This memoir by Lacy Crawford is the latest book I’ve started reading about rape and rape culture. I haven’t quite finished yet, but I can say with certainty that I love this writer’s voice, her way of speaking about the things we’d rather not say.

Crawford accounts her experience with sexual violence at a private school as a teen, and what happened after. I find that she perfectly rides the line of writing as an adult woman who is seeking to inhabit her teenage mind to tell a story.

I’m still in the process of securing interviews, so those are to come, stay tuned!

All I’ve been able to think and talk about for weeks is rape; rape culture, sexual violence, the complicity of people in power and those among us.

October 6 was ten years since the trial I went through with my own rapist, so it’s been heavy on my mind and I can’t seem to shake my anger and rage.

So, I’m putting it somewhere. I’m taking you through the books I read, the survivors and experts I’ll talk to, all to answer the question of how do we bring rape culture to an end.

If this does not interest you, I won’t be mad if you unsubscribe. That’s your right. If you are sticking around, let’s get to work.

Hey readers, sorry it took so long to get this one out to you, but as the French say: soo la voo! I’m here today with one of my favorite interviews I’ve done to date. This month, I talked with Ramón Pagán, otherwise known as glowbyramon online. Ramón, a self-proclaimed “child of the world,” is loosely based in Central Florida but talked with me out of a beautiful spot in London. Ramón is a cosmetic chemist, product developer, aesthetician, and a content creator. He identifies as a cisgender, Puerto Rican gay male. 

Ramón and I talk about makeup, ingredients in cosmetics, “clean” testing apps, and more. This one is so good. Ramón was a treat to talk to, and so gracious to talk to little old me! Hope you enjoy as much as I do. 

Dani Janae:

Okay, so here's some meaty questions. Was a love of the sciences cultivated in you as a child or is that something that you explored on your own?

Ramón Pagán:

That's a really good question. I liked science and I was really into different facets of science. My dad was really into tech specifically, so for him, his job dealt with maintaining and building equipment used in hospitals. He could build a whole computer from just, I guess, scrap parts. So that was definitely something that I was surrounded by.

But in terms of what I'm doing right now, cosmetic chemistry was never an interest. I was good at chemistry in school, but real talk, I think when I was a kid, I actually really wanted to be a knitwear designer.

Dani Janae:

Oh.

Ramón Pagán:

Yeah.

Dani Janae:

Awesome.

Ramón Pagán:

I love to knit. I taught myself how to knit when I was 10. And I guess something that really kind of planted a seed that's always been with me is if I want to do something, I always find the resources to do it and learn it and run with that. So that's really been a big factor in this career I am in now. Just trying to figure out what it is I need to do to get there and how to do it.

Dani Janae:

Okay, yeah. Are you still into doing knitwear stuff?

Ramón Pagán:

I am, actually. I still regularly knit. I love knitting, it's very relaxing. I crochet as well. And actually, I've been thinking about trying to find some sort of knitwear design course.

Dani Janae:

Yeah, totally. That's really cool. So this pertains to what we are just talking about, but was chemistry your first choice? Or was it more of a journey to get there?

Ramón Pagán:

It was definitely a journey. Again, I was really good at chemistry when I was in school, and it was something, because it's so logical, math-based, everything I've ever done, if it can be simplified down into an equation, basically, I will understand it very well.

For example, another interest of mine is language. Language, to me, it's very mathematical. So because chemistry made sense to me, it was easy. Biology, on the other hand, that's a mystery. I was never good at biology, but ironically, biology still plays a big part in what I do.

But I started going to school for biochemistry when I was 23. So I started this journey kind of late, I'm almost 30 this year. And I started that knowing I wanted to be a cosmetic chemist, but going to school in the US was really difficult, so I transitioned to going to school in Europe, where the coursework was more specific. And once I got into this coursework, I was like, "Okay, no, this is the right path. This is the right thing for me." And ironically, while I'm a cosmetic chemist, there's so much about this career that's not chemistry focused, thankfully.

Dani Janae:

Totally. Okay. So now we have some more cosmetic chemist focused questions. When you were studying to become a cosmetic chemist, was it because you already had an interest in makeup and skin care, or did that come later?

Ramón Pagán:

No, it was definitely, I loved cosmetics. I loved beauty. It stemmed from, I had really bad acne growing up. And with the acne, the pigmentation that was associated with it, and it was trying to... When you struggle with that, which is why a lot of us who actually became content creators kind of have a very similar start, you want to learn, “okay, what is causing this? How do I remedy it? What do I look for in products? If a product works for me, what specifically is it?” So it was always looking at ingredients.

But then also covering it up, makeup was a big thing of mine. So I was also like, "Okay, what textures do I like? What finishes do I like?" And that was the inception of it, and I was like, "I want to work in this. How do I get into this?" So that was what pushed me into wanting to get into this industry.

And then sunscreen was not a big thing of mine. My content actually is a big basis of it is sunscreen, sunscreen knowledge education. That was an accident. I do love sunscreen, but that was an accident in itself.

Dani Janae:

Totally. So the reason that I specifically was seeking out a cosmetic chemist to talk to was because I was seeing a lot of stuff online, and I am very into makeup, so a lot of the makeup world... Well, people in the makeup world were talking about ingredients like talc and mica, and those ingredients get labeled as unsafe. So I was wondering if you could talk a little bit about how those ingredients get labeled as unsafe, and are they something that people should really avoid? Or is it an in small doses sort of thing?

Ramón Pagán:

That's a great question. Love that question. To your point, sometimes dose is the really big factor. On that note, you have a really big thing right now is there's these apps and one of them is called Yuka. And people love Yuka because they're like, "Oh, it has studies that showcase that these ingredients are bad for you." And I'm like, "If you look at those studies, first of all, the dose is in the poison." They are giving or exposing mice to 50 times the dosage that you would ever be exposed to as a human in these cosmetics. I'm exaggerating a little bit, but for context. Obviously, if you as a person drink 50 liters of Coca-Cola, that's not going to be good for you. So that's how I liken Yuka. Also, they use the EWG as a resource, and the EWG is heavily biased through lobbying, so it's not a very reliable source.

Talc, you touched on talc, is a really big one right now. What I will say is any powder poses an inhalation risk, and so a lot of them are recognized as carcinogenic if inhaled. So I think that's one thing that talc kind of falls under. Titanium dioxide does as well, but that's actually one of the safest ingredients applied topically, but people don't associate it's applied topically, doesn't mean you can inhale it. And then, let me think. The thing with talc now, for example is, so there was the lawsuit from, I think it was Johnson & Johnson.

Dani Janae:

Yes.

Ramón Pagán:

First of all, anyone can sue, in the US, any company for any reason. It doesn't have to be legitimate. But due to the association of that, now there's just a big stigma as well around the ingredients, so a lot of brands are trying to steer away. So you see at Sephora right now, a lot of brands are actually going talc-free. Haus Labs by Lady Gaga is one of them.

In Europe, the full natural, all natural movement's even more strong. I did some time in Germany, and the German and French market are very hyper clean, hyper good for you, hyper natural. So talc reformulation was actually a big thing I worked on last year.

But, yeah, a lot of these unsafe or not good for you toxic claims, like you mentioned, it's dose, it's misinterpretation of studies, or it's just a matter of the manner in which it's applied. You can't inhale this, but it's safe for you to apply it topically.

Dani Janae:

Okay. Thank you for answering that.

Ramón Pagán:

That was a long answer. I'm sorry, that's long.

Dani Janae:

No, that's totally fine. I love long answers. With that in mind, I'm just curious about your thoughts on Sephora, and I think Ulta has this too, but the clean beauty, or I forget what it's called at Ulta, but it's just clean beauty in general, that movement. What are your thoughts on that shift, for consumers and for brands alike?

Ramón Pagán:

Yeah. In my sector, this behind the scenes portion of it, first of all, from a consumer perspective, it presents a lot of difficulties. It's really hard to get super elegant, really high quality formulations if the focus is high, high naturality. And natural doesn't necessarily mean safe. There's a lot of ingredients that are still considered clean, even if they are not natural necessarily.

A lot of what, for example, Sephora has under their clean program is really just European cosmetic regulations, so it's already stuff that we have to adhere to in Europe. But also, on top of that, just some extra things. They tend to err on the caution of where this ingredient was controversial. Instead of educating consumers, we're just going to say that that's unclean. I saw, going back to Haus Labs, I think they have... What was the marketing claim? It's like “questionable ingredients” or whatever. So it's just not even saying unclean, they're just saying, "There's some question marks around this ingredient. We're going to avoid it."

I always look at brands who choose to ignore that or would rather educate their consumers. I always see them a little bit more respectfully because you're taking the time to actually explain to your customers, "Hey, that's not a bad ingredient, it's not unsafe. Therefore, we're going to continue to use it."

But the other thing is, for a lot of brands who do adhere to that, we have a clean standard, they do incentivize the brands underneath them. That if you do whatever you need to do to become clean under us, we'll give you extra resources. So it's also, the brands kind of lean into it too underneath the retailers. But, yeah, it just kind of feeds, again, this unhealthy mindset around your cosmetics. There's rules in place for how we can formulate and what we put in your products at what levels. The intent is never to hurt or harm. No brand wants to get sued. That's money that's going to get spent on lawsuits, but it just unintentionally fuels more fear.

Dani Janae:

Yes, totally. My next question is about pressed pigments. How do those differ from a standard eyeshadow?

Ramón Pagán:

Pressed pigments. Where is an example of that?

Dani Janae:

I think ColourPop and some other brands have a warning on them that are like, "This is a pressed pigment. It's not safe to use on the eye or around the eye," that sort of thing.

Ramón Pagán:

Okay. Yes, yes, I got it. When it comes to any cosmetics, and this is applying in this instance to pigments, there are certain things that can be used around certain areas of the body versus others. So when you're considering the lip or the eye, those are basically mucus membranes. They're also essentially direct channels to internal pathways. So certain ingredients are approved for use in those areas, some aren't. And that's why, you say ColourPop, I remember Huda.

Dani Janae:

Yes.

Ramón Pagán:

Huda Beauty had a thing about that. So that's their liability waiver essentially, like, "Hey, this is a pressed pigment. It's not approved as an eyeshadow or a lip color." So us putting this here, this disclaimer, takes a little bit of liability from us because we're telling you it's not approved for use around the eye, so if you choose to do so, it's kind of on you.

Dani Janae:

Yes.

Ramón Pagán:

But it's just that it's just nothing that's been approved for safe use around the eye or the mouth. Therefore, it's not an approved pigment, it's a pressed pigment.

Dani Janae:

Yeah. Okay.

Ramón Pagán:

We're not saying it's an eyeshadow because we're not telling you to use this around the eye. It's a pressed pigment powder.

Dani Janae:

Yeah. Okay, got it. Yeah, I saw that today too, with… it was the Haus Labs liquid pigments, those are also... There's the red one and the pink one, you're not supposed to use them on your eye. So I was like, "That's interesting."

Ramón Pagán:

Yeah. Sometimes you'll have multi-sticks.

Dani Janae:

Yes.

Ramón Pagán:

And that's the thing. They're like, "We can use it on the cheek and the lip. Around the eye, this is a pressed pigment, not an eyeshadow."

Dani Janae:

Yeah. Okay. So this is a question about your work environment or work in general, but does your queerness ever become relevant or intersect with what you do on a daily basis?

Ramón Pagán:

As of right now, no. It's interesting because I've noticed every professional lab environment I've worked with, I'm the only queer person. And the thing with me is, we call it a one-mile gay. From one mile away, you can clock it. You're like, "That is a..." I'm a very effeminate man. I have this voice, I have my mannerisms. I have never been made to feel unsafe or been discriminated against in that, thankfully.

Which is part of why I do what I do with content, is I'm unapologetically me. I'm very open about who I am and what I do. And the goal is always, if I look like you or you resonate with me, because I do this job, you can do this. You should get into this industry because we need more queer people, we need more trans and non-binary individuals in this industry. Especially because, realistically, well, I'm not going to say we're the primary consumers of beauty, but the beauty industry in our world is such a major thing, in the queer spaces.

But yeah, in the professional space in the lab, you don't see a lot of queer people. That being said, I've never worked for a huge, huge beauty conglomerate like a Johnson & Johnson, L'Oreal, so I can't speak for those.

Dani Janae:

Okay. Okay. What's an ingredient in cosmetics or skin care that you think is underrated and one that you think is overrated?

Ramón Pagán:

Overrated first. I feel like a go-to, actually, no, I don't hate this. I just did a video about this today, vitamin C.I love vitamin C, do not get me wrong. It's good at what it does, but I think people are just so fixated on it has so many years of research and so much evidence. And I'm like, "Yeah, but it's so hard to work with and it's such a finicky ingredient." And based off of what it is you want out of vitamin C, you can find ingredients that are just easier to work with and more beneficial for that specific benefit. It's good to have in a routine, but I think it's not the star that everyone makes it out to be.

Dani Janae:

Yeah.

Ramón Pagán:

Underrated is a good question though. There's so, so, so many. I think a personal favorite of mine, panthenol.

Dani Janae:

Oh, I haven't heard of that one.

Ramón Pagán:

Panthenol, it's vitamin B5. Its primary function is it soothes, it hydrates, it conditions. It's good for skin and hair. And yeah, it's just nice. I'm someone who I exfoliate too much. I mess up my skin way too much. Panthenol is one of those that I can always resort to and it's going to calm everything down, soothe, moisturize.

Dani Janae:

Okay, cool. That's one I'll have to look into.

Ramón Pagán:

Definitely recommend.

Dani Janae:

Okay, so these are two listener questions that I have. Do you engage with beauty justice/unequal exposures in your work?

Ramón Pagán:

What's an example of that?

Dani Janae:

I should have asked, but I'm not sure. That's a concept that I haven't heard of, but I thought maybe you might've.

Ramón Pagán:

Repeat that again, sorry. 

Dani Janae:

Do you engage with beauty justice/unequal exposures in your work? I can email the person and ask them to expand on that and then email you their response and then see if you have an answer you can type out.

Ramón Pagán:

Yeah, because I feel like, based on what I'm assuming that could be, I'm like that could be a really interesting question, but I want to answer it accurately.

Dani Janae:

Okay, I will do that. Okay, and then the second one is, how long does face sunscreen stay effective once applied? And any non-sticky/non-pasty white recommendations?

