Season 01: Episode 04: Sarah Islam Transcript

Queer Diagnosis Podcast

Season 01: Episode 04: Sarah Islam

[Theme music plays]

Interview

Zarya: This is Queer Diagnosis, I'm your host Zarya and my pronouns are she/hers.

Srihita: I’m Srihita and my pronouns are also she/hers. Our guest today is Sarah Islam, a fourth year medical student at the Indiana University School of Medicine. Hi Sarah, could you please introduce yourself with your pronouns?

Sarah: Hi everyone, I'm Sarah. I'm a fourth year medical student, like you said, at Indiana University School of Medicine and my pronouns are she/hers.

Zarya: How do you identify with the LGBTQ+ community?

Sarah: I identify as bisexual, really it's more pansexual, as I've started to learn more about the queer community and about the different distinctions. So just to keep things simple I say bisexual.

Zarya: I think that's interesting because on one of our previous episodes, our last guest mentioned that they use bisexual because that's the term that they've grown up with whereas pansexual is more inclusive of, or more conscious, of gender as a spectrum. Do you feel that way about it as well?

Sarah: Absolutely. When I was growing up I always you know heard it as gay, lesbian, bisexual. As I went through college, I learned more about transgender populations. Pansexual was a relatively recent thing that I became aware of as a person in general and then, within the queer community, reading literature and trying to figure out how the different categorizations or terminology was implemented. I think it's very interesting how the dichotomy of the gender binary was sort of ingrained into queer labeling, As trans rights have become more important, it's become a little more inclusive. Being bisexual doesn't necessarily mean that you don't date or are not attracted to trans people. It's more so the terminology that's stuck around. Not to lie, sometimes it’s the colors. I like the colors for the bisexual flag a lot and I think that partly sways me. My partner is pansexual and they’re much more involved in the trans community as a nonbinary person. For them to explain to me how that’s viewed has opened my eyes up to how it’s not just a label. It goes deeper than that, depending on how other people view it.

Zarya: I also appreciate the fact that you're using the term partner. I’ve gotten more into med school Twitter and I saw a tweet yesterday that said “Oh, I hate when people use ‘partner’.” I think the term partner is so important because it's normalizing that word across the board. Even with pronouns, the way that you, Srihita, and I all have our pronouns on our zoom names right now, I think, add to the community

18:33:58 I think that kind of adds the community. Do you have any thoughts on the word partner versus saying boyfriend or girlfriend?

Sarah: Oh, absolutely. For me it really started right when we started practicing clinicals. In our first and second years of medical school, we had practice simulations and we were practicing on each other. I think with the interviewing part of seeing patients, a lot of times it's pretty easy to guess whether somebody will have kind of a ‘stereotypical’ cishet relationship. A lot of times, folks will volunteer that information before you even ask them, but I really try to get in the habit of being pretty neutral when I talk to patients. I don't want it to be that one time that somebody was going to share about their same gender relationship or about being transgender or being part of the queer community and I turned them of by assuming their

partner’s gender or their sexual orientations. For me that's been a big thing in general, but specifically with how I approach queer patients. I really don't want anyone to feel that they can't tell me anything, especially if it's going to be something that's important for their care. As a future psychiatrist, I would hope that queer patients will trust me with their mental health, so I don't want them to ever feel that I have any presumptions or prejudgments going into our appointments. That's definitely been a big thing. With my own relationship, transitioning from calling them my boyfriend to my partner has also been a learning experience. Many time, folks will assume that they are a cis male. So, I’ve gotten into the habit of making sure I use the term partner, so I can emphasize. “Hey, maybe you should listen to what I’m saying. Sometimes it’s hard to call people out, especially with physicians and the hierarchies there. In general, being neutral has been beneficial because you never know when someone is going to tell you something. If they’re not, it doesn’t hurt, but if they are, you don’t want to put a stop to something before it’s even happened.

Srihita: Do you think that instinct was something that you had inherently or was it something that was mentioned in class?

Sarah: A lot of my friends realized that they were queer throughout our college years. Freshman year, we all were like "Yeah, we're straight." The next few years, everyone was slowly coming to terms with their queerness. I was probably the last one. Actually, I think one of my friends came out after me. So, we were pretty slow to come to terms with our queerness. That made me realize that you never actually know because sometimes people don't know. You have to go into it without assumption and stop thinking of people as default anything, which can be hard depending on your upbringing or in a field like medicine where everything is either wrong or right. It's always this or that. It can be hard to break. I will say I don't think medical school did a very good job of trying to break us out of that. Actually, medical education relies on teaching people that in order to come to quick diagnoses. We're taught to rely on our base impulses to get the answer. So, if you're not already thinking about it, it might take much longer to come to that realization. That might be why the people who are best at it are queer physicians, or queer medical students, or queer pre-medical students. They're already thinking about those things. We do have a responsibility to teach that before they have their own queer journey. This is something that should be thought about and normalized. When you use the word partner or have your pronouns on display, you create that space for someone to tell you that they're queer or tell you something that they were uncomfortable with previously. You've shown then that you're creating space for them to reveal that information.

Zarya: Can you do my med school interviews for me because I think the way that your answer questions is amazing and I think it would really just save me the hassle?

Sarah: Do you know how nice that is to hear two days before I'm matched? That validated my entire interview season.

Zarya: Actually, before our interview, I was trying to explain what Match Day was. Would you mind explaining the role of a fourth year medical student compared to first and second year? And then, what is Match Day?

