Time Stamps

• 02:48 Minneapolis 2020 with Dr. Uloko
• 06:44 Early HIV/AIDS with Dr. Kalet
• 12:07 Hurricane Sandy with Dr. Hwang
• 17:20 Aftermath of the Syrian Civil War
• 20:25 Transitions with Dr. Arora

Show Notes

A big thank you to all the people who told their stories:

Dr. Maria Uloko @MariaUloko

Dr. Adina Kalet @AKaletMD

Dr. John Hwang 

Dr. Vinny Arora @FutureDocs

Dr. Abdeghani El Rafei

Transcript

Brinda: So one thing that I’ve been asking everyone that I’ve been speaking to, is how is your soul doing right now? 

Maria: Oh, my soul. My soul is heavy. There are times where I feel great sorrow, and there are times where I feel nothing.

Brinda: Between covid-19 and the protests catalyzed by the Black Lives Matter movement, 2020 has been a year of great unexpected change, and for many of us, we are starting new roles in the middle of unprecedented events.

“That’s like a common phrase around here, when things die down. We now no longer say that. They’re never gonna settle, because we don’t know what’s coming.”

“I think every generation of physicians has some experience watching something change so dramatically.”

“Whenever there is some sort of massive upheaval, some event, there is a tendency to try to create a narrative for lots of different reasons.”

“There is a light and hope that we can make change through the systems and structures that exist and make them more fair and more just to everyone.”

Solon: Hello, and welcome to a special episode of Core IM on stories from challenging times, inspired by this crazy year we’ve been having. My name is Solon Kelleher. I’m an audio producer with Core IM, and today I’m joined by Dr. Brinda Desai, a pulmonary critical care fellow. 

Brinda: Hi Solon!

Solon: Hi Brinda. So, one phrase you’ve probably heard countless times since March has been “these challenging times.” Brinda, have you heard this phrase?

Brinda: More than I’d like to. I think it’s in so many emails, so many newsletters. Kind of all over the place right now.

Solon: Yeah, I have sent that phrase in an email myself, maybe two.

So, as we kept hearing this phrase and maybe even writing it in an email, the more we realized that when we’re talking about these challenging times, what we’re really talking about is changes, often swift and unexpected ones.

As you listen to this episode, you’ll hear us circle around the following question… when the rest of the world is changing… what kind of change does it inspire in us? 

Brinda: We want to share a few stories with you from doctors who lived through other challenging times, … some of them even transitioning into new roles during this … with backdrops such as the early days of the HIV/AIDs crisis, Hurricane Sandy in New York City, and the Syrian Civil War.

Our hope is that in sharing their stories with you is that by hearing how they navigated through their situations, we can go through this moment with greater and more meaningful intention and effectiveness.

With that being said, this moment sounds like a great place to begin, so before we dig into the past, let’s start with one doctor’s story from Minneapolis in the summer of 2020. Meet Dr. Maria Uloko.

Maria: My family immigrated from Nigeria. We won the visa lottery. Because of that, I’ve always had this notion of you are very lucky to be in this country. You can make anything of yourself if you dream big enough and that’s what my parents always instilled in me. 

Brinda: Dr. Uloko took that dream of becoming a doctor and worked to make it a reality. Her training eventually brought her to the University of Minnesota, where she was slated to graduate residency in the summer of 2020.

Maria: I had this narrative of how I was going to leave Minneapolis. I was going to leave as the first black woman to graduate from my urology program. I was going to leave in this blaze of glory. It was going to be great. It was going to be just full of all of this, just joy. And honestly it was full of a lot of sorrow and a lot of tragedy. … 

Brinda: We all know what happened next … something that happens all too often in this country. A police officer took the life of a black man on the streets of America. 

Maria: It was my first day back on clinical duties at this community hospital after George Floyd’s murder. And I did not feel comfortable. I literally watched a man beg for his life for eight minutes and was so traumatized by it. And then the fact that I had to just go into work and pretend everything was okay. Like the world was fine and everything was right in the world. 

