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Customizing the Clinical Trunk: How I Engaged with Underserved Communities During My Clinical Clerkships

From the moment I decided to apply to medical school, I knew that I was interested in working with underserved populations. As someone from a low-income background myself and from working with many underserved populations through volunteering and working in Chicago where I did undergrad, I saw the immense need for dedicated healthcare providers in these communities.

When interviewing at Michigan, I looked for the opportunities to work with these communities, as I did in all of my medical school interviews, and remember students discussing various ways they worked with diverse and underserved populations. From opportunities such as volunteering at the Student-Run Free Clinic or completing my emergency medicine rotation in Detroit during the Branches, I was excited about the various options Michigan gave to create a path in medical school that aligned with my passions. Despite this excitement, I was also worried that a core of my clinical learning, the clinical trunk or M2 year, would lack the opportunity to work with underserved populations as most of the clinical year is completed at the University of Michigan Hospital. While the University of Michigan sees patients from all over the state and even the country, it is no secret that a lot of patients in the Ann Arbor area are more affluent than surrounding cities and have access to excellent health care that not everyone in the country is afforded. I knew that I would receive a great education, but would I be able to help the underserved like I wanted to? It turns out the answer is yes.

M2s Kyle Wickham and Taylor Morgan at the orientation for the Hamilton Community Health Network rotation.

One of my first clinical clerkships was Family Medicine where I worked at the Ypsilanti Health Center. Ypsilanti is a town just southeast of Ann Arbor and is home to some of the best food I’ve found in the area (check out Lan City and La Torre, you won’t regret it). I chose this location not only for the food, but also to begin to see patients from populations I eventually wanted to work with in my career. During this month, I worked with patients who could not afford medication to control their diabetes, who didn’t want to go to the emergency room despite our suggestion due to the associated cost, who was in the process of getting deported and had to leave their entire family behind, and many others with circumstances and experiences that were novel to my in medical career. I found that many of my appointments weren’t simply focused on diagnosing a condition and coming up with a plan to fix this medical problem, but rather having to discuss their life circumstances and put their health in the context of their overall life in order to come up with viable options that I might not have ever thought about with patients not in their position.

In addition to working in Ypsilanti, the Family Medicine clerkship also offers excursion days where you can work at various clinics or sites for a day to see different aspects of family medicine. These experiences ranged from doing home visits to working in a sports medicine clinic, but the one that interested me was the Corner Health Center, which is a clinic that provides free services to patients aged 12-25 that range from general health care, obstetric and newborn care, mental health, support services, and more. While I only spent one morning working at this clinic, I was excited to be able to participate in an organization that provided such necessary services and was working to improve the overall health of young people.

The last experience I had during my clinical year working with populations outside of Ann Arbor was during my outpatient month of Internal Medicine. During this month, students are typically assigned to specialty and general internal medicine clinics that they work at once a week; however, there is an option for students that are interested to request to work at a clinic that primarily works with underserved populations. As you can probably guess by now, I requested to work at one of these clinics and was assigned to Hamilton Community Health Network in Flint, MI. Hamilton Community Health Network is a Federally Qualified Health Center (FQHC), which means they receive money from the government to cover health care-associated costs for those who cannot pay and also see lots of patients with government insurance, such as Medicare and Medicaid. Their mission is to provide care for low-income patients, regardless of their insurance or ability to pay. In addition to general health care, the clinic I worked in included in- office dentistry, pharmacy, x-ray, blood labs, and subspecialty services from the University of Michigan such as urology and ob/gyn that saw patients weekly. Many of the patients I saw were unable to drive themselves or afford public transportation and needed to utilize transportation from their insurance to come to the office. With physical and/or financial restrictions, it was important for them to be able to see the doctor, get their labs, and pick up their prescription all in the same day at the same place or else they would not be able to. I saw how seemingly small things such as coming to a return appointment, which normally I would suggest to a patient without hesitation, were major barriers to the health care these patients received. This experience allowed me to see everything we take for granted in a well-resourced health care system and gave me experience working in an environment where all aspects of the patient’s life must be considered.

