Learning as a Resident with Dr. Mark Mullen

Mark Mullen: [00:00:00] Here's what I want to say to the clerkship students that I probably can't say. As a clerkship director, show up. Be on time, pretend to care. Be professional. Don't cross any boundaries, and you'll not do fine. You'll do great. How to be patient. 

Preston: Welcome back to How to Be Patient. On this podcast, it's a little bit more of a how to and less on being patient.

And we are joined by um, what our great guest, um, Dr. Mark Mullen. Dr. Mullen is an assistant professor at SLU and also the clerkship director of their, um, psychiatry clerkship for medical students. He hosts this podcast, psychiatry Bootcamp, which is trusted by academic institutions across the us, including University of Wisconsin, Mayo Clinic, Creighton University, and University of South Florida.

So thank you so much for joining us, mark, 

Margaret: and he's one of, he's a podcast brethren to us. 

Preston: Yeah. Hello bro. 

Margaret: He is part of the human content family. 

Mark Mullen: Yeah. Super excited to join. Very fun that we're all on [00:01:00] human content now. I'm a fan of your podcast as well and, uh, fan of all your work. So, uh, wonderful to be invited.

Preston: Oh, well, we have a lot to cover today. I think we first wanna get to know your story. Then we're gonna talk a little bit about one thing that you're passionate about, which is education and all levels of training, and kind of what the transition to into New Year is like. And at the end, we're gonna wrap up with our chalk talk round robin, and this is a new segment that we're gonna be doing.

So there may, there may be some, uh, some rust in the chains as we kind of get this thing, um, going. And then we will share a couple stories and anecdotes from what our life was like in residency. So, 

Margaret: and we want this, I know everyone episode to be, I'm in trusting because I can, we're gonna, we want this episode, it's gonna be coming out in February.

Uh, if you're watching on YouTube or Patreon, ignore the Christmas decor behind me. Um, but it is for the February intern, especially the February off service intern. 

Preston: Yeah. Very special person in all of our hearts that February intern. [00:02:00] So, mark, we all have an interesting relationship with podcasting. I think Margaret and I have our own story that got us into this, and I'm really curious, what made you wanna start a podcast?

Mark Mullen: I'm a fan first, so I've, I, it might be pathological. I feel like I can't be silent anymore. Like I always have a podcast running. I had a 10 hour drive to undergrad and I think I got hooked at that point. I just became a big fan. So podcasting has always been a big part of my life in that way. Um, and then for psychiatry, podcasting in particular, I remember getting to residency and sort of starting residency and feeling like I had been equipped with very specific skills from medical school, but that those skills weren't necessarily translating into my new job as a doctor, as the leader of a team, someone who was performing direct patient care.

And so I turned to podcasting and I found just a wealth of information there and. It changed my life, frankly, certainly my professional life. I felt a lot more confident in patient encounters. My pride scores, um, just skyrocketed. They went [00:03:00] from not very high to a lot higher. And that was because I was every day after work, taking an hour to walk my dog or just spend some time decompressing and picking a psychiatry podcast episode that related to a patient that I had at that time and just deciding to learn about one thing a day.

And it was so fruitful. And so I wanted to contribute to that. And I felt like there was a lot of good information out there about psychopharmacology and different diagnoses, but there was less out there about a how to approach. So more practical skills like how to do a risk assessment or how do I manage something that is not a diagnosis like agitation, um, or, okay, I know how to come up with a diagnosis, but how do I formulate it?

You know, what's that next step? And so I kind of set out to create the tool that I wished I had when I was an intern, and that is psychiatry boot camp. 

Preston: That's so what I think what a lot of people do is be the change they'll hope to see in the world. Um, I think Gandhi said that, and, and you, you're in a lot of ways following in his [00:04:00] footsteps.

It sounds like it was a tool of education, um, that you were using until you decided where you could add onto world. I didn't know where that 

[music]: sentence was going for us. 

Preston: Yeah, I don't think I knew where it was going either. That's nice thing about our podcast is that we were fans first. Um, and then we also, um, decided to just make it up as we go, which is kind of how we do with just about every one of our episodes with a little bit, with, with a little bit of education, a little bit of how to mixed into there, um, 

Margaret: a little bit of infighting.

Preston: Yeah. Yeah. Just, just enough to keep it exciting. I, I think it's a really, uh, powerful story and I resonate with that a lot actually. Um, I'm curious, what educational podcasts were you listening to as a resident? 

Mark Mullen: Sure. Yeah. I mean, I think David Ter, who's become a mentor of mine, 

Preston: shout out to, I listened to his, 

Mark Mullen: yeah, there's so much.

Yeah. I listened to Carlot. I listened to NEII listened to, 

Margaret: we met the Is Good. We were at a PA. We [00:05:00] met him. We were on a panel with him and we're like, mm-hmm. What? Curbside is great. 

Mark Mullen: Yeah, I mean, there's a ton out there. When I was a chief resident, I was in charge of didactics, and so I made a spreadsheet of different topics, different diagnoses, different medication classes, and I mapped podcasts that I had listened to and vetted to that spreadsheet.

And I made that the, um, on your own part of a flipped classroom model for didactics. Mm-hmm. And I still have that spreadsheet. I still share it from time to time, but I, um, I had a robust residency experience. I think I went to the best residency program in the country, Creighton University. Shout out to Creighton, but 

Margaret: Midwest 

Mark Mullen: there, you just are never gonna have the education that you need in that moment from lectures.

So you have to find it on your own. So, um, I think there's, there's tons of good psychiatry podcasts out there, but I gotta give a major shout at the David Peter. We 

Margaret: need. We're, I think we're, he'd still, I think he told us he would come on, but we're just like, well, we, we need to, we're slowly working through the, through, through the psychiatry.

We a couple more 

Preston: levels [00:06:00] yet. Yeah, yeah. Before we bring David putter on, so you started the podcast, uh, after you graduated residency, I'm assuming, when you were an attending, is that right? 

Mark Mullen: No, I started during my PGY three year, oh. Um, during my outpatient year actually for a few different reasons. One, I felt like having a listener go through the learning with me as opposed to me teaching would be extra meaningful.

Um, and then I also knew that my guests would be a lot more likely to work with me as a trainee. Um, I know that academics are bleeding hearts and that we will do, and myself included now that I'm an attending, will do anything for a trainee. And so I kind of felt like I had to strike while the iron was hot and while I still had that card to play.

And then lastly, I. So part of this came from a paper that I, I was on that went into the Journal of Surgical Education where we interviewed current interns and we said, what was helpful for you? And I did the data analysis of these interviews, and every single person, all 27, 27 out of [00:07:00] 27 interviewee said, I had a bootcamp and it was the best thing I ever did.

And I was like, oh, in psychiatry, we don't have procedures. So you could take a bootcamp and you could make it a podcast because mm-hmm. We don't touch our patients for fear of counter transference. Right. So it translates very well to a podcast. Mm-hmm. And I thought, this is such a, at the risk of sounding more an narcissistic than a podcast host always does.

I thought this is such a good idea that if I don't do it right now, someone's gonna steal it. Yeah. So I just got on my horse and I did it. 

Margaret: Yeah. No, I think that's like. I, I hear you. What you're saying that you feel like in training, like you had a robust experience. I think there's a lot of places where people don't feel that they have that or they don't have, there's areas where they're like, I mean, I feel really prepared in this, but not in the other.

Um, and I think I, my the, what you've provided and what other people in this space have provided is like, here's good teaching in someone who cares about medical education and has the dual skill of understanding the, the, you know, clinical learning. And it's [00:08:00] relatively close to it, especially when you started and can figure out a way to make it into a story and make it into like a lesson that makes sense or give it enough kind of hooks into it that different sorts of learners can get onto whether they're a med student, whether they're a resident, um, whether there are any other healthcare professionals that are just like related to this, um, I think is really, really great.

I 

Mark Mullen: think right sizing the information is one of the hardest pieces of medical education in general, right? Because I'm trying to build a podcast for apps, m threes, M ones if they're interested, and attendings, right? And so how do you know what level to hit it at? And so I tried to have kind of a layered approach.

Um, but I totally agree. 

Preston: Mm-hmm. And I think that's a good transition to kind of one of our early topics today, which is how do you navigate this transition as you kind of go up those rungs of ladder from learner? Because, um, you know, when you're saying like, how do I make the right bite-sized piece of information to dole out to these audiences?

