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the Department of Health in the United Kingdom (UK)1 has found that bed occupancy rates exceeding 85% in acute hospitals are associated with problems dealing with both emergency and elective admissions. That county has instituted a target bed occupancy of 82% as one of its hospitals' quality measures.

Borg3 also found a significant correlation between bed occupancy and MRSA infection rates.

The association between nosocomal infection and bed occupancy rate was also highlighted in another UK Department of Health report5 . That report revealed that hospitals with occupancy rates of more than 90% had a 10.3% greater incidence of MRSA infection than those with occupancies below 85%. Furthermore, the UK House of Commons Committee of Public Accounts has "repeatedly noted that high levels of bed occupancy are not consistent with good control of infections" 6 .

This model suggests that there is a discernable risk of a hospital failing to provide sufficient beds, and thereby safe efficient care, when average bed occupancies exceed 85%.

considering the nature of hospital system, "spare (bed) capacity is essential if an emergency admissions service is to operate efficiently and at a level of risk acceptable to patients".

Orendi6 has recently compared the circumstances in the UK with those in the Netherlands where the average hospital bed occupancy rate was 64%, as opposed to 84% in the UK (2005), with the same number of beds per head of population.

The lesser pressure on hospital beds may in part have been the result of the special level of care provided to nursing home patients

Canadian data also show that hospital bed availability has a significant influence on ED length of stay for admitted patients10 (access block) and thus a delay in patients reaching an appropriate inpatient bed. This was most marked when "hospital occupancy exceeded a threshold of 90%", as also found by Sprivulis et al11.

analysis of emergency presentations to an Australian hospital has shown that access block may increase a patient's overall hospital length of stay12

increased in-hospital mortality11,13

increase in the mortality of patients presenting to EDs in Western Australia11 independent age, season, diagnosis or urgency.

there appears to be sufficient evidence to support the contention that bed occupancy rates provide a useful measure of a hospital's ability to provide high quality patient care and that 85% is a reasonable target.

hospitals that often run at more than 100 per cent capacity

the health authority hopes to reduce hospital occupancy rates to 95 per cent at Calgary’s Foothills, Peter Lougheed and Rockyview hospitals, as well as at the University of Alberta, Royal Alexandra, Grey Nuns and Misericordia in Edmonton

The provincial health superboard has launched an “intensified, accelerated effort” to reduce occupancy rates in seven of Alberta’s busiest hospitals by October, including ambitious plans to clear out 50 per cent of the backlog of patients waiting for continuing care beds.

Alberta’s medical system also struggles with higher than average lengths of stay for most hospital patients in Edmonton and Calgary.

Liberal health critic Dr. David Swann said proper solutions are more important than “feel-good targets.”

“Where’s the evidence we can actually get there, both in terms of staffing number and new beds?”

489 Albertans waiting in hospital beds for continuing care spaces as of December 2011

creation of a provincial standard for acute care and capacity management (including standard processes for discharge), integrated continuing care planning across the province and ED (emergency department) patient flow improvements

The health board boss also pointed to additional acute care, continuing care and mental health beds, as well as boosted medical support within the community and in supportive living sites as “immediate, local actions” to help hit the new hospital targets.

Reducing acute care bed occupancy rates at the province’s busiest hospitals to 95 per cent by Oct. 31 was one of the recommendations contained in a Health Quality Council of Alberta report in February

There has been considerable recent interest in bed occupancy in Australia4

80% to 85% is widely, if anecdotally, quoted although the 85% level apparently arises from earlier work on queues.4

There is a great deal of evidence linking "overcrowding" and adverse events

We need to know the true cost of re-work in public hospitals that have become highly "efficient" and this should include costs to patients (who may require extended convalescence on welfare) and society as well as to the hospitals.

it seems unrealistic, at least in the foreseeable future, to be able to run a complex computer program in a busy public hospital at intervals to determine optimum bed occupancy

cutting bed numbers to promote "efficiency" may have unintended and perhaps unforeseen consequences

Now Complexity and Network Science tell us that sustainability and resilience are most important, that some redundancy is essential for resilience, and that as we become increasingly efficient we simultaneously become increasingly vulnerable to failures.

lowering average bed occupancy in busy public hospitals to an average of, say, 85% may still be feasible and very worthwhile.

