EP 25: Shrinking the Stigma of Mental Health

Episode Description:
On this week’s episode, we are joined by psychiatrist Dr. Garrett Rossi. Dr. Rossi shares the lessons learned on his non-traditional path to medicine and how he combated burnout during his medical training. We discuss the associated stigma of mental health labels, the anti-psychiatry movement, and changes we need to work towards to reduce the stigma.

Connect with our guest, Dr. Garrett Rossi
Website: https://shrinksinsneakers.com/
YouTube: https://www.youtube.com/c/ShrinksInSneakers

Transcript:
[00:00:00] Dr. JB: Ever wish for a safe place to have conversations that need to be had? A place where you could say the things that need to be said?. Well, welcome to Hope4Med.

[00:00:16] Hi, welcome back to the Hope4Med podcast. I am your host, Dr. JB, and today’s featured guest is Dr. Garrett Rossi. Dr. Garrett Rossi completed his psychiatry training at Cooper University Hospital. He has published articles in peer review journals, written a textbook chapter on sports psychiatry, presented at multiple national conferences, and currently serves in a leadership position as a member of the New Jersey Psychiatric Association. Welcome, Dr. Rossi.

[00:00:49] Dr. Rossi: Thank you so much, Dr. JB, for having me. It’s a real pleasure.

[00:00:53] Dr. JB: So first I want to start by congratulating you on a job well done. You just finished your residency, is that correct?

[00:01:01] Dr. Rossi: Yeah, that’s, that’s correct. It’s been a very long journey and psychiatry training’s total of four years, so it’s a little bit longer than some of the other medical specialties that people go into, but overall it was a great experience and I can’t say enough about the training that I had.

[00:01:18] Dr. JB: Again, congratulations, that’s a major feat and something that needs to be celebrated, so I’m sure my listener is celebrating with you. So, let’s go ahead and start in the beginning, so what made you decide medicine?

[00:01:31] Dr. Rossi: Yeah, it’s a very long story and I think it’s important to start all the way back to when I was in grade school, because that’s kind of where– and I’m not going to say the cliche things that a lot of people say, like, “I always knew I wanted to be a physician,” I actually did not know, but I had an interest in science. And specifically at that time I was thinking I wanted to work at NASA and maybe be an astronaut or something like that, so that was my initial foray into science. I always had a strong interest. The issue was I wasn’t performing well as a student at that time, and this is going all the way back to early, early grade school, like fourth grade. So subsequently at that point, I was evaluated by the child study team and they determined that based on my IQ and based on some of my other, all the neuropsychological testing that I had a learning disability. So being diagnosed with a learning disability so early on, it really kind of set my academic career up in a, in a poor way, because I was already kind of identified as a person who maybe wasn’t going to be a great academic performer, so things like working for NASA or being a physician were not going to be in my future. More realistic expectations were, had to be met at that point.

[00:02:46] Dr. JB: Oh, wow. And what was the learning disability you were diagnosed with?

[00:02:52] Dr. Rossi: So now, these days it’s changed a little bit. They specify, I mean, I know that these things because psychiatry training teaches you some of this stuff, we have to evaluate sometimes children in our child adolescent psychiatry training for things like learning disabilities, and now it’s changed to like where they would specify if it’s in the domain of mathematics or reading or language, so it’s different. Mine was kind of like a sort of unspecified. Basically, they knew I just wasn’t performing at the level I was potentially capable of and they didn’t quite understand why.

[00:03:25] Dr. JB: So that experience as a child, how did that affect you when you’re doing your assessments on kids during your training?

[00:03:33] Dr. Rossi: Yeah, I mean, recognizing that these, these labels don’t define you, I think that’s a key point for anybody, and this is big in my field of psychiatry because people have a diagnosis and sometimes they become defined by the diagnosis. “I’m depressed, I’m anxious, I have schizophrenia.” it really becomes something that they feel they’re incapable of transcending in any way, so for me, the lesson is that we’re, we’re definitely all capable of overcoming some of these deficits. Sometimes it’s just simple things like putting in hard work and effort but also, I think it’s about finding, especially for kids, what it is that interests them and trying to hone the training and education in a way that really speaks to that person because I feel like in my case, that’s a lot of what wasn’t going on in the traditional school system. I just needed to feel like the education was speaking to me in a way that I could really understand and get behind and find some passion for. So, my passion for academics came much later in life than most people.

[00:04:35] Dr. JB: Okay. So, you continued with your schooling and then graduated, and then what happened?

[00:04:41] Dr. Rossi: Yeah. So, I mean, as you could imagine, my schooling through middle school, high school age were not very good and I wasn’t really queued up to do anything spectacular. So I basically, when I graduated high school, I decided on criminal justice initially, so my plan was to become a police officer and that seemed like a good job. It seemed like one that, again, I was capable of, I had the grades for, et cetera, and I started pursuing that all the way from the bottom, basically. I was in a community college program and that basically only lasted two semesters before I was like, maybe college and academics are not for me, I’m going to go out and work. So that’s what I ended up doing after two semesters of community college.

[00:05:26] Dr. JB: Okay, and where did you work?

[00:05:27] Dr. Rossi: So after doing the two semesters of community college, I went to work for my father’s construction company at the time. So, he had his own business and he was doing general contracting, so I spent better part of the next like three or four years with him doing manual labor. And I feel, I feel like that was very valuable in my medical school journey, and the reason why that experience with manual labor and construction was important was because it teaches you about hard work, it teaches you about work ethic. That is an extremely important component, I think, to doing well in medical school is learning how to work hard. How to put in, put in a kind of effort, how to suffer through some of the difficult things that you’re going to be faced with, because although they’re different in the type of work, contracting has the physical components where with work as in medical school, it’s all, it’s all mental work. It’s all learning, understanding, memorization, but there’s very, there’s a lot of parallels and similarities and there’s a lot you can take from that experience and apply to your medical school journey.

