Yesterday I had the privilege of participating in my school's selection conference for the fifth time. The first two times I participated as an applicant. I still remember the first time that I went. I remember the awe-struck feeling that I had when I walked into that room and saw 40 of my peers milling around. The awe increased when I realized who my peers were - these were respiratory therapists, paramedics, military medics and corpsman, athletic trainers with 10+ years of experience as the head ATC for a professional sports team... I remember thinking, "How did I get grouped in with such highly qualified professionals?" I seem to remember thinking to myself that if these were the type of people who were applying to PA school, how could I consider myself ready when I had the bare minimum of qualifications? I was excited to be there, honored to be there. But perhaps not really ready. There was an undeniable desire to get into the program, to spend years learning alongside intelligent and driven people like these. There was no question of what I needed to do for my future - I needed to be a PA.
I didn't get accepted that first year, and by the providence of God. The second interview was much smoother for me - I was less nervous, certainly put a better foot forward, and had the confidence necessary to get the job done. But again I was awestruck by the quality of my peers. Again I felt that I paled in comparison to some, but would benefit others with my perseverance and diligence. It was a great group. I was honored to be among them, and this time I felt that I had something to bring to the table. It was an absolutely delightful day.
I got accepted the that year and began my PA school evolution the following year. As a student I helped out with some administrative details of the interviews and I helped to "sell" the program to the candidates by discussing with them the aspects of the school that I liked most, the things that were hardest but how they could be overcome, and just how interesting studying to be a PA is. We had several meetings with the students throughout the day - lunch and a social after the interviews. Again I was honored to be a part of the process in my small way. The group, once again, represented an amazing conglomeration of individuals, outstanding experience, and amazing drive.
Last year I was able to participate in the interview process for the fourth time. But this time I was given the opportunity to help select the next class of students to attend the program. You can read what I wrote about that last year, here. The experience was once again remarkably exciting, inspiring, and at the same time humbling. Again I was struck by the fact that there were some highly qualified applicants who were rejected for one reason or another, but here I was interviewing them as a current student. How did I get in, and these people were not going to? Again, the grace of God. But on top of this, and something I didn't realize until this year, is that now I am part of selected and building the class, and thereby the future of my PA program. What a great responsibility and privilege.
This year, that responsibility and privilege was more tangible. As a graduate now I have a new perspective. First of all, I am so thankful for my PA program - the instructors, the office folks, the student affairs coordinators - these people invested a lot in me and have helped me succeed. I owe them a lot. I have always appreciated them, but I didn't see it well as a student because I was in the middle of just trying to survive PA school. Secondly, I now see that I am part of their history, the school's history. And now, as a part of the profession that they have worked to protect and build, I feel greatly inclined to continue to be part of their future as well. The school and the people who make it up are all outstanding, and they have put together one of the top programs in the nation. From this new perspective on the PA program itself and on the people we select to represent us as future colleagues, I think there may be a place for me among the faculty. I feel a slight but not subtle calling to try teaching the next round of "kids" that come through our doors. It is an exciting calling, a humbling calling, and one that I look forward to.
And yet, I know I still have a lot to learn.
Sunday, November 20, 2011
Tuesday, November 15, 2011
First birthday
Today is my first birthday as a PA. Looking back over the last year, a lot has transpired. You can read the posts if you'd like, but to summarize it I have to say that I feel like somewhat of a different person. I feel a heavier weight on my shoulders daily, but I bear it gladly and it really doesn't impinge upon life in general. I still enjoy the things I used to, but to a different extent and I balance enjoyment with responsibility a little better than I used to. I feel, basically, like I've grown up quite a bit over the past year. My family can tell me if they believe that... I guess we'll see. But it's been a great year and I'm looking forward to what this next one has in store for me.
Friday, November 11, 2011
Busy month
This past month has been a blur. So much has transpired that I have difficulty keeping it straight. I think I saw something like 160 patients last month (though I had well over 200 on my schedule) - this is not a lot for some practices, but I work in a managed care organization so our rate is a little slower. That said, every patient that we see has 2-3 chronic medical problems - diabetes, hypertension, hyperlipidemia, coronary artery disease, chronic kidney disease/renal failure, congestive heart failure, chronic obstructive pulmonary disease (and still smoking a pack-a-day), you name it - and they are on a host of medications. So all our visits are just enough time to take care of them thoroughly and stay sane. I'm seeing almost the same number as my peers - some of whom have been there for 2-3 years, so I feel comfortable with my patient load. I know it will get higher as time goes on and I change jobs, but it really is perfect for a new graduate. I have seen some fairly scary things, picked up some odd diagnoses (though nothing spectacular like a pheochromocytoma), and done a few surgeries (minor things like skin biopsies). It has been humbling, frightening, exhilarating, and challenging. It is everything I had hoped for in a new career, and it pays the bills. I am remarkably blessed to have this opportunity and can't wait to see what the future holds.
Wednesday, October 19, 2011
Comments
I invite anyone who might read my blog to post comments - especially feedback or questions about PAs. I would be glad to answer anything that you'd like to know including questions about getting into PA school, what the didactic year was like, anything that has remained unanswered about the clinical year, and anything you'd like to know about clinical practice (that I can answer).
Thanks for reading.
Thanks for reading.
Sunday, October 16, 2011
So far, so good.
After 2 weeks on the job, I can gladly report that all is well.
Last Monday presented me with a unique challenge - I had my first afternoon as the provider assigned to minor care. Minor care is, essentially, a mini-emergency room. Most ERs now actually have attached minor care departments - a walk in clinic for everything from lacerations, to acute infections, to traumatic injuries sustained while playing sports (generally stuff that is acute but non-life threatening). Ours is no different from the ones attached to an ER except that we are a stand-alone facility. We are at least 20 minutes from the closest ER, thus in our minor care we often have patients walk in with worse problems than your average family practice clinic minor care. Crushing substernal chest pain (we're worried about heart attack here), inability to breath because of a COPD exacerbation or acute asthma attacks - these are but a few of the potentially life threatening problems we handle at our facility. We get fractured bones of all types, and there is a rumor that we once had a patient who had sustained a gunshot wound. We, of course, contact the local ER and stabilize these patient while paramedics are called to transport them to definitive care. But the process of getting a patient with acute ST segment changes stabilized and ready for transport can be... intense. I didn't have anyone complaining of chest pain, but my day was still jam packed with patients complaining of acute problems. The patients came every fifteen minutes, some complex, some simple. It was a busy day, the adrenaline flowed freely, and in the end everything went as smoothly as my first day in minor care could go.
The following day was also quite challenging - I had 12 patients on my schedule. Most were people I'd never seen before, so this requires an added level of attention to detail. I need to essentially do a complete H&P and complete their chart notes in 30 minutes plus I have to address their chief complaint with a plan and directions for follow-up. Generally this is a minimum 45 minute process (at least, for me it is). So I was stacked to the rafters again. Add to that an hour long surgical procedure in the middle of the day and by the end I was done. I can't remember the last time I was that tired. But it felt good to have accomplished so much.
By Wednesday I was only 6 notes behind in my charts. I had another relatively intense day (for a new provider) in that I had to man the minor care again to see the pediatric patients coming through our doors. Thankfully it was all straightforward and everyone, to my knowledge, was fixed up appropriately. I have only had a few of the 75+ patients I've seen so far come back in for care sooner than the scheduled 2-3 weeks - so hopefully this means I'm doing something right. Thursday came my reprieve.
I was scheduled for minor care again, but since Thursday is day #4 of minor care, there are generally only a few people who seek treatment. It was nice, slow, and nothing complex came through so I was actually done with work almost on time.
Friday was a sweet gift straight from God (all days are, but this one was particularly sweet). I saw just an average number of patients and all went smoothly. I had the opportunity to leave by 3:15 (very early, which is almost unheard of). I picked up two minor care patients - both with complaints in an area that I am very comfortable with - and was done precisely at my scheduled 5:00 leave time. A marvelous day!
I ended the week completely caught up. Tomorrow the cycle begins again. I find myself not exactly looking forward to it, and hoping that it goes better than last Monday. That said, I am not dreading the proposition and I think that this week will be a good one. As always, time will tell.
Last Monday presented me with a unique challenge - I had my first afternoon as the provider assigned to minor care. Minor care is, essentially, a mini-emergency room. Most ERs now actually have attached minor care departments - a walk in clinic for everything from lacerations, to acute infections, to traumatic injuries sustained while playing sports (generally stuff that is acute but non-life threatening). Ours is no different from the ones attached to an ER except that we are a stand-alone facility. We are at least 20 minutes from the closest ER, thus in our minor care we often have patients walk in with worse problems than your average family practice clinic minor care. Crushing substernal chest pain (we're worried about heart attack here), inability to breath because of a COPD exacerbation or acute asthma attacks - these are but a few of the potentially life threatening problems we handle at our facility. We get fractured bones of all types, and there is a rumor that we once had a patient who had sustained a gunshot wound. We, of course, contact the local ER and stabilize these patient while paramedics are called to transport them to definitive care. But the process of getting a patient with acute ST segment changes stabilized and ready for transport can be... intense. I didn't have anyone complaining of chest pain, but my day was still jam packed with patients complaining of acute problems. The patients came every fifteen minutes, some complex, some simple. It was a busy day, the adrenaline flowed freely, and in the end everything went as smoothly as my first day in minor care could go.
The following day was also quite challenging - I had 12 patients on my schedule. Most were people I'd never seen before, so this requires an added level of attention to detail. I need to essentially do a complete H&P and complete their chart notes in 30 minutes plus I have to address their chief complaint with a plan and directions for follow-up. Generally this is a minimum 45 minute process (at least, for me it is). So I was stacked to the rafters again. Add to that an hour long surgical procedure in the middle of the day and by the end I was done. I can't remember the last time I was that tired. But it felt good to have accomplished so much.
By Wednesday I was only 6 notes behind in my charts. I had another relatively intense day (for a new provider) in that I had to man the minor care again to see the pediatric patients coming through our doors. Thankfully it was all straightforward and everyone, to my knowledge, was fixed up appropriately. I have only had a few of the 75+ patients I've seen so far come back in for care sooner than the scheduled 2-3 weeks - so hopefully this means I'm doing something right. Thursday came my reprieve.
I was scheduled for minor care again, but since Thursday is day #4 of minor care, there are generally only a few people who seek treatment. It was nice, slow, and nothing complex came through so I was actually done with work almost on time.
Friday was a sweet gift straight from God (all days are, but this one was particularly sweet). I saw just an average number of patients and all went smoothly. I had the opportunity to leave by 3:15 (very early, which is almost unheard of). I picked up two minor care patients - both with complaints in an area that I am very comfortable with - and was done precisely at my scheduled 5:00 leave time. A marvelous day!
I ended the week completely caught up. Tomorrow the cycle begins again. I find myself not exactly looking forward to it, and hoping that it goes better than last Monday. That said, I am not dreading the proposition and I think that this week will be a good one. As always, time will tell.
