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Note: this is my initial reaction to one very narrow part of the guidelines. There are definite risks in adding alcohol to antidepressants and vice versa! I’m also not a doctor, clinician, or health researcher, nor do I play one on the Internet. I’m raising what I believe to be legitimate questions about the validity of one recommendation that seem to warrant additional objective consideration and further discussion.

As you’d expect, the recommendation from the new alcohol guidelines published in CMAJ getting the largest press is the one about antidepressants.

See: Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder.

The (strong) recommendation reads: “Prescribing SSRI antidepressants (ADs) is not recommended for adult and youth patients with alcohol use disorder (AUD) and a concurrent anxiety or depressive disorder.”

While it says it’s based on “moderate” evidence, this may be the weakest part of the paper.

The main data is an incidental finding in a RCT (n=265) relevant to a large subset (60%) of participants. The study looked at citalopram (an SSRI) and AUD.

The other main ref was a study about a non-SSRI (trazodone, a tricyclic antidepressant useful for insomnia but not depression).

A few other studies were cited, comparing citalopram/escitalopram or sertraline with medications designed to treat AUD, e.g., naltrexone, while people were also undergoing CBT, alcohol treatment, etc. Depression generally improved with all groups, btw.

The evidence has been clear for a while that ADs aren’t a useful treatment for AUD. No question. The finding that they MAY increase alcohol use is not well known but important.

But does that justify not using ADs when AUD is present?

It does argue that alcohol use be monitored during treatment (duh) and if it’s increased that AD use may be a factor, and if so, should be addressed.

Again, non-obvious or well known so worth highlighting.

Not using at all? The argument would work if there was no evidence that ADs improved depression when AUD was present.

The incidental finding from the n=265 RCT found this. Unfortunately, the evidence is very mixed.

I did’t see studies about SSRIs/anxiety and AUD at all.

Other studies, even on the same medication (citalopram) have found different results, e.g. in STAR*D (much, much larger data set).
See e.g. Does comorbid substance use disorder impair recovery from major depression with SSRI treatment? An analysis of the STAR*D level one treatment outcomes.

It showed same response with or without substance use (includes breakdown of AUD/other).

There are always a huge number of potential confounds in mental health studies involving study population, other concurrent treatments, etc. And AUD has an effect on other factors, e.g. nutrition, that are known to affect depression treatment. (I’ve talked about this before, e.g., here).

Very weakly controlled for here in these studies.

In summary, is there evidence to conclude that SSRI’s shouldn’t be used for anxiety or depression when AUD is present?

Not based on one study of one SSRI (with others studies showing conflicting results) and one non-SSRI (trazodone, not used for depression).

This does not take away from the other guidelines around diagnosing and treating substance use. In this context, taking a substance use history as part of a mental health history (should be standard) is important. As is monitoring treatment and addressing setbacks (duh).

But this will be interpreted as “if I drink, I shouldn’t be prescribed an SSRI AD.” This will have widespread clinical implications in practice.

Based on what I’ve seen so far, which is doubtless incomplete, that conclusion is not supported.

Use of any AD requires monitoring to determine its effectiveness (trial and error is involved) and side effects, including on substance use. History and followup are critical. Again, duh.

But a blanket recommendation against AD use when AUD present? Doesn’t make sense.

Editorial: Medicine has its tribes like every other field, and I suspect that was a factor here. It will be interesting to see how other tribes (e.g. psychiatrists) respond.

And yes, I’m holding my breath waiting for my fat cheque from big pharma now.

Dear Sonia, Adam, and team…

BC needs you to fight for a truly patient-centered mental health system. One that doesn’t simply expand the fragmented provider-focused disaster we have now.

I’m directing this toward you because you’re the only party in BC that takes healthcare and mental health seriously.

Whether it’s COVID-19, primary care, the opioid crisis, unaccountable bureaucracy, fiscal responsibility, or abuses of patient rights. You’ve sought out experts, taken the necessary time to really listen and understand, and put in the effort to stand up for people who need help. Even when it means taking positions that aren’t politically expedient.

Your political opponents are either fixated on soundbites and one-dimensional policies (sorry, mental health is more than inpatient addiction treatment) or inventing a press-release-driven fantasy world to distract from and obscure the Hunger Games reality of BC’s health system.

On mental health:

• You’ve supported those who’ve spent years fighting for change in places like Victoria’s Psychiatric Emergency Services.
• You’ve called for better regulation of counsellors, to ensure the public has the same protections and assurances working with these valued professionals as with doctors and psychologists.
• You’ve also recently called for greater regulation of the many privately-run mental health and addiction treatment facilities, which charge desperate individuals and families tens of thousands of dollars for frequently ineffective treatment with virtually no oversight and accountability.

You’ve also called for a pilot project where psychologist visits are paid for on the public dime, through MSP.

I’m glad you’re suggesting only a pilot project because while it will provide a bandaid in the short term, it won’t solve the problem.

While adding psychology to MSP might help, I worry it will become a naive “everyone has coverage for X sessions and then you’re done.” They’ll do what they can with the constraints they have available. That will help some patients. But if used wisely, psychologists could contribute so much more.

We keep giving more and more money to providers. They do what they can with what they’re given to work with. Delivering more interchangeable units of mental health will not solve the problem.

The way we continue to use primary care, psychiatrists, counsellors, and psychologists in this system is an incredible waste of their time and talents and provides limited benefit to patients at great cost. It’s a model focused on providers, not patients.

Let’s take some of your thinking on accountability and apply it here. We need to be smarter and use resources far more effectively. Provide care that’s focused on patient needs, and finding the best places for them to get it. This takes time, iteration, continuity, and learning rather than throwing random chunks of care at patients just because that’s what’s available.

We need professionals to focus on the big picture and ensure people don’t get lost like they are now. Psychologists are perfectly positioned to do that.

They have a broad knowledge of mental health, skills in therapy, diagnosis, and psychometry, and most understand the biological factors and can interface with doctors. They have the analytical tools to evaluate, plan, and collaborate. They’re perfectly positioned to take a leadership position in a more effective mental health system. To be a bridge between the different silos. To ensure we’re using all these different professionals far more effectively.

We could pay psychologists to deliver six sessions of therapy to whoever walks through their door.

That would be another provider-friendly and government-friendly solution. But it’s more of the same thinking that has failed patients so badly already.

We can do so much better. Psychologists could be the key to a patient-centered system. Let’s all be smart about this.

To avoid the worst consequences of the nightmare health scenario we’re on the road towards, we need to start making changes — now.

Incentives, in various forms, are key to that.

The previous article talked a lot about incentives and how they influence behaviours. They include straightforward financial incentives but also things like peer pressure and enlightened self-interest. Examples included “cleaning up your own mess” when it comes to patients you’ll see again or are shared with a small network of colleagues. Or being able to do more of the work you love.

Bad things happen when incentives become misaligned. That’s what’s happened in today’s healthcare system. But it also points the way to solutions — realigning incentives. Better encourage desirable behaviours and discourage less desirable ones. Incentives are powerful and effective tools that come in various forms.

