Episode 45: Dr. Nathaniel Gleason

Peter Poullos:
Doctors with disabilities exist in small but impactful numbers. How do they navigate their journey? What are the challenges? What are the benefits to patients and to their peers? And what can we learn from their experiences? Join us as we explore the stories of doctors, PAs, nurses, OTs, PTs, pharmacists, dentists and other health professionals with disabilities. We'll also be interviewing the researchers and policymakers that drive medicine forward towards real equity and inclusion. I am Peter Poullos, and I am thrilled to bring you the DocsWithDisabilities podcast.

 

Sofia Schlozman:
Hello and welcome back to the Docs with Disabilities podcast. In this episode we are joined by Dr. Nathaniel Gleason, an internist and associate professor at UCSF. Throughout this episode, Dr. Poullos and Dr. Gleason discuss Dr. Gleason's path to medicine, his experiences in medical education and strategies to improve care for patients with disabilities. Listen or read along as we begin with an introduction from Dr. Gleason.

 

Peter Poullos:
Nat, welcome to the DocsWithDisabilities podcast. Thank you so much for joining us. We've been excited about, um, interviewing you for quite some time. Can you introduce yourself to the audience?

 

Nathaniel Gleason:
Yeah, sure. My name is Nat Gleason, I am a general internist. I work at UCSF, I have a primary care practice and I teach residents and students. I'm about 10 years into my faculty position. I have had various innovation and administrative roles with a focus on primary care, specialty care and primary care kind of interface and trying to make the role of physicians as feasible and doable and, and rewarding as possible. And right now I'm the Interim Executive Medical Director for primary care at UCSF.

Peter Poullos:
I want to talk about your life experience in semi-chronological order. Can you just take me through your childhood and education, and your road to becoming a doctor? And how did your disability influence your decision to go to medical school?

Nathaniel Gleason:
Sure. So I was born in Puerto Rico, my parents both met there and lived there. And it took a couple years for me to get a diagnosis. I have achromatopsia, which means that I don't have any functioning cone cells and your cone cells on your retina are if you remember, that's your daylight, and your color vision, and more important than either of those things really, they are just much finer, in terms of the detail that they can discern. So your visual acuity if you don't have cone cells, by definition is about 2400. And then, um, I see black and white. And I'm really light sensitive.
So, I squint pretty noticeably, which I think is an interesting thing, it makes me look somewhat conspicuous. So a 2400 vision, which means that I sort of read late, I had a special teacher who came to my school, I wrote kind of poorly, it took me a while basically to get going as a student. But eventually I settled in as a good student. But mainly my love as a kid was music. So throughout high school and college, I enjoyed school, I liked science and math, but I really didn't question at all what I was going to do with my life because from about 12 on I was going to be a musician.

And I played in bands, and I played different instruments and I recorded music. I majored in American Studies in college, I went to Brown, and I, I majored literally by accident in that major because I realized that I already, I had already done the requirements for the major. So that tells you kind of how focused I was on music. And then after college, moved to the Bay Area, and played music, recorded music, taught guitar. I kind of did everything under the sun in order to have a career in music because I thought that's what I wanted to do. The long story short about my career in music is that I didn't find a particular style or group of people or outlet that was too terribly gratifying.

So, I wound up spending a lot of time alone, recording, engineering music, mixing music, mastering music, and playing in bands that I didn't love. And so during most of my 20s, I was playing music and kind of in a soul searching mode about what I wanted to do. Because I'd had this sort of plan to play music, and because I had a visual impairment, I had not entertained medicine as a possible career. I think my thought, this is a long time ago, but I think I would, I would think, I want to do something that's super connected to people where every day the conversations I'm having with people are really gratifying or really meaningful to them. And I think that medicine might be placed where I could do that, but I just didn't know how to road test the idea.

So I got some different volunteer opportunities, actually went on a couple of different public health programs, to Salvador, to Ecuador, to Mexico, and I volunteered at a, a Haight Ashbury clinic. I took a blood drawing course to literally test like whether I would be able to draw blood, I just thought maybe this is the thing that will help me get a feel for whether having a visual impairment is a deal breaker for going into medicine. Throughout several years of trying to understand whether this was going to be possible, and whether it seemed like the right thing, sort of emerged from that committed to doing it, I went back to school. I still had to take a bunch of science courses and things in order to make this possible.

So I went to San Francisco State, took sciences, actually really enjoyed it. And during that time, I started cold calling medical schools to understand what the application process was going to be like for a person who was legally blind. That was a little bit of a shock, a little bit disheartening for a while, it obviously has a happy ending. I found a medical school that was willing to work with me, but I did find a number of schools that were flummoxed by my call, I guess, to say the least. Had a hard time imagining what it might look like to have a student who didn't have perfect vision.
This is at a time when you could go on the websites of the medical schools and they had these technical standards, we still have technical standards, but they're a little bit different now, in one keyway. At that time the technical standards would describe the activities that a person needed to do, so in my case I'm looking at things like, the applicant must be able to use a microscope, or to observe various procedures from a distance, it literally said that and I thought, that's gonna be tough for me, I don't know if I can use a microscope. I don't know if I can read an X-ray. I think that was one of the examples.

 

And nowadays, these technical standards would say something like with reasonable accommodation. And so there's this latitude that's, that's in there now, which is very important, but at the time that wasn't there. So I was making calls and trying to find people at these organizations who could help talk it through with me. And for the most part, they had no experience with that. So they didn't really often even know who to pass me to. And when I found people, sometimes those folks were less, less creative than I would have hoped, in terms of thinking through what we could do. I found some people at UCSF who were willing to take the conversation further. And you know, it was my great fortune because I was living in San Francisco.

The idea that I might be able to go there was always this dream. I had a few discussions with them, we actually went and connected me with the person who taught histology and anatomy and, um, anesthesiology, and I got to talk through like, what would that look like? And then I got in, and then had a pretty uneventful and happy first two years of medical school. The accommodations around classroom learning, you had to be a little bit creative, like how do I take an anatomy test, for instance, but they were doable, those kinds of accommodations were things that we could think creatively around about. I was very, very fortunate to be working with professors who wanted to think creatively about those challenges. And sort of time is on your side, it takes some extra time to do a given kind of test and that, that worked well. And then the clinical years in medical school was another story, it was, it was challenging in a new way that I really hadn't anticipated.