Saturday, October 8, 2011
Calling the shots
This past week has been an incredible week. A year ago I posted about needing to get used to not knowing all the answers. In the classroom, I felt confident that I had the right answer most of the time. A year ago I transitioned into clinical learning, during which I felt confident in my abilities but remarkably uncertain about diagnoses and treatment because someone's physical being was dependent upon, in a small way, what I did - how I performed; whether or not I got the right answer. Clinical year was difficult because of the uncertainty, but excellent in that I had a safety net - a large and proactive safety net that would essentially reach out and catch me if I stumbled. My preceptors were there, watching over me, monitoring my decisions and consulting with me actively. I felt uncertain, but grew comfortable with that uncertainty because that was the name of the game. Last Monday, the game changed again. Now, instead of having people looking over my shoulder and actively consulting with me, educating me; I am calling the shots - making the decisions - about how to treat my patients. My patients. These are no longer someone else's responsibility, they are my responsibility. Yes, there are doctors, physician assistants, and nurse practitioners to consult with - and I do (especially for dermatology stuff) - but no longer do they look over my shoulder, review my charts, and guide me along actively. Now, the safety net exists only if I activate it - if I fall but forget to turn it on, the potential exists for me to fall a long way. And what hangs in the balance? People. My patients. It is both thrilling and frightening at the same time.
I enjoyed every moment - including the discussions about whether or not to send a patient to the ER for abdominal pain, kicking myself for missing something obvious (and taking solace in the fact that I wasn't the only one), fixing children (see a previous post - but there seems nothing more wholesome than having a child come into my office sick and leave with answers and medicine that has made them feel better), and falling back on my training when certainty about the next step avoided me only to have it reveal solid answers.
I am still intimidated, but having survived my first week in the trenches I feel bolstered about the next one and ready to take on more challenges. Uncertainty is still there, but it has served me well and I think I will grow comfortable with a little bit of uncertainty in my life - as long as I use it to the benefit of the patients for whom I am now responsible.
I enjoyed every moment - including the discussions about whether or not to send a patient to the ER for abdominal pain, kicking myself for missing something obvious (and taking solace in the fact that I wasn't the only one), fixing children (see a previous post - but there seems nothing more wholesome than having a child come into my office sick and leave with answers and medicine that has made them feel better), and falling back on my training when certainty about the next step avoided me only to have it reveal solid answers.
I am still intimidated, but having survived my first week in the trenches I feel bolstered about the next one and ready to take on more challenges. Uncertainty is still there, but it has served me well and I think I will grow comfortable with a little bit of uncertainty in my life - as long as I use it to the benefit of the patients for whom I am now responsible.
Tuesday, October 4, 2011
Day #1
Rest assured - I won't be doing a post-a-day about my experiences as a PA in a family practice clinic. But the first day was one that I will always remember - some good things, some bad things.
It was far from perfect, but always comical - the very first patient of the day needed a procedure. The procedure was one I know how to do and have performed several times. I got all ready to do it - pulled all my sterile instruments, laid them on a tray. Prepped the patient including an injection and then I realized that the equipment I had available was not correct. Not only that, we didn't have the correct equipment for the procedure I wanted to do. So he needed a different procedure at a different time. That was frustrating.
I also made a patient cry on my first day. It was completely inadvertent - but when I explained all the possible etiologies of her condition, it was a little much to take in. I was quick to explain that every one was treatable, there was nothing to worry about, but we needed to find out the right cause so we could help her. That softened the situation a little.
And of course there was the patient who comes in for one thing, but, "Oh, by the way...." and the problems keep on coming.
It was a good first day... typical. I loved it.
It was far from perfect, but always comical - the very first patient of the day needed a procedure. The procedure was one I know how to do and have performed several times. I got all ready to do it - pulled all my sterile instruments, laid them on a tray. Prepped the patient including an injection and then I realized that the equipment I had available was not correct. Not only that, we didn't have the correct equipment for the procedure I wanted to do. So he needed a different procedure at a different time. That was frustrating.
I also made a patient cry on my first day. It was completely inadvertent - but when I explained all the possible etiologies of her condition, it was a little much to take in. I was quick to explain that every one was treatable, there was nothing to worry about, but we needed to find out the right cause so we could help her. That softened the situation a little.
And of course there was the patient who comes in for one thing, but, "Oh, by the way...." and the problems keep on coming.
It was a good first day... typical. I loved it.
Sunday, October 2, 2011
Brief Update
On 29 September I woke at 0700 to my alarm blaring. This being the first Thursday after I had taken my boards, only one thing was on my mind: my scores.
I rubbed a little sleep from my eyes, then immediately picked up my iPhone (the first time I have ever been truly thankful to have this little gem that allows me to use an internet browser almost anywhere, any time) and looked up my board score.
To my utter elation, I passed. I lay there in bed contemplating that thought.... I passed. I passed! I PASSED!! I don't know that, aside from my wedding day or the births of my two children, I have ever been as happy as I was that Thursday morning. (Yes, these four events are comparable in the amount of happy that they made me.)
I am now Physician Assistant, Certified. It is among the most incredible feelings in the world.
And tomorrow morning, bright and early, I begin my practice of medicine.
The oddest thing - in two words I can sum up how I feel today: scared stiff.
I rubbed a little sleep from my eyes, then immediately picked up my iPhone (the first time I have ever been truly thankful to have this little gem that allows me to use an internet browser almost anywhere, any time) and looked up my board score.
To my utter elation, I passed. I lay there in bed contemplating that thought.... I passed. I passed! I PASSED!! I don't know that, aside from my wedding day or the births of my two children, I have ever been as happy as I was that Thursday morning. (Yes, these four events are comparable in the amount of happy that they made me.)
I am now Physician Assistant, Certified. It is among the most incredible feelings in the world.
And tomorrow morning, bright and early, I begin my practice of medicine.
The oddest thing - in two words I can sum up how I feel today: scared stiff.
Tuesday, September 13, 2011
Tension
As life has slowed significantly, I have directed my focus into 1 of 3 activities -
1. Spending time with my family.
2. Studying for my board exams.
3. Putting in my share of the work on our local ambulance company.
The only one of these three that has been at all stressful has been #2, otherwise life has returned to what we would consider normal. However, #2 has produced within me a significant amount of tension. I try not to presume that I will pass on my first attempt, thus allowing me to have a good work ethic. But the more I remind myself that it's possible for me to fail, the more I feel I need to stress about studying and preparing. On top of this, I'll score 80% or better on a practice test one day, then the next day I will score a meager 65% (sometimes lower). The latter days are very stress producing. All this serves to throw more uncertainty onto my perception of how I rank amongst my colleagues and whether or not I will pass on my first attempt. I add into the mix the fact that my employer is expecting that I will pass (and will be less-than-happy if I don't) and it goes up a notch.
All this to say that, though I've dealt with an inordinate amount of stress over the past 2.5 years without a hiccup, the final hurdle is causing me a little bit of heart-burn. I am trying to avoid worrying, doing my diligence by studying, and trusting that God has got me right where He wants me. I try to be reminded often that He got me into school, He helped me pass every test, He carried me through clinical year, and now, because of Him, I've graduated. If I were to fail, it would have happened long ago. So my hope is that this final hurdle will pass without difficulty. I'm scheduled to take the exam on 23 Sept, at 1100 hours. I think it will be a good day.
But in the meantime - I'm thoroughly enjoying having some extra time to take EMS calls with the wonderful crew of our volunteer ambulance agency.
1. Spending time with my family.
2. Studying for my board exams.
3. Putting in my share of the work on our local ambulance company.
The only one of these three that has been at all stressful has been #2, otherwise life has returned to what we would consider normal. However, #2 has produced within me a significant amount of tension. I try not to presume that I will pass on my first attempt, thus allowing me to have a good work ethic. But the more I remind myself that it's possible for me to fail, the more I feel I need to stress about studying and preparing. On top of this, I'll score 80% or better on a practice test one day, then the next day I will score a meager 65% (sometimes lower). The latter days are very stress producing. All this serves to throw more uncertainty onto my perception of how I rank amongst my colleagues and whether or not I will pass on my first attempt. I add into the mix the fact that my employer is expecting that I will pass (and will be less-than-happy if I don't) and it goes up a notch.
All this to say that, though I've dealt with an inordinate amount of stress over the past 2.5 years without a hiccup, the final hurdle is causing me a little bit of heart-burn. I am trying to avoid worrying, doing my diligence by studying, and trusting that God has got me right where He wants me. I try to be reminded often that He got me into school, He helped me pass every test, He carried me through clinical year, and now, because of Him, I've graduated. If I were to fail, it would have happened long ago. So my hope is that this final hurdle will pass without difficulty. I'm scheduled to take the exam on 23 Sept, at 1100 hours. I think it will be a good day.
But in the meantime - I'm thoroughly enjoying having some extra time to take EMS calls with the wonderful crew of our volunteer ambulance agency.
Saturday, August 27, 2011
Graduation!
Yesterday I graduated. It was awesome and awe inspiring. I, along with 18 other outstanding individuals, received the certificate that will allow us to practice medicine. I am humbled to be in this group. Our school has graduated almost 1500 PAs over its history and I am honored to be in this group.
I also received an award for exemplifying the spirit of our school. Our founder had a vision for the PA profession - namely participation in rural communities, improvement of access to the underserved, and commitment to excellence in medicine. On top of that, the school has made a commitment to the success of their students. To be very frank, I had no hopes of special awards and didn't purposefully alter any behaviors to achieve any. But my goal all along has been to be of service and support to my classmates, to maintain a positive attitude throughout all of the challenges we've faced, and, ultimately, to glorify God as Christians are called to do. I give Him all the credit for any achievements or excellence that I obtained over the past couple of years.
The past 2.5 years have been a wild ride. In reflection I went from someone who thought he knew a lot to someone who realizes, at least to a certain extent, just how little I really understand about science and the human body. There is a lot I have to learn and now I have been given the magical piece of paper that says I'm allowed to. Very exciting times.
I also received an award for exemplifying the spirit of our school. Our founder had a vision for the PA profession - namely participation in rural communities, improvement of access to the underserved, and commitment to excellence in medicine. On top of that, the school has made a commitment to the success of their students. To be very frank, I had no hopes of special awards and didn't purposefully alter any behaviors to achieve any. But my goal all along has been to be of service and support to my classmates, to maintain a positive attitude throughout all of the challenges we've faced, and, ultimately, to glorify God as Christians are called to do. I give Him all the credit for any achievements or excellence that I obtained over the past couple of years.
The past 2.5 years have been a wild ride. In reflection I went from someone who thought he knew a lot to someone who realizes, at least to a certain extent, just how little I really understand about science and the human body. There is a lot I have to learn and now I have been given the magical piece of paper that says I'm allowed to. Very exciting times.
Tuesday, August 23, 2011
T minus...
3 days and counting.
This week we are presenting and defending our final projects and performing some board review. So far, so good. I have been greatly edified by the board review and I feel a bit more confident today than I had been feeling about passing the exam that has appeared as the guide-post over the past 2.5 years.
I still find myself terrified of the responsibility that is coming, but I feel ready to pass the certification exam, get my license, and begin practicing as a PA. I have a job (I don't recall if I mentioned that yet) and am thankful for that. With all of this going on I have been humbled by the number of my classmates who have not had even an interview yet, let alone multiple interviews without a job offer. I am one of the fortunate - blessed - ones.
All is well, and I'm ready to go. Just 3 more days. And what a great 3 days it will be.
This week we are presenting and defending our final projects and performing some board review. So far, so good. I have been greatly edified by the board review and I feel a bit more confident today than I had been feeling about passing the exam that has appeared as the guide-post over the past 2.5 years.
I still find myself terrified of the responsibility that is coming, but I feel ready to pass the certification exam, get my license, and begin practicing as a PA. I have a job (I don't recall if I mentioned that yet) and am thankful for that. With all of this going on I have been humbled by the number of my classmates who have not had even an interview yet, let alone multiple interviews without a job offer. I am one of the fortunate - blessed - ones.
All is well, and I'm ready to go. Just 3 more days. And what a great 3 days it will be.
