How switching to psychiatry made me understand suicide far better [PODCAST]

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“I realized that training in psychiatry would give me the opportunity to understand suicide far better, and hopefully allow me to make a difference at an earlier stage. My exposure to psychiatry in medical school was clearly not enough. I was ill-equipped to fully grasp when individuals begin to have thoughts of suicide and when those thoughts progress into planning or researching methods – and then acting on them. As I thought back to the numbers of dead-on-arrival patients that I attended to in Detroit – dead by overdoses, self-inflicted gunshot wounds or stabbings, electrocution, asphyxia, drowning or jumping from tall buildings – I knew that I wanted to do more than pronounce people and fill out death certificates. Becoming a psychiatrist could help me save some of these despairing souls.”

Michael F. Myers is a psychiatrist and author of Becoming a Doctors’ Doctor: A Memoir.

He shares his story and discusses his KevinMD article, “Training in psychiatry would give me the opportunity to understand suicide far better.”

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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 Michael Myers. He’s a psychiatrist, and he wrote the book, Becoming a Doctor’s Doctor: A Memoir. There’s an excerpt from that book on KevinMD, and that’s titled “Training in psychiatry would give me the opportunity to understand suicide far better.” Michael, welcome to the show.

Michael F. Myers: Thanks for having me, Kevin. It’s good to meet you, and I’m delighted to be here.

Kevin Pho: So we’ll get into your book and excerpt in a little bit, but first off, can you share your story and journey to where you are today?

Michael F. Myers: Well, you’ve already touched on this. I’m a psychiatrist, I’m an author. In my current position, I’m a professor of clinical psychiatry at SUNY Downstate Health Sciences University in Brooklyn, New York. I’ve been here, actually, since 2008.

Prior to that, in fact, I finished my psychiatry residency training in the 70s, and then I embarked on a 35-year career, which was always the same: half-time academic work, doing research, writing, and teaching, and half-time private practice. For the last 20 years of my private practice, I basically limited it, or restricted it, to only looking after medical students, physicians, and their family members. That’s how I became a specialist in physician health.

My other area of research and writing is suicide, and as you probably know, sadly, too often those subjects overlap. I’m particularly focused on the aftermath of suicide and what we could learn about prevention from those studies.

Kevin Pho: So through your lens as a psychiatrist and medical educator, just give us a sense of what the current status is of psychiatry education, and what are some of the challenges facing medical education and psychiatry going forward?

Michael F. Myers: Oh, OK, that’s a great one. Well, what I like about that is that I think we are moving away, which I think is a good thing, from the biological ascendancy which has characterized our field for quite a while now. I mean, as you know, there’s a long history to psychiatry, but there’s been so much focus on the biology of psychiatric illness. We’ve learned a lot, of course, and our psychopharmacology is essential. But the psychosocial aspects, first of all of our world, and how all of this impacts on our patients and our research, are absolutely fundamental.

So it is really nice to see there’s so much focus, especially in the world in which we’re living right now, with just a look at the COVID-19 pandemic. So it’s not just the biomedicine of the virus, but it’s what this pandemic is doing to its citizens as well. And so, therefore, we’re particularly interested in the dimensions of this in psychiatry. As you probably know, we’re still learning a lot about this virus, and when we learn of some of these, well, sort of the neuropsychiatric complications, it’s extremely important for us to have a seat at the table as we go through all of that.

I mean, that’s just really one focus of a lot of our teaching. Another one, of course, has to do with the various kinds of psychotherapies that are now available, and we’re teaching a lot more about these in our training programs.

Kevin Pho: When you talk about psychiatry and behavioral health, there’s a massive shortage of behavioral health specialists and psychiatrists, especially going forward. After COVID, we’re going to be needing a lot more psychiatrists to deal with the fallout from this. Now, are you seeing the interest on the part of medical students in terms of going into the field?

Michael F. Myers: We sure are. In fact, I think there was a little bit of worry at the beginning of the pandemic, when of course we knew nothing about contagion, but there was this sort of fear, and we were right on the front lines at SUNY Downstate. But what we’ve noticed this application cycle, which is just sort of coming to an end, and as a segue into that, I interview applicants to medical school. I sit on the medical student admissions committee, and there’s actually been an uptick of applications to medicine this past cycle, corresponding with COVID-19. They’re interested. They want to be a part of this.