[00:06:33] Dr. JB: And so you said you worked in construction for how many years?

[00:06:38] Dr. Rossi: About three or four years. In total, I think between my going back seriously to college and finishing my prerequisite courses and graduating with my bachelor’s, I had about a five-year gap total in my time. So during that five-year gap total, I was, I was either dabbling in college or working.

[00:06:58] Dr. JB: So you were in community college and you said, “ugh, this school thing is not for me,” got into construction, then what made you decide to go back to college?

[00:07:06] Dr. Rossi: Yeah, it’s a, it’s a funny thing. I don’t want to sound again too cliche or anything like that when I talk about it, but honestly I always thought I was meant to do more, so that really– and I knew I had that interest, that passion for science never really left. I was always reading things and watching things, and I was always fascinated by the great physicians and scientists of our time, and so I spent my off time kind of doing that and kept an interest and I thought I was meant for more. And I said, well, being a contractor for the rest– I watched my dad and he struggled, I mean, his business wasn’t always good, he didn’t always make a lot of money to support the family, so it wasn’t an easy life. And I said, well, I think I could do more and I don’t think I have to do this kind of work for the rest of my life. And it really wasn’t, I mean, construction was not a passion for me, really it was more of a means to an end.

[00:08:00] Dr. JB: Okay. And so when you went back to college with that feeling like I could do more, did that make the experience for going back easier?

[00:08:13] Dr. Rossi: Yeah, a lot of that comes down to mindset. And I definitely credit not only the manual labor, but also at the time I had spent a lot of time training for like the police physical examinations, so I was doing a lot of running. I was doing a lot of weight training. I was doing other things and, and I think those things also teach you a lot about, again, hard work, work ethic, being able to push through adversity, and I kind of took all those tools I had gained over that, over those years and applied them to school. And I think that’s really what kind of changed, was my mindset was very different. I wasn’t going there with no plan, I was going there with a very, a very specific goal, and that was to be the best in every single class I entered and I went with that mindset to really crush those, those courses. And be mindful of the fact that I started with community college, so when I went back, I went back to community college first and I did two years there for an associates degree before transferring to a four year college. So I’ve really done like the whole non-traditional medical school pathway in a sense, because I’ve had experiences at the community college level, the university level, and then eventually medical school and residency.

[00:09:23] Dr. JB: And when you went back to school, did that diagnosis of learning disability or learning disabled, did that follow you throughout college and so on?

[00:09:33] Dr. Rossi: So when I was in community college I did keep it at the beginning, and then when I was finishing my two years at community, I had to be retested and recertified for it. And basically the only accommodation that they were giving me was extra time on tests, like I had unlimited time to take tests. I never used it in community college and then I decided not to be retested and not to continue the diagnosis at that point because I felt like in my mind, it was very important that I do this on my own without any crutches, without any benefits, like I wanted to be, I wanted to really prove to myself that I was capable.

[00:10:09] Dr. JB: So when during this period of being in, I guess, college, did you decide on medicine?

[00:10:15] Dr. Rossi: So I think I was kind of like in, but not in, if that makes sense. I knew I wanted to do something in the sciences and I had developed like really passion for pretty much every course I took. So I loved physics, I loved chemistry, I loved organic chemistry, which is probably odd to say for most pre-medical students because nobody loves that course, , but I just love, I mean, I loved playing with the models, I loved drawing everything out on the paper, it really just spoke to me. So I knew I wanted to do something in science, but I wasn’t a hundred percent sure on medicine. And I’d say one of the big reasons why I wasn’t sure on medicine was because I really had no idea how to get into it beyond like doing well in my courses and like having a good MCAT score. I had like very limited understanding of what a good medical school application looked like. And I really, my family, the people I was associating with, we really lacked good connections for things like observerships or like opportunities to kind of mingle with, with current practicing physicians so that I could get some good letters of recommendation. I just did not have any of those things. And I wasn’t really sure how to go about it. And at the time it wasn’t a lot of this information is now readily available on the internet. And there’s also plenty of people that you can go to and services you can use to help coach you through that process. But at the time, that was kind of limited when I was doing this. This is going back to like maybe 20-, 2010 we’re talking, so it’s evolved a lot now, but for me, that was difficult. But I knew after having some experience with basic science research during my undergrad, I kind of knew at that point I didn’t want to pursue a PhD. I wasn’t, I didn’t really want to do bench science for the rest of my life. And I wanted to work with people and I felt like , medicine was the thing I really thought spoke to me, but again, I was kind of apprehensive because I didn’t know for sure how to really get started with it.

[00:12:10] Dr. JB: So, you decided to try and you applied and what happened?

[00:12:16] Dr. Rossi: Yeah. So that’s, that’s another, you know, I mean there’s a lot of pain in this journey for sure. There’s a lot of like down, there’s a lot of parts that were like really where it didn’t seem like it was going to work out, and certainly applying for medical school was one of those times. Again, I really didn’t understand what a good application looked like and I also didn’t understand like what to apply to, like I never applied to any of the D.O. programs in the United States. That was probably a mistake, looking back on it, I would’ve maybe had a better shot at some of those programs. And I applied to a very small number of schools in the Northeast, basically surrounding the New York, New Jersey, Philadelphia area, and so I probably didn’t apply to enough places, but I also was lacking some of those key things that I think they look for when they’re trying to make a decision on applicants. While I had the grade point average and I had the MCAT score, I didn’t have those other, those other extracurriculars that they’re looking for. Things like volunteer experience and with other physicians or working as an EMT or something like that, something that would kind of show that real true passion and interest. So with that said, ultimately it was rejection after rejection from the U.S. schools.

