https://beexcited.libsyn.com/episode-009-clinical-medicine-psychiatry

Click above to listen to or download the episode!

Transcript:

Psychiatric Episode

Professor Hare: [00:00:00] Hey folks, Professor Hare here. Before we begin a brief warning about the content of this episode. Today we will be discussing suicide and a number of impactful psychiatric conditions, along with practical, trauma-informed approaches to psych patients. As always on Be Excited!, we will approach these topics with empathy and respect, and a focus on educating future PA’s. Now onto the episode.

Professor Hare: [00:00:00] Hello and welcome to the Be Excited Podcast. I’m assistant Professor Jason Hare, and today I’m joined by Ryan Davies an alumni of our program here at the mothership. currently a psychiatric pa. Welcome to the podcast, Ryan.

Ryan Davies: Hey, thank you so much for having me on. I’m really excited to talk to everyone today.

Professor Hare: Thank you very much for being here you have in your recent history graduated from the mothership here, the University of Pittsburgh and our PA program and have moved on to a residency,

Ryan Davies: yes, absolutely. So I, I will self-disclose right away that I kind of went to PA school to go into psychiatry.

 I am definitely a fresh new grad trying to get his feet wet. But, you know, I, I worked in mental health for a very long time prior to PA school. Going to Pitt was to actually become a psychiatric pa. So this was kind of the end goal the entire time.

Professor Hare: I think our students and I think all PA students need to understand that there’s a lot of benefit to looking at the future and saying, I may have other things that I wanna do, but.

Ryan Davies: well, and I think that’s one of the best parts about being a pa, you know, prior to PA school I knew I wanted to be a prescriber, but I didn’t know what, you know, I entered PA school at 28 and honestly, I, I didn’t really want to wait eight or nine years to start my career. I really wanted to dive in right away. There’s a big need in all of our communities for psychiatry. So I decided that either PA school or NP school was great for me. And you know, I have wonderful NP colleagues who I really enjoy working with.

But I love the PA model, especially in psychiatry, because oftentimes in psychiatry we overlook a lot of the medical concerns that patients have. It’s very easy to have that anxious patient in the ER and overlook the fact that this 30 year old female on birth control could be having a PE and just diagnosed things as a panic attack and move on.

 And the great part about being a PA is you get this wonderful generalist education, you get to experience all of the [00:02:00] aspects of medicine and you know, any specialty that you go into, including ortho, I would, I would venture a guess. I think it’s very easy to become narrow focused and think, you know, the classic ortho joke is, you know, bone break me fix.

But at the end of the day, you know, you have a human in front of you and there are lots of things that can cause bones to break. There’s lots of things that can cause people to feel anxious. that’s the wonder of the PA model is you, you get exposed and experienced to all that. And I think that’s really the big benefit that PAs bring to all of the places they go.

And also, you know, I will admit that, While I was in PA school that I may have dabbled with the idea of doing something else, but ultimately psychiatry has been my home and it will be my home. So I’m, I’m glad to have been able to find work in it as a resident.

Professor Hare: Aha. So you did have some, some moments of of being drawn in by the medicine.

I totally got understand that. Yep. And you know, I think your background, what you’ve done while you’re in your residency, I think that would be of some interest to students as well. Your time in that residency you did inpatient and [00:03:00] outpatient emergency presumably. What else, what else would you add to that list?

Ryan Davies: Yeah. So as a psychiatric resident, I work with Veterans Affairs. I moved down to Houston, Texas to pursue this. So the VA actually has four psychiatric residencies in place today. There’s one in Chillicothe, Ohio, one in Clarksburg, West Virginia, one in Houston, Texas, and one in Albuquerque, New Mexico.

 And as a shameless plug, I just want to give all of that information cuz I think the VA’s residencies are just so wonderful. So you know, as a resident here in Houston, Texas, at the va, we’re affiliated with Baylor College of Medicine. I attend the PGY one, two and three lectures three days a week with them.

So I, I learn alongside my physician colleagues. And then we rotate. We have four week rotations where we rotate for different specialties. So ones that I’ve done so far is three blocks of inpatient psychiatry, three blocks of outpatient psychiatry, emergency psychiatry, consult liaison psychiatry, geriatric psychiatry, addiction psychiatry.

I’ve spent time in our Suboxone clinic. I’ve spent time in our psychosis clinic. Which was my most recent, [00:04:00] where I got to actually treat treatment resistant depression, doing tms. And then now I’m actually in our primary care mental health clinic, which is a clinic that integrates the primary care model, but also having mental health staff to assist the primary care physicians and prescribers in their work.

I, I think of it as sort of a consult liaison, psychiatry in an outpatient environment, which is a pretty fun thing.

Professor Hare: So consultant liaison, I think is a term, To back up just a second that some folks are not familiar with. The consult liaison to my knowledge, it only really exists that particular C and L terminology.

It only exists in psychiatry. Can you tell us what that looks like?

Ryan Davies: Yeah, I sure can. some people love it. Some people myself, I do not like it, but, the nice thing about consult liaison is you end up being the subject matter expert for inpatient providers, a lot of physical medicine folks, and you know, there’s this.

I hate to differentiate physical medicine and psychiatric medicine because at the end of the day, it’s all medicine. But to do that, my physical medicine colleagues [00:05:00] often will have a psychiatric issue with a patient and sort of put their hands up and be like, ah, I don’t really know what’s going on here.

I need to find someone who does. Maybe a patient expressed strong feelings. Maybe they made a statement towards staff, like a homicidal or suicidal statement, and they’re looking for someone to sort of come in and assist with. So consult liaison specifically, we receive consults from other providers.

 We’ll go and assess patients and then we’ll provide our recommendations. Each hospital does this differently. There are some hospitals where the consult liaison provider will actually put in orders and write scripts for patients. Whereas in my setting at the va, we are strictly the experts. We provide the guidance and allow the primary team to take it from there.

 a typical case would be, let’s say you have a patient who presents with amphetamine induced psychosis. That patient would go to inpatient medicine to treat any sort of physical medicine abnormalities they may have. And while they’re there, the inpatient medicine provider would consult us. We would go assess the patient and provide recommendations [00:06:00] for agitation, PRNs, antipsychotics.

And I would put those in a note, talk to the provider, and then they would decide whether or not they wanted to actually listen to me.

Professor Hare: it sounds a little bit like the exact opposite of what I do. Nearly the exact opposite in the psych hospital. So I’m in the psych hospital, I see the medicine side in support of the primary diagnosis, which is always psychiatric obviously.

 And so we step in and help out with those medical things so yeah, I think there’s a, there’s a little bit of an analogy between the two in opposing directions.

Ryan Davies: I’d like to say, I, I just wanna thank you so much for your work because there’s nothing that a psychiatric provider wants to do less than manage an INR, and I’m just so happy that I can hit my consult medical PA button anytime one of the patients needs.

Something medical, that to me is just, it, it murders my soul in every possible way and I just wanna focus on the psychiatric problems.

Professor Hare: I can definitely understand that. although I will say it is nice from my perspective to be a fly on the wall to see the psychiatric side of things, you get a lot of insight and [00:07:00] interesting.

Interactions, certainly I say interesting, you know, sometimes they’re traumatic and and difficult, but there are some really interesting interactions to be had when you can cross lines like that, or at least be a fly on the wall when those interactions are occurring. It’s almost like being in PA school and clinical rotations for years at times

Ryan Davies: absolutely.

Professor Hare: I did want you to talk about your your history outside of the residency. Then prior to that crisis interventionist, which is a term that I’m not all that familiar with, honestly.

Ryan Davies: Yeah.

So I think it’s mostly a made up term to make myself sound more professional.

So, prior to PA school, I worked as a crisis interventionist. And what that means is I think everyone probably listening is familiar with the suicide prevention hotline. And if not, please familiarize yourself with it so you can give it to the patients.

So I started my career in 2012 doing intakes for a county mental health agency. And what that meant was is patients who had limited insurance or no insurance, would come to the, the county government and say, Hey, I have these mental health diagnoses. I’d like to seek services paid for by the county.

 And I would do an evaluation to determine both if that [00:08:00] patient met criteria for the diagnoses that we served, and then also to determine if they qualified. for our services. So after that I transitioned to working for our suicide prevention hotline talking to patients strictly on the phone, and then also driving out to the community to meet with patients in person.

 And that was honestly a wonderful way to cut my teeth in mental health because it gave me the opportunity to talk to all sorts of people. You would think that the majority of those phone calls were very, very high stress, that they were, you know, people who were acutely ill. And in fact it’s not the case.

Those were rarer phone calls when most of my time was just spent talking to people who were lonely and needed someone to kind of bounce things off of. And so that was the function that I served there. That very quickly transitioned to me working with the Lancaster City Police Department, where I developed a program called co response.

 And co response at the time was quite new but now has really taken off across the country. And what this does is it takes a trained mental health police officer and then a mental health professional who actually sit in a police car side by side. And then when someone calls 9 1 1 who’s suicidal, [00:09:00] homicidal, or acutely psychiatrically Ill, we would go out and be the first responders and talk to that patient.

So my partner, my police officer partner, would keep me and everyone else safe. And then I would do the talking. I would work with the patient to determine what needed to happen next. So most of my time then was spent talking to people who were acutely ill, you know, talking to people on parking garages, talking to people who had weapons and were unsafe.

 that’s really where I fell in love with psychiatry because it was a wonderful, wonderful privilege to be able to meet with so many interesting people. And that’s actually what really spawned the idea to become a PA was if we look into our communities right now, we have a really big crisis. There’s this common myth in psychiatry that if people want help, that they just need to reach out and get it right.

 Everyone, everyone has in all of their offices a list of phone numbers that if a patient mentions that they wanna see a therapist or a psychiatrist, you just call this list, this magical list, and one of those people will help you. I promise you, as a thought experiment. Anyone listening to this, [00:10:00] take that, find your list and call the top three people.

