It’s been nearly two months since I’ve blogged, and not without good cause. March and April have been incredibly busy months for me. In fact, just as I finished writing the second sentence of this entry, I paused and realized that there are some overtime hours that I hadn’t logged yet, so I navigated to my online time card and posted them.
To give you an idea of just how much I’ve been working, here are some numbers. The average work week consists of 40 hours (8 hours/day X 5 days/week = 40 hours), so the average 2-week standard pay period is approximately 80 hours long. Well, the last two weeks of March and the first two weeks of April, I worked 109 hours and 111 hours, respectively. That’s 60 hours of overtime, nearly an additional 2 weeks worth of work! The reason I’ve been scheduled so much is because our emergency department is severely short-staffed with PAs/NPs (and we’re losing another one soon), so everyone else has been asked to step up their hours. It’s been demanding to say the least, but I’ve managed to take it all in stride, learning as much as I can and getting better/faster every day. And, while the bump in pay was nice, I have truly appreciated the measly 84 hour pay period that I just finished. Phew…
Regarding work, specifically, I’ve noticed that I’ve gotten significantly faster in all aspects of seeing patients, from interviewing, to examination, to charting, across the board I have improved. By no means am I comfortable with my current abilities and pace, but I’m happy to be trending in the right direction. There have now been multiple days in which I’ve hit the site goal of seeing 2 patients/hour, and there have even been a couple of days where I have seen a bit more than that.
There have been a lot more firsts in the last two months as well. I’ve diagnosed herpes simplex virus (HSV) in a couple mortified young adults, identified a pneumothorax (collapsed lung) in a young man based on auscultation and percussion of his thorax, informed multiple different women that they have miscarried (or are in the process of miscarrying) their babies, diagnosed Bell’s Palsy, managed an acute diabetic ketoacidosis patient prior to admitting her to the hospital, sutured some gnarly lacerations, seen enough influenza and strep throat to diagnose both without the aid of rapid swab testing, drained abscesses in every corner of the body (mouth, face, shoulder, axilla (armpit), abdomen, back, groin, testicles, vagina, thigh, knee, calf, and foot), and many other interesting things that I can’t recall. I’ve also experienced my fair share of mistakes, but fortunately nothing serious. Nevertheless, despite my follies, I received an email this morning (05/07/2016) from the doctor in charge of my training regarding how the other ER docs perceive my abilities, and it reads, “Feedback from the docs has been overwhelmingly positive. Good job and strong start!” Pardon my boast.
It’s all been quite fun. The pace in the emergency department, as one might imagine, is accelerated. Time pushes onward like a runaway freight train, and by the time I manage to glance at my watch, I am always baffled by how soon my shift is over. There have only been 2-3 “slow” days in the department since I’ve worked there, otherwise it’s a nonstop whirlwind of controlled chaos. In fact, since it is seldom slow in the ED, people cherish those days, and if you so much as whisper to yourself about how slow it is, you will surely be scorned and scolded by everyone surrounding you, cursing, “Don’t jinx it!” I never believed in jinxing a situation, but the way everyone at my ED seems to believe in it has nearly convinced me that there is some magical truth behind it.
The last two months haven’t been all work though. As you might have noticed, there is one “Play” in the title of this blog.
April 16th through the 17th, my sister (Jami) and her husband (Bryan) joined me and my girlfriend (Roxanne) for a weekend trek of Pine Ridge Trail at Big Sur, a beautiful, popular hiking destination in central California. Given the fact that we only had the weekend off, we tasked ourselves with the entire 20+ mile journey in just two days, all the while carrying 30-40 lbs of gear in our packs, and we did it! 10 miles in on day one, 10 miles out on day two. It was rough, but well worth it. And I must say, I was thoroughly impressed with Jami and Roxanne’s performances. Roxanne carried just as much weight as I did, if not more, and she outpaced me on the trek in to camp. She frequently got ahead of me and had to stop and wait for me to catch up. On the way out, Jami lead the group as she and Bryan left me and Roxanne in the dust. Although, I think Jami’s pack was 10-15 lbs lighter than everyone else 😉 Anyway, it was a great trip. Here are some pics!
Oh, the naivety of the start of the hike…
Pine Ridge Trail
Reality setting in
My badass hiking girlfriend
Made it to camp! (I swear, I’m not even flexing) #CampLife
Downstream view from camp
Upstream view from camp
Camp
Jami and Bryan leading the way home
On the way home; exhausted.
All in all, the trip was demanding, but it was well-planned, went off without a hitch, and was so much fun! Unfortunately, Roxanne and I returned home to realize one of my worst fears. Jack, my black male cat escaped.
A few weeks prior to the hike, based on some online research/instructions I found, I fabricated and installed a net structure that extends 1.5-2 feet beyond the top of the backyard fence. The idea was to put this netting in place such that my cats could go outside and be free to roam the backyard, but only the backyard. Since adopting Iris and Jack two years ago, I’ve always wanted to let them go outside, but the living situation was never right for me to feel comfortable to do so. With this net in place, the backyard seemed secure enough to let them out. Clearly I underestimated the curiosity and cunning of a cat. Saturday night, the 16th of April, was the last time Jack was seen at home, as my dad stopped by to feed Iris and Jack while we were camping. When Roxanne and I returned home on the night of the 17th, Jack was nowhere to be found, and a close examination of the fence netting and its framework revealed obvious evidence that he had escaped. We believe he climbed the apricot tree adjacent to the fence and jumped onto and over the netting into my neighbor’s backyard. From there, he had access through gaping holes in their fence into the large field/vacant lot behind our house.
We went searching for him that night, as well as the next morning and many of the subsequent days. We posted over 30 fliers, and went door-to-door, handing out at least a hundred more. We visited the animal shelter, posted on Craigslist, Facebook Fido Alert, and contacted his microchip company for help. We had many different leads in the early-going – people calling us to say they think they saw him – but nothing that materialized. We quickly learned that there are a half-dozen black cats in the surrounding neighborhood, and they all look the same to the average person. We also learned that there are a baker’s dozen cat ladies in the area who put out food and water everyday for all the local stray cats.
Anyway, it’s now been three weeks since Jack went missing. Knowing how long it takes him to get used to new surroundings when he moves, and how shy/scared he gets, he is probably hiding most of each day, going out at night to score some food. It hurts a lot to know that he’s lost out there, probably very close in proximity to me, and that I’m unable to find him and bring him back home. Roxanne and I have both cried over his departure. He was such a good little friend, and a true lap cat in every sense of the term. Even in 117 F weather in Vegas, he would still want to lay in your lap, and despite how hot and sweaty that made me, I’d always allow it, because who can say no to this?
We have not given up all hope, but I’m also trying to be realistic about my expectations for him to return home. He’s a very smart cat, and despite his timid nature, I’m 100% certain he has what it takes to survive in the neighborhood. There are a lot of big backyards and open fields nearby, and as I mentioned before, there is an abundance of food available to him. I have no doubt that he’ll continue to live out the rest of his days comfortably and free. However, if he ever wanders back home, I’ll gladly accept his return. We miss you very much, Jack.
The day Jack decided to conquer the world, or maybe just the neighborhood.
How can you not miss this weirdo?
Of note, Iris has been much more affectionate since Jack disappeared. She hangs out with Roxanne and me much more frequently, follows us around the backyard, and is more affectionate than ever before. I hate to say it, but I think she doesn’t much mind Jack’s departure — they fought everyday, after all, and now she has more laps to plop herself in.
Back to happy thoughts.
April was a busy month, as Roxanne and I also made a quick, business + pleasure trip to Vegas. After watching me play blackjack for 5th or 6th time, she finally decided she’d give it a go. Over the course of our two-day stay, we lost a grand total of only $200. In Vegas terms, I chalk that up as a win! It was a lot of fun, and a nice distraction from missing Jack.
Isn’t she pretty?
I’m not sure why I haven’t made mention of it until now, but on May 28th, I depart for Rome, Italy! Roxanne is traveling there two days before me, and I will be meeting up with her. Together we will be spend two weeks exploring Rome, Florence, and Venice in Italy; then Paris, and finally Amsterdam. I’m so excited! It’s only 20 days away!! Not to fret, I’ll post a bunch of pictures from the trip, and I’ll return to regular blogging upon our return home.
