WEBVTT
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Hello and welcome back to the Thought Podcast, the trainee focused podcast for Australasian psychiatry.
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My name is Alan Hong, and I am an associate trainee editor of Australasian Psychiatry.
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Joining me today is editorial members Michael Waitman and Ed Miller.
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Welcome.
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Thanks, Alan.
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Also joining us today, after having flown more than 24 hours from the United States, is Dr.
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Margaret Chisholm, Professor of Psychiatry, and Dr.
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Dirgo Roy, who is the associate professor of psychiatry at the Johns Hopkins University School of Medicine.
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Dr.
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Chisholm has authored more than 150 scientific papers and two books, and is also the director of the Paul McHugh Programme for Human Flourishing, where she uses the art and humanities with medical learners to explore what it means to be human, to be a physician, and lead a good life.
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Dr.
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Roy is the director of education for the Johns Hopkins Psychiatry Internship and Program Coordinator for the Perspectives of Psychiatry program for international learners.
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She has authored numerous peer-reviewed publications focused on the neuropsychiatric outcomes after traumatic brain injury and is recognized as a national expert in the field of TBI and neuropsychiatry.
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Welcome everyone thank you, Alan, for having us.
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Thank you for having us.
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We're really excited to share our perspectives on the perspectives of psychiatry.
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Today we will be discussing the unique framework underpinning psychiatric education and practice at Johns Hopkins, as well as the new international program founded in 2024 for medical learners worldwide.
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So before we start, welcome to the Gold Coast in Australia, far away from the United States.
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How have you found Australia and the Gold Coast?
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I found it very welcoming and I love the kind of casual beach vibe here on the Gold Coast.
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It's been it's been a delight.
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Thank you.
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I echo the same thing.
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It's been very calming and very peaceful, and everyone here is so very kind.
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So it's been a wonderful experience so far.
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Have you managed to um hold any koalas or feed any kangaroos whilst your time here?
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That's tomorrow.
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We have been counting down the days till we go to the animal sanctuary.
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We have our list of, you know, the animal scavenger hunt that we're gonna be looking forward to tomorrow.
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We won't tell you about what lives in the water then.
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Oh yes, please.
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Oh that's that's good to know that uh you've enjoyed your time in in the Gold Coast, spending the next few days enjoying the wildlife of Australia.
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So before we start, just a few introductions.
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Meg, tell us a bit about yourself.
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Well, I am a professor of psychiatry, as you said, at Hopkins.
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I am married.
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I have an adult son, um, but I've been at Hopkins since about uh when I went for my residency, actually in 1988.
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Um more or less uh have been there ever since, been working full-time on the faculty since 2006, and have been directing the Paul McHugh program for about 10 years.
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And Dega, how about yourself?
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So I've been in many, many places.
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I actually started out of medical school in New Mexico, which is where my family is from, which is also where I kind of fell in love with psychiatry and a lot of the biological aspects of psychiatric illness.
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And then I went to um I jumped ship all the way to the East Coast to uh Long Island, where I did my residency at Long Island Jewish Medical Center, uh, Zucker Hillside Hospital.
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And then I was very fortunate enough to be accepted as a consultation liaison psychiatry fellow uh in 2012, where which is when I moved to Hopkins, and I've been at Hopkins since.
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I joined the faculty right after my fellowship and have really enjoyed my time there uh wearing multiple hats, as you've already mentioned.
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I run the education program at Bayview, which affords me the opportunity to work with the psychiatry interns and oversee all the operations that happen in medical education at Bayview.
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I run the CL Psychiatry Fellowship, which is another area of interest of mine and training future CL psychiatrists.
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And then my biggest passion clinically is in traumatic brain injury.
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So I run the traumatic brain injury clinic there, do a lot of research on traumatic brain injury and neuroimaging, and continue to teach on uh how we can get patients better after they have had a TBI.
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Sounds like you've done a lot in in your time and also trained in many different places.
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So unlike Meg, you've trained in many places before Hopkins.
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What was it like joining Hopkins and working there and learning how they've done psychiatry?
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I think the word I would use is transformative.
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Um, you know, I I came from so Long Island Jewish uh hospital and Zucker Hillside Hospital is located in New York.
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We were fortunate to have many faculty there that had various backgrounds, mostly in psychodynamic psychotherapy.
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So you may or not may not be familiar, but the New York Psychiatric Institute is there.
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So a lot of our psychotherapy training was sort of focused around psychodynamic approaches and Freud.
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And then we had a very strong biological component to our department as well.
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This is where clozepine was sort of put on the map and things like that.
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So I I came sort of to Hopkins with this kind of background, and coming to Hopkins was quite transformative and life-changing because I was introduced to an entire new world, um, but very almost familiar and one that made sense to me, world of approach to psychiatry, which I'm sure we'll talk about more today.
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What is this new world that you were introduced to when you arrived at Hopkins and what changed?
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It was really the approach to the patient as a whole.
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As a consultation liaison psychiatry fellow, it's uh Hopkins is unique because uh we don't just do inpatient consultation liaison work.
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So it's not just treating the medically ill patients who have psychiatric comorbidities, but there's a huge outpatient component to it.
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So my very first week there, I had an intake that I was uh interviewing a patient, and it was I was being observed by the at that time, the program director.
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And I started off taking a history the way I was taught how to take it, which was the history of present illness.
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And to me, that was probably the number one thing that I had noted was very different in how I was trained, because I was starting off with asking the patient why they were there instead of starting from the beginning of how their life was and developing forward.
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And so after that point, and after watching how other Hopkins-trained faculty and trainees were taking histories, I realized that this new world was essentially learning about a patient and becoming familiar with the patient as if they were a blank canvas and painting this picture of who they were starting from when they were born, coming down to now why are they here?
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So I think that was the part that was sort of life-changing, if you will, or different in that aspect.
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And sort of adopting that approach of interviewing and asking patients really then led into being able to formulate them in a different way as well.
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So I wonder if just for our listeners' benefit, if you could tell us a little bit about the perspectives model.
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I think for me, yesterday, going to your presentation here at Congress was really interesting.
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Learning about it as something I hadn't been aware of before, and I think it would be really beneficial to understand a bit more about it.
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Yeah, so the Perspectives model was developed by Paul McHugh and Philip Slavney, and they had come from Oregon, where they had been together as department chair and program director there of the residency training program.
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And they came to Hopkins when Paul McHugh in the mid-70s was named chair of the department at Hopkins.
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And when Paul McHugh came, he really started thinking, you know, what does the field of psychiatry need?
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And he wanted to develop his entire kind of vision for the department based on that answer to that question.
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And he thought that what psychiatry really needs is a way of organizing the information that we get from patients so that we can make sense of what they're experiencing and what the origins of their problems are and how they might be best treated.
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Obviously, psychiatry needs many more things, but at this point we don't have really good pathophysiologic explanations of most diseases and things like that.
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But he thought this was something that psychiatry needed that was within grasp.
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And so he started using sort of the evidence from science, biological sciences as well as social sciences, to make explicit what psychiatrists were already doing implicitly.
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And so he started thinking about the various natures or kind of explanatory methods that could be used for various psychiatric presentations.
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And he thought they fell into four groups, and so he and Slavny used this visual metaphor of the perspectives to say to really understand a patient fully, you need to consider their presentation from all four of these perspectives.
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And so the perspectives are the disease perspective, and so you might ask yourself when a patient comes to you how much of their problem is best explained as a disease, as something that somebody has that's sort of come upon them unbidden.
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And examples of that might be traumatic brain injury.
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It's clinical syndromes that run a course together for which there's, you know, evidence that this is indirect evidence, usually that this is a disease kind of syndrome.
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So other classic examples of the disease perspective, illnesses are things like schizophrenia and mania, where it just seems qualitatively different from other experiences that one might have.
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And that they might run in families, they might respond to somatic kind of treatments.
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So that's the first perspective, the disease perspective, and it's the one that most medical students and residents are familiar with because that's sort of like most of the rest of medicine, uses this disease explanatory method.
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So that was the first one.
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And then he thought, well, what else might be necessary to really understand a patient's presentation?
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And so then the next perspective is the dimensional perspective.
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And that really is in response to kind of a question about, you know, how much of this presentation of this patient is the result of who they are as a person, of who the person is.
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And that has to do with personality, both kind of cognitive dimensions of personality, like intelligence or executive function, and the affective temperament aspects of the personality like neuroticism or extroversion, things like that.
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And then the third perspective is the behavior perspective.
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And so he thought that there were certain psychiatric problems that didn't really come upon people unbidden, didn't really emerge from who the person was in terms of their personality, but was more the result of what somebody was doing.
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And so examples of that are these innate disordered kind of behaviors that are arising from innate drives like sleep disorders or feeding disorders or sexual disorders, and then disorders that had their basis in behaviors that were more acquired, like substance use that aren't necessary for the survival of oneself or the species, but have hijacked that underlying neurocircuitry of the innate drives.
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And then there were also these more kind of socially motivated drives, drives to fit in, other sort of behaviors that were reinforced by conditioned learning, like abnormal illness behaviors like conversion disorders and things like that.
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So there, so far we've got the disease perspective, the dimensional perspective, the behavior perspective, and then finally there's the life story perspective.
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And so this is the perspective that really describes the origin of a person's problems as a result of what they've encountered in life.
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And so a classic example of that is grief or demoralization.
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We think of those as adjustment disorders now, but the that really emerge from you know the events that somebody has encountered.
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Now, all these four perspectives obviously kind of intertwine, and so we tease them apart just for the teaching of the perspectives, but everybody has a life story, everybody has a personality, so those apply to everybody.
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And then diseases can happen in the setting of a specific person's life, in the setting of their personality, and the diseases may, people may respond to those differently or be motivated to take their medication differently depending on what they've experienced and the either the meaning that they're giving the disease or who they are as people.
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So that's sort of a kind of brief overview of the perspectives, but it's basically recognizing that there's we use different explanatory methods in psychiatry to understand a patient's problems, and we really need to consider all four of those explanatory methods to develop a treatment plan for a patient.
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Thanks, Meg, for walking us through the perspectives model.
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It's a really comprehensive way of thinking about people and formulating patients.
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And it seems to me that the value of the model is about bringing together existing knowledge in psychiatry in an integrated way that sort of really scaffolds things for people working in psychiatry.
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And my own kind of perspective of educating medical students and registrars is that often formulation is the hardest skill that people struggle with, and putting things together is really difficult.