[00:13:31] Dr. JB: But you still became a doctor, so then what happened? It sounds to me like you didn’t give up after you got your rejection.

[00:13:39] Dr. Rossi: Yeah, no, no. Well, I mean, you might imagine it’s a difficult time, because you’re thinking, what direction do I go now? You’re faced with this like kind of a situation where it’s like, well, you could take another year and you could potentially try to beef up your application. So, I had some thoughts, I was like, well, maybe I’ll go through EMT training, maybe I’ll work with my local ambulance corps for a year. I had some other ideas. I was like, well, maybe I could meet up with some of these, maybe meet some of these other physicians and get some, some time in their clinic to get to know the day-to-day work and maybe get a good letter of recommendation from one of them. I was thinking like that route, but I was also saying to myself, at this point, I’m already a little bit older than maybe your traditional medical student, so I was thinking about like, how much longer do I want to delay this process? So ultimately what that led me to was the idea to apply to the Caribbean schools. And in my mind, there was two Caribbean schools that I thought were reasonable to apply to that had relatively good reputations in the United States, and that was St. George’s University and Ross University.

[00:14:42] Dr. JB: So those Caribbean schools, do they have rolling admissions or how does that work?

[00:14:47] Dr. Rossi: Yeah, it’s not the same. It’s definitely not the same process as what you would think with medical school in the United States. So, what ended up happening was they have a rolling admissions process, you can apply at any time. And I remember going for the interview for , St. George’s specifically, and I drove out to Philadelphia to meet one of their alumni who was conducting the interview– and she’s a great person, I still keep in contact with her today and she’s actually doing really well as an oncologist– but it was not like what you would think a traditional interviewing process would look like for medical school. I’d meet her at her apartment in Philadelphia and we sit down and talk for 45 minutes or so and then she wrote her assessment on whether or not she thought it was a good candidate, and ultimately a few, I would say like maybe a week or so later, I had an acceptance letter saying that they had reviewed my scores, my grades, transcripts, et cetera, and agreed with admission to St. George’s. Ross was a little different, they were a little more formal. I actually went out to a place in New Jersey where there’s, because they’re affiliated with DeVry and they have a DeVry campus, and I actually met with somebody from Ross who wanted to interview, it wasn’t just like an alumni, it was a more formal interview process. And both of those interviews went great, because I think based on my scores and based on my conversation with both those individuals, they could see I probably had what it took to be a good doctor, but they knew that I was missing some of those pieces and so it was going to be hard in the states. And both schools had offered me acceptance and I decided to ultimately go with St. George’s University.

[00:16:23] Dr. JB: Okay. And so, how was that experience being in medical school?

[00:16:29] Dr. Rossi: I want to say that,, if you go into it with the mindset that somehow a place like St. George’s is an easier experience or it’s going to be less rigorous than what you’re going to find in the United States, you’d be completely wrong and you’d be making a major error in judgment there because when you, when you go there, it really is kind of like a survival of the fittest scenario. And it’s not, it’s not a knock on the, on the university. I mean, I’m happy with the education I got and they, they gave me an opportunity when nobody else would, so I can’t say enough about that chance and that opportunity, but at the end of the day, there’s a little bit of stuff that I think people don’t understand about these Caribbean schools that’s really important when you’re making the decision to go to one of them. So, as you might imagine, they accept a lot of people and sometimes they accept people that maybe aren’t good candidates to begin with, but they’re willing to give you a chance, and I’m not saying they accept everybody with really poor scores, but they do accept a larger number of students than what you would see in a typical school in the United States. And basically they put, they put you to the test because everything is maintaining a certain mean weighted GPA, so if you don’t maintain a certain average, you can get dropped from the program at any point. Basically, the fear of being dropped or failing out is constantly there during the time. And that’s one of the things I remember most vividly because even if you were a good student and which I was, I did really well while I was there, I always had in the back of my mind, any one wrong move might put me in a bad position here.

[00:18:07] Dr. JB: Hmm. Interesting. And that’s not just grades, it goes beyond grades?

[00:18:12] Dr. Rossi: Well, I mean, here’s sort of, like I said, when I talk with most of my colleagues that went to U.S. schools, a lot of times, like first term and sometimes even the whole first year, it’s basically pass/fail. It’s not a mean weighted GPA and our mean weighted GPA was, I think when I was there with 75%, now I’ve recently heard it’s 85%, which is pretty tough. I mean, to maintain 85%, an overall 85 percentile, that’s asking a lot for a lot of students. And that starts from day one, that starts from first term, even when you’re just getting used to being on the island. And when people ask me, they go, “well, weren’t you so happy like being on a Caribbean island?” And I was like, well, not really, because I didn’t enjoy the island very much. I had a few chances to like explore and to take a few breaks after like midterms or finals, but ultimately I was there putting in work every day. And I mean, and I’m talking like anyone else would do in medical school, 10-, 12-hour days at a desk in an air conditioned room basically, not necessarily outside on the beach or enjoying what the island really had to offer.

[00:19:18] Dr. JB: You said your class was larger than you would find in the U.S., so how large was your incoming class?

[00:19:24] Dr. Rossi: Yeah, I think mine, when I was coming in was almost a thousand students.

