Holding It Together (Kinda)
Here we will get real in our conversations about Mental Illness and Caregiving, and the messy reality of keeping it all balanced.
No sugar-coating, no clinical jargon—just real talk about the hospitalizations, the medication battles, and the toll it takes on a home
This is for the parents, siblings, and partners who are doing the impossible every single day.
Holding It Together is a home for the overthinkers, the multitaskers, and anyone who feels like they’re one spilled coffee away from a meltdown.
Holding It Together (Kinda)
When The Doctor Becomes Family with Dr Mohamed Elziam
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A white coat can make people think medicine is all control, clarity, and clean answers. Then a crisis hits your own family, and you learn how fast that illusion collapses. We sit down with Dr. Mohamed Elziam, a family physician, to talk about his brother’s late-onset schizophrenia and what it’s like to live in two roles at once: the clinician who understands diagnoses and pharmacology, and the brother who is grieving, advocating, and trying to keep everyone safe.
We get specific about the mental health system problems families run into every day: symptoms that get dismissed as “drug-induced,” discharge plans that assume motivation and capacity, and a fragmented pipeline where nobody owns follow-through once the patient leaves inpatient psychiatry. We also dig into the realities of schizophrenia and anosognosia, where medication noncompliance is not simple stubbornness, and where repeated decompensations can change a person’s baseline over time. Dr. El Zin shares why long-acting injectable antipsychotics can be a turning point, and why getting there often takes more persistence than families should ever have to provide.
We also unpack HIPAA and patient privacy, including the common misunderstanding that clinicians cannot even listen to family context. That myth creates silence where there should be collaboration, and it fuels caregiver burnout. If you’re supporting someone with severe mental illness, this conversation offers language, perspective, and a clearer map of the traps built into the system.
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A Provider Becomes A Brother
Michael MackniakHello and welcome back to the Holding It Together Kinda podcast. I'm your host, Michael Macniak. Today we're exploring a perspective that's rarely captured in its entirety. We talk a lot about providers and patients as if they're a distinct categories of people, but like two different species separated by a white coat and a sterile exam table. But what happens when that coat comes off and the provider becomes a family advocate? What happens when a physician, someone trained to diagnose, to treat, to control outcomes, finds himself sitting in a plastic waiting room chair feeling just as powerful and powerless as the rest of us? Schizophrenia is a diagnosis that doesn't just affect a brain, it reconfigures an entire family ecosystem. When it appears later in life, it isn't just a medical event, it's a structural collapse of the future you thought you knew. Joining us today is Dr. Mohamed El Zin. Mohammed is a physician, but today he's here primarily as a brother. His brother develops schizophrenia later in life, thrusting Mohammed into a dual role, the medical expert who understands the pharmacology, and the sibling who is mourning the person he grew up with. We're going to discuss the particular heartbreak of watching a sibling's world shift, the specific frustrations of navigating a mental health system that can feel uh sometimes opaque and bureaucratic, even to a doctor, folks, and how this personal crisis has reshaped his view of medicine, the quote-unquote system, and the enduring complicated bond of brotherhood. Okay, everybody, we made it. Dr. Mohammed is here, he goes by Dr. E, and we are back for another episode of the Holding It Together kind of podcast. And I'm really I've been really excited to have this conversation. And uh Dr. E and I have had some troubles with our schedules and mixing up time zones and things like that, but we're we're here. We made it and we're we're pinning each other. We pinned each other down, and now we're gonna have a good talk. Well, first of all, what I do is please introduce yourself and tell everybody what you're doing and what you're super excited about right now. And and I'm I'm actually interested in knowing a little bit more about the work you're doing, but that may not be what you're crazy excited about. So let's just the floor is yours.
SPEAKER_01Sure, sure. So, like uh you said, my name is Dr. Mohammed El Zaim. I'm a family physician practicing out of Richardson, Texas. I've been three years in practice, about three years, three years out of residency, and I've been doing a lot of like nursing homework and initially then I transitioned to purely more outpatient practice. And so now with this uh this AI craze and whatnot, we're trying to find like different opportunities. So I'm
Using AI To Give Time Back
SPEAKER_01trying to transition my practice more to the health tech side, and I met you at the conference as well, so he knows you know a little bit about the company, but basically trying to automate clinical audio transcription and stuff like that.
Michael MackniakSo I don't want to talk too much about that, but no, no, I think it's it's really important, you know, because we did we did do an episode with Emerson Kerr who talked about AI and the future of healthcare and and understanding that it's you know it's an it's going to be a very important valuable tool as long as we remember not to get away from the bedside manner and the human touch that makes medicine medicine.
SPEAKER_01Exactly. Yeah, yeah, yeah. So I'll tell a little bit uh so you want me to touch on a little bit more about the company?
Michael MackniakWell, no, I was just gonna say it's it's in and what you're talking about is a way to make so physicians can actually spend more time with their clients because they will have more access to information at their fingertips. And and it's just it's more efficient, it's a more efficient use of their time to be able to really dig in and give the clients and their patients the treatment that they they need and deserve.