Ramón Pagán:

Yes, so that's a really good question. That's my specialty. The recommendation, and it really comes down to, from a formulation basis, we call it, what's the emulsion type? So it's like you have generally an emulsion as a mixture of oil and water generally, and it's what's the primary phase, the water or the oil? If it's more oil based, those are going to last longer. And those are the ones you will see have the water and sweat resistant claims on them. Generally, if you see water and sweat resistant on a sunscreen, it's going to be a little bit more heavy duty, robust. Water-based ones, you can see those claims as well, and those are going to be a lot more lightweight as well. But you just have to know what to look for when you're saying those things. But that's why, generally, if a sunscreen lasts a long time, sometimes it's not going to feel the best on your skin.

But the thing is, and I actually posted a video about this today on my Instagram, there are some sunscreens that are tested. The brands did the work to test them, and they're like, "Oh, even after eight hours of just everyday wear, you're still going to get the SPF 50 we advertise." But not a lot of brands do that, and it's actually European brands. But no matter what, for every sunscreen, it's still recommended to reapply every two hours if you're under prolonged exposure. Just because, I'm oily, I have oily skin.

Dani Janae:

Me too.

Ramón Pagán:

Your oils break down the sunscreen film that has to form. Or sometimes people just touch their face, people rub their face just through wear and tear. I blow my nose a lot. People wipe their mouths a lot, wipe their foreheads a lot. That friction's going to rub off or compromise their protection. And so, just through that, that's why it's recommended every two hours no matter what the formula is. But yeah, if you want a more heavy duty sunscreen, look for sweat and water resistant.

My favorite, if you're in the US, if you want a heavy duty sunscreen that doesn't feel nasty, Banana Boat has, it's called their Light As Air. Banana Boat? Yeah, Banana Boat Light As Air. They have a face formula. I will say the face one is going to be the lightest weight one. They have a regular one too, that everyone says is good, but I've only used the face one and it really is light as air.

And then another option I'd recommend, Black Girl Sunscreen, they have a Make It Matte one. The only thing with that one is it's dimethicone and some people don't like that texture. If they want, and the thing is, a lot of brands have duped that formula, technically Supergoop did the formula first, but Trader Joe's has basically the same exact formula for $8.

Dani Janae:

Oh, okay. Good to know.

Ramón Pagán:

Yeah. It feels like silicone on the face, but it's lightweight. It's water, it's wet resistant.

Dani Janae:

Okay. Cool.

Well, that's all the questions that I have for you. Thank you so much for doing this.

Ramón Pagán:

Okay. Of course, thank you for reaching out. Again, thank you so much for being patient. If any other questions pop up or that person emails you back, let me know. I'm happy to answer whatever.

It’s been a while. I haven’t posted in the new year yet and possibly will not do a post for January, but my February interview is a highly anticipated one for me! As well as March! I can’t keep secrets so I’ll just tell you. For February, I’ll be talking to a cosmetic chemist.

If you know me, you know makeup is my jam. But there’s a lot of misinformation about which ingredients are safe for use and which have some sketchy history. I follow a few cosmetic chemists so I was excited when one said yes to an interview!

In March, I’ll be talking to a doctor that speciliazes in treating and talking about fat bodies. I think my last post here was expressing frustration around the way doctors treat fat patients, so this interview is gonna be healing for me.

If you have any questions you’d like to ask either of my guests, the comments are open!

I’m fat. I have been for most of my life. For a few years, as a kid, I was fat even though I ate a regular amount, exercised by biking, playing tag with my brothers, and other kid activities. Despite my active lifestyle, I was still putting on weight. I remember the day I reached 150 lbs as a kid. My doctor hung her head and said something had to change. I vowed to not gain another pound, and for years, I didn’t.

I started slow. 100 crunches a day. Then I started restricting my eating until I was down to 300 calories a day. This sharp trend down had consequences. I stopped having a period, I grew irritable and restless. My bones hurt. When I was 10, I was diagnosed with Marfan syndrome, a connective tissue disorder that caused my joints to dislocate. I was kept from exercise for months. I sat out with a doctors note during gym class. I stopped playing because of the fear of pain.

When I developed an eating disorder, this all went out the window. I exercised obsessively, despite the pain and my joints going haywire. Doctors were thrilled. I was no longer fat. They didn’t care that I had lost 60 lbs in a matter of months. All they cared about was not looking at a fat body anymore. When I reached college, I was right around 100 lbs.

When I look back on pictures of that time, I have to laugh at how I looked. My huge head and frail body made me look like a bobblehead. I looked gangly and uneasy, but I felt strong. Sophomore year I started to gain weight back until I was creeping up on 200 lbs as a 25 year old. Then I passed 200 lbs. I was mortified, I thought I was going to die from humiliation. But I didn’t. I’m alive and healthy. But let doctors tell it, I’m far from that.

I recently met with my PCP where, after gaining four pounds over 6 months, she brought up Ozempic. My hemoglobin A1C was a little high, but “not enough to be concerned” to use her words. Still, the specter of weight loss drugs had been brought up with another doctor, one who I had grown to like. Her small talk and cheery disposition made me let my guard down. I trusted her. Now, I felt the walls going back up.

My doctor wasn’t just bringing up any old weight loss drugs, she brought up the trendy one, the one accompanied by images of svelte celebrities with invisible waist lines and gaunt faces. My blood pressure was good, my cholesterol trending down, even my hemoglobin A1C was going down. By all standards, I’m a healthy woman. But weight trumps all.

Even doctors that tell you the BMI is trash still hold you to that standard. At 5’5” and over 200 lbs I’m morbidly obese by BMI guidelines. But the BMI doesn’t factor in my history with food, exercise, or genetic factors. It’s true I live a pretty sedentary life as I write and edit for a living, but I eat well. I’ve been vegan for the past 12 years. My diet consists of plant based proteins and veggies.

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Somehow, when you’re fat, none of this matters. You have to be less. You have to be smaller. You have to conform.

One of the things my doctor said that stuck out to me was that “if there were more things wrong with you, I’d recommend a weight loss drug,” but she still went on to recommend it. In the absence of real numbers that would show I was unhealthy, only left with the number on the scale, I was being treated like my body was a problem.

There are many lists now that show size inclusive and friendly doctors in your state. My state only has about two and they are both men. I like having an all woman healthcare team, but I often feel bad about the way I’m treated. When my period was gone for almost a year, I was told to lose weight and see if it would come back. So I did lose weight, and it didn’t come back.

I’m afraid to bring up my knee pain, because I’ll most likely hear weight loss will solve that too, despite the fact that my knees were their worst when I was a size 0.

All doctors have biases. It just so happens that you can hide your anti-fat bias under the umbrella of being “considered for your patient’s health.” But healthy isn’t the same for everyone. A number of factors, including genetics, region you live in, and financial status can determine whether a person is getting enough exercise or eating a balanced diet.

I don’t know why I’m writing this. I guess I’m just sad. I guess I’m just defeated. I’m tired of hearing that losing weight will solve my every problem. Tired of being treated like I am a problem. To be fat is just another way of being. You can’t judge someone’s overall health based on their weight. We know this now, but still, this notion prevails.

I just want to be free and happy. I don’t want to be tethered to a scale, not again.

If you know of a fat queer doctor I can chat with for this month’s episode, please get in touch with me on here or via Instagram!

This interview is with Yesenia Garcia Sifuentes.

Yesenia Garcia-Sifuentes (he/they) describes himself as a “first-generation Mexican non-binary scientist.” He studies and does his research at Emory University in Atlanta, Georgia. I don’t want to spoil too much in the header but his research is super interesting and cool.

We talk, of course, about the brain, animal vs. human trials, and forging a path in science for people that look like you. I hope you enjoy this interview!

Dani Janae:

Okay, cool. Yeah. Okay, so let's see. Okay, next question. Was the love for the sciences cultivated in you as a child, or was that something that you found later on?

Yesenia Garcia:

I would say I have always been very interested in biology in general, but I don't think it was very much cultivated in me by my educators, or by anyone else. I think it was just my own passion for loving animals and wanting to understand how people and life comes to be at a molecular level, which always made me very interested in my biology classes. I remember doing dissections in class and I thought that was the coolest thing ever, and I wanted to do every part, because I wanted to understand how everything was connected, and how it came to form a function. And so, I think just having regular class experiences is what made me seek out more of those experiences, but I never really had someone that told me that, "Oh, you should be a scientist. You're pretty good at this." I've never really had that in my life as a role model early on.

Dani Janae:

Okay, cool. Do you remember, were you involved in anything outside of class that was science geared? So like extracurricular activities, or afterschool stuff?

Yesenia Garcia:

Nope. I didn't do much of that. I remember having to come home and do a lot of babysitting, and taking care of family members, so I didn't really do a lot of extracurriculars growing up.

Dani Janae:

Okay. So you said you're studying right now for your PhD in Neuroscience. Was that your first choice or was it a journey to get there?

Yesenia Garcia:

Yeah, I think growing up, my parents always wanted me to be a doctor, because they are immigrants and so they were like, "The American dream is for you to be a doctor, have a very successful profession." And so I went through high school thinking that that was going to be the plan for me. But when I got to college, I then started doing pre-med courses and then getting more clinical experience, and I started getting trained as an emergency medical responder. And then I realized that I actually don't like interacting with humans on a clinical level.

And so I was like, well, I don't want to be unhappy for the rest of my life. So I had to have a conversation with my parents like, "I'm sorry to disappoint you, but I'm not going to be a medical doctor." So I just had to figure out what it was that I liked. And so, I really enjoyed the psychology and biology classes I was taking in college, and so I just kept going down that route. So I majored in neuroscience and my junior year of undergrad, I started doing research in a neuroscience lab and I really liked it, so I sought out more experiences, and now I'm here.

Dani Janae:

Okay, cool. So you said you just got back from lab, so what does an average day look like for you?

Yesenia Garcia:

Yeah, so my lab studies rodent behavior, and so every day I get to work with mice, which I really love doing, because I love working with animals. I'm really interested in studying social decision-making behaviors. So we basically have a lot of different behavioral experiments that we put mice through, to understand how they're using their brain and what strategies they're using to do these different tasks. So yeah, a lot of my day's putting mice into different boxes. Eventually we sacrifice the animal and then my job is to look at the brain and the tissue to try to understand which neural circuits are used in different behaviors, and what are the changes that are happening at a molecular level. I'm really interested in adolescent isolation. All the animals I work with have been isolated and grown up that way, but then reintegrated into social groups, and then I'm really curious into how that affects long-term social decision making.

So I want to see what the impact of this early life adversity is on their brains. Today I just got back, well, I got back last night from a conference, so I went to work late, but essentially one of my lab jobs is to make this chemical called paraformaldehyde, which is what we use to preserve the mice brains. And so, we all use that chemical, so it's up to me to make a big batch of it. So that's what I was doing just now, putting it into lots of test tubes for future use.

Dani Janae:

Cool. Okay. I have a question about that. So you said you sacrifice the animal and then you look at the brain to study what decision making pathways are involved in the decisions that they make. How can you tell looking at the brain after it's been sacrificed, what those pathways are and what do they look like once they are no longer alive?

Yesenia Garcia:

Yeah. So for example, the current experiment that I'm working on with a student is basically, when the mice are alive, we take them through a behavior task and get them to do the social interaction for an hour, and then immediately after that, the mice are then sacrificed, and then we’ll take their brains. And we are looking at this specific protein called CFOS. And so, CFOS is an immediate early gene, and what that means is that it's active after a particular activity, so we can time our experiments. So if we sacrifice them, we know that this protein is going to be active just before it was sacrificed.

So using tools like this, we can basically see which regions of the brain were active just before the mouse was alive. And so, yeah, after we take the brain, what we do is we preserve it and then slice it up into a little slices, and then mount them on slides so we can image them with a microscope. And then we can orient ourselves to which region we're interested in, and then we can go ahead and count the cells that are within each region that let us know the activity that was going on in those regions.

Dani Janae:

Okay. Got it. When you said the protein's name is CFOS is that C-F-A-S?

Yesenia Garcia:

C-F-O-S.

Dani Janae:

Okay. Got it. Thank you.

Yesenia Garcia:

Of course.

Dani Janae:

Okay, so next question, what is... Oh, sorry, I've worded this question really weird. What is a misconception about the brain that you would like to dispel?

Yesenia Garcia:

Yeah. Some of my earlier work when I started grad school was about sex differences, which are really interesting to me as a trans person. So essentially there's a lot of, I guess in science and in the world in general, these false dichotomies between male and females. And that translates a lot to the neuroscience research, where people believe that there are male brains and female brains, which is a very simplistic and incorrect way of looking at things, because basically all humans have, we all have the same hormones, and the chromosomes, and things, and not everyone aligns with the sex they were assigned to at birth.

And so, I think one myth that I think scientists and people in general believe is that sex is just one thing, but in reality, it's actually a collection of multiple traits that are related. So for example, people think if you're a male, you have XY chromosomes, and you have high levels of testosterone, and everything will follow in line. But biology and the world gives us a broader understanding of that. There's a lot of nuances essentially, that someone with XY chromosomes may not have the higher levels of testosterone that people associate them with, or things like that. So yeah, I think that is something I'd like to dispel, yeah.

Dani Janae:

Cool, thank you. Okay. What do people assume about you when they hear what you do?

Yesenia Garcia:

Yeah, people assume that I am a brain surgeon who works on people, and they also think that I am a therapist, and then they tell me all about their psychiatric problems. Every time I'm in an Uber and they ask me what I do, and I tell them, they start telling me about their grandparent who has Alzheimer's or Parkinson's. I always find that funny, because the work I do feel so unrelated to that, even though yes, I am a neuroscientist and I know a lot about the brain, but all of these different conditions are so specialized, and I have no idea about how I'm going to fix Alzheimer's, and so...

Dani Janae:

Yeah, totally. So right now you work with mice. Are there any other animals that you work with?

Yesenia Garcia:

Yeah, when I was an undergrad, I worked with birds. I worked with a species of birds called zebra finches, and I really enjoyed my research. We studied traumatic brain injury, and so we basically had to give these birds concussions. And the question we were studying was how do sex hormones influence the repair and regeneration of the brain after a traumatic brain injury? Because something that I find really cool is that the estrogen, the typically female sex hormone, is actually really helpful and beneficial in increasing healing in the brain after a traumatic brain injury. And so, we were interested in looking at different hormone levels and how that influences brain healing.

Dani Janae:

Yeah, that's really cool.

