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Have you ever felt you were treated differently by a medical professional due to their biases – whether toward your skin color, age, ethnicity, gender, or for any other reason?
If so, you are far from alone.
Here’s the uncomfortable truth: Ethnicity, gender, sexual orientation, age, body size, and other factors have a significant bearing on whether you will be diagnosed and treated correctly. Healthcare providers and their patients are human, and all humans have unconscious biases that affect how we listen, observe, and act. Bias impacts patients when they are at their most vulnerable. Medical bias can mean the difference not just between suffering and relief, but between life and death.
For the first time, an author with the unique perspective of being one of America’s top doctors, a woman, and African American, candidly addresses the issue of medical bias, sharing personal and patient stories and pragmatic solutions. Dismissed not only explains what so many people feel so profoundly – that the system is working against them. It also reveals what practitioners, patients, and society in general can do to make it better.
My guest today, Angela Marshall, MD F A C P, is the founder of Comprehensive Women's Health, Inc. A primary care practice for women, a board certified internist, and a fellow of the American College of Physicians. She has impacted the lives of thousands of women by emphasizing patient-centered, empathic listening. She's been featured repeatedly as the top doctor in the Washingtonian Megs magazine and a contributing health expert on CNN, Fox News, PBS News, and on Dr. Marshall currently chairs the board of directors for the Black Women's Health imperative, and she's the author of the new book that we're here to discuss today with all of its important concepts – Dismissed: Tackling the Biases that Undermine Our Healthcare.
For anyone who has ever felt vulnerable while navigating the healthcare system, this episode is a must-listen. Join us as we delve into this vital topic and shed light on the ways in which medical biases impact patient care.
Angela and I discuss:
- The death of a dear friend – a Black woman MD – due to medical dismissal and the loss of her own infant son, also due to medical dismissal, and how this galvanized her approach to being a physician.
- The deep-rooted indoctrination into biases that continues to exist within medical education and the healthcare system — and what needs to be done to enact real change.
- Fat shaming and the importance of finding a provider you feel comfortable and safe with in a medical setting.
- How we can better advocate for ourselves when we are in medical settings and when it's time to break up with your doctor.
- How we can find grace and compassion for ourselves when we've experienced medical dismissal
- And more
Thank you so much for taking the time to tune in to your body, yourself, and this podcast! Please share the love by sending this to someone in your life who could benefit from the kinds of things we talk about in this space. Make sure to follow your host on Instagram @dr.avivaromm to join the conversation. Follow Angela @angelawmarshall, learn more about Premedical Explorers, and find her book at www.angelamarshallmd.com
This conversation has been edited for clarity and length.
Aviva: Angela, thank you so much for joining me today and congratulations, you have a book coming out..
Angela: Thank you so much for having me. It was a labor of love.
Aviva: A total pleasure. Did you always know you were going to write a book?
Angela: Never.
Aviva: Never?
Angela: Never had any idea that I'd write a book.
Aviva: Wow. This is huge.
Aviva: It's compellingly written. It's a page turner. It starts right out as being a page turner. And I just want to emphasize, I love the title. Dismissed is a word that I have used in my books for decades, empathizing with patients, and have had more women and people than I can count use that word about how they felt entering a healthcare scenario, a healthcare consultation, in every setting pretty much. I'm just going to dive right into the deep end here with you. Sure. Can we start by talking about Dr. Susan Moore? You knew her personally.
Angela: So first of all, Dr. Susan Moore and I went to high school together, and we had a couple things in common. One is that we are both physicians and we also both were engineers as undergrad. So she majored in engineering first and then became a doctor. Just the sweetest person. And she unfortunately developed COVID. This was pre-vaccine COVID, and she was seen at a hospital in Indiana and she was having severe, severe neck pain. Susan was not the type to complain at all, as most doctors, not to make us any more tough than anyone else, but she just wasn't a complainer. And so the fact that she was having this excruciating pain and complaining about it, she felt that she wasn't being heard. And in a moment of absolute helplessness, she decided to upload a video of her experience to social media.
I can tell you as her friend, it was not just me, but several of our other friends, we saw the video when she uploaded it and we were checking in on her like, “oh my gosh, what's going on? how is Susan doing?” I won't go into the details of the video, but the gist of it was that she was complaining of her pain. She wasn't being listened to, and she maintained if she were not Black, that she felt that this would be going very differently. And needless to say, her video went viral. After the video, things went silent, and we didn't hear from Susan for a while, and we were asking each other, “Hey, have you guys heard from Susan?” We're checking on social media, reaching out to her. And unfortunately, the worst thing – it was that she passed away from complications of COVID several days later.
That really resonated with me, not only because I knew her personally, but because I had experienced that same feeling of being dismissed in a healthcare setting. Even being a doctor, and let's just say being a doctor doesn't put us in any special categories. But what it does is when you're a physician and you feel dismissed, you think, “Well, hey, I can advocate for myself. I know what I'm supposed to be getting.” God forbid someone doesn't know what they're supposed to be getting, and they may think that this is what they're supposed to get. It's just very sad and it's something that I had to do in her honor.