 I promise you their responses will either be we have a wait list that’s at least a year long, or we’re not taking new patients and we don’t have a wait list anymore. Specifically for therapists, it. Impossible to try and find one. For most psychiatric clinics, especially in Pennsylvania, it’s about a year long wait.

 And if you have Medicaid or Medicare, it’s even worse. If you have no insurance, you’re not gonna see anyone. I guarantee it. So all the patients that I would speak to, you know, on these parking garages in these acutely ill situations, they said the same thing. I want help. I went and they, they don’t have a wait list or they won’t get me in, or I went to the emergency department and they were just so busy that they, they pushed me out.

And then where do we find them? We find them on the edge of death. And it’s just an unacceptable situation that I think PAs specifically are so poised to fix. We have less than 2000 PAs practicing in psychiatry right now. And you know, the need is there and I think we need to do a better job of meeting that [00:11:00] need.

 I will say that the patient that I spoke with, the day that I got my acceptance into Pitts PA program was on the top of a parking garage. And I remember, this is what he said. He said, I went to the emergency department and they didn’t listen to me. They said, well, if you’re not actually gonna hurt yourself today, then we’re not admitting you.

And then where did he go? Yeah, he went straight to the garage. And that’s no indictment on our providers in the er. Right? My people in the ER they are overworked, they’re overburdened, they’re dealing with all these sorts of issues in a very, very brief amount of time. And COVID has not made that easier. But what we need is we need more specialty providers and we need more education about suicide prevention.

 We need more beds too. If I may, right now, we have this crisis where patients are waiting in our emergency departments for days and weeks at a time trying to find a place to go to get treatment, and we just have to do a better job. all that to say, so yes, my background is in crisis intervention, which if anyone’s ever looking to spend some time as a volunteer or even as a side hustle, please hit up your local crisis centers.

They [00:12:00] need people, they need compassionate people who are patient and kind. And for those pre PAs out there who may be listening to this, it is a great way to get your patient care experience, which is so vital to the PA profession. It, it’s a great way to build those skills in developing rapport with patients and to learn about patients

Professor Hare: One of the things that really, truly benefits. Students coming into PA programs that is probably underappreciated, is that patient care, that direct care aspect, that having that in your back pocket, having some knowledge of how to sit down cold with a patient and talk to them they’ve never met the person and pull details out of that individual that are helpful to their care and they’re therapeutic. I like that as an idea for patient care hours.

Ryan Davies: Are, are they serious about this?

Yeah. Call them because this is unacceptable all fucking day.

Yeah. I’m sorry, Jason. No. Now we gotta, I feel like I interrupted a wonderful statement [00:13:00] you were making. Oh, no, no, no, not at all. You sent us an email at eight saying that they were only gonna go off very briefly around nine, and then they’ve been going on and off all day now.

All day.

Professor Hare: I did want to this has been created since you graduated the University of Pittsburgh is the heart program, the Pittsburgh Higher Education Assessment and Response Team. this is one of those things, you know, when you talk about as faculty if we have a student in crisis, we are going to, call the police and ask them to do a well check.

And it was brought to my attention, that was one of those algorithmic kind of discussions, you know. Oh, of course. We’ll do that. You know, as you, as you mentioned it’s one of the things on the list of, folks that we’re gonna ask to, to come in on this But realizing of course, that having a, police person show up to somebody’s door, certainly by themselves or in a maybe even worse in a group, is not going to be a welcome thing for all of our students, and certainly not for minority students, HEART at the University of Pittsburgh, in collaboration with other universities in the Pittsburgh area. Have created this [00:14:00] crisis intervention team. I saw the van the other day actually. And they go out with police for well checks and those kind of interventional visits to students, apartments, housing, dorms, whatever.

They’re bringing counselors in to make those first interactions with the student. A lot more smooth, a lot more, let’s say, therapeutic. Small steps certainly, but certainly steps in the right direction providing counseling and expanding those counseling services in that way.

Ryan Davies: Absolutely. And I, I would agree completely with you. I would say that, my police partners were always so pivotal to me because my work was not able to be done unless I, I felt safe. Right? Right. And they provided that safety to me. And I think there’s this problem now, and we see it even in emergency medicine where because there’s such a lack of access to care and psychiatry that, that these psychiatric issues are spilling over to all of the other professions.

Right. Ems, police, all these teachers, professors are all being asked to, to care for patients with psychiatric needs [00:15:00] without any training. And I think that that’s, again, where I think PAs can really make a big difference is we can solve this problem. We can, we can provide that care very quickly.

Professor Hare: I’m getting a, a pretty good sense of your passion for psychiatry and and being a psychiatry pa and, I love that.

So I gather that you see psych PA as being a, a significant expansion of the physician assistant role in medicine.

Ryan Davies: Oh, absolutely. . I think that the opportunity is 100% available for PAs to dive into psychiatry. One of the big things I hear from other providers, the reasons they don’t do it is because they feel that because nurse practitioners have a psychiatric specialty, that they have a lot more training in psychiatry and are better suited to, to provide that care.

 While I would agree initially that I think that my nurse practitioner colleagues get very specialized training in psychiatry, I still really do think that PAs with their broad generalist education can catch up to that fairly quickly with on the job training. Or they can do something like what I do, which [00:16:00] is a residency, which gives me essentially that that one year of very focused psych training, right.

 PAs are perfectly positioned to jump into psychiatry. There’s tons of positions open available, and right now, like I said, with less than 2000 PAs practicing in psychiatry the jobs are there. We just need people who are, educated and willing to do them.

Professor Hare: most of the jobs, do you think inpatient, outpatient, emergency, how do you see those jobs skewing?

Ryan Davies: I would say probably 80% outpatient, 20% inpatient. There are definitely positions available for those who, like emergency medicine, wanna do emergency psychiatry. I get hit up by recruiters all the time asking for emergency positions. Most of the need right now as an outpatient, I would say that inpatient tends to be very, very difficult cases.

You tend to have your, the sickest patients there, and I think that you need to have a a psychiatrist who’s leading that team. We have plenty of PAs here at the Houston VA that work in inpatient psychiatry. But I really do think that those patients should be managed primarily [00:17:00] by a psychiatrist who has that extra training to provide for those very seriously ill patients.

Professor Hare: And so, on a day to day basis, in an outpatient setting, you would be seeing a roster of clinic patients and sitting down with those patients sitting across from them and talking.

Ryan Davies: Absolutely. So PAs who work in outpatient psychiatry work pretty much autonomously every setting that I’ve been in.

You may have a supervising physician, but they’re usually only there if you have questions, cuz they have their own panel. You’re managing your own patients, you’re managing your own follow-ups. Right now , in the VA world, we tend to see around 10 to 12 patients a day. We have 30 minute follow ups and one hour new patient appointments.

 Whereas in the private world, you can expect to go a little quicker than that. Mm-hmm. , it’s 15 minute follow ups and one hour new patient appointments. You tend to see 20 or so patients a day. There are some clinics that will see a lot more than that and I would steer everyone here away from working in that sort of environment.

I think that, especially in psychiatry, we need to be able to dedicate time to working with our patients, listening to them and hearing from them. And that just takes time to accomplish.

 [00:18:00]

Professor Hare: That’s one of those things that a lot of folks have to watch out for, especially new grads.

You know, those kind of things are in modern medicine, unfortunately fairly consistent in, in clinics that really turn patients over quickly. That’s a good point that you make

Ryan Davies: Because I’ve recently been doing interviews because I’m transitioning away from residency now, the number one question that I have for new employers is what, what percentage of the time do your providers get out on time?

 And that’s not because I wanna work less, that it has nothing to do with it. It’s if your providers aren’t getting out on time, and that means that they are hustling throughout the day to get through their patients, that’s very easy position to be in, to miss things. And in psychiatry, the things that we miss tend to kill people.

 If I can give the advice to your listeners that if they were interviewing for psychiatry positions, the number one question to ask is, what percentage of the time do your providers get out on time?

Professor Hare: Yeah. And it tells you what your workload will be like, right? Absolutely. Sure. Maybe you can work faster as you get more experience.

But certainly, especially as a new practitioner, a newer practitioner to that field you would want. A little bit more time, a little bit better ability to to [00:19:00] kind of sink into it just a little bit and, make those decisions more deliberately, I guess is the word I would use.

Ryan Davies: Absolutely. And, you know, this is one of my favorite parts of psychiatry. This is one of the things that makes me love it just so absolutely much is that, I mean, I’m very biased, obviously, as you can tell, but I, I can’t think of anywhere else in the world where I can walk into a room with a random stranger and they get to tell me things that they wouldn’t share with their wife, their husband, their, their closest friends.

 That is a wonderful and amazing privilege, but it’s also a very serious responsibility. These patients are coming to us and they’re sharing with us their deepest secrets, their trials, their troubles, their suffering, right? And we have to honor that, and we cannot do that by rushing through things, by going through checklists.

 You know, psychiatry is such a wonderful field of medicine because it’s so new, if you think about it, right? In the past 100 years in psychiatry, we have come such a [00:20:00] monumentally far way. Think about it. So everyone hopefully is familiar with the lobotomy, right? Where, where we would take a giant spike, go through the orbit, and scramble around the prefrontal cortex.

Now, if you read books on this, I’m sure the person who described the lobotomy said it in a much more eloquent way, but that’s what we were doing, last lobotomy was performed in 1967. I like to consider myself young, but I’m in my thirties, right? So, but even then, I’m one generation away from a lobotomy. And to think that absolutely 50 years ago, this is what we were doing to treat people. And now we’ve come so far, we have such wonderful things like s ketamine, r tms, psilocybin is on the, the, the forefront. We’re still learning about how a lot of our medications work.

Professor Hare: Rtms. So tell me about that. you’ve mentioned that twice already. Tell me about rtms if you would.