The United Kingdom and Australia consider an 85% acute care bed occupancy rate to be the safe upper limit, according to the OECD. But Campbell, who says the OECD’s figures on Canadian occupancy rates are probably accurate, is not interested in debating appropriate overall rates.

It may come as a surprise that despite these statistics, Ontario Hospital Association president Pat Campbell is not advocating for more hospital beds.

Between 1998 and 2011, the number of all types of hospital beds in Ontario remained “virtually constant at approximately 31,000” while the population increased by 16%, according to a 2011 Ontario Hospital Association document.

Rose says, for example, that occupancy rates in surgical critical care units, characterized by rapid turnover and short stays, should be about 75% to be efficient.

This kind of cooperation could also work when hospital crowding becomes excessive, for example when flu season hits, says Mike Tierney, vice-president for clinical programs at The Ottawa Hospital and one of the editors of Healthy Debate. What is needed is “an ability to look at hospital occupancy

Still, Schull does not advocate for more hospital beds. “It would be a mistake to add beds to a dysfunctional system,” he says.

Occupancy rates matter if you accept the premise that high rates lead to poor access for patients who need to be admitted from emergency departments, notes Michael Schull, an emergency room doctor at Sunnybrook who has published on wait times in emergency and overcrowding risks.

and bed availability across a region in real time, rather than each hospital trying their best to manage on their own

The sobering reality is that Ontario hospitals are tight for capacity largely because of the number of beds occupied by patients, most of them elderly, waiting for admission to another facility (such as rehabilitation or long-term care) or for support to return home.

Administrators at Health Sciences North in Ontario have discovered the benefit of very active cooperation between the 459 bed Ramsey Lake Health Centre (formerly the Sudbury Regional Hospital) and the local Community Care Access Centre (CCAC).

Working together, the result has been a reduction of ALC patients at the health centre from 133 to 78 in the period between September and December 2012, says David McNeil, vice president of clinical services and chief of nursing.

The challenge for the CCAC was to expand its capacity for community-based care, and some funding was received from the province for new programs including behavioural support and mobility programs. For its part, the hospital recruited a new geriatrician, gradually closed beds at the former Memorial Hospital site that had been used for ALC patients, and redirected money towards chronic disease management.

As well, community groups have been engaged “to help them understand that the hospital is no longer the centre of the universe,” McNeil says

And dozens of occupations, some that you've never even heard of, are exempt from basic rights entirely. "Keepers of fur-bearing mammals" have no right to minimum wage. Sod layers have no limits on their daily hours of work. Shrub growers don't get a lunch break. The system is so complicated that the Ministry of Labour has developed a special online tool to help decipher who's entitled to what. But as the province reviews its antiquated Employment Standards Act, critics argue that its confusing web of exemptions makes it harder for the so-called precariously employed to defend their rights - and easier for bosses to ignore them.

"When you distil it down to what these exemptions are seeking to achieve, really they are to give employers more control over work and more control over wages," says Mary Gellatly of Parkdale Community Legal Services. "It sends the message to employers that they can get away without complying." The Act was first introduced in Ontario in 1968 to set basic work standards, especially for non-unionized employees who don't have a collective agreement to provide extra protections. But there are at least 45 occupations in Ontario that are exempt from a variety of its fundamental entitlements, many of them low-wage jobs in industries where precarious work is rife.

The Ministry of Labour says many of the exemptions are "long standing" and related to "the nature of the work performed." But York University professor Leah Vosko, who leads research into employment standards protections for the precariously employed, says exemptions have come at least in part from industry pressure, leaving the Act a "complex patchwork that is difficult for workers and even officials to comprehend." Even when there are clear violations, speaking out can come at a cost. Reprisal is illegal under the Act, meaning bosses can't penalize employees for exercising their workplace rights. But the Act gives workers no protection against wrongful dismissal. Employers do not have to give cause for firing someone.