Sarah: Absolutely, this is my lived experience now. First year, you're doing your pre-clinical education. I always tell people it's an extension of the things you were doing in preparation for med school, but they hit you a little bit harder with it. You think a little bit more about the patient. You're not just learning the Krebs cycle. Sometimes you are just learning the Krebs cycle, but a lot of times it's tied into the clinical picture of how it might be relevant, here are a few disorders that this might be important for. The second year focuses more on body systems including physiology and the different pathologies you see. You're learning how to do the workup and what you are going to be interpreting. Your third year, when you do rotations, you're really taking care of patients for the first time. You have a decent amount of responsibility but there is definitely some scut work including calling patients' families, running papers to different departments, and checking updates on labs. You're probably not gonna be in a life and death situation. You'll probably be the person the patient sees the most because you have more time on your hands than anyone else on the team. The fourth year is when you start to take ownership of your patients. The goal is to be able to independently function while still getting a sign off from the person above you. You have the freedom to make decisions without hurting anybody because you have someone looking over your shoulder to make sure you're not doing anything wrong. Obviously, you're applying for your residency and things like that, so it can be a weird year. You're finally doing the stuff you're trying to match into. For me it was psychiatry. So, I spent months just in psychiatry which was really cool. You get the feel of what it would be like to be a resident which is really cool. It's hard to go back to doing required rotations after you've done the stuff you actually want to do.

Match is basically like a Nobel Prize winning algorithm, I've been told. Applicants and hospitals/programs can date and rank each other. Then they decide what's the best 'fit'. It's difficult to explain to the people who aren't in the medical field. When you apply for a job, you either get it or don't. With Match, you have to interview, and the applicant makes a ranked list of preferences. Then the programs make their own lists of applicants. The machine tries to match applicants with their most preferred program. So applicants do have some power, but when everyone is fighting for a chance to keep working, it may not feel like that. The Monday of Match Week, you find out if you matched. If you don't, there's a second round scramble to try to fill empty spots. By Friday, you know where you matched, if you did match. It's a pretty weird tradition in medicine. It's fine if you match. You're chilling for the rest of the week, but it's definitely a stressful couple of days leading up to it. I hope I did it justice. It is a weird thing to explain.

Srihita: My heart started beating faster when you started describing it and I'm not even going into the medical field. So, my heart goes out to everyone who has that coming up. The way you are describing it, I don't know if this is the same thing, but my friend is pledging for a sorority. It's a similar process with the ranking.

Sarah: A lot of people compared it to March Madness, in that it's like a bracket system.

Zarya: My March Madness was for music because I was in a marching band, but that's usually for basketball right?

Sarah: I have very peripheral knowledge of that. The only reason I know how it works is because I did so many brackets rating Carly Rae Jepsen albums in March Madness format.

Zarya: That’s so funny. Srihita mentioned she’s not in the medical field, which I happen to mention pretty often accidentally. But, you mentioned that it’s kind of like dating so maybe I'll try to set up Srihita with a medical school.

Srihita: Medical school or medical student? I am confused.

Zarya: Well, I'm your medical student, hopefully

Srihita: I'm not allowed to date medical students solely because Zarya is going to be one. That's actually a role that she has.

Sarah: What? Well, I would say you probably shouldn't date medical students because we're extremely busy.

Srihita: I just wouldn't see them. Zarya already does it to me sometimes. I'm like, “I'm never gonna see you when we get older”.

Zarya: I try not to surround myself with only students in the medical field. While it can be nice to have someone going through the process, it can get very single minded. You don't really get to talk about other things. I saw another meme, also on Twitter, that said, “If your friends are mostly in humanities, then you know that you're cool if you're a STEM major.” Srihita is also in STEM, so I guess I'm still working on it.

Sarah: I totally relate to that. When I was an undergrad, we were all, I think there were seven or eight of us in pre med, and then slowly everybody started drifting in different directions. We had engineering, we had some people who completely switched over to the non-STEM fields. My best friend is in her dental residency now, and that kept it pretty good. We both had a very similar path that we had to follow, but it was just different enough that we weren't competing with each other. We didn't feel negatively, based on somebody else's success. We were in it together but we had a different enough journey that we can be there for each other without it becoming like all we do is talk about grad school. But, I agree. Once you’re in medical school, that's all it is. It's just people thinking about medicine 24/7. You do have to set boundaries. For me, my partner not being in medicine was a huge relief. Even though I come home and I rant about things to them, I still always have a space where I can just talk about something that isn't about a hospital, talk about something that isn't whatever new thing is frustrating me about medicine. Sometimes it's interesting to see their perspective on doctors or just things that I take for granted. I’ll say something out loud and they're like, “What are you talking about?” It helps me understand how I need to talk to patients because they're not going to understand what I'm saying either.

Zarya: Yeah, I think it's good for me. Sometimes I talk to Srihita about things I see as an emergency medical technician, and she'll be like, “Huh, what's going on with that?” It's good to have somebody else who isn't in the same field because you learn so much more about how to talk to patients. Patients obviously don't know the same information you do. Actually, that's not fair to say. There are some patients who are very well informed, you, for instance. I’m not sure how to pronounce it.

Srihita: Can I try pronouncing it? Okay, can you tell us about your Non-Axial Radiographic Spondyloarthiritis story?

Sarah: That was really good. I’ve had attendings I’ve worked with before that have been unable to pronounce it, though they’re doctors that have been working for over 20 years. So, that was impressive. So, that was a huge part of my medical school career in 2019. I was just starting my fourth year and I started noticing that I was really stiff all the time in my back, mostly my lower back. I was having trouble just getting around. I would wake up in the morning and just feel really stiff as if I had worked out really hard, but it just never faded away. I was working out but I wasn't working out enough to have injured myself. I told myself it was no big deal. I just had to make it through. Then, I ended up in the ER one morning when I was supposed to work, because it felt like my back was frozen. I couldn't bend it. I couldn't move it. Every time I tried, it was excruciating pain. That started my winding path to figure out what was going on with me.

