SCUT Monkey

Many books have been written on this topic and every medical provider has had to perform this role at some point in his or her career.  The role of the "Scut Monkey" is one that some do not desire for, to be honest, it can be an undesireable job.  But this work has to be done.  I have learned to fulfill this role mainly in the form of taking care of our "frequent fliers."  It has been challenging, but interesting, and up to this point I don't mind the job too much.

The situation is usually the same - the doctor (my preceptor) will say, "I think you should go see Mrs. Smith," usually with a sly glint in his eye.  The PA working in the department will say, "Ooooh, yeah!  Mrs. Smith will be a good patient for you to see," with a wicked grin.  Of course the PA really means, "This is going to be a challenging and potentially annoying case that will probably end with the patient making inane requests or having a laundry list of complaints a mile long that we have already worked up literally twenty times without any new results... so let's see if you can get all the right answers."  I try to dutifully march off to see the patient, but often I say to myself, "Not another one!"

It is here that I must take pause and mention something that my preceptor and the PAs in the department have already taught me - even frequent fliers get sick sometimes.  The same things that can afflict John Doe can effect Mrs. Smith, and it is in this type of patient that we will most likely miss a major medical problem, because we've heard it all before.  We have heard the complaints of abdominal pain, or back pain, or headaches a hundred times (sometimes literally) and there is never anything to point to an actual cause of the symptoms, so we think, "Why should this time be any different?"  Isn't the definition of insanity something along the lines of repeating the same exact activity a number of times and expecting a different result?  Admittedly, it takes a bit of a naive mind to subject oneself to the difficulties of getting an H&P on this type of patient, but that is exactly what I am - a naive mind.  I need to fill it with something, right?  Who better for a naive mind to see than someone who has a number of complaints without corresponding physical findings?  It is this patient who will challenge my diagnostic abilities the most - and one that I have the luxury of time to examine.  Will I be allowed to assess a patient in flash pulmonary edema?  Not likely - this patient's respiratory compromise warrants more urgency than a PA student in his second week of emergency medicine can provide, especially since this particular PA student has only seen one or two of these types of patients in his entire life.  But the frequent flier...  This is a patient that the doctor already knows and someone that will allow the PA student the time to perform a solid H&P and the appropriate tests in the hope that this naive mind might give them whatever it is that they seek.  And this is why it is a good experience for me to see our frequent fliers.

Interestingly, in one book on the topic of "Scut Monkeys" the charge was given to think of SCUT as an acronym for Some Clinically Useful Training.  My charge to those that come after me is to adopt a constructive view of scut work for we will all have to perform these tasks - but they are what you will make of them.

Thrill ride

I have been having some trouble coming up with an update about where I am and what I'm doing.  I think this is mostly because I've been having too much fun doing it. 

Thus the update of the day is that I am currently doing an ER rotation at the largest regional medical center in our area.  It is so enjoyable that I hardly feel I am at school.  My preceptor has an amazing amount of knowledge to share and has been pretty willing to have me experience new things first hand - like suturing.  On my first day a patient came in needing a number of stitches... my preceptor said, essentially, "Go for it," and with the appropriate supervision (he looked over my shoulder the whole time) I closed the patient's wound with no trouble.  It was a good experience.  I have had many others already, and I've only worked 2.5 shifts (30 hours) so far. 

One dilemma I have faced so far - and one that hit a little too close to home - was that of how far we as providers should go for patients in a permanent vegetative state.  This came up in my last rotation as my preceptor and I listened to a radio news broadcast on the subject.  We discussed this and the question that arises is this: should we do absolutely everything for everyone?  Of course, if we say that we should not provide life support for people in permanent vegetative states then at what point will we draw the line?  Will we begin to draw it further and further down the line?  Will we start withholding medical care from the frail elderly or those who are simply so ill that they have no change of a meaningful recovery?  Truth be told, this decision does not lie with us (the medical providers) but often times families ask us what we think - what we would do.  It is their decision, but they seek affirmation of their choice and support for whatever they elect to do.  The weight of the situation is such that it warrants a great deal of forethought. 

One discussion point that I think helps me the most is this: perhaps we should draw the line between prolonging death and preserving quality of life.  If a patient is in end stage lung cancer with multiple metastatic lesions to their bones and in excruciating pain all day, every day then perhaps we should not seek to blast them with all sorts of chemotherapy and make them endure their pain longer by only slowing the progression of their disease without hope of a cure (aside from a miracle direct from the hand of God).  Perhaps in this situation we should simply help them be comfortable - not hastening or prolonging death, but providing comfort and care for the ill in their final days.  And I think that most reasonable medical providers can see the logic and compassion in this situation. 

But how does it change in a pediatric patient?  Perhaps there is more hope for a cure and long years of a high quality of life, or perhaps a child is so ill that he cannot be saved.  This is a huge dilemma for all of us, and the answers are not so clear cut.  I have struggled with this recently and will no doubt revisit it.  But my preliminary thought is that if, for example, a child has an injury that has left them without higher brain function such that they have a steady heartbeat and steady respiration we should do nothing to prolong their entrapment in that tomb made of flesh and bone.  We should not hasten death, but I have to ask a question: what good does it do a person to be trapped without hope of recovery inside a body that itches, that hurts, that will become ill over the years?  In this situation there is no expressive faculty left for the patient and no ability to move - in my opinion this would be more like torture than life. 

So where should we come down on this issue as medical providers?  Well, I have my opinion, and others will have their own.  And, to be honest, it is unlikely that all of us will ever agree.  But we should all give it a great deal of thought and we should all do it early in our careers so as to be ready for these situation because, as I have seen, they come up often. 

PA school interviews

Taking part in an interview for PA school is quite an adventure in and of itself - I should know: I did it twice.  The day begins as any other with an alarm clock blaring.  The first difference is that the candidate is most likely already awake and just waiting for the alarm clock to go off.  The morning routine progresses with more intensity, more enthusiasm, more attention to detail, and often more quickly than usual.  The trip to the interview site goes more quickly than ever before, too.  It is filled with thoughts about how to answer the questions, about what the future might hold, and often about how much the interview itself means to the candidate.  One question that comes up often is, "Why do I want to be a PA, anyway?"  Everyone's answer is different, but this is the central question that interviewers want to get at.  The interviewers want an answer and then they have to judge whether a person's motives are adequate.  This is the tricky part. 

It is this last part that I want to comment on today.  I have now had the experience of interviewing the next round of candidates to come through my school's PA program.  It was my task to assess whether or not the candidate's motives are right, whether they are at the right depth and maturity, and whether or not the candidate really knows what lies ahead - what a PA is and does, what it means to be in PA school, and what taking sips from a firehose is all about.  In the end, it comes down to one decision: accept or reject.  This was the hardest part for me.  Having been in their shoes so recently, I could see the future they were hoping for and that this interview was their first step.  I could still see it from their perspective very freshly.  Thus it was difficult to weed out those who just didn't have it - I wanted them all to succeed because they all brought some sort of promising characteristics to the table.  Some not as much, and these were the ones that I could not decide upon.  But weighing these things - desire, motivation, knowledge, maturity, motives - was done well and a good class is coming up for next year. 

I was honored to help select them and humbled by those that I did not select.  Afterall, I did not get selected once and I remember how it feels.  My hope is that all those who didn't make it will show their true character by keeping their chins up, setting goals to improve themselves over the coming year, meeting those goals and re-applying next year.  If they do these things, they will shine brighter among a group of bright young people next year and will, in the end, make a fine PA someday.