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!
This level of articulate cynicism deserves a Leacock Award! What is missing in the analysis, however, is any attention to the role our clinician community has played in (sometimes) creating and perpetuating these issues. As a radiologist, it behooves the author to also pillory the ways public investments in digital health turned into 100% raises for some specialties rather than systemic efficiency improvements of any kind. I’ve enjoyed the shellacking of public policymakers… but I fear we may be omitting some important actors from our list of perpetrators.
Excellent article.Dr.Marotta’s insightful exposure of the medical systems shortfalls/inadequacies needs to be spotlighted as they are disguised by terms,which he has reported,so not to draw the attention to the payers of our healthcare: the taxpayer.
In my 37 years of practicing direct,hands on patient care, I have been on the frontlines of healthcare and directly experienced it’s evolution.
As physicians we are bound to practice under the high standards of the Hippocratic Oath.Over my career,I have seen medicine morph into two distinct streams which I will call : “Patient care” medicine (those who directly treat the sick) and the “Corporate “ side of medicine (those who administer the business side of medicine).
“Corporate “side of medicine is a relatively new identity compared to “Patient care” medicine.
Although there is an exchange of concepts and strategies between the two streams ,my view is the “Corporate” side of medicine needs to reread the Hippocratic Oath and adhere to these stringent principles to insure their decisions/strategies do not compromise patient care and outcomes.
Dr. Sullivan, thank you for your decades of patient service. Your long perspective in healthcare adds invaluable weight to this critique—you’ve witnessed firsthand the evolution that’s brought us here. Your distinction between ‘Patient care’ and ‘Corporate’ medicine captures something crucial: the “moral injury” physicians experience when structural constraints prevent us from fulfilling our professional obligations. Other healthcare providers here have noted similar experiences. We’re trained to care for patients, bound by the Hippocratic Oath, yet increasingly forced to navigate administrative barriers that compromise the very care we’re oath-bound to provide. This isn’t just system inefficiency—it’s a fundamental misalignment between our professional duties and the structures we’re expected to work within. That disconnect is unsustainable. It is a root cause of physician “burnout” and that metric is dangerously increasing. Thanks for your thoughtful response.
RM
Brilliant!! Share this more
Thank you very much. I’m glad you enjoyed the article. More Ontarians should know how their healthcare system is being (mis)managed, as we are all potential patients.
RM
This manages to be provocative, informative, and painfully entertaining all at once.
After reading it, I recalled the many messages I receive, especially around Christmas, from hospitals in which they trumpet the world-class care they provide to patients (while also asking me to become a monthly donor). Never have I heard or read a word about unacceptable wait times, possible or actual emergency department closures, or, indeed, patients waiting or being treated in hallways. The message from the most high-profile parts of the healthcare system is that we should all be confident in and grateful for the care they offer.
I have one serious problem with the piece. At the very end Dr. Marotta lists the “median wait time for specialist care” in Australia (6 weeks), Germany (4 weeks), and Canada (28.6 weeks). Since we have 13 in many ways quite different health systems in Canada and since up to this point the article has been entirely about Ontario, citing Ontario-specific data would seem much more appropriate. But I also question the value of a single number for a median wait time since, in my experience as a patient and caregiver, sometimes the wait has been a few days and sometimes many months. I know the wait for a child to receive a developmental assessment is often much more than 28.6 weeks and the wait times for usually older adults to see an orthopedic surgeon about a possible joint replacement are far too long. But wait times are usually much shorter when cancer or heart disease is suspected. And, of course, the wait between the initial contact with a specialist and the time of actual treatment is sometimes more important than the wait to see the specialist for the first time. In short, the single figure, while alarming, needs to be supplemented by other figures that help the reader understand where the main problems are. Or maybe some other statistic should be used to make the point that our outcomes don’t come close to matching the outcomes elsewhere.
Finally, though this is beyond the scope of the article, the comments of some of the other readers prompt me to wonder whether the problems so well described here are related to where or how our public money for healthcare is spent. Does Ontario spend more or less than the other jurisdictions cited on hospital costs, on drugs, on payments to physicians, on administrators’ salaries, on the salaries of nurses and allied health professionals, etc.?
