Medicine as a Vocation

Many physicians perceive their profession as a vocation. In this episode we talk about how this affects our lives and our practice.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Neda Laiteerapong talking about callings in medicine, specifically, in her case, to do clinical and research work around mental health.

[00:00:16] Dr. Laiteerapong: Some people who know me know that I send early morning emails and they think, "Oh, God, she must have insomnia, she can't sleep." No, actually, I wake up early, that's just my biorhythm, I go to bed early, I wake up early, and when I wake up, I want to solve that mental health problem. I want to work on my research around mental health, like, that's what I want to do.

[00:00:40] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. Neda Laiteerapong. Dr. Laiteerapong is a general internist and associate director for the Center for Chronic Disease Research and Policy at the University of Chicago. She is a leading researcher in the field of individualizing diabetes treatment. She leads efforts here at the University of Chicago to integrate behavioral healthcare into primary care. She's also a senior fellow in the Bucksbaum Institute for Clinical Excellence.

Personally, I know Neda well because for years we've seen patients at the same time in our primary care group. I've come to know her as a wise and dedicated physician. She's also a great companion on the days that clinic takes a little more out of you than usual. Thanks for joining me today.

[00:01:33] Dr. Laiteerapong: I'm really happy to be here.

[00:01:35] Dr. Cifu: So I often begin questions on the podcast apologizing for choosing to focus on just one part of what people do, and that's totally the case with you. I'm going to like, leave out a lot of the things that I included in your introduction but a lot of people see medicine as you know, more than a job, more than a career, but really as a calling, a vocation. My sense has always been that that's true for you, not just for medicine, but for your focus on mental health. And however much you feel comfortable sharing, what was your kind of route into you know, medicine and then your route into this kind of sub-subspecialty, I guess?

[00:02:12] Dr. Laiteerapong: I'm happy to share. You know, I was really always one of those annoying children that when adults asked, "Y'all, what do you want to be?" I always said I wanted to be a doctor and my siblings would look at me like, "Oh, she's so annoying," but my father is a physician. He retired during COVID. COVID definitely put him out of doing medicine and he was actually trained in Thailand and came over to the States. He did a pathology residency, but he had to support his family, as he was an immigrant, so he was always moonlighting, and he was kind of doing the things that doctors were not... All the other doctors weren't interested in doing. So he ended up taking care of patients with substance use disorder. So he actually ran methadone clinics when they opened, he worked in a practice that saw patients before and after methadone treatment. And so he would come home with these stories about these people and their lives and the challenges they experience. And I was living in the suburbs of Chicago, a very different experience and I was like, "I always wanted to take care of these types of people." So that was sort of the beginning.

And then, so I always wanted to be a doctor and then when I was in medical school, I had the very unfortunate experience of losing my brother to suicide. And he had been really sad for a while, off and on, had failed, you know, relationships with women, and just wasn't where he thought he would be in life, never felt like he fit in, being, you know, a first-generation immigrant in the US, just never felt like he fit in, and he was very not interested in getting mental healthcare.

Even my Asian parents who also, you know, sort of were standoffish about mental healthcare were actually like, "You should get some help. You're in a bad spot." And he was like, "No, I'm fine. I'm fine. I'm fine." And in the end, he wasn't. And so I think that, sort of reflecting on that, it really to me is a calling, like something I just can't not do.

[00:04:01] Dr. Cifu: Did you consider psychiatry? Hearing about that sort of happening while you were in training.

[00:04:06] Dr. Laiteerapong: I did! I did think about psychiatry, but I love medicine. I love medicine. I love the pathophysiology of it all. I love the whole-person care. I love the social determinants of health and trying to understand like how people come to where they are when they get to your office and how that moves them forward. I really like the idea of like mental and physical healthcare are not two segments of a person. Your brain is not disconnected from your body. It's actually a part of it, and I like the two of them integrated.

