Welcome to MedCast, the podcast from MedChi, the Maryland State Medical Society. In episode 10, Dr. Stephen Rockower speaks with Dr. Karen Dionesotes, a psychiatry resident at Johns Hopkins University in Baltimore. They discuss Dr. Dionesotes' background, behavioral health, organized medicine and public policy.
Stephen Rockower (00:15):
Welcome to MedCast, the podcast from MedChi, the Maryland State Medical Society. Each episode, we'll be doing a deep dive into medicine and taking an insider's view on issues facing Maryland's physicians and patients and healthcare more broadly. I'm your host, Dr. Stephen Rockower. Today my guest is Dr. Karen Dionesotes, a psychiatry resident at Hopkins University in Baltimore. Dr. Dionesotes, thank you so much for being with us.
Karen Dionesotes (00:43):
Of course. Thanks, Dr. Rockower, for inviting me.
Stephen Rockower (00:45):
I'm so happy to have you. Let's start with a few basic biographical things. Tell me about where you grew up, where you went to school, medical school, and usually I talk about residencies, but here you are in your residency, so we'll talk about that some, too.
Karen Dionesotes (01:05):
Perfect. I'm originally from the northwest suburbs of Chicago, a place called Lake Zurich, Illinois. I went to college just a little bit north of me in Milwaukee, Wisconsin. I went to Marquette University for undergrad and then immediately following that, I moved to Omaha, Nebraska and attended medical school at Creighton University School of Medicine. I was originally intended to graduate in 2017 with my class, but took actually two gap years between my third and fourth year of medical school when I moved to Baltimore for the first time and got my Master's in Public Health at Johns Hopkins Bloomberg School of Public Health and then actually stayed to work for Maryland Medicaid for the state office here, doing financial analysis and fiscal analysis of bills going through the general assembly that would impact the Medicaid population. So got my feet on the ground and policy in that way and then returned to Creighton, graduated in 2019, and ended up matching out here at Hopkins for psychiatry residency, during which I'm currently in my fourth year, which is my last year of residency, which is wild.
Stephen Rockower (02:22):
And we were very glad to have you when you were doing your time at Hopkins getting your MPA because your stuff dealing with the Medicaid program and the legislature was very, very helpful. What led you to pursue a Master's in public health while you were in medical of medical school?
Karen Dionesotes (02:40):
Yeah, that's a great question. I feel like I almost had tunnel vision on going to medical school since I was really young, and I just felt like that's what you do and you graduate high school and you go right to college and you graduate college and you go right to med school. I do think some colleges just really pushed that almost, and having this thought or feeling, "Well, if I don't get into medical school right away, I'm going to be a failure," or "I'm never going to go back. I'm never going to make it," and so I started medical school when I was 21. I have a late birthday, so I'm a little bit younger than most people in my class, and I was the third youngest person in my class, which for me at the time, was really shocking to see that people in medicine who had completely different careers before deciding to change course and come back to medical school. And so it was during medical school early on that I joined the American Medical Association, the AMA, and I was part of the medical student section. I actually went to my first meeting. It was the interim meeting of my first year of medical school. It was in November and it was in National Harbor, Maryland, so that was actually my first trek out to Maryland.
Stephen Rockower (03:55):
Oh, wonderful.
Karen Dionesotes (03:56):
I know. And it was at that meeting that I was just so blown away by the passion and the knowledge that these medical students had about things outside of clinical medicine. I met all of these people who were MD PhDs and who were taking time off to do an MBA, taking time off to do an MPH, to do a MPP, all sorts of different things, and it really is what sparked that thought in me to look at what exists outside of clinical medicine, but still within the realm of healthcare. And so really, it's those people that I met and I'm still very close friends with through the AMA, that led to me exploring what a master's in public health would be and what that training would look like and how that would benefit my future patients.
Stephen Rockower (04:48):
Does a master's in public health have a area of expertise or specialty? I know that when you were here doing that, you were involved in policy making and the Medicaid program, but was that a track that you could have arranged or you just did that on your own?
