LCE – Semester 3

Semester 3 (May-July) was our last semseter of 1st year and we had one more round of LCE hours to complete. To read more about what LCEs are and why they are done in PA school, see my previous LCE post.

Family Medicine – FHO

In May, I joined a fellow PA at a Family Health Orgainzation (FHO) in my city. This was the very first time I had ever actually worked with/observed a real PA in practice, which was very exciting. While I was there, I took the opportunity to learn more about how the PA role was funded, the medical directives and how the physician-PA dyanmic worked. I learned that a great way for a team of physicians to make use of/fund a PA is by splitting the cost – Eg. If the PA works 2 days/wk for 1 doc, 1 day/wk for another doc and 1 day/wk for a 3rd doc, her salary could be divided accordingly by the physicians (50%, 25%, 25%). I also learned about one of the unique roles of a PA, which is to know & adapt to your current supervising physician’s “medical style.” This means that the PA really gets to know each physician and based on which one she’s working with that day, adjusts her prescribing or plan to fit with what the physician would likely do. Everything I learned this day was super insightful and really made me aware of how I myself might someday fit into a practice.

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Follow me on instagram for even more updates @daniellevpa

Pediatric Dermatology

Since I’ve been loving my time in pediatrics, I decided to gain some useful exerpience in pediatric dermatology. I can’t even tell you the number of times parents come in to the pediatrician to show their child’s rash; or how many referrals from family docs that say “query rash,” so I was glad to get some further experience in this area.

I saw atopic dermatitis (aka eczema, and a lot of it), psoriasis, hand-foot-mouth and many warts! One of the most interesting things I learned from this doc, is that off-label injection of Candida antigen serum (on-label used for allergy testing) into the wart has shown efficacy for stubborn pediatric warts. The theorized physiology is that the antigens (normally used to assess the immune system response) stimulate the immune system to recognize the area where the wart is (usually the warts persist because the immune system fails to recognize/attack the virus) and therefore attack & destory the viral-induced wart. It’s amazing what little tidbits you can pick up from a variety of physicians.

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Did some studying before heading to clinic!

Cardiology

I was so glad to be able to spend a day in one of my city’s top Cardiology clinics. This is an area of medicine we have been taught quite a bit about, since many cardiac issues can be life-threatening & are initally assessed in the ER. So, I was interested to know what happens beyond the phrase “follow up with cardiology” that I commonly see in the ER. I found that out of all the specialities I’ve experienced so far, my didactic work had most prepared me for cardiology. I’m not sure if it’s because I was intersted in cardiology so a lot of it stuck, or if it’s just a good starting ground for teaching medicine (probably a bit of both). Either way, I learned a lot this day & was also able to practice many skills – I saw real, bilateral pitting edema when assessing a man’s congestive heart failure (you have to press a lot hard than I thought to see the pitting!). The main thing I saw was a lotttt of Atrial Fibrillation, and I learned a lot about it including assessment, treatment and complications. We also assessed a man for restrictive pericarditis secondary to active tuberculosis infection; this was very rare to see in an outpatient clinic in Waterloo, so it was very interesting for both myself & my preceptor!

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Cardiology clinic room

 

 

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LCE – Semester 2

Every semester, part of our circulum involves Longitudinal Clinical Experiences (LCE). To read more about what LCEs are and why they are done in PA school, see my previous LCE post. In semester 2 (Jan-April), I has some new experiences and also re-visited areas I really enjoyed from last semester.

Emergency Medicine

A lot of the clinical skills we are taught in the beginning of PA school involve situations that typically occur in the ER setting (MI, appendicitis eg.). With that in mind, I was SO excited to be able to put my knowledge & skills to the test in the ER for real!! I spent 10 hours in a small-ish community hospital that had 2-3 ER docs on at a time. The day I was in, there were no other medical students so I was lucky enough to be taught by more than one doc (although 1 was my official preceptor). This paper-based ER had a wall with charts in clipboards and the docs would just grab each one by one & see the patients. Most of what came in on this day was not truly emergent – SOB workup for pneumonia ended up just being the flu; Flank pain with CVA tenderness workup for kidney stone ended up being a muscle strain. It also apparently was a slow day (although it seemed super busy to me!).

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My role as a PA student: I was treated much like a medical student (CC3/CC4). The doc gave me a choice of which patient I wanted to see and I went ahead to take a full history, perform some physical exams and then reported my findings & differentials to him. He would quiz me & prompt me for my plan, which was an awesome learning experience. I made my own dictations of my encounters in the chart. Him and the other doc took many opportunities to teach me (quiz me on what I saw on an Xray), show me techniques (casting) and let me practice skills (stapled a head lac!), which I was very grateful for.

A few interesting cases/procedures I saw:

  • Middle aged male, 3 months post-colectomy for stage 4 colon cancer treatment presented vomiting, feeling nauseous, faint & generally unwell. BP at admission was 50/30…His creat showed he was very dehydrated so he was treated with 3L of fluids to attempt to raise the BP. His SBP was rising up to ~70 but then plummeted again to 40/27 – a bunch more labs & imaging were ordered at this point & he was given norepi which raised his BP to 71/50. Unfortunately, I wasn’t able to find out what happened to him because was admitted to ICU as I was leaving my shift. This was the most emergent case I saw that day.
  • Young female with severe abdominal pain, cramping & vaginal bleeding following a miscarriage. On speculum exam, many clots were removed & it was found that her cervical oz was not closing because it was plugged up by clots. As much as possible was removed & she was discharged with a prescription to control the pain and reassurance that this part of the process.
  • Elderly woman brought to ER by daughter after she vomited that morning & the PSW reported her to have pale stool & orange urine (as per her full-time catheter due to incontinence). The pt was alert, appeared otherwise well & was not in any pain (she actually thought she was fine & wanted to go home!). Routine labs showed severe AST/ALT/alk phos elevation (in the 200s & 500s) & imbalanced electrolytes. She was also diabetic but did not check sugar (random plasma glucose was 27). Her renal function was also severely impaired & therefore she could not have a contrast CT so we had to get imaging of her liver, pancreas, gallbladder & kidneys via ultrasound. Gallstones were found as well as a dilated common bile duct but better imaging was needed to confirm – the plan was to improve her renal function in order to get a CT. A general surgeon consulted & made a plan with the family. Unfortunately, I was also not able to find out what happened to this pt b.c she was admitted to another service.
  • Others: young child with gingivitis (we had to do some digging to make this diagnosis!), lateral patellar dislocation (pt had to put under anesthesia for it to be reduced), 5 year old lip laceration (2 stitches – the bravest little girl I’ve ever seen; didn’t fight it and only shed a few tears), many influenza cases & falls (luckily, none serious).

I loved the fast pace of the ER; it was exciting & fun. I’m not sure I could do it for my whole life, but that’s one of the great things about being a PA – I don’t have to commit to a specialty 🙂

Pediatrics

When I was sending out feelers to hospitals in my area, I indicated I was looking for opportunities in Ob/Gyn, Emergency Med and Pediatrics, but really I was hoping for Ob or ER. The only department that reached out & said they’d be happy to have me was peds, and I was a little disappointed. I started this program being afraid of pediatrics – I thought it would be difficult to get children to cooperate for essential assessments/treatments (since they don’t understand the necessity) and that dying children would be too sad for me to handle. However, I was pleasantly surprised & relieved to learn that I absolutely love pediatrics. As I’m coming to learn, the preceptors/docs that you work with make a huge difference in your learning & enjoyment of a specialty. This doctor is held in high regards by his patients (I googled some reviews before I went – nothing but praises) and quickly learned why. He was a great doctor as well as teacher & I even went back 2 other times to his office this semester. I hope to go back next semester as well and hopefully have my 2nd year pediatric clerkship rotation at this clinic too.

