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Music and Medicine

Nearly two months ago, I had an epiphany about the similarities between two areas of my life that are important to me. My stepson had alternated between recordings of “Für Elise” and “Moonlight Sonata” on YouTube one night while doing homework, so my husband asked if I wanted to surprise him by taking in ’s performance of Beethoven’s Ninth Symphony. I enthusiastically agreed and the next evening we all got dressed up and without telling him what we were doing, went to the theater and purchased last-minute tickets.

Ann Arbor Symphony Orchestra (April 2019)

Our seats might have been considered nosebleed by some (and surely, each step brought a bit of trepidation as we climbed to a dizzying height), but once we were settled in, we realized it was the perfect vantage point to take in the entire panoramic view. is a gorgeous facility where I’ve seen everything from Handel’s Messiah to Snarky Puppy. It’s also the location where I received my nearly three years ago.

Despite the significant height difference, these are indeed my proud parents; it is a privilege having these folks in my corner. (White Coat Ceremony, July 2016)

All eyes were fixated on the performers up front, scanning the different sections. The most famous movement of the piece, commonly known to many listeners as the “Ode to Joy” theme, is full of moments of crescendo when the instruments and voices swell, concurrent with an emotional response from the audience. The sound reverberated throughout the building and made my heart race, much like on the day I nervously walked across the stage and entered my journey into becoming a physician.

My mind went to the scene of a patient with a racing heart due to unstable atrial fibrillation who required cardioversion earlier that week. You see, the evening of the concert, I was in the midst of a string of overnight shifts as part of my Emergency Medicine rotation. The parallels between the “resus” (resuscitation) bay and the activity on stage in the concert hall were many. Just as each group of instruments has their assigned part to play (literally), members of a health care team have their own roles. While most are adept at carrying out their part with little instruction, it is necessary to continually check in and take cues from the conductor. In the Emergency Department, the maestro may be an attending physician; often though, the faculty member stands back while a resident (physician in training) directs and guides the action, much like the concertmaster is an instrument-playing leader of the orchestra.

As a medical student, I often feel like the tambourine player in these situations: not yet useful enough to be integral in every song, but occasionally given a “solo” and allowed to intervene in an important and noticeable way, like pushing the SYNC and SHOCK buttons of a defibrillator to deliver electrical energy to that patient in the unstable cardiac rhythm. Or, for the patient who dislocated their patella (kneecap), grasping their ankle and gently extending their leg while a resident applied firm pressure on the knee to pop it back into place. These are moments that, much like a moving piece of music, make me hold my breath, filter out the distractions in the periphery, and focus on the art in front of me.

A few hours after the last note had been played, having changed out of my dress and heels and clad in scrubs and white coat, I felt lighter, and ready to work in “concert” with the rest of the group. Walking into the team area, there were numerous exchanges going on, the chatter of various tones and cadences. In between pagers going off, phones ringing and overhead announcements, conversations took place between techs and patients as they were wheeled to their rooms. “Music to my ears,” I thought, as I sipped my coffee and settled in for my Saturday night shift in the Emergency Department.

Parliamentary Procedure and Other Lessons Learned at the AMA’s Annual Meeting

This weekend, June 6th-8th, instead of studying for the Infectious Disease/Microbiology quiz, I opted to go the American Medical Association’s (AMA) Annual meeting in Chicago as U of M’s representative.

I joined our chapter of the AMA in January with the goal of creating and influencing policy to protect the health of our patients, learning more about how to effectively advocate for patients as a future physician, and, of course, getting that sweet, sweet weekly copy of JAMA. Since joining, I’ve participated in social media campaigns in support of specific legislation, directly lobbied lawmakers on behalf of patients, and helped write a resolution advising the Michigan State Medical Society to take a stand against gun ownership for people convicted of intimate partner violence. Organized medicine has proven to be an awesome experience. Until this weekend, though, I hadn’t taken part in one of the key activities of medical student AMA membership – the Annual Meeting of the Medical Student Section (MSS) Assembly.

I took the train to Chicago and got in late Thursday night. After an early breakfast on Friday, I got my credentials (a piece of yellow paper with UMMS written on it) that indicated I was a voting member of the MSS assembly. I didn’t realize how heavily these types of assemblies rely on Parliamentary Procedure (or Parli Pro, as self-proclaimed Parli Pro nerds call it) to keep things moving. The whole scene of the first session was one of ceremony and formality that I didn’t expect – a blur of motioning, seconding, and objecting to the various resolutions that medical students from across the country had submitted to be debated and adopted (or rejected) as AMA-MSS policy. Resolutions are proposals that ask the AMA to take a specific political position or to initiate an action. If a resolution passes with a majority of votes in the MSS, it can then go on to the full AMA Physician section to be adopted (or rejected) as the official stance of the AMA.

