EP. 80: FINDING HOPE AND HEALING IN THE ED

Sep 19

WITH MICHELE HARPER, MD

An emergency physician and bestselling author shares how she rose out of trauma and now seeks to heal traumas both individual and societal in the emergency room.

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Episode Summary

In many ways, emergency rooms are the frontlines of health care, serving as the initial point of contact for people experiencing sudden and severe health problems or accidents. In other ways, emergency rooms are the last line of defense, serving as a critical catch-all for vulnerable populations who have nowhere else to go. How can doctors reconcile the tension between the desire to help others with the frustrating inability to address the many systemic causes of health problems encountered in the ER—homelessness, mental illness, domestic violence, substance use disorder, and more? Here to explore this question is Michele Harper, MD, an emergency room physician and New York Times bestselling author of the memoir The Beauty in Breaking, in which she shares her journey from an abusive childhood home to working in busy ERs. Over the course of our conversation, Dr. Harper discusses the unique challenges she faces as a black female doctor, how healing from her own trauma was key to connecting with her patients, and how the issues she encounters in the ER are a reflection of broader societal ills.

As a content warning, this episode contains discussions of domestic violence and sexual assault, which may be uncomfortable for those who have experienced trauma or are otherwise sensitive to these topics.

Michele Harper, MD is an award-winning physician, New York Times bestselling author, and nationally recognized speaker whose work centers on individual healing and social justice. She is an advocate of personal wellness and evolution as a foundation for collective liberation.
In her memoir, The Beauty in Breaking, Dr. Harper shares her journey from an abusive childhood home to hectic ERs in New York City and Philadelphia as a Black female doctor—a demanding position in a profession that is still, today, overwhelmingly male and White. She describes how her own healing and that of patients she encountered along the way show we are all healing from something, and how, if we make the choice to heal ourselves, we can heal each other and society at large.
A popular speaker on healing from trauma, cultivating hope and transformation in difficult times, and health equity, Dr. Harper has appeared at Yale University, the University of California San Diego, the University of Texas San Antonio, the Society of Academic Continuing Medical Education, and the American College of Surgeons, as well as Kaiser, Womanspace, T-Mobile, and Microsoft. She has also appeared as a commentator for MSNBC, NBC, ABC, and on many popular podcasts.
In this episode, you will hear about:
• 2:42 - How Dr. Harper’s experiences growing up in an abusive household drew her to a career in emergency medicine
• 12:40 - The limitations ER doctors face in managing the underlying causes of the health problems they encounter
• 17:38 - The importance of fighting for health equity and what that entails
• 27:41 - What the individual clinician can do to advance health equity in the US
• 31:44 - Contending with the reality of race- and gender-based discrimination within hospital systems
• 38:58 - Connecting with your “calling” when making career decisions
• 44:23 - The importance of healing yourself in order to better show up for your patients
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] 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 healthcare 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 healthcare, 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: [00:01:03] In many ways, emergency rooms are the frontlines of health care, serving as the initial point of contact for people experiencing sudden severe health problems or accidents. Yet in other ways, emergency rooms are the last line of defense, serving as a critical catch all for vulnerable populations who have nowhere else to go. Societal issues such as homelessness, mental illness, domestic violence, and substance use disorder come into play on a daily basis. How can doctors reconcile the tension between the desire to help others with the frustrating inability to address the underlying injustices? Joining us to explore this question is Dr. Michele Harper, an emergency room physician and New York Times bestselling author of the memoir The Beauty in Breaking, in which she shares her journey from an abusive childhood home to working in the busiest E.R.s in the nation: in New York City and Philadelphia. Over the course of our conversation, Dr. Harper discusses the unique challenges she faces as a black female doctor, how she rose out of trauma, how healing herself was key to connecting with her patients, and how the issues she encounters in the E.R. are a reflection of broader societal ills. As a content warning, this episode contains discussions of domestic violence and sexual assault, which may be uncomfortable for those who have experienced trauma or are otherwise sensitive to these topics. Without further ado, here's Dr. Harper. Michelle, welcome to the show and thanks for being here.
Michele Harper: [00:02:39] Thank you. It's a pleasure to be here with you.
Henry Bair: [00:02:42] So to kick us off, can you share with us what initially drew you to a career in medicine?
Michele Harper: [00:02:47] So I believe it was the fact that I was born in crisis. I grew up in an abusive household with a father who was a batterer. And so from an early age, I felt what it was like to feel unsafe, to know that there could be danger at any time, even in these spaces where we're supposed to be protected. And because of that, I developed a sensitivity where, I mean, I knew for myself I wanted to grow out of that and ensure the safety for myself and of those I loved and also wanted to be part of a larger structure of doing that for other people. So in my mind, I mean, I grew up at a time where in my household and in my neighborhood, you could either be a doctor or a lawyer, maybe an architect. So I thought, well, doctor, doctor sounds good where I could where I could help people and be part of of healing. And so as time went on, that's how I started to pursue the field.
