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Learning about health disparities in Northern Michigan

“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.

Watching Lake Merritt at sunset is my favorite evening ritual here!

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.

Surgery Olympics: Gold Medal in Knot Tying and Other Useful Skills

From my first day at Michigan during interviews, I’ve been aware of two things. First, surgery is difficult to learn as a new student. Second, and more importantly, Michigan has a collaborative and supportive surgery department that helps you succeed, even if you’re not a natural upon first picking up a needle driver. I discovered this almost by accident during my Untour. We were in the simulation center with current medical students, residents and faculty trying out basic skills and mock operative situations the surgical students use to improve their technique in the operating room. While attempting a laparoscopic “video game” I struggled with depth perception as the screen slowly filled up with blood from a vessel I was supposed to tie off.

“Here, let me help you,” said an M4 who deftly took the mock laparoscopic controls and stopped the bleeding. I remembered watching the red color drain away into the digital suction, simultaneously grateful for the assist and that the evaluation portion of the day was over, but also wondering – how the heck does anyone get good at this?

Flash forward to the same room the summer after M1 year and you’d see me and a bunch of my classmates racing each other to tie knots, suture fake wounds and complete laparoscopic tasks, confident in skills we had practiced throughout the summer. What changed between interview day and that summer? Simple — the Surgery Olympics.

The Surgery Olympics is a 14-week program starting in June organized by SCRUBS, the surgery interest group, for all M1 students interested in surgery. The program has two parts: a surgery skills competition and a research component. Each small group of students is paired with a faculty member in one of the many surgical fields at Michigan. Their team also has a fourth-year medical student coach. The faculty member helps the team complete a research project in surgery over the course of the program. They also connect the students with residents and other faculty who can help. The students present their work at the end of the summer to participating faculty who score the presentations on quality.

As for the skills competition, M1s work with their M4 coach, faculty and each other to improve tying knots with one and two hands, practicing different kinds of wound closure, and laparoscopic skills. At the end of the summer, teams of M1 students compete to demonstrate both the fastest and highest-quality of these techniques. The winner of the combined research and skills components gets a prize – as do the second and third place teams, just like the actual Olympics.

I remember feeling so excited that my Olympics team finished in second place and eventually published a manuscript on our work. I also appreciated practicing the skills I needed to thrive during my clinical year surgery rotation. Now, as a leader of SCRUBS and a rising M4 applying into general surgery, I’m excited to coach a team of my own this summer!

Any M1 can participate in the Surgery Olympics, regardless of one’s desire to pursue surgery as a career. It’s a great way for everyone to get research experience, practice skills needed for the surgery rotation and spend time with your classmates outside of required lecture. It also sets up relationships and mentorship with upperclassmen and faculty. I am still in touch with some of the previous M4 coaches for advice today.

For anyone interested in learning more, please come to the SCRUBS Surgery Olympics kick-off planning meeting on Monday May 13th from 3:30-4:30 pm in THSL 6000. I’ll see you there!

Studying Anatomy on a Yoga Mat

Studying Anatomy on a Yoga Mat

The first letters I ever had after my name were “RYT,” which stands for Registered Yoga Teacher. Before medical school, teaching yoga was a significant part of my life, with classes catered to groups ranging from third grade students to the football team at my university. After starting school at UMMS, I still found time for my personal practice and even teaching a weekly class at the CCRB through UM Recreational Sports, but my identities as a medical student and as a yoga teacher seemed to exist in two separate worlds.

Until the M1 Musculoskeletal (MSK) sequence, that is. As we dissected the muscles of the human body and discussed their attachments, actions, vasculature and innervations, I found myself returning to a familiar language from yoga teacher training and my subsequent studies as a Kinesiology major at Wayne State. When it came time to memorize this wealth of information for the exam and anatomy practical, a fellow yogi-classmate and I rolled out our yoga mats, cracked open a book on the key muscles of yoga (which, incidentally, was written by a UMMS alum!), and literally moved our way through the list of structures. Our yoga-based studying proved to be helpful (or at least wasn’t an impediment), and, beyond that, it was fun.

