Providers as Patients

Obviously we are all patients at some point in time, and that is where we develop empathy for our patients and can really step into their shoes.  I wanted to share my most recent experience as a patient and how it's affected how I practice, and possibly can provide some clinical insight for your patients!  

I'm not a super "moley" (not a medical term, but commonly heard at my job) person, but I've always had 1 mole on each of my feet.  I've never worried about them, but over this past year I started to think they were maybe getting a little larger, and then one of them in particular began to darken.  Those are pretty typical signs of possible dysplasia (atypical changes) in pigmented lesions like moles.  I had shown them to my supervising physician when I first started about a year ago, and she thought they were fine at the time.  When I showed her this past week, her opinion had changed, which was what I was expecting.  If I saw these moles on a patient, I would want to take them off.  

You have to be really careful with moles on the feet because they can be forgotten and due to the volar skin that is a little different, the characteristics you look for are slightly different.  In dermatology, we use a tool called a dermatoscope, which is basically a magnifying glass with a light.  Dermoscopy is very helpful, but if you are suspicious of a mole with the naked eye, the dermatoscope should really only confirm your suspicions and decision to biopsy.  There pictures are of my moles (because I had to send them to all my friends from PA school of course).  

So here's the deal with moles and biopsies or removal.  There are 2 types of biopsies.  Both consist of numbing the area locally with a shot of lidocaine, usually with epinephrine.  A shave biopsy is basically a razor blade that you bend to shave underneath the lesion.  This is typically done for raised moles being removed or to biopsy possible skin cancers, among other various things.  A punch biopsy is like using a cookie cutter to remove a portion of skin all the way down to the subcutaneous fat, which requires stitches.  This gets the epidermis and the dermis, which provides a deeper sample.  There are different sizes of punches, ranging from 2mm-8mm.  These are done on any lesion suspected for melanoma or moles that are suspected to be atypical/skin cancers if you can remove the entire lesion.  Everyone has different standards and there are some practices that do more punches or more shaves and may not agree with those standards, but those are my (very rough) guidelines.  

So for the size of my moles and the dark pigment, punch biopsies were the best option.  I had about a week to think about how bad the shot was going to hurt, and honestly it was just as bad as I expected.  There are so many nerves in your hands and feet, that a shot there is killer.  And lidocaine burns like crazy.  Then it feels very strange when your feet are numb.  So we did the biopsies at lunch last Thursday, and luckily I didn't have to work on Friday.  Here is a picture of my feet post-biopsy (sorry for the ugly foot pic).  The white area around the stitches is the blanching from the numbing shot.   

I took a picture of the samples in the specimen bottles as well.  

Friday morning it felt like I had a chunk taken out of both of my feet, and they were extremely sore.  I basically hobbled around all weekend and sat as much as possible.  This process has made me very thankful for my feet, and I can't wait for them to feel like normal again.  

So here we are a week later, and only one of my biopsy sites is infected, even though I've been keeping them covered constantly, and both of my feet are still pretty sore.  But of course, I've been working all week and that probably doesn't help.  I feel like I have so much empathy for my patients now, and I know exactly what they are going through and how tender it is when I have to give them a numbing shot.  I understand that it's difficult to relax while someone is cutting on you.  I think it's helpful for patients to know that I've been through this as well and that I can relate.  I'm a huge proponent of being honest with patients and letting them know that we go through the same things they do.  I think there is sometimes a stigma with providers, but we're all just people too.   

My advice to patients who need a biopsy done is:

• It's not as scary as it seems 
• The shot does hurt pretty badly (especially on the foot), but it only lasts about 5 seconds.  
• The feeling pressure and no pain is very strange, especially when the suture are being put in 
• Even if you do everything you're supposed to do for aftercare, you can still get infected
• Stitches are really itchy!  
• The biopsy site may be sore afterwards, but it's nothing ibuprofen or acetaminophen can't take care of. 

My advice to providers doing a biopsy: 

• Don't try to pretend the shot doesn't hurt because it does.  Just try to get it done as quickly as possible, and remind your patients to take deep breaths while you are injecting.  And if you are injecting in such a sensitive area, you may want to recruit some help for keeping the patient still and ask the patient to try to not jerk with the needle stick.  
• If you think a spot needs biopsied, be confident in that decision and either take it off yourself, or if you are not working in dermatology refer the patient to a dermatologist.  If you really think it may be atypical or malignant, it's probably best for it to be biopsied in a dermatology office because it's really helpful to see a lesion before it's messed with.  

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Clinical Year: Psychiatry

So I'm going to be honest.  Psych was not my favorite rotation.  Actually, it was my least favorite, and I'll tell you why, but this was definitely the rotation that I most dreaded going to everyday.  I spent all 4 weeks of my rotation on the in-patient psych ward at the hospital, and a whole month was way too long to just be in the locked unit.  Patients in the hospital are sometimes there for an extremely long time, and so there were a couple of patients that I followed the whole time without many changes, and I just don't feel like I got the best exposure to psychiatry.  That influenced my opinion of the field a lot, and I wish I had some outpatient experience mixed in as well.  Even the med students only spend 2 weeks on in-patient at a time, and spend other time in outpatient, pediatrics, or the ER.  Anyways, enough of my rant, now on to the details of my time in psychiatry.