After the first session, we split in to smaller regional meetings. These regional meetings have a very ‘’-esque feel about them. In our region, medical students from Michigan, Indiana, Ohio, West Virginia, and Kentucky tried to reach a consensus on a wide range of resolutions that would be coming up for a vote in the afternoon and strategized about the best way to get resolutions authored by our students passed by the majority. After an hour and a half of deliberation, we broke for lunch and the afternoon session.

During the large assembly gatherings, if anyone in the room feels strongly about a resolution, they are encouraged to find a microphone and make their case to the group for passing or rejecting (or reaffirming or referring for study or tabling, etc., refer to paragraph 2’s comments on Parli Pro) it. I’m not a big fan of public speaking even to just our Leadership small groups, let alone hundreds of medical students at once. However, there were two resolutions that came up that would seek to expand the AMA’s efforts around ensuring patient safety and well-being throughout their recovery from opioid use disorder (OUD). This is a personal and academic interest of mine, and I didn’t want to miss my chance to inform my colleagues; decision about the policies. I nervously went to the mic and urged the Assembly to bear in mind the social and economic determinants that our patients with OUD and other addictions face, and to recognize that we should bring the resources of the AMA to bear on those problems where we can.

I’m not sure how much of an effect a single testimony like that actually had on people’s votes, but I was proud to stand up for vulnerable patients in that moment. Moments like that are why I joined the AMA in the first place. I’m on the train back to Ann Arbor while I write this, and I still need to take that Infectious Disease quiz. But I’m glad I didn’t miss a weekend full of learning, networking, and advocacy.

Staying Organized in Medical School

Medical school is complicated, and it can be easy to get lost in the process. Just three objects make my world a little easier to manage.

Paper Planner: I am a pen-to-paper gal, so I use a planner to keep myself organized. I divide each day into three sections: academics, wellness and other. For academics, I include the number of lectures I need to study, required activities, pre-work reminders and assignments. I try to keep this section less cluttered by using my phone for referencing the school class/activity calendar. My wellness section often includes yoga class times, personal training goals, and the occasional reunion with friends who are not in medical school. My other section is full of tasks such as folding laundry, preparing lunch for the next day, attending events at Michigan Medicine, and practicing for , a student-run dance organization at UMMS. I plan as far ahead in advance as possible to (1) maximize my study time, and (2) maintain professional and personal relationships.

A snapshot of one of the pages in my First Aid book and my new planner for the clinical trunk year.

First Aid for the USMLE Step 1: I use the First Aid (FA) text to complement my weekly sequence learning. This book was written to help students condense preclinical information into more than 650 pages of must-know concepts. Fortunately, FA was provided to incoming first-year medical students a couple of months into the first year. I wish I had received it sooner though because it helps me stay focused on retaining the most high-yield information. In addition, each sequence is taught by different instructors with their own style and determination of what is and is not significant to learn in the first year. As a result, FA complements what may or may not be included in classroom learning. I hole-punched the text at a local print shop to put it in a binder. Not all the information I need to know for the USMLE Step 1 exam is provided in the book, so I needed the space to include my notes from lectures and small groups. Some organization and preparation now will help me be as ready as possible for the USMLE Step 1 study period after my second year.

Tablet: Throughout my undergraduate studies at the University of Michigan, I used paper for all of my note-taking. Like I mentioned before, I use a planner to stay organized. I did not think I would like using a tablet for studying purposes, so I started medical school by printing out the lecture slides and writing directly on them as I had always done before. What I quickly realized was that (1) I was not helping the environment by printing so much, (2) I did not have the space to hold all those notes, and (3) I would spend as much money printing and purchasing ink throughout the year as I would investing in some convenient technology. On my iPad, I keep all the slides in dividers and subjects in an application called Notability, so I never leave notes at home! I can also easily transport my iPad to and from school, which makes room in my backpack for my binder of the First Aid book discussed previously. I chose the iPad because I determined that it was the best way for me to study efficiently. However, there is no specific technology that is mandatory for students to have or use. The UMMS Financial Aid Office is also available to help students finance educational items…such as a tablet!

