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Sunday, August 7, 2016

Sixth Semester at UTSW

Sixth Semester at UTSW
Updated: 08/07/2016
Below is a schedule taken from our program website detailing the clinical rotation schedule. Each student’s rotations are already set up for them (a huge plus), as I learned at the PAEA conference this year that not all PA programs do this. Some programs require that you setup your own rotations. Additionally, I appreciated an increased level of security that our rotations were quality - something not all programs ensure. Our rotations have been vetted before, dropping sites and preceptors who do not meet a high enough standard for our students. Our clinical coordinators have also done a great job of ensuring preceptors provide feedback to our students and that we get the most experience on each rotation, never being left in the shadows.


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This year our class also joined the many PA programs utilizing PAEAs end-of-rotation (EOR) examinations, streamlining the examination process and unifying rotation evaluation with an enhanced & secure online experience mirroring the PANCE. After each 120-question exam we received feedback about our performance, including a topic list of each type of question we missed and the task area. The content of the exams is provided by PAEA in a blueprint style and topic list format.


During the spring of 2016, I went through internal and family medicine, which were both 8 week long rotations. I was at Parkland and Zale-Lipshy hospital for my internal medicine rotation and I was in Bridgeport, Texas for my rural family medicine rotation. Both presented great opportunities for learning and included lots of 1-on-1 time with my preceptors as well as lots of procedural learning opportunities. Of note, since I was about 1 hour away from home during family medicine, my PA program located, secured, and paid for housing for all 8 weeks. This is something UT Southwestern does for all of its rural family medicine rotations - we are all very fortunate to have this provided for us.



MPA 5830 Internal Medicine
In my most challenging and feared rotation I found myself anxious and eager to learn more than I have before. My desire to comprehend rather than memorize has been demonstrated by a change in my own attitude to accept the things I don’t know and look for opportunity to learn more about the things I am already comfortable with. The crux of internal medicine, and medicine in general, is not to know everything about every disease, but to expand your differential and really compare the diagnostics with the clinical picture, always treating the patient, and not the disease. I’ve heard this phrase many times before, but it has never been more relevant than it has been during internal medicine. I hope that going forward I may continue to utilize this vital piece of knowledge and hopefully heighten my learning abilities and clinical acumen a step further.

PATIENT CARE
Patient care goals for Internal medicine were to elicit an accurate history and physical, develop and implement accurate assessments of patients and recommend a plan of care, provide quality patient education and preventive care, document my findings in complete and coherent notes, and perform any procedures accurately and safety under supervision. I am glad to say that I met every one of these goals. My time with one of the procedural-PAs was well spent performing paracenteses. I was eventually able to perform a paracentesis without assistance (albeit being observed). As I gradually increase my patient care skills, including history taking and assessment, I am increasingly able to come up with differentials and plans of care on the spot. One area of improvement I have recognized is my ability to confer massive quantities of patient history into a concise oral presentation, which I believe will come with practice.

MEDICAL KNOWLEDGE
Medical knowledge is one area I felt I greatly improved upon during internal medicine. One of my goals was to be able to select appropriate routine, initial, invasive, special or follow-up diagnostic studies, which I felt comfortable doing by the end of my 8 weeks. Another was to become proficient with developing a differential diagnosis for a chief complaint, which I found the most improvement with, especially with the workup for syncope and chest pain. I was able to demonstrate problem solving skills and apply my knowledge from anatomy and physiology to help reason through disease processes and comprehend rather than memorize symptoms, physical exam findings, and labs, which is more useful for time management and high patient volume.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Internal medicine really prepared me to manage health information using Epic, which I was previously somewhat inefficient with. With the aid of many preceptors and other students, I was able to navigate the EMR readily, documenting progress notes, pre-op notes, H&Ps, and consult notes. Navigating the EMR really saves you time when you are efficient and know where to look for outside records, labs, imaging, and nursing notes. It makes learning the medicine much easier when you can focus your time on other things, so it was definitely to my advantage to take the time to learn the language of IT. Coding and billing was never mentioned throughout this rotation except for during procedures, as the midlevel providers had to bill separately for their services. I was able to learn how to update patient histories with diagnoses, surgical histories, medication lists, and a number of other topics. I learned how to use Smart Phrases and “dot” phrases and create my own, which I found to be very useful.
INTERPERSONAL/COMMUNICATION SKILLS
As with all of my rotations, interpersonal and communication skills has played a large role. The role of all caregivers is always to empathize and provide the best care possible for the patient, no matter what role you play. The kitchen staff equally affect our patient’s view of our hospital care, as do the residents. It’s easy to forget that when you stereotype patients and categorize them before you make proper assessments. Being sensitive to financial, social, and political barriers patients face was something I felt comfortable with previously. Unfortunately, not all staff have this mindset and I found that maintaining a professional and empathetic manner even when others do not can mean the difference in how you perceive your career and how others perceive you.
SYSTEMS BASED PRACTICE
Working for a county hospital, which accepts the homeless, undocumented and uninsured citizens opened my eyes to a new type of patient population. The way we care for this category of patients is very different from insured and documented citizens because access to healthcare may be given, but financial, social, and political barriers inhibit quality care from being delivered. Fortunately, many providers I had the opportunity to work with were adamant to offer assistance wherever they could. Knowing the ins-and-outs of free and government assisted community resources can mean the difference between life and death. Making appropriate referrals, following up with social workers to find additional coverage and resources is all part of this huge intertwined community of miracle workers. Everyday I was at the hospital I learned of a new way patient access could be limited and sometimes it's up to us to deal with the complexities of our politically run healthcare system. Once we accept responsibility for fostering a patient-centered healthcare system, we finally recognize the factors that negatively affect our delivery and we become more involved.
MPA 5831 Family Medicine
If I took away 1 thing from my family medicine rotation, it is that ‘common things are common.’ This seems like a very simple truth, but in fact, it is challenging as a student not to want to go after the zebras in medicine. After spending time engaging with a very rural and unconventional patient population, my abilities to recognize the commonality and simplicity of an outpatient differential diagnosis has changed the way I think. This also goes along with tailoring each individual plan to the scenario at hand. For example, some patients may require more urgent care than can be provided in the office, and knowing when it is appropriate to refer is key.

