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First Year PA

How to Avoid Absolute Frustration
July 21, 2014 3:02 PM by Caroline Pilgrim

Primary care is so imperfect. Each day I could probably find as many things to complain about as complaints my patients come in with, and I am beginning to see why burnout can occur. That is, if you don't have the right perspective. As I forge ahead on this year-one journey, I am creating tenets to avoid burnout. I'm honestly not a huge believer in self-help or magical powers of positive thinking, but we all function day-to-day with principles and ideas influencing us, whether we admit it or not.  

  • Principle one: Poker face. Laughing on the inside is always acceptable, but patients will say the most outlandish things. "It's easier to get marijuana than an antibiotic so just give me a refill on this amoxicillin." Nope, not gonna do it, honey.
  • Principle two: Customer is not always right. This isn't Burger King, so I actually do have a right to be a little bossy sometimes.

    Patient's wife: "I'm pretty sure my husband had a stroke over the weekend but he refused to get on the ambulance to go to the ER." 
    Me: "Go to ER." 
  • Principle three: Your attending doctor is always right. This is just a trick to make life simpler. With that mindset, there's less frustration.
  • Principle four: Patients seem to respond to, "I am so very sorry for your wait," so I just keep this nice phrase on hand to try to ease the tension when I first walk into an exam room.
  • Principle five: When your staff messes up with just about anything, it's always your fault. Just take the blame when you're the one calling back the patient and they usually take it a bit better coming from you. Blaming others never makes you look good.
  • Principle six: This isn't about the paycheck. I thought getting out of school would end the paycheck-to-paycheck lifestyle, but the tsunami of loan payment hit. This is not about the paycheck. I "like" this job.  It's worth it. I "enjoy" it...most of the time.
  • Principle seven: Only a few more days until the weekend.
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What do you like best about people?
June 23, 2014 9:21 AM by Caroline Pilgrim

What I ask people who are considering PA school or trying to pick a specialty in medicine is that they decide what they like best about people. Do you like it best when people are passed out on the operating table, nonverbal? Do you like people when they're panicked and have chest pain? Do you like people when they are in their last days of life? Do you like people when they're less than 5 pounds and premature? Deciding that can be the difference between misery and fulfillment in a job that took no small sacrifice or student debt to arrive at. 

I personally like people who are verbal, who somewhat know what they want, and are not about to die. I like making decisions, but having a few minutes to reflect while you do is more my style. Then there are times patients think they know what they want, and we have to be the ones to steer them away and encourage the actual evidence-based approach. I have also seen patients this week who are a little too tough.  One patient has been suffering through agonizing abdominal pain all week and refusing to go to the ER. Another younger patient with three open heart surgeries under his belt with chest pain, not cardiac which we confirmed, shows up in the office late one afternoon. I like the tough patients, but it's hard to convince them that there's only so much we can do in an outpatient exam room. Yet I know for every three patients in our office, there are five who actually did go to the hospital for just the common cold.

I hope in my first days in this field to communicate effectively, not act rushed, actually listen, and be clear when I have to give detailed instructions about treatment. Most of the time patient's do want to hear you and do want to at least try your suggestion. I am so thankful that the most frustrating part of medicine is not the people but rather the computers, the insurance companies, the fax machines, and the nagging clocks that remind me how long that patient's been waiting.

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Are your patients “pain points” or people?
June 9, 2014 10:13 AM by Caroline Pilgrim

Going to work full time for the first time in my life felt surprisingly just like the first day of a rotation, except this time I walk into the office and notice my name on the front door at the bottom of the list of providers in the sort of transparent, white print they write those things in on glass. I’ve noticed the past couple of weeks that all my outpatient rotations really prepared me well for interacting with patients and looking at them as whole people. What is different is that I know that I may see these patients again, that I won’t just move on the next month. Amazon.com, a company that has become infamous for its poor treatment of their employees, calls interactions with people “pain points.” In their machine of efficiency, it is vital for them to streamline production so that “pain points” don’t slow down shipments and development especially in their web development sector. I would love to tell an Amazon CEO that my entire life is enriched by “pain points” and I would quit this field if people were ever de-prioritized.

Being a provider forces you to closely examine the medical record: past notes, labs, and procedures. I have found in the middle of very busy day a phrase or a brief encounter with a patient will stop me and strike me with the utter humanness that makes life sad and sweet.

