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A Month of Wilderness Medicine

From the moment I started medical school at Michigan, I had been looking forward to September of my M4 year, and not for the reason that might come to mind first – residency applications – but for the Wilderness Medicine elective. Spending a month mostly outdoors learning how to care for injured hikers, climbers and kayakers as well as a week backpacking at Isle Royale National Park seemed too good to be true. Then I heard about the caving. I had found the catch. I’m rather claustrophobic and there was no fiber of my being that wanted to go into a cave. The allure of backpacking on Isle Royale, however, won out and that’s how I found myself in a cave outside of Bloomington, Indiana.

One of the stunning views from our trip Isle Royale National Park that never grew old. Photo credit – Owen Brown, M4.

The caving trip was the last in a series of adventures of the Wilderness Medicine rotation. The first adventure was a drive to Copper Harbor, Michigan, population 108, on the tip of the Keweenaw peninsula followed by a 3.5-hour ferry to Isle Royale National Park, the least visited National Park. On Isle Royale we backpacked for five days along rugged, rocky coastline and across the central ridge of the island. In the evenings, after a dip in the frigidly refreshing Lake Superior, we had peer teaching on different wilderness medicine and survival concepts including foraging, emergency shelters and animal trapping. Upon our return to Ann Arbor, we kayaked and practiced drowning rescues, went rock climbing, and participated in the Midwest MedWar – a trail race with medical obstacles and orienteering. Suddenly three weeks had passed, which meant it was time for our our last adventure – caving.

We arrived at Buckner cave, outside of Bloomington, in the heart of cave country midday on the last Monday of the rotation. Once we got geared up and packed – helmet, headlamp, backup flashlight, backup candle, knee pads, snack – we entered the cave led by several members of the National Cave Rescue Commission. We spent five hours exploring the cave starting with about a ten-foot army crawl followed by hands and knees crawling that gradually progressed to crouching and then to standing. Our path – the Circle Route – consisted of narrow passages that opened into rooms where our group of just under 20 could sit comfortably and learn about various medical scenarios that occur in caves from strains and sprains to pelvic fractures to heart attacks to hypothermia – many similar injuries and medical conditions one would expect to see in the hospital just with fewer resources and tighter quarters. My favorite session was practicing with the Palmer furnace – a surprisingly effective hypothermia prevention technique that involves a candle and a garbage bag. Within minutes, I was nice and toasty in the 55 degree cave.

After a night tent camping in the field next to the cave, we spent an hour learning about how to actually extract an injured or sick caver using two different types of litters. Then we tested our knowledge by actually coordinating a mock rescue ourselves. Surprisingly the rescue was less about medical knowledge and more about communication, teamwork, problem solving and preventing hypothermia. After several hours, our group of 16 successfully got our “patient” out of the cave! Much to my surprise, I actually really enjoyed the cave rescue scenario. By focusing on the problem and what needed to happen to get the team out of the cave, I forgot about my claustrophobia.

Cave rescue in action. Photo Credit: Phil Azouz, M4.

Starting a Student Org to Solve Medical Problems

When I first started college at the University of Michigan, I had never expected to get involved in entrepreneurship, let alone lead and advise other students in their ventures. Yet here I am, seven years later, one of the founding presidents of Sling Health. Over the past two years of my time in medical school, as part of Sling Health, I’ve helped students from across the university form and develop multidisciplinary teams to address health care problems with innovation and entrepreneurship!

Here is a part of our executive board this year (from left to right): Ayush Arora, Allison Powell, (M2), Mario Russo, and Emily Dixon. Not pictured: Sudharsan Srinivasan (M1), Abhinav Appukutty (M2), and Phillip Yang (M1)

But how did I even get into entrepreneurship?

Oddly, almost overnight. During my senior year studying biomedical engineering at Michigan, I created an alternative communication device for people with ALS with another biomedical engineer. We didn’t want to leave it in the classroom, so I found myself plowing full speed ahead with the venture to hopefully get it to the people who needed it.

