Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman

Authenticity... it can be hard to tap into, especially in medicine when there are so many rigid ideas about how a doctor should look and act and talk. So how do we be doctors while also staying grounded in who we are? You're listening to The Nocturnists: Stories from the World of Medicine. I'm Emily Silverman.

Today, I speak with Dr. Ashley McMullen. Ashley is a Houston native who grew up nurtured by her mother, a pediatric nurse, and grandmother, an ordained minister. She attended UT Houston for medical school, internal medicine residency at UCSF, and was an ambulatory chief resident at San Francisco General Hospital. She currently practices primary care at the San Francisco VA and is the Associate Director for the UCSF Internal Medicine Residency Diversity Committee. She served as the host and producer of The Nocturnists' Black Voices in Healthcare series, and recently launched a new storytelling podcast with Dr. Kimberly Manning called The Human Doctor. But before we chat, here's Ashley's live performance from The Nocturnists in San Francisco in January 2020.

Ashley McMullen

So it's spring of 2018, and I'm nearing the end of residency. And I find myself back in one of my favorite places in San Francisco. It's a place for me that is familiar and warm and safe. It's my hair salon. A small studio out in the South Mission. So it's just me and Stacy, my hairstylist, and I'm post-call, so been up all night I'm delirious and my hair is an entire mess and I just cannot wait to sit in the chair and let Stacy work his magic as he's done month after month for the last couple years.

And so I'm sitting there and Stacy applies this chemical relaxer to my roots. And I feel that familiar tingling in my scalp that progresses into a sharp stabbing pain, which lets us know that it's time to move to the sink. And I feel that cold relief wash over me as he rinses out the relaxer and then massages my scalp with shampoo and conditioner. Afterwards we're back in the chair and I inhale that familiar sense of burning hair as he blow dries and flat irons and then empties half a can of hairspray.

And after this two hour process is done, I'm looking in the mirror and now my hair is fresh and clean. It's silky and very straight, just hanging right above my shoulders. And I'm thinking to myself, "Why the hell am I still doing this?' When I was a kid I used to wear my hair natural—meaning I wore it the way it grew out of my head. I didn't apply any chemicals to change the texture. My mom would braid my hair into these elaborate hairstyles and fastened them with all these colorful bows and barrettes and balls that really make me cringe when I look at those pictures now. But, at the time as a kid, I didn't really mind—it was just hair.

And then when we moved from Chicago to the suburbs of Houston, I found myself in my new elementary school as the only black girl in my class. And sometimes kids would ask to touch my hair. Sometimes they wouldn't ask. One kid even told all of my classmates that he thought my hair was stupid. I don't even know what that means. But at the time, I remember getting my feelings quite hurt. And I would ask my mom over and over again, if I could start wearing my hair straight. And after a little while, she finally relented. I think it was around the sixth grade, the first time I put a chemical relaxer in my hair. And for those of you in the audience who speak science, there's an abundance of disulfide bonds that give black hair its characteristic shape and texture and curl pattern. And out of all the chemical bonds that make up the hair, it's these bonds that are the strongest. So it takes an equally strong chemical to break these bonds. And that's what the relaxer is. Each time it's applied, it allows the hair to be permanently straightened after breaking those bonds. But even though after the process is over with and the hair looks great outwardly, inwardly, the hair becomes inherently weaker—it's more fragile and prone to breakage. It's harder to grow.

But I started doing this in sixth grade, and I would continue to go back to the salon and I'd wear my hair straight as I grew older. I moved away for college and I got into medical school. I graduated as the first doctor in my family. Yes, thank you. And then I matched to my first choice of residency. And I even got tapped to be chief resident. Yeah, in the words of that great philosopher, DJ Khaled, "All I did was win, win, win no matter what." But that was at least outwardly. I have to admit, inwardly I was a bit of a mess. I had this very fragile sense of self-identity and self-esteem that, up until that point, I'd done pretty well to hold together. But, I gotta say, there's nothing quite like residency to really just break you open and show you what's on the inside. And so that would happen for me a number of times in residency. There were a lot of late nights, a lot of lack of sleep, and 4AM pages about the potassium of 3.6. There are also times when patients and staff would confuse me for anything but a doctor. There were colleagues who would sometimes mistake me for other black women in my program...including one particularly "woke" white nurse who, after making this mistake and getting corrected, she decided to inform everybody how to distinguish two of us by saying, "Well, she's the one with straight hair, and she's dealing with kinky hair."

