DocsWithDisabilities Podcast #24
Dr. Ruta Nonacs
Dr. Ruta Nonacs received her M.D. from Cornell University Medical College and her Ph.D. from Rockefeller University in New York. She completed her residency in psychiatry and her fellowship in perinatal and reproductive psychiatry at Massachusetts General Hospital. Currently, she is a staff psychiatrist with the Perinatal and Reproductive Psychiatry Clinical Research Program at MGH, with an appointment as an Instructor in Psychiatry at Harvard Medical School.
Dr. Nonacs has received several honors and awards, including a NARSAD (National Alliance for Research on Schizophrenia and Depression) Young Investigators Award for her work on postpartum psychiatric illness in women with bipolar disorder. Her current research has focused on the course and treatment of major depression in women during pregnancy and the postpartum period. She has expertise in the treatment of women with postpartum depression (using medication, as well as psychotherapy).
Her work has been published in a number of scientific journals and books in the area of women’s mental health. She is the author of A Deeper Shade of Blue: A Woman’s Guide to Recognizing and Treating Depression in Her Childbearing Years (Simon & Schuster).
In this episode, Dr. Nonacs discusses identifying as a doctor with a disability, her experiences with training and employment and the changes needed in medical education.
Introduction: Lisa Meeks
Doctors with disabilities exist in small but measurable numbers. How did they navigate their journey? What were the challenges? What are the benefits to patients and to their peers? What can we learn from their experiences? My name is Lisa Meeks, and I am thrilled to bring you the DocsWithDisabilities podcast.
Join me as I interview Docs, Nurses, Psychologists, OT’s, PT’s, Pharmacists, Dentists, and the list goes on. I’ll also be interviewing the researchers and policy makers that ensure medicine remains an equal opportunity profession.
Sofia Schlozman (narrator):
Thank you for joining us today. My name is Sofia Schlozman and I am the new co-producer of the DocsWithDisabilities podcast. I am so especially excited to introduce this episode. Dr. Ruta Nonacs is a psychiatrist specializing in reproductive psychiatry and she is the director of scientific communications for the Department of Psychiatry at Massachusetts General Hospital.
Dr. Nonacs is the reason why I started thinking about disability in medicine, why I began listening to the Docs with Disabilities podcast, and why I wanted to become involved with and support this work. This is because Dr. Nonacs is also my mom.
As she will share shortly, Dr. Nonacs has a visual disability called Stargardt’s Disease. But while I was growing up, I never heard my mom use the word “disability” to describe her difficulty with her eyesight.
In fact, just a few months ago, I was eating dinner with my family, listening as my mom told us about attending a conference on Disability in Healthcare and Medicine, held by Stanford Medical Abilities Coalition. She told us how incredible it was to hear people talk openly about the existence of disability among healthcare providers, how much she related to the physicians who shared their stories. She was excited to find a community of healthcare providers who understood what it was like to navigate the healthcare system as a person with a disability.
My younger sister, sitting across the table from me, looked confused. “Why would you relate to those people so much?” she asked my mom, “When you don’t have a disability.”
This label of disability was so far removed from my mom’s presentation of herself, and, as such, my family’s conception of her, that my sister didn’t even register that this was a big part of my mom’s identity.
But in attending that conference, listening to these podcasts, and connecting with some of the many physicians who have shared their stories, my mom began to talk openly and thoughtfully about her disability; about the challenges she faces as a result of her disability, and about how confronting these challenges has made her a better doctor and person. I’ve rarely heard my mom as passionate and motivated as she sounds when she talks about the Docs with Disabilities community.
Through my mom, I’ve seen firsthand the power of this podcast to educate, to foster conversation, and to transform lives. I am so honored to now be a part of a project that means so much to me and countless others. And I am even more honored to have the opportunity to introduce this very special episode today.
I’m proud of my mom every day, for everything she has done and is doing, but I am especially proud of her today, for sharing her story here.
Listen or read along as Dr. Nonacs and Dr Meeks discuss having a disability in medical school, disclosing this to an administration, and choosing a specialty.