SPEAKER_01Exactly. I think the whole name of the game that we're trying to do right now, I mean, not just me, but just people in general with this AI craze and its application into healthcare, is to find ways to kind of ease administrative burdens, at least on the doctor side, because half of our time right now is just spent documenting patient encounters or just how many times has probably your audience seen a doctor carry their phone or their their usually it's like their laptop, and they're just like side-eyeing you while they're writing notes on the laptop. It's just like in an inorganic interaction, and I think beyond that's one aspect, and the other as they do that just to save time on their documentation. So there's sort of like an arms race right now of trying to find the best use cases and whatnot to kind of people hit it at different avenues. There's like automated AI receptionists that a lot of clinics have now. There's like different features to kind of like make the EMR experience smoother on the staff. But on the doctor side, I think that's probably the the how what is uh the right word, it's the biggest area of opportunity is to kind of decrease administrative burden, which is documentation and whatnot, as much as possible, just for them if to leave time for the doctor to focus on just the patient encounter, patient interaction. And with our product that we we had that design in mind. So right now there's transcription products where if you go to the doctor, more likely than not, he's sort of recording ambiently in the background the interaction between you and him. So, like whatever he says, whatever you say, it's all captured by AI, and then turn into a medical soap note. So that saves the physician a lot of time, but there it could be improved on the process some more. We wanted to fully automate that process. So, what we did, we created like a device that is equipped with a microphone, speaker, and radio frequency antenna that monitors the location of the healthcare personnel, whether a doctor or whatnot. As soon as the doctor goes into the room, the system understands and it'll start automatically automatically recording. So the idea of the physician can go to room to room to room, all their notes are automatically captured, they don't have to interface with the technology. You get to see, as a patient, your doctor just interacting with you face to face. And I think that's the biggest draw of this type of system is that you want to bring you you want technology to to free up the the human connection part of it. And I think that's what's missing a lot in current encounters between patients and physicians.
Michael MackniakWell, and one of the things that you hope is that, you know, with the advent of the internet and all the technology that we've had, it seems like we've become busier. So so what I'm hoping is that the insurance companies and all the third-party payors don't expect more of the doctors because now they say, well, you got all this free time because you got this wonderful AI stuff. But I think that we're at a point in a breaking point where the the physicians and the offices will start pushing back. I mean, as we said in in I heard multiple times in Vegas, and I've and I've heard multiple times on this podcast, you know, a physician more or less says that they have somewhere between eight to twelve minutes to spend with a with a client, a patient, and maybe three minutes to review the chart. So, you know, if we could if we could increase some of that time and and really try to get our get those numbers up and the time spent with the patient, the number the amount of view res research and and all that. So basically, I'm definitely gonna want you to send me your information so that people that are listening can get information about your company. How do you say SAMEO?
SPEAKER_01Yeah, SAMEO Systems.
Michael MackniakSAMEO Systems, right? And I'll put that in the description for for everybody. But the interesting thing about Dr. E, Dr. Mohammed here is that we were talking and I was describing what what I do, and his eyes were lighting up, and he was just nodding and smiling, and like you know, I like he's heard it all before. And I said, and he he said, Well, I know exactly what you're talking about, but go ahead, doc, tell it tell everybody your why
Early Signs And A Family Loss
Michael Mackniakwhy you and I related and why we thought this would be a good conversation for people to hear.
SPEAKER_01Yeah, so I was really f interested in what you had to say and offer because I've ran into the same pain point. So just a brief backstory. My brother basically, I mean, he was doing okay up until his like early 20s. There started he started to show signs of just kind of like odd behaviors, and I didn't see much, I didn't draw the connection that there was something really wrong, but then it just started to progress, especially after our mom passed away of cancer at 49. And from that point after, I guess it set him off the edge and the symptoms becoming worse. He just started having just like weird thought patterns, talking about that we're all in a simulation, and and this is like progressing over the years. He also had like some depression, but ultimately he ended up going to inpatient psych and getting diagnosed with schizophrenia. And I was like, Okay, great. Okay, we have a diagnosis, we understand what now we can help the man, right?
Michael MackniakYeah, that's wish we'll think, but yeah. Well, let me start you for a second. Yeah, did you did you know? I mean, were you already a physician at this time?
SPEAKER_01I believe I was in residency when things started to get pretty bad, but I had moved back into my mom's uh house just so I can help her, and she was just like the last year of her life or whatnot, and he was living there, so I got to yeah.
Michael MackniakSo you saw it you saw it both as a brother and as a physician, yeah, exactly. And did you ever experience this the clinical denial, or did you just kind of say, okay, something's going on here?
SPEAKER_01Yeah, no, no, I so I got to a point where I guess it was just like, okay, we need to find an answer. Like, what the heck is going on? So it's like you search for an answer, and I I guess being a medical professional, like I just take things as they are, you know. It's like, okay, these symptoms fit this type of these cluster symptoms fit these type of diagnosis. So I wasn't really in denial, I was kind of more in the opposite of just seeking answers. And if the schizophrenia diagnosis or it kind of fit his picture. So, and then that's where I I was kind of, I was like pretty, I knew there was something kind of pro like seriously wrong psychiatr uh psychiatrically with him, but I just didn't know exactly what. Yeah, so I wasn't in denial, it was more the opposite. But maybe that's due to my my way of thinking or my professional.
Michael MackniakWell, sure. But I mean, you know, a lot of our family members that I talk to, just like any of us, right? I mean, you Google your fingers to the bone trying to find out an answer, trying to find out what's wrong with you, or and then then all of a sudden you're diagnosing yourself with these most crazy, off-the-wall third-world diseases that you'd never heard of before because they meet every symptom you have. And I, you know, I think that some people wind up looking for the answers that they want to hear, or they deny the answers that they don't want to hear. So I'm wondering like, is your training as a physician did that help you in a way, or did it almost hurt you in a way?
SPEAKER_01I would say uh it probably did help me. I mean, I was always accepting the fact that he might have something more serious than just like so I'll take it back. So, like, so for the longest time he had some issues with like substances or whatnot. So we took him to inpatient psych, and they're like, Oh no, this is all drug-induced, drug-induced, drug-induced, drug-induced. I was like, I understand drug-induced, but I I live with the man, okay. I know his finances, I help him out financially. Like, it's there, he's not using drugs at the time, so like we need, I think there's something more than just to chalk it up to like a drug-induced diagnosis. And that was the most difficult part because I don't know if he was gaming it, but every time he would go, it's like, yeah, I smoke, I smoke a lot, and they would just go with that, and that caused frustration on mine as a physician. It's like, okay, but then I ended up like trusting their judgment. I was like, maybe that was part of it, wishful thinking. Like, okay, maybe if it is all drug-induced and great, then all we do is just stop the drugs and you'll get better. But he never got get better, it was just always worse, worse, worse, worse over the years.
