Porphyria: A Historical Mystery

Porphyria: A Historical Mystery

If you ever studied the English monarchy in your high school history class, you might have been taught that King George III suffered from a mysterious disease called porphyria. What your teacher probably didn’t add is that this diagnosis wasn’t made until nearly 150 years after the king’s death. In fact, most medical experts strongly disagree with the porphyria theory and believe that King George’s strange symptoms were caused by a completely different condition. 

So how did the story of this incorrect diagnosis become so widespread, and why do many people still believe it today? We’ll take a closer look at the origins of the porphyria theory and do a deep dive into the causes of this rare disease. 

  • King George III’s mysterious illness

  • 1966: mystery solved?

  • Causes of porphyria

  • Porphyria: Signs and symptoms

  • Porphyria over time: from death sentence to treatable condition

  • Back to King George III: debunking the porphyria theory

King George III’s mysterious illness

King George III’s rule over the British Empire lasted an impressive six decades, from 1760 to 1820, but today, he is best remembered in Britain as “the mad king who lost America.” A 1994 movie called The Madness of King George even earned several Oscar nominations and netted $12.5 million with its portrayal of the monarch’s mental decline. So what were the king’s symptoms, and why do they still fascinate the public two hundred years later? 

King George’s first serious bout of illness took place in the summer of 1788, and by November, his condition had reached a low point. He would often speak for hours on end until he was hoarse and foaming at the mouth. He also began to use increasingly convoluted and nonsensical grammar in his speech and writing, sometimes using sentences with more than four hundred words. Today, we would recognize this behavior as symptomatic of a manic episode, but contemporary doctors had no idea how to treat him. Eventually, they resorted to physically restraining the king during his episodes until he wore himself out. 

Over the next few decades, the king continued to have sporadic attacks of ill health, but he always recovered enough to resume his role in government. Following the death of his youngest daughter in 1810, however, he began his final descent into illness. For the next ten years, the Prince of Wales ruled in King George’s name while George himself lived in seclusion. During this time, the monarch’s manic episodes continued, accompanied by worsening dementia. By 1814, he had forgotten who he was, and contemporary reports show that he babbled for 58 hours straight during Christmas of 1819. Doctors continued to treat his symptoms with the limited resources they had available, and when the king died in 1820, so did any hope of diagnosing his illness with complete certainty. 

1966: mystery solved?

In the 1960s, two psychiatrists called Ida Macalpine and Richard Hunter began to sift through the king’s surviving medical records in hopes of diagnosing his debilitating illness. Previous experts had suggested manic-depressive psychosis (now called bipolar disorder), but Macalpine and Hunter disagreed, arguing that the king’s periods of excitement didn’t meet the criteria for mania. Instead, they focused on records of George’s physical symptoms, especially his frequent abdominal pain, tingling in his arms and legs, and periods of mental confusion. In 1966, Macalpine and Hunter published a paper concluding that these symptoms pointed to acute intermittent porphyria. 

Even though doctors disagreed with Macalpine and Hunter’s paper, a leading historian endorsed their theory, and sensationalist media reporting brought it into the public eye. It’s not hard to see why the story was so popular — porphyria is a rare disease with intriguing symptoms like purple urine (which is how the illness got its name). In the next section, we’ll take a closer look at what causes these symptoms in the first place. 

Causes of porphyria

The name “porphyria” actually encompasses a group of metabolic disorders characterized by deficient synthesis of heme, an iron-containing compound that acts as a cofactor to help the hemoglobin in red blood cells bind to oxygen. The heme production pathway has eight steps catalyzed by eight different enzymes. When any one of these enzymes fails to function properly, the molecular precursors to that step begin to build up and spill into the bloodstream, resulting in a different type of porphyria for each enzyme.

The most common type is acute intermittent porphyria, which is associated with a defective porphobilinogen deaminase enzyme. Since that’s also the type of porphyria King George III was proposed to have, it’s the kind we’ll focus on here.

We still don’t know exactly how porphobilinogen deaminase deficiency contributes to acute intermittent porphyria, but there are two different possibilities. The first theory focuses on the end of the heme synthesis pathway. Logically, if a step early in the pathway is blocked by a defective enzyme, there will be a shortage of everything produced after that step. That means there won’t be enough heme to meet the body’s needs. According to this theory, heme deficiency in neuronal cells is at the root of patients’ neurological symptoms. 

The other proposed explanation is based on the buildup of precursors in the heme pathway before the blocked catalytic step. Instead of too little heme, this theory points to too much δ-aminolevulinic acid as the cause of the disorder’s neurological manifestations. 

