FIG1 Years of being on call 24
hours a day, seven days a week finally took their toll on psychiatrist Joan
Dickson, M.D., R.N. Dickson and the Glendive Medical Center in Montana cannot
agree on terms for her future employment and have agreed to part ways in June,
leaving an area the size of Rhode Island without a psychiatrist.
Joan Dickson, R.N., M.D. "I'm the only psychiatrist in 17
counties, and I get two or three calls a night, every night...."
Courtesy of Joan Dickson
Theirs may be the story of just one psychiatrist and one medical center,
but it reflects a larger tale of the precarious status of mental health
services in rural areas.
"This is a matter of personal choice and professional sanity,"
Dickson told Psychiatric News. "I'm the only psychiatrist in 17
counties, and I get two or three calls a night, every night, from emergency
departments about one of my patients or other psychiatric cases."
It is common to be the only psychiatrist in remote regions, said Satya
Chandragiri, M.D., of Salem, Ore., the last chair of APA's Caucus of Rural
Psychiatrists, which has been inactive for the last two years. "You
can't avoid being on call. Burnout is a serious problem in rural areas because
there's just not enough support. You need to have the right attitude and
multidisciplinary teams with people like nurse practitioners and case
Practicing psychiatry in Glendive is challenging, Dickson said.
Professional boundaries are hard to maintain; there are no colleagues across
the hall or even across town to consult with. "I had to do a lot of
educating of the medical staff, center personnel, and patients about what a
psychiatrist does," she said. Part of her original agreement to work at
Glendive included purchase of an ECT machine.
Dickson now works 4.5 days a week, practicing both psychiatry and family
medicine. She would like to cut back to 3.5 days a week and have the medical
center hire another psychiatrist and midlevel professionals such as physician
assistants or nurse practitioners to cover part of the on-call work.
The medical center wants her to go to five days a week, be on call
regularly for general medical problems, and remain on call around the clock
for psychiatric emergencies, she said. "I don't need to drive myself to
the brink of exhaustion." She said she follows about 500 active
patients. Officials at the Glendive Medical Center did not return several
calls asking for comment.
Officials at the center told her that the main issue in the disagreement is
financial. They said that her practice has lost $238,000 over the last three
years, according to Dickson. She doesn't doubt that figure. Lack of insurance
and many Medicaid and Medicare patients mean that her services are reimbursed
at only 25 cents on the dollar, she said. Montana ranks first among the states
in the percentage of Medicare beneficiaries residing in rural areas (76
percent compared with 23 percent nationally).
The Glendive crisis comes as no surprise to Ann Rathe, M.D., co-director of
High Plains Psychiatric Associates in Billings and president of the Montana
Psychiatric Association."Her requests are not unreasonable," said
Rathe. "We're all overburdened. It's difficult to practice frontier
She knows Dickson and is already getting calls from some of her patients
looking for follow up after June. Local mental health personnel are worried
about the aftermath. Services in the region are slim. There are two
psychologists, a pair of social workers, and a licensed counselor with an
The need is there, however. Montana has ranked second in recent years in
the death rate by suicide (19.3 per 100,000 population) and seventh in the
percentage of population lacking access to mental health care (41.6 percent),
according to the state's Office of Rural Health.
Glendive Medical Center spent several years looking for a psychiatrist
until Dickson was hired, Rathe recalled. In fact, it's hard to recruit a
psychiatrist anywhere in Montana, she said. Whoever replaces Dickson will
still be the only provider, four hours by car from the nearest colleagues in
Billings. Rathe finds the current impasse disturbing.
"They could have her for 70 percent of the time rather than no one
for two or three years while they look for her successor," said
Employers may spend $20,000 to $30,000 and several years trying to recruit
a rural physician, said Chandragiri. Salaries are not as high as in
metropolitan areas, so other incentives, like loan forgiveness or beautiful
scenery, become important recruiting tools. "You can't practice in rural
areas like you do in Manhattan," he said.
Dickson would seem like the ideal rural doctor. She grew up 150 miles north
in Scobey, Mont., although she took a winding road to psychiatry. After high
school, she worked as a carpenter and truck driver before becoming an
emergency medical technician and then a nurse. She went to medical school as
part of the Washington, Wyoming, Alaska, Montana, Idaho partnership, which
directs students from Western states without medical schools to the University
of Washington. She did her residency in West Virginia and is board certified
in family practice and psychiatry.
Once she finishes working at Glendive, Dickson plans to take some time off,
then find a job as a psychiatrist in Billings or at another site in eastern
Montana, she said. ▪