Normalizing the Mental Health Struggles of Healthcare Professionals - Dr. Michael Foti, Clinical Assistant Professor at Touro College of Osteopathic Medicine

Michael Carrese: Hi, everybody. I'm Michael Carrese, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. 

As regular listeners know, we enjoy learning about osteopathic medical education programs on the podcast, and we've taken kind of a national tour of sorts in recent months with stops in Buffalo, Orlando, and Des Moines. Today's episode takes us to New York City, where Touro College of Osteopathic Medicine has its main campus in Central Harlem. 

Our guide to learning more about what the program offers and to give us a report from the front lines of medicine and medical education is Dr. Michael Foti, a clinical assistant professor of Internal Medicine at Touro University and coordinator of the Standardized Patient Program. Dr. Foti's primary interest is in academic medicine, so we'll be double-clicking on that topic, and we'll also talk to him about his interest in the current mental health challenges of healthcare providers, among other topics. 

Thanks so much for being with us today, Dr. Foti. 

Dr. Michael Foti: Thank you. 

Michael: We like to start with learning more about our guests, and in your case, what got you interested in medicine and then osteopathic medicine? 

Dr. Foti: Yes, definitely. Medicine itself...I've been interested in kind of all my life. It's funny, my grandmother always tells a story of when I was five years old, and my brother had the chickenpox. We walked out the doctor's office, and I was like, "Hey, I want to be that. I want to be a doctor.” So, that's been a constant my whole life. I think that once I started applying to medical schools out of undergrad is where I started learning more about osteopathic medicine itself. 

At the advising of my pre-health advisor, I shadowed an osteopathic physician. Even to this day, I have to understand concepts. I can't just memorize things, and when I was reading about what osteopathy meant, and using the musculoskeletal system to treat not just the musculoskeletal system, but everything else -- all the other organ systems -- and they really go down to the basic physiology and how it works. That really spoke to me. I was like, “Wow, I really understand that. That's really interesting. You have that extra tool.” And then the philosophy spoke to me. The body's tendency to heal itself, approaching our patient care with mind, body, and spirit in mind...all of that really spoke to me. Once I started at New York Institute of Technology, College of Osteopathic Medicine, I knew that I had made the right decision, for sure.

Michael: Do you remember a particular moment where you were like, ‘oh yeah, this is a good fit for me?’

Dr. Foti: Yeah, for sure. It was week one. I recall being in a lab and they were talking about osteopathic medicine and what we were going to be doing and I was like, “Wow, this is cool. I'm definitely in the right place. “

Michael: Your five-year-old self was very prescient, it sounds like. 

Dr. Foti: I guess so.

Michael: So, what would you like our audience to know about the program at Touro, and particularly what you think might set it apart?

Dr. Foti: Yes. It's a fantastic program. I think one thing that stood out to me from day one is when I walked the halls to just get a feel of the campus and meet everyone, almost every faculty member’soffice had a student or students in their office speaking to them, whether they were reviewing topics or just chatting. There was just great camaraderie of the students and the faculty together, you know, and I've just never seen that before, really. It was the student presence and faculty presence on campus and all of that. I was like, “Wow, I hope one day that'll be me here at Touro, having students in my office and just chatting or talking about career advice.” That really spoke to me and that's something that now, fast forward to seven months later, I can tell that was reaffirmed. Students are in my office all the time.

If you see my wall here in my office, it's full of pictures with my students. I mean, they're phenomenal here. That's the other part of Touro. The students are so engaged. They're so motivated. They have such a desire to learn from us and spend extra time outside of the classroom to learn, whether it be career advice or just what they're learning that day. It has really stood out to me every day and it's been phenomenal. 

Michael: And on the curricular side of things, what would you like to highlight? 

