Subscribe
Share
Share
Embed
Psychiatry, Education, Insight. Docs Tracey and Paul Discuss it All! Two psychiatrists — Dr. Paul E. Keck Jr., MD and Dr. Tracey Goodman Skale, MD of TMBO (Two Minds, Better than One) — illuminate mental illness, teach signs and symptoms, dispel myths, and advocate timely care and dignity. Nearly 70 years of combined expertise. DISCLAIMER: educational/general discussion only, not personalized medical advice; in crisis call the 988 Suicide & Crisis Lifeline.
678441
Welcome to the Two Minds
Better Than One podcast.
Docs Tracy and Paul Discuss it All.
Welcome to Docs Tracy and Paul
Discuss It All.
This is the first of a series
of podcasts about mental health and
mental illness.
I'm joined today by my wife, a
renowned psychiatrist, Dr. Tracy
Scale.
Hi, honey.
Hi, everyone.
And I am Paul Keck, also a psychiatrist.
And today's topic is what is
mental illness?
Right.
Thanks for leading us off, honey.
And so welcome, everyone.
We are talking about what is
mental illness, but we also want
to introduce ourselves because
this is the first podcast and there'll
be many.
And in this series, we will be
talking about all aspects of mental
illness.
So hence, docs Tracy and Paul
Discuss It All.
As the name of our podcast,
our company is called Timbo Enterprises,
Two Minds Better Than One.
Because we feel like the two
of us together have a synergistic
effect.
Right.
And we're work pretty well together.
So we'll be talking about all
aspects of mental illness.
We'll talk about depression
and bipolar disorder, schizophrenia,
some other topics.
Paul, what else?
Talk about obsessive
compulsive disorder.
We'll talk about anxiety
disorders, eating disorders,.
Post traumatic stress disorder.
Yes.
Anything that you could think
of related to psychiatry, we will
be talking about.
This is meant for the general
population, but our psychiatric colleagues
are obviously welcome to be
part of this as well.
A lot of the times will be
just us discussing things like it
is every day of our lives.
This is our lives.
We have these discussions over
dinner all the time.
Right.
But we'll also have guests in,
and we're looking forward to introducing
them to you a little bit about ourselves.
I'll talk about you, Paul.
So I've.
Paul and I have been married
for several years now, but we've
known each other a long, long time.
35 years, I think, now.
So.
Paul came into my life when I
was a resident at the University
of Cincinnati College of
Medicine, and you came over from
Harvard and brought
psychopharmacology to our program.
And I'll never forget that you
changed the psychiatric program from
more of a psychodynamic
program to psychopharm.
I learned a lot from you.
I took feverish notes.
And here we are all these
years later.
And what do you want to say
about me?
I guess.
How would you like to say that?
Well, I remember you as a resident.
I remember the chairman trying
to desperately recruit you to stay
in the department.
And I remember your courage
and commitment in wanting to be a
psychiatrist in the community
mental health system.
And you quickly ascended to be
chief Medical officer.
Well, medical director and
then chief medical officer at the
largest community mental
health system or center in Cincinnati.
And you devoted your life to
treating the most serious people
with the most serious mental illnesses.
And that took a lot of courage
and commitment.
Thank you.
It was the greatest honor of
my life serving in that role in treating
thousands of patients over the
years with chronic, severe, persistent
mental illness.
My specialty is working with
people with schizophrenia.
As you know, schizophrenia,
schizoaffective, severe bipolar disorder.
Paul, you're an
internationally known bipolar expert,
but you treat lots of people
with depression, bipolar disorder,
anxiety.
And you founded the Lindner
center of Hope in Cincinnati, which
is what?
Describe that to people.
Lindner center of Hope was the
first freestanding comprehensive
mental health center to be
built in about 25 years.
It opened in 2008, mostly
through the inspiration and philanthropy
of the Lindner family.
Yes.
And you were president and CEO
and treated patients for many, many
years.
I've always been a doctor.
I've been an administrator, a researcher.
But the most rewarding part of
my career has always been working
with people with psychiatric problems.
Same.
So we both think of ourselves
in the trenches as doctors.
We see people every single day
of our lives.
So why did we start this podcast?
People have been asking us for
a long time to do something like
this.
I know you and I have both
been on many radio shows and local
TV programs talking about
different aspects of mental illness.
So this podcast was long overdue.
We started it, as, you know, a
few years ago.
We started doing this, and
then life happened, and good, exciting
things happened, and including
a move across the country.
We're now relocated in
beautiful, sunny Arizona and a grandchild,
and all these different things
happened to us, which were all wonderful.
But then we had a serious
conversation, said, this is time.
It's beyond time.
We should be doing our podcast.
Between us, 70 years of
psychiatric experience, and you always
say we have bookends.
Talk more about that.
Yeah, I think our work has.
Well, first of all, we, I
think, together probably treated
thousands and thousands of
people, one on one, usually in our
offices.
And that was extremely rewarding.
But what we also figured out
was that our careers were complementary.
You worked with, in the
community, the public health system,
with, as we said, very, very
seriously mentally ill people.
And I worked more in the
private sector system.
And together, I think our
knowledge, hopefully, will help the
general public, not just
individual by individual, but amplify
what we learn and help people
identify when there's a problem and
go get help.
Right.
I love that idea.