Of course, it’s also possible that both theories are partly accurate. For all we know, symptoms could be caused by a lack of heme in combination with an excess of δ-aminolevulinic acid. In the next section, we’ll take a look at those symptoms in more detail. 

Porphyria: Signs and symptoms

As the name suggests, acute intermittent porphyria involves sudden and worsening symptoms, including abdominal pain, nausea, vomiting, and weakness. As the disease progresses, neurological symptoms become more severe. Patients may begin to have seizures or show changes in their usual affect or cognitive processing ability. 

Although the word “porphyria” comes from the Greek word for “purple” and other forms of the disease are characterized by purple or blue urine, this symptom is not typically seen in patients with the acute variety of the disorder. That’s because the main precursors in the pathway before the step with the defective enzyme – porphobilinogen, δ-aminolevulinic acid (ALA), and glycine – are colorless, although they will form purple pigments if the urine is exposed to light at room temperature for some time. 

Porphyria over time: from death sentence to treatable condition

The good news is that acute intermittent porphyria is rare. About one in two thousand people carries a gene with a dominant mutation in the code for this enzyme, but less than ten percent of those carriers ever experience an acute attack. It’s not clear what causes porphobilinogen deaminase to malfunction in these patients, but epigenetic and environmental factors almost certainly play a role. 

The bad news is that because porphyria is a rare condition and most patients experiencing an attack for the first time don’t know they carry the mutated gene, misdiagnosis isn’t uncommon. On top of that, the only test that can definitively confirm the disease (a measurement of the amount of porphobilinogen in the urine) takes four to ten days to be processed at a commercial laboratory, which means that treatment is delayed even longer.  

For these reasons, the prognosis for most patients was bleak until a few decades ago. Before the 1980s, up to a quarter of acute porphyria sufferers died due to a lack of diagnostic expertise and appropriate treatment options. Today, many patients receive intravenous heme to supplement their bodies’ dangerously low supply. Meanwhile, abdominal pain, nausea and other symptoms are managed with a combination of narcotic painkillers and other drugs. Although people who experience multiple acute attacks have an increased chance of developing liver and kidney disease, including hepatocellular carcinoma, the risk can be reduced if patients visit a healthcare provider once a year for abdominal screening and a blood protein test. 

Back to King George III: debunking the porphyria theory

Where does this leave King George III? His attacks of mental confusion grew more and more severe until he was forced to withdraw from governmental affairs entirely in 1811. He suffered from dementia for the last ten years of his life while his son, the future King George IV, ruled in his name. During this time, his doctors kept almost daily records of his behavior and any new medical developments. The doctors had plenty to keep track of: over time, the king developed muscular weakness, blindness due to cataracts, vocal hoarseness, a jaundiced appearance (indicating liver problems), and frequent abdominal pain. 

These accounts formed the basis of the later work by Macalpine and Hunter. Based on the recorded symptoms, they declared the king’s condition “a textbook case” of acute intermittent porphyria in their 1966 paper. 

Other medical experts were quick to disagree. One of the best-known signs of porphyria is purple urine, and Macalpine and Hunter had found evidence of this in the king’s medical records — but they had cherry-picked their data, focusing exclusively on four reports of discolored urine over a thirty-year period while ignoring six records of normal urine in the weeks before the king’s final descent into dementia. They had also failed to account for the doses of gentian that the king’s doctors had given him. This plant’s deep blue flowers could easily have turned the patient’s urine purple. 

On top of that, the medical reports that Macalpine and Hunter relied on actually supported the original diagnosis of bipolar disorder. Trademark porphyria symptoms like the inability to concentrate were missing from these records, but the king did regularly display intense, almost manic, activity according to his doctors at the time. As if all of this weren’t enough, eighty to ninety percent of acute intermittent porphyria patients are women of reproductive age, making this diagnosis even more unlikely.

When we consider the contemporary medical reports, bipolar disorder certainly seems to fit the bill, but it may not have been the only illness King George was contending with. After all, patients with bipolar disorder are expected to return to baseline functionality in between manic episodes, so a ten-year period with little to no relief suggests comorbidity with at least one other condition. 

Looking at the king’s medical history, depression and dementia are the most likely candidates, in addition to known physical ailments like cataracts and rheumatism that may have accelerated his decline. Following his daughter’s death in 1810, King George displayed extreme anhedonia, or loss of interest in his usual activities, and other symptoms characteristic of major depressive disorder. By this time, he had already lost his sight to cataracts and was quickly losing his hearing as well. The rapid decline of his sense of orientation — not just to time and place, but even to the identities of his closest family members — indicates that the monarch probably suffered from dementia for at least the last several years of his life. Combined with the likely diagnosis of bipolar disorder, the king’s condition would have been far beyond the abilities of his nineteenth-century doctors to treat appropriately.  

