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

You're listening to The Nocturnists: Stories from the World of Medicine. I'm Emily Silverman.Today we hear from medical student Oak Sonfist about a vivid dream they had. The dream took place during a hypoglycemic episode and serves as a metaphor for the challenge that Oak faces navigating two different worlds. Oak is a rising fourth year at Pacific Northwest University of Health Sciences and focuses on med school education reform, rural health, mental health, trauma informed care and Transgender Health.Oak is currently the Education and Advocacy Fellow with the American Medical Student Association (AMSA) and acts as a liaison between grassroots organizations and national institutions to foster growth and understanding. After the story, Oak and I talk about what it's like to be in medicine with a chronic illness, the mental health crisis that physicians are facing today, and their own journey as the first transgender medical student at their school.But first, let's listen to an intimate studio recording of Oak’s story, which was initially performed live at an event that we co-produced with the UCSF Memory and Aging Center in October 2022 on the theme of Sleep and Dreams. Here's Oak:

Oak Sonfist

I'm surrounded by murky waters, concealing monsters and creatures, things I can only dream of. I'm sitting inside of my small metal submarine, crossing the ocean floor. I can hear the metal creaking around me as we move forward, the pressure of the entire ocean on top of me. Of course, my ship is in the shape of an angler fish with one antenna and light coming from the top. The light bounces across the floor, illuminating only one moment at a time. It bounces from here, to there, to over there. Suddenly I see it light up something that looks different. As we get closer I see a hole on the ocean floor. I'm not sure what it is or where it goes. But I know that that's where I'm supposed to be. I direct my ship down into the long cavern. As I move forward, the walls scrape along the sides of my ship. In front of me the light shines one path forward. Behind me fills up with empty darkness.Suddenly, I emerge on the other side and I see exactly what I have been looking for. It's the Lost City of Atlantis. And it's not old and decayed like we expected. No, it's bright and a vibrant city. As I dock my submarine and on the shore, I see the paths of marble with green vines hanging between buildings. I emerge from my submarine and I can smell the fresh bread being baked at the nearby market. People are running towards me–so many people–all wearing white robes with gold adorned into them. They, so excited to see me, and I am so excited to see them. They're smiling and cheering. A couple people grab me and start bringing me towards the city center. We march up the steps going up, up, up into the castle. And there, I'm given an audience with the king. He looks down and smiles. This is a feeling I felt before and I knew I am exactly where I belong."Oak, come in," my radio at my hip is going off. It's the team of scientists at the surface. I completely forgot that I wasn't here alone. They were waiting for me to tell them what I found, if I found anything at all. "Oak, come in." What do I do? Do I tell them that I'm here and what I found? Am I supposed to expose the civilization that's been here for thousands of years, the horrors of modern society, to taxes, to the stock market, to McDonald's? "Oak, come in." I look at the king in front of me. I don't understand the language he's speaking. I can't ask him for permission. "Oak, come in!" The radio on my hip is just getting louder. Am I supposed to lie and tell them I found nothing? How everyone would be disappointed in the journey we took together? "Oak, come in!" My radio is yelling at me, telling me I have to make a choice. I can't stay here forever. "Oak, come in!" I need to make a decision. What am I supposed to do? "Oak, come in!"And with that, I'm awake. My continuous blood glucose monitor is beeping. "L-O-W," it reads low. That's something you never want to see as a type 1 diabetic. My head is spinning. I don't know where I am. But I know that I need to get up. I pushed myself onto my forearms and into my knees. I use my bed to stable myself as I stand up. I move towards my kitchen, gripping onto the couch in my living room. As I enter the doorway of my kitchen I see there the pizza that I was supposed to have eaten for dinner. This is not the first time. This isn't the first time this has happened. As a highly stressed medical student I often forget to eat, even when I've given myself insulin. I grab a juice box and I sit down at the table. And I begin to drink my juice and eat my pizza.I am seven years old. My dad comes to the school to pick me up one Friday afternoon. It's exciting to see him–I'm usually taking the yellow school bus home. But instead, today he's ushering me out quickly from the school yard and we hail a cab. Taxis, what a treat. New York City cabs are only for special occasions, and I know that something exciting is about to happen. We start driving the taxi cab all the way uptown. When we get to our destination, I turn to my dad and I say, "Dad, why are we here? This is just a big building." He looks down and he says to me, "We need to get some tests done." As we enter the hospital, I quickly realized I don't want to be here at all. There's four nurses who have to hold me down so that they can just put an IV in. That was just the first episode of two weeks of confusion, people running around saying things I don't understand, poking and prodding me with needles and medicine. All I can hear are sirens outside and announcements on the loudspeakers above me. I have no idea what's going on. After being there for two weeks, the doctor comes to sit with me. She sits close at the end of my bed, making eye contact with me at the same height. She asked me, "Do you have any questions?" I'm terrified. I don't know what to say. I say, "Am I going to die from die-abetes?" She chuckles, "No, you're not going to die. But you are going to have to choose to live."I hear her words clearly. The first clear thing that I've heard in weeks. She's like a rock in a storm. Everything that's going on around us, swirling. I know I'm gonna be okay. In that moment, I also know that I want to be like her. I want to be a rock in the storm. As I move forward, and grow joining the LGBTQ community, I realized that I want to become a physician. And my path forward is the same as searching for Atlantis.I'm 26 years old, and I start medical school. I'm so excited to be there. But at the same time, I'm the first openly transgender student at my school. And with that came a lot of questions. In addition to trying to learn medicine, I spent a lot of time trying to educate the people around me about my existence. In my third year, I took a meeting with my favorite preceptor, Dr. P. He was always so serious, wearing his scrubs and crocs. We sat in the lobby of the hospital building with the sun shining through the wall of glass. We had just gotten out of a four-hour operation together. It was time for my final review. Dr. P was not smiling at me, which is something I did not take offense to. The only people I ever saw Dr. P smiling at were his patients. And he smiled at his patients a lot. He said to me, "Oak, you're a great medical student, and someday you'll be a great physician. I'm so proud of you. I need you to know something though. Over this next year, things might get really hard. And I need you to know I don't want you to quit."I felt his warning deep inside of me. And soon after that, I quickly realized exactly what he meant. After a few more rotations went by and side comments were always made, conversations would end as soon as I entered a room. Things would be whispered as I walked through the hallways. I could feel a sense of differentness. Eventually, I chose to go back into the closet. I chose to detransition. I chose to change who I was so that way I could hide. This is a decision that still haunts me. I sit at my kitchen table with all of these feelings swirling in my head, my mind half in Atlantis and half in my present reality.I know I found Atlantis before. I know that I have felt that sense of belonging tingling on my skin, knowing that I'm exactly where I'm supposed to be. But these days, all I feel is my team of scientists at the surface calling down to me, forcing me to make decisions that I have no concept or ability to fully make. I can feel the table in front of me. I can feel the warmth of my dog's fur as she rests on my leg. I know that my blood sugar is going back up. I know, right now, I'm okay.