Unionized employees are generally protected by their collective agreements, and workers can sue employers if they think they have been unfairly terminated. But most precarious, low-income employees are not unionized, and most do not have the money to take legal action against an employer, says Parkdale's Gellatly. "It's the big reason why many people can't do anything if they're in a workplace with substandard conditions, because they can get fired without cause." Linda Wang, who worked at a Toronto cosmetics manufacturer for four years, was fired less than two weeks after asking her employer for the extra pay she was owed for working a public holiday. She says no reason was given for her termination. Wang, a mother of two, claims her employer repeatedly bullied her and her colleagues, and says she believes she was dismissed for asking for the wages.

She has filed a reprisal complaint with the Ministry of Labour, but Wang cannot afford to take her employer to court. "I feel the system is against workers," she says. "It's in favour of employers." "Whatever job you have, you put so much of yourself into it," adds Gellatly. "The fact that employers can just fire you without a reason is incredibly devastating for folks." The Act also contains significant gaps when it comes to sick leave and overtime. The legislation provides most workers with 10 unpaid days of job-protected emergency leave, which means they can't be fired for taking a day off due to illness or family crisis. Critics call this measure subpar by most standards, since it still causes many workers to lose a day's income for being ill. An estimated 145 countries give employees some form of paid sick leave.

"Unfortunately, we stand out for our inadequacy," says Brock University professor Kendra Coulter. But the 10-day protected leave doesn't apply to almost one in three of the province's most vulnerable workers. An exemption that excludes employees in workplaces of fewer than 50 people from that right means 1.6 million workers in Ontario are not even entitled to a single, unpaid, job-protected sick day. Fast-growing, low-wage sectors such as retail, food services and health care are most likely to be exempt according to a recent report by the Workers' Action Centre. While many small businesses voluntarily give their employees paid sick days, the loophole leaves many workers - especially the precariously employed - exposed.

Toronto resident Gordon Butler asked his employer, a small construction company in Markham, for one day off work after he sliced his thumb open on the job. He says his boss told him not to come back. "I didn't believe him," says Butler, 44, who has an 8-month-old child. "I tried to plead with him, and he said 'No, too bad.'" "The way it's stacked up right now is there are very few options for people who are in low-wage and precarious work to actually take sick leave when they're sick," says Steve Barnes, director of policy at Toronto's Wellesley Institute, a health-policy think-tank. "They not only have to worry about lost income, but the potential for losing their jobs," adds Brock's Coulter. "It's unkind and unnecessary." The stress caused by the province's meagre sick-leave provisions is compounded by exemptions to overtime pay, to which around 1.5 million don't have full access.

As a rule, employees should get paid time and a half after 44 hours a week on the job, according to the Employment Standards Act. But in 2014, more than one million people in the province worked overtime, and 59 per cent of them did not get any pay whatsoever for it, Statistics Canada data shows. This, experts say, is partly because enforcement is poor. But in Ontario, a variety of occupations don't even have the right to overtime pay, including farmworkers, flower growers, IT workers, fishers and accountants. Managers are also not entitled to overtime. Vladimir Sanchez Rivera, a 45-year-old seasonal farmworker in the Niagara region, says he has worked 96-hour weeks doing back-breaking labour picking cucumbers and other produce.

We don't have access to protections when we are working in agriculture," he says. "And our employers tell us that." Low-wage workers are even more likely to be excluded from full overtime pay coverage, according to the Workers' Action Centre's research. Less than one third of low-income employees are fully covered by the Act's overtime provisions, compared to around 70 per cent of higher earners, because they are more likely to work in jobs that aren't eligible. Workplaces can also sign so-called "averaging provisions" with their employees, which allow bosses to average a worker's overtime over a period of up to four weeks. That means an employee could work 60 hours one week and 50 the next, but not receive any overtime as long as they don't work more than a total of 176 hours a month.

Critics say the measure means more work for less pay, and paves the way to erratic, unpredictable schedules. "That's a huge impact on workers and their families in terms of lost income and having to work extra hours," says Parkdale's Gellatly. "It's certainly not good for workers, for their families, and it's not good for creating decent jobs in terms of rebooting our economy," she adds. For many of the precariously employed, falling through the gaps ruins lives. "Even now, when I think about the working environment, I feel very depressed," says Wang, who, 10 months later, is still waiting for the Ministry of Labour to issue a ruling on her complaint. "I feel panic."