Yesenia Garcia:

And so in that lab, I studied estrogen and also testosterone, and I always like to joke that it's because of that research experience that I became trans, because I had to read about so much testosterone and estrogen, and I was like, "Wow, this is really cool."

Dani Janae:

Yeah. I am kind of just unfamiliar with the world of scientific research. So is there a goal to get to looking at human brains, or are you just going to stick with animals for now?

Yesenia Garcia:

Yeah, so there's a whole bunch of research. And so, my type of research was a basic science research right now, which is, basically I'm just really interested in understanding what the biology is of something. And so, biology between mice and humans is actually pretty similar in that cells work the way that they work across many different species. And so, there's other types of scientists who are more translational. So they are kind of like the bridge between animal research and human research, and they're really interested in making those, translating that research experience. And then the more clinical research scientists are people who work with just humans. And so, for me, I am really just interested in the basic biology and understanding how these cells work. So that's going to be my focus going forward, yeah.

Dani Janae:

Okay. Thank you. okay. So this, it's a question that I'd like to ask, but it seems like you're going to have a good answer for it based on the other answers that you've given. But does your queerness ever become relevant or intersect with what you do on a daily basis?

Yesenia Garcia:

Yeah, I think it does play a very large role in what I do, and it's also the motivation for what I do. I remember when I first got into graduate school, I was very scared of being in academia, and as a first generation Mexican non-binary scientist, I just was very apprehensive about what my experience would be, and feeling isolated in grad school, and not having social support. So I decided then that I would make it my mission to be as queer and non-binary as possible, and just to build a community around that, so other people like me could see themselves in STEM. I created a blog my first year called nonbinaryneuro.com, where I just started... It was basically an online diary where I just talked about who I am, what I was going through, applying to grad school, all these different things that I never had much exposure to.

And so, I started just tweeting a lot and also posting on my blog a lot, and I began to gain a big following because of that, which translated to me getting speaking opportunities. So I got invited to speak at a lot of different conferences and schools, and I was being paid to give all these talks to students. And yeah, my overall message was, my aim was to foster belonging in these communities and in these spaces where people who look like me don't typically succeed in. So that's the reason. At the end of the day when I'm really tired and I'm like, "Why am I in grad school getting paid pennies?" I'm like, "Oh, yeah, it's because I want to be a role model and to be the role model I didn't have growing up, and I just want to be an example of what it means to be successful in that field."

Dani Janae:

Yeah, totally. Okay. So I have one more question, and then I have a reader submitted question that I forgot to send to you, but sorry about that, but I don't want to surprise you, but there's another question after that. But my other question is, are there other queer scientists in your field that you get to interact with?

Yesenia Garcia:

Yes, definitely. My lab is very gay.

Dani Janae:

Oh, cool.

Yesenia Garcia:

It's the reason why I joined my lab, is because my advisor did a very good job of fostering a diverse and inclusive community. And so, most people in my lab are queer and/or trans, which is great. But then, since I was so active on Twitter when I first joined grad school, I now am connected to lots of queer scientists in our field, which has been very cool, because I get to see them at conferences and in real life, not just online. So yeah, I've definitely done a good job of building and creating this community of queer neuroscientists.

Dani Janae:

Totally.

Yesenia Garcia:

And it's been really awesome to help each other get different opportunities. I got to invite one of my friends who is a really incredible researcher to give a talk at Emory. And so, yeah, it's been great to foster these connections that help me emotionally, but also we're helping each other professionally succeed. So yeah.

Dani Janae:

Yeah, that's awesome. Okay, so last question, reader-submitted question. This is from reader Stef. They want to know about our brain's role in processing and understanding physical pain.

Yesenia Garcia:

Let's see. Is it okay if I don't answer that question?

Dani Janae:

Yeah, that's totally fine.

Yesenia Garcia:

Yeah, I just don't have a good answer for it right now. Yeah. I don’t want to give misinformation.

Next month’s AAQD will hopefully be solidified this week, so when it is I will let you all know as soon as possible. In the meantime, listen to Dr. Kim Garrett’s episode! It’s a good one.

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She also attended Pitt for her Ph.D. in Environmental and Occupational Health, studying poisons that are similar to cyanide (Kim tells me these are poisons called azide and phosphine) and finding antidotes for them. Now, Dr. Garrett is in Boston, MA at Northeastern University in their Social Science Environmental Health Research Institute where she studies PFAS chemicals, which you may have seen in the news are called forever chemicals, and are a “really big environmental problem right now.”

This conversation was a delight. We talk about being a detective of sorts, modern snake oil salesmen, the train derailment in East Palestine, OH, and even get into snake venom. I hope you enjoy this one as much as I did. 

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Dani Janae:

Our first question is just a general one: throughout your school and throughout your professional background, what exactly stood out to you about toxicology? Why did you zero in on that field?

Dr. Kimberly Garrett:

I think it was that I've always had this understanding of how the environment impacts our health. Growing up in western Pennsylvania, I had asthma. I still have asthma and a lot of environmental allergies and so I could see that if I changed certain things about my environment, I would feel better. And so I think I had that baseline understanding, but I was also very into detective shows and wanting to be a detective when I was a kid. I always played detective. And I feel like toxicology is getting to do that at the scale of environmental pollutions and combining those two interests together. I was really interested in the fact that I know all of these principles from chemistry class, but they really inform the way that we interact with our environments and the ways that the environments impact our bodies.

Dani Janae:

Totally. Sorry. My phone needs to charge.

Dr. Kimberly Garrett:

That's okay.

Dani Janae:

For those that may not know, can you provide a quick summation, definition of what toxicology is?

Dr. Kimberly Garrett:

Sure. I should preface this by saying I'm an environmental toxicologist, which is different from a medical toxicologist. Medical toxicologists, we think of people working in hospitals and on the pharmacology side along with doing things like drug tests. I do what is called environmental science or environmental toxicology, which looks at the ways that different chemicals interact with our bodies. But generally, toxicology is the study of doses and outcomes of certain chemicals. So the first tenet of toxicology is that the dose makes the poison. And there are some exceptions that we're learning about where there are essential levels of certain vitamins and things like that, but for the most part, there is a lethal dose of every chemical agent and even some non-chemical agents like sunlight or heat and noise. Those can all be harmful to our health. And so what toxicologists do is they look using different models to see what leads to those adverse outcomes associated with those individual exposures. And we can think of that on, I guess the inverse, the positive side where pharmacologists and drug developers use that to the advantage to see what's the dose that brings about a particular outcome that we want to see. Whereas in environmental toxicology, I tend to err on the negative side of saying how much hurts.

Dani Janae:

Yeah. Totally. Awesome. I have a little bit more questions about stuff that we have talked about privately or things that I'm just curious about. But the first one is that we have discussed this new age-y, nebulous threat of people who are ... They're not health professionals, they're just basically wellness influencers that have this thing about “there's toxins in everything that you eat, everything's a carcinogen, here's how to detox your body of the toxins that are in there” and all that sort of stuff. So I want to talk a little bit about that and your thoughts on that and how people can ... Well, I'll get to that later, but just wanted to get your general thoughts on those discussions online and in print.

Dr. Kimberly Garrett:

Yeah. Absolutely. I have a lot of thoughts about the detox tea or all kinds of pseudoscience that you see floating around. And first I want to recognize that I understand why people will buy into these. Our medical system is not accessible. Especially as a queer person, and I know for your audience as well, not necessarily being welcomed to learn all about your body and things that can be different from what's expected. And so it can be really hard to access evidence-based medical care. And so I want to recognize that as an issue. And so I don't often blame individuals for buying into these pseudo-scientific cures when our system is set up so they're the most accessible option.

Dani Janae:

Yeah. Totally.

Dr. Kimberly Garrett:

Or they come in and say, "Well, the medicine you're going to have to buy is $300, but have you considered this detox tea which you can buy a subscription to," or things like that. But that's not how that works. Basically, my main response when someone asks, "Oh, well, have you seen these foot patches that take all of the heavy metals out of your body?" I say, that's not how that works. Part of what we learned in toxicology and what I wish was taught in general science curriculum are the ways in which our body systems work and our body systems work to keep us safe. And if one of those body systems are not working, you'll know. I see one a lot where they say, “oh, it boosts your liver function.” If your liver is not working, you'll know. You'll turn yellow. Jaundice.

And just all of these quack medicines, pseudoscience "medicines" are based in a rich history of grifting and I really love to learn about all of the historic grifters. There was a man who convinced people to get goat testicles attached to their bodies for virility and things like that. That was in the heyday of patent medicines. There are all kinds of old time-y medicines that you can go and see. I actually have a bottle from one of them that is called Hazeltine & Co Piso's Cure. Which I found at an antique store and washed it out. But it says for consumption. And it was a blend of cannabis, alcohol, opium. And those levels varied. They didn't have to say how much of each thing was in it. And it was sold during the time, late 1800s. I guess mid to late 1800s, early 1900s when consumption, which we now know as tuberculosis, was rampant and so people were desperate to find these easy fixes or these quick cures. And so, predatory salesman just came in and took advantage of that. Snake oil is usually what we call that, but it's still alive and well today. And I don't think our medical system is doing that any favors by continuing to be exclusive.

The fact that we have to have health insurance ... I'm a big universal healthcare proponent because that is a great public health intervention. I think that our current system allows these things to happen and I think it's really dangerous. So some of the issues around dietary supplements, detox teas, things like that, they're not regulated by the FDA. If you get a prescription for a medicine, you can be assured that it has been vetted by the FDA in the United States, and you can find a batch number. If you think something is wrong with your medicine there are lots of numbers that you can call. You can call poison control. There are avenues to find out what is wrong. And there are years and years of studies that are done to see what the side effects are and to make sure that the medicine actually works. And ideally, there are really high burdens of proof and standards of proof placed on pharmaceutical manufacturers to make sure that their products are consistent, they balance risk versus reward, and they contain what they say they contain. And that is also the case for most over-the-counter medicines like Advil. Things that we say are OTC or over the counter. However, dietary supplements which are allowed to be sold in the same area as OTC products are not regulated by any of those same governing bodies or even standards setting organizations.

I heard a lot about standards setting organizations recently with the submarine implosion or the submersible implosion where the entrepreneur in pursuit of innovation said, "No, we don't need these standardizing bodies to tell us what is and what isn't safe." Well, dietary supplement manufacturers take the same action, if not intentionally. So dietary supplements are not regulated as pharmaceuticals in the United States, and they are only regulated by the Federal Trade Commission, which you may recognize as advertisements. So the Federal Trade Commission, their only real oversight  is reactionary in that dietary supplement manufacturers, they can't claim that their product will cure a disease. They can suggest that it will help with symptoms and they basically figured out how to get the rhetoric directly around that limitation. But the only substantial action that the FTC can take is after evidence of harm has been brought to them.

So in order for the FTC to act, someone has to get hurt. And that in and of itself is unethical to me and I don't think that dietary supplements should be seen as neutral because of that. And also because they have no regulations, they can contain literally whatever because no one's going to check up on them. There are lots of cases of people getting heavy metal poisonings because arsenic can get pulled up into plants, and these are seen as herbals and they get up into plants, and then the manufacturers don't have any standards, so they just put however much of the plant in there, and then people get heavy metal poisoning, arsenic poisoning, lead poisoning. And that in and of itself is really toxic. And a lot of these things are branded on being so clean and safe. Well, we don't know, and there are absolutely no standards. So that's part of my little rant, but I could go on more about those. But I have trouble because I understand why people get into these ideas, but that's really not how the body works. And I'd be happy to talk about some of those systems that help to keep us safe. Our lungs are really incredible, for example. They have all different kinds of security systems that keep toxins and particulates out and keep the good air that we need in.

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Dani Janae:

Totally. Yeah. I would love to hear a little bit more about those other systems in the body that are in place for that measure.

Dr. Kimberly Garrett:

Sure. Yeah. So I guess this gets into the second tenant of toxicology, which is exposure route really, really matters. And an example that I like to give to get people into toxicology in social settings and at parties is that there are memes that go around that basically say if you smoke marijuana, you get high faster, but if you eat an edible, it takes forever to make you feel that high. And that's because of exposure route. So exposure route has to do with how fast and how easy something can get from outside in the environment into your bloodstream and to its target organ. And the bloodstream is really the highway that moves anything all around your body. And if it can get past the liver, if it can go through your bloodstream before getting to your liver and kidneys, then it can be way more potent. So this has to do with the ways in which your blood flows around your body, the directions and things like that.

But long story short, your skin is a really strong barrier against your bloodstream for certain molecules. Certain molecules have to have a certain polarity, different solubility in order to get through your skin barrier. But then once it's in there, there are different solubilities and so it can be really hard to absorb certain chemicals through your skin. Your lungs are a really close connection to the bloodstream, which is why we can breathe. So you inhale air and it goes down through your lung structure, which has an increasingly narrowing ... It narrows its diameter as you get lower in the lungs, so it keeps things like dust particles out. It unfortunately doesn't keep things like asbestos particles out, but that's why you cough and you sneeze because you have something called the mucociliary escalator which traps those particulates in mucus and escorts them up and out.

And so only certain things can get down into the sensitive area of your lungs, which has a direct connection to your bloodstream. And so if you smoke something that has a psychoactive effect, you're getting it to your bloodstream really fast. And so that's the case with smoking marijuana. The GI system or ingestion or eating goes through a kind of arduous process of digestion where you swallow and then it hangs out in your stomach for a little bit, and while it's in there, it's subjected to really acidic conditions, so some parts don't survive. And then other particles and other materials can survive the stomach and make their way into your GI tract. After going through the liver and kidneys, they get down into the intestines, and that's where a lot of the nutrient absorption happens. And so you have to wait awhile for the thing you ingested to get all the way down to where it can finally start to get close to the bloodstream. And because it goes through the liver and kidneys, it has a little bit of a molecular change. And so the molecule itself is a lot different than the one that you inhale. And so that's one of the reasons why. You know those memes that say, oh, this edible isn't hitting, or whatever?

Dani Janae:

Yeah. Exactly.

Dr. Kimberly Garrett:

And then of course we have intravenous administration, which can be either the most efficient for something like a medicine or the most dangerous for something like an illicit drug or some kind of old-timey poison.

Dani Janae:

Totally. Thank you for diving into that.

Dr. Kimberly Garrett:

Yeah. Thank you for letting me talk about that because I love the talk about the mucociliary escalator.

Dani Janae:

That's a cool name. Yeah. Okay. You answered that question. Okay. I believe it was Norfolk Southern. Is that the name?

Dr. Kimberly Garrett:

Yes. The train derailment.