Saturday, August 13, 2011
The last day
As it turns out, my last day of clinical rotations was a day earlier than I expected. At about 1430 and 3 patients into our "minor care" afternoon I experienced sudden onset of shaking chills, dizziness, fatigue, slight confusion (I kept getting words mixed up), and what later turned out to be a temp over 101. This developed into what I think was strep pharyngitis and otitis media. The first ear infection I ever remember having. Long story short, I didn't make it to work on Friday.
Thus Friday was a bittersweet day for me. Very sweet in that I knew there were no more clinical hours to be logged by me... No more patients to be entered into the computer tracking software... No more of the tedium of that part of becoming a PA. But it was quite bitter in that I had made it through 119 out of my 120 day rotation without an illness of any kind to be laid low by something so simple. It was frustrating - like being pulled from the big game in the last minute of the fourth quarter because my shoe came untied and I tripped.
That said - I did manage to have a good and productive week. I was reminded again that cultural differences mean volumes when addressing patients and working at providing good patient care. I must remind myself of this often. I need to be wary of bringing my pre-conceived ideas into the exam room when discussing options or the best method for caring for the patient, or even in how I approach decisions so simple as, "Sew 'em or send 'em to the ER?"
In all, though, I feel an enormous and immeasurable sense of relief. It is so good to be done with all of that. I can't really put it into words. Just a few small steps now until graduation and until I get that -C after my PA. Then the world will take shape and I'll actually realize what I've gotten myself into! I still can't wait.
Thus Friday was a bittersweet day for me. Very sweet in that I knew there were no more clinical hours to be logged by me... No more patients to be entered into the computer tracking software... No more of the tedium of that part of becoming a PA. But it was quite bitter in that I had made it through 119 out of my 120 day rotation without an illness of any kind to be laid low by something so simple. It was frustrating - like being pulled from the big game in the last minute of the fourth quarter because my shoe came untied and I tripped.
That said - I did manage to have a good and productive week. I was reminded again that cultural differences mean volumes when addressing patients and working at providing good patient care. I must remind myself of this often. I need to be wary of bringing my pre-conceived ideas into the exam room when discussing options or the best method for caring for the patient, or even in how I approach decisions so simple as, "Sew 'em or send 'em to the ER?"
In all, though, I feel an enormous and immeasurable sense of relief. It is so good to be done with all of that. I can't really put it into words. Just a few small steps now until graduation and until I get that -C after my PA. Then the world will take shape and I'll actually realize what I've gotten myself into! I still can't wait.
Saturday, August 6, 2011
1 week to go
There is one more week until I finish my clinical training. I am unbelievably happy about this. The excitement is barely containable. I have struggled with "short-timer's" syndrome a lot, but I think that I can finish strong.
Unfortunately, I don't have any in-depth insights on this upcoming week. It feels as if I have learned all the clinical year had to offer me. I know that the forty or so patients I will see in this upcoming week will teach me something, though. Let me just look back at what the patients in the past week have taught me:
1. When someone complains of a fever and shaking chills, ALWAYS check their ears. I knew this already, but got slapped and humiliated this week for an instant of complacency. Just because the patient doesn't complain of ear problems does not mean they don't have ear problems.
2. Hepatitis C is a nasty virus, but it is very treatable and our patients don't have to die of cirrhosis and horrible liver failure just because they've got this bug. Apparently, genotypes II and III are cureable at a rate of 70% and new medications on the market have brought genotype I up to a cure rate of at least 50%.
3. I will get yelled at occasionally by my patients no matter how much I know or how good my bedside manner is. There is always one out there that cannot be pleased.
4. 11 patients in one day is a lot for me, but I can do it, even if some of them are very sick or complex.
These are but a few of the lessons I've learned in the past week, but it shows that each week there is a list of lessons that can be gleaned. So hopefully as I enter the last week of my clinical training and as all those who come after me reach the same milestone, we will avoid complacency, we will always be ready to learn something, and hopefully this last week goes off without a hitch.
Unfortunately, I don't have any in-depth insights on this upcoming week. It feels as if I have learned all the clinical year had to offer me. I know that the forty or so patients I will see in this upcoming week will teach me something, though. Let me just look back at what the patients in the past week have taught me:
1. When someone complains of a fever and shaking chills, ALWAYS check their ears. I knew this already, but got slapped and humiliated this week for an instant of complacency. Just because the patient doesn't complain of ear problems does not mean they don't have ear problems.
2. Hepatitis C is a nasty virus, but it is very treatable and our patients don't have to die of cirrhosis and horrible liver failure just because they've got this bug. Apparently, genotypes II and III are cureable at a rate of 70% and new medications on the market have brought genotype I up to a cure rate of at least 50%.
3. I will get yelled at occasionally by my patients no matter how much I know or how good my bedside manner is. There is always one out there that cannot be pleased.
4. 11 patients in one day is a lot for me, but I can do it, even if some of them are very sick or complex.
These are but a few of the lessons I've learned in the past week, but it shows that each week there is a list of lessons that can be gleaned. So hopefully as I enter the last week of my clinical training and as all those who come after me reach the same milestone, we will avoid complacency, we will always be ready to learn something, and hopefully this last week goes off without a hitch.
Friday, July 29, 2011
2 weeks
Today marks the two week mark until the end of my clinical rotations. After that, I have two more weeks until I graduate. Thus, I am four weeks from graduating after 2 1/2 years of work that has changed the way I think, changed the way I function, and changed the landscape of my home and family. This is perhaps cheesy, but examining myself before PA school and comparing that individual to the present is an interesting mental exercise.
2 1/2 years ago I could not have told you what BUN, Creatinine, or GFR are. But this past week I spent a good amount of time managing a patient with wild abnormals for all of these and, essentially, turning kidney failure around. Now, granted, I have not repaired any kidneys and I have certainly not changed the course of kidney disease significantly. But I helped a patient stay out of the hospital, which was her biggest wish. And the idea that I could ever have the skills, the resources, or the will and daring to attempt to manage something like kidney failure in the outpatient setting would never have even crossed my mind. I had oversight - my preceptors were there the entire time and ready to keep me from killing the patient. But I put the knowledge that my instructors instilled in me to work and made the right choices so that they didn't have to jump in and take over and instead they stood by and watched as the patient's condition improved, much to my surprise. Despite knowing the right information and making good decisions, I still wasn't sure the treatments I prescribed would have the effects necessary to achieve the desired result - thus I was pleasantly surprised and gratified that things are looking up.
Even comparing myself now to a year ago - I had just finished my didactic year, my brain full of facts and protocols and ready to begin my real training. But when I set foot in my first rotation, my eyes were big as saucers and I had no idea what I had gotten myself into. My first consult in the ER was more a rote memory of how to perform an H&P than it was the application of learned skills. That I happened upon the right diagnosis at the time was more luck than knowledge, and even now I always say, "it's better to be lucky than good," when I have a success. The point is that I marvel at the change. It is cliche to say that I've progressed by leaps and bounds, but it describes the situation well.
I am grateful to God for my successes and give Him the credit. And I still pray that, even though I helped turn kidney failure around, my hands will be blessed and the patient will have a good weekend and be waiting to greet me at the door to the clinic on Monday morning rather than lying in a hospital bed having been admitted while I wasn't watching.
What have I gotten myself into?
2 1/2 years ago I could not have told you what BUN, Creatinine, or GFR are. But this past week I spent a good amount of time managing a patient with wild abnormals for all of these and, essentially, turning kidney failure around. Now, granted, I have not repaired any kidneys and I have certainly not changed the course of kidney disease significantly. But I helped a patient stay out of the hospital, which was her biggest wish. And the idea that I could ever have the skills, the resources, or the will and daring to attempt to manage something like kidney failure in the outpatient setting would never have even crossed my mind. I had oversight - my preceptors were there the entire time and ready to keep me from killing the patient. But I put the knowledge that my instructors instilled in me to work and made the right choices so that they didn't have to jump in and take over and instead they stood by and watched as the patient's condition improved, much to my surprise. Despite knowing the right information and making good decisions, I still wasn't sure the treatments I prescribed would have the effects necessary to achieve the desired result - thus I was pleasantly surprised and gratified that things are looking up.
Even comparing myself now to a year ago - I had just finished my didactic year, my brain full of facts and protocols and ready to begin my real training. But when I set foot in my first rotation, my eyes were big as saucers and I had no idea what I had gotten myself into. My first consult in the ER was more a rote memory of how to perform an H&P than it was the application of learned skills. That I happened upon the right diagnosis at the time was more luck than knowledge, and even now I always say, "it's better to be lucky than good," when I have a success. The point is that I marvel at the change. It is cliche to say that I've progressed by leaps and bounds, but it describes the situation well.
I am grateful to God for my successes and give Him the credit. And I still pray that, even though I helped turn kidney failure around, my hands will be blessed and the patient will have a good weekend and be waiting to greet me at the door to the clinic on Monday morning rather than lying in a hospital bed having been admitted while I wasn't watching.
What have I gotten myself into?
Saturday, July 16, 2011
Up in the air
I think I've discussed this in the past and if I haven't then I have certainly thought it - the uncertainty in life is killer for someone like me.
First I struggled with the uncertainty surrounding going to PA school. I put in a decent amount of effort the first year that I applied and interviewed with my program and waited as patiently as possible. When I received the, "We regret to inform you..." letter the uncertainty nearly overwhelmed me. Should I even be pursuing this? Am I supposed to go to PA school? I made up some ground by gaining more experience and applied again. Once again, the uncertainty ate at me. Will they call? For this program, if you get a phone call you're in... if you get a letter you're out. Now we know that the call came. Praise God.
Then there was a lot of waiting and uncertainty about how well the didactic year would go. Am I up for this challenge? I prepared myself mentally as well as possible and put in as much effort as I felt I could and the Lord blessed didactic year.
Following that I was uncertain about clinical year. You get the drift. What will come through the door next? Am I up to doing surgical consults in the ER on the first day of my surgical rotation? And so on. And here I am, almost done with clinical year.
The next level of uncertainty lies ahead of me. Where am I going to work? How will I be paying our bills in 6 weeks? What about our student loans? Things are looking up for us - there are definitely job prospects, yet nothing is set in stone. So there is a lot of room for uncertainty here.
In the end the take home point that I hope to pass along to my children and anyone who might take a moment to hear it is that there will always be uncertainty. Moving through life will present us with much uncertainty at every turn. The Bible tells us to be wary of saying, "I will do this or that tomorrow." This is the way God has made the world. And looking back, I see better why we need to trust Him to get us through each uncertain obstacle. He is good. Romans 3 tells us that "All things work together for those who love God and are the called according to His purposes." Looking back on the last 2 1/2 years I can see in a very real way how God works to bring all things together - how He blesses us.
My hope is that someday I will be able to relax and have faith during times of uncertainty to avoid overstressing myself and those around me. Maybe someday I'll grow up to that level... Only time will tell.
First I struggled with the uncertainty surrounding going to PA school. I put in a decent amount of effort the first year that I applied and interviewed with my program and waited as patiently as possible. When I received the, "We regret to inform you..." letter the uncertainty nearly overwhelmed me. Should I even be pursuing this? Am I supposed to go to PA school? I made up some ground by gaining more experience and applied again. Once again, the uncertainty ate at me. Will they call? For this program, if you get a phone call you're in... if you get a letter you're out. Now we know that the call came. Praise God.
Then there was a lot of waiting and uncertainty about how well the didactic year would go. Am I up for this challenge? I prepared myself mentally as well as possible and put in as much effort as I felt I could and the Lord blessed didactic year.