Sara Mojtehedzadeh can be reached at 416-869-4195 or smojtehedzadeh@thestar.ca. By the numbers 1.6 million non-unionized Ontario employees with no right to an unpaid, job-protected sick day 59%

of Ontario workers who worked overtime in 2014 did not get any pay whatsoever for it 71% of low-wage, non-unionized Ontario employees don't have full access to overtime pay 29%

of high-income employees don't have full access to overtime pay Sources: Workers' Action Centre, Statistics Canada Proposed solutions A recent report by the Workers' Action Centre makes a number of recommendations to rebuild the basic floor of rights for workers. The proposed reforms include: Amending the ESA to include protection from wrongful dismissal

Eliminating all occupational exemptions to ESA rights Repealing overtime exemptions and special rules Repealing overtime averaging provisions Repealing the emergency leave exemption for workplaces with less than 50 people Requiring employers to provide up to seven days of paid sick leave

"Whether you're in a healthcare facility, a manufacturing facility, driving a vehicle - if you're tired, the risks of mistakes are going to go up." Two studies comparing eightand 12-hour schedules during day and night shifts found that 12hour night shifts were associated with more physical fatigue, smoking or alcohol use, according to a 2004 report from the U.S. Centers for Disease Control and Prevention. "It's the law of diminishing returns," said Liane Davey, vicepresident of team solutions with Lee Hecht Harrison Knightsbridge, which specializes in talent recruitment and development.

"We think that we're staying and doing more and being more productive; but the negative outcome of doing that actually means our core quality suffers." Irregular schedules - such as switching from a block of night shifts to day shifts - can result in sleep disturbance which can become chronic, Mustard noted. "If you build up a period of disturbed sleep ... this is somewhat different from fatigue, although in a sense the consequence is kind of the same. "If we can't rest, we're not renewing our cognitive and physical capacities."

German-born Moritz Erhardt was a week from completing a work placement at Bank of America Merrill Lynch in London when he died in 2013. A British coroner said the 21-year-old intern died of an epileptic seizure that may have been triggered by fatigue. Erhardt's case sparked widespread speculation that the notorious long working hours and competitive environment at top investment banks were to blame for his death. Matt Ferguson said his 22-yearold brother, Andy, died in a headon collision in 2011 after logging excessive hours as an unpaid intern at an Edmonton radio station.

When Jeff and Andrea Archibald launched their design agency, the couple initially worked from home and logged significant extra time to establish their business. "We definitely hit 60-hour work weeks mainly because when there's two of you, you have to do all the billable work," recalled Jeff Archibald. "When you're starting out, your rate's a little lower, and then you have to balance out with all the business side of things, like invoicing. You don't have anybody on staff that can do those kinds of things, so you're basically wearing all of the hats," he said. "What ends up happening is you have all your meetings and your phone calls ... during the day and you do your production work at night - and that's not just us. A lot of our friends are in similar situations."

The Archibalds are now part of a team of seven at their Edmonton custom Web and branding firm, Paper Leaf. Weekly meetings help assess key tasks to accomplish within a given day and week - and avoid overbooking. "One of the singularly biggest concerns I think we all have is balancing the amount of workload so that we can have a profitable company - but also not overwork people," Jeff Archibald said.

"When you overwork, you're staring down the barrel of burnout. It's a real short-term gain." Mustard said employees logging overtime should be aware of the pace of their work and ensure they are taking breaks. "Being thoughtful about nutrition, making sure that you're not missing meals is very important. And then rest. Not shortening your chance to have sleep."

That’s supported by a recent cost comparison of private and semi-private hospital rooms conducted by Dr. Anthony Boardman, professor of business administration at the Sauder School of Business at the University of British Columbia in Vancouver (Journal of Benefit-Cost Analysis 2011; 2[1]:article 3). It found that private rooms were vastly superior on financial counts, as improved infection control, along with heightened privacy, improved sleep and fewer preventable medical errors contributed to reduced lengths of hospital stay. Taking everything into consideration, Boardman calculated the “net social benefit” (benefits minus costs) of a bed in private room compared to a semi-private room was about $70 000.