Intrinsic Motivation

Incentives can influence behaviour, but there’s a baseline motivation that serves as a starting point. For doctors, what attracted them to medicine? To help? Money? Status? Where do they get their satisfaction?

What’s the motivation for those who choose family medicine as a specialty (as opposed to those who use it as a fallback because they couldn’t match into ophthalmology)?

Most choose it because they find the idea of doing what we think of as “traditional family medicine” to be fulfilling. They value being a part of their patients’ lives, the continuity, the relationships, and the variety they know will come with every day.

They know it will be hard work compared to some other areas of medicine. They certainly know other areas will pay better. They expect to be able to make a reasonable living at it, given the amount of training, accumulated debt, and responsibility. They expect to command some degree of respect. But not super-rich or high status. They would consider that a reasonable tradeoff for the satisfaction the profession brings.

Increasingly, that idea of what they hoped for in their careers is vanishing. With the current fee structure and overhead, they can’t make a reasonable living doing traditional family medicine. They can’t afford it. That’s pushing them to do things they don’t want to do, give up all their dreams of being part of their patients’ lives, the relationships, and the fulfillment and satisfaction they went into family medicine for.

Nobody chose to specialize in family medicine to be a cog in an assembly line, working alone and dolling out prescriptions for antibiotics and heartburn meds to an endless series of strangers. That’s about as far away from their dreams as you can get.

As this reality becomes more entrenched, so does the inevitable result. Fewer medical students are choosing family medicine as a specialty. More family medicine spots are left unfilled after the first round of the CARMS match than ever before. Many who eventually fill those spots do so because they couldn’t match into their desired specialty. They’ll be the first to take jobs as hospitalists, open cosmetic medicine clinics, do insurance assessments, anything but traditional family practice. Why would they? The work isn’t something they’d get much satisfaction from, and the rewards to compensate for it aren’t there.

All those family medicine residency spots were carefully allocated to meet societal demands for traditional family practice doctors. But that’s not what they’re producing. That leaves a big hole.

We have all these people who really want to do this very high value work, and we’re driving them elsewhere. Nobody is happy.

They’re highly motivated to practice as full-service family doctors and will jump at the opportunity if we just stop penalizing them for it.

Productivity

If we’re still producing the same number of family doctors (even if they’re doing something else), they’re still contributing to the system. So, in the end, shouldn’t we still be okay?

When we consider how to best use a finite set of resources to achieve a desired outcome, we’re talking about productivity. In healthcare, we can think about productivity as delivering the best, most important health outcomes with the least resources. The value they contribute to the system. But what does that look like?

Let’s consider a traditional family doctor providing longitudinal care to patients they know. They treat for most things, bring in specialists only when their expertise is required, juggle followup and prevention, and more often make smarter decisions because they know their patients’ histories.

Let’s assign them a “productivity factor” of 1.0 (call it “1.0PF” for short).

A family doctor working in episodic care (walk-in or telehealth platform) may sometimes deliver higher productivity (simple presentation that turns out to be a simple problem fixed by a simple treatment, all with less overhead). More often, they’re still contributing to healthcare outcomes, just not as productively as a traditional family doctor. In particular:

• their patients are more likely to require multiple visits to achieve the same outcome
• visits with multiple different providers for the same problem leads to unnecessary redundancies
• being unfamiliar with full histories, it’s less likely the optimal path to the solution will be found
• with less solved in primary care, more use of specialist resources is demanded
• less follow-up and preventative care leads to more and repeated treatment
• serious problems are identified later when they are more difficult and require more resources to treat or result in worse outcomes

The net result is that episodic primary care contributes to improving health outcomes but not as efficiently as longitudinal primary care. That means a lower productivity factor. We don’t know the actual number, but it will not be a small hit, e.g. 0.9PF. Let’s say it’s 0.5PF.

If so, every time a family doctor moves from full-service family practice to environments offering exclusively episodic care, they’re contributing 50% less to health outcomes. That’s huge. Even if the actual difference is only 10% (which I think is far less than reality), with a resource as scarce as doctors specialized in family medicine, that has an enormous impact. Which, of course, is what we’re seeing today.

Making Things Worse

The main issue right now with traditional family practice is that it’s financially unsustainable. It’s contributing very highly productivity-wise. But, given the overhead, the unpaid work, the stagnant fees, and everything else, it’s just not providing family doctors the minimum they need.

Instead, they’d been gradually shifting toward the assembly line of episodic care. Less overhead and responsibility, same $30 per visit. Less job satisfaction, but less personal downsides. But providing less value to the system than that same doctor working in longitudinal care. Maybe up to 50% less productivity. By any measure, that’s an inefficient use of scarce resources.

And then, we take a bad decision and make it even worse. Two examples: telehealth platforms and UPCC’s.

The telehealth platforms are even more attractive to family doctors than bricks-and-mortar walk-in clinics. Low overhead, less ownership, lower responsibility, less structural pressure that encourages people to do a good job. Do the work, take the pay, and logout. And they’re compensating for things like no-show appointments that would otherwise be unpaid. Hell, the telehealth platforms are probably losing money doing this right now. But in various ways, they’re building demand to offer for-fee premium services down the road. And we’re incentivizing them to do it.

The second example is the UPCC’s. By any measure, providing episodic care that is both frighteningly more expensive than would be provided in other settings and removing all incentives to be more efficient and help more patients. So way worse productivity… 0.25PF perhaps? If they weren’t so poorly managed that nobody wanted to work there, they’d be hollowing out traditional family medicine even faster.

The sad thing is that you need fewer incentives to get people to do what they want than what they don’t want.

We’re paying the most for the lowest productivity when it would cost us the least to sustain the system proven to deliver the greatest contribution.

Traditional family medicine offers the greatest bargain by a wide margin, and we’re stomping on it.

Fix the Primary Incentives

So the first thing we need to do to solve this is to fix the main incentives.

Government has to stop trying to compete with independent family doctors, which they’re failing at miserably. They need to work to get the incentives right and then get the hell out of the way.

I’m not a small government absolutist, but what we’re doing now is insane. Now the reward is the same to provide lower-value care, which takes less time and resources, than higher-value care. Of course that’s going to drive people in the wrong direction. And increasingly, amoral bad actors will step in and take advantage of the situation.

Adjust fees so that care provided in longitudinal family practice is better compensated than lower-value episodic care. There are many ways this can be done; we’ve been hearing them for years.

That will shift people away from lower-value work towards the higher-value work they really want to be doing anyway. It doesn’t mean we get rid of all episodic care or ban the telehealth platforms. But adjust the incentives to closer approximate need and value, and the market will adjust accordingly.

Despite protests to the contrary, government has the power to do this. Yes, physicians are a party to this, and infighting, particularly between family physicians and other specialists has contributed to this problem. But the government is responsible for providing value on behalf of its citizens and needs to seriously step up.

Yes, there will be mistakes, we’ll overcompensate, there will be unintended consequences, but that’s not an argument for sitting on our ass and doing nothing.

Stop throwing away good money and complaining you need more money.

Job one is to rebalance the incentives. Now.

Service Level Agreements

Adjusting incentives directly to the service in question are the most obvious lever and often the fastest to apply. They’re certainly the most applicable to the primary care mess. But there are others.