Following that I was uncertain about clinical year. You get the drift. What will come through the door next? Am I up to doing surgical consults in the ER on the first day of my surgical rotation? And so on. And here I am, almost done with clinical year.
The next level of uncertainty lies ahead of me. Where am I going to work? How will I be paying our bills in 6 weeks? What about our student loans? Things are looking up for us - there are definitely job prospects, yet nothing is set in stone. So there is a lot of room for uncertainty here.
In the end the take home point that I hope to pass along to my children and anyone who might take a moment to hear it is that there will always be uncertainty. Moving through life will present us with much uncertainty at every turn. The Bible tells us to be wary of saying, "I will do this or that tomorrow." This is the way God has made the world. And looking back, I see better why we need to trust Him to get us through each uncertain obstacle. He is good. Romans 3 tells us that "All things work together for those who love God and are the called according to His purposes." Looking back on the last 2 1/2 years I can see in a very real way how God works to bring all things together - how He blesses us.
My hope is that someday I will be able to relax and have faith during times of uncertainty to avoid overstressing myself and those around me. Maybe someday I'll grow up to that level... Only time will tell.
Monday, July 11, 2011
Tragedy
The past few weeks have presented me and my family with the opportunity to work through the rigors of PA school while undergoing family tragedy. There have been a number of aspects to this struggle, as most of you have experienced with your own personal tragedies. We are by no means unique in this, but I am relating the story to share the experience with others so that they might better understand or at least commiserate with PA students and students of other medical professions. Again I apologize for being purposefully vague, but the details belong to us.
It began about three weeks ago when a routine doctor visit yielded bad news. News that we had dreaded, yet it came nonetheless. I was thankful for compassionate preceptors who allowed me some time to deal with the bad news, but the next day I was back at work trying to make good decisions and be precise through a muddied mind, distracted (gladly so) by grief. I was grateful that I had a supportive environment and a can-do family, otherwise I would have been unable to bear the weight of everything going on.
The second chapter (or the last half of the first) came today - another phone call striking me in my emotional gut, leaving me distracted and unable to think about anything but my family for quite a while. But today, right after the phone call, I entered a patient room and the nice lady sitting there immediately started crying. It seems our life tragedies had coincided on this day. The difficulty I had was that my mind wanted to be elsewhere, my emotions were flowing in the equivalent of a re-entry tachy-arrhythmia - feeding upon themselves and blunting my empathy. I was able to push it aside for our hour-long (though it was only intended to be a 1/2 hour) appointment and we even made some progress... for the patient. Following that patient, I saw a lady I have been treating for depression and we worked through her struggles. At the end of this day, my mind is numb, I lack much emotion and despite the weight of what is going on around me, I feel less than engaged, not as present as I should be.
Thus today I had a valuable experience - balancing the emotional needs of my patients with the emotional needs of my family have become truly competing demands and I have worked through the first in what I am sure will be a long series of such episodes. I can't say I have achieved success - it is too early to tell. But I have survived the day, my family is resting at apparent peace, and my patients ambled back through the waiting room with many a thank you, appearing content with meds in the pharmacy and consults/referrals ordered.
God is good, even in times of great trial. May we never forget it.
It began about three weeks ago when a routine doctor visit yielded bad news. News that we had dreaded, yet it came nonetheless. I was thankful for compassionate preceptors who allowed me some time to deal with the bad news, but the next day I was back at work trying to make good decisions and be precise through a muddied mind, distracted (gladly so) by grief. I was grateful that I had a supportive environment and a can-do family, otherwise I would have been unable to bear the weight of everything going on.
The second chapter (or the last half of the first) came today - another phone call striking me in my emotional gut, leaving me distracted and unable to think about anything but my family for quite a while. But today, right after the phone call, I entered a patient room and the nice lady sitting there immediately started crying. It seems our life tragedies had coincided on this day. The difficulty I had was that my mind wanted to be elsewhere, my emotions were flowing in the equivalent of a re-entry tachy-arrhythmia - feeding upon themselves and blunting my empathy. I was able to push it aside for our hour-long (though it was only intended to be a 1/2 hour) appointment and we even made some progress... for the patient. Following that patient, I saw a lady I have been treating for depression and we worked through her struggles. At the end of this day, my mind is numb, I lack much emotion and despite the weight of what is going on around me, I feel less than engaged, not as present as I should be.
Thus today I had a valuable experience - balancing the emotional needs of my patients with the emotional needs of my family have become truly competing demands and I have worked through the first in what I am sure will be a long series of such episodes. I can't say I have achieved success - it is too early to tell. But I have survived the day, my family is resting at apparent peace, and my patients ambled back through the waiting room with many a thank you, appearing content with meds in the pharmacy and consults/referrals ordered.
God is good, even in times of great trial. May we never forget it.
Saturday, June 25, 2011
Fixing children
I want to share a brief experience I had the other day that left me feeling essentially elated over the fact that I will soon be able to practice medicine.
The case was almost as straightforward a case as it gets - I won't include any details at all so it will be quite a vague recollection. At any rate, a kid comes into the clinic not feeling well. I took a thorough history, did a thorough exam, and everything was pretty unremarkable. I selected a medicine that would treat the symptoms well and allow the child to recover essentially without intervention aside from some short term diet changes. The kiddo had a very good response to the medicine, I monitored to make sure there were no side effects and that the medicine was indeed having the desired effect, and the child's persona changed on the spot. It went from looking and feeling sick to looking like a normal little one and almost bouncing down the hall on the way out the door. The turnaround was drastic, and gratifying.
Family medicine definitely has its perks, and fixing children is a BIG one.
The case was almost as straightforward a case as it gets - I won't include any details at all so it will be quite a vague recollection. At any rate, a kid comes into the clinic not feeling well. I took a thorough history, did a thorough exam, and everything was pretty unremarkable. I selected a medicine that would treat the symptoms well and allow the child to recover essentially without intervention aside from some short term diet changes. The kiddo had a very good response to the medicine, I monitored to make sure there were no side effects and that the medicine was indeed having the desired effect, and the child's persona changed on the spot. It went from looking and feeling sick to looking like a normal little one and almost bouncing down the hall on the way out the door. The turnaround was drastic, and gratifying.
Family medicine definitely has its perks, and fixing children is a BIG one.
Tuesday, June 21, 2011
Jading
This post is as much a request for feedback from experienced professionals as it is a warning to those who will be PA, NP, or medical students reading these words later on.
In several of my rotations I have noticed that some of the more seasoned providers have become rather presumptive about some of our patients. Granted, they know our patients better than I do and I am still the student so I have to learn to approach difficult patients with caution. But the providers I have worked with that I am talking about herein are providers who have made assumptions about our patients like, "He just wants pain meds," or, "She's just looking to get high." It appears from my perspective that these providers are becoming jaded with their experiences, as if they've been burned by drug seekers too many times to be able to remain objective and avoid jumping to conclusions. I say this because I, in my naivety, have approached them with a blank mind (quite literally sometimes) and have found some pretty profound pathology - a patient who I suspect of having an ACL tear, or a patient who has significant osteoarthritis, and several others.
To the experienced providers I ask this: is there a method by which you have avoided this pitfall so as to maintain functional ability with difficult patients? It is my short experience that if we can maintain a sensitive approach to even our most difficult patients, then we will be able to treat them more effectively. Am I wrong?
To those students who are coming after me, I offer you this from my experiences (stop me if you've heard this story): many months ago I was working in the ER when a patient bounced back from earlier that day. This was a young girl who had been complaining of back pain but now she was coming in with severe abdominal pain. In passing a nurse commented about her prior visit to the ER and the likelihood that she had, "Just not gotten what she wanted." I bought into that thinking about her right away and it was reinforced as I watched her roll by on the stretcher writhing in pain. As I went in to examine her I was unimpressed by her pain given that she reacted excessively to every test that I did - minor pressure on her belly elicited near screams. She had no other symptoms that I could find. I presented the case to my preceptor who taught me a valuable lesson that day - he said, "Yeah, it could be a bounce-back because she didn't get the meds she wanted... Or she could have something wrong in her belly, so let's look." He ordered an ultrasound and found a GIANT ovarian cyst, reaching nearly up to the patient's ribs. As soon as I heard that I hung my head in shame... I had made a bad assumption based on very little evidence, and I was dead wrong. I would have been infinitely better as a provider if I had not assumed as much as I did, and I hope that I never forget the shame I felt that day - it was a good teacher.
In several of my rotations I have noticed that some of the more seasoned providers have become rather presumptive about some of our patients. Granted, they know our patients better than I do and I am still the student so I have to learn to approach difficult patients with caution. But the providers I have worked with that I am talking about herein are providers who have made assumptions about our patients like, "He just wants pain meds," or, "She's just looking to get high." It appears from my perspective that these providers are becoming jaded with their experiences, as if they've been burned by drug seekers too many times to be able to remain objective and avoid jumping to conclusions. I say this because I, in my naivety, have approached them with a blank mind (quite literally sometimes) and have found some pretty profound pathology - a patient who I suspect of having an ACL tear, or a patient who has significant osteoarthritis, and several others.
To the experienced providers I ask this: is there a method by which you have avoided this pitfall so as to maintain functional ability with difficult patients? It is my short experience that if we can maintain a sensitive approach to even our most difficult patients, then we will be able to treat them more effectively. Am I wrong?
To those students who are coming after me, I offer you this from my experiences (stop me if you've heard this story): many months ago I was working in the ER when a patient bounced back from earlier that day. This was a young girl who had been complaining of back pain but now she was coming in with severe abdominal pain. In passing a nurse commented about her prior visit to the ER and the likelihood that she had, "Just not gotten what she wanted." I bought into that thinking about her right away and it was reinforced as I watched her roll by on the stretcher writhing in pain. As I went in to examine her I was unimpressed by her pain given that she reacted excessively to every test that I did - minor pressure on her belly elicited near screams. She had no other symptoms that I could find. I presented the case to my preceptor who taught me a valuable lesson that day - he said, "Yeah, it could be a bounce-back because she didn't get the meds she wanted... Or she could have something wrong in her belly, so let's look." He ordered an ultrasound and found a GIANT ovarian cyst, reaching nearly up to the patient's ribs. As soon as I heard that I hung my head in shame... I had made a bad assumption based on very little evidence, and I was dead wrong. I would have been infinitely better as a provider if I had not assumed as much as I did, and I hope that I never forget the shame I felt that day - it was a good teacher.
Sunday, June 12, 2011
Family Practice
Seven weeks ago I started my last clinical rotation - Family Practice. The first thing that struck me was that I was very excited to be starting my last clinical rotation. It's a little bittersweet, but mostly sweet so I like that very much.
Family practice is a different animal than any other specialty that I've worked in (for the most part). Here I have to be a Jack-of-all-trades, master of none. I have to understand and treat the major Ears/Nose/Throat (ENT) issues for infants, children, adults but I have to know when to refer to the ENT specialists when the patient keeps getting sick or when my treatments are not successful. The same goes for cardiology, pulmonology, gastroenterology, urology, neurology, dermatology, orthopedics, rheumatology, hematology/oncology, endocrinology - you name the specialty and we dabble in it. It is a MASSIVE amount of information to understand and have a handle on. Putting it into words is even more intimidating than just thinking about it - seeing that list is nearly frightening. Yet somehow, day in and day out, I go to work and know what I'm talking about for the most part.
