Professional gay: Charting a career in LGBTQ health [PODCAST]

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“After much searching, I was fortunate to find a fellowship that though inexperienced in LGBTQ health recognized an opportunity. Faculty and mentors worked from a growth mindset rooted in finding what I needed to succeed rather than what they knew they had to offer at that moment. With their and others’ support, despite the discouragement and fears of being “superficial,” I now try to serve as an example to other students and trainees who wish to pursue a career that weaves their personal and professional interests in LGBTQ health.

Carl Streed, Jr. is an internal medicine physician.

He shares his story and discusses his KevinMD article, “Professional gay: Charting a career in LGBTQ health.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Carl Streed Jr. He is an internal medicine physician, and he wrote the KevinMD article “Professional gay: Charting a career in LGBTQ health.” Carl, welcome to the show.

Carl Streed: Thanks for having me. Greatly appreciate it.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Carl Streed: Yeah, it’s one of those journeys where it’s easier to look back and say, “OK, this is the straight line through,” but it definitely wasn’t that. I’m from the Midwest, grew up in northern Illinois, in a family that valued education, but I am the first doctor in the group. I made my way through undergrad, took time off because I really didn’t know what I was doing with my life, and found my way into medicine. I moved to the East Coast and did training at Hopkins, which was remarkable and wonderful, but as you can talk about in the article, there were just a lot of gaps in how people were talking about LGBTQ health and so forth.

So I kind of moved my way from there into Boston, where I’m at now. I finished my training in general medicine and have a research career, and it is very fulfilling to be able to have patient interactions still and actually have their lives inform what the research questions are. That’s kind of where I’m at right now. As I mentioned, it’s easy to summarize very quickly, but it has been a lot of unexpected turns, and I honestly didn’t think I would end up here 10 years ago.

Kevin Pho: So as an academic internal medicine physician today, tell me some of the challenges that you face in everyday practice.

Carl Streed: Goodness. Well, I mean, the typical challenge you’ll hear from any academic clinician is funding: just making sure that you are able to continue doing the work that you want to do, that you think has an impact. My work is very much focused on the experience of LGBTQ individuals, particularly transgender and gender non-conforming folks. And only, what, five years ago did the National Institutes of Health actually designate LGBTQ populations as a population they consider of importance, something that they want to better understand. Before, it was always very much disease-focused, which is why there’s, for better or worse, a glut of funding for HIV but not much else as it relates to LGBTQ health.

So my day-to-day is sometimes worrying about grants, sometimes worrying about making sure I get my patients the resources they need, since health care in general still has a ways to go to address a lot of the discrimination that existed in the past and continues to exist now for LGBTQ folks, particularly LGBTQ folks at the intersection of other marginalized identities. It is not just that the system treats you as this one person with all these different identities separate. It’s that it’s all overlapping. The idea of intersectionality definitely comes to the fore in primary care.

Kevin Pho: So can you talk about some of the major issues that face LGBTQ patients that you see in a primary care clinic?

Carl Streed: Assuming they actually are able to get in the door, I think, is one of the biggest barriers. Being able to access health care requires the financial resources, the wherewithal, and overcoming the justifiable distrust of the health care system. It wasn’t too long ago that doctors were saying that being gay was a pathology, and we still have debates even now among politicians about whether trans identities are natural, which they are. We can look. We have a wonderful historical record going back centuries across multiple cultures showing that the diversity of gender is more than just man and woman. But medicine has often been part of this flattening of these categories and discriminates based on that.

So the biggest barrier people face is actually finding a trusting health care system, a trusting clinician, essentially. That’s one of the biggest barriers. Beyond that, there are a lot of other issues in terms of how society treats people in general, and a variety of disparities that play out in these populations: smoking disparities, alcohol disparities, but also anxiety, depression, suicidality, and then many other chronic conditions as those are related. That’s actually where a lot of my research lies, looking at chronic conditions as they relate to stress.

Kevin Pho: All right, let’s talk about your KevinMD article that you wrote. It’s titled “Professional gay: Charting a career in LGBTQ health.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Carl Streed: Yeah, this article has actually been kicking around in my head for several years. The article opens with an interaction that I had with one of my deans back in med school, very early on, where I got pulled aside after a lecture. To be perfectly honest, I wasn’t the top student, and they made a point to say that I was superficial for focusing so much of my efforts at that time on advocacy and understanding disparities in LGBTQ populations. That idea of superficiality, in caring for a disparity population, a population that I’m a member of, that has continued to face a lot of discrimination, has been bugging me, at least.

