Dr. Ariela Marshall, MD: Hematologist

Join me and Dr. Ariela Marshall, MD, in talking about her somewhat unconventional journey through specialty decisions and current roles! Dr. Marshall spent most of her career, through the end of residency, set on becoming an oncologist before starting her hematology/oncology combined fellowship and discovering her excitement for acute hematologic care. She is also a physician educator and director of her medical center's fellowship program, as well as an advocate for equity among female and male physicians! We discuss her path through medicine and how to make decisions about the way you want to interact with patients, along with having a combination of roles and interests in your career as a physician. 

Transcript

SPEAKER_00 0:01

All right, everyone. Welcome back to another wonderful long weekend, July 4th episode of In Practice. Um, I have the wonderful Dr. Marshall here with me today. If you just want to introduce yourself and tell us what you're what you do and where you're practicing.

SPEAKER_01 0:16

Sure thing. Well, thanks so much uh for the chance to be on this podcast. I'm excited. Um I am what we call a classical hematologist, meaning I do benign hematology or non-cancer blood disorders. Um and I am currently in practice at University of Minnesota, and I have some educational roles as well there that we can talk about if that's of interest.

SPEAKER_00 0:42

Yeah, that's so awesome. Um, I actually, you're the first hematologist I've spoken to, so this is really exciting. Um, and my mom actually a couple of years ago had a blood clot in her leg, and so had to see a hematologist several times. And she thought it was so fascinating how they're also a specialty like sort of neurology cardiology that deals with systemic issues, but you wouldn't necessarily think of it that way. Um, so I'm super interested to hear how you decided, like you wanted to be a hematologist, maybe something that sparked your interest and how you like the work now.

SPEAKER_01 1:17

Yeah, sure thing. Well, I have kind of a a little bit of a convoluted path um to how I came to be. So I actually didn't even know I wanted to do medicine until I went to college. So I know there's some people who are the exact opposite and know from age three that they want to be doctors, um, but I did not know for a long time. I mean, I had no doctors in my family, didn't really have exposure to the field. Um, I mean, I went through a series, I think at one point I wanted to be like a veterinarian and an architect and like all these different things. Um and when I started college, I think I was on an economics kick and that was my first major. But I think I decided first year of college that I really, you know, I like the sciences and I probably wanted to do something like biology, chemistry. And so that's what I decided to do. Um, but again, I hadn't really had exposure, so I tried to do a little bit of everything. I worked in a couple of different labs, like doing, you know, basic science with PhDs. And then I said, okay, well, I've done, you know, some have some experience here. Let me get um some exposure more on the medicine side of things. Um and I had an amazing mentor, you know, I just basically cold called a bunch of people and hospitals and said, Hey, do you have room for like a college student to maybe shadow you a little bit, do some research with you? And the person who got back to me ended up being my first mentor in medicine, and he was actually an oncologist. Okay. And so I think, you know, we know from work that I do now because I do a lot of career development work that kind of early exposure to mentors is really instrumental in how people choose their professions. And so I think my first exposure really to medicine was to oncology. And so I think that that really influenced me. And from the very, very, very beginning, I said I'm gonna do medicine and I'm gonna do oncology. Um, and I didn't really think about like, hey, let's get some exposure to what else is out there. I think I'm a person who likes to make decisions and just said, okay, this is what I've decided. So that led me down the path to do internal medicine residency after med school. And I didn't even really think that I should check out other specialties, which I I don't regret maybe, but I would do differently, and we can talk about that maybe later. Um, but uh, you know, the the person I was working with was lung, a lung cancer doctor, and I'd always had an interest in women's health and gender equity, even before I knew I wanted to do medicine. So I said, okay, how can I work this in? And so for the longest time, I wanted to be a breast cancer doctor. So that was my thought, like all through the rest of college and medical school and residency. So for like more than five years, almost 10 years, I thought I was gonna be a breast cancer doctor. And then I matched into fellowship and I was doing my hematology oncology fellowship because they're combined. And I got to my first breast cancer clinic, and it's like, eh, this is not so much for me. Um, and around the same time I did an inpatient rotation in hematology, and specifically it was in classical hematology, so kind of clotting and bleeding. And I really, really loved it because I'd always loved the inpatient setting. I like high acuity things. Like if I think I did a different specialty, I would probably be either an emergency doctor or like a trauma surgeon or something where there's like a lot of high acuity inpatient. So um I said, oh wow, you know, I really like this type, like I like the way this type of medicine is practiced. So I'm gonna, I'm already in my hemonk fellowship. You know, I'm not gonna go back and do like an emergency medicine residency that's too much of my life. Um, you know, I'm gonna do this subdivision because it allows me to practice, you know, more in the inpatient setting and have kind of that high acuity care. So I'm gonna do hematology, I'm gonna do classical hematology with rheumosis and hemostasis or clotting and bleeding. And then I said, like, well, I still am interested in women's health. How can I integrate that? And it turns out there's a really emerging field right now where women have a lot of bleeding disorder. You know, we bleed once a month once a month when we get periods, and you know, we can get pregnant and that increases the risk of blood clots. And like there's really a big overlap with hormonal health and women's health and hematology. And so I kind of found my way into that niche, which is still my love, like my specific area of interest. Although right now, I mean, I practice in the inpatient setting and we see everything, um, which is also keeps it exciting. But yeah, that's my kind of long convoluted story into hematology.