In addition to all that stuff, we also run a sort of minor care/emergency clinic through our family practice. This is for those things that just can't wait but aren't necessarily bad enough to go to the ER. Interestingly (very), since we are out in the boonies, we actually get a LOT of patients through our "quick care" that actually would be good candidates for the ER - women with severe lower abdominal pain and positive pregnancy tests, old men with crushing substernal chest pain, children who come in slightly confused with a fruity odor to their breath and blood sugars in the upper 500s. We get it all here and we have to know how to quickly and efficiently get the answers that we need to make nearly critical decisions. This part I love, very truly, but this is quite possibly the scariest thing I have done yet. The other day I had an older woman with diabetes tell me that it felt as if someone was sitting on her chest, but she just thought it was a bad reaction to her medicine and she wasn't even going to come in that day, but the clinic was conveniently located so she did. The problem: we are 40 minutes away from definitive care if the patient goes by ambulance - it would take the ambulance 20 minutes to get to us and 20 minutes to get the patient to the hospital. If something goes very wrong, we are essentially on our own.
So the last seven weeks have been yet another lesson in being appropriately uncomfortable which I am all the time. I have to work remarkably hard to know my limitations and stop myself from going over them. I am at the point now where I can see a patient in 20 minutes and have a good plan that will get to the root of the diagnosis, but I still consciously think, "Ok, what else could this be that might kill the patient if I don't look at it?" I do a few more tests than the experienced providers, but so far it's all been reasonable so I feel confident that even though I don't know and I'm uncomfortable I will still get the diagnosis that I need. And so far, I have. The pinnacle: I made a diagnosis of malignant melanoma on a patient who had a previously benign lesion re-occur. So, you never can tell what will come of a test or what might walk through your door - and that makes me uncomfortable, but I am slowly becoming ok with that.
Family practice is a different animal than any other specialty that I've worked in (for the most part). Here I have to be a Jack-of-all-trades, master of none. I have to understand and treat the major Ears/Nose/Throat (ENT) issues for infants, children, adults but I have to know when to refer to the ENT specialists when the patient keeps getting sick or when my treatments are not successful. The same goes for cardiology, pulmonology, gastroenterology, urology, neurology, dermatology, orthopedics, rheumatology, hematology/oncology, endocrinology - you name the specialty and we dabble in it. It is a MASSIVE amount of information to understand and have a handle on. Putting it into words is even more intimidating than just thinking about it - seeing that list is nearly frightening. Yet somehow, day in and day out, I go to work and know what I'm talking about for the most part.
In addition to all that stuff, we also run a sort of minor care/emergency clinic through our family practice. This is for those things that just can't wait but aren't necessarily bad enough to go to the ER. Interestingly (very), since we are out in the boonies, we actually get a LOT of patients through our "quick care" that actually would be good candidates for the ER - women with severe lower abdominal pain and positive pregnancy tests, old men with crushing substernal chest pain, children who come in slightly confused with a fruity odor to their breath and blood sugars in the upper 500s. We get it all here and we have to know how to quickly and efficiently get the answers that we need to make nearly critical decisions. This part I love, very truly, but this is quite possibly the scariest thing I have done yet. The other day I had an older woman with diabetes tell me that it felt as if someone was sitting on her chest, but she just thought it was a bad reaction to her medicine and she wasn't even going to come in that day, but the clinic was conveniently located so she did. The problem: we are 40 minutes away from definitive care if the patient goes by ambulance - it would take the ambulance 20 minutes to get to us and 20 minutes to get the patient to the hospital. If something goes very wrong, we are essentially on our own.
So the last seven weeks have been yet another lesson in being appropriately uncomfortable which I am all the time. I have to work remarkably hard to know my limitations and stop myself from going over them. I am at the point now where I can see a patient in 20 minutes and have a good plan that will get to the root of the diagnosis, but I still consciously think, "Ok, what else could this be that might kill the patient if I don't look at it?" I do a few more tests than the experienced providers, but so far it's all been reasonable so I feel confident that even though I don't know and I'm uncomfortable I will still get the diagnosis that I need. And so far, I have. The pinnacle: I made a diagnosis of malignant melanoma on a patient who had a previously benign lesion re-occur. So, you never can tell what will come of a test or what might walk through your door - and that makes me uncomfortable, but I am slowly becoming ok with that.
Monday, May 16, 2011
Come a looong way...
About a month ago I finished what I thought was the greatest rotation I could possibly have had. It was my hospital rotation in which I worked with four of the best preceptors a guy could ever ask for. I worked in a medical/surgical unit with an ICU on the side. The service was responsible for 6-10 patients on any given day, though we averaged closer to 6 - so it was a small service. But the size of the service was PERFECT. I had plenty of time to interact with my preceptors while not keeping them from their work and I got to help in the care of some very sick people. It was incredible.
In the first week, my lead preceptor discussed her expectations with me. I was a bit unnerved when she said that she expected me to be able to operate at the level of a 4th year medical student or medical intern (the intern year is the year after graduation from medical school - so she expected I would perform on par with a new graduate MD). Another of my preceptors said the same thing, so it was confirmed that I would need to step up to the plate on this one.
The thought that I would be able to operate at the level of a 4th year med student or intern was, in my opinion, setting the bar a bit high. I didn't exactly understand what that entailed, nor did I expect that I would completely meet that standard. As it turned out, though, I enjoyed the rotation and was able to step up in a way that worked out well. I actually wanted to get to the hospital early to pre-round on the patients so that when we did actual hospital rounds I was ready to go. I rounded by myself, got the labs/imaging compiled from the night before and presented my patients on morning rounds to my preceptor. I got "pimped" plenty and learned volumes about that management of really sick patients. I could have spent the remainder of my clinical year at that site and been plenty happy.
As it turned out, it was recommended to me by two of my preceptors that I go to medical school - one noted that I think more like a doctor than PAs he's worked with in the past. In all, it was a really gratifying experience. A very high bar was set and I was able to step up and get the job done, even though I didn't think I'd make it at first. But I'm curious about something... Do PAs and NPs think in a different way than doctor's do? My take on this is that NPs might think a little bit differently given their basis in the nursing model, but in the end they gather information the same way toward the same end - they have to make the diagnosis and treat the same as anyone. PAs are trained in the medical model so I would definitely expect that all PAs would think the same way as doctors. In the end, "mid-level" providers need to think the same way MDs/DOs do - we all have to come up with the same conclusion which means gathering the same type of information and applying the same type of decision making tree to the clinical problem so that the patients don't suffer. Thus I was really surprised at my preceptor's comment that I think more like a doctor than a PA - I thought we were all supposed to be on the same page. So, to everyone who comes along after me please take this to heart: be diligent about your information gathering and apply sound clinical decision making in order to 1. better represent our profession and 2. ensure that your patients are getting solid medical care.
In the end, the biggest thing that this rotation showed me is just how far I've come. A year ago, I was busting my tail to get through my last set of finals, struggling to maintain motivation in order to better regurgitate simple information onto a page. After just a year I have come a long way. Thinking back, if I had thought a year ago that I would be expected to be doing the job of a 4th year medical student I would have laughed at the idea. But I made it... Now on to family practice.
In the first week, my lead preceptor discussed her expectations with me. I was a bit unnerved when she said that she expected me to be able to operate at the level of a 4th year medical student or medical intern (the intern year is the year after graduation from medical school - so she expected I would perform on par with a new graduate MD). Another of my preceptors said the same thing, so it was confirmed that I would need to step up to the plate on this one.
The thought that I would be able to operate at the level of a 4th year med student or intern was, in my opinion, setting the bar a bit high. I didn't exactly understand what that entailed, nor did I expect that I would completely meet that standard. As it turned out, though, I enjoyed the rotation and was able to step up in a way that worked out well. I actually wanted to get to the hospital early to pre-round on the patients so that when we did actual hospital rounds I was ready to go. I rounded by myself, got the labs/imaging compiled from the night before and presented my patients on morning rounds to my preceptor. I got "pimped" plenty and learned volumes about that management of really sick patients. I could have spent the remainder of my clinical year at that site and been plenty happy.
As it turned out, it was recommended to me by two of my preceptors that I go to medical school - one noted that I think more like a doctor than PAs he's worked with in the past. In all, it was a really gratifying experience. A very high bar was set and I was able to step up and get the job done, even though I didn't think I'd make it at first. But I'm curious about something... Do PAs and NPs think in a different way than doctor's do? My take on this is that NPs might think a little bit differently given their basis in the nursing model, but in the end they gather information the same way toward the same end - they have to make the diagnosis and treat the same as anyone. PAs are trained in the medical model so I would definitely expect that all PAs would think the same way as doctors. In the end, "mid-level" providers need to think the same way MDs/DOs do - we all have to come up with the same conclusion which means gathering the same type of information and applying the same type of decision making tree to the clinical problem so that the patients don't suffer. Thus I was really surprised at my preceptor's comment that I think more like a doctor than a PA - I thought we were all supposed to be on the same page. So, to everyone who comes along after me please take this to heart: be diligent about your information gathering and apply sound clinical decision making in order to 1. better represent our profession and 2. ensure that your patients are getting solid medical care.
In the end, the biggest thing that this rotation showed me is just how far I've come. A year ago, I was busting my tail to get through my last set of finals, struggling to maintain motivation in order to better regurgitate simple information onto a page. After just a year I have come a long way. Thinking back, if I had thought a year ago that I would be expected to be doing the job of a 4th year medical student I would have laughed at the idea. But I made it... Now on to family practice.
Saturday, April 23, 2011
Changes... They're a-comin'
Well, here we are.... Nearing the end of my clinical year and coming fast upon graduation. Four months..... 123 days, 16 hours, and 39 minutes - but who's counting, right?
The biggest things going on at present are that I am trying to get a job. I have some prospects, which is very exciting considering the small area in which I had been looking. We come from two small communities and the area employs a total of 29 PAs in 2010. In 2009 the area employed 28 PAs - not a lot of growth over the past couple of years. Thus, not a lot of job openings. That's just fine. I have an opportunity with a local practice and negotiations are underway. I have secret hopes that more opportunities will come along (not that the one I have is poor) but I'm not holding my breath. We are blessed.
The other thing that has been a big change is that my wife is picking up her practice again - she owns a home based business doing landscape design. It has been a busy time for us, but seeing her apply her expertise and skill to beautifying peoples' homes and their land has been delightful. She took a hiatus for a year-and-a-half in order to support me through PA school. The sacrifices she has made have covered every area of our lives, and I am very grateful that she is able to re-institute one of the things she has always enjoyed. She is an expert in my opinion (admittedly, I am biased) and seeing her talents displayed permanently around town has been pleasant, to say the least. I am also glad to think that her sacrifices, as well as mine, will be coming to fruition very soon. Again, we are blessed.
So, where to next? I will be heading to an Indian Health Services Clinic in a very rural town. This promises to be an outstanding rotation, though the commute will a bit killer. I will be able to work in the quick care, pediatric clinic, and diabetes clinic each week. The providers I will be training under have many decades of experience, so there will be much knowledge I can gain from them. This is my final rotation - it will span the next four months and will culminate in graduation.
Six words: I cannot wait til the end.
The biggest things going on at present are that I am trying to get a job. I have some prospects, which is very exciting considering the small area in which I had been looking. We come from two small communities and the area employs a total of 29 PAs in 2010. In 2009 the area employed 28 PAs - not a lot of growth over the past couple of years. Thus, not a lot of job openings. That's just fine. I have an opportunity with a local practice and negotiations are underway. I have secret hopes that more opportunities will come along (not that the one I have is poor) but I'm not holding my breath. We are blessed.
