Remember when “pre-owned” cars used to be called “used”? When “rightsizing” meant layoffs? When reduced service wasn’t “streamlining,” it was just worse?
Welcome to Ontario health care, where we’ve spent the past three decades becoming masters of the euphemism.
Now, some might argue that euphemisms serve important communication purposes – reducing panic, maintaining professionalism, facilitating difficult conversations. And they’re often right! “Passed away” is gentler than “died.” “Let go” softens “fired.” These are reasonable human accommodations for uncomfortable realities.
But there’s a difference between softening language to ease emotional pain and softening language to hide systemic failure. One is compassion. The other is camouflage.
As a diagnostic radiologist who’s practiced in Ontario since the early 1990s, I’ve had a front-row seat to the most impressive linguistic innovation project in Canadian public policy. We’ve invented an entire vocabulary to describe things that used to be called “unacceptable” but are now just … another day.
Let me take you on a tour of our greatest hits – a timeline of terminology that tracks not just what went wrong, but how creatively we learned to describe it.
THE GOLDEN AGE: WHEN PROBLEMS HAD PROBLEM NAMES (Pre-2000)
Back in the dark ages of the 1990s, health-care language was embarrassingly direct:
– Overcrowding meant too many patients and not enough space.
– Long wait times meant patients waited too long.
– Staff shortage meant we didn’t have enough staff.
– Closed means closed.
We were primitives, really. When something went wrong, we just . . . said it went wrong. How unsophisticated.
But then the new millennium arrived, and with it, a revelation: if you can’t fix the problem, fix the language.
THE HALLWAY ERA (Early 2000s-2010s)
– “Hallway Medicine” (circa 2006-2008, popularized 2016-2018):
What it actually means: We ran out of hospital rooms, so patients receive inpatient care in corridors, storage closets and that weird space near the vending machines.
Why it’s brilliant: By giving it an official name, we transformed “this is a crisis” into “this is a thing we do now.” It even sounds kind of cozy – like “country medicine” or “family medicine.” Hallway medicine! It’s a specialty!
Peak normalization: When the Ontario government created a Hallway Health Care Task Force in 2019, we achieved the impossible – a task force dedicated to managing something that, 20 years earlier, would have triggered an emergency response and a whole lot of meetings. Normalized.
Fun fact: In 1995, if you’d told a hospital CEO that patients would routinely receive multi-day inpatient care in hallways, they would have assumed you were describing a war zone. By 2019, it had its own budget line.
– “Left Without Being Seen” or LWBS (systematically tracked ~2010):
What it actually means: Arguably one of my favourite euphemisms. Emergency department wait times got so long that patients gave up and went home, possibly while still having a heart attack. They just walked out of the ED. Tired of waiting.
Why it’s brilliant: We turned “we failed to provide care” into a neutral statistical category. No judgment, no alarm – just a percentage!
The real genius move: By 2024, Ontario’s LWBS rate hit 4.9 per cent – which sounds way better than “292,695 people gave up on emergency care that year.” Big numbers sound bad. Small percentages sound manageable. And that’s just one metric – a 31 per cent increase since 2019. Human cost hidden behind sanitized metrics.
Even better: These patients don’t count in our “percentage seen within target time” metrics, so they actually make our performance look better. They left! Problem solved! (Please don’t ask where they went or what happened to them.)
Peak normalization: When hospitals started tracking LWBS as a routine operational metric rather than a crisis indicator, we knew we’d arrived. It’s not failure – it’s patient-initiated voluntary care deferral!
THE GRIDLOCK YEARS (2010s)
By the 2010s, we’d mastered basic euphemisms. Time to level up.
– “Code Gridlock“ (emerged ~2014-2016):
What it actually means: The hospital is completely full. We have no beds. Ambulances are being diverted. We’re cancelling surgeries. This is what “catastrophic system failure” looks like.
Why it’s brilliant: “Code” makes it sound medical and official, like “Code Blue” or “Code Red.” And “Gridlock” suggests traffic – temporary, annoying, but normal! Just like the 401 at rush hour!
In the 1990s, this situation was called a “disaster” and triggered emergency protocols! In the 2000s, we called it “severe overcrowding” and it happened occasionally. In the 2010s, we gave it a code designation, implying it’s routine enough to need its own protocol. And by the 2020s: It’s just . . . winter. And spring. And fall. Sometimes summer.