Michael MackniakWell, I I think that you you're identifying a shortage, a shortcoming of the system. I don't know exactly how to say it, but one of the one of the issues that I I really struggle with is around addiction, you know, the code morbid disorder. You so you a diagnosis. So you have the addiction and you have the the mental health disorder. So right or wrong or indifferent, whatever my clients are winding up in the hospital setting, it's let's stabilize the addiction, stabilize them the addiction, get them detoxed, let's get the addiction stabilized. And I understand the health side of that. But when you when you break it down, if you just don't get to that underlying mental health issue, I firmly believe, and you could back me up or not, I firmly believe that you're you're never gonna get to what's causing the addiction or the symptoms that are leading to the the uh bad behavior.
SPEAKER_01Yeah, I mean, I think a big
Drug Induced Or Something Deeper
SPEAKER_01issue to I I agree with you 100%, is that it's just also like like the system is fragmented. They that maybe it's just due to like like low staffing or just like low energy, but like no one uh reached out to me as his primary caretaker, right? It's like what do you think? Like, especially like like you you taught them, I was like, Hey, I'm a physician, like oh okay, okay, that's cool. That's cool. Yeah, I have some special insight. Like, why is no one asking for my opinion? I live with the guy.
Michael MackniakThat's really interesting. That's I see this is exactly what it why I thought this would be an interesting call because on the one hand, you said that you were happy and you you respected the diagnosis of schizophrenia. You were happy that and you respected their choice to not happy, but to to look at the how much potty was smoking and stuff like that. And at the same time, you're a physician who has something probably pretty damn valuable to offer these teams. Yeah, it's gotta be incredibly frustrating from your perspective.
SPEAKER_01No, no, absolutely. And I felt that way like all across the board. Like, even when he got out, like we went to I took him to his outpatient appointments or whatnot, and he would just like it was like the history of oh, I don't want my brother to come in. I'm like, okay. Okay, that's fine. I just wanted him to go and see a professional, but it's like, and then no one cared to just come to me. I get like that's another issue, right? It's just like patient privacy and stuff, they still have autonomy.
Michael MackniakOh, yeah. Oh, we're gonna get to that for sure.
SPEAKER_01Yeah, yeah, yeah. It was incredibly frustrating to to at every stage, every stage. He had a prison for a while, couldn't get even even less information. You know what I'm saying? Like, I'm like, no, no, I have information that might be useful to you guys, and he's telling you he's everything is okay, everything's hunky dory. It's like, but I have a different perspective that might help the clinical case.
Michael MackniakSo do you think that that's do you think that there's clinical professional friction there? You know, he's here comes a doctor, he's gonna tell us all the answers versus this doctor thinks he's got it already, or your profession, your your specialty is one thing, my specialty is another back out kind of a situation.
SPEAKER_01Yeah, exactly. Because like on my perspective, right? Because I did a lot of nursing homework and stuff. It's like if a patient's family calls me and it's like, oh, that he's a uh this person's sister is a PA, she wants to talk to you. And it's like, I guess you get that hint of okay, maybe you're crossing boundaries. But from my perspective, I like to hear everyone's point of view on this because it might help the clinical case. And if anything, if they are medically inclined or or have some knowledge, it might be useful to get it from their perspective. I think sometimes they feel like that maybe you want to take control of the situation as a as a if you're medically inclined, or you want to steer the diagnosis, or you want to steer the treatment in some sort of way. And so, but my suspicion is I think it's just they don't have the resources, they don't have the time to just kind of gather all that information. I think maybe the fact that I am a physician is might be a secondary or tertiary reason. But from my sense, I think it's just like, okay, we need to get this person out. What's the story? All right, we'll give them the treatment, let's get him out of there. Because they had the especially in the public system, there's a lot of patients they need to take care of, and I think it's just resource limitation more than anything else.
Michael MackniakUm what's so so valuable about your your position and your experience here is that when you understand the frustrations that families feel, number one, about not being listened to. And let me be point blank, I've said this a million times before, I'll say it a million times more. There is no law on any books anywhere that precludes a medical professional, a clinician, etc., from taking in information. So if they're giving you folks that line that I can't talk to you because I don't have a signed release, well, I'm not asking you to talk to me. I'm gonna talk to you and tell you the history, etc. And I encourage families and to really become educated, really become advocates and to learn to talk the talk because now I've been doing this for 30 years, over 30 years. So when I get on the phone with a physician or a PA, like you're talking about, this has been happening a lot because I have two clients that are really in and out of the emergency rooms and psych units and rehab facilities right now. And they're just, you know, it's their time to cycle through and heat up. But you know, what I found is again, you you you know what you're talking about, you know what you're saying, you're not afraid, you're not hammering and hawing. And and I'm just offering you a perspective that you otherwise wouldn't have. And certainly your position, Doc, from being a being a physician living with your brother, God, I would think your insight would be so valuable. But that just goes to show that this kind of thing doesn't discriminate, that time constraints or time constraints, no matter if you're a doctor, a lawyer, or you know, a mechanic, it doesn't make a difference. We're we're we all get we all get treated the same and hopefully uh it's nicely, right?
SPEAKER_01Oh, absolutely. I think uh they just I'm just one of just a normal person to them, which is fine. Um back to your point, yeah, it does even breed a little bit more frustration because I'm like I probably have a unique insight as far as like family history um from a family per uh member than other people. So like why why can't you take that? But then that then it goes to the issue. Oh, I don't want you to talk to him because the patients, I mean, I guess when it came to my brother, he knew what I probably would say, and then he tried to block information from getting there. So it certain diagnoses make things worse, that's for sure.
