Tag Archives: PA Student

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!

Life as a Traveling PA

Recently I have had A LOT of questions about becoming a traveling or “locums” PA.  I decided to address everyone’s questions and tell everyone a little about my experiences to help out! Please leave additional question in the comments section and I will do my best to address them 🙂

FAQ:

1. Can I do this as a new grad?

You can.  However I imagine there would be pros and cons to this.  As a traveler/locum you are pretty much expected to go in somewhere, adjust to the EHR (electronic health record) if you have never used it before and roll like you’ve been there before.  So– there isn’t a lot of room for you to learn how to treat patients.
I tell most people that if you feel like you had great patient care experience, clinical experience and/or clinical rotations and if you can treat patients without feeling like you need to ask a lot of questions go for it.  I was a mental health therapist before being a PA and didn’t feel like I had strong rotations so it wouldn’t have been a great choice for me.
Second, expect to work in the “less desirable” areas or specialties.  I’m not trying to be rude or anything, but there aren’t a lot of people who wanna work in the middle of no where in North Dakota in psychiatry. BUT– if you take that job and get something on your resume it makes finding your next position a lot easier.  You have bargaining room.  Also, don’t expect the high-end of the pay spectrum (you would likely– most likely still be making more than anyone you graduated with).

2. What is the pay like?

It’s good.
I am unable to talk specifics, but it is definitely more than I was making as a new grad anywhere else.
You are paid hourly and always– ALWAYS high ball people.  The money is there.

3. What specialties can I work in?

It depends on what you are looking for.  As a new grad– see above. It also depends on what you have experience in.  You will always get more money in fields you have experience.  However, if you want to try something new and are ok with taking a little less money you might be able to try something new.

4. My friend/significant other and I want to travel together can we get an assignment in the same location?

Sometimes, yes.  Or it could be relatively close– or in between so you could share housing. But I would think with some positions this would be possible.

5. How do I find a company to work with?

NALTO is the National Association of Locum Tenens Organizations. This is basically the BBB for travelers/locum providers.  It is to protect you and the organization who is placing you from anyone getting treated like crap (for lack of better words)

6. Who finds your housing?

Your company has an entire department that is responsible for finding and paying for your housing.  And YES you can bring your dog =)  My nugget comes everywhere with me! I know some travel nurses who get a stipend and then find their housing– I haven’t heard or encountered this as a provider.

7. What about malpractice/licensing/credentialing?

Again, your company should have an entire department for this– if they don’t you’re with the wrong people.  I don’t lift a finger for any of this.  Make sure they cover “tail” insurance.

8. Can you pick your sites?

Yep.  I don’t go anywhere or do anything I don’t want to.  I’m an “independent contractor” which means I DO WHAT I WANT.  =) It also means I file taxes as an independent contractor— get a good CPA.

9. How long is each assignment?

It’s totally up to you.  I like to take assignments about 3-6 months long.  Then it is worth it for me to move all my stuff and be kind of settled, explore the area and peace if I want to!  If you’re good you’ll be offered extensions or permanent positions.  PRO TIP: a lot of companies have clauses about taking permanent positions out of a locum position.  As in how long you have to be gone from the position or there are also “locum to permanent” positions out there too.

10. What about benefits (medical, dental, vision, 401k)?

The only company I have come across that offers this is COMP HEALTH.  I didn’t take an assignment with them yet, but all of the recruiters I talked to were really nice and I would consider taking a job with them.  Their hourly pay is a little less compared to other companies, but you do get benefits.  PRO TIP: they have a 6% 401k match which is pretty good.
To give you an idea of benefits cost per year here is what I have been in for:
Health insurance: 260/month with a 4,500 deductible
Vision: eye exam was like 180$ and my contacts $120 for about a year
Dental: x rays and cleaning cost me $240.
I recommend a health savings account. I’m also increasing my disability insurance to better reflect my current earnings which will cost me about $150 per month.

11. Are you re-reimbursed for transportation and travel?

YES.  You should not drop a DIME.

12. What are the PROS and CONS?

PROS: 
The pay, no rent or utilities.
You get to travel and see the country on someone else’s dime. You aren’t subject to all the “office politics” because you are an independent contractor.
If you don’t like something about the job— it has an expiration date.
CONS: 
You move a lot.
You don’t have control over “the little things”– see below —

13. Are there positions outside the USA?

No idea.  Not that I have found yet.

14. How does retirement work?

I have my own retirement funds as of right now.  Comp Health (which is a locum company) does offer benefits to their employees.  6% 401k match.
I recommend a good financial adviser.  I love mine if anyone needs a rec.