“This patient is a 78 year old Caucasian who is presently living in a motel…”

Or during a patient encounter, “My wife of 28 years wants a divorce because she said she wants to ‘find herself.’  What does it mean to find yourself?”

While doing a physical exam for abdominal pain, “My sister died from an abdominal aneurysm. I have to make sure I don’t have one.”

Just yesterday, “I missed my follow-up in February because my daughter-in-law died… complications of anorexia.”

The appointments are so short yet there is so much in every brief, directed conversation I have each day.

I know it’s not just those who work in medicine who see raw human nature, but I have noticed that in primary care amidst the ‘boredom’ of another upper respiratory infection, another pain seeker, or another general checkup, you can find beauty and pain without even trying. It is there in 15-minute slots in the middle of the best health care system of the world.  It begs the question, “What are we living for?” And we often don’t need to look any further than the next patient to realize living for others is a worthwhile pursuit. Don’t be jaded this week by all the “pain points” but actually realize that in a small way you can alleviate another’s pain. All these patients probably have completely forgotten about the very young brunette in the white coat, but I don’t want to ever forget them.

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Which Diseases Deserve 'Awareness'?
May 22, 2014 10:06 AM by Caroline Pilgrim
May is Cystic Fibrosis Awareness Month, and for my family it is also a month of loss. My family is broken by awareness of this disease and the memory of the wonderful guy we lost last week -- my cousin -- who never once complained about cystic fibrosis and the lifelong struggle he waged against it.

I was supposed to start my new job yesterday and instead I'm going to a funeral. My amazing new attending doctor told me he too has lost someone close to CF. It's a terrible thing to go to a funeral of someone young like you, who had so much vitality and passion for others. Death never leaves us unchanged or unaware. My cousin was passionate about so many things in life, especially sharing Jesus Christ with young people, but he was also passionate about never letting a disease stop him. And even in his passing, CF never beat my cousin. He never let that disease control him.

I always wonder: What diseases merit an "awareness month"? Breast cancer, colon cancer, AIDS, heart disease and leukemia/lymphoma, to name a few. I have seen most of the "awareness month" diseases in loved ones or patients over the years, and my utmost respect is for the 30,000 Americans living with cystic fibrosis. CF isn't a disease that sneaks up on you and your family. It requires constant fighting, vigilance and self-discipline.

CF has come a long way even in my own cousin's lifetime, with new drug developments and a few research breakthroughs. But it's still a rare, recessive genetic disease and pressing Congress for funding remains an uphill battle. A lot of focus is now on lung transplants, which is not always an option for patients.

There are many ways to cope, but I think my cousin would have wanted his family to cope by doing life well - yes, raising awareness about CF, but also enjoying beach vacations, little kids, Frisbee, soccer and coffee. Being aware of a disease requires action at some points and prayers at others. I feel like my battle against CF is just beginning but along the way, there will be coffee and beach weeks, and good memories of a wonderful guy who never let anything stop him.

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Semper Gumby!
April 14, 2014 8:31 AM by Caroline Pilgrim

If there’s one thing most of us learned in our post-graduate training it was “semper Gumby” (translation: always flexible). And I have learned that lesson in my hunt for my first PA job. My last post I boasted on landing a great job serving the underserved but in the words of a good friend, “It seems like the more the organization wants to help ‘needy people,’ the more financial problems they tend to have. And that is what I encountered. That reality translated into the group redacting their offer to me due to “unforeseen financial difficulty” and threw me back into countless hours of online job applications, phone interviews, and email responses.

I am happy to say that currently hold in possession a legally binding contract with a great group that serves their community’s primary care needs in a financially sustainable model. My state license is rolling as is my DEA application.

A few lessons I learned in my job hunt number two that I hope might help you new NPs and PAs land a job efficiently. 

1)      Go to Craigslist.  I applied to at least 50 positions in two weeks.  I had a total of seven interviews and an additional two interview offers and seven out of those nine jobs were found on craigslist.  Most of the phone calls I got back were a result of CVs sent out to craigslist. 

2)      Practices generally are not interested in you if you cannot get to an interview on your own.  I speak as a new grad, but I noticed that having my address on my CV was a negative in getting call backs out-of-state.  I suggest taking off your mailing address if you wish to locate out-of-state.  Obviously, it will come up in a phone interview where you live but removing your address may help get you to that phone interview.

3)      Hospital applications seem to be a black hole unless you know someone who works at the hospital.  I applied through hospitals roughly 15-20 times and never received any response back.  I would love to hear feedback of success with this medium.

