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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.

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.

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.

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.”

Survivalists

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.

Practice update

My secretary, An, will be away until January 24. In the meantime, I will be handling my phone and fax machine (just like old times!) If you call the office it is likely that nobody will pick up, but please leave a message and I will endeavor to return your call promptly. I will be able to access my messages on weekdays even when I am not in the office.

An used to give appointment reminders by phone – I will not be able to do this while she is away. Automated email appointment reminders are high on the priority list but I have not gotten there yet – still working on getting electronic fax capabilities for consultation reports and switching to OSCAR-based billing, behind the scenes.

The office will also not be accepting new referrals for the first few months of 2015, to allow me to work through the waiting list, which is already several months long.

Thanks, and happy New Year to everyone.

MBCT at U of T

A work colleague and I have started a Mindfulness-Based Cognitive Therapy group for Anxiety at the University of Toronto. Our first week was the most fun I’ve had at work in a long time! Making the handouts and the guided meditation recordings has been a challenge in the best way. The university provided space and printing services, and I was also fortunate enough to be able to borrow some cushions from a friend so we’ll be able to sit comfortably on the floor for the next 7 weeks. I think this will enhance the group experience. We can do a lot by helping each other out, and collaborating with otheres like this makes the work so much more enjoyable.

Practice update – Hong Fook

I’m excited to start working one half-day per week at Hong Fook Mental Health Association, starting in April, seeing Vietnamese-speaking patients. This means I’ll be cutting my private office time back from 1 1/2 days per week to one day (Wednesdays). While my capacity to take new referrals from the community will be decreasing, I hope that I’ll be able to provide a much-needed service for people who would otherwise have great difficulty accessing care while improving my language skills and connecting with my roots.