Holiday Break

On break now and looking forward to some relaxation time. Well, to the extent possible-you see, I have spent my life in the sun - California, New Mexico, Texas, Hawaii and Colorado is where I've spent most of my life. As a result I have extensive sun damage to the skin on my face. My dermatologist looked me over, and I mean ALL over, and suggested I apply 5% fluorouricil cream to zap the extensive actinic keratosis on my face. Two weeks from the start of therapy and I look hideous. Angry red sore cover 90% of my face. They, hurt, burn, itch and sting. Needless to say I garner many stares when I am out in public and the neighborhood kids ask me what's wrong with my face. I hope that my follow-up visit with the dermatologist tomorrow will be the last day I have use the cream. But if it isn't I'll keep going, keep using it, and show up to my mental health rotation ready to give my patients some bad dreams. It's not like I had an excess of good looks to draw from in the first place so I am looking forward to being back to a 5 or 6 rather than the 1 I am now.

I cried today

I am not proud of it, but I'm not really embarrassed by it either. I don't want to do it ever again either.

We have a patient in hospice who is in her twenties. She has EXTENSIVE adenocarcinoma, that she ignored while she was caring for her ailing mother. She knew she shouldn't have been bleeding like she was or having the massive discharge that she was experiencing but rather than address it, she ignored the existence of any problem. A year later her mom forced her see a doctor but by that time it was way too late for any kind of treatment. She has a massive wound and an even more massive tumor burden, has been in hospice for over a month now and has been stable and in no acute distress. She participates in activities to the extent someone who is bedridden can. She is usually outwordly cheerful and upbeat, if not denying any problem really exists. Since late last week she has been getting worse (bleeding, tumor growth) and today we informed her that she may not have long to live. It was the first time I saw her openly grieve her own loss and perhaps accept that she would soon die. We left the patient to cry alone, as she requested, and a couple minutes after I left her room I began to cry. Not sobbing or whimpering, just quietly letting tears stream from my eyes. The PA followed and we sat down together to discuss my feelings and how this young lady's imminent death had effected me. It had touched me so much because she is so young and I know that there are so many things she has missed out on and will never get to experience. Too, I felt that I had whitnessed her accepting her death. Literally accepting the fact that she would not only never get better, but that she would soon no longer be on this planet. So we talked and I let a few more tears fly and blew my nose a couple times. The PA gave me some words of comfort and advice and we got up and went to see the next person not long for this world.

Hospice

My rotation in hospice is very interesting. We aren't running around doing procedures or doing detailed exams or even prescribing that much medications. We do focus on making the "patient" and their family comfortable, well informed and supported from many different angles. It is such a unique perspective to spend so much time with dying people and their grieving families. I am really just learning how to listen to people and to openly and comfortably discuss death and the process of dying.

The team that I work with is great. They truly work as a team and really get along quite well. The doctor treats me with respect and introduces me as his "colleague, PA Phooey." The PA is also great and is fun to work with. They both take time to teach me about listening and ideals of hospice and palliative care. I am really impressed with this group, as are most all the families who come here and can see why everyone has worked in the same place for so long. Not too many places have such a strong group of providers, nurses, social workers and clergy. I can't recall a place where everyone worked so well together.

I am slowly growing comfortable talking to families of dying patients, but have almost broken up a couple times when visiting with families or dying patients who are still able to communicate. The ones who come in already unresponsive are, for me, a little easier to deal with. It's just hard having a conversation with someone you know won't be alive in week. This is a good experience and will certainly help me help my patients deal with death and dying.

Next rotation: Hospice

This should be interesting and will definitely test my ability to keep it together.

I still haven't recovered from my month in the country and very little sleep. I am tired all the time.

The end is near!

For this rotation at least. My preceptor has relegated to me observing him and listening to heart and lungs sounds for 90% of the 10-12 hours I put in each day. I get the impression he doesn't like me, but then again his interpersonal skills are thin. He just seems very uncomfortable speaking to patients and carrying on small talk with anyone. He staff is irritated with him often because he is NEVER on time for anything. I wait at the office 15 minutes to 2 hours for him to come in or to call to tell me where to meet him. He runs through mid-levels fairly regularly and some of his office staff were openly wondering how long his newly hired, yet very experienced PA would last. Seems his PAs and NPs don't stay for longer than a few years at most. I truly look forward to moving on and putting this rotation behind me. It is as close to a waste of time as medical education could be. It's shame too because he knows so damn much. He's just too busy to share it.

Interesting patients

The town I am doing my rotation in this month has maybe 10,000 residents. Many are poor, most are older. Almost all have been very pleasant and friendly. The other day however I was asked to see a patient while my preceptor saw a couple of worker's comp patients. I knew I was in for something when the MA gave me a look of pitty as walked past her to greet the patient. Actually the patient came out into the the hall to meet the "PA student working here for the next month." She was agitated and came at me full bore, demanding to know my name, where I was from and what kind of student I was. I shook her hand and brought her back into the exam room to find out what brought her in that day. She was there with her 11 y/o daughter, there because she was again in pain and needed medication. She pulled a curling iron out of her jacket, plugged it in and began to curl her thinning hair in large loops. She explained to me that she was in pain but that my preceptor had cut her off from narcotics because she had just tested positive for cocaine. What she didn't know was that her test also revealed she wasn't taking any prescribed pain meds either. Her phone then went off and she answered it, and described to the person on the end of the line the quantity and size in milligrams of a substance she could provide to the caller. Soon she answered another similar call and replied to a text message too. She then went on to explain that because she could no longer get pain meds from the doc that she had to "hustle" to get her pain taken care of adequately. After 30 minutes of learning that she had a terrible childhood, had lived in the same town I had when I was young, was the same age as me, that her daughter's dad had been murdered and that she hid nothing from her daughter, I began to wonder where my preceptor was. The patient then showed me a text message from a "friend" looking for some help with their pain from her. One minute she was friendly and smiling, the next she was confrontational and aggressive. Her daughter was embarased, quiet, friendly and smart. She tried to read a book while her mom cursed and rambled and spilled her guts to a stranger. After talking to her for 45 minutes I went to look for my preceptor and to seek a break from the intensity this patient exuded. I waited for 20 minutes for my preceptor to finish with his patient and then we went in together to talk to her. While my preceptor, with his back to us for most of the time, reviewed her meds and medical conditions, she had her daughter apply a fentanyl patch to her back and then she dug through a large prescription medication bottle filled with meds of varying sizes and colors of tablets. She pulled out a few tabs and swallowed them without water. She was now very friendly yet apparently reeling in pain, unable to sit or stand still. I spent this time to talk to her daughter about school and her favorite subjects, while my preceptor sifted through her chart and made notes while occasionally asking a question of the patient. I felt bad for this young girl who would be lucky to have her mom around for her highschool graduation. I was mad at this woman for being so selfish and vile and manipulative. I was frustrated with my preceptor for having me spend and hour and a half with a patient that he never wanted to see and had made wait an hour before he sent me in to talk to her. And I was disappointed with myself for letting any of them make me feel they way I had. She left without any new meds, undoubtedly as frustrated as i was, but for different reasons. I wish i had learned something valuable form the experience but I didn't. It only reinforced my feelings that some people are shit and will not hesitate to put people - loved ones and strangers- in positions they shouldn't be in to meet their own selfish needs. It reinforced the notion that innocent kids everywhere have crappy parents and must beat all the odds just to have a decent life. I also learned that my preceptor is passive aggressive and puts off doing what he doesn't want to do by placing a student in a crap situation just to prolong the inevitable. Thank goodness for the many kind and truely friendly patients I hve met during this rotation.