We’ll probably never be completely certain of the true cause of King George III’s illness, but when we consider the archival evidence, acute intermittent porphyria can almost certainly be ruled out. Despite this, the myth started by Macalpine and Hunter has made a permanent place for itself in the history books. Rather than erasing the false diagnosis from the historical record, maybe we should celebrate the attention that this error brought to a rare and little-understood metabolic disorder.

Medicine Needs More Givers

Medicine Needs More Givers

Shortly after starting medical school, I found myself feeling a bit down, or as my wife would say, “in a funk.” Don’t get me wrong. I was more than excited to finally be pursuing my dream of becoming a doctor and practice medicine, but something was off. I couldn’t put my finger on it until one day, while walking back to my apartment, I ran into a friend who told me he was feeling the same way. As we walked, talked, and listened to each other’s frustrations, we came to the same conclusion.  The reason we were both feeling a little unfulfilled: our lives were currently all about us. 

It was an easy trap to fall into. In those crucial first few months of medical school, failing a test or course was constantly at the back of my mind. The fire hose of information had been turned on and it was all I could do to keep up. The thought of doing anything extra wasn’t even on my radar. Eventually, I acclimated to the chaotic pace of medical school and many of the worries and fears dissipated as I found my groove and learned to enjoy the challenges of the rigorous pace. Although the fear of failing was still present, it lessened as I learned to surround myself with Givers. 

Students pursue medicine because they care about others and want to help

Up until I started medical school, service had been an important part of my life. I was raised by parents who encouraged me to look around and see what I could do for others. For my Eagle Scout project, I fundraised money to buy special cleft palate bottles and other needed supplies to send to an orphanage in China. My dad always made sure my brothers and I shoveled the walks and driveways of our elderly neighbors after snowstorms in the winter.

When I graduated high school, I left home for two years to live in France and serve a mission for The Church of Jesus Christ of Latter-Day Saints. Not everyone wanted to hear a gospel message, but I found that many people needed help in one way or another. Dedicating two years looking for ways to serve others enriched my life and broadened my perspective. We share more in common than we have differences when we take time to get to know our neighbors.

In college, I met my wife, who is a special education teacher. I loved volunteering in her classroom where the needs of the students seemed to be endless. I helped kids with everything from reading and math to science fair and art projects. We started an early morning basketball club for kids whose parents couldn’t afford to sign them up for the county recreation league. I had as much fun playing basketball as the kids did. I mentored two teenage brothers in the foster care system and took our dog to visit patients in the hospital. Life was good and it was satisfying, feeling like I was making a difference in my community. I have always known that I wanted to make a career out of helping people and medicine seemed like a natural path. 

I have noticed that many of my fellow peers had similar experiences prior to medical school that solidified a desire to enter the healthcare field. Without these experiences, it would be impossible to see the light at the end of the long daunting tunnel that is four years of medical school. These opportunities to reach outside of ourselves remind us of the importance of our future roles and keep us motivated when the light fades and we start to wonder why we began this journey in the first place.


Medical school shifts the priority to studying and passing boards over service

In medical school and residency, the lamentable truth is that grades matter. You could be Mother Teresa, but if you flounder on Step 1, you’ve unfortunately closed a lot of doors to your future options. Moving to a pass/fail system will partially remedy this, but applicants will still need to be differentiated. Step 2/Level 2 scores, in conjunction with class rank and research publications, will become the main considerations for program directors looking to sort the thousands of applicants competing for a dozen spots in their program. 

Just look at the most recent 2018 NMRP Program Director Survey. In selecting applicants to interview, the primary factor stated by 94% of all program directors was Step 1/Level 1 scores. Only 54% of program directors cited volunteer work and extracurricular activities as important. It is no wonder that medical students spend significantly more time studying for their exams and boards than they spend looking for and participating in meaningful service opportunities.

I do scratch my head in wonder sometimes at the fact that a program can place so much importance on a score that is almost two years old at the time of applications and emphasizes material that a majority of doctors readily admit is useless in day-to-day practice. As a third-year medical student, I never once had an attending quiz me on the steps of the Krebs Cycle. Fortunately, more and more programs are placing a greater emphasis on the “whole applicant” rather than just a three-digit board score.

Givers and Takers: Which one are you?

I recently watched an amazing TedTalk by Adam Grant. The talk was so inspiring that I immediately bought his book and read it. Adam Grant divides people into Givers and Takers. We have all been involved in those group projects where someone does not pull their weight but still gets the credit of a job well done. If this experience doesn’t resonate with you, you just may be a Taker. Givers, on the other hand, are those who silently pick up the slack from the Takers. A Giver doesn’t always receive the credit for a job well done, but that doesn’t bother them. Their focus is on making sure the group is successful. As in life, medical school is full of both Givers and Takers. 