Brinda: And just as she’s trying to process what happened in her own neighborhood, an event that sparked a global conversation, she shows up for work. She collects herself in her car, she walks into the hospital, and hears this from her colleagues…

Maria: Complaining about how the protests are delaying his drive home. And people are making jokes and this is something that’s so serious for me. And yet it doesn’t affect you all at all. It was really hard to deal with.

Brinda: This is where Dr. Uloko decided that before she left for her new job, things had to change. 

Maria: Being in that space made me feel emboldened to email the head of the GME and say, this is unacceptable. Like I shouldn’t have to feel this way. And I’ve been here for five years. I can’t imagine. The residents that are just starting or don’t feel as empowered what they’re going through.

Brinda: Dr. Uloko created a forum for Black trainees to gather, discuss, and reflect on being Black in medicine. And that forum motivated GME to restructure their diversity and inclusion committee… to create more lines of communication between black trainees across different subspecialties.  

Maria: And so I think those experiences also helped me to say like, okay, this needs to change. Like something has to be done and the people who are in charge who are supposed to be doing something aren’t doing something, so I’ll do it.

Brinda: You know Solon, what I really admire about Dr. Uloko’s story is that it would’ve been much easier for her to just move to her next job in California and not think about the problems back in Minneapolis or the insensitive attitudes of those around her. She didn’t do that. She asked herself how can I leave this place better for everyone than it was for me when I arrived? She rose to the occasion, and changed the environment not just for herself, but for the younger residents who couldn’t or maybe just didn’t know how to speak for themselves. She became an advocate.

Solon: Yeah, I like about Dr. Uloko’s story is how willing she is to look around in what is an undeniably difficult moment and ask herself and her colleagues … can we be doing better right now?

Brinda: Yeah, I think when we do take that opportunity to reflect, we may realize that something we’ve accepted for so long as our standard of care … needs a huge wake up call. And there’s no better example of that than our next story. Let’s rewind back to the 1980s when Dr. Adina Kalet, was going through her own transformative experience during another global crisis.

Adina: I graduated from medical school in May of 1984. And during the six months prior to that, there were the first reports in the New England Journal of Medicine.

Brinda: Now, of course, we refer to this time as the early days of the HIV/AIDS crisis, but back then, we were only beginning to understand the condition.

Adina: These were case reports on a whole series of unusual cancers and infections in gay men in New York City. I was at Mount Sinai school of medicine at the time. And I still remember reading about this and hearing about it in rounds as a medical student and thinking isn’t that interesting? You know, it didn’t register at the time as something very frightening or something that was gonna impact my life as much as it did.

Brinda: But this didn’t just affect Dr. Kalet’s life. It was a period of time that changed the way we handle end of life and palliative care discussions. That July, Dr. Kalet began her Internal Medicine residency at Bellevue Hospital. And in any other circumstance she may have been a brand new intern learning how to replete electrolytes or order a bowel regimen, instead, she took part in creating a new way to treat end of life care.

Adina: Things are so much better now in the sense that you have the language to talk about end of life conversations. We didn’t have that language. We didn’t have a framework for thinking about what it meant to take care of a patient at home, or to choose not to continue with curative care.

Solon: Before we move on, I want to take a moment to provide some context here. Many of Adina’s patients … especially at the start of this crisis … were gay men who left their homes elsewhere in the country to live in New York City. They were often alone and terminally ill … with no families to turn to. 

Adina: The humanity of it was, was really inspiring on the one hand and terrifying on the other. And we were often the only humans  that would walk into the room and care– touch these individuals. 

Solon: This willingness to be close with her patients set Dr. Kalet apart from a few of her colleagues.

Adina: There were nurses and other physicians, some of the subspecialists who actually refuse to take care of certain patients because they were afraid of them. Um, and therefore the interns had to do whatever they were supposed to do. So I was delivering trays. I was transporting people to, you know, to, for, for imaging. I became a fierce advocate for the humans that were suffering from this disease. 

Solon: It was out of this sense of compassion and advocacy that Dr. Kalet, along with a team of like-minded doctors, decided to go against the rulebook to treat this immeasurable pain.

Adina: You know, those were things we felt like we were being Mavericks. Giving morphine to a man who we were not going to save his life is only compassionate … considered compassionate now, but at the time it was considered illegal or potentially murder actually, people were sort of suggesting those things to me. 

