Why Our Mental Health System Is Failing Us with Robert Smith, MD

Episode Transcript
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Speaker 1 (00:00):
Welcome to the Trauma THEAPIS podcast. My name is got McPherson.
I interview incredible people who dedicated their lives to helping
those who've been impacted by trauma. Here we go, So
five four, three, two and one, our folks, welcome back
to the podcast. Very excited to have us My guest today,
Doctor Robert C. Smith.

Speaker 2 (00:21):
Bob welcome, Thank you guys, looking forward to talking with you.

Speaker 1 (00:26):
Awesome. So, doctor Smith is a nationally recognized leader in
evidence based mental health care and doctor patient communication. A
University Distinguished Professor of Medicine and Psychiatry and Michigan State University,
doctor Smith developed the first patient centered method to train
medical professionals to build strong partnerships with their patients. His

(00:47):
expertise and dedication to reforming mental health care make his book,
Has Medicine Lost Its Mind? Essential reading for policymakers, healthcare professionals,
and anyone concerned about the future mental health care in America.
All right, Bob, welcome obviously again to the podcast. Before
we get going, and share with the listeners where you're

(01:08):
from originally and where you are currently.

Speaker 2 (01:12):
I right now have retired from Michigan State. I was
there from nineteen eighty five on, and I have just
recently retired and spent the time writing has Medicine Lost
its Mind?

Speaker 1 (01:25):
Okay, so look, we're going to get into that, but
take us back a little bit, give us some context.
How did all this start for you? How did you
get interested in this field? How did you share the
doctor in the first place.

Speaker 2 (01:40):
Sure, well, that's a strange story. I was raised. I'm
actually the sixth consecutive generation of physicians in my family,
and my dad was what they call then a general practitioner.
But I was raised to be a professional athlete. My
dad was very and athletics and wanted wanted me to

(02:02):
be a professional athlete, and so hung I always assumed
i'd be a doctor. There was no pressure on it,
I guess subliminally and unconsciously there probably was. But in
any event, I did not grow any bigger than I
am right now, which is five ten and one seventy.

(02:23):
And that didn't cut or sport all sports, but especially football.
That was a quarterback. Oh well, okay, and so I
wasn't quite big enough or probably not good enough either.

Speaker 1 (02:40):
Well, okay, so you're you're obviously pursuing athletics, were you
pursuing athletics at Michigan.

Speaker 2 (02:48):
State, No, No, I would. I went to the University
of Iowa, and I even went out there. I was
too small, but this is the time they were ranked
from one in the country nationally, and still decided I
couldn't get a scholarship. They saw that I couldn't make it,
but I didn't. So I went out anyway as a

(03:10):
walk on, and after about two weeks I thought I
was going to get literally get killed. Out there. They
would have exercises where people stood about fifteen yards apart
and just ran at each other. I did that one
day with a guy that waited about two eighty and
I said, this is it. There's gotta be a better way. Wow.

Speaker 1 (03:36):
Okay. So at some point you segued into getting more
serious about medicine.

Speaker 2 (03:43):
Yeah. Yeah. Then I went to medical school and so on.
I'm in and then went into practice and found that
I was not prepared for all the mental health problem.
I'm an internal medicine, I'm a primary care doctor. And
went into practice and found I was not at all

(04:04):
prepared for all the mental health issues and just emotional
issues that people had. And long story short, I worked
on that while I'm in practice, learned to listen better
and so on and talk with people and had some
success that even after six seven years doing that, it

(04:26):
dawned on me I just didn't know enough about diagnosis
and management. And so I then went back to the
University of Rochester and took a fellowship and what's called
biopsychosocial medicine, and I got some psychiatry training there and
also primary care and mental health, and I was done it,

(04:46):
as I said, at Michigan State from nineteen eighty five on,
and I focused on how best to conduct primary care
mental health in others, what does the primary care doc?
And we developed using randomized control trials, we developed evidence

(05:06):
based methods for how the doctor should communicate and best
establish a relationship. Then in a couple other studies, we
developed a primary care mental health care model, which shows
how to teach and to conduct primary care mental health.

(05:30):
And with that in mind, the whole idea was to
better train primary care doctors in mental health. And we
taught that and extensively to our residents at Michigan State
and they did tremendously well. So we showed doctors can

(05:50):
learn this, and indeed they're interested in it, and also
it benefits their patients, and we showed this in randomized
control trial. The discouraging thing that came about was that
I and there are many thousands of people like me
in medicine saying the same thing. We need better mental

(06:14):
health care. The discouraging thing is that medicine doesn't do
anything about it.