Spending 30 minutes updating my planner every week, consistently devoting a few hours every Saturday to adding information to my First Aid book, and regularly charging my tablet has made the transition to medical school just a tad less difficult. Every person is different, so when you matriculate as a medical student, spend some time adjusting to the pace of school and finding ways that work for you to stay organized.

Learning How Innovations Enter Medicine

During the last term semester for my dual-degree program at the Ross School of Business, I worked as a student consultant for , a company based in San Diego that makes continuous glucose monitors (CGM). This engagement was a part of the Michigan Ross 

The Team,The Team, The Team.

Our task was to evaluate a potential new market for these devices beyond Dexcom’s core market of type 1 diabetic patients. The project was a perfect opportunity to apply my clinical and business knowledge in tandem. One of the best parts of MAP was being able to draw from the expertise of my fantastic team members. Among us, one teammate had worked in financial regulation in Japan, another worked as a yield strategist for an airline, and another had experience in health care software.

As a part of the experience, we had the opportunity to try the devices on our ourselves for 10 days. I was impressed that I couldn’t feel the sensor at all, and it stayed put despite a week that included surfing and rock climbing. My main insight from having my glucose monitored around the clock was that earlier dinners significantly decreased my morning fasting blood sugar.

I was surprised by how much the research skills I built up through years of quality improvement work translated to a business environment. I also enjoyed the opportunity to dust off my clinical vocabulary. During the project, I felt lucky to be part of the University of Michigan network. Our requests to connect with physicians and other experts were quickly answered, and it was invaluable to be able to tap into their expertise.

San Diego had no shortage of beautiful places to explore in our time off

The experience was also educational in terms of best practices for team work. In a clinical environment, almost all of the work we do is in teams, but I have been part of very few teams where norms and expectations for the whole team are clearly laid out at the outset, in part due to a hectic schedule or due to frequent team turnover. Creating a team charter at the start of the project and intentionally thinking through the division of labor helped keep our workload balanced. It certainly helped that all of our team members were motivated to contribute.

This month, I am back in Ann Arbor seeing patients on endocrinology consults and clinic, and experiencing firsthand the impact that technologies like CGM can have in improving patient care.

We Mamas are Good for Medicine

It’s been almost 10 months since our white coat ceremony. I remember walking across that stage with confidence, despite being one of the oldest students in my class, without a pre-med background, without having cultivated a childhood dream of becoming a physician. I remember scooping up my daughter and handing her my brand new stethoscope with nothing but joy. I was certain I would crush it.

Spoiler alert: I was wrong.

Claire eating all of the cheese and crackers at our White Coat Ceremony reception in August 2018.

Very few women have children during medical school. There are even fewer of us who begin this journey with children, and it’s no wonder why. I could not have imagined how unbearably hard this year would be, nor how hard it would be on my family. I wake up every morning battling imposter syndrome, wondering what I’m doing here, barely sleeping, barely surviving, often barely passing alongside my extraordinary peers who average in the 90s on Every. Single. Exam.

The University of Michigan’s Medical School is a wonderful place. I am surrounded by brilliant and collaborative colleagues who not only want success for themselves, but for all of us. The intellectual curiosity and dedication to meaningful service is palpable in every lecture hall, every clinical encounter, and every conversation.

Above all, folks are generous and kind. When I show up late to Anatomy trembling and overwhelmed with guilt after fighting with my toddler all morning because I didn’t have time to find her favorite socks or read her another book, I know I can crawl into my house counselor’s office for a long hug and an overdue cry. When childcare plans fall through and my three-year-old audits my radiology small groups and free clinic meetings, I know my peers will gladly play hide ‘n’ seek in the halls of Taubman library with Claire so that I can have a moment to breathe.

Honestly, though? Medical school is just not made for mothers. Not yet, anyway.

I never had any intention of pursuing an M.D. I spent all of my twenties working in education policy and teaching in high-need public schools. Being an educator brought me tremendous joy; I saw great success within my classroom walls every day, and I thought I would do this good work forever. Then four years ago, I became unexpectedly pregnant with my daughter. In my search for prenatal care, I was surprised to find that my health insurance was not accepted by any of the many reputable medical centers in Chicago. I spent my entire pregnancy and much of my postpartum months in a thick cloud of depression and helplessness, not able to navigate this broken system that denied me access to quality care over and over again.