We have very Much cherished
our time seeing patients.
And you'll hear us say patients.
So we're both MDs, we both
went to medical school.
We both did residencies.
We both did internal medicine
and neurology before we did our psychiatric
residencies.
So you'll hear us say
patients, because doctors see patients.
If you had a cardiac
condition, you would be a patient
of the cardiologist.
If you had cancer, you would
be a patient of the oncologist.
Same thing.
If you have schizophrenia,
bipolar disorder, you're a patient
of ours.
Now, our colleagues, who we
love, our esteemed colleagues in
all aspects, then our nurse
practitioner colleagues, our PAs,
our therapists and social
workers, you will hear them say clients
or various other names.
But for us, you'll hear us say patients.
I think the word patient is
important to use because it stems
from the Greek to suffer.
And I think people come for
help to a mental health practitioner,
provider, whatever, because
they're suffering.
So why did you go into psychiatry?
So I know that your background.
You were a jock.
I mean, you played rugby, you
ran marathons, you played football.
I thought you were going to
orthopedic surgery.
How did you choose psychiatry?
As you know.
But maybe some people don't.
When you're in medical school,
you have some choice in the order
of your rotations, your
experience in the clinics.
And I had no history
whatsoever with psychiatry.
And in fact, where I went to
medical school, the lectures in psychiatry
in the second year were just
boring and uninspiring, really.
Psychiatry is so interesting
all the time to me, I think.
So what's your undergraduate
degree in?
Anthropology and biology.
So I planned my psychiatry
rotation, dead last in my third year,
because I didn't think I had
any interest in it.
I was going to go into
internal medicine.
Actually had a stack of
applications on my desk in my apartment.
And then I was assigned to
work at the Bronx va, which was a
Mount Sinai affiliate at the time.
And it was.
It was an epiphany.
I was assigned to work with a
young man who was almost exactly
my age, who had schizophrenia.
Very bad case of schizophrenia.
He could barely speak, nothing coherent.
And it struck me that there,
for the grace of God go I.
So I had a career ahead of me.
I had my health.
And he had nothing to look
forward to because the medicines
we had available then were
simply ineffective.
And so I thought, well, we
know a lot about how the heart works,
kidneys work, the lungs work,
but we didn't know much about how
the brain works.
And I thought if I could make
just a tiny Little contribution to
this field.
That would be a career worth living.
Well, you've had a career
worth living then because you've
made more than a tiny
contribution, I'm very proud to say.
And how about you?
So I had nobody in my life
that was a doctor.
Nobody was in medicine.
I'm from a small town in
western Massachusetts.
I always look back at this
because people ask me this, especially
with my special interest in
working with people with psychosis
or severe mental illness of
other sorts.
I must have somewhere seen
some show about somebody that was
hearing voices.
I read the book.
I never promised you a rose
garden early on.
I remember that being
instrumental to me too.
But I was always fascinated by
the brain.
Now I did not.
You had.
You said anthropology.
I was a neuroscience major.
I went to Amherst.
I was a neuroscience major.
I love science, I love the brain.
And so neuroscience is the
perfect major for me.
But I also had a major in
psychology, so I had a double major.
And at the time I loved my
advisors at Amherst.
And the psychology advisor
said, please, whatever you do, don't
be a psychologist.
Taking nothing away from our
psychology colleagues.
We love psychology.
But he said, there's so many
more opportunities for you if you
go to medical school and you
love science so much.
I really recommend you go to
medical school.
My neuroscience advisor is the
big reason I went to University of
Cincinnati, because he said,
cincinnati is a school for nice kids.
You need to go there.
Which was very kind of him to
say that.
My pre med advisor said, why
are you going to medical school?
I think you should be a writer.
You like to write.
I said, I really want to go to
medical school.
So went to medical school
knowing that I would do something
with the brain.
I loved all my rotations and
the rotation people liked me because
I was so interested.
I remember my surgical
rotation was great.
I was very honest.
A lot of medical students, by
the way, aren't.
They'll say they're going into
whatever rotation if they're on surgery,
ob, gyn, whatever, that's what
they're going into.
I was always, I'm going to be
a psychiatrist or a neurologist.
And they would, they
appreciated that I gave effort, you
know, and let Tracy see the surgery.
So I was leaning toward neurology.
But then the neurology
residents, you were talking about
the classes and not being
interesting in psychiatry or psychology.
The neurology residents
weren't particularly happy.
And in those days they were
doing a lot of post stroke care and
a lot of chronic pain.
And that didn't seem
Particularly interesting to me.
That's not what I wanted.
Had I gone into neurology, I
would have been interested more in
Parkinson's disease, seizures,
Huntington's or some more obscure
things.
So psychiatry made sense to me.
And then I did my psychiatry rotation.
Absolutely loved it, Loved
every second of it.
Especially inpatient, where
people are very, very ill. And if
you like that, you like
psychiatry, you know, but in terms
of other things in my life
that were pivotal to me.
You said you talked about that
patient that you met.
I've been thinking a lot about that.
So when I was 18 or so, I'm in
early college years, my boyfriend
at the time had a brother with
severe mental illness.
So I think that also played a
big part.
And I remember he was really
handsome and really smart.
And my boyfriend at the time
said, we need to go visit my brother
in the hospital.
And I didn't know anybody that
had psychiatrically hospitalized.