Henry Bair: [00:03:43] Did you have people you looked up to growing up who you aspired to be or whose work you aspired to pursue?
Michele Harper: [00:03:50] No, not really. No. When I was little, I was growing up in D.C. around a lot of professional people, and there were role models I met along the way. People who I looked up to, like my third grade teacher, Mrs. Bunyan, who I will never forget, for really believing in my potential as a student and putting me on this course to make sure I was in a school system that could foster and provide the resources I needed to excel. So there were always people like that along the way, but not really. I mean, apart from people I would look up to later on, I found my way to spirituality and and read Thich Nhat Hanh's book Living Buddha Living Christ, or later looking up to Tina Turner. But in my immediate environment, the mentoring that I found was often a kind word here or there, or seeing a role model on TV or again, a certain author, but not so tangibly and physically along the way during my education.
Henry Bair: [00:04:55] Well, we're certainly going to come back to the spirituality aspect of it. But before that, you eventually specialize in emergency medicine. Why did you make that decision?
Michele Harper: [00:05:05] I'm going to come back to the environment I was raised in. Later, In retrospect, I realized that a lot of the skills that I developed early in life were applicable to the skills that I would need in emergency medicine. So being in a situation where I just had a snapshot in time, just a moment to evaluate is there an immediate life threat right now? Is this situation dangerous right now? Or perhaps it will blow over and we'll really be okay? Or perhaps not? Perhaps the quiet is not cause for concern, but we really are okay right now. That's exactly the skill set that I use as an E.R. doctor. So in many ways, I think that I was groomed to be an E.R. doctor from my experiences in the household.
Henry Bair: [00:05:54] So for those of our listeners who maybe are not there yet in medical training or who are not on the path of medical training, we do spend some time looking into or learning how to identify risk factors or signs of trauma or abuse. Typically, yes, this is in the setting of the emergency room, I would say, because this is where it comes up a lot. And I'm wondering if this is too personal of a question, please let me know but did your own lived experiences through the kind of household you grew up in, did that make it more difficult when you were encountering those kinds of patients, those situations in the E.D. As the doctor?
Michele Harper: [00:06:40] No. And I know that people vary in terms of their responses. And also it's going to depend on the amount of processing one has done before. The work we've done before we entered these hallowed spaces of the hospital. So for me, it wasn't more difficult. I think it actually was very helpful for me. And I do I just do just want to add, because you kindly shared with me that there are so many people in training who tune in, and I want to say, yes, there's a lot of screening we do in the E.R. for interpersonal violence, for abuse, whether it's with two adults or child abuse or elder abuse. So there's all kinds of screening we do in the E.R. of course, when it comes to those matters. I will say it's so important in the outpatient setting as well, even in the inpatient setting, in case something slips through the cracks. Maybe we didn't get the history of elder abuse for whatever reason. Again, to reevaluate on the inpatient side still in clinic. This comes up a lot in pediatrics in ob gyn. I mean, honestly, it should come up in every single clinic. So I think there's opportunities for us all. And personally, with my experience, I think it's really been informative. It's I think it's opened my eyes. For example, I had a case where a woman was coming in with her and of course I change identifying information, of course. So her daughter, teenage daughter, she didn't know where else to go.
Michele Harper: [00:08:13] She was coming in because the daughter was increasingly depressed and anxious. She was aware that probably the E.R. was not the appropriate setting. She didn't know what we could possibly offer her, but she just knew that her usual tactics of being open to conversation with her daughter for working with the people in her school, she even called a therapist and set up an appointment. But if anyone's tried to get an appointment, there can be long wait times. So the appointment was weeks off and she was at her wits end and in so much pain over seeing what her daughter was going through that she came into the E.R. with her. So, of course, I did my requisite screening and there was no acute medical issue. And then I explained that I would need to speak to her daughter alone. I was I was talking to them both and I asked consent for them both to do that. She stepped outside. You know, I explained the confidentiality, but that if certain topics came up where I was concerned she would be in danger, that I would have to break confidentiality, because first and foremost, I have to keep her safe. And then I asked for her consent again, the patient who was the daughter, and she said, okay. And then she ended up sharing with me that she did want to do better in school. Her grades were suffering. No, she was not doing drugs, which was her mother's concern as well.