Speaker 1 (06:20):
They have all I mean, let me just interduct you, sure,
because you're saying a lot of things. I want to
squeeze more out of Sure. So you talked about when
you first started, you realize that you weren't prepared for
the mental health issues that were coming up. Why, I mean,
of all the doctors out there, and granted that, I'm

(06:41):
sure there are others who were interested, why did this
particular topic get you so much?

Speaker 2 (06:49):
It was it was the problems I had with it.
Patients would come in. I didn't know what to do.
They're one and this is in has medicine lost its mind?
That really was a turning point for me. She had
metastatic breast cancer, lots of pain in the back and hips.
I had no clue what to do with her. She

(07:11):
was like, why am I crying all the time? Why
can't you do something for me? What do you want
to do? What's our next step? And I was just frozen.
And I liked her. She was a nice, wonderful woman,
but she was anxious and she made and I got
anxious because I didn't know what to do to help her. Basically,

(07:32):
all I would ever come up with is I do
another test. I did an X ray or something like that.
I knew it didn't do her any good, but it
was just it was kind of bought me time. And
I was just woefully inadequate and managing her. And I actually,
quite frankly, was relieved when she died, but it didn't

(07:54):
last long. And this is this was the turn event.
Her husband came into my office about two weeks later.
He hurried in, dropped a book on my office on
my desk, and hurried out on the way out, saying,
here's a diary she kept. I thought you might be
interested in it. Wow, And it was replete with comments

(08:18):
about me and my care. The young doctor doesn't seem
to know what to do with me. The young doctor
doesn't seem to care. All the young doctor does is
order tests. The young doctor da da da da da.
And there were multiple references like this. I was just
absolutely shocked, and that was what kind of woke me

(08:39):
up to my own personal inadequacies and quite frankly, lack
of preparation. And it turns out it's quite like many
other primary cure doctors. Excuse me one thing, sure, sorry,

(09:05):
And it turns out it's like almost all other primary
care doctors. We're not prepared for these kinds of patients.
I'm sure she was depressed, but I had no idea
how to diagnose it or what to do with it.
And after that, I mean, this really bothered me for
two or three weeks in there, just it was in

(09:25):
my soul, as it were. And I gradually, of course,
came out of that and resolved that, tried started doing
things different. So I started listening to patients differently and
actually had some success. People liked it, and I had
good relationships with them, became a little more empathic. But
I didn't really know how to do that, and I

(09:47):
had no idea how to diagnose depression and drug addictions
and what to do with it. These frightening panic attacks
that would bring people into emergency rooms and so on,
and long story short, I decided to leave practice and
go back and take additional training at the University of

(10:08):
Rochester and so called biopsychosocial medicine. And I did some
psychiatry training while I'm there, but I'm an internal medicine doc,
primary care anon, a psychiatrist, but I've got extra training
in mental health. And it was then going to Michigan
State that we did all the stuff that I was
talking about. But that's kind of how I got into this.

Speaker 1 (10:32):
When you did your fellowship, what were some of the
things you learned there that kind of lit you up?

Speaker 2 (10:41):
The crucial thing is learning how to interact with patients previously,
and this is what most doctors are taught. Yet today
doctors just go in and start asking questions about physical disease,
where's the pain, where does it radiate, what medicines you're taking,
and so on. They never asked the patient how they're doing.

(11:02):
And this is this is where I became aware of
what is now called patient centered interviewing practices. And if
there is a fairly complicated technique that is required to
do that, it isn't It isn't a matter of just
being a nice, respectful person. There are actually skills that

(11:23):
are required to do it, and they're often counterintuitive. For example,
let the patient have some control of the interaction. I mean,
that's that's hard for us type A personalities. And it
came to the fore when I was in training and
that you've got to relinquish some control of the patient

(11:43):
if you're going to do this right. And still it
ended up it takes even less time than it did
the former way I interviewed, but that was not apparent
to me at the time.

Speaker 1 (11:54):
I would imagine two that one of the reasons why
that's not done commonly is it could take a lot
of time.

Speaker 2 (12:08):
Well, it takes talking to patients takes a lot of
time for untrained doctors, and that's what happened to me
in practice. And I would try to relate and do
the right things, but I didn't know how to interview.
I didn't know the skills of interviewing, and so I
asked questions, but they would go nowhere and so on,

(12:30):
and it did take a lot of time. Once howeveryone
learns to do again, patient centered interviewing. Once you learn it,
it takes no more time than it does in an
ordinary other type of interview and in fact, it's been
demonstrated that it takes less time over time, and then

(12:53):
there is patients feel heard. They don't keep coming back
with the same things, right.

