Is Psychedelic Therapy a Malpractice Risk? with Bill Green Malpractice Insurance Expert

Malpractice Basics and Standard of Care 0:00

So doctors don't understand this really too well, but patients don' understand it either. They go to the doctor and a patient and they expect that the Doctor is gonna cure them. You as a physician have no duty to cure your patient. Your only duty is to adhere to accepted standard of care. A month later, another image, still looks good, a slight little shadow but doesn't look too bad. Three times down the line, boy, that shadow looks so concerned. By the fifth one, shadows of tumor. Now, reverse the process.

Start with the very clear tumor and work your way backwards. You see a tumor all the way to the first image. And the example there is, in hindsight, it was clear, you're not as a doctor responsible to know that final image, responsible, to act within the accepted standard of care for the circumstances or the symptoms as presented. Welcome to The Two Curious MD podcast. I'm Dr. Ali Ahmed. And I am Dr Surya Rapan. With the wisdom from holistic, alternative and these conventional medicines, we are here to challenge the status quo.

We're curious about the connectivity and complexity between diverse fields of knowledge as a relief to consciousness, chronic illness, mental health, resilience and beyond. Learning more about art and science of healing or listening to stories of extraordinary healing. you're in the right place. Let's dive in. Today we have a special guest and we'll be talking to Bill Green, otherwise known as William Green but he goes by Bill. And he'll be talking to us about a very important topic, medical malpractice, which remains one of the significant legal and ethical concerns that doctors face on a daily basis and all healthcare professionals.

Medical mal practice occurs when healthcare providers deviate from accepted standards of care, resulting in harm to a patient. Added to that is the emergence of psychedelic assisted therapies, including ketamine, psilocybin, MDMA, and novel treatments. That introduces an even greater risk and sometimes opportunity for healing. And also the legal and ethical and clinical challenges we face with that. Providers practicing in this rapidly evolving field must also navigate these issues related to informed consent, scope of practice, patient selection and even possible adverse event management, documentation, supervision and the evolving standards of care even in psychedelic medicine.

And as psychedelic medicine transitions from experimental to actual, as it is, physicians, nurse practitioners, physician assistants, therapists, healthcare organizations must understand how malpractice principles apply to these innovative treatments just as well. The discussion I hope to have with Bill to explore medical malpractice risk, risk mitigation strategies, and responsibilities that healthcare professionals must understand as psychedelic therapies become increasingly integrated into modern healthcare.

I also want to learn more about from Bill's experience of 40 years in medical practice. So welcome Bill to our podcast. Tell us a little bit about your own personal story, 40 Years in Medical Malpractices. It's a, it is a little bit unusual. Ironically, I just retired, not by choice, but, um, just in the last two months after indeed 40 years in medical liability. And ironically, uh, the story didn't start there. I got my start in Medical Malpractice Insurance, Uh, through the Olympic Job Opportunities Program.

Now we're talking 40-years ago. Um, I was an Olympic track and field athlete. I, was a hammer thrower, which in America, it's kind of a funny story because we're not too good at that. One of the four throwing events in track-and-field, the shot clip that just gets the job done. And I wasn't a three-time American record holder and placed fifth Los Angeles games 40 years ago here in Southern California. Um, one of only three Americans since 1952 to place in the top five. The reason for that is not so much that I'm so better than anybody else.

It's that the event is very dangerous and I don't know if this is of interest to your audience, but it's a dangerous event and therefore is contested in high school. So like any sport, if you don' start young. You don't have much potential to go far by the time the pressures of making a living and a career hit anybody. And so by that time, most athletes get out of college and if they don' t show any potential, to make the little bit of money you can make as a quote amateur athlete. In the eighties, when I was doing it, amateurism rules were a big problem.

most athletes just have sort of had to get out of the sport because they just, there's not enough time to. But I got good very quickly and as I did TD commercials and for a short time, I, you know, it was kind of a small time success story, but anyway, opportunity through a program with the United States Olympic Committee, where they would place athletes with employers that would allow them time to train. And I had the great fortune of going to work for the second largest insurance broker in the world.

