Before I could even write another post about "1/2 of the summer over" or "2/3 of the summer over" we are just one week away from completing what most believe is the hardest part of PA school...THE DREADED SUMMER TERM! After all the rumors, fears, emotions and wonder about what the summer term was like, we finally not only figured it out, but we lived through it. Thinking more about this, I honestly, cannot believe that we have almost finished two terms of PA school already, it has gone by wayyy faster than I anticipated it to! We have learned so much in terms of common conditions like most common causes, risk factors, clinical presentation, diagnostic tests and findings, treatments, managements and preventions. I feel like I know so much medicine its unreal (well for the time spent learning about medicine at least). It won't be long before I start posting about suturing, casting, standardized patient scenarios and more exciting stuff coming this fall term! I know we are only half way done with the didactic part but.... WE ARE HALF WAY DONE WITH THE DIDACTIC TERMS! For all my readers who have stuck with me since January, thank you for your dedication and interest and for those new readers, stay tuned... there will be more fun to come in the PA program at AMC!
A few weeks ago we encountered a patient with depression and how we should go about our patient encounter to help her start feeling better. Today, we had a patient like no other. Most people think that they won't deal with psych patients often if they work in an urgent care or ER setting, this is true to a degree; however, the one's that you could encounter could be more than just a handful. Typically, I would not write this detailed about a real patient encounter but there was a lot to be learned from this interaction today in the classroom setting.
Our patient simulation today was a women who came in for a blood pressure check. Quickly after the encounter started she mentioned that she stopped taking her meds. The patient eventually revealed that she was diagnosed with schizophrenia at a young age. She sees the things on her medications and believes it will harm her through her pills and food, therefore she has stopped taking her medications and eating. She was told most of this information from another hallucination. Now, I only stated that information so that you could understand these lessons learned.
After this encounter we learned more than a few things about general psych patient interactions:
1. When a patient is hearing voices, go along with what they are saying. You need to gain the patient's trust, and in order to do that, you need to believe what they are saying. If a patient is hearing voices, you cannot tell them that "its all in their head" this creates unnecessary tension between the provider and patient. Most of their friends and family are probably telling them that same thing and another person will not help them get better. The patient is genuinely hearing things, they are not making it up, and as a provider you need to acknowledge that you believe them. One of the providers who interacted with her asked where the voices were coming from and she pointed to a vent on the ceiling. Later he asked for her medication list but the patient stated that the devils did not want him to have it. He said that he would hide it so that they could not see it. She agreed. Reaching in her purse she pulled out a black box wrapped with rubber bands. The provider put his hand over the box so that the devils could not get to it. Once she took the list out she handed it to him and he turned his back to the devils in order to read the list. This may seem silly but to the patient, this was very nice and showed that he believed her. This act helped develop trust with the patient.
2. Once you develop this baseline you need to constantly reassure the patient that they are safe. In this case you can tell the patient "no one is going to hurt you while you are here" "we will protect you" "you can tell me things while you are here in the office, you are safe, I won't let anyone hurt you here." Even as the patient encounter continues, the patient will start to withhold information because they fear something bad will happen if they tell you. Many times voices that the patient hears are telling them not to disclose certain information. In cases where you sense the patient is starting to fear releasing information or start to get anxious, reassure them that they are safe.
3. Do not press for information that the patient really does not want to reveal. For example, we asked about the patient's parents but she stated that the devils did not want her to tell us. When we asked again in another form she seemed to get more upset and state that she could not tell us. In this case, we were not going to get this information today. Maybe after she is medicated and feeling better she will tell us, but until then we do not necessarily need to know this information to treat her and it is not worth destroying trust that we developed during this visit.
4. Sometimes requests by the patient will seem strange, but if possible, these requests can be met. In this case, the patient requested that her meds and food be wrapped in plastic in order to prevent the devil from poisoning her. As a provider we could order that her pills must be from a blister pack that is opened in front of her before administering her meds. We could also request that they wrap her food in plastic at the house she was staying at.
5. Medications never treat these patients 100%. The voices can be muffled but never fully go away. This is part of the problem as to why she stopped taking her medications that were helping her. She started to hear voices that she could understand telling her to stop taking them. In this case maybe she needs a higher or lower dose of her medication to muffle the voices enough so that they are just sounds and not understood. To treat this patient in the best way, she needs to be carefully watched at her home to make sure that we know as soon as she starts to hear the voices again and can treat her sooner rather than later.
There were many other things we learned about psych patients with schizophrenia today that could fill this entire blog, but overall we learned patience, compassion, trust and creativity. We have to listen to these patients, show them care, develop trust and think of new ways to get them to work with us in order to make them feel better.