Thank you for your comments. You raise excellent points about wait time complexity. You’re absolutely right that a single median obscures crucial variation. I’ll explain below.
Why median? In medicine we use medians because averages get destroyed by outliers. One person waiting 3 years skews the average wildly; the median shows what the “typical” patient experiences. But you’ve identified the core problem: even that hides everything.
Wait times are actually multiple measurements poorly aggregated: time to specialist appointment, time to treatment post-consultation, time to surgery after being waitlisted. Each varies enormously by condition, urgency, geography, and specialty. A suspected cancer patient might see oncology in days; a chronic pain patient might wait years for the same imaging.
Governments love single numbers because they’re politically digestible. But “wait times” become meaningless when we’re comparing a cardiac catheterization (days) against pediatric developmental assessment (18+ months) against hip replacement (12+ months). Different queues, different resources, different bottlenecks.
The real question you’re asking—where does our money actually go compared to those other countries—is precisely what these simplified metrics help us avoid examining.
Medical wait times aren’t a single queue—they’re cascading, interconnected bottlenecks across multiple specialties, diagnostic services, and treatment phases, each with different capacity constraints, urgency levels, and resource dependencies. A patient’s journey involves waiting to see a specialist, waiting for diagnostic tests, waiting for those results to be reviewed, then waiting for treatment—and a delay at any point ripples through the entire system, making any single summary statistic essentially meaningless. And this is how the system is managed… or mismanaged.
Complexity is the friend of inaction.
Best,
RM
Well said Robert Marotta
This is hands down the BEST article I have read that captures with complete accuracy our healthcare system today. I’m a 30+ year healthcare professional and have witnessed all of this Exactly! You would think that after 30 years healthcare would be improved, perhaps exceptional by now, yet here we are worse off! The decline in patient care, staff wellness and compassion is the “New Norm” with nothing in sight for improvement. We all ventured into these professions as we are very caring individuals and to see how the systemic inadequacies have put such a burden on patients and staff is needless to say very discouraging. It truly is sad to see how the demand in all levels of Healthcare providers is at an all time high, yet the amount of people wanting to make this their career choice is at an all time low.
Thank you for sharing such a powerful perspective from your 30+ years in healthcare. Your experience validates what many are feeling—that despite dedication and compassion, systemic failures have eroded both patient care and provider wellness.
The paradox you highlight is striking: soaring demand for healthcare providers while interest in these careers plummets. It’s a troubling sign that caring professionals are being worn down by inadequate systems. This is the “ moral injury” we experience.
Your voice and experience matter. When seasoned professionals speak up about these realities, it creates pressure for the meaningful change that’s long overdue. Thank you for your continued service and advocacy.
With thanks,
RM
Your wit, tone and overall message just hits. Looking forward to your next piece. The institutional/organizational memory perspective here is refreshing. Thank you.
Thanks Seema—glad that you enjoyed it! I wish it were just repressed memory at this point, but the tragic irony of announcing “transformation” while everything gets demonstrably worse is too absurd to forget. Hopefully I’ve got a few more rounds in the chamber—plenty of things I’d like to forget, but can’t.
Cheers,
Rob
Fantastic article showcasing what I have seen in the last 20 years of practice. It actually made me chuckle as I rolled my eyes when these terms started being used. All I can say is I am glad I am not starting my practice now as it almost seems like we’re sailing on the Titanic. I think it’s high time we started thinking of more private healthcare that can help ease some of the burden of our system. With the population living longer and longer, it clearly isn’t sustainable with how it’s currently being managed. Let’s see if we can steer clear of that iceberg.
Great read Rob!
Thanks for the support. Your 20 years mirrors what I’ve seen—same deterioration, different specialty. The Titanic analogy is apt, but the iceberg’s already hit. Question is whether we’ll patch the hull or take lunch orders and keep rearranging deck chairs. Time to demand structural reform before we all go under.