Yes. I’m admitting that I did some things that in those days would have been considered wrong. I mean, illegal, maybe, but they weren’t wrong. And I learned that from a small handful of people I could trust to guide me. 

I think every generation of physicians has some experience of watching something change so dramatically in what everybody thought was just true about the practice of medicine, just wasn’t true. That we could change things; that we could learn new things; that we could work in teams.

And I think I wish for every generation of physicians …  I hope it doesn’t require an epidemic that kills a lot of people … but I wish for some event that gets us out of our sort of sleepy, and a little bit lazy sense that the rules have already been written and we know the answers. And then we just have to do the right thing based on the clinical prediction rule or whatever. There’s so many unanswered questions. There’s so much to innovate around that every generation should feel like they’re free to change the rules. 

I was in this amazingly complicated, very human place. And I got a deep sense of purpose out of that. I couldn’t have articulated it at the time. I think in retrospect it made me who I am, and so I’m very appreciative of having been through that. 

Brinda: This amazingly complicated, very human place. It just resonates with me. I feel like I’ve been in this place so many times recently.

Solon: When we think about challenging times, or what we refer to as challenging times, I think we often look for the silver lining to try to overcome how hard it is. But as our next guest points out, finding the narratives out of these unexpected turns of events is often way more complicated than just looking for the silver lining.

John: We create narratives to, you know, provide a source of comfort of stability. Um, we to provide a sense of meaning to provide a symbolic framework for growth, you know, for self exploration, et cetera, et cetera.

Solon: Loyal Core IM listeners will recognize that voice as none other than our beloved Dr. John Hwang, host of our Hoofbeats episodes. But what you may not know about Dr. Hwang, is that when he was an intern in NYC, he and his entire class was displaced by Hurricane Sandy and had to do their training at hospitals that they didn’t sign up for. Asked about making meaning out of this unexpected turn of events, the words came pretty quickly to Dr. Huang.

John: Had you asked me at the outset of intern year, like right when I graduated med school, do you think it’s important that doctors practice in a variety of settings that they see different types of patients, you know, that they’re forced to, um, work within different types of constraints? I would say. Yeah. Yeah, that’s important. Um, but I don’t think I would have ever fully appreciated how important it is, uh, to experience for yourself. 

Solon: But those lessons come with caveat.

John: My hesitation in answering your question is that it’s been eight years. And I think that the human brain has a remarkable tendency to turn things into a narrative, you know? And so whenever there’s some sort of massive upheaval, some event, there’s a tendency to try to create a narrative, right, for lots of different reasons? 

This narrative making was evident even in like the immediate days and weeks after hurricane Sandy hit, you know, the narrative of how the med center was coming together and how they were heroes that were emerging and how there were these remarkable things that happened, you know, like, babies that were evacuated… um, patients who are brought down 20 flights of stairs on sleds in the dark, you know, residents who were in a passing fuel up staircases and buckets, you know, as part of like a fuel line and people were, you could see that people were trying to synthesize that into a coherent narrative, a narrative of community coming together, they’re being communities united.

And I do accept that narrative to some extent, but these days when I see a lot of people and I see how people are trying to shape narratives, some of which are not entirely consistent with the facts, some of which conflict with one another, it makes me a lot more wary, I would say about, about this tendency of the brain.

Solon: There is a lot to say about this tendency towards drawing meaning out of hardships, and I could easily listen to Dr. Hwang talk about this and probably most topics for an uninterrupted hour, but I think what’s relevant to our story here is that sometimes we try to tell ourselves these narratives after an unexpected turn of events, because the way reality played out is so distant from how we were planning and working toward.

John: When hurricane Sandy did hit, I did think to myself, this is probably not going to be good for me as, as a doctor and I was already kind of struggling with imposter syndrome, you know? And so the idea that I might somehow be cheated or built out of a proper education, proper training did not sit well with me. And, uh, in terms of what I think now, looking back on my concerns, what I’ll say is I don’t think that those concerns were totally ill founded. I think that someone, if they studied me hard enough could probably find a way in which I was negatively impacted educationally. 

