Editor's note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
I arrived at the outpatient clinic for one of my third-year specialty clerkships early one morning. The front desk staff took me to my assigned attending physician for the day and I introduced myself like I always do: “Hi, I’m Nat, my pronouns are they/them.” My stomach turned as I saw my attending’s confused look. “What is that supposed to mean?” he asked brashly. “Like you have multiple personalities?” What followed was a painfully long and unwelcomed discussion about my pronouns, gender, and self.
Comments and unwanted conversations like this with professional superiors were a major reason I hesitated to come out as nonbinary earlier in medical school. In fact, the first time I brought up the nonbinary pronouns “they/them” to a physician, she responded dismissively: “Well, that is just not grammatically correct.” The other reason I hesitated was lack of representation. I had never met or even heard of a transgender or nonbinary (TGNB) physician. Combine this with my status as a medical student — at the lowest rung in the hierarchy of medicine — and I was fearful of coming out as a TGNB individual.
Less than 1% of medical students and physicians identify as TGNB, leading to calls for academic medicine to do more to increase those numbers. A recent shows an increasing percentage of Americans identify as LGBTQ, with 1.8% of Generation Z (born between 1997 and 2012) identifying as transgender, compared to 1.2% of millennials (born between 1981 and 1996). It is crucial for medicine to increase its TGNB workforce to reflect this growth.
And yet, the microaggressions and discrimination that I experienced as a TGNB physician-in-training left me feeling isolated. I was already part of my school’s LGBTQ PRIDE group, which was the extent of institutional resources for a TGNB student at the time. Even within that group, no one else identified as TGNB.
Then, in my second year of medical school, a friend started using — and raving about — #MedTwitter. I had a personal Twitter account from high school, filled with outdated memes, so I decided to make a new “professional” account. It did not take long for me to come across the subculture of #GayMedTwitter. I was floored. Scrolling through the users of #GayMedTwitter, I saw very out gay, lesbian, bisexual, queer, transgender, and even nonbinary residents and faculty. They existed. After setting my sights on becoming a psychiatrist, I reached out to psychiatrists who were members of the #GayMedTwitter community with the goal of learning about potential residency programs and how they support TGNB trainees. Given the virtual nature of interviews this year, the connections and information I gained from Twitter were invaluable.
There are many reasons #GayMedTwitter has been more successful in connecting members of the academic medicine community compared to other institutional efforts. One is simply speed. Though medical schools and other professional organizations continue well-intentioned initiatives to increase representation at their own institutions, this takes time. On Twitter, I found an abundance of representation in a matter of minutes. This makes it easy to connect with mentors with similar lived experiences — something have been shown to value in training.
While the details of my gender journey are personal, using social media to assert my identity and support other marginalized people is a professional act. Institutions that are serious about equity and inclusion for its trainees and patients should agree.
As my third-year specialty rotations carried on, I continued to enter spaces that made me feel unsafe as a TGNB medical student. On one occasion, I overheard an attending and resident discuss how strange it was that I asked them to use they/them pronouns and how weird I was in general. Whereas before I felt I had no outlet to seek advice from my community within academic medicine, this time I did. I tweeted about it and found needed validation and support.
There is a decent amount of fear instilled in students and residents when it comes to social media use. Beginning with applying to medical school, students are warned of the potential for their social media content to be scrutinized. While some professional organizations have begun to post about how to engage with social media as a medical professional, the American Medical Association and the American College of Physicians suggest separating personal and professional identity on social media. This advice fails to recognize that for many — LGBTQI+ individuals in particular — professional versus personal is a false and harmful dichotomy. While the details of my gender journey are personal, using social media to assert my identity and support other marginalized people is a professional act. Institutions that are serious about equity and inclusion for its students and residents should agree.
So, what should academic medicine do? Should they try to replicate this virtual community in some way? Instead of the instinct to build something similar, perhaps the lesson here is not to try. This space exists and works; my recommendation is to facilitate and support its use. Here are a few ways institutions can do this.
- Medical institutions should not discourage social media use by trainees. Instead, they should start to consider how they can help trainees navigate a setting like “professional Twitter.” At some institutions, is already underway.
- Medical institutions should listen to trainees who are underrepresented in medicine about what is and is not working when it comes to mentorship and community and remain flexible as this evolves past more conventional means.
- Academic medical organizations that publish guidelines for physician social media use should take a more nuanced approach to their recommendations. They should be crafted with consideration for how important these spaces are for trainees who are underrepresented.
- Much of the mentorship, advice, and work done by racial, ethnic, sexual, or gender minority physicians on social media goes unrecognized and uncompensated. In light of the phenomenon known as the (the extra burden minority individuals carry to represent diversity, mentor, and teach), academic medicine should find ways to validate this behind-the-scenes work as an academic accomplishment.
As I look toward starting residency in the next few months, I am glad to have found my community on #GayMedTwitter. I hope that my fellow TGNB students and residents will find similar success in connecting to the community both within and outside of their institutions.
Nat Mulkey (they/them) is a fourth-year medical student at Boston University School of Medicine (BUSM) pursuing psychiatry. They work with a committee at BUSM on LGBTQI+ curriculum initiatives and have written articles about contemporary LGBTQI+ issues for WBUR Boston, the AMA Journal of Ethics, and in-Training.