From the Editor

How do we practice today – and how will we practice in the future?

This week’s Reading includes three selections.

In the first selection, we consider how we practice today, with a new paper by University of Ontario Institute of Technology’s David Rudoler and his co-authors. Drawing on administrative data, they look for practice patterns, finding three distinct ones. Spoiler alert: practice patterns are very different, with 30% of psychiatrists seeing just two or fewer patients per month.

Then, we look ahead. In the second selection, we consider a new podcast discussing digital psychiatry. I talk with Dr. John Torous of the Harvard-affiliated Beth Israel Deaconess Medical Center. And, yes, he has tips on good apps for your patients.

Finally, in the third selection, we consider the recent Ontario government report on ending hallway medicine. The authors look to the future, and make several suggestions, including embracing the potential of digital health care.

messaging-appsApps – the future?




Section 1: “Closed for Business? Using a Mixture Model to Explore the Supply of Psychiatric Care for New Patients”

David Rudoler, Claire de Oliveira, Juveria Zaheer, Paul Kurdyak

The Canadian Journal of Psychiatry, 25 February 2019  Online First


How do psychiatrists practice in Ontario?

This new paper seeks an answer. Here’s what the authors did: they drew on administrative health data on all practicing full-time psychiatrists in Ontario over a 5-year period (2009-2010 to 2013-2014). Part-time psychiatrists were excluded. They then used a regression model to estimate the number of new outpatients seen, accounting for case mix, outpatient volume, and psychiatrist practice characteristics.

They find that there are three distinct patterns of practice – well summarized in this concise graphic (drafted by ICES, based on the paper):


What’s striking about the three classes is the incredible diversity of practice: from high-volume rural practice (one new patient daily) to low-volume urban practice (under two new patients monthly).

The paper has limitations, including that it didn’t consider alternative payment; perspective: “alternative payments accounted for 8.2% of total clinical payments to psychiatrists in Ontario.”

Like past papers on this topic, this study raises questions.  How could we better organize services? What will happen with an aging population of psychiatrists, particularly in rural areas?

The paper can be found here:


Selection 2: “What every physician should know about digital psychiatry”

John Torous and David Gratzer

Quick Takes Podcast, 27 February 2019


VR, e-therapies, chatbots. Mental health care is changing as we use technology to deliver services. What to make of it all? I sat down with one of the leading experts in digital psychiatry, Dr. John Torous of the Harvard-affiliated Beth Israel Deaconess Medical Center, to discuss how digital tools are now being used in patient care, and what tomorrow may bring.

Dr. Torous sees psychiatry changing.

On VR:

Not this year, not next year, maybe in four to five years… this would be very good for anxiety, for exposure therapy. It’s going to become more affordable, more accessible.

On E-therapies:

E-therapies can be very effective if people can get through them. We’re going to learn more about what type of human support [is needed]: coaches, auxiliary providers? What type of clinician support makes people actually get through e-therapy for the benefit?

On Chatbots:

Exciting potential. If you’ve ever used one of them for more than a couple minutes the limitations become pretty clear. That said, tremendous advances in natural language processing are always happening in machine learning. I think we’re going to hopefully see some more big pivotal studies later this year or perhaps in one to two years – but, too early to tell.

torous-gratzerInterviewing Dr. Torous (I’m in the grey suit)

Does he offer any practical tips for clinicians? Dr. Torous does, weighing in on apps he recommends:

PTSD Coach… which is part a very good suite of apps [by Veterans Administration]… They have privacy policies that really benefit patients. They’ve a lot of evidence to show that they work. The usability [is] improving… tell your patients: ‘I need you to stick with it. You can work around that.’ And it’s very easy to get the data off them.

The main podcast can be found here, and is just over 15 minutes long; there is also a “deeper dive” podcast, which is 9 minutes long, considering data and digital psychiatry:


Selection 3: “The First Interim Report from the Premier’s Council on Improving Healthcare and Ending Hallway Medicine”

Reuben Devlin et al.

Ontario Government, 31 January 2019


The big news in health care: late last month, the Ontario government announced its intention to re-organize its system of LHINs (referred to as regional health boards in other jurisdictions) and health care agencies (like Cancer Care Ontario). But while this re-organization seems quite profound, it’s not exactly visionary, and is somewhat inside baseball.

How to see the future of health care in Ontario – and its implications from coast to coast to coast? In late January, the Premier’s Council on Improving Healthcare and Ending Hallway Medicine released a report. That report is worth a careful read, and opens simply:

Hallway health care is a significant problem in Ontario. The entire health care system is too complicated to navigate, people are waiting too long to receive care and too often are receiving care in the wrong place; as a result, our hospitals are crowded.

The key findings:

  • “Patients and families are having difficulty navigating the health care system and are waiting too long for care. This has a negative impact on their own health and on provider and caregiver well-being.”
  • “The system is facing capacity pressures today, and it does not have the appropriate mix of services, beds, or digital tools to be ready for the projected increase in complex care needs and capacity pressures in the short and long-term.”
  • “There needs to be more effective coordination at both the system level, and at the point-of-care. This could achieve better value (i.e. improved health outcomes) for taxpayer money spent throughout the system. As currently designed, the health care system does not always work efficiently.”

Mental health is front and centre in the report. When discussing the challenges of accessing care, the authors write about Chelsea, who has panic disorder. “The Council is concerned that patients are unable to access mental health and addiction services when they are needed most.” They go on to cite: “Approximately 1 in 3 adults who went to the emergency department for mental health and addictions care had not previously accessed physician-based care for their mental illness.” (That statistics appears in a report written by Dr. Kurdyak, who was a co-author on the first selection in this week’s Reading.)

Where to go from here? They call for “digital and modern health care.”

Ontario’s health care system has room for improvement when it comes to using technology as a tool to help coordinate and deliver services, and improve outcomes for patients. As the Council continues its work, it will make a focused effort to consider technology solutions to help improve health outcomes for patients across the province. This could look like new partnerships to deliver specific services or to help support the integration of care at the local level. This could also look like identifying options for integrated health information systems that would help facilitate smooth transfers between care settings.

They also call for the health care system to be more integrated and efficient.

What exactly does that mean? The authors suggest that future reports will address these changes.

Two quick comments. First, it’s important that a report on health care includes significant consideration of mental health care. Second, digital health care is increasingly discussed – including in government policy documents.

The full report can be found here:


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.