EP165: Medicine's Lost Mind: Dr. Robert Smith's Guide to Transforming Patient Care

Reimagining Mental Health in Medicine with Dr. Robert C. Smith

In this episode of The Girl Doc Survival Guide, Christine hosts Dr. Robert C. Smith, a University Distinguished Professor of Medicine and Psychiatry Emeritus from Michigan State University. Dr. Smith discusses his journey from a traditionally trained internal medicine doctor to an advocate for integrating mental health care into primary care. He shares his experiences and the development of important works like Smith's Patient-Centered Interviewing and Has Medicine Lost Its Mind. Dr. Smith critiques the prevalent 'mind-body split' in modern medicine, arguing for a bio-psychosocial model that addresses both physical and mental health. He also emphasizes the importance of self-awareness for doctors and provides actionable steps for the public to advocate for better mental health care. The episode ends with Dr. Smith encouraging listeners to visit his website and engage with policymakers to drive change.

00:00 Introduction to Dr. Robert C. Smith

00:49 Dr. Smith's Journey in Medicine

03:34 The Mind-Body Split in Medicine

07:59 Bio-Psycho-Social Systems Approach

12:26 Challenges in Modern Medicine

17:41 Personal Reflections and Self-Awareness

23:38 Call to Action and Final Thoughts

Transcript

Christine Ko: [00:00:00] Welcome to the Girl Doc Survival Guide. I'm very happy to be here for the second time with Dr. Robert C. Smith. Dr. Smith is a University Distinguished Professor of Medicine and Psychiatry Emeritus from Michigan State University. He has been focused on patient-centered communication and primary care mental health since 1985. He is an internationally recognized author of the textbook, Smith's Patient-Centered Interviewing: An Evidence-Based Method. This textbook is widely used in medical and nursing schools across the US and internationally. More recently, he's written a book titled, Has Medicine Lost Its Mind: Why Our Mental Health System Is Failing, which explores the crisis in mental health care.

Welcome to Bob. 

Robert Smith: Thank you, Christine. Good to be here. 

Christine Ko: Could you first share a personal anecdote?   

Robert Smith: Sure. I trained in a traditional disease-oriented medical school and [00:01:00] residency. I got into practice, and all of a sudden I was seeing people I didn't know what to do with. They had mental disorders, they were emotionally upset, they were depressed, they were down, they were anxious, they had panic disorders, chronic pain. I didn't have a clue of what to do with them. I worked for a while trying to do better and did better. I listened better, and I talked and people seemed to like it and get better. But after six or seven years I realized I still didn't know how to diagnose mental disorders. I still didn't know how to treat 'em. At that point, I left practice and went back to the University of Rochester and took additional training. I'm a primary care internal medicine doc and took a two year fellowship in bio-psychosocial medicine.

And I then redirected my career to wanting to improve primary care mental health. My own experience was how [00:02:00] untrained I was. My focus became how do you train doctors in primary care mental health? That led to the development of the patient-centered Interviewing text, another textbook, which is Primary Care Psychiatry, and those describe how to do this. And I then wrote, Has Medicine Lost Its Mind, for the public. The other two were for professionals. And the reason for writing this book for the public is that medicine really isn't doing anything about all this work that I and literally thousands of others have been doing to convince medicine to address mental healthcare. 

I'm interested in angering the public 

about how poorly their mental health care is being given by a non-scientific medical profession. That [00:03:00] in brief is how I got here, Christine. 

Christine Ko: I love it. Thank you for sharing all that. I have had the great pleasure to read your most recent book. Has Medicine Lost Its Mind? I especially appreciate your honesty and vulnerability in the book. You write, during our medical training, we trained under kind decent physicians, but though they cared about their patients, they had little time for emotions or psychological issues. We didn't know what to say or do and generally did nothing at all. Could you talk about that? 

Robert Smith: It's the plight of modern medicine. We're taught just physical diseases. When the need for addressing people's emotions and their depression and so on come up, we're not trained for it. There is an ethos in medicine. Don't get involved with the patient. It'll ruin your objectivity. Another statement you might hear [00:04:00] from faculty is, don't talk about those touchy feely things. This gets into the culture of medicine. Not only do we not address psychosocial emotional, mental things, but they are negative things that only a psychiatrist would address. Another term for it is mind, body split: separation, Christine, of mental things from physical diseases. 

