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Healing ‘doctor drain’ in rural Minnesota provides additional community benefits
SIOUX FALLS, S.D. — One of the most difficult challenges rural communities face is not only how to attract health care professionals to their traditionally underserved areas, but also specifically how to train them for their unique local needs, and keep them from leaving for often better opportunities in urban areas. The situation, which has been extensively detailed during a conference here this week, is especially dire in the field of mental health due to the combination of increased need, long work hours, lack of professional networks and typically low pay.
In northern Minnesota, however, a small group of local behavioral health specialists have created a post-doctorate program that has not only established one of the nation’s first pipelines of providers, but has enhanced the way existing agencies and providers interact for the betterment of an entire rural region.
Dr. Jeffrey Leichter, one of five founding members of the Minnesota Consortium for Advanced Rural Psychology Training, told conference attendees on Tuesday that one of the major challenges associated with bringing behavioral health care providers into rural areas is that few are adequately prepared for the realities of practicing there.
“In a rural community, you can’t just say, ‘I treat eating disorders, and that’s all I do.’ You just can’t do that in a smaller community,” Leichter explained.
A mental health provider in a smaller community not only needs to be able to see a wide variety of clients at all life stages, often referred from various community agencies, but needs to understand when his or her scope of practice has been exceeded and a referral has to be made.
“That’s a very difficult thing to decide,” he said. “Do I keep a client even when I know that there is a provider several hours away with more knowledge about a specific condition? Since many clients won’t travel that far due to transportation or financial issues, are such clients actually better off with the care I can provide even when it will be more generalized? It becomes a question of whether some care is better than no care at all.”
There is also the aspect of running a “fishbowl medical practice,” in that clients and providers are thrust into the same day-to-day routines. The situation, he said, makes it difficult, if not impossible, for a provider to ever really leave the office.
“There are a lot of ethical boundary issues,” he said. “If you live in a small town, your client is pumping your gas. Your client is on the church committee with you. Your client is across the table at a supper you were both invited to attend. … Those are ethical issues that you don’t learn about in school.”
In addition to lower pay through a client-base that is primarily covered by either Medicare or Medicaid, the scrutiny and other unique demands that make it difficult for smaller communities to attract and retain providers, there is also the added burden of the inherent risk factors and cultural differences of working with a rural population.
“Most rural residents face triple jeopardy,” he said. “That is, they are poor, uninsured and live in isolated areas.”
Another way to describe the problem, he said, is by the “four As,” which are accessibility, availability, acceptability and affordability. Rural residents seeking even the most basic health care are impacted by each.
For all of these reasons and more, Leichter and four other local providers accepted a $23,000 Minnesota state grant and began writing a curriculum that would specifically provide post-doctorate psychologists with first-hand experiences of practicing in a rural setting. Since accepting its first psychology resident in 2006, MCARPT has graduated three students, all of whom have gone on to provide services in underserved areas of Minnesota. Two more residents are anticipated to complete the program this fall, and there is a possibility that the new section that begins in October will expand to three residents.
Those who developed and planned the Detriot Lakes-based training program, did so with a specific goal in mind: “Reduce the shortage of psychologists practicing in rural communities due to poor retention of mental health professionals in underserved parts of the state and thereby enhance access for rural residents to quality mental health services in their communities.” In short, it really was about creating a pipeline of professionals that could stem an existing and problematic shortage. The results of providing the service, however, have also had a local, positive impact.
“There are multiple benefits,” Leitcher said. “There is direct benefit to the community in the sense that we are populating the number of mental health professionals over the course of time that are going to be in the community. This particular project — and I don’t think I’m being overly boastful — has created cohesion among these 11 agencies that previously often times never talked with each other. There’s a connection … [and] now they all speak to one another in the interest of making sure the fellowship program works smoothly.”
Existing professionals within the community have also been able to combat feelings of isolation due to interactions, like group supervision meetings, that are built into the program.
“There aren’t a lot of psychologists in our area, but of those that are, many are involved in the program by doing supervision or teaching or some other type of training element,” he said. “I think it is very fair to say that a lot of folks who kind of felt like they were out there by themselves are now being brought into the fold of this project, and are feeling like they are a part of something that is very cutting edge and innovative.”
Since 80 of Minnesota’s 87 counties are considered to be mental health shortage areas, Leichter laughed when asked how long it would take MCARPT to provide psychologists to all underserved areas of the state.
“A lifetime at least,” he said and laughed some more. “But we are making a dent.”