From the Editor
As medical school classes have grown, the supply of physicians has increased across the country. Has this helped address access issues in psychiatry?
This week’s Reading seeks to answer some basic and important questions around physician supply and access in psychiatry. Following up on a major paper written in 2014, Kurdyak et al. have written another important and relevant paper.
The long and the short of it: there are significant problems with access – and they aren’t getting any better with time.
Care and Practice
“Changes in Characteristics and Practice Patterns of Ontario Psychiatrists: Implications for Access to Psychiatrists”
Paul Kurdyak, Juveria Zaheer, Joyce Cheng, David Rudoler, Benoit H. Mulsant
The Canadian Journal of Psychiatry, 28 August 2016 Online First
Access to psychiatrists is a challenge in Canada and internationally. In Canada, primary care physicians rated psychiatrists as the most challenging specialist to access. A study conducted in Vancouver, British Columbia, found that only 6 of 230 psychiatrists doing active clinical work were able to provide a consultation to a family health team in a timely manner. Patients also describe access to psychiatrists as challenging: A study in the United States found that psychiatrists were more likely to accept private patients and less likely to provide services to patients covered by Medicaid or other insurance plans than were nonpsychiatrist specialists; the authors commented that this low acceptance rate poses a barrier to access. Psychiatrists are only one aspect of a responsive mental health system, which typically includes primary care physicians, psychologists, social workers, and other allied mental health professionals; psychiatrists typically adopt the role of providing and/or overseeing the delivery of specialist mental health or addictions care. Indeed, the United Kingdom and Australia have both responded to poor access to psychiatrists by integrating the services of psychologists and social workers into the publicly funded system to provide evidence-based therapy and by having psychiatrists adopt the role of consultants, and a similar initiative has been proposed for Canada.
Previously, we reported that the supply of Ontario full-time psychiatrists is not equally distributed across the province, with many more psychiatrists practicing in Toronto and Ottawa than in suburban or rural regions. We also showed that as the supply of psychiatrists increased, the proportion of psychiatrists adopting low-volume practices increased.
So opens a paper by Kurdyak et al. from The Canadian Journal of Psychiatry that argues that big changes are needed to care delivery.
After acknowledging the controversy of their last paper on physician supply, they note questions that arose from it: are lower-volume psychiatrists closer to retirement? How has the gender diversification of the practice of psychiatry affected practice patterns?
Here what they did:
· They drew data from the Institute for Clinical Evaluative Sciences (ICES) Physician Database (IPDB). Billing information was gathered from the OHIP database.
· The data set was from 2003 to 2013.
· Inclusion criterion: psychiatrists who billed actively, meaning that at least 1 billing claim to OHIP was made in a year.
· They looked at basic characteristics of the psychiatrists: age, sex, years since medical school graduation, region of practice.
· “For each psychiatrist and in each year of our study, we measured the number of unique outpatients (defined as any patient with at least 1 visit per year), number of new outpatients (defined as no visits in the 12 months prior to the first visit in the year of interest), and number of patient encounters, overall and by location (inpatient vs. outpatient).”
· Statistical analyses including an ANOVA analysis were done.
Here what they found:
· In 2013, there were 2,070 psychiatrists in Ontario (meeting a minimal clinical activity threshold). 1 in 5 psychiatrists were within 15 years from their medical school graduation; 1 in 3 between 16 and 30 years; nearly half, over 30 years.
· Between 2003 and 2013, the total number of psychiatrists increased: from 1775 to 2017 (an increase of 16.6%). Demographically, psychiatrists were both older (the number who were 30 years after graduation rose 50.7%) and younger (the number of psychiatrists within 15 years of graduation increased 36.2%).
· “The Toronto Central LHIN had the highest number of psychiatrists per capita (61.0 psychiatrists per 100,000) whereas the Central West LHIN had the lowest (4.2 psychiatrists per capita), a 15-fold difference in psychiatrist supply.” Urban psychiatrists tend to be younger: 36% of all Ontario psychiatrists, and 41% of psychiatrists within 15 years of graduation, practice in the Toronto Central LHIN.
· “Male psychiatrists saw a higher number of unique outpatients, unique inpatients, unique total patients, and new patients in each cohort since medical school. Female psychiatrists had a higher mean number of visits per patient than male psychiatrists.”
· Psychiatrists saw more patients (the mean number of unique outpatients seen by a psychiatrist annually increased by 19.5%). The distribution also changed: the proportion of all psychiatrists who saw fewer than 40 outpatients annually, for example, decreased from 17.5% of all psychiatrists in 2003 to 14.5%; see the graph.
[T]he differential practice patterns of younger and female psychiatrists who are increasingly practicing in urban areas should worsen the access to psychiatrists in already underserved regions.
Another significant finding of our study is that despite the need for greater access to psychiatrists, the practice patterns of psychiatrists have remained largely unchanged over the 11-year study period. Our results suggest that the addition of younger psychiatrists to the current supply of Ontario psychiatrists will not solve the demand for increased access to their services. (!!)
They then look abroad for ideas:
In response to rising health care costs in the United States, health management organizations and behavioural health ‘carve-outs’ were developed, and the organization of psychiatric care for those with health insurance coverage changed. Along with these reforms, the role of a psychiatrist in the United States within these new managed care systems also changed, and the changes were met with significant criticism early on, which continues to this day. Thus, while the behavioural health carve-outs are associated with efficiency, the gains in efficiency appear to be at the cost of psychiatrist job satisfaction, related to the perception that psychiatrists are less autonomous in the way they can provide care to patients. In contrast, our study suggests that Ontario psychiatrists have not been ‘managed,’ with little change in practice patterns over the past decade despite an increasing awareness of a substantial amount of unmet need for psychiatric services and, according to Canada’s Wait Time Alliance, no current way to systematically assess access to psychiatric care.
There is an opportunity for Ontario psychiatrists, as self-regulating professionals, to be better integrated within the broader array of health services to align psychiatrists as a finite human resource with the existing need.
A few thoughts:
1. This is a good paper.
2. The conclusion is obviously concerning – and suggests ongoing problems with psychiatrist supply and access.
3. The larger question: what now? In an interview with CBC, Dr. Kurdyak made several suggestions. Among them: psychiatrists should work more closely with family physicians; telepsychiatry could help bridge the gap between experts in urban areas and underserviced rural areas; drawing a page from the UK and Australia, non-MD delivered psychotherapy could be funded by the government.
4. The paper itself ends with something of a challenge to the profession, suggesting that psychiatrists themselves need to find solutions to these problems. That sounds good – but is it overly hopeful? For one thing, it means that physicians need to set aside guild-biases, and focus more on resolving core delivery issues.
The CBC interview can be found here:
A past Reading considered the 2014 paper by Kurdyak et al. It can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.