EP. 13: FIGHTING FOR EMPOWERMENT AND EQUITY

WITH PAMELA KUNZ

Jun 1

WITH PAMELA KUNZ, MD

A leading medical oncologist shares how she overcame years of gender discrimination and how she now advocates equity in academic medicine.

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Episode Summary

Dr. Pamela Kunz is the Director of the Center for Gastrointestinal Cancers at Yale Medicine. For 19 years, she was at Stanford University, most recently serving as Director of the Stanford Neuroendocrine Tumor Program. But in 2020, Dr. Kunz announced her departure, citing years of gender discrimination, microaggressions, and harassment. In this episode, Dr. Kunz opens up about the challenges she faced, how she overcame them, and how she now taps into a clear-eyed awareness of her values to lead health care settings that empower underrepresented individuals and to advocate for diversity, equity, and inclusion in academic medicine

Dr. Pamela Kunz is an associate professor of internal medicine (medical oncology) at Yale Medicine, where she is Director of the Center for Gastrointestinal Cancers at Smilow Cancer Hospital, Chief of the section of Gastrointestinal Medical Oncology, and Vice Chief of Diversity, Equity, and Inclusion in the division of Medical Oncology.
Prior to Yale, Dr. Kunz was Director of the Stanford University Neuroendocrine Tumor Program and Director of Stanford Health Care’s Neuroendocrine Tumor Fellowship. Beyond her record of accomplishment in GI Oncology, Dr. Kunz is an international leader in the clinical care of patients with neuroendocrine tumors and is involved in clinical trials and translational research that are defining the next generation of therapies for patients with this rare diagnosis.
In 2021, Dr. Kunz was named Woman Oncologist of the Year by Woman Leaders in Oncology.
In this episode, you will hear about:
• How Dr. Kunz’s science-filled childhood led her to a career in medicine, and why she took on the daunting task of treating cancer patients - 2:21
• What it is like to build relationships with patients who have life-limiting cancer diagnoses - 7:25
• Dr. Kunz’s past struggles working in a toxic environment due to constant disrespect and denigration based on her gender - 12:18
• How leadership coach Rebecca Merrill (our guest on Episode 7) helped Dr. Kunz realize why she was so unhappy in her work and what she could do about it - 16:15
• The development of Dr. Kunz as an advocate of diversity, equity, and inclusion in academic medicine - 18:48
• Dr. Kunz’s advice for women and other underrepresented individuals going into medicine on preparing against potential hostility in their chosen careers, and how to create a “tapestry” of mentors - 22:01
• How Dr. Kunz addresses her own burnout, and how seeing oneself as an advocate can be a tool to self-empowerment - 32:25
• The advice Dr. Kunz would give to her past self if she could go back in time - 41:02
Transcript

Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:04] Our guest today, Dr. Pam Kunz, is the director of the Center for Gastrointestinal Cancers at Yale Cancer Center. For 19 years prior to that, she had been at Stanford University, most recently serving as director of the Stanford Neuroendocrine Tumor Program. But in 2020, Dr. Kunz announced her departure due to years of gender discrimination, microaggressions and verbal abuse. In this episode, we are fortunate to have Dr. Kunz join us and share her experiences while at Stanford, how she overcame these challenges and how she now advocates for equity in academic medicine at Yale Medicine. Dr. Kunz is currently also the Vice Chief of the Diversity, Equity, and Inclusion Initiative in the Medical Oncology Division. In 2021, Dr. Kunz was recognized as the Woman Oncologist of the Year by Women Leaders in Oncology.

Tyler Johnson: [00:01:56] And I will also say that she is a dear personal friend and mentor, and probably as much as any other person, responsible for both the current position -faculty position- that I have and also for a lot of the work that I do. So I will just start off by saying that we're greatly appreciative. I'm greatly appreciative for the effect that you've had on my life, and we're also greatly appreciative to have you here on the program.

Pamela Kunz: [00:02:18] Thank you, Tyler and Henry. Happy to be on the program.

Tyler Johnson: [00:02:21] So we would love to start by you just giving us your origin story. How did you decide that you wanted to go into medicine and then how eventually did you make your way into medical oncology?