SPEAKER_00 6:23

That is so awesome that I'm I'm so glad that you eventually found your niche, but it's very cool to hear like how you eventually landed there that it wasn't like, oh, when I was five years old, I decided to be a hematologist. Um a logistical question before I ask you more like personal things. You do he two logistical questions. You do internal medicine residency uh if you want to be an oncologist. So oncology is sort of a fellowship, not its own residency.

SPEAKER_01 6:55

Correct. So hematology and oncology is like a combined fellowship, but to do that, you would do a medicine or I mean that's if you want to be like a medical oncologist or hematologist prescribing chemotherapy, and I do blood thitters and this kind of. I mean, you could also be a surgical oncologist. So you would do general surgery residency and then do a surgical oncology fellowship. You could be a radiation oncologist, which is actually a residency. Um, so there's different ways to get into kind of the cancer field, but presuming you want to be a medical oncologist, and yes, it's a medicine, three-year internal medicine residency, and then a three-year hematology oncology fellowship.

SPEAKER_00 7:33

And hematology oncology fellowship is always combined, or are there ever situations where the most part?

SPEAKER_01 7:40

I mean, I will say we have like a pilot through the American Society of Hematology. There's a pilot kind of process going on right now where people can do just hematology training and a few centers will have fellows that do just hematology. And then in my fellowship, I mean there are people that just boarded in oncology. So it's a it's a if you do heme onc, technically it's a three-year fellowship. Um, but to be board eligible for hematology or for oncology, you need only two years and only 12 months of clinical training. So there's some people in my and many other fellowships who take the three-year fellowship but will do like the 12 months of clinical training and spend the rest of their time doing research because it's a very research-heavy field.

SPEAKER_00 8:26

Interesting. Why are they combined, heme and onk?

SPEAKER_01 8:30

That is an excellent question. It's like very, very like long historical response that would be boring. Um, but I think a lot of people, you know, the the field of oncology or cancer medicine actually started with a lot of pioneers in blood cancer. So things like leukemia. And there's a lot of overlap actually with pediatrics, too, because there's you know, kids like that, there's a lot of interest in in kids' leukemias. Um, but the um the field that kind of got a foothold because of early developments, especially in blood cancers, and so that was kind of and then so it was like hematology first, and then also like there's been a long-standing field of hematology for things like sickle cell disease and thalassemias and you know anemias in general. Um, and so then it's like, okay, this is all blood, this like this is all hematology, but now we're doing chemotherapy for cancers, and then as chemotherapy was developed more for the solid tumors, it kind of seemed natural, I think, to to combine that as well. But there's always talk now, like because of all the new medicines, all the new developments, like should we be splitting them off again?

SPEAKER_00 9:46

Yeah. That's so interesting. I actually had no idea about because I've never had an interest in oncology, and so I've never considered like what the path looks like. So it's just super interesting. I didn't know any of these things about it. Um well, so tell me a little bit about your residency path into heme onk and what you were finding in internal medicine that I don't know if maybe you realized you liked acuity then. How were you thinking about like inpatient-outpatient at that time? I know that theme came later, but I'm curious to hear sort of what you were feeling.

SPEAKER_01 10:22

Yeah, actually, I always liked inpatient medicine during my entire residency. So I liked being in the hospital way more than I liked being in clinic. Um, I was one of the few people in my class that actually enjoyed doing my emergency medicine rotations again because it's high acuity, you see a little bit of everything. Um, I liked being the wards, I liked being in the ICU. Um, eventually when I was doing my hemonc training, I thought about doing an extra year of training in critical care. So I could be like a critical care hematologist. Again, it was at the end of the day, I was like, I am kind of done with training. I'm tired. I want to just, you know, get my get my training done. Um, but yeah, I think um starting at the very beginning of residency, I realized I like that inpatient high acuity setting. Yeah.

