EP172: Dr. Ilona Frieden: Navigating a Groundbreaking Career in Pediatric Dermatology

Navigating A Stellar Career in Pediatric Dermatology: Dr. Ilona Frieden

In this episode of The Girl Doc Survival Guide, Dr. Ilona Frieden, a distinguished leader in pediatric dermatology, shares her journey and insights. Dr. Frieden discusses her personal background, the challenges she faced growing up in California, and her unexpected path into medicine. She underscores the importance of balancing career aspirations with personal well-being and family, talking about her own experiences with social activism, feminism, and motherhood. Dr. Frieden also highlights the significance of finding meaning and community in one's work, her pragmatic approach to problem-solving, and the vital role of humility and collaboration in medical practice. This episode offers valuable lessons on work-life balance, career development, and the evolving nature of professional fulfillment.

00:00 Introduction and Guest Background

01:27 Personal Anecdotes and Early Life

03:13 Career Journey and Achievements

05:13 Work-Life Balance and Parenting

09:55 Mentorship and Professional Insights

16:37 Reflections on Medicine and Legacy

23:28 Final Thoughts and Gratitude

Transcript

Christine Ko: [00:00:00] Welcome back to The Girl Doc Survival Guide. I'm very pleased to be here with Dr. Ilona Frieden. Dr. Ilona Frieden, MD is a Professor of Pediatrics and Dermatology, former Vice Chair of Dermatology, and former Chief of the Division of Pediatric Dermatology at the University of California San Francisco. She has been President of the Society for Pediatric Dermatology, President of the American Board of Dermatology, President of the International Society for the Study of Vascular Anomalies, and a member of the Board of Directors of the American Academy of Dermatology. She has won many awards including the Alvin Jacobs Award from the American Academy of Pediatrics, the Dermatology Foundation Lifetime Career Educator Award, the Mentor of the Year and the Rose Hirschler Awards from the Women's Dermatologic Society, and the Thomas Pearson Award from the American Academy of Dermatology. She's a former Editor-in-Chief of the journal Pediatric Dermatology, and is co-editor of the textbook, Neonatal and Infant Dermatology, now in its third edition. [00:01:00] It was back in 1991 that she founded the Birthmarks and Vascular Anomaly Center at UCSF and was also a founding member of the Pediatric Dermatology Research Alliance, or PeDRA for short, and she served on its Executive Committee for many years and is its current President. Thank you for joining me today, Ilona.

Ilona Frieden: Thank you. 

Christine Ko: You have this stellar cv and I read off only just a fraction of all your accomplishments. Can you share a personal anecdote, just to humanize yourself a little bit?

Ilona Frieden: Yeah, sure. I'm a Californian by birth. I've lived in California most of my life, and as someone now in their seventies, California was an intellectual backwater in the world of academics. Certainly when I was growing up, people from California stayed in California. We didn't go east to college, the way kids do now. It was its own kind of world. I was also a middle child. I'm the second of four. I have an [00:02:00] older sister and a younger brother and sister, and I've definitely considered myself a middle child. I was, in my mother's view, an underachiever. I was an A minus, not an A student, and much to her chagrin, but I was certainly expected academically to go to college and become educated.

But I never viewed myself as any kind of a superstar. The options for women as I was growing up were to become a teacher or a social worker. My mother was a teacher, actually. My mother had wanted to be a doctor, but growing up in the 1920s and thirties as she did during the depression, that wasn't even really an option. She didn't even go to college until she had already had children. So I didn't grow up with the sense that I would amount to anything really important. And I found my journey through many things, including social activism in the sense that the [00:03:00] second wave of feminism was occurring when I was in college, and women were beginning to recognize that they could have a voice. This came out of the civil rights movement and I was very influenced by that. In terms of directly translating to career, I began to realize I wanted to have a career. I thought about nursing, but in the end I meandered my way into a career in medicine. It was not like this auspicious intentional start to this career. It blows my mind when I hear you list all these accomplishments, which I am very proud of and believe are very real. But I also don't think that they are anything I was entitled to. I feel that I've worked very hard for them, but it's also been over decades. This is not a compressed career. We're talking about, four decades of gradually trying this, doing this. My career was atypical in that after residency, [00:04:00] first in pediatrics, and then I decided to do dermatology, there was no academic position for me. I ended up going to Kaiser, a big health maintenance organization for six years, and then got recruited back to academic medicine, which was at that time highly unusual as a career path. It's been an amazing career and I'm so happy. I'm so fortunate that things worked out the way they did.