One of the things I love now about peds, is that sick children are so resilient – I was imagining sadness & stress, but in reality, children are optimistic and actually can overcome a lot of adversity. There are so many success stories in pediatrics making it very rewarding. Another thing I enjoyed was how relieved parents can feel after simply speaking with their pediatrician: parenting (I can imagine) is stressful & when your child is sick, all you want is to make sure they are going to be OK, and when parents can’t do it themselves, the relief we can give them as practitioners by taking care of their kids is truly satisfying.

I noticed that this practice was very busy and that the doctor tries to see referrals/complaints within 1 week…on top of doing inpatient call at the hospital. That sort of dedication is a true sign of a good doctor. However, I also see that it is very stressful & that this would be the perfect scenario to add a PA to the practice to help stay on top of the patient flow as well as improve the quality of life of the physician. Possible job opportunity? 😉

Family Medicine

I don’t have much to say about FM; I love this field and have learned from a few amazing Family Docs. I can’t wait to do more family med!

Obstetrics & Gynecology

I had a very short day here, which was mostly Gyne. I don’t feel that I learned enough about this field to know how I feel about it, so I am excited to get more experience in Ob/Gyn.

 

April Residential Block – Vlog Style

As per the U of T PA program schedule, we had our third in-person Residential block for the last 2 weeks of April. This was a particularly exciting block as there was lots of hand-on learning, the weather was getting nice & we all hadn’t been together since December.

When I was thinking about how I would document this res block, I was stuck. I knew that there would be so much fun stuff that we would be doing, but writing about it seemed a bit boring. That’s when the idea struck me – I could make a video-blog about our 2 weeks so that I could SHOW what we were doing! I have recently been watching a lot of YouTube videos of medical students and PA students documenting their journey in the form of vlogs, and I have really enjoyed them. However, most of the channels I watch are American students. The content is interesting & informative but not always applicable to the Canadian health care system context. Then I came across a particularly interesting channel called ViolinMD, also known as Siobhan, who is a 1st year Internal Medicine Resident in Ontario. I loved seeing what a Canadian Medical Resident goes through & she inspired me to share what a Canadian PA Student goes through in contrast!

So I now have a YouTube channel with 2 videos posted: Week 1 and Week 2 of our April Residential blocks. I also provided some information about the U of T PA program schedule, how those who live out of Toronto deal with the Res blocks and some points about PA scope of practice. I hope you find them interesting and educational!

U of Toronto PA Program: April Res Block Week 1

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U of Toronto PA Program: April Res Block Week 2

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Some of the other YouTube channels I love to watch:

  • The Girly MD – A first year U of T Medical Student; love her Canadian content!
  • The Strive to Fit – A forth year American Medical Student in New York; her content is very artistic
  • Jenny Le – A first year American Family Medicine Resident; she’s balancing be a new mom while in residency!
  • James Kim – A first year American PA student; he started his journey as a pre-PA and finally achieved his goal, all caught on camera!

Distance Education in Medicine

The PA program at U of T is very unique: one of its many defining features is the incorporation of the distance education model.

Primer: (most) PA programs span 24 months straight, where the first 12 months are didactic & the second 12 months are clinical rotations.

The didactic year of this program is offered with a mixture of face-to-face and online learning. If you think about it, it makes sense: there are concepts in medicine that can be taught online by reading & watching lectures (eg. physiology, pathology) and other concepts that require hands-on learning (patient histories, IV insertion). The U of T PA program recognizes this and draws on it. I’d say the didactic year is about 65% online and 35% in person. The in-person time is divided into chunks called “Residential Blocks” which take place in downtown Toronto, on the medical campus. This is the schedule for this year’s didactic year:

  • Residential Block 1: September 2017 – In Person
  • October – December 08 – Online
  • Residential Block 2: December 11-20 – In Person
  • December 21 – Jan 02 – Holidays
  • January to April 13, 2018 – Online
  • Residential Block 3: April  15 – 27 – In Person
  • April 28 – May 04 – Holiday
  • May 06 – July 20 – Online
  • Residential Block 4: July 23 – August 17 – In Person
  • August 20 – 31 – Holiday

In this post, I am going to be explaining some of the methods used to learn medicine online, at a distance, during our Jan-April online chunk (which was the longest).

Problem-Based Learning: Online Edition

PBL is becoming common practice for learning medicine, and even though we are online, we still study cases via the PBL format. For this online chunk, our class had 5 cases to work through. We were divided into groups of 10. (PS. we also did PBL case studies in October-December). There were weekly individual assignments to guide our research/thought process as we worked through each case in a step-by-step approach. We would also meet as a group once per week, via an online meeting platform (through the U of T online portal) to discuss weekly group assignments & discuss our learning. A facilitator was present online at each of these meetings to guide our ideas and answer any questions we would have, but it was mainly run by us. In order to ensure equal participation, each group member was assigned a certain role to play: Leader (leads the meeting), Scribe (records everything discussed at the meeting), Timekeeper (to keep us on track) and Reporter (summarizes our findings & leads the final group assignment). The 5 cases we studied this semester: Hypertension, Diabetes, Lupus, Colorectal Cancer & Lung Cancer. Here is a brief outline of how a typical week would look for a PBL case:

  • Monday: read through the first section of the online case (usually History, Physical, Differential)
  • Tuesday: complete individual assignment regarding what you have learned so far
  • Wednesday: complete another individual assignment & post it to the discussion board to be discussed at this week’s meeting
  • Thursday: group meets, discusses discussion board posts & learning objectives, prepares for final group assignment
  • Continue to read through the other sections of the case & complete assignments accordingly

Overall, I really enjoyed this PBL course & felt that I learned a lot. I didn’t feel alone or confused since I had my group mates to bounce ideas off as well as our facilitator.

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An example of an online case!

Pharmacy

We were warned by the upper years that this would be the hardest course we would take throughout our entire degree, but also the most clinically relevant & useful: and they were correct. In ~3.5 short months, we learned the basics of pharmacy & prescribing as well as the indications/algorithms/side-effects/contraindications etc. for ~100 drugs. This course was divided into 3 chunks: first was prescribing basics, pharmacokinetics/dynamics, and Warfarin/INR. The second was cardiac management including hypertension, dyslipidemia, acute coronary syndrome and heart failure. The third was antibiotics, antifungals, antivirals, and corticosteroids. Essentially, this course has taught me to be competent to manage those conditions listed above – a lot of information, but obviously very useful. Thankfully, this course had a very organized instructor & was easy to navigate through on our own.

This course was a combination of weekly live video lectures and independent reading. We were also divided into small groups (of 5) and we had weekly cases to work through together (management-focused) and that we would present/discuss as a class each week. There were also weekly quizzes as an effort/incentive to ensure we were on track with the content (very easy to fall behind). Again, since our class “met” weekly online, I didn’t feel as isolated or helpless: the prof was always available to answer questions, and the weekly session discussions really helped to solidify understanding.

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So…Many…Drug…Tables

Diagnostics

This was the most independent class we’ve had so far. The majority of our learning involved textbook readings with a live review/summary lecture weekly with the prof. We studied hematology labs, electrolytes, kidney/liver/GI labs, endocrinology labs, cardiology labs, immunology/rheumatology testing, microbiology and genetic labs. We also spent a lot of time studying electrocardiograms & interpreting them. The second part of this course will be delivered May-July & will include abdominal, chest, MSK and neuro imaging.

