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Jordan Bawks: [00:00:05] Welcome to Psych, the psychiatry podcast for Medical Learners by Medical Learners. This episode is an introduction to the subspecialty of psychosocial oncology. It's a big topic, and today we will focus mostly on how to approach assessment in patients with cancer. I'm your host today, Jordan Box, a fourth year resident in psychiatry at the University of Toronto, working at Sunnybrook Hospital. And that's where I've met my guest today, Dr. Elie Isenberg-Grzeda. So why don't you introduce yourself and tell us a little bit about yourself and your training background and how you came to be interested in psychosocial oncology?
Dr. Elie Isenberg-Grzeda: [00:00:44] Sure. So first of all, thanks for for having me and for setting this up. So, as you know, I'm a psychiatrist here at Sunnybrook. My subspecialty training is in psychosocial oncology or psycho oncology, depending on which jurisdiction you're in. And, you know, essentially, I trained as a psychiatrist in residency at Albert Einstein College of Medicine in in the Bronx in New York, having really no idea what I wanted to do afterwards, other than maybe something HCL related. And one of my supervisors at the time, CL psychiatrist at my hospital, had suggested that I check out a program at Memorial Sloan-Kettering Cancer Centre. It's like a freestanding cancer hospital in New York City that they have a great CL fellowship program there. And even if I didn't want to work in cancer, it's a great training and the sort of thing that's generalizable to to other areas. So I said, sure, I went to check it out and I absolutely fell in love with it. I fell in love with the place and with the work and with the people and just really felt like a rich, interesting, stimulating area to to work in. So so that's where I trained for for psycho oncology. And for anybody who doesn't know what that is. I mean, essentially what we're doing is we're looking at the really the interface between mental health and cancer. You know, we treat patients, we treat their families, sometimes treat or support the oncologists. Yeah. And so that's the work that I do here at Sunnybrook at the Odette Cancer Centre.
Jordan Bawks: [00:02:30] Cool. And before I guess we go any further, I'll just make sure that we outline our objectives for today, which are really pretty self-explanatory, which is that we want our listeners to become more comfortable with the sort of unique aspects of a history assessment formulation related to patients who have history of cancer. And our hope through this episode is that after listening to it, you'll feel more comfortable both doing consults and follow ups because we're going to cover a lot of different unique areas. Ever since I've done kind of some electives in psychosocial oncology, it actually opened up areas to talk about my other patients, like when I talk to people about meaning and about impact of illness, like although we'll sort of talk about this as though this is stuff that's specific to cancer, I think kind of like you hinted at with your fellowship at Sloan-Kettering. You know, the sort of the mindset that we bring to doing a psychiatric assessment in patients who have cancer is one that we can apply in multiple settings. So moral story is we want people to learn a little bit about that kind of mindset. So this the outline for today is that we're going to cover some of these unique areas of the assessment. We have about ten of them. And then we're also going to spend some time towards the end talking about diagnostic issues in psychosocial oncology. But before we kick into that, I wanted to let Dr. Elie Isenberg-Grzeda to talk about a little bit about the history of psycho oncology, because it's an interesting one.
Dr. Elie Isenberg-Grzeda: [00:04:15] Yeah, for sure. And so, as you know, I find this area, the history of psycho oncology or psychosocial oncology very interesting. It's I mean, the history of medicine in general is is really interesting. And this is no exception to that rule. Cancer care in the 20th century is very was very different than than cancer care the way it looks right now in the 20th century. I mean, basically at the start of 20th century, you know, essentially cancer care was in its infancy. It was a very kind of rudimentary surgery based. A type of way of of treating people. And, you know, the surgeries were really not very well refined. Anaesthesia really was not very well refined. And so people kind of had these. You know, these tumours that were taken out and what felt like kind of barbaric procedures that, you know, would send us running if we were kind of given the option for those today. And so cancer itself was seen as something really, really scary and generally really, really untreatable. It was the sort of thing that came with connotations of. Of nihilism. Basically, cancer was synonymous with death. And if you could somehow avoid that fate from the cancer, then at the very least you'd be and you'd be left off with, again, some really disfiguring, barbaric, pretty awful surgical treatments and eventually maybe radiation. And then chemotherapies came about and. And anaesthesia techniques got a bit better and combined treatments came about. So chemo and radiation or surgery followed by chemotherapy or. And so slowly what happened probably around maybe mid 20th century is that there started to be a little bit more of a window of possibility when somebody was diagnosed with cancer beyond just death or suffering this inevitably barbaric, awful, torturous treatment.
Dr. Elie Isenberg-Grzeda: [00:06:47] And. And so then cancer went from this thing that represented. Death and basically really awful potential outcomes to something that that maybe had a bit more breadth in terms of possible outcomes and people could start to talk about it a little bit more. Certainly there was still a lot of stigma, but maybe a little bit less so. And eventually maybe around 1960s, 1970s, there was this kind of confluence of factors where you had better treatments. People were starting to survive a little bit more than they had been. Breast cancer, of course, one of the most common cancers, and that coincided with the time of women's liberation movements. Sexual revolution. You know, the idea of things that were taboo coming out of the woodwork. And so even the word cancer, which wouldn't have been allowed to be published in many newspapers up until well into the 1970s, slowly started kind of making its way into more lay media. And so people started hearing the word more. Again, less and less stigma associated with it over time. And what happened when you had more people surviving, more people talking about it? People becoming very interested in advocacy and awareness and sort of social responsibility. It is as a field. We started seeing patients going through this type of diagnosis and treatment. And. Starting to need more care beyond purely the the actual cancer treatment. The surgery, the radiation, the chemotherapy. And in the way that this had happened in other areas of health care as well, is we started seeing psychiatrists, psychologists, social workers, nurses and even some oncologists start to take more of an interest in.
Dr. Elie Isenberg-Grzeda: [00:09:13] Really the whole person. Beyond, let's say, the cancer itself. And what that meant was trying to understand what the impact was on people on their lives and. In as much as cancer caused distress. How we can actually help those people. And so that area of really the interface between health care, medical care and psychiatric care, body and mind essentially started to get looked at by more clinicians and researchers. And oncology was by no means the only area. I mean, certainly well into the 1980s, you know, there were many HIV psychiatrists, for example. But something about cancer psych oncology probably had to do with funding models. And again, just advocacy about cancer in general at the time really did help build a psycho oncology into what's probably the biggest of these subspecialty areas that that kind of rest at the interface of of medicine and and psychiatry. And so. You know, the field grew again. Cancer treatments got even better. Patients started living even longer. Many patients ended up surviving from their cancer. The cancer treatments issues of survivorship started to get looked at and again, the field continued to grow. There are professional associations. There's the American and the Canadian associations of psychosocial oncology. There's the international association. These are anywhere between maybe ten and 30 years old, depending on the associations. So, you know, not new, new, but certainly not associations that have been around for hundreds of years, like in some other areas of medicine.
