What Is Your Experience as a Rural Psychiatrist?

[AD04]

I'm currently in a very nice area seeing well-to-do to do patients, from college students to executives and business owners. I'm very good at what I do and for the most part, the patients are appreciative of the improvements in their mental health. (There is also a higher sense of entitlement which comes with the territory.) But truth be told, I am feeling a bit bored at work. And I'm not sure if I want to be in the area for the rest of my life as the glitz and the glamour don't appeal to me.

I prefer to be somewhere with more peace and tranquility. I would like to be a crucial part of the community instead of being the best option among many. Maybe this is a case of the grass is greener on the other side. Can anyone with rural psychiatry experience chime in regarding pay and practice structure and lifestyle and challenges?

This is a critical junction in life as after 1 year, I would have built up too much to walk away from and I would likely remain here for the rest of my life.

Thanks.

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[Sushirolls]

Instead of people cringing like they sucked on a lemon at the mention of Trump they will sing his praise - but only if brought up. They won't talk politics unless you bring it up first.
Know your guns, calibers, weapons, hunting seasons, fishing seasons, nuances of local crops, livestock - if they smell liberal on you they are less likely to open up, but if you can talk the talk, your in.
Therapy will likely want more directive, guidance, homework.
Less natruopaths, or supplements. Less cannabis. More alcohol. +/- meth depending on location.
I've had one patient who was better off not getting admitted but dropped off in the woods to just run in the woods. That decision of admit vs go run in the woods requires cultural competence.

 

[finalpsychyear]

I'm currently in a very nice area seeing well-to-do to do patients, from college students to executives and business owners. I'm very good at what I do and for the most part, the patients are appreciative of the improvements in their mental health. (There is also a higher sense of entitlement which comes with the territory.) But truth be told, I am feeling a bit bored at work. And I'm not sure if I want to be in the area for the rest of my life as the glitz and the glamour don't appeal to me.

I prefer to be somewhere with more peace and tranquility. I would like to be a crucial part of the community instead of being the best option among many. Maybe this is a case of the grass is greener on the other side. Can anyone with rural psychiatry experience chime in regarding pay and practice structure and lifestyle and challenges?

This is a critical junction in life as after 1 year, I would have built up too much to walk away from and I would likely remain here for the rest of my life.

Thanks.

I have the exact same experience in my PP which is balanced by the other extreme via my CMHC telepsych. DO NOT give up the PP or nice to do patients.
The telepsych gigs are plentiful and flexible and may add the pathology and other end of life circumstances that you are not seeing much of.

Ultimately, the CMHC patients will be much more difficult and improvements slower and that will wear on you over time. It is much easier to make $ as easily and with the least amount of stress as possible. You can always come up with additional work to keep your brain stimulated i.e. additional board certification exams, doing peer reviews or chart reviews and weekend side work is a dime a dozen not to mention learning about finance which is going to amplify all the work you do now by a significant degree.

Boredom via clinical work is a common thing that comes with experience eventually. Exploring outside work or perhaps other "fun" activities that challenge you is what has worked for me.

 

[Merovinge]

If you like being a big fish in a little pond than rural psychiatry sounds like a good home. You can easily set it up so that people know you everywhere you go, restaurants have your favorite food/drink/table available (mind you the restaurant is going to be rubbish compared to a big city). You can easily get invited to every rotary club/local fundraiser as you'll make more than 99.5% of the town.

People will be very grateful for your services, in a way that cities with more providers really cannot compared to.

Pay absolutely should be a significant setup from almost all major cities if you go from employed position to employed position as almost every rural location is desperate. If you want to run a PP, you will need to churn through patients for financial rewards or "supervise" a number of mid-levels as cash practice is not a realistic option - I strongly recommend a well negotiated employed position. Pathology is really not terribly different than inner-city urban so I imagine moving 20 minutes from your practice could change things just as much as 4 hours. I am amazed how low SES city people and low SES rural people imagine such a divide whilst being extremely similar.

I recently made this change (although for family reasons, not by choice) so feel free to DM me with any other questions you have.

 

[whopper]

Lesser if possibly no access to collateral mental health resources. E.g. most good eating disorders clinics are in a city. If you're in the middle of cornfields and you got a patient with a bad eating disorder expect no one to be able to help you much with this case. The local hospital may not be able to handle the cases you send to them well and then discharge to your care someone who is still suicidal. The local police might not know anything in terms of picking up patients from the office. The local pharmacy might not have half the meds you prescribe.

