Two recent articles in Academic Psychiatry (1, 2) advocated psychiatric residency training in rural psychiatry. The program described here has incorporated rural training into its community psychiatry curriculum. It represents an academic-state-rural partnership that is financially supported jointly by the state department of mental health, the university, and the agencies at the rural sites.
The program has existed for 12 years. Its goals are to increase the cultural competency of residents concerning the value systems of diverse populations, including rural populations, and how they affect people’s views of mental illness, homelessness, and substance abuse; to expose psychiatric residents to the particular challenges of working in a rural system and teach them how to maintain their professional identity in the midst of challenges such as role diffusion and limited resources; to help psychiatric residents develop as clinical scholars and encourage them to contribute as coauthors to clinical studies at the rural site; and to encourage psychiatry graduates to consider careers that incorporate service to rural communities.
Within this annual community psychiatry curriculum in postgraduate year 2 (PGY-2), 3 hours of didactic time are devoted to seminars on rural psychiatry (Table 1).
The medical school is community based, and faculty salaries are partly or entirely funded by psychiatry department or university contracts with community agencies and hospitals. In the rural psychiatry program, funding for a permanent full-time faculty member is accomplished by a combination of a year-long, renewable contract with the agency involved (40% of salary and benefits), the university (50% of salary and benefits), and the department of mental health (10% of salary and benefits). The rural agency pays by monthly installments. Benefits and professional liability coverage are provided by the medical school (as for all faculty), and the faculty member is considered a full-time university faculty member, with benefits calculated accordingly.
The faculty member works 2 to 3 days per week in the rural clinic. Driving time to the clinic is 1.5 to 2 hours one way, each day, so it is a significant time commitment. The remaining faculty time is allotted to teaching, research, and scholarship at the university. Independent practice through the medical school practice plan is also permitted. Each assigned resident comes to the clinic site for a full day, every other week. On alternate weeks, the residents rotate at an urban site.
The faculty member sees one patient in the clinic while the resident is seeing a different patient. The faculty member discusses the resident’s patient with the resident, and then the faculty and resident reexamine that patient together. Approximately 20 patients (two–three new, 17–18 returning) are seen in an 8-hour day by the faculty member, and the resident sees approximately eight patients. The clinic bills patients or third-party payers only for face-time by the faculty member. The clinic does not pay the resident nor bill for the resident’s time. Resident stipends are obtained by the department from a variety of sources, usually affiliated hospitals, and this covers the resident’s salary.
This program developed before telemedicine was in large use. The agencies have not determined how to bill for this service, so it is not provided at this time.
Rural areas used in the program are within 60 to 90 miles of the community-based medical school, so transportation to these sites on a part-time basis is feasible for academic faculty and residents, particularly if they live in a suburb nearer to the rural site than the department offices and drive directly from their homes. Although this degree of proximity to the medical school is not available to all programs, it provides a unique opportunity for learning when available. In addition to a rural experience, the resident also experiences working in an area in transition (i.e., changing from farming to manufacturing or other industries). Residents learn about critical rural challenges such as how cultural roles and systemic stress are affected by the loss of small family farms and gender roles as women move into the workplace.
At the rural site, residents use empirically validated outcome measurements that have been put in place since the program started. Residents utilize treatment algorithms for patients with schizophrenia, bipolar disorder, anxiety disorders, and major depression. They learn to consider the cost-effectiveness of medications (because most of the patients are indigent) and how to access state-sponsored medication programs and drug company programs for indigent patients. Residents incorporate best practices from the psychotherapy literature in a community setting.
Residents spend a full year getting to know rural patients, their families, and the staff members who live in the community and work with these patients.
Residents also experience the ubiquitous pressure on community psychiatrists to see large numbers of patients. They experience requests for advice and support by staff that would be directed to other supervisors at an urban site. They observe that medication choices are sometimes made on the basis of “sample medication” availability or generic cost for patients who cannot afford them and are uninsured but ineligible for public assistance (e.g., the “working poor”).
Residents and clinical and administrative staff members have coauthored a book chapter on the rural homeless mentally ill population (3), developed the peer review process used at the rural site as part of the quality assurance program (4), and written articles on housing options for the rural substance-abusing mentally ill population (5) and on the administration of mental health organizations in rural areas (6). An article on the adolescent crisis services project has also been published (7). In addition, the rural site successfully competed for a federal grant to assist the homeless population of the community (3).
Prior to the start of the rural training program, no graduates had selected full- or part-time careers in rural sites. Since the program was started, 14 of about 50 residents selected jobs at rural sites in the state. About half are now medical directors, and most retain a clinical affiliation with the university.
The rural psychiatric residency training program has been very successful at its original site and, by popular demand (a rural agency and the state), is about to expand into another rural county. Locations near medical schools that are within driving distance of a rural or rural/manufacturing community could use this model. The model would require modification (including telemedicine) where greater distances are involved or where faculty clinical work must be done at the medical school site to support a university-based hospital or clinic.
At the time of submission, the authors declared no competing interests.