It was a little nerve-wracking going into a unit of the hospital with 2 locked doors that required codes, but it's necessary for the safety of the patients. I spent a lot of time in the resident's room, and I spent a lot of time during this rotation on the phone.  This was my first rotation where I was working with med students and residents.  The med students that were there only stayed for my first week, but they were so helpful!  This was my first rotation using electronic medical records (EMR) since my family medicine rotation was still using paper charts, and the med guys showed me the ropes and were a big help to me.  Residents were a different story.  The first resident I was assigned to was actually a PA for about 12 years before deciding to go to medical school, and she was a little frustrating at times and would give me pointless things to do, like finding colleges for her daughter to apply to. Not super beneficial for my education.  But as bad as I though she was, it was nothing compared to the resident I was with for the last week.  She was extremely unreasonable and not helpful at all, so that was a challenge, and I was glad to be done!  I met some very nice residents, but I did not get to work with them personally.

My attending on psych was great.  He was very patient and a good teacher.  What's interesting about doing a rotation at a teaching hospital is that the attending is not around very much.  We would arrive around 7-7:30 am and go see our assigned patients and then the doctor would show up to round at 9.  Rounds on psych were also a little different.  We would sit in a big conference room (attending, residents, students, social worker) and bring the patients in one at a time to discuss how they were doing, any changes that needed to be made in medications, and possible discharge plans.  After rounds, we would put the plans into action, and like I said above, that typically meant a lot of phone calls.  There has to be a lot of communication with family members if considering discharge to ensure the patient will be safe and have support to continue medications and make it to follow up appointments.  One of the hardest parts of psychiatry is establishing discharge because the patient has to have somewhere to go. If they do not have a home or anyone willing to take them in, then the social workers try to find a shelter or halfway home for them to go to.

I saw some extremely interesting, and very sad, cases while on psychiatry.  I think for me personally it was just too emotionally draining.  There was one weekend that I felt very depressed and I think it was just the environment that I was surrounded by.

The second day I was there, a patient actually committed suicide and that was extremely troubling to all of us there including providers, students, and patients.  There are measures in place to prevent something like that from happening, but if a person is determined enough they will find a way.  There was a lot of procedure to go through after that and a patient limit was started on the unit, which decreased the amount of patients we got to care for.

There was an 18 year old who had been started on antidepressants before leaving for college, and 2 weeks into school called her parents with serious thoughts of hurting her roommate.  That progressed to thoughts of hurting other people, including her family and herself, and she ended up on the in-patient unit.  The new medication and stress of starting school had basically initiated a psychotic break.  She was experiencing very intense hallucinations.  For example, at one point the medical student and I were questioning her, and he asked if she was having any violent thoughts.  Her response was that she was imagining taking the pen out of his shirt pocket and stabbing him in the throat.  That was sobering and made me realize this was a serious place to be and it really broke my heart to see such a young, pretty girl struggling so much.  She was very sensitive to medications and one of the medications she was started on actually caused her to have tardive dyskinesia.

It was also interesting seeing how patients can work the system.  There was an Asberger's patient who treated his time in the ward as a vacation.  He found out that if he said he was suicidal, they would have to admit him and then he would keep saying it while he was there.  Patients would also occasionally come in if they needed a place to hide out, like if they owed someone money.  The attendings were good at recognizing these patients and finding out their motive.

Blueprints Psychiatry (Blueprints Series)

By Michael J. Murphy, Ronald L. Cowan MD PhD

Buy on Amazon

I also got to see great cases of schizophrenia and bipolar disorder, as well as drug and alcohol abuse.  I did learn a lot, and one of the good things about psych is that the test was very straight forward.  I feel like psych is easier to learn than some other areas.  The hardest part is the medications for sure!  The book I used the most was Blueprints Psychiatry, and I would recommend doing as many practice questions as possible.

My frustrations with psychiatry came from only seeing in-patient and feeling so limited by medications.  Some of the patients were on so much medicine, and it was very hard for me to see the effectiveness in the time I was there.  At least one person that I graduated with is working in psychiatry and I think it takes a very strong personality and someone who does not let their emotions get involved to work in this field.  I would love to hear about some of your experiences in psychiatry or answer any questions you may have!

Here is a blog post of another student's experiences while on her psych rotation.  

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Clinical Year: Family Medicine

I started my clinical year in Family Medicine, and personally it was a great place to start for me.  I was at a private practice with one physician who has been practicing for years in the area.  He's getting close to retirement, so he only sees patients in the mornings each day from about 8-12.  I was a little worried at first that I wouldn't see enough patients to feel like I was getting good experience, but that was not the case at all. We would usually see 12-15 patients each day and I think I had plenty of exposure to family medicine during my 4 weeks there.

My first day there I was a bundle of nerves for multiple reasons.  I was going into a new place where I didn't know a soul and it was my very first rotation.  I walked in and the sweet nurses told me where to put my stuff and then I went to meet the doctor in his office.  He was very nice, but had a somewhat flat affect and not much to say starting out.  I still didn't have any idea what to expect or what he would actually want me to do.  When patients started showing up, I was thrown to the wolves, which ended up being a good thing.  I would go to see the patient first and then come back and present to him.  He would ask me questions, which made me think about things I should be asking and considering.

Throughout my 4 weeks, I saw a large variety of conditions and types of patients.  Here are some of the main things I saw during my time there:

• Yearly well-checks/physicals - There is a lot of counseling done at these appointments and reviewing diet, social habits, medications, vital signs, and just basically a good check-up.  This is a great time to practice the physical exam.  Some preceptors may do a modified PE, but if you have the time, practice your skills.
• Hypertension (high blood pressure) - If the nurse checks the BP and it's high, you should recheck it manually in the room and possibly in both arms before reporting to the physician because they will most likely ask you to do this.
• Hyperlipidemia (high cholesterol) - If a patient ate a fatty meal the day before they had labs drawn that is not the reason their cholesterol is high....maybe triglycerides, but still.
• Diabetes - This is tough, and can be very difficult to control.  There's a lot of counseling involved in diabetes treatment, and if you have the chance to do a rotation in endocrinology, I would definitely recommend it.  Uncontrolled diabetes can lead to some scary stuff.
• Shingles/Herpes Zoster - This one is so easy to miss when it presents early, and I know that from experience.  And it still tricks me sometimes!  The biggest clue is if it only appears on one side of the body.  So if a patient is having symptoms (tingling, itching, pain) or even a slight rash and you feel like it follows a single unilateral dermatome, then you should at least consider shingles.

