You're scanning the EMR and you see four office visits in the past month with the same chief complaint. You walk in the room knowing it's not going to be an average cut-and-dry visit. The patient is frustrated about their bowel, their bladder or their other non-emergent complaint that keeps driving them back to the office, and you have to address them with firm confidence.
I have at least one or two of these patients per day and their persistent problem usually has an underlying obvious patient-dependent factor. A sampling includes the frustrated smoker with a lingering sinusitis, the overactive bladder women who refused surgical options, or the back pain patient who keeps missing their appointment with pain management - and I could go on. It's during encounters like that I am eternally grateful I can always tell the patient that, "I'm just going to step out of the room to discuss this with my attending" and basically pass the buck to someone else.
I also can't understate the power of a referral - which by the time they've returned again has usually been offered, but for various factors, the patient hasn't yet been able to go see. The struggle for me, beside the medical aspect of determining a diagnosis and treatment plan, is that I become frustrated with the patient. My inability to fix their core medical issue, though non-emergent and non-life-threatening shakes my own confidence, "What am I missing? What else could be going on here?"
Most of the time malignancy cannot even be in the diagnosis, but it can slip in subtly. "I could be missing cancer," is always in the back of my mind. Then, there's the fighting for prior authorizations for insurance companies for new medications, and the patient call backs that make me feel even more helpless.
So it takes a moment of perspective shift when I realize that though the patients and I may be frustrated, we are trying, we have options, and we have the greatest healthcare system in the world. We have modern medicine with all its glories and shortcomings. And it's in these moments of stepping back, even while I'm practically jogging from exam room to exam room, when it all becomes a surreal, wonderful moment of gratitude. We all have life, uncomfortable though it may be, and each day is worth being thankful about.
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.
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.
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.
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.
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.
"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!
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."
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.
"There's no way you should look so calm doing that."
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."
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
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.
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.
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.
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.
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.
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
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
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
The Top 3 Reasons to
Love the PA Profession:
- 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
- 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
- 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
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.
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.
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."
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."
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
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.
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.
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.
what I imagine happened, anyway. I wasn't there.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.