At the time, Johnson and Higgins, they were based in Century City, and they ran a malpractice insurance company, the Southern California Physicians Insurance Exchange, which for 40 years was the biggest mal practice carrier in California. Now they're no longer around. They were purchased in 2008 by the doctors company. I was vice president of sales. And then I actually left and went to the doctor's company before they purchased Skippy. And there's their VP of sales and then worked for a number of years for the medical insurance exchange of California in Oakland, where I just retired from.

So a funny way to find my way into the world of medical liability. And of course, that's the subject of this discussion today. I'm flattered to be asked to speak on this subject. We got first talking about this, and I think the reason you invited me on the program is the discussion around ketamine. I made some comments to you about all the controversy surrounding the Matthew Carey situation and which piqued your interest. And it got us talking about the intersection between the use of clinically apparently, and you're the medical professional, not me, that from everything I've heard from you and your fellows, apparently this is a drug that does miraculous things.

Clinically, it unfortunately we've seen has become popular for recreational use. And then of course, now with the legalization of marijuana for clinical use and for recreation use, but And also the discussion around the use of other hallucinogenic drugs that used to be only recreational are now being used clinically, apparently. And anyway, so the question of what is the medical liability concern around that? And so this is an area that I think I could speak to, although I'm not a legal person. I am actually a sales and marketing executive, formally, but I've had some experience in the risk management and loss prevention area to some degree.

have of course talked to many doctors for many years about a variety of subjects similar to this and So what we're talking about here is the danger of using any type of really procedure or substance, you know, medicine, and to the field of medicine that's not yet been tested as to its efficacy as a standard of care for liability reasons, faces a process, a legal process. And again, remember that I'm not an attorney. I am speaking about what I know about how that process works. is what you as doctors know is clinically indicated and effective will be described if you get caught up in a medical liability situation by the opposite side, by prosecution, you know, the people, as improper use of that substance or that procedure.

And that becomes really dicey when you're using something that's new, because the legal process is based, as we all know, on precedence and history. Standard of care is not what you say it is. It's what your fellows, it is defined not by the insurance company. It's not really even defined by a law. it's defined. By the standard of care in the medical profession, the community standard care, and that becomes the standards the law looks to. And when you've got a brand new substance or a branding procedure or brand-new way of using a substance that's now, that has not been tested in your court system.

be all kinds of suggestions about whether it was used correctly and not a whole history of precedent to say yes or no. And that's where it gets really dicey. Yeah. When that substance is something controversial, okay, may not be controversial to you as medical professionals, but when the press is, you know, trotting it out on television, you know, as the celebrity is using mushrooms that he got from his doctor, or ketamine that his assistant got

Bill Greenu2019s Career in Medical Liability 9:20

on the black market that the medical profession says is a miracle drug, but is being used to get high. It gets crazy as we all know. Yeah. This is a somewhat juicy subject because the press loves to go crazy with it. And I know it frustrates medical people. I mean, I've talked to so many psychiatrists that are so frustrated over how ketamine is, was portrayed with that front of her sad story about what happened to Mr. Perry. Um, and I'm quite certain that it's going to become. fodder for the plaintiff's bar in malpractice cases in the future.

I'm sad to say that we're going to have more situations like this, you know. And I can tell you right now, any psychiatrist that applies for a malprice policy that checks the box that says they use ketamine is going get an additional level of underwriting about how they're doing it. and how strict their, you know, their protocols are on how it's administered and the monitoring of it. And so it makes one, whether you like it or not, a higher level of risk of medical liability. Yeah. Not because your insurance company says it's dangerous.

We're not making a value judgment on that. In fact, it is unproven. As I said earlier, we just know it makes you a bigger target because it was un-proved and it a nice controversy. So you're highlighting some important points here and I want to make clear with our audience that points that this is a new new treatment option, call it a treatment options. It is a switch from something that was recreational to now becoming an option for treatment itself as well. And so there's a perspective shift on something was seen as a party drug to something is medically administered option.

You also point to the fact that we don't know everything, and it has to be still peer-reviewed, that the standards of care have to clear. And that may not be necessarily as clear as it is. There's a judgment around what is a standard of car,r and that can be variable from what's known to what actually implemented and evidence-based. Correct? Ascribed by the other side if you get sued. Fortunately, there is not a whole backlog of documented precedent supporting you yet. Yeah, exactly. What are the legal elements that establish a meta practice claim?

