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Advice From Current PA Students - From White Coat Dreaming

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I recently connected with Alex on Instagram (@whitecoatdreaming), and she introduced me to her awesome PA blog - White Coat Dreaming. Apart from sharing her own awesome advice, Alex has also interviewed her fellow classmates in PA school to get their advice as well.  In this post, I'm going to share some of the best points to help you succeed in PA school! If you want to see more, make sure you head over to her blog to see the interviews in their entirety. 

Interview Tips:

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I think that schools like to see that you have other interests besides medicine and that you make time for the things you care about.  - Megan

I would really recommend going on a mission trip before PA school starts because it gives you an opportunity to learn more about the medical field and prepares you for PA school. Not to mention, it shows the interview committee that you are well rounded and more than just your grades. -Norin

Career change?  Be totally honest with yourself about who you are deep down, what you like, what all of your motivations are, whether you could get what it is you think you’re looking for while staying in your current spot or with a less drastic change. -Craig

“The number one tip I can give you is to just be yourself! And I know that probably sounds super cliché, but it’s so true. Don’t try to be someone you’re not. Don’t try to put on an act, or memorize all the right answers to ace an interview or personal statement.”
— Giftson from White Coat Dreaming

I didn’t do anything to practice so I just showed up thinking I could charm some people. And then they were tough and I bawled in my car after 2 or 3 of them. - Megan

I would truly recommend helping out the community as much as you can. During interviews, they look at more than just your grades. They want to see that you are a caring individual that does more than just study.  -Norin

There is a lot of competition for spots in PA school for good reasons, you’ve got to show that you are the cream of the crop and are a good bet for the school in terms of being able to one day be a skillful, practicing PA. -Craig 

It is so easy to compare to others and feel like you fall short, but it is so not true. We are all worth so much more than how we perform or measure up to the world’s standards. Finding my worth in Christ and knowing that He loves me no matter how small I feel was the biggest game changer. -Michelle

Applying Tips: 

Don’t get discouraged if you are waitlisted! I know plenty of people who were waitlisted and got in as late as April. -Megan

I took a year off before starting PA school because there were still some pre-requisites that I needed to complete and volunteer hours that I needed to add into my application. This really helped me focus on my application and make it stronger. -Norin

While getting into school and becoming a PA might seem like the most important thing in your life right now, don’t fall into the belief that whether you become a PA or not determines your value. You are so much more than your career! Work hard, but rest in the idea that you are going to end up exactly where you are meant to be. You are no more valuable as a PA or less valuable as something else! -Jill

Find yourself a good group of friends who will provide you with love, tissues and wine nights. They will be your backbone throughout the ‘process.’ - Alexa

“People are afraid to major in something non traditional (like English, Poli Sci or philosophy), but I think it’s best to follow your own passions and interests. That will show that you are true to yourself, and are not just trying to do what you think you are ‘supposed’ to do.”
— Erica from White Coat Dreaming

For me the hardest thing about applying was the cost.  - Erica

I’ve tried to make the best out of every situation. I know right now school is kind of rough, and you have to give up a lot of things that you used to have, but in the end it’ll all be worth it. -Giftson

 It is good to always have a plan B after you apply and focus on areas that you need to work on before you know if you got in that cycle or not! -Norin

The hardest part of applying was sorting through all the various requirements and prerequisites for each program. -Jill

Also, I would recommend a strong personal statement. It summarizes who you are as a person and your purpose for wanting to pursue medicine. Every part of the application is important, however, the personal statements gives them insight into your life so make sure it is strong. -Norin

I feel like location was a big factor in my decision. I knew I wanted to be in an area where I could still be around family, and having a support group nearby definitely influenced that decision but I also was excited to be out of my comfort zone. -Giftson

When the competition is so steep, you want to have as good of chances as you can, and applying to multiple programs is one way to do that! - Jill

PA School Tips: 

Know what you are getting into before you come to PA school. I was not mentally prepared for the amount of dedication that it would take to be a PA student, and it took me about 2-3 months to truly grasp how much my life was going to revolve around studying. - Erica

If your heart is not in it and this is not something you truly want to do, then stop yourself before it gets too late. PA school is hard, and honestly the pressures of the program is going to take a huge toll on you…physically, mentally, emotionally, and spiritually. If you’re not doing it for yourself, then you’re going to crack under pressure. - Giftson

Once you get accepted, stop trying to ‘better yourself’ academically or otherwise– and just relax and enjoy yourself, as much as logistically and financially possible. If you can take a vacation beforehand or some time off, definitely do- you will be so glad later. - Erica

PA school ends up taking all of your time, so you don’t really get a chance to think about how much time you’re not spending with family and friends.  -Giftson

“I faced some of my darkest moments in PA school, because, surprise…it’s hard.  And the thing that kept me going above all else was having compassion for where these long nights of studying would take me.”
— Silas from White Coat Dreaming

It helped to have a running schedule that I would try my best to stick to. That forced me to workout most days after class even when I didn’t feel like it. -Michelle

Being professional and acting in a way that shows respect to others is honestly far more important than the number of years you have under your belt. I was always worried that patients or even other classmates wouldn’t take me seriously because I was so young, but over time I’ve learned not to worry about things I can’t change. -Giftson

Also, make efforts to stay balanced while in school. So many people seem to put everything aside for their grades- mental health, relationships, exercise, sleep– but those things are necessary to be successful. -Erica

We all are starting at different parts of our life, and just because you don’t have experience doesn’t mean you can’t do well. You have to understand your limitations, and strive to push those limits every day! You’re going to make mistakes. Learn from them, and keep pushing forward so you can be the best PA you can be! -Giftson

I realized when I ate healthy, it definitely helped my energy level and helped me focus better and not get so tired studying. -Michelle

Self-doubt was a huge problem for me. I would always see other people that knew so much, and wonder if I would ever get there (still haven’t got there by the way). -Giftson

Sometimes it can be challenging when you compare and think how far ahead your kiddo classmates are in terms of being about to start their career when you would have still been waking up at noon on a Wednesday to go do a half-shift of bagging liquor- but hey, whatever path you take, you are bound to have learned something that someone on another path hasn’t. - Craig

You learn quickly that your classmates are in the trenches there with you, and you depend on each other far more than for just explaining a concept you didn’t understand in lecture.  -Silas

5 (More) Things I Wish I Knew Before Starting PA School

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A while back, I did a post for Brittany at PA Fanatic on 5 Things I Wish I Knew Before Starting PA School.  When I was working on that article, I found it difficult to come up with only 5, so here are 5 more! 

  1. Don’t worry about loans, but be aware of them.

    For the majority of PA students, loans are a fact of life (unfortunately).  There's no need to dwell on your loans while you're in school because there's really nothing you can do about them at that time because most PA programs do not allow working while in school. And honestly, I think you would be crazy to try because PA school is a full time job. While you don't want to let your impending debt weigh on your shoulders too much, don't go crazy.  I had classmates who ate out for every single meal (using loan money), and then promptly bought a new car after PA school. If you've read my story, you'll know that I worked as hard as possible to pay off my loans after I graduated, but I also tried to be frugal throughout school.  Here's some tips to help you save money while in PA school! 
     
  2. Don’t be afraid of your teachers or preceptors

    The faculty of your program should be part of your support system.  Whether it's an advisor, teacher, director, or preceptor, find that person you can go to if you're struggling. And be honest about any challenges you may be facing.  If you're finding a particular section difficult or not sure how to study most effectively, ask for help! This goes for undergrad too. Your teachers and preceptors are the people who will be able to help you get a job in the future and they'll be your best references. I would frequently visit my advisor for advice or even just to decompress and talk about how stressed I was, and it was nice to talk to someone who had been there and understood what I was going through. You'll also want to keep in touch with these people after school. 
     
  3. Make time for yourself. 

    This is something I was terrible at when I first started PA school. I would go to school, study constantly, and basically never do anything else. I was living at home for the first year, and even if my parents asked me to go grab a quick dinner, I refused and stayed hoe to study. I was also supposed to be planning a wedding at that time. About halfway through didactic year, I loosened up a bit. I started going out to eat and doing some fun things (like going to see Taylor Swift with my classmates), and my grades actually improved while my stress decreased. The lesson I learned is that 30 extra minutes of studying when I'm tired or hungry won't make a huge impact on my grade. I also never read a book for fun while I was in PA school, and I love reading! Why did I do that?
     
