Head Inside Mental Health
Todd Weatherly, Therapeutic Consultant and mental health professional hosts #Head-Inside Mental Health featuring conversations about mental health and substance use treatment with experts from across the country sharing their thoughts and insights on the world of behavioral health care.
Head Inside Mental Health
Mental Health and Addiction Treatment: Finding the Balance with Lisa Wheeler, PA
The delicate balance between mental health medications and addiction treatment remains one of healthcare's most challenging terrains. Lisa Wheeler, PA-C, brings her 30+ years of experience to this conversation, sharing how her journey into addiction medicine revealed both her passion for helping marginalized populations and the systemic problems preventing truly integrated care.
Wheeler's refreshingly authentic approach stands in stark contrast to traditional healthcare environments. "The person you see here in the room is the exact same person I am on the street," she explains, describing how dropping the clinical facade helps patients lower their guard and engage more honestly in treatment. This authenticity becomes particularly crucial when navigating the complicated territory where substance use disorders and mental health conditions intersect.
Our conversation talks about how truly effective treatment requires both specialized expertise and meaningful collaboration between providers—something our current healthcare system, with its territorial silos and corporate-driven patient volumes, makes increasingly difficult. For anyone navigating these waters themselves or supporting someone who is, this frank discussion offers valuable insight into finding providers who can genuinely help rather than simply perpetuate problematic patterns of care.
Hello folks, thanks once again for joining us on Head Inside Mental Health, featuring conversations about mental health and substance use treatment, with experts from across the country sharing their thoughts, insights and practice perspectives on the world of behavioral health care. Broadcasting on WPBM 1037, the voice of Asheville independent commercial-free radio, I'm Todd Weatherly, your host, therapeutic consultant and behavioral health expert. Today I have the privilege of being joined by my friend and co-conspirator, lisa Wheeler. Lisa has a private practice, legacy Recovery and Wellness in Hendersonville. She's been a physician assistant for over 30 years, specializing in addiction medicine and chronic pain for over 10 years, specializing in addiction medicine and chronic pain for over 10 years. Lisa has her master's in education and athletic training from Old Dominion University and trained at Wake Forest School of Medicine. Lisa Wheeler, friend and colleague and person I've known now for probably, I think, 15 years, welcome to the show. I'm so happy to have you.
Speaker 2:Thanks.
Speaker 1:Western North Carolina. Strong though you know, I think the thing that I want to talk with you about today and the thing that probably hits everybody somewhere, somewhere at home, because of the, because of just the wide scoping presence of, of behavioral health medications, you know, medications to help people who are suffering from mental health conditions and those suffering from addiction, suffering from substance misuse, possibly even prescribed medication misuse, and the delicate and weird and often poorly managed territory that exists between those two things. And finding a prescriber, finding a person like a PA or a nurse practitioner or a psychiatrist that really knows their way around both ends of that spectrum, is difficult, honestly, it's just really hard to find somebody who knows what the pitfalls are and what to look out for and everything else. And this is something that I have. I have come, in our years of knowing one another, to entrust your opinion, your professional, uh, expression, your professional acumen and mostly, like we can talk about all your, all the accolades of things, places that you come to school.
Speaker 1:I personally find pas and ps often much easier to work with, but I also find that they, they, they, they live on the ground, they see where it's all happening, like what got you to the place. I mean, after 30 years of practice, what got you to the place? That really caused you to feel like this is an important place for me to focus. My practice is to help these people who are, you know, somewhere in this divide, don't know what's going on, need a prescriber who knows how to direct them well and give them the tools they need to be successful in recovery. Like how did you get here?
Speaker 2:Tell me the story. Yeah, it's a little circuitous but I'll try and keep it pretty fairly brief. So you know, historically, you know I had a consulting company. You, pretty fairly brief. So, um, you know, historically, you know I had a consulting company. You and I um collaborated on a couple of things back when I had my consulting company and um that was over 10 years ago.
Speaker 2:Um and I got a phone call from an opioid treatment program. They were looking for um. They actually called me for a headhunter. But um, as a headhunter person to go find a you knowlevel for like 10 hours a week and um, so I, you know, we chatted about that and I thought I can do that. That's, how hard is that? So I entered this place and with my job was just histories and physicals, and then um, just basically it the nature of my personality and curiosity. It just became more and more and more to the um point where, um, I was there a lot and spending a lot of time um and fell in love with um, this marginalized community that doesn't have a socioeconomic factor to it, you know, and in some respects it reminds. Well, let me back up. So there's that. But the other thing is that it was an area in which I could be authentically me, and there's not.