Lisa Meeks: We are so excited to have you Dr. Nonacs and thank you so much for coming onto the podcast to share your story.
Thank you so much for the opportunity to speak with you. I'm Ruta Nonacs and I am a psychiatrist. I am currently working at Mass General hospital in Boston, where I've been pretty much for the last 25 years since I completed my residency. And there I specialize in women's mental health and about half of my time is devoted to patient care. And the other half is more academic where I work mostly in educating patients and clinicians about issues and women's mental health. And I am the editor in chief of our website, of our program, and also the director of scientific communications for the department of psychiatry at Mass General.
What most people probably don't know about me is that I have a visual disability. I have Stargardt's disease, which is a form of juvenile macular degeneration. And although I started to have symptoms of visual loss during my early adolescence, it wasn't formally diagnosed until I was midway through medical school. And it hasn't resulted in complete blindness, but I have had vision loss and can no longer drive. I have a hard time seeing signs, reading books. A lot of these things can be overcome with various magnifying devices, but there are still a lot of things that I can't do.
You talk about your condition. Can you tell us a little bit about how that impacted you and the, the last few years of your training and how it may or may not have informed your decision to go into psychiatry?
I first started to notice that I was having problems in vision during middle school, and I was having problems seeing the Blackboard, and I thought I needed glasses. So, we went to see a lot of different ophthalmologists and ultimately a neurologist.
And every time I went to the doctor, they would say, there's nothing wrong. We can't see anything. And I could do pretty well on vision testing at that point, because you can guess at what letters are, and I'm a good student. So, I memorized things, but I knew that something was wrong. And I went through college with having my vision decline a little bit more. By the end of college, I couldn't really see the blackboards at all. I had to listen or supplement with reading books. So, I went to medical school knowing that something was wrong with my vision, but not really knowing what it was. And although I think in retrospect, that's a pretty awful place to be. I think having some sense of denial was actually helpful because I could almost pretend that there was nothing wrong and that I wouldn't hit stumbling blocks. AND I think for me personally, that was very helpful because it gave me the umph to do something that was really difficult. I hear premed students talk more openly about their challenges as they start to think about going to medical school. And I actually don't think I had those, those thoughts about whether or not I could do it because to me, I had a problem, there was something wrong with my eyes, but it wasn't really labeled as a disability at that point.
So, I went to medical school and did what I usually do, which is study hard and work really hard. And then it was kind of a random event that my diagnosis occurred. I was in an MD PhD program. So, I had completed my first two years of medical school. I was in the PhD portion of medical school. I wasn't in classes. I had a tear duct, which was blocked and swollen. And when I went to see the ophthalmologist, she said, why is your vision so bad? And I said, I really don't know. I just can't see. And she ran a lot of tests and, within a, a week or so, I finally had a diagnosis, which was Stargardt's disease. So, my vision didn't really decline that much, or I, it didn't go from having vision to losing vision. The real change in medical school was that I had a diagnosis and there was part of me that was really relieved, kind of to know what was going on. In some part of my mind, I thought I would lose my vision totally. AND Stargardt's disease doesn't result in complete loss of vision. It's a partial loss of vision. So, when I look at things, I see them in less detail. I have light and dark. I have color. It's just that I lose the detail of certain things. So, I'm by no means completely blind.
But I think the diagnosis served as a little bit of a crisis to me because now I had a disability and on Monday I didn't have one, but on Tuesday I did. And I think it really changed the way I viewed myself and my abilities. And I think it also changed my sense of what, what I could do and, and if I would be accepted in the world of medicine. So, in some ways there were decisions to be made with regard to, uh, what type of residency I wanted to pursue. But at that point, I really thought that I might be sort of kicked out of the club. I didn't feel like I fit in anymore.
Can you talk a little bit more about this fear of getting kicked out of the club? I can absolutely understand how that could be an immediate feeling. So, you have this information, but it's your information at this point and do other people get this information? As you had noted, it wasn't like your vision declined significantly in medical school you just had a label to it. Did you feel the need to tell anyone? Did you feel concerned about people finding out? What were the thoughts that were going through your head at that time?
