I want to thank you all for being here. Wow, we are at the very end of our conference, pretty much. And we only have a little bit of time left here, and you chose to spend some of it with us, so thank you. In a city where there's like a million other things to be doing, they need to start doing APA like Coachella, where it's like out in the middle of nowhere, and you just think there's nothing else to do, and you have to go to the conference. But anyway, this morning, I have the genuine pleasure of introducing what I think is going to be a really interesting panel about the importance of using the arts to teach psychiatry. I have with me here three psychiatrists from Naval Medical Center San Diego, Commander David Nisan, Lieutenant Anna Lochner, and Lieutenant Glennie Leshin. They are each going to be talking about a project they are undertaking or have undertaken toward the end of using the arts to teach psychiatry. I am here to tell you that we have no financial disclosures and the views expressed in this presentation are those of the authors. Beyond that, I did want to briefly touch on why these things are important to do. But first, a little bit about our presenters. I'm Luke White. I am a fourth year psychiatry resident, outgoing chief resident at Naval Medical Center San Diego in psychiatry. I have with me here Commander David Nisan. He is our program director at Naval Medical Center San Diego psychiatry. He has authored a paper on Moby Dick and its relevance to psychiatry that he's going to be talking about today. It's a really excellent paper. Although, to be fair, he did have a great co-author. It was me. We have Lieutenant Anna Lochner here. She is a second year psychiatry resident at Naval Medical Center San Diego. She has helped to develop and implement a curriculum using fiction to teach PGY1s at the Naval Medical Center about crisis management and psychiatric practice. And then we have Lieutenant Glennie Leshen. She is a staff psychiatrist at Naval Medical Center, the head of our first episode psychosis program there. And in what free time she manages to have, I don't know. She has really undertaken a litany of arts-based curricula for teaching psychiatry and just medical education in general. Today she's going to be talking about using film to teach cultural concepts. And I am very excited to hear about all three of these. Before we get into it, let's just talk about a general overview of why is it important. Why should we use art to teach psychiatry? If you're like me, there is a very extraordinarily high burden of proof to be met here. I was very reluctant when I initially heard about this, because the last thing I want to do is admit that we need to be using art to teach psychiatry. See, I hate art. So most of it's bad. Most of it's bad. There's so much bad art. Artists will tell you that. Artists will tell you most art is bad. And then you get to the good stuff. And the good stuff, it's just so exhausting. And it makes you feel all this stuff that the last thing you want to do when you get home at 7 PM is feel stuff. And my friends that are still in the arts are always like, you need to watch this six-hour silent Italian film that grapples with it. I'm like, let me stop you there. I don't want to grapple with anything. I have to be up at 6. I can't be grappling right now. But after much reflection and the persuasion of these three people you see next to me, I reluctantly admitted to myself that art is very important in teaching medicine, and especially in teaching psychiatry. So I want to get a little bit into why. I had a professor in med school. He was a neuropathologist, Dr. Sebastian Alston. He wore a belt and suspenders to work every day. And he loved to go on these soliloquies about the importance of a good diagram. He had looked at hundreds, as a neuropathologist, he'd looked at hundreds of thousands of tissue slides in his lifetime. But he said, no single tissue slide, even though it is a real instance of the natural phenomenon, it is a real snapshot in time of what's actually occurring, it is not going to illustrate the core concept of what's occurring, as well as a well-illustrated, well-executed diagram will. And this is something that medical educators have felt for a long time. This picture that you see here is from Manser's anatomy. Manser was a 14th century Persian physician who illustrated what is considered by many scholars to be the first color atlas of human anatomy. Here is an illustration of the circulatory system from his atlas. Now, I cheated a little bit. I think most diagram scholars, which that's a thing, by the way, diagram scholars, they have their own textbooks and journals and conferences, which I'm sure are riveting. They would consider this a medical illustration. A little different than a diagram, but the line is blurry. The line is blurry between what's a diagram and what's a medical illustration. Blurrier still between what's a medical illustration and what is art. For someone like Leonardo da Vinci, that line practically did not exist at all between medical illustration and art. He was known both as a great anatomist and scientist and as a great artist. So we see all these instances of representation being used to teach medicine. Representation, whether we call it diagram, whether we call it medical illustration, whether we call it art, it is a way of distilling the core concepts of millions of different instances of the natural phenomena into one didactic representation meant to illustrate the concept. Now, the core components of the diagram are the source, which is the concept itself, the transmitter, which is the author, the medium, which is whether it's drawing or some other medium, the message, which is the information being conveyed, and then the receiver, which is us, the reader. And I'll backtrack to that a little bit more. But when our source is medical knowledge, for instance, for a cardiologist, a diagram of the heart, it's very easy to draw a diagram of how the atrium pumps to the ventricle, et cetera, et cetera. For a neuropathologist, diagrams of the brain, diagrams of the way tissue is structured in the brain. For psychiatrists, what diagram or medical illustration or what have you, what representative didactic drawing are we to look at? I suppose you could look at monoamines binding to receptors and causing the voltage-gated channels to do things. But even if you still believe that's how things work, it doesn't tell us much about the actual disease states themselves, the actual phenomenology of disease, the actual experience of the patient. So what does? And I would contend that it's art. This is not a new contention at all. This was contended by Aristotle in his work, The Poetics. Aristotle came right after Plato. He studied under Plato. Plato was vehemently against the theater. He saw it as, because it's representative of our reality, which is already a shadow of the true, holy, sacred world of forms, we don't need to be imitating a world of imitation. That takes us further away from the truth. And Aristotle said, not so fast. Maybe imitation can get us closer to the truth. Maybe by distilling all of these lived experiences that we share in common and see in different ways and experience in different ways, we can come together and make some sort of sense of it in the shared space of the theater. And maybe for that reason, theater has value. Aristotle was not only an art critic and philosopher. He was a physician. He was a scientist. He exerted heavy influence upon Manser, who drew this color atlas. So he was thinking about the theater as a form of didactic representation. Perhaps a good summary of this concept comes from the Prince of Denmark himself, Hamlet, who, when instructing the players in how to perform the play The Mousetrap, he says, acting, whose end, both at the first and now, was and is to hold, as it were, the mirror up to nature and to show her own features, scorn her own image in the very age and body of the time, his form and pressure. And that, I think, is a good depiction of what Aristotle is saying here, that poetry tends to express the universal and history the particular, each instance of something. History, specific instances, specific facts, show