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.

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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.

Reflections on the Heart

I would say at this point in the rotation (more than halfway through) I have gotten used to the way this clinic operates. I’ve come to know how the staff works, how to conduct a patient visit specific to the doctor’s wishes, and how to complete my portion of the documentation. I see plenty of patients each day and I would say I work well with the doctor to care for the patients. But one thing I know I do not have a good grasp on is making decisions on initiating or altering management plans for a patient’s condition.

A typical follow-up visit consists of taking the patient’s height and weight, verifying their medication list, and then taking their history. I find out if they had or have anything new going on with them medically, if anything is bothering them these days, if they have any concerns, etc. Then I take their blood pressure, which my preceptor is quite particular about, with an actual sphygmomanometer, and then I listen to their heart sounds, lung sounds, carotid arteries, and check for any leg swelling. I also do an EKG on them if they are due for one. Then I report all the information I gathered to my preceptor and he heads in to see the patient and I go to take in the next patient and do it all over again.

If a patient comes in for a new patient consult, the history-taking is a little more extensive because I ask them all the questions you would find in a nice H&P note (past medical history, medications, allergies, surgical history, family history, social history).

At a cardiology clinic, some fun things I get to do is perform treadmill stress tests and observe echocardiograms and carotid doppler exams. The stress test is fun because it’s just hanging out with the patient and the doctor for about 15 minutes and monitoring their blood pressure. The only (and quite possibly the most important thing) about stress tests that make it hard is taking the blood pressure. The patient’s arm is bouncing up and down while they walk on the treadmill and it’s sometimes impossible for me to actually take their blood pressure. As for echoes, the first time I watched one I had literally no idea what I was looking at the whole time even though the tech was so nice and was explaining everything to me. For starters, the heart showed up upside down on the screen, which completely threw me off. But I love ultrasounds and I especially love listening to the heart, so any time I can observe one, I jump at the chance. The heart is really an amazing organ, and echoes indulge my fascination.

Interacting with patients is enjoyable and most of the patients who come in are very pleasant, so the short conversations we have during their visit are nice. This is different than what I experienced in the hospital because at the hospital it was kind of an in-and-out situation when we interacted with patients for the most part. I will say, though, that interacting patients takes a lot of energy. After an 8-9 hour day at the clinic, I feel more exhausted than after a 13-14 hour day at the hospital. Part of that is also because I see patient after patient at the clinic, and at the hospital it’s more stop-and-go depending on what I need to do at that time.

The greatest challenge for me at this rotation (and also in the past rotations, as well) is knowing how to adjust patient’s medication or management plan. Most of the patients I see at this rotation have either high blood pressure, high cholesterol, or both. When their blood pressure readings or their blood tests results come back unsatisfactory, I don’t really know how to alter their medication dosage or the medication itself so that their disease will improve. I know that if there aren’t any side effects I should increase the dosage but once it’s maxed out I should either add another one or switch medication families. But when it’s an actual person in front of you instead of just a table of lab values on a computer screen, I am much more weary to adjust medications. Also I don’t usually accompany my preceptor when he goes to counsel the patient because I’m off to see the next patient, so I haven’t been able to gain much insight on how to navigate such instances.

I’m sure I say this too often, but there is still so much to learn. I’m grateful for this experience at this clinic. Though I feel like I’m being worked a lot and maybe not gaining as much in comparison to the amount of effort I’m putting in every day at work, I’m thankful for all the exposure I’ve gotten to different patients and medical states. Such learning cannot be rushed, and I am excited to continue on in this journey.

