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My Mental Health Provider Left Me on Read

• Dominick Ramos

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0:00 | 36:06

During the pandemic, I finally did something I'd been putting off for years — I established care with a primary care provider. What followed was a months-long battle to access the medication I needed, a psychiatric provider who stopped returning my calls, and a prior authorization process I had to fight through almost entirely on my own. And I did all of that while being on Medicaid, working in healthcare, and coming from a culture that never really made space for mental health in the first place.

This episode is about what it actually takes to navigate a system that wasn't designed to make things easy. It's about the panic attacks I couldn't name, the moment a PHQ questionnaire cracked something open that I'd been carrying for years, and the first time I took Vyvanse and grieved everything I realized I could have had sooner.

But it's also about what I learned on the other side of it — about self-advocacy, about showing up for yourself even when the system doesn't show up for you, and about why none of us should have to fight this hard just to get the care we need.

Happy Mental Health May! Let's Have More Good Days Together 

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The conversations on Scrub Talk are meant to inform and inspire, not replace medical advice. The voices on this show — including mine — come with strong professional backgrounds and even stronger opinions. That doesn't mean anything you hear is medical guidance for your specific situation. Always talk to your doctor or a qualified healthcare provider about your own health. We're here to explore, not prescribe. 

SPEAKER_00

Hi everyone, I'm Dominic Ramos, and this is Scrum Tom. Well, uh, welcome back. We've been a little busy with Scrub Talk. Yeah, these past few weeks, I have been a content machine. Putting together these episodes and getting back into recording has been really exciting for me. So I just want to say thank you because the outpour of support has just been really motivating for me. Yeah, there's a lot that I want to cover. But before we get into the heart of this episode, I wanted to get a couple of action items off of the agenda. Just like every month, it feels like May is not without its own observances and recognition days and weeks. And well, this is probably one of the most jam-packed months, especially when it comes to the health and wellness space. I think a couple weeks ago was Nurses Week. So happy belated nurses week. Thank you to all the amazing nurses out there. You guys do absolutely amazing work. You know, I was raised by nurses. Um, my grandmother was a public health nurse, and my mom uh is a nurse as well. And uh I was just practically surrounded by nurses and doctors for most of my upbringing. So, to all the amazing CNAs and LPNs and RNs out there, you guys do really essential work, and you guys are at the heart of what makes healthcare so amazing. So thank you. Uh, next up, May is skin cancer awareness month. I feel a personal responsibility to you as both a dermatology MA and an Asian American to talk about this. Look, skin cancer sucks. That is my clinical, professional, non-professional opinion. And here's the thing about skin cancer it is one of the most preventable cancers out there. The steps are simple, guys. Sunscreen, shade, and protective clothing. Wearing sunscreen significantly reduces the risk of you getting skin cancer, especially melanoma. If you can't wear sunscreen, I get it, I know some of the stuff gets really goopy, and American sunscreens, in my opinion, they stink. So I guess that's a reason to not wear it. But if you don't like wearing sunscreen, at least try and engage in some sun protective behaviors, whether or not it's wearing sun protective clothing, wearing a wide-brimmed hat. Make sure that you cover up your skin. Your skin is your best friend. And if you do like sunscreen, which I'm going to once again recommend, it is absolutely amazing. Not only does it prevent skin cancer, but it has amazing anti-aging properties, which is probably why I have such amazing dewy skin. But anything that you can do to reduce your sun exposure, because like all things with our health, it does accumulate over time. And if you're ever unfortunate enough to visit my office and get treated for these precancerous lesions that we call actinic keratosis or even skin cancers, it can have a really brutal effect. So just remember that. If you want to learn more about skin cancer prevention, detection, and treatment, I'll leave a link down below to the Skin Cancer Foundation. Uh, May is also Asian American and Pacific Islander Awareness Month. So um, shout out to my fellow Asians, I guess. You know, there's a lot of things to unpack from AP Month, specifically within the realm of health disparities. But if you are someone who does like the Asian culture, whether or not it's the music, it's the cuisine, the fashion, you know, that that's something worth celebrating this month. And honestly, that requires a whole nother