Dani Janae:

Yeah. When that happened in Ohio, you were one of the environmental toxicologists that was interviewed by a few outlets. So I was wondering, do you know anything about where the town stands today or can you share a bit about the experience of being interviewed by these outlets and things like that and what you shared?

Dr. Kimberly Garrett:

Yeah. Absolutely. It has been a really interesting and a really impactful time for me in my professional development. I hadn't been encouraged to do any science communication while I was in grad school, but as soon as I saw that this happened ... And it happened about 30 minutes away from where my parents live, so it's about halfway between where they live in Pittsburgh, and I was familiar with the area, and I saw this happen and I said, “oh, wait, I have expertise here.” And I talked to my parents on the phone and they had some questions. And so I was talking to them, and then as supportive parents do, they said, "Oh, this is really wonderful. I wish other people knew about this." So I said, "Well, I'll get on Twitter." So I got on Twitter. The artist formerly known as Twitter, I guess. And I just made a series of tweets about what was going on, at least from my limited perspective not being involved in the surrounding area directly or any of the decision makers.

The thing that caught my eye was that they were going to do a controlled burn of all of the chemicals. And I looked at a list of the chemicals that were on board, and I thought about it, and then I said, "This is going to look really scary, and I would like to at least let people know what's going on from my perspective." And so I made a Twitter thread about what the main concerns are, why someone might decide to do this kind of controlled burn and it really took off. It was my first viral tweet. And I was happy to answer questions. I had folks from the community reach out to me, and I've been able to establish ... with residents directly, but I also saw a lot of misinformation. And misinformation is really my pet peeve. And so whenever I see it and I have the ability to counteract it, I like to do so.

And so I saw some figures that said that the entire Ohio River watershed was going to be exposed, and they showed areas that were clearly upstream from this area, and that's not how pollution works. And so responding to things like that. Then some news outlets reached out to me, and at first I said, "I'm not on the ground. I'm not in that community directly, so please if you can talk to someone who's closer to it." But then more folks started reaching out to me saying, "No, we want to speak to you specifically." And I was very flattered. So I got to share more about what was going on. And it's really been an exercise in, I guess, reflexivity as well, because with any unfolding disaster, things always change. We make decisions based on the information that we have available to us. And so while my understanding of the controlled burn was from my outside perspective, it's not the same as the lived perspective of people on the ground. Their houses still smell of different post burn contaminants and people don't feel safe going back to their homes.

Then there was some discussion about EPA standards. Whether or not the machinery they were using was sensitive enough to pick up on certain chemicals. And then there's also the complication of chemical mixtures. So we can say, we know that this much impacts this organ in this amount, and so if we do that in a lab, we can get a number. But that's not necessarily exactly what happens out in an atmosphere in which so much is going on. We don't know what that chemical does in combination with another. So what I've been encouraged to see was a lot of researchers coming in from different academic institutions to as soon as possible start interviewing people, ask about their symptoms and doing independent testing and so that's been really neat to see in partnership. Or I guess the data that I would see would be the independent researchers and you're able to compare that to what the EPA contractors and the Norfolk Southern contractors were putting out.

Dani Janae:

Yeah. Totally.

Dr. Kimberly Garrett:

Yeah. But for now, it seems to still be a politically divisive issue in the area. Norfolk Southern has come in and sponsored baseball teams and done a lot of PR activity to try to say, "Hey look, we're still a good neighbor." When they contaminated this community. And they have paid for some of the cleanup, but the transparency hasn't been as great as we would hope. And so there's an issue in the town now where some folks are like, "Oh, Norfolk Southern did sponsor these things. That's enough for me. I'm satisfied." But then there are other people who are still saying, "I'm not comfortable coming back to my house." So that's an interesting intersection of the chemical world and the social science and public world.

Dani Janae:

Definitely. Thank you for sharing that. So this is a recent addition, but you said we could talk about snakes, so I wanted to talk a little bit about snakes and venom and stuff.

Dr. Kimberly Garrett:

Yeah. Absolutely. So you had posted an Instagram story about a man who was bitten by a snake. And I said, I don't know a lot about snakes, but I know some interesting facts about snakes and they’re poisonous, or they’re venomous, because it's a pedantic discussion about venomous versus poisonous. So you eat something that is poisonous, something that is venomous eats you.

So there are so many different kinds of snakes and snake bites are actually a huge public health issue, and we don't necessarily think about them as a huge public health issue in the United States, maybe more so in the southern United States. But in South America and Africa and more tropical areas of the world, snake bites are really dangerous and really common. It's where the most toxic snakes live. They have the most potent venom, and in a lot of these areas, it's where there's a lack of healthcare infrastructure to deliver antidotes.

I know that snake bites are a focus of a lot of international public health research, and there have been large strides to develop more accessible antidotes. Some that are maybe shelf stable so you don't have to have them refrigerated, and some that can just be carried by EMTs in an area if an area has EMTs. Or it can be stored at a community center or anywhere that people who are going to be out and likely to be exposed to snakes will be. Which as it turns out, you don't have to be out in the wilderness to be exposed to snakes in many areas. My partner's sister lives in Australia, and apparently they just show up in your house. So I don't want to frame this as a necessarily rural versus urban issue.

Dani Janae:

Yeah. Totally.

Dr. Kimberly Garrett:

Yeah. But snake bites are a huge environmental health problem but what is very interesting to me is how the venoms work. I used to be really afraid of snakes, and I made an active effort to say hello to snakes whenever I saw them, and now I'm not so scared of them. And I became more interested in learning about how their venoms work and how we can counteract them. So I took a trip to Florida two years ago and I got to see a diamondback rattlesnake, and that is the most venomous snake in North America. And I said hello to her. She was very beautiful. And if you don't pester them, they won't pester you. And so I kept my distance, said hello, and kept walking.

So snake venoms, for the most part, act as chemical mixtures. So I mentioned we can know about how one chemical interacts with your body, but snakes are levels above that. They have different proteins and different compounds in their venom that launch a complex attack through your bloodstream. And I really think of snake venoms as kind of a bull in a China shop where once that gets in, the compounds go in all different directions. Some make it so ... They're anticoagulants so your blood doesn't clot, and so your blood thins out, and if you sustain a different cut, then you might bleed out from there. And others attack different functions of your cells. And so they do this all at the same time, and they're really complex. And so you can imagine that developing an antidote to counteract that is very difficult. And the way that we do that is an example of the dose making the poison. So in order to develop an antidote to such a complex toxin, we often harvest antibodies and other defensive molecules from something that has been exposed to poison.

You can't do that in a person because people have relatively small body volumes, blood volumes. And any useful dose or any dose that would yield a useful amount of antidote would be very harmful to the person. And so we take big animals and we give them a little bit of venom and it's not enough to hurt them, and they generate the defense systems that we can then use. And we use horses. Horses have a lot of blood, and they can sustain a little bit of snake venom. I guess horses can have a little bit of snake venom as a treat. And so then we harvest the immune and defensive molecules from horses, and then we store them to give to people so that those defenses can be available for injection into people so they don't have to make their own over a long period of time.

Dani Janae:

Wow. I didn't know that.

Dr. Kimberly Garrett:

Yeah. It's interesting. And I wonder as we move away from using animals for our consumption and things like that, if there're going to be more lab-grown versions or if there's a way to do that. I don't want horses to get hurt, but it's really a risk-benefit relationship right now because we also don't want people to get hurt. That's always on the mind of ... At least my mind, and other toxicologists that I know, how do we limit our use of animal testing and animal products, even though they still remain really necessary for protecting human health?

Dani Janae:

Totally. Yeah. Okay. Awesome. So I'm going to skip down to the Instagram questions right now and then close with my last question. Just because I think it'd be a good last question. Someone from Instagram wants to know anything about aspartame. How much diet coke do you have to drink to be harmful?

Dr. Kimberly Garrett:

I'm so glad someone asked this. So this gets into how we classify carcinogens. And so I'm going to be honest, I haven't really read into this. I have known that aspartame has been considered ... They've been considering designating it as some kind of carcinogen class for a long time, but I do not know the specific study that they used for this decision but I can tell you about how they classify carcinogens and it has to do with rhetoric and logic. So while it is easy to show if something is a carcinogen... I say easy lightly. Some of the most potent carcinogens that we know of, tobacco smoking, sunshine, those have very clear exposure to tumor development relationships. And there's been a lot of research into elucidating those pathways and the mechanisms both in order to understand how that happens and understand how to treat it. And so that is what is the highest level of carcinogen. You can say this is a carcinogen. We have seen it happen. If you get a little lower on the scale, you have things that under certain conditions lead to that relationship, at least that we've observed.

And so those are possible human carcinogens. No. I'm sorry. Those are likely human carcinogens, which we can't say we have the strength of evidence between exposure and the outcome like we do for cigarette smoke, UV radiation, or asbestos. But be careful. It's likely and under certain conditions. Maybe there are certain risk factors like a susceptibility gene or something like that. Down the scale from that is potential or possible human carcinogens, which is where all of the other chemicals are, except for a few. If you don't have the research to say this is a carcinogen, it's really difficult to prove that something is not a carcinogen is basically the argument here. So in the absence of evidence to the contrary, everything is presumed a possible human carcinogen because we don't know every single outcome that you could have. If we all moved to Mars and then got exposed to a chemical up there, maybe something in the environment leads to that being a carcinogen. We don't know every single exposure pathway.

And so it's a real challenge just getting over that rhetoric and that logic. And on the lower level, there are certain chemicals that have been assessed and are low likelihood to be human carcinogens and so those are seen as unlikely human carcinogens or not likely to be carcinogens. And so there are very few chemicals there, just again, because we don't know every exposure route, we don't know every individual susceptibility. And so when someone says this causes cancer, I want to know are we talking about possible human carcinogen, likely human carcinogen or a known human carcinogen? Because the number of known human carcinogens is really low compared to the number of chemicals that we use, which shows obviously we need more research and more information to see what is safe and what isn't. But a lot of science communication in the media doesn't take such a nuanced stance. And cancer is terrible and very scary, and I don't blame anyone for being scared by headlines that say something is called a likely human carcinogen. Aspartame is one such chemical in which it is not in the known human carcinogen category, but it has been brought into presumed and or possible and likely. And so that's where the discussion has come out around there.

It's also an individual risk decision. If something being a likely or a possible human carcinogen is really unsettling to you and you don't want to take that risk, by all means, change consumption habits and things like that. But I am not incredibly alarmed. I think there are lots of other things that we're exposed to every day that warrant more alarm than aspartame.

Dani Janae:

Awesome. Thank you.

Dr. Kimberly Garrett:

That's just my opinion. Yeah.

Dani Janae:

Yeah. Okay. So the second question is how common is serotonin syndrome? Is it deadly? So many people on SSRIs?

Dr. Kimberly Garrett:

I actually don't know too much about that. That would be a good question for a medical toxicologist. I do know that it is described as a crash in serotonin after exposure to something that changes your body's serotonin levels. Basically, your body has gotten a little lazy in its ability to produce serotonin or it's gotten used to a higher level. I'm on an SSRI, and I know that if I don't take it every day, my brain starts to have side effects that I don't like. And so I think that's because it's had that particular neural pathway operating in a specific way for so long that as soon as that goes away, it doesn't know what to do. Oh, no. I need a brain zap. I mostly know about that from personal experience, but I know that there are certain things that folks who are on SSRIs should avoid. Any recreational drug that's going to change your body's interaction with serotonin should really be avoided. I think it's MDMA that can impact your serotonin in a way that can be very risky. And I think LSD but I should look that up before saying that more explicitly, but that's just what I've heard. Yeah. So I unfortunately don't have a big answer for that question.

Dani Janae:

That's fine. Thanks for giving what you did.

Dr. Kimberly Garrett:

Yeah.

Dani Janae:

Okay. So my last question is how can everyday people spot misinformation more clearly when they encounter it online or in conversation?

Dr. Kimberly Garrett:

My biggest piece of advice is to watch out for absolute certainty. Any scientist worth their salt understands that science is an ever-changing area of knowledge where our intention is to be as accurate as possible under the conditions that we have. And so like I mentioned with the carcinogens, there is a large burden of evidence that allows something to be called a known human carcinogen. And so I can say asbestos is a carcinogen because there is a lot of evidence to back that up. A lot of peer-reviewed rigorous evidence. And I can't say that for something like aspartame. The information's just not there yet. So as scientists and as science communicators, it's our ethical responsibility to present information as accurately and with as much nuance as possible, which makes us end up sounding like big dorks.

And so I'm always hesitant of things that say they cure a disease and they don't give a lot of evidence for it. Or if someone is absolutely certain that some exposure causes some other kind of health outcome that may be contested or I guess something that can be used for political means. Speaking specifically about anti-vax sentiments. When I hear someone talking about anti-vax anything, I honestly pick my battles a lot of the time. But I would say it's not helping anyone to believe this. There is so much evidence, so much rigorous evidence that vaccines are helpful to the population. Their risks are very, very low. And I would also question their reasoning behind things like autism or other disabilities. Is your child getting the mumps a better trade-off for a child with a disability? Is a child with a disability worse than ... I don't know.

I think that it really stigmatizes disabled folks and neurodivergent folks to have this kind of conversation, and it really just hearkens back to eugenics. If they're saying, I don't want this because I don't want my kid to have a particular disability, but I'm fine with them getting the mumps and maybe dying, that's just absolutely bonkers to me, and I don't understand it, and it's really an ethical problem. So I get really frustrated when I am in conversations like that. Yeah. I like to sprinkle a little bit of medical ethics wherever I go, so you'll find eugenics all over the place. I hate that for us.

“Annoy an ER doctor in one tweet”

What proceeded was a few doctors describing things that their patients have done that have “annoyed” them. This varied from minor things like showing up at 3 AM to major things like demanding further testing.

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In no time, it went from doctors commiserating about their shared grievances to patients chiming in about being neglected by medical professionals.

The tweet was doomed from the start. The impetus of the tweet, that a patient can “annoy” you by simply asking for the best care, is one that many doctors share, and it’s a problem.

https://twitter.com/anonymousldb/status/1679593173675540490?s=51&t=kjdC3JWnluImhkpORAH_9w

When I was 19, I was home from college and doing one of my many Jillian Michaels ab workout videos to stay in shape. As I lay on the ground, doing cycling kicks to strengthen my core, I heard a pop and suddenly was doubled over in excruciating pain. I cried out and reached for my phone, and dialed 911. My mother heard me and asked what was going on. To make a long story short, I ended up at the ER driven there by a family friend to save on the bill I would eventually get.