Speaker 1:Well, there's not like you could be anything else right well, I know.
Speaker 2:Well, let me tell you I've done some things and it's like. You know, you got to wear the white coat, you got to be nice and you can't cuss, and you got. You know, you've got a, you've got a placate blah, blah and I'm like no, um, and you know, the other place that you really don't have to do, that you can be your authentic self, is emergency medicine, which i've've done, and so I I fell in love with this sort of platform and addiction medicine, that, um, I could be authentic, and I think the most important aspect of that authenticity is that allows me to meet the patient where they're at and, more importantly, when the patient sees or the client, because it depends on what, it depends on what aspect within medicine you are, whether you're a client or a patient. Obviously, in medicine you're a patient. So for me, patients but it lets them drop their guard because they see my authenticity and they see me kick back and laid back and my feet might be up on the desk or just chilling, and there's no white coat, there's no stuffiness. We've known each other for a long time and, like I tell my patients, the person you see here in the room with you right now is the exact same person that I am on the street. There is no difference. Um, you know, I will hug you and squeeze you and hold you and love you If that's what you need, I will drop, kick a boot up your tail if that's what you need, but this is a journey that we walk together. I will not work harder than you, um and um, and I think what that does with being able to be truly authentic.
Speaker 2:I fell in love even further with what I do for a living, and then I fell in love with this population and then, coinciding with that was running into chronic pain as an issue in my background, also with orthopedics, and my supervising doc at the time was a physiatrist who did chronic pain and also addiction medicine, and so it just dovetailed perfectly and the majority of all folks with opioid use disorder have chronic pain. So it just dovetailed really well. And then I mean that just sort of you know and away I went, and so my practice specifically focuses, you know, half the practice is chronic pain and folks that don't have a substance use disorder, and then the other half is substance use disorder and of that, probably two thirds of those folks have substance use disorder and chronic pain, and so with that, obviously, then we start getting into what are underlying factors that are going to threaten your sobriety, increase your pain and so that what are you doing to your body while we're doing all this?
Speaker 2:Exactly. And then that kind of that gets into the mental health aspect of stuff. And so you know, and you know this from doing what you do, I take folks in on an intake and particularly coming out of um some facilities or transferring some some places, there aren't a lot of meds and I'm like, well, you know what came first, the chicken or the egg, um, and how do we figure that out? And so my, my theory on that one is I want to, I want to. You know, you're on medication, assisted treatment, typically, assisted treatment typically, um, and I want to try and wean off what we can wean off, um, find an optimal dose on things that we can't Correct. Correct, that's exactly it.
Speaker 2:And then, because then I want to see what, I want the brain to marinate in sobriety for a bit and then we can kind of tease out really what's going on. We're not going to get you off your meds necessarily if you, if you don't need to come off of them, but I think we need to kind of let the brain marinate in sobriety for a while, um, and tease out, um, what is going on. And I, and I think that um, a lot of folks will be out there looking for maybe the quick fix of medication assisted treatment, um, and then mental health wise people are going to look, maybe the quick fix of medication-assisted treatment. And then mental health-wise people are going to look for the quick fix for their anxiety and their depression, which is a pill and get the primary care, et cetera, et cetera, when in fact, what we need to talk about too is the significant importance of getting therapists in there.
Speaker 2:Therapists in there, um and um, in some cases, peer support specialists, and you know kind of. I always tell folks, I will take care of the, the biology, the physiology, the biochemistry of the brain aspect of it, but your frontal lobe is going to be a process of doing some um, therapy. And that's just the reality. We, you know some therapy. That's just the reality. I mean, that's just the reality is that we've got to do this.
Speaker 1:I think you're addressing something here that's super important in my practice and in the clients that we work with in general First of all, the medical industry and even the insurance industry, and I know where it came from. I've discussed this with others before, but it's kind of the. It's an emergency, it's a reactive emergency model. You came in, you break your leg yes, at the leg. We put a cast on you, walk out, give you some meds come see us in a few weeks, uh, and you've got the, you've got you.
Speaker 1:You overlay that practice model over mental health and addictions. Uh, first of all and I just discussed this with an attorney with an, incredible uh, jordan litis has this incredible recovery story and has turned it into advocacy for his practice.
Speaker 2:But I know who the guy is, yeah.
Speaker 1:Yeah, good, yeah, cool guy, and his story is just like it's got. It's heart wrenching and and it's true that the medical that you walk into a person with addictions issues walks into a hospital, walks into a provider, walks into a pharmacy and and experiences experiences being discriminated against.