 

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A humorous & informative ECG resource

 

Pathology

This course had many different elements, but the majority of the content was delivered via pre-recorded online lectures, provided by the U of T medical curriculum. Therefore, most of our time was spent independently reviewing these lectures. We also had some guest lectures, individual assignments & group cases.

 

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My home study-buddy ❤

 

LCE

As mentioned in my previous post, during our online chunks, we are still required to obtain clinical experience, where ever we please (usually in your home location). A new post on the experiences I had this semester in my home town will be up soon!

Exams?

It is a rule for the program, that if your permanent residence is within 100km of downtown Toronto, you must write all midterms & finals on the downtown campus. The majority of our class fits this criteria, and therefore write their exams there. However, for myself & others, we could voluntarily commute to downtown and write our exams for free, or we can find accommodation at proctored exam sites closure to our residence. Some of these sites are free, but most require a fee. These sites are usually other university/college campuses (most expensive), libraries or adult learning centers. Costs for these sites range from free to up to >$100 per exam. Thankfully, the program assistant does a lot of work to find students close & affordable accommodations. For myself, I have tried 4 different sites (2 of my favourite ones closed down or could no longer accommodate me) but I am grateful not to have to commute downtown for every exam.

Advantages

The online model of this program was one of the main things that drew me to it. For those who do not live in downtown Toronto, it is very appealing to be able to stay in your home location & not have to relocate, especially to a very expensive city like Toronto. I’m happy that I’m able to save money by living at home as well as being able to spend lots of time with my family & friends.

Challenges

One of the main disadvantages of prolonged online chunks of time is feelings of isolation. It can get lonely when you are studying by yourself in your room. However, luckily our class is very close & I was able to connect/speak with many of my classmates daily, which helped. Another concern of studying all day at home is lack of movement & exercise. Although this is a problem with anyone in an intense program, it’s even more pronounced when you literally don’t need to move from your bedroom to get to class. I struggled with being stuck in my house a lot in November, but this semester I made a daily schedule that included walks & workouts, so I was able to not feel trapped & get more exercise.

 

*Overall, this last semester was intense & tough, but I made it through the dark tunnel and am out on the other side! I have learned how to maximize studying at home, while combatting the challenges that come alone with it. As per the schedule I posted above, we only have ~2 months more of online studying for didactic year before our last residential block, and then it’s off to clinical rotations!

 

LCE – Semester 1

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
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My essentials for my first day in FM

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.

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I love clinics where scrubs is the attire!

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!

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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.

Definitions:

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.

The Morning:

  • 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.

U of T PA Admissions

October of 2016 was the time I began preparing to apply to the U of T PA program. Since it’s that time of year again, I thought I’d share my admissions experience as well as some helpful tips! Some basic admissions stats: it was circulating on last year’s forum that there were ~650 applicants (not official) last year to the U of T PA program. Of those 600, 88 were invited to the MMI. And of those 88, 30 applicants were accepted for the class of 2019.

Admission

Step 1: Read & Evaluate

Before you put up your money & effort to apply to the program, make sure you know what you’re getting yourself into. This is the most important step. My #1 piece of advice for this step is to read. Get your hands on any/all info about the PA profession (Canada and other countries); what a PA does (or doesn’t do), what PA education entails, job opportunities for PAs etc. Read about other people’s opinions on PAs: get the positives and the negatives. Why do some physicians oppose while others praise PAs? What are other allied health care professional’s views on PAs? How do PAs work in interdisciplinary teams? What is the political, regulatory, financial state of PAs in Canada? All of these things you should be able to answer, even briefly, before you apply to a PA program. From this info, you should be able to rightly determine whether or not this is something that you want as a career. And then, you should be able to figure out whether or not you would be a great PA.

I also want to emphasize that the PA program is NOT intended to be a stepping stone to another profession (i.e medical school). The profession is working hard to lift off the ground & become established in Canada, and to do so, a strong body of PAs advocating for themselves is what is needed. So if you become a PA just to go to med school, you’re really just hurting the profession & it’s population.

Story-Time: How I Learned About PAs

In my 3rd year of undergrad, I took a healthcare systems class and we had to write an essay about a controversial healthcare topic. I thought this was a perfect opportunity to research the profession (and have it count for something other than my personal knowledge). As I continued my research, I quickly realized I wasn’t going to the get the full picture just from writing this essay. On my “undergrad bucket list” I wanted to be involved in a research project, so the next semester I found a professor to supervise me (she had done work with the midwifery profession) and set out to conduct a systematic literature review on PAs. My plan was for this to be a pilot study to orient me to the body of literature so that for my thesis in 4th year, I could do an actual study on PA regulation in Ontario (but I never made it to 4th year to do so). Anyways, during this literature review, I essentially read every single piece of academic literature on PAs in Ontario (and subsequently in other places, which I had to discard from my study, but still read them anyway). This was a conquerable goal for me as a 1 person research team as an undergrad because the body of literature on PAs in Ontario is not that big (still a lot to read for 1 person). So this was how I came to have a strong knowledge of the PA profession. You can still do this research on your own, without intending to publish it & follow a scientific method. GoogleScholar will be your best friend!

Other helpful resources that I used to become familiar with the profession:

Step 2: Requirements

Now that you have decided being a PA is your dream job & you know everything there is to know about PAs, you can start looking at applying to schools. The 3 civilian programs in Canada (McMaster, U of T, Manitoba) all have different admission requirements. Specifically for U of T you need:

  • Minimum 2 years of undergraduate study
  • Minimum GPA of 2.7 (although the average accepted GPA is much higher…)
    • GPA is cumulative (cGPA), not weighted
  • Minimum 910hours of healthcare experience (the more clinical, the better)
  • English language proficiency proof
  • Supplemental application (mandatory)

For U of T, there are also preferred admissions criteria (although I really think the course ones should be required because it would be really hard to do well in the program without them):

  • Full year course equivalent of Human Physiology, Anatomy & Chemistry
  • Ontario resident
  • Clinical experience that is recent, paid, & direct
  • Resident of Northern Ontario

More specific information can be found here: http://www.paconsortium.ca/admission-requirements

I will hopefully be able to survey my class to get insights into the demographics of who was accepted in our year (if I’m allowed!). So stay tuned for what our class GPA was, the type of experience & education everyone had!

If you meet all of the requirements, you make an application on OUAC (fee involved) & apply to your program of choice.

Step 3: Supplementary Application

This is the part of your application where you really get to show the admissions committee why you would be a great PA (fee involved). You need to show yourself off, brag about your accomplishments and skills. And you also need to not write this last minute in a short amount of time. Take your time with these questions; think them through; edit and re-edit your answers. Perfect them. I personally worked on mine with my career guidance counselor through my University’s career center. While she was not able to basically write my answers for me, she was able to help me take the answers I had written and edit them to be more articulate. I would highly recommend working with your institution’s career center (everyone I know who has been accepted to a professional program has done this).

This section is where you’ll also be able to use all of your knowledge of the PA profession and apply it to your answers. You’ll be able to fit together your experience/skills with what a great PA is.

Step 4: MMI

While it is a huge relief to receive an MMI invitation (competition just went from 649 people to only 87 people) the stakes are still high. ~65% of applicants at the MMI will still be cut. Not to scare you, this just means you gotta majorly prepare.

