In the context of emergency department (ED) overcrowding and long wait times, we are all looking for solutions. Introducing physician-in-triage roles or, put more colloquially, having a “doc at triage” has gained some traction in the literature and in conversations about potential innovations. [1,2]

In Canada, the issue had become enough of a topic of discussion to gain the attention of the Canadian Medical Protective Association (CMPA), a medico-legal mutual defence organization, which issued guidance on the topic in early 2026. [3] Of interest, the CMPA curiously suggested emergency physicians reach out to the Canadian Association of Emergency Physicians (CAEP), our national association, for further advice. The CMPA had not discussed this with CAEP, nor did CAEP have a position on the issue at the time (CAEP was working on it as I was writing this blog post in early September 2026). But I do have a position on this issue! In this blog post I lay out the pros and cons of having a triage physician, and I describe an alternative approach.

Does a doc belong at triage?

To answer the question of whether physicians should play a role in triaging patients in EDs, we should start by asking what problem we are trying to solve by having docs at triage. We must also ensure we are talking about the same thing when we discuss a strategy with a vague title.

Generally, having a triage physician is positioned as a strategy to use when ED wait times are long. It is intended to ensure patients get placed on the right care pathways and to reduce rates of patients leaving without having been seen, which can soar when waits are long and the waiting area is full. However, the roles assumed by a doc at triage vary, including those described in the following examples:

  • The physician does the triage instead of a nurse. I have not seen this in Canada, but apparently, it is a model used in some places in the US.
  • The physician listens to the triage interaction led by a nurse but does not interact with the patient directly. Rather, following triage they take what they observed and collaborate with the triage nurse to determine the urgency of the case and decide on early interventions (e.g., initial blood work, imaging), but no real doctor–patient relationship is established.
  • The physician listens to the triage interaction led by a nurse but also introduces themselves to the patient and does a focused assessment post-triage to inform early interventions to be undertaken. They write a brief note but generally do not follow up on results; all or almost all cases are handed over to another physician. However, a doctor–patient relationship has been established.
  • The triage physician observes the triage process and tries to cherry-pick patients they can see and discharge from the waiting area (e.g., those requiring suture removal, prescription renewals, or treatment for minor lacerations). This is sometimes called a “see-and-release” or “see-and-street” model.

In Alberta the “triage liaison” physician model had the physician also answers calls about interfacility transfers of patients expected to arrive at their tertiary care centre. [4] You can also replace the triage physician with a nurse practitioner or other advanced practice practitioner. There could be more variations still.

Potential benefits of having a triage physician

The advantages of any of these approaches are maximized when the department is regularly in gridlock, wait times are long, rates of patients leaving without having been seen are high, and —crucially — physicians are available to fill the role. It seems in most cases I’m familiar with, the strategy is deployed in EDs in which, on a fairly regular basis at certain times of day, there is stretcher gridlock. When there is stretcher gridlock, flow and new assessments grind to a halt and patients and physicians are waiting for assessment slots to come open. In that context, at least, depending on the model, a physician validates the triage decision, and/or initiates some investigations, and/or debulks the waiting room of patients with simpler problems not requiring resources within the main ED.

There can also be financial incentives associated with deploying a doc at triage. Depending on the jurisdiction and interpretation of compensation rules, the triage doc may add to total physician income through billings or targeted salary support from the hospital. In Canada, a triage doc may document their actions as constituting a physician initial assessment (PIA). The time is then reported in ED data as a PIA or PIA time, resulting in improvements in wait-time performance; in Ontario, this can potentially result in financial benefits for hospitals through the province’s Pay for Results Program.

Another variation on the doc at triage strategy is specifically scheduling a senior physician who is a respected clinician in the role, much as most EDs prefer to have a senior or experienced ED nurse in the triage role. The thought behind this is that an astute clinician will be best at picking up on clues from the information available at presentation and will therefore help ensure investigations are employed wisely and patients are routed to appropriate care safely. This makes sense if there is an adequate supply of such practitioners in the group to meet the need. In the right circumstances, it could even be a good role for end-of-career transitions for some physicians. However, this approach may not be easily or widely generalizable.

Potential concerns about the triage physician role

If having a triage physiian results in patient care and patient experience considerations being aligned with financial incentives, it sounds like a great strategy. But let’s break it down a bit.

The main concern of the CMPA appeared to be that physicians need to remain cognizant of the medico-legal risks involved in taking on this role. Doc at triage interactions are decidedly brief, but if they could be seen as creating a doctor–patient relationship, then the physician would be expected to meet usual standards of care in their interaction, including those related to documentation. A key consideration is the aspect of follow-up on tests that they initiate; if the physician who orders a test doesn’t follow up on the patient to view the results personally, are they confident a colleague will do so in a timely manner? If they have identified a concern with a patient, have they communicated that concern to a responsible colleague as part of handover or at least documented their assessment and actions? Have they explained their role or expected next steps to the patient? If things go badly, is there adequate documentation to explain and defend the triage doc’s actions?

The fact that the CMPA published an article on this topic might suggest it had concerns about whether these things were routinely being considered, and the design of doc at triage programs does seem to encourage brief interactions. Brief is fine as long as it’s not too brief and if true value is being added to the patient’s care through the interaction.

Of course, another concern with this model is whether this is the best possible use of available physician resources and funding.

