The Doctors Aren't In 

Where do 600 people turn when their psychiatrist retires? In Missoula, they’re turned out.

In early May, 600 Montanans went to their mailboxes, probably expecting bills, junk, or both. Instead they found a letter from their psychiatrist, Dr. Noel Hoell.

The tone of the letter was formal, and it got to the bad news quickly.

“It is with mixed feelings that I am writing to inform you that, as of approximately August 1, 2007, I will be discontinuing my private practice of psychiatry and, therefore, beyond that date, will no longer be able to provide your care,” Hoell wrote.

Normally, a retiring psychiatrist would help his patients find continuing care, but in Hoell’s case, that didn’t seem feasible.

“Options in our community at this point in time unfortunately are somewhat limited. I would prefer to be able to refer you directly to a suitable replacement, but will not be able to personally do this due to the present shortage of psychiatrists in the Missoula area,” the letter said.

Hoell’s retirement from his private practice with Montana Neurobehavioral Specialists is part of a national issue in psychiatric medicine: There are simply not enough psychiatrists to go around.

According to John Schroek, director of the Montana Department of Public Health and Human Services Primary Care Office, Missoula County has, roughly, one psychiatrist for every 20,000 people. According to the federal government, a healthcare crisis doesn’t exist until the ratio is one to 30,000. Schroek points out, however, that Missoula’s 1:20,000 ratio includes only county residents, and as anyone who’s ever heard a Life Flight helicopter overhead knows, Missoula serves a healthcare clientele beyond its county lines. Schroek assumes the number of patients seeking psychiatric help in Missoula is much higher.

Inquiries to Missoula psychiatrists made by the Independent confirmed that local private practice psychiatrists are not presently taking referrals, or are taking them only on a limited, case-by-case basis.

“Right now I feel that if I get into trouble…well, it’s fear. I wonder what will happen,” says Dan Morehead, a former patient of Hoell’s who is now without a doctor to treat the depression he’s been dealing with for nearly 15 years.

Psychiatrists are a vital front line in the treatment of mental illness; they’re trained in talk therapy and, unlike psychologists, are able to prescribe medication.

Besides psychiatrists, the only people trained to assess a mental health situation and prescribe medication are advanced practice registered nurses (APRN), of which Missoula has three.

“We’d like to have two psychiatrists, but we’re beginning to think that’s not possible,” says Dr. Julie Hergenrather, a psychologist at Montana Neurobehavioral Specialists, and a former colleague of Hoell’s. Hoell was the practice’s only psychiatrist. “We’ve been getting calls [since Hoelle retired] from people needing refills signed off on.” Hergenrather says some of Hoell’s former patients can have their primary physicians fill prescriptions, but she stresses that that’s not a permanent solution to the problem, and can enter ethically iffy terrain when physicians begin filling prescriptions for patients with whom they’re unfamiliar.

At St. Patrick Hospital, Missoula’s psychiatric shortage has been known for years, if only because evidence frequently arrives in the emergency room in the form of untreated individuals experiencing what healthcare providers refer to as a “crisis situation.” And that’s a scene Joyce Dombrowski, vice president of nursing at St. Pat’s, says she fears will soon be occurring more often.

“We’ve been treating mental health at St. Pat’s for 135 years, because we believe in treating everything we can here at the hospital, so the psychiatrist shortage has been a very important issue to us,” she says.

St. Pat’s currently employs three psychiatrists––one specializing in caring for children, and two adult practitioners––who share the workload of the hospital’s inpatient treatment unit, and also rotate shifts as on-call doctors every three nights.

“We’re afraid one of them is going to burn out eventually,” Dombrowski says.

Meanwhile, Hoell’s former patients have their own worries. They’re waiting for a new doctor to come to town, or for an existing practitioner to open the door to referrals.

Former patients describe Dr. Hoell as a kind and gentle person who’s easy to talk with, and with whom they felt a personal bond. One of those former patients, Geri Stewart, wrote in a letter to the Missoulian, “Just knowing that he won’t be there to call on causes me great distress and anxiety.”

Hoell, 68, says his decision to retire did not come easy. It took several years of mulling over the choice before deciding to end his practice earlier this year.

“It was a good time for me to retire––not for the community, but for me,” he says. “I don’t think anyone was shocked.”

Before deciding on retirement, Hoell went so far as to consult an attorney to check if he might face charges of patient abandonment. The attorney found no cause for alarm, and so Hoell proceeded.