So doctors don't understand this really too well, but patients don' understand it either. They go to the doctor and a patient and they expect that the Doctor is gonna cure them. You as a physician have no duty to cure your patient. Your only duty is to adhere to accepted standard of care. And in our profession, we like to describe it as With this example, you know, it's sometimes referred to in slang terminology as the retrospective scope. And I know that sounds silly, but the, the example would of the retrospective skill using radiology is patient goes to the radiologist and has a, an image taken and looks good.

No problem. Month later, another image still looks. Good. See a slight little shadow, that doesn't look too bad. Three times down the line or that shout was so concerned by the fifth one. That shadows the tumor. Now, reverse the process. Start with the very clear tumor and work your way backwards. You see a tumor all the way to the first image. And the example there is, in hindsight, it was clear, you're not as a doctor responsible to know that final image, You're only responsible, to act within the accepted standard of care for the circumstances of the and the symptoms as presented.

And if there are five or three potential accepted courses of treatment for the systems you're presented with and you choose course number three, based on those symptoms and now we're down the line and it turns out it should have been course number one and maybe the patient is severely impacted because you chose three and should've been one. You have not committed medical negligence because your within the standard of care. Now if you picked course five that wasn't on the list, now that lawyer that evaluated that patient to determine if the case had merit, he's got a case because he can go and argue he or she was outside the standard of care, they picked a course of treatment that I could line up all kinds of doctors and said, no, that's weird, these three ways.

So that is a layman's description, very laymen's, description of malpractice as defined to answer your question. Wonderful. And I think it does answer something very important that in medicine, as a doctor, things are always changing and evolving. What you're trying to diagnose or treat or support is in that moment, what's before you. The symptoms, the presentation, and the evidence of what are the options, in the moment of time. that in the world of the law, it's called the reasonable man's standard judgment of those circumstances you're presented with.

So standard of care in healthcare litigation, how is that determined? So that is a moving target, and it is not defined by us, even by the court. The court treats precedent based on how it was defined in each case throughout history, but it constantly evolving. Medicine is always changing as you know as a doctor. And things were discovered all the time. As your profession discovers this procedure works, or this force of treatment works and this one doesn't, what worked before, I mean, they used to do bloodletting for car sex in medicine.

Of course, that's ridiculous today, but at the times, it was how people were treated, right? We learn over time what the best way to go is in treating patients and then that becomes the new standard of care. So the law doesn't presume to know what you as medical professionals know is the right thing. And even doctors in different specialties don't presumed to no, shouldn't, presuming to what what a psychiatrist know was right in the world of psychiatry. That's why when an expert witness comes in, they need to be an extra witness in psychiatry if that's what we're talking about, you know, because that your specialization.

Yeah. And just so you're aware, ketamine or spravato has FDA approval for treatment resistant depression. Level three. Acute suicidality. There is a medical precedent, there's evidence. How does off-label use, say, of IV ketamine or other modalities of treatment that are coming online, as you mentioned, psilocybin, even with cannabis, I mean, how do these off label use get, you know, cleared, with from malpractice. How can one ensure again that this is the right option for this patient even though it's off label?

The fact that a drug has an FDA approval and categorization means that the doctor you know, prescribing it is within the law. It's a legal, legally prescribable drug. Now, if it's level one and it heroin that has no clinical indicated use, then we're going to be questioning your professional judgment as a doctor. But if its a benzodiazene level four, you're prescibing it, we as the public are relying on your personal judgment, as doctor, on the clinical use of the drug, okay? So now we have a level three drug called ketamine, which as defined by the FDA means it has a danger of a dependency and so it needs to be treated with care.

But here's the point that we were making earlier. The law needs rely on your judgment as a physician on proper clinical uses of that drug. And that's what's going to get debated in front of a jury if it comes down to a malpractice case. You're going go in there and you're gonna say, look, I'm the medical professional. I've been using ketamine for four years. Here is all the clinical evidence. It's all documented. Okay. And we're going to line up experts to support you as your malpractice carrier.

The other side has been said, Oh yeah, but here's all the evidence that says for this set of circumstances, it's still untested and it still experimental. It's going get argued. round and around and round. That's how the malpractice, the medical liability process works in court.