  4. Be honest about what you want to do. 

    Somewhere during clinical year, I decided that to get a job, I needed to tell every preceptor that I wanted to work in their field. Basically, I was trying to suck up. In my heart, I knew that I had a passion for surgery or dermatology. Once I started being honest about that with my teachers and preceptors, I actually started hearing about the open jobs in the area and getting more valuable information that would actually help me find the job I wanted. If I could do it again, I would have taken this approach from the very beginning of school. 
     
  5. Always be professional. 

    I feel like this should go without saying, but as a PA student and future PA just always carry yourself in a way that exhibits professionalism.  Whether that's in class, on campus, when you're having fun on the weekends, or certainly on rotations. Just always keep in mind that you are representing your school and the PA profession. 
That's my girl Taylor Swift back there!  Last minute floor seats can't ever be passed up! 

That's my girl Taylor Swift back there!  Last minute floor seats can't ever be passed up! 

What tips do you wish you knew before starting PA school? Comment below to share! 

Guest Post from Jamie - What's in my Medical Bag?

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I'm really excited to share this post today from Jamie, which was first published on Reddit.  It does contain some affiliate links, which means if you purchase any of the products from Amazon, Jamie will get a small cut. You may remember her previous post - The Unexpected Costs of Interviewing and Attending PA School

What’s in my medical bag?

Firstly, I carry two bags. The salmon colored bag is a little backpack by Dickies and the black bag is actually a diaper bag from Eddie Bauer. The Dickies bag was ~$23 at Sears and the Eddie Bauer bag was $39.99 at Target, but I used a 10% off coupon. On the outside of the backpack, I have a hand sanitizer (just Purell). I also carry a water bottle (Contigo brand because I hate having to bite the straw) and an umbrella. Because it’s a diaper bag, these pockets are actually insulated, which I think is funny, but awesome.

I don’t actually plan to carry both bags every day. I just don’t carry a purse and the med bag has stuff that I don’t really need on days like today or Wednesday when I only have one lecture. I do need the med bag on Tuesdays and Thursdays, though.

LET’S DIVE IN!

Medical Bag: Front Pocket(s) from left to right

Medical Bag: Inside View of Main Pocket

Laid out so you can see contents left to right

I am horrendously guilty of forgetting to put on deodorant, so I keep a little one in my bag along with some Kleenex!!

Backpack Front Pocket

Backpack Main Pocket

  • Microsoft Surface 3, 128GB Internal Storage, 4GB RAM ($399.99 from Best Buy) – this for me is an absolute MUST. It is lightweight, so I can carry it easily in my bag, it can be charged with an external USB power bank if the classroom doesn’t have outlets on the table, and it has the full functional Windows 10 operating system, including Microsoft Office. I live by OneNote for my notes. I use the cloud to store everything (with hard backups, of course), but it’s SO nice to be able to pull up my lectures from my phone or tablet, or my laptop at home. I can’t suggest this enough. I just hate that you have to buy the keyboard separate, and $400 is the cheapest I’ve ever seen it. I’ve had a Surface since the initial RT, though, and I’m a fan.
  • Microsoft Surface Type Cover - $116
  • Microsoft Surface Pen - $44.72 – I love this puppy, but you don’t need it if you prefer typing. I like being able to handwrite things easily, but it’s definitely not for everyone.
  • Tablet sleeve - $14.99
  • Bare Bones Anatomy textbook by Dr. Tracey Bee - $213
  • Flashcards for Unit 1: Intro and Back (came with textbook)
  • Folder - $1
  • Planner (MY LIFE) - $10
  • Pencil case - $1
  • Pilot G2 Pens - $10
  • Chargers, extra headphones
  • Glasses

And again, super forgetful with deodorant, so my backpack gets one, too – remember, I said I don’t always have both bags? And hey… sometimes I go to the gym… Also lip balms and a prescription topical steroid cream for my hands – I have contact dermatitis that gets bad with excess glove usage.

What’s in my pockets?? I just wore scrubs today, but this is the contents of my lab coat pockets!

  • Bath and Body Works lotion - $3
  • Bath and Body Works hand sanitizer - $1.50
  • Alcohol swabs
  • Pilot pen
  • NYX Soft Matte Lip Cream in Antwerp - $6
  • $2 for possible snacking needs
  • My locker combination

Not pictured:

  • Lab goggles - $1
  • Lunch: turkey sandwich, peppers and carrots with hummus, grapes, cantaloupe, and strawberries, Goldfish crackers.

Grand total: roughly $1600

Hi all. Thanks for reading! I'm Jamie Murawski, a physician assistant student at the University of Detroit Mercy. I have a Bachelor of Science from Grand Valley State University. I'm a Michigan girl through and through. 

I'm growing my online presence in the PA community through Reddit, where I moderate /r/prephysicianassistant along with some other pretty cool PA students. I also have an Instagram where I pseudo-blog about my journey (@jamienicole_pa.s). Please feel free to follow me or message me with any questions, I'm happy to help!

Guest Post from Holly: How To Study and Succeed in Didactic Year of PA School

Holly has some awesome tips on how to survive didactic year of PA school.  If you thought getting into PA school was the hard part, you better get ready for the didactic portion.  This post is great for whether you are just getting ready to start school or already pushing through PA school. I agree with so many of these tips, and I experienced or learned a lot of this stuff myself in PA school. 

Congratulations! You’ve finally made it to didactic year of PA school (likely your ultimate dream, just as it was mine). It’s a HUGE accomplishment so be proud, but now it is also time to start working the hardest that you ever have academically (or at least learning in a fast-paced environment that I definitely had not experienced prior to PA school). Didactic year was definitely something I was absolutely terrified of when I first started the journey a year ago, but I am here to tell you that it is not impossible, and in fact, was one of the best years of my life! Being fresh out of didactic year, I’d like to provide some study tips I learned throughout my time as a PA student in the classroom. 

  • Don’t be afraid to completely change your study habits. Your previous study habits may or may not be as effective during your time as a PA student. This was something I was initially super resistant to (I always took hand written notes in all of my past college classes), but I quickly learned it was hugely beneficial to tailor my note taking to each individual class, and what I needed out of lectures in order to properly study and succeed in learning the material. Think about how you might best benefit during lecture for retaining the material long term. I used print out PowerPoint slides for Anatomy (they were all pictures, so I would bring a bunch of colored pens to color in what I was writing about and then write any additional notes about the structure we were discussing). In most of my classes, I realized it was most time efficient for me to type out notes on PowerPoints, and either study from them or create Word document study guides to print out. Pharmacology and Laboratory Medicine were 2 classes I struggled with, especially when only viewing the PowerPoints with my notes, so I made sure to create my own personal study guides for each of those, organize the material in a way that made sense to me, and would print out and write additional notes on my notes especially a few days prior to exams. Flash cards are also a great idea for subjects that require a lot of route memorization (Infectious Disease, for example). Figure out what works best for you, and constantly be willing to re-evaluate if that method is working well for you.
     
  • Work with others and study alone. This was another thing I was initially resistant to as a new PA student. In undergraduate classes, I never studied in groups because I assumed I wouldn’t be as productive. And it worked for me then, but I found it took way too much time to figure out everything on my own in PA school. I tested out quite a few study groups before I found the right group of people, but it was especially helpful to have a few classmates and friends to rapid-fire study. During finals, we usually had about 2 exams every day for 2 weeks straight, so even if we tried not to wait until the last minute, sometimes it was inevitable, and having others to quickly help me retain information and make me think about aspects I wouldn’t have on my own was extremely beneficial. Again, do what works for you, but definitely don’t be resistant to change if you have not tried a study technique in the past!
     
  • Use any mean of studying you can think of! Some examples include (but are certainly not limited to!) videos, audio, flashcards, study guides, charts, pictures, writing on chalk/white boards, sketching out images, and more. Really, use anything that will help you to retain the information and truly understand it on a fundamental level. Some of my favorite tools included Khan Academy, Online Med Ed, PANCE Prep Pearls (I highly recommend this book, even for didactic year! It is meant as a review for Boards, but I found it quite helpful for exam reviews and also for freshening up prior to OSCE’s and the PACKRAT exam), Physician Assistant Boards (I found both the Pharmacology and Boards Review audio files particularly helpful for my commutes, especially for solidifying information prior to exams), and the Physician Assistant Exam Review podcast. Many of my classmates shared groups on Quizlet so that we were able to use each other’s Quizlet online flashcards. Our class even had a shared DropBox where we would upload any helpful information or study guides we completed for the rest of the class to utilize. I found it super helpful to hear information over and over through multiple sources, and it has certainly helped me to retain a lot even after exams were finished. 
     