Emily Silverman

I am sitting here with Oak Sonfist. Oak, thank you so much for being here today.

Oak Sonfist

Well, thank you for having me.

Emily Silverman

So Oak, we first met when you submitted your story idea for our live performance in San Francisco on the theme of sleep and dreams. And I still remember hearing you describe your dream in this detail. And I was so sucked in. And it was just so fantastic. And I think after the live show in San Francisco–I remember we were standing together and talking–and you were talking about your diabetes and how your dreams are impacted by your blood sugar level, for example. Tell us about your dream life.

Oak Sonfist

So something that's really interesting about who I am is the intersections of my chronic illness and also my profession. Being a type 1 diabetic, I have to already be hyper-aware of my physical health and I have to notice trends, like: When I eat a certain type of food, when does my blood sugar go high? How many hours afterwards? If I have something that's high in fat, do I have to extend a bolus over a long period of time, instead of just doing something that's rapid acting? It's a whole bunch of minute details that kind of overlay with each other. And when I started medical school, I found that I had to really regulate what I put into my body–like, exactly what kind of foods I ate affected exactly how much energy I could sustain to study and sit and learn. As I've gotten older, I have noticed trends between my type 1 diabetes and my dream states. When my blood sugar is low, I actually have these dreams of endless wonder and kind of like this sinking feeling of nothingness. It's hard to explain beyond that. And when my blood sugar is high, I have these nightmares–the types of dreams where it's like it's a zombie apocalypse and you have to survive. And there's a very clear-cut solution, but you're just not there. So it's kind of like a horror movie, hyper-fixated on a solution. And when my blood sugar's a normal range, those are the nights that I get my best sleep because I usually have either no dreams at all or dreams about pleasant things.