I had my first encounter with a drug seeker/addict on my first rotation as well, and I felt like the most naïve person alive when I reported by my preceptor.  He had known the girl for years, so he had expectations that were different than mine.  She gave me a really intense story about how her life had been crazy lately and she really could use some help with anxiety, and she has a lot of trouble paying attention at work, and she has to stand a lot so she has a lot of back pain.  I told the physician about all of her ailments, and his response was, "Ah, the trifecta."  I came to learn that people will frequently want not only pain medication, but also medications for anxiety and ADHD as well.  These substances are so commonly abused by patients and by providers prescribing them incorrectly that you have to be a little skeptical of patient's intentions, which is sad but also the real world.

I had one very scary experience while I was on this rotation with a diabetic patient.  I knew he was somewhat uncontrolled going into the room, but at first glance this patient was flushed and just didn't look good.  I started questioning him, and he had been having diarrhea for about 2 weeks.  A change in fluids or intake/outtake in a diabetic patient is a dangerous thing.  He was on insulin, and his blood sugar was reading in the 300 range consistently.  He was basically going into a diabetic coma (hyperosmolar hyperglycemic syndrome) and needed to be at the ER, but was at our office.  I left the room to grab the doctor and we heard a loud noise, which was the patient basically passing out and falling back on the table.  That could have been really bad, and led to one of the lessons I share below.  We called an ambulance to help him get some fluids, but that was a learning experience for sure.

Things I learned:

• Be skeptical.  It stinks, but there are some patients that may try to take advantage of you, so just be careful.
• If you get to present, go for it.  Go ahead and say your differential and what you would like to treat with.  The physician is likely going to ask you about this anyways, so no harm in just presenting it from the start.
• Never leave a patient's room if you think they may not be stable, like I learned from my diabetic patient.
• Don't laugh at what patients say no matter how hard it is at times.  People will say some of the craziest stuff and pronounce things a little funny sometimes, so try to stay neutral if possible.  Like "asmur" (asthma) and "diabeetus" (diabetes).
• Work on your shocked face.  I'm really bad about showing all of my reactions on my face.  This is still something I struggle with at times, but I've gotten a lot better.  Whether it's a baby moving in a mom's belly (that can be strange) or a 4 cm skin cancer that is bleeding like crazy and has been there for 5 years, it's best just to smile.

Step-Up to Medicine (Step-Up Series)3rd EDITION

By Steven S. Agabegi MD, Elizabeth Agabegi MD

Buy on Amazon

As far as resources, since this was my first rotation, I was just trying to figure out what the best book might be.  I ended up using my PANCE review book (which every PA student must own) a good bit, but sometimes it just didn't have as much specific information as I was looking for.  I ended up also using Step Up to Medicine as well, and I really like this book for both family medicine and Internal medicine.  

Overall, I really liked family medicine.  I love that you get to know your patients so well and follow them closely over time.  The one thing I didn't like was seeing "sick" patients like ones who have the flu or colds.  I didn't see as much of this here because it was August though.  I would love to hear your thought or questions about family medicine!

Here is a blog post of an interview with a rural medicine PA.  And another one with a family medicine PA

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Tips for Rotations

 So once you've successfully completed your didactic year of PA school, it's time for the clinical year.  This is an exciting time because you finally get to put your knowledge and skills to the test and it's so much easier to remember a disease or medication when you see it in practice.  Most PA programs try to incorporate some clinical time during the didactic year, but after that it's no more classroom time, which is awesome and scary!  Here are some of my tips for making the most of your clinical year.

