I ran across the story posted by Minnesota Public Radio
about a psychiatrist retiring in northern Minnesota. The past 30 years or so
Dr. Hardwig was the only psychiatrist in International Falls Minnesota. For
people not familiar with Minnesota geography I included a map of the state at
the top of this post. It is a town of
about 6400 people right on the Canadian border.
It is ranked as the 133rd largest city in Minnesota. The
closest Metro area would be Duluth with a population of about 85,000 people. International Falls is 163 miles from Duluth
and 296 miles from Minneapolis. As noted
in the article, this is a tough place to practice psychiatry. There are few
resources and no easily accessible psychiatric beds.
Dr. Hardwig practiced exclusively in this environment until his recent retirement. In the article we
learn that his schedule was always full. He was always willing to fit people
into his schedule based on need. He provided a valuable service to this patient’s
and primary care physicians in the area. He successfully developed a way to
interact with his patients in the community and maintain clear boundaries. He
treated the entire spectrum of psychiatric disorders out of necessity. There
were no specialists for him to refer to at least in the practical sense. When
you advise people that they have to travel 100 or 200 or 300 miles to see a
specialist they are willing to do it once or twice but not for the rest of
their life.
Full disclosure on my part, I know Dr. Hardwig
professionally. He was one of my predecessors as president of the Minnesota
Psychiatric Society. That means over the
three years of that professional cycle, he commuted to the Twin Cities and
developed agendas, ran meetings, met with MPS members, and conducted all of the
other duties of those offices. He was a thoughtful president with a unique
perspective also conducted one of our more unique scientific meetings. He also
belonged to a discussion group about medicine and psychiatry in that group he
talked about his ideas for recruiting psychiatrists into rural areas. That idea
was one of the main points of the MPR article.
The shortage of mental health professionals in general and psychiatrists
in particular was emphasized.
This shortage is nothing new. When I started out as a
psychiatrist back in the late 1980s, I was assigned to a physician shortage
area in northern Wisconsin. I was the only psychiatrist in a county of about
50,000 people for a period of three years. During that time I was the medical
director of a community mental health center and for one year commuted to a
town 65 miles away to keep their small inpatient psychiatric unit open. They
had a deal with the federal government and would lose significant funding if
that unit closed down.
One of the early lessons I learned was that I was no longer
practicing medicine in a large multi-specialty clinic with unlimited resources. It is quite a shock to go from an academic
psychiatry department with about 60 full-time staff and 24 residents to be the
only psychiatrist in town. Professional isolation has been the term used to
characterize that situation and also explain why psychiatrists don’t want to
wander too far from Metropolitan areas. The atmosphere has improved to some
degree with the advent of a functional Internet. While I was in that position, they
were trying to get me a telepsychiatry connection through a local hotel satellite television. In the end the cost was exorbitant at about $20K/year and we never tried it. Today telepsychiatry is routine in the same
area and has been used for a decade by the local VA clinic.
The workload was fairly intense at times because our clinic handled all of the crisis calls from the county and I was backup for any nurse, case
manager, or psychologist who was doing crisis intervention in the community or
in some cases the county jail. There was no cross coverage for vacations or professional conferences. I was on call 24/7 wherever I was across the country. On any given night I could find myself seeing somebody in jail, at home, in the small general medical and surgical hospital in town, or any of several nursing homes. But even more pressing was the fact that I was a
lightning rod for those people with mental illness and a propensity for
violence. All these factors led me to return to a large multi-specialty group
at the end of my three-year tenure.
When it comes to figuring out what it takes to be the only
psychiatrist in town, treat all possible problems, and do that for decades - I
don’t have the answers. Dr. Hardwig clearly
does and by all accounts he did a great job. In my postings of the MPR article
in various places around the Internet, I had another psychiatrist question my
use of the word “great”. I don’t really see any other way to describe it. What else can you say about the psychiatrist or any physician who practices
intensely with minimal support and resources and gets the job done?
There are all kinds of reasons why physicians are critical
of one another. There is the competitiveness of youth and the need to secure a
position. Most physicians notice that slips away by midcareer and a more
important function is teaching and mentoring rather than competing against
everyone in the field. Psychiatry is at a disadvantage relative to other
medical specialties. The media spin on psychiatry is decidedly negative as I
noted in several recent posts. I don’t know if that just gets uncritically
accepted or internalized especially by psychiatrists who are criticizing the
rest of us. Even though this MPR story was positive it mixed Dr. Hardwig’s career
accomplishments with the specter of psychiatrist shortages in rural America. I
understand their point, but in terms of motivation focusing on this
accomplishment would have potentially done more to motivate people to practice
in that environment. The accomplishments of Dr. Hardwig are certainly inspirational.
I have nothing but the best wishes for Dr. Hardwig in his
retirement. Even though there are tens of thousands of psychiatrists to go to
work every day and get the job done, his job was probably more demanding with no cross coverage for call or vacations. They
have been trying to recruit a replacement ever since he announced he was going
to retire and have no success so far.
I hope they do succeed in finding a psychiatrist as unique as the one who just retired.
I hope they do succeed in finding a psychiatrist as unique as the one who just retired.
George Dawson, MD, DFAPA
References:
Alisa Roth. In International Falls, the last psychiatrist for 100 miles just retired. December 20, 2019. Link.
Graphics Credit:
User: Wikid77 (from National Atlas of the United States) [Public domain]: File URL: https://upload.wikimedia.org/wikipedia/commons/e/ed/Map_of_Minnesota_NA.jpg