Pamela Kunz: [00:02:35] So I have always enjoyed science. I grew up in a family with a father who was a biologist, and he studied bats, which is really far removed from medicine, but really grew up being encouraged to pursue science, being exposed to science, asking scientific questions. I spent time in his lab. I spent time in New England, barns with him looking at bats and even got to go to the Ecuadorian rainforest with him to also trek around and look at bats. And it was through that that I actually pursued an undergraduate degree in ecology. So at that point I still thought I wanted to be like him. And I studied tropical ecology and went to Costa Rica and Jamaica and did that through a program at Dartmouth College. And I still wasn't really sure what I wanted to do when I graduated from college, but I knew that I loved science and I loved teaching. So my first job out of college was as a middle school and high school science teacher. I taught seventh grade, ninth grade and 12th grade science at a small girls school outside of Boston and coached soccer and lived in a dorm and made no money for that first year. But to think back on that, it was still really true to what matters to me, which is teaching and science. And eventually I made my way into working with a physician scientist at Massachusetts General Hospital in a lab, Dr. Vivian She was a pediatric metabolic disorders specialist. So think back to the rare inherited metabolic syndromes that we all learned about in medical school, like maple sirup, urine disease and some of these rare cycle and urea cycle disorders. So she not only did.

Tyler Johnson: [00:04:29] My palms are sweating as I stepped back on this thing, so I.

Pamela Kunz: [00:04:33] Don't ask me any details. I don't remember. But she did prenatal testing, saw children in a pediatric clinic with these inherited syndromes and did original research looking at novel inherited genes. And so it was really my first exposure to this blend of how to be a physician scientist. And I was hooked. And after two years, I then went to medical school, much to my father's disappointment, who told me many times that real doctors had PhDs.

Tyler Johnson: [00:05:08] And so so then you get into medical school. One of the things that we have talked about with some of our other guests is that, you know, there are arguably some parts of medicine that maybe don't involve as much suffering and where you could understand how someone would would find it that a welcoming place to go with in medicine. But medical oncology certainly doesn't fit that bill. Right. And particular as in particular as a person who focuses on gastrointestinal malignancies like that's just a lot, right? I mean, those people can be very, very sick. The diseases can be life threatening. And even if they're not immediately life threatening, they can be they can just make people miserable. Right. And so I guess I'm I'm curious, especially as someone who arguably came to medicine a little bit on the lighter side, at least after you had graduated from college and whatever, once you got into medicine, what then drew you to becoming an oncologist?

Pamela Kunz: [00:06:06] That is a great question. And I'm Tyler. I'm sure you get similar responses. If I'm at a social event or out with my kids and their parents and I get asked what I do, I get often sort of questions like, Oh gosh, that must be so hard that you're an oncologist. Or I can't imagine being in that field, and I just don't feel that way. I feel really grateful to be in the field, and I was actually really drawn to the intensity of the physician patient relationship. It's such a privilege and I really embrace that aspect of what we do. And thinking back to medical school and residency, I was really drawn to fields that had long term continuity, kind of intense relationships. And so it ultimately came down to the fields of oncology and cardiology. And I really enjoyed chronic illness and I was the sort of person that if I was in an urgent care clinic or emergency room rotation, I couldn't stand not knowing what happened to the patient because I wasn't going to see them again. So ultimately, I think it was the blend of this, that intensity of the physician patient relationship and the science that ultimately sold me on oncology.

Henry Bair: [00:07:25] You know, as a student, I obviously haven't practiced. I haven't seen patients independently, but I have worked with patients who have cancer. And I've talked to residents who are going into the specialty and I talk to attendings and heard their experiences. One of the things that stood out to me when you mentioned your interest in oncology was the longitudinal relational aspect of it. You get to walk the path with your patients. But I can easily imagine someone thinking, "I get to form this long, deep relationship with the patient and then they have a very high chance of passing away. I can't stand that. I can't imagine being able to deal with the emotional burden that comes with that." How do you think about that aspect of your work? How do you confront that? And then despite that, continue doing what you do?

