Navigating the health care system as a chronic patient and physician [PODCAST]

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In this episode, we talk to Holly MacKenna, an integrative psychiatrist, about her experience as a chronic patient in the health care system. Holly shares how emotional and overwhelming the process was, and how she was able to draw on her own experience to better understand and support her patients. Holly also reflects on the importance of family and cultural values in her journey towards getting a diagnosis, and the relief and sense of validation that came with finally receiving an answer. Listen in to hear Holly’s unique perspective on navigating the health care system as both a patient and a physician.

Holly MacKenna is an integrative psychiatrist.

She shares her story and discusses her KevinMD article, “Balancing the roles of patient and healer.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Holly MacKenna. She’s an integrative psychiatrist. Her KevinMD article is titled “Balancing the roles of patient and healer.” Holly, welcome to the show.

Holly MacKenna: Hi, thanks so much for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, just briefly share your story and journey to where you are today.

Holly MacKenna: Yeah, I’m an integrative psychiatrist, as you mentioned. I started practicing traditional psychiatry about 20 years ago. Looking back, I think probably about 10 years ago or so, I started integrating more of a mind-body practice with meditation. I studied dialectical behavior therapy, which is very mindfulness-based, and then things kind of evolved.

I went to a leadership program at Duke University that taught the business side of integrative medicine and met some healers there who had completed Andrew Weil’s program, who encouraged me to do the same. So I entered into his fellowship and became board-certified in integrative medicine as well. Now I have my own private practice out of New Orleans, and I also do telemedicine.

I focus primarily on folks with trauma and also traumatic brain injury, because a lot of the folks dealing with that have a difficult time with traditional medication. So I’m able to offer traditional medicine but also supplement it with mind-body work. I’m certified in Reiki and auricular acupuncture, so I can kind of do a whole-person approach.

Kevin Pho: Take us into your office. Walk us through some of these integrative techniques that you would use and some typical cases that you would see, and just give us a sense of how your practice differs from a traditional psychiatry practice.

Holly MacKenna: I learned that a good interview is really the basis of excellent work, and so I actually take up to two hours to evaluate a person. I ask what you might expect a psychiatrist to ask as far as history and medications, but I also get into what their exercise practice is, whether they have a spirituality practice or a mindfulness practice, and whether they are on supplements. People are usually taking supplements, but they don’t tell their physicians about it, and not all supplements are good supplements.

Then I also ask what their diet is like. Gut health, we’re learning more and more, has a lot to do with brain health. With that connection, a lot of the serotonin is made in the gut, and melatonin, all the things that we really need for a healthy brain. So we talk about all those things. Then I do a pretty thorough feedback session, going through all those different areas and recommendations.

I’ve come to realize, being on the patient side, that can be quite overwhelming. So I try to break it down as to where we can start and let them know, “This is what we’re going to be following over the coming months, but not something you need to do all at once,” because it’s a lot.

Then, depending on the person’s needs, some folks come for therapy. I do have a membership program to help people be able to engage in all the things in a way that is more economically friendly, because I do like to have that integrative practice, but I also understand that not everyone is going to be able to pay for all the things. So instead they pay a monthly fee, and that includes Reiki, acupuncture, and coaching, and that way they can engage as much as they need. There are different levels, and some folks just do a basic membership where they don’t see me as a patient, but they still get all the education and bells and whistles outside of that.

Kevin Pho: Now, what are some common conditions that people will come see you for?

Holly MacKenna: A lot of folks will see me with brain injuries. I have an association with the Tulane Center for Brain Health, where I see former NFL players and veterans with traumatic brain injury. I think the word got out, so a lot of folks who maybe have had a car accident or a sports injury and haven’t felt the same since will seek me out for that, and I see folks nationwide for that.

I also have a lot of folks with bipolar disorder who do need to be on traditional medicine. They do need that mood stabilizer, but I’ve found that with different supplements we can maybe help them manage it in a way that we don’t have to get to the maximum dose of drugs. Bipolar folks don’t like that drugged-out feeling. The mania or hypomania is really kind of fun, which can be kind of helpful for people. So it’s that balance of getting to more of euthymia, not so hypomanic, but not feeling so dulled that their creativity isn’t something they can tune into, or other things that are often common complaints of our bipolar patients.