His 90-day notice was also in compliance with Section 6-C of the American Psychiatric Association’s “Opinions of the Ethics Committee on the Principles of Medical Ethics.”

The guidelines also state in that same section: “Your colleagues might wish to consider their roles as ethical practitioners in assisting you and your patients in your time of need.”

Despite criticism from local attorney Helen Orendaín that he didn’t do enough to help his patients transition when he retired, Hoell says he stands by his decision. After 30 years of service, Hoell says, he wanted some time to focus on his own activities.

“If I had known that, gee, in six months we’ll get a couple or three [psychiatrists] here in town, I would have stayed on a little bit longer to make a smoother transition for everybody. But there wasn’t any visible prospect of that happening,” he says. As a player in recruitment efforts over the last five years, he had firsthand knowledge of the prospects.

“So this year I thought, ‘well it could be the same situation next year, and the year after, and I can’t put off my plans indefinitely because of this particular predicament,’” he says.

Hoell advised some of his patients, the ones he felt were stable and no longer in need of formal psychiatric care, to have their primary physician fill prescriptions for them. Others, some of whom he described as critical cases, he told to find a new psychiatrist, and urged them to call local doctors even though he knew few were taking referrals.

Though he’s obviously slowing down, Hoell isn’t completely retiring from psychiatry. This school year Hoell will be working part-time with the University of Montana’s Curry Health Center, helping students in crisis as the facility’s only psychiatrist.

“I’ve just seen, for myself, that students these days are dealing with much more stress and anxiety than when I first attended school,” he says.

As for the 600 people he left behind, he wishes them his best in their search. But for the first time in 30 years, he can focus on his own needs and wants. And like many people his age, he’s looking forward to that.

“The first thing I did when I got [Hoell’s] letter was go to the phone book and open up to the Yellow Pages. There are 14 psychiatrists in there and I started calling each of them,” says Dan Morehead. “They all said the same thing, that they weren’t taking any new referrals.”

Fifteen years ago Morehead was a corporate banker with Wells Fargo in Green Bay, Wisc. He was making plenty of money, had a great investment portfolio, was married and had a son. It was a good life by most standards, but he wasn’t enjoying it. Though he didn’t know it at the time, Morehead was dealing with depression.

“I grew up in a kind of grin-and-bear-it life, so I just figured that I was unhappy and that’s just how it was going to be. You keep going,” he says.

After years of feeling low, Morehead attended a clinic offering free depression evaluations. He was immediately referred to a psychiatrist, and has been in some form of therapy for the 15 years since.

Morehead’s first psychiatrist wanted him to step back from the daily grind and focus on himself, which he refused to do. Eventually, after five years of prodding and a brief but intense stint of suicidal contemplations, he took the break.

He felt better right away, which is why Morehead has never returned to banking full-time for more than a few weeks since. “The stress of having to present a certain image for people, it’s too much. I would find myself [depressed] again,” he says.

So he abandoned his lucrative career in Green Bay and moved his family to Missoula for a fresh start.

His decade in Missoula has been full of ups and downs, but today he feels better than he did in Wisconsin. That said, every day he fears that something will happen––that the medication he’s on will become less effective, or that he’ll encounter any number of other problems, and he’ll have nowhere and no one to turn to.

His friend Geri Stewart, another former patient of Hoell’s, is experiencing that same fear, and she knows from personal experience that depression is much more than lows.

“It’s affected my work. It just affects everything you do, your appetite, and your relationships. It really affected my kids while they were growing up. They had to walk around on eggshells wondering if I was going to get upset…It affects more lives than just your own,” she says about the disease.

The medication Stewart uses to treat her depression has been effective, but she says every treatment she’s tried has lost its effectiveness eventually. Without a psychiatrist to monitor and treat her illness, Stewart says she feels nervous and stressed every day.

“I’m kind of floundering. I’m okay right now, but I’m having some ups and downs,” she says. What she’ll do when those “ups” go away is a mystery.

Morehead and Stewart, though they continue to struggle with depression, are examples of successful treatment. Not all depression stories end this way.