1. Be confident. You've worked hard to get to this point, and although you might not feel ready to see real patients, you are likely more prepared than you think.  So trust yourself, and trust that the answer you're unsure about might just be right! Or it could be wrong, but there's no harm in getting an answer wrong and you'll at least learn something in the process.  I got plenty of answers wrong when being "pimped" (this means quizzed) by preceptors, and there were times I didn't answer out of fear of being wrong and I would have gotten it right!
2. Be honest.  When your preceptor asks you a question, whether about yourself or what field you want to work in, just give them a real answer.  I thought at first I should tell all of my preceptors that I wanted to work in their specialty so they would give me a job, but that didn't work. What did work, was when I started saying I would actually like to work in Dermatology or Surgery, and then my preceptors helped to use their connections and that's how I ended up with my job.
3. Ask questions.  If there's something you don't understand, then ask about it.  As a student in a new setting, it can sometimes feel like you're in the way so you try to be invisible.  Most preceptors are not getting paid to spend time with you, and even though some will try to use you like free labor, a lot of the physicians and PAs love to teach and want to pass their knowledge to you.  The only problem is they may have been practicing so long that they assume you know things that you may not.  This is your education, so get the most out of it by asking the experts while you have access to them as a student.
4. Be helpful.  Having a student can slow physicians down at times, so try to be helpful when you can.  Whether that's going to get printed prescriptions, doing tasks that you think are pointless (like making copies for the psych resident, but that's another story), or setting up for a procedure.  Try to think ahead and do anything that the nurse or MA might do if they are not around to do it.  Sometimes PA or med students feel these tasks are beneath them, but really it makes you look good to show that you are willing to do some grunt work.
5. Be nice to everyone.  You are a guest and need to keep that in mind.  Whether its the nurse or the front office staff or the drug reps, kindness goes a long way, and you'll likely need their help at some point during your rotation.  This goes for other students you may be on rotations with as well.  You don't want the reputation of someone who isn't supportive of their colleagues, or the "gunner" (someone who goes out of their way on rotations to show off or look better than someone else).
6. Be professional.  This should be common sense, but no matter how close you get with staff or other students on a rotation, stay professional.  As in don't bad mouth the doctor or staff ever, dress appropriately, be on time, and don't complain.
7. Know your boundaries.  As rotations go on, towards the end you'll feel more comfortable with what you're doing, but keep in mind that you are still a student.  Sometimes preceptors will forget this or not take it into account as they should.  Just be sure not to do anything that could get you into trouble.  On my internal medicine rotation, it became very common for the preceptors to tell me the patient could leave after I gave my report and potential plan, which is not appropriate by the way.  I would have to say, I really think you need to see the patient and confirm my plans or diagnosis.  So don't be afraid to say no if there's something you don't feel you should be doing or if you don't feel you're getting adequate supervision.  And if you are ever put in a situation where you're asked to do something inappropriate for your skill level, tell your clinical directot so they will know the practices that are in place.
8. Be bold.  Again, you are there to learn, so if there's a chance for you to do a procedure or take a history and do a physical, go for it!  As long as you feel comfortable(see #7 above) and are capable, take every opportunity given to you.  And as long as you have someone supervising and guiding you, there's no reason to pass on a chance to learn a new skill.
9. Keep PANCE in mind.  So once clinicals are done, there's boards.  And if you thought the first year of PA school went by fast, then the clinical year will fly by.  As you study for end of rotation exams, really think of it as practice for boards, and use this to focus your studying.

I hope these help to get your mindset ready for your clinical year, and congrats on making it this far!  You're on the homestretch!  I'm going to start doing some specific articles on different rotations during clinical year, so if there are any specific questions you have please leave a comment!

Here is a blog that has some posts about a student's experience while she was on rotations.  And here is a different blog with tips gathered from 2nd year students.  

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How to Save Money in PA School

Unless you have someone supporting you financially or have been saving extensively, the cost of physician assistant school can be quite overwhelming.  If you attend a public program, your debt won't be quite as much, but some of the private programs can cost over six figures just for tuition and fees without considering the cost of living.  And most programs do not allow students to work during school, and it really isn't feasible with the intense schedule of PA school.

I was really lucky to go to PA school where I grew up, so I lived with my parents the first year before I got married, which saved a lot of cost of living.  They helped me out with fees and I covered all of the tuition with loans.   I attended a public program so tuition was about $7,000 per semester.  I also got a random scholarship that gave me $2,000 a year which helped as well.  I chose to not look at any of my loans until the end of school and that number was quite shocking to me.  I don't remember the exact number, but it was a little over $60,000.  Now I realize that many people have loans that are WAY more than mine, but it was amazing to me how much interest can accrue over a short period of time, and it really got me motivated to getting my loans paid off as soon as possible, which I am currently working on.  I'll share some ideas here on how to save money while you're in PA school because every little bit helps!  I would also advise only taking out the minimum that you need because if you have the money in reach, you're more likely to spend it.

1.  Find roommates:  Whether it's your parents or classmates, you'll find cheaper living options if you live with someone else.  A one-bedroom apartment is typically much more than a 2 or 3-bedroom.  Whenever you find out you're accepted, usually there's a Facebook page where you can connect with other students and see what their living situations are.  If you're in class together, you can carpool as well or split a parking pass!

2.  Bring lunch and don't eat out:  There were so many of my classmates that would eat out for every meal, and those costs can add up quickly.  You definitely have to eat and want to be healthy if possibly, but packing a lunch will save you some money in the long run.  If you currently eat out a lot, look at your food costs for one month, and then try to eat out less for the next month and compare.  As much as I love to save money, I'm also support splurging occasionally on meals or events, so if you're saving money on lunch each day, you won't feel as bad going out to eat with your class or going on a date night!

3.  Avoid online shopping during class:  I know this one from experience actually!  One of my good friends sat beside me in class and there would be times that one of us would find something really cute or a really great deal online and if she bought it, I would just get her to throw one in for me too, or vice versa.  It saves on shipping right?  I'm all about a good deal, but I also make the occasional impulse buy.  If you like to shop for clothes, you could try Stitchfix because they have a great referral program and if your friends sign up you get a 25 credit.

4. Referral Programs and Surveys:  You won't have a ton of extra time in PA school, but there are some survey sites where you can actually make a little money.  Swagbucks is a really easy one to use, and I don't do it quite as frequently, but I've gotten over $200 in Amazon gift cards over the past few years, and that really comes in handy!  As for referral programs, if you are purchasing something see if they have any kind of program.  Sites like Groupon and LivingSocial will have deals, such as if 3 people buy the same deal you got with the link, then you get it for free!

5. Make money!:  If you have any extra "stuff" think about selling it on eBay or another resell site, like Craigslist.  There are multiple "Garage Sale" Facebook groups in our area, which are a great way to sell things locally and find good deals.  If you have extra clothes, there's Poshmark online or Uptown Cheapskate or Plato's closet, which will pay you for clothing.