Aviva: I am so sorry that you lost a friend, and I feel like I'm always apologizing on behalf of the system too, that anybody would be treated that way, and die as a result. And there's so many little pieces there that I want to tease out that I know we'll get more into, but there were three really significant phenomena that you mentioned. One, she's a woman, two, she's a Black woman, and the fact that she had pain, and we know that women's pain is often dismissed, Black women's pain is more likely to be dismissed, and that goes back to slavery tropes that still impact Black women. And even like we look at the statistics, for example, on maternal mortality – she was educated. And we can think of Serena Williams, arguably the most powerful, recognizable athlete in the world, or Black woman in the world practically. And she had to fight to advocate for herself. And we know statistically around maternal mortality, even the wealthiest and most educated Black woman is more likely to have adverse outcomes and even die in childbirth than a high school educated white woman in a low socioeconomic setting. So these are some big, big pieces and big biases that you mentioned right out of the gate.
Angela: Yeah. And the interesting thing is when you feel dismissed immediately, as a Black person I think it’s because I'm Black. And so when I originally sought out to write this book, at first I wanted to write it about medical racism, but then I thought about all the patients I've seen in my career and all the women I've treated who've come to me who said their previous doctor didn't listen to them, all the folks with mental illness, disabilities, elder patients, folks with obesity who felt like their doctors dismissed their concerns or blamed everything on their weight. I felt that this was something that had to be way bigger than race, and if I'm going to do it, I needed to include some of these broader categories that make us more vulnerable to being dismissed in healthcare.
Aviva: It's interesting too because you mentioned your patients coming to you saying they'd been previously dismissed. And when I have a patient who comes to me and says that, I look her square in the eyes and I say, “I believe you.”
Angela: Yes, exactly.
Aviva: Because one of the phenomena that happens, and this has been statistically borne out, when a person goes from one doctor to the next and says, “My last doctor didn't listen to me,” the next doctor is more likely to label them with a psychiatric problem or a mental health issue.
Angela: Exactly. Exactly. Yeah. And I mean, it's one of those things where it makes sense because as women, we typically have different symptoms, and that's because we're different from men physiologically. It's not just the reproductive organs that make us different. We are different through and through. And so it makes sense that we may present differently. We may not present with male symptoms that are recorded in our textbooks. So when we have symptoms that are different or may not be textbook, that doesn't mean we're not sick. It just means that we're presenting differently. We need people to believe us when we say we're not feeling well. And that's not always the case.
Aviva: Totally. And even women who do present with typical symptoms like women who are having chest pain, nausea, shoulder pain – they're in the ER, they're in the hospital – they're more likely to be given an anxiety medication or pain medication where a man presenting with the exact same symptoms is going to get an appropriate workup for a heart attack. And that's why so many women's heart attacks get missed in the hospital. It's crazy.
Angela: Yeah. I can't tell you how many patients I've seen that have had legitimate heart disease that were diagnosed with anxiety. In fact, I had one patient whose male doctor told her she just needed transcendental meditation because she was anxious. She happened to be a Black woman, she happened to be overweight, and she suffered from anxiety. And so the intersection of all three of those, who knows what the issue was for him to just zero in on the anxiety. But he told her she needed anxiety-reducing measures like meditation. Well, I sent her to another cardiologist, a woman who I called and advocated on her behalf before the visit with, and come to find out one of her coronary arteries was 95% blocked, Within another two years, she had to have open heart surgery. These things, like you said, this is not just about feelings. This is about life and death, and it really does make a difference when people are not listened to in the healthcare setting.
Aviva: Are you okay staying in the deep end with me? I wouldn't ask, but you share a story at the beginning of your book that just took my breath away. Susan isn't the only one that experienced profound medical dismissal. You did. And I wonder if you'd be willing, I know in your book, you just go right there and say that you hadn't shared the story of your son so publicly before. So many of my audience are mamas, and I think if you're willing to share it, it would be just a gift. If you are comfortable with that.
Angela: Yeah, yeah. Well, interesting. My son's name was Nathan, which means a gift from God. I had him during my last year of medical school. I'm a pretty big planner. I like to plan everything, and I planned everything so perfectly. I would have him, and I'd have several months off to take care of him before starting residency. Things didn't go as planned; we found out that he had a birth defect. It's called posterior urethral valves. It was pretty severe, and he was born with some abnormalities, but he was doing well, making progress, and we were waiting for him to get old enough for transplantation – for a kidney transplant. One day he was four months old and he had an appointment at the hospital with his doctor that day, but he happened to wake up and his eyes were moving in different directions, and he just looked to be in a lot of distress.