Speaker 2:Oh, you know, it's a daily, daily conversation with the majority of all my patients, because and because of the medications I write, whether it is, you know, an opiate, a partial opiate, vivitrol or naltrexone, it's like all of a sudden.
Speaker 1:Oh, you're this person, right you?
Speaker 2:know, now we've got a profile. Yeah, yeah, I um, yeah, we're going to profile and it essentially I have one, one motto that drives me in the practice of my uh and care for my patients, and that is don't mess with my patients. Not the mess is the usual word that I use, it's a cuss word and everybody else can figure it out.
Speaker 2:But do not mess with Wheeler's patience, because I will come after you, I will come after you and you know, I mean it's funny because you know I have a very, very small staff, but they know they can watch me on the phone with the insurance companies or with the pharmacies. And they're uh-oh and I'm like, oh, you bet, yeah, you know we are gonna go to town and I, I have, truly I have sat there and called a, um, um, pharmacist. I called one pharmacist, a big at one time, and one one discriminates, and that catches them in their path. They're like, well, no, no. I said well, yeah, yeah, I mean, let's just call it what it is, you know if I were writing this person different than you treat everybody else, that is correct.
Speaker 2:If I wrote for um because I do chronic pain management right. So I'm writing for traditional opiates for that population that doesn't have a substance use disorder. If I write for morphine or oxycodone, you hand that out to them two days in advance of when their start date is. You don't think twice about it. But I write for buprenorphine or Suboxone and you won't let the patient get it until the day that their start date is based on when you last filled it for them. Because you know and here's the great story If we give them two days early, then they'll have an addition. They have the potential to have an additional. If we keep giving them two days early, then they'll end up with an additional 24 pills or films at the end of the year. And I'm like where do you, where do you even get that? Well, you know they can abuse it.
Speaker 1:I'm like like no, they can't, that's not, that doesn't cost that amount of extra, doesn't constitute abuse for one.
Speaker 2:Yeah, and I and I have yet to hear of anybody overdosing on it. So, um, but then, but, but, todd, I come back to, which is why I love doing what I do, where both sides of the coin and I come back and go. So you're also doing the same thing with the guys that are getting morphine and oxycodone You're giving them 24 extra pills. Um, no, no problems there, right, like, seriously, like you do. You even hear yourself.
Speaker 2:And one of the other ways that I love to deal with the pharmacy and insurance industries is I like to ask questions, and I learned this as a consultant and you know, when people are stuck in their way, the way you get them unstuck is not to necessarily directly push at them, but basically start asking questions and you can ask yesuck is not to necessarily directly push at them, but basically start asking questions and you can ask yes and no questions, to a point where they get themselves turned around to where they're answering your question in the affirmative ultimate, like what you were saying from the get-go right, like, why are you doing this?
Speaker 2:And they're like well, because blah, blah, blah, blah, and you go through a series of questions and you come back and go all right, so then why do we go back? So let's go back to the original question. And they're stuck. There's no way around it. I had that situation happen with Medicaid up in Virginia and this gal was holding her line. She was like the director of Medicaid in Virginia this is years ago and she was holding her line.
Speaker 1:She had already decided what the right answer was right.
Speaker 2:You betcha, and you know me well enough to know that I was, like you know, for that you know, when I was accepted, that challenge accepted, and I'm and you know, I'm like, oh well, this is cool, this is sport and you know we've talked about it. Sometimes doing this it's a, it is it's time consuming, it's a pain in the tail, but, depending, depending on the daytime and situation, sometimes it's sport and challenges, and this is sport and this gal was really stuck in her in her way and and and I was like, okay, so I, we, basically I did a series of questions and this, at this point, this one was mental health and it was surrounding the coverage of equine assisted psychotherapy, and you know why you couldn't do it and, um, it's actually you and I have spent time together yeah, yeah, but it was a really funny story and it really comes down to.
Speaker 2:It really relates to this when, if for anybody listening, when you start asking these questions, you kind of change the scenario as you go with well, we won't, you know, we're not going to let people do anything with a horse. Okay, why? Well, because it's not in an office. I'm like, well, you know what's the size of an office? What do you mean?
Speaker 1:what is?
Speaker 2:it? What is an office? Yeah well, you know it's, it's, you know, got four walls and I'm like, well, barn has four walls, so keep going, help me out here. Well, sheetrock walls and everything else. And I'm like, oh, you want them in a, you want them in like a nine by 10 office? Yeah, okay, well, do you have? Do you have that in pop in writing somewhere?
