It's All About the "C" (30/30)

     What a month.

     May has simply flown by, which I suppose is not very surprising considering all the big events it included. In this month I've attended four graduations, taken one 3-day review class, summitted two mountains on a 4.5 mile hike, visited three states, helped coordinate one very big surprise, and taken one 6-hour exam. In between all that I used every spare moment to study for the Physician Assistant National Certifying Exam (PANCE). I attempted to use my study breaks to finish a post on my final rotation, but that one still needs a bit of work so today I'm skipping ahead to the milestones I hit this month. To start at the beginning: I GRADUATED!

     I finished my final rotation on April 27th, had my final graduate seminar and End of Rotation Exam the next two days, and then spent the beginning of the next week taking a 3-day day PANCE review class, before it was finally time to walk across the stage and end my time in PA school, officially. My graduation happened to fall on the exact same day as my sister's (she earned her Master's in Education), so my family not only endured the bitter cold and drizzly rain of a May morning at Gillette stadium, but they also drove straight from my commencement to arrive just in time to sit through a second outdoor ceremony in Quincy. My Californian aunt and uncle had to stock up on some extra layers, but they joined my parents and roommate in enduring the weather to show their love and support for us. There were cheers and pictures and hugs and toasts and celebratory feasts and everything one could need to feel loved and encouraged. As an added bonus, MCPHS actually had diplomas ready for graduates on the day of graduation so, rather than having to wait a few weeks for it to arrive in the mail, I left Gillette with proof that I had, in fact, completed PA school.

My cold, but wonderful, uncle and aunt

My long-suffering, and always encouraging, roommate

My parents, who have supported me in every imaginable way

My brother in-law and sister, both of whom completed their Master's this month

Mother's Day hike to Mt. Welch and Mt. Dickey

     After graduation I took a well-deserved, though brief, break to celebrate Mother's Day with mine and my brother in-law's families, and then it was back to studying. The NCCPA requires that PAs wait at least 7-10 days after graduating before they attempt to take the PANCE, but otherwise the choice of when you take the exam is up to you. Seeing as my brother in-law was about to graduate with his Master's on the 22nd, and his thesis art show was on the 20th, I scheduled my exam for the 19th. I wanted time to study, but I also didn't want to have the exam hanging over my head while I tried to participate in the upcoming celebrations and family time. So, from May 9th until the 19th, it was non-stop studying, with few exceptions. My roommate needed to calm me down on the 17th, when I suddenly became convinced that I must be woefully unprepared for the exam, but after some

Studying at my friend's graduation

reassurance, and a massage on the 18th to help relax me (thanks parents!), I entered the testing room on the 19th feeling surprisingly calm and ready to tackle the PANCE. The exam can take up to 6 hours (there are five 1-hour blocks, and 45 minutes of break time), but thankfully I was able to finish up at least an hour ahead of time, even with the breaks I took mid-exam to do some deep breathing. Even though traffic on the drive home was horrendous, it was such a relief to be done. Plus, I knew that my roommate and friends from the coffee shop were waiting to hang out and celebrate with me. All these people deserve a shoutout and a huge debt of gratitude for all the support they have given me over the years, not to mention all the times they've cheered me up, made me laugh, switched shifts with me, and even helped me study. They belong to the very long list of people I couldn't have made it through PA school without.

     My classmates and I had been informed that it would take 2 weeks to get our PANCE results, so it was with some surprise that, a few hours short of one week after I'd taken my exam, I received an email informing me that my results were ready. To be completely honest, I got this email early in the morning and actually fell back asleep briefly, only to be haunted by a nightmare in which I was told I had failed, so it was with some trepidation that I longed onto the NCCPA site when I woke up again. Before I could even get to the page with my exam results though, I knew. There, underneath my name on my profile page, was a bright and shiny:

Obviously after my nightmare I needed confirmation, so I quickly clicked on the Exams tab to find:

     Just like that, ladies and gentlemen, I am official. I am a certified PA and, while I still need my state and drug license before I can actually start working, those licenses are simply a matter of paperwork and time. The hard part is over. I am a really and truly Physician Assistant at last.

     There are more people who deserve gratitude for getting me to this point, and trying to list all of them would take too long (though I did try in my last Thanksgiving post), but for now let me once again give a shout out to some of the people I haven't already mentioned in this post: my older sister, who sadly couldn't make it to my graduation, but was able to celebrate belatedly when she came for my brother in-law's; my grandparents, my aunt and uncle in Seattle, my cousins, and all my extended family who couldn't come to the graduations but were there in spirit; the friends who have mentored me throughout these years and guided me not just through my studies, but through the emotional, spiritual, and psychological trials I've encountered; the health care professionals who gave me advice, encouragement, and sometimes a necessary push; and last, but certainly not least, my Bible study girls, who supported and encouraged me every week, not just with prayers, but by always going above and beyond (e.g. offering to run errands for me when rotations made me insanely busy and buying me an ice cream cake to celebrate the last day of my final rotation). I do not have the words to adequately express my gratitude, so I shall simply say: thank you from the bottom of my heart.

     At some point I will actually finish my post on my final rotation, and I'll probably write a short one on the PANCE (just a few tips for anyone studying for it), but for right now I'm going to bask a little in the fact that I am not simply a PA, but a PA-C, and that I am well and truly done with PA school. 

It's What's On the Inside That Counts: Internal Medicine

Storm coming in over Revere Beach

It did it's job, but I'm
ready to trade my short
coat for a long one.

