Category Archives: Physician Assistant

Lack of nutritional education in PA curriculum

Why aren’t we taught about nutrition?

I was talking to my boyfriend last night who told his doctor about what his diet consists of based on macronutrient (proteins, fats, carbs) amount per day.  His healthcare provider had nothing to say or add.  They were clearly not well versed on the topic.  And I can’t blame them.  It isn’t something we are taught (at least in PA school– I cannot speak for medical school)
BUT WHY are we not taught about the one singular thing that sustains us to live? (well that and hydration) on a very basic level.  Yet, we are teaching medical providers absolutely nothing about it (that I know of at least–someone correct me if I am wrong :).  
What do we learn as first line treatment for EVERYTHING? “diet and lifestyle changes”.  Right?!
Yet, America overall is so very sick. What is causing this and how do we on a small individual level begin taking steps to mitigate this issue? 

1. Set a positive example

I think that a portion of lack of nutritional and lifestyle counseling comes from either lack of personal knowledge or providers who do not follow the advice they would like to provide their patients. 
I’m not suggesting this is always the case or that the majority of health care providers are overweight and know nothing about nutrition. I’m simply suggesting there is a gap. Between what most providers need to know and what knowledge they have.
 
We need to set an example of responsibility for health and wellness in our own lifestyles so that we are comfortable discussing nutrition and exercise with patients. The best boss I have ever had led by example, and it made me want to work harder and be more of a team player.  I know it isn’t exactly the same, but hopefully the concept is appreciated. 

2. Put the patient in control

When anyone is approaching change, they determine where they are ready to begin.  Meet your patient wherever they are in the change process.  Frequently as helpers we seek to “fix” and tell patients how they need to be “fixed”. 
 
I am SO guilty of this!  “do this not that” “avoid this and do this”. 
 
Recently, I have taken on some different language.  
 
“What changes are you willing to make to achieve a healthier lifestyle/weight/etc?”
 
“What are your reasons that are meaningful for you to seek out these changes?
 
“What goals do you have for your health?” 
 
WHAT IS YOUR “WHY”?
 
Talking to a patient about exercising 5 days per week when they do none or maybe they don’t WANT to do that is going to only lead to frustration. 
 
Baby steps.  I love the quote “slow is smooth and smooth is fast”.  Once they are able to make 1 or 2 things they want to make habit and a lifestyle, start suggesting additional small changes.  Small things ADD UP!

3. Seek out knowledge

There is an ABUNDANCE of educational materials and courses on nutrition available out there.  As providers, maybe we have a responsibility to learn some basics (I know don’t we go through enough school).  I am not suggesting we attempt to take on the roll of a clinical dietician or nutritionist. 
 

What is the purpose/function of each macronutrient (protein, fat, carb)? How does each one serve our body and needs in a different way.  We need protein, fats AND CARBS (yes you need those) on a CELLULAR LEVEL. Our cell walls are comprised of all three. Our cells make up our tissues, tissues make up our organs and our organ systems make up our WHOLE BODY.  NOTE: There are variations of needs for each individual based on coexisting disease, goals, desires and basically how you FEEL.  Some people do great eating vegan: good for you.  Some people count macronutrients: good for you.  Not every way of feeding and honoring our bodies works for each person.
 

Learn the basics of some of the major types of nutrition programs (macros, paleo, keto, vegan, vegetarian).  I am definitely victim to pigeon holing myself into IIFYM (if it fits your macros)– because it is what works for me (disclaimer: this does not mean one eats only donuts because “it fits my macros”).  Admittedly, I’ve had a judgemental approach in the past towards other nutritional approaches.  Until I realized we are all not the same round peg going into the same round hole. And as long as your nutrition supports your body and wellness, I’m taking the approach of “good for you!” 
 