And as you probably know, too, a lot of the medical students who have had to have this hybrid education for the past year, especially the first-year students, have really missed getting the hands-on experience. There’s been some of it, but not nearly as much as they would get if we weren’t in the midst of a pandemic.

So I find that very encouraging, because at the other end, there’s concern about early retirement. So many of the physicians, and the other health care workers who were right at the epicenter in New York, many of them have said that they don’t know if they can do it again, should we get a big surge.

Kevin Pho: So let’s transition now into your excerpt and book. The excerpt is titled “Training in psychiatry would give me the opportunity to understand suicide far better,” and it’s an excerpt from your book, Becoming a Doctor’s Doctor: A Memoir. Now, for those who didn’t read that excerpt on KevinMD, can you just walk my audience through it and share the story of why you decided to share that particular one?

Michael F. Myers: The reason I put that in, fairly early, in the first third of the book, was that actually, when I graduated and finished my training, I did what was called in those days a rotating internship. I did that in Los Angeles. Then I worked as an emergency doc in Detroit, Michigan, for a year. There wasn’t even such a thing as an emergency medicine specialty in those days. Then I went back to Los Angeles to start internal medicine.

So with those three years under my belt, this was the segue into meeting Dr. Bill Kyle, who was instrumental. He was a consultation psychiatrist, and I really, really learned a lot more about digging deep with my patients, because I had felt frustrated. We were so busy with what I would call the biology of their illnesses, especially in gastroenterology. I just learned so much more that I really wanted to delve into.

And it was through this, then, that I had this unusual motivating factor going into psychiatry, which was my medical and surgical experience with suicide. We had seen so many people who had made horrific suicide attempts. Either we were looking after them in our medical intensive care units because of the profundity of their overdose, or perhaps in the surgical field, because of self-inflicted gunshot wounds, injuries from heights, and asphyxiation, many things like that, so that I had this need to really understand suicide at an earlier stage.

I was spending so much time either not being successful in getting our patients off peritoneal dialysis, or breaking the sad news to their bereaved family members in the waiting room of the ICU, things like that. That’s how I made the transition, then, into psychiatry. And so I wanted to explain that pretty early in the book, about that journey.

Kevin Pho: So I’m an internal medicine physician myself, and we actually don’t get a lot of psychiatry training. So after you made that transition from internal medicine to psychiatry, what were some of the things that you’ve learned as a psychiatrist, perhaps, that you were missing during internal medicine training, as it relates to these patients who attempted suicide that you saw?

Michael F. Myers: Yeah, and that’s it right there. It was appreciating the various, what we call, psychosocial factors going on. So the psychological part, not just in their own personal background, in a history of trauma or family breakup, but all of those sociological factors: the impact of homelessness, poverty, immigration, bullying, being LGBTQ, what we now call the social determinants of health. All those kinds of things, and what big factors they make on whether our patients are feeling stressed, and then how that, of course, dovetails with their biological propensity or vulnerability, depending on if there’s a family history of diabetes or high blood pressure, things like that, that can put them at risk for various medical and then, slash, psychiatric issues, too.

So that, to me, was all very exciting and very engaging. And I had to unlearn a lot, though, which had to do with, speaking to an internist, the type of interviewing that we do. What works for us in that branch of medicine is so very different in psychiatry, where, first of all, you’ve got more time, and then, secondly, you can be asking these open-ended questions and letting your patient, kind of narrative medicine, tell the story, which is so rich and helpful.

Kevin Pho: So that leads me to my next question. In primary care, which I do, there is a lack of time. We have 15 to 20 minutes per patient, and we have all these check boxes that we have to fill in through electronic medical records now. From your lens as a psychiatrist, what are some tips that you could share with your non-psychiatry clinicians on how we can elucidate some of these factors that may be contributing to a patient’s psychiatric health?

