The current state and future of psychiatry [PODCAST]

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What are the challenges facing psychiatry? How does psychiatry need to innovate the continue to thrive? What is the future of psychiatry What’s your #1 tip for those considering the profession? What advice can you give to primary care clinicians as it relates to behavioral health issues?

Owen Muir is a psychiatrist and host of the podcast, Pandemic Check In.

He shares his story and discusses the present state and future of psychiatry as a profession.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Owen Muir. He’s a psychiatrist in the New York City area, and he’s a podcaster and, most recently, the host of the Pandemic Check In podcast. Owen, welcome to the show.

Owen Muir: Thank you so much, Kevin. A pleasure.

Kevin Pho: My first question always is sharing your story, your journey to where you are today.

Owen Muir: I walked into medical school at the University of Rochester to be a child and adolescent psychiatrist. I had worked at St. Vincent’s Hospital in New York City, when it still existed, on the kids unit, because a friend of mine, who’s now also a fabulous child psychiatrist, convinced me, “This is a place you’re really going to get some experience working with people.” And I fell in love with working with kids. So I knew from the get-go that’s what I was going to do, and the University of Rochester let me do it. That’s the place that focuses on narrative. It’s the home of the biopsychosocial model. I was into all sorts of stuff like that.

So, you know, when I got to residency, I was learning at Zucker Hillside Hospital out of Queens, which had to take really sick people. But in my third year of residency, I had a really severe depressive episode and ended up being hospitalized myself. When I got out, I started doing some reading about stigma, and I learned something really important: It’s only stories from people we can relate to that change people’s minds. No amount of education does it. And that was the first piece of the puzzle.

When I met my wife shortly thereafter, Carlene MacMillan, who founded Brooklyn Minds with me, the company we run together, she convinced me that, you know, narrative was really a passion of mine, and podcasting was kind of the perfect form for that. And I learned mentalization-based treatment, which we use to take care of the sickest individuals, along with, you know, interventional methods like TMS and working with large teams. We have about 56 employees now, and that includes coaches who work in the fields, psychiatrists, social workers, psychology. You know, you have to do it together, was the takeaway.

We actually have someone on our team who used to be a Navy SEAL trainer. When he came to work for us, it really crystallized things for me, because he said, “Wow, this is like working with the teams I remember working with.” And that’s when I recognized we were doing something different, which was looking at outpatient mental health care as a way we can actually take care of sick people and not rely on hospitals, which are largely harmful. But in order for people to accept help, they have to have some trust, and it’s really hard to build that. Stories you can relate to are one way of doing so. And that’s why podcasting, which is so intimate, was part of the picture in my mind for how to build trust in help, so people might actually come get it.

Kevin Pho: Well, that’s a wonderful story. Tell me how your approach to psychiatry is really different from, say, the traditional approaches, if you could go into more detail about that.

Owen Muir: Yeah, I like things that work, and I don’t like pretending that things that don’t work do. Hospitalization increases your rate of completed suicide by 200 times immediately after discharge, and it remains 30 times higher for the rest of your life. And people don’t trip and fall into a hospital; this is not a randomized group. But if it was helpful, the numbers would go the other way. Locks on the doors: We have, from a very large German study of over 15 years, for the psychiatrist, the rates of completed suicide are higher in locked units, and the elopement rate between locked and unlocked units is the same.

So we have these interventions for chronically suicidal people: hospitalization. We’ve virtually never tested medications. You know, we have ECT and now accelerated TMS interventions, and most of those things aren’t used very often. And so we have a lone artisanal practice. You know, you sit in your office and you call yourself a psychopharmacologist, which is nonsense, to me at least. Like, I get it, you’re good at drugs, but this is a medical specialty. And there’s no neurosurgeon who’d say, “All I do is cut people.” You decide whether the person has a medical condition that requires appropriate care, which may involve cutting. But neurosurgeons don’t just sit in an office with a scalpel by themselves either. They have the whole OR, with sterile technique and surgical techs and MRIs and technology and teamwork, and that’s why we can get rid of brain tumors and have people live. That’s amazing.