Well there those audiences are [00:09:00] also dynamic. Like, I think I learned differently when I was an M1 from when I'm an M three versus an intern versus now PGY three. And eventually you knock on wood, a fellow just like Margaret, and then, you know, God willing and attending someday I'll, I'll have a different relationship with information at each of those stages.

And today we're kind of talking about the transition from med student to residents. Changes do you see in how we like have to learn or consume knowledge, um, when we kind of make that first initial jump to become an md? Or do 

Mark Mullen: I remember being relieved at the transition in primary objectives from medical student to resident?

Because I feel like, and felt like as a medical student, your primary objective is do really well, be really successful, match into the residency program of your dreams. And part of that is just wanting to succeed professionally. Part of that's also, I think, really reasonable. It's geographical, it's, I have a family here and there's only [00:10:00] one program in town, and so I have to work my tail off to match that program.

And so it becomes a game of who can be the best, who can score the most points, um, who can get the best evaluation from the attending. And that objective is different than how do I become a great doctor? How do I serve my patients? How do I. Live a meaningful life and also practice evidence-based medicine.

And when you get to residency, the evals matter, but a lot less, right? It's so much less of a rat race and you're the one making a clinical decision. So it's a lot more meaningful. Um, when I think back to medical school, I always felt like I was standing in a corner trying to hide my personality and do well on standardized exams.

And now as a practicing doctor, that is like the furthest thing from what I'm doing every day. I'm having really intense conversations with people that often really don't wanna talk to me or are talking to me about information they would much rather not cover. And so it's kind of a whole different skillset and I, so I was relieved when I went to residency at that changing goal.

But I also [00:11:00] found that all of these strategies that I had used to meet the objective at medical school were no longer meaningful strategies. And so I found that I needed to change the way that I learned, change the way that I organized my day, change the way that I thought about what I'm doing from nine to five every day.

Mm-hmm. Um. And I would say lastly, I navigated each transition with great difficulty. You know, I think mm-hmm, mm-hmm. It's only through falling on your face and realizing, oh my gosh, I am an idiot. That you can really begin to grow. And I definitely have had a lot of those moments. 

Preston: Yeah. I, I remember as a third year med student, I would start to filter stuff down to like, what is relevant versus what is not?

Because your bottom line is so strictly like, how do I get into this next exclusive club? And like, there are jokes that there are memes about it. You'll see where like, is this high yield or not? Like, am I gonna care about it? And, and residents will try to say like, oh, but like, this is important for doctoring.

And, and as a student, sometimes your blinders are on so much you're like, I. I [00:12:00] get it. And like, I almost appreciate ethically that it's important, but like I'm tucking this away because I need to think about my shelf exam. I need to think about step two. I need to be, I need to shove as much trivial information as I can through note cards, through flashcards and um, practice questions to regurgitate them that almost like the how to doctoring stuff gets pushed to the wayside.

Margaret: I think about the transitions and I feel like every, I've told my, like people who are a couple years younger than me, or when I was like a fourth year in med school, but even in residency as like a chief last year, that I had the experience that every transition was into something better in terms of like, I like loath.

The first two years of med school. I like, there were parts I didn't like about the judgment third year, but I was like, I wanna do psychiatry, like whatever. And then getting into intern year and then fully into psychiatry was like, I think going into med school and being like, I'm like pretty sure I wanna do psych.

Made it be like. Okay, like I'm not doing [00:13:00] histology anymore now I'm just in this, and I remember like switching to intern year, like my program was six months and six months on psych. And then either internal medicine, neurology or like peds and pediatric neurology if you were child track, which I was. Um, and the reason we said February intern at the beginning of this episode is because I feel like February intern year in PS in any intern year, but also in psychiatry is like when you're starting something over brand new that everyone else around you is good at already.

And I think that transition in psychiatry and probably, I don't does any other specialty do it that way because neuro has a full year. Right. 

Preston: I think, I think we're only like, I dunno, half TY year. 

Margaret: Yeah, so I remember showing up to peds and being like, we're like on a like super specialized peds floor in like rheumatology.

This is like 2021. So like, like MISC, which looked like Kawasaki's [00:14:00] after COVID was like this huge brand new thing that I didn't know what it was. And I stepped in and these are like month seven interns. And I was like, so I've been, I've been doing brief therapy and talking about like antipsychotics. I with like average age 40-year-old man in an inpatient unit, so I don't know what's going on.

Mark Mullen: I remember on my internal med rotation, we had a patient with COPD and I presented the patient and I said something to the effect of like, this patient has gold stage three COPD, and I think I just read it, you know, in the chart. And the attending was like, oh my gosh, that's wonderful. Like, tell me what that means.

I was like, come on, really? Like out. You're like, it's 

Preston: worse than stage two, but not as bad as stage four. 

Mark Mullen: I'm like, it's not platinum, it's not bronze, I don't whatever. You know? I dunno. Yeah, 

Margaret: it's number one. Yeah. 

Preston: Yeah. What's his meld score? Ah, 

Margaret: yeah. So I think that this point, our [00:15:00] listeners are hearing this, um, they can be in this intern transition.

They can also be in these other transition points we're talking about when you are mentoring people. And I'm curious, Preston, for you what you think about this question. Let's say you meet an intern for the first time, they come on your service, or it's a brand new third year med student who hasn't been clinical before.

You're meeting with them and they say to you, it's February, or it's like, you know, week two on psych, whatever. I'm struggling with this. I wonder what you would say to the intern and then what you would say to the med student transitioning into their third, their clinical year. 

Mark Mullen: Preston, do you wanna bite this off first?

Preston: Sure, yeah. I guess being the most proximal to intern year, um, I, I guess I, I went through like a lot of tough stuff. My, uh, intern, my February of my intern year actually. Um, there was like a suicide on the inpatient unit and I like found them and had to do the code blue and I was like, just like trying to survive, I think was how a lot of the days went through.

Like, I [00:16:00] remember like trying to deal with the fallout of that and then the, the, you know, all the program supports come through and people are like, you know, if you need anything, be there for you. And they're like, I don't know if I need something. I think I'm doing okay. And then I remember just spending a lot of time at that stage intern year, feeling like I was figuring out some of the hospital function stuff, but then still nowhere near where I wanted to be as far as like understanding the medicine of what I was doing at each moment and making these diagnoses.

And so. The person who actually gave me the, uh, the most grace and he didn't do it to me, pers to me personally. Dr. Strom, my program director, shout out to Dr. Strom. He says, um, your objective intern year is to get home every day. 

[music]: Hmm. 

Preston: If you make it home at the end of the day, you have succeeded each day of intern year.

And I would really resonate with that because you are trying to learn, you are trying to drink from the fire hose, and it's all this stuff that has nothing to do with medicine. It's like, how do I, how do I get this bed [00:17:00] order transfer in correctly to the EMR so the patient actually goes from the ED to this unit?

Like, that's what I'm learning about. And if I made it home and nobody died, like nice. So if someone was like coming to me and they're really stressed about learning during their I year, the first thing I would say is like, are you making it home every day? You are awesome 

[music]: advice. 

Preston: And I was just let let it go after that.

Mark Mullen: I think that's brilliant. I, I, my. So how would I advise an M three and how would I advise an intern? I think I'll start with, how I would advise them is different depending on where I am in my career. So the way that I would interact with a medical student when I was a resident is a lot different than the way that I interact with medical students.

As a clerkship director, love boundaries. It has to be manipulative me, right? Like, thank you Margaret. Thank you. Wait, 

[music]: shout out. 

Mark Mullen: Yeah. And part of that was trial and error, right? I mean, I, I, as an attending, I've had to have some, first of all, I'll say in defense of all the attendings out there, [00:18:00] giving feedback sucks.

No one likes to give feedback. It's super hard to do. It's really hard to do it specifically. You have to do it. That's why people are there. And you have to not only give formative feedback, how do you give better, but summative feedback, what's your overall grade relative to your peers? And that is a job that's really difficult.

And I, I, I hate doing it, even though I love being an educator. So. My approach as a, as a resident, and my approach as an attending is different. But here's what I want to say to the clerkship students that I probably can't say as a clerkship director, you 

Margaret: can say it here, show on a podcast, 

Mark Mullen: show up, be on time, pretend to care, be professional.

Don't cross any boundaries, and you'll not do fine. You'll do great. You'll do great. Be enthusiastic. Um, and then my advice to residents and I, I learned this advice the hard way, which is why I give it out freely. And I, I haven't changed this in attending just because I believe it's as strongly is whatever your attending is selling, you're buying it right for that month.