particulars, but as we create art and we can kind of distill those thousands of different instances into one representation, we can start getting at something a little more universal. So on one hand, we can kind of look at art as this kind of didactic diagram, but we also need to be mindful that not only does it represent psychic phenomena, but it's also the product of those same psychic phenomena and a product of its time. This illustration, I initially had a very hard time making Heads or Tails of. It is emphasizing the circulatory system, emphasizing the circulatory system, although also somewhat the GI tract. You can see there's a heavy amount of emphasis placed on the circulatory system. Mansur taught that the heart was the first organ to develop. The circulatory system was the first part of the body to develop and held a certain primacy in the body because it delivered heat. Medicine at the time taught, basically, kind of as a growth of Galenic tradition, that the four humors essentially became dry, wet, hot, cold. In all specialties outside of dermatology, we now recognize there's probably more to the body than that. But because of the emphasis on heat, the circulatory system and the heart are very emphasized here, and that gives us a glimpse into the culture of the time, the medical thinking of the time. So if we look at this strictly as what can we learn from this, we're probably going to fall short, but if we start to incorporate what were they thinking, then we can start to glean a little bit more, and we can even glean more about the time. So to take art on its face, we don't always get as much out of it as we can. We need to consider the time, consider the reality that that art was produced in, and I think Commander Nisan has an excellent talk about context, about how it can enable us to see the whole. Particulars do carry particular considerations, and sometimes there's gray area, and I think Dr. Lochner has a talk that's going to tell us a little bit about how we consider these kind of case-by-case, and sometimes things do require particular considerations. And then this art does, in examining its context, give us a glimpse into the culture it came from, into the society it came from, and Dr. Leshin has a great talk planned about that. So without further ado, I'm going to hand it over to Dr. Nisan to talk about Moby Dick. Thank you. Thank you, Luke. Thank you, I'm Dave Nisan. While you're listening to this talk, if you're a resident or a medical student, or if you're in a training program, or have to make a pitch to people around you about what they should read, or how they should prepare themselves, and this is what I use to introduce people to the idea that reading beyond specifically psychiatry is something that's valuable throughout life, but something that I didn't do in medical school or residency. So I really liked reading as a kid, and a proud memory that sticks in my head is going to our high school library and checking out a book by John Steinbeck that had never been checked out of the library before. And the librarian was so excited that I had chosen to read Sweet Thursday. But then in med school, I shifted away from that. I don't know if that has happened to other people in this room, but it got hard to see everyone around me and feel like I didn't know enough about medicine and feel like everybody else knows or is ahead of what I'm doing. So I have to buckle down and focus in on the things that are truly important now. And it wasn't until after residency that I started to expand that window a little bit. And then I did by making the mistake of only reading things that I was super hyper into. And so after falling into a rabbit hole about World War I and reading a lot about that, and gradually have come to develop the habits of being deliberate about what I choose to read, expanding the zones of the things that I'm interested in and comfortable with. And I'll tell you a neat little story that is hidden within Moby Dick that I think can help to exemplify this. So if you don't know, Moby Dick is a fun adventure tale about a disastrous cruise gone wrong where this fanatical captain takes control of a ship that's supposed to be innocently going out and murdering a ton of whales to capture and get sperm oil to fuel America's thirst for light. And he instead decides we're going after the whale that took my leg and mauled him. And I admit I'm not a literary scholar and I imagine there are people in this room that understand these themes better than I do. And I'm humbled before in the, I was lucky to have a mother-in-law who asked me if I'd read Moby Dick. And when I said yes, she didn't believe me because it was when I was in high school and not when I accumulated a bit more experience in life. But I've gone back to it and read it on a ship when I was deployed and got to grapple with some of the deeper hidden meanings like the vastness of the ocean and being unable to understand or comprehend or contend with nature. And it's the non-adventure parts of the book that are really off-putting to a lot of folks when they read it first. It's got a lot of dense biblical analogies that went way over my head and still do. And then there are weird intersections where they spend an entire chapter talking about the classification scheme of whales that the author just decided to make up and put in. But there are some hidden meanings that I think are specific to psychiatrists that you can think of. I'm not encouraging you go to read Moby Dick. I think you should go read stuff that's interesting to you or means something to you and your community and your patients, but here we go. So when I, like my first guess when I would think of what's interesting about Moby Dick to psychiatrists would be this like lunatic Captain Ahab who's permeated our entire culture. He's synonymous with a fanatic and somebody who's singularly focused on something that ends up destroying him and bringing everybody down around with him. He's named after a biblical figure, somebody who I think did exist and is like the last king of Israel that was written about in the Bible as the person who brought immorality into the kingdom and led to the downfall of that kingdom. But that is what he named him after and portrayed this very ungodly godlike figure. But the book doesn't do a great job, I think, of describing him as a full person. You do get this like interesting glimpses and I missed these when I read it for the first time for sure, but I didn't know Captain Ahab was a husband and he had a son and he was leaving them for years and years at a time and he'd made this very conscious decision to do something incredibly risky, that he knew that this was a powerful monster that he was going after and to leave them and make that calculation, you don't have any sense of why or who he was before this traumatic event and what led to that change. And I think it's set up to be rather flat in that sense as opposed to the more complete picture that we would appreciate when we're meeting with somebody for the first time to understand how something traumatic changes them and what we can do to help them understand who they are now. So my mother-in-law, when I started talking about Moby Dick talking about Moby Dick, that I'd read it more, she encouraged me to read books about Moby Dick and this is a rabbit hole that you definitely don't need to go into, but one of them is this. Nathaniel Philbrick is an author who wrote In the Heart of the Sea. It was made into a movie with Christian Hemsworth was in it. Really cool book that is the basis for the end of Moby Dick, that this was an actual event that happened. A sperm whale actually rammed a whaling ship in the South Pacific and then he goes on to describe how these three whale boats full of people made it to dry land and escaped and then Herman Melville was on a whaling ship and heard about this tale and borrowed it and used it to use as the end of his book. So Philbrick, his book is why do you read Moby Dick and he lays out that this is something that's fundamental to Western culture, that it is seeped into everything, that most forms of media have central themes like this and that in order to understand lots of other books