Interviewing a Women's Health Internist: Dr. Juliana Kling

Interview

I am Dr. Juliana Kling. I am a women’s health internist. I am the chair of the Division of Women’s Health Internal Medicine as well as the associate chair of Equity Inclusion and Diversity for the Department of Medicine at Mayo Clinic, Arizona. I have the coolest profession ever. My practice is this hybrid model where we do primary care predominantly for women, although I have men, transgender, and gender diverse people in my practice. As well as consults in the area of menopause, menopausal hormone therapy, female sexual dysfunction, complex contraception, and I also work in our breast clinic looking at breast disease.

1. Can you tell us a bit about how you decided to become a doctor and why you wanted to join the medical field?

• I think my reason for going into medicine changed over time, but was really rooted in a desire to advocate for others, especially those that were less fortunate. My parents both worked in careers where they served as advocates for our community. My mom was a therapist that worked for sexual assault victims in Tempe after getting her masters when I was younger. And then, my dad was a homicide and sex crime detective, and he would work with perpetrators of those crimes. But, he also worked a lot with hate crimes and worked to reduce the amount of hate crimes in the city of Tempe. So, I can remember him going to talk to large groups of LGBT people about the presence of hate crimes, and how to work as a community to reduce that. It was really powerful, thinking back, to see those that weren’t a part of the community stepping up and advocating on behalf of that group. It made me realize that it should not fall on the part of the minority shoulder to advocate on their behalf. But really, it should be all of our responsibilities. I believe strongly in that social justice advocacy.

2. I understand you have an interest in LGBTQ+ health. Can you tell us what fostered your interest in this?

• I think a lot of it has to do with my parents. Seeing them advocate for the LGBTQ community, particularly my dad. During undergrad, I went to Arizona State University and had the great honor and privilege of acting in, producing, and directing the Vagina Monologues. Eve Ensler was the playwright, and she interviewed over two hundred women and used that to write these monologues. Some are sad and some are hilarious. The whole goal of the movement is to allow communities to put on this play to provide funding for anti-violence efforts. It was through that work where I became familiar with same sex violence or just the trauma that LGBTQ people face. Also, that propelled me to work with a group called AMSA (American Medical Student Association) both as a pre medical student and medical school student. In medical school through AMSA, I became a gender and sexuality chair. I got to continue working on both the policy angle in D.C… and other areas. Teaching medical students and others how to care for LGBTQ people. Through my residency training, I have had the opportunity to do lots of education for both the medical students and residency. Probably the biggest honor was serving as the coacher for the lesbian, gay, bisexual, transgender, intersex male employ research group for a couple of years and really advancing the safe space for our employees and also for our patients here at Mayo Clinic.

3. What do you think every doctor should know when treating someone of the LGBTQ community?

• I would say treat every human being equitably. That’s important. And I guess the difference between equally and equitably is recognizing that some of our patients need different things to get the same care but with compassion and being non judgmental. Also, having a bit of an additional understanding about the health disparities that LGBTQ people face can be helpful in guiding those interactions. But also, recognizing that those disparities are not rooted in their sexual orientation or their gender identity. It is likely rooted in decades of stigma and discrimination in the healthcare system. So it is kind of our responsibility to own that, acknowledge it, and then do what we can to create an inclusive and safe space for LGBTQ people to come and receive care. Once you establish that safe space, provide them with excellent and passionate care you would with anybody.

4. What issues do you think people of this community face because of their gender or sexual orientation?

• Probably similar to what I talked about in the last question. Still, there is quite a bit of stigma and discrimination when it comes to gender and sexual orientation minorities. In fact, we see that in lots of studies, the rates of things like trauma that likely fuel the higher rates of depression and anxiety in people that identify as lesbian or gay or transgender and gender diverse are much higher than heterosexual or cis gendered people. Well, we are taking steps in the direction of creating a safer space to live your life authentically. Part of that has been met with that counter to it which still means that stigma and discrimination exist.

5. Do you think the medical community has improved with addressing the issue of pronouns?

• I’m not sure… you know that would probably be... the best person to answer that would be somebody who is transgender and gender diverse to see what their experience has been like, navigating the healthcare system recently. But what I can tell you is that this has been a topic that has come up so much more now in my medical career than I ever heard it before. And somebody who is passionate for advocating in this area as an ally was kind of attuned to that...but I didn’t hear it at times where our AMSA group was going and saying, “hey, we need to learn this stuff,” but now medical schools, education committees are taking the time and putting in the energy and effort to make sure that is being put as part of the medical curriculum which means that’s going to trickle down to the trainees and ultimately the faculty. So, I suspect it was better than before, but I think it will just continue to improve.