  • Connect the dots. I cannot emphasize this enough, but making connections between classes is super important. This helped me to not only better understand material in all of my classes (everything eventually starts to overlap!), land a pretty awesome PACKRAT score (the PA student exam that predicts how well you might do on the PANCE, or certifying PA exam), and helped me to feel much less stressed when it came to OSCE’s where we had to put all of the information together in order to diagnose and treat a hypothetical patient. It certainly shows if you are learning the material for life and not just for exams, especially at the end of didactic year when your professors will expect much more out of you. Don’t let yourself fall into a place of complacency – after all, as one of my favorite professors stated, “you are learning this for life and to keep your future patients alive”. It’s a pretty serious task, and I always want to make sure I am doing my best for my future patients. 
     
  • If you are losing speed and struggling to continue studying, change gears! This happened multiple times to me. Didactic year was a lot of studying. If I found myself losing focus or feeling burnt out, I would make sure to have some fun or reward myself to keep up my motivation. My friends and I often made trips in between classes or during day-long study sessions for coffee, cupcakes, chocolate, ice cream, you name it! Of course, it wasn’t the healthiest choice, but it kept us going and motivated to move on to more material. Another tip I can provide you with is to exercise! I didn’t do much exercising during my first 2 semesters, but at the beginning of my third semester, my friends and I decided it would be a great idea to attend work out classes twice a week through our school’s gym. It was actually a brilliant idea because we held each other accountable to attend every class, and we got in a great work out and felt mentally and physically refreshed afterward to continue studying if needed.
     
  • Know when you need help. This is probably the most important piece of advice, in my opinion. You’ve worked so hard to get to where you are at, and you don’t want anything to get in your way of continuing through the program and becoming a future PA. Know your limitations and shortcomings, and realize when you need to ask a professor, advisor, classmate, friends, and/or family members for help. Didactic year is super challenging, mostly because of the amount of information they throw at you all at once, and because of the time constraints you might find yourself in because of your dedication to studying and passing your classes. Unfortunately, 2 of my classmates were disqualified from continuing the program due to poor academic performance, and from what I observed, both were too late in asking for help. If you see a classmate struggling, make sure you reach out if possible. Had I known these students were struggling, I definitely would have, but by the time they let me and other classmates of mine know that they needed help, it was too late to bring their grades up enough to pass. I personally struggled with Pharmacology and with my first Psychiatry exam. It was actually a double whammy because I failed both exams in the same week, and immediately went to both professors (one while I was in complete tears). Take your professors’ advice – they are there to help you and it certainly will only benefit you if you can obtain tips for how to succeed in their specific classes. I also let my friends know that these were 2 subjects I struggled with, and asked them for advice especially if they did well in the classes. I studied with classmates that were able to help me in these classes, while I was able to help them in other subjects, and it worked out really well. I also made sure to change up my study techniques to ways that helped me retain the information in a more efficient way, and was able to pass both classes with pretty decent grades! 
     
  • Know that you might not be perfect, and that is perfectly okay! I watched a few of my classmates strive for perfection, and sometimes it worked but other times it simply stressed them out more than they needed to be. I learned that even though I may not be the smartest person in the class, and certainly did not receive straight A’s by any means, I could still succeed in PA school and make sure I was learning everything I needed to along the way. My hard work paid off and was evident with my PACKRAT score, and if you keep motivated and work hard, I am positive you will succeed! 

Holly is a second-year PA student at Marywood University. Prior to attending PA school, Holly graduated from Temple University Honors Program in 2014 with a degree in Neuroscience and minor in Psychology. She then worked for two years as a mental health worker, direct service professional in an autism center, and as an emergency department scribe. You can find Holly on Instagram at @xohollyd and on her blog XOhollyd for more PA tips!

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How I Paid Off my PA School Debt

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So have you heard that PA school is expensive?  Well, that might be an understatement.  Any graduate program is going to be a little pricey, but medical programs tend to be on the higher end of things.  If you look at estimated costs for PA school, you'll see a broad range from 5-digits all the way to hundreds of thousands of dollars.  That's a lot of zeros.  And you have to look at tuition + fees + books and other resources + tools + traveling for clinicals + housing + food + everything else!

Thankfully, I went to a public program so that initially cut my costs.  My second choice school would have cost 4x as much as my program cost.  Unfortunately, that's the norm.  I had a few other advantages that helped me to cut back on the amount of loans I had.  Which brings me to Tip #1 - Take the minimum amount of loans possible!  I was able to live with my parents for the first year, and although they couldn't cover all of my expenses, they covered my fees.  I only had to take out loans to cover my tuition.  I also went to a public program, and that decreased costs significantly.  Tip #2 - Don't take out extra money to put into savings.   The amount of return you get in savings is so much less than the amount you're being charged in interest, so it's just not a smart financial move.  

I took out federal loans though Sallie Mae, which is now Navient.  I made an interesting, somewhat subconscious, decision to not ever look at how much I owed until the end of PA school when they make you do financial literacy training.  I guess I figured that it wouldn't make any difference since I wasn't able to start paying them off yet anyways.  And although I was not able to do this, here's Tip #3 - If there's any way that you can make payments during PA school, do it.  (Even if it's a small amount.)  If you get any extra income, have a spouse who works, or have savings you're sitting on, think about putting some of it towards your loans.  Those small payments make a big difference in the long run, especially with high interest rates.  

So anyways, when I pulled up my loan summary, I owed around $75,000, and that was shocking to me.  Now I know that PA school costs a lot more for a lot of people, but you can't deny that 75K is a big chunk of money.  I mean, that's the average starting salary for a new grad PA.  About 55K was principal (meaning that I had actually borrowed that much), and the other 20K was interest (the fee for the money I borrowed).  My interest rates were varied, but averaged at about 6%.  

After you graduate, there's a grace period where you are not required to make payments on your loans.  Tip #4 - If possible, start making payments during your grace period.  While you don't have to make payments, your interest is compounding and growing.  From day 1 of getting a paycheck, it helps if you start making payments right away.  You won't miss the money if you already have it dedicated to your loans.  I committed to this at first, but then I got a little lazy.  My original goal was to put at least 1/2 of my salary each month towards my loans.  But then I got the great idea that I would just put whatever was left over at the end of the month towards them.  Just kidding.  Not a great idea.  That only lasted about 2 months before I got myself back in check.  After working so hard for 2 years in school with no compensation, it can be easy to go a little crazy.  I would love to tell you to make a budget and stick with it, but I'm personally terrible at budgets, so I can't give you much advice in that area.  

So I went back to committing at least half of my salary to go straight towards my debt.  Tip #5 - Decide how much you want to put towards loans each month, and do it.  As you see the amount you owe decrease, it's so reassuring.  There are differing views on what loans to pay off first.  Dave Ramsey has the "Snowball" plan, meaning you pay the one you owe the least on, without regard to the interest percentage, and go from there to gain momentum.  I paid off the one with the highest interest rate first, and then worked my way down.  If you do automatic payments, you may get a decrease in the interest amount.  

After you've put your committed amount towards loans, if you have any extra money coming in, consider putting it towards your loans.  Tip #6 - Try to put extra funds towards your loans.   Every little bit makes a big difference.  It may not seem like it at the time, but I don't think I would have paid off my loans as quickly as I did if I hadn't done that.  And I can think of specific purchases that I made that delayed my final payment, and they probably could have waited.  

So back to my loans.  After I found out how much I owed, I committed to paying half of my salary each month to my loans, and any bonuses I got.  There were a few hiccups along the way, but I got better at it with time.  I tried to put any extra funds to my loans.  I started working in August 2014, and this past January 2016 I made my last loan payment!  It felt awesome.  Took my entire bonus/commission, and drained our bank account, but it was worth it.  I feel like a weight has been lifted off my shoulders, and I have a lot more freedom at this point.  Instead of going to the beach a few hours away, I can afford the trip to the DR without feeling guilty for not paying towards my loans.  Tip #7 - Make frugal choices while paying your loans, not extravagant ones.  

Everyone is different, and I'm sure not everyone will agree with how I did things.  But that's ok, and I'm extremely happy with where I'm at.  Debt-free, and able to start saving more and making good financial decisions.  Tip #8 - Do what works for you.  I'm a generally frugal person anyways, but I can splurge on something like a vacation or good meal.  Making big purchases, like furniture, are a lot more fun now too.  