Surgery Pt. 2

On to the OR. The last 2.5 weeks of my surgery rotation were spent assisting in the OR and taking care of patients on the floor. There were four other medical students with me and the last three days I was there, there was also another PA student. Each day we would round with the residents, go to morning report, and spend the rest of the day checking in on patients and following up on all the labs and imaging and whatever other things the patients needed. Each surgical case was supposed to have a student, and typically each student was assigned to one case if there were enough to go around for the day. As students we were to prepare for rounds, which were at 6 a.m., to present to the chief resident. I normally arrived at the hospital a little before 5 a.m. so that I would have time to change into my scrubs and read up on my patients and go see them before rounds started, and on most days I had two or three patients that I chose to follow.

The first day I knew that we were going to have rounds but I did not really know how the medical students worked and I didn’t know the situation of any of the patients. I was given one patient to present and I spent a good half hour looking through the patient’s chart, though I didn’t really know what to look for to adequately prepare for rounds. The chief that day had a reputation for being tough and short-tempered when he didn’t find something satisfactory or he found people to be lacking in competency. I was one of the last to present, and when my turn came, I started my first sentence strong…and then that’s pretty much where I ended my presentation. I was scared the chief was going to rip me apart, but he just looked at me, sighed, and said one of the interns (first year residents) would teach me how to properly present. It also helped that one of the medical students came to my rescue and told the chief it was my first day so I should get a pass. At the end of the day the students would split up the patient list so that we knew who we were going to present the next day. Since one of the students went home during the day because she was coming off of a 24-hour shift, we split up the patients without her and assumed she would pick up the rest. But the next morning, after I had already started preparing my presentations for my assigned patients, the student came and told me that one of my patients was actually hers so I had to take a new patient. In that moment I thought I was going to break down and cry. I was so nervous about presenting to the chief after failing the day before, and after I had worked so hard on perfecting my presentation, I had to rip it apart and start over for a new patient. But it turned out that that day we got a new chief who came from a different hospital, so that day the chief from the day before presented mostly all the patients to update the new chief. God is so merciful! By the third morning I was getting the hang of presenting.

The thing about presenting a patient is that anyone can read a chart especially if they have a lot of time on their hands; the main point of presenting is to update coworkers of any important information and to come up with a plan to appropriately manage the patient. Our goal was not to show how well we could read or gather information. The goal was to take the given information and use it to assess if the patient was healing well or not, if the patient needed any new or additional labs or imaging, if the patient needed new or additional medical management or therapy, and if the patient was ready to go home. Many times I would feel like I wasn’t really learning much through presenting. I didn’t really learn in those 2.5 weeks what labs or imaging I should order for each situation we encountered. I didn’t really come to know when it was appropriate to change a patient’s medication or when a patient was ready to go home. I didn’t come to a full understanding of how to properly manage a patient from pre-op to intra-op to post-op to discharge. What I did learn was that everything you do, every test you order, every medication you administer should be in the patient’s best interest, and it should be done with the goal of getting the patient out of the hospital and back to their normal lives as much as possible. In every situation, do your part in full completion and do not rely on others to get back to you about your patient. Your patient is your responsibility so you are the one who has to make sure the patient gets all the necessary tests done, is healing well, is not uncomfortable, is getting the adequate care, and so on and so forth. Other healthcare professionals (such as nurses, phlebotomists, imaging technicians and radiologists, therapists, etc.) are busy, and often things fall through the cracks so you have to personally make sure every aspect of the management is followed through accurately and thoroughly so that your patient gets the care he or she needs.

Heart Problems

I’ve been at my new rotation site for three days and it’s completely different compared to my last few weeks. Right now I’m at a cardiology clinic for my internal medicine rotation. I’m not quite sure why my internal medicine rotation is at a cardiologist’s clinic but that’s besides the point. Since I am at a cardiology clinic, the patients I see are mostly a very specific population group (50 years old and older with comorbidities) and they mostly all have one or a combination of the following: high blood pressure, high cholesterol, heart valve problems, atrial fibrillation.

I’m trying to describe how I felt on Monday but my thoughts keep jumbling as I am try to organize my thoughts, so bear with me.