 

[FrustratedFamDoc]

I'm family medicine, but have seen my small town eat many psychiatrists for breakfast. Most only last a few years before moving on. They're quickly over run. In general, rural = lower SES, larger percentage of 'care/'caid/ 'self pay.' Much higher percentage of substance abuse. Many patients who have been poorly managed for years/decades. Fewer resources compared larger cities.

 

[SeniorWrangler]

Where you are in Rural America is important too! Rural Michigan or rural Oregon has a lot of outdoor recreation to do, rural Kansas is a whole lot of nothing IMO.

 

[whopper]

I worked in a small town outside of Cincinnati for a few years. Anyone I had as a patient in my office who was truly suicidal the hospital the police sent them to had an incompetent psychiatrist. I had no faith the guy would do anything right by these patients.

What I later did was if I could tell they were suicidal, I'd try to have them sent to the Lindner Center, a private and highly respected psych treatment center with an inpatient facility. The police wouldn't bring them to the Lindner Center cause it was 1 town over while they were also mandated to send them to the local hospital with the incompetent psychiatristl. So whenever a patient was suicidal but not yet quite hospital/emergency worthy I'd tell them and their friends/family (of course with the patient's persmission) to be prepped to go to the Lindner Center so they wouldn't have to leave it to going to my office where I'd have to call the cops and have them sent to that other local hospital. The situation was so bad that most patients I had already knew who that guy in the local hospital was, that he was incompetent, and were on-board with why I wanted to avoid them going back to that guy, and the same with their friends/family.

Several patients who never knew each other who had been to that hospital independently told me stories of how that other doctor would openly call them a loser to their face.

Now let's make this a step worse. I was working in a small town about 20 minutes outside of a metropolitan area. Imagine the local area having no psych resources at your disposal. E.g. you prescribe Buprenorphine but the local pharmacy doesn't carry it nor will carry any when you and the patient request they carry it.

This is why the idea of trying to rake up tons of cash by working in the middle of nowhere doesn't exactly sound appealing to me.

The most I'd be willing to do is work in an area outside of a metropolitan area where it's more rural but not completely devoid of other psych providers other than yourself. If I did work in a very rural area devoid of other psych services, and I'm being serious is I'd get together with lawyer and start having some algorithms and legal fire-walls set up for situations where the lack of collateral psych services doesn't end up with you getting screwed for something you could not prevent.

 

[Mass Effect]

Instead of people cringing like they sucked on a lemon at the mention of Trump they will sing his praise - but only if brought up. They won't talk politics unless you bring it up first.
Know your guns, calibers, weapons, hunting seasons, fishing seasons, nuances of local crops, livestock - if they smell liberal on you they are less likely to open up, but if you can talk the talk, your in.

This is dependent on where you go. Big difference between rural Oklahoma and rural Vermont.

 

[dl2dp2]

But truth be told, I am feeling a bit bored at work. And I'm not sure if I want to be in the area for the rest of my life as the glitz and the glamour don't appeal to me.

I prefer to be somewhere with more peace and tranquility. I would like to be a crucial part of the community instead of being the best option among many. Maybe this is a case of the grass is greener on the other side. Can anyone with rural psychiatry experience chime in regarding pay and practice structure and lifestyle and challenges?

This is a critical junction in life as after 1 year, I would have built up too much to walk away from and I would likely remain here for the rest of my life.

Thanks.

It's very likely that if you just drive about 30-50 min out you'll get to your peace and tranquility. IMO you just need a real estate agent. I'm not even joking.

Frankly, you have NO idea what it's like to actually live in a rural area, and having had that experience, it's not for the faint of the heart. If you are bored now, I can't even imagine what it's like if/when you moved to a rural area [for the rest of your life]. Do everyone a favor and just AirBnb a farm for a week.

 

[Sushirolls]

It's very likely that if you just drive about 30-50 min out you'll get to your peace and tranquility. IMO you just need a real estate agent. I'm not even joking.

Frankly, you have NO idea what it's like to actually live in a rural area, and having had that experience, it's not for the faint of the heart. If you are bored now, I can't even imagine what it's like if/when you moved to a rural area [for the rest of your life]. Do everyone a favor and just AirBnb a farm for a week.

