Longitudinal Clinical Experience (LCE)
As part of the PA program at U of T, each student is required to do a minimum of 30 hours (max of 40hrs) of clinical experience per semester. These experiences are arranged by the student and are flexible, except that at least 10hrs have to be primary care. In the first semester, it is strongly recommended that we have allied health experiences (ie with healthcare professionals who aren’t MDs).
Why bother having small clinical experience when we are going to have clerkship rotations for all of second year? The answer is that earlier exposure to clinical settings & real life patient interactions better prepares you to make the most of your 2nd year rotations. These LCEs take care of all the “firsts” in clinical care; then in second year, you can jump right in and practice medicine! Also, it’s all fine & well to learn your anatomy, pathology and clinical skills, but having early opportunities to practice your knowledge & skills is extremely useful, especially in this program where a lot of the learning is online. It’s nice to get in a hands-on learning environment!
Between October-November, I have scheduled an average of 5-6hrs per week for an LCE. As with the McMaster equivalent of this LCE (called a Longitudinal Placement, LP), students are responsible for arranging these LCEs are their own. This gives you flexibility but is also a great deal of work. I’ve had great experiences and have fulfilled my requirement. I also built great MD-PA relationships so that hopefully I’ll be able to return to some of these places in 2nd year for clerkship.
I’ve had to write about my experiences as I go to be marked in school, so I have translated some of that here to give those interested an idea of what LCEs are like:
Primary Care – Family Medicine
This was my first LCE & it was with a local family physician in KW who has multiple practices. I joined him at his less-busy clinic, which I was grateful for since this was my very first day in a clinic as a PA student. The only other people in the office besides the patients were myself, the physician, the receptionist & a nurse – it was a very stress-free day. The physician I was with had hired/worked with a PA a few years ago (that PA ended up going to med school & is now an MD returning to become a partner with his old supervising physician!) so it was nice to not have to extensively explain PAs & my role. The nurse presented the patient’s brief history, vitals & reason for follow up to me & showed me how to use the electronic chart system, which helped me out a lot. There were no new patients but I was able practice history taking/interviwing & report to the physician.
What I Saw:
- Congestive Heart Failure – measured JVP & listened to chest
- Vasovagal syncope with sinus infection – took a thorough history & learned a lot from this case (I was unfamiliar with vasovagal)
- Diabetic meds update & counseling – took history
- 9 month well-baby checkup – observed
- Lots of psych counseling & prescribing – observed
- R supraspinatus tear secondary to trauma – read imaging report
Primary Care – Walk-In
I was very fortunate to be taken on by a new physician in Waterloo who had just opened up a beautiful walk in clinic (soon to be converted to a family medicine practice). This clinic was in the heart of student housing, between the University of Waterloo and Laurier University. As such, a large portion of our population were students which means 4 main things – Strep throat, Mono, Birth control counseling and sick notes. However, there were also babies, children and older adults. I really enjoyed the diversity of patients and the physician was an amazing teacher who I look up to! I hope to be able to go back to this clinic in the future.
I was also able to share some of my knowledge & make a recommendation to the doc re: a 67 year old man with a foreign body sensation in the right eye. Since we did not have a slit lamp to assess him, the doc’s initial plan was to send the man to emerg, in order for the on-call ophthalmologist to assess him. However, since I have worked in ophthalmology, I knew that this would not be a quick process in this region. Since it wasn’t extremely emergent (he said it first started over 1 week ago), I knew it would be much quicker for him to be assessed by an optometrist, for which it would be covered (b.c hes older than 65) and for which there are very many optometrists in Waterloo (b.c UW has the only optometry school in the country). I’m a huge advocate for optometrists as primary clinicians for eye issues & even felt confident that if there was a foreign body, that the optometrist could easily manage it or refer to ophthalmology if needed (also, ophthals like referrals from optoms b.c they’ve already had a good look & reason for referral). Anyway, I was just glad I could help streamline the care for this patient & also provide this information to the doc who was new to Waterloo.