Speaker 1:No, Is there evidence-based practices that say a nine by 10 office is the optimal treatment environment for your client?
Speaker 2:Exactly, exactly.
Speaker 1:You don't do you.
Speaker 2:No, you don't, no-transcript a true story. And and the lady came around and she was like, oh, I get it now. And I'm like, yeah, you got it. But that you know that the whole point of that is we have to. We end up pushing against resistance, and so we have to figure out sometimes how to kind of go around, and sometimes going around is not, is is literally just asking questions, until you this is the wrong verbiage, um, but I think you'll know what I mean and you may get have better verbiage, but you know, until you trip them up, um, because you'll hit the point in dialogue of questions and you can ask questions in a way that are non-challenging, non-threatening, and they just answer them just kind of like oh yeah, you know like what's for breakfast?
Speaker 2:Okay, Um, and then, as you've asked your questions, you come around and they're like oh, so that's.
Speaker 1:That's a lot. There's this. There's a dawning revelation that happens in these and you know part of it. I, I love to sit around a clinical team inside of a hospital with a bunch of psychiatrists and social workers and make them feel uncomfortable. Yeah, I do a very similar thing. Well, guys, you know. So what you're telling me is that you know, you end up in a line of questioning and they realize that what they're doing is referring an individual to inappropriate levels of care. Yes, that's the conclusion I need them to reach here. I'm an advocate and they all get on their toes anyway, but you know.
Speaker 2:I met them directly. Right, you couldn't have said, hey, we need to refer them to X, y and Z because they're going to go. Well, I'm the doctor, you are not, and I know what's best for the patient.
Speaker 1:Well, there's this, you know. The thing is, you know there's, we thought we started little trip. We're starting with talking about stigma and how a person you know they find stigma when they go to these environments. And then you've got mental health environments where you've got these standards, which is what you're addressing when you're talking about whether it's the use of equine therapy or standard doses of a particular mental health medication. This is the standard dose, yeah, but this person doesn't need that much.
Speaker 2:Exactly.
Speaker 1:So there's all these protocols that are written, and then you've got these doctors and practitioners that live in these silos. They don't really live out in the real world. They live in a hospital, or they live in a practice that does a certain thing, or they live in this policy world where, oh, you don't go live out in the real world. They live in a hospital, or they live in a practice that does a certain thing, or they live in this policy world where, oh, you don't go outside of this policy.
Speaker 1:I've decided how to interpret this policy and this is how it gets interpreted. I pass that interpretation on to all the people that I supervise, train or teach. And all of a sudden, you've got a whole field that's operating with inconsistent philosophies, ideologies, interpretations, policy about how to treat these individuals, none of which actually lives on the ground, and we end up with the complexities that we have in the treatment environment and in the population that we're serving and suddenly we've got real problems. I think that this is the reason why we end up with such complexities and conditions and people on things like 300 milligrams of methadone, like how in the world is prescribing a person more methadone after you get up over about 80 milligrams?
Speaker 2:Yeah, the average person is somewhere between 80 and, and that, and one of the things I want to add on to the, to tag onto that is that we also are in a climate in which we change tunes so quickly that we create whiplash in our in our industry, and in ourselves as providers.
Speaker 2:You know, one day benzos are um, are great, they serve a purpose, there's a place for them, and the next day it's like, oh my God, it's the worst thing. You know, we can't ever do that again, and so we can't. We are not a society or system and I can't speak for the rest of the world. I can only speak for the United States of America. We are not a society or system. Who can find the middle of the road? Um, I had a. Either do do it or you don't do it. This is bad or it's good, yeah, and so it is that balance. And it is that balance and it is it is.
Speaker 2:You know, I had a um, a colleague of mine who had someone with um, opioid use disorder and chronic pain, and we were talking about it and I'm like I can help you with the chronic pain, part of this, if you want, because, um, you know, um, buprenorphine is a partial agonist, it's um. Butrans and belbuca are used for pain management etc. And let feel free to just holler at me and I'll help you with this, with take care of this person well and I haven't heard a thing, because the whole deal is well, that's not their problem.
Speaker 2:The problem isn't their chronic pain, the problem is their opioid, and this is true they've got more than one problem.
Speaker 2:No, no, no, no, but that's what you run into and so, yeah, and so you know, getting back to more than one problem, it's like, well, all right, so you have opioid use disorder, or you have stimulant use disorder, alcohol use disorder, and then I have to go there and I have to go, all right, well, you have bipolar and disorder and you have schizoaffective, or you know, you've got all these other things, and then it's like and then personality disorder, which is, you know, we'll run you all, we'll run you ragged on medications.
