A major gap exists between the mental health care received by residents of rural communities, versus their urban counterparts, encompassing disparities in access to and quality of care (1). Recruiting and retaining mental health professionals who have experience and expertise in clinical work with rural patients is extremely challenging and are major contributing factors in these disparities (2, 3). This is particularly germane for rural veterans, whose barriers to care include not only geographic distance but also a scarcity of available psychiatrists in rural locations with expertise in veterans' mental health issues (4). Rural veterans' mental health issues are escalating at this time, with returning OEF (Operation Enduring Freedom)/OIF (Operation Iraqi Freedom) veterans having high rates of mental health conditions and disproportionately rural backgrounds (5). Telepsychiatry, in the form of live-interactive videoconferencing, is being widely adapted as one tool to address gaps in rural mental health delivery (6). This treatment has been shown to be effective with a wide range of populations and settings during the past two decades (7, 8).

The Department of Veterans Affairs (VA) is the world's largest telemedicine provider, with a robust and growing telepsychiatric program (9). In order to continue to expand and capitalize on this work in rural areas, the VA needs psychiatrists to gain training, comfort, and experience—not only in the provision of telepsychiatric care, but in work with rural populations. Most telepsychiatrists have lived and trained in urban areas; they provide care from urban sites to rural sites, and have limited experience working in rural and frontier communities. There is a paucity of literature on telepsychiatry training for psychiatric residents; a recent literature search found only one article describing tele-health training for residents, and one describing a model of such a program (10); thus, more information is needed to demonstrate the usefulness of training residents in telepsychiatry, the sustainability of these services, the model of teaching applied, and the impact of telepsychiatry on recruitment and retention into systems of care with telepsychiatric and rural missions.

The purpose of this article is to present a model of a resident telepsychiatry training service, which began in 2003 at the Denver VA Medical Center in the Eastern Colorado Health Care System (DVAMC). This service was created to improve the access for rural Colorado veterans to mental health care, train psychiatric residents in the use of telepsychiatry, introduce residents to issues surrounding veteran populations from rural areas, and increase recruitment of psychiatrists with interest and expertise in using telepsychiatry into the VA system to provide care to this population. We provide a descriptive account of the telehealth training program at the Denver VA, including the clinic model and structure, process, and a discussion about VA and rural mental health workforce issues.

Clinic Background and Structure

The clinics developed out of a need to provide psychiatric care to veterans receiving treatment at VA Community-Based Outreach Clinics (CBOCs) in rural Colorado. Although psychiatric care was available in these CBOCs, there were challenges regarding the availability of providers, wait-times, and provider panel size. Local VA psychiatrists spent hours driving to and from the CBOCs to treat patients. Also, there was a high provider turnover, with providers changing every 2—3 years. In response to these needs—coupled with the desire to expose psychiatric residents at the University of Colorado to work with rural veteran populations—discussion began in 2003 about the creation of a resident-based telepsychiatry service. The first clinic began in 2003 at the La Junta CBOC and has subsequently grown to four clinics, serving the La Junta, Alamosa, and Burlington CBOCs. The provider site consists of four private offices at the DVAMC, with a mix of desktop and room-based videoconferencing units and space for a resident and attending psychiatrist. Each contains a VA computer, linked to the VA network and electronic medical record. The clinics use remote IP videoconferencing links (>384K transmission) on the VA Intranet connecting the DVAMC with videoconferencing units in CBOCs, allowing live instantaneous interactions. The DVAMC transmits into CBOC rooms that are either conference rooms or private offices, using standing unit videoconferencing systems with full remote capacity, allowing the clinicians in Denver, CO, to control the cameras on the CBOC systems remotely. The VA electronic medical record system is used for documentation, ordering medications, and lab work. On-site social workers conduct a brief psychiatric intake before the first session and provide emergency support and case-management for the clinics The clinics run simultaneously one-half day per week for 3 hours, with an additional hour for group supervision. Appointment scheduling is done by the CBOC clerks, under the direction of the residents. Typically, 1 hour is allotted for new patient visits and 30 minutes for follow-ups.

