Episode 14: Psychiatrist Howard Liu intersects mental health, workforce, access

 

 

     

 

 

It is estimated that 18.7% of residents of nonmetropolitan counties had some sort of mental illness in 2016 — more than 6.5 million people. In addition, 1.3 million (3.9%) residents of nonmetro counties experienced serious thoughts of suicide during the year. In Nebraska, 88 of the state’s 93 counties are recognized as mental health professional shortage areas by the U.S. Health Resources and Services Administration.

Dr. Connie is proud to host Howard Liu, M.D.,  Interim Chair of Psychiatry and Director of the Behavioral Health Education Center of Nebraska (BHECN) at the University of Nebraska Medical Center, to address the critical area of mental health care access for rural communities. As one of the only organizations of its kind in the United States, BHECN works as a skunkworks to solve the wicked problem — a critical shortage of mental health providers in the highest underserved areas of the state. He also addresses the signs and signals of mental health illness we should all be aware of and emphasizes the need for self reflection and self care.

RFI is proud to have supported two projects with Dr. Liu and the BHECN team, “Addressing the Rural Shortage of Mental Health Providers Through a Virtual Mentorship Network,” and “Ending Mental Health Stigma & Promoting Mental Health Among Rural Nebraska College and University Students.”

Howard Liu, M.D.
“If you ever ask me, ‘Should we protect our turf in psychiatry?’ Versus ‘Should we get some more access?’ It’s always going to be about access.”
Howard Liu, M.D.
Director, Behavioral Health Education Center of Nebraska, University of Nebraska Medical Center

About Dr. Liu

              

Dr. Howard Liu is a nationally recognized educator, behavioral health workforce expert, and practicing child psychiatrist at the University of Nebraska Medical Center (UNMC). He serves as the Director of the Behavioral Health Education Center of Nebraska (BHECN); a state funded office whose mission is to recruit and retain a skilled and passionate behavioral health workforce in Nebraska. He also serves as Interim Chair of the UNMC Department of Psychiatry.

Previously, he served as the Assistant Vice Chancellor for Faculty Development at UNMC. Clinically, Dr. Liu maintains an active child psychiatry practice as an Associate Professor of Psychiatry at UNMC.

Regarding workforce development, Dr. Liu serves as a founding member of the Medical Directors Institute for the National Council for Behavioral Health and as a member of the National Advisory Council for the Clinical Scholars Program for the Robert Wood Johnson Foundation (RWJF). In 2016, BHECN was selected to receive the National Council for Behavioral Health’s Champions of Training and Workforce Development Award.

Dr. Liu is an innovative teacher and an expert in faculty development and medical student education. Nationally and internationally, Dr. Liu has presented over 65 peer-reviewed abstracts and is a frequent invited speaker. He serves in educational leadership positions at the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) and the American Academy of Child & Adolescent Psychiatry (AACAP). Dr. Liu is a recipient of numerous educational awards including the Outstanding Teacher Award from the UNMC Faculty Senate and the Creativity in Psychiatric Education Award from the American College of Psychiatrists (ACP).

Show Notes

Dr. Connie: Hello, and welcome back to the Rural Futures podcast. I’m your host, Dr. Connie, and joining me today is a very special guest, Dr. Howard Liu of the University of Nebraska Medical Center, where he serves as Interim Chair of Psychiatry, but also as the Director of the Behavioral Health Education Center of Nebraska (BHECN). Welcome to the podcast, Howard.

Dr. Liu: Thanks so much, really enjoy being here, Connie.

Dr. Connie: Well, we’re excited to have you. Many listeners may not know, but a lot of them will—mental health is such a huge issue in rural areas, and you’re one of the leaders and the mavericks, really finding resolution to this, but also innovating in the space. So tell us a little bit more about you, Dr. Howard Liu.