Personally, the nutritional approach I follow is IIFYM (if it fits your macros).  Precision nutrition is the certification that my nutrition coach attained and most of the coaches who work for the company.
Excuse my fine dinnerware 😉 
 
PLUG/RECOMMENDATION: if you are interested in learning more about the IIFYM approach visit http://www.workingagainstgravity.com or feel free to message me!  (I love to talk nutrition).  As an active mover– weight lifter, orange theory, crossfit, hiker, runner, etc etc and health care professional I FULLY endorse their approach and coaching.  Their blog also has so much information available for FREE!  Definitely check them out (I get nothing for recommending them!)
DISCLAIMER: I am definitely biased towards this approach because it has worked for me. 🙂
There is also a great deal of information available on podcasts which I have branched out to, and they are FREE!  I encourage you to listen to  nutrition based podcasts and also listen to the ones you may not necessarily agree with. This not only helps gain perspective of a patient or future patient, but also simply because you don’t agree with the entire basis of the program doesn’t mean you can’t take bits and pieces and make them useful 🙂
 
A simple quote that we can ALL live by no matter what nutritional approach you follow is the following:
 
“Eat real food, mostly plants, not too much” -Ben Bergeron
 
I am not advocating veganism or vegetarianism with this concept.
 
Eat real food. 
 
What does this mean? If it is on a shelf or has an expiration date > 2 weeks– its not real food. 
 
Mostly Plants.
 
Micronutrients are SO important and vital to maintaining health and wellness.  There are micro’s that you can only get from a diet that is rich in veggies! Magnesium, zinc, vitamins, etc etc.  Don’t get me wrong I love my steak once in a while, dairy and ALL sources of protein (if you don’t, that is ok, too!)
 
Not too much.
 
This means something different for everyone.  For most of our patients this can be simplified to prevent being overwhelmed:
 
1/2 your plate is veggies
1/4 lean protein
1/4 starch/carbohydrate
1-2 thumb size of healthy fat (nut butter, avocado, egg yolk, etc). 
 
I think if we can all follow those 3 principles and relay them to our patients we might instill some wellness! 
Example of what I bring to work to eat during a day 🙂

4. Encourage wellness instead of treating illness 

I listen to a podcast called “Pursuing Health” By crossfit games athlete and now medical doctor, Julie Foucher.  On one episode, she discussed where medicine is heading and I LOVE that she said that we are gearing more towards KEEPING PATIENTS WELL instead of treating illness. Instead of incentives for how many patients we see it will be based on quality and wellness. 
 
The problem with this: you can give patients all the information and tools, but if they don’t do the work– will we be getting “dinged” for their illness?  
 
I see both sides. I want to promote wellness, but we cannot FORCE people. I’m interested to see where this is going.  Also, definitely check out Julie’s podcast!  She was the first CF athlete I cheered for and love seeing what she is doing!

5. Advocate change

This is more of a MACRO (as in large) concept.  I would love to hear if people actually THINK nutrition needs to be incorporated and on what level into PA (and/or medical) school curriculum.  Are there people out there who encountered nutrition as part of their pre-req’s or in PA/Med school?  I’d love to hear experience and/or opinions about this!  (Especially because I know I tend to be really biased about wellness/nutrition/exercise 🙂

If you want to see a physician, I want you to see a physician.

“When will I see the doctor?”

For those of us who are practicing PA’s, there is no shortage of this statement. Up and coming PA’s: get used to it.

I know for me, I expected to hear it.  I have ZERO ego about someone who makes this statement to me.  If you do, consider a different career.

I had a patient today who was fairly rude about the fact that I was not an MD/DO.
“Well when are you finishing school?”, “Did you go to Stanford?” (so random), etc etc.

I told this couple that there wasn’t a physician on site.  We never have a physician on site.  I further told them that I am licensed to do everything in a family practice setting that a MD/DO can do.

They still weren’t satisfied.

At which time I said “If you prefer to see a physician I suggest you contact your health insurance company for a provider in your network”.

Why did I let this go so easily?

Establishing a relationship and actually getting a patient like this to value your words is worse than slim to nil. They’re wasting their time, I’m wasting mine and honestly I probably open myself to a law suit HEAVEN FORBID the slightest thing goes wrong.

Dear patients, if you want to see the physician–I want you to as well.

But not before I educate you about how capable PA’s are 🙂

What Specialty is Right For You?

Wow.  I feel like this is a huge one for me– and also will display a lot of how I have grown and developed as a person, student and now medical provider.  I am no where near the person I was in 2013– I am such a better version of myself and I grow, develop and learn everyday.

