Fix the Foundation Before We Add More Floors:
Colleagues and friends, grab a coffee. This is a longer read.
Let’s turn down the temperature and revisit how we got here, because history matters if we want a better future.
Anmol, I agree with you on one key point: we need full-service, team-based family medicine, properly resourced and compensated for evenings and weekends.
I also miss the era, especially in major urban centres, when family physicians admitted their own patients, delivered babies, worked in the ER, long-term care, and clinics, and did far more care in-office (suturing, casting, same-day labs and X-ray). This still happens in many smaller communities across Alberta and Canada.
Family doctors sent patients to the ER only when truly necessary, and they called us first. That continuity worked and trained generations of family physicians.
In the early 1990s, family physicians did most bread-and-butter hospital medicine. Specialists focused on complex cases. The system was balanced.
I started in the ER at the Royal Alex in 1992 as a family physician. Emergency Medicine wasn’t a specialty in Edmonton until 1993. I worked a lot, about 300 shifts a year for six years, often single-coverage nights at one of Canada’s busiest trauma hospitals. At 3:30 a.m., one-third of the emergency department would close.
How did that function? Because the system worked.
We had an integrated primary care system, adequate acute-care capacity, long-term care, rehab, and auxiliary hospitals, and clear accountability to move admitted patients out of the ER quickly. There was no ALC bed block. Every family clinic functioned as a de facto urgent care centre. Ambulances were back on the street within 30 minutes 90% of the time, completing 10–14 trips a night. We didn’t have, or need, special after-hours urgent care clinics, more ER beds, or more ambulances.
Then came the Barer–Stoddart report and the Klein cutbacks in the mid-1990s.
In Alberta, the result was stark:
~1,500 acute-care beds lost in the Edmonton region
-A 1,000-bed hospital demolished in Calgary; Holy Cross and Grace sold
-Family physicians, nurses, and staff driven out of hospitals or out of Alberta
-Medical schools and nursing schools were cut
Labs and imaging centralized
-Emergency departments became de facto inpatient wards, waiting rooms ballooned, ER footprints expanded, and this remains the case today
Short-term costs fell. That’s when the system broke, became fragmented, and long-term costs began to rise, along with access problems.
The facts in Alberta:
-Early 1990s: ~11,700 acute beds for 2.7M people (4.3/1,000)
-By 1994/95: ~7,600 beds (2.4/1,000)
-Today: ~8,800 beds for 5M people (~1.76/1,000), with ~1,400 ALC patients in those beds and an older, sicker population
-Many European systems average ~4.2 beds/1,000, anchored in strong primary, preventive, and community care
Add to that:
~1 million Albertans without a family doctor
-A workforce hollowed out by burnout, moral distress, and cuts that hit generalists hardest
-Income gaps driving medical trainees away from family medicine
-Specialists billing for generalist care because patients have nowhere else to go
Today, admitted patients routinely remain in ERs 27–80 hours at the 90th percentile. With every hour, they decondition, their length of stay grows longer, and some never return home, losing independence and driving up costs for taxpayers.
ERs are the 24/7 safety valve for the community, hospitals, and the profession, and they are no longer able to perform that role safely.
Minor illnesses: flu, migraines, palpitations, gastroenteritis, minor injuries and fractures, and even “the drunk”, are not the cause of the ER crisis, even if they dominate waiting rooms.
It’s understandable why the public, policymakers, politicians, and even physicians such as yourself often see them as the problem when the real pressures in the system aren’t visible to most.
These patients sit in RAZ chairs and are usually in and out once they are seen by the ER physician. At the Alberta Medical Association section level, ER physicians have consistently directed resources and fees toward complex care and resuscitation, not minor cases.
Edmonton already has two 24/7 standalone emergency departments with full labs and CT/US. Let’s call them “super UCCs” (my apologies to my ER colleagues who staff them). They are also full of sick and admitted patients who cannot be transferred, and their waiting rooms are full. The label doesn’t change the physics.
Building bigger ERs or more urgent care centres won’t hurt, but finite tax dollars and scarce staff are better deployed elsewhere.
What we need is system flow redesign. Bring in flow process engineers. Apply Lean or Six Sigma. Identify bottlenecks and fix flow.
I learned this in the early 1980s, working every job in a lumber mill in Squamish, B.C., from log inflow, the sorter, conveyor belts, to the green chain and chipper.
When you understand flow, you fix problems downstream (ALC), midstream (hospitals), and upstream (primary care). Frankly, that mill manager could run a health system, so long as politics didn’t interfere.
The bigger truth:
-No one owns end-to-end patient flow
-Flow failure is the most expensive way to run health care
-ERs used as warehouses drive burnout, staff loss, and compound costly medical errors and increases costs
-EMS offload delays quietly degrade public safety
-Data exists, but accountability does not
-“Innovation” without integration fragments care
-Leadership and investments in the right areas are sorely lacking
This is why the U.S. system, as you reference, is the costliest for families and businesses, leaving many without access to care, while European systems perform better at lower cost.
Repair the foundation and fix the leaky roof before renovating the main floor.
(For those interested:
edmontonjournal.com/opinion/…)
Finally, as a former leader of Alberta’s ER physicians, If you want to fix the acute-care and ER crisis, support what allows ERs to function:
- Full-scope family medicine, including after-hours care
- Geriatrics, pediatrics, rehab, home care, long-term care and respite care for home caregivers
- Removal of ALC patients from acute beds within 24 hours, 90% of the time
- Clear accountability for patient flow: discharge medically well patients within 2 hours, 90% of the time
- Timely specialist uptake after ER stabilization: admit patients to wards within 2 hours of consultation, 90% of the time
- EMS offload fixes so paramedics can get back on the street and answer 911 calls
ERs don’t fail because ER teams fail. They fail when the rest of the system can’t receive the patients we stabilize.
If you want to understand the problem, spend a Monday or Tuesday evening in a city ER. The issue becomes obvious very quickly.
A sincere thank-you to all frontline staff who work 24/7 to keep our communities safe.
And a belated Merry Christmas and Happy New Year to everyone.
Raj Sherman, MD, CCFP(EM), FCFP
Assistant Clinical Professor
Former Associate Minister of Health
Former Chair, HQCA
@pfparks @Bjwrz @CAEP_Docs @ABDanielleSmith @nenshi @AlikaMD @Albertadoctors @UnitedNurses @JMeddings @NightShiftMD @AdrianaLaGrange @MattJonesYYC