What the Virus Spread

This Rural Mission is a podcast brought to you by Michigan State University College of Human Medicine, the Herbert H. and Grace A. Dow Foundation, and the Michigan State University College of Human Medicine, Family Medicine Department. We are so excited to bring you season three. I'm your host, Julia Terhune, and I hope you enjoy this episode.

So, I remember it being the week of March 9th, that we got the news about us needing to pretty much convert our lives in the office, working directly with our students and I remember that being the last time that I walked into the office until I went back in late July.

That's Susan Tincknell. She's the director of student programs at our Marquette Campus in the Upper Peninsula. In November, I asked her to recount what's gone on since that early March date last year. It felt like we were talking about a time long, long ago, but I also hear from Susan in just a bit the impacts of COVID on our health care systems and our medical education at MSU, all of those impacts are happening still and right now. To explain a few of these ongoings, I want to walk you through a very rough timeline of everything that happened to our students from that March 9th date, going onwards to today. COVID landed in the United States, but seemed to relegate itself to major cities. That was until it didn't anymore. When it hit Michigan, it felt inevitable and unbelievable at the same time. Maybe you can resonate with that feeling as well.

Once it hit Michigan, our students were pulled first from the Traverse City Campus, and then from all of our other six campuses. The reason really was that there just wasn't enough personal protective equipment to keep our students safe. And the more people gathered in one space, the more likely they were to contract and spread the virus, so they were pulled. Since our curriculum at MSU put students in clinical settings starting year one, all 800 of our students at the college were not in clinical settings for several months. Now, doctors, medical students, residents, all of these individuals who go into a medical career are smart and resilient people. It seems like an understatement, they obviously are smart and resilient, but you'll never really know how smart and how resilient you can be until those skills are put to the test.

And the physician faculty at MSU and our medical students are some of the most resilient and smartest people I know. Within days of things going into lockdown, our college had online learning that was keeping students on track with their education and helping give them the skills they needed to tackle COVID-19 when they return to the clinic. The online education that was implemented was revolutionary. But as we know from other forms of online experiences, it's not ideal and can't last forever, especially when you're talking about clinical learning. Nevertheless, it was the best thing we could do with what we had, but learning wasn't the only thing that moved online.

Match Day 2020, and Match Day was Friday, March 20th. And that was supposed to be a grand celebration, in-person to celebrate some really hard work and accomplishment in finding out where everybody goes to residency. And that was converted last minute to virtual. It's not the same. That was really an eye-opener that this is actually happening and we're not able to gather with people. And moving forward, that same thing happened with commencement.

We are going to share the perspectives of students on this episode. Something that I think many people are interested in, but there was a whole group of non-clinical people who have been affected by this pandemic and their story is important to hear too. There's something we at the leadership in rural medicine programs share about our campuses. And that's the real personal connection you have with our staff and faculty and preceptors. But we don't just say that to promote our program, we say it because it's true. Not only that, but we have staff members in these communities that want to have connection with students, that have gotten into this work because they like and desire to work and impact student lives. COVID-19 has taken away a lot of human connection for a lot of people. And that has extended to our medical school administrators as well.

Very, very strange and somewhat difficult to change my life working with medical students to remote work. Zoom, although it's nice that we have it, isn't the same as meeting in person. And I'll just give you a little view of what the days were like if I were in my office. I would be sitting in my office and doing whatever it is I'm doing and a student would pop in and they'd say, "Hey, can I talk to you for a minute? I'm really wondering about finding a mentor in the specialty of surgery." And that would turn into a 30-minute conversation about their goals for their life, why they love surgery, who would be great mentors, okay? And then they'd leave and I'd have a smile on my face. And I'd think, "Wow, that was just a really great connection with that student."

And then maybe an hour later, a student would come in and say, "Hey, do you have a minute?" And they're struggling with something personally and we talk about that, or they've decided that they no longer want to be an anesthesia. They don't want to do that anymore, they want to go into pathology. And so we just have this great conversation that happened on the fly, in-person. I could give them a hug if they needed a hug and Kleenex if they needed to dry their tears. And because now we have to schedule, schedule, schedule, schedule.

