’t admit patients to the hospital anymore because there was no doctor scheduled after me to care for them. I had to either discharge or transfer all sick patients to other hospitals, including those I’d admitted earlier that week.
On my last day, I examined a baby with bronchiolitis — a viral wheezing disease — and recommended his mother make a three-hour trip to Gander for the weekend, just in case the baby’s wheezing got worse.
Two weeks later at home, I called up Fogo Island’s mayor, Andrew Shea, to learn how things were going. “Since you left, we’ve had two days with a doctor. That’s it — we’ve had no other doctor,” he said.
Instead of seeing a doctor, Fogo Islanders either have to leave the island or access Health Hubs — the region’s virtual-care solution for those without a family doctor. According to Central Health, the regional health authority to which Fogo belongs, the phone service is staffed seven days a week by physicians in Gander and Grand Falls-Windsor.
However, Shea criticizes the Health Hubs as inadequate to address the current gaps in care.
“So they only book one week [at a time] and it gets blocked up within the first 20 minutes. If you don’t get in, they won’t take an appointment for the next week. You’ve got to phone in Monday morning the following week and then, possibly, it’ll be blocked up again before you get through,” he says.
Dr. Katharine Smart, president of the Canadian Medical Association, says many Canadians living in rural and remote communities may face a similar fate to those on Fogo Island. “The reality is that’s a quarter of our population, so these are not small numbers we’re talking about when it comes to impact,” she says.
Things weren’t always this way on Fogo Island, though.
Shea says the island has continuously had doctors ever since European merchants arrived in 1792, bringing doctors along with them. “[Up until] a few years back, we had basically three doctors — we had a great system,” he says.
Then that number shrank to two, then to only one from April 2020 until this past June.
Fee-for-service and bureaucracy
When it comes to the root of the problem, Shea says one cause is the provincial fee-for-service model, which pays doctors per patient visit. In small towns with few visits, he says, this incentivizes physicians to be on call more to supplement their income.
“No matter how much money a person makes, after a few short months of being 24/7, he’s got to leave. He can’t do it,” says Shea.
Despite being vocal about his town’s problems, Shea says local advocates don’t have much influence with Central Health. “We don’t have any power to make decisions. Whatever they tell us, we have to go along with it because they’re the ones in power,” he says.
Smart is calling on Canadians to speak out more about increasing gaps in rural health care.
“We need to be showing politicians that where we’re at isn’t good enough.… We’re seeing people dying sometimes because they don’t have access to care,” she says.
(Dr. Anthony Fong is a freelance journalist and emergency physician in Vancouver.)