By Kirsten Mowrey | Photos by Joni Strickfaden
Every July the University of Michigan Medical School ushers in a new class of future physicians. Those students spend a week in September scattered across the area visiting, conversing, observing, and receiving treatments from holistic practitioners to learn about healthcare from their perspectives.
I have been practicing massage, Trager®, and trauma healing work for 18 years. I am one of many practitioners hosting students that week. My visits are from 8:00 to 10:00 a.m., early hours for most students, and they often arrive groggy or flustered from dealing with traffic and unfamiliar directions. I typically host four students at a time, and I wait for all of them to arrive before beginning. We spend the first hour in discussion: What are the modalities I offer? Have they ever experienced any of them? What kind of healthcare and patients are they interested in? After that, some physical work: I give each of them a hands-on mini session of Trager® (movement reeducation work), offering gentle movement to the hands, feet, shoulders, or neck, and I have the group get up and do different movements, just as if I were doing a session with my clients. Nowadays, most students have had a massage of some sort, so we discuss the differences between massage and Trager®, and contextualize where each is more appropriate. I also explain trauma healing work. After their initial arrival, they relax in the dim room, and after receiving, they relax even more, their bodies getting lower in their chairs.
Opening the Conversation
When I first began practicing bodywork, connection between physicians and alternative practitioners was not common. At times, I felt that there were two systems running parallel to each other: conventional and holistic. When the U-M Medical School field visits became possible, I signed up, excited by the chance to begin building bridges between these two communities
I have always wondered what went on at U-M Medical School preceding and following these visits. Was there discussion? What effects did this have on their development as physicians? To answer my questions, I had several conversations with physicians who have been a part of this program. The first was with Dr. Sara Warber, one of the principal creators.
““We thought about what students knew and what we wanted them to know and came up with field visits as the best way to have a deeper understanding of CAM.” ”
Kirsten Mowrey: How did you create the field visit program for the medical students?
Sara Warber: In 2001, we received a grant from the National Institutes of Health (NIH), which coincided with a time of curriculum revision at the Medical School. This gave us the money to hire curriculum experts for design, and both the associate and assistant dean, who were intimately involved in the grant process, wanted Complementary and Alternative Medicine (CAM) as part of the curriculum.
Kirsten Mowrey: What was the motivation behind creating the field visits?
Sara Warber: We thought about what students knew and what we wanted them to know and came up with field visits as the best way to have a deeper understanding of CAM. The field visits occurred in a week where the curriculum was focused on patient care, with a lecture on CAM, a discussion group, and the field visits — not just to CAM practitioners but also to conventional medical practitioners’ offices. It also included a conversation with a senior citizen. We wanted them to observe the doctor/patient relationship and think about how what they saw in alternative medicine was different from and similar to what they saw in conventional M.D. offices. We wanted students to understand why patients would choose CAM and how important that was. I felt strongly that students should have a basic ability to converse with patients — that to say “I don’t know about that, don’t do it” was unacceptable as a medical doctor. Physicians need to have the language and terminology to talk with their patients, to come from a compassionate stance instead of an authoritarian one.
Kirsten Mowrey: Are there challenges associated with field visits? What happened when the grant finished?
Sara Warber: Regarding the logistical challenges, I know sometimes students were startled to be going to what looked like a home address and realizing that the buildings used [for care] may be different. The Medical School readily took on the expense after the grant because they felt it was successful and important information. I’m glad it’s continuing. I remember, at the end of the patient care week, the students had a final with several essay options, one of which asked why patients chose CAM. Generally, more than half the class would choose to do that particular question, to put together all the information.
““Physicians need to have the language and terminology to talk with their patients, to come from a compassionate stance instead of an authoritarian one.””
Mowrey: You are currently not involved with the program, correct
Warber: Yes, I passed the medical student program on to Dr. Amy Locke.
Mowrey: As you reflect back on your work with the Medical School, what stands out?