PATIENT CARE
Patient care goals for family medicine were to elicit an accurate history and physical, develop and implement accurate assessments of patients and recommend a plan of care, provide quality patient education and preventive care, document my findings in complete and coherent notes, and perform any procedures accurately and safety under supervision. I am glad to say that I met every one of these goals, especially becoming more confident in my ability to perform a quick and tailored history and physical, as well as developing individualized quality plans of care with both speed and ease. During my time in Bridgeport I was able to meet many patients and their families, so much that I became very interested in the routine of following up and learning more about them rather than just their disease. This was an important takeaway from my rotations because a patient is more than their disease.

MEDICAL KNOWLEDGE
Medical knowledge is one area I felt I had a sound foundation in at the start of family medicine. Many of the diseases we managed were common and I had seen in prior rotations. An important area that I improved on in this rotation was learning the appropriate therapy for individual age groups, the necessary follow-up and routine labs based on risk factors. We also covered a variety of EKG and CXR findings and reviewed many labs that were not routine. I was very pleased with the variety of diseases we were able to come across during family medicine and it actually drew my interest further.  
PRACTICE-BASED LEARNING AND IMPROVEMENT
Family medicine really prepared me to manage health information using e-MDs, which I was previously unfamiliar with. With the aid of my supervising physician and PA and the LVNs, I was able to navigate the EMR readily, documenting history and physicals, searching previous visits, reviewing labs, and sending in referrals and prescriptions. I was initially very apprehensive about navigating the EMR because I was not very familiar with it and was not given a formal introduction to its features. Over time, as I became more familiar, I really took off and became independent. It was extremely rewarding to have the autonomy we were allowed on this rotation and was one of the highlights of being in a rural family medicine clinic. Coding and billing was intermittently discussed, but since e-MDs calculates charges automatically, it made it very simple to navigate.  
INTERPERSONAL/COMMUNICATION SKILLS
During this rotation I faced several unanticipated challenges in creating relationships with patients. When your patient population is unlike anyone you’ve ever been around it makes it a little difficult to relate to them. For example, most of my patients and the clinic owner believed in allowing guns in the clinic during normal business hours. Most of them were either truck drivers or worked in the nearby quarry. The oil business was also a commonality and I quickly learned that many individuals and their families, including staff, have been affected by our low gas prices. After acknowledging these subtle differences between my own life and theirs, I began to understand why many patients do not adhere to medications, do not eat foods we recommend, and why they may not exercise as we request. Individualizing a plan is easy, but accounting for environmental factors and offering suggestions for how patients can still accomplish those goals is the real challenge. Developing a cultural sensitivity to this patient population was necessary for me to understand how these people coped with the various stressors in their lives, which are far different from my own.

SYSTEMS BASED PRACTICE
In a rural setting like Bridgeport, I was exposed to patients with a variety of medical coverage. About 30% of our patient exams were for patients on Medicare and about 20% of them were for Department of Transportation (DOT) physicals. Then there were about 10% of patients that came in for Workers Compensation. All of these exams were similar, but were handled so differently and it was an interesting to have understood them. The funding of these patients really determined the outcomes for many people. After learning more and more about DOT, I realized that employers really keep patients in-check with their health, which can be seen as very beneficial for people like myself who are very pro-preventive healthcare. On the flip side, the human in me understands that losing a job over high blood pressure is seldom seen by the patient as a positive thing. Patients are put under an insurmountable stress by being forced out of their own will to come in for further evaluation after failing a pre-employment physical. Occasionally, time may be the limiting factor, but other times money, transportation, and other factors can mean the difference between having a job to support your family. Looking at Workman’s Comp, we clearly have a way to go with our healthcare delivery system. Many patients who need care do not receive it because of denied coverage from Workman’s Comp. Additionally, with all types of insurance, some previously routine medications are not being covered because insurance companies do not want to fork over the bill when less effective generics are available. These are the problems at hand and hopefully will be addressed in the near future.

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