I walked in on the first day freaked out because cardio was not my best unit during didactic year and it’s also such an important component of a patient’s well being so I didn’t want to mess up. Also in this clinic I’m the only student except for when a med student comes for a few hours once a week. In the hospital I had other students I could turn to for backup or advice and it was comforting to have others alongside me. As the only student I cannot let anything slide because it’s my sole responsibility. This isn’t a problem, and I’m glad I am the only student, but it shakes my confidence.

The doctor who is my preceptor is a very experienced, knowledgeable, well-connected practitioner and professor, and I find him to be nice but also intimidating. Not because he is mean or unprofessional. It’s because I’m sure he expects a lot and I feel like I can’t live up to his expectations because I’m inadequate at taking histories and doing physicals, and I’m bound to mess up some progress notes. (Sidenote: he takes blood pressure in like 2 seconds and I’m in awe but also at the same time dumbfounded)

My first day there I got a quick introduction to the EHR system the doctor uses and he showed me how he wanted me to set up and complete the notes for each patient encounter. Then he briefly walked through how the clinic operated and what my tasks would be. Following that he had me go take a couple patients’ blood pressures and after a few patients he had me go take histories and do physicals on patients.

During that one day I was learning about the operational side of taking care of patients but also trying to figure out how the doctor wanted our workflow to be between him and me and what exactly I was supposed to do when I saw patients, and I was also trying to get my brain into cardio mode despite my poor grasp on all things cardio. Even little things such as wondering if I was supposed to go back out to tell him I had finished taking the blood pressure or should I stay in the room and wait for him to come see the patient made me anxious because I didn’t want to be that student that fumbles around. The schedule was also backed up so the undercurrent of needing to hurry up added to my stress.

This was such a change of pace compared to surgery. In surgery we spent a lot of time reading patient charts and getting to know their medical history and there would be a team of surgeons, residents, students, and other consulted medical professionals that would follow them for consecutive days regarding an acute problem. At this clinic, most of the patients are established patients who come every 3-6 months and the doctor knows their history. But for me to come in for a short period of time is hard for me and also for the patient because the continuity isn’t there.

Anyhow, the past two days I have gotten a better feel for the swing of things and I’m slowly adapting to properly conducting patient visits for this clinical setting. But I still have a lot to learn and I’m hoping this rotation will help me figure out how to ask all the right questions, hone my physical exam skills, and learn how to manage patients medically.

And to end with a random tangent…  

I was feeling so tired as I wrote this and I was thinking about my last week. Last Wednesday I worked 6 hours and then traveled 2 hours to end up at school and studied for 5 more hours. Then Thursday I went to school and studied the whole day. Friday was Rotation 3’s callback day. I took two exams and had class meetings and went home to pack for an out-of-town Christian conference. I drove 4 hours and arrived at the conference site at 8 p.m. just in time for the beginning of the conference. Saturday and Sunday I was at the conference and Sunday night I drove back and arrived back home a little after midnight. Monday morning I started at my new rotation site. And so far I’ve had 8+ hour days at this clinic and afterwards I go home and work on assignments for school and my preceptor. So though I’m not studying 12 hours a day, I still have a lot on my plate, and this is the reality of a PA student.

Surgery Pt.1

My apologies to all two of my readers for not writing about my experience this rotation sooner. For the past five weeks I was in my surgery rotation, and I was so tired from work I didn’t have it in me to write. The rotation was broken up in two sections: the first two weeks I was in the surgical clinic, and then the last two and a half weeks I worked in the OR and on the floor. Going in I was extremely nervous for multiple reasons. I knew surgery had a lot of GI, which was one of my least favorite systems, and had cases with a lot of labs, medications, procedures that I was not familiar with. Also, I was under the impression that I would get yelled at and would be under pressure to perform at a level I wasn’t at. All things aside, I was there to learn about what a surgical PA does and how to practice as a surgical PA.