Before I went into PA school I was “strictly surgery…actual medicine is so boring and for weaklings”.  I also thought medicine was black and white (ha!) When asked at the beginning of PA school I was specifically strictly ortho or trauma surgery.  I actually did my elective rotation in trauma surgery. We were surveyed and when “orthopedics” was prompted I quickly raised my hand.  For anyone who knows me– you know I am enthusiastic and passionate about anything I do.

During didactic year we went through our system based modules and I was in for the surprise of my life. I slowly but surely became more interested in the art of medicine. When our module for women’s health came along, I never expected to love it.  I did.  Our teacher for this module is also the shit. Rosa is one of those people who has a gift to teach.  Everything clicked pretty well for me. I was hooked– like immediately.  I e-mailed our clinical coordinator that day and asked if I could please be placed with her on my OB/GYN rotation.  It was my 3rd rotation and hands down without a doubt my best rotation.  I struggled clinically A LOT on my rotations– my medical background was not strong and taking histories and putting the puzzle together simply took me a bit longer to grasp than others.  And that is OK– because I progressed. Anyways, I fell in love with women’s health here is how and why and how I have decided to pursue this career.

  1. Independent Practice

    Going through PA school and rotations helped me realize I wanted more collaboration as needed as opposed to supervision.  I also realized that the operating room just wasn’t for me (shout out to Dr. Opacic who called that shit first year of PA school– I get it now). I can’t describe it– I just simply don’t like the environment.  Plus I need frequent feeding and a sterile environment does NOT allow for that 🙂
    I wanted my own patient load.  I wanted to be responsible for treating and seeing my own patients– basically I desire to practice to the fullest extent of my license.

  2. Procedures

    I want to be able to do my own procedures, too.  IUD’s, Nexplanon, colopo’s, LEEPs– whatever I can get trained in and be competent in to do on my own.

  3. Some GYN’s also provide primary care

    I don’t want to lose my roots and ability to practice general medicine. PA’s are trained generally and I always want to try and keep a little bit of that flexibility whether it is in my every day practice or in a per diem job or volunteering at a clinic.

  4. The patient population

    Sometimes we need to figure out what we don’t want, in order to be certain of the things we do want.  I’ve decided this is true of everything in life from relationships to medical specialties.  I have spent almost 3 years practicing general medicine of varying acuity levels.  Medical consults, Hospitalist, Urgent Care and Family Practice.  Here’s what I know I DO NOT want to see everyday: really sick people, patients who have not “tried anything at home”, narcotics– I do NOT want to deal with pain management, children– especially babies (I swear I’m not that evil), people who have a runny nose who think it is an emergency (it’s not the person with the GSW to the head is), etc etc.
    Which leads me to well ok well why women’s health then? No one (ok 99% of people) do not show up for an invasive vaginal exam if there really isn’t something wrong. Most patients are able to provide you some semblance of a decent HPI because when something is wrong with your vagina you pay attention to it. They are typically somewhat on the healthier side.  The reason I say this is that if you have an awareness of “needing your annual exam” chances are you pay even just a little bit of attention to your health/wellness.

  5. Setting and work/life balance

    Are you looking to work in a hospital, ED, operating room or clinic?  What type of hours do you want to work? Do you want a set schedule, shift work, do you hate working nights, etc etc.
    I am NOT a night person. I worked nights and it was not easy for me.  I love being up at 4:30am. I love my workout before work and I want a job that allows me to do these things 🙂
    As I said before I do not want to be in a OR– or at least to this point in my career I have not found a position that has made me go “owe I wanna do that!”  Never say never, but I know right now it isn’t in my cards.
    12 hour shifts are also not up my alley.  To me it was like– ok I’ll do EVERYTHING that needs done in my life 7 days from now when I have a day off.  Simply not for me.  Some people love it.

    All things to consider!

Healthcare Culture: Everything Hurts and I’m Dying

There are a lot of issues being discussed in healthcare today.  One point I don’t hear a lot about, but see everyday comes directly from our patients mouths.  They come in to clinic with the mindset of “everything hurts and I’m dying”.  What this means is that if they have a headache they think and know that they have a brain bleed and they need and MRI.  If their child has a cough they definitely need an antibiotic.  They woke up sick this morning or have an ache in their shoulder x1 day: everything hurts and I’m dying.  