On Saturday, Aug. 18, Missoula resident Julie Ann Huguet, 49, took a large number of prescription pills in a suicide attempt, and was involved in a standoff with Missoula police during which she held a gun to her chest and placed it in her mouth while threatening to pull the trigger. After the pills rendered her unconscious, police moved her to St. Patrick Hospital, where she underwent psychiatric evaluation. The following Tuesday, after being released, she committed suicide.

n early June, Morehead, Stewart, and Helen Orendaín, whose daughter is a former patient of Hoell’s, formed the Mental Health Crisis Prevention Coalition (MHCPC). Their focus and purpose so far has been advocating for the recruitment of a new psychiatrist for Missoula.

“It’s a crisis, and we felt maybe we could do something, since no one else really is,” Orendaín says.

The three activists were lucky to find each other. The Health Insurance Portability and Accountability Act does not allow doctors to reveal the names or payment histories of patients, without permission from the patient or a subpoena. That makes it virtually impossible for one person to gain medical information about another, and thus know the outcome for most of Hoell’s patients.

The problem is further exacerbated by the fact that Hoell was treating patients from Butte, Polson and other cities around the state, meaning his absence impacts communities all around western Montana, not just Missoula.

“One problem is that we have no way of knowing if anyone else is getting help,” Orendaín says.

MHCPC organized a meeting in late June at St. Pat’s to discuss the psychiatric care shortage issue in Missoula. They brought together everyone they could, including local politicians, mental health workers, state officials, representatives from the offices of Sen. Max Baucus and Rep. Denny Rehberg, and more.

No solution was found that day, nor has it been found since.

Ideas continue to be discussed by local medical administrators, but MHCPC sees a lack of action on the part of St. Pat’s and Montana Neurobehavioral, and it has them worried––especially since subsequent meetings have drawn diminished attendance.

“I just feel that there should be more help. There wasn’t any effort to find new psychiatrists for the patients and it’s unconscionable,” Orendaín says. “We have been doing the work of Montana Neuro by trying to help people.”

Recruiting a psychiatrist to live and work in Missoula sounds easy. How could someone in a field concerned with quality of life not want to live in a town where fishing, hunting, skiing and more are only a short trip away?

But in talking to various people involved in recruitment efforts, it becomes clear that Missoula’s proximity to nature isn’t even a factor for most potential psychiatric recruits.

Most doctors are apparently more worried about how they’re going to pay off their student loan debt, which is usually in the range of $150,000 and up, in a market where, according to Hoell and others, their pay will be far from staggering.

Hoell says it’s nearly impossible for Missoula institutions to offer big dollars, in part because of the high rate of psychiatric patients paying for service with Medicare and Medicaid.

“These programs set a rate, let’s say $60, and say that’s all you can charge. Then they pay you a percentage of that,” Hoell says.

“There is a national shortage in psychiatry, so we are recruiting against many places,” says Joyce Dombrowski, of St. Pat’s. For more than five years St. Pat’s has been trying to recruit a psychiatrist to no avail, she says.

Hoell attributes the failure to several factors often cited by others as well: low pay, and a lack of personal time.

“When I came to town 30 years ago, it was still accepted [that] you came to town, you hung up your shingle, you went around, you pressed the flesh, you introduced yourself…borrowed money from your mother––you built up a practice,” he says. “Those days are, by and large, over. Now people want a guaranteed salary,” he says.

Most relevant of all, however, is that new psychiatrists don’t want to do time on call––24-hour stints during which a doctor must be reachable at all times.

“That’s not welcome news, being on call. Being on call basically means taking care of a lot of indigent people…They call you at midnight Friday night and tell you that Joe Blow broke up with his girlfriend and drank a six-pack of beer and said he wanted to be done with it,” Hoell describes. “[Psychiatrists have] always traditionally accepted it as part of the deal. Lawyers call it pro bono, and we don’t use that term, but that’s what it is. It’s just expected.”

Dombrowski says the mention of on-call work can stop a recruitment negotiation in its tracks.

“Call is difficult. You might get a call in the middle of the night and then you have to go to your practice in the morning,” she says. “People don’t want to do that.”

Dombrowski says the current situation in Missoula could also be hindering recruitment, because new doctors fear burning out in the over-stressed environment.

“It’s not just the recruits. You know, we worry about our doctors becoming burnt out with all of the work they’re being asked to do,” she says.

The problems run up the chain from Missoula to the capital.

“We’re constantly looking at how to keep and recruit mental health professionals,” says Joyce De Cunzo, Administrator of the Addictive and Mental Disorder Division of the Montana Department of Public Health and Human Services. “We’re stumped.”