[00:19:29] Dr. JB: And how many people made it to the end?

[00:19:31] Dr. Rossi: So how many people left the island? I want to say we we’re somewhere about 680 people.

[00:19:39] Dr. JB: Left the island?

[00:19:41] Dr. Rossi: Right, graduated the first two years.

[00:19:43] Dr. JB: Oh, graduated, I thought you meant like they didn’t make it, like they got dropped.

[00:19:48] Dr. Rossi: So, no, those are the, those are the people that made it. Cause I only remember that because of a statistic I saw on one of the surveys. How many people were offered the survey, the ending survey, like the survey they provide at the end of the two years. So, that was only the first two years. I guess an important point here is with a place like St. George’s, you go there for your first two years, and that’s where you’re doing all of the academic, lecture type of work and a little bit of clinical work, but mostly it’s like being in college again, learning all of the necessary prerequisite stuff to get you ready for clinical rotations. And then when you come back for years three and four, there going to be in hospitals within the United States, and they have various affiliations that actually change pretty much every year, depending on, I would argue probably depending mostly on money, but I don’t know all the fine details, but I knew they tend to have changing hospital affiliations. But they are more stable than other Carribean medical schools, which I think is important.

[00:20:42] Dr. JB: Once you get past those first two years, are you kind of set or is that fear of being dropped still present?

[00:20:49] Dr. Rossi: So it’s less likely at that point. And the reason behind that usually is clinical spots are hard to come by, so if someone’s not going to do well, they, the hope is that they would probably not do well during the first two years before they take one of those clinical spots. So a lot of times once you get to year three and four, you’re kind of, you’ve kind of made it, so to speak. You still have, of course, your board exams to pass, which can hang people up to, I mean, I’ve seen people lose out because of failures on CK or something along those lines.

[00:21:23] Dr. JB: And so you’re on this beautiful island, you’re not able to enjoy it. You’re studying tons of hours a day. And how did that, did that affect you in any way?

[00:21:32] Dr. Rossi: Yeah, I mean, I think that’s one of the lessons I really took from that experience and then I applied to my residency, was that you need to keep something for yourself. So what I mean by that is if you have a hobby or interests outside of medicine, you’re going to want to at least carve out a little bit of time each week to do that. Because one of the mistakes I think I made was actually going way too hard, way too fast. And then kind of by the end of the first two years, hitting the wall a little bit.

[00:22:03] Dr. JB: But I can’t see how you could have done it any different because the fear that you’re going to be dropped out of this Caribbean medical school and you had to have, you said 70, 75%?

[00:22:14] Dr. Rossi: 75%, yeah for my class. I think the other thing to be mindful of is that while is, depending on how you’re funding your education, so for me, like I said, I come from a blue collar background where resources were pretty limited, so I had to fund my education through student loans. Now, when you’re taking student loans out for hundreds of thousands of dollars, that adds even more pressure, I think, to your desire to succeed. And, unfortunately all of these things take the pleasure out of learning because learning can be a lot of fun and enjoyable, but when it’s, when you’re faced with that kind of pressure, both financially and academically, it does hurt you.

[00:22:55] Dr. JB: And so how did that kind of pressure affect you?

[00:22:58] Dr. Rossi: I mean, I think I handled it well initially, because it was new and I had a lot of energy and I was very, very motivated. So basically my, the mental strength that I gained over those years off and away from academics, I was able to apply very successfully to the training. However, towards the end of the second year, that’s when I really started feeling the pressure because they changed the way some of the classes were structured. I personally am an independent learner and I prefer to do like the lectures virtually and learn on my own. I just am much better that way, I always have been, but they started making some of the classes mandatory to attend, and there was a lot more lab time and things of that nature. And so it was kind of cutting into my traditional way of learning and I was resisting that, which you know, is never a good thing. Anytime someone’s resisting, you’re putting additional stress and pressure on yourself because you’re like, this should be different. Why isn’t it different? Look how good I did in the first couple of terms, now I’m here and it’s getting, it’s more difficult, and my grades are slipping a little bit, all those things started happening. And I think, I think that’s when I started panicking a little bit towards the end and I think that’s kind of what hurt me going into my Step 1 as well because I was pretty burned out by the time I hit my Step 1 board exam.

[00:24:21] Dr. JB: That’s interesting. You’re a medical student and you’re feeling burnt out.

[00:24:24] Dr. Rossi: Yeah, exactly. It starts early, right? Burnout, I think it starts early, and a lot of these things about burnout though, I feel like are systemic problems. And lately what we observe as physicians, is that a lot of the burden falls to you as the individual to figure out how to recharge your batteries and how to avoid feeling burnt out. But there’s not enough responsibility, I feel like, on the systems for some of these things and some of the ways that not only medical school training is, but also the way medicine is practiced.

[00:24:57] Dr. JB: Hmm, so talk more about that. What do you mean? How could the system do better?

[00:25:02] Dr. Rossi: Yeah, I think it’s, it’s the things that eat up your time. One of the things I can think about as a, as a physician now and having gone through my residency training that took majority of my time was documentation. And a lot of times I was documenting with legal things in mind, I wasn’t documenting with like the patient’s interests in mind. I was documenting, did I hit all my points? So that I’m going to be sure if something, if there’s an adverse outcome, I’m going to be covered and that’s not really, I think the way to practice medicine, unfortunately. I think that’s one of the biggest problems we face as physicians. It’s always kind of worrying like, are we documenting appropriately? Are we saying everything that needs to be said? And it’s a little unrealistic because we’re all still human and we’re going to make mistakes, we’re going to have oversights, as trained as you are, you’re still going to face those situations. So I think that’s one place certainly that leads a lot of people to feeling just kind of burned out from the process.