Ryan Davies: rTMS stands for repetitive transcranial magnetic stimulation and it’s an alternative to treating treatment resistant depression. Right now, the gold standards for treatment resistant depression would be electroconvulsive therapy.

Mm-hmm. Which I, you know, I think gets a really [00:21:00] bad rap in the media. You have this kind of image of the, the provider in a white coat who’s an evil scientist giving people seizures with a shock when in fact it’s not that I’ve been able to participate in some ECT sessions with patients and it can be a very life saving treatment.

 However, it does come with a very significant set of sequelae, right? It can cause by definition we’re causing a seizure, but it can cause memory loss all sorts of things that can be uncomfortable for patients. Also, it requires sedation which brings its own host of potential risks. RTMS is an alternative.

What we’re doing is we’re using essentially an MRI magnet now, not as big, not as strong, but a magnet. And we’re focusing on the dorso lateral prefrontal cortex, which is the area of the brain that we believe to be responsible for regulating our mood. And what we do is we give very quick pulses of magnetic stimulation with the hope of stimulating that area of the brain to make new connections and to start firing again.

And this theoretically helps us treat treatment resistant depression. Now, of course, this comes with its own side effects. Some [00:22:00] people report headaches. The machine is quite loud, so it can cause tinnitus for some people. And incredibly rare cases, I’m talking handful of cases over the course of all of RTMS that can cause seizures.

Mm-hmm. . So we do have to screen patients very carefully, but I have done this treatment for patients. I’ve spent time with patients receiving this treatment, and there’s a lot of folks out there with treatment resistant depression who meds were not effective, but R TMS has been, and it can be quite life

saving.

Professor Hare: is that done bilaterally then?

Ryan Davies: Different parts of the brain, even though the brain is obviously mostly symmetrical only the do, so lateral prefrontal cortex is stimulated.

 To the, the point about our medial portrayal here, like there’s such an immense amount of stigma with mental health. Think about it. Everyone listening, I want you to think about this.

So Halloween, we just had it, we just had it in October. Think about your local horror attraction. What’s one of the haunted houses they had? Oh, the insane asylum, right? And it’s meant, so what does that tell us? It says, oh, people [00:23:00] with mental illness are scary when in fact one in five people in this country is diagnosed with the mental illness.

One in 25 people is diagnosed with a serious mental illness. If it’s not us, it’s someone else near to us who has mental illness and we have no idea. Right. It’s not that these people are wandering our streets trying to hurt us. It’s not true. The incidence of violence with mental illness is no greater than with any other person.

 So I think that’s one thing we really need to drive home for all of our patients. Absolutely. This is a completely normal thing. It’s fair. And even when we’re talking about suicide, my first statement to patients is, Hey man, this is a normal thing to think of. People, all people have thought about this for centuries.

This is nothing new. I don’t want you to feel out of place. This is a normal thought for you to have and I’m really glad you shared it with me.

Professor Hare: Thinking of this as illness, in other words, and not a failure of some sort. not of a moral failure or, a legal failure of some sort on the part of the patient, but rather true illness that we.

Diagnose and treat in the same way that we diagnose and [00:24:00] treat anything like hypertension. I, you know, granted there are other aspects of it, the behavioral aspects that can cause difficulty one of my favorite colleagues in my work in the psych hospital said once that people expect psych patients to be violent.

They expect them to be dangerous somehow, or that they need to, to pay attention to themselves when they’re in the presence of those, patients. And in reality, most of our patients are simply, especially in a psych hospital setting, an inpatient setting, are too disorganized and too focused on their own illness in those moments to really be violent outwardly to other people or to really cause anybody else around them difficulty.

 It’s still illness. It is still, these are still people. These are still people that we can approach and address and work with. And ally with them, I think would be the term that you would use in your training that you provided for our students you know, ally with them to really work together , to help them through these situations. I think it’s, it’s an important point.

Ryan Davies: Absolutely. And I’ll tell you, so I just gave a lecture yesterday at the [00:25:00] mothership.

I love that name by the way, . So I just, I just gave this lecture yesterday and one of the students very bravely, I thought there was such a wonderful thing that , this student was able to ask me this question. They said, I really want to go into, to working in psychiatry, but I’m worried because what if I have my own mental health needs, you know what, if I’ve been diagnosed with a mental illness, can I still practice psychiatry?

 And of course I said to that person, you know, that’s a very brave thing to say. I, I think it’s wonderful that you’re able to ask that Stigma is pervasive in all of us. And I just wonder, I wonder, does someone with type one diabetes have to think, well, I would love to go into endocrinology, but I just, I just wonder if I can, because of my type one diabetes,

it’s truly no different. You know, mental illness is illness. And I say the same thing to my patients. And I would ask that your listeners take this away when they’re trying to explain medications to patients with psychiatric illness, which is, if I told you that your pancreas did not make the insulin that you needed to put sugar inside of your cells, right?

 Would you come [00:26:00] to me and say, wow, this is a failing on my part. I shouldn’t have to take medicine? No. You’re gonna say, thanks, Ryan. I’m gonna go ahead and take that insulin. Now taking a, a medication for depression, anxiety, psychosis mania is absolutely no different. I’m saying, Hey, there is a malfunction somewhere in your brain.

Could be your prefrontal cortex, dorso, lateral prefrontal cortex. Your amygdala somewhere in your brain, and this medication is going to help fix that. There’s no difference for me prescribing you insulin versus me prescribing you Prozac. It’s medicine. And sometimes we need medicine.

Professor Hare: I think you would appreciate hearing yesterday, so I was unable to attend your lecture that you were doing with my students.

 But I, was walking the halls as they were taking a break in, in the middle of the training and, just approached a couple of folks and said, Hey, you know, what do you think? How’s it going in there? And the enthusiasm was palpable. They, they said to me, I wish I had had this training in my former job as an [00:27:00] emt.

And one person said, yeah, just in life. Right there, there are moments in life in which knowing how to help somebody who is having difficulty, even if it’s not durable mental illness. Maybe a transitional moment for, someone that you can help that person. They were very excited and appreciative of your expertise during that training.

Ryan Davies: That makes me so happy. I do love to teach and I think it’s such a, a wonderful part of our profession, and obviously I’ve made it my life’s work to prevent suicide. That’s what drives me. And any chance that I get to share that with others is important.

Professor Hare: That’s a great transition, a great segue into the must not misdiagnoses in this field.

So let’s talk about I certainly have a good sense of what your first one on that list and a must not misdiagnose. The, the things that caused disability dysfunction and potentially death in our patients that we have to pay close attention to as a must not misdiagnoses in every field. So what’s number one on your list?

Ryan Davies: Absolutely. So as everyone hopefully listening can guess number one must not miss in psychiatry is suicidal ideation. I would also lump [00:28:00] in homicidal ideation. Well, but it’s just not as common. So I’ll talk primarily about suicidal thoughts. Let’s talk about the numbers, right. So I said one in five adults in this country are diagnosed with some form of mental illness.

One in 25 is a serious mental illness, and that’s a state dependent term, serious mental illness. But we tend to say it’s any of the psychotic disorders. So schizophrenia, schizoaffective disorder, bipolar disorder borderline personality disorder, and major depressive disorder. This isn’t to say that other illnesses aren’t serious or aren’t serious mental illnesses, but this is our kind of, these are our four biggies.

Now going back to suicide, we have approximately 47,000 suicides a year in the United States of America. That’s up from recent statistics, used to be about 44,000. Now it’s 47,000. It’s the number two leading cause of death for young people. Check that out. Number two. Number one, I’ll give everyone, I’ll do a brief pause here and give everyone a chance to think about what the number one could.

Okay, I’ll tell you, it’s accidental deaths. So that would be car accidents, you know, [00:29:00] anything that can go wrong, right? Selfie sticks, you know, all sorts of things. Number one, cause of death. Number two, cause of death completely preventable is suicide. And I’ll tell you, we have 47,000 suicides a year for every single one of those patients who had, who completes a suicide, 25 people attempt.

That is an astronomical figure that we must do better. We must identify this in our patients and we must not miss it because the truth is, is that mental illness kills people. We just don’t get to see it because where does that patient complete the suicide? It’s not in our office, it’s not in the emergency department.

 It’s not like a cardiac arrest where we wheel someone into the ER and we get to do cpr. A lot of these patients who are completing suicide do so without our knowledge. So this is absolutely our number one must not mis diagnosis. My next point would be is , how do we avoid missing it, right?

How do we avoid missing it? And I think that the number one thing I can give to your listeners is we must take this questions seriously. I’ve trained providers, police officers firemen, EMS, octors, PAs, NPs, all over [00:30:00] the country on suicide prevention. And I still hear the same thing when we ask this in our offices, right?

When we ask about suicide, how do we ask it? We say, I. Well, you’re not suicidal, are you? Right? We go, oh, well you’re not. You haven’t had any thoughts of killing yourself, right? We’re assuming the negative. Why? I’ll tell you why. It’s because it makes us uncomfortable. We don’t like asking this question because we’re very scared.

If the patient says yes, we go, well, what the heck are we gonna do now? We want the patient to say no. There’s sometimes when I want my patients to say no, right? It means I have to engage a , whole host of resources to get this patient help that they’re gonna need. But guys, it’s true. This is an important question.

We have to take it seriously. So we ask our patient the exact same way at every single visit. Do you now, or have you ever had thoughts of killing yourself or hurting someone else? Not, have you had thoughts of not being alive anymore, or have you ever had thoughts of passing on, have you ever [00:31:00] had thoughts of doing something negative?

No. We ask them directly. Do you now, or have you ever had thoughts of killing yourself or someone else?

Professor Hare: I would just point out that, the idea that actually asking the question puts the idea somehow into someone’s head in those moments is completely false.