As compelling is research showing that single-occupancy rooms actually lead to higher hospital occupancy rates (Bobrow M, Thomas J. 2000: Building Type Basics for Healthcare Facilities. p. 145–57). Because of the need to isolate patients with nosocomial infections, hospitals with multi-bedded rooms can only reach a maximum occupancy of 80%–85%.

At the same time, public funds allocated for at-home and community-based therapy services have been cut. This means more and more patients are being forced to pay for private therapists, whose fees start at about $60 an hour.

Between 2007 and 2012, the number of community-based visits to patients by physiotherapists plunged by 22 per cent, or 130,000 visits, according to the government’s own most recently published figures. Visits by occupational therapists fell by 30 per cent, speech-language pathologists 47 per cent, social workers 22 per cent and dietitians 20 per cent.

By 2003, the company owned more than 100 homes and was attracting the attention of investment bankers.

a company that leases its homes from landlords can make good profits.

It was blatant financial engineering but it made sense on paper: acquisitions could be financed by spinning off the bricks and mortar into a different company, selling it on to property investors and then using the proceeds to buy more care operators.

The sale-and-leaseback model worked fine when property prices were heading north: property players were happy to invest, and Southern Cross was willing to agree to upwards-only rents as it could borrow at cheap rates.

Even during the best of times, profit margins in the care homes business are thin; as long as occupancy rates remain comfortably over 85%,

Southern Cross's operating company and property assets were separated

occupancy rates fell

Barclays Capital, for instance, took over Care Principles, a company that looked after patients who had been sectioned under the Mental Health Act

A report in the Observer last month disclosed that nearly 30% of the group's 581 centres in England had been served with improvement orders by CQC inspectors.

Local authorities were trying to care for more elderly and frail people in their own homes, so by the time they arrived at residential centres, their condition had deteriorated to include dementia, immobility and incontinence, which are more expensive to care for

Blackstone left long before the bust. It floated the company for £640m in 2006 and sold its last Southern Cross shares a year later. In total, the private equity firm made a profit of £1.1bn on its original investment. Others were left to pick up the pieces.

But Emily Thornberry, shadow health minister says: "Social care cannot be left to uncontrolled market forces."

But surprisingly, no body in the UK seems to have direct responsibility for ensuring private care companies avoid risky business models of the kind that sank Southern Cross.

One year after Dr. Parks’s letter was leaked, the government claims the ER wait times issue is under control.

Should we believe the hype?

In October 2010, local media published a leaked letter from the province’s chief emergency room doctor to Health & Wellness Minister Gene Zwozdesky and other government officials warning of “catastrophic collapse” if immediate action wasn’t taken. The letter was written by Dr. Paul Parks, president of the Alberta Medical Association Section of Emergency Medicine

Dr. Parks started to collect examples of substandard care and “adverse events” caused by overcrowding in the ER

When the letters and reports were eventually leaked to the media in 2010, they launched a firestorm.

It’s common to have five-plus EMS units and their medics tied up for hours while they wait for an ER stretcher to be freed up so that they can download their patient and get back on the streets

The situation has gotten so out of hand that we now have patients calling 9-1-1 from the ER

ER was overcrowded because hospitals were overcrowded

A study in the British Medical Journal found that patients whose ER wait times were six hours or longer were more likely to suffer an “adverse event,” such as the need for hospital admission, or even death.

Dr. Parks estimates that Alberta’s large-volume hospitals are still hovering at around 30 per cent of beds occupied by patients waiting to be admitted—meaning that those hospitals are still operating at well over capacity.

Dr. Parks, ER doctors were clear from the beginning of this crisis that the issue of overcrowding in emergency was due to downstream capacity problems, mostly a lack of long-term-care beds in nursing homes.

despite our vast wealth, Alberta has fewer hospital beds than the Canadian average.