[00:26:05] Dr. JB: That’s true. I mean, it’s been shown by research that EMRs are contributing to this burnout epidemic.

[00:26:12] Dr. Rossi: Absolutely. And I mean, like, I’ll say I was trained in my training on, I think, three different EMRs. I used the VA system, I used Epic, and I used Cerner. And I got to say like, people love Epic, but for me, Epic was way too busy. It was actually contributing to more– like, it has tons of great information, but it’s impossible I think for anyone to process all of it in, in any kind of meaningful way. So to me, like while people say it’s a great EMR, maybe arguably the best EMR available, I did not find it that way, and I thought because it was too busy.

[00:26:51] Dr. JB: So you’re telling me that Epic is not the holy grail?

[00:26:53] Dr. Rossi: Yeah. I mean, not the, you know, they’d probably want to kill me for saying these things, but it’s just like, and again, this is, of course we have to take I’m biased. I have my own opinion on things, I have to recognize my own bias here, so I’m not saying my opinion is gold here either, but just from my experience, I actually thought in many ways that was contributing to more of the difficulty with documentation than it was actually helping. So it’s a great concept in a way, provide an abundance of information so that everything is there at your fingertips, but I think it’s overwhelming and again, it all takes away from the most important thing, which is patient care. That’s one of my biggest things I think is, and psychiatry is maybe one of the worst places now because they want psychiatrists to practice like family physicians, they want you to be able to understand the intricacies of the mind in 15 or 20 minutes. And that’s, that’s very, very hard to do. I think even 30 minutes is not enough time.

[00:27:54] Dr. JB: Really? So they’ve cut back on the amount of time you’re able, it’s not 55 minute session anymore?

[00:28:00] Dr. Rossi: So a lot of places will say something like this. They’ll say you have 30-minute follow-ups, let’s just say we’re talking about follow-ups, you have 30-minute followups, but we prefer you to be able to do it for 20 minutes. That will be kind of the way it’s, it’s phrased to you, so it’s like, yeah, we’re happy. Now, I’m not doing outpatient work so I’m largely spared of a lot of those aspects of it. I’m doing inpatient work as a psychiatrist, which is definitely different. And that was one of the things that actually attracted me to inpatient work was the fact that I wasn’t responsible for these like kind of timely visits. I could structure my day how I wanted to, as long as I saw my patient load for the day.

[00:28:36] Dr. JB: Wow. That’s very interesting. So, in 20 minutes, is this just essentially medication reconciliation, or are you supposed to be counseling during that time period too?

[00:28:45] Dr. Rossi: Well, yeah, I mean, so that’s a great point. I think one of the things you’re hitting on here for sure is the aspect of therapy, and in psychiatry, we know that the most important thing, and this is probably true for all of medicine, but I know specifically the data for psychiatry shows that the therapeutic relationship, that therapeutic alliance with your patient is actually the most important aspect of them getting better, regardless of medication or therapy modality that you choose to use. So techniques are great. Medications are great. They definitely work for the right patients in the right circumstances, but ultimately it’s all about that relationship and that’s the part that we’re losing in these short interactions, because like you said, you– you have basically enough time to say, “okay, you’re on this medication, are you having any side effects from this medication?” “Well, is this dose adequate?” A quick symptom check and that’s basically it. It’s a few minutes to kind of check on their symptoms, see if there’s any adverse effects happening, make sure everything’s stable and move on to the next person. And it’s unfortunate because again, a lot of what we do I think happens in the relationship and not so much in the medication management.

[00:29:50] Dr. JB: So, with these changes, does the patient have somebody else in your team that they go to for therapy like counseling or no?

[00:29:59] Dr. Rossi: Yeah. So there are, like in my experience in the outpatient community clinics, I’ve always worked in the community setting, which is kind of important to know, because that’s a little different than like say a private practice or something along those lines. But in the community setting, they essentially employ various therapists, but I’d say, we’re not talking about PhD or PsyD level psychologists, we’re talking about people with like maybe master’s level training, which is fine, but one of the things I personally ran into is if I want to refer a patient for therapy, a lot of times I would be hard pressed to find a therapist who did a specific type of therapy. So let’s say I wanted to do, or I thought cognitive behavioral therapy was the right way for this patient to be treated. I would not be able to find someone who really was an expert in cognitive behavioral therapy. Basically, what I found was most people were doing some type of supportive, basically what amounts to a supportive psychotherapy, which is great, I mean, it’s better than nothing, but it was difficult to find, again, experts in certain types of therapy when you thought they were appropriate for your patients.

[00:31:07] Dr. JB: Wow. Who knew?

[00:31:11] Dr. Rossi: It’s a very challenging situation, but I can say the place where I found so much value in my fourth year of training was with my therapy patients. I mean, the connection and the bond that we had was so strong. I was like, I was distressed about letting them go, in a way, even for, and that’s my, in psych talk here, countertransference, for these patients. And to me, like that experience, like I learned things about those patients that I didn’t know about them at all during my medication management with them.

[00:31:44] Dr. JB: Oh, interesting. Because you didn’t have time, you didn’t have time to find out about it, right? You’re just focused on side effects and do you need to refill and et cetera.