Ryan Davies: 100% a myth. Absolutely. So thank you so much for bringing this up, because this is always the second thing that I hear is, well, I don’t wanna put the thought in their head, right. So think about it. Right? Albert Camus famous French existentialist philosopher, one of my, one of my heroes , he says this, he says, the primary question of all philosophy is whether or not life is worth living. This is a question that we have all grappled with sometime in our lives. Right? I’ve thought of this, i, I grasped myself as life is worth living. We, we affirm our will to live every time we cross the street.

Every time we stand out of a balcony, it may not be conscious. We’re not thinking, oh, I could stop here and get hit by a car. But the the possibility, the option is always present. This is something that is a very normal [00:32:00] thought and we must ask our patients. It is so vital to preventing suicide by simply asking this question and taking it seriously if a patient gives us anything other than a negative response.

 And the truth is, is that when you ask this question, patients aren’t going to be forthcoming. They’re not gonna say, yes, Mr. PA-C I have in fact had suicidal thoughts. No, they’re gonna say something like, things haven’t been that great lately. You know what? I’ve been under a lot of stress. And that’s your in, that’s your, the, the patient just opened the door for you.

All you have to do is walk in. Now we get to ask the real juicy questions, the things that made us want to be prescribers and providers in the first place. That’s our moment to jump and talk to the patient and get to know them and find out what makes them tick and actually help someone.

Professor Hare: You point out that those, juicy questions, so to speak, are the ones that really get you into that, patient’s state of mind. And I, I, you had mentioned this earlier and it strikes me that I benefit in family medicine in a psych hospital from.

 The approach [00:33:00] that psych has because I’m able to then when I go into my medical history and physical exam patients are, are kind of open, right? They’re, they’re opened up to those kind of questions and they’re used to getting those open-ended questions. And as long as I stay away from those leading questions, which I think, you know, it’s certainly a risk.

Not providing confirmation bias with a patient and saying, well, you don’t have any suicidal ideation, do you you know, those kind of questions I think are, really dangerous. But I’ve always benefited and been able to get very deep into those stories of patients because of psychs already being there.

They’re already asking those questions and patients tend to be very honest with those things. They tend to be very open and honest and maybe more than you’re prepared for as a person sometimes when those questions, when the answers to those questions are not what you anticipate, but they can be really dramatic and, and interesting stories along the way.

Ryan Davies: Absolutely. That’s my favorite part of psychiatry is I get to hear an amazing number of different things on a daily basis from my patients. I love my patients with psychosis because you [00:34:00] really do never know what’s going to to happen. Right. It’s such a wonderful thing. You never know what they’re gonna say next.

I will, I will jump back to the, the preventing suicide part and not missing this and say that if your patient ever, ever reports to you that they’re having suicidal thoughts, there are two questions that I want your listeners to not, not forget that they need to ask. One, do you have access to lethal means?

Lethal means is, do you have access to a firearm or a large stock pile of medications? Right? And I think this question of firearms is, is a big one. And I’m not gonna get into politics. No one wants to have this conversation at the dinner table. I’m not gonna have it now. Right. But, The truth is this, owning a firearm does not make you any more likely to attempt suicide than anyone else on this planet.

What it does make you more likely to do is if you attempt suicide, the rate of completion, we don’t say successful. Successful is a positive connotation. We say the rate of completion is monumentally higher just immeasurably higher, right? Because there’s no chance of rescue. Same with large quantities of medications, specifically opioid medications.

 Number two question. So we asked about lethal means number [00:35:00] two. Question is do you have a plan? So of 10 million people in one single study who had serious thoughts of completing suicide, about 1 million of those had a plan. About 300,000 of that 1 million actually attempted. But the vast majority of patients who attempted suicide had a plan prior to their attempt.

We must be asking our patients if they have a plan. Okay. So those are my two big takeaways for your must not miss in suicidal ideation is we wanna ask the question seriously. And when we do ask the question to give us a positive response, we wanna ask about lethal means. And if they have a plan,

Professor Hare: So let me ask you this. The terminology “contract for safety” has been around for a while. How do you feel about the terminology “contract for safety”?

Ryan Davies: I hate it so much and I’m gonna tell you why. So we say contract for safety, the historical pattern with this, this term contract for safety. So take the word contract. This is where it started.

 What used to happen is when you go to see your, your psychiatric provider, they would have you sign a paper and that paper says, “I, Ryan Davies, [00:36:00] promise to never kill myself.” And then you sign it and then the provider keeps it in their office. I want everyone to think how, how successful they think that little form was in preventing suicide.

 The correct answer is 0%. Research has showed time and time again that having a patient sign a form saying they’re not gonna kill themselves, it’s not gonna prevent them from killing themselves. Now we use the term in a more nuanced way. So when I say contracting for safety, what I’m looking for is a patient who can plan for their own future.

Are they future oriented? That’s the big question. So my golden question for contracting for safety is this. If you ever have a suicidal thought and you feel as though you’re going to act on it, what could you do to keep you and everyone else safe?

I’ll say the question again. If you become suicidal or homicidal in the future and you feel as though you’re going to act on it, what could you do to keep you and everyone else safe? The answer to this question is, In my opinion, completely irrelevant. I don’t care. You can give me a whole host of answers.

I don’t care at all. As long as it’s plausible and as long as you come up [00:37:00] with something reasonable, I’m fine with it. What is important is, can you answer this question? Can you plan for your own safety? And honestly, this research shows time and time again that this is really the best that we can do in preventing suicide.

 You know, at this point in time, we don’t really have good screening criteria. We don’t really have a good risk assessment strategy for preventing suicides. We just have to do our best with the tools that we have. And the best tool that we have is this Quote Unquote “contracting for safety”, which is asking a really important question and making sure we get a valid answer.

 So if you’ve learned anything from what I’ve just said in the last two minutes, please do not ask your patients to sign a piece of paper saying they won’t kill themselves. It’s not gonna help.

Professor Hare: Yeah. Asking them to think about it even is, you know, the thought that goes into it and, and watching the thought that goes into it as a practitioner can be very telling as to their state of mind.

Absolutely. So let’s move on to to number two on your list of must not miss diagnoses.

Ryan Davies: Yeah. So my number two must not miss diagnosis is something that’s going to be quite rare, but it would be serotonin syndrome or it’s [00:38:00] counterpart NMS, which is neuroleptic malignant syndrome.

So both of these syndromes present a little differently. Serotonin syndrome specifically what happens is we have too much serotonin in our body and it becomes quite toxic. Patients tend per to present with extreme diarrhea. They have shivers, they have irritability, they have profuse sweating.

And then another big telling sign is autonomic instability. So your vital signs are gonna be all over the place. We can’t miss that because it kills people. Same with neuroleptic malignant syndrome. So instead of the serotonergic medications, now I have my dopaminergic medications, which are the antipsychotics in excess. They can cause life threatening neuroleptic malignant syndrome, which essentially is very similar to malignant hyperthermia, where patients become so rigid that their temperature elevates quite drastically and it can kill them.

So this would be number two on my list of must not misdiagnoses. I will say that there is a very fun pneumonic. It is somewhat inappropriate. the mnemonic for serotonin syndrome is shits and shivers, and that would be [00:39:00] significant diarrhea. And then shivers, and I will, I will let you all look that up,

Professor Hare: Okay. And NMS is actually, because I covered the schizophrenic and schizoaffective floor, the psychosis floor at the psych hospital for a while. That was one of those things that we were always on the lookout for with our psychotic patients. And you know, I think over that time we only had one patient who kind of lapsed ever so slightly into some of the initial stages of NMS.

And of course we were able to, to, to pull him back outta the, or, you know, at least remove medications and make that a little bit better. But certainly the, the vital signs aspect of NMS was something that we kept a close eye on

 Then how about number three on that list? So that’s a medical, that’s almost a medical condition we’re talking about there when you get into serotonin syndrome and nms. So that’s, that’s interesting from my perspective.

But how about number three on your list?

Ryan Davies: I think it’s important to remember right, that our patients with psychiatric diagnoses, they have medical conditions too. And a lot of the medications that we prescribe often providers think are benign. I am always blown away by the number of people who come into [00:40:00] my office on 50 milligrams of Quetiapine, brand name Seroquel, that were prescribed by their family medicine providers for sleep.

So please, do not prescribe your patients Seroquel for sleep. Okay? Don’t do it. And the reason for is my next must not miss diagnosis, which is Tardive dyskinesia, which is another medication side effect. So Tardive dyskinesia is a likely irreversible medication side effect to our dopaminergic medications like the antipsychotics.

What happens is,

There are four dopaminergic pathways in the brain. We have the meso limbic pathway, which is where we see the positive symptoms of psychosis, right, where there’s too much dopamine in there. Patients are having too much salience, they’re making too many connections in schizophrenia. So we decrease the dopamine.

It reduces the positive symptoms of schizophrenia, like hallucinations and delusions. Then we have the meso cortical pathway. Which helps regulate our, our cognition and our thought processes. the problem there is we have too little dopamine. There’s not a lot, a lot of dopaminergic neuron firing.

And that’s where we get our negative symptoms of schizophrenia, like our [00:41:00] alogia, which is lack of speech. We get our abolition, which is our inability to kind of go about our day and do things. And this is why negative symptoms are so hard to treat. It’s because we. Medications that decreased dopamine.

But now we have this meso cortical pathway where we’re decreasing dopamine even more, right? Mm-hmm. . Then we have our tuberoinfundibular pathway. This results in you know the function of this is to regulate a lot of hormones released in the pituitary gland chief of which is prolactin, which is why if you ever prescribe a patient risperidone, you should be careful about gynecomastia lactation because it can cause prolactin elevation.

 And then lastly, the whole point of this very long rant, is the nigro striatal pathway, which helps us our brain coordinate movements. And when we decrease dopamine, our nigro striatal pathway starts to make connections that should not be made and it can cause movement disorders. So this is where we get our extra pyramidal symptoms from, which is acute dystonia akethesia.