[00:04:36] Dr. Cifu: I always love stories about people who immigrate to this country and then end up, I'm talking about medicine particularly, you know, working in, you know, sort of difficult settings with people who are kind of at the edges of society. And I feel like it's interesting because those are often very, I don't want to say very difficult people to work with, but they're people to work with in very difficult situations. And it's interesting that a lot of that care in this country ends up with people who are not quite of this country, right? Or just adjusting to it.

[00:05:11] Dr. Laiteerapong: Yeah, I think you're certainly right. And, you know, asking my dad, like, did he love taking care of these people? I'm not sure he would say he loved it. It was challenging, it was hard. And, you know, it's not like he was at a place that was very well-resourced where he understood the social safety net that the US does have for people. He didn't understand it. He was also learning just, you know, how to be an American himself but...

[00:05:39] Dr. Cifu: It brings me back to that first Abraham Verghese book, the... In my country? In another country? I can't remember the name of it, but sort of him as an immigrant taking care of patients who are a little bit outside the society, forgetting everything about the book, West Virginia, Kentucky, Tennessee, something, listeners to the podcast will be appalled that I can't remember, um, but very similar.

So this gets to something that I think you and I have talked about a lot. We've talked about burnout and sort of dealing with burnout and avoiding burnout. And I know there's some research that I'm not sure I buy as great research, but that says that people who sort of see medicine more as a vocation, as a calling are maybe less susceptible to burnout or maybe more susceptible to sticking with it through burnout.

For you who, you know, always seem like someone who's, you know, absolutely dedicated to their career, are there sort of pluses and minuses for you, you think, personally, like, having that sort of, I don't know, commitment to your work?

[00:06:45] Dr. Laiteerapong: It's a really important question, I think. You know, as we see so many people are burned out in medicine, it's like, what can we do to stop that, you know? And hey, why don't we just make it a calling? There are a lot of pluses, like, I joke that I don't have to volunteer because I get to help people all the time. I think it keeps me passionate and driven. I mean, a lot of what you do as a doctor, especially as an, you know, academic medical center or a researcher or just any clinician is you've got to keep up to date in your nights and weekends. Your daytime job is not keeping up in medicine. It's the nighttime job, it's the weekend job. And so the passion definitely helps me want to read those articles because, you know, it's like what I would do in my free time, you know because I feel so passionately about it. I think that every day comes with purpose and meaning, and that makes my job, my life integrated.

Yeah, the minuses are the... There are minuses, I mean, the burden I feel when I hear about cases of people with mental distress. So I've become a resource, which is wonderful, I'm not complaining, for other clinicians to try to figure out what to do with some of their patients when it's challenging to navigate the healthcare system for mental healthcare. And there's secondary trauma that comes from hearing all these patient cases. You know, like, I feel that patient's suffering by just hearing about it or even the clinician's suffering as a clinician trying to take care of those people. And so that does have a minus to it because there's a psychological burden that every mental health provider and me as a secondary mental health provider get. And so all that talk about self-care and, you know, all that stuff, that stuff is so important for someone who's working in this type of area. I mean, it's important for everyone in general who does healthcare work, but even so for someone who's doing mental healthcare work.

But I would say that the pluses are that, like, you know, I'll stay late at work to try to solve something because I'm really passionate about it, and I have a very forgiving family and other people who support me and allow me to do that.

[00:08:50] Dr. Cifu: Your point about, you know, I love doing the work to keep up, or I love reading, for me it's often, you know, I love writing about medicine, that... You know, I like doing that in my spare time because it's something I enjoy, right? And it's sometimes hard for people around you to accept that they say like, "Oh God, you got to take a break," and you're sort of like, "This is my break. You know, as strange as it may sound, yes I like to go to the museum, yes I like to go out for a run but I also like to sit here and, you know, think about the things that I love and I can't really think about at work," right?