4)      Reach out to friends but realize they can only help so much.  I just read “The Defining Decade” by Meg Jay who says to utilize your fringe acquaintances to get a good job.  I took her advice and facebook messaged, emailed, and texted old classmates, relatives and distant “friends” for leads.  A few responded but nothing materialized remotely except my increasing lack of faith in humanity

5)      When you get an offer, ask them to give you at least five business days to decide.  For one position, this gave them time to actually offer me an increase in salary and gave me time to consider the other offer I ended up accepting. 

I have other tips, like how to get through six interviews in three days and still not chuckle with you hear, “What is your greatest weakness?” asked for the sixth time. Or how to survive an 8:30 p.m. interview (that was supposed to be at 7 p.m.) at the most disorganized practice you have ever seen. But I will leave those for another discussion.

I am new at this job search business so comments from human resource experts on do’s and don’ts appreciated.

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Never Give In
March 6, 2014 12:32 PM by Caroline Pilgrim

"Never give in, never give in, never, never, never-in nothing, great or small, large or petty - never give in except to convictions of honour and good sense.  Never yield to force; never yield to the apparently overwhelming might of the enemy."  - Sir Winston Churchill

If you are a new grad and you haven't nailed down a job yet, I don't doubt you feel like you have applied everywhere. You have scoured the internet's most popular resources: paworld.net, healthecareers, indeed, doccafe, craigslist, pajobsite, and even our own ADVANCE.

You get calls from recruiters daily. You have emailed all those weird friends of your parents who "might be able to help." By Facebook stalking friends from undergrad, you realized two of them live in the city you're trying to relocate to. "Will messaging them make me seem as desperate as I feel?" you wonder. 

Maybe you got an interview offer but it was in bariatric surgery and you realized that you love tackling public health issues like obesity, but not when the issue is 400 pounds on the operating table with you assisting the surgeon. 

Or your recruiters would love to get you set up with a practice "near" a major city which turns out to be in one of America's most rural counties and a two hour drive from a Target. All your colleagues somehow got their dream jobs, right? A cushy dermatology gig or a fellowship that pays off their loans; meanwhile, your credit card is maxed out for the tenth time since you started grad school and you're asking for a loan from your grandma. 

Maybe you interviewed at three places but none of them called you back and you are on the verge of annoying the office secretaries into making the no-hire decision on you. How far is too far?

Perhaps you have woken up in the middle of the night in a panic and checked your LinkedIn app and realized that no one who would even know what "ACLS" is has endorsed your skill. Just your dad. "Maybe that's why I don't get calls back," you think.  

You keep reminding yourself of all your friends who are Starbucks baristas because they got a master's degree in Medieval English; not you, and you chose a highly marketable skill. But no sooner do you think that until that causes you to doubt your ticking time bomb of student loans that are four and a half months from suffocating your budget. 

And in long days of internet searching you find yourself Googling, "motivational quotes" and re-realize your love of Winston Churchill and think maybe your English major friend wasn't so crazy after all.

After what seems like months (because it was months), finally, you get a call back from a normal sounding human who asks if you will come interview with the cost of your travel covered even though the recruiter you applied through didn't even give them your CV (that you had spent countless hours polishing). 

They ask you a lot of direct questions, "Well, don't you want to know how much you'll get paid?"  And you answer, "Uh, yeah?" though everything you read on how-to phone interview weblogs said to never ask about salary during a phone interview. 

You fly to the interview, end up getting a free $400 voucher from Delta (that will pay for your flight to your best friend's wedding), and you love the practice. Then you get hired at your dream job and you forget all the self-doubt you had about choosing your career. 

You then spend the next month frantically filling out paperwork and calling a medical board that you are pretty sure has not realized that the internet exists. 

Happy job hunting, friends!

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Until We Meet Again
January 9, 2014 2:45 PM by Harrison Reed
I sat in the airport terminal in November of 2012 and stared at my cell phone. I flicked the screen on and off as I waited out another wave of anxiety. I was about to place a call that would dictate the course of my life. At the time, I could barely comprehend the changes that would take place over the next year.

It would be the year that changed the way I looked at life. The year that changed the way I looked at patients and at medicine. It would be the year that I learned to trust my gut ... that I even had a gut to trust. It would be the year that I learned my own limitations and how to first accept, then overcome them. It would be the year that I would lose someone very dear, but help dozens of strangers overcome that same loss. It would be the year that I befriended death but fell in love with life.

