The Interview

The start of September, my second to final month of PA school, was quite welcome. Because my preceptor was away on vacation for the first two weeks of the month, I was able to take two weeks off.. Err, two weeks of* studying. Let’s be honest, I relaxed and studied in equal proportions, which ultimately felt like 100% relaxing compared to past months. Nevertheless, it was nice to decelerate a bit.

Although I remained mostly idle during those two weeks as a sort of “staycation,” the time was highlighted by interviews with Southwest Medical Associates (SMA) regarding a job opportunity in their adult medicine division. For those who haven’t heart of SMA, it is an HMO medical company, and much like Kaiser Permanente is to California, SMA is “one of Nevada’s largest multi-specialty medical groups,” per their website. From regular outpatient care to specialists, and urgent care to surgery, they basically offer all-encompassing medical care. Moreover, they offer excellent compensation packages and generous structured bonuses, make a concerted effort to ease new-grads into practice, and most importantly: they’re hiring!

If you recall from one of my last blogs, I met a recent Touro grad at a drug rep-sponsored dinner at the end of last month, and he was going to put me in contact with a recruiter from SMA. Well, he did. Since then, I’ve completed two telephone interviews which went exceedingly well, and I was invited for a final (panel) interview to be completed Wednesday (09/23/2015) at 3:30PM. From what I understand, the panel interview is with 3-4 physicians who will present me with several clinical scenarios and ask me what I should/would do — should be fun! Between the two telephone interviews, my PA friend/SMA contact invited me to his clinic during lunch time and he and his supervising physician gave me a full tour of the facility, outlining how efficient and effective their practice is. I must admit, I was sincerely impressed with what they have going on. In short, they’ve implemented the Lean Principles, made famous by auto manufacturers, and notable for its ability “to create a state of perfection in which perfect value is created with no waste.”

All in all, the office ran like a well-oiled machine in which the patients’ and providers’ time was maximized. Everyone seemed very pleased with it, and I was certainly impressed. Anyway, hopefully by the time of my next blog I will have an official offer on the table from SMA to write about.

More on my staycation: I did manage to make a weekend trip home over the weekend of the 12th and 13th to see family, go hunting, and go to the Raiders’ home opener vs the Bengals. Everyone knows how the latter turned out, so I will discuss the former two activities.

I haven’t been hunting in years; specifically, I haven’t been dove hunting in over a decade. It’s no wonder I felt rusty. I did have a lot of fun, though. I went with my dad and cousin, and between my dad and I, we were able to take home enough birds to cook up for dinner. I’m writing this around lunch time and thinking about that dinner is making my stomach growl — the dinner was fantastic — thanks Dad! My grandparents came over for dinner that night as well, and my grandma was thrilled to finally receive her gifts from me from my trip to Tanzania. She collects decorative spoons from all over the world, and I brought her home spoons from Dubai and Zanzibar, filling two voids in her display case.

Below is the video of us dove hunting:

Although I don’t care to touch on the Raider game, which can barely be called a contest at all because they laid an egg, I will just mention that I went 3-0 between all three of my fantasy football leagues, including a HUGE (>42 point) comeback in one league with only two players remaining. Thank God for fantasy football! This weekend proved to be a sort of switch as the Raiders pulled off an amazing come-from-behind victory vs the Ravens and my fantasy football teams suffered the injuries of Romo and Lacy. I’ll gladly trade a Raiders’ win for fantasy football losses any day, though.

My second internal medicine clinical rotation began on Tuesday, September 15th, but not before I embarrassed myself in a text message conversation with my new preceptor. It was Tuesday morning and I was lifting weights when my preceptor texted me to tell me to meet him that afternoon at the hospital to discuss the rotation and his expectations for me. I mention that I was lifting weights because I blame my endorphin high for convincing me that what I said would be hilarious. Here’s screenshot of what was said:

WUPS! No worries, though. We both acted like it never happened when I met him later that day. As it turns out, he’s a really great internal medicine physician and an excellent teacher. In fact, he’s such a great teacher that he regularly has about 5 Chinese doctors shadowing him on a three month cycle, every three months. When we walk around the hospital following him like ducklings, the hospital staff says, “Here comes Dr. Abraham and his entourage again.” -__-

More on this rotation in my blog at the end of the month — don’t want to give up all of my material. However, I will mention this: today I overheard a nurse exclaim, “Oh, today is payday!” and I was flushed with nostalgia. I haven’t experienced a payday in some years now.

