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HEAL: Health Care for the Homeless

Ruth:
Healthcare Education and Access Liaisons, better known as HEAL, is the health care for the homeless group at the University of Michigan, where students partner with physicians and community health workers to provide basic medical care and social services to the members of the Ann Arbor community experiencing homelessness. Due to the variety of barriers that this population faces in accessing health care from an often unbending medical system as well as their historical mistreatment by health care providers, there is great complexity in HEAL’s work. More than an act of service, HEAL is a learning opportunity for students to enter into these men’s and women’s spaces and act as witnesses to their suffering. We try to better understand their challenges with overcoming poverty, addiction, abuse, etc., so that we can provide culturally-competent health care and social services to the homeless.

A core component of HEAL’s work are twice-weekly street runs, facilitated by Jim, a nurse/street navigator, and Dr. Russell Pajewski, an internist at Michigan Medicine. Each run is different, but all of them begin in the early morning at a local church and may include visits to camps, warming shelters or Washtenaw County Community Mental Health. First-year medical students Allan Metz and Eric Steinbrook describe their first street run experiences:

Allan:
My HEAL run started on a cold morning at St. Andrew’s Episcopal Church in Ann Arbor, where the church was serving a free breakfast to those in need like it has done everyday for the past 36 years. Another medical student and I went around to the individuals in the church, speaking with them about their day and getting to know their stories. Typically, our conversations would shift focus to their health concerns, with some individuals even wanting physical exams like blood pressure screening. We were able to help some individuals bandage up cuts and abrasions they had sustained since our group had visited with them last. We worked closely with a physician and a nurse while at the church, and this allowed us to address more pressing health concerns such as chest pain, flu-like symptoms, and stomach issues by helping to set up clinic appointments and writing prescriptions. Our team was also able to provide information on shelters to stay at if there was interest, or programs to help with food insecurities in this population. It was a really interesting and eye opening experience to see health care delivered in such an unsuspecting place outside of the typical settings I’ve experienced it. Even if the medically-related things we did that morning were just to address the symptoms of an ailment, starting the conversation around a person’s health and how they can work to stay healthy seemed to be the real goal of the morning.

Eric:
The four of us followed a lightly trodden path that led into the woods behind a local supermarket. We were on a “street run,” part of HEAL’s efforts to offer holistic care to the homeless of Washtenaw county. Our team–made up of a social worker, nurse, physician, and myself–makes weekly visits to camps, and no two visits are the same. We might provide medical care or help draft applications for county housing. Our mission is best summarized by Dr. Jim Withers, the Pittsburgh physician who founded the street medicine movement in 1992: “We offer health care that comes to you as you are, on your terms, accepts you, acknowledges your strengths, and that is committed to you no matter what.”

That day we made visits to eight tents behind the parking lot. We met one man for the first time: he was new to Ann Arbor, and had just found his way to this camp. We recognized another man who was in particularly good spirits that day. We talked with him for 10 minutes about the long and difficult process to find stable housing, and our social worker set up a time to follow-up with him the next week. As we piled back into the car–off to visit another camp–I felt gratified to have started building relationships, which are at the foundation of HEAL’s work.

Finding Spanish Opportunities in Medical School

When you receive an interview from the University of Michigan Medical School, they ask you to share something unique about yourself that you can do. While some responses are funny, like being able to eat a 3-lb. cinnamon roll or talk like Stitch from “Lilo and Stitch.” Others are more serious:

“Can run an ultramarathon.”

“Can read Arabic and Hebrew script.” 

“Can build and race cars.”

I can honestly say everyone in my class has a passion outside of medicine, a skill they are trying to enhance, or a hobby they love. Whatever this may be for you, I think a natural concern for applicants is, “Can I continue this while in medical school?”

2016, living in Nicaragua. My host-mom and host-sister are two of the most loving people and the best teachers. My friend who recently graduated from UMMS did a global health rotation in Nicaragua, and I hope to do the same.

