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Internal medicine physician and author Robert C. Smith discusses his article, “Medicine’s mental health crisis: why the system is failing us.” He reveals the shocking disparity in care, where only 25 percent of patients with mental illness receive any treatment compared to 70 percent for physical conditions. This crisis, Robert explains, stems from a fundamental failure in medical training: primary care clinicians handle over 75 percent of mental health cases but receive only 2 percent of their training in this area. The conversation delves into the historical roots of this neglect, citing the centuries-old “mind-body split,” and argues that medicine continues to ignore the scientifically superior and integrative biopsychosocial model. Ultimately, Robert issues a powerful call to action for the public to become informed and demand political change, drawing parallels to successful citizen-led movements that mandated seat belts and banned harmful chemicals, offering listeners a clear path to help reform our nation’s approach to mental health care.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Robert C. Smith. He’s an internal medicine physician, and he’s the author of the book, Has Medicine Lost Its Mind: Why Our Mental Health System Is Failing Us and What Should Be Done to Cure It. There’s an excerpt from that book on KevinMD. Robert, welcome to the show.

Robert C. Smith: Thank you. I appreciate the opportunity, Kevin.

Kevin Pho: All right, so tell us a little bit about yourself and what led you to write your book.

Robert C. Smith: Sure. I was trained in the standard way at a very high-pressure institution. I knew all about physical diseases and all rare diseases we emphasized. I went into practice and was unusually confident in my skills but soon realized how inept I was. This was because there were so many mental health patients and other psychological and social problems. Long story short, I had lots of trouble with these people. It turned out, in talking to other doctors, they were having the same problem.

Through the years, I finally started listening better, talking more, not asking so many questions and things. People seemed to like that and get better, and I liked it. I felt more at home and more comfortable with them. But I still realized I didn’t know what to do with the panic attacks that would come into the emergency room or depressed people, or particularly alcoholism and drug problems.

I then, at that point, this is after about eight or nine years in practice, went back and took training in bio-psychosocial medicine at the University of Rochester under George Engel. At that point, I committed myself to primary care mental health, and I did randomized control trials that identified the first evidence-based, patient-centered interviewing method. We have a nice textbook out on that. I then did randomized control trials and identified the first primary care mental health model. These are designed not only for teaching but for practitioners to use so they didn’t have the same problems I did with these difficulties. And so I’ve been in academics then doing this since, oh, it must be 1978 or so.

What has happened more recently though, and that’s what led to writing Has Medicine Lost Its Mind, is I realized that me, you, and many other people like us are trying to convince medical people to do better mental health care. But it’s not working. Mental health care is no better now than it was 25 years ago. Thomas Insel, a former director of NIMH, says it’s a human rights crisis, how poor mental health care is.

And so what I’ve done, and this is what Has Medicine Lost Its Mind is about, is to go to the public to inform them. Medicine, I’m afraid, is refractory to change. We can maybe talk about why that’s the case, but it’s refractory to change and it will not change unless the public becomes involved.

Kevin Pho: Now, like you, I’m an internal medicine physician. One of the statistics that you wrote was that primary care clinicians handle over 75 percent of mental health cases but only receive 2 percent of their training in this area. Tell me more about that.

Robert C. Smith: It’s a disaster, Kevin. People like you and I are handling 75 percent of all mental health care. The problem is we weren’t trained to do this.

Only 2 percent of total training. This is across four years of medical school and three to five years of residency. Only 2 percent of that time is devoted to mental health care. Much of that is a five-week experience in the third year of medical school in inpatient psychiatry where patients are very unlike those we see in practice: schizophrenics or severe personality disorders. And so, even if that had an impact, it’s washed out over the next year of medical school and residency.

The problem is we’ve always assumed, people like you and I, I think, always assume psychiatry would take care of the problem. Psychiatry doesn’t see any more than 12 percent of all mental health patients, and that’s often only just for one visit. Psychology probably sees another 12 or 15 percent, but that’s why the remainder see people like you and me for their mental health care. But we’re not trained, and the downside of that is just disastrous.

There are still something like 15,000 opioid overdose deaths per year. These are prescribed by doctors who are not trained in the use of opioids or in chronic pain, which is why you give them. There are 48,000 suicides a year. Half of those people see their primary care or other medical doctor in the two to four weeks beforehand, but doctors are not trained to recognize this. Many of these lives could be saved.