Best,
RM
‘Covering shame with virtue’—as Ivan IV of Russia put it about the British ruling class. Canada’s ruling class have apparently been perfecting the art: normalizing a thoroughly disastrous state of affairs.
There’s a method in Hamlet’s madness!
Agreed. Either spectacular incompetence or spectacular success at something we’re not supposed to notice. (We’ve noticed)
RM
Excellent article explaining much of the political vocabulary that sugarcoats the systemic shortfalls. Stop collecting meaningless government directed metrics and use those funds to promote a more functional delivery model. Well said Dr Marotta.
Thank you Paul for reading the article and providing commentary. As Drucker observed, what gets measured gets managed—which becomes the problem when we’re measuring the wrong things. Burying real issues under useless data and carefully crafted euphemisms has become an art form: it creates a dazzling illusion of progress while the actual problems remain comfortably untouched.
RM
As an emergency physician for 27 years, thank you for putting into words the lived experience on the ground. It’s baffling to me that successive provincial governments are allowed to “lead” in this way. That we use words like surge as a way to make everyone feel like this is temporary. Why has this been allowed to happen? Patient morbidity and mortality increases when there are delays to treatment. When one of these unfortunate things happens in an emergency department, waiting room, all eyes focussed down on the unfortunate nurse or doctor who can be blamed for the event. No one cares to look at the fact that the system has been operating in a way that made this inevitable. And no one holds politicians accountable for creating this. The moral injury of working in a system like this is why burnout is rampant. It’s sad and infuriating at the same time
First off – Thank you for 27 years of dedicated service in what is undoubtedly the most challenging front line of modern medicine—where government failures meet clinical reality.
You’re absolutely right about the elevation in patient morbidity and mortality with delays in diagnosis and treatment. The moral injury you describe is real: being forced to deliver care you know falls short of what patients deserve, while bearing individual accountability for systemic failures. Healthcare workers are trapped between their professional obligations and impossible conditions created by deliberate policy choices. The burnout epidemic isn’t a personal failing—it’s the predictable outcome of asking clinicians to absorb the consequences of political decisions while those responsible face no accountability whatsoever. Physicians are trained in diagnosis and treatment, not managing waiting lists, rationing care through triage, and explaining why patients can’t access the services they desperately need.
With thanks,
RM
Brilliantly said Robert Marotta,
With over thirty years of experience in the healthcare sector, I have seen industry standards and acceptable practices evolve significantly. This transformation raises an essential question: Where has the ‘care’ in healthcare gone? Throughout my career, patients often remark, “If this were my business…” This sentiment highlights a critical issue: hospital patient care does not align with a standard business model. Despite this misalignment, we have adopted strategies that no longer prioritize patient well-being. Consequently, we must examine how many readmissions result from the shortcomings of this paradigm shift.
Thank you! After thirty years watching “care” get MBA’d out of healthcare you must be exhausted. “Lean” promised efficiency; we got assembly-line medicine where patients became throughput metrics. Turns out humans aren’t Toyotas—who knew? Those readmissions you mention? That’s just patients boomeranging back because we optimized out the actual healing part. We applied factory logic to bodies and wonder why it’s broken.
Cheers,
RM
Atta go Bowby!!!!
This article nicely outlines how we have ‘normalized’ unacceptable realities and minimized their importance.
It is a slippery slope as standards become lowered yet accepted.
Healthcare leaders from government through to healthcare organizations and the public need to recognize that its a slippery slope – what will healthcare in the next decade look like?
Thank you for the thoughtful comment and for taking the time to read the article. I’m glad it resonated with you—the normalization of declining standards is indeed one of the most concerning aspects of this crisis.
Your question about what healthcare will look like in the next decade is exactly what everybody should be asking. I’ve done some work on projections in an unpublished piece, though our visibility really only extends to around 2030 with any confidence.
Based on current trajectories, here’s what 2030 could look like:
**Primary Care**: If trends continue, 4.4 million Ontarians could be without a family doctor by 2026, potentially reaching 5-6 million by 2030—nearly one-third of the population. The traditional family practice model may effectively cease to exist for most Ontarians.