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So it feels like there's a really valuable opportunity to use this model to help make that task a little bit easier for learners.
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Yeah, I think that you're that's very well said.
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You're exactly right.
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You know, I think of it as a framework, kind of a way of scaffolding, all this information that we get from patients, how to make sense of it.
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It can seem very chaotic, and it's just a way of organizing it that will be helpful for the care of that patient.
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And it helps, I think, the patients understand their own experiences too.
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We often ask a patient, you know, when they tell us their current problems, you know, how much of this is really, do you think is due to something that you have?
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Or how much do you think this is really, you know, a result of who you are as a person or what you're doing?
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And I think patients have a it's sort of a common sense way of they're able to kind of put that, answer those questions and reflect on those in a way that can be very insightful.
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And Durga sort of touched on this.
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So when you see a patient, how would you structure your sort of clinical, you know, history taking?
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And Durga mentioned, you know, going all the way back to the start.
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Can you just run us through, you know, what that would look like?
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Yeah, so I do a little bit of role induction with patients, so I will ask them if they've ever seen a psychiatrist before or a mental health professional, and I kind of warn them this is probably going to be different from what they've experienced before.
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And I say, I'm gonna be starting with, you know, learning about you and your life and moving forward in time because I really want to get an understanding of where or how what you're experiencing now fits into who you are as a person and what you've experienced in your life.
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I literally have done hundreds and hundreds, probably thousands and thousands of interviews with patients, and I've never had anybody get upset about that.
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They kind of value that I really want to understand what's going on.
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So that's I think of value to the patient.
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They really recognize that somebody's really taking a personal interest in them.
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I would say from the clinician's point of view, it's also very helpful in making sense of the history of present illness to know when they talk about Uncle Ted, who that person is and how they fit into their life.
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So for me, it's a lot easier to make sense of the history of present illness when I have the context in which that's occurring.
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So I think that's really important.
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So I think that chronology is important.
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I do a role induction, and like I said, I've never had patients be upset about that.
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So the other thing I do is I advise patients that it's going to take a long time, that this is gonna be at least an hour of questions, it might be more.
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Then at the end of those questions, I usually say what my impression is in terms of my understanding of what's going on with them, and then I ask them how that seems to them.
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The funniest thing is that I was in private practice for about 13 years, and I got all these patients coming to me, and the very first thing they said was, I don't want to be on medication.
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And I'm like, Okay, cool, let's just meet and we'll talk.
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And and so I would have this lengthy interview, and then I'd say, All right, you know, this is how I understand things.
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I understand you don't want to be on medication, so let's talk.
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Oh, no, no, no, it's fine.
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If you won't think I need to be on medication.
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So when you've taken a lot of time with patients and you've come to the conclusion that your best recommendation is that medication might be helpful, they're usually very willing to accept because they know that it's based on a solid foundation of knowledge.
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The funny part was I was getting a lot of referrals from Hopkins, and I said, Why am I getting all these patients?
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And they're like, Oh, you're on our list that says ideal for people who for patients who don't want to be on medication.
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I'm like, oh, okay, that explains it, because it just seemed so weird.
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Anyway.
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I guess my point is I think there's role induction that's really helpful in preparing somebody for the kind of chronology of the interview, the time it's going to take, and people are generally very appreciative of the time and effort that goes into those evaluations.
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With with my students, I always teach the myth that if they haven't taken developmental history, they haven't taken a history from a patient.
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Sounds like your model really emphasizes that developmental history by putting it at the beginning.
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I suppose the contrast with Australia is we would use the what's called the Maudsley history format, and often the developmental history comes towards the end.
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So yeah, that strikes me as one difference.
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And I suppose one of the I think one of the reasons for doing that is is at the beginning of the interview, we would often tend to start with very open questions and allow the patient to say why they're here and really give the floor to the patient to bring what they want to to the interview.
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And I just wonder do you find at all with flipping things around that there's perhaps less space for patients to have that opportunity to direct where they want the interview to go?
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Well, I mean, I I do ask sort of a chief complaint, uh you know, what brings you in here, and then I say we're gonna get to that, and people are you know, they still have ample time to air that.
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Um so again, I think it's all about just what preparing people and setting those expectations for how it's gonna go.
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But I haven't had complaints or people saying, you know, wait, I want to tell you, you know, why I'm here first.
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People are usually pretty patient with the process and and there's still plenty of time to have those questions at the end about, okay, so now bring me up to date what's been going on lately.
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You know, tell me more about what you're seeking and why you're coming to a psychiatrist now.
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I really I think it's more the role induction.
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I do think that's very important.
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I think if you just jump in, people would feel unheard or feel like, uh, are you ever gonna get to why I'm here?
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Yeah, and just to kind of uh piggyback on that, so you know, the Phipps history that's taken is um very structured and uh starts not not with the developmental history necessarily, but actually with the family history.
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So absolutely without a role induction, it would be very awkward to say, so did your mother have any psychiatric illness?
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If that's the first thing, that's the opening line.
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And as I mentioned when I came from my previous training, that was sort of, you know, we we would definitely save that for the very end.
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We would start off with the history of pretension illness.
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But without a role induction, and I and very similarly, I basically tell patients, you know, I'd like to get to know about you a little bit more, and I'd like to start from the beginning of your life and come all the way up to what's been going off now.
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Is that okay?
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What I found, and and this is why I use the word life-changing almost, because when you start with, tell me what brought you in, inevitably you're gonna hear, well, when I was five years old, and they're going, the patient themselves are typically going back into their own past and trying to tie it into the future.
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And so it really helps to scaffold and organize in a chronological way.
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And as I mentioned, it's almost like a blank canvas, so you're really painting a picture of where this person is coming from.
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The other thing I would say is, as I've learned, the way the Phipps history is organized, is that for our trainees, it also provides a roadmap to, okay, this patient has this sort of family history and genetic loading.
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Can this speak to some of the disease aspects?
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Here's how their upbringing was, can this speak to some of their life story?
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Here's how they've had sort of, you know, behavioral issues or substance use, can this speak to so not only does it scaffold in a way that you're getting uh historical data in an organized fashion, but it's also allowing you to help interpret it in a certain way as well.
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I think one of the questions as an intern with time as a big thing that we don't have is how do we take this history?
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It sounds like this history takes hours to do.
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How do we do this in like a setting where you only have half an hour to take a history from a patient, for example, in the ED?
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And should interns and students and trainees make shortcuts?
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You know, the ideal, what we're talking about in terms of the two-hour uh evaluation, that's really, I think, best suited for getting in a non-emergency kind of situation where we are trying to develop a really comprehensive formulation and know sort of what a long-term treatment plan is.
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I think in the emergency room, for the most part, you're confronted with the question, does this person need to be hospitalized or not?
00:20:54.480 --> 00:20:57.599
Um, and you know, what's your best guess about what's going on?
00:20:57.759 --> 00:21:03.599
So I think that there's certainly, you know, targeted aspects of the history.
00:21:03.759 --> 00:21:12.160
We're not going to be asking about, you know, father's occupation necessarily or whether somebody was breast or bottle fed in the emergency room.
00:21:12.240 --> 00:21:13.440
It's not going to be relevant.
00:21:13.680 --> 00:21:18.000
I don't even know if that other question is relevant anymore to the outpatient.
00:21:18.079 --> 00:21:19.839
That was in my training, we had that.
00:21:20.000 --> 00:21:22.079
We don't have it as part of the history anymore.
00:21:22.400 --> 00:21:23.920
But you sort of adapt it.
00:21:24.000 --> 00:21:36.319
But I think having the experience of using it in its fullest form and practicing using it and knowing what those questions are pulling for, right?
00:21:36.400 --> 00:21:40.400
In terms of affective loading in the family for disease.
00:21:40.640 --> 00:21:48.480
With time, you can use it in a very intelligent, targeted way in the emergency room with you know more practice.
00:21:48.720 --> 00:21:49.920
So it does.
00:21:50.160 --> 00:21:59.200
I think the more you use it and the more you recognize patterns that come in certain situations, you can adapt it for emergency situations.
00:21:59.279 --> 00:22:01.039
But I would Never adapt it.
00:22:01.119 --> 00:22:05.440
You know, if I were seeing somebody in the outpatient setting, I'm gonna be following them for a long time.
00:22:05.599 --> 00:22:24.480
I would never adapt it because I think you risk, you know, if you leave out certain questions because you just assume you already know the answer or that it doesn't apply to a certain patient, you're really setting yourself for, you know, well, first of all, you're opening yourself up to bias and uh setting yourself up to miss some things that could be really major in a patient's care.
00:22:24.559 --> 00:22:26.319
So I was going to ask a similar question.
00:22:26.480 --> 00:22:34.640
So I'm a child and adolescent psychiatrist, and the majority of my assessments take about two hours, and I also have a you know strong developmental focus and systemic focus.
00:22:34.960 --> 00:22:40.880
And I was wondering what what context, what clinical context was this program developed in or for?
00:22:41.119 --> 00:22:52.319
And so we've sort of touched on that maybe not so much for an emergency department, but you know, would you see this as applicable in an inpatient adult ward, for example, or an outpatient child and adolescent unit, for example?
00:22:52.400 --> 00:22:54.000
I'm keen to hear your thoughts on that.
00:22:54.400 --> 00:23:09.039
Yeah, it was, I mean, it was developed for both inpatient and outpatient evaluations for both general psychiatry as well as specialized psychiatry services, different age groups or different specialty conditions.
00:23:09.200 --> 00:23:17.920
So I, you know, I used it in uh when I trained the Kennedy Krieger Institute in child in, you know, in the autism clinic.
00:23:18.000 --> 00:23:19.680
We used a very similar format.
00:23:19.839 --> 00:23:22.559
Going back to this mentioning of the Maudsley, Dr.
00:23:22.640 --> 00:23:32.400
McHugh trained at the Maudsley and uh was very influenced by not only uh Jaspers but also uh you know the training he got there at the Maudsley.
00:23:32.640 --> 00:23:36.799
So it was a sort of a combination of the Meyer, Maierian history.
00:23:36.960 --> 00:23:51.759
Maudsley was influenced by Adolf Meyer was our first chair of uh psychiatry at Hopkins, so it has that Meyerian influence, the Maudsley influence, and a lot of the perspectives comes from you know Jasper's writings and thinking about psychiatry.
00:23:51.920 --> 00:23:55.839
So, but it was developed for inpatient, outpatient, child, and general.
