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Autumn 2007 | Vol 11 No 1

Focus

Opening the lines of communication

Mentoring network supports family physicians

By Anne Ptasznik

“Dr. Cleo Mavriplis, an Ottawa family physician, was overwhelmed and exhausted trying to provide care for her patients with mental illness. She had trained at the Montreal Jewish General Hospital, where there was a focus on psychosocial issues, but on her own, she says, “I’d be trying to help patients, but I didn’t really know where to go, especially when resources have become so limited. You’d try to call psychiatrists to get some advice over the phone but they were very difficult to reach.” Mavriplis would refer patients in crisis to the hospital emergency department, but in less urgent situations, it could take months to obtain a psychiatric consultation or ongoing care for her patients.

Family physicians are often the first point of contact for people with mental health issues. According to the 1997 Ontario Health Survey, between 30 and 40 per cent of family practice patients have a diagnosable mental health condition. In Ontario, 35 per cent of people with mental illness are treated by their family physicians only. Yet studies have found that family physicians report problems with accessing timely psychiatric consultation, poor communication with psychiatrists and a lack of support and respect for their role. But this is slowly changing, as psychiatrists and family physicians look at ways to work more closely together.

“It’s all about the relationship,” says Lena Salach, former director of the Collaborative Mental Health Care Network (CMHCN) developed by the Ontario College of Family Physicians. The CMHCN, established in 2001, is a mentoring program that links family physicians with psychiatrist and general practitioner psychotherapist mentors in a collaborative relationship to provide family physicians with the help they need in providing care for people with mental health and substance use problems. There are currently 65 mentors and 440 mentees in 23 regional mentoring groups throughout the province and 10 groups based on common clinical interests.

The program takes a three-pronged approach: one-on-one mentoring, largely through e-mails and telephone contact; small-group learning sessions and an annual conference, which this year focused on therapeutic techniques. “The primary purpose of the group sessions and conference is to foster that relationship,” says Salach. “We’ve also seen that the more small-group sessions we’ve had and after the annual conference, use of mentors increases significantly.”

Mavriplis joined the program four years ago. “It definitely helps to be in the small group because you get to know everyone and develop a sense of comfort. In the beginning, nobody knows one another and you may be unsure about how much you should reveal about what you’re thinking.” She says any discomfort is quickly dissipated, thanks largely to her two psychiatrist mentors, Dr. Spencer Tighe, with Ottawa’s Pinecrest Queensway Health and Community Services ACT team, and Dr. Helen Spenser, a child and adolescent psychiatrist with the Children’s Hospital of Eastern Ontario in Ottawa.

Tighe, who joined the CMHCN around the same time as Mavriplis, says their group is unique because while most of the other groups have one GP psychotherapist and one psychiatrist mentor, he was accepted to work with Spenser because of their different areas of expertise. Initially, most questions in their small group of 20 were about diagnosing and treating complex mental illnesses, including bipolar disorder and psychotic disorders like schizophrenia because physicians felt they could provide care for patients with straightforward mood disorders, but lacked training with persistent and severe mental illness.

Tighe has been committed to working with this population from his residency days at the former Queen Street Mental Health Centre’s Archway Clinic. The CMHCN allows him to support physicians who often see patients at the onset of illness and who also provide care for patients’ multiple medical issues. “I can help with a whole group of people I would never be able to see if the mentor program didn’t exist. I don’t see these people personally but I can assist in their care from a distance through the network.”

Mavriplis says she has benefited from Tighe’s knowledge of pharmacology. Now, instead of having to wait for a few months for a referral, she can start giving the patient the right medication on her own. “I have more confidence and knowledge in dealing with medications, so it’s quicker access to the right treatment, the appropriate treatment,” she says. Also, as mentees are free to contact any of the mentors, Mavriplis was able to get a quick answer from a mentor with an interest in pregnancy and antidepressants for a patient who was on Paxil and had just become pregnant.

The one challenge that Mavriplis faced was writing out her concerns about a patient. “That is a bit of a barrier at the beginning, getting used to having to write out the case. It takes some time to do, but once you do it, it’s quite helpful.”

Tighe says that he and Spenser e-mail mentees’ case vignettes to all mentees in their group as a teaching opportunity. He likes to go beyond what is available in a textbook or a website and provide insight into how he thinks through a diagnosis and treatment. He says that the mentees also provide their colleagues with good suggestions. “They’re using up all my tricks,” he jokes. Another reason for documentation is that both mentor and mentee have some legal liability, but Salach says this has never been an issue.

Salach says that mentors are expected to respond to mentee questions within 24 to 48 hours, although when relationships become established, mentors sometimes respond more quickly. She stresses that the network is not an emergency or referral service, which is critical for psychiatrists who are already in demand. Salach says the psychiatrists are often doing this work informally and the CMHCN formalizes the relationship. Also, they enjoy doing it, want to work with family physicians and want to teach.

The commitment of the mentors shows in an evaluation report recently completed after the CMHCN’s sixth year of operation. Based on pre- and post-evaluation questionnaires and mentor logs, the research shows that mentees feel they have quick access to quick clinical help and have greater confidence in treating patients with mental illness and addiction, including complex conditions. Overall, mentees were satisfied with the mentors, whom they found very easy to access. As well, the small-group case-based sessions expanded their knowledge. While Salach says the program currently lacks the resources to research any reduction in visits to emergency wards and hospitals, anecdotally, physicians report that, feeling supported, they now rely less on formal consults and more on this informal mentoring.

One surprising finding is that mentees consult with their psychiatrist mentors on average just over four times per year. Salach says some mentees contact their mentors more often, but even those who contact them less often are happy knowing that immediate access is available. But Salach admits that this remains one of the challenges the network faces: “Physicians are trained to know everything, and they may not feel comfortable asking someone they don’t know a question.” She frequently advises mentors to call and e-mail their mentees regularly when they join the program. The network has also added adjunct social work mentors and distributed a resource list to address the need for better access to community resources.

Salach says the network has begun to focus on psychiatry and family medicine residents in the belief that if they work together during training, they will continue to do so when they start to practise. Last year, the CMHCN piloted a program at the University Health Network’s Toronto Western Hospital. This year, it is being rolled out across all University of Toronto teaching sites.

Salach, Mavriplis and Tighe agree that it would be good to have more family physicians involved with the network. One challenge is funding. Program expenses include mentor honorariums, program support, administration and the small-group sessions. The Ministry of Health and Long-Term Care has provided the program with base funding for five years – the program is currently in its fourth year of that funding – but it is limited for expenses including mentor honorariums, program support and the small-group sessions. So while the program accepts all family physicians who apply, it has not actively promoted itself.

Mavriplis says that the ministry has gotten its money’s worth with her participation. She has been willing to provide care for patients with mental illness and not use referrals to psychiatrists as much because she knows she will get the help she needs. “I feel much more ready to take on patients with psychiatric problems because I know that I can ask a question if I need to and that the response is fairly quick,” she says. “It’s difficult when you’re stuck trying to refer to some psychiatrist who says ‘I can’t see the patient before two months.’ Having the network helps my confidence and willingness to take on more patients like that and follow them, and feel like I’m actually doing something positive.”

For more information about the CMHCN, visit the Ontario College of Family Physicians website at www.ocfp.on.ca/english/ocfp/cme/cmhcn
or call (416) 867-9646.