At the end of the day, whether you're still in undergrad or worried about affording PA school, your loans will be paid off at some point.  It may not be as soon as you would like, and you'll probably make some mistakes, but it will happen!  If you have any other tips for others about paying off loans, please comment!  Or if you've paid off you're loans, I would love to share your story and help others to have confidence that it is possible!  

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PANCE/PANRE Review Course - The Resource You Need to Pass Boards!

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From the first day of PA school, you are fully aware that boards will be necessary at the end to practice as a Physician Assistant.  Although some people wait until after school to buckle down and study exclusively for the PANCE, I think it's best to start studying from day 1.  All of the tests during didactic year and clinical year are important, but that last test is the MOST important.  

I'm really excited to be able to share an awesome resource when it comes to studying for the PANCE - the PANCE/PANRE Study Guide and Review Course. There are so many aspects to this that will be helpful to every kind of learner.

The Study Guide - When studying for this all important test, you want to make the most of your time and focus on high yield material. The Study Guide is a 109 page PDF that focuses on everything you need to know. It's short and sweet, and to the point. It's essential that you are able to recognize buzzwords and match them with diagnosis, imaging, or treatment. For example sausage mass on palpation in a pediatric patient should automatically make you think of intussusception. This is the resource you need to focus your brain on what you NEED to know. If you just want the guide, you can download the study guide for 9.99.

Online Content - For the review program , you log in, and are able to access a ton of content. The course is organized based on the NCCPA Blueprint, so again, the focus is everything you actually need to know. In each section, you'll find an introductory video, the NCCPA Blueprint information for that section, the percentage it is on the PANCE, an audio review section, the PANCE Study Guide for that section, quizzes, flash cards, and more review material. Basically, there's a little bit of everything and the material is reviewed in multiple ways.

Quizzes - There are different options available when it comes to the quizzes.  There are basic ones that just ask pretty straightforward questions and some situational ones, and then there are buzzword matching ones.  Practicing actual questions is the best thing you can do because you are testing your understanding and knowledge.  Knowing buzzwords for the PANCE is also necessary.  Like other standardized tests, there is strategy involved, not just knowledge.   I was reminded just how much I don't remember from school after taking just 2 quizzes.  

So why should you invest in this review course?  Well, if you don't pass your boards, you get a full refund.  That's a pretty bold promise.  There's a free trial available that still has a ton of valuable knowledge, so you can try it and see if it would work for you.  For lifetime access, it's $199 (and there's a discount below!), and you get access to so much knowledge.  And that means you can start it the day you start school and use it throughout your program.  This is a resource that I will use to stay up to date on the material I need to know and I plan on using it when I have to recert.  The creators have worked really hard to make this an all-inclusive study guide, and I think they have succeeded.  

I think if I was using this today to study, I would do a practice quiz, then read through the study material, listen to the audio review, and then take more quizzes.  It's basically everything I did to prepare for PANCE 2 years ago, just in one source instead of multiple books.  

If you are interested in checking out the study guide or review course here is a coupon code that will get you 15% off of your purchase!! - thepaplatform15

I was provided access to the course and a copy of the study guide for free, but my thoughts are completely my own!  

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My Favorite Books to get through PA School

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If your program is anything like mine, they will give you recommended books or resources for each section.  While a few of these were helpful, there were other books that I used during the entire didactic and clinical years, and I don't think I would have made it without knowing where to find the information I needed.  The internet is a great resource, but I love being able to flip through a book and highlight and make notes too.  Here are some of my favorite books, and make sure to comment below with anything you think I left off! This post contains some Amazon affiliate links. 

A Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants - This was my main PANCE study book, but I used it all year long.  It is based off of the NCCPA Blueprints for the PANCE exam and goes through every single section with the main ideas that are important for PA school.  I would always read through the related section the morning before a test just for a refresher.  My only complaint about this book is that the medications are not always specific in the treatment section, and I could use a little more info there.  

Step Up to Medicine - While this book is technically for medical school, it's great for studying all of the basics of PA school, especially all of the Internal Medicine topics.  It's split up really well and easy to read.  This book fills in what the PANCE review book leaves out, and I wish I had known about it for more of didactic year, but it's great for clinical year too.  

Pocket Medicine - This is a pocket reference for your white coat that I actually didn't have, but I wish I knew about it.  My husband currently uses this book on his medical school rotations, and it's really cool.  It has all of the current recommendations for Internal Medicine subjects, and also all of the articles that the recommendations are based on, so it's truly evidence-based.  If you're in an academic center, the attendings love it when you can reference an important study.  There's a Pediatric version as well.  

Maxwell Pocket Reference - This is another book you should have in your white coat.  It's really small, and for $5 it comes in handy.  This little book has outlines for different types of notes in the hospital, ACLS codes, physical exam and history, and all kinds of other important topics.  Unless they've stopped, if you join the AAPA as a student, they will send you a copy of this.  

Lange Smart Charts for Pharmacology - This was my go-to for pharmacology, aka the worst class of PA school.  It's just so hard until you're actually seeing these drugs on rotations or practicing .  This book is a flip chart of all the drugs separated by class with everything you want to know, including brand name, mechanism of action, side effects, and contraindications.  I love a good chart, and these made studying so much easier.  

Bate's Physical Examination - This is basically the go-to book for learning how to do a proper physical exam.  It was required by my program, and my husband used it as a reference in medical school too even though it was never recommended.  There's pictures and great explanations for any part of the physical exam that you can imagine.  And there's even a pocket version as well.  

Lange Q&A Book - This was my main book for practice questions.  Doing questions and attempting to apply the knowledge I'm trying to learn has always been the best way for me to evaluate where I'm at.  I used this book during the clinical year and studying for the PANCE, but I wish I had it for didactic year as well.  The questions cover all subjects, and have awesome in-depth explanations.  

Tarascon Pocket Pharmacopoeia 2015 - Shirt version and White coat version - This is another reference book you can use on rotations.  I know you have Epocrates on your smart phone, but I liked having this book as well.  It's really easy to find what you're looking for and they update it every year.  

Basic Concepts in Pharmacology - This is a small book, and it has really short and straightforward chapters about different drug classes.  I liked to read the relevant sections before Pharm tests as just a quick overview.  I probably just need to read this book every month to retain some of the knowledge from PA school.  Sometimes it feels like all I prescribe are topical steroids and acne medicine! 

First Aid for the USMLE Step 2 CS - If you have physical exam or practical examinations with standardized patients, then you need this book.  This is another one that I unfortunately did not have while in school, but it would have made my life so much easier.  I spent hours trying to come up with practice cases, and come to find out, here's a book with everything I was looking for.  There are checklists for each case, and you'll need a partner to get the most out of this book.

Pance Prep Pearls - This book had just come out when I was in study mode for PANCE, but a few of my classmates did use it, and they passed!  I've heard a lot of buzz about this book recently, and I definitely plan on using it when it comes time for me to recertify...in 8 years! 

Here is a blog post from a fellow blogger with her recommended resources, some of which are the same as the ones you will see here.  

Clinical Year: Pediatrics

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There are a couple of rumors that go around about pediatric rotations.  I heard them multiple times, and I've heard them from students in all different programs.  

  1. The parents are the worst part of working in pediatrics.  
  2. You will definitely get sick while on this rotation.  

Unfortunately there is some truth to these rumors.  Most of the time parents are fine, but every once in a while, there will be one that is very difficult to deal with, but they weren't that bad.  And I definitely got sick because kids don't even try to not cough or sneeze in your face.  I felt kind of bad for the last week of my rotation, so after multiple negative strep tests, I went to the student health clinic. Just a mild case of pneumonia, but that was resolved with some steroids and antibiotics.  And I learned my lesson and decided I should probably go to the doctor if I'm feeling bad for a week or so and it's not getting any better.  

My pediatrics rotation was at a small clinic in town.  All of the staff and the physician are hispanic, so about half of our patients were mostly Spanish-speaking.  I took some Spanish in high school and college, but I am in no sense fluent.  I can understand some things and carry on a very basic conversation.  So that was a challenge, but I tried!   And everyone was really nice and understanding about my lack of ability to communicate.  

My preceptor was a great teacher.  He had been practicing for years, and had seen some tough cases.  He liked to pimp me, whether we were in the room with patients or during lunch, and his questions were extremely specific.  I rarely knew the answers, but I would always try, and I learned a lot.  He was always nice when I didn't know too.  We had a document as a class with notes of questions he had asked other students in the past, so I tried to study that, and it helped me to get a few right.  There are so many strange congenital defects and diseases that it's impossible to feel prepared to know them all coming out of PA school.  We learn the basics.  