rural family practice

1) meeting lots of really nice people. really nice.
2) bought my SP a wireless router so I can do school work at the office rather than at mcdonalds.
3) bought a can of raid to kill the multitude of beetles that invade my living quarters.
4) doing a little more now on this rotation. SP a bit more social and friendly.
5) lots of the same here compared to the "city" - chronic pain and worker's comp mostly.
6) small town = lot's of old folks, not too many young folks.
7) miss my son like nobody's business.
8) rides back home with classmate are entertaining, enlightening and awakening.
9) not a damn thing to do or places to eat at 10 pm when I finish for the day
10) can't sleep for heck with the beetles and trains
11) bonus - ALL learning experiences are valuable.

Family Practice

I am in a rural, under-served area now with a doc who has been here for 26 years. He has his own, sizable practice, admits to the small local hospital, is the county health department's medical director, sees patients in the nursing home and the county jail, plus he covers the ER a couple days a week. I am staying in a trailer in the country where there is no internet and the TV doesn't work. We got a foot of snow last night so we didn't have too many patients come in. Unfortunately he is under the impression that students can't write in the chart so I don't get to do any documentation. Plus he does a LOT of workers comp which he has to see in their entirety so that cuts back more on what I get to do. He is a great doc who is very thorough and he spends 20-30 minutes with each patient. But that means we often aren't done until 10 pm. I wish that since i am putting in all this time I could do more, and in turn learn more. Well, I guess I'll just have take as much away from this experience as I can squeeze out of it.

I am driving back home tomorrow so I can go trick-or-treating with my boy. I sure do miss him already.

ME

A few of my patients and "co-workers" have asked me about my background and how I got into PA school. I thought that it would be interesting to show one PA student's qualifications before entering school, mostly in order.

BA - biology
Master health administration
6 yrs firefighter/EMT
EMT/CPR instructor at college and hospital
PT tech 2 years
10 years in Sr. position in health insurance
2 yr volunteer medical assitant in under-served pediatric clinic
1 yr volunteer EMT private ambulance company
1 yr cutting edge job at #1 rated research hospital

My undergrad GPA was 2.8 but my last 100 hrs had a GPA of 3.75 which helped alot. I worked 20-40 hrs a week in college, paid for most of it myself, hated every minute of and couldn't wait to be done with it.

I applied to 10 PA schools, got interviews to 5, was waitlisted at Pacific University and Drexel, accepted to my program and decided to skip the interview at Cornell since I had already been accepted where I really wanted to go and the person I talked to at Cornell was a jerk. It was the first and only year I applied to PA school, which I consider very lucky.

So far my GPA in PA school is 3.65 but I stopped stressing about getting A's the second semester. I failed 2 tests in my first year and rarely aced any. I really enjoyed PA school even though it was very difficult and very stressful. Being in clinical rotations now I don't have to study every night and have a lot more fun than in didactic year. My preceptors have given me a great deal of praise. In just my second rotation I am seeing patients on my own (roughly 10/day) with the preceptor stopping in to see how I did and to hand me signed, blank scripts and referrals. My current preceptor told me he thought I was ready to see half his patients on my own. I disagree, but it is a great compliment nonetheless for a doctor who has been in practice for 35 yrs and has a strong patients base who really love him and the way he treats them.

So enough bragging. I simply like to point out now and then that regular people can succeed in PA school and that it is not just for the type A overachievers.

More IM

Along with the numerous, somewhat annoying "pain" patients and type 2 diabetics I have seen, I have also come across some interesting cases. I saw a guy with hemochromatosis and polycythemia, Another guy in his 30s with Dandy-Walker syndrome, a 50-some yr old today with epiglotitis and a lady in her 50's who developed severe liver disease from poorly controlled DM. The doc I am working with complemented me by telling me and his staff that I am a big help seeing patients for him and that I have I come up with some good suggestions for dx/tx/rx. He has been in practice for 35 years and is very knowledgeable and he takes the time to teach me and his patients - which his patients love. I am calling patients with lab results, seeing patients almost entirely on my own on occasion and writing scripts for everything. I really am having fun when I stop to think about it. And I am proving to my self-admitted skeptic doc that PAs (students) know what they are doing and can take care of a lot.

I have eaten lunch in the doc's lounge once and was sorta surprised that all the docs talk about is golf. OK I wasn't surprised at all and actually find quite humorous.

Internal Medicine rotation...