Jordan Bawks: [00:11:21] So what I'm hearing is that as cancer treatments progressed. Longevity increased. Also, morbidity increased as people lived with kinds of consequences of treatment. Some of the stigma softened to the point where people were kind of allowed and encouraged to start talking about it. Advocacy groups sprung up to sort of advocate for the well-being of people living with illness or diagnosed with illness. I always like to have that kind of context. Where is where is the field at now? Like what? What are the current things that psych oncology are grappling with? Where does it see itself?
Dr. Elie Isenberg-Grzeda: [00:12:11] Yeah, that's a good question. So right now, and I'd say this is probably true for me the last ten or 15 years or so is we really seem to be in the era of distress and distress screening. And, you know, there's very good data out there to show that that we continue to really not pick up on people's distress all that well, generally speaking, in the oncology setting. And so there's been a lot of work done by research groups into creating distress screening tools that looks at not only psychological distress, the things that, you know, in psychiatry we tend to talk about and think about all the time depression, anxiety, but also physical distress, spiritual or existential distress, distress around social or practical concerns. And so really, where we are right now is in the era of distress screening. And and we're sort of veering into the era of how best do we then help people who screen high on their distress, on their distress screeners, for example.
Jordan Bawks: [00:13:21] And like what role psychiatry would have in that? Because I imagine that I mean, this is certainly a bigger conversation than we're able to have just on this podcast today. But, you know, a certain degree of distress, I imagine, is a sign of actually psychological health in the face of certain diagnoses.
Dr. Elie Isenberg-Grzeda: [00:13:39] Yeah, Yeah, that's absolutely true. I mean, the overwhelming majority of people will experience distress around the time of diagnosis and it's completely normative and the overwhelming majority of them will have their distress levels decrease right back down to baseline can take weeks sometimes, but that's the general pattern. And so you're absolutely right. Do we need to call psychiatry? Do we need to call anybody, frankly?
Jordan Bawks: [00:14:03] And I imagine that that's one of the things that's on your mind when you're seeing people is to what degree is this sort of transient, expected healthy reaction and to what degree may this distress be, for lack of a better word, pathological or stock?
Dr. Elie Isenberg-Grzeda: [00:14:20] Yeah, exactly.
Jordan Bawks: [00:14:22] So maybe that's a good Segway to talk about the different areas to consider when interviewing somebody in a psycho oncology kind of setting the sort of unique aspects of the history. And just to be clear, if this is the first time that you're joining us or you're new to a psychiatry rotation, you probably want to go back to some of our earlier episodes on some of our basic diagnoses to to get familiar with the basic kind of aspects of a psychiatric history and a symptom screen. We've done episodes on the psychiatric interview. That would be a great place to start. So the areas that we're going to cover, I'm just going to quickly list them off. So we're going to talk about cancer history, beliefs about illness, physical symptom, burden, body image and sexual identity. Coping /mental health. Family and supports work and life disruption, disclosure of illness, religion, spirituality and death and dying. And in our show notes, I'll try and earmark the times that we are touching on each of these unique areas. But for now we can just go into them one at a time and spend a couple of minutes on each. And what are the kinds of questions you ask about and why they're important to you? So starting with cancer history, what are your typical openers? What are you really trying to find out?
Dr. Elie Isenberg-Grzeda: [00:15:49] Yeah, so cancer history and this is an interesting one because this is basically also very generalisable to other areas of these kind of like medical surgical areas that overlap with psychiatry. We want to have a good understanding of what the medical situation is, plain and simple. And what's interesting about this is sometimes when I'm reviewing a case with a resident, we could be sort of well into the history before I actually hear about what type of cancer the patient has, why they're in hospital, what sort of cancer treatments they're receiving currently and. You know, of course, when we think about a psycho oncology consultation, when we think about it, psycho oncology assessment, the cancer piece is really front and centre. You sort of can't extricate that from the sort of overall situation. And so usually that's the sort of thing that we'll want to find out about basically right away what type of cancer the patient actually has. Many most patients have one type of cancer. Some people have the unfortunate reality of having two completely unrelated. So the type of cancer they have when they were diagnosed, what sort of treatments they've received, treatments come like a variety of different shapes and sizes and flavours, and there's chemotherapy, radiation surgery. And nowadays you hear people talk about targeted therapies and essentially having a good understanding of what treatments the patient has had, what those treatments have been like for them. Some of these are extremely onerous, some of them are painful.
Jordan Bawks: [00:17:38] And what the treatments mean is also sometimes interesting to to get a sense of as well, like is this something that people are understanding is going to cure them? Is it something that they're understanding is to improve their quality of life and or whether they even know that at all? Like I encountered patients who like, yeah, they don't know. And that's distressing in itself. And I guess kind of like what you're saying is that the cancer history is almost like the skeleton by which we drape everything on. And I often that's advice that I give to junior residents when I often try to keep in mind as well when I'm interviewing any patient is to get if you can try and get a clear sense of what's been going on in someone's life and the most stressful thing that's been going on in someone's life, then it gives you an opportunity to both really understand that person and create timelines for things. So when you're hearing about something like Low Mood, it's like, well, in a setting of psycho oncology, did you know, was the low mood there before? You know, right at the beginning, Is it thereafter? Was it thereafter the chemo? Was it there after the surgery? Was it, you know, and by having those different time points, that gives you that kind of structure to jump around?
Dr. Elie Isenberg-Grzeda: [00:18:58] Yeah, totally.
Jordan Bawks: [00:18:59] Do you have like do you have a typical go to line? Is there any magic to this? Or like, how do you usually open this up?
Dr. Elie Isenberg-Grzeda: [00:19:06] Well, so in reality, just by nature, by virtue of of the work that I do here as a consultant at the cancer centre, I always have access to the patient's chart. I've already seen the diagnosis. I have some sense of that kind of skeleton framework. I will usually tell the patient that, you know, that I received the referral from Doctor So-and-so and that I have some understanding of their cancer, their cancer journey thus far, and that I've read through the chart and I've read through their paperwork that they've done for me and but that I want to hear in their own words what the cancer journey has been like for them up until this point. If that's too vague, sometimes I'll ask people. So take me back to when you were diagnosed, and I can definitely say my experience. I don't even have to say diagnosed with cancer, Right? If you say to somebody, take you back to when you were diagnosed in this type of setting in the psycho oncology world, they they know what you're talking about.