     As of yesterday, I am done with PA school. One week from today I will go to graduation, put on my gown and hood, collect my diploma, and everything will be official, but in reality, I don't even have to do that. The final rotations have been completed, my last exams are finished, and there is nothing else I have to do. Once MCPHS processes all the paperwork, I am a Physician Assistant. For real. 

      Right now my brain can't quite process that. Perhaps I'm still too tired from the massive sleep debt I accumulated over the last three years. Perhaps my brain is still recovering from the five hour exam I took on Thursday. Perhaps it's because, while I am now a PA, the studying is not quite over. To practice as a PA, I have to be certified, which means taking, and passing, another 5 hour exam called the Physician Assistant National Certifying Exam, or "PANCE" for short. This also means that I will spend most of the next 3 weeks squirreled away in a study cave to prepare. For now though, I'm taking a quick break to finish my post on my 8th rotation.

My alarms for my 1st Saturday
shift. Thankfully my other
weekend shifts let me sleep
in an hour more. 

     My penultimate rotation was in Internal Medicine, which was all inpatient. Inpatient medicine is certainly a different beast from outpatient medicine. There are a few ways you could almost call it "easier." The patient is right there and they're not going anywhere, so it's easier to track their progress, labs and diagnostics can be done faster, and you can be sure that the patient is actually taking medications you prescribe at the right times, in the right doses, and in the right manner. Of course, I don't think anyone actually claims that inpatient medicine is easier than outpatient. The whole reason why patients are admitted and treated inpatient, is because they are too sick to go home, so the conditions you treat in inpatient medicine are naturally more complex and difficult than outpatient issues. It's also more difficult because, while every medical specialty involves some level of psychiatric care for a patient (from being a listening ear in primary care to being a reassuring voice before a surgery), inpatient medicine seems to demand a bit more from the clinician. No one is at their best when they're admitted to a hospital, and the internist has to recognize this. They also need to recognize that it might not be just the patient who needs psychological support and a listening ear, but also the patient's friends and family members.

This was the weather I
came back to after temps
in the 60s back in OR.

     To be honest, I think the friends and family members need more help than the patients more often than not. The worst might just be the friends and family members who are also medical professionals. If this surprises you, that probably just means you're not a medical professional, or related to one, yourself. People who work in healthcare tend to make the worst patients, or patient's loved ones. We know just enough to make us dangerous, but knowledge does not equal wisdom. One of my first patients was the only child of a nurse and a physician. The patient was great; her parents were difficult. The mother worked in geriatrics, and the father had been in public health and management for almost his entire career, so they knew enough to know the worst that could happen, but didn't have enough recent experience in young adult medicine to realize that their daughter was doing well, and was being well-cared for. They tended to become overly anxious without cause, which then tended to freak out their daughter. It made taking care of her a bit more difficult, but, at the same time, we all understood. They loved their daughter and, even though she was now a grad student in her early 20s, they would never stop trying to ensure that she was safe and healthy. I can't fault that. I also can't fault the family who had a hard time accepting that they had very little time left with their husband/father, but that's a story for another post. 

Technology: making it obvious just how frequently I failed at getting 8 hours of sleep (or simply 6 or more)
during this rotation.

My roommate and I considered this an acceptable
self-treatment for a rough week. Just add some
friends and a ridiculously dramatic Spanish tv
show and we were all set.

     Sometimes the person who most needs to be attended to is the clinician. For the students on this rotation, we typically worked 11-12 hour days, and never really had a break during those hours because we even had lectures during lunch.* Once you added in the commute, this often meant that I had just enough time when I got home each night to make and eat some dinner, shower, and attempt to do some studying or work on my resume and cover letters before crashing into bed so I could start it all over again the next day. Beyond the physical stresses, however, the rotation was also emotionally and psychologically demanding, though not all of the demands were directly related to the the rotation itself. On my second day in internal medicine I found myself bombarded by bad news. First there was the worrying report from a CT tech about the abdominal pain a relative had been having. It ended up being a simple appendicitis, but it was hard not to infer something much more ominous when the tech reported that he could see something in the scan, and that, though he wasn’t at liberty to say what it was, he did recommend that my relative have someone with her when they delivered the news. Until this error was cleared up, my family and I spent about a half hour assuming that cancer was involved. I’d just recovered from this unnecessary shock when I learned that something bad really had happened to a person I loved. A good friend of mine texted to inform me that she’d miscarried at 16 weeks. Her pregnancy had been high-risk from the start, so this had always been a well-known possibility, but that didn’t make the news any easier to hear, and it's always hard to watch a friend suffer and be powerless to make it better. Just over a week later I was nearing the end of another long day when I learned that another good friend, who had been diagnosed with preeclampsia and successfully delivered her baby three days before, was still in the hospital with high blood pressures. She recovered, and she and her baby are doing well now, but initially hearing about her felt like yet another blow to my already fragile emotional health. There was also an incident that occurred during my rotation that made it clear that the other students and I were not the only people in the hospital who were stressed and emotionally drained. 

My roommate looking at a
sculpture the size of a whale
heart when we spent a couple
stolen hours at the PEM.

