Synapse at Cal
Connecting the Healthcare Community
Synapse is a collaborative, open platform where individuals of Cal’s pre-med community can each contribute their conversations with leading healthcare professionals or share their unique experiences or ideas for others to learn from.
By reflecting on our own experiences as well as those of our peers and mentors, we can motivate, empower, and remind each other why dedicating our lives to medicine is so worthwhile.
Dr. Matthew State, MD, PhD
[Teddy Wang] What made you want to pursue and study psychiatry?
[Dr. State] I got interested in psychiatry for a couple of reasons. Very early in my clinical days as a medical student, a very close friend of mine suffered a psychotic break - it was bipolar disorder. It threw me into the world of psychiatry; I saw both what was incredibly interesting about it but also what was so challenging and how the system was so broken. I’d spent my life before that interested in politics and social issues, so psychiatry captured my interest in a range of things - that nexus between medicine and neuroscience, the personal experience. That’s how i started pursuing the idea of being a psychiatrist.
[Teddy Wang] Why did you decide to pursue a Political Science major instead of something in the sciences?
[Dr. State] Because I was interested in political science! I was not someone who thought i was going to be a scientist from when i was young; I was interested in a variety of things when i was younger. I was an undergraduate at Stanford and got involved early with an interdisciplinary group there working on nuclear arms control, which at the time was a really oppressing issue during the Reagan Administration with concerns about escalation of the Cold War with the Soviet Union. I fell into a group with all sorts of interesting folks who came in with all different perspectives - Bill Perry, who later became the Secretary of Defense, Condy Rice, and Chip Blacker who worked with several administrations. They were taking a multidisciplinary approach to a problem and that totally fascinated me. I spent most of my time as an undergraduate working on those issues and spent some time in Washington. I was pretty immersed in political science and can talk about how i made the shift. But bottom line is that it was kind of a different era then, and the idea where you just studied what you were interested in was pretty commonplace. There weren’t many people around me talking about what they were going to exactly do after undergraduate. It was more about what you were interested in.
[Teddy Wang] Could you talk about your transition?
[Dr. State] I was working in the senate staff in Washington at the time. There were a whole variety of things that made me re-think where i was headed. I loved it substantively, but when i thought about what my life was going to be like working in Washington, going to grad school in political science, or being a lawyer, there were certain things that I needed to rethink. I liked being actively involved in the broader social mission, but the idea of working on that by remaining in Washington as a staff member didn’t really suit my personality. I started thinking about how I could be involved in something professionally that I would enjoy day-to-day and while also being connected with trying to make the world a better place. It sounds cliche, but that was what i was interested in doing. My dad was a physician, and I started thinking about what his career was like. I started entertaining the idea that, by being a physician, you could do both. I liked the idea of seeing patients and working collaboratively to make things better, but I also wanted to work on something broader than patient care. At the time, I thought it might be social issues and healthcare policy. i had to go back to do the pre-med requirements and learn more about medicine and its day-to-day. But since I had grown up with it, I had a pretty good idea of what that life would be like. It was really an epiphany that showed me it was time to take a turn and head in another direction.
[Teddy Wang] Why did you decide to go into research, rather than focus on medical practice?
[Dr. State] Well, I do both. Now that I’m chair, I have much less time and still have a handful of patients. I initially went to medical school with very little science background. I didn’t study it in depth as an undergrad. I had most of my pre-med requirements, not even all of them, when I started medical school at Stanford. My interest, at least initially, was to learn how to be a clinician. I did my fellowship in child psychiatry, and that was all clinical training. It was really during that process that I had the additional realization that I wanted to go back and learn more science. I loved taking care of patients, but it was particularly frustrating in psychiatry with how little anyone knew about why these diseases were happening, what the underlying mechanisms were, how to treat them better. I decided that I didn’t have this background to delve into that, so I went back to school and got a PhD in genetics after my clinical training. I was 37 years old and started my PhD at Yale. I already knew that i wanted to be a clinician; what came later was realizing that I needed to be a scientist. People ask me how much time I spend in the lab. I spend 100% of the time in the lab and about 15-20% of time in the clinic. The lab was, particularly in the early parts of my career, completely encompassing but incredibly fascinating. At the same time, I ran a child medical service in a community clinic outside of New Haven for 17 years, so I’ve always had one foot in clinical care and one foot in research.
[Teddy Wang] How do you balance all of that out?
[Dr. State] Medicine is an incredible career in that it’s very diverse, both across specialties and within specialities. You can make career choices that balance your lifestyle in significantly different ways. That balance is easier in psychiatry than in many other fields, mainly because the practice moves so slowly. i could practice once every five days and feel like I’m up to date. I do my reading and stay on top of it, but we haven’t had a new medication with a different mechanism of action in six decades within our field. There are new brand names, combinations, and studies that show efficacy or not, but it’s not moving like many other fields where there are entirely new classes of treatment. Most psychiatry also doesn’t require a lot of technical precision and expertise. All of these things - both the pace and the technical requirements of the field - push on the amount of time you need to put in the clinic to be first rate.