The other thing that has been a big change is that my wife is picking up her practice again - she owns a home based business doing landscape design. It has been a busy time for us, but seeing her apply her expertise and skill to beautifying peoples' homes and their land has been delightful. She took a hiatus for a year-and-a-half in order to support me through PA school. The sacrifices she has made have covered every area of our lives, and I am very grateful that she is able to re-institute one of the things she has always enjoyed. She is an expert in my opinion (admittedly, I am biased) and seeing her talents displayed permanently around town has been pleasant, to say the least. I am also glad to think that her sacrifices, as well as mine, will be coming to fruition very soon. Again, we are blessed.
So, where to next? I will be heading to an Indian Health Services Clinic in a very rural town. This promises to be an outstanding rotation, though the commute will a bit killer. I will be able to work in the quick care, pediatric clinic, and diabetes clinic each week. The providers I will be training under have many decades of experience, so there will be much knowledge I can gain from them. This is my final rotation - it will span the next four months and will culminate in graduation.
Six words: I cannot wait til the end.
Sunday, April 17, 2011
Sick vs. Sick-sick
So, on the third day of my rotation with the hospitalist group, my preceptor told me that I needed to learn how to tell sick from sick-sick. This is a variation on the idea of sick vs. not-sick that we discussed earlier. Those of you who are in medicine know that it takes time to be able to tell the difference very quickly from sick or not-sick. It takes a lot of experience and a keen eye, as well as (in some cases) a medical "sixth sense" that we students admire and hold in awe. "You mean, you can tell from the way the patient smells just how sick he is...?" - or some variation of this amazing set of skills.
Thus you might understand my reaction when my preceptor said (on a Wednesday), "I want you to learn the difference between sick and sick-sick and we'll review it on Friday." I knew what she was looking for so all I could do was blubber a, "Sounds goo-ood???" She passed on some hints to focus my research: Rapid Response Teams (RRTs). And thus I got the picture a little more fully.
RRTs are a group of providers in the hospital setting who are dedicated to being at the patient's bedside within five minutes of activation no matter what time of day. RRTs are made up of physician(s) (sometimes specialists, sometimes just ER or Intensive Care doctors), PAs (sometimes), Nurses (the backbone), CNAs, Respiratory Therapists, etc. who all have trained together and come together at any time to manage a patient who is, essentially, rapidly getting worse and on the verge of dying in the hospital. It makes sense to have such a team. So when should we call them?
This is the question - when do we activate the RRT and get this medical juggernaut rolling along to save a life? How do we know when they need to be called? The short answer is this: how does the patient look? But this isn't a well enough guided answer. To a noob like myself, a patient might look "Bad, but not really bad," when in fact they are two steps shy of meeting their maker. Thus, many great minds have gotten together and created some criteria for the activation of RRTs. One sample is as follows:
Respiratory signs:
Resp rate less than 8 or greater than 28
SpO2 of 86-90% for greater than 5 minutes
Increasing amounts of supplemental oxygen to maintain SpO2
PEDS - child (18-30), infant (30-60)
* Any significant change in respiratory status*
CV signs:
Rate 40-160 or
Rate greater than 140 with Sx
PEDS - child/adolescent (60-140), infant (85-190)
*Any significant change in pulse with Sx*
BP signs:
Systolic 80-180
Diastolic > 100
PEDS - age x 2 systolic
Neuro signs:
ALOC
Acute mental status changes
Unexplained lethargy/agitation
Seizure
Stroke Sx
- loss/change of speach
- sudden loss of movement/weakness of face/arms/legs
- numbness and tingling
Chest Pain:
No response to NTG
Acute or new onset
Other changes:
Pain
Fluid Status
Skin color (pale, dusky, blue)
Uncontrolled bleeding
Behavioral Emergency
This is the most comprehensive list of activation criteria that I could find. It comes from the Institute for Clinical Systems Improvement protocol that you can go do by clicking here. The utility of this set of guidelines is that it helps us to have some hard and fast references for activation. As one nurse that I interviewed about this topic said, it gives you something to know early on... After you get these numbers down and understand what they might indicate, then you can put it all into the context of the patient and the clinical picture and it will help you know sick from sick-sick (this is paraphrased).
A medical intern's perspective on this topic can be found here. This intern's perspective is what led to my interview of the nurse that I referenced above. Thus, another note to all of us who are fledglings out on the wards: ask your nurses... They'll be the first to know if something is going wrong - if you find out what they know, you'll have a much better chance of doing the job well.
Thus you might understand my reaction when my preceptor said (on a Wednesday), "I want you to learn the difference between sick and sick-sick and we'll review it on Friday." I knew what she was looking for so all I could do was blubber a, "Sounds goo-ood???" She passed on some hints to focus my research: Rapid Response Teams (RRTs). And thus I got the picture a little more fully.
RRTs are a group of providers in the hospital setting who are dedicated to being at the patient's bedside within five minutes of activation no matter what time of day. RRTs are made up of physician(s) (sometimes specialists, sometimes just ER or Intensive Care doctors), PAs (sometimes), Nurses (the backbone), CNAs, Respiratory Therapists, etc. who all have trained together and come together at any time to manage a patient who is, essentially, rapidly getting worse and on the verge of dying in the hospital. It makes sense to have such a team. So when should we call them?
This is the question - when do we activate the RRT and get this medical juggernaut rolling along to save a life? How do we know when they need to be called? The short answer is this: how does the patient look? But this isn't a well enough guided answer. To a noob like myself, a patient might look "Bad, but not really bad," when in fact they are two steps shy of meeting their maker. Thus, many great minds have gotten together and created some criteria for the activation of RRTs. One sample is as follows:
Respiratory signs:
Resp rate less than 8 or greater than 28
SpO2 of 86-90% for greater than 5 minutes
Increasing amounts of supplemental oxygen to maintain SpO2
PEDS - child (18-30), infant (30-60)
* Any significant change in respiratory status*
CV signs:
Rate 40-160 or
Rate greater than 140 with Sx
PEDS - child/adolescent (60-140), infant (85-190)
*Any significant change in pulse with Sx*
BP signs:
Systolic 80-180
Diastolic > 100
PEDS - age x 2 systolic
Neuro signs:
ALOC
Acute mental status changes
Unexplained lethargy/agitation
Seizure
Stroke Sx
- loss/change of speach
- sudden loss of movement/weakness of face/arms/legs
- numbness and tingling
Chest Pain:
No response to NTG
Acute or new onset
Other changes:
Pain
Fluid Status
Skin color (pale, dusky, blue)
Uncontrolled bleeding
Behavioral Emergency
This is the most comprehensive list of activation criteria that I could find. It comes from the Institute for Clinical Systems Improvement protocol that you can go do by clicking here. The utility of this set of guidelines is that it helps us to have some hard and fast references for activation. As one nurse that I interviewed about this topic said, it gives you something to know early on... After you get these numbers down and understand what they might indicate, then you can put it all into the context of the patient and the clinical picture and it will help you know sick from sick-sick (this is paraphrased).
A medical intern's perspective on this topic can be found here. This intern's perspective is what led to my interview of the nurse that I referenced above. Thus, another note to all of us who are fledglings out on the wards: ask your nurses... They'll be the first to know if something is going wrong - if you find out what they know, you'll have a much better chance of doing the job well.
Saturday, April 16, 2011
Families and Medicine
One of the items on our checklist of things to practice during this rotation is consulting with family members. This has been particularly interesting as it is something that healthcare providers do very often, but not something we think an awful lot about. We, of course, learn "people skills" as part of our training (as much as "people skills" can be taught) but it is not something that we study in depth like we would cardiology or acid-base disorders. But I have to say that this rotation has been particularly rewarding because talking to the families has been both valuable and enjoyable now that I'm focusing on it a little.
I have found that the best rule of thumb about this topic is that we as providers simply need to listen. We are taught that we need to listen from day one. We need to listen to the patient because if we do, they will likely tell us the diagnosis. The same applies to listening to the patient's family. You will learn how to make them happy and take care of their concerns if you just listen. This takes a couple of different forms - of course, we need to listen with our ears to what they say. Answer their questions thoroughly, without guessing, and with complete honesty. Additionally, we can listen with our eyes - something like 90% of communication comes via non-verbal means. This applies to patient's families as well. Many times, patients will be reticent to express concern or discomfort with the situation verbally, so they will do it by fidgeting or having a constricted affect or something along these lines. Providers can pick up on this via observation of the family and we can head off future problems by addressing their comfort level (or lack of comfort) early even before they have had to say anything about it.
I have had the pleasure of dealing with many family members over the past three weeks. I have earned their trust, answered their questions, and put them at ease about their ill loved ones. I have listened to them and it has been great. So, my advice to other students, learn to listen.
I have found that the best rule of thumb about this topic is that we as providers simply need to listen. We are taught that we need to listen from day one. We need to listen to the patient because if we do, they will likely tell us the diagnosis. The same applies to listening to the patient's family. You will learn how to make them happy and take care of their concerns if you just listen. This takes a couple of different forms - of course, we need to listen with our ears to what they say. Answer their questions thoroughly, without guessing, and with complete honesty. Additionally, we can listen with our eyes - something like 90% of communication comes via non-verbal means. This applies to patient's families as well. Many times, patients will be reticent to express concern or discomfort with the situation verbally, so they will do it by fidgeting or having a constricted affect or something along these lines. Providers can pick up on this via observation of the family and we can head off future problems by addressing their comfort level (or lack of comfort) early even before they have had to say anything about it.
I have had the pleasure of dealing with many family members over the past three weeks. I have earned their trust, answered their questions, and put them at ease about their ill loved ones. I have listened to them and it has been great. So, my advice to other students, learn to listen.
Saturday, April 2, 2011
Hospitalists
This month I am doing a rotation with a group of hospitalists. A hospitalist is a medical provider who works, as you might guess, in a hospital. These providers are responsible for the day-to-day management of patients who have been hospitalized for conditions ranging from severe pneumonia to flares of inflammatory bowel disease. In smaller hospitals, the hospitalist also covers the intensive care unit (the really sick-sick patients). So, I am getting a dose of very intense medical training - and I love it.
So far, I have had a patient who nearly died from very manageable conditions that got out of control very quickly, a patient with pain disproportionate to physical findings, severe pneumonia possibly complicated by malignant disease, and one patient with blood counts that are completely abnormal and that I have found very difficult to interpret (these are just a few examples among many). I have been challenged every day and this rotation is absolutely fascinating. If I could, I would become a hospitalist PA (and I might someday, if we ever decide to move to a big city).
Of interest is the fact that hospitalists as a specialty have only been around for a relatively short time (somewhere around 15-20 years). In the good 'ol days, day-to-day management of hospitalized patients was the responsibility of the family practice provider (be that a doctor, PA, or NP). But as family practice providers have grown increasingly busy, managing the really sick patients in the hospital became unfeasible. Thus, hospitalists became the next link in the medical-provider-chain. It's a very intriguing specialty - where else can you manage someone with acute abdominal pain who is alert and talkative one moment and seconds later be preparing another patient for the operating room so they can have life saving surgery? This is like zero to a hundred miles per hour in the blink of an eye.
I wish I could share more details, but a lot has been said recently about public media and medical/PA students who have gotten in trouble for just that. I'm erring on the side of caution such that none of my patients can be identified. After all, I would like to graduate.
So far, I have had a patient who nearly died from very manageable conditions that got out of control very quickly, a patient with pain disproportionate to physical findings, severe pneumonia possibly complicated by malignant disease, and one patient with blood counts that are completely abnormal and that I have found very difficult to interpret (these are just a few examples among many). I have been challenged every day and this rotation is absolutely fascinating. If I could, I would become a hospitalist PA (and I might someday, if we ever decide to move to a big city).