Givers are those who go into situations focusing on what they can do for others. Takers, on the other hand, look for what others can do for them. It is often difficult to recognize a Taker at first. They can be charismatic and outgoing, but eventually their needs have been met and they move on, having gotten whatever they needed from the relationship. Individuals who give, of course, can be just as charismatic and outgoing, but they work to benefit others, even if it means that a promotion, scholarship or award goes to someone else. 

Givers At The Bottom and Givers At The Top

People who give constantly, those who sacrifice themselves for the good of others, consistently finished towards the bottom of their class according to Adam’s research. He summed this up nicely with the following example: You’re at school studying and you notice one of your classmates just isn’t grasping a topic you’ve got down.

Instead of moving forward and learning new material, you pull back and help your classmate learn what you’ve already mastered, sacrificing time you could be using to move on to something new. The classmate could possibly have an advantage over you come test day, but you’re a Giver, so this doesn’t even cross your mind.  

Consider cycling. Lance Armstrong, love him or hate him, would have never won 7 Tours de France without his trusty domestique, George Hincapie by his side. Domestique is a cycling term and identifies a rider whose sole job is to support and sacrifice for the team leader. It is a French word that translates to ‘servant’ in English. Michael Jordan? Probably wouldn’t have won 6 championships without Scottie Pippen and Dennis Rodman on his team. In a way, these Giver athletes sacrificed the spotlight and personal fame for the betterment of their teams. These teams and their stars had tremendous success because of these silent Givers. 

Givers fell to the bottom of their medical student cohort, so it would seem logical that the Takers took the top spots. Surprisingly, Adam Grant’s research found that another set of Givers rose to the top of their class ranks. The reason actually makes a lot of sense. The first two years of medical school are book heavy. This course load tends to favor Takers as they can focus on their own needs without having to look out for those who may be struggling. During the third and fourth years of medical school, students transition to clinical rotations.

Teamwork is rewarded and students who are Givers tend to stand out more and make lasting impressions,  not just with the doctors who evaluate them, but also the nurses, medical assistants, and other team members they interact with on a daily basis. 

Looking back at the 2018 NMRP Program Directors Survey, while Step 1/Level 1 board scores make up the top spot, Letters of Recommendation and the Medical Student Performance Evaluation (MPSE/Dean’s Letter) make up the second and third spots respectively. These evaluations actually favor Givers. While impressive board scores may get your foot in the door, Letters of Recommendation and the MPSE are what seal the deal and get you the residency spot you desire. In this sense, there is real value in being a Giver.

The most successful people in your class are most likely Givers. It’s the Givers who will most likely excel during those coveted audition rotations and land their dream residency spots. Better residencies have the potential to lead to better job and fellowship opportunities and these opportunities will most likely turn into increased earning potential. In a sense, it literally pays to be a Giver.  

Givers are needed now more than ever

Medical school is hard. A quick Google search for ‘burnout in medical school’ comes up with almost 19 million hits. The National Academy of Medicine defines burnout as “a syndrome characterized by high emotional exhaustion, high depersonalization (cynicism), and a low sense of personal accomplishment.” Early on in my first year of medical school, during that walk back to my apartment, my friend and I were already experiencing symptoms of burnout. We weren’t alone, as over 50% of medical students will experience similar symptoms over the course of their education. Take a minute to think about that. Half of your class is struggling with “emotional exhaustion” and “a low sense of personal accomplishment.” Half of your study group is experiencing cynicism. Burnout can affect not just your peers’ school performance but also their physical health. 33% of medical students surveyed by Mayo Clinic researchers admitted to alcohol abuse or dependence. Only 16% of their non-medical peers admitted to the same problem.

I have found that I tend to experience burnout in projects where I’ve been burned (pun intended) by a Taker. I become more cynical. I wall off and turn off my giving nature. I take a “fool me once, shame on you, fool me twice, shame on me” mentality. I focus so much on not getting burned again that I end up helping no one. I become by default, a Taker. 

How to Be a Giver in a Takers World

During my second year of medical school I surrounded myself with Givers. We shared study guides, memory aids, and helped each other overcome our weaknesses. The weekend before a test we would all get together, order a few pizzas and go over the material together. Our review sessions weren’t “high yield,” they were “massive yield.” My mental health skyrocketed. I can’t help but think that there would be a lot less than 50% of medical students suffering from burnout if their classes were made up entirely of Givers. 