Dr. Foti: I think that Touro is one of, I think, a unique set of institutions that are really advanced in terms of the medical education trends that are out there right now. We've really taken hold of the flipped classroom model and self-directed learning...understanding that all students learn in their own unique way. It’s also understanding that to really have the students grasp a lot of these high yield concepts, a big part of that is having them be engaged in the classroom, do the learning before in terms of the basics that you need to grasp, that basic fund of knowledge you need. So, watch these recorded lectures, read these texts, come in, and now let's discuss them with a faculty member who's really advanced in their field, who can really engage the students in that. 

I think it's a fantastic model of medical education that I was always researching before I came to Touro and then once I got here, it was a plus. I think this is what we should be doing everywhere in education. So, I think that sets us apart from a curricular standpoint, too.

Michael: What a different task for the instructor in that setting. Instead of being the ‘sage on the stage’ and lecturing, it’s interactive, small group learning. How do you pick up those skills and how are you finding that work? 

Dr. Foti: I think actually in a way it takes a bit of the pressure off the faculty because you don’t have to lecture for an hour and try to engage the students. I think that has been a misstep for so many years...expecting the students to just absorb all of these high yield concepts by listening to a lecture. Instead, as a faculty member, you're doing less talking because now you're engaging with the students and you're really going back and forth and having a discussion. In my opinion, the faculty seems so engaged and they really seem to love this model of learning and I think that's why it's become such a hot kind of trend in medical education.

Michael:  Yeah. Less performative and more of an ‘on the ground, in the mix’ approach. 

Dr. Foti: That’s exactly right.

Michael: Which I would think would be kind of energizing in a way for faculty. 

Dr. Foti: That's the perfect word to use. Because like I said, you're more engaged yourself, right? Instead of having to stand here and just talk, now it's a back and forth discussion. And that's how you can really also gauge as a faculty member, are my students understanding these high yield topics? That's the best way to gauge it. There's no way to really gauge that besides exams to say, “oh, after these x number of lectures, now are they ready?” With this new approach you're seeing in that moment if you’re students are ready for this and if not, they can also recognize that because now they have to be engaged. They have to participate in high yield questions for an hour or two hours or three hours, and they're now determining -- instead of right before the exam or a couple of weeks before the exam -- in that moment, in that topic, they’re realizing, “I need to go back and review this again.” So, it's on both sides of it. 

Michael: Well, and you can catch problems earlier instead of finding out after the first set of tests that people aren't getting it.

Dr. Foti: That's exactly right. Yes. 

Michael: Well, that's great. It almost makes me want to go back to school, but not quite. So, I noted that you help oversee the Standardized Patient Program, and I wanted you to help people understand what that's about -- what a critical role they play in medical education generally speaking -- but also help us understand how you guys use them in particular at Touro. 

Dr. Foti: Yes.The major reason I came to Touro is to be able to run this program. Standardized patient programs are relatively new in medical education. If you go back twenty, thirty years, they didn't have these types of programs. But I myself as a student did have that. Maybe you can't tell this now, but I was a very shy student in the beginning and I had a lot of stress and angst over those standardized patient encounters. I'll explain what they are in a moment, but my standardized patient encounters are what prepared me to develop those interpersonal communication skills to be a physician in that respect, in terms of building the trust, building the rapport with my patients.

So, to explain to the listeners, standardized patients are trained actors who simulate a clinical scenario. They simulate what the patient experience would be. In most respects, it's actually a medical student's first patient, so to speak. It allows the student to practice their clinical skills -- their history taking, their physical examination, discussing a plan -- but also their interpersonal communication skills. I believe all of our students have that innate ability to display empathy, to display compassion, to really connect with our patients. But it does take time to really hone those skills because as a student, you're so focused on, ‘I have to get this right. I have to do this clinical exam maneuver correctly. I want to pass my Objective Clinical Structure Exam (OSCE).

