Month: April 2021

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

There needs to be more access to counsellors, psychologists, and other therapists, particularly for patients who do not have the financial means. They provide essential services that the medical system (i.e., family doctors and psychiatrists) cannot offer. Full coverage is a bigger issue, but there are areas we can target now.

Expanding DBT

In particular, focused investment to improve access to dialectical behaviour therapy (DBT) groups would be invaluable. In DBT groups, patients typically attend weekly two-hour sessions for around 26 weeks and learn a wide variety of distress tolerance skills.

These skills help prevent stressors from escalating to the point they result in a crisis presentation to PES. DBT is the most effective treatment for many personality disorders (unfortunately named and oft-stigmatized). The ER or PES may defuse an acute crisis but is the wrong place to treat the underlying problem.

In Victoria, affordable DBT is scarce, usually only available through a group at USTAT. However, with limited capacity and wait times that have escalated from weeks to many months, that’s no longer a viable option for the majority of people who would benefit.

Making it Happen

Expanding DBT groups would require funding for several therapists. Each full-time therapist hired could handle several DBT groups in parallel. While this would divert resources from individual private-pay therapy available in the community, it would provide a much-needed treatment option and keep many people out of PES. Much more could be offered, but it’s a start.

Ideally, access to DBT groups would be similar to BCalm or CBT Skills groups (both run primarily by family doctors, not mental health), needing only a doctor’s referral. Both of these provide a great service accessible to many. Neither require dedicated funding, but are facilitated by doctors who bill group medical visits through MSP. However, that wouldn’t work for DBT, which would require hiring specifically-trained therapists; very few doctors have that training and are in very short supply as it is.

As with the above groups, expanded access to DBT groups doesn’t have to happen through VIHA. Issue an RFP and let private counsellors or counselling groups provide this service.

Related: see all Victoria posts here

Access to outpatient treatment is one of several intertwined mental health crises in Victoria. We can fix it if we make it a priority. Ownership must be assigned. Gaps between silos called out and eliminated. It demands public metrics and accountability. Better access to therapists and psychiatrists won’t happen otherwise.

I’ve previously described the impact that woeful access to mental health care in Victoria is having. Patients can’t access essential care, and family doctors on the front lines are stuck. The impact is spilling over to the emergency room.

There are concrete, incremental, and realistic steps we can take to improve access. We can make progress without relying only on pie-in-the-sky “let’s remake the system in one fell swoop” or “cover all therapy through MSP” long shots. But these cannot succeed without clear ownership and accountability.

Access is Nobody’s Problem

Access to essential mental health treatment in Victoria is a problem. And nobody owns that problem. We can’t fix it until that changes.

To the best of my knowledge, nobody has clear responsibility for ensuring an adequate number of psychiatrists and other mental health resources are available in Victoria. Or at least, that’s not an essential component of anyone’s job performance. I don’t mean just in VIHA or a particular service like USTAT or mood disorders, but overall. I hope I’m wrong; please correct me if so!

I don’t mean accountability or responsibility in a punitive or backward-looking sense. Criticism and identifying flaws have their place. And witch hunts may be cathartic, but they can’t be the entire answer. Assigning ownership should be a positive step towards solving problems.

As a specific example, nobody is responsible for ensuring we have enough psychiatrists in community practices, which generally fall outside health authority concerns. It becomes a system-wide issue when health authorities choose to exclude large classes of patients and expect “the community” (i.e., maybe a dozen psychiatrists) to pick up the slack, as happened at VMHC a few years ago.

Such decisions aren’t malicious. Someone decides “we’ll prioritize X.” Implicitly, that means “we won’t prioritize Y,” or less charitably, “Y is not our problem.” The latter statement is often unsaid (at least in public) or not kicked back up the ladder to properly review. We celebrate “X.” We don’t ask: “What are the consequences of not doing Y? Should Y be prioritized higher? If you’re not doing Y, who is?” It’s not visible, so it slips through the cracks. (In this case, “Y” has become “patients who need psychiatric care but haven’t required extended inpatient hospitalization.”)

Expectations and Disclosure

Expecting a 100% solution any time soon is not realistic. Just pinning failure on someone or creating a scapegoat isn’t helpful.

