Are we the problem?

It was 11 p.m. on a Friday in January when I got the call. The emergency physician had a 33-year-old man – experiencing homelessness for the first time, no psychiatric history, no substance use, no psychosis – crying and threatening to jump off a bridge if discharged. “I think he’s probably depressed,” he told me. “But the real problem is he doesn’t have anywhere to sleep. Can I admit him to psych under you?”

I admitted him. Of course I did. And in doing so, I made two system failures disappear. The social system had no housing for him. The health-care system had no community-based alternative. So, a psychiatric bed – designed for acute mental illness – became the solution to both. Neither system had to confront what it lacked because I had filled the gap.

It wasn’t until later that the analogy occurred to me. We all learned this in first-year medical school. A failing heart compensates – it thickens its walls, it dilates, it increases its preload via multiple up-and-down regulated hormonal pathways. The patient looks stable. But the compensation masks the underlying disease. It delays intervention. And when the compensatory mechanisms exhaust themselves, the crash is catastrophic – far worse than if the problem had been addressed when it first appeared.

I’m starting to wonder whether physicians have become the compensatory mechanism of Canada’s health-care and social systems. Whether we are the thickened heart wall. Whether we have been masking the underlying disease for so long that from the outside, the system still kind of looks like it works – while from the inside, we can feel it failing.

If you are a physician reading this, I suspect you already know the pattern.

The psychiatrist admits a patient who could be managed as an outpatient – because the outpatient care doesn’t exist. The emergency physician manages chronic hypertension, diabetes and COPD – because the patient has no family doctor. The surgeon does the post-operative follow-up indefinitely – because there’s no one to discharge the patient to. The internist spends an hour coordinating home care by phone – because the system that should do this was never built. The family doctor carries a panel of 2,500 patients – because there is no one else. The pediatrician refills psychiatric medications they didn’t prescribe and weren’t trained to manage – because the child psychiatry waitlist is two years long.

None of us take lunch. We stay late. We chart at home. We spend hours on uncompensated paperwork because “someone has to.” We keep patients on our lists who should be discharged to primary care – but they don’t have primary care. We make concession after concession. Most of us used to fight. But we asked, we were ignored, and eventually we stopped asking.

Here’s what I’ve started to notice: every time we deploy one of these workarounds, we absorb a consequence that wasn’t ours to carry. And every consequence we absorb is one the system never has to face. In addiction medicine, there’s a word for that: enabling. Absorbing someone else’s consequences so they never have to face them. The parent who pays the addict’s rent and makes the excuses – they’re not trying to perpetuate the problem. They’re exhausted and surviving the night. But by shielding the addict from consequences, they remove the pressure that would force change.

I’ve been wondering whether we’re caught in a version of the same bind. When I admit a homeless man to a psychiatric bed, the housing crisis shows up as a psychiatric admission. When I admit someone for stabilization that could happen as an outpatient, the absence of community infrastructure registers as inpatient volume. When I keep a patient on my list because they have no family doctor, the primary care shortage surfaces as a specialist waitlist.

Is it possible that we’re laundering both systems’ failures through our own capacity? And if so – like any compensatory mechanism pushed too hard for too long – what happens when we burn out?

We like to call our work a partnership with the system. But I’m not sure it is. In a partnership, both sides hold up their end. The system pays us – but not for all the work we do. And it may have built a trap. The system holds us by two things we can’t let go of. Our compassion – we won’t walk away from a sick person. And our license – which says we can’t. So, the system creates the gaps – and our professional obligations compel us to fill them.

And here is what I think may be the most uncomfortable part: the system trained us to self-sacrifice – because without that, it doesn’t survive. This is operant conditioning, the same mechanism we teach in first-year psychology. We compensated, the patient survived, nobody thanked us, but nobody died. So, we did it again. And again. The system reinforced self-sacrifice until we mistook it for professionalism – until we couldn’t tell the difference between being a good doctor and being consumed. The system survives because of us.

I don’t know exactly what to call this relationship between physicians and the system. But I notice it has features I’d recognize in a patient’s life. One party creates dependency. The other can’t leave – partly out of love, partly out of obligation, partly because they’ve been told that leaving would make them the problem. Over time, the one who stays stops recognizing the dynamic as abnormal. They start to believe the way things are is the way things should be. In clinical practice, when we see this pattern, we don’t call it a partnership.

What if we stopped? What if we didn’t admit patients whose primary need is social, or who could be managed in outpatient care the system chose not to build? What if we discharged patients who no longer need specialist care – regardless of whether a family doctor is available? What if emergency departments only saw emergencies?

When we work with families caught in enabling, we teach them to set boundaries. And we warn them: it will feel wrong at first. The parent who stops paying the rent will feel like they are hurting their child. The spouse who stops making excuses will feel like they are abandoning someone they love. Every instinct they have will tell them to go back to absorbing the consequences. But we teach them that the short-term pain of the boundary is what creates the long-term pressure for change – and that without it, nothing ever will.

I wonder if physicians need to hear the same thing. Setting a boundary with the system – refusing to admit a patient who doesn’t need a psychiatric bed, discharging someone who no longer needs specialist care – will feel like abandonment. It will feel like we’re hurting the patient. Every instinct we have, every value that drew us to medicine will tell us to keep compensating. But if the enabling framework holds, then the opposite may be true: the longer we keep absorbing the consequences, the longer the system never has to build what it should have built all along.

Systems would visibly fail. And perhaps – like the family that finally sets the boundary – they would be forced to build what they’ve never needed to, because we were always there.

I admitted the man that Friday night. He got a warm bed and a few days of safety – while someone with a psychiatric emergency may not have had a bed at all. I’m not sure it was medicine. It may have been compensation. It may have been enabling. And I think it’s worth asking whether there’s a difference.