As they continue to do it, they become more comfortable with it and then they can start honing those communication skills and say, “How is that symptom affecting your quality of life? Is it affecting your day to day?” They can ask those questions and really build trust because at the end of the day -- and I know any physician would agree with me -- if you don't build trust and a good rapport with your patient, it doesn't matter how much knowledge you have. They will not trust you to do the plan that you have for them, to take that medication, to go get that MRI. So that's what I work with my students on every week as the coordinator of the program.

Michael: I worked at an academic medical center and saw some of these sessions. The other thing that was really cool about it is that after the scenario is completed, the standardized patients can give a little feedback and say, you know, this was good, but I noticed you never made eye contact with me, or I laid out a prettybig issue there and there was no follow-up, that sort of thing. So that's kind of a nice aspect to it. 

Dr. Foti: Yes, exactly, and they get both written and verbal feedback at different times and the students love it. I mean, this is what they really want feedback on. They always get feedback from faculty on that other aspect -- the clinical skills, both in the lab and at part of the OSCE -- but they really do enjoy that because it's something they want to improve upon for sure. 

I give the students a benefit of the doubt. You know, a lot of my, my colleagues say I act as a champion for the students and I really do. Maybe I’m closer to them in age and closer to their training experiences. It's not, in my opinion, a lack of empathy or a lack of compassion when, for example, students may not express empathy in a clinical encounter . Maybe the standardized patient script called for the actor to say, “My mother passed away a few years ago.” Let's say a student said, “Okay, what about your father?” That answer didn't really give that empathy. 

You have to understand, we can only simulate a clinical scenario so much. In real life you don't have an overhead prompt saying ‘two minutes remaining.’ You know what I mean? You’re not thinking ‘I have to leave and go do this test or some evaluation or some sort of SOAP note that's going to be graded.’ It’s a different environment. It's very much a test atmosphere and they get locked into that, so they forget almost to display that normal empathy and compassion that they do have, and that's what I try to get out of them.

The improvement from first year to second year is 180 degrees. It’s remarkable how they improve it. It’sgreat to watch. 

Michael:  It must be. I'm also wondering about AI and the role it's going to play. I think most people consider the idea that it's going to replace doctors to be pretty ridiculous, but it can perhaps -- in its decision support with diagnostics and other things -- maybe place less of a premium on the amount of knowledge you can memorize and how quickly you can look it up, and more of a premium on interpersonal skills. I wonder what you think about that. 

Dr. Foti: Yes.Doctors will always need to access their databases to look things up. No doctor knows everything at all times. We’re human beings and the brain can only hold so much knowledge. So, we always accessing our evidence-based resources. It's funny you bring this up because I actually recently attended an Elsevier workshop on AI. It's interesting because I agreed with it so much. I think AI, in the interpersonal communication skills, can play a great role in simulation -- standardized patients are under simulation -- in enhancing that simulated clinical scenario even further. Let’s say you're using, virtual reality and you could be at the bedside and actually have a patient's family member there and the kind of the chaos of that type of environment before you actually go into the clinical world. I think that can play such a role in helping students get that early clinical exposure in a safe environment because it's not an actual clinical environment before they go out there. We have so much applicability for that. 

Michael:  And it's early days. So it’ll surprise probably all of us, in the ways that it impacts things, but it's going to be a big help in a lot of ways, I think. 

So, you've been involved in medical education. You mentioned the New York Institute of Technology and Touro, of course. At the national level, you're a member of the national faculty of the National Board of Osteopathic Medical Examiners. So, I'm wondering, with that lens, what are a couple of things that you think really need to change about medical education and  where are you hoping to make an impact playing that role? 

Dr. Foti: I think that we can dig deeper with regards to self-directed learning. Much of our curricula across the country have a lot of these mandatory sessions where students are expected to be somewhere and have to sit there and absorb a certain amount of material. We have to understand that all students really learn differently, right? Some are more video based, they’re more visual based. That's why myself as a student and as a professor, and a lot of my students, love resources like Osmosis because they're visual learners. Others need the texts. Others just need to listen to some sort of audio. Others need to look at lecture slides. Everyone learns differently. 

