Psychiatry Boot Camp

In this episode of Psychiatry Boot Camp, Dr. Mark Mullen continues his conversation with Dr. Jacob Appel, covering two intersecting frontiers. The replacement of human physicians by AI "replicants" and the emerging use of AI as a surrogate decision-maker, or "robo-proxy," for patients who lack decisional capacity. Dr. Appel argues that while AI will outperform human physicians in probabilistic, pattern-recognition tasks, it is structurally incapable of providing the authentic empathy, shared vulnerability, common sense, and irrational human trust that constitute the actual substance of healing and that deploying replicant physicians at scale will produce a deeply inequitable two-tiered healthcare system where wealthy patients see humans and less wealthy patients see machines.

The second half of the episode addresses the coming reality of AI robo-proxies where patients appoint chatbots as their legal healthcare proxy to make decisions in the event of incapacity. Dr. Appel outlines four models by which this might occur, then catalogs the serious structural problems each presents. His closing advice is disarmingly simple. Write your advance directive the old-fashioned way, on paper, and tell someone you love what you want.

Takeaways:

AI performs well at tasks requiring 90–95% accuracy but medicine often demands near-certainty, and the "negative outcome penalty paradox" means physicians face increased liability whether they follow AI recommendations that turn out to be wrong or override them when the AI turns out to be right.

Authentic emotional support, not simulated empathy, is a core component of healing.

The deployment of replicant physicians at scale will create a two-tiered system in which those who can afford to will see human doctors while the majority of patients will be increasingly funneled toward AI-driven care.

AI "robo-proxies" present profound legal and ethical problems as surrogate decision-makers.

Until legal frameworks are built around robo-proxies, physicians who follow a robo-proxy's instructions over a family's objection face serious liability exposure regardless of whether the law ultimately supports the decision.

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Chapter:
00:00 Meet Dr Jacob Appel00:29 Values Based Capacity Model02:15 Can Clinicians Make Time03:13 Will AI Replace Doctors06:47 Replicant Pros And Cons10:35 Empathy And Shared Vulnerability14:57 Trust Liability And Policy30:21 Robo Agents As Surrogates32:46 Robo Proxy Basics33:34 Can AI Improve Living Wills35:06 Why Choose a Robo Proxy36:38 Hallucinations and High Stakes38:06 Four Robo Proxy Models42:29 Bias and Family Fallout52:22 Legal Standards and Liability59:07 Activation Risks and Final Advice
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In this episode of Psychiatry Bootcamp, Dr. Mark Mullen welcomes Dr. Jacob Appel, psychiatrist, attorney, bioethicist, polymath, and emergency psychiatrist, for a rigorous and clinically grounded critique of the Applebaum-Grisso "Four Abilities Model" of decisional capacity assessment. Dr. Appel traces the model's origins in the 1980s as a patient-empowerment tool, examines how its statutory adoption across more than half of US states has calcified it beyond its original intent, and describes in detail the categories of patients for whom the model systematically fails.

As an alternative, Dr. Appel describes the values-based model, which asks clinicians to identify a patient's current expressed choice, explore the underlying values that have governed the patient's life, and determine whether the two are congruent. He also introduces the consistent preferences approach, which situates capacity within a person's narrative arc rather than a moment-in-time snapshot.nce intervention programs in their own communities.

References:

Irrational People Have Rights Too: Moving Beyond Rationality in Decisional Capacity Assessment: https://pubmed.ncbi.nlm.nih.gov/41801616/
A Values Based Approach to Capacity Assessment: https://pubmed.ncbi.nlm.nih.gov/36638303/

Takeaways:

The Applebaum-Grisso model was designed for patients who temporarily deviate from a Western allopathic baseline.

Documented racial bias in capacity assessment stems in part from the model's privileging of patients who can articulate reasoning in medical-legal language, systematically disadvantaging those with less social capital who may know exactly what they want but cannot express it in those terms.