After graduating from college three years ago, I set out to learn Spanish. This involved living in a Spanish-speaking country, traveling and getting involved with organizations locally. One of my main goals when starting medical school was to not only maintain the progress I had gained, but also improve.

I have found the opportunities to learn, practice and apply a second (or third, or fourth) language are everywhere if you search for them. Since starting medical school four months ago, I have been able to translate at a free clinic for migrant workers, where medical student Spanish-speakers are paired with non-Spanish speaking clinicians. I have worked with Washtenaw Health Initiative to help Spanish-speaking community members enroll in health care coverage. I have also helped orient Spanish-speaking patients at the U-M Student-Run Free Clinic in Livingston County.

These experiences have been some of my favorite experiences thus far in medical school; however, my most educational Spanish language experience has been the student-run medical Spanish elective. This is a class where a small group of medical students meet in the evenings two or three times a month with a Michigan Medicine physician who is either a fluent or native Spanish speaker. The session is entirely in Spanish and usually begins with the physician pretending to be a patient as the students walk through an entire visit, starting with taking a complete history. We then discuss the case in-depth, and possible diagnoses and treatments.

November, 2018. Volunteering for Washtenaw Health Initiative to get the word out about open enrollment for health insurance and connect people to resources.

During a year where our academic material focuses on the details of organ systems, drug mechanisms and anatomy, this course, refreshingly, has an entirely clinical focus. We not only learn Spanish medical vocabulary and phrases, but as a group we walk through creating a differential diagnosis and learn more about how doctors think. It has also been a wonderful opportunity for students among different classes to spend time together.

Whether you are interested in improving on a second language, taking piano lessons (seriously, these are offered to medical students), or perfecting your Disney character impersonations (consider auditioning for The Smoker), just because you are in medical school does not mean you need to put these goals away for four years. In fact, I’m learning it’s better if you don’t.

Learning to Choose Wisely

In January of 2018, then-M1s James Haggerty-Skeans and I escaped the cold Michigan winter for Austin, Texas as part of a new US Medical School initiative — Choosing Wisely STARS. Having already taken Canada by storm, Dell Medical School spearheaded the US campaign, inviting two M1s from 20 medical schools across the country to discuss the importance of value and resource stewardship in medicine.

M2s James Haggerty-Skeans and Katherine Wolf meet with their mentor Dr. Micheal Heung and the American Board of Internal Medicine Foundation Executive President and COO Daniel Wolfson

After surviving an unnecessarily eventful evening of travel that involved an unexpected detour to Chicago, a pair of lost shoes, and a minor run-in with security who tried to confiscate my tuning forks, James and I were ready to meet our cohort and get to work.

Throughout the following two days we uncovered the history of the Choosing Wisely Campaign, which was initially launched in 2012 by the American Board of Internal Medicine Foundation. Based on a 2010 article in the New England Journal of Medicine by Dr. Howard Brody, the campaign focuses on encouraging medical sub-specialties to identify five tests or treatments from their specific field that are overused and offer limited benefit to the patient. Since the initial nine publications, more than 80 societies have joined the initiative and published their recommendations.

James and I were subsequently tasked with bringing this national campaign to UMMS. Although perhaps more challenging than our other options, we were excited by the idea of systemic curricular change and sought the help of our faculty adviser, Dr. Michael Heung, to lead us in our endeavor. In our quest for space within the curriculum to emphasize this topic, we quickly found an ally in Dr. Jennifer N. Stojan, director of the Doctoring course. Over the past several months, our team has worked to construct an M4 Doctoring Session, which will launch in March of 2019, and will cover US health care expenditures, the impact of cost on patients, and how they will be able to reduce waste in their own practice.

As James and I transition into our lives as newly minted clinical students, we are lucky to have added two M1s to our team as they prepare to fly to Austin for what we hope will be the second of many Choosing Wisely cohorts from UMMS. While resource stewardship was not a passion of mine prior to medical school, I look back on the impact it made throughout my first year and am confident this experience will influence my clinical decision making, patient interactions and research interests both in the remainder of my education and in my future practice.