Michele Harper: [00:09:38] No, there was no interpersonal violence with her boyfriend, but she was just increasingly sad and didn't know what to do about it, but wanted to feel better. And when I asked her if she had any thoughts about how that might have started, she shared, It was when a family member who was visiting from another country had subsequently left. She does not spend time with this family member, but this person sexually assaulted her, sexually abused her. She went on to say that at the time, which was a couple of years ago from when we were speaking, she did share that with her mother. And her mother said,"How could you say such a terrible thing? It's not true. So I don't want to hear about it. We cannot speak about it again." So she never mentioned it again, but she knows that it's just been festering inside of her. So of course I then explained after saying how horrible that was and how sorry I was that that happened to her, that this person violated her in this way, this criminal act, and how also in not listening and believing her, how her mother also betrayed her trust. And I explained that this is one of those situations where we need to break confidentiality. And I asked her if it was okay for me to bring her mother back in the room so we could all speak together. And she said to me, Please do, please do, because maybe if you tell her, she'll finally believe me.
Michele Harper: [00:11:06] So we did all speak together and when I explained what the daughter had shared, the mother broke down. She broke down and said how sorry she was, how she was sexually abused. And she feels it triggered in her all the unexplored, unhealed wounds that she couldn't face within herself, so she couldn't face it in her daughter. And it was a really important interaction. I mean, the daughter at the end of this, I could see in her countenance and her posture how she finally felt heard and seen and also supported by her mother. Her mother said apologize to her directly and also said she she wanted to make this better. Not only would her daughter get therapy, but they were going to go to therapy together, at which the patient smiled and she already told me that she had a good relationship with her mother. She felt safe at home. She was not being abused by anyone else. But it was this critical issue that they both needed to address and heal from and move forward from. Now I ended up discharging from the department. I'm an E.R. doctor, so I wasn't following them, but I know it's because of experiences that I have had that influences my approach, that make those interactions, those conversations, the possibility of healing. It just it allows it because of the work I've done, because of the experiences I've had before coming into the room.
Henry Bair: [00:12:40] So when it comes to emergency medicine, I think obviously people are attracted to different medical specialties in part based off of personality and part based off of their prior experiences. The stereotype of I would say that I certainly personally carry of emergency doctors or people who love the instant gratification of hands on saving a life like literally. Right? Because on a daily basis you can whether it's someone coming in for opioid overdose, you give them naloxone, you just saved a life or someone coming in with shock and you use pressors to stabilize them enough. So right there you just gave them a life back. Or if it's someone coming for trauma and they have air trapping their lungs, causing part of their lungs to collapse, you can literally stab a huge needle into their lungs to alleviate that air trapping like this is very concrete, tangible things that you're doing with your hands and instant gratification. You see the results right there. And I appreciate that. That is what draws a lot of people to emergency medicine. At the same time, as you alluded to, sometimes there are problems happening behind the scenes, right? So if someone's coming in with opiate overdose, why were that? Why were they in that situation in the first place? They're often so much background events happening that finally culminates in someone coming to the emergency room. When I think about it, I imagine that it would be frustrating to feel as if, yeah, you can fix the acute problem, but there's so much going on behind the scenes that you can't really wrap your hands around because you know, you treat them, stabilize them, and they're they're either admitted to the hospital out of your hands or you discharge them also out of your hands. So can you share with us maybe what is that dynamic like for you in the Ed? Does that is that something you consider And how does that how do you reconcile that tension?
Michele Harper: [00:14:33] Okay. So I will say that that thrill, that kind of adrenaline junkie mentality, it really wears off quickly and it gets old quickly. It's not real. It probably has to do with like the age we are and level because the physicians there's this stereotype, which is probably correct, have a lot of delayed development because we've been in school forever and then we finally emerge as an adult and have to learn how to grow up and be an adult, right? So it probably has to do with our stage of development. We're going into this field, but then we grow up. And I would contend that for the vast majority of us, that just wears off and gets old. Sure, it's important to save a life, but then we understand because we grow up, we understand more the nuance of it. I mean, as you alluded to, even in that moment, that person who they have a tension pneumothorax. So yeah, sure, we put in the needle we have like ASMR. Is that what it is? ASMR? That people talk about that like the tactile. Yeah.
Henry Bair: [00:15:39] Yes. Yeah.