[00:31:52] Dr. Rossi: Right, exactly. I mean, you’re focusing on kind of the basics and unfortunately, psychiatry kind of gets a bad rep to begin with. We have, interestingly enough, we’re the only specialty that has an anti- movement. There’s no other medicine, medical specialty, as far as I’m aware of, that has an anti- movement, but there’s definitely an anti-psychiatry movement for sure. And I’ve encountered some of these individuals here and there along the way, especially if you’re out in the public eye in any way.

[00:32:17] Dr. JB: Ah, speak more about that. What do you mean by an anti-psychiatry movement?

[00:32:22] Dr. Rossi: Yeah. So there’s a large group of people and some of this was actually the church of Scientology had kind of promoted a lot of these ideas, but there’s other groups as well. It’s not just them, but they might be one of the larger groups. And basically it’s a group of individuals who feel like psychiatry has harmed them in some meaningful and appreciable way. And they’ll basically come to you and say that the medications don’t work at all, there’s no benefit, they destroy people, all psychiatry’s ever done is harming people. Now for me, being a student of the history of psychiatry, when you look back on these things, and I think you could do this with any medical specialty, you can look back and say like, why were there some atrocities? Yes. Do we take responsibility for them? Yes. We have to, we have to take responsibility for those, those things that didn’t go the way they were planned but I think one thing that’s lost in society today is intent. And if you do the reading, the historical reading on the field, you’ll see that the intent was always good. The intent was always to help people. It didn’t always work out that way, but based on the available information, based on the things that people had at these times, these were the best options that they came up with. And so, I think again, intent matters and most of the physicians that I work with, I mean, all of the ones that I work with honestly, are really good-hearted people who I think genuinely have the patient’s best interest in mind.

[00:33:49] Dr. JB: I wonder if part of this has to do with bringing to the surface repressed thoughts and memories that you feel like you were functioning just fine without thinking about them or remembering them. And now you are remembering them through your therapy sessions and you feel like it’s having a detrimental effect on your life.

[00:34:06] Dr. Rossi: Well, I mean, you’re making a great point about therapy in general, and that is that it’s very hard work and it’s at times very painful and you have to be prepared for that experience, unfortunately, and a lot of people aren’t, and that’s why I think that’s why I think medication became so prominent in the field in some ways it’s because people didn’t really want to do the work. And I don’t blame them because it’s very hard work. I mean, I can think of some of the cases that I treated where trauma was a big part of the issues and things like post-traumatic stress disorder were one of the primary concerns, and just having to, like you said, relive those experiences. And what I did in some of those cases was I used what’s called cognitive processing therapy and what that requires someone to do is to essentially go back and relive in vivid detail through writing their narrative, those experiences, and so it’s not for everyone. It’s not for every patient. And luckily I was able to identify some people that were very good candidates for it and who really did extremely well with that type of therapy, and it really helped them move on from those traumas. But again, during that 16 weeks of cognitive processing therapy, it was tough. I mean, it was even hard for me to listen to at times because some of these things are, are just, are so devastating and so tragic.

[00:35:28] Dr. JB: So many questions I’d like to ask you, but let’s go back a little bit back to, you were finishing up your medical school and you hit this wall, and how did you overcome this wall? And what do you mean by you hit the wall, can you explain that a little bit more in detail?

[00:35:44] Dr. Rossi: Yeah. So I think hitting the wall is when you wake up in the morning and you don’t feel like doing the things you need to do. I was kind of, I remember vividly even having some like nocturnal panic attacks during the end where I would wake up in the middle of the night kind of like shorter breath, like, and have to get out of bed and kind of gather myself and calm myself down to go back to sleep. So I was, and part of that was the pressure from the school like we talked about, but part of that was my own pressure, cause I always wanted to be great. I always wanted to be perfect, and that is a dangerous game to get into with medicine because it’s so hard to be, to operate on that level on a day-to-day basis. You’re really putting a lot of stress and pressure on yourself, so I was putting pressure on myself too, and it was all kind of culminating and that’s the thing that really stood out to me. It was just like a lack of motivation and drive to keep going at that point. And, basically what I did, like, I think I took like, almost like a military-esque style of thinking at the time, which again, probably wasn’t the best choice, but I just pushed through it. I said, okay, well, you know what, you don’t feel like doing it? You’re going to do it anyway, and that was that. That was how I treated it. Now, looking back on it, it probably would have been better to step away and just say, okay, you know what? This, this stuff isn’t going anywhere. A couple of days to recharge the batteries is not going to destroy your Step 1 score or anything like that. You’ve been working hard, you have to remind yourself you’re working hard all the time, and you have to trust a little bit in that process and have the ability to step away.

[00:37:17] Dr. JB: You said that when you finished medical school, you changed the way you approach things. And so, how did you approach residency that was different than when you were in medical school?

[00:37:28] Dr. Rossi: Yeah. I mean, one key point I think everybody who graduates medical school should take away from it is that once you finish the training of medical school, you feel a little bit more like you belong. When you’re in medical school, you’re trying to find your place, even in your clinical rotations, like where’s my place within the team? But once you become a resident, that part like, kind of goes away. Right now, you start to become a valuable, a really valuable part of the team. Someone who can actually do some things and create some benefits and provide some value to the treatment teams in general, so that part changes for you. But for my own mental perspective, I decided to pick up back on some of the hobbies and interests that I had. I decided, you know what? I need to go out with friends for those occasional dinners. I need to continue my workouts, which were very important. Being healthy and lifestyle medicine is a passion of mine, that’s a whole ‘nother topic we can talk forever about, but basically I wanted to keep those things that mattered to me in my life and I just made the decision to do so.

[00:38:33] Dr. JB: So it was an intentional conscientious effort to really incorporate things outside of the day-to-day of residency.