Karen Dionesotes (05:08):
That's a great question. The master's in public health actually has multiple different concentrations. There is a general curriculum that everyone needs to complete, but then on top of that, you take classes in specialty curriculums. And so I was in the school for Health Policy and Management, and then within that, I had a second super specialization almost, in health policy systems, economics, and policy. So I really, really focused on health policy as that was really, at the time, one of the things that I realized that as physicians on the ground, we have an understanding of the mental health system or of the healthcare system in a way that others don't. And so being able to apply our knowledge broadly to affect a general population at a policy level, that is really making just an incredible impact in a way that sometimes the frustrations of one on one clinical medicine can't.
Stephen Rockower (06:13):
Oh, I agree. I've said all along, and you've heard me say it, that our work in public policy is so important because each of our work, day to day across the desk to our patients is one on one. But when we're working in public policy, we're working for everybody and it affects everybody and what happens in Annapolis affects all of us, whether we're in psychiatry or orthopedics or internal medicine or family medicine or whatever. What led you to psychiatry?
Karen Dionesotes (06:50):
During medical school, I actually clinical rotations third year, I generally enjoyed all of my rotations, which was stressful at the time since I took a break between third and fourth year and was not totally sure what I wanted to do. I really love primary care and I love continuity of care, having a relationship with patients. I love preventive medicine, all of these aspects of care. And when I really looked back and reflected upon my clinical experiences, I realized, "Oh, wow. When I was in OB, I really loved learning about and taking care of the patient with that postpartum depression or with the anxiety that has a peripartum onset," or when I was in primary care or in pediatrics, doing screenings for different sorts of behavioral health disorders or talking about just patient anxiety or ways to improve coping skills, quality of life, and so those things really led me towards psychiatry.
(07:57):
And then I also really do think that there's so much work that needs to be done within the behavioral health system at large and anybody with a mental illness, whether what degree of socioeconomic status you have, it's a vulnerable population because unfortunately, there's so much stigma involved in mental illness. And so there's just so much work to do on a population level, on an education level, on a policy level in the behavioral health system and so that also really drew me here because I knew that's something that there's work to be done and I could make an impact.
Stephen Rockower (08:34):
Yeah. Behavioral health is really so important, especially in training. I know one of the big problems is suicide among trainees, medical students, and residents, and even physicians as well. I don't know if you've had any contact with any of that at all or dealt with any of these people.
Karen Dionesotes (08:58):
Yeah. I think my thoughts are that as physicians and as leaders of a healthcare team, we are viewed by our patients as invaluable. We're viewed by our patients as superhuman and so that is the way that we feel like we need to come across. And it's seen as frowned upon to have vulnerabilities in medicine or to show vulnerability in medicine.
(09:28):
I know for myself personally, I really, really struggled with depression during medical school and I didn't really know what was happening and I didn't really understand why I was so miserable, and it wasn't really talked about in our school and it was actually seen as unprofessional that I was dealing with a medical illness in the same way that someone deals with diabetes or someone deals with high blood pressure. But for me, depression was really debilitating. And the thought of taking medications and being in therapy and then as a student, you're so stressed about, "Well, what about my future licensure? What do I need to report in the future?"
(10:11):
All of these things really stigmatizes physicians having mental health things and really, we want people to be getting help. We want people to be proactive about acknowledging when they have an issue and following through and taking medications, if that is what is needed, or being in therapy to really help with things. But unfortunately, because our field continues to stigmatize physicians who have mental health problems, people don't come forward and then it gets to a breaking point. And unfortunately, death by suicide is a fatal one and it's a huge problem, I think, in our medical field and I really hope that by talking about it more and by being more open about our own experiences, that hopefully, that stigma will decrease and hopefully people will be able to reach out and get the help that they need.
Stephen Rockower (11:01):
I know there was a number of articles and a lot of publicity about Dr. Lorna Breen, who was an ER physician in New York in the middle of the pandemic, who ultimately took her life, and there's a whole foundation set up in her name that helps with that.
Karen Dionesotes (11:25):
Yeah. That was a really important piece of legislation that came through, I think, just acknowledging and also having this living memory and response to a problem in Dr. Breen's name. I know I personally have, I can't even tell you how many of my friends matched in New York, and so our emergency medicine, med peds, internal medicine, psychiatrists, all sorts of residents in New York who were on the front lines during the pandemic. I continue to still worry about this group as now Monkeypox is coming in and is this going to be a second pandemic that they have to really worry about, because frontline doctors are really the ones getting the brunt of what's going on. They are getting sick from COVID. They are the ones being exposed to Monkeypox and having to take off work, and that stretches our residency programs really, really thin, and so people become really overworked and really burnt out. And I think it's a systemic problem in the way that we, as physicians and as public health professionals, deal with when something new like this is coming out. We don't always know how to protect. We don't always prioritize protecting our workforce and I think that that's another really important lesson that we've learned from COVID.
