What's the smallest population that can support one psychiatrist?

[Red Beard]

What is the ballpark minimum community size needed to support one psychiatrist? 10,000? 20,000?

Wife and I may want to work in an isolated area with a population of about 9,000 in the future....

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[pingouin]

Rural communities are extremely underserved for mental health services of all types- I suspect you'd have a booming practice in very little time.

There are a few counties in my state that have zero mental health providers- masters-level therapists, psychologists, or psychiatrists. A close LPC friend was the only mental health provider in her county and the community hospital contracted with her to do PRN mental health assessments because there was literally no one else to do it. And I don't know if it's still open, but we also have a town of ~8000 with a small inpatient psychiatry unit at their hospital because the next-closest is a 2-hour drive away. (That was several years ago- budget crunches could have changed things.)


Go for it.

 

[The Long Way]

sorry, double-post.

 

[The Long Way]

I agree with the above post. Many rural areas are desperate for psychiatric services. I do not think that it is necessarily the size of the town that matters, however, but the size of the area that you would likely draw from.

When I was doing my rural FM rotation, I was in a town of 2,000 people. They had a 5 doctor FM practice and were busy, busy, busy... I suspect that if you were willing to travel a little and do satellite clinics, you could also be very busy within a short time of setting up your practice.

One word of caution that I picked up on my rural FM experience. Boundary issues will be of much greater importance as a rural psychiatrist. If you practice in a community of 9,000, you will more than likely have patients that you bump into at the grocery store, your church, social gatherings, etc... Also, gossip can be a real pain in smaller communities and unfortunately patient confidentiality will be harder to maintain there.

 

[alina_s]

The department of health and human services designates areas as underserved based on the mental health professional to population ratio:

"A population-to-core-mental-health-professional ratio greater than or equal to 6,000:1 and a population-to-psychiatrist ratio greater than or equal to 20,000:1 or
A population-to-core professional ratio greater than or equal to 9,000:1 or
A population-to-psychiatrist ratio greater than or equal to 30,000:1"

The HRSA.gov web site gives some information about the need and number of providers in each county, although it's not always up to date.

So, if you were the one and only mental health professional in your small town, the government says you'd be working in an underserved area, and I guess busy enough? I suppose that it would depend on how isolated the area is. Some small towns in Alaska have psychiatrists (or would like to) - Nome, Sitka, Bethel- and even the ones on islands or that aren't connected by roads serve populations from the general region. I'd wonder about the mental health system, though. I have to go work in an underserved area and am distinctly disinterested in being the only mental health provider, and the only person having to sort out the insurance/medicaid/uninsured issues, nevermind after-hours coverage. I don't have any plans to ever open a private practice but I would guess that that isn't viable in a rural area because it takes a higher-income population to support this.

 

[Red Beard]

It is clear that there there are many rural and isolated areas that are underserved with respect to mental health services.

My question is more about what is the smallest population that would still have enough work for a psychiatrist to stay busy?

And I also agree that things could get sticky in a very small community where you are very likely to be seeing your patients or their families around town frequently. In fact, one of preceptors in medical school left his practice on one of the islands in the San Juans (Washington) for exactly this reason--no matter where he went, he was either running into someone he had seen in his office or their family member.

Out of curiosity, anyone here ever practiced in such a community?

 

[pingouin]

I don't think there is such a thing as the "smallest population" required. As it stands, rural families will drive 2-3 hours to see specialists of all types. So even if you're in a town of 1,000, it won't matter because you'll pick up business from all the surrounding towns because you'll only be 30 minutes from them... or even an hour.

I worked for almost 2 years as a community mental health therapist in a town of ~9500. Definitely interesting to try to go out to lunch- I ruled out a bunch of restaurants because my clients worked day shifts there.. my coworkers had clients working at other restaurants... You can't avoid running into people altogether, but it does help to set up boundaries in the first session regarding what will or won't happen if you see them in town. I didn't live there, however, so it was much less of an issue than my colleague who could walk to our office.

 

[Sneezing]

Red Beard you have asked a good question IMO.

A primary care doctor will have a patient panel of 2000 - 4000. The ball park figures I hear are usually a pcp will see 1/4 to 1/3 of their patients having psych issues.

In residency a resident will have in their 3rd year clinic a panel of 120-300 patients from what I've read.

I'm just taking a rough guess and saying one pyschiatrist working a 40hour week could be full off of 500 patients of different levels of management. Recognizing the 1/4 PCP prevalence I would say at the bare minimum a town of 4000 could support a psychiatrist.

When I consider going rural I'm thinking a town of 10,000 or more and incorporating telepsychiatry. With that technological aid you can fill in any slots not met by your local area.

I have observed a hospital of 200 can support a 1/3 - 1/2 time psychiatrist for frequency of consults.

This is just my opinion and likely filled with errors in my sweeping generalizations.

 

[Regnvejr]

My question is more about what is the smallest population that would still have enough work for a psychiatrist to stay busy?

Doesn't really matter. People will drive to see you.