The undertone of this statement that they don’t directly say: And you BETTER do something– better yet– what I think you need to do. 

Now, let me be clear it isn’t that I’m not empathic to patients who are feeling ill or in pain.  However, there is this culture out there that extreme measures, investigations and treatments need to be taken if you have a headache.  Are there the small percent of people who do need these measures? ABSOLUTELY.  That is why we do history and physical exams to weed these people out and send them for these tests.  

Why does this matter? What is this causing in medicine? Cost. Waiting room lines. The emergency department being used for non-emergencies (sorry people this was not created for you to get a pregnancy test free or score some morphine for back pain– it was meant for people with asthma exacerbation, CHF, PNA amongst so many others). 

How does this effect providers? We also have to act like someone who thinks they are dying are dying.  If we don’t they’re not satisfied. Re-assuring patients has become the most difficulty part of my job.  We all know when we have this person in front of us.  I always make sure to do a full physical exam.  I talk them through it saying “your ears are clear–no infections, airway is patent– tonsils are not enlarged, no lymph node enlargement, lungs sound great, your neurological exam is completely normal, vital signs completely within normal limits—– etc etc”.  But for some people they just aren’t satisfied.   

What else are we to do?  Patients who push for further intervention, I tell them I cannot treat an infection that is not there or worry about signs or symptoms that you do not have.  I tell them this is good news.  

My question is where are we going wrong? It seems like more and more people are lacking basic concepts about colds, headaches and belly aches.  I do my best to educate my patients.  Viral bronchitis is a BIG one.  I tell them 98% of bronchitis is caused by a virus. The cough can last 3-4 weeks even after you begin feeling better.  I state “Scary symptoms that you DO need to be concerned about are persistent fever or coughing up blood streaked sputum.” I ask them EVERY TIME “do you have any questions”.  I usually ask this twice. Yet somehow there are still people who come back a week later cause they have a dry lingering cough?  

Would love to hear thoughts from students on rotation and practicing providers with how you best handle these situations.  As well as suggestions.  May this serve as a reminder to always educate your patients as much as possible!

The Hierarchy of Medicine & Minding The Gap

Medical careers have always had somewhat of a tough, rough and tumble appeal.  It’s difficult to get accepted, get through school, residency, fellowships, boards, etc etc. We’re all these type A, rise-and-grind people. Whatever your particular career may hold, whether you are a nurse, doctor, PA, NP, Pharmacist.  The culture of medicine is BRUTAL and our jobs are difficult enough, so I pose the question: why are we making it more difficult on each other?

Who remembers being a PA/RN/Medical Student and being terrified of Residents or Attendings?  Allow me to raise my hand first. I cannot help but think how backwards this is.  Think about it, we are in a field that most people would say they enter to “help people”.  That is what we write in our personal statements and tell admissions committees I guarantee it. So, if we are truly in the business of helping people and “working as a team” why am I getting yelled at for calling an on call Fellow Physician at 2am? Why do I hear providers yelling at nurses? Confession: I’ve done this. Second confession/further information: Don’t page me “Pt has a fever.  Please advise” when they already have Tylenol ordered. (If I had a dollar…)

Ok, anyways I’m getting off track. When did medicine become a culture of “I’m higher up than you so I can yell at you/treat you like crap?” Back to that 2am call to a Fellow Physician: If you do not want to be woken up, don’t be a GI doctor– it will require call. Second, since when did I have to apologize for waking someone up because I have a patient that truly needs you to get your ass up and come in and do something?  You chose this, you wanted to pursue this career and help patients.  Get up. Put on your shoes and get your ass to the hospital. No, I didn’t say this– but I thought about it.

Perhaps the greater question is: Does this behavior and interactions harms patient care?  Especially in a hospital setting at teaching institutions where environments can be quite cut throat and hostile.  Residents fighting for cases, PA’s trying not to get their ass chewed out by fellows and attendings, providers getting pissed at nurses, nurses getting pissed at CNA’s. etc etc.

Like I said, have I been guilty of being an asshole when I’m dead tired and can’t handle another trivial request? Yep, sure have. Am I proud of this? No.