During the clinical year of PA school, one of my most-hated tasks was completing SOAP notes. As a reminder, SOAP notes are the notes that providers take for each and every patient encounter they have, and they consist of:
Subjective: what the patient tells you about their condition
Objective: the provider’s physical findings during examination
Assessment: the provider’s diagnosis
Plan: the treatment rendered by the provider aimed at improving the patient’s diagnosed condition
One of the more frustrating aspects of SOAP notes in school was the assessment section in which we were made to explain why we chose the differential diagnoses and final diagnosis that we chose. It was not good enough to document the patient’s history of present illness (HPI), our physical exam (PE) findings, and give a diagnosis. We also had to explain our decision-making process so that our professors could ensure that we were getting to the right diagnosis for the right reasons. I always understood the logic, but hated it nevertheless. “Duhh…” I thought. “Isn’t it obvious why I chose this diagnosis? I mean, just read the HPI and PE and you’ll come to the same conclusion.” But, that was the rule, and I followed it knowing that after graduation and upon landing my first real PA job I would no longer have to justify my diagnoses because people would see the “PA-C” after my name and just trust my judgement. Ha! Wrong!
Enter “Medical Decision Making.”
Medical decision making (MDM) is a very specific section on every single note that I and every other provider at my emergency department completes. It is arguably the most important part of any emergency medicine patient encounter note. In the MDM, a provider summarizes the entire patient encounter, offers multiple differential diagnoses based on the patient’s clinical presentation, weeds through the differentials to select the final diagnosis, and, most painstaking, explains why each of the other differential diagnoses are believed to be wrong. Confused? Here’s a few examples of some MDM’s that I have done. Names and ages have been changed for HIPAA compliance.
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Sorry for all the abbreviations. Here’s another example:
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As you can see, there is a lot of documentation involved in each and every note. Keep in mind that this is only one section out of many! Fortunately for the providers at my emergency department, we have scribes that do 80-90% of the typing for us, leaving only the medical decision making and some of the treatment plan for us to complete. Otherwise, most of the encounter note is already done by the time I receive it from the scribe. Of course, I have to read through what they’ve written to be sure that it is accurate and makes sense, and this takes some time, but all in all, the scribes save the providers a considerable amount of time. In fact, one study showed that the utilization of scribes increases emergency department productivity by as much as 17%. Nothing to laugh at.
Something else that many providers, including myself, have done to save time is create templates for the simple and common complaints that present in the emergency department. For example, I created templates for chief complaints such as cough, back pain, vaginal bleeding, abscess, rash, and etc. These notes are already completed with an HPI, PE, MDM, and plan. The only thing that the scribe and I have to do is change subtle bits and pieces to match the particular patient’s presentation, otherwise the majority of the note is already complete before I even see the patient. This spares me and the scribe a bunch of time we would have spent charting. It’s a great system and has definitely improved my productivity overall.
Before I hang up this blog, here’s a quick patient case that I saw in March that I found to be fun.
As of the time I am writing this, I have completed 10 shifts, and I feel like I’m slowly but surely improving — grasping the concept and flow of emergency medicine, and the practice of medicine in general. If there is one glaring difference between the practice of medicine during clinical rotations in PA school and the practice of medicine as a certified PA, it is that practicing medicine in the real world is much more specific than I was lead to believe in school. For example, in school, a preceptor or instructor might ask, “What would you order for a patient presenting with severe, colicky right flank pain and a history of kidney stones?” And, in school, I would have likely answered, “I’d order IV fluids (to increase urinary output in an effort to expel the likely stone), ketorolac (an anti-inflammatory medication for pain), ondansetron (an anti-nausea medication if the patient is nauseated from pain), tamsulosin (a selective alpha blocker that relaxes the prostate and bladder neck allowing decreased resistance to urinary flow), a urinalysis (to evaluate for infection and blood in the urine), a complete blood count (CBC) with differential (if the patient has been dealing with the pain for days, has a fever, and looks ill), a basic metabolic panel (BMP) (to evaluate overall kidney function to be sure that there is no acute kidney injury associated with this suspected stone and to assess electrolyte abnormalities), and possibly a CT scan (to evaluate the size and location of the suspected stone).” *Note* the information in the parentheses are for my blog readers; I would not have actually said that to my preceptor.
In PA school, this would have been a fine answer. However, in the real world, it’s not nearly specific enough. For example, nowadays I have to specify which IV fluid, how much, and what rate of delivery. Moreover, I need to specify the doses of ketorolac, ondansetron, and tamsulosin as well as the route of administration, i.e., if the patient is nauseated (and therefore likely to vomit), he won’t be receiving any PO (oral) medications, instead opting for IM (intramuscular) injected meds or IV (intravenous) meds. Additionally, I need to be specific about the urinalysis that I order. Do I want a urine dipstick that can be completed in minutes, but is less specific in it’s findings? Or, do I want a true urinalysis with microscopy and reflex culture and sensitivity, a test that takes more than an hour to receive initial results and days to receive final results? The answer to this question belies on the patient’s presentation. If he was feverish, retaining urine, and complained of blood in his urine, I might order both tests. I would order the urine dipstick because I want to know quickly whether or not there is bacteria in his urine, and I would order the full urinalysis with microscopy to evaluate which type of bacteria I am dealing with. Similar logic applies to whether or not I order the CBC w/ diff. If I suspect that the patient might have a blockage that has caused stagnation of urine proximal to the blockage and a possible infection of the affected kidney, I would order the CBC w/ diff to check the white blood cell count and type as an indicator of just how infected the patient is. Regarding the BMP, I might order this simply based on the fact that the patient has had kidney stones in the past, so perhaps I could identify an elevated calcium level causing his stones to form, or worse, I might identify a decreased glomerular filtration rate (GFR) or increased creatinine (Cr) that are indicative of a kidney’s failing ability to properly filter blood. Finally, if I decide to order a CT scan, I must specify where exactly on the patient’s body needs to be scanned, and whether or not I want IV or oral contrast dye in the study. Fortunately, in the case of ordering CT scans for identifying suspected kidney stones, PA school served me well: CT abdomen/pelvis without contrast.
As you can surmise, upon graduation, practicing medicine became a lot harder for all kinds of reasons. I now must identify not only which medication is best, but more specifically, the proper dose for each patient depending on their age, weight, current medications, allergies, and etc. It is no illusion to me that mastering this will take years and years; challenge accepted.
Practice:
The actual application or use of an idea, belief, or method as opposed to theories about such application or use.
Repeated exercise in or performance of an activity or skill so as to acquire or maintain proficiency in it.
Practicing medicine is hardly different from practicing any skill or sport. It involves repetition, self-reflection, and often times critiquing from experts in the activity, all in order to decrease the number of mistakes made, thereby nearing ever-closer to perfection. It is therefore an expectation of practice that mistakes will be made. Thus, by logically justifying mistakes in the course of practice, I am not ashamed of the mistakes that I have made over the last 10 shifts. Can’t you tell?
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As for me on that day, I ended up leaving two hours past my original shift end time, and that was only because one of the PAs working a later shift graciously agreed to presume continuity of care for my patient. Otherwise I could have been there for several hours more.
What did I learn? Always evaluate all of the patient’s chart information prior to assuming the patient’s level of acuity.
I have a shift in two hours and I need to eat lunch, shower, and get ready for work. Until next time.
I began physician assistant (PA) school on July 8, 2013. Finally, after exactly two years, six months, and four weeks, or 941 days, or 22,584 hours, I officially entered the workforce as a certified physician assistant (PA), practicing medicine for the first time.
If you’ve followed my recent posts, you know that I landed a position working in the emergency department (ED). On February 5th, 2016 at 1100, I used my nifty badge given to me by the hospital to enter the ED through the large ambulance bay doors and begin my first shift.
Rewind.
Two days prior to my clinical start date in the ED, on February 3rd, I was oriented to the emergency department and hospital by the hospital’s on-site administrator, I’ll call her Debra. We spent some 5 hours touring the hospital, meeting ancillary staff, shaking hands, obtaining security badges/clearance, and etc. My favorite part of the day was when I received my “Physician Parking” placard for the provider’s parking lot. “Awesome!” I exclaimed. “I’ve grown so tired of parking off-site for my clinical rotations in school.” The two women helping me smiled, nodded, and pretended to understand my grievance. I quickly remembered how this hardly matters since I will primarily be riding my bicycle to work (unless it’s raining).
Also during this orientation day, Debra took me into the ED and introduced me to the doctors, PAs, nurses, and techs, but not in the manner which you might expect. “Ahem!” She clears her throat. “Everybody! I’d like to introduce Anthony Ambrosino, our new PA!”
There I am, standing beside her like she’s the teacher and I’m the new kid in school, like…
Fortunately, everyone seemed to be thrilled to bring a new PA on board because they had lost two PAs in the last couple of months and are losing a third early this year, so they have been severely short-staffed, working a lot of overtime.
At the conclusion of the tour, introductions, and general orientation, I was feeling excited to get home, read up on some medical conditions, and refresh my skills prior to starting. Then Debra turned to me and asked, “Okay, can you start tomorrow?” I’m not sure if my angst was outwardly visible, but I think I made it pretty clear when I replied, “Uuhhh…” She totally caught me off guard! The truth of the matter was that I actually did have an obligation to tend to the next day (thank God), so we agreed to make the following day, February 5th, my first clinical shift.