So my first week of of my first IM rotation is almost in the books. On Monday my boy took a header at pre-school and knocked in 3 top-front teeth. Later that day we began a 13 hour journey at Children's Hospital because he wouldn't stop throwing up. SO I get home from my first day of IM to greet my beat-up little boy barfing frequently and uncontrollably. Was it from a head injury? Was it the copius volume of blood he had ingested that day? Was it a bug. Well, it took 12 hrs waiting in the room, a couple doses of Zofran, many tests, 15+ episodes of emesis, 5 nurses, 2 ER docs, an hour and a half wait in the waiting room to be triaged and 500mL of IV fluids to feel pretty safe it was just shitty luck and coincidence -and oh yeah, some bug. Today he got the teeth pulled, and I was there by his side for every nasty moment. That kid is tough and resilient. He's back to eating Mac and Cheese despite the severe lac on his gum that the DDS couldn't repair. In fact he is bed now, tlaking and playing, back to his normal self. And I couldn't be happier. IM rotation is going fine. Mostly diabetes and chronic pain. I can write for schedule IIs in my sleep after one week there. The doc is nice and takes time to teach me. He slammed today in front of a patient for recommending Augmentin. He justs hates it and spent 10 minutes expaining to the patient why my suggestion was so bad. Funny, the Peds docs Love it.

One down

Can I just say I had a blast on my peds rotation. It was a lot of fun, way too short and now it's over. Internal Medicine is next - I have a 10 minute drive ahead of me and some pretty reasonable hours. This stuff is fun. If only I could remember all the stuff I learned last year. I am afraid that I have see something 3 times for it to stick. At least once I actually do something (hands on) I usually don't have a problem doing again. Usually. I have the weekend off for the most part and look forward to starting my next clinical on Monday.

I am tired

getting up at 5:30 and getting home at 6 with 2 hrs of driving is making me a tad bit tired. I am still having fun on my peds rotation. My docs tell me I am doing fine, especially for my first rotation. My diagnostic skills seem pretty good. I wish I knew more about drugs. I mean I feel like my pharm classes were very good but they covered the basic pharmacology of the various drug classes ad not all the specific brands and dosing considerations. All in time i am sure.

More on my first rotation

For my peds rotation I rotate through 3 different docs. It is good because I get to see different techniques and approaches and philosophies. So halfway through my third day the doc says "how about we start throwing in on cases/" to I say "sounds good." I saw a hand full that day and at the end of the day the doc was running late for a conference call with two patients left. He actually considered letting me handle them all on my own but thought better of it - as students we are not supposed to do the work of anyone or be used to extend productivity. I was flattered that thought enough of me to take that on but I know I don't know enough to do that just yet. Right now I commute one hour each way and wake up at 5:30 ang get home by 6:30 most days. Friday stunk because I got out at 4:30 and because of traffic didn't get home until two hours later. I have a free apartment provided to me which I may use once in a while. The wife is going out of town wednesday through friday so I will have get the boy to school extra early and pick him up extra late. The doc on Friday complemented me that I work really well with the kids and they respond well to me too. I thought that was cool. It seems that kids and dogs like me the most - perhaps they can tell just how much I have in common with them?

Pediatrics Rotation - my first rotation ever!

Today is the fourth day on my first rotation. I've been seeing patients by myself for the last two days. Naturally the docs will go in a follow-up after I give them my report. The place is really relaxed and collegial and they really want me to learn. Everyone is super nice and friendly - at least it seems that way to me. I am having fun seeing patients and learning the practical application of the past year of book knowledge. It is fun!

My back is slowly getting better an I am encouraged that stretching improves or alleviates my pain for a while. The more I stretch the better I feel, but I get tight very quickly. Many people have asked why I haven't gotten an MRI yet. My reasoning is as follows: The MRI will find something. That something may or may not be the cause of my pain. Other than PT, which I am doing on my own as much my schedule allows, I am not willing to consider any other treatment options (surgery) that might apply to the dubious finding on an MRI that is guaranteed to show something wrong with a 39 year old former football/hockey/martial arts participant who has had other minor infrequent back problems.

Back from vacation

We went up to the cabin my wife's grandmother has in MN. Right on a good size yet very quite lake. TV reception stinks and no cable worth a crap. It was really nice. My boy did some swimming in the lake and he drove the pontoon boat we rented for 2 days. I went fishing, played hell with my new rod, caught 2 tiny fish and gave 'em back. Ate at Zorbaz pizza the last night there. Slept with my boy on the air mattress - he peed the bed each night and took a bath in the lake each day.The drive was a real and literal pain in the ass. It sure didn't help my back much either. Mostly the pain is confined to my right ass and leg, consisting mostly of muscle spasms that clamp down on my sciatic nerve creating a searing pain that forces me to limp around like an old coger. It is getting better, at least that is what I am telling myself.

My first rotation starts the 31st. Ill be doing pediatrics in a town 60 miles away. The housing scheme is run by another school and they have not gotten back to me yet so it looks like I may be commuting each day for at least a while. My neighbor who is a nurse got me a women's helth rotation with an OB/GYN she works with so I hope that pans out. Otherwise I'll have to go to a much 'less desirable' city to do my WH rotation. White coat ceremony is tomorrow - gotta go iron my coat........

Year One is over!

Yesterday was our last final. It was tough just beacuse it tended to cover all things we didn't go over in class and we had a lot of interruptions by the instructor. That said I think I did well enough to keep my B in the class - had no way of getting an A however. In total this semester I got 4 A's and 4 B's. My goal this semester was to keep stress to minimum and to help make my wife happier when I could. This meant less studying. Overall I am satisfied with my performance.

I feel like I should be really excited and celebrating like crazy that this hellish year is over. Really I am just plain tired and my back is not helping anything right now. My PA wants me to get an MRI but I don't want to because I am not willing to do anything about what they might find (e.g. surgery) and I haven't had any time to go either. I have been stretching, one of my classmates gave me acupuncture treatment and another has been doing some deep tissue and muscle energy work on it. It really is nice to have classmates with such varied and valuable experience. I'll miss not hanging out with them, I really will.

Pediatrics is my first rotation and it starts 8/31. Peds was not one of our stronger classes so I have some level of anxiety about it. I like kids and they like me for some reason so I am just going to approach it all with that kind of attitude and work my butt off to learn as much as I can. We go up to the cabin tomorrow and I look forward to some peace and quite on the lake.

Thanks to all who left comments/questions. I appreciate the support a great deal.

My back is a pain in the ass and vice versa

So Thursday my back just went crazy on me for no good reason. I didn't play hockey (I am done for a while so I can heal). All I did was play ping-pong with a classmate on Wednesday. I missed class Thurs. and went to see my PA - she was really off her game by-the-way, and an MD who does acupuncture. I took 40-some needles, she did some cupping on my back that left pepperoni-like bruises and she also did moxabustion - burning some balled-up herb on my back. Went to massage today, but still walk with a limp. My ass has taken to a rivalry with my back to see who can cause me the most grief. 1g of naproxen, 3 flexaril and 100mg of tramadol per day and I still hurt. My PA wants an MRI but I am going to have to hold off until after finals and vacation to the cabin. The real pain is 6 cumulative finals in 4 days!

