Born to Bridge Psychiatry and Medicine
Sitting at a small conference table in his sunlit office, Hochang Benjamin Lee, MD, speaks with confidence in a soft voice. It is easy to believe what he says; his manner is relaxed but attentive—a natural connector, colleagues say.
Lee will be the first to say that everyone has a story to tell, and, in sharing his, he leads by example. Shortly after he was recruited from Yale University to chair University of Rochester Medical Center’s Department of Psychiatry in late 2017, Lee added “compassion” to the department’s list of a clinician’s essential traits. Department cofounder George Engel, MD, spelled out the others long ago: communication, collaboration, complementarity, and competence.
“I went into medicine specifically to become a psychiatrist,” Lee says. “Because of all the stigma attached to people with mental illness, a lot of people—including physicians—are afraid of them. But in my case, I always felt sad for them.”
The Psychiatry department has a prestigious reputation, and the move puts Lee further into the spotlight as a national leader in the biopsychosocial model of health care. It was in Rochester that this model, now widely used, came into full bloom midcentury under psychiatrist John Romano, MD, the son of an Italian immigrant who grew up in Milwaukee, and internist Engel, a pedigreed New Yorker whose uncle was a well-known physician. They met in 1941 at Peter Bent Brigham (now Brigham and Women’s) Hospital in Boston and began working together on delirium research. Like most physicians of his era, Engel believed biological factors alone determined health and disease. He resisted the notion that matters of the mind and the social environment played a role and was skeptical of psychoanalysis and psychosomatic medicine. But as the field developed, he broadened his thinking.
“I was introduced not just to the human psychosocial dimensions of medicine, but, even more importantly, to what constituted the primary data of that realm and how to gain access thereto,” Engel later recalled.
The two spent four years at the University of Cincinnati, where Romano chaired the Department of Psychiatry, before Romano was recruited to Rochester in 1946 to start the Psychiatry department. Engel joined him, with dual appointments in Psychiatry and Medicine. With the full and unusual support of the chair of Medicine, William McCann, MD, Engel established a medical psychiatric liaison service staffed largely by internists. McCann also saw to it that the Psychiatry department’s beds, labs, and offices had their own wing in the hospital—a bold and pioneering move.
Rochester was well ahead of its peers. By the 1950s, Engel had stepped firmly into the psychosomatic camp as a leading scholar. He and Romano revolutionized teaching in the medical school by incorporating psychiatric training in all four years—at a time that psychiatric issues were deemed out of the realm and interest of physicians and surgeons and best left to the psychiatrist’s couch. Students in most medical schools received little or no psychiatric training.
Lee was 12 when his family emigrated from Korea to the United States to settle near relatives in the Seattle area. He didn’t speak English, and he spent his teen years in a mighty struggle to connect. Instead of hardening him, the experience opened something inside. He started realizing an empathy for others who were on the outside looking in. He saw in people with mental illness and intellectual disabilities fellow aliens—at times invisible, feared, abhorred. He understood why early 20th-century psychiatrists were called alienists.
“You are suddenly—because you don’t speak English—deaf and dumb and misunderstood. So you inherently understand what a patient with severe mental illness feels like,” he says.
In science, Lee found his zone. As a high-school student, he took a summer job in a genetics lab at a residential facility, lining up chromosomes and karyotyping for intellectual disabilities. The biological underpinnings of a socially stigmatized condition fascinated him. But he was far more interested in literature and people’s stories, and he grew curious about a world beyond chromosomes.
“The attraction of psychiatry was that you meet people at their lowest point in their life story plot,” he says. “The question is, can you help them steer that plot into more of a happy ending as a psychiatrist? Can you change the arc of the story? That’s what I was interested in.” Lee set his sights on medical school. He took on three majors as an undergraduate at Cornell University: biology (with a neuroscience and behavior concentration, he says, to understand the biological basis of behavior); philosophy (discerning people’s thoughts); and psychology (focused on the evolution of human behavior). He graduated magna cum laude with honors in psychology.
To his delight, his first rotation in medical school at Jefferson Medical College, now Sidney Kimmel Medical College, in Philadelphia, was psychiatry. He realized right away he loved it, and his first patient did not disappoint. She had a diagnosis of multiple personality disorder and presented all 11 personalities on Lee’s first day of rotation. But instead of major mental illness, he found himself drawn to the intersection of medicine and psychiatry, where mind and body connect. He became a follower of the biopsychosocial model before he knew it.