And we're.
My little small town.
There wasn't anywhere.
There wasn't even a
psychiatric hospital, you know, where
I was.
But this was closer to the
Boston area.
And we went to see him in a
psychiatric hospital.
And it was a bad experience.
So don't Forget, I was 18.
I'm in my 60s now.
This was a long time ago.
And much like you said, there
weren't many good treatments then.
And I remember this handsome,
smart man, shuffling gait, drooling,
flat facial expression, still
mumbling in a nonsensical manner,
but with all these side effects.
And I remember thinking, this
is really horrible.
And if I ever go into
psychiatry, I'm going to try to make
someone's life a lot better
than this guy's life is right now.
Unfortunately, he went on to
die by suicide.
Very, very tragic.
And you will hear us say, die
by suicide.
We don't ever say, commit suicide.
That's passe.
No one says that anymore.
You'll hear that on TV every
once in a while.
And we cringe when we hear
that, because just if you would die
from your cancer or your heart
disease, you can die from your refractory
illness.
Mental illness, right?
Yeah.
I had a friend from college
who died by suicide, and it was a
shock to everyone.
He was married, had two young
sons, and for about six months, I
would talk to his wife about
once a month to help each of us try
to understand what happened.
And she was a doctor.
She was a neurologist, actually.
And finally she said, you know what?
I realized he died from depression.
Just like you die, you can die.
The heart attack is the End
result, but usually of atherosclerotic
heart disease.
And I thought that was a great
way to frame it.
It is a good way to frame it.
And you'll see more in
obituaries now talking about that.
People are more forthcoming
about that, which is good because
it really helps destigmatize
when people are more open about talking
about their mental illness.
Another pivotal thing for me,
I was in medical school already and
I got paged.
That's in the old days, we had
these pagers and they said somebody
was there to see me.
And it was this teacher I had
in high school.
And here, you know, I went to
high school in Massachusetts and
now I'm in Cincinnati.
And here's this teacher from
high school found me and wanted to
talk to me.
I went down and this was one
of the most important teachers of
my life.
Very important person in my
life in high school and my memory.
He was my math teacher.
I was a math lead.
I love math, you know.
And he was very buttoned up,
serious guy.
And he showed up there and the
reason is he was on his way to some
pilgrimage in Indiana and it
was a religious retreat of some sort.
And he, this very short
haired, tie, buttoned up man, had
long hair and kind of wild
clothes and he was talking really
rapidly and he was completely
different than I remembered.
And don't forget, I'm a
medical student and now I'm not in
psychiatry.
But I knew, oh my goodness, he
is in mania.
And then I did something,
probably not smart, but I ended up
okay.
He said, you want to go have coffee?
And I said, sure.
And I got in a car with him
and now hadn't seen him in years.
But this is an important
person in my life.
And his car had all kinds of
religious figures, Virgin Mary statues
everywhere and bumper stickers
and things.
And we started talking and he,
he said, what are your plans?
And I said, well, I am going
to go into psychiatry.
He said, really?
I don't believe in psychiatry.
And again, this was said with
very rapid speech and some disorganization.
But this came out and I said,
why is that?
He said, well, I have an
identical twin brother.
And when we get into our
bipolar discussion, another, you'll
see the strong genetics
associated with certain mental illnesses.
I have an identical twin
brother who was diagnosed with bipolar
disorder.
And my mother was diagnosed
with manic depression, which is what
we used to call bipolar disorder.
And people tried to say I have
that, but I don't have that.
I just don't believe in that.
And I thought, oh, wow.
And we sat and it was just
really touching to be with him, and
he was able to come out of his
psychosis here and there, and we
had some meaningful
conversation, and he went on his
way, and I never really heard
about him ever again.
But that was also really an
important piece of my life.
And he also exhibited.
And I think we'll probably do
a podcast about this, something called
anosognosia, which is one of
the most insidious symptoms of a
severe mental illness, is that
you don't recognize that you have
a mental illness.
So, you know, anosognosia is
one of my favorite things to talk
about.
We are doing a whole podcast
on that, and there's books written
about it.
We might actually have one of
our guests be someone that specializes
in anosognosia.
So it's the lack of insight,
but it's truly, you do not believe
you have mental illness.
So it's not unique to the
psychiatric world, people within
the neurology world.
For example, some people had a stroke.
They can't move their right
arm, yet they think they can.
Some people have lost vision
in one eye.
They think they can see.
With us, especially with my
patient population, we had several
ACT teams, assertive community
treatment teams.
Many people are in and out of
the hospital all the time, and they
could be hospitalized 40
times, and they would say, there's
nothing wrong with me.
My mother must have paid off
the police.
This is a conspiracy.
And there's just not any
insight about that.
And then that becomes
particularly challenging.
How do you get someone to take
a medication that they might need
when you really don't think
there's anything wrong with you?
So that's also very fascinating.
Yeah.
Should we talk a little bit
about how common mental illness is?
Sure, go ahead.
And some facts.
I've.
You do facts and figures
because you like facts and figures
more than I do.
We might say when we were
preparing and we did a little synopsis
of who are we?
I said, paul, we should
probably figure out, you know, who
are we?
How are we approaching this?
And it was really interesting.
I wish we should have brought that.
We might bring it another time.