Warber: I think that this work has contributed to an overall greater acceptance of CAM among young medical doctors — not just the University of Michigan. Twelve schools got grants to do this; it was an amazing investment on the part of the NIH. In all this, people like yourself, people who volunteered [to host the field visits], it was people who really made this alive and real. The set of resources we have in this community made this possible; we couldn’t have done it if it was just academics [involved].
Mowrey: Thank you Sara, and best wishes.
Back in my room, the students have reached the limits of their attention for this early hour and are losing focus. Then I announce that I will be working with a client for the last hour, and the students’ attention sharpens. This is what they really have come for; this is the action, where it’s all at. They lean forward, they wake up, stir themselves. The anticipation is palpable as they await the opening of the door and meeting my client.
The Current Generation
To understand where field visits stand now, I met with Dr. Amy Locke and Dr. Amanda Kaufman, who, at the time of our interview, co-directed this program for the Medical School. Since this interview occurred, Dr. Kaufman has left U-M and gone into private practice.
Kirsten Mowrey: What brought each of you into integrative medicine?
Amanda Kaufman: I graduated from the Med School in 2002. My residency was done in 2005. I joined the faculty in 2005.
Amy Locke: Well, I went to medical school here at U-M and residency, and joined the faculty here in 2002. As a part of my medical school training, we had elective time available, and so I did some elective rotations with local integrative physicians. We also had a very active integrative medicine interest group at the time and so we brought in a lot of community practitioners to demonstrate what they do and to talk about their methods and the kinds of things they offer. That was very helpful. The Medical School didn’t have a formal piece of their curriculum to expose all students [to CAM] then, but students who were interested would spend time.
““Even the people who aren’t particularly interested in integrative medicine, they have a baseline exposure to different kinds of practices, which is different from what it has been.” ”
Kirsten Mowrey: So, the interest group was something you did beyond your regular curriculum?
Amy Locke: Exactly, so at lunchtime, or on the weekend or evenings, we would do different activities.
Kirsten Mowrey: Are there still those interest groups for students?
Amy Locke: Yes, and I am the faculty advisor for the student interest group right now.
Mowrey: And what is their particular focus?
Locke: It really depends on the group of students. So if there is a particular interest in there for meditation or Reiki or herbs or acupuncture, whoever is leading it that year tends to use their own interests to explore different modalities.
Mowrey: And what would you say interests you the most?
Locke: I would say I am most interested in prevention, preventive medicine and lifestyle, so that you stay healthy and don’t need to do lots of intervention. I would say I’m interested in nutrition as a primary basis for that.
Amanda Kaufman: The mind body aspects, manual medicine, I love osteopathic manipulative therapy, and herbal products when they can be useful have been helpful. I would like to say I’m competent at homeopathics, but every time I feel like I know a little bit more, there’s too much more to know.
Mowrey: I’m curious, Dr. Locke, was your particular visit with an alternative practitioner around nutrition? Or that didn’t exist at the time you went through the program?
Locke: I don’t think we had any visits with people around nutrition. I think that’s something that I’ve just done a lot of reading and worked through continuing medical education courses to get more information about.
Mowrey: Is part of what you offer at the Integrative Medicine Clinic training in that?
Locke: Well, certainly we teach medical students in the Med School in the pre-clinical years, so for M1’s and M2’s, the first two years [of medical school], and then we have M3’s and M4’s who are in their clinical years who rotate with us at the [Integrative Medicine] Clinic. We also have residents who rotate through our clinic and then we lecture in the residency in Family Medicine and then we have a fellow who works full time at our clinic. So one of our docs each year is our fellow who comes for one year and, as a part of that year, they learn quite a bit about nutrition, as well as all sorts of other things.
Mowrey: Is that something you brought in when you arrived in 2007?
Locke: No, that was part of the clinic’s inception, was the fellowship and the clinical practice.
Mowrey: How actively involved with the M1’s and M2’s are you?