[00:09:25] Dr. Laiteerapong: Yeah. So, I mean, some people who know me know that I send early morning emails and they think, "Oh, God, she must have insomnia, she can't sleep." No, actually, I wake up early, that's just my biorhythm, I go to bed early, I wake up early. And when I wake up, I want to solve that mental health problem. I want to work on my research around mental health, like, that's what I want to do, but I also want to figure out how to delay my emails on my laptop, so people don't comment on how early I'm, you know, sending emails in the morning.

[00:09:54] Dr. Cifu: So they're not worried about you.

[00:09:55] Dr. Laiteerapong: Yes, so then I don't have insomnia.

[00:09:58] Dr. Cifu: So let me step back a little bit to more of the clinical care, I guess, of our patients. I'm sure that we share the experience that we take care of many people who are much more comfortable kind of attending to their physical challenges rather than their mental health challenges and that's even when the mental health challenges are clearly, you know, to us as their physicians or maybe to any outsider, you know, clearly the main issue, right?

[00:10:26] Dr. Laiteerapong: Mm-hmm.

[00:10:28] Dr. Cifu: It's the thing which is leading to most of their disability, maybe it underlies what they see as their physical complaints. So first, just like, is this your experience? You know, why is it that people seem to be so much more willing to take, you know, an antihypertensive than an antidepressant? And, you know, what the heck can we do?

[00:10:50] Dr. Laiteerapong: Yeah, you know, yes, that is certainly my lived experience. You know, I think it's really common. Somehow, I think it's a lot of American culture that has done this when we separated the brain, the emotional part of the brain from the thinking part of the brain, and as a result, we have this disconnect, where we think, "Oh, my abdominal upset symptoms can't be my anxiety. It must be my abdominal upset symptoms because I have a condition that needs to be diagnosed." You know, I explain to my patients when I start like an SSRI, you know, it's selective serotonin reuptake inhibitor, "Remember kids. Kids when they're little they have butterflies in their stomach when you're nervous or maybe you have butterflies in your stomach when you have to give a big presentation. That's because," and psychiatrists will certainly correct me, "that is because you have serotonin receptors in your gut, you have serotonin receptors in your brain. When you start an SSRI, you will feel uncomfortable in your gut. That's normal, and that's because the drug is getting into your system and working."

But yeah, I think people just, especially in this country, have disconnected their heart from their brain in a sense, you know, their feelings from the brain.

[00:12:01] Dr. Cifu: I wonder if that's something... Because I do feel over the course of my career, and maybe this was well before my career, that there is a set of mental illnesses that people are much more likely to see as mental illness, right? I think of like, you know, psychotic diseases, bipolar disease, things like that...

[00:12:20] Dr. Laiteerapong: Yes.

[00:12:20] Dr. Cifu: ...that people are like, "Oh, we get that this is an illness of the brain," you know, like hypertension is an illness of the blood vessels, something like that but then, right there, all of the, I don't know, you know, more mild depression, anxiety, and then also the more kind of ambiguous illnesses that we deal with all the time, that probably have more of both a physical and mental component, that that seems to be where the problem is most.

[00:12:51] Dr. Laiteerapong: Yeah, I think, you know, it's easy to see someone with schizophrenia and say that is definitely, you know...

[00:12:58] Dr. Cifu: That person's sick!