Michael MackniakOf course, and especially paranoid schizophrenia, right? But but you know, you have to be able to overcome that and say, listen, I you know, I understand my brother said that, but you understand that he's saying this to you as a manifestation of his illness, it's not anything but that. And and here's the paperwork that says you should be talking to me, right?
SPEAKER_01Right, right, right, right.
Michael MackniakWell, and and the thing that makes me happy is that you're a doctor, you're you're a young guy, you're coming into this, you have lived experience with it, and you're seeing it from the trenches on both sides. And hopefully this change is coming where doctors will be more appreciative of the family historians, of the good reporting that a family can offer to make your job easier, along with your AI and all that wonderful stuff, right? I mean, job is easier when you include the family and and whatnot.
SPEAKER_01Exactly, exactly. No,
Why Families Are Not Heard
SPEAKER_01I'm 100% agreeing with it. It's like, especially for like a big diagnosis like schizophrenia, it's just you need all the like typically those type of people, patients, they they're not the most reliable historians, so it's important to seek out that's my biggest surprise. I guess there's no seeking out of external information to help aid the case. I guess they have like maybe like repeat people that come in inpatient.
Michael MackniakOh, absolutely, yeah.
SPEAKER_01And they're like, Okay, we have all the information we need. They just they've seen it a million times, like. Medication noncompliance goes into psychosis, and here he is again. What other information do we need, really?
Michael MackniakWell, but that's what the and I agree with you with the frequent flyers, but the person who's presenting for the first time, you can't just pigeonhole them and say schizophrenia is schizophrenia is schizophrenia. It's like every cancer is different, right? Every and the way it impacts the person, the family, etc., is different. So I think that that's very important that we don't put cookie-cutter labels on people, and we're not just handing out pills that you know, the hot new drug of the of the day. And I think that that's you're bringing up a really important point. And and and I do agree with you. I think that there's a resource issue where they these the the staffing and and whatnot is such that they don't have time to be doing the outreach that they really should. And I I firmly believe that more and more physicians should be bringing social workers onto their staff just for this reason, if nothing else. And I do see that happening. I really do.
SPEAKER_01That that'll be amazing. Like if we had a social worker in our in our staff that can handle cases like that, especially if they have like a we have a primary care practice that can help patients like that. Because I run into a lot of I have schizophrenic patients of my own that I that I help treat, you know, and it's like the same issues, it's just the biggest one is like medication non-compliance, they're agnostic to their condition, and yeah, having an advocate that especially that's a late like social workers are heroes in a way is because they're like official advocates of the patient. And if we have maybe like an easy medium to to of communication, tell the case and stuff, but then that goes back to I guess them still not seeking external information is that's the friction because I feel like maybe it just adds complications to the to the case. Maybe it helps, but maybe they're thinking is it just adds further complications and more time.
Michael MackniakSometimes you get too many seats at the table, right? It's just too many voices. But but you know, my my goal is to really advocate that the medical professions start looking at this in terms of what happens when the when the patient leaves your office. So if you have a staff who's following up on did you get to your appointment, did you have you been taking your meds? Did you see the VNA? Did the you know, and all these different aspects of follow-up care in the community and the coordinating all those different care, which is obviously what I built my whole career around is the care coordination piece. I would love to see that, and I'd love I'd love for it to be it. I would just think it's I really think it would be a real help to the entire team, particularly the doctor, to have that information when they need it and where they need it, you know.
SPEAKER_01No, absolutely to piggyback on your social worker point. I think like anyone that's diagnosed with a heavy diagnosis like schizophrenia, if they're in any way part of the system, they need to be assigned a social worker or some care advocate. Over time, that would save them money, yeah, in my opinion. Yeah, because like right now, like when I'll give you an example. When my brother got released from the psych hospital, I went to pick him up, right? They gave him some paper about his follow-up appointment. No one, if I wasn't on top of his butt to go to the appointment, dragging him to the appointment, that wouldn't happen. And so what happens is okay, okay, once this script runs out, maybe he doesn't take his meds, and you're back into that same cycle, you know what I'm saying?
SPEAKER_02Sure.
SPEAKER_01And it's gonna cost the government money on the back on on on in other ways if they continue to be not treated. There's no systemic program or sit or or system that can take care of these people. I think that's what the biggest issue is.
Michael MackniakWell, especially for people who are not hooked up with services like their Department of Mental Health and other social service agencies that are out there, either state funded or private. That's definitely the case. And and I you you touched on something that drives me up a wall, and that is we know that this gentleman is in denial, we know that he malingers, we know that he doesn't take his meds, and we also know that he's generally not very uh uh ambitious, let's say he's he's not highly motivated. So we're gonna give him an appointment card and we're gonna hope that he shows up at our at our office. That's just not good enough. And and believe it or not, some of the psychiatric hospitals and the outpatient teams on the psychiatric hospitals subscribe to that model. I call it the medical model, where you're expected to you know take it upon yourself to get to that doctor's appointment. I'm sorry, my dog is on my lap because he's freaking out from the thunderstorms. So, yeah, so this guy can't even get off the couch, and you expect him to make it, you know, get on a bus or however and get to the doctor's appointment. And like you said, without you being there, that is that the the likelihood of that is suspect at best, right?
SPEAKER_01Yeah, and then guess what? And then we make it to the appointment, and then he says, You know what? I don't want my brother there, I don't want you talking.
Michael MackniakI know, I know, and it's and here you go having to fight that fight again.
SPEAKER_01Yeah, and then he'll tell them everything is fine. Yeah, are you having hallucinations? No, are you feeling depressed? No, you're taking medications, yes. You need refills, yes. Okay, we'll see you later. Bye-bye. Here's your follow-up appointment. And I'm like, what is going on with this? Because you know what I'm saying?