6.  Use coupons:  I'm not talking about extreme couponing, but if you want to do that then go for it!  Using coupons occasionally can help you to save some money though.  Kroger and other grocery stores have some great apps now that you can add coupons to.  You can also use Groupon and LivingSocial or Restaurant.com to find deals on gift certificates to restaurants to eat out.  If you use this link to LivingSocial you'll get $10 off of a deal that's at least $20.

7.  Textbook alternatives:  Whenever we got our textbook list, I would always check to see if there was an online copy for free either as a PDF or app.  Our library provided some great access to textbooks online.  I personally like to have the physical books, so the best places to check for this are Amazon or eBay, or with the class above you to see if they are willing to sell.  I think it makes much more sense to purchase the book and then sell it to another student or to Amazon's Trade-in program than to rent the books.  Amazon is amazing, and as a student you can get a great rate on Amazon Prime, which includes free 2-day shipping on most items and a ton of music and videos as well.  With this link, you can get a free 30-day trial!

8.  Scholarships:  Make sure to check and see if there are any scholarships offered by your school, and if they have any financial aid survey, fill it out!  The scholarship I received was called the Lettie Pate Whitehead Scholarship, and I got it just because I filled out the survey and qualified.  I think some of my classmates could have received it as well, but they just never looked into their options.  Here is a post with a good list of scholarships!

Here is a blog post with some other tips on how to afford PA school as well.  

I hope you found some of this a bit helpful, and if you have any other tips please comment below!

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Resources for Anatomy

Anatomy and Physiology is not only required to get into PA school, but will be one of the courses you'll have to require while in the program, usually near the beginning.  The A&P of PA school is a whole different level from most undergraduate programs, in both amount of material and intensity.  My program was done over the summer.  We had lecture 4 days a week and then switched off lab time each day so 2 days were spent in the cadaver lab.  The experience was great, but that's a smell I don't wish to revisit.  It's still hard for me to wrap my head around the way all of the structures of the body function together, and that I actually have all of those muscles and nerves!  We had 3 tests during that first challenging course, which I achieved a C, then a B, then an A.  Progress is great, but I wish I knew which tools were going to be the most beneficial for my limited study time.  Below are the resources I used outside of our required textbook, and I hope you will find them helpful!  I've included links to the most updated sources, but for most of these the previous editions will likely be sufficient (and cheaper).  Comment below with any other books or websites you've used during anatomy. This post contains some Amazon affiliate links. 

Netter's -  This is one of the classic resources.  It's an atlas of drawings of every single part of the body.  This is an essential book for learning the structures, and if you are able to know these pictures when it comes to practical time you should be prepared.  I had a copy I kept at home and then my lab group had one as well to keep in the lab (this one gets a little messy).  These are hand-drawn pictures by the way!

Color Atlas -  This book is also a collection of pictures of anatomy, but it's actual pictures of cadavers.  If you have a real cadaver lab, this book is invaluable.  It makes it much easier to identify the structures when you know what colors they actually appear, instead of blue, green, purple, and yellow.  I preferred studying from this book once I figured out what I was doing.

Netter's Flashcards -  There are flashcards of essential structures that have Netter's drawings and all of the important material on the back.  I didn't know these existed until my husband went through medical school, and they are pretty awesome.  He used them a ton.

Thieme Atlas - This is another atlas set that actually has little blurbs of information as well instead of just pictures.  Here is a link to the book on Google Books.  There are a few pages missing, but most of the content is there if you want to check it out!

University of Michigan Practice Questions -  These questions are amazing!  There are also practical identification questions.  I didn't do these for the first test and I truly regret it.  They are vignette style questions on high-yield material and give explanations for why an answer is wrong.  Great, free practice!

Lippincott's Illustrated Q&A of Anatomy and Embryology -  Lippincott has a great series of Q&A books, and this one may be the first one you use.  It has explanations for why answers are right or wrong, and these are also vignette-style.

Netter's App -  If you're more advanced technologically, you will love this app.  You can choose which structures you want to view and quiz yourself on different parts of the body.  It's a 3-D view and my husband still uses this to study.

Zygote Body -  This is similar to the Netter's app, but available on the internet.  There are different levels you can subscribe to, but sometimes it helps to get a different view and be able to customize quizzes.

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Respecting Patients

There has been a lot of press about a news story that came out recently.  Basically, during a routine colonoscopy, the patient accidentally had his phone recording, and happened to hear some very insulting remarks being made by the anesthesiologist during his procedure.  The things that were said were pretty outrageous, but unfortunately it is not too uncommon in many medical settings to hear negative comments about patients at times.  There were many things wrong with this case, including that the physician was making inappropriate comments, no one tried to protect the patient, and the physician made comments about billing for diagnoses that weren't present.

This case is a good reminder that it is our job as healthcare providers to protect our patients, and not just because you could lose money over it.  Working in the medical field day after day can be exhausting and sometimes it is easier to complain and rant then to just keep the frustrations in.  Whether it's the late patient, the difficult patient, or a drug seeker, it is not our job to judge the person who comes to us for help.  Even if you're not the initiator, you can help to be a positive influence in your workplace.

A story like this gives medical providers a bad wrap, and makes patients even more skeptical about whether we are really there to help them.  Especially if a patient is going under for a procedure, there's a good chance they are nervous about it, and the focus needs to be on "doing no harm" at all times, even when it's hard.  I hope you keep this in mind when you are out in clinic or hospitals and let's be more aware of how we are treating our patients.

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Free Apps for Clinic Use

We're lucky to be practicing medicine in a time where technology is readily available.  As frustrating as working on an EMR can be at times, I'm thankful that my computer is there if I need to look anything up or get more information about anything.  Phones and tablets have also found a place in medicine, and can be great tools to look something up quickly.  Today I'll share some apps with you that I use frequently in practice and that would also be useful for rotations.  Make sure to comment with any other apps that you find helpful!