Kids can be tough.  If they're sick, then they are already upset and really don't want you messing with them.  I think its's hard for them to realize that you just want to help.  Some kids will automatically start sobbing when you come in the room.  I learned to look for tears because otherwise they are just putting on a show.  There are a lot of well checks, along with the sick visits.  

One of the interesting things I got to see on this rotation was a child with chicken pox, which my preceptor said he hadn't seen in a few years.  It was a textbook appearance, but it's become very rare to see it in clinic.  The pt was about 2 weeks away from getting her chicken pox vaccine.  I also saw a teenager in sickle cell crisis, which seemed to be very painful.  He had experienced it before and really needed to be at the ER, but it was still a good thing for me to see.  

I enjoyed pediatrics, but it was a little exhausting as well.  My preceptor would just hold kids down if he really needed to, but he was a big guy, and I'm not.  Even now I don't even try to restrain kids while I'm treating them because I usually end up getting kicked or not being able to do what I need to do.  In dermatology (at my practice), I do get to see a good bit of kids.  I think if that's all I saw, I wouldn't like it as much, but I do like getting to see them occasionally.  

Here are some other resources to check out as well:

  • A blog post about a student's experience during pediatrics

Clinical Year: Internal Medicine

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I'll go ahead and say this was one of my least favorite rotations, not because of the area, but because of where I was.  Just a disclaimer. 

My internal medicine site was an outpatient clinic that also took care of multiple nursing homes and did home visits, so I spent some time at those as well.  There was an MD and a PA in the office, and a PA who only saw nursing homes and home visits.  

Over time, the site I was at had somewhat transitioned into a pain management clinic, which is questionable territory for an IM practice.  There were a lot of suboxone patients (a medicine to help patients addicted to pain medication) and a lot of chronic patients, some who were getting over 300 pills of hydrocodone or oxycodone a month (if that sounds a little excessive, it's because it is).  This practice also regularly prescribed drugs for ADD and weight loss.  There were also some regular IM patients just coming for check-ups, but not as many as I would have expected for an internal medicine residency.  

Anyways, I definitely learned a lot during my month there.  They would call me to come and do every physical and rectal exam.  Lucky me!  (Thankfully, I don't have to do those in dermatology, but I got plenty of experience there.)  It was the 2nd day when I was let loose to go see patients on my own, and when I started to feel slightly uncomfortable.  Everyone was very nice, but after presenting to either preceptor, there were times when I was encouraged to go forward with my treatment plan and let the patient go (without them ever seeing the patient).  That is just not appropriate.  I was a student.  I learned to stand my ground and I let them know that I was not comfortable with that.  I also let my clinical director at my program know what was being encouraged.  

The good things about this rotation were I got lunch everyday because if there wasn't a rep on the schedule, they would call around and find one.  I did get to see a lot and I learned a lot, especially about pain management and being in uncomfortable situations.  That physician has recently lost his DEA license, so I think that speaks a little bit to what was going on.  

So this is an example of how where you do your rotation can make a huge impact on your feelings for the specialty.  If you have a bad experience, you may want to consider doing one of your electives in that area just to get another look in a different place.  And again, never do anything you aren't comfortable with and tell your program if you feel like a rotation site wouldn't be good to use in the future.  

Some other blog posts and articles that may be helpful: 

  • A blog post with an interview with a cardiology PA
  • A blog post with an interview with a nephrology PA
  • A blog post about a student's experience on her IM rotation.  And some recommended resources.  

Clinical Year: Endocrinology

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At my program, we had 8 weeks of internal medicine total and could break it up into 2 separate 4-week rotations.  I did one of mine in general IM and the other in endocrinology.  My initial thoughts about endo were that I didn't know that much so I needed to do it, and lots of diabetes was in my near future.  

So what I learned on this rotations is that I was right that I didn't know much and that endocrine does see a lot of diabetes, but there's a bunch of other stuff too.  And there's a lot more to diabetes and treatment than we learn about in school.  Probably because they have new drugs and insulin more often now.  

My rotation was about 30 minutes away in a small town, and the office was a really cool old Victorian house (which I later found out was apparently haunted).  There was a physician and a PA and I was able to spend time with both of them.  The MD at this practice was a little picky about things, and would have a mini breakdown if you happened to forget the patient if they were taking aspirin or another minor detail.  I would always remind him that the patient was still there and go ask as promptly as possible.  Interesting dynamics in that office.  

There is a huge lack of endocrinologists right now, and that need is just going to grow as America continues to lack understanding about their health.  The patients would come in and have vitals done, occasionally a DEXA bone scan, and then be seen.  It's really important that diabetes patients keep a good record of their blood sugars, meals, and medications, especially if they are uncontrolled.  I would say about half of the patients actually brought these with them, which was a little frustrating.  The office I was in would do something called continuous glucose monitoring on patients that were having trouble getting their sugars under control.  Basically they wear a monitor for 3 days that takes periodic measurements of their blood sugar and then provides all kinds of graphs.  These can be done from blood glucose monitors too, but take a little more work.  If the patient is diligent about recording their meals and medications, that data shows when they may need more or less insulin or what meals they need to adjust.  It was really neat.  

Besides diabetes, there were also a lot of thyroid issues.  Whether it was hypothyroid or hyperthyroid or thyroid nodules or masses.  The MD had an ultrasound that he would do on patient's thyroids and he also performed fine needle aspiration biopsies as well when needed.  Those were very neat to see, and similar to what I had seen on my surgery rotation for breast mass biopsies.  

I went into this rotation thinking I was going to hate it, but I actually ended up liking it a lot.  In fact, I think if I wasn't working in dermatology, I would have looked for a job in endocrinology.  My husband is a 4th year medical student applying to internal medicine residencies right now, and I secretly hope he ends up doing an endocrine fellowship so I can work with him some.  I considered endocrine "lab medicine," and while labs are important, it's also important to talk to the patients and educate them on their disease state.  Unfortunately, I never saw the ghost of the little girl that had been seen multiple times in the office, but that's probably for the better.  I think doing this rotation helped me on boards a ton, and gave me a much better understanding of diabetes medications and interpreting thyroid labs, so I would definitely recommend doing one if you can!

Clinical Year: Emergency Medicine

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Going into my Emergency Medicine rotation, I was a little apprehensive.  I mean, anything can walk through those doors right?  At this point about halfway through my clinical year, I wasn't really thinking of myself working in the ED.  

The hospital I was working at was a smaller one, where there are usually 2-3 physicians and 2-3 PAs or NPs on at any given time.  My preceptor was great!  He loved to teach, and if we had any downtime, he would try to fit in a quick lesson about one of the many essential topics in the ER.  Everyone at that hospital was so nice and helpful.  I was the only student there and if anything interesting came in, the nurses or physicians or PAs would always come and get me.  

Basically the way the ER works is that a patient comes and signs in and they are triaged.  Their name and chief complaint are displayed on the provider's computer, and then each MD or PA decides who they are going to pick up.  It's important to keep a good balance of straight forward cases (like a cut that needs sutured) with more complicated cases that will require labs or imaging.  Since I was there, my preceptor would usually pick up 2 cases at a time and I would go see one patient while he saw the other.  

I was definitely right in assuming that the ED is unpredictable.  There would be some days that we were sitting around with not much to do, and then other days that there were so many patients, they were being treated in the waiting room.  Literally, one of the PAs would go in the waiting room, and if there was something simple they would treat the patient there.   Since the shifts are usually 12 hours, there would often be busy times and slow times during the same shift.  I ended up staying late a few times, just because it had gotten so crazy by the time I was supposed to leave.  

