"My responsibility is toward the public as a whole"
Practising in an under-resourced area, Dr. Ian Slayter is working hard to see more patients and to encourage more doctors to work in rural communities
Deciding to become a doctor came at unlikely point in Dr. Ian Slayter’s life: while he was selling encyclopedias door-to-door.
“I loved books and found that I could connect with people over the value of reading and learning,” said Dr. Slayter, a psychiatrist in Antigonish, N.S.
Those candid conversations he had with people on their doorsteps got him thinking about how meaningful it is to have someone really listen. “I realized that I enjoyed talking and connecting with people, and that I could do that if I went into medicine.”
He studied family medicine at Dalhousie University. But after three years in family practice, he switched to study psychiatry. “I enjoyed working with people who had situational and emotional problems,” he said.
Over four decades, he’s lived and worked in many communities: from Halifax to rural Bridgewater and New Glasgow, N.S. to small towns in Maine and Pennsylvania. In 2003, he returned to Nova Scotia, taking an administrative job in Halifax.
In 2011, at age 60, he decided to resume practising clinical psychiatry in a rural community and moved to Antigonish.
“I like working in a small town because the health-care services tend to be more effective and congenial,” said Dr. Slayter. “You know the family doctors, the specialists. We have a great sense of community here.”
He works in the outpatient mental health clinic at St. Martha’s Regional Hospital. He also covers the ER two days a week, helps cover the inpatient unit, and works call one night a week (and one weekend in six).
“I like treating a variety of patients, mostly people with anxiety disorders, depression, bipolar disorder and psychotic conditions,” he said. “Most have a combination of psychiatric disorders and psychosocial problems that exacerbate each other. Looking at both aspects, and how they interact, makes psychiatry very exciting for me.”
Doing more with less
The psychiatry department at St. Martha’s is under-resourced, with three psychiatrists doing the work of four. “We get by,” Dr. Slayter said, “But we don’t get by when there’s just two of us, which has often been the case.”
Dr. Slayter and his colleagues do what they can despite the shortfall and the pressure they get from other areas to see more patients. “New Glasgow and Sydney have severe psychiatrist shortages,” Dr. Slayter said. “They’d like us to help, but if we do that, we’ll struggle to keep up with care for our own patients. And then there will be three towns with severe psychiatrist shortages.”
It’s not just his own patients Dr. Slayter worries about. “My responsibility is toward the public as a whole,” he said. “I also have to keep in mind the people who are waiting to be seen.”
Reducing his waitlist
To deal with that, he’s developed a consultation model that lets him see more patients. Contrary to what you might expect, it actually lets him spend more time with them. “I meet each patient for up to two hours,” he said. “The longer session gives me more time to listen and to help them better understand their problems.”
He sends about three out of four patients back to their family doctor – often with a referral to a psychotherapist – without needing to see them again. He follows the more complex patients. “This lets me see more patients than psychiatrists who follow their patients for a period of time.”
If a patient is referred with a psychiatric disorder that looks straightforward, they’ll receive care from a mental health social worker, nurse, or psychologist. Often, after discussing a case with a mental health worker, Dr. Slayter outlines his recommendations in a letter to the patient’s family physician without seeing the patient. He always takes calls from family doctors who need a quick consult.
He’s shrunk his waitlist from 15 months to six weeks using this strategy.
One of the patients who has benefited from this care model is Shannon Avery. She has bipolar disorder, which can cause extreme mood changes, from mania to depression, and can be difficult to treat. Dr. Slayter has followed her for several years.
“We always work through things together,” said Ms. Avery, who is from Larry’s River, in Guysborough County. “He didn’t just give me a prescription and walk away. It makes me feel like I’m part of things and that I have control over my situation.”
Rural areas overlooked
Recruiting and retaining psychiatrists in rural communities is difficult. “In Halifax, it would be a matter of months before we’d find someone,” said Dr. Slayter. “In Antigonish, it can take up to two years.”
Medical students and residents live and train in cities. “Most specialists want to stay in an urban, academic environment,” Dr. Slayter said. “They’re not attracted to rural practice settings.”
Rural areas have smaller hospitals with less equipment and a more intense call schedule. “That makes practising here less attractive,” said Dr. Slayter.
While there have been some improvements recently, being a rural specialist also means a smaller paycheque. “There should be an incentive for psychiatrists to work in rural areas because they’re working harder and it’s harder to recruit to these areas,” Dr. Slayter said.
Physicians recruit physicians
To end the psychiatrist shortage in Antigonish for good, Dr. Slayter says his team needs some buffer room. “We should aim to have our full complement of psychiatrists so we don’t fall behind when someone leaves. Once we slip below the number we need, it’s harder to recruit. No one wants to go to an under-resourced area.”
Physicians should also be in charge of recruiting physicians, he said. “I’ve been recruited a number of times. Physicians being recruited like to talk to other physicians. It helps the physician being recruited to better understand the position, the opportunities, the hospital and the community.”
Dr. Slayter enjoys living and working in a rural community, and knows that other physicians will too. “I finish any conversation I have with physicians from elsewhere by asking if they’d like to consider moving to Antigonish,” he laughed. “I’ve learned how to deal with the pressures and to focus on the opportunities.”