Locke: We do a little bit, we give a lecture each fall to the M1’s and M2’s. There’s a musculoskeletal sequence for the M1’s where community practitioners come in. So they work with a chiropractor, an acupuncturist, and a massage therapist to understand musculoskeletal from those viewpoints. And then the M1’s do the community visit and that’s about it. They have a mostly classroom-based education, with a couple of visits to see physicians in practice, and that coincides with their CAM visit week, and then they do a compare and contrast.
Mowrey: So there is a meeting after their CAM visits to compare and contrast?
Locke: Yeah, they meet in their small groups to debrief and they talk about what was it like for the patient who was sitting with the CAM practitioner, or the cardiologist, or M.D. they visited.
Mowrey: They debrief in their small groups and then they write a paper?
Locke: Yes, so they debrief and then they have an exam and they choose a certain number of questions and one of the questions is ours. So I have a stack of sixty [essays] and Mandy has another sixty to go through and comment on their visits. This year was the first time we tried to go through and figure out, when they are writing their essay, who they worked with. We have this huge list of practitioners, and sometimes we hear great things and sometimes we hear things that are concerning, but we haven’t had a great way to link that back to the actual person. So I’m hoping that it will allow us to give feedback and make the experience more valuable. I would say the only complaint I’ve heard this year was some folks who went out and worked with a physical therapist group, that it wasn’t alternative enough, they wanted more exposure.
““…Every experience where they understand a patient’s perspective is helping them to be better…. It’s a leap for them to understand where a patient is coming from. They are still very new.” ”
Amanda Kaufman: It is integrative, but they don’t see it as integrative. Some of the rehab specialists we send people to, they [the students] were like, “Well, I didn’t have the experience my colleagues had.”
Mowrey: So that was one of my questions, because I’ve been a massage therapist for 18 years and I find it is very different now from when I began. Do you find there is a general knowledge base among medical students that is higher than there used to be, from when you went through school?
Locke: You know, it’s funny. So I give this lecture, and this year, I think it was the M1’s, I just asked for a raise of hands as to who had tried this modality. And, you know, half the class’s hands go up. So even the people who aren’t particularly interested in integrative medicine, they have a baseline exposure to different kinds of practices, which is different from what it has been. Like massage therapy isn’t very out there, so people don’t think of that as, “Ooooh I’m doing something kinda crazy,” like they might if they were getting Reiki or acupuncture, although that’s becoming more mainstream too. So I think it feels less fringy than it was.
Mowrey: What modalities do you see as generally accepted now? You mention massage therapy and acupuncture, what about others?
Locke: I think it depends on your population; in Ann Arbor chiropractic care is still considered a little bit edgy, but if you were in rural America, everybody’s got a chiropractor.
Kaufman: Most people feel that massage is part of our world...good medicine becomes assimilated into the Western model; massage has become assimilated into the Western model.
Mowrey: And what do you see as the fringe now?
Kaufman: I think that we are always apt to get complaints about those who go see our energy practitioners, Reiki or other, just because if they are not open, they can’t see the healing there. They are so used to this model of “there’s this drug and it does this” that if you try to explain the healing from within or the person’s self healing, they are just “eh.”
Locke: A lot of people have trouble with energy work; it’s harder to study, to get a good research base for those sorts of things. Depending on the group, homeopathy, sometimes; colonics; things where you look under a microscope and diagnose someone’s whole body based on one drop of blood; I think those things are still kind of edgy. I think it really depends on whom you are talking to.
Mowrey: So for energy workers, to be able to articulate what is happening would be very helpful for the student visits.
Kaufman: Very helpful and I think that the way that energy practitioners articulate it to their patients needs to be different from the way they articulate it to the medical students. Maybe dumbed down for the medical students, rather than the medical students hearing that they are connecting the energy. One student complained that they got told that the practitioner was connecting the energy from the core of the earth or the universe, and, of course, the medical student just shut down.
Locke: But I think that’s good to bring that back to the group and talk about.
Mowrey: Amazing discussions!
