Buddhism and Psychiatry Fellowship

It’s official… I jumped through all of the registration hoops and I am back at U of T for a clinical fellowship in Buddhism and Psychiatry.

I attended the orientation session for Clinical Fellows last week. I wasn’t sure what I would get out of it but came away with the insight that there are so many people who know more than I do about particular things, so if we collaborate more we will be more productive. This was in the context of publishing more papers (it’s U of T, after all) but I think it applies to many things in my life.

When I look back on things I wrote about 1 or 2 years ago, a lot of it had to do with running an office and DIY electronic medical records. Having been there and done that I would say in retrospect that it makes more sense for me to let someone else do that so I can focus on other things. It really isn’t efficient to manage an office and practice medicine at the same time, and even though doing everything yourself may keep more money in your pocket it’s really a drag on quality of life. It’s not really all about maximizing billable hours (that means seeing patients!) either. I found out that a lot of the satisfaction in this work comes from having some quiet time to look up the answer to an interesting question or just look out the window.

Doing the fellowship so far has given me a new appreciation for learning and it has been a good excuse to dig deeper into Buddhist philosophy and psychology than ever before. It is also kind of amazing how being “officially” a clinical fellow seems to give permission to talk to other people and share ideas. Hopefully it will be a good year of collaboration and producing something new and creative. Maybe get a couple of papers published too.

p.s. Not to worry – my private practice is still going. It’s full – but still running.

Are we dinosaurs?

This morning I heard someone speaking on the CBC about the proposed Physician Services Agreement, and this evening I paid for my office insurance for the year and as an aside I worked out my overhead costs – roughly 25% of my billings, not including taxes. It really drove home the current economic reality for physicians. If we agree to the new PSA all previous cuts from government unilateral action will stay, and doctors’ fees will be funded at a level that is expected to keep up with growth in demand for service. We’re not going to be making more money, and between cuts and inflation our actual income is going down.

It occurred to me that it would cost me less in overhead to treat fewer patients. If I didn’t take new patients I wouldn’t have to have a website so they could find me. I wouldn’t have to handle as many phone calls or deal with as many scheduling issues so I wouldn’t have to hire staff. I could rent part of an office by the day, and not buy furniture. I might not have to keep an electronic medical record, and if I didn’t have that, I wouldn’t have to have electronic fax service either. If I didn’t have electronic systems I could probably get away without paying insurance against Cyber security disruptions. Provided I could still fill my schedule, I could bill the same amounts as I do now. Sadly, given the demand for psychiatric services, one could probably make this work fairly easily.

Supposing that money follows creation of value, you would think it doesn’t make sense to try to run a tiny practice and see the same bunch therapy patients every week. Publicly funded health insurance is a strange market-distorting effect, though, such that running a small therapy practice might actually do better financially than running a more complex one with more patients.

Here’s another thing to consider, though – in the next few years, the funding agreements are likely to change. Someone once told me that people who do the kind of work I do in private practice are on the way out, and I told her we would change when the funding model changed. Looking back, maybe we were both right. One psychiatrist treating one patient is turning into a luxury that we cannot afford as a society with massive government debt, an aging population to look after, and an economy propped up by a massive housing bubble. It probably would not be wise to put more money into services that only benefit a handful of people even at the best of times. Whether we like it or not we are most likely moving into an era of one-off consultations, group-based treatment, and possibly even hard caps on the number of individual visits per year. As much as I like individual therapy, these are probably changes that need to happen, so that there won’t be a financial incentive to shrink instead of grow. Throwing more money into a process that doesn’t work efficiently probably isn’t good in the long run. Being in a city the size of Toronto and still struggling to be seen by a psychiatrist is a sign that something isn’t right. I think we should still do individual visits – there is a place for that – but they should be a lot more precious. Another possible benefit (questionable benefit to the doctors affected, maybe) of the squeeze on the solo practitioner is that it might drive more psychiatrists out of the big cities, especially where the cost of doing business is very high. This might just improve access across the province.

