Ortho Reflections

Throughout this rotation, I’ve been able to work with a lot of different PAs and doctors in the hospital and an outside office which has been really great. I get to see how they work in different settings, how they balance their work, and how they manage patients. More and more I’ve realized how nice it is to have rotations as part of my schooling.

The PAs are well-utilized in this orthopedic department and they work in so many different capacities. They man the ortho floor, first assist in all the surgeries, see patients for and with the doctors in the clinics and at the outside offices, tend to patients’ phone calls and inquiries, and on top of that, deal with a lot of paperwork that comes in. I’ve been part of the PA team the past four weeks and it’s been really great to be immersed in this team. I’ve been able to really see all the different duties of a PA; by seeing them perform day in and day out it’s the encouragement I need to reaffirm the fact that one day I will also play an important role on a medical team. This team has been so great to work with and I can only hope that I’ll one day be able to also work with such a team.

It’s pretty wild that I get to do this for school. I get to join a team in a hospital and they treat me as one of their own and let me do as much as I want. I get to assist in surgeries, I get to meet many, many patients, and I get to be a part of the patients’ health care. As a student I’m not responsible for any of the documentation or paperwork, and at the end of the day I can go home and not have to worry about the patients. It doesn’t mean that I don’t care about the patients, rather, as a student we get the full experience but also have some freedom before we hit the real world. Also I’m very grateful we get a year to acclimate to the work world before we have to jump into it. I know this is the same for all PA students and all med students, but I think it’s so beneficial to do this. In school we only learn about the diseases and how to manage them, but when you’re working it’s much more than that. It’s also about how you carry yourself around patients and coworkers, how you deliver information, how you make decisions, how you communicate with everyone you need to for one patient’s care, how you manage your time, how you document and take care of tedious paperwork, the list goes on. Of course it really helps that I’m at a fantastic site right now. I’ve had some rotations where I couldn’t wait til the end of the rotation and I think that really detracts from the overall PA school experience. At this site, I’ve been able to spend many hours in the OR and work alongside some great people who happen to also be great PAs who know what they’re doing and know how to get things done. There are more reasons, but even these two reasons alone have led me to look forward even more to becoming an PA.

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Student Struggles

As the end of week 2 is approaching, I’m pretty happy with how this rotation is going so far. Because this is an ortho rotation in a hospital, there are many OR cases and less time is spent in a clinic setting. I’m at the site with a fellow classmate and we’re assigned with different PAs every day. The service has 14 PAs and they’re all over. There is one chief, some seniors, and the rest are juniors. The PAs run the ortho floor, assist in hospital clinic hours and outpatient clinics, and many of them operate. Many of the juniors are recent grads of my school’s program which is pretty fun. I don’t even know how many attendings are in the department, but they deal with joints, sports medicine, trauma, and there are others who are non-operating.

The surgery I’ve done the most is called a total knee arthroplasty, commonly called a knee replacement. Some have been your typical TKA and others have been robot assisted. The first time I scrubbed into one of these surgeries, I was blown away. I think my jaw dropped more than once and I probably said “whoa” too many times. First of all, the PA is the first assist, which is pretty awesome. The tools and equipment they use is unlike anything else and a lot of it is quite heavy duty. I had no idea what really happened in a knee replacement but when I saw the surgeon drill holes into the femur and tibia, and pound cut-up bone back into the hole later on, my mind was blown. It was so crazy to see the surgeon use specific gadgets to cut the bone just so and then fit all the pieces together with implants and cement.

Of course, the surgeries haven’t just been a spectacle for me to enjoy. The first day I didn’t scrub in and only observed but with the surgeons and then PA and the robot, I wasn’t able to see much. The second day I scrubbed in but I had no idea what was going on. The surgeons I was used to working with during my general surgery rotation were very different compared to the ortho surgeons at this rotation. In gen surg the surgeons were the very by-the-book, serious, only-do-what-I-tell-you-to-do type. And at that hospital the residents were the first assist, so as a student, I was there to help but most of the education was for the resident. Here in ortho, the surgeons expect you to jump right in and help. The first time I scrubbed the surgeon told me to not be a statue and be more dynamic. I literally had no idea what was going on and I didn’t know how to help. After the surgery the PA gave me pointers and the next case I observed instead of scrubbing. As I observed I mentally took notes on the steps of the surgery so that I could become better oriented with the surgery. The next time I scrubbed into the same type of surgery, I was with the same PA and he seemed to appreciate how much more I was able to assist with the surgery.

