S3E18: Supporting Self Identity

Harjit: Do you hear that?

Dr. Sullivan: I actually can't hear you.

Dr. Agarwal: I don't think I have it in mute.

Dr. Sullivan: Oh.

Dr. Agarwal: It's not on yet.

Dr. Sullivan: It's not on.

Harjit: Mine is on.

Margaux: Hey, everyone. Welcome to "Bundle Of Hers." Margaux and Harjit in the studio today with two very special guests. We have Dr. Cori Agarwal who is a plastic surgeon here at the University of Utah and Dr. Erika Sullivan, who is a family medicine physician also here at the University of Utah and they are both part of and have an integral role in the transgender program here at the University of Utah, which is what we would like to talk about today.

So, first, we just previously to this episode we did an interview with another student and we talked about gender. So a lot of the definitions about gender, sex, and transgender will be in that episode. So please refer back to that. We always like to start with episodes just for you guys' reference, but let's go ahead and do quick introductions. I think we'd really like to understand just a little bit about you, but also how did you get involved in transgender health? Dr. Agarwal.

Dr. Agarwal: Okay. I'm up. Thank you so much for inviting us to talk about this. This is something that Erika and I are both very passionate about and I think we both feel kind of ownership. This is our baby. It's something we've been working on to create a multi-disciplinary program for a number of years. So I'm really excited to share this with your listeners.

So, anyway, I'm Dr. Cori Agarwal, I'm a plastic surgeon here. I've been at the University of Utah for about 13 years now, and I didn't really plan on doing transgender surgery or creating a transgender program. I don't think many of us had it in our training as a medical student or in residency in plastic surgery. It wasn't standard part of training. When I started doing general plastic surgery, wasn't really on my radar and it was a patient that came to me asking for it.

And what I mean by it is at the time it was a patient who was transitioning to be male. It was early on in their transition. So, when they first approached me, they were still identifying as female. But in the course of knowing them, they said, you know, "I really don't want my breasts to be smaller. I want them to be gone. I want a masculine chest." And they really educated me. I needed to go back and do as much reading as I could and really educate myself about what is this that this population is looking for. And I was able to do that one operation and then word of mouth, that patient talked to another patient and before I knew it, I was kind of the expert in the area. And so that was, you know, 10 years ago or so.

Harjit: Dr. Agarwal, I really appreciate when you say that this patient had come to you and that's where they educated you. I think that's a concept that I often think about, but it's so cool to hear your experience, how that actually happened, how our patients are such a source of knowledge for us.

Dr. Agarwal: And we're hoping that that's not going to be the case going forward. I think it's a common problem for patients when they go seeking hormones or seeking care and they reach out to their doctors who have no idea. And I think in this day and age, we shouldn't be encountering that. We should be teaching it in medical school, in residency so that people don't have to be like I was. I mean, that's how it was 10 years ago, but we're really trying to put this education early on so that we can offer good care to these patients and not the other way around.

Margaux: Building off of that, I forgot to introduce that Harjit and I are part of the transgender health care elective that is offered at the school of medicine, which both of you guys are the directors of. And so, as a way to extend that education into medical school, that's how we became involved. Dr. Sullivan, would you like to share your story?

Dr. Sullivan: Sure. So I think my story is very similar to Cori's in that I didn't sort of know that this is something I would be passionate about and didn't receive any training on it in medical school, but actually did get some training in residency. So my sort of now colleagues in family medicine, Dr. Bernadette Kiraly had been doing hormone therapy. She was lowering the amount of clinics she was doing because she was going to become our clinic director. She approached me as one of the residents and said, "Hey, would you be willing to see one of these patients?" And I thought, I don't really know what I'm doing. And she's like, "You don't have to worry about that. I'll give you the things that you need to sort of look things up."

And that's what we do in medicine anyway, especially in family medicine. I mean, I don't know if it's good to say in an open mic how much I don't know. But I mean, you look stuff up a lot. And so, yeah. And so I saw my first patient and again, I just felt like I was so grateful for sort of the education that they provided to me and it was a really good experience for me. And yeah, I just sort of built it into my practice and then suddenly it sort of just became, "This is what I want to do." Like, this is my passion, this is the thing that I want to you know, think about like academically and I want to make sure that we're making programs to have, you know, students and residents have the opportunities to do this.

Margaux: Yeah. I really appreciate your vulnerability and saying that you don't know everything, and I think that intellectual humility is super important, especially in recognizing the care and the discrepancies in care for different patient populations that have not traditionally been served. And so I think it's really awesome that you said that. So thank you for saying it.