Emily Silverman

You may not have an answer to this, but I'm just curious: Any idea why the difference between the lows and the highs and the endless wonder and the zombie apocalypse? Like is there something about bottoming out versus being hyperglycaemic that lends itself to those types of narratives? Or is it just something that is a mystery?

Oak Sonfist

I'm honestly not sure. It does really kind of parallel what I feel when I'm awake though, especially in those like hypo-states. When my blood sugar is super low, sometimes it does feel so overwhelming that I do just want to give up because, you know, it's like, "Man, I just had this meal and now my blood sugar is going low and I have to drink some more juice and I don't want to have anything." It's like this mindset that just kind of takes over you. Obviously, I still always treat myself but I think that's like really reflected in the dreams. I guess it does parallel my awake states.

Emily Silverman

You talked about how having type 1 diabetes requires you to be really attuned to what's going on in your body and in your environment, at any time–nutrition, exercise, studying, all of those things, sleep. As a medical student, I'm just wondering, like how do you navigate that? We all know that medical school is really grueling and there's a lot of overwork and a lot of unhealthy behaviors. You know, staying up all night and eating junk or not eating and things like that. And so I'm just curious, how have you been able to navigate that tension between that presence and attentiveness to oneself and the stressors of medical school?

Oak Sonfist

I know so many type 1 diabetics who are like so excellent at their management of their diabetes, and I have to be honest, like, I am not one of those people. I was diagnosed when I was seven. When I was a teenager, I really struggled with managing my type 1 diabetes. I actually had gotten to a point where my average blood glucose, my A1C, was so high it couldn't be recorded. You know, the lab value was off the charts high. That was when I was 16 years old. And I had to make a conscious choice when I was around 22 after, you know, having so many physicians, so many people who cared about me tell me that if I don't change, that I was going to die. I was going to lose limbs, I would never be able to have children, all types of physical health issues. I had to really choose to be healthy. And that was while I was in undergrad. I went on an insulin pump, I got a continuous blood glucose monitor, I really started to take care of myself, and I chose to put myself first. You know, after undergrad, I took off a few years before medical school. And during that time, I really learned what it meant to be me, living in my body with my diseases with my identities. And I really found strength in myself. During medical school, there is so much new information that comes at you so quickly. There's so many personalities around you, so many intelligent people who all want to do the best. It's inspiring and also terrifying at the same time. I do remember the nights when I'd be in the anatomy lab till 11pm working on a cadaver, trying to memorize the last, you know, couple of nerves I needed for the next exam, you know, eating one of those frozen burritos being like, "Wow, my blood sugar is really going to suffer because of that." But I also remember all the times when I said, "No." There were so many times when I was expected to do things that an able-bodied person could do that if I had done in that moment, I wouldn't have been okay. You know, working past 12 hours. You know, not being able to take a break for lunch. If I need a snack, I say I need a snack. Like, it singles me out sometimes. But at the end of the day, when I create those boundaries around my own physical health, and I refuse to get caught up in the drama of whether or not someone likes me, or if I'm not studying enough, it really helps me learn who I can trust. Because the people who respond to me well and understand–I know that those are people that I want to work with in my future, that I respect, that I want to learn from. It has been hard at times to take care of myself. But at the same time, I'm fortunate enough to have had the experiences of what it's like to not have good control over my diabetes, to know that I never want to be there again.