I heard many people on forums say to read some book called “Doing it Right” or something, but I personally never read it. I think some of my classmates did. However, I have a different piece of advice for those of you in your undergrad: take a variety of health courses. While knowing your biology and chemistry is important, they won’t help you in the MMI. What I found prepared me best, were the courses I took in undergrad including:

  • Social Determinants of Health (don’t bother going into medicine without knowledge on this subject, it changes your whole perspective)
  • Public Health/Health Promotion
  • Aging & Society
  • The Canadian Healthcare System
  • Philosophy
  • Medical Ethics
  • Sociology
  • Psychology etc.

If you’re out of school & have not taken these courses, this technology era is to your advantage: do some self-teaching & read about these topics online or find good textbooks. I recommend Social Determinants of Health 3rd Edition By Raphael for a good Canadian context.

Having a broad understanding of the non-biological aspects that impact human health will not only help you in the MMI but also in your medical career. Seriously, take these courses. Thank me later. These also helped me greatly with my supplemental application (*add to step 3*).

SDOHGraphic

In addition to building up your body of knowledge, I utilized my career centre for MMI preparation. At UW specifically, they had online modules regarding MMIs (basically a mini online course) & also practice sessions. I practiced with my career counselor individually & received feedback and also in a realistic mock MMI, which was basically what the real thing was actually like. I took notes on the modules & studied them right up until I walked into the Michener Institute for my interview. I prepared answers to typical medical school interview questions (although none were asked) to get a flow of how I would describe myself (it’s harder than you’d think).

Since I’m about a 2 hour drive from downtown Toronto, I stayed overnight in a hotel for the interview. I don’t have a car & my parents were out of town so I had no one to drive me. Plus I did not want the stress of Toronto traffic & parking. So staying overnight, the night before, worked well for me. I was able to be comfortable and in a stress-free state of mind going into the interview.

Other general MMI tips:

You’re In!

So there you have it: If you followed steps 1-5 correctly, you should be accepted to the PA program 🙂 (I am not liable if you do not). Just kidding, everyone does this process differently and this was just the way I went about it. I hope you found it helpful! I will go into more detail in another post about examples of clinical hours (since that’s always a HUGE question since the program doesn’t explicitly say what is considered good & bad). Stay tuned!

 

*Disclaimer: After posting this blog entry in October, I was elected to be the Year 1 Student Representative on the Admissions & Selections Committee for the U of T PA Program. The advice given in this blog is purely from personal experience & the path I took to become a successful applicant. The information posted here is in no way “official” nor reflects the views or confidentiality of the committee.

University of Toronto PA Program – Month 1

Preamble:

OK – I have sat down at my computer to write a post like this, over 10 times. I hesitated diving into this documentation of this program before writing a dedicated entry on what the PA profession is, since I still have a lot to learn about it. And that’s usually what I do when I’m stuck on something…I leave it, and leave it, and don’t touch it. But I decided to just get over the hurdle, ignore what I’m stuck on and start writing about the program itself. I would like to be able to document my journey through these next 2 crazy years for myself & for self-reflection, but also for those interested in the program to get a good understanding of what it entails – there’s no better time to write about your experiences than while they are happening! Before I knew it, my first month was done and I hadn’t written a thing, so I’m starting now and hope to continue all the way through! So here it is:

 

Physician Assistant Professional Degree Program

I will insert my “elevator speech” here as a brief primer on what a physician assistant is: “A Physician Assistant, PA (also called a Physician Associate in other countries), is a mid-level clinician who works under the license of a physician in any setting to practice medicine by extending physician tasks. Under medical directives, PAs are trained as generalists to perform all/any physician-delegated tasks, with room for on-the-job learning to increase their scope of practice. PAs can do most things a physician can do, and can practice in any area of medicine they can be hired into. They are NOT the physician’s assistant. They differ from Nurse Practitioners.”

So essentially, the PA program is a professional, second-entry undergraduate degree program under the faculty of Family & Community Medicine (at the University of Toronto). In Canada, there are 4 PA programs: University of Toronto, McMaster University, University of Manitoba, & the Canadian Armed Forces. Generally, the program is a full-time, 24-month long curriculum delivered non-stop for 2 years that merges didactic & clinical training. It’s really just a condensed version of medical school (PA = 24 months, Med = 32 months, Difference = 8 months). Each PA program is structured differently, and since I am enrolled at U of T, I will be describing the U of T format.

When you graduate from an accredited PA program in Canada, you are eligible to write the certification exam. Although you are not mandated to pass the exam to practice under a physician, the likelihood of being hired without a successful exam score is low. Once a PA is hired (by an institution, family health team or private physician), they start out on the job with similar competencies to a first year medical resident – they have a lower level of autonomy, are still learning/checking in the with supervising physician and are receiving income. As the PA continues to learn in their workplace, they gradually have more autonomy & have less direct physician supervision, the same way a medical resident would. The only difference is that there is no “official” graduation from non-autonomous, to autonomous practitioner. But while you are always legally working under a supervising physician, the autonomy you can gain can be very high. I will make another blog post regarding how PAs actually practice medicine.

The Consortium of PA Education – U of T, NOSM & Michener

Although I said I attend the program at U of T, the program is actually a consortium that includes NOSM (Northern Ontario School of Medicine) and the Michener Institute, but is centrally delivered through the U of T Faculty of Medicine. This program is unique in that it has a distance-education structure with a mission that focuses on “building a foundation of social accountability, particularly to rural, remote and underserved communities.”

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What does distance-education look like in medicine? The way this program is structured, students are required to be physically present in Toronto for learning clinical skills and other hands-on learning (such as Anatomy labs), which are combined into  a few consecutive weeks, called a Residential Block.  For this first year, residential blocks are as follows:

  • September 03 – 30, 2017
  • December 07 – 20, 2017
  • April 09 -27, 2018
  • ~July 23- Aug 20, 2018 (Not yet official)

During these Res Blocks, students are basically in class 8 hours/day learning things that you can’t learn online (how to listen to heart/bowel sounds, how to do a vaginal speculum exam, locating the phrenic nerve on a cadaveric specimen etc.). The December, April & August Res Blocks are also the time for final exams. (Aside: Midterm exams are held at proctored centres nearest to the student’s permanent residence).

FYI: Living accommodations for residential blocks are the responsibility of the student. AKA the program does not provide/pay for living accommodations. The majority of my class lived in/moved to Toronto. A few commuted daily from Mississauga and Brampton. Myself and a few others got AirBnB’s for the month. All others lived with friends/family in Toronto for the month.

Day 1: September 03, 2017

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This day was kind of a blur and was packed full of orientation information & attempts to remember names. There were lots of opportunities to introduce ourselves, and team building activities.

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The Marshmallow Challenge. Our group came 2nd!

We finished off this day of firsts with a beautiful Stethoscope ceremony. As a class, we had our family/supports come to the event and watch as each of us was decorated with our stethoscope, signifying our official entry to the PA program. There were many guest speakers, current/past PA students and faculty. The lovely event was put on by the 2nd year PA Student Association (PASA) and was much appreciated 🙂

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The Class of 2019!

