My journey with ADVANCE began July 7^th 2008 as I wrote about my days leading up to physician assistant school. I was excited, yet nervous, about what I was getting myself into. There were PAs in my life that encouraged me with words of hope and peace. They said the road would be hard, but each day would make me stronger. I remember feeling like my head was barely above water throughout that first semester. The only thing that kept me going was the thought that PAs are made, not born. They are shaped and refined daily. They are a product of the journey.

Often I have pre-PAs approach me with discouragement in their eyes because they experienced denial or simply found the application process very difficult. I remind them of the process. I tell them there is purpose in their circumstances. I tell them to hold on. 

Already now there are pre-PAs who are about to graduate from PA school. They are equipped beyond comprehension when compared to before. When you are on the path to become a professional, the days are tough and sometimes defeating. However, when you look back, you will see how far you have come. It's a glorious thing.

Today I am a PA in the emergency department. I encounter many patients with various needs, ranging from minor to critical. I have done things with my hands that I never would have believed, from sawing the femur for a knee replacement to repairing a complex laceration on the arm. Had I been thrown into these situations prematurely, I would have caused more harm than good. 

Yes, I wanted my life to be on my terms and start when I wanted. I wanted to start PA school right away. I wanted to make all A's. I wanted to be the smartest and the best. Life didn't happen as I chose. Life happened as it was supposed to. The journey became clear as soon as I stopped worrying and as soon as I started trusting. Our days have purpose. 

This is my last post for the ADVANCE Adventures of a New PA blog. There will be others like me who will write about their journey through the process. I encourage you to learn from them. Learn from your own journey.  Don't curse it. There are valuable things to learn along the way.  Your days are like bricks that slowly build up who you will become. Don't skip over the steps or you will have a faulty structure. You are a unique individual with special talents and abilities. And no matter how young or old you are, the process never ends. Your days have purpose. We are continually shaped and refined. The journey is beautiful. Press on, friends!

Thank you for giving me the chance to share my adventures! This has been an incredible 4 years! I am blessed beyond belief by the amount of people who have taken the time to read my posts. Thank you, thank you, and thank you! If you have any questions or want to bounce ideas off me, feel free to email me (timothyloerke@gmail.com).

Signing Off,

Tim Loerke, PA-C

The nurse asked, "What labs do you want?" Like clockwork I responded, "CBC, iSTAT, POC UA and UPT." I walked away thinking about what I just ordered. Really?  Are those even necessary? Am I simply in robotic-non-thinking-mode? My suspicions were confirmed when the supervising physician asked me, "What are those labs going to tell you?" I pondered for a moment and gave my best answer. It was reasonable. The doc went with it. But it left me thinking. Testing before purpose makes for an aimless pursuit.

Emergency medicine is fast and furious. The primary goal is to rule in or out emergency medical conditions. Yet, it's all too easy to hit the "pre-select" button in the computerized order entry. Fast and furious can't be the excuse to rely upon a template. I am a medical professional. I have been trained with the ability to assess a situation, come up with probable causes, and choose a path in order to dictate the outcome. 

Yet, when I am pulled in many ways, my reasoning becomes blurred. Recently, I have honed in on the purpose. I pause a moment before I hit the order button. I explain to the patient the needed tests and why. I confidently convey my thoughts to the attending physician. 

This is not an issue specific to emergency medicine. It applies globally to medicine. The more we understand the pathophysiology, the better we can chart our course. We were warned in PA school to order the necessary items. The true challenge comes when the patient or nurse is waiting for you to make the decision.

We can cave and say, "We are going to run some generic tests, that could tell us a number of things not related to your specific problem." Or we can relate our actual purpose for the "tests." I'm guilty of this. It takes lots of thought and self-control in the midst of fast-paced medicine. I hope to make those I work with and for feel as though time has paused and genuine meaning conveyed. 

There hits a point in the evening where patients flow in like a raging river. No matter how much you try to divert or stop the traffic, progress seems futile. For instance, after 1AM in our ED, there are two PAs and a doc. This is the time when everyone has an "emergency." The waiting room begins to fill up and then people start to get roomed, all while ambulance after ambulance arrives. 

I will start heading towards the waiting room to see new patients and notice a patient was just roomed. As soon as I finish up a focused H&P and start management, an ambulance arrives and I have to jump over to that patient.