He was breathing fast. And so I called the hospital ahead and said, “Hey, we're on our way, but I know he is coming for a routine appointment, but he's really sick. Something's really wrong.” We were only a few minutes from the hospital so we got there right away. Immediately I'm like, ”We’re here. Can you guys see what's going on? Immediately I felt that the doctor didn't share my concern. I was at a thousand and he was just like, oh, well, okay, we're going to get him admitted and we'll get him a bed. And so after about 15 minutes or so, nothing was happening. They weren't treating him; they just left us in a room. The nurse would come in every so often.
I called the doctor back and I said, “Hey, what's going on?” “We’ll, we're waiting for a bed.” “Well, hey, the hospital is full, but you know, you can't wait to treat him. Can’t you start treating him now/” Long story short, he kept saying, oh no, we'll just wait until we get him into bed. So I kept calling the doctor back. The doctor kept saying, “Oh, he's fine.” And then finally I was literally yelling, “look, you guys need to do something.” He was actually breathing a hundred times a minute. His respiratory rate was a hundred times a minute. And I knew from pediatrics that in kids, the respiratory rate is a big deal. That's a big indicator of distress. I even said, “How much longer do you think he can breathe a hundred times a minute? He's going to give out what? What's taking so long?”
I was pretty much at the point of being indignant, and I was about to take him downstairs to the emergency room instead. Just as we were about to go down, the doctor came back and he reassured me and he said, “Look, I know you're upset or nervous about this. but I've been doing this for 30 years and I see this all the time. We're going to get him admitted, get him tanked up, and he'll be back to himself in no time.”
At that point I thought, oh wow, here I am overreacting. Let me just trust the doctor and let him do his job, because I was a medical student. I knew enough to know that things weren't right. But then again, I wasn't a doctor yet. You know what I mean? When he reassured me and talked me down, then I felt almost guilty. Like, oh gosh, did I overdo it? And I don't want them to think that I'm a difficult mom. The last time he left the room, the nurse was there, and within a few minutes of him leaving, my son stopped breathing and his heart stopped and he coded and he passed away.
I have to tell you, that was the worst day of my life, the worst day of my life. I don't even have words to describe how, not only to have the pain of the loss, but to also have the pain of feeling abandoned and mistreated and dismissed. It took me literally over 20 years to even be able to speak about it. I had to go to therapy. I can talk about it now because I’ve had time to heal. But as if that weren't bad enough, I had one month left to graduate medical school.
It just so happened that the last rotation that I had to complete was in the same hospital where I lost my son, the children's hospital. In order to graduate, that was the only hospital that that rotation was offered in. So every day for a month, I had to go back to that same hospital where he passed away and where we had that awful experience with the doctor. I remember the first day of my rotation, I sat outside the hospital on the bench and I almost quit. I mean, it was so difficult. I mean, talk about PTSD – because it was still fresh. I remember sitting on the bench and I thought to myself, I don't have to do this. I could quit right now. And then I thought, but how can I best honor my son? For me in that moment, the best way for me to honor my son was to go in there and get my degree, finish medical school, and become a better doctor than what I experienced on that day. And that has been my driving force ever since.
Aviva: Thank you for sharing.
Angela: Thank you for listening.
Aviva: I don't know how you got up and did that every day, a month, a year after a loss like that. In that setting, it took an incredible amount of courage and dedication. And you had a toddler also?
Angela: Yeah, I had a toddler. He's 27 now.
Aviva: So you also had a toddler expecting you to come back home with his baby brother.
Angela: Exactly.
Aviva: And a partner going through whatever he was going through with loss. That's a lot. . That's a lot.
Angela: It was a lot. It was a lot.
Aviva: One of the things that women who have shared with me that they've had a more extreme situation like yours, with a loss at the end of dismissal, sometimes feel guilty themselves, as if they should have advocated harder, they should have been able to overcome the system in some way. Did you go through any of that?
Angela: Oh yeah, I did. In fact, for the longest I felt like, why didn't I just go to the emergency room, just go downstairs to the emergency room? But actually, I said it out loud, I said it to my ex-husband, I said, we should just take him to the emergency room. And then I said, well, but they're just going to call the same doctor right back, because that was his doctor, his main doctor. Then I thought about him treating him differently if I were too aggressive, if you will. So it was just a very complex situation. I feel like I said all that I could without being belligerent and getting kicked out of the hospital, but that still wasn't enough.
Aviva: Is there anything you wish you could go back and tell yourself as that young med student-mama who was being told to trust this doctor with decades of experience, even though your gut was screaming something different? What would you go back now and give yourself as grace or a gift?