 

Peter Poullos:
So you talk about how in the process of reaching out to the different medical schools and talking to them about the technical standards that you thought, at one point before getting a hold of UC San Francisco that the answer was no. And you said, that's a really big deal, because now I've invested a lot at this point going back to school, doing my post baccalaureate studies, planning to apply to medical school. So this was a real crisis. And your lifeline came in the form of another physician with a visual disability who mentored you. Could you talk more about that?

Nathaniel Gleason:
Absolutely. There are, of course, folks who've gone through medical school before me, not a lot, but some notable people. And I found someone who was at University of Iowa at the time, who was two years in, and she had a different fundamental retinal disorder, but pretty similar functional capacity in terms of vision. And so she was in medical school and making it work, and so that simple knowledge and her attitude about it, and her willingness to just like keep on experimenting and keep showing people who wondered if she was gonna be able to do the next thing, that she could find a way, was the critical difference between is this going to work and feeling like I'm going to make this work.

 

It's one thing to know that people had pulled this off, but it was another thing to talk to someone who is actively doing it and just kind of a, a step ahead of me. And she continued to be a step ahead of me through the clinical years and residency. And so that connection was just amazing, and I've talked to many people since who have described a similar experience of somebody who just like represented the possibility, and the practical possibility of solving some of these really tricky problems and in settings where you're pretty much the only person trying to do something in a special way, that was super important.

 

Peter Poullos:
You must have been so relieved to learn of her existence.

Nathaniel Gleason:
Absolutely. Yeah.

 

Peter Poullos:
And I bet you UCSF was also fairly relieved and made more confident knowing that someone else had done it and made it work.

Nathaniel Gleason:
I think so. Medical schools are funny, and incredibly conservative institutions in general. So I did find schools where I would describe that I thought there was a precedent for something. And then the school would say, well, that's not how we would do it. But I think it does help. And over time, as more and more people demonstrate that something's possible, it does help.

Peter Poullos:
Can you talk more about the importance of mentoring and your role in mentoring others?

Nathaniel Gleason:
Oh, my gosh, I mean, I've had a number of people over time, who have found me, let's say, in the last years of undergrad, or early years of medical school, and just hitting this crisis point that feels so familiar. It's like somebody said, I can't do this next thing. Or I had an experience and I'm worried that I'm not going to be able to do this next thing, because the mystery of it all, of course, is like when you're an undergrad, you don't know what's actually required in being a clinical medical student. You can only explore it so much. And I think people do their best to understand what's involved, but if somebody asks you like, can you see an X-ray? Well, how would you possibly know how to answer that until you have seen some X-rays and, and decided whether you'll be able to interpret an X-ray.

 

I think I've played the role in just describing what's involved and, in a few cases, I think people have taken up those conversations and determined that they didn't want to pursue medicine, which is completely fine. It's all about just getting more information. But in a lot of instances, people have gone ahead, which is awesome.

 

Peter Poullos:
Let's go back for a second, I want to talk a little bit more about your experience in medical school, and specifically with the clinical rotations. You said, "The most challenging part of medical school was the clinical part. While you had taken tests and learned information throughout your life, the logistics involved in caring for patients made for a totally different experience, navigating different hospital and clinic rotations was incredibly challenging." You said, "Noting examples such as the ability to recognize a particular nurse, quickly scan a stack of records, or see displays in the ICU." And you said, "I was completely floored by the clinical environment. I've worked so hard to figure out if I could be a doctor that I hadn't thought about the physical environment. But boy, you couldn't come up with a worse environment for a learner with visual impairment." Can you talk a little bit more about what makes the clinical environment so adverse for people with visual impairments?
Nathaniel Gleason:
Yeah, and I should give a caveat that I really do believe that a person with limited vision can find a, a home where they can become quite comfortable with the environment. But the trick, the problem is, is as you know in medical training, both in medical school and residency is we literally move you around, right? Every two weeks or four weeks or eight weeks, we send you to a different hospital, a different ward, a different service. And that is a different physical environment. It's a whole bunch of new people. Maybe you get used to the 14th floor of X hospital, but then even then the nurses change shift, so right as you figured out like who's who it is incredibly challenging.

 

There's also a lot of on-the-fly visual learning that takes place in medicine. If you picture like just people standing and rounding, say in the ICU, and the team is looking in say 25 feet away at a patient and the monitors around that patient at her bedside and talking about what they're seeing. I would need to be right up next to those monitors in order to see the same thing. And so trying to navigate that and figure out whether I was going to come back or break away from the group and go over, and try, and see or just try, and listen and understand. That was a, a real special, unique challenge of training.

And I knew in the back of my mind that I would find a place where I knew the people, where they didn't change, (laughs), where things were, where I imagined they would be. You know, at the time, we still had a lot of paper forms. And I have this haunting image of a wall of forms with tiny little labels. And typically, someone would walk up to this wall and they would look at it, they were in no particular discernible order. And they would look at it and they would find the form for like patient on insulin, but not eating because they're NPO and they're having a surgery the next day. Or patient on insulin, but they are eating and, and so-

Peter Poullos:
Yeah.

 

Nathaniel Gleason:
...  this wall and scan a wall of like hundreds of little boxes of forms, to find what you needed. So for me, I would literally have to be against this wall, scanning from top to bottom for each row, until I found the format I was looking for, it is utterly preposterous. And then the computer for me was such a promise, I thought once we get on computers, which that transition happened while I was a resident, once we get there, everything will be great. And of course, anyone who's used a modern EHR knows that it's almost like you couldn't design an EHR that was more chaotic and challenging to navigate. It's the digital replication of a physical environment, we just crammed everything in there. There's no rhyme or reason where things are, the font is, is incredibly small, there isn't a way to make it bigger. My, my only remedy was to just get the largest monitor that I could in every setting. But I still scan from kind of left to right across the EHR looking for a certain button or a certain menu, because I swear, they move them.

 

Peter Poullos:
They do that. They do that just to mess with you.

