The patient, a military veteran, was in a crisis all too familiar to psychiatrists at the Robert J. Dole VA Medical Center in Wichita. Suffering from post-traumatic stress disorder (PTSD), his symptoms included irritability, depression, mood swings, nightmares and flashbacks.

The rural Kansas man's finances and distance from Wichita made it difficult for him to get to the VA medical center for the regular follow-up appointments, and he resisted suggestions that he seek help in his community hospital.

"He felt that they would not understand how to treat a veteran with PTSD," recalls Alexandra Flynn, M.D., chief of psychiatry at the Dole VA.

Now, in a telephone visit with the veteran, Flynn and a resident working under her supervision, Syeda Quadri, M.D., from KU School of Medicine-Wichita Department of Psychiatry & Behavioral Sciences, realized that his condition was worsening. Psychological stressors had the man thinking about harming others. Flynn and Quadri urged the veteran to call 911 or allow the VA to do it for him. He refused.

While Flynn and the resident took turns keeping the veteran on the phone, they had their VA team staff contact his local police department, asking officers to perform a welfare check. After being evaluated in his local hospital's emergency room, the veteran was transported to the VA for acute psychiatric inpatient care.

"It was a unique clinical educational opportunity for the resident to learn how to manage an emergency psychiatric crisis, especially a long distance one for a veteran living in a rural medically underserved area," said Flynn, site director of the VA's psychiatry rotations and a volunteer associate professor at KU School of Medicine-Wichita.

The veteran's status has improved, thanks to both Flynn's and her resident's commitment to his care.

"Dr. Quadri was professional, enthusiastic and patient - she stayed with the veteran on the phone as long as it was needed," Flynn said. "She did not get scared of the crisis, but was very compassionate and responsive to the patient's needs."

"I had to think quickly in this critical situation," said Quadri. "It was helpful to have that clinical experience while being supported by my attending (Flynn) and seeing that exceptional collaborative VA team's effort. Residents are trained about cases like this, but we rarely are able to provide the care in such a crucial situation."

The partnership between the VA and KU Wichita's psychiatry residency program is valuable for both institutions.

Residents treat veterans while training under Flynn and other KU volunteer faculty psychiatrists on her team, Muhammad Ali, M.D., Daniel Ketema, M.D., Laurie Coyner, M.D., Rhanda Eboh, M.D., and Alisha Coulson, M.D.

KU Wichita's psychiatry program has utilized rotations at the VA for at least 20 years, but in recent years that effort has grown. Generally, four to six of the program's 24 residents are performing a rotation there at any given time, according to Matthew Macaluso, D.O., associate professor and director of the KU psychiatry residency program.

"This includes new rotations in consultation-liaison psychiatry" - that is, working with the hospital's physicians across all specialties - "addiction psychiatry and outpatient psychiatry as well as some innovative patient care models, including telehealth," Macaluso said. "These have been valuable educational experiences for our residents because the VA has a unique patient population and a unique set of services that our residents otherwise don't gain experience in."

"Without a doubt there is excellent care going on at the Dole VA and I'm glad our residents are getting exposed to it," Macaluso added.

After Ascension Via Christi, the Dole VA hospital now provides KU Wichita's second-largest number of psychiatry rotations. Beyond the educational experience, there was another impetus for growing the VA-KU Wichita relationship, Macaluso said. "We have used the VA expansion to expand our overall program, which allows us to produce more psychiatrists for Kansas."

Thanks in part to funding from the VA, the school's psychiatry residency program has grown from 20 to 24 participants per year. Like most if not all states, Kansas has a shortage of psychiatrists. In 2017, the Kansas Psychiatric Society said all but five of the state's counties suffer from a shortage of mental health professionals.

"I think across the board, we're seeing more and more patients present with psychiatric illness," Macaluso said. "In light of the opioid crisis and rise in suicide rates, society is starting to realize what it means to have mental illness and that mental illness can be treated."

Psychiatry residents perform three one-month rotations at the VA during their first year, two months during their second year and a full day each week during their entire third year. Elective rotations in PTSD, outpatient clinic, consultation-liaison, substance use disorders and other subjects are available during their fourth year.