Angela: I think I would give myself the confidence and courage to stand my ground and to stand up even when it was uncomfortable, even when he tried to reassure me. For me to insist and say, No, that's not the case. I need you to treat my son or else I'm going downstairs to the emergency room. At that point it was so late in the process anyways. But it's really tough for patients because as a patient you're so vulnerable. And the power dynamic that exists between doctor and patient, it's interesting feeling that as a patient, especially now as a physician. When I go to the doctor's office even now, it's a totally different feeling. I actually feel the vulnerability of being the patient and I don't have any control. It's very profound and it's a difference. And so I try to keep that at the top of mind with every patient that I see – is that how vulnerable they are coming in and in how sensitive they may be, even to the whole power dynamic. They're vulnerable, they're sick, and they don't know if I'm going to give them what they need. And so I try to keep that in mind when I'm delivering care, just because I think that keeps us grounded and it helps us to better connect with the patients.
Aviva: I feel like as physicians, I mean we can certainly call on the doctor card if we need to get something expedited, and we have our colleagues and friends to turn to. But if your child is sick, you're not a doctor in that moment. You're a mama.
Angela: Exactly.
Aviva: I feel like it's also incredibly unfair and unfortunate that people have to manage their medical encounters and even manage and anticipate the emotions and biases of the providers. You're thinking to yourself, “Well, I don't want to appear this way. I don't want to appear that way.” Studies have shown, for example, that women who suffer from pain actually will alter the way they dress, sit and talk in a doctor's office because they don't want to get perceived as overly put together because then they're dismissed as like, “Well, if she looks that good, she's probably not in that much pain” or too disheveled because then it's like,” Oh, well she's clearly drug seeking,” because we have all these visual biases. It’s really unfair and unfortunate.
I wonder how you encourage women, and also especially Black women, to address and overcome dismissal or even overt medical bias in a real-time setting. You're in the ED, you're in the birthing room, you're in a pediatric appointment. Without getting further labeled as, and I'm doing air quotes here cause y'all see me as a difficult patient or for Black women who have told me, they fear also being labeled by the kind of caricature of a loud Black woman. And even in some cases with parents and Black parents particularly, there have been some cases where social services have been called when parents have questions. Of course we can do this for our patients, we can have the empathy in our clinical setting or if we're the one meeting the patient at the hospital. But that's not the case for so many encounters. So how do you think that people can respond in those moments and advocate?
Angela: Yeah, that's a great question. First of all, I think it's important to have someone else who can advocate on your behalf as well. And that's because when we're seeking healthcare, oftentimes we're in our most vulnerable states. We may not be feeling well. We may not have the energy to even advocate on our own. So I think it's important to have, whether it's a spouse or friend or family member, whether they're there in person or just on speed dial. So if you feel like you're in trouble, if you have a doctor in the family or any healthcare, a nurse, someone in the family who's knowledgeable and who can advocate on your behalf, I think that's important to have in your back pocket, so to speak. I also think it's important to use the right language when you do feel like you're not being listened to.
So I kind of go back to the ”I” statements like they used in psychology and say, “Hey, I feel like you may not be getting the gist of how I'm really feeling,” or “I feel like you may not be understanding how much pain I'm having. Your response doesn't seem to match the level of discomfort I'm having. I just want to emphasize that I'm really suffering and I hope that you can help.” Using I statements to kind of call them out. The third thing I would say is it's so incredibly important to find the right physicians or providers who are going to listen to you. I almost think of people who seem dismissive, it's like a warning sign. If someone's not listening to you, they're not making eye contact, they're not validating what you're saying. Like you say, “I'm in pain,” and they're not saying anything. They're just staring into their computer, that's not a good sign. You want someone that is going to be responsive to your complaints and responsive to your needs. I think that goes a long way. Not every doctor has the bedside manner that we desire, but there's certain must-haves, I’m sorry, but there's certain things that you know, you at least have to look at me and pretend like you care if you don't feel it in the moment, but give me something because your health is just too important to trust it with anyone. So I think, hey, we've got choices and we've got to, as women, we have to exercise our choices.
Aviva: I 100% agree. I want to just emphasize too, I feel like we have to almost exercise our muscles of trusting our gut and not feeling like we have to be the good girl, the nice girl. Why do you think it is that we so often just override our inner knowing? And do you see that happening a lot?
Angela: I do. And I think part of it is socialization. It's for the same reason that sometimes we don't raise our hands in class or when we go in a conference room, we don't sit at the table, we sit in the side seats. It's those kinds of things that I think we've been socialized to do; it starts at birth. I am very grateful to be in a country where women have so many freedoms, but they're not enough. We still have some serious issues and we're socialized a certain way that I think it affects our ability to be assertive even in normal situations, let alone when we're feeling badly.
Aviva: It's so true. I tell my patients, and just like women I teach and my online community, I'm like, if your food is too salty at the restaurant, it's a great time to practice sending it back.
Angela: Yes.
Aviva: If you get sent the wrong meal, it's a great time to practice. The little moments in life where you can exercise that confidence and assertiveness. Practice in front of the mirror if you have to, script out what you want to say to your doctor ahead of time so that if you get nervous in that setting, you can go back to your notes. Just be prepared, but practice exercising that skill.