- Medscape - This is one of my favorite resources for an all-inclusive source of information.  When you look something up on Medscape, it includes physiology, presentation, work-up, differential diagnosis, treatment options, prognosis, and basically anything you would want to know.  Even when I google stuff on the computer, Medscape is typically my go-to source if I'm not using UpToDate (which requires a paid subscription).

- Epocrates - This is a very important pharmacology app.  It can be especially tough to keep up with all of the changes in medications.  There are constantly new drugs coming out and changes being made in availability, and this app does a great job of staying up to date.  On the free version, you can look up specific medications and find out dosing, alternate names, how it is supplied, adverse affects, contraindications, and even pictures of what the medications look like.  There is also a feature that you can add all medications that a patient is on and see if there are any cross reactions.

- Figure 1 - This app is like Instagram for medicine, and it is amazing.  Since I work in dermatology, and a lot of my cases depend on what I see, it's especially interesting to me.  Basically, people can post pictures and descriptions of cases for discussion.  Sometimes people will be looking for input into a case, or they may post something that they have seen to let other people become familiar with it.  This may not be something that you look things up on in clinical, but it may be helpful if you have a question, and it can familiarize you with diagnoses you may not frequently see.

- GoodRx - This is another pharmacology app, but it is more to the benefit of your patients.  You are able to put in medications and your zip code and find out the cost of the medications based on dosage.  This helps to compare and see what the most cost effective option is for your patient if you are deciding between medications.  There is an app, but you can also just pull the site up on your phone.  You can also print out coupons for specific pharmacies that make the prescriptions cheaper.

These are the ones I use the most, but I would love to know what you use as well!  And definitely check with your school or hospital and see if there are any apps that they offer subscriptions to as well.

And here are some other sites with their lists of top apps!

• Dose of PA blog

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The PA Job Search: Where to Find Jobs

Earlier this week, I did a post on what to look for when first starting a job search, so here's a follow-up post about where to actually look for the jobs.  I promise they're out there!  Some areas are more saturated with PAs than other areas so it can be a little more challenging, but the more flexible you are, the better luck you'll have finding a job.

The Internet:  This is pretty obvious, but it's a good idea to start with Google to get an idea of what may be open in your area.  When I was first starting, I would just search "physician assistant job augusta ga," and it usually took me to indeed.com or some other job site.  Most of the results from these searches go through an agency or are hospital listings.  Looking at specific hospital websites that are in the area you are interested in can also be helpful.  The only issue with these is that they may not update the listings very frequently, but there are usually at least a few positions posted at each of the hospitals in my area.

Preceptors:  When you are on rotations make it well-known what areas you are interested in working in to your preceptors and staff at your rotation sites.  When I first started rotations, I thought I should act like I loved whatever area I was working in for the month, but once I started being honest and talking about my love for dermatology and surgery was when I started hearing about job opportunities.  I attribute to my job to my surgery preceptor for the most part.  He was a colleague of a doctor that I heard was hiring and gave her a call on my behalf.

It's sometimes said during rotation orientation that you should expect to get numerous job offers while on rotations, but that isn't always true.  If most of your sites are ones that have been used for a long time and always have students, it is not likely that they are looking to hire.  You're going to have a much better shot at a job offer if you are able to do rotations at sites that have not had students in the past.

Cold Calls:  One of my teachers recommended this and it was incredibly intimidating, but now I definitely recommend doing it.  The best way to do this is to call offices, ask to speak to the office manager, and then ask if they are looking to hire a PA.  The majority of offices I called said not currently, but asked me to send my resume anyway.  I felt like this was possibly a dead end, but I actually met 2 different PAs during the time I was looking that recognized my name from my resume, and then told me about jobs they had heard about.

Program Resources: Some programs are really great about helping their students to find jobs after graduation.  Ask your advisor and any faculty you feel comfortable with if they know of any open positions (if you want to stay where your program is).  Our program also has a job board and a Facebook page for alumni where jobs are posted frequently, so see if your program has this, and if not just start one yourself!

Staffing Agency: Some offices go through agencies to find PAs.  I've talked to a few of these, but I'm not sure how effective they are.  Two of my closer friends from my program applied to and interviewed for programs through an agent, but from what they said they had to follow up very frequently and ultimately didn't get anywhere.

If you are starting your job search, I highly recommend watching my three part video series on Youtube with Lianne Hahn! In this three part series we explore Resumes and CVs for PA School and Physician Assistant Jobs, Interviewing for PA Jobs, and Contracts and Negotiations for Physician Assistants. Make sure to check out the series and subscribe to The PA Platform on Youtube!

I hope this gives you some direction if you're job searching, and please comment with your tips for finding a job!

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The PA Job Search: What to Look For

About this time last year, I was nervously getting ready to start my final 2 rotations at the dermatology office that so graciously decided to take me on as a new grad.  Looking back, that job search was a bit exhausting and honestly there were some tears involved.  I love my job, and I feel very fortunate as this is my first position, but I thought it may be helpful to share some of the things I learned along the way.  As a new grad, you're excited and ready to get out into the working work, but getting there takes some effort.

So congratulations if you just graduated/are graduating soon, or if you are finding yourself looking for a new position and leave a comment below if you have any other tips!

What to Look For:

So when looking for a job, I've read multiple theories and recommendations about what you should focus on.  You have to decide what's important for you personally.  It seems to me the more essential aspects of a Physician Assistant job are - location, specialty, supervising physician, salary/benefits.