     The hospital where I did my rotation was preparing for a huge switch to a new computer system. At one point they decided to learn how the new alert system worked. The only problem was that they forgot to put the system into test mode, which led to people all across the hospital receiving pages stating that there was an active shooter in one of the lobbies. I was in lecture at the time, and initially we weren't sure what to do since only one girl received the page. When someone else got it, however, our teacher (an excellent Infectious Disease doc who looks like a mix between Jim Broadbent's versions of Professor Kirke and Professor Slughorn) sprang into action, corralling people from the hall into our room, turning out the lights, locking the doors, approving the suggestion to flip tables and make a blockade, and calculating the angle bullets shot through the doors would enter the room. He did it all in just a couple minutes, and by the time the the mistake was discovered and pages were sent out to everyone to apologize for the false alarm, we were already all in position. The levelheadedness of the doc, and his clear instructions kept us from being frozen in place in fear or uncertainty and, while everyone in that room thought the mistake was horrible, we weren't traumatized by it. Some people were. Some even needed counseling and trauma therapy afterward. The possibility of an active shooter in a hospital is just too likely to easily dismiss. Many people at the hospital knew the doctor at Brigham and Women's Hospital who was shot in an exam room last January. I myself had been just down the street when it happened, the sound of sirens disrupting my class. That experience, and the false alarm on my rotation, certainly drove home the point that healthcare workers are at high risk of experiencing workplace violence, often from patients, and that this risk is increasing (before anyone starts suggesting that the solution is to arm security guards at hospitals and healthcare facilities though, you should really read this New York Times article or listen to this episode by This American Life). 

This is an actual Emmy. It belonged to one of our
patients. He had it brought in on the day he was
discharged so we could take pictures with it.
And yes, I am very red in this picture. I'd just
come running from a lecture and a white coat
over a sweater is toasty.

     If my time in Family Medicine could be described as admitting what I don't know, then Internal Medicine could be described as learning to be confident in what I do know. There are few things more terrifying than when your preceptor tells you, "I'm not telling you the plan. You're in charge. You tell me the plan, you write the orders, and I will sign them." It feels a bit like jumping off a cliff. There's no safety blanket. You know that if you get it right, it will be amazing and will prove that you might just make a competent PA after all. The fear, of course, is that you will get it wrong, there will be no one to blame but yourself, and you will have to live with the consequences. Now the truth is that, when my preceptor told me to come up with a plan and refused to discuss it with me until I'd set in stone, he wasn't truly leaving me on my own. If I'd really been on the wrong track, he would have corrected me (the care of the patient trumps a learning experience any day), but the other truth is that he didn't need to.Whether I acknowledged it or not, I was ready. I'd been formulating plans for patients since day 1 of rotations, and while my initial input into the care plans for patients had been limited at the beginning of my clinical year, I'd spent rotation after rotation reinforcing what I'd learned in school, learning from those with more experience, and discovering how the theories of medicine play out in the real world so that, when the time came, I could provide my patients the best possible care. That is, after all, the goal: to become a PA. This also means, of course, that oh so soon I will be responsible for the care of many people. I better start getting used to it, even if it scares me half to death. So I did it. I made the plan, I put in the orders and, even though he didn't ask me to, I explained my reasoning to my preceptor. He simply nodded, signed the orders, let me tell the nurse the plan, and that was it. And it worked. My patient did well. When she was discharged her husband told me she loved me, and she tried to convince me to work with her PCP. And it felt amazing. And when my preceptor told me that the next day he wasn't going to help me with the plans for any of my patients, it felt less like jumping off a cliff and more like accepting a challenge. 

Locker on my last
day: so many notes.

     There is still much I don't know, and I need the humility to acknowledge that and to keep pushing me to learn. However, sometimes what you don't know is just how much you are capable of, and how much you already know. Sometimes you need the push into the pool to make you realize you can swim.** Internal Medicine, and my awesome preceptors, did that for me. In PA school it's easy to get discouraged, to think that there's no way you'll ever learn everything or that you've made a horrible mistake, so those moments of recognizing how much you already know are invaluable. Those moments, and the confidence they built, are part of why I loved this rotation so much. Yes, had it lasted just one week (or possibly even one day) longer the schedule likely would have driven me to illness or a mental breakdown*** and I did start to look forward to the end, but leaving was bittersweet. I only hope that I can continue to carry the lessons they taught me into these next weeks as I study for and take my PANCE, and then into the months that follow as I begin my life as a PA.

*Those lectures were catered, however, which was an incredible blessing, both physically and financially.
**Perhaps this is not the best metaphor for me considering I drowned as a child and later failed swimming lessons three times, but you get my point.
***The schedule is really only feasible for the attendings and PAs at the hospital because they work 1 week on, 1 week off, and they don't have to use their "free time" to study, write resumes/cover letters, and apply to jobs. And 3 of the other students on this rotation with me did, in fact, have to miss days due to illness.

PSA: Smoking (29/30)

     I'm now in my ninth and final rotation, and in each rotation I have counseled multiple patients on their smoking use, so it seems appropriate to do a little PSA on smoking for everyone reading and, hopefully, reduce the number of people I'll need to counsel in the future. The thing is, I think most people are aware that smoking is not a good idea, and for me to repeat the same warnings most people have heard hundreds of times seems ineffective. So here's another approach: in my clinical medicine classes, my classmates and I joked that smoking was a risk factor for everything (and not just lung cancer as many people believe), so I started writing down all the conditions that listed smoking as a risk factor. I present this list to you now, with no further comments other than to say that in the interest of simplicity I'm going to refer to any type of cancer by the organ it affects (rather than differentiating it by cell type) and that I will continue to update this list as I discover more conditions linked to smoking.