Just a nice day

I sat through 3 hour of pharm and then we had a cook-out on the patio outside our classroom. It was a beautiful, sunny day and we had music and hamburgers and hot dogs (no beer though) and it was just really nice. 8 more school days left.

Pharm test went well

I was the first to finish - 20 minutes for 50 questions and I got a 92%. Yeah I was surprised too. This wasn't an easy test and some people barely passed. I just knew the answers to almost everything right away. That was a nice feeling for sure. I got up at 5 this morning and was at school by 6 so I could go over things one more time after studying for a few hours last night. I used the same study method for clinical medicine and got the class high score of 94% on that test. My grades are such now that I'd really have to hose things up to lose a B in any of my classes and A's are in reach for all of my classes except Pharm. I had a grin on my face all day today that several people comented on - I just felt great knowing that in less than 3 weeks this didactis year and its hassels will be history. You know when I first started school I wasn't sure if I could do it and now I am all but done with what is in my mind the hardest part of it. Still nervous but looking forward to starting clinicals in September.

3 weeks left

I can't believe that the didactic year has almost reached its conclusion. I'm not sure I am ready for clinicals but I'd much rather take a different sort of beating now.

We had a clinical medicine test last week that covered hematology, some oncology and ENT. The test was only 33 questions, like always. Somehow I managed to only miss two questions, which was a nice surprise. Usually if I feel good about a test I don't do as well as when I am nervous and study till 11 and get up at 5 to study more and feel like I don't know a thing going into the test. I have cemented Bs in most of my classes which is kind of nice. There's less pressure to sweat an A or freak out over getting a C or worse. I have to study Pharm till the cows come home because it is so much of what a PA does and there are plenty of chance to harm the patient if you don't know what you are doing.

My son's bedroom is 8 feet from my "office" and he is battling my wife over going to bed. He didn't take a nap or eat anything for dinner so he is an emotional rollercoaster now. No studying till he is sound asleep - I am guessing another hour from now. I probably have to go in and take care of some emergency he'll fabricate to keep from going to sleep. He is so much work but I wouldn't want it any other way. He offered to get his buddies together and catch the guy who stole my chaco flip flops at the gym. How can someone who pays big money to go to a really nice gym steal someone's shoes there? It pisses me off that someone has stolen from me again and that they took my really nice, every day attire chaco flip flops. We're talking $50 (I didn't pay that much) here damn it! Sometimes I really hate people.

I Tweaked my back months ago playing hockey and it just won't get better. It really hates it when I have sit for hours on end, daya after day in a chair that amanesty international wouldn't let a political prisoner use for one day. At least in three weeks that damn chair won't be able to torment me any longer. I am popping cyclobenzaprine and ibuprofen like they were tic tacs and to no avail. I can handle injuries to most parts of my body fine. But when the back is dinged it really screws up EVERYTHING. I like playing hockey so there is little chance of getting better untill the season is over. Besides I probably won't have time to play once clinicals start and I am driving/living all over the state. Gotta get my Herriet Lane handbook for my first rotation - Pediatrics. Should be interesting. I hope my preceptors like to teach and provide guidance. Time for more muscle relaxers and a heating pad. And back to studying pharm.

5 weeks left

5 weeks remain in the semester and it feels like it can't come soon enough. The didactic year has been demanding in ways I never imagined. I've written about the toll it has had on my family life and to some extent it has had on my psyche. I've wondered out loud to my classmates if we'll look back on this time with any nostalgia or fondness. None of them seem to think we will. I don't know, but I think it is possible. One of our intructors likend it to childbirth and the amnesia that goes along with it, ensuring that women don't quit having kids after the first one. I will miss my time spent with classmates and the camaraderie we have built through our shared struggles. Most have not experienced the the problems I have, yet I dont see my classmates who would easily or freely admit to struggling in anything.

Some of my single classmates have made this time little more than an extension of their undergraduate studies and therefore have little problem going out several times a week and partying on the weekend. It seems to work fine for them, and at times I am envious at their lack of apparent effort or stress; I couldn't do what they do and get away with it. I do wish that my wife were interested/involved in my studies. She hasn't helped me study for a single test and seems at times confused and dismayed as to why I would want to spend my professional life peering into strangers orifices, not to mention the requisite physical contact of exams.

But it is what it is and I am almost done. I have worked my tail off and have gotten good grades and evaluations. I made some good friends and tested myself under some difficult scenarios. It hasn't been perfect and I have made some mistakes. At times it was all I could do to keep from defenestrating myself, other times I had a ball doing and learning and trying. 5 more weeks of class. It feels like I just started yesterday. It feels like it's been forever.

IV practice (and some other stuff)

So we had practice with intra-venous access and venapuncture the other day. I haven't done that stuff in a while but I use to be able to get 16 gauges in on a trauma patient in the unlit median of the interstate. I screwed up every attempt I had the other day. I either let got of traction on the vessel or blew through the vein or whatever. I was so nervous I couldn't believe it. My partner is the nicest young lady who was very patient and able sink all her sticks with no problem. I run through a bunch of excusses but in the end I just didn't do what I should have to get it done. Whatever sort of anxiety I am experiencing is systemic. HR, BP, tremors, insomnia, lack of concentration, nervousness.... I do have a hx of depression and the anxiety thing isn't new, it's just I have never felt it to this extent or for this long.

I know I'll pop out of this funk some time so I am not freaking out. The problem is that I am so acutely and constantly self-aware, to the extent that on occasion I can only concentrate on myself. There isn't a thing I haven't thought about lying in bed at 1 am or on the drive to school. I used to be so laid back and carefree that people would be describe me as having a type Z personality. I liked being that way. It was good. I don't really care for being pissed frequently or losing my temper over stupid shit. But I do it. I tell myself not to. I tell myself it's coming and to just let it go but I have a hard time letting stuff go. I take things personally that I know I shouldn't. I complain all the time on this blog. I know why I feel the way I do. I will feel better without the stress of school. Some free time and leisure activities will help. But, I can make my situation better if make a loved one's situation worse. Not A loved one, THE one and, well, only loved one. I can't do that yet. It's not bad enough yet. I don't know what bad enough will feel like, but I can't yet. The words and the hope work too well, ok just well enough right now. The pain it would bring him is not worth removing the pain I am going through now. She's going through it too.