Resident Training

Third- and fourth-year psychiatric residents participate in the clinics as an elective training experience, one-half day per week for an entire year. Residents are oriented to the clinic through a day of training in equipment use and clinic protocols, a clinical manual, and a site-visit with the attending psychiatrist to the CBOC for which they will provide care. During the visit, residents are introduced to the local CBOC staff and oriented to the CBOC infrastructure, and they gain an impression of the local community. There is one attending physician for the clinic sessions, which are simultaneous. The attending physician rotates between rooms, observing resident—patient interaction, and provides direct immediate feedback on clinical skills, with emphasis on telepsychiatry and work with rural veterans. The supervision focuses on 1) cultural interactions that have an impact on telepsychiatry and the doctor—patient relationship; 2) individual clinical skills; and 3) assigned readings around pertinent topics (Table 1). Each clinic day concludes with a 1-hour group supervision, where cases for the day are discussed, along with rural issues and career guidance related to the VA. Research training and board preparation are also undertaken.

Data are presented for the first 4 years of clinic operations. By 2007, there were a total of three clinics, seeing 1,078 telepsychiatric encounters. Figure 1 demonstrates progressive growth in the number of patients and encounters. The clinical population reflects the gender and race/ethnicity breakdown for this rural, veteran population. The majority of patients are male (91%) and Caucasian (48%); however the authors also see a high Hispanic representation (40%).

Figure 1 illustrates the major diagnoses treated in the clinics: posttraumatic stress disorder (PTSD), depression, and addiction, with a variety of other diagnoses treated less frequently. The clinics focused on medication management, but the psychiatric residents also provide a range of care, including emergency assessments, case management, crisis management, supportive psychotherapy, cognitive-behavioral therapy (CBT), family therapy, and couples counseling. Table 1 presents the learning objectives and core curriculum for the rotation by telepsychiatric and rural veteran issues, describing the learning materials and methods to achieve clinic goals. These objectives are achieved over the course of the rotation through the site visits and the supervisory model previously described. They are assessed on an ongoing basis by the attending physician, with oral feedback given on a regular basis and written feedback at the midpoint and end of the rotation. Eleven residents participated in this elective rotation from July 1, 2003 until June 30, 2008. Eight of the 11 were eligible for recruitment into the VA system, three going on to further training in child psychiatry. Five of the eight eligible residents (63%) have sought to continue with VA experiences (either as chief residents or as VA clinicians).

Only one previous article addressed training with telemedicine, but this is the first to describe, in detail, a model of training, characterizing patients seen, and specifically describing a VA-based residency training model. This model is timely, given the current pressures in the VA mental health system related to returning OEF/OIF veterans and workforce issues. The common diagnoses (PTSD, depression, substance use disorders) treated in this clinic are typical of the veteran population. The system uses a range of psychiatric treatments (medication management, individual psychotherapy, and family psychotherapy), and demonstrates the versatility of this model of care. The anecdotal clinical impressions and feedback from the residents, attending physicians, CBOC, and DVAMC staff is that the clinics are an extremely valued addition to VA care in the CBOCs. The vast majority of patients, although unhappy about the yearly resident turnover, expressed high levels of satisfaction with the clinical services offered, and over 95% continue with the clinics once they are enrolled. The clinics have treated chronic and complicated cases, successfully handled acute emergencies (suicide, homicide, and gravely disabled patients) and helped reduce the number of hospital admissions per year for several severely ill patients.

The training and supervisory model differs from the classic model of psychiatric supervision of case presentation without direct observation. The importance of developing telepsychiatric and rural veteran expertise "in situ," with appropriate supervision and ongoing feedback and training, presents an example of how residents can become better exposed to and more proficient in clinical work with diverse populations. Before working in the clinic, most of the residents participating in this service (7 of 11) reported limited exposure to rural environments. This is typical of many telepsychiatry services, which often treat patients in rural areas from urban centers that utilize urban-based and urban-trained providers. By running simultaneous resident clinics, the clinic gains efficiency in both the training and clinical care provided and supports a group learning experience. Services such as this can address not only workforce-shortage issues but, by providing exposure during training, may influence providers to continue this type of work upon graduation, as supported by the recruitment rate into the VA from this clinic.

Future work is needed to examine further this model as well as other models for training of residents in rural telepsychiatry. If rural workforce issues are truly to be addressed for American psychiatry, then, arguably, all psychiatry residents should have exposure to this type of experience during their residency. The ACCMG may want to consider making such an experience, even if limited, part of mandated residency-training requirements. Training in telepsychiatry can be valuable in helping residents develop skills in telemedicine while delivering psychiatric treatment to rural populations, and it serves as a means for improving access and quality of mental health care to rural veterans. Also, resident telepsychiatry services can increase the recruitment and retention of qualified psychiatrists with both the skills and interest to continue working with rural veterans, specifically, and rural populations, in general.

At the time of submission the authors reported no competing interests.