So, after I got the diagnosis, I think a lot of people already knew that I had something wrong with my vision, although it didn't have a label. So, I had various advisors and mentors who knew that I had something wrong with my vision and it didn't feel like a huge deal. They would help me along with what I needed. And I felt very supported.
What happened when I found out about my diagnosis is that I thought it would be important to disclose this to the medical school. I went to talk to the Dean of the medical school and I said, you know, this is what I have. I've been diagnosed with Stargardt's disease. I gave him some information about my abilities and the prognosis and his first response was, "well, what will you do? Do you plan to complete medical school? And, you know, certainly you won't be able to practice medicine."And he continued and said, “well, it's a good thing. You have the background in research because you could probably do research that would be open to you.” And I think that kind of put me in this place where I wasn't really eager to disclose after that point and really felt that they were going to shepherd me through the rest of medical school, but then it was up to me to figure out what I was going to do next.
This was either right around the time of ADA coming into play or, a little bit before it, and there was no sort of disability office to go to, to talk to. There were no accommodations to ask for, so, I felt really abandoned. I didn't know anybody with any disability of any sort. I didn't, you know, there were no people with disabilities in med school. There were no professors or physicians with disabilities. There was no real diversity that people would talk about, and I just felt like I don't belong there in some way. And that was very, very hard.
Through your podcasts, this is the first time I've had a chance to listen to the stories of other people who have struggled with disabilities and some of the disabilities have been very similar to mine. But I didn't know that these people existed.
To be honest, I would say even now post ADA, 30 years post ADA, some people might have the same experiences that you had back then, especially when they don't know what can be done to mitigate the impact of a disability.
There would probably be a lot of institutions where a student, especially an MD-PhD student might even be shepherded out of the MD portion to complete their PhD and move on from there, thinking that a physician with a visual disability would not be able to navigate the complexity of medicine. And when you received your diagnosis, you were at a pivotal point in that you were about to enter the clinical phase, which is highly dependent on visual kind of input. Of course, now there are all kinds of technologies that allow somebody with a visual disability to navigate the clinical space with a lot more ease. And of course, as we start to become more and more aware of disability inclusion and the value of disability, there are schools that are coming full circle to the, the idea that a physician with a visual disability might bring to the table, some unique aspect or perception of medicine and patient care that would be valuable.
I wonder early on in your description, you, you talked about navigating kind of the undergraduate space and needing to really listen, because at some point you couldn't see the Blackboard. I have to ask because I would assume that then you’re listening skills became really heightened, and you became very attuned to what was said, where some other people might tune that out and, you know, fall back or rely on visual indicators.
I wonder how much of this fine tuning of listening skills played a role in your choice of specialty and becoming a psychiatrist where a lot of the work is, is listening and picking up on, on things that people are saying, how did you decide to go into psychiatry? And can you speak to whether or not you think your disability was part of that decision making?
I think when I met with the Dean of medical school during my interview, he said, what area of medicine are you interested in? And I said, I know I'm not interested in psychiatry or surgery (laughs). Um, so a lot changed through the course of medical school. And I think when I got the diagnosis and got the sense that medicine might not be such a welcoming place, it was kind of a crisis. And I really thought about what other things I could do besides medicine. What was I interested in? Could I pursue any of my other interests? And I really wanted to continue to do what I was doing. I didn't see any other alternatives, but I really have to look for a place in medicine where I would feel valued and accepted. And I think as a result of having this crisis, I also spent a lot of time in therapy. And I think that was very pivotal in learning about psychiatry and mental health and wellness, and the importance of talking to people about issues that are difficult or complicated or life changing. And I saw a lot of psychiatrists in our program who were very happy with what they were doing and they were making a huge impact. And certainly, the field of psychiatry made a huge impact on me and helped me get through a crisis. So, I think I learned a lot about it in that way.
