PA profession, the AAPA's annual IMPACT conference is like Thanksgiving Day
wrapped in Halloween and smothered in the Fourth of July. It really is the
center of the social, educational and leadership universe around which the rest
of the PA calendar rotates. If you don't believe me, ask anyone who ventured to
Vegas two years ago (what happened there, stayed there) or stamped their
passport last year for a Toronto trek. If they can't convince you, here are four
more reasons to go to Washington, D.C. this year for the event your classmates
and coworkers will be talking about.
- The Social
Network - The
IMPACT conference produces a mob of people who have one big thing in
common with you and a million cool differences to share. This diverse
group of people takes time off work and school to fly across the country
and socialize with strangers. And you better believe we have fun. I still
keep in touch with dozens of friends I met at conferences. If you show up
alone, you will leave with a gang of friends. Guaranteed. (And just in
case, you can find me on Twitter for a meet-up @harrisonreedpa)
- Take Me To
Your Leaders -
The IMPACT conference is your best opportunity to get in touch with the
leadership of the PA profession. Past conferences have featured town-hall
style "listening sessions" with the AAPA president. The House of Delegates
debates important professional topics in an open forum and then puts them
to a vote. The Student Academy holds open elections for its board positions.
You may even bump into your AAPA CEO between lectures. (In fact, I first
met the wonderful folks at ADVANCE
at the Toronto IMPACT conference last year). If you ever wanted to be
involved in shaping the future of the profession, here is your chance.
- The Gauntlet
Has Been Thrown -
Two words: Challenge Bowl. This
medical knowledge battle royale between PA programs draws a huge crowd. As
a proud former competitor for Yale, I can honestly say this was one of the
most thrilling moments of my PA student career. Put on your school's gear
and cheer for your alma mater. Even the Challenge Bowl powerhouses aren't
safe anymore. Last year's contest featured a huge upset victory for the
young Nova Southeastern Jacksonville program. Who will take the crown in
Washington D.C.- The
AAPA couldn't have picked a better host city for this year's conference. Washington
D.C. finds plenty of ways to entertain. Between the world-famous monuments
and enthralling museums, you can visit many attractions without spending a
dime. Add fantastic restaurants and a vibrant nightlife and you might
struggle to make it to the conference lectures. After you grab all of your
CME and scream your lungs out at the challenge bowl, relax at the
Smithsonian Museum and grab a drink at Dupont Circle. Besides, spending
Memorial Day weekend in Washington: You can't get much more patriotic than
free to share your favorite reason for attending the IMPACT conference!
If the Medical Intensive Care Unit has a scoreboard,
I don't want to see it. Some days it feels like the home team always loses. Patients
that look like they are about to recover take a nosedive. The real fighters
eventually give up. The most hopeful clinicians must face the grim inevitable.
But sometimes you just need one, good victory.
"The way I look at it, every patient who comes into
this ICU should die." My colleague's comment may have sounded harsh but I knew
exactly what he meant. You don't get a ticket into intensive care unless you
have a serious problem.
If people that sick were left on their own, none of
them would make it. Everyone we save is a bonus. That thought comforts us a
little when a patient arrives at the end of their long journey with disease.
But it brings a different feeling when we treat a 20-something-year-old in
His family shook their heads, wondered how he got
here, and looked at me for answers. Just last week, they said, he was outside
playing soccer. Then he was in the ICU with a tube down his throat, breathing
on a machine.
All of this from the flu? The flu? One doctor at a hospital hundreds of miles away had already
given them the "There's Nothing More We Can Do" speech. I've given it myself. It's
hard enough when the patient is an elderly woman with advanced cancer. But someone
my own age? I like to avoid that discussion.
The kid's one shot is to load all of that expensive
equipment onto a jet and fly him to my ICU. We are a magnet for the nation's
sickest patients. Tilt that scoreboard a little more against us.