For what its worth I have fun at school. Not sitting there for hours on end being killed one powerpoint slide at a time. I get along with my classmates. We joke around. We are silly. We do fun things to honor our struggle. We give each other a lot of shit. We bitch and moan. We play sports together. We drink together (not enough it seems right now). We understand each other right now more than our parents do, or our friends, or our S.O.s do, at least on some basic yet vital level. Soon that is going away. When clinicals start that support net will be gone. I hope it will come back now and then though.

Hmmmmm

Below is a post I put up this time last year. It came after I read some physician bloggers comments about how midlevels simply don't stack up to the care required by many patients. I amde some minor adjustments to the post below to make it read better this time around, but the changes are minor. I should have documented the offending blogs but I think white coat and panda bear were two of them - not sure about white coat though and I don't feel like searching their archives now.

Why the Mid-Level Hate, Docs?

As I get closer to attending school I have found myself reading more and more medical blogs. I find many of them to be humorous, well-written and insightful. During my admittedly shallow investigation into these medical blogs I came across a disturbing and somewhat disheartening trend. There is a group of vocal and relatively popular blogs written by physicians and med students that go to some length to question and/or discredit the role of Physician Assistants in modern American health care. Their anonymous supporters chime in with an occasional ‘here-here’ and are equally, if not more so, anti midlevel. These doc bloggers point out that since PAs do not have the extensive training that a residency trained physician does, they are incapable of treating most patients, and that anyone who chooses to become a PA is lazy, not smart enough to handle any of the rigors of physician training or is simply wasting their time in such a limited and undignified role. They also argue that patients who see a PA are selling themselves short by forgoing the artistry and command of the obscure that a Physician provides and that these patients may likely fall victim to a disease or injury because their lowly PA simply couldn’t wrap their reptilian brains around a medical condition or was being a renegade by practicing outside their scope.

First I want to get the points of agreement with out of the way. PAs do not have the extensive training that physicians do. PA school is two to three years long and usually doesn’t have a residency component. The time spent in school is not nearly as long a residency trained doc. Great! While most med students have no real world experience, let alone any that would serve them in a medical field, most PA students are required to have extensive direct patient care experience in order to gain admission to the highly competitive programs. With this medical experience often comes maturity and knowledge of how the world outside of school operates. PAs learn a great deal about the practical application of medicine during their time on the job. PAs should not operate independently. That’s why they call them Physician Assistants. The PA’s job is to assist the doc where needed, see the lesser acuity patients, free up the doc’s time to do what he/she needs to, get more patients seen and hopefully improve patient satisfaction and practice profitability along the way - under the supervision of a physician. PAs are limited in what they can do. I’ll add that PAs are also limited in what they should do. That is to say, recognizing the inherent limits of a PA, they should consult with/differ to their supervising Physician when a questionable case arises and should only operate within their scope of practice as agreed upon by the PA and their SP. However, a PA’s training allows them to diagnose and treat illness and injury, order and evaluate labs and x-rays, splint and cast fractures, repair lacerations and in most states, prescribe any medication. A PA cannot perform open heart surgery (may assist however) or perform certain independent medical research, for example. Sounds good to me…..

Now, here is where I feel these doc/Med School bloggers are off their nut. Some have insinuated that PAs are simply not smart enough to be a doc and are PAs because they couldn’t get into med school. What crap – all crap with absolutely no proof. With all the education these folks possess, how can they still make completely unfounded and uneducated statements? It is a sad attempt to undervalue the training and intelligence PAs possess. Some doc bloggers have hinted that those in the profession are inferior or lazy for accepting the simple role of assistant when becoming an elite medical leader is possibly within their grasp. As if being a doctor is the ONLY way one can and should be able to treat the sick and injured and that anyone who attempts to do so by other means are hacks and poseurs, regardless of their education, training and commitment. This kind of attitude reinforces the not uncommon notion that doctors can be arrogant, pious and controlling tools. I imagine that since their views are so strong that these doc/MS bloggers tend to stand out among the crowd. Finally, and most aggravatingly, these bloggers posit several medical scenarios that may not have a clear diagnosis or outcome and then use the rhetorical question, “what if you had this disease/injury? Would your PA discover it in time or would you die having forgone your only true salvation - being seen by a MD/DO?” They bring up fictitious scenarios where some cowboy PA operates outside of scope and harms a patient. As if only PAs were capable of such arrogance. Well, we can find numerous documented instances where doctors operated in such a way and injured or killed their patient. These pseudo scare tactics are almost silly, save their attempt to undermine the PA profession in a most classless way. These bloggers will also argue obtusely that a medical practioner with anything less than 6-8 years of medical education and residency is not only useless, but is dangerous to boot. No offense to my medical colleagues, but doctors through the decades have led oft-esteemed and privlegded lives killing countless patients, couldn’t you all use a little help? Until there is scientific proof that PAs are more dangerous or incompetent in their scope of practice than doctors, please shut your highly educated and well trained yap.

http://www.healthbeatblog.org/2008/06/the-silence-sur.html

Here’s why I wanted to become a PA and not a doctor. At this point in my life I have neither the time, energy nor resources to tackle med school. It is difficult - not impossible, but it takes more time than I care to give. Nor I do desire to be burdened with the additional debt and lack of free time that becoming a physician requires. I’ll have a loan of $60k plus when I am done - that is already too much in my opinion. I also have a young son I’d like to see grow up. Being a PA will allow me see patients, learn and grow as a clinician, have a comfortable income and see my family often.

So, I’ll gladly take my BA, MHA, 15 years of experience as an EMT and 10 years in the health insurance industry and try to make due as a PA.