Service level agreements (SLA’s) are another. They can provide incentives to do things people otherwise might not do or where they might prefer alternatives.

A simple example: if you don’t finish your dessert, you can’t go out to play. Another: I’ll pay you two dollars every day you keep your room clean and an extra ten dollars if you keep it clean the entire week.

In the healthcare realm, it would be governments saying to large providers like healthcare authorities: if you want us to pay you to do expensive surgeries, you have to do all the cheap ones too. Or: we’re paying you to provide psychiatric consults, but for every week people have to wait longer than an agreed-upon wait time, we’ll pay you 1% less.

Right now, health authorities have little motivation to deliver services at a given level. It’s not like there’s extra profit if they do more. So why bother to build capacity? This is why there’s so little effort towards recruitment and retention.

There’s one colossal obstacle that needs to be overcome. This strategy depends on actual accountability for results. Ideally, public. Part of the whole reason for health authorities in the first place is to separate them from governments and thereby provide some political cover. Mandate reporting. Make it part of the SLA. One of the few advantages of our dozens of health systems is it allows us to draw comparisons across them — recognition (or shame avoidance) is another incentive. But needless to say, actually being open with metrics, whether good or bad, has not been a strength of our healthcare system.

These are bigger contracts and take longer to sort out, but will increase productivity and help stem the waste.

Common Infrastructure

Sometimes, direct incentives or SLA’s aren’t appropriate. Fee codes are a fairly blunt tool and can’t capture all the complexities of delivering care. Sometimes there are things that would benefit everyone, but the costs to any one individual would be too high to justify the benefits they receive.

Roads are a great example. Infrastructure that benefits everyone but are prohibitively expensive for any individual entity to create and maintain. Their value increases as more people use them, even those that don’t directly contribute resources, which we call network effects.

Governments can play a valuable role in building common infrastructure that everyone benefits from. With good roads, the costs of delivering services for everyone decrease. They (literally, in this case) reduce friction. They’re an indirect incentive.

Government can do that in healthcare, too. They already do. The whole MSP system. Pharmanet. They’re slowly trying to get there by tying together a common backend for health records. The more people use it, the more benefits everyone gets. Having anyone else responsible for them wouldn’t make sense.

What other infrastructure would ease healthcare delivery? More work on the records front. More tools to help centrally identify referral resources system-wide and even help manage pooled referrals, etc. There are many more examples. These investments reduce the disincentives to providing certain services, which sounds a whole lot like boosting the incentive.

These are massive projects and will take longer. But they’re examples of places where government can positively contribute in ways that others can’t.

Bottom Line

Government has some responsibilities it must shoulder.

Get the structure of the system right, including incentives of all forms, to reflect value.

Put in place contracts and regulations to enable effective service delivery and protect the public interests.

Level the playing field for providers.

Provide common infrastructure when the net benefit is positive, but the individual payoff is prohibitive.

There needs to be more of those things and less trying to compete with others who can do a far better job far more efficiently.

I’ve been critical of services that are providing largely episodic primary care via telehealth, Telus Health being the most prominent example.

That’s easily construed — particularly in a brief comment on social media — as being critical of providing healthcare via communications technology. I’m writing this to make it clear that the use of technology is about the last thing I’d object to.

It’s about episodic care: when it’s appropriate and when it’s not. Whether that’s delivered in person or using technology as an intermediary.

When it comes to these services, the question is not about technology but appropriate use of technology.

This is the Future. Leave the Technophobes Behind!

The healthcare field has its share of Luddites afraid of new technologies or clinging desperately to the past. I’m not one of them.

I’m a computer scientist by training. My graduate work, subsequent research, and professional career focused on using technology to facilitate communications and remote collaboration. I published probably 15-20 papers in this field. I’ve started companies that created software solving the same problems that people use tools like Zoom for today.

I’m about the last person to say, “oh please, the ’70s were so great, let’s keep fax machines.” Hell, one of my early jobs was as lead developer of some advanced email software.

Here’s the thing. Supporting people to collaborate through technology is tricky. The success (or, more often, the failure) of these systems has far more to do with the context in which they’re used than the technology itself. You need to understand all the subtle details and nuances underlying the social dynamics of how shared work actually happens. Adding technology into the mix is likely to interfere with effective communication, not make it better.

It’s a highly multidisciplinary field. It includes not only technologists but psychologists of many types, sociologists, anthropologists, management and communications experts (and at times even diverged into more obscure areas like existential philosophy). Definitely made the conferences fun.

Video Calls Are Mature, Well-Understood Technology

Technology to do video calls has been around since the 1960s. It’s not new, though the widespread adoption is. Its strengths and limitations have been well studied. We know that video calls are closer to telephone calls than face-to-face interactions in many measures of communication effectiveness. We know they’re better used to maintain existing relationships than to develop new ones, better for some tasks than others. We know the effects that quality parameters like latency have on communication.

I help with my wife’s psychiatry practice (including on the technology front). She
uses tools like Zoom extensively. But she uses them, appreciating the benefits and limitations, in the context of longitudinal, not episodic, healthcare. In other words, appropriately.

The widespread adoption of these technologies is one of the few small benefits of the pandemic. There offer considerable benefits in reducing (some) barriers, travel, environmental impact, and more. They often save time and make (some) things more efficient or even possible in the first place.

I’m hardly suggesting we stop using telehealth or other technologies. But I am urging that we use them in ways that enhance the quality of healthcare, not detract from it.

History of Information Technology in Healthcare

Other than things like diagnostic imaging and medical devices, technology use in healthcare doesn’t have a great track record.

The prototypical example is point-of-care electronic medical records. They’ve turned physicians into data-entry clerks focused too long on their screens rather than the person in the room with them.

They’re big, complex, awkward to use, and disrupt the flow of clinical care. They still create massive problems when they’re implemented. They require massive volumes of information, much of it not needed for clinical purposes. Instead, it allows hospital administrators can generate all kinds of financial and operational statistics that ultimately don’t provide any value for patients or clinicians.

Why? Because the people who source these systems and get the benefits from them (managers, administrators, IT) are not the ones who actually have to use them. The people who use them have to jump through all kinds of hoops, making their work harder and take longer, but they don’t get the benefit.

This mismatch between who does the work and who gets the benefit comes up all the time. It’s not new, and not only in healthcare. One of the classic examples was meeting scheduling systems. Before everyone had a supercomputer in their pocket, and secretaries and typewriters were still a thing, the poster child for “office automation” was shared calendars to arrange meetings. They flopped because the people who got the benefits (managers, who had many meetings) weren’t the ones who had to do the work (the peons who had to keep all their availability up-to-date in their calendar, even if they themselves had very few meetings).

Telehealth Use and Misuse in Longitudinal Care

Let’s focus back on telehealth and its appropriate use. It’s important to separate the medium (audio/video or face-to-face) from the type of care (longitudinal or episodic). They’re two separate things. Your long-term family doctor can provide longitudinal care both face-to-face or via telehealth. You can also receive episodic care face-to-face or via telehealth.

