Delivery of Care

When the profession of medicine is a calling

At 42, having just graduated from med school at Brown, Dr Kelly Skrable brings a wealth of work experiences and maturity to the practice of medicine, as she begins her residency

Photo by Richard Asinof

Dr. Kelly Skrable, M.D., shared her experiences as a older medical school student at Brown.

By Richard Asinof
Posted 4/1/19
Dr. Kelly Skrable, M.D., shares her experiences attending med school at Brown as a single, older student, graduating when she was 42, and the twists and turns in her life and work experiences that brought her to see medicine as a calling.
Besides medicine, what other professions would benefit from having those later in life pursue careers? How important is the mixing practical experience with clinical learning in the profession of medicine? How does the humility to admit your own vulnerabilities become an asset when you become a doctor? Does Brown need to do a better job of seeking out older med school students and, perhaps more importantly, sharing the stories of their success? How important is it to recognize that medicine is a business, even if health care is a right, not a privilege?
Last week, after seven months of trying, I had the opportunity to sit down to talk with the new president of Hampshire College, who, in response to a perceived financial crisis of survival, has been pursuing a strategy of merger with another academic institution and, at the same time, deciding not to admit a new entering class in 2019, throwing the college, its students, its faculty, its staff and its alums into turmoil.
I had first reached out to the new president, in September of 2018, when she assumed her role as president, in response to her asking to engage with alums, sending her an essay about the value of a Hampshire College education, written as a member of the first entering class in 1970.
In the essay, written in 2015, following the 45th reunion, I had focused on a quartet of four unlikely conversations that defined, in large part, the contours of my education: with John D. Rockefeller III, with Charles Mingus, with John Updike, and, indirectly, with Anais Nin. For whatever reason, the essay was apparently not shared with her until January of 2019. Yet I still received regular fundraising appeals.
My message delivered in person last week to the president was that the value of my education was not to be measured in achieved status, fame, fortune or success that could be harvested by Hampshire as a way of selling the college. How many advanced degrees, how many NIH grants received, how many Oscars won.
Rather, it was in learning how not to expect someone to figure things out for you; when you became stuck, instead of moaning about it, you needed to find a way to make things work. It was about learning to believe in yourself, and your abilities; recognizing that in order to learn how to nurture the world you first had to learn how to nurture yourself, in order to find a place where you belonged. My greatest accomplishment? Seeking to be a good parent and a good neighbor.
I explained to her, in the politest manner possible, that many former Hampshire graduates, like myself, felt they had been left out of the conversation; the only outreach had been regular attempts to mine them for money. Unless you had lots of cash, status or prestige, it was an unrequited relationship.
The president said, in response to my willingness to speak with her: You do care, don’t you? I responded: I wasn’t sure; as much as I valued my education at Hampshire, it was not healthy to pursue an unrequited relationship, to be thrown into rescue mode. Yes, I wanted to speak out and be heard, to make the effort to talk with her directly, but I had no expectations beyond that.
The conversation was my way of letting go; the story of Hampshire College would go its own way.


PROVIDENCE – It could have been the bright sunlight on a dazzling spring day. But last week, when the newly minted Dr. Kelly Skrable, M.D., Brown 2019, entered the small coffee shop and bakery in Wayland Square, the L’Artisan Café, to talk with ConvergenceRI about her experiences as an older student attending medical school, there seemed to be a kind of glow surrounding her: call it an aura of self-confidence; a purpose in her step. [Skrable has completed all her med school requirements; she officially beomes an M.D. when she graduates on May 26,]

Skrable had just finished up after four years at the Alpert Medical School of Brown University and she had matched to be a resident at Brigham & Women’s Hospital in Boston, training in infectious disease.

But, unlike many of her fellow med students, Skrable entered school at age 38 in 2015, having already pursued a successful career and earned an advanced degree – a master’s in Public Health from Johns Hopkins University.