Michele Harper: [00:15:41] Of the whoosh. And then we do the chest tube and it's all very dramatic and very, you know, made for TV. And then we talk to this real human and find out that they're a young person who has emphysema and COPD and doesn't follow up with primary care because they don't have health care, because their work doesn't offer it. They're working two jobs just to get by. And by the way, they don't even know how they're going to pay for this hospital admission. They're wondering if they're going to go bankrupt. And they also really need to get better quick so they can go back to work because who's going to pay the rent? And there's no affordable housing. So, you know, these complex matters, they're not just an issue for the E.R., but when they're admitted to the hospital, they're stabilized. Most of those matters are not fixed when they're discharged, when they follow up in clinic. They go with all of those same issues. The clinic doctor, even less so than the hospital, is going to be able to fix any of those matters. So I feel that as an E.R. doctor, sure, it's very obvious to us in the moment many social issues that we need to confront in the moment that may be more subtle in a setting that's not acute care. But the way that I see the world, the way that I do medicine, the way that I choose to walk this life is being sensitive to the complexity. And I think that as a community of health care providers and as a community of people in this country that we really are in this together. There's a job I do in the E.R. That's true. And I need to collaborate with the other people of this nation to make it equitable, to give people the opportunities to actually be healthy.
Henry Bair: [00:17:38] So you mentioned the word equitable. So can you share with us what exactly that looks like for you and means to you in the context of your work?
Michele Harper: [00:17:49] The way I see it. And this is. Gosh, there was a great definition I saw by the Robert Wood Johnson Foundation. I'm going to paraphrase it. The way I see equity is that we all have health equity. We all have the opportunity to be healthy, which then means we have access to quality care. We have access to the components that allow that care, which is again, affordable housing, safe living environments, quality education, a living wage. And also what is absent from those factors are things that would take away from health or take away from that opportunity, like toxic stress, like discrimination. But when we have that, we won't only have health equity, but we'll have true equity in this nation so that a person has the chance, just the opportunity to live their best life.
Henry Bair: [00:18:53] So I haven't worked in the E.R. yet As an intern, resident physician. I will, though, in a few months. But so far it's just been the inpatient floor units. One thing that I've noticed and heard over and over again that I don't feel great about is that when we are rounding each morning on each patient, invariably the question will arise Is this patient safe for discharge? It's that exact phrasing, safe for discharge that I'm uncomfortable with. And here's what I mean. You'll have a patient admitted with terrible heart failure and after a week of giving just the right amount of water pills, putting them on the most effective regimen of heart failure medications, scientific evidence tells us, and doing all the imaging workup to make sure their heart function has recovered. They are now deemed safe for discharge, meaning that they are now stable to go home. But once they go home, are they going to be able to sustain the proper diet? Do they have transportation and time off work to go follow up with a cardiologist? Can they afford their new medications? In many of my patients, the answer to those questions is no. And so are they safe for discharge? I don't think so. They won't have the resources to maintain their health, and in a few weeks or months, they might come back to the hospital with the exact same issue. And so the cycle continues. This makes me think of moral injury, a subject that has come up a lot on this show. Moral injury describes when you are compelled to witness, participate or unable to stop things that go against your own values. I know that this patient is not safe for discharge in a broader sense. Yet from the perspective of the system of the hospital, there's nothing we are doing for them in the hospital that they can't do at home, at least right now. Therefore, they got to go. How does this dynamic play out for you in the E.R.?
Michele Harper: [00:20:52] You know, it is challenging. There are times where, for example, I had a patient who came in with low blood sugar, an adult man with low blood sugar. And when his blood sugar was corrected, I mean, of course, then he's lucid. So I was speaking to him, reviewing the medications to see again, assessing is he safe for discharge? Is he on something short acting where we can feed him, we can maybe adjust the medication regimen and then he will be safe for discharge. But as I was speaking to him, some of his answers were so brief that I really questioned if he had insight. It was a little subtle. And we're busy in the E.R. You do a quick interview and you move on. And I needed to move on. There are a lot of patients, a lot waiting, but something just didn't really add up. And the answers, even though his blood sugar was now normal, he was not confused. He didn't seem altered, but he didn't seem to fully have insight. And I asked him if I could speak to his family since he's an adult. He's got to agree to this. So I called his it turns out I reached his adult sister and his mother.
Michele Harper: [00:22:02] They put it on speaker so they could both be on the phone. And they were so grateful that I called them because he has some cognitive impairment. So he lives with them and they're his caretakers and he does not know how to take his medications. The problem is, additionally, that they were having a lot of difficulty administering his medications. They're not formally trained in health care. It was difficult for them to check the checks and give the insulin and all his pills. They've been asking for some social services to help them. And they also have to work in shifts because they have to work to pay the bills so that all of them can live. I knew that if I discharged him because there were no services in place, he would end up right back. Best case scenario, or heaven forbid, die at home. There was so much pushback because the issue was the issue of the blood sugar was corrected. And I wasn't allowed to admit him to the hospital. I called a caseworker. I tried to see what I could do. I mean, luckily, his blood sugar kept dropping despite optimal treatment. So on my third call to the hospitalist, they said, okay, well, well, now we have to admit him because the blood sugar keeps dropping.