00:23:56.240 --> 00:24:04.000
To help our listeners with a practical understanding of this model, I wonder if we could perhaps go through a case example of what this might look like with a with a theoretical patient.
00:24:04.400 --> 00:24:04.720
Sure.
00:24:04.880 --> 00:24:16.319
So uh one of the things that is you know very rewarding about working in the field of traumatic brain injury is that you first of all get to see patients, you know, chronologically uh throughout their course after their injury.
00:24:16.400 --> 00:24:22.240
And many of them come with this sort of expectation that I can be back to the person that I was before, you know.
00:24:22.400 --> 00:24:34.880
Um and so oftentimes when patients come through our clinic, they themselves have already identified that I have a disease with my brain because it was damaged, and that's basically who I am, and conflate so many elements of that.
00:24:35.119 --> 00:25:00.240
So, one of my very first and memorable patients that I can uh kind of recall being very influential in my training and in my sort of conceptualization of how you can actually use the perspectives of psychiatry really in any patient population and apply was um a 50, a mid middle-age uh woman who was a very, very successful business owner and sort of at the top of her game and you know, quite socially active, very financially successful.
00:25:00.400 --> 00:25:05.279
And one day, very on a lunch break, she was going to meet somebody.
00:25:05.359 --> 00:25:10.799
Um she was driving in a car and she was T-boned and she lost consciousness for a mere few seconds.
00:25:11.039 --> 00:25:18.720
She ended up going into the emergency department, getting evaluated, and they said, you know, you have a mild concussion, just walk it off, you'll be fine.
00:25:18.880 --> 00:25:20.799
And uh there's nothing much more that we can do.
00:25:21.039 --> 00:25:28.720
As the months ensued, you know, we started to hear a lot about, or she reported, lots of mood lability, irritability, starting to forget things.
00:25:28.880 --> 00:25:32.720
She was snapping at her family members, having what her family members called mood swings.
00:25:32.799 --> 00:25:40.319
They thought she was perimenopausal, um, you know, all sorts of different things that really weren't being connected to this accident, but sort of progressing over time.
00:25:40.480 --> 00:25:48.000
So when she came to our clinic, it was in her mind and in her family's mind that some brain injury issue made her the way she was now.
00:25:48.160 --> 00:26:08.079
But in fact, a lot of what was happening was that, you know, when you start to, and and this is why it's very important, regardless of what the chief complaint is or what patient population you're working with, to take the same systematic methodical approach to asking the same questions the same way with various patients, because that's when you start to extract a lot of these kinds of things.
00:26:08.319 --> 00:26:19.200
And what we had learned was that the first thing is that she, because of the issues that she had with this traumatic brain injury, she felt that she had lost function.
00:26:19.359 --> 00:26:31.359
So it wasn't just that there was something wrong with her brain, but her body was physically kind of in pain all the time, and she wasn't able to sort of exert all the tasks that she was able to do, which therefore resulted in her not being able to take care of her family.
00:26:31.519 --> 00:26:34.880
And so she had this sense of kind of demoralization that was occurring.
00:26:35.119 --> 00:26:42.880
Then there were these other things that sort of emerged that there were sort of sort of um interpersonal dynamics with some of her family members.
00:26:42.960 --> 00:26:49.440
And so she was somebody, and again, only learning this through taking the Phipps history that felt her emotions very strongly.
00:26:49.599 --> 00:26:58.720
She was extremely conscientious in everything that she did, and the fact that she wasn't able to complete these tasks now or the tasks that were advised of her and asked of her, was um very frustrating for her.
00:26:58.880 --> 00:27:05.039
She was someone who used to be extremely agreeable to treatment and sort of participating with doctors, and she became very resistant.
00:27:05.119 --> 00:27:12.319
And so that lended us to start discussing aspects of her personality and how that was going to play into the role of how she was going to interact with us.
00:27:12.480 --> 00:27:25.200
Um so, and I don't know if that kind of answers if you wanted to sort of get a full VIPS history on the patient of time, I wasn't sure, but this kind of highlighted the fact that this is somebody that came to us that clearly had some kind of physiologic thing happen to her brain.
00:27:25.359 --> 00:27:32.319
But really, the thing that was bringing her to us, and actually the treatment for her, was focused on how we could rescript her narrative.
00:27:32.400 --> 00:27:36.960
So it was not just we may not get you back to who you were before, but we can get you better than you are now.
00:27:37.039 --> 00:27:40.960
And how do we do that by rescripting your own narrative and focusing on your life story?
00:27:41.039 --> 00:27:46.720
And how can we sort of guide you to help with your interpersonal interactions with people?
00:27:47.440 --> 00:27:57.920
That's a wonderful case, and it it really sounds like, as well as being useful for formulation, there was a therapeutic element as well to going through the case with the patient like that and helping them to understand more about the problem.
00:27:58.240 --> 00:28:15.599
Yeah, I I that's a great observation because that's been my um impression that the lengthy history and kind of working together collaboratively to come up with the formulation that both parties agree upon really is a therapeutic exercise in itself.
00:28:15.759 --> 00:28:22.960
I mean, I think that's the only explanation I can give for somebody that says, I don't want no medication, and then two hours later is like, yeah, whatever you want to do.
00:28:23.200 --> 00:28:41.119
It's a therapeutic intervention and then this uh helping people gain insights into their own personalities and the stories that they're telling themselves and the they have problematic behaviors, how they are caught in a cycle of those behaviors can be really empowering for patients.
00:28:41.680 --> 00:28:48.640
In Australia and New Zealand, many will know about the biopsychosocial model as well as the five Ps model of formulation.
00:28:48.880 --> 00:28:53.359
Sounds like the perspective psychiatry is similar in that way, but also different.
00:28:53.599 --> 00:28:58.319
What makes the perspective psychiatry different from these models that I mentioned?
00:28:58.960 --> 00:29:01.200
Well, at this point, I usually quote Dr.
00:29:01.359 --> 00:29:05.359
McHugh on the biopsychosocial model because I think he says it so well.
00:29:05.519 --> 00:29:15.519
Because the biopsychosocial model came out in the mid-70s around the same time that McHugh and Slavny were just beginning to think about or composing the perspectives.
00:29:15.599 --> 00:29:17.039
And he said, this is a quote.
00:29:17.200 --> 00:29:25.039
We think the biopsychosocial model survives because it can act as a slogan justifying any practice.
00:29:25.279 --> 00:29:42.559
It falters because it is neither refutable nor heuristic, by solemnly noting the obvious underpinnings of human life, but providing no way to derive mental distresses and disorders from them, offering ingredients without recipes, it's sophistry.
00:29:42.799 --> 00:30:07.599
So the shorthand answer that I give is there are a list of ingredients in the biopsychosocial model from atoms to so on, but it really doesn't give you a recipe for how to take those elements and organize them in a way that is linked to explanatory methods and treatment aims.
00:30:07.759 --> 00:30:32.640
And that's the beauty of the perspectives, is you take that data that is represented by the biopsychosocial model, you take that data and you put it into kind of this framework that not only describes the conceptual underpinnings of these families or these various natures of psychiatric disorders, but also links those to treatment aims.
00:30:32.960 --> 00:30:42.079
And also, we we haven't gone into this, but each one of the those ways that mental life can go awry are based on aspects of mental life too.
00:30:42.240 --> 00:30:44.559
But I think that's beyond this uh discussion.
00:30:45.039 --> 00:30:58.160
And that's one of the things that we'd really try to enforce and reinforce in our trainees is this idea of these conceptual triads of each perspective, which is important because, for example, with the life story, the setting sequence outcome, it is linked to a treatment aim.
00:30:58.240 --> 00:31:11.039
And I think that is exactly what the biopsychosocial model does lack is this sort of the way that you scaffold it, but then you have this sort of triad that is then linked directly to a specific aim that would be addressed by that triad.
00:31:11.599 --> 00:31:20.400
Another example is the behavior perspective, where the conceptual triad is choice, conditioned learning, and drive.
00:31:20.559 --> 00:31:24.799
So somebody might make a choice to try alcohol.
00:31:25.039 --> 00:31:44.880
Yes, there may be some biological predisposition that makes them really respond to alcohol in a very positive way, so that they get conditioned more easily to the positive reinforcers of alcohol as well as negative reinforcers like withdrawal if they're not drinking, or rebound anxiety if they're not drinking.
00:31:45.200 --> 00:31:53.599
And then that conditioned learning increases their drive to drink and narrows their ability to choose not to drink.
00:31:53.680 --> 00:32:06.160
And that just keeps that cycle keeps happening, and the drive keeps increasing, the choice keeps narrowing to becoming, even in the face of all kinds of life problems.
00:32:06.319 --> 00:32:19.519
Like I saw a patient once who had killed his girlfriend accidentally by driving drunk, had been lost his job, had hepatitis, was kicked out of his apartment, had gone to jail for his manslaughter.
00:32:19.680 --> 00:32:25.359
And I said, Well, you know, how important do you think it is to like go to AA or Alcoholics Anonymous?
00:32:25.519 --> 00:32:27.039
And he was like, Oh, I'm not that bad.
00:32:27.200 --> 00:32:44.720
So I mean, his drive was so strong in the face of all the and it defies logic unless you look at that conceptual triad and you realize that actually some of the treatments for alcohol use disorder really are targeting various aspects of that cycle.
00:32:44.880 --> 00:32:48.079
You know, the Alcoholics Anonymous one day at a time.
00:32:48.319 --> 00:32:51.279
Every day you make a choice to drink or not drink.
00:32:51.519 --> 00:32:58.160
The ways of, you know, if you do drink and you take disulforam or antibuse, you get sick, right?
00:32:58.400 --> 00:33:01.599
It's targeting these various uh aspects of the cycle.
00:33:01.759 --> 00:33:19.279
So I think it not only informs our teaching and our clinical care, but it also informs sort of, you know, development of new treatments if you understand these conceptual triads, which again I don't see from the biopsychosocial model, but I really didn't train in a place where that reigned.
00:33:19.440 --> 00:33:25.119
I trained primarily at Hopkins and I went to medical school at a psychodynamically oriented medical school.
00:33:25.200 --> 00:33:30.079
So you had more experience, Turgo, with the biopsychosocial model at places you trained.
00:33:30.480 --> 00:33:40.079
Yeah, and that's exactly as I was describing what I felt was the gap was that sort of uh conceptualization of these three components that were directly linked to an aim.
00:33:40.480 --> 00:33:47.119
I mean, the biopsychosocial model we were asked to formulate in those three prongs, but then what did we do with those three prongs?