It gets even worse. We are talking there in the tens of thousands. Now talking in terms of tens of millions, there are nearly 100 million major mentally disordered patients in this country. They are not receiving care. The problem that results when we fail to diagnose and treat them effectively is divorce, school failure, job loss, addiction, homelessness, incarceration, and on and on it goes. There is a tremendous death rate from our lack of training and also morbidity from our lack of training. It is just devastating, and somehow medicine just doesn’t recognize what the solution is: to train the doctors who provide the care.

They don’t do this, and they have been refractory to changing this. Medical education in mental disorders has not changed in the last hundred years since the time of Flexner. And so why don’t they do this? It is so obvious.

Kevin Pho: So let’s get into some of the reasons. Why do you think medicine is so refractory to change and devoting more resources to mental health training?

Robert C. Smith: Sure. I want to emphasize one thing before I get to that. You and I are primary care doctors, and I suspect many of your listeners are primary care or other medical doctors. It’s not your fault. You haven’t been trained. Doctors are doing the best they can, and in fact, they are doing a lot better than you would’ve expected us to do without any training.

Now, why does medicine do this? Basically, Kevin, medicine has brainwashed us. Four years of medical school, three to five years of residency: nothing but physical disease medicine.

Now, where does that come from? The ancient mind-body split back in the scientific revolution, the 16th and 17th centuries, is where it started. Up until that time, doctors always saw the mind and body as related. But at that time, for a host of reasons I won’t go into, the net result, and this is where Descartes, who people have heard of, came from, the net result at that time was that the church, the all-powerful church, was going to let medicine start having some action because medicine and science were burgeoning at that time and they were wanting to become more involved.

So the church said, OK, medicine, you can have the physical body from the neck down. We keep the head. That’s where the mind, the spirit, and the soul reside. That’s ours alone. And that basically is the origin of the mind-body split.

Up through the centuries, it got incorporated into clinical medicine, what we know as clinicopathological correlation, which is a focus on disease. And this was very effective. In the last century, life expectancy doubled, no question. But this isolated physical disease approach has been effective, but we’ve been brainwashed with it.

What has happened now is that medicine’s population of patients has changed. It’s no longer the acute, infectious, and surgical problems. Rather, mental health problems have surfaced as the most common, along with chronic physical diseases. And both of those suffer from this exclusion of the mind and the mental and the psychosocial in our training.

It’s obvious how mental health suffers. Medicine just ignores it. As I already told you, we have no training whatsoever in the people providing the care. It’s not so obvious how it affects chronic physical diseases. That’s medicine’s forte, right? Diabetes, heart attacks, hypertension. Well, 17 percent of people with chronic physical diseases have a major mental disorder. If it is not treated, which it is not because it’s being cared for by untrained primary care doctors, the physical disease does not get better. This is why you see, for example, all these problems with recurrent hospitalizations for heart failure or whatever the problem is. People are depressed, and it’s not being treated. And so, this is much of the problem.

Now, psychosocial factors apart from mental disorders are also important in these same chronic disease patients that we’re seeing: diabetes, heart attacks. Lifestyle factors, which are psychosocially based—alcohol use, tobacco use, overweight, lack of exercise, and so on and so forth, stress—these cause 80 percent of all heart attacks, strokes, and diabetes, and 40 percent of all cancers. But we don’t attend to them. We are not trained in the skills needed in so-called motivational interviewing to interdict these.

Now, of course, we say you need to quit smoking or lose weight, but that doesn’t do any good. There are complex skills required to affect that, and Kevin, it gets even worse for medicine. Remembering how much of this is preventable, what if instead of waiting for this disease to occur, we prevented it? Medicine doesn’t focus on prevention. A case in point: 15 percent of the population was obese in 1990. It’s now 50 percent. That is just a colossal condemnation of medicine’s preventive activities. They just don’t do it. Medicine waits for the disease to happen and then treats it.

And so, there is just this tremendous downside. You can imagine with a $5 trillion health care expenditure, how we could save two to three trillion dollars and prevent all these problems. That’s what populates our hospitals: heart attacks, strokes, diabetes, cancer. What if you prevented half of those? You’d save two to three trillion dollars a year.