This cycle repeats itself a few times before I even make it to the waiting room. And when I go to the waiting room, I immediately get pulled in by a nurse who says, "This is a quickie, come over here to see this one." Agghhh!!! So, I will tell you a little about my mental triaging and hopefully this might help some of you.

When there are a ton of patients waiting to be seen, here is my priority system:

1. Drop everything and see the ambulances (you don't want to miss vital history or an opportunity for swift care)
2. See the patients roomed (the faster they are assessed and cared for, the faster that room can open up. This also includes procedures)
3. Listen to what the nurses tell me (it may be important or not, either way it's up to me to prioritize their concerns)
4. The waiting room (more often than not, patients in the waiting room can wait because there are nurses in triage who know which patients need immediate attention) 

Often it feels like you are pulled in every direction and there is no way to keep up. Mental triaging is a skill learned over time. Aside from learning what patients come first, the most critical practice is proper communication and follow-up. If a nurse says, "Come here and see this patient," you need to communicate your availability rather than being diverted from something more important. This takes patience. It is very easy to snap at people when they are unaware of your current task. 

Emergency medicine is a team-effort. Yet, the most important ability is self-triage. We have to sift through what is most important in the midst of all these important things. You have to know where you are needed most and nobody can determine that but you. It can make you go crazy or be incredibly efficient. I hope for the latter as the months pass on by. Thanks for reading!

The shift was packed with the normal complaints of atypical chest pain, febrile illnesses, and other vague concerns. My brain felt like it was 100lbs. My body moved like a sloth. Why was I here? To make a living, that's right. No rest for the weary.

Throughout the day/night, I kept missing the little things that assist in diagnosing and treating due to my overall fatigue. Thankfully, I work in an environment where everyone is looking out for everyone. The docs and nurses saved me countless times, ultimately saving the patients. I was incredibly humbled, yet grateful for their support. I apologized several times for my sluggish nature and explained my travel fatigue. They kept assuring me that I'm doing a great job and there are no problems. 

The environment I work in is like this on a continual basis, even when I'm at my best. We are a team and back each other up throughout the day. It's comforting to know that I am a part of a team. And it's days like yesterday that make me want to become better, push through the weariness, pay attention to the details, and support others. Today will mark day two of three in a row for the 4P-4A. Wish me luck and hope for an alert brain!

Today I want to give you an insight into the emergency medicine world. This is one of the few areas of medicine where the focus is general, but the depth is shallow. We are looking for things that will kill you now, not later down the road. For instance, if a patient sees an outpatient internist or family practitioner, they might undergo a thorough evaluation in order to manage their many conditions and to maintain good health. The patient who comes to the ER is in for a different approach. Let me explain.

There was a 11-weeks-pregnant woman who complained of spotting and lower abdominal pressure. On the outside, it looked like a normal experience for someone in their first trimester. The husband only brought his wife in because she was concerned, but honestly, he was more concerned about the bill. So, what do you do for this patient who comes to your ED? You think of the worst possible things that could be going on inside this woman and rule them out. They are in your care. You can’t say with full integrity, “You’re fine. Just follow up with your OB.” You have to run the tests. You have to do the full exam. You have to not be concerned with the bill.

Finding out that your “emergent” issue is nothing at all can be defeating. I try to present this as a win-win situation. There are many patients who present similarly but have different pathological finds. It’s a win-win because the absence of life-threatening etiologies means that their life is not in danger, which is why they came in the first place. We are taught to have a top-3 list of things you never want to miss when a patient comes to your emergency department. Abdominal pain: appendicitis, perforated bowel or AAA (abdominal aortic aneurysm). Chest pain: myocardial infarction, pulmonary embolism or aortic dissection. Pelvic pain: pelvic inflammatory disease, ectopic pregnancy or pregnancy complications. Sure, we want to find what’s bothering the patient but now may not be the time and we may not be the right people to explore.

It has taken a little time to adjust to this mentality. Each patient tempts you to pull back the reins on how aggressive you want to be in evaluation. In the ED, we can’t write off “nonsick” patients because we will miss something critical sooner or later. Every patient is different and disease did not write our textbooks, we did. Emergency medicine teaches you to have eyes like a hawk, looking for the worst possible causes, but yet, in the back of our mind, we hold onto hope for our patients.