Dr. Liu: Well, I appreciate it. Actually, I’m a MD, which means I can prescribe medications, and I’m still a practicing child and adolescent psychiatrist, but I also see some adults as well, and so I have a fairly good sense of what the needs are just from a clinical practice. Rural needs are certainly one of our biggest mission areas for BHECN, the workforce center for the state. I still have some patients that will drive literally all day to come see me here in Omaha, and they have to stay overnight and it’s very challenging. The other piece we know is that there is stigma for all mental health, but I think it’s strong in rural communities as well. For example, there’s a higher rate of depression and also there’s been recent data about suicide in farmers as well, and that’s really been a concern. So really trying to find those that are coming from small towns to train in a licensed mental health profession, and then go back to practice where they grew up.

Dr. Connie: Why do you think this issue of mental health has become such a big challenge in rural areas? How have you seen that transpire over time?

Dr. Liu: Well, I think that there’s a demand and supply imbalance. So frankly, the demand for mental health is increasing across the U.S. And so, as for example, now pediatricians are screening all teens for depression at age 12. Imagine that there’s a good number that would screen positive, and where do you then send them? And if you’re in an urban area, you could probably find a specialist, but in many small towns and rural communities typically you rely on a family physician, family doctor, or maybe some other kind of primary care provider. And many of those docs and advanced practice nurses and PAs had a very short rotation in psychiatry. They often feel comfortable with maybe ADHD, or depression, but less comfortable with something more severe, like bipolar disorder and certainly if there’s issues, also, with what we call substance use disorders, or addiction, that also is a challenge. So really, not having someone to refer to, and then feeling like they’re a bit out of their elements, is a real challenge. And most of the workforce is clustered in bigger cities in Nebraska, and certainly across the U.S., that’s true as well, so there’s a geographic gap.

Dr. Connie: Well, let’s talk a little bit about the future. I want you to put your futurist hat on, Dr. Liu, and tell us how you see this evolving in the future. What do you think the future of mental health looks like?

Dr. Liu: Well, there’s two principles I would say that really should define training in the future and the future workforce for mental health. So one is that it has to be in a team, and right now—I would say this is true, not just in mental health, but many areas of healthcare— everyone does things in their own silo, right? So, we have psychologists that train separately from psychiatrists, who often have limited interaction with social workers, and they don’t really train with counselors, and this goes on through all the professions. And then everyone graduates, and people in primary care really don’t know how to navigate working with these individuals. So early in their training, I believe that we need to have a lot more interprofessional activities where people are working in real teams on actual cases, thinking through how do they function, at the highest part of what they call their scope of practice. There are many professions that can prescribe medications, but, typically the most complex will go to a psychiatrist because they have the longest training, typically 12 years. Whereas, many straightforward cases can go to a physician assistant or advanced practice nurse, and then only on the more complex cases would they potentially refer them on, and I think that’s a good population health approach. The second thing is not every patient needs to be seen by a specialist, so we have to do a much better job of supporting those in primary care, and also, frankly, supporting those who are teachers, and even in settings such as corrections, where people are incarcerated, really making sure that those individuals have access to expert consultation. So I think just looking at different ways that aren’t just the same old, well, you have to get on the waitlist to come see me in my clinic, even if that’s six hours away, that’s not the right model.

Dr. Connie: Yeah, I agree. I mean, I think this is what’s so exciting about the work you’re doing, a lot of what the Med Center, other partners are doing. How do we create these new models that are more wholistic and really patient-centered, to give them the help they need, in a better way, and just a higher quality way, but also faster? With a lot of this, there’s that need for speed, so to speak, so that people aren’t out there really challenged in their lives and not getting the help they need.

Dr. Liu: That’s right. Well, and I think that speaks even in the way we’re having this interview today, virtually, we’re not in the same room, right? And I think telehealth is certainly another area, particularly as it eventually expands more and more into people’s homes and mobile phones. I think that will be another path to access. But I think there’s no way around the idea, though, that even if we have the best tools, we’ll have to face stigma head on. I think that there are many people in all professions in all communities that are frankly, scared to death to admit that they may have depression, they may have post traumatic stress disorder, they may be struggling with drinking, excessively, whatever it might be, but, that’s something we’re going to have to address as a society. There is a place for leaders, and I see that, there’s a lot of folks that are even healthcare providers, or academics or even presidents of universities that will sometimes tell their story, and they may not be on CNN, but they’re certainly known to their community. And I think knowing someone real, that you actually know, that is open about having gone through that depression, or that severe anxiety, or whatever it might be, that prolonged grief when someone passed away, it’s very helpful, and many of those that I’ve talked to will say when they come out of their story, then all sorts of people will come up to them, often quietly, just to share their own experiences, and that’s the kind of thing that I think, whether you’re in a small town Nebraska, whether you’re in a bigger city, we need more of that.