Speaker 1 (12:58):
Right, right, all right. So let me just remind everyone
we're speaking with doctor Robert Smith. His book is called
has Medicine Lost Its Mind? Why our mental health system
is failing us? And what should be done to cure it?
All right, Bob, So give us a little bit about
this process, and then I want to ask you more

(13:21):
broadly about the book. What does this interviewing process look.

Speaker 2 (13:25):
Like, oh, the patient centered interview? Yes, well, it basically
means keeping your own issues to yourself. In other words,
I may want to know about chest pain, shortness and
breath or diarrhea or whatever, but let the patient bring

(13:47):
it up. Set an agenda and let the patient start out.
Tell me more about the back pain you've had, but
let them unfold that using so called patient centered skills
like silence like that, it allows people to come forth.

(14:08):
You're not interrupting them, or tell me more about the pain,
and they will and lost my job. Tell me more
about losing your job, and if that story will go
on for a little bit and eventually the pinnacle of
the pasion centered interview who is emotion and eventually you'll
get a story that sounds like there ought to be

(14:29):
some emotion there. This guy has lost his job, his
wife's out of work. What's the emotion going? And you say, so,
how does all this make you feel? Now you've got
the emotion, this is where you want to be to
establish the relationship. And you hear that out a little
bit and you then address the emotion. Everybody says, be empathic,

(14:52):
address emotion, but nobody tells you how. And here's how
we developed and this is comes out of these randomized,
controlled trials. You've had to systematize it to do it,
and it works highly effect even it's very individual, it's
very unique to be empathic. Let's just say this guy says, well,

(15:14):
I'm really upset and angry because my boss said I
would keep the job and I didn't. Okay, so he's anger.
You've got some expressing anger. You name it, you understand it,
you respect it, and support and naming is how I
can see that makes you upset. I understand Respect then

(15:37):
is you've been through a lot with this, appreciate your
telling me about this. Support is let's work on that together. Now,
you typically don't use them all four at once like that.
It sounds kind of canned. He's just one or two
at a time. But you used them repeatedly. Maybe the
first time you might say, oh, that's in a tough

(15:58):
time for you. Let's work on that thirty seconds later, Oh,
I understand how you get it thirty seconds later, and
tell me more about how you felt then, and you
keep developing that and that basically is the patient centered interview.
And then as part of that, with most patients, that

(16:19):
doesn't take more than a minute or two. It sounds
like it takes longer than it does. They don't only
take them in two and then you make a transition.
You still find out. Now you mentioned you had diarrhea,
tell me when that started. When medicines you're taking any
pain with the DA DA DA, all the things you
would ask about diarrhea. So nothing gets lost. And when

(16:40):
one learns how to do this, it's quite efficient, doesn't
take any more time than otherwise. It takes, however, significant
amount of skill in trainers and a significant amount of
time for the learners to learn it. And when we
at Michigan State would teaching residents and students, ordinarily you

(17:04):
would start out in role play they learned some of
the basics of how to do this and then using
it with patients and after two or three experiences with
either a real patient or a simulated vision, they can
start getting the hang of it. But it basically takes
being supervised eight or ten times in doing this, which
is what we did with our residents. They all were

(17:26):
very good at it, but it takes supervise eight or
ten times. That's a lot of time and a lot
of training that goes into it, and quite frankly, medicine
doesn't do that.

Speaker 1 (17:37):
Yeah, yeah, wow, I love this. I mean, this is
obviously very much like therapy, provide the therapeutic skills it is.
But what is so interesting, as I hear you speaking,
is I could just imagine the rapport that's built, the

(17:58):
trust that's exactly which in and of itself allows so
many other doors to open up. Right and correct me
if I'm wrong here, But generally speaking, we in our
culture here at least in the United States, we don't
think of doctors doing this, not at all. In fact,
we think of doctors not doing this at all. They're

(18:23):
not right, So is medicine changing.

Speaker 3 (18:29):
Not really Okay, I'd like to tellnalogy that the analogy
of the giant cruise ship trying to turn.