I also see a lot of women with polycystic ovaries or fertility problems, because I do that whole-person approach. I’m able to work with their fertility physician or their primary care doctor and make recommendations that are going to help not just what you would think a psychiatrist would address but also their ovarian health, their weight, what have you.

Kevin Pho: Tell us a success story. You mentioned that you’re a nationwide expert when it comes to traumatic brain injury, so tell us a success story where your approach moved the needle in one of these patients.

Holly MacKenna: Yeah, I actually had a college student reach out. She had been doing well in one of the local universities but had a car accident and noticed from then on that she wasn’t able to focus. She had a lot of anxiety that had come up and a lot of mood dysregulation, and these are things that we see with a brain injury. Every brain injury is different. It’s not like, “This is the absolute, this is what it’s going to look like, this is how we have to treat it.” But in her case, it was a one-time injury, and she was having difficulty not only staying focused but also getting out there and enjoying her college life. The anxiety was kind of taking over, and the mood dysregulation was taking over.

She had a great family and a loving relationship, but she had been given just your typical antidepressants, maybe a stimulant at one point, and none of those things really worked, because brain injuries affect not only how you’re feeling and thinking, but they can also affect how your brain responds to medication. She really had a lot of side effects from medicines, and that’s a common complaint I see with folks with TBI.

So we were able to lower the medication and use some micronutrients, which are basically all the vitamins and minerals that you would need to make the neurotransmitters in your brain. Sometimes that works. The folks in Arizona, where I studied for my fellowship, use those a lot and are big fans of that. There are actually lots of studies coming out from Canada and different areas about the use of those. So we were able to use that to lower her medications and allow her to still have some focus.

Then I added supplements. I added supplements for chronic stress. When we have a trauma like a TBI, it is like a PTSD, but oftentimes you don’t remember what we call the Criterion A stress, or the stressor that really causes the PTSD, and that adds stress in itself: having the symptoms but not necessarily remembering why. So adding what we call adaptogens, those types of supplements, can help lower that fight-or-flight tendency and allow your body to respond to stress more normally. So I was doing that with some other supplements. I added some that help with anxiety and help with obsessive-compulsive thinking, which is what she was experiencing.

In time, she told me, “You know, Doc, when I do all the things you tell me, when I take the supplements you recommend, when I do these breathing exercises, I actually feel like I did before the accident.” To me, it was like the archangels were all singing. I’m like, “This is why I’m doing what I’m doing, to help folks like this.”

I treat folks that also have a number of injuries, like my veterans, and for them it’s a stepwise process. It’s not going to be something overnight, and it’s a team process. I work a lot with physical therapists and speech therapists. I can’t say enough about the ancillary services that are going to help with the whole person, because I am only one person. I’m not a magician, but I do like working with that team approach and offering what I can to help the person think and feel more like what their normal should be.

Kevin Pho: All right, let’s shift gears and talk about your KevinMD article titled “Balancing the roles of patient and healer.” How did this article come together?

Holly MacKenna: I’ve been dealing with chronic illness myself since, looking back, probably high school. I started having issues with fatigue and palpitations. I was a teenager kind of living my best life, and next thing you know, I’m going in and out of doctors’ offices, getting my heart evaluated, and getting lots of labs done. At the time, they only found a heart murmur. I think they probably rolled their eyes and were like, “Oh, overreactive teenager,” which, you know, had I not had the experiences I had, I wouldn’t.

Then I went to college and was doing OK until my senior year, which is where all the stress was. Then I was in medical school, again kind of in a good place, and I started experiencing a lot of sinus infections, kidney failure, the whole nine yards. Fast-forward, I actually ended up having to take a year off of medical school because this ebbing and flowing of illness kept happening. With time, I decided, “This is something I’m just never going to know what it is.” My rheumatologist said it’s an undifferentiated connective tissue disorder, and I kind of decided, “Well, that’s what it is.”

