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Reform of the health and mental health care systems has been a significant Canadian concern for over 2 decades. Epidemiologic data (such as the Mental Health Supplement to the Ontario Health Survey) have consistently shown a mismatch between those apparently needing mental health services and those using them (1–5), but these provide only part of the picture. A major gap has been the lack of data from the provider perspective about who uses services and how they are used. In 1996, the Canadian Psychiatric Association (CPA) Executive commissioned a practice profile survey. Intended to update and expand information gathered in 2 previous CPA surveys (6,7), the practice profile had 4 key goals:
The CPA contracted with an external research team, including the 2 senior authors, to design the questionnaire, assist the CPA in project administration, and analyse and report the results. The rationale for choosing an external party was that this would increase the likelihood that the instrument and methodology would be unbiased and scientifically sound and, therefore, that the results would be more credible to audiences outside the profession. The result was the 1997 practice profile survey (PPS). This and the following article (8) are the first reports from the PPS. Survey methodology, questionnaire content, and a discussion of the sampling frame and response rates are presented here, along with a general description of the sample. More detailed results about clinical activities and patient profiles are covered in the companion report. Survey MethodologyIn addition to the key goals of the practice profile, the research team had 3 objectives: 1) create a questionnaire that was both comprehensive and easy to administer; 2) maximize credibility by ensuring that results were as unbiased as possible and that the response rate was high; and 3) maintain confidentiality. The procedures designed to accomplish each objective are described in the next 3 sections. Developing the Questionnaire This draft, along with the overall goals of the survey and possible methodologies, were discussed with the CPA Executive. In addition, the draft was reviewed by a focus group facilitated by a third-party firm that was independent of both the research team and the CPA. This group consisted of practising psychiatrists representing the various psychiatric subspecialties and practice settings, who were invited by the CPA to participate. Based on the feedback from the CPA Executive and the focus group, the research team revised the questionnaire and tested it on approximately 50 psychiatrists from across Canada. These pilot-study participants were also asked to complete an extensive evaluation form containing both structured and unstructured questions focusing on survey design as well as on overall content, specific questions, and visual layout of the questionnaire. Feedback from the pilot study was, again, generally supportive but also suggested important missing areas in the questionnaire. These included questions covering on-call and commuting time and greater detail on type of practice (for example, forensic and geriatric). The final questionnaire was a self-administered, mail-in instrument available in both French and English. It consisted of 6 pages and gathered general information about a specified 24-hour day. Detailed information was also elicited about 1 random hour (described below) within that day. Most questions required a checkmark for response, with only a few items needing written answers. Maximizing Credibility Because credibility was so heavily dependent on the survey’s response rate, both the CPA and the research team paid a great deal of attention to encouraging participation. Past experience with the 2 previous CPA surveys, reports from the literature, and suggestions from the focus group led to several strategies: 1. The survey was widely publicized to the CPA membership through the Association’s newsletter and through flyers mailed out for posting. Non-CPA members interested in the survey were encouraged to add their name and address to the mailing lists. Letters were written from the CPA to other psychiatric professional organizations, provincial associations, and department and division heads to inform them of the survey’s purpose and to enlist their support. 2. Based on focus group feedback, the cover letter was strongly worded to emphasize the fact that the CPA would be using the information to advocate on behalf of the profession with government and planning audiences. 3. While the original plan included only 1 designated day, it was felt that a backup day for nonresponders would significantly improve the response rate without seriously compromising validity. These dates (May 28 and June 26, 1997) were chosen to minimize conflict with professional conferences and summer holidays. 4. Feedback from the focus and pilot-study groups affirmed the need for a clearly written glossary of terms and suggested that including a list of DSM-IV codes would facilitate answering the questionnaire and consequently improve the response rate. 5. Based on anecdotal evidence from the pilot study, a toll-free help line was established to answer questions that participants might have about completing the survey. 