6. How do you think a physician should communicate with a patient to talk about gender or sexual orientation?

• Probably an important point to say here is that we need to make sure we have a good understanding of what sex and gender is and that’s often times where we’ll start when we’re talking about education for medical school, trainees, residence, all of us. Sex is a biologic variable, so every one of our cells has a sex, typically XX XY but there are varieties of that, and gender is a social construct. When we think about the larger LGBT or sex and gender there’s four criteria. Sex assigned at birth, so whatever usually it’s kinda the anatomy that you’re born with, y’know you’re born and your doctor says oh it’s a girl and that’s what recorded on your birth certificate. Gender expression, so that’s what you wear and how you present yourself, that can be feminine or masculine. The example I often give is that when I grew up I was a tomboy so I dressed more masculine with big baggy shorts and such although my sex assigned at birth was female and my gender identity was female but gender expression was different. The third is gender identity and of these three that’s probably the most important; that’s the internal sense of your gender; what you are: male or female. And then there’s sexual orientation, so who you’re attracted to or who you love. I think historically we’ve thought about most of these as a dichotomy or binary — either you’re male or female either you’re gay or you’re straight or masculine or feminine. But as we understand them more we realize that all of them work on a spectrum that really evolves over time, so people when they’re five may have a different gender expression, gender identity, or sexual orientation that evolves as we go through our lives. And the other important thing is that you can’t assume one based on the other. For example if someone dresses feminine that they’re heterosexual or that their gender identity is male and they dress this way that you can assume they’re this. All of these are separate things and that’s a really important point for physicians or medical practitioners when they’re approaching patients, is not to assume based on one thing that you’re seeing about something else about that person’s life. In an open non judgmental way just asking about that. Maybe it goes something like, “Hey I’m Dr. Kling. I use she/her pronouns. Tell me about yourself. How do you prefer I address you?” Something like that where it creates that space where people can share their authentic selves.

7. What is your favorite thing about your job?

• There’s so many fantastic things about my job and as young women going into medicine I hope you’ll consider going into leadership as well. That’s one of the hugest honors and privileges in my current job is that I do get to help lead our team in women’s health and work with our department in medicine to make sure we’re providing the most equitable inclusive space. Having that role and that trust from your colleagues and your institution, and such a fantastic institution like Mayo Clinic, is such an honor. When we look at the amount of female leaders we still have a lot of work to do. I know you’re asking about my favorites but what I’ve learned from all the mentors ahead of me is the importance of all of us coming up together so I’d encourage you to do that too. But of course my patient care — I went into medicine wanting to be the advocate for my patients and, I’m going to say this word probably way too much, but it truly is a huge privilege for somebody to trust you with their lives and the most intimate details of their life and I just feel so grateful to my patients that they do that and I take that very seriously. I want to do the best by them so that provides a huge sense of honor and pride and is certainly one of my favorite things. And then the other is doing research, especially in the areas of my clinical research focus like menopause and sexual health. These are areas that we still have a lot of unanswered questions, so being able to look at the science and using my science training to attempt to answer questions that will then trickle down to that ability to advocate for our patients in the exam room, to say “I do have a better idea of why you’re having those menopausal symptoms or sexual dysfunction. Let’s figure it out together. Here’s this new research finding.” And lastly I love that I have profession that gives me so much pride and joy and allows me to be a great example for my family. I have a seven year old daughter and an eleven year old son and I love being able to share that with them.

8. Can you tell us a little bit about your research into menopause and sexual health?

• So, I guess we have done a couple of different things. One of the really fantastic things about our division is that we have a clinical database that we have been able to build along with our colleagues in Rochester and Florida called the Dreams Database. It is the data registry on experiencing aging menopause and sexuality. Any consults that we see from menopause or sexual health complete validated questionnaires about menopause symptoms, sexual dysfunction, quality of life, relationship status faction, and sleep issues. And all of that goes into the database and then as we identify trends or the scientific hypotheses that we want to look at; we are able to go to that database and evaluate observational data, but we can look if there is an association between outcomes. The most recent one that we published was on the associations of sleep and sexual function, and we found women that had poorer sleep quality had higher odds of sexual dysfunction. We were able to control for a lot of different variables or different diseases or disorders that explain either poor sleep quality or sexual dysfunction. So even accounting for those, we see a relationship which tells me as a doctor that if a patient comes in with sexual dysfunction then I should be asking about her sleep and trying to figure out ways to help her through her sleep as well. This goes into kind of the bigger picture that our whole body is connected and one thing contributes to another, and providing whole person care is so important. I guess that demonstrates that utilizing that database or research infrastructure can also kind of translate straight to the clinic to help provide better care to our patients.