• Cardiovascular
• Atherosclerosis
• Peripheral Artery Disease (PAD)
• Coronary Artery Disease (CAD)
• Angina 
• Stable, unstable, and Prinzmetal (variant)
• Myocardial infarction (aka heart attack)
• NSTEMI and STEMI
• Aortic stenosis
• Renal artery stenosis
• Aortic aneurysm
• Dyslipidemia
• Thrombophlebitis
• Both superficial and deep vein thrombosis
• Chronic venous insufficiency 
• Varicose veins
• Hypertension
• Intracerebral hemorrhage
• Subarachnoid hemorrhage
• Intracranial aneurysm
• Respiratory
• Chronic Obstructive Pulmonary Disease (COPD)
• Risk factor for both types (chronic bronchitis and emphysema)
• Pulmonary Embolism (PE)
• Asthma
• Interstitial Lung diseases
• Interstitial pneumonitis
• Respiratory bronchiolitis
• Idiopathic pulmonary fibrosis
• Desquamative interstitial pneumonitis (DIP)
• Anthracosis
• Smoking cessation is also a recommended part of treatment for most interstitial lung diseases to improve overall lung function and to decrease risk of developing a concurrent lung cancer.
• Pneumothorax
• Specifically linked to primary spontaneous pneumothoraces
• Bronchiectasis
• Pneumonia
• Bronchiolitis
• Lung cancer
•  Gastrointestinal
• Barrett's esophagus
• Peptic Ulcer Disease (PUD)
• Particularly gastric ulcers
• Acute gastritis
• Esophagitis
• Gastroesophageal Reflux Disease (GERD)
• Crohn's disease
• Esophageal cancer
• Pancreatic cancer
• Gastric cancer
• Small bowel cancer
• Colon cancer
• Rectal cancer
• Anal cancer
• Liver cancer 
• Reproductive 
• Female Reproductive System
• Placental abruption (aka abruptio placentae)
• Ectopic pregnancy
• Breast cancer
• Uterine cancer
• Pelvic inflammatory disease (PID)
• Male Reproductive System
• Erectile Dysfunction (ED)
• Both genders
• Infertility
• Musculoskeletal
• Osteoporosis
• Medial Epicondylitis (i.e. "golfer's elbow")
• Lateral Epicondylitis (i.e. "tennis elbow")
• Lymphatic
• Acute Myeloid Leukemia (AML)
• Nodular Lymphocyte-Predominant Hogkins Lymphoma
• Head, Ear, Eyes, Nose, and Throat (HEENT)
• Acute otitis media (AOM)
• Seen in infants due to second-hand smoke
• Tinnitus
• Eustachian tube dysfunction
• Rhinosinusitis
• Chronic pharyngitis
• Peritonsillar abscess
• Laryngitis
• Reinke's edema
• Vocal cord polyps
• "Singer's Nodules"
• Blepharitis
• Retinal artery occlusion
• Cataracts
• Macular degeneration
• Periodontal disease
• Oral leukoplakia
• Hairy tongue
• Laryngeal cancer
• Nasopharyngeal cancer
• Oral cavity cancer
• Oropharyngeal cancer
• Neurological
• Complex Regional Pain Syndrome (CRPS)
• Migraine
• Renal/urinary
• Bladder cancer
• Kidney cancer
• Rheumatological
• Buerger disease
• Systemic Lupus Erythematosus (SLE)
• Raynaud phenomenon 
• Giant Cell Arteritis (GCA aka temporal arteritis)
• Rheumatoid Arthritis (RA)
• Miscellaneous
• Sleep disorders in the elderly
• Skin cancer
• Hiccups
• Incisional hernias
• Increased surgery complications and recovery times 
• Sudden Infant Death Syndrome (SIDS)
• Increased risk in infants exposed to cigarette smoke
• Common cold

     If you are a parent, please be aware that second-hand smoke can have a big effect on your children, so do not smoke around them. You should also be aware, however, of the dangers of third-hand smoke. Third-hand smoke is essentially the residue left on surfaces by cigarette smoke. It's not a big deal for most adults, but for small children who touch everything and also put their hands into their mouths without washing them, this is another way for them to take cigarette smoke into their bodies. That being the case, please don't smoke inside, even if you don't smoke when your kids are around. 

     If you're interested in quitting smoking, and thus reducing your risk of getting anything I've listed, here are some resources for you:

• The toll-free number from the National Cancer Institute is 1-800-QUIT-NOW 
• For information about quitlines, see here. 
• For your state quitline, see here. 
• For the American Lung Association, see here. 
• For information about quitting and access to quitting apps, see here. 
• For information about your quitting options, see here. 

Life is Open Book: Family Medicine (28/30)

I do miss having this as a view on my commute to work.

These two are alright.

     I've mentioned in previous posts that an important part of clinical rotations is learning to be flexible. This was certainly true regarding my rotation for Medicine 2*. I had originally been scheduled to return to my Primary Care site for a second rotation there, but plans don't always go the way they're supposed to, and, before my initial Primary Care rotation was even over, I found myself working together with my clinical coordinators to find a new site for Medicine 2. As luck would have it, my Medicine 2 rotation was scheduled for the first block after Christmas break, and my coordinators were completely willing to let me pursue a rotation back in Oregon, which meant that I could come back for the holidays and stay for 2 months. It took about 6 months to get all the pieces in place, with multiple people on both sides of the country working tirelessly to make the rotation a reality, and I technically didn't receive the final stamp of approval until just 4 days before my rotation was scheduled to start, but it all went through in the end, which is how I found myself doing Family Medicine in Oregon this January. 

I do not get to see my cousin, or her
kiddos, nearly enough.