Michael F. Myers: Oh, that’s a very good question. Yeah, I think one thing, of course, that we’re hearing about so much is when and if we can still make good eye contact with our patients. And just on a personal note, I’ve got to tell you that my personal primary care physician and internist does it in spades. He somehow is able to enter data but still engage me, asking me questions, asking me things about my life. And I try to speak quickly. I don’t want to take up a lot of his time. But yet the other thing he does, too, is say, “Is there anything else, or do you have any questions for me?” Things like that.

That importance of explaining things, as you know, is very critical. I mean, I happen to be a physician patient, but when people don’t have that background, it’s still very important, obviously, to explain things.

The other thing, too, is the so-called high index of suspicion. I think that for all people in primary care, where somehow this just isn’t fitting together, and it feels like, in this interview, this person, my patient, is withholding, and things like that, there are things that you can say or do, by just, first of all, making sure that they don’t feel rushed. Or even if it means saying, “Unfortunately, we don’t have much time left today, but I’m curious about a couple of things, and I’d like to see you again, perhaps in a week or two, and then we can maybe explore what you just mentioned to me again,” something like that. No, you don’t have to do it as a psychiatrist, but I think it will give you a leg up in appreciating why this individual is having so much chest pain at the moment.

Kevin Pho: Now, are there any other red flags that would tip you off to delve further into that patient’s life? Any other signs that you should look out for with the patient in the exam room in front of you that may tip you off and then get you asking more questions to see what’s going on?

Michael F. Myers: Well, I think we’ll use as an example this other area of subspecialty of mine, which is suicidology. And so I think when and if a primary care physician has even gone there with the individual and asked them questions about, “How are you feeling about your life these days? Have you had thoughts of, is your life worth living? Any thoughts of wishing you were dead? Any active thoughts of actually hurting yourself?” And if that draws a big blank, but yet you have the sense, “I just don’t like the way this person’s answering my questions, though. It feels as if I’m just making them defensive, or I’m not sure how truthful they’re being with them.”

So obviously, you can’t just confront them about that. That’s just going to make it worse. But yet it’s something that you can certainly make a note of and realize that maybe this is somebody, again, that I’d like to see again soon. Or raise the question of going at it through the back door, which might be then asking a bit more about, “Tell me more about some of the other things that are going on in your life right now. What’s it been like for you, to make it contemporary? How’s the pandemic been for you?”

And you just see then if they talk about, “Well, it’s been tough,” et cetera, et cetera, and maybe they’ll get into those themes of loneliness, isolation, not seeing their kids or grandkids, or working remotely or some type of hybrid thing, or concerns they have about finances. I mean, as you know, the fallout in this pandemic is so big.

So I just think, going there, I think you’d find that this is somebody, then, who’s going to come away from your office feeling, “Wow, this guy’s really asking a lot of questions. I mean, he seems to want to understand,” or, “I didn’t feel rushed despite the fact that I realized we only had 15 minutes or 20 minutes. We covered a lot,” or something like that. Of course, that’s always a good thing.

And the one final thing I’ll say, and I tell this to all doctors: When or if you ever have a patient who says to you or about you, “He gets me,” or, “She gets me,” I consider that the best compliment we could ever get from a patient.

Kevin Pho: We’re talking to Michael Myers. He’s a psychiatrist, and he wrote an excerpt from his book on KevinMD titled “Training in psychiatry would give me the opportunity to understand suicide far better,” and that’s from his book, Becoming a Doctor’s Doctor: A Memoir. Michael, tell me more about the book that you wrote.

Michael F. Myers: OK, well, I wrote the book because of what we’re talking about today, Kevin: The doctors are human, too. And I really wanted to get that out there. I just said, “You know, we’re not just workhorses.” And we’ve certainly learned for the past couple of decades, with high rates of burnout and moral injury and depression or other things that are happening in our physician workforce, that something’s got to change. Something’s got to be different.

Of course, I was seeing this clinically. I wanted to capture that through a lot of case stories, which are all through the book. And I traced it back. It is chronological, because I wanted to explain to individuals, too, about my experience going through the AIDS pandemic, for instance, back in the 80s. And then I moved it on through there, and then it ends with the COVID-19 pandemic.

