Dr. Rosie Pitkin and Dr. Michael Krauthammer are both originally from the United States, both trained in American hospitals, and both ended up in Antigonish as ER physicians. In this episode, they give us the lowdown on what is happening behind those closed doors at the St. Martha’s Regional Hospital Emergency Department. The Question Everyone Actually Has Justin opens with the question he knows everyone wants answered: why do we have to wait so long when we go to the ER? Rosie notes that the doctors tend not to be the ones who hear complaints about long wait times. The triage nurses are front-facing, first-contact, and closest to the waiting room, and they usually are the ones to field complaints about waiting times. The physicians, shielded by a pair of swinging doors, are perceived very differently. This observation turns out to be a recurring theme in the episode: nurses absorb a disproportionate amount of everything - from complaints to workload. The structural answer to wait times is the triage system; a 1-to-5 scale of urgency rooted in a military model. After seeing the tirage nurse, each patient is assigned a number indicating how urgent their particular medical case is. A code one is cardiac arrest: everyone in the resuscitation room, blood from the blood bank, the ICU physician called in. A code five is someone who needs a prescription refill because their family doctor is on vacation. The system means that when a heart attack or stroke arrives, everything else pauses. Often these most urgent cases are hidden from those of us in the waiting room; an ambulance that has just arrived at the back door with the whole department scrambling to deal with a code 1. The broader explanation is space. There is simply not an unlimited supply of beds and medical personnel to handle the influx of people arriving at the ER each day, so the triage system is in place to move people with the highest priority issues through as fast as possible. This is not uncommon for waiting rooms in both Canada and the US although, as we find out later in the episode, the family doctor shortage in Nova Scotia is likely a contributing factor. This Is Not The Pitt Brendan, a fan of the medical drama The Pitt, asks how closely the show reflects reality. Both doctors are diplomatic about the show. The chaos is dramatized, they agree. The last thing you want in an emergency department when someone is genuinely sick is chaos — you want calm, method, priority. The volume of patients crammed into every corner is, however, a fairly accurate portrayal of what a big inner-city hospital looks like in both the US and Canada. St. Martha’s is a different scale entirely. Some days people end up in the halls like on TV, but this is rare. Most days it’s quieter. And experienced physicians, they note with mild amusement, are probably simply more chill than the residents featured on The Pitt. Canada vs. the States: The Honest Version Both Pitkin and Krauthammer trained in American hospitals before coming to Canada, which gives them a comparison most Canadians don’t have. Rosie’s assessment is unambiguous: it’s a thousand times better here. Every metric. Quality of life for the physician. Quality of the nursing team. The sense of internal closeness among the staff. In the States, as Rosie describes it, medicine is a product to be bought and sold, and that reality shapes everything — how patients interact with staff, what happens when the bill arrives, what gets ordered and why. Michael describes Canadian healthcare as a limited resource that the system is set up to conserve — which has its frustrations — while American healthcare is a product, which has a different set of problems. Where the American system works, he says, is in access to specialty care and innovation, provided you have the insurance, the funds, and you happen to live near a centre that has what you need. For the routine stuff — the things most of us actually need most of the time — Canada is significantly better, they both suggest. The Nurses Are Running the Show Both physicians agree that nurses are the beating heart of the ER. The nurses at St. Martha’s are, in Rosie’s words, “bananas good”. She insists that nurses, like teachers, should probably be paid more than doctors. They work longer hours, do most of the physical lifting, absorb the patient frustration, manage the actual logistics of who goes where and when, and serve as the central nervous system of the whole operation. The triage nurse in particular, she says, has one of the hardest jobs in the building. Every single patient walking through the door is having their worst day. They’re in pain, they’re frightened, and they can’t concentrate on anything other than the physical complaint that brought them to the ER in the first place. Whatever friendly version of themselves shows up in the supermarket is not the version showing up to triage. The triage nurse takes their vitals, takes their history, assigns a code, and does this all day — so intensively that the role typically has to rotate between two people over the course of a single shift just to manage the load. Rosie also notes with evident pleasure that St. Martha’s is, in her experience, a nurse-run department — something she has never had before. Her previous working environments were predominantly led by men in suits with bow ties who talked down to her. Her current boss, Dr. Tania Sullivan, is, in Rosie’s words, “like a god to me”. The person who actually knows the most about what’s happening in the emergency department at any given moment, Rosie adds, is the housekeeping staff — because they know exactly which bed is empty, which is dirty, which is clean and ready for the next patient. This is invisible, essential work that nobody talks about. Is the ER filled with people who don’t have a family doctor? Justin ask what percentage of ER patients, at a rough estimate, are there not because of a true emergency but because they don’t have a family doctor and need a less urgent medical consultation? This, it would seem, must be one of the main reasons the ER is so busy. While they don’t have the actual numbers, Michael estimates that somewhere between 30 and 50 percent on a given shift fall into this category. Michael notes it varies depending on which community hospitals are open that day, since St. Martha’s serves a broader catchment area when satellite sites are closed. Neither of them minds this. From their perspective, if you’re in the emergency department, it’s not a low-acuity (meaning non-urgent) situation for you regardless of what the problem is. Something brought you to the ER, and so you were meant to be there. The challenge isn’t resentment from ER staff — it’s limitation. Emergency physicians are trained to a specific scope of practice, and the family doctor shortage is pushing the ER to expand that scope in ways it wasn’t designed for. These are physicians trained to be experts in resuscitation and urgent diagnosis, not dermatology or obstetrics. The example that illustrates it best: Rosie tells the story of a colleague who ordered punch biopsy kits so that ER physicians could take skin biopsies and send them to Halifax for patients who have been waiting years for a dermatology referral. Michael’s response to this was a pained expression. Who, he asks, is going to get those results and call the patient back to follow up? Is a punch biopsy even the right test? These are dermatology questions, not emergency medicine questions. The well-intentioned workaround creates new problems for ER docs being asked to work outside of their scope of practice. He puts a name to this: scope creep. It means being expected to do more than you were trained to do. He doesn’t resent the patients for needing it. He just knows it has limits. How They Both Got Here Both Pitkin and Krauthammer took unconventional routes into medicine — routes that both, in retrospect, seem perfectly logical but at the time felt like accidents. Rosie majored in art history at college because she thought it was cool. Her mother wouldn’t let her go to art school. She eventually decided that art conservation — the science of preserving and restoring artworks — required organic chemistry, and if she was going to take organic chemistry anyway, she might as well see what else was possible. She shadowed a doctor in an emergency room because that was the one medical environment where a college student off the street could walk in and observe. She liked what she saw. She went back. Both she and Michael ended up doing post-baccalaureate pre-med programs — a US pathway for humanities graduates who want to do the pre-med sciences without going back to undergrad — and she describes medical school with a mixture of disbelief and joy: she still doesn’t entirely know how she got in, she says. She was also, she says plainly, ready to quit before she moved here. The pandemic left her, like many physicians, burnt out and running on fumes. COVID accelerated a wave of early physician retirements in both countries that meaningfully worsened the doctor shortage that already existed. Antigonish changed her calculation. Michael started in a psychiatry lab as a research assistant, studying mind-body interventions for chronic pain at a time when most American doctors were prescribing opiates for everything that hurt. The research was ahead of its time. Like Rosie, he hadn’t taken a single science class in college. He describes being about 26 or 27 and realizing he had spent his youth doing things that came naturally, when what might actually be interesting was doing the things that were hard. He thought throughout most of medical school that he would go into psychiatry — a natural trajectory from a humanities background. Then he hit every rotation and found something interesting in each one. He landed in emergency medici