I had a lot of pushback from a lot of the doctors that I saw. They saw that I was on anxiety and depression medicine, which I had been for a few months, so they thought it maybe was psychological or maybe I was stressed out for medical school. I didn’t know why I would be stressed out at the beginning of my fourth year. I finally get to do what I want to do, psychiatry. I'm getting ready to apply for residency. This is actually the least stressful year of medical school. So, I doubted myself a little, but I knew what I was experiencing wasn’t made up. Because I was lifting about five times a week at the time, they thought I might have injured myself. So, I went to a spine specialist and everything would just keep coming back normal. I finally felt like I needed to diagnose myself. I started hunting down different clinical conditions we had learned about in medical school. I thought I had something called ankylosing spondylitis, which we learned about in my musculoskeletal course in my second year and. It's like usually young people, usually men, but it can happen in women. It's an arthritis of the spine and it can end up with people almost being hunched over because their spine just fuses together. That’s what it felt like to me, like my spine was fusing. I had a hard time getting people to believe me. My spine specialist finally referred me to a rheumatologist because everything else has been negative.

So I finally got a rheumatologist and he believed me. He saw people like this all the time and told me that we didn't have to worry about this. He started me on the medicine that folks take for rheumatoid arthritis, the stuff that you see commercials for all the time. He started me on that and it actually helped quite a bit. I was able to go back to rotations and I didn't get diagnosed officially until this past fall. So I was already on that treatment and now I'm on an injection treatment called Cosentyx. You have probably seen commercials for it, but it's something people take for Crohn's disease and different autoimmune diseases.

It was hard, even knowing what I knew, just going into the office and trying to explain my symptoms and my experience. I don't even know how folks who don't have the language to back it up do it. It made me completely change how I talked to patients. I realized that I could walk into an office with all my training, but if I'm not listening to what the patient is telling me, I will never figure out what their diagnosis is. I would be trying to pigeonhole them into what I think is going on as opposed to listening to what they think is going on. There is psychosomatic stuff; there is malingering and seeking drugs. All of that is real. But you know what else is real? Chronic pain. It’s hard for me to assume it's psychosomatic or that they're stressed out, especially when we're living in a post-2020 world where everything is stressful. I can't assume that everything is due to stress. For me, that's been a life-changing experience, because now I know how it feels to be on the other side and have someone tell me that they think I’m faking it. For me, at the very least, if I leave the room and the patient trusts me to not screw them over, I will feel that I have done a good job by my patient. It’s okay if it takes me months to figure out what's going on with them. Do I wish it hadn't happened? Of course. It made me have to do an extra year of med school. I had to push off my match to 2021 because I just didn't have enough time to get all my rotations done. Financially, it was just terrifying.

Ultimately, I probably will be a better doctor for it. Especially in psychiatry, so many of the patients we get are ones that everybody else has written off. They'll say, “Oh, we've worked them up for everything, we think it's psychological; we think they're depressed.” They might be, but they also might not be. That's definitely in the back of my mind every time I see somebody who's complaining about pain and they're being pushed away to psychiatry. Is this person really coming to me because they need my help or are they coming to me because people have given up on their symptoms? That was just a very long summary about being a patient and being on that side of things.

Srihita: That’s really important. Not being in the medical field, when doctors tell you things, you think they must be right because they’re doctors. So that's super important to share because, to an extent, people do know their bodies better than anyone else will ever know them. It’s important to trust your instinct. Obviously it’s important to be informed if you’re not in the field, but still trust your instinct. So can you talk about how this experience informed your idea of affirmative care and how you would define affirmative care?

Sarah: Absolutely. One of the big issues with queer patients is finding physicians and healthcare practitioners who actually understand what they're experiencing. To a certain extent, unless they are queer themselves, I don't think they will understand. Also there are limits to what people are willing to do in order to understand their patients. A lot of times we sort of step back and say, “Okay, this is what I can do in this situation, for sure, so that's what I'm going to do.” There's some overlap in how I think of queer issues and disability issues. It is about the lived experience. In terms of affirming care, you need people in the field who have that experience to truly get to that affirming point. That's not to say that, you need a queer or disabled physician to feel understood, but it helps. Being able to cross that baseline of understanding what the patient is saying to get to the point of how to help is huge. So many physicians get stuck in the “here's what I'm trying to say” portion that they never actually get to the point where they are doing anything to benefit the patient.

I do think it's a recruitment and retention issue. AAMC just released a study today that said 3.1% of all physicians. I think 26% of all Americans are disabled. So, the disparity is huge. I'm sure that it's similar numbers for for queer patients and physicians. People who are already in the field have a lot of onus on them to provide better affirming care. There's more wraparound service clinics coming up now where it's family doctors, endocrinology, psychiatry, OBGYN, and urology all working together. Especially for trans patients, you can't really get one service and then leave and go to another clinic. You need a group of clinicians who understand what's going on. Those are really awesome and that was something that I looked for in my residency application process. I tried to find programs that had pre existing clinics where psychiatry was incorporated with family medicine or an OBGYN. I do think that’s needed in one place. I don't think we can get them to follow through with this many specialists separately. I do think that's progressing in the right direction, with the clinics that are available. I don't think there's enough of them. With academic centers, folks who are working there will leave to go to other places that have more research and opportunities. Then that clinic is without the people that know how to run it. I think that we need to get students and residents involved at an early level. Then, if the main person leaves you're not left high and dry without those services. That is something that's happened here at my school. We had a surgeon who used to do gender affirming surgeries, and they moved to some other facility. Now the future of it is in flux which is terrible because people used to drive from all over the Midwest to come here and get surgery. It's just one of those things where we just don't have enough people to meet those needs. We can't really do it with the number of people we have so it's important for us to get queer pre meds into med school and keep them here and train them into being queer residents. That's the only way we're going to be able to provide affirming care.