Walking into the ED on the morning of my first shift, I felt nervous, but not as nervous as one might expect. At this juncture in my medical career I had grown accustomed to being the “new guy” month after month at each of my clinical rotations in school, so I was well-prepared in that regard. Much like previous clinical rotations, I spent the first few hours of my shift shadowing a doctor, watching him see patients, order tests, prescribe medications, document on the computer, and so on and so forth. Also similar to my experiences in the last year, the doctor eventually released me to see my own patients and present them to him. However, after presenting my first patient I saw to my collaborating physician, I noticed a stark difference from my days as a student. For the first time, the doctor left the medical decision making to me. I got to decided whether or not to order diagnostic tests. I got to decide how to treat the patient. I got to decide if the patient needed any outpatient care or medications. Out of habit, I ran my diagnosis and plan by my collaborating doctor. He agreed with my proposals and left me to take care of it.
This was a revelation; I was finally in control of my own patients.
Once I was set free from shadowing, I ended up seeing a total four patients that first day from start to finish, i.e., from collecting their history of present illness, to performing a physical exam, ordering tests, diagnosing, and treating. However, the moment it truly hit me that I was a licensed provider and no longer a student was when I received my first prescription to sign. I was sitting at one of the desks, typing away about a patient when a nurse came around the corner and asked, “Are you Anthony?” “Yep.” I replied. “Great! Can you sign this please?” she asked as she handed me a blue sheet of paper. I looked at it and instantly recognized it as a prescription. “She’s asking me to sign a prescription!!” I screamed inside my head. The script was for naproxen (Aleve), and it was for a guy I was discharging who had a minor ankle sprain. Too eager and overly excited, I answered, “SURE!” I was so hyped up about signing my first prescription that my signature was a disaster. I was literally embarrassed by how scribbled it looked. There was no semblance of any of the letters of my name, or any name for that matter. It looked like I drew a pubic hair on the sig line. In any case, the nurse had no way of knowing what my signature is supposed to look like, nor would she care, so the embarrassment soon subsided and I reveled in the elation for a little while longer.
As I write this blog, I have completed a total of five 8-hour shifts, working with three different physicians. February is technically my training month, so depending on the doctor I’m scheduled with, I receive varying levels of supervision and attention. Nevertheless, I’m more free than I’ve ever been to make my own medical decisions and I’m only going to gain more freedom as time goes on. I was just expressing to Roxanne last night how excited I get about every little thing that I do because I’m finally permitted to do everything by myself. Otherwise I can’t imagine being so excited about performing a speculum exam on a woman with vaginal bleeding during the first 20 weeks of pregnancy or incision and drainage of a scrotal abscess.
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This case took a lot time and effort to work up, but with help and affirmation from my collaborating physician, I feel like I got it right, and that’s extremely gratifying. Moreover, not only was it my first time diagnosing new onset heart failure, it was my first time breaking such news to a patient. I believe I handled it well, but only the patient and her husband would be able to vouch for me on that front. Two takeaways that I got from the whole case was that: 1) I need to have more faith in my exam skills, and 2) I have a long way to go before I become the knowledgeable provider that I aim to be. Regarding the first point, when I first noticed the dullness to percussion and decreased breath sounds, I almost didn’t believe it, preferring instead to believe that I had performed the tests wrong in some way. However, as the X-ray showed, I was right to find what I found on exam, which was important for my confidence. Regarding the second point, despite the fact that I am technically certified to practice medicine, I have a great deal of learning yet to do, and it’s key for me not to lose sight of that.
Okay, that’s all for now. Until next time, stay out of my ED! 😉
“Ruta del fin del mundo” when translated literally means “route to the end of the world.” However, a simpler, lay-person’s interpretation of the phrase amounts to “doomsday route.” As ominous as it may sound, allow me to set the record straight — the route to the end of the world is beautiful. If you have any interest in hiking in the shadows of astonishing, snow-topped mountains, drinking the purest water directly from the springs of melting glaciers, and being awestruck by countless breathtaking reminders of why the great outdoors are meant to be explored, go to Patagonia.
On January 4th, Brittney (my PA school classmate and good friend of mine) and I departed from San Francisco International Airport to Santiago, Chile.
We only had about 24 hours in Santiago, so we made the most of it by doing some local sightseeing and eating local foods. I’ll let the pictures tell the story.
Weekday lunchtime in Santiago
As you can see, it’s early January and people are in t-shirts. January = Chilean summer.
Cerro Santa Lucia, Santiago.
View from Cerro Santa Lucia
Stairway to where?
Santiago’s vastness coming into view
Street Art, Santiago
Cerro San Cristobal in the distance
An hour later, the view from Cerro San Cristobal
72 deg F. Chillin.
Zooming in through the smog
Mother Mary
At the peak of Cerro San Cristobal
Lonely chair in the sewer
Public Display of Affection (PDA) is too real in Santiago.
I’m tryna tell ya…
*gulp*
Live amateur music in Parque Forestal, Santiago
Just past sunset at the hotel
Our room
Breakfast, lunch, and dinner in Santiago:
After spending approximately 24 hours in Santiago, we hopped a flight to Punta Arenas.
One hour later, we caught a bus to Puerto Natales.
It was during this bus ride that I started to feel like I was embarking on an epic journey. Here’s an excerpt from my travel journal:
I slept for the first two hours, but awoke for the final hour. Brittney and I had to split up because all of the seats were full, and I sat in the front row next to a very sleepy lady. The view is fantastic because we’re in a full size tour bus with large windows. The landscape consists primarily of lush green grass with clusters of cows (and even wild horses) grazing about. There are countless moss-laden trees shading the grass, but its the dead trees that eerily seem to take precedent. Thousands of dead, mossless, fallen trees are everywhere and I can’t help but feel like they are serving as some kind of warning to whomever enters: “Beware, entering harsh, unforgiving climate — we kill our own.” Did I mention it’s windy? It’s windy as hell, which probably explains why there are so many horizontal trees — they don’t survive long upright after the roots desiccate. The wind is hitting the bus in gusts every 3-6 sec and pitches us from side to side with every blow, pun intended. There are many large puddles (or small lakes) along the road, not far from the asphalt that I can only estimate were formed by rainfall because the mountains are too far for the pooling to be from watersheds. In the distance I see the first town I’ve seen since beginning this ride three hours ago. It’s probably our destination: Puerto Natales. The mountains still seem very distant and mostly sheltered by cloud coverage. I’m excited to explore that which the precipitation hides behind its grey cloak.
Blurry picture from the bus depicting the bare, fallen trees
Daylight hours in Puerto Natales are from approximately 4AM-11PM, so Brittney and I did some exploring after our arrival.
Statue in Puerto Natales
Memorial in Puerto Natales
The Puerto Natales Bus Station – Rodoviario
One of the many dogs that roam the Puerto Natales streets
Brittney and her gear
Every building is a different shape and color
Iglesia Parroquial Maria Auxiliadora
Plaza de Armas Arturo Prat
Fountain at the center Plaza de Armas Arturo Prat
Only 6,917 mi to Sierra Nevada, CA
Slow-cooked lamb over coal
Sunset at the Plaza — approximately 10PM
Espacio Cultural Natalis
At 6AM the next morning (01/06/16) we woke up, ate breakfast, and walked 10 minutes back to the bus stop. We were headed to Torres del Paine, the park in Patagonia that people think of they hear the word Patagonia.
It was on our way to “The W Trek” in Torres del Paine that we took the “Doomsday Route.” Over the course of the next 3 days and 3 nights we would hike for miles and miles and miles…
The W Trek (in red). We started at Hosteria Las Torres on the far right of the W and hiked westward to end at Paine Grande Camp (at the northern tip of Pehoe Lake).
Before I flood the screen with all my amazing pictures from this hike, I have to talk about the hike itself for a moment. The days that I spent hiking the W trek were the most grueling, arduous, and exhausting days of my life to date. I am not a novice hiker, but this hike took more out of me than I thought I had available to give. The uphill stretches seemed to never end and my legs were abundantly fatigued by the conclusion of day one. When we finally reached the mirador (viewpoint) of each hike and headed back down, I wished I had never cursed the uphill portions because returning downhill was just as treacherous on wobbly legs. For all the uphill and downhill hiking, it was the sum of the distances traveled each day that nearly killed me.
Day 1: 12 miles.
Day 2: 7 miles with 45 lbs backpack on and an additional 9 miles without a pack.
Day 3: 8 miles with the 45 lbs pack on again.