15. Can you get hired on permanently?

This depends on the company you are currently contracting through and their rules.  Some have clauses in your contract that state “cannot work for x,y,z for one year after end of contract” others don’t care and some positions are also noted as “locum with opportunity to transition to permanent”

16. Are there any PA schools that incorporate study abroad?

Yes, my friend is applying to one but I cannot remember which.

17. How does state licensing work?

Literally your company should do EVERYTHING for you.  You should not lift a finger. Or pay a dime.  And don’t let anyone ever tell you that you cannot work for another company because “they paid for your license” that is complete bullshit and a rep just trying to bully you into staying with them.  I highly recommend not working for someone who tells you this as they definitely don’t have your best interest at heart.

18. Do you get a living stipend?

No.  My costs are literally all covered.  I don’t pay rent or utilities.

19. What is the best way to prepare for this type of position before/during/after PA school?

Before: Get experience as a CNA, in a hospital, work as a nurse– some type of position that prepares you to be immersed in health care and you don’t feel like a fish out of water as you graduate.
During: Really really really focus on the plan of care.  Know what you would do for the patient.  Also know what you would do if something went wrong.
After: Apply? And be willing to take a job somewhere not ideally located or not in the perfect specialty

20. How competitive is being a locum?

There is a HUGE need.  This also is variable based on specialty.  I have done all hospital, family or urgent care med.

21. Can you change specialties?

Sure. It helps if you have prior experience in these specialties.

22. TAX DEDUCTIONS

So– you can turn A LOT of things in to tax deductions.
Flights
Food
Coffee
Health Insurance
Dental work
Vision
Hotels
Cell phone
Electronic purchases
Amazon Prime
Kindle
iPad
Anything that “is a cost of operating business”

23. Are certain areas in higher demand.

Yes Rural areas.

24. How does salary/payment work?

You are an hourly employee
If you don’t work you don’t get paid– but you are paid well and honestly it doesn’t matter.
You are paid through your company.

25. Is salary competitive?

Yes.  More than competitive. And again– always, always HIGH BALL on your offer for what you want compensation wise.

26. If you live in a state that NCCPA exempts you from taking PANRE and you travel to a state that requires it, do you have to take the PANRE before you go?

So, as a traveler I would no recommend going without NCCPA cert. Most locations want or require it.

27. Are you given additional training?

I have not been.  You need to be ready to step in to someones shoes for the most part.  But– I do think there are jobs out there that are longer contracts that may be willing to train if you took less pay or something.

Tid-Bits:

  • Keep copies of everything.  Especially the malpractice insurance you have with each company/position.  You will need this with each new position you apply for
  • Make a folder for each company/position you work in your e-mail.  Keep everything.
  • As for copies of proof of wherever you are living.  I recently lost my housing (which wasn’t my company’s fault but a total pain in the ass) Ask for every damn thing in writing.
  • If people are interested in how I cook/eat/count macros while living in a hotel let me know.  I’ll write a post all about that
  • Yes, your dog can come.
  • Get a file folder for all of your “business related” receipts

Things you don’t have control over that you probably haven’t thought about:

  • Your shower pressure
  • closet space
  • washer/dryer
  • neighbors
  • dishwasher
  • how long does the hot water last?
  • sometimes contracts fall out.  I swear all of the “this never ever happens” have happened to me.
  • Fridge space
  • THE MATTRESS.  I swear if any performance mattress companies out there want to sponsor me I AM IN.  My last 2 places had shitty soft mattresses and I have honestly thought about having one sent to me.
  • Concealed carry license.  I’m not trying to be political at all but if you have a concealed carry license for a weapon it will be a pain in the ass to transfer it so you can actually use it.
  • If you like your position and they want to hire you depending on your contract they might not be able to
  • Auto insurance.  As long as you are only in a location for 6 months you can use whatever permanent location you want.

Stuff you wouldn’t think of but need to know:

License plates.

Yea totally didn’t think about this.  There are a couple routes you can go.  You can sell your car or park your car somewhere and have your company rent you one.  Or you can say “eff it” and figure it out as you go– which is what I did because I LOVE LOVE LOVE my Nissan Rogue!!!!  My plates actually expire this month.  I am using a co-workers address in a county in California that doesn’t require smog inspection. What is tricky is that in order to change your drivers license address you normally need a lease, mortgage or utility bills to “PROVE” you live there.
Well I have none of those. So, what do you do?
The DMV also accepts bank statements.  So, I changed my investments and my bank statements to that address and I explain my situation and bring those documents.  That has worked with me in the past and hopefully when I go for my license plates and address update they change it for me!