In surgery, being called out is to be expected, but I don’t mind it if it means that I will improve. Of course it would be great if all surgeons spoke to you without bite, but not all surgeons are cool and collected. Overall, the surgeons at this rotation are very willing to teach, which I really appreciate. Many times the surgeons explain what they’re doing and point out anatomy during the surgery, and sometimes afterwards they will even draw out the main idea of the surgery on paper.

Unfortunately, I’m still not a pro at operating in the OR. In class we barely talked about how to function in an OR pre-, intra-, and post-op, which is annoying because a lot of times I stand there not really sure what I should be doing, and I feel like I’m the annoying student that just gets in the way. There was one day I felt like I kept making the wrong move and I just wanted to bury my head in the ground like an ostrich. I walked into the OR without a mask because I was wheeling the patient into the room from the holding area and I forgot to put on a mask. Besides forgetting things like that, I’m also not 100 percent confident on my sterility awareness, which gets me into trouble. The surgeon and the PA were getting gowned after scrubbing and I was also getting gowned, and after I had my first pair of gloves on, I stood there waiting for the next pair. The surgeon looked at me and was wondering what the hold up was, and he was annoyed that I was standing there instead of putting on the gloves myself. I totally forgot that I could touch the gloves after I had my first pair of gloves on. Then after I scrubbed the PA asked if someone could do something with the water and I made a move to fix it, but this was a no-no because I was already sterile, which irked both the PA and the surgeon. After we finished the cases for the day I felt so ashamed. This all probably makes me sound like a train wreck, and I often feel like one, but for some reason, I still like the OR.

Fortunately the PAs have all been nice, and they’re good about teaching. This is really great, but at the same time I’m concerned about what they think of me. Each day I show up and I’m nervous I won’t be able to perform and will disappoint them. They’re all willing to help and only one is my preceptor, so I don’t really know what they think of my capabilities. Another thing that’s always in the back of my head is the fact that each rotation they have two students from my program, and I feel like they compare all of us with each other. I’ll often hear either the PAs or the doctors mention other classmates that rotated through here, and then I wonder how I compare to them—whether I am doing everything wrong, if I’m not capable, if I’m not likable, etc. While it’s good the team is pretty tight-knit and they all talk with each other and speak freely it also can be an obstacle I have to overcome.

I’m hoping in the next two and a half weeks I’ll be able to become more competent in the OR and in the clinic for all things ortho. Though it hasn’t been totally easy, it’s been enjoyable so far.

Transitions

Switching from one rotation to the next is always an experience, but this time I strangely didn’t feel the crazy butterflies in my stomach. I don’t know if it was because I was becoming used to the shifts, or I felt comfortable going into an orthopedic rotation, or I just felt calm about where I was, but anyhow, I was grateful I was going into the next rotation with utter peace.

I left my oncology rotation with strong attachments to the specialty, but like I mentioned previously, I wasn’t really sure how to proceed with this love for oncology in hand. On the first day of the current rotation (orthopedics), I felt like I was in a daze because I had entered such a different world. I could barely remember special physical exam tests and terminology specific to ortho and I was not used to the pace and process of seeing patients after shadowing for five weeks at the cancer center.

At this ortho rotation I’m in the hospital for the most part, often in the OR, but also in clinic. The first day I was at an outpatient clinic, which was good for easing me into all things ortho because it gave me an idea of the patients who come in to be evaluated, the problems patients come in with, and it gave me a sense of who is a good candidate for injections or surgery. I was with a PA who had graduated from my school not even two years ago. It was a great experience working with him because he was so competent, efficient, and knowledgeable at what he was doing, and it gave me great comfort seeing someone who had the same educational experience as I had turn out to be a capable PA.

Starting the second day of the rotation I was in the OR everyday. The moment I got into OR mode, I was reminded of just how much I love being in the OR. There’s just something about helping a patient with their complaint or disease by using your hands alongside a team.

It’s great that I’ve been enjoying this rotation and it’s been good familiarizing myself with the ortho world, but it’s also raising more questions within. I loved oncology, yes, but I also like surgery. How do I choose between the two specialties? Do I have to choose, or can I somehow combine the two? Is this the right path I should take? I don’t know the answer to any of these, and I don’t think I will unless I ask God to guide me. When I think about such things it makes me restless because I don’t want to address these questions but I also know I need to.