The records say she has been here 14 times over the past year for trivial complaints, all of which resulted in “take ibuprofen and follow up with Dr. So & So.” Today she states the abdominal pain is “10/10 and started this morning.” Is she being dramatic? Is she trying to get another free pregnancy test? Is she for real? This is the typical patient that frequents the emergency department. They have a poor support system, may be on welfare, and have no regular physician. You are their regular physician, you, being the “ER.” You can’t deny treatment because of law passed in 1986 (Emergency Medicine Treatment and Active Labor Act [EMTALA]). So, you’re the emergency provider who cares for everyone that walks through those doors. Regardless of the complaint or past history, every patient should receive the same altruistic, unbiased care. The frequent flyers will keep coming and sometimes they will have serious medical concerns. The real “emergencies” will also come, probably right after 15 frequent flyers. You are at risk for compassion fatigue. So how do you prevent the numbness and potential clinical dysfunction that ensues?

Every patient is a person. Simple. They come to us, the healthcare provider, because they have a need that cannot be met on their own. Most of the time, they can meet their own need, but they just don’t know it. Our job is to consistently extend a helping hand, reassure, empower and maybe even educate the ones in need. So, our charge is to serve the patient.

For whatever reason, this charge does not always penetrate our inner-self. We are people, too. Yet, we were entrusted with the responsibility to provide care for those in need. Our patients trust us. But we are still human, and caring for the “human” is a big job.

Compassion fatigue develops when we give, give, give to those in need and neglect to care for ourselves. Compassion fatigue grows out of a constant exposure to hurting people, when we ourselves might be hurting. Compassion fatigue captures those who allow themselves to be entranced/jaded by the crazy things of this world. Symptoms might include: crass/dark joking, cold interactions with patients or even a lack of compassion for the true emergent situations.

The duty to serve is a non-negotiable. We cannot skirt that issue. To prevent compassion fatigue, we have to take care of ourselves. Healthy living (diet & exercise), strong support groups (friends & family), and active involvement in life-giving arenas (church, sports, etc.) are a must. For each patient, they deserve a “reset button.” We cannot go around giving patients our leftovers. Compassion is a part of the job. It’s important to take hold of your professional outlook before it gets too late.

This patient began with the luxury of his PA using the translator phone, but as fate would have it, the phone lost service in the beginning of the evaluation. I had 3 years of high school Spanish locked away somewhere deep inside the brain. When the only source of communication went AWOL, I was helpless. The patient was helpless.  The situation was critical.

I came from a program that did not offer Medical Spanish. Their reasoning was that a little Spanish could be dangerous. "Every patient is entitled to an interpreter" was a common point that echoed the lecture halls. Although true, this is often not feasible. My broken phone, case in point. 

You can't run around the ER looking for someone who speaks Spanish while the patient is in pain, waiting for someone to administer quality care. I understand how one could use broken/limited Spanish at an inappropriate moment (e.g., consenting for a major procedure or any type of surgery). The patient needs clear communication for what their options are and the ability to have all of their questions answered. Ok, so that's a small portion of the overall clinical picture. What about the rest? Is it beneficial to know enough Spanish to evaluate and manage a patient?

I don't know the exact percentage of Spanish-speaking patients that frequent my ER, but it's a lot. Lately, I have rounded up all of my resources to start learning the language: iPhone apps, old CME workshops and online translation services. They are all out there and help out with talking to the patients, but when it comes down to it, it's inconvenient because I don't know the language. Things would run much smoother if I knew enough, rather than rely upon something else. 

As you would guess, my patient had appendicitis. I went off of gut instinct and the physical exam, rather than wait around for someone to speak the language. Was I in the wrong for not finding an interpreter? Ask the patient. Do I need to learn the language to better help people? Absolutely. What do you all think?

He went on to explain that mistakes are avoided by asking questions whenever you're unsure about something. He referred more to the critical scenarios of chest/abdominal pain. I walked away thinking this shouldn't be a problem. Then I started my first few shifts.

I would continually run into situations where tests seemed right, procedures appeared to be doable and the diagnosis could be appropriate. Part of it was adapting to a new system of EMR, hierarchy and protocol. The other part was the wave of medical knowledge coming right back at me from the past 4 years.

Asking your superiors, colleagues and staff questions is a humbling experience. Often I feel dumb for asking the things I do, but you really never think about such things until you're actually there. It's surprising though how helpful people are.