Two sides of burnout

So along with most of my classmates I am officially burned out. I can and will keep going but I am over this didactic year. I have 7 weeks to go and I can hardly wait to go out on clinicals. The downside is that I have little or no energy to read the hundreds of pages that are assigned each week. The 3 hour classes this semester are simply excruciating for the mind, soul and ass. The upside is that I finally got in the study groove and am pretty proficient. I can pass my tests with a modest effort and can get As if I work hard. I am learning along the way which helps but I can't remember all I was taught - to both my horror and bitter acceptance I understand that "getting it and keeping it" will come with practice, use and seeing "it" over and over and over again. I learn best by doing, rather than reading or seeing - so doing this stuff will really help me retain and synthesize better.

Seven weeks is so long and yet really just such a short period of time to get my shit together. Will 7 weeks make a difference in how I will approach a patient? I hope so because even though I really look forward to getting out there on clinicals, I am pretty nervous too. Shhhhhh. Don't tell anyone though, OK?

Pharmacology

Took the first of four Pharm exams today and got a low B. I thought I had a good grasp of the subject (parasympathetic, syspathetic, asthma, allergies, GI) - at least better than my grade would indicate. I overheard a classmate complain about the ONE question they missed. Others were talking about getting straight A's last semester. There are certainly some very competitive people in my class who always want to know if they got the best grade or how they faired compared to everyone else. I don't really talk to those folks too much. Not for any reason, just 'cus.

Today

Today was one of those soul draining, mind bending, ass numbing days. We had two 3-hour lectures- pharmacology and clinical medicine with PBL and lunch in the middle. pharm is great, our instructor is great, the information is great. However our instructor has a very laid-back delivery style that is almost monotonous and is certainly sedating. I cannot drink enough coffee in the morning to keep me alert. I can however induce some pretty amazing tremors and palpitations with an adequate intake of caffeine. Our clin med class consisted of 175 power point slides of various problems one will encounter when dealing with the penis. Horrific photos. Enough is enough already! Tomorrow our clin med class is four hours long but at least we get a new instructor every hour. 8 1/2 weeks to go!

Last semester's grades

Just to point out that given all the crap I've gone through and not being particularly brilliant I was able to get 4 As and 4 Bs last semester. This is really encouragement for those just starting school or perhaps hitting a rough spot yourself. It can be done. Not easily. Not without some carnage. But it can be done.

Great vacation. Too short, too expensive. But fun!

Got back from Sedona yesterday. My wife made arrangements at what turned out to be a really nice place. I'll post some photos soon. On Memorial day I spent the day with Vince Vaughn. What I mean is that he sat at the table next to us for breakfast and lunch and we even spent some time together in the steam room. Like 2 minutes. Anyway, I am not one to follow celebrities and such but I do like Mr. Vaughn's work and feel I can relate to the characters he plays. Very unpretentious. My wife and I went on a long hike, ate some great, expensive food, drank $15 margaritas with prickly pear in them and layed by the pool and got massages. Oh, and I spent a lot of time in the steam room trying to heal my back that I injured playing hockey last week. I have been injured severely on more than one occasion playing hockey, but I keep coming back for more...hit in the throat with a stick, two concussions, re-dislocated shoulder, separated ribs, and numerous contusions. It goes to show you that one doesn't really have to be too bright to get into PA school.

Sedona, here I come

Going to Sedona tomorrow for a few days of R & R with the misses. ACLS & PALS went fine. I noticed that I heard the preceptors describing a patient a certain way but my thought process would hang on something else unrelated. Sitting back as a "team member" in megacodes I could easily and correctly think through the algorythm , but as a team leader I would have dumb little brain farts. It was interesting to watch my classmates respond to the stress too. I am an observer - by that I mean that take pride in and enjoy observing people and their behaivor and quirks and what not. Observing my classmates in these scenarios was interesting and seem to corelate with previous observations. It was fun to see some of them try to figure out what sort of antibiotic they were going to give to some baby in septic shock during the megacodes.

ACLS and PALS this week.

So we have ACLS today and tomorrow and PALS Wednesday and Thursday. Today went by quick and tomorrow we practice and test for ACLS. It sure has changed a bit since I last took it in the late 90s. It seems to be going well and I am told it was simplified a great deal since I took it. I had no problems then so I don't anticipate any this time around. It is nice to be learning and practicing some "real" medicine finally.

ACLS & PALS this week

So we have ACLS today and tomorrow and PALS Wednesday and Thursday. Today went by quick and tomorrow we practice and test for ACLS. It sure has changed a bit since I last took it in the late 90s. It seems to be going well and I am told it was simplified a great deal since I took it. I had no problems then so I don't anticipate any this time around. It is nice to be learning and practicing some "real" medicine finally.

Whew!

The second semester is in the books and I couldn't be happier. Looks like I got mostly Bs with a few As. all things considered, it couldn't have turned out better.

My wife did a really nice thing for me this past weekend. She used some of her Marriott points and got me a suite so I could study without any distractions. I think it helped and I really do appreciate her giving me all that time to myself. Thanks a lot.

My classmates are out now celebrating and drinking. I am at home having ice cream with my son and celebrating the fact we both had a good day. Yep, a good day.

4 more tests to go

Unfortunately 2 of them are going to be brutal (Pharmacology and pediatrics) and all four come before wednesday. At least when Wednesday rolls around I'll be done for a few days before ACLS and PALS start. Then a week off before summer semester begins.

I am lucky to have the classmates I have

My program is one that requires a significant amount of direct, hands-on patient care. As a result my classmates are older and well, more experienced. I have people in my class to go to with questions about sports medicine and orthopedics, EMS and emergency med, phlebotomy, cardiac care, PT and OT, alternative medicine, mental health, women's health, radiology, cytology and hospice. Since everyone has been around the block a few times there are no head games or overt competition. No holding out on your classmates if you know something they don't. Everyone really does help everyone else out. There a certain cliques as is expected in any situation like this this, but I don't feel overly excluded by any group. Much like in high school, I belong to no one group but hang out with all them.

5 tests this week and 4 next week. I just have to remember how much I really wanted to be in this position this time last year and how fortunate I felt to be accepted. This semester really is as tough as our instructors told us it would be. Fortunately everyone in my class feels about the same way I do and are just trying to push through and learn something along the way.

I also have all but one of my clinical rotations set up for next year and wee are planning a celebration for our white coat ceremony. I can almost see the light at the end of the tunnel!

Food and Medicine

I have noticed the disturbing trend in medicine of name pathological processes and nasty stuff after food. Just a few examples: Strawberry tongue - Kawasaki's; Chocolate cyst - endometreosis; rice water stool - Cholera. There are a bunch more but that being said, which ones have you heard and do you find these comparisons a little unnerving?