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Dr. Liu: There’s a lot of family history and genetics that play into this, as you know very well, and some of us are more vulnerable. And we’ll see this also in veteran populations, of which many rural communities have a lot of veterans, and a lot of folks that are active duty. And you may have four individuals that are in the same Humvee or something, and a blast goes off, well, why is it that one of the four has more severe symptoms even though it’s the same stimulus? I think there’s different factors that make us vulnerable.

Dr. Connie: When would it be time to seek help, and what would you recommend around that?

Dr. Liu: It’s an excellent question. For me, sort of like asking what is normal, and when should you get help, right? And I think, it’s really when you have problems functioning in the key areas of your life. So, if you are a student of any kind, whether it’s K through 12, or you’re higher education, grad student, and normally, you’re a A or B student, and then you see that it’s really been declining consistently, it’s not just one class, there’s an overall trend, that would be a concern for me. If you’re someone that’s working right now, and that you normally enjoy work, and have a lot of energy and a lot of passion for it, but you’re finding it much harder to go in, maybe having more absenteeism, more conflicts with colleagues, those kind of things, that would be a concern. And then your home or social life, I think those are areas that, particularly in depression, and other kind of things that might happen, that we’ll see a really big hit because often, many of these disorders are quite isolating. If you’re anxious, or you’re depressed, you typically will find less energy to go out and hang out with friends, you may become detached from them. You may be isolating at home, even if you’re living with your family, and spending your time in your room. It’s a lot of these is pieces, so I would say, if you’re really seeing a hit on your social life, your home life, your work, or your school life, I think it’s time to seek help.

Dr. Connie: Thank you for that, I think it’s great for our listeners to know, they don’t have to power through it. That’s not really the way this works, but there are people like yourself and others, the people you’re training and teaching, that they can reach out to and get that help. And it doesn’t have to be a bad thing or a mark on their employment record, but rather, it’s a healthy way to live, because we do live in a time of rapid change and high stress, and in many ways, this rapid pace of life, humanity hasn’t really kept up with it yet, and we’re still figuring out how to deal with it all. So I do think this mental health piece will continue to be such an important part of society, as is change continues to evolve.

Dr. Liu: I think that’s a great point. The idea of having a clean desk, or I guess, an empty backpack or whatever it might be, an empty inbox, it’s a goal we all have, but at what cost, is always the question. Nowadays, with the technology it really is something where it’s always there. For example, there has been a spike for adolescent girls in suicides across the country, and something that may be related to negative effects of social media, and cyberbullying, and some of those things, because they’re always often times without the parents’ knowledge, immersed in those worlds. And I would say the same for folks that are working and sort of burning both ends of the candle. I think everyone works in administration, but I think everyone that’s working and knows that when you’re short-staffed, and you’re staying extra, it’s going to take a toll on you. All those who are in a so-called sandwich generation who are taking care of aging parents, their own kids, any sort of caregivers, there’s a high risk to burnout. So I think, just being aware of those things, and sometimes your peers and your family members, your loved ones, may be more aware of it than you are, but they might just say to you, you seem stressed lately, or, you really haven’t been yourself. I haven’t seen you smile in a while, you seem really worried. That might be another sign that maybe it’s time to pause and just think about how do you set up your own schedule in your own life.

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Welcome to Bold Voices, our segment with rock star students from the University of Nebraska, who are making a difference in rural.