Pseudo Parkinsonism. And then lastly, and Worsely, tardive dyskinesia. Tardive dyskinesia comes with these various [00:42:00] stereotypical facial movements. It can be anywhere, but we really think stereotypical facial movements where lip smacking, tongue rolling. The problem with this is it can be permanent and the longer the symptoms are occurring, the more likely it is to become permanent.

 a lot of providers think that you need to be exposed to the antipsychotic medications for quite some time in order to develop td. It’s not true. Research has shown time and time again that every single exposure is one, one hit. Think about it. Every time that patient gets that PRN haldol, because we didn’t want to talk to them, we just wanted them to sleep, right?

Every time they get that is a roll of the dice, it’s a pull on the lever of the roulette wheel that sometime maybe a year from now, maybe 10 years from now, they’ll develop this. people need to be very careful that even, especially in primary care, that if they see these very stereotypical facial movements in a patient who’s ever had an antipsychotic, they need to identify that immediately and refer to a psychiatric provider urgently.

Professor Hare: One of the interesting asides for many folks about schizophrenia and [00:43:00] psychosis is not being aware that there are positive and negative symptoms, and some patients present predominantly with the positive side of those. And of course saying positive being the more hallucinatory delusional And really outward facing kind of symptoms, more active symptoms.

 And then the negative side tends to be folks who sit and, don’t say much, don’t speak alogia, as you say. A lack of cognition in some cases. But these folks, at one point we had at the psych hospital, a positive schizoaffective and schizophrenia unit, and we had a negative unit.

And I remember thinking at the time that, you know, this is one of those moments where they’re gonna ask nursing and the medical staff and psychiatry, which of these two units would you rather cover? And my immediate thought was, well, there are two kinds of people in this world.

There are the people who enjoy the the positive side schizophrenic patients who are always going to be interesting and outgoing and, you know, difficult to deal with. Certainly. But, and a handful at times. [00:44:00] And then you have the folks who prefer to work with the negative side patients who are always gonna sit and be quiet and never really gonna cause them any problems.

 I always thought it was an interesting dichotomy between our nursing who wants to work on the negative unit and nursing who wants to work on the positive unit. Those are two very distinct types of folks there.

Ryan Davies: That is so interesting. I’ve never heard of a psychiatric hospital that was broken up in that way.

I would assume that with the psych hospital you’re referring to, it’s incredibly massive. So they have enough space that they can break that up. That’s, that’s, that’s a very, very much so. I will say for the people listening to remember for your board exams, your EORs and all, all things psychiatry test questions that the easy way to remember positive versus negative symptoms is positive symptoms are present in schizophrenia, but not in everyone else.

So this is like auditory hallucinations, delusions, right? These are things that are present in schizophrenia but not in everyone else. And negative symptoms are not present in schizophrenia, but are in everyone else. So abolition, alogia, all of these,

Professor Hare: so [00:45:00] let’s perhaps move on to the next, in your list.

 The

Ryan Davies: next in my list is a big pet peeve of mine. I will say it’s bipolar disorder. And I would not say patients with bipolar disorder are pet peeve. It’s the fact that we don’t ask patients if they have any history of manic episodes before we prescribe them antidepressants,

Professor Hare: assuming that they’re depressed, in other words.

Ryan Davies: Right, right.

So we, we think that there’s this common thing I hear from people all the time that bipolar disorder means that you go back and forth from angry to not angry very fast. And that is in fact not bipolar disorder, bipolar disorder. Folks tend to have manic episodes, which last a week or more.

And these manic episodes are marked by periods of not sleeping, feeling very energetic, they’re grandiose. And then those manic episodes, which usually maybe two or three a year are punctuated by very long periods of depression. And depression can be quite severe. But the depression in bipolar disorder is usually predominant.

 It’s usually when we see our patients. So a patient may present to the primary care office, urgent care, or the emergency room. And say, I’ve been significantly depressed for two months [00:46:00] now. I can’t get out of bed. I don’t want to do anything. I don’t do anything I enjoy. And we go, I have the medicine for you.

It is my friend Zoloft, right? Zoloft very common selective serotonin reuptake inhibitor, antidepressant. So we give them this and then they’re back in our ER two days later and surprise, they’re manic now. We need to ask every patient that we’re about to prescribe an antidepressant if they have any history of manic episodes, because the takeaway here is that the antidepressants in rare cases can induce manic episodes in patients with bipolar disorder.

So I have no problems with providers in primary care prescribing SSRIs or serotonergic medications. But please, before you do, always screen for a patient who has a history of manic episodes.

Professor Hare: So how would you approach a patient if you were well, highly suspicious or let’s say had some significant indication that they had manic episodes in their history.

 How would you approach the prescribing of medication then, if not to go straight to the ssri?

Ryan Davies: Absolutely. That’s a great [00:47:00] question. So the gold standard of treatment for bipolar disorder, our medication class called mood stabilizers. The three most common ones that we use would be lithium, which is a very favorite medication of mine for a number of reasons.

Depakote, and then lastly, Lamotrigine brand name Lamictal. I think the easiest one of these to approach in a outpatient primary care setting is Lamotrigine. Lithium is a wonderful medication. It’s been shown as one of only two medications to prevent suicide or decrease suicidal thoughts. However, in the primary care setting, it’s quite scary because it’s been shown to cause damage to both the kidneys and the thyroid.

It’s also quite toxic, especially in the first trimester of pregnancy. But you know, I wouldn’t prescribe it to a patient who’s pregnant anyway. And then Depakote has been shown to be hepatotoxic. You need to monitor LFTs. It can cause thrombocytopenia all sorts of things, and both lithium and Depakote need blood monitoring.

We need to make sure that the levels are within. 80 to one 20 for Depakote are 0.8 to [00:48:00] 1.2 for lithium. And you can remember that for your tests by the eight to 12 rule. So 80 to 120 for Depakote or 0.8 to 1.2 for lithium. Outside of that, these drugs become completely toxic. Very dangerous in overdose.

 So that leaves my good friend Lamotrigine, as everyone should remember, for their test questions and their prep and for their prescribing practices. Lamotrigine very famously in very, very, very rare cases, can cause a very serious rash called Steven Johnson syndrome. Which is why we need to titrate it slowly and educate our patients to avoid new soaps, avoid new things because any rash that they, they develop, especially within the first month of starting Lamotrigine would mean that we would have to stop it.

 Lamotrigine comes in colored dose packs for initiation. You can, you know, reference whatever pharmacy you have to see which ones you have. But makes it very easy cuz it needs to be titrated very slowly. So that’s how I would approach it, especially in primary care. I would probably start my patient on Lamotrigine if I was felt confident of the diagnosis and felt comfortable prescribing that.

 And then [00:49:00] anyone with bipolar should be referred to a, a psychiatric provider.

Professor Hare: Nobody who has seen a manic, even a hypomanic patient in clinic. Forgets that forgets that moment because those patients you know, and, and again, as you say, it is relatively rare that they make their way to us as practitioners because they feel great, right?

They feel over the top great in those moments. And it’s often their, the people in their lives that bring them in to, to be seen but you certainly don’t forget those individuals. You know, they’re giving away their car keys to, to someone randomly or thinking that they can jump off the roof of a building, all of which have by the way occurred in my presence. Absolutely in the psych hospital in the emergency room. There are are unforgettable moments. Again, feeling as if you are invincible is really quite dangerous.

 You don’t often see the, the manic side of those in their initial presentation in your settings?

Ryan Davies: I would say I actually see man mania quite frequently. You know, I think that hypomania is probably much more rare. Those are the folks that are out there kind of living their best [00:50:00] life, having all the energy, you know, cleaning their house for days at a time, and it’s still very dangerous and needs treated.

Let me say this. Mania is life threatening. It needs treated every time and we treat it with antipsychotics, right? The mood stabilizer are great for preventing mania. The antipsychotics are great at treating mania. I’ve had patients go out and buy multiple cars.

I’ve had patients overdose on drugs. Patients who drink a lethal amount of alcohol. Patients will go out and have sex with multiple partners, potentially acquiring sexually transmitted infections. So folks are usually brought in when they’re manic, either, like you said, by family members oftentimes are brought in by police because their behavior are so erratic that it’s causing a concern in the community.

So on inpatient psychiatry specifically, we see psychosis in mania very, very frequently in the emergency department. We see mania all the time in outpatient psychiatry. I very rarely see my manic folks. I talk to them on the phone when they’re manic and then get them to the er.

Professor Hare: Anything else on the must not miss side of things?

Ryan Davies: I think we covered the big ones. Obviously I’m biased in saying that you must not miss any psychiatric diagnosis, but if you’re not [00:51:00] gonna miss some specific ones suicidal ideation for sure. Bipolar disorder, especially when you’re starting an ssri.

And then the medication side effects such as serotonin syndrome, nms and tardive dyskinesia.

Professor Hare: Looking at your list we have addiction and borderline personality disorder as other potential big morbidity and mortality causing conditions in psychiatry. Obviously addiction and problematic substance use are rampant these days.

 Can you speak to the psych presentation and the way, that they are usually brought to your attention as a psych practitioner?

Ryan Davies: In substance dependence treatment program we often get referrals one of two ways. The best way, my favorite way is the patient directly.

It’s always great when patients are in a state of change and feel ready to start tackling substance use. More commonly we get referrals from other providers or friends or family members who identify problematic substance use and ask us to evaluate the patient. Unfortunately, those tend to be the situations in which we are least helpful because patients need to be in a state of change where they’re ready to make the changes needed to [00:52:00] treat that addiction and problematic substance use.

Problematic substance use encompasses a whole variety of different substances, It can be tobacco, alcohol, amphetamines, heroin, all sorts of things these patients all present differently. Oftentimes, patients who are on stimulant medications present emergency to the ER because their behavior is erratic.

 Oftentimes opioid abuse tends to present with overdose and then problematic alcohol use tends to present because people who are intoxicated will either be confronted by the police, friends or family members, or maybe they’ll say something dangerous and then we’ll get in touch with them.