But then there was Mr. D. Mr. D was one of my primary care patients. And he's the patient who, when you open your schedule before clinic to pre-round and you see that name on there, you just sigh a little bit because you know, it's going to be one of those sessions. Mr. D was that patient for me. And I knew about him even before my first visit because he was someone who came to clinic often. He had a very long list of medical problems, literally anything that could go wrong with an organ system, this man had. He had a long list of medications to treat those problems. And then the list of medications to treat the side effects of the other medications. But more than anything else, Mr. D was a man in a lot of pain—pain that was both emotionally and physically debilitating, and very hard to treat. So hard, in fact that he had fired a number of his previous providers because they couldn't agree on a treatment plan.

And so I'm gearing myself up for what could potentially be a challenging visit. But I'm hopeful that you know, perhaps I'm the hero this patient needs to really establish rapport and get them on the track to wellness. So I put on the white coat and I put on the stethoscope and made sure the doctor badge was facing forward and hair was on point, looking myself in the mirror, I'm ready to go.

And I go to the exam room, and I open the door to walk in, and I see this middle aged white man sitting there, reading a sci-fi novel. And he's wearing cargo shorts and a graphic T and these little wire rimmed glasses that he takes off when he sees me walk in the room. So I close the door behind me and I smile big. I'm going to introduce myself. But before I could even get the words out, he says to me, “Your last name is Irish. I thought you'd be a white woman.”

Cool, cool. I wasn't expecting that. But that's okay. Shake it off. I introduced myself I say, "Hello, I'm Dr. McMullen." Even something to the effect of, "I'm sorry, I wasn't quite what you were expecting, hahaha!"

And he looks at me, and he shrugs and says, "I guess it could be worse."

Awesome. So we're off to a great start. I sit down and open the chart and start to take the history. Mr. D opens up a little bit and tells me his story. I asked him about his pain. He tells me the quality, what's worked for in the past, what doesn't work. And I start to notice that as he is referring to his other providers, he's calling them Dr. so-and-so, but he's continuing to address me as Ashley. And I'm noticing this, and I think to myself, "I should say something." But I don't. I finish the history. I get up and I listen to his irregularly irregular heartbeats. I listened to his wheezy lungs and look at his swollen ankles. I write him for some prescription refills, finished the encounter, and I send him on its way.

And I remember after that clinic feeling so broken. Just took off the white coat and stethoscope and the badge. And I was just so angry. I was angry at the patient, I was angry at the clinic, I was angry at the residency program. And I was angry at myself for ever believing that that coat and that stethoscope and that badge and this straight here would ever make me anything other than a Black woman in this society. And so sometime after that clinic that I found myself at the salon, looking in the mirror thinking, "Why am I still doing this?" And I didn't have an answer. So I decided I was gonna stop going. I was gonna stop chemically straightening my hair. I started wearing my hair in braids. I also decided to tell my family and friends that I was gay because why not?

Yeah. I figured if I was gonna transition back to natural hair, I should really learn to love this awesome trifecta of being a Black gay woman in this society, even if this society didn't always love me back. And so on my second visit with Mr. D, he was dropped into my schedule, because he had developed some new knee pain. So I see his name on the list and I sigh, put on the white coat and stethoscope, and I go to the exam room. And I look at his knee, and it's definitely swollen. It's definitely painful—he did something to it. So I order him some x-rays, and I'm writing some new prescriptions for pain medications.

And I'm noticing again throughout our interaction that he's referring to me by my first name. But this time I said something. I said, "Mr. D, I want us to continue working together. I want to treat you. But honestly, if this is going to continue, you have to show me the same respect you show to your other providers. That means you're not going to call me by my first name. And you're not going to make any comments about my race or that of any of my other colleagues or staff."

And as the words leaving my mouth, I'm feeling my heart starts to race. And there's silence in the room for a little bit as he's looking at me. And then he apologizes. Sincerely. And we never had that issue again.