Katelyn Ideus: It’s Katelyn, producer of the Rural Futures podcast, and with me today is Brierly Kuhudzayi, a University of Nebraska-Lincoln graduate, and Rural Futures Institute Serviceship alum. Briley, thank you for joining us!

Brierly: Thanks for having me, Katelyn, I’m excited.

Katelyn: And tell us exactly where you’re joining from.

Brierly: I’m joining you from the airport, our international airport here outside Harare, Zimbabwe, and I had to come here because this is where I could get the best Internet connection. It was either this, or getting some data on my cell phone and climbing a rock out at the farm.

Katelyn: So Brierly, we want to give our guests a little bit of insight into who you are.

Brierly: I would refer to myself as a entrepreneur, a innovator, community development-infused formal entrepreneurship, social enterprise, essentially. And let’s see, I like to watch movies, I like to read books. I like the cold breeze in the evening here in Zimbabwe.

Katelyn: Explain your home there in Zimbabwe. I’m on a small plot of land, I call it the farm, but if you think about it from a Nebraska context, you’ll be misled. The core part of it is just 20 hectares, which is about 50, 60 acres. We have cattle, goats, and sheep, and our goal is to raise the livestock, butcher them ourselves, and market directly to the customer. If you think of it kind of like a safari, savanna setting, so plenty of grass that browny, goldy grass that when you picture when you think of Africa, we have that, but all the wildlife and stuff is in a national park, so we don’t have those. We have these beautiful granite, big rocks, that stick out of the ground in all sorts of places, and people that have crops have to farm around them. They’re not going anywhere. But they’re great to climb, they’re great for kids, and they’re great for catching cell phone signal. And it takes me about 30 or 40 minutes to get into town from where I am.

Katelyn: You have to kind of tell us your story. How you ended up at the University of Nebraska, and then what brought you home?

Brierly: I left Zimbabwe just wanting to go to college, and it happened to be that this college in Michigan gave me the biggest scholarship, that’s how I ended up there. Then I met with a Lexington native at a student conference in D.C., and he basically said that he was prepared to hire me with no farming experience whatsoever. And I jumped at the opportunity, and that was my taste of agriculture. That was my first taste of rural, because I grew up in an urban setting. And it was a steep learning curve. After about six or eight months I was trying to get it, and kind of just fell in love with it. While I was doing it, started thinking about doing a master’s degree, met up with Tom Field of the Engler Institute, and he recommended master’s in community development, because I had future plans of going back to Zimbabwe, and as you know, in Zimbabwe, we have a variety of economic and social problems, and I wanted to play my part.

Katelyn: What value has your University of Nebraska experience and your Rural Futures Institute experience, what value has that brought you in building your life in Zimbabwe?

Brierly: Definitely, if you think about Africa, and you think about less economically developed, or developing countries, or whatever the case may be, you kind of think that Africa’s a few steps behind. And we know in terms of technology, or the amount of value added for agricultural, we might be a few steps behind in that regard, but in terms of the people, and in terms of the community, and in terms of the coming together that’s needed to bear the community, we’re not so different, and RFI really helped me dig into that. RFI allowed me to put into practice all of the things that I was learning in my Community Development program. The Community Development program itself gave me tools to understand the dynamics of a community, be it rural or otherwise, and how it’s functioning, I would say that that’s culminating and understanding that we’re not so different, and we all just need to tie our shoelaces and get to work.

Katelyn: What types of experiences do you suggest that they embrace as a student?

Brierly: Meet someone who is not like you. Sit down, and have a good conversation, a good experience, with someone who’s not like you, and talk about everything. Meet someone whose ideas and experiences are different from you, and engage them. It’ll make you that much of a better person if you can, maybe not understand them, but appreciate where they’re coming from. The ability to appreciate someone and respect someone that is not like you, is crucial in this global society we’re developing where the world is just getting smaller.

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Dr. Connie:  I do a lot of work, of course on strategic foresight and futuring, but part of that is creativity, part of that is innovation. And it’s really hard for people to be creative when they’re just focusing on a to-do list and a massive amount of activity, rather than being very intentional and using discernment on what’s really important, what can you say no to, what’s maybe not in your wheelhouse, how do you engage a team around these things and create different systems that really support the ability to be creative? So many organizations say, yes, we want to be innovative, we want to really be competitive in the future. But they really aren’t designing the lives of their employees to be that way because innovation does start with the individual.