The treatment is different for all of these folks. I will say that substance use is very common co-occurring diagnosis with all of the mental illnesses. A lot of times people use substances as a means to cope, but it can also be its own primary diagnosis, and we need to be very careful when we’re treating it because oftentimes it’s just as stigmatizing as mental illness.

 And you know, this is one of the few things where we blame the patient for their problem, right? And I see this, [00:53:00] the other place I see this very commonly is with obesity medicine, is we’re often blaming patients for their disease. And it’s just not fair. And I like to use this in terms of obesity because it’s, I think, more approachable for folks.

 Think about sugar Studies have shown time and time again that sugar is actually more addictive than cocaine. So when a person with obesity goes out and says, you know, I am having a trouble stopping eating, well, it’s not because they enjoy being obese. It’s because they, their brain is preventing them from, being able to stop.

So it’s the same with our substances. We prescribe benzodiazepines much less now, but 10, 20 years ago, we would prescribe Xanax like it was candy. We would give it out to everyone. We say, oh, you’re anxious here. Take this medicine. You’ll feel better. Well, highly addictive substance. It makes people feel better, so they’re going to abuse it.

 And now we’re dealing with these problems later, but we’re blaming the patient. We’re not blaming the people who prescribed the medications or the people who, who marketed the medications. We’re blaming the patient and we need to do a better job at that.

Professor Hare: for the first couple of years [00:54:00] that I worked at, at the psych hospital, I didn’t understand why the 10th floor was dual diagnosis. And I guess at first I didn’t put much thought into it.

Yeah. That’s what it is, is dual diagnosis, realizing that the comorbidities that it’s describing that most of those folks have substance abuse issues, substance use disorders but then also if they’re in the psych hospital, they are most likely having a second diagnosis, a dual diagnosis

and, if they’re in a substance abuse spiral where they are bad enough to make their way into the hospital, that second diagnosis is, not a reach at all to make in those patients. It’s very easy to see the anxiety that they’re going through, the depression that they’re suffering from in the moment.

Even outside of the withdrawal that they may be experiencing or the acute intoxication that they may be experiencing. And that, that to me was always one of those things in the emergency room at a psych hospital that I had to remind myself, let’s ask the questions to figure out if this person’s acutely intoxicated right now.

 Let’s ask when the last time they had used that particular [00:55:00] substance. Are they acutely intoxicated right in this moment or are we far enough away from the last use. That they might be in withdrawal And of course, creating exactly opposite presentations when they are intoxicated versus in withdrawal.

Absolutely. It’s always a really interesting aspect of that to me to observe, if they’re acutely opioid intoxicated they’re incredibly constipated. If they’re in withdrawal, they can’t sit still long enough for a history and physical exam cuz they have to get up and run to the bathroom every 10 minutes.

You know, sure. And their nose is running and they’re yawning. You know, all of those things are going on at the same time. It’s a very different presentation, a very different picture, but the depression and the anxiety that comes along with that that second diagnosis that is psychiatric is a significant part of their picture and needs to be addressed

as well.

Ryan Davies: Absolutely. And my two favorite questions when working up problematic substance use.

First one is always, what does this do for you? Okay? So I see that you’re, you’re drinking 12 beers a day. What does that, what does that do for you? And patients kind of will pause and they. Well, [00:56:00] you know, I have dealt with these flashbacks from this experience I had in Vietnam. And you know what the alcohol does is it makes them happen less.

And even when they happen, I can cope with them better. And then you go, oh, that’s my in right there. So we need to work up ptsd. If we can help the ptsd, then we can start tackling the thing that you’re using to treat it. And then my second question, and this tells me how severe the problem has become, is what’s your longest period of sobriety?

What’s the longest that you’ve gone without taking this substance? And if the patient’s like, well, you know, in the last 10 years that I, I maybe went one day, two days without it, then I know that we’re dealing with some pretty significant problems here.

Professor Hare: there’s a little bit of motivational interviewing going into that process as well.

 If you can see the thing that has caused it, can you also see the thing that might make them want to. Step away from it for a short period of time, a long period of time. What has made them step away from it in order to to recover. And the recognition of that need for recovery gets wrapped up in that as well.

Ryan Davies: Absolutely. [00:57:00] Great point.

Professor Hare: the one that you have on the list is borderline personality disorder. I covered the, personality disorder unit in the psych hospital for a period of time, and it, it is certainly a very challenging population of patients to, to work with at times.

Tell me your thoughts on borderline personality disorder, if you would.

Ryan Davies: Yeah, so borderline personality disorder is such a. Misrepresented and misunderstood diagnosis that I think it really does warrant some conversation. These patients tend to be our heavy utilizers of services, right? They’re in our offices quite frequently.

 Oftentimes they’re reporting suicidal or homicidal thoughts, self harm, and that that ends up requiring a, a significant amount of resources to treat and manage.

 We tend to view those with borderline personality disorder as being manipulative and as lying, right? And it’s just not the case. So at the heart of borderline personality disorder is a difficulty with expressing one’s needs and feelings. So you or I, we feel lonely. We look at [00:58:00] our partner and we say, Hey, I’m feeling lonely, and that’s a way of getting our needs met.

 A patient with borderline personality disorder has a hard time doing that due to affective instability. So perhaps a patient with borderline personality disorder feels lonely, so they’ll say, I’m feeling suicidal, and that’s a way of getting that need met. So I want everyone to know that anyone who reports suicidal thoughts is 30 times more likely than average than someone else to kill themselves? Our folks with borderline personality disorder report suicidal thoughts quite frequently, and it’s very easy to talk to the same patient in the ER five days a week for two years and hear the same complaint and go, Ugh, it’s fine.

It’s, you know, they’re just saying this like they have the last hundred times. That patient is still 30 times more likely than average to kill themselves. Patients with borderline personality disorder do in fact suicide. And this is a condition that I think it’s very easy to get very cold to.

So in the psych world, we have something called negative counter transference, and what that means is I’m having negative feelings towards my [00:59:00] patient. Right. So the patient has been in front of me a hundred times. I’m feeling very frustrated. They’re making me angry. And it’s important as a provider that you understand that you’re human, this will happen.

But it’s also important to account for that. So it doesn’t affect patient care. And I see that the most with borderline personality disorder. The treatment of choice for borderline personality disorder is something called dialectical behavioral therapy. I have patients quite frequently, so I, I’ve had a patient come to me on

the inpatient unit who came to me on lithium , Olanzapine.. So lithium’s a mood stabilizer. Olanzapine is an antipsychotic. Fluoxetine, Topamax, all of these medicines, right? And you sit back and you think, what are we treating? What am I doing to this patient? And you do some digging and you realize.

This patient has borderline personality disorder and they’ve been going to the doctor so, so much. Well, guys, what? What happens, what do you do when you go to a provider? They prescribe you medicine, right? Yes. Yes. So you go to 15 doctors, or you go to 15 different [01:00:00] providers, you get 15 different medicines.

So we end up with these patients with borderline, and that’s one of the big clues for borderline is if you have a patient who comes in and you’re not sure of the diagnosis and they’re on a hundred different psychiatric medications, that’s a big.

Professor Hare: Well, not just psychiatric medications. I would argue that a lot of my patients would come in and they would have a hundred medical medications a hundred PRNs that would, they, you know, well that’s in case I get a little bit, you know, sometimes I get constipated, sometimes I have diarrhea.

So they’ve got both of those as PRNs. They, you know, sometimes I get a runny nose, and so I have Zyrtec and I also have pseudoephedrine, and I also have Benadryl, and eventually the anticholinergic start to pile up and they can’t pee. Those are, not just limited to the psychiatric side of things.

Ryan Davies: Absolutely. So a case in point fibromyalgia, fibromyalgia is a very real diagnosis. I think there’s a big debate in the medical community about that, but I am very firmly in the camp that is a real diagnosis patients present with chronic pain at, at least, I’m trying to remember from my clin med days under you, I wanna say it’s like nine [01:01:00] out of 18 trigger points or something of pain.

Professor Hare: Well, so they got rid of the trigger points. Oh really map at this point. And so there is now, now some folks will go back to it, to to poke a couple of those points and give, get their own sense of what’s going on with those patients. It’s essentially sore points is, now what we’re looking at, on the medical side to make that diagnosis of fibromyalgia.

It really has been expanded, I think over time. To make it a more inclusive diagnosis for more folks to have that diagnosis as opposed to fewer. But it is something that I, I agree with you a lot of folks have difficulty with that diagnosis.

Ryan Davies: I will say with fibromyalgia, it, it very, very much real.

But it does tend to be overdiagnosed in patients with borderline personality disorder. And it makes sense, right? you go to the, the PA a hundred times and you say, my X hurts and they can’t find anything wrong. Eventually they’re gonna find a diagnosis that meets that and generalized body pain, fibromyalgia, here we go.

Right? And that, I’m sure your [01:02:00] rheumatology PA-C friend is. Cringing at me saying, generalized pain, thus fibromyalgia. But with borderline personality disorder, we see this diagnosis quite frequently. It can be another clue. But to, to go back, the, the main treatment for this is dialectic behavioral therapy.

So for you, when you are a great psych pa and you are out there practicing and being awesome just to remember that if your patient comes to you on all these medicines and they, you believe they have a diagnosis of borderline personality disorder, it is completely fair, appropriate, and within the standard of care to stop those medications in a safe way and refer to D B T.

Professor Hare: D B T , as a therapy dialectic behavioral therapy, I believe.

Yes, correct. Yes. Um, That is can you describe. A little bit of the application of D B T,

Ryan Davies: . I am by no means an expert.

I have, there are very few, right? There are very few experts out there actually on

dbt. Yes, there are. Yes. So the, the gist of D B T is we’re teaching patients how to cope with their strong feelings and emotions in an appropriate way.