Nathaniel Gleason:
Yeah, they do. Or the other thing I'm acutely aware of, and ironically, this has become like a lot of the focus of stuff that I've worked on, I think because I'm so attuned to it. But there's just an extraordinary amount of extraneous information. You notice this? So if you can see well, you sort of s- sit back and scan it and find the result. Also, the result is often in another color, which I can't see. For me, I'll be, it'll be surrounded by some order number and other different various numbers associated with it, all those things kind of surrounding the actual result that I'm looking for. It's not the panacea that I had hoped it would be.

 

And I'm convinced that it's actually a real tax on everyone, but people aren't as aware as I am, because I'm four inches away trying to see it. But I really do think that it, it hurts us to have information be that hard to find or that I think the lack of clarity isn't good for anyone.
Peter Poullos:
You received an award called the Gold Headed Cane Humanism award when you graduated from UCSF. And there's an article about your receiving it and you said the following. You said, "Many schools I applied to said if you can't use a microscope, you can't come. UCSF School of Medicine said, "If you can't use a microscope, we'll make bigger photographs of the histology and microbiology slides." They were completely unfazed by the whole idea of having a blind medical student."

 

Now, I had a different experience applying for radiology residency at UCSF. My experience at UCSF was that they really weren't interested in having a quadriplegic radiologist. In fact, I remember a conversation where someone said, "I can't imagine you on call, you know, you're hanging films, you're going to the scanner, you're moving around. They're so busy, you have to be mobile." You know, and I think that person was looking at me with genuine concern for my success, and perhaps the success of his program. He's probably thinking a bit too much out loud. He should have maybe kept some of that into his inner voice or maybe for the selection committee. But Stanford's approach to me with radiology was kind of like UCSF response to you.

Nathaniel Gleason:
Mmhmm.

Peter Poullos:
And I can just paraphrase your quote, the radiology residency at Stanford was completely unfazed by the whole idea of having a quadriplegic radiology resident. And the reason I'm bringing this up is because I think it exemplifies the wild West situation of medicine, and how you talk about this in our disability conference, saying that you got lucky to get the right people together to have the conversation. That was really fortunate, and there's no centralization of attitudes. So we're talking about the very same institution, but one person in the admissions office thinks that we want to have more disabled medical students and another guy down the hall thinks it's a bad idea.

Nathaniel Gleason:
Yeah, isn't that amazing? I mean, you realize with so little precedent and so little framework for these things, it's going to come down entirely to the individual, and probably even where that individual is like on that day in terms of their risk taking, or their willingness to think and pause. And I've been asked that, and I know other people who have been asked about applicants, and it's a similar thing. It's like this moment to moment, institutional randomness sounds terrible. But it, it is a little bit of thinking on the fly about, like, how can we make this work?  And I think it's much better now than it was, this is almost 20 years ago when I'm having these conversations. But I still think it's real, and I think it's important to keep asking and keep looking around for people who are willing to pause and think a little bit. Right?

 

Peter Poullos:
Yeah, I mean, absolutely. We were literally having this discussion early today. We were talking about accommodations in clerkships. And I was saying that it really gets very granular when you talk about your experience on a rotation, and what site you're at, for, on what team, with what resident and what attending, it can completely make or break your experience. And, I mean, randomness, I don't think is an exaggeration. But how do you change that situation? Like how do you, not mandate, but how do you take the sentiment of inclusion that the leaders of an institution espouse and get them out to that community clinic attending who doesn't know anything about disability as diversity, or the benefits of having disabled students or doctors?

 

Nathaniel Gleason:
I will tell you how I handled it and how I would recommend handling it. But that doesn't make it the right thing. I wish it weren't this way, because this involves taking on more, which is always the story with succeeding in, in an environment that's not designed for you. But it's still worth thinking through. So I went in every single course, and then every single clinical rotation, I went well beforehand and talked with the course director or clerkship director. And every single time the conversation started off with them being uncomfortable, because I think they were nervous about this student that they'd heard was coming their way. Or, or maybe they hadn't heard anything except for the email that I wrote that then alarmed them, oh, there's somebody coming my way who doesn't see well.

 

Every single time we landed at a place where they felt I was prepared to figure it out, or that I had an idea of how it would work. It's like tension and release, right? I created, there's a tension and then I talked to them through it. And it's sort of telling the main person in our administration at UCSF when he retired, I remember this so well, he said, "You always just told us what to do." And that for them, that was success. It's an important lesson because it's true and it worked. And at the same time, it's kind of a tall order to ask a student with a disability to always tell the institution how to handle it. Right? That's not actually, I think in retrospect, really optimal, but it's worth noting.

 

And I also have an exception that proves this rule is that at one point, I thought I wanted to go into primary care. And I thought, okay, I really need to test this notion. So, I got a springtime, semester-long rotation at Kaiser Oakland. It was across the Bay, so I didn't go over there and do my usual like, let's meet the person who's in charge of this rotation and kind of look around, is was literally, the only time that I didn't do that. This is in my second year of residency. I went over for my first day and they had these computers in each exam room where the keyboard, the whole thing was mounted on a big metal cart. And the keyboard was in front, obviously, and then there were two feet away from me. Now for me to see the computer, I get six inches away, maybe four. And so everywhere I've done clinic, I've propped up the display on some books. Sometimes I've even brought my own display because it's bigger, but at every hospital I rotated at, every clinic I rotated at, I set up a region for myself where I could type and see the computer and the display was a couple inches from my face. And sometimes that was a little tricky to do. This setting, I literally would have had to lay my body on top of this desk in order to get my face close enough to the screen to read.

 

And so it was really embarrassing actually, is really uncomfortable for me. They had patients scheduled for me, it was supposed to be like a working rotation where you're seeing patients and they're kind of counting on your work. And the person who's supervising is also seeing patients and not counting on seeing your patients. It took so long, it took weeks for us to get a solution where there was, they, they wound up mounting the display to a wall with a keyboard below it, so I'd stand up and look at this display. And it worked great. It was in a weird kind of supply closet, but it worked perfectly. But it took weeks.