Michael MackniakYou have to be heard, you absolutely have to be heard. But I want to talk to you about some of the specifics of schizophrenia, if you if you don't mind. And I don't know if you've from your physician's perspective or from your brotherhood's perspective, may have some insight into this.
Noncompliance And The Autonomy Trap
Michael MackniakBut what do you think some of the biggest failures of the system relative to schizophrenia are? And and I'm talking specifically about schizophrenia, like I kind of think we're talking a lot about it, you know, the from acute care, even a doctor's office visit back out into the community, and that that push and pull between community care and inpatient care or community care and physician. So we really tackled a lot of that.
SPEAKER_01Yeah, yeah, yeah. So just to clear, can you clarify your question as far as like you want me to touch on like what are the deficiencies in in in regards to this specific diagnosis?
Michael MackniakWell, I we've been talking about schizophrenia, and and I don't get a lot of I don't I don't have a lot of people who have the kind of experience with schizophrenia that you do in terms of being a doctor and and knowing how the system's supposed to work for all of our patients. Do you think that there's anything specific? And it may be just what we already talked about is this lack of follow-through and communication. Is there anything specific to the needs of the schizophrenia diagnosis that you'd like to see more of?
SPEAKER_01Yeah, I mean, the this is kind of like a difficult question because it tramples or it touches on like patient rights and autonomy and decision making and whatnot. But the fact that the main feature of the diagnosis is that they're agnostic to their diagnosis, they don't think that there's anything wrong with them, is especially even in florid psychosis, which leads to medication non-compliance. And if they if they have, I mean, usually a lot have like preserved mental capacity, if they fake it or if they tell the doctors that they don't want to be treated or whatnot, they can still refuse treatment. So you get a lot of uh yeah, like like for example, when I went to his outpatient appointment, like listen, I I had to email her on a private email that she slipped me. I'm like, this guy is gonna take pills, he's not gonna take pills, like he definitely needs to be on the injections, like otherwise it's not gonna work. Like he's gonna be back into the inpatient psych next week, and then we'll be back here next month. And yeah, and then they said, Well, he has to he has to consent to that, he has to be in agreement with that. He's telling me he's taking his his his meds, and then but the biggest thing, yeah, it's like if you see a pattern of non-compliance, right? Is there a system which again it's a touchy subject because it it touches it it transgress it transgresses on their like on their rights in a way, and it's a more like legal, medical, legal discussion. Why don't we have a system where maybe we can get a panel of psychiatrists that can say, okay, this patient has a pattern, fluorid psychosis, inpatient psych, back to outpatient psych. Why can't we? I don't want to say forced, and I might get in trouble with this, but just maybe like to to to induce them to take their medications. Maybe we can give them one month shot of respiratone, get psychosis down, and then maybe we can revisit because they're they're not consenting in a state of floor psychosis anyway. That's uh that that's the biggest holdup, is they're agnostic to their condition and they have the right to refuse treatment. So then it leads to these cycles of non-treatment, which leads them into inpatient psych and even jail, as in my brother's case, because he ended up going to an inpatient psych, floridly psychotic, ended up hitting a nurse, right? Got charged with a felony uh from this incident. They sent him to the county jail. Guess what? The county jail, he refused treatment, right? Ended up in jail for like three months, got discharged. Guess what? They gave me a paper slip. Hey, you need to schedule he needs to show up to his follow-up appointment, outpatient appointment with uh MHMR. So I'm like, okay, this is like the craziest, most inefficient system if if they're not taking treatment. So I hope that answers.
Michael MackniakBut you you just touched on so many things that I want to back up for. You're right that this topic is very touchy, and a lot of people in the profession and in the legal community and in the clients' rights community get all up in arms about it. But I will say that probably 90 to 99 percent of the people who are listening to you and I have this discussion right now are absolutely agreeing with you that we need to be able to do more to acknowledge that this individual is not in the proper state of mind when he is refusing treatment. Therefore, we have to be able to take more, for lack of better word, I'm gonna say aggressive steps to get him to his baseline. So then we can work from the baseline, say, okay, now you are at your baseline, what we would, you know, euphemistically say normal, quote unquote. Now we can talk to you in a rational way. So yeah, we're going to step on toes and people are going to get mad about this conversation, but but that's the reality that we live in when you are talking about severe mental illness, and the cycle that you just described is spot on for in so many ways. The non-compliance leads to the decompensation, leads to the episode that brings you back to the emergency room, or God forbid, in into an involvement with the police, and as your brother experienced, right? So, so there's that. That's an argument. And and you know, we many states, I'm from Connecticut, we do not have an outpatient commitment statute that would require compliance with a medical protocol. And we probably never will in Connecticut just because of the way that well, there's certain powers that be in politics that go into it, but other states do have it around the country, but they find that it's very difficult to enforce and implement. It costs a lot of money to do so because there's lack of this outreach that we were talking about before. And and when it comes right down to it, you say, Well, how exactly am I supposed to enforce this? Does this mean if this guy refuses to take his meds or he's not taking his meds, I gotta pin him down and give him his meds? Well, we can't do that either. So somewhere in there, there's is there's an answer that we need to be willing to have this conversation. I I I went round and round one time with an advocate telling me that her client has rights. And I said, he absolutely has rights. That's and I respect those rights, but right now he is completely floridly psychotic, and his decision making is so compromised that he does not have the capacity to exercise those rights. And oh my God, that was that she it's I set her off on a way, you know, you can imagine. I mean, you know, I thought that I was making a very rational sound point, but she didn't want to hear from that from a patient's rights perspective. We'll get back to our conversation in just a minute, but I want to take a second to talk about something that many of us in this community deal