Angela: I think that's a great point. Have a plan A, a plan B. What if they don't give me what I want? What am I going to say in that event? And I think that's a great point.
As women, we have to work on standing up for ourselves. Sometimes it's even our relationships that cause us to be less assertive. And so making sure that we're assertive in our relationships and our interactions at work and in a healthcare setting, I think we could all use support and encouragement on that.
Aviva: And have each other's backs as women too when we're doing.
Angela: Exactly.
Aviva: I want to talk about this. We know from numerous studies now, for example, that Black babies cared for by Black doctors in the newborn period are much more likely to thrive and survive than Black babies who are cared for by white or non-Black doctors. And that kind of study has been repeated across different settings. I know that it's something you talk about in the book, incredibly important. You're like one of 2% of primary care physicians that are Black women. I mean, that is just astonishing to me. So we need to encourage a lot more diversity in medical education.
I want to ask you about something about that. So half of all primary care doctors are women, but we're still kind of barreling down this very dangerous road in medicine now with increasing diabetes, increasing obesity, increasing maternal mortality. Half of all OB GYNs are women now. And one thing that really also struck me is the story of Tyre Nichols, who was a Black man in Memphis beaten by five Black police officers. remember watching the videos, which I intentionally watched. I wanted to really understand what was happening to the best I could. And I remember thinking, how could this happen? I listened to Van Jones who's a commentator. I think he's quite intelligent. He said that when we enter a system that is inherently racist or sexist or ageist or any of the things, that it doesn't inherently matter, it should, but whether you're Black or you're a woman or whatever the -ism is that you would be treated as a victim of, you can still be so indoctrinated in that system
So that as a Black police officer, you're still neurologically ingrained to see a Black man as a threat and a potential person who should just be pulled over at a stop sign, profiled, and accosted like that. And he was beaten and ultimately died three days later. And you and I am sure know of women, I can think of quite a few.
So we need more diversity in the system. We need more women, we need more Black women, we need more Black people, we need more older students. We need more people who are differently abled. But how do we still make sure that the system isn't, as Bob Marley would say, getting inside their heads. Right.
Angela: Yeah, that's so true. And you used the right word. It's indoctrination. And it's interesting because a friend, a colleague of mine and I were just talking about how as physicians, we're indoctrinated. Everyone is in our training. Think of how many hours and how we push ourselves. We work sick, we don't take vacations, we put off going to the bathroom, eating, all our basic needs.
And so we are indoctrinated to suffer and to put our personal needs last in caring for the patients, which interesting enough, that's not good for patient care because we're not operating at our best selves. So I think that part of it is changing the system because the system is broken in some places more than others. But overall, I'd say the US healthcare system is broken in many ways. From physician reimbursement to just all the hassles and administrative paperwork, and it's just so many, the number of patients that you have to see just to make a living wage and pay your staff, it's just very onerous. I think that the system has to change. I think we're all indoctrinated into this system. And in order for it to change, in order for us to change, the system has to change. But I agree, we can advocate for more women physicians or more Black physicians or more every other group. But the system is broken. Just having a Black person treating a Black patient may not be the answer, although we need representation in the healthcare system for everyone.
Aviva: Agreed. Totally not mutually exclusive. We need it and we need the system to change.
One of the things that I know that you're concerned about and I'm concerned about is that the constant dismissal that people experience when they go to the doctor's office. Like me, I'm sure that you've seen patients, for example, I can think of more than one patient who was afraid to go to the doctor when I was working in hospital or clinic and she'd put off abdominal pain for six months or 12 months or more, kind of just sucking it up or ignoring it or saying, “Oh, it's probably just digestion or hormonal,” only to finally, sadly end up with a diagnosis of ovarian cancer. Or sometimes more benign situations where somebody's had rampantly out of control, hypertension or diabetes, all the things. I'm sure that each of us can cite thousands of examples of people who were too afraid to go and didn't go.
Another thing that's happening thanks to the internet, which is a beautiful thing, that people can be more empowered and find information that they need and sometimes that they're not getting from their doctor. But another thing that's happening is people are scouring the internet for answers that may or may not be reliable because they don't feel like they can go to the doctor, and sometimes for serious situations. So I wonder how we can help people and how the medical system can help people to overcome personal mistrusts that have happened from direct insults or hearing about a story from a family member or friend, decades of insults, and centuries of insults. I mean, when I think of Tuskegee, that wasn't actually that long ago. So what does the system need to do to rebuild trust?
Angela: Well, I think it's on the system. It's on the physicians and the healthcare providers to build trust with the community, with our patients. It's on us because, I think you're right, we have seen a lot of patient disengagement because if you have a bad experience, then what do you do? You pull away, you disengage, and a lot of patients end up doing what I call DIY-ing, their health. They go to their own devices. Sometimes they're going to natural supplements and things, trying to self-medicate and things. And that's not the answer. But I think as physicians, we have got to raise the bar. We've got to work on building trust with our communities, with our patients. I think that is the only way that it's going to change is that we have to make a concerted effort to rebuild trust. And there are many ways we can do that, but I think we have to care enough to even try in the first place.