that you should grapple with this one. That's not a very particularly strong argument for a psychiatrist specifically, so we'll move on. My mother-in-law gave me this book, which it contains the central thesis that I'm going to lay out here for you, which is this is a book about the naturalist themes in Moby Dick. And the author picks out every description of every animal or weather phenomenon and then compares what did people know about this in the middle of the 19th century and what do we know about it now. And one of the things that he talked quite a lot about was something that I definitely didn't pick up or understand while I was reading the book. That Moby Dick contains a running dialogue of Ishmael to the reader trying to convince you that the old naturalists have it wrong. And that the sailors, the people in the ocean amidst these animals, that they know the real truth about what's going on. The background of that, the gentleman naturalists in the 1800s didn't go on ships. It was dangerous. To go on a ship for three years at a time was quite risky. It took you away from the rest of your life. And so they stayed on dry land for the most part. And they dissected whales as they'd wash up onto the ocean and they'd write treaties about their anatomical depictions of it. And that was the key of what science had to offer about whales and all these other creatures was through the eyes of these gentlemen sitting in ivory towers. And the sailors knew that that was wrong. They knew they could see lots of things that these folks, that nobody else knew about this. But they weren't writing books about it. And I think Melville had another reason for doing this. He was probably upset that he was this real man doing real dirty work as a poet, as an author. Riding on these ships for years at a time, living the life of a sailor. And his work kind of being ignored and not really elevated to the literary canon, which didn't happen until after he died. But I think it's in this that we have a message for psychiatrists that I think you could take away. That if we only think of the world through our offices and our encounters with patients in an artificial environment. And don't think of ways that we're interacting with the broader world or encountering things that take us out of our comfort zone. Then we're going to miss something about humanity. Miss something that we could use to understand our patients better, our systems better. To improve them and help them. And that we need to avoid looking at the world through carefully manicured experiments. Or depictions of circuits and receptors that are not going to necessarily capture what it's like to be a human experiencing a condition. So, that having been said, there's a risk in being too extreme in either direction. And here again, I think there's a fun story in this. Just as the crew is all on board the ship and they're getting ready to set off on this adventure that we all know is going to end in tragedy. Herman Melville makes the decision to stop telling you about the adventure. And to spend like 15 pages talking about different classifications of whales. And it is a part that is removed from most abridged versions of Moby Dick. And I don't take much, I think that makes sense to me in some ways. But it's inserted, he ends it with sort of a joke that I think makes this point. He ends this elaborate discussion about how whales should be classified. And throughout it he's kind of having a debate with himself about are whales mammals or are they fish? And he concludes without hesitation that whales are in fact fish. And that the sailors know that that is to be true. And now we know that that's not true. So, if you only relied on the humanities or relied on your experiences with others. And didn't learn about where science is taking our field. You'd also miss something important and maybe make a crucial mistake like Melville did. And this to end, I am not encouraging you to go read Moby Dick by itself. I think the message to take away would be be intentionally broad about what you do decide to read. Be mindful of what traps you're falling into. If you've for instance purchased three books about Moby Dick. That might be a warning sign about trying to be more intentionally broad about what you're trying to read. And then to use it as a way to understand patients. And understand patients that you might not frequently encounter. Might be a way to help expand your horizons out of your typical orbit. And with that, thank you. And I'll let Dr. Lochner continue. Applause. No? Okay. Hello everyone. I guess I'm speaking now, so. I'm going to be speaking about using film to teach cultural concepts to kind of get there. This presentation has evolved a little bit and has become a little bit more broad. I did want to start with a quote from Irving Schneider who was a psychiatrist who wrote a lot about using film. And he said, if psychiatrists did not exist, the movies would have invented it. What does that mean? It means that in film, in media in general, psychiatrists, they serve as purpose. They serve as someone that moves the story along sometimes. They serve as maybe an antagonist in the story, a protagonist, a tool. That just kind of occurs in the movie and helps things move along. In that the protagonist, the characters in the movie, usually have to talk to someone. They want to say something and oftentimes they want to unload something upon someone. So from the Kinetoscope to IMAX and from Sigmund Freud to TMS, cinema and psychiatry have really had their own evolutions. That oddly enough kind of occurred during the same time period. So why am I even talking about this? At the end of the day, we're all teachers. We educate the public. We educate each other. And media and film in general acts as a great way to simplify everything. It gives a shared language. Often, especially nowadays, most are really easy to get. It also kind of demonstrates the zeitgeist of the time, which could be important to speak about. And it could be used in therapeutic applications or to discuss things with students as more of a Freudian displacement type of thing. Where we're replacing something with a mere illusion. Something that could be uncomfortable to talk about. There are problems with using film. It's often a matter of perspective. There could also be a problem in that films don't discuss symptoms. So they don't really go through the symptoms characters feel. It is going through a plot, which means you're seeing issues, obstacles, problems in that plot that kind of moves things along. And also, oftentimes, there are a lot of incorrect portrayals in film of various issues, various diseases. Schizophrenia is often portrayed very poorly in film. But, weirdly enough, delirium tremens is frequently portrayed very well. I was watching a movie with John Cena recently. It's not very good. I don't recommend it. Unless you want to watch something where you don't have to think. It's called Ricky Stanicki. He was going through alcohol withdrawal at one point. And they portrayed it quite well. Going into a little bit more about portrayals and inaccurate portrayals. Psychiatrists, you might read if you're going into psychiatry in the cinema. Psychiatrists are usually differentiated or put into three different buckets. One is like Dr. Dippy, which is based off a psychiatrist from 1906 in the movie called Dippy Sanatorium. And that's the silly, kind of comedic, goofy psychiatrist. Then there's Dr. Evil, not like Austin Powers' Dr. Evil, but just an evil psychiatrist. As well as Dr. Wonderful. These were described by Schneider in 1985. And then 25 years ago, the Gabbards identified 450 films with psychiatrists or psychiatrist-like people in them. And in those films, they kind of differentiated them some more. Saying there's a faceless, plot-facilitating psychiatrist. This is more like if you watched Westworld Season 3. The therapy service with a deceased friend who would just kind of call and help move things along. But you've never seen this person. The active, kind of manipulative psychiatrist. This could be like the psychiatrist in Nightmare Alley, if you've seen that movie. Where they have their own... Cate Blanchett played the psychiatrist