The same situation exists for long-term care, where Alberta’s number of beds per capita falls below the national average. But don’t think the province makes up for this by supporting those folks in their homes. Alberta also sits close to the bottom of provinces for home-care spending.

the government opened 360 new hospital beds in Edmonton and Calgary in 2011. It announced plans to open 5,300 new long-term care beds by 2015 (1,174 of them were ready by April 2011), to make additional investments in home care (800 new clients in Edmonton and Calgary) and to improve patient discharge planning. It also announced a five-year plan that includes a primary-care focus

But there’s no plan to increase full long-term care, nursing homes and auxiliary hospitals. This is the category of care that is most needed to take pressure off our hospitals

He also says that even if beds are created, they may not match the needs of hospitalized patients, because of the lower levels of nursing support and the high personal cost for the patient and his family. “Indications are that the private, for-profit care model may actually create barriers to moving patients out of hospital beds,” he says.

“There is strong evidence of an association between high bed occupancy and (the superbug C. difficile),” researchers wrote recently in the journal Infection Control and Hospital ­Epidemiology.

Ontario has 2.4 hospital beds for every 1,000 residents, less than half the European average. Of 39 countries compared by the Organization for Economic Co-operation and Development, only three had fewer hospital beds than Ontario: Mexico, India and Indonesia.

Precisely how bad the bed crunch is now in Ontario isn’t clear. Last summer, a period when demand for hospitals typically drops, the average occupancy was 92%. Health Ministry bureaucrats were unable this week to provide more current data.

Asked about overcrowding, Health Minister Deb Matthews wouldn’t say if more beds are needed. Just because infection rates rise when wards get crowded doesn’t mean the latter causes the former, she said.

But data collected by her ministry tells another tale: While beds were freed up from 2008-11, progress has stalled for a year or two, experts say.

Sinha isn’t convinced the jam in all hospitals is the result of too few beds — some hospitals have been slow to adopt best practices to free up beds faster, he said.

But hospitals that operate at or above 100% capacity do so at the risk of patients, he said. “Everyone agrees that’s not a safe level to run,” he said.

Some hospitals may need more beds, said Dr. Michael Schull, president of at the Institute for Clinical Evaluative Sciences, which independently analyses Ontario health care.

The numbers underscore the need for improvements to hospital staff safety measures, something the Ontario Nurses' Association (ONA) has long been calling for to better protect health-care providers. "Violence isn't part of this job. It shouldn't be part of this job," said Andy Summers, vice-president of health and safety with ONA. "Eventually, somebody will get killed."

Summers called the current situation of violence against nurses in Ontario "completely unacceptable." At UHN, which includes Toronto General Hospital and Toronto Western Hospital, there has been a consistent increase in reports of assault in the past three years. The number of reported violent incidents doubled in two years, jumping from 166 incidents in 2012 to 331 in 2014, according to data provided to the Star. In 2014, 11 workers who were injured were unable to return to work for their shift following the assault. Spokeswoman Gillian Howard said changes in reporting standards probably account for the rise. The changes include a Behaviour Safety Alert, implemented at UHN in 2014, which requires staff to put an alert on patient records if the patient has aggressive or violent behaviour. Howard also said increased reporting could be attributed to the fact that unions are encouraging staff to report every incident: "a very good thing," she said.

"We do not want any staff member at risk from a patient, but given the care we provide, the medications used, the fact that some patients have cognitive impairment as a result of injury or aging, the impairment of some patients when they arrive, and the risks associated with some of the treatments, it is not likely that we will see a year with no incidents," said Howard, adding that UHN employs approximately 13,000 staff and has over one million patient visits per year. But ONA lashed out at this explanation, saying employers are trying to downplay the issue.

Erna Bujna, occupational health and safety specialist with ONA, said some employers "absolutely" still discourage staff from reporting incidents, by telling workers that violence is just part of the job. ONA wants to see a violence strategy implemented at hospitals across the province. The strategy would include mandatory reporting of every violent incident reported to the Ministry of Labour - currently, employers are only required to report fatalities and critical incidents to the ministry - mandatory risk assessment of every patient, increased security and more health-care providers hired. They also want the Ministry to charge individual hospital CEOs when workers are not adequately protected from violence.

