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Health Policy Beyond Healthcare Policy: Lessons from a Dual Degree

A few weekends ago, I, a medical student interested in ob/gyn and domestic health disparities, was the French representative to the (mock) United Nations at a summit on climate refugees. It was, in a word, unexpected. How had I found myself addressing the UN General Assembly? While the specifics of that January morning are still a bit confusing, it happened because this summer I decided to pursue a dual degree in Public Policy at the University of Michigan Ford School. A bit of an unexpected detour to my medical education.

Last spring, as COVID-19 descended on Ann Arbor, I witnessed the stories of this pandemic. On phone calls to tell patients about the transition to hybrid virtual prenatal care, pregnant patients told me of empty grocery stores, dissolving support networks, and job loss. As the pandemic worsened, it became clear that there was differential impact. Health disparities that had once felt abstract were suddenly in sharp focus and the medical community could not look away.

As a former social worker I am good at identifying problems, and as a medical student I am good at identifying the consequences of those problems. But I didn’t have the tools to address the issues these pregnant patients were facing: a disorganized food distribution network, loss of neighborhood cohesion, an economy in freefall. It was not news that these variables affect health, but what was less clear to me was what I could do about it. Carrying these patient stories, I decided to enroll at the Ford School of Public Policy because, as COVID-19 made clear, health starts outside the hospital.

Every day at Ford, we explore the biggest problems affecting our world. In fact, today alone I discussed optimal public insurance payment levels, affordable housing tax breaks, and privacy rights. I most appreciate the opportunity to go deep into complex problems. Some of my work has clearly been about health: I’ve explored the ethics of cost-benefit analysis of family planning programs, evaluated the ways trade policy affected the domestic supply of medical masks, and examined why the Affordable Care Act did not dissolve when the insurance mandate was nullified. But it isn’t health policy I’m interested in. The primary reason I came to Ford is to understand the scaffolding that supports my patients and shapes their lives. This year, I’ve written policy proposals for unemployment insurance, a campaign plan focused on childcare deserts (“no American family should need to make 1950s choices in a 21st century economy!”), and conducted an analysis of election day operations in Detroit. After all, more generous unemployment insurance keeps workers healthy, safe childcare helps stabilize families, and analyzing elections taught me about how complex systems, like hospitals, succeed and fail.

Complex problems require multi-tiered solutions, and while physicians and social workers are indispensable to any solution, so too are policymakers and community advocates who shape the communities our patients live in. The opportunity to pursue both ends of this continuum has been inspiring.

The Best Teacher

I met Cassie on the first day of my longitudinal “high-risk” obstetrics clinic. Diagnosed with type 2 diabetes, she would require intensive counseling, treatment and monitoring during her pregnancy. Cassie was a big personality with a refreshing honesty and a quick laugh. We immediately hit it off, joking about our shared weakness for French fries. We also explored more weighty subjects like the disproportionate rates of pregnancy complications for Black women in America. On her medical history, though, it was hard to pin her down. Her responses to my questions were contradictory sometimes, a mixture of gaps in her health literacy and obfuscation. People are complicated, I told myself, and trust has to be earned. While it made it more challenging to decide on the initial treatment approach, I chose to let it ride. One thing was clear: She had felt unheard and misunderstood by the medical system for years and wanted the best outcome for her future child. This, I could work with.

In the Branches, the third and fourth years of medical school where students are able to pursue electives and career interests, students can choose to have a longitudinal clinic for 6-12 months. They work with the same provider each week and get the rare opportunity to see the same patients multiple times, build relationships and watch the arc of their medical concerns play out. Thus, in an obstetrics clinic, I have the opportunity to follow a patient through the entirety of their pregnancy. Because the patients have complex medical needs, I can also watch the ways their unique comorbidities affect their experience.

Cassie’s pregnancy went smoothly, however as she progressed her blood sugars became more difficult to manage. She had strongly wanted to avoid insulin, shots a pregnant patient has to give themselves multiple times a day to control their sugars. Insulin administration is uncomfortable, expensive and needs to be given at specific times: it is not an easy treatment. Cassie had been on a pill to control her diabetes before pregnancy, why couldn’t we just keep using that? And why did her sugars get so difficult to manage after weeks of being stable? With these questions in mind, I explored the use of oral diabetes medication during pregnancy for my Patient-Based Scientific Inquiry (PBSI) presentation. In PBSI, students research the basic science behind a clinical question and give a 15-minute presentation. With the help of a pharmacy faculty member, I learned about blood sugar regulation during pregnancy, the mechanism of Cassie’s medication, and the research into its effects on the fetus. While she eventually chose to use insulin, I left with a much stronger understanding of diabetes and its management.