Zarya: The statistics you provided are shocking, so I’m trying to process them. There’s only one surgeon that does gender affirming surgery in your area?

Sarah: There's multiple surgeons, but the surgeon that headed it was the expert in that topic. There are people doing more routine procedures like hysterectomies or ovary removal. It's not really the full-spectrum gender firming care that they were previously receiving. There will still be surgeons who will do the surgery, but it may not be as well-rounded as it would have been if the person who was doing the surgery was educated on how to provide gender affirming care.

Zarya: For our viewers who may not be as familiar with the terminology, what exactly does gender affirming surgery entail?

Sarah: There's a few different types. There's top surgery. The terminology is a little bit outdated already. It’s described as “M to F” or “F to M” depending on the assigned gender birth and the desired gender. There's bottom surgery which is a little bit more complicated. You have more specialists involved: gynecology, urology, plastic surgery. It's interdisciplinary. There's different people involved, even anesthesia. So, there's a lot of potential for there to not be gender affirming care in a gender affirming surgery. You're being seen by surgical staff who were not trained in that field, who are there because they work at that OR. So the surgeries will happen, but the focus is not necessarily always on making sure that the care is affirming.

Zarya: To clarify from earlier, you said that 3% of medical students are disabled or is that for the percentage of students that are queer?

Sarah: AAMC just posted earlier today. It was for disabled physicians versus the number of disabled people in the United States. I think 26% of Americans are disabled and 3.1% of physicians are disabled. There's a huge gap.

Zarya: Granted, you can always try your best to educate yourself on the important issues and try to understand something from somebody else's perspective, but when you've gone through it yourself, it definitely changes the importance of it and how that affects your interaction with the patient directly. I don't know the number of physicians who identify as queer in the United States, compared to the number of total people who identify as queer in the United States. I would hope that the urologists and plastic surgeons. whoever's involved in the surgeries, have a mindset of trying their best to do well by the patient. That’s not to say that everyone isn’t.

Sarah: It’s like what you guys were saying earlier, about trusting that doctors know what they’re talking about. There's such a disconnect between what physicians are taught to know about queer and other marginalized groups of patients versus how many of them we actually see. You could totally walk into a room with a queer patient and have absolutely no idea how to approach taking care of them in any situation. It could be as simple as someone coming in to urgent care for a cough. If their pronouns from the interview don’t match the ones in electronic medical records, you may not have the skills to conduct that interview. It's getting a little bit better. We're taught how to ask certain questions. Even as recently as my second year, I was never taught how to conduct interviews with trans patients. Anytime I've encountered that it has been through efforts by queer students. It has not been from any established curriculum. There’s no governing body requiring training. It's always been queer students and queer residents taking it upon themselves to put that information out.

That is a huge problem because it puts the onus on people who are already marginalized to do the work. They become the automatic representative of the entire group, when there can be difference within the group. There are people in the disability community who hate being called disabled and then there's people in the disability community who say it's infantilizing to call them special needs or some other euphemism. You can't really be the spokesperson for an entire group of people. That's why we need more people from that group to be in these jobs and in these positions. Then we can actually get a sense of what patients need. We can’t treat the entire group as a monolith. Otherwise, we assume that they’re here for the same reason. It's usually related to sexual history or depression. We're taught that if they're queer, they're here for an HIV tests or because they're depressed or sexuality related. We’re never taught how to you know take care of a queer patient who has diabetes and just happens to be queer, but it's part of their identity. That's never not going to be part of the conversation.

It’s hard for queer patients to go into a clinic not knowing if the person on the other side is gonna even accept that. You can always tell when somebody is not accepting of who you are as a person. So I think that makes it hard to acknowledge the very real issues in the queer community. We need more, not just representation, but more vocal support from the people who actually make these decisions. They need to say we're done doing surveys; we're going to actually implement changes, instead of waiting on students to point out what's missing.

Zarya: One thing that you pointed out that resonates with my experience as a medical scribe is when there's a queer patient, you ask about sexual history and I remember. There was one patient was told us he was gay. The doctor automatically ordered blood work. It was an assumption that was made without waiting to hear what the patient was there. It could have been a sore throat. They just happened to share that they're gay on the side.

Sarah: It always blows my mind. Our first and second years, when we were getting ready for boards, that was how we were training ourselves. What answer does the question want me to pick? It’s going to ding me for picking what feels more organic. It’s different when you go into clinical practice and you're sitting across the room from a queer patient. In one of my first clerkships, there was a lesbian patient coming for reproductive cancer prophylaxis. She had the gene for it and was trying to have surgery to reduce the risk. Every time she came in, we would have to talk to her about the risk of losing your uterus and not being able to have children, or we would have to get a pregnancy test. Finally, she said that she was with a woman. She was not having sex with anyone that could get her pregnant. She didn’t want children. She didn’t care about losing her uterus. She just wanted to keep her ovaries so she didn’t go through menopause early. It took her three visits to finally say that. If we had just asked during the first appointment, that could have been avoided. But, we’re taught that any woman of childbearing age gets a pregnancy test. That's fine to a certain extent because we want to make sure we're not doing any imaging that's harmful or giving any medicines that can hurt a fetus. But, if a person is telling you there's no chance they’re pregnant because they do not have sex with people who could get them pregnant, it is disrespectful to constantly interrogate that and insinuate that there is a chance. All you need to do is listen a little bit closer to what the patient is telling you. If their history says “lives with girlfriend”, you can say, “Is there a chance you could be pregnant?” instead of ignoring them and asking them to agree to do a pregnancy test.