Primary Care – Nurse Practitioner
As part of my learning of allied health care professions, I wanted to work with an NP to really be able to answer the question I get asked all the time: “What’s the difference between a PA and NP?”
After 1 day with a lovely NP, I was able to learn a lot about her role. This clinic also had PAs working as well so it was awesome to see the MD – NP – PA dynamic. At this clinic, when the NP and PA were in, the physician used EMR to bill for their service. This involved setting up a laptop or iPad & briefly consulting with the doc between patients. Although on this day, there were some internet difficulties so I was not able to actually see this process actually working.
The PA and NP each get their own list of patients to see and work independent of each other. Both were relatively autonomous clinicians who (usually) consulted the physician. Each of them would interview & assess patients, perform physical exams, order labs/tests, wrote referrals and prescriptions. Practically, both had the same responsibilities but some of the administrative details are what separated their roles.
*I will be doing an in-depth post on the differences between MD, PA and NP both clinically and legally. Stay tuned!
Respiratory Therapy – ICU
It was a wonderful learning experience to learn from a respiratory therapist. The main thing I learned: RTs are ventilator masters. In the ICU, the RTs are responsible for patients on ventilators (very complex), they are part of the intubation process and they also provide recommendations to the physician on how to proceed with the plan, based on their respiratory stats. In addition, the RTs are apart of a large interdisciplinary team that cares for the patients in ICU. These teams include a physician, residents, nurses, dieticians, RTs, social worker, pharmacist, physiotherapist who all round on patients together & formulate a plan for each patient – it’s truly amazing. So, in addition to learning about the role of an RT, I also learned about how many allied clinicians work together in interdisciplinary teams.
Psychiatry – Inpatient
I know I keep saying all of my preceptors are amazing, but that’s because they are! I have been so fortunate to have wonder physicians who are happy to teach me & treat me with respect – the same goes for the physician I worked with in the psychiatry ward at Grand River Hospital. Going into this LCE, I was nervous & did not know what to expect; but I ended up learning so much & loving this field. Much like the ICU, there were interdiscplinary teams involving the physician, nurses, social workers, CCAC workers & other professionals that help patients develop skills & make plans for how to manage their symptoms after they are discharged (usually a short list of places for them to go and numbers to call if they are feeling unsafe). What I loved most about psych was the relationship built with the patients & the care given to how their life will be after they’re discharged. It was an amazing experience that I hope to go back and do again in the future!
Pathology – Coroner’s Autopsy
This was a very unique experience (to say the least). Since this semester there was an emphasis on primary care & allied health, one of my classmates, who was a former pathologist’s assistant, offered to arrange for anyone who wanted (almost everyone in my class did) an LCE at the coroner’s office where she used to work. Essentially, us as PA students (up to 4 of us at a time) would join pathologists, researchers, fellows, residents & medical students to observe autopsies for a day.
1. Coroner: medical doctors who have been through specialized death investigation training and have been appointed to investigate sudden deaths. A coroner is called to investigate a death that seems to be the result of unnatural causes or natural deaths that occur suddenly and unexpectedly.
2. Pathologist: medical doctors who are experts in disease and injury. May perform autopsies.
3. Forensic Pathologist: pathologists who are experts in disease and injury that result in death. Perform autopsies.
4. Medicolegal Autopsy: The coroner, usually in consultation with a forensic pathologist, will decide if an autopsy is needed. An autopsy (postmortem exam) is when a pathologist/forensic pathologist examines a decedent’s body to help determine cause of death.
- 8:00am – Arrive, sign in, get badges, discuss the day, dress in lab coats & shoe covers
- 8:30am – Rounds start. The whole team visits the gurney of each patient to plan the autopsy & discuss each case: the team included myself & 2 of my classmates, a few pathology fellows, a 2 pathologists, 2 clinical researchers, 1 PGY1 pathology resident, 1 medical student, many pathology assistants & case photographers
- 9:30am – Autopsies begin. The team splits up into pathologists/pathology assistants; one team starts on one case, another starts on another & so forth. There are multiple autopsy stations (~10) set up in the room so that many can occur simultaneously. As learners, we could circulate between cases as we pleased.