I don’t really like reading what I’m writing. I love coming into my office and handing things off to my secretary, who I don’t have to share with anybody, and seeing my patients, some of whom I’ve gotten to know over a number of years. I have a view from my office of a tree-lined street and the pace is relatively relaxed. At what point will this hobby become too expensive to maintain, and talking about “my patients” is a thing of the past? It’s hard to say, but it does feel strange to think of oneself as possibly one of the last of a group that may soon disappear. I like to think that we can find a way to adapt – become more efficient and effective, and be compensated for doing it. With another opportunity to negotiate with the government, now may be our chance.

New fax number

We’ve switched from RingCentral electronic faxing to SRFax, so we have a new fax number: 647-689-3288.

RingCentral worked quite well but due to security concerns about faxes being sent through servers located in the US we have switched to a service that uses servers on Canadian soil. This will hopefully reduce the potential for confidential communications and patient data being intercepted by foreign authorities.

We will still be able to receive faxes at the old number (647-557-3622), however, we strongly encourage the use of the new fax number.

Improving email efficiency – ONE-Mail on desktop

For the doctors using ONE-Mail, the Ontario government’s secure email service, it is now possible to connect to your ONE-Mail service using desktop software (MS Outlook or Apple Mail). Instructions are here. They are simple and take 5-10 minutes to implement.

I am not sure how long it has been possible to do this but I’m sure these instructions weren’t available when I first signed up for ONE-Mail. I think it does introduce a possible security concern whereby downloaded email messages could be compromised; therefore it is advisable to use hard drive encryption. In terms of the risk of email being inadvertently forwarded or replying with the wrong email address, I believe it may be slightly higher than when using a webmail app because one could be accessing work and personal email from the same software.

In any case, I have found that it does make the email much more usable as it decreases the time spent reading and replying to messages, and it facilitates good email hygiene (checking messages daily, early in the day). The ability to quickly manipulate (trash, archive, reply) an email message also allows for an “inbox zero” strategy to be implemented whereby emails are cleared, filed, or acted upon immediately rather than allowed to accumulate.

A counter-argument to downloading messages introducing a security vulnerability is that avoiding the secure email address because it is too cumbersome to access the webmail app then could lead to use of personal email addresses for office-related communication. In that case, there is no point having a secure work email address if you don’t use it.

I continue to encourage patients to call instead of send emails as email is inherently insecure regardless of what server is being used. However, when email must be used and precautions are taken to avoid including personal health information it may be a valuable practice management tool.

Advocacy work

Last month CityTV covered some grassroots advocacy work that Dr. Yusra Ahmad, a psychiatrist friend and colleague organized. I find it inspiring that even in this economic climate physicians are still taking time to volunteer and do the work that needs to be done.

There was an article in the Toronto Star covering the event as well. In my mind, this kind of work makes a strong statement – to the physician who volunteers his or her time for anything, the cause is worth more than the dollars that time would bring if spent in the office, so the rest of us should pay attention.

Buy less stuff this Christmas

A friend sent this post from Plum Village monastery regarding the holiday season. I don’t think I could really add much to the message so I’ll just post the link: http://plumvillage.org/news/a-green-santa-and-a-hug-of-love/

One sentence that popped out at me: “We do not need to wait for our governments and corporations to do the right thing.” It looks like such a simple sentence, but how to put it into practice? I suppose that buying less stuff this Christmas would make a difference, but it then begs the question, if we spend less on stuff, what should we do with that time or money instead? How could it be better used? I suppose that if we didn’t have to spend that time and money shopping, we could improve our knowledge to add more value to the world, spend the time with someone we care about, go look at some art, walk around in the park, clean the garage, catch up on paperwork so we’re less stressed… actually, there are a lot of things we could be doing that would make our world a better place. Maybe just about anything would be better than spending money to buy people things when we’re not even sure if they need or want them, or buying things for ourselves that we don’t need just because it’s Boxing Day.

So maybe I will add to the message: this Christmas, let’s give the world the gift of not being stressed out and broke.

What is medically necessary?

Andre Picard made some good points in the Globe & Mail two days ago, entitled “Honest talk about private health services is long overdue” – points that need to be made in light of the current debt crisis / austerity hysteria that is overtaking our province.

Perhaps the most important observation is that contrary to what many people believe, Canada does not have a fully publicly funded health care system. For all the people who protest two-tier health care, the truth is, we already have it. Mr. Picard elaborates in more detail in his article, so I don’t have to, but the essence is that some aspects of health care (like physician services) are covered by public insurance, whereas others (like most dental services, and medications for many people) are not.