SPEAKER_00 11:09

And what what is it do you feel like that you like about that as opposed to outpatient clinic?

SPEAKER_01 11:14

Yeah, I feel like there are big kind of serious issues, you know, whether it be the person who comes in with septic shock, you know, and on pressors in the ICU or for heme is the person who has massive bleeding or like a huge thrombosis. So it's I mean it's a very serious problem that needs to be dealt with on a very rapid time scale. And if things go well, you can see things improve very quickly as well. So maybe I'm just somebody who needs that immediate gratification of say, like, hey, I made an intervention and I see that it either worked or didn't work right away. Um, I mean, that's probably why I also was never super drawn to basic research and kind of lab-based research because like I can't wait that's like five years to see whether my research is going anywhere or 10 years. Um so yeah, I think it's like that seeing things in real time. And I also really like working right alongside other specialties. So as consultative hematologists, I mean we're always working with cardiologists and the ICU folk and the surgery teams and the anesthesia team. So I think it's that, you know, you're getting a lot of collaboration, like working for the patients together, like right in something where you see the outcome of your effort right away, whether that's good or bad.

SPEAKER_00 12:35

That's very cool. It's yeah. I've always thought that I wanted to be outpatient just because of lifestyle factors. I think it, you know, you have a regular schedule and all that stuff. So actually leads me into my next question. But it's interesting to think to think about, you know, always to think about all the other aspects, like what you lose versus gain when you go into one versus the other. It's not just about the hours. Um, so this actually leads me into my next question, which is what is your day-to-day like? And then also what is your week to week like? Are you on like a lot of call or not? Or how do you how does that work?

SPEAKER_01 13:07

Yeah. So I mean, I have a very unique position that I've kind of crafted for myself. So I don't think it's like representative. Um, I can talk about so before I was at my current institution, I had a more traditional kind of classical hematology position where I was doing basically like five half days of outpatient clinic a week. And then I did maybe about 10 weeks of inpatient service where you work, you know, doing inpatient consults like a week at a time. And that I would say that in hematology is like a very standard, you know, if you're in an academic institution, um, I've always been in academic institutions. Um now I actually was able to craft kind of my dream job where I only have inpatient consult time. So I don't have any clinic right now. Um I just do one week a month of inpatient consults. Um my clinical FTE, the full-time equivalence, I'm if you ask like how much do you work clinically and part-time clinically because I have other like education leadership roles that take up the remainder of my time. Um, so I'm about like a 0.4 clinically, and that comes out to about one week a month. Um, and I love it. I mean, that that week is very intense, right? I'm usually in the hospital by 7 a.m. latest. Um, I'll finish, you know, maybe uh 5 or 6 p.m., but still have notes to write, and you're on call 24-7 during that week. So I mean, again, at an academic institution, we often have fellow like trainees that are kind of the first call, and then they'll call us if they're running into a complex situation or want some advice or need help. Um, and I want them to call us, you know, because these are tough questions and they're there to learn. Um, but yeah, I mean, it's a it's a tough week. Um, but I really enjoy it because it's like all of the intensity is there at once. And then after that, it's like, okay, you know, I get that breathing space to focus on the other aspects of my work.

SPEAKER_00 15:14

There, and there are so then in the weeks that you're not there, it's like other physicians have these rotating like one week. Exactly, exactly.

SPEAKER_01 15:22

So within our group, I probably have the highest number of inpatient weeks because I only do inpatient and other folks may have, you know, like half that time or or something like that.

SPEAKER_00 15:35

And then you're leading me in very nicely. What are the other aspects of your work? You know, you've mentioned some education stuff. I'd love to hear what what you what it is that you're doing outside of inpatient consults.