- 11:30am – First autopsy that I observed, completed. This one took longer than the others, because of many findings & difficult dissections. Head to another case.
- 12:00pm – I left before the next case was done. I had enough for the day.
If I’m honest, I was terrified to do this LCE. I was in the 4th “round” of students to go & after hearing about everyone’s experiences, my fear only intensified. I was comfortable around cadavers but I was told (and now know) that the deceased are totally different from cadaveric specimens. A lot of my classmates witnessed homicide & suicide cases; many felt very traumatized. We spent a lot of time as peers discussing our experiences with each other, since it helped us overcome our sadness/fears/concerns/anxiety/distress. We were all very supportive of each other, which I am truly grateful for.
I felt lucky, in the sense that I did not experience any major traumatic cases. Other than rounds, I followed the same pathologist working on the same patient for the whole morning. I’m going to describe very briefly a run down of the case to give an idea of what we experienced.
*CAUTION, SENSITIVE/DISTURBING CONTENT WILL BE DESCRIBED. READ ON AT YOUR OWN DISCRETION. NO IMAGES WILL BE SHOWN*
- 48 y/o paraplegic for 10 years (secondary to MVC) with recurrent osteomyelitis in the R hip (present on postmortem CT). I did not record/cannot remember other history about his initial ER presentation, previous surgical history etc.
- Images were taken posteriorly & anteriorly of specific regions (by a specially trained pathology photographer)
- R hip examined closely; bone samples taken; exterior examination (by pathologist assistant & pathologist)
- Sternum/anterior rib removal. Bowel drainage & removal. (by pathologist assistant)
- Peritonal & mediastinal organs removed. (by pathologist assistant)
- Face/skin from skull retracted. Skull top removed to retrieve brain & associated features. (by pathologist assistant)
- Heart dissected; R coronary artery thrombosis & atherosclerosis found. No signs of myocardium damage; likely no MI. Sample of artery & myocardium saved for microscopic exam. (by pathologist)
- Spleen dissected; excessive spleenomegaly. Indicative of sepsis. Sample for microscopic exam. (by pathologist)
- Lungs, trachea, esophagus, tongue, stomach, duodenum, gallbladder, liver dissected. Duodenal ulcers, fatty liver & esophageal petechiae found. Samples saved. (by pathologist)
- Spinal nerve, brain, meninges dissected. Samples saved (by pathologist)
- Organ remains placed in bag. Bag tied & placed into abdominal cavity. Abdomen sutured shut. Facial skin pulled back over skill & stitched.
- Pending verdict for sepsis originating from R hip
What I found particularly interesting was the different roles of the pathologist and the pathology assistants.
Advantages & Challenges of LCE: Location?
The great thing about having a portion of this program distance-based, is that you can organize these clinical experiences wherever you want, including your home town. Not only is this spatially convenient, but it also allows you to build professional relationships with future employers in the city of your choice. (Eg. I would love to work in Waterloo someday so by having placements here, I’m building connections with possible employers & gaining a good understanding of the potential PA job market here!). You’re able to being to establish yourself in a place where there may not be a saturation of PAs (is there such thing in Canada?) or med students (competition is tough). The freedom also gives you the opportunity to have a wide variety of experiences, such as when I went to Toronto for the pathology day.
Personally, I have experienced some challenges with arranging my own LCEs. Although we have the freedom to arrange LCEs where we want, that isn’t to say that everywhere will take us. Competition with medical students and residents at teaching hospitals makes it hard to get in. However, with perseverance, an excellent recruitment speech/strategy and the right contacts, anything is possible.
Bonus: Ultrasound Skills at CHEST Conference
Although this was not an LCE, I learned the basics of ultrasonography that will help me in future LCE’s & clerkships.