We're going to now fast forward to the fall. The campus and the Upper Peninsula was able to send their students back to in-person learning first. At the time, there were limited cases of the virus in the Upper Peninsula region. It was a wonderful thing for these students and for the staff at the campus, but it didn't last long. After the summer months were over, Marquette County and parts of the Upper Peninsula and Wisconsin showed the highest rates of COVID-19 in the country. And all of a sudden, the situations that the UP campus had thought were in the past were blazing a new trail for their students.

I am now finding myself having to tell students, I'm sorry, you can't do this elective because COVID has affected that physician's office. I'm sorry, they're shutting down whatever office it is due to COVID. And to be honest, that the UP was immune from all of that. I thought, "What? Can this be happening?" And it is, and our students are being affected by it. And our community is definitely affected. Our hospital is affected and I'm scared. I'm scared for the remainder of the year. I am not so much scared that it's going to be harder work for me, but I do worry about our students' safety first and foremost. They'll become physicians, okay? I truly believe that that is going to happen, but for them to have the potential of not being safe, scares me.

When I reflect on what's gone on in our college, within our hospitals, within our personal lives and the lives of our students and faculty, preceptors, and doctors, I just feel heavy. I don't know if there will ever be enough words or interviews to tell you all what it's been like to be in medical education, let alone rural medical education during a pandemic. But like I said before, you just don't know how resilient or smart you are until it's been put to the test. And if the pandemic was a test for our medical students, I would say that they would graduate with the highest honors.

I would say that since our world was turned upside down, I think the students' resilience has been absolutely amazing. They amaze me every day. I could actually tear up talking about it because they're the heroes in this, they made it through. I'm here no matter what. I get paid to do this job, right? These students, yes were scared about their future, right? They were asking a lot of questions. Their rotations were all affected by this virus. We had students that really had some big plans to go and do some pretty amazing away rotations and to check out residency programs and cities and towns that they'd never seen before. And they were so excited and we've been prepping them for the whole year. And then I know isn't going to happen. And these students took it with class. They just amazed me and still do. And they still do.

I just think, "Wow, you'd never know that you guys have gone through medical school in the craziest time of this life." It's insane and they are rolling with the punches and they will do great things. We graduated students during a pandemic, okay? But then we kept the next group going and we started another group and all of these students have smiles on their faces. I am proud of our students. I am proud of our students. And what, if we didn't have great people helping the students and our staff has been amazing, it's just everybody's pulling together. Everybody's just wanting the same thing and that success for our students.

So there it is in a nutshell, the timeline of COVID-19. Students were pulled in March, by May, June, we had students back in learning situations in hospital systems with fantastic PPE and lots of precautions and yet with surges, ebbs and flow, changes in vaccination availability and the like, our students are still always being tossed back and forth. But that's what this story is about today. It's about our students, our residents, our faculty, it's telling the true tale of the type of people that we recruit to the leadership in rural medicine programs, the people who are going to serve your rural communities as leaders in the future, and the people who are currently leaders in your hospital systems, rural communities and larger urban centers. Shelby, who you'll hear in our podcast about 20 Years of Medical Education in the Thumb was in the Thumb when she found out that she wouldn't be returning. Here's her story of leaving and coming back.

Yeah. So I was actually working with Dr. Ramsey in Elkton, and we had been discussing the possibility that things could shut down from the MSU standpoint. The day beforehand and most of that day, I had heard other people had gotten pulled, another student that was in the clinic with nurse Burr in the system with the nurse and her sisters. She was pulled the weekend before and she had been my roommate leading up to that at the system. So we kind of knew that something might be coming down the pipe. So everything was pretty normal. We were seeing patients. This was before all of the mandated masks and everything, I believe. Things still seemed normal. So I went to see my patient and I came back and I could tell he was going to be a couple more minutes in the room he was seeing and so I checked my email. I don't know why I chose to check my email right then. And it said that we were being pulled from clinic at 5:00 PM that day and did not know when we were going to be coming back.

So it was around, I think probably late afternoon, the day was already pretty much over. It was our last couple of patients of the day. We came back and asked about the patient and I told him what was going on. And then I said, "And also, I will be leaving at five o'clock today." And that was kind of it. It happened, he quick threw a bunch of lectures together because we had wanted to talk about it. I had another half of a week or so with him. We'd wanted to talk about these subjects, he threw them together really quickly. We said goodbye at the end of the day, hoped everything would be okay in the end and I went back to the house that she was providing and packed up my stuff and left.