     Having almost two full months in Oregon was wonderful. This meant that, even before I started my rotation, I had my own form of "family medicine." I was able to not only live at home with my parents and sister (and kitty!), but also see all my grandparents (even getting to celebrate one grandma's 88th birthday), and much of my extended family. The last time I'd seen my cousin's boys was last Christmas, which was much too long ago (especially given how fast kids grow), but being home for my rotation meant I got to play around with them on two separate visits! I not only had quality time with family, but I was able to catch up with friends, some of whom I hadn't seen in years. Having two months in which to see everyone was so much nicer than trying to cram all the visits into 7-10 short days like I usually have to do. I certainly had less time to hang out once my rotation started, but it was alright because family medicine was quite enjoyable, and chock-full of important lessons, some of which were new, and some which I simply needed to re-learn.

MAs are also super helpful
with doing procedures like
orthostatic vital signs.

     One important lesson I was reminded of was to learn from everyone around you. As students we know (or at least we should know) that we have much to learn from our patients and our preceptors, be they PAs or physicians. Sometimes, however, we forget that there are many more people who can teach us, and, as an introvert, it can be difficult for me to reach outside my comfort zone to talk to yet another unfamiliar person. It's worth it though. Especially when you're a student or new provider, the wisdom that can be gleaned from the MAs, nurses, floor managers, etc. is invaluable. During my first two weeks in family medicine I often worked with an MA who gave me her spiel on each patient before I went to see them. She'd been an MA long enough that she was often quite good at guessing common diagnoses and she usually added a couple tidbits about the patient's personality or attitude. Even if I didn't always agree with her proposed diagnosis or interpretation of the patient's character, I still found her insights helpful, I loved that she prepared patients to be seen by me, and it was always nice to be forewarned when a patient was hostile. 

Picture taken with patient's permission.
I took that hook out, and the next
day removed another foreign
body from an ear.

     Another thing I needed to be reminded of was that sometimes Nike is right; sometimes you need to just do it. In the case of family medicine, this meant being willing to do new procedures and see unusual or difficult patients. Both the PAs I worked with during family medicine performed procedures and provided cross-coverage care  for their practices. This kept the days interesting, as the regular routine of patient visits was broken up by small procedures like skin biopsies or joint injections, and even the regular patient visits were often surprises since many were same day appointments or walk-ins. I'd done plenty of joint injections during my orthopedic rotation, but family medicine was the first time I'd done trigger point, bursa, or tendon sheath injections, and I certainly hadn't done any skin biopsies or fishing hook removals on my previous rotations. It's always a bit nerve-wracking to try something new, and often the desire to learn a new skill is dampened by the fear of failure or disappointing your preceptor. The fact is though, you'll never learn if you never try, and sometimes you have to just be bold and do it. Now, obviously, this doesn't mean that any time a preceptor offers to let you do a procedure you just waltz right in without preparation or supervision. For the trigger point and bursa injections, I followed the "see one, do one" pattern. For my punch biopsy though, my preceptor talked me through the steps before I entered the room, and then watched me do it, providing additional coaching as needed. I'm glad I didn't demand to see one first as that was the only punch biopsy we did, and it's really something you can only learn by doing. Sometimes I was nervous, but both my preceptors were great coaches and pushed me when I was hesitant, usually proving that I was more competent than I'd realized. I say usually because no learning process is ever mistake free. My first shave biopsy was excellent, and I think I definitely got the hang of toenail removals, but the first time I froze a wart on someone other than myself I managed to give them a blister because I had not yet mastered the staccato pattern of administering the freezing spray, which is so necessary to keeping the affected area small. I felt awful when the patient returned with their blistered foot the next day. I still feel awful, and I was definitely reluctant to try freezing the next wart that came through. But I did. You have to. You cannot be paralyzed by fear of failing when learning; you simply have to make sure that you are learning new skills in a safe manner, under guidance, and that you minimize the risk of damages as much as possible. When you do mess up (and you will), apologize and learn.

Impromptu lessons on alveoli and pulmonary
vasculature in different disease states.

     The last lesson I learned was one I really should have known already. In fact, before I started clinical rotations, PA students from the year ahead of me met with my class and even told us about it. The lesson? Admit when you don't know an answer. Now, I've known for a long time how important it is to know what you don't know, and I've certainly made it a point to look up anything I didn't know right away, but admitting when you have no clue is easier said than done. In school you cannot simply leave a question blank on a test or say "I don't know" in the middle of a practical exam, so when stumped you get into a habit of throwing out answers and demonstrating your train of thought, hoping to get partial credit, and it's hard to fight the training of always needing an answer. One of the doctors I worked with during my first two weeks figured this out about me very quickly. He then made a point of asking me questions to which he knew that I did not know the answer, just to see how long it would take me to say, "I don't know." 

A walk-in patient we promptly sent to the ED. The right
picture was taken first, and shows a pneumothorax in
his right lung. 

     In the instance I remember best, he'd asked me to see a patient who had been scratched by a monkey on a visit to a southeast Asian country, and then asked me what we should do with her. I was at a loss. In my head, I was planning to look up the shot she'd been given shortly after the incident to determine what it was and whether she needed more, followed by further investigation into what foreign illnesses were endemic to that area, but the truth is that I could not give any definitive answer as to the plan until I knew more information. Rather than simply saying that I didn't know and needed to get more information, I rattled off what I did know: the incident happened 3 weeks ago, the wound was well healed without any sign of infection, and the patient seemed completely healthy and without any systemic symptoms. The doctor was in the middle of asking me if, based on that, I really thought she could just be sent home, when his phone rang. It was the Infectious Disease consult he'd requested while I was in seeing the patient. The point of his lesson was immediately clear: even physicians who have been practicing for years need to ask for help, or, as he put it, "life is open book. Use your resources." I'll admit that there were still times during the rest of the rotation when I struggled to provide an answer rather than asking for a minute to do some quick research first but I did learn. In an interesting twist, I even discovered that you sort of can answer "I don't know" on an exam in PA school. When I did my OSCE,* I forgot to ask my "patient" one part of her history. It didn't actually affect her diagnosis or treatment, but when my proctor asked me a question that related to this information, I had to answer with, "I don't know, but I can ask the patient." My proctor smiled, thanked me for not making up the information, and passed me. In medicine, as well as the rest of life, honesty (and humility) really is the best policy. Acting the "cowboy" might save you some embarrassment, briefly, but sooner or later, it will hurt your patients.
     There are far more lessons I learned, and far more stories I could tell, but time grows short and this post grows long, so instead I'll simply leave you with this bit of advice from my beloved Dutch Bros Coffee: 