set of episodes. But the big ticket item for this episode is May is also mental health awareness month. And there's a lot that we have to talk about when it comes to mental health. What I think is important here is that the literature and data that talks about mental health disparities and outcomes, especially here in the US, is quite robust. And since COVID, it's no secret that mental health and mental illness have become a real hot button issue. There's a lot going on. Social media is obviously a big factor, access is a big factor. We are becoming more polarized and divided than ever. It just seems like no matter what we do in today's world, we're continuously becoming more isolated. And there are a lot of things that contribute to that. But the one thing I want to talk about more than anything is the importance of advocacy. More importantly, self-advocacy. But instead of presenting you with facts and figures, what I want to do is share with you my experience accessing the mental health care system here in the US. Before I get into my story, I want to take a moment to thank this episode's sponsor, BetterHelp. I'll be honest with you, getting into therapy wasn't easy for me. I grew up in a household where you just didn't really talk about this stuff. And even after I started, there were sessions where I just didn't want to show up. Where I just wanted to sit in silence and pretend everything was fine. But some of the most important realizations I've had about myself happened in therapy. About why I operate the way I do, why I push as hard as I do, and what I actually need to feel okay. Therapy gave me a space to figure that out, and I genuinely believe everyone deserves that. If you've been thinking about trying therapy, better help makes it easier for you to start. You get mashed with a licensed therapist quickly, and you can communicate however feels most comfortable, by phone, by video, or by text. And if it's not the right fit, you can switch anytime at no extra cost. Go to betterhelp.com slash scrub talk. That's betterhelp.com forward slash scrub talk for 10% off your first month of therapy. All right, let's get back to the story. So about three or four years ago, I had started working as a pharmacy tech. And at the time, I was really getting used to a new reality. Trying to work full-time, going to school full-time. Working during the pandemic was really hard for me. At the time, I was basically trying to get my life together. Not just my professional and academic life, but my personal life too, my health. I hadn't seen a doctor since hmm, maybe when I was in high school. I really never felt the need to go. But working throughout COVID was really a wake-up call for me. And it opened my eyes to not only the gaps in our healthcare system, but also to how precious life is and how much, to put it plainly, I care about living. So while I was working, I was starting to get less sleep. I was becoming more agitated throughout the day. And honestly, I started having panic attacks. And they would happen at very odd times. When I'd go to the bathroom, when I was getting ready for bed, and I didn't exactly have a name for what was going on at the time. But I remember that experience. It felt like this noise canceling feeling. Like there's just a bunch of ringing going on in your ears, but it's very dull. And it wasn't until I went to my first appointment to establish care with a primary care provider that mental health had even been discussed. And oddly enough, it came up through the PHQ. And if you don't know what the PHQ is, it usually asks questions like, in the past two weeks, how many days were you feeling down, depressed, or hopeless? And you had to check off the boxes, you know, none of the days, several days, every day. And I answered pretty candidly without really thinking about it. When it comes to filling out medical paperwork, it really never occurred to me that my provider was actually going to look at that stuff. And if you've been to a doctor recently, you know that whenever you're filling out new patient paperwork, you're basically asked to tell your life story. Nevertheless, she did. And during the visit, my provider, who was a nurse practitioner, by the way, had uh started probing me. The questions had been flagged, and she just kept going deeper. And I remember becoming very emotional because with every question, I started to realize that I was experiencing a lot of turmoil that I'd been carrying internally. And in my lifetime, I'd never been asked about my mental health. My culture doesn't really make space for that. I'm Filipino American. I grew up in a deeply religious household with people who worked in healthcare. And regardless of if it's mental or physical health, you had to be really messed up in order for anyone to take you seriously. My uncle had gone through some mental health issues when I was younger. And I remember my family more or less treated him like something was wrong with him. And there's honestly no room for mental health in the role that I grew up in. But I chose to be honest with my provider, nonetheless. And what really stood out to me about that encounter was she