But that also means, in our ICU, this guy stands
out. He is stronger and more resilient than any other patient. We pour
sedatives into his blood but he still fights against his ventilator with
rebellious breaths. We finally paralyze him to keep the air going in and out in
Two weeks pass and my patient's sister and mother spend
every day at his side. I rotate to a different team with different patients but
I still visit the young man every day. His sister says he makes friends everywhere
goes. I realize she's right. Soon, surgeons open a tracheostomy and pass the
ventilator's tube through the hole in his neck, just in case this goes on for
But one day I walk into his room and he turns his
head to look at me. I introduce myself and he raises one unsteady arm, trailing
IV lines, to shake my hand. I thank him for being so strong and he nods. Then
his lips move to form silent words.
"Where am I from?" He nods and I sit at his bedside.
"I'm from Florida, actually," I say. "It's really nice there this time of year.
Let me tell you all about it."
Finally, a victory.
Since graduation, I've had plenty of reminders - good and bad - that I am no longer a student. There is the "PA-C" behind my name and my shiny new state license. A paycheck arrives every two weeks like an airplane dropping supplies on a desert island. And, of course, I now hold myself to an even higher professional standard.
While these changes are pivotal and exciting (and the basis of this entire blog), part of me will always be a student. Any dedicated PA will agree: In medicine you are either learning something new or you are falling behind. We are all required to obtain continuing medical education (CME) hours to maintain our certification. But at this early stage of my career I feel like I need to do more. There are several ways I have tried to get a jump start on the ICU's steep learning curve.
A wise co-worker told me: "Treat this first year like a residency." At a large teaching hospital, there is no shortage of opportunities to do just that. Every day attending physicians, fellows, residents and PAs/NPs round on our patients as a team. Case discussions often break into impromptu lectures or discussions of practice-changing studies. The presence of residents ensures a persistent teaching environment. PAs can jump into as many or as few of these discussions as they choose. Fellows also provide a formal daily lecture for residents. The content and depth is often perfect for a new graduate PA.
When the resident lectures become repetitive, new PAs can participate in Fellow Education Days. We are excused from the ICU for an entire day to attend fellowship-level lectures and discussions from our hospital's expert staff as well as visiting lecturers from around the world. These dedicated learning days are an excellent way to foster expertise in PAs who otherwise do not receive formal specialty training.
Sometimes you can't sit back and wait for education opportunities to materialize. To supplement my on-the-job training I enrolled in an online critical care course for residents and other clinicians-in-training. I also bought the most popular ICU textbook for more self-directed study. This allows me to focus on a specific topic that relates to one of my patients.
The largest and most popular sources of CME are national conferences. PAs can often accumulate a year's worth of CME hours in a single week. I love the networking opportunities of large events like the AAPA's annual IMPACT conference. But I also plan to attend a specialty-specific conference for critical care providers. This offers specific information related to my specialty and allows me to network with non-PA clinicians.
The expanse of medical information is not just massive; it is ever-changing. A clinician who is not dedicated to constant study and education will always be at a professional disadvantage and, more importantly, will not provide the best care to patients. Feel free to comment and share the ways you stay up-to-date in your field.
We made it through one quarter of my first year as a
physician assistant. Let's take this opportunity to reflect on some of the
lessons learned during my first three months. It's sort of like your boss'
90-day evaluation, but without the sense of impending doom.
is Tough - Whether you are moving into a new career or a new
city (or both at the same time), the shift from student life to professional
life is an imposing obstacle. Don't underestimate this task. Allow yourself
enough time, resources and social support to pull off the big move to PA-C.
Manage your expectations and mentally prepare for the inherent stress of a
major life change.
Carefully - Your first job is not just your gateway to the PA
profession. It can determine the course of the rest of your career. Choose a
job that fits your preferences and personality, offers challenges and learning
opportunities, and creates a teaching-friendly environment for a new grad. A
solid foundation now will launch a successful career.
No Bridges - Every person you have met in the past is
a potential friend, mentor or supporter. Keep your previous relationships
strong even as you forge new ones. (Speaking of which, I need to thank everyone
back at Yale who dropped what they were doing to help me with the state
licensing process.) The PA profession is a small network, so work to keep all
of the bonds you create.