Peak normalization: When hospitals started including “Code Gridlock protocols” in their annual operational planning – not as emergency backup, but as routine seasonal management.
Bonus points: We now have “pre-gridlock” and “post-gridlock” phases, suggesting gridlock itself is just the middle of a natural cycle, like metamorphosis.
– “Capacity Protocols“ (mid-2010s)
What it actually means: We’re so full we’re implementing emergency procedures to ration care.
Why it’s brilliant: “Protocol” sounds organized and professional. “Capacity” sounds like we’re just . . . managing our capacity! Very responsible!
What we’re not saying: The protocol is “decide which patients don’t get beds” and the capacity we’re managing is “zero.”
Peak normalization: When “capacity protocols” became a permanent operational state rather than an emergency measure. We’re not in crisis – we’re just in continuous capacity protocol mode! Totally different!
THE INNOVATION PHASE (Late 2010s-2020s)
By the late 2010s, we’d run out of ways to rebrand “too many patients, not enough space.” Time to get creative.
– “Alternative Level of Care” or ALC (increasingly used late 2010s)
What it actually means: This patient is medically ready for discharge but has nowhere to go, so they’re occupying an acute care bed while waiting for long-term care, home care, or literally anywhere else care.
Why it’s brilliant: “Alternative” sounds progressive and patient-centered! “Level of Care” sounds clinical and evidence-based!
What we’re not saying: This patient is blocking an ED admission, which is blocking an ED bed, which is causing ambulance diversions, which is causing . . . well, everything else.
Peak normalization: When ALC patients constituted 15-20 per cent of hospital bed occupancy and we just accepted this as normal hospital operations rather than a massive system coordination failure.
The irony: We created an official designation for “patient who shouldn’t be here” and then left them there. For weeks, months.
– “Virtual Care” (COVID-era, 2020-present)
What it actually means: (Context-dependent) Sometimes it’s telemedicine, which is legitimate. Sometimes it’s “we’re discharging you but you still need monitoring, so . . . good luck, we’ll call you, maybe.”
Why it’s brilliant: “Virtual” sounds high-tech! Innovative! Digital transformation!
Peak normalization: When “virtual care” became the default answer to capacity problems rather than a complement to in-person care. Can’t find a bed? Virtual! Can’t see a specialist for six months? Virtual! Can’t access diagnostic imaging? Well . . . that one’s harder to virtualize, but we’re working on it!
– “Temporary ED Closure” (normalized ~2020-2022)
The emergency department is closed. The EMERGENCY department. The place you go for EMERGENCIES. It’s closed.
Why it’s brilliant: “Temporary” suggests this is brief and planned! Professional! Under control!
The reality: 2024 was the worst year for Ontario hospitals experiencing temporary ED closures, with one out of every five suffering that fate. 38 Ontario hospitals experienced temporary closures between January 2022 and November 2024, some repeatedly, some for weeks at a time. But they’re all “temporary,” so it’s fine!
Peak normalization: When we stopped treating ED closures as front-page crisis news and started reporting them like weather: “Cloudy with a chance of your local emergency department being closed this weekend.”
Pre-2019: ED closure = immediate government intervention, emergency task forces and significant political consequences.
2020-2022: ED closures = concerning trend, some media coverage, promises to address. Nothing.
2023-2024: ED closures = check the website before you have your heart attack!
Fun fact: Ontario cottage country has achieved the impossible – making emergency department roulette a legitimate vacation planning strategy. With more than 200 temporary ED closures between 2022-2023 and 2024 the worst year on record, cottagers now check ED schedules with the same diligence they check the weather forecast. Nothing says “relaxing getaway” quite like confirming which hospitals actually are open before your medical emergency.
MASTER CLASS (2020s-present)
By the 2020s, we’d achieved true mastery. Why describe problems when you can describe solutions that don’t solve them?
– “Surge Capacity” (COVID-era, but now permanent)
What it actually means: We’re operating beyond our designed capacity because we have no choice. Oops…our bad.
Why it’s brilliant: “Surge” sounds temporary and manageable – like surge pricing or a power surge! And “capacity” sounds like we planned for this!