Ketamine, Psychedelics, and Legal Risk 18:30

Our experts versus your experts. Everybody's credentials are going to be challenged, and they're going be debating whether your use of this new, untested, without lots of precedent, as I started off talking about, drug, which now we know has some miraculous properties, but we also know can be very dangerous if not used clinically in the correct fashion. Right. So in the United States, just for the audience to know, to give them some background, the Federal Control Substance Act, LSD is Schedule I, MDMA is listed as Schedules I.

Cannabis is Listed Scheduled I federally. And as a Schedule I substance, which is usually defined by the federal law as having anything that has a high potential of abuse, no currently medical accepted standard of treatment under federal laws, and a lack of acceptable safety use under medical supervision. The landscape of this is changing. MDMA went through kind of breakthrough therapy demonstrated in PTSD in veterans and other cohorts of patients. It also has been used in research under federally guided clinical approval trials.

it didn't make it to phase three approval for FDA in 2024. It remains still investigational, although it did go through phase one and phase two trials. LSD remains scheduled one. There is evidence and research for ongoing anxiety, addiction, but there's no current, no FDA-approved medical use indication at this time. Cannabis remains a scheduled 1, federally, as of 2026. And many states have legalized medical and recreational cannabis. The federal government currently may be considering rescheduling cannabis, but there's no final word on that.

Ketamine, though, unlike LSD or MDM, is schedule three, not schedule one. It is an FDA-approved medication for anesthesia. Esketamine or Spravato is FDA approved for treatment-resistant depression, as we mentioned. And there are medical use indications for ketamine. So it's categorically, and that's why it is categorical in a different schedule, correct? Yeah, I mean, that as I understand it, okay, remember, Yeah. I think the best way, so trying to sort out how should a medical professional address the nexus between how the legal process works and how a clinical viewpoint should balance, right?

We call that in my profession, loss prevention or risk management education, evaluating risk. Whenever risk of malpractice application and, how defensible are you if you get sued, So any time a medical professional, whether they be talking about psychiatry and like we are now or any new brand new procedure, whenever you're doing something new, you are potentially at greater risk than the guy that or the gal that is not doing that, that's following the old school medical approach because there's all kinds of precedent to defend you in court.

You know, so a doctor that wants to engage in the cutting edge and has great belief in use of ketamine for its miraculous properties needs to realize that they are at greater risk. And don't be surprised when the underwriting process is more difficult, or maybe they get a surcharge. We're not saying there's anything wrong with you as a physician, we're saying the business that you've chosen, the course of your practice that, you selected is on the leading edge and therefore is a greater liability risk.

There's a price and an under writing process for every liability risks and We as an insurance company have to evaluate that. And if a doctor wants to go that direction, it's a business decision whether they may have pay a little bit more for the insurance protection to do so. So what are the things that clinicians and patients can do to really trust this process without this concern for risk? I mean, even though there is risk, what are the things that they can do to prevent risk to ensure safety and to build into their processes as things are new and evolving?

becomes the old school answer, but it's really the tried and true answer. Okay. We all, you all know about the informed consent process, the risk benefits and alternatives discussion. So often to a doctor that becomes routine. Sometimes it gets distilled down to nothing more than the signature, stack of papers when you're first either getting ready for a, a brand new patient or a procedure. It's not that it has to be a joint discussion between coach and athlete. Here's the problem. And here's the other ways to go about it.

Now, we're going to do this together, right? And we go arm and arm into that. These days, I'm a former athlete that's got four joints replaced, hopefully only four. When you go in for surgery, it gets so redundant, and it's ridiculous how many times they'd ask you, what are we in here for today? Fight it on your body. because of wrong site surgery, the stories I could tell you about surgery done on the wrong joint, right? They've learned, surgeons have learned how to prevent wrong side surgery from the informed consent process.

Well, that has to be true, especially when you're going to the no man's land legally of brand new medical procedures or substance, you know, political use of substances like ketamine or God forbid anything like other experimental drugs. You have to have a clear understanding with your patient on what we're doing, what are the alternatives to doing that. So if something goes wrong and document it like crazy, so if Something goes Wrong and the other side says, What are you doing treating my client with this crazy ass drug?

And, and the jury who doesn't know anything different wants to believe them. You can pull out your file and show them, well, look, we talked all about it and this patient knows exactly what the risks were. And we decided together to do it. It was a collaboration, top to bottom. That's informed consent. Coach and athlete jointly deciding how we're going to go about. and how realistic we are going to be on the outcome. That's how you protect yourself against medical liability, and you are able to prove it with documentation.