To me, the most important question is this: In a gridlocked ED in which flow is frozen until stretchers become available, is having a doc at triage the least bad thing we can do?

An alternative to triage physician

Let me suggest an alternative approach. A well-run ED should always leverage triage assessments to identify early interventions that could help expedite care overall. A suite of medical directives can empower nursing colleagues to do electrocardiograms, send blood work requests, order basic imaging tests, give initial IV fluids and/or analgesics, or place a urinary catheter to relieve retention. Overall, this would ensure we are making the best use of registered nurses’ full scope of practice. In general, we may draw a line at medical directives for cross-sectional imaging (CT and ultrasound), but at my ED we have identified a few scenarios in which we encourage nurses to seek a “stat” order after triage from the doc on duty (e.g., CT for thunderclap headache, CT or CT angiography for acute stroke, ultrasound for suspected ectopic pregnancy) or for other very easily defined and time-sensitive situations. Thus, a good medical directive program should minimize any incremental benefit that could be derived from a physician ordering tests at triage based on a very limited assessment.

I have previously written about another strategy used to avoid having physicians just waiting for stretchers to become available — seeing patients in the waiting room. [5] The difference is that these are not supernumerary physicians, they are scheduled physicians who have run out of patients to see in normal assessment areas, and they will take full responsibility for their patient until they make a disposition or until the end of their shift when they do a handover like in any other circumstance. When the patient moves out of the waiting room, if they do, the same doc is their most responsible physician. They follow the tests they ordered as they would for any other patient.

It does take an organized effort by the full department to create and maintain an efficient and effective medical directive program and to enable minimally acceptable waiting room assessments. There needs to be designated space for a private conversation with the patient, as well as staff designated to carry out physician orders or medical directives. However, the same things are true of a triage physician strategy! The doc needs some space, the waiting area needs someone able to carry out orders, and the approach must be explained to staff and safely monitored. However, no extra physicians are required above the usual scheduled complement, which is an important consideration when so many hospitals and communities are short staffed. No extra handovers with the inherent risks of handover are created. In the approach I’ve just described — a combination of medical directives and enabled waiting room care — staff can easily move between the waiting room when needed and other areas of care as flow demands. The movement of staff in a flexible manner could be true in a doc at triage model, but this is less automatic when staff are specifically scheduled or assigned to triage. Another way of looking at it is that enabling waiting room care is a rapidly deployed, nearly automatic surge strategy, whereas having docs at triage requires advance scheduling.

Bringing it all together

The see-and-release model has benefits when you are in an ED with a high enough volume that there are enough patients whose needs match this level of care to justify having a dedicated physician. That is, you have enough patients and the physician resources to make it work. But for all other approaches to having a doc at triage, I believe the combination of medical directives and enabled waiting room assessments is a more efficient use of resources and provides better care overall.

We of course also need to do what we can to minimize wait times and avoid waiting room care. [6] Basic strategies such as matching staffing to arrival patterns, streaming patients to an intermediate zone with shared stretchers (a rapid assessment zone), and fast tracking should be universal in all EDs with volumes above 30,000 to 40,000 patients a year. Accountability for flow across the ED and hospital should be clearly established. Data-driven reviews of processes should be done intermittently and routinely. Busy EDs can consider the strategic use of venipuncture technicians, registered practical nurses, or other practitioners to support registered nursing staff.

If you were a patient in a very busy ED, which would you rather have — a doctor who will be your most responsible physician throughout your course of care and who comes out to see you in the waiting room, or a doctor who may or may not introduce themselves and who at most will do a very abbreviated assessment and then never see you again?

References

  1. Alsuliamani A, Badawi R, Alrehaili JA, Alsayed AS, Alawad Y, Khalifah MR, et al. The Impact of Involving a Senior Emergency Physician in the Triage Process. J Med Law Public Health. 2024;4(3):391-8. Available from: https://jmlph.net/index.php/jmlph/article/view/127. Accessed September 19, 2026.
  2. 2.     Leger L. MDs in triage face medico-legal risk, even when role is limited. July 10, 2026. Canadian Healthcare Network. Available from: https://canadianhealthcarenetwork.ca/mds-triage-face-medico-legal-risk-even-when-role-limited. Accessed September 19, 2026.
  3. Canadian Medical Protective Association. Physicians-in-triage: Understanding your role and managing medico-legal risk. April 2026. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2026/physicians-in-triage-understanding-your-role-and-managing-medico-legal-risk?lid=x5dyqrwqsz99&utm_source=26May29en-D-Emergency-Medicine&utm_medium=Email&utm_campaign=Ebulletin&utm_content=bfd5e82e-1231-447c-b2cf-26a2f2d8e9be. Accessed September 19, 2026.
  4. Holroyd BR, Bullard MJ, Latoszek K, Gordon D, Allen S, Tam S, et al. Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Acad Emerg Med. 2007;14(8):702-8.
  5. 5. Ovens H. What would Osler do? CJEM. 2019;21(5):567-8.
  6. Li MK, McLeod SL, Affleck A, Bhate T, Innes G, Parks P, et al. Emergency department overcrowding: a CAEP position statement. Can J Emerg Med. 2026. Available from: https://doi.org/10.1007/s43678-026-01228-w. Accessed September 19, 2026.

Dr. Ovens has no conflicts of interest to declare.