But mine was all, hi, I'm
Tracy, and my husband's Paul, and
rah, rah, rah, you know, we.
We love treating patients, and
we love, you know, and Paul's was
very.
Tracy went to this school, I
went to this school, we, blah, blah,
blah, and all that.
And it's funny, but together
it works really well.
So you do do some statistics
for us.
Well, it's been estimated that
anywhere from one out of four to
one out of five people have a
mental illness in their lifetime
at some point.
So when, you know, there's a
lot of focus on cancer, heart disease,
diabetes, appropriately, but
mental illness in aggregate is more
common than all of those
illnesses combined.
So it's the number one public
health problem in our country and
actually globally.
So it's not just a product of
industrialized society, Western lifestyle,
things like that.
The organ is the brain.
85 billion nerve cells plus or
minus in the brain, and over a trillion
connections among those nerve
cells, which makes it obviously the
most complicated organ.
Most fascinating.
That's why I've always been
interested in the brain.
And again, taking nothing away
from the heart, very important organ.
The kidney, also important organ.
They're all important.
But the brain, that's the
final frontier.
And as you were saying with
your patient years ago, we didn't
have much to offer.
We still have a long, long way
to go, but we've come a very, very
long way and we'll be having
discussions about psychopharmacology
and other therapeutic
techniques that we use.
Yes.
So I think there are some
myths about mental illness.
One is that these are
character defects that, come on,
just pull yourself up,.
Pull yourself up by the
bootstraps, right?
Oh, I'm sure anybody out there
that has psychiatric illness or knows
someone, that's a really rough
one to take.
I, I, we hate hearing that.
Well, that's why I, honestly,
my, my agency was something Behavioral
health.
Sir, I don't like to, I
personally don't like behavioral
health because to me it
connotes that you have some control,
misbehavior.
I don't like that.
You don't say again, oncology, behavioral.
I don't know.
Nobody else says that.
So I don't like that.
No, I got voted on that one, I guess.
But you hear it a lot, right?
Behavioral.
You hear it a lot and it' syou
know, we talked about stigma a little
bit ago, but I actually prefer
the term discrimination because I
think people with mental
illness, again, not to make comparative
statements about other people
who are discriminated against, but
they are among the most
discriminated against people in our
society.
And they're among the most
vulnerable among us as well.
Yes.
Another myth is that diagnoses
are imprecise, they're psychobabble.
But I think in the 40 years
that I've been in this field, our
diagnostic precision accuracy
is about as good as most fields of
medicine.
Now, we still lack blood
tests, still Lack X rays.
But we rely on the old school
way of diagnosing which is basically
history, physical lab tests
and course of illness.
And using those, they're
called validating criteria.
Using those criteria, our
accuracy for diagnosis is actually
quite good and very important.
Well in the book.
So we use a book and it's
called the DSM Diagnostic Statistical
Manual 5 Text Revised.
So they update it and we do
rely on that.
But you bring up an important
point is that the patient is of a.
As a whole, you cannot get
accurate diagnosis in psychiatry
by five minute appointments.
So I'm going to preach that
till the end of time.
So again I was chief medical
director but I saw patients every
single day and I saw some of
the most ill people because I chose
to and I wanted them to get
the best possible care.
And it, and I'm good at this.
It takes time.
You're good at this.
It takes time.
We, I insisted on an hour
intake or more.
We had what we called a first
break team, which is very important
team.
We had, we took, I'm an adult
psychiatrist but I took people as
young as 14 in that program,
14 to 40 within the first 18 months
of any signs of psychosis.
And we wrapped services around
them, try to keep them on a trajectory
of wellness.
The longer you stay in an ill
state, the harder it is to get out
of it.
And if you start losing things
like dropping out of school and relationships
fall apart and lose work and
it's hard to get back in that world.
So we wrap services around
them with those patients.
You're telling a family that
their 15 year old scholar athlete
son is hearing voices and they
have schizophrenia.
Now that's a hard diagnosis to tell.
And, and we need, and we're
trying to rule out all kinds of things.
Please tell us if you're using substances.
We're not judging you.
We need to know.
And again our medical
expertise comes into play.
Is there something medical
going on that could potentially be
causing this?
You know and initial workups
with head CTs.
Right.
I know you sometimes,
sometimes at Lindner center and it
depends on how they are
presenting, but definitely taking
a thorough evaluation and
spending time.
Our follow up appointments
were always half an hour.
It depends if someone, if
there was a person that said I just
need a refill on my Prozac,
that was rare in my life.
That's not my typical patient.
That's a different story.
But most people, you need time.
So you and I give lots of
presentations to our colleagues.
And after this happened, I
swear I told this story 400 more
times because it was so disturbing.
I was giving a talk to a large
group of nurse practitioners.
Again, it could have been.
We have great nurse
practitioner colleagues and I'm still
consulting and collaborating
with many of them.
Just spoke to two of them this morning.
But this one woman, she was a
new nurse practitioner in family
practice.
And much to the chagrin of her
supervisor, she spoke in front of
the whole group and I said the
importance of spending time with
patients.
And she said, excuse me,
that's very old school.
And I said, oh, tell me more,
I want to hear more.
And she said, oh, I only spend
five minutes with every patient.
And she was really proud of this.
I spent five minutes with
every patient.
And she said, yeah, like I
have one pill for every disease state.