Skrable described her decision to pursue medicine as a career as her calling, as her vocation, as someone who said she thrives doing research, in delivering care, in asking questions. Her story is one where Skrable kept uncovering new paths of learning to pursue, both experiential and academic, on a journey of self-discovery.

Fluent in Spanish, Skrable spent her first five years after college working on the southern border of the U.S., between Texas and Mexico, assisting immigrants and asylum seekers in homeless shelters.

After getting an advanced public health degree, Skrable later spent two and half years living in Africa in Botswana. It was during her stint in Botswana that she met some expatriate doctors who encouraged her to pursue a medical career.

When Skrable spoke, her voice had a sense of humility about all she had accomplished as being part of a continuum of learning in the practice of medicine. Call it maturity.

“Yes, I definitely feel like there are advantages doing medicine later in life,” Skrable explained. “I was 38 when I started med school; I’m 42 now. I think for me, it was easier to put medical school in context, simply because I had a broader context.”

Skrable continued: “I’ve had a lot more life years; I’ve seen a lot of different things at this point [in my life.] I had a lot of family issues happen. I had a lot of life experiences. I’ve traveled a lot because of the previous work I used to do. I lived in Africa for two and a half years.”

As a result, Skrable said, she brought with her a broader perspective, which would have been impossible for her to have if she had just gone straight from being an undergraduate to med school.

“I think as a clinical provider, one of the things that you are required to do is really to establish a rapport with your patients and try to understand as best you can, where their particular medical issues are falling within the context of their lives,” Skrable said.

Having life experiences helps with that, she said. “The other piece is that I’ve had a lot of jobs,” Skrable added, laughing.

The different jobs and diverse life experiences, Skrable said, taught her a valuable life lesson: “You understand that no job is perfect, that there is a grind to everything, that there are a lot of aspects to your work that you are simply not going to like. Or, that you leave to the last minute [things] you don’t like doing, like charting,” adding a peal of laughter.

Recognizing that there is a grind to everything, she explained, doesn’t mean that the profession isn’t right for you. And, it doesn’t mean that you call into question if you should be following this path anymore.

“It’s just that there is a grind to everything,” Skrable said. “And I think I have a much better perspective on that, because I’ve seen that before, I knew what to expect coming in [to med school]. Medicine is a job, just like any other job. I’ve had a lot of jobs.”

Skrable paused, and said: “Was I intimidated? Absolutely!”

Here is the ConvergenceRI interview with Dr. Kelly Skrable, M.D., talking about her experiences entering medical school at the age of 38, and what she learned about herself and her profession in medicine.

ConvergenceRI: Can you describe what it was like to be an older med student at Brown and the ways that you have grown?
SKRABLE:
Let me preface my answer by saying it has been absolutely fantastic. It’s been different than I thought it would be, and a lot better than I thought it would be.

ConvergenceRI: In what ways has it been different and better?
SKRABLE:
I think, coming into medical school, I felt very called to medicine as a career. This is a second career for me. I felt like this was what I should be doing.

I think I expected a lot of the intellectual challenges; I expected the academic stimulation. What I didn’t expect was the degree to which this feels like a vocation for me. The extent to which I feel that this has been a period of intense personal growth, coming into my fullness as a person, if that makes sense. This [experience] integrates all of the best things about all of the work that I have done before.

ConvergenceRI: Can you tell me about that work?
SKRABLE:
I started my career out of college living and working on the border of Texas and Mexico, in a series of homeless shelters.

I did that between my junior and senior years of college at William & Mary, and then I graduated early in December and went back for another six months to be in the shelter system.

At that point I was learning a lot more from that kind of experiential learning than academic learning. Although I loved college; I felt I had learned what I needed to from that environment, and I was being really challenged and stimulated by being in the shelters.

ConvergenceRI: What were the things that stayed with you as part of your experiential learning?
SKRABLE:
I had always had this sense in my life that I wanted to be of service to those that were underserved, to serve “the poorest of the poor,” in a biblical sense, in liberation theology. I did go to Catholic school for 12 years [laughing]. Preferential options for the poor, that really resonated with me.

