Thursday, March 01, 2007

Small Town Shrink with Insights From Guest Blogger Mellowdee

I'm city folk, all the way. I've never lived in a small town much less anywhere rural. And while Baltimore sometimes feels oddly provincial, we have lots of docs. Lots. With Johns Hopkins, the University of Maryland, and Sheppard Pratt as the forces in academic psychiatry, there are also many community hospitals which offer inpatient and emergency psychiatric care, plenty of psychiatrists in private practice, and I'm fond of saying that in my neighborhood there are more psychiatrists than cockroaches. How many shrinks can fit in one community pool at a time? Oh, a bunch.
I've always thought it would be hard to work as a psychiatrist in a small town where everyone knows everyone. If there's only one psychiatrist, doesn't that mean that he probably treats some of the other docs, some of the people he may run into socially? And what if the only psychiatrist, or his family member, has a mental illness: where does he go for treatment? And what if he needs psychotherapy-- who does he talk to? And what about professional consultation on difficult patients, a friend to blow things by (see my post on Camel), or finally, how does he get together to do podcasts for his blog?
So when I put up my post on the 10 things I don't like about being a shrink, there came a reply from Mellowdee, a small town psychiatrist. I liked her response so much, I wanted to put it up as a guest post. And here you have it, insights from a small town shrink:
mellowdee said...
I, too am blogging when I should be working! In addition
to all the biggies, like getting shafted by insurance companies, what I find
annoying about being a shrink relates directly to the fact that I live in a tiny
town. There are only four other psychiatrists in private practice, and one of
them is my husband. There is a small local hospital which I would never in a million years use if a patient needed admission, the care is so abominable.

1. Lack of referral resources means I'm taking care of super sick people that should be referred to a more intensive setting, but there is no such place to send them. There are many patients in the practice that aren't going to get better as a result, when they might if the resources were available. It's extremely frustrating.

2. Firing patients for not paying, and then seeing them at the post office, the movies, a restaurant, at my kid's school, etc. and having them come over, to tell me how much they need my services (without mentioning the outstanding balance), while everyone around is listening with ears flapping. It would be a challenge for Emily Post.

3. Having local idiot GPs change my patient's psych meds. Either because a. the patient calls/sees him/her for psych symptoms instead of me (while extremely annoying and grounds for firing the patient, the patient is still the patient and can't be expected to be reasonable), or b. the GP is an arrogant idiot who has boundary problems and changes psych meds during an annual checkup or whatever. When the patient crumps, guess who has to deal with it?

4. Prescribing off label doses (standard practice since I get the sickest of the sick) of the one medicine the patient
has responded to, which, even though I take the time to fill out the proper
paperwork, the insurance refuses to pay for.

5. Being a doctor, even if only a shrink, in a small town makes me a celeb, and all my behaviors (my husband's and my kid's) are observed with great interest. It's taken me years to stop worrying about it, and simply to live. Early on, I had a patient tell me that the state of my husband's car was a disgrace (he's a slob, it was undoubtedly littered with take out bags, empty cardboard coffee containers, dirty snotrags, drifts of articles, sneakers and exercise equipment...). I had to laugh! I shrugged,and commented that when you're married, you have to pick your battles.(The patient didn't agree with me.).

6. Getting stuck with a patient that should be a clinic patient (i.e. doesn't pay reliably, is very needy, has constant drama in his/her life, calls and pages a lot) but the clinic is so overwhelmed it would take six months to get the patient there, and the patient isn't behaving in a way that's obvious enough to justify refusing to continue seeing them....

Sigh. I have to stop. There's more, but why go on?
As you may have guessed, I won't be moving to South Dakota anytime soon.


Anonymous said...

And what if he needs psychotherapy-- who does he talk to?

Umm, see a psychologist like me. Which is what the psychiatrists I have seen in my practice have done. And I live in a small town.

Unknown said...

I lived for years in a small town with one psychiatrist: He was the big kid down the block when I grew up and a good friend of mine; I was also his patient as he was the only one in town who might be able to figure out a solution to my sleep problems. His wife was my boss.

Then they split up ... OI VEI! What a mess.

Rach said...

Great post. That is exactly the reason that I've stayed in a large city thus far... too many confusing, potential problems to even think about.

Bardiac said...

I know someone who, as a faculty member at a small college in a small town, got a phone call from their college president, warning them that he'd gotten a call from a community member complaining that they'd bought a bottle of wine at the grocery store.

Birth control for single women? Anti-depressants? We would have been totally stupid to try to get anything like that prescribed or purchased in town.

Vet care's usually great in rural areas, though!

Dreaming again said...

I grew up in a town of less than a thousand. My mom was a teacher. Your post cracked me up!

People would go to our pastor or the school principal and tell them that they didn't think she should let us wear a certain style of clothing.

Good gravy! It was absurd. Maybe I'm not as homesick as I thought I was! You've just cured me!

Midwife with a Knife said...

When I was in medical school, they had this program where 1/3 of the class spends their first year of medical school in a rural area. The hope was to recruit more physicians to rural areas.

Now if you're a family doc or a general pediatrician or internist I can see how a rural area would be great in some ways, professionally. What I came away from the experience with was knowlege that I didn't want to practice somewhere where 1) everybody came up to me in the grocery store to talk about their medical stuff and 2) my patients who needed specialized care would often be stuck having to drive 2-3 hours to find the nearest oncologist, psychiatrist, pulmonologist, etc.

Now, with my specialty, I simply can not practice in many rural areas. They don't have the facilities to take care of the kinds of babies I deliver or the medical illnesses of the moms I deliver. So, I basically can't practice in a rural area now.

They do have their advantages. My cats had a great vet, it was pretty, the hustle and bustle were less; but it isn't for me.

Anonymous said...

"4. Prescribing off label doses (standard practice since I get the sickest of the sick) of the one medicine the patient has responded to, which, even though I take the time to fill out the proper paperwork, the insurance refuses to pay for."

Boy, I'm glad I don't have a doctor like this.

So how often do you prescribe off-label to be able to say which is the "one medicine the patient has responded to"?

How many off-label scripts do you usually try before you get a response?

How long a lead-in, tapering and wash-out for the drugs that don't work?

And how much damage do you do by using your patients as guinea-pigs for unapproved drug treatments?

I'm not usually one to support insurance companies, but if their refusal to pay is reducing this sort of irresponsible behaviour, more power to their (claims dismissal) arms.

Anonymous said...

Michael, you bring up an issue that bothers me also. I think that there should be a requirement for obtaining informed consent when off label doses are prescribed. There is a mountain of paperwork required during a clinical trial, yet no informed consent is required when a doc prescribes off label doses of a drug that is already on the market. Why?