April came to see me shortly after I began my practice as a physician. “Can’t you do something?” she pleaded. “I can’t sleep. I cry all the time.” “Life’s no fun.”
She was 40 with metastatic breast cancer that had spread to her lower spine and only had months to live. The treatments available today had not yet been discovered, and there was “nothing left to do” her referring doctors said. I didn’t know what else to do except order tests and prescribe narcotics. Even when she raised the question of her outlook, all I could muster was, “…we’ll have to see…” I didn’t know how to talk to her about death or that it was even appropriate. I’d been taught, “don’t get too personal with patients, it will destroy your objectivity.” Similarly, I’d been taught not to address personal issues like her grief.
A couple weeks after she died, her husband showed up unannounced at my office with her diary. He thought I’d be interested. He left quickly without further explanation. On the first page I read, “The young doctor doesn’t seem to know what to do with me…he just orders more tests…so depressed, so alone, it would help if he just tried to understand what I’m feeling. I don’t think he cares.”
Her words, page after page of them, stopped me cold. I’ve never forgotten them. I failed her, not because I didn’t care, but because I didn’t know how to be the kind of doctor she needed. I should have known how to be empathic, answer her questions about death, and simply be there with her in a supportive way. And she probably would have benefitted from medications to treat depression.
More than 40 years later doctors are still woefully unprepared to care for the mind and the body as one. I’m retired after a career as a physician and academic, at Michigan State University, but the legacy I hope to leave in medicine is only beginning. I’m raising my voice in calling for revolutionary reform in how Western medicine treats the psychological, social, personal, emotional, and mental health aspects of its patients. I’m heartened by the reaction I’m receiving. Together, real change is possible. But it requires all our voices.
The problem lies in the historical division splitting psychosocial issues, including mental health, from general medicine practice. Doctors still focus almost exclusively on treating and prescribing medicines for physical illness, the personal and mental health issues of someone like April given short shrift. It not your doctor’s fault: medical education provides no more than 2% of total training time to mental illness and other mind-based issues, even though they are the most common problems physicians see in practice. Yet, the untrained primary care and other medical doctors provide 75% of all mental health care; psychiatry and psychology combined provide only 25%.
Nearly 100 million people in the US have a mental disorder, so the downside of this is devastating: ill-advised use of opioids by doctors not trained to use them or in chronic pain led to over 200,000 preventable overdose deaths; half of 48,000 suicides each year could be prevented if doctors were trained to recognise and treat it in the patients who visit them in the 2–4 weeks beforehand. Tens of millions more Americans suffer these nonlethal complications because doctors do not recognise and effectively treat their common problems of depression, anxiety, and substance use problems: divorce, job failure, poor school performance, addiction, incarceration, and homelessness. And it’s not just unnecessary deaths and devastating personal problems that follow, the financial cost to society is in the trillions of dollars. Medicine could prevent this carnage by the simple and obvious corrective measure: train the doctors who provide the care.
As a society we don’t have to accept this. We have made revolutionary changes in medical education before. We’re long past due for rethinking health care. Mental health and other emotional and mind-based issues can be a more robust part of medical education without short-changing physical medicine. Others and I have created the blueprint for this evolution. What our country lacks is not the resources, but the will.
If you’ve ever tried to talk to a doctor about depression, grief, addiction, “stress,” or trauma and felt dismissed or ignored, I want you to know: You’re not alone. And there is a way forward.
Dr Robert C. Smith is the author of “Has Medicine Lost its Mind?”. He is also a University Distinguished Professor and Professor of Medicine and Psychiatry Emeritus at Michigan State University.