The problem: When “surge” becomes permanent, it’s not surge anymore. It’s just . . . capacity. Which means our baseline is “overwhelmed.”
Peak normalization: When hospitals started budgeting for permanent surge operations, we achieved the impossible: planning to be in crisis forever.
– “Enhanced Discharge Planning” (early 2020s)
What it actually means: We’re discharging patients faster than we used to because we need the beds.
Why it’s brilliant: “Enhanced” sounds like an improvement! An upgrade! You’re getting Enhanced Discharge™!
What we’re not saying: Sometimes “enhanced” means “earlier than medically ideal because we have 47 people in the ED waiting for beds.” You need to go . . . Now.
The genius: We took “discharging patients too early” and made it sound like a premium service.
– “Integrated Care Pathways” (ongoing)
What it actually means: (Variable, but often) We’re coordinating how to move patients through a system that doesn’t have enough capacity at any point.
Why it’s brilliant: It sounds so organized! So evidence-based! So . . . integrated!
The reality: You can have the most integrated pathway in the world, but if it leads to a six-month wait for imaging, a 12-month wait for surgery and a 28-week wait for specialist consultation, you’ve just built a very organized route to pain, suffering, delayed diagnosis and treatment.
Peak normalization: When we focus all our energy on optimizing the pathway while ignoring that the destination is “wait longer.”
THE DASHBOARD DELUSION (ongoing)
But wait – if all these things are problems, why haven’t our hospital performance metrics caught them?
How charmingly idealistic. Let me introduce you to the metrics that make everything OK:
– “90 per cent of Patients Seen Within Target Time”
Sounds great! Unless you realize:
- The 10 per cent who weren’t seen waited REALLY long.
- Patients who left without being seen (LWBS) don’t count . . . they weren’t even “seen,” so they’re not in the denominator!
- The target time has been quietly adjusted over the years.
- This measures ED triage, not total ED time, not time to admission, not time to actual treatment. Not time for things that actually matter. Just fun with math.
But 90 per cent! That’s an A-minus! We’re doing great!
– “Occupancy Rate: 105 per cent”
Wait, how can occupancy be more than 100 per cent? That’s not how percentages work! Ah yes, 105 per cent capacity – because apparently we’ve discovered beds that can hold 1.05 patients each. Not really.
Answer: Hallways, baby! And closets! And that space near the vending machines!
Bonus: High occupancy looks efficient on reports! We’re maximizing our bed utilization!
What we’re not saying: Operating at 105 per cent occupancy means we have zero surge capacity, can’t handle normal variation in demand and are one bad flu season, trauma, catastrophe away from complete gridlock. But the dashboard shows green, so we’re good! Green’s our favourite colour.
– “Cost Per Weighted Case: Decreased 3 per cent”
Translation: We spent less money per patient encounter! Possible meanings:
- We got more efficient (this is good!).
- We deferred maintenance, reduced services and cut corners (this is bad!).
- We’re seeing fewer complex patients because they can’t access care (this is really bad!).
All of the above (most likely!).
But the number went down, and down is good, right? Right?
THE INTERNATIONAL FIELD: WHAT HAPPENS WHEN YOU DON’T EUPHEMIZE
Here’s the awkward part: other countries with universal health care don’t have most of these terms.
Australia doesn’t have routine “hallway medicine.” Germany doesn’t have “Code Gridlock.” Switzerland doesn’t have “temporary ED closures.” The Netherlands doesn’t need “capacity protocols.”
Why? A major factor: they use activity-based hospital funding (ABF), in which treating patients generates revenue instead of consuming fixed budgets. With ABF, patients are actually referred to as patients and not “cost centres.” Their hospitals want to increase capacity. Their emergency departments want to stay open. Their hallways are for walking, not inpatient care.
Yes, there are other differences – workforce models, capital funding, regulatory frameworks. But when your fundamental incentive structure rewards treating patients rather than rationing care, the rest tends to follow.
They spend similar amounts per capita to Canada. They have universal coverage. They just have . . . different incentives. And better outcomes.
Median wait time for specialist care:
- Australia: 6 weeks
- Germany: 4 weeks
- Canada: 28.6 weeks
But at least we have better terminology!