September Residential Block

Here’s what the Res Block for September 2017 looked like for me:

Clinical Skills

Definitely the meat and potatoes of Res Block. Essentially, there were various topics that we had to learn regarding physical exams (Respiratory, Cardio, Abdomen & Pelvis). These were covered in 2 sessions:

  • Session A (4 hours) included a summarized lecture of the components of the exam:
    • Brief anatomy, questions to ask in the history, specific things to look for on observation, and physical exams to perform such as auscultation (listening with the stethoscope), percussion (sound vibrations for dullness), vaginal and/or rectal exams.
    • After lecture, we had the opportunity to go to different stations in groups and practice the exams on each other or on rubber/plastic “patients” (for obvious pelvic reasons)
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PSLs mandatory
  • Session B (4 hours) was the time to put everything you just learned to practice:
    • We were divided into small groups of 6 and went around to stations that had Standardized Patients/SP (patient actors) and a facilitator
    • There would be 1 student assigned to take a focused history and 1 student to perform relevant physical exams, as per the patient STEM (description of the “patient” and what you need to do)
    • The students and patients would act out their roles accordingly, and after the encounter, the student would get feedback from the SP, the facilitator and the peers in the room. It was very stressful but also rewarding when we all could see our own progress!
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First Session A: Vitals

We had up to 2 topics/week (meaning 16 hours/week of clinical skills) and there was a lot of reading to do. For example, for the abdominal topic, you couldn’t just show up to session A knowing nothing, you had to come prepared to practice what you had read! You had to read about relevant questions to ask in the history (OPQRST of abdominal pain), you needed to know the signs/symptoms of common differential diagnoses, you had to know what sort of physical exams to perform, how to perform them and when it was necessary to do so. Basically what I’m trying to get across, was that I spent most of my September preparing and practicing clinical skills. I definitely have learned a lot!

Anatomy

2 hour labs, 3x/week with cadaveric specimens. Online lectures & readings were expected to be done upon arrival to the lab. A lab manual was provided with focused topics and diagrams for labeling. On the last day of class, we had a Bellringer-style exam in the lab: ~30 stations set up with specimens that had pins/markers pointed to a specific part. Questions were asked about each pin such as “Identify; Name one branch off of the specified vessel; *on X-ray* Identify X, be specific” etc. Topics covered were Thorax, Abdomen, Head&Neck and Pelvis. It was interesting because although I had taken anatomy with cadaveric specimens in my undergrad, we had not cover face/neck or pelvis so I was able to learn many new muscles/arteries/bones! The TAs were great and labs were a lot of fun.

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Brought a piece of UW with me

Intro to the PA Role

During Res Block, we essentially just had a few lectures in person as an introduction to the course. There were 3 in-class quizzes and a few modules we had to do at home (work place safety stuff). This course is definitely important, but was not the focus of the Res Block since a lot of the learning can be done online.

Other Sessions

We had various sessions from guest speakers, which included:

  • Study strategies & Learning preferences
  • Canadian Association of Physician Assistants – Discussing the association & membership
  • Interprofessional education introduction
  • Various debriefing sessions with admin in the program – Discussing areas for improvement and areas of strength

Intro to Physiology

We had 2 in class lectures as a primer on physiology before we started the online course on October 02. The session was nice to meet the profs/TAs but was not that helpful honestly (since all lectures are videos that are posted for us to watch whenever).

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Ending our Res Block at Mill Street Brewery

Transition to Learning Online

The rest of the first year (October, November, January, February, March, May, June) is didactic (basically knowledge acquisition through traditional teaching) online. There are lectures/group discussions held via Webcast and there are recorded lectures/videos students to go through on their own time. There are few structured time sessions each week, meaning that you have the freedom to do your studying when you want…as long as you cover everything before the exams. There is a downfall in a short professional program/compressing med school, and it is that each class has ~7 hours of lecture/week (regular undergraduate class is 3 hours/week). So although you have freedom to arrange your schedule as wanted, it’s definitely not “easy” to do the work just because you’re home. It requires vigorous time management skills and discipline in order to succeed. I’m writing this post on my first day back home and already I feel like I’m behind! Here is my first semester online schedule:

  • Physiology: 51 recorded lecture sets, ~45mins/lecture, 1 hour live web-cast tutorials/week, ~11 weeks long, 6 quizzes, 2 midterms, 1 cumulative final exam December 07/2017.
  • Anatomy: 10 modules (1-4 done in September), 1 bell-ringer lab exam (completed in September), 1 midterm, 1 cumulative final exam December 08/2017.
  • Clinical Skills: Transitioned to electronic Problem Based Learning (ePBL) involving 6 case studies with various assignments throughout the term. Oral presentation done in September. Assessment of actual clinical skills learned in September (Cardio, Resp, Abdo, M/F Pelvis) will be assessed via simulation in December. There is also a written final exam in December regarding core competencies.
  • Intro to the PA Role: Various lectures, quizzes, essays, reflections & modules. No recorded lectures, just reading & live Webcast discussion-style lectures.
  • LCE: Longitudinal Clinical Experience … coming soon

I still have yet to navigate this part of the program (moved home 1 day ago) but will keep you updated on how it all goes! I definitely have a FULL schedule so I must get back to physiology. Stay tuned for more info on LCEs & my experiences.

 

 

 

OR 101

This past week, I was fortunate enough to have my first Operating Room (OR) experience. I have had many questions about how I got the opportunity, what I saw and what I experienced so I thought I could make a quick blog post to address these topics!

Disclaimer: All clinical explanations are very basic. Do more research at your own discretion. All images are from google.

How?

As many of you know, I currently work for an ophthalmologist (eye surgeon) and she was kind enough to invite me to one of her Strabismus OR days at Grand River Hospital. Since she doesn’t get many of these blocks, I immediately took up the offer and it was up to me to gain observatory privileges. The hospital doesn’t let just anyone into the OR to watch, so I had to find and fill out quite a lot of paper work beforehand. Luckily, since I have been working with the HELP program at GRH (read more here) I had many of the “tests” completed (this included the blood work, TB skin test, police check etc.) so it was fairly straight-forward to get OR access for me. The forms I had left to fill out included my personal information, the Dr.’s signature, type and date of surgery and other logistics.

Since working in a surgical specialty, I have been considering it as a potential career path and I was so glad to have the opportunity to see if surgery was for me, before applying/making any decisions. It was definitely not what I was expecting and it was not like Grey’s anatomy (mostly).  If any of you are interested in observing surgery or are considering it as a career path, I would recommend volunteering in the hospital or getting to know some surgeons. It’s definitely possible to observe without working for a surgeon, you just have to build connections (and ask nicely!).

What?

As mentioned, I was observing a Strabismus surgery. This surgery is done on the rectus muscles (side muscles) of the eye to change the muscle’s position, weaken or strengthen the muscle in order to make the eye straight. Patients receiving Strab surgery have one or both eyes turning inwards or outwards, obscuring their vision. If prism therapy (making them look through prisms in their glasses to adjust where they look), patching therapy or other non-surgical interventions are unsuccessful, strabismus surgery is recommended at a young age in order for the brain to adapt to/adjust the vision. The older you are, the less likely the surgery will be able to fix your vision (the actual eye will look straight, but your brain won’t interpret the vision and it will still seem like you are seeing cross-eyed). Strabismus surgery can still be done on adults, but mostly for cosmetic purposes.

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The surgeon can perform muscle resection (strengthen) or muscle recession (weaken) in order to turn the eye straight. All of the surgeries I observed were both eye, muscle recessions. Each surgery took about an hour (because all 4 patients were both eyes) and she performed recessions on medial (inner) and lateral (outer) rectus muscles – lateral is much easier since the bridge of the nose does not get in the way.

The eye is prepped with a lid speculum (to hold the lids back) and it must be held in place/fixated with forceps (since we need to get to the side of the eye). Then an incision is made in the outer “fascia-like tissue” called the conjunctiva of the eye. The incision can either be Limbal (less damage to tenon’s capsule, but also much more uncomfortable recovery) or a Fornix incision (less anterior segment blood supply damage, comfortable recovery). Dr. McAlister performed Fornix incisions since post-operative comfort is a large benefit and she doesn’t find that there is ever much difference in scarring of the tenon’s capsule either way.