But Cassie didn’t stop teaching me there. Later in her pregnancy, she had concerning symptoms and came to the hospital. There, she had an interaction with staff that upset her so much she left against medical advice. The next week I saw her in clinic. While the symptoms resolved safely, I was concerned because she had numerous risk factors for having pre-eclampsia, a condition that would require immediate delivery. Given her perception of poor care at the last visit, would she present next time she had a concern? Her response was non-committal. The United States has high rates of pregnancy complications and death, and researchers have thus far struggled to entirely understand why. What we do know, however, is that women like Cassie, women of color with multiple comorbidities, experience poor outcomes at disproportionately higher rates than their white peers. As part of my interest in maternal mortality, faculty mentors and I had been exploring ways to improve clinical encounters for patients of color. With Cassie in mind, I turned back to this work, which had begun to flounder under the stresses of COVID, with new energy and focus. Yet again, Cassie had taught me something: an important factor in poor pregnancy outcomes is the extent to which patients are comfortable sharing their concerns.

In June, Cassie delivered. While the birth required emergency surgery, she and her child were safe and healthy when I stopped by the room the next day. In spite of the intensity of the previous 48 hours, and the complete lack of sleep, she was just as funny and ebullient as always. That day, she taught me about resilience. She had had a complex, high-risk pregnancy, and we had made outrageous demands of her: Told her what to eat and how to sleep and to give herself shots twice a day and to come to clinic twice a week for monitoring and to keep working and to take a handful of medications every day and on and on and on. She didn’t do it perfectly, but she did it extremely well and now she and her partner were growing their family. I was so overwhelmed in the room that day: by their happiness, by the near misses, by the intensity of every clinic visit over the previous six months. Cassie had made a (future) doctor out of me: she taught me about prenatal care and diabetes management, and challenged me to think differently, to step back, build trust and ask big questions. They say your best teachers are your patients, and after Cassie, I believe them.

*To protect her privacy, the patient’s name and identifying details were changed.

What becoming a doctor taught me about being a social worker

Like a number of my peers, I am a career changer. Having started in social work, I shifted course four years ago this month, returning to school to complete the dreaded pre-medical sciences. Social work is an amorphous field, one that both the public and practitioners sometimes struggle to define. After all, it seems like they do everything, from individual therapy to foster care case management to public health education. More and more, physicians are also being tasked with “doing everything.” A growing body of research, for example, has linked adverse childhood experiences and other social determinants of health to poor outcomes over the lifetime. Interdisciplinary practice is clearly the linchpin of addressing these intersections, but the field continues to struggle to understand how.

Piloting a sexual health curriculum in rural Rajasthan, India as a social work student.

As a social worker, I thought a lot about how to create change and how to empower others to be thoughtful, value-informed actors in their communities. The sudden transition to studying the basic sciences was, thus, jarring. Whereas in social work I often worked in the liminal space between the rational and irrational (what makes us act the way we act and think the things we think?), the sciences were somehow both rigidly delineated and also impossibly abstract (see Schrödinger’s cat). To my great surprise, however, I began to think like a scientist over time, applying rigid rules to natural phenomenon. Nobody cared about how the molecules felt, only how its electors were distributed. But then medical school happened. Medicine exists somewhere in between these two, which is why it is often described as both a science and an art. While this maxim was originally used to describe how to treat illness when we only had a partial understanding of its mechanism, it is evermore becoming a way to understand the relationship between the physiologic and the social. For example, physicians today are working to understand both the underlying mechanisms of COPD and why people don’t stop smoking. As physicians, we are taught to understand the body rationally: X process leads to Y disease. But the waters become muddied when we factor in human behavior: Why would someone smoke when they know the harms to be so great?

In my previous career I often struggled to describe what I knew how to do. As I’ve embarked on a new process of professional acculturation, however, I’ve begun to realize that my previous training gave me a way of thinking systemically, evaluating how individual experiences relate to the larger sociopolitical processes that shape everyday experiences. This, for instance, can help us understand how an individual opiate addition relates to prescribing patterns, the legal system, economic markets, and public health infrastructure. With my growing knowledge of medicine, however, I’ve been better able to understand the biophysiological processes that underlie both pain and addiction, creating a much richer understanding.

