Friday, February 4, 2011

Family Doctors -- The Default Psychiatrist

I thought there would be lots of colds, flu, and diarrhea in my rural medicine rotation, remember? Ordinary, boring pathology that mom could treat as well, if not better, than the doctor. This week, I've seen shingles (a burning, painful rash that sometimes hits on those who've had chickenpox), polycystyic kidney disease, a transient amnesia that I thought represented a transient ischemic attack and may still prove to be, and a boatload of psychiatric issues couched (no pun intended) in the guise of daily life. To my friends in family medicine, I can only say, you were right and I was wrong -- family med is anything but boring.

It's easy to create the impression that "rural" automatically means "country," especially when referring to communities like the one I've been describing. Well, it does and it doesn't. My preceptor practices in a small town of about 1200 persons but his patients come from miles beyond the town limits. It is country, no doubt about it. But rural really means under-served more than anything else. For instance, in a community that numbers, including outlying farms and communities, a population closer to 12000, the yellow pages lists one psychiatrist.

True, patients could drive to Augusta or Bangor or even Waterville, but that's hardly a realistic expectation when gas is $3.19 a gallon and the average family limo is a four-wheel drive truck that drinks gas faster than you can put it in the tank. Even if they have insurance, considering the limits placed on psychiatric care by most policies as well as sky-high deductibles, having insurance doesn't simplify the problem of paying for ongoing care.

That's what "rural" really means. Limited access as well as limited services to begin with. It's almost easier for a dairy farmer to make a living in these more remote areas than it is for a mental health clinician. For that reason, because doctors also have to put food on the table and payment can be uncertain, it's difficult for a community to keep a psychiatrist in practice even when they find a willing victim.

So, what do you do? You either keep your depression, anxiety, tormenting internal voices, or suicidal thinking to yourself until they get out of control or you go see the family doc who takes care of your high blood pressure. But, lest this sound like a good deal, it's not really. Family doctors function by necessity as default psychiatrists, but their training has its limits, as does the psychiatrist's. It has to be that way because no one can possibly learn everything. Not even doctors.

One solution involves dual-tract medical education: family or internal medicine slash psychiatry. If you're fortunate enough to match in one of these highly competitive residency programs, you're ahead of the game because at least you can count on physical medicine to help subsidize the psychiatric care you deliver. But Maine doesn't have a dual residency program and students tend to practice near their training site and that leaves us, once again, out in the cold.

It's a dilemma that needs serious attention. And we've got to do something because the needs of patients in outlying areas for psychiatric care are overwhelming and as things stand, there just aren't enough of "us" to go around.

(Photo of a park in the snow in Skowhegan, Maine copyright 2011 by the author)

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