in their most recent iteration of Nightmare Alley. Where she had her own type of plot going on that really affected the film. There's also the oracular psychiatrist. The one who kind of knows everything. Is a little bit arrogant. This is Hannibal Lecter. Who's also probably a Dr. Evil. The social agent psychiatrist. Which can be a little bit like... They're really more reconciliatory. And this could be like Anna Kendrick's character in 50-50. The eccentric psychiatrist. The neurotic one. Frasier. If you ever watched that show from way back when. As well as the emotional psychiatrist. So this one could be like... If you've seen the recent show on Apple TV Plus. Shrinking. Where you have a very emotional therapist. Kind of... Who's somehow still giving therapy to their patients. It's very much a show of what not to do in therapy. But very funny. There's also an issue of a sexual relationship with psychiatrists in movies. This often happens. You also see it in Nightmare Alley and in 50-50. Interestingly both are portrayals of women psychiatrists in film. They're often portrayed very poorly. As either needing therapy themselves. Or often requiring love to be effective. Which you'll see in movies like 50-50. But what I really wanted to talk about is ways to use film. In training new psychiatrists. So you could use it as educational examples. Do's and don'ts. Like I mentioned shrinking on a very good what not to do. It pretty much hits everything you shouldn't do ethically. As a therapist or psychiatrist. You could use films to open up the discussion to the complicated. Use it as an example to kind of give prior to teaching a concept. So that way there's something tangible for people to use. As well as you could use it to get a little bit more about patients' perspectives. And lastly cross-culturally. Which we'll talk about a little bit more when I go into the examples. Who are your patients? We practice in a Navy program. Navy institution. So we don't get a huge. We get a surprisingly more diverse patient population than you'd think. But we also don't get a hugely diverse patient population. We don't see necessarily everyone from every culture. Every once in a while we'll run into a patient who's Uyghur. Which is again they're from western China. And it's a very specific cultural region. But oftentimes they're young. They tend to be white. And they tend to all come from the U.S. Using film can kind of help you become a little bit culturally competent in psychiatry. Because they give the different perspectives. They give the different problems. And they kind of illustrate different concepts. So thinking back. If you wanted to even use children's movies or Disney movies. Like Encanto and Turning Red came out. Which gave an excellent view and perspective of those various cultures. Where you really see that whole family centered view. And Encanto as well as in Turning Red. You see that plight of being just a first generation person in a new country. And both of those do a good job of it. And could also be used as a really excellent jumping off point. To discuss these things. There's also different cultural aspects of bereavement. That are portrayed in film really well. Like in the Farewell. Which is a movie with Awkwafina. The entire movie is about not wanting to tell the grandmother that she had cancer. Which again is a very culturally specific thing. Where the entire family decided together. That they didn't want to tell their grandmother this. And the grandmother was okay with it. With not knowing and just continuing to live her life. And all of these things. There have been a few good movies that have come out recently. That I also recommend for this. Like Past Lives came out recently. As well as Minari a few years ago. And those also really delve into the Asian culture really well. We'll talk a little bit more about very specific examples. But what can we again do with these? It's more using it as the jumping off point. Maybe even having a film. You know how we have journal clubs. Have a film club a few times a year. To discuss something interesting. And have a full discussion on how that relates to things. We'll just kind of jump into the example discussion. We'll start with something a little bit broad. And not necessarily culturally related. But if you wanted to for example show Erickson's Stages. The recent movie of Banshees of Anishinaabemowin. That came out maybe two years ago. That involved two older males in Ireland. Really kind of demonstrates generativity versus stagnation. Because one of the males. His name is Colm. Decided that he didn't want to be friends anymore. With another man named Podrick. And they've been friends forever. Been friends for years. But at some point Colm said. I have done nothing with my life. I want to do something. I want to make art. And in order to do that. I have to leave this friend. The whole movie is about that kind of conflict. But again it's very interesting. Because there's not a lot of movies that really. Necessarily demonstrate that as specifically. Another thing or another interesting movie. That came out recently. Was Everything Everywhere All at Once. While being fun and delving into the multiverse. Really at the end of it. It's about a mother and daughter relationship. And in some ways that could be used to teach. I did a whole object relations talk yesterday. So it's on my mind. But I'm like Fairbairn. And object seeking libido. Because healthy parenting should result. With the child kind of going outwards. From Fairbairn's point of view. Whereas in Everything Everywhere All at Once. The daughter kind of. She fell apart. In one of these little multiverses. And the whole conflict kind of stems from that. And the resolution of it. Involved the mother and daughter kind of reconciling. And lastly. Going back into the cultural discussion of psychiatry. There have been a lot of excellent Native American. Based films and movies and TV shows. That have come out recently. Like Fry Bread Face and Me. Which is about. I believe. He's an LGBTQ child of Native American descent. Who basically goes back to the reservation. After living in San Diego. And kind of really feels the cultural differences. And learns to embrace it. There was Reservation Dogs. Which came out. And also really demonstrates. The thought processes of Native American adolescents. In these towns that look like they're dying. But they also have this whole. They want to stay with their families. They want to stay with the people that they are. As well as The Curse. Which had Emma Stone in it. Which also kind of demonstrated. That feeling of like colonialism etc. So all of these kind of exist. And they're all tools for us to potentially use. It's just more like building something from it. So that's everything I have to say. And from that. I'll pass it to Dr. Lochner. To talk about fiction in crisis. Hi everyone. Okay. So as Dr. White said at the beginning. I'm Anna Lochner. I am a second year resident. At Naval Medical Center San Diego. I'm going to be talking about a course that we have. That is directed at our interns. Where they are able to pick a fictional character. And describe them as if they were coming into the emergency department. So when we first were talking about media for curriculum. The first image that popped into my head. Was back in elementary school. Seeing the overhead projector coming out. And just the joy that I felt. In knowing that we weren't just going to sit and listen to a teacher talk. For a little bit. But there was going to be some type of interaction. I would say that the only thing that was better than that. Was when we would have that giant TV come in. On the big wheels. With the VCR attached. Because then that wasn't just that we were looking at TV. Or at images. We were getting to watch a movie. So that was always the best. Thinking about how movies and curriculum come together. Even movies outside of things that we're learning, we get to see fantastical places, go on adventures, but also see quotidian life that might be exaggerated, but it might just be realistic and something that we haven't experienced ourselves. Thinking about relationships and what humans are capable of in different situations. And