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Once the conjunctiva is reflected, the muscle is isolated on a hook, cut appropriately and reinserted with absorbable stitches. The conjunctiva is then stitched up and that’s really it. The surgery is very straightforward in concept, but the most difficult part is placing the muscle at the exact measured distance and stitching it in place. The surgeon measures and remeasures multiple times to ensure that it is accurate. Also, since the muscles are so small, it’s very delicate work that takes concentration.

While preparing for the surgery, I watched videos on YouTube of the procedure and read my Ophthalmic textbook, and I have to say that it was not as bad in real life as in the video. I do get squeamish and it was difficult for me to watch the video, but somehow in-person it wasn’t so bad. It could be because I was prepared for what I was about to see, the Adrenalin in the excitement or how calm everyone in the OR was. Either way, I actually enjoyed the surgeries (I was worried I’d feel faint/nauseous) and I was able to stand right beside/behind the surgeon to get a great view.

Orthopedic Surgery Too?

Whilst talking with the incredibly nice staff and anesthesiologist in between and during procedures, they offered to talk to one of the practicing orthopedic surgeons to let me observe a knee replacement. Since everyone there is SO NICE, I was able to observe that surgery as well. The operating room was much bigger and there were 5+ tables of tools for the surgery (unlike the single tray in the strab surgery!) with much more people working in the room. Overall, the orthopedic surgery was much more intense and I stayed pretty far back, mostly because it was much more gruesome than I was anticipating. Drills, hammers and sheer force were all elements that I had not encountered during the eye surgery. I didn’t stay for the whole surgery for a few reasons: 1) I was getting pretty grossed out at all the flying bone material, drilling sounds and blood 2) I wasn’t read up on the surgery, so I didn’t really know what all they were doing and didn’t want to interrupt asking what the surgeon was doing all the time 3) it was very busy in the room so I was just glad to get out of everyone’s way.

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For some reason, I was worried that eye surgery would be much more difficult to watch because there is something so human about eyes. I thought if it was a limb or something else, I could easily de-humanize it as an object and not feel grossed out but that wasn’t the case. Especially since I had experience with cadaver prosection, (read more here) I thought I could handle ortho surgery, but there’s much more blood and the tissue is so alive, it made it harder for me to watch. It could’ve also been that I wasn’t prepared for what I was going to watch or the loud sounds… (sounded like construction work!). Either way, I’m glad I had the opportunity to experience it and I do not regret it at all.

My Experience

Unexpectedly, I learned a lot more about the OR than just surgical procedures. My day started at 6:30am when I woke up, to be at the hospital for 7:30am. I met the surgeon on the main floor and she showed me to the OR “department.” It’s like it’s own little section of the hospital that felt like it’s own building (very isolated). I got to the locker room (verrrry small and squished) where I had to change into the hospital’s scrubs and put on a hair net.

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Then we headed to the one of ten operating rooms, put on a surgical mask and scrubbed. But scrubbing isn’t how it is in Grey’s anatomy any more: The foot-peddle sinks to wash hands and arms are still outside of each OR but today, gel sanitizer is used instead. Similar to grey’s anatomy however, you do keep your hands up and don’t touch anything until you’re in the OR where the OR nurse puts on your gown and shoves gloves over your hands. One thing I wasn’t expecting, was how bright the OR actually is: Grey’s Anatomy always had a very dark OR but everything was actually well lit (Grey’s was my only OR reference before I got to do this!).

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Next, the surgeon and I talk to the family (the patient is usually a child) and have a “time-out.” A time-out is an official confirmation that we have the right patient and they’re getting the correct treatment: we get them to state all of this information out-loud and we confirm it. The anesthesiologist also meets the family with us and discusses the anesthetic briefly. Then, we take the child back to the OR, lay him/her down, reassure them, the anesthesiologist assistant (see what they do here) & the anesthesiologist start the IV, intubates the patient (tracheal tube) and sets up blood pressure/heart rate monitors. Something very interesting I learned, is that there a common parasympathetic reaction that occurs in children when the rectus muscles of the eyes are pulled. Their heart rate drops and it’s actually life-threatening. So before surgery, the anesthesiologist treats the patient with atropine, which increases their heart rate to avoid the parasympathetic reflex. (I thought that was pretty cool!)

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Once the patient is under general anesthesia, sterile gowns are placed all over the patient except for their face. Betadine (an iodine-based antiseptic) is spread across the face on all skin to disinfect the surgical field. Then the surgery is performed. About 5mins before the surgery is over, the surgeon tells the anesthesiologist the 5min mark and he/she begins to slow the patient off the antithetic. I found the anesthesia part particularly interesting; one of the patients kept unconsciously holding his breath every few minutes so the anesthesiologist had to keep a close eye on him and manually ventilate – The anesthesiologist does so much!

Another interesting thing about anesthesia is that there are different types. For the eye surgery, the patients were put under general anesthesia, putting them completely to sleep. However, in the knee replacement, the patient was given spinal anesthetic (similar to an epidural, just in a different location in the back) and laughing gas to make them sleepy, but not fully unconscious. This means that a “wall” needed to be put up to block the patient’s view of the surgery in case they were lucid enough to realize what they were seeing. One of the main complications during surgery is due to being put unconscious from the anesthetic so the less that can be used, the better so when it’s not necessary, it isn’t given.

After the surgery, the betadine (it’s like orange/brown looking) is cleaned off of the patients face, they are extubated (tube taken out), are transferred to a moving bed and are wheeled off into recovery. The surgeon then signs a bunch of papers and makes notes about how the surgery went and then goes to tell the family that everything went well (or not well depending).

And that’s pretty much what I experienced 4 times in a row! Now that I’ve finished explaining everything, I realize that I really did learn a lot in one day and I’m so thankful for the experience.

The Flu Shot: Making Your Immune System Stronger!

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To get more information on topics I don’t cover such as what’s in the flu vaccine, influenza symptoms vs. the common cold and additional ways to protect yourself from the flu, see Ontario’s Flu Facts!

Here’s Why

I thought I’d make a short blog post to spread the importance of getting your flu shot before the flu starts spreading itself! We are so privileged to have free and easy access to vaccinations like the flu shot every year that we as a community should do our part to keep our population safer. I could talk all day about the medicine behind vaccines and how they work and how there are no adverse effects, but it’s almost as useless as explaining why the sun rises everyday. So here are some reasons why you should get the flu shot, other than fearing you’ll get autism, and not all of them revolve around you! For more information on the medicine behind vaccines, see the Centre for Disease Control and Prevention’s vast evidence.

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“The Flu Shot Doesn’t Work”

While it’s true that the flu shot is not 100% effective, it can have enormous impacts on population-wide immunity. The only way you could still get the flu after receiving the flu shot is if you were already exposed to the virus beforehand, or if there is a new strain of the virus circulating.

People who get the flu shortly after receiving the vaccine often attribute the sickness to the vaccine itself, but this is a very common misconception. The flu vaccine takes several days to build up your immunity and if you were exposed to the virus before your immunity is built, you will still get sick. It is very important to note that in no way, shape or form can receiving the flu vaccine give you the flu. See here for more information on why. You can avoid getting sick before getting the flu shot by getting it early on in flu season and taking sanitary measures (washing hands thoroughly, not touching your eyes/mouth/nose excessively, etc.).avoid-flu

If a new flu virus evolves during flu season, the vaccine that you received will not protect you against it. But that isn’t to say that the vaccine hasn’t already protected you from the other strain that has been buzzing all around you! If you think of immunity as a protective wall around your body, why wouldn’t you take the free and accessible opportunity to add just one more brick to that wall?