It can be frustrating for Givers to see Takers getting ahead and getting recognition when most (if not all) of their success was secondary to a Giver. How do we learn to strike that balance of being a Giver without letting our efforts go unrecognized? It is easier said than done. And I don’t have a clear answer to that yet. Givers are what make our classes great, they are what keep us going and make us successful. We can all think of someone who is naturally a Giver: someone who goes above and beyond to help others without even taking a moment to think about it. Thank them. Appreciate them.  

Don’t shun the Taker in your group, work a little harder to make them feel like part of the team. Give them the opportunity to feel the satisfaction that comes with working in a group. It may seem like a longshot, but I believe that once the Taker starts to identify with the group and feel like they are part of the team, their selfish desires will start to fade as they realize what is good for the team is actually good for them. 

Just as most issues are not simply black or white, the world is not made up of just Givers and just Takers. Giving and taking is a behavior, and behavior can be changed, just like any other behavior. Everyone, even self-identified takers, can benefit from being generous. It is my hope that anyone reading this (especially Givers who are feeling burned out) finds a little inspiration to help those around them. As our education has shifted to a virtual platform, it is even more difficult to spot those who may be in need. Now is an excellent time for all of us to get out of our comfort zone and actively search for those who may need a little extra help.

Ask questions, share helpful study finds, and most importantly, remember why you went into medicine in the first place. Think back to that one experience or patient that inspired you and keeps you going.

With a little bit of effort, we can turn medicine into a true field of Givers. 

Medical Student: Unorthodox Connections in a COVID-19 World

Unorthodox Connections in a COVID-19 World

Ah, the bright-eyed medical student. It’s 6:00 AM. The eager student has her fresh crisp whitecoat on embellished with her stethoscope, clipboard, and neatly arranged pens. However, there’s just one problem — it’s COVID-19 season. Many medical students have been stripped of access to clinical rotations and have been forced to enroll in online coursework. Let’s face it – nowadays, students can learn just as well outside the classroom setting, in an era of online question banks, flashcards, and of course Physeo. While students can maximize their strengths by studying on their own with due diligence… how can they maximize key vital relationships from residents, faculty, and beyond? As a rising intern and former student mentor, I realized that there are some pearls from my time with COVID.

Here’s an overview of what we’re discussing:

  • Tip #1: Don’t be shy 
  • Tip #2: Start within your circle 
  • Tip #3: Leveraging connections in your medical school
  • Tip #4: Who’s who in your city
  • Tip #5: Online networking 

Tip #1: Don’t be shy

While we all may not be extreme extraverts, this is the time to get out of our comfort zones and start to mingle with departments that we are interested in. Are you interested in forensic pathology? Or is it perhaps pediatric neurosurgery, but you don’t have exposure to it? Well, I’ve got some news for you. Even before COVID-19, you would have to start meeting some people at your school early on. But the question is — how? In a time of limited clinical opportunities for students and cancellations of away rotations, some of the best mentors are at your fingertips. If your school is still closed due to unprecedented times, it’s time to channel your inner telemarketer. Start reaching out to the chiefs, residents, and even faculty! While it may be intimidating to do some cold calling, you may be pleased with your results. More often than not, people love meeting those who are genuinely interested in their craft. It’s a great way to break the ice, get familiar with them, and leave a strong impression. 

For instance, before switching over to internal medicine, I was interested in pursuing a career in clinical pathology. I started early by reaching out to residents and faculty who helped organize and present lectures in my preclinical years. While it is cold calling, my calls were received warmly. I was able to meet with the chairman and other big whigs. In fact, I was able to work on a few research projects that were submitted to a few conferences. This opened the doors to many faculty across the nation. Even with a change in specialties, the pathology faculty were quite helpful in providing their insight into the internal medicine faculty.

Tip #2: Start within your circle

As students are concerned with the USMLE Step exams, virtual clerkships, and limited facetime with faculty, many are worried about how they can earn a strong letter of recommendation. It’s not a surprise, but it takes a whole village to raise a child. Likewise, a successful student who will apply for the MATCH requires the strong connections of peers, residents, and faculty. 

An amicus curiae, or friend of the court, can be useful to obtain new relationships. From upperclassmen to that one intern, an introduction can provide a good impression and everlasting connections. For instance, one of my best friends to this day is an upperclassman (and now anesthesia resident) who I have met early on during my first year as a medical student. We grew close, and eventually, our circle of friends merged. By having the wisdom of those that came before me, I had my very own personal oracle. This special friend of mine made sure to keep an eye out for me during both pre-clinical and clinical years – from study tips to even “pimp” questions during rounds to surviving the not-so-glamorous night shift. Beyond the classroom and wards, I also gained invaluable advice on how to crush the residency interview trail.