Listen, the reality about medicine is that you deal with people all day and it gets rough and sometimes you lose your shit.  (I hope I’m not alone here) Have I let this realization alter me for the better?  Sure have.

I’ve been reading a lot of Brene Brown’s work lately.  In one of her books (I think it was “Daring Greatly”) she talks about how you are not who you say you are or who you want to be.  You are only what you do.  The difference between this, she refers to as “minding the gap”. The space between who you are/what you actually do and who you want to be/what you actually do. 

Everyday I look at my fridge where I have a dry erase board that says “Mind The Gap”. And I think about the person I want to be in the present and how I want to become better every day.  Am I perfect? Hell no.  Am I trying? Hell yes.

 

I Don’t Have Time VS. It’s Not a Priority.

I cannot emphasize how much “I don’t have time” correlates to “It’s not a priority.”  I challenge everyone to take the phrase “I don’t have time” and replace it with “It’s not a priority”.  I guarantee you that it will be eye-opening.    

Quite frequently I have individuals who talk to me about my workout regimen and my food prep and I’m amazed at their ability to find reasons as to why I am able to do the things I am able to do for my health and how those reasons correlate to why they absolutely cannot.  
The most recent incident occurred as someone proceeded to tell me that I have time to workout because “I’m not responsible for other people”. Translation: I don’t have a husband or children.  First, I believe this is an excuse.  Do individuals who have families have a time management and priority challenge: yes. Do individuals like me have a priority challenge?  YES. Everyone’s time management challenges are unique to them.  I feel as though others have attempted to make me feel that because I don’t have a family, my priorities and check lists of things to complete are somehow easier to accomplish or not as important as those with families/husbands/wives.  I proceeded to tell this person that I work full-time. I run a side business and a website.  I have a dog that is a priority and I make sure she has food prepared and gets a walk 6 days a week. I spend a lot of time on the website/blog and other projects I’m working on collaborating with other professionals.  I also spend a decent amount of time reading about medicine and investing into my career. 
Everyday I wake up at 4:45am. I go to the gym participate in group crossfit class 5-6 days per week and 3 days a week I do extra individualized programming.  I’m either out of the gym by 6:30 or 7:30am on days that I work depending on my programming.  I go home walk my pup and listen to my HIPPO education RAP, shower/get ready/pack lunch(already prepped for week)/eat breakfast. Any extra time is dedicated to editing statements or working on the website OR a special project I’m working on with National Physician Assistant Eduction (its secret for now 😉  I arrive at work at 9am.  9am.  By the time I get to work I’ve done more with my day than most people do with 12 hours.  Currently I work in an urgent care.  This morning in 3 hours and 15 minutes I have seen 11 patients and written most of this blog.  Any down time at work I spend editing, reading medicine or responding to emails. 
We all have priority challenges.  We filter massive amounts of information, people and tasks daily and we decide consciously and unconsciously what we prioritize.  You are what you do, not who you say you are or what you say you will do. 
We all have the same 24 hours in the day, it’s all about finding ways to maximize every minute and hour afforded to you. 
I challenge everyone who reads this article– for ONE WEEK: Replace “I don’t have time” with “It’s not a priority” and I guarantee you will learn a great deal about yourself.  

Don’t Call Me Honey: An Open Letter to Patients Older Than Me 

When I enter a room with a patient I have a routine.  I knock, I introduce myself “Hi my name is Danielle, I’m a Physician Assistant I’m one of the providers here today”. I give a firm, confident handshake looking the patient in the eyes. I’m self assured and confident–not cocky, confident. I’m 32 years old.  I have a bachelors degree and two masters degrees.  I look like I’m about 18 and at least once per day I get asked “Are you old enough to do this” or get called “Honey” or “Sweetie” or “Dear”. 

Let me be clear, when older adults call me these things in different contexts of my life such as someone holding a door at Starbucks or in the check out line at the grocery store it doesn’t irritate me.  Hell, thanks a lot I’m 32 and you probably think I’m in my early twenties.  

However, when you walk in to a providers office I view these potential “terms of endearment” quite differently.

