Reading of the Week: Dr. David Goldbloom – Reflections of a PGY42

From the Editor

“Work with people who are sick. They don’t have ‘mental health issues’ just like people with cancer don’t have ‘cell proliferation issues.’ Don’t live in the land of euphemism. Call things what they are.” 

So offers Dr. David S. Goldbloom (of the University of Toronto).

With such a long and distinguished career – senior medical advisor at CAMH, professor at the University of Toronto, former chair of the Mental Health Commission of Canada, former associate editor of The Canadian Journal of Psychiatry – Dr. Goldbloom has much advice for work and life. Back in the winter, after his retirement, he was invited to speak by the University of Toronto’s psychiatry residents. After, he shared his notes with me and I asked him to consider writing them up for a future Reading of the Week, which he generously agreed to do.

This week, we feature the resulting essay, relevant for residents, yes, and everyone else. Enjoy.

Please note that there will be no Readings for the next two weeks.

DG

Reflections of a PGY42

David S. Goldbloom, OC, MD, FRCPC  

In December 2022, I retired from clinical practice and an academic career spent entirely in teaching hospitals – an environment in which I had happily worked since starting my internship in 1981. Over those years, it was a particular privilege and pleasure to train generations of residents in psychiatry. At the end of my career, I received a request from the Psychiatric Residents Association of Toronto (PRAT) to speak at their winter retreat. They opted to ignore my caution that I was retired and past my best-before date. Rather than impose a topic on them, I asked them to survey their members and find out what they wanted me to talk about, and that would be the framework for my address.  

Over the years, I have found this to be a great way to shape a talk, including standing at a blackboard immediately beforehand and writing down topics as the audience shouts them out – and drawing a line through each of them as I finish talking about them. Admittedly, beyond the “learner-centred” aspect of this approach, there is the juicing performative element of improvisation (not to mention the time-saving element of no preparation).  

Excellent suggestions came in from the residents that allowed me to gel some thoughts that involved reflecting on what I had learned – albeit slowly – over 40 years. Unfortunately, the talk was virtual. While there were no slides involved, I did have some speaking notes to stay on track, and I have learned to have them on my computer screen just below my camera and use them like a poor man’s teleprompter. This way, I don’t have to look away and can maintain virtual eye contact with the 69 residents who were tuned in. 

Because it was a (nominally) academic talk – or at least one that occurred under an academic umbrella – I began with disclosures and disclaimers. My observation of this process is that the more disclosures a speaker has, the less time is spent revealing them. Instead, these slides whizz by at the speed of subliminal advertising. My disclosures included no funding of any kind in decades from the pharmaceutical or technology industry and an income now limited to book royalties, occasional speaker fees, investment income, and, of course, the Canada Pension Plan. While disclosures relate to potential conflicts of interest, disclaimers are more related to a disavowal of responsibility – and why the audience shouldn’t even listen to the talk. My principal disclosure was the exponential decline in my credibility due to stopping seeing patients and teaching residents, despite having seen thousands of the former and trained hundreds of the latter. 

As to why I chose a career in psychiatry, as for so many of us I had an inspiring mentor, who also happened to be my father-in-law, Nate Epstein. He was a charismatic and gifted psychiatrist who was also an academic pioneer, one of the “founding fathers” of McMaster medical school as Chair of Psychiatry. However, on starting medical school, I had no idea what area would be my ultimate focus. As my older son (now a lawyer) said as a teenager, when asked what he would like to be, he answered, “either a doctor or an actor who plays a doctor”. The difference isn’t clear until you truly inhabit the role. 

The experience of clerkship in psychiatry underlined a pretty simple rule for me regarding choosing an area of focus: you like it, it likes you, and you think you would be good at it. As is sometimes said, “it’s not rocket surgery!”. On reflection at the end of my career, however, I realized that important prerequisites for a career in psychiatry included: a curiosity about people and illness; a tolerance for ambiguity; a willingness to balance multiple and disparate approaches; and an interest in trying to reconcile the unique trajectories of people’s lives and character with the extraordinary reproducibility of symptoms. 

When I began my career in the early 1980s, the recent arrival of DSM-III was greeted like Moses’s tablets and was perceived as truth rather than committee consensus. It was a radical shift, more so than the editions of DSM that preceded it or the ones that have followed. It came at a time when some psychiatrists proclaimed with pride that they had never prescribed an antidepressant, preferring not to take “the easy way out” of human suffering and instead opting to excavate the purported root causes. Although training in psychotherapy was essentially psychodynamic and psychoanalytic, there was rigorous supervision, with audiotaping and videotaping of sessions that led to mortifying listening and viewing sessions with supervisors (although we didn’t get to see their work much – part of the continuing secrecy around the practice of psychiatry that leaves much latitude, for better or worse).  