Caregiver Mental Load And A Tool
Michael Mackniakwith every single day, and that's the mental load of caregiving. If you're like me, your brain is probably filled with appointment dates, medication schedules, and a never-ending list of questions for doctors. It's exhausting trying to keep it all in your head while also trying to show up emotionally for the person you love. That's exactly why the team at the Care Coalition created the Care Navigator Journal. This is not just another notebook. It's a tool specifically designed to help you to stay organized and more importantly, to help you feel a little more in control when things start feeling really chaotic. It gives you a dedicated space to track medical updates, manage daily tasks, and even process your own thoughts. Imagine such a thing. Your well-being matters just as much as the person that you're caring for. If you're feeling overwhelmed and looking for a way to stay organized, I highly recommend picking one up. You can find it right now at www.carecoalition.org slash holding it together. Again, that's carecoalition.org slash holding it together. It's a small way to start holding it all together, one page at a time. All right, let's get back to the show. Your your brother assaulted a staff member at a facility he was
When Psychosis Meets The Court System
Michael Mackniakat, and this is not to defend that or anything, but I have I I see that, and I that makes me cringe too when a a person is working in a facility with clients who are psychotic or or or whatever. You know, they're experiencing their own form of mental illness. And and I hope that I get a response from people on this one because it's it's an important discussion. To me, it it doesn't make sense for me that a nurse would turn around and press charges against somebody who was, for lack of better terms, doing his job as being floridly psychotic, as you say. I just don't understand how that that happens. Of course, he's not supposed to hit her. Nobody's supposed to hit anybody. But he again, he's not doing it because he had in law we call it the mensrea. He did not mean to do it, he didn't have the thought process to go ahead and do something criminal. So the fact that it went that far to me is just it it screams, it screams of just a broken system. It really does. And the last thing I want to ask you because you get into this let me let me touch on this point.
SPEAKER_01The lady that you're referring to, I think she would be on board with you with your rationale as far as like he shouldn't be coming down with an assault charge because he is psychotic, right? I think she it's a basic point because that's a feature he's not himself. So who pushed it who pressed the charges? I I think it was like a facility, yeah, it was a facility thing. Really, yeah, yeah, getting him out, and then it was just uh a mess, like going back to jail.
Michael MackniakYeah, it's just then you're expected to follow your terms of probation, right? And now how are you gonna do that if you're psych if you're experiencing psychotic episodes too?
SPEAKER_01Yeah, well, the good thing is like out of the out of uh like part of his, I guess his plea deal, they have different programs, right? So after he got his charge, he's like you could, I forgot what they call it, but there's basically like a program where he has to comply. He he goes to he has to comply with the treatment regimen, right? Uh and then there's like he has to check in with like an I guess a mental health officer like once a month. I'm like, why that's perfect, perfect. We we we we have the system in place, okay. But why do we have to wait for the person to go through the court system in order to do that, right? Like, why can't we put that in the beginning to prevent things like that from happening in the first place? So go to to go back on your point on the family side, caregiver side, at least to like caregiver burnout, caregiver, caregiver fatigue, and just like a sense of hopelessness. It's like you're trying to help the person that doesn't want to help themselves. And the system, it has the right intention, it definitely wants to help them when they're inside the system. But if they don't have a system to help the person outside of the system, they're just gonna keep going back in the system.
Michael MackniakNo question about it. And and you know, you start, and we could go around, we could go around with these issues for for a long time because these are important, very important issues, particularly around when should we be able to impose what you just described. I would I would consider to be an outpatient treatment, an outpatient psychiatric outpatient treatment statute. Uh you could go that route or you can go a probation route, which if you don't follow either one of them, it you run the risk of going back to jail. And and and I think that they're they both have their place and they both sometimes have the persuasion power. I don't know what that's not the right word, and coercion isn't the word I want to use either. But you know, if you know you have a sword hanging over your head, you're you're gonna behave yourself theoretically. Sometimes, unfortunately, people with advanced stages of of psychosis aren't able to do that under the best circumstances, right? And I did also want to say that I have seen medical staff people get the shit kipped out of them.
SPEAKER_01Yeah.
Michael MackniakI mean, and really hurt bad. Yeah, I've seen I've seen it in schools, I've seen it with you, and that's not cool, that's not right. And I'm not at all trying to say that that's okay and you should blow that off and ignore it. That is not what I'm trying to say, and I don't think you are either, and I don't think that woman that he assaulted would say that either. I mean, there's a line that we have to draw, but but I think I think we have to be, especially if we're we're in this profession, a little bit on the side of I don't know, understanding where it's coming from. Does that make sense?
SPEAKER_01I mean, yeah, I I agree with you 100%. I think uh I mean to to to tie it back to the medical legal aspect of this, which is very important, it's like, okay, you want me as a physician, right? You you you don't want to do no harm and you want to do things to benefit the patient, right? So allowing the patient to have full autonomy over a psychiatric in select cases like this one, okay, you can make the argument that that his decision making is harming himself. And and if that's the case, then we he needs to have at least maybe like an assistant uh assisted decision maker, or somebody has to make those on his behalf.
Michael MackniakYeah, guardianship, conservatorship, something along those lines.
SPEAKER_01But that's uh almost impossible to get, you know what I'm saying? So really, yeah. I mean, uh we we talked with uh two lawyers about it, and he said uh you know, the process is is very difficult in Texas to get to a point where you have the authority to kind of induce treatment on him.