It is their license and it's gonna make your life a lot easier if you [00:19:00] disagree with something, right? Ask one question, Hey, did we think about this? Why'd you decide this? But then you have to move on with your life, right? And again, I learned that the hard way. That's really difficult to do. Um, but I, I think that's, it's similar advice to, you have to go home at the end of the day, right?

You have to keep your eye on the big picture. But I think whatever you're attending is selling, you're buying in it. Reduces a lot of stress for residents. 

Margaret: I am gonna press against that because I think that that advice given to residents, at least when I, I mean I think it also depends who you're speaking to, as I'm sure you would do if this was like a, A one-to-one kind of thing.

But I ultimately, in the end, I don't disagree with you, that it's like it cannot haunt you. Like all the problems in healthcare, which you become very acquainted with during training. I think even more than when you're a med student for a lot of people cannot take over your life. And my mom, my dad's primary care doctor, like my family's very medical.

My mom would always say, my mom was not medical. And she would say, you can't let medicine eat you [00:20:00] because it will, if you like, don't go home. At the end of the day is the point that both of you're making. And I think like depending where someone is like. I feel the skills that, at least what I think about in med school and even getting into med school, are so much about performing to do well and like externally showing something.

And depending on your personality type and how early you start Med Med school in terms of your like own personal age and maturity levels, that like the ability to even recognize that like, hey, someone's doing something that is not, it's not like it's abuse, it's not like it's definitely bad medicine, but you can hold like, what can I learn from this person whether I agree or don't agree with them and hold that like, there may be part of you that is reacting like that That is right.

And like we should have places for you to explore that little voice too, because I think that is such a huge part of moral injury and burnout, even when it's not like, I mean, I think all of us have also had things where we're like, um, this feels [00:21:00] really wrong in psychiatry. Um, but that, that I guess is just my pushing point against it because my thing I was gonna say to interns was like.

It makes sense if you cry, if you know the best bathroom to cry and in the hospital, because what you're going through right now is kind of a nuts thing to have to go through as a human being. And then if you tell any of your friends who aren't in healthcare what you see every day, uh, they almost start crying when you tell them.

And so I, I just think that, not like, at least even just on the inside, being able to know that what you're feeling is not because of there's, there's some flaw in you. It's like this is kind of, I was about to say, excuse my language, but every episode we do is explicit. This is fucked up. Like it's a beautiful, meaningful job and a privilege, but it's fucked up some of the stuff we see.

Mark Mullen: It's nice to be able to drop an F bomb on a podcast 'cause I'm not in the habit of doing that on mine. So I, well, you feel for here, I totally agree. I I avoided it earlier, so I won't do that going forward. I'll say I don't, to me, that's not disagreeing with me. Maybe you're just being nice. That's what I'm trying [00:22:00] to say is that you're gonna see some stuff and think to yourself, I sure don't wanna do it that way and clock it and then you're there for a month and then do it differently.

Learn from it. Learn what not to do. But if you're trying to fight your attending on everything, or you know, if you're losing sleep over the attending that your decision, who it's their medical license made, you're gonna be in for a pretty rough ride. The other piece that I should have set, this is better advice, is my expectation of my residents is there are no stupid questions.

You have to admit what you don't know. Your job is to admit what you and ask. The residents that struggle the most, that are the most difficult to work with as an attending are the residents who are afraid to ask for help are trying to impress me too much, are more confident than they should be. And what, you know, I think as a resident, again, because you're not just going for an evaluation, you have the privilege of using this time really wisely to identify your knowledge gaps and fix those.

And as you're attending, that's what I'm here for, right? So [00:23:00] don't blow smoke up my ass. Don't pretend that you know something. Don't pretend that everything's going well, right? I don't know. I'm a resident. Yeah. I'm an intern. I need help. And as an attending, that's music to my ears. 

[music]: Yeah. 

Preston: Yeah. It's, it's interesting how comfortable I've gotten through residency hitting the, I don't know, button and, and then you realize like the world is an end when you get pimped and you don't know a question.

Just, I don't know that, you know, um, like the other day, I think. I, I met, I totally messed something up. Um, I was like starting a patient on Lamotrigine and um, you know, you ramp for, you start out 25 milligrams after two weeks increase to 50 is like the FDA approved ramp. And I suggested to the patient, okay, after one week you can switch up to to 50, which is like, I think how I'd seen anecdotally before, but never looked it up myself.

And so the attending was like, well, do you actually know that, you know, the FDA approved ramp up for Lamotrigine? And I sit with it for a second. I said, I don't know. And she was like, okay, well, like, look it up, then call the patient and then like tell 'em the actual appropriate way to do it. And like, that's, that's how I've learned the [00:24:00] most, honestly, as, as an intern, as a resident, is when someone asks me something, just making eye contact and just flatly saying, I have no idea.

I don't know. I dunno. That. And then, and then you do learn. And even if there's a little bit embarrassment for not learning or for not knowing that like emotional embarrassment, that'll help seal sear the memory in to your brain. You know, use it, capitalize on it. 

Margaret: I mean, that's what we do since our podcast is more like we, neither of us knows everything, nor do our two brain cells together, as the internet would say, know everything at this point, nor will we ever, uh, someone I had like put something on our story about season three coming out, which we're, we're in right now filming this episode, and they were like, can we do more like functional, like neuroscience episodes, like neuroanatomy things?

Like one of the, a couple of the ones Preston did last season and they go, sorry Margaret, I just like, I'm practicing not knowing I'm, I'm in the cloud of unknowing mm-hmm. As my [00:25:00] theology one would say. 

Preston: Well, and, and even when I try to know, I think one thing we approach on the podcast is I'll say, here's what I found.

Here's what I think is right. Mm-hmm. But ultimately, guys, I'm trying. And, and actually aside, I think this is good advice too, to say, saying, I don't know, to a patient is also really powerful. Um, not necessarily about like what's happening to them or like, what medications should we try? What 

Margaret: am I getting outta here?

I don't know. 

Preston: Like, yeah. They're like, what is, what is Lexapro? I don't know. Like, I don't know if that's the best. I don't know to drop, but sometimes patients will say, you know, like, doc, what do you think will happen to me next if I take this medicine? And then you can you just say, I don't know, but I'm also gonna figure it out with you.

Mm-hmm. Each step of the way. And, and then I think people respond well to that authenticity at, in every interaction. 

Mark Mullen: You gotta That's, and that's. What I think psychiatry gets so wrong, and that's one of the reasons that I started the podcast, is there's this perception of psychiatry out there that if you are distressed, if you're having psychiatric symptoms, you can go to a wizard wearing a white coat, they can put you in this [00:26:00] little box, pull a couple of numbers in, check, check, check, and then spit out something that's gonna fix your neurotransmitters.

And it's garbage. It's garino. Right? And by saying you're a complicated person, and I'm not a hundred percent sure how to solve your life, I think it helps people to feel seen. And I think that level of authenticity is probably more healing than psychopharmacology in a lot of cases, especially patients who have more mild symptoms.

Preston: Mm-hmm. Or when you respond with kind of the distant customer service, like, this is what we recommend for everyone, X, Y, and Z, yada yada. They're like, but I asked you, is this medicine gonna help me? And you can say like, I don't know for sure, but I think it will. Like that's, that's a much more human way to respond.

So I don't know. I think maybe the lesson is whether you're a learner, whether you're a physician, whether you're, anybody saying, I don't know, is a pretty good thing. 

Margaret: I do wanna point out some positionality here, which is that women in medicine might need to hear something different than men in medicine.[00:27:00] 

Um, that's like, and that's not to say that there aren't points for me, myself. There are times when I'm like, I know, and maybe I needed to not know. But I think that it is, there is still quite a bit of sexism in medicine that comes from many directions. And so obviously women too get scared or get up in their ego and struggle to say, I don't know.

But I also think that there's a force that maybe you guys are less familiar with experientially that is like, what does it mean? For a woman to come in and be like, here's our plan. Not in a paternalistic way, but to be, do it exactly the same way as either of you would. And a patient would look at you and say, thanks, doctor.