I wouldn’t change where I am, what I’m doing, and how I got to where I am because it’s been such a rich experience of growth. I was just thinking the other day how crazy it is that as a PA student I get to see so many cool things. For example, I get to scrub in and assist in surgeries and take care of patients while I’m in school and though I may feel and treat the patients as my own, I’m not solely responsible for them, which is a freeing feeling as a student. PA school is difficult, tiring, challenging, but it also allows for so many moments of personal growth, lasting memories, valuable lessons that I carry as I near the role and responsibility of being a physician assistant.

Decisions, Decisions

When I started this rotation, I was anxious because with it being my elective rotation, I really wanted to like it. Turns out, I didn’t need to worry about liking it because I fell in love with the world of oncology. But what I’ve been struggling about is figuring out where to go from here. Each I came to like oncology more and more, but I never felt like I was well-equipped to take care of oncology patients alone. But as I thought about it more, I didn’t feel like I was well-equipped to take care of medicine patients alone either. I know this isn’t a new thought because I’ve had this fear all along, but now that I found something that I want to pursue, I want to go into it knowing that I’m qualified.

Many people I met while at the cancer center followed different paths that led them to oncology, and they all had different opinions about the ideal path to oncology. Many people were in internal medicine for years and years before going to oncology and they strongly recommended this. My preceptor was in inpatient medicine for seven years before she moved to oncology, and she said that it was a great foundation for her. She said that she learned so much in internal medicine and she felt some level of confidence with dealing with anything that could come up. This type of confidence is something I aspire to achieve, but it seems too far away.

Another reason deterring me from pursuing inpatient medicine is the fact that I don’t really like medicine all that much. Treating uncontrolled diabetes or pneumonias does not really interest me. I understand that my primary care rotations and internal medicine rotation didn’t really reflect what I would see in an inpatient medicine setting, but those rotations definitely did not stir excitement in me for internal medicine. So now I am stuck at this point where I wonder if a couple years in internal medicine will be completely invaluable, though perhaps not fully enjoyable, or if I should just go straight into pursuing a career in oncology.

I don’t know about other PA students, but choosing a field or specialty is such a nerve-wracking decision. But the good thing about being a PA is the ability to change between specialties, so this provides some relief knowing that my decision isn’t an end-all-be-all.

So now I have to somehow decide because I should start looking for jobs.

Oncology: Not Just Medicine

I really love working in oncology. Most people’s first reaction to that statement is something along the lines of: that’s so depressing. I totally understand where people are coming from, and I can attest it isn’t always rainbows and butterflies, but I think the people in oncology are doing such important work, and being part of it the past few weeks has really captured me. Many times when patients come in for appointments it’s for following up on them and seeing how they’re tolerating their treatments. For the most part in the few weeks I’ve been here patients have been doing well or they have symptomatic complaints that can be managed.

But the last patient I saw on Friday, my last patient of 2017, did not have a routine trip to the doctor’s. He had been coming in for treatment quite often, and I saw him twice in the treatment area the two weeks I had been there. The first time I saw him in the treatment area he was tolerating the chemo but he was concerned that the tumor in his neck area was growing, and he felt more nodules in the back of his neck. What really struck me was though he was uncomfortable, he wasn’t whining or making a scene. He carried along with his kind, gentle nature. The second time I saw him in the treatment area, he was experiencing a reaction to the drug he was getting. His whole face was flushed, he was having some difficulty breathing, and he was shaking. The team of PAs and nurses responded very quickly and calmly and he went back to normal. You could see on his face he was not comfortable at all, but he never complained and kept calm and steady the whole time.

Unfortunately, his tumor has kept growing and is in a location where it will compromise his bodily functions. On Friday, the doctor told me before we went to see the patient that she was going to offer hospice for the patient because his cancer was not responding to the chemo and radiation. The visit was so hard. The doctor started off by talking about how the patient had been going through treatment with chemo and radiation and it didn’t appear to be fighting the cancer, which was confirmed by the scans that he did that day. Along with that, the patient was in a lot of pain and the chemo was taking a toll on him. The patient’s wife and son were in the room and his daughter and son-in-law were on the phone as the doctor talked and she involved all of them in the conversation. The doctor asked the family what their thoughts were, and I could tell they were hesitant to speak for fear of what was to come. When the family asked the doctor what she thought the next step should be, she choked up and said, “I think the best thing for your dad is to put him on hospice.” At that point there was not a dry eye in the room. The doctor reassured the family that on hospice the patient would be able to stay home instead of coming to the treatment every day in the cold and there would be a team to help him figure out the best regimen to keep him comfortable and pain-free. The family was so, so kind and understanding of the situation. They went so far as to thank the doctor for all her professional help through the entire process and for doing all she could for their dad.

