Unique Challenges and Joys of Rural Small-Town Outpatient Psychiatry

When I started my residency, I did not know which branch of psychiatry I wanted to pursue. As years passed, I enjoyed inpatient services more than outpatient. In the inpatient setting, I could manage patients in a crisis situation, stabilize them, and send them out, with the sense of instant gratification. I never saw myself as an outpatient provider sitting in the clinic waiting for patients to show up. I wanted to get going and get things done.

As destiny had it, I ended up at the community mental health clinic in a rural setting for my first real job. Although I really would have preferred to work in an inpatient setting, I loved the idea of a community clinic because I would be helping people in need, including those with no insurance. Patients would travel hundreds of miles just to see me. I soon realized the pressing need for medical providers in rural communities . . . it seems many health care providers are not attracted to rural settings.

The closest psychiatric hospital was about an hour’s drive away. When I was in residency, finding a bed was very “tricky”; now, out here the middle of nowhere, I don’t have the luxury of having a hospital at my disposal for admitting patients.

I started questioning myself about my career path. “Did I make a mistake?”

As word of my arrival got around, patients came in droves to see the new psychiatrist in town. Some were probably relieved to find a doctor who (they hoped) would stay long enough to provide consistent follow-up care. Some wanted to test the new doctor to see whether she would prescribe their “favorite pills.” Others were just glad that the wait to see a psychiatrist would not be so long.

I quickly realized that, out here, I was treating as outpatients those whom I would have admitted at the drop of a hat during my residency. I started seeing a variety of patients-the compliant ones, the drug-seekers, those who regarded me as their guardian, grateful patients, no-shows who missed multiple consecutive appointments, and even some miraculous turnarounds that we all dream of.

I treat patients in crisis situations in the clinic just as I would if they were inpatients; the same medications are used. These patients may return to the clinic for follow-up the same day, the next day, and the day after. Inpatient hospitalization is discouraged unless it is absolutely necessary.

The clinic staff consists of a strong team that includes a social worker, therapist, nurses, and clerks. Local agencies that work with the mentally ill help the clinic and function as “extended eyes.” In certain situations, family members are very helpful. Even the local sheriff’s department is available to help when needed. So far, I am proud to say, the clinic staff has been able to provide intensive treatment for some critically ill patients on an outpatient basis-and at a reasonable cost. However, there are occasions when inpatient admission to the nearest city hospital cannot be avoided.

I feel very fortunate to be able to practice in an inpatient-like setting on an outpatient basis. I get instant gratification from helping patients who are in crisis.

I have come to realize that it does not really matter where you are located or what kind of setting you practice in. The key to success is a team of people who think alike and who have the same goal. My team and I sometimes spend hours trying to find the right kind of help to assist our patients who are confused and without orientation in life-and we occasionally spend hours helping our patient understand the plan.

Our team has challenges, but we help each other out and try to have fun together-for example, by experimenting with our culinary skills. Overall, we enjoy our small-town setting. Without the team effort, it would not be possible to provide holistic care for all the patients we serve. I am proud to be a part of such a great team and realize that teamwork is the real key to success.

When you have a strong team, you can provide quality mental health care and have an immensely satisfying career-even in the middle of a cornfield.