The $250-an-hour Band-Aid: How this rural northeastern Ontario hospital keeps its emergency room open

This is the first in a two-part series looking at what it takes to deliver emergency care in the central Manitoulin region in Ontario.

The family doctor shortage in northeastern Ontario has caused some emergency rooms to close, but what may be less well known to the public is how many others are frequently on the brink of going dark and being shuttered due to a lack of physicians.

Hospital measures to avoid closure include increasing the fees to attract locums — temporary, visiting doctors from other areas — some of whom are being offered $250 an hour to cover emergency shifts.

Locum remuneration depends on a complex balance of contributions from provincial programs that relate to hours, demands and levels of care, and, increasingly, financial incentives for rural and remote work.

In northeastern Ontario, ERs in communities like Thessalon and on St. Joseph Island have temporarily closed in the past year, forcing patients on the north shore of Lake Huron to go further down the road for urgent care.

However, on Manitoulin Island, about 2½ hours west of Sudbury, at the two hospitals that make up the Manitoulin Health Centre in Little Current and Mindemoya, there have been no closures.

Paula Fields, Manitoulin Health Centre’s president and CEO, said that doesn’t mean they haven’t come close on several occasions, and she expects they will at some point be faced with a crisis that will trigger a temporary closure.

Most recently, Fields said, a locum who was booked for a week cancelled due to a personal emergency. Seven local physicians, on what is supposed to be a team of more than 13, pulled together to fill in and they kept the doors open.

Fields said she’s not sure the general public is aware of the precarious nature of emergency health care..

In the ER on one winter day, Karlee Demera was seeking help for her child, unaware of the threat of closure.

“I have two children and I can’t even tell you how many times we’ve been here,” she said. “And we recently have lost our family doctor, so we just have nowhere else to go now.”

While the Little Current hospital site limps along with about seven local doctors, the sister site in the smaller Manitoulin Island community of Mindemoya is down to just over three.  However, it’s seeing about the same number of visits at its emergency room as there are in Little Current, between 12,000 and 13,000 a year.

Dr. Kevin O’Connor has lived and worked in Mindemoya since 2008.

Eighteen months ago, he said, doctors at the family health team in his community gave the province an ultimatum.

He said they were working 60 hours a week in the emergency department and putting in another 60 to 80 hours seeing patients in the clinic.

O’Connor said they told the “powers that be” that the local doctors would cut down to two ER shifts a week, per their contract, with locums needed to cover the rest of the time, but if locums couldn’t be found, the ER would have to close.

The outcome, he said, was the province committed to doubling the fee for locums to $250 an hour to entice them to fill in at the ER so it could be kept open.

O’Connor said he doesn’t begrudge the visiting doctors the money, even though he doesn’t qualify for that hourly rate, up front, getting it retroactively, only if the ER remains open for a period of time.

He added, however, that there are structural problems within the system, especially as fewer medical school graduates choose family medicine and fewer still choose rural practice.

“In general, people like to make more money and work less,” O’Connor said. “And they do not like the extreme stress sometimes of working in an emergency room in a rural area, which just by it’s very nature is isolated and you lack supports.” 

He’s happy that, for now, locums are filling in the schedule and the ER is staying open, but said the pressure remains high.

“People want some work-life balance. Even I want it and feel, in a way, a bit trapped, because I know if I leave here, there’s going to be a lot of people without a doctor and there’s a lot of people relying on you,” he said. “Do I consider it? All the time.”

His colleague, Dr. Maurianne Reade, said the local doctors inevitably work more than two ER shifts a week because of the uncertainty of getting locums.

She said because of surges in patients or illness among doctors, she never feels sure she won’t be called in unless she leaves town. 

You put into consideration how people are in dire situations looking for services and how your colleagues are looking for a break they can’t get if you don’t help.– Dr. Shady Tadross

Recently, Dr. Shady Tadross signed on to provide locum coverage in the Mindemoya ER on a two-week on, two-week off basis.

His practice is in Mississauga, but he’s been moved to help his colleagues and their patients in rural areas.

Tadross said he hasn’t been home in three months, covering shifts across northeastern Ontario and Newfoundland.

“It is difficult, and it has an impact on my family, but you put into consideration how people are in dire situations looking for services and how your colleagues are looking for a break they can’t get if you don’t help.”

As for relocating permanently to Mindemoya, he said he would consider it after he fulfils his family obligations in southern Ontario.

Lori Oswald, executive director of the Manitoulin Central Family Health team, is also the point person between locums and government, and helps fulfil contracts and arrange coverage.

The increased fee for locums is one solution, she said, but not the best solution.

She feels the situation is increasingly unfair for doctors who commit to living in the community, calling it a “moral injury” that they are responsible for keeping the lights on despite not receiving the same remuneration as visiting doctors.

On the other hand, O’Connor said he doesn’t see it as a moral issue, but rather just a Band-Aid solution to a system that has broken down.

He said an overhaul is needed to attract full-time doctors to rural areas and make sure their needs are met so they can have work-life balance, something he doesn’t see happening soon.

Some patients in Mindemoya are well aware of the precarious nature of urgent health care.

Dave Clark, 72, said he and his wife recently lost their family physician.

Clark said they have been to the emergency department about six times in the last 12 months, receiving good care, often from locums, but he wonders how long that will last.

“How deep is that resource?” he wondered. “How many of those people are out there? I would think that at some point in time that will become a finite resource. We’re going to run out of people, doctors to come and do locum work for us. Then we will be in significant danger.”

The Ontario government recently announced it will put $1.4 billion of new funding into the health-care system to link two million people to family-care providers over the next four years.

In Mindemoya, O’Connor is non-committal, saying he hasn’t seen any details yet of how that will be accomplished.

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