Rural / Frontier Psychiatry

[CMartel3]

I'd be curious to see if some here might have some knowlege about rural psychiatry care, particularly in areas of the mountain west or praire states (Wyoming, the Dakotas, Montana, Idaho, parts of Colorado). These states all appear to have massive shortages of psychiatrists, and I've done searches that show that many of these locales have preposterously low numbers of child & adolescents psychiatrists (which I plan to specialize in). This is in part due to the rural nature of these states and likely also due to many not having med schools/residency programs.

Even in some of the "larger cities" (read: 35,000 - 60,000), you have very few practicing psychiatrists. Some of them have none.

What are these odds in these areas of being able to run a practice in a very small town: say 10,000 people? In some of these areas, I'd be the only provider around for hundreds of miles. I'm not quite sure of the logistics / practicality of all of this, as so few do it.

Potential downsides:

- High risks of no-shows given weather and distance
- Few opportunities to rely on colleagues
- Perhaps dealing with populations that have little access to healthcare and lower paying jobs
- Your patients knowing one another
- Higher rural risks in your patients (e.g. access to gun)
- Being on-call all the time

Advantages
- The ability to set-up your own practice as you see fit
- Filling a vast need
The potential to set up a fee structure for missed appointments, etc...
- Potential for telepsychiatry
- Availability of outdoor recreation and owning my own land
- Possibly minimizing overhead, though if I'm on my own, less so
- Potential for higher income with lower costs of living.

I guess there's always the question of whether you'd form your own private practice or join a network of providers. I'm just not sure I even know where to look about the practical matters of setting up such a practice at this point, and it's not exactly a cornerstone of focus at all in my residency program.

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[whopper]

I can't think of anyone really giving any organized type (e.g. publication) of advice on this. Heck, I don't see a lot of printed advice on things a lot of doctors, much less psychiatrists typically encounter in specific clinical scenarios such as the frequent malingerer in the ER claiming he'll kill himself if he doesn't get a sandwich, and within minutes is groping a nurse's gluteus maximus.

A factor I've noticed in practicing in a smaller community (and I haven't worked in small rural areas) is if you see someone as a patient, since the community is smaller, you're not as camouflaged by other people. E.g. you're more likely to see them in the community such as a church, mall, popular event, etc.

Some stereotypes I've seen are turning out to be true. Where I practice, I get patients from rural areas of Northern Kentucky. Some of those patients are having sex with relatives, and the phenomenon is not out of the ordinary in some localities, and some subcultures in the NKY area.

But getting to the point, lots of the dynamics you're going to want to learn, you're going to have a hard time learning.

I mentioned before that I don't think residents, even if legally allowable (and I question if it is legal) should be opening a private practice. Likewise, I'm going to say that if you open your own business in a rural area, you should have some experience on top of residency training.

I'd recommend working in an inpatient hospital with at least a few hours on the side doing clinical outpatient for 1-2 years before trying an venture completely on your own or as you being the boss.

I've noticed several things I learned not taught in residency concerning business dynamics by working in someone else's private practice.

I do think someone could start a PP in a rural community and do well, but that person will make mistakes, some of which may not be corrected for years (if at all) because of lack of experience and lack of peer-review. Those mistakes include possible tens of thousands of dollars in loss of revenue and bad patient outcomes.

Not the same thing exactly, but the parallels about the same. It's about a wannabe who made the bold move to start his own business but didn't quite know what he was really getting into.

http://www.youtube.com/watch?v=1X6u7sfu0N0

 

[Daedra22]

I can't speak as a physician of any kind yet, but as someone who hails from a rural area, I can attest that it will be a big adjustment if you aren't used to living in a rural area. It might be kind of difficult to establish a decent practice in a town as small as you're imagining, in part because of a public stigma towards psychiatry. This is anecdotal of course, but women in my hometown avoid going to the Planned Parenthood nurse who visits once per month because they don't want anyone to see their car in the parking lot (nurse only provides birth control, but birth control is kind of taboo in this hyper-religiously conservative area). It's possible that a mental health office would have this kind of problem. In a small town, people worry about things that you might not think of.

 

[Chimed]

Whenever I hear about "Frontier Psychiatry", this come to mind:

http://www.youtube.com/watch?v=qLrnkK2YEcE

(Sorry to hijack your important questions, but I couldn't help myself 😀)

 

[dl2dp2]

I think a good alternative would be the burgeoning field of telepsychiatry. I'm dreaming of having part of my career doing telepsychiatry on weekends with rural residents who has no contact with anyone else for months or for prisoners who live in the middle of nowhere. Fascinating psychopathology without the problems associated with face-to-face interaction.

Is this viable?

 

[nitemagi]

I think a good alternative would be the burgeoning field of telepsychiatry. I'm dreaming of having part of my career doing telepsychiatry on weekends with rural residents who has no contact with anyone else for months or for prisoners who live in the middle of nowhere. Fascinating psychopathology without the problems associated with face-to-face interaction.

Is this viable?

Telepsych is definitely growing. Most people don't recognize you have all the liability in telepsych that you would if you saw them in person. Which means if they need other interventions (medical, involuntary hold), you're still on the hook as the assessing doctor even if you're thousands of miles away. And if you plan to do it for out of state technically you need to be licensed in the state the patient is in. Those're the biggest concerns I've heard from colleagues and my malpractice company.