First rotation as a PA Fellow

As a PA fellow, much like a second year PA student, I have different rotations in all areas of ENT. My first rotation was in general outpatient ENT. I saw many ENT pathologies including: benign paroxysmal vertigo, dysphonia, epistaxis, cerumen impaction, acute hearing loss, nasal polyps, sinusitis, laryngitis, vocal nodules, and so much more. I learned a ton during this rotation, but I will continue to be part of the ENT clinic throughout my year, so I kind of got an introduction here. 

My second rotation was Head and Neck surgery. This included me seeing patients in clinic for pre and post op follow ups, assisting in the OR, and rounding on patients admitted to our service every morning. I learned SO much during this first rotation. We had some very long surgeries.... like 14 hours. But they are some of the most amazing surgeries I have every seen. 

An example of a flap reconstruction of the right cheek

We work with a lot of head and neck cancer, and utilize flaps for head & neck reconstruction. These flaps typically are harvested from the anterior lateral thigh, radial forearm, or fibula and lateral leg. As part of the process the flap, along with an artery and vein, is harvested and reanastomosed with an artery and vein in the neck. This new flap is what repairs the defect made by resection of cancer.
 This is truly life changing, as it can affect how the patient eats, swallow, smells, and especially how they look. I am always humbled when I get the opportunity to be part of these surgeries. 


My third rotation was rhinology. I got to be part of some amazing surgeries during this rotation. I learned so much about nasal anatomy, and nasal obstruction. I got to see patients in clinic, and assist in the OR. We performed lots of different types of surgeries including: Septoplasty, turbinectomy, frontal sinus entrostomy, ethmoidectomy, resection of polyps, nasal valve surgery, rhinoplasty. I had no clue how much an individual's nose effects the look of their entire face. I learned to respect the ENT surgeons who are part of this sub-specialty as it is truly an art form. Most of our patients left home from the hospital as outpatient surgeries. However, we would have a patient every once in a while that would have to stay a night or two. In which case me and the resident would round on them, and make sure they had all their progress notes and orders in daily.

One great thing about being part of a fellowship is it has allowed me to learn how to do the little things like putting in orders, or how to dictate a note, honing my interviewing skills, and getting better at what questions to ask patients. The fellowship is allowing me to gain confidence in myself and my recommendations to patients. Each rotation builds on the next, and I feel I understand the principles of ENT a little bit better and more thorough than before. I have also got the chance to practice common ENT procedures including flexible nasopharyngoscopys, ridged rhinoscopys, trach replacements, prosthetic speaking valves, and microscopic cerumen impaction removal. 

An example of flexible nasopharyngoscopy

An example of ridged rhinoscopy
(notice the straight long scope vs the flexible scope in the above picture)

As part of the fellowship I go to weekly "core curriculum conferences" along with the residents. These conferences cover topics in ENT and help to serve as a foundation for ENT anatomy, pathology, and treatment plans. Surgical modalities, difficulties, and common mistakes are discussed. I always learn so much during these conferences. I also attend Sim lab trainings with the other PA fellow in the ENT program and PA fellows in the internal med program. These are always helpful, as they give us the chance to learn in a safe environment and learn from each other.

I also share first call about 4-5 times per month. It can be really taxing at times as you get calls all night, and sometimes get very little sleep. However it always provides some great learning experiences.

My next rotation is Oral Maxillofacial Surgery, then general outpatient ENT, followed by pediatric ENT. I cant believe how fast everything is going. I feel like I just started, but with all i've learned it feels like i've been here for years! 

Graduation and First day at Mayo Clinic

I thought I would have more time during my "time off" after graduation and starting my job... lets just say I was wrong! 

I have been very busy getting settled that I haven't had a chance to update my experience with my final rotation and graduation... So lets summarize quickly to catch up.

My last rotation was at a VERY busy trauma center in Portland. I worked 6 days/wk 14hr shifts... I basically lived and breathed there. It was a great experience and I had the opportunity to do a lot, and get a lot of great exposure. The PAs there work very hard, and they have a lot of knowledge. Needless to say I was happy to be done with the crazy shifts, but I learned a lot and it did go by fast at the same time. 

