'Leading the Charge' on Racism, Sexism, Activism in Medicine

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. I'm Eric Topol, editor-in-chief of Medscape, and I'm really delighted to welcome Dr Esther Choo from Oregon Health & Science University to talk about all of the great things that she is doing in medicine. Esther, welcome.

Esther Choo, MD, MPH: Thank you. I really appreciate the opportunity to be here.

From Emergency Medicine Doc to 'Public Health Guru'

Topol: You are really making hay out there and doing a lot of great stuff. Let's briefly review your background. Your parents came to the United States from Korea in the 1960s and you were in Cleveland, one of my old stomping grounds. You even interned at the Plain Dealer newspaper after your Yale College English degree, which is interesting. Your background is very unusual because you went to medical school at Yale, did your emergency medicine residency at Boston Medical Center, and then went to Oregon Health & Science University for your master of public health degree. What is the connection between an emergency room doctor and a health policy/public health guru?

Choo: It's not a traditional path. But no one more than an emergency medicine doctor sees the problems that we need to fix in order to provide the public with excellent healthcare and improve public health in general. During my emergency medicine residency, it was eye-opening to see that what we do in terms of providing procedures and medications does so little in a context in which people have very few resources even to fill basic medications. We would create a health plan under the assumption that somebody is housed and has easy access to transportation for follow-up care. There were a million barriers to good healthcare for underresourced people. I also had a greater appreciation for some of the chronic health problems that people find so hard to get adequate treatment for, including mental health problems and substance use disorders.

That made me want to seek further training so that I could look at some of the big health systems and resources in place and see how the policies we make actually impact our patient population and help make what we do in the hospital more meaningful.

Topol: Your transdisciplinary perspective is really exceptional. You went to Alpert Medical School at Brown University and were recruited back to Oregon to join as an associate professor a couple years ago?

Choo: That's right. I came back 3 years ago.

Taking a Lane and a Stance Regarding the NRA

Topol: In that time, you became very well known, certainly to me first through Twitter as we became friends. You were really leading the charge in so many respects in medicine. Let's discuss some of these topics—you do not miss too many, as far as I can see. One topic was the National Rifle Association (NRA) issue of #ThisISMyLane. What were your thoughts when that came up?

Choo: I felt that we as physicians probably do not do a good job communicating how deeply we are affected by some of these big public health issues. I don't know that people know what we see on a day-to-day basis or how much we bear personal responsibility for the health problems that show up. It's not just gun injuries; it's any type of injury. There is a revolving door when people present to the health system again and again and again for these very preventable things. It was quite shocking to me, the dismissal of the voice that physicians have when it comes to injury prevention. A huge chunk of what we have been able to do for the public is impact deaths from car accidents, preventable diseases, and all kinds of high-incidence childhood events. I just had this immediate gut reaction, and I know a lot of physicians did. It's a ridiculous statement to say that physicians have no voice when it comes to improving gun safety.

It's exactly what we have been doing all along. Smoking is a great example. Saying, "We'll just treat the lung cancer when it gets to us" would be a ridiculous stance for us to take. For anything that overlaps public health, we have a huge role. We have made huge strides in other areas, and we see ourselves as central to this conversation.

Topol: I could not agree with you more. Fortunately, physicians weighed in with you.

Diversity and Racism

Topol: Other big topics that you have been all over have been diversity and racism. In fact, we recently had the issue between the high school students and Native Americans. What is your sense about where this is going?

Choo: I feel very optimistic about this conversation. This was not something I felt comfortable talking about all through my training. When you are a trainee, you do not want to call out instances of racism or sexism; it's just not your place. But we all quietly observe that medicine is a pretty traditional place. We still have very traditional hierarchies. You can pull up the website of almost any hospital or health center, and the leadership looks very traditional. That is reflected in the day-to-day experiences of women and underrepresented minorities. As I get further in my career, it is something I feel more comfortable speaking about, and I also feel a great obligation to comment about it because I know how impossible it is to comment on it when you are going through it.

My optimism comes from the fact that there are a lot of people in on this conversation now. I feel like we are much more open about our distress over the lack of equity and inclusion and safety in our healthcare settings. We also are beginning to realize, in a very concrete way, how if we are healthcare organizations that do not treat our employees with respect and equity, how can we deliver care that is respectful and equitable to our patients? You cannot behave one way in that setting and then walk into an exam room where some switch goes off, and you are perfectly fair and compassionate to all patients no matter what their background—it does not work that way. We need to bring more consistency in reflecting the values that we have across our healthcare systems and across the workforce. There is a big movement behind this. It is coming whether people like it or not. We are going to see a lot of fundamental changes in the culture of healthcare. I think it will really pay off when it comes to the type of healthcare that we provide to our patients.

Salary Parity

Topol: You have been standing up for women in medicine and in all aspects. You have been working on a blog and with social media. We have a long way to go—you might agree with that. Where are we now with parity, and how do we get to the right level playing field?