And the biggest problem on Earth, the number one cause of disability according to the WHO, is depression. It’s not the only mental illness, there are plenty of others, but it’s the biggest problem on Earth, and we treat it like it can be dealt with by one dude, if that. And we’re lucky if it’s, you know, a competent person. Maybe making technology, you know, the solutions have been like, “OK, we’ll do Talkspace.” That’s worse than sitting next to someone on a log. Like, would you rather have your therapist next to you on a log, or texting eight other people at the same time? So I see a lot of unreal solutions to unreal problems, and I was more interested in actual solutions to actual problems.

Kevin Pho: So that leads me into some of the challenges that are facing the psychiatric profession today. Where I practice, in southern New Hampshire, I think there’s a shortage of behavioral health specialists. Now, what do you see as some of the challenges facing psychiatry today?

Owen Muir: Well, psychiatry is one of the challenges facing psychiatry, because it’s not treated like any other medical specialty, and it’s not treated like any other field of human endeavor where we tackle serious problems. It’s treated like a pretend thing. We don’t pretend we can solve brain cancer alone. We don’t pretend we can fight wars with one person at a time. And we do pretend we can solve the biggest problem in health care with people who are lone wolves, and that’s how we’re trained, that’s how we’re taught, that’s how we practice. We don’t take insurance. We’re not accessible. Even if we are, we don’t see sick people. It’s frankly unethical.

Kevin Pho: Now, what are some of the solutions that can help the profession going forward?

Owen Muir: First off, being realistic. There are not enough psychiatrists in the world, ever, to actually treat all the mental illness. That’s just the way: 8,000 child psychiatrists worldwide can’t see all the kids, right? So if we can’t do that, we really have to work with systems. And this is something I learned in Rochester from the trauma surgeons. They got involved in violence prevention because it was a better use of their time than stitching up bullet holes.

And I think psychiatry needs to think similarly. How can we prevent and support people using things in their lives that already exist, that they already trust, working with other medical specialties in deeply integrated fashions to deliver help that’s helpful? Because who’s more helpful: your psychiatrist or your drug dealer? By the way, it’s midnight.

Kevin Pho: You have students who may be interested in psychiatry. Any advice or tips that you could give them, knowing what you know now?

Owen Muir: It’s the best specialty on Earth. Oh my God, you can change the world with what we’re able to do. If you like clinical medicine, it’s really kind of the best, because it’s a specialty where the instrument is you. And if you like reading scans, well, then radiology is fabulous. It’s a great specialty. But I think if you like thinking about things, and humility, because you’ll be wrong a lot, then psychiatry is kind of the last bastion of clinical medicine, because we just don’t have enough diagnostics to know.

And I find the range of things I’m able to engage in as a physician, Kevin, as someone who does a lot of media stuff, you know, psychiatry is perfect for that. It’s perfect for consulting. It’s perfect for forensics. Anything you want to do, you can kind of do as a psychiatrist, and, you know, that even includes procedural medicine. So, you know, if you want to use your hands, you can be doing Botox for depression or migraine, which you have to be ABPN-certified for. You can be doing TMS or TMS research, or any of the other things that are coming down the pike. It’s really, you know, finally moving in a direction that’s exciting.

Kevin Pho: I’m in internal medicine. I do primary care, and because of the behavioral health shortage, I’m seeing a lot of these behavioral health issues in my clinic. Now, do you have any tips for us in primary care who are seeing an increasing number of behavioral health diagnoses?

Owen Muir: Yes. First off, have a psychiatrist in your phone and call them. Collaboration is so valuable, and I’d much rather spend my time working with colleagues, and obviously figuring out models in which we can actually get appropriately paid for that, than trying to see everyone individually.