Graduation snuck up on me very quickly... Before I knew it we were saying the PA Oath and getting our graduation certificates and Masters degrees! It all went by in such a blur... It was such a strange feeling to know that was it; Last week I was a student, and now i'm a PA... Sure I still had to study and pass my PANCE, but school was officially done! It was a love/hate relationship, I already miss my classmates. Its fun to see where they are working, and get excited for the awesome opportunities that they are getting.

I am thinking of dedicating an entire post to PANCE prep and taking the test... It wasn't as bad as I thought it would be, and although I didn't feel 100% prepared (not sure if anyone does) I passed and performed just fine. Waiting for the results was the hardest part I think... just a constant worry all the time! 

Today was my first day and orientation day for Mayo Clinic... what an AWESOME opportunity. It is crazy to think that I am now a PA-C and will no longer be the "student". I will still have a learner role as a fellow... but I am no longer simply a spectator from the sidelines, its time to get my hands dirty! Basically today was just orientation and computer training for the EMR. I have a feeling that things will pick up very quickly... We do have rotations in different specialties in ENT, i'll update the blog when I get my schedule. In the meantime... i'm just trying to get adjusted to the new hospital, schedule, staff... just everything! Great things are coming though... I can feel it. 

PA-C!

I thought I would update everyone that I am now officially a PA-C! I just found out this morning that I passed the PANCE. I will post an update on my final rotation of PA school and preparation for the PANCE in the upcoming weeks. 

Thanks everyone for following along with me during this long journey! 

Accepting a job and my thoughts on post graduate fellowships

When I first started PA school, I had the mindset that post graudate fellowships, or residencies for PAs was a waste of time. I mean, why work for less money as a resident when you can get hired on making a great salary and do training on the job... It makes sense right? or does it? 

I started thinking more about this topic during my job search over the past few months. I had applied to about 3 or 4 job postings for emergency medicine. Every single organization replied back with an explination that they were looking for a PA with experience and not a new grad... this got me thinking of the old conundrum "how can I get experience without a job, and how can I get a job without experience?!"

So I took a serious look at what a residency program would entail, and if it would be a good fit for me. During my research I learned that a PA residency is a lot more than just getting some extra experience in order to get hired with that ideal, great paying job... its an opportunity to make you an amazing PA!

Ok, so now you're thinking to yourself... if this is such a great opportunity why doesn't every PA do a residency?! Well, it is a matter of personal prefrence, and It really depends on your career goals as a PA. A residency is not for everyone, but if you pushed it out of your mind, like I did, because you would make less money for a year... take a second, read my experience, and give it a chance to bounce around in your brain to see if it fits your PA career goals.

When starting as a brand new PA most places give you a few months to get settled in and learn the ins and outs of the hospital or clinic. After this period of time typically productivity is increased in order to see a bigger case load. This can really make it difficult to continue to learn and to make matters worse many collaborating physicians don't have the necessary time to teach when a unique case presents itself.

As a PA doing a residency you get an opportunity to take on a smaller caseload to really understand each medical decision, be part of unique cases, and get many opportunities to practice proceedures and perfect them.

Also, any hospitals require that you do a certain amount of proceedures before you can get credentialed to perform them at their facility. (chest tubes, intubations, ect.) Doing a residency gives you the opportunity to do many proceedures and get good at them, so you can not only get credentialed in them when you get your job, but perform them more often after you are hired.

So when I looked up PA residencies in Arizona, I found only a few. I saw that the Mayo clinic offered one in abdominal organ transplant, hospitalist medicine, and ear nose throat-head/Neck surgery. I always enjoyed surgery and wanted to go into a field that would provide me the opportunity to work in clinic and in the OR, as well as do many different proceedures. I had a history of going to an ENT doc when I was younger for vocal chord nodules, and I always found the field interesting.

The deadline had already passed for applications... but I figured I would send out an email and ask anyway, I figured the worse they could say was no. Lucky enough they asked me for an interview! I flew back home to Arizona and had an awesome time at the interview. I loved the environment there and found that all the PAs had a really great friendship and relationship with eachother. It felt like they were all just a bunch of friends hanging out. It was a really cool environment.