didn't dismiss me. She validated me. And we ended up having this entire discussion about the steps that I could take to stabilize myself. She had suggested that maybe I try an antidepressant, which I was honestly against at first. I had this real visceral struggle, the stigma of being someone who was quote unquote medicated. But what I appreciate was that she appealed to my practicality and she reminded me how important it is to take care of myself. And so I got started on Zoloft. We also determined that I was struggling with focus at school and work, and that maybe I needed to be evaluated for ADHD. And she wasn't really comfortable with prescribing a stimulant herself. So she ended up referring me to a psychiatric practice. So I got set up with therapy, and I also ended up meeting with this psychiatric NP. And this is where the story begins. So my provider was a really nice guy. Um, you know, he was an older male provider, very warm, very smart and reassuring. And we eventually came to the conclusion that I did have ADHD and that I also suffered from an eating disorder, too, and that maybe I would benefit from taking a stimulant that could address both. And so we landed on Vivance. I did everything I needed to do. I did a drug test, I did all the paperwork, all the blood work, and he even started me on Adderall and Guanphacine, but I ended up breaking out in hive. So that honestly ruled me out for any of the generic medication. But as I was going through this process, my insurance kicked it back. They weren't going to cover Vivance without a prior authorization. Part of the issue was that my provider had listed the wrong diagnosis code. He put down the eating disorder diagnosis when the primary reason should have been ADHD. I ended up following up with him about a month later and explained what I had learned, and he said he'd fix it. And that in the meantime, while we wait for my prescription, because we had we were pretty much operating under the assumption that I was going to get my medication within the next week, that we should follow up in three months. So three months go by and nothing. I tried calling my insurance. I tried calling the pharmacy. I tried to find out if the prior authorization even went through. Nothing. And when I saw him again for our three-month follow-up, I once again explained everything and, you know, was like, hey, it's still not going through. What do I do? He reassured me that we were gonna get it fixed. He asked me to give him about a week. He even gave me his cell phone number to message him if I'm still not able to get the medication. With me being ADHD brain, I ended up waiting more than a week. I think it was about maybe two or three weeks, and still nothing. And I ended up texting him, letting him know that the medication was still not there, and I got nothing back. He left me on red. I ended up calling his office. Nobody answered. I even tried emailing the practice, emailing him. There would be days where I would leave a voicemail, and the voicemail would say, please allow for like 48 hours for us to call you back. I would wait for 72 hours and still not get a call back. At this point, I was getting extremely frustrated. There were times where I would go in for my weekly therapy sessions, and there wasn't even a front desk person to greet me. My therapist would be the one to come to the door himself. And I don't know if that's how most outpatient therapy practices work, but it just felt like there was nobody that could follow up from me administratively. I was at this point where I was just waiting. I thought, well, maybe there's something I could do, right? I'm a pharmacy technician. I do a lot of work with prior authorizations already. Maybe there's something I can do on my end. So I did some digging. I called my insurance company. I asked them the right questions. And the technician on the phone had told me that that all my provider had to do was just fill in the correct diagnosis and also check off that I was 18 and older. It was that simple. I even texted him the form, and that was the first time I got a response back from him, which seemed pretty annoyed from what I remember. He had basically told me that that form is not going to work if I try to send it. I need to try and fail two other medications before Vivance is going to be approved, and that he knew what he was doing. And I tried my best to be respectful, and I even pushed back a little bit. I told him, well, if you look at this form, it doesn't necessarily say that. We already have a documented case of me trying and failing at all. We already have documented evidence that Guamphosene, which is a non-stimulant, isn't working. And nowhere in this paperwork does it require step therapy for someone over 18. All it needs is for you to fill out a few sections and sign your name. I was left on red again. And at that point, it had been almost four months since I was given this diagnosis and told that only this specific medication would help me. Four months of nothing getting better. My therapy sessions had basically become a place for me to process my frustration with this provider because it felt like I wasn't