  1. Just because you are older than me doesn’t mean that you have better judgement with your google search

    Let me be clear, I don’t disregard statements my patients make.  Many times per day I have patients that come in and say “my kid just isn’t acting right” or “Every time I have a UTI this is what it feels like”.  However, you walked in to this office and you are paying for my medical opinion and clinical judgement. If I am unsure of something, I am the first person to directly tell my patient and seek a second opinion.  Until that time, please remember that you sought out a medical professionals opinion.  Again, let me be clear it isn’t that I don’t listen to my patients.  I understand when a patient says “Yea, my fever is only 99.5 but I am never about 97 or 98” or “Last time this happened I ended up with pneumonia because it wasn’t treated right away”.  Those are important things to know, and I am more than happy to hear those statements–hell it helps my clinical judgement. Saying “honey I looked this up on the internet and this is what it is,” is rude and disrespectful.  Don’t talk at me, speak with me. I give you this same respect and decency, please give me the same.

  2. Its degrading

    I’m not “honey” or “sweetie” to you.  I’m your medical provider. I’m here to offer the solution I believe based on my clinical judgement and education best suits the ailment or symptoms you are presently experiencing.  Also, dare I ask the question: If I were a man would you still use these terms? If I were older or looked older or always wore a white coat–would you make these statements? Perhaps, but I do strongly believe that it is geared towards the female gender and that if I were a man it wouldn’t occur nearly as frequently.  

  3. Your terms of endearment undercut my education.  

    You may not intend to do this, and maybe I am misinterpreting.  Think about it, we frequently call small children “honey” and “sweetie” or “dear”.  They sure don’t have the education or intellect necessary to perform a clinical assessment and prescribe treatment.  Using the terms you use to speak to children makes me feel like you do not respect me as a professional medical provider.  Period.

  4. Please do not ask me if I am “Going on to Become a Physician”

    Ok, confession this doesn’t quite fit the mold of this blog.  However, I am a Physician Assistant.  It is a profession and a damn good one.  In fact it is projected to be the #1 Masters degree and profession through 2025 at this time.  We are not in 1970 where “people just don’t know what it is”.  This is 2016.  PA programs are more competitive by the numbers to earn acceptance than medical school.  I am not a medical assistant, nurse or resident.  I’m a PA.  If you want to know more about my profession, please ask me I am happy to speak with you about it.  But please, please do not ask me when I’m becoming a physician.  

Don’t Call me Doctor, A spin off…

I must first reference and give credit where credit is due to http://www.mypatraining.com (Inside PA training) Find their podcast HERE.

As PA’s we get called pretty much anything but “Physician Assistant”.  Nurse, Doctor, Medical Assistant and my LEAST favorite “Physician’s Assistant”.  I have several points to make which I feel strongly about regarding this topic, much like Paul from Inside PA training.

#1 Introduction and Correction
The absolute first thing I do when I walk into a room with a patient is introduce myself as a Physician Assistant.  Not doing so I believe is a violation to your patients.  They deserve to know who is seeing them and treating them.  Plus, I’m really proud of being a PA.Secondly, if they refer to me as “doc or doctor” I immediately correct them.  I also agree with Paul, that correcting patients more than once gets redundant and IMO you can appear a bit rude continually correcting.

#2 Gender Dependence (unfortunately gender bias does exist my friends)
I definitely get referred to as a nurse more than a doctor.  Although I get both the ratio is ill proportioned.  I notice when seeing patients they refer to my male colleague PA’s as “doctor” more frequently.  I’ve worked with many female residents who were continually called nurse, after they introduce themselves as a resident physician (COME ON PEOPLE!)
Now, to be clear I’m not hating on nursing at all.  However, medical schools are becoming to be predominated by women.  PA’s and NP’s are predominantly female. Female providers of the medical field are not sparse, yet this continues to occur.

#3 NP’s with Doctoral level degrees
This might be my top pet peeve.  Not all, in fact very few NP’s do this.  However, I have come across several who introduce themselves as ” Hi, I’m doctor so-and-so the nurse practitioner”  OK, I know what some of you are thinking “But they said they’re an NP!!!”  Lets think about our general patient population and telling them you’re a doctor and an NP in the same sentence. It’s confusing.  Most people aren’t aware NP’s can obtain  a doctoral level degree, but this doesn’t make them an MD or DO.  I understand you earned that education, by all means but those initials after your name on your white coat–but in my opinion–keep it simple for patients.