Leap ahead to getting into medical school. When I was looking at schools to apply, I had a driving biomedical engineering/design emphasis. Beyond just the medical school itself, would I be able to still pursue my interest in the collaboration of biomedical engineering and medicine?

Through my previous experience in entrepreneurship, I got connected with medical students looking into founding a chapter of Sling Health on campus. Sling Health is a student-run organization that brings together graduate and undergraduate students from multiple disciplines including medicine, engineering, law and business to collaborate and address medical problems. We created an incubator to support team formation, development and acceleration into health care solutions.

The University of Michigan as a whole was the perfect fit for Sling Health. Our task was to unite students with different perspectives but similar passions.

With extraordinary support from the University of Michigan Medical School, the Zell Lurie Institute, the AAMC, and our national Sling Health chapter in St. Louis, we were able to found our chapter and hit the ground running.

We are now in our third year as a Sling Health chapter, coming full circle to our first event of the year, Problem Day! During the last month, we had interested members apply, including team leaders interested in leading a project. Our team leaders, equipped with a couple of clinical problems they are interested in solving, pitched ideas to members. Members then mixed in with the leads, discussing backgrounds that align with one another to find a project they fit with.

Teams forming at Problem Day this year

Looking forward, teams will present their progress at a series of Design Reviews throughout the upcoming year and receive feedback from professors across campus. The faculty are extremely influential in ensuring student success both in and out of the classroom, and many of them take time from their weekends to guide our teams!

Our experiences both define and guide us towards where we want to be. I could not be happier with seeing teams learn, sometimes struggle, but flourish. I had many people who helped guide me through this process when I first started, and getting to be a guide and mentor for others has been such an incredible part of my first two years at the medical school.

Seven years ago, I never would have imagined I would be here today helping push the needle on medical innovation. As I start my clinical rotations, I look forward to seeing Sling Health grow and continue to have a positive impact on the medical entrepreneurship community at Michigan!

Dust or Bust: If Medicine Doesn’t Work, There’s Always Graphic Design

June 2018

“Kris-Ti-An, what’s this JerkXJollof thing you do? I see fancy pictures of you guys and cool graphics; do you think you can make Twitter graphics of professors presenting at my D.U.S.T. symposium in August? If so, this will be your first job in our lab!” said Dr. Ghani.

And like that, I had made it to the big leagues. This was my first job as a newly minted researcher and student in the Master of Science in Clinical Research program. Not quite what I expected when I joined the team but hey, we all having a starting point! I could tell my future as the lab’s go-to graphic designer depended on this, so I worked tirelessly to produce a product even Donald Trump couldn’t refute as fake news. Now you may be wondering, like I at the time, what is D.U.S.T. and how does it relate to Urology?

D.U.S.T. (Developments in Ureteroscopic Stone Treatment) is an annual endourology symposium led by Michigan Medicine faculty Dr. Khurshid Ghani (director) and Dr. William Roberts (co-director). Each year at D.U.S.T., world renowned urologists are invited to give talks and demonstrations on the latest techniques in the field. What started four years ago in Ann Arbor as a small meeting composed mostly of residents has now expanded to a robust symposium nestled in the heart of Chicago attracting community urologists and major academic players alike.

August 16, 2018

The day had come at last. As I sat through grand rounds listening to Dr. Mahesh Desai, who had flown from India to present at the symposium, speckles of dust twinkled in my head. While I knew very little about percutaneous nephrolithotomy, Dr. Desai’s pride and joy, I knew that in a few hours I would be on my way to the beautiful city of Chicago for a well-needed change of scenery where my Twitter artwork would be on display for the masses. Like I said, the big leagues! After grand rounds had finished, my lab mate Ali Aldouhki and I heard a familiar British accent call out to us saying, “Kris-Ti-An, Ahh-Lee—you boys ready?” This was the beginning of a tiring but very rewarding weekend.