Pamela Kunz: [00:08:21] Henry. You're right. That element is definitely hard, but it makes those relationships so much more meaningful. I mean, I can think of so many examples. I'll give you one. I have three sons. They're 16, 13 and ten. My ten year old, his favorite stuffed animal named Pokey, was given to him by one of my dear patients who's now deceased. And it was given to him before he was born. And right around the time that this patient died, I'm still in touch with the patient's widow. We still text. I text her pictures of Pokey, and I feel like I have this guardian angel for my family and my son. And as kind of silly as that sounds, I still am connected to them. And she sent my son a letter and a picture of this patient of mine just to try to make that connection for my son. And it's stories like that that just bring such deep meaning to what we do.

Henry Bair: [00:09:25] Was there a moment in particular you can talk about perhaps early in your career that helped you realize why this is the most meaningful work that you can do?

Pamela Kunz: [00:09:37] That's a great question. You know, I don't know that it's any one patient. I'll sort of talk just more generally that I think some of the patients that have been the most memorable have been the ones that have been close to my age. Now, that certainly has changed over the last 20 years as I get older. But I think when when we can find that common denominator with the patient, I think not only does that allow us to really connect with the patient, it makes the relationship meaningful. I think it makes me a better physician. I can understand them better. And I think what I've learned as I've gotten older is that we can actually find that common denominator with just about any patient. It takes some time and I think that I try to teach that to my fellows and trainees is to look for that common denominator because it makes the relationship with the patient that much more meaningful.

Henry Bair: [00:10:31] So I'm curious, how do you teach that? What do you tell your fellows about that search for the common denominator?

Pamela Kunz: [00:10:38] It evolves. It's not necessarily on that first visit. I think it's about building trust. I think it takes time. I think it requires us as physicians letting our guard down a little bit. I think I probably do that better now than I did as a new doctor. I share and maybe I share too much with my patients, but my patients know that I have kids. They know we talk about a variety of things. But I think by my sharing some, it helps create that connection and and that bridge. And I think the trust piece is really important is I think building that connection that allows patients to trust us more and trust us with some of these really hard conversations around goals of care when it's time to stop chemotherapy. So I actually think that it benefits both of us. I get so much more out of these relationships when I can find that common denominator and I can have some of the harder conversations more easily when that connection exists. But it's hard to teach. I mean, I try to role model it, I try to point it out. I try to make a point of specifically with a patient, for example, that I may not otherwise have a natural connection with. I try really hard at finding something that we can connect on, and I'll ask them about what they do. Tyler and I both have a mentor at Stanford, Dr. Dimitri Colevas, who makes a point of saying, Spend 5 minutes talking to your patient about something other than their cancer. And I think that's really important. I've certainly taken that to heart.

Tyler Johnson: [00:12:18] So, Dr. Kunz, I'd like to take the story in a little bit of a different direction. And to do that, I'm going to start with a little bit of back story that might make your ears burn a little bit, so I hope you'll forgive that. So every year, the Stanford Oncology Division has a retreat at Asilomar down by Monterey in California. So I remember it was probably around the time when I was a senior fellow. I don't know exactly what year being at this retreat. And this was when Dr. Kunz was probably like six years into her faculty-dom. So Dr. Kunz had given some sort of presentation and the old chief of oncology just sort of like spontaneously got up in a way that only a chief-emeritus could do and just started to spontaneously talk about how Dr. Kunz was so wonderful and she had fulfilled the hopes that they had when they hired her in the division and had accomplished all these things and anyway, etc., etc., etc.. I was saying a lot of nice things, which is all to say that I think at that time, maybe four or five, six years out of fellowship, at least by all outward appearances, it seemed like your career was just on the trajectory, right? You were like heading towards promotion and everything was all sort of figured out and it looked all nice and linear.

Tyler Johnson: [00:13:31] And yet, because we're good friends, I know that maybe even starting then, but then certainly in the years after that, you went from a place where everything seemed to be right on track to a place where it kind of maybe felt like everything was falling apart. And one of the purposes of this podcast is to help people who may be themselves in the middle of a period where it feels like things are falling apart to hear testimonials to how physicians, how that happened to them and how they made their way through a dark time. And so to whatever degree you feel comfortable, given that this is a a public forum, I was hoping that you could talk a little bit about what happened, what that looked like, and how you made your way through.