Prior to going to see the patient, the doctor had told me putting a patient on hospice was still something she couldn’t handle well. As she spoke to the patient and his family, she was choked up and I could see how hard it was for her. She told the family, “The nicest ones suffer the most. I truly believe that.” This was such a bold statement, and I know it was to comfort the patient, but I also realized how much suffering she endures in her job. She does such important good work for many, many patients, and to see her care for each one of her patients so deeply is such an inspiration.

The doctor and I stepped out of the room and I went to retrieve a box of tissues for the family. When I opened the door a crack to hand the box over to them, the wife and son were silently crying and comforting their dad. It broke my heart. As I left the room and walked back to the office, I kept thinking of how in my life I have the Lord and I know without a doubt He will be my peace in any situation I am in. I hoped and prayed it was the same for that patient and his family.

As heart-wrenching that patient visit was, I felt even more strongly that working in oncology is something I really gravitate to. It’s not that I like seeing people suffer—it’s quite the contrary. These patients have cancer. If I can help these patients in any way by either curbing their disease or providing relief from their suffering, and hold their hand along the way, it would be a special privilege.

The “Care” in Patient Care

After spending just one day at the cancer center, I already saw how much the PAs and doctors truly cared for their patients, and it has really drawn me into this specialty even more. My preceptor and her physician work very well together and they’re seriously the best to have as a patient’s oncology team. My very first day was Monday, which is more of an administrative day for the two of them. Even so, they saw a patient who came in for an urgent visit and they visited all their patients who were getting infusions in the treatment area. That afternoon they decided to walk across the street to the hospital to visit their patients who were admitted for one reason or the other. None of these visits were mandatory, and yet they searched up all their patients who were in the hospitals and spent time talking to the patients and their family members and reviewing the patient’s most recent blood work and imaging. It was so striking to see them care so much for their patients, and I know the patients appreciated their visit immensely.

My preceptor told me in the beginning that oncology is part medicine, part hand-holding, and I really see this to be the case. Cancer is such a heavy, heavy situation for every patient to deal with, and the patients seem to really need a medical team that not only knows cancer, but also knows how to care for them as a person.

So what does it mean to care for a patient going through such a difficult ordeal? In the past few days I’ve been with various PAs and doctors, and though they each have their own approach, they all have shown immense compassion for their patients. For the patients in the treatment area, the practitioners take their time visiting all of the patients to greet them, make sure they’re doing okay, and to answer any questions they have. For the ones who come in for follow-ups, the practitioners are very good at delivering news, both good and bad, and answering any questions the patient or their family members have. And they don’t make it just about the medicine. They really want to know how the patient is doing. How is their quality of life? How is their family life?

Another aspect of caring for a patient is being honest and allowing the patient to have as much control over their journey as possible. On my second day there was a patient who noticed two days prior that she had turned jaundiced for unknown reasons. She had already been on therapy for a while and her numbers had been improving and she was feeling better. Then it seemed like things had taken a turn, and both the PA and doctor didn’t know why this was happening. I found the way the doctor spoke to the patient to be very impactful. He said, “I’m going to be honest with you. I’m confused. I don’t know why you are having these symptoms because I can say with full confidence the treatment was working.” Then he continued by stating he would hold treatment for the day, as she was supposed to get an infusion that day, but by doing so it would not harm her. And he reiterated that two more times, saying, “I’m going to say it once again. By withholding treatment today, we are not causing you harm. Haste makes waste so I would rather go back to the data and the imaging and figure out what we’re dealing with and come back and make an informed decision about what our next step will be.”