The golden era of discovery in biological psychiatry was already over – ECT in 1938, lithium in 1948, the first generations of antipsychotics, antidepressants, and anxiolytics in the 1950s and 1960s. The second generations of these medications in the 1980s and 1990s did not outperform them despite the hype, and there have been no profound paradigm shifts in drug treatment in many decades. 

My own career was shaped by a “sliding doors” moment. As a senior resident, I had been accepted for a research fellowship in schizophrenia at the National Institute of Mental Health in Bethesda, Maryland. But one day a guest lecturer from Toronto, Paul Garfinkel, gave a grand rounds at McGill on eating disorders – a subject about which I knew nothing and I could not recall having seen any patients with these diagnoses (obviously I had but hadn’t known enough to ask). He spoke persuasively about the integration of biology, psychology, and culture in a way that made complexity alluring. He spoke with rigor about research and with compassion and humility about patients. I was hooked. 

We spoke after the rounds (yes, I had the audacity to think he would want to know that I had enjoyed his talk) and an instant chemistry followed. He invited me to visit his team in Toronto and learn more about what was going on there. All I knew about Toronto as a Montrealer was its forever-losing hockey team. 

In the wake of that encounter, my life – and our family life – changed. We came to Toronto “just for three years” of a research fellowship. We never left. There is an old Yiddish expression, mann tracht und Gott lacht – man plans and God laughs. Looking back, I never had a five-year plan but rather antennae that tingled at opportunity. 

I knew I wanted to be first and foremost a good clinician, but I also wanted to be a teacher and researcher. These were broad goals. What I did not anticipate was becoming a writer, advocate in the political and policy arenas, media spokesperson, and fundraiser. 

One of the takeaways for me of my fellowship experience is the importance of chance encounters, of curiosity, and openness to new experiences. Similarly, I have long been opposed to the announcement of the topics for weekly Grand Rounds; these details serve to persuade people not to come because “I’m not interested in that subject or that speaker”. Grand Rounds should be a weekly gathering point for a community of colleagues who share curiosity as well as support for each other. Learning by surprise is enriching. 

The other takeaway was the importance of having a mentor. I met with Paul formally as his Fellow on a weekly basis but probably bothered him on a close to daily basis; our offices were a few yards apart at Toronto General Hospital. Paul taught me how to be an academic physician – reviewing grants and papers with me, supporting me attending and presenting at scientific meetings, encouraging me to teach, and protecting me from administrative burdens. It was a profoundly valuable and extended tutelage, and one that continued for the entire run of my career. 

My curriculum vitae does not list the jobs for which I applied but was not selected. It includes some impressive rejections at the hospital and university level. Naturally, I felt very disappointed initially, as well as less noble feelings of anger, rejection, and self-doubt. But looking back, each door closed led to unanticipated doors opening: helping in the creation and running of the Mental Health Commission of Canada, editing textbooks, and writing about psychiatry for the general public. It was the triumph of serendipity over thwarted plans. 

And ultimately it left me feeling that knowing yourself was important in terms of: 

1. What you want to do. 
2. What you’re good at. 
3. What you enjoy. 

Hopefully there is a high degree of overlap. 

The residents attending today’s talk asked me to solve the conundrum of balancing work and family life – surely a lob of a topic, and obviously one for which I knew the Cadbury secret. Not. My wife and I married when we were 22 and 21 and then enrolled in medical school together a year later. Simply put, getting married was the best decision we ever made together (getting pregnant was the most fun decision). We did so when we were young and stupid (we’re old now), without an exhaustive list of required attributes in a partner or a delineated roadmap for our lives and careers. Fortunately (a recurring theme in my life), it worked out really well. But it was a different time (not to mention century) where both the externalized and internalized role expectations for each of us were far different than they are now. She finished her residency in ophthalmology only nine months pregnant with our first of two sons. She ultimately decided not to do surgery in her career despite being proficient at it, which was a bigger professional sacrifice than I made. The plain reality is that she shouldered the overwhelming responsibility on a daily basis for the oversight of our children’s lives and our home that was far from egalitarian. There is no way to dress it up to resemble the more equal division of labour that I witness among young professional couples today. But she has also had a rich and rewarding career, with unanticipated niche areas of expertise, clinical stimulation, and professional reward. 

Our figurative bacon was saved by a live-out nanny who started with us 38 years ago and continues today as a part-time housekeeper. Luck played a huge role – but so did making our nanny a member of our extended family and treating her with the respect she deserved. We were also unencumbered by the availability of continuous feeds of information via audio and video monitors, text messages, and social media. We had to trust that our kids were okay. 