Never have I sweat so profusely for so long. It was a true physical and mental test of my determination and will to accomplish a goal, and I’m proud to say that I almost did it. Haha, that’s right. 36 miles of hiking in 72 hours had the balls of my feet hurting like never before. By the time we reached the final camp, I was done. Brittney somehow managed to push on to the final mirador (7 additional miles of hiking) with two Australians that we met on the first day, Jill and Alex. “Good for them,” I thought to myself as I melted my jelly-like body in a hot shower at the hostel. “I admire their determination,” I slurred to myself, eyes closed, as I drifted off to sleep for the best afternoon nap of my adult life.
Had I done better to physically prepare myself for this hike, I believe I might have been able to hit the final stretch, but I’m not entirely convinced of this because it wasn’t my endurance that failed me, it was my feet. Nevertheless, Brittney, Jill, and Alex came back looking dogged and airdropped me the photos they took of Grey Glacier — no harm done.
Without further ado, here are the pictures from the most epic hike I’ve ever completed — The W Trek. (along with some journal excerpts):
Day 1 of W Trek (01/06/2016):
Guanacos (Patagonia’s llama species) on the hillside on the way to the start of the W
Our first glimpse of Las Torres
Smiley and naive after walking ~0.25 miles on the way to Mirador Las Torres. In the background is a fancy refugio (hostel/hotel) and behind that are the mountains we’re about to traverse between.
The start of the journey
Nearing halfway to Mirador De Las Torres
The view behind us
The view from Camp Chileno. Note how overdressed I was. We really didn’t know what to expect as far as weather goes, so on day one I wore wool thermals beneath my zip-off pants as well as my waterproof, triple layered snow jacket (wrapped at my waste in pic). I was sweating profusely at the time this picture was taken as I was learning the hard way that we were extremely fortunate to have amazing weather during our stay in South America.
There’s always time for a selfie
I was always thankful for shade
View from Camp Torres
Final climb before the mirador
Behold, Mirador De Las Torres!
My Instagram upload from Mirador De Las Torres.
Here’s a short excerpt from my journal after returning to camp from the day’s hike:
We hiked for approximately 3.5 hours generally uphill the entire way, stopping occasionaly to fill up our water bottles in the glacier water runoff. At the top of the path was the quintessential mountain range that people think of when they hear “Patagonia” — Los Torres. The sky was incredibly clear, and we overheard a local guide say, “I’ve been up here 10 times and this is the first time I’ve been able to see all three peaks. Every time before this the clouds had covered them.” Talk about good fortune. I hopped onto a large boulder, cutting and bruising my left shin in the process, then helped Brittney up as well as an Australian couple (Jill and Alex) that arrived at the same time as us. The four of us would become fast friends, linking up again down the trail, bunking together twice, taking the same bus back to Puerto Natales, and sharing multiple meals. After taking a number of pictures, Brittney and I made our way back towards our camp with sore feet and tired legs. We had hiked for 12 miles today. Worth noting, we were warned by many that the winds on the W trek can be severe, but we have yet to experience anything of the sort.
Day 2 of W trek (01/07/2016):
On the trail by 8:20AM
My attempt to be more artistic
One of my favorite pictures from the trip. A goucho and his horses carrying cargo on the W.
Lago Nordenskjold
Footbridge over glacier runoff
The mountains to our right
Creepy, spider-like flower
Following the trail up through the valley ahead
… and now down the other side of the valley
Mad because I realized we really hadn’t traveled very far yet despite my feet, legs, back, and shoulders telling me otherwise. This is, by the way, what 40+ lbs of gear looks like in a 55L backpack set.
Sometimes you have to stop not to take a break, but to take in your surroundings
Pretty spectacular
The buildings below are Los Cuernos Refugio, our next camp site.
Of course, we didn’t stop at Los Cuernos because we still had to ascend to the French Valley and back before the day was done. Onward…
Another one of my favorite pictures from the trip. For as many people as there were at the camps, the trails were largely devoid of people for long stretches. One can truly feel alone and small in a place like this — and it’s an amazing feeling.
Water bottle refill stop
Not sketchy at all
Finally made it to Mirador del Valle del Frances
Looking down on our ascent
The wind that we were warned was finally found at the French Valley. I was seated for this picture because standing was nearly impossible at times due to the insane gusts of wind that occurred at random.
If we were feeling up to it, Mirador Britanico was another ~3 miles further uphill. We were not feeling up to it.
More French Valley
Journal excerpt from day 2 of the W trek:
Departing at 8:23AM, we headed toward Camp Cuernos, which would be our next refugio. It was four hours away, and our bags felt twice their weight by the time we arrived. Worth noting, as we walked into the reception office at Camp Cuernos in one of the most remote locations that I have ever traveled to, they were playing Drake’s “Hotline Bling” followed by Justin Beiber’s “Where Are You Now?” Is no place safe?! Once we finally made it, we set down our large bags, ate a quick lunch of dehydrated food, and set out again with our smaller day packs toward the French Valley, a 6 hour round trip in itself with steeper climbing than the day before. I was feeling haggard by the time we arrived at Cuernos, and to think that we were only half done with the day’s journey was depressing as hell. Nevertheless, we booted up and headed back out, making it to the French Valley and back to Cuernos by about 7:30PM. This day was much windier, especially at Mirador Frances. Brittney and I both had to get low to the rocks and hug them to prevent from being blown clear over.
Day 3 of W Trek (01/08/2016):
Looking out over Lago Nordenskjold on the hike to Camp Paine Grande.
Looking back
Finally, a group pic with our Australian friends! From left to right: Alex, Jill, Brittney, and me.
Tired AF
Fire damaged trees
View from the trail to Camp Paine Grande
We finally arrived!
View from our room.
Chillin with my cerveza, bon o bon, and gear next to Lago Pehoe.
Getting in on the selfie action at Camp Paine Grande (after my nap).
Close-up 1/2 of the mountains surrounding us at Camp Paine Grande.
Close-up 2/2.
On the way to Glacier Grey. Photocredit: Brittney.
Glacier Grey — the glacier I visited vicariously… by proxy… during my nap.
Pisco sours to celebrate completing the W
…and I see fire inside the mountain…
Sunset over Camp Paine Grande
At 10AM on January 9th, we boarded a boat that would take us back to the start of the W trek. From there, we rode a bus back to Puerto Natales. We arrived with approximately 2 hours to spare before Jill and Alex had to leave for northern Chile, so we shared one final meal together and went our separate ways. As I am writing this (01/26/16), they are still traveling. Probably somewhere in Ecuador by now if I remember their plans correctly. Here are some pictures from the 9th:
The national park rangers were pretty chill
View from the boat ride.
Hit a quick 30 min hike to a waterfall while waiting for the bus back to Puerto Natales.
Dead trees, mountains, and clouds.
Beach next to the Edificio Intercultural Costanera
View from the beach.
Anchored ship at Puerto Natales.
Brittney and I abandoned the windy beach and returned to the hostel at about 9PM. Until this point in time I had only communicated with Roxanne (my girlfriend) via text and email, so I decided to FaceTime her as a surprise. I recall her being both upset that I was so far away from her and happy that we were speaking for the first time in nearly a week. Truth be told, I missed her like hell, and it sucked not being able to communicate with her effectively or as often as I would have liked. I purchased an international cell plan that allowed me to send unlimited SMS text messages, but the cell towers in Chile and Argentina are not what I would call reliable, so messages usually were sent and received in large caches, or often times not transmitted at all until days later. It was incredibly frustrating! Nevertheless, it was refreshing to see her face again, even if only for a few minutes.
On January 10th, we boarded a bus at 7AM that would take us from Chile to Argentina.
It would be the first time that I ever crossed a national border by way of any vehicle other than an airplane, so I was kind of excited and curious to see how it worked. How did it go? Slowly. We arrived at the Argentinian border at 7:30AM, but the border guards don’t show up for work until 8AM. Why did the bus need to depart at 7AM?! At 8:01AM the 40+ passengers on the bus filed out and got in line at the customs desk. Since Brittney and I were seated towards the front of the bus we were one of the first to be processed. After receiving my passport back from the custom’s agent I rifled through it looking for the Argentina stamp, but I didn’t find it. Instead I found an exit stamp from Chile. As it turned out, crossing the border was a two step process: 1) officially leave Chile, 2) officially enter Argentina. 30 minutes after arriving at this checkpoint we were all shuttled down the road a mile or so to the true Argentinian border where we repeated the process we had just completed. All in all, it took about an hour to cross the border.
Once in Calafate, Argentina, Brittney and I ate and explored a bit. I only have two pictures from that day.
Casino in Calafate. All user interfaces were in English. Note: I did not actually play, but I HAD to check it out.
My first encounter with Argentinean meat from Don Pichon restaurant. This was a slow-cooked lamb shank with a bunch of slow-roasted vegetables, berry BBQ sauce, and razor thin potato crisps on top.
