Usually my online activity focuses on updates about my practice locations and thoughts about electronic medical records. Lately the question of why it is so hard to get psychiatric care in Toronto (or anywhere in Ontario, for that matter) seems to be coming up a lot more often – patients I have seen, trying to access treatment, or people I know personally. Even pulling strings there isn’t much I can do for my own friends or family because it seems that the services are just not out there.

Why we are in this predicament is a somewhat complicated question to answer but it is important for the public to think about. Our society likes to talk a lot about destigmatizing mental health and doing more for people in a vague and noncommittal sense but without accurate knowledge of our present situation we will not make any progress. I will start tackling this with my perspective from the ground, and most likely it will require a multi-part answer that spans many posts.

The highly simplistic answer to the question of why it is hard to find a psychiatrist is that there are simply not enough psychiatrists. Currently, the Coalition of Ontario Psychiatrists estimates that there is a shortage of about 200 psychiatrists in the province of Ontario. It is simply difficult to see one because there are not enough of us doing this kind of work. The more interesting questions are why there are not enough psychiatrists and whether the psychiatrists who are in practice are actually using their time as efficiently as possible.

The money 

Let’s get this one out of the way first. According to ICES data (a non-profit health care research institute) from 2015-2016, psychiatry is currently the lowest paid Ontario specialty. That was surprising news to me to read – I thought we were second or third lowest, but it turns out we recently had the dubious privilege of being at the very bottom. Comparing averages, it’s about a third of what an ophthalmologist makes, and we do the same amount of post-graduate training. That, perhaps, does not take into account the fact that many psychiatrists only work part-time and it is an attractive specialty for that reason. Maybe psychiatric work is easier too – I’ve never been an ophthalmologist, so I don’t really know how they compare. It’s also important to make the usual caveat that billings don’t take into account overhead costs, and psychiatry is a relatively low-overhead specialty with little need to invest in equipment and staff, depending on how one practices (paper charts, no secretary, only doing psychotherapy for a small population – keeps costs down). But, in any case, most people would probably not try to argue that psychiatry stands out among medical specialties for high earning potential.

Recent developments have actually made the income gap worse. In arbitration with the Ontario government, physicians were awarded an across-the-board return of “redress monies” during arbitration with the provincial government (i.e. the across-the-board cuts unilaterally imposed by the previous Liberal government were reversed). This is a flat-rate percentage that applies to all specialties. That means the higher-billing specialties get back a higher dollar amount than the lowest-paid specialties. Comparing psychiatry to ophthalmology, the difference in the average increase is $20,998 according to the OMA section on psychiatry. That’s about enough money to pay for all of my secretary needs for a year, or my office rent.

My opinion (and I don’t have data to back this up) is that when you see a psychiatrist, the person sitting across from you is there for one of two reasons – 1) they love the profession and they couldn’t really see themselves doing anything else, or 2) they couldn’t match to the specialty of their choice and they ended up in psychiatry as a back-up profession. I doubt they did it for the money, though. Now, in this line of work we want people to do it because they love it. However, there may be bright young people who thought about it, and then considered the fact that if they went into psychiatry, they likely (now) would not be able to afford to buy a house in the city where they trained (Toronto is the largest training program in Canada, if not the largest in North America). If there was another specialty they also were considering, other factors being equal, they would probably opt for more money. 

The money factor doesn’t make it easier to recruit people into this profession. The overall average billings are only part of the picture, when it comes to money, however. In order to understand how we got where we are now, we also need to look at another important monetary factor that influences psychiatrist behaviour – the fee structure – and that’s a topic for another post.