So, if you’re a fan of Game of Thrones, you’ll realize it is often who you know and not what you know. Our cunning friend, Petyr Baelish was ever-resourceful and able to make critical partnerships to advance his power. Like in medical school and residency applications, it is critical to elevate yourself with who you know. 

Figure 1: Spoiler alert: The despicable, but quite capable, Petyr Baelish “gunning” for the throne aka that letter of recommendation. Don’t be like him exactly, but you get the point.

Source: Promotional photo of Aidan Gillen as Petyr Baelish on Game of Thrones. Courtesy of HBO.

Tip #3: Leveraging connections as a medical student

Now that we have channeled our inner Petyr Baelish, we understand the importance of making vital connections with faculty and residents. However, how do we utilize our connections? Since we do not want to come off as a nuisance, it is important that we understand how to be tactful about it. First, and foremost, do your job well. If you’re in a school that has just started opening up their rotations, it’s a good idea to understand how to become a good medical student first. Show up on time. Prechart. Help with orders or any “scut work” if necessary. By understanding the workflow, students can be integrated more seamlessly. Once this occurs, residents and faculty will notice. As you gain their respect and trust, it is easier for all parties to open up and help each other. With more trust, you gain more responsibilities. Perhaps now you have the privilege of gaining authorship on a case report or just a simple strong evaluation and letter of recommendation. 

Tip #4: Who’s who in your city

Maybe connecting with your faculty and residents at your school are not panning out. Maybe it’s time for you to look at your neighbors — literally. If your city has other institutions with academic affiliations and residency programs, it may be strategic to set up early relationships with them. If you are able to reach out to the program, often through a coordinator or secretary, they are usually more than happy to help facilitate a meeting for you to meet with the program director, chairman or -woman, or another faculty member that could help. However, in a time of social distancing, reaching out to these entities may be more difficult to meet in person. Online correspondence may be a potential method, but your email may be lost in a sea of other messages that plague the doctor with more bureaucratic shenanigans to deal with. So before that email is sent, make sure to proofread it and send it right in the morning – from 6 AM to 8 AM.

Tip #5: Online networking 

Ah, the Internet. Today, everything has become more digitized, it has become more important to use online communication platforms. Specifically, the modern age of social media. In a world where everyone and everything is profiled, so is our professional and academic careers. With platforms such as LinkedIn and Doximity, finding connections in other medical students and institutions has become much easier. It’s as easy as 1-2-3. Use a professional photo that you would for ERAS and fill out the sections that include your education, work experience, volunteering, research, etc. You want the reader to get to know you and see how you are as a professional and future physician. First impressions go a long way, so make sure you proofread your LinkedIn and Doximity profiles! 

You can literally find a mentor within seconds while you’re in your PJs at home watching reruns of The Office. By advertising your attributes and goals online, you will end up matching with people with similar backgrounds and goals. This is a great initial step in your search to meet and network with your future colleagues and other medical students. Don’t pester them with incessant emailing, but a brief genuine message can go a long way. And if that person can’t help you, they often have people in their network that can. 

From short research gigs to potentially meeting your future PD, the sky’s the limit. While you’re maintaining social distancing, remember the world is still closer than ever. 


How To Engage In Professional Activism In Healthcare

How To Engage In Professional Activism In Healthcare

Are you tired of fighting Facebook Trolls denying the reality of COVID-19? Do you no longer want to remain a passive bystander in the fight for justice? Is your family ready to disown you because you pick arguments about politics at family functions? No? Oh, then it must be just me. But if you are like me and you want to be an activist without feeling angry or attacked every time while maintaining your professionalism, it’s time we talk about what we can do, as a person in healthcare, to present ourselves with decorum and class while engaging in activism. 

Before entering professional school, it is recommended you ‘clean up’ your social media to have it better reflect your more mature self. This may include deleting old photos, posts, comments, that may be immature or inappropriate. In some cases it may be better to delete your social media accounts altogether. However, if you are interested in a public platform especially for activism, there is a way to be both professional and advocate for your beliefs. 

Recent events have led to an increasing number of medical professionals utilizing public social media platforms to defend the scientific process and refute false information on the internet. Politicization of public health, science, and medicine have put professionals in an awkward position to dispel harmful rhetoric without ‘being political.’Research funding, health education, and the pandemic response have become political. 

In being vocal, using anything from social media to cable news, you may open yourself to the liability of losing your job. For example, ex-surgical resident Dr. Euguen Gu was terminated from his residency program in Vanderbilt for posting tweets condoning white supremacy on his twitter because it violated Vanderbilt’s policies. So what should we do to protect ourselves and our careers when speaking on controversial topics?

The question we need to ask ourselves is whether we extend the idea to ‘do no harm’ beyond the confines of a hospital. If you find yourself in a situation where you feel that not speaking will do more harm than speaking, then you should do so!