In 2013, I transformed from a scared student to a slightly-less-scared clinician. I became a teacher and a mentor before I even hung my diploma on the wall. I met some colleagues who seemed bent on stopping my progress but many more who supported me like family. I discovered that my passion mattered much more than my age and experience to the patients and families experiencing their own personal hells.

I dipped my toe into the waters of medicine and-without warning-someone pushed me into its depths. I coughed and sputtered and kicked my legs just hard enough to stay afloat. But by the end of the year, I swam.

And, perhaps most important of all, I was privileged to share my experiences with you. This blog has served as an outlet for my triumphs and failures. It has connected me to people around the world who have felt the same fear and pain and elation in their own careers. It, hopefully, can teach future clinicians a few lessons that I only learned through sweat and tears and heartbreak.

The experiences of the first year of clinical practice are invaluable and beyond replication. However, they come at a cost. Like training for a race, the first day is always the hardest. Remain dedicated and persistent. Surround yourself with supporters. Heed helpful criticism. Mute those who detract for their own pleasure. And on the days when you feel beaten down, exhausted and close to failure, just remember that somewhere there is someone grateful that you entered his or her life.

Of course, you will have to figure most of this out for yourself. Because a year ago even this blog would not have prepared me for what lay ahead. I sat in that airport staring at my phone, took a deep breath, hit the "Call" button and waited for the voice on the other end.

"About that job offer," I told the recruiter, " I'll take it."

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The Secret of Death
December 17, 2013 9:56 AM by Harrison Reed
I'm too young for this. That's what everyone says-or at least thinks, the way their eyes track across my features, down to the name on my coat, then back to my face. It's OK. I tell myself that I can earn the respect automatically granted to someone with a few gray hairs. Besides, there's a difference between age and maturity and these days I don't feel young.

It's not that I'm jaded. Far from it. I still care about every patient that rolls into my unit and every family member that shuffles out of its doors. But I watched a man die on Thanksgiving Day. I wrapped my arm around his wife's shoulders-a woman my mother's age-while I switched off his life support and bid farewell to my innocent youth.

Don't feel bad. I know what I write can be a depressing but that's not what I want. Most days I don't even leave work sad. Because every time I see someone die I get a little closer to learning the secret of life.

I've already told you that, in the ICU, the scoreboard is rarely in our favor. I've shifted my goals away from "saving lives," though my mom still thinks that's my job. If it was, I wouldn't be very satisfied. People will die. I've decided to worry less about the existential question of "why" and focus on what I can control, the "how."

I think everyone has some idea in their head about how they would like to die. They might say "in my sleep;" that's always a popular answer. The lack of awareness brings comfort. Most people would choose "painless" and in modern medicine that's easy enough (though the application is often botched). But these answers are reflexive, generated by fear and aimed at avoiding the physically unpleasant.

The next response will be some variation of "surrounded by those I love." Children and grandchildren are often mentioned as well as the companionship of a long-wed spouse.  Ah, now they are starting to get it. These answers aren't offered impulsively for a sense of protection. They come to mind because they represent something else: a sense of accomplishment in life, a completion of purpose.

In a fantasy death, most people are 80 or 90 or even 100 years old. And from what I've seen, the older someone is, the more accepting they are of death. I don't think that the age itself is a comfort or that the number on your birth certificate matters. But even the most deliberate person figures 80 or 90 years is enough time to accomplish the things that matter.

But what about the others? What about the globetrotting businessman in his 60s or the 54-year-old mother of two college students or the 32-year-old who hasn't sent her first daughter off to kindergarten? Surely their greatest deathbed fears revolved around unfinished business. The same reason I had a lump in my throat when they passed.

Now you remember that this wasn't supposed to be a depressing blog and I promised some bigger lesson. Here it is: death will happen and there is no telling when. You can't be angry about death just like you can't be angry about gravity. There is no debate. So don't ask what we will do about death. The real question is: what will we do about life?

The daily brush with mortality has had a strange effect on me. It didn't make me sad or scared or even pessimistic. If anything, it produced the opposite effect. I've started to take a few more risks, have a little more fun. I spend a little more money and eat a little more dessert. I skip the gym on occasion for the opportunity to try something new. And if something scares me, I do it.