So if they have high blood
pressure, they get Norvasc.
If they have diabetes, they
get Metformin, if they have depression,
they get Prozac.
And I, I was mortified.
But I've told again, I've told
the story so many times and here
I am telling it on our
inaugural podcast.
So if you are a person that's
seeking psychiatric treatment and
you go to your insurance
company and they say, here's a provider,
here's a psychiatric provider
for you and they spend five minutes
for you with you, please try
to, if you can get a different provider,
that's not good care.
Especially in early on, they
need to be spending time.
I don't like it when people
make a diagnosis.
When a couple minutes.
I remember even as early as
residency, because you talked about
bipolar disorder a lot.
When I was a resident, I
remember there was a resident in
my class, someone would start
presenting and they would be two
sentences in, you know, Ms.
Smith is a 43 year old Caucasian
female with blah, blah, blah.
And the person would say,
bipolar disorder.
Like, I don't like that.
Like, you shouldn't be making
snap decisions like that.
If there's a lot of things to
consider making a diagnosis.
Yeah, so I've always said
psychiatry is a pretty low tech field,
but what we have is our mind
and our experience and time.
The other point I think it's
worth emphasizing is diagnosis is
important, but people are not
their diagnoses.
Right, Right.
And I think one of the most
important aspects of finding a mental
health provider is not just
time, but are they authentic?
Do they care about you?
They care about you as a human being.
So when I left my practice of
31 years.
And how many years were you in practice?
40, 40, 71 year.
Well, that was very emotional.
We should write Books about
that, Just the whole saying goodbye.
I had some patients at my
agency, so I had some patients I
had when they were 20 and they
were 51 when I left.
Can you imagine what life we
experienced together?
So very emotional, saying goodbye.
And I gave lots and lots of
notice, nine months notice and lots
of, you know, we have five
more sessions, we have four more
sessions.
And I had all kinds of
inspirational quotes in my office.
Never, never, never give up.
And the journey starts here.
And.
But the one that people love
the most besides never, never, never
give up was I don't care how
much you know until I know how much
you care.
And that was right behind my head.
And I also had all kinds of
brain charts and brain models because
these are neurobiological illnesses.
Right, but you're an excellent psychopharmacologist.
I'm a very good psychopharmacologist.
But I think the thing that we
are best at, Paul, is that you just
talked about authenticity.
We truly care.
Our patients knew that.
When I got so many cards and
letters from my patients at the end,
that was the theme that kept
recurring is I know you really cared
about me.
And we would show that and we did.
We actually genuinely cared
about them.
So I know, same with you.
When someone was in the room
with me, they were the center of
my universe.
Nothing else mattered.
I wasn't distracted.
They are my higher levels.
We were 100% present.
And most people don't get that
in their lives and certainly many
people with serious mental
illness really don't get that in
their lives that someone is
paying attention to them and listening.
So when my patient with
schizophrenia would come in, for
example, but I remembered that
last time they were in, they were
really concerned about Uncle
Bob was having gallbladder surgery.
And that was important to that person.
And I said, before we start,
whatever happened to Uncle Bob in
that gallbladder surgery?
Taking that few seconds to ask
that meant so much because she remembered
that she cares that I care
about that.
And those were these connections.
So people would often say to
me, how do you get people to take
long acting injectables?
So some of our patients on
with long acting medication, we weren't
forcing people to do it, but
some people was highly recommended
that they be on it.
But people would say, how do
you get people to do that?
Why?
How?
Why?
They took these medications
because they trusted me.
It wasn't, I was spending five
seconds with them and I was saying,
by the way, you need to be
injected with this heavy duty medication.
We had a relationship.
They Trusted me.
And over time they thought,
wait, she cares about me.
She knows me.
And if she's suggesting this,
I might consider this.
And I think that was really powerful.
Our title of this podcast is
Docs Tracy and Paul.
That's pretty informal.
We're not going by our last names.
Dr.
Skill, Dr. Keck.
And so many of my patients
called me Tracy.
I don't care.
So many called me Paul.
And much to my mother, may she
rest in peace, is rolling over in
her grave because she, my
mother was, was so proud that I was
a doctor, first doctor in the family.
And she really wanted
everybody to call me doctor.
And she was appalled that.
That I always introduced myself.
But I would say to everybody,
I would say, hi, you know, welcome.
I'm Tracy Scale.
I'm the lead psychiatrist here
and I'm looking forward to working
with you.
And then we would go from there.
It was just two people having
a discussion.
Well, so I have a close friend
from college who also became a doctor
and he retired before.
Well, a couple years ago.
And he and I still write long
hand letters to each other.
So I wrote him.
I found myself sitting down
writing a letter congratulating him.
And as part of that letter, it
occurred to me that while we were
all pre med and studying and
trying to get good grades and all
that, we didn't realize that
we were being given a gift.
And the gift is a sacred one.
We know things about people,
our patients, that they probably
never told anyone.
It's as sacred as the confessional.
I love the word sacred.
And I feel like this is.
We have a very sacred profession.
You know, as a callow youth, I
didn't really appreciate that until
later in my career.
But towards the end, I started
telling patients that I was working
with some like you for decades.
I said, thank you for giving
me the gift of giving you my gift.
And the gift was caring.
And I meant it.
Right?
No, they knew you cared about them.
