Iowa Funds Expansion of Rural Psychiatry Training, Services for Underserved Populations
Abstract
In the face of a vast pandemic of mental illness and a severe shortage of mental health professionals, some institutions, like the University of Iowa, are expanding services in underserved areas and their training of new psychiatrists.
Growing up with two physician parents in Hannibal, Mo., the boyhood home of Mark Twain, Katie Meidl, M.D., saw firsthand the enormous health care needs of rural communities—especially for psychiatric care.
“There was only one psychiatrist at the time for a very wide area and so much need,” she recalled. “My parents talked about it. My own experience and background were what led me to want to seek out training in rural psychiatry. I wanted to bring care to the kind of community I had grown up in.”
Today, Meidl is a third-year resident in the University of Iowa’s Public and Rural Psychiatry Track, which provides an additional layer of training in rural psychiatry on top of the standard training in the four-year residency program at the university in Iowa City.
As part of the training, she meets with patients using telepsychiatry at Clarke County Hospital, in southwestern Iowa. During her second year, she served a four-week rotation at a rural clinic where she worked with an Assertive Community Treatment (ACT) team serving patients with serious mental illness, a first-episode psychosis team, and an Integrated Health Home (a program that provides wraparound services to patients with serious mental illness). Throughout the four-year specialty track, trainees hear monthly lectures on topics relevant to rural care.
The Public and Rural Psychiatry Track, begun in 2020, is the fruit of a 2019 competitive grant from the state that provided $800,000 for the University of Iowa to train two extra residents a year in rural psychiatry, increasing the training slots offered by the University from seven to nine. And that was just the beginning of what now appears to be a remarkable growth of the university’s training program, a product of advocacy and a recognition on the part of the state’s legislators that the shortage of mental health professionals is a crisis.
In June 2022, Iowa Gov. Kim Reynolds signed a multimillion-dollar public health bill that included $100,000 in funding for up to 12 additional positions for each residency class at the university to work at five designated state facilities, pending approval by the Accreditation Council for Graduate Medical Education (ACGME).
Once it is approved, participating residents will complete a portion of their training at State Mental Health Institutes in Cherokee and Independence, Iowa, serving people with serious mental illness; the Iowa State Resource Center in Woodward, serving individuals with intellectual disabilities; the Iowa Medical and Classification Center at Oakdale, a medium security correctional facility; and the Iowa State Training Center in Eldora, serving adolescents with a history of criminal justice involvement.
Jodi Tate, M.D., a professor of psychiatry and vice chair for education at the university, credited Iowa state Rep. Ann Meyer and Iowa state Sen. Jeff Edler for championing the investment in expanding Iowa’s psychiatric workforce. “We are always advocating for better mental health for Iowans, but this really came from our legislators,” she said. “They are the ones who pushed this through.”
Ensuring Capacity for Training
The expansion of the University of Iowa’s residency program is an example of how some states are addressing the severe shortage of mental health professionals and ways in which some institutions are making creative use of state funds to expand their training programs. Five-hundred and fifty miles to the east, Cleveland’s MetroHealth Hospital—the safety-net hospital for Ohio’s Cuyahoga County—opened a behavioral health hospital last year on Cleveland’s east side that will add a total of 112 psychiatric beds and expanded the hospital’s psychiatry training program from 20 residents for all four classes to 32 (see “Cleveland’s Safety Net Hospital Builds 112-Bed Psychiatric Facility”).
New York Gov. Kathy Hochul announced, as part of the 2023 State of the State, a comprehensive plan to overhaul New York’s continuum of mental health care including a phased increase of 1,000 inpatient beds. Several years previously, the New York State Office of Mental (OMH) had begun paying for additional psychiatry training slots with the agreement that residents taking those slots would commit to working in an OMH hospital setting following completion of training.
But growing a residency is not just a matter of finding the money; it means meeting stringent ACGME requirements regarding faculty capacity and time spent by residents meeting specific learning requirements. The ACGME recently formed the Medically Underserved Advisory (MUA) Group to provide consultation specifically to institutions serving medically underserved areas and populations.
Tate said a principal obstacle to building training capacity in a rural community is ensuring there are faculty to provide supervision—in this case, at the five sites where the new trainees will be rotating. “We also have to think about housing in these remote areas—where will our residents live when they are doing monthlong rotations at these sites?”
She said the university will add more residents incrementally as capacity for training and supervision grows, first developing elective rotations at the five sites that will be launched by spring of this year, while collaborating with two institutions in Des Moines to train child and adolescent psychiatrists who will work at the State Training School in Eldora and the State Resource Center in Woodward. In July, the university will launch a public psychiatry fellowship, whose graduates will be able to provide faculty supervision at the five sites.
Over time, the program will work toward accommodating the 12 new residents the state has funded. “What we hope to do is create a culture of excitement about serving in underserved areas and working with underserved populations,” Tate said.
“A major appeal of this work is the difference you can make, because there is such a lack of services,” says Shea Jorgensen, M.D., who is photographed with her son, Finn.
Training director Erin Crocker, M.D., said past graduates of the university’s training program who have dispersed around the state have helped provide supervision for new residents in the Public and Rural Psychiatry Track. “This has been a great opportunity to partner with our own University of Iowa graduates who have stationed themselves around the state and are passionate about serving these rural areas.”
Second-year trainees in the rural track have the option of working four-week rotations at several sites throughout the state, one of which is Prairie Ridge Integrated Behavioral Healthcare in Mason City, Iowa. Katie Meidl, M.D., did her four-week rotation there, under the supervision of Medical Director Shea Jorgensen, M.D., a graduate of the university’s residency program and director of the Public and Rural Psychiatry Track.
Jorgensen told Psychiatric News that working as a psychiatrist in a rural region means being able to treat patients with a range of needs who might in a more urban region be farmed out to subspecialists.
“I wear many hats,” she said. “I work on a first-episode psychosis team, I treat geriatric patients and patients with addiction, and I am the psychiatrist on the ACT team. I’m all of those specialists in one. A major appeal of this work is the difference you can make, because there is such a lack of services.”
‘So Much More I Need to Learn’
The growth of the training program at Iowa ensures that a crop of young psychiatrists will be “in it for the long haul” to treat patients in underserved areas of the heartland. Meidl said that her work with the ACT team, in particular, was transformative.
“It really impacted what I want to do in my career,” she told Psychiatric News. “For an ACT team to work well, you need to have patients [with lived experience] as part of the team, and you have to travel, because the patients we see live so far apart. It takes more organization, but we are able to do it. It was so valuable to learn how I can work with the resources that exist and how I can integrate into the community.”
She said that she wants to follow her residency with the public psychiatry fellowship that the university expects to create.
“There’s so much more I still need to learn about systems of care for rural communities,” Meidl said. “I see myself working in a rural clinic while also building projects and creating connections between hospitals and institutions to bring better care to rural communities.” ■