Stephen Rockower (12:44):
And that goes to not only physicians, but the residents, the nurses, the staff in the hospital, the people who were cleaning the beds and mopping the floors who were exposed to all this at the same time, and they all have families and go home and get on the subway and et cetera, and they have to be cared for as well.
Karen Dionesotes (13:09):
Yeah, absolutely. All frontline workers have been impacted on so many different things these past few years. I think we're only starting to maybe get back to some sort of normalcy within our hospital system. I mean, everywhere is different. We definitely still have COVID cases. There's definitely still a significant number of people dying from COVID every day. And so while part of me wants to leave COVID in the past and move on and forget that it happened, we can't.
Stephen Rockower (13:41):
No.
Karen Dionesotes (13:41):
People are still being impacted by this on a daily basis and we also really can't forget the losses that we had these past three years. It's really crucial that we keep those memories alive and also that we learn from the mistakes that we made from a public health surveillance and public health perspective.
Stephen Rockower (13:59):
And that's the nexus with public policy to get government, both on the administrative side and legislative side, to do things to help the people involved who have all these problems.
Karen Dionesotes (14:13):
Yeah, absolutely. And that's also why it's so important for us as physicians and all healthcare workers to be the ones advocating for change and why it is so crucial for us to be the ones having these discussions with our legislators because we are seeing things right in front of our eyes and we all have a story or two or three or 100 to tell somebody about why this is such an issue. And so I really do like to think of advocacy as another duty of a physician on top of being a clinician or being a researcher or however you want to define yourself. I do think that being an advocate and being involved in advocacy is crucial to our profession.
Stephen Rockower (14:56):
Absolutely, and doing it through organized medicine. Why do you think that trainees, such as medical students, residents, fellows, should be involved in organized medicine?
Karen Dionesotes (15:09):
Yeah. I mean, I think it gives you exposure to the system at a larger level that's more difficult to get if you are just one person going to the Hill talking about a topic. I remember as medical students in the AMA, we had Advocacy Day every year, once a year, where we'd all go to the Hill and we'd have specific training in talking about topics and then we would bring that to the staff members, usually the health policy staff members of these legislators. And getting to be able to talk about your own experiences and why it's important, these are things that people with their feet in Washington, they're not seeing these things like we are. I do think that advocacy and having this training, it's a skill. It's a learned skill and so I feel like involvement in organized medicine is a really great way to learn that skill and also gain leadership experiences in so many different aspects, meeting other physicians and networking, being able to lead committees, join committees, write resolutions.
(16:15):
I mean, these are all things that are, I don't know, I feel like have really opened up my eyes as someone in healthcare to be able to look at things outside of a direct patient encounter and really look at a lot of the gaps that exist and then work to be the people that are solving them. And so I do think whether you're joining your specialty society or your state society or a national organization or even a county medical society, every level of organized medicine is incredibly important to make sure that we're advocating for our patients and also advocating for our profession.
Stephen Rockower (16:56):
Oh, I love this. Speaking of advocacy, we've had Dr. Terry Hill on our program earlier and Dr. Clarence Lamb will be upcoming, but I have to put in a quick plug for the AMPAC Candidate School for any physician or resident or fellow or student who is actually interested in policy and interested in becoming involved in a campaign for office, either themselves or working with somebody. AMPAC runs a school here in Washington to teach people how to do that, give them all the tips and help. So if anybody listening is interested in that, contact AMPAC.
Karen Dionesotes (17:52):
And you can actually ... Oh, sorry to interrupt, Dr. Rockower. I was going to say you can actually do that as a medical student. I went to AMPAC's, I went to a campaign school probably the year I was doing my MPH.
Stephen Rockower (18:04):
Oh, okay.
