Meet the Psychiatry Bootcamp Podcast brought to you by Dr. Mark Mullen

Dr. O'Leary is excited to introduce you to  Psychiatry Boot Camp (PBC), a podcast created by Dr. Mark Mullen during his psychiatry residency to help prepare medical students for psychiatry residency. It covers fundamental topics in psychiatry and inspires young psychiatrists to think critically about their approach to the field. The curriculum is based on published literature on psychiatry crash courses and boot camps, and features interviews with experts in the field.   Some specific PBC episodes that are discussed include those introducing students to psychiatry as a discipline with unique challenges, including interviews with Dr. Awais Aftab, Clinical Professor of Psychiatry at Case Western University,  and Dr. Allen Frances, Chair of the DSM-4 Task Force and Chair Emeritus at Duke.  We also discuss Dr. Mullen's eye-opening interview with Dr. Tyler Black, a suicidologist and child psychiatrist at British Columbia Children's Hospital who provides the best foundational discussion of the suicide assessment that Dr. O'Leary has ever encountered.

Enjoy this interview and afterward, please check out Psychiatry Boot Camp.

https://pubmed.ncbi.nlm.nih.gov/38724723/

https://podcasts.apple.com/us/podcast/psychiatry-boot-camp/id1671902940

https://open.spotify.com/show/4Vjlz4CO0G5D6nGo74O0jE

https://www.audible.com/podcast/Psychiatry-Boot-Camp/B0BVK4HYLW

https://x.com/markrmullen

Please leave feedback at https://www.psydactic.com or send any comments to feedback@psydactic.com.

References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com.  All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else.  We reserve the right to be wrong.  Nothing in this podcast should be treated as individual medical advice.

Transcript

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SPEAKER_00 0:06

Welcome to Psychactic. Today is Thursday, January 9th, 2025. And I'm your host, Dr. Brian O'Leary, a psychiatrist and a fellow in child and adolescent psychiatry from the U.S. National Capital Region. This is a podcast about psychiatry and neuroscience. And I created it as a way to help me learn more about the things that I love. One of the most recent things I've come to love is another podcast called Psychiatry Bootcamp. And it was created by Dr. Mark Mullen as a way to help prepare medical students and young residents for the rigors of a psychiatry residency. What he created is that and much more. Psychiatry Bootcamp, or PBC for short, does a fantastic job of covering fundamental topics in psychiatry and additionally inspires young psychiatrists to think about things like how they think. But before we get there, let me introduce you to Psychiatry Bootcamp and its creator, Dr. Mark Mullen. Mark, welcome to Psidactic. It is a pleasure to have you on. Thanks for having me. Yeah, really excited about this collaboration. I really got interested in uh your podcast when I discovered it because you have so many amazing guests on it. And it was called Psychiatry Bootcamp. And I remembered going in as an intern and thinking to myself, I wish psychiatrists had something like what internal medicine doctors have, or many of the resources internal medicine doctors have, which include like these somewhat intensive boot camps or these study sessions you can do online or these podcasts that kind of go over everything in a way that's like when you show up on day one, if you've if you've got this, you're gonna be more successful. Thank you for that.

SPEAKER_01 3:13

You're welcome. That's that was kind of the genesis of the podcast. Like anything else, the podcast was born out of my developmental level. And where I was at the time was a fourth-year medical student who was really frustrated with the match process. Like everything related to the match and how it works was just mind-bogglingly poorly done to me. And so I joined up with the folks in OBGYN who were really working on like reforming their match and doing some creative stuff. And I worked on a study with them. And my job was to analyze interviews of 27 surgical residents, mostly OB residents. And every single interview, all 27 people said the same thing, which was the most important thing for my transition to residency was having a boot camp. And I thought, you know, a lot of these surgical specialties, they're learning surgical skills, maybe they're learning how to use an EHR. But in psychiatry, a lot of what we do could probably be translated into podcast format. I mean, our physical exam is relatively minimal, like it seems to lend itself to the medium. And so that's just kind of what I set out to create is I thought if it was helpful for them, I hope it'll help a couple of learners in psychiatry. And so far, so good.

SPEAKER_00 4:21

Let's talk about your paper. You published a paper about your podcast and also asked a mixture of medical students and residents and some attendings to talk about the kinds of resources they felt were good. And so the highest ranked was formal didactic sessions, but podcasts were very close, like basically the same. Of course, journal articles were below that. Everybody hates journal club except for me. And then textbook chapters were at the lowest. The people who produced educational content would have, you know, taken textbook chapters and put them at the top. Like this is the primary source. But for people, they seem to be the least helpful. When you first started to do the podcast, what were some of the big obstacles you encountered that you didn't really expect? Like, oh, I'm going to do a podcast, but then like, oh, wait, I there's all this stuff.