Your Elders - Pay attention to the experienced
coworkers at your new job. Even if they don't have an official role in your
training, they can provide useful insight and support as you orient to the new
environment. And remember these moments when the next rookie shows up in a few
Thank you to everyone who has read and commented on
this blog for the last three months. Coming up next quarter: I begin practice
as a fully licensed PA, attend the national AAPA conference in Washington D.C.
and plan my next international excursion. Stay tuned!
Her only enemy was time. There was too much of it. As my
patient lay in her bed and slowly suffocated, each tick of the clock brought a
desperate battle to stave off panic.
Ms. M had dealt with her difficult lungs for years. Without
explanation, the delicate tissues and air sacs had hardened and scarred; they stiffened
and refused to perform their vital function. For a while the fibrosis merely
hampered her life, stole the small joys and the ease of her breath. But now my
patient's disease had reached a critical point and one thing was clear: her
lungs were killing her.
She arrived in our critical care unit and fought to buy us
time while we worked on the one solution that might save her: a lung
transplant. She lay in bed and gulped air while we ordered tests and requested
imaging. She panted for breath, night and day, while we consulted the
transplant specialists and put a neat little checkmark in every box the massive
surgery required. She gasped for oxygen while we finally listed her for a new
set of lungs.
Lung transplants use a special score, called a lung
allocation score (LAS), to determine the need and urgency of each patient
eligible for new lungs. The highest possible score, indicating the greatest
need for transplant, is 100. Ms. M scored a 95.
Ms. M couldn't help but panic. She had suffered from anxiety
forever but the combination of stopping her usual medications and the struggle
to breathe was too much. She tossed in her bed; the fear burned even more
oxygen. Her nurse gave every medication that was prescribed and called our team
when nothing worked.
When my PA colleague and I entered the room, Ms. M was in
distress. A large plastic mask covered her face from the bridge of her nose to
her chin. The device, a non-invasive positive pressure ventilator, pushed 100%
oxygen into her body with each breath. Under the mask her mouth opened wide and
her lips flapped with the force of flowing air. Her chest, belly and shoulders
heaved and she occasionally flopped her limbs back and forth as if some new
position might relieve her agony.
My colleague explained that any extra movement raised her
oxygen requirements and made her shortness of breath worse. It would help if
she could calm down. She wanted more anxiolytic medications. More drugs could
sedate her and diminish her impulse to breathe, the PA said, and if she didn't
get enough oxygen on her own we would put a tube down her throat to breathe for
her. We need to avoid that at all costs, he said, because an intubation would
severely hurt her chances of a successful lung transplant. She nodded as her
whole body shuddered.
Before we left the room her wide eyes darted to mine. "You
can do this," I said. She held up one hand with the index and middle digits
intertwined. Fingers crossed.
As I walked to the parking garage at the end of the day, Ms.
M continued to fight for air. She struggled while I stopped at a grocery store
on the way home. While I slept in the next day and later went out for dinner,
Ms. M bought herself one more second of life with each terrified gasp. The
seconds became minutes and the minutes became hours and no new lungs arrived.
I was still enjoying my weekend when Ms. M had enough.
Without news of a matching organ, she and her family made a merciful decision.
She removed the breathing mask and died.
This story isn't about a horrific mistake or an unexpected
tragedy. In fact, similar situations occur every day in the ICU. Instead, it is
a reminder that at the end of the day, I clock out and go home but my patients
do not. This doesn't mean I carry every worry of the day home with me. If I do
my job right, I don't have to. But it is worth remembering that even when I take
off my white coat, my patients are still working to stay alive.
You don't have to break the law to fail a
pre-employment drug test. In fact, you could lose your job just by using
countless products hanging on the wall of your local gas station. That's
because at my hospital, when an
employee's urine drops into that little plastic
device during a pre-employment drug screen, it is checked for something more
than cocaine, opiates and marijuana. It is tested for nicotine.