Let’s say you have concerns about abdominal pain, and nobody examines you but just tries to refer you off to a specialist or says, “it’s probably…”. You’re getting lower-quality care than if someone can actually palpate your abdomen. Most of the time, things may work out okay for you, but it’s wasting system resources and has led to situations where serious cancers, etc., have been missed.

The high volume of telephone-only health appointments (more common in independent family practices than the large telehealth platforms) has also raised alarm bells. It’s easy to miss all kinds of things that would be obvious if you saw the person. Even with video calls, it’s not the same. Full embodiment is missing, making it easier to miss or deemphasize some things. It can take more time to get the same quality of info.

If the only option available for healthcare is telehealth, that also presents challenges to access for some people, many already at a disadvantage due to poverty, education, etc. It can worsen inequality.

Telehealth can also have unique advantages over face-to-face. For someone who is physically disabled, telehealth can reduce inequality vs. traveling to appointments or lining up for hours at a walk-in clinic. And I’m sure many doctors have gained new insights into their patients by observing them in their homes or other more naturalistic settings. They can better appreciate their social determinants of health. This information is infinitely more valuable in the context of a long-term relationship between a patient and physician.

Walk-In Clinics, Virtual or Otherwise

The massive corporate telehealth platforms are not replacing full-service family practices offering primarily longitudinal care but bricks-and-mortar walk-in clinics offering primarily episodic care.

I don’t want to dwell on this. The tradeoffs between longitudinal care and episodic care are pretty well understood by now. I just want to emphasize two distinct advantages of longitudinal family practice that can result in improved care.

The first is the value of patient history, implicit (getting to know patients) and explicit (medical records), built up over time. I’m not a doctor, but I’d guess that patient history is easily the most valuable tool they have in many situations.

The second is the incentive doctors have to clean up their own mess. In other words, they’re going to see these patients again, have to deal with them, and deal with the aftermath of the care they provide. That’s a pretty good motivator. Contrast that with a provider who will meet a patient once and never have to see them again. They may provide just as good care, but the motivation to do so is much less. It’s easier to buff and turf them: give them a pill, send them for tests, refer them. Let it be someone else’s problem. They’ll likely not have to see the patient again.

Downsides of Virtual Walk-In Clinics

So, what happens when episodic care is combined with telehealth on a large scale?

On the plus side, it can increase access for some. It can bring down some wait times (one queue to access a larger pool of resources is faster overall than a very large number of queues each accessing a very small pool of resources). Plus, there’s the same advantages around travel, environmental impact, etc. mentioned before.

But there’s a down side. It damages some of the key pillars that delivering good care requires: motivation and incentives, relationships, and sustainability.

The motivation for doctors to clean up their own mess is even lower. In a bricks-and-mortar walk-in clinic, you may have a rotation of 10 doctors servicing the clinic. There’s a reasonably good chance you’ll see that same patient again. And there’s an excellent chance that one of those other 10 doctors will be the one who has to clean up any mess. And that same group of doctors is picking up your mess for all your patients. And you’re picking up their messes. These are doctors who effectively share many patients, communicate with each other, and work together frequently. If it’s not professional pride, the peer pressure to pull your own weight and do a good job is significant.

In the telehealth platform situation, you’ve gone from a small group of doctors you regularly intersect with to several hundred spread out across the province or country. The odds of having to deal with any one of them closely or regularly drop exponentially. So does the peer pressure to do a good job.

In medicine, geography still matters. A family doctor working in a particular area gets to know the resources that are available for their patients. They know who the specialists are and who is best for what types of problems. They see the wait times, the alternative resources and options. They develop relationships with other physicians and organizations that come from sharing several patients over time. Ask any specialist physician, and they’ll be quick to tell you about the family doctors they most (and least) enjoy working with.

In the telehealth platform situation, you have family doctors from one part of the country who are completely unfamiliar with specialists, resources, constraints, and procedures in another location. That’s what leads to all the bad referrals specialists receive from telehealth platforms. You’ve got a doctor in Vancouver referring a patient for care in Victoria with limited knowledge of what’s available. And because they’re not referring to the same set of specialists all the time, there’s less of a relationship and less peer pressure to do a good job with the referral and follow-up care.

Medical care is built on relationships and tacit knowledge, most of which is local. It doesn’t scale. There are ways we could improve this somewhat, which I’ll talk about another time.

Skimming. The people most likely to use telehealth platforms are young, middle-class, and overall healthy, who need help with simple problems. This takes less time and effort than dealing with more complex problems. If they’re paid about the same, whether it’s a simple or complex problem — which is the case now — it’s easier and more profitable.

Full-service family practice is less attractive, which drives more doctors to telehealth platforms, further hollowing out the availability of high-value care. It’s even worse if the telehealth platforms can make things more attractive: less overhead, compensation for no-shows, etc. Again, I’ll have much more to say about this another day.

It’s the Incentives, Stupid

There’s a common theme running through this entire piece. When you have the right incentives in place, quality care follows. When the incentives are wrong, it damages the system and favours bad actors.

Some of this is financial — not just “more money” but more equitable compensation based on the value of care and effort required to provide it (a spin on “equal pay for equal work”). There’s no simple answer like “replace fee for service” that will magically solve these problems, but there are solutions.

But it’s not all financial. Other incentives like fostering relationships, peer pressure, job satisfaction, and ensuring that those who do the work get the benefits.

We can fix these things. Not just by throwing money at it. And there is a critical role for government. Not in trying to compete with current providers. But by working to rebalance the incentives. And where incentives won’t work, supporting all practitioners by providing infrastructure that makes important but difficult jobs easier.

Next time, I’ll talk about strategies to solve these problems.

“We sent in a referral right after your last appointment. It’s not our fault that the psychiatrist won’t see you or that you have to wait for over a year. Blame them — we did our best!”

In a previous post, I alluded to the poor quality of referrals we often receive from telehealth, episodic care.

While I’m more inclined to bitch about the mental health services side of things and stand up for overworked family docs, there’s some blame on that side of the fence. Though who is responsible may surprise you.

What you expect to happen

Many people go to a family doc when they’re struggling with mental health. That’s what we tell them to do. Increasingly, it’s via a telehealth service since they don’t have their own family docs and walk-in clinics are jammed or closing.

You might directly ask for a referral to a psychiatrist. Or, in the course of the brief appointment, the family doc you see tells you a referral would be the best thing to do. They promise to refer you.

As the “gatekeepers” to the specialists in our system, you expect the family doc to decide if the specialist needs to see you. If they send a referral, then a specialist should see you. Hopefully sooner than later, but you’ve heard that waits can be long…

What you see happen

Hearing nothing for several weeks, you arrange another appointment with the family doc (or someone else working through the telehealth service). They tell you they’ve tried to refer you to several places. “Nobody is accepting patients” or “they wouldn’t see you” or “they’ll contact you when they have room to see you, but it might be six months or a year… we really don’t know.” But it’s not the fault of the GP!

There’s some truth to that. But let me show you what you’re not seeing.

The other gatekeepers

When a referral gets sent to a specialist or specialist service, it’s reviewed by someone, whether a doctor, nurse, mental health manager, dedicated intake worker, etc. In my wife’s solo private practice, it’s first me.