SPEAKER_01 5:13

To be honest with you, it was less difficult than I thought. It was more time-intensive, but the people were more gracious. I was pretty deliberate about basing the curriculum and designing the season around the published literature on psychiatry crash courses, psychiatry boot camps. And then I went to recruit guests. And yes, a lot of emails went unanswered, but I figured shoot for the moon, right? And even if you miss, you'll get some good folks. And I was really actually pretty amazed by the people that did say yes. I was very pleasantly surprised how willing the psychiatry community was to work on a project like this. The hard part is the editing, scheduling, back-end stuff, designing the series, and doing all of it in your free time while you are trying to make it through residency. So I think from a time standpoint, it was difficult, but I had much more gratitude than I did consternation.

SPEAKER_00 6:07

It is a lot of time. It could also be pretty rewarding, I imagine, because you get to talk to a lot of super competent uh people who have been, some of them doing this their entire lives. How in particular did you find it sort of helping you as you went through your residency?

SPEAKER_01 6:25

I mean, it helped me in so many ways, right? The goal was find smart people, ask them stupid questions, right? How do you how do they understand the most basic fundamental aspects of our field? And can that inform the way that I understand it? I had only been a resident, I had completed two years of residency when I set out to create this. So I was very much in a seat where I didn't know what I didn't know. And I was kind of exploring it alongside the guests, and I think probably 90% of what I teach now to third-year medical students basically comes directly from the podcast because that's what I want third-year medical students to know. You know, I think sometimes when we're teaching at that level at the M4 level, it's easy to get involved in medical decision making that you might want your fourth-year resident to know, but we have to understand our audience. And my role now as an attending is teaching primarily third-year medical students. So I think it's helped me to understand things on that more foundational level and serve my students better.

SPEAKER_00 7:24

Can you think of any way that you heard someone on your podcast explain something and now you're like, oh, I'm gonna use that forever?

SPEAKER_01 7:30

Oh my gosh, there are so many examples. 75% of their responses were things that I had never really considered before. And a lot of them really blew my mind. I mean, one of them, I could I could go on about this for hours. I'll just give you a couple examples. One was in the first episode of the series when Awise Aftab talks about how we all have a sort of baseline level of mental health, it's a dimensional landscape. There's no clear demarcation between so-called disorder and so-called normal. And he says that's not really unique in medicine, right? It's it's a lot of the disease processes that we study, there is no clear demarcation. And he uses the example of a blood pressure. Everybody has a blood pressure, and at some point we need to draw a cutoff and begin treating it to have better outcomes for our patients. And I think describing mental health systems like blood pressure was one where my head just kind of exploded. And I thought, that's an amazing analogy, and I'm gonna spread that to the masses.

SPEAKER_00 8:29

Tyler Black, in I think it's episode 1.4, talks about the suicide risk assessment. And he talks about how you can view you know this as the same kind of risk that you would view someone in uh in any other field of medicine who has a disease. He talks about patients who are chronically suicidal. And the way that he conceptualized that to me was pretty profound and it it uh it left a huge impression. And it's something I'm gonna listen to again multiple times for sure, just because I I felt so edified by what he was saying. And it was different than what I had been taught before. I think a lot of times, especially for these suicide risk assessments, there's so much defensiveness, defensive medicine, you know, trying to protect yourself, trying to write the note just perfect so that you don't get sued kind of thing. But doing that, it's easy to forget the humanity in the process. And Dr. Black definitely brought out that pretty profoundly. Um, so thank you for bringing that to us.

SPEAKER_01 9:31

You know, I've been a full-time student essentially for 26 years, straight basically, until I just finished. And I learned more in the 90 minutes with Tyler Black than I have in any other 90-minute interval of my entire life. I mean, he is he is just dumping knowledge on us in that episode and doing it so humanistically. I mean, it was a real masterpiece, I think, from him. I'm very, very blessed that he agreed to come on.