looking at patterns and relationships, and it helps us remember what we saw. There are examples out there of med schools using movies to teach things. Generally speaking, my med school, before we even started, as part of our pre-summer orientation, they sent out a list of three movies that they wanted us to watch. Clearly not all of them were impactful, because I can only remember what two of them were. But one of them was The Diving Bell and the Butterfly, looking at locked-in syndrome. And it was a great example of movies that give us an opportunity to experience diagnoses that aren't common, that we talk about in med school, but to be able to see how it impacts someone's life and their relationships. Other examples that came to mind were Brain on Fire, about NMDA encephalopathy, The Theory of Everything, thinking about ALS, and To the Bone, which was looking at eating disorders. One of the other ones that was assigned, I believe it was a French film, called Dirty Pretty Things. This actually was looking at some of the more ethical and legal considerations for medicine, looking specifically at black market organ harvesting. So hitting things from a totally different perspective. There's also courses out there that med schools do that teach professionalism through movies, beginning to see examples of good and bad professionalism, and even teaching things about American culture and history to IMG residents. So there are these frameworks out there for teaching psychiatric principles, as well in med school and in residency. And there is one course out there that uses horror movies to teach psychopathology, which is one that I find particularly interesting. It does look specifically at horror movies as more metaphors for psychopathology, not usually the best examples of actually things that we see. But there's also articles that look at pop culture figures to exemplify different aspects of psychiatry. One of our residents put out a paper looking at Encanto and how it can model psychodynamics. There's ones where they're looking at Star Wars and Fatal Attraction to demonstrate different personality disorders. These are fun and engaging, and generally if I have to present an article, these are the ones that I want to talk about, because they're the ones that if I'm lying in bed after a long shift, I'm open to reading and actually enjoy reading. So the course that is Fiction in Crisis. It really started after a conversation with a couple residents and one of our attendings and one of our APDs, where we came and said, we don't really go through cases. We might talk about specific examples, but we don't do that noon conference setup where we say someone's coming into the emergency department and walk through the whole thing. And he said, great, let's do it. So this is an eight-week course, one hour each week, presented by an intern. They pick any character, could be from film, TV, books, or any other source, most common was film, and presented this patient as if they were coming into our emergency department. Part of it was to address a gap in our first year. As Dr. Leshin said, we have a pretty specific patient population that we see. And in addition to the cultural piece, there is a certain medical and psychiatric piece where we see young, healthy, active-duty service members who don't tend to have particularly complicated medical history, because you really shouldn't be active duty if you've got a lot of medical stuff going on. And then we see very few vets and dependents right now, just because of staffing. So this is a way to explore some of those more complicated cases that we wouldn't get to see otherwise. So picking a character, we present them as if they were coming into the emergency department. We talk about how they got there, if it was that they were brought in by family, ambulance, police, and then walk through the entire presentation. How did they look as you were talking to them? So we're going from our HPI, our past psychiatric history, medical history, labs, imaging, whole thing, and also thinking about, okay, as this patient is sitting down there waiting, is there stuff that we want to be doing? Is there medications that we want to start, collateral that we might be able to obtain? And it's supposed to be an interactive thing. So having the residents ask questions and really get into a discussion, ultimately leading to a discussion of assessment and disposition. And part of this was really aimed to highlight some of the grayness of psychiatry. The most obvious example that came up in most of the cases was thinking about the legality of civilian holds for some of these cases. And the ones that really prompted the best discussions were the ones where it wasn't clear. If the patient came involuntarily, we would have one answer. But if it came to a conversation of involuntary, things often changed. We also were able to look at some of the variation in rhetoric across state lines for the laws themselves. While we practice in California, and we therefore need to be very well acquainted with California law as Navy psychiatrists, we are guaranteed basically to not stay in California. So not necessarily knowing all of the state's laws, because that seems unrealistic, but knowing how to find them and how to look them up. And so talking about cases in Virginia and Iowa and Pennsylvania, getting to see how we look up those laws, and also thinking about maybe overseas, in Japan, where it's a very different system there. So being able to have that conversation has been very helpful. Then we also have the question of, all right, what if this patient is active duty? So we have our own set of holds. They're generally comparable to the civilian world, but they are slightly different. We have other considerations as well. So while most of the characters that we talked about weren't civilian, getting to play around with that and say, OK, if this was an active duty member, are they someone that we can say, yep, they are fit for full duty, meaning they can go out and do everything that we would expect them to do as an active duty service member? Or do we need to do some things? Do we need to consider that they need to be on a do not arms list? Are they able to go underway on a ship? That's something that comes up a lot. Or deploy worldwide? Also, are we going to start medications on them that might change that duty status? So things that mean that we can't operate heavy machinery, or some that are just straight up duty limiting. You cannot be active duty on an antipsychotic. So things like that. Does this patient need a little break, and then they'll be able to come back? Or do we need to start processing them out of the military? So without having a set curriculum where our interns just get to pick the case year to year, there is this ability to see differences. Even talking about that grayness. If an intern picks a case one year, and then a different person presents that exact same case the next year, you can be looking at the exact same source material, but come to different conclusions. So it depends on what that resident chooses to highlight. Focusing on different pieces of the history. Maybe intentionally leaving some things out. Or not just focusing on different episodes, if it's a TV character. And really getting to see that just the way that we present that case can completely change the outcome. So I'm going to give an example case. This was one that I presented as an intern. This is a 36-year-old civilian male with no past psych history who was brought in by his family for new auditory and visual hallucinations and delusions that are occurring in the context of a recent relocation. First experienced hearing a voice about a month ago. Sounded like it was coming from outside of his head. Wasn't a voice that he knew. Started only when he was alone. Then started happening when his wife and daughter were around. Over time developed visual hallucinations as well. Getting to the point where he was seeing up to eight men. So we worked through this case. The other residents asked lots of questions. We went through a good history. Learning that he was also being sent on missions. He was seeing signs. Even went up to Boston looking for Darth