Specialists have referral criteria: what patients they’ll see, who they won’t, what information they need sent. Some prioritize more urgent referrals (triage). Sometimes (but not always), referral criteria are documented. Ours are clearly stated on our website and referral form. They include things like age (18-64) and the main problem being referred for (mood or anxiety, but not, e.g., psychosis or ADHD).

Given the scarcity of psychiatrists and that she treats most people (vs. one-time consults), there are other restrictions. She doesn’t see people who are stable and want to connect with someone to stay that way or when some basic things haven’t been tried by family docs before referring. And she needs a patient’s physical and mental health history, previous records if available, lab work, and a few other things. Not all practices ask for all that, but she does and uses it to help prioritize.

Before all the telehealth care, we used to joke about some referrals we’d occasionally get. They’d have just a patient info sticker and the single word “depression,” or the Canadian-ized variant, “please see for depression”.

Our experience with telehealth referrals

I took a look back at the referrals that came into my wife’s practice from telehealth docs that we did not accept. On a quick scan, I pulled out 33 from our records (there were probably a few others I didn’t catch). They were from a range of different telehealth providers (Telus Health was the largest in the batch, with 13 referrals).

Throughout this, I’m using “telehealth docs” as a shorthand for the episodic care that happens when you use one of these services that connect you with a random doctor from whereever. That’s very different than your own doctor seeing you via phone, Zoom, etc.

Here’s what I found:

• 22/33 were sent at a time when we were not accepting patients (we stop accepting referrals when our waiting list gets to a certain point)
• 3/33 were for patients outside our age range (11, 12, and 15)
• 10/33 were for patients whose primary reason for being referred was to get an ADHD assessment (which we explicitly say we don’t do)
• 4/33 were for other things we don’t do, e.g., find a counsellor, or were stable

What required information was (wasn’t…) included in the referrals?

• Not a single referral provided any lab reports, though 3/33 did give a requisition to the patients to get the tests we asked for
• 2/33 provided previous records (both had been sent to the service in advance by the patient), with 3/33 others having enough information we could infer that the person hadn’t seen anyone before, i.e., no records exist
• Only 7/33 provided any information whatsoever about the patient’s physical health, or even “no physical health concerns”
• 8/33 did not mention any medications the patient was currently taking or even “not on any prescribed meds”
• 26/33 appeared to be, with the most generous interpretation, a clear “dump” to psychiatry when no interventions had been tried through primary care

And yes, we tell the referring doc why it was not accepted and they can resubmit with missing info — not uncommon for “regular” family docs to do. And if, for example, it just didn’t include labs, we’d accept it and ask the referring doc to order labs.

The “dump” referrals are worth highlighting, given the shortage of psychiatrists and long waits. Not offering any care whatsoever at the primary care level — particularly given the wide range of reasonable interventions well within the scope of any family physician — may be a real disservice to the patient.

The waits are long everywhere in BC, so not knowing is not an excuse. It’s probably worst on Vancouver Island. But then again, at least 22/33 were from doctors we could identify (with digging) to be from the mainland. They’re at a distinct disadvantage in not being familiar with area resources. Only 1/33 was from a doc elsewhere on Vancouver Island (several we couldn’t tell).

On the plus side, the referrals were mainly (30/33) for patients who lived on Vancouver Island, mostly in Victoria.

Standards for referrals?

There are actually standards for referrals mandated by the College of Physicians. Many referrals pay lip service to them. The Telus Health referrals are four–five pages of boilerplate, often filled in with three lines of actual information. Sections like “Reason for Referral” may just say “depression”, “Expectations” may say “management”, “Relevant Clinical Information” may be two lines, and “Relevant Labs, Reports, …” may be left blank.

And my favourites (this is a recent thing) are referrals that are 95% autogenerated textual versions of the patient’s answers from mental health scales (e.g., PHQ-9, GAD-7, …). These were obviously completed online in advance of their telehealth appointment. Don’t get me wrong, I love scales, but they aren’t a referral and are much easier to read if you don’t try to turn them into prose.

In contrast

The contrast with some of the referrals we get from family docs providing longitudinal care couldn’t be greater. They’ll spend months or years working with the patient, trying all kinds of reasonable things that didn’t fully work. When they’re referred, they come with a ton of supporting documentation.

Whose referrals do you think get accepted more often because they actually meet referral criteria?

Of course, not all “regular” family doc referrals are that good. Some we get from in-person walk-in docs aren’t much better than the telehealth ones described above. And not all telehealth ones are horrid. But as a general rule, the telehealth ones are in a class of their own.

Consequences

And how many referrals did we accept from pure telehealth services?

During the timeframe we received those 33 (rejected) referrals, I know for a fact that we accepted only 2 that came through a telehealth service:

• One was a patient who contacted us first, who was given explicit instructions on what they needed to get through the telehealth doc and provided a good part of the information themselves.
• The other referral was a bit sparse but said a couple things to suggest more might be going on. I contacted the patient to get the rest of the story and then arranged to get their previous psychiatrist’s records.

We generally get back to referring docs quickly if we can’t take a patient. But in many places, two weeks is the standard. For a bad referral that never had a chance of getting accepted, that’s two weeks you’re not getting better and wasted time in both the referring clinic and the specialist’s clinic.

So to anyone who thinks that episodic care through a random telehealth provider is a “good enough” substitute for a real family doc… guess what? It’s not.

Incidentally, I (mostly) don’t blame the individual docs. They’re forced to practice in walk-in clinics and telehealth services where they can’t reasonably provide good quality care and make a living. As we all know, there isn’t proper financial support for full-service family medicine practices.

What can you do?

This does leave patients, who often don’t have (and can’t get) a family doctor, completely screwed.

However, there are things you can do to improve your odds of getting better care.

Things like specific ways to work better with family doctors or get the most out of referrals and waiting lists.

Collect previous records and (even better) prepare a concise summary of prior history, current concerns, and needs. A referring doctor who doesn’t know you can easily attach it to a psychiatry referral. That can go a long way. If you know who you’ve been referred to (or have someone in mind), consider reaching out to their office.

You shouldn’t need to do these things. And unfortunately, not everyone is in the mental space to do them or has people to help them. As usual, the people who most need the help are least likely to get it.

Related: see all Victoria posts here

Great, the advertisements for Bell’s annual “Let’s Talk” feel-good event have already started.

Certainly, this overly-sanitized marketing machine does some good for some people, despite how many more who really need the help it ignores and leaves behind.

And I’ve talked before about the less-than-picture-perfect responses that often greet those who do come forward for help with their mental health.

That post was seven years ago. Things have gotten a lot worse since then when it comes to finding help. Some unexpected places, like Victoria, seem to exist in an alternate reality when it comes to mental health services. Scary for a place dripping with more money than anywhere else we’ve lived.

In the medical system, lack of psychiatrists is certainly a problem. But perhaps more critical is how completely unsustainable family medicine is. That’s leading to totally predictable closures and anger from GP’s who tried to make it work.

Remember, traditionally most people received most mental health care in the medical system from family doctors. With five minute appointments, and never seeing the same doctor twice, that’s not working.

