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Presidential Address
The Doctor–Patient Relationship
The psychiatrist in clinical practice knows the doctor–patient relationship
is at the core of the practice of psychiatry and, for that matter, of medicine.
Psychiatrists specialize in the doctor–patient relationship: whether one
is trained in the psychotherapeutic side or the neuroscientific, one learns
as a budding psychiatrist that giving one’s patients time is the essence
of the art.
Patients expect and demand this communication. Physicians should have the
skills required. The psychiatrist has already experienced, or will shortly
feel, the advent and the impact of information technology that will insert
itself in the relationship.
The impact of information technology on the practice of psychiatry will
affect psychiatrists:
but we will not be the only group changed by this revolution. Consumers
of mental health services will have a greater access to expanding realms
of information. They will gain answers concerning their questions about
psychiatric disorders, treatment modalities and alternative medicine theories
and applications through their home computers via the internet. The internet
is highly available for a patient or a family member; he or she can enter
a wide variety of internet sites based on his or her level of understanding
of the disorder. However, this benefit for the patient can create potentially
greater complications in the therapeutic alliance and the doctor–patient
relationship. Conflicts in establishing a collaboration between the patient
and the practitioner have been addressed over the years and have consistently
identified the need for better patient education as a means of facilitating
collaboration. A psychiatrist may be faced with the dilemma of being less
informed than his or her patient (9).
Psychiatrists know that to examine the life system called the mind, they
have to rely on a systematic way of talking to patients—the mental state
examination and the interview.
Thoughts and feelings are real and can be described to others and then
rendered objective enough to identify and treat. But the “psychoscope”
has yet to be invented.
The psychiatrist in clinical practice knows he or she is the integrator
par excellence of the biological and psychosocial in both diagnosis and
treatment:
That integration is a critical component to the provision of optimal clinical
care. Without it the patient is fragmented into either a “mind” or a “brain.”
So would be the specialty of psychiatry (10).
The practitioner of psychiatry knows it is imperative that psychotherapy
continue to be thought in psychiatric residency training as a core skill
of the psychiatrist. The advances in neuroscience have produced a somewhat
paradoxical development.
The overreliance on psychopharmacological treatments has underscored their
limitations. Moreover, neuroscience research has reached a level of sophistication
that allows it to serve as a bridge between the genetic and the environmental
on the one hand and between the psychopharmacological and the psychotherapeutic
on the other (10).
And as stated by Gabbard:
The principles learned in psychotherapy will serve the clinician well,
regardless of the psychiatric activity in which he or she is engaged. Even
when psychotherapeutic interventions are not explicitly called for, the
understanding of what is going on within the patient or within a treatment
system, enriches the psychiatrist’s everyday experience in the workplace.
Much that is obscure becomes understandable (10).
Psychiatrists and Values
Psychiatrists know or should know that
Western culture is wary of values. Values in matter scientific have been
suspected for at least the past two hundred years. Enlightenment rationalism
permitted reason little of anything smacking of emotivism or the passions,
the wish of science has been to eliminate value in true science. Value
considerations in science, in sum, are often considered pollutants. But
this aversion to values is changing. Perhaps most obvious has been the
bioethics ‘mouvement’ Scientific concepts are value laden also. Some theories
or explanations are better then others, which means that judgement of good
and bad are indispensable to knowledge. Psychiatry as always marched in
step with the culture that generated such rethinking of the role of values
in science, knowledge and human action (11).
We are aware or must be aware that psychopathology involves value judgements.
DSM-III wished to make diagnosis more reliable and ultimately more valid.
Numerous advantages were expected: clinicians could discuss similarly diagnosed
patients with greater confidence that their patients were truly similar
in salient ways; researchers could have more homogeneous populations of
subjects in which to develop general explanations and treatments.
With a “postvalues” awareness, we might say that the DSM-III made mental
disorder diagnosis more accountable: one could not label a patient with
a diagnosis in just any way or without reference to a method, a system—which
is a great step forward. DSM added an explicit emphasis and method to half
of the experimental universe of mental disorders. There is the other half,
that of value and evaluation in mental disorders: “For every delusion there
is a complementary jealousy, fear or family member’s tears; for every addiction,
there is tragedy; for every depression there is at least one lament” (11).
Psychiatry has always had its evaluations: indeed, without them, it would
be an impoverished field.
The Psychiatric Workforce
Are We Too Many or Too Few?
Psychiatrists in the field are preoccupied by workforce issues. The CPA
has major concerns about human resource planning for psychiatry in Canada.
This is a very complex issue.
The move in 1994 to reduce the number of places in medical schools is only
now showing up as deficiencies in the number of practitioners in all areas
of medicine, not least in psychiatry.
The pace of work continues to increase: according to the CPA Practice Profile
Survey, psychiatrists work an average of 46.1 hours per week not including
on-call, 45 to 47 weeks per year. The average age for psychiatrists is
49 years, 123 psychiatrists can be expected to leave practice each year,
and an average of 82 new psychiatry resident positions are available to
Canadian medical schools graduates each year (21). Assuming 100% subscription
on the first and second iteration of the match, psychiatry is in a net
deficit position of 45 per year just to maintain the status quo. This crude
calculation does not account for subspecialties, the current global deficit,
and other factors, and therefore can be seen to be a gross underestimate
of the true deficit picture (3).
Most psychiatrists work in more than 1 clinical setting. Psychiatrists
see ill patients: 86% have an Axis I diagnosis, and 43% will have more
than 1 diagnosis. Between 13% and 22% of the patients have attempted suicide
at some point; 14% to 26% have been hospitalized (3).
The CPA has been and will continue to be concerned and involved. So are
the CMA (Task Force), provincial governments, provincial associations,
colleges, etc.
Une liste d’épicerie (a grocery list) concerning human resources (psychiatrists):
Numbers Distribution or maldistribution Admissions in psychiatric residency programs Distribution between specialties Distribution between specialties and family physicians How do we attract medical students to psychiatry? Survival of university department programs Le corps professoral (teachers) Changing demography: male–female Changing lifestyle of psychiatrists CPD: How do psychiatrist keep up with knowledge? Dissemination of information Clinical practice guidelines Development and quality criteria Dissemination and implementation criteria Monitoring results Remuneration Retirement
In summary, and to quote from “Human Resource Planning for Psychiatry in
Canada: A Background Paper” (3):
There is a shortage and maldistribution of psychiatrists in Canada. No area is exempt. The 1:8400 ratio can only be considered an historical reference point and
no longer reflects contemporary realities. The ratio should be replaced
and new algorithms developed reflecting diverse realities. The ratio will
not be the same in all instances. The failure to develop a common language with respect to full-time equivalents
and other human resource definitions has inhibited adequate planning. Population trends and burden of illness factors predict increasing demand. Increasing knowledge and diversity of subspecialty practice predicts greater
physician need. Alternative health care delivery models, like shared care, will alter roles,
increase surveillance, and have complex but yet-unknown impacts on human
resource requirements. As practice complexity increases and the responsibility and roles of psychiatrists
change, practice profiles will evolve, impacting population-based ratios. Practice profile changes suggest that retiring psychiatrists will need
to be replaced by a ratio greater than 1:1. Geographic maldistribution begins prior to residency and may be perpetuated
by the training experience. Health care reorganization has changed workload patterns, demands, and
complexity, resulting in increased psychiatric human resource need. Third-party opportunities are increasing and compete with public systems.
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