At the ER, I, still doubled over and wincing, explained what had happened. I was immediately treated like a drug seeker instead of someone genuinely in pain. I was asked no less than four times if I was sure I wasn’t just pregnant. I explained that it wasn’t possible, and they of course forced me to do a test before administering pain medication.

When the test came back negative, they gave me morphine and did some imaging which revealed a small yet mighty hernia. I was sent home with some literature and told to be careful the next time I exercised. I had already had surgery for a hernia as a baby which I told them about, still, that history wasn’t enough for them to believe me when I said I was in pain.

When we see tweets or media of doctors talking about just how annoying their patients are, it strikes a chord, because many doctors have fallen victim to bias. Especially when dealing with Black, fat, queer, disabled, or houseless patients. Many doctors operate from a place of disbelief, and it’s your job as a patient to “prove” you really have a problem.

Doctors are annoyed when patients google things about their condition, annoyed when they self-diagnose, annoyed when they ask for MRIs, and annoyed when they ask for more pain meds. Not long ago, a group of labor and delivery nurses were fired because they posted to TikTok a video of them describing their patient “icks,” things that pregnant women did that got on their nerves.

What doctors fail to understand is that they may be annoyed for a split second to an hour, but their patients have likely been suffering for months and years. It should not be an inconvenience to do your job, serving the community you swore to serve.

Under that tweet I mentioned were doctors from all walks of life laughing at desperate patients. It’s one thing to talk about working in a high-stress situation. It’s an entirely different scenario when you make light of other people’s misfortune. These same doctors will scold a patient that has come in with an exacerbated problem that could have been resolved years ago, but that patient was either ignored or was too afraid to “annoy” a doctor.

When you have people going into debt for years for one doctor’s visit, one surgery, it’s downright egregious to see doctors post things like this online. If doctors want to work on the trust between themselves and their patients, they must deal with the unconscious bias that makes them think every other person is drug-seeking or just looking for attention.

The tweet mentioned has since been deleted, go figure.

Dr. Gukasyan is the Medical Director at the Johns Hopkins Center for Psychedelic and Consciousness Research. She identifies as a cis, queer woman and a “zero generation immigrant” having moved to the US from Russia when she was around four.

In this interview, we talk queer mental health, psychedelics, and the oftentimes harmful history of psychiatry. Enjoy!

Dani Janae:

All right. So this is the first question that I asked. It's a softball, but it can be hard sometimes, too, but when did you first realize you wanted to get into medicine?

Dr. Natalie Gukasyan:

From what I can recall, I think I liked to play doctor when I was a kid. I had a little doctor set, I remember when I was four or five years old, and I always thought it'd be a cool thing to do. Later, as I went through high school and college, I wasn't totally sure and I explored some other career options, mainly research, but then I actually met a doctor who was doing research. I was like, "Oh, you could be both a physician and be learning and studying all sorts of interesting things at the same time, and you get to do it with humans, most of the time."

So eventually, I decided on that, even though there was a little bit of a detour at some point, trying to figure out if I wanted to make research a focus of my career, but along the way, I learned that people who are strictly researching and don't have necessarily a good clinical option to fall back on do have it hard sometimes because, essentially, you're stuck working, writing grants all the time and, if your grants don't get funded, and it could be really competitive out there, then you're out of luck and it can be really stressful for people. So it's not that it's necessarily any less stressful, but I do have a little bit of security, as a clinician, that I could fall back on.

Dani Janae:

For sure.

Dr. Natalie Gukasyan:

Wait, tell me the audience of your podcast. Who are we talking to?

Dani Janae:

Mostly, from what I can tell, it's queer people who are ... some of them are involved in the arts, some of them are involved in medicine and the sciences and stuff like that. The age range, I think is, around 25 to 40. So that, but yeah, I think that's mostly just queer people that are interested in learning about medicine. And I guess, usually, what I'll do before I do interviews like this is I'll ask, "Do you have any questions for this person?" And sometimes they'll have questions and sometimes they won't. But yeah, just I think that people are generally curious about medicine because it can be shrouded in mystery, at least from my perspective, doctors know what they know and they sometimes will impart their knowledge to you and sometimes they won't. I think just people that are interested in demystifying it a little bit.

Dr. Natalie Gukasyan:

Okay, cool.

Dani Janae:

Yeah. Oh, okay. So was psychiatry your first choice or was it a journey to get there?

Dr. Natalie Gukasyan:

It was most definitely a journey. Early on, when I decided I was going to go into medicine, I worked at a couple of different labs and one of them was a surgery lab. So for a long time, I thought I was going to be a surgeon, in particular a cardiothoracic surgeon, so a heart/lung surgeon for whatever. I know why, because I worked in a lab where we got to see a very exciting and very cool aspect of that kind of medicine. I helped with an organ procurement team and I got to do all sorts of glamorous stuff, like fly around in private jets to collect organs with a team of doctors and stuff. And so I had a very unique glance at what that kind of career would look like and I've continued doing some work toward that and some research toward that.

In the back of my mind and in my free time, though, I'd always be looking into things about philosophy and psychology, and mental health sorts of topics. Psychedelics were an interest. And so it was always just a back burner interest, but not something I really thought of making a career out of. I think I've had some personal biases also against psychiatry, and cultural biases probably also. Russian people generally don't think very kindly of psychiatry and mental health. In the former USSR, that was like if you don't act right, then you can get sent to the asylum, basically, if you're not a good enough party member, let's say.

So I think, in general, mental health stuff is viewed with some skepticism among Russian people, and I did absorb some of that, but again, various aspects of that were always an interest of mine. And eventually in med school, I went through my clinical rotations, I did my surgical rotation where I spent a month with this group of surgeons, a month with another group, and I realized those are not my people. I did not have that temperament, really. I just saw that, a. they weren't especially happy. They worked really, really messed up hours well into their old age, waking up at four or five in the morning to get to cases at seven. And as much as I enjoyed surgery, I didn't think it was something I enjoyed to the exclusion of everything else in my life.

So I thought about some other stuff for a while. I thought about neurology because it was maybe more of, in my biased view, a more legit way to get at the brain and all that sort of nice, interesting mystery going on there. And I thought about OBGYN also. I really enjoyed that sort of ... What I like is that you get a mix of all different kinds of things. There's some surgery, there's some radiology, and I can do scan for people, do that sort of thing. And in general, your patients are responsive and care and, for the most part, are pretty generally fairly healthy. And usually, there's a good therapeutic rapport, I think, between clinicians and their patients when they're in OBGYN.

And eventually, I still had this bias against psychiatry until I did my psychiatry rotation. It was one of my last ones. And then I was like, "Oh, okay, these are my people." So I dispelled some of my own internal myths about psychiatry. I saw some ways that people were really, truly helped quite a lot by psychiatrists. I saw that there's an opportunity to spend time with your patients to get to know them and to really make a big change for people. And in terms of interesting research questions, psychiatry is wide open. There's still so much we don't know-

Dr. Natalie Gukasyan:

... about the brain and the mind, of mental health issues. And so there was a lot there. And another extra bonus was that maybe someday, maybe in the future, there might be a chance to do some kind of work with psychedelics, be it research and clinical work, but I didn't think that would happen anytime soon, certainly not as quickly as it happened for me. [inaudible 00:09:33] happening for me.

Dani Janae:

Totally. That was actually leading into my next question because you did mention psychedelics earlier and I was wondering if you could speak a little bit about advancements in psychiatry or things that are happening in psychiatry, as far as treatment goes, that you're excited about or that you think are interesting.

Dr. Natalie Gukasyan:

Yeah. So I think a lot of people right now are calling this the renaissance for psychedelic research. The first wave of research happened back from the '50s to the early '70s and they got shut down when the government got a little nervous about people taking drugs and thinking and behaving in ways that were not conducive to participating in the Vietnam War, things like that, among other issues that were going on. So that research got shut down for a long time. And back in probably the late '90s, early 200s, it started creeping back up quietly and Hopkins was one of the places where that was happening.

And I remember being a college student when some of these early papers were coming out from this lab that I'm a part of now, showing that drugs like psilocybin, which is the active compound in so-called magic mushrooms, fairly reliably, can produce really profound, meaningful experiences that people end up, months later, saying that, "I still think that has been a benefit for me, for my mood. It's led to a bunch of positive behavior changes, strengthened my relationships," all that kind of stuff. So that was really exciting to me, but it was still early days for that. And a lot's now developed since then, but we're probably, at this point, we're talking, it's June of 2023, we're probably less than a year out from potentially approved psychedelic medicines for mental health conditions on a federal level.

So MDMA is pretty close to approval. They have all their data and it's up to the FDA now to make a decision about whether they're going to allow people to get this medicine prescribed for them. And then psilocybin, the drug that's accompanying the magic mushrooms, is probably another two to three-ish years behind that. So the research basically has shown so far, in the studies that have happened and the data that I've seen or research studies I've been a part of, that, not for everybody, but for a good chunk of people, in some studies as much as 70% or more of people, there could be a really rapid and really large antidepressant effect for psilocybin and one that lasts for potentially a long time.

So in this one study we did, we followed people for a year after they got two doses of psilocybin and we saw basically the same rates of clinical improvement one year out as we did a month out. So a lot happened in that in-between time. Some people went back into other kinds of care, but in general, most people stayed around the same level that they were at about a month after treatment, which is really exciting because you don't see that with many kinds of therapies. People take antidepressants for a little while, but there is a fairly high risk of relapse, but we didn't see that. It was a small study, so that's the caveat, is that we still need more and larger research studies. That's what's happening now, but it's looking like some psychedelics, specifically psilocybin, MDMA, which seem to be furthest ahead, in terms of research, might be really interesting clinical tools for us and they might be available pretty soon if things continue to look the way that they've looked in the early research.

Dani Janae:

Totally. That's really cool.

Dr. Natalie Gukasyan:

Yeah, it is pretty cool.

Dani Janae:

So this question is just one that is not on my list of questions, but it just popped into my head. And you might not be able to answer it, so that's fine if you don't have an answer.

Dr. Natalie Gukasyan:

All right. I'll try.

Dani Janae:

But it seems to me, as a queer person that is in community with a lot of other queer people, that mental health care and mental health awareness seem to be at a higher, rate is not the right word, but I'm going to use that word, a higher rate of acceptance within the queer community. So most of the people I know have therapists, most people I know have psychiatrists or have been diagnosed with whatever diagnosis they have and stuff like that. So I'm wondering if you have seen that in the people that you work with of more of an acceptance and more care around mental health within queer patients?

Dr. Natalie Gukasyan:

Within queer patients specifically?

Dani Janae:

Yeah.

Dr. Natalie Gukasyan:

Maybe. So I have this research stuff that I do and then I also have a clinical practice. And I work at a community clinic, so I see all sorts of folks from the community, some queer, some not queer. I'd say that the distribution is pretty similar to what you'd just see in a regular community sample, so just average people. I think, in general, there's more awareness among everybody, especially younger people. I think part of it is fueled probably by social media and how we get our [inaudible 00:15:19] now. In general, I think it's good that people are more aware, that there's less of a stigma around it.

Dani Janae:

For sure.

Dr. Natalie Gukasyan:

I don't know, there's probably actual research on this, about rates of mental health care access among queer people or people who identify as queer. So I don't actually know the numbers off the top of my head. I wouldn't be surprised if they're higher. One set of numbers that I'm a little more familiar with is just trends in mental health issues overall, which seem to be rising, especially among very young people. I don't know, I'm not sure how old you are, but I'm guessing, I think you're probably my age-ish. I'm 35.

Dani Janae:

Yeah, I'm 30.

Dr. Natalie Gukasyan:

Yeah. So I think people who are much younger than us, I'm talking late teens or early 20s or so, they seem to have much higher rates and things are rising. So the question is, why is that happening? And so one possibility is that people might actually be having health mental health issues more frequently than they were before, but another possibility is just that there's more awareness, people are getting diagnosed more, not that the real rate is changing, but just the level of diagnosis and treatment is changing.

And it's hard to say which it is. I think there's evidence probably for both happening because, if you look at other more objective numbers, like the number of people showing up to the emergency room in crisis, for example, the number of suicide attempts or something like that, those also seem to be rising. I don't know, there's another, probably, whole conversation we can have about why that is. There are a lot of changes lately in our society, a lot of really stressful things going on, but I guess in terms of ... It's hard to say about your initial question that, are rates of accessing care higher among queer people? I can tell you, among some of my queer patients, they do say things like, "Yeah, it took me a long time to make a decision to try to get some help," and now they're finally doing it. So I think it's possible. I don't have concrete numbers for you.

Dani Janae:

Thank you for answering.

Dr. Natalie Gukasyan:

Yeah, sure.

Dani Janae:

So I'm also curious about just, what does an average day look like for you?

Dr. Natalie Gukasyan:

I think my average day might be a little different than the average psychiatrist's day. And I'm also in the middle of transitioning. So I'm in the middle of leaving my current job for a new job, which means that my day looks quite different than it did maybe six months ago because I'm closing everything up. I don't really have the same kinds of responsibilities, but I can tell you about, six months ago, what my typical week maybe would look like, or day.

So most of my time is actually research time. So I'm really only about 10% to 20% clinical. And the rest of my time, I'm here at the center doing various sorts of things. So I might be in various sorts of meetings with my study teams where I'm talking with the research coordinators, therapists about stuff, and filling out all sorts of boring paperwork or the kinds of [inaudible 00:18:52] doing. On a fun day, I might be analyzing some data that we have from one of our studies, designing some study, or putting something together to get ready for a study launch or something like that.

I was, for a time, also serving as a clinician for some of the studies I was working on. So that would mean doing things for psychedelic-assisted therapy, so doing preparation visits, doing the actual dosing visits, follow-up visits. That would take up a big chunk of my time. And then half a day a week, I'd have my clinic, which is my community outpatient clinic, where I'd see anywhere from a couple to maybe eight patients for establishing care for follow-up or something like that.

And then once a year for a month, I cover the inpatient unit here, in which case my schedule gets totally out of whack because I'm on the inpatient unit for the first half of the day, I might be going back and forth there between my office afterwards to see any new admissions, but on an inpatient day, they usually start with getting together with my team for what we call rounds, which is when we sit with the other people on the unit, so the nurses, social workers, case managers, peer recovery specialists, and we go through the list of patients who have admitted, we hear any updates about how they did overnight, if they had any issues with anything to do with the treatment plan or medication reactions, or they're not doing so great or whatever, and we make any necessary changes.