Working in the ER is a really great opportunity to see a lot of different cases and also to practice a lot of skills.  It's not the time to be shy.  If they give you a chance to do something, and you feel comfortable, then go for it!  There are so many skills I got to practice or see during this rotation, that it was extremely valuable.  I'll list a few off just so you can get an idea:

  • Suturing a cut from a chainsaw - I did this all by myself!  My preceptor said he would come check on me, but I finished before he had the chance.  I had a little suturing practice from my surgery rotation, but those were cleaner cuts.  My patient was really nice, and I remember his son was there and they were watching a show about puppies on the Animal Planet, which didn't seem quite characteristic, but was funny.  
  • Lumbar puncture - I was able to see an LP on a 4 day old (which was really hard to watch), and practice on a pt with advanced diabetes who we suspected might have meningitis 
  • Start a central line - My preceptor helped lead me through this one because I had only ever done it on models, but he helped me to find the femoral artery and go through the process, so that was really cool.  That's not something they do a ton at the ER I was at, so I was glad I got to see it
  • Intraosseous IV - I performed this on a pt who was currently having CPR done, and both efforts were unsuccessful unfortunately.  You really want to make sure you go in at a 90 degree angle to have a successful intraosseous IV
  • Remove a fishing hook from a pt's neck - Definitely interesting.  I just used a pair of pliers that look like they came from my dad's toolbox.  The pt did great though! 
  • See CPR - I didn't actually participate because by the time the pt got to the ER, the respiratory team was bagging the pt and they had the LUCAS machine on that does chest compression.  Pretty crazy to watch.  
  • Staple a child's head - Not the most fun, but good practice for working on kids.  You just have to be fast and hold them as still as possible.  
  • Drain a cyst - This was good practice for my current job in derm.  I still hate draining cysts.  The smell is just too much. 
  • Set a broken radius- I don't do well with bones.  Like those videos with people breaking their arms and legs?  I just can't handle them.  So when an 8 year old has a broken arm and they asked me to set it, I said sure just like any good student would do.  And then I almost passed out.  Whoops.  The feeling and sound and the MD "recreating the injury" to then put it back into place after I failed, that just didn't work for me.  So I turned sheet white and started blacking out as I ran out of the room to find a place to sit down.  I got made fun of just a little bit for that one.  
  • Watch a dislocated hip be realigned - More bones.  This was after the arm, and once the MD was standing on the bed and pulling on the patient's leg, I just decided to look at the ground.  But I heard it go back into place! 
  • Pop a dislocated shoulder back into place - For some reason I handled this ok.  It wasn't that bad.  Basically you pull down on the patient's arm, and then rotate their arm backwards and up and it slides back into place.  

So by the end of my ER rotation, besides the bone stuff, I really felt like I would enjoy working in that field.  I really liked the hospital I was at, and it would be a wonderful place to work.  Of course, in the ED, you get some drug seekers and difficult patients, or patients who really should just be at prompt care, but what can you do?  All of that is really just a part of medicine, so we deal with it.  The one thing I didn't love about the ER was the long shifts.  I felt like I went to work, came home, ate, slept, and then did it again for 3-4 days in a row.  So it was pretty exhausting, but I think it would be something you get used to if you do it all the time.  

Other Resources:

  • Here is a blog post with an interview with an ER PA.  And another one as well.  
  • "Advice to New Interns" - or to new PA students on rotations.  
  • ALiEM (Academic Life in Emergency Medicine) - This is a site with great articles and videos about emergency medicine
  • Here is a blog post from a fellow student about her experience and tips for an ER rotation.  

Choosing Elective Rotations

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One of the fun parts of clinical year is getting to choose where you will do electives, but this can be stressful as well.  There are a lot of different things to take into consideration when trying to figure out where you want to spend your extra time and various strategies for making those decisions.

Is there an area that you weren't able to rotate in that you think might interest you?

  • Electives are a great opportunity to explore your options and find out if you would like a job on a daily basis without committing to a contract.  For example, my school doesn't require an orthopedics rotation, but it's a very popular area for PA students (and a good chunk of the PANCE) so a lot of my classmates chose to rotate through ortho.  Even if you don't love the exact area that you choose to rotate through, it may give you some direction.

Was there a rotation that you loved, but not sure if you would want to do it daily?

  • Maybe you just need more time to figure it out, and you can use that elective to find out.  If you liked a specialty, but spent most of your time in a hospital setting, you could try to find an outpatient office to get some experience in a different setting.  There can be a huge difference in working in a private office and working in a hospital.  I was on the inpatient wards for my whole psychiatry rotation, and I hated it, but some of my classmates had great experiences in outpatient psych.

Is there an area that you feel like you are not as proficient at or really worried about for boards?

  • For me, it was cardiology.  I still wish I had the opportunity to do a rotation specifically in cardio because it's such an important part of boards and seeing patients in multiple areas.  I chose to do a general internal medicine and endocrinology (which I would recommend for sure) instead, but I think cardio or pulmonology would have been really useful.  Doing an elective in an area that you don't feel as comfortable in will help you to step outside of your comfort zone, and help you to feel more ready for boards.

Is there a specific area you are interested in working in?

  • If you already have an area of interest, but have not found a prospective job yet, you may try to do a rotation in that area.  It's always a good idea to make your interests known so that potential employers or preceptors who have connections can help you to find a position.  By doing electives in an area you want to work in, it will give you extra experience, which is a plus when applying for jobs in that area.

Do you have a prospective job opportunity?

  • If someone has made you an offer of employment or is possibly considering that, you may want to do one or all of your electives with that group.  It gives you a chance to see if you would fit in and feel comfortable, and it gives them a few months of free training, which means you'll be working on your own sooner potentially.  Personally, I knew I wanted to work in dermatology if possible, and I was able to use my 2 months of electives as a benefit during my interview.  I was hired before my electives and that time was great for training, and I was able to start seeing patients on my own about 1 month after I was officially licensed because I had 3 full months of training done already.

If you already know what area you will be working in, is there a different specialty that would make you a better provider in your field?

  • Many fields have a lot of overlap, or you may end up sending patients out to a specific specialty, so it wouldn't hurt if you are able to spend some time in an area that is complementary to your field.  In derm, we send patients to Rheumatology a lot for example, and Mohs surgeons as well since we don't do that at the practice I'm at. If you're going to be working in primary care, I think extra time in any specialty is helpful, but consider derm, endocrine, or ER.  If you're planning on working in an ER, I think a derm or surgery rotation where you'll be able to really work on suturing is a good idea.

Do you feel like you need more study time for PANCE, but still want to take it early?

  • Some rotations are more laid back and less time consuming than others, which would give you more time to study.  ER is one that typically you have to do a set number of shifts so if you have flexibility to do them all at the beginning, you would potentially finish a rotation early and have extra study time.

Is there a different city or state you are possibly interested in working there?

  • Elective rotations are a great opportunity to explore other areas of your state or maybe another part of the country.  A classmate of mine did rotations in Texas, Tennessee, Wisconsin, Washington, and Alaska, where she is now currently working.  If you have the financial means and the flexibility to travel, then go for it.  Doing rotations in other geographic areas will also help expose you to how healthcare is different among regions.  
     

Other resources to check out:

Let me know in the comments if there are any electives you would or would not recommend and your tips for how to choose those rotations! 

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The Hard Parts of Practicing

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As much as I love what I do, I have days that are just really tough, or entire weeks, like this one.  When I first started working, there were more days and weeks like this just because I felt like I didn't have a great grasp on dermatology and felt like I should already know everything.  It's definitely gotten easier, but there are still some days that are just so hard.  

I feel like we mostly talk about the good stuff of practicing medicine while we're in school, but there's a lot more to it than that.  Occasionally, we'll learn about difficult or non-compliant patients, but that just barely scrapes the surface of what it's like in the real world.  You can role-play situations as much as you want, but you won't know how to react or what to say until you're actually encountering patients.  I work in dermatology, so I know there are others in specialties that deal with even more difficult situations than me.  

These are the things that I've found difficult during my first year of working, and during this incredibly long week:  

  • When patients are frustrated that the treatment regimen you gave them for their eczema or acne didn't work
    • I promise I gave you what I thought would work the best and be most cost effective.  But sometimes, I'm wrong.  I didn't do it on purpose, and I will keep working to find what works for you.  
  • When a patient wants you to inject an area that you know may cause blindness 
    • There isn't always a quick fix for everything, and I would never purposefully do something that would harm my patient.  Like injecting steroid into a stubborn acne bump in an area (the glabella, aka in between the eyebrows) that could potentially cause blindness.  Sometimes we have to wait it out and let our body heal itself, even if it takes longer than we would like.  
  • Having to make a phone call to a patient to tell them they have melanoma
    • I hate melanoma phone calls.  That's about the worst thing to do in dermatology, and it can be a really tough conversation.  Most of the public is not very knowledgeable about skin cancers, or don't consider them "real cancers."  I think once you have a 50-year old patient with a melanoma that gives him a 15% 5-year survival rate, that counts as real cancer.  
  • Having 3 patients in a row no-show, but also patients showing up 30 minutes late or with no appointment at all, which just throws the whole day off
    • This is something I still have trouble not getting frustrated about, but things happen and I try to give patients the benefit of the doubt.  
  • Having to tell a patient she might have MRSA and probably shouldn't hold her new grandbaby until the culture results come back, and then her calling saying I "didn't help at all"
    • It's not a good feeling to have a patient call with a complaint like that.  Especially when I treated her appropriately.  That's where emotions of the patient get involved, and things get complicated.  A phone call usually helps.  I was dreading calling this patient back, but when I did it actually made the situation better.  I was able to tell her she has normal Staph and not resistant Staph, and although I still want her to avoid the baby, it made it not quite as bad.  Patients will most always appreciate your time, and I think as providers we should take the time to make situations like this better if we can.  
  • Seeing a 7-year old with a skin disease that could potentially cause him to lose mobility of his leg
    • Kid stuff is hard.  This kid had something called lichen sclerosus et atrophicus, and areas had progressed to morphea.  This was something I had read about, but never actually seen.  Hopefully, we should be able to help him before things progress too far.  