Mayo clinic selects only 2 PAs each year to be a part of this one year ENT fellowship (residency). I was hopeful, but at the same time I understood that my chances of getting accepted were low out of pure statistics alone. I must have done something right during the interview because... 

 I was selected to be part of the fellowship!

I was SO excited upon hearing the news... and of course i'm still very excited.  

I learned that this is a very surgical heavy fellowship (which I like very much) and I also felt like the program would allow me to work in many different areas after completion. The education is so broad and provides some great rotations in peds, oralmaxillofacial surgery, reconstructive and plastic surgery, along with all the ENT specialties. I feel that I will be able to find an area I really enjoy and make my PA career out of it.

As PA residencies are not very common, I will continue to document my experiences for those who are contemplating if they want do complete one as well. And as always, feel free to ask any questions.  

AAPA conference and being the AOR rep for my school

I just recently returned from the AAPA conference in Boston. I honestly didn't think I would have such a good time, especially as a student. I was wrong! I really had a great time making new friends, getting to speak with PA students from other programs and hearing their stories. 

The main reason I went was to represent my school in the Assembly Of Representatives (AOR). This is a basically the governing body for the Student Academy of the AAPA. We voted on resolutions that were brought forward from ordinary PA students like you and me in order to create a focus and schedule for the student academy in the upcoming year.

Anything that students have an opinion about can be brought up to make changes, even to be brought up with the House Of Delegates in order to make changes for students with the AAPA. 

I never really understood this before attending the AAPA conference. 

For example... A student from a PA program resolved to speak with the ARC-PA about developing a "standard set of PA school pre-requisites" in order to remove the frustration of different pre-reqs with each program. This way students could complete the "standard pre reqs" and focus on how they fit with whatever program instead of focusing if they can even apply or not.

I never realized how much of an impact we can make for current and future PA students. My suggestion is, if you have a complaint or want to make changes for PA students, figure out who your class AOR rep is (for us it was the class vice president) and submit a resolution to make it better. Then they can bring it with them to the AOR meeting at the AAPA conference and make a difference.

Boston was really beautiful and was fun to explore for the short time I visited. 

This is the AOR  meeting where we voted on resolutions

One of the Keynote speakers

This is where the knowledge bowl took place

I highly encourage everyone to attend the AAPA conference as a student, the knowledge bowl was a really cool experience to watch and I bet it would have been fun to be a part of. Its only a short amount of time that you are a PA student... enjoy every minute of it!

Applying for the PANCE and Starting my Internal Med Rotation

A very scary reality came to me a few weeks ago when I paid the money and scheduled my date to take the PANCE. I cannot believe that I am so close to becoming a PA-C! (assuming I don't completely fail the test and have to retake it) However, I am thinking good thoughts and assume that I will pass the first time I take it... 

So let me explain the process:

•  When I was officially 90 days away from graduation my program submitted my name and info to the NCCPA. 
• I was then able to create an account with the NCCPA. (It took a few days after creating the account for the PANCE test to show up in my "Dashboard" before I could apply for it)
• When the test finally showed up in my account, I signed up and paid the fee for the PANCE.
• I waited a few days for my application to be processed and receive my "official test acceptance email". 
• I was then able to schedule my exam with Pearson VUE. (They have testing locations all over) I picked a date and time and its now officially scheduled!

So there is my process so you can know what to expect when the time comes for you to do the same. I scheduled my PANCE as soon as possible after I graduate (the earliest that someone can take the exam is 1 week after graduation). So the end of August is when it is scheduled. I'm excited, nervous, and scared to death!... but its the next step and I can't wait.

I just started at the Prison in Texas and so far have just been exposed for only a few days of prison life. Lets just say its not as exciting as I kind of imagined it would be. Its not the crazy inmate fights and altercations you think you would see on TV. This location is basically a big infirmary. Prisoners come here for recovery from surgery, management of chronic conditions, or hospice care. I basically am doing the history and physicals for the incoming prisoners and following up and doing progress notes on the patients I have worked with. This is my first time really writing out inpatient notes and working in an inpatient setting. It is a little intimidating, however it is a great learning environment and my preceptors are all willing to be patient and teach me.