Also being a naive and optimistic medical student, I had this elective on my transcript, but also some research that I had done with you, Dr. Sullivan on my CV for residency applications. And when I was on that residency trail, in my head, I didn't realize it at the time, but I think subconsciously I was like assumed that transgender programs were something that were everywhere. And when I was interviewing people would ask me about what is this transgender program at the University of Utah? And then I realized what an amazing thing we have here and how unique it is. So there are only a couple, a handful of institutions that have a fully integrated interprofessional transgender program at their institution. But you know, University of Utah is one of them. And so both of you are integral in starting that. And we'd love to hear how the program came to be.

Dr. Sullivan: Like I said, this is a labor of love. When I mean labor of love, this emphasize the labor. This was a lot of work to get this program to where it is. And you know, I look around right now and what we're able to offer and I still, I feel like we have a long way to go. Although you know, we could easily double the amount of people working with us and still probably not meet all of our needs, but I look back to where we were five years ago when it was like just kind of a couple of us in a room and we didn't even have a name. We didn't have the University of Utah Transgender Health Program. We couldn't even brand it without a lot of red tape. And we had to figure out, we needed a seat at the table, but there was really no table. We needed to figure out which table . . . who could authorize this.

And it's hard because we're each coming from different departments and different divisions within departments and you know, we needed this to be kind of under the umbrella of the hospital. And it was just a lot of years actually navigating who could actually say yes to this. And so we kind of continued to make our case. And there was also some leadership changes at the University of Utah around the same time and nobody wanted to kind of make a stand. So I think we had to wait in line for a little bit longer. But it was about three . . .

Dr. Agarwal: It was three.

Dr. Sullivan: . . . years ago, and I want to say three or four.

Dr. Agarwal: I'm glad your memory's as bad as mine.

Dr. Sullivan: I think it was maybe three or four where they finally said, "Yes, you can exist, you can have a program." And they're, you know, even that, we didn't know for sure how they would feel because you'd get some pushback and they were afraid they might get some pushback just in this state, you know, it's a conservative state and there's some people who don't support what we do. So I think there's always, you want to do things carefully and cautiously as you go forward and not put it on, you know, banners on the buses driving by necessarily. So, you know, we were able to exist and so we created a website and at that it at least allowed patients to find us. And that actually probably was the most critical thing starting the program.

But we did things a little bit backwards. I think we had people finding us, but then we didn't have any infrastructure. We had nobody who was actually hired to coordinate this. And that took another year and a half or two to get funding to actually hire someone to answer the phone. Because like I said, there's a bunch of different departments and it's not who's going to actually pay this one person. It just took some time and you know, there was lots of frustration in there. But when I look around it's pretty amazing how far we've come.

Harjit: Yeah. It seems like it was a struggle to kind of get this program up and running as you have just discussed. And when we come into medical school we're like, "We're going to be doctors and we're going to take care of patients." But then you know, there's a need and for you to be fully present and do the job that you want to do, you kind of have to create this whole department. How did you come to terms with, I not only have to be a doctor, but I have to be a leader in this arena?

Dr. Agarwal: Actually, I have something I want to say about this because I've been thinking about this a lot about, you know, you go to medical school and what are you thinking? Just want to, you know, get a good grade on your steps and you want to figure out what specialty you want. And then you go into the residency and all you want to do is, you know, pass the tests and learn your specialty and get a job. And then when you get a job, you want to pass your boards and start seeing patients. No one ever really asks you, what's your big plan? What are you really passionate about? What do you want to grow and build? Until you're a few years in and I think if you don't step back and no one asks you that or you don't think about it, I think that's the path to burnout.

I've been thinking about burnout a lot lately and I think if you just take care of patients, and when I say just take care, I mean, it's amazing to take care of patients. That's why you're in medical school. You're excited about it. But 5 years into that, 10 years into that, you're going to probably feel very burnt-out if you're just going to work every day and taking care of the next patient who's on your schedule.

So I think it's important in your career, somewhere along you know, when your first job comes around or earlier you guys were already thinking you're a few steps ahead, but to think what do you want to build? And that could be a leadership role in something, that could be research in something. In my case, and you know, this was building a program that can, you know, do a better job taking care of this patient population.