The consequences of the nicotine check are serious. My
employer has decided to not just ban smoking
but smokers. It is part of a push to
put the health back in healthcare workers. Tobacco users are given an
opportunity to quit with the help of employer-provided resources. If their
urine continues to test positive for nicotine metabolites, they must find
This campaign goes beyond tobacco use. The hospital
system made headlines with its efforts to promote a healthy lifestyle for
employees. The CEO expelled fast food chains from the campus food court; for
those that remained, he purged the trans fat. Sugar-laden drinks and snacks
were stripped from vending machines and replaced with healthier alternatives.
The cafeterias overhauled their menus and even the snacks at employee
orientation got a nutritious tweak.
The hospital also focuses on employee fitness. They
provide memberships to Curves gyms and several hospital-owned gyms. Employees
can form work-out teams and record their progress online. Those who take
advantage of these exercise perks make their waistline smaller and their
wallets bigger: participants in any fitness program get slimmer health
These actions generated media attention and a
heaping serving of controversy. Supporters appreciate the convenience of
healthier options; detractors despair over the loss of choices. However, a
larger question is lost in the personal freedom debate: Does a healthy patient
require a healthy provider?
The ability to lead by example certainly has value.
As healthcare providers, we depend on our patients' trust in nearly every
aspect of our jobs. The appearance of hypocrisy on our part damages the
patient-provider relationship. How can a clinician who reeks of cigarettes
counsel a COPD sufferer to quit smoking? How can an obese primary care provider
counsel his diabetic patient to lose weight?
A clinician's appearance, habits or lifestyle does
not affect his clinical knowledge or technical skill. But patients open up the
private details of their lives to medicine's critique. Most assume their
medical providers hold themselves to the same standards as the advice they
give. Granted, it is unlikely a patient will see their clinician lighting up a
cigarette outside of a local bar. However, it is difficult for us to battle
internal hypocrisy and still achieve the sincerity required to change a
Personally, I don't mind the hospital's bold
lifestyle moves. Medical providers are already held to a higher standard than
other professions in countless ways. Perhaps personal health should be one of
them. In the meantime, if I want to eat a cookie, I will bring it from home.
I feel obligated to warn you. I normally don't use this blog
for public service announcements but I learned of a disorder that all of you
will suffer from, if you haven't already. The good news: it doesn't last
forever and there is a treatment.
I am talking about New Graduate Syndrome (NGS). It affects
men and women of all ages after graduation from physician assistant school and
it is debilitating. The etiology of NGS is multifactorial and can vary in each
situation. However, most experts agree that it stems, in part, from No State
License Dysfunction (NSLD).
This primary pathology typically occurs early in the PA's
career but can also emerge later in life during geographic relocations. PAs
suffering from primary NSLD experience the inability to touch patients, perform
procedures or write prescriptions. In most cases, new PAs are unable to begin
work and collect a paycheck. One recent retrospective study linked this
disorder to an increased consumption of Ramen noodles.
A more severe form of New Graduate Syndrome occurs as a
result of No Physician Assistant National Certification Exam. Those with No
PANCE suffer further frustration and social stigma. New graduates who lack the
"-C" at the end of their credentials find they are easily mistaken for cities
and towns in Pennsylvania. For example, I spent a month explaining to confused
travelers that I am a person and not the city of Harrisburg, PA. No PANCE can
be treated by the administration of the national exam, though these treatments
cost nearly $500 each.
Even when No PANCE is successfully treated, the process is
far from over. No State License Dysfunction typically lasts for months while
PAs endure the lengthy therapy. This consists of a series of forms, notaries,
references, notaries for the references, background checks, fingerprinting and
Even when NSLD goes into remission (for only two years in my
state, after which time another round of therapy is needed), NGS rages on. PAs
working at hospitals will continue to experience symptoms until they receive privileging
or credentialing at their place of employment. This takes more applications and
forms leading to sequelae like Carpal Tunnel Syndrome from excessive
Luckily, your future employer is in the business of treating
illness and disability. Many are willing to take in New Graduate Syndrome sufferers.