Lastly, every time I log on to Pancemaster.com to do practice questions, the homepage tells me how many days remain until my board exam. The current count is 54.

Dun dun dunnn.

The Real OSCE

The days of prominently arching my back, stretching my arms above my head, and bellowing a powerful roar of a yawn are over.

On clinical rotations, yawns such as these are sure to draw scorn from my clinical preceptors and feelings of disrespect from the patients. Instead, when I’m feeling a mid-afternoon yawn come over me, I internalize it, showing only the slightest outward signs — clench teeth, close eyes to about 60%, roll pupils up into the northern-most recesses of eye sockets. Hmm, when I put it that way, maybe an actual yawn might look better.

The last couple of weeks have been tiring. Between long clinic hours at the cardiology office and studying for the internal medicine end-of-rotation (EOR) exam #1 in the evenings, I haven’t had energy remaining to do much else. I will be very glad when I no longer feel the seething pressure to study every night, and this relief is not far off. I have only two clinical rotations remaining before I am a full-fledged graduate of Touro University of Nevada’s PA Program. In fact, in early August I registered for said graduation, and just two days ago I received an email notifying me that I can now order my commencement ceremony announcement letters. Commencement ceremony?! I haven’t had one of those since, well, college! Lol, college.

Exactly two weeks after my November 1st graduation date I have scheduled myself to take the Physician Assistant National Certifying Examination (PANCE), AKA board exam, which means by Thanksgiving of this year I will either have something new to be very thankful for, or I will eat more for dinner than I ever have in an episode of consummate depression.

On Thursday, August 27th, 2015, I lost my third and final birthday to PA school. I’m 28 now, and my back hurts just thinking about it. The 27th also happened to be marred by the aforementioned EOR exam, so that was pleasant. I have actually had an exam on 2/3 of my birthdays over the last 3 years — something to be said of consistency? Nevertheless, I performed well on the exam so perhaps it was a nice birthday present. For future reference, PA school, a card will suffice.

My class suffered our 2nd and final objective structured clinical exam (OSCE) on the following day. In a previous blog I mentioned us taking a practice OSCE with a “real” OSCE looming in the coming months. This real OSCE is a graduation requirement, so everyone must pass if they wish to take part in said commencement ceremony.

The “patient” that I had suffered from progressive dysphagia (difficulty swallowing) over the last 3 months, that started only with solids and progressed to include liquids. By the time she presented to me she was only able to take small sips of water and tiny bites of food; otherwise, she would regurgitate everything she swallowed within 20-30 minutes. I asked her a bunch of questions regarding her symptoms, assessed her risk factors, noted her comorbidities, and then I examined her. Upon completing a thorough exam of her neck, cardiovascular system, pulmonary system, and abdomen, all findings were completely within normal limits (WNL) and I was left with only her history of present illness (HPI) to make my assessment. That is, until I remembered that I can ask for appropriate lab/radiologic findings, and if they are available, the proctor in the room who is grading my performance will provide me with the results of the tests.

I asked for a complete blood count w/ differential (CBC w/ diff) to assess for any anemia or infectious problems; it was was normal. I also asked for an upper GI X-Ray with barium swallow, and he handed me a piece of paper with this image on it:

Upper GI series w/ barium swallow in patient with dysphagia

This image, along with the information I had already gathered was enough to make my diagnosis: achalasia. Achalasia is defined as lower esophageal sphincter hypertonicity (inability to relax) which alters or halts the passage of food from the esophagus into the stomach. On the SOAP note that I wrote after exiting the exam room, I added differential diagnoses of adenocarcinoma of the distal esophagus (most common esophageal cancer in the U.S.), Schatzki ring formation, hiatal hernia, and esophageal dysmotility disorder from diabetes, because she was also a diabetic (I was really reaching with that one).

