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. 

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.  

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.

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. 

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. 

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.

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. 

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.

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.  

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?