SPEAKER_00 9:57

Your very first episode, I think, is actually pretty advanced stuff. You interviewed Dr. Alan Francis for part of that as well. He was uh the the chief of the task force for DSM 4. And he has his a very, very deep experience in watching how we diagnose patients change over time. Having been involved in that process, too, he got to see what he says. And I he said this on your podcast and in others that I've heard him on, where it's like everybody is advocating for their diagnosis, and everyone wants to expand our diagnoses, but nobody wants to uh make them smaller or fewer. Thinking about it like that from his perspective and seeing this historical push toward making more and more categories to fit things into helped me to see in a way why how psychiatry in some ways is different than other medicines, while being at the same time very similar, more similar than we imagine. But the diagnostic process and our diagnostic categories present it present difficulties for all of us.

SPEAKER_01 11:00

I think if you go into psychiatry and you think that you can operate the same way that a surgeon or an internal medicine doc would, that's a real disservice to your patient. Um, our diagnoses are different, our frameworks for understanding things are different, the way we understand our medications are different. And I think we need to respect that and appreciate it. I mean, when I made the podcast series, my biggest fear is that someone would listen to nine, eight, nine episodes and say, actually, I think I can do this job now. Pretty sure I can make these decisions. So I really wanted to start from a place of all I know is that I know nothing. And we're gonna give you some nuts and bolts here, but we are not even scratching the surface of what it means to really be a psychiatrist and make some of these decisions. Um I think he did a really good job of kind of pulling a lens back and saying, you know, what is our role here? Is there anything we're doing that could be dangerous? Are we making sure that we're protecting normal human functioning, not over-medicalizing normal human problems? Because I think that that's a real problem right now. And I think that if you don't have the appropriate training to understand what frameworks we're using, the tools we have, and the limitations of those tools, you wind up giving someone five labels that mean different things. And each label has an FDA-approved first-line treatment. And so now you have a person who is one person with a unique set of problems, but they have five diagnoses and therefore they're on five medications. And I think I just see it too often in clinical practice. So I wanted to make sure that no one listened to Psychiatry Bootcamp and then went out there and kind of practiced that check checkbox psychiatry. That was my worst fear.

SPEAKER_00 12:36

Yeah, I've I've noticed that too. Partly I think because a lot of systems are overwhelmed with psychiatric patients. Uh, and the way that insurance companies are structured and how we have to do billing creates a strong pressure to do things like that, to think like that, to use screening instruments as diagnostic tools because of the time limitations instead of um you know taking the time we need. And I think that drew me to psychiatry in the first place was how much time they let me spend with my patients and how I got to know them. But for models of care that we have, that's not feasible a lot of times. Um, so to do a good job, it's very difficult. There are a lot of studies out there that show the number one factor, no matter what kind of psychiatry you're doing, is the therapeutic alliance. Getting to that takes time, and it's it's really the art of psychiatry.

SPEAKER_01 13:32

Yeah, I think it takes brave leaders to defend kind of the spirit of psychiatry, the ethos of psychiatry, the fact that connections in and of themselves with other humans can be healing, the fact that many humans are resilient and over time they may get better on their own. But there's a lot of different entities at play in the world of healthcare that have interests that are different than simply providing the best care possible. There are large entities who have a vested interest in making sure appointment times are quick, making sure that we can solve a problem with a pill instead of having to invest hours of human resources into it. And so I think it's really incumbent upon us to defend that ethos of our field and say, it's really easy to practice bad psychiatry. I mean, it really is. We have very limited objective tests for how our medications are working, if people are getting better, right? It's really not hard to fill out some checklists and prescribe a pill that somebody takes. I think it's really hard to practice excellent psychiatry and to build connections with people who are not predisposed toward building strong connections and to have a strong enough connection that that person will trust you and trust your opinion and be honest with you so that you can get an accurate assessment and a treatment plan that has a chance of working. And I think it's infinitely difficult. So we need, you know, brave leaders like Alan Francis to push back against some of these entities and say, you know, wait a minute, we need to spend time with our patients. We need to understand them on a level that goes way beyond the PHQ 9. And so that's one of the things that I held tried to do was hold space for people who are delivering that message of nuance and that message that time and emotional connection with the patient really should be the first priority.

SPEAKER_00 15:13

The more connection we have, it seems like the less connected we are. And it's a it's a strange problem. You have all these perspectives to listen to. Do you have a preferred kind of perspective in psychiatry that that you like to incorporate into your practice as sort of like your this is my baseline way that I approach things?