Jordan Bawks: [00:20:10] Our next area here is beliefs about illness.
Dr. Elie Isenberg-Grzeda: [00:20:15] Yeah. So when we were talking about beliefs about illness, I mean, you know, this can sort of go two ways. Some people interpret this as illness understanding, which I think you were alluding to before. You're talking about does the patient know whether or not the treatments are curative, intent or not? And so there's an illness understanding or an understanding of treatments that are being offered sort of illness, understanding or awareness or health literacy. It kind of all lumps together. But I think what we're getting at more with this idea of beliefs of illness are how does somebody actually think they got cancer? And ultimately. I won't say always, but maybe almost always people have some sense, some belief. Sometimes it's completely rational. Sometimes they'll even tell you, I know this is irrational, but. But everybody, or almost everybody has some. Belief about where or how or why they got cancer. In my experience, it's often not rooted in scientific evidence. Many people are are well aware of that and they'll say, I know this sounds like garbage, and everybody tells me this isn't even possible, but I know it's because of that trip we took that time and and there was that that sort of like chemical smell in the hotel room. And and I know it had something to do with.
Jordan Bawks: [00:21:43] And why why do you find that important to hear about or know about?
Dr. Elie Isenberg-Grzeda: [00:21:48] Well, so sometimes it gives a sense of who the patient actually is, kind of what their own just sort of background is, what their relationship is with science, what their relationship is with their doctors or their treatment team, the extent to which they might require some. Myth busting, the extent to which they may or may not even be open to myth busting. And for some people and I tend to see this more. With people who have a real. Sense of control. Sometimes delusionally. So. A sense of control in their lives in the world and how things work. That consequences follow actions. Those types of folks that that sometimes there can be a sense of guilt that goes along with it. I know this. This has to do with that year that I had in that, like that really stressful job. Had it not been for that, then I wouldn't have. And so sometimes that can also be an area of of focus. Something worth exploring to see if you can try to help alleviate the person of that guilt, or at least of the distress that comes with it.
Jordan Bawks: [00:23:06] Yeah, that I know you've we've talked about this in other kinds of settings when you've given this talk. It also follows with a kind of moralistic like Western attitude that we kind of grow up with. Good things happen to good people, bad things happen to bad people. So if I have a bad disease, it must be because I was a bad person. Yeah. And I've seen people really grapple with that, either believing that they were a bad person or trying to understand it, sort of like people with strong, certain spiritual faiths. I don't understand how this could have happened to me in this with the beliefs that I have.
Dr. Elie Isenberg-Grzeda: [00:23:50] Yeah, that's exactly right.
Jordan Bawks: [00:23:52] Moving on into physical symptom burden. You know, it's funny. This is actually one that overlaps also with some of our depression and anxiety screening symptoms. So this is always a tricky one. I've found and I've had junior residents or medical students sort of ask like, I don't even know why I'm asking about their energy. Like, of course they're fatigued, they have cancer. Like, of course they're nauseous, they're getting chemo. But at the same time, it's important to know, like just because we can't know the validity of the sort of symptom for depressive diagnosis may be in question. Does it mean that we still not important to know about what the kind of symptoms that that person is living with and to what degree they're bothered by those things?
Dr. Elie Isenberg-Grzeda: [00:24:38] Yeah, exactly. So all of that is an extremely important reason to ask. I mean, these are all important reasons to ask and might get information that, like you said, will really help you understand the person and understand their experience. Another reason to ask these questions is because not everybody actually gets optimal symptom management, and we happen to be extremely lucky at this hospital. I think my colleagues in palliative care and parenthetically the palliative care docs are really the ones who who treat people's symptoms. They're really the experts in symptom management here and elsewhere. But at this hospital, they're really excellent. And and I think the oncologists are also really good at picking up on people's physical symptoms and knowing when to refer. But even with that, not everybody has optimal symptom management, not everybody who's been seen by the symptom management experts when they need to. And sometimes even in psychiatry and psycho oncology, we might be picking up on something that nobody's really asked about yet. And it's not that uncommon that I actually end up making a referral to palliative care.
Jordan Bawks: [00:25:59] Because you're picking up on pain or nausea or something like that. And that's something we can do something about, right? Pretty quickly, Yeah. Next up, we have the area of body image and sexual identity.
Dr. Elie Isenberg-Grzeda: [00:26:15] Yeah. So these areas are are really huge in the in cancer care and the cancer world and. I mean, let's face it, human beings are sexual beings and we all have body image. You know, these sort of internal representations of what our bodies are like and how they appear and how we feel sort of in our bodies. Sexual health is like a really big part of that, and sexual identity is a really big part of that as well. And so breast cancer, prostate cancer, colorectal cancers, right. Are three certainly on top five most prevalent cancers, maybe even top four lung is in there somewhere. Right. So breast, prostate, colorectal, these are cancer areas that really cause huge, huge impact on people's identity, on their sort of integrity of their of their body and in a way that really affects sexual organ, sexual functioning as well. We also happen to live in a world or in a society at least that sometimes a little sexually averse and stigmatising. And people don't always ask their doctors and they don't always share symptoms that they're experiencing. The oncologists don't always ask their patients. And so sometimes what happens when people are experiencing sexual sort of body image or issues related to sexual identity or sexual functioning during or following cancer is that they can, a, be experiencing these really unpleasant symptoms or experiences and then be actually kind of left with it alone in a very isolating, unnecessarily isolating way. And so issues related to body image, identity, sexual health, sexual functioning are critical. They're like a core part of the human experience. They're a part of the experience of cancer care. And so we really need to. Be better about, you know, asking.
Jordan Bawks: [00:28:32] Yeah. Leaning into those kind of questions because I think it is, you know, people are it's already hard to open up to somebody that you've never met before who's kind of a stranger to you. And so to expect the majority of our patients to volunteer that kind of like aspect of their lives that's often so private, it's unlikely. I think it's a good reminder for us to that we should be the ones to open up these conversations and can play a role in kind of normalising these conversations and identifying these areas. At least just so someone else can hear about it and understand it and empathise with them. And they're pretty common experiences to.