Speaker 2 (18:38):
It's taken forever. It's taking a long time. Medicine, in fairness,
does teach interviewing in most medical schools now, but it
never gets carried on. Is typically taught the very first

(18:59):
year in medicals, and of course there's four more years
to go and four more years of residency after that,
so it was long washed out because it does not
get reinforced. And in fact, the culture of medicine often
will tell people trying to use it, don't talk to
patients about that touchy feely stuff. Were interested in real

(19:21):
disease like cancer and things like that, And so it
not only is not reinforced, it is actively discouraged oftentimes,
and so there's a long long way to go.

Speaker 1 (19:35):
Well, when you first developed interest in this, Bob, were
you at any time disinclined to pursue this? Did you
ever feel like what am I doing? Why am I
this is quite frankly, this is stupid? Why am I
wasting time on this? And what did colleagues.

Speaker 2 (19:52):
Think on the interview or on mental health? Well? Both, Oh,
people thought I was nuts to leave. Oh they couldn't
believe it. Why would you be interested in all that stuff?
Oh no, I was making good money, went back to
making next to nothing. But oh no, I never had

(20:15):
the second thoughts. I can remember when I got to
Rochester and put on that white coat. I somehow I
knew I was on the right track. And even though
I had loved practiced, and the people I worked with
I loved have primary care, but I was not quite
in the right place. And so this I knew I

(20:35):
was in the right place. No, I never I often
say I make a fourth as much money and now
as I did in practice, and I'm four times as happy.

Speaker 1 (20:45):
So let's talk about the book. Has medicine lost its mind?
Why did you write it?

Speaker 2 (20:51):
I wrote it because in spite of the fact that
I and thousands of others minority within medicine keep telling
medicine they need to improve mental health care, and we
know how, we can tell them exactly what to do.
It's all there. It's just a matter of doing it.
In spite of that, medicine does nothing. And that's why

(21:15):
I just had just go public, as it were. And
this is shocking your viewers, listeners will be very perhaps
even frightened by what I'm going to say. But primary
care doctors like I was in practice, and like every
other one is now conduct seventy five percent of all

(21:36):
mental health care in the US. The problem is, as
you've just heard me say about myself, we're not trained
for this. And the downside of that is just incredible.
Doctor prescribed opioids. Untrained doctors not trained in using opioids

(21:57):
or in pain are causing fifteen to seventeen thousand overdosed
deaths per year, two hundred thousands since this opioid epidemic began.
Another example, forty eight thousand suicides a year. Half of

(22:18):
those see their doctor in the month before they commit suicide,
but doctors aren't trained, so they don't have a clue
of what to do with it. Many of those can
be saved. We're talking in the thousands of people, guy,
Let's now talk in the millions of people. There's something

(22:38):
like one hundred or nearly one hundred million people in
the US with major mental disorders, seventy five percent of
whom are cared for by untrained primary care doctors. And
when these doctors do not recognize depression, anxiety, addictions, common
mental health problem when they don't reckonize and treat them, divorce,

(23:04):
job loss, school failure, addiction, incarceration, homelessness, and on and
on the lisc go. There is a tremendous downside for
millions of people. It's not the doctor's fault. They're not trained.
And if you ask any one of them, they'll tell
you what the problem is. Bob. One of them told

(23:26):
me today, there's no psychiatrist in my town. What am
I supposed to do? An other one says, you know,
there's two or three psychiatris, but it's thinks nine or
ten months to get somebody into ESUM. And so the
problem is everybody thinks psychiatry is somehow going to take
care of mental health. They see only twelve percent of

(23:49):
all mental health asients, and oftentimes that's only one visit.
Psychology sees another twelve to fifteen percent. But that's why
seventy five percent is with untrained primary care docs like me.
Answer is simple, train the doctors who provide the care,

(24:10):
but medicine doesn't do it. Has medicine lozed his mind?
That's where the title comes from. And so that is
the issue. That's where the book comes from the idea
is that medicine is not going to change. It has
been hearing people like me say this, and as they say,

(24:32):
thousands of others, a significant minority in medicine say this.
They need to change, but they don't do it. It's been
going on since the seventies. A gust institute like the
Institute of Medicine, National Academy medic have said this, they
don't do it. Training is no different than it ever was.
Doctors receive no more than two percent of total training

(24:54):
time in mental health care, even though it's the most
common health condition they see in practice. How could medicine
do something this stupid? Has Medicine Lost his Mind? So,
in any event, that's why I am going public with it.
And medicine's just completely refractory, and there is evidence that