LOL

 

[Sushirolls]

But if you got a truck that belches dinosaurs, and you view the calendar not as 12 months, but seasons with which to transition to, rural is amazing. Turkey season, planting season, fishing season, deer scouting season, harvest season, hunting season, relax & prep season, fishing season again, etc. Can't beat looking up at the stars and actually seeing them without light pollution. Or find yourself worried more about what might eat your livestock (chickens, goats, cows, etc) then the latest restriction of a housing association about mailbox standards. Target practice in you backyard, basically shooting (bow or gun) is essentially biofeedback. Have space to park your rig at establishments. The quiet - ability to purchase enough land to not have to hear your neighbors talk/party/blast music/cut their lawn *silence* or the sound of owls hooting at night or the occasional (musical) bang of gun shots in the distance almost like the comfort of a church bell, letting you know you are home. Oh, let's not forget tractor time! Who doesn't love a little tractor work. Real fireplaces, with real wood.

Elk meat? Can I get a high five!?! No need to get rabbits off the hospital lawn - just pick one off out back for dinner. Or even deer biriyani, or fresh backyard chicken, fresh spicy egg curry with backyard eggs. Fresh fish to make your own Sushirolls. Growing your own egg plants, onions, carrots, okra, tomatoes, ... it's the life. Let everyone else think the concrete jungles are cool.

There is reason why there are songs like John Denver's 'Thank God I'm a Country Boy'

My spouse wasn't really rural minded but after getting a taste, only now idealizes urban for the food scene.

 

[Mass Effect]

It's very likely that if you just drive about 30-50 min out you'll get to your peace and tranquility. IMO you just need a real estate agent. I'm not even joking.

Frankly, you have NO idea what it's like to actually live in a rural area, and having had that experience, it's not for the faint of the heart. If you are bored now, I can't even imagine what it's like if/when you moved to a rural area [for the rest of your life]. Do everyone a favor and just AirBnb a farm for a week.

It also depends on what the poster means by rural. Few people can handle living in a town of 500 people, but many city folk move to towns of 20,000 - 40,000 people (which is rural compared to the city) and do just fine. It also depends on which part of the country you're in. Rural upstate NY state will be about 4-5 hours to the city, but rural Virginia may only be a train ride or an hour or 1.5 hours to DC. There are also some people who are more bored in the city because "all" the things to do aren't things they like. One of my med school classmates grew up in Maine and spent summers white water rafting and camping and the winters skiing and snowtubing. Guess where she ended up for residency? I don't think she even applied to any city programs. She's now considering setting up shop in (very) rural northern Maine. She even considered moving to Wyoming, but said she'd miss her family too much.

 

[Taddy Mason]

There is reason why there are songs like John Denver's 'Thank God I'm a Country Boy'

There’s a reason he crashed his plane too...

 

[penpenclown]

But if you got a truck that belches dinosaurs, and you view the calendar not as 12 months, but seasons with which to transition to, rural is amazing. Turkey season, planting season, fishing season, deer scouting season, harvest season, hunting season, relax & prep season, fishing season again, etc. Can't beat looking up at the stars and actually seeing them without light pollution. Or find yourself worried more about what might eat your livestock (chickens, goats, cows, etc) then the latest restriction of a housing association about mailbox standards. Target practice in you backyard, basically shooting (bow or gun) is essentially biofeedback. Have space to park your rig at establishments. The quiet - ability to purchase enough land to not have to hear your neighbors talk/party/blast music/cut their lawn *silence* or the sound of owls hooting at night or the occasional (musical) bang of gun shots in the distance almost like the comfort of a church bell, letting you know you are home. Oh, let's not forget tractor time! Who doesn't love a little tractor work. Real fireplaces, with real wood.

Elk meat? Can I get a high five!?! No need to get rabbits off the hospital lawn - just pick one off out back for dinner. Or even deer biriyani, or fresh backyard chicken, fresh spicy egg curry with backyard eggs. Fresh fish to make your own Sushirolls. Growing your own egg plants, onions, carrots, okra, tomatoes, ... it's the life. Let everyone else think the concrete jungles are cool.

There is reason why there are songs like John Denver's 'Thank God I'm a Country Boy'

My spouse wasn't really rural minded but after getting a taste, only now idealizes urban for the food scene.

That sounds like my personal hell haha.

To each their own I suppose.