After my residency and going into my chief year, Mr. D and I would continue to see each other regularly in clinic. And I would come to understand that at least part of his behavior wasn't just that he was a man in a lot of pain. He was also someone dealing with a lot of profound loss: loss of identity, loss of function, and loss of control.

Throughout that year, I was also dealing with a lot of loss of my own. Some really good friends that I had during residency had moved away during my chief year. My relationship ended, and I lost my partner and really good friends. And I really missed the hair salon. You know, I missed Stacy, my hairstylist, and I missed having that space to go back to month after month. But you know, I got through it.

And at the end of that year at my last clinic encounter with Mr. D—even though I know we didn't always see eye-to-eye—when we were done, he thanked me for my time and wished me well in my career.

So after my chief year, as I'm getting ready to transition into my new position as an attending at the VA hospital, I decided it was time to take those braids out, and I was going to start wearing my hair natural to work. So I sent a text message to Stacy and it was like, "Hey, want to come back for an appointment." It had been almost a year and a half at that point. And I found myself back in that salon chair, looking in the mirror, Stacy standing there. And I had the braids out and my hair was just sitting naturally on its own. And instead of putting a relaxer in this time, he's getting ready to cut off all the remaining chemically-processed hair that I've been hanging on to for that year. But before he's getting started, as he's looking at my hair, he says to me, "You know, a lot of that straight hair actually already broke off throughout the last year." And I look in the mirror, and I realize he's right. What was left was hair that was fully-transitioned: natural, healthier, stronger, and authentically me.

Emily Silverman

So I am sitting here with Ashley McMullen. Ashley, thanks for being here today.

Ashley McMullen

Thanks for inviting me. It's amazing to just be together again, in an actual studio. So I'm really happy.

Emily Silverman

It's great to be here with you, too, in person. And I'm wondering, when you think back to that night, where you stood on stage and told your story at The Nocturnists—this was pre pandemic in January 2020—how does it feel to think back to that night, after everything that we've dealt with over the last 18 months?

Ashley McMullen

I mean, just the magnitude of how so much has happened since that January. It is so meaningful to look back and realize...just to actually be proud of myself, which is not always easy. And particularly to get on stage and tell that story. I think even a year before that performance, I'm not sure that I could have done that. It felt very empowering.

Emily Silverman

I'm curious, after you told the story, did you get any responses or comments or thoughts from people in the audience are friends and family?

Ashley McMullen

Yeah. Yeah, I had a number of friends in the audience. It's just like, a lot of love came out of that. Even though these are folks that I've known for years—been through residency with. I shared a part of myself that I don't think I had shared before, and to have people respond in a way that was affirming and loving was immensely valuable. And then of course, like, with folks who I didn't know, there are folks that I didn't know as well, people were able to resonate with that story. I think many of us have embodied these kind of narratives and trying to always fit ourselves into the molds of what society expects, what society values and then getting to that point where you can start to dismantle these structures that keep us from being who we are and what that feels like and... Or if you're still working through it. Understanding the pain of that process but also the beauty that comes after it.

Emily Silverman

And at the time that you told that story, neither of us knew that soon we would be producing a whole podcast series together.

Ashley McMullen

No, I can't say I saw that coming!

Emily Silverman

So we produced that series together Black Voices in Healthcare over a year ago. I'm wondering what is it like to reflect back on that because even that now feels like it was a long time ago

Ashley McMullen

My God, yeah. I mean, 2020, just in and of itself—if we could just pause to pay homage of how much life can change in such a short amount of time. And I just love the trajectory and beauty of our collaboration and our friendship and dovetailing into this series. I think back, especially in...where my mind was at immediately after George Floyd. I was having such...such conflict internally, like wanting people to respond, but also not wanting to be bothered and having to manage other people's discomfort.