And random telehealth service (Bell competitor’s Telus Health service is only the worst, but by no means only, example) is making it worse. I’ve lost track of how many useless referrals we’ve gotten from those services. Google psychiatrist, ignore very blatant “not taking patients” notice or mandatory referral criteria, send a generic boilerplate referral “see for depression” with no required information. It’s an automatic reject, but that’s for the next random doctor who sees the patient on the telehealth service to deal with. It’s taken buff and turf to a whole new low.

Make no mistake, this is the system we’ve built for ourselves.

My previous Let’s Talk post had a tone of “expect the worst, but keep at it, and you’ll eventually find help.” I’m less sure of that than ever before.

TLDR:services are the biggest problem, not stigma

In the previous post, I highlighted the deliberate absence of performance measures for our mental health system and why that is.

I gave an example showing that when people in the system work in an information vacuum, it becomes impossible to prioritize or assess the impact of their efforts. In this post, you’ll see another example, more directly related to patients’ experiences of the health system: shared care.

But first, pop quiz! What is shared care in mental health?

1. more than one treatment provider is involved with the patient
2. a family physician refers the patient to a specialist for advice
3. treatment providers talk to each other about a case
4. different providers divide up the work so each has their own piece
5. bouncing patients between treatment providers so they never see the same person twice
6. a meaningless marketing label that means whatever you want
7. a solid, meaningful treatment philosophy that is universally diluted and abused
8. whatever receives funding from the shared care committee

Theory

“Shared care” is another of those aspirational motherhood terms like “patient-centered” that are hard to disagree with. In the psychiatric context, it means that family physicians, psychiatrists, and potentially other professionals work together to provide the best care for the patient. Each contributes as part of a unified, cohesive treatment plan.

Notice words like “together,” “unified,” and “cohesive.” Shared care is all about effective collaboration.

Collaboration requires many things to be shared: common goals, awareness of others’ needs, roles, actions, and responsibilities, the context in which people work. Lots of feedback and listening to each other.

As it happens, my previous work was all about facilitating effective collaboration and how technology can affect that, positively or negatively. It’s a highly multidisciplinary field, bridging technology, psychology, sociology, management, and other specialties. So yes, this world of Zoom we’re in now is right up my alley. For two decades, I did cutting-edge R&D, published extensively, and ran companies built around collaboration practices and technologies.

How it could work

There’s no one model of shared mental health care. But what would shared care, say between a family physician and a psychiatrist, look like? You’d expect to see several practices like these:

• understand the skills and limitations each brings to the case
• understand each others’ needs, work context, challenges, and resources
• work together to create a treatment plan that meets everyone’s needs
• psychiatrist and family physician at times jointly meet with patient
• each professional learns from the other
• shared understanding of patient’s goals and progress
• assessment and appreciation of what individual contributions bring, how effective they are, and which parts can be improved
• ongoing two-way communication over time regarding the case
• back-and-forth discussions, questions and answers, etc.
• awareness of what each participant contributes to the case, as well as gaps in the overall treatment

If done well, patients benefit from consistent and improved care. Practitioners develop increased skills by learning from each other and better appreciate how their contribution fits into the overall system. Scarce resources can be used more effectively.

Practice

If there’s virtually no feedback, interaction, or awareness between collaborators, is it really shared care?

Consider a traditional referral-consultation model:

• family doc sends in referral
• psychiatrist sees patient once for consultation
• psychiatrist sends written report to family doc
• family doc resumes care based on psychiatrist’s suggestions

Technically, both the psychiatrist and the family doc are involved in the treatment. There is some information going back and forth. But it’s pretty thin as far as collaboration goes.

It’s not one or the other, of course. Shared care is a continuum. The family doctor might call the psychiatrist later with questions or seek clarification. Other interventions may be discussed. The psychiatrist might see the patient again, send another report or make further suggestions. And so on.

Psychiatrists may be trained to do a full assessment in under an hour, but that doesn’t mean it will be complete and accurate. That may be because it’s a particularly complicated case, or the patient may not (for many reasons) be able to fully understand or give accurate answers to all questions.

Most psychiatrists who see a patient multiple times find their understanding of the patient evolves over time, as do their recommendations. Seeing someone for a one-off visit can result in significant simplifications, omissions, and errors.

Measuring success

For straightforward cases, a one-off traditional consultation may be all that is required. The report gives the family doc what they need to better manage the patient, and the patient gets better. Everyone is happy.

Notice that even here, success is judged from the perspective of the patient, as well as the family doc (in terms of having gotten what they needed from the psychiatrist). The psychiatrist is providing a service to the family doc.

But how does the psychiatrist know if the service they’ve provided is useful?

If there’s no further communication after sending the report, they don’t. They don’t know whether the patient got better or not. They don’t know if their recommendations were helpful, tried, or even made sense. Without feedback, they don’t know what value, if any, their participation added.

At most, they might get the hint when people stop referring to them. If there are other options.

Importantly, the psychiatrist learned nothing more about the needs of the family doc, the constraints they work under, or how they might provide better assistance in the future.

Pitfalls

Unless that feedback is provided by some other means, they’re operating in an information vacuum. And as we know, the overall system is in no hurry to provide any concrete information about the quality of service.

What could possibly go wrong?

• If a psychiatrist does a shitty assessment or makes poor recommendations, they’ll never know about it. They think they’re doing great and have no reason to change what they’re doing.
• If their recommendations don’t work, aren’t useful, or can’t be followed by a family physician, they may never know. Again, future improvement isn’t likely.
• The psychiatrist might assume that family docs have the time, skills, resources, and willingness to follow up with treatment recommendations. There’s little opportunity to learn about the constraints family docs work under and what they need.
• Most psychiatric treatments involve trial and error, and without follow-up, may mean re-referral. Which can involve lengthy delays. And often, the patient starts from scratch with another psychiatrist.
• Patients may receive inefficient, ineffective, disjointed, sub-par care. Especially if their illness is at all complex.

In other words, one psychiatrist may be doing the most horrific job in the world. Another might be doing the best job in the world. It’s possible that neither would ever know.

And nobody else in the system sees there is a problem or what needs to improve.

Hidden problems

These problems are hidden, and you need to go digging to find them.

Nobody measures or reports on these things, so how do we know these problems occur? We hear lots of stories from patients. We ask and then listen to family doctors to appreciate their needs and struggles.

Many people find ways to get feedback, engage in more collaborative activities, and learn from patients and colleagues. But it’s a deliberate effort. Not everyone bothers.

Some psychiatrists pretty much do only one-size-fits-all, one-time assessments. If you asked them, how many would say their advice isn’t helpful or sufficient for family doctors to manage cases? Some may be surprised at the question, not having considered how their assessments are used at all. Family doctors see it differently.

How widespread are these problems? They “seem” pretty common, but that’s largely anecdotal and based on our very narrow viewport on the system. Other people have vastly different perspectives.

There’s really no way to know the frequency and severity of these problems. Which is really the issue.

Escalation

The busier things are, the worse it gets. Waitlists are longer. Time to see patients shrinks. Services are more tightly restricted. The distance between family docs and psychiatrists grows. Opportunities for feedback and collaboration wither.

For many, job satisfaction suffers as they find it more difficult to provide the type of care they want, especially for more complex patients. Burnout increases. More people leave. Others get more jaded. Some just keep their head down and continue on, oblivious.

