I'm city folk, all the way. I've never lived in a small town much less anywhere rural. And while Baltimore sometimes feels oddly provincial, we have lots of docs. Lots. With Johns Hopkins, the University of Maryland, and Sheppard Pratt as the forces in academic psychiatry, there are also many community hospitals which offer inpatient and emergency psychiatric care, plenty of psychiatrists in private practice, and I'm fond of saying that in my neighborhood there are more psychiatrists than cockroaches. How many shrinks can fit in one community pool at a time? Oh, a bunch.
I've always thought it would be hard to work as a psychiatrist in a small town where everyone knows everyone. If there's only one psychiatrist, doesn't that mean that he probably treats some of the other docs, some of the people he may run into socially? And what if the only psychiatrist, or his family member, has a mental illness: where does he go for treatment? And what if he needs psychotherapy-- who does he talk to? And what about professional consultation on difficult patients, a friend to blow things by (see my post on Camel), or finally, how does he get together to do podcasts for his blog?
So when I put up my post on the 10 things I don't like about being a shrink, there came a reply from Mellowdee, a small town psychiatrist. I liked her response so much, I wanted to put it up as a guest post. And here you have it, insights from a small town shrink:
I, too am blogging when I should be working! In addition
to all the biggies, like getting shafted by insurance companies, what I find
annoying about being a shrink relates directly to the fact that I live in a tiny
town. There are only four other psychiatrists in private practice, and one of
them is my husband. There is a small local hospital which I would never in a million years use if a patient needed admission, the care is so abominable.
1. Lack of referral resources means I'm taking care of super sick people that should be referred to a more intensive setting, but there is no such place to send them. There are many patients in the practice that aren't going to get better as a result, when they might if the resources were available. It's extremely frustrating.
2. Firing patients for not paying, and then seeing them at the post office, the movies, a restaurant, at my kid's school, etc. and having them come over, to tell me how much they need my services (without mentioning the outstanding balance), while everyone around is listening with ears flapping. It would be a challenge for Emily Post.
3. Having local idiot GPs change my patient's psych meds. Either because a. the patient calls/sees him/her for psych symptoms instead of me (while extremely annoying and grounds for firing the patient, the patient is still the patient and can't be expected to be reasonable), or b. the GP is an arrogant idiot who has boundary problems and changes psych meds during an annual checkup or whatever. When the patient crumps, guess who has to deal with it?
4. Prescribing off label doses (standard practice since I get the sickest of the sick) of the one medicine the patient
has responded to, which, even though I take the time to fill out the proper
paperwork, the insurance refuses to pay for.
5. Being a doctor, even if only a shrink, in a small town makes me a celeb, and all my behaviors (my husband's and my kid's) are observed with great interest. It's taken me years to stop worrying about it, and simply to live. Early on, I had a patient tell me that the state of my husband's car was a disgrace (he's a slob, it was undoubtedly littered with take out bags, empty cardboard coffee containers, dirty snotrags, drifts of articles, sneakers and exercise equipment...). I had to laugh! I shrugged,and commented that when you're married, you have to pick your battles.(The patient didn't agree with me.).
6. Getting stuck with a patient that should be a clinic patient (i.e. doesn't pay reliably, is very needy, has constant drama in his/her life, calls and pages a lot) but the clinic is so overwhelmed it would take six months to get the patient there, and the patient isn't behaving in a way that's obvious enough to justify refusing to continue seeing them....
Sigh. I have to stop. There's more, but why go on?
As you may have guessed, I won't be moving to South Dakota anytime soon.