With regard to being a listener and an observer, I think those have definitely helped me to be a psychiatrist, but I think those are probably skills that any physician can benefit from because we have to observe, we have to listen, we have to use all our senses to gather data. And I think, I think those skills have made me a good student. Um, but they've also made me a good doctor. And I think I would use those skills in any field.
What drew me to psychiatry is probably the level of acceptance that that career path offers. I think with my level of vision, I probably could have been in other areas of medicine and have done fairly well, although I would have definitely faced more obstacles, but I think psychiatry was more welcoming to people who were different or didn't fit in. And that's, that's what I was feeling at the time I had to make my decisions and because I wasn't totally sure about psychiatry, I entered into a program where I did a medical internship so that if I wanted to change at some point down the line, I wouldn't have to go back and repeat my internship or get more training. But I ended up really loving psychiatry. And although I was determined not to enter that field, when I entered medical school, it's been a wonderful experience for me. And I really love my career, uh, at a time when medicine is going through a lot of, uh, difficult times. Uh, I'm really happy to be here.
Dr. Meeks and Dr. Nonacs discuss the current state of medical education, the increasing demands on the learner, and why we might want to change our definition of the perfect medical student.
Dr. Nonacs, you're an instructor in the medical school, and I'm wondering how, as a physician with a disability and given all of your experiences, you view what's happening in medicine now and the increase in depression in our learners, and that the intensity and the demands that medicine is placing on the learner that may not have been there 30 years ago. How do you view what's happening in medicine, and what are some of the things that you think would be positive changes?
I think, first of all, what we ask of pre-meds, um, in terms of determining who should get into medical school, and what's the ideal medical student, we kind of look for these super performers, people who can do everything, whether it's, you know, getting a 4.0 at Stanford and then being on an Olympic team and then throwing in a few extra research papers. I don't think that that sort of emphasis on super humanism is great. First of all, we can't all be superhumans and it's unrealistic to continue that level of performance throughout one's life. Uh, one can sustain it for some number of years, but that's probably not ideal for physicians and it doesn't create an environment of tolerance. So, we've created this environment where we expect physicians or medical students, or pre-meds to be self-reliant and take care of all of their problems and asking for help is a weakness. So, there's no culture of, of asking for help when you need it.
So, I think as the demands of medicine become greater and greater, because we're expecting so much of medical students and trainees, they have to incorporate so much more knowledge. A Lot of the patients we see now are much sicker than those we saw 20 years ago. And we expect them to be able to do it all and offer so little in terms of providing space for mental health. So, I think that's a crisis. And I also think just sort of more academically, I don't know that I, as a psychiatrist, have to learn what it's exactly like to be a surgeon as part of my medical school training. And I feel this need to teach medical students about every aspect of medicine, puts so much pressure on the education. And it also ends up limiting medical school to people who have disabilities. And there's no way that I could perform surgery. I just couldn't, but I don't think that's a loss. I don't think I'm any worse a doctor for not being able to do surgery. I know what surgery is. I know a lot about it. I just can't do it. And I think that's okay, but the way medical school is set up currently, you have to become an expert in everything. And I think that just doesn't make sense. Uh, but it, it, unfortunately a lot of us think, well, that's the way it's always been done. And there's so much resistance to change.
This is really nicely leading into a discussion about Admissions. And what does it take to be a good physician so much of what makes someone a, a competent and good physician are these kinds of other soft skills, the ability to listen, a specific, you know, focus in one area that you just find a lot of joy in. So, for you, that psychiatry, the ability to, to be resilient in the face of what is increasingly a very uncertain profession, and one where you can't always control all the variables around you and so how do you deal with that? Innovative spirit. The ability to think quickly on one's feet to shift and to be creative.
For so many people with disabilities, they have had to be creative their entire lives, or if the disability was acquired at a later date, they've had to reorganize their lives. And just the ability to be able to do that, to be creative, to shift, is so important and shows a level of resiliency that I think we can't measure in our typical scales of resilient behaviors. In some ways, this unique perspective and this resiliency makes individuals with disabilities really nice candidates, really could make them very sought-after candidates. These are very resilient students and creative students. And that those are qualities that we are absolutely looking for in, in medicine.