*All PA students are required to have two rotations in general medicine, one of which should be inpatient, usually internal medicine. The second is more flexible and can be in anything from primary care to family medicine to women's health to rehab to geriatrics, as long as it's not overly specialized. 
*Objective Structured Clinical Examination -basically a practical skills exam that all medical and PA students have to perform and pass in order to graduate. Part of it includes performing aspects of the physical exam as instructed, and another part is taking the patient's history, asking for the physical exam and lab findings (without actually performing the exam), and presenting your assessment and plan to both the proctor and the patient in medical and then layman's terminology.

Dem Bones: Orthopedics Elective

     I'm already starting week 3 of my eighth rotation, but it's taken me until now to finally finish writing about my sixth rotation: my elective in orthopedics. I will admit that when I initially ranked orthopedics as a high preference for my elective rotation, I did it primarily because the rotation site was only 3 miles from my apartment, and I'll also admit that it was so very nice to have such a short commute, especially after months of commutes that usually lasted an hour (if not two) each way. However, in my life I have often found that some of the things I've done for purely practical (or at least not lofty) motives, have sometimes turned out to be some of the best things I've done. I think this was the case with my orthopedics rotation, which quickly became one of my favorites. 

     The biggest factor in my enjoyment of this rotation came from the people there. The practice was made up of both PAs and MDs, plus the radiologists, scrub techs, and administrative staff, and it often felt like a big family. My very first day I noticed the picture at right and felt put at ease by the obvious sense of humor that seemed to pervade the office. Soon I noticed more and more signs: a My Little Pony sticker on the hand sanitizer, evil eyebrows and mustache on a baby photo, even fart jokes on a calendar. I learned that practical jokes happened fairly often, and that, once everyone was comfortable with you, sarcastic and snarky quips would be headed your way. It was great. It frequently felt like I was back at the coffee shop with my wonderful coworkers there but, instead of catering to customers, I was caring for patients. It was truly the people who made this rotation so enjoyable, and after emergency medicine, where I'd had a different preceptor almost every shift (which made it difficult to know and become comfortable with any of them), it was a relief to feel relaxed and like I belonged. As I'm now looking at applying for jobs and beginning my life as a PA-C, this rotation was an excellent reminder that the people you work with can make or break a position. Before this rotation I had not been particularly interested in orthopedics, but I began to think that it was maybe something I should look into, if only so that I could work in such an environment with such people. 

Hoppenfeld's, the classic text on orthopedic
examination, has some great illustrations

     It wasn't just the sense of humor and friendliness of the office that was so appealing; everyone was eager to teach. Again, compared to some of my previous rotations, this was a dream come true. Rather than feeling like a nuisance or that my presence only slowed things down, the doctors and PAs took time to train me, going over the way they performed exams or presented patients or did procedures. I think it worked out pretty well for everyone, because by the end of the rotation I began to function similarly to one of the PAs employed by the practice. I would see patients, presenting them to my supervisor with my assessment and plan, and would move on to see the next patient while they checked out my first. Then, by the time they finished, I was prepared with the next patient and could keep things moving smoothly. Obviously I was still learning and I wasn't correct 100% of the time, but it certainly boosts your confidence to have the MD or PA come out of the room and say, "I agree with what your assessment. Go give them a shot/PT referral/prescription/etc." If I was off, they always made sure to explain why they thought differently and went over any exam findings I missed or extra tests I could have done to get a better differential. It was excellent. 

This doctor looks way too pleased to be
palpating some glutes.

     Another things my preceptors did wonderfully? They made their patients active participants in their care and made sure their voices were heard. One thing you definitely notice in medicine is that patients can often fall into one of two extremes: either they have little to no trust for any clinicians (sometimes reasonable, and sometimes not), or they put all their trust in their clinicians and prefer not to make any decisions themselves. There are frustrations to dealing with both kinds of patients, but whether the patient assumes that a provider is only suggesting a treatment because they're greedy and want money, or the patient is prepared to let the provider make any and all decisions, it's important to hear from the patient and get a sense of what was most important to them when it came to their issues and treatment. This was often obvious in orthopedics. If a patient came in with horrible arthritis of their knees, we could be fairly certain that NSAIDs and cortisone injections might help to keep the pain under control, but they wouldn't cure the problem, and that a knee replacement would probably be needed in the future. The question was most often when, not if. However, the timing of such an operation was not really a question we could answer. We needed to know if the patient could take time off from work, could get help while they recovered, and if the surgery would allow them to continue to participate in the activities they enjoyed. The question tended to come down to "how does this pain affect the life of the patient, and when do the cons of the surgery become less than the cons of life without it?" Only the patient could answer that. We could provide information (e.g. how long the recovery time was, what the chances of improvement were, how long the alternative therapies might work, what activities will be limited after a replacement) and advice, but, though some patients asked, we could not make that choice for them. I really appreciated how the MDs and PAs were willing to have these conversations, often multiple times, so that the patients had a chance to ask all their questions, voice all their concerns, and express their values. It might have required more time and effort, but I think it was best for everyone in the long run, especially the patients. 