 Is there a safe way to stand up for what you believe in without risking your livelihood? Yes! Follow these 10 steps to ensure that you are engaging in professional activism. 

Step 1: What Exactly Do You Believe In?

People need to educate themselves to form a valid opinion. Really sit down with yourself and articulate to yourself your beliefs. Write it down, read literature and books to form more cohesive opinions, and talk to other people. If you find yourself being indifferent or under-educated about a certain topic, research it and ask questions! Be open to new opinions, other perspectives, and critiques of your own opinions. Be an active listener. Take an implicit association test and reflect on your results. 

If you are a healthcare student or professional, it is non negotiable that you are on the side of science. You should be echoing scientific literature, expert opinions from professionals in the field, and proven scientific fact and reproducible theories. Do not make baseless scientific claims based on whims and feelings, it is a sure-fire way to lose credibility.

Step 2: Include Your Credentials In Your Bio

Which social media do you want to use? Are you going to use your personal account? If you decided on posting from your personal account, delete anything that you think is in poor taste or does not reflect your current values. Another option is start a completely new public professional account for your activism, and build a following. 

If you are using Twitter, Instagram, or TikTok, update your bio to include your credentials such as your degrees, education background, and if you feel comfortable, the name of your institution. It is incredibly important to be transparent on social media so you are not subject to ad hominem attacks by people questioning your intelligence. I would stay away from platforms such as Snapchat as information disappears after 24 hours, and you don’t have an option to include a bio. 

As a person in healthcare, your opinions and judgments carry a lot of value as people look up to you. You can provide intimate knowledge and first hand perspective that people cannot otherwise get. Since you may encounter people who are misinformed on a certain scientific topic, it is important to educate them and be able to be in a position to say to yourself: “yes, I have studied this topic through my xyz degree and I am confident in the information I am posting publicly.”  

Step 3: Follow Accounts of Fellow Academics, Journals, and Credible News Sources/People

Before you start posting, study the way verified, established organizations are engaging in activism on social media. Examples include the American Civil Liberties Union (ACLU), New England Journal of Medicine (NEJM), and the Human Rights Campaign (HRC). Be selective with the accounts you follow and where you are learning information, since it reflects on your credibility. 

Here’s a life hack: Look at the users respected organizations are following. Those users have probably been vetted and post high quality content. Following these accounts gives you an opportunity to repost published information that is accepted in professional organizations. It is a good place to start if you don’t feel comfortable posting your own hot take on a current issue.

Step 4: Vet information Before Posting

When we come across statistics and statements that prove our point, it is easy to post it and say “I told you so!” Before posting it, check whether the information that draws from reliable sources.

Examples of credible sources include:

  • Reproducible recent literature with peer-reviewed sources
  • Textbooks 
  • Databases like Google Scholar, UpToDate, and JSTOR.
  • Government and educational institutions, examples include .gov and .edu.
  • First hand information from leading experts and respected authors. 
  • Academic podcasts like The 1619 Project, Code Switch, and Bloomberg Law
  • Centrist news sources (are there truly any?) that report without bias and provide citations. Politico, Wall Street Journal, and The New York times are neutral and reliable sources for current events. 

Examples of unreliable sources: 

  • Blog Posts
  • Social Media Posts without credible sources
  • Websites ending in .com, .net and .org
  • Retracted/Out-of-date literature 
  • News articles without citations 
  • YouTube Channels that do not provide sources 
  • Ted Talks 

If de-bunking information from an unreliable source, use a reliable source to do so. 

While you are not writing a thesis, it is still important to directly include the source from which you are referencing.

Step 5: When In Doubt, Don’t Post It

It is always better to post high-quality content less frequently than frequent content that varies in degrees of quality. If you are uncomfortable speaking about a matter, don’t do it. Be fully transparent in the limits of your “wokeness” as there is no such thing as a “perfect ally.” 

For example, if you are a cis, heteronormative individual you may not completely understand the scope of sex anatomy, behavior, and identity, and that’s okay! So in this case, it would be inappropriate of you to post your thoughts on something you are not completely privy to. It would be appropriate however to use your platform to ask your audience to send you resources so you can be a better ally.

Step 6: Post Literature and Published Research

I’ve seen healthcare professionals on social media do it a couple of ways:

  • “Mini-Journal Club” approach.  For example, pick a broad topic to talk about like “racism and stop/frisk policies”, and then find an article and annotate it using simple diction, and present your annotations of the article to your audience. Screenshot sections of an article and underline sentences to either make a point or refute a point from an unreliable source. You may choose to include relevant figures and explanations of the data. 
  • Reaction and Review. Pick any source such as a clip from a news segment, a podcast or a YouTube video. Watch the video in real time and pause the video and play devil’s advocate to a claim said in the video. This presents a good opportunity to interject with peer-reviewed literature on the subject. Dr. Mike, the OG senpai of healthcare workers on social media, has a slew of reaction and review videos that are a good guide to follow.  