My next door neighbor at Yale, who got into neurosurgery and is in the lab doing genetic research, is the one that you need to ask that question. How in the hell do you do that? But for psychiatry, it’s one of the reasons people like to go into psychiatry, because it has that dual interest and it is possible to have a balanced life, particularly for those who want to be researcher and active clinician.
[Teddy Wang] How has psychiatry changed and why is it so slow?
[Dr. State] Clinically, psychiatry moves very slowly. The research is light speed. Over the last few years, the lab has been completely overwhelming; we’re on the cutting edge of neuroscience. We’re making it much harder for people because now you have to understand both systems of neuroscience and genomics. It still hasn’t completely penetrated clinical practice but genetic testing is starting to be part of the world. For a long time, psychiatrists didn’t have to worry about that stuff. On the clinical side, it’s been slow. When you compare how we treat depression compared to how a cardiologist treats angina, we’re as good as they are when you look at the stats. But the medications we identified serendipitously in the 40’s and 50’s have fundamentally not changed since then. Whereas in cardiology, the understanding of cardiovascular physiology and why you get heart disease has advanced tremendously. Pretty much everyone would say the main reason why it’s moving so slowly is because it’s the hardest part in medicine. The brain is the least understood and most complex organ, so the things psychiatrists work on are the most complex and least understood. We work on behavior and emotion and social relatedness and salience. Those things are more ephemeral and more difficult to characterize than memory or motor function, which are what much of neurology is focused on. It’s extremely difficult to understand how to leverage tools from other areas of medicine, like model systems, to really understand psychiatric disorders. It’s not an obvious thing how you would model delusions or language development in a rodent model. One of the reasons why I’ve been interested in genetics is that it’s an avenue to do that; rather than relying on what something looks like, you can rely on the gene that causes the problem. The pharmaceutical industry has invested billions in trying to find new medicines. Largely over the past 5-10 years, they’ve been pulling out of psychiatry because the yield has been so low. What’s happening now is, we’ve had exponential advancement. So we went from a very long period of flat progress. In the last 5-10 years, the slope of the curve has changed dramatically, both in genomics and neuroscience, which are highly relevant for psychiatric disorders. In genetics, the last few years has been a bonanza of discovery in autism, schizophrenia. Today, our lab has a paper coming out about Tourette’s syndrome and at least lays out the path for successful discovery. For 20 years, I’ve been in the field, and for 15 of those, we’ve had a real struggle about how to find these genes. In the last few, we have the computational tools now to look at the genome and sequence it. At the same time, in neuroscience, there has been an explosion of tools in molecular biology and systems-level neuroscience, such as editing the genome. Faculty at your place (Berkeley) have led in being able to use that enormously powerful tool. Also, Stanford has developed approaches that will allow you to manipulate circuits in living, awake, and behaving animals. The Bay Area has been a hotbed for what’s been going on. Those kinds of tools combined with the knowledge of molecular underpinnings of serious psychiatric disorders will accelerate the field. It’s going to be a wild ride for the next few years, and I’m really excited to see how things begin to come together to change this equation so that we begin to move into the development of novel treatments into the clinic.
[Teddy Wang] What are some flaws in the healthcare system regarding psychiatry?
[Dr. State] Everything about psychiatry’s broken in the healthcare system. It really is. You’re lucky enough if none of your family members or close friends require serious psychiatric care. If you get sick and have reasonable insurance, you pick up the phone; in most cases, you’re either told what doctors you can or you just choose a doctor that accepts your insurance. In psychiatry just the ability to find someone who will care for you can be a real challenge. Much of the system of psychiatry in private practice outside of academic institutions exist outside of the insurance system - particularly in a city like San Francisco. A lot of it is cash pay because psychiatrists cannot afford to live on what insurance companies have decided they’re willing to pay for psychiatric services, so that’s pushed people outside of the system. Very simply, even if you have insurance, they’ll give you a list of 10 or 15 psychiatrists that you can call. We do the experiment every once in a while, and you’re lucky to find one who will be willing to take you, even though they’re all listed potentially as being available. So getting access to care is a big problem.
Second is that there’s unfortunately a general link between serious psychiatric illness and other social challenges. People have a tendency to have declines in income and standard of living if they’re seriously mentally ill, particularly as they move to adulthood. Society’s willingness and investment in taking care of those things has changed dramatically over the last 30 or 40 years. We took apart the system of care that put people who are more seriously ill in institution. The de-institutionalization would be great if there were other things that were provided to people to address the very serious challenges of mental illnesses. They say, “We don’t want people in the hospital, so we’re going to provide something else, like outpatient care.” The problem was that we took away the hospital for people with serious mental illness, and we did not provide for the outpatient care for those folks. What ended up happening was that the psychiatric system has ended up in the streets and in the jails.
