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Finding your Path

Poetry.

Before you skip over this post because of the previous sentence, I want you to think about something that fascinated you far more than you thought it would. That’s what I think poetry is for most people: that interesting thing that they never knew existed. I truly, maybe a little naively, believe that those who don’t like poetry just haven’t been exposed to the poems that they would like. And there’s a lot of poetry out there, far more than what the volumes on that one shelf at your nearest major book retailer might suggest. (I had originally titled this post “The poetry section at major bookstores makes me really sad,” but then I realized that THAT was one way to make sure no one reads this post!)

I recently finished Step 2. I’m officially an M4 now. Like the characters in the title short story I recently read from Anthony Doerr’s amazing 2002 collection The Shell Collector, who are bitten and rendered briefly comatose by a venomous sea snail, I’m in shock. I took Step 2 on Monday, and for the past three days, all I’ve done is read (I’m on my vacation month). They say that there are two types of people: those who read to remember, and those who read to forget. What about those who read to figure out what they want to do for the rest of their lives? In which camp do the nuances of that desire fall?

In truth, I know what my next four years will look like. I am ecstatic to have found, through my M3 year, the medical field that I will go into. I also know that I will be writing poetry. And here is where a less stubborn version of myself might throw up her hands and say, “This- this is not happening” — “This” meaning a career path that lets me combine my love of medicine and poetry into something that (can I say this without sounding completely delusional) could be helpful to both fields. I can’t say that it’s been easy so far– being a medical student and a writer. “I’m a poet” is not something that I volunteer on the wards, mostly because that’s like randomly telling people that you love kayaking or have a fondness for turtles in the middle of a conversation about your career ambitions. Because, despite the successful integration of creative pursuits and medical careers by physician-writers such as Atul Gawande, Amit Majudar, C. Dale Young, Rafael Campo, and so many, many more, creative writing is still seen as being separate from medicine, as evidenced by the furrowed brows and blank stares I’ve received on clerkships in response to the phrase “I write poetry” (sometimes also to the phrase, “I like to write,” at which point I’m like, This…is going to be a long two weeks).  When I’m feeling adventurous, I will tell attendings or residents that I write poetry, but for the most part, I don’t bring it up unless asked about hobbies or interests outside of medicine (and instead use my energy to plan events that integrate medicine and the arts, like this one with the poet and internist Rafael Campo back in March: http://www.literatibookstore.com/event/site-humanism-and-ethics-night) Small but gradual change!

What this gap between medicine and the arts boils down to, for me, is an awareness gap. Just as you might hypothetically think that all the poetry in the world is of one homogeneous note if you only consider the poems in your high school literature textbook (was going to write, “the poetry section at the major book store,” but then realized that probably NO ONE besides writers look at, and cry over, that section), so might physicians, when it comes to possibilities within a medical career.  What does this mean for me, an M4?  As I go through this year, I hope to continue to work with the Medicine and the Arts Program to plan events that bring physicians and medical students together with writers. I’ll work on my IMPACT project, a collection of poems about dementia (more about that in a later post). I’ll mentor some of my peers within the Medical Humanities Path of Excellence, for which I’m planning a lesson that involves reflection and writing.  I’ll continue to learn, and think, and write.  It’s unfamiliar territory for most, but that’s what makes it exciting–at least, definitely, to me!

~

Ting Gou is an M4.  Her first collection of poems, The Other House, is forthcoming in the Delphi Poetry Series from Blue Lyra Press this November.  Her poems have been nominated for the Pushcart Prize three times and can be found in various literary and medical journals.

Innovation and Policy at AMA Annual Meeting

Earlier this month, a group of UMMS students travelled to Chicago, IL for the AMA Annual Meeting as delegates from our school to the medical student section.

UMMS Crew at AMA Annual

UMMS at AMA Annual in Chicago, IL

In addition to voting on policy issues that affect medical students, physicians, and patients, we also attended educational sessions such as “professional advocacy in an election year” and “outbreaks and the olympics,” which was focused on the Zika virus and other communicable diseases.

One of my favorite parts of the weekend was attending the AMA Healthier Nation Innovation Challenge finals. There, we had the opportunity to hear from innovative startups about how they are solving pressing issues in healthcare.

These remarkable projects ranged from a technology solution that empowers first responders to share real-time patient data with healthcare providers in hospitals (Twiage) to a novel catheter that self-disinfects using phototherapy. Amazing solutions that are widely applicable!

The final day of the conference we attended reference committee meetings for the House of Delegates, which is the full voting body of the AMA. I particularly enjoyed hearing and live tweeting the debate on the End Step 2CS resolution that Andy Zureick (M4 from UMMS) and other students and physicians from across the country had been working hard on. Step 2 Clinical Skills has not been shown to improve patient care or education quality, has an extremely high pass rate, yet costs medical students over a thousand dollars plus travel time and expenses. The proposal to advocate for elimination of this exam in its current form was passed in a form that combined four separate resolutions with the same intent.

We are all grateful to the Washtenaw County Medical Society and the Michigan State Medical Society for providing funding without which we may not have been able to attend! I look forward to continuing to work on AMA projects:  Andy and I were elected to leadership roles at the Regional level. He will be serving as our region 5 vice chair and will be serving as our region 5 AMA foundation liasion.

Attending this meeting was incredible opportunity to partipate in policy-making and connect with students and physicians across the country. I left feeling more energized to lend my voice and enthusiasm to organized medicine & health policy!