00:33:47.200 --> 00:33:53.440
You know, we just formulated the patient, and that's what's wrong with the patient, or not wrong with which, but what's we'd seen with the patient, but then what do we do?
00:33:53.519 --> 00:33:55.519
And that was the piece that I felt was the gap.
00:33:56.160 --> 00:34:03.680
So Doug, I understand that you have also founded a new program in 2024 for international learners, wanting to learn more about the perspectives.
00:34:04.160 --> 00:34:06.319
Can you share about what inspired you to start this?
00:34:07.039 --> 00:34:07.680
Absolutely.
00:34:07.920 --> 00:34:22.320
So, one of the best parts, and if not the best part, of my job at Hopkins is teaching and specifically teaching our first-year psychiatry interns who are coming in from various institutions all over the country to train with us.
00:34:22.639 --> 00:34:28.800
So many of them have not been exposed to the perspectives as our medical students at Hopkins have the opportunity to do.
00:34:29.119 --> 00:34:35.599
With this, I've kind of seen a lot of interest from people coming generally from the outside to come to Hopkins to learn about this.
00:34:35.920 --> 00:34:41.679
Within the nation, we have a visiting medical students program where people in other medical schools come and kind of rotate for a month.
00:34:42.000 --> 00:34:55.679
But what really sort of pushed the needle a little bit was when we started getting this interest from, you know, across the globe and overseas of learners who were hearing about this program, specifically about the perspectives and Dr.
00:34:55.840 --> 00:35:05.679
McHugh's work and trying to understand how something like this could be implemented in their own institutions, in their own countries and in the within their own system.
00:35:05.840 --> 00:35:13.039
And so our inaugural uh learner was Johannes Thorman, who reached out initially and asked about, you know, opportunities to rotate.
00:35:13.199 --> 00:35:25.199
And so that sort of sparked the question of oh, we're doing, you know, all these efforts at Hopkins within our own institution to treat our trainee, to teach our trainees and bring medical students from within the country to come learn about this.
00:35:25.360 --> 00:35:27.039
Why couldn't we expand beyond that?
00:35:27.199 --> 00:35:31.840
And it really was sort of an easy recipe because we already have the infrastructure in place.
00:35:32.079 --> 00:35:44.960
We already have a very structured curriculum and rotational sort of setup for our interns and our medical students, and it was just an easy plug-in for anyone that would come from the outside to do such a thing.
00:35:45.199 --> 00:35:57.119
So that's how the uh after Johannes came and rotated for a month, then we um had the opportunity to meet Alan and started realizing that this repeat rotational experience could be duplicated in multiple ways.
00:35:57.920 --> 00:36:02.800
How can the listeners of this podcast find out more about the perspectives and this program that you mentioned?
00:36:03.280 --> 00:36:03.840
Absolutely.
00:36:04.000 --> 00:36:07.440
So I'll just describe a little bit of the detail of what one would go through.
00:36:07.599 --> 00:36:15.599
So it's a one-month experience that would award our learner who is visiting the opportunity to have four specific rotational objectives.
00:36:15.679 --> 00:36:19.519
So the first is an inpatient rotation month on the inpatient psychiatric unit.
00:36:19.679 --> 00:36:22.960
The second would be a concomitant outpatient elective experience.
00:36:23.119 --> 00:36:28.320
The third would be meeting with all of the Hopkins faculty who are involved in educational leadership, including Dr.
00:36:28.400 --> 00:36:29.039
McHugh and Dr.
00:36:29.119 --> 00:36:31.760
Slavley, who are the founders of this framework.
00:36:31.920 --> 00:36:38.400
And then the fourth would be sort of longitudinally having scholarship and research opportunities with each of us.
00:36:38.960 --> 00:36:49.760
So with that said, it is a very competitive application process because we have very limited faculty that we could sort of who attend in certain months of the year that could work directly with our learners.
00:36:49.920 --> 00:36:53.760
But they would reach out to me, deroy4 at jhmi.edu.
00:36:54.079 --> 00:36:58.000
That's my uh email address, d-roy4 at jhmi.edu.
00:36:58.559 --> 00:37:03.519
And that would start with then um a formal application process of completing a form that Dr.
00:37:03.599 --> 00:37:15.679
Khalid El-Samzami has created, who by the way is also the co-director, um associate director of this program with me, completing the form, meeting with us virtually, and setting up a rotational plan and an educational plan with us.
00:37:16.079 --> 00:37:16.559
Thank you, Dr.
00:37:16.800 --> 00:37:17.119
Roy.
00:37:17.280 --> 00:37:21.199
So this is all the time we have for today, so I wanted to bring this discussion to a close.
00:37:21.679 --> 00:37:22.880
I'd like to thank both Dr.
00:37:22.960 --> 00:37:23.840
Chisholm and Dr.
00:37:23.920 --> 00:37:28.159
Roy for making a trek to the land down under and having this very interesting discussion.
00:37:28.559 --> 00:37:29.679
Thank you so much, Alan.
00:37:29.760 --> 00:37:30.880
It's been a great pleasure.
00:37:30.960 --> 00:37:31.280
Thank you.
00:37:31.519 --> 00:37:32.159
Thank you, Alan.
00:37:32.239 --> 00:37:35.760
You have really been very inspiring and we've been very honored to work with you.
00:37:36.000 --> 00:37:40.800
I would also like to thank Michael and Ed for joining us and asking the very interesting questions as well.
00:37:41.199 --> 00:37:41.840
Thanks, Alan.
00:37:42.000 --> 00:37:44.079
Thank you very much, Alan, and good to meet you both as well.
00:37:44.559 --> 00:37:50.800
Also like to acknowledge David Beale and Nishda Kuma from the college who give us so much support in producing and editing the show.
00:37:51.119 --> 00:38:00.079
We are also thankful to Osha Lazen Psychiatry for the opportunity to make these podcasts, as well as Sidoni Prentice for our artwork and Shetty Day for our music.
00:38:00.719 --> 00:38:08.400
We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrars or supervisors.
00:38:09.039 --> 00:38:14.800
We also love getting feedback or suggestions for further episodes, including volunteers interested in being a guest.
00:38:15.280 --> 00:38:21.920
Please get in touch by email at the thought podcast.org.
00:38:22.639 --> 00:38:23.360
That's all for now.
00:38:23.440 --> 00:38:25.119
My name is Alan, and thanks for listening.
00:38:25.440 --> 00:38:26.559
We'll catch you next time.
00:00:07.200 --> 00:00:12.480
Hello and welcome back to the Thought Podcast, the trainee focused podcast for Australasian psychiatry.
00:00:12.960 --> 00:00:17.519
My name is Alan Hong, and I am an associate trainee editor of Australasian Psychiatry.
00:00:17.760 --> 00:00:21.679
Joining me today is editorial members Michael Waitman and Ed Miller.
00:00:22.000 --> 00:00:22.160
Welcome.
00:00:22.559 --> 00:00:23.039
Thanks, Alan.
00:00:24.160 --> 00:00:28.640
Also joining us today, after having flown more than 24 hours from the United States, is Dr.
00:00:28.800 --> 00:00:31.600
Margaret Chisholm, Professor of Psychiatry, and Dr.
00:00:31.760 --> 00:00:36.719
Dirgo Roy, who is the associate professor of psychiatry at the Johns Hopkins University School of Medicine.
00:00:36.960 --> 00:00:37.200
Dr.
00:00:37.280 --> 00:00:51.759
Chisholm has authored more than 150 scientific papers and two books, and is also the director of the Paul McHugh Programme for Human Flourishing, where she uses the art and humanities with medical learners to explore what it means to be human, to be a physician, and lead a good life.
00:00:52.079 --> 00:00:52.320
Dr.
00:00:52.399 --> 00:01:00.799
Roy is the director of education for the Johns Hopkins Psychiatry Internship and Program Coordinator for the Perspectives of Psychiatry program for international learners.
00:01:01.039 --> 00:01:12.000
She has authored numerous peer-reviewed publications focused on the neuropsychiatric outcomes after traumatic brain injury and is recognized as a national expert in the field of TBI and neuropsychiatry.
00:01:12.319 --> 00:01:14.719
Welcome everyone thank you, Alan, for having us.
00:01:14.879 --> 00:01:15.840
Thank you for having us.
00:01:15.920 --> 00:01:20.480
We're really excited to share our perspectives on the perspectives of psychiatry.
00:01:20.959 --> 00:01:31.599
Today we will be discussing the unique framework underpinning psychiatric education and practice at Johns Hopkins, as well as the new international program founded in 2024 for medical learners worldwide.
00:01:32.079 --> 00:01:36.480
So before we start, welcome to the Gold Coast in Australia, far away from the United States.
00:01:36.719 --> 00:01:39.280
How have you found Australia and the Gold Coast?
00:01:39.680 --> 00:01:45.920
I found it very welcoming and I love the kind of casual beach vibe here on the Gold Coast.
00:01:46.000 --> 00:01:47.280
It's been it's been a delight.
00:01:47.439 --> 00:01:47.680
Thank you.
00:01:48.000 --> 00:01:48.959
I echo the same thing.
00:01:49.040 --> 00:01:53.200
It's been very calming and very peaceful, and everyone here is so very kind.
00:01:53.359 --> 00:01:55.120
So it's been a wonderful experience so far.
00:01:55.680 --> 00:02:00.560
Have you managed to um hold any koalas or feed any kangaroos whilst your time here?
00:02:00.799 --> 00:02:01.280
That's tomorrow.
00:02:01.439 --> 00:02:04.640
We have been counting down the days till we go to the animal sanctuary.
00:02:04.719 --> 00:02:09.599
We have our list of, you know, the animal scavenger hunt that we're gonna be looking forward to tomorrow.
00:02:10.240 --> 00:02:12.080
We won't tell you about what lives in the water then.
00:02:12.479 --> 00:02:13.360
Oh yes, please.
00:02:13.680 --> 00:02:21.840
Oh that's that's good to know that uh you've enjoyed your time in in the Gold Coast, spending the next few days enjoying the wildlife of Australia.
00:02:22.319 --> 00:02:25.120
So before we start, just a few introductions.
00:02:25.280 --> 00:02:26.960
Meg, tell us a bit about yourself.
00:02:27.520 --> 00:02:31.120
Well, I am a professor of psychiatry, as you said, at Hopkins.
00:02:31.360 --> 00:02:32.400
I am married.