being heard. I wasn't being listened to. And my therapist, who was his colleague, could only offer reassurance. And it just didn't feel like anything was working. I tried other outlets. I tried, um, I tried reading self-help books, I went on trusted medical sites, I tried these mindfulness and other self-help apps, and nothing was helping. And eventually I got fed up and went back to my PCP. And she suggested that maybe we could refer me to another practice. But the only caveat was that I had Medicaid. And with me being on Medicaid, my options were pretty limited. It got to a point where I was really frustrated and I just said, Why can't you just prescribe it? She raised a pretty valid concern. She just didn't prescribe scheduled medications. I basically said, Look, I'd hate to lose you as my provider, but I really need someone who is going to actually be comfortable with prescribing this. I feel like I was given false hope, and I honestly need someone who will follow through. And sure enough, she validated me, and together we made the decision to transfer me to another provider in the practice who was an MD. And I finally made the switch. I told her my concerns. I even showed her the form and just asked her to fill it out directly. Like, please just entertain me and send it to my insurance. Thankfully, she said yes, she filled it out and it got approved. And I'll tell you, the first time that I took my viance, it was probably one of the most eye-opening and God. I'm getting a little uh a little choked up here. It was it was one of the most eye-opening and emotional experiences of my life. Because my whole life, I feel like I'd been wandering. I don't fit the Asian stereotypes, at least academically. I mean, do I have dewy skin? Yes. Do I look really young? Yes. Am I really smart? Yes. Am I pretty? Yeah. But gifted academically in the way that most people assume just by looking at me, that wasn't me. Throughout my childhood, my teachers would tell my family how brilliant I was and how well I absorbed information. But my ability to translate that by doing my homework and doing well on tests, being responsible, it just wasn't there. And for most of my life, my academics reflected poorly on me and on my family. And for them, it looked like I just didn't care, which was far from the truth. So when I finally took that medication, and I know this isn't how it works pathophysiologically, but taking a stimulant actually slowed everything down for me. It allowed me to focus on what actually mattered. And that moment was visceral because the best way I can describe it is like a windshield wiper. You know, when you're driving and the rain is pouring and it's really hard to see, and when you finally turn on your windshield wipers, it doesn't necessarily clear everything, but it at least provides a little bit of clarity so that you can drive. That that's what it felt like for me. And there was this part of me that that still wonders what if I had had this medication when I was little? What if what if I'd known sooner? And for someone like me who who constantly beats himself up for taking too long to do things, you know, part of me wonders, like part of me would have been able to finish medical school by 22, 23. Maybe today I'd be close to wrapping up my residency. There's a large part of me that wants to be angry about it. I mean, just talking about it right now invokes a lot of really raw emotions. And I so badly want to blame that provider, the nurse practitioner who dismissed me, who left me on red. And for some reason, I can't. Maybe that's my trauma speaking. I might have a touch of Stockholm syndrome, I don't know. I when I contextualize it, trying to access mental health care in the middle of a pandemic while also adding the lens of mental health disparities in the US, it's astonishing and it's sad. Because I know there's a lot of people out there who have the same lived experience as I do. And part of me has Has to ask, would things have been different if I wasn't working in healthcare? And in retrospect, I think I can say this with full certainty. I don't think it would have been any different. Because I was already working from a place of disadvantage. I had Medicaid at the time, which already limited me from the start. And even with every resource I could bring to the table, it didn't make the system any simpler. It just meant that I knew what I was up against. I'll give you an example. In my work as a medical assistant, I work with a lot of patients on Medicaid. And there are people who have severe chronic conditions that require serious medications to manage them. Dupixen, for example, it's a biologic that has been around for years. And it's pretty much the gold standard for the condition it was created for. And a lot of Medicaid patients have to jump through enormous hoops just to access it. And what's amazing about the place that I work at is that we have an entire team dedicated to handling prior authorizations. People whose sole job is to fill out that paperwork, do the digging, and do the coordinating. And these people single-handedly are responsible for ensuring that people who have some real barriers