You need to rank these factors in order of importance to you.  A year on rotations should have helped to make it a little more clear what your priorities are.  I decided that having a great supervising physician and doing something I loved were more important to me than salary.  In my opinion, I would much rather wake up and want to go to work than dread my job or who I'm going to work with.

Location is important if you have an area you really love or family you want to be near. I was raised in Augusta and went to PA school in Augusta. My husband is still in medical school here, so that was an obvious choice for me. If location isn't as important to you, it may be a great opportunity to try out a new place and get some experience so later you can find your dream job in your dream location.

Rotations give you a good idea of what areas you do and don't want to work in. The main questions that came up for me were sick vs not sick and appointment vs walk-in and procedures vs no procedures and continuity of care. I'll explain that a little more because I didn't really get it until I was in the field.  When it comes down to specialty as well, I will mention that it seems any experience you have makes you very valuable for other fields, so I think it is much better to have an open mind when starting your job search.

Sick vs not sick - Some specialties you see "sick" patients, which I consider the ones that have things you could catch. This includes pediatrics, family medicine, internal medicine, urgent care, and ER. Other specialties like dermatology, pulmonology, cardiology, hem/onc, GYN, and lots of others have patients that may have diseases that make them very sick, but they aren't going to cough on you so you could catch it.  Personally, I didn't love seeing the flu and strep throat all winter long.  And when other students say you should plan on getting sick on your pediatrics rotation, it's absolutely true.  (And sidenote - go to the doctor or health clinic when you start feeling sick, and not the last day of your rotation, so maybe you can avoid being diagnosed with pneumonia like me.)  A lot of the patients I see in dermatology have very real, serious disease that affects their lives, so I definitely still feel like I'm helping patients even though I'm not seeing the acutely "sick" ones.

Appointment vs walk-in - If you're working in private practice, you will likely have a schedule of patient appointments that you are expected to stay pretty much on time with.  If you are good at time management and a fairly quick decision maker, this should be fine for you.  The frustrating thing about having a set schedule is that it can easily get thrown off by late or complicated patients.  It's personally very important to me to stay on time out of respect for my patient's time, but there are definitely days where it seems like everyone is complicated, so they need more time (and I'm becoming a little more okay with that.)  Areas like urgent care, emergency med, or being in the hospital will mean that your patients just show up or are already there.  This has it's advantages because you don't have to worry as much about the late patients or your own punctuality, and it's ok if you need to take longer with some patients.  The disadvantages to not knowing your schedule for the day mean it's a bit of a surprise, and you can't predict as well if your day will be slow or hectic.

Procedures vs no procedures - This is pretty straightforward, but if you loved surgery and getting to do things with your hands, then you probably want to do something where you can do procedures.  I would say in most specialties there's at least a possibility of being able to do some hands-on stuff.  Specialties that are more lab-based (ex - endocrinology) may not have as much going on there.  General or family practice is a bit of a toss-up because there are some that do their own injections and even biopsies, and then other practices that don't do any of this.  So that's just something to consider when looking for what field you want to be in.

Continuity of Care - It was really important to me that I know how my patients are doing after I treat them, and I wanted to be able to build relationships with my patients.  You may get a little bit of this in urgent care or emergency med, but usually when you recognize a name there it's not a good thing.

Now on to supervising physician(s).  It's much easier to work under one SP, but sometimes if you're looking at working for a large practice or hospital, that's not going to be the case. I cannot stress how much having a supportive SP who is willing to adequately train and teach you is important.  My SP will stop what she's doing, even if she's running behind, to come see a patient if I ask her to.  You also want a SP that will support your decisions, and although they may not agree and will tell you that in private, they should never throw you under the bus in front of a patient.  There's a saying that if a patient sees a bad doctor, they'll find another doctor, but if they see a bad PA, they'll never see another PA.  I think that's true because most patients still have a little bit of a difficult time understanding what a PA is and what we can do, so they are quick to lose faith if something happens.

Now for salary and benefits.  I have a much different opinion on this than other PAs from things I've read and discussions I've had.  I definitely believe in not being lowballed, but I also believe in being willing to accept a fair offer, especially as a new grad.  It is going to take both money and time, and probably mistakes, to train you to be a good PA.  And you have to weigh the worth of location, supervising physician, and experience you will gain.  So really look at everything involved, and not just the number.  Is there a bonus structure in place?  That can potentially make a huge difference.  There's a lot out there that says you should never take a job if it's less than the national average and that new grads should be making 90K+.  I think this is possible, but is not necessarily the norm, so you have to be realistic.  Also, consider vacation/sick time, CME days and money, insurance, retirement, and just quality of life.

I recently sat down with Lianne Hahn for a three part series on my Youtube channel where we discuss Resumes and CVs for PA School and Physician Assistant Jobs, Interviewing for PA Jobs, and Contracts and Negotiations for Physician Assistants. Make sure to check out the series and subscribe to The PA Platform on Youtube!

What are some of the things you are looking for in a job?  What helped you make the decision to take a certain job?

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How to Stay Sane in PA School

If you are just applying to PA school or just starting in a program, it may not have hit you just how intense it is.  When they say the program will pretty much become your life for the next 2+ years, they mean it!  But with all of the studying and multiple tests per week, you have to take care of yourself and find some way of maintaining your sanity. Here are some of the tips that helped me to get through it all.

Find some friends!

When you start PA school, you're going to be meeting a lot of people who are pretty similar to you and ya'll will become fast friends.  A strong support system of people who can relate to what you're going through is so important.  You'll not only be spending hours together during the day, but it also helps to have someone to study with, take a break with, or even cry with.  Some of my best friends have come from PA school, and as much as I love my family and the friends it definitely helps to have someone to commiserate with who can actually empathize.

