Upstate program encourages psychiatrists to work in the state's sparsely populated areas

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center.

I'm your host, Amber Smith.

The U.S. census projects a significant shortage of doctors related to population growth, aging and a growing need for medical care. This applies to the field of psychiatry and especially in rural communities. But psychiatrists at Upstate are working to address the predicted shortages.

And here to tell us about a novel strategy is Dr. Justin Meyer. He's an assistant professor of psychiatry and behavioral sciences.

Welcome to "The Informed Patient," Dr. Meyer.

Justin Meyer, MD: Thanks so much for having me.

Host Amber Smith: Why are rural communities hit harder with these shortages?

Justin Meyer, MD: Well, I think there's a lot that goes into it, needless to say that the amount of people in a rural area is smaller, and so there are fewer physicians that are there in those communities, and there are fewer subspecialists or specialists in those areas as well.

Host Amber Smith: Why do you think that most doctors stay within a hundred miles of where they complete their residency training?

Justin Meyer, MD: So for those that aren't so familiar with residency and medical education in general, you have to get a bachelor's degree first. So that's your college. Then you go to medical school, that's another four years. After that, there's something called residency and that's where you're trained in a specialty, sort of practicing that specific profession, for example, psychiatry, which is what I do.

As you grow older, you're also a human being, so you're going to come into your own, you might get married, you might have kids, you might buy a house. The longer you wait, the more likely these things happen.

So that's a major factor. During residency, it's when people start putting down roots and settling down, and so it's less and less likely as you get older to move out and further away. Additionally, people in their 20s and 30s generally like to live in urban areas. That's just a demographic and population-based issue. And so for that reason, a lot of people wind up settling in urban areas.

Host Amber Smith: What does Medicare have to do with graduate medical education?

Justin Meyer, MD: This is an interesting one to dissect. Believe it or not, Medicare, so the insurance that we pay for in our taxes, pays for almost all of graduate medical education or residency.

So part of that is built into the insurance of Medicare, and historically, in order to get that funding, you have to be an academic facility. Usually this would be a place like Upstate, where there's a medical school, and there are multiple residencies attached. One of the unfortunate consequences has become that these tend to be in urban areas, where there's more people, so that they can train more people.

And so, how do you navigate that when you're looking at rural communities? This is becoming an interesting problem to solve.

Host Amber Smith: Would you say that it's common or unusual for people living in rural America to have access to a mental health provider?

Justin Meyer, MD: I would say it's unfortunately pretty usual to not have access, so the opposite.

In fact, about a quarter of people in cities are able to have access, to have psychiatrists. About 65% of those in rural communities do not have psychiatrists. So again, the majority of people, unfortunately, do not have access to psychiatry in rural areas.

Host Amber Smith: So how does the Rural Academic Partnership Program address this?

Justin Meyer, MD: So back in about 2015, this was prior to me coming to Upstate, some of the innovative people, Dr. Dewan, Dr. Meszaros, Dr. Gregory (Mantosh Dewan, MD, Zsuzsa Meszaros, MD, PhD, and Robert Gregory, MD), these are all psychiatrists, saw this problem on the forefront and wanted to be proactive. And they started partnering with some of the regional, health care systems and hospitals in more rural areas. Think about Oswego. You think about Watertown, there's a lot of them nearby Syracuse.

And the idea was to have those hospitals sponsor a residency spot. Essentially, they pay for a resident to get trained, with the understanding that after they're trained, they can come and work at their hospital.

Host Amber Smith: And so how many rural hospitals so far have funded residency positions like this?

Justin Meyer, MD: It started before I began, but I believe it's on the order of at least 10 or so different sites. So it's a number of different hospitals, and each year we're growing, and there have been more and more sites. This upcoming year, starting in July, we're working with two new sites we haven't worked with and one we previously have.

Host Amber Smith: So do the rural facilities have any obligation to do the selection process? Do they help you choose which resident is going to be placed in at their location?

Justin Meyer, MD: Yeah, they absolutely do. We meet, as a residency, we help figure it, curate that list, and then we bring it forward to them and say, here are the people we think would be great for the program. What do you think? And then they certainly have essentially final say, since they're the ones that are going to be working together for the long haul.

Host Amber Smith: How popular are these residency slots with the new doctors that are looking for residencies?

Justin Meyer, MD: They're increasingly popular. So in the beginning, it was tough, but it's been getting in some ways easier to recruit for them. There's a lot of factors that go into that, and I'm happy to expand if you like.

Host Amber Smith: I do want to get into that. Now just getting a little bit ahead of things, the program's about 7 years old. Does it seem to be working?

Justin Meyer, MD: Yeah, it does. So we've had a number of residents that have graduated, five have graduated so far, and all work in rural areas.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Justin Meyer, an assistant professor of psychiatry and behavioral sciences, about a program designed to increase the number of psychiatrists working in rural areas.

Let's talk about the residency training at Upstate, which is four years, is that right?

Justin Meyer, MD: Yeah, that's right. So within psychiatry, residency typically is four years. If you're interested in doing child psychiatry, you can shorten it to three and then do an additional couple of years for further training.

