COVID-19 has re-inforced Canada’s need to strengthen generalist models of hospital care
Original author: Fahad Razak & Amol Verma
Published: March 29, 2021
Hospitals have faced tremendous pressures the COVID-19 pandemic has spread globally. As Canadian hospitals have come under increasing strain, there has been an appropriate focus on intensive care unit (ICU) capacity and access to life-sustaining therapies, such as ventilators.
But what may be less apparent to Canadians is that the majority of patients who are sick enough to require hospital care for COVID-19 do not require the ICU. We recently completed the largest study in Canada to look at acute COVID-19 care, and one striking finding was that 80 per cent of hospitalized COVID-19 patients are cared for on what are called “general medical” wards.
Prior to the pandemic, general medical wards were already the workhorse of Canadian hospitals. They were increasingly a catchall for a diverse range of conditions, such as pneumonia, heart failure, dementia or severe alcohol withdrawal. Our research demonstrated that nearly 40 per cent of all patients in the emergency department who required hospitalization were admitted to these general wards – by far the single largest group of hospitalized patients.
Part of the inexorable drive toward the generalist model of hospital care is an aging population and the increasing proportion of Canadians living with multiple chronic health conditions. More than 50 per cent of those over the age 60 have three major chronic medical conditions, making it less likely that any one specialist can truly provide holistic care. Consequently, many specialty wards that were once a mainstay of hospital care, have largely been replaced by general medical wards.
General medical wards take a team-based approach to care for patients, who often have complex medical and social backgrounds. They are typically staffed by physicians, such as family medicine-hospitalists and general internists, and health professionals like nurses or pharmacists, who are trained to care for patients with a diversity of diseases. The rise of high-quality generalist hospital care has been a strength of the Canadian system.
In the decade leading up to the COVID-19 pandemic, the volume of admissions to general medical wards rose by more than 50 per cent. At the same time, the number of hospital beds remained largely unchanged, leaving Canada with the second lowest number of acute care beds per capita among all countries tracked by the Organization for Economic Co-operation and Development. Hospitals routinely operated at more than 100 per cent capacity.
It’s therefore important to acknowledge that the hospital capacity constraints we now hear about nearly every day are not new or unexpected. Reactive steps such as canceling elective surgeries or treating patients in hallways have existed for years. They reflect, in part, the escalating problem of insufficient general medical ward capacity.
The COVID-19 pandemic occurred against that backdrop. Over the past year, the strain on hospital wards has proven to be so great that patients needed to be rapidly transferred between hospitals to offload overwhelmed sites. These unprecedented temporizing measures allowed us to weather the second wave of COVID-19 and are being ramped again in the third wave. But now more than ever, we need to think proactively to address well-documented gaps in our health-care system.
First, we need to ensure we have the human resources in place to care for an aging and medically complex population. This can be challenging. For example, one of the largest hospitals in Ontario recently posted for emergency recruitment of generalist physicians.
The annual number of physicians being trained in any specialty is a negotiation between universities, the provincial and federal government. It’s past time to proactively increase the number of physicians trained to be generalists. And the need for increased training extends well beyond physicians to other health professionals, such as nurses.
Second, our dismal ranking within the OECD in per-capita hospital beds suggests we are sliding out of the norm of what is considered effective and acceptable. Ontario just opened its first net new hospital in three decades, an event worth celebrating while recognizing that we need many more beds.
The pandemic highlighted known gaps in our health system and increasing our human resource and ward capacity will take a significant generational investment. We believe this crisis should be a catalyst to build on our strengths in generalist care and expand toward the kind of health system capacity Canadians need.
Fahad Razak is a general internist at St Michael’s Hospital and an assistant professor at the University of Toronto. He is also a member of Ontario’s COVID-19 Science Advisory Table. Amol Verma is a general internist at St Michael’s Hospital and an assistant professor at the University of Toronto.