Why Advocacy Is Medicine Too

Image provided by Esther Choo.

Dr. Esther Choo, MD, MPH has long been an outspoken advocate for both patients and healthcare providers, but she became something of a media sensation last summer when she sent out a series of tweets about white nationalist patients refusing her care because of her race. Hundreds of thousands of people retweeted the thread and chimed in with similar experiences. Doximity had the pleasure of chatting with Dr. Choo about her medical career and social advocacy and how the two are intertwined. Dr. Choo is a writer, medical researcher, and an Associate Professor in the Department of Emergency Medicine at Oregon Health & Science University (OHSU). She tweets under the handle @choo_ek.

Doximity: How did you get into emergency medicine?

EC: I left college…thinking I wanted to be a writer or a journalist. But at some point, I felt like I wanted to be on the other end of things. I had worked on a number of stories where a tragedy had occurred, and I felt very strongly that I wanted to be one of the people in a position to help when tragedy struck.

On Advocacy…

Doximity: You seem to have a very active social media presence and history of advocacy. How does this relate to your medical and writing interests?

EC: I’m more and more aware that as a physician, your responsibility is so far beyond doing scientific research and taking care of patients. You have a responsibility to share your knowledge with the public and advocate for changes to the general public and policymakers. So I am trying to fulfill that part of my obligation.

Doximity: A lot of physicians tend to shy away from talking about things that might be construed as political. Have you gotten pushback for your outspokenness?

EC: I’ve been lucky. I’ve had some people say to me, “If I did that at my institution, I would be worried for my job.” But really, it’s patient-centered. I think [my institution] likes that i advocate for patients. I try to look for the data, and when I see that something is hurting patients, I feel that there is something I can say.

Doximity: You received a great deal of press coverage on your tweets about racism in the ER after Charlottesville. How has that affected your advocacy?

EC: It made me realize that something I think a lot about resonated with a ton of people, and it made me feel more obligated to step up and talk about these things. A lot of [medical students] were the people responding to that story, and it made me feel bad that I hadn’t been more of an advocate for people in the hospital who were experiencing these things.

Doximity: Now that you’ve had this experience in a very public way, what do you think you would do the next time you experience this?

EC: It’s a little different depending on the scenario. I had a patient the other day who told me to go back to my own country. I’m already in my own country. I just looked at my nurses, and we shrugged and moved on. It’s easier when you’re later in your career to walk away from that sort of comment without much psychological damage. It’s just a thing that happens to people of color. But if I saw this happening to a medical student, I think I would have been all over that in a really aggressive way, because that person is starting out, and the impact on their confidence and joy in medicine is much higher than at my stage in my career.

On Gender Disparities in Medicine…

Doximity: You’ve also been pretty outspoken about sexism and issues affecting women. I’m wondering if you can speak a little on that?

EC: That is something that I’ve been involved in for some time now — I was the past president of the Academy of Women in Academic Emergency Medicine. I’ve been very engaged in looking at gender disparities among physicians and trying to figure out what the actual solutions are. I say that because we’ve known for a long time that there are these disparities at every level — [women] make less, we’re not promoted as often, we rarely occupy leadership roles, we’re not nominated for awards, we don’t win awards. There are really persistent disparities in every category of accomplishment you can think of, and it’s not obvious why. It’s not that women are poorer performers. That’s not my experience at all or true when you look at the national data.

There are a lot of myths about how to fix this. The solution was going to be time — we’re just going to wait, and it’s going to get better. But time didn’t fix it. We just achieved 50% women in medical school. So what’s [the solution] going to be? What are things we can do that will actually apply to every hospital in the country? How do we systematically eliminate bias? How do we give women the chances that men have? And more than that, how do we change the culture so that women feel valued and respected, comfortable and safe in the workplace, not subjected to harassment, and they have opportunities for leadership and growth? I think there’s much more identification of problems than solutions right now, so I’m trying to engage in that conversation and trying to work towards solutions.

Doximity: What do you think are some possible solutions?

EC: I think the onus can’t be all on the women. [Women’s development programs] are necessary but not sufficient, and I certainly don’t want the only conversation we have to be focused on what women should be doing. We need to look at what the system can do. We need to look into every phase of recruitment, hiring, retention, promotion, and leadership. One example is promotion — the process of promotion in most institutions is really opaque. It’s very subjective, and I think the process could be very objective. We should be much more transparent about how these decisions are made.

Doximity: You very recently founded a company called Equity Quotient, and it looks like that company is focused on finding similar solutions. Can you talk more about that?

EC: It’s brand new and still in development. I’m really happy you noticed it. It came out of an observation that my friend and I made — there are all these proposed solutions to gender discrimination, but nobody knows if they work. There’s no standard. We came up with an idea to create an app that would measure gender culture. [By] having employees answer questions on an annual basis, [this app would] allow organizations to really track their gender equity metric over time and see how they’re doing. And, if they’re [doing] organizational training around topics that have to do with women in the workplace, they can measure whether [the training] has an impact on the culture.

On Making a Difference…

Doximity: What has been your most gratifying moment as an advocate and a clinician?

EC: Can I say two?

Doximity: Please do.

EC: When I think of my advocacy for gender disparities, I had a few moments that were deeply moving to me when young people — people just starting out in their career — reached out to me and said, “You made a difference.” Ultimately, that’s who I think about. A lot of my work has to do with thinking about the challenges that I had when I was a very junior person, and I wasn’t really aware of what was happening to women. I thought it was personal, and then I realized we were all having these experiences. So when someone really early in their career reached out and said that because of me, they were able to feel more confident choosing a subspecialty or asking for an opportunity or negotiating more assertively — that’s exactly what I’m hoping to accomplish. That’s very special to me.

When I think about the broader aspect of healthcare reforms, when the healthcare bill did not pass, even though I don’t know if I played a role, it was so important to me that I had done as much as I could to be a part of that conversation. Whichever way the healthcare bill fell, I would have felt horrible if I hadn’t done what I could to influence the outcome. I realized what is lost by sitting on the sidelines because it was something that had huge implications for a huge portion of the patient population. I entered medicine because I care about my patients, and I want them to have the best care and the best life possible — it doesn’t just get turned on here [at the hospital] and then turned off when I leave. That was a huge moment for me, [realizing that] the things I’m not paid for — the advocacy — is as much a part of my job [as a physician] as the patient care that I am getting a paycheck for.

Doximity: Do you have a message for fellow physicians about speaking up?

EC: I think physicians carry enormous weight when they weigh in on healthcare and public health. We have the patients’ stories, we have the data and the science, and we have influence when we speak. And with all of that comes a lot of responsibility. When I talk to individual physicians, they say, “Why does what I think matter?” It’s not just that they’re busy and stressed — there’s a little bit of that — but I think they’re underestimating their influence. You’re a physician. You have trained a long time to do what you do.

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