to care, perhaps the most significant barrier, get taken care of. And as a medical assistant, I would have killed to have had a prior authorization team because when I worked in oncology, where there were tons of prior authorizations that I had to get approved for imaging, for narcotics, even for simple things like magic mouthwash, those were things that I had to handle on my own. And even on my best days, when I was getting these prior authorizations through like clockwork, I knew that those patients were still being forced to wait because I had other duties. I had to see patients in clinic, I had to take phone calls, I had to check people in, check people out. It still sucked. So even knowing the language of the system, even knowing how to communicate with providers and knowing how to navigate it, I'm not sure it made the difference I thought it did. Honestly, part of me kind of wonders if the deference that I gave to that provider was my own barrier. Maybe I should have been more aggressive, more outspoken. You know, someone shared something with me recently that really stuck. She talked about her experience in the hospital where she felt dismissed by her providers. As a woman of color, she had grown up in this culture that had taught her to always respect doctors, never speak out, because if you speak out, you're difficult. And the perception is that difficult patients have worse care. They have worse outcomes. And I'm not trying to make this an episode about race, but I can honestly see how being an Asian American, being a so-called model minority, is also a barrier to getting good care. And it's not necessarily about how other people perceive you, it's about how you were raised to think, how you were raised to act, raised to behave. That right there is very interesting to sit with. These experiences really shaped how I approach the system. And I've come to realize that no matter how much you know, no matter how much formal education you have in healthcare, in the business of healthcare, in the social determinants of health, it does not make navigating the system any easier. My first instinct, obviously, is to just basically turn the whole system over on its head and start over. And that's a nice thing to think about. But I also know that with the social psychology, the social neuroscience of it all, we crave order. We crave structure. And it's ironic because this whole thing was messy from the beginning. But the through line for me is advocacy, specifically self-advocacy. It's one of those buzzwords that you hear when people voice out their frustrations about the healthcare system. Always advocate for yourself. And I'm all for that. But there's a part of me that needs to stress something. Advocacy isn't just speaking up, it's being tactical and thoughtful about how you speak up. A couple years ago, one of the headlines that was essentially part of the impetus for me starting this podcast was surrounding the murder of the CEO of United Healthcare. His assailant was someone who had been deeply hurt by the healthcare system. Someone who didn't feel seen, didn't feel heard. And I know that many of the people listening to the show probably don't fit into that camp. At least I hope you don't. It's something we ought to sit with. Not the hurting people part, the feeling unseen part. Because mental health is serious. Advocating for your mental health is serious. And when people feel like there is no legitimate path forward, some of them stop looking for one. So the question I want to leave with you and with myself is this how do we actually advocate? What does that actually look like in practice? For me, in its purest form, I think advocacy looks like you doing your homework. And I know that sounds pretty vague to say, but hear me out for a second. I don't like doing homework any more than the next person. But there is nobody who knows your body, knows your health better than you. That's not me saying to hell with the experts. That's far from what I'm saying. What I'm saying is that you are the only person who lives inside your health. And that means that you have to show up prepared, learn about your condition, learn what treatment might be involved, and be ready to ask those questions in the room. And if you don't have the questions in the moment, because sometimes a provider just drops the bombshell on you and says, I'll see you in a couple weeks or a couple months, it's okay to ask for more time. Ask to follow up sooner. When it comes to educating yourself, use the tools available to you, like social media, trust the medical content, even AI, but use them carefully. The internet is a tool, not an authority. Take what you find there seriously enough to bring it to your provider, but not so seriously that you stop listening to your provider. And honestly, take what your provider says with a grain of salt, too, because not everything they tell you will apply to you specifically. And that's why it matters to find someone who actually listens to you. Shop around. And I'm not talking about the type of shopping you do until someone gives you a painkiller. I mean, look for a provider who meets you where you