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“I Don’t Need the Flu Shot, I Don’t Get Sick” (or “I Don’t Care If I Get Sick”)

While this may be “true” for some of you, chances are that you will eventually get the flu at some point in your life if you never receive the vaccination with the current population vaccination rates. If the healthcare system knows that many people do not get the flu without the flu shot, why would the public health system spend a huge chunk of valuable healthcare funding to advertise the flu shot and make it so accessible? Simple answer: They care about more than just YOU. Most of the time, the average, young, healthy adult can get the flu, be really sick and then recover in a few weeks. And while you may fall behind in work or school and feel terrible for a few weeks, by getting the flu you’ve actually increased the chances of getting other people sick in your community. These other people could include those who are at a higher-risk for developing complications from the flu that are life threatening.

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“Herd-Immunity” Would Rock

These high-risk individuals are those with cancer, diabetes, heart disease, lung disease, children under 5 and older adults over 65. If 70%of the population got vaccinated, anyone else in the population who didn’t/couldn’t get vaccinated would be protected, as per the herd immunity theory. And the high-risk populations who are prone to the vaccine not being as effective would also be protected. But even with the accessibility, the lack of financial requirement and wide variety of locations and times to get the vaccine, only 33% of Canadians receive the vaccine. If nothing else, you should get vaccinated to protect all of the babies in your community under 6months old who are not old enough to get the vaccine. Babies getting the flu is a serious matter that can result in numerous complications and if no one was sick with it, no babies would get sick with it. In addition, the more people infected with the virus, the more powerful and able to mutate the virus becomes, which is dangerous to everyone! It’s simple logic: If no one gets the flu virus, no one will spread the flu virus!

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Just Get the Shot!

As I’ll say one more time, we are SO lucky in Canada to have immediate and FREE access to the flu vaccine in all sorts of facilities and at all sorts of times – there really is no reason why you can’t make it out to a flu clinic! Even being one of the most healthcare-rich provinces in Canada, Ontario is actually seeing a decline in vaccination rates. So do your part for your province, your community and for yourself, and just get the shot! (Don’t be scared of a little needle).

Even though I would love to believe otherwise, I know there are people hoping to work in or have started working in the healthcare industry or with at-risk populations who still don’t get their flu shot. All in all, it’s just unethical that you would put your patient’s life at risk just because you won’t get the flu shot. So please, if you are working with children, older adults or anywhere in the health field, get your shot!

Where to Get the Flu Shot

Most family doctor practices, walk-in clinics and even local pharmacies offer flu clinics…for free.

There are also additional flu clinics set up large-scale in public areas such as recreation centres and schools during peak flu season (October-November).

University students can get free flu shots on campus (at University of Waterloo for sure) through health services!

You can even use this web-service to find flu clinics near you in Canada.

Keep an eye out for your local flu clinic postings!

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Summer 2016: All Eyes on the Clinic

 

ophthalmic-assistThis summer, I can confidently say that I have started on my path in healthcare. I have learned so much about many different aspects of healthcare and I’m eager to share my experiences! I was so fortunate to be hired at multiple places this summer, so I thought I’d share all the different things I’ve done at each practice.

Optometric Assistant

This is where I definitely got my foot in the door where healthcare is concerned. I went around to every Optometrist I could find in the area to apply and was lucky enough to be taken on by Dr. Linda Daniar. She is a very experienced and respected Optometrist, running her own practice along side an Optician to provide optimal eye care. After getting a lens prescription from her, you could turn the corner to see the optician to pick out frames to order your glasses right then and there.

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I got to try on a lot of glasses lol

Definitions:

  • Optometrist: An Ocular Doctor (OD) who studies eye care in a four-year long University post-graduate program. They mostly work with refraction, providing lens prescriptions to put in glasses to improve vision. They also work a lot with simple eye infections and can do diagnostic eye tests to refer to Ophthalmologists.
  • Ophthalmologist: An eye surgeon who focuses on eye pathologies with mostly surgical cases. To become an Ophthalmologist, you must attend 4 years of medical school and then 4-5 years of Ophthalmology residency.
  • Optician: An ocular technician who studies lenses and eye care in a two-year long College post-graduate program. They learn a lot about the physics of how glasses lenses work and how they are made and how to fit a person with the right lens and frame.

Working for Dr. Daniar is awesome. Since this was my first exposure to a medical practice, the most important thing I learned was the work flow of a medical office. I learned how the referral system works between doctors in different specialties, how to read/write consultations and referrals, OHIP billing, patient filing etc. Clinically, I learned the basics of auto refraction (a diagnostic machine that essentially gives a glasses prescription automatically). We did this test on children (who’s eyes change rapidly as they grow) and new patients. I learned what prescriptions (-1.00 vs. +3.00 vs. cylinder and axis) actually mean about the anatomy of the eye.

Having an Optician in the office was also an asset to what I was able to learn. I learned a lot about how to fit patients for bifocals (progressives and lines) and how to match the patient with the perfect type of lens for their needs. I learned how to take measurements for lens orders and helped so many people pick out their perfect frames.

Although I was loving my time with Dr. Daniar, I wasn’t able to get full-time hours, which is why I went job searching again.

Pharmacy Assistant

After diligently researching my way through the entire medical field, I found a job-listing for a pharmacy assistant at a Shopper’s Drug Mart. Upon being hired, I was SO excited! I was especially excited that everyone else who worked in the pharmacy had completed some sort of pharmacy program and that I was just going to march right in and start working without all the studying.

This job definitely challenged me the most with regards to all that I had to learn. I really had no idea how the pharmacy field operated and I felt really overwhelmed for the first few weeks. I felt especially overwhelmed since I was thrown into a position in the pharmacy that had way more responsibility than just filling prescriptions: I had two weeks to completely take over for the person in charge of blister packs.

Blister packs (also known as compliance packs) are for people who have lots of medications to take at different times during the day: They are essentially little plastic bubble containers with all of your pills in it for the week that you have to take at breakfast, lunch, dinner and bed time. (See the pic below, it’s hard to explain in words).

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A blister pack

So pretty much, I had to fill on average 10 prescriptions per person and then sort their pills into the correct time 1 week at a time – It is very easy to make mistakes and very important that there are no mistakes. So not only did I have to learn how to fill prescriptions (which includes learning the HealthWatch computer system, all of the medications, how to read prescriptions, how to charge drug plans etc.) but I had to it for 10x more medications than normal and then sort them perfectly by hour of the day. And since patients who require blister packs are often on medications that change frequently, I always had to keep track of when a prescription was cancelled, added or if the dose changed for each patient. And I had only 2 weeks to learn all this before the person who I was taking over for was leaving and then I was the sole person responsible for making these packs for over 150 patients.

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A very complex blister pack that took me a long time to complete. Very satisfying!