This rotation is typically done with 2 PA students from our program completing the rotation together. However, for some reason, I am the only one here for this rotation. My preceptor said it is the only time he has had only 1 PA student. But I see it as a good opportunity to learn, because I am not splitting up the patients, I get to see all of them the easy and the difficult patients.  

Like always this rotation will fly by and I will be onto my final rotation in a level 1 trauma center! I may be way too busy to blog during those final 5 weeks, but i'll try my best to keep everyone up to date.

Making the transition from didactic year to clinical year -- What I wish I knew when starting rotations.

In honor of the first year students in our program I have decided to share some of the things I wish I knew when I started clinical rotations. They start their first rotation in June 2014, and it honestly feels like I was just in their shoes. So here is my attempt at producing useful information while sharing my thoughts.

1. Clinical rotations are still part of your learning

         I cannot begin to tell you how nervous I was starting my first rotation. "Will they think i'm an idiot", "do I know what I am supposed to know for having just completing the first year", "what if I totally forget everything I learned". These were just a few of the thoughts that entered into my mind. My suggestion is that you put all that aside, know that you can look anything up if you need to, and realize this is still part of your learning. I found that I didn't remember or memorize any dosing of medications for certain diseases in the first year. When I first started, I didn't know the typical dose of Amoxicillin to give for a strep throat infection... but I can look it up! That became a phrase I would use a lot with my preceptors. And honestly... for the most part, they were ok with that. 

           These things are the type of things you should learn in your second year- what dose, how much, for how long, calculating and adjusting the dose for a child... ect. The other thing I felt I learned and am learning is the typical course of a disease and advice to give. I didn't know with a certain disease when patients would typically get better, or how long patients needed to avoid certain activities, or medications ect... this knowledge comes mainly from experience, of which I had, well... none! So soak all that stuff in when you hear your preceptors talk about it.

2. You don't have to know everything

              Like I mentioned above, remember you are still learning and you are not expected to know everything. You will at times have a preceptor that will push you until you don't know the answer. They do this so they know where you are at in your training and what they need to focus on with you. They want to make sure you will do well with their patients and they can trust you to do certain things. They want to make sure that when you don't know something, you'll come to them for help. Remember you can always look it up, and when you have seen a disease a bunch of times, you will know start to know it very well.

3. Keep a record of the little tips you find along the way

       I found that during my rotations I received so many little tips from preceptors. These ranging from dosing with certain medications, treatment duration, approach with certain patients, ect. I started to keep a little notepad, but found that it was a bad way to keep it all easily accessible. Sometimes I would forget it, and keeping them organized was not easy. I always had my phone with me, so I started taking and keeping notes on my phone. This turned out to be the best way for me. They are easily accessible and I can always whip out my phone and type in a note. It is already my go to source for anything I need to look up... So now its my go to for writing down these little tips of the trade. 

4. Always learn from your rotations-for good or bad

          Some rotations, no matter how many people have given it awesome reviews before you, can be a bad fit for you and your learning style. Don't give up and just check out till it's over... as tempting as it may be. Really strive to learn something that you can take with you. You can always learn what you don't want to do, however it is important that you take advantage of what is available to you. If the nurse or MA who does blood draws will give you the chance, ask if you can do all the blood draws so you can get practice, and start to get good at it.

          If you feel you are not getting the chance to visit with patients on your own, go in with the the nurse or MA to help with vitals and do a brief history with the patient, and maybe even a physical exam. You can get practice and you'll have the details to present to your preceptor. All I can say is try and make it a good learning experience. However, as an aside- sometimes its not you and you should bring your concerns to the clinical team to make changes for the next class if it really is a dysfunctional site.

5. Take advantage of the opportunity

        Picking up a little from my last point, always put yourself in situations to learn something. Your skills become much better with repetition, and you learn more from struggling through it yourself than just simply observing. So always find a way to practice being the provider, interviewing patients, and doing physical exams on your own. I recall being intimidated to go in and interview patients when I first started. This is totally normal. You're afraid of messing up, that they will ask you a question you don't know the answer too, that you'll forget something, ect... however this became MUCH easier as the clinical year progressed. Try to jump in with both feet and don't be afraid to make mistakes, just blame it on being a student! 