Pamela Kunz: [00:14:13] Thanks, Tyler. I'm happy to talk about that. I mean, yeah, it's a good reminder that we all carry a burden and we don't know what burden other people carry. And I definitely went through a period of really falling into a deep, dark hole and I can rewind a little bit. So I think it was around that time, Tyler, that I was kind of reaching mid-career or mid-assistant-professor-dom and had gained some level of success and some national positions suddenly really was feeling like I was hitting up against some walls and barriers in terms of an ability to take on leadership positions. I felt like my leadership was getting undermined and it was really due to what I felt at the time was related to gender discrimination. I had certain more senior male faculty members say things to undermine my authority in public, say things like, "Oh, I'll let Pam answer first so that I can correct her." I felt very labeled as being difficult and it was not a single person. It was, I think, part of the culture. And I felt that it was a really toxic work environment at the time, and I felt I was made to feel like it was my fault for bringing on some of these things and so really shook my self-confidence and I was crying a lot. And in fact, I think, Tyler, I cried on your shoulder and it was hard. It was really one of the hardest professional times in my life. And you're right, I had really prided myself on having this, what I thought was this linear path and being successful. And I'm a bit of a perfectionist, so kind of admitting that I was not okay and that things weren't going okay was really hard. And I know you've had Rebecca Merril on as a guest. And it was just at this time that I happened to be taking one of her leadership courses in mindfulness called Space, and I was in one of the early cohorts. And it was just I don't know, the the world knew that I needed that at that time.

Henry Bair: [00:16:28] Sorry to interject here, Dr. Kunz, but just to help clarify this for our listeners, Rebecca Merrill is a leadership coach who specializes in coaching physicians at Stanford Hospital. She runs workshops for doctors to help them cultivate mindfulness and reconnect with what matters most to them in their work. To learn more about Rebecca and how she helps doctors, you can listen to our conversation with her in episode seven of this podcast. Back to you, Dr. Kunz.

Pamela Kunz: [00:16:55] I was so unhappy, but really hadn't put my finger on why yet. And we had to do narrative writing through this course. And I had never been someone to take on or to try narrative writing as a way to express how I was feeling. And I remember the first assignment I went towards the end we shared. You kind of read what you wrote to this small group of other members who are taking the course, and everyone was so vulnerable and I was so impressed. And meanwhile I had done like a bulleted list of how I was feeling or something totally like not what? Not not the assignment. I went home and wrote and cried and really put down how I was feeling. And it was really through that exercise and through multiple other narratives that I really came to realize that I was feeling discriminated against and harassed and I felt really stuck. And it was through working with this with Rebecca Merrill and in the small groups and one on one coaching. That was an incredibly transformational experience for me. We did a lot of work on finding what mattered and finding meaning, and I'm a big fan of Brené Brown and read her "Dare to Lead" book, which has a chapter on finding what matters and did this deep value in inventory. And I just feel now like this is now four years later that I have all these skills to be more resilient and I follow a use that value assessment as kind of my true north in terms of leading through this meaning and purpose. And it's just it's been completely transformational in terms of how I approach challenges and how I dug out of that whole.

Tyler Johnson: [00:18:48] Now, the thing that's really striking to me is that on a personal level, I hear what you're saying about that. You were in this very dark place. And then through all of the the means that you've discussed, you came out better on the other end. But the other thing that's striking to me as someone who has observed your career, is that not only have you, it's not as if you were sort of doing things A, B and C, and then you had a really hard time doing them for a while. And then you went back to doing things A, B, and C again. That is true that you went back to your prominent researcher and clinician in terms of treating your endocrine tumors and other things. But not only did you go back to that and not only are you still doing that very well, but then when you came out on the other side, you took on this whole other aspect of your career that I think for the most part was pretty much not even there before. So can you talk a little bit about what is that additional aspect and what has it been like mid-career to add this entire additional plank to your platform, so to speak, that just wasn't really there before?