Mr. Picard observes that there is a problem with the way that “medically necessary” services are covered by public insurance and services that are deemed not medically necessary are not. As he points out, this distinction at times becomes ridiculous.

Some delineation is positively absurd: Some provinces pay for cancer drugs if you take them in hospital, but not if you take the same drugs at home. Psychiatric care is covered, but most psychological care is not.

In my field, this absurdity is painfully obvious. A course of psychotherapy from a psychologist for a depressed person would not be medically necessary (even if prescribed by a physician), but the same treatment provided by a medical doctor would be. In practical terms, this means that it in theory it might be possible for me to expand my clinic and provide care for more people by providing counseling through allied professionals under psychiatric supervision – try to leverage my skill set to see more people. However, I would need to fund that privately (so that rich people could access this kind of care, but other people would not), or find some other alternate funding source. However, the province would fully fund me to spend most of my time asking about symptoms and doing counseling that another (probably less expensive) provider could do, because I couldn’t bill for the service if I hired someone to do it under my supervision. Meanwhile, the size of my practice maxes out at 150 patients or so, more or less depending on how frequent the appointments are and how long they are. What is even more absurd is that I could make the same income seeing the same 30 patients every single week for the next 10 years and beyond. Dr. Paul Kurdyak discusses this issue in a study covered by this article in Maclean’s.

I’m not putting down psychoanalysis or long-term psychotherapy. I do a small amount of that kind of work, I’ve seen it help people greatly over time, and yes, I think in some cases it is the best treatment. If psychiatrists want to spend some or all of our time doing that kind of work, more power to them. The decline of psychodynamic thinking and deep self-reflection in our work, in favour of prescribing, is in many ways lamentable (and I prescribe a lot of medications). What I do think, however, is that it does not make sense that some people can access this treatment with public money if they can manage to see a psychiatrist, and the rest of the population cannot. Deciding whether something is medically necessary or not based on who is providing the service is a rather strange way of rationing care. That is not really equal access, but it pretends to be. Everyone who buys a ticket has an equal chance of winning the lottery, but most of them won’t walk away with money in their hands.

It also does not make sense that what might be more efficient models of service delivery may never be incentivized under the current funding model. Also, much of our preventative care is an out-of-pocket luxury while we spend thousands or more to treat someone after their life has completely broken down. I don’t think that type of issue is limited to psychiatry. It also goes far beyond funding – I believe good mental hygiene is not expensive, but it does take a lot of time and effort. This is not something someone can do for you. You have to put in the work.

So, what is medically necessary?

I think this is the kind of thing we should be discussing at a higher level (in addition to other questions, like – how did Ontario become the world’s most indebted sub-sovereign borrower and what does that have to do with health care), but we are deadlocked at the level of squabbling about unilateral action. In our current mental health system, we pay the architect to lay the bricks and build the house himself, and since it costs too much we’re are now trying to pay him less to do it. We’ve totally missed the point, haven’t we?

Getting involved with health care

I wanted to send a quick shout out to my colleague and friend Dr. Anh Tran for putting together a new website with some of our colleagues. You can check it out here at www.carenotcuts.ca. What I like most about the latest round of government cuts is that it got people who would otherwise never have become political to be political. It has made advocates out of people who would otherwise have gone on with life as usual. Threats to health care may give us a better democracy, and for those of us more personally affected, if nothing else we have great motivation right now to reflect on the state of our lives and make moves we never would have made if we weren’t challenged.

More cuts!

The Ontario government recently announced another 1.3% cut to physician OHIP billings applied across the board, following cuts that happened in January of this year. I’m happy to see this has been hotly discussed in the news, and online. Dr. Ming Yu’s article in the Huffington Post, for example, has gone viral (according to the OMA). Most of the current debate, as far as I can tell, centers on the plight of doctors – are we are being undervalued and disrespected, or maybe we are too wealthy and entitled?

There doesn’t seem to be much argument about the discrepancy between projected growth in health expenses and the increases in funding to health care in the budget. Whoever is making the estimate, the consistent point seems to be that anticipated growth in healthcare expenses will exceed increases in government funding of health care. We can spend a lot of time talking about how much doctors get paid, but it made me wonder, if the government is willing to make this potentially very unpopular move (if comments on Kathleen Wynne’s Facebook page are a reliable indicator) what does that say about their other options – and the current state of our health system and economy?