Christine Ko: Yes. Can you talk about this mind body split?   

Robert Smith: In the scientific revolution of the 16th and 17th centuries, philosophers like Descartes got involved. Prior to that time, from Hippocrates in the fifth century BC up until this time, the mind and body had always been linked. People, doctors saw no difference in them. Somebody might have bipolar and chest pain and so on, and they saw that just as one whole. But [00:05:00] come the 16th, 17th centuries. There was a bargain, as it were. The Catholic Church, which was all powerful and had ruled for over a millennium with an iron hand, compromised with a now burgeoning scientific field of medicine to say, okay, medicine. You can tell what to do with patients, but only in their physical body. The church keeps the head, that's the source of the mind, the soul, and the spirit. We keep the head and the mind, you get the physical body from the neck down. Long and short, that has translated up to this day. Mind body split. Medicine has never addressed mental healthcare. Medicine continues to focus just on the physical disease part and [00:06:00] ignores the very centerpiece of the subject of its science. Who is the patient? Or, their social environment? 

Christine Ko: Why do you think medicine is so resistant? 

Robert Smith: In one real sense, they're brainwashed. Students coming into medicine, receiving no more than 2% of training time in mental health, 98% in physical diseases, then go into residency for three to five years where there is no mental health training. By the time they finish training, they are completely brainwashed with this idea that medicine addresses only physical diseases. Piggybacking onto this, Christine, is the medical industrial complex: hospitals, insurance companies, drug houses, equipment manufacturers. These people all have [00:07:00] piggybacked on medicine's isolated physical disease approach to make billions and trillions of dollars every year on this isolated physical disease approach. And so you not only have a brainwashed medicine, but you have people running medicine with a vested interest in the status quo. Doctors no longer run medicine. Deans of medical school, the head of the AMA, head of the American College of Physicians, docs like you and I have no meaningful input anymore into how medicine is run. It is run by this medical industrial complex. Their powerful control of a medicine already imbued with the mind body split is the impediment to change today.

Christine Ko: You [00:08:00] mentioned this bio psychosocial systems approach. Can you talk about that and contrast that with this mind-body split? 

Robert Smith: Systems hierarchy starts with the simplest of all the sciences, which is physics, quarks, anti quarks. You combine those together, you get up to chemistry. You combine those together, you start getting up to biology: the body organs, body systems, and eventually get up to the whole person. Then keep going on up: two persons together starts to constitute relationships, families; on up, communities, societies, political systems. Now the cosmos, the Milky Way, and the Big Bang, that's the system's hierarchy.

Multiple aspects of each level combined to form the next level. That's the system's view of man. The medical part: medicine's focus is [00:09:00] the human being. The physical body, that's where physical diseases occur. And the next level above the human is their social, their environmental aspect. And what the systems hierarchy says is join the physical, the psychological, and the social or the bio-psychosocial model. That's the systems model applied to medicine. My work and that of many others has demonstrated that it is effective and more effective than current medical practices that focus just on physical disease. That's unequivocal. There is no question about what is superior. 

Christine Ko: You can correct me if I'm wrong, but an example, say a patient who has high blood pressure. So primary care medicine just focuses on the physical disease, that mind body split. It's just focused on the body and the fact, [00:10:00] the blood pressure's high. And then what do you do about that? Send to the ER if it's an emergency, or if it's just slightly high, give them a blood pressure medicine, and that's it. But in the bio-psychosocial model, you would evaluate the high blood pressure and decide is it an emergency or does it need a medication or something else. But then also think about the patient's family, their culture, their situation. Maybe they can't afford.... 

Robert Smith: Exactly right. 

Christine Ko: That's the bio psychosocial. So I guess the social is, can they afford it? And the psycho would be, maybe the patient is absolutely reluctant to take anything orally by mouth. And go home and not take it at all.

Robert Smith: Or they might be depressed. 

Christine Ko: Okay. Yeah. So would you say that's correct? 

Robert Smith: That's a very accurate rendition of it, Christine. It is all of those psychological and social factors, and cultural [00:11:00] things that weigh against maybe taking the medications.

Depression makes people so they can't concentrate and pay attention to it, and so they don't take it. All of those things, a trained bio-psycho-socially trained primary care doctor would know to address those things. And the isolated physical disease primary care doctor simply would give medications.