Good employers will reimburse fees for exams and applications. Great employers
will take you by the hand through the intimidating process. Excellent employers
will pay you while you orient to your new setting and await the completion of
all of these therapies.
I suggest finding an employer who specifically wants someone
with New Graduate Syndrome. Like many genetic disorders, there is an
evolutionary advantage to NGS in spite of all of the symptoms. New grads come
without previous habits, tendencies or clinical bias. They are easily molded by
their clinical environment and tend to adjust quickly to their setting. They
come directly from training and national board certification with the most
current and up-to-date knowledge. Employers who recognize this will deal with
the trouble of NGS in order to train the perfect PA for their position.
As I approached high school graduation years ago, my Health
Careers teacher shared the popular modern parable, Who Moved My Cheese? It is a story about mice and miniature people who
look for cheese (a metaphor for happiness and success) in a maze. Silly, for
sure, but I found that the story's lesson sticks its nose into my life on
occasion. Essentially, the author asserts that change is often the scariest for
those who need it the most; those who resist change are eventually left with a
dwindling supply of smelly, spoiled success.
As you may already have guessed from previous blog entries
posted here or on my semi-retired student blog, PA-Ssed Out I am not the kind
of person who objects to the occasional reshuffling of cheese. On the contrary,
I chased new cheese from the warm comfort of Florida to PA school in
Connecticut and eventually to my first job in the (currently frozen) Midwest.
That is precisely why it surprised me when this most recent transition hit me
like a kick in the teeth.
After a successful migration from Florida in 2010, I felt
bullet-proof as I approached the next jump in my career path. I imagined I would
blast off to success like a rocket leaving the launch pad. I was generous, I
thought, in allotting myself four days to move into a new city in a new state before
starting a new job. I was wrong.
You see, my rocket analogy was much more accurate than I first
realized. When a rocket ignites its engines, it spends an incredible amount of
energy in those first few seconds and it goes nowhere. For all the impressive
fire and smoke, the altitude gained is downright frustrating.
In the same way, I spent the first four days of my new life
stumbling through the snow, looking for a grocery store that I still haven't
found. I slept and ate on the floor while I tried to decide if it was more
important to shop for a bed or a shower curtain. During this time, it struck me
that I had never really accomplished anything like this alone; I always had a
support network, even if I didn't fully appreciate it until they were hundreds
of miles away.
Even though it seems physically improbable, those rockets
always seem to escape Earth's gravity and make it to space. I eventually got a
bed and a shower curtain and even a couch and cable television. And though the
snow is still falling and I don't know anyone for miles around, I find myself
inexplicably happy. The day I have waited years for has finally arrived. This
week, I start my dream job.
Tips for Your
Manage Expectations - Your new life isn't
necessarily bliss from day 1. Expect the path to be littered with obstacles.
Don't look past the "everyday" challenges like assembling furniture, which can
be just as taxing as your new job.
Keep Your Support Close - Even if you have moved
miles away from your family and friends, rely on them for help. A phone call or
email can remind you that you aren't in it alone.
Keep Your Sense of Adventure - Though a career move can be
stressful, it is also full of exciting new opportunities. Look forward to the
positive aspects of change like meeting new friends and coworkers.
Remember Why You Do It - There's a reason we sacrificed so much to train and work in the
healthcare field. Remind yourself how good it feels to help others.
Every day was Groundhog
Day. Well, to be fair it was early January but, like the 1993 Bill Murray
comedy, I felt like I was stuck in a time loop. The high of my graduation
ceremony had worn off weeks ago, so I made like a retired snowbird and headed
south to Florida for the winter. I camped at my mother's house while I waited
for the next stage of my life to begin, aware of the massive obstacle that
stood between me and the start of my new career: the Physician Assistant
National Certification Exam (PANCE).
I thought the strut across stage in my funny cap and
gown marked the end of my study grind, but now I felt like a man wandering the
desert who had just come across his own footprints. Each morning I slapped my
blaring alarm and prepared for the cycle I left behind in PA school. I stuffed
my textbooks into the tattered backpack that had been my extra appendage for
the last two years and faced the inevitable hours of review for the single test
that would determine the rest of my career.