And so I really appreciated your...your approach to that situation, because we talk a lot about allyship. And just recognizing that human interaction is inevitably messy, especially interacting across differences across cultures and all the fear and anger and wanting to do something, but not knowing quite what to do. What you did in that moment was you reached out with an invitation to use an existing platform to do what we both care about, which is tell stories, but perhaps we can do this in a way that sheds light, or maybe tells a story that hasn't been told in a way that can bring healing and empathy and compassion in this moment that really, really needs it. And not coming with an agenda, not coming like asking me to explain or try to understand, but just, "Hey, like I'm here. Can we work together? Can I help?" And so that was kind of the basis for how this podcast came to evolve. And, other than a few occasional NPR episodes, I knew nothing about podcasting. And it was such a deeply moving and meaningful experience to have the small team with you and Adelaide and Kimberly Manning coming on board and our amazing students and Jon, and invite these stories and cultivate this tapestry of different narratives that highlights an aspect of healthcare that perhaps had not been seen. The word that comes to mind is just gratitude, and also humility, to be able to participate in that project to have people who trusted us with those stories, and to have the resources to put together that project. It was just so, so beautiful.

Emily Silverman

One of my favorite episodes of The Black Voices series was the episode on hair. And it reminded me, it reminded me of course of your story that you told at The Nocturnists on stage. And so I'm wondering what was it like to have had this experience of standing on stage and telling this story about your hair in January 2020, and then later to be putting out a call for stories about hair. And I think that's one of the themes where we got the most submissions, and it was especially difficult to narrow down which ones we had time to include in the episode. So what was that like? Connecting the hair episode with your story?

Ashley McMullen

Oh, my God. I mean, I will say before we even knew exactly what the Black Voices in Healthcare series was going to be, we knew that hair would be included. And it's just such an important aspect of our culture, and particularly among Black women. I think anything that really makes you stand out, it's both a challenge and such a unique gift and opportunity to really make it authentically you. And I had such a fraught relationship with my hair for so long. It really became a metaphor for a lot of things that I found challenging growing up as a Black queer woman, particularly with darker skin, very kinky, curly hair, and all these aspects that seemed to go against what was accepted as beautiful and valued. And so to tell that story, and then listen to all these other unique stories about both women and men, just describing their relationship with their hair, and what that means for them in this personal and professional space, and the stories that are embedded within our hair throughout the generations and then how that connects us with our families and our colleagues. I just love it. I mean, if you happen to listen to the human doctor, I'd say that in almost every episode, hair comes up. And my hair also has a name now... her name is Mahalia. Yes, yes. So I feel like Mahalia and I have just evolved so much.

Emily Silverman

You mentioned The Human Doctor podcast, which you co-host and produce with the incredible Dr. Kimberly Manning.

Ashley McMullen

Yes.

Emily Silverman

So tell me a little bit about that journey. How did you all conceive of the series? I know that you've produced now, over a dozen episodes, I think.

Ashley McMullen

Yeah, we landed right at 15 for season one, and they're gonna pick up the baton again soon.

Emily Silverman

And it's so, so good. It's so joyful to listen to. You know, it's very simple, and I love the way that you structured with something I learned, what is the what, and then one of you shares a story, and then there's some discussion. So tell us a little bit about that process and creating it and how it's going.

Ashley McMullen

Kimberly and I actually had met before, just a few months prior to our work with the series. But she had come to UCSF for a visiting professorship and we'd gotten connected through a mentor of mine that allowed me to get on her very, very packed schedule. And it was just kind of like, love at first sight in the sense that it was just this ease of relationship and understanding and Kimberly's just a natural storyteller in a way that's just so authentic and disarming. And that doesn't come easily, at least not to me. You know, I'm usually or I've kind of, at that point had grown into this pattern of cultivating who I thought I needed to be, and whatever given moment, particularly working in an institution where there aren't a lot of folks like me, and she just, like, threw that out the window. Granted, here we are, two Black woman in academic medicine with a couple of different shared identities. But she's also got years of experience ahead of me, like, well-respected, this whole social media following. And in the room, it's just two women, friends, like sharing stories with each other.

And so that's how we we met, and then come back full circle working on a project together. And so a lot of gratitude to the work with the Black Voices series, because it made me a little bit more comfortable with recording, podcasting, and recognizing this is a very powerful medium that can reach a lot of folks outside our usual academic circles. That was kind of the launching point for us to try something new. And so that was how we approached it. And it was like a bit of a labor of love in terms of getting the structure right. But, at its core, the idea is that here we are two women in medicine, both who identify as Black, both who are descendants of survivors of slavery, but a lot of diverging identities as well. Like I said, Kimberly's got a couple years on me, both in age and experience, she's got a family, she's a mother, she's a wife, she grew up in a predominantly Black neighborhood went to two, historically Black colleges for undergrad and medical school.