So, I think we need to be implementing more flipped classroom and digging even deeper into self-directed learning not only in terms of how they absorb the material, but also in what manner. Not just being in the classroom or not having that option, but also giving them all the resources. We, as faculty, should vet those resources and make sure they're evidence based and then say, “Now you have audio resources, video resources, texts at your disposal that we know are evidence-based. Go and use them as you see fit.” As long as you have learned the material, that's the most important thing. We can't expect everyone to learn the same. 

Secondarily, I think we could do much better in making a lot of our sessions more interdisciplinary. What I mean by that is having a clinician and a basic scientist or a clinician and a pharmacologist be in a learning session together. For example, when I was a student, I struggled with pharmacology and that was because we learned it in isolation. ‘These are all the medications you need to learn, now learn them.’ A lot of that is rote memorization. I really grasped it when I was a resident in clinical scenarios. That’s when it stuck in my brain. 

Why not start that now from day one? Have a clinician and a pharmacologist and go into these medications in the context of the clinical scenario that they just learned. We need to be more into this scenario working together. 

Michael: On the self-directed piece, how does that look when it's working really well?

Dr. Foti: I think it looks well in terms of really keeping the classroom sessions optional, but also providing a vast array of resources that are evidence based. Really, we have to dig deeper into what resources are out there because I think there's a lot of institutions that don't know about a lot of these resources, and they allow the exams to tell the students, ‘okay, I need to kind of readjust here.’ Not us. 

We can't assume that the students all learn the same, and just say, “You need to do this because I know if you do A and B, then C, you're going to do amazing, on your test.” We can't assume that. Let them determine those two, and if they struggle on exam, it's okay. It's not the end of the world. Readjust. We, as faculty, serve as mentors and guides to guide them and say, “Okay, what did you do for this exam? How can we readjust? You know, work with them as opposed to kind of giving them these expectations that ‘we know everything you need to do to be successful.’ We have to allow the student to determine that. That’s life, really. 

Michael: It’s really more of a partnership model in learning. 

Dr. Foti: Exactly. Right. Yeah. Big shift.

Michael: So, I know you have an interest in the mental health challenges facing healthcare providers. I’d love to learn what that's rooted in and have you tell us what you're seeing and hearing among your students and colleagues these days in that regard.

Dr. Foti: Definitely. Yeah. This has been a growing passion of mine, especially of recent. You know, I've given a talk at my institution here in Middletown, also at our Harlem campus. I'm going to be speaking at our Montana campus as well later in the month. It's rooted in my own personal struggles, actually, with anxiety and depression. 

I was a first year resident when COVID-19 arrived here in the U.S. in 2020. I witnessed a lot of suffering on a daily basis. I was part of the RRT, or rapid response team. Those are teams that respond to changes in a patient's clinical status and you know, sixteen hours a day, every half hour, we were responding to emergencies in the hospital. I was seeing patients in their thirties and their forties passing away from COVID-19. I was calling their loved ones to tell them that they loved them because they couldn't do it themselves. I was holding my patient's hands when they were passing away because their families couldn't come into the hospital. 

This was every day for months on end. I witnessed all of this, but I really never processed any of it. And then soon after that, unfortunately, I lost my mother suddenly to what we found out to be lung cancer. So, a lot of this happened. I had to go right back to work. We're still in the thick of COVID. I don't think I really ever fully grieved her loss at the time, unfortunately, and I think I still kind of am doing so now.

Once I graduated residency, I suffered severe anxiety and panic. I changed jobs thinking that it was the job itself. It was not, of course. It got to a point where I had to go to the emergency room. I thought, “Well, is this my heart, or is this a panic attack? I really don't know.” So I went to the emergency room. It wound up being that everything was normal. I had anxiety and depression and I felt a lot of shame because I couldn't live up to that five-year-old expectation that we talked about. I shuttered away from my son. I shuttered away from my wife. I felt ashamed to be me. 