So I went back with Dr. Ramsey in Elkton. It kind of seemed like no time had passed when really a decent amount of time had passed. I had left his clinic that day to go home for an unknown amount of time. And just the same, I pulled up on that Monday and parked in my parking spot that I had been in the other weeks and walked in. And it was like nothing changed except now you have to check your temperature and wear a mask. And the whole office staff is just very like, "Oh, your back. We're so excited. Welcome back. What did you do in your time off? How did that work?" Dr. Ramsey went right back to our normal schedule of, "Well, you know how we did things. So here you go, go see this person." And it was like no time passed at all really, which was kind of an odd feeling like so much had changed, but also so little had changed.

I had my own strife when the pandemic hit as we all did. At the time, I was not only working as the assistant director for our rural programs, but I was also filling in as an interim director at one of our campuses. A job that's not easy on a normal day, let alone when you have to keep up on the medical education of students who can't work. But you want to know what I took away from that was how gracious all of our students were, especially when they were lurched into a new reality. Shelby was so gracious. She made our lives easier. She made my life easier.

I guess at the time, there wasn't really any other options. There was nothing that could really be done. So getting upset and being annoyed or frustrated or whatever it wasn't going to change what was going to happen. Obviously, MSU wasn't going to completely stop teaching students, no medical school in the country was going to just shut down. You can't. You can't just have a whole gap in students. So, I guess keeping the perspective that at some point it would be okay, maybe not perfect, maybe not back to what it was, but it would be okay, and we would get there. And in the meantime, I would get to spend some quality time in my apartment that I hadn't seen in a while. So overall, there just wasn't a good response that we would be productive, it was just kind of go with the flow and see what happens in the end.

And that grace has been extended to the communities students are learning in. Emily, a student who is now completing her rural clinical medical education in the UP, chose to take the time she couldn't be in the hospital setting or the classroom to help the community she was living in.

Yeah. So I Joined the MSU COVID volunteer team. And so I have been staffing the call center and also screening patients at some of our health office buildings to make sure that we're keeping our patients and our visitors safe during these scary times, and then also providing reassurance to patients as well. And so, I've been doing that and throughout my time in East Lansing, I've been volunteering at Cristo Rey Community Center, which is over in Lansing. And so they are still serving the community in this time and even may now be playing an even bigger role in helping the community get through this crisis. And so they provide a number of services to the community. They have free breakfast and lunch every day, they do food distribution. They also have a health center amongst another number of other services, many of which I think have been put on hold at this time just to reduce foot traffic inside the building, but they are still serving meals every day and distributing food. So I've been helping in those ways as well.

The thing about working and learning through a pandemic as a medical student is that even the hard stuff is beneficial. I think it either builds you up, helps you grow, or it's something that you can use to say, "Nope, that's not how I'm going to do things when I'm a doctor." Because you'll be a doctor. That's what I learned from talking with Evan. He was also one of our Thumb Rural students and you will hear him again this season. But this is what he had to say about being uprooted from the clinical learning setting just a few short weeks before he started residency.

On the one hand, it's certainly uncomfortable because like I said, I want to be in the clinic and I want to be using my skills and strengthening those skills as best I can and seeing the things I need to see to be prepared to start residency. But at the same time, I recognize that medical students are not necessarily essential team members at this point in time, and they would be using up that PPE that may be other team members would need. So I can totally understand why we might be asked to step out of the clinic for a few weeks. So I think at this point in time, while I may be feel frustrated, I think that's sort of a selfish thing to feel. And I'm trying to sort of understand the broader argument and appeal and looking to make the most out of these couple of weeks where I'll be doing distance learning and trying to make the most of that.

Some of the advice that I got was take notes, everything you're seeing now take notes. What are your thoughts? What are your feelings? What are you seeing done right and what are you seeing done wrong? Take note because the next time this comes around, you're going to be in that leadership position helping to make those decisions. So I think for me, I'm trying to keep my eyes open as wide as I can and try to capture some of that so that maybe the next time this happens, people will be more prepared. So I think having an emphasis on preparedness is maybe one good thing that will come out of this. There may be some bad things that come out of this, but I think there could be some good things that come out of this too.