Vader at one point. Spent a lot of money and time on these missions. To the point where the farm and his house were at risk of foreclosure. So we keep going. We get an extensive workup, including a medical workup, because he's 36. So we want to make sure that there's not something medical going on. And multiple points of collateral. So we talked to the wife. We talked to the brother-in-law, who have very different opinions on what's going on. Go through this whole case. But interestingly, when I was presenting it, no one asked what that first voice said to the patient. If they had, they probably would have known who the patient was a little bit faster, but would have been, if you build it, he will come. So this is Ray Kinsella from Field of Dreams. So when we initially are going through this, when we say that this patient is civilian coming in voluntarily, pretty unanimously everyone agreed that he should be hospitalized. But as we kept going, saying, okay, maybe he's involuntary now. There was a little bit more of a discussion, since he was spending a lot of money, but did he really meet criteria for being gravely disabled in the state of California? And there were arguments for and against. Then when we got an additional piece of collateral that he had also impeded life-saving care for his child when she was choking, because he believed that one of the White Sox players was going to save his daughter. Everyone was pretty unanimously thinking that he met criteria for great disability. Similarly, thinking about, okay, what if this patient is active duty? Pretty short discussion, active hallucinations and delusions are not generally considered compatible with active duty service. So we were able to get into that a little bit more. Also thinking about the Iowa law. But some other really memorable cases that we saw was Dennis from It's Always Sunny. Thinking about a case with known ASPD, who was brought in by police. And getting into the conversation of, is this psychiatry or is this law enforcement? Who takes primary in this, and what is our role in that? Also, Wednesday Adams, thinking about auditory visual hallucinations in an adolescent. And she was at boarding school, so the legality of that piece, where we have an adolescent whose parents are unavailable. And who's in charge of this patient? And looked at a couple of characters from SpongeBob. So Squidward was depressive disorder in the context of hypothyroidism. That's when I learned that squids don't have thyroids. And Plankton with narcissistic personality disorder. I talked about Rambo. So that was a case where, again, we were talking about the forensics, but also there was a military connection in that one. And Rosemary's Baby, thinking about baby blues, postpartum depression, postpartum psychosis. And also getting to talk about the complications of having a mom who is in that immediate postpartum period coming into the hospital. And how that changes medications, if it does at all. And just some of the logistics of if this mom is breastfeeding and what does that mean for that hospitalization and the baby. So really, crossing into so many different domains and getting to talk about these things in addition to some of the cultural aspects that Dr. Leshin was able to touch on. I'll turn it back to Dr. White. Those were all awesome. Thank you all so much. So I think we kind of covered it. I'm not going to belabor the diagram thing anymore or else we'll turn this into a diagram conference like I was talking about. And how the art can kind of go beyond the diagram. The social and cultural considerations of the art and how vital those are to understanding. And then how it fosters discussion and creates the interesting debates and some people calling something black and some people calling it white. And how important it is to consider who is the receiver of the art. Who has questions? Yeah, you can come with the microphone. Perfect, we can, we can, yeah. Hi, I'm involved in training young psychiatrists. And we have a film club running, and this is our second year. We show movies, we call them films, in Ireland. And once a month, we have a film club run by young psychiatrists. And we have a film club run by young psychiatrists. And it's extracurricular, so it's kind of voluntary. So it's not didactic, but we try to pick, we pick movies that people have never really heard before. But when you mention them, they say, my dad said that was a really good movie. So we started with Rashomon, and then we went, we did one from the Apu Trilogy and Sataji Ray. And we did a Brazilian one recently, Central Station, where there's this boy. And the issue of harvesting organs, this homeless boy, and it's just a wonderful film. And just before that, we did the Vin Vendor's Perfect Days movie set in Japan, the toilet cleaner. And I guess my question is that, so we've been really gratified that people actually really enjoy it. It's not just the pizza and beer afterwards, the chat, the discussion. But I would like to move this on and get them to think about literature. And while I'm struck by people's enthusiasm, also, young people nowadays don't read fiction. And I try to do this with patience as well, but it really, it's very rare that you get even very, very intelligent people who are very familiar and passionate about literature. So we've spoken to one guy about bringing in, starting with, say, a short story club, which could be a way of, everybody reads a short, because nobody's going to read a novel in a month. They are, but not everybody will. But if you have a short story that they could read in 20 minutes, half an hour, that could be a way of doing it. So I guess I am just wondering about any experience about that, using short stories as well as in addition. Would that be okay? Thank you for that. We haven't created a curriculum where we use short stories. But it's funny you mention it, because I had the thought just the other day of how interesting it would be to discuss it, in that I was reading a short story collection by Shirley Jackson, who's a horror writer from way back when. And all of her short stories really do demonstrate psychopathology a little bit more, kind of like Dr. Lochner was saying, and show all of that. One, our didactic curriculum, we need to delete stuff and add. We do that from time to time to update things and add to it. But a way that I've started to play with encouraging more broad reading is I send a weekly update to the residents, as opposed to lots of frequent e-mails of schedule changes and things. I use that as a forum to highlight accomplishments in the program, great things that are happening. And at the bottom I often leave a recommendation or something that I read or somebody in our education committee read that had some interesting tie-in to psychiatry. And it's just a really brief review, but it's sort of more of a prodding to, like, this is something that we think is a good idea to do, as opposed to getting everybody again together for a specific class or a more detailed discussion. I briefly want to say I think mentorship is going to be a big part of this, because I think medical education has suffered tremendously at the hands of the idea of high yield. Every point on every test you take, starting with the SAT counts. And if you're not studying to get points on that test, you are wasting time. So drop stuff that's not high yield. Even scientific stuff. If it's not board testable, don't waste time on it. Move past it. Get back to clicking through Anki. Get those points on that board exam. And that's what medical education has become. I mean, medical education used to revolve around, like, the classics. And now it's we're having to ask ourselves, how do we even get people time to read a short story? And I think that's horrible. I think that that idea still permeates so much through residency. But here's the thing. As you mentor people, you have to tell them, like, yeah, your boards are important. But, like, the score kind of doesn't matter as much as it did when you were trying to get into a residency program. Like, in this idea of every only focus on what's high yield, I think telling people that you're mentoring, like, you have to kind of drop that mentality