One day, finally, I mustered up the courage to say, “I really need to get help if not for me, but for my son and my wife.” And I did. I saw my primary care doctor. He started me on an antidepressant. I saw a psychologist every week. I put in a lot of hours and really worked on myself and tried to figure out what was going on. I came out so much better for it. 

I learned that I kind of tied my identity with being a doctor and when that came into question, so did me as like a person. I think that was a part of it, for sure. That's why I’ll tell all your listeners that for those in the healthcare profession, being a doctor, being a nurse, being a PA -- whatever profession you have in the healthcare field -- it’s not who you are, it’s what you do. Because if you pair that with your identity, and if that ever were to come into question, it could be really detrimental to your health.

Another part of it is that the shame that I experienced goes into a lot of the stigma about mental health. That kind of goes to your second question, and I'll talk about that too, but the stigma that exists is that as healthcare providers, we're afraid to speak up when these things happen because it's seen as a weakness and we might lose our careers. But just as much as we are healthcare professionals, we're human beings, right? It's part of the human experience to suffer, to grieve, to lose and to experience the effects of that, which can be anxiety and depression. And so to expect that we wouldn't have that happen to us is unfair. It's naïve, really, because we're just as human as anyone else.

So, I would tell anyone, you know, we are human. It is part of the human experience. Get the help that you need. It is not a weakness. Rather, it'll be the strongest thing you ever do to get the help that you need. 

Michael: There's a common phrase about you have to be healthy yourself to be able to help other people, and it couldn't possibly be more true than in the healthcare profession, right? 

Dr. Foti: That's exactly right. I mean, for medical students to be able to take those high stakes exams and for medical professionals to be able to take care of patients, you’ve got to take care of yourself first, right? Like in the airplane, when the oxygen mask comes down, they tell you to put yours on first before you put someone else's on. You’ve got to help yourself before you can help others. You have to be your best self and get that healing that you need.

So, what I'm hearing in my profession and among my colleagues is that, unfortunately, the stigma very much still exists. I will tell you that many organizations such as the National Board of Medical Examiners are doing a lot to try to promote wellness. We just have a long way to go in terms of professionals such as myself speaking up. I think that's the way we combat the stigma is continuing to speak up and share our stories to normalize the human experience for healthcare professionals.

Michael: Well, I should thank you for speaking up and sharing all that with us. And I’m sorry to hear about that incredibly challenging period you went through. 

Dr. Foti: Thank you.

Michael: On the stigma thing, I'm just wondering...what are some things you think might work? What would have gotten through to you, I guess, is another way to ask that. If you can put yourself back in those days, was there anybody trying to say to you, “Hey, you don't have to be a tough guy here. It's okay to ask for help.” And if so, what would you have said to that? 

Dr. Foti: Unfortunately I didn't have much support in the healthcare field. In my personal life, I had a tremendous support from my wife and a very close brother of mine and sister-in-law. They were very much there for me in my darkest moments. But in terms of someone from the industry that I work in relating to me and saying, “Hey, it's okay that you're going through this even though you’re a doctor,” I didn't have that. 

What I would tell myself now is it's okay that you're going through this. Yes, you're a doctor, but you're a human being. Look at everything you just went through over the last three years. It's actually very much what my psychologist told me. He said look at everything you just experienced. You have to kind of give yourself a little bit of credit that you’re standing here today being able to talk about it, that you made the decision to get the help that you need. So, at that time, I was being told ‘you can do this’ but not from those I could relate to in terms of my field. 

Michael: Not from colleagues. 

Dr. Foti: Not from colleagues, right. Because I was too afraid to even speak up in that arena. It's hard. So, the more we speak up and normalize it, the more that we can and share these stories amongst colleagues, then our colleagues will feel more empowered to get the help that they need. 

Michael: Sure. What about medical educators? Is this being formalized in any way into med school curriculums? How can you help this next generation of providers get into a different situation? 