If someone were to say, this is not what I signed up for. I mean, that’s what I was hearing during COVID right from, you know, students and interns who were scared, they were doing their jobs, they were doing them great. They were doing things that, you know, it would have been inconceivable for us to ask them to do and other times, um, but it wasn’t what they signed up for.

Solon: You’ve probably heard the phrase, “this isn’t what I signed up for,” referencing 2020 from people in and outside of the medical community. And while Dr. Hwang can see both the positives and negatives of a big, disruptive event, he also acknowledges that in the end, both viewpoints are true, and it’s just a complex narrative that each person has to work through in their own way.

John: At this point enough time has passed that I can acknowledge both that I was hurt by that experience and that I gained things from it. And that overall the effect is not one that is easily summarized in a simple narrative. I guess what’s trying to say, I think I learned this from taking care of patients who get sick. It’s true that illness often brings out the best in us and the people around us, but it also brings out the worst too, sometimes in the same person. And so when you ask a patient who’s sick, you try to get at how it’s changed them. You get an answer that’s usually pretty nuanced. 

Brinda: Moments like these demand for the ability to reflect and find ways to process the events around you. For our last story, we’re going to look at the impact of  trauma on one individual who wasn’t able to take a moment and check in on himself.

Dr. Abdeghani El Rafei was a young medical student, witnessing the collapse of civil order around him and trying to balance studying for his new profession with engaging in protests he believed in.

Abdeghani: Things just don’t change in Syria. We have a very famous saying in Arabic that goes like [in arabic].  I don’t know who TT is, but the moral of this story is that, you know, TT goes away for a long time and TT comes back and nothing changed and TT doesn’t change and everything stays the same. 

Brinda: As you may know, Syria did undergo a big change — a Civil War, which took a toll on Dr. El Rafei.

Abdeghani: When the revolution was happening, you figured you’re trying to figure out how to be part of it and how to be a rebel. You also have your duties as a medical student.

Brinda: Trying to find that balance became impossible when the unrest and violence came to Dr. El Rafei’s doorstep. Protestors were being killed in the streets, and the violence kept getting worse.

Abdeghani: So that was quite scary going through going through this. Um, so after this we decide, you know, it’s getting too dangerous, we have to leave the country. 

Brinda: The next few years away from home fly by for Dr. El Rafei. From Lebanon, he goes to the USA where he gets a rotation at the Mayo Clinic and does research. After there, he applies for residency, and graduates, and becomes a doctor. And this entire time, he was so focused on achieving his professional goals that he forgot to check in with himself. He forgot to ask himself, how is my soul doing right now?

Abdeghani: You know, the reason I wanted to tell my story is … I want to tell people not to do what I did. I dealt horribly with this. I didn’t stop, despite all of this craziness that was going around me. I just put my head down and focused just on work. And I figured that if you would work hard enough, all of this uncertainty would kind of disappear and would go away.

So don’t be afraid to stop, you know, during the middle of the craziness and ask yourself, like, how are you doing? How are things going? Are you doing things just to avoid the uncertainty or are you doing things because you’re kind of embracing the uncertainty and you’re making your next move? We’re all going to be faced with uncertainty in our lives, whether it’s because of pandemic or COVID, or, you know, something happening at your personal life or making your next move or deciding if you want to go into surgery or medicine, these are all points about certainty. And yes, sometimes it can be hard, it can be painful. But it’s never a reason to put your head down and just try to avoid asking the questions because the questions will never go away.

Brinda: I couldn’t agree with that more. It’s easy to feel overwhelmed where there’s so much work to be done in very limited time. It’s easy to forget to stop for a moment and reflect. That’s why I wanted to close out the episode with someone who has concrete advice on how to not just make it through these challenging times, but to make them more meaningful.

Vinny: I am Vinny Arora. I’m a physician and internal medicine doctor at the university of Chicago medicine where I serve as the associate chief medical officer for the clinical learning environment. 

Brinda: You might know Dr. Arora from her twitter @FutureDocs where she’s currently advocating #AmericaMaskUp. Not only has she presented on transitions at the ACGIM conference in 2019 but she also went through quite a transition of her own over the last few months.