at a certain point. As you get out of training, that's not going to be your life anymore, you know? And you have to start figuring out how to be a person again. And so as you're mentoring people, I think, is really where to do it. So thank you for mentoring your trainees in that way. Luke, you didn't graduate yet. So we do need you to get back into the clinic, do some work. And interestingly, I actually have talked to one of our incoming chiefs about doing a book club. So I think we are going to do one and try to kind of find that balance of having it be optional, definitely not making it mandatory, because there are going to be months where you do not have time to read an extra page. But also balancing books that are more directly related to psychiatry and ones that aren't, and trying to hit both of those things. Please, go ahead. Next question. Hi, my name is Noah Rodriguez. I'm a fourth year medical student from the CUNY School of Medicine. And actually, I've done a lot of work in medical humanities through narrative medicine, actually, in the last seven years. And so I wanted to talk about, like, I've seen this kind of work done in sort of, like, an informal way on YouTube, actually, where actually there's a licensed marriage family therapist who works with a film, what is it called? A film major, and they call it cinema therapy, and they actually analyze psychological concepts on YouTube. And it's very accessible to the public. There's another person named Georgia Dow, who's actually a master's in mental health counseling, who also dresses up as characters while she analyzes them. And so I say this because there's a lot of value in your talk, and I really appreciate it, because it showed that even at the highest level, it shows that we can do a lot of psychoeducation for residents and practitioners of psychiatry. But I also wanted to bring into attention that, do you think that there's any possibility of, you know, considering part of psychiatry is psychoeducation for patients, and that can be quite therapeutic, is there any discussion of possibly expanding the range of this program to possibly even discuss films and books and art with patients, potentially, considering that you've already laid the groundwork of saying, hey, here's what this is, this is what it is based on research. So, that's the question. I mean, I was wondering kind of the same thing throughout this talk. So thank you for putting it so well. And by the way, what was the name of that program one more time? Which program? The one you mentioned where they discuss kind of the psychoeducation. Oh, it's on YouTube. So one of them is cinema therapy, but the other one, she just goes by Georgia Dow, and I can give you the specific name and write it down later. Oh, thank you. Yeah. And also, just like, also, I just want to stress, narrative medicine, it's like a different modality. I'm not sure if you guys are aware of it. It seems very overlapping with this. But yeah, no, this is literally bread and butter to us, with the added thing of expressing, what is it called, in response to the works that you analyze, you actually make artwork in response to it as well, and share it non-judgmentally and openly with the group. So that's another thing that you could consider looking into. Excellent. I think it's, you know, as we kind of were talking about, patients conceptualize their illness based on the media they've consumed, you know? And I think that maybe exposing them to different things, like instead of just watching, like, One Flew Over the Cuckoo's Nest, maybe read, like, The Center Cannot Hold, and, you know, start to kind of, like, even though, you know, I know we're talking about fiction, but you get the idea, and to kind of help them reconceptualize, I do think it's a place to tread lightly, because as we've kind of talked about, people can get two very different things from a single piece of media. So, you know, they might come back and, you know, I've definitely, I had a colleague recommend a movie to a patient recently, and he came back, he's like, I watched it, and he got exactly the wrong thing from it. And so it's just about, I think, a matter of knowing your patient, if you kind of, that's, that would be my two cents. If you know your patient, and you kind of see where they're at, and you have an idea of how might they take this. So I think there's definitely a place for it, but I think to be done with great care. Us being doctors, that should be everything, right? And in a slightly separate vein, I've never assigned, like, a movie or something to a patient, but I do work with, like, a lot of adolescents in one clinic who, it's easier for me to describe something to them if I use something I know they've already watched or played. So I'll bring up, like, a video game and be like, hey, remember this? It's kind of like that, and kind of see where they go with it as a way to help, I guess, improve communication. Thank you for great lectures. The thing, like, it will be just a completion to what you said here, and what you said here, and maybe also a question. I come originally from Iraq, so I haven't, the first time I see a U.S. Navy personnel, I have heard about the bombs in Iraq, coming from U.S. Navy. But regardless of that, the thing that I think is interesting was your title here about, like, Moby Dick. Why should psychiatrists read Moby Dick? And it was, like, interesting. I have translated a simplified version of Moby Dick to Kurdish. So I have read it, but I think the thing that's interesting is, like, in the Oriental cultures, the literature was originally used to teach psychiatry, and to teach the psychiatry, and maybe I was saying, like, the psychological aspects of the psychological world to the public. And you showed, like, the anatomy picture, but, like, Rumi, who has, like, 25,000 verses in his Mahatma, it's all about talking about the psychological world and going into this. And even other, like, the other stories, like Sindbad and Aladdin and those, were about going to this Navy trip and coming back with so much treasures, going through the sufferings and come back with this. So it was always something behind the original story. And that's why I think it's interesting, because now we are living in a world that you come here and say, like, why should we read those stuff? I think it's very interesting and very, very good that we take up those stuff, but I think it's also a manifestation of how much we have gone far from that world, which also can help both to understand the things that are beyond these categorical thinkings of diagnosis, but also to establish an alliance with the patients that come from different cultures that have, like, a connection to those literature. And personally, it has helped me, like, if I talk with a patient that comes from a Muslim background, to take up some things from that literature, which can help me make an alliance and then talk about the treatment. So I want to get also your reflections, and also if it's okay and someone of you know a list of those films and movies that you talked about, because I don't have, I have learned about some of the movies, because they are in, I work in Sweden, so most of my patients talk with this Hollywood culture. They talk about, okay, I had this feeling, and it's the name of a movie that I didn't have, like, access to it. I have to Google it. So it will be good also to get something, some, like, list like that, and your reflections. Thank you. Yeah, we'd be happy to come up after, and we can talk more about that. I had a note that I'd forgotten to say more explicitly, but the Western canon is really white male centric, and doesn't have a broader representation of folks, and I chose that book because I had read it before, and now as a psychiatrist reading it, it came with a different perspective, but that, again, it's not, it's, the more important take is the one that you'd settled on, if you have a patient that presents you something, a piece of media that you've never come across before, it's really cool to learn about it, and then understand, well, how did, what did it mean that that patient shared it with me, what does it mean to them, and then to get a deeper understanding of