EP. 89: A SEAT AT THE TABLE: LEADING THE AMA

Nov 21

WITH JESSE EHRENFELD, MD

The first openly gay president of the American Medical Association shares how his experiences facing discrimination have shaped his LGBTQ advocacy and inclusive leadership.

Listen Now

Episode Summary

When Jesse Ehrenfeld, MD attended his first meeting at the American Medical Association (AMA) as a first year medical student, he was struck by the collaborative spirit he witnessed among physicians of all specialties from across the United States. But he was also filled with insecurity over whether he, as a gay man, would ever be truly accepted for who he was. 22 years later, Dr. Ehrenfeld is now the first openly gay president of the AMA. An anesthesiologist by training, he is also a senior associate dean and tenured professor at the Medical College of Wisconsin. In this episode, Dr. Ehrenfeld shares his journey in medicine — from how he has channeled his experiences with discrimination, to becoming a leading advocate of health equity especially for LGBTQ individuals, to his time as a combat veteran in the Navy, to now leading one of the most influential medical organizations in America. Our conversation also ranges in topic from the future of medical education, to physician burnout, to the promises of digital health, and more.

Jesse Ehrenfeld, MD is the current president of the American Medical Association. He is a clinical anesthesiologist with strong interests in health care systems design, education, research, technology, and health policy. His clinical interests are anesthesia for neurosurgery. His research interests focus on two areas: (1) how we can leverage technology to improve learning and practice and reduce health disparities, and (2) how information technology can more effectively protect patients from harm and impact processes of care within the acute care environments. For the past decade, he has advocated on behalf of LGBTQ patients, physicians, and trainees. He has conducted health services research focusing on education and biomedical informatics leading to the presentation of over 250 abstracts at national/international meetings and the publication of over 200 manuscripts in high impact peer-reviewed journals. Additionally, he has co-authored eighteen clinical texts and over 50 book chapters. He has received funding from the National Institutes of Health, the Robert Wood Johnson Foundation, the Foundation for Anesthesia Education and Research, the Anesthesia Patient Safety Foundation Grant, and the Department of Defense. In 2018 he received the inaugural NIH Sex and Gender Minority Research Award in 2018 from the NIH Director.
In this episode, you will hear about:
• 2:18 - Dr. Ehrenfeld’s path to becoming an anesthesiologist
• 5:03 - How health equity came to the forefront of Dr. Ehrenfeld’s work and how it has taken center stage in his leadership at the AMA
• 11:57 - The role that the house of delegates plays within the AMA
• 13:37 - How Dr. Ehrenfeld represents the democratically determined positions of the AMA
• 17:03 - Dr. Ehrenfeld’s mission for his year as President of the AMA
• 19:26 - How the AMA invests its resources on tackling systemic issues that affect health
• 24:42 - Dr. Ehrenfeld’s perspectives on physician burnout
• 32:02 - How medical training needs to change in order to prepare for the dawning of AI
• 38:38 - Engaging with the politics of healthcare
• 41:45 - How the AMA is working to ensure that doctors can affect the future of medicine through programs including Health 2047 and the Physician Innovation Network
• 45:27 - Why Dr. Ehrenfeld believes that medicine is still a worthwhile calling
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: [00:01:02] "It's like having a backstage pass to the world." That's how Dr. Stephen Fabes describes his epic adventure exploring all six inhabited continents on a bicycle. Over the course of 6+ years, he cycled across 75 countries and 53,000 miles, discovering how human stories shape our conceptions of health and illness. Currently an acute medicine specialist at the Royal London Hospital, Dr. Fabes is also the author of the 2020 memoir 'Signs of Life A Doctor's Journey to the Ends of the Earth.' His writings have also appeared in The Guardian, The Telegraph, CNN and the BBC. In this episode, he joins us to share thrilling, thought provoking and amusing moments from his journey. What his travels through refugee camps and war torn hospital wards have taught him about health care at the margins and stories of everyday kindness that underscore our common humanity.
Henry Bair: [00:02:01] Stephen, thank you so much for taking the time to join us and welcome to the show.
Dr. Stephen Fabes: [00:02:05] Thanks very much.
Henry Bair: [00:02:07] To start us off, can you share with us briefly your path to medicine?
Dr. Stephen Fabes: [00:02:11] I think I probably applied to medicine just because I was told it was difficult to get into medical school. So, you know, I didn't apply to medical school for any of the reasons you'd hope a doctor would.
Tyler Johnson: [00:02:21] Actually, if you don't have an inspiring origin story, we can't allow you on the podcast, so we'll just have to end it right there. I'm sorry. Yeah.