I couldn’t sleep the other night, and here is what I found out: the Fraser Institute published “Ontario’s Debt Balloon: Source and Sustainability” in February 2015. To sum it up, it says the source of Ontario’s debt balloon, which reportedly expanded from 28% of the provincial economy in 2008/09 to an expected 40% in 2014/15, is mostly due to high operating expenses, and that without significant changes, the level of debt is unsustainable, i.e. the province will default on its debt at the rate it’s going. Ontario’s credit rating was downgraded in 2012. The Council of Canadians published “A Difficult Road Ahead: Canada’s Economic and Fiscal Prospects” in 2014. It concluded: “If spending on health care increases at rates close to the pace recorded over the past decade, Canada’s provinces and territories will have to raise taxes to avoid deficits growing even larger.” “If Canadians don’t want to pay higher taxes to cover surging expenditures on health care, the only other option will be to cut spending on social programs and education”. Blame our current woes on mismanagement by our government, but it seems to be a nationwide issue.

This is a selected representation of sources; maybe other authors have reached different conclusions about our state of affairs. However, working with very basic assumptions it seems possible to reach similar conclusions. In a big-picture sense – and I think these observations would be accepted by a casual observer – the population is aging and health care costs are therefore rising. For the same reason, revenue (and future revenue) is shrinking. Furthermore, economic growth on a worldwide level cannot continue indefinitely as it involves extracting finite resources from the planet. The idea that the province is in massive debt is another extra detail. Therefore, we are going to have major problems sustaining our current way of delivering health care regardless of whose fault it is (and maybe it isn’t anybody’s fault), and maybe what is happening now to physicians is a sign that we finally can’t keep throwing more money at the problem, because the credit line is maxed out.

To the doctors posting in online forums that they feel undervalued and they are thinking about moving elsewhere, so the government should pay us more – I think we need to grieve, and then we also need to move on, for our own good. To put it another way, if you see steam coming out of your faucets you should wonder if maybe your house is burning down instead of worrying about what is wrong with the tap. We could diversify our income streams, cut expenses, reduce our lifestyle, even look at overseas options, however one wants to cope in the short term. Then, we can move on to deciding if we should be advocating for cuts to other social services, convincing the public they need to pay more taxes, abandoning the idea of universal healthcare,  coming up with our own proposal for rationing health care, or some other plan of action to dramatically increase efficiency. Unilateral cuts aside, we’re all citizens and we’re going to need health care someday.

Even if I don’t agree with the Health Minister’s actions, I can certainly thank him for getting me (and other physicians all across the province, and the public) more engaged in thinking about the situation of health care in Ontario. If not for the repeated pay cuts I probably wouldn’t have turned onto the fact that big problems have been brewing for quite some time and that we really need to do something about it.

To be fair, I think doctors and the public are thinking about the bigger picture. The public discourse seems to be focusing mostly on the (relatively) smaller issue of physician compensation, but I imagine people are thinking about the larger context. We are likely to face some difficult questions as a society – are we going to spend proportionally more on health care, or are we going to accept that health care needs to look different than it does now, and different in what ways? How much can we gain by making health care delivery more efficient? If we can’t make up the difference by increasing efficiency, what do we cut? How little we can get away with paying our professionals before we really start hurting from it? Which ones can we really do without? If we have to start cutting services, how will we decide which ones? Can we go further down the road of the two-tier health, shifting more services into the private sector for those who can pay for them?

I haven’t heard anybody saying that universal public health care is unsustainable and dying a slow, inevitable death, and I hope it’s because that’s not true. The conspiracy theory loving part of me can’t help but wonder if all the hand-waving about cuts to physicians is a distraction from the larger issue, because the political will to confront the difficult questions doesn’t exist and whoever brings it to the attention of the public is going to look bad. On the other hand, to echo Dr. Gail Beck’s sentiment – it is a good time to be a doctor in Ontario. I would add, maybe there hasn’t been a better time in a long while. There’s nothing like a crisis to put into perspective what really matters.