The values-based model offers a simpler alternative.
Capacity assessment is an intervention, not a neutral evaluation
In states without statutory definitions of capacity criteria, the values-based and consistent preferences approaches are likely protected under the respectable minority

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Chapter:
00:00 Meet Dr Appel01:27 Capacity Model Origins02:21 Four Abilities Breakdown03:26 Standard of Care Law05:46 Why Model Falls Short06:22 Religion Culture Exceptions07:07 Rationality Bias Inequity12:02 Refusing To Engage13:03 More Failure Prototypes15:41 Not Capacity Abolition16:39 Physician Exceptionalism20:51 Values Based Model Steps25:52 Sponsor Break Medlines27:07 Standard Of Care Revisited32:07 Bioethics Teaching Favorites36:50 Genetics Incidental Findings38:52 Closing And Credits

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In this episode of Psychiatry Boot Camp recorded live at Saint Louis University, Dr. Mark Mullen is joined by Dr. Kristin Mueller, an emergency medicine physician and physician-researcher at Washington University in St. Louis, for a discussion on firearm violence as a public health crisis. Dr. Mueller, who works closely with the Life Outside of Violence hospital-based violence intervention program, walks through the clinical fundamentals of lethal means counseling, including a live mock counseling session demonstrating how to approach a patient in mental health crisis with access to firearms. The conversation covers practical, evidence-informed strategies for secure storage counseling, verbal de-escalation, and navigating patient resistance without leading with statistics alone.

The discussion then turns to the epidemiology of firearm injury, including findings on non-fatal firearm injury rates, recurrent injury risk among adolescents and young adults, and the structural factors that shape risk beyond individual behavior. Dr. Mueller details the design and outcomes of the Life Outside of Violence program, a hospital-based intervention that pairs licensed clinical social workers with patients ages 8 to 30 following violent injury, and shares emerging data on goal-setting, goal achievement, and patient-reported outcomes. The episode closes with guidance for clinicians seeking to identify or refer patients to hospital-based violence intervention programs in their own communities.

To find your local hospital violence intervention program, visit www.HAVI.org.

Takeaways:

Clinicians in all specialties can and should ask patients about access to firearms and medications as part of routine safety counseling, not only during acute mental health crises.

Secure storage counseling is most effective when delivered with a calm, nonjudgmental approach that avoids leading with statistics alone.

Non-fatal firearm injuries vastly outnumber fatal ones, with 93% of firearm-injured patients at St. Louis's level one trauma centers surviving and returning home.

Patients treated for a firearm injury face a 7% risk of re-injury within one year and up to 17% within eight years, with adolescents and young adults at highest risk.

The Life Outside of Violence program pairs licensed clinical social workers with patients for up to a year after injury, addressing housing, transportation, and trauma counseling alongside medical recovery.

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Chapter:
00:00 Live Show Intro00:45 Meet Dr Mueller01:36 Asking About Firearms04:12 Mock Counseling Roleplay10:28 De Escalation Secrets12:50 Legal Options And EROs14:36 Psych Care Gaps In ED18:49 Clinical Pearls And Resources23:24 Ad Break26:01 Back From Break26:40 Firearm Violence Public Health27:00 Firearm Injury Public Health28:02 Beyond Politics and Blame29:48 Data Gaps and Hospital Sharing31:34 Nonfatal Injuries and Recurrence33:49 Funding and Program Origins34:45 How LOVE Works37:39 Meeting Patients Where They Are41:50 CVI Ecosystem Partnerships43:26 Measuring Impact and Outcomes51:54 Success Stories and LOV Meaning55:27 Call to Action and Resources57:14 Outro and Listener Review

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Dr. Mark Mullen welcomes Dr. Allison Hadley, a psychiatrist and medical director of the psychiatric emergency service at Oregon Health & Science University, for a discussion on motivational interviewing in high-acuity psychiatric settings. Dr. Hadley introduces a novel teaching framework that draws on Tina Fey's rules of improv from her memoir Bossy Pants, mapping core improv principles, including "yes, and," making statements rather than only asking questions, and treating perceived mistakes as opportunities, onto the foundational techniques of motivational interviewing. The conversation covers the OARS mnemonic (open-ended questions, affirmations, reflections, and summaries), the relationship between motivational interviewing and trauma-informed care, and practical strategies for identifying and reinforcing patient change talk.