Dr. Liu: It really does. I think it does start with the individual, but I think it’s fed by the culture, or stifled by the culture.

(laughing)

Dr. Connie: No, that’s true! That is absolutely right.

Dr. Liu: And I know you’re someone that’s a futurist, and so you really think ahead, and I have no doubt that you found ways to really carve out that time. I believe in two things. As a child psychiatrist, and also as a parent of four kids myself, I think that adults often don’t take the time to play in the same way that kids do. And there’s something that, I don’t know if you grew up watching Mr. Rogers, but Mr. Rogers actually was quite a profound thinker, as it turns out, and then one thing he said is sort of like, play is the work of childhood. You really are trying things out, you’re processing things. We notice in kids who have been through traumas, well, often you’ll see in the play some of the terrible things they’re trying to work out, and what happened, and reenact, and so on. But on the positive end, I believe that for all adults, you have to have some time to play, but that entails two things. One is, it takes some risk, right? Because if you’re going to play, you might mess up, because you’re probably not the world’s expert in that thing, you’re sort of processing in the back of your mind, or balancing off a couple other people. And then, second thing is then, if it’s going to be risky, you have to be ready to fail, and that’s have to be okay, right, with the organization, with your unit, with your boss, whatever, or your colleagues. And I think for a lot of people, those two things are hard, because it’s a little bit of a risk, and you don’t want to put yourself out there. I recently read a book. It’s about the founding of Pixar, and written by Ed Catmull, the president, I believe, and it really said the manager’s job is not to prevent risks, is to make it safe to take them, and I really like that, because it makes you really think about, well, as a leader, am I stifling creativity by saying, oh, you messed up here, do better next week, or do I say something different, wow, it looks like you really put yourself out there. Maybe it didn’t work this time, but I’d love to see you keep trying new things. I think there’s different ways we can approach it, and kind of buffer that risk for our employees and our colleagues.

Dr. Connie: So the culture norm is to be so serious, and really stiff.

Dr. Liu: Right.

Dr. Connie: It’s nice to see some of that changing that, but, a lot of the high level leaders I’ve coached, that’s the thing that is missing from their lives so often, and part of coaching them is to encourage them and help them create some time, and make that time to actually play. I mean, there’s nothing more refreshing than a snowball fight with your kids, even. Go sledding, go do these things.

Dr. Liu: Yes.

Dr. Connie: They’re actually fun, or if you were a musician and you haven’t picked up your instrument, like you had mentioned earlier, for years, reengage that part of your health because it really brings out the best in you. And when I used to say that, people would look at me like, oh my gosh, she’s talking about having fun, and we’re talking about leadership and futuring and all these things, but then, it’s like it clicked, and people are like, okay, now how do I do that? Because it was really lacking from their life, but I always say fun is the fountain of creativity, but it’s also the fountain of youth.

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Dr. Liu: I have this philosophy about workforce, future workforce, future people in any field, and it’s that, kinda like what you were saying, you can’t just do the routine things if you’re going to flip something, there’s not enough people in any field, right? So otherwise, in 25 years, guess what? Exact same thing, if we’re going to use this same approach. But there’s some science, and I do believe there’s some art to it as well. So my first job in this department was, the only formal title I had was to help build a psychiatry interest group, which was medical students, and there was only one in the interest group, so it wasn’t very successful.

