From papers, podiums, and mobile devices, Esther Choo is getting her message out about ED discrimination.
Esther Choo was waiting for a hero. A charismatic, incredibly knowledgeable presence with a passion to speak out about issues of injustice, disparities in the health field and advocacy for women, minorities and equity on a national scope.
Choo recalled the damage inflicted on women in the ED and as an Asian-American, she felt the double dose of discrimination.
“We need to start the business of serious cultural change to one that’s positive instead of so damaging to the work lives of women,” she said. “When your own employer is not behind you, that makes it demoralizing and hard to work. And when your leadership will back the patient instead of you, it leads to burnout.”
That hero wasn’t showing up so Choo, associate professor of emergency medicine at the Oregon Health and Science University, and a nationally recognized public health researcher on gender bias in medicine, decided she’d be the voice of the voiceless.
Choo spoke with EPM Senior Editors Judith Tintinalli and Mike Silverman about her journey and steps to becoming a truth speaker one tweet at a time.
“I was waiting for someone to come along who was better at it,” Choo said. “I felt like I had to pass this invisible threshold where I had to be enough of an expert to speak about it. I could have waited forever. Now I wish I’d spoken up sooner and not let my insecurities hold me back.”
Choo’s over 62,000 Twitter followers are thrilled she stopped listening to her inner doubts and started tweeting her truths.
The biggest came in the wake of the Aug. 12, 2018 white supremacist rally in Charlottesville, Va. Choo tweeted Oregon has a “lot of white nationalists” and a few times a year patients refuse treatment because of her race. Choo’s Twitter thread went viral, sparking more than 25,000 retweets including Chelsea Clinton.
Choo’s spotlight on an unspoken national ER issue put her in the spotlight. Despite doubts and fears she wasn’t adequate enough, Choo became increasingly comfortable sharing her views on CNN, other news channels, and Twitter.
“It’s all about managing the invisible gate that we have and speaking out about things that are not right and fair,” said the Yale medical school graduate. “The entire system is not fair and if you see something that’s not right, you need to speak up. Think about your own sphere of influence.”
Choo reflected on tweets from followers who shared their encounters of discrimination in different EDs from patients and supervisors. Those tweets and her own experiences helped empower Choo to want to speak out on ways to improve the status of women physicians. Last year, Choo co-founded Equity Quotient to monitor and address equity culture in healthcare organizations.
“We’re so socialized to accept bad behavior from our patients, behaviors we wouldn’t take from our peers and supervisors,” Choo said. “We probably have a high threshold of the bad behavior we will take without thinking to complain. The right thing to do is bring it to people’s attention.”
While visiting a shopping mall, Choo said its shopper code of conduct stood out. The simple sign made her question why the same isn’t true in most EDs.
“We don’t announce parameters, which codify patient and visitor behaviors in the ED, and which clearly state that discrimination against health care providers is inappropriate.” Choo said. “I’ve never walked into a hospital when it’s been as visible as in that mall. We don’t display our message clearly to our patients and our colleagues. There’s a lot we could do to make it better.”
Choo credits former Surgeon General Vivek Murthy for initially encouraging her to start using Twitter more proactively.
Among her other influences, Choo cites Kathleen Clem, the first Chair of the SAEM Academy for Women in Academic Emergency Medicine, for encouraging her to speak out. “We’re really lucky in EM to have women who are not shy,” Choo said. “AWAEM women have learned how to deliver a master class about these systemic issues without mincing words.”
Choo hopes to see a physician workforce that more accurately reflects the patient workforce. Under the current dynamic, Choo said it’s harder for people to feel understood, fully respected and treated in the way they feel like they want to be treated due to the patient/physician mismatch. Choo wants to see more diversification of the health workforce to address some of those issues.
Being a prolific Twitter user allows Choo a viable platform to discuss vaccines (she’s a supporter), sexual harassment in the ED, and the wage gap. Naturally that leads to a healthy share of criticism and critics, whom Choo said she is happy to engage with in productive and respectful dialogue.