Honestly, those are just the few highlights, and there were plenty of other situations I could talk about.  Part of what makes my job so tough is that at times I get the feeling that patients are thinking I just gave them a medicine for the heck of it, or that I didn't make them better on purpose, or that I don't care that I'm 30 minutes behind and they had to wait a little longer.  Truthfully, these things actually bother me.  A lot.  And I know they bother most other providers as well.  I wish patients were able to see the behind the scenes sometimes, instead of thinking we just mosey around at our leisure.  

I've been on the patient side too.  At my annual GYN appointment last year, I waited for 3 hours to see my physician.  And she spent about 5 minutes with me.  But she had an emergency patient that had to be seen to, and when it comes down to it, I know that if I was the one having an emergency she would have made someone else wait.  People are very quick to make judgments these days and very impatient.  I see Facebook posts almost weekly about "Why would my appointment be at 3:00, but the doctor didn't see me until 3:30?" or continual updates about how long the person has been sitting in the doctor's office.

 As someone who has seen both sides, and is sometimes responsible for people sitting in the waiting room, I think we need a little more grace.  Both patients and providers.  It is not uncommon for my patients to be late.  And not just a few minutes.  I've had patients show up an hour late and most of the time they don't even mention it.  If I make a patient wait more than 5 minutes, I apologize because I hold myself to higher standards than that.  So I do get frustrated with those patients who are late.  At the end of the day, we're all just people.  Both patients and providers, and we all make mistakes, so I hope we can give each other a break.  

Clinical Year: Surgery

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Surgery was by far my favorite rotation while I was in PA school.  I had already been exposed to a bit of surgery in OB/GYN where I learned I could see blood and invasive surgeries without passing out, so I was excited and ready to go for my surgery rotation.  

The surgeon I worked with was a general surgeon, but he specializes in breast cancer.  He is seriously just a great person.  He is kind to his office and surgical staff, spends time with his patients and truly loves them, and awesome at what he does.  That probably was part of why I loved this rotation so much.  And he helped me get the job I have now!

While surgery was my favorite overall, it was also one of my busiest rotations and during the 12-hour days I would rarely sit down.  Maybe for 30 minutes total out of the whole day.   After the first week, I was feeling like my body just wasn't going to make it.  This rotation is where I learned it is important to wear good shoes and compression socks and that it will actually make a difference.  Danskos are a good option, but if you can't bring yourself to look like a little dutch girl, a good pair of tennis shoes with supportive insoles will work too.  I went to The Walking Company for some shoes, and then got some Dr. Scholl's inserts at the fancy machine at Bed, Bath, and Beyond that tells you what kind you need.   Compression socks take a little getting used to, but I wear them daily still.  VIM & VIGR are my favorites right now because they have some patterned ones, but also they give good compression and really maintain it throughout multiple washes.  I have 3 pairs I've been rotating through for the past year, and they are all still doing great.  

Before this rotation, I did not have much knowledge of breast cancer.  No one close to me has ever had breast cancer, and the few lectures we had during the didactic year were a little over my head for where we were at the time.  Dr. C did a great job of explaining the different types of breast cancer, how hormones play a role, and surgical options when breast cancer is found. 

I became very proficient in breast exams during this rotation, and I realized the importance of women doing self-exams.  It was very interesting seeing a case from start to finish, and all of the emotions involved.   I actually really like getting to help patients through that process, and it's something I still get to do in dermatology.  One case that sticks with me was a 35 year old woman who happened to notice a lump while on vacation.  Mammograms are not recommended (or covered by insurance) until age 40, so she had never had one.  (This is something that insurance companies are trying to change to make the recommended age older, by the way.)  She came in and we did an ultrasound first.  Typically a dark shadow that blocks the waves completely and shows nothing underneath it means the tissue is thicker and not doing what it is supposed to be doing.  Then a fine needle aspiration was done, and I learned early that if the tissue sinks in the specimen cup, that is also not a good sign.  The surgeon told me that he can usually tell by how the tissue feels during the biopsy if it is cancerous, and I can confirm that's true after working in derm.  When I biopsy a basal cell or squamous cell carcinoma, the tissue seems to almost fall apart and it is very friable.  

Anyways, this patient had both of those signs, and Dr. C told her his suspicions.  It is hard to watch someone receive that news, but everyone reacts differently.  Some people are ready to know what's next and how to fight it, while others start throwing up and need some time to come to terms with the disease in their body.  Whenever a patient is diagnosed with breast cancer, Dr. C would bring them in for a "talk" to go over the diagnosis and discuss options.  

In the OR, we did a lot of lumpectomies and mastectomies, with a few gall bladder and lipoma removals and hernia repairs as well.  I love the OR setting.  I was able to make incisions, suction, help remove tissue, and suture.  This rotation is where I really learned to suture and got a ton of practice, which I am so thankful for.  

The worst day was when the air was broken in one of the ORs, so it was about 80 degrees.  When there are a lot of hot tools being used and you're wearing scrubs and a gown and mask, it can get pretty hot.  That was the only time I almost passed out while in the OR.  

Here is a blog post of an interview with a PA who works in orthopedic surgery.  Broken bones are not my thing, so if you can set a fracture without passing out, then more power to you!

Here is a blog post of an interview with a PA who works in neurosurgery, so check it out if that is a field that interests you.  

Surgery is interesting because you have to be ready for complications, and be able to think through problems.  I really enjoyed it, but it's not for everyone.  Let me know if you have any questions! 

Some other posts or articles that pertain to working in surgery: 

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1 Year Out

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I just recently realized that I've officially been a graduate for 1 full year, and it was about this time last year where I was nervously awaiting PANCE results.  It's been somewhat of a whirlwind year, and I wanted to reflect and share some advice to you guys as I look back.  It's amazing how time flies in PA school, and then it still goes as fast when you're busy working.  I went to a pharmaceutical dinner last night for PAs, and some of my past professors, and now colleagues, were there.  It was so funny because one of the teachers couldn't even remember when I graduated!  And she wanted me to call her by her first name, which just still seems weird to me.  It's amazing what a difference a year can make.  

This time last year, I had officially graduated, taken PANCE, and was training at my dermatology job.  I was almost as nervous to check my board results as I was to actually take the test.  I was at work that day and as soon as I got the e-mail that scores were posted, I went outside of the building to check them.  I had pretty much decided that if I failed, I would just leave and not go back.  Luckily, I didn't have to do that, but passing boards is what made it feel real, like I had finally made it.  I'm dreading retaking them in 10 years, but I just won't think about that for now.  

Some advice to Pre-PA students - Being a PA is a great job, and I definitely recommend it, but look at all of your options closely and decide why being a PA will be a good job for you personally.  Although in many fields, you do most of what the physician does, PAs are not physicians, and some people will never be happy in that role.  It takes hard work to become a PA and you have to decide that it's worth it you.  While you're doing all of the prerequisites for PA school, have some fun.  Looking back, I had a great college experience, but I was almost too goal focused and I do wish I was a little more laid back at times.  The stress and tears weren't really worth it.  

