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Trial By Fire

The learning that takes place during medical school is often described as “trying to drink from a fire hose.” As a former firefighter/paramedic who was affiliated with two departments over the course of seven years, I have found it an apt expression. The deluge of information that comprises the preclinical scientific months is enough to keep you rustling through books, scrolling through thousands of PowerPoint slides, poring over study guides, and yes, turning to Google and YouTube to understand complex concepts of anatomy, pathophysiology and pharmacokinetics.

At first, entering a new patient’s room to take a history and conduct a physical exam can feel as daunting as this image conveys

Firefighting has simplistically been summarized as “putting the wet stuff on the red stuff” and the grind through medical school employs another water-based saying: “Just keep swimming.” There are formulas to learn and memorize in both fields and ultimately, the stakes are high. Failure to master pump operations means that an inadequate water volume per unit time is delivered to the fire, which can result in a failed effort or even put the people inside the structure at risk. Forgetting to calculate an anion gap when assessing a patient’s laboratory results may cause you to overlook underlying physiological responses.

Thirteen years ago, my training included the complexities of a fire engine pump panel

Of course, there are other parallels between my time on a fire department and medical education. Now that we are on our clinical rotations, my M2 classmates are also fellow comrades in a larger system entrenched in its own traditions. It’s the kind of teamwork that comes with having shared familiarity of a process – even though you’re assessed singularly for your contribution. All the while, our inexperience makes us the “rookie” on the team.

Rounding at the hospital with a team means discerning when to lead versus when to follow (photos courtesy of Ohio Fire Academy Class 0022-2005-003)

Finally, it seems there’s another silly tradition that has carried through for me: At some fire departments, it’s customary for someone to have to buy ice cream for the station when they experience a “first” (first time intubating a patient, first time using the defibrillator, first time they set up the helicopter landing area, etc.). I didn’t make the connection initially, but in retrospect I definitely swung by the hospital cafeteria for a cup of soft serve after a long day in the operating room during my obstetrics/gynecology rotation!

On Making an Impact

You know those days that you spend forever planning, and then they’re over before you know it?? I had one of those this past Saturday. Here’s the story.

I’ve spent the past seven months on leave from class doing research with the Michigan Opioid Prescribing Engagement Network (Michigan OPEN), a group started by three faculty members here at the University of Michigan who wanted to develop a preventative approach to the opioid epidemic by improving post-operative and acute care opioid prescribing practices. Now in our second year, we work to accomplish these goals through education, development of prescribing guidelines, quality improvement interventions and safe disposal. This past Saturday, our efforts to promote safe disposal culminated in our largest state-wide medication take-back event yet with 27 different sites in 17 counties participating. Some of these sites had collaborated with us several times before, others – like the one I organized – joined for the first time.

Some of the pills we collected and passed off to the Pinckney police for safe disposal.

Given the risks associated with keeping leftover prescription medications at home, and a general public unawareness of proper disposal options – like authorized drop-off sites in your area – I think there’s a lot of value in organizing local take-back events. These initiatives go where people already are, making the drop-off process easy, and providing education on safe disposal through a friendly, community-based approach. Having volunteered with the UM Student Run Free Clinic (UMSRFC) for the last two years, I especially wanted to bring Michigan OPEN’s take-back events to Livingston County. With the support of the UMSRFC, the local board and police, and the Michigan Institute for Clinical and Health Research, I managed to get the village of Pinckney added to our list.

Our awesome group of student volunteers and officers who made Saturday’s event a success. And the sun finally came out! ☀️☀️

Organizing the event involved weeks (or was it months?) of conference calls, ordering supplies, designing flyers, and lots of tweeting. When April 28th arrived, it was – of course – cloudy and freezing. But our wonderful student volunteers and police officers came with plenty of enthusiasm. By the end of the day, 20 people had dropped off medications, and we had collected nearly 9 pounds of pills, including 638 opioids. More importantly, we had many valuable conversations with community members on what compelled them to come, and how to take action in the future. Some had heard about our event by social media or local news, others had simply seen us as they drove through town. Many took our information sheets on year-round disposal sites in Livingston County. And nearly all asked when we would return.

