Rashmi Ojha, MD

When I started my residency, I did not know which branch of psychiatry I wanted to pursue. As years passed, I enjoyed inpatient services more than outpatient. In the inpatient setting, I could manage patients in a crisis situation, stabilize them, and send them out, with the sense of instant gratification. I never saw myself as an outpatient provider sitting in the clinic waiting for patients to show up. I wanted to get going and get things done.

As destiny had it, I ended up at the community mental health clinic in a rural setting for my first real job. Although I really would have preferred to work in an inpatient setting, I loved the idea of a community clinic because I would be helping people in need, including those with no insurance. Patients would travel hundreds of miles just to see me. I soon realized the pressing need for medical providers in rural communities . . . it seems many health care providers are not attracted to rural settings.

The closest psychiatric hospital was about an hour’s drive away. When I was in residency, finding a bed was very “tricky”; now, out here the middle of nowhere, I don’t have the luxury of having a hospital at my disposal for admitting patients.

I started questioning myself about my career path. “Did I make a mistake?”

As word of my arrival got around, patients came in droves to see the new psychiatrist in town. Some were probably relieved to find a doctor who (they hoped) would stay long enough to provide consistent follow-up care. Some wanted to test the new doctor to see whether she would prescribe their “favorite pills.” Others were just glad that the wait to see a psychiatrist would not be so long.

I quickly realized that, out here, I was treating as outpatients those whom I would have admitted at the drop of a hat during my residency. I started seeing a variety of patients-the compliant ones, the drug-seekers, those who regarded me as their guardian, grateful patients, no-shows who missed multiple consecutive appointments, and even some miraculous turnarounds that we all dream of.

I treat patients in crisis situations in the clinic just as I would if they were inpatients; the same medications are used. These patients may return to the clinic for follow-up the same day, the next day, and the day after. Inpatient hospitalization is discouraged unless it is absolutely necessary.

The clinic staff consists of a strong team that includes a social worker, therapist, nurses, and clerks. Local agencies that work with the mentally ill help the clinic and function as “extended eyes.” In certain situations, family members are very helpful. Even the local sheriff’s department is available to help when needed. So far, I am proud to say, the clinic staff has been able to provide intensive treatment for some critically ill patients on an outpatient basis-and at a reasonable cost. However, there are occasions when inpatient admission to the nearest city hospital cannot be avoided.

I feel very fortunate to be able to practice in an inpatient-like setting on an outpatient basis. I get instant gratification from helping patients who are in crisis.

I have come to realize that it does not really matter where you are located or what kind of setting you practice in. The key to success is a team of people who think alike and who have the same goal. My team and I sometimes spend hours trying to find the right kind of help to assist our patients who are confused and without orientation in life-and we occasionally spend hours helping our patient understand the plan.

Our team has challenges, but we help each other out and try to have fun together-for example, by experimenting with our culinary skills. Overall, we enjoy our small-town setting. Without the team effort, it would not be possible to provide holistic care for all the patients we serve. I am proud to be a part of such a great team and realize that teamwork is the real key to success.

When you have a strong team, you can provide quality mental health care and have an immensely satisfying career-even in the middle of a cornfield.

Articles

Unique Challenges and Joys of Rural Small-Town Outpatient Psychiatry

Like every new resident just starting to work in an outpatient clinic, I was nervous about the patients I would inherit from the graduating resident. It did not help when the graduating resident warned me that one particular patient “could be difficult.” I comforted myself with the thought that every psychiatric patient has a “difficult life” and that is why they need our help.

After the first 2 visits with the patient I had been warned about, I began to understand what my senior resident had meant-or at least I thought I did. The patient seemed frustrated and angry with his care providers and repeated that they did not care at all about him and were only there to make money. He carried on about how all doctors were the same and accused them (and me) of being money-sucking parasites who cared only about money and who did not care whether he lived or died. He hated the group home where he was living and was nonadherent to his medication regimen. He was also receiving bimonthly injections of haloperidol, which he seemed to hate.

On our third visit, the patient seemed to be overtly suicidal. I sent him to the hospital, where he was admitted. Shortly after he was discharged, he showed up in the clinic again. When I saw him, I had one of those “I wish I did not have to see him” moments. On this visit, I decided to just listen to him. He was focused on how much he hated living in the group home. We then started talking about how things differ between group living and independent living, and we discussed such practical issues as expenses and bills. He seemed more comfortable as we began to have some meaningful conversation. I realized that I had started to provide psychotherapy after my supervising attending psychiatrist pointed it out, and I was glad that something was working for the patient.

The patient again started to complain about the haloperidol shots. I told him that we could eliminate them if he would take his other medications regularly. Surprisingly, he agreed. He became more adherent to therapy and started to show up early for all his follow-up appointments. He said he always looked forward to his appointment and wanted to use every minute of our allotted time. He required a good deal of reinforcement, but he always followed my directions. He quit drinking and smoking on his own. He was still frustrated with living in the group home and we discussed the possibility of him joining the Assertive Community Treatment (ACT) team, which would give him some independence. He hesitated to take this step, because it would mean that he had to be discharged from my clinic and would have to follow up with a new doctor. He finally agreed, but not before bargaining to be able to keep me as a doctor. (I told him this was not possible.) Ultimately, he decided he needed this chance to show that he could live in a community with some support, and he reluctantly agreed to follow up with the ACT team’s doctor.

On our last visit, the patient said to me, “I didn’t even cry this much when I lost my mother.” He became tearful and offered me a bottle of pink lemonade. I was unwilling to accept it because accepting gifts from patients was not recommended. He persisted and told me how much it would mean to him if I would accept his small token of appreciation. I struggled to hide my own tears. I finally took his lemonade but insisted that I could not accept future gifts.

I don’t like pink lemonade, so after the patient left, I offered the bottle to my colleagues. No one wanted it. I left it in the refrigerator thinking that someone might drink it. When I opened the refrigerator a week later, it was still standing there, untouched. Staring at it, I somehow felt guilty and disrespectful of my patient. I reached inside the fridge, grabbed the lemonade, opened the bottle, and drank the contents at once. Although I disliked the taste, it gave me a real sense of satisfaction. At that moment, I realized, I had a motherly counter transference toward my patient. I have never felt so strongly about any of my patients, and suddenly I had a grown-up man-child of my own.

After I came to this realization, I began to feel more confident of myself. As clinicians, we tend to notice negative countertransference and forget that positive countertransference can also be difficult to deal with. Now I need to learn how to control my emotions and how not to let my man-child act out while he awaits transition to the ACT team. This, I guess, is also part of the process that will help transform me from a resident to a psychiatrist.

Author | Rashmi Ojha, MD

Articles

Unique Challenges and Joys of Rural Small-Town Outpatient Psychiatry

Bottle of Pink Lemonade