*the patient actor in this case was unbelievably amazing and so realistic it was very easy to forget that she was an actress.
I haven’t had a blog entry in a few weeks mainly due to the business of our schedule. The summer has definitely been different than what the upperclassmen were telling us about. They were stressing certain classes to be difficult that our class finds easy. I guess I'll address the things that were told to us that proved to be untrue.
You need to memorize everything from Physical Assessment (Spring Class) and perform it in a 30 min physical exam... perfectly! Be prepared, practice every day, practice practice, practice.
Now this could not have been more untrue to what I experienced. They were stressing about the Clinical Competency Exam where we perform a physical exam with a patient in the PSCCC. Think of what your provider does when you go for a physical... the provider doesn't do every tiny detail and exam because... its just a physical. If there is a finding, then, they exam further. I am not sure why everyone in the class above us made this seem like it was one of the worst parts of the summer. Most people in our class seem to find this pretty easy and … fun! Even though they told us to study and practice a thousand times, I felt that I did not really need to. Its pass/fail. There was no need to completely change my study habits and review this more than I felt necessary. I honestly ran through it once before every practice and before the final testing date and passed without any issues. I am not saying this to "boast" I am saying this because I have a hard time memorizing things (it takes me much longer than I would like it to) but even with this which is a heavy memorizing activity, I did not need to review it as much as they made it sound like I needed to. Now, I cannot speak for others, some people wanted to review this everyday before the exam, and thats fine there is no problem with that, but I would say that not everyone needed to do that (at least those in my study group). Others are nervous about it but do not think, by any means, that its very "difficult." I actually loved this part the most because it is pass/fail and we get to actually pretend to be providers for once.
FCM is the hardest class you have ever had up so far
Granted, we have a different instructor, however, she still claims she uses many questions from the other instructor and our class have averages 88-90 almost every exam. Yes, there is a ton of studying required for this class but the exams are not anywhere near what the upperclassmen were making it sound like. If you study the important parts, "most commons" "least commons" gold standards, treatments of choice etc then you know enough about a condition to get by. Before this class they even had an introductory about how to study and how to plan everything out .... which was very nice in thought but it did not help us as much as they probably thought it did. I guess it was partly our fault too for thinking we would have the exact experiences as them even when they told is that we may be different students.
*DISCLAIMER* I know it seems like I am bashing everything they told us, but that is not true. This upperclassmen class has been super helpful acclimating us the area, PA school and everything in gradschool life in general. They are amazing and have helped in more ways than they have hurt. NEVERTHELESS, the information they provided for us about the summer term was more inaccurate in my mind than accurate. (no one is perfect and our class may simply be different than their class, so I am not upset, but I just wanted to address these because many students who I study with discuss the misinterpretation on how difficult this would be due to skewed advice).
HERE ARE SOMETHINGS THAT THEY WERE SPOT-ON ACCURATE ABOUT:
You will be spending all your free time trying to study and get ahead
They could not be more accurate with this statement. Every second of everyday I am thinking about what I should be studying if I am not already studying it. (Don't take that as that I study every second of every day... I just think that I should be studying. e.g. going to get my car inspected I was thinking, 'I need to review my patho slideshows so I dont get behind') There is about 1-2 tests a week during the summer which pretty much destroys any weekend plans you want to have. The good news is that it is not HARD per se but its just a lot of information all at once that you need to organize into class tests.
You will surprise yourself
There are many things that I have learned and am almost confident that I will forget, but I go to work and then realize... I know more than I thought I did. Little things about a patient's presentation will key you into a memory of the condition and the rest just flows naturally.
So my I always wonder if I actually know some of this information outside of the classroom setting and today, I could. My boyfriend is on rotations at an ER for pharmacy and had a patient who presented with an abrupt onset of epigastric pain that radiated to the back, tachy, fever etc. I asked him if a Lipase and Amylase was run on the patient and if it was high... he said yes. Then he told me LFTs were run on the patient. I asked if AST and ALT were also elevated and he said that he believed they were. Finally, I asked if they did any imaging studies on the patient and he said they did an ABD X-ray. Without even knowing the rest of the patient's story I asked..."did the providers think it was acute pancreatitis?" To my slight disbelief he said yea... thats what they were talking about.
Now, this may seem silly to all of you reading this, but this was a huge moment for me. After I took the test on the GI unit I was convinced that I did not know enough to get by just because I did not feel confident enough. But right after the exam and talking to my boyfriend about this patient case, I realize that I do know far more than I ever thought I could. I do not by any means know all that I need to know yet (and probably never will) but I feel that most of what I have learned carries with me more than I realize.
Moments like this make me extremely excited for rotations where I can actually interact with patients and use the knowledge that I spent so long studying.