Emily Silverman

You mentioned how, you know, advocating for yourself and your health helps you see who around you in your environment you can trust, who are your mentors, and so on and so forth. And I wanted to touch on two people that came up as characters in your story. So first, you have the moment where you're diagnosed, and the doctor comes and sits at the edge of the bed–I think you said you're seven. And you say, "Am I going to die of diabetes? And the doctor says, "No, you're not going to die. You just have to choose to live." And you describe this doctor as a rock in a storm. And you say, "I wanted to be a rock in a storm," and just that moment of inspiration. And then the other character that comes forward is your mentor with the crocs who sits you down and tells you, "Oak, you're going to be an amazing physician and things are gonna get hard," and really encourages you not to give up. So, where is your compass pointing in terms of people to admire and mentorship right now?Oak Sonfist
I'm involved in this street medicine organization in Portland, and I went to a seder with some of the people who, you know, volunteer–a lot of them work in the medical field. This was before I started med school. And when we were sitting down at the seder, I was talking about how I was trying to decide whether or not I should apply to med school. It's always been my dream, but you know, maybe I didn't have to become a doctor. I could do something else with my life. I wasn't sure what. This woman was sitting across from me. She was a physician and she looked at me and she said, "We need more doctors like you." And when she said that I didn't really understand what she meant. She was like, you know, chronically ill, like queer, trans...you know, what type of doctor am I? And I think not until, you know, now, I've almost finished my third year, I think I'm starting to finally understand what she meant, which is the ability to be understanding, and to know when you have limits, and to know why your patients have limits, and not to just give up. Because I've seen that. I've seen that on my rotations, just, you know, so many doctors who I'm trying to learn from, but I see them burnt out themselves and not able to take the space that they need to heal, and to be present, and to be happy, and to enjoy what they're doing. And it's sad, because I know that I'd say for at least most people who go to med school, I think we all want to help people, we want to change you know the world for the better, and be a provider to others. And I think what we need is more doctors who say "no" when it's time to say no and accept nothing less.

Emily Silverman

First, what you said about we need a generation of doctors who's okay saying "no" and setting boundaries. I think that's so true. And just to share a little bit with you. I don't have type 1 diabetes, but I did often find that working as a hospitalist my pager was just going off constantly and 3pm would roll around and I'd have a migraine and I'd be like, "Why do I have a migraine? Why do I feel so terrible?" And then I'd look at my watch and be like, "Oh, that's because I haven't had anything to eat since breakfast or at 7am." And I remember one day, I decided to take a stand. And it was a Thursday, and we had these divisional meetings on Thursday where our chief would sit and give us updates about the division and they serve lunch. And my patients were stable and I said, "I'm gonna go. I'm gonna go and sit in the meeting, eat lunch." And toward the end of the meeting, I started getting paged again and again. And it wasn't about any medical issue with a patient–it was a logistical thing where somebody had come out of the OR, and they were in the PACU, and they needed me to click a button on the computer so that their bed would release so that they could move from the PACU back to the, I don't know, back to the floor or something like that. No, like medical symptoms or anything, just purely flow issue. And I was in this room eating lunch. And I think there was like 15 minutes left. And I decided like, you know, this can wait. I'm eating lunch. And I knew as I was sitting there that I was doing something rebellious. And when I did finally get out of the meeting and call the nurse back, she was extremely upset. And she said, you know, "Why weren't you answering?" And I said, "I was eating lunch." And she actually reported me to–there's something, a button you can click, called an incident report where you submit an unusual incident. And so I got an incident report filed for that. And, you know, there's probably an argument to be made that that was appropriate because I was holding up the hospital flow. And she had her boss on her back who was, you know, getting on her about moving patients through. But it did bring up this question of like: Then, where do we set the boundary? Or like, how do we create a hospital where doctors can eat lunch?