Dr. Stephen Fabes: [00:02:29] And luckily it seemed to suit me. And it was one of these things that you kind of grow into it. I don't know really, if you know what you're getting into at that age when you make the decision to apply to medical school. And I think this sort of weirdly echoed or mirrored what was going to happen later, because I sort of dived into this around the world bike ride without really knowing what I was in for as well. So it's a similar kind of thing, but luckily I found myself really enjoying studying medicine, fascinated by it, and particularly drawn to the stories that I was hearing and the sort of storytelling aspect of it. And yeah, I'm still very passionate about medicine. I left my career for a significant chunk of time to travel, but I always knew that I would come back to it.
Tyler Johnson: [00:03:09] I'm just curious if you went into it mostly because it was, you know, sort of a hard thing to do, and maybe because you liked biology in school. Were you surprised by the degree to which you were drawn to the storytelling aspect of it, or what? What was it in particular that stuck out about the storytelling aspect that sort of drew you in closer?
Dr. Stephen Fabes: [00:03:27] That actually was maybe more true when I came back from the bike ride, when I was traveling for a long period of time, I was reading a lot, and I was reading a lot of books, and I became sort of, I guess, more interested in stories and storytelling through that. And then I could see then how that sort of meshed so well with medicine. But I hadn't I hadn't really been a big reader prior to that.
Henry Bair: [00:03:50] So you've alluded to this bike journey odyssey multiple times, and we're going to spend a lot of time delving into that. But your undertaking is so singular in its ambition that I must imagine that this spirit of adventure, of travel must have been in there somewhere early on. Can you tell us more about some of the formative experiences that seeded this interest in travel and exploration in you?
Dr. Stephen Fabes: [00:04:15] So my first big bike ride was when I was 19. In the UK, there's a year sometimes people take between school and university, and I had this plan to try and cycle the length of Chile, huge array of different landscapes and climates and things from the Andes, the Atacama Desert, the driest desert on Earth, Patagonia, sort of wild and windswept, and lots of coastline and beaches and even a bit of rainforest. So everything in one country. And I thought the idea of cycling this would be, would just be a supreme adventure. So I finished school. I was going to do it with my friend Simon. And Simon was your sort of my sort of worst best friend? He was a bit off the rails. He was drinking one night and he went out on his bicycle and got hit by a car and was very seriously injured and lost his spleen and pneumothorax, head injury, broke lots of bones and was in intensive care. Very traumatic experience for him and he could no longer come with me and my brother at this point had just my younger brother, who was only 17, had just dropped out of school and my mum said, take him with you, which was a very brave thing for her to do. Grew up, I grew up in a sort of single parent family and, you know, she saw the opportunity, I think, but also very courageous of her, I think, to let her two teenage boys off to South America alone for what ended up being 5 or 6 months rough camping by the side of the road. But really, that that trip was the making of us. Really. It was such a great experience. It was a complete disaster in lots of ways as well, because we were pretty wet behind the ears. We didn't really know what we were doing. We got lost a lot. We ran out of things constantly. We ran out of money. We ran out of food. Water had to rely on local people to help us.
Tyler Johnson: [00:05:53] As a parent, I definitely think this is a trip I want my kids going on for sure. You're really inspiring me here.
Dr. Stephen Fabes: [00:06:00] We got stuck on a like an island off the coast of Chile because we couldn't afford to come back to the mainland, and we even think even starting the trip, we kind of screwed the pedals on against the thread and just broke the bikes even. Like we got stuck in this outpost town in southern Patagonia for two weeks, waiting for new parts to arrive. So it was a disaster in lots of ways, but also this massive adventure. It was an introduction to, well, the sense of vulnerability that I think is the essence of a good adventure and being out in the world in these big, wide open spaces, the freedom rough camping every night, and also in particular traveling long distance on a bicycle is something that I grew really fond of. And by the end of. The journey. And it was, I think, something about the fact that you're moving very slowly and sort of blatantly through places. So you kind of stand out and people come and ask you what you're up to, and then they invite you into their homes. It's a bit like having a sort of backstage pass to the world. And we spent lots of time in people's homes and also sleeping in the local church or hospital or school or monastery or whatever. So lots of hospitality and relished this, you know, working hard on a bicycle outside as well.
Tyler Johnson: [00:07:12] You know, it's funny when I hear you talk about that. And then I go back to the answer you gave as to why you went into medicine, which I'm not sure we've had anyone give us quite that candid of an answer about that particular thing, but it reminds me of this, and I appreciate the irony of the fact that I'm going to quote from Alexis de Tocqueville writing about Americans to a guy who's sitting in London. So I get the irony. But still, I think that the quote is apropos. So Tocqueville, right, is visiting in the early 1800s, and he's trying to figure out sort of what makes America tick, what makes the democracy here work. And he writes, the desire of prosperity is become an ardent and restless passion in their minds, which grows by what it gains. They early broke the ties which bound them to their natal earth, and they have contracted no fresh ones on their way. Emigration was at first necessary to them as a means of subsistence, and it soon becomes a sort of game of chance, which they pursue for the emotions it excites as much as for the gain it procures. And there's sort of this, like restless, whatever you want to call it, wanderlust or this energy where it's not even so much necessarily the thing as that it is that you're exploring a new thing, right? Like that's all. I mean, that's like the central metaphor is the bike is always going, I mean, you on the bike is always going to a new place. But I guess as someone who doesn't quite feel that same restless, ardent passion like that sounds like almost the animating force of your life, is that, like inspiring or tiring or both? Or what's it like to just have that sort of a wanderlust that never dies?