Michele Harper: [00:23:13] And I was so grateful. I bring that up because, well, of course the importance of going with our instinct and taking those couple minutes out just to pursue something when it doesn't add up. And then again, continuing to be willing to go even when there's pushback from the systems we work in, being willing to go above and beyond for a patient, a family, a community, and showing also the limitations of our system, because everything you said is correct: the way it's structured and increasingly so with the influence of like the worst instincts of capitalism, with private equity in medicine, where it really is about profits, it is about maximizing the billing and not about patient outcomes. I want to spend a moment on this for a second because. This is a podcast. You're in an educational community. I think there's discussions we need to have in this country because a lot of what we're seeing in terms of the limitations in health care, it's not standard and it's not quote unquote normal. And as a nation that has a lot of resources as one of the wealthy nations, we truly are an outlier.
Henry Bair: [00:24:29] Can you tell us more about what you mean by the normals that are actually abnormal?
Michele Harper: [00:24:34] What I mean is that for wealthy nations and there's data from other places like the UK, but we have data from the US showing that we have in terms of wealthy nations, we have the worst health care outcomes, the worst. It's not subtle like we are winning in our failure in terms of health care outcomes. The commonalities in in every other nation who's doing better is that they all have a universal health care option. It is not normal that we don't, and we do pay a price for it. They also have other safety nets that the US doesn't have, like in terms of paid family leave, in terms of there being free education, in terms of sick leave. We don't have those things and we do pay a price. And when we talk about health care outcomes and how do we support the health of a nation, all of that matters. And it's amazing because when I think back on my education, my time in medical school. I mean, I don't know what curriculums are like now, but we did not talk about this. We did not talk about comparative outcomes in nations and how we are outliers and the consequences of that. We just didn't. And so when I bring up charts and reference data and when I go on speaking events around the country with hospital executives or universities, there are always audible gasps. It's really as it should be disconcerting to people.
Michele Harper: [00:26:03] Also, I want to make a note of this. We're also in terms of wealthy nations, again, because I want to compare apples to apples, one of the least equitable nations. We have such income disparities in this country compared again to other similarly resourced nations. And our outcomes are worse because sometimes people will say, well, yeah, but if we're so unequal, then of course we have a lot of people without resources. Health care outcomes for people who are poor are going to be worse. And that's true. And they are. But I also noticed that sometimes when people say that it is from a place of privilege and they feel somehow protected. From having these outcomes themselves because they have resources. And not only is that like a morally reprehensible position to take, but it's also inaccurate because when we separate the data and look at each income strata, these relationships are maintained when it comes to higher rates of infant mortality, overall mortality, rates of incarceration, suicidality, homicideality, mental illness, substance abuse, educational attainment, social mobility. At each strata it is worse in this nation. And I think it's important to understand that because I think knowledge is so important so that we can reimagine to radically reimagine what could be possible here, which is possible and is happening on the ground in other places, that we can change our outcomes. We can have something better if we're willing to do the work.
Henry Bair: [00:27:41] I'm glad that you brought that up. At the same time, you know, what you deal with in the Ed on a daily basis is often the end result of all of these abnormal normalities that you just outlined for us, Right? Because if people don't have the right health literacy, then they're not going to know how to take care of themselves and they're not going to know how to manage their diabetes. Which led to your patient that you described for us earlier. Right. So I fully agree that there are so many big picture problems operating at a high level that we should all be aware of and push for change. But I mean, I'm one intern, right? And you are also a clinician. You are currently practicing in an emergency room. So with all of that as context, what can you do on a day to day level with that one patient sitting in front of you like, what are what are the little things you can do to begin trying to address these problems in a practical way?
Michele Harper: [00:28:39] So for example, with the diabetic patient, with hypoglycemia, because I that sensitivity and knowledge is percolating in the background. So that's why I did advocate for the patient in the moment. Like I didn't just normalize the blood sugar, stop checking and sent him home. I observed him longer just to try and maximize his quote unquote stability. That's why I spoke to the caseworker in case, worst case scenario, I had no choice and had to send him home. But then ultimately it was able to admit him. I mean, I think those are that's why I spoke to the family because I really wasn't sure how this was going to go. And I wanted them to have enough information and tools as possible to take the reins once he was either out of the E.R. And I did explain to them, even when he's discharged from the hospital, these are going to be ongoing matters. And if, heaven forbid, the nurse is supposed to show up and give them education, needs to reschedule, just giving them information so that they would be able to advocate for themselves moving forward. So I think those are the details. On a practical level, the things I can do or any clinician can do in the moment to help that one patient again, that one family again, that one community.