[00:38:40] Dr. Rossi: Absolutely, because residency can be another difficult transition for people. I feel like one of the challenges of being a trainee in medicine is that every three or four years or so, your life is abruptly changing. When you graduate your undergrad and you go to medical school, that’s an abrupt change. When you finish your four years of training in medical school, you go to residency, that’s another abrupt change, and they all require sort of different skills to navigate. And they’re all like, I mean at least for me, stressful times because you, by the end of your four years of medical school, you’ve developed a good routine for yourself where you’re comfortable and confident, and it’s very easy to kind of continue that process. Then going into residency, you’re kind of asked again to take on different responsibilities and play a different role, which takes some time to get used to.

[00:39:30] Dr. JB: And it can feel very terrifying with each new experience, cause it’s an unknown, you don’t know what you’re getting yourself into.

[00:39:39] Dr. Rossi: One of the best things, and the best piece of advice I could give for any new incoming interns, I would say that you want to jump right in to seeing patients and treating patients. Get started, start seeing patients, start putting medication orders in. You want to be writing your H&Ps and progress notes, you really want to like start right away. Don’t take it slow. Don’t be apprehensive about it. I had a great attending who, I mean, as much as like he didn’t do as much like teaching teaching, he gave me that autonomy that I needed to kind of develop my confidence early on. And that was key, I think, at the beginning of my residency to being successful over the course of the four years, was I developed a confidence early on in my management of patients and I felt like right away I could do it. And that was helpful. And that will help carry you through the rest of your training.

[00:40:30] Dr. JB: And when you started medical school, did you come into it knowing you want to do psychiatry?

[00:40:37] Dr. Rossi: During the first two years, I actually thought I wanted to be a general surgeon. I was pretty sure that’s what I was interested in, and I was focused on anatomy and things of that nature during my first two years. And my first rotation in third year was general surgery and I absolutely hated it. I don’t, I mean some people will love it so again, this my bias, my opinion, but I did not like it at all. I thought it wasn’t a very nurturing learning environment at all and when you’re new to something, like I had never tried a suture before, so I had a lot of work to do in terms of just getting comfortable in the operating room and getting comfortable with patients in that setting. And it was tough for me and I just, I didn’t like it and I said, well, all right, glad I figured this out early on. I definitely don’t want to be a general surgeon anymore. And my second rotation was actually my psych and I just loved it, And I think the thing that stood out to me about it was not only did I have a passion for the information and for the training, but I was pretty good at it right away, which was different than my other clerkships. The other clerkships you had to work at getting good at them, this one, I just like, there was something natural about it. There’s something that felt like home for me.

[00:41:50] Dr. JB: Hm. Okay. And going back to what you talked about early on when we first started talking was about labels and the effects of labels and as a psychiatrist, part of what, well, I mean, part of what we do in medicine in general is put labels on people. You have diabetes, you have high blood pressure or whatever, you have major depression, et cetera. But when we think about these labels, when you think about stigma associated with some of the psychiatric labels, can we talk a little bit more about that?

[00:42:21] Dr. Rossi: Yeah, I’d love that because as much as we’re doing our part and I’m certainly trying from my perspective to eliminate some of the stigma surrounding psychiatric treatment and also even again for psychiatric training and for people who are interested in the field, it still exists. And it’s a big part of what we have to face on a day-to-day basis, is how to kind of reduce that stigma, how to help people to feel comfortable. Now, what differs between diagnosis in psychiatry, I think, and a diagnosis in other areas of medicine is because we don’t understand fully the mind-brain disconnect. Right? We have a disconnect. There’s like the physical components of the brain, the neurons and neurotransmitters, but then there’s this concept called the mind that really, we still have no idea what it is. So we lack those objective measures that things like emergency medicine or internal medicine have, where you’re able to look at imaging, you’re able to order a blood test. There’s things that can lend themselves to the diagnosis that help make people feel a little more comfortable that that’s exactly what’s going on. If there’s an arrhythmia in the heart, we have an EKG, we can identify it and we can show the patient, “yeah, this is the problem, we’re going to take care of it by doing X, Y, or Z.” In psychiatry, we don’t have that option. They have to come to trust basically our clinical assessments based on what ultimately amounts to a cluster of symptoms, whether it’s major depression and the old SIG E CAPS mnemonic, two weeks or more of those symptoms. And I think people are a little skeptical of that, number one to begin with. And the other problem I’ve observed as a clinician practicing is that the diagnosis can sometimes evolve. You may initially think somebody is more of like a major depressive disorder and then it turns out that you’re thinking now, no, after working with them for a year, I’m thinking this person’s more on like a bipolar spectrum and may not benefit from an antidepressant medication, they may actually benefit from a mood stabilizer. So I think that sort of evolving diagnosis doesn’t exist as much in other areas of medicine, again, it’s more cut and dry and easier for people to understand.

[00:44:27] Dr. JB: And then when you apply these like psychiatric services to your colleagues in medicine, your peers, and this stigma associated with that in medicine, how that label could affect credentialing.

[00:44:43] Dr. Rossi: Yeah, for sure. I think a lot of people who are physicians– and there’s a lot of physicians that seek psychiatric treatment, so I don’t want to make it sound like all physicians are apprehensive about seeking treatment. If they need it, they do get it. I mean, the only thing I think that could maybe affect your credentialing and things of that nature would be an involuntary admission to a psychiatric hospital. If you were say acutely suicidal and determined to be a danger to yourself, and then you were committed, those things do follow you around. They prevent you from things like firearm ownership. They could prevent you from certain careers. So, there are some things to be mindful, but the general treatment of say depression or anxiety or something along those lines, I think is largely a reasonable thing and shouldn’t affect physicians too much. But again, there’s that worry that, “well, what if my colleagues find out, ” will people see me differently or view me differently?” And I think that that’s a lot for my colleagues to kind of deal with, so there’s always that stigma and worry.

