“Hey, doc,” our new patient said as I walked into the room, grinning at me without teeth. He only wears his teeth to eat peanuts, he explained, but today he had opted for a ham sandwich, so he left the teeth at home. Here in the clinic straight from his logging job, he wore steel-toed boots and layers of heavy clothing, hands covered in dirt. Clarifying that I was a medical student, I asked him if he had any medical concerns. “Oh, not really, just the usual stuff, nothin’ too bad,” he said.
He then disclosed what his “usual stuff” entailed: chest pain, on and off, nearly all day, sometimes so bad it took his breath away. Eyes going black, sometimes one eye, sometimes the other. Pain in his fingers and toes, twice so painful he went to the hospital and ended up with an amputated digit—he wasn’t sure why the amputations occurred, but was glad they didn’t need to take off a thumb. Smoking since adolescence, now racking up more than a hundred pack-years. Waking up soaked in sweat most nights, and weighing just above a hundred pounds, even with those heavy boots and layers.
“But generally, things are goin’ good!” he said cheerfully. He explained that he hadn’t seen a doctor in years, but came in today to double check that there wasn’t any chance he could end up with a heart attack.
I left the room and frantically relayed this list of problems to my preceptor. She listened patiently and asked what I wanted to do. A flurry of medications, diagnostic tests, and lifestyle changes stormed my mind, turning it into a white-out. “Umm…” I stammered. There was so much to do, I couldn’t slow down my racing thoughts enough to name a single individual action item. “First step,” she filled in, “is saving his life by giving him clear instructions on when to go to the emergency room. Can he read?”
Hello from Cadillac, Michigan, where I have been rotating at a federally-qualified health center for the past month. The clinic, called Family Health Care, uses a sliding fee scale to accept all patients, regardless of insurance status. I chose this elective because I wanted to gain more exposure to rural health care and health disparities. In my clinical rotations in Ann Arbor, I’ve gotten great training in high-resource and primarily inpatient settings, but before this month, I hadn’t yet experienced health care in a lower-resource or a more rural setting.
Having grown up in Iowa and Utah, and going to college in Western Massachusetts, I cherish the sense of peace that I feel in rural places. And as a former anthropology major and grassroots organizer, the social and environmental contexts of health are what drew me to medicine. So when an amazing med-peds attending from one of my U of M inpatient teams said she was moving to northern Michigan to work at a rural clinic for underserved patients, and asked if anyone wanted to tag along, I jumped at the opportunity.
It has been an incredible experience! Here are three key highlights of what I’ve learned:
First, this rotation has helped me to realize that, despite my strong intentions to keep the social contexts of disease at the forefront of my approach to patients, as a medical student I’ve inadvertently gotten wrapped up in the pathophysiology and treatment of disease. Learning the intricacies of the human body over these past three years has been fascinating, challenging and all-consuming. That scientific and clinical foundation is critical for becoming an excellent doctor. But it is not sufficient.
This month has been a wake-up call, bringing me back out into the broader picture again of the social contexts of disease. For example, there’s no point in recommending a high-fiber diet if my patient doesn’t have teeth. There’s no point in orchestrating referrals to far-away specialists if my patient doesn’t have reliable transportation. There’s no point in creating detailed instructions for a meticulous treatment plan if my patient can’t read.
Second, being far from specialty care makes family medicine here feel almost like an entirely different field to me. The U of M family medicine clinics I rotated in come with the privilege of easily referring patients to specialists. Here, such referrals are often last-resort options. There are very few specialists in the area, and many of them do not accept Medicaid or uninsured patients. Transportation to appointments is often challenging. Wait times can be several months or longer. (And for many mental health patients, there simply are no psychiatrists available to see them, ever).
Due to challenges like these, my preceptor needs to do extensive diagnostic sleuthing herself, diving into the literature of fields like rheumatology and hematology far more than she ever needed to at the U of M. This can be scary and stressful when a patient’s symptoms don’t make sense, and there is nobody available to help put the pieces together. But as a student, this has also been an amazing opportunity to stretch my brain, improving my differential diagnosis skills and my comfort with managing complex conditions. Regardless of the setting I end up working in, I hope to carry this detective mentality with me: it is making me a better doctor.
Third, despite that patients’ formidable health and social needs often remain unmet, there is nonetheless a wealth of incredible resources in the Cadillac community. My preceptor facilitated days in which I spent time with people who work in support services, such as Community Mental Health, insurance enrollment, hospice, physical therapy, and the WIC (women, infants and children) program. She has intentionally built connections with these organizations because collaboration and communication improves patient care. I had inadvertently taken this for granted at the U of M, where if you have a question, there is always someone you can call for input, either as a formal consultation or as an informal “curbside” question. Here, there often is nobody to call.
My preceptor’s intentional creation of connections among health providers has made a huge difference in her ability to serve her patients. For example, given the difficulty getting psychiatry appointments, her outreach to Community Mental Health enables her to get input on her patients’ psychiatric conditions; the psychiatrists, in turn, can ask her about their patients’ medical conditions. Likewise, through connecting with people at the WIC program, she can better understand the social contexts of her pediatric and maternal patients, thus enabling her to better address their needs holistically.
As a student, exploring these community resources gave me new windows through which to view patients’ journeys through the health care system. One of the most meaningful parts of medical school for me is the privilege of being with patients in vulnerable moments. Through spending time with people who work in these community support services, often meeting patients in their own homes, I witnessed types of vulnerability that often hide from the white-coat, sterile settings of clinics and hospitals: financial, cultural, spiritual vulnerabilities.
For example, an elderly veteran who proudly worked his whole life only to become ill, lose all financial resources, and end up with nowhere to live and nothing to eat. A teenage Spanish-speaking mother living in an isolated trailer with three children, trying to navigate health care in a new country without transportation or with an unfamiliar language. An impoverished middle-aged man with a deep distrust of the medical system and a home in shambles, diagnosed with incurable lung cancer, facing his imminent mortality as rain poured through his broken roof.
Witnessing these situations has been bleak. Sometimes it has felt impossible to make a difference. But these experiences have also brought me hope, in various shades: People are resilient. Small changes can improve lives, often with effects not immediately apparent. And, as with my preceptor and her colleagues, the people working at the community support services are incredibly motivated to help their community, with a mission-oriented ethos that becomes a powerful emotional buoy.
Overall, I am so grateful for my month with Family Health Care in Cadillac, which has taught me a tremendous amount about both clinical and social aspects of health care. It has rekindled my passion for working in underserved areas, given me a broader view of our health care system, and highlighted the importance of thinking about every patient’s situation holistically. I encourage this rotation for anyone interested in rural health disparities or anyone simply wanting an adventure!
*Details have been changed and omitted to protect patient privacy.
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Hanna is a fourth-year medical student and future pediatrician. She loves mountains, potlucks, and cappuccinos. Preferably all at the same time. Twitter: @hannasaltzman