While the exact date is still TBD, our team is already looking forward to our next Medication Take Back Event at the Pinckney Town Square Park, across the street from our little clinic. Our first event might have been small, but it unquestionably made an impact. We collected thousands of pills and brought people together to talk about our future goals for the community. The solution to the opioid crisis feels distant, but I believe it starts close to home, through initiatives in the spaces where we already work. It will be through collaborative efforts – like our event on Saturday – that we will manage to make a lasting impact.

How Flexible Are You?

Not yoga-wise, but given the lecture Friday on degenerative disc disease, maybe we should all consider it.

This is a very important question to consider and revisit with a modified, “how flexible can I learn to be,” specifically when learning how to create a balanced life in medical school.

Some coin it as efficiency, which doesn’t encompass the idea entirely since efficiency is essentially how quickly you can improve on a repeated skill. However, with our curriculum, you are in a sequence for no more than three weeks, and your mastery of navigating a study guide may prove to be of little use in a shorter time frame.

You are faced with the same challenge each sequence: “How am I going to tackle this sequence?” a.k.a. “What is my study strategy this week?” Since the answer to this question will usually determine how much remaining time you have to incorporate outside activities (whatever that may mean to you: spending time with your significant other, baking, exercising, Netflixing), I advocate for the strengthening/finessing of the broader skill of being flexible. This includes taking cues from your environment and knowing what resources are available for your use.

One of the weekly yoga sessions offered at the med school.

(In full disclosure: I have by no means perfected this skill, but I know the importance of being flexible after having completed three-fourths of the Scientific Trunk. When I choose correctly, it shows in the more balanced weeks I have, as compared to when I choose incorrectly.)

There are entire sequences that I did not stream a single lecture. For one week, the route I chose to take was a bundle of flashcards, learning objectives and reading the assigned textbook written by the sequence director. For another, it was only reading a study guide, reviewing the slide deck and watching osmosis videos. And, in yet another case, flashcards only was the main staple for the week. I remember the surprise that some people expressed when they heard that I did not stream at all: “How could you not?” My answer: because for me personally, there are better ways to cover and master the material we will need to know for the week’s quiz and on the wards.

One error in a slightly ambiguous slide could have consumed hours of my study time, but I knew that for that topic I could look to Pathoma (an online medical course review resource) and spend approximately 12 minutes at double speed to figure it out. Meanwhile, in another sequence using outside resources was a phenomenal beginner’s mistake and would prove to lead me down a road of extreme time-wasting, to the point where I almost understood less than when I had begun.

Asking those who have gone before you (by referencing Code Blue, our compiled tips from older med students, or speaking to them directly), and brainstorming with classmates what internal and external resources are available to cover the week’s topics are crucial. But being willing to ditch a study strategy when it’s not working is the hardest but most important thing to learn because everyone likes routine.

As for me this week in Musculoskeletal Week 2, it looks like I’ll be doing a lot of going to the gym to learn about muscles I never knew I had until I feel them the next morning, yoga with a peer instructor who will in practice highlight material we need to know, and hanging out with cadavers who can show me a thing or two about origins and insertions. Then, when I have the free moment that I have worked for and to bring some balance to my week, I will go back to lorio’s and see if Stracciatella or Tiramisu has returned to their gelato menu.

Big ‘I’s, Little ‘U’s

“There are no big ‘I’s or little ‘u’s here” was the first pearl of wisdom my supervisor gave me on my first day of work at N Street Village (NSV). Though I didn’t fully understand her at the time, I would carry those words with me to work everyday for the next two years.

My NSV coworkers and I in our “office” during a team meeting.