6. Don't neglect the opportunity to make connections with patients

          

            About halfway through rotations, when I got more comfortable with the "medicine" part of seeing patients, I tried to practice listening to what the patient was saying and wondering what their actual concerns were. This takes practice. Instead of racing through my mind "what disease could they have" or "what special physical exam tests am I going to do" I started thinking along the lines of "what are they hoping I can do for them" and "what was it that brought them in now".  It helped me taylor their treatment plan and they were more satisfied with their care because their expectations were met and addressed. It also allowed me to make a connection with patients.

          As a student I am not always rushed to see so many patients as my preceptors, and because i'm learning I can take more time to sit and listen to patients. Patients feel valued and cared for, plus when I saw them again we had an instant connection. It helped relieve the patients anxiety and fear when they knew I was involved with taking care of them. 

These are just a few of the thoughts that came to me while pondering on my time as a PA student thus far. I hope you will find this helpful, especially to my fellow classmates who are about ready to start their second year. Feel free to ask questions and leave comments too.

Community Medicine - Rotation 7

So I am now into my Community Medicine rotation. For this rotation I am in the most rural location I have been yet... Christmas Valley Oregon. Lets just say its out in the middle of nowhere! It has a total population of about 800 people (this is an old stat, so it could be more or less now). 
Anyway, I am enjoying my time trying to adapt to such a rural community. I must say it is beautiful at night, you can see every single star in the sky. However I do have to travel about 90 miles to the nearest grocery store... 

Being back in family practice after working in the ER is really a challenge. I have to think in a totally different way and document things differently. Not only that... It is also a challenge to think about what I do while being in such a rural environment. Some patients cannot afford to drive 2 hours to the nearest big town to get certain tests or diagnostic procedures. Or they can't do it within a certain time schedule.

I have been able, however, to work on some of my hands-on skills a few times already. Since we are the only clinic in town (in fact for like 90 miles or so) we are also the Urgent care. So we get the opportunity to sew up some lacerations and work up some acute care or trauma care. 

I also have to do a community medicine project, which involves me speaking with my preceptor about needs of the community. We decide something that I can do to bring awareness to the community or serve them in some way. We decided that I could introduce people and help to make them comfortable with some complementary medicine. I wrote my clinical project paper on Yoga as a means for treating cardiac arrhythmias (especially atrial fibrillation). So I wrote an article that went in the towns newspaper reporting my findings. We also have a Yoga instructor in town who holds classes and can help individuals get started or come regularly.

It has been an enjoyable experience, the staff here are very friendly (as with everyone at all of my clinical sites). This rotation is flying by, I only have 2 more weeks left. Then I am down to my final 2 rotations before graduation! (it still doesn't feel real). Also on a second note, my wife just accepted a job as a speech therapist in Arizona, and her graduation is in 2 weeks! So a lot of things are changing, finally we will start to get some income and begin to make a dent in our student loans! 

End of Emergency med, Finals, and Job hunting skills

I have now finished my Emergency Medicine rotation and loved every minute of it! I learned so much, and got to practice my hands-on skills a lot. I also got to tap into the mindset of ER providers and how to think differently from other areas of medicine. 

I really enjoyed my time in the ER and feel I could find myself working there after graduation. I really like being able to see so many different areas of medicine. 

After finishing my time in Ohio my class got back together for end of the second year written finals and physical exam finals. They put it at this time in our clinical year so when we come for graduation we aren't stressed out with having to pass a test or not graduate with our class. I thought it was a good idea, and i'm happy to be done with it... and yes, I passed. 

I am now officially done with all my testing for PA school!!   (well... besides the PANCE which is technically after PA school.)

So we also got some great job hunting skills, CV tips, interviewing skills, and other topics that will be helpful when i'm looking for the place I want to work. 

I also just started my 7th rotation, community medicine, which is in rural Christmas Valley Oregon. Today is my first day here and I have had a good experience. Although when I arrived last night I didn't get any cell phone signal... none... at... all... it was, needless to say, pretty scary. It was dark, no real street lights, way to call the owner of the place where I was going to stay. But I found a pay phone and was able to call... not long after that my phone started working (not sure why I had no signal?!). 