Dr. Elie Isenberg-Grzeda: [00:29:18] Well, that's it. And so not feel so alone. And patients will often say that is they didn't realise that this happens to everybody or this is so common. Or one thing I would definitely suggest to to trainees is really just to practice asking, even if it means starting like just practising in front of the mirror or, you know, in like a study group kind of thing, throwing around different questions, different ways of asking and literally getting comfortable with the words coming out of your mouth. Mm hmm. I mean, the last thing the last thing a patient wants is for their doctor to ask a really important question in the most awkward sounding way.
Jordan Bawks: [00:30:02] Do you have any problems with, you know, that thing that people sometimes do? Yeah. Yeah.
Dr. Elie Isenberg-Grzeda: [00:30:10] So don't do that. Yeah.
Jordan Bawks: [00:30:12] Yeah.
Dr. Elie Isenberg-Grzeda: [00:30:13] I'll usually actually start off just by asking about intimacy, you know, And I'll sort of normalise by saying that, like cancer and maybe certain cancers have a way of really, you know, negatively impacting on people's intimacy and, you know, has that been an issue for you? And, and usually people know what we're getting at with that. Sometimes they don't. And then I'll make it a bit more explicit and literally just use the words sexual functioning. Mm hmm. You know, might ask about intercourse and penetrative sex and and sort of the list goes on and on. But ultimately, what I'm trying to do is sort of start by something that's maybe less stigmatising, that's normalising for people, and eventually sort of building up to questions that that might feel a little bit more uncomfortable, but that are important nonetheless. Mm hmm.
Jordan Bawks: [00:31:05] And this I'm just going following along in your slides and was cued to something sexual intimacy versus relationship intimacy. And I believe we had a talk this year by a couples therapist that you had brought in, and she was sort of mentioning that for many couples, they sort of rely on their sexual intimacy as a way of sort of being close and supportive in the relationship and getting through rocky patches. And when that is vulnerable or disrupted because of a treatment, then you don't have that thing to go to and rely on to stabilise the relationship. It's important to find other ways to navigate around that. So this is something that kind of is, for lack of a better word, intimately related to attachment and relationships and social functioning between partners.
Dr. Elie Isenberg-Grzeda: [00:32:03] So yeah, and you know. We could sort of talk about this issue at length. But, you know, suffice it to say that that even when sexual intimacy takes a real hit because of cancer or cancer treatments or anything in between, there is still a degree of physical intimacy that isn't. You know, truly sexual, something like hand-holding, hand-holding or cuddling or a sort of physical closeness with one's partner that. You know, I often hear patients say seems to get something about the hand-holding, feels stronger, more loving, more tender, special or different than it did before. And so there is a. Really an ability to actually kind of further grow one's intimacy in a in a couple, even if true sexual functioning is impaired or sort of sexual closeness is kind of prohibitive, that there's still a way to to actually really kind of build upon and improve physical intimacy and closeness among partners.
Jordan Bawks: [00:33:34] Mm hmm. And that's also another opportunity for a pretty early work. Like, that's not something that requires weeks and weeks of intensive psychotherapy, right? Like, that's stuff like basic psychoeducation and encouragement, normalisation that you can make an impact on. Yeah, on a pretty short basis. This is another good general area of assessment asking about coping.
Dr. Elie Isenberg-Grzeda: [00:33:59] This is where we try to get a sense of how somebody is actually managing. And usually what I'll do is I'll ask sort of up until this point, what I would have been asking about was about the illness, about aspects of function or dysfunction that have come from the illness. So sexual functioning, for example. But now what we're doing is we're talking about coping and adjustment and how somebody is actually managing with the diagnosis or the treatments and the sort of emotional distress that that comes with it. And I usually yeah, I usually just ask in a very kind of open ended way and almost always that's enough to sort of spark enough conversation around these issues that, you know, that I can get a good sense of how somebody is coping. We can then sort of whittle it down all the way through the most kind of checklist we review of systems if if needed, but we often don't really need to to get there.
Jordan Bawks: [00:35:04] Mm hmm. And when you say open ended, you're not I take it you're not sort of saying, how are you coping with that? You're rather than that you're saying how are you coping with your symptoms? How are you coping with your sexual functioning? How are you coping with that diagnosis? So it's tying it to those kinds of concrete things that the person's already told you that they're struggling with.
Dr. Elie Isenberg-Grzeda: [00:35:26] Exactly. So relating it back to what they've told me exactly. You know, in the cancer world, generally, if I had to go for kind of one thing and one thing alone, what I would ask is how are they coping with the diagnosis? Yeah, that's usually just in my experience, sort of where where the money's at.
Jordan Bawks: [00:35:43] Yeah, I find this question. You know, it's funny because, you know, we reference this as like a bread and butter thing we could do in our sleep as psychiatry trainees. And, you know, this is, this isn't actually something that I felt like I was good at until recently, like how useful this question is. You know, you can kind of use it to try and get symptoms like or are people withdrawing or are they not eating or are they? But I find this really helpful to to also look at people's kind of attachment styles, like, you know, is this the kind of person that's going to be talking to their partner like late into the night about this or just the kind of person who's going to pretend like nothing's happening? Is this the kind of person who is going to be looking up on the Internet like over and over and over? Are they going to be going to reach for natural health products or supplements or really, are they trying to rigidly control their diet or their medications? I find these kind of coping questions to be like really rich from a formula, like a formulation kind of perspective, just even in the way people kind of answer them sometimes. Like, what do you mean, coping? Like.
Dr. Elie Isenberg-Grzeda: [00:36:51] Yeah, no, totally. These are like really, really like high yield questions and whether we think long attachment lines or personality inventory lines. I mean, either way, this question and the way people approach illness coping style really tells us a lot about who they are and actually about how they're going to manage moving forward as well.
Jordan Bawks: [00:37:15] Yeah, Yeah. And then how we can adapt ourselves to perhaps like kind of meet them where they're at. Right. But like when you see kind of a particular coping style, you might want to adapt. Like if this is someone who kind of downplays their distress a little bit, then you're going to want to maximise their sort of sense of autonomy in this process and not go to too quickly for the emotions. And the other thing I find coping really helpful for is to normalise stigmatised areas like areas of coping, like people cope through being angry, they cope through drinking, they cope through withdrawing and avoiding and some of those things can be shameful. And so I find sometimes the coping language as a helpful way to get into that. You know, it's this sounds so hard. I am I, I imagine that you must get really desperate to deal with these kinds of feelings. And no wonder you've been drinking more.
Dr. Elie Isenberg-Grzeda: [00:38:20] Mm hmm.