Driving Insurance

I left my insurance under the town I lived in for my first travel assignment in Danville, PA because the rate is dirt cheap. You are “LEGAL” as long as you are only staying somewhere for 6 months. You don’t necessarily have to change your location.

Health Insurance

So, I haven’t had to deal with cross states yet.  I’m also for national health insurance (bring on competition and drive down rates hahahaha).  However, my guess is that moving to a different state would be a “qualifying event”

Voting

See my debacle regarding license plates!

Banking

I recently switched all of my regular banking with USAA (my dad was in Vietnam so I automatically qualify to have accounts with them).  I HIGHLY HIGHLY recommend them.  They are so kind and always willing to help and EVERYTHING– EVERYTHING can be done on the internet or phone.

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!

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.  

Medical Musing of the Week: Behcet Disease

Overview

  • Disease marked by recurrent eye and genital lesions as well as ocular involvement.  Autoimmune/autoinflammatory disease with a hereditary component.

Etiology/Pathogenesis

  • Perivasculitis and early neutrophil infiltration w/ endothelial swelling
  • Association with HLA-B*51
  • Mediterranean descent/region, middle east and far east

Clinical Manifestations

  • Recurrent oral and genital ulcers
    • Painful with yellow necrotic base
    • Can occur alone or in clusters
    • Subside in 1-2 weeks w/o scarring
  • Integumentary Involvement
    • 80% of patients also have skin lesions
    • Folliculitis, Erythema Nodosum, Vasculitis (infrequent), sweet syndrome and pyoderma gangrenosum
  • Ocular Involvement
    • 50% of patients experience ocular symptoms
    • iritis, uveitis, retinal vain occlusions, optic neuritis
  • MSK
    • 50% have arthritis or arthralgia
    • Knees and ankles most common locations
image
                                               Clinical Manifestations of Behcet’s Disease

Diagnosis

  • Clinical
  • Pathergy Test
    • Introducing a needle under the skin resulting in an abnormal healing and development of ulcers and raised erythematous area demonstrating irregular healing
Positive Pathergy Test.  Increase in inflammation and erythema represents impaired healing
Positive Pathergy Test. Increase in inflammation and erythema represents impaired healing

Treatment

  • Methylprednisilone 
    • 1 g administered intravenously for one to five days,  for progressive, severe, organ or life-threatening disease.
  • Colchicine
    • Effective for mucocutaneous involvement
    • Also associated with decrease in joint involvement for men and women and genital lesions and erythema nodosum in women
  • Azathioprine
    • Patients treatment with steroids and AZA demonstrated less vision deficits and blindness
  • Cyclophosphamide
    • 1 to 2.5 mg/kg per day, orally
    • 1 g or 0.75 to 1 g/m2 by monthly infusion IV
    • Effective for neurologic and vasculitis associated with Behcet’s

Complications

  • 30% develop DVT and PE is a rare complications
  • Blindness may ensue from Panuvitis
  • CNS Behcets: IL-6 is persistently raised in cerebrospinal fluid of these patients

 

 

 

 

Medical Musing of the Week: Hyperthyroidism

Overview

  • Excess Synthesis and secretion of thyroid hormone by the thyroid gland
  • Hyperthyroidism exists as Graves Disease, Toxic Multinodular Goiter, Toxic Adenoma and Subacute Thyroiditis
  • The MCC of hyperthyroidism is Graves Disease  (50-60%)
  • Increased FT4 
  • Increased T3 in Subacute Thyroiditis
  • TSH is suppressed 

Pathophysiology

  • TRH is produced in the Hypothalamus which then signals the Pituitary Gland to secrete TSH to the Thyroid Gland signaling T3 and T4 to be released to peripheral tissues (see picture below if you are a visual learner.  C/o Medscape)
  • When adequate levels of circulating T3 and T4 have been achieved in the normally functioning thyroid a negative feedback signal is sent to hypothalamus to temporarily halt TRH production (and begin reproducing when T3 and T4 levels are low in periphery) 
  • Iodide binds to thyroglobulin via peroxidase.  This results in monoiodotyrosine (MIT) and Diiodotyrosine–combining to form T3 + T4 which are then stored in the thyroid as preformed hormone (these were terms I haven’t seen since didactic year, hah!)

image

Etiology & Risk Factors

  • Genetic predisposition
  • Additional Autoimmune diagnosis
  • Pregnancy (Use PTU not MTU)
  • Women > Men
  • 20-40’s
  • Amiodarone toxicity (rare)

Clinical Manifestations

History

  • Nervousness/Restlessness
  • Increased bowel movements
  • Anxiety
  • Palpitations
  • Weakness
  • Menstrual Irregularities 