Pamela Kunz: [00:19:54] That's a great question. I think honestly, it was part of my healing process. So again, I was feeling so stuck and actually really angry and sad and all these kind of negative emotions when I was in this deep, dark place, and it was really through working with the coach to help me kind of pivot out of that, to really start focusing on, well, how can I contribute to solutions around promoting gender equity, eliminating disparities, promoting diversity, promoting an inclusive environment, creating a respectful workplace, like all these things that I felt I didn't have at the time, like, how can I be part of the solution was sort of the pivot. And then I just started relentlessly looking for opportunities nationally at my own institution. Ultimately, I moved institutions, and in the course of that move, I think that actually opened up a number of opportunities for me. So I now also serve as the Vice Chief of Diversity, Equity, and inclusion for the section of medical oncology at Yale have taken on some national roles in that space and speak about gender equity. And I think it was really leaning into this element of what I had discovered really mattered to me. That has given me kind of another professional hat to wear. But I think it's really aligned with that whole process that I went through and actually I think very aligned with your podcast of Can we kind of live a life of purpose? Can we find that meaning and live by pointing our arrow at that? I'm so passionate about it. It really gives me a lot of meaning and I think gives me a platform to help other people. And I think I can sponsor trainees and junior faculty in that regard. I'm a sounding board for lots of people, both at my institution and nationally around this topic, and it just makes me feel good.

Tyler Johnson: [00:22:01] So I want to drill down on something there that I think is really important. As you know, I serve as a mentor for a lot of medical students here at Stanford. And I had a student who I had mentored for a number of years who this was a couple of years ago was getting ready to graduate from medical school. And this was a woman and she was seriously considering going into orthopedic surgery. And it is just true that at least reputationally, many people think still of orthopedic surgery as a field that is dominated mostly by men as all branches of medicine do. But that still has a lot to work out in terms of gender equity and in terms of empowering women and making sure that the the field, let alone any individual institution, is empowers women and is hospitable to them. And and I know that one thing that she really struggled with as she was deciding whether to make orthopedic surgery, her life's work was in addition to the very difficult, challenging, rigorous process of just becoming a surgeon, did she want to knowingly add on top of that feeling like she was going to have to be constantly battling against forces that would make her feel unwelcome or that would make her feel like she didn't have a place because that is just not a place where where women were supposed to be? And I know that this was a really personal process for her, figuring out whether she wanted that included, and if so, how she wanted it included. And if it was worth going into a field where arguably she would feel like she had more of that onus on her than she might have if she had gone into internal medicine or something else. And so I guess, as somebody who has sort of fought through the screen and come out on the other side, If you were counseling, whether it's a young doctor who is a woman or who is in some other historically underrepresented or under empowered group within medicine, who's grappling with some of those questions, kind of definitional career questions, how would you counsel them to think about that?

Pamela Kunz: [00:24:10] You know, I actually think one of the reasons I was able to take this on was also given that I was more senior, was given in my new institution, have a leadership role that gave me authority, responsibility and ability to make decisions. I think as a trainee or as a junior person, it's objectively really hard. And I think that my advice to junior people would be to find and create this network. I have a friend and colleague who's CEO of Sarah Cannon Research Institute. Her name is Deanna Smith. We gave a talk together and she coined a term called Your Tapestry. And it's sort of a tapestry of allies, mentors, sponsors, coaches, all these different people who can serve different roles for you. And I think that that's the advice I give to trainees. And I think this is one thing I learned the hard way. I really put all my eggs in one basket, so to speak, in a single mentor, and was really let down by that person. And I think that the kind of old fashioned one on one mentoring really is a setup for this hierarchy and power differential that in medicine can sometimes create these power dynamics that can be set ups for discrimination and harassment and and disrespectful behavior. And so I think that my advice is cast this net, no one person can serve every role for you and someone may be a better ally than a sponsor or a mentor. So it requires all of those things.