Aviva: Now you mentioned natural supplements and in getting ready for our interview, I spent a little time on your Instagram, and I know in your book you do talk about your concerns about people going to natural supplements. My sense that I got from you and also your Instagram, because as an herbalist, I of course noticed your lovely post on turmeric and ginger, you weren't feeling so great. I think you maybe had some cold symptoms coming on, and you said you went to some of your favorite medicines. So my sense in reading the book and hanging out on your own personal stuff is that it's not that you're opposed to natural supplements or integrative approaches, it's that you are concerned when people are using those without guidance. There's just an insane amount of unregulated misinformation on the internet, I spend so much time at each patient appointment saying why that test or that supplement is not, or that diet is not what it's cracked down to be.
Angela: Yeah.
Aviva: My sense is that you're more just wanting to make sure that people are also getting the medical care they need. But I'm curious because respect and empathy are such deep parts of how you practice, and are as a human and a physician. How do you handle it when you have someone who, let's say is a 65-year old, a 70-year old African American woman who remembers her grandmother talking about Tuskegee. She grew up in the South and now and now it’s COVID and she's like, “Yeah, Dr. Marshall, I'm not getting vaccinated.” Or she has a diagnosis and says, “Well, Dr. Marshall, I'm going to do the celery juice diet.” How do you meet people where they are and honor where they are, and also insert yourself in what you feel you're there to deliver?
Angela: Yeah, that's a great question. Well, first of all, I do embrace all forms of medicine and I feel like the true complement does include everything. It includes the natural, the allopathic, the whole thing. But I think one of the things that I do often is I explain the importance of randomized controlled clinical trials because a lot of time people have anecdotal knowledge or facts and they say, “Oh, well this person had the exact same symptom that I had and they took this supplement and they got better, so therefore the supplement will work for me.” One of the things that I try to explain is why that doesn't always work out, and why we do the clinical research to begin with is to prove, because we want to have a control group and a treatment group. Once you can study those two different groups and get different results, then you can say the treatment works for sure scientifically.
I think for one thing is we've got to do a better job of teaching our young kids and even our college students the importance of scientific fundamentals and understanding data and how we come to make conclusions about medical treatments and things like that. Understanding that just because I saw a treatment or something on TikTok, it doesn't mean that it is true. I think that right now is a potentially dangerous time, because I have lots of patients who come to me and say, I saw this thing on TikTok and they said that this is caused from that. They said, I might have that. And making sure that we remind our patients that it's important to have a medical advisor or medically trained professional who is guiding our care and not just doing it on our own just because it can be so detrimental by trying to be our own doctors.
Aviva: We watched a television show recently and, we usually watch movies and are not watching commercial TV with commercials, and I was shocked. It was an evening program and every commercial was two drug ads. Two drug ads. It's always this thing. There was one that was for eczema. I was like, all right, eczema is uncomfortable, but it's not going to kill you unless you get some bizarre secondary infection that you don't get treated – the chance the effects eczema are killing you, pretty much none. And it was one of those medications like, “do not use this drug if you have taduh, taduh,taduh… The side effects of this drug can be poor sleep, bleeding from your gums, and death. But similarly, I have patients who come in, they're like, oh, “I saw this pharmaceutical on TV” and I'm still having to do some of the same education. Cause we know those aren't always the best drugs for the job either.
Angela: Exactly. And sometimes they don't even have the condition that the medicine is for and they're asking about the medicine. And so yeah, I agree. I don't know why the pharmaceutical companies even advertise on television because they have to list all those side effects in order to advertise to the public.
Aviva: Yeah, it’s a cash cow though.
One of the biases that I would love to touch on before we go is fat shaming. I read a statistic that something like, and I think you may talk about this in the book too, but 70% of doctors have reported discomfort working with people in, I'm just going to say larger bodies, bigger bodies, curvier bodies. And a study I read that said that percentage of doctors actually reported being disgusted or having disdain for people in bigger bodies. Another study showed that people who are in bigger bodies actually get better care on telemedicine because they're not typically seen from the neck down. What are you seeing, what are you hearing? You did a survey of 300 people, what are you hearing and concerned about and encourage people to do around fat shaming?
Angela: Well, first of all, I believe in body positivity and in just embracing yourself. When I have conversations with patients, it's about health and it's objective. One of the things that I hear repeatedly, both from patients and from our Pulse Survey, is that patients say that when they're overweight, that no matter what they complain about to their physicians, that they blame everything on their weight. I have pain in my elbow. Well, oh, it's just because you've got too much weight pressing on your bone, and if you lost weight, it would probably go away.
