Select Page

Fighting Desensitization

I’ve been in medical school for 11 months and 15 days. For the past couple of months, I’ve found fewer and fewer things shock me. I’d like to think it’s a good thing—I’ve become acclimated to the medical community and a quarter of a way closer to becoming a physician. But mainly it seems as if I’ve just become more desensitized.


During the first few months of medical school, everything seems novel and eye-opening. It’s not about the practice of medicine per say – everyone probably has done a fair amount of shadowing prior to entering medical school. It’s more about the fact that you’re embarking on a journey in which you become responsible for the lives of someone else. There’s something magical in that.

As such, many things take on new meaning when I started medical school. When talking to a patient, I wasn’t just talking to a patient, but to someone who could someday be someone like my patient. A HPI became not just a series of meaningless random questions, but a systemic process that would help me reach a diagnosis. Patient panels were more riveting than an episode of Game of Thrones. And then of course, there was anatomy.

Admiring peonies in bloom at Nichols Arboretum

There are few things as defining about medical school as anatomy. It seemed like all along the interview trail, medical schools were showing anatomy labs as part of their campus tours – although I never really understood why. But looking back over the year, even though I’ve long forgotten what happened during our 2 weeks of orientation or details of our doctoring sessions, I still distinctly remember the first time we walked into the anatomy lab and looked at the face of our donor.

As I made the first cut into the back of our cadaver, there was a deep sense of awe and also a bit of fear too. What we were doing did not seem natural – it felt as if I was breaking some unspoken rule of the universe – I couldn’t help but see a face to my donor. Even though the feeling faded over time, I still remember feeling a faint sense of unease throughout the first half of the year. But somewhere along the way, instead of being novel, a lot of things became the new normal.

gardenIt isn’t the first time for me where things once novel became “normal” or part of a routine. After I graduated college, I joined Teach For America (TFA). My first few months teaching were utter chaos  – I had students throwing water bottles at each other and totally ignoring me during the lesson. It was dark outside when I got up and equally dark when I got back to write my lesson plans for the next day. While I didn’t necessarily mind the long hours, the sense of feeling completely out of my comfort zone and that I was making little difference was difficult. But as the weeks went by, even the utter chaos that was my classroom became normal in that I could almost no longer perceive the destructive patterns. Sometimes looking back, I wonder how something so crazy could have ever become “normal”?

Perhaps it is a coping mechanism that allows us to see things once shocking as normal – at least that is what we often thought in TFA. It could be also why we are able to dissect the face at the end of the year in anatomy when even looking at the cadaver in the beginning of the year fazed so many of us.

Enjoying a relaxing Saturday morning at Juicy Kitchen

But what do you do when the “newness” of something wears off? Is the feeling of things being “normal” even justified? For me, in teaching, it was clearly a no. It was wrong that I had come to see a dysfunctional classroom as typical. But it took me the summer when I finally had time to take a seat back and contemplate the year as a whole to figure that out. When I started my second year of teaching while I might not have been as green or untried as I was in my first year, I was still just as ready for an adventure and able to recapture some of the feeling of novelty to teaching that had seemed to fade towards the end of my first year. While I think some amount of acclimation and acceptance is helpful – it helps me do things I would otherwise be too paralyzed in fear to do, some amount of everlasting feeling of newness is needed too to keep me on my toes. I’d like to take this summer to recapture some of the magic so to say.


“Navigating complex systems”

If I were to draw the interconnections between the patient, the health providers, insurers, and relevant stakeholders, the diagram would likely be crowded with lines everywhere. I am tempted to simplify the relationships when explaining my experiences with ICE (Initial Clinical Experience) to friends and family outside of the medical community. But have discovered that it is difficult to do so. In reality, patient care is truly all that complex.


When I think of operational management and quality improvement, the areas of possible near misses and unexpected deviation are so numerous that it is hard to imagine where to begin. After all, with so many people, how does communication flow to ensure the best quality care?