And, you know, my experience—I grew up with my grandparents in Chicago, moved to Houston and was in a predominantly white suburb, and move through institutions where I was, you know, felt othered and many ways and just derive this intense desire to fit in and be accepted. And part of that was sacrificing a lot of my authenticity and favor what I thought other people wanted me to be in on. I also identify as queer as was told in my story, and that whole coming out process, and so we both embody stories that aren't told often in our profession.

Emily Silverman

A lot of the stories and a lot of the—I don't wanna say lessons, because that makes it sound too, like didactic—but insights, I guess, from the stories they feel applicable to medicine and medical education, but they also just feel applicable to life. Right? Right? It kind of feels like I'm listening to life coach, podcast, because so much of what comes out of it is is, you know, how do we relate to other people? How do we orient ourselves in the world? I loved the episode, where Kimberly told the story about being stoppable or unstoppable. Yeah, so for the listener, Kimberly was talking about how people just tend to stop her on the street to ask for help, ask for directions. And one day, somebody said to her, you just look, stoppable. So she was reflecting on what that means. What does it mean to move through the world with an openness? And how does that apply to medical education? How does that apply to patient care? And the story that you told recently, you called it a success story about the patient who you took the time to slow down and identify what he really wanted and helped facilitate him going back to Mexico where he wanted to die and where he did die. And I think framing that as a success story is so important. And so powerful, because in medicine, we frame death as failure, and so on and so forth. So anyway, I guess I'm just kind of rambling about how much I love the stories and how I feel like they transcend medicine and just apply in general.

Ashley McMullen

I love that. That's what stories do. They transcend a lot of the structures and barriers we have that keep us divided and stories. They just have a simple mechanism that can really just bring people together. It changes the game, but particularly in a field, like medicine, where you're constantly interacting with folks who are different from you.

Emily Silverman

What kind of response have you had from the audience of your podcasts? Do you have a sense of who's listening? Is it students? Is it faculty? Is it people outside of medicine? And have you received any feedback about the series?

Ashley McMullen

Yeah, it's funny, sometimes I forget that people are listening. Because, you know, I mean, we do have a structure. But you know, at some point throughout the conversation, it's just me and my really awesome, amazing friend who are sharing stories and the same way we might do on the phone or in a coffee shop. For some reason, it still shocks me when I get feedback from colleagues, again, across the spectrum of identities, so a lot of folks in medicine, but also a lot of folks outside of medicine, who have been patients before, or have had other interactions with the healthcare field, whether it's staff or administrators, messages from people on Twitter who follow and I've been able to look at some of the data of folks who are downloading the episodes, and I see folks from Australia, India, like places around the world. And it's a humbling reminder, again, how stories speak to humanity. These are the stories of human beings.

Emily Silverman

So you work in primary care at the VA? And you also teach?

Ashley McMullen

Yeah.

Emily Silverman

How do you incorporate storytelling into patient care and into medical education? How are you bringing this ethos into the hospital?

Ashley McMullen

Doing the work of reflecting on my own story and recognizing what narrative I'm bringing into the room was really important. And being able to recognize that everybody has a story, and how do we interact and extract that story in our patient encounters? One of the benefits of being at the VA is I do feel like I have a little bit more time with my veterans. And, you know, it's a very unique population. These are folks who have served their country. And that process has endured a lot of deep personal wounds and triumph and pride and also struggles on the back end.

And so how do we capture that in the standard clinical visits? It's hard to do in the 20 to 30 minutes that we're allotted. But I try to really bake that into that space. And so we're taught sometimes to condense the social history in terms of social or health-related behaviors. And I've tried to take that opportunity to really leave it open-ended and ask questions like, "Tell me your story," or "What's something important that you think I should know about you?" And often, I'll ask my veterans to tell me, "What are the things that bring you joy in this life?" And I'm often surprised by the answers, stories of resilience, stories of love.