6. Finally, a reminder letter was sent in early July to remind participants to return any forms that had been completed but not mailed. Confidentiality Questionnaire Content Descriptive information gathered from PPS respondents included age, sex, province, CPA membership status (yes or no), and occupational status (for example, full-time or retired). General questions on their practice covered the number of hours worked in an average week and the percentage of their total practice devoted to different types of psychiatry (child, adult, psychogeriatrics, and forensics) and spent in different practice settings (agency, teaching or nonteaching hospitals, and private office). They also indicated the percentage of professional time spent in small (< 10 000 population), medium (10 000 to 100 000), and large communities (> 100 000). Respondents unable to provide detailed information about the specified day were asked the main reason why (for example, on holiday or illness). Questions covering the 24-hour designated day included the total number of on-call and travel hours and the number of direct care patients seen that day. In addition, for each of the 24 hours, respondents were asked to indicate their main activity, source of revenue, and activity setting. Main activity was defined as the activity consuming the most time during the hour and included the categories of personal, administrative, teaching, research, and clinical. Individuals choosing the clinical category were asked to specify the main type of clinical activity (record maintenance, supervision, telephone consultation, or direct or indirect patient care). Revenue sources included fee-for-service, sessional, salary, other, and not paid. Activity settings included private office, hospital inpatient, hospital outpatient, community agencies or schools, and other. Respondents were then asked to provide details about the amount of time spent on each type of activity during a randomly chosen hour within that day. For patient care and telephone consultation, further details were elicited (for example, type of direct or indirect care, or party involved in consultation). Patient information was gathered for a maximum of 2 specified patients: one receiving care during the random hour and the patient identified by the physician as the most seriously ill receiving clinical services that day. The individuals to be described were selected as follows: the first direct patient contact; if none, the first subject of a clinical consultation; if none, the first supervised contact; if none, the first patient receiving any other clinical service. Patient-related questions covered descriptive variables, diagnostic profile, level of functioning, risk of harm to self and others, disposition, and other services needed. Descriptive variables included patients’ age, sex, and marital status as well as their referral source and whether they were new patients. Diagnostic questions covered Axes I, II, and III (allowing multiple entries for each). Level of functioning items were adapted from the BASIS-32 (9). Patients were rated using a 5-point scale (ranging from “no difficulty” to “unable to function”) in each of 5 domains—work, school, household or family responsibilities, leisure, and interpersonal relationships. The PPS respondents were also asked whether patients had actually attempted suicide or physically harmed themselves or others in the previous 6 months and evaluated the current risk of such behaviour. Finally, respondents indicated each patient’s disposition (including referral information, if applicable) as well as whether other services, such as housing or case management, were needed and were locally available.
Sampling Frame and Response Rates There were 1651 questionnaires returned—a response rate of 45.5%—of which slightly more than 17% were completed in French. A breakdown of response rates by region, sex, age, and CPA membership status (Table 1) shows significant differences by region, sex, age groups, and member status. The lowest rates occurred for Quebec (36.9%) and for nonmembers (24.8%), respectively. Women were more likely to respond than men, and the proportion of responders decreased from nearly 90% to 31% as a function of age. Of the 1651 returned questionnaires, 76 (4.6%) were completed by nonpsychiatrist physicians, and 5 (0.3%) could not be analyzed because of missing data. These 2 groups were excluded from further analysis. The remaining 1570 surveys were checked for inconsistencies to evaluate the validity of each questionnaire section. Nearly one-quarter (n = 388) were categorized as providing only valid background and descriptive information (labelled “cover page only”). This was a legitimate response option for those on holiday, ill, or otherwise unable to complete the questionnaire (93.3% of this subgroup). A small number (n = 26) were judged to have completed the survey for the wrong day (either because their completed questionnaires were received prior to the designated day or because they indicated a date other than the one assigned). In addition, 41 surveys providing information for the correct day but not the correct random hour were labelled as “incorrect hour.” Table 2 shows the questionnaire completion patterns for the 1570 respondents by region, sex, age, and CPA membership status. Regional rates for “cover page only” ranged from a high of 29.2% in Quebec to a low of 21.1% in Ontario, with the national average being 24.7% (c2 = 14.8, df 4, P < 0.01). Differences between CPA members and nonmembers were not significant (c2 = 1.59, df 1, ns). While there was some variation in the distribution of “incorrect hour,” the overall total was small (n = 41).
For the sample characteristics reported here, responses from the full set of 1570 surveys will be used. The companion report will be based on different numbers depending on whether the findings are for the designated day (n = 1182; that is, 1570 surveys minus “cover page only”) or the random hour (n = 1141). Sample CharacteristicsRegional, sex, and age characteristics of the PPS respondents are shown in Table 3. Nearly one-half of the sample practise psychiatry in Ontario, and two-thirds are men. Fairly even proportions of the sample fall into the 3 middle-age groups (average age 48.9 years; range 28 to 79). Sample distributions roughly approximate those of the mailing list population (Table 1), with the most notable differences occurring for psychiatrists living in Quebec (21.6% vs 25.7%) and those in the youngest and oldest age groups. Respondents from British Columbia and the Prairies and female psychiatrists are slightly overrepresented as are those aged 45 to 54 years.