where they came from, and why that meant something to them. Hey, I'm Victor, I'm an attending in Connecticut. It's my first year as an attending, so having time again is cool. I think one thing I would be curious to know is whether you ever explore in your discussions, whether directly or indirectly, countertransference, as in the feelings that is elicited in the viewer toward either the protagonist. Two examples I'm thinking of, this one particularly blew my mind, but I'm sure we've all seen or know of The Shining in some form or fashion, but the Kubrick, the movie, I just learned there's an analysis of Kubrick throughout the film, having instructed Nicholson to look into the camera, which, basically the implication being that we, the viewers, are seeing things from the point of view of one of his hallucinations, or ghosts, depending, but I'm not sure that that's the point of view of one of his hallucinations, or ghosts, depending, which is really interesting, and there's so much external stimuli in that movie, it's hard to think about the internal stuff, but I thought that was a really interesting addition Kubrick made, and you could only do that in film. And then the second, another Stephen King reference, is if you ever read his book on writing, he talks about his own challenges with PTSD and alcohol use disorder and stuff, but he also talks about his writing technique being to take three ideas and just combine them into one, so like haunted house, psychotic man, and psychic child, and Carrie is another example. The thing that I thought was interesting about Carrie is he doesn't want you to like her, so he took the heroine, or anti-hero, or villain, whatever you want to call her, and made her purposefully unlikable, so that even though you're supposed to empathize with her as the bullied protagonist, you also feel that kind of, he's putting, he's making you feel toward her to a degree, he's projecting her, how do I want to put it, it's complimentary countertransference, I think it's called, where she's making you feel like her object as a, when she was a child, which is just a really interesting thing to like, be feeling sympathy, but also like, wow, this girl's not a very likable person anyway, so what does that entail? So I was just wondering if you ever talk about countertransference in your discussions over the years, or in training programs, et cetera. Yeah, I can't think of an example off the top of my head where we did get into that discussion of transference and countertransference too much, but I think that's certainly an interesting piece that should be considered, especially with some of these cases where we're talking about things that we don't see as much in our population, or things that we do see a lot. So at this point, like I said, I can't think of anything, but I think that there is a whole world to explore with that, for sure. Hi, thank you all for the talk. I'm Josh. I'm from the Army side. I want to thank you firstly for actually bringing arts into a military residency, because I think that's super important, and something that people can kind of, like, oh, we're in the Navy or the Army, like, why, what do we have need for the arts? But I was, I'm recently out of residency, and one thing, gears were starting to turn in my head, is it seems like you did something, you brought the arts into the curriculum, but you also made didactics fun, which is a very difficult thing to do. Coming out of residency, I know even myself, a lot of residents can be resistant to any sort of new curriculum or change. Do you have any suggestions or comments on how you integrated these things successfully into the curriculum, and what the resident feedback and engagement was like? Yeah, so, like I said, I, it was very easy to integrate. I asked the APD, and about a week and a half later, he said, okay, I did it. So that was just a credit to our faculty and their willingness to listen to what our feedback was and make a change, in my opinion, exceptionally quickly. But as far as the feedback, I am biased because I was the one that requested it, but that was one of my favorite things that we did, and they've continued it this year, and it is one where even in that, you know, 12 to 1300 block, where everyone is kind of sleepy because they just had lunch, you can hear, luckily we're in kind of our own hallway, and there's no patients with us, because you can hear from across the hall, like, the discussions going on in there, and how into it the residents are. And it's one where we have sometimes med students come in with us and get to sit in on it. We have off-service trainees, when we have our transitional year interns or our pediatrics interns or things like that, who get to come over and hang out with us in psychiatry for a couple weeks, and it's one that they also, I've had feedback from them that they enjoyed getting to come in and sit in on those, because like you said, they're fun. So in general, what I have heard has been very positive feedback. I kind of want to ask my fellow panelists here, any advice on kind of selecting the things you've chosen to select to kind of edify yourself or others? My advice would be to, and I think this ties into why that class was, like why people liked it, was it was resident-led, and it was open. We were not dogmatic about these are the choices that you have, or you have to find a way to represent this specific theoretical concept, but just kind of gambling on, we know that cool stuff will happen if we give this small prompt, and that ties into the philosophy, like really anything that you read, there's a way to connect that to psychiatry or something interesting, or something that your patient would find interesting or meaningful, and that that's a guiding principle that we believe and want to offer. Yes, I completely agree, and as Sir said, you know, while he was talking about Moby Dick, it should be something that you are interested in. I did not read as a child. I hated reading, and I would read the 20 pages that I had to for class to get it signed off, and that was it. And it's something that I've just actually recently started doing, where now I realize that there are books out there that are fun and not super boring to me, and so I think it's what Dr. Nissan said, of finding the things that are interesting to you. It doesn't really matter if it's interesting to anyone else, and having the, I think allowing yourself that flexibility. I know during residency, this has come up of, I go home and I feel like I'm so exhausted that I can't do anything, and that sometimes makes me sad, because I have a book that has been sitting on my shelf for three years, and I'm still only five pages into it, and allowing yourself to say, if I read two sentences, that's okay, and if I read none, that's also okay. Also, just give yourself that grace, and that also watching a movie, if that is more fun for you, that's okay too. I would just say read and watch broadly, so there are a lot of things you might not know you're interested in yet, and so maybe a new genre from a different country, things like that, but if you're interested, just look at it, watch it, see it. You don't have to watch or read the whole thing, you can always stop if you find it boring or problematic, but yeah, just read and watch broadly. I mean, recently I found a French anime about mountain climbing that I'm not interested in mountain climbing at all. That was actually very fascinating and interesting. It was an interesting perspective on some aspects of PTSD and depression in this mountain climber that, again, I would never have watched if it wasn't an animated French film, which was solely the only reason I watched, and I'm like, well, French cartoons are usually pretty good, let's see where this goes. But yeah. Thank you so much. Any parting thoughts, guys? Any saved rounds, other questions? Yeah, it's everywhere. I agree. Well, thank you all so much. We will be up here if you have other thoughts or questions.

arts integration

psychiatry education

Naval Medical Center San Diego

literature and film

Moby Dick

diverse perspectives

cultural competencies

cross-cultural psychiatry

fictional characters

psychiatric training

mentorship