OSCAR and survivalists

It has been a bit over a year since I started using OSCAR and coming up on a year that I’ve been with my current OSCAR service provider. I’ve learned a few things along the way that I thought were worth sharing.

The first topic I thought I’d tackle is something I’ll call EMR survivalism, which I believe highlights some important aspects of the psychology of OSCAR. According to Wikipedia, survivalism is “a movement of individuals or groups (called survivalists or preppers) who are actively preparing for emergencies, including possible disruptions in social or political order, on scales from local to international.”


OSCAR users – looking to survive catastrophe? Photo from nytimes.com

I have noticed this kind of survivalist mentality can to be one factor that draws people to OSCAR. From my perspective (and please note I’m not trying to paint all OSCAR users with the same brush, here), the prototypical OSCAR survivalist is an individualistic physician who is looking to maintain control over clinical infrastructure and patient records – in essence, one who believes that the physician bears ultimate responsibility for the care provided and therefore must also strive to maintain complete control over their clinical infrastructure and patient records. Such an individual may be suspicious of abuses of power by large corporations, inappropriate intrusions into clinical decision-making by administrators, government snooping and surveillance, and potentially preventable disasters / outages that disrupt clinical work. From the perspective of a survivalist, OSCAR seems very attractive – allowing one to maintain control over patient data and to prepare for the worst – power outages, networks going down, hardware failure, theft, EMR provider failure – at least in theory.

Does it actually work that way in practice? My best answer so far: sort of.

Does the average physician with some inclination to learn about computers know enough to effectively maintain server hardware, set up a secure network, and monitor for intrusions? I suspect not – at least not as much as a specialist would know. Also, it’s ongoing maintenance and a mental diversion that takes us away from doing what we’re good at (and what brings in the money) – looking after patients.

Is it cost-effective for the average physician or small clinic to retain in-house IT support? I would say no.

Does the average physician have access to the infrastructure needed to maintain EMR functionality in the face of unanticipated disruptions – redundant and separate internet connections with sufficiently high upload speeds, independent power supplies, ready access to replacement components in case of hardware failure, backup server with automatic switchover in case of primary server failure? Possibly, but it’s not very efficient to set all of that up for one individual system. It would probably be much more cost-effective (and environmentally friendly) to pool resources and share server space in a dedicated, secure server facility – in other words, a cloud solution.

So, why go through all the trouble of setting up an in-house OSCAR solution at all? I believe it’s the same reason why people buy farmland in the country, stockpile supplies, and build bunkers. My hypothesis is that the kind of people who worry about a zombie outbreak, nuclear attack, and foreign invasion are similar, in ways, to a subset of the people who use OSCAR.

Fallout shelter

Are OSCAR users the kind of physicians who would build a place like this? Image from spiritmeetsbone.me

There are arguments for and against this way of living; in the event that nothing happens, it seems more efficient not to worry and trust in the people in charge. In the event of catastrophic failure in social order, though, the people with canned goods, medical supplies, and ammunition lining their basements look like they had a good idea. I suppose that whether or not it was “the right thing” to set up your own OSCAR server looks different depending on whether you’ve had years of reliable service from an EMR provider or you bought into a lemon and the company went belly-up or just didn’t pick up their phone when you needed them, leaving you stranded.

Is there a third way? I think there might be – and it comes down to trust and cooperation. In the event of a world-ending scenario I’m inclined to think that the people who prepare but also cooperate with others stand the best chance of doing well. Blind trust and obstinate self-sufficiency are two extremes, and let’s face it – not everybody is going to have a country estate with a bomb shelter to fall back to. So, too, with OSCAR – by sharing resources, hardware, and infrastructure, individual physicians could have access to more reliable EMR service with lower overhead and possibly better security and maintenance expertise, without needing to put the keys in the hands of institutions or companies that may or may not come through. I’m talking about a co-op situation – physicians pooling their resources to run their own OSP (Oscar Service Provider), hire support staff, and put together a server farm. At the end of the day we are responsible for the work we do and the people we hire, so I think we need to know at least something about the computer systems we use, as well. However, we don’t have to do it alone.

As far as I know, the OSCAR co-op doesn’t exist yet. So for now, unless a doctor can do everything independently, the next best option is to find an OSP they trust, and for the extra-paranoid among us, keep a backup system handy.