Michele Harper: [00:29:56] I will also say. Because all of those other factors are always percolating in the background, and I'm always thinking micro and macro. And yes, it may be because I'm an Aquarius, so that's just how it's going to go then, but that is why I am not satisfied personally. This is a lifestyle, right? So I love seeing patients and despite the limitations, the bureaucracy in a hospital, I like being able to do what I can in a clinical setting. And I also recognize it's not enough. And that's why I ended up writing a book and that's why I do public speaking, and that's why I am subjecting myself to the process of writing another book. Because because there's there has to be this larger discussion beyond the hospital. The change we need is not going to happen if we're just doing good work in a hospital. And it's great to do good work in a hospital and God bless everyone who in this day and age is still able to do good work in a hospital. But it's going to take a lot more than that.
Henry Bair: [00:31:08] Yeah, and I just want to make the point that, you know, I think what you've shown us is that it is possible to do both. You can be a wonderful clinician and help that one patient sitting right in front of you right now, but also what you've shared with us, your story encourages us to think more broadly about what else we can do. What else are our unique talents, right? If it's writing, if it's speaking, if it's policy work, if it's bringing teams together, I think it's just nice to be reminded that those are all realities that we can bring to fruition.
Michele Harper: [00:31:35] Our coaching a little league or being involved in the PTA, which really matters now with all the book bans and stuff. But there's just so much.
Tyler Johnson: [00:31:44] I wanted to ask you a question that so I'm a primary mentor for medical students at Stanford, so I have like a group of students every year that are kind of my students. And then through things that I do in that capacity, then I end up meeting other students and end up talking to lots of people about lots of things. And one thing that relates very directly to what you were just discussing that is a situation, a question that has been brought to me multiple times that I have to admit, I really feel in some ways definitionally unqualified to answer this question. So I'm going to ask you because you may be better qualified as this question based on what you were just talking about. So there is a person who presents as a woman who comes to me and is all excited, let's say in year two of medical school about going into orthopedic surgery and they're just going to light the world on fire because not only are they going to fix every bone in the human body, but they are also going to be the person who, like, single handedly overturns centuries of chauvinism within orthopedic surgery and makes the place hospitable to all health care workers instead of being sorry, but a sort of old boys club, right? Yeah. And then I have seen this more than once in the third or even into the fourth year of medical school. The person will come back to me and now they have some time in the hospital under their belt. They have some rotations under their belt. They've been in the O.R. and heard the sexualized banter or the you know, I could tell you stories. But anyway, they've been faced with the reality.
Michele Harper: [00:33:23] I've lived those stories.
Tyler Johnson: [00:33:25] But in general, not to make it too specific. And then they come to me and they say. "Oof! Dr. Johnson. Like, I still have this burning desire. Like, of course I want to change the system. Like, because if I don't and nobody else does, then nobody ever will. And then the system is just perpetuated forever. Right? But on the other hand, like (a) for many years, I'm going to be a little baby intern and then I'm going to be an R2 and like and nobody's going to listen to me. I'm not going to have any institutional power. I can't do anything about it. And then even when I become a faculty member, like, really like one, like what am I going to do? So all of this is to say that then they are coming to me and they're saying on the one hand like, Yes, I want to, but on the other hand, like I just need to be a doctor and to your point, go to PTA meetings and my son's soccer game and like whatever. Right. So what's the answer? I'm sure you have a really easy, nice encapsulated answer. So if you could just go ahead and give that to us that.
Michele Harper: [00:34:29] Yeah, it's an easy fix. Yeah. No, but and all of that is real, right? It just is. And so this is my take on it. And this is honestly why it's important for me to write and to speak and why I did a book called The Beauty in Breaking, Sharing Difficulties and Difficult Stories. Because I'm not about sugarcoating. I'm not one of those people who says if you just have a burning desire and you're nice and you like eat granola, you're going to be fine, right? Like the road just unfolds so smoothly. And just as.
Tyler Johnson: [00:35:08] Granola was the key, all these years I've been eating granola like it's nobody's business. What?
Michele Harper: [00:35:15] Thank goodness you asked. So it's just not right. And that's why, you know, one of the stories that at any point in time we can be. Broken down and feel like we want to stop and that it's not worth going on. And I want to assure people that that will happen and then it will happen again and probably again. But it'll get a little easier as we go on. I think of it as warrior training. We're playing a long game here and this is a lifestyle. You know, one of the stories I share was when I became an attending. You know, I'd been an attending for a little bit and I thought, you know, in addition to seeing patients, I want to have a larger impact. And I thought, okay, I can do my departmental leadership. But a hospital position opened up. That way I can have a larger impact because now I'll be doing work on a hospital wide system wide level. I did the interview series of interviews. I enjoyed it. I like getting dressed up and, you know, talking to strangers. It was very fun. And then I just waited. I waited for my director to call me to his office to let me know how I got the job. And he said to me, Michele, you were you were great on the interviews. You're super qualified. And in fact, the only person who applied, but they just want to leave it open. They don't want to hire right now. They're just going to wait. And then he said, But I hope you stay. I hope you stay. It's just that in this hospital, we can never promote women or people of color, so they leave. So I did I did resign.