The next day, on the 11th we visited Perito Moreno Glacier. Not only did we visit it, but we actually put on crampons and hiked on the glacier. It was enormous! I’ve never seen a glacier before, but its vastness was impressive. Pictures do not do it justice, but they will have to do.
Perito Moreno Glacier coming into view while riding the bus.
Riding the catamaran across Brazo Rico.
Those black specks are people on the glacier.
The above-water height of Perito Moreno Glacier is 240 ft. It has a total ice depth of approximately 558 ft beneath the surface.
My tour group.
So easy to get lost out there.
I went into a crevasse, exactly what my parents asked me not to do.
Ice spikes.
This is the only glacier in the world that is at a low enough altitude for it to be surrounded by trees and other foliage.
Canal de Los Tempanos. Watching ice chunks break off the wall was my favorite part of viewing the glacier. It would start with a loud, prolonged *crack*. My eyes would dart up and down the wall face looking for any sign of movement. When I spotted the fracture, it was amazing to watch the piece(s) break off, creating a momentous *boom* as it crashed into the water below.
Brazo Rico. During winter months, the glacier extends deep into the trees at this junction, separating the two water ways, Brazo Rico in the south and Canal de Los Tempanos in the north (see prior picture). Thus, depending on glacier runoff, the northern lake could rise dozens of feet taller than the southern lake. When the summer months hit and the glacier recedes, you have what is depicted in this picture — the glacier allows water to be exchanged between both lakes such that they are the same height.
Panoramic shot of the glacier. Believe it or not, in it’s hay day Perito Moreno Glacier was tall enough to all but eclipse the peak of the mountain seen just to the left in this image. Also, at its widest point, the glacier is 3 miles across.
Our final night in Calafate was highlighted by souvenir shopping and this:
Cast iron pot full of pan seared sirloin, roasted vegetables, and some kind of amazing tomato sauce. I ate it all.
The 11th and 12th, the final two days of our Patagonian adventure were spent hiking out of El Chalten, another 3+ hour bus ride away.
El Chalten is a tiny village that exists only because of its proximity to Fitz Roy Glacier and surrounding mountains. From our starting point in El Chalten, we hiked 11.2 miles roundtrip to Laguna Torre on the 11th and 13 miles roundtrip to Laguna de los Tres on the 12th. Perhaps it was all the hiking we had done previously in the trip or perhaps it was the 2,460 ft of ascension during the final mile of the hike, but our final hike (to Laguna de los Tres) on the January 12th was decidedly the most difficult single-day hike I’ve ever accomplished. I can’t even count how many breaks Brittney and I needed to take, but it was a lot. It didn’t help that during the final climb we were covered with furry flies the measured the diameter of a quarter. Between swatting at flies and trying to maintain my balance on my Stretch Armstrong legs on the steep mountainside, it’s a feat that I made it to the top alive. I’m sure glad that I did, though, because the view from Laguna de los Tres was my favorite of the whole trip.
Arriving at El Chalten, trailhead to many miradors in el Parque Nacional Los Glaciares.
El Chalten and his breathtaking backdrop.
On the way to Laguna Torre.
Laguna Torre. Once again, we couldn’t have asked for better weather.
I reached the summit.
A view of El Chalten from the trail.
Laguna Capri. On the way to Laguna de los Tres.
The path less traveled. Looking behind us on the way to Laguna de los Tres.
This pictures does not do justice the height which we had to climb to reach this point.
Neither does this one.
Eating lunch with my feet hanging off the cliffside over Laguna Sucia, just south of Laguna de los Tres.
Laguna de los Tres.
So there you have it, my trip to Patagonia — blogged. It was one hell of an experience and I’m so glad that I did it. At this point I have to give a huge thank you to Brittney!
Whipping my ass into shape from day 1
Not only for planning the trip, but for letting me use her Mom’s standby flight passes which saved us thousands of dollars on airfare. I came into this trip expecting adventure and exploration and I was not let down in any way, shape, or form. In fact, not only did I hike some of the most picturesque places in the world, but I honed my Spanish as well. By the trip’s end I was able to communicate very well with nearly everyone I spoke with. Sure, my Spanish is rudimentary, i.e., I only know how to use present tense and my vocabulary is likely that of a 5th grader, but it worked just fine, and I got better and better as the trip progressed.
The adventure didn’t stop when I reached the States either. Just a few days after I arrived home, Roxanne and I took a 5 day trip to South Lake Tahoe using a timeshare pass that my sister let me buy from her. I haven’t snowboarded since 2012, so it was great to shred some gnar’ powder, as the local snowboarder dudes would say. I was way impressed by Roxanne, too. She led on like she was some novice but she was really good. Talk about a hustler.
Speaking of hustling, we went to Stateline, NV and I used my Las Vegas skills to win us $170 playing blackjack over the course of two nights. I still got it, baby.
Roxanne and I at Heavenly Ski Resort 🙂
A terrible view of the ugly South Lake Tahoe.
It hurts my eyes!
I thought this was supposed to be a blog about becoming and being a physician assistant. What happened to your career, buddy? All you have been doing is traveling! Do you even work, bro?!
Good questions!
As it currently stands, I begin work on February 8th, and I can’t wait. I must admit that I’m getting sort of nervous about starting, mostly because I haven’t studied anything medicine related in months; I feel rusty. In an attempt to prepare myself I bought a few emergency medicine reference textbooks on Amazon.com and I intend to browse through them during the coming weeks. So, if these blog entries that are travel-inspired bore you, don’t fret, PA blogging will recommence starting with my next entry. I’m also going to try to return to a bi-monthly blogging cycle again so that the blogs don’t have to be so damn long. This entry alone took > 6 hours. With that being said, I think I should end this thing. Thanks for reading! Until next time…
I get nervous whenever I sign my name on official documents. I’ve never truly established a consistent signature for myself, and frequently one signature will look different from the next. The problem is that my name is too long, and I don’t have time to sign A-N-T-H-O-N-Y A-M-B-R-O-S-I-N-O. Instead, I normally get about 3-4 letters deep into my first and last name before I just quit and put a line through where the rest of the letters would go. Still, it never quite looks the same each time, and this lack of consistency leaves me worried and wondering, “What if it doesn’t look like my real signature? Will they accept it? Will they think it’s fraud?”
Never before has my signature needed to be consistent and uniform until I was made to sign dozens of documents as a part of my credentialing packet from the hospital I was hired by. Because I work not only for the hospital, but also for a company that the hospital employs, I had to complete two credentialing packets. I’m also a new participant in the MediCare and MediCal provider network, so I was required to sign up for both of these entities as well. Accordingly, I signed my name over and over and over… BUT, before I did, I practiced. I literally repeatedly signed my name on a note pad until it came out the same each time. I definitely over-thought the whole process, but I’m a n00b! And the MediCare form said that if my signature didn’t match the signature on my driver’s license that it wouldn’t be accepted! Give me a break!
The month of December moved pretty quickly for me. While I was hurriedly completing credentialing documents for the company/hospital I will be working for, I also had to re-register my residency and vehicle title in California. Hurray, DMV! Things weren’t all busywork, though. My dad and I went to a Warriors game on Dec. 23, when they beat the Jazz. While we were there we saw our names on the Raider’s Wall of Fame between the Coliseum and Oracle Arena where we have been listed ever since being Raider’s season ticket holders back in the day.
Hard to read, but it has the names of my parents, sister, and me.
Not to mention, late December is globally notable for the fabled birth of a boy from a virgin mother, because of which we exchange presents in a celebratory manner, and Christmas gift shopping is a drag. However, I must admit that using Amazon Prime to purchase most of my gifts was a huge plus. Not sure how people survived the holidays before Amazon Prime or online shopping in general.
Speaking of Christmas, I must have been a “good boy” this year because Santa, err… my family and friends, bought me a lot of awesome gifts. I was most excited to receive equipment for my pending trip to Patagonia that is fast approaching (January 3rd, 2016)! I have barely had time to think about this trip because of how busy I’ve been, so it’s sort of surreal to think that I’m leaving in a matter of days… Nevertheless, I now have nylon boxer briefs, wool socks, dehydrated food, fine merino wool base layers, a tri-piece Colombia waterproof jacket, 20+ degree F sleeping bag, and an assortment of other winter travel gear. Safe to say I won’t freeze to death! Thank you parents and Roxanne for all that!
Christmas Day w/ my Mom’s family. Roxanne, Me, Jami, Bryan, and Mom.
My Christmas Day top hat
Grandma and Grandpa Ambrosino wearing their cheeriest Christmas gear
Another nice thing about the month of December is that I received a slow trickle of certifying documents in the mail. First I received a document from the NCCPA stating that I passed the PANCE, then I received my official California PA license. Lastly, I’m just waiting on my California PA license wallet ID card and my DEA license, which I have already been approved for. Although, I can’t imagine my DEA license not being approved after I paid a whopping $731 for it. I feel like I submitted a bribe to them and they said, “Eh, this’ll do.”