Christine Ko: Even when you say you were an A minus student, I assume that's because that's the amount of effort you wanted to put in at the time.

Ilona Frieden: I'm not a perfectionist, and I think that's been a real saving grace for me personally. I do a lot of mentoring of students, residents, faculty, and I think perfectionism, particularly for women, is a real liability. I never felt that urge. I had an older sister who is more perfectionistic than me, and I think the A minus part was in contrast to her because she did everything perfectly. I didn't feel like I had to do everything perfectly. I'm not quite sure why, but it just didn't strike me that had to be the [00:05:00] goal. But I always had high standards for myself. I still do. But there's a difference between that and perfectionism. It doesn't have to be that I get a gold star for every single thing that I do.

Christine Ko: Is there anything that you wish you had known earlier?

Ilona Frieden: Wow. There's so many things I wish I had known earlier. Life is both long and short. You don't know how much time you're going to have. You have to balance so many different aspects of life. I guess I wish I had known more that there were good times to dig in and to really invest in career. And other times when it's more okay to give yourself a break, understanding that you don't have to keep pressure and that you can come back to things. The key there is to be willing to come back to things because what I do see among certain colleagues, who put a lot of pressure on themselves and then burn out, [00:06:00] is that then they've truly burned their bridges. They really can't come back. And that was never really the way it worked for me.

I wish in a way I had known a little bit more of that organic nature of that upfront, which would've kept me from feeling as much pressure on myself as I did at times. But looking at the trajectory of so many people's careers, there are times when you can't be a hundred percent because especially if you have children at home, you need to invest in that process and not try to be doing everything at once. It's hard to balance these things. 

Christine Ko: I agree wholeheartedly. I was super stressed as a young parent. I felt like it needed to be now, everything. I felt like I couldn't say no to things. There were things I think that I could have said no to and it would've been completely fine. And I would've been less stressed, and I would've had a little bit more time.

Ilona Frieden: I think that being a parent is definitely more [00:07:00] challenging than being a physician. It was for me. I'm not a nervous person. I'm not someone who's a super anxious person. But I was so much more anxious and nervous about them than I even really allowed myself to realize, because now with my grandchildren, I don't feel that at all. I look back and maybe you really can't have that sort of unbridled enjoyment and joy because in the back of your mind you still have to get dinner on the table. You still have to try to keep your marriage intact. You still have all of these other conflicting priorities, and I think that's hard. It was very hard. I won't deny that, and I have ways in which as a parent, I feel like I wasn't the best. It wasn't my best self at times. I was less playful than I had hoped I would be. I wasn't very playful as a child either, to be honest. I was a serious kid, so it shouldn't have surprised me that's what I would be like as a parent. And yet I wished I could have been more whimsical. Women in my [00:08:00] generation, we were really the first sort of big bolus of women coming in for the first time into medicine. There, there had been 5% of the class, 10%. Ours was like 25% of the class for the first time ever. Most of us knew that we wanted to get married and have children. We didn't really think we had to give that up, and we didn't want to, and we didn't plan to, but we had no idea how to navigate that. I still find that it's still every person for themselves in terms of the solutions you make for childcare in terms of the compromises you make. There's no manual for it, and everyone is doing the best that they can.

Christine Ko: Yeah. Why? Why is there no manual for this?