I picked out a corner of the library at the local
community college, a place my academic journey had never before taken me. Now
it was my sanctuary. If I ever thought for a moment that I was better than this
place, it didn't seem to hold a grudge.
I dusted off the study skills that, I must admit, I
never truly honed until I was faced with the avalanche of exams in PA school.
Each day I dug into a new medical topic, prioritizing the subjects that
saturated the PANCE and the ones that were my greatest weaknesses. The relative
footnotes like hematology (3% of the PANCE), I saved for last. Then, after two
weeks of seclusion and countless cups of coffee, I was locked in the steel cage
of the testing center to face my computer-based adversary.
The morning after test day my alarm didn't ring. My
bags weren't packed with books and I didn't order any coffee. I languished.
Because the only thing harder than forcing myself to study every morning was
the purgatory that followed: waiting for the results.
for PANCE Preparation
Your Routine If you are in a different location or
living situation than you were in PA school, it can be even harder to get back
in the swing of studying. Find a quiet place that suits your style and make a
study schedule. Then stick to it.
you're like me, it's been a while since you sat down for a marathon
multiple-choice test. Practice grinding out one or two-hundred multiple choice
questions at a time to get used to the motions. The NCCPA website even has
practice tests that most accurately recreate the PANCE experience (for a fee,
Sweat the Normal Stuff Normal lab values are provided on
test day, from ABGs to CBCs and even BMIs. Don't stress about any you haven't
Early, Bring Food It took a full 30 minutes for my test site
to process the handful of people that had arrived before me. Arrive at least 30
minutes early if you want to get started on time. Also, you will manage your
own break time during the exam (45 minutes divided into 4 breaks as you
choose), so bring snacks to maintain your blood sugar.
The airplane shuddered around me and somewhere in the back a baby began to cry. I looked out of the window, past the carpet of clouds to the countryside that rolled in every direction. The plane shook again, even harder this time, and a few rows away a man cursed. I couldn't help but smile; I always loved the turbulence.
A limousine driver 30,000 feet below waited to take me to a steak dinner at a lavish hotel where my accommodations, like the plane ticket, were compliments of one of the most prestigious hospitals in the world. The next morning, some of the nation's top medical professionals would work to convince me to join their team. It all seemed strange and overwhelming for the son of a single school teacher who had never made more than 10 dollars an hour.
But nothing about the last two years was typical. I had left my home state of Florida while the ink on my Bachelor's diploma was still wet. I entered PA school -and the foreign world of the Ivy League-and was told to learn a medical school curriculum in half the time. I grew up fast; I had to. The lessons of my first year blew by. Twelve months after I arrived I was shoved into the hospital where the drugs, the blood, the scalpels and the patients were real.
Be comfortable being uncomfortable. That was my Zen-like approach to the chaos. Each clinical rotation brought a new environment, new colleagues and new opportunities to learn. Of course, it also meant new challenges tailored to wreck that fragile student self-esteem. The start of every rotation was like the opening to the middle of a book everyone else had already read.
I leaned back into the airplane seat. My gray suit had been crisp and new three years ago when I traveled to my PA school interviews. Now the cuff of the left leg was ragged and there were moth holes in the pants and jacket. I hoped the hospital's top-brass wouldn't notice.
Sure, PA school was a challenge. But students have a security I never really appreciated until it was gone: the expectation of ignorance, of ineptitude and of constant mistakes. When my plane landed and I began shaking hands and answering questions, my potential employers wouldn't see me as a student. They would see a professional PA paid to do a job.
The plane rocked again. Even after a year of constant change, my biggest adjustment is still ahead. Yes, it is the greatest opportunity of my life. My mom would cry tears of joy, my brother would pat my back and my nephew would give me a little smile and eye-twinkle-the look of admiration that always kept me going.
Still, most sane people would be a little scared. A major shake-up is about to hit my life. But that's ok. I always loved the turbulence.