I now have a 10-year-old daughter. I have two children, and they’re both rainbow babies, because I’ve had multiple miscarriages, which is part of what’s been going on with me. At age eight, she started falling asleep over her homework. This was during the pandemic, but her school had actually gone back to face-to-face, and she was doing the exact same thing she’d done the year before. So part of me was like, “Am I overreacting?” I was in a fellowship at the time, so I’m like, “Am I kind of going to the extremes of what I’m learning in fellowship, or is this just stress? This could just be stress.”

This is why I choose doctors for myself and my family that I trust, because I don’t want to treat my family or myself. I try to get that out of my brain. So I went to the pediatrician and said, “Listen, I could be overreacting, but do you mind maybe taking a look at her? She’s falling asleep over her homework.” She admitted to my friend who cuts her hair that she was pulling her hair out. She was getting super anxious and really tearful. It just wasn’t herself.

So we started doing some labs. I have a family history of autoimmunity. My parents are both from Ireland. It’s a very small country; as I joke, it’s very inbred because it’s a very small area. So yeah, we have a long history of autoimmunity in my family, and she had some labs that suggested a positive ANA. She ended up seeing rheumatology. Every rheumatologist’s nightmare is the positive ANA; that’s the complaint. They did some more labs and saw that she had some autoimmune indicators for her thyroid, but her thyroid tests were normal. They actually suggested waiting until the thyroid was not normal, and this is where I put on the doctor’s hat and was like, “I’m not OK with that. She’s miserable.”

I’d also reached out to a friend who is now a very successful pharmacist with NASA, who I remember had thyroid issues during high school, and she told me, “You know, Holly, I didn’t realize until I was on the thyroid medicine how miserable I was without it.” So that really drove me to reach back out to the pediatrician. He fortunately agreed, and we got in with the endocrinologist, who got her on Synthroid, and it was like night and day. She started growing, because she was always kind of a shorter kid, and she started feeling a lot better.

Then more recently she had a setback again, and it turned out she had some nodules on her thyroid, which I write about in my article, just to give a little bit to those who have read the article or are reading it. They turned out to be benign, fortunately, so we’re monitoring those.

At the same time, partly because of what was happening with her and partly because I have a colleague who works in Tulane’s hypermobility clinic who kept poking, I realized that maybe there was more happening with me than I had realized. So I also re-entered that journey, which I didn’t realize my defenses had really kept me from doing for 20-something years, and I have since gotten a diagnosis of Ehlers-Danlos for myself. So we’re both kind of re-entering that phase of the system and dealing with it as chronic patients.

Kevin Pho: So what’s it like entering that system as a chronic patient as well as being a physician?

Holly MacKenna: You know, I was actually surprised by how emotional I got. I remember early in the process, before I saw the doctor, they have a 600-person waiting list, because this is a nationally known clinic, so they have a lot of pre-work that you do before you see the physician. One of them is getting a lot of imaging done, and they had said, “We don’t know if your imaging is going to be covered by insurance.” I’m now on my husband’s insurance, which isn’t as great as when I worked for the VA. Previously I had insurance I didn’t have to worry about. So I found myself trying to figure out, “Is this covered? Do I need to go to a different place for the imaging?” and trying to navigate that.

I found myself getting super tearful, super anxious, just all the feelings coming up, feelings that I had really buried for decades of, “Maybe I’m full of it,” all the things that I had been told, or interpreted as being told to me, as a young adult: “Maybe I’m just a whiner. Maybe this isn’t anything. Why am I bothering?” A lot of self-doubt, a lot of anxiety and upset.

Really, the driving force for me to keep going is my daughter and my children. It turns out this diagnosis is autosomal dominant, so it’s something that I do need to know about, to let my family know about. Family is an important thing in my culture; it’s very much about family. So I was doing that not only for my kids but also for my ancestral line. I look back, and my grandmother had multiple miscarriages that were upsetting for her. My dad had issues before he passed away. Just getting answers, even for them, is what kept me going.

But it was definitely a time of looking at my own dark side and things that maybe I hadn’t dealt with, which is interesting as a physician, because as a psychiatrist I’m helping others do that all the time. It was really a “physician, heal thyself” moment.