Reflecting on my clinical year, I am grateful for the opportunities I was given to work with populations that I care so much about. These experiences were among the most impactful I have had this year and have taught me important lessons that will make me a better doctor. While not everyone has the same experiences as me, I saw that you are able to tailor your clinical year to your interests and can see patients from different backgrounds than those at Michigan Medicine. As I enter the Branches, I am excited to continue to incorporate these experiences into my medical school career, and I have already scheduled a month to return to the Corner Health Center for an adolescent medicine rotation! While the Branches are a great place to explore your interests and passions, know that the clinical trunk has lots of flexibility and many unique opportunities to work with patients from many backgrounds.

Welcome to the Branches: An Intro to the M3/M4 Curriculum at Michigan

The trunks on most trees can look fairly similar. But the leaves on the branches can look quite different (like our curriculum)! Photo taken outside Taubman Health Sciences Library.

“Just wait until you get to the Branches!” I had heard some variation of this statement throughout my first two years of medical school whenever conversations about curricular flexibility came up. After finishing clerkship year and USMLE Step 1, my class entered into the “Branches” of the curriculum. As a brief primer, the University of Michigan Medical School divides the curriculum into two parts, the “Trunk” and the “Branches”. The Trunk is broken up into the pre-clinical and clinical trunks, which encompass the first two years of medical school at the University of Michigan. The Branches, the third and fourth years of medical school, is the 17-18-month period leading up to graduation that offers the freedom to explore future career choices and develop personal interests.

Admittedly, when I first heard about the Branches when I was as a pre-clinical “Trunk” student, the concept felt elusive, as our house counselors had told us that our experience would be what we chose to make of it. At baseline, we choose one of four possible Branch pathways, each offering a specific focus into patient care (Patients and Populations, Procedure-Based Care, Diagnostics and Therapeutics, or Systems and Hospital-Based Care) and establish relationships with advisors, both in our Branch and in our future specialty of choice (faculty career advisors). As part of our graduation requirements, we also must complete several rotations during the Branches, including at least four graded clinical electives, an ICU rotation, a sub-internship, and an EM rotation with protected time for residency interviews, a residency prep course, and vacation.

What I hadn’t realized as an M1 student was that as Branches students we would have a broad spectrum and diversity of opportunities at our fingertips, as long as we wanted to pursue them. We are encouraged to explore fields and interests that we may have a low likelihood of experiencing through residency that can help deepen previous interests or layer other interests to diversify and offer breadth to our personal studies. There are clinical electives from across 20+ departments — see a taste of what’s available below. Other more niche elective options include Wilderness Medicine, Comparative Medicine, Street Medicine, Disability Health, Visual Arts in Medicine, Medical Communication through Wikipedia, and more.

  • Consult Service (Adult or Pediatric, 20+ services including cardiology, infectious diseases, and allergy)
  • Anesthesia electives (Adult or Pediatric)
  • Clinical Ethics Service
  • Family Medicine in Japan
  • Sleep Medicine
  • Reproductive Endocrinology and Infertility
  • Forensic Psychiatry
  • Addiction Treatment Services
  • Nuclear Medicine
  • Interventional Radiology
  • And…

The Branches offer significant time before working on residency applications to define and solidify future planning as well. For those who remain uncertain about their eventual field of choice, the Branches offer two week “exploratory” electives for students to learn more about fields that they hadn’t had previous exposure to, such as radiation oncology, dermatology, physical medicine and rehabilitation, anesthesiology, and sub-specialty surgical fields (orthopedics, ophthalmology, plastics, otolaryngology, neurosurgery, etc.). These electives are different from sub-internships (sub-Is), which are clinical rotations where the medical student is given the responsibilities and expectations to perform at the level of a first-year resident. A sub-I can be done on a variety of different services in a multitude of specialties.

There are many opportunities for creativity in the Branches as well. If a particular elective doesn’t exist, you can create your own individually arranged clinical elective (or INDARR as we affectionately call it). I have had peers create self-driven courses with topics such as cardiac electrophysiology, the intersection of transplant medicine and surgery, and narrative medicine (complete with a book reading list!). We can dedicate time and resources to work on research and our Capstone for Impact projects, our passion project intended to create a positive impact within health care. If there is a faculty physician we want to clinically learn from, we can arrange a longitudinal apprenticeship in which the student will go to the attending’s clinic on a weekly basis. During the months leading up to ERAS submission, some students will schedule clinical rotations at a different institution (“away rotations”) with the aim of experiencing a different institutional culture or eventually ending up there for residency.