Looking back, there was no magic formula. I was focused from the beginning on an academic clinical career while Nancy worked as a clinician first before becoming more active as a teacher at a hospital in the second half of her career. We both had “homework” to do every weeknight after our boys went to bed – she was reading around cases, I was writing research papers, and we were both figuring out our personal and professional roles. It is, like all marriages, still a work in progress, even after 47 years, as we navigate different aspects of our careers and lives, witness our children as actual adults, and welcome our grandchildren. My career would have been frankly impossible without her support and sacrifice. 

The residents also asked me to speak of what I am excited about today in psychiatry, which felt like a request for what horse to bet on in the third race at the track. The short answer is that I would encourage people to enter the field of psychiatry today enthusiastically. In part, this reflects some of the shortcomings and disappointments in our field in recent years and the need for fresh blood and new ideas. 

A number of years ago, I told my good friend and colleague Shitij Kapur, one of the smartest psychiatrists and neuroscientists I have known, that I was suffering from cusp fatigue; the beginning of every decade for the last 40 years was heralded as the cusp of a neuroscience breakthrough. But the last four decades, while characterized by unimaginable new techniques and tantalizing new findings, has not transformed the field. In 2007, I was asked to speak to an international summit of neuroscientists in Alberta at a meeting grandly titled “From Synapse to Society”. The organizer asked me to be provocative. I professed my genuine awe at their work as well as my hope and enthusiasm for its future. However, I pointed out that to date neuroscience had not had any transformative impact on our ability as clinicians to diagnose, classify, predict, prevent, or treat; other than that, it was great. A seemingly interminable silence followed and I contemplated entering a witness protection program. I was reassured we were, once again, on the cusp. And I remain hopeful and eager. 

At the level of therapeutics, we need to maintain necessary zeal but also be mindful of our history and our missteps, recently described by Andrew Scull in his 2022 book, Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness. We need to believe we are on the cusp to keep our momentum and commitment. But we will only see the cusp in retrospect. 

Short-term psychotherapy and its efficacy was evident when I was a resident, but it was only psychodynamic. Now we have an alphabet soup of evidence-based approaches: CBT, DBT, IPT, ACT, SFT, etc. They all work and mostly they work equally well. What is different now is the degree to which they are manual-driven, outcome-measured, and rigorously evaluated. That’s the big shift, the pulling back of the curtain of mystery around psychotherapy. It is still a secret clinical act, as opposed to surgery and the “operating theatre”, and it is rare for therapists to “show their work”. 

Advocacy and work against stigma and discrimination is a huge change in the last 40 years, with lots of opportunity for ongoing work. Each of you should think about how you can make your voice heard beyond your office – in your hospital, your community in organizations, in media. There is a hunger for the knowledge you possess – and there is also better opportunity now to leverage the knowledge your patients and their families possess. When I edited the textbook Psychiatric Clinical Skills, the concluding chapter was titled “What Matters to Us: Perspectives of Patients and Families”, by Scott Simmie and Julia Nunes. They are journalists who have written about mental health but who also have grappled with Scott’s bipolar disorder and its impact. Why wouldn’t consideration of clinical skills include the perspectives of people on the receiving end? 

I had the privilege of serving on boards of CMHA Metro Toronto, Canada’s largest community mental health agency; jack.org, a national youth mental health awareness organization; the Mental Health Commission of Canada that achieved a number of policy objectives; the CAMH Foundation which has raised closed to $1 billion; and two family foundations focused on mental health initiatives, the Graham Boeckh Foundation and the Daymark Foundation. There are ample opportunities for psychiatrists to be engaged outside their hospital, clinic, or community office in ways that serve patients and their families who we may never meet.  

There is no simple training program for advocacy (or if there is, I missed it). My informal recommendations for learning the ropes include: 

1. Seize the day (back to the opportunity theme). 
2. Appreciate the power of human stories over data. 
3. Learn to speak simply. 
4. Try to be less thin-skinned and defensive. 
5. Remember that humour can defuse tension. 
6. In the words of Beamer Smith, a smart and funny patient advocate in the early days of CAMH, be respectful, which is different from merely acting respectfully.  

I smiled when I reviewed the topic requests of residents for this talk and saw one called missteps and how to avoid them. You can’t. You’re a doctor, not an insurance agent or an actuary. If you have not had a suicide among your patients in your career, you have successfully avoided treating people who are ill. Would you go to an oncologist who told you he/she had never lost a patient to cancer? 

It is important to know the difference between aspirational slogans – like “conquer cancer in our lifetime” – and the clinical reality. This was captured in the wisdom of Edward Livingston Trudeau, a 19^th century physician, who described the mission of medicine as “to cure sometimes, to relieve often, to comfort always”. And when it comes to treatment, I always invoke the wisdom of my late father, Richard Goldbloom, who often said that “today’s dogma is tomorrow’s malpractice”. 

Between 1985 and 2020, I worked with many talented residents in inpatient, outpatient, and emergency settings. In the last 15 years, I supervised only PGY4 and PGY5 residents who opted to work with me in weekly new outpatient consultations for 6-12 months. It was only when I stopped that I could look back and reflect on that experience. 