 One of the, the cornerstones of [01:03:00] D B T is agreeing that you will not present to the emergency department unless you absolutely are in an unsafe situation. D B T provides support via phone, via a therapist who’s on call at all times so that patients with borderline personality disorder can call and have their needs met and also can, can cope with some of these things.

That’s probably a very oversimplified discussion on D B T. I have never done it myself. I am by no means an expert. My most of my experience is clicking the consult D B T button and hoping that there’s a D B T therapist somewhere that’s willing to take

patients.

Professor Hare: I think it’s an unfortunate reality of the eventual treatment of some of those borderline personality disorder patients. I became very practiced with my patients because this was, you know, half of my patient population was approaching those patients and not betraying my own thoughts on what they were saying to me. And simply having not, not a cold response, but a, a clinical response in which, , I say that, that sounds difficult. It sounds difficult, what you’re expressing to me there. So not giving them the [01:04:00] response that they may be looking for in that moment, which is an extreme sympathy and we’re going to send you immediately to the medical hospital across the street for imaging or surgery or something of that nature. And simply saying, okay, so this is, this is how we deal with this problem. And it sounds difficult. I’m sorry you’re going through that right now.

Ryan Davies: Well, you know, my question, and this pertains both to borderline personality disorder and really anything else, not only in psychiatry, but all of medicine is, you know, patients are gonna come to you with very strong emotions. I’ve had patients hurt insults at me and my previous work as a crisis counselor, I had patients try to assault me.

My, my question is always, what is the need that is not being met? Right? So, I think it’s very easy to kind of symbolize a patient borderline personality disorder as attention seeking because they’re, they’re kind of always asking you to provide something. You know, there’s what they’re, they’re, they’re coming to you with these multitude of complaints and requests.

My question to them, and my head is always, What is the need that’s not being met, right? So if patient comes in and says, you know I’m feeling [01:05:00] suicidal. I, I I just don’t feel safe at home, what is the need that’s not being met? Are they feeling socially isolated? Are they feeling as though they’re unable to cope with their inner sense of self?

What’s going on here? Just like your patient who’s screaming at you in the emergency department. You know, I’ve been waiting 12 hours because I came here to your emergency department for a covid test. And I just damnit, I, I, I want my covid test right? Hopefully all the e DPAs who are listening are rolling their eyes because I, I eyes with you.

But the question is then what are the, what’s the need that’s not being met here? And it’s that the patient is, is feeling as though they’re not being valued or listened to. So how do we address that need? It’s very easy to respond and kind and yell, and sometimes it’s even fun. I will admit that I have done it in the past.

But what’s the best thing to do? What differentiates good providers from bad providers is the ability to look past that. I’ve had patients scream at me all the time, especially inpatient psychiatry. We, we have what’s called at the va, we [01:06:00] have what’s called code greens, which anyone in the hospital can call this code green and it’s a psychiatric emergency.

And you go and inevitably someone is upset. And my question is always, what? What’s the real problem? The patient may be screaming at me, but it’s not me that they’re upset with. In this case, it’s the hospital I work for, or perhaps it’s the tech who yelled at them or said something mean to them. So that’s when we can start really getting down and fixing things.

 I think it’s the same anywhere in medicine that we need to really focus on getting past these strong emotions that we feel and see and trying to find what’s beneath them, what is, what is really going on here.

Professor Hare: Absolutely. And of course as practitioners, the ability to deal with those things.

 This is also something that I think is incredibly important in psych medicine but across medicine in general. my mentor when I first started working in family medicine in the psych hospital, said to me, take every one of those days off that you have available to you.

Take every moment of PTO that you have available to you, because [01:07:00] these are sad situations that we are often exposed to with our patients. They’re difficult situations that we’re exposed to with our patients. And you can only give so much of yourself before that starts to chip away at your resolve and chip away at your patients.

And losing that not pulling yourself away from that occasionally to take a break and give yourself credit, , give yourself time to recover from that, and then come back refreshed and, , with your patience reserves refilled, so to speak.

is incredibly important. I think as much in psychiatry as anywhere else, I honestly can’t think of anywhere else. Addiction medicine certainly falls into this where , if your patience reserves are limited in those moments, It’s hard to deal with that on a regular basis.

Ryan Davies: Well, and if I can get on my soapbox for just a minute and say, I will. And I, I will. So I, I just googled top 10 professions by suicide rate, right?

So here we go. Here’s the list. Number one, medical doctors, and I would throw [01:08:00] PAs in with that, right? PAs, n prescribers, number two, dentists. And then we’ll skip down to number four, veterinarians. And then number 10, pharmacists. So four. Of the top 10 medical professionals? Yes, there is a reason for this, and the term that we’re looking for is called vicarious trauma.

 So vicarious trauma is not being a participant, but being an observer to the trauma of others. So it doesn’t mean that you need to be near death, dying and all of that on the regular But little things on the day. So in psychiatry, I hear from people all day. They talk to me about their problems, their suffering, maybe their divorces, things going wrong with them.

Say a patient in family medicine, they’re oftentimes diagnosing very serious illnesses. Even something like. Hypertension can have significant impacts over time, but also diagnosing things like rheumatological disorders and cancer and all these things in the moment, you don’t [01:09:00] think about it, it becomes routine.

You do the diagnosis, you provide the treatment. Sometimes you look it up to date, no judgment. Mm-hmm. And then you go home and you live your life. And the unfortunate part however, is that not everyone does this happily ever after. And in fact, the vast majority of us don’t. And if I may, when we look at the way we’re all educated, and this is no different for PAs and I will not sugarcoat this, right.

 PA school is hard. It, it requires a massive amount of our time. Clinical year requires a massive amount of not only our time, but our emotional, physical and financial resources, right? And we all talk about this self care. We all say about, oh, self care is so important. And it’s really easy to to, to write that down and say, oh, we need to practice self care.

But in reality, we don’t do that. And in fact, the system is rigged against it. look at your didactic year for those practicing PAs and those students, your didactic year, right? Think about the sacrifices that you have to make. Think about your patient care when you’re [01:10:00] practicing pa, the long work days, the long hours, all of the admin issues, all of the billing nonsense.

 Your nurse called out today, so guess what you’re doing? Vitals. All of these things add up over time. And if we don’t deal with them, if we don’t actually take them into account and do something about it, It makes sense that we’re all top of the list for suicide and mental illness and substance use.

 Because if we’re not coping in a positive way, we will absolutely cope in a negative way and we have to take care of each other. Sometimes that means saying to a colleague, Hey, you look burnt, you look burnt, you should take some time off. And I don’t, when I say take some time off, we throw that around, right?

Hopefully as good PAs, you’re all advocating for, massive amounts of PTO that you deserve. But even if you get two months of pto, a. If you just use that PTO to go home and sit on the couch and do nothing, then you’re wasting it. Even if you’re gonna go home and you’re gonna sit on that couch and , that’s your day off, I want you to do it with intention.

 [01:11:00] Sit there with purpose, find something meaningful to you. Even if I don’t need to play Xbox, I play video games. And you know what? Some, some people look at that as being lazy, but for me, it’s a way I intentionally cope with the world around me. Step away. And yeah, as long as you’re doing that with intention, you’re protecting yourself.

So please, if I can finish my soapbox with this, it is take care of yourself as a medical professional because you are a finite resource and your patients need you, and the work that you’re doing is significantly traumatic on a daily basis. So please, please, please take care of yourself. Ask for help if you need it.

 People like me, psychiatric PAs like me, we, we have our own problems, right? we identify this, but I also want you to know that we are here not only for your patients, but we are here for you. If you ever need us, please curbside consult me. I love when my colleagues and other disciplines are like, Hey, I’ve been having this rough home situation.

This is going on. What do you think? I’m happy to talk to you anytime, please.

Professor Hare: [01:12:00] Well, that’s good because I’ve got your phone number now, . So that the, the possibility that you might get a call at some point is is, is ever present. Yeah, I, one of the things, and, and I really appreciate that, I think that’s is an ever present moment for a lot of practitioners, certainly in psychiatry.

 and across the board I had a a colleague who was one of the nurse managers in the psych hospital who every time there was a significant event, a trauma of some sort that occurred in that hospital, which is fairly frequently, and certainly for the, the larger traumatic events that happened there, you know, shootings, et cetera.

He would go around to folks and talk to them, and he approached me after one particularly traumatic event and said, Hey, you know, how are you doing? Yeah, I’m doing okay. I don’t think this, this impacted me all that much. And he goes, you know, Please talk about it. Please talk to me about it. Please talk to the people around you.

And, and this was a, a regular commentary for him around these events that you need to talk about these events, you need to talk about the way that you’re feeling. Sometimes those feelings are simply going to [01:13:00] be, for lack of a better word, repressed until later on. It will come out in some way, shape or form, whether you make it a controlled release with talking to people around you about it and expressing, you know, you’re gonna be surprised about the things that you say in those moments sometimes that’s coming out in that fashion versus kind of holding it all back and, and not talking about it and not checking your own temperature, and understanding that you really do need to get that out. Bottling that up will make it 10 times worse down the road when it eventually does come out.

And, you know, of course, this is counseling, right? this is counseling and talking to the people around you, talking to folks like you. you know, whether it’s talking to your family, your friends, or an actual counselor a valuable resource.

Ryan Davies: Absolutely. And you know, I, it’s all about taking care of each other.

We’re in this together. The most wonderful thing about being a PA and being in the medical community is we’re all in this. You know, it’s like sometimes we view this, the ship as sinking, you know, especially during Covid, that our ship almost sunk a few times. But at the end of the day, we’re in the boat together and we have to raise each other up.

 [01:14:00] one other piece of advice I would give is, and I, I give this advice to police officers that I work with quite frequently is make sure you develop a life outside of medicine. It’s very easy to become obsessive with all of this. . It becomes our identity. And it’s okay to have part of your identity in medicine.