As one example of the thousands of available permutations, my Branches schedule (listed below) has been focused on developing the perspective and skills to be a good general surgeon as well as revisiting my previous experience in health care finance and administration. However, this course I’ve charted for myself looks starkly different from my friend’s path (listed below mine), who is deciding between internal medicine and emergency medicine, with the final goal of critical care. If it’s not already obvious, some of the difficulty of broadly advising for the Branches is that your path forward is truly based on your own personal interests and future aspirations.

“Flight Paths” by Steve Waldeck, a 450-foot multisensory walk through a simulated Georgia forest, with a sculptural tree canopy that filters layers of light, surrounded by sounds and animation of local wildlife. Photo taken at Atlanta International Airport on my way home from Academic Surgical Congress (February, 2020).

My Branches path:

  • Strategic Management for Physicians
  • Anesthesia Clinical Elective
  • Sub-I in Endocrine and Minimally Invasive Surgeries
  • Surgical ICU Rotation
  • Palliative Care Elective
  • “Problem-Based Scientific Inquiry” (PBSI) Course
  • Online Opioids Elective
  • Research Elective

My friend’s Branches path:

  • Anesthesia Clinical Elective
  • Online Pediatric Injury Prevention Course
  • Orthopedic Surgery Consult
  • Medicine ICU rotation at St. Joe’s
  • Emergency Medicine (EM) Rotation
  • Sub-I in the IM Hospitalist Service
  • EM away rotation at Henry Ford
  • Apprenticeship with a pulmonary critical care physician

As my class enters the residency application season, the Branches have offered a wonderful period to prepare and propel us towards defining the careers we envision. We have the ability to draft the narrative we want as long as we’re willing to imagine it.

You can find more information about the Branches here.

Pride in Practice: Enhancing LGBTQIA+ Health Education at Michigan Medical School

LGBTQIA+ people face a number of challenges in everyday life, including many health disparities. On average, LGBTQIA+ persons have higher rates of many chronic diseases and poor physical and mental health compared to cisgender and/or straight people. In addition, micro and macro aggressions when seeing a doctor are all too common for LGBTQIA+ people, whether that be in the form of non-inclusive intake forms or insensitive history taking or physical exams by physicians. When we started medical school as new M1s, and as members of the LGBTQIA+ community ourselves, we were acutely aware of this fact and were resolved to learn more about these health disparities from our patients and our curriculum, as well as seek and create methods to combat them.

Hannah Glick (left) and Anuj Patel (right) are leading the effort to create the first ever LGBTQIA+ Health elective at the University of Michigan Medical School.

In our M1 year, both of us were immensely grateful to have had the opportunity to serve on the leadership team for OutMD, our LGBTQIA+ medical student group at the University of Michigan. OutMD provided us a community of like-minded, queer medical students who were passionate about LGBTQIA+ health. Through our gatherings and monthly lunch talks, OutMD allowed us to learn about a number of topics in LGBTQIA+ health, including transgender hormonal care, LGBTQIA+ health policy, and primary care.

 As medical students at the University of Michigan, we have a unique ability to incorporate our passions, like LGBTQIA+ health, into our education through curricular and extracurricular activities. However, while we were able to easily organize learning about these important topics extracurricularly, we felt that there was not nearly enough LGBTQIA+ health education embedded within our medical school curriculum.

 As part of a collaboration with Dr. Dustin Nowaskie at IU School of Medicine and OutCare Health, we conducted a research project on LGBTQIA+ health medical education where we learned that medical students may need as many as 35 hours of curricular education in order to ensure high levels of LGBTQIA+ cultural humility in patient care. Michigan medical students were receiving far fewer hours than this benchmark. Driven by this gap, we aimed to create a new LGBTQIA+ Health elective for our medical curriculum as our Capstone For Impact project: a unique part of our curriculum which encourages students to reflect on their interests and passions, and to determine a project which results in a positive impact upon health, health care, and/or health systems.

