Most New Psychiatrists Live Where They Trained...and Why It Doesn’t Matter.
A guest post from a fellow Frontier Psychiatrist about addressing barriers to rural care.
The Frontier Psychiatrist—singular—is a song by the Avalanches. Frontier Psychiatry, the medical practice, is a Montana-based psychiatric practice. Its leader is Dr. Eric Arzubi. He’s my guest author today! We connected on LinkedIn, and I asked him to write about his experience making care more accessible. My big contribution was asking for some Montana shots to spice up the visuals. I think we can all agree—the moose delivers!
—Owen
About 2/3 of psychiatrists continue to live in the state where they completed their residency. Psychiatry's geographic retention rate is the highest among all the medical specialties, but I'm not sure it matters anymore.
In the past, this statistic was highlighted to make the case for the launch of a new psychiatry residency or the continued funding of an existing one. I made this very case to policymakers and philanthropists to get Montana's first psychiatry residency off the ground in 2018.
I became the Chair of Psychiatry at the Billings Clinic in Montana in 2014, only a year after finishing my child and adolescent fellowship at the Yale Child Study Center in New Haven, CT. I got the role in part because I worked in business for 8 years before pivoting to a career in medicine. I was also the last one to call: "not it!"
One of our department's biggest challenges was the recruitment of psychiatrists into Montana and their long-term retention. I thought it would have been less challenging. After all, the Billings Clinic was a well-respected health system located in a beautiful state. We also supported the entire continuum of mental health care: outpatient, inpatient, consultation liaison, and emergency care.
"Doctors stay where they train!" I was told. It made sense, but I moved across the country after finishing my own training. I guess I was the exception to that rule?
I looked at the statistics published by the American Medical Association (AMA) and, sure enough, most new physicians continue living in the state where they completed residency.
I took those numbers, put them into PowerPoint slides, and did my best to convince potential funders that investing in Montana's first psychiatry residency would improve access to quality care statewide. I argued that these newly minted psychiatrists would choose to stay in Montana and help improve the state's dismal mental health statistics.
As an aside, I had to go through the trouble of raising private and public money to train psychiatrists in Montana because the Centers for Medicare and Medicaid Services (CMS) put a cap on the number of funded residency spots in 1997. Most of those spots were allocated to academic institutions in major population centers. Chalk up another reason for poor access to psychiatry in rural communities. CMS recently added a small number of funded residency spots nationwide.
For decades, Montana, Alaska, and Wyoming have posted the three highest suicide rates in the U.S. These states are similar in that they have low population densities, large healthcare deserts, and problematic social determinants of health. Alaska and Wyoming still don't have psychiatry residency training programs. Montana has only had one for 6 years now.
According to the AMA's latest numbers, based on residents graduating between 2013 and 2022, about 57% made their home in the same state where they finished residency or fellowship training. Here are the 5 specialties with the highest post-training geographic retention rates:
1. Psychiatry (67.0%)
2. Family Medicine (66.5%)
3. Pathology (65.8%)
4. Internal Medicine (60.5%)
5. Pediatrics (60.5%)
Ironically, this statistic matters least for psychiatry.
You'd hope that having more psychiatrists in your community would directly impact access to care. Improved access to quality mental health care should improve local population health, resulting in a return on investment that keeps policymakers and funders happy. Unfortunately, I don't think that happens.
First, only 55% of psychiatrists accept Medicare and only 36% accept Medicaid. If we assume that individuals with public insurance are among the most underserved, they just aren't getting access to the most highly trained mental health and addiction care professionals. As a result, having more psychiatrists in the community likely won't benefit a significant proportion of the most vulnerable patients.
Second, telehealth has made psychiatric care highly fungible. Post-covid, a psychiatrist, with the right licensing, can care for patients located in any of the 50 states. Local healthcare organizations now have to compete with healthcare organizations nationally for a psychiatrist's services. This is a new dynamic in the marketplace to which most healthcare organizations have yet to adapt.
Finally, residency training programs don't teach many skills that future psychiatrists need to deliver care in the 21st century. We are terrible at delivering evidence-based care at scale to the people who need it most. Don't take my word for it. Thomas Insel, MD, the Director of the National Institute of Mental Health (NIMH), recently published "Healing,” a book that eloquently describes our field's shortcomings.
Leaders in healthcare and government point to mental health statistics and declare we have a mental health crisis. They've been doing that for decades, so it's not really a crisis anymore. It's our new normal, and the sense of urgency to act on worsening statistics doesn't appear to be growing.
Things won't change unless we change the way we train future psychiatrists. Residency programs need to inspire courage and vision to disrupt the way we currently deliver care. We need to equip new graduates with the ability to do the following:
1. Provide effective organizational and clinical leadership.
2. Educate local and federal policymakers about the critical gaps in care.
3. Understand the business of medicine as well as any of the non-clinical leaders in an organization.
4. Understand implementation science so that effective clinical solutions can be delivered at scale.
5. Embrace change and innovation.
6. Join patient-centered advocacy organizations like NAMI and Mental Health America.
If psychiatry residency programs can empower new graduates with these skills, location will start to matter again. Future psychiatrists will be more invested in their local communities and they will have what it takes to improve the population's mental health outcomes.
My endless thanks to Dr. Arzubi for joining us here in the newsletter! It’s a bold call to action and attention. Thank you, and consider sharing the message with those in your life!
My new book, Inessential Pharmacology, is available on Amazon. It is suitable for psychiatric trainees or curious members of the public.
Does patient centered mean a better grasp on potential iatrogenic harms of involuntary treatment? Maybe I am misunderstanding but it seems like so much of psychiatry is about “punting” the liability ball, with patients often stuck in the middle.
Look at this thread…. Or this one:
https://www.reddit.com/r/Psychiatry/s/FEBC3GQuQF
Or this……
https://www.reddit.com/r/Psychiatry/s/sgYVGuL5Zs
It breaks my heart that ppl in crisis are not treated well :(