Physicians Connected

I struggled with severe depression and suicidal ideation during my second year of medical school. Depression robbed me of the things I value most – my intellectual curiosity, my motivation to help others, and my will to live. I had come to Michigan armed with a genuine love of science and an earnest desire to do good, but there was a miserable period of time when I lost touch with both. I spiraled. I started to perceive myself as negligent, unlovable, a failure. Thankfully, a member of the medical school administration recognized how much I was struggling, and connected me with lifesaving mental health resources. With the school’s support, I took time off. I worked with a psychiatrist. I took medication. Gradually, over the course of many months, I recovered. I became curious and motivated again. Overcoming depression was unequivocally the hardest thing that I have ever done.

Hanging out with one of my best friends in medical school, Jasmyne Jackson, after the ‘Out of the Darkness’ walk put on by the American Foundation for Suicide Prevention.

Since getting better, I have become passionate about diminishing mental health stigma, publishing my personal narrative and producing a short film about depression with contributions from over thirty students, residents, and faculty at Michigan Medicine. I founded the grassroots initiative, ‘Physicians Connected,’ in the hopes that more medical trainees who need help will not be afraid to ask for it. I have worked to bring more attention to the issue of physician mental health through interviews with the E.W. Scripps news company and with NPR (airing soon on Michigan Radio’s Stateside!).

Primarily because of the energy and enthusiasm that abounds at Michigan, my advocacy efforts have taken on a life of their own that I could never have anticipated. On September 29, 2018, Physicians Connected participated in an ‘Out of the Darkness’ walk, put on by the American Foundation for Suicide Prevention (AFSP). Our team of medical students and attending physicians joined the citizens of Ann Arbor in a walk around the city in an effort to combat mental health stigma and raise awareness about depression and suicide. In the two weeks preceding the walk, we raised over $3000 to support AFSP’s important initiatives, which are all focused on preventing suicide and supporting those affected by suicide. At the walk’s start, we were joined by Debbie Dingell, U.S. Representative for Michigan’s 12th congressional district since 2015. Congresswoman Dingell (bottom left in the group shot below) gave a moving speech about losing her own sister to suicide, and emphasized the importance of the physician voice in changing the way that mental illness is conceptualized. It was a truly beautiful day!

The Physicians Connected team (comprised of medical students, residents, and attending faculty from Michigan Medicine) at the ‘Out of the Darkness’ walk, put on by the American Foundation for Suicide Prevention!

I felt so alone when I was depressed, and so ashamed. But since sharing my own story, I have received hundreds of letters from physicians and medical students from around the world, empathizing with my struggle. I have learned that depression is an epidemic in the physician and physician trainee populations, and that as is the case with any epidemic, committed people are needed to put up a fight. Somehow, a great passion has developed out of my darkest hour – one that lends strength and meaning to my personal and professional identities. I have truly never felt more in touch with my motivation to help others, or more excited to be a doctor. As I express in my essay, ‘I Solemnly Share,’ “If I have learned anything after spending most of my short life in pursuit of academic distinction, it is that the appeal of the dividends – good grades, high praise, awards – is as ephemeral as the warm glow felt on their receipt. Not so with the call to protect human life; that’s something truly worth living for.”

Ann Arbor Delonis Clinic

It has been a dream of mine to attend the University of Michigan Medical School since I was very young. This is partly because I have always been a huge Michigan football fan, but more importantly because of the tremendous amount of opportunities Michigan offers to help people who are financially disadvantaged. Coming from poverty, I have always wanted to give back to this community to hopefully give them a chance at following their dreams, as my mentors have done for me. I took advantage of one of these opportunities last week by volunteering at the Delonis Clinic in downtown Ann Arbor, and wanted to share this experience with you.