Not your word. If it isn't in the file, it didn't occur. Very important, conformed consent documentation, how you go into something as a collaboration versus a, you know, forced or feeling pressured. I definitely think that's very valuable, especially even more so in this new space. What is it that patients, and what you're speaking to is trust and communication. and making sure that that's clear on both ends. What are the questions that you think patients should be asking their provider, especially in these areas of psychedelic treatments, ketamine, and off-label use of other substances once they get approved?

The tendency, I think, for most patients is to be trusting to their doctor and that's good. You know, my wife was a nurse and she always says, you have to advocate for your family member when they're in the hospital. Ask a lot of questions, be a pain in butt. Advocate, question, ask every question you can think of, understand the process as much as possible. Don't try to pass judgment or don't become such a problem that your impediment to the physician, but, you know, understand what's being done.

And a good doctor should not have disdain for those questions. A good Doctor that has good bedside manner. There are so many funny little colloquial statements that I've learned in my years in this business. But one of them is, some of the best physicians in the world with terrible bed-side manners get sued the most. Some of those physicians of a world where great bed side manner never gets sued. You know, how well your people like you and understand you, and then agree with you collaboratively, like we're talking about, is the best defense that you have against Mark Wailoo.

So a patient should be asking those questions that concerns them, that they're heard, understood, and that can trust their provider. A good doctor will tolerate those question no matter how ignorant they seem or persistent they are presented because that's the informed consent process and it can be tedious. And don't forget. It has to go in the file because when you go into court, it'll drive you crazy what's said about you. And it may have no bearing on reality. If you can't prove you had that discussion happen.

Correct. Do you feel informed consent as you described your own experience, you know, in joint replacements and surgeries is less, there's less emphasis on it. Something's changed about the way informed, consent is obtained in your experience. Yeah, a lot. I mean, using surgery as an example, it's almost ridiculous now. It is ridiculous. Now, I counted it. My last surgery, seven times I had to answer or sign a document verifying exactly which joint and what surgery was being performed.

Off-Label Use, Scheduling, and Underwriting 28:30

Seven times. Ridiculous. There was zero danger of a wrong side surgery. Yeah. But it's because it is the insurance industry. After Obamacare and all the new quality standards that are imposed on the hospitals now, and the revenue that's tied to infection rates and readmission rates, the dollar figures associated with all this stuff are so enormous that the medical profession can't afford for anything to go wrong. So their redundancies, on top of redundancy, have become an expense burden unto themselves in life.

Yeah. I definitely think there's a lot of fear around in healthcare practice that's built up over time that has gotten worse, I believe. And that the logistics around consent and paperwork and documentation has added a little stress on the system for that very reason. Especially in the United States of America, to be honest. And in my decades in this business I've seen, I have seen how miraculously medicine has learned to protect itself against the danger of medical liability. I mean, when I got started in the business, if you did a cost inflation adjustment to malpractice rates, doctors would be shocked to know what they're paying today relative to what were paying in 80s.

It's less on an inflation adjusted basis. And it's amazing because we've driven down the frequency of loss When I left Southern California after 20 years with Skippy, I remember these statistics. You know, the frequency of loss rate against orthopedic surgeons in Southern, California was one in four, uh, doctors or surgeons getting sued in a year. I mean, that, now that it was all claims, frivolous and otherwise, it ridiculous. These frequency rates have dropped dramatically because of little things like we're talking about.

We're not getting long-site surgeries like these to do. Infection rates had been driven down by dials to turn to squeeze out the peripheral problems that have led to liability. And I'm a hospitalist, so I also see and witness the use of patient advocates and support staff that really come in when there is a risk issue to help. facilitate that communication that sometimes gets misconstrued or misrepresented or addressing mistakes, you know, as they can happen. And I think that infrastructure has come to light as a much more stress around in the system to really support and provide training for providers.

Bedside mannerisms and communication, I thinks, is very, very important. and you hope that that would be, that continues to develop and be supported for physicians. The other factor that I think, the other side of that is that there's a lot of burnout. There's lot time constraints, there is a documentation requirements for physician and providers. Less contact time with patients because You're pulled away from your EMR and you're pull away all the logistical things you have to do. And the potential risks are always present with, you know, when you order a lab and the patient gets billed by the insurance company, but not completely, and they're reliable for the rest of the cost.