As I sit on a stool in the staff clinic space, the dietician announces without logging into MiChart, “let’s go see the next patient”. Puzzled I ask her how she knows. She explains that she sees the patient whenever there is a gap in the patient’s schedule. This could be after or before the physician has seen them, before or after the social work visit or pulmonary function testing. There is no exact place to check the timing, so she pops into the patient rooms to see if they are currently available. With no exact schedule in place for nutrition and social work visits, it seems as though seeing patients may be messy. “Sure”, she admits, “sometimes we do miss seeing patients.” But for the most part, surprising enough, it appears to work for them. It does however require lots of communication between the physicians, social workers, and dietician.

michartIn today’s world of increasingly complex medical care and specialization of roles, the importance of communication between all parties cannot be understated. Patient disgruntlement with clinic experiences is often a result or at the very least exacerbated by communication mishaps that can occur at any point in the clinic visit. At one visit, I watched a visibly distraught patient argue with the front desk clerk. The patient had checked in nearly an hour ago but had been waiting for her visit for a while and became increasingly upset as time went by. Unsurprisingly, it was an error in communication. The clerk had thought that the patient was going to get her labs done on another floor first before the clinic visit. This was not true. It was an unintentional mistake, but no doubt resulted in ill feelings towards the health system. In other instances, patient paperwork such as request for lab copies or documentation would occasionally become lost or not get to the appropriate channels. These are clearly system issues, but perhaps more difficult to fix because the large number of different healthcare provider roles. white coat

The delineation of roles can be difficult to see at times. At the pulmonary clinic, the nurse and medical assistants would take turns or occasionally help fill out insurance or prior authorization paperwork along with the nurse assist. The large number of contact points can also be confusing for patients. In one particular instance, despite introducing ourselves, a patient began explaining all his medical problems in great detail for nearly 10 minutes before thinking to ask, “Who are you again?” For patients with chronic conditions, navigating the healthcare may become eventually easier. Yet for newcomers or those previously in good health, determining the roles of all the different healthcare providers (other than the physician) and available resources can be a huge barrier to receiving excellent care. Increasing communication between all stakeholders is only all too important for making this transition easier.uofm72314b

At the end of each clinic visit, I like to ask the healthcare provider what he or she would like for us to know or take away from the experience as future physicians. The nurse I shadow says immediately and unequivocally, “communication is so important – it is so critical for making a strong team, good working environment, and better patient care.” I think she is right.


What I’ve Learned from UMSRFC


UM Student Run Free Clinic Leadership Team

Just recently, as a clinic team, we were writing handwritten thank you cards to all our donors of the free clinic (running a free clinic is quite expensive even with completely volunteer labor!). While admittedly the cards were somewhat of a “thank-you-for-donating-please-donate again”, it was also truly a great way to thank donors and think back to how much it’s impacted my medical school experience. So here are some things about what makes the free clinic so great + what I’ve learned over the year:

  • Running a clinic efficiently and on time is incredibly difficult. When talking with a patient, time seems to go by so quickly and it can be hard to keep appointments to the times allotted.
  • It takes a lot of time (or people in the case of medical students) to keep a clinic running. Our leadership team has 17 people on it! When I had initially heard the number of people on the leadership team, I had to wonder, was there really enough work for 17 people to do? Surprisingly – the answer is yes. We’ve even considered adding additional leadership positions to handle the workload. Even now I do not know all the details of each position – but I do know that there is a lot that goes on behind the scenes.
  • There’s also a fair bit of random things to operating a clinic that I had never even considered before to running a clinic too. Soap, blood pressure cuffs, custom-made appointment cards, stool sample cups, hemoglobin A1C cartridges? I didn’t even know what of some of things were prior to ordering to them – it was surprising to me the number of medical things you can purchase online. Thank goodness for Amazon!
  • While we certainly can do more now than at the beginning of the year, it is somewhat neat how much pre-clinical students can do even only months into medical school. UMSRFC has been great in offering early exposure – the system of pairing one clinical student with a pre-clinic student definitely helps.
  • The hurdles to attaining care are extremely high for economically disadvantaged individuals.

I unconsciously tend to think of the medical experience from a physician’s point of view – whether an accurate diagnosis was given, were good doctoring skills utilized, whether the physician seemed empathetic. But in reality, a patient’s perspective is influenced by the healthcare system as a whole including how well and smoothly a clinic is run. Working as part of the UMSRFC has given me a new appreciation for how much goes on outside of the patient-doctor interaction. It truly takes a lot outside work from many people with diverse skill sets to provide high quality care.


Clinical Reasoning Elective

Last month, we were given the opportunity to sign up for the clinical reasoning elective (CRE). As part of the elective, we go as pairs to work with a faculty member for 2 shifts per month (3-4 hours per shift) in either Emergency Medicine or Internal Medicine. Initially, I had thought it would be similar to shadowing, but instead it is more like we get to practice being clinical students in a low-stakes environment.

This has been one of the most enjoyable medical school experiences thus far. Through the experience, I’ve been able to attempt differential diagnoses and see clinical presentations of diseases I’ve learned about. Somehow, it feels as though seeing actual cases of a disease makes what we’re learning so much more real. I think only medical students could be so excited to see someone with norovirus.