Dr. Stephen Fabes: [00:08:42] Well, I think it did die a little bit. By the end of the trip. I was a bit burnt out by the end. Certainly. I'd been traveling a very long time. Six and a half years by bicycle, and I remember coming home. I was pushing a shopping cart through the supermarket, and my hand rotated around the handle, and I realized that I was trying to change gear as you would on a bicycle. I'd probably been probably been on the road a bit too long. I think.
Dr. Stephen Fabes: [00:09:05] What excites you about travel, or certainly what excites me, is this sort of this unfamiliarity. And you could become obsessed with being in different places amid different cultures and tasting different food and different sights and sounds. But that does get tiring after a while, and you start to crave for familiarity at some stage. So I think that initially that restlessness is inspiring. Yeah, but you can certainly... You can travel for too long. And there was a character who I write about in the book. This is a guy who was cycling around the world for 51 years, and he was in the Guinness Book World Book of Records as the most traveled man in history in the 90s. And I tracked him down, and we kind of hung out in Germany, in his home town. And he was a very interesting character, quite eccentric. We had quite different views on things and got into quite heated discussions late at night, but I felt very different to him. He I think he was just, you know, continually moving. And by the end of my journey, I felt that my wanderlust was sort of somewhat quenched. Really.
Henry Bair: [00:10:05] Okay, so then you had this pretty remarkable first experience cycling through South America, and then you go start your medical training, right. At what point did you decide to undertake this second, even longer, more ambitious journey which would later become the basis of of your book?
Dr. Stephen Fabes: [00:10:26] I think memories of Chile were sort of floating back to me whilst I was working as a junior doctor in the UK, and I felt very much torn. I was loving my job, fascinated by medicine, and one part of me wanted to climb the ladder, gain more responsibility, kind of upskill and just sort of devote myself to my job. And there was another part of me that just wanted to blow up my life and go on an adventure, and I knew that I would come back to medicine, and I thought, I have to do it now or never sort of thing. So it was these kind of competing ambitions, and it came to a head about two years before I left, and that was I went to the pub with some friends after work, and I brought down a little mini atlas with me, and I sort of traced out this, drew this line around the globe, and I announced to my friends that I was going to cycle around the world, and I think I probably like crossed the whole Sahara in a few milliseconds and then quickly over the Andes, the, you know, the Himalayas in a few more milliseconds. And I explained to my friends that not only would this be a great adventure, but probably be quite easy because I'd been on bike rides before, and if I just took it day by day, eventually I'd get around the world.
Dr. Stephen Fabes: [00:11:38] That was two years before. So two years after that, I was outside my hospital. And I was working at the time at Saint Thomas's, which is this. It's quite a prestigious like ivory white hospital. It's opposite the Houses of Parliament, right on the Thames. And I left from that hospital with the sort of group of doctors and nurses outside and friends and family outside the hospital to wave me goodbye. And my, my life was contained within these four panniers attached to the side of my bicycle. And I was feeling quite good. I was feeling kind of excited and confident and really up for it. And those feelings lasted about until about 50m later when I got to Westminster Bridge. And then I started having a bit of a crisis of confidence, where I wondered what I was getting myself in for, started thinking about all the ways that maybe I wasn't quite suited to such a long journey on a bike and hadn't really done much. Cycling was the other thing, because my attitude at the time was, I've got a lot of cycling to do, why do any more? And so I hadn't trained or anything and I was quite unfit. And all these thoughts come into me as I traveled over Westminster Bridge. That was the first day of cycling round the world. I think I'd been cycling around the world for about 20 minutes when I stopped in the pub where I'd had the plan in the first place, and I had a beer, and that turned into another beer. And then eventually some friends came down to the pub like a kind of intervention, and I was like pushed back onto the road. So yeah, that was my first, my first day of cycling around the world.
Henry Bair: [00:13:04] So you took some time off in your medical training, right? You were still a junior doctor at this point.
Dr. Stephen Fabes: [00:13:08] Yeah. So I'd been qualified for about four and a bit years. So I was a junior doctor, so 29 when I left. Yeah.
Henry Bair: [00:13:16] A lot of our listeners may not be entirely familiar with the process of medical training in the UK. Yeah, it is quite different from the US. How long is the training path of a junior doctor?
