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Lessons from Across the Pond: Part 2

Time continues to pass at a surprising rate, and I find myself with yet another term complete. Lent term, what our winter term is called at Cambridge, has come to an end. My courses brought more insight into a variety of topics, ranging from building a business strategy to understanding time-based cost models of, relevantly, hospitals.

The Cambridge MBA Team ready to take on the Kellogg Case Competition

While my Healthcare Strategy concentration doesn’t begin until next term, I was pleased that in several of my classes health care topics seemed to make an appearance. This integration of health care into the business curriculum served as a reminder that health care systems, regardless of our perspective, are indeed businesses. In January, I joined a stellar team of four other Cambridge MBA students to compete in a Healthcare Case Competition in Chicago at the Northwestern Kellogg School of Management, allowing application of our course principles to a real-life health care case (and a school-sponsored trip to Chicago!).

Dr. Sanjay Saint at the THIS Institute launch

In addition to the case competition, I looked for other ways to stay involved in the health care space, and I found myself at the launch of THIS (The Healthcare Improvement Studies) Institute. I joined the celebration of a promising initiative to improve health care research in the NHS, and was pleasantly surprised to find out that one of the speakers was none other than Dr. Sanjay Saint, a clinical leader and M3 lecturer for our internal medicine rotation at Michigan. No matter how far you find yourself in the world, there seems to always be a Michigan Medicine connection to make you feel right at home.

Keeping my priorities in line, I made sure I could come back to Michigan mid-term to be in the 100th Galen’s smoker. After a lovely (and tearful) reunion with my soon-to-be graduating friends, I was back on a plane to start the next part of the term. Half of our term consisted of the Global Consulting Project, an opportunity to work abroad with a team of MBA students on a specific project. In an effort to branch out and expand the repertoire of experiences I gained from this year, I opted to participate in a project in Kuala Lumpur, Malaysia working for a fintech start-up in the cryptocurrency space. In the four weeks I was doing the project, I learned more than I can describe in this short blog, and was able to see what it was like not only to work for a start-up, but also to work in a culture with infrastructure and norms very different than what I am used to in Michigan. The diversity of cultural exposures continued as I concluded this project and traveled to India, to be part of the wedding of one of my classmates in Delhi!

At the Sangeet, ready to dance!

This past term was filled with submersion in new cultural experiences, application of coursework to real-world problems, and of course strengthening of the bonds of friendship with my classmates here in Cambridge. Looking forward to another term, and trying to pretend that this year never has to end!



An Unexpected Lesson

I’m going to be up front with you and let you know that I am not always on top of checking my email inbox. So, months ago when I was clearing out the dozens of unread messages in my inbox, I saw an email about the Clinical Reasoning Elective (CRE) at Michigan and deleted it without a second thought. Fortunately for me, my friend and classmate does read her emails and texted me to see if it would be something I would be interested in. This course has turned out to be one of the most meaningful experiences I have had during my time here at Michigan.

The Clinical Reasoning Elective (CRE) is an optional course for first year medical students. Students who choose to participate in CRE work one shift a month in either the adult or pediatric emergency room, or on an inpatient floor. My partner and I were placed in the fast-paced adult emergency room, where we have the opportunity to see patients and work with our attending to hone our clinical reasoning skills.

CRE has given me the opportunity to take the skills that I have learned in the classroom and use them in practice, and has taught me so many new skills that I can bring with me onto the wards in a few months. Perhaps more importantly, connecting with patients and being part of the health care team in my preclinical years has helped to keep me motivated through our weekly quizzes and exams. The patients I work with during my CRE shifts always give me a renewed sense of purpose, and I value the time that I spend in the ER as an integral part of my education as a student physician. My time spent during CRE has helped to make me more confident in my skills, more caring for my patients, and more careful about reading my emails.

Where the Sidewalk Ends

There is a place where the sidewalk ends

And before the street begins,

And there the grass grows soft and white,

And there the sun burns crimson bright,

And there the moon-bird rests from his flight

To cool in the peppermint wind.

-Shel Silverstein

Since entering the first clinical year of medical school, I’ve started to think a lot about endings. That is, what it means to have finally arrived at the end of something.

The accelerated curriculum adopted by our school has precipitated all sorts of awkward conversations on the wards about trunks, trees and branches. This is the first time that students have begun clinical training in their second, rather than third, year of medical school, and many attendings and residents still refer to us as M3s. For the first time, I’ve felt like the amount of experience I’ve accrued is not worthy of my title. Answering the question “So what year are you?” has been very conflicting for me. I can see the skepticism take over a patient’s face when I tell them I’m a second year. But it somehow feels worse to say I’m an M3 and have them overestimate my abilities. When we, the students, are brought face-to-face with the incompleteness of our knowledge – which happens often – we are told that time will bring experience. In high school, in college, I knew this to be true. I would wear my class year like a badge of honor: “I’m a senior now. I’ve done my time.” I point to my badge sheepishly now: “I’m a clinical student. But I’m technically an M2.” When does M2 year end for us? When does M3 begin?

Whether you are an M2 or an M3, the clinical years are just as emotionally as they are academically taxing. I have not seen a person die, but I have seen a person dying. I have watched lab values skyrocket and plummet, analytical proxies for the signs of impending death. How exactly do you define when a person has reached the end of their life? A last breath? A final beat of the heart? A silent brain? It’s a philosophical and ethical dilemma for the ages, but what frightens me the most is watching physicians make the final call. They take in the gestalt of a patient and declare that this person is not long for this world. One day, I will be the one leaving a patient’s bedside, slowly shaking my head, calling it the end.

You take on the burdens and concerns of your patients because you love them. But there are also loved ones outside of the hospital that need you, your time, your energy. Life happens outside of the wards. Things come to an end out there, too. I’ve mourned the end of friendships, relationships, the end of my parents’ marriage. Endings that are just as messy and difficult to pinpoint and define.

Soon, I’ll have to accept that as doctors, as adults, we will be the decision-makers in life. No longer are there the neat bookends of a school year to let us know that it’s time to move up and on. No longer can we rely on other people to declare what is so or not so, alive or not alive, dead or not dead. Maybe I hold on to my M2 status because it is something familiar and safe. But I also don’t see much wrong with spending a little more time in this liminal space; at the cusp of professional responsibility; where the sidewalk ends and before the street begins.

A view of Lake Michigan at Sleeping Bear Dunes.

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.