Dr. Esther Freeman started learning about outbreaks around the kitchen table! As a trained epidemiologist and dermatologist, she has become an "inadvertent" outbreak dermatologist during the COVID-19 pandemic. She shares her experience with emotions across cultures, the value of hard work in dermatology (and life), and a story about the refrigerator. Dr. Esther Freeman, MD PhD DTM&H is Associate Professor of Dermatology at Harvard Medical School. She is a board-certified dermatologist. She attended Dartmouth College and the London School of Hygiene and Tropical Medicine before receiving her MD from Harvard Medical School, where she also did her dermatology residency. She received her Diploma in Tropical Medicine and Hygiene from the Gorgas Memorial Institute in Peru. Her research looks at HIV-associated malignancies like Kaposi sarcoma and consults for the World Health Organization.
Dr. Esther Freeman started learning about outbreaks around the kitchen table! As a trained epidemiologist and dermatologist, she has become an "inadvertent" outbreak dermatologist during the COVID-19 pandemic. She shares her experience with emotions across cultures, the value of hard work in dermatology (and life), and a story about the refrigerator. Dr. Esther Freeman, MD PhD DTM&H is Associate Professor of Dermatology at Harvard Medical School. She is a board-certified dermatologist. She attended Dartmouth College and the London School of Hygiene and Tropical Medicine before receiving her MD from Harvard Medical School, where she also did her dermatology residency. She received her Diploma in Tropical Medicine and Hygiene from the Gorgas Memorial Institute in Peru. Her research looks at HIV-associated malignancies like Kaposi sarcoma and consults for the World Health Organization.
[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I have the honor of speaking with Dr. Esther Freeman. Dr. Esther Freeman has an MD, PhD and DTM&H, and she's an Associate Professor of Dermatology at Harvard Medical School. She is a board certified dermatologist who attended Dartmouth College and the London School of Hygiene and Tropical Medicine before receiving her MD from Harvard Medical School. She also did her dermatology residency at Harvard. She received her Diploma in Tropical Medicine and Hygiene from the Gorgas Memorial Institute in Peru. Her research looks at HIV-associated malignancies like Kaposi sarcoma, and she consults for the World Health Organization. She has become a premier expert, among other things, in COVID-19 effects on the skin.
[00:00:45] Welcome to Esther.
[00:00:47] Esther Freeman: Thanks so much for having me, Christine. Pleasure to be here.
[00:00:50] Christine Ko: Can you share a little bit of a personal anecdote, first off, just to help people get to know you a little?
[00:00:56] Esther Freeman: Sure. I grew up in a family of doctors. My father was an infectious disease epidemiologist, and he unfortunately passed away when I was about 20 before I became a physician. Growing up in that household really had a big effect on me. My father ran the outbreaks course at Harvard School of Public Health. He would come home at the end of the day, and our dinner table conversation around the table would be actually solving real life outbreaks, which is practicing what we call kitchen table epidemiology.
[00:01:21] Christine Ko: Oh wow.
[00:01:21] Esther Freeman: He would basically have us solve these outbreaks around the kitchen table. And I never knew that was actually kinda weird until a lot later in life. It was really only when I got to medical school when I realized that all of my co-Harvard med students thought that epidemiology and statistics were like, really boring. I had no idea that other people thought this was boring because to me it was like living this Agatha Christie novel. So yes.
[00:01:42] Christine Ko: That's cool. So your dad inspired you to do the PhD in epidemiology, it sounds like?
[00:01:48] Esther Freeman: Students that he had trained actually reached out to me early in the pandemic. One was telling me about these things that he had learned from my dad. And it was really nice to come full circle; he called them Freemanisms. And the first one was: During an outbreak or during a pandemic, you really have one job, and that job is to stop it, and you need to do whatever you can do to make it stop. That's your number one priority. That has really helped me thinking about my priorities over the last couple of years. Having one of my father's students, who's now a senior leader in outbreak control, reach out to me at the beginning of the pandemic really had a lot of meaning for me, having these guiding principles.
[00:02:21] Christine Ko: Awesome. I'm gonna move on to a question on how you define and use emotional intelligence.
[00:02:28] Esther Freeman: Understanding and managing your own emotions and how those emotions can ultimately influence people around you is a constant challenge for all of us. And one thing that's really important to me, is mentorship. And in a number of different ways this kind of carries through in my derm career. One way is I take two research fellows that spend a full year each year. And, we started in the past year, the International Alliance for Global Health Dermatology, known as GloDerm, an international organization for global health dermatology. And it's a really a way to bring people around the world together. So we have over 800 members. It's free to join, very low bar of joining our team. We're mentoring seven dermatologists from Burundi, the DRC, Northern Ethiopia, Ecuador, Brazil, Mexico, and Indonesia. And these are dermatologists who are really going to, I think, create change. Thinking through this year has been really fun for me to think through how do we structurally mentor people across a broad swath of time zones and cultures and languages. That for me has been one of my highlights: really thinking about coaching and mentoring our next generation.