Speaker 2:And I don't want to, and it's really important for me to really respect and honor my inpatient colleagues, and they're seeing them in the worst of the worst conditions, and so I get how some of the prescriptions are set up and handed out at inpatient.
Speaker 1:You go into a hospital, they're giving you the velvet hammer, right, and you're coming out on the velvet hammer. But the velvet hammer, you're not supposed to stay on that.
Speaker 2:No, I like that term the velvet hammer. I I'm going to have to steal that from you, whether I did not create it.
Speaker 2:You're welcome to it, the velvet hammer. I'm like good God, almighty, yeah. And then, exactly, Todd, you come out and you're like, and you know, then you end up in the outpatient providers and we're all like I get it. So, first of all, I get it, I understand what we have going on here. But, holy cow, and you know, I've I've had the privilege of doing some um, um, medical management for sober living houses and catching these guys right when they come out of inpatient. And you know these are folks that were never on meds before. Um, it doesn't mean that they shouldn't have been on some sort of medication for something typically a depression or anxiety type deal. Um, and now they're on like seven meds.
Speaker 1:Yeah, what do we do with this?
Speaker 2:Where do we find the middle road here? And you know. Then you're like, well, you know, well, I got to start peeling, it's peeling an onion, I got to start peeling this crap off. And T you know and for, and people need to understand. You know, well, I got to start peeling, it's peeling an onion, I got to start peeling this crap off. And you know and and people need to understand. You know, for your audience members, that may not be providers. Um, there may be providers out there that are going to take multiple, that will make multiple changes to medications all at once. I'm not that person, because then I don't know when we have a result of that, I don't know what caused the result. So I'm someone who, basically, you know we're going to adjust your meds, but we're going to adjust one at a time.
Speaker 1:A little bit at a time.
Speaker 2:And figure out, you know. Okay, well, that was it or it wasn't it.
Speaker 1:You might want to consider a residential environment if you're going to baseline off of all meds because you don't know what's going to happen.
Speaker 2:That's it. So, yeah, no, no, no, that's totally it. Yeah, it's a challenging environment, but I'll tell you what. I think it's important for people to know the lanes that they're in. Um. I, you know, just like um specialists, you know. Let's take orthopedics. You know, orthopedics, there's usually the guy that, like he really likes knees, he's the knee guy right, or she's the upper extremity, or she's the, she's the hip person, hip gal and and this is you know, they can be a general surgeon. That's fine. Um. And with mental health and substance use disorder, when you combine those two um, I tend to find that you have a um within that. Whoever that provider is, tends to be um more more proficient. I'm yeah, I'm going to go there more proficient and has a tighter leaning towards mental health or towards substance use disorder, but not necessarily 50-50 as good on both sides of that page.
Speaker 1:Yeah, they've got a leaning and they walk into the other side going hey, I need to know enough about this to be able to do this other job. Well, that's correct, Right.
Speaker 2:So my deal is I always like to tell people that you know I am substance use disordered. Um, strong, like, like. I take it to the bank every day. I've got that inside out backwards and forwards, um, and.
Speaker 1:I'm not going to leave you hanging on your mental health or, frankly, your medical health Cause I know what I'm looking at Right.
Speaker 2:But I also know and I tell them I'm like so here's the deal, I'm going to take care of your mental health up to the point where I feel like I'm not the person for you and then I'm going to refer you to someone who you know, where I'm so super strong with substance use disorder. They're that strong in mental health and we'll get you over there and we'll work tandem.
Speaker 1:I am very, very fortunate to have Well, I'm going to stop you there, like like, right there, you just said it. You just said the exact thing that I think a lot of the medical world, psychiatric world, addictions treatment world is missing. I'm going to, first of all, you know where your line is. You're like, hey, we're starting to get into territory that I don't feel as comfortable in, where you've got a lot of docs that are just making decisions, sending their patients on to wherever they go home, the farm, whatever, and calling it a day.
Speaker 1:The second thing that you said, which is something that I kind of have to just make happen for lots of different siloed providers that are working with one person and everything else. You're going to reach out, you're going to communicate with that person, you're going to work in collaboration with them. Hey, I'm doing this, what are you doing? Let's make sure that we're not at odds, that you're not doing something that's counter-indicated, or I'm not, that you're actually having a communication with the other professional and have a working relationship so that this person's getting that, getting that really high quality like where does the middle live? So that this person can get the best care, like that's the trick, right there.