So it wasn't that it was a problem doing this, this was actually identified it as something that was really exciting and it's probably the reason I love my job today as much as I do is that in addition to doing surgery and taking care of day-to-day patients, I see it as a bigger picture that we are training medical students and we're putting together a bigger program.

Dr. Sullivan: Yeah. I couldn't agree more. I think that during my residency, I started doing trans care. I don't know that I sort of at the time envisioned how this would play the role that it has in my life. But when I joined the Faculty of the Family Medicine Department here, I realized that there really was a need and I say that for the reasons that exactly what Cori mentioned, which was that I joined at a 0.8 FTE. So, basically, full-time seeing patients and really struggled with the amount of time and sort of the strain that that put on me and my young family and really saw all kinds of teaching as a way of sort of lowering my clinical FTE and thinking like, okay, that will help because I'll, you know, I won't be in clinic so much.

But what I didn't anticipate or maybe I did, it was just 10 years before I had anticipated, it's actually the education part that makes me so excited about the work that I do. I enjoy seeing patients, but it turns out that I love being in the room with students as well, like with learners because the exact same knowledge transfer that happens between patient and a provider occurs in a very similar way when you're in a room with learners.

And so working with residents in all the capacities that I do, so I'm on the curriculum committee of the family medicine residency and working with medical students in the capacity that I do either through the family medicine clerkship or through, you know, the fourth-year elective has really just been such a source of like insurmountable joy and optimism. And again, not to say that I don't also enjoy the clinical part, but it has been sort of an unexpected way of bringing a lot of vitality into my career.

You just need to find out what you're passionate about because when you're passionate about it, it won't seem like work. The piece of advice I would give to, you know, people who are starting off early in the process is kind of don't panic so much right now about what's my passion going to be. Allow all the things that you have to do, the check marks that you have to cross off, check those off and then get to a place where you are receptive to having sort of passion thrust upon you and then just be open and willing to engage in the opportunity.

Because again, none of us saw this coming, like none of us went into medical school thinking, you know, "This is what I want to do." If you do, if you have that, great, you know, go ahead and pursue it, but don't worry if you don't.

Margaux: Dr. Sullivan, you highlighted a core value that we try to emphasize in this podcast, which is find your passion in the work that you do because like you said, Dr. Agarwal, burnout is such a huge thing and while we're all in it for the patient care and for helping people on some level, that becomes, if you don't have the passion and find the things that bring you joy in that work, you will get burnt out.

Dr Agarwal, when I was in clinic with you, you mentioned an earlier too that this was about 10 or more years in the process to be where the transgender program is now in its defined space. And I imagine during the whole process of going through, waiting at the table and finding the table, you guys were still caring for patients. And so how did that passion carry you through and what was it like to be communicating with each other and working in a program that wasn't defined yet?

Dr. Agarwal: It's easy to be passionate about this patient population. You know, from the moment I started to work with this group of patients, these individuals, I realized this is easily the most gratifying thing that I do. That's saying a lot because in the field of plastic and reconstructive surgery, we take care of a lot of cancer patients, a lot of trauma patients, a lot of difficult things and you know, just a little plug for plastic surgery, one of the reasons I chose it is that you're always rebuilding and reconstructing something. You're always kind of offering something positive, even though they may have had a large portion of them removed by an oncologic surgeon, we're rebuilding. And so it's bringing positivity to someone's life.

But with the transgender population, you're able to allow them to step out into the world and present as themselves. And you see them stand up straighter, you see them go to school, you see them get jobs and really contribute to the world as they want to rather than kind of hiding. And that's when they usually come to me in the beginning, they're hiding some body part. And so you really see them thrive, you see a whole different individual come in, you know, after you've done some kind of intervention and whether that you see them transform on hormones or something surgical and they stand in the room and they can't . . . the trans boys you know, can't wait to whip their shirt off. And you know, just very confident and tell you these stories about how they went swimming for the first time. And it's really gratifying kind of work. And so I think that easily carries us through while we're trying, you know, the frustrations of building a program is that the actual care is really gratifying.

Dr. Sullivan: Yeah. I completely agree. I think that sometimes as a family doc I feel like I'm not helping anyone. And so I think what makes this population so sort of unique and so attractive and so amazing to sort of be a part of is that they give me the gift of change, that they are anxious for change, they are so desirous of change. You know, change is really hard for many people. You know, behavior change in particular is really hard. And that's a lot of what family medicine is, you know, is you've got to take your meds and you've got to exercise and you've got to eat right and you've got to do these things that are really hard to do. And that honestly, if you'd been doing them all along, like you probably wouldn't be here in my office you know, at this stage and this group of people is sort of the exact opposite. You know, they want to change and being able to be a part of their journey is so gratifying. And so, when I give talks, I think people are expecting me to kind of guilt trip other and providers and saying, you know, you need to do this kind of medicine because of the sort of their status as gender and sexual minorities and there's this great disparity in health care and all of that is true.