And they would look at me or one of my co female, you know, physicians or providers and say, when will the doctor be in here? Or she was being kind of mean. And I, I just wanna say that 'cause I actually, I'm thinking a lot of my female friends and like mentors and mentees in medicine [00:28:00] that I don't, I don't know that they need, and I don't think you would necessarily say this, but I don't, I don't think their issue is always like, you need to be more comfortable with not knowing because I see them, you know, classically internalized much more versus like, so I, I just wanna say that 'cause as I'm listening to it, I'm thinking about like, what would intern year or med school, me here.

And it would hear this and it would internalize it and be like, I've gotta study more. I really don't know. And what she needs to learn was like. Your voice doesn't need to shake while you're doing a presentation. Like, you know, as much as some of these other people who are more comfortable asserting themselves naturally or whatever.

Um, so I just wanted to say that for some of our listeners, there are other intersectional identities that I can't speak to as a white woman, but that exist too, of like, who gets to feel like they can assert themselves in medicine? 

[music]: Hmm. 

Mark Mullen: Great take. Couldn't agree more. I think there's a few different variations on, I don't know too, there's, it, it's never, [00:29:00] I don't know, but I'm gonna bill you anyway, so good luck, right?

Mm-hmm. It's, 

[music]: mm-hmm. 

Mark Mullen: I don't know, but I'm gonna figure it out for you. I don't know. Meaning we don't know. Mm-hmm. Or maybe there's some times where I don't know, and I'm gonna have to ask a colleague because this is a really complicated case, but I, I think that's, you're right on the money, Margaret, and I really appreciate that perspective.

Preston: And then there's, I don't know, because what even is knowing at the end of the day. What is a fact, even, you know what, if anything, and I, I try not to get too, uh, ontological with peach You, but, but sometimes I'll go there, they're like, do you know for sure? And you're like, well, you don't know anything for sure.

Really? Do you? 

[music]: I'm like, well, who, who is to say, 

Preston: yeah, yeah. Where are we right now? Even? Are we on earth? Are we conscious? Is this a simulation? Well, on, on that note, I think we'll take a quick break and then when we come back, we'll go into our chalk talk round Robin, 

[music]: love it.

Preston: You tolerate [00:30:00] so much during the day, and if you're anything like me, the last thing you wanna deal with when you get home is uncomfortable bedding. 

Margaret: I want the experience to be as luxurious and as not reminiscent of any call room, any hospital blanket that I've had to use on a 24 hour shift. And that is why we use Cozy Earth.

I use Cozy Earth. At least 

Preston: we use Cozy Earth. I'll correct you there. I I love to throw my sheets in the dryer for 15 minutes and the Cats and I cozy max after for the rest of the evening. And if you want to try it too, there's a risk-free purchase for a hundred night sleep trial that works out for you.

You have a 10 year warranty on these. So why don't you start the year off right? Give your home the luxury it deserves and make home the best part of your life. Head over to cozy rec.com and use our code patient for up to 20% off. And if they give you a post-survey at the end, let them know that we sent you, 

Margaret: give the gift of comfort that lasts beyond the holidays and carries into the Coziest New Year yet.

So in 2026, my goal is to open a very small private practice as a post-grad [00:31:00] psychiatrist. And one of the tools that has helped me do it is Simple practice. Preston, have you heard of Simple Practice? 

Preston: Yeah, I have heard of Simple Practice. Actually. I use it as a patient, well I guess my therapist technically uses Simple Practice 

Margaret: and is it in fact simple?

Preston: It is very simple. It's, it's convenient. Um. I would recommend. 

Margaret: Yeah, well, from, from the therapist side, simple Practice is an all-in-one EHR that is HIPAA compliant, high trusts certified, and it is built specifically for therapists. So it brings scheduling, billing, insurance, and client communication into one place so that you are not juggling multiple systems just to run your practice.

Or if you're Preston's therapist to see him, 

Preston: I, I mean, I'm enough to handle as is. She doesn't need to worry about other complicated things. 

Margaret: And if you're just starting out or growing your practice, there's also credentialing service that takes the headache out of insurance enrollment, which honestly can be a huge lift and something that I was a little scared of.

Preston: So if you're ready to start the business side of your practice, now is the perfect time to try Simple Practice. Do it with us. Well, I guess me in the future, and Margaret now. So [00:32:00] start with a seven day free trial, then get 50% off your first three months. Just go to Simple practice.com to claim the offer.

That's Simple practice.com.

Okay, and we're back with chalk talk round robin. This is the first time doing this segment, so get your chalk and your board out because we're whiteboard gonna do, we're doing some talking. Yeah. 

Margaret: What was the most absurd timing of someone trying to give you a chalk talk during training so far, or Preston, but in general for you?

The rage I knew it would cause rage. 

Preston: Yeah. I mean I, I think I, most of mine have just been the classic like 6:00 PM on a consult service when you're like trying to move to your like overnight call shift and you're like, this, this is so interesting. But I have to go, sir, please, 

Margaret: lemme go. 

Mark Mullen: I'll get you upset.

I can't talk about it. But what I will say is that I tell my med students, if you want afternoon teaching, that's what the podcast is for. So go walk your [00:33:00] dog and listen to the podcast. 

Preston: Oh nice. That's smart. 

Margaret: Mine prepackaged. We woke up, we woke up. I an off service when I was on peds. To help some kid who ended up not needing even any help.

They were fine. They were like, went right back to sleep. Nothing was wrong. 4:30 AM my senior who knew I was an off service psych intern was like, do you wanna do a chalk talk on sodium? We had done one, two days ago. We had done one two days ago. And I was like, it's four 30 on Sunday morning Am No, I don't wanna do a fucking chow talk.

Uh, so in lieu of that, here's a awkward listen. Needless to 

Preston: say 

Margaret: she was 

Preston: salty about that.

Margaret: Okay. Preston, explain your idea because this, oh, I 

Preston: think 

Margaret: segments yours. 

Preston: Wait, I did have a pretty rough one. Um, so I've been awake for 24 hours and I'm like presenting after my, my call shift. And I said, you know, this is a patient that came in. They had a suicidal gesture. And then my, [00:34:00] my attendee like perked up at that.

He was like, gesture, do you even know what a gesture is? And I was like. Um, you know, I think it's, it's communicating with movements and not words. And he is like, well, what's the psychiatric definition of a gesture? And then the next thing I know, it's a whole chalk talk on, on the entire spectrum of like, what is suicidal behavior from like, 

Margaret: you're like 

Preston: morbid idea Lloyd to like preparatory behavior.

And I was like, well, like he held a gun to his head to like gesture that he was gonna become suicidal. And he was like, no, that's preparatory behavior because you're preparing to shoot yourself as a gesture if you like cut yourself lightly, but it's not lethal because then you're like implying it. And I was like, is this written anywhere?

Because I'm, I'm like getting confused too. So I don't even know if it was a chalk talk or just kind of like dumping someone's opinion on me. But I'd been awake for 25 hours and I think I was, I was kind of just like crinkling the, the round sheet, like under my hand, like, thank you for this information.

Some appreciative and 

Margaret: well, then you ask that kind of person like, [00:35:00] why does that, like, what is the validity? I mean, you don't ask that hour 25, but you're like, so what's the validity for why we should use a specific term and why you're correcting me? And and they go, well, I was under forbid from ever 

Preston: using the word gesture again actually 

Margaret: hundred years ago, who did?

Like, it's, 

Mark Mullen: so here's the dialectic there, right? Here's the tension between opposites that attending was wrong, and whatever your attending is selling, you're buying it. 

Preston: Yeah. And I, and you know, I bought it. I just said, 

Mark Mullen: right. 

Preston: Even, even kind of me, I think I had an uppity response to the, like, what even is a gesture?

I was like, a movement with act or like a, a message sent with actions. Yeah. And then after that I was just like, thank you for the learning. Thank you for the learning. Like, I almost go into this robotic, like, thank you for the learning, sir. 

[music]: Mm-hmm. 

Preston: That's, that's what military teach you. Yeah. 

[music]: So delicious.

Preston: Oh, more please. 

[music]: Preston, 

Preston: what are we doing here? Okay, we're, we're on topic here. So, so my idea for the five minute chalk talk is basically [00:36:00] what is, um, something that you can go into like a quick, almost like rant about within anything within medicine or psychiatry that you would want to tell your intern self.

So someone, and it, and it could be anything from interviewing patients to like, here's the thing about a syndrome, here's what you do about this medication. Um, and how to prescribe it. So I think a, a great example of this was like, I'm, I'm on internal medicine, right? Um, this will be like a 32nd example.