9. Can you share an interesting experience you have had with a patient?

• I think in medicine what happens is many of us get our patient caught in our head, especially those that had a bad outcome. And so that’s a lot of the patients that come to mind when I think about that. Many of those are patients that I’ve continued to take care of and are doing very well, some are not. Maybe instead of a specific patient example I can share with you the perspective of doing ongoing primary care, which is different sometimes than subspecialists. But I am able to build relationships with patients over time, which is not only personally satisfying and I think helps really build that trusting rapport and relationship with a patient, but also is able to inform your clinical decision making. I know some of my patients better than I probably know my parents! You just know every single thing that has happened in their life; I can remember the medication, where I was, where they were, when we prescribed that medication. If they call you and say, “Hey Dr. Kling, I’m not feeling well,” that patient is not feeling well; I need to see them tomorrow. It’s really fantastic to be able to have that relationship with patients and doing ongoing primary care. One of my patients I took care of when I was a resident here at Mayo and then she and her husband followed me into my practice so I’ve been caring for them probably for over ten years. And they’re the only patients I have, well there may be a few more but the most memorable, that call me by my first name, and they don’t even call me by my right first name. I go by Jewel and they call me Julie, and they have this really thick New Jersey accent that I can just hear in my head. But it’s great! I think they talk about me at their dinner table because we’ve all been together for so long.

10. How did COVID impact your work experience?

• Covid impacted things pretty significantly. When I was going through medical training I never once thought I would be teleworking for my job, and there were many days where I did most of my patient care from home. We’re still doing some of that, which I think is really exciting, and as a working mom it’s lovely to have some opportunities to look at work life integration or balance strategies. We’ve been able to implement that into our group here at women’s health, which is all working moms so we all are attempting to figure out that work-life balance. Others got called in the hospital to work and I hadn’t been in a hospital for seven or eight years since my medical training finished so it really empowered me and taught me I’m capable maybe of more than I thought having gotten very comfortable in the outpatient space and I also gained a deep, deep profound respect for all the frontline people that have been working in the hospital all during covid, especially the nurses that were not only serving as nurses but confidants and friends and those people that were there at people’s last moment when their family couldn’t be there because of covid restrictions. That not only from a work perspective impacted me, but from a personal perspective also certainly did.

11. Can you share any tips for people who are interested in going into your medical field?

• If it's specifically women's health internal medicine, that's a fairly niche kinda area. In fact women's health internal medicine is not an accredited subspecialty of internal medicine like for example cardiology or rheumatology. Many of us that do this work have sought out additional training or certification like the North American Menopause Society, menopause practitioner, which is a certification that you get. But I think it's a fantastic field and if you're somebody that may be interested in internal medicine, which is the field where you get to take care of adults from eighteen till whenever... till death I guess, that taking care of women in particular that are having complex medical issues that likely have some intersection or overlap with their reproductive hormones or menopause transition or perimenopause. There's just so much going on and so much we can do to help our patients as well as so much that we don’t know that we need to learn to be able to help our patients. So if those things interest you then I certainly encourage you to go down the path of women’s health internal medicine. But I think speaking more broadly to young women like yourself that are interested in medicine I would say stay the course. We need strong, smart women in medicine, particularly in leadership, and so I hope you hear that not just from me but many people along your medicine journey and just keep persevering and when you feel like you’re up against a barrier that you look around at other people don't have that barrier find somebody to talk to or somebody ahead of you that can sponsor you and help break that down. It’s not always easy, but there's more and more of us that are here to support each other — to raise us up. All of us in medicine, regardless of if we identify or self identify as leaders, are leaders. We’re looked on from our community and from our family members and so taking that responsibility seriously and doing all you can to train yourself and such. I think that’s really the gist. Please just stay the course — we need you in medicine.