The day after Christmas, my buddy Sean thought it would be a good idea to invite me and a couple others to hike Mt. Diablo, the biggest local mountain range in the area. Needless to say, 13+ miles and thousands of feet in elevation later, we were all humbled by how out of shape we were. We did reach the summit though! Here’s some pics:
When Sean slipped on the icy step and nearly broke his wrist. LMAO.
Is this the path our grandparents said they took to school and back?
Summit Crew
Sean, Mike, Me, Jason
Mt. Diablo Summit – Southeast
Mt. Diablo Summit
Mt. Diablo Summit – East
Mt. Diablo Summit – West
By the way, happy New Year to everyone! For NYE, Roxanne and I joined a group of her friends on the 32nd floor of a high-rise building in SF overlooking the Ferry Building on the Embarcadero. It was the perfect place to watch the 12:00AM fireworks out over the bay while in a well-heated room far above the hoards of onlookers on the streets below.
Cheesin’ it on BART
Puckered up
As the last blog of 2015, I suppose a brief reflection on the last 365 days is in order. 2015 was a great, productive year for me. Ten months of clinical rotations (in addition to the previous 18 months of study/rotations) culminated in graduation and passing the PANCE. In the blink of an eye, I’ve become a licensed and certified PA, and in a matter of a couple months I will be practicing medicine without the requirement to consult another provider before and after seeing patients. I will finally be able to make my own medical decisions! How exciting! Yep, in 2015 I finally accomplished the most ambitious goal that I have ever set for myself. I did it my way, but with the help of many, and I am grateful for every single supportive human (and feline) that helped me along this journey that is now complete.
Looking forward, I am enthralled by the prospect of what’s next. 2016 will begin with me entering the work force as a PA-C, and all the challenges that come with being new. The learning curve will be steep, but I’m confident that I can scale it — blogging about it each step of the way. I also look forward to my future travels. There’s a Euro trip in May/June that Roxanne has planned and I seem to have weaseled my way into it 🙂
We’re cute when I’m getting pwned
To everyone that has followed my blog on a regular basis or just casually read an entry or two, thank you!
You read correctly. Somehow, by some stroke of profound luck (or some epic mistake), the National Commission on Certification of Physician Assistants (NCCPA) has certified that I passed my board exam, and the state of California is in the process of procuring a license for me to practice medicine. In other words, I am officially a certified PA, AKA, Anthony Ambrosino, MSPAS, PA-C! *Insert longest humanly possible sigh of relief here*
Truth be told, it wasn’t dumb luck; my exam score was well above the minimum required to pass. I worked my ass off over the last 28 months, and on Nov. 14th, 2015, the day I took the PANCE, all of my hard work came to fruition when I came in like a wrecking ball and ruined that test like Miley ruined her public image.
The results of the exam came 12 days later in the form of an email from the NCCPA stating that my score was available for review. I hurriedly logged on to their website, and the home page was plastered with the only thing I needed to C, err.. see*.
A round of phone calls to family/friends, and a Facebook status update later, and I was back to the job hunt. By the time I returned home for Thanksgiving I had secured the three interviews that I mentioned in my previous blog. Each of the interviews went very well, but one interview was exceedingly more challenging than the others. This particular interview was with a primary care physician in Folsom, CA, and it was an extensive 1.5 hr telephone conversation that I had while seated in the backseat of my sister’s car as her husband drove me, Jami, and Roxanne to a Thanksgiving party in Bodega Bay. The setting was definitely not ideal, especially considering the fact that 90% of the call was spent discussing a hypothetical patient who was a train wreck health-wise.
The patient was a 64 year old Caucasian male who was found to have elevated blood sugar and high blood pressure at a community health screening fair and is now presenting for initial evaluation after not having regular medical care for > 5 years. “What would you do?” Asked the doctor. I’ve always enjoyed being put on the spot with questions like this, so I was excited to answer. I explained to her how I would educate the patient regarding his blood pressure and blood sugar, provide information about a healthy diet to address both, implement the use of a dietitian and exercise routine, and start the patient on blood pressure medication (because his BP at the time was 160/95). I told her of all the blood tests that I wanted to order to check the patients lipids, fasting glucose, thyroid hormone, and a basic metabolic panel to assess renal function so that I might be able to prescribe metformin for the patient to treat his elevated blood glucose. I further addressed the patient’s need for a colonoscopy depending on if/when he last underwent same. In essence, I gave an extremely thorough answer, one that I was proud of and was sure would impress her.
When I was finished, she asked, “Okay, and when would you want to see him back?” “Two weeks,” I replied, sure to hear her applaud me and immediately offer me a 1 million dollar contract to work for her. Instead, she said, “Okay, so, two weeks later he returns with his blood lab results which show LDL of 170, TSH of 8, HbA1C of 10.4, creatinine of 1.1, GFR > 60, but his U/A shows microalbuminuria. His blood pressure is 158/93. What do you do now?”
SIX TIMES, we went back and forth like this. By the end of the hypothetical scenario I had turned this patient’s medicine cabinet into a pharmacy. I tried him on three different oral diabetic medications before deciding that he needed insulin injections; I put him on three different classes of drugs for his hypertension; I started him on a lipid lowering agent and thyroid medication; and I dealt with side effects from each of the drugs I put him on. I dealt with a hospital admission he encountered while overloading with fluid from his amlodipine, I treated an episode of hyponatremia he suffered due to his hydrocholorothiazide, and I adjusted his night time insulin dose to counteract the dawn phenomenon he was having. Long story short, my aptitude and knowledge was put to the test.
All in all, the interview with this doctor and the other doctors went well. In fact, I was offered jobs at each location within 24 hours of interviewing, which created quite the decision for me to make at the end of the week.
Because each position is unique, I created “pros vs cons” tables for each and then compared them with each other. The tables helped a lot as I was able to make a clear cut decision without having any doubts or second thoughts. Thus, despite the title of this blog, I am actually no longer jobless; I have accepted a position at an emergency department somewhat close to my home.
All in all, I’m extremely excited and overly relieved — I finally feel like everything is coming together the way I want it to. Here’s my upcoming timeline:
12/06/15 – Fly back to Las Vegas and spend the week packing
12/11/15 – Sister arrives in Vegas to help pack the U-Haul
12/12/15 – I drive the U-Haul and my sister drives my truck (with cats) aallll the way back to the Bay Area, some 8-9 miles NorthWest
12/25/15 – Christmas with family
12/31/15 – NYE party in San Francisco with Roxanne
01/04/16 – Depart with Brittney for Puntas Arenas, Chile where we will spend 12 days or so hiking Patagonia and other beautiful, scenic trails in Chile and Argentina
01/16/16 – Return home
02/01/16 – Begin work as a PA-C
^^ Pretty freakin’ sweet, right?
It’s all happening quite fast. I have a feeling my final week in Las Vegas will be loaded with nostalgia. No more gambling, no more running into friends from school, no more nights on Fremont Street, no more friendly gun laws. It’s not all bad though, i.e., California has some things that Nevada doesn’t, like income tax and painfully slow traffic. Home, sweet home!
I contemplated not posting this next part, mostly because I don’t want to be “that guy,” but I think it’ll be more helpful than anything else. Let me explain. Between study sessions during the two weeks leading up to the PANCE, I spent some time combing through PA forums searching for any extra information I could find about the exam. A few search terms and clicks later, I stumbled upon a forum in which test-takers shared their PANCE results in addition to their average percent correct on practice questions from all of the test-prep websites they’d used to study. It helped me to get a better grasp of how I could expect to perform based on how I had been performing on the practice sites. Ultimately, in the hopes that I might be able reduce someone’s pre- or post-PANCE anxiety, I have decided to share all of my results below. Keep in mind that I studied a lot.
PACKRAT #1 (from end of didactic) – 138 (out of 220)
Pancemaster.com – 67%
RoshReview.com – 74%
Kaplan Qbank – 75%
Summative Exam (faculty written) – 90%
PACKRAT #2 – 183 (out of 220)
PANCE – 563 (for reference, the highest score ever reported was ~800, and the minimum score to pass is 350)
Okay, I’m sick and this NyQuil is starting to kick in — this blog is done. Good luck to everyone out there that has yet to take the PANCE or is looking for a job! Both are easier than you think!
Just two months ago I had it all figured out. Though I had one clinical rotation remaining, my post-PA school life was already laid out for me as I had a sweet gig lined up in adult medicine — one with excellent compensation, great benefits, and an exciting opportunity to learn a lot while working for a company that is new-grad friendly. It’s amazing how much can change in so little time.