Most of the PPS respondents worked full-time and in large (population > 100 000) urban areas (Table 4). Nearly 82% concentrated on 1 type of psychiatry, with most (64.5%) devoting 80% or more of their practice to adult psychiatry. Roughly 18% (not shown) reported a mixed practice covering 2 or more psychiatric specialties. Community size was defined as large urban (> 100 000 people), small urban (10 000 to 100 000 people), and rural (< 10 000 people). We examined this variable in 2 ways. First, we examined the numbers of psychiatrists who spent 100% of their time in each of the community-size locations. Second, we examined the number of psychiatrists who identified themselves as working at least 80% (4 days weekly) in a given setting. The results from these 2 approaches were similar (Table 4). Most psychiatrists practice in large urban areas (72.8%), with much smaller numbers in small urban (10.6%) and rural (2.1%) areas. A substantial minority of psychiatrists work in more than 1 size of community, working at times in larger and at other times in smaller areas. We examined domain of practice (adult, child, geriatric, and forensic) in a fashion similar to community size—that is, we first examined those psychiatrists who identified themselves as practicing 100% in a given domain and then classified psychiatrists into a given domain if they worked at least 80% in that domain. Most psychiatrists identify themselves as having a mixed range of practice (56%), with fewer specializing in 1 age group or special problem. Only 4.9% of psychiatrists practise exclusively child psychiatry; 1.9%, exclusively geriatric psychiatry; and 0.6%, exclusively forensic psychiatry. Slightly more than one-third (36.5%) of psychiatrists practise exclusively adult psychiatry. Redefining these data to focus on main area of practice (80% of time spent) increases the number of adult psychiatrists to 66%, child psychiatrists to 10.5%, geriatric psychiatrists to 4.3%, and forensic psychiatrists to 2.0%. Psychiatrists work in various settings. Most work in more than one setting (57%), while smaller numbers work exclusively in hospitals (24.4%), private offices (16.7%), or community agencies (1.0%). When redefined to identify main setting of practice (80% of time spent), 37.7% of psychiatrists work mainly in hospitals, 36.7% work in a private office, and 2.3% work in agencies. The remaining 29.7% do not spend 80% of their time in any single setting.
Occupational Status and Hours of Work One-third of the sample reported being on call during the survey day. On average, the number of on-call hours was 5.1, one-third of these involving a clinical activity. For those actually on call, the duration of on call was 15.2 hours, with 3.9 hours spent engaged in clinical activities. DiscussionThe major concern in interpreting PPS results is the impact of the 45% response rate. This figure is at the low end of the 45% to 78% range reported for physician surveys, although the rate among CPA members is comparable with the American Psychiatric Association’s survey of its members (10,11). The nonresponder data suggest potential biases, particularly in terms of psychiatrists practising in Quebec, non-CPA members, and the youngest and oldest members of the profession. The strengths of the study relate to the use of a carefully designed instrument that can allow for the ongoing assessment of the profession to assess trends over time in the practice of psychiatry. Should the survey be repeated, participation rates may increase over time. Data relating to the demographics of the profession reveal certain trends. The proportion of psychiatrists across the 3 age groups (35 to 44, 45 to 54, and 55 to 64 years) is larger for the 2 younger cohorts, which does not suggest that the profession is facing a manpower problem related to the imminent retirement of a large senior cohort, as is the case in some other specialties. However, the youngest cohort is the same size as the middle cohort, which is likely to result in a smaller number of practitioners as deaths and premature retirements affect the size of this youngest cohort. As well, the number of female practitioners is nearly 50% in the youngest cohort, and at present our best estimate is that female practitioners are working about 80% of the hours of a male practitioner—thus reducing the effective size of this cohort by 10%. While it may be that younger women alter the nature of their practice as they get older (that is, work more hours as their children grow up), it may also be that we are observing a cohort effect in practice pattern that will result in many fewer full-time equivalents available to provide clinical services over the next 20 years. Further surveys to follow our cohort of younger female psychiatrists