As for the “haters” hoping to rile her up or stoke the flames of discontent for their brand, Choo said she learned to stop making time for them.
“The more the tweets get attention, the more trolls come out. People say terrible things,” she said. “Some say I’m making things up to advance my professional goals. I’ve gotten to the point where I stop listening. There’s two people I don’t engage with any longer – trolls and people whose career depends on maintaining a viewpoint. If that’s your livelihood you cannot have a healthy lifestyle.”
While the intent is to be respectful and thoughtful with her tweets, Choo admits sometimes she’s not in the mood to be overly cautious.
“There will be times when I think today I’m too tired to be rational and I am angry,” Choo said. “There is a mental health function to Twitter and at times there’s a very satisfying egress, but you can’t live in that space all the time.”
There is a wide discrepancy at times from the weeks and years Choo said she spends on research to a limited audience versus the appropriately timed tweet.
“After I got my career development [grant] from NIH, I wanted to see the stats. This was my life’s work for five years and it received 18 downloads compared to a tweet that gets 30,000 reads the first day,” Choo said. “The impact piece just doesn’t compare.”
Choo said she loves the scholarly life and being able to speak about health policies based on her research on women’s health, intimate partner violence, substance use disorders and technology-based interventions. One of Choo’s priorities is to take her research and move the field forward with what she’s learned. As a founder of Time’s Up Healthcare, Choo works with women in various industries and she said she’s found their experiences are so similar, particularly with women of color.
“I have this social media platform that I’m so grateful for and the main question is how do I use it for good?” Choo said. “What do I do now? Do I do a little more of that and move forward with advocacy?
Becoming a physician influencer has opened up opportunities like speaking gigs in Australia and regular features in HuffPost and other publications where she writes about gender, racism and wage equality.
“I always thought sexual orientation wouldn’t be an issue,” Choo said. “One time, I couldn’t find anyone to cover me [during a shift] for an interview and I had a friend who is gay offer to fill in to speak on his behalf of all the overt bigotry he’s received in the ED because of his sexual orientation. It is invisible in these one on one bedside interaction that no one sees.”
That high profile status is not without drawbacks as Choo said she knows she makes people uncomfortable and her outspokenness has cost her access to some rooms and meetings.
“I get it. People think someone who talks about problems would tend to be divisive,” Choo said. “I’ve gotten complaints that my feminism is over the top and wasn’t appropriate or they didn’t agree with me. I’ve given talks and people will walk out.”
Choo said her approach is disruptive to the establishment.
“If you’re in an institution it can seem like I’m talking about the leaders of that institution, but no one is exempt from these issues,” she said. “It’s uncomfortable. I’m questioning how people do things and how it’s always been done. It is uncomfortable to have someone like me.”
Crafting viral tweets is rarely an objective for Choo. Instead, she largely tweets whatever comes to mind with the agenda being to bring some issues like the gender and wage gaps to the public space. She’s found followers respond to her personality, sharpness, typos and all.
“Once every couple of months I have a planned strategic tweets around some initiative,” she said. “Everything else is very spontaneous. I think for about 10 seconds before I do it. I have a framework for doing it with the diversity of who I promote like women and minorities.”
Choo said it’s important that she instills a sense of hope while she brings awareness to societal problems.
“They need to be balanced with hope otherwise there’s no action,” Choo said. “If you’re too negative people feel depressed and despaired and not feeling like they can do anything anyway so I always end on a message of hope for people.”
As for her future goals? Choo said she could see a dramatic second phase of her career, but doubts her path will take her down the political arena. For now she’s enjoying being a change agent helping to draw attention to important issues and marginalized communities.
“What I learn in the ER is mind blowing. I take those reflections and take them into research and move the field forward with what I’ve learned,” Choo said. “This advocacy piece makes me feel like if I can do more it’s great. That part has all been unexpected. I’ll be open with whatever happens, which is how ER docs deal with things, right?”