In computing, there’s a phenomenon called “thrashing.” As a system gets busier, more and more time is spent on busy work (housekeeping, management, repetitive and redundant tasks which have little impact overall). This leads to less and less time for productive work to achieve goals. An apt metaphor here?

Everyone lives more and more in their own echo chamber. Viewpoints narrow further, and system thinking decreases. “The way we do things around here,” good or bad, becomes increasingly entrenched.

Toxicity

Isolation breeds misconceptions and contempt.

Psychiatrists see themselves more and more stretched. The scarcity of specialist time feels more pronounced, justifying ever-more abbreviated patient involvement. Ongoing treatment of patients and follow-up care is a luxury they can’t afford.

Resource-wise, it just makes sense to devolve follow-up care to family doctors who have so much more time to spend with patients. Except, of course, they really don’t. Family docs are stretched beyond belief and have far less time. But the family doctor crisis isn’t in the face of specialists each and every day.

Good mental health care takes time that doesn’t fit into increasingly abbreviated family medicine appointments. Family docs who devote that time do so at the expense of their other patients or their own health. Most do what they can, even if it’s not enough. Some do virtually no mental health care. And what about the growing numbers without access to any family doctor?

System access problems? Not a thing. Any family doctor can get a consultation by referring their patients through mental health intake. Crisis? USTAT is there. If only.

Yes, psychiatrists may be working flat out and focused on the task at hand. But if they’re too entrenched in their bubble, they may not be fully cognizant that the one hour they spend follows many months of rejections, waiting, and other delays.

Without evidence to the contrary, some people (who should know better) are deluded into thinking that the system on paper reflects reality.

Misconceptions flow in more than one direction. Frustrated family doctors may feel psychiatrists don’t care or are completely oblivious to the needs and realities of family practice. Private-practice psychiatrists who follow patients? Obviously, a ludicrous and inefficient drag on resources, who cherry-pick the “weepy well” patients who don’t need to be seen at all. The family doctors can see them. That’s why we do shared care here.

Reckoning

Without rich feedback and collaboration, shared care is an empty buzzword. A myopic fantasy.

It justifies silos, narrows thinking, reinforces the status quo, and abdicates responsibility. It stifles innovation and suffocates empathy.

It reassures us that we’re each playing the part we should be.

It’s not our fault.

Any system this large, this complex, and this important needs to deeply incorporate shared understanding, awareness, collaboration, feedback, and empathy. Only then can true shared care follow.

Individual efforts are important but only go so far. Systemic solutions are at odds with the perverse incentives at the core of the system.

There’s no easy path forward.

Related: see all Victoria posts here

Minister of Mental Health and Addictions Sheila Malcolmson sounds very proud of our new mental health system:

We inherited a broken system that had been long neglected, and over the past four years we have made historic investments to patch the holes in this fragmented system. But now we are now moving beyond filling gaps, to make true system-level change.

Our government invested a historic $500 million in Budget 2021 to build a comprehensive system of mental health and addictions care that people in British Columbia deserve. (emphasis added)

What we deserve?

I don’t know about you, but I’d be offended to think we deserve what we have, given most people believe what we have now is pretty horrible.

People often want to know why the system works this poorly or why someone doesn’t fix it.

Actually, it’s working exactly as it’s supposed to.

People may be surprised (or a bit pissed off) to hear that, but it’s true. It’s working very well to achieve its goals. Unfortunately, those goals don’t have a lot to do with providing effective mental health care.

We may not have the system we deserve, but we have the one we designed.

It doesn’t work? Prove it!

For such a large, frighteningly complex, and enormously expensive operation, there’s very little data saying how well it actually works. You know, at providing people with mental health care.

I’ve talked about this before. Nobody publishes useful measurements or metrics about what seem to be obvious things like how long it takes to see a psychiatrist or counsellor.

What we have instead are periodic funding announcements. “We’ve invested XXX million for…. opened XXX new beds for…”

And you think there’s any kind of measure for any given person that says how they are when they first encounter the system, or at any time after that? Don’t be ridiculous!

Would you tell me, please, which way I ought to go from here?

So, if there’s no data about how the system operates, how do you know how well it works or where the problems are? Where should effort be focused?

Let me answer that by talking about navigation (in two senses).

First, there is navigation in terms of people finding the right services in the system. It’s not easy. So people want to fix that. A lot of people.

I’ve lost track of the number of databases, directories, websites, referral services, processes, and other overlapping efforts spawned by a wide range of individuals, organizations, and committees. An incredible amount of time, energy, and manpower has been devoted to this.

“Imagine, if only everyone could use the same referral system, we’d be able to effortlessly track all referrals and know about wait times everywhere in the system…!”

And how much better would things be if this problem was fully solved?

Think about the benefit of replacing smoke detectors in a building… as it’s burning to the ground. That much better.

It’s more likely planning stakeholder meetings about visioning for replacing smoke detectors…

The best navigation and referral system in the world doesn’t help if there aren’t enough resources to refer to in the first place.

But it’s hard to appreciate the scope of the resources problem without data. You can’t assess the full impact of a potential project. So we devote countless efforts to projects that can’t work or will have minimal impact.

Planning and prioritizing can’t be effective when we’re all in the dark about how the system functions.

To be fair, many people deeply involved in the system generally appreciate, albeit imperfectly, how it functions. That’s why they’re desperate to do what they can to try to improve things. While they may not be able to create accessible treatment resources, carving off a piece of the problem within their circle of influence is a natural and human response.

The unacceptable alternative is sitting there and doing nothing. They likely know the odds of their navigation system being meaningfully different from others. Or the odds that the largest organizations—with the worst wait times, with zero incentive to give up control or want to see their wait times published—would participate in their universal referral system.

Optimize for minimum negativity

If providing the best mental health care possible isn’t the system’s primary goal, what is it? This may sound cynical, but minimizing embarrassment for the government seems to be the overriding principle.

Health care (including mental health care) is ultimately the government’s responsibility. If things aren’t going well, the government is ultimately blamed.

Yes, other things being equal, better care is preferred to worse care. The people working in government, health authorities, and health care settings aren’t monsters, and they don’t enjoy seeing suffering.

But at what cost? People may bitch and moan, but the situation isn’t bad enough that it’s gained enough traction in the public eye to influence voting patterns. Other issues are more pressing. The downsides (higher taxes, etc.) could have more impact, e.g., providing leverage for the BC Liberals to attack the NDP. Plus, nobody is (credibly) seen as doing anything better; the Liberals aren’t about to invest more.

Conversely, an excellent mental health system isn’t seen as enough to swing voting patterns in the positive. It’s not just a matter of it being too expensive. We’ve repeatedly seen that when money is truly seen as needed, it’s available (COVID, bailouts, etc.). The political backlash that would have resulted from ignoring those situations justified the costs.

Drawing more attention to the problem would be a political liability.

In this view, transparency in the system is a negative. Concrete data on how poorly it functions is ammunition for opponents.

If there’s no data, you can claim anything you want.

If we don’t measure, we don’t look as bad.

As I said, the system is doing exactly what it’s designed to do.