I think that is, in essence, a form of dismissal when they absolutely blame everything on their weight. It's complex though because there are certain situations where, you know, you do want patients to lose weight for their health. I've had a couple recently where they've been postponed from having knee surgery because the surgeon wants them to lose just a huge amount of weight that is impossible for the patient. I had one person, she said that he wouldn't even consider doing her knee replacement unless she at least lost 50 pounds. And for someone to lose 50 pounds, that's a big undertaking. Now she's got bone on bone in her knees, and so she has to suffer. She can't really exercise, so it's really, yeah, there's so many forms of fat shaming going on.
I think that, again, for patients who are plus size or have larger bodies, it's important to go where you feel comfortable. I want for everyone to be seen. When they go to the doctor, they should feel seen and feel heard and not be objectified or not be dismissed because of some physical characteristics. I think we can trust our intuition as women. We know when we're with providers who actually care about us and are not focusing too much on whatever distracting characteristic that offends them.
Aviva: I think there's so many important things in that that I just want to pull out a little, if you don't mind. One is just that I've heard the same thing – surgeries being put off – but also patients who have had fertility treatments put off, being told they couldn't birth vaginally, they had to labor because they may have had a high risk pregnancy, but it doesn't mean they have a high risk labor and birth. And I'm really concerned that we conflate weight with health. So yes, there's a point where with very significant obesity, it becomes a health risk. But we also know that people can be in bigger bodies, have perfectly healthy blood sugar, cholesterol, heart, brain, bone.
Angela: Completely.
Aviva: Being underweight is actually also a significant risk. My heart just goes out to women who are in a medical setting. It's hard enough to speak up for ourselves when we're being dismissed, but when you're being dismissed and shamed about something that's such a cultural phenomenon of looking a certain way, I think it just makes people shrink and shut down and not speak up and then not get the treatment. And you said that it's so important that as women we know – that we trust that we know. When you're in a relationship and somebody's not treating you well. How often as women do we say, oh, it's because, oh, they must be tired. They must be in a bad mood. I must have done something. That trusting that knowing, that feeling that you are not comfortable is so important.
Angela: It's so important. One of the things that I had to teach my daughter very early on is how people treat you when you're vulnerable really matters. Pay attention to that. When you're sick or you're vulnerable or you're upset and someone mistreats you or doesn't listen to you – that speaks volumes. And so I think it's important as patients to pay attention to that as well.
Aviva: So you are a busy author now, and you have a not-for-profit called Premedical Explorers, where you encourage and mentor young African American high school students who want to become physicians, which is amazing.
Angela: Yes, yes.
Aviva: And you're seeing patients and you're a mom. How are you dealing with the time pressures that are already on physicians in order to provide compassionate, humble care and also take care of yourself?
Angela: It is a real challenge. I feel like a hypocrite just about every day when I'm telling patients, oh, you should practice more self-care. But one of the things that I do is I take breaks. I can recognize when I've reached the brink of jumping out of a first floor window, and so I take a lot of breaks. For example, I sometimes say, I'm taking medical leave. I have to protect my mental health. I have to take breaks. I have to guard against burnout because burnout with physicians is so common, just about everybody suffers from it from time to time. That is how I kind of keep it together. Every year I take an entire month off. That is my time to relax, to catch up on things that I don't have time to do the rest of the year. And then I'm also kind of cutting back with patient care a little bit now that I've been practicing for 22 years.
So, you know, you just have to do what you have to do. But it's really, really tough I feel like as physicians, we're caregivers and we always talk about people who take care of their loved ones, the risk to their health. I think one of the studies in the Journal of the American Medical Association said that caregivers who experience stress have a 70% greater chance of dying an early premature death. And so we have to think of ourselves as caregivers since we're seeing patients every day. And so that puts us at risk if we're not careful.
Aviva: That’s a beautiful way to frame that, and I'm going to bring that to my students who are healthcare providers. I think it's so easy to forget that we are caregivers and caregiver burnout is very real. And as you said, I mean, everyone suffers in healthcare when the physician is burnt out. We know that it increases mistakes and irritability and dismissal and all the things. Tell us a little bit about Premedical Explorers. It's really exciting. And I love the name too.
Angela: Oh yes. So after Susan passed away, just because of how similar it was to my experience of feeling dismissed and how much I just cared about her and everything, I, along with two of our other classmates came together and said, how can we best honor her memory? We went back and forth and we kind of resonated with that last statement she made was that “I contend if I were not Black, that this would not be happening.”
And so we thought, well, what if Susan had a Black doctor? Would her outcome have been different? We decided that was going to be our mission – to recruit and train more Black doctors. We decided to start at the high school that Susan and I and our classmates attended.
We did a pilot a year and a half ago. We meet with the students and mentor them and try to spark their interests in science. What we're finding is a lot of students who are kind of disadvantaged or may not have the exposure, a lot of students never thought of being a physician. They never thought that that was even a possibility. And so the most important thing we do is show up so that they can see Black doctors, they can see that it can be done. It's been amazing. We've had such a great experience so far. We look forward to growing the program to an even larger group.
