Interviews with Joshua Lowinsky, M.D., and Max Schaefer (3rd Year Medical Student)
David Parker had the pleasure of (separately) interviewing CRG psychiatrist, Dr. Joshua Lowinsky, and Max Schaefer, a 3rd year medical student at Marian University. Max completed a month-long clerkship at CRG in early Fall 2015 under the guidance of Dr. Lowinsky. This was the first of what we anticipate will be a series of clerkships here that provide future physicians with direct access to behavioral healthcare practices. Read on to learn more from both men about their experiences with this dynamic partnership. We’ll begin with Dr. Lowinsky.
DP: Where did the clerkship idea at CRG come from?
JLMD: I worked with Gallahue Mental Health Center before joining CRG. While there, I took Indiana University 3rd year medical students weekly for half-day semi-rural community mental health experience over a one-month period. I very much enjoyed my involvement with students at this early part of their training, watching some of them enter with certain ideas about patients with mental health problems and, perhaps, leaving with new, more hopeful, ideas. A lot of us who go into medicine are afraid of mental health problems, both in ourselves and in others. Finding ways to increase students’ comfort and interest level with mental health issues may allow them to more easily and positively work with the mental health challenges of their patients in all specialties of medicine.
DP: How will future psychiatric clerkships play out here at CRG?
JLMD: Right now, I am available for a month long rotation with 3rd year medical students at Marian University. They can contact me through the MUCOM clerkship director. At this point, I’m available three months out of the year. What I think we offer as a clerkship site is the opportunity to work with children, adolescents, adults and families in a middle class, resource – rich setting at CRG. In addition, med students who clerk with me here can join me on Fridays as part of my work with the Indianapolis Public Schools. I work on Fridays with biopsychosocially challenged youth and their parents, many of whom come from an inner city lower income setting. They will also learn about working as a member of a health care team that has become even more important for the future health of the medical field. Students will probably see a greater variety of age groups, diagnoses, and types of presentations here compared to other settings. They will see that working as a psychiatrist in 2015 means taking into account multiple layers simultaneously from inside the brain cell, to brain circuits, to the effects of adverse childhood experiences on the structure and function of brains (epigenetics), to the effects healthy and unhealthy family functioning have on the patient presentation, to the mental health effects of racism, discrimination, and stigma. The student will learn that prescribing psychotropic medications is but one important tool in the psychiatrist’s tool kit and it must be done in the context of a relationship based on trust, hope, and working together. They will learn about the uniqueness of each person, the empowering experience a patient can have when telling his/her story and being empathically understood, and the importance of placing evidence-based treatments in the context of that uniqueness. Finally, the student will learn about the use of self in the patient-physician relationship and the potential role of humor in their interaction with patients.
DP: How would you summarize your experiences with Max?
JLMD: I was privileged to have an excellent medical student who was interested and motivated in this area from the get-go. He has two professional educator parents; one of whom works with behaviorally challenged youth. Max also brought a certain seasoning and maturity, having not gone straight through school Max was always extremely respectful of all patients who came into the office. He had a quiet and soothing manner about him, which made almost everyone comfortable speaking with him. He had a very nice way of connecting with patients and families. While every patient has the opportunity to say, “No, I don’t want a student in the room with me” (and, indeed, some patients chose not to have Max in the room), the vast majority were fine with having Max present and actually asked about him in future appointments when he was no longer working with us. One thing that Max and I talked about to improve the rotation further was, when possible, to allow students in their first week to play an active role in the interviewing process with a new patient.
I got an amazing chance to watch Max grow, learn, and leave here as hungry for additional learning and growth opportunities as when he came in. Being part of a medical student’s growth and development, particularly with respect to their interest in the mental health of their patients, is the most rewarding thing for me about being a mentor. It certainly makes me realize that what I receive from mentoring is greater than anything I can give.
And, now, let’s hear from Max Schaefer:
DP: How did your experience at CRG get set up?
MS: I did my medical clerkship – or medical rotation – in psychiatry at CRG. These are one-month blocks. This is the first year Marian University’s new DO program put people out on rotation, so we have a list of settings to choose from. I saw Dr. Lowinsky’s name and CRG’s address and signed up.
DP: What were some of the most important or helpful things you did at CRG?
MS: The Psychiatry rotations are different from other specialties in that standard procedures to follow are less explicit. It is different in that it is more cerebral. For example, rather than relying on a stethoscope or an x-ray, you rely on yourself as your primary diagnostic tool. We began with me observing for a few days so I could appreciate what a typical day for Dr. Lowinsky was like. Then we added a new component each week. There are certain questions you want to ask for certain diagnoses during the patient interview or med checks. As we went on, he encouraged me to step in and ask those questions as I thought appropriate. Dr. Lowinsky would have me read articles [about current issues or emerging treatments] and we’d discuss it the next day.
After we saw a classic presentation of a certain psychiatric disorder, Dr. Lowinsky would guide me in a debriefing: What are the three main things you were looking for? What is the first line treatment? It was a good way to see how primary care is provided. At times I didn’t know the diagnosis so this gave me the opportunity to practice my ability to formulate a differential diagnosis. It’s also a chance to learn how to have a focused interview. In a hospital or even primary care settings, you rarely have 30 minutes for an appointment. You have to identify things quickly, so these exchanges helped me learn how to group things, differentiate things, in order to understand what a patient was actually dealing with. Dr. Lowinsky helped me to identify ways to hone my efficiency by utilizing certain questions to ask and by grouping things by age of diagnosis.