Speaker 2:It is, and but let me tell you some of the underbelly of that is is that you know I want to reach out to somebody who you know, let's say they do substance use and mental health. They tend to do a lot more mental health than do substance use disorders, and so you know I send them up there for the higher level game of psychiatric stuff. And I am not and so, talking about me, I am not the only one who experiences this. But you end up getting poached.
Speaker 2:You know they go into a facility and then they poach your patient. And I've made more than one phone call in our area going do not poach my patient. Like what are you doing? You know? I mean, I referred them up there for the purpose of X and you basically kind of said you know, instead of seeing two people, you could actually just come to us and get you know, get the, you can get the everything here right, like we are we are the Walmart.
Speaker 1:We can prescribe all that buprenorphine or Suboxone or whatever you need. We can do it all right here, right Right.
Speaker 2:We are your Amazon, we are your Walmart, no, you know. And so that's so, I think, where people sometimes get stuck in. So first of all, they get a, they get in their own way, first and foremost, we, they get in their own way, we, they get in their own way. And then, two, I think that you know there is a concern when you develop and establish a relationship and then you're going to transition them out for a medical problem, in this case, a mental health, medical problem that you have. But for me, I feel like I've done as much as I can do, um, and they're going to poach them.
Speaker 2:So I can, I can very, very strongly and passionately say if I got a referral for someone for substance use disorder from um, a behavioral health um, nurse practitioner, pa or physician, and they are working on that corner of the world, I am in no way, shape or form stepping into that territory. Um, I will take care of their substance use disorder. I'm happy. Thank you very much for the referral. You will never have to worry about me poaching. But I think that that's a reality, that when first, well, first of all, when I, when I first say so, let's start with the ego when I first say well, you know I don't have the chops for this. Well, you know there are lots of people with lots of egos out there and you and I both know how that goes. So when you first acknowledge the ego issue and you're able to get beyond your own ego and then ask for help, you need to feel comfortable in the sense of your community that your patient isn't going to get shitty bad care. Sorry, you have to edit that out.
Speaker 1:Get bad care or they're going to get poached, and so well, and, and, and you know, part of the issue in being poached is is that you, you lose that person's done it lives, doesn't live on your side, you know, and and just because you've established a regimen that you think is probably workable, by the time this person who's on the mental health side, let's say, is putting in other medications. Well, that equation's changed now, isn't it? Are they reaching back out to you to collaborate? Are they reaching back out to you to understand the side that they need to understand? No, they're not doing that.
Speaker 1:You know it's like there's this territorialism that goes on. That's how silos get created, and you know that's how the field and I don't, you know, honestly, in many ways I don't really understand it, because it's not like every psychiatrist, it's not like every area that I know of is not woefully, woefully low on the number of psychiatrists with open, open, open area. You know, the ability to take another patient in there to their practice. They're all full or they're almost next to full. You have to be on a waiting list to get in with them. They're all full or they're almost next to full. You have to be on a waiting list to get in with them. You know, there's there's all these very these kind of subtle uh problems and and issues that arise out of this kind of what I would call personality driven uh issues that happen with high level professionals, right yeah you know, I mean, nobody likes to get their toes stepped on, but, being collaborative, they don't get trained in in medical school.
Speaker 1:It's something that either people do and they're good at and they and it makes them better docs, honestly or they don't and they're just kind of these people who this is my practice, this is what I do. I'm the authority I say what's going on. You know that's the way. That way I can have control over everything. The truth is is that they don't, because they don't have the expertise. I mean, this is a bunch of stuff that was like Robert Robert Whitaker, you know the anatomy of an epidemic.
Speaker 1:He talks about a lot of this stuff in his book. Just the medications and the high doses and the. What are we doing? And we're not collaborating with one another doing? And we're not collaborating with one another and we don't know what the mix of these medications is doing, because we don't cross? We don't cross channels with others because we're too busy in this silo, right, right and and all the while, you know the the pharmaceutical industry is laughing to the bank and they are and here's another deal and and, and this is um.
Speaker 2:It's two points. One real quick on the. You know, I'm the provider and I know what you know, I know what's best for you. I literally just had that conversation with a patient yesterday where I said you know, you've had this, you know very. It's kind of a zebra in the sense that it's not a common disease, congenital issue. And then this person happens to be dual substance use disorder and chronic pain and mental health. So not dual, but trifecta, it's a lot. And so they're new to the area. And I said you have to remember that you are the expert in your health and your disease. You've had it for as long as you've had it and you have to be able to have those conversations. And this is where you know for some patients that you know you, the doctor, knows best. I'm like, eh, not always Um. And then it the, the whole aspect of um being in the silo and trying and staying kind of in the middle of. Well, this is what the diagnosis is. And so this is our, this is our menu.