Advice to current PA students - Eventually, you will be done with classes and rotations and boards and you will be a PA too!  It does end, so just remember that during the weeks that you think you might just not make it.   There are still about 2 weeks that I remember as just being terrible, but we all made it through.  I would encourage you to still take care of yourself and your passions.  It can be easy to lose those things when you're so microfocused on school all the time.  I don't think I read a single book for fun while I was in PA school, instead I would read study material until I fell asleep.  Was that necessary?  Probably not.  Also take time to invest in your friendships and family.  The first 2 semesters of PA school, I wouldn't even go out to eat with my family because I "had to study."  Looking back, it would have taken probably 30 min- 1 hour, given my brain a rest, and given me nourishment and fellowship.  Maybe I got 1 point higher on the test by skipping dinner?  But I think I would have rather gone to dinner.  So don't be so uptight that you let things slip away.  Become friends with your classmates too, and hang out with them outside of school!  Some of my best friends are girls I met in PA school, and most of the things we did were unplanned and random, but just what we needed to survive.  Like buying last minute floor seats to see Taylor Swift 2 days before the show, with multiple tests the next week...maybe not the best plan, but exactly what we needed at the time.  (And it was so worth it.)  One last thing, you will find a job.  So no need to cry over that like I did either.  Your first job probably will not be your last job, but there are plenty to go around.  While job searching, I would recommend not discussing specifics of jobs with your friends or close classmates because it can get a little uncomfortable if you and your best friend are interviewing for the same job.  So just make a plan to hold off until you've signed the contract.  

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Advice to new grads - Congrats, you made it!  Welcome to the real world!  Vacation is something different now, and if you're working in a clinic with a set schedule, be prepared to ask off months in advance because they really don't like having to move 20-30 patients when you decide you're ready to go to the beach. Be wise with your money.  I had a great plan right out of school that I would just buy whatever I want and then whatever was left would go to my student loans.  Yeah, that's  a terrible plan.  Look into paying off your loans early and investing as soon as possible.  (A great resource - White Coat Investor).  While being wise with your money, don't be afraid to have some fun too.  You've deserved it!  Like if you want to plan a random trip to Las Vegas with your spouse or buddies, do it!  And keep up with your classmates.  It takes a family to get through PA school, and now that you have a bunch of new colleagues, use those resources to make each other better PAs.  If you hate your current job, look for a new one.  I once heard that you should never stop looking for a job, and there are tons out there so don't stay somewhere that you are unhappy.  Don't forget to give back to your program either, and not necessarily financially.  If you are able to lecture or be a preceptor for students, that's a huge help to the program and even more to the students.  

Overall, I'm extremely happy with my decision to become a PA and I love my job.  There are still some days when I feel overly stressed and exhausted, but there are far less than when I first started working.  I'm excited to see where our profession is heading, and how it will change and evolve.  I'm still figuring everything out, but it's getting much easier.  And I'm just happy to not be studying for the PANCE right now.  

Clinical Year: Obstetrics and Gynecology

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This was my first surgical rotation, and I don't think I realized how much surgery is involved in OBGYN until I was there.  I have to admit I was not excited going into this rotation.  I had never done a Pap smear up until this point, and I was thinking I would be just fine if I never did.  Nonetheless, it is an important skill that I did get some practice with.  

Anyways, I showed up on the first day and met my preceptor and her medical assistant.  They were so much fun to work with, always saying hilarious things, even if they were sometimes slightly inappropriate.  My preceptor was from Europe, so she was raised with a different medical model, and she has extremely strong opinions about our government.  That made for some interesting discussions, and I did learn a good bit about politics so I could keep up with her jabs at political figures.  She was really fun to work with, and a very patient preceptor.  She would ask me questions, but was never rude or condescending towards me (or any of the staff for that matter.)  I really respected how laid back she was, and I honestly don't think I ever saw her stress out about being behind or having to run back and forth from the office to the hospital.  

They told me to meet at the hospital at 6 am for my second day to go into the operating room.  I was so nervous.  My biggest fear was passing out when the surgeon made their first cut.  While shadowing in dermatology, I had a close call when I saw a punch biopsy, and that's nothing.  I mean, I actually do those myself now, which is especially silly to think back on.  When I saw the PA cut into the patient, for some reason my face turned white and I started blacking out.  Luckily, the PA looked over at me and asked if I wanted to sit down, which was a great idea.  So needless to say, I didn't really want to make a fool of myself at the beginning of my rotation.  

I showed up at the hospital to watch a laparoscopic tubal ligation and an abdominal hysterectomy.  During laparoscopic surgery, you watch the monitor more than anything else.  Hysterectomies can also be done laparoscopically in some cases, but this one wasn't.  As they started to do the transverse abdominal incision, my nerves melted away, and I was intrigued by getting to see all of the organs I had been learning about in a real person.  This is where having a cadaver lab in anatomy really became helpful.  Although cadavers don't have the same fluids that a live body has,  I had already felt the difference in an artery and a nerve, and when there are a bunch of fluids, it can become hard to differentiate.  That was a fun day, and really started my love for surgery.  

When we weren't at the hospital for surgeries (which were almost every morning), we saw normal patients at the office.  This consisted of a lot of annual checks and pregnancy checks.  I learned to do a Pap smear and vaginal exam, which I don't use at all in my current job, but still good to know.  I wouldn't say that I feel proficient in those skills, but if I need to do it I can.  It came in handy during my internal medicine rotation, where they had me do every single Pap smear that came in to the office (not awesome).  Pregnancy checks consist of a Doppler ultrasound, measurement of the abdomen, palpating the abdomen, and towards the end, a vaginal exam for dilation and effacement.  I've never been pregnant, and I had never even seen a very pregnant belly, but here are the things I learned about pregnancy:

  • You can visibly see the baby moving, and it's kinda freaky.  Try not to make weird faces because the baby daddy might call you out, and that's embarrassing.  
  • If you are more in shape/fit/healthy before you get pregnant, you will likely have an easier pregnancy, less weight gain, easier time losing the baby weight.  If you are more unhealthy, you will likely be more miserable.  
  • Pregnancy is different for everyone!  Here's hoping when that time comes, I get the easy kind.  
  • Pregnant women seem to be doing great, but at a certain point, they're all ready to not be pregnant anymore.  And those last vaginal exams seem to be really painful.  
  • If you've never been pregnant, an OBGYN rotation can freak you out and prepare you way too much for what's to come.  

My rotation was in October, and I'm not sure what holiday happens 9 months before then (New Year's maybe?), but there were SO many births while I was there.  I assisted in 9 C-sections, and saw 5 vaginal births.  My classmate who rotated in February had no births with the same preceptor, so it's really hit or miss with what you'll actually get to see.  Cesarean sections (C-sections) are really interesting surgeries.  The patient is awake for one thing.  Basically an incision is made through the skin, and then the fascia, and then you can see the uterus!  We had one patient who was on her 4th C-section, and she was a very high risk pregnancy.  When we got to her uterus, it was about as thick as plastic wrap, and you could see through it like plastic wrap!  Once the uterus is opened, there's a whole lot of fluid that's released.  Births are extremely messy.  It is really cool getting to see the baby delivered and how excited the parents are.  Vaginal births are also interesting, but honestly neither option looks quite natural.  I wish I had seen a multiples birth while I was there, but I got to see plenty of single births.   

On my longest day there, I arrived at 6 am and didn't go home until midnight.  We had 3 women in labor at the same time by the time we were done with clinic patients.  2 were first time mothers, and the other was having her third child.  It was definitely worth staying around, but I was exhausted by the time I made it home that night.  

One interesting case I saw was a woman who had a procedure done for abnormal cells on her cervix.  She called the office because she had started bleeding about a week after the operation.  She came in and was extremely pale, and she was bleeding through at least one pad each hour.  That's too much blood loss.  We ended up having to go back to the OR to stop the bleeding, but it was pretty scary seeing her so unstable.  

I ended up actually really enjoying my time in OBGYN.  I liked the OB part of this specialty much more than the GYN part.  There are some residencies available if this is a field that you are really interested in.  Unfortunately, in Georgia, PAs are not able to deliver babies.  We actually had a PA who had done a residency in California come talk to our class, and although she had done over 500 deliveries, she still wasn't given clearance to deliver in Georgia.  If you are into the OB part of things, you may want to look into state laws before doing a residency.  

Obstetrics and Gynecology
By Charles R. B. Beckmann MD MHPE, William Herbert MD, Douglas Laube MD M ED, Frank Ling MD, Roger Smith MD
Buy on Amazon

The main book I used to study for this residency was Beckmann's Obstetrics and Gynecology.  It's very easy to read and very thorough.  I think I felt most prepared for the OB/GYN end of rotation exam out of all of the exams.  

Some other good choices are: 

And here are some other resources to check out:

  • Here are one and two blog posts about a student's OB/GYN rotation
  • And here is another fellow student's tips for OB/GYN

I would love to hear about some of your experiences in OB/GYN or answer any questions you have so feel free to leave a comment below!  

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Providers as Patients

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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!  

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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.  

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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.   

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

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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.  

Clinical Year: Psychiatry

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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.  

Clinical Year: Family Medicine

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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

Tips for Rotations

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 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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