Jordan Bawks: [00:38:20] No wonder you've been getting so angry. No wonder you've been pulling away from your friends. It takes away the shame. If we can connect that behaviour to their underlying pain or distress.
Dr. Elie Isenberg-Grzeda: [00:38:31] Yeah, totally.
Jordan Bawks: [00:38:32] So the next couple of sections, you may most naturally fit into a personal history asking about. So the first one is asking about family and supports.
Dr. Elie Isenberg-Grzeda: [00:38:45] Yeah. So family and supports are always important, but they are particularly important I think in psycho oncology when people are often. Been getting treatments that they. Almost just can't do without some sort of support in their life. You know, a lot of radiation treatments require five or six weeks of coming to the hospital every day for 30 or 35 treatments in a row. Even if you can actually make it to the hospital on your own, like who's at home taking care of the kids and. Right. And often people can't make it to the hospital on their own. They really do need help. So it's not to say that people are doomed if they have no family or other supports, but it really makes things more challenging for them. And so having a good understanding of who this person's family is, if we're going to support people, where do we add kind of that extra cushioning, that extra padding?
Jordan Bawks: [00:39:53] So how do you usually phrase questions like who? Who are your supports or who's supporting you through your cancer? Who's in your life? Yeah.
Dr. Elie Isenberg-Grzeda: [00:40:02] So sometimes I'll, I'll say, yeah, any of those I mean often I'll ask people, I'll say, who do you have in your life to help support you through times like these? Usually once they've identified people that that they see as supports, I'll kind of ask them, you know, in what ways these people help. So what is the actual support that they give? You know, is this somebody who drives you to appointments? Is it somebody that you can call to vent to if needed? You know, is it somebody who will keep their phone on and let you call them if they if you get a fever and have to come into hospital? Is it you know, this also gives people the opportunity to talk about family members that might actually create more stress or distress in their lives that, for better or for worse, are very much part of their families. And as far as kind of doing an inventory of what the current context is, it's still really helpful to know who are the players in somebody's life that might sort of add to the stress rather than help alleviate some of that. Mm hmm. So it's really getting an inventory, I would say, of who's around, who's around and what they're capable of.
Jordan Bawks: [00:41:15] Yeah, it reminds me a little bit of interpersonal therapy, the sort of interpersonal inventory where you're like, who is the closest? Who is. Who do you talk to when things are really bad? Like, who can you go to? Yeah. What are the people that you've told and maybe bring in meals or babysit or, you know, and this also, I think this is an area that also lends naturally to a big topic that I have found really interesting and challenging and working with this population around disclosure. So who knows exactly and why if people don't know, why not? And what's that like? And that's a very intense area for some people.
Dr. Elie Isenberg-Grzeda: [00:42:03] Yeah, So that's a really, really good way to put it. It's intense. And, you know, the idea of disclosing the illness, who have you told and what have you told them is such a critical one? When when we work with folks going through this type of thing, because, number one, by not telling. Right, by not always disclosing, it's basically the equivalent of really having to keep a secret of putting pieces in place so that nobody spills the beans, so to speak. And that's incredibly stressful for people. On the other hand, if one is to disclose to their friends, their family, their kids, their parents, whomever, that's equally stressful. And so I think no matter how you slice it, there's this is a it's a very intense kind of stress laden topic that in most cases that I've been involved with tends to need some handholding, some support, some guidance, some education. It's not rocket science. I mean, essentially what we want to do is we want to be as open and transparent as possible, certainly with the people who are closest to us, people who will otherwise know and find out. You know, I think a big piece of this conversation involves what do we tell kids? Mm hmm. And so in a hospital like this, we don't it's an adult hospital. We don't treat kids here, but we treat a heck of a lot of patients who have their own kids and who often present with a lot of stress around this very topic of do I tell my kids and and what do I tell them? And the general rule is openness, transparency, honesty.
Dr. Elie Isenberg-Grzeda: [00:43:57] Better to explain to them now why you're telling them something then? To have to explain to them later why you didn't tell them. And that includes using adult language, even for young kids. You know, a lot of parents want to protect their kids. All well-meaning parents want to protect their kids. And sometimes parents have a misunderstanding of of how best to protect them. And so they think by kind of hiding information from them or not telling them or sort of sparing them until they really have to know. And, you know, usually comes from the way they were taught implicitly or explicitly and how to deal with these situations. But invariably, what ends up happening is kids will find out from maybe an oldest sibling or a cousin or an aunt or opening the mail. We're seeing an email or picking up a phone call or sometimes from the backseat when mom or dad drives the other parent to the cancer centre. And if a kid is old enough to read, they can read the sign that says Cancer Centre.
Jordan Bawks: [00:45:13] And also that kids are exquisitely sent. I mean kids are wired to. Breed their parents. Most cancers. Cancer treatments are going to have a visible impact. It doesn't matter how hard we try. You know, there's like infant literature that, you know, pre-verbal kids can pick up on moms who have been experimentally stressed or not stressed before they walk into a room. So that's you know, that's the kind of language I sometimes use, is, you know, how do you know that they know something's going on, Right? And so bringing bringing your children into that. To me. I know it's a sign of kind of respect, transparency, of collaboration, of openness, because kids have really active imaginations.
Dr. Elie Isenberg-Grzeda: [00:46:09] Yeah. I mean, so at the end of the day, really what we know is that kids just do better when the parents are open with them. And I think it's for exactly the reason that you're alluding to is that kids have. Incredibly wild and creative imaginations. Even when they know that a parent has cancer, there's a way for them to imagine or fear that the cancer is worse than it is. Even if a parent's dying, there's a way for a kid to imagine that it's worse than it is. Maybe they're dying in pain, maybe they're dying and there's an afterlife and something bad is going to happen to them after. Or maybe they're dying and the kid is. And I'm next. Yeah, exactly. Yeah. So openness.
Jordan Bawks: [00:46:54] And that's that. Ever since I learned this, it's really stuck with me is like the language as well is so important, right? To say like mommy or daddy is sick, like really loads sickness for someone who doesn't really understand it. All of a sudden, you know, the same word you're using for someone with the sniffles is the same word that's related to this horrible thing that you're witnessing that's stealing your parent from you. And so that the use of that language is so important to create a different category that allows the child to still be sick, just to interact with others who are sick and know that it's a different thing. Yeah, and there's an evidence base for this, right?
Dr. Elie Isenberg-Grzeda: [00:47:38] Certainly there's a lot of literature out there, including different sort of age categories and kind of developmentally, typically at a given age category, what kids are able to comprehend and sort of what language to use with them. And usually as a general rule, from about the age of five onwards, we'd recommend just open, honest adult language, not euphemisms like sick or booboo.
