Dialing for Doctors
Network, Winter 2006
The typical day in a family physician’s practice in northern Ontario is hectic, to say the least. The average workload for family doctors in Canada is more than 75 hours per week, and the much-publicized shortage of general practitioners across the country is even more pronounced in northern communities. According to the College of Family Physicians of Canada, 30 percent of Canada’s population lives in rural, remote, and northern areas, but only 17 percent of family physicians practice in those areas, and the ratio of doctors to people is dropping even faster in rural areas than in cities. As the Centre for Addiction and Mental Health’s Anne Hoelscher, who is based in Parry Sound, says, “Family physicians are on the spot with a wide range of primary care demands, and they’re making the best decisions that they can, but they’re often on their own.”
While doctors’ time is becoming more pressured, an increasing proportion of that time is spent addressing the mental health needs of their patients. According to the Canadian Institute for Health Information, the average number of mental health-related billings increased by 12 percent between 1992 and 2001. And mental health issues may be an associated reason for many other visits to family doctors — as many as 40 percent of individuals seen in primary care have identifiable mental health problems.
Family doctors must be able to respond appropriately to the mental health needs of their patients, because they are often the first and the only source of mental health services. According to the Institute for Clinical Evaluative Sciences, they are the sole source of support for as many as 84 percent of individuals seeking mental health care.
Given how much time family doctors spend addressing issues related to mental health, the question of whether primary care physicians receive enough mental health training is often posed. Dr. Peter Voore, clinical director of the General Psychiatry program at CAMH and an assistant professor of psychiatry at University of Toronto, says, “Much has been written in the past about how primary care physicians may not have sufficient training in the treatment of addictions and mental health issues, and given their busy clinical practices, they may not have enough time to access new research and best practice information.”
Hoelscher feels that training is not the only issue. “I don’t think it’s just about having insufficient training. I think it’s about the reality of how complicated some of the mental health needs are, the complexity in treating mental health problems, and just the fact that they’re so prevalent. It’s so much a part of what a physician is providing in terms of care.”
In an attempt to respond to northern doctors’ need for support in providing mental health care, the Centre for Addiction and Mental Health (CAMH) and the University of Toronto Psychiatric Outreach Program have developed the Mental Health Clinical Consultation Service (MHCCS), a six-month pilot project that allows family doctors in northern communities (as well as a limited number in the Toronto area) to call a toll-free number to access psychiatrists and pharmacists who can provide clinical advice. The project launched on October 1, 2005 and is slated to continue until March 31, 2006.
The benefits of the service are numerous. As Hoelscher, who manages the project, points out, the doctors can access not only the psychiatrists themselves, but an entire team of mental health-related resources. One particular call stood out, recalls Hoelscher: “It involved a reference librarian doing a literature search, the pharmacist saying, ‘Have you come across anything like this?’ and the psychiatrist saying, ‘I’ll check with my colleagues,’ and so drawing on the whole team.”
MHCCS helps address the isolation that doctors in northern communities experience. Says Hoelscher, “We recognized that the North was an under-serviced area, that it was an appropriate place to start.” She adds, “It’s like that hallway chat — here at CAMH or in other settings, we can walk down the hall and chat with each other. You can chat, come up with a plan, and move on.”
Dr. David Mamo agrees. A staff psychiatrist in the Schizophrenia program at CAMH, Dr. Mamo was the expert on call during the first two weeks of the pilot. “The discussions [with family doctors] were not dissimilar to those I would have in a general hospital cafeteria: ‘I’ve got this particular patient with this problem, what’s your usual approach to managing such cases?’ It is very collegial, very informal.”
“If I had the opportunity as a psychiatrist to have this kind of service with, say, an internal medicine specialist, I would find it quite useful,” continues Dr. Mamo. “The opportunity to informally discuss a case outside my area of expertise with another specialist, without having to go through a formal consultation process, would make for efficient use of resources in certain clinical situations, not to mention the educational benefits.”
MHCCS builds on an understanding of the need to deliver primary care and mental health care in an integrated fashion. “That’s the whole foundation of shared care — we know that physical health and mental health shouldn’t be split,” says Hoelscher. “You can treat one independent of the other, but you do better when you look at the whole picture.”