Physical Exam

image
Exopthalmos
  • Fine resting tremor
  • Warm skin/heat intolerance
  • Thinning hair
  • Increased reflexes
  • Onycholysis
  • Enlarged thyroid
  • Sinus tachycardia/PAC’s/A-Fib
  • Exopthalmos

    image
    Pre-tibial Myxedema
  • Upper eyelid retraction
  • Lid lag w/ downward gaze
  • Pretibial Myxedema

Diagnosis

  • The single most important test is TSH (will be decreased)
  • The severity of clinical manifestations does not necessarily correlate with TSH level
  • ELISA for Anti-TPO for Graves Disease
  • Free T4 and Total T3 levels
  • EKG if Sinus Tachycardia (may also want to check electrolytes) 

Treatment

  • Methimazole
    • Starting dose: 5-20mg Q8h
    • Once euthyroid 5-15mg QD
    • Inhibit coupling of iodotyrosines in thyroglobulin resulting in a gradual decrease in circulating hormone over 2-8 weeks
    • Monitor levels Q4 weeks when first starting treatment
  • Propylthiouracil
    • Starting dose: 300-400mg/day divided Q8h
    • Once euthyroid 100-150mg Q8h
    • Preferred in pregnancy (MTU is safe after first trimester)
    • More potent–also blocks T4 -> T3
    • Inhibit coupling of iodotyrosines in thyroglobulin resulting in a gradual decrease in circulating hormone over 2-8 weeks
    • Monitor levels Q4 weeks when first starting treatment
  • MTU & PTU side effects:
    • Fever, Rash, Agranulocytosis, Aplastic Anemia, Hepatitis
  • Radioactive Iodine Ablation (most common and effective treatment)
image
Radioactive Iodine Ablation in a patient with Graves Disease
  • Thyroidectomy (not frequently performed due to effectiveness of RAI ablation)
  • Symptom relief (Beta blockers)
    • In addition to treating the symptoms of tachycardia, tremor etc– beta blockers also decrease conversion of T3 to T4 (which I didn’t know before!

Complications 

  • Patients who go through RAI ablation or thyroidectomy are often left hypothyroid.
  • Thyroid Storm
    • Acute life threatening hypermetabolic state caused by excessive thyroid hormone
    • Fever, tachycardia, hypertension, diaphoresis, AMS
    • Cardiac manifestations and complications can range from sinus tachycardia to high-output cardiac failure and arrhythmias 
    • Treatment
      • Methimazole is first line
        • 20mg Q4-6 hours
      • Propanolol is first line Beta Blocker
        • 60-80mg Q6h or .5-2mg IV Q10 minutes for the first few hours
      • Glucocorticoids
      • Supportive Measures

 

Sources:

Current Medical Diagnosis & Treatment 2015
UpToDate
Medscape

How to Choose an Elective Rotation in PA School

This is probably one of the vital mistakes I made in PA school.  We had to choose within our first six months of didactic year and I was on the clueless train as to what area I wanted to practice.  So, here is the advice I wish I knew when I chose my elective rotation.

 1. Play the Numbers for the PANCE.

Yep this means Cardiology.  Cards makes up 16% of content on the boards.  It’s also a huge part of practice no matter what area you go in to, especially if you are practicing in any type of medicine. Learn everything you need to know about treating STEMI’s, NSTEMI’s, CHF and A-Fib.

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2. Increase the Acuity

If you have any interest working in general medicine or in any specialty practicing in a hospital setting think about Critical Care.  I realize that the more rapid responses I’m involved in and forced to handle critical patient situations the more I advance as a provider.

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3. Future Job

Preceptors hire previous students, so think about what area of medicine you want to practice and where you might want to live.  Try and get a rotation based on where you want to live, or even just experience in an area of medicine regardless of location. For example rotating in dermatology would give you an edge over an applicant who did not complete a rotation in dermatology.

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4. Infectious Disease

Bugs and drugs people.  Everyone needs to know about antibiotic coverage.  I definitely wish I would have dug more into what antibiotics cover what types of bacteria in school. Although you probably don’t need a lot of this information for boards (you likely won’t get questions like what is the best drug to treat gram negative bacteria) it will help you when you graduate.

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5. Once in a lifetime

Some people take the opportunity to learn an area of medicine you may never practice or experience again.  For example neonatal medicine, maternal fetal medicine, specific area of oncology, pediatric neurosurgery, etc. You get the idea.

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Medical Musing of the Week: Autoimmune Hepatitis

Overview

  • AIH is a chronic disease of unknown etiology marked by hepatocellular damage, inflammation and necrosis
  • 3 Subtypes: AIH 1, AIH 2, AIH 3 (2 is the most common!)