(laughing)

Dr. Liu: But I had in my fellowship, encountered a really outstanding mentor. Her name was Dr. Paula Rauch, who’s a child psychiatrist. And when were trying to learn development, normal childhood development, she would invite all the fellows over, there were nine of us, to her house for breakfast for I think six or nine weeks. And we’d go sit around the table, and she’d serve us a very simple breakfast —just bread and peanut butter, and whatever, and we’d talk about development. And one of the things that we then did was go to see a preschool where her kids had gone to school, and then  just see what they did in their sort of all day recess. And that experience always stuck with me for two things because one is that it takes a little courage to open up your home to trainees, or to colleagues, whatever. It’s an extra step, but two was I never have forgotten it, and I think others have never forgotten it either. Many of us remember it fondly as one of the best parts of our training. And I realized that when I started here, and there’s one person going into psychiatry, and that we needed to do better than that. And so I started hosting things in my home, and we’d invite students and faculty, and you really see outside of the work environment, people really let their hair down. It’s best if they can show up in their shorts or something, and it’s casual, and they can just relax and get to know each other, and I think as the students get to know the faculty, then I think that we’re also sort of unconsciously sort of auditioning them as future colleagues. They’re looking at their lives, and sort of auditioning their lives. Is this the kind of person I want to be? Is this the kind of balance I want to pursue? And as it turns out, the latest study on why students choose psychiatry, work life integration and balance is one of the top three factors. So the only way you could show that is definitely not in your office, but by showing them that thing. Maybe it’s piano, maybe it’s something different. It needs to be something that gives them some sense of who you are outside of work.

Dr. Connie: Oh, absolutely, you get to see the real person. I mean, in so many ways, when we go to work, it’s not really a facade. I mean, I think for some people it is, but you don’t see the family that they’re raising. You don’t see who they are, or the hobbies they have. You don’t see them as a whole person. My previous position before coming to the Rural Futures Institute, I did a lot of team building at the Kimmel Education and Research Center, which is on Kimmel Orchard in Nebraska City, Nebraska. We’d have companies come and we’d do things like Iron Chef cook-offs.

Dr. Liu: That’s great.

Dr. Connie: Real active, very fun, but also very purposeful types of activities. It’s the same thing you’re saying, I mean, so often, a lot of team conflict is because people just really don’t know or understand each other outside of the meetings they sit in. So how can we break down those barriers, really understand people as people, and build that camaraderie, but also that compassion, and real like for other people. And we’re more apt to do that if we know them and appreciate who they are rather than judging who they are.

Dr. Liu: That’s really well said.

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Dr. Connie: You are a leader in your space. I’d love to know more about your leadership philosophy, your style. There’s a psychologist that said, with any organization, it’s always good to be half in and half out, and what he meant by that was that if you have six different jobs, no one really feels like you’re part of that organization because you’re running around, and you’re not really present, right? And people understand that, right?

Dr. Liu: So you have to be at least half-time in, doing that thing, where people see you, they recognize what you do in that work and that kind of thing. But this goes back to your earlier point about creativity. You have to find that thing, you have passion area, and you have to carve it out. And it may not be there right away, but however you get there, that’s what’s going to create vitality for you in the workplace, is having that thing and for some people, that’s research. For some people, that’s community engagement. I really enjoy that piece, for example. For some people, it’s something different, right. It might be building infrastructure, or could be anything, publishing. But having that space to really carve that out, is so important. And then not being too committed to too many things is very important as well. So that was one principle. Another one that someone told me was, think about your portable skill set, because in a career, you may wear six, ten, many different hats, but what do you take away from each, and have you grown? And as I’ve thought about my career, I came in, again, really just as a clinician, which is a great thing, but I didn’t really know anything about leadership, and so a lot of what I’ve learned has been on the job. But I do try to be intentional about it, and try to write some things down. At some point I realized, there’s some major gaps of what I do and don’t know. I know a little bit on managing budgets, but I really don’t know about healthcare economics in the same way as someone who’s running a hospital does, and if I’m going to ever do clinical leadership, I should probably learn something about that. So for example, last year, I enrolled in an executive MBA program that’s sponsored through our hospital. Having those relationships, what Gallup would say, is the “friend at work” is so important. It’s so easy to neglect, but if you don’t have it, I really feel it So it’s the people that you can go and really debrief with, that aren’t doing it because of your role, but really, they genuinely, you like each other, that you can share your woes, and they can share theirs, that kind of thing. You can’t just create it, you have to find it. You have to carve that time out, and then you have to nurture it once you have those people. I’ve been lucky to have those people here, and it’s so important just for attention and for your own vitality as a leader.

