Opinion Article

First published in The Gazette (Montreal) on Wednesday, March 14, 2001

Psychiatry at the MUHC -- It's all about beds

by Dr. WARREN STEINER - psychiatrist

As a psychiatrist working in the Montreal General Hospital and a potential patient now in the middle of my baby-booming, mid-life years, I take a personal interest in the debate over the proposed size and number of beds in the new MUHC hospital.

I like the idea of having my soon-to-be statistically predicted major illness treated in a new hospital centre. When I need treatment, what could be better than being in Westmount (even if it is lower), lying in a private room with light streaming in the windows and a private bathroom. I would be comforted by the knowledge that my room air is filtered and safe, my high-tech tests are easily available and state-of-the-art medical care is waiting to treat my next crisis. The question is whether a new hospital will deliver on these promises, or will it become a centre where too few benefit, leaving most of us worse off than before.

As a psychiatrist, I am concerned with the position of my department within this new, high-tech, ultra-specialized centre. After medicine and surgery departments, psychiatry is the third-largest utilizer of beds in the McGill hospitals, but we use these beds in a very different way. While our hospital patients suffer from illnesses that are equally life-threatening (for example, the high mortality rate seen with an untreated major depression), they cannot be treated with a quick, high-tech solution. Medications and specific therapies take time to work, meaning patients are often in hospital up to three weeks before it is safe to discharge them to community-based treatment teams. The major advancements in medical and surgical equipment that allow for day-treatment and day-surgery are unlikely to be replicated in psychiatry.

This means that psychiatry will need a sufficient number of hospital beds to treat our patients effectively and, most importantly, with compassion. What we do not want to see is a replication of the current situation where patients can wait several days in the emergency room for a bed, or families must bear the burden of caring for a seriously ill relative at home. In the past five years, we have reorganized outpatient services to provide more direct community-based care. This has allowed a decrease in beds by up to 40 per cent in some centres, with continuing good care. However, the bottom line is that we still need sufficient hospital beds to treat our patients. This is the debate now being heard at the Montreal University Health Centre and aired in The Gazette's Comment page.

Currently, in the MUHC hospitals there are 1,124 beds in use. The planning groups are looking at models that will provide between 841 and 967 beds in the new hospital. While these reductions might be possible in medicine and surgery, it is unlikely that psychiatry would be able to provide good care with a proportionate 16- to 25-per-cent decrease in beds.

In adult psychiatry, the Montreal General Hospital and the Allen Memorial Institute (Royal Victoria Hospital) are responsible for providing services to a population of 235,000. In 1995, the health minister set ambitious targets for decreasing hospital beds for treatment of acute psychiatric illness. The norm was set at 25 acute beds per population of 100,000. With much hard work and staff sacrifice, that target was achieved: at the two hospitals we now function with 59 acute-care beds.

However, this leaves no room for other needs. Providing care for all of anglo Quebec, the drug-and-alcohol program struggles with just four beds for in-patient treatment. For all of anglophone Quebec, the child and adolescent psychiatry division manages with just 16 beds for treatment of serious illnesses such as life-threatening eating disorders. And for those with severe and chronic psychiatric illnesses who might never be able to live safely outside of a hospital setting, we at the MUHC can only provide 10 beds, rather than the minister's target of 35. The chronic-care hospitals, such as the Douglas, are struggling with their own bed cuts and have not been able to accept patient transfers from the acute-care MUHC hospitals for years.

So, while I look forward to eventually working at the new MUHC site, I worry that my patients and their families will pay a price. We are not able to give them what they need today, in our current state. In 2007, in a centre that has 16 to 25 per cent fewer beds, if psychiatry is given fewer beds than we have now, even more of a burden will fall on patients and their families.

Telling someone who needs a hospital bed that we have no place for him is not what this new project is all about. While some might say that high-tech is the future of medicine, we cannot forget that compassion is an integral part of what we do. And that means having the medical resources and bed numbers to heal our patients in a compassionate, human and effective way.

- Warren Steiner, MD, is director of outpatient and community psychiatry at Montreal General Hospital.