In the Branches (as third- and fourth-year students) we are allotted ample flexibility to schedule a variety of clinical and non-clinical electives for in-person and online formats. Knowing this, we set a goal to create a new two-week, fully online Introduction to LGBTQIA+ Health elective for students to participate in during their third and fourth years. While creation of our curriculum is just getting underway, we have already received tons of support! We are lucky to be surrounded by brilliant faculty like our Capstone Advisor, Dr. Julie Blaszczak who is a member of the Family Medicine Department and an expert in LGBTQIA+ Health. She has been instrumental in supporting us to get this project off the ground. With the timeline we have in place, we are hoping to start offering this course to students in the Branches by 2022.

Our hope is that this new course will offer our fellow medical students a broad, comprehensive introduction to LGBTQIA+ health care. We plan to include a number of modules in our course that will cover basic background, language, and definitions, relevant history and policy, health disparities, clinical skills, and specialty topics in the care of LGBTQIA+ patients with input from faculty in primary care, psychiatry, pediatrics, Ob/Gyn, urology, plastic surgery, ENT, and dermatology. We plan to incorporate a number of different learning media including graphics, recorded presentations from content experts, news and research articles, and other existing resources.

We are incredibly excited and grateful to have the time and the support to incorporate our passion for LGBTQIA+ health into the curriculum at UMMS. We feel that this elective will leave an important and lasting impact on the UMMS curriculum and is a critical step in creating a new generation of LGBTQIA+ sensitive and competent physicians. Happy Pride!!

The Show Must Go On

The show must go on.

I am told this cliché holds special weight for those who have spent significant time working in the theater, but I wouldn’t know. I was never a “theater person.” I had never acted, sung on stage, or produced any sort of production before coming to medical school. I never would have guessed that as an M4 I would find myself as one of the five people in charge of the massive production that is the Smoker.

The 2021 Smoker Czars standing in an empty Lydia Mendelssohn Theater looking super fancy.

The Smoker is an annual tradition and an integral part of the fabric of Michigan Medicine. For 103 years, students here have conceived, written, performed, directed, and produced this comedic musical. It is our way of satirizing the life of a medical student, reminding us all that those awkward encounters or difficult days are shared by us all. It is a chance to come together as a community, forget about studying, and share a laugh.

Additionally, the Smoker is how we show our love and gratitude for our educators. Faculty relish the opportunity to be “smoked” and regard it as the highest honor that students can bestow. As an M1, I fondly remember one of our most revered faculty appearing on stage dressed in a green morph suit and rainbow tutu, just days before he would welcome us to the neurology block. The support from the entire Michigan Medicine community (faculty, residents, students) fosters the idea that this place is not merely a hospital, but a family.

Neurologist Dr. Doug Gelb (far right) appearing onstage in the 100th Smoker “Harry Polyp” in 2018.

I found a home in the Smoker as an M1. I found best friends, faculty mentors, and lifelong memories. I knew I had to keep this tradition going and cultivate this same atmosphere for all. I spent the next two shows doing everything I could behind the scenes to help make the show happen, and as a fourth year I was named a Producer Czar (yes, the leaders of the show are arrogant enough to call themselves “czars”).

The cast of the 2020 Smoker, “The Nightmare Before Match Day” at the end of the show.

As I stood on stage for the final curtain call, I had no clue that in two weeks the University and world would be shut down due to the coronavirus. Everything I had ever hoped to bring to the stage was thrown into flux. For a few months, my fellow czars and I did what everyone else did: hoped things would blow over and we could go back to normal. Quickly that became unrealistic, and we knew we could not safely have an in-person musical. But, the show must go on. We knew that after one of the most tumultuous years in recent memory that we needed to give people a chance to laugh. It was then we decided to make the first ever The Smoker: The Movie.

The two Producer Czars for the 2021 Smoker sorting through the Room of Requirement that we refer to as the prop closet.

Making a musical as a medical student with limited theatrical experience is hard enough. Making a feature-length film with no movie making experience in the middle of a global pandemic is insane. Everyone filmed their own individual scenes, sang their individual parts, and danced their dances at home. I learned how to do LEGO stop motion and video editing for a scene in the show. In the end over 1,100 individual video files, 250 audio files, and 350 band tracks were submitted by students (who were still studying, on rotations, interviewing for residency, etc.) and stitched together into a full-length movie. Unlike a normal year when they can see the scenes come together in rehearsal and over Tech Week, the cast had as little insight into what the show would look like as the audience. Yet, they listened to our instructions and trusted our vision for a show–a fairly apt metaphor for medical training, too.