 

And so for weeks, I went over there, didn't see patients, was very conspicuous. In retrospect, it feels like that wasn't my fault. And I don't know why, but I remember being really embarrassed and feeling really uncomfortable. And feeling like well, I'll never get a job here. And it was a really terrible experience. And that was the one time that I didn't prep. So all this prep takes extra work. And yet, it was really the reason that the whole thing was possible.

 

Peter Poullos:
Yeah, I think our students are having a hard time just getting the information that they need, for example, with the mobility disability, like where are the disabled parking stalls in relation to the ward where I'm going to be working. How much walking is involved, just they really want to know, and have more information. Information is power, when you have a disability.

 

Nathaniel Gleason:
Yeah.

Peter Poullos:
It's crucial.

Nathaniel Gleason:
Yeah.

 

Peter Poullos:
And so we're trying to improve that for them right now and trying to centralize a repository of accessibility information for the clerkships. And I hope that makes it better, in a sense, because you'd lived with your disability your entire life, you had a good idea of how to maneuver things. I think that for so many students, they're at a huge disadvantage, because you know, as you know, some chronic and disabling conditions develop demographically around the time of life where most people are in medical school.

 

Nathaniel Gleason:
Yeah.

Peter Poullos:
So in their early 20s, they're developing inflammatory bowel disease-

 

Nathaniel Gleason:
Right.

Peter Poullos:
... or autoimmune conditions or having their first bouts of mental illness. And they're having to navigate the medical system as a patient and as a student at the same time, you know, we call it the disability tax, right?

Nathaniel Gleason:
Mm-hmm (affirmative).

 

Peter Poullos:
That all of this preparation work that you have to do beforehand. And for you, I think it was a lot, but for some of these other students who are just learning their disability can be quite a bit worse.

 

Nathaniel Gleason:
Yeah, I think that's right. I'm talking about one variable, which is you got your experience based on classroom learning and say, college, that only takes you so far. Right? You can't anticipate what it's going to be like on a clinical rotation at a federally qualified health center that has paper records, or on a new computer system that you've never seen. And then you add that to another variable, which is your own functional limitations that may be changing. And that's just becomes just really hard.

Peter Poullos:
My experience with my radiology residency was that they were very much willing to work with me, but that they expected that I would tell them what I needed.

Nathaniel Gleason:
Yeah.

Peter Poullos:
And when I was interviewing for residencies, I had been coached actually, to tell the interviewers, to spin a story of the success that I'd already had, and how I was overcoming, to throw in stuff about learning to walk again, which is just completely inappropriate inspiration porn.

Nathaniel Gleason:
Yeah, boy.

Peter Poullos:
And even beyond that, just emphasizing that, during the course of my rehabilitation and recovery, that I had learned how to navigate life with a spinal cord injury. And I remember telling somebody that I had seen a rehabilitation specialist from, from San Francisco State University, and he set me up with these devices, and they're like, ooh, ooh, say that in your interview. Yeah, rehabilitation technologist. They'll love that.

 

Nathaniel Gleason:
Yeah.

Peter Poullos:
Show that you know how to solve your own problems.

Nathaniel Gleason:
Right, that's the thing.

Peter Poullos:
Its good advice.

Nathaniel Gleason:
It's troubling, but its good advice. That's the, that's the trick here, right?

Peter Poullos:
Yes. Okay, I want to go back to this ACP article, the ACP article I was talking about. You were interviewed for this. There's this part about the undifferentiated graduate. So the article says, "Accommodating a student with a disability takes overcoming the false ideal of pluripotency. That is that every applicant should have the potential to become any kind of doctor. It's hard from that starting place for some physicians and medical school administrators to look at a candidate and say she has the strength to be a great doctor, even if her particular set of abilities and disabilities makes a certain field of medicine less likely to be a great fit." Can you comment more about this?

Nathaniel Gleason:
So, this idea, when you are sitting and interviewing for medical school, let's say, and the interviewer is picturing and maybe saying out loud, and maybe not, doesn't matter. How would this person do surgery? How is Pete going to stand and do surgery, how, how is Nat going to be a dermatologist, right? That notion is so pervasive in medicine, we just have this idea that you should be able to take anyone and turn them into any kind of doctor, that's a given. That's what all those technical standards are about. And the idea that you would take someone into medical school who, let's say, wanted to be a psychiatrist, who for whatever set of structural reasons, let's just imagine couldn't become anything other than a psychiatrist, that is anathema to a medical school leader. It's just an age-old assumption.

So, but the thing about it that's so comical, if you really, if you really think about it is there's all kinds of people who, for interpersonal reasons, should not be a psychiatrist. And there's all kinds of people who shouldn't be a pediatrician or a surgeon or anything else, right? People have their strengths. It's just that we become really fixated on these particular functional limitations that might limit a person from having every avenue available to them at a medical school. I just find that to be real and troubling. And I think it's worth just saying out loud, when you have the chance.

 

Peter Poullos:
But let's take that argument even further and say, are we really going to graduate a doctor who can't do CPR? Who can't put in an IV? Who can't run a code? Why are we letting these people into medical school?

 

Nathaniel Gleason:
Okay, so it's a fair question. First, there are many careers in which that doctor could have a lot of success and contribute as much as someone else who doesn't have the same disability, right? So can we stipulate that much, once you are out of residency, and you have found your niche, there's a place for anyone talented enough to get into medical school. That's the limited side of the counter argument, the much more important part of the counter argument is, what would be the advantage of bringing that person into the medical field, right?  And that is a whole other big question that I think we don't talk enough about. But I'm convinced that there's this whole giant advantage to bringing people with disabilities into medicine that goes way beyond just the representativeness, right? The like, we should see people in medicine who have disabilities, that's super important, the representation is super important. But I think there this other much bigger reason to bring people with disabilities into medicine. Can we talk about that?

Peter Poullos:
Please.

 

Nathaniel Gleason:
Okay. So, here's the interesting thing about disability, most people acquire disability over the course of their life. And if let's say you define disability as something concrete, like inability to perform one or more ADLs without assistance, most people acquire disability over the course of their life. And so by definition, they, they don't identify, they don't tend to feel like they are a part of some culture or some group, and that they are part of the shared learning of some group, or that they have any sort of identity, that's called disability. That is just not the case for most people who acquire a functional impairment.