Sometimes for patients, it's hard for them to come up with that answer. And that also speaks to their health and well-being. It's not always perfect, but what I try to do is at least set the intention that I care about you as a person, and I'm trying to position my self and how I take a history, my body language, and do so in a way that allows people to see that I'm trying to see you for who you are.

And when I teach this approach, particularly with trainees in the primary care setting, I tried to start by adapting what we call the one liner. So this way of talking about patients that convinces their story to the—we call the pertinent positives, or the pertinent negatives—so what are the important things that we can say one line about a person. It usually relates to age, past medical history, active issues, so a number and a list of problems? And I usually will tell learners this is important part of, like, understanding how to solve medical problems, but also, like, how do we—how do we engage the humanistic element of this? And so I usually will ask my learners to tell me what's something more unique to this person as a human being? What have you learned about them? And how can we reframe this one liner in ways that include that? I think we all inherently want to be seen. And we want to be seen, especially by the people who have aspects of power and influence in our lives and for better for worse, doctors embody that privilege and power in society.

So I think it's not just helpful—it's imperative that we learn how to approach the practice of medicine with narrative competence. I also tried to embrace this practice with longitudinal curriculum of trainees who are interested in health equities. And so what this practice involves is diving deep into literature and stories that currently exist. And talking through narratives that speak to identities or circumstances in medicine that are really hard—hard to empathize with, it's maybe easier for us to pat ourselves on the back about dealing with patients who have certain identities that are easy to sympathize with—children, for example, which I don't treat. But what about the person who is marginally housed because they can't keep a job because they've been dealing with addiction to opioids? Or the person who's manipulative, the person who has deep delusions around their bodies, or doesn't believe in science or vaccines? What narratives exists there that can help us restructure who deserves empathy and who doesn't? And I think stories kind of open that space for us to do so. And so that's what I try to impart on my learners is that stories matter across all aspects of medicine, but especially with folks who are traditionally harmed and marginalized.

Emily Silverman

I really love what you say about how it's especially important with people for whom it might be more difficult to empathize with and how that is where the curiosity is even more important. And my last question for you is coming back to this theme of authenticity. So your story is all about finding your own authenticity, tapping into it, embracing it, celebrating it. Do you have any words of advice for our listeners, maybe people who are struggling to—to find their authenticity? Or maybe they know who they are, but they still experience fear around authentically being who they are because of the barriers that exist in healthcare? How would you speak to an audience of people either at the beginning of the careers or even late in their careers who are really wanting to realign and reground themselves?

Ashley McMullen

Simple question. Yeah, well, I can, I can say what was helpful for me, especially early on. You know, ironically, I was actually sitting in church, when this came to be...and this was around the time where I was really deeply struggling with my sexuality. And the message that I remember from that evening of the night service was, there's so much work to be done. I believe this to be true—that there is an inherent purpose and potential in every human being. But you cannot do what you're supposed to do if you are too busy trying to be someone that you were not meant to be. The cognitive load is so heavy already, just with everything that's going on.

And life is short. Life is short, and that is—if you didn't learn that in the last year, I don't know what else I can tell you. If you're doing something out of fear, then that something that's worth exploring—the why. You're going to stumble a lot. Anybody who's transitioned to natural hair, knows it is not easy, but the process is so beautiful. And surround yourself with the people who nourish that authentic version of yourself. That might mean letting some relationships go or embracing others. But this work of becoming is a continual process. It's up to you to take those steps, especially taking those steps past fear. But recognizing the beauty is in the formation, not necessarily the destination, and carry that with you. And also be kind to yourself, goodness gracious! Part of my transition into and in towards authenticity has been allowing myself the space to fail, to not get it right—the first or the second or the third time. And still smiling at how far I've come.

Emily Silverman

Thank you so much, Ashley, for coming in today to speak with me.

Ashley McMullen

Thank you.

Emily Silverman

Thank you for telling your story on The Nocturnists' stage. Thank you for collaborating with The Nocturnists’ team on Black Voices and for spearheading this amazing new show, The Human Doctor. I can't wait to keep listening and to see in what direction it evolves and in what direction you evolve and all the great things to come.

Ashley McMullen

Excellent. Well thank you for having me.