Documentos

It was clear throughout this thesis that family physicians are not well trained in

conducting psychotherapy and this is supported in the literature.(13)(14)(15)(7)(12) In the qualitative study, most family physicians professed to practicing psychotherapy but

could not describe in detail what they did. The training they received was both heterogeneous and did not include any formal psychotherapy teaching in their

undergraduate and post graduate medical training. The skills they used were gained based on heuristic principles. However, paradoxically, about 50% of family physicians were satisfied with their training. Alternatively, we saw in chapter 2 the robust training requirements by other professional bodies before their members can practice

psychotherapy. Psychologists require a doctoral degree and many hours of supervised training. The training requirement for social workers, counselors and psychotherapists is equally robust. Compared to the above-mentioned professionals, family physicians’ training is certainly very limited. However, family physicians are permitted to provide psychotherapy as per the College of Physicians and Surgeons of Ontario.

The criteria to practice psychotherapy in Ontario and to use the title of psychotherapist, is being set by the nascent CRPO. This College came into formal existence by the

proclamation of the Psychotherapy Act of 2007, on April 1 2015. (16) It is the official body that will regulate all professionals who call themselves psychotherapists. The premise for the genesis of this college is to prevent harm to patients by therapists who are not well trained. Physicians may or may not be required to be registered with this

College; however, they will not be able to practice psychotherapy unless they meet the criteria set by this College. The optics of how physicians in general, and family

physicians in particular, will fit into this registration process is yet to be determined.

Some pertinent questions arise from this paradoxical situation. First, should family physicians be registered with the CRPO? If so, they will require a certain level of training to be able to fulfill the requirements for professional therapists. Is the time and effort

needed for such robust training necessary when we already have trained psychotherapists available to provide good care to patients? If it is not, then should family physicians be doing psychotherapy at all? Perhaps, they should be providing alternate forms of

psychotherapy which could be tailored for application in family medicine, like attentive listening, Motivational Interviewing or psychoeducation.

Data from the interviews with family physicians shows that most participants expressed a need and desire for more training in psychotherapeutic skills. The General Physicians Psychotherapy Association in Canada has come up with guidelines in 2010 for the practice of psychotherapy by physicians who are not psychiatrists. Most of their

recommendations are in line with what the family physicians wished for in the qualitative study, i.e. more formal training in psychotherapy throughout the continuum of

undergraduate, graduate and continuing medical education.(17) These guidelines also lay down other general rules for the conduct of therapy and are a very timely document that needs to be implemented throughout family medicine training. Competency in diagnosing and managing mental health in general, and psychotherapy skills in particular, is much needed by family physicians. The prevalence of mental illness is rising and family physicians need to be competent in diagnosing and managing mental illness to a certain extent, since they are the first point of contact. They can prevent mental illness from worsening and become a catalyst for change in patients by engaging them in therapy, connecting them with the right resources and empowering them.

The second question that arises is whether psychotherapy by family physicians is or should be different? Whether there should be a focus on change-theory-based therapies, such as Motivational Interviewing. The nature of psychotherapy in primary care has been

debated in the literature in the last decade and “brief psychotherapies” in the treatment of mental health have become popular.(18) They are defined as therapy that typically end by 25 sessions.(19) Although there is substantial literature available on brief psychotherapies in primary care, the majority of it is conducted by psychologists and/or psychiatrists. Hence the effectiveness of these therapies with family physicians as the psychotherapist is unknown. Alexander et al. systematically reviewed studies on brief psychotherapies tailored for primary care and suggest that they are effective in the treatment of multiple mental illnesses.(18)(20)(21). Thus, implementation of these techniques is still

challenging, as family physicians will need to be trained in them and evaluated for their effectiveness as psychotherapists.

The third issue centers around remuneration. Despite their limited training in

psychotherapy, family physicians can provide insured psychotherapeutic services for patients through the OHIP, while many trained psychotherapists are not covered. In the past there have been very limited insured psychotherapies in Ontario. However, with newer models of care like the Family Health Teams, professional psychotherapists can be part of the team and as such, can be available to provide patients with psychotherapeutic services.(22) This, however, has large funding implications; the Ontario government has to provide extra funding to cover psychotherapist fees within the Family Health Teams which increase health care spending. Even though the long term benefits of having a strong primary care have clearly been established in the literature(4), there is currently a moratorium on implementing new Family Health Teams in Ontario in an effort to curtail health care spending. Hence, there are many family physicians who do not practice within Family Health Teams and do not have access to trained psychotherapists. They

still have to provide mental health care to their patients themselves or refer to hospital clinics, other agencies or private services. For a patient who does not have the financial means to afford psychotherapy in the community, his or her family physician may be the only person to provide them with care.

5.2.3

A strong case for the provision of psychotherapy in primary