I mean, and it should be something we mention all the time because that disparity is ever prominent. But honestly, the pitch for me is you need to do this for you. You need to do this because allowing this, you know, this population and not just transgender folks, but I think sort of the broader aspect of LGBT care, educating yourself on the needs of the LGBT patient population and being able to be a provider who you know, provides evidence-based, competent, compassionate care to this, you know, group of people is going to make you like your job better. You're going to enjoy going to work better. It's something that I again, totally didn't anticipate. It just fell into my lap and I think I'm just ever so grateful that it did because you know, I don't know if I would still be as excited as I am about going to work every day if I didn't have this sort of niche part of what I do. See change and help people in a way that they want to, you know, be helped.

Harjit: One thing that really surprised me about this elective is how strong that value of interdisciplinary work is integral to this program. I think it really exemplifies that you need every single field of medicine to like fully take care of an individual, but it's done so well here. So can we talk about that a bit?

Dr. Sullivan: Absolutely. I will say that when we first started meeting I definitely said, "Okay, when is our summer party?" Like, when are we all getting together where we can hang out and just be human and be people and have our families come and sort of, you know, mix it up. Because, you know, whenever I schedule meetings I'm always like, okay, well we're meeting over food because that's how humans communicate you know, as we share and we break bread together. And I do, I think it's absolutely astounding that every month, multiple people from family medicine, multiple people from plastic surgery, multiple people from urology, multiple people from adolescent medicine, vocal therapy, OB-GYN, endocrinology, physical therapy and I am now feeling a little bit of pressure like the people in the Oscars where you're up on stage and trying to remember . . .

Margaux: Mental health?

Dr. Sullivan: Like all in mental health, I mean, there are so many disciplines who come to this meeting and we hear about other programs and especially when there's like multiple programs in the city and they're sort of like fighting over patients. And obviously, that is not the situation we are in and we sort of have more, you know, the demand outstrips the supply. But I really think it's because of Cori's leadership in just setting the tone for what collaboration and being a part of this sort of core group is going to be like. And then of course I was like, and now you're going to come over to my house and we're going to have a party and play basketball.

Dr. Agarwal: Yeah. That's really nice. Thanks. I agree with everything. I think our team, we're so lucky, the team that we have that gets together every month and then some, I mean, we really respect each other in what we do and we like each other. You know, we each bring something different to the table. I know very little about what other specialties bring. I mean, we learn from each other, but I know very well what I do and I'm expecting everyone else to bring their piece. And so, when we're talking about what's the best way to grow this program, how are we going to educate our patients and create seminars every single month for them, which we do at the Pride center and we have different topics and who's going to bring what knowledge to the table every single month?

And we've been presenting at national meetings over the past couple of years. And what we've been talking about is exactly what we're talking about today is, "How do we grow this program?" And it's really exciting all the other programs from different states, other institutions I should say, come to us and say, "How did you do this and how can we do this at our institution?" And for us to be kind of the pioneers, we've only been out doing this for three years, but we're really kind of ahead of the curve on putting together a multi-disciplinary program. So we have some talks that we've done different sessions about, you know, what lessons learned and advice that we can give to other programs and that's really exciting to be presenting with this group on that.

Dr. Sullivan: And I think that the thing is that our program really was born from the bottom-up. The providers were sort of all doing this separately. And if there wasn't a program, if there wasn't a branding, we'd still be doing it. We still feel value in serving this patient population. And so, if we didn't have a logo, we'd still do it. But because we were all still doing it, we sort of recognized this need to like, you know, "We should probably be talking to each other." And so what ended up happening was is that because all of the different programs were kind of doing their own separate thing, we were then able to kind of, I'm such a doctor, I keep thinking about dermatological things.

It's like when a macule becomes a patch, you know when you have this confluence of macules that actually it's this larger thing. I think that part of what makes this possible is the interdisciplinary nature of it because in this particular patient population, some but not all of these patients could make use of services that are across sort of department lines and as a patient you don't think of it in terms of like, oh, well, I need to see a surgeon for this and I need to see you know, a physical therapist for this and I need to see my regular doctor for this. You just sort of think, "I need to be who I am. How do you help me be who I am?" And you're not realizing that then you're coming up against the health care industrial complex, which is like, well, no, that's family medicine and that's plastic surgery and that's OB-GYN, you know, this kind of thing.