So I think that's one of the
beauties of being a doctor in general,
but especially being a psychiatrist.
I love being a psychiatrist
and you do too.
We really chose the right professions.
Absolutely.
Again, love all aspects of
medicine, but psychiatry is.
It's so special to have
someone telling you their deepest,
darkest things and their fears
and their shame and their.
All these things and being
able to bear witness to that and
being able to provide some
solace is unbelievably powerful.
So I was always aware of that
and always very grateful for that.
And I just, I've also loved
people's stories So I think that's
another thing.
I watched the Biography channel.
I always read biographies and autobiography.
I love people's stories and
everyone has a story.
So I worked with many people
that literally lived under a bridge
or in the woods.
I worked with what we called
the Homeless act team as people who
are unhoused with serious
mental illness.
And I learned some of the most
important things in my life from
those people that allowed me
to share their lives.
I remember telling you this
story and I am will write a book
about this and this will be in the.
But this man who I was working
with, very sweet, had psychosis,
was living under a bridge.
The team kept trying to get
him in.
Housing we did have in
Cincinnati was called Housing first
model, which is based on
Maslow's hierarchy of needs.
At the base of the triangle is
security and safety.
We all, everybody deserves
that dignity.
And then you keep working your
way up to self actualization.
Right?
But everybody deserves a safe
place to be.
So it was a very good program.
New York City, I believe, has
multiple places have it.
But you don't have to jump
through hoops.
You don't have to not be on substances.
You don't have to take medications.
We just want you to be safe.
So we kept trying to offer
this man and he wasn't ready to do
it.
He was relatively content
living under the bridge.
And he had a series of people
on there.
And he came into the office
one day and was very disheveled and
malodorous.
And many of my patients were.
I always say we worked with a
lot of people that the general public
often would walk on the other
side of the street if they saw many
of my patients.
And we were the opposite.
We welcome you with open arms,
you know.
And he came in and he.
I had a care manager, love my
care managers.
They're the backbone of the organization.
Was sitting in the room and
the patient came running to behind
my desk to me with a little
flip top, little grainy phone that
he had.
And it was like, I think they
called them Obama phones then.
That was the, you know, little
phones that he got for free.
But it had a little grainy
picture in it.
And the care manager was
afraid that he was gonna hurt me
or something.
I wasn't afraid at all.
And he was.
I said, no, no, it's okay.
And he said, I.
Can I show you something?
I just wanna show you something.
I said, sure.
And he held up this picture.
And it was this little picture.
It was a.
It was a goose.
And there were, if you
remember In Cincinnati.
There were lots of parts of
Cincinnati that had a lot of geese.
That was actually a problem.
It's a problem.
Caus messy.
They were kind of messy.
So most people would have seen
these geese as a nuisance.
But he held up this thing,
this picture of a goose, and he said,
look at this goose.
Isn't it majestic?
And he was so happy to share
this with me.
And it's just.
I don't know, I felt emotional.
I remember feeling emotional
when he told me that, because I thought,
wow.
And it was just this beautiful moment.
And then I remember one day I wear.
We lived in an affluent part
of Cincinnati, and I went to get
Starbucks or something, and I.
There was a woman in line,
wealthy, who was yelling at the barista
because something with her
order was being really difficult.
And here's a woman that all
the financial things she could ever
want.
And I go to work, and I'm working.
Homeless clinic, right?
And here's this guy, really,
not a penny to his name.
This is a different person.
Comes in all bedraggled.
And I said, Mr. Smith, how are
you today?
Well, I am blessed because the
sun is shining and I get to see you.
Right.
It just puts everything in
perspective, you know?
Yeah.
So we have so many stories.
Docs Tracy and Paul discuss it all.
This is us.
We like to discuss.
We like to discuss.
We never shut up.
We talk constantly.
But this is our dinner conversations.
Right.
We talk about all these
things, but we.
I think the bottom line is we
feel so blessed to have had these
incredible careers and have
touched so many lives and so many
people.
Touched our lives and very,
very lucky.
We're so lucky.
Yeah.
We have incredible gratitude,
which, by the way, gratitude is a
key to mental health.
Mental health.
And we're going to talk about
that a lot.
You know, keeping a gratitude journal.
And, you know, we both.
No matter how ill our patients
have been, we've talked about gratitude
to all of our patients, you know.
Yeah.
Mental illness, you were
talking about statistics and touching
so many people's lives.
So we've now moved to Arizona,
and we have a whole new group of
people in our lives.
And it is fascinating to me,
and it just corroborates everything
we've been saying.
Mental illness touches
everyone's lives.
We know many, many very
wealthy people, and mental illness
does not discriminate.
It's not just for people who
are poor living under the bridge.
You know, that's partly why
the Lindners, you know, made the
Lindner Center.
Right.
They wanted help for people,
for their own Family as well, right?
Yeah.
So there's not a week, I would
say, every couple of days that goes
by that someone doesn't say to
us, my brother, my uncle, my sister,
and you know, somebody has
mental illness.
Can you help us?
Which is one of the reasons we
emphasize that this podcast is we
want to make people aware of
what to look for.
How do you seek mental health?
How do you navigate the system?
Right, yeah.
When I was CEO at Lindner
Center, I would get at least a call
a day from a family, a family
member, sometimes from the person
themselves.