The process for the service is straightforward. The calls to the service are received by CAMH’s reference librarian who, after an initial consultation, decides if it should be directed to the pharmacy team or to the psychiatrist on call that day. An initial response to the call is made within 24 hours, although the difficulty of connecting with busy family physicians sometimes means that it takes a little longer for the psychiatrist and the doctor to connect to get further details if necessary. The team will then consult or conduct any research necessary, before responding to the family doctor with clinical advice. Hoelscher says, “We have very experienced psychiatrists and pharmacists, experienced in a range of topics, and so if one can’t answer this question, they’ll feel comfortable contacting a colleague. So really, when you call that number you have access to the larger resources that you wouldn’t have if you were working in isolation in a family physician’s office.”
CAMH and U of T have come together as funding partners for the project, but they also share resources. Both institutions have psychiatrists who act as consultants, and they have worked together to share resources to ensure the best possible response for the family doctors calling in. The calls the service has received are sophisticated, reflecting the knowledge and understanding that family doctors already have. According to Hoelscher, “This isn’t ‘Call the service if you want to know the initial dose of Paxil,’ this is ‘Call us if you have a complicated situation.’ We’re getting very well thought out kinds of calls, very appropriate.”
“I have a lot of respect for family doctors,” adds Dr. Mamo. “They’re very well-rounded physicians. They’re not going to call for things that are trivial. Some of the questions were very good, and led me to conduct a number of literature searches as well as stimulating interesting discussions with some of my own colleagues. For one particular excellent question, I recall, there was no good answer — the physician had completed all the relevant literature searches herself and it was simply one of those pharmacological questions in psychiatry for which we have no clear answer of yet.”
“To be quite honest, I enjoyed the calls. I found them very stimulating. The questions were interesting — including questions relating to long-term effects of medications or the use of medication during pregnancy, as well as management of other behavioural issues.”
The response doctors receive is very clearly advice, not direction — the family doctor must still decide on the best course of treatment for their patient. Hoelscher notes, “Basically, our response has to be, ‘In this type of situation, or working with a patient with that type of symptom, I would look at or recommend this.’ We’re not saying ‘You need to prescribe this, or you need to get this person cognitive behavioural therapy.’”
“It’s called a ‘consultation’ service,” explains Dr. Mamo, “but in truth it’s not exactly a consultation because you’re not seeing the patient and have not established a clinical relationship with the patient. You’re being presented a case and you’re giving your thoughts about it. When I interact with family doctors on the phone, I make it quite clear that my recommendations reflect what I would do if I were managing a similar clinical situation.”
“The family doctors I’ve spoken with are happy to have this kind of service,” continues Dr. Mamo. “The immediate feedback I got was positive — almost a sense of relief that they could talk about the case with another peer who happened to be a specialist in that particular clinical field. Even if I did not say anything that they were not already planning to do, just stating ‘your plan seems to be reasonable, that’s exactly what I would do,’ can be very reassuring and validating, especially since some of the cases they’re dealing with can be quite challenging.”
MHCCS is modelled on a similar service that CAMH has been providing for a number of years now, called the Addiction Clinical Consultation Service. The advice that service provides is specifically related to addiction treatment, and is provided to any kind of addiction service provider, including family doctors, counsellors, nurses, social workers and pharmacists, across the province. As Hoelscher notes, “This mental health piece is really building on the ACCS experience.”
While Hoelscher acknowledges that limited access to mental health services is problematic across the province, particularly in underserved rural and northern communities, she says that MHCCS cannot address that larger issue. “This service does not pretend to provide a comprehensive solution to the gaps in the very complicated spectrum of mental health care services. I think what we saw ourselves doing is saying, ‘We can be one piece, but it’s certainly not the solution.’” Further, she feels that there is a need for more services like this one. “There is certainly more demand for psychiatric outreach program consultants than there is funding or capacity to provide them, as an example.”
But when asked about the future of the six-month pilot project, Hoelscher is enthusiastic. “There’s lots of potential. We have to really work with it. I think a big part of it right now is getting family physicians to be aware of the service, increasing our promotion and getting more experience. Physicians are very, very busy. They do find this useful, but how can we get them to think about it when the need is actually there to make the call?”
For more information about the Mental Health Clinical Consultation Service, contact Anne Hoelscher at 705-746-7440 or firstname.lastname@example.org.
Liz Scanlon is the former public relations and policy coordinator for CMHA, Ontario.
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