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Dr. Connie: So I’d like to touch a little bit on BHECN, the Behavioral Health Education Center of Nebraska. Tell us a little bit more about your work there, and how you see that evolving into the future.

Dr. Liu: Well, that’s the half of my job that is creative work, I would say, in that there’s not really another center like BHECN in the 50 states, that we’ve seen. It was created out of passion by a group that included a philanthropist, an academic psychiatrist, those senior administrators, government leaders, and so on, but it creates, it functions almost like a skunk works, in that, because there’s not 50 BHECN’s around the U.S., we don’t have to do it any which way. And that was super important, because I think we’re trying to solve what we call a wicked problem, which is the shortage of providers in the highest underserved areas in the state, which have always been very underserved, and the current provider population’s getting older. In fact, I’m not calling them old, but the data suggests that over half of the psychiatrists psychologist, advanced practice nurses in psychiatry, are 50 or over, which means there’s a very high number retiring every year, and just to retain the same number, you have to have a lot more people coming in. So when we saw that, we also looked at, are there healthy pipelines for people coming in? And there’s some great programs for healthcare professionals, and so-called Rural Health Opportunities Program [RHOP Program] and so on, that pipeline people. I’d say primarily for MDs into family medicine, internal medicine, primary care and those are great areas. But they weren’t really turning out psychiatrists or psychologists, so we realized that we had to put our own pipeline together, and the last nine years frankly have been from the inception to now, have been really trying to get all those kinks out of that pipeline as much as possible, so we started working with high school students from around the state, and that’s been great collaboration, with a number of different training organizations. We work with college students around the state, hosted different college symposium, particularly for those in highly underserved areas—so rural students, we’ve always prioritized, but also those from, it might be North Omaha, South Omaha, Native American individuals, so those that are missing, basically, in the workforce. And then we worked in medical school, and over the last four years, we’ve increased the number of medical students going into psychiatry by about 63% or so, so really, it’s gone up, and there’s been a sustained increase in those folks. And now we’re just about to help work with our Department of Psychiatry here, to put up a new psychiatry residency program, along with the one that currently exists, to try to increase those in that part of the pipeline. The last part is something we’ve been doing throughout, which is trying to support the providers who are already out there, by providing a lot of training for them, but not just what random training, but the things that really would help them in the practice. nd the great public health needs in Nebraska, so you’re talking about addiction being a major shortage area, how do we increase those who have expertise in prescribing some medications, or help with addiction. It might be to alcohol, it might be to opioids, that kind of thing. We talked about Integrated Behavioral Health earlier, and this is a way to how do you train up social workers, counselors, psychologists, psychiatrists to really work with four or five primary care clinics, and really serve those patients in a very smart way, where really, you’re spreading your expertise out. So there’s really a lot of things we’ve learned, a lot of mistakes we’ve made as well, I might add, but this goes back to taking risks, and really looking at the data and outcomes.

Dr. Connie: Now, thank you for all you’re doing to help enhance that capacity, and congratulations on the growth and success, and we’re so excited to be able to promote and really get it out to people, so they know what you’re doing. I heard, I think, a statistic the other day, a thousand people a day are retiring right now, so creating this pipeline, helping people get to capacity in their licensing, so important, in especially the healthcare field. Working in this area of mental health, I mean, obviously we hear and see a lot about the challenges, and we can imagine it might be a difficult field to work in in many ways, so what excites you about working in the field of mental health?