00:02:32.560 --> 00:02:40.319
I have an adult son, um, but I've been at Hopkins since about uh when I went for my residency, actually in 1988.
00:02:40.719 --> 00:02:52.960
Um more or less uh have been there ever since, been working full-time on the faculty since 2006, and have been directing the Paul McHugh program for about 10 years.
00:02:53.439 --> 00:02:55.120
And Dega, how about yourself?
00:02:55.520 --> 00:02:57.120
So I've been in many, many places.
00:02:57.280 --> 00:03:07.599
I actually started out of medical school in New Mexico, which is where my family is from, which is also where I kind of fell in love with psychiatry and a lot of the biological aspects of psychiatric illness.
00:03:07.680 --> 00:03:17.199
And then I went to um I jumped ship all the way to the East Coast to uh Long Island, where I did my residency at Long Island Jewish Medical Center, uh, Zucker Hillside Hospital.
00:03:17.360 --> 00:03:27.840
And then I was very fortunate enough to be accepted as a consultation liaison psychiatry fellow uh in 2012, where which is when I moved to Hopkins, and I've been at Hopkins since.
00:03:28.000 --> 00:03:35.039
I joined the faculty right after my fellowship and have really enjoyed my time there uh wearing multiple hats, as you've already mentioned.
00:03:35.120 --> 00:03:45.280
I run the education program at Bayview, which affords me the opportunity to work with the psychiatry interns and oversee all the operations that happen in medical education at Bayview.
00:03:45.439 --> 00:03:52.000
I run the CL Psychiatry Fellowship, which is another area of interest of mine and training future CL psychiatrists.
00:03:52.080 --> 00:03:54.800
And then my biggest passion clinically is in traumatic brain injury.
00:03:54.879 --> 00:04:04.479
So I run the traumatic brain injury clinic there, do a lot of research on traumatic brain injury and neuroimaging, and continue to teach on uh how we can get patients better after they have had a TBI.
00:04:05.120 --> 00:04:09.680
Sounds like you've done a lot in in your time and also trained in many different places.
00:04:10.159 --> 00:04:13.280
So unlike Meg, you've trained in many places before Hopkins.
00:04:13.520 --> 00:04:17.680
What was it like joining Hopkins and working there and learning how they've done psychiatry?
00:04:18.240 --> 00:04:20.720
I think the word I would use is transformative.
00:04:21.040 --> 00:04:29.199
Um, you know, I I came from so Long Island Jewish uh hospital and Zucker Hillside Hospital is located in New York.
00:04:29.439 --> 00:04:36.800
We were fortunate to have many faculty there that had various backgrounds, mostly in psychodynamic psychotherapy.
00:04:36.879 --> 00:04:40.639
So you may or not may not be familiar, but the New York Psychiatric Institute is there.
00:04:40.720 --> 00:04:45.439
So a lot of our psychotherapy training was sort of focused around psychodynamic approaches and Freud.
00:04:45.600 --> 00:04:48.560
And then we had a very strong biological component to our department as well.
00:04:48.639 --> 00:04:51.680
This is where clozepine was sort of put on the map and things like that.
00:04:51.839 --> 00:05:08.160
So I I came sort of to Hopkins with this kind of background, and coming to Hopkins was quite transformative and life-changing because I was introduced to an entire new world, um, but very almost familiar and one that made sense to me, world of approach to psychiatry, which I'm sure we'll talk about more today.
00:05:09.040 --> 00:05:13.680
What is this new world that you were introduced to when you arrived at Hopkins and what changed?
00:05:14.480 --> 00:05:18.160
It was really the approach to the patient as a whole.
00:05:18.399 --> 00:05:25.680
As a consultation liaison psychiatry fellow, it's uh Hopkins is unique because uh we don't just do inpatient consultation liaison work.
00:05:25.759 --> 00:05:32.319
So it's not just treating the medically ill patients who have psychiatric comorbidities, but there's a huge outpatient component to it.
00:05:32.560 --> 00:05:40.160
So my very first week there, I had an intake that I was uh interviewing a patient, and it was I was being observed by the at that time, the program director.
00:05:40.480 --> 00:05:46.079
And I started off taking a history the way I was taught how to take it, which was the history of present illness.
00:05:46.240 --> 00:05:58.800
And to me, that was probably the number one thing that I had noted was very different in how I was trained, because I was starting off with asking the patient why they were there instead of starting from the beginning of how their life was and developing forward.
00:05:58.959 --> 00:06:20.079
And so after that point, and after watching how other Hopkins-trained faculty and trainees were taking histories, I realized that this new world was essentially learning about a patient and becoming familiar with the patient as if they were a blank canvas and painting this picture of who they were starting from when they were born, coming down to now why are they here?
00:06:20.240 --> 00:06:24.800
So I think that was the part that was sort of life-changing, if you will, or different in that aspect.
00:06:24.959 --> 00:06:31.759
And sort of adopting that approach of interviewing and asking patients really then led into being able to formulate them in a different way as well.
00:06:32.079 --> 00:06:37.040
So I wonder if just for our listeners' benefit, if you could tell us a little bit about the perspectives model.
00:06:37.360 --> 00:06:40.959
I think for me, yesterday, going to your presentation here at Congress was really interesting.
00:06:41.040 --> 00:06:45.759
Learning about it as something I hadn't been aware of before, and I think it would be really beneficial to understand a bit more about it.
00:06:46.160 --> 00:07:01.439
Yeah, so the Perspectives model was developed by Paul McHugh and Philip Slavney, and they had come from Oregon, where they had been together as department chair and program director there of the residency training program.
00:07:01.680 --> 00:07:07.680
And they came to Hopkins when Paul McHugh in the mid-70s was named chair of the department at Hopkins.
00:07:07.839 --> 00:07:14.000
And when Paul McHugh came, he really started thinking, you know, what does the field of psychiatry need?
00:07:14.240 --> 00:07:22.240
And he wanted to develop his entire kind of vision for the department based on that answer to that question.
00:07:22.319 --> 00:07:40.079
And he thought that what psychiatry really needs is a way of organizing the information that we get from patients so that we can make sense of what they're experiencing and what the origins of their problems are and how they might be best treated.
00:07:40.240 --> 00:07:49.759
Obviously, psychiatry needs many more things, but at this point we don't have really good pathophysiologic explanations of most diseases and things like that.
00:07:49.920 --> 00:07:53.439
But he thought this was something that psychiatry needed that was within grasp.
00:07:53.680 --> 00:08:07.759
And so he started using sort of the evidence from science, biological sciences as well as social sciences, to make explicit what psychiatrists were already doing implicitly.
00:08:08.000 --> 00:08:19.600
And so he started thinking about the various natures or kind of explanatory methods that could be used for various psychiatric presentations.
00:08:19.759 --> 00:08:35.039
And he thought they fell into four groups, and so he and Slavny used this visual metaphor of the perspectives to say to really understand a patient fully, you need to consider their presentation from all four of these perspectives.
00:08:35.200 --> 00:08:50.159
And so the perspectives are the disease perspective, and so you might ask yourself when a patient comes to you how much of their problem is best explained as a disease, as something that somebody has that's sort of come upon them unbidden.
00:08:50.320 --> 00:08:53.519
And examples of that might be traumatic brain injury.
00:08:53.679 --> 00:09:03.440
It's clinical syndromes that run a course together for which there's, you know, evidence that this is indirect evidence, usually that this is a disease kind of syndrome.
00:09:03.600 --> 00:09:15.039
So other classic examples of the disease perspective, illnesses are things like schizophrenia and mania, where it just seems qualitatively different from other experiences that one might have.
00:09:15.200 --> 00:09:20.320
And that they might run in families, they might respond to somatic kind of treatments.
00:09:20.480 --> 00:09:33.360
So that's the first perspective, the disease perspective, and it's the one that most medical students and residents are familiar with because that's sort of like most of the rest of medicine, uses this disease explanatory method.
00:09:33.600 --> 00:09:34.480
So that was the first one.
00:09:34.559 --> 00:09:40.559
And then he thought, well, what else might be necessary to really understand a patient's presentation?
00:09:40.720 --> 00:09:44.240
And so then the next perspective is the dimensional perspective.
00:09:44.480 --> 00:09:54.559
And that really is in response to kind of a question about, you know, how much of this presentation of this patient is the result of who they are as a person, of who the person is.
00:09:54.720 --> 00:10:11.120
And that has to do with personality, both kind of cognitive dimensions of personality, like intelligence or executive function, and the affective temperament aspects of the personality like neuroticism or extroversion, things like that.
00:10:11.279 --> 00:10:15.120
And then the third perspective is the behavior perspective.
00:10:15.360 --> 00:10:30.559
And so he thought that there were certain psychiatric problems that didn't really come upon people unbidden, didn't really emerge from who the person was in terms of their personality, but was more the result of what somebody was doing.
00:10:30.799 --> 00:10:57.919
And so examples of that are these innate disordered kind of behaviors that are arising from innate drives like sleep disorders or feeding disorders or sexual disorders, and then disorders that had their basis in behaviors that were more acquired, like substance use that aren't necessary for the survival of oneself or the species, but have hijacked that underlying neurocircuitry of the innate drives.
00:10:58.080 --> 00:11:10.320
And then there were also these more kind of socially motivated drives, drives to fit in, other sort of behaviors that were reinforced by conditioned learning, like abnormal illness behaviors like conversion disorders and things like that.
00:11:10.480 --> 00:11:20.639
So there, so far we've got the disease perspective, the dimensional perspective, the behavior perspective, and then finally there's the life story perspective.
00:11:20.799 --> 00:11:30.799
And so this is the perspective that really describes the origin of a person's problems as a result of what they've encountered in life.
00:11:30.879 --> 00:11:34.960
And so a classic example of that is grief or demoralization.
00:11:35.200 --> 00:11:42.240
We think of those as adjustment disorders now, but the that really emerge from you know the events that somebody has encountered.
00:11:42.399 --> 00:11:55.039
Now, all these four perspectives obviously kind of intertwine, and so we tease them apart just for the teaching of the perspectives, but everybody has a life story, everybody has a personality, so those apply to everybody.
00:11:55.120 --> 00:12:18.080
And then diseases can happen in the setting of a specific person's life, in the setting of their personality, and the diseases may, people may respond to those differently or be motivated to take their medication differently depending on what they've experienced and the either the meaning that they're giving the disease or who they are as people.
00:12:18.399 --> 00:12:36.720
So that's sort of a kind of brief overview of the perspectives, but it's basically recognizing that there's we use different explanatory methods in psychiatry to understand a patient's problems, and we really need to consider all four of those explanatory methods to develop a treatment plan for a patient.
00:12:37.120 --> 00:12:39.279
Thanks, Meg, for walking us through the perspectives model.
00:12:39.440 --> 00:12:42.799
It's a really comprehensive way of thinking about people and formulating patients.
00:12:42.879 --> 00:12:52.559
And it seems to me that the value of the model is about bringing together existing knowledge in psychiatry in an integrated way that sort of really scaffolds things for people working in psychiatry.
00:12:52.639 --> 00:13:02.480
And my own kind of perspective of educating medical students and registrars is that often formulation is the hardest skill that people struggle with, and putting things together is really difficult.
00:13:02.639 --> 00:13:08.399
So it feels like there's a really valuable opportunity to use this model to help make that task a little bit easier for learners.
00:13:08.720 --> 00:13:10.960
Yeah, I think that you're that's very well said.
00:13:11.039 --> 00:13:11.759
You're exactly right.
00:13:11.919 --> 00:13:18.159
You know, I think of it as a framework, kind of a way of scaffolding, all this information that we get from patients, how to make sense of it.
00:13:18.240 --> 00:13:24.159
It can seem very chaotic, and it's just a way of organizing it that will be helpful for the care of that patient.
00:13:24.320 --> 00:13:28.960
And it helps, I think, the patients understand their own experiences too.
00:13:29.200 --> 00:13:37.120
We often ask a patient, you know, when they tell us their current problems, you know, how much of this is really, do you think is due to something that you have?
00:13:37.279 --> 00:13:42.159
Or how much do you think this is really, you know, a result of who you are as a person or what you're doing?
00:13:42.320 --> 00:13:52.639
And I think patients have a it's sort of a common sense way of they're able to kind of put that, answer those questions and reflect on those in a way that can be very insightful.
00:13:53.120 --> 00:13:54.879
And Durga sort of touched on this.
00:13:55.039 --> 00:14:01.039
So when you see a patient, how would you structure your sort of clinical, you know, history taking?
00:14:01.120 --> 00:14:03.679
And Durga mentioned, you know, going all the way back to the start.
00:14:03.919 --> 00:14:06.320
Can you just run us through, you know, what that would look like?
00:14:06.559 --> 00:14:19.200
Yeah, so I do a little bit of role induction with patients, so I will ask them if they've ever seen a psychiatrist before or a mental health professional, and I kind of warn them this is probably going to be different from what they've experienced before.
00:14:19.279 --> 00:14:36.159
And I say, I'm gonna be starting with, you know, learning about you and your life and moving forward in time because I really want to get an understanding of where or how what you're experiencing now fits into who you are as a person and what you've experienced in your life.
00:14:36.399 --> 00:14:45.200
I literally have done hundreds and hundreds, probably thousands and thousands of interviews with patients, and I've never had anybody get upset about that.
00:14:45.279 --> 00:14:49.360
They kind of value that I really want to understand what's going on.
00:14:49.519 --> 00:14:51.919
So that's I think of value to the patient.
00:14:52.080 --> 00:14:56.559
They really recognize that somebody's really taking a personal interest in them.
00:14:56.720 --> 00:15:09.120
I would say from the clinician's point of view, it's also very helpful in making sense of the history of present illness to know when they talk about Uncle Ted, who that person is and how they fit into their life.
00:15:09.279 --> 00:15:15.360
So for me, it's a lot easier to make sense of the history of present illness when I have the context in which that's occurring.
00:15:15.519 --> 00:15:17.360
So I think that's really important.
00:15:17.840 --> 00:15:20.240
So I think that chronology is important.
00:15:20.399 --> 00:15:25.360
I do a role induction, and like I said, I've never had patients be upset about that.
00:15:25.519 --> 00:15:33.759
So the other thing I do is I advise patients that it's going to take a long time, that this is gonna be at least an hour of questions, it might be more.
00:15:33.919 --> 00:15:44.159
Then at the end of those questions, I usually say what my impression is in terms of my understanding of what's going on with them, and then I ask them how that seems to them.
00:15:44.399 --> 00:15:54.559
The funniest thing is that I was in private practice for about 13 years, and I got all these patients coming to me, and the very first thing they said was, I don't want to be on medication.
00:15:54.639 --> 00:15:57.519
And I'm like, Okay, cool, let's just meet and we'll talk.
00:15:57.679 --> 00:16:02.960
And and so I would have this lengthy interview, and then I'd say, All right, you know, this is how I understand things.
00:16:03.039 --> 00:16:05.600
I understand you don't want to be on medication, so let's talk.
00:16:05.759 --> 00:16:07.360
Oh, no, no, no, it's fine.
00:16:07.519 --> 00:16:09.360
If you won't think I need to be on medication.
00:16:09.519 --> 00:16:22.559
So when you've taken a lot of time with patients and you've come to the conclusion that your best recommendation is that medication might be helpful, they're usually very willing to accept because they know that it's based on a solid foundation of knowledge.
00:16:22.720 --> 00:16:27.759
The funny part was I was getting a lot of referrals from Hopkins, and I said, Why am I getting all these patients?
00:16:28.080 --> 00:16:34.240
And they're like, Oh, you're on our list that says ideal for people who for patients who don't want to be on medication.
00:16:34.399 --> 00:16:37.440
I'm like, oh, okay, that explains it, because it just seemed so weird.
00:16:37.600 --> 00:16:37.919
Anyway.
00:16:38.159 --> 00:16:51.360
I guess my point is I think there's role induction that's really helpful in preparing somebody for the kind of chronology of the interview, the time it's going to take, and people are generally very appreciative of the time and effort that goes into those evaluations.
00:16:51.759 --> 00:16:56.879
With with my students, I always teach the myth that if they haven't taken developmental history, they haven't taken a history from a patient.
00:16:57.120 --> 00:17:00.720
Sounds like your model really emphasizes that developmental history by putting it at the beginning.
00:17:00.960 --> 00:17:07.759
I suppose the contrast with Australia is we would use the what's called the Maudsley history format, and often the developmental history comes towards the end.
00:17:08.000 --> 00:17:10.640
So yeah, that strikes me as one difference.
00:17:10.880 --> 00:17:25.680
And I suppose one of the I think one of the reasons for doing that is is at the beginning of the interview, we would often tend to start with very open questions and allow the patient to say why they're here and really give the floor to the patient to bring what they want to to the interview.
00:17:25.759 --> 00:17:35.519
And I just wonder do you find at all with flipping things around that there's perhaps less space for patients to have that opportunity to direct where they want the interview to go?
00:17:35.839 --> 00:17:46.960
Well, I mean, I I do ask sort of a chief complaint, uh you know, what brings you in here, and then I say we're gonna get to that, and people are you know, they still have ample time to air that.
00:17:47.119 --> 00:17:55.039
Um so again, I think it's all about just what preparing people and setting those expectations for how it's gonna go.
00:17:55.200 --> 00:18:02.079
But I haven't had complaints or people saying, you know, wait, I want to tell you, you know, why I'm here first.
00:18:02.400 --> 00:18:13.839
People are usually pretty patient with the process and and there's still plenty of time to have those questions at the end about, okay, so now bring me up to date what's been going on lately.
00:18:14.000 --> 00:18:18.559
You know, tell me more about what you're seeking and why you're coming to a psychiatrist now.
00:18:18.720 --> 00:18:20.559
I really I think it's more the role induction.
00:18:20.640 --> 00:18:21.839
I do think that's very important.
00:18:22.000 --> 00:18:28.160
I think if you just jump in, people would feel unheard or feel like, uh, are you ever gonna get to why I'm here?
00:18:28.480 --> 00:18:40.160
Yeah, and just to kind of uh piggyback on that, so you know, the Phipps history that's taken is um very structured and uh starts not not with the developmental history necessarily, but actually with the family history.
00:18:40.319 --> 00:18:45.759
So absolutely without a role induction, it would be very awkward to say, so did your mother have any psychiatric illness?
00:18:45.839 --> 00:18:48.079
If that's the first thing, that's the opening line.
00:18:48.240 --> 00:18:53.759
And as I mentioned when I came from my previous training, that was sort of, you know, we we would definitely save that for the very end.
00:18:53.839 --> 00:18:55.839
We would start off with the history of pretension illness.
00:18:55.920 --> 00:19:05.920
But without a role induction, and I and very similarly, I basically tell patients, you know, I'd like to get to know about you a little bit more, and I'd like to start from the beginning of your life and come all the way up to what's been going off now.
00:19:06.160 --> 00:19:06.799
Is that okay?
00:19:06.960 --> 00:19:22.319
What I found, and and this is why I use the word life-changing almost, because when you start with, tell me what brought you in, inevitably you're gonna hear, well, when I was five years old, and they're going, the patient themselves are typically going back into their own past and trying to tie it into the future.
00:19:22.400 --> 00:19:26.640
And so it really helps to scaffold and organize in a chronological way.
00:19:26.799 --> 00:19:32.559
And as I mentioned, it's almost like a blank canvas, so you're really painting a picture of where this person is coming from.
00:19:32.720 --> 00:19:46.240
The other thing I would say is, as I've learned, the way the Phipps history is organized, is that for our trainees, it also provides a roadmap to, okay, this patient has this sort of family history and genetic loading.
00:19:46.400 --> 00:19:48.960
Can this speak to some of the disease aspects?
00:19:49.200 --> 00:19:52.880
Here's how their upbringing was, can this speak to some of their life story?
00:19:53.039 --> 00:20:05.759
Here's how they've had sort of, you know, behavioral issues or substance use, can this speak to so not only does it scaffold in a way that you're getting uh historical data in an organized fashion, but it's also allowing you to help interpret it in a certain way as well.
00:20:06.160 --> 00:20:13.039
I think one of the questions as an intern with time as a big thing that we don't have is how do we take this history?
00:20:13.200 --> 00:20:15.519
It sounds like this history takes hours to do.
00:20:15.759 --> 00:20:23.039
How do we do this in like a setting where you only have half an hour to take a history from a patient, for example, in the ED?
00:20:23.200 --> 00:20:27.440
And should interns and students and trainees make shortcuts?
00:20:27.839 --> 00:20:47.759
You know, the ideal, what we're talking about in terms of the two-hour uh evaluation, that's really, I think, best suited for getting in a non-emergency kind of situation where we are trying to develop a really comprehensive formulation and know sort of what a long-term treatment plan is.
00:20:47.920 --> 00:20:54.319
I think in the emergency room, for the most part, you're confronted with the question, does this person need to be hospitalized or not?
00:20:54.480 --> 00:20:57.599
Um, and you know, what's your best guess about what's going on?
00:20:57.759 --> 00:21:03.599
So I think that there's certainly, you know, targeted aspects of the history.
00:21:03.759 --> 00:21:12.160
We're not going to be asking about, you know, father's occupation necessarily or whether somebody was breast or bottle fed in the emergency room.
00:21:12.240 --> 00:21:13.440
It's not going to be relevant.
00:21:13.680 --> 00:21:18.000
I don't even know if that other question is relevant anymore to the outpatient.
00:21:18.079 --> 00:21:19.839
That was in my training, we had that.
00:21:20.000 --> 00:21:22.079
We don't have it as part of the history anymore.
00:21:22.400 --> 00:21:23.920
But you sort of adapt it.
00:21:24.000 --> 00:21:36.319
But I think having the experience of using it in its fullest form and practicing using it and knowing what those questions are pulling for, right?
00:21:36.400 --> 00:21:40.400
In terms of affective loading in the family for disease.
00:21:40.640 --> 00:21:48.480
With time, you can use it in a very intelligent, targeted way in the emergency room with you know more practice.
00:21:48.720 --> 00:21:49.920
So it does.
00:21:50.160 --> 00:21:59.200
I think the more you use it and the more you recognize patterns that come in certain situations, you can adapt it for emergency situations.
00:21:59.279 --> 00:22:01.039
But I would Never adapt it.
00:22:01.119 --> 00:22:05.440
You know, if I were seeing somebody in the outpatient setting, I'm gonna be following them for a long time.
00:22:05.599 --> 00:22:24.480
I would never adapt it because I think you risk, you know, if you leave out certain questions because you just assume you already know the answer or that it doesn't apply to a certain patient, you're really setting yourself for, you know, well, first of all, you're opening yourself up to bias and uh setting yourself up to miss some things that could be really major in a patient's care.
00:22:24.559 --> 00:22:26.319
So I was going to ask a similar question.
00:22:26.480 --> 00:22:34.640
So I'm a child and adolescent psychiatrist, and the majority of my assessments take about two hours, and I also have a you know strong developmental focus and systemic focus.
00:22:34.960 --> 00:22:40.880
And I was wondering what what context, what clinical context was this program developed in or for?
00:22:41.119 --> 00:22:52.319
And so we've sort of touched on that maybe not so much for an emergency department, but you know, would you see this as applicable in an inpatient adult ward, for example, or an outpatient child and adolescent unit, for example?
00:22:52.400 --> 00:22:54.000
I'm keen to hear your thoughts on that.
00:22:54.400 --> 00:23:09.039
Yeah, it was, I mean, it was developed for both inpatient and outpatient evaluations for both general psychiatry as well as specialized psychiatry services, different age groups or different specialty conditions.
00:23:09.200 --> 00:23:17.920
So I, you know, I used it in uh when I trained the Kennedy Krieger Institute in child in, you know, in the autism clinic.
00:23:18.000 --> 00:23:19.680
We used a very similar format.
00:23:19.839 --> 00:23:22.559
Going back to this mentioning of the Maudsley, Dr.
00:23:22.640 --> 00:23:32.400
McHugh trained at the Maudsley and uh was very influenced by not only uh Jaspers but also uh you know the training he got there at the Maudsley.
00:23:32.640 --> 00:23:36.799
So it was a sort of a combination of the Meyer, Maierian history.
00:23:36.960 --> 00:23:51.759
Maudsley was influenced by Adolf Meyer was our first chair of uh psychiatry at Hopkins, so it has that Meyerian influence, the Maudsley influence, and a lot of the perspectives comes from you know Jasper's writings and thinking about psychiatry.
00:23:51.920 --> 00:23:55.839
So, but it was developed for inpatient, outpatient, child, and general.
00:23:56.240 --> 00:24:04.000
To help our listeners with a practical understanding of this model, I wonder if we could perhaps go through a case example of what this might look like with a with a theoretical patient.
00:24:04.400 --> 00:24:04.720
Sure.
00:24:04.880 --> 00:24:16.319
So uh one of the things that is you know very rewarding about working in the field of traumatic brain injury is that you first of all get to see patients, you know, chronologically uh throughout their course after their injury.
00:24:16.400 --> 00:24:22.240
And many of them come with this sort of expectation that I can be back to the person that I was before, you know.
00:24:22.400 --> 00:24:34.880
Um and so oftentimes when patients come through our clinic, they themselves have already identified that I have a disease with my brain because it was damaged, and that's basically who I am, and conflate so many elements of that.
00:24:35.119 --> 00:25:00.240
So, one of my very first and memorable patients that I can uh kind of recall being very influential in my training and in my sort of conceptualization of how you can actually use the perspectives of psychiatry really in any patient population and apply was um a 50, a mid middle-age uh woman who was a very, very successful business owner and sort of at the top of her game and you know, quite socially active, very financially successful.
00:25:00.400 --> 00:25:05.279
And one day, very on a lunch break, she was going to meet somebody.
00:25:05.359 --> 00:25:10.799
Um she was driving in a car and she was T-boned and she lost consciousness for a mere few seconds.
00:25:11.039 --> 00:25:18.720
She ended up going into the emergency department, getting evaluated, and they said, you know, you have a mild concussion, just walk it off, you'll be fine.
00:25:18.880 --> 00:25:20.799
And uh there's nothing much more that we can do.
00:25:21.039 --> 00:25:28.720
As the months ensued, you know, we started to hear a lot about, or she reported, lots of mood lability, irritability, starting to forget things.
00:25:28.880 --> 00:25:32.720
She was snapping at her family members, having what her family members called mood swings.
00:25:32.799 --> 00:25:40.319
They thought she was perimenopausal, um, you know, all sorts of different things that really weren't being connected to this accident, but sort of progressing over time.
00:25:40.480 --> 00:25:48.000
So when she came to our clinic, it was in her mind and in her family's mind that some brain injury issue made her the way she was now.
00:25:48.160 --> 00:26:08.079
But in fact, a lot of what was happening was that, you know, when you start to, and and this is why it's very important, regardless of what the chief complaint is or what patient population you're working with, to take the same systematic methodical approach to asking the same questions the same way with various patients, because that's when you start to extract a lot of these kinds of things.
00:26:08.319 --> 00:26:19.200
And what we had learned was that the first thing is that she, because of the issues that she had with this traumatic brain injury, she felt that she had lost function.
00:26:19.359 --> 00:26:31.359
So it wasn't just that there was something wrong with her brain, but her body was physically kind of in pain all the time, and she wasn't able to sort of exert all the tasks that she was able to do, which therefore resulted in her not being able to take care of her family.
00:26:31.519 --> 00:26:34.880
And so she had this sense of kind of demoralization that was occurring.
00:26:35.119 --> 00:26:42.880
Then there were these other things that sort of emerged that there were sort of sort of um interpersonal dynamics with some of her family members.
00:26:42.960 --> 00:26:49.440
And so she was somebody, and again, only learning this through taking the Phipps history that felt her emotions very strongly.
00:26:49.599 --> 00:26:58.720
She was extremely conscientious in everything that she did, and the fact that she wasn't able to complete these tasks now or the tasks that were advised of her and asked of her, was um very frustrating for her.
00:26:58.880 --> 00:27:05.039
She was someone who used to be extremely agreeable to treatment and sort of participating with doctors, and she became very resistant.
00:27:05.119 --> 00:27:12.319
And so that lended us to start discussing aspects of her personality and how that was going to play into the role of how she was going to interact with us.
00:27:12.480 --> 00:27:25.200
Um so, and I don't know if that kind of answers if you wanted to sort of get a full VIPS history on the patient of time, I wasn't sure, but this kind of highlighted the fact that this is somebody that came to us that clearly had some kind of physiologic thing happen to her brain.
00:27:25.359 --> 00:27:32.319
But really, the thing that was bringing her to us, and actually the treatment for her, was focused on how we could rescript her narrative.
00:27:32.400 --> 00:27:36.960
So it was not just we may not get you back to who you were before, but we can get you better than you are now.
00:27:37.039 --> 00:27:40.960
And how do we do that by rescripting your own narrative and focusing on your life story?
00:27:41.039 --> 00:27:46.720
And how can we sort of guide you to help with your interpersonal interactions with people?
00:27:47.440 --> 00:27:57.920
That's a wonderful case, and it it really sounds like, as well as being useful for formulation, there was a therapeutic element as well to going through the case with the patient like that and helping them to understand more about the problem.
00:27:58.240 --> 00:28:15.599
Yeah, I I that's a great observation because that's been my um impression that the lengthy history and kind of working together collaboratively to come up with the formulation that both parties agree upon really is a therapeutic exercise in itself.
00:28:15.759 --> 00:28:22.960
I mean, I think that's the only explanation I can give for somebody that says, I don't want no medication, and then two hours later is like, yeah, whatever you want to do.
00:28:23.200 --> 00:28:41.119
It's a therapeutic intervention and then this uh helping people gain insights into their own personalities and the stories that they're telling themselves and the they have problematic behaviors, how they are caught in a cycle of those behaviors can be really empowering for patients.
00:28:41.680 --> 00:28:48.640
In Australia and New Zealand, many will know about the biopsychosocial model as well as the five Ps model of formulation.
00:28:48.880 --> 00:28:53.359
Sounds like the perspective psychiatry is similar in that way, but also different.
00:28:53.599 --> 00:28:58.319
What makes the perspective psychiatry different from these models that I mentioned?
00:28:58.960 --> 00:29:01.200
Well, at this point, I usually quote Dr.
00:29:01.359 --> 00:29:05.359
McHugh on the biopsychosocial model because I think he says it so well.
00:29:05.519 --> 00:29:15.519
Because the biopsychosocial model came out in the mid-70s around the same time that McHugh and Slavny were just beginning to think about or composing the perspectives.
00:29:15.599 --> 00:29:17.039
And he said, this is a quote.
00:29:17.200 --> 00:29:25.039
We think the biopsychosocial model survives because it can act as a slogan justifying any practice.
00:29:25.279 --> 00:29:42.559
It falters because it is neither refutable nor heuristic, by solemnly noting the obvious underpinnings of human life, but providing no way to derive mental distresses and disorders from them, offering ingredients without recipes, it's sophistry.