It made sense to me that movement-based education could supplement the traditional musculoskeletal anatomy curriculum, so I proposed the idea of an anatomy through yoga workshop to the MSK sequence directors, Dr. Hearn and Dr. Alsup. They were incredibly supportive. Over the following months I drew upon my knowledge and experience both as a yoga instructor and as a medical student to design the curriculum for a session that reviewed the key muscles of the upper and lower extremities along with their attachments and actions. The session goals, in my mind, were not only to create a structured space for review of important content, but also offer participants a new way of engaging with anatomy and a chance to bring wellness practices into the classroom.

During my M2 year in the Clinical Trunk, the M1 MSK sequence fortuitously fell in line with the Intensive week for clerkship students, giving me the availability to lead the MSK “Anatomy through Yoga” sessions multiple times. With the support of the MSK sequence directors and the Division of Anatomical Sciences, the sessions were well-advertised and attended by over half of the first-year class. I was even listed alongside the faculty lecturers as an “MSK course instructor”!

In the spirit of self-assessment, we administered a short, anonymous quiz before and after the session, as well as a post-session survey, to understand the value and impact of the workshop. The results demonstrated that the session significantly improved participants’ objective knowledge of the content and subjective comfort with the material. Students found the session valuable and overall left the class in a better mental state than when they arrived.

As an M3 in the Branches, I had the flexibility to ensure that I could offer these sessions to this year’s M1 class as well, and under the auspice of the Capstone for Impact program, I am working on developing this into a resource for the MSK anatomy curriculum that exists beyond my graduation. Exactly how that will happen? Still to be determined. But as I look forward to the next steps for this project, I am confident in its success largely because of the immense support from UMMS faculty and the extent of resources made available for students to turn their ideas into tangible impact.

Our Trip to the State Capitol

Earlier in my M1 year, I learned about organized medicine and through the last few months, I have engaged in ways to promote positive change in our communities. A few weeks ago, my classmates and I had the opportunity to meet with state senators and representatives to advocate for issues on vaccinations, Graduate Medical Education, the opioid epidemic and many more!

Advocating with my classmates (left to right): Alex Reardon (M1), Kathryn Quanstrom (M1), Lilia Popova (M1), and Phillip Yang (M1)

Eight short months ago, with my white coat in one hand and stethoscope in the other, I began my studies at the University of Michigan Medical School (UMMS) with the dream of becoming a physician. I was excited to learn as much as I could about human anatomy, physiology and pathology, but as the school year progressed, our UMMS curriculum integrated sessions on public health, policy, leadership, quality improvement and other topics designed to help us explore beyond the scientific foundations of medicine. With these sessions, I connected with passionate physicians and upperclassmen who introduced me to organized medicine. Fascinated by the potential to make nationwide improvements on key health-related issues, I joined the American Medical Association (AMA) at the national, state and county levels.

As a current member of the Michigan State Medical Society (MSMS), I had the opportunity to share the medical student voice at the MSMS Medical Student Section Spring Lobby Day. Together with three other UMMS classmates, and around 30 other medical students from schools across the state, we met with key lawmakers in Michigan to advocate for meaningful changes to state policies.

In light of the recent measles outbreak in Michigan, including cases here in Washtenaw County, we advocated for the promotion of vaccinations to protect the public from other preventable diseases, such as pertussis, meningococcal meningitis, and hepatitis A. Specifically, we asked our legislators to increase funding for the I Vaccinate Campaign, which provides parents with information based on medical science and research about the benefits of vaccinations in preventing certain diseases.

Me, moments before meeting with Representative Yousef Rabhi in the Michigan State Capitol!

We also asked our legislators to protect and expand Graduate Medical Education (GME) state funding in Michigan to support physicians training and working in Michigan, especially for those who pursue a career in primary care areas. As a native Michigander who hopes to give back to the communities that have given me so much throughout my childhood, continued support for these programs, including the Michigan State Loan Repayment Program and MiDOCS, is close to my heart.