Ilona Frieden: I think it's just the stakes are so high and each person is themselves. You've met one kid, you've met one kid. They're so different from one another. One thing that did help me, and it turned out to not be really my preference, but I was an older mom, and by then I already had my career skills down. By then, I [00:09:00] had already given some lectures. I had already written a few chapters. That was a help to me in terms of keeping those academic things on the back burner and being able to draw on them because I think the hard part of any career is the startup piece of it, where you're really inventing who you are, what role you're gonna take, what's your voice gonna be? What's your voice in the process? That takes enormous amount of energy. Once you've done it, it's easier to modify it, to take it in a slightly different direction. Those things are much easier. It's similar to me to writing a manuscript. If you're starting a project, you need time for deep thought to really dive in, to really conceptualize. I tend to do that by writing, physically writing outlines for myself. With a pen and paper. And then once you've got your core, then it's easier to keep things going. And that turned out to be true for me. In terms of this sort of question, which you is one, you're interested in work life balance. [00:10:00] It's easier once you've got something in progress to work on it for an hour here or there, whereas in the beginning you need much more dedicated, concentrated time to figure out what direction to go in.

Christine Ko: I agree. There's a certain amount of time that it takes to figure something out. To figure out a direction you wanna take a project even, but definitely a direction to take your life takes time.

I used to think work-life balance is achievable. I thought I've never consistently felt like I was achieving it because I'm a failure at it. You know what I mean? Not to beat myself up, but there's something I could do to make it better. And then I gave a lecture. They asked me to give a lecture on work-life balance at the American Society of Dermpath this past fall. And when I was putting it together, I just felt like it just doesn't exist. Like you were saying, there's something that takes priority, whether it's work for a certain day or month or week or hour even. And then especially with a baby, [00:11:00] like on parental leave, that baby is number one. At different points in life, something is gonna be more important or less.

Of course, there are things, like you touched on, like having a head start for your career before you have a child might be easier than having kids during residency.

Ilona Frieden: I've given lectures for the academic Dermatology Leadership Program, and I don't think work life balance is the correct conceptual framework. You're never in equipoise, so how can there really be balance? There's a fundamental fallacy. If you wanna look at it that way, you're always in some ways out of whack. So it's really a question of shifting priorities, and there are lots of techniques I think within that, that can be helpful. Through the leadership journey that I took, I got a lot of training and I'm very grateful for it. I don't think I was smart enough to figure out I needed soft skills. People can learn through books, self-help books, leadership training.

I'm definitely a list keeper. [00:12:00] I also make appointments for myself. I find if I don't, things will drift away that are really key priorities for me. You have to figure out what those priorities are. There are time management techniques that are very helpful. But it's not work-life balance. It's ways to prioritize what's important to you. I always made sure that I was doing something other than medicine because I just didn't wanna completely give myself over to that and not experience the other parts of myself. I'm a big hiker and walker, and I love that.

Christine Ko: I think you just touched on when you said you didn't wanna give yourself over to medicine completely, medicine can just be all consuming with Epic and electronic medical records. I agree that something that I fully appreciated more recently, once my kids were a little older, that I do need to, and it sounds like you do too, have something that's just separate from [00:13:00] medicine that stimulates me. 

Ilona Frieden: I agree. Because eventually people stop working and then what do they have at that point if their entire identity has been work? Now I'm still working very part-time and I'm very fortunate I've been able to do that. I'm really lucky that I found something that really perfectly suited me. I could not have predicted that or known that it would've been the case. I feel that I stumbled into it, without even understanding that I had a pretty refined visual aesthetic. Sort of the way my brain works allowed me to be very good as a dermatologist. It's been a great gift to have that. But I think I also have to look at what would happen if I couldn't do that anymore.

