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?
REDACTED
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.
Pre, Present and Post-Physician Assistant (PA) School 