It shouldn’t be this way. Women deserve more. We deserve better. I know now that I must be a part of the solution. And every morning — when my daughter wakes me up at the crack of dawn, three hours after I’ve reviewed my last lecture slide and all I want to do is curl up in the fetal position and give up — I know that I just have to get up and do my best again.

It’s just so hard, y’all. And I’m so, so tired.

Our first UMMS Mamas Playdate in May! For many of us, it was our first time meeting other mothers in the program.

A few months ago, I was invited to a brunch at Dr. Helen Morgan’s house with an unbelievably impressive group of U-M Women’s Health physician mamas. I was so hesitant to attend, knowing that I’d be the only woman there without an M.D. in a sea of attendings and residents. Honestly, I was terrified.

But perhaps the best part about Michigan is the sincere commitment to creating a collegial and collaborative culture between faculty and students. It’s real, you guys; I saw it firsthand. Their kids played with mine. Their spouses commiserated with my husband. And these beautiful, brilliant women included me in their honest reflections about the struggles of doing it all. That morning, I got a glimpse of what might lie ahead. It appears the exhaustion never ends, but there is persistent joy. Persistent reward. Persistent community. And persistent love.

So to the mamas here with me at the medical school: Thank you. Thank you for your tenacity and strength. Thank you for contributing your ever-valuable experiences and perspectives to our medical training. Thank you for choosing to care for each other, even when you barely have time to shower or get your kids to daycare before your classes or clinical shifts. Thank you for reminding me that it’s never too late for us to pursue our dreams and do more good.

And to the mamas who are considering this path, who dream of becoming physicians: Join us. There are strong mothers here at Michigan who are doing it, and doing it together. Together we will continue to strengthen and grow our community. Together we will advocate for change so that mothers don’t just barely survive in medical school — we, too, deserve the opportunity to thrive.

We need more #MamasInMedicine because we mamas are good for medicine.

Learning about health disparities in Northern Michigan

“Hey, doc,” our new patient said as I walked into the room, grinning at me without teeth. He only wears his teeth to eat peanuts, he explained, but today he had opted for a ham sandwich, so he left the teeth at home. Here in the clinic straight from his logging job, he wore steel-toed boots and layers of heavy clothing, hands covered in dirt. Clarifying that I was a medical student, I asked him if he had any medical concerns. “Oh, not really, just the usual stuff, nothin’ too bad,” he said.

Watching Lake Merritt at sunset is my favorite evening ritual here!

He then disclosed what his “usual stuff” entailed: chest pain, on and off, nearly all day, sometimes so bad it took his breath away. Eyes going black, sometimes one eye, sometimes the other. Pain in his fingers and toes, twice so painful he went to the hospital and ended up with an amputated digit—he wasn’t sure why the amputations occurred, but was glad they didn’t need to take off a thumb. Smoking since adolescence, now racking up more than a hundred pack-years. Waking up soaked in sweat most nights, and weighing just above a hundred pounds, even with those heavy boots and layers.

“But generally, things are goin’ good!” he said cheerfully. He explained that he hadn’t seen a doctor in years, but came in today to double check that there wasn’t any chance he could end up with a heart attack.

I left the room and frantically relayed this list of problems to my preceptor. She listened patiently and asked what I wanted to do. A flurry of medications, diagnostic tests, and lifestyle changes stormed my mind, turning it into a white-out. “Umm…” I stammered. There was so much to do, I couldn’t slow down my racing thoughts enough to name a single individual action item. “First step,” she filled in, “is saving his life by giving him clear instructions on when to go to the emergency room. Can he read?”

Hello from Cadillac, Michigan, where I have been rotating at a federally-qualified health center for the past month. The clinic, called , uses a sliding fee scale to accept all patients, regardless of insurance status. I chose this elective because I wanted to gain more exposure to rural health care and health disparities. In my clinical rotations in Ann Arbor, I’ve gotten great training in high-resource and primarily inpatient settings, but before this month, I hadn’t yet experienced health care in a lower-resource or a more rural setting.

Having grown up in Iowa and Utah, and going to college in Western Massachusetts, I cherish the sense of peace that I feel in rural places. And as a former anthropology major and grassroots organizer, the social and environmental contexts of health are what drew me to medicine. So when an amazing med-peds attending from one of my U of M inpatient teams said she was moving to northern Michigan to work at a rural clinic for underserved patients, and asked if anyone wanted to tag along, I jumped at the opportunity.