Kaufman: The layer that we have no control over is that we are not in charge of who discusses this in their small groups.
Locke: It’s a physician who leads them through their whole curriculum. If the person who leads that group is into integrative medicine, that’s great. If not, it’s through their filter. We used to do this discussion co-led with a CAM practitioner and a physician. They stopped doing that a couple of years ago. I’m not sure of all the details behind it.
Mowrey: How do students feel about that week of visits to alternative practitioners?
Kaufman: In general, it’s very positive. They are hungry to understand what the patient’s experience is, both in conventional medicine and other venues. I think that the feedback I get from them is that every experience where they understand a patient’s perspective is helping them to be better, to guide people better, to know what they are going through. It’s a leap for them to understand where a patient is coming from. They are still very new.
Locke: At that point they don’t know much about clinical medicine, so they focus more on interpersonal skills: how did the patient feel listened to, more of that “how do you be a provider” kind of thing rather than “they prescribed XYZ treatment or therapy.”
Mowrey: Have any students reported a change in mindset or viewpoint based on their visits?
Locke: I feel like reading the essays last year was really educational for me because they made all kinds of comments about changing in perception and it not being what they expected. Really a lot of comments around the humanism; [that] the patient felt listened to in a way that they maybe didn’t [feel listened to] by the M.D. Really being listened to and respected. And it being a very comfortable environment, versus a very sterile environment.
Kaufman: A very healing environment. They mention objective facts, like integrative practitioners spend more time [with patients]; a massage therapist is going to spend more time than seven minutes.
Mowrey: I saw on the website that all medical students have to go through this. I believe you said there are 170 medical students. As for participating practitioners, the website says you have over 200?
Locke: It is hard to find that many people. That is a lot of people, and Washtenaw County is big, but it’s not that big (laughs).
Mowrey: So you stay within the county? You don’t go up to Brighton?
Locke: Sometimes we do, but they don’t all have cars. We try to keep them as close as possible, just for transportation issues.
Kaufman: Amy and I have tried really hard to send students who are going to be engaged; try harder to get them to do their pre-reading [of materials practitioners send before the visit], emphasizing their job is to be professional and respectful so people don’t accidentally get turned off. In my experience with doctors, there are some who have really good people skills and there are some that don’t have the best people skills, and the same carries through with students. I want as little as possible for one student to turn off one of our volunteer practitioners.
Locke: We’ve had experiences where we’ve sent students and we’ve heard back from the practitioner that they don’t want to do this anymore [because of students] leaving their blank face or making their snarky comment. I tell the students, it’s not whether you believe in what the person is doing or not…
Kaufman: They are volunteering!
Locke: ...it’s still a valuable experience. They have this pedestal thing going with the M.D. faculty, but when they are going to their CAM visit, they get kind of touchy. This is a good time to practice respect and learning outside of your own paradigm.
Mowrey: Well, you never know who your patient is going to present you with!
Kaufman: That’s the other huge eye-opening part that comes through in their essays; patients are not cookie cutter two-dimensional humans with whom you are going to assess the situation and answer multiple-choice questions. They are diverse in their thinking, and whatever that client thinks is going to heal them, the power of their paradigm, probably will.
Mowrey: Who oversees quality control for the selection of CAM practitioners?
Locke: We use practitioners that we know or know of by recommendation. We will drop practitioners for future years if there are problems identified. We want the students to have a positive experience. Mandy and I work with Joyce [Kiger, administrator for the medical students] to choose practitioners each year. Many, if not most, of the practitioners are known by someone affiliated with Integrative Medicine at U-M and come by recommendation. These relationships have been built over many years in many formats: met in person in any number of settings, shared patients, and so on.
Mowrey: You mention dropping practitioners. What type of problems have you identified?
Locke: I don’t know of anyone off hand that we have chosen not to use again. Obviously, some have moved or changed their practice such that we don’t send students anymore. Some haven’t been deemed “alternative enough,” like last year when we sent several students to a rehab facility. It seems like occasionally a student identified not feeling welcome.