Host Amber Smith: Now, how does this work with the rural partnership residents? Do they do the same training as the students that are in downtown Syracuse?

Justin Meyer, MD: Pretty much, so about 20% of their time is a little bit different. So we designed it to really be about getting the same academic, city experience, with a little bit, about 20%, of the time, they wind up going to those rural sites.

And why did we settle on 20%? Well, the thought was, this way they can get familiar with the rural site, make sure they're comfortable there, and also they're interested in doing rural psychiatry. They're in it for the long haul. So why would we withhold that completely? At the same time, we wanted to make sure they had a really thorough training at our site, which we know and love and are comfortable with, and so that accounts for 80% of their training.

Host Amber Smith: So do they live typically in Syracuse and commute to the rural area, or do they live in the rural area and come downtown on occasion?

Justin Meyer, MD: I would say that a majority wind up living in Syracuse and then commute to the rural area. But we've had it both ways.

And it's interesting as they get more comfortable with the rural site, so in the second or the third and fourth year of their residency, that's when we start seeing them move closer to the rural sites, knowing that that transition is coming up.

Host Amber Smith: So the transition, after they complete their residency, they stay for what, five years at least? I mean, they could stay permanently, I guess, at the facility, is that right?

Justin Meyer, MD: Yeah, the agreement is basically to pay back the time they've been in residency. So about five years after, they wind up working, at least, at the rural site.

Host Amber Smith: So they're an attending, a staff member, of that hospital or mental health facility?

Justin Meyer, MD: That's correct. Yeah.

Host Amber Smith: Now getting back to the overall shortage of doctors, I understand, nationwide, there continues to be a lot of interest in medical school. Are adequate numbers of students entering medical school with the thought of going into mental health care, becoming psychiatrists?

Justin Meyer, MD: One thing that we've done really great in this country is increasing the number of medical students, and we've done this through a number of different streams, both expanding it from MDs to DOs (doctor of osteopathy) to people from outside the country as well. So we actually have a number of people that are ready for residency.

Unfortunately, there hasn't been a commensurate increase in the number of residency slots, which is part of why we really needed this program.

Amber Smith: So there is interest, but because we don't have enough slots, well, your program kind of addresses that by adding slots, right?

Justin Meyer, MD: That's right. So, historically, these slots have been paid for out of Medicare, and still a vast majority are.

But this, part of what we were excited about with this program and what we wanted to share, was that this was a new way of funding those slots, sort of a combination of public and private funding in order to help pay and educate and ultimately get more doctors into more areas.

Host Amber Smith: What would you say to a person who's interested in the field of psychiatry or mental health?

What is gratifying to you as a provider? Why would someone want to choose this line of work?

Justin Meyer, MD: I thought a lot about this question. I mean, I can't imagine doing anything else, so you're going to get a little bit of a biased stance, but I really love what I do, and if you're interested, I think you should pursue it. You get to see patients that are incredibly ill go from, for example, not being able to eat, drink, take care of themselves, to being back to normal, functioning at very high levels. We're talking about doctors and lawyers that have become so severely depressed, they can't do anything. And you really can see them get much better. And one of the perks of psychiatry is you actually get to be a part of that change and see it happen right before your eyes.

Host Amber Smith: How would you advise a medical school graduate to go about selecting the right residency for them?

Justin Meyer, MD: You've got to know yourself and take it one step at a time and figure out all that. Typically, a lot of students come to me and ask, should I do psychiatry? Should I do emergency medicine?

And there's no one size fits all. One of the best things about medical school, one of the things that I remember enjoying the most, is it's pretty unique. You get to try out all the different specialties and see what one fits, and you'll know when you're in the right one. You'll feel pretty much just at home.

Host Amber Smith: Why would doing a rural residency appeal to someone?

Justin Meyer, MD: Well, I think for a lot of reasons. There's been increasing interest in serving the underserved across this country, and certainly the rural areas are decreasingly served, or more underserved, and so I think there's been a great deal of interest in making sure that we serve these communities that are in need of our help.

Additionally, because of that, you're going to get a lot of grateful clients that you're there and that you're able to help them. So those are a couple of reasons.

Host Amber Smith: Do you ever encounter someone who's a little hesitant about going into a rural area? What do they find appealing once they get there?

Justin Meyer, MD: I think the most common thing that people enjoy when they are there is the access to the outdoors.

I'm originally from New York City myself, Manhattan specifically, and coming back to Syracuse where I went to medical school, I really appreciate the fact that I can go 10 minutes in any direction and feel like I'm in a different part of the planet and in a really rural community.

And it's really nice to see, and I think many of our rural residents share that interest. It's also a part of being that community. You really become an integral part of that smaller community in a rural site. That's been a real great thing to see.

Host Amber Smith: I know a lot of people that sort of pine for the small-town lifestyle and values, and there you have it, all around us in all of these rural communities, it seems like.

Justin Meyer, MD: Yeah, I think so.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Meyer. I appreciate it.

Justin Meyer, MD: Absolutely. It's been a pleasure. Thank you for having me.

Host Amber Smith: My guest has been Upstate psychiatrist Dr. Justin Meyer.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.