The article goes on to explain that, despite that professional setback and multiple professional setbacks as it relates to people you think are going to support you but end up not. The article goes through ways I navigated that, ways other people actually took a chance and were like, “I don’t know how you’re going to make a career focusing on LGBTQ health, but here are the resources we have available that might be helpful.” Some key mentors within my med school, including the dean of students, were very helpful: Dean Koenig, who’s now retired, but also my residency program directors.

I always remember, when I was looking for a residency that was going to be supportive of me having an advocacy bent, having a focus on LGBTQ populations, in addition to doing general primary care for everyone, my program director saying, “Carl, we’re going to help you do whatever you want. You can do any elective. You can build it, as long as it meets our academic rigor, and essentially, as long as it’s not illegal, we’ll help you do it.” That was a major help and relief in my training.

But actually, there were still multiple barriers down the road in terms of going on to fellowship. I remember interviewing with faculty who I actually identify as part of LGBTQ populations, but who didn’t understand how a career could be made out of understanding the disparities faced by our population particularly. It was very discouraging to have those kinds of interactions as part of my interview trail. But again, finding those mentors who were like, “I have no idea how this is going to work, but we’re going to help you make it work,” was really the key.

The title kind of comes from when I was fortunate enough to get an award from the University of Chicago, my undergrad alma mater. I had no idea what I was going to say. They shared my biography up to that point, and I said, “Well, as you can tell, I’ve made it. I made a career out of being a professional gay at this point,” being somebody who is part of a community trying to do work that better improves the health and well-being of our communities. That’s kind of the gist of the article. There are definitely a lot of links in the article to some of the data to support what I’m saying and so forth, but it really was, and continues to be, somewhat uncharted territory as it relates to being very specific to LGBTQ population health and well-being.

Kevin Pho: So when you talk about your medical training, and you are a member of the LGBTQ community and you want to do research in this area, you said that the support that you encountered was varying. So can you give some examples of this varying support that you mentioned?

Carl Streed: So some of the key examples, aside from what I portrayed as it relates to one of my deans who said I was superficial: I remember one of my faculty members, at that point I think I was a second- or third-year med student, saying, “You are, to me, my expert on LGBTQ health. I know nothing about this. And because you’re my expert, me asking you questions is going to make you more of an expert, because you’re then going to have to go find out about this.” That was Dr. April Fitzgerald. I remember taking that to heart. Essentially, being willing to do the work, to truly try and understand how some people who are not members, or are not aware that they’re serving LGBT populations, and helping them answer questions and helping them do better, made me a better expert for them. That was a pivotal point in my mind.

And then also in residency, I was very fortunate to train at Johns Hopkins Bayview, which has much more of a primary care focus, very community-oriented as it is, in terms of home visits, geriatric care, and the like. All of the attendings were very supportive. I was able to be out there. They were able to support me going to conferences and being active in organizations that had a particular focus on LGBTQ health and advocacy. As I mentioned, again, my program directors, the key ones in charge at that time, Dr. Colleen Christmas and Dr. Erica Johnson, were very much wanting to make sure that my passion for this work, my passion within medicine to serve LGBTQ folks, remained intact while going through training.

I think it’s not unique in medical training, or in any residency, that sometimes a little bit of that shine can rub off of people, because training’s rough. I greatly appreciate that my residency program directors and the faculty really made sure that that continued and moved forward. They were also guiding me towards a fellowship in general medicine, which allowed me to get more research chops, but also allowed additional focus on establishing myself as a leader within LGBTQ health research and advocacy. So those are some key ones.

And then I want to point out that, during the fellowship interview process, again, it came down to somebody taking a chance. I remember interviewing for the Brigham, for the Harvard General Medicine Fellowship, and the site director for the Brigham, Jeff Linder, who’s now at Northwestern, very much was like, “We have no one here who does what you want to do,” just up front, essentially saying, “This is a deficiency on our part, and we would like to address that. We would like you to help us address that.” It was again an example of somebody kind of sticking their neck out, taking a chance, and I really appreciated that. At least I feel it paid off for me. I think it paid off for them as well.

Kevin Pho: Now, during your medical training, especially early on, when these people doubted you and called your research interests superficial, how did you find the strength to persevere? Because at that time, I assume you were a medical student, and you had these attendings telling you that it wasn’t a feasible path. How did you find the strength to overcome that obstacle?