Mowrey: Are there specific CAM practitioners that you would like to add?
Kaufman: It would be nice if most of the groups had someone in their group who had a visit with an alternative practitioner: a chiropractor, an acupuncturist, an energy worker. It’s been very hard logistically to make that happen.
Locke: People who want to work with students and share what they do.
Kaufman: Enthusiasm.
Locke: At this point, I don’t think there’s a kind of practitioner we would say no to. I think it’s more about interpersonal skills.
Kaufman: And letting the students see actual patients.
Mowrey: Are there still elements in the medical school strongly opposed to the one-week CAM visits? How is CAM received by other faculty?
Locke: I don’t know of anyone strongly opposed, but Joyce might know better. My impression is that the visit is well received. There seems to be a gradual increase in support at the med school level, including faculty.
[Joyce Kiger via email: “There are individuals (both students and faculty) who aren’t overly receptive to CAM but I believe the numbers are declining. The field visits are very well received by the students.”]
Mowrey: What are your future goals for this program with the medical students?
Kaufman: Right now, we still have a lot of work on “buy in” with our volunteer practitioners, and working with the really tight time constraints the medical school gives us.
Locke: Look for ways to thank people. You want people to feel like they are making a difference, because it’s a hassle to take time out of your day to meet with students, and if you don’t feel appreciated, why would you add it? The gift of time, everyone is busy, everyone has things to do, so, giving the gift of time is to be acknowledged.
““That’s the other huge eye-opening part that comes through in their essays; [they realize] patients are not cookie cutter two-dimensional humans…. They are diverse in their thinking, and whatever that client thinks is going to heal them, the power of their paradigm, probably will.” ”
Mowrey: What would be your hopes for the students at the end of it? Multiple visits?
Locke: What would be really great would be to have an opportunity for those who were interested in more elective type opportunities — [for the student who says,] “Oh, if only I could have seen this type of person or been able to compare [modalities]” — to have a list of practitioners, if you have a student who is interested in this, [that a student could] call.
Kaufman: There’s about 10-15 percent who would be really interested in more time, and it’s such a great space in their learning to have their minds opened.
Mowrey: Thank you so much for meeting with me today, and good luck!
The Expanded Scope
Back at my field visit, the door opens, my client enters, and the last hour flies by. In preparation for this moment, I have discussed and received permission from my client to talk about the care they have received, their past and current condition, and openly discussed any health information. Every year I do this, my client is eager to talk to the students, to answer their questions and to be listened to by conventional medical practitioners. Clients are so willing to share their stories, the details of their care, the decisions carefully weighed.
When they are on the table, they will often take students’ hands and place them where mine were, urging the students to feel the difference in the tissue. They may say, “No, lighter; she was touching lighter, she was using her hand this way, that direction; do you notice this here?” — teaching the students through direct feedback. I watch each of the students interact with my client, respond to the directness and immediacy of the experience, their frustration when they don’t know how to use their hands, their wonder when they feel the change in the joint or the limb from how it felt before. I observe each of them struggle with their learning edge — for some it is understanding what my client means, for others it is learning to use their hands as sensory devices, to learn information kinesthetically, not cognitively. They are profuse in their thanks to my client when they depart. As we do a final roundup, I see an openness in their faces, an awareness of people learning together how to help each other. I wish them all well as they depart on their journey back to the medical school, hoping that my client and I have planted a seed that will grow as they learn.
***
Kirsten Mowrey is a Licensed Massage Therapist, Trager® practitioner, and trauma healing therapist with 18 years of experience as a bodyworker. She loves activities in the outdoors and brings that joy and fluidity to her work. She may be reached at kirsten@kirstenmowreynctmb.com.
For practitioners interested in volunteering with the Medical School’s CAM program, please contact Joyce Kiger, Office of Medical Student Information, at (734) 763-0169 or Comp1-2staff@umich.edu.
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