Random strangers sometimes refer to me as ‘Doctor.’ Cue anxious laughter and inner terror.

I feel like I’ve expressed this sentiment so many times that anyone reading is like, “WE GET IT ALREADY,” but medical school passes by so quickly that it seems to defy the laws of physics. …Not that I remember much about the laws of physics. Not only have I officially started my core clinical rotations, but I’m already practically done with my first: Internal Medicine (which, coincidentally, is also the longest). I’ve spent time at the Ann Arbor VA, General Medicine at the University Hospital, and I’m currently on the Hematology/Oncology service also at the U. The majority of my experience thus far has been overwhelmingly positive. I have, however, never felt more stupid in my entire life (and have frequently expressed this out loud and received confirmation of the same from my classmates).

The transition from the classroom to the clinical realm is NUTS. For all the fuss I made over Step 1, it’s like the vast amounts of information I crammed into my head in preparation have magically disappeared now that it’s time to start actually utilizing it (thanks a lot, brain; you traitor).

She knows what she did.

She knows what she did.

There’s also all this other stuff that suddenly comes into play that lectures/Step 1 didn’t even touch. I have to know which antibiotics are oral and which are IV only? You do realize it’s a minor miracle when I even remember that they’re antibiotics, right? I’m continuously bewildered by the sheer quantity of knowledge that my superiors possess. I’ve not yet decided if they’re robots or wizards, but I’m pretty sure it’s one of the two. I’ll get back to you.

OR MAYBE BOTH!

OR MAYBE BOTH! Tricksy hobbitses…

Probably the hardest part of figuring out how to navigate my new life (and it really does feel like an entirely new life) is balancing the fact that I am constantly findings topics that I need to study and have practically no time to study. I’ve heard that Internal Med is pretty hardcore in this regard and am hopeful that this balance will be easier to strike in the future.

My current feelings expressed above are highly colored by the fact that my end-of-rotation Shelf Exam draws ever closer. I must say that on most days during the past several weeks I’ve called my mom in the evening and essentially said, “I’m really happy and I don’t even know why.” Being part of a healthcare team, participating actively in patient care, learning by doing; it’s all permeated by a general sense of contentment. I just feel good (and exhausted, but that’s a given) at the end of the day more times than not. Honestly, one of my biggest fears at the moment is that I’m going to love everything and be an absolute hot mess when it comes time to decide what specialty I want to pursue. There are worse problems to have.

Summer in Ann Arbor

It’s summer for the new M2s!! Actually, this is old news. We took our last exam on May 15th and so we have enjoyed almost six weeks of break. Since we start class again on August 1st, we are almost exactly at the halfway point of our summer. Time is flying by, so I’m not going to think about that; instead I’ll focus on how wonderful these past 6 weeks have been.

A few days after the end of term I headed northeast…really northeast…all the way to Iceland! I traveled around the island hiking above fjords, ogling beautiful glacial waterfalls, waving at sheep, camping under the midnight sun, and forgetting that I was a medical student.

 

Me and my travel buddy in Iceland! Ps. That's my Michigan Med shirt. :D

Hiking in Iceland! (Wearing my Michigan Med shirt, of course.)

 

I needed the break. I came back ready to get to work on my task for the summer: my SBRP project. The Student Biomedical Research Program (SBRP) is organized by the medical school, and provides a stipend for 10 weeks of research that medical students complete in partnership with a faculty member. I am working with Dr. Maggie Riley, a family medicine physician here at UM, to analyze the effectiveness of a program called MiHealth. MiHealth was designed by two M2s last year, and was piloted this spring. In the program, groups of medical students teach a series of health lessons in high school health classes, covering Smoking & Drugs, Mental Health & Depression, Healthy Relationships, Sexual Health, Nutrition, and Fitness & Exercise. The goals were to increase high school students’ health knowledge and reduce their risk behaviors, and to create a program that everyone involved (high school students and medical students)  valuable. We gave everyone involved pre- and post-surveys to measure these metrics. I helped teach some of the lessons, and I certainly thought the program was valuable! It was great to get out into the community and interact with the high schoolers. By the time I finish my SBRP project we’ll know if the others involved agree with me. Stay tuned!

M2s working on research in a coffee shop.

My summer days have developed a rhythm: wake up early and go running, make breakfast and pack a lunch, walk downtown to work for a few hours in a coffee shop, change to a different coffee shop or the library after lunch and work some more, head home to relax or hang out with friends. After a year of keeping my nose to the grindstone for school, even working full time on a research project feels like a break. Having time to hang out with classmates without having to study at the same time feels particularly novel and fun. We’re working hard at completing the “summer in Ann Arbor bucket list,” which includes things like going to free concerts at the Summer Festival, tubing down the river, trying new restaurants during Restaurant Week, drinking sangria at Dominick’s, watching Shakespeare in the Arb, and walking the streets during the Ann Arbor Art Fair.

I’ve had time to read as well, which is great! My favorite book for this summer so far has been The Ghost Map, by Steven Johnson. It tells the story of the 1854 London cholera outbreak that, through a groundbreaking epidemiological study, resulted in the discovery that water coming from the Broad Street pump was the source of the bacteria, advancing public health, epidemiology, and bacteriology. Johnson writes a great narrative and incorporates aspects of sociology and urban history as well. I definitely recommend it.

A parting word of advice, if you are attending medical school in the fall, relax and soak up as much sun as you can now! I know I am.

Fighting Desensitization

I’ve been in medical school for 10 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.

UMMS

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.