Ensuring that there are enough physicians to staff the emergency department (ED) is a major issue for hospital managers. According to a recent ICES Practice Atlas on ED Services in Ontario (Chan et al.2001), this task may become increasingly difficult. From fiscal year 1993 to 2000 , the number of physicians working in EDs declined by 21%, from 2,525 to 1,987. One reason fewer physicians are practicing emergency medicine is because the ED is an increasingly taxing work environment. Although the per capita use of EDs has declined by 10% in the past seven years, this decline was attributable to lower ED use by children, who tend to be lower acuity cases (e.g. colds and ear infections). On the other hand, the per capita use of ED services by the elderly is rising and they present with much more complex conditions. Furthermore, 19 hospitals in Ontario out of 201 closed during the study period. As a result, ED visit volumes at the remaining hospitals rose by 10%, from 19,100 to 21,000 per year.
Another warning sign is the aging ED physician workforce. In 1993, 40% of ED physicians were under the age of 40. By 2000, this proportion dropped to 24%. This phenomenon may be related to policies in the 1990s that were implemented to restrict the growth in the supply of physicians (Barer et al. 1996). These policies were targeted, perhaps unfairly, at young physicians.
A third issue concerns the existence of highly predictable peaks in ED volume. EDs see 9% more patients per day on weekends than average. The week between Christmas and New Year's is the busiest of the year, and volumes increase by up to one-third above the volumes seen on other public holidays. This raises the question of how to ensure sufficient staffing on these days.
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Emergency medical services