Zarya: I understand to some extent why we ask for urine tests. I actually recall an instance in which a patient did not know that we ran a urine let alone knew that they were pregnant. They came in for something like a sore throat. We ran the urine test anyway because they were female and that's just part of our protocol. I remember the doctor asked them if they were expecting a positive pregnancy test. The patient was caught in headlights. They were, rightfully, overwhelmed. It was just a really sad moment to be part of for both of us. I was grateful to be there in the room with the patient and to experience that with her, but the look of fright and distraught that came with it, I don't think that was fair for us to do. If you're coming in for something totally unrelated to pregnancy, you should be made aware that we're running a urine test. We should ask if they want a pregnancy test. I understand it could be important to know whether or not the patient is pregnant, but if that's something that's totally unrelated to what they're coming for, it shouldn’t be the standard.

Sarah: I've had that same thought just on my ED rotations when we would order labs. Coming from a psychiatry perspective, all we do is talk. We have to have that dialogue with the patients for them to be really involved. In the emergency room, you just tell them that you’re going to run some labs and leave. They don’t go over it at all. We don’t tell them what our thoughts were. In your first and second year, when you're practicing, they want you to say everything over and over again. You get graded on that at the end of your simulation. You have to repeat and summarize everything that you talked about with the patient. You literally get points taken off if you don't do that. And then we go into practice and that just goes right out the window. So, the disconnect for me between first and second year and then third and fourth year has been wild to process. I'm sure it's only going to get worse from here right. I think that's something that being a patient on the other side has helped me realize. I've been like, “Why didn't they run through the list of everything they were going to order with me?” To a certain extent, because I'm very nosy, I like to know everything that's happening with my care and my family's care. I ask all the time: tell me exactly everything you're going to order. I need to know. I feel like every patient deserves it. It takes 30 seconds. They may not understand a lot of what you're saying but they deserve to know.

I'm thinking more about how I'm going to be as a physician. I do not want to do that, where I go into the room and not provide adequate information. Especially with patients who might be from a marginalized background, they're the ones who feel the least in control of their lives in the United States. I do not want them to feel that this is another person who is taking their power away from them. The worst thing I could do as a doctor is to go into a room and make them feel that they have just been victimized or violated. It doesn't have to be physical; it doesn't have to be abusive. It can be a lack of agency. In medical school, you'll hear a lot about patient autonomy and non-maleficence, like buzzwords. In practice, a lot of times, you don't see that happening. It's concerning. It makes me question the model of medical education. We focus so much on all these topics early on but, then we're letting people run with it once they're in practice. I'm making it sound really bad. There's obviously doctors who are wonderful and you want to emulate. But, it's the negative stuff that sticks with you. It shapes how you're going to be as a doctor. I think that's definitely one that stresses me out quite on a day to day basis - when I feel like I haven't done my due diligence in making sure the patient knows what exactly is happening. It's something I try to do on my own rounds in the morning. I give updates on every single lab. They're probably not even listening. They just trust you but I need them to listen to me. It stresses me out to think that they may not know what's going on with their care. I don’t like that at all.

Srihita: As a patient, I could see myself not paying attention to all the details being thrown at me. However, from the perspective of having a family member going through something, I would want the doctor to tell me everything in excruciating detail because I want to be informed about their care. Even if doctors do have the impression that a patient doesn't want to hear, it's way better to give them more than they asked for. If they have follow up, they'll ask. It's better to do that than to not say anything at all. So you've mentioned this a few times but you are planning to become a psychiatrist. Can you talk about what drew you to psychiatry?

Sarah: It's really interesting timing for that question because the person who drew me to psychiatry passed away earlier this month. My uncle had schizophrenia that was diagnosed when he was 12. When I lived in India, my family used to stay in the same house as my mom's parents and siblings. It was very tight knit. I was around for his medicines. I was one of the people, four or six year old, I was the one who would tell him to calm down and center him. So, growing up I, weirdly, had a lot of contact with psychiatrists and the mental health field in general. When I was trying to figure out what to do with my life, I thought maybe I'll go to law school. Maybe I’ll do the thing that everybody dreams of: become an English Lit major and read Jane Austen forever. Then, I thought about who I'd want to work with. I realized I wanted to work with people like my uncle. I figured that psychiatry was the best way to do that. I wanted to be on the medicine management side because my uncle's medicines were never quite right. It’s especially hard with schizophrenia. I realized how much potential there is for early intervention to keep people from progressing and getting worse. My uncle didn't get to have that, so that was definitely one of my motivations. With my residency applications, one of my main goals was to find programs that had early psychosis intervention and clinics where I could work with people in middle adolescence and try to help them before it gets too hard to try to keep them from what we call, colloquially, full blown psychosis. That's definitely what drew me in.

Through med school, I realized that I actually really liked psychiatry. I was lucky enough to be going through clerkships and having my choice validated repeatedly. I was lucky because it doesn’t always pan out that way. I'm really excited. Working in hospitals in the Midwest, I see how little access folks have to psychiatrists. Sometimes, they'll have therapy set up, which is great. But, they're not on meds when they should be or they're on too many meds when they shouldn't be. Things slip through the cracks. It can take six months to schedule outpatient appointments, it’s a mess. My brother is going through right now, trying to get a psychiatrist and it's just awful. I'm really lucky that I wanted to be an outpatient psychiatrist. If anything, I can at least be an outpatient psychiatrist that can get people in and take care of them longitudinally because seeing people who are mentally ill decompensate is one of my one of my motivations behind being in medicine. I want to keep that from happening as much as possible. So yeah, that's my psychiatry story.