But some quick tips for primary care: If you think you need an expensive drug, you need a psychiatrist. If you think you need an antipsychotic and you’re not talking about bipolar disorder or schizophrenia, you need a psychiatrist. If it’s your third antidepressant trial, you know, again, consultation. No. No Xanax, ever. Very rarely prescribe benzos. I’ve prescribed them three times in my career, and if you have a no-benzo rule, so much the better.

Every once in a while, take the extra time to book a visit that’s a little bit longer, so you can listen to what someone has to tell you, because history and exam is the thing primary care is the best at. And to emphasize something really important, you have the trust of your patients that I can only dream of. You have the trust of their entire families. And in just a couple of extra minutes, if you spend the time to listen and understand, you may be able to make massive changes, because they trust you, and that’s the most powerful tool we have as physicians.

Kevin Pho: Well, thank you for sharing that advice. I think that is wonderful insight. One of the things that you mentioned in your answer was some of the payment issues facing the profession. I was wondering if you could share a little bit more detail about that.

Owen Muir: We developed medical necessity criteria to associate with CPT codes, and that’s how we decided what we pay for. And it says if you’re suicidal, you need to be in the hospital, and that’s what we’ll pay for. If you’re less suicidal but you can’t take care of yourself, you’re in partial. And if you’re generally OK and don’t disagree with your treatment plan, you can be an outpatient. And that’s hogwash. OK, so they have this whole set of, you know, things designed to pay for things that don’t exist. So the current payment models are broken and don’t apply to actually taking care of sick people in the outpatient setting. And so it’s no wonder people don’t do it. When you don’t have outcomes driving and value driving health care, you’ve got real problems. And I think we’re starting to see that systemically, but it’s really brutal for doctors who are trying to play by broken rules.

I encourage, my one really easy takeaway: For every single denial you get of a medically necessary treatment, every state has an attorney general. Your patient can file a complaint with the attorney general’s office against their insurance company for that denial. And I tell you, I get 80 percent of the things I want approved, and they call me at 10:45 at night on a Sunday to let me know I got that medication or treatment or whatever it happens to be. It’s the law that patients get medically necessary care, and the attorney general of your state will help you do that and not charge your practice a goddamn dime. It works better if the patients file the complaint. Your office can file a little supporting documentation, but they’re the best advocates our patients have. So use it.

Kevin Pho: All right, and where do you see the future of psychiatry, if you had a crystal ball to look into?

Owen Muir: I hope it’s at the heart of coordinated teams supporting primary care, who is the front line of health care. You are the ones who are trusted, and most things are going to come to you, whether we like it or not. So we need to support our colleagues with our expertise when they need it, and when you need to call on the A-Team. If you’ve got a problem, if no one else can help, well, I hope it’s easier to find us than it was B.A. Baracus. But that’s when you need psychiatry, when things get really tough. And I hope psychiatrists reconceptualize their specialty from one that deals with chitchatting about mild anxiety, because you make a million dollars, to dealing with really severe problems and helping coordinate whole systems of care to support our colleagues in the front lines, who have the trust of people already.

Kevin Pho: All right, we’re talking to Owen Muir. He is a psychiatrist in the New York area. He’s the host of the Pandemic Check In podcast. Owen, what is your take-home message for the KevinMD audience?

Owen Muir: Psychiatry is the most fun medical specialty, and it is a medical specialty. This is not something that, I think, can meaningfully be done by people with 800 hours of shadowing experience. I have 45,000 hours of experience before I even got out of training, and that matters. We’re here to help people who desperately need it, and we should take that seriously. And if our patients think drug dealers are more responsive, we’re doing it wrong.

Kevin Pho: And how can people get a hold of you?

Owen Muir: The website for my practice is [website removed by the editor], and [email removed by the editor] is my email. And, you know, you can Google me and see how a patient sued me and I ended up in the New York Post on account of it. So I’m eminently findable. And if you want to find out what it’s like to survive a malpractice suit unscathed, relatively speaking, feel free to give me a call for that too.

Kevin Pho: That’ll be a topic for another podcast, a good one. Thank you so much for joining me on the show.

Owen Muir: A pleasure, Kevin. Thank you.

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