This is not normal. Just FYI.

     One last kernel of wisdom I learned during my time in orthopedics, which is relevant to both patients and clinicians, is that you "treat the patient, not the imaging." Many times we had patients who came in and thought if they just had an x-ray or a CT or an MRI, their problem would be obvious, and they sometimes became upset that we insisted on taking a history and doing a physical exam. The truth that we had to explain to them was that imaging gives us just that: an image, a picture of their anatomy. It doesn't come with a diagnosis written at the top, and even when radiologists provide a report, they are rarely 100% certain of the diagnosis. Often a read comes back that says something like, "abnormalities consistent with a or b, but c, d, or e cannot be excluded at this time. Please correlate with clinical exam." Certainly there are times when the imaging seems obvious, but even then the history and exam are important. Time after time we'd see an x-ray that showed horrible arthritis or bunions, only to discover that it was the other foot or knee, or even something entirely different, that actually bothered the patient. Sometimes we had the opposite problem: someone's x-ray seemed normal, but they were in horrible pain or had lost function of a joint. Those were often harder discussions. We'd have to explain that all imaging is limited, each imaging modality is better for different things (e.g. x-rays are great for bones but not soft tissues), some abnormalities in anatomy don't even show up in imaging right away, and that, all too often, getting the imaging doesn't change how we treat the problem. These hard discussions seemed to come up most frequently with spine patients. Those patients often had very painful problems, but the treatments we have for back issues are still rather limited or take a good deal of time, so it was understandable that they were eager to have any and every imaging if it meant finding a solution for their pain. Sadly, imaging for spine problems isn't always helpful or justified, or at least not right away, so frequently we had to give the hard and disappointing answer. Whether you're a PA, MD, NP, nurse, etc., most of us went into medicine to help and to heal, which makes it so much harder when our options to do just that are limited, or when the timeline is longer than we'd like. This is the situation we clinicians live in, however, and until someone figures out how to cure every ailment in the world, we have to acknowledge these difficult issues, be honest with our patients when they arise, explain all the options, and then work with our patients to do whatever we can to aid healing and alleviate pain. It's not always easy to do, but it can be done, as my time in orthopedics showed me over and over again. 

Lent 2016 (27/30)

     This Wednesday I will leave Oregon after a lovely Christmas break and wonderful rotation in family medicine, and return to snowy Boston. I will also be celebrating Ash Wednesday, the beginning of Lent. I grew up in "low" churches that did not celebrate the seasons of the church year, so as an adult who now tries to incorporate some of these traditions into my life, Lent can feel like a fresh and interesting way to connect more deeply with God, as well as with the Christian community as a whole. However, I know people who've grown up in churches where traditions are followed, but only after these traditions have been stripped of all meaning, joy, and purpose, and I can understand why people who have experienced this might be reluctant to participate in Lent, or anything that resembles empty traditionalism or legalism. All good things have the potential to be corrupted and twisted, and the traditions of the church are no exception. To those people though, I'd like to recommend that they give it another chance. Look into the history of Lent, its origins and original intent. See as a time of preparation, self-reflection, and joining not just in the sufferings of Christ, but in the shared experience of Christians throughout the world and throughout the ages. I'd also give the same advice to those who have never celebrated Lent before, though I'd add that perhaps it might be best to start slow and to seek guidance from those who have done this already.
     Whether you're new to Lent or have been observing it your whole life, I have a few suggestions of ways you can celebrate it this year. As I'm in the middle of clinical rotations right now and my life is pretty packed, I don't have the time to write a post quite as large as the one I did last year. Instead, I plan to update and reemphasize some things for this year, and I'd suggest that anyone looking for further ideas or guidance go to my post from last year: 40 Ideas for Lent (just be aware that some of my comments are a year old and a few cultural references I make are no longer valid) or to some of the links I include at the end of this post. I'll admit that some of my ideas for this year are colored by the fact that, for Americans at least, 2016 is an election year. To me, that makes the idea of a time of self-reflection and confession even more important than it usually is. And now, without further ado, my top recommendations for Lent this year: 