And Craig Lindner, who was
chairman of the board, he once asked
me, how often do I get these calls?
And I said, and then how much
time do I spend on.
I did a quick time in motion study.
It was about five hours a week
or about an hour a day.
And people were scared, as
they should have been, but also didn't
know, like, when.
When should I be worried about
my teenager who's saying he wants
to kill himself?
When should I worry about such
and such family member?
Is this just acting out or is
this for real?
What happens if.
Do we call the police?
Well, what happens if we
hospitalize my son?
Will he hate me forever?
I mean, these kinds of things.
All the.
You still get calls like this, right?
And I think the gist of our
podcast isn't that we expect people
to be able to diagnose, but be
able to at least be appropriately
concerned or recognize some
behaviors, signs and symptoms that
are worth crossing the
threshold to go see a mental health
provider.
That's so scary for so many people.
I mean, I'm a doctor and I
hate going to the doctor.
Yeah, that's for sure.
That's why I'm going with you
to your next appointment, because
I don't trust that you're
going to give all the information
you're supposed to give.
Thank you for sharing that.
I'm sharing that.
That's true.
No, I think.
No, I think that's true.
The point is, it's scary for
all of us to go to a doctor for any
reason.
I think it's even scarier for
people who have never seen a mental
health provider to go see a
mental health provider.
Don't understand psych.
We still see this.
People think we'll.
We'll be at dinner.
People think, are you
analyzing me?
Are you?
And it's kind of tongue in
cheek, but truth and all humor.
They kind of think that, don't they?
That just happened at dinner
the other night when we went out
with.
And everybody was Laughing.
Everybody was laughing.
But truth and all humor.
Then you get a psychiatry couple.
Holy cow.
They're really thinking.
We're analyzing every move
they make, but we're off.
We're off the clock.
We always say when we're at dinner.
But they also think people,
psychiatry, psychic powers or something,
that we can kind of read their
minds and all that.
No, it's not that.
We're just.
We are really good listeners.
And then I think people are
afraid that they're going to be thrown
into the hospital against
their will, which occasionally happens,
but not very commonly.
I'm glad you brought that up,
too, because as chief medical officer,
I would really impress upon my staff.
You know, we were.
We were all able to write
psychiatric holds called Different
Things in Different States.
I took that very, very seriously.
And I would always tell my
staff, you do not write a psychiatric
hold unless the first of all.
Most people needed to discuss
it with me before they would do that.
But I rarely wrote a
psychiatric hold.
But if I wrote one, they
really needed to be in the hospital.
And we had a psychiatric
emergency room we were very fortunate
to have in Cincinnati.
And they knew that if I wrote
a psychiatric hold, that person needed
to be in.
So really, the person needs to
be at imminent risk.
And imminent is the key of
harm to themselves, harm to someone
else, or they're so psychotic
they can't put a spoon to the mouth,
can't take care.
Of their basic needs.
Right.
So we took that very seriously.
So no one should be loosey
goosey just writing a psychiatric
hold on someone.
Right.
Another myth you.
I know we're bouncing around,
but another myth is that if you're
really intelligent, you can't
have psychiatric illness.
I've had this happen so many
times, people saying, I can't have
schizophrenia, or my son can't
have schizophrenia because he went
to Harvard, or he was the top
of his class.
That has nothing to do with it.
Again, it doesn't discriminate
against intelligence.
And if you've seen A Beautiful
Mind, highly recommend that.
Also the book, beautifully written.
Also another book, the Center
Cannot hold by Ellen Sachs, is beautiful.
Ellen Sachs.
I've been on many panels with her.
I mean, she's a lawyer.
She won the MacArthur Genius
Award, and she talks very openly
about her psychiatric illness
in that book.
The Center Cannot hold, so it
doesn't discriminate against intelligence.
Another story I always like to
tell is I had medical students in
residence rotating with me,
and we saw a young man who was beautifully
dressed, very articulate, But
I had given the heads up ahead of
time to this student that this
person has a history of schizophrenia.
I probably shouldn't even have
said that, but I gave a.
Said we're going to be seeing
someone with schizophrenia.
And we did the interview and
again, the importance of spending
time because had I spent six
minutes with him, he would have kept
it together.
But the 14th minute everything
kind of falls apart and the delusion
started coming out and all of
these things.
And he was very delusional and
a delusion.
We'll get into it in that podcast.
But it's a fixed belief that's
not reality based.
And he had lots of delusions
about this woman being attracted
to him.
And it was a rotomanic
delusion and led to stalking behaviors
and it was bad.
It led to legal issues and
things like that.
And he left.
And I had discussion with the
student afterwards and she said I'm
confused why you said he has schizophrenia.
And.
And I said, well, tell me more
because I'm confused that you're
confused by this.
Why do you not think.
Why, why don't you think he
has schizophrenia?
And she said he was wearing a
polo shirt, Paul.
She really said that.
And those are the days.
Polo shirts were popular, but
he was.
Because he was clean and neat
and he didn't have aluminum foil
on his head or some stereotype
of what someone with schizophrenia
would look like.
And that was concerning to me.
Luckily she did not go into
psychiatry, but that was concerning.
Oh, I have another story.
Could I tell you another story about.
That was hugely impactful to me.
Please.
This is seriously so important.
I'm so glad that this just
came up now.