Speaker 2:So you know, we've got our, our this is the boxes, and then you've got. But then you but, todd, you have people out there that like really interesting cases. You have what we call. I call them zebra hunters. And you know, for your audience, we all, we always think about Dr.
Speaker 1:Strange.
Speaker 2:Yeah, well, yeah, and when we think about in healthcare, you know, when you hear hoofbeats, think horses, not zebras. So when you're looking at something, and in medicine, if you hear hoofbeats, what's the? If I look out my office window, am I more likely to see a horse going down the street or am I more likely to see a zebra? Well, you're more likely to see a horse, right? So everybody's trained for horses, everybody anticipates horses, everybody likes treating horses. It's simple. We've got a map, we've got the buffet menu. It's pretty straight up. We don't have a lot of people who are good zebra identifiers and like to chase zebras. Now, I love to chase zebras. I was actually talking to a physician colleague yesterday and I went. I'll tell you what I'll chase a zebra all day long. So if it's a complicated health situation mental health or substance use disorder or a combination physical disorder I'm on it. Man it's. It's fascinating to me.
Speaker 2:But part of what we're lacking in these siloed worlds are curious providers who are willing to chase stuff. And that goes back, todd, into insurance and pharma and big pharma, because they don't. First of all, you do have people who don't want to chase zebras. You know. They just want to go to work. They want to take care of the normal easy stuff that they can take care of. Um, the, the really thought challenging things. Um, there are some people who are great at it and they, they find pure, like me, pure joy and pleasure and in the mystery. But the majority of health providers are not like that. They're going to go in and they are going to not challenge big pharma. They're not going to challenge the industry, the insurance industry. They're not going to work to. They're not going to work to the to, you know, to seven o'clock or eight o'clock at night for that one patient on that one thing. They're not, that's a zebra, they don't advance.
Speaker 1:I mean, it means basically that whatever training they got in school, they're observing the rules and regulations that they've been given. They're doing just enough. Just enough continuing ed to make sure that they stay true to their license, whatever their board is telling them they got to do.
Speaker 2:Yeah.
Speaker 1:And then, but none of that drives a person to become better in the place where you can, in the only place you can really get better, after that level of training, which is in the real world, facing challenges that you don't know how to face without collaborating with others. That's what causes people to get a lot better at what they do. They're not reaching out and doing it, and maybe it's because their caseload is too high. Maybe they're sitting in a hospital. They got no time for that.
Speaker 2:That's a lot of it, particularly in mental health. I think that's a lot of it. It was really interesting to. I sit on. You know a couple of or I don't sit, but I follow on social media some psychiatric and substance use groups and it's fascinating to watch. You know people go. Well, you know I see 35 people a day. Well, I, you know I see 35 people a day. My max load a day is 14. Now I'm sunsetting in my career and I own my own practice and I'm not chasing the dollar. Um and so I've hit a point where I want to do um.
Speaker 2:I want to talk about yeah, exactly so, um, but it's you, you 30, I mean, think about that. You come in at eight, 30 or eight o'clock and you're your last patients at 430 or five, and somehow you've seen 35 patients. And this is mental health, this is primary care, this is pain management, this is specialties. You're just. How do you provide good service and good care and take care of that complex patient that needs more than 10 minutes or 15 minutes? When you got, they're going to give you a ridiculous caseload. And they're giving you the ridiculous caseload because corporate medicine more importantly, pharmaceutical or not pharmaceutical, insurancement rates and chasing the God Almighty dollar, and so that breeds poor medicine and it breeds laziness and it's not a purposeful laziness.
Speaker 2:There's no such thing as a lazy provider who chooses to be lazy. They are tired and they are taking the easier way out and, quite frankly, a lot of places are running into corporate medicine and they're just basically, you know, they're just kind of like all right, what do I do? So here's your checkbox go. Here's the parameter, here's your menu go. And so I mean wheelers in private practice and owns their own business, because lots of circumstances. But I'm done, I have played, I've been on the hamster wheel. I've followed the checkboxes. You know, I've followed the bouncing ball.
Speaker 1:And you know, particularly in the area that we work in, right, mental health and for me, Concierge mental health, private pay mental health, a lot of that category where people who afford to pay to slow down.