And usually, the interns or the residents who I work with write up all their notes, and I'll write up my notes, and then I might go see the new patients and we'll talk about it, come up with a plan for somebody, and then we also see all of the patients. We go and talk to all of them as a team or bring them into the office to meet with us and things like that. So my schedule's all over the place. I do all sorts of different sorts of things and my day-to-day can vary quite a lot. On a good day, though, it's all sorts of fun research, data analysis, and other kinds of interesting things, like psychedelic dosing sessions.

Dani Janae:

Totally. Okay. So this is my favorite question to ask, just because I think that it's important, but if there are any, what are misconceptions or things about your field that people think that are not true or things like that, that you'd like to set the record straight on?

Dr. Natalie Gukasyan:

Well, I think psychiatrists may be the most contentious area of medicine. It is a subfield of medicine. I think maybe one issue is that people sometimes get a little confused about psychiatry versus psychology versus other kinds of mental health providers. Psychiatry is a field of medicine. So every psychiatrist goes to medical school, they go to residency, they learn, they usually have some training in internal medicine, neurology, and that sort of thing.

Some misconceptions, I would say the other interesting thing about psychiatry is that it's probably the only field of medicine that has groups of people who are specifically against it. You don't see anti-neurologists or anti-cardiologists out there, but there are anti-psychiatrists out there. And I'm sure and I know that there have been people who've been harmed by psychiatry, especially in the past. Psychiatry has a messed up history, a racist history in this country in particular, and there were real abuses of human beings of all various sorts. That led to a lot of changes in psychiatry over time. Probably before the '50s, '60s, a lot of psychiatry happened that was asylums and things like that, usually state hospitals, and then we had a period of what was called deinstitutionalization where people started to become more vocal about some of the really messed up things that were happening there and just the conditions that people were being kept in are not great.

And that coincided with the time that we started to develop medications for the first time that seemed to be helpful. So before then, we didn't really have very much in the way of treatment, apart from some kinds of psychotherapy, which obviously weren't enough for people with serious mental health issues, like schizophrenia, severe mood disorders, and things like that. So people were like, "Okay, well, we have medication now. It seems to really help a lot of people. Do we really need all these state hospitals?"

And so the government started shutting down state hospitals and moving into community-based care clinics, which had some benefits because people who were previously institutionalized were now free in the community to do whatever and they had some level of independence, but I think we're at a point where that's backfired and we now see a lot of people who probably would be much better served by a high-quality state hospital to [inaudible 00:24:41], and instead, they're bouncing around from the emergency room to the inpatient unit, where they stay for a week, back to the street, sometimes to jail because they're in a crisis and they do something that upsets somebody, or commit a crime, or hurt somebody because they're not well. And really, that would've been prevented if we still had beds for people [inaudible 00:25:05] just don't. So I think there is some lobbying efforts to increase the number of state beds to get more chronically ill people help, but it's not going quickly enough.

I think, with the whole anti-psychiatry thing, like I said, there are certainly people who've been harmed by psychiatric medications, by providers, and I don't mean to minimize that because that's a real thing. I don't know. I think, in general, mental health is such a complicated set of questions and issues that we still don't really have all figured out. We're just trying to do our best with what we know about. I think, at the end of the day, a good provider will be as upfront as they possibly can with the known risks of a particular treatment, explaining the real basis for why a clinical decision is being made and working together with their patient, but I also know that not all psychiatrists are like that because I hear about it all the time. My patients are like, "Oh, you actually sit and talk with me and explain why you're doing this and don't just say it's a chemical imbalance," which is a BS explanation that isn't-

... exactly totally right. And there's a lot. I think I touched on a couple of things. I don't know, do you have anything that you think is a misconception or something that comes to mind for that question?

Dani Janae:

This comes from what I've heard from other people who have, especially people that have been harmed by psychiatry, but also people that just have never been to a psychiatrist and just make assumptions about what they do, but there's this idea that psychiatrists are just almost mouthpieces for pharmaceutical companies and their job is to push meds to people and not really be invested in care and stuff like that. So that's one that I think of the most when I think about misconceptions about psychiatry.

Dr. Natalie Gukasyan:

Yeah, but that's also definitely the case for some providers. They really do push medications. It's really easy to check a bunch of boxes, say, "This person meets criteria for this or that disorder," and, "Hey, this medication is approved for that, so let's try it." So I think, certainly, some providers do end up doing that.

Dani Janae:

Yeah, for sure.

Dr. Natalie Gukasyan:

That's a real thing. I think that was one of my own personal things I didn't like about psychiatry, is that, especially for children and adolescents, I had this whole sort of thing, I was like, "Oh, they're just over-medicating kids," and things like that. So overall, I think any well-trained psychiatrist understands and can effectively communicate the complexity and the nuance of the current standard of care and what it is and what it isn't.

If someone comes to me and we're trying to figure out if they have depression, we don't actually know what major depressive disorder is exactly. It's probably an umbrella term that comes as a lot of different actual kinds of conditions. One of them might actually be a real biological problem that responds to medication, another thing might show up and check the same boxes as somebody who looks depressed but is really more related to what's going on in their life, a normal, natural reaction to a whole lot of stressors and things like that.

Dani Janae:

For sure.

Dr. Natalie Gukasyan:

There's no test I can do that'll tell me with certainty what you have. And unfortunately, we're still at this time in psychiatry where it's a lot of trial and error with figuring out what treatment is going to work. And I think, unless you have someone you're working with who you could like and who you have some alliance with, who can sit with you through trying different things that might or might not work, it's a very stressful process, especially when you're already feeling bad to begin with.

Dani Janae:

Yeah, definitely.

Dr. Natalie Gukasyan:

Yeah. So I'm excited to be a part of this research that might offer another option to people. The interesting, nice thing about psychedelics is, for the people they do work for, they seem to work with only a few doses. And I think it's also potentially more of a ... Another thing that's happened over the years, probably since the '90s, is there's been, because of the way that insurance companies will ... the services that they'll reimburse for will incentivize psychiatrists to offer certain kinds of services over others. So even though somebody might actually benefit more from therapy, insurance is not going to pay me to do therapy at the same rate that they would pay me to write a prescription, unfortunately. So with psychedelics, it seems like the research is showing that you probably do need a robust and solid therapy around that medication. So it's almost a nice marriage of the return to what psychiatry probably should be more like.

Dani Janae:

Cool. Okay. So this other question is, what do people assume about you when they hear what you do or what are things that you've heard when you tell people, "I'm a psychiatrist," that are either funny, or jarring, or anything like that?

Dr. Natalie Gukasyan:

I guess it depends on ... When I'm talking to someone who's not a doctor, usually, it's like, "Oh, we're going to need your help. Everyone has mental health problems in my family," blah, blah, blah. I don't know that I've actually really encountered this, myself. Some people will say, oh, when you tell them you're a psychiatrist, they might think that you're analyzing them all the time, analyzing their behavior, what they're doing, which is not usually what I do. Even within medicine, though, even from other doctors, there's a little bit of stigma sometimes still about what we're doing, the utility of what we're doing, if it's helping or harming people, that sort of thing. So yeah, I'd say there's some stigma, for sure.

Dani Janae:

For sure. Okay. This is also a question that I like to ask, but it may not be relevant. Does your queerness ever become relevant or intersect with what you do on a daily basis?

Dr. Natalie Gukasyan:

Good question. Obviously, it's been a part of my own life experience, and you bring that into any encounter you have with another person. Usually, as a mental health provider of any kind, most theoretical orientations, psychodynamic ones especially, will say it's usually not a good idea to disclose much about yourself to the patient because it's about the patient. You don't want to bring your own stuff and stress them out. It's a complicated sort of thing.

And so it's not like I'm bringing it up, for the most part, though there are some situations where it seems like it's probably more of a benefit that I am a queer person than not. I'm thinking, for example, of someone I've worked with in a study of psilocybin for major depressive disorder who was a queer person, who was figuring out gender identity stuff and having some issues with their family.

So for the psilocybin therapy, we usually work in teams of two therapists. That's two therapists per patient. And so my co-therapist was also a queer person. And I remember having a real conversation about, "Well, should we disclose? What should we disclose?" I think I read kind of queer, but maybe not to everybody. I don't know that I was as queer presenting as my co-therapist in that situation, but I don't know. Look, I think what I've been told is that, as soon as I open my mouth, that's when people can tell.

I don't know, but I've also still lived quite a privileged life. It's not like I've necessarily always only seen some hardships as a result of my identity and all that kind of stuff, but it certainly helps me relate, I think, to a broader group of different kinds of people.

Dr. Natalie Gukasyan:

I think a lot about intersectionality also and, as a Russian immigrant, being queer in that circle means something very different from being queer here, hanging out with you or with my peers. And so I think that's helped me understand where many of my patients might be coming from, too, whose families necessarily aren't the most accepting or whose communities are not accepting. So certainly, I think it's helped me to empathize with that and be able to relate to that. So I think, overall, it's a benefit to me as a clinician and for my patients, I think.

This next interview was a trip to get on my calendar, and it was my fault, Dr. Scantland was nothing but accommodating. This was around the time that I was adopting my dog, Cashew, and trying to get a meeting with him and the rescue was taking up all my free time. Anyway, this interview with Joshua Scantland (he/him) was a pleasure. Joshua is an Integrated Interventional Radiology Resident in his last year of residency practicing in Indiana. 

Joshua identifies as a gay man, and we talk about how that identity intersects with his work a little in the interview. We also talk about dogs but I cut that part out for the sake of time. While we talk Joshua is on a walk with his dog who I learn hates skateboards. 

It might sound intuitive but this interview taught me what Interventional Radiology is, so I now have a new medical specialty that I’m aware of. I hope you enjoy this one as much as I did!

Dani Janae:

Okay, so when did you first realize you wanted to get into medicine?

Joshua Scantland:

I was actually pretty late in that realization. I was the first in my family to really go to college. And so once I got there, I was not sure what I wanted to do with it. My first declared major was psychology, but that didn't go anywhere. So at some point in time, maybe two or three years into college, I took some, a lot of self-exploration exams are like the personality exams, and they determined that I would like to work in an environment that let me work with people but also was very technical. By that nature, I kind of landed a little bit on medicine and then started shadowing people and that's kind of what further solidified things. So it was kind of a slower realization, and not as like a lifelong dream as some people might have had.

Dani Janae:

Yeah, totally. Yeah, that's cool. So was radiology your first choice? Or was it like a journey to get there as well?

Joshua Scantland:

It was kind of a journey to get there. I mean, it ended up being my first choice in the end. Yes, but I really didn't know what I wanted to do. But initially, I was very interested in neurosurgery for a long time. But then I kind of stumbled into interventional radiology and radiology, and that kind of snared me, in a way. It was the incorporation of technology and equipment. And so that kind of was really appealing to me. And so that's kind of how I got latched.

Dani Janae  

Totally. Just because I'm curious, and also I feel like it'd be good for readers to know, what do you mean when you say interventional radiology?

Joshua Scantland  

Yeah. So, radiology encompasses multiple different sub-specialties. Whether that's breast imaging, like breast radiology, but specifically, there is a side with sub-specialization. That is where we do additional almost surgical-like training and we perform minimally invasive procedures or surgeries with imaging guidance. So that would be like like ultrasound guided biopsies or CT guided CAT Scans, CT guided placements, or fluoroscopic guided vascular interventions. We use the combination of radiology and interpretation skills and use that to guide our hand when performing certain procedures.

Dani Janae  

Yeah, yeah, that sounds cool.

Joshua Scantland  

Yeah, it's really fascinating. And I think it utilizes a lot of skill sets. That was really fascinating to me.

Dani Janae  

Yeah, totally. So I think like, I've only done a couple of these interviews so far and one thing that I have noticed as I'm moving through them, is that the people that have volunteered to talk to me, have been in very different kinds of fields of medicine that don't get a lot of like shine or attention. So like, I talked to a family medicine doctor, I talked to an emergency medicine doctor, and I'm wondering, what does an average day look like for you? As like an interventional radiologist?

Joshua Scantland  

Yeah, so I guess I start off early. Not as early as some, but similarly, I try to get into the hospital, usually around 6:30 in the morning, and I start my day off by kind of running through our tasks. We'll have a list of surgical cases or procedure cases that we're gonna have going for that day and I will, at that time, just review what cases are happening and make sure things are lined up, orders are put in so that we have a smooth start to the day. Sometimes there'll be a conference that I have to attend usually at seven o'clock in the morning. I'll kind of attend that conference, as I'm also continuing to work and then begin cases usually close to eight o'clock. And just keep running through various different cases throughout the day until we get to the end, which hopefully is near five, sometimes six, it has gone as late as 8:00 pm before and then sometimes I might have to do some call coverage, like essentially additional ships and evening or overnight.

Dani Janae  

Yeah. Okay. What would you say on average is the number of people or cases that you see a day?

Joshua Scantland  

it's really variable on the complexity of the cases. If we see simpler cases maybe 8-10 or more. It doesn't sound like a whole lot, but just given the turnaround time and how much time we're spending on these cases can be a lot. And then, for more complex cases, which could take up to a couple of hours, the number is lower. Now, a lot of it also too, is dealing with consultations. Some people will ask us in the hospital, requesting certain things or, you know, if they need help with something and they're gonna try to figure out if we're going to be able to help them or not. So, throughout the day these will be peppered between cases and I will have to review patient cases and see if there is something that we can offer to help.

Dani Janae  

So this question I like to ask but, what do people assume about you when they hear what you do?

Joshua Scantland  

So this is actually funny enough. Sometimes I'm cautious about telling people about exactly what I do and I will paint it in a language that is a little vague intentionally because I think it does sometimes change the dynamic of interactions. I, you know, am not really sure exactly what their assumptions are, I think, I always worry that assumptions might be more negative if anything. I think they might assume…I don't know like, maybe arrogance, or something like that, you know, like, if I am opinionated, and I'm a barber, people will just say I'm opinionated, but if I'm opinionated but also a physician, people are gonna think that I’m arrogant. Either that or they assume that I'm judgmental. When I met people and tell them what I do they almost have an immediate sense that they're trying to justify their career decisions to me like I'm judging them. I don't like that feeling. I want people to be comfortable around me so I just downplay it a lot. I will say like, oh yeah, “I work in healthcare in the radiology department.” And if they try to ask for more usually I'll just say like, “Oh, yeah, I you know, I deal with patient care or ensuring patient quality care.” Like just to mitigate that.