Zarya: Your story really resonates with me because I have an uncle; I'm Pakistani, and Muslim as well. In Pakistan, my uncle has dementia and it's interesting to see how it's not exactly a family secret, but it's definitely something that we don't talk about openly. He is independent in the sense that he has his own living space and he can eat by himself, and he takes medications with the guidance of somebody else. Sometimes he will go out and just see the community. I remember, one time, the police had stopped him, and they were asking a bunch of questions and he couldn't answer them because he just wasn't able to at that moment. It became somewhat of an abusive scenario. Following that, my family had decided that they were going to tattoo the address and the name of my uncle onto his chest. Then, in the event that he took off his shirt, at least the police would know who he was and what his condition was. Having tattoos in Islam is a no-go. To have overcome that and cross that barrier for what I consider to be a very religious family was difficult. Do you feel like you've had to deal with those misconceptions and the taboo of being in psychiatry as a Muslim Indian?

Sarah: The story you shared is interesting. I think of dementia and schizophrenia as being very different but it's interesting how people on the other side see it as the same: as somebody who isn't normal or right. and that's, I've had similar situations where we've been worried about my uncle, with people reacting to him inappropriately or abusively. It’s an interesting question. It's funny because, for the longest time, most of my family thought that he was under some kind of spiritual possession while he was growing up. I didn't hear about it until later. They spent a lot of time going to different religious leaders and trying to get prayers to cure him of the possession. There were times when he would have psychotic breaks and they would see it as the devil coming out. There's a lot of things like that, that I think, prevented him from getting care in an appropriate timeline. Even now, knowing that I'm in medical school and am going to pursue psychiatry, there were times where my grandmother would say that he's acting like he has a curse on him and we knew he had schizophrenia. We've talked about this a bunch of times. He's on medicine; he sees a psychiatrist. The path of least resistance has just been to not disagree but also get him on clozapine. So I definitely get that.

I think when I first shared that I was interested in psychiatry, it was like your family deciding to get the tattoo for your uncle. I had assumed everyone would say no or that I shouldn't do that, but they thought that I could maybe fix him. Now he’s passed so it won’t happen. In reality, it never was because of the way that chronic mental illness works. I think it speaks to how Muslim families, despite different rules and expectations, they will still put it on the line when it comes to taking care of their family. I think that's definitely been my experience as as a Muslim going into psychiatry. The families that I see who are multicultural, I haven't seen many Muslim patients yet, but I have seen a lot of patients who are Hispanic and patients who are immigrants. Their families have similar cultural and spiritual beliefs that have initially prevented the patient from getting care. Then, once they see the path, they put their feelings aside for the betterment of the patient. I was really lucky to be in a family that, despite their beliefs, saw that what I was going to pursue was going to be a net positive, whether it was going to be for my uncle or for people like him. They never told me not to do it. If they did, it was because they thought I was going to be too busy to have kids. I don’t want to have kids but that’s for a later conversation. One step at a time. I was lucky enough to not have to think about something that might have been not okay with a lot of people. Also, I have three tattoos, So I’m on thin ice as far as what Islam will and will not allow.

Zarya: Let me ask you about that. I saw that you have a tattoo and thought “This is one of the cool ones.”

Sarah: I get all the time when I meet other Muslim people, especially people who are from families that are more religious than mine. They will say, “Oh my gosh, this means you're cool.” I just don’t want them to tell their parents because I want them to let me hang out with them. My cousin said that me getting a tattoo meant she could too. I don’t need anyone using me as a yardstick for what is and isn’t allowed. I have very chill parents, so I’m lucky. But, I don't want to be kicked out of family celebrations.

Zarya: You have a partner, and we know how Islam feels about that.

Sarah: My partner is a white Catholic, so that was a journey on its own. I already had one tattoo before we started dating and then I got two more. I'm living with my partner and we're not going to have children. So it’s just all stacked up against me.

Zarya: That's awesome. How does being queer factor into that?

Sarah: It’s interesting. For the most part, I’m out to my friends and classmates and, on a national level, I’m on the MSPA board. I’m loud and proud on Twitter. But, I have never actually come out to my parents. I have a funny feeling that if they hear the podcast, that's going to be the first time they find out. The reason I never came out to them was because my partner and I are cishet appearing in our relationship. I do not anticipate that we will break up and that I will be in a situation where I am dating other women or anything like that. It's almost been a self preservation thing; the conversation really doesn't need to happen. I know that's very privileged for me to be able to say that because there are people who have to think about this regularly. Also, I'm 26. I'm never going to be living with my parents again, hopefully. My situation has allowed me to keep it on the down low. They know I'm on the MSPA board and I've shared that with them. Through our conversations, they may know. I haven't really hidden it. I just haven't sat down and had that conversation. If they do know, it's a mutual decision to not talk about it. In their eyes, I'm with a cis man and we're together forever and all that. But, me and my partner know what our relationship is. We know that we're not what everybody thinks we are and that's challenging for my partner sometimes. They have to live with that passing privilege being a regular couple. You can have all these internalized feelings about whether or not to tell people. I'm very lucky that I can just roll with it and not have to worry about it so much. I do think I will tell them eventually, especially, if there's ever a direct question. Both of you have probably experienced that If your parents aren't directly asking you something, it's just easier to not worry. In Indian and Muslim families, a lot goes unsaid and that is just fine.