Tyler Johnson: [00:36:48] Really? They said that, actually?
Michele Harper: [00:36:50] Yeah. Which everybody already knew. Like that was like the open secret. But yes, he said the actual words. And since I was still in area and still knew people there, I did find out- coincidentally, it turned out to be the right time not long after I left, and they did hire someone for the job. They hired a white male nurse for the position. And I share stories like this because it is a real true fact that there are a lot of structural barriers, structural inequity, a lot of bigotry. And it's unfair. We give our blood, sweat and tears for this path to do good work, and it can feel like we can never get a hand. It can feel like standing alone frequently, no matter who you are. First of all, because this is not just for me to stand up for as a black woman. This is for anyone who has any privilege. Like, for example, I make it a point to stand up for the LGBTQ community because as a heterosexual and I never would have chosen to be a heterosexual like I know sexuality is not a choice because I was just born this way. So I use my privilege as a heterosexual to stand up for the community when I can. And so I think anyone with privilege should be standing up for underrepresented disenfranchized groups. That's how we move towards equity. And I make it a point to share my stories because I know people who've been in these positions. First of all, it's validating to know you're not alone. When many days in these hospitals in the workplace, it can really feel like you're alone. And I want people to know they're not. I want them to feel bolstered in that way, to know that there is a community, even if it's not in your immediate environment, there's a community for you. And also it is worth it to keep going. I come back to the fact that this is a long game. It is a lifestyle and so we pick ourselves up and just keep doing this mission oriented work.
Tyler Johnson: [00:38:58] So I'm going to probe just a little further there because I'm genuinely curious because when I get asked this question. So during the pandemic, I had a lot of social media presence during the pandemic, which I usually don't have because I was trying to get good information out about all the things right. And so I wrote this this Facebook post about how one of the things that the pandemic had taught me was to better see people who had theretofore been invisible to me, to my embarrassment in the hospital, like the person who collects the trash. Right. Because what more frightening position could there be in the hospital during the pandemic than the person who has to, like, close the trash bag with all of the soiled linens and masks and whatever? Right. So anyway, as a point of contrast, when I was writing this Facebook post to try to acknowledge my own sort of positionality in all of this, I said I didn't realize until all of this how invisible so many other people in the hospital had been to me. And I think that part of the reason for that is because when I walk into a patient's room, like every eye turns to me, everybody stops talking and everybody like waits for what I'm going to say. And in my telling, when I told this on Facebook, the reason that people were doing that is, quote, because I was a doctor, but then a friend of mine-.
Michele Harper: [00:40:19] Definitely not.
Tyler Johnson: [00:40:21] No, I know. But that's the thing, is that a friend of mine who's a woman of color and is a doctor and the person is like Mhm. And then was like actually When I walk in the room that is not what happens and sometimes. Even after I tell the person that I am the doctor, they still don't think I'm the Doctor.
Michele Harper: [00:40:36] Exactly.
Tyler Johnson: [00:40:38] But here's the reason that I'm probing on this particular topic. When people come to me, for example, like a woman comes to me who's thinking of going into orthopedic surgery and then starts to realize like the weight of the burden that that would entail and say, should I do that? Like I feel so like, what am I going to say about like, I don't know, because I don't really like I can try to. I do. I really do try to imagine what the burden would feel like, but I don't know in my bones. Right. So my question is, do you think it's appropriate, helpful to like kind of give a little bit of a nudge and say, well, like, yeah, you should go into that world and change it? Because I feel like, what should I say to these people? Because I really wonder.
Michele Harper: [00:41:23] And I have to be honest, I wonder the same truthfully. I mean, I feel like this is more of an existential question and a spiritual one because I've had people ask me and tell me how they want to go into different surgical general surgery or surgical subspecialties or even these days, medicine. Honestly, just the question should I even go into medicine? Yeah, and that is hard to answer. But for me it always comes back to and I will always ask the person what they feel their calling is. And I mean that because no matter when we're limiting the discussion to medicine, no matter what you're going into, it's going to be difficult for many reasons. Just the the corporatization of medicine or because you're a black woman or a black man and less than 6% of practicing doctors are black people. I mean, whatever the reason, it's going to be very challenging. So in my opinion, increasingly, it really should be a calling so that it's worth it. And I always come back to that because I think it's going to be difficult. So for me, it's a question of what is in your heart, what impact do you want to make and what tools do you want to use to get there? Truly. And it comes down to that every single time. And if the answer is I want to go into X, Y, z field for whatever reason, when I when I think about myself a couple of years from now, that's where I see myself then do it because anything worthwhile is going to offer its challenges.