But I also wanted to highlight in the book that doctors can become ill, get good treatment, and get back in the saddle again. Because I’ve been an educator all my life, there’s always this worry in medical students or residents that if they have a hiccup or something, or have the first break of something, and might even have to take a medical leave, that they’ll never get back into training, or they won’t be able to get a license, so they won’t be. And that cohort of individuals is actually very, very small. Most individuals in medicine who have had something happen to them, they’ve gotten treatment, they’re now well, they’re back to work, and, in fact, just feel really, really great, if not better, that type of thing. So I was trying to also instill that sense of hope and explanation.

The other thing is, I wanted the general public to have some insight into us as well, as to what makes us tick. And I also wanted to capture the stigma that we feel, both internally and externally, as physicians. It’s not that easy for us to get help, and we worry about how that’s going to affect our medical license, our credentialing applications, disability insurance, malpractice insurance, things like that. So I got all of that there.

And the final thing was that I just really wanted to also capture for individuals that a whole systemic approach has to occur in our society, and we all need to play a part in that. And with that, then, I think we’ll get back to just a healthier workplace for physicians, so that they can, as they all say, “If I could only practice medicine the way I was trained, I would be a very happy camper.”

Kevin Pho: Sure. So the statistics show that greater than 50 percent of physicians today experience some type of symptoms of burnout, and who knows, after that pandemic, that number probably is going to go up. Now, from the book, what are some actionable tips that you can share with these doctors who may be listening to this podcast and maybe considering leaving clinical medicine, or perhaps considering even seeking help? What are some actionable tips that you could share with them?

Michael F. Myers: Great question, Kevin. The first one is toward the end of what you just said. One of the commonest complaints I got from a doctor, the last 20 years or so of my private practice, was something like this: “Hey, Dr. Myers, Dr. Brown calling. I’ve been feeling kind of burned out the last six months or so, blah, blah, blah, but my wife thinks I’m depressed. She’s been picking up other stuff in me in the last six weeks or so, et cetera, et cetera. Could I come see you? Is this something that you could sort out?” And I said, “Absolutely. That’s what I do. That’s what I’m here for. Set up an appointment,” that kind of thing.

So my first message is: Don’t make any decision about your career, or whatever, without going for some sort of professional consultation. And of course, you could start with your primary care physician. It might be a psychologist, it might be a psychiatrist, it could be a physician coach, someone like that, because it’s a very big decision to leave medicine, and I think it’s got to be very carefully thought out.

There are so many physicians who hadn’t realized, “You know, I think the reason I’ve been so burned out is that there’s so many things that I just haven’t been dealing with in my life, and they’re not all related to my work. I’ve got troubles at home, and now that I’m getting some good psychotherapy, I’m happier at work, and I’m actually happier in my personal life as well.” So that’s the kind of thing that can be so beneficial.

The second, the third thing, is to pay attention to those first-person accounts that we see published now more and more commonly in JAMA, the New England Journal of Medicine, Archives of Internal Medicine, the Washington Post, and the New York Times, written by doctors who have been diagnosed and treated for something and are now well, and they’ve got the courage to just put it out there. Those stories are a gift. They’re a gift to all of us in medicine, because we realize we’re not alone, and there’s help available, and we can learn so much from those accounts. So those are kind of like three takeaways that I would put out there.

Kevin Pho: And my final question is, what is your take-home message that you specifically want to leave with the KevinMD audience?

Michael F. Myers: There are two parts to that. The one is, make sure you’ve got a primary care physician. So many doctors don’t. I’m not exactly sure why that is. Obviously, it’s got something to do with, we’ve trained in medicine. But before we became doctors, we had to go to a doctor. Why not continue to go to a doctor, even with our MD behind us? So that’s the one thing, and just let yourself be taken care of. I mean, it’s not a bad feeling to just kind of turn off that cap, let somebody else sort you out and comfort you, help you with the correct diagnosis, or refer you on as necessary.

And the second part of that: If you’re privileged to look after physician patients, then do your best to make that person feel safe, comfortable, respected, and the recipient of evidence-based care.

Kevin Pho: Michael, thank you so much for sharing your time and insight, and thanks again for being on the show.

Michael F. Myers: Thank you, Kevin.

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