Care is shifting out of hospitals, the traditional power base for specialist physicians, and into the community.
A new report suggests that people who check themselves out of hospitals against the advice of their doctors are likely to make a return trip in the near future.
The report says people who discharged themselves were more than twice as likely to be readmitted to a hospital within a month, and three times as likely to visit an emergency room within a week, when compared to people who leave when their doctor says they are ready to go.
And three out of five of the people who self-discharged and then came back to an emergency room for help ended up being readmitted to hospital.
The findings are part of a national study from the Canadian Institute for Health Information.
It is based on an analysis of data from all provinces except Quebec.
It shows that 1.3 per cent of all discharges from Canadian acute inpatient care hospitals in 2011 to 2012 and nearly 1 per cent of discharges from emergency departments in Alberta and Ontario were made against medical advice.
The report says the rates are comparable with those of other countries.
The work supports other studies that have found people who leave hospitals against the advice of doctors often end up needing additional care. In fact, a study based on Manitoba data that was published in the Canadian Medical Association Journal in late August found that self-discharge from hospitals was associated with higher rates of readmission and of death.
Dr. Stephen Hwang, who specializes in inner city medicine at St. Michael's Hospital in downtown Toronto, suggests the problem is a complex one.
"It's a reminder that this is an important problem and we should be developing problems to it," Hwang says of the study.
While close to half of the people who discharged themselves from hospitals had a documented mental health disorder or a substance abuse problem, more than half did not.
"It is important to realize that all kinds of people do leave against medical advice. Young and old, men and women. Sometimes people of higher income as well as those of lower incomes," he says.
The reasons why people ignore the advice of their doctors are also varied, says Hwang. Some say they are leaving because they feel better. Others with a substance abuse problem may leave to be able to drink or get a drug fix.
Some people report needing to go home to take care of a family member or a pet. In other cases, an income cheque may be due and the person needs to deposit it in time to cover their rent and avoid eviction.
And in a number of cases, people simply say the reason they are leaving hospital early is none of the doctor's business.
"Hospitals are not jails and they're not obliged to give us the reason that they disagree with us and want to leave," Hwang says.
He suggests that rather than trying to dissuade a patient from a path they are determined to take, doctors should try to organize some support for the patient. They could ask if it's okay to notify a family member of the patient's plans and health needs, or contact his or her family doctor to discuss ongoing care.
"We should proactively try to put in place that safety net rather than in a moment of irritation with the patient who is not listening to what we're telling them to do say 'Well, okay, out you go. My responsibilities are absolved,"' Hwang says.