You have to find meaning in life. That's really the thing. I'm not somebody who can just drift through with a very purposeless life and just enjoy each moment as it comes. But I think you can find lots of things that give you [00:14:00] purpose. For me it's still a balance of some work, but also lots of other things that are, related to travel and the outdoors and friendships and family. That's the space I'm trying to navigate right now. But you're right, you don't want to just be a hundred percent work, and I don't think most people are very suited to that. There may be exceptions.

Christine Ko: May I ask how long you've been working part-time?

Ilona Frieden: Yeah. In 2019. I had already cut back and started to transition the Division Chief to Kelly Cordoro. I was really grateful that I had someone who I felt was gonna be so capable of doing a great job, which she has. I'm a plodder. I'm not someone who sprints to the front of the line. So I really wanted to begin to slowly divest from leadership positions, which I began to do, and make sure that there were people who I could transition those to. I did that in about 2018, 19. I went down to [00:15:00] 80% work effort, and then 2019, we have a system at UCSF where you can retire, and you take a pension, which is just an amazing gift. So you get a pension and then you can work part-time. And that part-time work is like 40%. Gradually over the last few years, it's down to about 20 to 30% work effort, but with some spurts because like right now I'm involved in a big research project that I'm really excited about. And so that's a lot more work, but that's a hobby at this point. It's completely of my own choosing, and I'm enjoying it. The things that have kept me in that position of wanting to continue in my part-time status are just the connections to people, my colleagues, to working with young, really interesting, fun people. Because people, when they get older, they can often get cut off from people of different ages. I feel like I'm still able to keep my hand in, which I feel very grateful for that. It's still fun for me, for now, but [00:16:00] every year is its own kind of state of affairs. 

Christine Ko: You seem to know yourself a good amount and know what you want. It seems like that's been consistent through your career, and you still are doing the projects you want as a "hobby". I think that's wonderful.

Ilona Frieden: Being curious is an intrinsic characteristic for me. I think I've always been a pretty curious person, and also, I'm a very pragmatic person. I'm not somebody who's really in my head in theory. I like the idea of being able to say, this is a problem. I don't understand. One of the things I learned early on, and everyone should learn this, I'm sure you did too, is you know not to believe everything you read and not to believe everything you're taught. That starts to come home to you when you're out on your own. And it did for me. I think my whole history with hemangioma research is very much related to feeling like I was taught things that weren't true. It's like [00:17:00] how could they have said, Oh, don't worry about this. It's completely benign. And then, it turns out it's like leaving these huge scars on little baby faces. It's like, why was I taught that? And I think that really got me, that bothered me a lot, and I needed to find the answers to that question, and I've spent a kind of a career doing that. Trying to mine those areas where there is some cognitive dissonance or where it just doesn't make sense to me and finding like-minded people. That's one thing I haven't maybe emphasized enough in this conversation. That turned out to be huge and I found that in both dermatology and pediatric dermatology more specifically, that I really found my tribe of people who like to think the way I do, who like to talk about the same things. We may be completely nerding out on topics that seem obscure to other people, but it doesn't matter because to us it's fun, it's interesting, and that's certainly career advice I would give to [00:18:00] any young person starting out. Try to find your tribe. If you wanna use that terminology. It's not always so easy to do. In dermatology, for me, it also required ignoring parts of dermatology where I didn't feel such commonality with people. But that's okay. Most of the people I think that I'm close to really wanna take care of people who have serious skin disease and help 'em. That's more of my motivation for what I do.

Christine Ko: Yeah. This might be a hard question to answer. You said that we do need meaning in our lives. What do you think that means? For you. 

Ilona Frieden: I think it's just my observation that just drifting along doesn't quite give you the satisfaction in embracing life. I think the meaning can change over time, but it can't be too tied to a title. There's a really wonderful New [00:19:00] Yorker article that I read years ago. There's a guy who's swimming, a professor at some Ivy League school, in a swimming pool. He's swimming and kind of looks up and says to the person who's swimming next to, he said, I used to be a judge. Clearly he is a retired, older person. The point being you have to be able to give up that, being the judge. It's who are you now and what and what's your role in life or your roles in life that give you reasons why there's still something to continue to live for. Whether it's just going to see a beautiful place, or there's lots of ways to do it. I feel very fortunate because I'm actually pretty healthy. I'm economically affluent enough to be able to travel. But even without those things, I think finding meaning in helping other people in just trying to do small acts of kindness. Those count too. But it's [00:20:00] gonna change over time.