**Surgical Wait Times**: Hip and knee replacements could exceed 50-60 weeks median wait times. Cataract surgery waits may approach one year. We’re looking at a system where “elective” procedures become effectively inaccessible through the public system for many.
**Emergency Departments**: Rural ER closures will likely become permanent rather than temporary in many communities. Urban EDs will face sustained overcrowding with wait times for admitted patients potentially exceeding 24 hours routinely.
**Physician Workforce**: With 52% of family doctors considering retirement and only 42% of medical students interested in family medicine, we face a demographic cliff. The exodus we’re seeing now is just the beginning—the 2025-2030 period will see the largest cohort of physicians retiring in Ontario’s history, with insufficient replacements.
**Mental Health**: Youth wait lists will likely remain elevated or worsen, with maximum waits potentially exceeding 3 years in some regions.
The slippery slope you mention isn’t theoretical—we’re already sliding down it. The question is whether there will be political and governmental recognition and will to stop using euphemisms to camouflage failure and deal with the real problems.
RM
Yes, but that is what “best practices” in business is about, reducing standards and providing to shareholders return for investment. In the heathcare system, non-profit supposedly in Canada, the same, you simply reduce standards to be able to contract out, reduce staff whatever to achieve what the EBM model of practice guidelines/technology assessment reports tell you “all you have to meet” for “best practice” patient care to be accepted for accreditation. It’s actually quite simple when you think about it and everyone buys into this make-believe “we have a state of the art” medical system. It’s a joke really. Ask Dave Webster, nuclear medicine specialist in Sudbury, he’ll tell you all about it.
Thanks for your comments. Having been through accreditation processes many times myself, I can certainly agree with the sentiment. It’s remarkable how clinical excellence frameworks—ostensibly designed to elevate care—have been co-opted by financial and administrative interests to justify doing “less with less” while maintaining credentialing. The real genius of it is the veneer of legitimacy: evidence-based guidelines establish minimums, administrators treat them as maximums, resources get stripped to the bone, and everyone walks away with their accreditation certificate and a straight face. We call it “best practice,” tick our boxes, and pretend we’re operating at the cutting edge when we’ve really just found a sophisticated way to rationalize mediocrity.
Regarding accreditation – that is truly something to behold—suddenly beds vanish from hallways, fire lanes miraculously clear, equipment that’s been cluttering public corridors for months gets stashed away, and everything gets a fresh coat of paint and compliance is on display. The moment the accreditors leave, of course, it all creeps back to the usual chaos. It’s performative compliance at its finest: we know how to look good for the inspection, which ironically just proves we know exactly what the problems are—we simply choose to live with them until someone’s watching. Shameless.
RM
Back in the day, hospitals tried to operate at about 85% capacity, so there was flexibility for coping with extra demands. When an extra patient came in there was a place for them. If patients needed to stay on a few days longer, they could. When staffing was short, there was flexibility to move them around. And there was time for staff to have discussions about doing things better. But over the years, health care has become more “efficient”. Squeezing in more people, and speeding up turnover enabled us to cope with increasing population without building new facilities – for a while. But now we have reached beyond such gains. We need to build more health care facilities to provide for the needs of our ageing population. We need to spend more: and private funding will not provide what most of us need. So we need to tax ourselves more.
Thank you for taking the time to read and respond – I appreciate your thoughtful perspective. I think we may actually be more aligned than it first appears, though I may not have been clear enough in my article.
You’re absolutely right that hospitals operating at 115% capacity (up from the 85% you describe) is unsustainable and dangerous. Where we may differ is on the solution.
The problem isn’t that we need more tax revenue – it’s that we’re hemorrhaging the money we already collect. Between 2013-2025, documented government waste in Ontario healthcare includes:
– $9.2 billion on staffing agencies (at 3× the cost of permanent staff)
– $1.4 billion on expired PPE that was incinerated
– $1.4 billion on a non-functional eHealth system
– $2.1 billion annually in patient wage losses due to wait times
– ~$1 billion annually on an archaic billing system
That’s roughly $40 billion in waste – enough to build the facilities and hire the staff we need multiple times over.
