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Practicing in Rural America Often a Juggling Act

Wide-open spaces and psychiatrists stretched thin complicate mental health care in rural America. Greater inclusion of primary care clinicians could improve the availability of care.

Psychiatrist Kenneth Gladieux, M.D., is a transplanted native of the Washington, D.C., suburbs now practicing at the Ozarks Medical Center in rural West Plains, Mo. He works closely with Barbara Pearson, L.P.N., who grew up nearby. Credit: Aaron Levin

"Rural psychiatry is not simple psychiatry," said Kenneth Gladieux, M.D., sitting in his small office in the Ozarks Medical Center in West Plains, Mo.

The range of diagnoses he sees in this quiet town, where streets are named after country-music stars and local boys who grew up to play major league baseball, equals anything psychiatrists see in metropolitan areas, he said. Finding the resources to provide care is, however, a never-ending balancing act.

"Our part of America deserves the same level of care as any other part," added Gladieux's colleague David Evans, L.P.C., a native of the region. "Poverty and remoteness shouldn't keep people from getting the care they need."

The Health Resources and Services Administration's (HRSA) Shortage Designation Branch says there are 1,621 nonmetropolitan areas designated as mental health Health Professional Shortage Area (HPSA), covering more than 55 million people.

To help lessen the shortage of psychiatrists and reach a population-to-psychiatrist ratio of 30,000:1 (or 20,000:1 where high needs are indicated) in mental health, HPSAs require an additional 1,113 psychiatrists in those areas, according to David Bowman, an HRSA spokesperson. The shortage designation also takes into account needs for other mental health professionals.

Those numbers may not even represent the full extent of the problem, since there may be areas or populations that might qualify as underserved but have never requested an HPSA designation, he added.

So for the moment, filling the need for psychiatric services in rural America, as in most underserved areas, requires cobbling together a patchwork of professionals, programs, and payments to contend with widespread need, geographic isolation, and cultural mores.

Primary Care Doc Studies Psychiatry

One way to improve mental health care in America's small towns and rural counties is to bolster the psychiatric knowledge of primary health care professionals already working there.

For instance, Alan Allmon, D.O., has been a family practitioner outside Sedalia, Mo., for over 30 years. The last time he'd had any formal psychiatric training was the month-long rotation he'd spent in Fulton (Mo.) State Hospital in 1971. About four years ago, he sensed how little he knew about how psychiatrists today use psychotropic medications. He started reading, first short works, then standard textbooks on psychiatric drugs. He felt more adept thinking about drugs eventually, but then wanted more training on how to diagnose the conditions those drugs treated.

Luckily, Allmon had an option designed for primary care physicians and nurse practitioners, a program developed at the University of Missouri and partially supported by the U.S. Department of Labor (Psychiatric News, December 1, 2006). The course included 84 hours of classroom and clinical study in general psychiatry, child psychiatry, and psychopharmacology. Once he finished, Allmon grew more confident in his ability to differentiate and diagnose the anxiety, depression, bipolar disorder, and other psychiatric illnesses that he encounters in his private practice. When faced by more severe or complex cases, he can call for help from psychiatrists at the university's medical center in Columbia.

"The outpatient psychiatry I do in family practice is more rewarding than anything else," he said recently. "I can make a real difference in people's lives."

Another approach has been to encourage graduates of international medical schools to work in underserved areas under J-1 visa waivers (see "J-1 Visa Rules").

Baskar Gowda, M.D., works at a clinic in Osage Beach, Mo. He needs more outpatient substance abuse programs there. Credit: Aaron Levin

Bhaskar Gowda, M.D., trained in his native India, completed a psychiatry residency at the University of Missouri and then held an externship in New York. He came to the United States on a J-1 visa six years ago and now lives and practices in Osage Beach, Mo.

Although it took some time to break through the social barriers in Osage Beach, Gowda said, "people here are friendly, and once the community knows you, it's no different here than in New York City."

The area remains poor and rural, even though it lies on the fringe of a resort area. Many people in the area don't have access to health care because they lack private health insurance but don't meet income guidelines for Medicaid, Gowda said. The area is also short on inpatient services for women and group outpatient substance abuse programs. His office is now part of a nonprofit system that operates on a mix of private insurance and subsidies from the state mental health department.

"We stretch ourselves to cater to our patients," he said. "It's a wonderful experience serving in a rural area."

Advantages Outweigh Lower Pay

Down in West Plains, psychiatrist Elizabeth Bhargava, M.D., who was born in Bangalore, India, has worked at the Ozarks Medical Center on a J-1 visa since 2003. Having a relative who was a cardiologist in the area made the transition easier, she said. She finds advantages to living in a small American town, even if the pay is lower than in cities and the nearest major airport is two hours away.

"It's more peaceful here; there are lots of open spaces and birds and animals," said Bhargava, who trained in Chicago. "In a big American city, you can get overwhelmed. Here you get to know people in the community who can help you make a difference in the lives of people. My expertise is useful and important. I've been able to take leadership positions in the hospital and the medical community in general."

Bhargava is now working on a grant proposal to expand treatment for dualdiagnosed patients.

Program Repays Medical School Loans

Yet another source of mental health professionals lies in HRSA's National Health Service Corps (NHSC). The NHSC recruits primary care clinicians and psychiatrists to provide care in underserved communities. The nationwide program repays medical school loans and offers scholarships for those willing to commit to service at the start of medical school. There were 229 psychiatrists serving as NHSC scholars or loan repayers in 2005, said HRSA's Bowman.