Christine Ko: Yes. I really like the way you put that. It will change over time.

Ilona Frieden: I think you can leave a legacy in terms of a body of work that you can be proud of. And I do feel a satisfaction in having done that, but I don't feel that it's what defines me as a person. I'm proud of it. I certainly take ownership of it. I love it when people ask me questions about difficult cases, and I do my best to answer. One of the best things about the culture that I've been able to live in at UCSF Dermatology is that there really has been a culture of this very special combination of rigor and humility. To me, that's a magic sauce. In medical school there was a lot of arrogance in the way that information got passed along that I really disliked, but I didn't have a strong enough professional identity at that point to push back against it very hard and say, this is really wrong. But I look at it now, and I think it was wrong, and my [00:21:00] instincts were correct about that. I can remember the first time, this was with Nancy Esterly, who was a huge mentor to me. She was one of the founders of pediatric dermatology, and I went to work with her at the end of my training. She walked out of a room, and she said, I have absolutely no idea what this child has. That's what she said. It was a jolt to hear someone of her stature admit they absolutely didn't know. I never forgot that. But she didn't stop there. She went on to say, we have to call this person. We have to do this. We have to do this test. She had an approach. She didn't just stop, but she admitted to herself, and I thought, oh my God, this is fantastic. That was one of the most important lessons I ever learned. It came at the end of my training, but I never forgot it because I just think you have to admit if you don't know something, or you're really working off of a false premise. So to [00:22:00] me being humble and turning to other people for help has been a central core of the way I operate.

I imagine in dermpath, it's the same thing. You want really wanna share. That's the whole point of being in a group, right?

Christine Ko: Dermpath, I feel, is like a cauldron of error in the sense that the slide is static. The slide is exactly the same. So if there's something in there that I didn't see, I literally didn't see it. And, yes, I can see my own errors when they're pointed out to me. Obviously if I knew I was making it, I wouldn't have signed something out the way I did with an error in it. That has been something I've been grappling with because I think it's the culture of medicine that doctors don't make mistakes. I know that I do, but no one else does. I've seen my errors over the years. I realize we're human. Not that it's okay, you're right. It's this balance of rigor, humility, high standards. 

Ilona Frieden: Even in dermpath, I learned this from another colleague, Tim [00:23:00] McCalmont. He would say, this is highly negotiable. Which made me laugh. Even though what's on the slide is on the slide, the context of the information that you're interpreting changes the lens a lot. And it was true though. 'Cause if you said but this is the context. It's a 2-year-old child, it can't be that. Then you would have to go back to what the clinical pathologic correlation was essentially. It was a great way to think about it. The interpretation can vary a lot depending on context.

Christine Ko: Do you have any final thoughts? 

Ilona Frieden: People trying to find community in what they do, it's so important. The infinity of biology just continues to boggle my mind. I see things all the time that I don't think I've seen before. Right now, I'm helping on a case where I literally don't know what this child has. I like the idea of sharing with other people when I have uncertainty and asking for their help. And I try to be generous in giving back as well. I think it has to [00:24:00] go both ways, but that part of medicine has been very sustaining, and I guess I would just end with I just feel incredibly fortunate to have stumbled into this pathway and found fulfillment. Certainly had a lot of fun and been able to learn. So much science going on and the genomic revolution. UCSF is a giant place, but my little environment that I live in has been a very good one, a very supportive one, and I hope that I've been able to contribute for others to have that same experience.

Christine Ko: That's awesome. Thank you so much.

Ilona Frieden: Great talking to you.