Michael MackniakWell, that's and that's true anywhere. I mean, I think that people are are mistaken and they have a mistaken belief that well, if I'm a conservator or a guardian, I could just tell him that he's gotta go and you know the ambulance has to take him. That's just not true. That's just not true. But one thing that you that we keep sort of touching on and dancing away from really quickly is
HIPAA Myths And Sharing Context
Michael Mackniakthis idea of confidentiality and privacy. People call it HIPAA. HIPAA's HIPAA is a privacy and confidentiality rule. I'll give you that. But it's not the you know, we use HIPAA like we use Kleenex. It's an it's a they use it like it's a generic term. HIPAA is a very specific rule, but for for purposes of this discussion, we talked about how frustrating it can be from a person from a parent's perspective or a or a brother's perspective when we Have to figure out ways to backdoor HIPAA and other privacy rules. And I think if people would get a better understanding, and when I say people, I don't mean the laid people, I mean the people in physicians' offices would have a better understanding of what HIPAA tells them and what it says as opposed to hiding behind it, it would go a long way. For instance, folks, HIPAA, HIPAA specifically, when you go to the doctor's office and you sign a HIPAA release form, that release form is not saying anything along the lines of, I know that you cannot tell anybody anything about me. It's just the opposite. If you really read that form carefully, and none of us do, we all just sign it because if we want to get treated, this is what we got to do. The HIPAA form basically tells you under what circumstances your physician and your treaters can shall, must, and can release information about your health care. And that's what the HIPAA release form is. And I think that more medical staff need training around the idea of bringing in other people like families, like the brother, who also happens to be a physician, to talk to us and join this team so that we can all pull the oars in the same direction for the benefit of our mutual loved one or patient. Do you think that that would be a benefit to people in your offices that you see?
SPEAKER_01Absolutely, because I did not know about what you told me as far as like if you call up a hospital, they're like they they can listen to what you have to say.
SPEAKER_02You know, absolutely.
SPEAKER_01So educating people about those different ways where you can help within the system itself, I think is absolutely invaluable. It's it'll be very big help to any office or or even families, especially families.
Michael MackniakSo I think you got like a three-hour training on it if you want me to come in because it's important, it really is. And one of the things that that used to be uh I don't hear it as much anymore, but it used to be you'd call up and you'd get somebody on the other end of the phone saying, I cannot confirm, nor can I deny that Dr. E is here as a patient in this facility right now. Yeah, so I got to the point where I'd be like, Okay, this is attorney Mike Maknac. I know that you cannot confirm, nor can you deny that Dr. E is not a patient, right? I said, but I'm not asking you to do that. I'm just gonna tell you about Dr. E. And if he happens to be there, let him know or let your doctor know this, this, and this, and this. I mean, I to the point one time where I called up and said, Yeah, I know you're not gonna tell me if he's there or not, but just tell him I'm I'm on my way with his cigarettes and I'll be there in an hour, you know, that kind of thing. It's like I know he's there, I know you you have to go through this song and dance, but kind of let's cut the BS and and and just help me help me to help you to help him, right?
SPEAKER_01Yeah, yeah, yeah. No, absolutely. I mean, HIPAA is very valuable, obviously. Everyone has rights to kind of choose where their health information is going, but it does it makes things kind of like people are wary of any lit litigious actions towards them, and it just makes sort of like a very scared system, especially not psychiatry.
Michael MackniakOh god, it's creates logjams. There's just no two ways about it. We have a logjam system as it is, and HIPAA and all this, as you said, this paranoia around it makes that logjam even bigger and harder to break through.
SPEAKER_01I need to learn about uh how other people, how other countries actually deal with their severe psychiatrically ill people in their population and how they kind of go about that because I'm sure everyone, every modern country has patient privacy laws and like HIPAA and whatnot. But maybe they have different uh ways they handle this type of situation, but it definitely needs to change because the current system is definitely it helps people acutely, but on the long-term side, it it doesn't if people don't have a maybe family that that that enforces compliance, which at the at the end of the day it's always left up to the patient. But there's patients that don't have family that don't follow up, that don't you know, like what happens to those patients?
Michael MackniakYes, yes. We look at we don't look at the macro level, even even the doctors when they're going through trying to, for instance, say whether or not they should uh commit your brother to an inpatient facility, they're looking at him in an in an acute moment right now, right here. Here's what's in front of me. They're not listening to you coming in and telling the whole story. You know, he was chasing me around the house with a knife just 20 minutes ago, you know, that kind of thing. And I'm not saying that was your brother, that is another case that I did have. But we really need to look at the totality of the circumstances and get beyond just the one patient who, as you said, has no friends or family, and look at how, as a community, as a society, we can wrap up. Because as you were getting at before, how much money can we save if these people don't recidivate back into our emergency rooms and our psych units?
SPEAKER_01Exactly, exactly.
Michael MackniakThat's what it's all about, and the trauma that they go through by having these decompensations and what they put their family through with each one of these decompensations, it's just it's terrifying.
SPEAKER_01No, it makes their condition worse, it makes their prognosis worse over time. It's like it's not useful to the patient, it's not helping. And if you can make an argument, it's hurting the patient by not enforcing or having some sort of system to guarantee that they get treated. I mean, you see that with the homeless population. I see, yeah, uh, yeah, like you go, like homeless people, a lot of them are schizophrenics or have some type of severe illness. They'll get like maybe they do something off, they get sent to the inpatient psych, and then what and then like if you go to any inpatient psych hospital, like right outside the hospital, you'll see like homeless people with their their psych garb when they were in the inpatient psych unit, they just get discharged back into the back into the outside world, and then until we wait until another thing happens, and then it's just repeats the same cycle. So, not to be to beat a dead horse, but yeah, it's just a problem that needs fixing. But I feel like it's it has to be on more of like the lobbying side, political side. The biggest issue, I think the biggest hurdle is this patient autonomy, legal rights and whatnot, which I get, but there has to be some nuance in navigating it with specific patient populations that like their whole patient condition kind of hurts their hurts themselves over time.
Michael MackniakI think we can't, I think we need to get to the point where we're not afraid to ball fall back on a best interest standard, yeah, and and look at it and say, you know, am I doing am I doing harm by not doing something, you know, in terms of the Hippocratic Oath? And so let me ask you this question: how is your brother now? How's that relationship and how how is all that doing?