NSV is a non-profit organization in DC that provides wrap-around services to women experiencing homelessness, poverty, addiction, or anything in between. I worked in the day center, a safe and communal space for women, with services ranging from meals, showers, laundry, and a vast array of emotional, physical, and mental support groups. My experience at NSV was transformative and humbling. I learned how to deal with unexpected crises, witnessed the direct impact of systemic barriers to upward mobilization, and learned to meet people where they’re at when it comes to decisions about their lives and health. I was also able to share my choices for wellness; I taught a dance class every week and led a walking group (though walking was often replaced by playing charades in the park or women teaching me songs and games from their childhood.) Though I saw many women on the worst days of their lives, I was also privileged to share so many moments of joy with them.

As the beginning of medical school drew closer, I was apprehensive at times about my decision; I feared how much time I’d spend studying and that the pressure of school would make NSV a distant memory. I wasn’t sure that the skills or lessons I acquired would stick. Nonetheless I trusted my gut, and when July 2017 came, I packed up my bags, said goodbye to all of the strong and wonderful women I knew, and moved to Ann Arbor.

It’s eight months into medical school and I can safely say that not a day goes by that I don’t think about the women at NSV. I would like to say that’s all of my own volition, but I owe much of those reminders to Michigan’s opportunities and intentions, allowing me to weave my past experiences in with the new. Through patient panels I’ve learned more about substance abuse, intimate partner violence, and social determinants of health. My fellow med students have exposed me to skills they’ve gained through backgrounds in economics, social work, teaching, and beyond. I’ve had the privilege of being on the leadership team of the Student Run Free Clinic, spending time talking to patients and using skills that I first learned at NSV but have nurtured and refined even more in medical school. In our Doctoring course, we are continuously corrected for using too much medical jargon–not because faculty wants to be critical but because they also know there are no “big ‘I’s or little ‘u’s” when it comes to compassionate patient care.

Over spring break, I went back to DC and visited NSV. I was greeted by warm smiles and exuberant hellos from so many old faces. The feelings were mutual–I was elated to see individuals to whom I grew so close not long ago. In the months since I left, some women had gotten housing, become employed, reached new sobriety milestones, or were simply taking life day by day. We cheered, high-fived and hugged. It was just like seeing old friends, a tug at my heartstrings–difficult to tell the difference between happiness and sadness.

As I walked out, Ms. C, a woman particularly dear to my heart stopped me and said, “When are you going to come back and be my doctor?” And just like that, I knew my experience was not lost and a new one had just begun.

A goodbye sign the NSV community made for me before I left for medical school.

Topography of a Spring Break

The author’s Yiayia with her father’s model built during the Golden Gate Bridge’s construction from its scraps.

My family’s been on the same San Francisco hill for the last one hundred years. Emigrating from Greece in the 1910s and 1920s, my great-grandparents built the first house on the block (48th Avenue then was a sand dune) and ran restaurants on the road that wraps around the hill and connects the Outer Richmond to Ocean Beach. My Yiayia raised her family a block away, the home in which my mother was raised. Standing in front of her house, looking down 47th, you see the city sweep out down the peninsula – Golden Gate park interrupting rows of houses ending at the beach and ocean.

I’m from Kentucky, a landlocked state known for its rolling hills. I now live in southeast Michigan, an area that is as boggy and flat as it is beautiful.

Seven months into my first year of medical school, spring break was not only a much-needed change of pace but also a change in landscape. Visiting San Francisco for the week, I didn’t stream any lectures, review flashcards or localize hypothetical lesions. But I did explore San Francisco. It meant familiar walks: through Sutro Park, down past the Cliff House, and then the flat, windy walk along the beach. Or along the coastal trail below Legion of Honor, where you turn a corner and there’s the Golden Gate Bridge spanning the entrance to the bay. I know these routes well and they are for reflection and quiet appreciation.

The mouth of the bay.

Some of the exploration is new. One afternoon I take a bus, and then the metro, before climbing a hill to Corona Heights Park. Although there is less wildlife, navigating the subways is also a lesson in topography. It begins with a descent and ends with a climb up and out. Breezes are produced mechanically and carry the smell of oil and other things of a city. I read in the park and wrote a bit.