In addition to PTSD, residents at the VA learn how to treat military sexual trauma (MST), which is defined as assault or harassment of a sexual nature committed against a person during his or her military service, and which the military considers a problem of serious proportions. Macaluso called it another condition "our residents otherwise don't have much exposure to."

Residents also work in the VA's "integrated care model, where psychiatrists are integrated into primary care settings," Macaluso noted. "The VA is also doing a lot of innovative things with telehealth to serve a larger population."

Rachel-Anne Magsalin, M.D., a fourth-year psychiatry resident, said the one-stop shop nature of the VA is something that's made an impression on her.
"The VA does have a lot of support services that are all housed in one, convenient location. A patient can receive medication management, psychotherapy, group therapy and support services for most of their psychiatry care and needs."

From the residents' point of view, they're seeing a lot more cases of PTSD and other military-related issues than they would in the general population, but that's not to say all VA patients are the same.

"We treat everyone that is eligible for health care benefits at the VA - all types of patients, whether they've been in (the military) a few months or years, and all different age populations as well," Magsalin said.

Magsalin hopes to follow her older sister, Eboh, into a job with the VA. Eboh recently transferred to Wichita from a VA hospital in Las Vegas, where she'd worked for three years.

"I really like the patient population. We are able to work with such a unique group of people. It is extremely satisfying to be able to treat veterans who have risked their lives for us. We are giving back to men and women who have given a lot to our nation."

If she does land in Wichita, she'll be in familiar company. Many of the VA's staff psychiatrists came through the KU Wichita residency program.

"It's probably the most rewarding job I've ever had," said Coyner, who completed her residency at KU Wichita in 2004 and joined the VA staff in 2017. Coyner is currently in charge of the residency's consultation-liaison rotation, in which psychiatrists see patients who've come to the ER or who have been admitted at the request of general physicians. Along with treating Vietnam vets and former soldiers who served in Afghanistan and Iraq, Coyner said she's "even had a few World War II veterans, which is cool."

The VA started paying salaries of psychiatry residents as a way to better serve veterans, said Rick Ament, Dole VA Medical Center director, and now officials from KU Wichita and the VA "all the way up to Washington" are in strategic discussions about how many additional residents can be added to the program.

"One of the most difficult (employee) recruits in the country right now is psychiatry - because of the shortage - and clearly one of the biggest problems for the VA right now is psychiatry, and yet it's one of our most important service lines."

"Here, we produce psychiatrists," Ament said. "We want to produce more of them."

In fact, Ament said, the Wichita facility would like to help produce "VA friendly and VA hungry" psychiatrists for other VA hospitals as well.

One of the biggest factors driving the effort is suicide prevention among veterans, which Ament said is the VA's top clinical priority. One study showed that 22 veterans kill themselves every day. Homelessness, addiction and other problems are pressing concerns as well. Ament called them "societal problems" that the VA is on the front lines of addressing.

"I don't want to get political," Ament said, "but our society stopped investing in community public health and community mental health 30 years ago. Insurance doesn't pay for it. The difference is we do invest in it, because we subject our veterans to warfare.

"Because we invest in it, we do fund recruitment, we do pay very good salaries for our psychiatrists. We would like the rest of society to mirror us."

Flynn said that in addition to expanding, the residency program has become more hands on in recent years and has grown to provide telepsychiatry service to rural community-based clinics in Hutchinson, Salina, Parsons, Hays, Dodge City and Liberal.

For the residents, Flynn said, "It's a lot to learn. They develop an understanding of how to develop a rapport with veterans. Some of them need more time, just to learn how to listen. It takes special communication skills, expertise, compassion and knowledge to take care of our hero veterans, to give back to those who have given a lot."

In her own case, Flynn said, completing the KU Wichita residency program, joining the VA staff and then becoming chief psychiatrist fulfilled a long-held dream inspired by her grandparents, who were World War II veterans.

"Since I always dreamed of taking care of invisible wounds, that made psychiatry my passion," Flynn said.

Veterans like the patient mentioned at the beginning of this article are often still reluctant to seek help, she said, but when they do, the result can be rewarding for both patient and the VA psychiatric staff. As Flynn recalled: "He said thank you so much for giving his life and his happiness back to him."