 

And we can talk about disability, functional impairment, definitions, but just the important part here is that you have a, a whole bunch of people, let's call it 90% of people who have some functional impairment, who don't consider themselves to be a part of some community where they would learn from that community. Then you have these younger, mostly people who would be thinking about going into medicine with a disability, who actually do represent the relatively unusual people who think about the fact that they have a disability. And think about what that means and try to find within that, some shared identity and some knowledge base, and some way forward with other people who have figured out how to accommodate and how to work with that.

 

And so they go through medical school, and they do incredibly creative things to figure out how to read faster or get from point A to point B, or manage to function well in a certain loud, noisy environment. Those folks then go into medicine and they bring the actual knowledge to their patients, right? So they become these emissaries. I do primary care and most of, most of my patients are quite a bit older, and a lot of them are slowly losing their vision. Now for them, there's nothing good about this. This is just terrible, and it's just a quiet, slow, painful thing where they're reading less, or knitting less, feel less safe out on the street. And nobody ever asked them about it.

 

Nobody ever talks to them about how do you get around? How are you seeing? How do you read? Or even really notices. But what I've found is I've had a number of interactions with people where I just noticed for one reason or another, that they're not seeing well, because often we don't even ask, and then I'm able to talk to them about that and what that means for their own life, for their own functioning, and have them then start to adopt different things, go to the LightHouse for the Blind, get a magnifier.
One person has a closed-circuit television that she uses to sew. That's a really basic example, but it's actually still profound for those individuals. That's what I'm getting at, by the additional value of people with disabilities can populate in the field of medicine, beyond just the representativeness, having them there, right? To be visible. That makes sense?

 

Peter Poullos:
Yeah, that makes total sense. I mean, that's what we're trying to promote, is the idea that doctors with disabilities have insights into health and life that otherwise healthy non-disabled people do not. And that, that will translate into better care for our patients.

 

Nathaniel Gleason:
Nice.

 

Peter Poullos:
Wouldn't it be a lot easier rather than letting ... Let's just say this, for example. I've made this statement half joking a bit ago, I said that, "You wouldn't hire a professional football coach who had never played football, so why are you hiring all of these young, able bodied people to be doctors? You should be only hiring students with disabilities, because they've been through stuff, they know what it's like to be a patient, and they will take better care of our patients. So why not just admit a whole class?" Or maybe you agree with me?

 

Nathaniel Gleason:
Well, I love it. Yeah, it's actually a really powerful statement, we should just aspire to that. We say disability as though it's a thing. And of course, there's an infinite number of combinations of experiences. And so you really could keep going with that argument and down this continuum.

 

Peter Poullos:
If you had more doctors with disabilities, it would improve life for the non-disabled, because people with disabilities, because they do have to place some boundaries or limitations, whatever you want to call it on, say, for the amount of time they can be on their feet, or the amount of hours that they're willing to work without forgoing sleep. If those were the people running medicine-

 

Nathaniel Gleason:
Mm.

 

Peter Poullos:
... that it wouldn't be such a cruel field.

Nathaniel Gleason:
That is very likely, the diverse array of those real human needs would add up to a fabric that was much more accommodating and human, I think.

 

Peter Poullos:
Yeah.

 

Nathaniel Gleason:
Yeah.

 

Peter Poullos:
We wouldn't have this culture of medicine eating its young.

 

Nathaniel Gleason:
Yeah. I think that's probably right.

 

Peter Poullos:
You and I talked about this, I don't know if you remember. But you and I talked about this at the conference, about how the elderly population doesn't get taught how to live with age acquired disabilities.

 

Nathaniel Gleason:
Mm-hmm.

 

Peter Poullos:
And contrast with how I, after having had an acute spinal cord injury, got hospitalized and then put into a rehabilitation pipeline with every kind of therapist imaginable. Physical therapy, occupational therapy, recreational therapy, et cetera, to help me put my life back together again. But when disability creeps up slowly, those people don't have that benefit. And so, you mentioned your experience being a benefit to your patients, but how do we serve our elderly patients more effectively on the whole?

 

Nathaniel Gleason:
Yeah. You know, this might be a good time to just say, there's this definition that I really like that I borrow from Margot Kushel at UCSF, San Francisco General, which is the distinction between disability and functional impairment. So you have some pathology, like macular degeneration, and then you have some impairment, which is you have decreased visual acuity. And then the disability is that you can't read say the prescription on a pill bottle or a newspaper, right? And the disability then, you realize quickly is the interaction between that pathology, right? That like medical thing, and the world.

 

And so what you're talking about, I think, is all of the stuff that one can do about the latter, right? Yeah, I can't see perfectly but I can read, I read all day and that's because I have a million accommodations to read to me, or to make text giant. And so how do you take who you are and whatever medical functional limitation you have, and then transform it with accommodations. So does that make sense?

 

Peter Poullos:
Right, but not everybody can have a Nat Gleason.

 

Peter Poullos:
So how do we take these ideas-

 

Nathaniel Gleason:
Yeah.

 

Peter Poullos:
... about serving our elderly patients better and disseminate them to the rest of the world to help society?

 

Nathaniel Gleason:
Yeah, and it's a really good question. And I think it's one of these things that I guess I hope spreads, you get a, a couple hours in a medical school curriculum. And then you show a class of people about, let's say, mobility aids. Right? Before there was no curriculum around canes and walkers and wheelchairs. And then that group of people really, very quickly, because people write to me about this, how meaningful these kinds of simple lessons are, they recognize the value that that brings to their patients, and then they, I hope, go on and teach the residents and people that they encounter.

 

So I do think there's a lot of very practical knowledge that does exactly what we're talking about here. And spreading it is the key. Getting that time in medical school curriculums is really hard. You know, your, your competition is like the geneticists who feel like they don't have enough time in the medical school curriculum, it's hard. So getting a little real estate and then, I actually really think there's room probably to think creatively about, about how to introduce these concepts throughout medical school curriculum.

 

Like, I often think that the secret weapon would be to integrate disability into lots of cases during kind of case-based learning in medical school. But in any case, that's my hope, I guess is, is that introducing basic sort of what you could call cultural competencies will spread as people realize their practical value and how meaningful they are for patients.