Speaker 2:They need time and listen to them. I always laugh because everybody gets 30 minutes with me and they, you know, I'm like you got to go get a therapist. And they're like well, you're my therapist, I'm like I am not a therapist and, of course, todd, you've known me for a long time. I'm like, I am a lot of things. A therapist is not one. My spouse right my spouse is is a licensed um mental health therapist and like that, you know that's the person you need to see, I'm going to tell you like.
Speaker 1:I'm going to tell you like it is pretty much and then you, then you might have some feelings about that. You should process it with that, with somebody else, because I don't have the time it's not that I don't have the time, but I'm like I don't have.
Speaker 2:That's not my. So um, I, I am. Um, I will toot my own. I'm very good at motivational interviewing. Um, I am trained in tfcbt.
Speaker 1:Um you lack the skills but, but it's not you're staying in your lane and in my lane.
Speaker 2:Well, in addition to that, you know like here's, here's.
Speaker 1:The thing is that you know you're not chasing the dollar. You know I because I've seen, I've seen the analyst slash therapist, slash psychiatrist. I'm not a huge fan like the. The 90 minute, 90 minute and this is not just the first meeting, this is the every meeting, the 90 minute meeting where there's a lot of processing around feelings and everything else. In truth it's a conflict of interest.
Speaker 1:In truth it becomes it's like you know you got feelings about these things and you want to, you want to compel me with your feelings, but I need to look at you objectively because what we're talking about is the science of your chemistry and the biology of what it is that your care needs to look like. Now you're going to have feelings about that. You're going to go through a process as you engage in changes with medications and other kinds of things like that. I need you to take that to a therapist, because that's the mill for them, that's the territory they live in. They want to do that with you, me. I've got to. I've got to make sure I'm paying attention to the chemistry and I can't get distracted by all the, all the nuance of how you, of how your process unfolds in your feeling environment, like I don't think that people understand that I really don't, and it's not meaning to be disrespectful either.
Speaker 2:It's like. You know I'm not in fact. You know, in fact, if anything, I'm championing the therapist here because I'm like this is look man, these people are wonderful at what they do, they're great at what they're trained at. They have the time. They have the time they have the skills um and they want to do it.
Speaker 2:And it's not to say I don't want to sit in and, you know, spend an additional. You know time's up with me because really, and and and therapists also have a time up, like you know. Hey, we're in it too and I have another patient or another client, but the that is not so you hit. You hit it perfectly. Um, my job is the physiology and biochemistry of what's going on with you. That is not to put in second place by any means, cognitive processing, behavioral processing and all those things. But I'm not your gal, but I can get you to the guy or gal who is that person for you. And I always said at the opioid treatment facility I'm like I will take care, and I said this earlier, I'll take care of the biology and physiology, but we have to have you see a counselor, a therapist, because we have the entire frontal lobe that we have to work through.
Speaker 1:This is a multi-pronged approach. Oh my God, you can't just. I mean sure there are people out there who have gone through processes, or maybe they're what they, you know, kind of gets referred to as the worried. Well, they can come in, they know what their issues are, they can see somebody like you or their doc, get the basics, go home, feel better. Maybe they've got a therapist they see infrequently but frequently enough, like there's a, there's a group of individuals that can live in that world and that's sufficient. The world that you and I are talking about, it's not even it's. It's inadequate to it's an inadequate to the need that we're serving.
Speaker 2:You know, and we can go down the line too, of whether you know. So here we get into, and this is I think this is a conversation for another day, and it'd be a great topic. Why are you here, are you? Here, because, or are you here because the court system said you need to be here and you're went to impatient because you've got a dui or a possession or or whatever, and so you're following groups, right.
Speaker 2:So, um, you know, I so I think. Certainly, Todd, this is a conversation I'd love to have with you?
Speaker 1:Why are you here? Because if you follow up on this topic, let's talk about golly yeah.
Speaker 1:It's going to be well, you know, I, I you've dealt with the courts. You've dealt with people in sober homes that are, you know, faced the courts. You've dealt with people in sober homes that are, you know, faced with consequences. You've dealt with people that are just coming to you on the street. You've dealt with 20-somethings and you've dealt with 50-somethings Like there's a whole spectrum of who are we providing services for. That's a great conversation for us to hit next time. Lisa, god, I love having you on the show. I love talking to you. I love having you on the show. I love talking to you. I love having you as a friend and colleague there on the world doing the good work. I appreciate you coming on. We're going to do it again very soon. This has been Head Inside Mental Health with Todd Weatherly on WPBM 1037, the voice of Asheville. No-transcript.