Henry Bair: [00:25:56] Dr. Kunz In my own experiences, when I have found mentors, it's been a rather organic process. Most commonly, I get assigned to work in the clinic of an attending who I happen to enjoy working for, and I will afterwards say, Hey, can we talk outside of clinic and tell me more about how you got to where you are? So in my own experiences, I haven't exactly searched for mentors the way that you have described. I have not deliberately cast a wide net. I was wondering if you could be more specific in your advice for medical students such as myself about how I might begin to go about that process of purposefully assembling my committee of mentors, if you will?

Pamela Kunz: [00:26:48] Sure. I mean, I agree with you, Henry. I think it has to have some level of being organic mean. I think those relationships really can't be forced. But I think that for trainees and certainly I do a lot of mentoring our first year fellows and even junior faculty of spend some time having these listening sessions or informational meetings with people that you think you might be interested in working with. And it's through those that you can sort of slowly develop a relationship and determine, well, what role is it that that person could serve for you? So someone who's a sponsor is someone who can create opportunity. They may not be that person that has time to meet with you once a month as a really dedicated mentor. But they might be able to suggest you for a speaking role or suggest you as an author for me on a manuscript. So it's kind of figuring out what role those people can serve and how they can fit into your network.

Henry Bair: [00:27:49] So I've been fortunate that I haven't really faced the challenges that we've been discussing that you had to face. Let's say that someone was a junior clinician or a medical student, perhaps, where right now encountering some of the obstacles that you had to manage. What are some of the practical steps this person might be able to take to combat that?

Pamela Kunz: [00:28:20] So my hope is that that person has a few trusted members of their tapestry or network already. So I think it's going to someone that you trust and talking to even peer mentors, I mean, I spent a lot of time talking to Tyler about this when it was happening and really was grateful for his listening and advice. And I think that it's finding some trusted people that you can talk to. But I think we really do need more senior people who can help navigate that situation. So it's finding through that network, is there someone more senior or do you already have someone more senior who can really help you navigate and serve as that sponsor to help create a different environment or a different situation or help create an opportunity if you need to kind of get out of an existing situation. The other thing I really I give this advice all the time is work with an executive coach. And I think that as a medical student and trainee, I had no idea what that was. And again, I know you have this podcast on on coaching. I was new to coaching when I met Rebecca and met her through this space program, the leadership program that I mentioned earlier. And executive coaches, I think, are really intended to be kind of objective listeners and are really well trained at helping to navigate an individual situation.

Pamela Kunz: [00:29:45] And I think that coaching is now been become part of many institutions, wellness programs and wellness initiatives for physicians. And I like to think of a coach as a mix between like really an objective coach who's teaching you new skills and a therapist and a cheerleader and is kind of all mixed into one. And, and that was really valuable for me and I certainly don't want to discount the value of really objectively seeing a therapist if you if that's something that you think that you need. I think that I was personally, clinically depressed at the time and did meet with a therapist. And I think that kind of that element of we're all the whole medical profession is facing issues around burnout. And I think that really talking openly about mental health issues is important. I think there's just there's lots of layers of that. And I think when I talk about gender discrimination, I also mention elements of intersectionality around kind of women who have other underrepresented characteristics, whether it be race, ethnicity, disability, age, etc., really often face heavier burdens of discrimination and harassment. And I recognize I bring kind of a level of privilege as a white woman to this conversation. And so I now when I kind of talk about all of these things, try to bring in that element. And I think that it's important to acknowledge that in this conversation.

Tyler Johnson: [00:31:15] One thing that I want to just this is just highlighting something that Dr. Kunz has mentioned, but that, I think is an important nuance to drawx out, because it may not be intuitive, especially to people who are very young in their medical training, like medical students, is that it's really important to have trusted people that you can talk to who are not in your direct chain of command. Right. Because I think what happens is that a lot of times, just by virtue of where you're placed in the ecosystem as a medical student, the people who are most readily available. You are your residents on your words team or your attending from your surgery team or whatever. Now, those people can be wonderful resources for you, but I know that many medical students, no matter how much they're assured that the reality is otherwise, are always going to have this sense of like, well, but maybe they're evaluating me and maybe they'll think that I'm this or that if I talk to them about something that's hard, hard that's going on. So it's just to say that precisely because of that additional evaluation element, it's really important to have people that you can talk to who are not in that structure so that you can be truly candid. And so for Dr. Kunz, that was having a coach, right, or a therapist or whatever.