Dani Janae  

Yeah, totally. Understand that. So along those lines, I'm wondering if there are any misconceptions or myths or anything about your field that you feel like you would want to dispel or things that people think about what you do that aren't true? 

Joshua Scantland  

Yeah. I think one that I hear sometimes— I don't hear it a lot— but when I do hear it, it's equally disturbing. People have heard that physicians don’t have the patient's best interests in mind. Sometimes they think they're motivated by external factors. And they think that the recommendations are based on external factors like money. In the end, at least all the physicians I know, the decisions they make because they truly do believe in them and they would recommend it to their own mothers the same advice, you know. But I mean, granted, it's because there have been people in the past who have abused the system and ruined it for everybody else. But you know, I think that's kind of a thing that I would like to dispel. There is just this distrust, people assume that physicians are self-motivated, when in reality, it takes a lot of effort and skill. When I talk to other physicians, they're all motivated by the sense of altruistic means of making the world a better place, so it's because that's the center of it all, at the heart.

Dani Janae  

yeah, exactly. Yeah. The interviews that I've done already, I feel like a lot of what I've heard and like what I've heard from other people that aren't in medicine, is that people get into medicine because they want to make big money and things like that. 

Joshua Scantland  

In the end, like even the high-end earning physicians, they delay making money until their late 30s or 40s. Or, like, those who started working a job as an autobody mechanic at the age of 20 will have the same net worth essentially all the way up until maybe the age of 50. You know, it's not really that much of a profit-turning career, not like something like pharmaceutical sales or someone who's an entrepreneur.

Dani Janae  

Exactly Okay, so this question is about the ways that queerness or sexuality and gender identity intersect with the work that you do on a regular basis. So, do your sexuality and your role ever meet?

Joshua Scantland  

I think so, usually, and it comes up in how I'm able to interpret the experience of someone who is clearly in the community. There are and I think it's no mystery there are a lot of straight white men in medicine. And I think, as you know, diverse representation is important so that these people who are providing care can relate to those individuals’ experiences. And I think that's where I see the play between my field and my identification is usually in my ability to relate, and I think even in the same way, the fact I mentioned before, for people that come from a lower socioeconomic status or low-income settings. That was kind of what I grew up in. And so I think I can also relate and understand struggles and barriers to care a little bit more, maybe more than someone who has not experienced that.

Dani Janae  

Totally. Are there other doctors in your hospital that you get to interact with who are also queer or gay?

Joshua Scantland  

Yeah, there's a couple. There's one that I consider a friend. I've hung out with him outside of the workplace. He's actually one of my staff, one of my attendings, so there's another of my interventional radiology staff who is also he's gay as well. I've not really hung out with him outside of the workplace. He's a little bit older, but he's also known to be gay. There are a couple of co-residents of ours in my program. They are diagnostic radiology residents interventional, which means that they are just looking more at images and interpreting them. One is a lesbian and the other one is as well, so yeah.

Dani Janae  

If we could just go back a little bit. I wanted to talk a little bit more about if it's okay if it's like not to talk about then that's fine. But coming from a low-income background. How do you think it has that affected your approach to care?

Joshua Scantland  

Well, and I think this should be comforting too,  in the sense that I don't notice differences in my approach to care than others. And I think because so many people still regardless, despite of their upbringing, or the backgrounds of the patients really try their best to do the right thing. So I don't see too strong of differences in how I choose to practice or what kind of care I provide. And then often, I think it can help me interpret some of the more complex social situations, for the most part, but I think, in the end, everybody's heart is still in the right place. If they're able to really put those pieces together the same way. You know, they're always still wanting to do the right thing.

Dani Janae  

Totally. Okay, so my last question is, if you could change one thing about how medicine is practiced, what would it be?

Joshua Scantland  

I think most of the things that I want to change would be more public health related. And I think it's all centered on the fact of a more corporate capitalistic drive. There's a more corporate capitalistic drive behind medicine in some cases, which inflates healthcare costs, and I think has impacted patient care globally. Or I guess I should say nationally. Regulating patient costs, over-utilization of imaging and diagnostics, and medicine, all in the interest to have quicker turnaround times for things. And so I guess I would like to see better access to care, primary care. Of course, the challenge too is there's a cultural component to it. 

A lot of people in my family, I get really frustrated with them because they need to get something taken care of, but they just don't want to pay for it. Don't want to wait for the primary care doctor or they didn't want to go in because they think it’s a waste of their time. And it's because people, strangely enough, if the maintenance of their health is secondary to whatever else. It's a cultural thing. Which really kind of makes it more challenging. So there are ways to receive care and a way to treat something as opposed to preventing it. This causes flooding in the emergency rooms, which causes inflation of costs, but also for people with cancer, who need to make sure they go see a cancer doctor so that it's appropriately managed and that they are followed for the duration of the treatment. They can't really just go in to see their specialist because of this issue, which makes it a really multifaceted problem. 

But in the end, I think if we could restructure the system in such a way that people have much better access to primary care. And, of course, there would need to be some legal changes to help protect patients against the increasing expenses, and the cost of certain medications and whatnot. And there's a really good book called American Sickness, which talks about like, inflation of health care costs related to factors like hospital administrations and pharmaceutical companies that are both competing for increasing profits and the patients have little to do with negotiating. You know, they don't really know what's being asked or like, when a lab or whatever is recommended by a physician, patients are always gonna say, “Yeah, sure” without really knowing costs. And so there's just all kinds of issues and I think it's just all centered around this fact that the people who are not being consulted to help in these situations and patients aren’t being given the knowledge to be as involved in their own care.

So when I talked to Dr. Francesca, I brought this notion up. Mostly because I’m so curious about how a doctor manages that kind of pressure. To know what you know and then when you don’t know, have the wherewithal to say so and be direct about your not knowing.

Dr. Francesca asked that I not use her full name, so I’ve honored that here. She is a family medicine provider in a city I won’t name either. She is also super funny, and charismatic, and you can clearly see she cares about the work she does. We talk about, unsurprisingly, health insurance, being a lesbian in hostile environments, meeting her wife and working together, and being an immigrant to the US.

Also, side note: the sound quality was not great during this interview so I won’t be uploading it as a podcast, but will do so with the next interview. I hope you enjoy this second installment!

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Dani Janae:

When did you first realize you wanted to get into medicine?

Dr. Francesca:

Oh, I think I was five or six or something like that. I've always wanted to be, well, I wanted to be a doctor, but I also wanted to be an artist. It's a stereotype, but if you come from an Asian household, going to art school is like a hobby, it is not a profession. But the interesting thing is my parents actually wanted me to go into finance, because that's what they do, my entire family is in finance and business and all that stuff, but I didn't want to do that, because that would mean if I... Well, I think they would be fine with me going to art school as long as I became an architect because then I could work for them, or in finance so again, I could work for them. I did not want to do that, so my form of rebellion was going to medical school, which I think I was doing rebellion wrong, but it was a good way to get away.

Dr. Francesca:

That's one thing too, though, in an Asian household, you can't really be gay, so I had to figure out a way that I could make a living and support myself. I guess I was just planning on that, if I got disinherited or whatever, I could at least do what I do and not have to worry about that. But I also did like medicine, so it kind of worked out.

Dani Janae:

Totally. Can we talk a little bit more about wanting to go to art school? I know it's not the crux of the interview, but I'm just curious about that.

Dr. Francesca:

Well, I went to art classes and all that, I always wanted to do art. I think I wanted to be an animator for Disney at one point.

Dani Janae:

Oh yeah?

Dr. Francesca:

But again, we get told that it's a hobby, not a profession, so that never panned out. I still kind of do that when I have free time, which is not a whole lot these days, but it's been turned into a hobby, and it's still nice. I think at some point, too, in medical school, I ended up doing medical illustration, which is kind of a mix of both.

Dani Janae:

Yeah, totally. That's really cool.

Dr. Francesca:

I guess I got some of that art to apply to medicine, which was very helpful.

Dani Janae:

That's really cool. Was family medicine your first choice or was it a journey to get there?

Dr. Francesca:

No, it was actually a journey. After I finished medical school, I actually went into an OB-GYN residency because I really actually liked surgery and I liked delivering babies and all that stuff, but I think I did a year of it and then just realized it was not for me. It was super stressful and I was turning into this person I didn't like because it was very stressful. I just realized I didn't want to do that for the rest of my life, so I went to family medicine, which actually worked out really well, because actually in family medicine, you could actually choose to do prenatal care with the little babies and all that stuff, which I did train for, as well, and then I think it just didn't work out. It works really well, say, if you worked in more of a rural area where there's not a lot of providers, but then there's not a lot of support is the problem there. If I would do prenatal care, I would have to be on-call all the time until that baby gets delivered because you were the only person in the area to do that.

In the cities, obviously, they would go to OB-GYN, so I ended up not doing that anymore, but I guess it's fine. I did that for a few years and then just left because I actually did like rural medicine, I worked in this small town in Wisconsin for four years.

Dani Janae:

Oh wow. How was that?

Dr. Francesca:

It was interesting. It was interesting for a while and then when you're only the only brown person in a small town, it gets really scary after a while. I got called a colored doctor from Hawaii. I'm sure they didn't mean bad by it, but these are nine-year-olds who probably have never left their town, that's just how they were, but that happens. It's a small town where over the years, the opioid crisis got worse, I guess, so you'd get patients who want you to give them opioids and you would say no and then they'd threaten to kill you. These are people who can have weapons and firearms and all that stuff, and if you call the police, they take 30 minutes before they get to you, so that just made things stressful.

This was before the ACA was a law and the people would not have insurance. That's also the problem with medicine over the past couple of years, it has just become increasingly more corporate, and that's kind of still happening right now. The healthcare system I was working for just wanted the bottom line like, "You'd have to see this many patients," but it's a small town, there's only so many people who are going to go see you. I'm not going to stand by the side of the road and beg people to come into the clinic. And then I think in Wisconsin around that time, they didn't want, because I think Scott Walker was the governor, it was a Republican governor at some point and they wouldn't expand Medicaid and all that stuff, so it just made it increasingly hard to practice there, so I ended up moving back to the city, which is a little safer.

Dani Janae:

Yeah, definitely. When did you make that move?

Dr. Francesca:

A couple of years ago. I think, how long have I been here, for 10 years now?

Dani Janae:

The way that I've always understood family medicine is that you are a jack of all trades, do a little bit of everything type of doctor. Is that a fair assumption or is there more to it?

Dr. Francesca:

Yeah, that's a fair assumption. A general practitioner is basically someone directly out of med school, who just decided to hang a shingle on the door and then practice medicine. In family medicine, it's still a residency program, but basically, you train for three years in various different areas, so you can focus on outpatient care, like ambulatory medicine, you can focus on emergency care, urgent care, you can also be more of an inpatient hospitalist person, you can be an OB. They basically train you in everything and then you get to choose where you want to focus.

My wife did sports medicine, that's what she's doing right now, and Ortho. I have classmates from residency that do more inpatient hospitalist care. In small hospitals that don't have hospitalists, you are the hospitalist, basically. In the cities, it's more internal medicine that tends to go into the hospital to do inpatient care, which you could also do, actually, but I'm just doing more outpatient now, just because it's a lot less stressful, so that's where my practice is right now. It's supposed to be an 8:00 to 5:00 kind of job, but it's not really, but it's as close to an 8:00 to 5:00 job as you can get, family medicine, at least.

Dr. Francesca:

After a while, you can't... I used to do hospital work when I was in Wisconsin. We worked in a small clinic, but you also worked in the small local hospital there. But after a while, being on-call for 24 hours every three days gets old.

Dani Janae:

I can imagine.

Dr. Francesca:

So now, I'm just doing more outpatient, which is still not an 8:00 to 5:00 job, but it's close enough.

Dani Janae:

That's another thing that you hear a lot about doctors, but I think especially doctors that don't have that very narrow specialty, is that you work a lot of hours and being on-call, all of that stuff, is a part of the experience. Can you talk a little bit about that?

Dr. Francesca:

Yeah. When you're straight off the residency, most people are kind of idealistic, you kind of want to do everything, so I used to do everything, really, literally did everything, because you didn't really have a choice. You were the only person there in a 30-mile radius, you were it. We basically learned as you go and figured things out, I don't know, like how to take a fish hook out of somebody's lip, the things you don't plan on in medical school, you figure it out, you find a YouTube video. But over the years, I think it just wears you down, and then you figure out where you want to be. Most of my friends, they have families, they have kids, and that changes your priorities after a while.

The problem, too, though, is not a lot of people do primary care, which is a problem, and even before the pandemic, that was a problem, there was a shortage. Because most people, when you graduate from medical school, you're in a lot of debt, so people will go to specialties or fields where they can earn more so they can pay off that debt. Primary care doesn't pay that well in medicine, so I think that's why there's a shortage in primary care, which got worse with the pandemic, obviously. In my clinic alone, we lost nine doctors. Nine people retired or just left medicine in the past two-and-a-half years or so, so that's not good right now. People are complaining they can't find doctors, and there's only so many of us, so you would probably hear from a lot more people that it's kind of hard to find a doctor or takes weeks to see somebody, which is unfortunate.

Dani Janae:

Yeah, definitely. Along those lines, I'm wondering what an average day looks like for you. How do you start your day and then move through that?

Dr. Francesca:

Let's see, my average day starts at about 8:00 most days. I do have a day where I start later, but that's because I also finish later, I think it's a 10:00 to 6:00 day because some people who work, obviously they can't see their doctors during office hours without taking off work, so lots of patients appreciate that. Occasionally, I work weekends, but pretty much 8:00 to 5:00 on most days, and you just start seeing patients until you see all of them. That's the thing too, nowadays with technology, people can send you messages and questions and there are phone calls, and it's a lot to do in between the actual seeing the patients. It's interesting, sometimes people are like, "I want my doctor to call me," and I'm like, "I would like to do that, but I just don't have the time." Some people are just like, "I want you to drop everything and call me right now." I'm like, "No, I can't do that." But that's where support staff helps, we have RNs, we have LPNs, and things like that to call them and figure that out.