That goes to the physician. Why did you want to these tests that aren't covered by insurance? Even though that's not the provider's responsibility. It is really the system of care that we're in that creates these system issues that are potential for risk, potential again for mistrust. It's been complained to me for years about all the bureaucracy they have to deal with, all of the advocacy they had to do for the patients. When I had one of my surgeries, the work that my surgeons, he had a person in his office, his only job, very prominent Newport Beach orthopedic surgeon, and this person's only was advocacy to convince the health insurers of the medical indicated nature of his surgeries that this doctor performed.

because everyone came to him, people flew in from all over the world for this surgeon and so he found himself needing this person in his practice because the insurance industry learned that he was so sought after that people weren't just going to them because They need a surgery. These were people that wanted him because of his prestige. So he had a full-time person whose job it was to argue with health insurance companies. I was amazed by this. That's the state of affairs in healthcare today in America.

It's amazing, isn't it? Yeah, totally, very much so. And I think the same applies to what we're seeing in terms of treatment resistant depression options. They're so limited that by the time patients do come in for treatment, they're already been beaten down.They have a lot of medical trauma. they've not received the care that they could have gotten. even early on in life, there's been barriers to care access issues. And now we're seeing the cream of the crop of that struggle, the patients coming in through our doors for treatment that again is different and is an alternative and still uncertain.

So there is such a lot of It creates a very interesting kind of understanding of and supporting that patient's experience as well through the systems of care and the malpractice that they've experienced as, well, call it literally mal practice, right? Yeah. I mean, whether you're a patient or a doctor, you have to learn. the background. It's amazing how much you have to understand about how healthcare is administered to be a patient today and how you much have know as a doctor about what your patients have go through to come to see you.

Used to you got sick, you just made an appointment with your doctor. Now you may have wait for weeks and weeks to meet your doctors. Do you believe that all patients are receiving the same standard of care? It's so funny. You know, just in the last few years, I became a Kaiser patient. My wife's a Pfizer nurse, and I remember everybody hated Kaiser in that early nineties. The backlash against the early days of HMO medicine, in medical liability. And now everybody loves Pfizer. I love Pfizer and I think Pfizer is excellent medicine, but I remember when it was disdained.

Um, and before I was Pfizer, I came from the PPO world and like I told you, it, when, he was incredibly hard to get. my double hip replacement surgery in 2016 before I was Kaiser. I had to go through that process I just described. No, I mean, a lot of people are going without surgery because they just can't get their health insurance company to approve it and it's needed. In my opinion, I'm an insurance person. It's a different type of insurance, but I think I, this is a controversy. These routinely reject your request for surgery and make you work a little harder to get it approved, whether it's indicated or not, you know.

So, you're talking about a bigger system and that once there's a system that seems to know how to navigate through some of these barriers, say, call it insurance, called it access, calls it sub-highest level care, subspecialty care that, once, there is a systems for that it seems avoid risk. Integrated delivery has solved that problem pretty effectively. So you get a different level of care, in my opinion, if you're with an integrated delivery system. They've filled all the gaps between that existed before.

Medicine's changed so much just in me lifetime, my adult lifetime and where it was. So let's talk a little bit more now in terms of What are the things that both patient and doctor can really just outline a few things, that you feel are necessary currently in that shared decision-making and informed consent that especially can be applicable in psychedelic medicine and off-label use of other substances in treatments? Well, that's hard for me to do because I'm not a clinician. I can only speak to it from a patient standpoint.

Um, I've recently gone through a horrific trauma in my personal life. And so I am currently a, a patients of a very good psychologist and did not go well with other people before that.

Informed Consent and Documentation 38:00

So I could speak, to, um, speak about process a little bit, sure. It has to do in my case, personally with developing a relationship, you know, um, no talk therapy had no value to me at all. The times that I tried it and I'm really hard for a long time with a number of different professionals. I just got nowhere with it. It showed no effort whatsoever until I. You know, and I'm really developing a relationship with my clinician and, it was bad at one point. I was, you know I, was relying on Xanax and they were getting concerned about too much use of benzos.