#4 “But I want to see the DOCTOR”
This honestly has happened to me only once or twice.  It was so insignificant that I can’t even remember the instances.  You absolutely have to oblige with patient request.  I mean, they say the number one factor in being sued is likability of the provider.  Imagine if you gave someone flack and forced them to see you and god-for-bid something went wrong.

#5 “Are you going to finish your education”
I usually take this opportunity to quickly educate patients on the PA profession.  A short sentence will do. “Actually as a PA I am already licensed to provide medical care under the supervision of a physician”.  Sometimes they ask a few more questions, if they ask why most of the time I tell them well I get to do most of what a doctor does with a 1/4 of the debt (which in my case isn’t necessarily true but it gets the point across) 🙂

Medical Musing of the Week: Atrial Fibrillation

Overview + Definitions

  • Most common arrhythmia
  • Increased risk with age
  • Irregularly, irregular rhythm and absent P waves on EKG
  • Valvular vs. non-valvular (valvular means that arrhythmia is being caused by some type of valve disease ie rheumatic fever or from a defect in a prosthetic valve)  Most cases are non-valvular A-Fib (you will hear that term frequently!)
  • A-Fib w/ RVR (stands for “rapid ventricular response”): This basically means that the person is not in rate controlled A-Fib and the ventricles are trying to keep up with all the beats being initiated by the atria.
  • The more days/weeks A-Fib persists the increasing likelihood that it will be permanent
  • Paroxysmal A-Fib: Self-terminating within 7 days onset.  Usually terminates <48 hours. Recurs with variable frequency.
  • Persistent A-Fib: Atrial fibrillation that fails to self-terminate within 7 days or requires medication for termination.
  • Permanent: Has persisted >12 months and cardioversion has usually been unsuccessful.  Focus shifts to rate control

Etiology + Risk Factors

  • Coronary Artery Disease
  • Congestive Heart Failure
  • Acute Coronary Syndrome
  • Hypertension
  • Pulmonary Disease (esp COPD flares)
  • Pneumonia/Infection
  • Etoh (“Holiday Heart”) –> Lots of patients will show up to the hospital around the holidays because of increase of alcohol use
  • Surgery or anything that will cause fluid shifts in the body either overload or dehydration
  • Has patient missed any doses of rate controlled medication?

Clinical Manifestations

  • Palpitations/Chest Pain
  • SOB (may have increased O2 requirement secondary to heart beating so fast patients are not perfusing appropriately and become SOB– once their HR slows the will perfuse better and O2 requirement likely subsides

Diagnosis

  • EKG
  • Troponin x3 + CKMB x1
  • CT PE study (for rule out–in hospitalized patients who have a new oxygen requirement
  • Telemetry Monitoring

Treatment

Steps to take/Questions to ask:

  • Calculate Cha2ds2 Vasc:
    • The “chads vasc” is a scale that determines an individual’s risk per year for stroke.  Based on their risk have a discussion with the patient about risks and benefits of oral anticoagulation
    • Scale includes:
      • Congestive Heart Failure
      • HTN
      • Age (2pts) >75, (1 pt) >65
      • Diabetes
      • Stroke/TIA history (2pts)
      • Vascular Disease
      • Sex (+1 if female)
  • Is the patient rate controlled?
  • New onset?
    • If rate controlled determine need for oral anticoagulation (watch providing with elderly who fall frequently)
    • If rate isn’t controlled do so with a BB
  • Is the patient rate controlled? (<110 BPM)
    • A-Fib RVR:
      • In a hospitalized patient options for treatment include IV Lopressor (may repeat for 3 doses, Cardizem 5mg +/- drip (may also repeat), Digoxin or Amiodarone bolus +/- drip
      • If low BP will want to hold off on Cardizem or Lopressor–cardizem will really drop the BP
      • Amiodarone is my go to when a patients BP is low 150mg bolus followed by a drip of 1mg/kg x6 hours, .5mg/kg for 6 hours, 400mg daily and then 200mg daily for maintenance
  • Are they hemodynamically stable?