But it all worked out... only 2 more rotations after this one! I can't believe how quickly things are moving along. It really does move by fast!

Emergency Medicine Rotation- my first night shift!

Hey everyone, so I am now in the first week of my Emergency Medicine rotation. I am in Circleville, OH and have really enjoyed the atmosphere here and the people I get to work with. At this particular rotation we have 2 PA students that are assigned the rotation at the same time. We split up the rotation alternating working 12 hour night and day shifts. So when one student is working night, the other is working day and vice versa. I get to start out with night shift and its the first time i've ever worked nights... lets just say its REALLY strange. I don't know if it is just a mixture of being in a new hospital with new people... but its really weird working through the night and sleeping during the day. 

 

 

The schedule also makes it hard to be in contact with my wife due to the time change and me working through the day... but like always, I tell myself (and her) that its only temporary. We have been sending video chat texts back and forth, its pretty fun! I can't believe how much being apart from eachother has actually helped us grow closer. We have learned to appreciate eachother so much. 

I have already been able to start IV's, suture and staple lacerations, insert foley catheters, and see a lot of different illnessess. I am really enjoying being able to see a bunch of different things. In one shift I could see skin rashes, lacerations, chest pain, shortness of breath, UTI symptoms, and a sore throat. That could be within only a few hours! I get to see a lot of patients and really enjoy being there to help patients when they are at their worst.

I will continue to keep you up to date on my first few weeks, and switch to the day shift. As always if anyone has questions, feel free to ask away.

  

Surgery and half way through rotations!

My surgery rotation has been an awesome experience so far. I have some really great surgeons as preceptors who have been helpful and so supportive of my learning. I was a little nervous and excited about starting surgery, I had never scrubbed in before, and although was taught everything in the classroom, I was still a little unsure of myself at first. I had a really great team who was there to help me and remind me of proper sterile technique... which made things so much better. I feel a lot more comfortable with scrubbing in and a lot of general surgical procedures.

I have yet to "contaminate" myself yet while in surgery, although I have had itches and had to think to myself not to itch!

 I was given the opportunity to place foley catheters in women and men, and to intubate a patient. 

I have been able to suture a lot, and am getting a lot more comfortable with using needle drivers and pickups. 

I also have a preceptor who really likes to pimp me on lots of different topics. Because he is so smart and retains everything he has ever remembered (I swear he does)... he makes our time together a really great learning opportunity. He will quiz me on things I may not have thought of before, and it has really helped me to think about what i'm doing.

Also I have seen a lot of breast cancer patients and have come to appreciate all that goes into the treatment of breast cancer. I have been in on a few partial mastectomies where I was able to see the resection of the cancer. I have yet to do a sentinel lymph node resection, however we have at least one schedule before I am finished here. 

Also... I am now over the mark of the halfway point for my clinical year! I cannot believe how quick things are moving. I only have 4 more rotations left and about 6 more months. I can't wait until I can get out there working as a PA-C!

Family Practice finished and the beginnings of surgery

I am now finished with my 12 week family practice rotation. I am constantly amazed at how fast things have gone since I started PA school. It is amazing to look back and see how much I understand and how much medical knowledge I can recall. I still have so much to learn and experience, but I am excited to end the last portion of my PA school journey and start working! 

A brief overview of my last little bit of my Family Practice rotation:

I saw a case of shingles:

I also saw a patient with Bell's Palsy:

This is a picture I found on google of an individual with Bell's Palsy. Notice how the left side of his face is completely paralyzed, including his forehead showing that this is not a stroke, but a palsy of the fifth cranial nerve (trigeminal nerve). 

I also got to manage patients with hypertension, Diabetes, hyper/hypo thyroid and chronic pain just to name a few. 

My youngest patient was 7 days old and my oldest patient was 91 years old. This was the great part about family practice, you get to see a variety of patients and diseases. 

Next rotation is Surgery, which I am very excited about! I have not had the opportunity to scrub in on a surgery as of yet, but I am sure I will love it. As always I will keep the blog up to date with my experiences.