I sometimes think that I'll get razzed or viewed as an idiot. Maybe it's the emergency department, but people don't mind answering your questions. The downside to asking a lot of questions is being viewed as needy, but the best defense is a good offense.

Proactivity and servitude will help to prevent Q&A fatigue. Each time, my approach is to do everything I can, think of all possible methods and then ask. Also, go above and beyond to help those who help me. It's not about "I'll scratch your back if you scratch mine." Rather, serve others as you want to be served.

The proactivity component is more to assist you in developing into an adequate clinician, rather than a dependent person. Even when my years of practice make me "adequate," I know that I will always need to ask questions, because I want to avoid mistakes. Because mistakes mean people hurt. It's not worth it.

Friday was my last day as a full-time PA in orthopedics. We had two knee scopes. The day seemed typical. I arrived early so that I could read more from the Tintinalli Emergency Medicine Manual. The supervising physician noticed my studies and made some comment.

I said, "Yeah, I have to be constantly reading because I never know what will come through the doors.Honestly, I keep reminding myself that the ability to practice medicine in the ED will come with experience." He then said, "Yeah, but you can't miss the stuff that will kill people." I sat there. The overwhelming sensation came back over me. I have to know all of this stuff so I won't kill anyone. Sigh.

As defeating as it was to hear his direct statement, it was also somewhat encouraging. Throughout the weekend, I noticed a confidence building; not one that says, "I know it all. Bring it!" Rather, one that says, "Although I know little, I've been there before." Yes, I had a 1-month rotation. Yes, I have spent the last 8 months working in orthopedic surgery.

I have helped patients both in the controlled educational environment, as well in the professional. Now when I read through Tintinalli, I remember what was once taught, paired with what I have personally learned on the job. My "experience" is actually aiding my preparation for the next chapter.

No matter how long a PA has been practicing, everyone becomes the new guy when changing jobs. However, I imagine that this transition becomes easier for those with many years of experience. Sure, they are reviewing "foreign" material in preparation, but in essence, the things they read are enhanced by their past clinical exposure.It no longer becomes methodical protocol paired with common presentations. The various conditions/diseases are brought to life because you saw them, you dealt with them and you helped that person.

In school, I remember feeling exceedingly bewildered by all of the knowledge a physician assistant should possess. How could someone possibly know all this stuff and properly assess and treat a patient? It's now apparent.

Each day, my experiences solidify what was once learned. The knowledge is locked away. It is up to me to pause, reflect and use what I have. I hope to never miss anything that would harm a patient. If I do, that encounter will forever inform my future decisions. 

Studying gets better with time because we have the real-life encounters that add color to the mundane. The emergency medicine text I read now is meant to wash over me as I remember the past and press on towards the future.

Next week I will start my new job in the ER. Along with reading my Tintinalli Emergency Medicine Manual, I have spent a little time at the PA Forum. If you have not been over there, they have a little something for everyone (pre-PA, PA-S, PA-C).

Their emergency medicine section is packed with pearls of dos and do nots, odd case presentations and tips of the trade. Essentially, it's like sitting down with a veteran ER PA who is giving me all the down and dirty before I start. Something in particular stuck out.

The emergency department I will be working in has multiple divisions of care; among those, a fast track. Fast Track ERs are meant for "minor" emergencies. But who is the one determining what is minor? Yes, there are trained triage nurses, but PAs/docs/NPs cannot rely upon triage fully. 

When a patient is labeled as having a minor emergency, the sense of urgency lessens. However, what if the apparent "minor" injury turns out to be life-threatening? That is where the provider must be keenly aware of the patient and not swayed by the "minor" label. 

When you hear, "It's probably nothing" from one of the triage staffers, stay tuned. Don't discount the patient. I'm sure it's easier said than done. I'm eager to get started so that I can develop my own pearls. Can't wait to share what I learn!

If you are interested in surgery, there might be a few things to think about. Yes, there is nothing like the rush of gowning up, seeing/holding the inner-parts, closing up the incisions and seeing the patient off to recovery. It is very rewarding, yet incredibly taxing. Is surgery for you? 

I am in surgery 5 days per week. I will arrive at least 30 minutes before start so as to intercept any issues prolonging the case. For orthopedic cases, my role is to hold retractors and body parts for long periods of time. At times, I will have about four different tools going at once. Anything for the sake of my surgeon being able to get the job done. 