Dr. Stephen Fabes: [00:13:29] So, it varies, but the medical school five years and then you'll be a sort of junior doctor as a sort of foundation doctor for a couple of years. And then you work at what was called a senior house officer for a couple of years. The terms keep changing, actually. They keep sort of redefining and changing things around. But essentially then you're you're a registrar probably nine years or something as technically as a junior doctor. And often more than that. I just got to the point where I was a registrar. That's the sort of grade, and I just passed my postgraduate exams. So I felt that this was a good, a good opportunity to go at that point.
Tyler Johnson: [00:14:07] As in most everything else in life, everything sounds smarter and more official when it has a British title, right? So I just assume that anyone who is a registrar, I don't even really still understand what that means, but it must mean a very smart doctor with a really good accent. That's sort of my assumption.
Dr. Stephen Fabes: [00:14:24] Yeah, it's kind of the idea of the junior doctors. Yeah, it's a bit weird to still call it. You're still technically junior doctors when you're a registrar, even though you've got quite a bit of experience. But that's how it is. Yeah.
Henry Bair: [00:14:34] Okay. So even before you embark on this journey, how much planning had you done beforehand? Right. In the sense that did you know how long this was going to take? How much flexibility did you a lot in your path and don't know what what was that like?
Dr. Stephen Fabes: [00:14:49] Most of the planning I did, in retrospect, was useless. It was kind of, you know, obsessively pondering all the kit that I would need and things. And I don't think much of that really mattered. And I wasted a lot of time, probably. I tried to get sponsorship and things. I didn't spend much time planning the route in detail, and I'm glad of that because I relished that flexibility. And I would often meet other cyclists in the road, you know, from other places, and we'd swap tips. If they were coming in the other direction. We'd exchange maps and things, and I, I liked sometimes just getting to a junction and deciding right on a whim, I'm going to go right instead of left in the next. You know, my whole life could change based upon that. Just these sort of, you know, sort of snap decisions.
Henry Bair: [00:15:30] How were you navigating your way around? Using maps?
Dr. Stephen Fabes: [00:15:33] I didn't have a phone or computer and that was actually, in hindsight, great. It was really good that I didn't have that. I think I wasn't distracted by my phone, and I read a lot in the evenings. I read a lot of books and again, just speaking to people, really, I did obviously I did get online in towns and things and do a bit of research that way, but what I would try to do is sort of make up the distance, always avoiding the busier roads. But then I'd go off on these little mini adventures into very remote places. But that's again when I felt that it felt much more intense. The experience of travel when I was in remote places where I would be feel a bit more self-reliant, and I knew that things could go sideways, and I felt a bit more vulnerable. And again, as I was saying, that feels like the essence of a good adventure. So so that's kind of what I would do, really.
Henry Bair: [00:16:20] Mm. Can you trace for us just in general where did you end up going?
Dr. Stephen Fabes: [00:16:25] So I started from London. I cycled across Europe very cold winter. It was 2010. It was the coldest European winter, I think, for 31 years. And in the western, Western Europe. And so it was brutal, like the beginning was just really. Thought you would be the easiest continent of the lot, but it turned out being quite grueling really, because it was so, so much snow and got over the Alps still very cold and eventually got into Eastern Europe and things sort of, kind of that was less than one really is persevere and things will get better. And the tough times don't last for too long generally. And then I was much happier in Eastern Europe. I was sort of cooking over fires and rough camping and things were warmer. I got I went through the Middle East. This was just before conflict erupted in Syria, but I got through Syria and then into North Africa. And then I traveled with my friend Naomi. We cycled the length of Africa to get together, mainly down the east side of the continent, following the Nile initially, then into the deserts. And we had this kind of usually this nice tailwind which accompanied us through the Sahara. We would sometimes sleep underneath the road in the metal culverts during the daytime, because it was so hot through Ethiopia and then through a quite remote area where I was able to Turkana in northwest Kenya.
Dr. Stephen Fabes: [00:17:48] We might go on to talk about some of the medical projects I visited, but there was one in that particular region, and then I cycled all the way down to to South Africa and then really a lot of hospitality all the way through the African continent. It was great. And even coming into South Africa, a car stopped and gave me a big like sack of oranges through the window of the car. And then another guy tried to give me money, and then another car stopped on my way into Cape Town and a guy said, I've got a city house or a beach house. Which one would you like to stay in? And we stayed in both in the end. So it's a huge amount of hospitality all the way through. So that was from South Africa, traveled to the bottom of South America and a so-called essentially from the southern southern Chile, all the way up to northern Alaska to Deadhorse on the Arctic Ocean. And you really need to be in Alaska in the summer time. So I was on a bit of a mission at some point because I spent a lot of time in the Andes, I loved I got really addicted to the mountains, and I crossed the the Andes multiple times on my way through Chile and Argentina, sort of winding my way up. And some of these were big, big climbs, you know, bigger than anything in the tour de France, from sea level to 5000m, unpaved roads on a heavy bike, steep grades.