[00:12:59] Dr. Laiteerapong: That person has a psychiatric disorder but the depression is, I think it's hard with the... It's sort of, I don't know, the road of diabetes in a sense and prediabetes, you know, where we're like, oh, well there's lifestyle and then there are medicines and people don't want to take the medicines, they want to do the lifestyle and do that as long as possible. You know, it's the same sort of road that we have this inbred desire to enter this world with no additional medicines, nothing taken out of us and leave this world the same way, not taking medicines but gosh, if it's your blood pressure, I mean, 80% of people, whatever, have blood pressure, it's normal, you start to hear other people are having high blood pressure. "Okay, fine. Everyone in my family has high blood pressure, I have to have high blood pressure." I think the COVID pandemic for all of its badness has done both good and bad for mental health. You know, we're asking like, what the heck can we do? So normalization of the problem, normalization of the treatment of the problem I think can be really important for mental health. You know, hearing famous people have these conditions and are dealing with it, you know, I think actually does wonders. You know, sometimes you know, if they say... They go down a path where you're like, "Oh, don't advise that," that's a problem, but when they're, you know, advising people to get treatment for depression, anxiety or PTSD or ADHD, and they've admitted that they have it, that certainly helps. And then the other part is clinicians and healthcare workers being comfortable with it themselves. You know, there's the patient side, which... They could want help but if the clinician is saying, "Just exercise, you will exercise [unintelligible]." And not to say exercise doesn't help for depression because it does but like, there are certainly other things that can be effective, especially therapy and sometimes medicines.

[00:14:42] Dr. Cifu: Let's give the podcast industry some kudos, you know since every podcast you listen to has ads for therapy.

[00:14:48] Dr. Laiteerapong: Yeah.

[00:14:50] Dr. Cifu: Let me just, before we finish up, let me latch on to one thing you said because I kind of like this analogy and I'm trying to figure out if it's actually real or not, you know, that maybe part of the problem with mental health and people accepting it is that, you know, there's a spectrum of disease which gets into normal, right? I mean, sadness, grief, you know, dysthymia...

[00:15:12] Dr. Laiteerapong: Loneliness.

[00:15:13] Dr. Cifu: Loneliness, all normal, right?

[00:15:14] Dr. Laiteerapong: Yeah.

[00:15:16] Dr. Cifu: ...but can certainly cross over into illness where it's disabling, it makes people's life less enjoyable. And it is a problem I think, that I see counseling people with some diseases, diabetes, hypertension, right? Where there are phases of prediabetes, impaired glucose tolerance, which is hard to even know if we should call that a disease or not. You know, everything kind of increases risk on some slow linear curve and sometimes it's hard to get people to start therapy because they're like, you know, "Why now? What has changed? Am I that sick at this point?" What do you think?

[00:15:57] Dr. Laiteerapong: I mean, I think I took you in this direction so I probably just want to go with it. I mean, I think it's true. You know, I think that so much of what we're doing I think in therapy, when I say we, it's not me, but I, you know, facilitate the process, is trying to teach people coping skills for life events that happen. Bad things happen to good people. Bad things happen to bad people. Bad things happen. So some of it is coping skills around regular life events but some of it, a lot of it is also when it gets really bad. So some of it is preventive, like when someone has prehypertension, we say, "Okay, you should start to fall in love with exercise and diet," and some of it is like, "Oh, you should go to group therapy or you should read some books on self-management and, you know, how to change how you think the negative self-talk." And then you get kind of more serious you know, and you're like, "Okay, now you really have to do it, we really... You know, you are not getting out of bed. You're having a tough time. You're not going to work. You've got to go to an intensive outpatient program. You really need to do this." So I do think that there's a spectrum of prevention of mental health problems. And then, you know, prevention leads to the need for treatment if things go too far, or life is just too hard and too many bad things have happened.

[00:17:13] Dr. Cifu: I think these parallels are often good since so often the sort of first place of contact with people with, you know, mental health challenges are not mental health providers, right? And so it's those people who have to kind of frame it for patients about, you know, why is this important? Why should you get help? And maybe this is one more thing to use.

[00:17:37] Dr. Laiteerapong: Well, there's this... Yeah, there's a whole area around like, how do you approach it in a way that doesn't reinforce the stigma of mental health and get people running in the opposite direction never to share or open up again, you know?

[00:17:50] Dr. Cifu: I've done that on occasion. Just to be honest.

[00:17:54] Dr. Laiteerapong: You know, we're not all at our best every day. We do our best that we can.

[00:17:58] Dr. Cifu: So Neda, thanks so much for coming by, taking the time, and thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page, or I guess, now X page.

The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.