Below is one of my favorite flow charts from UpToDate (love this source!)  This is a really good place to start to understand the treatment of A-Fib

image

 

Prognosis + Complications

  • The longer a person remains in atrial fibrillation the greater the risk it will be a permanent rhythm
  • RVR (rapid ventricular response)
    • Frequently seen in the hospital especially with CHF exacerbation, surgery (because of fluid shifts)
  • CVA/TIA
    • Because of the irregular rhythm of the atria and valves individuals with a-fib are at increased risk of developing clots on their mitral valve and throwing ot through their aortic valve and to the brain
    • Calculate chads vasc as above to determine risk

 

Tearing off Training Wheels

PA school is super stressful and overwhelming.  Graduating and starting your first job and your first year out in the real medical word is equally stressful; but, in different ways.  I started my first job and felt like I had no idea what I was doing and like I hadn’t even prepared in the least to walk around a hospital.   Not because I didn’t get a good education at Pitt.

I believe there are several factors as to why I felt like I was attempting to ride a uni-cycle at first.  First, just as elementary and secondary schools are pushed toward performing for a test–so are PA students.  We spend 2 years obsessing about passing the PANCE and all of the horrific things that can happen if we fail.

Second, the PA profession was derived around filling the shortage of Family Physicians.  Thus the education model we follow although follows a general medical concept has a strong focus on family medicine. As I have talked to students who have gone through the same program as me I hear that they are adapting and learning different information and procedures to adapt to the ever diversifying role PA’s are filling.

Third, PA school is FAST.  There is only so much time to learn a lot of information.  I look at the doctors I work with or PA’s with  couple years more experience than me and I think damn “when will that be instinctive for me?”  I quickly decided I would treat my first couple of years in medicine as a resident would.   I do a lot of reading and ask A LOT of questions.

The next reasons are a bit more unique to me; but, perhaps others have experienced them as well.  Before PA school I did not obtain my HCE in a hospital or medical setting.  Even though I had a couple of rotations in hospitals they were pretty sub par despite my constant asking to learn ad do new things my preceptors weren’t particularly helpful in these settings.  So, when I started work I felt like I was still acclimating to a lot of things.  The job I took was also pretty low acuity patients with repetitive problems. The group I was with was great; but, once I got out doing hospitalist work I was like “holy shit”.  I worked basically taking care of post operative patients medical needs.  It got really repetitive pretty quick–every once in a while we had a unique case.  Usually it was standard post operative stuff surgeons didn’t want to handle.

So, when I started my position as a travel PA as a hospitalist at the largest medical resource between Pittsburgh and Philidelphia I felt really intimidated.  I remember my first night getting my first page I had to go and assess a patient.  I felt like I forgot to do a H&P and how to critical think.  it was a really weird feeling that I  can’t quite explain.  I look back at that day and I laugh to myself.  I’ve come a long way since then.  Practicing more independently and handling floor patients in the middle of the night pretty much independently (unless you have to push adenosine–then you call your Attending because–well that was above my pay grade to do that alone the first time on a patient who was a no code).  I’ve become more comfortable responding to RRT’s, even getting a system down as to what I would do to assess the patient and what questions I would ask the nurses.

I still feel like I’m losing my balance some days.  I partially think that is the nature of medicine and also being a PA–we’re expected to know about a lot of things in a short amount of time.  However, I think back a lot to my first day of PA school and my first clinical semester and first rotation, etc.  I realize I’ve come really far.  Even if some days I feel like I know nothing when it comes to a really complicated patient.  Then I remind myself that I would rather feel stupid temporarily and learn as opposed to feeling like I know everything all of the time.  First because that is dangerous and second that would mean I’m not being challenged.

The past can be evil, but it can also be our friend.  Make sure to realize how far you’ve come and everything you’ve learned!  Feel lost, ask questions and take things on before you think you are ready.  You will be ok and your medical knowledge and skills will advance. I sure as shit had never heard the term protein losing enteropathy before and I remember feeling super intimidated by trying to figure out how the hell to order sliding scale insulin.  I still don’t know much about protein losing enteropathies; but, I’m pretty sure I’ve gotten insulin and a lot of other things down since I was cut lose a year ago.  Always remember progress is always being made!!