The behind the scenes process of making LEGO stop-motion animation for the 2021 Smoker.

This past Saturday, all of their hard work was realized, and we were finally able to release the 2021 Smoker, titled “Herpules.” I may be biased, but I think Herpules is as good as any other Smoker. Yet, I am proudest that the elements that made me fall in love with the Smoker survived. While the show will be memorable as the first movie version of the Smoker (and hopefully only), it should also be remembered as the year that despite every obstacle, the spirit of the Smoker lived on. Through all the virtual interactions, friendships were made, classes became closer together, faculty were smoked and made accessible to students, and, most importantly, the Smoker family grew. You can’t stop our team.

The Czars of the 2021 Smoker along with the new czars minutes before the release of Herpules.

The show went on. The show will always go on.

The 2021 Smoker, Herpules, is available to watch here. On this website you will also find a virtual program for the show, which contains even more history and insight into what the Smoker is about. Decades of past Smokers are also available to view on the Galens Smoker YouTube page.

SafeMD: Training the next generation of MDs to care for survivors of sexual violence

Content warning: This post will contain discussions of sexual violence and misconduct. We recognize that readers of this post may have experienced sexual violence firsthand and/or have loved ones that are survivors. Supportive listening, help, and resources can be found at RAINN

Our names are Anna, Courtney, and Stephanie, and we are the M1 leads for SafeMD, an organization founded in 2015 to promote an environment in which sexual assault is illuminated, understood, actively combated, and not tolerated. The three of us were deeply involved in sexual assault prevention and awareness prior to medical school and were eager to continue this work during our medical training.

SafeMD members presenting a poster at Health Professions Education day in 2018.

Anna spent her undergraduate years working with the Sexual Assault Prevention and Awareness Center at the University of Michigan and spent her gap year doing research on trauma-informed care. Courtney has an extensive history of engagement with activism to support survivors of sexual violence and spent her gap year working at a domestic violence shelter in rural Michigan. Stephanie has been involved with Title IX advocacy and survivor support and is currently studying applications of trauma-informed care. 

Specifically, we are working to promote an environment in which survivors of sexual violence have access to and are aware of supportive resources in the medical community. We hope to provide future medical professionals with the necessary education to become proficient in caring for patients who have experienced trauma with nuance, skill, and empathy. To accomplish these goals, the founders of SafeMD in 2015 developed the initial projects of the organization: Allyhood Training and the Launch (M1 orientation) presentation. 

SafeMD founder Seth Klapman presenting at the AAMC conference in 2016.

Since 2015, the role of SafeMD has evolved and expanded to fill identified gaps in the curriculum. For example, during this year’s M1 sequence on reproductive sciences, SafeMD invited a sexual health educator at the University of Michigan’s University Health Service (Laura McAndrew, MPH, PMP) to present on the origins and implications of sexually transmitted infection stigma, its impact on sexuality, and how to provide affirming care that increases treatment engagement and reduces inequities.

During February, Teen Dating Violence Awareness Month, SafeMD held a virtual journal club to raise awareness about the causes and consequences of adolescent dating violence. Additionally, because the M1 didactic session on intimate partner violence (IPV) in healthcare settings was asynchronous this year due to COVID-19, SafeMD hosted a live, interactive virtual session with the intimate partner violence (IPV) Doctoring content lead (Dr. Vijay Singh) to provide information on how healthcare providers can identify and respond to IPV. 

SafeMD executive board members hosted a virtual journal club in February 2021 for Teen Dating Violence Awareness Month.

SafeMD has also developed a trauma-informed care workshop for medical students. Trauma-informed care in the healthcare field is an approach that assumes that a patient is more likely than not to have a history of trauma, and advocates for the promotion of a safe, transparent, and empowering patient-provider relationship. This interactive workshop, designed by current SafeMD executive board member Isabel Lott and former member Petrina LaFaire, was designed to provide medical students with an understanding of the principles of trauma-informed care and the importance of IPV screening, as well as give students a chance to gain confidence in effectively treating and communicating with a patient who has a history of IPV.

SafeMD Allyhood Training in 2017.