Jordan Bawks: [00:48:05] Or yeah, it's important for me to keep in mind when I, you know, sometimes I'll hear this and or I'll be thinking about this and think, okay, well, the right thing to do is for them to disclose. And I always have to be careful to hold that as well, because people go they go through their own process at their own pace. And, you know, obviously, if somebody hasn't told their child, they're doing that with the best of intentions. And if you're going to be able to work with somebody, they need to be able to know that you respect them, where they're. At Where they're coming from, and not to be judgemental about what they're doing or not doing or saying or not saying.
Dr. Elie Isenberg-Grzeda: [00:48:38] So that's a really excellent point, is that so I will always praise a parent and reflect to the parent that they are trying their best to be a good parent and I'll usually ask them if they're interested in hearing what the experts say. And I tell them, Look, I'm not a child psychologist, I'm really not. But, you know, certainly I have lots of patients and I've studied this. And and there is a sort of commonly accepted sort of best approach. Are they interested in. Hearing what that is and sort of the aspects of what they've done already that that are really in line with that. Do they want to wait for another time or is this a conversation they don't want to have at all? Like, you know, really trying to to respect where they're at rather.
Jordan Bawks: [00:49:27] Than just sort of dropping your exclusive knowledge? Well, you know, what's best is Yeah, yeah, yeah. Meeting people where they're at. So important in our field, the next area is work and life disruption.
Dr. Elie Isenberg-Grzeda: [00:49:43] Yeah. So this is also a big area. I mean, this comes up a lot during active cancer treatment. So somebody diagnosed and they go in for whether it's surgery, chemo or radiation and and their bodies recovering and there's a period of time. Maybe a month, maybe six months, maybe a year, depending on the type of treatments, the type of cancer, where they might just simply not be able to go to work either because they've too many appointments and they're coming in for treatments too often, or the treatments really make them feel quite sick with side effects or get rid of their energy and they just can't sort of peel themselves from from bed. And and so that's one big area. And the other big area is this idea of returning to work after the cancer has resolved. Right. So somebody is done with their cancer treatments. They're in a phase of the journey that we most people would probably call survivorship. And the question of when to return to work, will I be able to return to work? Am I going to have the mental Energy and capacity to to really do the job that I used to do. Am I going to feel as alert? Am I going to be able to multitask? Will people be able to rely on me the way that they used to? These are questions that that almost invariably people have at some point. They become stickier for certain people. There are some people where the question is sort of resonates more with them and they have trouble kind of shaking it and where the issue of returning to work becomes the focus of the treatment, it becomes the focus of the pathology, if you want to call it that, although that might be a strong loaded term, but certainly the focus of the treatment.
Jordan Bawks: [00:51:32] So this might be a big focus of distress for certain patients.
Dr. Elie Isenberg-Grzeda: [00:51:36] Yeah, so focus of distress and there are actual sort of treatment interventions, programs that that are geared towards helping people get back to work.
Jordan Bawks: [00:51:46] Well, I can't help but think of Freud's old saying right, that like, like his definition of mental health was to be able to work to love. So that's a fitting.
Dr. Elie Isenberg-Grzeda: [00:51:58] Yeah.
Jordan Bawks: [00:51:59] Then we're our last two kind of areas of assessment are ones that I think are somewhat unique to psycho oncology, or at least where you access the most kind of readily. One of them is the first one is religion and spirituality. How do you usually open this up in your assessments?
Dr. Elie Isenberg-Grzeda: [00:52:22] Yeah. So, I mean, as far as religion is concerned, usually I'll, I'll start by normalising and actually this is probably something I do for, you know, for, for everything that I ask about is I'll, I'll try to normalise it and so I'll say, you know, for some people religion is a way that kind of helps them get through tough times, including through illness and, and through cancer and. So what role does religion play in your life? Something like that. Usually that's a good opener to let me know if religion is something that is important and the extent to which, you know, plays a role in the patient's life. Many people cope through tough times in life by drawing support from their religion, whether it's the people that they interface with. So, you know, parishioners or congregants, people in their religious community, or whether it's drawing on support from God, whatever God means to them. And for people who do do that, for people for whom religion does play that role, it is a big enough role that we'd be missing an aspect of who this person is if we don't ask about it. And so I'll be the first person to admit that sometimes even that question can kind of turn people off a little bit. There are people who are very anti religion and who are sort of, you know, turned off or at least quickly dismissive of that word and sort of all the connotations that it brings up for them.
Dr. Elie Isenberg-Grzeda: [00:54:11] But again, in normalising it, usually even those people understand kind of where the question comes from, why we're asking about it. And I think appreciate the opportunity to appreciate the fact that we're sort of thinking about people as whole people. And so religion and spirituality, I mean, first of all, you'll find tons of different definitions on these. But the definitions that I tend to subscribe to are the following is that religion essentially is the stuff of divinity. Right. There's usually we're talking about something that's related to God, that there's often an organised aspect to it. Spirituality. It deals with the the essence of something bigger and greater than us. Not necessarily God based, right? It's not necessarily in the realm of divinity, but it looks at and thinks about something bigger than us as individual human beings. And so there are people who many people who will say, well, I'm a very spiritual person, but I'm not religious. I don't subscribe to a certain religion, I don't have a God, but I'm a very spiritual person. I feel like there's something sort of bigger than than me. There's. The idea of purpose. And purposefulness. And that's often associated with religion and the idea of a purposeful world. So a sort of God driven or higher power driven world, that there was a purpose and intention, usually as a concept that. That people think about when they think about religion. And it was sort of God based religion.
Jordan Bawks: [00:56:23] And so I guess that kind of circles back to that earlier phenomenon I was referencing where people can sometimes sort of in if they have a belief structure in which there's a purpose to life and life's events, then they can be kind of sometimes put in a spin of what is the purpose of me having cancer?
Dr. Elie Isenberg-Grzeda: [00:56:42] Yeah, yeah, why did I get cancer? Or for the really religious folks, Why did God give me cancer? This is the true essence of the phrase. Why did this happen to me? Right. Has a real flavour of purposefulness, as though there was some reason that this happened, that it. That there's a purposefulness to me having cancer. So whether or not people realise it or rather not, people mean it in this way, there's, you know, those, those questions are the stuff of religion.
Jordan Bawks: [00:57:13] And I think this, you know, I've also encountered patients who have become more interested in spirituality and religion when faced with like a cancer diagnosis. People have said, you know, I never really thought about it until now. And my take on that is that it's related to our last area of assessment, which is around death and dying.