Dr. Stephen Fabes: [00:18:59] So it was tough, but it was really, really very beautiful. And, and then I sort of whizzed through North America and up to Alaska. And then I flew from Alaska to Australia. I cycled the east coast of Australia from Melbourne to Cairns. And this was the sort of theme to the next part of my journey was really being in the wrong place at the wrong time, because I was just that was in the summer time, so very, very hot. As you get towards Cairns, very humid and then really for the next year and a bit, I was seemed to be either in the wet season or in very hot places or sometimes very cold places because I cycled through Mongolia in the winter time as well. But that was a great adventure and the lakes were frozen over, had ice tires with spikes on. I could cycle across the frozen lakes and then eventually I got into the Central Asia. So the Stans, so through a bit of Afghanistan as well. And then I kind of came out into the Caucasus and then cycled across Europe for a second time with different routes and then back to London. And that was, yeah, six and a half years by the time I got home.
Henry Bair: [00:19:56] Wow. What was the six and a half years like broken up into segments? Like, did you take breaks in the middle?
Dr. Stephen Fabes: [00:20:02] No, no. The only time I took a bit of a break was in Cape Town. I was there for a couple of months. Most of the time I was moving.
Henry Bair: [00:20:09] That's really incredible. Out of curiosity, were there any issues crossing international borders, especially with more contentious territories?
Dr. Stephen Fabes: [00:20:18] So there was a little bit of problems with the borders in Asia and sometimes the stans. You just had to, like, plan ahead and everything. But I think it's you're so privileged having a British passport or having a passport for a number of Western countries where that you have permission to travel through a lot of countries that other people wouldn't necessarily have permission to, to travel through. So I was always very aware of that. So even when I got a bit defeated by, you know, being turned down visas and things, you have to remember that it's a very privileged position to be in. And there were a couple of visas that I was refused, and I ended up having to take a bit of a detour. At one point, I got stuck. I'd gone south of the Himalayas and I couldn't get into Pakistan, and I couldn't get permission to travel through Tibet. So I went backwards and I flew from India to Hong Kong, and I cycled home from Hong Kong via China and Mongolia.
Henry Bair: [00:21:07] Thanks for taking us through that long journey. But this does help frame the rest of our conversation. Was there at any point during the six years when you wanted to, for lack of a better term, give up?
Dr. Stephen Fabes: [00:21:22] Not really. I convince myself fairly early on that if I've persevered through the harder times, then things would get better and that that's what generally happens. The hardest times, I guess. There were long periods of loneliness. I was on my own for a long time and the cold was not a big fan of. And cycling through Mongolia was really tough. It's -40°C night time. There was a bit of a low point, I think, when I got to sort of roughly around Malaysia, which was a lovely place to cycle, but I was just a bit... I'd been in a relationship that had cycled with a girlfriend for five months and that just ended. I was pretty fed up being broke. I looked a bit like a sort of Frankenstein's monster. I'd had to sew all my clothes together because I was too scared to buy new ones, and I was fed up of living on a very small amount of money per day. And I'd had dengue fever as well, and been unwell with that. And that was probably a bit of a low point. That's when I started visiting medical projects as I traveled, partly because I miss my job and I was just very interested in medicine, and I thought that could be an interesting way to gain some perspective on places.
Dr. Stephen Fabes: [00:22:26] I think because I think as a cyclist moving through places, you, you get a bit of a rose tinted view sometimes, you know, you get a lot of this hospitality. But I was getting the sense that I wasn't getting a rounded view. And although you'll never get a sort of, you know, I'm only a fleeting visitor and I don't have the language to get to the heart of things. I thought by visiting medical projects I might get a bit more of a perspective. And that's certainly true working in London as well. I think any any medical professional will appreciate that. You get a bit of an angle on the social and political forces at work. I think it's a very privileged position, and I felt that by visiting medical projects, perhaps I would get to understand a bit about that in the places that I was, I was visiting.
Henry Bair: [00:23:11] So you mentioned being ill. Can you tell us more about the moments when you felt as if your own safety was truly at jeopardy? How did you grapple with that vulnerability on the road?
Dr. Stephen Fabes: [00:23:23] I had a few problems. Bear in mind. So I was I was rough camping, right? So I would by the end of the day, I would throw my tent up by the side of the road. I spent more than a thousand nights by roadsides, and in those thousand nights, more than a thousand nights, actually very few problems. But there was always going to be some. And I think what I, I always used to think of rough camping as kind of hide and seek against the world, because if someone spots you, it's probably, you know, not necessarily a problem. But in a lot of villages around the world, you know, maybe not very much happens and, you know, you're news, basically, if you get discovered and then suddenly you're overseas, you might report it to more people, and then 100 people know where you are. In places like Ethiopia I'd wake up and I'd find that some kids had found my tent in the night and unzipped it and were kind of watching me sleep. You got like 15 faces looking in at you.