Make sure you are not cherry picking data to support your premise. Always remember the scientific process – you consider all the research and evidence before stating a hypothesis, not forming a hypothesis and supporting it with data. 

Step 7: Repost Tasteful Memes

Humor is an amazing way to alleviate tense situations and to lightheartedly discuss heavy topics. There are tons of spicy fresh memes that are funny but questionable. In this case, you need to use your best judgment to deem a meme tasteful vs. offensive. Consider avoiding reposting a meme if there is an opportunity for someone to misunderstand or is too niche.

There’s not much to say here other than know your audience. 

Step 8: Don’t Engage in Logical and Rhetorical Fallacies

This is probably the most important step. One of the most powerful ways we can make an impact is to have tough conversations and perform the emotional labor on behalf of marginalized people who were otherwise forced to do throughout history.

When someone disagrees with a point you made, keep the following Do’s and Don’t in the back of your mind when engaging in a productive discussion. 


  1. Reflect and ask questions. When people disagree with something it is usually because they have a strong conviction in their beliefs. If you give someone a chance to explain themselves and understand their perspective, it leads to a good discussion. For example, if someone says “I don’t believe in xyz…”, you could follow it up with the following statements“could you clarify what you mean by that?” 
  2. “I’m having trouble believing that, could you provide evidence to support what you are saying?”
  3. “What do you think would be more effective?”
  4. “Well, what is preventing you from believing in xyz…?”
  5. Stick to facts and make neutral statements.  Offer time (if you can) to chat about things further and share resources. 
  6. Use trigger/content warnings. Although you may have noble intentions, it is vital to consider what you are sharing could be traumatic and triggering to many people. 


  1. Use profanity and undignified language. It’s just not a good look.
  2. Make hasty generalizations. Sometimes it’s easier to use generalizations to prove your point and not engage in discussion. Unfortunately, this can cause a slippery slope and lead to other unproductive methods of discourse like red herrings, circular arguments, and confusion of correlation/causation. 
  3. Tone police. Just because you don’t like the way someone said something, doesn’t mean it’s not their truth. Try to be patient and lead the conversation with empathy.
  4. Don’t attack something a person cannot control, like their physical appearance 
  5. Use anecdotal evidence to prove a point. Using anecdotal evidence is often pseudoscience and does not validate anything. 
  6. Sound confrontational
  7. Center the narrative around yourself/make it about you.

It’s always hard to call people out on problematic behavior. Both parties can experience feeling disheartened, sad, and angry. Don’t think of calling someone out as something inherently confrontational but a chance to genuinely gain perspective of someone else’s convictions. Diversity of thought and the ability to hold a different point of view than others allows sociocultural evolution in society.

 Remember how in High School you were forced to argue the opposite of what you believe in as a learning experience? Try to exercise the same restraint you had to not cross a line when questioning others and while others question the validity of your claim.

 No one said being an ally was easy, it is both mentally and emotionally exhausting. You cannot be a good ally without taking care of yourself and drawing boundaries with people, even online. Do what you can at the present moment.

Step 9: Know When To Quit

When there is a lack of functional conversation it is usually because people have triggered something in each other. People don’t act rationally when dealing with public embarrassment. If someone feels that a disagreement is a direct attack on them, it’s nearly impossible to have a dialogue. 

If someone starts attacking you and is using inappropriate language, you are allowed to remove yourself from the situation and stop engaging. It is okay to quit when the conversation becomes an argument, and the person is committed to misunderstanding you. You are allowed to rest and recover while fighting for what is right and social change. 

Step 10: Always Keep Receipts!

Transparency is key, so archive your work whenever possible. Do not underestimate the power of the FBI-level sleuthing people are capable of to find skeletons in your closet. To prevent this, it is best to never delete and just own your mistakes. 

If someone has called you out for a problematic post, it is important to address it. When you make a mistake such as posting incorrect or misleading information, do not delete the post. Instead, take a screenshot of your original post and highlight what was incorrect and provide sources that shows that you have educated yourself on the matter. 

At the end of the day remember you are a human being, just show up authentically. Being an ally is not static. The point of allyship and activism especially is to constantly educate yourself and amplify the voices of the oppressed and marginalized. 

When asked “Why Healthcare?”, all of us said that we wanted to help people. Helping people includes advocating for the most vulnerable. I’ll leave with a final thought.

If you don’t fight for what you believe in, do you truly believe in it?