The largest provider of healthcare in the United States is the criminal justice system; the largest clinic in the United States for psychiatric treatment is the Cook County Jail in Chicago. Can you imagine any other medical specialty saying that, when you look at what’s happening in San Francisco? About half of the current population of people on the streets have a drug abuse or psychiatric problem, and when you look at those who chronically homeless who are most in need and present the most serious challenges to the city, the majority of those folks have a psychiatric illness. People with serious psychiatric illness die on average two decades before they should. Honestly, we don’t know why there’s an absence of appropriate care for the psychiatric illness and the socioeconomic issues, both of which are clearly having an impact. This has been an area in which society has turned its back on people who are really seriously ill. There’s still a tremendous amount of stigma.
We live in San Francisco where people are supposed to be very forward-thinking here. We say that it’s okay to have a mental illness, but it’s still really profound. People feel that, if they admit that they have a mental illness, some part of it may be weakness. In ways, it’s like cancer was 50 years ago, when it was shameful to say the word; people didn’t want to admit that they had it. In many respects, we’re fighting a similar battle in psychiatry now. People often don’t want to say that they, or their children, have a psychiatric illness. It’s more acceptable to say, “My kid has cancer” than “My kid has schizophrenia”. One of the reasons why I took the job as chair is because I think that UCSF and the UC system are committed to trying to do something about this at every level - in advancing the science and being committed to the public mission. We run San Francisco General Hospital, which is the place where the most seriously ill and the neediest people in San Francisco go for their care; we’re the court of last resort. We run Children’s Hospital Oakland and just took over the psychiatric service there. UC is a place that’s committed to really doing something. Unfortunately, there’s a lot to do. What’s it like in your world? Would people be willing to admit that they had serious depression, or would someone be more likely to tell you if they had a health problem than if they had a psychiatric problem?
[Teddy Wang] There’s still stigma against psychiatric problems.
[Dr. State] When you look at the stats, if you’re mentally ill, you’re much more likely to be the victim of violence than you are to be a perpetrator. But as soon as something happens where there’s an overlap between psychiatric illness and violence, it’s all over the news. Blaming the Newtown shooting on Asperger’s syndrome reinforces the stereotype. When there’s a mass shooting, one of the first questions is “Were they mentally ill?” There’s a real misunderstanding about what mental illness is and how it’s related to violence, and it helps drive this sense of shame of having it. There’s also the moral weakness part, which is trans-generational. The old views of psychiatry had it for a long time that, if you had autism, it was the fault of your mother who was not being sufficiently loving and socially connected to the child. We’ve done a lot to add to the narrative in a negative way, and I think part of what we’re trying to do at UCSF is to address that on multiple levels - not only scientifically, but also considering the kind of signals we send. UCSF is constructing a new building for psychiatry focused on providing an environment that will decrease stigma. We’re combining a bunch of medical services to avoid relegating patients with mental illness to “that building over there.” You go where you need to go for your healthcare. We’re integrated with pediatrics, neurology, and even to some degree, neurosurgery. We’re trying to make a building that, in its physical layout, does not reinforce stereotypes about mental illness. It seems like a small thing, but in everything that we’re trying to do in the Department of Psychiatry here, much of it is thinking in part about keeping an eye towards eliminating or reducing some of the stigmas associated with having mental illnesses.
[Teddy Wang] Is there a moment in your life that you are most proud of, either personally or professionally?
[Dr. State] Personally, there’s constant pride associated with my kid. I’ve got a wonderful daughter who’s doing wonderfully well. Nothing really equates in my view with family, so my personal life is the source of my greatest satisfaction and pride. Professionally, today’s a pretty good day. I’ve been working on Tourette’s genetics for 20 years. Today, we finally published a paper in Neuron that shows that the problem is not entirely solved, but entirely solvable. We now have all the parameters in place where it’s clear how we’re going to be able to do this. It was a long road with a lot of bumps and obstacles. I love our autism work, but it feels particularly rewarding today to have the work on Tourette’s after all this time. Ultimately, what I want to do is turn that stuff into something that will actually help a patient, so I still got a ways to go. Finding the gene is an important first step, and it took a long time to get there, but it really is not the end goal by any stretch of the imaginations. I hope again, if I get interviewed again years from now, that I’ll be able to say that my proudest moment was when our gene was leveraged to identify our first new treatment for psychiatric illnesses, which is more than anything we’ve been able to do in the past.
[Teddy Wang] Is there any advice you can give to undergraduate students?
[Dr. State] I think that there is a misapprehension that people who end up as Chair of Psychiatry or do molecular genetics or whatever knew what they wanted to do when they were 10 years old and followed a linear path. The one thing I’d say is, when you take a look at what has happened in my life, it’s been about doing things that I thought were interesting at the time and following those paths. I’d say it was the cumulative experience that was most important. The message that I would give particularly for undergraduates today is, be open to thinking about where you want to go and follow things that you really care about. If you are interested and engaged and do stuff that you really care about, you will likely be surprised and hopefully rewarded, as I’ve been, in following what fires your jet. When you look at people who are “successful” and end up in places, it’s surprising to go back and ask them how they got there. I started political science. I had a lot of twists and turns that I haven’t even talked about here and other things that I’ve tried in life, and it’s more common than people appreciate. This is particularly for pre-med students who worry that if they get one B or B+, that they’re not going to be able to get where they want to go. In reality, the world doesn’t really work that way.