 

[AD04]

I'm family medicine, but have seen my small town eat many psychiatrists for breakfast. Most only last a few years before moving on. They're quickly over run. In general, rural = lower SES, larger percentage of 'care/'caid/ 'self pay.' Much higher percentage of substance abuse. Many patients who have been poorly managed for years/decades. Fewer resources compared larger cities.

Why do psychiatrist move there in the first place? To make money to pay off loans or to establish roots? How do the small towns attract and then repel the psychiatrists? How are the reimbursements in FM in rural areas compared to urban areas?

The situation was so bad that most patients I had already knew who that guy in the local hospital was, that he was incompetent, and were on-board with why I wanted to avoid them going back to that guy, and the same with their friends/family.

Several patients who never knew each other who had been to that hospital independently told me stories of how that other doctor would openly call them a loser to their face.

Now let's make this a step worse. I was working in a small town about 20 minutes outside of a metropolitan area. Imagine the local area having no psych resources at your disposal. E.g. you prescribe Buprenorphine but the local pharmacy doesn't carry it nor will carry any when you and the patient request they carry it.

This is why the idea of trying to rake up tons of cash by working in the middle of nowhere doesn't exactly sound appealing to me.

The most I'd be willing to do is work in an area outside of a metropolitan area where it's more rural but not completely devoid of other psych providers other than yourself. If I did work in a very rural area devoid of other psych services, and I'm being serious is I'd get together with lawyer and start having some algorithms and legal fire-walls set up for situations where the lack of collateral psych services doesn't end up with you getting screwed for something you could not prevent.

How long has the incompetent psychiatrist working in the area? If quite a while, it seems those in rural areas are less likely to pursue actions against the physicians compared to those in urban areas.

 

[keifernny2]

My experience practicing rurally....

1) When you want to do something, it becomes an event. ie: "Let's go to the nice mall that has more than a JCpenney" means: board your pets, book a hotel room, drive 90 minutes, and plan a nice night out. Hope there's not a snowstorm. Then, drive 90 minutes home the next morning. Or, you can order everything online.

2)traveling. My rural airport only has 2 flights each day, and they go to the same hub, which is not a city that anyone would ever want to go to. I've been stranded twice this year (in the summer!) when my flight home got cancelled and airline rerouted me to the next larger city, which is 1.5 hrs away. Try convincing an uber driver to take you that far at midnight (because you parked at your home airport). You end up having to take off an extra 1/2 day of work on each end of the trip just to get out of town. One the plus side, my local airport doesn't charge to park in the gravel parking lot. In the winter, I always drive to the larger airport to reduce likelihood of being stranded.

3) You will run into your patients everywhere. Yesterday I was at the local warehouse store and ran into 2. One made a joke because I had a 12-pack of beer in my cart. This isn't necessarily a bad thing, and happens everywhere to a certain extent.

4) Food: lots of diner food, few upscale restaurants. You'll have to learn to cook or order Hello Fresh/Blue Apron (this has been a lifesaver). Plan for better dining experiences when you're on vacation.

5) Rural employers here don't usually shut down due to weather, because they're already on a shoestring budget and are paying a premium to have you there. If they shut down, they lose even more money. You don't get to sit home and enjoy the peaceful snowfall. You wake early, clear your sidewalk, and then head into to work, or take a vacation day.

I second the suggestion above, to look at houses slightly outside of the suburbs that still allow access to amenities of the city, and I wouldn't accept a rural job unless there was an extra 1-2 weeks of vacation built into the salary to make up for the travel issues above.

 

[birchswing]

Dropping someone off in the woods instead of inpatient hospitalization?

Turkey seasons?

If I still had a parody account, these are the sort of things I'd be writing.

 

[Attending1985]

I work in a rural area. I think the hardest thing is the high rates of psychosocial stressors that bring people to you. A nice thing is being really appreciated. You have a lot of leverage as far as negotiating for better hours/pay ect.

 

[FrustratedFamDoc]

[

Why do psychiatrist move there in the first place? To make money to pay off loans or to establish roots? How do the small towns attract and then repel the psychiatrists? How are the reimbursements in FM in rural areas compared to urban areas?

Everyone has their reasons for being somewhere and they're usually pretty unique so I can't really comment on that. I did residency here and stayed. I've been here 10 years now. It's not a truly small town as the city is 30,000 people, county has 90,000. We are a medical hub for our region of the state and 1-2 hours from 3 major academic centers. We have pretty much all adult specialties represented locally so it was a good fit for me.

