Winning and Losing

Today started out less happy than most days. I got a call from a patient who had a serious problem - a problem I had been worried about developing. Part of the problem was brought on by the medicine I gave to my patient. It was a known risk, one that I felt was outweighed by the benefits that were experienced. My patient agreed with that, until we both realized that the opposite was true. The natural adverse effect of the medicine was worse than either of us expected. No harm is done, it is all completely reversible. The patient will, in the end, be fine. But the hardship and emotional stress was more than expected, and I was a contributor to that. Chalk one up in the "Loss" column.

But later in the same day, I checked my inbox and found a magical piece of paper. It was a radiology study result that another patient and I had been waiting for for over a month; the patient had in fact been waiting for about the past 6 months for someone to make the diagnosis and get this magic piece of paper in their hand. And today I got it. The results of this test explained some very concerning and dangerous symptoms, and more than that offered hope of a cure of these symptoms. It was very good news and a long time coming. Chalk one up in the "Win" column.

This is life now. Wins, losses... Big wins, and big losses. But more than that, each win is a patient, each loss is someone I am responsible for. The gambles, the risk/benefit analyses I go through each day end up affecting someone else in a large way. This is not news to me, but this is the first time that I have had such a stark contrast in the same day. The gamble for one patient did not pay off, while the roll of the dice on a diagnostic test for another patient was completely successful. I am thankful that, to this point, I haven't had to gamble with someone's life. But I know that it is coming. And days like these make me one step more prepared. But it is still humbling, still intimidating, and incredibly challenging. I am just hoping that I stack up a whole bunch more wins than losses.

Candy, Toys, or Recess?

I have been thinking about these three things frequently since my emergency medicine rotation over a year ago.  I may have commented on it at that time...  I don't recall and don't want to sort through a host of old posts to find it.  Suffice it to say that a wise preceptor of mine once told me that people who go to an ER or Urgent Care want one of three things: they either want candy (medicine), toys (protective equipment/braces/ace wraps, etc), or recess (time off from work/school).  I spent my day today doing urgent care (aka minor care) and it was evident that the desire to receive one of these things is present in nearly everybody.

I had a patient today who basically came in because of cramps.  As it turns out, the patient had not been drinking any water to speak of...  at all.  For days.  But this simple explanation was not sufficient.  This person was sick, according to relatives, and it had to be something worse than a water deficit.  For almost everyone else, there was medicine or bracing or just a day or two off from work that helped them leave happy as clams.  But for the one person who didn't get one of the three, there was little closure - little apparent relief given my assessment and treatment planning as well as the counseling on nutrition and hydration guidelines.

Several of my preceptors discussed with me the importance of "reassurance" as part of a treatment plan and counseling of my patients.  This works well for a few patients, but mostly only those who schedule routine office visits and yearly exams on a regular basis.  Reassurance for the "worried well" works fine in most cases...  For those who are convinced that they are emergently or urgently sick, a little "reassurance" is much more difficult to make sufficient.  At the same time, that should never keep us from trying. 

Art

I know that I have talked about the art of medicine before.  I have also talked about the lack of certainty that is ever present when practicing medicine.  Endless study and research has gone into removing the uncertainty from medicine, but there is no way to do so completely.  The human body is too complex, too poorly understood, for us to know 100% what the right decision is for every patient. 

It truly is an art.  I will briefly share an experience from a few weeks ago that illustrates this - again, please pardon the vague references, but I want to protect confidentiality.  So, a young woman comes to me with signs of a relatively common problem that is quite serious.  I followed all the scientific evidence to diagnose the condition with laboratory tests - but none confirmed the diagnosis.  Because of her prior history, I referred her to a specialist she'd been seeing so that he and I could get her referred to another specialist ASAP.  They screened her for the same condition I screened her for and did not find any evidence for it.  The other specialist didn't find anything either.  Basically, as a last resort, a risky procedure was done with what seemed like little evidence - and all of her symptoms resolved.  She'd had the condition we were worried about the entire time, but had none of the standard manifestations of the condition. 

I shrugged my shoulders and threw my hands up in the air when I heard that she'd had what we were worried about all along.  She had only one sign, and though the books say that someone with this condition should have laboratory findings to confirm the diagnosis, she did not.  My question was, "How am I supposed to make the right diagnosis and save lives when they don't exhibit the signs they're supposed to?  Don't they read the books?"  I know, of course, that uncertainty is inherent in the job.  That this is an art, and that sometimes I have to follow paths that are not spelled out 100%.  This is why I enjoy the job, but it is also something that makes the job quite frustrating and at times remarkably scary.  All in a days work, I suppose. 

Absence

It has been quite some time since my last post.  In the intervening time, a lot has changed. 

The major change is that I am going to be moving to a new job.  I got a phone call out of the blue about five weeks ago with an excellent proposal.  The new position will have me seeing more patients weekly, but working fewer hours.  I will be moving from government medicine to private practice.  I will be working in a larger practice with many excellent MDs, DOs and NPs around me.  Interestingly, I will be the only PA in the practice.  I am a bit intimidated by this fact - what will it mean for the future?  Will the group transition away from PAs in favor of NPs?  Why did they pick a PA in the first place?  I am grateful for the opportunity and I believe it will be an excellent one - there is already some talk about working with the local emergency room and there may be opportunities to work in surgery as well. 


I deeply regret leaving my current clinic - the need for providers is very great.  But with this move I am putting my family first.  I feel good about that. 

Selection Conference / PA School Interviews #2

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. 

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. 

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.

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.

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.