Stay Active!

It can become very easy to feel like you need to devote every waking second to studying, but you need to take care of yourself.  By working out or doing something active, it will most likely help to relax you and get some of your focus off of the vigorous routine of school.  I personally do not enjoy working out a ton, but my friends would invite me to the gym and encourage me to work out with them and I'm so glad I did.  You are probably already paying for a gym membership as part of your fees so take advantage of it!  If your school offers intramurals those are also fun.

Get Involved!

There's no reason to lose your interests while you're in PA school.  If you loved volunteering at the animal shelter or nursing home before school, you may not be able to do it as frequently, but it will benefit you in the long run if you make the time to do what you love.  Or if there's a way that you feel like your class would be able to help people then do it!  A few classes above us started a free monthly screening clinic downtown in an underserved area, and it's still going strong!  You can also consider becoming an officer or joining a committee if that's your thing.

It's OK to not Study 24/7!

And you will probably go crazy if you do!  One of my biggest regrets during PA school is that during the first 2 semesters I would literally turn down any invitation to do anything.  Even if it was just going to Mexican food with my parents (which would likely take about 30 minutes) or going to church.  During the 2nd half of didactic year and especially now, I realize that PA school and being a PA is not my life or my complete identity, so I hope that you figure that out before I did.  I also fully support recreational reading while in school because that is something I missed so much!

Enjoy where you're at!

This is something a lot of people in my class struggled with.  They would refer to Augusta as "Disgusta," and while it may not be the most exciting place in the world there's plenty going on.  Some of my classmates just couldn't wait to get back home and I think it made their experience more miserable than it had to be.  Learn how to enjoy where you've been placed because it is likely for a short time, and there's no reason you shouldn't have a good time!

Here is a post from a fellow blogger with her tips on if you are just starting PA school.   And she is finding ways to not only stay sane, but to do it with kids!  I'm not there yet, so check out her blog if you want advice on surviving PA school as a parent.  

What are your tips for making the most out of PA school and maintaining your sanity?

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Dermatology Resources

After I graduated, I went straight into working in dermatology.  During didactic year in school, we got about 2 weeks of derm, and it makes up a whopping 5% of the PANCE.  Those 2 weeks and some dermatology shadowing I did before were enough to spark my interest in the field, but not quite enough to make me feel confident enough to know what I really needed to.  I am extremely lucky to have a great supervising physician and I was able to do my 2 elective rotations in dermatology, so that was helpful, but even after being at my job for almost 3 years, I still find myself looking up information multiple times daily!  Today, I'm going to share with you some resources I found helpful while in school and what I currently use in practice!

In school:

• AAD Basic Dermatology Curriculum - The American Academy of Dermatology has a specific curriculum for medical education, and it's awesome.  The lessons are thorough and a great overview of some basic dermatology topics that are likely to come up both on boards and rotations.  They don't take a ton of time, and I think are definitely worth taking a look at.
• Dermatology Secrets Plus - This is a small, simple book that is filled with pictures, which are so helpful in dermatology.  I used this book during didactic year, and I still refer to it occasionally in practice as a quick reference.  Not the best book if you are looking for every detail on a subject, but more of a quick overview w/ pics.

In practice:

• UpToDate -  I recommend UpToDate for any specialty really!  Like the title says, it has the most current information and is updated regularly.  One of my favorite features is print outs for patients!  These are so helpful, and the majority of the time there is one for what I'm looking for.  The drug information is also very specific and always provides exactly what I'm looking for, including dosage and how the medication is supplied.
• VisualDx - This is a resource that I use on a daily basis.  I pull it up on the computer as soon as I get to work to have it ready to go!  You can look up multiple dermatologic subjects and there is a huge photo library with great examples, and it provides all the info you need to know, including pearls, diagnosis methods, differentials, and treatment.  There's a really nice accompanying app as well!
• Habif's Clinical Dermatology - This is the first actual textbook I got for derm when I started working, and I have used it a bunch!  For a textbook, this one is very easy to read. My one complaint is that sometimes it does lack some of the details I'm looking for so I'll visit my supervising physician's library to borrow one of her books. 
• Practical Dermatology- Practical Dermatology is my favorite journal for getting all of the up and coming derm news.  It's very easy to read and the topics tend to be more common things that I actually want to read and learn about.
• Litt's Drug Eruption and Reaction Manual - Possibly my most helpful book.  This is my go to for any rashes that could be caused by drugs. It lists every medication and the possible side effects.  Great for my itching, photosensitive, and hairloss patients when medications are involved. 
• Wolverton Comprehensive Dermatologic Drug Therapy - This is the most in depth book about dermatology medications. If I have any question about side effects, contraindications, dosing, etc, this is my go to.  UpToDate is great, but this is strictly derm, and sometimes I just sit and read it. (Nerd alert)
• Andrews' Diseases of the Skin and Bolognia's Dermatology - These are my supervising physician's favorite books. She can actually just pick one of these up and turn to the page she wants because she used them so much during residency.  It's amazing! But they have so much detail and every obscure derm disorder ever. 
• SDPA Diplomate Fellowship Program - I've just started these modules, but so far, they are very well done. This is training specifically for derm PAs, and it follows Bolognia's Dermatology Essentials

Some of these links are affiliates, which means if you use them, I get a small cut from Amazon, but you pay the same low prices and get your Prime shipping! I hope that some of these are helpful to you, and please comment with any other resources you love to use!

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