In my “plan,” among other treatments, I referred the patient to a gastroenterologist for esophagogastroduodenoscopy (EGD) with biopsy, as needed, to rule out some of my differential diagnoses. I haven’t received my grade back yet, but I’m confident I did enough to pass 🙂

In the afternoon on that same Friday, upon personal request from the faculty at my school, I, and five others took part in a 6-person Q & A panel for the underclassmen that was designed to answer their questions, reduce their apprehension, and quell their anxiety about their upcoming clinical rotations. As if I haven’t already belabored the point, we are so close to the finish line that the underclassmen are now about to begin their clinical rotations! Crazy.

Anyway, it was the first time our program has ever done this (previous classes, including mine, were sent into the clinical realm with our fears intact), and I think it not only went very well, but it is an excellent idea to continue in the future. Its success could be judged by attendance alone as approximately half of the class of 2016 took part in it despite it being held after lunch and with no other classes remaining that day, i.e., they could have just gone home and napped. Nevertheless, many of them were there, asked a lot of great questions, and received a lot of great answers, answers I wish I would have had when I was in their shoes one year ago. I’m sure they will succeed; they’ve made it this far.

I’m writing this blog from home on a Tuesday morning because the second month of my internal medicine rotation doesn’t start until the third week of September. That’s right, my first two weeks are wide open. I found out about a week ago that my preceptor would be out town for the first two weeks of the month, but would be working every single day during the second half of the month. Despite being away, I was informed that the doctor really wants to take a student, and the choice was ultimately mine regarding my desire to keep the rotation or change preceptors. I don’t think I need to explain my decision-making process on this one, but in addition to the obvious reasons behind taking a two-week staycation toward the end of PA school, I was told that this preceptor is specifically looking for a PA to hire to work internal medicine at UMC, Las Vegas’ largest hospital, so my decision also has to do with researching and investigating a potential landing spot once I graduate. That is, and will remain, my alibi.

Lastly, last night I attended my second drug company-sponsored dinner of the month at Del Frisco’s Double Eagle Steakhouse. I was invited by a drug rep while working with my previous preceptor and decided to attend the dinner regardless of the fact that my rotation had ended with her. Something about a savory, medium-rare filet mignon from a 4-5 star steakhouse was telling me I should really learn about this new drug for heart failure treatment. To be fair, the drug is called Corlanor, and it seems to be quite effective at decreasing costly hospitalizations in patients with stage II-IV heart failure (25% reduction in hospitalizations) by decreasing heart rate by an average of 10 beats/min. Why would you want to decrease heart rate in a patient with heart failure? Excellent question; I asked myself the same thing. The answer is quite logical, however. Patients with heart failure can often times have elevated resting heart rates (>70 bpm). When the heart rate is too high, the heart doesn’t spend enough time in its relaxed state (diastole). During diastole is when the heart fills with blood to be pumped out to the body during its active/pumping state (systole). So, decreasing heart rate allows for more diastole, more diastole allows for more filling, more filling allows for a larger stroke volume/cardiac output, and increased cardiac output can decrease symptoms of fatigue and swelling that frequently hinder these patients, causing them to seek care from hospitals. All in all, it’s a great idea.

Del Frisco’s

Del Frisco’s

While at this dinner, I happened to meet a PA-C that graduated from my school last year. He works for Southwest Medical Associates (SMA) in adult medicine, the exact company and field of medicine that I’ve been leaning towards applying for once I graduate. We exchanged phone numbers, and he told me he would put me in touch with the SMA job recruiter. Win-win kind of a night.

Okay, I need to go exercise. Until next time.