Dr. Liu: Well, I think the future of mental health is really going to be a collaboration across professions. And you have to practice it, you can’t just talk about it, and then train in the same specialty and then stay with your colleagues. You have to practice working in areas that are frankly uncomfortable. It might be scope of practice, it might be training, it might be areas where you might not all agree, but the needs are great. Two weeks ago, I was in D.C. helping lead a behavioral prescribers summit, and the national group for the physician assistants, psychiatrists, nurse practitioners in psychiatry, and pharmacists, we were all together in one room. We were talking about the future, and when you look at things like all the opioid deaths that are happening in the U.S., you can’t just rely on one profession to solve them. And I think, as a group, if we can unite around a common behavioral health flag, and say that this is something we all will do together, and if I have expertise, I’ll share it, if you have expertise, you’ll share it, I think we’ll be a lot better off. And I always come out of those conversations, especially the tough ones, a little bit more inspired, because I know some real work has happened, because you’re a little bit uncomfortable, frankly, and that’s kind of when I know we’re making some progress.

Dr. Connie: I think, too, that just, makes sense to me, because knowing you, I can see how you stay on that cutting edge by enjoying a challenge, but also, you bring so many people around that, and a lot of capacity around that, to really solve those grand challenges in unique and innovative ways.

Dr. Liu: Well, I would say that every one of those interactions kind of, that’s very kind, I learned a lot at the table, and there’s all sorts of things that I just had wrong, and then when you hear it from the pharmacist about what they’re doing, and the VA hospitals, that was a revelation to all us of. Many of them are running clinics like psychiatrists, in VAs. So I think the more conversation that happens, the better, and then frankly, it does take a little bit of spirit of it being a maverick, as you said earlier, to say, you know what, there’s some things my own profession has wrong, and I’m not always going to agree with our state chapter of our national organization because my greater duty is to the workforce of the state, and sometimes, that means some tough choices, but  if you ever ask me; “Should we protect our turf in psychiatry?” versus “Should we get some more access?”, it’s always going to be about access.

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Dr. Connie: One last question for you, Dr. Liu. What parting words of wisdom do you have for our audience?

Dr. Liu: Well, I would say that, when I went through training, I think I got an incomplete tool kit, and it was really about just the nuts and bolts and how to take care of patients in the old model. And if I were to say, talk to tomorrow’s students, if any of them are listening, if tomorrow’s providers, I would really encourage them to learn more about two things which I failed to learn about when I was in training. So one, is population health. And that really means that, my client is not just the person sitting with me in this exam room, but my client might be a neighborhood, and it might be a school. It might be county corrections, it might be some other area. But how am I going to take my limited time, and work as smartly as possible to help the entire population, and that’s something that  I feel like needs to be taught, especially in a state like ours, where there’s so many gaps, to really think about those skills. The second piece, which we’ve talked about in many, many ways this hour, is sustainability yourself. Really being thoughtful about self-care, wellness. We know that sometimes the work is hard. A lot of clients we work with have had a lot of trauma, and sometimes that can weigh on people who have their own trauma histories, and just suddenly, we call it compassion fatigue, and sometimes you get a little burnt out. So really taking care of yourself, making sure that you have good colleagues, the friends at work, making time for those hobbies, those areas, I would say, that would help you to be retained in the workforce far longer, and really to thrive and have joy in your practice, I think that is really the key. So I would say those two areas, if there are future students that are listening.

Dr. Connie: Yeah, I love that word joy, and I’m so glad that that’s really becoming something people are focusing on. How do we create joy in our lives in this busy time with all this rapid change and so much being thrown at us all the time, but still, making priorities around well-being people, joyfulness. I think it’s an exciting time, and I’d love to see how that evolves in the future, because I think it’ll become more and more priority, for people, as they want more of a life experience, and not just a to-do list. That’s good for us. So we know you’re active on social media. We follow you, we’re huge fans, but where can people find you, Dr. Liu?

Dr. Liu: Well, if they want to, if they’re on Twitter, it is @DrHowardLiu, L-I-U is my last name, so they can follow me there, and I pretty much put a few things out there almost every day. There’s also just a tremendous community out there for mental health, and I think that if they’re a consumer of mental health, if they’re a provider of mental health, if you just put in so-called #mentalhealth, or #addictions, any of those, you’ll find so many advocates, and frankly, sometimes, when I’m a little burnt out, that’s where I find inspiration, and I seek every day an act of courage online, that inspires me, people telling their stories and standing up for things that really, that gives me hope for the future.