Why should we be looking more favorably at this student population and what they can bring to the table?
What I've learned from being in medicine for the past 25 years is that physicians in general have had a lot of suffering. I think most physicians don't talk about the stuff they've had to deal with, but I think some of the best physicians have dealt with things that have happened to them or around them, whether it's being in a war torn country and having to immigrate to the United States, whether it's being in a situation where they were exposed to a family member with mental illness and have to hold together, the family or a variety of things. And I think that disabilities or dealing with chronic medical illness fall under that umbrella. And what I've learned is that most of those physicians don't talk about it. It's just something that's happened to them. They move on, they deal with it. But I do think that suffering is something that physicians can benefit from.
Obviously, we don't want people to suffer, but I think we learn from hardship or being close to someone who's suffered hardship. It makes us empathic. It makes us understand our limitations, that we can't always fix things. It makes us understanding in a way that somebody who hasn't had hardship may not be able to do, they might not have those qualities of understanding. The irony is that I think a lot of people recommend that you talk about your hardships in your application. At the same time medical school hasn't been particularly welcoming to people with disabilities. And speaking to some of the things that you said about having a disability is that every day you have to be a problem solver. Every day, you have to be creative and innovative because you will hit obstacles. Every day I will have many, many of those obstacles. And I think that happens in medicine. You have complications, you have side effects and you have to be able to quickly pivot and figure out a solution to the problem. So, I think in that way, physicians with disabilities have certain advantages, because they've had to deal with that all their lives. I think also in terms of some soft skills that physicians have is that they're role models and sources of inspiration. A lot of our patients look up to us because we've done X, Y, or Z. And if you have a patient who has a chronic medical illness and feels that their life is limited, if they could see other physicians who are dealing with disabilities or medical illnesses and see that those physicians are succeeding, I think that's a very powerful moment for them.
Listen or read along in this final segment as Dr. Meeks and Nonacs move the conversation from getting into medicine, to staying in medicine. Central to this success is mentorship and working in an environment with a culture of inclusion.
Mentorship. I would say that's critical for, for everyone in medicine, but the idea for individuals with disabilities. So often they don't, they're not able to identify physicians that quote unquote look like them, or that are similar in their lived experience. Because we don't have a vast physician network for disability. I wonder what your thoughts are on this sort of need for mentorship or need for storytelling and sharing of experiences for students with disabilities. Can you speak to that?
I think as you said, mentorship is so important for everybody in their professional development and especially in medicine where it is so emotionally challenging. And it's also, there are so many transitions that one has to negotiate. So, I've had many good mentors and they've been really important to me and learning about what's out there and what's available, but I have never had a mentor with a disability. That would have been incredibly helpful to know how to navigate certain things, how to ask for accommodations, how to feel okay about accommodations, how to advance in one's career, how to deal with promotions. Should there be accommodations made if you can't complete, complete all the things that are required for promotion?
I still don't have a lot of mentorshipin that arena. I have discovered some other physicians with disabilities, both through the conference that was held earlier this year for health care providers with disabilities, and also through your podcasts, which have been incredibly important to me in terms of realizing that I'm not alone. And I think it's been interesting to see how medical schools and the profession of medicine has been trying to come big, to become more diverse. And there have been more people of color and LGBTQ people coming together to ensure more inclusiveness. And I think it really takes a group of people to advance inclusiveness. I don't think one can do it alone, and I felt very alone in this. But I'm inspired now that I'm sort of meeting more people in this situation. And I hope that as people realize that there is a community, a supportive community out there, they can be more open about their disability. And I think nobody really knows that I have a disability. I don't really tell people I'm uncomfortable sharing that information. Because it is very hard for me, and very emotional at times. If there were more acceptance about it, it would be easier to talk about it. I think it would be easier for other physicians to become more of a supportive network and to provide mentorship to people in the early stages of their career who have disabilities. And I just don't, I think we have the ADA and I think many people have become advocates for people with disabilities, but I think medicine kind of lags behind in terms of accepting this level of inclusiveness.