And I mean, I had suicidal ideation. It was. You wouldn't go, into my personal story, but I'd go through two. I've lost three immediate family members in five years, including the suicide of my 19-year-old son five-years ago, and the psychiatry with the psychiatric problem. And the best way I can answer your question is to say that the development of the relationship, when I came to the process, I was total skeptic and in real trouble when came in. I developed a relationship with my clinician. She graduated and then I had a relapse due to another tragedy in my family.

And had I not had that relationship with her, I don't know if I would have been able to get through this recently. So the best answer I can give you is how effectively you can develop that relationships with your patient, know their story. And, uh, and this was all a first for me. I never imagined myself needing a psychiatric clinician. Life can be funny, life can really deal with people truly. And when it does, And we need people like you, it's that relationship that gets the patient through. Thank God for medical, you know, mental health professionals.

People like me would not be sitting here if I want to be for mental, medical health professional. Well, thank you for sharing that, Bill. That's deeply felt, your emotion, and your experience, how this becomes personal and how important it is to you and what you've had to work through, even from your perspective in your work that you did professionally. So thank you for sharing that. I think it really allows us to really connect in another way, right? That when we are talking about such important things, these are really deeply personally felt experiences and what we can do better from them.

Your story, you know, and it's how we deal with trials and tribulations of life. Maybe I'll have to balance our professional life and their personal life, I guess it's interesting that this discussion is all about that very subject, right? We're talking about the professional question of medical liability and also- Yeah. And I want to take a moment to just honor the space that you just shared. So thank you. Thank you very much for having me. And I think there's so much that you, I mean, that first conversation I had with you and many before that too, but I could sense the need and indication to share what you know, the wisdom of what, of which you've experienced in your life on this podcast and to show it widely, because I heard you speak to that.

I've heard that in a very honest way, you spoke about where you were at and, and I, I recognize how much you had knowledge about and how that was important to kind of bring it together. Times in life, you get caught at a weak moment. Yeah. Fight our battles in live, darling. We do. If you read about mine or heard about our own, even as doctors, some of the things that we talk about in this podcast is story and what brings people together, their life experiences. I mean, who I am as a doctor, it has a lot to do with the trauma that I've experienced.

What brings patients through the doors and makes them better is exactly that pain point that you just connected with. Because that's where growth curves right there, right from that moment that just experienced it. You're in different directions. Yeah. I really want to thank you for being here. And I know we're coming to a close here, but I wanted to close with a question as we spoke about. What is something that you feel that your curious about? in medicine, psychedelic, and the work that we're doing here in this podcast, which is narrative medicine story, conventional treatments, evidence-based treatments and of course, alternative options like psychedelics medicine and other integrative medicine modalities, bringing it all together.

What is something that you're curious about that would you like to ask me or the audience? It's kind of a weird question, okay? Yeah. It's kind of strange if you, I don't know if it's appropriate, but when I was talking to you and said a number of other psychiatrists, like I ended up having discussions about ketamine because it was coming right off that horrible story. Cause I, was a friend of a fan of that TV show friends and that story, and he just got all the. Yeah, The news that his personal assistant got handed off, got hammered by the judge just the last week.

The Matthew Perry story was fresh off the news when we were talking. And it sparked a curiosity in me because I went through suicidal ideation and I'm not there anymore now, thank goodness. But I am curious, what is it about ketamine that is so miraculous in treating suicidal-ideation? What does it do? I'd like to have had it when I was in that position, I guess. That's a great question. I believe that when we ask the patient about suicide ideation, we have a lot of stigma around that term, first of all.

People are afraid of talking about it. They're afraid to talk about that deep place that's hurting, that they're ruminating in, and that their circulating in. And it's often a question of, well, before that thought comes to your mind, before that thought is, I'd rather not be here. I rather end my life. What is it that you're experiencing that takes you to that place that want to escape from? And with ketamine, we get to take away or decouple from that ruminating, both physiologically and with the medicine, kind of just kind decouble from the raminating cycle.

We call it the brain reset. Your brain kind just turns down offline for a little bit. That one space, that default mode operating system does that physiologically. But more important is your own access to that deep self, accessing the meditative mind, connecting to something that you're unable to do because you are emotionally so entangled with it. Just to decouple from that emotional experience and to be able to process it, ketamine allows for that. I say that ketamine is the key that opens the door.