If you believe age matters, maybe I really am too young for all of this death. But I'm not afraid of it. I've seen it enough; we are old friends. The only thing I am truly afraid of is not having lived.

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The First Race
December 2, 2013 10:48 AM by Harrison Reed
"There's no way you should look so calm doing that."

Early during the first year of PA school a handful of my classmates had met at the gym before our lectures. One of them looked over the numbers on the display of my treadmill and shook his head.

"If I was doing that right now, I would be in serious pain."

His comment turned up the corner of my mouth in a smile. He couldn't tell but, with the machine set at my race pace, my legs screamed with every stride. My lungs burned. A little stab of pain jabbed my side once and then again. But none of this showed on my face because of one key factor: experience.

I had been there before, hundreds of times. Years of running and dozens of races meant I know how to flirt with the edge of exhaustion. My body could shout at me, warn me of the danger, but it wouldn't cause panic. I knew when to press my pace and I knew how to rest in motion. I knew my abilities and, more importantly, I knew my limits.

New runners often start too fast. They are excited and confident. They haven't failed enough, haven't smacked into a wall down the stretch and watched the competition speed past. And when they near that limit, they panic. They waste the last of their energy and stop in their tracks.

New runners haven't mentally overpowered that physical limit, so they don't know that they can. They don't recognize the positive signals, sensations of "Yes, this works," because they haven't crossed enough finish lines. They can't predict a mistake because they haven't lost enough races.

I began this first year of my career like a new runner. I jumped at the blast of the starting pistol, ignorant to what lay ahead. Far too soon, I encountered obstacles that left me gasping for breath. Some were professional, the gaps in knowledge and expertise. Some were interpersonal, the potholes of workplace politics. Some were emotional, the search for satisfaction in daily tragedy.

The first several months I still doubted if I would make it as a critical care clinician. The occasional awkward stomp of my foot resonated louder than the more frequent precise ones. As my lungs burned from the steep learning incline of this first year the temptation to stop moving, to flop to the ground and attempt some easier path, nearly overpowered me.

Doubled over, hungry for air, I wondered where the finish line stood or how far I had come. I watched more experienced clinicians run past with ease. I thought I was in great shape, smart and well-trained, but they had something I lacked: experience.

I had forgotten a painful lesson I learned as a runner many years ago: the first race is always the hardest.

Recently, though, a strange thing happened. I struggle a little less. Small tasks that once baffled me became just a bit smoother and more natural. I stumbled less and found a better pace. I started to recognize the patterns before me, steered toward the successes I previously found and avoided some of my old mistakes. This somewhat more graceful stride reminded me of another lesson that I had taken for granted: you conserve more energy when you relax.

I started to become familiar with my route. Soon, the ominous twists and turns became more friendly territory. The role of perpetual newcomer I had played as a student in clinical rotations changed. Strangers knew my name. Some of them even asked for my advice and, inexplicably, took it. The road, once crowded with competitors, now seemed packed with teammates.

I know that I am still a novice and the real race is far from over. I have miles and miles to cover before I will feel comfortable with my role. But even the slightest wisp of experience is a wonderful gift. Because if, like my first race, I cross this first-year finish line with sore legs, burning lungs and bleeding knees, I will have passed the hardest miles of my career.

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I Used to Be Afraid
November 15, 2013 8:29 AM by Harrison Reed
I used to be afraid

Cold sweat across my brow

Cotton mouth and tremble legs

My voice could not be found

 

I used to fear the sick

Such fragile flesh and bone

Their mist of breath dissipate

And they are taken home

 

I used to fear mistakes

Until I made a few

The sun still rise, globe intact

No matter what I do

 

I used to fear my path

Pure darkness leads the way

Tangled weeds that reach for me

A toll for all to pay

 

I used to fear myself

Clear hurdles set so high?

The doubt and hate replicate

No ceiling but the sky

 

So yes, I'm still afraid

Respect my mortal bounds

But I gaze celestial

With feet firm on the ground

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Reasons to Love the PA Profession
October 31, 2013 4:02 PM by Harrison Reed
The first year of clinical practice can chew through the toughest skin right down to the marrow of your bones. Doubt creeps into the crevices of your brain, the dark recesses that you never knew existed. The early challenges of your career can force you to examine the biggest decisions of your life. Fortunately, there is one I have never doubted.

People have questioned my decision to become a physician assistant throughout my career. The inquiries are usually based on innocent curiosity. Many of my coworkers have had limited exposure to PAs or grew up and trained in countries where we simply don't exist. My position at a large, globally recognized academic center has, in a way, turned me into an international ambassador for the profession.