That’s perfectly fine, right? It’s a big part of who we are. It’s why we got into this business. But 20 years from now, 30, 40 years from now, this is gonna stop. You’re gonna retire. And on that day of your retirement, I promise you, you will ask this question. What now? And if you didn’t spend time before developing your identity outside of medicine, you’re gonna have nothing left then, and it’s gonna be a much more difficult road for you.

 find what makes you happy and pursue it. Remember that medicine is not your end all, be all of life. There’s more outside of it. There’s more than adjusting INRs and managing SSRIs and side effects and all that stuff, okay? So find what makes you happy and make that a part of your identity and your patients will actually be thankful for it.

 And this is even more, notable in [01:15:00] psychiatry when I’m training folks about how to deescalate and just how to talk to people. I say be yourself, be a human being. I’ve, I had a patient once. With schizophrenia who did not wanna talk to me at all had this Nintendo Ds and was playing Pokemon, and I’m a huge Pokemon nerd.

Self-disclosure, I love Pokemon. , he’s playing Pokemon and I can tell he is very much not interested in talking to me about his psychosis, which is fine. And I, I say, Hey, well I see you playing Nintendo DS. You got the Pokemon there. Talk to me about it. So we start talking about Pokemon and he pulls out his backpack, all these other Pokemon games, and, we’re going through all the different Pokemon he has.

And by the end, that conversation about his mental illness was so much easier because I shared with the patient a part of myself. This is not to say that you should disclose anything, right? Self-disclosure should always be very limited and be only ever for the, the, the, the betterment of the patient.

 But, it’s Okay. I ride motorcycle. It’s a big thing. I enjoy a lot of my vets that I work with, ride motorcycle. And whenever they talk motorcycles, I’m always happy to talk with them and take five, 10 minutes and we’ll talk about your Harley. Right? We miss [01:16:00] this in medicine and in psychiatry it’s so important, right?

So medicine, you prescribe hydrochlorothiazide for patient’s blood pressure, you assume they’re gonna take it. You don’t have to convince anyone, they’re just go, okay, I’ll take it now. Maybe 60% of them on a good day will actually remain compliant. But in psychiatry, half of my job is sales. Hey, this medicine will help you, I promise.

What’s it gonna take to get you to take it? You can be the best damn provider. In the world. You could be the world’s most learned pa You could memorize current medicine, you could memorize the DSM five. Right? What does it matter if you get the right diagnosis and the right medicine? If your patient doesn’t put the pill in their mouth and the patient, I promise you, is not taking the medicine, they’re taking you, whether or not they trust you is the largest determinant of whether or not they actually take your treatment.

So to, to back out, I would say make sure that you’re developing a life outside of medicine and bring that to work with you. Bring that, enthusiasm for your passions to your patients, and they will pay you back [01:17:00] dividends.

Professor Hare: That’s funny you say that. That is actually my advice, that’s my exact advice to people getting married and having kids.

Ryan Davies: Okay. I’m getting married next year, so I wanna hear it. Tell me

Professor Hare: Somebody stands up on the dais and, with a drink in hand toasts the newly. Engaged or at the gender reveal party

and folks are, asking for, advice, what’s it like being a parent? What do I need to worry about? Gimme your best piece of advice. my best piece of advice is always that you still need to be a person and you still need to be a couple. And in 18 years, when that kid hopefully goes off to their big purpose in life that you still need to be a couple and you still need to be a person and you still need to have some life outside of that.

The worst thing that could happen is your kids go away to school and you look at your significant other, and you don’t have anything in common anymore because it’s been all about the kids for the last 18 years. If you can’t have a discussion outside of the dog that you’ve adopted then there might be a little bit of a problem there.

 It is a, a very parallel discussion to the one you describe as being a professional in medicine. [01:18:00] Making sure that you’re have a life outside of that.

Ryan Davies: Well said. Well said. And I will take that with me to my wedding, my fiance, the door here. I’ll tell her that’s the advice.

Professor Hare: It’s the same way with being a practitioner.

Take your time off, do your thing, and find things outside of, the primary purpose to work to enjoy on a day to day basis.

Ryan Davies: I like it. I like the metaphor that being a PA is a lot like being married, . We are married to our profession and we are learning things, new things every day.

We’re learning how to be a better partner to our profession and our patients.

Professor Hare: I like that very much. . So I’m just looking at your list. The last section that I have here we’ve really wrapped all of those into the individual discussions of these things already.

 You mentioned the X waiver

Ryan Davies: so for those who don’t know one, for those of you who are PA students one day you will have to apply for a DEA license.

It’s gonna cost you $888. Hopefully your employer pays for it. For those of you who are practicing PAs, you know very well the frustrations of having to work with a DEA on a regular basis. But there’s one thing that you can do for your DEA [01:19:00] license to make it even better and it’s completely free.

Get your X waiver, right? Get your X waiver. So here’s what the X waiver is. The X waiver is your ability to prescribe a lifesaving medication called Buprenorphine. Brand name Suboxone. Buprenorphine is a opioid. Buprenorphine is a partial opioid agonist, meaning that you cannot overdose on it. It regulates its own levels when you take it. And it is combined with the life saving medication, the naloxone, which prevents overdose even further. We use this medication to treat patients with opioid use disorder.

So a patient’s addicted to opioid medications like heroin or even pills, that sort of thing. This medication can be prescribed by absolutely everyone, so long as they have an X waiver. There are some requirements for being able to prescribe it, but it it should not, and I repeat should not be only used by psychiatric providers.

It should be used by everyone. We can do suboxone, inductions in the emergency department. We can do suboxone inductions and maintenance in primary care offices. The opioid use pandemic is massive problem. For my [01:20:00] younger folks out there who are maybe new to being a pa, you did not create this problem, but congratulations.

The gift you get at graduation is inheriting it. For my older PAs out there perhaps you didn’t contribute to it expressively, but by being a provider, I’m lumping you in with the category. This is a problem that we created and we need to fix it. our patients need our help and it’s on us to fix the problem that we created, which is opioid use and addiction.

 the X waiver is free. All you have to do is take a 24 hour training. You can treat up to a hundred patients as long as you get your X waiver.

And your patients will thank you very much for it. It’s a very easy medication to prescribe. There’s only a few lab values that you need to monitor. It’s very easy to monitor for diversion. People tend to shy away from it because they’re worried that the patients will be challenging or difficult.

They tend to be very appreciative and thankful for, and I will tell you that these patients will all come to their appointments. It’s very rare that one of my patients on Suboxone misses their appointments because they know that this medication is so essential. So please, absolutely, please get your X waiver.

You do not need to be a psychiatrist, psychiatric pa, or psych nurse practitioner to get [01:21:00] it.

Now there’s an app that people can use, I don’t know it off the top of my head, but there is an app that you can give to the patient so they can do their own CAL score. And the CAL score is essentially a measure of in what state of withdrawal the patient is and they can actually self dose the buprenorphine at home.

And remember, they can’t overdose on it. It’s very hard to get high on it. So it, it’s perfectly safe to do this in the right patient.

Professor Hare: In wrapping up, I do wanna to point out that there are there are certainly other mental illnesses here that we haven’t broached.

And that’s not to say that any of those mental illnesses are not important. That they are not somehow impactful. They certainly are incredibly impactful for the patients who suffer from them. , we’ve caught. The heavy hitters. Sure. Absolutely. The, the most common and most impactful seen on a day to day basis in practice.

Not to say that , panic disorder anxiety, ptsd, O C D you have listed here. That’s not to say any of those are not potentially severe and impactful on patients. We’re simply going for the the big must not miss cases and talking through those today.

Ryan Davies: I wanna say thank you [01:22:00] very much for having me on your podcast, your show. It’s been a, absolute pleasure being able to speak with you.

 I will say to your listeners who perhaps don’t know you so well, you’ve always been such an enthusiastic and passionate professor, your care and time that you provide with your students, I, I’ve never seen you talk to a patient, but I’m sure it’s no different. The care and time that you provide with your students is evident in the passion that you have, and it doesn’t go unnoticed.

I’m sure you’ve trained scores now of PAs and the medical community is very thankful for you. So I give you a very big props and a very big thank you, not only for all that you taught me but for all that you’re teaching has enabled me to do as one of your students. I thank you for that. And then I also thank you for letting me speak at length

about all of these topics which are so important to me. I will say that my passion for suicide prevention was born. As I was a crisis counselor. My long time, one of my very first partners, officer Mark Garron, who was one of the police officers who helped me develop my correspondent program, he actually completed suicide.

And that helped me kind of develop this training and, and develop the passion that I [01:23:00] have now for educating people about suicide. So any chance that I get to honor his memory and talk about this is, is very, very important to me. So I, I thank you very much for having me on your show.

Professor Hare: Well, I, very much appreciate your sentiment and I certainly share the idea that these moments that really impact us and push us into news spheres, new areas, new passions in our life.

You know, whether it’s a podcast or seeing patients or Teaching students.

 It has definitely been a privilege for me to. Bring students back yourself included, and use your expertise in the community. You know that on-the-job training that you get after you leave here and the passion that you develop for the things that you do , you’d be one of the, most significant examples of that.

And, my goal has always been 80% of my guest lectures and the people that I bring back as alumni, my former students who come back to do that because that’s a sign to me that we’re doing things the right way. And that you find this program to be useful.

And I really appreciate the fact that you’re willing to come back and teach our students.

 thanks for your time, [01:24:00] thank you for your service, because I know, certainly in the VA system and your residency, that has been something that you have provided to a lot of folks who are service members. And that is a significant contribution to our country and to our collective mental health. So very much appreciated,

Ryan Davies: thanks, Jason.

Professor Hare: Hopefully this has been helpful, Be sure to check out the podcast website, at BeExcitedHQ.com for more episodes, show notes and full transcripts of every show.

Email us at [email protected], with questions, comments and future show suggestions.

And of course, follow us on Facebook and Instagram at Be Excited podcast for news, new episode notifications, and maybe a few pictures. Thanks for listening, and…. Remain Excited!