6 more weeks in the semester

I am continually amazed at how difficult school is and the fact that I continue to progress. I envy my classmates who are single and can study when they please for as long as they please where they please. I envy the fact that they have fewer responsibilities than I do. For some of them school is easier and some are having fun to boot. I've written about how my wife and son have responded to me going to PA school. I wish that I could enjoy the process for what it is. I wish that I didn't feel like complaining as much as I do. I am so glad that I am in PA school and am learning all that I am. I feel that there is so much i don't know, that I don't know enough, that I'll never know enough. I really look forward to the clinical year and applying what I've learned and learning so much more. I look forward to not feeling guilty for sleeping in or playing with my son instead of studying. I look forward to being normal again. I look forward to being a PA.

I failed my first exam

Luckily I am still passing, but geez does that sting! Got the lowest grade in the class which is a first for me in my PA studies. I will take this as a sign that I need to get my ass in gear and study better and more often.

I got the new iPod touch and is it sweet. I discovered skyscape I am amazed at all they give you for free.

5 tests this week

3 tests are in the books, one huge test tomorrow and another on Friday. I should be studying now but I need a break. I am REALLY looking forward to spring break.

Just to clarify my previous post: I was miffed that an instructor of mine tested us on a poor quality photo that we had never seen before and were asked, as we have been many times before, what is the medical problem that this person has. So, in any given lecture we will be given 100-200 PowerPoint slides with 1/3 of them containing photos of various disease processes. Then for the test, a new, poor quality photo is cast upon the whiteboard, all washed out and glaring. There would be no way to study for such things and unless you have an exceptionally good eye and ESP, it is difficult to figure out what is going on with this "patient."

I am also really grateful for some awesome instructors who really know their stuff, want to teach and care about us as people and students. They put forth the same kind of effort that demanded from us students daily and I appreciate that. I have taught before and know how difficult a job it is. I don't think I'll ever do it again because I feel to be a good teacher you need to know your shit forward and back, put a fair amount of time into your presentation and have an engaging delivery of the material. I am lucky to get 2 of those criteria on any day and I don't think it's fair to short change students with anything less.

There are tough teachers and then there are unreasonable teachers

Guess which type we dealt with yesterday? One of our core classes is taught by a rather hyper, unorganized and socially awkward person. She uses 10-12 different fonts in her hand-outs, tests us on poor quality photos of vague skin conditions and material and procedures that are the personal preference of various guest lecturers. e.g. "According the Dr. x, from his lecture in early February, the examination of y should be in the following order." It doesn't matter if our instructor never covered the right way to do it or that several multiple choice options are right. So I am pretty sure I failed the first test of my PA student "career." The only reasonable thing about our instructor is that he allows us to throw out one test. I didn't think I'd have to use this option, but I have changed my mind now. If only I didn't spend 2 hours late last night laying in bed thinking about it. Moving on....

I survived

My 'standardized patient' experience was better than I thought it would be. It was still a little odd but overall a good thing to get done. At least now I know for sure how perform these exams along with all nuances and such. The teaching associates were very patient and spent a great deal of time teaching us the ins and outs (no pun intended, I think) of these very invasive and uncomfortable exams. They didn't seem to be terribly odd people and one of them mentioned they get paid "very, very well" so that clears it up a bit. Still, I'd think there would be many other jobs I'd rather have.

I've got two exams tomorrow and four next week; then spring break. Will the fun never end?

Thanks

Thanks for the words of support. I plan on continuing the blog, if only because it is a good means of letting off some steam. And boy, do I have some steam built up lately.

On a lighter note, I face my first encounter with standardized patients next week. This includes the full female breast/pelvic exam and male rectal/GU exam. These standardized patients are people who receive special trainnig regarding the speificds of the exam and they then teach the students and guide them through the exam. I often put myself in other's shoes in order to gain a portion of their perspective, but I can't fathom why any "normal" or "average" person would want to do this? I understand they contribute a great deal to medical education and are an invaluable resource, but from a person-to-person interaction standpoint this seems extremely strange to me. I've heard that prostitutes are commonly used - they would seem to be the best fit for something like this - but I also know that there are just as many people, if not a lot more that are not prostitutes or the like. I'd like to know what motivates these people and what they really think about they are doing. Ideas?

Pile it on

My dad, who has a 70 pack year history just had to undergo emergent CABG. They bypassed 3 coronary arteries that were 90% occluded. He has come out of it as well as expected, but he is still really gorked. It's tough seeing your hard-ass, drill Sargent, bar brawling dad near comatose and helpless as a baby. It is tough having so much extra crap to think about.

Pratice on my classmates?!

So for our history and physical class we have to practice almost all physical exam techniques on each other. That of course means that one must also be the patient. It is a little weird for me to see my classmates at various, albeit not necessarily inappropriate, levels of undress and to palpate their abdomens and percuss their backs etc. We have standardized patients for the DRE and pelvic exams, but we are expected to practice frequently on each other for all the other examinations. Not something you think of - I am not even sure it is common across programs - but as much as I'd prefer not to be shirtless for an hour in front of my classmates, I understand its necessity.

It's a distinguished look

I keep getting asked by the student employees of my wonderful learning institution if I work there or what class I teach. More on these and other school employees later. It must be the few gray hairs on my head that have them confused. I'll take the employee discount at the coffee shop though.

Not what I needed at this point

There are still tears in my eyes as I type this, but since I don't have any real close friends this is my only outlet. So, my wife and I have an argument tonight and she informs me, after vigorous and heated pleading from me to get her to talk, that she hasn't been happy with since we got married (seven effing years!). She's been mad at me on a near daily basis for a lot for the generic husband things and because I haven't been too romantic really since school started, even further back. I left water in the bath tub a couple days ago and she was furious that our 3 year old son would drown because of my negligence and stupidity. I accidentally shut the door too loudly and she chewed me out for being insensitive to our son's sleep needs. A previous post of mine re: "listening" was about her. She actually read it and commented on it I think. Anyway she says she's sick of looking at me and feels like she does everything while I do nothing. This is true since my studies take up almost all of my time so I can't argue with that. It's funny (not in a ha ha kind of way) that she was the one who encouraged me to go after this dream of mine - now it's ending in a nightmare.