SPEAKER_01 15:34

I think as a podcast host, my approach has been to try to keep my cards pretty close to my vest and try to stick to these are the guidelines, this is what the research says, you know, this is what you need to do to help your patient, and I can back it up with facts. As far as my particular lens, frankly, I'm an acolyte of Alan Francis. It's the first book I read in psychiatry. Everything I've ever written, everything I've ever read by him or listened to by him, I just find myself nodding along. Even though he was the chair of DSM4, his perspective is a bit different than I think many mainstream voices in psychiatry. So my lens would be very similar to his. I think that we are over-diagnosing, I think that we are over-prescribing. And I think that we are grossly under-diagnosing people that really need our help and grossly under-prescribing for people that we could drastically change their lives if we were able to build a therapeutic alliance and get them on a medication that they need. I think that it definitely cuts both ways, and that's what I try to keep in the forefront of my mind in my clinical practice. Is this someone who we are over-labeling, over-prescribing, and we need to normalize their human experience and provide some empathy? Or is this someone who we are shamefully neglecting as a society? And I need to do everything I possibly can to help them get better. I think that uh the population of patients that we see ranges extremely broadly from distress that should not even be diagnosed or even have a treatment plan. It should just be normalized and say, yeah, this is a really difficult thing, and it's really difficult to be a human being. And I'm happy to talk with you while you go through it or refer you to a therapist who can. Um, and then I think there are definitely people on the other side of the spectrum where they're going to be incarcerated or dead within a year if we do not really get on our horse and intervene in this person's life. So that's the lens that I try to take.

SPEAKER_00 17:29

Johns Hopkins especially talks about this thing called the perspectives in psychiatry. It tries to bring together all sorts of different dimensions that a patient might experience. You know, it talks about the more innate things like even someone's IQ and their ability to understand and interact, you know, with with their world and how effective they can be at that. And you know, what kinds of things might overwhelm a person like that versus a person who is extremely high functioning, dealing with a ton of anxiety, but you know, still able to go to work every day and do their job. And then think about a patient's life story. I think when most people go to a therapist or a psychiatrist, they kind of have this idea that they're going to tell them their life story, you know, that that they're gonna get to tell them the story of them. And I think very few times is there enough time for them to be satisfied in desire.

SPEAKER_01 18:20

I think to your point about people's expectations coming in to see a psychiatrist, we really need to honor that. You know, from a common factors approach, this is what we would call the therapeutic ritual, right? And rituals have been important throughout all of human history. Any society you look at has had really important, meaningful spiritual rituals. And in our society today, when you're not feeling well mentally, one of those rituals is coming to a person with expertise in the area, whether it's a therapist, a counselor at school, maybe it's a priest or clergy, maybe it's a psychiatrist, but you come and you sit in front of this person and you pour your heart out, this person gives you a response that helps you to feel understood and not alone and able to get better. And I think that ritual in and of itself is incredibly powerful. And we need to be respecting that and harnessing that as much as we possibly can.

SPEAKER_00 19:13

Part of me thinks that, like, if I were ever a program director, the very first set of didactics I would send someone through would be how to establish a therapeutic alliance. Like, not how to prescribe medicines, not how to um not what what to therapy would be best for this kind of patient, but how to get the patient to trust you, not in a manipulative way, but in a way that you can now really start to understand them. Because that is like the effect sizes are enormous compared to anything else that we do. And in fact, the effect sizes of the other things we do highly depend on that as well.

SPEAKER_01 19:45

Exactly. And that I couldn't agree more. And to be honest with you, that is the first change that I made as a clerkship director was I looked at the entire clerkship and I said, this whole thing should be about the therapeutic alliance. That is what I want all these featured doctors to know about psychiatry. I don't really care if they ask about caffeine use at every visit. I do care if the person that they are treating feels like this doctor cares about them, understands them, can listen to them, has expertise. And I could not agree more that that needs to be the foundation of all training in psychiatry.

SPEAKER_00 20:17

Because the story we tell is so huge and there's so many details we could ask about a patient's life, things like you mentioned caffeine, and there's all these things that if you work in an institution where a reviewer like the Joint Commission comes in, they're going to look at people's notes and they're gonna say, Well, you didn't ask about this, and you didn't ask about this, and you didn't ask about this, and then that becomes the priority. Instead of uh having a very comprehensive view of the patient, and like, well, you'd have to check all of these boxes. And those can be done, I guess. You know, we could give people a digital thing, they just click the right box. But in my practice, I have found that to be mostly noise and not much signal. Finding the signal, I think, has a lot to do with letting the patient tell you what that is. We talked about the first episode and how it sort of set the tone for everything. Do you have another favorite episode that you did?