And then one of my senior wants to go into GI and he, he like freaks out and goes, why are they ordering a fecal occult blood test in the ed? Don't they know that there is like no utility to ordering a fecal blood blood test in the ed? And I was like, why is that? And they'd be like, because it's a way to screen for like any amount of like, blood in the stool.

And like, like when you're actively trying to diagnose a GI bleed that like doesn't offer you anything. It's like a cancer screening that you do in the outpatient setting. But like the positive screen and the negative screen don't offer any utility at this moment because you can't like differentiate between like the [00:37:00] types of blood.

And I was like, oh, very useful for me to know, you know? And then I, I'm pretty sure he went on for another four minutes. All I took away from it was that initial part. So if I'm ever needy doc, I'm not gonna get a fecal call, blood test. I'll have to do a digital rectal exam and just kind of look for the bright red blood.

Um, but, but everything else, you know, it's all in GI land as far as I'm concerned. So this is our opportunity to have that. You stare at the computer, you start banging your head and you say, here's the thing about X, this is our five minute chalk talks. 

Margaret: Amazing. 

Mark Mullen: I did come prepared for this. 

Margaret: Amazing. 

Mark Mullen: I excited to see.

I have two options. 

Preston: Oh, 

Mark Mullen: we can do agitation or suicide risk assessment. Which do you prefer? 

Margaret: I vote agitation. 

Preston: I was gonna vote agitation. 

Margaret: Uh, twin. Twin. I'm getting agitated. Twin two diva Voting for the same thing. So first 

Mark Mullen: I'll say in defensive chalk talks, I think some people think they're a little bit outdated and I like podcasts myself, so I, I always hated it when I was held hostage for a chalk talk.[00:38:00] 

Um, I think there is value to like a real visual aid. My number one mentor of all time PJ Malin at Creighton. I love her so much. She, she impressed upon me that some learners don't know what to do with their eyes. They get anxious. Mm-hmm. They need somewhere to anchor their eyes so that they can allow their mind to focus.

So I do bring computer paper around and I'll, I'll write out my chalk talks. So this is about agitation, um, and agitation when you're not on psychiatry is a very broad term that's used to describe any number of behaviors ranging from being a little bit crabby to attempting to stab someone. Right? Those are both agitation and so calling those agitation is not very specific.

And when you're on your psychiatry rotation, when you're a psychiatrist, we're really the experts in this area. And so we need to use language that is more precise. So I like to walk my learners through the crescendo from irritability to violence. So irritability is a mood state. Everybody gets irritable sometimes I get irritable a lot.

I skipped dinner at 7:00 PM I'm a little bit irritable right [00:39:00] now. I'm sorry if that comes through. If you're working nights, if you've just had a bad day to steal an acronym from aa, I think of halt, hungry, angry, lonely, tired. This is irritability, right? It's not a mental disorder. It's not pathological. It doesn't necessarily need to be treated.

But as a doctor, if your patient is irritable, it's good to pick up on that and then maybe ask them how you can help them to reduce that irritability. 

Preston: Sorry to interrupt, but HALT is also an acronym for how you're supposed to store olive oil or the things that can cause olive oil to go wrong. It's heat, air, light, and temperature.

So you wanna make sure your olive oil is stored in a cool area, not exposed to air in a dark place. 

Mark Mullen: I literally just told you that I skipped dinner and haven't eaten in 10 hours and you're gonna hit me with that. 

Margaret: I literally just told you, you knew I was sensitive about that. 

Preston: So just remember, halt guys.

Margaret: We gave you 

Preston: break, eat. I dunno what you want. Irritability in your 

Mark Mullen: Preston, you're giving neurosurgery right now, I gotta tell you. So, so that's irritability, immune state. He's gonna 

Margaret: make ski [00:40:00] about that. 

Mark Mullen: It doesn't need psychopharmacological intervention. Um, and then a step beyond that is agitation.

Agitation is where the mood state has become behavioral. So you have increased psychomotor activity. Maybe you're pacing around, maybe you're moving your leg, and of course agitation can be a catchall term. But in this model, you go from irritability to agitation. Behavioral state becomes targeted, it becomes goal directed, and we call that aggression.

So two examples of aggression. Aggression is defined as ready or likely to attack or confront. The two key examples here, one would be threats. If a patient makes a threat, like either you let me out of here or else this, um, that would be aggression, right? There's no question if the patient is ready or likely to attack or confront.

The patient just told me they are ready or likely to attack or confront. And so that would be aggression. The other would be posturing stands up, makes a fist, drops one foot behind the other. That's an aggressive act. And so when I'm documenting that, I'm not documenting, this was agitation, I'm documenting.

This [00:41:00] was aggression. And then the final step is violence. And this is one, this is a pet peeve of mine because it's hard to define violence. If you look at 10 different psychiatric sources, five of them will say violence has to be directed toward people. And five of them will say violence can be directed toward objects.

And that's my preferred definition. So if you are throwing your IV pull across the room, that's violence. If you throw your remote at the tv, that's violence. We don't have to actually wait for you to try to harm someone to call a behavior violent. And the reason these terms are so important is they guide our treatment plan.

So I'll skip to kind of the final point of the chalk talk. Sometimes I talk through like various verbal deescalation strategies and various psychopharmacological approaches. But AKI point here is when do you need to. Intervene in voluntarily using either, uh, medication or restraints. And the answer is when there is imminent risk of violence and where do I define imminent risk of violence?

I make it very easy for my learners. It's right [00:42:00] here at aggression. Once we've passed into aggression, we are ready or likely to attack or confront. And so there's an imminent risk of violence and I'm going to need to intervene. And so I think that this framework makes those really difficult decisions about when do I need to intervene?

Involuntarily a lot simpler. It gives you a mental model to make those decisions. 

Preston: Mm-hmm. So in our documentation, we're often asked for agitation recommendations. So using your model where irritability is like kind of, um, emotional discontent, frustration without any direction of this, uh, anger, we would say like nothing for irritability.

And then for. Aggression, non redirectable aggression or aggression that's non-responsive to verbal redirection. Then we'd offer recommendations and almost like do away with the, the terminology of agitation. 

Mark Mullen: Yeah. I mean it depends on your nursing staff's comfortability. So if they prefer the terms mild agitation, moderate agitation, severe agitation, then we can take our [00:43:00] higher level medical decision making and translate it into the, into that vernacular.

Um, but I, I would say too, like offering a voluntary PRN for a patient who is irritable is a really good idea and it can prevent that crescendo. So, but, but my point is you don't have to treat that. You don't have to medicate that. And just coming into the bedside as a doctor and saying, I care about you.

I'm here to serve you. What can I do to help you? Might be a more effective treatment for a lot of irritability than five milligrams of halol and two milligrams a Ativan. 

[music]: Mm-hmm. 

Margaret: What about verbal screeching that is not gonna stop and is like threatening, like, not even threatening, but like unpleasant.

Racist, sexist, um, like screaming up and down the hallway. What do you think about that? 

Preston: Yeah. Mr. Aggression, man, what do you think about that? Yeah, yeah. I 

Mark Mullen: think I don't wanna talk about it on the internet. Should I? Can I not? 

Margaret: Yeah, you can pass chalk talks over. Only got a few minutes. 

Mark Mullen: One thing that did happen to us recently [00:44:00] was a patient exposing themself to staff.

And is that violent or is that something that you can tolerate? And I had to really think on this and pray on this and seek supervision on this. And I think that's violent. I think it's sexual harassment, and I think that there are severe negative consequences for our staff when that behavior is present.

And frankly, it's criminal. So they're lucky they're in the hospital because if they were anywhere else, they'd go to jail. Um, and personally, 

Margaret: if they're very psychotic, 

Mark Mullen: I, I think either way, right, that that can be an aggressive behavior that can cause harm to others. That's, and I would probably intervene.

But the question of just like nongo directed yelling is a much more difficult one, and I probably wouldn't have to approach that on a case by case basis. 

Preston: A good case by case basis is good answer to a lot of Margaret's questions. Apparently in law school they say no hypotheticals. Um, because, because I don't know, I know med students are little bit this, but law students are like the worst at like asking for like, what about this actual scenario where technically, you know, technically, um, in [00:45:00] tort law he was left-handed and he was driving a yellow car and it was midnight.

Does that change the scenario? And they're like, 

Margaret: but that's how you understand a rule. That's how you question it. But you say, well what if this, and you, you give them the worst example and see if the rule still fits. 