In the takeaways, you had written back to me after the invitation to, to be on the podcast. And one of the things you said really stuck with me, and that was “the absence of discrimination is not the same as inclusiveness”. Can you tell me more about that?
So, I wish I could take credit for that. I don't know where I heard it, but it also stuck with me. Um, and I feel, um, that I haven't really experienced discrimination because of my disability, but the world isn't necessarily set up to make it easier for me. And one of the hardest things is as someone with a disability, we're often forced to ask for what we need, as opposed to knowing that it will be provided. And I think with inclusiveness, the sense is that you're welcome here. And even though I've been a practicing physician for 25 years, I don't feel entirely welcome. And it might be related to other things besides my disability. I don't come from a medical family. I didn't grow up in this world, but I never feel entirely welcome even though I don't feel that I'm openly discriminated against.
I do think there are things that people with disabilities may do, which hold them back or, interfere with their ability to be included. Those are harder to get at and I know that in terms of my professional development, there have been things that I don't do, which have held me back. And I think people don't realize these things. In terms of getting promotions, you have to speak at national and international conferences. You have to do a certain number of lectures. And for me travel, especially when alone is really difficult. So, I tend not to pursue it because it takes a lot out of me and it's very, very challenging. Similarly doing a talk takes a lot out of me. I can't see my slides. So, in a 40 to 45-minute talk, I have to memorize all my slides and what order they come in. And when I was younger, that was a whole lot easier and I had more time, but now I just can't do that. So, I don't accept a lot of invitations to do talks. I don't travel. And that, that holds me back. It makes me feel less included, but I don't know that we can ask the field of medicine to change everything so that I can feel more included. But I think it does sometimes feel like a club or someplace that you work really hard and you get to belong at some point. But it doesn't always feel that way. If, if there's something about you that makes you feel different.
The show is set up for this asynchronous mentoring. And so, we ask every interviewee to give us the advice or give the audience really if you're speaking to the audience advice for those that are in the pathway of medicine or thinking about medicine. What would you say to someone, especially maybe somebody that has a visual disability that's thinking about going into medicine? What advice would you, would you give them?
I'm going to frame this as the advice I wish I had had, um, which is to talk to as many people as you can, about some of the concerns that you have about approaching any challenge with, with a disability. And I think there was part of me that may be, was fearful of the obstacles I might encounter. So, I didn't talk to other people and there weren't that many people to talk to. There's always discrimination, so it doesn't have to be necessarily on the basis of disability. So, there are plenty of people to talk to. Who've experienced challenges in the field of medicine, but I think feeling alone and feeling like you have to do this alone makes you feel less powerful. And if you have other people who have had similar experiences, it's important to learn from them so that you don't have to reinvent the wheel. And that is something that I, I hope other people are able to do because there's more willingness to talk about disabilities and to be more open about inclusiveness. So, I do hope that will change and I hope people will not have to be so secret about these things in the future.
Thank you Dr. Nonacs — Mom — for sharing your journey through medicine and your insights into how to make healthcare more accepting and inclusive.
In your interview, you described how listening to this podcast helped you to realize that you’re not alone; that there is a community of physicians with disabilities that you can look to for mentorship and support. I know that you understand the power in sharing these stories, and I hope you understand the impact you have made by speaking openly and honestly about your experiences. Making this episode and hearing you explore this part of your identity has been so-so special for me, and it is so valuable to our readers and listeners as well.
To our audience, thank you so much for joining us. We hope you will tune in next time for a discussion with Dr. Pete Poullos, associate professor of radiology at Stanford Medical School.
This podcast is a production of the University of Michigan Medical School, Department of Family Medicine, MDisability initiative. The opinions expressed in this podcast do not necessarily reflect those of the University of Michigan Medical School. It is released under a creative commons, attribution noncommercial, non-derivative license. This podcast was produced by Lisa Meeks and Sofia Schlozman.
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