Michele Harper: [00:43:07] An author that I really like Elizabeth Gilbert, she tells a story. She and I'm paraphrasing, she would tell the story of the shit sandwich and she writes, She loves writing. She knows people who they can't stand it all the constant rejection, how difficult it is to break in even once you're there, staying in. But for her, it's her calling as she articulates it so she doesn't care. She'll take the good and the bad. She will eat the shit sandwich of this work because it means that much to her. And I think the very much, very much the same goes for medicine. Anything worthwhile is going to be hard and that's it. It also doesn't have to be permanent. I mean, look, I just went part time in emergency medicine. We'll see what else happens. I'm doing these other things on my literary path. I mean, I think. I used to say, it's not like you're like marrying this field. Although marriage doesn't have to be permanent either. Like, there are ways. Like life is about change. Ideally, we are always changing and evolving. Nothing is going to be stable or stagnant. I mean, if it is, we're probably holding ourself back and living a much smaller life than the one intended for us.
Henry Bair: [00:44:23] Yeah, to your point earlier, the stories you share, I think really get at the fact that there are still moments of beauty and sanctity and grace that you can find like little pockets of it, right? Yeah, that's all the other terrible stuff. I think it's really important for us to also, you know, hold those hold space for that and not just always focus on all the terrible things that are happening. We tend to close our episodes with like asking you to share some advice, like concrete advice you have for trainees and clinicians. So with the last few minutes, we're going to take some time to do just that. So earlier you mentioned that in the Ed, you have so many patients and you don't have a whole lot of time. How much time would you say you have per patient?
Michele Harper: [00:45:02] I don't know. And I'm going to say so much of it is going to depend on if you're working nights or days, if it's a community hospital, single coverage academic. I'm also a terrible person to act because one of my acts of resistance is that if I need to take extra time with a patient, then I will. And, you know, as you start practicing, you'll see that is an act of resistance. So I will be an outlier in that respect.
Henry Bair: [00:45:28] Okay. Well, I mean, I remember even as a medical student when I did my emergency medicine rotation, I didn't have the luxury to or the bravery or whatever you want to call it to have that that resistance. So I think it was if I was lucky, I would have ten minutes per patient. Yeah, I think that's fairly luxurious. But most a lot of times on busy days and it could be like five minutes per patient. So given that you have generally fairly limited, much less time than you might expect, much less time certainly than the patient would like, right. Given that a lot of them have been in the waiting room for hours, what are the concrete things you can do that you do do in your daily work to better connect with that patient?
Michele Harper: [00:46:12] I would say in the room in that those minutes with the patient being present because people can tell if you're like tapping like energetically, just like tapping your foot energetically, looking at what they can tell, but listening to what they're saying, waiting at least a couple seconds before cutting them off and redirecting them, but but listening and validating their fear or concern. And I'm putting aside people who who need firm boundaries in place because they're inappropriate. Okay. Those people aside, but validating their fear, typically they are scared in that moment. They are concerned about something and listening and seeing them so that hopefully you can address that. Whatever's going on with them medically, surgically and in the moment, and also the roots of that fear and concern. Okay. So that's what I would say in the moment. The only way to really do that, though, is all the work we do before we come into the hospital. And so I think that is working on ourselves, recognizing whatever our unhealed wounds are and addressing them so that it is possible so that we are relatively whole. Yes, we're always growing. We're always evolving, we're always improving our but that we are relatively sound before we come to that room so that we truly can hold that space and see and hear clearly. That would be my biggest advice. And that's really all we need to do to fix the world.
Tyler Johnson: [00:47:48] There you have it, folks. You heard it here first.
Michele Harper: [00:47:51] But I'll say something else. Okay. There's something else I want to add, because whenever I'm asked a question, my answer is always going to be the same. And I think it's important to come from a place of radical honesty. And I just think this is at the core of everything to be willing to be honest about ourselves, our situations, our circumstances, and then radical integrity. Because it matters what we do with that knowledge. And if we're going to have the courage to act from an informed, honest place so no matter what it is. No matter the question, it's always are we coming from a place of radical honesty and integrity, which of course, like anything else, is a practice.
Henry Bair: [00:48:39] Well, with that, we want to thank you so much, Michele, for your time, for for coming on and being so open with sharing your experiences and your wisdom. I'm sure it'll be very, very valuable for our listeners.
Michele Harper: [00:48:52] So thank you. It's delightful spending time with you.
Henry Bair: [00:48:58] 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 www.thedoctorsart.com. 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: [00:49:16] 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: [00:49:31] I'm Henry Bair.
Tyler Johnson: [00:49:31] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.