So since we are on the subject of residency, let's talk a little bit more about it. Residency is the final step in medical education. Four years of undergrad, four years of medical school, which gets you a doctorate in medicine and three to seven years of residency, depending on what kind of doctor you want to be. It's a huge process. It's what you are working for every day of medical school. Without residency, you can't practice clinically. Students spend months applying, months interviewing and Match Day, which Susan mentioned earlier can be the happiest, saddest and most anxiety-riddled day of many students' lives. It's not just that they find out where they are continuing their education, these students will uproot their lives. And the majority of providers practice within 50 miles of where they went to residency. So having a clear picture of where you want to go, where you can go and why you want to go there, is huge, really huge.

This year, everything is online. Students will meet with their residencies and complete interviews online. They can't travel to these facilities and these facilities don't get a chance to show them anything. So I spoke with Dr. Julie Phillips about this. She's also going to show up again this season. Dr. Julie Phillips is a professor at the College of Human Medicine and the assistant dean of student career and professional development, along with being a family medicine doctor who does OB. And she works for the Family Medicine Residency at the Sparrow Hospital in East Lansing. So I think she might be an expert on residency. One of the things that I think we have all experienced during the pandemic is that the outcomes of what we expected to happen have really thrown us for a loop. So when residency went online, we heard often from students that they felt like they wouldn't do well with interviews, turns out that might not be the case.

I heard something about that in the beginning that the students were nervous about the video process itself. And the program was nervous about getting to know people on video, that it wouldn't be as easy. I actually think as we have done a few weeks of interviews now, we're getting a little more comfortable with that. And that doesn't seem to be quite so challenging as it did in the beginning. I think people are just more comfortable with the process. I do think though... Well, I don't know if this will be true, but I'm a little worried that it is harder for applicants to differentiate programs, one from another, and that it might be hard for them to actually put together a rank list. I was actually talking with an applicant the other day about a few different residency programs where she was applying. One of them was actually a rural program.

And I remember saying, "A lot of this really depends on where you want to live and what it's going to feel like to you to live in this place versus this place. These are two very different places." And she was looking at a rural program in Michigan, and then we were talking about what it would be like to live in Grand Rapids. And she'd never really spent time in Grand Rapids. And I actually said to her... The words came out of my mouth, "When you go, you'll figure it out." But of course she's not going to go, so that's going to be harder to figure out.

And I think that every year, applicants struggle a little bit with all the programs blurring together, especially at the end, which is one of the reasons why I really counseled them to take good notes and to really be thoughtful as they're going through the process about what they like about one program, what they like about another. But I am somewhat worried that this year that's going to be harder for them to really choose because they won't have seen many of the places where they will have interviewed.

So residency placement is uprooted, but residency itself has also been changed. While residents weren't asked to leave the clinical setting, their workload has increased, their stress has increased, and the requirements that they need to finish residency have also been interrupted with limitations in clinical learning. But it seems like our affiliated residency programs at MSU do a pretty good job at recruitment, just like our leadership in rural medicine programs.

There are some things that are unexpected and positive. I am incredibly proud of my residents and how much they have really stepped up and engaged and been cheerful and volunteered for things. And I have so much respect for them. I think they're wonderful physicians. And it makes me proud when I see them do great things for patients because the patients need it, even if it's not like the best learning experience. They take care of the patients first and they understand that and they take care of each other really well too. Just this week, our number of... This is such a thing that you wouldn't even think about. Our number of phone calls to inform employees that they had COVID, there was one day this week when it got crazy. Historically had been a couple of phone calls a day, and then all of a sudden there were so many phone calls. They just had to make so many phone calls and they're not easy phone calls because you have to help the person think through things.

And I watched them really help each other out and take care of each other. And that made me very proud. So I think that even though we're in a difficult circumstance and we all recognize there's an added workload, I also feel very strongly that our residency community is coming together in taking care of each other and I'm grateful for that and pleased for that. I still feel close to my colleagues and to my residents, even though I don't see them as much and even though we're not in the same spaces very often.