Dr. Stephen Fabes: [00:24:15] So during the course of my journey, I did one of the sort of scary moments was when I was rough camping and it was in Peru. I was in a fairly remote part, and I'd seen this sort of what I thought was a derelict building and settled in, didn't think anyone was around. And then I woke up in the night time because I heard footsteps outside my tent, and I laid very still. Then I realized they were sort of circling my tent. So I looked outside and I could see the silhouette of a person, and they came over to the door of my tent and I realized they were holding a gun. I just heard this voice say, 'afuera, get out!' And I just sort of grabbed some clothes and jumped out of my tent. And then this guy and he was looking quite nervous, and I wasn't quite sure how to interpret that. I didn't know whether that meant he would do something rash or whether, you know, perhaps I wasn't in as much danger as I thought I was. I didn't know, but anyway, he sort of basically marched me at gunpoint into this building, which was turned out to be his home, although it looked fairly empty because had looked inside beforehand. I didn't think anyone was living there, and I tried desperately to explain that I was just traveling and had a bit of Spanish, and I was just, you know, doing my best to explain that I was just a tourist, etcetera. And then he offered me some soup. And so I said, I asked him if he could put the gun down, and then he said he was, and then he said, chicken or tomato? And I said, tomato soup, please. And then he made me a bowl of tomato soup. And he explained that men with guns had come to his home and taken everything. And he was he was concerned. He didn't know who I was. He thought I might be associated with them or he wasn't quite sure he was. He was scared of me, really. And he was out at night because he was illegally mining gold, and he had a family on the coast, and he was trying to raise money for them. Yeah, it was just one of these situations that it ended. Okay. He brought me breakfast in bed the next morning. So I went back to my tent and he brought me some soup the next morning and had a few scary experiences, but very often things would end up okay, Generally.
Henry Bair: [00:26:11] Yeah, You know, I like travel. And when I think about quote, like roughing it the way that you have, I think probably the single aspect that scares me the most. Is actually being injured or being sick, right? Like, I have been fortunate to grow up and live in places that are. Pretty much like as safe as can be. And if I'm ever sick, I can go to the local pharmacy. And to me, the thought of falling ill for whatever reason in the middle of nowhere, that really terrifies me. Right. It's quite remarkable that you were able to think about that and overcome that and survive and thrive.
Dr. Stephen Fabes: [00:26:53] Yeah, I think, I think that I was worried about a lot of those things as well. And you start off the trip worried about tropical infections and being abducted and all of these things that really are not a particular threat. I realized during the trip was not a particular danger. It was much more about being hit by a car was by far and away the biggest danger to me personally. And some of the roads, especially in Asia, were really quite hectic and you had to be very on your guard and you just had to be plan your route very well, because that's the main thing in being safe on a bike is just to make sure you're not on the roads, those roads, those types of roads in the first place.
Henry Bair: [00:27:28] Let's talk a little bit next about something you've already mentioned before, which is your medical experiences that you ended up participating in. It sounds like they were mostly unplanned, but can you tell us more about what you meant by medical projects, as well as just some of the moments that you happened upon during your journeys, where you ended up being able to draw upon your skills, your training as a physician.
Dr. Stephen Fabes: [00:27:50] I mean, I was interested as I said, to visiting these medical projects, just because I was missing my job. And I was also reading a lot and very much wanted to write a book at the end of the trip, and one of the threads of the book I thought would be interesting to write about medical projects. So I wasn't there to work. I wasn't anywhere long enough to do that, and I didn't have the language or anything. I was there really to observe. So it was more journalistic, I suppose, but obviously I'm a physician, so I thought that would be interesting to try and draw some parallels between the different medical projects that I visited, and also think about some of the things that they had in common with my work back home in the NHS. So I reached out to different organizations and projects that I heard about. As I traveled. I was able to visit some of those, luckily, and the theme, I suppose it was about marginalization and about how that impacts on health. And there were a number of projects I visited and wrote about those floating medical clinics from the Tonle SAP in Cambodia. There were I visited victims of Taliban shootings in Afghanistan. Mazar e Sharif I visited a clinic on the border of Myanmar and Thailand, which serving Myanmar, refugees from Myanmar and lots of other projects as well, including people living in a rubbish dump in Indonesia and and a TB sanatorium full of ex-prisoners in Georgia and a bunch more. It was thrilling for me, I think, because I suppose I was being a bit nosy, but it was. I was just very curious, and I was curious about how health care works in different settings. And I was also looking for common threads, and I was interested in this social context of health and disease and the social drivers of disease. And, and that's, that's I suppose I was visiting these projects really just to sort of indulge that curiosity.
Henry Bair: [00:29:40] Well, I think the next logical question for me to ask then is what insights did you learn about the questions and the issues that you were trying to explore?