As the interaction between society and health becomes even more clear, medicine and medical education is changing. For example, our Doctoring course helps us to both learn how to listen to the heart and to counsel patients on exercise, and the Paths of Excellence give us an outlet to explore fields such as public policy and the humanities. It was in this spirit that I initiated two projects this summer to help us be better advocates for health. In one, I am working with the Center for Experiential Learning and Assessment to develop a self-reflection module paired to clinical simulation. Physicians are given the tremendous privilege of working with patients on some of the most stressful, emotional and personal aspects of their lives. How we process these situations, and learn from them, is an important professional skill if we are to gain comfort navigating these complex situations. In the other project, I am preparing a study to examine sexual violence amongst gay and bisexual men. Given that life experiences can impact the health of our patients in myriad ways, better understanding their context can lead to tools to identify and address these factors.

As summer draws to a close, I am struck by the tremendous intellectual diversity that defines medicine. From basic scientists to clinical investigators to public health researchers to health care economists, all collaborate to give an understanding of what makes us healthy and what makes us sick. No one discipline can do it alone, but also our collaboration is only as effective as our insight into what we bring to the table.

What I learned from watching a tiny vacuum cleaner

In the last two months, I have been to six surgeries. I have felt warm, viscous, blood course over my gloved hand as I held a retractor during a Cesarean section. I have seen the inside of a man’s abdominal cavity as I held a laparoscopic camera. I have watched as boogers were pulled out of a man’s sinus by a tiny vacuum cleaner. And I don’t even want to be a surgeon.

As a social worker, I often encouraged the teens I worked with to step outside their comfort zone in order to learn more about themselves (and I practiced what I preached, like zip lining!). Medical school shouldn’t be any different.

My journey to medicine began in social work school in Chicago. There, I focused on health disparities and working with teenagers, thinking I would spend my career as a community organizer and health educator. And thus, I was shocked when my advisor connected me with a watchdog group conducting citizen oversight of the Illinois prison system for my social work field placement (a residency, of sorts, conducted in your final year of school). “You should try new things,” she said as I left her office that day, deeply disappointed. She was, of course, correct. My time working on prison reform gave me tremendous exposure. Not only did I collaborate with an interdisciplinary team of lawyers, I also learned that I could connect with people very much unlike myself by being open and honest. I learned that changes in bureaucracy happens both at a policy level but also in hundreds of individual decisions by the hundreds of employees carrying it out. I learned to elicit information not from asking questions but by staying silent, and I learned how to cope with moral ambiguity. But in the end, after graduating, I did not go into prison advocacy, or health education for that matter. Because truly, that wasn’t the point. Instead, I took a job running youth leadership training programs at a synagogue. Go figure.

Which brings me to my first time in the operating room. It was by a chance invitation that I found myself standing there at 7:00 a.m. one morning, the patient confirming his identity one last time before being put under anesthesia. I looked around, at the sterile instruments laid out on the table expectantly, at the phalanx of monitors beeping indecipherably, at the resident typing furiously, at the nurses conducting a stream of seemingly endless tasks. I wasn’t just out of my comfort zone, I was out of my league.

As an older student, and a career changer, I feel that I have some sense of my skills and interests. I like building partnerships for change, synthesizing information and prioritizing goals, working with children and teenagers – all of which have been pushing me towards medical, not surgical, disciplines. “Why am I even here,” I asked myself, intimidated by the charge nurse who kept eyeballing me as I tried to blend in with the tiled walls. And yet, slowly at first, but then all of a sudden, I started to become comfortable and fall into the choreography of the surgery.

With the arrival of the attending, I was invited into the small community of health professionals who would, over the course of the next three hours, become a self-contained universe focused on the removal of a tumor growing in the patient’s sinus. I marveled at the surgeons’ knowledge of anatomy, at the technology employed, at the teamwork exhibited, and at the fact that I didn’t contaminate the sterile field. Near the end of the surgery, peering deep down into the patient’s sinus through a pencil sized hole through his gums, I didn’t know what to make of it all. It had been a tremendously exciting morning, not at all what I had expected, but I also didn’t feel like it was my calling.

Again, by chance, five other surgeries followed in two different ORs. While I didn’t seek out these opportunities, I also didn’t say no to them when they appeared. There is something magical and disquieting about being inside of a body, seeing an artery pulsate or a uterus be pulled outside the abdomen. I still do not think I am interested in surgery, too technical and goal oriented, but I am grateful for the chance to be able to have decided this through experience not bias.

Like my time working in prisons, I have learned a tremendous amount from being in an unexpected environment. I learned that hierarchy is not the same as devaluing other’s contributions. That trust is shared not just between surgeon and patient, but also between surgeon and nurse and tech. That honesty about one’s capabilities is respected by the right kind of leader. And that there is such a thing as a very tiny booger vacuum cleaner.