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Building Bridges: Michigan Medicine in Brazil

“Study abroad” isn’t something most students can say they did in medical school. This summer I had the opportunity to rotate in Brazil entirely in Portuguese to bolster my language skills and cultural humility to serve Portuguese-speaking patients. This experience was part of my broader goal to serve patients in their preferred language and to build an impactful career in global health.

At the entrance of the Orthopaedics and Traumatology Institute, affiliate of the Hospital das Clínicas and University of São Paulo School of Medicine.

It has been estimated that more than 25 million people in the United States have limited English proficiency and regularly struggle to communicate with their health care providers. As the United States becomes more linguistically diverse, our health care system must continue to adapt to serve the country.

The desire to serve patients with limited English proficiency is one of my strongest motivators for entering the medical profession. I grew up in a bilingual household where my grandmother, who immigrated from Cuba and never felt confident in English, always felt uncomfortable seeing physicians who did not speak Spanish. The fact that mastery of a patient’s preferred language not only improves clinical efficiency and quality of care but also enriches the patient-physician relationship has inspired me to study world languages and global health care systems.

As an undergraduate at Harvard, more than half of my courses were in foreign languages: Spanish, French, Portuguese or Mandarin Chinese. I took literature and history courses about the lands where these languages are spoken alongside organic chemistry, biology and physics with the hope of one day bringing them together in service to patients. I volunteered as a multilingual interpreter at Massachusetts General Hospital and spent a summer researching the Zika Virus in Brazil during the 2016 Olympic games. I spent time at clinics, shelters and food banks in the Boston-area that served predominantly Portuguese-speaking communities. Not only did these include Brazilians, but also immigrants from rural Portugal, Cape Verde, Angola, Mozambique, and São Tomé and Príncipe. After graduation, I pursued a master’s degree in health economics and management at Peking University in Beijing and wrote a thesis comparing health care systems in America, China and the U.K. My goal in these endeavors abroad was to evaluate the physician and patient experience in diverse health care delivery ecosystems.

When applying to medical school, the opportunity to develop clinical skills in a multilingual context and to pursue global health was a top priority and one of the main reasons I decided to attend University of Michigan Medical School. Not only does our school offer programming in Medical Spanish, Chinese and French, but as a clinical student I applied this skill set in real patient care, especially in the emergency department, primary care clinics, and the Labor and Delivery service during the OB/GYN rotation. Moreover, Michigan’s accelerated pre-clinical phase opens our third and fourth years (called the “Branches”) to customizable clinical, research and entrepreneurial opportunities that are rare at other medical schools. Global REACH, Michigan Medicine’s international office, provides unparalleled administrative and financial support for medical students dedicated to projects pursuing global health equity.

Thanks to the support of Global REACH’s Dr. Joseph Kolars, Dr. Denise Tate and Tania Piotrowski; U-M Orthopedic Surgery Department’s Dr. Jaimo Ahn, Dr. David Walton and Dr. Eileen Crawford; and University of São Paulo’s School of Medicine’s Dr. Júlia D’Andrea Greve and Dr. Linamara Rizzo Battistella, I designed a four-week clinical program in comprehensive musculoskeletal medicine and orthopaedic surgery in São Paulo, Brazil at the Hospital das Clínicas, the largest hospital system in the Western Hemisphere and affiliate of the University of São Paulo School of Medicine (FMUSP).

During my rotation in Brazil, I rotated through operating rooms, inpatient floors and outpatient clinics, including orthopaedic trauma, sports orthopaedics, spinal cord injury, traumatic brain injury and amputations. I also had contact with emergency rooms and primary care clinics to broaden my exposure to the Brazilian health care system as a whole. Rotating in a city as large and dense as São Paulo offers a wide range of clinical scenarios unlikely to be seen in Michigan or even in the United States! For example, one patient presented with cervical spine trauma after a jackfruit – a tropical fruit weighing up to 80lbs – fell from a tree and struck his head while he was strolling on the sidewalk. Culture plays a significant role in medicine as well. Given sport, music and dance are salient features of Brazilian society, clinical research often explores topics in soccer, volleyball, footvolley, Futsal and samba.

Delivering a virtual presentation in Portuguese on the American Medical Education System to medical students, residents, faculty and researchers at the University of São Paulo Medical School.

My rotation in São Paulo also exposed me to how medicine is studied and practiced in Brazil. Learning about the Brazilian medical education system made me reflect on my educational experience at Michigan and the American system more broadly. At the end of my rotation, I gave a presentation in Portuguese to medical students, residents, attending physicians and researchers about American medical education. We exchanged so many interesting ideas and insights that we decided to build a formal program to connect our institutions at the trainee and faculty level to give continuity to these valuable conversations.

For me, medical school is about becoming the best doctor we can for our future patients. The opportunity to combine the clinical skill set I am learning at Michigan with my Portuguese language skills to care for patients in Brazil was by far the most impactful experience I have had during medical school. Not only did the experience improve my medical Portuguese, but I also feel more nimble navigating new clinical and administrative environments and better equipped to serve patients in high-volume settings. Additionally, given the stark differences in health care infrastructure, building bridges between American and Brazilian medical institutions offers the opportunity to share insights about best clinical practices and systemic design. Rotating at the University of São Paulo motivated me to continue mastering the skills necessary to serve vulnerable patients and to build on my career goals in health care delivery optimization.