Oak Sonfist

During one of my rotations, my insulin pump failed. It wasn't working, I wasn't getting enough insulin. I actually went into like a minor episode of DKA, which unfortunately, for me is something I experience so often–and DKA, for people, is when your blood sugar goes very high and you develop ketones, which make you feel really sick, eat away your muscle mass, it's not great. But this isn't something that I have experienced on a regular basis, especially when I was younger. So it's something I usually manage at home. I had to call out of my rotation for three days and I said, you know, "My insulin pump is broken. I don't have a way to get regular insulin delivered into my body. And I'm struggling with some symptoms of DKA. I'm gonna handle this at home." And because of that, they tried to fail me. Which, you know, after we had many discussions, my school decided not to fail me from that rotation. But it's still something that's gonna go on my record forever. Which, is that fair? Like, no. Like, was it fair that that nurse reported you for having lunch? No. So it is hard. It's hard to say no. Maybe you get to take a lunch. Maybe you get to take care of your physical health. Maybe, maybe you just get written up, you know. It's hard to say no in those situations, and I understand why so many people don't. But, just–I could imagine also like a world where you know, even though it's you know, medicine and lives are on the line, and everything's always high stakes, and everything has to be really intense...I also imagine a world where there's like enough staff, where somebody can take a lunch and someone else can, you know, sub in for them. Or, if there's a student who has different abilities and they need to take a couple days off, it doesn't mean that patients won't be seen on time. I like want to imagine a world where these things can be worked around and these things can be incorporated and planned for. And I know that that's possible.

Emily Silverman

Tell us a little bit about your role with AMSA because I know there's an advocacy component to that role. And, you know, what I'm hearing is that there's just a lot of structural issues with medical culture and medical labor issues. So is that at all rolled into your role at AMSA? Or, tell us a little bit about what you're doing with that.

Oak Sonfist

With AMSA, I'm actually the education advocacy fellow, which is a gap year, for one year where I'm focusing on physician burnout and suicide prevention. So, we are focusing on how we can change the culture of well-being in medicine, to not only include our patients, but also include our providers. Some of the work that I've done over this last year has been actually pretty exciting. I have been working with the state medical boards of every state across the United States to revise their licensure questions. So right now, we are working based off of an act that was passed by the Dr. Lorna Breen Heroes Foundation, encouraging state medical boards to either remove any questions about mental health from state licensure applications, or ask it in a way that is noninvasive with a clause at the end to clearly define what they want to know. So we're basically asking them to remove any stigmatizing language. There's a long history that physicians do not feel safe to access their own mental health care, because, in part, state medical boards ask them about it. So what we're doing right now is trying to remove that barrier, so that way, especially after the COVID-19 pandemic with so much burnout, and also in a profession with such high suicide rates. We're really trying to encourage physicians and all medical care providers to take care of themselves. And we're trying to remove the barriers in order to make that happen.

Emily Silverman

I remember hearing about this work with the state medical licensing and for the audience, my understanding is that there's many reasons why physicians don't seek mental health care, including they don't feel like they really need it, or they're just too busy, or you know, all of those things. But another one is that they fear that if they seek care–whether it's going to a therapist, or a psychiatrist– that when their paperwork comes up to be certified, or recertified, and the question says, "Have you ever needed mental health care?," that they're afraid that they're going to have to put it and that they're going to lose their license. And so, you have these physicians sometimes either just not seeking care, or in other cases, even like driving hours to like get mental health care under a fake alias, like paying cash so that, you know, there's no record of it so that they...I mean, it's just really bizarre what kind of distortion exists around the mental health care space for physicians. And so, have you found it pretty hopeful that the state medical licensing questions will be reframed and asked in a way that is non-threatening? Because, you know, we want patients to be safe, obviously. But we also don't want to discourage physicians from getting the care that they need, because that's also unsafe for patients. So what kinds of responses have you gotten from the different states?

Oak Sonfist

I've actually gotten really great responses. You know, we did a survey back in September, and as of September 19, states had changed the wording. I'm sure at this point, we're probably at more. I think that right now, especially in the wake of the COVID-19 pandemic and just seeing how much that impacts everyone and seeing so many people leaving medicine who are working in medicine. You know, everyone is realizing that it's time to address this, as you know, a topic that we need to focus on in order to move forward–not only as physicians, but as a community and as a country, and as a world. We can't take care of other people if we can't take care of ourselves. So, I am very hopeful to see more changes in the future. I know so many different organizations and programs that are working on this same initiative. I go to these meetings and I see such inspiring work. I think that we will have a better future and I'm–I know that this is going to be changing within the next, I'd say, at least within the next five years. I'm expecting to see some major changes, and it's not going to be just from one person. It's going to be from many people working together on this.