But I had no idea of how that would manifest in my life. I had no concrete way of saying: I want to do this kind of work.

At that point, all of my life had essentially been in the school, and when I went to the shelters – which incidentally are getting a lot of attention now because of the border issues; the organization I was [working] with has been featured in The New York Times and on NPR, so it does come full circle.

For me, that was the first time that I saw a clear, concrete context, like, I can work in social services, I can work in case management, I can learn Spanish, I can learn about these issues; I can do this. And, so for me, that was why I wanted to go back. Because, I’ve done the book learning, I understood the intellectual aspects as much as possible, now I can see the context, and now I can learn by doing. For me, that was absolutely key, and why I was really drawn to that.

ConvergenceRI: What happened next?
SKRABLE:
From there, I spent six years working in social services and program development for a nonprofit, predominately with immigrants and refugees from Latin America.

ConvergenceRI: In the Southwest?
SKRABLE:
No, I moved back to the D.C. area. Through the work that I was doing, I was getting more and more interested in health, and health systems delivery. I decided to do a masters in Public Health, because I would get a much better academic understanding of these issues. And, I had become very, very interested in understanding more about where the people with whom I was working were coming from, what were their life experiences that were driving them to immigrate, often at great personal and familial cost.

I knew that I really wouldn’t be able to transition to global work unless I had some sort of additional training or degree, because I had never done that work before. So, I got my masters in Public Health from Johns Hopkins University in 2005.

And then I spent the next decade, until 2014, working in global health, as a monitoring and evaluation specialist, for a couple of different NGOs.

ConvergenceRI: And then you decided to go to medical school? Was it a daunting decision?
SKRABLE:
What it takes to get into medical school now is unfathomably difficult.

ConvergenceRI: What do you mean by that?
SKRABLE:
There is an expectation, I think, to come to a medical school, particularly such as Brown, where students, it’s not enough to be a high performer academically, and, to have done well on your MCAT, or maybe have a couple of extra curricular activities.

All of the applicants sort of have that. And then there is expectation [that there will be] other things layered on top of that: that you are a published researcher, or that you have done some sort of global work, or that you have started or founded organizations.

I am constantly impressed and humbled by what my classmates have accomplished in way fewer life years that I have had. When I think about the degree of maturity that many of them have, at their age, versus where I was at that age, I am so impressed.

So, it was very intimidating, on that level, to know how accomplished they were.

The other piece was, I didn’t know how socially I would navigate that [gap]. I finished my MPH in 2005; I started medical school in 2015, so there was 10 years difference.

ConvergenceRI: Was it hard to learn and become adept in electronic health records? Or, was it part of the grind, where you figured out how to make it work for you?
SKRABLE:
I am grateful that I started my medical training within a system that has well-established EHRs. Because, for me, I didn’t know anything different. To me, this is part and parcel of what the work entails.

Training at Brown is interesting because you train at multiple hospitals. Most of which have different electronic medical records.

So, I have learned multiple different versions of Epic, which is a major system. And, at the Providence VA, where I did all my medicine training, which has a completely different system.

ConvergenceRI: Haven’t they recently decided to move to Cerner?
SKRABLE:
As of October of 2018, they have not made that transition. They were still using CPRS.

The Care New England hospitals use Cerner. So I had to learn that. I did [rotations in] Ob-Gyn at Women & Infants and Psych at Butler.

There is a high degree of time that is devoted to charting that could probably be reapportioned to patient care.

But the flip side is that documentation is a key part of the job. Because I worked in social services for so long, I was very used to patient charts. And, you know, in social work, you document all of your interactions with patients and clients.

For me, it was like, I used to do it in Word, and print out my notes, and now, I just do it in this system. That for me was not a huge issue.