My hands, forearms, biceps and deltoids are on fire daily. The surgeon will often ask if I'm alright. I'll tell him everything is fine. It's only that way because I disconnect my brain from my body. What am I going to do? Quit? It's only temporary pain. There are days when I start to shake, but then I turn my body in such a way to transfer the load (body mechanics). You find tricks to not tire out. All in all, this job is a daily upper body workout. 

Surgery is fun, but it can be demanding in many ways. I remember my rotation in pediatric cardiothoracic surgery where it wasn't uncommon for an average case to take 6-8 hours, not to mention the 14-hour heart transplant cases. As a PA, your body can be pushed to the limits because your primary role is to ensure a smooth surgery. You are the driving force and support that makes surgery possible. Like I said, it's rewarding, yet taxing. Is it still for you?

If you have applied for any job, they always ask for your résumé. Prior to PA school, it may have been a straightforward task to create your file packed with every possible job and accolade to impress. You may have not been in a field where it mattered what was on your résumé, as long as there was something. Now we are in the medical field where it doesn’t matter that you delivered pizzas, organized data or trained dogs for a living. They want to know what you have done as a PA and what relevant experience you have that would make you suitable for the job. Nothing more, nothing less. Simple?

Since you graduated or are getting close, you are probably wondering CV or résumé? Curriculum vitae (CV) is Latin for “course of life.” It is widely used in academic and medical settings. A CV is essentially everything you have ever done, from research titles to volunteerism to professional memberships. I don’t believe there is a limit of how many pages you can use. A résumé is more succinct. It gets to the point. It’s directed toward the job you are applying for. A recommended length for a résumé is 1-3 pages; however, the more you can narrow it down, the better.

As a PA, what should you use? Most of us will use a résumé; however, those going into education or working for a large teaching hospital may want to submit a CV. Why a résumé? You are looking to fill a particular gap in a practice and the most important thing your employer wants to know is are you qualified and do you have the experience to back it up. Yeah it’s great you wrote a research paper on hypertension but how will that benefit the orthopedic group? These are things to consider.

There are lots of examples out there for résumés and CVs. The CV has more of a cookie-cutter layout because again, you are placing everything on there. The résumé is more strategic. Initially when I was in school, the bulk of my “PA” experience was clinical rotations. My advisors said it was appropriate to put the clinicals on the résumé until you acquired actual “PA” experience. Ok, so I have worked on the job for 1 year, so wouldn’t that make my résumé pretty scant? Yes, and that is why I would recommend including “related experience.” So, that would comprise things like research jobs, scribe positions or the hands-on medical roles. Over time, you will have worked enough PA jobs that the “related experience” section may not be necessary. Just my two cents.

Your go-to will probably be the résumé, yet I think it’s safe to also create a CV. You never know when you’ll use it. Also, the best thing you can do for yourself is to always update your file. You don’t want to be slammed one day with thinking up 10 years worth of events. Any questions or tips from my readers?

When starting your first job as a new grad, there are a lot of things required to be “official.” Not only are we paving the way to legally practice, we are dealing with the site-based requirements of credentialing. Transitioning to a different job is not as strenuous as the initial but there are still a lot of things to consider. Here are some tips for the switch:

1. Remember to keep record of everything: Every job seems to ask for the same things (copy of your license, immunizations, diploma, etc.). If you have the capability to scan in documents, do so because it saves you the hassle of hunting down files. Also, keep track of all procedures and CME you do. Employers, specifically from big groups/hospitals, ask for that stuff.
2. Know your expiration dates: If your license or ACLS/BLS is due to expire soon, be sure to either renew before or shortly after being hired. Many employers pay for these types of things but regardless it’s our responsibility. Oh, and if your license is expired by even one day, you can’t work. Bummer.
3. Study up: Maybe this is a no brainer but I’m sure it’s something that can easily be overlooked. Obviously this does not apply to a lateral move into the field as you have practiced before. At the moment, I am spending 2-3 hours per week reading up on emergency medicine and will up the load the closer I get. It almost feels like I’m preparing for a test again
4. Know your start date: This is important when providing your current employer notice of departure. I know it sounds simple.