The problem is medicine is brainwashed in this physical-disease-only approach, and it’s somehow like a fish that knows only water. Medicine knows only physical disease.

Kevin Pho: So when it comes to preventing mental health disorders on a population level, what are some ideas that you have? What would that look like?

Robert C. Smith: The main thing in preventing mental disorders is to recognize them early. Many mental issues come from childhood trauma and socioeconomic deprivation, and many of these things have to be addressed. Nobody expects doctors to be psychiatrists or to handle all the social problems, but they do need to recognize them and know how to access support for them, just as they need to know how to access psychiatry and mental health specialists. And so the crucial thing is identifying these problems early. Most mental disorders have been going on for six or seven years before they’re even recognized, and that’s often way too late.

Kevin Pho: Now, one of the things that you wrote in your excerpt is that you want to create a level of public awareness and anger about mental health care. You draw parallels to Ralph Nader’s work on car safety and Rachel Carson’s work on environmental pollution. I see articles in The New York Times, for instance, about mental health issues all the time, but tell me, is that enough? What more needs to be done to create that groundswell of public awareness?

Robert C. Smith: There are a lot of people who write about mental health problems and complain about doctors like you and me. And again, that’s unjustified. What you don’t see is the explanation for why this occurred, this mind-body split. And the fact that this has made doctors and the whole medical organization—our AAMC leaders, our ACGME leaders, our AMA leaders—this has made medicine unable to change on its own.

All of medicine has been so brainwashed in this physical disease approach that they have not recognized it. People have been telling medicine what I’m saying since the 1970s. That’s when George Engel made the bio-psychosocial model, which integrates the psychological, mental, and emotional with the physical disease. But medicine gives it lip service. It basically ignores it. It hasn’t changed its mental health or psychosocial training at all since the 1970s, and so medicine is refractory to change. It’s not going to change on its own. It is too brainwashed.

And we have to go to the public. This is where people like Ralph Nader who wrote Unsafe at Any Speed come in. He basically blew the whistle on the automobile industry. They had seat belts. They knew they worked, but they didn’t want to put them in cars because they were afraid they would cost too much. This led Congress to act, and that’s why you have seat belts in your car today.

Rachel Carson, the same thing. A recalcitrant chemical industry was polluting everything they touched. We had DDT in our water, but they knew that doing anything about it would have cost too much. And so what came along from that? The public got enraged, got Congress going, and you have the Environmental Protection Agency to this day. That’s why you don’t have DDT in your drinking water anymore, and a host of other savings.

Has Medicine Lost Its Mind seeks to do the very same thing with a now-brainwashed, recalcitrant medical industry. This is the only way it’s going to change.

The public needs to know what is going on. As with Carson and Nader, they can have an impact once they’re informed and become outraged and insist that their politicians do something.

Kevin Pho: Now, what are some things that you and I or listeners of this podcast can do on an individual basis?

Robert C. Smith: My website is RobertCSmithMD.com. And don’t forget the MD part of it. There are too many Smiths; you won’t find me otherwise. RobertCSmithMD.com. On the very landing page, when you click on that, there is a little square, and then it says, “Act Now.” This will take you to a page that has the president’s email address, the Surgeon General’s, the National Academy of Medicine’s, your congressperson’s, and your senator’s email address. There is then a small paragraph there that requests action by our political people, our Congress, and the president. Plug that paragraph into the email to these people and send it. That’s something everyone can do right now.

Kevin Pho: We’re talking to Robert Smith, internal medicine physician and author of the book Has Medicine Lost Its Mind: Why Our Mental Health System Is Failing Us and What Should Be Done to Cure It. Robert, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Robert C. Smith: It’s hopeful. What Nader and Carson did provides hope. Once the public is aware of what’s going on, change will occur. We’ve already decided. The public started hearing about test-tube babies and they decided in a hurry that wasn’t going to happen. The public has heard about AI running us and us being its servants. We’ve decided that’s not going to happen. Once the public is informed, action occurs, and that is what’s needed. And I do want to say one thing for the primary care and other medical doctors listening to this: it is not your fault. You have not been trained. We have all been put in a very awkward, untenable position, and I understand the plight that you have.

Kevin Pho: Robert, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Robert C. Smith: My pleasure, Kevin. Thank you for having me.