Of interest is the fact that hospitalists as a specialty have only been around for a relatively short time (somewhere around 15-20 years). In the good 'ol days, day-to-day management of hospitalized patients was the responsibility of the family practice provider (be that a doctor, PA, or NP). But as family practice providers have grown increasingly busy, managing the really sick patients in the hospital became unfeasible. Thus, hospitalists became the next link in the medical-provider-chain. It's a very intriguing specialty - where else can you manage someone with acute abdominal pain who is alert and talkative one moment and seconds later be preparing another patient for the operating room so they can have life saving surgery? This is like zero to a hundred miles per hour in the blink of an eye.
I wish I could share more details, but a lot has been said recently about public media and medical/PA students who have gotten in trouble for just that. I'm erring on the side of caution such that none of my patients can be identified. After all, I would like to graduate.
Friday, March 18, 2011
Break Time
It has been a while since my last post... Sorry I haven't kept up well. Life has been a whirlwind - I spent four weeks away from home at my psychiatric rotation and the following two away from home for an endocrinology selective rotation. All-in-all a good six weeks, but I was glad to get home last week and finally sleep in my own bed for more than two nights in a row.
I have been trying to use this past week as a chance to recharge the batteries and help my family out as much as possible. I initially thought I'd have tons of time off and we could relax and just fellowship a whole bunch... But I was wrong. I have actually worked more this week on homework than the last month combined. I have been trying to catch up on a number of projects for school, some home projects, EMT recertification, a side project for my EMS division chief, running ambulance calls, taking care of the children so my wife can see some of her friends, spending time with some of our mutual friends, meetings in Spokane with advisors and a PA working in orthopedics, helping a friend with a project at home, just trying to spend down time with the kids, making sure my wife still knows who I am.... Oh, and sleeping as much as possible. It has been the busiest week on record in a very long time.
All that said - things have gotten done that I've been putting off for a while and it appears as if I am almost completely caught up. Yesterday we raised a glass to St. Patrick and, if I had the time, tonight I'd raise a glass to accomplishments.
I have been trying to use this past week as a chance to recharge the batteries and help my family out as much as possible. I initially thought I'd have tons of time off and we could relax and just fellowship a whole bunch... But I was wrong. I have actually worked more this week on homework than the last month combined. I have been trying to catch up on a number of projects for school, some home projects, EMT recertification, a side project for my EMS division chief, running ambulance calls, taking care of the children so my wife can see some of her friends, spending time with some of our mutual friends, meetings in Spokane with advisors and a PA working in orthopedics, helping a friend with a project at home, just trying to spend down time with the kids, making sure my wife still knows who I am.... Oh, and sleeping as much as possible. It has been the busiest week on record in a very long time.
All that said - things have gotten done that I've been putting off for a while and it appears as if I am almost completely caught up. Yesterday we raised a glass to St. Patrick and, if I had the time, tonight I'd raise a glass to accomplishments.
Tuesday, February 15, 2011
The little things...
Today I want to post about the little things that make the grind of PA school a little bit better. This is meant to be something of a celebration as we are now 190 days out from graduation and being done with all challenges associated with school (and after those 190 days, I get to enjoy all the challenges that come with actual work, but that's for another post).
First, and foremost, my wife has made it all endurable. She has helped me in every way from taking care of the kids with often minimal input from me to packing me a lunch almost every day for the past 1.5 years. She deserves high praise and all my love for her endurance and her efforts, and the fact that yesterday she had to take a "rain check" valentine from me for something really special next year when the finances are more stable.
But today, the biggest "little thing" is that they gave me an office. It isn't much to look at, but the benefits one receives from having a quiet place to eat lunch or do a chart review are marvelous for one's psyche.
First, and foremost, my wife has made it all endurable. She has helped me in every way from taking care of the kids with often minimal input from me to packing me a lunch almost every day for the past 1.5 years. She deserves high praise and all my love for her endurance and her efforts, and the fact that yesterday she had to take a "rain check" valentine from me for something really special next year when the finances are more stable.
But today, the biggest "little thing" is that they gave me an office. It isn't much to look at, but the benefits one receives from having a quiet place to eat lunch or do a chart review are marvelous for one's psyche.
Saturday, February 12, 2011
Digging deep...
This week I had a chance to go back to the school office and chat with one of our faculty members about how everything is going and share some stories about lessons learned over the past six months. It was a good time, mostly filled with laughter at all of my shenanigans.
One episode that I haven't shared yet occurred during my orthopedic surgery rotation and drew a raucous laugh from my former instructor. It was an early morning, before 0700 and we were preparing to perform a total knee replacement on an elderly woman. Just the previous week I had been verbally cautioned against scrubbing in too soon because it made me useless in prepping/positioning the patient. This morning, I was determined not to make that mistake, so I waited in the hall outside the OR with my attending and his Nurse Practitioner. They were hurriedly doing their last minute tasks and I didn't have anything to do. The NP told me to get scrubbed and I began to meander through the task not wanting to get done too soon (in the end, I was simply woefully unmindful of the situation). As soon as the attending stood up and started getting ready I snapped to scrubbing my hands and getting ready, but it was already too late. They finished scrubbing moments ahead of me and the attending stepped into the room one step ahead of me. And here is where I made the mistake: I didn't realize that stepping into the OR behind the attending was tantamount to being 20 minutes late to surgery - ie it was a total disgrace to me and I should be ashamed of myself. The attending took the opportunity to inform me of my failure in front of all of the OR staff. I was behind him, so he couldn't see the look on my face or the sweat beading on my brow, but the rest of the OR staff could. There were a few snickers and chuckles (well deserved), but in the end I got gloved and gowned and did my job at the side of the operating table. I was adequately shamed and I never repeated that particular error.
As I talked with my former instructor, this story brought much delight. But we talked about other things going on - about psychiatry, about the struggles that PA school has brought with family, money, and time. After I left I kept feeling that gut feeling that anyone who has played competitive sports has felt. That feeling that says, "Time to dig a little deeper... It's fourth quarter, we're holding on to the lead just barely, and the other team has just put in a fresh set of players." It's that feeling of exhaustion, pride, diligence all mixed together but looking at a finish line that is a full lap in the distance... It's time to dig deep so that I can finish strong. I have fewer than 200 days left, just six months. I am fully 4/5 of the way through PA school and though things have been tough, we are doing quite well. My prayer is that God will finish what He has started well, and I have no doubt that He will be faithful to do so. But I know, through this feeling, that without Him I would be struggling very much.
One episode that I haven't shared yet occurred during my orthopedic surgery rotation and drew a raucous laugh from my former instructor. It was an early morning, before 0700 and we were preparing to perform a total knee replacement on an elderly woman. Just the previous week I had been verbally cautioned against scrubbing in too soon because it made me useless in prepping/positioning the patient. This morning, I was determined not to make that mistake, so I waited in the hall outside the OR with my attending and his Nurse Practitioner. They were hurriedly doing their last minute tasks and I didn't have anything to do. The NP told me to get scrubbed and I began to meander through the task not wanting to get done too soon (in the end, I was simply woefully unmindful of the situation). As soon as the attending stood up and started getting ready I snapped to scrubbing my hands and getting ready, but it was already too late. They finished scrubbing moments ahead of me and the attending stepped into the room one step ahead of me. And here is where I made the mistake: I didn't realize that stepping into the OR behind the attending was tantamount to being 20 minutes late to surgery - ie it was a total disgrace to me and I should be ashamed of myself. The attending took the opportunity to inform me of my failure in front of all of the OR staff. I was behind him, so he couldn't see the look on my face or the sweat beading on my brow, but the rest of the OR staff could. There were a few snickers and chuckles (well deserved), but in the end I got gloved and gowned and did my job at the side of the operating table. I was adequately shamed and I never repeated that particular error.
As I talked with my former instructor, this story brought much delight. But we talked about other things going on - about psychiatry, about the struggles that PA school has brought with family, money, and time. After I left I kept feeling that gut feeling that anyone who has played competitive sports has felt. That feeling that says, "Time to dig a little deeper... It's fourth quarter, we're holding on to the lead just barely, and the other team has just put in a fresh set of players." It's that feeling of exhaustion, pride, diligence all mixed together but looking at a finish line that is a full lap in the distance... It's time to dig deep so that I can finish strong. I have fewer than 200 days left, just six months. I am fully 4/5 of the way through PA school and though things have been tough, we are doing quite well. My prayer is that God will finish what He has started well, and I have no doubt that He will be faithful to do so. But I know, through this feeling, that without Him I would be struggling very much.
Wednesday, February 9, 2011
Confessions
As difficult as it is to admit this, there are times at the psych ward that scare me. I am not one to be easily put-off. In fact, I deal with most incidents that might make one frightened well (though, if you ask some people I scared easily when I was a teenager). Whatever the case may be, some of the patients on the psych ward give me the creeps, the heebee-jeebees, and otherwise make the hairs on the back of my neck stand up.
The reason: we have some patients who are not your run-of-the-mill mentally ill folk. We have a couple of hard core patients who have gone above-and-beyond - they are psychotic criminals. These are the guys who hear voices in their heads ("nice" or "happy" voices some say) that tell them to do things like kill their entire family. Now, admittedly, none of them have killed anyone. But they have caused serious, permanent disfigurement of others as well as themselves. And these guys are the ones who make me look over my shoulder every time I unlock the ward door at night. They are the ones who cause me to sit with facing all entrances into the room, and they are the ones who make me extremely uncomfortable when we are in the same room together and they are between me and the door.
Perhaps these guys are the reason I don't like psychiatry much. I can't really pin it down. But the other confession of the day is that I am having some trouble enjoying this rotation like I have enjoyed other rotations. I am working shorter hours, I am home before the sun sets, and I get a one hour lunch break. This is by far the least medically intense rotation I have had, but it is also the most mentally taxing in some ways. Never before have I been required to NOT wear a tie for fear that I will be strangled with it. At any rate, I certainly enjoy the medical side of what we do for our patients - and we do quite a bit. One aspect that I have identified is that psychiatry has few objective measurements by which we can measure progress. Much of what we know is subjective reporting and there are few examinations we can do to obtain any objective idea of how the patient is doing. I suppose I prefer the objective measurement of a patient coming to the clinic or ER ill, receiving treatment, and leaving well.
And once again I come back to the truth that there is yet much I need to learn - not all medicine is objective. There is a lot that comes down to judgment of the provider and I know this in an academic sense. Nowhere is this more important, in my fledgling opinion, than with psychiatry. I welcome the challenge and hope that by the end of my time here I can gain at least a little bit of insight into this judgment.
The reason: we have some patients who are not your run-of-the-mill mentally ill folk. We have a couple of hard core patients who have gone above-and-beyond - they are psychotic criminals. These are the guys who hear voices in their heads ("nice" or "happy" voices some say) that tell them to do things like kill their entire family. Now, admittedly, none of them have killed anyone. But they have caused serious, permanent disfigurement of others as well as themselves. And these guys are the ones who make me look over my shoulder every time I unlock the ward door at night. They are the ones who cause me to sit with facing all entrances into the room, and they are the ones who make me extremely uncomfortable when we are in the same room together and they are between me and the door.