Karen Dionesotes (18:04):
I was in Baltimore and so I took the train down to DC and was staying with friends in DC and that's actually the year I met Bobby, Dr. Mukkamala. So that, I feel like, is a great way to meet people who are involved in elections and politics, both at an organized medicine level, as well as people who are interested in running at a local level, at a state level, or a national level. I learned so incredibly much from these experts who are campaign managers and run campaigns, and it was actually just such a fascinating and amazing learning experience. I also highly recommend, and I would put a plug in, not just residents and fellows and other physicians, but this is something that medical students are able to be involved in as well.
Stephen Rockower (18:52):
Okay. I didn't know that. You were a grad student [inaudible 00:18:55]. That was a good tie-in. What are your plans after residency?
Karen Dionesotes (19:01):
So as I mentioned, graduating from residency this June in 2023, which is wild to think that we're already coming up on 2023. I'm very fortunate to be at such a supportive institution and with such incredible mentors. And so I'm actually staying here for another year and doing a one year geriatric psychiatry fellowship. I've really found a home and found a place where I feel like I can make an impact in medicine as well as on a policy and systems level and I have just really, really enjoyed taking care of older adults. And so I'll have a one year geriatric psychiatry fellowship training, which I'll graduate from in 2024, and then will be looking around for a career and for a place that I can know that I will be able to make an impact in some way.
Stephen Rockower (20:00):
Where do you see the field of psychiatry moving forward, where in geriatric psychiatry?
Karen Dionesotes (20:05):
Yeah. I mean, in psychiatry in general, there's such a need. There's never going to be enough psychiatrists. I've spoken with a few people from the APA, the American Psychiatric Association, Council on Healthcare Financing and Systems, and there are people who really feel that psychiatrists are going to move towards practicing at the highest extent of our license. And so seeing only the most severely mentally ill as opposed to people that we sometimes refer to as the worried well, so seeing the most severely mentally ill patients, and then also supervising others who see the rest of the population with behavioral health needs. And so I could see psychiatry moving in that direction as the need for a psychiatrist grows greater, especially in older adults, as the Boomer generation is aging. It's only going to create a greater need for more geriatric psychiatrists in which there is already a really significant gap. I'm hopeful that we'll continue to have residency slots and increase residency slots and fellowship spots for people going into psychiatry and really also destigmatize the field in general.
(21:25):
I remember in medical school so many people just really talking poorly about the field of psychiatry and psychiatrists as physicians and I can tell you as a psychiatrist here at my program, my intern year was at Bayview Medical Center and was mostly doing wards and the cardiac ICU and the medical ICU and then, obviously, the COVID units that came about that spring. I actually do feel very well prepared from a medical perspective and I think that is also what's allowing me to pursue geriatric psychiatry, is having that degree of medical training is so crucial, but I do think that sometimes people view psychiatrists as not physicians. I think we really need to stop having those conversations and we need to stop that rhetoric because it's really only hurting the field and it's actually hurting the patients who have such a great need for the type of care that we provide.
Stephen Rockower (22:26):
Let's take a quick break. We're speaking with Dr. Karen Dionesotes, a psychiatry resident at Johns Hopkins in Baltimore. Funding for this podcast has been made possible by Mid Atlantic Medical Collection Services. Mid Atlantic works with your patients to help them understand their bills, review charges, and consider repayment options. When it's easy for patients to make payments, they're more likely to pay you and pay you sooner. That's the Mid Atlantic approach. To find out if Mid Atlantic can help you, email collections@mamcs.net. Funding for this podcast has been made possible by Unity Insurance, a full service insurance agency specializing in solutions for the healthcare profession. Since 1975, they've been providing solutions to meet the needs of physicians like you. Learn more at unityinsurance.co.
(23:37):
Welcome back to MedCast, the podcast from MedChi, the Maryland State Medical Society. We're continuing our discussion with Dr. Karen Dionesotes as she discusses psychiatry and policy making in Baltimore. We were talking about psychiatry and taking care of older people and some of the interesting experiences that you've had. What are some of the most interesting experiences you've had, either in psychiatry or in your involvement in organized medicine?
Karen Dionesotes (24:11):
Yeah. I'll talk a little bit about organized medicine first. I mean, I think one of my greatest experiences that I had is when I had the immense privilege of being the chair of the medical student section of the AMA during my fourth year of medical school. And so while that position, I felt like I was hanging out while everybody else was doing a lot of work. I got to travel around a bit and meet medical students across the country and learn about the incredible things that they're doing for their communities and really just meet these incredible medical students, who were so passionate about topics and they would join our committees that we would have and really just make a difference and do great work and write policy and put on workshops at the meetings and engage in online conversation about different topics.