Countries like Australia, Germany, and Switzerland achieve better outcomes with similar per-capita spending through activity-based hospital funding (ABF), where treating patients generates revenue rather than consuming fixed budgets. They don’t have “hallway medicine” or routine ED closures because their incentive structures reward capacity, not rationing.
The crisis isn’t a funding shortage – it’s a governance failure. We don’t need higher taxes. We need to stop lighting our existing healthcare dollars on fire and restructure how funding flows through the system.
At least, that’s what I hope my article conveyed.
Cheers, RM
Difference between Canada and Australia and Germany is a parallel private system.
Thank you for your thoughtful comment—you raise a fair point. Canada does have elements of parallel private care (ophthalmology, radiology, executive health, some surgeries), but unlike Australia and Germany, we lack a fully integrated private system. Australia’s model, where private hospitals handle 40–70% of elective surgeries, delivers shorter wait times while maintaining universal coverage. We need to do better.
Excellent read I will say Dr. Marotta. And pertinent points concerning private health care within a universal health care system. Unfortunately private health care often gets a bad rap in the media by certain politicians in this country which confuses healthcare delivery issues among many, see below for example, and thus Canada is left in a quagmire of “what to do” sort of thing, along the lines of a maze with no clear way out.
“NDP targets health care privatization as party hopes for inroads in Alberta”
https://www.ctvnews.ca/federal-election-2025/article/ndp-vows-to-push-back-against-health-care-privatization/
Hi Mike
Thank you very much for the kind words and for taking the time to read the article. I really appreciate your thoughtful commentary and have read the piece you shared.
You’ve identified the central contradiction perfectly. The NDP’s statement that “we reject the notion that you should make money off the pain of Canadians” ignores a critical reality: the current system is literally causing pain. When emergency departments close 200+ times, when 292,695 patients leave without being seen, when specialist wait times stretch to 28.6 weeks – that’s not preventing pain, that’s creating it.
And it’s not just patients suffering. The CMA’s National Physician Health Survey documents escalating rates of depression and suicidal ideation among physicians, with system factors—inadequate resources, inability to provide timely care—consistently cited as primary drivers.
Germany, Australia, the Netherlands, and Switzerland all have universal healthcare systems that incorporate private delivery. They don’t have “hallway medicine” or routine ED closures. Their specialist wait times are measured in weeks, not seven months.
The ideology that demonizes any private participation has given us a system where we’ve normalized the unacceptable. We’ve become so focused on who provides care that we’ve lost sight of whether care actually happens.
The current system is causing pain to patients and doctors alike, and will continue to do so until something changes.
RM
Private vs. public is an ideological, not a substantive, argument.
Public health systems in Canadian provinces do not provide truly universal access. Patients with heart disease, for example, often have to travel from Prince George to New Westminster for diagnostic or therapeutic procedures, even though they pay the same taxes as residents of the Mainland.
Public healthcare is not uniform: how someone is treated often depends on their postal code.
The quality of public medical care is also uneven, with both overuse of unnecessary treatments and underuse of beneficial ones, as well as medical errors in treatment delivery.
Yet the prevailing attitude remains, “If I’m not getting it, no one is getting it.” What we should be asking instead is: What arrangements will allow everyone to get more from the health system than they do now?
Your closing question—’What arrangements will allow everyone to get more from the health system than they do now?’—is precisely what we should be asking, yet ideology keeps blocking that conversation. You’re absolutely right: we don’t have universal access, geography creates unavoidable disparities, and quality is uneven. But the Fraser Institute’s verdict is unambiguous: ‘The structure of our health-care system created the crisis; not the amount of money we spend on it’—after 30 years producing increasing wait times, the data is dismal. Clinging to ‘if I’m not getting it, no one is getting it’ ensures we all sink together rather than exploring structural reforms that could improve capacity and outcomes for everyone. Defending this system is defending failure. jmo
RM