It has been an incredible experience! Here are three key highlights of what I’ve learned:

First, this rotation has helped me to realize that, despite my strong intentions to keep the social contexts of disease at the forefront of my approach to patients, as a medical student I’ve inadvertently gotten wrapped up in the pathophysiology and treatment of disease. Learning the intricacies of the human body over these past three years has been fascinating, challenging and all-consuming. That scientific and clinical foundation is critical for becoming an excellent doctor. But it is not sufficient.

This month has been a wake-up call, bringing me back out into the broader picture again of the social contexts of disease. For example, there’s no point in recommending a high-fiber diet if my patient doesn’t have teeth. There’s no point in orchestrating referrals to far-away specialists if my patient doesn’t have reliable transportation. There’s no point in creating detailed instructions for a meticulous treatment plan if my patient can’t read.

Second, being far from specialty care makes family medicine here feel almost like an entirely different field to me. The U of M family medicine clinics I rotated in come with the privilege of easily referring patients to specialists. Here, such referrals are often last-resort options. There are very few specialists in the area, and many of them do not accept Medicaid or uninsured patients. Transportation to appointments is often challenging. Wait times can be several months or longer. (And for many mental health patients, there simply are no psychiatrists available to see them, ever).

Due to challenges like these, my preceptor needs to do extensive diagnostic sleuthing herself, diving into the literature of fields like rheumatology and hematology far more than she ever needed to at the U of M. This can be scary and stressful when a patient’s symptoms don’t make sense, and there is nobody available to help put the pieces together. But as a student, this has also been an amazing opportunity to stretch my brain, improving my differential diagnosis skills and my comfort with managing complex conditions. Regardless of the setting I end up working in, I hope to carry this detective mentality with me: it is making me a better doctor.

Third, despite that patients’ formidable health and social needs often remain unmet, there is nonetheless a wealth of incredible resources in the Cadillac community. My preceptor facilitated days in which I spent time with people who work in support services, such as Community Mental Health, insurance enrollment, hospice, physical therapy, and the WIC (women, infants and children) program. She has intentionally built connections with these organizations because collaboration and communication improves patient care. I had inadvertently taken this for granted at the U of M, where if you have a question, there is always someone you can call for input, either as a formal consultation or as an informal “curbside” question. Here, there often is nobody to call.

My preceptor’s intentional creation of connections among health providers has made a huge difference in her ability to serve her patients. For example, given the difficulty getting psychiatry appointments, her outreach to Community Mental Health enables her to get input on her patients’ psychiatric conditions; the psychiatrists, in turn, can ask her about their patients’ medical conditions. Likewise, through connecting with people at the WIC program, she can better understand the social contexts of her pediatric and maternal patients, thus enabling her to better address their needs holistically.

As a student, exploring these community resources gave me new windows through which to view patients’ journeys through the health care system. One of the most meaningful parts of medical school for me is the privilege of being with patients in vulnerable moments. Through spending time with people who work in these community support services, often meeting patients in their own homes, I witnessed types of vulnerability that often hide from the white-coat, sterile settings of clinics and hospitals: financial, cultural, spiritual vulnerabilities.

For example, an elderly veteran who proudly worked his whole life only to become ill, lose all financial resources, and end up with nowhere to live and nothing to eat. A teenage Spanish-speaking mother living in an isolated trailer with three children, trying to navigate health care in a new country without transportation or with an unfamiliar language. An impoverished middle-aged man with a deep distrust of the medical system and a home in shambles, diagnosed with incurable lung cancer, facing his imminent mortality as rain poured through his broken roof.

Witnessing these situations has been bleak. Sometimes it has felt impossible to make a difference. But these experiences have also brought me hope, in various shades: People are resilient. Small changes can improve lives, often with effects not immediately apparent. And, as with my preceptor and her colleagues, the people working at the community support services are incredibly motivated to help their community, with a mission-oriented ethos that becomes a powerful emotional buoy.

Overall, I am so grateful for my month with Family Health Care in Cadillac, which has taught me a tremendous amount about both clinical and social aspects of health care. It has rekindled my passion for working in underserved areas, given me a broader view of our health care system, and highlighted the importance of thinking about every patient’s situation holistically. I encourage this rotation for anyone interested in rural health disparities or anyone simply wanting an adventure!

*Details have been changed and omitted to protect patient privacy.

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