To begin, the Delonis Center is a homeless shelter that started in 2004 with the goal of providing homeless people in Ann Arbor and surrounding areas free housing while they help them get back on their feet, find a job, and find permanent housing. The Delonis Clinic, where I volunteered, is the medical center inside of this building. It resembles a small urgent care facility, but the impact it has had on the greater Ann Arbor area is extensive. Anyone who meets a certain financial need is eligible to either make an appointment at the clinic or stop in during business hours to be seen for a variety of ailments. This has been a blessing for the people who have used the service.

I can relate to this personally as I have lived most of my life without health insurance. The stress of deciding what is “urgent enough” to go see a doctor is something I hope none of you have to experience. Considering almost all of the patients the clinic sees are also homeless, one can see the difficulty these people experience when trying to manage their health. The fact that Ann Arbor has a place in the Delonis Clinic where they can effectively treat this population is something that makes it a very special place to me.

The role of the medical student at the Delonis Clinic is also very rewarding. As an M1 you are paired up with a senior medical student (usually M3 or M4) and a family care physician. The M1’s role is to greet the patient, take their vitals, then spend about 20 minutes taking their medical history and doing a relevant physical exam for whatever brought them to the clinic. The M1 will then present these to the attending doctor, go over a possible treatment plan for that patient, and then see the patient with the doctor to explain their options to try and find a patient-centered solution to their concerns.

This experience is priceless. For me, much of the first year of medical school has been trying to figure out how to tie in the massive amount of information we are learning into actual clinical care. Being able to volunteer at the Delonis Clinic gave me a low-stress experience to help me answer some of those questions and serve a population that is less fortunate than myself. Having this type of opportunity is something I believe makes the University of Michigan Medical School a special place to train.

My “First” Tag Days

I’ve never liked walking around outside in the cold, even if I did grow up in Ann Arbor, Michigan. I therefore never quite understood why my parents would bundle my twin brother and me up to walk around downtown Ann Arbor late at night the first weekend of December every year as a kid. Even though I had to succumb to the frigid temperatures and be dragged in and out of stores participating in the annual Midnight Madness sales, there was one thing I remember loving about that tradition: collecting all of the colored tags from the University of Michigan Medical School students around town. I didn’t really get why there were “grown ups” dressed up in funny costumes and red capes around town exchanging dollars for colorful tags, but I never really questioned it.

Tag Days has always been important to my family (see picture of my old dog, Hunter, with tags on his collar in 1998). My mom was a Galens member when she was in medical school at U of M. Since becoming a faculty member, she has been a Happy Van driver countless times, distributing hot chocolate and snacks to cold, hungry taggers around town. My dad recalls that one of his favorite Tag Days memories was when he would walk my brother and I around from corner to corner trying to find my mom’s van so we could see her and say hi. Growing up, Tag Days brought my family and the local community together as we’d celebrate in downtown Ann Arbor each year. And so, my love and appreciation for Tag Days started to bud far before I understood the full extent of what Tag Days means.

Fast forward to December 2, 2017. I woke up on what seemed to be the most important day of my life—the day I interviewed at the University of Michigan Medical School. Before I walked out of the door in the morning, my mom flagged me down and reminded me to grab a couple of bucks so that I could donate to the students spread throughout the hospital and receive a tag, which I proudly wore on my coat for the rest of winter. Less than a year later, I am now a student at UMMS with the first weekend of December fast approaching. Over this year, I have learned that the funds raised through Tag Days go to local organizations in Washtenaw County that work with underserved kids. I’ve also learned about all about the logistics of planning such a large event, and have eagerly helped fold tags in the student lounge as a late-night study break. Now that I’m finally starting to understand what Tag Days is about, I can’t help but feel honored to be a part of a tradition that I grew up with, and which means so much more to me now. For me, Tag Days is about bringing together and supporting community, as it brings Washtenaw County and Michigan Medicine together in the most beautiful way. I am so excited for my “first” Tag Days as an M1 and to be able to bring together and give back to the community that I grew up in.