Additionally, we had many thoughtful discussions with our legislators on ways to address the opioid epidemic in Michigan, opportunities to reform auto insurance to lower rates for drivers, and methods to streamline prior authorization protocols to deliver the highest quality and most immediate care to our patients.

Although spending a single day in Lansing is not nearly enough to direct change on these policies, all the senators and representatives that we met with thanked us for being there and for voicing our perspectives and opinions on these current issues. I hope that as a group of medical students we built onto all the work that the MSMS and physicians before us have done, letting us give our legislators an extra nudge in the right direction.

My involvement with organized medicine the past few months and this most recent trip to meet with legislators has led me to the realization that being a physician encompasses much more than learning the physiology of the body and the pathology of diseases – it requires working with policymakers in order to make widespread improvements to public health. As a first-year medical student, I appreciate being exposed to this side of health care at such an early stage of my career, as it has instilled in me a long-term commitment to learning about the issues and working with policymakers to tackle new challenges that arise.

Targeting Pancreatic Cancer with Radiation & Immunotherapy During the Branches

As a student at the University of Michigan Medical School, your last two years of school are collectively referred to as the Branches. Essentially, it’s a flexible framework of elective time that allows you to pursue your unique interests. Although the prospect of customizing two years of scheduling might sound daunting to some medical students, don’t worry, each student receives individualized support and mentorship through a Branch advisor. Due to my interest in radiation oncology, I joined the Diagnostics and Therapeutics Branch, and for advising I was paired with Dr. Michelle Kim from the Department of Radiation Oncology.

As someone who is passionate about translational research, I wanted to pursue my research interests in pancreatic cancer. More specifically, I wanted to build off the work I started in the summer after my M1 year. I worked in the Morgan radiation oncology lab assessing novel molecularly targeted agents as tumor cell-selective radiosensitizers for pancreatic cancer. One drug in particular, a DNA-PK inhibitor, demonstrated profound radiosensitization, and even more intriguing were preliminary findings that it might substantially stimulate the immune system.

Subsequently, during my M2 year of core clerkships, I saw firsthand how major breakthroughs in immunotherapies for several solid tumors, such as melanoma and non-small cell lung cancer, were rapidly changing the landscape of oncology. And I wanted to apply some of the concepts behind these immunotherapeutic strategies to pancreatic cancer in the context of targeting the DNA damage response.

Since the core principle underlying radiation’s immunogenicity is DNA damage and creating genomic instability, I thought we could potentiate the immunogenicity of radiation for pancreatic cancer by employing a DNA-PK inhibitor that would inhibit the most common mechanism for DNA double-strand break repair (i.e., non-homologous end joining). I hypothesized that this would increase both the rate of immunogenic tumor cell death and the absolute quantity of unrepaired cytosolic DNA, both of which would initiate an immune response.

One important caveat to this robust immune response is that cytotoxic T cells – important for killing cancer cells – have checkpoint proteins that can turn them off if they are active for too long. And this is why I hypothesized that immune checkpoints inhibitors – anti-PD-L1/PD-1 drugs in this scenario – play a critical role in maintaining a strong, sustained anti-tumoral immune response following treatment with radiation and a DNA-PK inhibitor.

My proposed therapeutic combination of radiation, DNA-PK inhibitor, and immune checkpoint inhibitor has generated compelling pre-clinical data thus far, but there is still plenty of work left to do before translation from bench to bedside. Fortunately, I have a supportive mentor, Dr. Meredith Morgan, and numerous collaborators in the lab (Sarah Zhao, Qiang Zhang, Josh Parsels, and Leslie Parsels) who will help with the project while I am completing clinical electives.

My Branches story might sound like a niche experience, but there are countless other opportunities for you to pursue your unique research interests within Michigan Medicine. Your Branches experience is not meant to conform to a one-size-fits-all construct; rather, your schedule is customized to align with your individual interests. Before you start your Branch years, you meet one-on-one with a Branch advisor to define your area of interest and create an individualized development plan. And, during the Branch years, you meet with your Branch advisor on a monthly basis to discuss your progress and goals.