Lee faced a barrier of his own. Well into his third year of medical school, his English pronunciation remained poor. How could he plan a career in psychotherapy, his friends wanted to know, if he couldn’t make himself understood? So during a summer fellowship on addiction at St. Francis Medical Center in Pittsburgh, Lee sat down every day to record himself reading from Our Daily Bread, a devotional reader. Over and over he played it back and said it again.
“When I recorded myself the first time I totally understood why people couldn’t understand me; I couldn’t understand myself either,” he says, laughing. “I did that the whole summer.”
Lee’s medical school rotations under Mitchell Cohen, MD, a former Johns Hopkins faculty member, on the psychological effects of pain led to a psychiatry residency at Johns Hopkins Hospital, where he could further train in the inpatient chronic-pain unit in the Department of Psychiatry. There, his interests in pain expanded into a more general curiosity about the mind-body relationship.
James Potash, MD, Director of Psychiatry and Psychiatrist-in-Chief at Johns Hopkins, met Lee at the start of his residency and was his psychotherapy supervisor for a while.
“I immediately liked him a lot,” Potash recalls. “He’s very attuned to understanding the subtleties of the disease process. But he’s also very attuned to thinking about issues about the person’s life experience, their cultural background, that have an impact on the nature of their distress.”
A Natural Collaborator
Lee’s training at Johns Hopkins was one of the most grueling experiences of his life, with an exhausting on-call schedule. But it was also “the greatest time,” he says. He was right where he wanted to be: He looked forward to seeing his patients. He loved his didactics and seminars. He had access to experts who took the time to answer his questions. After the overnight shift in the psychiatric emergency room, he disappeared for hours into the Adolf Meyer Library, where “I could look up any question that I had.”
“Learning psychiatry was a pure joy,” he says. “It was probably one of my happiest times because I got to do what I always wanted to do.”
His first rotation was in the Neuropsychiatry unit, working with dementia patients and their families. He felt confident he could manage their depression, psychosis, and agitation, but he regretted that clinicians could do nothing about their deteriorating cognition.
“The fact that their memory becomes worse over time, regardless of what the clinicians do … that really bothered me. And I just felt sad for them, especially for the family, to suffer the cruelty of watching their beloved ones fade away right in front of them,” he recalls.
Research at the time suggested that delay in the onset of dementia by five years could halve the number of dementia incidents in our society. (In this scenario, many patients would die of old age before they developed dementia.) Lee wondered: What if he could identify a reducible risk factor and delay dementia by just two years? That aspiration led him to pursue a combined research fellowship in dementia care and psychiatric epidemiology at Johns Hopkins School of Medicine and a K-grant from the National Institute of Mental Health to study early-to-midlife depression as a risk factor for late-life cognitive decline. This career-development grant was the first of several NIH-funded grants he received to research the relationship between depression and dementia.
Lee is a natural collaborator who can pivot when needed, says his mentor at the time, Constantine Lyketsos, MD, who is Elizabeth Plank Althouse Professor and chair of Psychiatry and Behavioral Sciences at Johns Hopkins Bayview Medical Center.
“He’s always got his eye on the prize, where he wants to end up,” Lyketsos says. “He finds ways to get there. Now sometimes people bend the rules to do that. But he inspires with integrity.
One of the first things that strikes anybody when they first meet him is his warmth and his kindness. It invites people to work with him. As well, he’s very creative and good at adapting. There were challenges with implementing his research at Hopkins and he modified and adapted his research.”
Lee decided it would be difficult to determine if treatment for early and midlife depression prevents dementia. Searching for a faster research paradigm, he found it in the cardiovascular realm. Many patients decline cognitively after coronary artery bypass surgery. Lee received an NIMH RO1 grant to study if patients with cerebral vascular disease before CABG surgery have a higher likelihood of cognitive decline and depression. He found evidence of complex interaction among cerebrovascular disease burden, pre-surgical depression, and post-operative cognitive changes.
Lee was working more with anesthesiologists and surgeons and got involved in a series of NIH-funded, post-op delirium-prevention clinical trials. At the same time, the Department of Psychiatry at Johns Hopkins needed someone to be specialty-boarded in psychosomatic medicine in order to develop a fellowship program in what is now known as consultation liaison, or CL, psychiatry. He volunteered without giving it much thought, and it led to his recruitment to Yale. Yale-New Haven Hospital needed someone to lead its new service—Lee later named it Psychological Medicine Service—which oversees all psychiatric care for medical and surgical patients. When he interviewed, it was a tiny CL service with roughly three FTEs, low morale, and a poor reputation. Residents were angry about rotation. Four of five fellowship spots went unfilled.