No matter what stage cancer the patient has, I believe this must hold true. Before the doctor and I went to go see a patient, she told me the patient had already been on about ten different therapies and her cancer kept progressing and she had nothing else to offer the patient. When we went into the room to talk to the patient, we greeted the patient, asked her how she was doing, and after the patient was settled, she asked how her most recent scans were. The doctor simply said, “It’s not good.” Then she went on to explain that the mass in her liver had nearly quadrupled in the time between scans and the therapy she was on wasn’t doing anything for the cancer. In addition, the scans showed metastasis in other parts of her body. The patient took it quite well and she asked some questions and then she said, “So I’m dying?” The doctor handled it very well and told her that it didn’t look good, and since her medications weren’t working, she should stop taking them and without the side effects, she would probably feel better. Throughout the entire visit the doctor kept asking if the patient and her sister were okay, if she had any questions, that she was very strong and she looked good despite the cancer. But the doctor also helped guide the patient in taking the next steps including giving her an estimate of how much time she had left, offering to talk to the patient’s children, giving her copies of all her blood work and scans so she could better explain to the children, etc.

One of the most powerful things I saw patients respond to was when the PA and/or doctor gave the patient a big hug and assured them that they were there to help, that they would answer any other questions they had, that they were not alone. On more than one occasion during the patient visits I’ve teared up. I used to think that this was very unprofessional, but there was a doctor who told me that she would many times tear up and cry with patients because that’s just who she was. And I think that’s okay. I think it’s just another way of showing how invested we are in our patients, and of course it’s not professional to just bawl and forget about your duties, but we’re human. The bond that the PAs and doctors have with their patients is real and I think it’s so necessary to help the patients go through their journey with cancer. It’s surreal to think that I can be a part of that.

 

Fresh Start, Elective Start

I have been waiting for this rotation for what seems like years—my oncology rotation. I remember throughout my late elementary/middle school years I hated reading books, but of the few books that I would read, they were fiction novels about kids who were diagnosed with cancer and their life as they went through the illness. While I was growing up, I would hear my dad tell many stories of my grandfather, who passed away at 44 due to liver cancer. I knew it always affected my dad, especially since it happened when my dad was young and it was during the Cultural Revolution in China, which hit my family hard. There were other deaths in the family due to cancer, which made me more aware of this disease growing up. Fast forward to didactic year, I always knew the topic of cancer interested me, and when we studied the hematology/oncology unit, I was utterly fascinated.

Even before I began PA school, I knew I wanted to have an oncology rotation with the idea of maybe one day going into oncology. When we ranked our elective choices last spring I knew I wanted it to be in oncology. Thankfully my professor paired me with a great cancer center in the area, and here I am.

Of course, like all my other rotations, I was anxious before I started the rotation, but for reasons other than the normal fear of the unknown, uncharted territories.

I really want this rotation to be one that I absolutely love, otherwise it will feel like everything that has built up to this point will be somehow in vain. It sounds so strange because of course, I didn’t go to school and go through all that studying with all of my expectations riding on this one rotation, but since this is something I want to potentially go into, I want it to live up to everything I hope it to be. On the flip side, I’m scared this rotation will be very disappointing, and then I will feel lost in terms of figuring out which specialty I will pursue.

In addition, oncology is an entirely different world, and what we learned in the short unit at the end of the spring semester doesn’t even begin to scratch the surface of all the complex information and medicine currently known to the oncology world. So while I usually am distraught about how much I don’t know in preparation for a rotation, I REALLY don’t know all that much going into this rotation.

Studying oncology and working in oncology are two different things, and my hope is that I would enjoy both aspects. People have told me their opinions about working in oncology, and not all of them are encouraging, but I’m going into this rotation with a cautiously hopeful outlook.

Internal Battles

This rotation has been difficult—not because of the workload—but because of interpersonal interactions and my swimming thoughts that continuously bore on my mind. Most days I shadowed different practitioners including a physical therapist, neurologist, internal medicine PA, cardiologist, vascular surgeon, etc. This was fine because I was able to see how practitioners interact with patients, navigate through an interview, and implement a management plan. But at times I stood in the room with the practitioner and patient and I just felt that even though I would mentally assess the visit, I wasn’t really learning how to practice myself.