[00:03:29] Christine Ko: That's so inspiring. When I spoke to David Caruso, he's a expert in the emotional intelligence space - I'm not - about emotional intelligence, he said it's about relationships, like you said, to manage and to recognize your own emotions so that you can continue to build and make stronger rather than weaker relationships. And I think it is harder the more cultures there are, how different you may be from the other person you're speaking to, right? Because it can definitely affect the interaction.
[00:03:57] Esther Freeman: Very much I think the cultural aspect, really, makes things extra challenging. My research life, in terms of Kaposi sarcoma, is primarily in East Africa. So we have a team of East Africans who live and work in Kenya. And this is a team that I've been working with now for almost 10 years. I know them very well. I see them in person. But it's very interesting that culturally my colleagues generally have a tendency not to be willing to share bad news or challenges on the phone or on Zoom. And even though this is now a team that I've cultivated and worked with for an extremely long time, when I go on site and I'm in our site in Western Kenya, all of these things will come out. Even though I've asked, problems, any issues you're having, things that I could potentially, have started to solve when I wasn't on site; and it's culturally not something that they're going to share with me until I am sitting in person in front of them. No matter how much I try and speak to them every single week, until I'm on the ground sitting face to face at a table with them in Kenya, they're just not going to share certain things.
[00:04:51] Christine Ko: Interesting.
[00:04:52] Esther Freeman: Yeah, so it's really interesting, I think in becoming aware; I'm constantly learning how this cultural influences affect our relationships and research and how often research partners can even fail because of a lack of cultural understanding of what people are and are not willing to share with you in certain contexts.
[00:05:06] Christine Ko: I recently read this book called Between Us. And it's by a Dutch emotions researcher. And so she makes the point: she grew up in the Netherlands and then she came to the US. She was saying how she committed a lot of emotional missteps, because the Dutch culture that she had grown up with didn't really fly in American culture and she needed people like her friends, to kindly point it out to her, like, Oh, you were really rude just now. And she's, No, I wasn't. I just, I was just answering the question. Reading that book opened my eyes too, because I'm Korean American, but my parents are both Korean, they would always tell me like, You're not really Korean. And I was like, Thanks. But I realize it's this cultural, emotional, sort of cultural component that the way that I express my emotions and express myself is probably really not Korean, the way that they grew up culturally.
[00:05:52] Esther Freeman: That's so interesting because I think you're totally right, which is that it really colors the way we enter conversation, how we talk, what we perceive as like rude or domineering or really quiet. Our perception, a lot of that, is driven by cultural norms. And I think being aware of that, especially where working in global health where often I'm in a room with people from many different cultures and countries; it really colors the way that you interact and engage with the world.
[00:06:13] Christine Ko: Yeah. I appreciate how you said that you've been collaborating with your Kenyan collaborators for years, and yet you have the awareness that they aren't going to maybe tell you certain challenges and problems until you're in the same room as them. So you have that awareness, you've developed that, and so that's very important. And I think that's a really great example of using emotional intelligence in the way that I think of it. That you have this awareness that, you know, you could potentially like maybe say in a sort of "negative" way, just be like angry. Like, why aren't you telling me this stuff earlier?
[00:06:44] Esther Freeman: That would definitely not get me very far!
[00:06:45] Christine Ko: Yeah. You're like, No, this is cultural. I'm aware of it and I can adapt to it. So I think that's great.
[00:06:50] Esther Freeman: Through many, I will say through many, years of missteps, right? It does take some learning.
[00:06:54] Christine Ko: So then I'm going to move on from emotional intelligence to visual perception, because that's how I got into this stuff. I realized, it's not just talent, it's not just how fast can I recognize a rash on the person or under the microscope. But there is a lot of, at least for me, hard work involved. Can you comment on how you think of your visual perceptive skills and how you think of talent versus hard work in that?
[00:07:15] Esther Freeman: Oh, great. I'm so glad you asked that, because I would say I probably have very low talent levels and I think a lot of hard work. There are some people who are like innately gifted in our field and I would say I am someone who gets there by hard work. So I think that's actually a really good point for our trainees. It's not like dermatologists are born having some innate, magical visual skill. Probably some people do. I would not classify myself as one of them. Two and a half years ago, we started hearing murmurings that there were some skin manifestations of COVID-19, but we didn't know what they were going to be. And I was working really closely with Lindy Fox, who's at UCSF. I consider her to be probably one of the key expert morphologist in our field. I was working really closely with her, and we'd have these extremely late night conversations, being like, Okay, which reaction? We don't know how to classify this. This is previously completely unclassified. What reaction pattern does this fit into? Going back to these basics of like, how do we classify this in what reaction pattern?