Perhaps these guys are the reason I don't like psychiatry much. I can't really pin it down. But the other confession of the day is that I am having some trouble enjoying this rotation like I have enjoyed other rotations. I am working shorter hours, I am home before the sun sets, and I get a one hour lunch break. This is by far the least medically intense rotation I have had, but it is also the most mentally taxing in some ways. Never before have I been required to NOT wear a tie for fear that I will be strangled with it. At any rate, I certainly enjoy the medical side of what we do for our patients - and we do quite a bit. One aspect that I have identified is that psychiatry has few objective measurements by which we can measure progress. Much of what we know is subjective reporting and there are few examinations we can do to obtain any objective idea of how the patient is doing. I suppose I prefer the objective measurement of a patient coming to the clinic or ER ill, receiving treatment, and leaving well.
And once again I come back to the truth that there is yet much I need to learn - not all medicine is objective. There is a lot that comes down to judgment of the provider and I know this in an academic sense. Nowhere is this more important, in my fledgling opinion, than with psychiatry. I welcome the challenge and hope that by the end of my time here I can gain at least a little bit of insight into this judgment.
Monday, January 31, 2011
The psych ward
Today kicked off the first day of my psychiatry rotation. I get to spend the next four weeks learning to manage the myriad psychological issues that will afflict my future patients. To say that I had a deer-in-the-headlights look all day would be an understatement. It was both frightening to the core and a remarkable experience.
Beginning the day, I took the road to the hospital with cheerful confidence. It is a nice leisurely drive from where we're staying to the hospital. For the most part, the area is quite beautiful - wide open fields, gently rolling hills with long shadows dashing across them early in the morning. The nearer to the hospital you get, the more the trees close in and the last stretch of road is a mildly creepy meandering road through the woods. As the trees thin the hospital jumps into view, looming three stories above you. It looks exactly as a psychiatric hospital should - pale brown bricks, a flagpole standing tall at the front door, and long wings stretching to either side of the main entrance. The whole picture is topped off by that which only nature can provide - a permeating chill cuts through me and the grass crunches as a fresh coat of frost gives way under my feet.
The day went just fine - there were no issues with any of the patients at all. In fact, I enjoyed getting to know a couple of them and putting their angst-ridden minds at ease a bit with a few soft words and a plan to help them. But the entire ward was, just as the outside of the hospital, exactly what one would expect from an institution like this one. The lights were down low (in fact only every other light fixture was on), each door requires opening with a key are re-locking after passing through. The basement (which is used by the staff as the main mode of movement from one building to another) is a half-lit labrynth of hallways and corridors, offices and conference rooms. I was lost instantly. Simply leaving the hospital at the end of the day took me a full 15 minutes and I have a set of keys to the place.
Overall, this will be a challenging rotation. I did not thoroughly enjoy my first day which I usually do. I mean to make the most of the time I will spend here, but I anticipate that it will be a bit difficult. Only time will tell.
Beginning the day, I took the road to the hospital with cheerful confidence. It is a nice leisurely drive from where we're staying to the hospital. For the most part, the area is quite beautiful - wide open fields, gently rolling hills with long shadows dashing across them early in the morning. The nearer to the hospital you get, the more the trees close in and the last stretch of road is a mildly creepy meandering road through the woods. As the trees thin the hospital jumps into view, looming three stories above you. It looks exactly as a psychiatric hospital should - pale brown bricks, a flagpole standing tall at the front door, and long wings stretching to either side of the main entrance. The whole picture is topped off by that which only nature can provide - a permeating chill cuts through me and the grass crunches as a fresh coat of frost gives way under my feet.
The day went just fine - there were no issues with any of the patients at all. In fact, I enjoyed getting to know a couple of them and putting their angst-ridden minds at ease a bit with a few soft words and a plan to help them. But the entire ward was, just as the outside of the hospital, exactly what one would expect from an institution like this one. The lights were down low (in fact only every other light fixture was on), each door requires opening with a key are re-locking after passing through. The basement (which is used by the staff as the main mode of movement from one building to another) is a half-lit labrynth of hallways and corridors, offices and conference rooms. I was lost instantly. Simply leaving the hospital at the end of the day took me a full 15 minutes and I have a set of keys to the place.
Overall, this will be a challenging rotation. I did not thoroughly enjoy my first day which I usually do. I mean to make the most of the time I will spend here, but I anticipate that it will be a bit difficult. Only time will tell.
Sunday, January 23, 2011
Daylight
A few months ago I had been under the impression that I was busy. I realize now what busy really means but what gets me is that I am still probably wrong about what I consider busy. At any rate...
The past week has been rather intense. We have seen 80+ patients over three days and performed 14 operations. Each day has been longer than 12 hours for the surgeon and myself. Of course, this week is offset by the prior week in which we only had 60 patients and 9 surgeries. I understand that not all weeks are like this one, but it's still to the point that I have to ask myself - how do they do it? I am thankful that I don't have a residency waiting for me in which these hours would be pretty much normal. I don't envy anyone that mental stress but I also am thankful that I will not subject my family to that. Not seeing the daylight for four straight days (literally) definitely has an adverse effect on me but also for my family.
An important part of all of this is that we all (my family and I) will have to understand that there will be weeks like this one - there will be weeks when I need to work a lot of extra hours because there is a lot of work to be done. We can handle that. But we also need to understand that when the weeks are a bit slower, we need to recharge the batteries a bit - we need to let things be a little slower and spend some extra time doing family centered things. I guess I need to point out that I need to learn to take it a little slower on the slow weeks - and it's something that everyone coming after me should take into account.
My advice: as students, take the slow weeks to tend to the family/friends.
Now, if only I could take my own advice.
The past week has been rather intense. We have seen 80+ patients over three days and performed 14 operations. Each day has been longer than 12 hours for the surgeon and myself. Of course, this week is offset by the prior week in which we only had 60 patients and 9 surgeries. I understand that not all weeks are like this one, but it's still to the point that I have to ask myself - how do they do it? I am thankful that I don't have a residency waiting for me in which these hours would be pretty much normal. I don't envy anyone that mental stress but I also am thankful that I will not subject my family to that. Not seeing the daylight for four straight days (literally) definitely has an adverse effect on me but also for my family.
An important part of all of this is that we all (my family and I) will have to understand that there will be weeks like this one - there will be weeks when I need to work a lot of extra hours because there is a lot of work to be done. We can handle that. But we also need to understand that when the weeks are a bit slower, we need to recharge the batteries a bit - we need to let things be a little slower and spend some extra time doing family centered things. I guess I need to point out that I need to learn to take it a little slower on the slow weeks - and it's something that everyone coming after me should take into account.
My advice: as students, take the slow weeks to tend to the family/friends.
Now, if only I could take my own advice.
Saturday, January 8, 2011
Orthopedic surgery
This past week has been spent learning the ropes of a local orthopedic surgery practice. To say that we have been busy is an understatement. We have had over seventy patients in the office (on the three days that we saw patients in the office) and have performed twelve surgeries. It has been a whirlwind and I have tried my hardest to keep up. Whether or not I have done that well is up in the air. Regardless, I have enjoyed the ride.
We began on Monday in the clinic doing some pre-op and follow-up appointments. We had a few new patients, so in all it was a well-rounded day. On Tuesday it was all OR - seven cases in total. And we began the day with a procedure I had never seen before - a total knee replacement. It was an eye opening day and I was reminded of how much I enjoyed the OR during general surgery some months ago. More clinic and surgery on Wednesday, then Thursday just clinic. Friday was another day of surgery in which we performed a meniscus transplant. What an experience! The surgeon took a piece of donor meniscus (knee cartilage) and sewed it into a patient whose knee cartilage was pretty much plum worn out.
The emotional ride has been a little less extreme, but I am still humbled by all that I am doing now as a student. The job that we have as medical providers is, in a word, huge. I am enjoying learning that job and I am truly awestruck by the extent of what we need to know and be able to do. At this moment, I feel very tiny in the world of medicine - as if I am too small to be able to do my job. Yet in eight short months (ok - seven and a half, but who's counting?) I will need to be a functional part of this system. I know I will get there, but it still seems so far away.
We began on Monday in the clinic doing some pre-op and follow-up appointments. We had a few new patients, so in all it was a well-rounded day. On Tuesday it was all OR - seven cases in total. And we began the day with a procedure I had never seen before - a total knee replacement. It was an eye opening day and I was reminded of how much I enjoyed the OR during general surgery some months ago. More clinic and surgery on Wednesday, then Thursday just clinic. Friday was another day of surgery in which we performed a meniscus transplant. What an experience! The surgeon took a piece of donor meniscus (knee cartilage) and sewed it into a patient whose knee cartilage was pretty much plum worn out.
The emotional ride has been a little less extreme, but I am still humbled by all that I am doing now as a student. The job that we have as medical providers is, in a word, huge. I am enjoying learning that job and I am truly awestruck by the extent of what we need to know and be able to do. At this moment, I feel very tiny in the world of medicine - as if I am too small to be able to do my job. Yet in eight short months (ok - seven and a half, but who's counting?) I will need to be a functional part of this system. I know I will get there, but it still seems so far away.
Saturday, January 1, 2011
Funny pictures
As anyone else, I enjoy a humorous picture every now and again. This picture isn't quite as funny as the story behind the employees reaction when I took it. First, the picture:
Then the story:
We were out at some establishment (I don't want to name any names, of course) and I happened to be wearing a jacket that identified me as a local ambulance company member (a Christmas gift from the company). An employee had noticed my coat and wished us all a quiet evening (which didn't happen by the way). As we were going about our business, we noticed that there was conspicuously no fire extinguisher on the wall and, what with the big sign and an arrow pointing to where it should be, we got a good laugh and I decided to snap a picture for giggles. Well, the employee took note that an ambulance company member was snapping a picture of a place where a fire extinguisher is supposed to be and got just a little worked up -
"Wait, wait... We have a fire extinguisher right here!" She dutifully pulled one out from behind the counter. "It just fell down and we haven't had a chance to put it back up yet," the look on her face a mixture of "got caught with a hand in the cookie jar" and "please don't tell anyone... it was an accident, honest."
I reassured the kind employee that I was snapping the picture for my own personal amusement and that I really do not care about the fact that the fire extinguisher is not exactly where the sign on the wall says that it should be. I tried to convey that I was confident that they had everyone's safety well taken care of and that there was really nothing to worry about. But I don't think I succeeded.
In the end I got more of a chuckle out of the employee's reaction than I did over the photo itself. And I realize that this means I am a horrible person.
Then the story:
We were out at some establishment (I don't want to name any names, of course) and I happened to be wearing a jacket that identified me as a local ambulance company member (a Christmas gift from the company). An employee had noticed my coat and wished us all a quiet evening (which didn't happen by the way). As we were going about our business, we noticed that there was conspicuously no fire extinguisher on the wall and, what with the big sign and an arrow pointing to where it should be, we got a good laugh and I decided to snap a picture for giggles. Well, the employee took note that an ambulance company member was snapping a picture of a place where a fire extinguisher is supposed to be and got just a little worked up -
"Wait, wait... We have a fire extinguisher right here!" She dutifully pulled one out from behind the counter. "It just fell down and we haven't had a chance to put it back up yet," the look on her face a mixture of "got caught with a hand in the cookie jar" and "please don't tell anyone... it was an accident, honest."
I reassured the kind employee that I was snapping the picture for my own personal amusement and that I really do not care about the fact that the fire extinguisher is not exactly where the sign on the wall says that it should be. I tried to convey that I was confident that they had everyone's safety well taken care of and that there was really nothing to worry about. But I don't think I succeeded.
In the end I got more of a chuckle out of the employee's reaction than I did over the photo itself. And I realize that this means I am a horrible person.
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