Zarya: I'm operating on a need to know basis. If they can figure it out from the rainbow shoelaces, that's up to them. Otherwise, they’re just cool shoe laces.

Sarah: I have giant pink, purple, and blue hearts all over all my social media profiles. If they haven't put two and two together, I honestly don't know what I should do at this point.

Zarya: Actually, I feel like that's harder. Looking at those, I just thought it was a cool color scheme. I wouldn't recognize it at first.

Sarah: It's not my fault that Apple doesn't have a bisexual pride flag.

Zarya: I think that we should get our families together and just tell them. But they're going to focus on the fact that we’re Pakistani and you’re Indian.

Sarah: Right, it’ll be about the World Cup or nationalism.

Zarya: Let’s make a plan for that. We will have to wrap up soon, but Srihita had a really important question she wants to ask about your Instagram.

Srihita: I know you did hand embroidered art and I was just wondering if you'd like to talk about that because I thought it was really interesting.

Sarah: It ties into my year of being really sick. I actually started it right around the time when I was feeling uncomfortable. I didn't know what was going on. I am not the kind of person who can meditate. I have undiagnosed ADHD. I'm not saying that to be quirky. I really do have it and I'm not willing to spend the money to get diagnosed. Anyay, I can't meditate. It stresses me out. I needed to do something where I could just sit and focus, and have the TV on or a podcast in the background. I just needed to not have to interact with anyone and do my thing. I used to try to do cross stitch when I was a kid and I just never could finish the project. I started doing that again off of Etsy with kits. Once I got tired of following other people's patterns, I decided to teach myself how to embroider. It's pretty easy to do it now because there's YouTube and Instagram videos. So I started doing that and then people started paying me to make their photos into embroidery. At first, I didn’t get it. You have the photo, why do you need this embroidered? That was my first thought, but people thought it was beautiful. I was okay with it as long as I didn’t need to do faces. I can’t do faces. Then, it just popped off a little bit. Now, I'm booked through mid-May. People give me, I won't say hundreds of dollars, a significant amount of money to do these pieces. A lot of them are for anniversaries. Wedding gifts are my favorite to do. They'll take pictures from people's wedding photo shoots and ask for it to be embroidered. It’s cool to me because they're going to see this after they're married.

It’s really fun and it's a way for me to decompress after work. Especially, when I’m sick, I will sit and embroider for hours and binge-watch something. It’s the closest I've come to meditating, and the extra cash has been pretty nice as a medical student. It’s @stitches.in.indy. It's probably going to change because once I find out where I'm matched. I will have to either change to a permanent name that is not location dependent, or I'll keep going and keep changing based on locations. I haven't decided yet. That seems like a bad marketing strategy so I should probably pick one. It's really fun. I do pets and people send me quotes. Pets are hard; I'm trying to get better at it. I've met a lot of very interesting people through doing this. I have customers in the UK and it's just wild.

Zarya: Perhaps you can do that for mine and Srihita’s wedding anniversary. She hasn't said yes but I'm getting there.

Sarah: Oh my gosh, that would be so cute.

Srihita: Keep dreaming buddy.

Zarya: We're just roommates right now but perhaps someday.

Sarah: This is just an elaborate way for you to flirt with her.

Zarya: It is. I'm trying to do a better job because ever since I learned that she is leaving me to graduate and move on with her degree, which I don't understand.

Srihita: I got into grad school recently and ever since, it's really changed our dynamic. I feel like she’s not flirting with me as much anymore.

Sarah: She's preparing herself mentally now.

Zarya: Don't analyze me. I could be your patient later on, though.

Sarah: Oh my gosh, no. This is now like a conflict of interest. I know too much.

Zarya: I have so many different faces, you won’t recognize me. We do have time for one more question. And that question is if you could turn back the time and talk to your pre med self, what would you tell them?

Sarah: I thought about this a lot when I saw the question. So, keeping with my career trajectory, I would say get a therapist. Get on antidepressants and anti-anxiety medicine, whatever psychiatric help you need. Get it before medical school starts, especially if you think it's not a big deal. Medical school, no matter where you go or what you do, will compound on your pre-existing anxieties and worries and any kind of negativity you have towards yourself. Be proactive. Get a therapist. Get your conditions diagnosed. Get on it. Otherwise, it's going to be the month after your take Step One and you're going to freak out. You’ll tell yourself you made a bad decision and you should drop out and things that you probably don't want to do. It's just that your brain can't keep up. Sadly, it’s normal. Medical school is just a very competitive and strange environment that people outside of it don't understand. You have to be proactive, and that's true for everything. If you're feeling burned out, take a month off, move your vacation schedule, or take a year off to do research. Just be proactive. Do not let it build up to the breaking point. That is something I don’t do anymore.

Zarya: I guess I'm winning the game because I have therapy times three.

Sarah: That's fantastic. I did some therapy in undergrad and then stopped because I didn’t feel anxious anymore. In medical school, I realized I had to get a therapist. I had to get on medicine. Now I do group therapy and I'm fully planning on continuing that in residency. I can't even imagine what it would be like to start therapy for the first time in residency as an almost-30 year old. I'm glad I have like a few years of experience behind me. I always tell everybody that I talked to who's younger than me to get therapy.

Srihita: I tell everyone that I know as well. Zarya and a few of my other friends are planning to apply to medical school. It's interesting because you’re always told to be proactive about applying and that entire process. I think it's really healthy advice to be proactive in taking care of yourself. I've been going to therapy for about a year. One of the most important lessons I've learned is that the universe rewards you for taking care of yourself, way more than you think it does.