ConvergenceRI: Did your professors understand that they had someone, in my words, who was “special,” who was coming into the program with a lot of experience and had values that were different from other students? Did they appreciate who you are?
SKRABLE:
Yes, but I don’t think it was any different than they appreciated the unique characteristics that any med student brings to the table.

Oftentimes, I think, if you put everyone in a white coat and you all stand together as med students, I don’t think anybody initially registers that maybe one of these [students] is not like the other.

The focus of my training was really on the clinical aspects [of medicine]. Occasionally, we would talk a little bit in more detail about what I had done before. Rightly so, the focus is most of my interactions has been on the clinical topic at hand.

I did do a fair amount of research.

ConvergenceRI: What has been the focus of your research?
SKRABLE:
I did a couple of different projects. I did research with an emergency medicine attending physician, who does a lot of global work. I wrote two research papers with him, one on the natural history of Ebola, with an Ebola dataset that he had, because he had led an international medical team.

Because, with this kind of a disease, there is so much we don’t know. You don’t know how long you are going to go between outbreaks.

The kind of opportunity to collect this information and be better prepared the next time was really invaluable. I worked with him during my first and second years of med school on that paper.

He also does a lot of research with diarrheal diseases, so he had a dataset from the International Center for Diarrheal Disease Research from Bangladesh. I did a secondary data analysis with him and we published our paper on that.

And then, my third year happened, and I had no time for research.

And then, this year, he was on a leave of absence having a baby, and so I ended up doing some research with an infectious disease doctor, because I want to go into infectious disease, on C.difficile infections.

ConvergenceRI: Is research something that motivates you?
SKRABLE:
I love research. Absolutely.

I think the degree to which I will focus on that in my career is still a little bit [unknown], I’m not exactly sure how that is going to be distributed time-wise between my clinical responsibilities.

But I absolutely love research and you know, I think at heart, I am a scientist, so I love asking questions and analyzing data – trying to figure out, we’ve got this unanswered question. How do we understand this? How can we set up a system to collect data? How do we analyze those data? How do we use it to make our decisions?

Because there’s so much we don’t know. Also, I find research very humbling. By trying to answer one question, you inevitably come up with five or six or 10 more questions. This is the way the world is; how exciting is that? We will never be able to know all of this; there’s an endless amount of information out there to be learned.

ConvergenceRI: Listening to you, and your effervescence, it that’s the right word, your enthusiasm, seems contagious. Yet, there is research showing that a lot of medical students find themselves not doing what they wanted to do, with a high rate of suicide ideation, because they wanted to help people and they don’t see themselves in a position to do that.

On the flip side, you seem to find pursuing a career in medicine as a source of great empowerment. Can you talk about that sense of empowerment?
SKRABLE:
That’s a great question. I’ve never thought of it that way. But I have certainly had an overwhelmingly positive training experience.

I think, for me, I alluded to earlier, I feel very much a sense of vocation. That this is really what I am called to do. It’s more than a job for me.

ConvergenceRI: Is it a calling?
SKRABLE:
Definitely. I use that language. There is a sense of identity; I will always be very proud and humbled to say that I am a doctor.

ConvergenceRI: Should I call you Dr. Skrable?
SKRABLE:
I am making my family address me as such. [laughter]

My father has a Ph.D. in Economics, and he is like: just remember whom the first doctor Skrable was. [laughter]

To me, it is a sense of identity. And so, this was a kind of identify that I had thought about for many years before I finally got up the nerve to do something about it, if that makes any sense.

The way that I actually got to medical school was through a very bizarre series of random circumstances, when I was living in Botswana, in 2012-2014, I happened to meet a number of physicians, expatriate American physicians who were working in sub-Saharan Africa.

They were the ones who told me, if you are really thinking about medicine, and you feel that you are called to do that, it is not too late. Many of them had done Peace Corps first, or had many years of global health experience before they decided to go to med school.

It was, simultaneously, a very difficult and very easy decision to make, to say: I need to go for this.