Other valuable resources available to Michigan Medical School students include the Paths of Excellence. Since I am interested in research, I joined the Scientific Discovery Path. Through this Path, you learn about the different types of research available to students at the Medical School and they can facilitate research opportunities tailored to the student’s individual interests. This Path can also assist with applying for research grants, including a select number of NIH grants available to University of Michigan medical students on an annual basis. There are also numerous grants offered through the medical school to fund students’ Capstone for Impact projects.

I am also currently the co-president of the Radiation Oncology Interest Group. Since radiation oncology is a small field with limited exposure built into the core curriculum, we aim to bridge this knowledge gap through organized dinners where students can interact with faculty and residents to learn more about the specialty. In addition, we facilitate shadowing and research opportunities within the radiation oncology department for medical students.

I hope the story of my Branches experience will spark the interest of prospective students who are interested in the research opportunities available to medical students at the University of Michigan Medical School. And, if you are interested in working with radiation therapy, DNA damage response inhibitors, and immunotherapy for solid tumors, the Morgan lab at the University of Michigan Medical School would be an excellent place for you to pursue your interests.

Transgender Health Care at Michigan Medicine

A couple of months ago I was lucky enough to snag a spot to participate in the transgender health care clinical elective here at the University of Michigan Medical School. Michigan is one of a handful of (maybe three) medical schools who offer similar electives and right now it is only offered six months out of the year.

Dr. Shumer and me in the Mott Endocrinology clinic!

Transgender health care is often interdisciplinary; therefore, the elective draws from a variety of specialties. On average, I spent a day per week each in the pediatric and adult gender clinics, staffed by pediatric endocrinologists, and adolescent medicine specialists as well as reproductive endocrinologists. I worked with patients who were following up after surgery, initiating hormone therapy for the first time, receiving counseling on removing their GnRH analog implants, and anything in between. I also went to the Michigan Medicine Comprehensive Gender Services department to observe gender assessments performed by mental health providers. Finally, I spent time in the plastic surgery department, participating both in clinic and in the OR, with patients undergoing procedures like penile inversion vaginoplasty or top surgery (bilateral mastectomy).

Community outreach is also a huge component, which really appealed to me. I had the opportunity to meet with representatives from our law school’s Know Your Rights Project, UM sex therapy, and UM speech pathology. It was great to have an inside look at how trans folks might interface with these groups.

Last year as an M2, the clinical trunk year was all about learning the basics and understanding the foundation of clinical medicine, however, as a student it was often difficult to find continuity. You may be placed in a single clinic for a couple of weeks, without the opportunity to participate with a patient’s follow-up. The trans elective has been a welcome departure from this paradigm. One patient in particular stands out. I went with one of our social workers for the initial mental health gender assessment with a pediatric patient who wanted to start hormones. As he told his story, I couldn’t help but feel humbled and privileged to be even a small part of an identity journey and a medical intervention that he had wanted for so long. This patient was so brave and thoughtful and a teenager. I was in awe.

He came to the medical clinic the following week. Under supervision, I was invited to run the entire visit and the discussion surrounding initiating testosterone therapy. The patient and his family members were so excited to see and speak with a familiar face. It felt like a reunion of sorts. It was one of the more striking times in medical school that I’ve felt the ownership that comes alongside taking care of patients from the start of their medical journey. Side note, I actually wasn’t even supposed to be in clinic that day, but I invited myself in (shout out to the real MVP, Dr. Shumer!) because I loved this patient and his family so much.

As my M4 friends get closer to graduation and I move toward residency application season, I’ve been thinking a lot lately about the type of doctor I aspire to be. I’m planning to apply into Obstetrics and Gynecology this fall, and the reality is there isn’t a lot of formal training out there on how to provide trans inclusive care. I’m grateful that this elective exists and I’m grateful that I get to train at the University of Michigan. Here, we understand that it is our responsibility as future doctors and human beings to care for this population, in all senses of the word.