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Etiology

  • Unknown
  • Potential post viral (EBV, Hep A, Hep B or Measles)
  • Toxin exposure (Macrobid, Minocycline, Infliximab

Pathophysiology

  • Genetic predisposition w/ environmental triggers
  • Cell mediated immunologic attack
  • High serum globulin concentration
  • Potential alterations of T and B cell function

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Risk Factors

  • Women 40-50
  • Known Autoimmune disease

Clinical Manifestations

  • History: fatigue, myalgias, pruritus, RUQ pain, amenorrhea
  • PE: jaundice, rash, spider angiomata, hepatomegaly, ascities, encephalopathy
  • Labs: prolonged PT, new coagulopathy
  • Onset is usually insidious
  • Up to 40% of individuals present with acute fulminant hepatitis w/ jaundice + new coagulopathy

Diagnosis

  • Liver biopsy is gold standard (mononuclear cell infiltrate & bridging necrosis on histologic examination
  • Elevated IgG, + ANA, +ASMA
  • Elevated AST/ALT AT LEAST 1.5x upper limit of normal

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Treatment

  • Indefinite treatment is liver transplant
  • Prednisone w or wo Azathioprine
  • Prednisone:
    • If patient is symptomatic w/ AST/ALT 10x upper limit
    • AST/ALT 5x upper limit of normal + 2x increase in serum globulins
    • Start 30mg then taper after 1 wk to 20mg, 15mg for 2-3 weeks and then maintain at 10mg
  • End points of treatment:
    • Remission, failure, incomplete response or drug toxcicity
    • Average duration of therapy is 1.5-2 years

Follow up & Considerations

  • CBC weekly x2 if Azathioprine therapy
  • Monitor for osteoporosis with prolonged steroid therapy
  • Repeat liver biopsy after 18 months to confirm histologic improvement to d/c steroids
  • Relapse rate is 60-80%

Complications

  • Primary Billiary Cirrhosis
  • Primary Sclerosing Cholangitis
  • Progression to Cirrhosis or Liver Failure
  • Varicies, encephalopathy, coagulopathies

Board Review Product Focus: Physician Assistant Study Guide

 

Physician Assistant Study Guide

By: National Physician Assistant Education

First, I would like to say that I love ALL of these products and if I were taking the boards I would definitely be purchasing from National Physician Assistant Education. They offer three products which include PANCE/PANRE Study Guide PDF, PANCE/PANRE Study Guide Paperback Book & PANCE/PANRE 2016: Online PA Board Review Program.

PANCE/PANRE Study Guide PDF

This is the most concise resource I’ve seen while still being able to maintain comprehension.  The readability of the product is wonderful, the PDF could not be better organized.  It is put together by organ system just as the PANCE/PANRE so you won’t miss a thing you need to be prepared for your exam.

Helpful Hint: Download to google drive on your iPad to have easy access on-the-go! (or whichever tablet of choice you may own :))

Access PANCE/PANRE Study Guide HERE.  Original price: $14.99.

Use “allthingspa15” for 15% off! 

Example of PDF presentation below:

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PANCE/PANRE Study Guide Paper Back Book

If you are old school like me and prefer having a physical book in front of you to jot down notes and make your own, this is a great option. What’s also wonderful about getting the paper back book is that you get a TON of bonus materials!  In addition to a printed version of the PDF, you also get access to the online PDF for quick on-the-go access, full length 300 question practice exam access, and a comprehensive review list.

Access the PANCE/PANRE Study Guide Paper Back Book HERE.

Use “allthingspa15” for 15% off

PANCE/PANRE 2016: Online PA Board Review Program

The whole she-bang. The online review program is honestly awesome.  It has everything you need to prepare and excel for the PANCE or PANRE. The whole program was developed through a website and App called Schoology so you can conveniently study whenever and wherever you want! The website, program and app are incredibly user friendly and well organized.  The content is beyond comprehensive.  Organized by organ system and the NCCPA blueprint. With each organ system you get the PDF, Audio review, several matching quizzes.

In total you get 2000+ practice questions, 10 hours of audio review, 100+ flash cards, 109 page PDF review, 13 progress quizzes and 5 full-length exams.  

For $199 this is an awesome deal.  I paid $400 for my Kaplan review course and ended up not even using it because I didn’t think it was worthwhile.  I would have much preferred the PANCE/PANRE Online PA Board Review Program.  

Access PANCE/PANRE Online PA Board Review Program HERE.

Use “allthingspa15” for 15% off

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