In Ann Arbor I often take walks. I notice the slight hills and admire houses in Kerrytown and the west side of the city. I let my mind wander between lectures, or in the evenings when I’m done for the day. I’ll walk in all sorts of weather – I’ve made good use of my coat this winter. Ann Arbor is full of reminders of the medical school. There’s the corner where I did tag days for Galens, right by the State Theater. The hospital, massive and lit up at night, can be seen from much of my walk to the Arb and is a sometimes exciting, sometimes intimidating reminder of rotations to come.

An old tree in Ann Arbor that caught the author’s eye.

For me, the landscape of San Francisco is tied to family. In the mornings, instead of an alarm clock, I wake to fog horns and the creak of the my grandmother moving around the house. My great-grandmother died a couple years ago (at 102!), but we still bake her cookies and tell her stories. I visit her house and weed her sandy backyard.

This landscape grounds me because it is a reminder of where I come from – my family, as well as who I am without quizzes, pre-clinical training, or medical ambition. I can read books and my mind doesn’t wander to things I need to get done. I can walk without a timeframe.

Spring break is over and M1s have finished Neurology. The days are getting longer and yesterday it snowed as the sun set and I found a little of the peace I had over spring break. Even though my family isn’t here and I can’t hear the ocean, the Arb was quiet and I noticed flowers beginning to spring up.

Ocean Beach at dusk.

 

 

 

Perspective

I started writing this post on Match Day as I anxiously waited to open my envelope:

Today is Match Day. I have spent the last few weeks in full-blown panic mode, peppered by occasional minor panic attacks. I found out that I matched on Monday, which helped somewhat, but I never realized how much I hated the idea of not being in control of my future until recently.

As many others have said, the Match is a binding contract for the first year, and, despite feeling reasonably secure up until rank lists were submitted near the end of February, that knowledge has affected my stress levels far more than I would have guessed. After all, I understand how the algorithm works (and could probably code a reasonable facsimile of it myself) and I’m going into family medicine, which I love but is not one of the traditionally more competitive specialties.

But nevertheless, here we were. I did not sleep well last night. My alarm went off this morning, turning on the radio, which was just beginning its news report. The top story was that a local Michigan boy had his heart transplant last night after a perfect match was found. The boy had been in normal health in early January but has since developed congestive heart failure and he got his new heart last night.

So, suddenly Match Day doesn’t seem as important. Perspective is something, isn’t it? Helping people lead better and healthier lives is why I want to be a doctor in the first place. No matter where I go, that part will not change.


My family at Match Day – Mom, Grandma, me, brother Jeff, and Dad

It is now a few days after Match Day. I am very happy to be sleeping better, to feel less panicked, and to report that I will be doing my family medicine residency at the University of Utah in Salt Lake City! I am very excited about this new opportunity and what the future has in store.

After my early morning dose of reality on Match Day, I was much calmer as the zero hour approached. My stomach was absolutely tied in knots as I waited in line to receive my envelope, walk back to my family, and open it with baited breath. It is bittersweet to realize that soon I will be leaving Ann Arbor, the city where I was born and have spent more than half my life, and the routines I have developed here. But I will go to Utah, with several of my current classmates, and develop new routines and continue to grow into the doctor I strive to become.

It is now several weeks after Match Day. My family and I are creating lists upon lists to ensure that all logistics are in place for my move to Utah. I have been a Michigan lifer up until now; moving for college/med school was definitely low-stakes – my hometown is 20 minutes away from Ann Arbor. Salt Lake City, however, requires over 20 hours of driving. (I am happy for the invention of airplanes). But I am very excited for my next adventure and am already plotting how to watch Michigan football games with my co-interns.

The Alumni Association’s motto is “For those who leave Michigan, but for whom Michigan never leaves.” And this will absolutely be true for me as well. I am forever changed by my experiences here at UMMS – particularly every time I hear the word “tragedy” 😉 – and they will guide me as I embark on my new journey.

I have enjoyed sharing my perspectives with you over these past five years; thank you for reading! As past UM president Mary Sue Coleman would say, “For today, goodbye. For tomorrow, good luck. And forever, GO BLUE!”