And, I had to do all the pre-med requirements, so I did that as a post-doc; I did that at Hopkins as well.

I think that the sense of empowerment came from having no idea whether or not I was capable of doing this, but feeling I had to try. And, then, I had to let go of an expectation of success.

Success meant that I was going to try this. If it meant that I got into medical school, fantastic. If it meant that I did the post-baccalaureate [course work] and I didn’t get to medical school, that was also a success, because I tried.

I thought that I wanted to do something. And I had to let got of a lot of very secure things – a field position, and seven years of seniority with my organization.

So I went and took undergraduate courses for a year in my late 30s.

The fact that all of this happened, and I realized that I was capable of doing this, I think that is where that sense of empowerment comes from.

That I, that I didn’t have that expectation or knowledge that I was able to do that, until I actually started doing that.

ConvergenceRI: I have a feeling, talking with you, that you have been waiting for someone to ask you these questions for a long time.
SKRABLE:
[laughing] It’s totally fine.

ConvergenceRI: As you move forward in your career, do you see yourself becoming a mentor to other people who have found themselves in similar positions?
SKRABLE:
I actually just this morning participated in a conference call with the current post-baccalaureate class of 2019 at Johns Hopkins to talk to those current students about what medical school is like. What questions do you have? What did I wish I knew when I was in their shoes in 2015?

I stay very connected to the post-bac program. I have actually worked as a mentor for MPH students at Hopkins.

Myself and another one of classmates, we did the post-bac together at Hopkins, we always joke, that any time there is a “geriatric” medical school applicant, he and I get the call.

Hey, someone is thinking about going to med school, and they’re 30, do you think you could talk to them?

It’s one of my greatest joys in life, to see other people follow their own paths, and however it ends up for them, to be a person they can come to and talk to, who has done this in a non-traditional point in their lives.

I absolutely love and welcome talking to anybody, at any stage of the education processes, in large part because I have gotten so much from this.

And to see someone experience that same degree of joy in their lives, who had not believed that they would be able to do it. And then get to a point, and say, wait a moment, I just did that.

It’s just phenomenal. So, I definitely see myself staying in academic medicine. And working with learners in a very direct capacity.

ConvergenceRI: You are now going to what might be called the heart of clinical medicine, Harvard and Brigham’s. Is this another dive in the world of unknown that you have some intimidation about? Or, are you now like a fish in water and you know how to swim?
SKRABLE:
I don’t know. I like to say that the only test I ever scored 100 percent on at Brown was the test for Imposter Syndrome?

ConvergenceRI: What is that?
SKRABLE:
Basically, it’s the idea that you really don’t know or believe you are capable of something, and you’ve been able to bluff your way through and you’ve been found out. You always feel like you are an imposter. And, it’s very, very common in medicine.

It’s why Brown openly addressed this concept of imposter syndrome with us, that everybody kind of feels, like we’ve been faking it.

Oh my gosh, I really don’t know how to diagnose that, or I’m going to walk into a room and I don’t even know where to start.

And I think, for me, I have all of those insecurities. Certainly, I’m excited, but I’m scared to death. For somebody to say, you are my primary care physician. Right now, I don’t have that pressure because as a med student, there is always someone immediately above you. And, there will be as a resident. But your identity is not as a student; it is as a doctor, a brand new doctor. So, I’m terrified, I’m absolutely terrified. I don’t know how it is going to go.

I would like to believe that the feedback and training that I’ve gotten here at Brown is sufficient to have gotten me to the next step.

That’s what I trust. I know that I am well trained, I know that I’ve gotten really good feedback to be better from the people who have worked with me here at Brown.

And with that, a good dose of humility, going in, to say that there is a lot that I don’t know, I have to fall back on what I do know. To be very proactive about reading, learning, filling in gaps in my knowledge, and just really actively trying to get experience.

And to take any feedback and incorporate it into my practice, so that I become provider who never takes feedback in a negative way. Hopefully, that attitude will really go far.

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