SPEAKER_01 21:10

I'm glad I don't have children because you probably would ask me to pick my favorite. I'll say, yeah, I think one and four are really good. I think I think Dr. Francis apptop is good. I think Tyler Black is really good. I guess if I had to pick another one to say that I love it, it would be the management of acute agitation one. Um, I really come to life in that one because that is one of the topics that I truly love to teach, like in my own world. And it's really hard for me to just be this sort of interviewer that asks basic questions and I kind of can't help myself but like get on my little soapboxes that I'll do with my medical students and residents. Um and I think that management of acute amputation is something that any person who works in healthcare is using all the time, and we spend like a good set. 25% of that episode talking about verbal de-escalation strategies, body language, safety, things that anyone who's interfacing with irritable people will be able to benefit from hearing. And um, Dr. Thrasher also was just a wonderful guest. So I would say management of acute agitation, I believe that's 1.5 is another uh favorite for me.

SPEAKER_00 22:21

Yeah, Dr. Tony Thrasher, I remember really enjoying that too, especially it was affirming because um first I hated the word agitation when I was a resident. I still do. I still have this, like you talked about soapboxes. I'll get on a soapbox about the word agitation. I'm like, what does that mean? Tell me what that means, peace. And uh, and but it's used ubiquitously in the and it is used as a justification for some pretty heavy-duty medications. And so we really need to understand what we're talking about and and how to respond in a way that definitely does not make things worse and allows things to take their natural course toward like fizzling out.

SPEAKER_01 22:59

Yeah, I think giving people an unexpectedly compassionate response. A lot of people have seen that moment where all of a sudden the patient goes from, I have to be violent to get what I want, and I have to yell and threaten to get what I want, to, oh, you're going to treat me with compassion no matter what, and you're gonna be a you're gonna serve me, I think can be very de-escalating. On the other side of that coin, there are certainly times where verbal de-escalation by itself is not going to cut it and symptoms need to be managed. And I think Dr. Thrasher does a good job of talking about where those boundaries are and how we need to navigate them, and doing also all of that from a lens that says the patient is the first priority. I want to alleviate the patient's suffering. There is not even an aspect of punitive measures to this approach. It's all about maintaining safety for the patient, helping the patient to be comfortable, you know, humbling myself to be in service of the patient, to be in service of the other staff. I think was a really refreshing take on agitation. Wow. Do you have any questions for me, Mark? What do you think Psychiatry Bootcamp offers to the podcasting space?

SPEAKER_00 24:09

When I started listening to it, the first thing I saw was the boot camp word. And I was reminded uh that I wished I had one.

SPEAKER_01 24:19

Yeah.

SPEAKER_00 24:20

And I had uh, and then I listened to the first episode, and I had been listening to Dr. Alan Francis uh on a podcast called Talking Therapy, I think. He's he's on that with um Marvin Goldfrey. Yeah. That podcast is fascinating listening to the goes of those guys talk because they're both so such amazing people who know so much and they are they argue with each other on the podcast, which I think is the best. I love listening to that because it's there's such an honest discussion. They're not ashamed to disagree with the other person. Listening to him on there, I was like, wow. And then I listened to a couple more episodes and I thought, I wish I had had this. Um I wish I had had this, especially the suicide risk assessment. When I got to that, I was like, this is something I'm gonna recommend to everyone from here on out, even attendings, especially who've been doing outpatient or something, and they find themselves, okay, now I have to do uh an assessment in an emergency room. And I haven't done this in a long time. I've been able to, you know, tell people you need to go to the emergency room for a long time. But to be able to actually do it in that setting, uh, this would be good for anyone, anyone to do. Um, I loved your episodes on delirium as well. I find it even now as a board certified psychiatrist, to it reminds me of fundamentals that in as a child and adolescent fellow, I might be losing some of my skills a little bit. You don't use them, you lose them for sure. You know, and so I'm gonna be using psychiatry boot camp to go back to be like, okay, what are some of the real fundamental things that I can't forget?

SPEAKER_01 25:54

Good. I'm glad that is that was my dream when I made it was that someone would say, Gosh, I wish I had this when I was going into interneer. So I'm glad. Well, you have that now.

SPEAKER_00 26:07

Thank you for joining us today. Like I said in the beginning, the next few episodes are going to be from Psychiatry Bootcamp, some of my favorites and some of Mark's favorites. Very confident that you will love them. And if you do, please go to Psychiatry Bootcamp. Just type in Psychiatry Bootcamp into any browser. It will be the first thing that pops up, most likely. It's on all the podcast platforms. And if you enjoy it, let Mark know. And tell your friends. Until next time. This has been an episode of Psydactic.