It has also exposed me to some of the more emotionally challenging situations in medicine as well. This included exploring the social history of a patient living with organ transplant and how the disease has impacted the relationship between her and her daughters as well as talking to a patient who was just diagnosed with advanced ovarian cancer. We learned how to assess whether a drug overdose was accidental or intentional.

There are also cases that are memorable because of their atypicality such as the case where an individual was bitten by a squirrel on campus. The patient was concerned about a possible rabies infection and came to the emergency department to have it assessed. No worries though! We had just recently learned in our sequence that one does not get rabies from squirrels, which I guess is a good thing given that it would be pretty hard to track down the particular squirrel to assess for rabies! Ann Arbor squirrels all look somewhat like this:


While we have only recently started the elective, I am excited to connect what we’ve learned in the past year with real patients and looking forward to the next few months!

Tackling Uncertainty

I can recite enzymes involved in nucleotide biosynthesis, identify the sternohyoid muscle or ilinguinal nerve on a cadaver, tie a square knot, and list pithy acronyms for expressing empathy, but in some ways I still curiously feel like the more I learn, the less I really know.

In his book “Being Mortal”, Atul Gawande suggests that “[we] become a doctor for what [we] imagine to be the satisfaction of the work, and that turns out to be the satisfaction of confidence.” As an engineer, I was drawn to the challenge of solving difficult, intricate problems and the seemingly precise logic of medicine that clinical diagnoses entailed. And while medicine is certainly complex, I have discovered in my limited training that it rarely is so neat and tidy. Even in the comfort of my apartment while studying, I struggle at times to learn the nuances between what seem to be similar presentations. It is daunting to imagine that in a not so distant future, I will need to do the same in front of a patient who expects an actual diagnosis.

5-15-2016-muskegon 0 copy

Being a pre-clinical student especially in the first year of med school is kind of like being an honorary member of a team in the sense that we probably are not contributing much but are included anyways. I often know just enough to realize that there is still a lot that I do not know.  It’s a lot like when you hear the first part of a question and think you know the answer only to hear the second part and realize that you only know half the answer. In the hospital, I hear of diseases like cystic fibrosis and excitedly think “it’s a defect with chloride channels” only to deflatedly realize that while I can describe the genetic mutations that result in the disease, I know little on how to go about treating the patient. And yet maybe that is ok.

I was watching Z as she was making a butterfly out of fuse beads as part of her occupational therapy while at Mott’s Children Hospital. Z was a sweet and energetic thirteen year old girl that had fractured her tibia, fibula, and pelvic bones from a car accident and after 3 months in the hospital, she was to be discharged from the hospital the next day. As she finished her session with the occupational therapist, she said, “I’m thirsty”, but at that point the occupational therapist was more occupied with helping transport her to her session with the physical therapist.  As the therapist began packing Z’s belongings, I walked to the water jug dispenser, filled a cup of water, and handed it to Z in the wheelchair. “Thank you”, Z said smiling at me. I couldn’t help but think that I was glad to be of use.

As observers, we have the unique ability to watch without being tied to specific responsibilities. This is a privilege in some ways because at some point in our careers, I imagine we will be saddled with numerous responsibilities and time will become a luxury that we do not have. To pass time, at times I’ll find myself chatting with patient families and the healthcare provider. “How old is she”, I asked the great-grandmother of one such patient. “Two”, she replied as A, the 2 year old patient, adorably crawled on the floor searching for tossed coins as part of her physical therapy. As I conversed with the family member, I learned more of the diagnosis, but also was able to ask clarifying questions to the physical therapist. This sparked further questions from the great-grandmother, who was then able to learn more about appropriate follow up treatment and rationale for the plan.


In the moment of things, I often question my ability to contribute meaningfully in clinic. “What do I really know” I will doubtfully ask myself. But in thinking back on experiences, I realize that sometimes it is in the small things that I can assist in –I can help advocate a bit for patients and their families by helping to ask questions and to provide an extra set of hands when a care provider is busy. These are small things, perhaps barely perceptible, but I like to think that I am helping in some small way.

I tend to think of medicine as a scientific endeavor, but if I really think about it, a good doctor is equally defined by both clinical expertise and people skills such as communication and empathy. I remain confident that somewhere along the way at a place as great as Michigan I will develop the technical expertise. And at this stage while I am still building clinical skills, perhaps it is ok that I don’t know the answers to everything – I can practice in the softer doctoring skills that are perhaps just as important or even more than nucleotide biosynthesis or locating a nerve.

*patient details modified to protect confidentiality