Thoughts on Residency

As many of you know, I’m a student finishing my final year of medical school. After I graduate, I plan to spend the next four or five years in a residency program training to become a psychiatrist. It’s not a decision that I came to easily.

Deciding on psychiatry wasn’t too tough–it was the decision to complete a residency that I found challenging. I’ve always felt a pull to do more than just practice medicine. Part of this drive has come from my medical school, which has encouraged me to learn the skills needed for a career that includes medical research. But I also completed a minor in business as an undergraduate, and the thought of actually implementing medical research has always excited me. Over the last two years, I’ve thought long and hard about whether residency was the right choice to help me achieve my long-term goals.

Here are a few reasons why I think that residency will be valuable:

  1. Residency will help me become an excellent clinician. I love building personal connections with patients, and clinical medicine embodies the spirit of service that initially drew me to medicine. No matter how my career changes in the future, I always want to spend at least some time seeing patients.
  2. Residency (and especially a psychiatry residency), will help me become a better team player. I’m going to see countless examples of great leadership. I’ll learn how to rely on the strengths of a team of diverse professionals, and have opportunities to do my best and fail in a supervised environment. Rotating between teams at regular intervals will also be an incredible opportunity to learn from hundreds of colleagues in only a few years.
  3. Residency will help me understand the actual problems facing people with mental illness. Textbooks can only go so far, and I find that my experience with people is much more nuanced than anything written in the Diagnostic and Statistical Manual of Mental Disorders. It is through these interactions that I hope to develop and refine hypotheses about how we can improve mental health care. Developing patient-centered interventions far away from the front lines seems like a foolhardy prospect.
  4. Residency will make me scale my efforts. I am good at putting my head down and getting work done. Now I need to learn to shed the superman complex and rely on others. I know that I won’t be able to design, code, and market apps on my own anymore–and that’s a good thing. Being further constrained for time will force me to leverage my efforts and further build my ability to lead.
  5. Residency will help me build a network of mentors, colleagues, and friends that I’ll be able to work with and serve for a long, long time. It’s no secret that mental health workers are some of the most compassionate and dynamic people around. I look forward to being a card-carrying member of the mental health community.

To sum it up: I’m expecting residency to be extremely challenging and immensely rewarding. What more could I ask for in the next stage of my career?

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Why I’m Blogging

I hear a lot of good and bad things about blogging. Some people say it’s a waste of time–and I certainly see how it could be. I started blogging with a modest goal: to enhance my own learning. Writing makes me encapsulate what I learn into meaningful chunks. I can’t promise that what I’ve written will be helpful to anyone else, but it has been extremely useful to me. Now that I have a few posts under my belt, I’ve decided to lay out three main goals from this blog.

1. To learn how to write. My training has focused on technical writing–and I finally feel like I’m becoming comfortable with that style. I love how technical writing emphasizes clear communication of complex concepts. I can’t imagine a better format for writing as a professional. However, my skill at writing to a broader, non-technical audience is much weaker. I struggle to explain what I think with clarity. Hopefully, this blog will help me learn how to write in a crisp, authentic way.

2. To connect with others. There are so many smart people working on difficult problems within the behavioral health community, and I want to learn from them. I believe that there is immense innovation in the pipeline from patients, consumers, doctors, therapists, allied health professionals, academics, and entrepreneurs, and I want to be here as it unfolds. If you’re reading this, I’d love to get to know you better!

3. To advocate for better behavioral health. Behavioral health is misunderstood and often maligned–even within the broader healthcare community. There are many voices for good, and I want to add mine to the conversation. I don’t have many answers, but I am passionate about finding and implementing better solutions.

Behavior is the wild west of medicine

In 2010, I was getting ready to graduate from college and start medical school. I was excited for the a new challenge and confident that a career in medicine would be a way for me to make some small impact in the world. Medicine, it seemed, was the ideal way to help. And then I stumbled upon some data that really bothered me.

It came from a review article in the New England Journal of Medicine–the flagship journal for clinical research. Among other ideas, it revealed that healthcare plays only a minor role in preventing premature death. Behavior, it turns out, has a much bigger upside for preventing death than just about anything else we can do. And among causes of premature death linked to behavior, obesity and smoking are far and away the biggest opportunities to really make a difference. The actual delivery of healthcare is a fairly minor factor in how long people live.

5-26-2014--Contributions to Premature Death

Modified from NEJM

Fortunately, most physicians get this. They know that behavior is important, and they try to talk with their patients about smoking cessation, exercise, diet, and illicit drug use. But we are still failing to move the needle in producing substantial behavioral change. Part of the reason for this is that many behaviors are really, really hard to change. Another reason is that evidence-based behavioral change therapies are few and far between–especially regarding obesity. Physicians also receive very little training about how behavior and its determinants should be approached. Likewise, their appointments tend to be shorter than they’d like them to be, preventing them from addressing every issue they want to cover. Some have even lost faith in behavioral change and focus their attention in a manner that reflects this. Whatever the problem may be, the evidence suggests that physicians have a long way to go in promoting better behavioral health.

Some might argue that it is the job of public health professionals and policy makers to address these issues. I agree wholeheartedly. These problems are complex enough to require a system-wide approach. However, I don’t think that the medical community can pass the buck onto others. We need to be at the forefront of the design and implementation of behavioral health strategies. Because realistically, helping patients to quit smoking, lose weight, and even just to take prescribed medicine may be the most important things that can be done in a routine doctor’s visit.