That's all it does. It's the key that opens the door. You have to walk through it, but can you walk though it with support and facilitation? It shuts off the racing thoughts and it gives you a chance to have a more normal thought process. Correct. When it's done correctly and with facilitations. Is it because they're so keyed up all the time and then they can't get out of that, their own mice, and they need that all of the Yeah, then they're not doing their work. They're going to that escape zone and they are accessing disconnection or dissociative experience and that becomes the addictive behavior that drives that need.

Patient Advocacy, Trust, and Shared Decision-Making 46:00

Not that it's physiologically addictive, but it drives this motivation to escape. in a way. Thoughts feel in that state of mind, feel like they're driving you mad. You can see that. Yeah, but they are natural ways to do the same thing. It's just ketamine is a catalyst that gets you there faster. I had a discussion. This is really off beat. I don't know. He might find it interesting though. Had an interesting discussion with my very good friends. It was a text discussion, my friend, he's a really great guy, but he relies too much on alcohol to escape.

And he is going through a real terrible trauma to his wife right now. His wife. and I told him, you know, one thing I'm doing right. Now. That's very good for me. I'm a big film fan. Totally alone right now because of what's happened with my family and getting divorced. And I go to the movies like a 10-year-old, I want to walk in there and be taken away. Yeah. That I am going to see the new Steven Spielberg movie because it's getting all this great buzz. Like I did, I find that you can be taken to another place with suspension of disbelief.

Like, like the drug you're talking about, it takes me to this mindset where I forget my problems for two hours in another zone. It's like a drug to me and it's healthy. And I was telling my friend, you know, You don't need substances to get what you looking for. So you could find other, i did it with exercise for years and years. Correct. There's other ways to get that high or whatever that is that we're talking about, you know? Yeah. Yeah, there is. There is connection with others. The community that used to be, as a family, a unit, society, the disconnection until reconnecting to that are ways of healing.

We need to go to this zone. Why can't we stay in the hearing now? Why do we have to do that? It's weird. Yeah, very true. And I think there's more to be learned from that. It's a great question and I really appreciate that question. I thinks it really brings us to our discussion on medical malpractice. Medical ethics is really kind of, I feel like, what we're really talking about. The ethics of care and what is the important components. and i really want to just kind highlight and summarize some of the things we've talked about One is, What is The Standard of Care?

Second is, how do we really incorporate that and document that, and recognize and make decisions that are appropriate, that ethical, because this is nuanced type of care. And it always has been. Healing has always been, the doctor-patient relationship has also been nuanced, but we're forgetting that it is. It's not as one cookie cutter. thing, your surgeries that you experienced were not cookie cutter. There were definitely very unique things that your body had that the surgeon, doctor, provider had to recognize.

It's unique, it's completely unique. No one has the same joint as you, as anybody else. I love that we spoke about informed consent and how important informed content is, that it's really brought up to light. It's not something just a paper that you're signing over and over again, people are really understanding what that means. And the vulnerabilities, we're talking about the risks. We're really opening that transparency and I think that's something that is important, that we're also recognizing what are the unique risks in psychedelic medicine, ketamine, and that that they're looking back on those and making sure that have standards in place and protocols in places and we have a way of measuring that and reviewing that.

the patient is selected, their safety addressed. I think these are the things that are important safeguards for both patient, provider, and the system. And I'm glad we had a conversation about that. The doctor should remember that because the drug is used, the use of the drugs is new and untested still in the precedent system of court process, that he or she is in a new realm and is at greater risk. And even though they know what they're doing and using it, they are in untested water in doing so.

Yeah. And thank you for bringing in your own personal story because I think that really rings true with a lot of other patients too and how they experience healthcare and what we can do better. I really feel like you really brought in that. There's a lotta meaning in what you've done and experience and sharing to that, I appreciate you being there, being vulnerable with me in this podcast, so thank Thanks for joining us on the Two Curious MD podcast. We hope today's episode inspired you to ask new questions and explore fresh perspectives.

we challenge you ask us those unasked questions that you're curious about in your medical practice, condition, health and wellness. If you enjoyed the podcast, don't forget to subscribe, share it with somebody just as curious and leave us a review. It helps us keep the curiosity alive. post or comment with a question or curious inquiry that you have and seek to explore or learn with us. Stay curious and we'll see you next time.