When I first got to the hospital, the orientation process was not very orientating and it was kind of frustrating. There were things I had to figure out on my own such as getting access to different places in the hospital, getting access to the computer systems and learning how to navigate them, figuring out what time I should arrive where, etc.

As a student I was required to attend morning report, which was a daily meeting with all the students, residents and attendings that worked with the surgical floor patients, surgical consults, and surgical ICU patients. For the first two weeks of my rotation I barely had a clue what was going on during the meetings. I had no idea who was who and I had no clue which patients they were talking about because I worked in the surgical clinic, and therefore I didn’t see any of these patients they were discussing. Slowly as I kept trying to follow their conversations, I started picking up small tidbits such as disease processes patients had, having an idea of what the doctors were seeing on imaging, figuring out management plans, etc. By the time I got to the OR portion of my rotation, I was able to grasp more of the discussion and I was able to gain information from the meeting that helped me care for my patients better.

In clinic there were many different clinics held throughout the week. There were usually two or three PAs working with one attending and the different clinics were vascular, general surgery, breast, head and neck, thoracic, hand, colorectal, and ENT. Patients came for surgery consults, to be assessed if they were good candidates for surgery, and to follow up after their procedure was done to assess adequate healing and progress. PAs would see their own patients, take a brief history and physical and the attending would pop in to see the patient quickly, address any more technical/surgery-specific questions, and then leave the PA to wrap up the rest of the visit. Some attendings saw their own patients, some attendings only saw patients with the PA. As I observed and took part in caring for the patient, I felt like I could do this in the future. I enjoyed getting to see all different types of people and medical issues, and I liked seeing the difference the surgery would make to help the patient’s ailments. However, I felt that since the clinic was so problem-focused, I did not utilize a broad range of knowledge and skills while seeing these patients. This isn’t necessarily a problem, especially if what you are doing is adequately helping patients, but I also felt that this would possibly become monotonous over time.

Overall the time I spent in clinic was good. I was able to interact with patients, perform histories and physicals, practice documentation, and work with other PAs and doctors. The clinic setting was at a good pace, not too rushed, and the hours were very reasonable (9 a.m. – 3 p.m. Monday-Thursday, 9 a.m. – 1 p.m. on Fridays). What I did not enjoy as much was the excessive complaining and grumbling from clinic staff. I felt like this was somewhat a stumbling block for productivity for not only the staff member who was griping, but also the rest of the workers in the clinic, and it most definitely affected the patient’s impression of the clinic. I feel this is typical in any place of work, and I’m glad I witnessed it to become more aware of office politics and happenings, but it did affect my view of the clinic.

To be continued…

 

Progress (Notes)

During this rotation part of my position as a PA-S at the clinic required me to complete progress notes for all the patients that I saw. After about the first week of the rotation I was instructed to see patients on my own. I would greet the patient and then subsequently follow the clinical approach my preceptor taught. Then my preceptor would come see the patient with me and after his history and physical we would formulate an assessment and plan.

Progress notes were written and stored on a computer software, and my preceptor structured the software so that there were many templates that would be used for filling out the progress note. For example, if the patient presented with and was diagnosed with GERD, I would type in “esophageal reflux” in the template search bar and then click the arrow to populate the note. That template would automatically fill out the chief complaint, history of present illness (HPI), physical exam, assessment, and treatment. This was useful but I also thought it was sometimes too generic or not detailed enough for the patient’s specific presentation. Typically I would use the template and then go back and edit the HPI so that it included details the patient said during the interview.

Oftentimes the treatment would be appropriate for the patient, but sometimes the doctor would change it to tailor it to the patient’s particular needs. This was good, but I did not really learn how to know what to change the medication to or how to adjust the medication dosage. This is something I still need to practice.

This clinic has only been in the area for about two years and the number of patients seen each day is not overwhelming, which is great for my pace at this time in my clinical experience. On the days where I would see patient after patient, I would not be able to complete the progress note until after the rush of patients. By that time I would maybe have three or four patient encounters to complete. Usually during the patient visit I wouldn’t type the HPI while talking to the patient so during the lull times I finished up notes.