Tyler Johnson: [00:32:25] But it's just important to also have that that element. One thing that I wanted to ask Dr. Kunz, so one thing that I'm really struck by is that you had, I think, going into your faculty career, found medicine to be very meaningful. That's why you had gone into oncology and you were sort of setting up this career. And now it's clear from the way that you talk and write about these things that it's very meaningful. But there was a period in the middle where you had kind of lost the meaning, right? You had sort of lost the thread. And and you've talked a little bit from sort of a big picture sort of life philosophy perspective, how you got the thread back. But I'm curious if you can just be a little bit more concrete now. Are there things that you do day to day or week to week that helped you to? I'm not sure how you can un-burnout, but whatever that process is called about getting burnt out, like are there day to day or week to week things that you do that help you to keep touch with both the deeper meaning of your job and also then with the deeper meaning of your life.

Pamela Kunz: [00:33:26] Hard question. So maybe I'll rewind to kind of when I was going through this process. I mean, I actually literally made a spreadsheet. I know that sounds kind of silly, but of kind of what I liked about my job, what I disliked about my job, and then the list of values. So the things I valued were respect, collaboration, diversity, teamwork, family, you know, sort of a mix of professional and personal. So I actually literally made a list and then I realized pretty quickly that I was not getting those values met in my then current work environment. And I needed to figure out, could I change that environment? And often that is possible, or did I need to find a different work environment?

Henry Bair: [00:34:19] To your point about making a list of your values, you know, you mentioned it as a silly exercise. You know, I don't think so. You know, Tyler and I teach a class at the medical school here called Meaning in Medicine, and we help PA students and MD students engage in reflective practice thinking about the things that are most meaningful in medicine. And we were having this discussion the other day about burnout rates among doctors and among physician assistants. And the PA students noted that there just doesn't seem to be that prominent of a problem of burnout among physician assistants, and that all the PAs they've encountered generally seem to be very satisfied with their careers. So I ask why they thought that was. And they made this fascinating point that all patients at some point had to sit down and think deeply, carefully about whether they wanted to go to PA school or medical school. Many of them had, in fact, taken out pen and paper, much as you had, and listed out what they were looking for out of their careers, what their values were for them. Opting to go to a PA program was a very purposeful decision after having weighed what was most meaningful for them in a health care profession. Then they turn around and ask me whether medical students went through the same process. And what I think is, they don't. I think most medical students, and especially the ones who came straight through from college to medical school like myself, never really sat down and formulated a values driven framework for considering how they wanted to balance their professional and personal lives in medicine. And all of that is just to say that, taking a piece of paper and listing down your values isn't such a bad idea, and thank you for sharing how that has helped you. But getting back to Tyler's question, I think he had asked you about what some of the small things you do on a daily basis for keeping unburnt out. Can you tell us more about that?

Tyler Johnson: [00:36:55] One example of the kinds of daily habits I'm talking about is that if you send Dr. Kunz an email when she's out of town with her family, what many clinicians will do is they'll either just respond to it or they'll have a generic out-of-office response and then they'll still respond to it or whatever. But if you send something to Dr. Kunz, you'll get an email back that says, "I'm currently on vacation right now. I'm probably either in the pool or playing basketball with my boys. I hope you'll do something like that too" or something, and I'll get back to you when I get back or something to that effect. Right, which I just feel like that's such an unusually candid acknowledgment that actually you're also a person and you're not necessarily going to respond to every email within 5 minutes. Right. And I gather from having talked to you before that some of those things are sort of part of the recalibration that you've done over the last five years. But I just on a really concrete level, are there some of those kinds of things that have helped you to sort of keep better touch with the things that are the most important to you?