The discussion also addresses the stages of change model and the ask-tell-ask method for delivering psychoeducation in a patient-centered way, along with harm reduction interventions used in the psychiatric emergency department, including methamphetamine safety kits. The episode concludes with an extended clinical role-play demonstrating how to apply these techniques with a patient presenting with anxiety and co-occurring cannabis use, illustrating how motivational interviewing can be used to build therapeutic alliance without alienating patients who are ambivalent about behavioral change.

Takeaways:

Motivational interviewing is considered a cornerstone, evidence-based treatment approach for substance use disorders in psychiatric practice.

The improv principle of "yes, and" can be applied clinically by affirming an emotionally salient part of a patient's statement before introducing a new therapeutic direction.

The OARS framework, open-ended questions, affirmations, reflections, and summaries, provides a structured method for conducting motivational interviewing conversations.

The ask-tell-ask method allows clinicians to deliver psychoeducation only when a patient has explicitly consented to receive it, preserving patient autonomy.

Harm reduction tools, such as methamphetamine safety kits distributed in emergency settings, reflect an evidence-based, non-judgmental approach to meeting patients where they are in their stage of change.

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Chapters:

00:00 Why Motivational Interviewing

01:09 Meet Dr Allison Hadley

02:33 Who MI Is For

04:37 How MI Works

07:27 Tina Fey Improv Lens

09:06 Improv Rules In Practice

19:19 OARS Core Skills

23:13 Reflections That Land

24:25 Summaries And Change Talk

25:01 Sponsor Break

27:38 Spotting Change Talk Cues

32:08 Stages Of Change Basics

34:23 Ask Tell Ask In Practice

39:30 Roleplay And Final Takeaways

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Dr. Mark Mullen welcomes Dr. Christine Crawford, Chief Medical Officer at the National Alliance on Mental Illness (NAMI) and author of You Are Not Alone: For Parents and Caregivers, alongside Steve Hoffmann, Senior Vice President and Chief Preclinical Officer at the Foundation for the National Institutes of Health (FNIH). Dr. Crawford discusses NAMI's mission and its 650 chapters nationwide, the concept of the "distress radius" as a framework for identifying when a child's behavioral changes warrant professional evaluation, and practical strategies for engaging skeptical patients and families through primary care. She also highlights dialectical behavioral therapy (DBT) as a broadly applicable clinical tool and underscores the importance of evidence-based education for patients and caregivers navigating the mental health system. The conversation then shifts to Steve Hoffmann's work at the FNIH, including the newly launching Multimodal Assessment and Phenotyping in Depression (MAPD) study, a longitudinal, multi-site initiative designed to identify biological, clinical, and digital biomarkers associated with depression subtypes. Hoffmann outlines the study's design, including neuroimaging, genetic testing, digital wearables, and patient-reported outcomes, with the goal of moving depression treatment away from a trial-and-error model toward a precision medicine approach. Dr. Crawford and Hoffmann both emphasize the importance of including patient voices in research design, drawing parallels to the foundational impact of the Alzheimer's Disease Neuroimaging Initiative (ADNI) on that field.

Takeaways:

The "distress radius" framework encourages parents to evaluate whether a child's behavioral changes extend beyond the home into school, social, and extracurricular settings as a signal for further evaluation.

NAMI operates 650 chapters nationwide and offers peer-led support groups and educational workshops that clinicians can use as a clinical resource for patients and families.

Dialectical behavioral therapy (DBT) skills, including emotional regulation and mindfulness techniques, have broad applicability beyond borderline personality disorder and may benefit general populations.

The MAPD study aims to identify multimodal biomarkers, including neuroimaging, genetic, sleep, and digital data, to enable more precise, individualized depression treatment selection.

Engaging primary care providers early in the mental health conversation can reduce reliance on long specialist wait lists and help identify safety concerns sooner.

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Chapters:
00:00 Meet the Guests
00:58 What NAMI Does
02:31 Why NAMI Matters
04:24 Why Write You Are Not Alone
05:38 Building a Parent Roadmap
09:08 Distress Radius Warning Signs
12:46 NAMI as a Clinical Resource
18:37 Skeptical Patients and Primary Care
23:29 DBT Skills Everyone Needs
26:56 Sponsor Break
29:26 What Is the FNIH
33:32 MAPD Mapping Depression
46:40 Hopes and Takeaways

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