Sarah: I will even go as far as you can definitely finish your med school application and personal statement the week leading up to it. You cannot build your emotional stability the week leading up to it. That is just not going to happen. I am proof that this is possible. I did my personal statement the week before I applied, because it just didn't come to me until then. So, that is fine. You will get it done; you have gotten this far. Push comes to shove, pre meds are better at doing almost anything last minute than anybody else I've ever met. Therapy, getting your meds right, and getting your mind right is not something you can 50% to the end. You have to really do it 100%. That's way more important than any score or any application you'll ever do.

Zarya: Y'all heard it here first, folk. Pre meds do it better than anyone and everyone.

Sarah: Pre meds have so much energy. I don't even remember what it was like to have that much energy.

Zarya: Anyway, thank you so much sir for coming out here. It’s crazy that we haven't talked about psychiatry or mental health on the show. Right, Srihita?

Srihita: We really haven’t. I’m way more comfortable talking about this then like medical school because I know nothing about med school. I love divulging experiences about therapy. It’s all I talk about to my friends. I'm trying to trick my friends’ Indian parents into letting them go to therapy. It's a whole thing.

Sarah: I am forever trying to trick my own dad into going to therapy.

Zarya & Srihita: If you figure that out, please let us know!

Sarah: Every brown person I know says the same thing. My dad will say that he’s depressed so I will tell him to go to therapy. But then he’ll say that he's not spoiled. I’m literally studying to be a psychiatrist. Apparently, in his day, they just suffered through it. That’s why they’re all messed up.

Srihita: I had to go to therapy because you wouldn’t

Sarah: Exactly

Zarya: On that note, we’re going to wrap up this awesome conversation. It was really great meeting you.

Sarah: It was really fantastic talking to you guys. Thank you for having me.

Reflection

Srihita: We just wanted to say a big thank you to Sarah for joining us, Zarya and I wanted to talk about a few things that stood out to us. The first thing that I wanted to talk about is Sara mentioned that in Indiana, where she attended medical school, there was a surgeon known for performing gender affirming surgeries. The surgeon had recently left due to a different opportunity. That left a lack of access to gender affirming care. What I wanted to point out is this distinction that Sarah made between gender affirming surgery and gender affirming care. When a patient is going through the experience of receiving gender affirming surgery, the surgery itself is only one component. What made this surgeon so special is that not only did they obviously offer that component of gender affirming surgery, but they also were able to create an experience that provided gender affirming care. I think it also points out the lack of infrastructure and accessibility that we have to these surgeries, which is something that will come up in future conversations. Zarya, what did you want to talk about?

Zarya: Going along the lines of lack of access to surgery, it can be difficult even if you’re certain there is an issue, similar to Sarah’s story. Can you pronounce it one more time?

Srihita: I've been waiting for someone to ask. It was called Non-radiographic axial spondyloarthritis.

Zarya: I remember you were helping me prepare for an interview with a cardiothoracic surgeon and I couldn't nail the wording of a device they created. I don't think you've let me live that down in the past year, which you really should at this point. Srihita demonstrates excellent pronunciation of this device, at least once a month. For the record, it didn't come up in the interview. Honestly, I don't expect Srihita to give that up for the next five years. One thing that I appreciated about our interview with Sarah was that she emphasized her position as a medical student and how that gave her access to the knowledge and language that patients may not have. Even at the pre med level, where I'm shadowing surgeries and clinic, I can feel the difference between having familiarity with the terms and not. Recently, my mom had a sonogram and I was able to dissect what was important in the radiology report in seconds. I think a lot of that comes from what I've seen in clinic. Also, I think my confidence gave my parents a lot of reassurance. If my mom got that sonogram a few years ago, I don't think I would have been able to comfort them in the same way that I can now. Even though I'm not the one giving the medical diagnoses, at least there's somebody in the family who understands what's happening.

As someone who's shadowed in different clinical settings, one of the biggest shortcomings that a healthcare provider can have is overconfidence is diagnosis or assessment. The physicians I work with who take the time to listen to the patient's concerns and consider them often make more accurate diagnosis. They're also less likely to see the patient two days later. I don't think that goes just for physicians. I think it goes for EMTs too. There's been times where we see the patient and decide they maybe don't need to go to the hospital. They refuse medical care, and then guess what? We're back at their home five hours later. It's not that we didn't take the time to consider what was happening. We’re not going to leave the patient if we were uncomfortable or leave without giving them the knowledge we have and helping them make an informed decision. But, I definitely do think there's some extra steps that we can take to make sure that the patient is getting the best care possible. I also appreciate what Sarah said about therapy. I think we should talk about that more. I used to think that there was something to be ashamed of, since no one I knew was in it. Once I started telling my friends I was in therapy, many of them admitted that they were in it too. And I wonder why that is? What do you think?

Srihita: Sometimes. it feels like a cult that you're inducted into when you start therapy. Then you realize there's a lot of people that actually do this. I recently had to have a conversation with one of my friend’s mom. They're family friends so I knew her mother pretty well. I was telling her that she needed to send her daughter to therapy. I thought it was important. For me, I've been going to therapy for a little over a year. What I really appreciated about what Sarah said was she realized at some point that it wasn't stress, right? She knows what stress is like. Being a medical student is a stressful experience. She was able to recognize that there was something else going on. One point that I try to reiterate, almost every episode, is just listen to yourself. I think when we really sit with ourselves, we do know whether it's just stress or if it's something else. So take care of yourself, I guess.

Zarya: Treat yourself as they said in Parks and Recreation. On that note, we're gonna wrap up here. Thank you so much for listening and we'll catch you on the flipside.

Srihita: Bye!

[Theme music plays]

This transcript has been edited for clarity. This text may not be in its final form and may be updated or revised in the future.