over time will help to answer this pressing question. Another important observation is the relatively small number of practitioners who spend time seeing the very young (a recognized underserviced group) and the very old—one of the fastest-growing groups in our society. If the pool of psychiatrists is effectively shrinking, then these groups will continue to experience relative underservicing. Location of practice information suggests that the solo, office-only practitioner accounts for about one-third of psychiatrists. Nearly 40% of the profession spend most of their time in a hospital, with 30% spending at least 20% of their time in a nonoffice environment. It will be interesting to examine these data further to see whether there are discernable differences between various regions in these patterns. The importance of data such as these is multifold. First, these data can be a source of reliable information to the profession as it attempts to make representations to various stakeholders about issues relevant to psychiatric practice. Data collected in a scientifically sound manner cannot help but be of interest to the stakeholders themselves, who often have difficulty in obtaining reliable data. Because the situation is fluid, ongoing ascertainment of the state of the profession is critical and deserves careful consideration. Many of the most important questions raised by this data set can only be answered by repeated surveying. Funding and SupportThe CPA practice profile survey was funded by a grant from the Canadian Psychiatric Association. All opinions expressed herein are those of the authors and may or may not coincide with those of the granting agency. AcknowledgementsWe acknowledge Stephanie Ali for technical assistance. We also thank the Canadian Psychiatric Association for providing the nonresponder data presented in this paper. References1. Lin E, Goering P, Offord DR, Campbell D, Boyle MH. The use of mental health services in Ontario: epidemiologic findings. Can J Psychiatry 1996;41:572–7. 2. Lin E, Goering PN, Lesage A, Streiner DL. Epidemiologic assessment of overmet need in mental health care. Social Psychiatry Psychiatr Epidemiol 1997;32:355–62. 3. Shapiro S, Skinner EA, Kessler LG, von Korff M., German PS, Tischler GL. Utilization of health and mental health services: three epidemiologic catchment area sites. Arch Gen Psychiatry 1984;41:971–82. 4. Bland RC, Newman SC, Orn H. Health care utilization for emotional problems: results from a community survey. Can J Psychiatry 1990;35:397–400. 5. Andrews G, Henderson S. Unmet need in psychiatry: problems, resources, responses. Melbourne (Australia): Cambridge University Press; 2000. 6. Bebchuk W. 1993 human resource survey. Internal report. Ottawa (ON): Canadian Psychiatric Association; 1994 7. Anderson K, Catterson A, Gaudet M, Gautam M, Kerr PJ, Pecher M, Waiser D. The contribution of private psychiatrists to the delivery of psychiatric care. Internal report. Ottawa (ON): Canadian Psychiatric Association; 1993. 8. Woodside DB, Lin E. The Canadian Psychiatric Association practice profile survey: II. General description of results. Can J Psychiatry 2003;48(4):244–9. 9. Eisen SV, Wilcox M, Leff HS, Schaefer E, Culhane MA. Assessing behavioural health outcomes in outpatient programs: reliability and validity of the BASIS-32. J Behav Health Services Res 1999;26:5–17. 10. Zarin DA, Pincus HA, Peterson BD, West JC, Suarez AP, Marcus SC, McIntyre JS. Characterizing psychiatry with findings from the 1996 national survey of psychiatric practice. Am J Psychiatry 1998;155:397–404. 11. Blanco C, Carvalho C, Olfson M, Finnerty M, Pincus HA. Practice patterns of international and US medical graduate psychiatrists. Am J Psychiatry 1999;156:445–50 Author(s)Manuscript received June 2002, revised, and accepted September 2002. Previously presented at the Ontario Psychiatric Association; January 22, 1998; Toronto (ON) and at the American Psychiatric Association; June 1 and 3, 1998; Toronto (ON). 1. Research Scientist, Health Systems Research and Consulting Unit, Clarke Site, Centre for Addiction and Mental Health; Assistant Professor, Department of Psychiatry, University of Toronto; Adjunct Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ontario. 2. Director, Eating Disorders Clinic, Toronto General Hospital; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario. 3. Research Associate, Arthur Sommer Rotenburg Chair in Suicide Studies, St Michael’s Hospital; Assistant Professor, Department of Psychiatry, Toronto, Ontario. Address for correspondence: Elizabeth Lin, PhD, Health Systems Research and Consulting Unit, Clarke Site, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8 e-mail: elizabeth_lin @camh.net
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