These challenges are tough. I don’t expect that we will find many easy solutions. But I do believe that discovery and implementation of effective, evidence-based behavioral change therapies is one of the most pressing concerns in medicine today.

Over the next few weeks, I’ll be looking into the literature to find out about therapies that actually do work for behavioral change. I’m planning to write about therapies for smoking cessation, obesity, alcoholism, medication compliance, opiate addiction, and motivational interviewing (I’m not going to make any promises about a particular order). Let me know if there is any other treatment that you are curious about.

The story behind CBT Keeper

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In July of 2012, I took a year off from medical school to complete a research project sponsored by the National Institute of Mental Health. It was the opportunity of a lifetime. For the first time ever, I spent almost 100% of my time dedicated to a project that I dreamed up. I worked with incredible mentors, heard from amazing speakers, and rubbed shoulders with some of the biggest names in my future field: Child and Adolescent Psychiatry. Plus, my schedule allowed me to work from 9 to 5, something I had never experienced before given the rigors of working, a neuroscience degree, and the challenging first two years of medical school. This schedule allowed me to spend plenty of time with my wife and newborn daughter.

While my time spent doing research was great, I realized that it would be many years before I would be able to fully devote myself to another project. Two more years of medical school lay ahead, and then it would be another five years before I completed my residency training. After this seven year hiatus, I would finally be in a position where I have control of my time once again. Sure, there will be small opportunities to collaborate and write papers here and there, but most scientific papers have very little impact—especially the ones you can bang out in your spare time. The greatest value of research comes from the constant interactions among a community of devoted investigators, and it is difficult to be an active member of that community without a full-time research career.

I was discouraged. Although I was developing skills that would make me a better clinician and scientist in the future, I wanted to have some form of impact right away. Wasn’t there something I could do to give back to the community as a medical student? The need for evidence-based mental health treatments is immense, and although study after study has shown that the combination of medication and therapy is the most effective treatment for most mental illnesses, many people never receive therapy.

And then it hit me: what if I could write software that delivered evidence-based psychotherapy to people for free? That seemed too difficult to do without a ton of time. But what if I started by writing a basic smartphone app that at least helps people practice some of these principles?

Of course, this thought came to me during the last month of my research year, the only period where I could have actually dedicated a substantial amount of time to development. Now I was being thrown into the fire of third year rotations; a crazy time where I would rotate through every service in the hospital, pretend to be a doctor, and actually need to know what to do with sick patients. Sure, there would be supervisors to keep patients safe, but they were also the ones that would continuously bombard me with questions to ensure that I was learning everything I needed to know. The mornings started early, and the evenings were devoted to study. And to make matters worse, I didn’t really know how to code.

To be fair, programming wasn’t completely new to me. I had taken one college class that taught the basics of Java programming. But that was almost ten years before, and my programming experience since that time had been limited to Excel spreadsheets. My undergraduate degree was in neuroscience, which is great for teaching you how to think like a biological scientist, but terrible for answering any kind of computer question. In short, I had no idea what I was getting into.

Choosing a platform was easy. I didn’t have a Mac, an iPhone, or an iPad, so developing for iOS was at least $1300 too rich for me. I did, however, have my less-than-trusty med school laptop and an Android-powered Nexus 4. So my out of pocket investment was just $100; $25 for a Google Play Developer Account, and $75 to register an LLC so that if—heaven forbid—someone hurts himself while using my app, I won’t lose everything.

I started to re-learn Java in the best and worst way possible: Codecademy.com. I say best because the user interface is amazing, the lessons are bite-sized, and I personally learn best by doing. I say worst because Codecademy doesn’t actually offer a course on Java, and I was naive enough to think that Javascript and Java have a lot in common. That’s not Codecademy’s fault, but it did shine a light on just how much I didn’t know. Even with this setback, I did learn some useful information about loops, switch statements, and data types, which seems to translate well across platforms. But, before I wrote a line of code for my app, it was time to start my rotations.

My development plan was fairly simple. I had become a big fan of Duolingo, and so I decided to draw inspiration from their process. The gimmick of scoring points, leveling up, and extending my streak was surprisingly satisfying, and I was able to attain a 90 day streak in something I had never been able to stick with before. What if I applied the same process to psychotherapy? I could make basic exercises, create simple goals, and see if racking up a score inspires people to actually use these proven principles. I would make all of the essential features free, and then hope that a few people would be willing to pay a few dollars to support future projects.

So, for the last 9 months, I’ve been plugging away at this app in my increasingly rare spare time. I’ve downloaded sample code, searched all over the internet for answers to ridiculously simple programming questions, and written what I imagine to be some of the messiest code possible. I’ve learned what tasks I can attempt in five minutes of spare time, and which I should save for those precious moments when I have a full hour. I’ve created more bugs than I’ve fixed, but learned more than I’ve forgotten. Most importantly, I’ve created something that gives back and that inspires me to reach further with the next project. Now I’ve got to figure out how to get it to the people who need it.

Is it perfect? Of course not. Is it useful to a few people with depression and anxiety? I sure hope so. Is it the start of something bigger? Absolutely.

P.S. Make sure you check out CBT Keeper! A modified version of this piece originally appeared on Medium.