[00:08:05] Christine Ko: Yeah. I love also many of the comments you just made. Just to be able to talk with Lindy Fox about it, feel comfortable and safe and just be like, Yeah, I don't know. We don't know. Let's explore together. And I think it's cool that, I'm not sure that it's true, but you're saying that she knows way more than you.
[00:08:21] Esther Freeman: She's such a kind human that she would never herself say that. Maybe this is going back to your emotional intelligence question, but I've learned a lot in working with the registries is a huge international collaborative effort. And what I've been able to do is surround myself with people who have key skills that you need to make this effort work. And knowing that you as one person, are not going to have all those skills and that's okay. So you know, what I bring to the table is I'm a trained epidemiologist. I can build international databases very quickly. I have the ability to communicate with a lot of people worldwide and build these coalitions and bridges, but I'm not necessarily an expert morphologist. For me, really being able to cultivate those friendships and relationships and collaborations with people who have really unique skill sets. I think of Lindy and morphology. I think of Misha Rosenbach at Penn, who's been, hugely instrumental in all the registry work, and keeping things moving, and really collaborating with. I think about Jules Lipoff who's also at Penn, who's like an incredible editor. And over time I've accrued this team of people that have all these wonderful skills. So that's been really fun.
[00:09:16] Christine Ko: That's awesome. I was reading this book by Simon Sinek called The Infinite Game, and he talks about his concept of The Worthy Rival. He's saying instead of being jealous, work with it: Oh, this is my Worthy Rival, and I'm going to try to learn as much from them, and collaborate with them, and, like you, have their skills compliment mine.
[00:09:35] Esther Freeman: It's not either or! Yeah.
[00:09:37] Christine Ko: All the collaborative work you're doing is really inspiring. Speaking of COVID and how we didn't quite know what the skin manifestations might be. How did you use metacognition? In terms of thinking fast and slow, System 1 versus System 2, gut instinct versus more logical process, mathematical types of analytical thinking. Did you have a process like that?
[00:09:55] Esther Freeman: I was interested because you had brought up the idea of thinking of fast and slow. And I have to admit that I was actually totally unaware of it before we talked about speaking on this podcast, so this is definitely an area I don't know a lot about. I will say I think that the process is a little bit of a combination. I do think that primarily, though, when you're creating a coding framework for an international registry, international database, there is a lot of thought and slow process that goes into it.
[00:10:20] Christine Ko: Yeah.
[00:10:20] Esther Freeman: And I think also a lot of iteration that goes into it because we had no idea what was gonna happen. I think back to my epidemiology training, and this is a quote, London School of Hygiene Tropical Medicine. They always started with when they were training us in epidemiology, which was, Dirty hands, clean mind. And I think about that a lot actually with our research we're doing. Outbreaks: it's pretty quick and dirty and you have to do real time data analysis, but you have to do it in a way that's very structured and thoughtful. . So I feel like a lot of what I do ends up with dirty hands and attempts at a clean mind.
[00:10:49] Christine Ko: Yeah. No, that's perfect. Is there a lesson or more than one lesson that you wish you had learned earlier?
[00:10:55] Esther Freeman: I would speak a little bit to the concept around perfectionism. So I think something that is a challenge is carried through my life: the idea that things should be perfect or done at a very high level before I'm willing to let the public or other colleagues see it. Dealing with becoming an inadvertent outbreak dermatologist...
[00:11:10] Christine Ko: [Yeah.]
[00:11:11] Esther Freeman: ... over the last two and a half years studying COVID and now studying monkeypox is that I've had to let go of a lot of that sense of perfectionism or having things be perfect before I share them with the world. Because a lot of what was happening with these outbreaks and with these pandemics was that you had to actually share data before you were even totally sure if all of it was right. I came back to that first tenant from my dad, which was your first job is to stop an outbreak. And so if you have information that can potentially influence a course of events in terms of transmission or transmission dynamics, you need to share that, and you need to let go of the fact that normally in science we want these very glossy, publications where you have dotted every I and crossed every T, but when you're working in outbreaks, you cannot do that. Speed is of the essence and getting information out there that could potentially save lives is important.
[00:12:00] Christine Ko: Yeah.