(25:06):
I just feel like out of all of the things that I've done in organized medicine, that has really been just really special to get to bear witness, actually, to the incredible things that students are doing across the country.
(25:22):
As a resident, I'm very fortunate, as I'm a part of the American Psychiatric Association Leadership Fellowship, and so I meet every month with other Leadership Fellows from across the country who are either residents or fellows and we work on leadership development and Dr. Rakar, you know our colleague, Agni Patel, so she's joined the fellowship this year and so her and I are working together on creating educational experiences and creating a program for the group for this year, and so that's also really been a great experience.
(25:59):
In terms of clinical medicine, gosh, I mean, I think for me, it's the patients that I feel that I connect with on a very personal level and that I feel like I have a good relationship with their families and I feel like I'm able to be there for their highs and their lows and that just is really what brings me a lot of joy. I really love taking care of my outpatients and many of them are older adults, and so some I see in person and some I have phone calls and some I see via Zoom and some I dash across town to see them when they are going to an appointment for another specialty. But it's better for me to lay eyes on them and see them in person than have them come downtown after being here. And so actually, I'm at Bayview Hospital today right now because I came to see one of my patients before one of their appointments. It's being able to provide that kind of care as a resident that I love, and having that flexibility and really, that's something that I feel like residency can really only grant and I've just been soaking it in and taking advantage of it.
Stephen Rockower (27:13):
Yeah, that's terrific. I never had that variability or ability to do anything like that when I was a resident. One of the things that I always found, not so much as a resident, but through my career, was talking with patients and following them along and their families and you'll eventually get to this, of dealing with parents and children and grandparents and talking to the children about their grandparents. And they look at you like, "Oh my God, he really knows."
Karen Dionesotes (27:48):
Yeah. And I love that part of my job, the fact that I know enough about my patients. I know the names of their siblings and their parents and I know what their kids do for work and I am able to ask about how they're doing by name. And I know these things because I really put in a lot of time to know my patients and I think that that is crucial in psychiatry, especially, to be able to know your patient as a full person as opposed to just an illness or someone that you're treating.
Stephen Rockower (28:20):
Let's switch gears for a little bit. What might you be doing if you were not a physician?
Karen Dionesotes (28:27):
That's actually something that I've thought about quite a bit. I think realistically, in the somewhat Type A neurotic person that I am, I think that being in public health and or public policy is probably where I would be if I weren't a physician. But I like to daydream about the life where I'm an art historian working in Rome or I'm retired on a vineyard in Tuscany and that's my job, so that's a little bit more romantic than is probably more what is realistic for me.
Stephen Rockower (29:05):
I know you're a resident and you're busy doing all sorts of things, but what are you reading or watching or listening to?
Karen Dionesotes (29:12):
Actually after medical school, well, actually, probably after intern year, because intern year was just very difficult and emotionally draining and time consuming, I really made in an effort to reclaim reading as a hobby versus you spend all of medical school with your nose in a book and the last thing you want to do is read for fun and enjoyment. And so I've really reclaimed reading as one of the things that I enjoy and I have a subscription to Book of the Month that I get a new book every month and I actually end up getting more than one because I just love to have books. And so right now, I'm currently reading the Goldfinch by Donna Tartt. It actually won the 2014 Pulitzer Prize for fiction. It's almost 800 pages long, I think, and I'm finally on page 700.
(30:04):
I'm getting there slowly. It's definitely one that's taken me a bit longer to get through. And then what am I currently watching? My partner and I are watching Obi-Wan Kenobi, which speaks to me being a nerd, so the Star Wars spinoff show that Disney+ has on. And then listening, I've been really, really into Lizzo's new album, Special, pretty much been listening to that on repeat. And then actually also Miley Cyrus's album from a couple years ago from 2020, Plastic Hearts, and have been really vibing on those and then some background jazz music.
Stephen Rockower (30:45):
Interesting that you're reading The Goldfinch. When I was reading it, I think I had it at the book or maybe I had it on my Kindle, but I had my iPad open in front of me with the picture of the goldfinch that this whole thing is about sitting right in front of me. And so I'd be watching The Goldfinch while I'm reading The Goldfish, so I really like doing that.