That's pretty much it. I used to see about patients every 20 minutes, so that would be 18 patients a day or so, sometimes, sometimes 40 minutes if they were more complicated patients. But I think recently, I just moved to more 30-minute visits, just because patients are just a lot more complicated. I ended up being behind most of the time and patients didn't like waiting, but they also wanted their doctor to spend more time with them. If you do that, then you're just going to be late the entire day, so I just increased the patient visits, which means fewer people to see. With medicine, you get paid, and this is the icky side of the business side of medicine, which I don't like, you basically get paid by work units, so it's not by patients, it's basically how complicated a patient is and how much you do and that's worth a dollar amount, but obviously, the more patients you see, the more you can make.

If you work for a health system, you're employed and they have an expectation that you're supposed to see this number of patients or earn these number of work units, so if you take more time with the patient, that's fewer patients you see and that's less money. I like spending time with my patients because I think you can't really do a whole lot in 20 minutes, or they come in, they haven't seen a doctor in 10 years, they have a list a mile long and they expect you to fix everything in 20 minutes, I'm like, "That just doesn't happen," or like, "I wish I could make that happen, but I'm a doctor, I'm not a magician," but that's the thing. But I figured I'd rather spend more time with the patient and give them the care they need, so that's where I'm at right now.

Plus, I've been super burned out, so I figured I'd probably just do that, or else I probably won't last another couple more years in this job, but we'll see. We'll see. I'm sure they'll want me to see more people because there's not enough doctors to see the number of patients we have.

Dani Janae:

One thing that you said that led me to this question is that this idea of getting paid by the work unit was the term you phrased. I think that's not something that a lot of people know about medicine, that that's how you get paid, because everyone just assumes that you work 8, 9, 10 hours a day and you get paid by the hour, or like a fixed salary. I'm wondering, are there any other things like that, like misconceptions or surprising things about your field, that people would be surprised to hear?

Dr. Francesca:

Let's see. Oh, recently, I had a patient get really mad because their insurance wouldn't cover this particular medication they were on that they had been on forever. But what happens typically with insurance is they have what we call formularies, there is a set of group of medications that they have, I don't know, made deals with the drug manufacturers that they can get, say, this particular brand of medication cheaper, these insurance companies negotiate with the pharmacy companies. You could be on one medication one year and be on the same insurance and on January 1st, your insurance company changes their formulary and something you were on just is not covered anymore.

I had a patient who used to be on this medication and now it's not covered and I told them that. There's this process called a prior authorization where basically, you answer questions, you try to justify why you are giving this particular medication to the patient or why they are on this medication, what purpose, and then you hope somebody in the insurance company understands and says, "Okay, fine, we'll pay for that medication." Sometimes it works, sometimes it doesn't. I could tell them all the information about why I think this patient needs it, but they can still say no. I did that with this patient and insurance said, "No, we're not paying for it. You have to try this medication that we are covering," and he got so mad. I'm like, "I don't know what you want me to say." I think patients think we are all-powerful. I would have patients say, "Why don't you write a letter to my insurance so they cover it?" I'm like, "I could write 100 letters, if they're not covering it, they're not covering it."

I think that's maybe a misconception that patients will have, that they somehow think we actually run things. We do not run things, your insurance actually runs things. We can tell you what to do, we can tell you what we want to do, but that doesn't mean your insurance will pay for it. Patients hate insurance, we hate insurance more, because you have people in their offices not with patients, that are not in the clinical setting, and they make these decisions, and it's all business and money, which is kind of sad where our healthcare system is. It shouldn't be for profit, but it is. That's probably one big misconception that patients have, that their doctor can just write a letter or say something, and magically, the problem will be fixed. Unfortunately, it doesn't work that way.

Dani Janae:

What do people assume about you when they hear what you do?

Dr. Francesca:

I don't know. Mostly, they just start asking me questions, which is funny. If I meet new people, it always happens that they start asking me medical questions, which for the most part, I don't mind.

Dani Janae:

Personal medical questions?

Dr. Francesca:

Yeah. Sometimes they'll ask me about things and I'm just like, "Okay." I'd rather answer their questions rather than have them Googling things. Oh, I always hear this from patients like, "You probably hate that I Googled this." I'm sure there are doctors that hate the people who Google, I don't mind. I don't mind that patients research their own conditions and things like that. The problem, though, is not everybody is good at filtering out information on the internet, or there's just a lot of misinformation. I don't mind if patients come in with information and questions about their condition or things that they feel that they have, because sometimes actually when you research things, then you're able to communicate exactly what's going on with you.

Because that's a problem, sometimes patients have something going on and it's hard to figure out because they don't have the language to basically tell you what's going on, so I have to tease this out, asking them specific questions to figure things out. So sometimes it actually is helpful when people research what's going on with them because then they can narrow things down, and they have a better way to describe what's going on with them. But then the problem becomes when they already diagnose themselves based on the internet, which it doesn't always work that way, or they think they have this weird condition and you have to tell them, "Yeah, it kind of fits, but this only happens in this situation, so it's very much not something that's going on with you, I'm pretty sure," but that kind of helps sometimes.

But most of the time, I only have a problem with it when patients come in and they demand certain tests be done, because sometimes it's not the right test to do and then they get mad, but I'm like, "Some of it, yes, it's probably a reasonable thing, but some of these tests, you can't really get until you go through certain steps." Some people will have back pain, maybe they just pulled something, but they come into the clinic demanding an MRI, that's not going to happen, or you could probably get it, but your insurance is not going to pay for it. I have to go through certain steps to get there for you. Maybe at some point, it is needed, say, but it's not the first thing you do when somebody has back pain. I think some people get mad at that, they think their doctor doesn't want to do something for them, but there are some tests that we do have to order and there are some tests that you order if you suspect something else. I try to explain that, but I don't think everybody does.

Some doctors will just say, "No, I can't do that." I try to explain to people why I'm not doing something or why I'm doing something first, and for the most part, it works. Iit doesn't always. I'm sure I know some doctors who would just say no, and that doesn't always work with patients. Not everybody really takes that time to explain things to patients, I think, which then becomes a problem. Things like that, I think, would be some of the common things that patients probably should know. There are so many threads sometimes I run by on Twitter and they're talking about their doctors and I'm thinking, why didn't their doctor do this and this, that seems to be pretty routine. And they don't. I think patients really should advocate for themselves, as well, especially people of color, because oftentimes, and I think we just had an unconscious bias training yesterday so this is really new to me, because some people will not advocate for themselves, or they don't know or they are afraid to.

Certain doctors will certainly just minimize symptoms, especially women, they will say it's anxiety or they will blame everything on the fact that the patient's overweight or obese, which yes, may contribute to things, but it's not the only reason for everything. People will minimize people in pain, that's a problem, though. I admit that's still a problem for me, because we went from one end of the spectrum where it's like, "Let's fix everybody's pain and give everybody pain medication," then you get an opioid crisis and now, it's swung over to the other side where "I'm not going to give anything." It's finding that middle that's been more difficult. But there's definitely a lot of bias, unfortunately, that's still a big problem right now and there's no easy way to fix it, unfortunately.

Dani Janae:

Speaking of bias, I'm wondering, and this is kind of a personal question, you can answer it or not answer it, but are you out at work, and if so, how did that process go for you?

Dr. Francesca:

I wasn't originally, because actually, what happened is my wife actually went to this health system first, I was still in Wisconsin, and then a job opened up and I applied, and she didn't say that I was her wife so that it wouldn't influence anything, things like that, so we weren't out initially. I think my wife started to talk about me to one of our colleagues, and then it was just fine, they're just like, "Oh, I really realize that." Initially, we weren't out because you never know with people, but over time... This happened a few years into us working in the clinic, so that kind of worked out fine, so now I'm mostly out to most people. But patients, though, sometimes I don't say, because you never know. But when patients are, say, LGBT and they will talk about that, then I know I'm a little bit freer to talk to them about that, but obviously, I don't volunteer at the first thing, because you never know with people. But I found over the years, I've seen more LGBT people, I guess people talk and then they just find you.

Dani Janae:

Definitely. Does your sexuality or queerness ever become relevant or intersect with the work that you do?

Dr. Francesca:

I think so, because now I have a lot more LGBT patients, especially young people, and they're a little more open to talking about it. I'm having more non-binary teenagers, more people are realizing they're transgender, so we're doing a lot of transgender care, so that's helpful, I think. I think there's a lot of people, too, who are LGBT, they don't necessarily want to be open with their doctors about that because they may not feel safe, as well, there are certain doctors that do not know what to do in that case. That's been helpful in certain cases, but there's still a bit of a minefield that you have to navigate every day, but I think it's helpful. I think there's a lot more resources now. I know, I can't recall the name, but there was actually a database or a network where you could sign up if you were LGBT or you were open to seeing LGBT patients or doing LGBT care, which I think is helpful when you're looking for a doctor. Hopefully, that gets more common, but it's not yet.

Dani Janae:

Along those lines, are there other queer doctors, besides your wife, that you get to work with or interact with on a daily basis?

Dr. Francesca:

Let's see. Do I? Not in my clinic. Oh, wait, no, our clinic director is a queer man, I just completely forgot about that. He's a pediatrician, he's pretty cool, so that's one. Oh, and there's another doctor who actually did work for us, he was also a gay man, but he's retired now. So there are some people, at least in our clinic, and I'm sure there are more people out there places and whatnot. My previous primary, she was a lesbian, which was helpful, but now it's super hard to get in to see her, so I had to see another doctor. I couldn't see my doctor. I think she did transgender care because we actually have a gender clinic in my health system, which is really nice. I don't think every health system has that. They're like the one blue state in the sea of red.

Especially nowadays with all these laws that they're putting in, it's certainly a strain on a lot of our patients, for sure.

Dani Janae:

How do you manage that with your patients who are feeling a bit scared or uncertain about the care that they're receiving, not from you, but the future of the care that they'll receive?

Dr. Francesca:

I try to find them, especially over time as you practice, you get to know some of the specialists and who is a good doctor and who's maybe not so good with patients and things like that, so I usually try to direct them to those people. Even in our gender clinic, there was one doctor that most people didn't like, so I tried to steer them away from that one. That's how I do it, I guess, I try to get them to the people that will likely work well with them. The problem is access, though, because I certainly have a lot of people who want to see, say, a therapist, and therapists of color are hard to find, but my Black patients would rather see a Black therapist. I get why, it's just a different experience, and that's super hard to find nowadays. I think it's a four-month wait to see a therapist, just any therapist is a four-month wait and it's difficult. But that's how, I try to direct them to the right people as much as I can, which gets increasingly harder because there's not a lot of people to send them to.

Follow Dr. Francesca on Twitter at docwhatever

I screamed for twenty minutes in pain, waiting for someone two floors down to hear me. When my mom finally did, she was stunned. She didn’t know what to do but remembered my niece had knee surgery for a torn ACL that year, so she called her doctor. The doctor walked us through how to put my knee back in place. I collapsed crying as pain seared through my leg.

That was the beginning of what would be a year-long series of trips to a variety of specialists to find out what was wrong with me. Along with my joint problems, I had bad eyesight, a heart murmur, and flexibility in my hands and feet. We started with the obvious, an orthopedic doctor, who recommended us to another, who recommended us to another. I walked gingerly through the halls of UPMC facilities, afraid to test the limits of my knee braces. Afraid to move at all.

It wasn’t until we went to visit a neurologist that we found some answers. I was a problem sleeper, and I had gaps in my memory that couldn’t be explained. I got an EEG and reveled as the nurse set the nodes on my scalp, and watched as they scanned my brain for unusual activity. On a follow-up appointment with the neurologist, Dr. Painter, he asked questions with my hands in his, bending my fingers in all directions.

He did the same with my legs, bending, extending, and contracting. He looked at the results of the CAT scan that had been ordered and said that he believed I had Marfan Syndrome. The CAT scan showed that my kneecaps weren’t being supported, making them prone to slippage. When the doctor that ordered the scan saw it, he recommended knee replacement surgery. My mother scoffed and scolded him, I was only ten years old. Instead, I was put in physical therapy which helped but did not solve the problem.

Dr. Painter had finally given me what I wanted, a diagnosis. I exalted him for years, to the point where I wanted to be a doctor myself all the way up until my second year of college. I thought all doctors were infallible, even as my experiences with them scarred me.

On the day that I got the CAT scan, I had been told that I could keep my bra and underwear on. This changed when I got to the office, as my training bra had writing on it: Jansport. I had to take it off. In a room with my mom and a handful of female nurses, I felt fine. The CAT scan room had a large window that faced out toward a hallway that didn’t seem too busy. I took off my bra, exposing my chest, when a male doctor walked by and glanced at me. I froze as I watched him notice me and pass by, but when he doubled back to get a better look, I shivered. The nurses noticed him and scolded him, hustling a gown over my shoulders.

When I started struggling with my weight, doctors turned a blind eye to my eating disorder because they were happy I wasn’t fat anymore. My first trip to the OBGYN was painful and scary, and the doctor scolded me for being dramatic as she continued to probe me despite my pain. As a fat adult, doctors dismissed my other concerns, telling me that losing weight would solve all my problems.

When I was 18 and struggling with a hernia after I hurt myself exercising, doctors refused to believe that I wasn’t just hiding a pregnancy because I was a young Black woman.

Even the most well-meaning doctors are not without bias. I abandoned my love of science and medicine at 19 and focused on literature and poetry. I didn’t look back for years and years, never becoming curious about what my life would have looked like if I had gone to medical school.

That was until recently, when I found a renewed interest in science and medicine, the reason why I started this newsletter. I would be remiss not to mention my good friend Kimberly Garrett, an environmental toxicologist who I often have a laugh with about the strange, fru-fru pseudo-science posts we see on social media. Because of all the pre-med training I did, I can spot some misinformation, but certainly not all of it. That’s why I’m doing this project now. As we stare down year four of a global pandemic, it has become so important to me to know what medical professionals are saying, what scientists are saying.

Doctors are not infallible, they have room to grow and learn too, and they learn by starting a dialogue with their patients and everyday people they may come across. I believe this to be true in most academic settings. We let those with knowledge sit in ivory towers and hoard what they know, keeping it from us or publishing it behind paywalls. Occasionally, the media will pick up a study and slap on a sensationalist headline to get clicks. There’s so much we can learn from each other if there were fewer barriers to that knowledge.

I don’t think this newsletter is gonna solve this problem on a huge scale, but it’s a start. A new interview dropping next week, so stay tuned!

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After that, my interview with a queer radiologist will be up and available. The interview with the family medicine doc will run in April, and the radiologist in May.

As always, if you’d like to nominate a queer doctor, be my guest! I’m excited to continue this venture and would love your recommendations.

This is the first episode so please forgive the lack of an intro and the sound quality, it will be better next time!