I found it to be a little repetitive and a lot of work, though I recognized the importance of a good note. Sometimes when I read older progress notes from previous patient encounters it would be difficult for me to get the full picture when the HPI basically only consisted of the template’s description. The whole point of the note is to communicate to other health care providers a comprehensive picture of the patient’s condition. If many details are too vague or left out, it makes it very difficult for the provider to fully understand the reasoning behind previous visits assessments and plans, and also it is annoying for the patient to have to explain themselves visit after visit.

I remember one day after work I went home and I told a friend that I realized being a PA is a lot of work. Of course I knew this going in, but oftentimes in class I only thought about making the diagnosis and coming up with the management plan that the documentation portion of a PA’s duties went over my head. In my first rotation I never wrote the notes, so when I got to primary care, my tasks were such a contrast to emergency medicine. I would not say that I really enjoy writing notes but I know how important it is to a patient’s medical care, and I would not skimp out on work just because I felt like it was a lot to do.

 

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Primary Lessons

It’s been hard to figure out what to write about throughout this whole rotation. I feel it was easy to reflect upon all the different things I experienced and learned from working in the emergency department because it was my first rotation and I saw something different every day. Here at the family medicine private clinic, I find it harder to pinpoint things I have gained from working in this setting.

Many patient visits are very routine. Patients come in for physicals or for routine blood draws, or to review recent imaging or blood test reports. These encounters are all fine, but when I am speaking with patients I don’t really feel like I’m accomplishing much. It’s strange. I know that as a primary care provider, I am the first line medical contact for the patient. There’s a relationship that is supposed to form between the patient and his or her primary care provider. As a primary care provider, I am supposed to treat the patient in a way that shows I care about them, their well-being, and I am there to support them medically. But I don’t feel this trust relationship is reciprocated, as in the patient is not invested in me as a trusted figure in their life. I feel like they come just to see if they have any illnesses and/or to get medications. And yet, I still want to make sure they monitor their chronic illness and they complete all preventive medicine measures to ensure they’re healthy and to catch diseases early.

Even though sometimes I feel like what I’m doing is not making that big of a difference, I feel strongly that no matter what, it is important to do your job well. If not, there were be repercussions. A few days ago, I saw a patient who came for a vaccination and also mentioned that her last menstrual period was more than 2 months ago. After a confirmed negative pregnancy test, I looked at her problem list in her file and did not see anything unusual that would correlate with her menstrual period, though she did mention she felt fatigue often. The patient also said she was not taking any medications currently. I thought the best course of action would be to call it amenorrhea and do a workup for it. But after I presented the patient to my preceptor and after further conversation with the patient she mentioned she ran out of her thyroid medication. This changed the picture entirely. The visit ended up being much different than how the patient, and I, had expected it to go, but in the end everyone was on the same page. Whoever saw this patient in the past did not indicate in the patient’s file she had some sort of thyroid dysfunction and did not educate the patient about her medication. Because these things were not done, neither the next provider (me) nor the patient was able to follow through properly to take care of the patient’s health.

Thankfully the patient’s condition is not extremely serious and she is able to get back on track with treatment and my preceptor was experienced enough to get the whole picture and properly advise the patient. For me, I learned the hard way to not overlook anything in the patient’s chart from previous visits and to always check lab values. It’s hard to do especially when you’re rushed to see patients, but a quick glance at values is much better than not pulling them up at all. My preceptor semi-scolded me for not fully investigating the presentation and lab values and documents, and therefore not realizing the patient had a thyroid problem. The feeling of failure was not pleasant, and from then on I was again determined to always strive to do my best work, all the time.