These are just a few things to keep in mind. Obviously you need to know what you’re getting yourself into but that goes without saying. Anybody have anything to add the list? Thanks for reading!

When considering my first job as a PA, a topic of concern was the commute. At the moment, I drive about 30 to 45 minutes each way, not to mention the time spent between the offices, hospitals and surgery centers. I initially thought this would not be an issue since I drove 3 years from Dallas to Fort Worth (1.5 hours round trip) for my PA education. During the interview, I was willing to take the risk because the job seemed worth it. I knew deep down this wouldn’t be my permanent place of employment given the distance between home and work. I was open to the possibilities that lay ahead.

In October 2011, I was approached by an emergency medicine group notifying me that a position had opened up. The big catch was that the hospital was 2 minutes from my house! I had applied for this job during my last month of school. At the time, there was nothing available and the prospect seemed dim because PAs stay an average of 8 years with this group. Nobody leaves because they love working there. You can see my dilemma? After lots of thought and talking with the trusted people of my life, I opened myself up to this option. Long story short, they offered me the job in November. I talked with my current employer last month and I start in mid-February.

So what if your situation is similar to mine? I’ll try to offer up some bits of advice:

1. Consider what’s best for you and your family: You owe it to them and yourself to consider opportunities that are far more favorable than your current situation.
2. The grass is not greener on the other side: Be aware of your current state of being when looking at other jobs. Emotional decisions can be detrimental to your career. Just because your dissatisfied, don’t tap out in pursuit of something “better.” The pitfall is making a habit of this approach.
3. Provide ample notice to your current employer: If you are switching, respect your boss enough to provide at least 1 to 2 months of time to prepare for your departure. Most practices request a particular length of time before you inform them of leaving. Some don’t and as I found out, this can instill fear that your employer could fire you at the moment you put in the notice. They can but they won’t. They need your help.
4. Think through and rehearse how you will tell your current boss: This is not an easy conversation. I wanted to provide my employer the privacy and the time to carry on the conversation with me when I gave notice. Avoid doing it in the middle of a busy day. Be prepared to communicate your logic in a clear and concise manner as to why you are leaving.
5. Don’t let someone else be the first to tell your boss you are leaving: Be careful whom you share your intent to leave with. You don’t want it getting to your boss before you do. This also goes for the credentialing office of your new job.

This may be a common dilemma for a new PA to face. A few of my classmates have already changed jobs in their first 6 months. It happens. You get into a job and find it is different than you thought it would be or in my case it was more than you thought it would be. It’s ok to switch jobs; however, be careful not to make it a habit. Your future employers will examine your work history and wonder. Sometimes opportunities pop up when you least expect them. Maybe that’s going to be the norm from this point forward. Maybe there is always a “better deal” out there but do we always need to take it? As PAs, we are not bound to one discipline of medicine so we can move if we want. The real test of time is knowing when to stay. We all want that job where we don’t see an end in sight, where we see ourselves there forever. For me, I am confident in this move and I don’t see a change for at least 8 years (remember the average length of stay for this particular job?). The adventure continues!

Last week, I was about to enter the OR when I saw a sign on the door that said, "Patient Awake." I asked one of the staff what that meant, because I had never seen this sign before. I never thought it actually meant that the patient would be awake during surgery, partly because nobody told me this during pre-op. I was shocked to find out the reason this patient was staying awake. He wanted to be a PA! I went up to the patient and said, "You know, there are easier ways to watch a surgery." He said, "Yeah, I know, but I really wanted to see my own." Anyway, the surgery went fine. The patient didn't suffer anything ghastly.

What was most interesting about the surgery was not the patient or the procedure. It was the fact that the overall atmosphere of the OR changed. No music. No joking. No angry surgeons. Just polite, professional and educational talk filling the suite. The sign was on the door so that people wouldn't walk in blabbing away about this or that, or make inappropriate comments about this or that ("What is said in the OR stays in the OR"). I began to think how medicine would be different if at all times we acted like patients were awake, even when they weren't in the same room. People would be treated differently. Minds would be kept clear and sharp. The attitude would be to serve and to educate. Medicine would be totally different.

In ways, I wish every patient stayed awake, because it causes you to slow down and think before you speak. But then again, I would never wish for anyone to be awake during his or her own surgery, not even my arch nemesis. It's a novel concept to consider, but it may change the behavior of us medical professionals.