 

Peter Poullos:
And I know that you have done a lot of work in this arena at UCSF, right? Now, so tell me about the work that you've done at UCSF, putting education about disability into the medical student curriculum.

Nathaniel Gleason:
Okay. So when I was a third year student, and at that time, that's when you started spending time on the wards, I was suddenly like really struck by the prevalence of physical visible disability that I saw. If you stand at the doorway to any hospital, you quickly see that a really significant number of people going in and out of the hospital are using mobility aids, for instance. I was struck that there was no acknowledgement in the curriculum at all, at all, at that time about disability. And so I did a bunch of interviews with people about their health care experience in light of a disability. And there was some literature at the time, but I tried to put together a curriculum that was practical, that was about kind of culturally competent accommodations for patients with mobility impairment and, and sensory impairments, so hearing and vision.

And I actually got a couple hours, an hour of, of lecture time, and then an hour and a half of a panel of patients with disabilities, and we had that as part of the core curriculum in the third year for eight years, I think. And it was really highly rated, it was really fun. People responded well, they told me later that they used these tools. The panel was the most highly rated section of this. We did it in the third year of medical school between clerkships and this session that at the time was called intersession. That panel was the most highly rated thing that happened during that intersession every year consistently, because these were the real patients talking about their humiliating, often, experiences of going to the doctor.

 

But this is a bit of a cautionary tale, because we had a total curriculum redesign a couple years ago. And those particular activities I just mentioned are not, they don't have a new home in the curriculum. So there are some activities, it's not a total loss, but, um, there's been a reshuffling and I think if you were to quantify it, it's an overall decrease in the curriculum. And that's one of my goals, is to get back to identifying more time and opportunities to make this happen in medical school. I just think that's the perfect moment. Whenever your health science training program, that right as you start seeing patients, you have a particularly clear eyed view of like, what are we learning? What are the biggest challenges people are dealing with? I think it's an important time.

 

Peter Poullos:
Were you consulted at all on this curriculum redesign? Were you told that your real estate in the curriculum was at risk?

 

Nathaniel Gleason:
I was not.

 

Peter Poullos:
That must have been a really pleasant surprise.

 

Nathaniel Gleason:
You know, I recognize these kind of curriculum redesigns involve really hundreds of people in the end because there's so many people who deliver different pieces of a curriculum to, in, in undergraduate medical education, it's a complex beast. It is something that I need to create some time for in order to figure out where this might be appropriate and to re-propose. And I've just in that particular world I'm in right now, I haven't had that bandwidth, but it's something I really want to do. One heartening thing is, is there's quite a large group of medical students that have formed a extracurricular committee on disability. 

 

Peter Poullos:
AT UCSF?

 

Nathaniel Gleason:
At UCSF. Yeah.

Peter Poullos:
Oh, tell me more about that.

Nathaniel Gleason:
The general community of people who are interested in disability and the general understanding of the breadth of that term has grown so much, that I talked to that group every year and there's often like 30 or 40 people who attend which wouldn't have been the case when I was a student.

 

Peter Poullos:
Our MSDCI students who helped plan the SMAC conference, they are trying to start a national organization, I wonder if the UCSF guys might like to join them?

Nathaniel Gleason:
Yeah, absolutely. I'm sure they would. And several of them attended your, your conference.

 

Sofia Schlozman:

In the next section, Dr. Poullos and Dr. Gleason continue their conversation with a discussion about how their experiences as physicians with disabilities changed throughout their careers.

 

Peter Poullos:

What is different about your experience as an attending with a disability compared to being a resident or a student with one? But I'm just wondering if your approach to asking for an accommodation or you're being taken seriously in your request or just the response to, of people, of patients or your staff to you being a blind attending versus a blind medical student or resident, how things have changed for you?

Nathaniel Gleason:

I'll tell you, it's, it's interesting, it's, so I don't need a cane to navigate. I've navigated for my whole life mostly without a cane, can see just well enough. I do trip, I definitely kick the curb and trip or hit my head more often than than the next person, but I've gotten around without a cane. But in the last couple years I've started carrying a cane at work, as really a signifier, so I'm, I'm very much in touch with this question you're asking about like what is it like for people around you to know or not know and how do they respond to you presenting with a disability?

And the reason I'm doing it is that I've been in the sort of administrative roles where now there's a bunch of primary care practices that I'm accountable for. And so if I go to a practice that I've never been to before, and I show up with the cane, I have just told 45 people that I don't see well. The upside the utility of that is actually really high. The downside is it feels a little bit uncomfortable, I'm sort of just presenting myself as visually impaired and like letting people deal with that, which is not something that I'm used to, right? It's not my norm. My norm is I meet you, maybe you notice that I don't seem to see well, why are you looking so close to the computer and then at some point as we get to know each other I explain my vision to you. That's what my life's looked like.

Now I show up somewhere and I immediately announce that I don't see well. It's been a powerful shift for me. I think it's super important because that way then if you see me, say I walk right by you, you, you meet, someone introduces us and then 10 minutes later I walk right by you and I don't acknowledge you at all. Now you'll have some idea of why that's true, right? As an attending, you're likely to be more known to people around you and then I've almost doubled down on that by just like having this visual representation of my disability with the cane.

Peter Poullos:

That's so interesting. Yeah, people have spoken with me about, for example, taking on the disability identity or calling themselves disabled and they'll say something like, "Other people have it so much worse." And I'm wondering if, when you first started using the cane, you were thinking to yourself, "I'm such a poser."

Nathaniel Gleason:

Yeah, that's actually exactly right. So, (laughs) it's a funny story. I used it briefly when I was about 22. I went and did a semester at Cal at Berkeley and it was the busiest place I'd ever lived. And so, early on, I walked into somebody, I knocked her over, and I was mortified. She started to cry, and it was clear that this is a really striking moment like she thought it was her fault, and she was very upset. And I just felt like, "Wow, I need to start using the cane." I'd actually had one since childhood that I used when I was a really young kid to cross the street to get to my parents work and it's like magic, right? You take out a white cane and cars stop. If you don't see well and you're nervous crossing the street, it's remarkable.

So I got that same cane out and started using it to go to class and I immediately felt like you're saying, I felt like I'm overstating my vision, because I can walk through this crowded plaza without a cane, it's just that sometimes I'll knock someone over, right? So which way am I going to err on this? And there, there was one point where, um, I was getting on a bus and someone tried to help me get on the bus, was directing me and just like, it felt so over the top like I felt like I was really broadcasting to the world something that wasn't quite accurate. The benefit of making clear that I don't see perfectly is what counts. That's much more useful and important than my overstating.

Peter Poullos:

It's tough. I was talking to someone recently who was expressing their fatigue at having to just constantly round the hospital, you know, do rounding and walking around the hospital all day, and I saw that they could really, most likely benefit from having a scooter or a wheelchair. But making that leap, it's a tough one.

Nathaniel Gleason:

Giant in our environment. That's right, yeah.

 

[music transition]

Peter Poullos:

You got funding, I think, fairly early on in your career from the UC Office of the President and the Medicare Innovation Grant with the AAMC for your eConsult Program. What was your motivation for applying for that grant and did this have anything to do with your disability?

Nathaniel Gleason:

So this work came out of something I developed right out of residency, which was, uh, an eConsult program at UCSF, where a primary care doc could ask a question more formerly of a specialist and get an answer formally through the EHR, and both of them get some credit for doing that work and keep the patient out of the specialty practice. We have terrible access to specialty practice, a real mismatch between the supply and demand. So serve that patient, and yet not require a spot for them in the specialty practice. And the really compelling thing is for a lot of patients, the question is, is one that's well suited to an eConsult, the data are all in the record, right? And then the PCP is capable of executing the plan or the recommendation, they just need a little backup or a little extra guidance at a juncture in the management of a given condition.

There's several things that were compelling to me about this. One of them is just healthcare value, right, so not sending someone to cardiology, have a bunch of tests when you need just a bit of guidance in order to keep evaluating that condition or managing the condition in primary care, that's very compelling. But the other piece is the trouble that you save the patient. When you work with older patients who have multiple comorbidities and functional limitations, if you're paying attention, you quickly recognize that for that person to go to a visit across town to the pulmonary clinic is like a whole day, right? They're going to take the bus or they're going to get up super early. Walking is difficult.

It's just remarkable how much time we cost people, particularly older people with, with, with disabilities by sending them around to doctors. So that piece of this program, that like efficiency for the patient and taking away that cost to the patient in terms of time spent was an important part of this program that I found exciting, but really, honestly, it was professionally interesting, as something to pursue because each of those eConsult program to any specialty involves kind of getting in depth with that specialty about the kinds of things that we're referring for primary care, and what we might be doing ourselves and what specialists might what might be the right time in the course of someone's illness to refer to a specialist and so I really liked that those clinical conversations, and then the grants, let me go do this work at other institutions which was super fun. I've probably been to 20 different academic health systems over the last few years, last seven years now, to help support development of a similar system, and they all have very similar dynamics and challenges that they face being academic, often highly specialized organizations that are the hub of their medical system in their particular part of the country, that's just been really interesting.

Peter Poullos:

Do you bring your white cane when you go?

Nathaniel Gleason:

I haven't because the great majority of those trips took place before me starting to use the white cane, but I absolutely would and will. The one trip that I went on since I started using the white cane was, I went to our annual society for general internal medicine meeting, which was in DC, I realized that I really didn't want to go to this national meeting, and I couldn't figure out why I didn't wanna go. And people really like these meetings and there's lots of learning and opportunity and stuff but for some reason I just did not want to go, and I finally realized that the experience of being in like, you know these meetings, I was in a big hotel. This is not large by professional standards, let's say there's 2,500 people, in the lobby people just mix and mingle and run into each other all day.

That's the nature of these things and for most people that's super fun, I realized that that experience for me was just really not fun. I couldn't see anyone I couldn't tell if I was walking past someone that I'd gone to medical school with, and potentially you know, snubbing them. It's really difficult to navigate sort of social settings when you can't see everybody. So when I realized that, I just started experimenting with the cane and so I brought it and it really changed my whole experience of being at this meeting. And my whole experience of travel frankly, travel is much nicer with people that you interact with just recognizing that you don't see well.

Peter Poullos:

How is it better for you with the social engagements and the lobby mingling with the white cane?

Nathaniel Gleason:

Yeah. People will see me and see the cane will be reminded, "Oh right, Nat doesn't see well." And if they care about me, will come over and say hi. And that happened a lot.

 

Peter Poullos:

So we were talking about the eConsult Program just reminded me of something. So you are, yes, blind but you have this career that has nothing to do with blindness.

Nathaniel Gleason:

Mm-hmm (affirmative).

I'm curious how you view the work that you do in medicine versus the work that you do that's directly related to disability inclusion.

Nathaniel Gleason:

Yeah, I would say, I've erred for my whole life on the side of, of not acknowledging my disability, of trying to do things that seem unlikely or impossible, it's only in the last couple of years that I've been using the cane as I mentioned. And so, for me, having a career that's not about my disability is probably a given. And my challenge actually is and is going to be folding it in, right, I want more overlap with my disability, I want to get back to the medical school curriculum piece, I want to figure out, is there some research path that I might take in a future incarnation of my career, where we know so little, right? And there's not that many people paying attention and so I feel there's a lot of opportunity, so I'd really like to get to a place where I apply for grant or find some way to study the population that we see, and their various functional limitations and their preferences around those things. We don't know anything about that, so that's where I'm at with it, your conference was the first time that I had thought about this for more than a few minutes in a pretty long time.

Peter Poullos:

That's so interesting. There are days now, where I'm very happy, in fact, most days I'm very happy to be doing this work and I often ask myself, "What was I so afraid of before?" I find myself now, 48 years old, having already 12 years of being an attending under my belt, under my belt but I am only now within the last two years really doing hardcore work related to disability.

Nathaniel Gleason:

It's impossible to know but there's a richness to having some part of your life be not so tied to disability right?

Peter Poullos:

Oh absolutely and radiology for me, the reason I did it is because it matched my abilities. And now, I've been stuck at home the last year because of COVID, normally when I'm at the hospital I have a whole team of volunteers who make the world accessible to me and help me with my coffee and my food, getting into the car and making this inaccessible academic medical center accessible to me through human intervention. And now, even though I'm stuck at home, I get through my day basically with just myself, I mean, my wife is here in case I need something she makes lunch. I, I do have help in the morning and evening but that's the same help that I was always getting for my ADLs, from my caregivers.

Nathaniel Gleason:

Yeah.

Do you know who Stanley Wineapple is?

Peter Poullos:

No.

Nathaniel Gleason:

He's a PM&R doc in New York who is blind. And he lost his vision much later in his career. When I talked to him I was in that early phase of crisis around, can I be a doctor? And he just kept on saying, "You're the brain." That's what I hear when I listen to you talk about your role is like, you can set up a lot of different ways in medicine to both gather information, to access the physical place like you described, and also to execute the orders, right? We literally write orders in medicine, someone else often does the order. But you are the brain. And I just think that's kind of an awesome idea.

 

Sofia Schlozman:

In this final section, Dr. Poullos and Dr. Gleason discuss the challenges of balancing tokenism and representation as a physician with a disability.

 

Peter Poullos: 

So you hold a lot of leadership positions. I was wondering, we talk a lot about disability discrimination but we don't talk as much about the halo effect for physicians with disabilities where people see us as amazing and inspirational and want to showcase us. Do you think that your blindness has had any beneficial impact on your career?

Nathaniel Gleason:

(laugh) I don't, I don't know, I do have a really strong memory of being in medical school, I think in my first year, and the people who planned the next unit coming up which had something to do with the eye, it was the brain and the eye, and said you know we're gonna have this session, would you be willing to present or share, and I think a lot of people with disabilities who go through medical training are sort of asked to be like the, would you represent bipolar for us please during our discussion, during our panel. That's a story I've heard more than once. Subsequently, I sort of add, dropped, and put other ones down, I think it's actually a personality quirk I'm somebody who's there, who cares a lot about how we deliver care, and I'm just too eager and wind up absorbing these kinds of roles that truth be told, the pandemic has been pretty clarifying for me it's like everything is quite accelerated, and I'm pretty clear that I really want to get back to patient care and do a lot less administration, so I'm kind of excited about returning to a role that's much more focused on taking care of patients.

Peter Poullos:

You can slowly extricate yourself from these.

Nathaniel Gleason:

I'm going to replace myself like we're hiring a replacement and I didn't put my hat in the ring.

Peter Poullos:

Oh that's beautiful. But what do you think about an institution? Do you think that institutions might want to show off doctors with disabilities to demonstrate how inclusive they are? Is there any sort of ulterior motive where a disabled doctor might get used in that way?

Nathaniel Gleason:

Sometimes. I think so. I think there's a handful of us who are a little bit, we could feel slightly tokenistic sometimes but I'm mixed about it because when I hear someone reference a colleague, I have one colleague who has a physical disability that people often reference him and I'm, I'm sort of proud in a way of what he's achieved and that I guess I'm mixed. (laughs) But it's really hard to know isn't it? From like inside of the story? (laughs)

Peter Poullos:

Yeah, I don't know. I wonder sometimes if somebody refers to me as amazing are they talking about me as a person and like that I really am a special person or that there's something about me that's amazing?

Nathaniel Gleason:

Right, right.

Peter Poullos:

Or are they like, he's paralyzed and he still gets out of bed in the morning and therefore he's amazing?

Nathaniel Gleason:

I hear you but what if it were some of the latter?

 

Peter Poullos:

I'm saying perhaps I may have benefited actually from some of this halo effect that maybe, if I didn't have my injury, I would be less...

Nathaniel Gleason:

Yeah.

Peter Poullos:

... well perceived in my job. Sometimes I ask myself if like my disability actually is beneficial?

Nathaniel Gleason:

Okay. Well, you know, we, a few minutes ago we were, were talking about the goal and the benefits of building up and populating healthcare and the healthcare workforce with people with disabilities. So if people who have hired you or promoted you, have a little bit of that goal in mind, I think that's good. I think the fear is that it somehow means that your mind and intellect and abilities and interpersonal abilities, somehow weren't the thing, and of course they are. But I'm okay with the fact if Stanford also wants to populate their ranks with physicians with disabilities.

Peter Poullos:

Yeah, I think they should. And maybe, you know, it's warmer down here on the peninsula Nat.

Nathaniel Gleason:

It's true. Although one really can't live there without driving.

 

 

Peter Poullos:

What's the role of music in your life now?

 

Nat Gleason:

Oh, you know, um, I didn't play for years really. I got kind of burned out playing, because as I said, I didn't play a lot of music that I really loved. I played really to make money because I was so just hell-bent on having a successful music career because that was my whole ambition. When I started medical school, I just didn't play very much through throughout medical school and training. and over the last few years, I have two sons who are now young teenagers and, they're both really self-taught, I've taught them and they've taught themselves to play guitar and bass and drums. And they both are quite wonderful. Uh, so I’ve created my own rhythm section. They’re not quite beyond capable. They're actually like inspired and fun. So I am playing more, still not enough because I work too much, but I am playing more now with them than I have in a really long time, which is, which is pretty fun.

 

Peter Poullos: 

My kids are going to be awesome at range of motion exercises And Segway handling. They're going to be awesome.

Sofia Schlozman:

To our guest, Dr. Gleason, thank you so much for joining us for this interview. Your insights about inclusion, accommodations, and strategies to improve medical education for students and patients with disabilities are so valuable and we are so lucky to have you on the show. To our audience, thank you for joining us for this episode. We hope you subscribe to our podcast and tune in next time.

Sofia Schlozman:

This podcast is a production of the Stanford Medicine Alliance for Disability Inclusion and Equity and the University of Michigan Medical Schools Department of Family Medicine M Disability Initiative.

The opinions on this podcast do not necessarily reflect those of their respective institutions. It is released under Creative Commons Attribution Non-Commercial, Non-Derivative License. This episode was produced by Pete Poullos, Gillian Kumagai, Lisa Meeks and Sofia Schlozman, with support from our audio editors, Amy Hu and Jacob Feeman.