Ministry of Mental Health and Addictions

There’s no clearer example than this recently created ministry responsible for mental health and addictions.

Does it manage the system? Does it actually provide treatment? Of course not.

I have yet to be convinced that spinning it off into its own ministry was about anything other than creating a glorified public relations factory.

Drip, drip, drip. Bits of funding here. Bits there. Announcements and announcements. Sprinklings of good news.

Nothing about how well the system works or what’s still needed.

The public doesn’t need to know that. There’d be no benefit.

You may have missed the Minister of Health rallying against a proposed federal mental health transfer. While the federal effort may well be as cynical a public relations effort as the provincial one, it would involve the province reporting actual data on access to mental health care in BC. That disclosure is not in the BC government’s best interests, no matter if the extra investment could improve care.

Instead, we see the usual political playbook trotted out, as reflected in the quote at the start of this piece. To paraphrase:

After discovering the (shocking!) horror left to us by the previous (evil) government, we’ve gone to heroic lengths to dig ourselves out from the disaster we inherited. We are now selflessly going above and beyond to build an even shinier future. And everyone gets a pony! This radiant future (and the pony) will immediately burst into flames if anyone else were elected.

Could we build a better system?

At finer-grained levels, we know that some things would help the system deliver better mental health care.

And that while there are definite costs, in the long run, it’s usually cheaper to fix problems early on when they’re small than wait until they’re bigger and cost more to fix. Which is how our crisis-driven system functions today. That doesn’t even factor in the indirect costs of not providing timely and effective care.

For the sake of argument, let’s say that our idealized system measures people’s needs and routes them to the right place for treatment with the appropriate professionals. It continually measures their progress, publishes and manages wait times and outcomes against some set of standards, ensuring sufficient resources to meet those standards. These types of systems are generally classified as stepped care.

Could we build this?

Given the broad scope of such a system, encompassing so many professions and organizations, it would require tremendous leadership at the highest levels.

For all the reasons already given, this would be a disaster politically.

In our short-term, next-election-focused system, no politician in their right mind would be okay with this. The price to pay is way too high.

Until the price of suffering is perceived as too high…

Until mental health affects the electoral calculus…

Until the perverse incentives at the root of the system change…

The system will keep doing exactly what it was designed to do.

No single raindrop believes it is to blame for the flood

Until then, we continue on, and we all continue to suffer. Without a clear picture or adequate data, everyone runs around doing what they think is right, with no feedback to the contrary. The blind leading the blind. Or, if you prefer, the inmates running the asylum.

Next time, I’ll provide another example of the consequences of this approach on patient care. I’ll explore the promises and pitfalls of shared care in a landscape devoid of shared information.

Related: see all Victoria posts here

Our healthcare system is broken, no question. But we can’t afford to fix it, can we?

See Dick. Dick gets sick. Treating Dick would cost $5000, but there aren’t enough doctors, so he needs to wait one year. The Ministry of Health (MOH) saves $5000.

Dick works for the city. They spend $50000 for sick leave, disability benefits, and lost productivity. The city’s costs go up, which we all pay. Businesses Dick patronized lose money and pay less tax. But the MOH saves $5000.

See Jane. Jane gets sick. One year wait. MOH saves $5000.

Jane is a doctor. She can’t work, pays $50000 less tax. Businesses Jane patronized lose money, pay less tax, lay off employees. Government loses more, we all pay, MOH saves $5000.

Jane’s patients can’t see a doctor. Many get sick, $5000, off work, wait one year. Less income, less tax revenue, lower productivity. Less revenue for businesses they patronized. Government loses more; we all pay. Some need government income supports; we all pay. MOH saves $5000 for each of them.

Hurray for MOH and their shiny financials! Hurray government! Aren’t we all further ahead?

Do the math.

Victoria has far too few psychiatrists to provide anything close to the level of service required.

Funding Isn’t the Problem

Contrary to some peoples’ impression, this is not (primarily) about a lack of funding. No dedicated funding is required for a psychiatrist to come here and open a practice. They need a BC license and can bill MSP for their services. If they want to work at Island Health clinics (which, among other things, pay some overhead costs), there are 20+ job listings for open (funded) positions, several posted for years. So it’s not just a money thing.

Recruitment and Retention

Recruitment and retention of psychiatrists are problems. Without going into details, I can safely say that we’re here despite a wretched recruitment/hiring experience. Given the shortage of psychiatrists, it was shocking how badly it was handled. Retention has also been a significant problem. We’ve had lots of psychiatrists leave, many who retired or fell ill, but also many who didn’t find working here to be a good fit for them.

Many people who’ve left (and many still here) aren’t shy about sharing their stories.

We need a more professional approach to recruitment and retention. That means ownership and accountability. There are proven approaches to this if we want to make it a priority.

Someone has to own it and be accountable. You don’t just post a job ad on Health Match BC and hope for the best.

Marketing

Marketing ties into recruiting. Psychiatrists don’t grow on trees, and while there aren’t nearly enough throughout Canada, we can do more to attract our fair share. Yes, this is a zero-sum game, and our gain will be someone else’s loss.

But honestly, this is Victoria. Tell me that reaching out to someone in Winnipeg in the middle of January wouldn’t at least pique their interest. And in the province next door, there is a government actively at war with its doctors, many of whom are very pissed off right now.

Two years ago, a Westshore GP placed an ad in a national trade magazine for doctors. He was recruiting to replace another doctor at the practice who retired. The ad featured lovely pictures of the adjacent beach, office-grown pineapple, etc. How rarely we see this kind of initiative!

Psychiatry in Victoria has a bit of an inferiority complex and maybe a bit of a backwater reputation because it’s not Vancouver. And there are (ahem) challenges in practicing here. But if we are successful at making some of the changes we’ve all been discussing recently, we should have something positive to share. People are excited to be part of something on the way up.

Finally, BC has historically paid psychiatrists at or near the bottom of all provinces. Plus it’s expensive to live here. That’s many potential candidates’ first reaction. But the story has significantly changed in just the last few years, and compensation is now far more competitive. Nobody will know that if we don’t reach out.

A few examples: outpatient fees raised to match inpatient fees; new billing codes for phone calls, emails, longer consults; substantial fee bump for psychiatry to reduce inter-provincial and inter-specialty fee disparities; fee premium to offset higher overhead costs in Victoria.

Marketing would likely require a small amount of new funding for resources and personnel.

Rebalance

Psychiatrists in Victoria see too many people for one-time consultations but do not provide enough ongoing treatment. Worse, one-time consultations are often not sufficient to help family doctors and particularly wasteful for many patients with chronic mental health concerns.

This likely started out as a temporary stopgap to deal with a mismatch in supply and demand at VMHC. It has turned into a permanent state of affairs. This imbalance of services needs to be measured and corrected.

Slightly tangential, but many psychiatrists are scared off at the thought of opening a private practice in the community, especially ones newer to practice. Few are exposed to community psychiatry in residency, and it’s often looked down on by the psychiatrists in academic centres who train them. This is a missed opportunity to provide a broader mix of treatment. It can also help attract or retain people who, for whatever reason, do not want to practice within Island Health.

Related: see all Victoria posts here