SPEAKER_01So my brother now,
New Baselines And Long Acting Injections
SPEAKER_01I mean, we don't have the best relationship because part of his paranoia is he's paranoid towards me now, right? So he's had he has another caregiver, which is my aunt, so she kind of took over his care. The good news is he's taken he's finally on the injectables at the the two-month injectables.
SPEAKER_02Oh, good.
SPEAKER_01So he's improved a lot, but still not where he was probably like six, seven years ago. And I don't know if he'll ever come back to that point, but it just helps to uh you can't help but wonder. I mean, maybe are these frequent repeated like decompensations affected his new baseline? Like, is this his new baseline? They do.
Michael MackniakYes, that you the answer is yes, they do. Every one of them, it's it's a compounding effect.
SPEAKER_01Exactly.
Michael MackniakMore medications and the more of these episodes, it it is a compounding effect. So you're absolutely right. We need to be able to nip that in the bud, so to speak, right? And you know, you also see changes in people as they get older, right? And and we all change as we get older. Why do you think a person with schizophrenia wouldn't? And their illness will change and morph with them as we go through life cycles and life stages and things too. So I'm glad that he I'm glad that he's uh got somebody that's looking out for him. But you know, it's again it falls back on the family on a long-term basis to be that be there and be that caregiver. And frankly, without the families that are out there doing this work, our system is not designed to handle it. We just can't. It's suit it's too much. And it's not just with mental illness, it's with every type of illness. We need we need willing and able participants to be in the community and and uh helping us to help them. I really believe that.
SPEAKER_01That's why I think what you're doing is super valuable, and its intention is to help people, help families, but ultimately help the patients that are patients, the people that are going through this condition. And it's a lot. I think most people don't appreciate it unless even me as a physician, right? Like even before my brother, like med school and stuff, you go through and you see psychiatric patients, you see severe schizo, you see severe bipolar and whatnot, but you never really understand unless it's right there in your face how difficult it can be.
Michael MackniakYeah, and how it's gonna impact the the outside of your four walls. What what does it look like outside that that institution? Yeah, it's it's big stuff, it's it's heavy stuff, man. And I'm I'm really thankful that you gave us some some time and some insight into this from a physician's perspective and from a brother's perspective. How how now how are you just just to wrap up? You got anything big on the horizon with SAMEO systems? And
SAMEO Systems Update And Final Takeaways
Michael Mackniakyou you where are you with that whole process at this point?
SPEAKER_01Yeah, yeah. So right now we're building, we're still developing it, kind of finalizing the the build out of the actual devices. So all the software is done. So we're basically we're just kind of gearing up to launch, probably full launch. We're targeting at the end of June, early July. Oh wow, not really.
Michael MackniakThat's I thought you were gonna tell me two years. That's fantastic.
SPEAKER_01No, no, no. Yeah, you must be excited, man. Yeah, I'm pretty excited. I'm pretty excited. I think it will hopefully we get traction. We have another show upcoming in Vegas in August. It's uh AI four. Then we have another one, Smart Facilities Convention in Dallas at the end of the month. So I think it'll be good to kind of get feedback on how they perceive the product. Is it and the the the interesting is thing is is that we're gonna run into the patient privacy aspect of it too, because it's like we have a device that records inside the room, but oh yeah, you can the doctor's in there, so yeah, you are for sure.
Michael MackniakYeah, but I think I you know, you can have that sign, you can have a waiver signed for that. I anyway, we can get into that another day. So, anyway, I I really appreciate you being here, Dr. Mohammed El Zaim. You know, the thing that makes me happy is that there's guys like you that are out there in the trenches doing this work every day, and as you get into not only your technology side of the medical practice, but also the building your your hands-on patient side of your practice. I'm excited and I'm hopeful that there's going to be a lot more guys like you that recognize the need for sort of changing the way that the industry's operated for hundreds and hour hundreds or thousands of years, right? So really, man, thanks for being here. Thank you for your insight for everybody, and and and thanks for the work you do for everybody else.
SPEAKER_01No, no, no, same to you. I think you're doing valuable work, you keep helping people, and then I'm excited for your project to to to come and help a lot more people. It would definitely need it for sure, and I appreciate your time again.
Michael MackniakOh no, thank you for being here, and we'll certainly stay in touch, okay?
SPEAKER_01Absolutely. You have a good rest of your day, man.
Michael MackniakIt's easy to look at a medical chart and see a set of symptoms, a medication list, and a discharge plan. And the sterile light of a clinic, those are just data points to be managed. But we heard from Dr. Mohammed today, when that chart belongs to your brother, those symptoms are actually stolen memories. That medication list is a hope for a conversation that feels like the old times. And the discharge plan isn't just paperwork, it's your family's Friday night, your parents' peace of mind, your own sleep sometimes. Dr. Muhammad's story reminds us that this system isn't just an abstract collection of buildings and laws and insurance codes, it's it's a machine that families are forced to live inside of every day. We learned today that even a medical degree doesn't insulate you from the clinical denial or the sheer exhaustion of advocacy. As I always say, folks, mental health, mental illness does not discriminate in any way, shape, or form. So whether you have an MD after your name or a JD like me, or you're a layman just trying to find a bed for a loved one, the fear is identical and the hope is just as fragile. If you're currently navigating a mental health crisis with a sibling, remember that the system will try to turn you into a caseworker, a paralegal, or a nurse. But your most vital title, the role that you have to play, the one that the system can't provide and should not try to take away, is brother or sister. That connection is the only thing that the machine can't replicate. Thanks for joining us again for this look behind a curtain. Take a breath, look after yourself, and keep holding it together, even if it's only kinda. We'll see you next time.