[00:45:41] Dr. JB: And there’s the questions about, have you been diagnosed with psychiatric conditions that is on that application for renewal of your medical degree.

[00:45:55] Dr. Rossi: Yeah, that’s a problem with the way that, I mean, I personally view this as no different, like, I would view depression as no different than diabetes, like the example you kind of gave before. It’s a disorder, it’s a dysfunction that we believe it should be treated no differently than any other medical condition, but unfortunately, you’re right, there’s still this idea that’s not the same. And that’s what we need to work to change and still need to work on. Personally, I also think it’s honestly none of their business what you’re being treated for. I mean, I think your medical stuff, just like we do with like HIPAA, it’s your own personal medical data and whether or not you choose to disclose those things should really be up to you.

[00:46:36] Dr. JB: I agree, it’s none of their business, but they ask the questions still. And I learned that you are very active in advocacy, is that an area that you’re focused on right now or not really?

[00:46:47] Dr. Rossi: So, one of the major areas that I focus on was this idea of a collaborative care model and how that relates to stigma is a lot of patients in general are going to access psychiatric care through their primary care doctor first. So, what the collaborative care model does is it allows for there to be a psychiatric consultant available to the primary care doctor to precept on difficult cases or to potentially see difficult cases if they think it’s beyond their scope of practice and something that they think would be better suited for a specialist. So that helps with stigma because it’s very different, I think, for people to say like, “oh, I’m going to see my doctor, my primary doctor,” versus “I’m going to see my psychiatrist.” So that’s definitely one area where we’re looking to reduce stigma. That’s one of my advocacy, that’s probably the one I’ve worked the most on.

[00:47:37] Dr. JB: Remember how like maybe 10 minutes ago I said, oh, I have so many questions for you? So the other question that I had in that moment was you mentioned how when you’re providing counseling or therapy services and they’re re-experiencing a traumatic event and how sometimes it’s hard for you to even hear it. So, what do you do to take care of yourself as a psychiatrist?

[00:48:03] Dr. Rossi: Yeah, I think that’s where, especially when you’re a trainee, getting mentorship with your therapy cases is important. Having someone that you can discuss the cases with and kind of work through that countertransference, because countertransference works in strange ways. I mean, sometimes it can come out as like a deep empathy and for the patients, sometimes it can come out as things like anger and frustration too, depending on what’s going on within a case. But I think having a good therapy mentor is very, very important because these things have to be talked about. And sometimes somebody with a little bit more experience than you as a trainee can help guide you and help not only guide the therapy, but also work through some of those countertransference situations.

[00:48:46] Dr. JB: Because what we’re seeing nowadays, not only are healthcare professionals and whatnot getting burnt out, but also, therapists are experiencing burnout.

[00:48:57] Dr. Rossi: Yeah. We’re, I mean, everybody, I think anybody that’s working in this modern medical model is going to at some point or another experience in burnout. It’s kind of impossible to not because, again, of the demands that are kind of placed on you, whether it’s as a physician, as a therapist, as a nurse, I think it goes all the way through the medical field in general. So, we have to all definitely do the things for ourselves. So I don’t want to, I know I said at the beginning, I feel like some of this is systemic issues, but I also don’t want to undermine the utility of using things like, your own outlets, whether that’s physical exercise, things like healthy eating, some people like mindfulness meditation. You know, it all depends on the person. You can tailor it however it suits you, but doing those things to recharge your batteries, doing those things to step away from the job for a little bit. Another good one is technology breaks, because, I think, we’re kind of attached to our cell phones at all times of the day, and if you’re in medicine, there’s nonstop, text messages, emails, phone calls, and that in and of itself can also be a big source of burnout.

[00:50:08] Dr. JB: So, I know that you are involved in things outside of direct patient care. I think you have a YouTube channel, you have a website. If my listener wanted to learn more about what you’re doing and how they can get in touch with you, how can they do that?

[00:50:22] Dr. Rossi: Yeah. So, I think one of the best places to find me would be the website and that’s shrinksinsneakers.com. The name came from one of my best friends during training, she and I would always, I would always wear a Chuck Taylor Converse sneakers to work as my work shoes and we kind of got this idea that we’re kind of the shrinks in sneakers, cause we were both always wearing sneakers to work. I came up with that name, but yeah, that’s a good place to find more information. On there, you’ll find links for our YouTube channel and other social media outlets. I think I would direct anyone to the YouTube channel for the most content, because I’ve just found that to be a much easier way for me to create that takes less time than writing blog posts and things of that nature.

[00:51:07] Dr. JB: Okay. And do you have any final words for medical students, residents, anybody, that you’d like to share before we end our recording together today?

[00:51:16] Dr. Rossi: Yeah, I think for medical students and even for undergrads, you have to definitely believe in your own capabilities and you have to follow your goals and dreams, regardless of what other people are telling you. And even if you don’t come from a prestigious background or don’t understand all the intricacies of medical training, it’s definitely still possible for you. And if you put that work in, you will find that there’s a lot of payoff at the end of the journey.

[00:51:49] Dr. JB: Yeah. Who says a doc can’t rap? D O C T O R J B. The greatest doctor to ever touch the mic. The greatest podcast ever broadcasted or prerecorded. Come learn some. Each one, teach one. I’m done.

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