• If you give something up, make it count -This means not only deciding to fast from something that will actually be a sacrifice for you (e.g. giving up asparagus is not a sacrifice if you hate all vegetables anyway), but finding ways to take the time, energy, and money that would have gone toward your chosen sacrifice and redirect it toward something good. In the past, when people fasted from meat on Fridays (or all through Lent), they could take the money that would have been used to purchase meat and instead give it away as alms. Blood: Water Mission (who have also created a prayer book for Lent) is encouraging people to give up all beverages except water for Lent, and then to donate their saved money toward building a well in a community in Africa. If this is something that interests you, you can set up an account with them and track your donation. Other people can choose to support you and add to your donation, or, if you have a competitive spirit and prefer to make life a game, you can join with others to create a team and compete to see who can raise the most. Alternatively, the book A Place at the Table gives ideas of how to live in solidarity with the poor for 40 days, and then donate the money you save to charities and organizations who help these same people. 
• Try a spiritual discipline -The 12 spiritual disciplines suggested by Richard Foster are prayer, meditation, fasting, studying, submission, solitude, simplicity, service, confession, guidance, celebration, and worship. Dallas Willard's list is similar, but slightly different. His highlighted disciplines are solitude, silence, fasting, frugality, chastity, secrecy, sacrifice, study, worship, celebration, service, prayer, fellowship, confession, and submission. Other disciplines, like hospitality and observing the Sabbath, are also common suggestions. I wouldn't try tackling a set of twelve, or all the ones suggested here, during Lent, since there's not enough time to do them all justice and you'll just get stressed out, but perhaps you could pick just one or two to focus on. For suggestions and guidance, you could read one of the linked books by Foster or Willard, or Jana Riess' account of trying to do 12 disciplines in one year. You could also try reading just a book or two that focuses on the discipline you choose. I don't have a good list of suggestions for that yet, but I'm practicing one spiritual discipline each month this year, and with that I'm trying to read at least one book for each discipline during the month I focus on it, so hopefully by next Lent I'll have some good recommendations.  
• Read a Gospel (or four) -N.T. Wright has done three great devotionals for Lent, each based on one of the synoptic gospels, so any of the three could be an excellent choice to guide you this season. You can also choose one gospel to read on your own, or perhaps read all four. As you go through the gospels, I'd challenge you to come up with some questions to ask yourself and focus your studies. Some suggestions could be: What did Jesus focus on? Which topics did He talk about the most? With whom did He become angry? With whom was He most gentle? What practices did He follow that you wish to emulate? What aspects of your life should you change to be more like Him? As we are in an election year, perhaps you could ask yourself some questions like the following: How did Jesus interact with the government of His time? In what ways was His death driven by political motives? What would He consider to be the most pressing issue of His time, or of our time? If I heard Jesus make some of the statements made by some of this year's candidates, would that seem fitting or disturbing?* 

• Try to see another side -Lent is traditionally a time of self-reflection, and I think a large part of this can be to challenge yourself with differing views. Humans are prone to many biases, including selection bias (purposely selecting only the data with which you agree) and confirmation bias (only interpreting data in a way that fit your preconceptions), and both biases can make self-reflection and personal growth difficult (after all, why change if everyone around me agrees with me and says I'm doing everything correctly?). As a countermeasure, perhaps this Lent you could set out to purposely hear from others who might disagree with you. I'm not saying you'll necessarily change your mind, but trying to understand why someone holds a differing viewpoint will guard against the assumptions that everyone thinks as you do, or that everyone who doesn't agree with you is a fool. Whether or not your position changes, truly wrestling with the other side of an issue will likely make you more empathetic, reveal some strengths of the other view, and make you reevaluate just how valid your own position is. This seems particularly important this year. I think we'd all like a lot more respectful debates and a lot less mud slinging and name-calling out of our politicians, no matter which party you below to. So how do you do this (for my examples, I'm mostly referring to discussions of different issues within Christianity, though the principles can apply to issues in other realms as well)? One way is to pick a specific issue (e.g. non-violence, women in leadership, homosexuality, etc.) and find a book or blog written by someone whose stance differs from yours (I have suggestions for particular topics for anyone who is interested). You can also change the time period of the authors you usually read. If, for example, you normally gravitate toward Lewis or Bonhoeffer, perhaps try reading works from the first centuries of the church. If you love reading works by the Puritans, try reading some Progressive authors. You could also stick to the same time period but switch the authors, like reading the Desert Mothers rather than the Desert Fathers. 
• Visit another church -This is sort of along the lines of the previous suggestion, though the purpose would be less to change your stance on a particular issue, and more experience the varied expressions of the Christian faith and to understand that just because your church has "always done it this way" does not mean it's the only way. Many churches collaborate during Lent (like the Catholic and Episcopalian churches of my hometown that share a Stations of the Cross), so it might not even be difficult to find an opportunity to do this. I especially suggest this if you're from a "low" church and have never experienced a "high" church celebration of Lent and Easter. Not everyone likes the "smells and bells" approach, but I still think there's something significant and beautiful to Catholics performing baptisms as part of the celebration of Christ's resurrection, or the Greek Orthodox standing in darkness on the night of Holy Saturday, waiting for midnight to strike and the Light (in the form of candles held by the priests) to reenter the world on Easter morning. Experiencing different traditions might just develop within you a new appreciation for your brothers and sisters, and/or deepen your own worship.

     Sarah Bessey gives a beautiful explanation of why Lent is important to her, and provides some great resources for people looking to celebrate it, in her blog post "Why Lent is Matters to Me." For a discussion of human biases and ideas on how to see "the Other Side," I recommend this podcast episode from Don't Feed the Trolls. For reading suggestions, this post, and the comments on it, include some excellent suggestions: Lent: Book Recommendations. This website also has some suggestions specific to Lent 2010, but it's a pretty great overview of Lent and includes some excellent, and simple, suggestions: Lent 2010. Finally, here are some more book suggestions, though, with the exception of The Grand Paradox, I suggest these based on the recommendations of others, and not my own experience. 

• Bread and Wine: Readings for Lent and Easter
• God For Us: Rediscovering the Meaning of Lent and Easter
• A World Worth Saving: Lenten Spiritual Practices for Action
• Forgiveness: A Lenten Study
• Hidden in Christ: Living As God's Beloved
• The Grand Paradox: The Messiness of Life, the Mystery of God, and the Necessity of Faith
• The Kingdom and the Cross
• The Ignation Workout for Lent: 40 Days of Prayer, Reflection, and Action
• Small Surrenders: A Lenten Journey
• The Way of the Heart: The Spirituality of the Desert Fathers and Mothers
• Fasting: Spiritual Freedom Beyond Our Appetites
• Journey to Easter: Spiritual Reflections on the Lenten Season

*For anyone wondering just what that would look like, Jimmy Kimmel has done his own take, and I think by watching the video you can guess my opinion on whether or not these politicians' statements are fitting or disturbing.