Choo: I am afraid that where we are now is very similar to where we were 20 or 25 years ago, and that is what is so discouraging. If I saw that there was natural momentum, I would not feel as much that I needed to jump into the fray. What I've seen from the data coming out is that if you take any domain—say, salary parity—looking back at the past 20 or 25 years of data, it appears that there was a sizeable gap between men and women physicians and how much they earned, even after controlling for things like part-time work, choice of specialty, and years since residency, and it is not getting better on its own. As more women came into medicine and have evened out numbers in medical school, as we move forward as a society in our ideals about gender equity and we are shifting our ideas about what are natural roles for men and women, you would think that part of that evolution would be salaries getting closer together.

But in fact, we see that salaries are remaining split. There is a gap between what men make and what women make, adjusting for all of these things that might naturally explain it. And that gap, if anything, seems to be getting worse every time we measure serially. It seems to be widening and not narrowing. That is the frustrating thing: It's not just that there is this gap; it's that it's not getting better. That is amazing to me, but that is what the data are showing. This is a lot of what fuels my interest in addressing this head-on and trying to find the solutions that will actually change the course that we are on.

Engaging in Activism

Topol: There is no shortage of work needed, and having you and your energy and leadership are going to be vital. You are an activist; you are the prototypical activist of people I know. We do not have enough people in medicine [like you]. Do you think that is just because people are too busy? Why don't we have more people standing up for causes like you do?

Choo: I am seeing myself in great company these days. People are jumping in, particularly the younger generation, who feel very natural expressing their views pretty openly on social media. I do think it's changing. There were a lot of reasons why I hesitated. We are not trained in social media, or really any media, as we go through medicine. If there is any training about communication, it's training to communicate with each other well in scientific atmospheres, like conferences, or through manuscripts, or on campus, giving these formal talks to other scientists and healthcare providers. That idea of standing up and stating things that might be seen as controversial or divisive, and that are very public-facing messages, is not built into what we do at all.

We really exist in a bubble from our training onward. It certainly was not a natural thing for me. I also think there is a downside to putting your neck out there. On social media there is a lot of attention, and some of that is positive. But no matter what you put out there, there is a lot of negative energy. For busy people who are doing a lot of important work for healthcare and saving people's lives, it can be an extra burden and a troublesome aspect of your professional career that you just do not need. Some people do not have the bandwidth. I also think there can be professional penalties for speaking out against some of these things that are very real. Who wants the equity agitator in the room, you know? There may be people who invite me to the table to speak about some of these things, but in other settings there are people who distinctly do not want me there because I am not going to keep my mouth shut in edgy conversations. It's not very safe. There is a reason that I came into this kind of activism in my forties, when I've passed the junior career hurdles and have a little bit more freedom to speak up. There are a lot of challenges to this kind of work as well.

Topol: You could train people to do what you do, because you are one of the very best of all physicians I know out there. You use Twitter as a kind of main platform to communicate your views. Over time, the things you put out there really resonate. What got you started with that, and where do you see it heading?

Choo: Early on I was [on social media] for medical education. I found other physicians who were active on social media, and we really had fun engaging with each other and with younger learners. We felt like this was a great place to reach medical students, residents, and peers around the world who could challenge our ideas. You can find collaborators that you would never meet in a million years just in your regular career. I wrote a paper with six other people but have only met about half of them, and it's been a well-cited paper. Exciting career opportunities and opportunities for creativity play out on social media in this very interesting and stimulating way. That is why I was there. Then one day, around the time of the Charlottesville Unite the Right rally, I put out a thread about racism, and that took off. I realized that I could have a huge impact if I started talking about the issues of racism, sexism, equity, and inclusion. I felt like that was the right place for me, and I have never looked back.

Personal Tweet Goes Viral

Topol: It's fantastic. It's not just that you are out there on these issues that we have been discussing, but you have also thought of ways to bring out the positives in medicine. Lisa Rosenbaum, the New England Journal of Medicine (NEJM) correspondent physician, wrote a whole article about your #ShareAStoryInOneTweet.^[1] What was that about?

Choo: It was one of those really organic things. There is no rhyme or reason for what takes off and what is virtually ignored. I've been on Twitter all this time, I post every day, and I still cannot tell you what takes off and what does not. It feels like it depends on many factors that I do not completely understand. On that particular day, I was waiting for my child to come out of a birthday party and I was bored. So I used a hashtag (#ShareAStoryInOneTweet) and shared a story that was on my mind about a patient I had treated who has become a lifelong friend.

Nothing happened for a while. Then one person picked it up and used the hashtag with a very riveting, touching patient story. After that it just exploded. The next day I spent several hours going through all of the stories. Many were very moving and inspirational stories about relationships they had had with patients, cases that went well or did not, moments where they felt really low in medicine, and times where they really felt uplifted by the career. I know I missed a lot of great stories. Lisa, who is this fabulous, lyrical, lucid writer for NEJM, decided to turn that into a commentary for NEJM and really captured what I love best about it, which is that we are so focused on headwinds and fighting the battles and the challenges, that sometimes we forget to celebrate the tailwinds, the things that lift us and hold us up in medicine. I could not have imagined a more beautiful analogy for how we need to refuel ourselves and spend some time dwelling on the joys of this incredible profession. I appreciated her spin on that even more than the hashtag itself.