Luckily I learned very quickly and soon became a compliance pack queen and learned so much about pharmacy. I know a fair bit about many common medications for heart conditions, diabetes and various mental illnesses (there are a lot of meds). Becoming familiar with many medications has really helped me in other medical fields and I believe will be a huge advantage to me later on in my career. I also learned sooooooo much about how pharmacy in Ontario works in general and what retail Pharmacists do. For instance, I learned how important Pharmacists are in actual patient care: They don’t just get a prescription from a doctor and fill it, they are crucial in detecting possible drug interactions and altering your medications to avoid them as well as being able to prescribe generic drugs over brand name (if the Doctor ordered brand name) and making sure dosages are appropriate for patients. I learned about how drugs are distributed throughout provinces and what happens when the province over uses it’s supply. Pharmacy really is it’s own world in healthcare and is very difficult to understand until you are fully immersed in the system. I am very thankful to have gotten the opportunity to learn so much so early on in my career. Although this job was very educational, what I didn’t like about pharmacy was the idea of working for a corporation and the lack of clinical skills I was learning. I’d say that my role in pharmacy was secondary care (although pharmacists directly provide primary care) since my work was “behind the scenes” to the patient. I was more interested in pursuing medicine versus medication, which is why I went job hunting one last time…

Ophthalmic Technician

Since I knew I wanted a job that was more clinically focused, I searched the city for clinical jobs I could apply to that didn’t require a specific certification. With the help of many forums and google-searches, I applied to areas like Podiatry (feet), Physiotherapy, Chiropody and Ophthalmology (eye pathology and surgery). My experience in Optometry landed me the best job I’ve ever had: An Ophthalmic Technician for Dr. Chryssa McAlister, who I believe is one of the best doctors I’ve ever met.

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Although Dr. McAlister is paper-less, the other Dr.’s in the office have such pretty files!

 

Dr. McAlister is an Ophthalmologist who specializes in Cataract surgery, Glaucoma treatment with laser surgery, Strabismus surgery, Lucentis injections and many other ocular pathologies. She works in a practice with two other Ophthalmologists and the office atmosphere is amazing where I can learn so much every single day from many different people. I worked most closely with a fellow technician who is currently an Optometry student at the University of Waterloo. She knew a lot and taught me so much. It was really nice to be working along side another student since everyone else in the office was working there as their career. Whenever I had a question about anything, everyone was always very willing to help/teach me and I am still learning more every day.

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The textbook I use often to look up specific cases and how surgeries are performed.

Definitions:

  • Cataract Surgery: When the lens of your eye begins to build up calcified proteins, it clouds over and impedes light from entering your eye (you can’t see clearly). An Ophthalmologist can remove the lens and replace it with an artificial lens so that you can see clearly.
  • Glaucoma: Glaucoma is very complicated and is a set of diseases that essentially causes high pressure in the eye, which can damage your optic nerve. Ophthalmologists monitor and manage glaucoma and can use various laser treatments should eye drops and medications not be sufficient.
  • Strabismus: This is when the alignment of your eyes is off (one or both eyes are out to the side or turned in) causing your vision to also not line up producing double vision. This can be treated with prism in refractive treatment (glasses) or by surgery to adjust the origin or insertion of rectus muscles that move the eye.
  • Lucentis injections: This is a medication used to treat macular degeneration, macular edema, and other eye pathologies that requires the use of a hospital room. Not many Ophthalmologists in the area use this newer technology so I am so lucky I get so work under someone so innovative!
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Basic eye anatomy

For Dr. McAlister, I get to do so many clinical things that it literally blows my mind. In a typical clinic day, I do the work up for the patients based on what we are seeing them for. I generally examine the patient’s vision (eye charts), pressures (with a rebounder! More new technology.), medical history, pupil responses (always looking for afferent pupil defect where one pupil has optic nerve damage causing the opposite pupil to dilate instead of constrict!! Very cool). I also record a run down of the patient’s concerns, symptoms, medications and reason for referral. For new cataract cases and other retinal/back of the eye issues, I dilate their eyes with Mydriacyl and Mydfrin drops. For pediatric neurological cases, I dilate their eyes with Cyclogel 1% (if they haven’t already received atropine drops the night before). For Strabismus cases, I do a whole series of tests to examine their eye alignment including red/green light suppressing OD or OS at near or distance and their ability to see 3D. For Glaucoma and other neuro patients who have decreased vision, I do a visual fields test on them to assess their entire visual field. This is done on a big machine and takes about 7 mins per eye. It was really exciting to me at first but now they’re kind of a drag since they take so long! All of this and more happens in a typical clinic day. But that’s only 2 days a week (except this week when we are doing 5 days because she’s going on maternity leave next week!).

On OR days, Dr. McAlister is at St. Mary’s hospital or Grand River Hospital doing surgeries, lasers or injections. For cataract surgery days, she does surgeries from 8-4 while I’m in the office doing visual fields or clerical things (receiving/sending faxes, referrals, appointment bookings, consult responses, patient concerns etc.) and then all of the patients come to the office at the end of the day for a post-op check. 18 people all pile in at 4pm while I race to take their vision and pressure and asking if they are having any major issues after the surgery. I also write up the prescriptions for the drops Dr. McAlister prescribes for her cataract surgeries (vigamox and maxidex).

And then there are on-call weeks. All Ophthalmologists in Southern Ontario (I think), take turns being the on-call Ophthalmologist for all of the surrounding areas. So anyone with an emergent eye issue will be sent to us (or we see them at St. Mary’s) when we are on call. A few weeks ago we had one of the busiest on-call weeks there has been in a long time. We had multiple retinal detachments (symptoms are flashes and/or floaters), eye herpes, and high eye pressures…patients whom we had to add to our clinic days on top of our regular patients. It was absolutely crazy busy but I loved every second of it! I got to see such a large range of cases that I wouldn’t normally see outside of the emergency room. I even got to go to St. Mary’s and work in the eye clinic there with Dr. McAlister while she was on-call and do the work-ups there! It was seriously awesome. I’ll also be accompanying Dr. McAlister for her Lucentis injection day next week at St. Mary’s for pre-op checks. (Provided her baby doesn’t arrive early). I’m so excited!

I have learned so much working under Dr. McAlister and I am so blessed to have been able to be her technician. She is definitely what has made me feel confident in my passion for medicine and she supports and teaches me every day!

Volunteer Prosection Training Program

In addition to all of these jobs, I also had the amazing opportunity to work with the VPTP! After taking anatomy last year, I felt really lucky to have been able to have the resources of human cadavers in my anatomy lab. When the opportunity arose to be able to prepare these specimens for the Optometry school and the anatomy classes, I took it since it really is a once-in-a-life-time chance. In all medical post-graduate programs, students are required to study human specimens, which have been prepared for them to examine. It is so rare that you get the opportunity to prosect cadavers for examination so I’m so lucky! Essentially, the program involved prosection training and preparation of cadavers where we would remove skin, fat and connective tissue from human cadavers in order to expose and differentiate muscles, nerves and vessels. Since we were required to have been successful in the anatomy lab, we already knew a lot of the human anatomy and were taught how to use dissection tools like scalpels. We were also taught dissection techniques, which was a very unique opportunity. I worked in the beginning stages of the program mostly removing skin and fat from the chest and lower back. It is definitely a fine skill that takes practice since you must be careful not to cut any muscle tissue, which I found especially difficult on the neck! I will be working in the last rounds around the posterior leg and foot in the brand new anatomy lab! (SO EXCITED!!!!) Every round focused on a different area of the body and involved a study of the anatomically relevant features beforehand. This program was not only an amazing opportunity, but also kept my anatomy knowledge very sharp! (Get it? Scalpel? Sharp? lol)

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Image from http://www.uwstout.edu/news/articles/Cadaver-training-gives-rehab-providers-inside-look-at-human-body.cfm

In Addition

On top of all of these jobs this summer, I was also able to keep up my work with the Hospital Elder Life Program at Grand River Hospital (see my previous blog post for more info!), although I did take August off since I was so incredibly busy.

I also successfully completed my required philosophy credit in an online class at U Waterloo.

I was also able to pick up a few life guarding and daycare shifts to exercise those skills as well.

Irrelevantly, I was able to take an amazing trip to California with my family as well as spend some good relaxing time up in Muskoka. It truly has been a great summer and I’m excited for what is to come!