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Can Psychiatrists Be Enticed to Practice in Rural Areas?

The need for more psychiatrists in rural areas might be addressed by adding rural components to residency training programs and increasing cooperation with other primary care providers.

Changes in residency training and better integration of psychiatry with other health professions may offer new paths to increasing the number of psychiatrists in rural America, according to two articles in the November-December 2007 Academic Psychiatry.

"An increased emphasis on rural psychiatry in residency could contribute to overcoming barriers to providing quality mental health care in rural settings," wrote William Nelson, Ph.D., Andrew Pomerantz, M.D., and Jonathan Schwartz, M.D., of the Dartmouth Medical School in Hanover.

Psychiatry is not the only branch of medicine stretched thin in rural America, but a mix of geographic, social, and personal issues renders rural mental health practice more problematic, said the authors. Simply getting to the nearest provider may require driving several hours in regions that lack public transportation. Rural populations are overall poorer, in worse general health, and less likely to be insured than people in metropolitan areas. Reimbursement may be subject to the dictates of Medicaid or Medicare, when it is available at all.

At the same time, rural values such as self-reliance and self-care may delay seeking help. Stigma against mental illness may mean that patients don't want family and neighbors to know they are seeing a psychiatrist or make them reticent to disclose symptomatic information fully.

Professionally, rural practitioners of any type may feel isolated without the circle of colleagues found in cities. Workloads and on-call demands may be heavy, and inpatient facilities scarce or distant. Finally, the close social networks in small towns mean that a psychiatrist is likely to encounter a patient in social settings, blurring professional and personal boundaries.

Meanwhile, changes within the field may mean that fewer psychiatrists are available for patient care, wrote Ann Freeman Cook, Ph.D., and Helena Hoas, Ph.D., associate professors of psychology at the University of Montana. Cook is also director, and Hoas the research director, of the National Rural Bioethics Project, based at the university.

They noted that many psychiatrists do not practice in hospitals, limiting the number available for on-call or emergency-room duty. Others may limit the type of mental illnesses they treat. Older psychiatrists are approaching retirement age, while the younger cohort includes more women, who more frequently practice part time.

The two sets of authors emphasize somewhat different approaches to filling the gap in rural psychiatry.

Family practice residency programs with strong rural components have shown some modest success in boosting the number of practitioners, and similar programs could do the same for psychiatrists, Nelson, Pomerantz, and Schwartz suggested. They would not limit exposure to rural settings or practice to volunteers.

"[A]ll psychiatry training programs should provide various levels of rural focused training," they wrote. One avenue for introducing those rural elements might be the American Council for Graduate Medical Education's guidelines for teaching about American culture and subculture. Beyond that basic level, they propose grand rounds or journal-club programs on rural mental health issues, and developing opportunities for training at rural community or research sites and rural-urban exchange programs. An understanding of health policy, management skills, and alliance-building with other professionals would also help.

Many medical schools in the Untied States incorporate rurally focused training in their postgraduate programs, ranging from rotation opportunities to specialized tracks. Four Western states that have no medical schools—Wyoming, Alaska, Montana, and Idaho—have allied with the University of Washington in Seattle in the 30-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program. WWAMI's goal is to train physicians who could return to practice in small towns and rural areas in their home states, said Deborah Cowley, M.D., a professor and director of the psychiatry residency program at the University of Washington Medical Center in Seattle.

The psychiatry department set up a residency program 15 years ago that allows interested residents to spend their first two years in Seattle and their second two in Spokane—the latter is a city, but one that draws patients from a largely rural area. A second program has just begun in Idaho.

"Our program teaches residents how to be general psychiatrists and also how to provide consultation to primary care doctors," she said. WWAMI also offers an elective rotation in telepsychiatry.

Two years in residency in Spokane seem to be paying off, said Cowley. About 50 percent of the program's graduates practice in eastern Washington, and 90 percent of those who go through the program work in underserved areas, rural or otherwise, somewhere in the United States, she said.

Brief exposure to rural medicine is unlikely to make much difference, said Cowley. A prior training program allotted only one- to four-month rural rotations, but only 5 percent of participating residents went to practice in the countryside.

"People need to spend a substantial amount of time in nonurban areas" to get a better feel for life there, she said.

The University of New Mexico's program is structured differently from WWAMI's, but fourth-year residents can spend six months to one year working at rural sites, said Helene Silverblatt, M.D., an associate professor of psychiatry and family and community medicine and medical director of the Rural Psychiatry Program. The program operates in conjunction with nurses, pharmacists, physician assistants, substance abuse counselors, social workers, as well as other psychiatrists. Residents care for patients but also act as a resource for the local medical and mental health communities—and learn how to do it diplomatically. They are encouraged to explore related interests that will help them when they go into practice—such as administration, tribal government, schools, churches, and the consumer movement.

Cook and Hoas, in contrast, think that changes in residency training, while admirable, are unlikely to fill the need. Instead, they prefer a "mentored approach to mental health care." More effort should go into training primary care providers to better diagnose and treat mental health problems. Psychiatrists could learn to organize and supervise local master's-level providers such as social workers, nurse practitioners, and counselors.

Nine residency programs around the United States offer a combined psychiatry/family practice track, but there is no general requirement specifically for rural training, said Nancy Delanoche, M.S., associate director of APA's Office of Graduate and Undergraduate Education. Including new rural elements in residency would take time because standards are reviewed only at five-year intervals, she said.

In reality, said Silverblatt, there will be no single answer to improve access to mental health care in rural America. Almost every possibility will have to be explored and evaluated in the hopes that it will contribute in some way to easing the shortage, she said.

"Putting 'Rural' Into Psychiatry Residency Training Programs" is posted at <http://ap.psychiatryonline.org/cgi/content/full/31/6/423>. "Hide and Seek: The Elusive Rural Psychiatrist" is posted at <http://ap.psychiatryonline.org/cgi/content/full/31/6/419>.

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