Dr. Elie Isenberg-Grzeda: [00:57:37] What cancer almost invariably does, as you've pointed out, is it really makes people think about death and dying and thinks makes people think about their own mortality and love it or hate it. We are mortal beings, right? We are animals, and we are doomed to suffer the same fate as all animals, which is that we are going to die, all of us at some point, and human beings. You know, the sort of cruel irony is that we have the the the cognitive capacity to really understand our own awareness, right? To have an awareness of our own existence, the fact that we're alive now, that we won't always be so we have this cognitive capacity, but in the bodies of animals, right, the same animals that will end up dying if we get hit by a car, if we get cancer, if our heart stop at the ripe old age of whatever, if we get the wrong infection. Right. So we we are animal species that happen to have this really complex, high level brain functioning that allows us to be aware of our own existence. So there is a sort of almost cruel irony joke to it. Death, of course, is inherently scary. It's a scary concept almost universally so. And as a society, we've done a really good job at trying to avoid death as much as possible. So it's no wonder that we have you know, we're we're a culture of heroes, basically have the, again, very understandable need to sort of to sort of dismiss death from the realm of possibilities until we can't. And so sometimes, whether it's, as you said, some sort of cardiac event or in this case, cancer. All right. Sometimes that's just enough to really trigger people's sense of their own mortality and gets people questioning sometimes things that they have never questioned before.
Jordan Bawks: [00:59:50] Before we move on to sort of distress as a diagnosis versus depression, how do you ask how do you ask your patients about this?
Dr. Elie Isenberg-Grzeda: [00:59:58] So when it comes to working with cancer patients, in my experience, almost always people have thought about death and dying. They've almost always asked their doctors, or at least thought about asking their doctors. And so it's usually not the first time. If I were to ask about it. It's not usually not the first time that somebody has thought about this. And so in some ways, it's not as high pressured of a question or high risk of a question. And so usually I'll just ask people point blank if this is the type of disease where they've had to start thinking about death and dying, or is the type of cancer where they've had to start thinking about death and dying. There are times when it's the answer is obvious, right? And if it's obvious enough, I might not ask that question. There may have been other questions that come up. Usually I'll ask people if they've thought about asking their oncologist about prognosis, because again, it's on many people's minds. And oncologists don't always have the skill set to talk about prognosis in the way that's most effective and most meaningful for patients.
Jordan Bawks: [01:01:22] What what would that look like, an effective and meaningful conversation?
Dr. Elie Isenberg-Grzeda: [01:01:25] Yeah. So, you know, generally speaking, what patients what we've what we've all learned to ask is how long do I have? Right. It's what we hear people say in movies and TV. And maybe we've heard parents say or it is how long do I have? It's probably the worst question for somebody to ask, because essentially what that implies is that you have to have a crystal ball and that doesn't exist. And so it's sort of a meaningless question that can only get a sort of meaningless. Unhelpful answer. And inasmuch as that's the case, generally speaking, all that's going to do is sort of push the oncologist into a corner and they're going to usually say, well, you know, I can't answer that. You know, I can't answer that crystal ball. And so maybe, you know, when the time comes, I'll let you know. Don't worry. I'll let you know when we start talking about that. And so what's much more effective than that is, is actually asking what a best case scenario looks like and what a worst case scenario looks like. And, you know, with generally speaking, the oncologist should be able to quote sort of a median. Right. So 50% of people will be alive at this point. Let's call it ten years. And based on that, there are some calculations that they can do to essentially capture probably 95% of people kind of under what looks maybe like a bell curve.
Dr. Elie Isenberg-Grzeda: [01:02:54] And to the right, there are some patients who will be these miracle cases, and maybe to the left, there will be some unfortunate people who died because they got hit by a car or for whatever reason, that was just completely unanticipated. But most people will fall between these two. Best case and worst case scenario. And there's the likeliest scenario as well, which is going to be something hovering around the median. But the reason patients find this this information more meaningful is because it allows them to have something to hope for. That's realistic if they're hopeful people and it also allows them to prepare for the worst if needed. And at the end of the day, knowing that knowing that we don't have crystal balls and that we only live in a world with as good information as the information that we've got, then what people really want is they want to be able to retain hope for something and also to prepare for worst case scenario so that they know that they're as ready as they can be. And then my job becomes or any of our jobs becomes about figuring out, well, how do we help support somebody? How do we help get them as ready as they need to be if that were to happen? And so ultimately, as far as kind of meaningful, applicable, useful information is concerned, that's generally speaking, what patients will find to be most useful. Yeah.
Jordan Bawks: [01:04:22] And so you can also even kind of guide them in that process if they're not.
Dr. Elie Isenberg-Grzeda: [01:04:26] Sure that's exactly it. And that's usually what I'll do is I'll tell them if they haven't yet had the conversations about prognosis or or if they haven't been satisfying and kind of gotten them the information that they're looking for, go back to your oncologist and ask it in this way. Best case scenario. Worst case scenario, Likeliest scenario. And then what do we have to do to get me ready for the worst case scenario?
Jordan Bawks: [01:04:50] Yeah. Yeah. We've we've talked about a lot of different aspects of the assessment when we interview patients with a cancer history. How does all of this trickle down into questions of diagnosis? How do you synthesise a diagnosis? What's the use of the diagnosis? What are the relative pros and cons to having one, not having one?
Dr. Elie Isenberg-Grzeda: [01:05:16] Yeah. And so you're talking about a DSM diagnosis. And so I think the overwhelming majority of patients that we end up seeing, if we were to sort of map their symptoms onto a diagnosis, it would be adjustment disorder, right? I mean, that's going to be the probably the most common and understandably so. There's a small percentage of people who will have a pre-existing psychiatric diagnosis, and in some cases the cancer then becomes something that might tip them over the edge, might mitigate their sustained remission, and or it might be something that seems almost inconsequential that the stress and trauma and burden of the psychiatric diagnoses that they've had throughout their lives just kind of dwarfs the cancer diagnosis. But generally speaking, it's actually that's kind of a small slice of the pie. What we tend to see a lot more is people who come in with what almost seems like normative distress. And it's a word that really, over the last maybe 20 years or so, has been a real push to try to use that term distress rather than the more pathologizing DSM diagnoses actually is a way of trying to get more people, more help. There was a thought that perhaps if we use diagnoses, if we say you're suffering from major depressive disorder and there's something more stigmatising about it, people might be less likely to to look for help, oncologists might be less likely to to sort of buy into that. And so distress was also kind of this user friendly word.