SPEAKER_01 15:45

Yeah, so I'm actually the program director for our hematology oncology fellowship. Um, so that is something that I came into after years of interest in medical education. That was, again, education has been something that I wanted to do even before I got into medicine. Um, so ever from you know, the time that I started in medical school, I said, how can I get involved in education, you know, being on education committees, and I continued that through residency and fellowship. And then my first, you know, five, seven years in practice, I was like an assistant and then associate program director um for different fellowships. Um, and now currently as a program director, that's a bigger role because you're essentially overseeing everything, right? So everything from the the season, so to speak, the year is about to start. So in July, you know, we just welcomed our new fellows on July 1st. So our first years are starting. Um, and it's about to be application season for fellowships. So then we'll get hundreds of people that I will review those applications, we'll decide who to invite for interviews, and then we interview everybody and then we rank them, and then there's the whole match. And all this while I'm, you know, while we're looking to select new fellows, I'm like listening to our current fellows, you know, how are things going for them? Are they getting the education that they need? You know, what types of you know educational programming are we arranging for them? How do we get them prepared for their board? So it's like everything, but I I really enjoy it again. It it keeps me busy, but it's like a very exciting type of busyness. And I like the interpersonal aspect of it too. I mean, I'm an advisor, I'm like a coach, I'm a mentor, you know, I'm a cheerleader, you know. My the person who asked me if I was interested in the position said it's kind of like being a mom and a sister, like a mom, you have to put the discipline, the sister, you're there is the cheerleader. So I liked that way of explaining it.

SPEAKER_00 17:42

That's really cool. Yeah. I also have an interest in education. So I like to hear what like medical and other education, you know, physicians are doing in their roles. Because I've I've talked to a couple of people that are involved in some sort of like educational capacity that they run like the residency program or like you are like running a fellowship program. And so it's very cool to hear like the breadth of things that you can do. It's not just like a clinic all day, every day or consult all day every day. Um and then I wanted to ask also about you mentioned like the this interest in women's health equity and like women's health and stuff. Are you exploring that at all right now in in any other capacity, or is it just like through your education and work?

SPEAKER_01 18:21

One of my other hats, I've done a lot of probably the majority of my research has been kind of in gender equity. Um, is mostly for physicians, actually. So physician gender equity in the workforce, like how are we promoted? How do we mentor? How do we get more women in leadership roles? Um, I do a lot of work with physician fertility as well. Um, having experienced infertility myself and recognizing that we need to have better awareness and advocacy for that. So, and I do a lot of research on burnout and work-life integration and how that interacts with gender. Um, and so yeah, that's actually a big, a big part of what I do in terms of my kind of advocacy work.

SPEAKER_00 19:04

That's very, very cool. And so you're it's it's not like a lab though. It sounds like it's sort of statistical research and and things like that.

SPEAKER_01 19:12

Exactly. It's like survey-based research and this type of thing.

SPEAKER_00 19:17

Any findings that you have off the top of your head that would be interesting to share or curious?

SPEAKER_01 19:22

Yeah, I would say one of the interesting things we recently published on, I mean, we know at baseline that women physicians have higher rates of burnout than male physicians. Um, but we also did a study recently where we looked at spousal support. Um, because, you know, again, I don't want to like be exclusionary at all, uh, but we know that, you know, 85% of physicians are so are married or have partners or spouses. And of those who have spouses, the ones who have higher levels of support, it's actually like an ameliorating factor for burnout. So it's like protective against burnout, which I think is not surprising, but it's also something that had never been reported on. So that was a cool thing we just published on.

SPEAKER_00 20:08

Well, yeah. No, it's you know, sometimes these findings in in research are definitely like that. It shouldn't surprise anyone, but no one's ever actually, you know, put in put in the numbers and and things to really truly prove it. Um, so that's that's very, very cool. Um, is there anything else that you want to share about like sort of an unconventional? It sounds like you have a slightly unconventional job, like work balance arrow. Um how do you feel like you came to build that? I guess is my question. Like I'm sure it just took time, but do you feel like a lot of that?

SPEAKER_01 20:43

You know, a lot of my current position is out of necessity, actually, because my hospital is an hour and a half from where I live. So through like a long, long, long series of like life events and decisions and working with my spouse and having a child, you know, this is how it worked out best. But literally when I started, I said, I can only do this if I can come up for a week at a time and that can be once a month. Like I can't be going back and forth and doing clinic like multiple times a week. It's just not gonna work. But luckily, you know, that's also the setup that I like, you know. So it was kind of out of necessity, but it was also like, hey, this is the setup that I really like. Um, so I got very lucky that they were open to that. And I'm very lucky that we're in an era where a lot of things can be done virtually from like the education and the admins. I mean, 10 years ago, it would have been, I think, unheard of to have somebody who's working virtually a lot of the time. Um, so I think it was just like the right time, the right place, the right set of circumstances, and my institution being very flexible, but also I've learned to advocate for yourself. And I think that's really important training for for young physicians as well as kind of saying, and I think you know, the the idea of the Pacasino is specialty choice. So one thing I would say is you know, a lot of us. Make these specialty choices by like, what am I interested in? And I think that's great to some extent. Yes, you don't want to do a specialty that you're not interested in, but it's more than just are you interested in it's like what how do I like to interact with patients, right? Like, how does that go? Like, I like to interact with patients in the inpatient setting in a very, you know, kind of acute condition and say, this is what we need to do. This is a very serious situation. Like, here's what we need to do. Um, different people may say, that's really stressful. I want to interact with people where I see them, you know, like once a month or once every three months for the rest of their lives and have a longitudinal relationship. And so I think it's what are you interested in, but also like how do you like to interact with patients and in what setting? And that is what finally clicked for me with the way that I practice now.