[00:12:00] Esther Freeman: And so I've really had to let go of a lot of perfectionism. And I think it also comes around when I speak to the press because the temptation is to feel like, Oh, there's probably someone better they could be talking to; or maybe, I don't know everything about this topic. It's actually okay because you need to be the person who can explain it in a clear way to the public. You don't necessarily have to be the ultimate expert in left pinky toe nail growth to talk about left pinky toenails, right? You can know a lot about it, and you need to be able to explain it well for the public, but you don't need to be necessarily the perfect expert in everything. Yeah, I think that's something, and I will say I'm still learning it, but it's something that's been forced for me to reckon with a little bit more in the past two and a half years.
[00:12:41] Christine Ko: I agree. I think most doctors are perfectionists. Partly the medical culture. I think we are not supposed to make mistakes. We certainly don't ever want to make a mistake on a patient, for sure, so there is a need for being perfect in our diagnoses and our treatment plans for patients.
[00:12:57] But, and it is a but, there's no way to be perfect. It's a hard thing to try to know what to do in the perfectionistic medical culture because we do want to get things as close to 100% correct as possible for patients' sakes. COVID's a great example for all of this stuff because it just shows that there has been misinformation. No one's fault, exactly, right? But it did really probably change the course sometimes of what is happening with the pandemic. And so while we do want to get information out there as quickly as possible, yeah, there's a balance between being as accurate as we can be, and then being able to accept we needed this information out there. And then now we know maybe there's a spin on it that we didn't realize. None of this stuff is easy.
[00:13:47] Esther Freeman: Also being able to apologize or acknowledge when you get it wrong, I think is so important. We think about, medical error, bringing back to individual patients. I have one particular patient I've been taking care of for a long time, and to be honest, I'm still not really sure what he has. We tried a lot of things for him, and he stuck with us, and I think the key was being really honest, being like, Okay, that didn't work. Thanks for bearing with us. I read about it, we thought about it, we asked this other expert, we're gonna try this next thing. And so he went through a lot of different treatment processes before we got to something that ultimately worked. And as I said, I'm still not really sure that I know exactly what he has. I'm like, I'm sorry I haven't been able to give you a concrete answer. And he's kinda like, All right, at this point I'm okay with it. It's gone. I appreciate your honesty in saying that you don't know, but you're still gonna keep track. I think sometimes just acknowledging when we don't know in that areas of uncertainty, I think people respond.
[00:14:33] Christine Ko: I agree with you. Every human being, every individual is different, and so every patient is different, and every doctor's different. So I realize, I think the patients that stick with me are the ones who they are, they're okay with my style of being a doctor. I've had experiences where patients just never come back, which I think, says something right? They didn't appreciate my style, and I've sometimes gotten direct feedback: No I don't want to see you again. It's not fun to think about that kind of thing. But I realized, we all have those experiences. It is also a perfectionistic standard that every single patient is going to really like me and my style of doctoring. It's just not true.
[00:15:11] Esther Freeman: Sometimes it's a match finding a healthcare provider or physician that fits with you. There's no one way to respond. It's a bit like when you go into a furniture store and you look at a couch and you're like, Oh yeah, that couch would be great in my house. And then you look at another couch and you're: Never in a million years am I going to put that couch in my house. It's just not comfortable. It doesn't feel like me. And so I think about that a lot with our patients. There's gonna be certain patients where as a doctor you feel like a comfortable couch to them. Yeah. And otherwise where you're gonna be like, Oh, that is not my style.
[00:15:38] Christine Ko: Absolutely. Yes. I've so enjoyed this. Do you have any final thoughts?
[00:15:43] Esther Freeman: So much fun to chat with you. I do have one funny story to end on. I cannot find anything in the fridge. Ever. You open the fridge to me, and it's just visual noise. Like it does not make any sense. If it's not in the front row, it's just like it doesn't exist. My husband was like, I don't understand how you're a dermatologist. You can never find anything in the fridge. And I was kinda worried about myself like, maybe I'm like not a good diagnostician because I can't find anything into the fridge. So then I was at one of my mentor's houses, my mentor is Dr. Johnson, he's the editor of the Fitzpatrick Skin Atlas. He literally can see something, never having seen it before, he can just see something and knows; talk about innate talent, right? So I'm at his house and he opens his fridge and he's looking at his fridge. He goes, Oh, I can never find anything in my fridge. And I was like, Yes! If the world's best diagnostician cannot find anything in his fridge, I feel so much better about myself.
[00:16:33] Christine Ko: Thank you Esther for spending the time with me. This has been so fun. I really appreciate your time.
[00:16:39] Esther Freeman: Oh, my pleasure. Thanks so much for having me.