Real ownership requires responsibility and resources. Accountability means reporting on efforts and progress. Equally, it requires reporting on why things have fallen short. What stands in the way of solutions? Are there alternatives? What needed resources aren’t available? Where could we find them?

Honesty and a solution-focused orientation must take priority over providing political cover for those higher up the food chain.

Measure and Report

Let’s start by recognizing the management truism that you can’t improve what you don’t measure. Metrics need to be frequently updated, reviewed, and public. Think report cards.

Some possible metrics to start with:

• number of psychiatrists (or FTE’s) and where they work
• psychiatry referral statistics (e.g., how many received, accepted/rejected, wait times for each service)
• level of care provided (e.g., single consult vs. ongoing care, frequency seen)
• affordable counselling and therapy groups (e.g., number of referrals, number served, wait times)
• outcomes (e.g., re-referrals, crisis line usage, PES presentations, hospital admissions, other service utilization)

Some of these may need substantial effort and new resources to collect. They need to encompass all services, not just within VIHA.

We generally do a poor job of measuring and reporting on health care performance in Canada. Wait times are a good example; ridiculously few are published. The overall culture leans towards not wanting to highlight news that might reflect poorly. For change to happen, that’s not good enough.

A Starting Point

In future posts, I’ll be suggesting several concrete steps we can take to improve access. Ownership, accountability, and good metrics are necessary for any such efforts to succeed.

I also believe that ownership, accountability, and metrics for both access and quality are necessary to address PES concerns. Without baking these into the system, the temptation is to treat the current situation as a short-term PR crisis. Without structural improvements, any fixes will be temporary. While it’s beyond the scope of what I can usefully comment on, I hope others will take up this call.

Related: see all Victoria posts here

A survey of family doctors in Victoria highlights the challenges they face in providing mental health care to their patients. Hampered by poor access to treatment from psychiatrists or therapists, they’re overrun by the ever-increasing demand for essential care.

Background

Victoria, like many other places in Canada, faces several intertwined mental health crises. The pandemic is exacerbating them all. We’re acutely aware of the opioid crisis and the homelessness crisis (often driven by severe mental illness and substance abuse). Recently, two young women spearheaded a Facebook Group to draw attention to concerns with Victoria’s Psychiatric Emergency Services (PES).

Access to mental health treatment is a fourth crisis. As I’ve said elsewhere, access issues compound the problems at PES. Too few people can access treatment earlier and in more appropriate settings. Far too many people end up in PES that never should have. But there are no options.

Family doctors are at the front lines of mental health care in the medical system. They’re frequently the first and often only care provider patients see. But they need the support of a robust mental health system behind them. How do they think that system is functioning?

What do family doctors think of the mental health system?

This week, Pauline and I put out an informal survey of family docs in Victoria. Most of them are referral sources for her private psychiatric practice. We feel their voice is crucial to hear.

We’re still collecting answers. But of the first ~30 responses we’ve received so far, some themes are emerging. Keep in mind, this is not a rigorous or quantitative analysis, and respondents are self-selecting.

Here’s a snapshot showing the percentage of respondents who chose each answer:

Bottom line: we’re not doing great

We first asked if the overall healthcare system meets their patients’ mental health care needs. So far, the vast majority strongly disagreed that it does. The remaining handful only disagreed. Some specific comments:

There is a crisis in mental health access in Victoria that has been worsening over the past 10 years.

Main issue is lack of resources for mental health and substance use.

Access to psychiatry is severely constrained

All respondents reported difficulty getting their patients seen by psychiatrists at all. Referrals were often rejected outright, or waiting lists were too long.

This was true both for psychiatrists through Island Health and elsewhere. Most outpatient psychiatrists in Victoria work through a handful of clinics run by Island Health. There are about a dozen in private practice.

No psychiatrists accepting referrals.

No psychiatry outpatient options.

I have essentially stopped trying to refer to community psychiatrists due to the extremely low number of available physicians. I see this, and lack of coverage for counselling, as the two largest barriers.

Even access to treatment for urgent situations (but not an emergency or crisis) has stretched to unacceptable levels. In the past, this was a matter of weeks. Family doctors noted:

Getting psychiatry consults in a timely manner when people are in crisis is very difficult (rarely happens). This places a huge burden on family doctors.

It is up to 18 months wait to see a psychiatrist (USTAT)!