Preston: Okay. 

Margaret: It happened. I was thinking that happened recently i's you 

Preston: push all to its limits.

Margaret: Okay. If I had been like, I don't know, I could've like someone, we have all dealt with cases where it's like we're getting called from the primary team. It's like this person won't stop screaming. And you're like, they're agitated. And then it's like, what are they doing? It's like, well every time they're like, wife tries to enter the room, they call her whatever, blah.

And like, then they scream for the next 10 minutes. Like that all of us had a client, like something 

Preston: like 

Margaret: that. 

Preston: Mm-hmm. 

Margaret: So 

Preston: I guess I would, I would say extreme irritability, 

Margaret: extreme 

Preston: irate. Irate ability. 

Margaret: Irate ability. 

Mark Mullen: And ultimately nine times out of 10 you can probably treat that or deal with that without having to rely on involuntary [00:46:00] mechanisms.

So that's probably plan A. And then the other classic multiple choice answer is treat the underlying cause. Right. Love that. So there's your good Jeffrey. Cause 

Preston: love that answer's so cheeky when we do that. We're like for, they're delirious. What do we do? Treat the under everything. Cause morons what do want us to capacity 

Margaret: for what?

Preston: Okay. Um, so Margaret, you or me who, who wants to do the next chalk talk, 

I'll 

Margaret: go. Margaret. I know. I don't know. My mine won't be as good and like well prepared, but, so, um, mine is on something that I accidentally did a deep dive in when I was an intern after hearing something from my medicine intern and having a couple patients on Clozapine, and it is constipation and psychiatry, uh, we'll say inpatient, but it comes out honestly just inpatient, outpatient, what have you.

So what, this is my annoying style of teaching that is useful, but does, people don't, like if you guys have a patient, which, you know, I, whatever, I have a podcast so I can do it to you too, on air. [00:47:00] What is your go-to if you have an outpatient who comes in, let's say, and is like, doc, I don't know what it's been, but I haven't had a bowel movement for three days.

They don't have any abdominal pain. There's not been blood, so they're not vomiting, dah, dah, dah, dah. They, you know, kind of had this a little bit before and then you started them on a medication a couple weeks ago and they didn't pick it up until last week. What, how does the conversation go from there?

What kind of things do you ask about or think about as a psychiatrist who's not a internal medicine or GI doctor? Secretly, presumably, but this comes up quite a bit if you ask about it. I 

Mark Mullen: guess I'm asking about the regular pattern of bowel habits. For some people is normal not to have a bowel movement for a day or two.

I'm definitely asking about abdominal pain, abdominal discomfort. I'm asking about their diet if they have any upper GI symptoms. Um, but I don't work outpatient and when I'm in the hospital, this is i's problem. So I haven't thought about this in years. Mm-hmm. 

Margaret: Yeah. Preston, what do you ask, 

Preston: I guess [00:48:00] I ask 

Margaret: or think about in your head?

Preston: Oh, I guess I'm thinking like how much is this person moving around? Um, I guess so I, I, I was an athlete in college and I know better than a new one. Like 

Margaret: pre, pre fit? 

Preston: Yeah. Pres Instagram, nothing clears your bowels like a brisk walk through the neighborhood or a jog or something, you know, like if you, if this person's like up and moving around, um, I kind of like try to ask about that.

And then if they're like having issues eating or like wanting to eat. So if their appetite decreases, they're not gonna be having bowel movements. Like the whole system's probably gonna start slowing down. So yeah, those are the only other things I would add on. 

Margaret: Neither of you asked about our medications, which a lot of them do cause constipation.

So what medicines do you think about that may cause constipation that we as psychiatrist prescribe? 

Mark Mullen: Oh, I see. Clozapine, Clozapine. Clozapine, 

Margaret: yes. 

Preston: Um, amitriptyline, [00:49:00] peroxetine, um, 

Mark Mullen: anything. Olanzapines 

Margaret: got 

Mark Mullen: allergic 

Margaret: activity. Sleep ones have, yeah, Trazodone. First 

Mark Mullen: generation antipsychotics for sure. 

Margaret: Yeah. So a lot of our medicines have mild to moderate.

In the case of clozapine severe, if we were working in addiction, psychiatry, obviously we would be thinking about that with things like suboxone, methadone, but any, you're right. Anything with kind of loading from the cholinergic side is going to cause this. So let's say someone, you finally, this person's been struggling for years and you finally, you know, you are the best, most magnanimous, most informed from all the podcasts.

You listen to psychiatrist and this medicine finally works. There's just one problem. They have really significant constipation. It's, it's a run of the mill. Like, um, let's say that it's, they're on a second generation for, uh, mood stabilizing with another med, whatever. That's like less, you finally 

Preston: titrated their olanzapine now 

Margaret: constipated.

The mes are [00:50:00] perfect. Yeah. You're not gonna change the med itself. How would you help them reduce their side effects or deal with this constipation? And you're, you cannot say call. I am. Okay. How would you explain this to them, why it's happening? 

Preston: Well, I would say that, here's the thing, um, olanzapine does a great job of blocking those receptors that make antipsychotic, but it also hits some of the receptors that ke keep your gut moving along.

Instead, acetylcholine. So the, the way your gut moves your stool along is that it injects water into it, and that helps it pull out. So right now we need to get more water into your stool. So that, kind of use that to say, this is why I'm gonna start you on half a packet of MiraLax in the morning. If that doesn't work, go to one packet of MiraLax a day.

If that doesn't work, do one packet of MiraLax in the morning, one the evening. Uh, I would stay away from Docusate and Sena. Um. It's that effective. Why, 

Margaret: why would you stay away from Docusate? 

Preston: Because they so docusate, it's, it's like a sate or something. It's essentially just [00:51:00] coats the lining of the, of the stomach and the intestines, but doesn't actually have any osmotic function that's gonna pull water into a stool to get it moving along.

So I'm like more motility. 

Margaret: Yeah. Yes. Yeah. 

Preston: I'm not docus. I'm not wasting my time with that. I don't know how Sena, I don't remember Senna's mechanism. 

Margaret: Sena does work. Sena does work. But you're right that Docusate or Colac does not work. So things that I think about with people, so let's say the meds are right, meds are perfect.

Pressing, you're right on, uh, MiraLax. MiraLax, MiraLax. Don't add a fiber supplement until things are moving. You add a fiber supplement, you're backing up traffic even further, you're in trouble. You're a dumb psychiatrist who doesn't remember they went to med school. That is my internalized voice when it comes to this.

I think that that is a step that we should be appropriate with. If we're moving beyond, it's like. Obviously if there's any acuity to it, that's not our job. If there's any super acuity, they need to go to the ed. But talking to their internal medicine doctor is important on this. But I do think we should be able to handle some of these basic things of are they moving?

Like what are some broad things about their diet? Like eventually, do they eat enough fiber or [00:52:00] kind of like bulkier foods that help form stool. And then not prescribing coase and understanding that it's MiraLax, MiraLax, MiraLax. Some of the things you were saying mark of like what, you know, what are the usuals, when do we need to be worried?

What do we ask about? And then my last question, and I only say it because this is what I had the deep dive about because I got something changed in, I don't know if you guys are familiar with the like CERs or CERs Illustrated psychiatry guide. One thing in there about Clozapine got changed 'cause I emailed him, was like, what is this intern year?

Um, Clozapine impacts, there's so much constipation because clozapine actually has some like. Anti like mu opioid locking, uh, and it causes constipation in the same way that opioids do. So the reason I say this is because I went on this deep dive where I was like, well, does this secretly work for psychiatry?

And like, we should have coase in here. 'cause they had coase in it before. [00:53:00] And I went deep into the palliative care and opioid research to find out no. And so now there's no colac in the C guide to constipation on clozapine. And uh, the other thing I always do, I agree with you on visuals, not just for learning, but for patients, which is like, I'll draw them just like a tube and be like, okay, so this is your stool right now.

Preston, like you're saying, it's kind of dried out. We want water to osmos kind of through and into it so it'll move and isn't just like a hard rock. We want water to do that. MiraLax helps bring the water in. Um, things like Sena and some other things help increase the motility in the contraction and movement in the wall and docusate, but does basically nothing by studies.

So we do all these things and then you add the lifestyle things of walking and eventually you say, let's slowly add fiber, please for the love of God. And I think about this 'cause eating disorders, their guts are slow, like a lot of them have, um, motility issues because it's like been down regulated in terms of function.