The times that I did see patients on my own, I was put to the test intellectually and mentally. I saw very few patients here. The first time I saw a patient on my own at this clinic, the PA told me to see a patient who came in with a sore throat. It wasn’t like I had never seen a patient on my own, but somehow I felt so frazzled. Perhaps it was because I don’t feel comfortable at this clinic—like I don’t belong. Along with that, I was seeing the patient in the triage room so there were some pieces of equipment missing, namely an opthalmoscope/otoscope. Anyhow, the patient was very nice, answered all my questions while juggling her young daughter in her lap, and didn’t get impatient when I had to leave the room and find an otoscope to fully assess her. Then I went to the PA to present the patient to him and when it was time to decide the treatment plan he asked me what I wanted to do. I told him I wanted to do an antibiotic, so we chose to use Augmentin. And then he asked me what dosage I wanted. I told him the dose and he went, “Are you sure?” And then he asked me if I wanted to prescribe once a day, twice, or three times. These aren’t hard questions, but I felt so nervous because I hadn’t really interacted with the PA, much less worked with him, and he was questioning everything I did as a way to let me have the reins and learn as a student, but I lost all the confidence I had regarding tending to a patient with a fairly simple complaint.

I know that in order to get better at something, you need to practice at it. I know that. But the few times that I saw patients on my own at this rotation site I just felt so dejected, and I felt like I was regressing, not progressing. I don’t know how often this happens to other people during rotations, but to me, it’s been such a demoting feeling and I can’t quite shake it. In the back of my mind, there’s a voice that keeps taunting me, “This is rotation 5. Why don’t you get it? What’s wrong with you?” It wasn’t even that I was put down excessively by the doctor or PA, but I felt like there wasn’t anything I did that pleased them.

Another thing that has been eating at me is the fact that I don’t enjoy the pace of a private practice. In the past few months I’ve enjoyed working in hospitals more than at clinics. Naturally, this would lead me to the conclusion that I should work in a hospital instead of a private office. But then the taunting bites back telling me that I’m not smart enough to work in a hospital, I don’t know anything, how will I be able to work in a hospital?

Up to this point, this rotation has been an extremely difficult internal battle, and this is just one aspect of the many things I face and think about while on rotations.

Worrier/Warrior

The night before the next rotation I am always scared out of my wits. It doesn’t matter what specialty is next, they’re all frightening to me in their own way. Last night was the night before Rotation 5, which is Primary Care 2 for me. The whole day yesterday it felt as if I was free falling on a rollercoaster with butterflies in my chest. I’m not sure why it seemed so prevalent this time around. It could have been because I’ve heard mixed reviews about this site, or because it’s primary care, something I’m not in love with. But also, I think I’m feeling a lot of stress because in my mind by the fifth rotation I’m supposed to have an idea of what specialty I’d like to pursue for my career, and I’m supposed to be getting the hang of practicing on my own as a PA. Along with that, last week I took the most difficult PAEA test (in my opinion) and I feel like I’m not where I should be in terms of being board-ready. So many looming thoughts with the taunt of the unknown has given my mind such unrest.

I don’t really bring up the future when conversing with others, mostly due to fear. I fear that others have their lives all planned out. I fear that people will tell me I’m not on track to a successful career. I fear that I’m doing everything wrong and everyone else is doing it right. I believe that God has a plan and His plan is good, but it’s hard for me to always come before Him in rest and say,  “Yes, here you go, direct me.” But then if I try to do it by myself I’m completely lost and my insides get twisted.

Knowing this, I’ve been struggling to take this rotation in stride. My first day ended up being kind of a dud. It was quite frustrating because it seems like the PA student does not really have a role in the office and is kind of dead weight. It doesn’t really help that I report to an MA, and an MA has a different role in a patient’s health care compared to a PA. I was told by my preceptor, an MD, to shadow various doctors that come to the practice and gain exposure. This is all fine, but I don’t know how much practice I’ll get in terms of coming up with an assessment and plan, which is what I think as a PA student is most important. From my few conversations with the MA I report to, her focus for me is learning how to present a new patient the way they do it at that office and how to use the EHR, which frankly I don’t think I’ll need five weeks to learn.

So where does that leave me? I will continue pressing on by God’s grace and I am certain He will always have my best interest in mind and will always hold my hand. From what I can tell right now, this rotation is not a stellar site for honing skills to become a PA, but I haven’t written it off and I have hope that good will come out of the next five weeks.

 

Two Funny Patients

This week I had two particularly odd patient encounters.