Topol: In a time when there is so much burnout, dissatisfaction, and depression, that was so enlightening and positive. It was great. Hopefully more physicians will get active on Twitter and other social media to share those upbeat things.

Topol: You also wrote a piece in NEJM^[2] about the National Academies of Science, Engineering, and Medicine (NASEM) report.^[3] Can you tell us about that?

Choo: Yes. I've been very interested in issues of sexism and inequity in medicine, things that disproportionately affect women in a negative way and prevent them from being as productive as they have the potential to be—things that can stand in the way of having a successful career that fulfills all of the early promise that young female and male physicians demonstrate. Last June, this NASEM report came out on sexual harassment. It was a broad view of the literature and a summary of the state of the problem in academic sciences, engineering, and medicine; it also proposed solutions.

That report, which is about 300 pages long, was incredibly moving to read. I am not even kidding you when I say that if you just open the first page, it sucks you in and you have to read to the end, because it is a very probing investigation into the forces that allow harassment to happen. The really humiliating thing for medicine was that of all of the sciences, medicine is the worst. We have an environment in which harassment clearly flourishes. I knew it was bad but I did not know that we would distinguish ourselves so much among all of the sciences. I thought medicine was maybe equal, or even a little bit better, because we were the people-facing scientists. But no, medicine is actually the worst for a number of factors that they outline really well in that report. After I read that, it stimulated a lot of conversation with my networks of women who are working on this issue. We have a lot of plans for how we want to start addressing this in a really proactive way. Writing that piece was important for us to articulate our feelings about that report and how it's not just time for change, it's so beyond time for change. It really is terrible that we have let the problem go so far and get to the point where we have to do so much cleanup and damage control rather than being able to approach this proactively and from a more primary preventive vantage.

Topol: It was really well done. In just a limited number of words you summarized such vital aspects of that report.

Life Is a Pendulum

Topol: You mentioned one child at a birthday party who you were waiting for, but I think you have three others.

Choo: I do.

Topol: How do you do it all? You are on Twitter and do other writing, and you have your emergency medicine work. For career advice, how do you balance all aspects of your very busy life?

Choo: I stopped aiming for balance as a goal a long time ago because if that is the goal, then you feel like a failure all the time. One of my mentors at Yale, Gail D'Onofrio, said, "Think of it more like a pendulum." When she said that, I instantly felt better. When the pendulum swings, something occupies you that feels crazy that one second. Then very naturally, the pendulum swings in the other direction. There are times when my kids may get a little bit of short shrift, and there are times when I'm completely absorbed in what they are doing. Sometimes the pendulum swings violently all on the same day; sometimes it's more spread out. Be flexible with what is the primary thing. I would also say that everything that takes my time has to be something that I really believe in and involve something that I think I uniquely bring to the table. If somebody else can do that job and would be happy to do it, there is no reason for me to do it just because I can and I happened to be sitting there in the right place.

It's all about making choices and constantly saying no to open up the yeses that are really important, so that you can be at the most impactful place at that time. I don't think I have it figured out, and often I default by trimming a little bit of sleep off the end of my day, but I do know that being a little too busy is kind of a first-world or champagne problem, as we call it, and I'm just lucky to have a career where I get to do lots of different things that I love and enjoy with great people. Things like this. I cannot complain about any of it.

Topol: I can identify with the need for lots of stimulation and being charged up about a lot of things that you do. I like that analogy of the pendulum. It's amazing that we met through Twitter. You are just a phenom in terms of all of the things that you are speaking up about and the colleagues, physicians, and medical community that you are representing. We are going to continue to turn to you—not to put any burden on your shoulders, but for all of your leadership. You represent a new form of medical leadership, one that is young and that represents true activism and uses the platforms that are out there. With great admiration, I know that the folks at Medscape will really enjoy hearing about you from this interview. We look forward to following you with great interest, Esther. In the short time of your career, you are just setting the world on fire. I know there is a lot more to come.

Choo: I really appreciate this chance to chat with you, Eric. You have been such a great supporter and mentor. I sometimes forget to call out the he-for-she's, as we say, or the men who are supporting the women who are fighting for gender equity and inclusion. It is not something we do alone but something that we do with great partners and allies. I feel very lucky to have had you as one of those supporters. It's important to acknowledge that out loud.

Topol: Thanks so much, Esther. I'll try to help the cause as much as I possibly can.

We will leave it to the folks at Medscape. I'm sure they are going to have some comments. For some who have not met you before, it's going to be really gratifying for them. We will see you on Twitter and in all of the other writing and things that you are doing. A lot more to come. Thanks a lot, Esther.

Choo: I appreciate it. Have a great day.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube