ASH B. ALPERT, MD, MFA
Preparing for a patient I was going to see in breast oncology clinic, I noticed she was single and that her partner was female. The information system at the hospital I was working in included a patient photograph along with the usual demographic and clinical information. The photograph had caught her in the process of smiling, her mouth lopsided. I felt a strange sensation looking at her, which reminded me of the feeling I had in high school when I met the other young people in the lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth group in the next town over. At the time, I was ashamed because of what they represented about me.
The Patient History
I went in to meet my patient who stood when I walked in. She was tall and had boy-short hair and dark eyes. She looked like my friend Karen, a butch lesbian I met in Michigan who used to whistle at me when she drove by. We shook hands while she kept her eyes on me, like she was waiting for something. I asked about the other person in the room, and she introduced her partner who had long hair, wore glasses, and had a pad of paper in her lap, which she held with strong, sturdy hands. She was an electrician, who often worked at great heights, maneuvering around live wires to avoid being shocked.
I explained my role as a clinical fellow in hematology and medical oncology and asked the patient to sit next to me. She held one hand within the other, as if to comfort herself. I asked the usual questions and learned that she was otherwise healthy, smoked a pack a day, and worked as part of a grounds crew for a local university. She had noticed a lump while in the shower and her primary care doctor had ordered a mammogram which was read as normal. Her partner insisted on more imaging, then a biopsy. We sat close together as I gathered the history and explained everything I knew about her 7 mm, grade 1, estrogen receptor/progesterone receptor–positive, human epidermal growth factor receptor 2–negative breast cancer. I explained the concept of micrometastases, cancer cells which may or may not have escaped the primary tumor and which we wouldn’t be able to see. I went over the adverse effects of aromatase inhibitors and answered her questions as her partner took notes. I noticed she did not interrupt or correct the patient’s history, unlike many husbands.
The Treatment Plan
I told them I didn’t think she would need chemotherapy. They looked at me for a few seconds as if to be sure they had heard me correctly. We rereviewed the low-risk features of her cancer and her partner put her hand on the patient’s thigh. Then, the air in the room had changed and my patient unclasped her hands. I could feel us all breathing easier and, as we did, I asked them how they spent their time in Rochester and if they had been to ImageOut, the Rochester LGBTQ film festival. They had not, and by way of explanation, my patient said, “Most of our friends are straight.”
“Straight people are okay,” I said. They both looked at me and I did not look away. Then, they laughed and I laughed with them and our laughter felt very healing, like we were breaking something open. I knew they understood that I was coming out to them.
The Patient-Physician Relationship
The room felt unusually comfortable when my attending and I went back in. The patient and her partner directed most of their questions and comments to me. My attending commented on our rapport and I nodded but wasn’t sure I knew how to explain what had happened or if she would understand. When I shared this narrative with co-fellows and staff oncologists, they questioned the purpose of my coming out. At first, I was frustrated that I was being asked to justify being open about who I am. The motives of my straight male attending physicians likely are not questioned when they wear their wedding bands or mention their wives off-hand. I did not want to have to explain what it is like to be queer and how much time I and my LGBTQ patients spend with parts of ourselves hidden. Coming out was intuitive and unscripted, a way to break down the boxes binding us, the walls between us. Coming out to my patient and her partner felt like going to where they were, like cracking an ill-fitting shell. I wanted my patient and her partner to know who I was and that I connected with a part of their lives they may have felt needed to stay hidden. I wanted it for them and for me.
Systemic Imbalances
Working within a system that doesn’t acknowledge my existence as a queer and nonbinary person creates a sense of being disconnected from my day-to-day life. Part of me stays hidden while the outside version puts on work clothes and tries to perform well every day in my hematology and medical oncology fellowship. During lectures that use a cisgender, heterosexual paradigm, I take notes like the other fellows. At tumor board when I am called on by the wrong name, my legal name, which I no longer use, I simply answer the question.
I do not often use the word “queer” at work, but it is the only one I’ve ever found to describe my sexual orientation. I’m in a long-term relationship with a cisgender, heterosexual man. Most of my life, I dated butch women and transgender people. I am not a lesbian nor am I cisgender, and the word “bisexual” doesn’t apply. I learned the word “queer” in high school, which was the first time that I met other people like me. An umbrella term and a reclaimed slur, “queer” always felt right. I have never heard the word mentioned in a medical school lecture nor printed in any of the study guides I used to prepare for exams. The word for what I am has had no place in medicine.
The Silver Lining
I am a qualitative researcher and my work investigates what lesbian, gay, bisexual, transgender, queer, and other non-heterosexual and non-cisgender patients (LGBTQ+) need from their doctors. LGBTQ+ patients tell me that physicians coming out to them is a silver lining around the very gray cloud of transphobia and homophobia. When physicians come out to patients, both patients and physicians can be freed of the mistaken assumptions and expectations that a cisgender and heterosexual world has placed on us.
I wrote this piece to be an example, a corollary to the research I do. I didn’t expect to write about what happened in me when I connected to this patient and her partner and allowed some hidden parts of me to shine on the surface—safe, happy, and warm.
Acknowledgment
I thank Mohamedtaki Tejani, MD, Jennifer Griggs, MD, MPH, FACP, FASCO, and David Korones, MD for their support and assistance with this manuscript.
Dr. Alpert is currently Assistant Professor of Internal Medicine, Medical Oncology & Hematology, at Yale School of Medicine in New Haven, Connecticut. At the time this article was originally published, Dr. Alpert was working at the University of Rochester Medical Center in Rochester, New York.
Reprinted with permission from: Alpert AB: J Clin Oncol. Published online February 11, 2020.