Psychiatric treatment is virtually nonexistent

One particular trouble spot was that when psychiatry sees patients, it is nearly always for a one-off consultation. Actual treatment through psychiatry is frequently not available except for the very sickest patients.

It has been extremely difficult to arrange psychiatric referrals, and if accepted for assessment it is often only a one-time consultation.

Often complex patients – bipolar etc. – seen once for a consult and sent back to GP to start meds/manage. This is too complex for us.

When psychiatry is able to see a patient, it is usually just a one-time consult… followup would be very helpful as multiple medication trials or adjunct treatment are often needed to treat significant anxiety/depression.

Biggest issue is wait times and lack of followup for people with chronic mental health issues. Every time they get worse, they start over with a new care provider. Unless acutely ill, will only get one-time consult and no followup. Many people would benefit from ability to go back to same psychiatrist when ill.

In one-off consultations, psychiatrists see patients for a single visit (typically 45-60min). They then send treatment recommendations to the family doctor. Given the broad scope of topics that need to be covered, it’s tough to get through everything in that time. Interviews are tightly circumscribed. Patients must give brief, specific, and rapid answers to often profoundly personal questions in front of someone they’ve just met, with few opportunities to elaborate.

It’s hard to get an accurate picture of anyone in that single visit. Most psychiatrists who continue working with patients find their understanding improves over future sessions after gathering more information and as patient trust and rapport deepens.

Access to therapy is not much better

Nearly all survey respondents noted that a lack of accessible and affordable counsellors, psychologists, and other therapists was a major issue. Unlike doctors, fees for therapists are mostly not covered by public health insurance (MSP).

Victoria is blessed with many talented therapists. No doubt, our generally well-off populace and abundance of government jobs with excellent extended health benefits helps. Even still, increased demand from the pandemic is testing that capacity.

That still leaves many, many people without the financial resources to access this essential form of mental health treatment. There are very few no-fee or low-fee options available, and wait times can stretch several months or longer.

Lack of available counselling is the worst.

One bright spot mentioned by several family doctors was group therapy available via BCalm and the CBT Skills Group. These groups are organized and facilitated primarily by family doctors. Because they are treated as group medical visits (paid by MSP, not special funding), they require minimal or no fees from participants.

CBT skills group is a god-send!

Too Acute Patients, Too Little Time

For family doctors providing mental health care to patients themselves, two mutually reinforcing problems recur. The first is that they have to manage increasingly complex and acute problems in the primary care setting (because psychiatrists aren’t providing treatment). But that runs up against the nature of family practice – too many problems to squeeze into too short appointments.

Often takes so much time just to calm people down initially, it’s difficult to come up with a treatment course.

I spend way too long (regularly > 30min) to try to help… if a cardiac patient was as sick as my psychiatry patients they would be followed by cardiology!!

Other factors

Doctors raised a smattering of other factors. Many noted that demand for mental health care (especially anxiety) has increased due to COVID-19. Financial disincentives for GP’s providing mental health care were frequently mentioned. Certain other areas, e.g., treatment for adult ADHD, also came up. Patients having poor experiences in PES was also mentioned. This list will be expanded as we collect additional survey responses.

Family doctors are stuck

All this leaves family doctors in an untenable position:

• they have an ever-increasing number of people seeking mental health care
• they are unable to access psychiatrists or therapists to assess and treat their patients
• that leaves them stuck managing patients who are too acute or complex to treat in a primary care setting
• people are coming to appointments with too many problems, all of which are time-consuming
• family doctors are unable to provide longer appointments which would be needed to make headway

Family physicians can often manage patients who respond adequately. It is the complex patients or severe patients who need treatment urgently who cannot be seen.

Fallout

The family doctors who responded to our survey are clearly frustrated. They can’t provide the mental health care they’d like to without better support. Unfortunately, access to needed psychiatrists and therapists is at crisis levels in Victoria.

Patients are suffering as a result. They’re not getting the help they need. Illnesses that could be treated early instead worsen over time until emergency services are required. But that’s just the tip of the iceberg.

This survey isn’t telling us anything we haven’t all known for a long time. But at least on the ground, the problem feels to me like it’s accelerating. If we continue on this course, I’m worried about how the future will look.

Related: see all Victoria posts here