Ali and I assist Dr. Matthew Bultitude with his presentation during conference registration.

I had volunteered to drive Ali to Chicago, which hadn’t seemed like a problem until I remembered something very important: I’m addicted to trap (a subset genre of rap) music. While Ali was a cool guy, most of time we had ever spent together involved shooting lasers at fake kidney stones (aka our research) and there was definitely no music involved. But crossing cultural boundaries is sorta my thing, so I figured it would be okay. We jammed out to Lil Baby, Travis Scott, Gucci Mane and a smidgen of Drake before I handed him the aux cord. After some relaxing traditional Arabic music, we switched it up and bumped some original rap straight from his home Saudi Arabia. The trip was off to a lit start.

Dr. Khurshid Ghani greets guests at the opening reception of D.U.S.T. 2018.

After arriving, I was introduced the conference coordinator Christina who I had been anonymously chatting with for two months. We hit it off by bonding over the Dr. Ghani quirks that you only understand after rehashing a graphic design for him 100 times until it’s perfect. I knew at that moment if the conference was anything reminiscent of that process, I was in for quite the show. As we walked around setting up I was blown away by the quality of the signs, brochures, visual media and overall aesthetic Christina had created for the conference. To top it off, the graphics that I had toiled over were displayed as brilliant 3’x5’ posters adorning the entrances. Mama, I made. My expectations for a beautiful weekend were confirmed that evening at the opening guest reception. As I stood sipping Pinot Grigio and nodding at the sunset from the rooftop terrace overlooking the Chicago River, I knew the hustle was worth it.

Rooftop terrace views at the Loews Hotel.

 

Dr. Manoj Monga takes visual puns to a new level.

The opening of the conference began with Dr. Ghani standing on stage in front of a roaring, introduction video, similar to how Steve Jobs would introduce an Apple event. And like an Apple product, this conference was sleek, flashy, and wrapped in an intelligent design. While Ali and I ran the mics, cued up presentations, and ran the Twitter wall, participants witnessed a seamless Broadway level production on the latest opinions in endourology. Talks were bursting with cutting edge techniques from world class faculty, an industry sponsored skills lab demoed the latest in laser technology, all while the Loews’s hotel staff supplied a constant assortment of grade A food and beverages. And while I’m sure the participants enjoyed the all the educational aspects of the conference, they had no choice but to be inundated with laughter after Dr. Ghani’s colleagues managed to sneak in a few Photoshopped pictures of him in various costumes in their final talks.

At the end of the tiring weekend Dr. Ghani asked, “Well Kris-Ti-An, what did you think?” While, I admitted the conference was an amazing success because of the brilliant minds that worked diligently to make it so… HONESTLY, I couldn’t help but to think: Would D.U.S.T. have been a Bust without my Twitter graphics?

Graphic displaying Twitter handles of speakers at 2018 D.U.S.T. Symposium.

Lessons from Across the Pond: Part 3, the Finale

St. John’s Mayball

“Three suitcases just won’t work” I whispered to myself in defeat as I (unsuccessfully) tried to force my gown into an overly-packed bag. This past year living in the UK has given me many things, complicating my attempts at packing to return to Ann Arbor. I collected art from a variety of countries I had the privilege of visiting. I now own my very own Harry Potter-esque gown. What is my favorite of the things I’ve gained from my year living abroad, you may ask? The memories. The year was filled with once-in-a-lifetime experiences, ranging from discussions with experienced astronauts to over-the-top Mayballs (extravagant formal events hosted by the colleges in June as an end-of-the-year celebration). It was with tearful eyes and a full heart that I said goodbye to my home-away-from-home, Cambridge, and to my new cohort of lifelong friends.

 

A beautiful Cambridge sunset.