Carl Streed: I mean, I’m stubborn, to say the least. I think anybody would acknowledge that about the characteristic, as it relates to: I think something is right. I think this is almost a moral, essentially a moral imperative, to serve marginalized populations, because honestly, when we do better by marginalized populations, we do better by everyone. With that stubbornness, I kind of dug in, but it still was like a negative kind of nagging in the back of my mind.

I think I was fortunate enough, before going back into training, to have time between undergrad and med school actually working at an LGBTQ health-focused community center. I was like, “Well, I know this is a possibility. I know there are people who are able to make a career out of serving, in a primary care setting, LGBTQ populations and marginalized populations.” So even though they said it’s superficial, I saw value in those mentors, Dr. Tom Barrett, Dr. Kathy Kurtikos, people who had been doing this for a long time in smaller settings, and maybe not getting the attention they deserved from academic medical centers. But knowing that that was a possibility really helped me move forward.

And again, like other people early on in med school who were visiting lecturers: I think of Dr. Ken Mayer, who’s a lead for the Fenway Institute, which is one of the largest LGBTQ health-focused research centers now. It had just been established early at that point, and he came to visit Hopkins, and I was like, “I want to have a career similar to what you have.” He’s been a lifelong mentor as a result, maybe not necessarily within any institution that I’ve been at, but he has been one of those external mentors who’s been pivotal.

Kevin Pho: We’re talking to Carl Streed. He is an internal medicine physician, and he wrote the KevinMD article “Professional gay: Charting a career in LGBTQ health.” Carl, for those other medical students, residents, and interns who want to follow in your footsteps and pursue a research interest in LGBTQ health, what kind of advice do you have for them?

Carl Streed: I think the key thing is to find people who are supportive. I think there’s always going to be a naysayer. There’s always going to be somebody who challenges you, and some of those challenges will be helpful. Some of them will be able to help you focus and really kind of think about how you should ever overcome something that’s going to come down the road, but some of them are just going to be flat-out not helpful, discriminatory, and so forth. So it’s really about trying to find those mentors who are supportive no matter what, and more often than not, they might be outside the institutions that you’re training at.

So that means trying to go to conferences, trying to be involved in organizations that are across institutions, across the U.S., and global in reach, because there are people at the same level of training as you who can be peer mentors, and you’re going to find people who are further along in their careers who will be able to mentor you along. That was my biggest saving grace: being active in organizations where I could meet other people who had similar interests to mine, and we could problem-solve together. I think that was the biggest thing that I always tell all my students: “While I’m here for you, I want to make sure that you know there are other folks out there.”

Kevin Pho: One of the things that you mentioned earlier when you were talking about the LGBTQ population is their inherent distrust of the medical system. I’m an internal medicine physician myself, so for the primary care physicians in this audience, what are some ways that we can allay their distrust?

Carl Streed: There’s a lot of different things that we could be doing better about, particularly as it relates to just training: going out there and doing the training. There is a lot of continuing medical education for practicing physicians now to kind of brush up on this and understand what are the issues that our LGBTQ folks are facing. But I think it also gets down to: How aware are you of the experiences of LGBTQ folks in your institution?

Imagine, as a patient, all the different friction points they may face when they finally get to you. You might be the best clinician in the world, but that’s not the entry point for them. The entry point is looking on the web page. The entry point is registration, dealing with registrars, working with medical assistants and nurses, and all that. So that means we have to train up everybody within our institution. That means addressing policy issues. That means talking to HR. To do well, to do right by marginalized populations, we really have to imagine the ways in which they interact with the systems, and the systems are designed to cause these problems whether we are aware of it or not. And so we have to really think of system-level solutions.

Not to put in a bit of a shameless plug, I’ve written multiple articles on how this can be done, some of them within Academic Medicine, some of them within the New England Journal itself. So the idea that people are now paying attention is really exciting, and I’m happy that we are getting the word out more, but we actually need people to make the change. And so I’m a big fan of making requirements around training, making requirements around changing policies and institutions.

Kevin Pho: My final question: What’s your take-home message that you want to leave with the KevinMD audience?

Carl Streed: I think the take-home message is doing right and doing well by marginalized populations will allow us to do better for everyone. Having a focus on underserved and marginalized groups of people will mean we can do better for everyone, them in particular, but your regular John Smith coming through the door will also have a better experience with you as well.

Kevin Pho: Carl, thank you so much for sharing your time and insight, and thanks again for being on the show.

Carl Streed: Thanks for having me.

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