Rural Psychiatry

[Sneezing]

Can anyone comment on rural psychiatry? Anything really. Ranging from practice size, insurance issues, frequency of after hour calls in a solo practice, community support, pressure to incorporate child, how removed from a central hub you must be for patients to not travel to the city, etc... Any thing on the topic is welcome.

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[whopper]

I don't know much other from what I hear from friends in rural areas and what I read.

Rural areas tend to have scarce sources of psychiatrists. Psychiatrists tend to want to be in large metropolitan areas. This can lead to a psychiatrist being the only one in several counties that in effect can lead to tremendous amounts of pay. Being one of only a few also increases the opportunity for you to do something big in terms of developing a practice and a local reputation.

While that may be appealing to a psychiatrist, also expect much higher levels of responsibility and a decreased opportunity to work and confer with colleagues that can assist you in several ways. If you're the only psychiatrist in a large area, it's tougher to refer out to others, you'll not be able to take as many vacations as you'd like because you do so, you might be screwing several of your patients who have no one else to turn to, and you may have a lack of colleagues you can ask for advice on difficult cases.

You'll also notice different local variations in culture. Where I work now (southern Ohio), it's not out of the ordinary to get someone having sex with his sister, aunt, daughter, etc. Not bathing, coming in, and wearing some type of Rebel flag or WWE t-shirt, and then mentioning having sex with your sister.... Yep, it's weird and not something I experienced in NJ. I don't work in a rural area, but just 20 miles down the road--it's very rural. I'm talking Dukes of Hazard type rural and yes Hazard isn't too far from where I work. In Iowa, there's a big amphetamine problem. Lots of more people have guns and this has become a problematic issue when discharging depressed patients.

I only had one patient so far commit suicide within a date of proximity where I felt it was foresee-ably preventable.. I asked her family if they owned any guns and they told me no, but they in reality had dozens of guns in their home and she blew her head off a few months after her discharge. They lied to me because they wanted her home faster. Yeah, I guess I'm not liable when the family didn't tell me the truth, but had I known the truth, I wouldn't have discharged her because I saw her as a strong long-term risk, but not an immediate one.

 

[Chimed]

I only had one patient so far commit suicide within a date of proximity where I felt it was foresee-ably preventable.. I asked her family if they owned any guns and they told me no, but they in reality had dozens of guns in their home and she blew her head off a few months after her discharge. They lied to me because they wanted her home faster. Yeah, I guess I'm not liable when the family didn't tell me the truth, but had I known the truth, I wouldn't have discharged her because I saw her as a strong long-term risk, but not an immediate one.

As an aside to the original post....You could have had the family secure the guns if you had known; but, obviously there is no liability on you. Are you sure keeping her inpatient would have made a difference? A patient that is that determined to kill themselves is going to do it no matter what. We can only do our best to provide the best treatment and decrease any modifiable risk factors. But I think this increasing pressure on psychiatrist to be the behavior police and expecting us to "predict" suicide is getting out of control.

 

[whopper]

Are you sure keeping her inpatient would have made a difference?

I think it would've.

Her long-term risk was still tremendous but there were possibilities she could've gotten her life back on track.

In short, she was a teacher that loved her job. She became manic, during her mania, she hooked up with an physically abusive and antisocial loser. She was married and her husband didn't want to have anything to do with her unless she stabilized for at least one year. The father got full custody of the child. Even after she stabilized, no school was willing to touch her with a ten foot pole. The antisocial loser spent over 100K of the patient's savings on drugs. She went from respectable middle class person to woman trapped in a relationship with a stalking a-hole.

(By the way, remember that. I only learned that after residency. If a teacher is mentally ill, even if he/she stabilized, expect the person to be defacto black-listed if the school administration or board finds out.)

So the thing she loved, she could not get back to it. I figured if she could've maintained stability, she could've at least got her husband and child back, and from that foundation possibly go back into teaching or something else that would've given her meaning. The husband told me he was willing to wait for her and had for over 6 months, but he was in the phase where he had to set up a boundary until she got help on her own.

But the law is what the law is. In my neck of the woods, it defines that I must discharge her if there is no immediate risk. IMHO we gave her the most rock-solid discharge plan we could think of that provided the least restrictive environment (family residence that was extremely large, several family members, good outpatient services, and I was told---no guns). I thought the long-term risk was high, but I thought if she were to do it, it'd be months down the road, and only if there were something immediate that was available.

Unfortuantely I was right.

 

[BloodnGuts]

bump for the original post. I am considering applying for the NHSC scholarship, and I am interested in what my possible career options would be.

 

[st2205]

I'd peruse the NHSC website and search for sites with a score of 21 or greater. That will tell youyour career options, at least during payback. They also reserve the right to change any portion of the contract any time they feel necessary.