are, who's willing to engage with you as a person. There are providers out there who are simply under-resourced. And on the other side, there are some who are just jerks. You can't control that, but you can control where you put your energy, where you bring your business to. And I want to be clear about something else. Podcasts like Scrub Talk or your favorite medical influencer, even a board-certified physician on social media, none of that replaces a licensed practitioner who knows you, someone you've built a rapport with, someone who knows your medical and social history, someone who can work with you on a plan that actually fits your life. And the last thing I'll say here is this it also takes time. We have been conditioned to think that the healthcare system delivers fast results. And in many cases, it does. But no disease processes, especially chronic conditions like mental illness, move on a timeline that we can control. Getting on Vivance was eye-opening for me, but there was also a lot that I struggled with while being on it. Just like I struggled with antidepressants, because it took more than medication. It took a multidisciplinary approach. It took a village. And I mean that literally. I had to keep other people in my life involved. People like my grandma, someone who was not open to the idea of therapy or medication, someone from a generation and a culture where those things simply weren't discussed. But she is someone who I trust, someone I love, and someone that I wanted in my corner. And I had to be strategic about bringing her in, letting her know what path I was taking and why. And a lot of that came from me having to learn about my diagnosis. We had to work together on it, and we still are. I also had to let my friends into that part of my life too. And honestly, it was probably one of the most uncomfortable things that I did because coming from a background like mine, where you're taught to hold things together and not be a burden to people, to just handle it, asking for help from the people closest to you is quite vulnerable. But it mattered, it made a difference, and it was worth the discomfort. Your health is paramount, and you don't have to navigate it alone, but you do have to be willing to show up for yourself first. That's the work, and it's ongoing. Okay. Well, that feels like a pretty good place for us to end. If there's one thing I want you to walk away with, it's this mental health matters, and so does your role in taking care of it. A few years ago, the U.S. Surgeon General noted that we are becoming lonelier. And as good as the medicine gets, as good as the technology gets, as much progress as we make clinically and medically, I think it's very easy for us to hand off our autonomy to the people who are trained to handle it. And listen, that's not entirely wrong. You should listen to the experts, you should follow their guidance, and you should consider their training. But that doesn't mean you get to be uninvolved. Being a patient is not a passive act. And I know that it's easier said than done because honestly, some days are just hard. Some days you don't want to show up for your own health. I'm still in therapy today, and there are days where I just don't want to sit down and talk. Days where I just want to sit in silence or talk about anything other than what I actually need to address. And thankfully, my therapist gives me that space. But I think that from my own experience, it's very easy to do a lot of work and feel unrewarded for it, burn out and give up. And that's the last thing I want for you. There will always be peaks and plateaus. That's not failure. That's just part of the process. I'd also feel remiss if I didn't speak directly to the people who come from backgrounds similar to mine. And I'm not just talking about people who identify as AP, it extends beyond that. People of color experience mental health differently. People from immigrant families, cultures that think collectively, that prioritize the group over the individual, can find that the collectivist framework becomes its own kind of trap when you're trying to understand yourself, trying to feel better, trying to name what's wrong. It's also worth considering the mental health of healthcare workers. We are the worst patients. We tend to prioritize other people's safety and well-being over ours. And as beautiful as that is, it can make it feel impossible to carve out space for your own healing. That tension is real and it deserves to be named. There's a philosopher named Ludwig Wittgenstein who said, The limits of my language are the limits of my world. When I was having those panic attacks, I didn't know what they were. Partly because naming something makes it real. And what's real is scary. But here's what I know now. If you are ready to name what's going on with you, just like any diagnosis you're afraid of, go looking for it. Because the answer, as scary as it sounds, might also be the one that sets you free. Anyways, thanks for listening. I'm Dominic Ramos, and this is Scrub Talk.

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Dominick Ramos

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