Lee built bridges with other departments, including cardiac surgery, where he continued his research. Key among the improvements the service made was to develop the Behavioral Intervention Team (BIT) model that changed the paradigm of how psychiatric consultation is provided at Yale.
In many academic departments, the consultation liaison service is a career dead-end for faculty because it generates hardly any revenue or research. Typically, psychiatrists are called in to a medical unit only when a behavioral crisis has occurred. But Lee believed the service was the face of the department and sensed a promising opportunity to prove its value to the hospital administration and better serve psychiatric patients in medicine units.
The service was staffed with the best, most experienced clinicians in a variety of disciplines: a CL psychiatrist, an advanced practice RN, a clinical nurse specialist, and a psychiatric social worker. Based on the admission notes and the nursing interaction, patients are screened for behavioral and psychiatric issues as soon as they are admitted to the medicine unit. If an intervention is needed or expected during their hospital stay, the BIT team matches the patient’s behavioral issue to the expertise of a BIT member’s discipline. By assisting the patient and the medical team at the earliest moment, the BIT team prevents a behavioral crisis and avoids further delays in delivery of often life-saving medical treatment.
The traditional consultation liaison service typically doesn’t make or save any money. But the BIT program turns that around, shortening the patient’s hospital stay, cutting the cost of care, and reducing the need for 24-hour supervision.
“It actually showed that the hospital sees substantial return-on-investment despite the initial cost of employing a larger, multidisciplinary team,” Lee says.
The program was a hit at Yale. Lee’s team presented the results at conferences, and word spread; today the model is used in more than a dozen academic medical centers around the country. A large randomized trial based on the BIT model is in place in the United Kingdom. Lee’s work will be recognized with the Don Lipsitt Award at the Academy of Consultation Liaison Psychiatry meeting in November.
Under Lee’s guidance, Yale’s consultation liaison service grew into a major academic clinical section, employing 17 faculty members and 50 clinicians. Today it has one of the largest consultation liaison groups in the country, and its fellowships are highly competitive.
“Ben showed remarkable diplomatic skills in melding his colleagues in Psychological Medicine into a team and in building bridges with other departments,” says John Krystal, MD, the Robert L. McNeil, Jr., Professor of Translational Research and chair of the Department of Psychiatry at Yale. The two met regularly to discuss clinical, research, and training issues. “He is one of those rare people who quietly conveys brilliance, creativity, and vision and kindness and humility.”
The Right Thing to Do
The average life expectancy of a person with schizophrenia is 53 years. People with severe mental illness of all kinds have similarly shortened lifespans. This is due in part to the obstacles they face in medical care. That makes access to quality care for the mentally ill a moral imperative, Lee says. “I go back to this concept of compassion for patients with psychiatric disorders. The fundamental motivation of the Behavioral Intervention Team was to really place psychiatric care providers in a position to advocate for mentally ill patients while assisting our surgeons and medical doctors in their practice, so that the behavioral barriers for the surgical and medical care are removed.”
The result is a cost-effective delivery of quality care—but there’s more to it than the bottom line, Lee says.
“In reality it’s the moral rationale that really allowed me to justify my effort,” he says of his work at Yale. “Unless you have a moral rationale, it doesn’t matter how much cost-saving there is. A financial argument never inspires your clinicians. Psychiatry by nature is mission-based work. We are a mission-based department. We are not going to inspire our staff by saying we are going to reduce costs. We will inspire each other by doing the right things for our patients.”
Lee translates that clinical mission into the financial language of value-based care that administrators understand.
Lee was recruited to the Medical Center in part to build on what he had achieved at Yale—integrating mental-health services across the system. Officials hoped he could stitch new connections between psychiatry and other specialties in the hospital and the larger system. In an ironic twist, given its history and reputation as the birthplace of the biopsychosocial model, Rochester’s Psychiatry department has operated somewhat in isolation from other departments, he says.
Lee, who, in addition to being the John Romano Professor and chair of the Department of Psychiatry, is professor of Psychiatry and Neuroscience, says this does not reflect the many relationships he quickly established with the other chairs. On the contrary, he has great admiration for the way they have welcomed him. Easy collegiality is a big reason he took the job, and they are eager to work with him.