On Tuesday I called in my first patient of the day and from the get-go I knew he would probably be a difficult patient. I called his name from the waiting room and when he saw me he kind of rolled his eyes as he got up from his chair and walked over. He walked into the exam room and was reluctant to tell me the medications he was on and answer all the questions I asked. It didn’t bother me, and I continued on with the rest of the history-taking and physical. When I was listening to his heart sounds, he said, “Is there a heart?” I laughed and said something along the lines of yes, there is a heart. And then when I put my stethoscope on his back I asked him to breathe in. All of his sudden he breathed with his mouth open, his tongue hanging out, eyes wide open with an obnoxious wheezing sound and after he took the breath and breathed out he looked at me with a smug look. I laughed it off at first and I asked him to breathe in and out again. He did the same thing again. By then I was thinking, “This guy is just playing me.” So I asked, “Can you breathe in a normal breath?” He said, “What’s a normal breath?” I told him to breathe in normally through his mouth and out, but he continued to do the same strange breathing thing. I tried once more but he didn’t stop so I moved on to listening to his carotid arteries. He did the exact same thingsticking out his tongue, mouth open wide, wheezing soundsand so I just ended the exam. I didn’t feel like I was cheating him out of an exam because one, the doctor was going to repeat the exam right after anyways, and two, the patient was breathing normally the entire interview and exam until then and I had read his chart before seeing him so I was quite certain he was okay.

When I left the exam room, I didn’t mention anything about what happened to my preceptor because I honestly thought it had nothing to do with the patient’s health, and it would just seem like I was whining after being disrespected. But that night when I was driving home, I wondered whether I should have said anything. The patient’s behavior was rude, yes. But some people are rude. As a student I think it was okay that I just left the issue alone, but one day I’ll be a practicing PA, and if similar situations arise I’ll have to be up front with the patient. The patient is just doing a disservice to himself, but I do not want to be held liable for the impeding of quality care due to disrespectful behavior on the patient’s part.

On Wednesday I had a new patient who came in and something seemed a little off. He was nice, but he also seemed like he didn’t trust anyone in the office. In the beginning of the interview he asked me what year I was in school, and I told him I was in my last year. I didn’t think that was too strange because I get that question a lot. But then he asked me if I was in college or in med school, so I told him I was in college. I proceeded to ask him some questions about why he was here and if I could take a look at the papers he brought in from his primary doctor. While I was looking at his old EKGs he asked me if I could read them. I replied I could, and he wondered how I was able to, and I told him we were taught in school. Then he went, “I thought you weren’t in med school?” I said to him I was in PA school. And then he said, “I thought you were in college?” And then I had to give my little spiel about how my program is a bachelor’s program but, yes, I am in PA school. So that seemed to appease him. As I interviewed him and performed a physical exam on him, he kept using medical terminology. It’s actually quite strange when patients do this unless I know beforehand that they also practice medicine because when we interact with patients we try to use simple communication so that nothing gets lost in translation.

Then when I was setting him up to do an EKG he asked why I didn’t choose nursing or med school. I told him I had originally thought about med school, but since I wanted to specialize, I didn’t want to go through all those years of schooling and I didn’t want the doctor lifestyle. So he made this remark, “So you’re not that committed, huh?” I laughed and replied, “I guess so.” It didn’t really bother me that he belittled my commitment to medicine, but I thought it was odd that someone would say that. Then before I went to go make copies of all his papers so that we could have records of them, he asked me to not show the doctor so that he would have an “unbiased opinion” of his medical state.

When he interacted with the doctor and the other staff, he also made somewhat pompous remarks and showed distrust of the practice, which rubbed them the wrong way. Since the patient complained of intense palpitations, the doctor wanted to hook him up to a holter monitor. Once the MA hooked up the monitor, the patient’s blood pressure dropped 20 points in some sort of vasovagal response. I honestly had no idea that could happen by hooking up a monitor to someone. Anyhow, we almost sent the patient to the emergency room, but he recovered in maybe 20 minutes so we sent him on his way. The next day he spoke to the staff and questioned the sanitation of the holter monitor. Then when he came for his stress test and echocardiogram, he made a fuss about the practice not having a wireless printer, a patient portal, not being up to date, etc. Throughout everything I just let all his antics slide and focused on his physical state and health. But I could tell the doctor and staff didn’t want to deal with him.

The vast majority of the patients I came across were very pleasant and I saw a lot this week and learned, but these two patient interactions stood out in particular. Handling patient interactions is such a large part of practicing medicine, and though I wouldn’t want to relive these encounters again, I’m glad I had them to become more acclimated to all different personalities and scenarios.