Kevin Pho: Now, are there any lessons that you’ve learned being a patient in the system that you could apply in the exam room or your office as a psychiatrist?

Holly MacKenna: Yes. One was, as I mentioned, that it can be overwhelming. I try to be so thorough, I think, just because I have been on the side of seeking answers. I know from my traumatic brain injury folks that oftentimes they don’t know what’s going on, because it’s another diagnosis that people are kind of learning more about, and the research on it is still happening. So I understand that feeling of, “If I just had an answer, a lot of this anxiety would go away.”

That’s true. When I had that diagnosis, I cried when the doctor told me, and he’s like, “Are you OK?” I’m like, “For my science brain, these are tears of relief.” This is 20-something years of unknown and of not feeling seen, finally coming out. So I know that sometimes that’s what people truly need. When they’re asking for a diagnosis, sometimes it’s easy for us to get judgy about it. I worked in the VA system for a decade, and sometimes there you get a little burned out and think, “Oh, they just want service connection and benefits.” But sometimes, no, they just want the answer. They just want to know, “Why do I feel this way?”

Then there’s having that space to talk about it. When I finally did see the doctor, he just let me talk. He was doing his exam, but he didn’t interrupt me as I just processed all the things and stuff that was coming up from 20 years before, things that had happened and situations: “Hey, is this because of that?” It probably, maybe not to him, because he’s dealt with it, but to me it felt very scattered, the way it was coming out.

But allowing space for that, I think just giving people time to talk and feel heard, there’s so much value in that, and it doesn’t have to be a long time. I don’t think I necessarily had the longest visit, but it felt long because he gave me that space. I mean, that’s why we got into healing. It’s just that the big system, organizational medicine, has kind of gotten in the way of that, but I think that’s where the beauty, the magic, of medicine is.

Kevin Pho: As you know, I’m in primary care, and time is at a premium. Sometimes we have 10 to 15 minutes with these really overwhelmingly complex patients. So what are some techniques that you can suggest in order to give patients space so they can tell their stories? Any tips that you could share from your experience as a psychiatrist as well as a patient?

Holly MacKenna: You know, even just five minutes. You have this podcast that’s a brief podcast, but it’s full of juicy tidbits. I love listening to it, and I think it’s a perfect example of how you can really get a lot out of just a small period of time. This is something I remember an old professor saying to me way back when, and now that I’m on the patient side, it comes back to me: Just give them those five minutes to tell their story, and then get into it.

I mean, you can be making notes to yourself as they’re talking, but definitely give them the visual feedback of listening. We’re multitaskers; our brain can still be going, but just allow them that space. Or if you’re doing a physical exam, I mean, that’s how my doctor did it. He was doing all the parts that indicated the Ehlers-Danlos and telling his assistant, “Yep, this is scapula, this,” and all that, while I’m going on, and he was just letting me talk.

So it might just be that you, in a way, let it happen while you’re doing something else. You’re listening, you’re checking, you’re doing things that maybe they can still be talking during, and just allowing space for that, allowing that human connection. There’s so much power in that.

Kevin Pho: We’re talking to Holly MacKenna. She’s an integrative psychiatrist. Her KevinMD article is titled “Balancing the roles of patient and healer.” Holly, what are some of your take-home messages that you want readers to come away with after listening to you today and reading your story?

Holly MacKenna: I think it’s allowing yourself to partner with your patient, and really remembering, especially those of us who are in health care, what drove you to go into health care. As we’ve touched on, sometimes the big system that is often not run by physicians or healers can get in the way of that, with the electronic health record and reminders and all the things we have to do. But really allow yourself space, whether it be taking a few breaths between patients so that you can then be present with them in that moment, or, as we’ve said, just giving them a few minutes to talk.

I think that connection not only serves the patient, but it serves us as physicians and providers, because it feeds our souls. It reminds us why we do what we do. That’s so healing for everyone in the room, us included.

Kevin Pho: Holly, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Holly MacKenna: Thank you for having me. I appreciate it.

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