As our time together progressed and I became more fluent with the procedures, Dr. Lowinsky and I would both be in the office. He’d have me take the lead during the interview with a new intake. He would jump in to ask any important questions I may not have asked. After the session was over, Dr. Lowinsky would have me “present” on that patient by asking me to summarize the key things I had learned. This clearly helped him monitor how I was growing in that skill set. It’s one set of skills to gather and integrate information; it’s quite another to verbally summarize all of that quickly and accurately.
Dr. Lowinsky was good about getting me involved with other healthcare providers here and in other settings. He helped me observe and learn about sleep studies, substance abuse treatment, and pain management. These were all important to understand within the context of psychiatry. He kept me involved in that combination of presenting issues from the beginning.
DP: What did you hope would be the benefits of your time at CRG?
MS: Most psychiatry rotations are at in-patient facilities. So, one of my expectations was the diversity I found here. Because CRG is a multispecialty healthcare practice, I was hoping to see a broader picture of mental health. You do testing. You work with children and adults. As a medical student, you don’t want to go into something very specialized when you’re still learning. You want to see as diverse a patient population as possible. I think the only thing I didn’t get here was the in-patient experience. No matter what branch of medicine you go into, you’re going to see behavioral health. You’re going to see it. Sometimes you’re the only provider who will see it. Many people, particularly lower income or certain ethnic/cultural groups, are very reluctant to discuss their mental health issues. Seeing Dr. Brophy do testing, following Dr. Norris’s work with trauma, seeing ADD coaching with Dr. Parker… I got to see different branches under the same umbrella, which was very helpful.
This diversity helped me parse out common disorders and how they present in people. It’s important to know what to look for in people who may not even recognize it in themselves. For example, many patients with substance abuse issues have underlying anxiety issues. They drink or use some sort of substance to cope with the [social] anxiety. Unfortunately, many people even in the medical field don’t understand what resources are out there for their patients. For example, a kid with ADHD, I didn’t know anything about coaching. And this experience also reminded me of the importance of testing kids [with dyslexia and other learning issues] when they are young. The testing makes it possible to provide accommodations that can make a huge difference.
Due to the volume of information you have to acquire in med school to be competent, we kind of block out the rest of the world. As strange as it may sound to those outside the field, physicians may not know about these other resources or the behavioral health issues to look for. Further complicating the issue is the fact that a stigma still exists – mental health is considered very private in our culture. So it’s hard to train medical students in settings where they can see these things and hear these difficult conversations.
DP: How did this rotation enhance your professional development?
MS: I have a personal interest in dyslexia. When a kid can’t read in class, they can easily begin to have feelings of inadequacy. If they can’t keep up with their peers, they can avoid the tasks that call for the most improvement. However, If they have a parent or teacher or provider who encourages them and keeps them on track, that’s huge. For many people with disabilities, school is the hardest part of their life. If they can hang in there and get through school, their differences can become real assets. They may have developed compensatory strategies (social, athletics) along the way. But if you don’t catch that reading disability early on, it compounds every year. You fall farther and farther behind every year. It can affect you emotionally, in your knowledge base, and in your self-confidence.
One of the big differences I saw at CRG was, there’s a team. Providers, parents, teachers and others really work together to help a student be successful. It’s hard to find good behavioral health. One issue is continuity. Another issue is coordination. The fact that you have med providers and therapists in the same building at CRG is a huge benefit. You can talk over lunch and share important information about a patient’s care. That cross talk is pretty rare. Testing – whoever does the evaluation can talk directly to other providers here who work with that patient. This contact is really important. You get a clearer picture [of the patient’s needs and strengths].
DP: How did Dr. Lowinsky mentor you?
MS: He was flexible and laid back in his style of mentoring me. Almost all the patients here were very open and welcoming to me. They essentially were my teachers while I was here. We did some of the more traditional things: What are some things that can cause psychosis? Very fundamental. Talking about that and how, say, drug-induced hallucinations contribute to that? How do you differentiate between induced psychosis and schizophrenia? One nice thing about being at CRG, Dr. Lowinsky made sure I’d sit in on other providers’ appointments when patients were okay with me being there.
On Fridays, we’d visit an IPS program that dealt with the most difficult students. Many were living with significant psychiatric concerns, traumatic backgrounds, and unstable home environments. Talk about grit. Dr. Lowinsky spends his Fridays working with these students, their families and their teachers. Seeing him with this patient population [compared to CRG], it was very helpful to see both ends of the continuum. He’s pulling students out of class; he and the providers then team up to coordinate care. I got to see his flexibility and how he works with teachers and social workers.
DP: How did Dr. Lowinsky’s mentoring style match your own personality or preferences?
MS: He was really nice to work with because, early on, we developed a good level of trust in each other. Even after the first week, we were working as a team. I felt very comfortable asking questions and exchanging perspectives with Dr. Lowinsky about patients we had seen. He’s very good at what he does. He’s done it for so long that he doesn’t have a rigid list, but is flexible in knowing what to ask and, perhaps more importantly, how to ask. He has a wonderful knack for making people feel comfortable, including me. I think it’s a function of both his personality and his skills. Dr. Lowinsky really cares. He doesn’t come off as scary or condescending. Sometimes when people think of a psychiatrist, they think of someone who’s distant. You often see a high level of burn out in a lot of mental health providers. I don’t know if he’s avoided that, but he was always excited to teach or talk about how a patient was presenting. He has a very playful approach to how he comes at this.