SPEAKER_00 22:49

That's a great, that's a great way to put it, actually. I feel like that really sums up the advice I get from a lot of people. And you know, a lot of people say you don't really know. Most people actually, it's interesting. Most people say you you figure out what you want to do when you're rounding in your third and fourth year of medical school. It sounds like you are not representative of that, but rather later on figured it out, which is also comforting to realize you don't have to know at that point either. Um, you know, some people it seems like they know when they're 17, 25, whatever. Um but yeah, I think that's a really good summary of what it is. You know, how how do you want to interact with people? Do you want a longitudinal relationship or not? Do you want to have a lot of interaction with them, right? You know, some people become surgeons because they really like medicine, but they're not so keen on talking to people all the time. Or on the total opposite end, like psychiatry, people all they want to do is talk to people. Um, so I really like that you put it that way. Yeah. Um any advice for women in medicine, since that's your, I guess, niche a little bit. Any advice for kind of how you navigate that? Um, I know it's much less of a male-centered field now, but I think it can be tough to think about like building your personal life outside of medicine. So I'm wondering if you have anything that you would say about that.

SPEAKER_01 24:15

Yeah, I mean, this is a conversation that could take up an entire podcast on its own. Um things have gotten better over time in general. There are more and more women in leadership positions, and that's what I think it takes, right? Because we're always so keen on telling people here's what you can do as an individual. What we really need to do is change the system to make it more receptive to women. And what does that require? That requires women leaders, right? Because no one's that the people who make the change are the leaders. And if the leaders are always men, they're not gonna realize it's something we need to change. So we need to have more women leaders who are willing to enact change to make it a better environment for more women physicians, no matter what the specialty. And the other thing is that I think it's still this cultural mindset of, yeah, like thing what's one thing that's changed, I think, is more receptivity to work-life integration and people saying, like, yes, I'm in medical training, but I still need to like do doctor's appointments and like because when I trained, it was like people didn't see a dentist for like 10 years and got 20 cavities because it was you're just not allowed to do that. Um, yeah, but that's crazy. Um, so I think times have changed. There's more receptivity to work-life integration, and that's good. But I think we're still stuck in this cultural mindset of like it's the woman who needs to be thinking about the work life in it. Like, how many men do you think? Uh like, how do I balance like having a career in medicine with having a family? No, they don't think about it, they just like do it, they do what specialty they want. And a lot of them have families, right? They're like a lot of them are not thinking about it. I'm not gonna say everybody because that's you know, again, times have changed, and I think everyone is thinking about this more, but we can't just make it the woman's obligation to think about how to balance things. So that's where I think this research that we found that spousal support, you know, is so protective against burnout is really important because it's like choose a partner wisely if you're going to have a partner, right? So somebody that's going to be supportive, so you're both in it. Right. Right. Because it can't just always be one person's obligation to figure these things out.

SPEAKER_00 26:31

Is your spouse also a physician?

SPEAKER_01 26:33

He is, he is. And so I think on the one hand, it's good because they understand what you're going through, what the training's been like, what the schedule is like, what the demands are like. On the other hand, I mean, you both have that schedule and the demands now. And so especially, you know, if people become parents, that makes it very challenging. Yeah.

SPEAKER_00 26:54

Well, it was so great to hear about your journey and to hear about what you do. Um, it makes me think a little bit more about hematology, although I'm not interested in oncology, unfortunately. So that might deter me, but I'm sure other people are going to be incredibly fascinated by the specialty. Um, and I love the the equity and the the leadership work that you do. So I really commend you on that.

SPEAKER_01 27:18

Well, thanks so much, and thanks for inviting me.

SPEAKER_00 27:20

Yeah, of course. So grateful to have you. Have a great weekend.

SPEAKER_01 27:24

Thank you. You too.