Our relationship hasn't been the best for a while now. She hates her job and wants a new life. She wishes that I wanted to go running and skiing every day and go on last minute trips every month and we could be this mythical uber-couple that she imagines infest a nearby, ultra-yuppie, outdoorsy, fit and wealthy community. She hates our house and wants to move; hates the city we live in; wants to live in the mountains or the beach where everyone is what we are not. Now she wants a different family. The grass is always greener ain't it Sugar? Now it's all pretty much over - at least from the look in her eyes. She'd deny it but she had a slight smirk on her face as I asked her, tears streaming down my face, if this was how it would end. She is notorious for the faces she makes - they show how she really feels. Her face was otherwise emotionless, except for a hint of irritation at having to discuss this with me. I thought we could push through these two years and then the stress would be so much less we and my son would be in school so things would be easier on us all. Not so much.

Considering how little I can count on my family for anything, loosing the only person I ever really loved hurts. It hurts knowing the pain my son will have to go through - it really rips my heart apart. He is innocent and will truly come out the loser in all of this. That really kills me. But I can't be with someone who is so consistently and utterly sick of me. To her it doesn't matter that I am a good dad - well I can't even say at this point that she thinks I good at anything honestly. My only sense is that she would rather simply have me out of her life. So as soon as I can swing it we will get this THING ironed out and done.

Financially, I have nothing and am really living off of my wife and loans. Unfortunately those loans will have to get a lot bigger soon sine I have more than a year of school left. I wish rents were cheaper around here. I wish I had some money saved. I wish I new someone I could move in with. Her parents sure will be happy. My son sure will be sad.

I imagine I'll be ending this blog anyway since no one really sees it. It's kind of like writing in a diary actually except I don't feel as wussy as I would writing in a diary. Back to studying!

Don't get me wrong

I am fortunate and 'happy' to be in PA school. Any PA school for that matter. I am making it and soon enough I'll be in clinical rotations. This schoool thing will be a distant memory before I know it. I wouldn't rather be anywhere else.

Still, isn't it human nature to see things that can be better and want them to change for the better? Am I being a jerk to complain about this kind of stuff (oh, and there is lots more!) given the fact I have been given an opportunity that many people would give there left gonad for? I guess the way I see it, as students we are held to very high standard - much different from regular undergrad students, we pay no small sum of money in tuition, fees, books, books, books, etc and we are stongly discouraged from working. We are told we must sacrifice and give to succeed. Why can't the people who demand so much from us step up to the plate and bring some sacrifice and professionalism to the game too? I understanding paying your dues and all that crap, but passing the pain down the chain, just because you can or because that's the way you came up will simply never cut it with me.

So, my regular readers out there: what do you think? Where do you stand? where are you in the this crazy process? Am I full of it?

There is always one a semester

Crappy instructors that is. In a core class, not that any are unimportant, but a major clinical discipline. This instructor talks 120 mile an hour. She crams, by her own admission, 5 hours of material into 2.5 hrs. She refuses to take questions during her "lecture." She glances over material or doesn't even cover material that she feels is important - important enough to test us on. She refuses to clarify her unclear and poorly worded test questions. The entire class is disappointed in how the class is shaking out so early in the term. I am usually the person who will talk to the instructor and let them know how things are going or aren't going - but I've been the sqeaky wheel for too long. Unfortunately no on else will suck it up and talk to to an instructor if things aren't going well. This is going to be the class we all complain about during lunch but that no one does anything to change.

2nd semester classes are under way

Our instructors told us that this semester would be the most difficult of all. They told us this was typical of most PA programs though I am not sure what their reasoning is. Perhaps their experience with other programs allows them this foresight. Needless to say, I am beginning to think they are telling the truth. Pharmacology will certainly not be a breeze. Our instructor told us that we will get about 30 hours more of pharm than the med students she teaches. I don't know how I feel about that other than to say I better know my shit when this is over. I am not terribly psyched about our Pathology instructor. He seems a little ill prepared - so we'll have to take up the slack as students. OB/Gyn will certainly be interesting - my only practical experience with the subject is recreational and the birth of my son.. Peds should be fun. I have some expereince working with them, I like them and they like me. I think they can sense my inner goofball so they tend to gravitate toward me. During the summer the neighborhood kids come by the garage to see what I am working on or fixing, or just to tlak to me. The kids at my son's school always come up to me and ask me to play or show me what they are doing. This is interesting to me because adults tell me I am imtimidating or aloof at times. Perhaps I let my guard down around kids. The other classes will be challenging as well since we will be expected to integrate all we have learned and are learning - to start thinking clinically and to see the whole patient rather than simply the problem they present to us.

Spring semester awaits!

Classes start in one week and I am ready to get crackin'. This semester I have pathology, pharmacology, OB/GYN, Peds, History and Physical, Psych, and Clinical Medicne. This round of classes promises to be very intense but at least they are more applicable to being a PA than last semester's classes. I also look forward to starting my clinical experience this term as well.
My break didn't go as I would have liked, but it was good to be able to spend so much time with my Boy.

Why is LISTENING so difficult?

Being human necessitates communication with others (absent disorder or pathology). What I continue to struggle with is others' lack of understanding that true communication is something that involves give and take, multi-directional exchange of thoughts, feelings and ideas, and a tacit understanding that the other party will evaluate your input by putting forward some effort of thought. In my daily life I, like most of you, attempt to have meaningful conversations with those around me. I take the time to listen to what the other person is saying (most all of the time) and attempt to to put togehter a thoughtful response given their input. I expext the same from others who are "listening" during a conversation with me. I expect them to remeber what I just told them, or if the other party is particularly close to me I expect they will have a memory and understanding of most of our prior conversations. I cannot describe the intense feelings I experience when I speak to someone, be it family, classmate or friend, who cannot or will not make the effort to mentally process a conversation we have shared and make meaningful efforts to have a quality interaction. My point is that so many people do not listen -they hear so that they can respond. They do not process but rather prepare to expell. So many of us are not in the least bit interested in what the other person has to say, let alone give it any real thought. No, we are simply interested in our own interests. This could be extended to people who may actually listen but choose to ignore out of hand the information presented to them. I could go on and on but you get the idea. Stay tuned for my next bitch session when I complain about people who choose not to think.