Christine Ko: I'm a dermatologist. And I think we're very subspecialty wise focused on the physical disease. What rash is it? What cancer of the skin is it? I did not get any bio psychosocial training that was of significance, I would say.

Robert Smith: With primary care going down in numbers, no more than a third of all doctors, dermatologists, orthopedists, [00:12:00] anesthesiologists, even, and cardiac surgeons and so on, need to know the psychosocial dimensions. Doctors must graduate as expert in psychological, social and mental health medicine as they are in physical disease, and that means a dramatic increase in training, not separate from physical disease training, but integrated with it.

Christine Ko: What would you say though, if I play devil's advocate right now and say... 

Robert Smith: Sure.

Christine Ko: Say how could there even be time to explain to them the social and the psychologic aspect when I haven't even done a good job of telling them how to follow up on the physical part?

Robert Smith: Yeah, that's a good question. You see what's happened with this mind body split is physical disease itself has split apart.

In dermatology, there's cancer and all of that stuff. Everything is getting split apart and doesn't get integrated. [00:13:00] The answer to your question, where does the time come from? We're already doing a terrible job, how you're gonna add more to it?

The answer is that if someone is aware that the psychological and social factors are just as important as the medical, it will take less time. 

Let me give you a couple examples. Chronic diabetes and heart failure and emphysema and so on. They are the major physical disease problem in the US. 17% of them have a co-occurring comorbid mental health disorder. If the mental health disorder itself is not recognized and effectively treated, the physical disease does not get better. That's why those people with heart failure keep coming back in. Medicine treats only 12% of those people, and then it's mostly by untrained primary care [00:14:00] docs. If a hundred percent of those people were treated and it's some 30 million people, 17% of all chronic disease, if these 30 million people were effectively treated for their psychological problem as well as their medical problem, it would save from 26 to $48 billion every year. That's more than the National Institutes of Health budget. These are astronomical savings.

Social parts: cigarette smoking, alcohol use, lack of exercise, overweight, stress, so on and so forth. These are all factors that medicine omits in its training. Now, of course, medicine and doctors know, quit smoking, or lose weight, or you need to get more exercise. That doesn't cut it. Telling people that doesn't work. There are intensive skills [00:15:00] required to do this that take a long time to teach and a long time to master called motivational interviewing. Medicine does not do that, okay? 

Okay, now let's take this diabetic, 30 years before. Why not address cigarette smoking, alcohol use, stress, overweight, lack of exercise in a preventive way so that the person never develops diabetes? 80% of all heart disease, strokes and diabetes, 40% of all cancer, could be prevented if we did that. We have a $5 trillion healthcare budget. If you prevented 80% of all of that, you would save two to $3 trillion a year. Now we're talking big money. That's enough to start working on the deficit or to give people a tax break. 

Christine Ko: Because of that medical, industrial, pharma, et cetera, that whole system, the [00:16:00] system doesn't actually want to save that money, right?

Robert Smith: They don't want to. No, they don't want to. What would happen to this new anti-obesity drug that costs $1,300 a month if there were no obese people? These people are vested in the system just like it is because they are making tons of money. 

Christine Ko: So we create a problem, this mind body split, not just doctors, but history. The way things have evolved, now there's this whole industrial complex that's not willing to let go of it because it makes money. Instead of learning how to be doctors who can do motivational interviewing and get people to lose weight in a way that is just hard work, right? Eat properly. [Yeah.]. Exercise. Now we have a new medicine that costs $1,300 and they can just take it. 

Robert Smith: This shows how poor medicine is at [00:17:00] prevention. Obesity was about 15% of the population in 1970. Today it's 50. What if medicine was serious about prevention? You wouldn't have all the problems that we have today. They wouldn't have heart attacks and strokes. People retire, they've already got heart attacks, stroke, cancer, diabetes affecting their eyes. That's not a happy retirement. If you prevented that, they're now 65 and healthy, and they have a happy, healthy retirement. Quite a different thing.

Christine Ko: In our training, we're generally told to split ourselves, not just a mind body split, but also split ourselves off from the patient and how they're really feeling so that we can be objective. In your book you wrote about treating a patient with terminal cancer and [00:18:00] I appreciate your honesty. You say that you didn't speak with her about her terminal prognosis because you were afraid to, and you felt like you didn't know what to say. You found out later through her husband bringing you her journal that she wrote, he just orders more tests. I don't think he cares. And you wrote that this is likely a product of our medical culture of, don't get too personal. Would you say more about how you deal with that now?   

