For the 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.

1. 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)
2. 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.
3. 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 2013?
4. It's 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 that!

Feel 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 perfect health.

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 gentle puffs.

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 much longer.

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.

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.

Transition 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.

Choose 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.

Burn 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.

Respect 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 years.

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!

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 employment elsewhere.

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 insurance premiums.

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 patient's life.

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 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 invasive questionnaires.

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 signatures.

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 Transition

• 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.

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.

Tips for PANCE Preparation

Find 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.

Practice! If 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, of course).

Don't 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 already memorized.

Arrive 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.