Out of curiosity, anyone here ever practiced in such a community?

I live in a town of about 55K, 3 outpatient psychiatrists and 3 CNPs. Next place with 33K people, 2 hrs away has 2 psychiatrists, other direction 3-4 hr drive has 4 psychiatrists, etc. Going west, it is 5 hrs before a psychiatrist, and I get lots of clients from there, even though it is only thinly populated. People in open areas are used to drive far, even for groceries. I probably got 300-500 patients who live more than 1 hr away.

So pick a nice place, let local PCPs (up to an hr or so drive) know you're there, and start wondering how you can find room for all your patients in your schedule.

 

[Red Beard]

Doesn't really matter. People will drive to see you.
I live in a town of about 55K, 3 outpatient psychiatrists and 3 CNPs. Next place with 33K people, 2 hrs away has 2 psychiatrists, other direction 3-4 hr drive has 4 psychiatrists, etc. Going west, it is 5 hrs before a psychiatrist, and I get lots of clients from there, even though it is only thinly populated. People in open areas are used to drive far, even for groceries. I probably got 300-500 patients who live more than 1 hr away.

So pick a nice place, let local PCPs (up to an hr or so drive) know you're there, and start wondering how you can find room for all your patients in your schedule.

That makes sense, I am thinking however of a fairly special situation: an island with a population of about 8-10,000.

 

[Regnvejr]

Then you're dependent on local culture. Is there even an acceptance of mental health? Is there enough stress and life complications to warrant help from mental health (f.ex., working poor lobster fishers vs. rich retirement community)

 

[kugel]

What's the smallest population that can support one psychiatrist?

ONE very narcissistic gazillionaire with a 2500 sq ft "guest house" that he's not using out near the pool and tennis courts, right next to the women's "bikini changing cabana."


Whoa! Guess I need to let my Id out for a walk more often.

 

[OldPsychDoc]

What's the smallest population that can support one psychiatrist?

ONE very narcissistic gazillionaire with a 2500 sq ft "guest house" that he's not using out near the pool and tennis courts, right next to the women's "bikini changing cabana."


Whoa! Guess I need to let my Id out for a walk more often.

It sounds like your id has left the building, and is hanging out down by the pool at the moment.

 

[whopper]

Hard to say because...

1) the money: some doctors won't care to make as much. Then again, underserved areas may be willing to pay more. Iowa for example is extremely underserved, and several psychiatrists are making more money there because of it.

2) PCPs can offer psychotropics. (Though clearly IMHO, most PCPs will not want to service those who are extremely ill. E.g. very bad psychosis, MDD with suicidality etc.)

3) An area may be underserved, but the doctor can work in multiple areas.

4) Telepsyche can be introduced into underserved areas.

 

[Doctor Bagel]

Just a few quick questions. Have you done any rural medicine yet? My school requires us to do a month of rural medicine, and the vast majority of people I know have not enjoyed it. I also know people who've done rural medicine and thought it was very challenging. Rural docs work a lot! Also, it's hard to have a life outside of work when you live in a community where you're running into your patients wherever you go, which is especially an issue in psych. As a doc who's part of a smaller group, it's also harder to have coverage on nights and weekends, which means you might essentially be on call 24/7 for your whole life.

On the other hand, I don't think the money is as big of an issue as it's made out to be -- since rural areas are underserved, you could potentially do better there. Also, small town hospitals are often willing to give docs money to pay off school loans.

 

[Red Beard]

Just a few quick questions. Have you done any rural medicine yet? My school requires us to do a month of rural medicine, and the vast majority of people I know have not enjoyed it. I also know people who've done rural medicine and thought it was very challenging. Rural docs work a lot! Also, it's hard to have a life outside of work when you live in a community where you're running into your patients wherever you go, which is especially an issue in psych. As a doc who's part of a smaller group, it's also harder to have coverage on nights and weekends, which means you might essentially be on call 24/7 for your whole life.

On the other hand, I don't think the money is as big of an issue as it's made out to be -- since rural areas are underserved, you could potentially do better there. Also, small town hospitals are often willing to give docs money to pay off school loans.

I actually rotated in a general practice in the community I have in mind (island, population 8,000) and loved the work, and also the community. Also, it is my fiancee's home. Part of my decision between IM and psych was considering that in IM we could easily go back there--the preceptor I worked with basically offered to give me his practice after residency. And his practice is wonderful, and fun....really a rare thing in this country, and really what I had in mind when I started medical school.

But I ended up ranking psychiatry as my first choice, returning may or may not be an option. It remains to be thoroughly explored, but I thought I would throw the idea out here to see what people say.

One thing I am sure of, which you touched on, would be the boundary issues as a mental health worker in the community, vs. those for a general practitioner. I absolutely loved that people would see me around town and say 'hi' only a week after I was working in the practice, and it was easy and friendly to engage with them.

The second concern that I have is whether or not there would be enough business....which I doubt, considering the population size and the fact that I wouldn't be able to draw from any neighboring areas due to the geography. Not that I am attached to making a ton of money, living lavishly, or needing to be extremely busy, but at least I need to make my loan payments and save for kids education, retirement, etc.