I am so grateful for my mentors at the University of Michigan and University of São Paulo who support my academic and professional pursuits. When we say “Go Blue” it truly is a statement of family and community that spans across the globe. I am proud to be a Michigan Wolverine.

I am more than happy to speak with prospective or current students about Michigan. Please do not hesitate to reach out on LinkedIn, Instagram or Twitter!

What is Social Medicine? An experiential course in Africa inspires and motivates two future physicians

Hi! We are Anita and Ione, and we’re writing today in the wake of our return from a four-week trip to Uganda and Rwanda where we participated in an experiential course about Social Medicine.

We first heard about this course nearly two years ago through the Global Health & Disparities Pathway of Excellence, of which we are both a part. At the time, we were in the midst of our core clerkship rotations, deep in the weeds learning about the presentations of various clinical pathologies and the process of disease diagnosis and management. The title of SocMed’s course, “Beyond the Biologic Basis of Disease: The Social and Economic Causation of Illness,” stood out as a chance to revisit and go deeper into the structural framework that shapes health outcomes. We both kept the course on our radar as we moved through the Branches phase of the medical school curriculum, and the stars aligned for both of us to enroll in the January 2020 course in Uganda and Rwanda, with the generous support of Global REACH.

On a village visit in Northern Uganda to learn about culture as it relates to health

Arriving in Uganda at the start of the course, we joined a diverse cohort of learners from a spectrum of nationalities, ethnicities, professions, and personal experiences for a truly global educational immersion. Approximately half of the course students were from African countries, and the other half were from Western countries. The structure of the lesson plans offered ample opportunities to share and learn about the similarities and differences of our different contexts. Thus, as students we were also each others’ teachers, and through this approach we learned from our fellow classmates in ways that would have been impossible to organize into any kind of syllabus.

The curriculum of the course ensured that we spent our days exploring the structural causes of disease and the response of health systems to these structural causes, not only through conventional techniques like classroom-based lecture, discussion, and group projects, but also through reflective writing, dramatic expression, and place-based site visits. These layered exercises in critical thinking and action (termed praxis) encouraged us to interrogate how and why health systems are structured, and the considerations that must be given to demand, resource availability, and resource distribution. Moreover, the course structure left space to discern the values that define these health systems, and what implications that has for health equity.

Anita and Ione at the peak of Mount Kalongo!

However, we didn’t stop at the level of health systems: we also investigated the role of social movements in addressing structural causes of disease, and implementing the principles of advocacy for change. We practiced engaging with these practices in an intrinsically personal way: by drawing upon our personal histories and situating those within the work we do, we can approach action, agency, and change from a place of authenticity and security. Moreover, we can give ourselves the space to reflect on how we, too, are a part of the structures we choose to critique, and how power dynamics and systems of oppression that we might learn about in an abstract sense unfold on deeply personal levels. After completion of this course, we both feel inspired and motivated to use our voices as future physicians to engage with our communities at a grassroots level, and organize to effect change at a structural level!

Winter is Warm Somewhere…Rotating Abroad in Med School

Each year, the Universidade de São Paulo Medical School in São Paulo, Brazil hosts Winter School. It is a program that brings together medical students from all over the world to further develop and explore their interests in various medical specialties such as psychiatry, neurology, tropical medicine, surgery, cardiology, OB-GYN, and dermatology, just to name a few. Didactics and hands-on clinical experience take place at the Hospital das Clínicas medical complex, which is the largest hospital system in Latin America. While participating in the program, students are integrated into medical teams according to the specialty of their choice and take part in clinical care alongside residents, medical students, and attendings just as they would at their home institutions. University of Michigan Global REACH offers travel grants to medical students who participate in Winter School.

My classmates. 24 countries…60 new friends!

What really set the tone for the entire experience was the official welcome on orientation day. There was genuine excitement among the members of the University that we were joining their school, even if for a short time. As they introduced the history of the school and the mission statement for Winter School programming, the term “academic internationalization” stuck out to me. It was the term they used to communicate their belief that their medical students were better able to provide care to their patients when they invited other cultures and ideas into their sphere of practice. This openness laid a foundation of respect, curiosity, humility, and cooperation so that as we set off onto our respective rotations, we did so excited to learn about one another and this new health system we were so privileged to join.

During my rotation in Trauma Surgery, we completed a mixture of didactics, ultrasound/surgical skills labs, OR observation, and rounding with patients on the ED, ICU, and general wards. These experiences typically sparked in-depth case discussions as we followed our patients throughout the course of their treatment and explored the nuances of care within our international team. What was awesome about the clinical experience was that our reception on the wards as Winter School students was just as welcoming as it had been on orientation day. Everyone was excited to chat with us, to teach, and to give their time to make this experience a superb learning opportunity.