Early last week I contacted my recruiter at Southwest Medical Associates (SMA) and informed her that I would no longer be able to uphold my end of the contract with the company. Shocked, she called me to make sure that I was sure and to see if there was anything they could do to help me stay. I reaffirmed my sentiment over the phone, she expressed how sorry SMA was to see me go so soon, I replied appreciatively, and we hung up — contract annulled. For reasons that I don’t wish to get into in my blog, I decided that I want to move back to Northern California, and I decided that I want to do it sooner instead of later.
Fast-forward to today, I’ve joined a number of my former classmates on the job hunt. I’ve narrowed my focus to the Bay Area and greater Sacramento area, where all my friends and family reside, and the ball is rolling. For the past two weeks I’ve spent countless hours sifting through Indeed, Monster, DocCafe, Craigslist, and many other career-building websites. I’ve also spoken with at least a dozen recruiters who are actively trying to match me with an employer. This search has added some unwelcome turmoil to my post-grad life, but it’s not necessarily all bad. For one thing, it gives me a great topic to expand on in my blog!
Like most job seekers, I was familiar with websites like Indeed, Monster, and Craigslist which allow one to search for positions based on job type and location, and submit applications to the desired listings. However, recruiters are very new to me. Although I worked with a recruiter for SMA, she recruited for only one company: Optum. The recruiters I’m dealing with now work for independent firms that are hired by various hospitals and clinics nationwide to seek out and recruit doctors, physician assistants, and nurse practitioners for hire at their facilities. It’s quite surreal. You’re telling me that I am in such high demand that companies are paying other companies to track me down and get me a job, and it’s free?! Yeah, sign me up.
As for what sort of specialties I’m pursuing, I decided that in order to improve my “hireability,” I should expand my search to include not only adult medicine, but also family medicine, internal medicine, emergency medicine, and urgent care. My hope is that this will afford me more options… because I need more options.
Despite the overwhelming demand for medical providers throughout the United States, it is not as easy as one might assume for a new graduate to find employment in their desired field and location. Over the last two weeks of searching, I have been offered multiple promising opportunities in my preferred medical specialties, but they have all been in locations much too far from Sacramento and the Bay Area.
Understandably, all employers prefer hiring providers with a minimum of 1-2 years of experience — more experience means less time/money lost to training a noob; it makes total sense. In Nevada this is not a significant factor in one’s hireability because Nevada’s patient-to-provider ratio is the 4th worst in the United States and clinics are desperate to hire us. California, however, is the most populated state in the U.S., which means it is home to more PAs than any other state… and where do you suppose a large percentage of these PAs want to live and work? Correct; the Bay Area and Sacramento. Hence, most of the clinics and hospitals in these areas are quite content to not entertain the idea of hiring a new grad since they receive plenty of interest from experienced providers. This has left me in a precarious situation, but still very far from hopeless, as I have managed to secure interviews at three different sites during the week following Thanksgiving, including urgent care clinics in Sacramento and Modesto, and an emergency department in Antioch. Moreover, some conversations that I had today with a couple recruiters have left me feeling hopeful for the possibility of gaining 1-3 additional interviews during this same week at three different primary care clinics in Vacaville, Sacramento, and Stockton.
While it has taken some initiative on my part to put together a CV, write a number of cover letters, and sift through countless job listings, the overall process has not been as bad as I anticipated. There is absolutely interest for PAs in NorCal, including new grads. I remain hopeful that all will work out soon enough; it’s just going to take some flexibility on my part, and someone willing to give me a chance. Ideally someone will give me a chance sometime in the near future, too, because I have a trip to Patagonia coming up just over a month from now, and I will feel much more comfortable about traveling if I know that I have a job waiting for me upon my return.
As for my old job, it seems that a friend of mine from school has landed my abandoned position, i.e., he was hired at the same clinic and is working with the same collaborating physician that I was to have. I’m so excited about this, for two reasons: 1) It’s awesome that he got hired doing what he wants to do at a great company with a very friendly preceptor, and 2) I will now have the ability to live a parallel life vicariously through him as I check in with him periodically to see what the job is actually like. Win-win!
I haven’t even mentioned this yet because I’ve been so busy going on about my job search, but hey, I’m coming home! I always knew that I would move back home, but I had recently grown accustomed to the idea of moving back home after a number of years working as a PA in Vegas first. Yet, here I am, about to move back to NorCal to be near family, friends, (and the Raiders) again. 😀 I’m so excited! I’ve tentatively picked December 11th as my move date, so everyone back in the Bay should have ample time to coordinate the parade with floats and a marching band.
Last bit before I put a bow on this entry, I haven’t found out the results of my board exam yet. A small group of my former classmates took the PANCE on November 9th and they all found out the their scores on the following Thursday. I believe they all passed, which is great news! After reading some forum posts and speaking with graduates of the 2014 class, I’ve determined that I will likely learn my results on 11/25/15, the day before Thanksgiving, which is perfect because I’d hate to wait any freaking longer. I already mailed my California PA license application to the California Physician Assistant Board; they’re just waiting on my exam results in order to begin processing the application. Did you hear that NCCPA?! Everyone is waiting on you!
The next few weeks will certainly be interesting for me as I try and determine where I will work for the next year or two of my life, so stay tuned if you care to find out!
The Physician Assistant National Certifying Examination, aptly abbreviated PANCE, and pronounced as one might assume: “pants.” It is a 300 question, five-hour marathon designed to license those who may practice medicine as a PA whilst simultaneously weeding out those who may not, and is the biggest, most importantexam of my entire life.
The day before the PANCE I barely studied. For perhaps two hours in the morning I reviewed my infectious diseases chart as well as sifted through some of the childhood viral exanthems. I attempted to review my hematology chart one more time and ultimately gave up due to the incessant voice in my head that was chanting, “Heme is only 3%! Heme is only 3%!” I was done studying by 10AM. I had planned it this way, though. I told myself a long time ago that the day before the board exam that I wouldn’t attempt any test questions so that my mind would be relatively clear the next day. Believe it or not, after attempting 30-60 practice board questions nearly every day for a full year, there comes a time when you’re burned out. I didn’t want to be question-fatigued coming into the big day, so I gave myself a rest. Instead, I spent time playing Call of Duty Black Ops III, watched an ESPN documentary about Dirk Nowitzky on Netflix, shopped for some winter clothes and a few grocery items at Target, prepared everything for tomorrow morning, and began writing this blog.
I faired okay on CoD, cried tears of joy at the end of the documentary, and I really like the green sweater I found at Target. However, at the core of the afternoon was my preparation for the morning of the PANCE.
My goal was to disallow any potential hiccups that might prevent me from (A) arriving on time to the exam center, (B) sleeping well, and (C) testing as comfortably as possible. I addressed “A” by cleaning and preparing the kitchen for breakfast: I poured whole coffee beans into the grinder and filled the glass kettle with water so the coffee-making would be seamless. I addressed “B” by washing my sheets and making my bed. I addressed “C” by only eating foods that day that I had eaten before. I did not want to take the risk of eating from a restaurant; can you imagine getting food poisoning the day before the PANCE?! Diarrhea is very distracting (and persuasive), and I only have a limited amount of break time between question sets. My friend Brittney helped me out with “C” as well. She took the PANCE at the time and location as I, and she brought me snacks and water to keep my brain fueled and hydrated (since there is no true lunch break). Additionally, I set aside my most comfortable casual clothes for the next day, including my favorite pair of blue jeans, now named the “PANCE pants.”
The morning of the test proved to be as uneventful as I could have hoped for. I woke up on time to the symphony of dueling alarms, one from my phone at the bedside and another from my watch on the bathroom counter. I swiftly cooked and ate breakfast, downed my coffee, urinated, and made my way to the testing facility, diarrhea-less.
The pre-testing procedure was far more sophisticated than I imagined. In addition to showing the woman behind the counter two forms of identification, I was also required to have my palms scanned by a biometric recognition device that recorded the pattern of my palm veins. Later, during breaks I was made to scan my palm upon exit and re-entry to the testing room, as well as turn all of my pockets inside out and show that I was not hiding anything behind my belt. The testing room itself was under CCTV monitoring, i.e., if you so much as think about cheating, you will be caught. #MinorityReport
So, the test. It’s 300 questions separated into five sections of 60 questions in 60 minutes. At the end of each section you have the option of taking a break or moving on with the test. You are allotted a total of 45 minutes of break time to be divided however you please. When I took the test, I took my first break after 60 questions because my morning coffee had run through me quickly. I took my second break after completing the next 120 questions and ate some food. I then powered through the final 120 questions to finish. By the time I was done, my eyes were irritated as hell and I felt like I was in a fog. “What just happened?” I thought to myself.