De Cunzo says that Butte-Silverbow County is in the same predicament as Missoula. The counties are ranked first and second, respectively, in the number of admissions they send to Montana State Hospital in Warm Springs. She described the flow as steady.

“Treatment is really derived from a caring relationship between the consumer and the caregiver…so patients want to have a doctor they can trust, and when they don’t have that, there are chances for a destabilizing situation,” says Ed Amberg, CEO of Montana State Hospital (MSH).

Amberg says the psychiatric situation in Missoula affects MSH in two ways: 1) More people are committed or otherwise sent to the hospital, and 2) releasing a person back into the community is made more difficult because Missoula lacks the medical staff to continue treating patients locally.

“People go to the hospital emergency rooms and the hospital doesn’t have the staff to help these people so they pass them along to the state hospital,” De Cunzo says.

St. Pat’s Dombrowski says that their facility, a 30-bed certified unit, “feels full at 24 people.”

“We have one doctor working in there on a daily basis, and when you have one doctor for that many people, it’s too much for one person. It’s not fair.”

With every passing day the shortage problem continues, and the consequences continue to take their toll. Whether it’s the people in crisis taken to emergency rooms, or the patient load being passed to MSH, it affects facilities, patients, and communities at every level.

John Schroek of the Montana Public Health and Human Services Primary Care Office offered several potential solutions at a recent MHCPC meeting that quickly became popular amongst the attendees. The first idea is seeking to have Missoula County designated a Health Professional Shortage Area (HPSA), at least in regard to mental health workers, by early next year. He says the HPSA designation would help attract psychiatrists with several incentives, ranging from $25,000 in loan repayment to increased payment on Medicare cases. Such incentives would, in essence, increase income for new psychiatrists, which would help alleviate at least one part of Missoula’s recruitment issues.

The problem is that a HPSA designation is not a quick solution.

For instance, one way to qualify is through a poverty ranking based on Medicare and Medicaid cases. But there’s the matter of how long the federal government takes to accept or deny the designation, and how long it then takes a group in Missoula to recruit a psychiatrist with the extra incentives.

Another HPSA program Schroek discussed at the meeting would have Missoula seek a JV-1 Visa Waiver. This federal program allows foreign-born medical graduates to outstay their student visa so they can practice in a region where their services are needed. Schroek says the program has been successful in many cities around the country because many foreign doctors want to stay in America after they’re trained.

That’s the solution Helen Orendaín and the rest of MHCPC think would work best, but they aren’t about to put all their faith in one idea.

MHCPC recently sought its own solution by contacting Merritt, Hawkins and Associates, an Atlanta-based headhunting firm that, for a substantial fee, aids communities in their efforts to fill healthcare vacancies.

Since 2001 the company has helped five cities in the Northwest fill psychiatric positions, the only drawback being the price.

The company requires $3,000 up front. Then there are payments for the headhunters’ time, which range between $60 and $120 hourly. When a doctor is found and signs a contract, the company gets a $12,000 bonus.

And these are just the standard fees paid to Merritt, Hawkins.

The company also insists that clients pay travel expenses for their recruits, charges $1.95 for every recruitment letter the company sends out, and gets bonuses upwards of $5,000 for finding doctors quickly.

That may be too expensive for many hospitals and private practices, which is why MHCPC is urging local parties (St. Pat’s, Montana Neurobehavioral, etc.) to work together. MHCPC reasons that the benefits for each party would more than make up for immediate monetary losses. An example would be that a psychiatrist working at Montana Neurobehavioral could do on-call at St. Pat’s.

In the meantime, patients are getting by, or not, as best they can.

Morehead recently received an e-mail from Missoula-based Winds of Change Mental Health Center saying they had found a psychiatrist in Helena willing to come to Missoula two days a week. The problem with this is a Helena-based doctor would not be readily available if one of his patients were to have a crisis in the middle of the night.

“I know a doctor in Portland [Ore.] who someone once told me was really good, and I’m considering that as an option,” Morehead says.

After the Missoulian published Geri Stewart’s letter, she was contacted by a local doctor willing to at least meet and discuss future treatment. Stewart says she is hesitant at the prospect of starting over with a new doctor.

Orendaín says her daughter is doing well for the time being, but says that isn’t much comfort.

As for Hoell’s other former patients, no one can be sure if they’re getting help. For them, and for any other Missoulians who develop a need for psychiatric services, the doctor is out.
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