Doing More With Less: Practicing Psychiatry When Resources Are Limited
- Dr. Lloyd
- Aug 27
- 5 min read
I was in the 7th month of my first year of Psychiatry residency when quite a surprise was waiting for me in my mailbox.
It was an official looking letter from the US Selective Service System - my Draft Board in the Bronx. It said I had been drafted into the US Army. It was 1971 and the country was further prosecuting the Vietnam War. Doctors were needed.
I obediently drove some 200 miles to the Bronx and appeared before the Board (4 men as I recall). They didn’t know what to do with me since I was their first Conscientious Objector. After drilling me with questions, I was told they me they would be in touch, and I was dismissed. Some weeks later, I was summoned to a second meeting, a replica of the first except this one was followed by another official letter detailing the conditions of my two-year CO service.
I was to propose to the Draft Board, within a month: a job at no higher pay than I made as a Psychiatric Resident; at least 50 miles from where I was living; and would be determined to be of public service. If not, they would find one for me (not a sane alternative to take).
I hustled, and long story short, I accepted a job at the Aroostook County (public) Mental Health Clinic, which my Draft Board approved.
Aroostook County is near to an 11-hour drive, 298 miles from where I was living in Syracuse, NY. It is a County the size of Connecticut, then with a population of 100,000 people, and the farthest northeastern County of Maine, bordering on Canada. Aroostook was a Federally declared economically impoverished, and medically underserved area. With no psychiatrist at its one state Mental Health Clinic.
The County’s population included multigenerational farmers of English and Irish ancestry, French Canadians at the border, Native Americans, near to feral men hired by the timber companies to arm themselves, live on and protect the forests from logging that could be stolen. There were also military families at the nearby Loring Air Force Base (now closed).
I would not be deployed to the jungles of Southeast Asia. But my proposed job, with its greatly underserved population, did merit military “alternative service”. Two years would meet the military requirements of my draft.
I would be working in one of the early community mental health programs that President John Kennedy had championed. I took a leave from my Residency to satisfy my draft requirements, as ordered by the Government of the United States.
But I had no idea what I was in for. Nor that my time as a community psychiatrist was to be the most transformative - and thus the best - training experience in my career.
My wife and I packed and drove very north from Syracuse to my new job in Fort Fairfield, Maine, where the mental health clinic was located. In Maine, we passed endless fields with small white potato flowers that ran to distant horizons across the flatlands. It was spring. Not a bad time to be in an area where winter nighttime temperatures could fall to -40 degrees - when I had to thread a small, electric rod into the oil tank to keep the engine from dying overnight from the cold.
When I met with the Clinic Director, he described the clinic services in its three towns as well as 10 unlocked psych beds in the town’s small community general hospital. The clinic was funded for two psychiatrists, but there were none. Until me! I was to be only psychiatrist in the vast, high- need County.
To survive my new, community psychiatry job called for my doing more with less - than I would experience in my further, residency training or as an independent practitioner.
First, I had no supervisor, not even a consultant. With seven months of psych training, I had to deliver when faced with the utterly novel clinical demands of a highly diverse and dispersed populations in the County’s four rural towns, in its vast, unpopulated logging forests, and the Native Americans at a nearby reservation.
In addition, I would not escape the general medical demands of my patients, like hypertension, Type 2 diabetes, COPD (chronic obstructive airway disease), and the DT’s (not uncommon, especially among those living on the Reservation).
The four towns where the clinic served became my regular monthly “Circuit”. There were also my regular, though unexpected, patients in the timber lands, the native Americans, and those jailed.
I was very green: not yet even a psychiatrist, though I had a medical license having completed my one-year internship. There was no place to run - from my Draft Board, my new Northern Maine community, and from my medical oath “To cure sometimes, to relieve often, to comfort always”.
Second, absent the usual resources of a University hospital, whom could I turn to? I had to learn to work with the small police departments in each of the towns, the county Sheriff, and the state troopers for all in-between. I saw patients in the jails and admitted some to my “inpatient unit” at the hospital. To gain the protection and help of the officers of the law I needed to be helpful to them. In turn, I would see and treat seriously mentally ill people with guns and other weapons, when I had to turn to the locked safety of the State Hospital, three hours south, with transportation there by The State Troopers.
A third example was families. The most enduring of supports for a person with a serious or chronic mental illness, any chronic illness for that matter. As weary, hopeless, angry, frightened, or hopeless they might be. I soon learned how families can make a great difference in the life of a person with a chronic mental disorder. Families surprise themselves in finding the reserves they still had when they are respected and guided, by docs like you and me. My first book for the general public, The Family Guide to Mental Healthcare, found a significant, unmet area of need, and still sells to this day, twelve years after it was published.
Fourth, were nurses. Nurses run acute care hospital services, not doctors. They are there 24 hours a day, in communication with one another, and far more trusted by patients and families than doctors. They don’t focus on lab and imaging studies, like doctors increasingly do; they focus on the patient. You better learn this if you are going to be able to do your job and help acutely ill people recover, not to mention to save your ass.
Fifth, character. Being a community psychiatrist takes courage; resolve; harvesting resources; persistence; and not letting healthcare corporations make demands upon you that put their profits before patients. When acceding to business and corporate interests, you become their victim and soon suffer.
Finally one more quality essential to the making of a community psychiatrist: a positive view that people with Serious Mental Illness (SMI) can achieve lives of contribution, be a part of their communities, and feel dignity in their lives. Which was not the prevailing view when I trained - and remains far from that today. People with SMI were considered fated to dark and disabled lives. But many people with SMI do recover. We help them and ourselves (as clinicians) when we believe in recovery, recovery with illness, and never give up hope.
After two years in Aroostook County, I returned to complete my residency. I was older, a bit wiser, and ready to pursue the ever-challenging moments of my psychiatric residency and what lay beyond.
Dr. Lloyd Sederer is a psychiatrist, public health doctor, and non-fiction writer.
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