We're going to end today with words from two students, Logan and Emily. Both weren't born here in rural Michigan, but chose to stay in rural Michigan for the leadership in rural medicine programs and to stay in Michigan during the pandemic to support their friends, families, and communities. I wanted to highlight these two students because I think what they have to say brings hope for all of us. They are the next generation of physicians who will be serving you, your families, and maybe even your children. When were pulled out of clinical learning, their focus wasn't on the what's in this for me, but rather how could I be helping? I know that's what I want in a rural physician. And I hope it's what you want too. Here is Logan.

If anything, I feel a lot of angst that I wish I could do more as a medical student and knowing that I'm years away from being really useful in a hospital and helping patients, but also that's the things that I want to do and that's why I chose to be a doctor and to have that drive and that want to help people but to know that I'm not useful yet, it's pretty hard, especially... I see my wife go and she is useful in a hospital and she also has that drive to take care of people and that's one thing that we both have, and she is at a place in her career where she can use her skills and take care of patients. And as this grows and grows, she's going to be on the front lines and I'm going to be home.

And the only thing I can do is social distance and flatten the curve and I can be a responsible citizen that way, but I think a lot of things that I really feel is just like... I don't know, regret's the wrong word, but I wish I was born three years earlier. I wish I was born in 1993. That way I could be a fourth year medical student, maybe I could help out more than I can right now, because I know how useful I would be. I know I wouldn't be very useful at all. So, I don't think I should be in that situation, especially with the lack of protective equipment that we're having right now. I know that my me being in the hospital, taking up that protective equipment wouldn't be anything useful when there's other doctors and nurses and healthcare members who need it and are useful. So, it's not that I want to be in a hospital, I just wish I could be useful.

I think as medical students, it's hard to feel like you're having an impact because we're not on the front lines. We're not serving in that position role that we foresee ourselves in two to three years. And our goal right now is just to study and be students. And I think that's not always fulfilling because you're like, "There's a greater purpose. Our communities are suffering and studying at home isn't really helping to fight COVID." But realizing that there is the balance between our studies, but also finding those things that you do enjoy to do like volunteering or in whatever capacity and [inaudible 00:32:35] if it's donating blood or it's helping gather PPE supplies or assisting your friends and neighbors if you are healthy, getting groceries for a neighbor or cooking meals for someone. Just finding that way to feel like you are playing your part.

And I think as a community, and as a globe, as the world in general, we got into this together and it's going to take the entire world to get out of it. And so that means every person doing their part and individualism is not going to help us fight COVID, it's communities supporting each other and whatever that may look like for you. And I think that's going to help us in the days to weeks to come.

If I spent my goodbye thanking every single person who has been helpful, kind, gracious and just all in all interested in making a difference in our medical education efforts at MSU and the leadership in rural medicine programs, I don't know when this podcast would end. I am so grateful to our rural hospital partners first and foremost, because so many of them when I put the call out saying, "If you're willing to take a student, please help us," answered saying, "Send them over." When surges were low in these regions, they took it as an opportunity to educate our students. And then when surges have gone up, they have been careful and protective of our students' safety and wellbeing as well. And I can't thank them enough. I am also grateful to all of the students at the Midland Regional Campus who were a part of my life when I was doing the interim work, because they really all were that gracious and completely understood the need to be cautious and protective.

I know that our administration at our other two rural campuses felt the same about their students and I know those students were wonderful as well. I know how hard it has been for our medical students this year with everything being uprooted and unsure and just plain old different than what they expected their medical education to be like. My heart especially goes out to our first year students who entered medical school in the midst of a pandemic. I don't know what the outcome of all of this is going to be, but I have hope for it. I have hope that it's going to show the resiliency of our students, make better doctors and make us more proud of the efforts that medical scientists have made to protect us and to advance medical care.

So thank you. Thank you to Susan, Shelby, Evan, Emily, Logan, and Dr. Phillips. Thank you for speaking with me and helping me tell a little bit of the story of COVID-19 in medical school. There's a lot more to tell and if you have your own stories to share about how the pandemic impacted your life, I encourage you to share those with us online. You can check us out on Facebook and on our website. I hope that learning about how our medical students, our residents, our faculty, and our administrators care and have worked hard even in the most uncertain of times inspires you to make rural your mission.