So I think that's a lot. There's more complex things than [00:54:00] that, but I think so many of our meds cause constipation. So all psychiatrists should know at least the first steps and not tell people to have fiber and coase and put them in the ED with a bowel obstruction. That is my choc talk. Mm-hmm. The end.

Preston: It's a good chalk talk. Docusate 

Margaret: is canceled. Canceled, 

Preston: yeah. 

Margaret: February. 

Preston: Sorry, you watching? Unsubscribe from the Patreon Docusate. We don't want you 

Margaret: Coley's smear campaign. 

Preston: Yes. Smear campaign. It's not a SI know what iCampaign I that's coming out. Yeah. 

Mark Mullen: Go hang out with Taylor Swift. She likes her friends 

Preston: that 

Mark Mullen: way, but you're not welcome here.

Margaret: Okay. That's a deep cut. 

Preston: Okay, that's good. 

Margaret: I 

Preston: busted. Um, yeah, so I, I kinda have two some options I was thinking about. So I'll let you guys guys choose. Um, I'm between catatonia Insight and Judgment or Motivational Interviewing 1 0 1. 

Margaret: I'll let Dr. Mullen chose. 

Mark Mullen: Yeah, [00:55:00] I don't know that it's gonna be most helpful to learners, but I would love to hear you talk about insight and judgment.

I think it's a fascinating topic and I think it's taught a bunch of different ways. So I'd love to hear what you got. So, 

Preston: so that's actually how I open it. I say inside judgment will be taught many different ways. You ask five different psychiatrist how they judge insight, you get five different answers.

This is Preston's interpretation, uh, is kind of like how I start with that. 

Margaret: My insight, 

Preston: and I usually say like, um, insight is it's important for you to identify because your job as a psychiatrist is try to predict someone's future behavior. And we are terrible at doing that. The, in general, humans are really complex systems, like we talked about in another podcast there.

They're what we call a type two chaotic system, which is a system that actually changes when it's aware that it's being monitored. So, you know, something like the economy or, or like a human brain, you know, who I thought is complicated. So you need to feel to tabulate every little way you can to, to measure where they're at and inside judgment is a great way to do that, to, to reassure yourself and your [00:56:00] colleagues when you're writing about what this person's risks are for, for certain future actions.

So starting with insight, I kind of like to think about there being five levels. I kind of do a crescendo because, you know, what is, what is insight? I'm kind of, you know, stealing your agitation spectrum as well. Yeah, because, so, so first of all, I think a lot of people are like, well, insight is, do they understand and appreciate what is happening to 'em or not?

You know, it's kind of binary, but that, that's not necessarily true because your level of understanding and your level of appreciation can vary and you can have insight into some aspects of your illness, but not all aspects of your illness. So, for example, I may be able to have insight into the fact that I have an alcohol use disorder, but also I have no insight into my psychosis and my schizophrenia.

Um, all those things. So I've always thought it's kind of interesting when, you know, you just write insight, good or fair or poor. It's like, well, referring to what? Um, so I usually just say like, okay, I, I say what they have insight into. Like particularly in the mental [00:57:00] SA exam, I cared a lot more intern year, and I'm a little more brief now.

Dialectically, that's what I did. So starting out at the bottom, you have obviously zero insight. So this is like complete denial. Um, like classically, a delusion would fall under here. So, so a fixed false belief that you have, um, no zero insight into complete denial, which means you can't entertain the possibility of it ever being true, ever being the opposite of true.

So like, I'll say that to students, I'm like, okay, so let, so like, do you think this patient has a paranoid delusion about their being followed? Or do you think they're just anxious and they're like, I don't know, they might just be anxious. And you go up to the patient and say, do you think there's any world where there is a single possibility where the FB is not following you?

And they're like, no, that's not possible. I didn't, I can't even consider that, can't even comprehend that. And then I, you kind of like look back at the bedside suit and like, see, that's like they, you 

[music]: do that to 

Preston: your med students, that's complete denial. No, not really. But like afterwards we like come out and be like, okay, you know, like, like I'm not trying to dunk on you, but like, I'm trying to say like, you know, there's, there's make.[00:58:00] 

Interesting. Yeah. Fascinating. Um, but that, like this level of delusion, um, when we were in denial that, that it's gonna guide your future interviews with that patient. So as an intern, I remember I spent so long trying to talk with someone. I'm like, I I, if I just give them more information, I'll break this delusion.

I just, just gotta, I just gotta explain it right. I just need more time. Darn it. Like you did 

Margaret: the, I dunno, 

Preston: nursing staff can, like lunch can wait. I, I've got explaining to do and, and, and it's just not true. You know, like, um, I had, um, one of my, uh, great mentors, he, he teaches, uh, therapy at a residency program.

He did, uh, like seven years of research, like applying therapy to psychosis and, and like, that was one thing he told us too. He was like, when someone's in that delusional state, no amount of talking will do anything. So that's actually one thing that like, if you can take that denial part initially, and you identify they don't have insight, then you can kind of like save your breath.

Because you're realizing like, okay, [00:59:00] I'm not gonna be able to get a foothold. Like I'm not getting on this rock wall to start climbing up on it, but then moving up a little bit. So going from no insight to poor insight is you can identify a problem, but where that problem is coming from is being attributed to everything else externally, if that kind of makes sense.

So I think a, a great way to look at this is with like substance use for example. So, um, in denial would be like, I don't have a drinking problem. Like I just like to have fun, you know, let's just say it. But then when you get a little bit of insight, you might say, oh yes, I acknowledge that my DUIs are like making it hard for me to do things and I got let go from my job.

But it's really just because, you know, I wouldn't got that DUI if Mark wasn't just like such a douche who let me at the bar. And, you know, I really lost my job because my coworkers ratted on me. Like, what's their deal? It's like no one around me supports me. So like, yeah, I get like, the drink is an issue, but it's just because [01:00:00] everyone around me is just like hanging out, out to dry 

[music]: me drinks.

Yeah. 

Preston: Yeah. So, so that's like, they've gained some insight into it, but they're externalizing everything. And I think that's, that's important for you to kind of acknowledge that you can both give the patient credit for realizing there's a problem in general. 'cause I think a lot of people will bristle at someone blaming, um, their issues on other people, but you need to knowledge that this person can't recognize they have an issue.

Like that's step one. So that's, that's a positive thing. Then the next stage of insight that would say this is still kind of in the poor range, is you can identify a problem but you don't know where it's coming from. So it's, yes, I've like been getting so much trouble drinking and I, I, I don't know why, like, I don't know why I keep getting these DUIs.

I don't know what's happening. I lost my job and I, I just, I just can't stop. So that that person who's kind of at the, I don't know, stage, they have more insight than the person who's externalizing. They're more open to counseling or to, or they're more suggestible to new ideas. And then the step after that is [01:01:00] now they appreciate that there's a problem and also that they have some agency and some contribution to that problem.

You know, I, I realized that my drinking has led to negative effects in my life, you know, or I realized that like I actually, I am, I have a low mood. I don't want to do things like I did before. Maybe I do have depression. Whereas someone with low insight in their depression might be like, yes, I'm pissed off all the time, but it's because, you know, I live in Austin, Texas and everyone in the city sucks.

You know? And, and yeah, I sleep like crap, but it's just because my neighbors are so loud. And yeah, I don't like to do things the way I used to, but it's because none of my shows, like all my shows, the writing sucks, you know? And then they realize, oh, maybe I'm not enjoying things the way I used to because like I am, you know, feeling depressed.

So that'd be kind of like that range of appreciation. And then I say like, that's, that's level [01:02:00] four. Like that's good insight or, but like to get to kind of great insight is you have to have that appreciation that there needs to be change, which is kind of like what goes into like the judgment part of it.

So I appreciate that there's a problem. I appreciate that I have agency somewhere in that problem, and also I'm going to modify my future behavior to change that problem. So like that's the person when you kind of start going into like that prepper preparatory behavior change. So I say like, that's kinda like the highest level of insight that you'll see.

And, and honestly those, like, along that spectrum, I kind of see people that fall into like every little section there. And I, and I always say like, that final step is the hardest one to get across. So when you're at the stage where you're like, oh, I figured it out, you know, I have a, I have an alcohol problem, and you're like, nice.

