From "the Good Psychiatrist" to "All or Nothing Care"

I changed my mind about this Substack. If you know anything about me, you're not surprised. Oh, and sorry I've been away for a few weeks.

It’s good to be back on Substack. Sorry I was away for a few weeks. I launched this Substack, posted a few articles, and disappeared. A few life events have kept me away.

August was a month of mixed blessings, extremes that were hard to navigate at times. My 18-year old twin daughters went off to college. They are our only children, so we became empty-nesters all at once.

On the one hand, I’m beaming with pride that my girls have successfully transitioned to a new phase in life. On the other hand, I miss them terribly. Thank goodness for Snapchat. Seriously.

Ela, my wife, and I have been back to Colorado State University to visit them twice already. I know. It sounds ridiculous. Our excuse is that we had to make it back to Fort Collins to attend the Rocky Mountain Showdown featuring the big football rivalry between CSU and Boulder’s Colorado University.

I took this last week off from running Frontier Psychiatry and spent most of it in and around our hometown, Billings, MT.

We rented a tow-behind camper and spent two days in Red Lodge, a nearby mountain town. We parked ourselves about 20 yards away from Rock Creek, a powerful and appropriately noisy flow of water that kept us anchored to nature.

Over the last few weeks, I’ve also rethought how best to make use of this medium and maximize its impact on the people who care about improving mental health and addiction care outcomes in rural America.

I first called this Substack “The Good Psychiatrist” because I was planning to write to an audience of new and future psychiatrists who are interested in transforming the way our country delivers mental health and addiction care. I still like the idea, but I changed my mind because I think the impact of my writing would take too long to be felt.

I’m operating under the assumption that my writing would have a positive impact on someone, somewhere.

I’ve pivoted and changed the name of this space to “All or Nothing Care”. It’s based on the descriptor I’ve often used to explain the stark choice facing rural Americans who struggle with mental illness and substance use disorders.

Most people in rural and frontier communities have to wait until symptoms escalate to a dangerous crisis point to access care. Even then the care is hard to get and is often not very good. My rural neighbors experiencing mild or early signs of mental illness and substance use disorders don’t have a lot of options beyond a visit to their primary care provider.

These clinicians are helpful when signs and symptoms are of mild to moderate intensity. They feel comfortable prescribing some of the more common psychiatric medications and they appropriately refer patients to local therapists. However, since primary care providers aren’t specialists, they sometimes get the diagnosis wrong or underdose a potentially helpful medication. And, their go-to therapists are often booked 6 months out.

So, when these patients start to deteriorate and the acuity of their problems grows, there are few viable clinical options for them. A timely appointment with a board certified psychiatrist becomes the indicated next step, but travel and wait times can be unreasonable.

That’s “All or Nothing Care” for you. Our non-system of mental health and addiction care has been designed for its professionals to mostly play defense. I know that access to high quality mental health and addiction care is a challenge nationally, but the barriers are more difficult to overcome in rural and frontier communities.

I didn’t know what I was going to find when I decided to start my career in psychiatry on the other side of the country. I had just spent 10 years at Yale University, completing medical school, psychiatry residency, and child and adolescent psychiatry fellowship. My wife and I moved our twin 7-year old girls to Montana in 2013 for me to start my first job as a staff psychiatrist at the Billings Clinic.

We moved from Connecticut to Montana for largely personal reasons. I really had no idea what my career would look like 5 years, let alone 10 years, out. I had never been a psychiatrist before, so how could I know? After graduating college in 1991, I spent 2 years as an Argentina-based journalist and 6 years as a Wall Street bond trader. I had yet to understand how to apply those experiences to my new career in medicine. It would take me years to figure that out.

And why Montana? Ela had been to the Big Sky ski area before and loved it. So there was that. And, we wanted our girls to grow up in a different environment than an academically and financially hypercompetitive Northeast.

While I was attending medical school, I spent thousands of hours tutoring adolescents in Connecticut as a way to make some extra money. I met wonderful families, but I also met way too many young people who were saddled with unrealistic expectations related to school, sports and the accumulation of extracurricular experiences. So much time and energy spent on crafting the perfect curriculum vitae. Why? To crack open the next door that led to a series of increasingly steep steps and a version of success that left them feeling empty in the end?

I saw the pressure cause so much anxiety among parents and children that I feared for my young girls. Ela and I both worried that the same pressure would make our family miserable.

So, when I saw the Montana job posting in my email inbox in the spring of 2013, I didn’t delete it right away. I remember sitting at a computer in the doctor’s lounge at the Yale New Haven Hospital when I opened the message and called Ela right away.

“What do you think?” I asked her.

“I love Big Sky!”

“Yeah, but what about moving to Montana? We won’t be living at a ski lodge,” I replied.

“I don’t know. It could be a great move for the girls. Maybe we should check it out.”

So I called the recruiter who sent me the email and started to ask her some questions. The job was based in Billings, where the cost of living was a lot lower than that of any town in a 200-mile radius around our rental in Fairfield County, Connecticut. And, the scarcity of psychiatrists in Eastern Montana drove the average salary about $75,000 beyond what I had seen associated with similar jobs in New England.

I was 44 years old when I started applying to psychiatrist jobs. By that time I had accumulated over $300,000 in student loans to make it through 2 years of pre-med requirements and 4 years of medical school. I had put repayment of those loans on hold during my 5 years of clinical training in psychiatry.

The salary of a psychiatry resident or fellow is around $60,000 and not nearly enough to cover the cost of living for a family of four in Coastal Connecticut. So, I spent much of my time as a resident and fellow moonlighting at a local psychiatric hospital for us to make ends meet. It was tough, but the extra clinical experience in that setting turned out to give me much-needed confidence when it was time to launch my career.

A move to Montana seemed to be a good move for the health and development of our daughters, and it appeared to be a smart financial move. So, I told the recruiter to set up the initial phone interviews. Zoom meetings weren’t a thing yet.

The interviews went well and there was only one red flag, but it wasn’t enough to turn down the invitation from Billings Clinic to visit Montana for an in-person visit.