So fourth year of medical school.
This is another reason I went
into psychiatry.
So fourth year of medical
school we had this rotation and I
want to say it was called a hac.
And I don't even know what
that stands for, but it was you.
It was either family medicine,
pediatrics or psychiatry you could
do.
And it was an additional one
month rotation and it was public
health.
Was public health thing.
That's what it was.
And I remember I would walk
down to the clinic in downtown Cincinnati
and it was a primary care.
I thought I'm going to do this
family practice clinic.
So I go down and there was this.
The primary care physician
who'd been there forever and he was
late 70s and he was a pretty
serious guy and kind of scary.
And.
And I was.
Went in to see this patient.
So the patient, if you're
watching the pit, highly recommend
by the way.
We're watching it right Now, Absolutely.
People present.
Talk about authentic.
Yeah.
So medical students and
residents have to present.
So I'm, you know, fourth year
medical student, I go in and I do
the exam and it said, you
know, man complaining of abdominal
pain.
So I go in to do this exam and
the man, yes, he was disheveled,
he was malodorous, he was
talking in a nonsensical way, but
he was holding his belly and
complaining of abdominal pain.
He's on, he's laying down on
the gurney.
I start palpating again.
We're real doctors.
I know how to do it.
You know, palpating the abdomen.
Start pressing.
He has an acute abdomen.
He jump, he almost jumps off
the table.
You learn that right away in
medical school.
That's potential medical emergency.
It could be appendicitis, it
could be pancreatitis, could be some.
It's an acute abdomen.
Some acute abdomen, right?
Yeah.
And I go then, and I said,
sir, we're going to help you.
I'm so sorry, we're going to
help you.
And I'm trying to reassure
this man.
I go out and present to the
family practice older man that's
been there forever.
And I say, Mr.
So and so is a so, you know,
42 year old man with.
Presenting with an acute abdomen.
He dismisses me.
I barely get the words out of
my mouth.
And he's like, ah, he's crazy.
He.
Did you see that guy?
He smells.
We want to get him out of here.
He's stinking up at the, the
whole place.
And he's just, he's crazy.
He's like a, he's a vagrant.
Yeah, I said.
And I remember it was shocking
to me.
And again, how many years
later is this?
50.
I mean, I'm still thinking
about how stressful this was, how
horrible this was.
And I had no power as a student.
Yeah.
By the way, it's not 50.
I would make me my 70s.
I was, I had no power as a student.
But I tried to again, I said,
but he really.
But, but Dr.
So and so, he really does have
an acute abdomen.
I think he might have appendicitis.
And he would not admit, do
anything to help him.
He, they call him street him
or something.
Right.
He just sent him out to the street.
And that bothered me.
It was so horrifying.
And just because someone has
severe mental illness doesn't mean
they can't have an acute
abdomen or a heart attack or something.
And that still haunts me.
And that doctor's long gone.
But I remember thinking when
I'm a doctor, whatever kind of doctor
I am, I'm going to make sure I
treat the whole patient and I listen
to people and I show that I
care and get to the bottom of things.
So there's.
Many times, haven't we, as
psychiatrists, diagnosed lupus, diagnosed
Huntington's disease?
There's many other things
we're trying to figure out as physicians,
what's going on with that person.
And we'll probably have a
podcast about this, too.
But unfortunately, people with
severe serious mental illness are
at higher risk for having
other serious medical problems.
Comorbid.
We call it comorbidity.
Comorbidity.
And so you really have to look
for those comorbid medical conditions
because one, they could be
caused by the psychiatric illness,
but two, left untreated,
they're exacerbated.
By the one exacerbates the other.
It's a vicious cycle.
Yeah, right.
See, there's so much to talk about.
You were also.
We're talking about
authenticity and the patient being
the center of the universe and
all that.
And so another story.
So part of our intro to our
podcast, we want to tell you a little
bit about us.
And so one of the other key
things for me is when I was a teenager,
I worked at a place that
doesn't exist anymore, but it was
an institution for people who
had developmental delays.
But it also, it was actually a
terrible place that's now been torn
down, and there's stories
written about it.
But we.
My father worked there, and we
all got summer jobs there.
And there was a.
Every day I would see a man
that was picking dandelions and things
like that, and I would say
hello to him, and he would say hello
back, and we would smile and
say hello to each other.
And one day my father was.
We were going to lunch, and he
said, why are you saying hello to
that guy?
And I said, I don't know.
I just, like, see him and I
say hello to him.
And he said, that guy doesn't talk.
He's been here his whole life.
And he's muted.
He doesn't say any words.
And I said, well, yes, he does.
And no one told me that.
And I just treated him with dignity.
With dignity.
And that's how we treat every
single person, with dignity and respect.
We could go on and on forever.
We will.
We're going to have many, many
podcasts, but we want to just.
We just wanted to introduce ourselves.
We're going to be talking
about depression, bipolar in the
next couple podcasts, and
we're looking forward to that.
I think, Paul, the biggest
thing that we offer is not our psychopharmacology
skills, not our therapy,
psychotherapy skills, is that we
are keepers of hope.
Never, never give up hope.
We never, never give up hope
with each other, with our friends
and family, with our patients.
And we just never give up.
And we can't wait to share
more of these stories with you.
Thank you so much.
And until next time, Sam.