After posting on Facebook that I had completed the test, a few people contacted me to ask me how it went. I will tell you what I told them. When it was all said and done, I left the testing center feeling like, “Ehh.” It was challenging!! I’ve attempted PANCE-like test questions by the thousands from seven different resources over the last year; I’d thought I’d seen it all, but I definitely had not. Some of the questions that the PANCE asked were obscure, and I found a number of them to be nit-picky. However, after doing some post-PANCE reading, I discovered that many of the questions on the PANCE do not count towards your score; rather, they are built-in “practice” questions, i.e., the NCCPA is trying out these questions for future PANCE use, but they do not count against one’s score at this time. Unfortunately, us test-takers are unaware of which questions do/do not count, as well as how many “practice” questions are actually included.
I wish I could lend examples of test questions that I remember, but the post-test printout that was given to me upon dismissal from the testing center was crystal clear about the consequences of disseminating specifics about the PANCE, and I do not intend to have my license suspended before I even receive it. What I can tell you is that there seemed to be a fair balance of long and short question prompts such that time was never an issue, at least not for me. I consistently finished each section with 5-7 minutes of additional time remaining. As far as test prep recommendations go, I highly recommend completing all of the Rosh Review and Kaplan QBank practice questions as they seemed to be a good representation of the PANCE questions. I also suggest paying the $35/each for the two NCCPA practice tests that you can find on their website. Do these two tests when you’re within 1-2 months of your test date so you can assess your weaknesses and strengths prior to your final study push. I should mention (again) at this point that the above is only my personal opinion, and I have no doubt in my mind that someone else who took the exact same test as I might sit here and tell you to prepare in a completely different manner from what I am suggesting, and they may be right! Bottom line: do what helps you the most.
The NCCPA officially states that PANCE results will be available within two weeks from one’s test date. This is too broad for me, so I did some poking around and found that a better time frame is between 7-13 days. When my score is available I will receive an email stating such. From there, I will visit the NCCPA’s website, login, and check my score. Trust me, it can’t come soon enough!
In the days following the exam I have tried to find something to occupy my time. I have nothing more that I need to study, so what do I do? I decided that I should finally, once and for all learn Spanish. Not only will it help me with my upcoming trip to Patagonia, but it has major positive implications in terms of my salary as a PA. Long ago I got myself Rosetta Stone, so I’m finally committing to it now. You are all my witnesses.
Other than that, not too much going on, and kind of like it. I think I’ll go shooting soon — it’s been a while since I played with my new toy. I’ll also be making a trip back home for Thanksgiving, but that’s about it for now.
I blinked. For one quarter of a second my eyes were closed — when I opened them, it was over.
On Nov. 2nd, 2012, I received a letter in the mail congratulating me on my acceptance to Touro University of Nevada’s Master of Physician Assistant Studies program. I remember vividly the sheer elation that came over me when I was accepted; I was going to be given an opportunity to achieve the most important, ambitious goal of my life, to date. One day short of exactly three years later, alongside some amazing people and before my family and friends, I walked across the stage and graduated from PA school. If not for the memories that I have, pictures and video that I captured, blogs that I wrote, and friendships that I made, I might not believe that the past 28 months even happened — that I ever attended PA school at all. How can two years and four months feel like 250 milliseconds?
Indeed, it was brief. However, without a doubt, undeniably, unequivocally, the time that I spent in (and out of) the vortex of PA school was the best time of my life.
It took me an hour to write the above… As I type, the pauses between each sentence fill with distractions — fleeting memories of laughs I’ve shared, things I’ve seen, places I’ve been, and sstruggles I’ve known over the last 2+ years. I’m finding it difficult to maintain a thought stream for the first time in a long time, and though I am trying my best to stay focused, I can’t help but ask myself if this is what flight-of-ideas feels like… as I diagnose myself with a hypomanic episode.
I’m just going to come out and say it: I’m going to miss PA school. Upon arrival, I knew it would be difficult, and I was right. What I didn’t realize and could never have guessed was how fun it would be. Not only did I quickly make truly great friends that I intend to keep for a lifetime, but I traveled like I never have before, awakening in me a passion for exploring the world that I previously never knew. Reflecting on it now, I have no idea how it was even possible to do what I did and go where I went. PA school is hard as hell and deserves a lot of respect for what it requires in terms of dedication to academia, but somehow, through the murky sludge, I found windows of opportunity to travel to places inside and far outside of the United States that I never thought I would see. I mean, I went to Australia, New Zealand, Dubai, and Tanzania!! Are you kidding me?! Not to mention I stood at the southern rim of the Grand Canyon, hiked at Zion National park in Utah, and partied at Kylie’s parent’s cabin in Flagstaff, AZ. (If Kylie’s parents are reading this, we didn’t party that hard and we didn’t break anything. Also, thanks again!) Now that school is over, I have another trip planned for the whole of January, 2016. I’ll be flying out of here with my friend and classmate — err, ex-classmate, Brittney — headed for Punta Arenas, Chile where we will spend time hiking one of the most scenic, beautiful trails in the entire world in Patagonia, and that’s just the first three days. Who am I?! I don’t even recognize myself. Anthony Ambrosino, PA, world traveler… Nevertheless, I’m incredibly excited to travel without that sinking “I should be studying” feeling.
I wish I could spend time reminiscing over the innumerable highlights that the last 28 months have provided me, but I have neither the time, nor the patience for all that writing. Instead, it is sufficient to periodically revisit pictures, videos, and memories, and remember that the events of the last 250 milliseconds did occur, and now I have graduated. I am officially a master of physician assistant studies 😀
Proud Dad
The kid’s table krew
Sister isn’t impressed
Megan and Me 🙂
Me, Branden, and Steven
Proud Mom
Myself, PA Vicki Chan-Padgett, and Dr. John Padgett — Our program will sorely miss you both!!
Roxanne and I, cute as ever
Hooded Selfie
#Elation
Before I get into what’s next in my life, I want to again say thank you to everyone that supported me throughout the last couple years, especially my mom, dad, and sister. You are my biggest supporters and this dream of mine would have been unfathomably difficult without your love and support. Also, thank you to Roxanne for being one of my constants throughout the past couple of years… and for making me look like I won the lottery whenever we take pictures together — it made my day that you were there. Thanks to my cousins for coming to watch it unfold too! I know you guys were here on vacation, so I’m glad you took some time to see me walk the stage!
I had a shitty night, and Jami was a cat.
A couple quick, noteworthy items:
For the first time, this year my PA progam staff hosted a luncheon at a bankquet hall following the PACKRAT exam to hand out some faculty-selected awards for a number of students. For example, some of the categories were “best mom,” “best dad,” “most improved,” “leadership” award, and etc. It was a fun and thoughtful get-together, and it was even graced by the presence of the Touro University Western Division CEO. Naturally, when it came time to announce the winner for “most humerus,” I was selected. Haha! And if you didn’t catch it, they spelled it H-U-M-E-R-U-S, as in the upper arm bone! I love puns. Can’t wait to hang this baby up on my diploma wall.
TUN PA Class of 2015 “Most Humerus” Award
A self-admitted long-time follower of my blog and recent interviewee at TUN emailed me not too long ago to ask for advice regarding the interview. In our correspondance, she mentioned how proud she was of me that my article was included in the packet that all of the interviewees received upon arrival to the school. Confused, I asked her to elaborate. She sent me this:
Apparently the PA program has a 8.5″ x 11″ copy of my award winning piece that was published in the PA Professional magazine back in May, 2014. How cool is that?! I’m famous!
November 1st, 2015 marked the end of PA school, and so marked the closing of book two of the three “books” in my blog series. “Pre-” and “Present-PA School” are finished; “Post-PA School” begins with this entry. As always, I’ll focus primarily on my professional life, i.e., what life is like as I transition from a student to a licensed medical provider seeing my own patients. However, you can continue to count on me to tangentially go off topic and bore you with my personal life as well.
The first item, and really the only item of such significance on the agenda in my post-PA school life is the Physician Assistant National Certifying Examination (PANCE), aka board exam. As previously mentioned, I am taking it on the morning of 11/14/2015. I honestly feel like I’m ready, although I’m reluctant to admit it to myself as I fear that I will slack off from now until then. No, seriously, I’m ready. I performed better than I could have hoped for on the PACKRAT, and high PACKRAT scores correlate with successful board exam completion. Moreover, I continue to score very well in practice tests that I take on a daily basis, so I’m looking forward to getting this thing over and done with — so much so that I checked to see if I could move it up to an earlier date, but all the dates are full. Seven days isn’t long enough to forget everything, right? Right?!
Okay, that’s all for now. Congratulations to the Class of 2015!! We did it!! And best of luck on the boards! 🙂
I’m going to miss these amazing, beautiful, brilliant people. #PAFramily2015
Pre, Present and Post-Physician Assistant (PA) School 