Thanks for your thoughts.

 

[Sneezing]

Dude, you're not dreaming enough. You can so pull off being the island psychiatrist in the sound. If you start to discover one island isn't enough, there isn't any reason why you can't also open an office on another? 3 days on your home island 2 days you commute to a neighbor island. Best part is, the weather in the sound even in the strait is pretty decent. It's not like your on the open ocean with bigger swells. All you have done is traded a car for a boat as commute vehicle. Ideally, use a hovercraft, which are the vessels of choice for rough water/ice rescue even in places like Anchorage. Do some digging into the 10-12ft range hovercrafts.

 

[Red Beard]

Dude, you're not dreaming enough. You can so pull off being the island psychiatrist in the sound. If you start to discover one island isn't enough, there isn't any reason why you can't also open an office on another? 3 days on your home island 2 days you commute to a neighbor island. Best part is, the weather in the sound even in the strait is pretty decent. It's not like your on the open ocean with bigger swells. All you have done is traded a car for a boat as commute vehicle. Ideally, use a hovercraft, which are the vessels of choice for rough water/ice rescue even in places like Anchorage. Do some digging into the 10-12ft range hovercrafts.

Commuting between offices in a freakin' HOVERCRAFT! I love it!👍

 

[kugel]

Ideally, use a hovercraft, which are the vessels of choice for rough water/ice rescue even in places like Anchorage.

Put a couple of chairs and a table or desk in the cabin of the hovercraft, and have pts come down to the dock to see you ON the boat. Save the rent/utilities of an office on the second island. On a small island, everyone will already know who's seeing the psychiatrist anyway.

The Boat gets written of as a business expense!
Letting pt's drive the boat is probably billable as Recreational Therapy AND Vocational Therapy.

 

[Doctor Bagel]

I actually rotated in a general practice in the community I have in mind (island, population 8,000) and loved the work, and also the community. Also, it is my fiancee's home. Part of my decision between IM and psych was considering that in IM we could easily go back there--the preceptor I worked with basically offered to give me his practice after residency. And his practice is wonderful, and fun....really a rare thing in this country, and really what I had in mind when I started medical school.

But I ended up ranking psychiatry as my first choice, returning may or may not be an option. It remains to be thoroughly explored, but I thought I would throw the idea out here to see what people say.

One thing I am sure of, which you touched on, would be the boundary issues as a mental health worker in the community, vs. those for a general practitioner. I absolutely loved that people would see me around town and say 'hi' only a week after I was working in the practice, and it was easy and friendly to engage with them.

The second concern that I have is whether or not there would be enough business....which I doubt, considering the population size and the fact that I wouldn't be able to draw from any neighboring areas due to the geography. Not that I am attached to making a ton of money, living lavishly, or needing to be extremely busy, but at least I need to make my loan payments and save for kids education, retirement, etc.

Thanks for your thoughts.

OK, cool. I've just seen a lot of the downsides of rural medicine recently, maybe explaining why we don't have enough doctors in rural areas. But it sounds like it works for you, which is great.

 

[fornoca]

My Psychiatrist lives in a populated place and can easily support around 600-800 patients each month. I think for this profession to work, you need to stay in city and practice there and you will get much more patients than staying in rural area.

 

[Sneezing]

Redbeard, I'm assuming you are talking about the san juans, you still thinking that's where you want to go?

Is there really any room for a private practice psychiatrist to establish in a really rural area that already has a Community mental health center?

 

[tehdude]

Is it possible to run a cash-only practice in one of these rural areas, or do you need a larger city with a more affluent population?

 

[whopper]

There's no way to answer this question except to say the smallest population is one provided that one person is willing to pay the doctor enough.

e.g. a type of billionaire patient who wants a psychiatrist available at all times just for him. While this type of thing is extremely rare, there are people who want a psychiatrist to limit his patient load to give that person more time.

Let's assume the psychiatrist works in a small community. That psychiatrist can also choose to drive for an hour to be at other communities as well. You are in one community that's too small? Fine, then serve 2 communities with being in one on one day and the other on another.

The question is too fluid and dependent on too many factors to give a rock-solid answer.

 

[kugel]

"What's the smallest population that can support one psychiatrist?"

4'6"

 

[zenman]

That makes sense, I am thinking however of a fairly special situation: an island with a population of about 8-10,000.

You heading to Molokai?

 

[wholeheartedly]

Just as an example my hometown was about 10,000 people. We had at least 4 psychiatrists that I know of that did well, on top of quite a few other mental health professionals. One was strictly child and adolescent, one was the director for the mental health unit at the local hospital. It was the largest town in the county, so they probably got quite a bit of influx from a lot of neighboring towns including some from across state lines. There was a pretty high level of drug and alcohol abuse for the population as well.

I'd also keep in mind the boundary issues thing as well. Everybody knows everybody and their business in towns that size. Or at least thinks they do, which can be worse. That has it's good points and bad.