Robert Smith: Now, I would establish a relationship using so-called patient-centered interviewing skill. But also Christine, there's another level to this. It's my own personal reactions. I was afraid with her, I didn't know what to do. She was dying right in front of my eyes, and I was scared and felt incompetent. Doctors always must process their own [00:19:00] stuff, where am I at with this? Because it will affect your behavior and you better know about it and how it's going to affect it. That in fact is what was going on with this patient. I hadn't ever pieced this together quite this way, but I was afraid. And so I did not address her psychological, social, emotional depression problems for that reason. And number two, I didn't know anything about them or what to do with them. My fear led me to totally keep her at arm's length. And that it guess that this whole idea that in my opinion, all doctors, at least doctors interacting with patients, should have some form of, whether you call it psychotherapy or self-awareness or some work devoted [00:20:00] to that. 

Today, seeing someone like that, I would say, oh, this is a difficult situation. I would be comfortable talking to her when she said, why do I cry all the time? Tell me more about that. She'd had all the chemotherapy, there was nothing to do. You see this all the time on hospital wards. I had a student once. I noticed on rounds and she just looked in, waved at this guy and walked on. I said, aren't you gonna talk? She said, no, he's got cancer. He's depressed. She said, I'd be depressed too. There's nothing I can do. This is the attitude. This was my attitude. You're helping me recreate some of what was going on with me. I was being physically disease oriented. There was nothing to do from that standpoint. 

Christine Ko: Yeah. 

Robert Smith: I didn't realize until I read her notebook.

Christine Ko: Yeah. Yeah. 

Robert Smith: I basically was relieved when she died. It was [00:21:00] only when I read what she said about me that that's what crystallized me changing. 

Christine Ko: Yeah. And you're absolutely right. As I've gotten older and I've understood myself more, it definitely helps when I'm talking to patients, but also anyone. It helps when I have more understanding of myself.

Robert Smith: That's a nice recognition, Christine. These things that happen in medicine also happen outside of medicine. When I was at Michigan State, I taught residents about this self-awareness and so on. I can't tell you how many times they came back and said, I tried that with my wife. Other ways to do this: meditation. Another thing that I think is very effective is free writing. Write your thoughts of the day, but focus on what you liked that happened to you, what you didn't like that happened to you, and what the emotions were in all [00:22:00] instances, and what behaviors followed the emotion. This is how you develop self-awareness with patients. You need to be aware of it with each patient, right there with them, and in tune with yourself.   

Christine Ko: Yeah.

Robert Smith: This is what in the psychiatry literature is called countertransference. It's the doctor's emotional reaction to the patient. It's powerful. I'm control oriented. I would get into battles with control oriented people. Two type A personalities, they're clashing. That's not a good doctor patient relationship. And so over time you learn to release control, let the patient have some control, and yet tactically yourself remaining in control of the overall interaction.

Christine Ko: Yeah. 

Robert Smith: These are incredibly complex skills. They're counterintuitive. 

Christine Ko: System change needs [00:23:00] to happen, and I appreciate that you did talk about what an individual can do. You said, barring psychotherapy, just meditate or journal or think about what happened that I liked, what I didn't like, and then what I did. I appreciate those. 

Robert Smith: Christine, as I recommend, it doesn't have to be one of these, it can be all of 'em. Work with emotional people. Most of us are taught to suppress emotions in the professions. Work with emotional people, read emotional, inspiring books and movies, waken your own emotional self. 

Christine Ko: Yeah. That's great. Do you have any final thoughts? 

Robert Smith: I'm interested in angering the public. I would like people to go to my website. It's robertcsmithmd.com. Don't forget the MD. Smith is too common a name. You won't find me without it. So it's robertcsmithmd.com. The [00:24:00] landing page there, you will immediately see a square that says, act now. This will lead you to a sample letter that you can send to the president, the National Academy of Medicine, the surgeon general, your senator, and your congressperson. All you do is hit the email and plug the letter into it. Ideally, given that so many people among us have had mental health problems themselves and probably trouble accessing good care, put a paragraph in also about your own problems and why it's specifically important to you, and then send it. This is the way we want to activate the politicians to do something about this.  

Christine Ko: Okay. I appreciate that. Thank you so much for your time.

Robert Smith: Oh, my pleasure, Christine. Good to talk with you again.