And so that part of it I think can be challenging for patients and so it's much easier I think on the patients if those individuals can sort of say, yes, we're all doing this, you know, separately, let's sort of join forces almost like a transformer, you know, like we sort of join into like, I don't know, Optimus Prime or something like that. You know, it just maybe more powerful when all the pieces come together and can sort of make this bigger construct.

Margaux: And something that stood out from our conversation just now is very unique to me in your leadership style and creating this program is that you first built the community around storytelling and sharing your experiences with each other. Because like you said, each department seems to be very siloed in our historical model of health care and coming together and having that space to share community with each other I think is a really cool way to break that model and to change. And obviously, it worked very well for you guys.

And like you were saying, it's hard to explain how other programs can do that. But I would think it comes down to the core value of what we do every day is just like talk to each other. Like we talk to our patients, talk to each other. And when you're trying to implement a change, it's easy to send an email that's like, "Hey, we're going to start doing this now." And because it is the person at the front desk, the MA, the lab tech who are also involved in that individual's health care and creating that safe environment for them. And so, when we all have the community together first and have that common understanding through storytelling, I think it makes it much more easy to implement change. And so I think you guys have done a beautiful job in just showing a new way to do leadership, which is very exciting to me. Before we wrap up, do either of you have any final thoughts you'd like to leave our listeners?

Dr. Sullivan: I'm really excited by the fact that, you know, your cohort of class really is sort of demanding for this knowledge. I see that in the medical students, and I see it in our residents, and I think that's how the needle changes. Learners who have actually quite a bit of power, although it feels powerless, I totally get it, I think your power probably comes in volume and numbers, you know, but you have power in sort of saying to your program, to your advisors, to your mentors, "This is knowledge that is core to what I'm going to be doing and it is my expectation that you teach me how to do this." And but, of course, you say it nicely.

But I think that's actually something that I'm really excited about and I really see that as being something that we could also kind of export in terms of talking to other programs about how they could set up something like this and have this information. Because I don't want 10 years from now to sort of be in the same place where we're sort of telling other people, well, this is what we do here, but sounds like you're pretty light years away from doing that. I want other programs and other medical schools to really recognize the value of this knowledge. And I think that they will because of folks like you guys who . . . y'all gals, people because you're demanding the knowledge in a very nice way. And I think that's really important. I think that's an important part of what we do and why we do it, for people to be able to get the care that they need. And so I'm really excited by the enthusiasm from the younger generation.

Dr. Agarwal: Everything, you just wrapped it up perfectly. So that should probably be at the end of our podcast. I just want to say that you know, you don't have to be delivering trans-specific care to be taking care of trans folks and really no matter what specialty you go into, you should be absolutely prepared for a transgender individual to walk into your office and to be able to treat them very comfortably. You shouldn't be afraid. You shouldn't be afraid to ask the questions. How do I address you? You know, what names and pronouns should we use? And it should just be part of the regular education in medical school and not as you don't have to have a transgender elective to be able to take care of this patient population. And I hope that's what we see going forward, that any transgender patient can go to any doctor for the care that they need and get it without having to be afraid to go and step forward.

Harjit: Dr. Agarwal and Dr. Sullivan, one thing that I learned from this program is I was a little bit taken aback about the sheer volume of individuals that are trans. And like you said, that anyone could encounter these individuals and we should feel comfortable working with them and I think that's the biggest reason why both Margaux and I seek this elective is because we knew no matter what field we'll go into, we were going to encounter trans patients. So I am super thankful that you highlighted that point and I'm also very thankful that you both were vulnerable with us and shared a lot of your own story, which I think is really important for our podcast as well, because we want to listen to people's experiences and understand how they've become leaders, how they found their passion. So, hopefully, we all and all our listeners can find that as well.

Margaux: So, if you have anything you'd like to add to this conversation or your own story, please share with us on Instagram at Bundle of Hers or on Facebook at Bundle of Hers Podcast. And until next time, bye-bye.

Harjit: Thank you.

Dr. Sullivan: That was fun. That was so much fun.

Dr. Agarwal: Thank you so much. How long was that? Did we go like we like way over time?

Margaux: No.