Dr. Stephen Fabes: [00:29:51] Well, a few things really. I think one of them was about the impact of a lack of health care professionals in different places that I was traveling through, just to, to mention one of them. So this is the floating medical clinic on the on the Tonlé SAP in Cambodia. This lake has a huge floodplain, and it's a big lake in Cambodia, where the quirk of the sort of ecosystem is that twice a year, the direction of flow in the Mekong will change, and that the lake kind of expands and contracts. And they call this the flood pulse. And about a million people live on the floodplain and these floating villages and houseboats and these there was a floating medical clinic that I was able to visit. It wasn't there was no heroics, really. It was just good, you know, community health care and dentistry. But at the time, Cambodia had one of the lowest ratios of doctors to population in the world, sort of 1 to 10,000 or something like that. And the impact of that was fairly plain to see. There was obviously this void where there weren't enough doctors and people would step in, and sometimes there would be traditional healers, and sometimes that would be kind of volunteer medics who'd served in the military. And whilst they they certainly had a really useful role and were able to offer some important health care and had some experience, there were also instances where, you know, babies were overloaded with intravenous fluid, or a famous case where one of these medics had been reusing syringes and inadvertently affecting infecting people, it turns out, with HIV. So that was a disaster in that region. And so you do see the impact of that when visiting the healthcare projects where people have had diseases that have been untreated for a long time just because of lack of access to health. Really.
Dr. Stephen Fabes: [00:31:31] That was the same in Afghanistan as well, where I was visiting an orthopedic ward where a young boy had been. He'd been at the market and a woman had come to the market with a pressure cooker and blown up, blown herself up. He'd blown him into a ditch with a fractured femur and a head injury. And again, he was sent to a sort of a local clinic with a surgeon who wasn't well trained and ended up with nonunion of the bones and was obviously severely psychologically traumatized as well, and disabled. And then his mum had to take her other kids out of school because she was looking after him. And that's again all down to a lack of trained professionals and a lot of that, you know, this speaks to a lot of the sort of global inequalities and the fact that a lot of the countries that I visited had a very much a brain drain, and a lot of the experienced and well trained professionals would would follow the money as anyone might do and would work overseas and would certainly work in my country and work in the US. And and that has a huge impact on, on local health care systems.
Henry Bair: [00:32:38] So then after six and a half years, you return to the UK. You go home. What was the plan? How do you always plan to go back? Just, you know, right where you left off, pick it up and then finish your training or what was what was the plan there?
Dr. Stephen Fabes: [00:32:53] Yeah, that exactly was the plan. It sounds really easy, doesn't it? And in my head it was very easy as well. Yeah. Just slot back into life and medicine. It'll be all be fine. And of course that wasn't fine at all. It was really, really hard. And I'd spent long periods of the trip alone, so that was problematic. Coming back, I think. And actually returning to medicine was not the hardest part. You lose a bit of confidence. A lot of my knowledge was well embedded and it just needed to sort of revise stuff. But coming back to the profession wasn't too much of a difficulty. It was just hard to slot back into life. I was living with my mum. I was like 36, I think I was living with my mum. I was in debt to my friends and to her. I remember at one point she took me like clothes shopping and this like I can go back to work immediately. I was like, I had various administrative things to do to get to slot back into the job. I had a period of supervision, etcetera. So I wasn't working and she took me clothes shopping. And I remember following her around this kind of like sports clothes outlet. And I looked and she was holding up jeans for me to try on. And I looked over and there was a ten year old following his mum around, and we sort of swapped a little look that was just like, oh, you know, mums. And I just thought, oh, my life is kind of sucks at the moment. This is not great. So it took me a while to get back on my feet. It was challenging coming coming home after such a long period away, but it's probably best not to have known that before I left, because I certainly don't regret the journey. But it was. It's just it was always going to take a while to reintegrate.
Henry Bair: [00:34:18] What was it like to go from spending so much time on the road, often totally independent by yourself? What is it like to go from that to now you're back essentially like in a very well structured hierarchical system with more or less like a very stable, regimented work schedule. What is that transition like?
Dr. Stephen Fabes: [00:34:40] Well, I think for that reason I didn't want that that hard transition. So what I did is I worked part time initially, and I also was very, very keen to write a book. I was I read a lot. I was I really wanted to write essentially a travel book, but it had these couple of other threads running through it. One was this sort of medical thread and the other one, and there was a bit of memoir in there and a bit of reportage, and then there was a little sort of thread as well that was about the history of exploration and cycle touring in particular. And so I treated that as a job, really. And I was I was working on the book part time, and I was working as a doctor part time, with flexible hours and taking shifts when I wanted. And that helped a lot to transition. And then now, yes, it's much more regimented, but I didn't do it abruptly.
Henry Bair: [00:35:27] What have your observations and learnings from your journey shaped how you practice medicine today?