He added that legislation requires employers to assess the risks of workplace violence, create workplace violence and harassment policies, develop programs to implement those policies, and take every precaution reasonable to protect workers from workplace violence. ONA's call for an updated safety strategy comes on the heels of a decision by the Ministry of Labour to lay charges against Toronto's Centre for Addiction and Mental Health (CAMH) in December 2014. The charges - made under the Occupational Health and Safety Act and relating to failure to protect workers from workplace violence - stem from a violent incident in January 2014 in which a nurse was dragged, kicked and beaten beyond recognition, according to ONA.

Toronto police later charged the patient, who was found guilty of assault causing bodily harm, according to court documents. "We don't want staff ever to feel that aggression is the norm," said Rani Srivastava, chief of nursing and professional practice at CAMH, in response to the comments. "We are committed to a culture of safety and recovery and that means safety for staff and patients." Jean Dobson, a nurse at University Hospital in London, Ont., said she's been strangled with a stethoscope, stabbed with a metal fork and spat at by patients over the course of her 42-year career. "People think that they can hurt a nurse and that's OK," she said. "We have to smile and take it."

In one incident, Dobson had her nose broken when she was kicked in the face by a patient. She was forced off work for weeks and suffered from PTSD, she said. Dobson said she's seen the frequency of patient-on-nurse assaults and the severity of violence increase during her career. At Sunnybrook Hospital, reports of abuse against staff by patients and visitors jumped from 140 in 2012 to 320 in 2013. The hospital attributes the increase mainly to their move to electronic reporting, which makes it easier to record violent incidents, a spokesperson told the Star. According to a 2005 national study from Statistics Canada, 34 per cent of nurses surveyed reported being physically assaulted by a patient in the previous year, and 47 per cent reported experiencing emotional abuse. For those working in psychiatric and mental-health settings, 70 per cent of nurses reported experiencing emotional abuse.

But stress is not the sole explanation. As both the coroner and the ombudsman note in their reports, the medical classroom and workplace are brutal: Bullying and psychological harassment are commonplace in hospitals, and the stigma about mental illness is pervasive in the medical profession. In short, medical education is too often imbued with a macho attitude that learners have to be broken down and toughened up and that those who can't take it are weak and unworthy.

On Nov. 17, 2014, the inanimate body of Emilie Marchand was found in a parked car in the north end of Montreal. The 27year-old medical resident at the University of Montreal died by suicide, from an overdose of the painkiller hydromorphone. Unlike most suicides, Ms. Marchand's death garnered a lot of media attention. It occurred at a time when the dysfunctional administration at University of Montreal-affiliated hospitals was under scrutiny, and came on the heels of a damning report by the university's ombudsman about another medical student's suicide. Now Quebec coroner Jean Brochu has weighed in, pointing a finger at the University of Montreal for sitting idly by while a sick, troubled student was "slipping slowly and solitarily toward a dead-end of desperation."

There is also an open recognition of the problem; when residents and doctors killed themselves before, it was hushed up - now it is at least talked about. But while the system has become adept at collecting data on depression and suicide, it has done little concrete to offer help and invest in prevention. Emilie Marchand, like all her classmates, had stellar marks and, from the time she was in high school, dedicated herself heart and soul to the goal of becoming a doctor - in her case a specialist in internal medicine. When she was in medical school she was diagnosed with a personality disorder and, in residency, suffered from bouts of depression so severe that she had to be hospitalized. She also had a previous suicide attempt, using the same drug, hydromorphone. But Ms. Marchand continued her studies full bore and - her friends testified later - lived in mortal fear that her illness would be exposed and her career derailed.

Increasingly, research is showing that so-called superperformers (such as those attracted to medical school) are particularly vulnerable. Paradoxically, the very qualities that make someone a good doctor - empathy, caring, perfectionism - make them vulnerable to burnout, depression and suicide. The students attracted to medical school are among the best and brightest of their generation. They are smart, talented and driven. But many are also anxious, overwhelmed and lost - sick, not weak.

We cannot simply respond to the wounded healers with the age-old admonishment, Cura te ipsum (Physician, heal thyself). We must create an environment in which our future doctors can learn to heal, beginning with caring for themselves.