Practice

At the current clinic my preceptor has this clinical approach:

5 Fingers

  • Chief Complaint
    • This is documented in the patient’s own words. It reflects the reason why the patient came to the clinic.
  • Problem List
    • This shows the past medical history of the patient. By going through this, the practitioner has a better idea of what is already going on with the patient and this will allow you to have a better idea for diagnoses when they present with symptoms.
  • Medications
    • It is important to review what medications the patient is currently taking, what have they stopped taking, and if it matches up with the medical history.
  • CDSS
    • This stands for Clinical Decision Support System. There are some guidelines recommended by the government in order to practice good preventive medicine. These ones are in the top portion of the CDSS tab. The bottom portion encompasses additional preventative medicine the clinic would like to include in the patient’s care.
  • HPI
    • After you have gone through the first four “fingers” you can evaluate what the patient presents with in a comprehensive way.

Physical Exam

  • No matter what the patient presents with, it is imperative to always do at least a brief physical exam of all systems. There may be incidental findings which would be missed if only a focused physical exam is done. These findings may be serious. Patients will only respect you more for being thorough.

“See something, do something”

  • This means if you see something, even if the patient doesn’t complain of it, you should implement some sort of treatment for it. Patients may not be aware of the problem, but if you find it, you should act upon it.

The traditional approach we learned in school is termed SOAP, which stands for subjective, objective, assessment, and plan. Basically it’s what the patient presents with, what you find, the diagnosis, and treatment plan. When taking the history (as I’ve written about before), it usually starts with the present illness, then past medical history and medication, surgical history, allergies, family history, and social history.

The approach that my preceptor has adapted is actually very similar to the overall SOAP format but within the “subjective” portion, the five fingers approach is a little different. Because my preceptor reviews the patient’s problem list first, this gives an idea of what he’s working with. If you have a blank slate, it’s hard to know where to start, but if you already have a landscape it allows you to more accurately map out a direction where to go. For example, if a patient comes in complaining of a cough, instead of going through all differential diagnoses for causes of a cough, you could look at the patient’s medical history. Perhaps this patient has a history of hypertension and is taking an ACEI which can have a dry cough as a side effect. After you review the medical history and medications and address any preventive medicine measures, you go through the history of present illness and ask appropriate questions to lead you to a diagnosis. Of course, this is not to say that you don’t explore other differential diagnoses when the patient already has a medical history.

I think it’s important to always do a brief physical exam even when it doesn’t seem warranted. Incidental findings could be the only way a patient finds out early about a cancerous growth or a concerning condition. In my personal experience, I once saw a doctor for a sick visit and she happened to palpate an enlarged thyroid. From there I had an ultrasound and learned I had a thyroid nodule. Though it’s not cancerous, I’m grateful the doctor was thorough and brought this medical problem to my attention. To contrast, I went to a different doctor for a physical exam and to get a medical form filled out for school. He barely even looked at me, checked off everything on the form as normal, only listened to lung and heart sounds, and signed and stamped his name on the form. This was after I knew I had an enlarged thyroid, so I knew he missed findings during the visit.

At my rotation I’ve been told that a lot of the patients come to the doctor but they don’t want to hang around—they just want to get in, get a prescription, and get out. One of the people I’ve been working with told me to work fast because the patients don’t want to stay a long time. I have mixed feelings about this because I understand people have lives, but also this doesn’t allow the practitioner to do a good job. If you don’t allow your practitioner to do his or her job, what is the point of visiting? And to be quite honest, I only had one patient where she was actually in a rush to leave. All the others never mentioned to me that they didn’t have time to talk to me because they were short on time. Though this isn’t to say that we should take all day to talk to one patient. In my opinion, being thorough never hurt a patient, and patients will recognize your genuine care for their well being.

In the past three weeks in a family medicine clinic, I’ve been able to practice more medicine and interact with patients in a way that allows for more patient interaction based on the principle that as health care providers we are to care for the entire person so that they will live healthy lives. I stand behind this and it’s nice that I get to build this foundation as part of my clinical experience.