Occasionally, less respectful (though often well-intentioned) comments require a response as well. As a student, I cringed the first time a respected preceptor told me "You are really competent, you totally could have gone to medical school." While the influx of young, talented students to the PA profession seems to have baffled some outsiders, these (now frequent) comments merely serve as a reminder that our ranks are still misunderstood.

I'm known to delve into lengthy, animated rants on the virtues of the PA profession, but I try to limit the number of people I expose to that treatment. Instead, I prefer to distill this tirade into some key points.

The Top 3 Reasons to Love the PA Profession:

  1. Ultimate Career Flexibility - The PA profession is the slinky of healthcare. It offers flexibility beyond any other career. Our chameleon-like ability to adopt the practice scope of our supervising physicians means we can transition from prescribing outpatient medications to managing an ICU ventilator to opening an abdominal cavity in the operating room. We aren't limited by specialty certifications or required residency; we can collect an eclectic mixture of experiences and skills over the course of a career.
  2. An Emerging Healthcare Force -The PA profession hasn't turned 50 yet. That youth offers some great advantages. PAs are not hampered by centuries of outdated tradition or insurmountable political hierarchy. Like a hot piece of metal, the profession is malleable to the changing forces of the healthcare landscape. It is wide open for young leaders and pioneers to offer new ideas and leave an immortal impression. You can pretty much be the first PA-anything. Just ask PA Karen Bass; that is, if she isn't busy representing her district in Congress.
  3. Return on Investment -Money should never motivate someone to enter the healthcare industry. However, if you decide to dedicate your career to serving others, there is nothing wrong with getting a bargain. Based on the initial time and economic investment, PAs receive outstanding compensation, job security and career options nearly anywhere in the country.

Much more importantly, the job satisfies those who wish to impact the lives of others in a deep and meaningful way. It's hard to find another master's degree that offers the same career rewards.

The Not-Top List

While the above list is far from comprehensive, I purposefully omitted several common (and erroneous) ideas I have heard over the years. Responses like, "We work less/have a better lifestyle," or, "We get to spend more time with our patients (than physicians)," or, "PAs are just better at dealing with people," are impossible generalizations and, in nearly all cases, are factually inaccurate. Anyone supplying these reasons, especially at a PA school interview, should explore more hands-on opportunities with PAs in the work force.

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Beyond Recognition
October 17, 2013 10:02 AM by Harrison Reed
PA Week recently brought well-earned recognition to physician assistants across the country. Our profession was featured in major publications, national television spots and popular morning shows. The most powerful government and industry leaders expressed their appreciation and countless breakfast, lunch and dinner gatherings were held in our honor.

Formal acknowledgement from the general public feels great. Our profession can sometimes feel like the neglected middle child of the healthcare industry. A little cheerleading boosts the morale that the daily work grind drains out.

But unsung praise resonates louder. I will always remember the day I accidentally overheard one nurse tell another: "You're lucky you are with Harrison today. He's a great PA."

And even that praise can't outshine the recognition that comes straight from the source: the patients. They don't always say it out loud in the Intensive Care Unit. Some just ask for my name, smile and nod. Others grip my hand and give a squeeze before I leave their room. After one particularly grueling day, a patient's family sent me a present from the hospital pastry shop. "I don't know what you did," the unit secretary said as she handed me a box, "but that is a lot of cookies."

A little appreciation can even change the course of your career. I sat in the cafeteria of a Veterans Affairs hospital on one of my final rotations as a student. My white coat and name badge were stuffed in a desk upstairs as I enjoyed my meal in relative anonymity. Until an unfamiliar voice called out my name.

It took me a moment to place him. Then it struck me: the last time I saw this man he was sprawled across a hospital bed, a porcupine of lines and tubes. He had never said a word to me-an endotracheal tube saw to that-but we had shared conversations every day in the surgical ICU. Now he stood before me in jeans and a t-shirt with an outstretched hand.

He thanked me for the time spent with him while he recovered from cardiac surgery. I was so taken aback by his transformation that I could only smile and shake his hand. Seeing him walk out of the door that day, after being so close to death, may have led to my eventual career in critical care medicine.

