Rural mental health specialists have heavy load

By JOHN LUNDY, Duluth News Tribune

DULUTH, Minn. (AP) -- Five days a week, Dr. Karen Pajari drives from her home in Ely to start seeing her psychiatric patients at Range Mental Health Center in Virginia at 7:30 a.m.

Starting with in-house patients from the chemical dependency treatment center, she works through the day, but doesn't have time to do it all. By mid-June, she had patients scheduled through August and into September.

"I could do with about 10 hours more a day if I could stand it," Pajari said.

She enjoys her job, Pajari said, but admits, "I've made several efforts to retire."

She's 71.

If there's any health-care shortage in rural areas that exceeds primary care, it's psychiatry, the Duluth News Tribune reported.

The Health Resources and Services Administration designates "health professional shortage areas" across the country in dentistry, primary care and mental health.

In Minnesota, all but the counties surrounding the Twin Cities and Rochester are designated as shortage areas for mental health. Although large, mostly rural areas of the state also are designated as shortages for primary care, there are more exceptions -- including the immediate Duluth area and all of Lake County.

At the Range Mental Health Center, which serves about 7,000 people a year, the crunch became a crisis in mid-April. That's when one of two psychiatric nurse practitioners left the clinic. The nurse practitioner's 700 patients were divvied between Pajari -- who already had 800 patients -- and the remaining nurse practitioner, Pam Jarvis. The overall staff is considerably larger, but only Pajari and Jarvis can prescribe medications.

"Between us, we take care of, as well as we can, everybody who comes who needs medicine," Pajari said. "We both work long hours, see a lot of patients and are very tired."

Pajari said the optimum size of the prescribing staff would be two psychiatrists and three nurse practitioners. But the center has lost three or four prescribers within the past year.

Laura Tovar, recently named the center's co-CEO with Mary Carpenter, said their top priority is rebuilding the psychiatry department. For help, they enlisted a recruitment firm that promised three "nibbles" from prospective professional staff within 90 days. In the first 30 days, they heard from no one, Tovar said.

It's hard to attract psychiatrists to northern Minnesota, Pajari said.

"Florida is full of psychiatrists," she said. "California is full of psychiatrists. They have no problem whatsoever getting people to go there. But then they don't have seven-month winters. They have many cultural activities that we don't have."

There's an area of even greater scarcity within the scarcity: child and adolescent psychiatrists.

"I don't think we have one on the Range at all," Tovar said.

Pajari said the center once had a nurse practitioner with skills in child psychiatry, but she left for "greener pastures in Duluth."

So Pajari sees adolescents when she can, "and we try not to do children at all," she said.

There's a similar situation down the road in the mental-health section at Fairview University Medical Center-Mesabi in Hibbing. Paula Pennington, the hospital's manager of behavioral health, said the center's 19 acute inpatient beds are full most of the time, but the unit is amply staffed. However, there are no services for children and adolescents.

With psychiatrists overtaxed, some of the burden shifts back to primary care, said Dr. James Hartert, chief medical officer for Fairview-Mesabi. But their patients are complex and require potent medications.

"I think our doctors and advanced-practice nurses do a great job but clearly could be aided by a greater supply and access to people formally trained in psychiatry," Hartert said.

Pajari and Jarvis only treat people with the most serious mental illnesses, leaving the rest for the family doctors, Pajari said.

"We only get 10 to 15 percent of people with emotional problems," she said. "But the numbers are still very large."

Outside of Virginia and Hibbing, Iron Range residents travel to Duluth, Grand Rapids and even International Falls for psychiatric care, Tovar and Pajari said.

They'd welcome competition closer to home.

"We'd be happy to have them take about half of these people off our hands," Pajari said.