As SafeMD continually strives to maximize our impact on the Medical School community, we have incorporated self-analysis of training efficacy into the workshop by deploying a pre-post retrospective questionnaire to elicit feedback on the strengths and weaknesses of the intervention. We were able to analyze our data from Allyhood Training and present a poster at Health Professions Education Day. Furthermore, SafeMD also works with the Medical School’s Student Diversity Council to ensure that the curriculum is reflective of the fact that physicians across all fields of medicine will care for survivors of sexual violence during their careers.

April is Sexual Assault Awareness Month, and the SafeMD team has been busy! At the beginning of the month, we hosted a lunch talk from Dr. Tim Johnson, who discussed his work on the National Academies of Sciences, Engineering, and Medicine committee studying sexual harassment within academia. We also participated in Ann Arbor’s virtual Take Back the Night rally, and are providing free copies of Jennifer Hirsch and Shamus Khan’s book, Sexual Citizens, to medical students who would like to participate in a book club. Additionally, we are collecting messages of support for survivors of sexual violence throughout the month and will be organizing these into an art piece to be displayed long-term in Von Voigtlander Women’s Hospital.

If you’re interested in SafeMD, be sure to follow us on Twitter @UMichSafeMD and visit our website https://sites.google.com/umich.edu/safemd/!

Sketching Out a New Visual Arts in Medicine Elective at Michigan

What role do the arts play in medicine? When we first started medical school at the University of Michigan, neither of us could imagine that the arts would play a significant role during our four years here. We both came from undergraduate institutions with science-focused degrees, where art had been a hobby rather than an academic interest. However, over the last four years we have discovered a vibrant art and humanities scene that exists here at UMMS. Within it, we have found a community that seeks to bridge the gap between the arts and humanities and medicine. Now as we finish our last weeks of medical school, we can both agree that our exploration of this intersection has been a defining experience in our paths to becoming physicians.

At UMMS, we’re fortunate to have a robust Medical Arts Program that aims to help trainees provide more humanistic care through the study and reflection of the arts. This, and other programs like it in medical schools across the country are supported by increasing research that shows the benefits of art and the humanities in fostering important clinical skills. The Medical Arts Program at UMMS hosts a variety of extracurricular programs that include trips to local museums, musical performances, and opportunities for students to create their own art while reflecting on their experiences in healthcare. However, within the Medical Arts program, we thought there was space for more curricular medical humanities opportunities; this was the foundation behind our idea to create a formal elective experience for medical students at UMMS that similarly focuses on bridging the intersection between medicine and the arts: an elective called ‘Visual Arts in Medicine.’

Once this idea was born, we started with a needs assessment to look at the interest for a visual arts in medicine course amongst our peers. What we found was that many students felt that there was room for more curricular opportunities centered around the medical humanities. Once we knew a demand existed, we delved deeper into the literature and were excited to find that visual arts courses already existed at several medical schools across the country including Columbia, Harvard, Baylor, and more. Many of these courses focused on the connection between the visual arts and improving student’s objective observational skills used in clinical practice. However, when considering the breadth of our course, we decided that instead of covering one specific aspect of the medical arts in depth, we wanted our course to explore a broad number of ways in which art and medicine intersect. Our hope is to spotlight a wide variety of topics in this field and to spark an interest that may drive students to further embrace and explore the medical arts and humanities.

Our course is a two-week elective that will be piloted this month. It consists of 10 sessions, each focusing on a different aspect of art and the ways in which they can help us grow and develop as physicians. Sessions cover a wide range of topics from ‘graphic medicine’ and ‘art therapy’ to ‘plagues and pandemics in art’. Our course is sponsored by the Medical Arts Program, and we are supported by its incredible faculty leadership including Dr. Joel Howell and Dr. Lona Mody. Through designing this course, we have also been able to connect with an interdisciplinary group of individuals across the University of Michigan including art therapists, physicians, and graphic medicine artists, who do amazing work that intersects both medicine and the arts.

We have learned so much through this whole experience and are excited to see our course kick off. We consider ourselves very fortunate to have connected with such a rich medical arts community within the University of Michigan, and we hope that this course will allow other students to do the same. This whole process has been very empowering for us as students as well. When we decided to pursue this path in order to explore an area that we were passionate about, we were met with wholehearted support and encouragement. We found that as students here at UMMS, we have access to the resources and mentors we need to pursue or create new experiences that reflect our unique interests in medicine.