That was the route that led Gladieux, to West Plains.

He joined NHSC when he applied to medical school at Virginia Commonwealth University. His tuition was paid, and he received a stipend while he studied. In exchange, Gladieux must work one year in the program for each year of medical school.

"I think of psychiatry as primary care," said Gladieux during an interview that took place in the small house where he lives with his wife and two children in West Plains. "I was always a lot more concerned with people's emotional well-being as part of their complete health rather than just the physical elements."

After residency at the University of Virginia, Gladieux was assigned to a hospital in Helena, Ark.; he came to West Plains in July 2005.

The medical center is a 114-bed, not-for-profit system with its main hospital in West Plains and a dozen smaller sites scattered around the surrounding 12-county area. The medical staff includes more than 100 physicians. The center should have a complement of five psychiatrists, but two staff departures late last year have left it shorthanded, although recruitment efforts are under way.

A conversation with Gladieux and his colleagues reveals the spectrum of mental illness in the region and the juggling act they perform to cope with it.

Pathology the Same—Mostly

"The range of pathology is about the same here as in a large city," said Gladieux. "If there's anything prominent among the ills of the region, it's substance abuse, especially methamphetamine and alcohol."

"Meth is a source of easy money for poor, rural people," said Evans, Gladieux's colleague. "Add alcohol and opiates and you increase the danger, especially for children in these families. People do bizarre things—incest, negligence, accidents—and they end up in the E.R."

Like Evans, Barbara Pearson, L.P.N., who works closely with Gladieux, grew up nearby. "I always wanted to take care of people, but I can't believe the things that happen," she said. "I was very innocent."

As happens elsewhere, though, socioeconomic circumstances play a role in who seeks and who gets treatment. A culture of poverty and disability becomes more complex as one looks below the surface, said Patty Carson, A.P.R.N. Disability checks may effectively support a wider circle than just patient and family, she said, and that may discourage movement toward recovery.

A combination of undereducation and deeply held religious conviction can exert a paradoxical effect, said Carson. "People have difficulty understanding concepts of mental illness, but they are also inclined to say `I couldn't commit suicide because I'd go to hell.'"

Stigma contributes its effects, as it does in most places, said Evans. People often keep mental illness in the family a secret until danger arises. "It has to get really bad before they come in to see us," he said.

Sheer distance can complicate staffing and cultural issues. Along with the psychiatrists, nurses, and counselors, the unit has 23 case workers, paid by state funds. Each case worker has 20 patients, many living at the end of long gravel roads. The problems of distance are compounded by a lack of public transportation. Often, case managers must drive 20 miles out and back on country roads just to pick up patients and return them home.

Adaptability is a helpful trait in a region where specialists are in short supply, Gladieux has found. He filled a position formerly held by the only child and adolescent psychiatrist in the area, even though he had no advanced training in child psychiatry. Now, he says he's prepared to evaluate anyone of any age.

"It's very rewarding to take care of kids and also more stressful because you're really treating families," he said. "The problem really isn't the child, it's the family or their social circumstances. There are a lot more variables in the assessment. Sometimes I think of myself as a social worker with a prescription pad."

Dealing with these interconnected medical, psychiatric, and cultural issues with two fewer psychiatrists has meant the staff must juggle schedules and assignments. They manage to see all the patients, but individuals may be shifted to alternate professionals within the behavioral health unit when demand on the psychiatrists rises.

Recruiting physicians, especially psychiatrists, is difficult because of the small-town setting, admitted Carol Eck, M.Ed., L.P.C., executive director of Behavioral Healthcare at Ozarks Medical Center. Time and distance make professional education hard to arrange. On the other hand, the location can be attractive for the right person, one who likes country life, she said. West Plains touts its schools (two elementary, one middle, one high school) and low crime rates, said Eck. "People come here to raise families."

With one year to go on his contract, Gladieux is open to the thought of staying in West Plains—his wife likes the area—but he would prefer a position that grants him more autonomy in making clinical decisions. An infusion of greater resources could provide both better services to patients and generate more revenue for the medical center.

"I have no regrets about choosing the NHSC," he said. "I really do love my profession. I feel that I've done a lot of good in three years, but I'm looking forward to being captain of my own ship."

He also misses the experience of working with more experienced colleagues.

"I don't have a mentor now. I don't feel I need other psychiatrists to learn from, but I do wish I had a mentor who might be there in an area with a higher concentration of psychiatrists."

Nonetheless, he has learned a lot by having to cope with a variety of challenges. He sees a wide range of pathologies and does inpatient consultations with the medical, surgical, and obstetrical wards. "I'm working in one of the tougher outpatient psychiatric populations, so I've gotten good experience here."

What's the best part of working far from his hometown in the Washington, D.C., suburbs?

"What other options do these folks have?" he said. "We're the end of the line for them. That's a big responsibility. It's challenging and gratifying at the same time. It hasn't always been easy, but I've gotten experience here I could not have gotten any other way."

Information on the National Health Service Corps is posted at <http://nhsc.bhpr.hrsa.gov>; on health care shortage areas is posted at <http://bhpr.hrsa.gov/shortage>; and Criteria for Designation of Areas Having Shortages of Mental Health Professionals is posted at <http://bhpr.hrsa.gov/shortage/hpsacritmental.htm>.

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