Similar to my previous semesters, I added to my newfound understanding of business with continued coursework. This time, my personal experience became relevant as I began the health care electives. How impactful is management in medicine? How is value-based care successfully implemented? How do we organize and capitalize on the mounds of data we are now collecting through technological advancements and electronic records? These are the questions I sought to answer as I engaged in “Health Care Coach Nights” and an “Organizing Health Care” course. While I unfortunately did not walk away with the catch-all answer to solving the health care crisis or lowering all insurance premiums, I was able to discuss these pressing issues with leaders in the field, and expand on the minimal understanding I was able to gain in medical school. This was followed by working with KPMG in a south England NHS hospital emergency department, tackling ongoing issues negatively impacting care delivery. I was able to lead my own quality improvement project and gain a Lean Six Sigma Green Belt (who said nerds can’t get belts?!). I am looking forward to taking the tools I’ve gained during this year and translating them to dissecting these critical issues, to better understand, and ultimately improve, health care as we know it.

 

My volleyball team at MBAT after a victory! (prior to my injury)

There’s no learning that surpasses first-hand experiences. While in France for the annual MBA Tournament, a sports competition amongst MBA students from across the globe, I was able to experience emergent care abroad. A volleyball incident led to a facial laceration (don’t ask how…) landing me in a hospital in Versailles, France. Being in a foreign country emergency room, unable to fully communicate with a provider and unfamiliar with the reimbursement system, left me concerned and uncomfortable. While this was a new experience for me, so many of the patients I have seen and will see moving forward in my career are experiencing just that feeling. Given how minor my injury was, saying I can fully understand how these patients feel would be a stretch, but I most certainly gained a level of empathy that I hadn’t reached before.

As I return to medical school, I eagerly anticipate joining the Class of 2019, and attempting to re-learn all of the medical facts I once regurgitated in my sleep (azithromycin is what class of antibiotics again?) and prepare myself for the next part of this journey. Though my days ahead are sure to be filled with long days, late nights, and countless call shifts, I will be sure to follow the future leaders that I got to know so well during this year. Congratulations to the Cambridge Judge Business School 2017-2018 class – until next time!

 

My class at the end of the year summer soiree.

What becoming a doctor taught me about being a social worker

Like a number of my peers, I am a career changer. Having started in social work, I shifted course four years ago this month, returning to school to complete the dreaded pre-medical sciences. Social work is an amorphous field, one that both the public and practitioners sometimes struggle to define. After all, it seems like they do everything, from individual therapy to foster care case management to public health education. More and more, physicians are also being tasked with “doing everything.” A growing body of research, for example, has linked adverse childhood experiences and other social determinants of health to poor outcomes over the lifetime. Interdisciplinary practice is clearly the linchpin of addressing these intersections, but the field continues to struggle to understand how.

Piloting a sexual health curriculum in rural Rajasthan, India as a social work student.

As a social worker, I thought a lot about how to create change and how to empower others to be thoughtful, value-informed actors in their communities. The sudden transition to studying the basic sciences was, thus, jarring. Whereas in social work I often worked in the liminal space between the rational and irrational (what makes us act the way we act and think the things we think?), the sciences were somehow both rigidly delineated and also impossibly abstract (see Schrödinger’s cat). To my great surprise, however, I began to think like a scientist over time, applying rigid rules to natural phenomenon. Nobody cared about how the molecules felt, only how its electors were distributed. But then medical school happened. Medicine exists somewhere in between these two, which is why it is often described as both a science and an art. While this maxim was originally used to describe how to treat illness when we only had a partial understanding of its mechanism, it is evermore becoming a way to understand the relationship between the physiologic and the social. For example, physicians today are working to understand both the underlying mechanisms of COPD and why people don’t stop smoking. As physicians, we are taught to understand the body rationally: X process leads to Y disease. But the waters become muddied when we factor in human behavior: Why would someone smoke when they know the harms to be so great?