“What convinced me was that when I got to meet the chairs in the other departments, I knew I could really work with each of them and develop close relationships with them,” he says.
In his foreword to Lee’s new book, Perioperative Psychiatry, David Linehan, MD, chair of the Department of Surgery, extols the importance of addressing the psychiatric health of surgical patients based on the biopsychosocial model. The connection he and Lee have—as part of the university’s mentoring program for new chairs—fits the DNA of the institution, Linehan says. “You can’t just treat the medical issues without addressing the psychological ones.”
“I don’t have to explain the biopsychosocial approach here,” Lee adds. “That’s what separates URMC from other medical centers. As someone who is always thinking, how can I integrate, this is about as ideal an environment as you can get.”
The goal to eliminate boundaries across disciplines, missions, departments, and service lines already is being realized. During a recent psychiatry recruitment, Lee says, five departments in the Medical Center pooled resources for the recruitment package for a pain researcher in psychiatry. “How many medical centers around the country can do recruitment by crowdfunding among the chairs? At one faculty recruitment dinner, we had four chairs and a dean, and I was so proud to be a member of URMC,” Lee says.
Rochester is a good fit for Lee in another way. It’s a full-circle story that begins with his father, who took a business trip to Rochester to visit Eastman Kodak Company in 1975. He was so impressed that upon returning, he announced the family would be moving to America. When Lee got the call for an interview at Rochester, he knew he had to come. “By that time my father had passed away,” he says, “but I wanted to see what it is that he really liked about Rochester.”
As someone who has struggled to be understood, Lee frames his own work and that of his colleagues in the language of connection. To be understood, and to understand self and others, means building bridges.
The department’s Bridge Art Gallery displays artwork by patients and community members along the halls. There is a lot of anxiety associated with psychiatric care. Art is one way the department shows it is a safe and accepting place for people confronting mental illness.
“The more humanizing our field is, the better it is for our patients,” Lee says. “We have to make it more approachable. That’s why our hallways are different. Art is another way— and music is another way—to be able to relate to others, to relate to people with mental disorders through a common language.”
Intervention in Practice
A recent example to bring mental-health care into the medical and surgical units at Strong Memorial Hospital is PRIME Medicine, which stands for Proactive Integration of Mental Health Care in Medicine. Led by Mark Oldham, MD, it is one of a growing number of collaborative QI projects and programs being fostered in IDEA (Implementation, Dissemination, Evaluation, and Analysis) Core, a new initiative that helps clinicians and researchers develop pilot research and quality-improvement projects. Lee founded IDEA Core to bolster innovation in clinical care, one of his key aims for the department.
Other innovative models of delivery are the Rochester Psychiatric Assessment Officer (PAO) telepsychiatry model, led by Michael Hasselberg (SON MS ’07, PhD ’13), and Jennifer Richman (MD ’05, Res ’09); and the telepsychiatry-enhanced Monroe Mobile Crises Team, led by Yilmaz Yildirim, MD, PhD.
Lee is collaborating with several departments in another major researchrelated endeavor: the recruitment of the new George Engel Professor to bolster the research infrastructure to develop translational research with Del Monte Neuroscience Institute.
Departments are eager to collaborate. It took less than a few months to start a psycho-oncology program, he says, as well as initiatives in primary care, dental care, and women’s health. The award-winning Medicine in Psychiatry Service provides comprehensive outpatient medical care to adults who may also be receiving mentalhealth or substance-abuse services through the health system. Within MIPS, Rochester is the only academic psychiatry department to run its own acute medicine unit, the 20-bed Inpatient Medicine in Psychiatry Service, or IMIPS, under director Marsha Wittink, MD. The physicians, nurse practitioners, social workers, and nurses on staff work as a team to address the combined physical- and mental-health needs of patients.
The challenges of behavioral health integration remain largely financial, and so Lee’s job as a translator continues as he works with administrators encouraged by growing evidence that investing in it ultimately enhances revenue.
As long as there are barriers to physical health, there is no mental health, Lee says.
“That’s why we are so keen on integrating medicine into psychiatry and vice versa. We have to help them live longer before we improve their lives. That is one of the most paramount goals that we have. And the beauty of URMC is that we have an environment that actually allows us to do that.”