(25:19):
refractory institutions can be changed by books like Has Medicine
Lost His Mind? Rachel Carson wrote Silent Spring and blew
the whistle on the chemical industry, who was polluting everything
that touched this led angered the public. First they got

(25:42):
to their politicians. The politicians formed what today is the
Environmental Protection Agency, the EPA. It's why we don't have
ddt in our water. Ralph Nader wrote, unsafe at any speed.
He inflamed and angered the public. They found out that
the automobile industry had seat belts but didn't want to

(26:05):
put them in cars because they were afraid it would
cost them too much money. That led to similar political moves,
and that's why you have seat belts in your car today.
Has medicine lost its mind will do the same thing.
It will inform the public. They will become angry about
how poor their mental health care is and insist the

(26:29):
politicians make change. And the thing the politicians will do
this is what's in mental health in them? Has medicine
lost its mind? They will set up a federal commission,
presidential commission, congressional commission, something like that to investigate medical
education for its scientific principles one and number two, if

(26:56):
it is meeting the health care needs of the population.
It's clear that it is not with all the terrible
mental health care going on. But they will also find
that medicine in its current structure is functioning in a
non scientific way. And here's how all sciences at the

(27:22):
last beginning back in the sixteenth seventeenth centuries adopted reductionistic
approaches to their science, which means just looking at one
part of the science as opposed to all the parts
of it. All sciences, starting in about nineteen hundred have

(27:42):
scrapped that approach for a systems approach, which looks at
all parts of the problem, not just one, and how
they interact. Only medicine continues to look at just one
part of its science, physical disease part. It ignores the

(28:03):
person part, the very person they're taken care of, the
psychological part, and the social part, their environment. It ignores that.
And this is what this commission will find that will
then lead to requirements. And this is top down. Medicine
is not going to change on its own. And well

(28:23):
there will then be top down recommendations for how medical
education needs to change.

Speaker 1 (28:30):
Wow, you've already got to figure it.

Speaker 2 (28:32):
Out, yep. So I'm committed.

Speaker 1 (28:36):
So this book is for the lay audience.

Speaker 2 (28:39):
This is for the people, for the public, because it
should be read by professionals too, but it's intended for
the public.

Speaker 1 (28:47):
Okay. So for let's say we have a lot of
mental health clinicians, therapists of all kinds listening to this.
What do you think they would get out of this.

Speaker 2 (28:59):
Book, I think mental health clinicians will find be very encouraged.
In addition to recommending more training of psychiatry, I also
recommend the active inclusion of psychology and other mental health

(29:20):
counselors into medicine. They now lie completely outside of medicine.
How this ever happened, I don't know, but they should
be brought into medicine and integrated as part of this training.
I can't say enough about how effective psychology and other

(29:40):
counselors have been in when I was in practice, and
so I think they can be encouraged by this. More broadly,
I think they will be encouraged by this systems approach
that I'm describing, whereas you you take all parts of

(30:01):
the problem, not just one part of it. This is
what many of them already understand and practice. This is
not new news to anyone, and so this medicine needs
to make a radical new change, and I think this

(30:23):
is what's exciting about. This change is possible, but it
cannot come from the bottom up.

Speaker 1 (30:30):
Well, all right, Bob, what's the best way for people
to learn more about you and the book?

Speaker 2 (30:36):
And the best place to go is my website. Robert C. Smith, MD,
and don't forget the MD. Robert Smith is a very
common name and you'll never find me just using that,
So it's Robert C. SMITHMD dot com. Go to that
and you will find plenty of information in the book.

(30:58):
You will find my social media you on there, follow
me on there if you would like. We'd love to
have you. And you'll also find on the landing page
a box that says act Now. This is where you,
as an individual can become involved. There is a letter

(31:20):
in there which requests a federal commission just like I've described,
and email addresses to the President, the Surgeon General, the
National Academy of Medicine, you're congressperson, and your senator are
provided in there. All you need to do is plug

(31:41):
the two together, put the email address in, and paste
the letter in and send it. This is the way
individuals can have an impact on changing things. People need
to be angry about how bad their mental health care is.
This is the way to operationalize that.

Speaker 1 (32:03):
Awesome, all right, We'll have that linked up at the
show notes page here at the Trauma Therapist podcast dot com. Uh,
doctor Smith, awesome, so inspiring. Love to have you back
at a later date. It seems like there's a lot
to talk about. Thanks so much for being here.

Speaker 2 (32:19):
Thanks for having me, love talking did

Speaker 1 (32:21):
You all right,

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