I still remember some of the “cool” cases we saw, but more than anything what I remember is how the attendings and residents went above and beyond to make sure we felt valued as clinical colleagues and as guests in their country. For the duration of Winter School, the attending physicians and residents halted all of their normal clinical activities and dedicated all of their energy to teaching Winter School students. That was no small feat for such a high-volume medical center. The dedication of so many resources to our learning and growth is something for which I will always have tremendous gratitude. At the conclusion of this time, I was truly saddened to leave the new friends I had made from around the world and this beautiful city. This was truly one of the greatest experiences I have ever had during medical school, and I think there is no substitute for what we can learn when we pair an open invitation with an open mind.

My journey to a research year in global health

My journey to a research year in global health

Are you a prospective medical student wondering how you can incorporate global health into your medical school career? Are you a current medical student considering a research year or a dual degree? Or maybe you are one of my family members who wants to better understand why I am living in Uganda for a year? Here is a bit more information about how I decided to take a year away from medical school to pursue global health research.

Global and public health are the passions that brought me into medicine. My mother immigrated to the US from Venezuela, and I grew up hearing stories that compared her life in Venezuela to my life in the US. From a young age, I was acutely aware of my own privilege and of global health disparities. I expected that I would get a Master’s in Public Health (MPH) during medical school, so much so that I applied to several dual degree MD/MPH programs in addition to MD programs.

My mentors came to Kampala and gave a talk on mentorship! Pictured are Dr. Kolars, Dr. Moyer, Catherine and Hilda.

During my clerkship year, I had two important realizations: (1) I absolutely love clinical medicine, and (2) I miss the global and public health roots that brought me into medicine. Armed with the knowledge that I made the right career choice, but also eager to learn about ways to diversify my future career and incorporate global and public health, I consulted multiple mentors. Pivotal insight came from a peer mentor, a fellow medical student, who had applied to multiple research fellowships as well as MPH programs for her gap year. It was invaluable to hear about her thought process, how she approached researching each program, and what she did to be successful in her applications. The University of Michigan Medical School invests in teaching medical students about mentorship and leadership, and my mentors were pivotal in helping me think through my gap year plans and successfully apply to a research fellowship.

In retrospect, I am glad that I did not have to decide about a dual degree during my first year of medical school. The experiences during my clerkships heavily influenced my thinking about the gap year. As I checked in with myself during the clerkships, I realized that I loved working again and learning on the job. I felt so much fulfillment from studying material that directly applied to my patients. I also realized that I struggled to focus during our three-hour lectures on Friday afternoons, and I didn’t feel as much eagerness to return to the classroom just yet. Another important factor for me was, and is, cost. I only explored fully funded programs, including funded research years and MPH scholarships.

At the NIH in Bethesda, Maryland for the Fogarty Orientation!

Ultimately, I learned of the NIH Fogarty International Center global health research fellowship through my mentors. The fellowship is a 12-month global health research training program for post-doctorate and doctoral trainees in the health professions. It is awarded through the University of Michigan, which is part of the Northern Pacific Global Health (NPGH) Fogarty research fellow consortium that includes the Universities of Washington, Hawaii, Indiana and Minnesota. Respective projects range from researching the continuum of care for triple negative breast cancer to diagnostic algorithms for tuberculosis meningitis to community-based death investigation of childhood mortality. What excited me most about the Fogarty program is that it would allow me to genuinely delve into global health research, own my project from start to finish, get on-the-ground experience, and have the space to reflect on what I want my career path to look like going forward. During my research about the Fogarty program, I felt that the fellows and program directors strived to approach global health research in an ethical, collaborative and sustainable manner.

Mentor team meeting in Kampala with Dr. Cheryl Moyer, left, and Dr. Peter Waiswa, center.

In order to apply, I had to find a research mentor based at the University of Michigan as well as a local research mentor based in one of the consortium’s partner countries. Next, I had to develop a project with my mentors, write a research proposal, and outline my previous experience in research and working abroad. I prioritized finding an excellent mentorship team because my prior research experiences taught me that mentorship can not only influence the success of the project, but also can define the extent of my personal growth and learning. Since I was in the midst of my core clerkships, I met potential mentors during the evenings and on my days off. I found that dedicating specific time and energy to networking with and identifying faculty who would be best positioned as well as willing to support me was an invaluable step of the application process. I am fortunate to have found a phenomenal research triad in Dr. Cheryl Moyer, Dr. Peter Waiswa and Dr. Joseph Kolars.

Many people asked me why I did not consider a two-month away rotation with a small research component instead. The short answer is I didn’t feel that would adequately allow me to reach my goals. I preferred to seek an immersive experience where I could fully own a project, learn research skills while directly applying them to my project, and gain an intimate understanding for what it takes to conduct global health research. My journey to the Fogarty fellowship required me to reflect on what I want and how I learn best. I can confidently say I made the right decision. I am incredibly grateful to the University of Michigan Medical School and the Fogarty International Center for the opportunity to pursue my passions.

Stay tuned for another blog next year with updates about my research project!

Snapshot of rooftops in Kampala