Last week a crowd of PAs gathered in my hospital to celebrate the PA profession. Someone stepped up to a podium with a microphone and announced that my Medical ICU colleagues and I were named the Best PA Team in our health system. Everyone clapped and some of my coworkers accepted shiny plaques and took a bow.

That's what I imagine happened, anyway. I wasn't there.

I was across the campus, several buildings away in a completely different world: the ICU. I was busy arranging a last-minute procedure for one of my patients. It meant I would stay late and miss the ceremony, but that is exactly where I prefer to spend my time.

After all, it seemed a little strange to accept an award while I am still working to earn it. And while the praise of my employers was a generous gesture, my real boss was the sick lady in that hospital bed.

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The Quarterly Check-Up: Part 3
October 3, 2013 4:31 PM by Harrison Reed
We have carved deep into the second half of my first year as a professional physician assistant. This is the perfect time for a Quarterly Check-Up to examine some of the biggest lessons over the last three months

We learned that our patient's beliefs can trump the strongest medicine and that our acceptance of those beliefs makes us better clinicians. We felt the growing pains of a young provider, the thousands of little mistakes and the attitude it takes to overcome them.

We realized the strength of our profession: the collaborative system that makes us the most flexible professionals in healthcare. We accepted that our time as a student is over, but our scattered network of PAs brings a new sense of security and adventure. We finally tackled some of that pesky debt. And we taught ourselves a lesson that could never fit into our textbooks.

Random Thoughts from This Quarter:

  • The single biggest breakthrough of my career may have been earning the respect of my nurse colleagues. I have never been an RN and won't be able to fully appreciate what they do, but it's clear that they run the show. So here's a big thank you to all of the patient nurses who hung in there while I figured out all of the little things.
  • On a not-so-unrelated note, discontinue rectal Tylenol when we have oral access. Got it!
  • Working weekends has totally different consequences during football season. Oh no, what have I done?
  • Show a spark of your personality on the job. In a field that typically represses its own humanity, this can really improve your environment. When people die every day, it's even more important to smile.
  • Many issues debated among our profession bring an emotional payload. This is understandable, as a group that has dedicated an enormous amount of time, money and energy to their craft has really invested a portion of their soul. By expressing my views on a public forum, I occasionally disagree with some of my more experienced and respected PA colleagues. One of my recent blog posts in particular touched off a debate.

    I understand the impulse to dismiss the insights of younger and less experienced members of the profession. But there is value in a fresh pair of eyes on an old set of problems. Progress is rarely jump-started by strictly following the ideas handed down before you. Some "unpopular" viewpoints from the new blood of this profession may be exactly what it needs.

I've tried to take you as far into the ICU as possible without violating HIPAA or the privacy of those around me. The next three months will end my first year as a practicing PA. The best may be yet to come. But if there's one thing I have learned in the ICU so far, it's that you can never predict the future.

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The Lessons Never Taught
September 19, 2013 3:09 PM by Harrison Reed
I remember all of my great preceptors: The ones who reaffirmed my choice of career or mentored my special projects or were less of a taskmaster and more of a friend. As a student, I pictured myself in their position, guiding some wide-eyed student through the treacherous surf of clinical rotations. I imagined that sage, professorial Harrison would have years of experience and a few gray hairs to prove it.

I was wrong. That first PA student bounced into my office during my first year of practice. She arrived to glean some wisdom from a veteran intensivist and instead found a fresh clinician still kicking the tangled graduation robe from around his feet. I've heard some cliché about faking things and making things and luckily, in this ICU, even just six months provides plenty of stories.

Besides, this PA student was sharp. She sat on the unit and dove into chart reviews. She tore apart the history and performed her exams on our sickest patients. She tackled ABGs and dissected the most complicated acid-base disorders. She was overwhelmed, she said, but then again, who wasn't? Perhaps the biggest difference between her and I was a diploma and a paycheck.

She was also lucky. Her first day with me in the ICU produced a shocking finish. A previously stable patient began to crash. As his heart rate soared and his blood pressure dropped and we slapped the pads on his chest to cardiovert him, my student witnessed a real critical care emergency. She stayed late to watch his intubation and by the time she left she had finally seen a truly sick patient.

But my student missed something. It is something I also missed as a student but it has defined my career in critical care. While the ventilator puffed its breaths and the vasopressors dripped and the million-dollar work-up cooked in the lab, we performed a different kind of task.

There was the long bedside talk with my patient's wife, the tears and the hugs and the promises to not give up. As my patient slipped into death that night, there was a phone call that left the base of my skull tight.