Dr. Elie Isenberg-Grzeda: [01:06:59] But I think it also is a really great word to use. And as much as it sort of sums up the experience, I think for a lot of people, which is that there's this unpleasant emotional experience that they're that they're experiencing that can be mapped on to either psychiatric symptoms, physical symptoms, concrete kind of social, practical concerns, existential or religious concerns. And thinking about it that way then allows us to formulate and to then come up with a treatment plan that sure might include antidepressants or but it might actually be more tailored to some of the sources or foci of distress that the person's experiencing. And so, for example, if the emotional distress, psychological distress that they're experiencing is because they don't have any close family members to help take care of them as they're recovering from chemotherapy and well, So then the answer isn't going to be antidepressants. It's going to be maybe trying to see if we can hook them up with some home visiting nurse services, if their distress is about the finances, financial burden that they're going to have to incur by coming for radiation every day over the course of six weeks and the cost of parking that they have to pay and the fact that they're going to be missing work while they're coming here. Then again, antidepressants might not be the answer. The answer might be. And helping them with whatever sort of resources are out there to allow for compassionate, you know, funding finances.
Jordan Bawks: [01:08:43] So I guess that ties back to these kind of specific areas that we're including in our histories is, you know, we're seeing people with a high degree of distress. And that distress may be in areas that we're not always tuned to as psychiatrists. Like I can imagine, you know, seeing somebody in doing an Capps depression screen and a gad screen and a panic disorder screen and a bipolar screen and a psychosis screen, and, you know, you could do a 45 minute assessment and miss like so much like you miss the core areas of distress. And, you know, maybe that person doesn't meet criteria for DSM five diagnoses, but that doesn't mean they're not in distress. And also that by doing a good history that covers these kinds of areas, we find places to intervene with them.
Dr. Elie Isenberg-Grzeda: [01:09:35] Yeah, and that's really what we want to always, right, is, is the whole purpose of formulating period is to know how to actually have that effect. Are management or.
Jordan Bawks: [01:09:45] Are you sure that it was just to impress supervisors.
Dr. Elie Isenberg-Grzeda: [01:09:48] Well, there's that too. Yeah.
Jordan Bawks: [01:09:52] So, you know, this is such a huge area and I hope that we can come back and talk about it more. I think one of the things that I'd like to be able to revisit is treatment. You know, like, how do we take all this information and how do we make decisions about medications? And I know that there are some kind of relatively unique medication decisions and in psycho oncology and also some unique psychotherapies. Absolutely, psycho oncology. So I do hope that we take the time to come back and take a look at those.
Dr. Elie Isenberg-Grzeda: [01:10:29] Yeah, I'd love that.
Jordan Bawks: [01:10:30] All right. Super. Any closing thoughts or comments? One of the things I'm actually wondering is you want to make an argument for why psychiatrists should do some training in this area. Like what? Why this has been meaningful to you? Why you think it's helpful for the general psychiatrists?
Dr. Elie Isenberg-Grzeda: [01:10:53] Yeah. I mean, so so it's an interesting point about the training, because on the one hand, we can say that, you know, the recent stats about what do they say one in two people will end up getting cancer at some point in their lifetime. And I mean, this is like huge. And so you can argue that, well, every psychiatrist should be trained in how to do this. On the other hand, you could also say, well, this is becoming so common that psycho oncology won't even really need to be a thing, meaning it's own subspecialty area, because frankly, cancer is just going to be so darn common. Personally, I think that this is one of the most, again, enriching, stimulating areas that I could ever imagine working in. You really. Connect with people in a way that, you know, that really kind of enhances the human experience. Like my human experience. What people want at the end of the day is to feel understood, to feel like they matter. Sickness and illness really get in the way of that. And, you know, I think the work that we do in psycho oncology is on the one hand so skilled and sub specialised and niche in so many ways. But on the other hand is also just plain, plain old good work, just connecting with people in a human way, trying to understand their experience, helping them understand ways in which they do matter. And you know, there's never a day that goes by that I'm not stimulated. It's, I think, just part of what happens when you work in this in this type of setting.
Dr. Elie Isenberg-Grzeda: [01:12:41] And, you know, we work with patients and their families, we work with the oncologists. It's just really there's so much breadth to it. I think the one very sort of kind of expert you almost just can't really get good at if you're not trained is the existential piece. And it could be that if we do connect again and talk about treatments and and all that, maybe we'll take a look at that as well, is, you know, understanding people in the human experience and the type of existential distress that people can experience when they're faced with something like this, like cancer, knowing what to ask, how to ask it, how to address it, and how to sort of help re ground people when they're so they're in such existential crisis, I think is a very kind of skilled process without being trained in it. You really just can't do it all that well, all that skilfully. So that would be one my one pitch in terms of whether everybody should be trained in this or not, I'd say everybody should be trained in that. And I think that is part of the work that is also then generalisable to other areas of of psychiatry, other areas of consultation liaison psychiatry, other areas of medicine in general. And it's rich. It's really like one of my favourite parts of my day is when I'm doing that type of existential work.
Jordan Bawks: [01:14:08] Well, I, I hope we do find the time to do that and trust that we will. I'll be around Stony Brook for another six months, even though I'm leaving the service. Try and come back and do more of that.
Dr. Elie Isenberg-Grzeda: [01:14:20] You're going to be missed.
Jordan Bawks: [01:14:21] Yeah, I'll miss you guys too, but I'll see you around. And now our voices will live forever in the internet.
Dr. Elie Isenberg-Grzeda: [01:14:28] Awesome.
Jordan Bawks: [01:14:30] So thanks so much for giving me your time this afternoon.
Dr. Elie Isenberg-Grzeda: [01:14:33] Yeah, you're very welcome.
Jordan Bawks: [01:14:35] Look forward to hopefully having you back.
Dr. Elie Isenberg-Grzeda: [01:14:37] Great. Thanks, Jordan.
Jordan Bawks: [01:14:38] You're welcome.
Jordan Bawks: [01:14:41] PsychEd is a resident driven initiative led by residents at the University of Toronto. We're affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced, hosted and edited by Jordan Bawks. He therefore takes credit for any and all imperfections and errors. Our theme song is Working Solutions by all Means. Special thanks to the generous Dr. Elie Isenberg-Grzeda for serving as our expert for this episode. You can contact us at PsychedPodcast@gmail.com or visit us at PsychedPodcast.org Thank you so much for listening. Catch you next time.