What are you gonna do about it? And they're like, huh. You know, it's, it's, it's, a lot of people can almost get complacent when they like, realize that they have a problem or where, or the source of where it comes from. You know, I, I yell at everyone at work and I treat them all like crap [01:03:00] because I was abused as a kid and I never learned how to have healthy relationships with other people.

And you're like, that is true. And they're like, I figured it out. You're like, well, you have to treat people nice now, you know, now, now you have to kind of move on to that next step. And that's something we talk a lot, we've talked about in like our ACT episodes before that, you know, it's, it's, it's not your fault, but it's your responsibility.

And that, that takes a lot. A lot of humility and a lot of introspection to kinda get to that, that last part. Um, so that's kind of my, my chalk talk on the spectrum of, of insight. I feel like I've talked a lot. We can, I can do a similar one on, on judgment.

[music]: I, 

Mark Mullen: I haven't, I haven't heard it reflected that way, but I agree that you painted a picture of a patient that can fit into any of those categories. Mm-hmm. I would say, well, the most common mistake that I see made for insight is it's taught at like an M1 level for us. There's a standardized question. You find a stamp, sealed and addressed [01:04:00] envelope on the ground, but what do you do with it?

And if the patient says, I put in the mail, then they have good insight. And that is just not true, right? Mm-hmm. Because a patient who has extremely poor insight into their psychiatric illness would know to put a stamp sealed and a dress envelope in the mail. So I feel like. Um, getting medical students to understand what insight is, is sometimes half the battle.

And then the other half of the battle is, once I know what it is, how do I stratify them along these different words that we use. And I've never heard that explained well until now. So Thanks, Preston. 

Preston: Oh, thank you. 

Margaret: You had me until stage five, the first four. I agree with the fifth one. I feel like you're, it's, it's merging into sort of judgment slash motivation that I don't know that I would think about with insight.

And I recognize you said, this is my view of it, but I do agree with you on the first four. I just think someone could actually have very good insight and like their motivation might [01:05:00] be down because they're depressed. Mm-hmm. And they can't, they still can have very, I don't know that that's like an alteration of depression that is like a blunting of insight as much as it's like if someone has narcolepsy.

They don't have enough energy to like do everything that they need in a day, but they know how to do the things. Mm-hmm. And so in this situation, it would be like they have the insight into what they need to do and what they'd like to do and what's going on, but they don't have the, they apathetic from like the anhedonia or something, but I could see an argument mm-hmm.

That the anhedonia is, but yeah. 

Preston: Yeah. No, and I, I've like gone back and forth on that a lot because that's usually the criticism I get when I sh kind of share this modality. And I guess my res, my justification of it is that like, true insight is realizing that there is a need for change and, and so, but that, that, that goes right upon the, the border of like behavior and activation and judgment.

But I think there, there is a line between I know where all the problems are coming from [01:06:00] and I'm also not motivated, or I don't believe that there's something that should be done about it. And then there's, okay. Now I'm gonna go seek out help or accept help even if you don't have the motivation to actually like, act on it yourself.

[music]: Mm-hmm. 

Margaret: Mm-hmm. Yeah. 

Preston: Because, because I think we all know those, those people that they, they say, oh, like I went to therapy and my therapist told me I just have too much insight and I know everything that's going on. You said that, said 

Margaret: that to me before. 

Preston: I don't think I've said that to you. 

Margaret: I'm pretty sure you said it to me.

Preston: I I, I don't wanna get us into his sibling fight in front of, uh, Dr. Mullan here, but Margaret's also said that she has too much insight and that No, I did not, won't do. I did her 

Margaret: intellectual, I understood. 

Preston: You know. No, 

Margaret: I did not podcast listeners say that. And if you saw the text that he's quoting, you would agree with me.

You did not understand what I said, and then you misrepresented anyway. Fine. That's fair. 

Preston: I 

Margaret: think 

Preston: it's fair. Yeah. So I, I guess it's, it's, it could go either way. I, I think [01:07:00] ultimately, I think there's a difference between appreciating where the problem's coming from and then appreciating that that problem needs a solution, I think is what I'm trying to get at.

Um, and that final part, and maybe I'm just not articulating it well enough, any who welcome or thank you for sitting through Chalk Talk Bingo. That's gonna conclude this section. So, um, we can quiet down over there, Margaret, if anymore comments about how much insight Preston has, and then we're gonna move on to our eye salty about 

Margaret: comment, because pissed me off when you said this a year ago and.

Preston: And we'll go into triumphs and failures of, um, intern years. We're gonna go fight on 

[music]: Patreon. 

Preston: Yeah, actually, yeah. Come, come to the boxing match. It's like, yeah. You thought, um, Mayweather v Paul was crazy. Just wait till, uh, Roche and Duncan, it's gonna be a YouTube in Netflix. Exclusive 

Margaret: psychological warfare will be.

Preston: Oh, man. Yeah. I'm gonna take a dive in the first round, I think for [01:08:00] women everywhere. 

Margaret: You can catch the next part of this on Patreon. 

Preston: It's patreon.com/happy Patient Pod. And we are back in the real world. 

Margaret: We are out of Patreon. 

Preston: Thanks so much. Listening. We said some 

Margaret: shit in there. Just kidding. 

Preston: Yeah. You, you won't even believe what went down.

Um, I, I really want 

Mark Mullen: any things on Patreon. That was wild. 

Preston: Yeah. Oh my gosh. Okay. If my patients 

Margaret: ever hear this, that's not true. 

Preston: Yeah. Okay. 

Margaret: Alright. 

Preston: Alright, Margaret, get out of the tank. You know, I'll take, I'll take my help, my scuba gear off. Um, shout out to Canyon Dixon. So, um, this, this person wrote into the pod page and said, you guys are my top podcast on my Spotify wrap.

Hats off to you. Lots of support coming from the Caribbean. Can't wait for season three. And that honestly, um, like really surprised me and like put a dumb smile on my face today when I was reading that, uh, in clinic or, or on my lunch break, I guess between [01:09:00] clinics and then also to everyone on Insta, on Instagram that tagged us because two months ago we were on Spotify wraps.

See this, I don't, I think three years ago I couldn't imagine. Being on someone's Spotify rap is like one of their most listened to podcasts and that's, it's just surreal. I, I texted Margaret, you know, I can't, I can't believe that people listen to us and I know they listen because I look at the charts and the, the chart say the numbers, that there are people listening, but they listen and that, that's you.

We can't, we can't do this without you. So I just wanna say thank you and I'm excited to see what season three has to offer. Um, for those of you who are new and joining us, you can always find, wait. Did we say where 

Margaret: we can find Mark first? 

Preston: Oh, well, mark, we're gonna save Mark for the end, so everyone remembers where to find Mark.

Oh, 

Margaret: okay. Good idea. 

Preston: Yeah, you can find me at its prerow on Instagram and TikTok. You can find Margaret at Badar every day. She's also on Substack. She's got a new journal out on Etsy, girl that three months 

[music]: now from now. But thank you. Thank you for your 

Preston: support as always. She's, she's [01:10:00] got a journalist's been out for three months on Etsy, you know.

Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan. Our executive producers are Preston Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aron Korney, Rob Goldman, Shanti Brook. Our editor and engineer is Jason Portizo. Our music is Bio Mayor Ben v and our wonderful guest, Mark Mullen.

Where can we find you 

Mark Mullen: if I me, on TikTok and Instagram at Psych Bootcamp. 

Margaret: And where can they find your podcast? 

Mark Mullen: Anywhere you get your podcast, part of the human content family. So, um, we're all in this together. Q we are family. Um, yeah, anywhere, anywhere. You watch. We're on YouTube, we're on Spotify, you name it.

Margaret: In the new year, we are gonna start a beef with you and, uh, psychiatry and Psychotherapy podcast. So watch out for that. 

Preston: Good. 

Margaret: We're very excited for the first ever Psychiatry podcast. Uh, pop Cultural Beef. Don't know what it's gonna be about yet, but we'll 

Preston: figure, figure out something out. We're gonna go to St.

Louis and TP your house probably. That's say I, I reveal that pending already as the first [01:11:00] plan. But we'll do something else to learn more about our program, disclaimer and ethics policy submission verification, licensing terms, and our HIPAA release terms. Go to how to be patient pod.com or reach out to us at how to be patient@humancontent.com with any questions or concerns.

How do be patient as a human content production 

Margaret: and so is psychiatry bootcamp. Bye guys.

Preston: Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm [01:12:00] gonna go dance in the background.