Pamela Kunz: [00:37:54] Yeah. So that Tyler is right. That's true. And I borrowed that from somebody. That was not my original idea. But I challenge you both to create a fun out of office vacation email. It's actually kind of fun to do, and then the responses that you get back are actually awesome. So, you know, I think what I also try to do is incorporate an element of this kind of what matters to me in like almost everything that I do, it's sort of this like lens that I look through now. It brings meaning to them, like everything that I do. So it's in faculty recruitments or it's in meetings that I have. I now have a diversity, equity and inclusion minute at every division meeting, every medical oncology division meeting. Again, I think it's just this like how I look at the world now, but it is very intentional. Tyler To your point. So it's kind of how can I think about that? I know when I give scientific talks, I say something about equity and I and I say how they're related. And it's trying to teach others like they're not disconnected and they're not unrelated. And and I'm a scientist, but I'm also an advocate. You know, this is something to both of you that I've thought some about, but it's like sort of physicians as advocates, I think is something like new for me. We have such an amazing platform in medicine to to be advocates and it's like, how do we teach that and how do we embody that for our trainees? And it's something I'm exploring myself, but I think that it's an interesting topic.

Henry Bair: [00:39:32] I can imagine how some clinicians might think that advocacy is not for them because there is often an undertone of politicization when it comes to advocacy, and some clinicians really don't want to be involved in that at all. So how do you respond to that? How do you think about advocacy versus its potential politicization? Is it politicization at all and how do you navigate that?

Pamela Kunz: [00:39:56] Well, it's a good question. It's very it's timely and we don't have time for all of that today. But I think there is an element of the population that thinks that advocacy does not belong in medicine. And that's certainly been a lot on social media. In fact, even in the last few days, I actually see and think about my role in promoting diversity, equity, inclusion in the workforce, which is kind of my platform that really goes hand in hand with us providing better patient care. I went into medicine really to provide direct patient care and certainly research. And I now have really, I think the way I connect the dots and the way I talk about it is that by creating a more diverse and equitable and inclusive workforce, we are going to have more innovative science. We're going to have more creative science. Our patients are going to ultimately get better care because we're being more creative and we're meeting the needs of a diverse population. And so for me, those make a lot of sense and really belong together.

Tyler Johnson: [00:41:02] So, Dr. Kunz, you've been so generous with your time. And I guess the the thing that I would like to end with is this. You know, we have all seen the really startling and troubling statistics of the number of health care workers who have left the field of health care in the last two or three years now. Granted, the immediate context for that is the pandemic, which is hopefully a once in a century phenomenon. And so we should acknowledge the unique nature of that. But nonetheless, I think there was kind of a sense, even leading up to the pandemic, that the health care world was sort of primed for this. Right. Because we've been talking about the epidemic of burnout for five or ten years. And there are statistics from even before the pandemic, about the percent of physicians and other health care workers who are considering leaving the workforce and all the rest of it and all of that is to say that I feel like you can correct me if I'm wrong, but it seems like it's not too much of an exaggeration to say that it would be not too hard to imagine a world where you could have left the physician workforce right during this time when when things had gotten really, really dark. And so if you could sort of appear as a guardian angel to your former self during the darkest time of your questioning everything about your career, and if you were to give some words of wisdom to the person who is to your former self in that dark place, or to the person who's listening to the podcast who's currently in that dark place, what would you what would you say?

Pamela Kunz: [00:42:34] You know, I think it really goes back to finding out what matters most to you and doing that value assessment. I wish I had done that value assessment years earlier and really figured it out and taken time. And I think that's the thing in medicine we are so programed to go from the next rotation to the next rotation or the next thing that we don't actually take time to sit down and figure out what matters to us. And that can shift and change over time. To Tyler's point earlier, I've taken on kind of a completely new role and this second phase of my career. But I think we need to follow and be driven by what matters to us.

Tyler Johnson: [00:43:17] All right. Well, Dr. Kunz, thank you so much for all of your wonderful work in multiple facets. And thank you for your very helpful example in the way that you have ordered your life over the last few years. And we really greatly appreciate the time you've taken to come and talk with us.

Pamela Kunz: [00:43:31] Thank you for the opportunity.

Henry Bair: [00:43:36] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:43:55] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.

Henry Bair: [00:44:09] I'm Henry Bayer.

Tyler Johnson: [00:44:10] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.