00:29:42.799 --> 00:30:07.599
So the shorthand answer that I give is there are a list of ingredients in the biopsychosocial model from atoms to so on, but it really doesn't give you a recipe for how to take those elements and organize them in a way that is linked to explanatory methods and treatment aims.
00:30:07.759 --> 00:30:32.640
And that's the beauty of the perspectives, is you take that data that is represented by the biopsychosocial model, you take that data and you put it into kind of this framework that not only describes the conceptual underpinnings of these families or these various natures of psychiatric disorders, but also links those to treatment aims.
00:30:32.960 --> 00:30:42.079
And also, we we haven't gone into this, but each one of the those ways that mental life can go awry are based on aspects of mental life too.
00:30:42.240 --> 00:30:44.559
But I think that's beyond this uh discussion.
00:30:45.039 --> 00:30:58.160
And that's one of the things that we'd really try to enforce and reinforce in our trainees is this idea of these conceptual triads of each perspective, which is important because, for example, with the life story, the setting sequence outcome, it is linked to a treatment aim.
00:30:58.240 --> 00:31:11.039
And I think that is exactly what the biopsychosocial model does lack is this sort of the way that you scaffold it, but then you have this sort of triad that is then linked directly to a specific aim that would be addressed by that triad.
00:31:11.599 --> 00:31:20.400
Another example is the behavior perspective, where the conceptual triad is choice, conditioned learning, and drive.
00:31:20.559 --> 00:31:24.799
So somebody might make a choice to try alcohol.
00:31:25.039 --> 00:31:44.880
Yes, there may be some biological predisposition that makes them really respond to alcohol in a very positive way, so that they get conditioned more easily to the positive reinforcers of alcohol as well as negative reinforcers like withdrawal if they're not drinking, or rebound anxiety if they're not drinking.
00:31:45.200 --> 00:31:53.599
And then that conditioned learning increases their drive to drink and narrows their ability to choose not to drink.
00:31:53.680 --> 00:32:06.160
And that just keeps that cycle keeps happening, and the drive keeps increasing, the choice keeps narrowing to becoming, even in the face of all kinds of life problems.
00:32:06.319 --> 00:32:19.519
Like I saw a patient once who had killed his girlfriend accidentally by driving drunk, had been lost his job, had hepatitis, was kicked out of his apartment, had gone to jail for his manslaughter.
00:32:19.680 --> 00:32:25.359
And I said, Well, you know, how important do you think it is to like go to AA or Alcoholics Anonymous?
00:32:25.519 --> 00:32:27.039
And he was like, Oh, I'm not that bad.
00:32:27.200 --> 00:32:44.720
So I mean, his drive was so strong in the face of all the and it defies logic unless you look at that conceptual triad and you realize that actually some of the treatments for alcohol use disorder really are targeting various aspects of that cycle.
00:32:44.880 --> 00:32:48.079
You know, the Alcoholics Anonymous one day at a time.
00:32:48.319 --> 00:32:51.279
Every day you make a choice to drink or not drink.
00:32:51.519 --> 00:32:58.160
The ways of, you know, if you do drink and you take disulforam or antibuse, you get sick, right?
00:32:58.400 --> 00:33:01.599
It's targeting these various uh aspects of the cycle.
00:33:01.759 --> 00:33:19.279
So I think it not only informs our teaching and our clinical care, but it also informs sort of, you know, development of new treatments if you understand these conceptual triads, which again I don't see from the biopsychosocial model, but I really didn't train in a place where that reigned.
00:33:19.440 --> 00:33:25.119
I trained primarily at Hopkins and I went to medical school at a psychodynamically oriented medical school.
00:33:25.200 --> 00:33:30.079
So you had more experience, Turgo, with the biopsychosocial model at places you trained.
00:33:30.480 --> 00:33:40.079
Yeah, and that's exactly as I was describing what I felt was the gap was that sort of uh conceptualization of these three components that were directly linked to an aim.
00:33:40.480 --> 00:33:47.119
I mean, the biopsychosocial model we were asked to formulate in those three prongs, but then what did we do with those three prongs?
00:33:47.200 --> 00:33:53.440
You know, we just formulated the patient, and that's what's wrong with the patient, or not wrong with which, but what's we'd seen with the patient, but then what do we do?
00:33:53.519 --> 00:33:55.519
And that was the piece that I felt was the gap.
00:33:56.160 --> 00:34:03.680
So Doug, I understand that you have also founded a new program in 2024 for international learners, wanting to learn more about the perspectives.
00:34:04.160 --> 00:34:06.319
Can you share about what inspired you to start this?
00:34:07.039 --> 00:34:07.680
Absolutely.
00:34:07.920 --> 00:34:22.320
So, one of the best parts, and if not the best part, of my job at Hopkins is teaching and specifically teaching our first-year psychiatry interns who are coming in from various institutions all over the country to train with us.
00:34:22.639 --> 00:34:28.800
So many of them have not been exposed to the perspectives as our medical students at Hopkins have the opportunity to do.
00:34:29.119 --> 00:34:35.599
With this, I've kind of seen a lot of interest from people coming generally from the outside to come to Hopkins to learn about this.
00:34:35.920 --> 00:34:41.679
Within the nation, we have a visiting medical students program where people in other medical schools come and kind of rotate for a month.
00:34:42.000 --> 00:34:55.679
But what really sort of pushed the needle a little bit was when we started getting this interest from, you know, across the globe and overseas of learners who were hearing about this program, specifically about the perspectives and Dr.
00:34:55.840 --> 00:35:05.679
McHugh's work and trying to understand how something like this could be implemented in their own institutions, in their own countries and in the within their own system.
00:35:05.840 --> 00:35:13.039
And so our inaugural uh learner was Johannes Thorman, who reached out initially and asked about, you know, opportunities to rotate.
00:35:13.199 --> 00:35:25.199
And so that sort of sparked the question of oh, we're doing, you know, all these efforts at Hopkins within our own institution to treat our trainee, to teach our trainees and bring medical students from within the country to come learn about this.
00:35:25.360 --> 00:35:27.039
Why couldn't we expand beyond that?
00:35:27.199 --> 00:35:31.840
And it really was sort of an easy recipe because we already have the infrastructure in place.
00:35:32.079 --> 00:35:44.960
We already have a very structured curriculum and rotational sort of setup for our interns and our medical students, and it was just an easy plug-in for anyone that would come from the outside to do such a thing.
00:35:45.199 --> 00:35:57.119
So that's how the uh after Johannes came and rotated for a month, then we um had the opportunity to meet Alan and started realizing that this repeat rotational experience could be duplicated in multiple ways.
00:35:57.920 --> 00:36:02.800
How can the listeners of this podcast find out more about the perspectives and this program that you mentioned?
00:36:03.280 --> 00:36:03.840
Absolutely.
00:36:04.000 --> 00:36:07.440
So I'll just describe a little bit of the detail of what one would go through.
00:36:07.599 --> 00:36:15.599
So it's a one-month experience that would award our learner who is visiting the opportunity to have four specific rotational objectives.
00:36:15.679 --> 00:36:19.519
So the first is an inpatient rotation month on the inpatient psychiatric unit.
00:36:19.679 --> 00:36:22.960
The second would be a concomitant outpatient elective experience.
00:36:23.119 --> 00:36:28.320
The third would be meeting with all of the Hopkins faculty who are involved in educational leadership, including Dr.
00:36:28.400 --> 00:36:29.039
McHugh and Dr.
00:36:29.119 --> 00:36:31.760
Slavley, who are the founders of this framework.
00:36:31.920 --> 00:36:38.400
And then the fourth would be sort of longitudinally having scholarship and research opportunities with each of us.
00:36:38.960 --> 00:36:49.760
So with that said, it is a very competitive application process because we have very limited faculty that we could sort of who attend in certain months of the year that could work directly with our learners.
00:36:49.920 --> 00:36:53.760
But they would reach out to me, deroy4 at jhmi.edu.
00:36:54.079 --> 00:36:58.000
That's my uh email address, d-roy4 at jhmi.edu.
00:36:58.559 --> 00:37:03.519
And that would start with then um a formal application process of completing a form that Dr.
00:37:03.599 --> 00:37:15.679
Khalid El-Samzami has created, who by the way is also the co-director, um associate director of this program with me, completing the form, meeting with us virtually, and setting up a rotational plan and an educational plan with us.
00:37:16.079 --> 00:37:16.559
Thank you, Dr.
00:37:16.800 --> 00:37:17.119
Roy.
00:37:17.280 --> 00:37:21.199
So this is all the time we have for today, so I wanted to bring this discussion to a close.
00:37:21.679 --> 00:37:22.880
I'd like to thank both Dr.
00:37:22.960 --> 00:37:23.840
Chisholm and Dr.
00:37:23.920 --> 00:37:28.159
Roy for making a trek to the land down under and having this very interesting discussion.
00:37:28.559 --> 00:37:29.679
Thank you so much, Alan.
00:37:29.760 --> 00:37:30.880
It's been a great pleasure.
00:37:30.960 --> 00:37:31.280
Thank you.
00:37:31.519 --> 00:37:32.159
Thank you, Alan.
00:37:32.239 --> 00:37:35.760
You have really been very inspiring and we've been very honored to work with you.
00:37:36.000 --> 00:37:40.800
I would also like to thank Michael and Ed for joining us and asking the very interesting questions as well.
00:37:41.199 --> 00:37:41.840
Thanks, Alan.
00:37:42.000 --> 00:37:44.079
Thank you very much, Alan, and good to meet you both as well.
00:37:44.559 --> 00:37:50.800
Also like to acknowledge David Beale and Nishda Kuma from the college who give us so much support in producing and editing the show.
00:37:51.119 --> 00:38:00.079
We are also thankful to Osha Lazen Psychiatry for the opportunity to make these podcasts, as well as Sidoni Prentice for our artwork and Shetty Day for our music.
00:38:00.719 --> 00:38:08.400
We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrars or supervisors.
00:38:09.039 --> 00:38:14.800
We also love getting feedback or suggestions for further episodes, including volunteers interested in being a guest.
00:38:15.280 --> 00:38:21.920
Please get in touch by email at the thought podcast.org.
00:38:22.639 --> 00:38:23.360
That's all for now.
00:38:23.440 --> 00:38:25.119
My name is Alan, and thanks for listening.
00:38:25.440 --> 00:38:26.559
We'll catch you next time.
