Maria Elena Arizaga, M.D., is in her fourth year of residency in the
Department of Psychiatry at the University of New Mexico (UNM) in Albuquerque.
She works two days a week as part of her training at Hidalgo Medical Services,
an outpatient, federally funded agency in Silver City, N.M., population
30,000, and Arizaga's home town.
Placing residents in rural clinics is just one piece in the mosaic that her
department has put together to help address the shortage of mental health
services in remote and underserved parts of the state (see Rural Psychiatry
Isn't Easy, but Rewards are Ample).
New Mexico is a state marked by high desert, deep canyons, steep mountains,
open spaces, great distances, a thin economic base, and a scattered and
ethnically diverse population. Most of those facts make it an extraordinary
place to visit, but the combination also makes connecting people with medical
care—especially mental health care—all the more difficult.
Outside the capital, Santa Fe, or the state's largest city, Albuquerque, a
psychiatrist may put in more time driving (or flying) than seeing patients.
Patients may have to drive for hours to reach the nearest clinic or even a
remote telehealth site.
Closing that gap is an uphill struggle in many parts of rural America.
Myriad solutions have been tried, from federal loan forgiveness programs to
The Department of Psychiatry at the University of New Mexico School of
Medicine has adopted a number of initiatives to bridge the
gaps—collaboration with other behavioral health professionals,
integration of psychiatry with primary care, computer technology for
telehealth services, and programs tailored to the state's large
Native-American and Hispanic populations.
But for the last 14 years, the residency option, part of the Rural
Psychiatry and Behavioral Health Training Program, has been at the center of
efforts to reach the underserved. The rural track sends psychiatrists in
training to clinics in outlying areas of the state to learn, to provide
clinical services, and to awaken residents' interest in working there after
they complete the program.
Arizaga is a part of this solution. In her PGY-4 rotation, she works with
primary care providers to clarify diagnoses and manage medications. She does
psychiatric evaluations and may see a patient from one to three times before
transferring long-term management to the primary physician.
In most ways, the UNM residency program is like most others, said Stephen
Lewis, M.D., an assistant professor of psychiatry and head of the residency
program. It meets all the usual standards of the Accreditation Council for
Graduate Medical Education, but differs because of the special ethos of the
entire medical school and the added dimension of the rural track.
"I'm a UNM medical school grad, and if there's one thing they ingrain
in you, it's that New Mexico is a poor state, and it funds the medical school
to provide a service to the state," said Lewis. "This is the
underlying premise of all specialties here. We've turned out good scientists
and researchers, but our goal is to produce good clinicians. When we're
interviewing candidates for residency, we ask ourselves—how will our
decision affect practicing medicine in the state?"
Helene Silverblatt, M.D.: "The program encourages psychiatry
residents to integrate into the community and not just be a prescription
Credit: Aaron Levin
The rural residency track began 14 years ago, shepherded by Helene
Silverblatt, M.D., an associate professor of psychiatry and family and
community medicine and medical director of the rural psychiatry program. The
program is funded by a contract with the Behavioral Health Services Division
of the state's Department of Human Services.
Silverblatt built the program by connecting with small-town clinics around
the state and finding psychiatrists who already practice there to help with
"We don't oblige residents to go into the rural program, but will
accommodate anyone who chooses to do so," said Silverblatt. "About
four or five—half the average of eight residents in each class—do
the rural training."
They arrive by different routes. Some come from rural backgrounds, others
grew up in cities. Some hear about the rural track early and choose New Mexico
for that reason, while others find out later.
The program initiates residents gently. They travel to a rural site for one
day each semester in the second year of residency. In the third year, they go
out one day a month, mainly to observe how that site works and to develop
ideas for their fourth year, when they spend a day or two a week for between
six months and a year. Their assignment goes well beyond practicing psychiatry
"The program encourages psychiatry residents to integrate into the
community, and not just be a prescription writer," said Silverblatt."
We try to vary the experience. They may teach other staff, or visit the
local schools, or develop some research project, or learn negotiating
skills—like how to refuse to work in 10-minute blocks doing med
She gets the rural residents together once a month for lunch to share
If Arizaga was drawn to rural psychiatry by her own roots in the state, two
others took the long way around.
Caroline Bonham, M.D., came to New Mexico precisely to do rural psychiatry.