Aviva: That's beautiful. So I grew up in a housing project in New York with a single mom, but I had the privilege of being in a white body; that gave me some advantages over many of the other members of my community, and had a mom who really also gave me a lot of extracurriculars at home. So I remember for me, I saw a PBS special when I was in third or fourth grade. It was on neurosurgery. and I thought, that's it. I'm going to be a doctor. But I had no idea that I could be. I went to a private school for three years. I got a scholarship. I bused into it, and developed a friendship with a woman who's still my best friend from middle school. Her father was a physician, so they lived in a very wealthy neighborhood, and he really said, you can do this.
You grew up in poverty. What was it that ignited that for you? And how did you know that you could do it? And you are an engineer.
Angela: Yeah. So for me, when I was about seven years old, I also was raised by a single mom in poverty, and my mom was a smoker, and I just detested smoke. I just…I didn't like it. Gave me headaches. Back then they were smoking in cars. And I can even remember going to the hospital, they were smoking in hospitals back then. When I was about seven years old, or seven or eight, I called the American Cancer Society to get some literature for my mom to help her stop smoking because I had seen some stuff at school and seen the pictures of the black lungs and all that. So I called and requested some materials thinking they would just send me a couple pamphlets. They sent me this big box of all these brochures and pictures and models and stuff. I read all the pamphlets from front to back and used the little gadgets to do little demonstrations to show my mom – this is why you can't smoke. This is why you have to stop smoking. Look at what your lungs probably look like. And so that was a good exercise. I think that was the thing that kind of sparked my intellectual curiosity for medicine.
Aviva: Did you have teachers along the way or your mom that really said, “Okay, here's a pathway or that just let you know you could do it?”
Angela: That's a great question. I knew zero physicians growing up. Zero. But my grandmother, who was one of my first mentors, she was a learned practical nurse, a two-year degree. And I remember telling her one day, I used to love the way she smelled coming from the hospital – back then, I think the smell of ether or the soap. I can remember telling her one day, I said, “Nonni, I want to grow up and be a nurse just like you.” And she looked me in my eyes and she said, “Well, don't just be a nurse. You should become a doctor.” The fact that she looked at me and said that I should do that, that made me feel like I could do that. That was like everything. That's all I needed to hear.
But when I went to college, I had planned to do pre-med or to go to medical school, but I barely had resources for college. So I decided to major in engineering because I said, look, if I stop at the four-year degree, I want to make sure I can make a good living. And I was interested in engineering, and I actually had a family friend who was an engineer. So I was interested enough in the field. I really enjoyed it actually. But after working as an engineer, I realized there was one thing missing and that was helping people. I learned that I needed to have social interactions. I don't know if you saw the recent article about the importance of having social interactions in the workplace; that loneliness leads to unhappiness in the workplace. I experienced that as a woman engineer, just feeling so isolated because I worked with all these guys that just wanted to peck away on their computers all day. And so I'm like, I'm wasting my personality. I need to feel like I'm helping people. I was doing a lot of community service after work and I realized that, hey, if I did medicine, I could have that part of me fulfilled in my daily work.
Aviva: So when you finally went to medical school, did you learn like I did that nurses are actually the ones who run the show?
Angela: Absolutely. Yes, I did. Exactly. And they're honorary engineers too, by the way, because they can rig up anything.
Aviva: Anything. Get you anything you need. Know those patients.
Angela: That's it.
Aviva: Doing all the things that keep it all going.
Angela: That's right.
Aviva: Bear a lot of the burden of the system and bear a lot of the horizontal and vertical abuse and biases that happen too,
Angela: For sure.
Aviva: All right. Lovely woman. You're incredible. Your book is incredible. We're going to put everything in the show notes for where folks can reach you. The book is called Dismissed: Tackling the Biases That Undermine Our Healthcare by Angela Marshall, MD with Kathy Peikoff, who also inserts some humor into the book.
I have one question to ask you that I love to ask my guests before we go. If you could tell your younger self anything, anything, how old would she be and what would you say?
Angela: That's a great question. I think I would tell my 12-year old self that you are more than enough.
Aviva: Wow. Maybe we should all just say that to ourselves right this minute.
Angela: Yeah.
Aviva: Angela, thank you. Thank you for sharing your personal stories about Susan and Nathan, for your commitment to empathy and equity and kindness in healthcare and for being here with me today. And this really wonderful book.
Angela: I look forward to staying in touch. And thank you for hosting. This has been amazing.
Aviva: It's a total pleasure. Thank you everyone for listening. I know you're going to want to read this book, learn more about Angela, find out more about her Premedical Explorers and all the things she's doing, and we'll have all that for you in the show notes over at avivaromm.com. And make sure to share this podcast because it's a really important episode for everyone who is going to enter the healthcare system. For most of us, we have some encounters at some point in our lives that we do feel vulnerable. Thank you for joining me, and we'll see you next time.