There are a few older psychiatrists and several family docs in town that do things the right way but all it takes is a few to really screw things up
1. Unethical doses of benzos
2. Opiates
3. Soma
4. Drug/alcohol/tobacco abuse
5. Unemployment/despair/crappy life syndrome

Secondly, our main, public local inpt psych hospital closed years ago so, yeah. All long term patients were released.

With that said, it is a good town and has been good to me. The first few years of establishing my practice were difficult. My payor mix was heavily govt and the days were difficult. Very high rates of no shows, poor compliance, bad attitudes and in general things rarely ever got 'better'. It's hard to even get through a regular follow-up without there being at least 1-2 new problems that also need to be addressed. Of course I had govt patients that didn't fit this mold, but they were definitely the exception. It can be very frustrating.

With time, my payor mix has changed and now resembles more of what you're describing as your current population. In general, much easier to take care of and more rewarding. Compliance is better. Office visits are much shorter and I'm much more of a physician than their social worker. I go home less drained and am getting paid FAR MORE in the process. You can't expect to have a majority of your mix as govt and earn well unless it's heavily subsidized from somewhere... and there's ALWAYS a good reason for it.

If you want to feel like you're helping an underserved population then you can always volunteer. Don't give away your golden goose.

 

[Ironspy]

I wouldn’t be comfortable working with patients who had a lot of poverty &social issues and most also had guns at home

 

[nexus73]

I work in a place with about 40,000 population, but draws people from up to 2 hours away to see a psychiatrist. I work for a hospital owned clinic that has an RN and front office staff person. No therapists or case managers. Because of these limitations, I've set fairly firm boundaries on the severity of patients I can see. I'm basically running a hospital supported solo private practice and do not have the resources to manage SPMI population, so they get referred to the county health clinic that has psych services including the full gamut of case management, therapy, and ACT services. The main problem is the county clinic does not have adequate capacity to take everyone who is appropriate for that level of care so there are a lot of pretty sick patients being followed by PCPs waiting to get in to the county clinic. I've talked to the hospital about hiring staff to be able to take on sicker patients but there are financial realities that make it a difficult proposition. Basically psychiatry is a money loser for the hospital and hiring on social workers and increasing the Medicaid numbers will lead to even more losses. So, I go about my day seeing patients with depression, anxiety, OCD, bipolar 2, some bipolar 1, and the occasional patient with schizophrenia who has solid family support that functions like case management.

If the family medicine clinics were fully aware I am screening out referrals like this they would probably be upset, but there's very little I can do. I'm unwilling to create a job with the sickest of the sick psychiatry patients without adequate resources to treat them.

 

[Sushirolls]

I work in a place with about 40,000 population, but draws people from up to 2 hours away to see a psychiatrist. I work for a hospital owned clinic that has an RN and front office staff person. No therapists or case managers. Because of these limitations, I've set fairly firm boundaries on the severity of patients I can see. I'm basically running a hospital supported solo private practice and do not have the resources to manage SPMI population, so they get referred to the county health clinic that has psych services including the full gamut of case management, therapy, and ACT services. The main problem is the county clinic does not have adequate capacity to take everyone who is appropriate for that level of care so there are a lot of pretty sick patients being followed by PCPs waiting to get in to the county clinic. I've talked to the hospital about hiring staff to be able to take on sicker patients but there are financial realities that make it a difficult proposition. Basically psychiatry is a money loser for the hospital and hiring on social workers and increasing the Medicaid numbers will lead to even more losses. So, I go about my day seeing patients with depression, anxiety, OCD, bipolar 2, some bipolar 1, and the occasional patient with schizophrenia who has solid family support that functions like case management.

If the family medicine clinics were fully aware I am screening out referrals like this they would probably be upset, but there's very little I can do. I'm unwilling to create a job with the sickest of the sick psychiatry patients without adequate resources to treat them.

This description could be rubber stamped across so many places.

 

[AD04]

Thanks for sharing about your experiences. You convinced me that the grass isn't greener on the other side.

 

[Merovinge]

Thanks for sharing about your experiences. You convinced me that the grass isn't greener on the other side.

Actually the grass itself is a lot greener here than the city I came from...