In my previous career I often struggled to describe what I knew how to do. As I’ve embarked on a new process of professional acculturation, however, I’ve begun to realize that my previous training gave me a way of thinking systemically, evaluating how individual experiences relate to the larger sociopolitical processes that shape everyday experiences. This, for instance, can help us understand how an individual opiate addition relates to prescribing patterns, the legal system, economic markets, and public health infrastructure. With my growing knowledge of medicine, however, I’ve been better able to understand the biophysiological processes that underlie both pain and addiction, creating a much richer understanding.

As the interaction between society and health becomes even more clear, medicine and medical education is changing. For example, our Doctoring course helps us to both learn how to listen to the heart and to counsel patients on exercise, and the Paths of Excellence give us an outlet to explore fields such as public policy and the humanities. It was in this spirit that I initiated two projects this summer to help us be better advocates for health. In one, I am working with the Center for Experiential Learning and Assessment to develop a self-reflection module paired to clinical simulation. Physicians are given the tremendous privilege of working with patients on some of the most stressful, emotional and personal aspects of their lives. How we process these situations, and learn from them, is an important professional skill if we are to gain comfort navigating these complex situations. In the other project, I am preparing a study to examine sexual violence amongst gay and bisexual men. Given that life experiences can impact the health of our patients in myriad ways, better understanding their context can lead to tools to identify and address these factors.

As summer draws to a close, I am struck by the tremendous intellectual diversity that defines medicine. From basic scientists to clinical investigators to public health researchers to health care economists, all collaborate to give an understanding of what makes us healthy and what makes us sick. No one discipline can do it alone, but also our collaboration is only as effective as our insight into what we bring to the table.

Leading a C.A.M.P. Trip: Mentoring and Reflection

The new Creating Adventurous and Mindful Physicians (CAMP) program at UofM aims to provide an opportunity for incoming M1 students to venture into nature while reflecting on the transition to medical school and their anxieties leading up to Launch week. To lead these students on this journey, several lecture-hardened M2s were tapped due to their experience navigating the new curriculum and willingness to sacrifice the first week of their admittedly short summer vacation. I was one of these lucky guides chosen to embark on this school-sponsored trek into the woods.

From growing up in what was essentially a fancy cornfield with houses in rural Southwest Michigan, to hunting and hiking the wooded areas near Ann Arbor during college, I always found the outdoors to be a sanctum where I could relax and reflect. Nature can be a truly soothing resource to relieve the increased stress of medical school. I wanted to help students recognize the therapeutic aspects of nature and the wealth of natural beauty to be found within 45 minutes of Ann Arbor. Additionally, there was a similar, albeit unofficial, trip when I started which I missed due an unfortunate obsession with the (then optional) pre-work modules, and I needed to redeem that mistake.

My initial fantasy of the trip involved me being the “wise old sage” character to a group of bright eyed youngsters about to embark on an epic journey, think Gandalf and Hobbits. Realizing that was a bit extreme and very unlikely, I accepted that I would simply be there to answer their questions and maybe give them pointers on hiking, nature, surviving Neuro, and finding the best study spots in Taubman.

My experience during the trip was quite different. Yes, I answered plenty of questions, discussed tricks of surviving in the library, and also showed a trick to vaguely identify poison ivy. However, I found myself reflecting on my start last fall, the weight of beginning medical school, nerves about my ability to succeed and perform, and the sheer overwhelming nature of it all. These are the same anxieties and fear I have about starting my clinical years as an M2.

During the discussions on the trail and debrief sessions in the evenings, I found the advice I was giving them – it will be fine, you will find a way, you have the resources for success – was exactly what I needed to hear for my own transition. Members of my group also provided insight and strategies for tackling the transition that I hadn’t thought of or tried. It was an odd yet refreshing look at the nature of transitions and the importance of trusting yourself to adapt and improvise to whatever challenges await. I was not only able to help them remain calm about embarking on their journey, but I also reassured myself about rising to the next level of mine. It was a powerful experience being able to mentor these incoming students while learning far more from them than I ever expected.