Vinny:  I had a baby at the height of the surge here and Chicago, in my hospital. I will say that’s an incredible transition as well. We went from a family of three to a family of four, which was very exciting, but no one plans to do that during a pandemic. 

Brinda: Not to mention, in addition to having a baby, Dr. Arora also transitioned into a new job role and dealt with a workforce strike. She had a lot going on, and so we asked Dr. Arora about how she finds that balance, and the metaphor she preferred to use was juggling.

Vinny: Usually I will say that we all have a lot of balls in the air. Are all of them falling down at the same time? And so if otherwise you can’t juggle, right? So the challenge with COVID is that they were all falling down at the same time. And in general, a lot of academic career jobs have a lot of balls in the air. 

We all wear a lot of hats, but they’re all not falling down at the same time. So I would say that’s the number one challenge is, you know, whatever your hodgepodge or mixes, you know, clinical research administration, quality education are all your balls able to be an error, or when we one falling down, because you can handle one emergency, but I don’t know that you can handle two or three, um, personally and psychologically it’s very difficult. 

Brinda: But how do you decide which balls to juggle or which hats to wear? Because that’s the part I kind of struggle with on a daily basis.

Vinny: I just always say, okay, let’s eyes on the prize. What are we doing? Sometimes people feel like, especially when you’re more junior, you’re just spinning your wheels and you’re not going anywhere, and it’s because of the external climate, you can feel really, really demoralized. 

And so that’s where I would say, this is where expertise and years of having that those experiences do help and just having that strong compass inwardly to be like, what is it that I want to get accomplished and do, and how can I make the biggest impact.

Brinda: And part of making that impact is being able to adapt to the quickly changing circumstances.

Vinny: You have to be agile, capable. That’s really what the pandemic has taught us. The same is true in your personal life. You don’t know what’s coming. And so it’s your ability to respond in the moment that really matters.

Brinda: And as you’re making these in-the-moment decisions, you might just rise to the occasion and even demonstrate skills you didn’t even know you had.

Vinny: I would say that the recent pandemic and even the issues around racism that are occurring and police brutality… really what we’re seeing is doctors stand up for not only stamping out racism, standing up for their black patients, their black colleagues, black physicians, being like this is not right is actually transitioning in place. We are seeing leaders emerge, whether it be at the student level all the way to the faculty level, who are, who are being asked to do more. 

Brinda: There’s no way around it. The choices we make during times like these will shape not just our own lives, but the lives of those around us for years to come.

Solon: Whether you bring the conversation of race into your institution like Dr. Uloko or witness the emergence of a more compassionate way to treat patients like Dr. Kalet… whether you’re reflecting on the nuances of your own narrative like Dr. Huang or you’re trying to balance achieving your goals while caring for yourself like Dr. El Rafai….experiences such as these, can be the ones that shape us.

Brinda: To my colleagues listening right now … I know you feel the weight of this moment. I am right there with you. You got this. To paraphrase what one of my mentors, Dr. Partha says, sometimes the only way to get to the other side of something is to go through it. One way or another, we will go through this.

Thanks for listening and thank you to Dr. Maria Uloko, Dr. Adina Kalet, Dr. John Hwang, Dr. Abdelghani El Rafai, and Dr. Vinny Arora for being so generous with your reflections and letting us share your stories with our audience.

Solon: Thank you Brinda for lending your voice to this episode and for all the thoughtful questions in interviewing our guests. Thank you to our Chief Executive Producer Dr. Shreya Trivedi for coaching me through the production of this episode. To Vickie Kassapidis and everyone who provided feedback to earlier drafts. To Sam Woodworth for creating our episode’s graphics. And thanks again to you for tuning in! If you enjoyed listening, please share it with your colleagues and team // and rate our show on whatever podcast app you used to listen to our show. It truly does help people find our show. As always, you can drop us a line on Twitter @CoreIMpodcast. Until next time, thanks for listening to Core IM.

References

• https://www.sgim.org/File%20Library/SGIM/Resource%20Library/Meeting%20Handouts/ACLGIM/2008/Summit08_Arora.pdf