The next morning, another phone call, this one to my patient's daughter. It left a lump in my throat after all of the apologies and condolences had escaped. That afternoon, more phone calls: An angry brother who wanted answers-a conversation that left my head pounding-and a depleted widow who extended her thanks and broke my heart.

I wondered later if my student had missed out on the most important part of critical care. I wondered if I should have told her that the medicine was easy but the humanity was backbreaking. I wondered if it would turn her away.

Ultimately, I think she saw what she needed: the excitement and the glamour. After all, it's what draws us to critical care. That other part, the part when we tear off a little corner of our soul and hand it to each family, is reserved for us. Those brave or stupid enough to enter the ICU day after day may be driven away by the burden. Or they will stay because it is the only weight that feels real.

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Dodging Your Debt
September 6, 2013 10:30 AM by Harrison Reed
You saw it coming, but there was nothing you could do to stop it. It sat in the back of your brain during school and, as graduation date approached, it grew. While you battled the more horrifying demons -- exams, clinical rotations, sleep deprivation -- this little gremlin lurked in the shadows and waited for its turn to terrorize. Now that you are certified and your dream job is secured, you must face what has grown into a true monster: your student loans.

Nothing sours the taste of those first, glorious paychecks like a fat bill from the Federal Loan Service (or, heaven forbid, a private loan source!). Never fear. As a professional in one of the most in-demand fields, there are plenty of sources to help relieve your debt. Here are five that you may not have considered:

  1. National Health Service Corps (NHSC) Loan Repayment Program: NHSC is by far one of the best options to quickly repay your debt while serving a population in dire need of medical providers. Clinical sites nation-wide are graded based on their need for medical providers; the highest-scored locations will give up to $60,000 of loan repayment for a two-year commitment from full-time clinicians. Smaller sums are offered for part-time commitments and candidates can extend their contracts beyond the initial two years. Sites are typically primary care clinics in rural or inner city areas. If your prospective employer is not listed as a rated site, you can submit an application and make them an eligible site.

    This option is often viewed as a "primary-care-only" opportunity. However, many people forget that all Indian Health Services (IHS) and Federal Bureau of Prisons (BOP) sites are also eligible, including hospitals and the larger Federal Medical Centers. Be sure to apply if you work at any of these locations.

    More info here: http://nhsc.hrsa.gov/loanrepayment/

  2. U.S. Armed Forces loan repayment programs: Most branches of the U.S. military offer loan repayment in exchange for a service commitment. This option is also available to the Reserve and National Guard components, though the amount of repayment, length of service and other details can drastically vary. Clinicians with a strong interest in military service should discuss these options with a recruiter and ensure they are added to any recruitment contract.

    Additional information is available on the websites of the particular military branches:

  3. Public Service Loan Forgiveness Program: This often-overlooked loan repayment option is perfect for clinicians entrenched in debt for the long haul. The program is geared towards graduates working in federal government positions or nonprofit organizations (many hospitals are in this category) and forgives the remaining balance of all loans after 120 payments are made. What does that really mean? If you work for a qualifying employer, you need to make only minimum payments for 10 years to wipe out your debt. Who says procrastination doesn't pay off?

    More info: http://studentaid.ed.gov/repay-loans/forgiveness-cancellation/charts/public-service#what-is-the-public

  4. Perkins Loan Forgiveness: You may have this in your back pocket and not even realize it. Perkins loans are federally-sponsored loans that are awarded based on financial need. Just fill out a Federal Application for Student Aid (FAFSA) prior to each school year and accept the loan. After graduation, complete the appropriate paperwork. The loan is deferred and a portion is cancelled each year for graduates working in healthcare (just like you, PA-C or NP).

  5. Private employer loan repayment: It's a job-seeker's market. Exceptional candidates, even new graduates, are commanding excellent incentive packages, especially in specialties with high demand (primary care) or high turnover (emergency medicine, critical care). Employers are focused on retaining talent and will sometimes offer loan repayment packages in exchange for a time commitment. This is an excellent compromise during negotiations when employers can't or won't budge on the base salary offer.

A Final Word

Above all else, relax and have patience. You will make plenty of money during your career and the burden of debt will eventually become a distant memory. While these programs can certainly give you a boost, any PA or NP can easily manage their debt with hard work and responsible spending. Don't forget to stash away a portion for retirement from the beginning and allow yourself the occasional short-term reward.

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