The COVID-19 pandemic and the isolation caused by public health measures to slow its spread exacerbated a mismatch between the need for mental health care and the number of professionals trained to provide that care. Even though stigma prevents many persons with mental health problems from seeking care, there has never been enough go around. In Has Medicine Lost Its Mind? Why Our Mental Health System is Failing Us and What Should Be Done to Cure It, Dr. Robert C. Smith, a general internist and professor of medicine and psychiatry at Michigan State University, explains why our medical system consistently prioritizes physical over emotional health and presents some ambitious proposals for how to rectify this harmful disparity.
This relatively slim volume is divided into three parts. The first few chapters discuss the problems with mental health care in the U.S. and the suffering that they cause. Dr. Smith shares the stories of several patients he met during residency and his early years in practice who illustrate the bad outcomes that accompany not attending to patient's emotions and focusing solely on their physical problems. These experiences motivated him to complete a two-year fellowship in behavioral health and psychiatry, where he learned the biopsychosocial model and decided to make primary care mental health the teaching focus of his academic career. Dr. Smith notes that less than 5 percent of the preclinical and clinical curricula in medical school, absent electives, is devoted to teaching students about behavioral health or psychiatry. Thus, he argues, physicians were ill-prepared to confront the opioid epidemic, increasing rates of depression and anxiety in conjunction with chronic illness, and the negative effects of COVID-19 on mental health.
The second part of the book traces the history of the "mind-body split" in medicine, starting with Hippocrates, through the Flexner Report (1910) to the present day. In contrast, he presents the infrequently taught patient-centered interview as a paradigm shift (a la Thomas Kuhn) with the potential to revolutionize medicine. In the concluding chapters, Dr. Smith proposes a pathway to redirect the medical-industrial complex "back to a more humanistic orientation," which involves commissioning a "New Flexner Report" and federally-led reforms to medical education to require schools to fully embrace the biopsychosocial model. Primary care medical and residency faculty will learn the principles of mental health care via a train-the-trainer approach.
Although I dispute Dr. Smith's assertion that primary care physicians receive next to no training in mental health care (though I can only speak to my specialty of family medicine), I agree that structure of our health system discourages meaningful doctor-patient interactions, and that the assembly-line mentality of traditional primary care practice incentivizes drug prescribing over active listening. Medicine could do a far better job of diagnosing and treating mental health conditions, but absent a robust public health structure, their root causes - worsening economic and political inequality, a deteriorating environment, and a weak social safety net - will remain. And having the federal government or the Association of American Medical Colleges (AAMC) lead a national effort to dramatically expand the footprint of behavioral health in medical education is likely a pipe dream. This is not to say that this book is not worth reading - far from it. But I fear that it is too far ahead of its time.