Emily Silverman

I wanted to bring forward a really important aspect of your story, which is that you were the first openly trans student at your medical school. And as you move along, you know, you get the warning from Dr. P that things may not be easy. And then you see that he was right. And in the story, you say you make the decision to stop transitioning, and you say, quote, "a decision that haunts me to this day." And then you leave us with an image, which is the same image that you started with, which is this dream image of, there's this beautiful underwater world of Atlantis, where there's such a beautiful feeling of belonging. And then there's the scientists in the boat, on the surface of the water, who don't know about this place, and they keep calling you and they say, "Oak, come in. Oak, come in." And you're kind of stuck between these two worlds. I don't know, I guess I don't really know what the question is. But you know, with all of these things that we've been talking about, wanting to change the culture, like it's not going to happen overnight. It's going to be incremental. It's going to take time. And so, we're going to have to be in that in-between space for a while. And I don't know where you've landed on your process transitioning, but it seems like maybe you're also in an in-between space. So how is it to be in that in-between space? And how do you be underwater and in the boat with the scientists at the same time?

Oak Sonfist

You know, I know, I'm not the only one. And in a lot of ways, that gives me a lot of hope. It's hard because what I've learned throughout my life, you know, since I first came out when I was 17–I belong to one form or another of the LGBTQ community, and I've primarily existed within those spaces–is that often, we keep ourselves separate from everyone else to protect ourselves. I understand why. It's safe when, you know, you can surround yourself with people like yourself. It's safe when your rights are debated on TV, but you can laugh it off sitting next to a friend. But at the end of the day, it's hard, you know, putting yourself out there, trying to exist within, you know, the normal realms of society, trying to go after something that, you know, a lot of people perceive as prestigious, like becoming a doctor. Because at one end of the spectrum, you're gaining a new community of physicians and people who you share so many identities with your aspirations and dreams and goals. But at the same time, you're losing, almost losing the trust of a community that has to isolate itself to protect itself. I don't know if trust is the correct word there. But you have to earn your trust, I think is a better way of putting that. And I'm okay doing that. And, you know, as far as my own transition goes, I have restarted. You know, the path is a long one. Surgery–wait lines are years. But irrelevant of my own identity, I am in flux. And as I go through the next few years of my medical training, I'm going to continue to present in flux. It's definitely you know, you feel a little torn inside. Or, I feel torn inside. But I also know that I can exist in both. I just have to figure out how.

Emily Silverman

We have a lot of doctors, nurses, students listening to this podcast. So as we come to an end, just curious, what would you like to say to them, if you wanted to, maybe leave them with a message or a thought?

Oak Sonfist

There's a phrase that I have often used to motivate myself. There's a couple of phrases that I'm thinking of. There's this like pamphlet of phrases that you should say as a good parent to your child. And this is something that, years ago, from my therapist, I got this sheet of phrases that you should say to your child. And she said, you know, "You should say this to yourself, so that way you can be, you can parent your inner child," which is something I firmly believe in. But if you haven't heard of that phrase yet, it might seem a little out there. But the phrase is, "I say “no” because I love you." It's important to remember that we have to say no because we love ourselves, because we need to protect ourselves. Even if it might hurt in that moment, it is still because I love you. And the second phrase that I would love to leave you all with: "Become the change you want to see." It's going to take every single one of us working together, and I know it's gonna happen. And I'm excited to see us all working together towards it and excited to see where we all end up.

Emily Silverman

Great, I have a one-year-old daughter, so I'll definitely be using that a lot. "I'm saying “no” because I love you," as she like, you know, tries to throw my underwear in the toilet. No, no, I really think that that's a beautiful sentiment to end on. I couldn't agree more with this idea of you know, really being tender with ourselves and our inner child, and just wanted to say thank you for submitting your dream story, for coming to San Francisco to tell it on stage at our dream event, and for coming to chat with me today. It's been wonderful to speak with you, Oak.

Oak Sonfist

Thank you so much, Emily, for having me. It's been such a pleasure.

Emily Silverman

I have been speaking with medical student Oak Sonfist. Thanks again, Oak.