Dr. Foti: Yeah, I wouldn't say it's formalized into the curriculum. I have given a talk here at Touro COM. I've been reaching out to try to give more and more talks to other institutions. For example, I just spoke at the Council of Osteopathic Student Government Presidents, and I'm trying to speak up more and more. I'm just trying to reach as many students as I can. 

But I think as medical educators, this should become formalized as part of the curriculum, for sure. Because, you know, every medical institution has clinicians teaching their students and so if the students can relate to the clinician faculty that they look up to and respect so much and have that person tell them, “Hey, it's okay if you're going through this,” that helps a lot. 

My students have told me, “I want to be in your shoes one day, and you're telling me it's okay for me to feel this way.” It's got to happen across the board nationally and really globally. You need that person in that industry, to say ‘you're going to become a doctor one day and if you go through this, it's okay, because I went through this or I have colleagues that have gone through this.’ 

Michael: The role modeling is, is very powerful, obviously. 

Dr. Foti: Yeah. 

Michael: So as you know, we're a teaching company. We love to fill knowledge gaps. Is there a video or a course where you'd say “Osmosis, I would love it if you guys could address this issue.” It may be related to medicine and what we've been talking about, or it might be something completely different. 

Dr. Foti: Well, I’ve got to say, Osmosis is phenomenal. I’ll just put that in there not just because I'm here on the podcast, but I used it as a student myself and I loved it. But it's funny, when I looked through your series and catalog recently, one thing I might say is -- because you have many, several wonderful series -- but if you could have a series on guiding students through study habits, board study habits, or something along those lines and how to kind of maneuver going through their preclinical years, but also introducing studying for the boards and how to kind of fit that in, and using their resources appropriately for that, I think that'd be a wonderful series to introduce something along those lines.

Michael: Yeah, because obviously the test taking is such a huge, huge part of the experience. 

Dr. Foti: Yes, definitely. 

Michael Even though Step 1 has gone pass/fail. I think Step 2, also. Is there any talk about that with COMLEX going pass/fail? 

Dr. Foti: Level one is. Yeah. 

Michael: Oh, it is. Okay. 

Dr. Foti: Like Step One. 

Michael: That’s another reason to go back to school, right?

Dr. Foti: Right. That's right.

Michael: Although it's never going to happen. So, we have a lot of students and early healthcare professionals in our audience. You're around students all the time, obviously. What's your go-to advice about them heading out into the world and creating a career in these very challenging, interesting times?

Dr. Foti: Yeah, definitely. Don't become a cog in the wheel, meaning don't feel stuck in any career path. I think the beautiful thing about the healthcare field is your ability to pivot. You've learned so much to get this degree. There's so many avenues to be able to pivot to, whether to be into academia, business, entrepreneurial...what have you. There's so many ways that you can pivot in medicine. I think it's phenomenal. 

And two, to remind yourself why you're doing what you're doing, but also make sure that you're happy doing it. So, sit there and say, “Ok, this is what I've gone through. This is where I'm going. Am I happy on this path? Am I enjoying this?” You can be happy in medicine. It's not enough to say, “Oh, well, it's just stressful and you’ve got to stress your way through it.” Like, no. You should truly enjoy whatever you're going to spend this many amount of hours doing as a career. Make sure you enjoy it. 

So, I would say make sure you enjoy what you're doing, be adaptable and know that you can pivot into whatever career you think you have a passion for. For me, it was academics and I couldn't be happier.

Michael: Wonderful advice and a great place to wrap up the discussion. I want to thank you so much, Dr. Foti, for being with us today and more importantly, for all the work you're doing there to educate the next generation of healthcare providers. 

Dr. Foti: Of course. Thank you so much. Thank you for having me.

Michael: I’m Michael Carrese. Thanks for checking out today's show. And remember, as always, to do your part to raise the line and strengthen the healthcare system. We're all in this together.