Karen Dionesotes (31:12):
I love that.
Stephen Rockower (31:17):
You talked about meeting Dr. Mukkamala somewhere along the way. Have you had anybody give you good advice? What's the best part of advice you've ever gotten?
Karen Dionesotes (31:32):
I feel like, and this is probably as a psychiatrist and as someone in behavioral health and as someone who's had depression and has really had to take a step back and look at my own wellness, but the thought that you can't take care of others unless you take care of yourself. And I think that is so important because as physicians, we pretty much have to prioritize our patients. I mean, I can't tell you the number of people that I know that have come to work just violently ill because that's the expectation, but I actually really like to challenge that. I think it is so crucial that in order to take care of people and be able to provide the best care, you need to be in the best head space, so both mental and physical health. If I had a stomach bug right now, would I really be that focused on this conversation or would I be so stressed and anxious about, "Well, am I going to get sick during this?"
(32:34):
All of these kinds of things, and so the thing that I think about is that as physicians, we're always counseling our patients on getting more sleep and exercising and eating healthy and having open communication and healthy boundaries and putting your physical and mental health above all else, but then we don't do that ourselves and the expectation is that we don't do that ourselves. And it's honestly, sometimes almost inhumane. We push ourselves to the very limit of what we're capable of and because of this, patients, unfortunately, suffer when we're not at our best. And so I'm a huge proponent of being in therapy and having conversations about wellness and really processing the things that we see because also as physicians, it's hard to see the things that we see sometimes and then go home and just pretend like it didn't happen or take off your theoretical doctor code at the end of the day and leave all your patients at work. And so I think processing the things that we see and the experiences that we have is crucial in being the best physicians that we can be.
Stephen Rockower (33:45):
And that brings us back to what we talked about earlier, about the stresses and the stigmas that physicians have, as far as admitting to these kinds of things and the trouble of having to just have a very difficult conversation with a patient and then just move on to the next room with your smiling face on. It's very, very tough.
Karen Dionesotes (34:12):
Yeah. I spent yesterday in our emergency room here. I was working in the PAs, and I think a lot about the docs on the other side, outside of my little psychiatric area. The emergency med docs who really are just going from patient to patient. There's traumas being called overhead. They're telling people, sometimes, the most difficult news they've ever heard in their lives and they're just moving from person to person. And I think about that sometimes because I cannot imagine myself doing that. And of course, there are different temperamental things with different specialties and you do have to be able to handle keeping on that smile or moving from one thing to another and really just blocking it out.
(35:02):
But I do think that after a shift, it's really important to debrief and to process the things that we're experiencing because then they do tend to build and build and build. I even have issues like that as a psychiatrist. I have seen really difficult things. I've heard about really traumatic experiences of my patients and even carrying that secondhand trauma can be difficult. And so being able to process that in a safe way and feeling like you can debrief with colleagues when hard things happen, I just think it's such an important part of our field.
Stephen Rockower (35:38):
And I think that we need to also mention that MedChi and many of the other medical societies locally, Montgomery County, I know for sure, have programs for doctors who have difficulties and can keep things private so that you're not worried about the stigma and you can talk about any problems that you have.
Karen Dionesotes (36:06):
Yeah, I think that that's really helpful. There's definitely a lot of psychiatrists who treat our physician population. I think that the one thing that I think of though, is that, I mean, feel like, at least I'm very upfront with my patients about being in therapy and I think that therapy is something that honestly every person should be in because there's always something to really reflect upon yourself and try to better yourself in a way or there's always something to process. And so while I appreciate that not everybody is at the point of their lives where they want to have all of that information out there or they want people to know that they are taking care of themselves and are in therapy, I do think it's important for us to begin to have those conversations as well, too, and normalize that as physicians.
Stephen Rockower (36:59):
Well, I think this has been a fascinating discussion. I want to thank you, Dr. Karen Dionesotes, who has been our guest on MedCast, the podcast from MedChi, the Maryland State Medical Society. Tune in next time as we can continue our conversation with the leaders of medicine in Maryland to discuss issues facing physicians and our patients. For all of us here at MedChi, I'm Dr. Steven Rockower. Thank you and good bye.