Dr. Stephen Fabes: [00:35:34] Right, a good question. I sort of became a writer, I guess, and I was earning money as I was traveling through writing and writing for magazines, newspapers, and I think actually. It's being a writer that has changed my practices as a doctor more than anything. And I think that's because writing encourages us to ask questions. It's something that requires curiosity. I think that's that's true of a really key attribute to being a physician as well is being curious. I think if I had to choose any attribute, that would be the one. And writing has helped me in lots of ways. I mean, it's obviously a great catharsis, but it helps you to reflect in a way that you just don't normally take the time to. I think you can really, even if it's not for publication and not very often for me, it's not. It's just writing stuff down after an event, especially if it's been stressful. That's a really good way to sort of think about your emotions and about just exploring why things happen and how you feel about them. I think it's just a very useful thing to be able to do.
Henry Bair: [00:36:42] I want to explore the idea of curiosity more, because, you know, from your writings, from the stories you've told us so far, I think you certainly approach your encounters along your journey with with a very open mind. Right? And you tried to live in the cultures many times that you found yourself in. And I'm wondering what lessons or advice can you share with medical trainees based on the insights you've gained from your journey? What lessons on connecting with people, with being open minded and being curious do you have for people who are clinicians right now?
Dr. Stephen Fabes: [00:37:21] I guess respecting people's ideas about health and disease, and they might not always align with your own, but I think sometimes you can cause a great deal of damage as a doctor to kind of argue with quite entrenched beliefs about health and disease rather than and that can sometimes impact on whether you can help somebody. And I encountered people with lots of different ideas about health and disease as I traveled.
Henry Bair: [00:37:50] Can you share with us some concrete examples and stories?
Dr. Stephen Fabes: [00:37:53] So, Takano, is this region in South Kenya, a very remote region? I was there, I didn't even know if I would actually get through because there were no roads on my map. And it's a large area. It's about the size of Ireland. It's desert, very hostile climate, and there's a lot of tribal conflict in the area. When I was there, it had just been a short wet season, but no rain had fallen at all. So it was amidst a very severe drought. And also you had sort of multinationals building dams and planting cash crops. So there are a lot of that would mean that the cattle were dying and and it was having a huge impact on the health of the people who lived there. They're nomadic. I was able to visit one of the health care projects there. They had ideas about the cause of diseases, some attributed sometimes to God. They would think of diseases as being caused by sort of the evil eye or bad luck, and some to God, and they had different ideas about what caused disease. And sometimes they would utilize traditional medicine, and sometimes they would utilize sort of more Western medicine, and sometimes they would combine the two.
Dr. Stephen Fabes: [00:38:56] So I was visiting the project there. It was interesting to think about how you develop a relationship with people who maybe have a distrust of outsiders and are marginalized in almost every way you can imagine, certainly geographically, economically, politically, culturally. And that marginalization has a huge impact on their health. When I was there, they were weighing the babies and three of the babies. I'd only just arrived or they'd only just started, sorry. And three of the babies had been deemed to be suffering from severe malnutrition, and they were going to be taken to the stabilization unit in the nearest town, which was quite a long way away. So you could really see the impact on their health and and just the importance of developing a sort of relationship with them in order to provide health care. How difficult that must have been for the agencies working in that region. I was very inspired by the people who were doing that work, and I could see that the difficulties and the and how hard that must be to navigate.
Henry Bair: [00:40:02] Thanks for sharing that. What is your current practice like? What do your days look like right now?
Dr. Stephen Fabes: [00:40:07] Well, I'm working in a specialty called acute medicine. I do not don't know if that's the same whether you have that specialty in the US or not. I don't know. It's a kind of branch of internal medicine.
Henry Bair: [00:40:18] So it's not really emergency medicine, right?
Dr. Stephen Fabes: [00:40:20] No, it's not emergency. It's basically a branch of internal medicine where it's the first 48 hours of someone's admission to hospital, but still very broad. So I think I don't know if it exists in the US. It's I think it might be more specific to the UK, but that's my specialty. So I'm working in that and I'm writing a second book as well. My first book was Signs of Life, and that's the travel book. And the second one is a is an essay collection and not an academic thing and more for a general audience. So I'm working full time, but I'm trying to, you know, in any, any bit of time, scraps of time I've got, I'm working on the other book. So that's kind of how things are at the moment.
Henry Bair: [00:40:56] It's really great. Well, with that we want to thank you so much, Stephen, for taking the time to join us, for sharing your stories and your insights and for writing this beautiful book. It's been a true pleasure talking to you.
Dr. Stephen Fabes: [00:41:06] Thanks for having me.
Henry Bair: [00:41:12] 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 Doctor's Art.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: [00:41:31] 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: [00:41:45] I'm Henry Bair.
Tyler Johnson: [00:41:45] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.