Each week we took turns doing full assessments in front of each other. Many had not been observed doing a full interview since PGY2 and the same goes for observing staff doing a full interview. They also watched me dictate the consult immediately afterward, taking about 10 minutes to do so. They often confessed they spent hours dictating and editing reports and were ashamed how slow they were. Their interviews initially often reflected the triumph of comprehensiveness over curiosity and took too long. Residents had difficulty using plain language and conversational tone, falling back on “tell me more about that” clichés. Occasional notes sometimes morphed into courtroom stenography, with a negative impact on eye contact and therapeutic alliance. I asked them to take part in an experiment of doing an interview without note-taking while I took notes (as their safety net), and then reflect on the impact of the experience. They discovered that they were able to obtain more information and connect better with the patient in the same amount of time. The fear that they would forget important things the patient said was not realized. I worked with a superb group of residents who I am lucky now to call friends and colleagues – and even bosses. 

As a fan of David Letterman’s Top 10 lists, I provided a similar list of ten things it took me 40 years to learn: 

1. Don’t believe everything patients tell you about their families. Meet them and make meeting the families a given rather than an exception in your clinical practice. You see the patient occasionally and they often see them all the time. They are valuable early warning systems with deep knowledge. If you don’t talk with them, they will be afraid that all your patient does is complain about them. Set up ground rules that facilitate rather than obstruct communication. 

2. Recognize that you are far from a tabula rasa and that you are telling patients thousands of things about yourself in a variety of ways. Even when you choose to write something down versus just listen is a clue to the patient about what you think is important.  

3. The greatest privilege in teaching is to teach the most junior students in their “precynical” years. Taking young medical students into the hospital for their first interviews ever with patients was a particular thrill. 

4. There is an excess of good work needing to be done in every area of psychiatry; nothing is overserved. Who you work with as colleagues may be more important and satisfying to you than what you do. 

5. To quote John Evans, the great medical innovator, “It’s more fun to make a mess than to clean up a mess”. My experiences reflected multiple startups: the psychiatry Fellowship program, the General Psychiatry Program, CAMH, the Kirby committee of Senate, the Mental Health Commission of Canada, etc. I generally served only one term in these jobs, as the building phase is more exciting than the maintenance phase. 

6. The rewards of educating the public and engaging in advocacy: it gets you outside the clinical and academic bubble. In our polarized, echo-chamber world, that’s a good thing. 

7. The rise of PowerPoint and the decline of oratory: I was an early adopter of PowerPoint until I realized I was spending more time on graphic design than content. I abandoned using slides more than a decade ago, except to display images that cannot be conveyed in words, and it made me a better speaker. Audiences seemed more engaged when they were not triangulating cognitively between the spoken word, words on a screen, and words on a handout. 

8. Administration is 90% management of interpersonal conflict and 10% substantive issues. 

A policy and procedure manual will not save you as a leader. 

9. The extraordinary reward of helping colleagues clinically and mentoring junior ones: I have been lucky to treat health professional colleagues over the years from a variety of clinical areas and settings; it has reinforced my sense of community. And in the post-leadership years of my career, informal mentoring of younger colleagues, almost always over food, has been deeply satisfying – and payback for what I received early in my career. 

10. To paraphrase the American humorist Dave Barry, a colleague who is nice to you but rude to the maintenance or housekeeping staff is actually not a nice person. This has become an important yardstick for me. 

I concluded with ten pieces of unsolicited advice for the next generation of psychiatrists: 

1. Work with people who are sick. They don’t have “mental health issues” just like people with cancer don’t have “cell proliferation issues”. Don’t live in the land of euphemism. 

Call things what they are. 

2. Make house calls and see where and how people live. Covid’s unanticipated benefit was the virtual house call, let alone the convenience for many patients. I made house calls throughout my career and always found it deeply informative and a respectful way of connecting with patients. 

3. Know what your patients pay in rent relative to income, their debt severity, what percentage of their income goes to substances, etc. Know their financial context, because being a physician makes you a one-percenter who is insulated from many harsh financial realities. 

4. Work in underserviced areas and feel overappreciated.  

5. Keep your sense of humour (if you have one) and use it appropriately. Don’t try to be funny with patients if you’re not naturally funny. 

6. Wait until you know something before you write a book. 

7. Get involved with your community, both within and beyond mental health 

8. Keep up hobbies that allow you to zone out and let go of the burden of what you witness at close range (for me, piano and squash; importantly, the adjective for engaging in both of these is “play”). 

9. Figure out what allows you to have fun within your career, not simply outside it.  

10. If possible, find a partner you love who enriches you and supports you. It’s a tougher road alone – but not impossible. 

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.