She was born in the United Kingdom, the child of American parents, and went to
medical school at the University of Nottingham.
"I like the land and the experience of meeting different
people," she said. "In rural clinics the teams are smaller; the
interdisciplinary training is less siloed."
Now in a fellowship year, Bonham is working on a research project on
behavioral health in rural areas. She's learned that attitudes about mental
illness vary by subpopulations. In rural areas, she finds, people adopt a less
biological point of view than their urban counterparts.
"They'll talk about community and explain things by unemployment or
drugs," she said. "There's not more stigma, but a different kind
Differences go beyond that, as well.
"A lot of evidence-based psychiatric services are validated in urban
settings, but many won't work in rural areas," she said. For instance,
with smaller staffs, people often have to double up on tasks.
She's also doing a clinical rotation, flying once a month to Carlsbad,
N.M., and doing further consultation twice a week via telehealth. In Carlsbad,
she's booked all day with patients, doing a mix of initial one-hour
evaluations and medication discussions. She supervises two therapists and
discusses patients with them. She also sees some developmentally disabled
patients, who come in with their parents and case managers.
"In Carlsbad, I see a similar mix of patients as I might in a city,
but also a lot more co-occurring disorders complicated by methamphetamine
use," she said. Many people have less access to psychiatry and to
medications. "I see many more cases of never-treated major depressive
disorder than in Albuquerque, because here they would be treated in primary
Florian Birkmayer, M.D., grew up in Austria and Germany, came to the United
States for college (Princeton) and medical school (Columbia). He went to UNM
for his residency and did his rural rotation at Na'Nizhoozhi Center Inc., a
Navajo alcohol detoxification and rehabilitation center in Gallup, N.M.
"I was always interested in Native-American culture, and I wanted to
learn how to use Navajo traditions in a clinical setting," he said."
The Navajo were very kind and took me under their wing. The key was not
my job description but the relationship."
He arranged to get a full two weeks away from the medical school during
residency and went to ceremonies in a sweat lodge and the hogans (traditional
Navajo houses). People explained to him traditional healing and, with that
knowledge, he could serve as a bridge to hospitals.
Arizaga also seeks to tie contemporary psychiatry to indigenous healing
traditions. She hopes to learn more about curanderismo, a form of
Latin American folk healing, because many of the Hispanic patients she sees in
Silver City believe in its value.
Curanderismo looks not only at the individual but also at the family and
community surrounding them, said Arizaga.
"I see a lot of analogies with psychodynamic therapies," she
said. "There are a lot of transcultural differences and
similarities—but more similarities."
Understanding the local cultures is a necessity in New Mexico, said Bonham."
When I began, there were things I didn't know or I felt uncomfortable
However, the rural program gave her more confidence to ask patients about
their lives and plans. Now, if patients want to take part in a Navajo healing
ceremony, she knows they will be fasting and spending time in a sweat lodge,
and she will adjust their medications accordingly.
She's also learned about the challenges facing her patients in the simplest
aspects of medical care.
"Don't assume that the same resources are available to your
patients," she said. "If you ask them, 'Where do you get your
medications?' it may be 90 miles away."
Most of the graduates of the program stay in New Mexico, and perhaps 25
percent end up in rural areas, said Lewis. About half practice in underserved
Birkmayer specialized in addiction psychiatry now and is an assistant
professor at the medical school. He lives in Albuquerque but maintains
contacts with clinics around the state. "You don't have to live in a
small town to work there," he said.
After residency, Arizaga plans to return to Silver City and extend her
family's commitment to the medical profession there. Her father practices
dermatology and her mother holds a Ph.D. in clinical psychology.
Her sister, Teresa Arizaga-Morales, M.D. (another UNM grad and former
resident), is an inpatient attending psychiatrist at the Gila Regional Medical
Center in Silver City. The two have talked about how best to help their
community and provide services to the underserved.
Maria Elena has decided that to reach the greatest number of people when
she returns home, she will eventually develop a consultation service and
medical management practice and serve as an outpatient consultant to jails,
schools, and nursing homes.
When she does, she'll be doing her part to complete the vision of UNM rural
psychiatry residency program.
Information on the University of New Mexico's Rural Psychiatry and
Behavioral Health Training Program is posted at<http://hsc.unm.edu/som/psychiatry/crcbh/rural.shtml>.▪