Most of this morning’s patients were follow-up patients. Two were acute add-ons. Many of the patients see her regularly, but at least one was seeing her because she was the first provider available.

I knew the PA from previous working experience, so we were able to dispense with the introductions and get right to the job at hand. The first thing she showed me was the electronic medical record (EMR) upon which she had two charts open for patients she had seen the previous day. She reminded me that, though the patient leaves the office with his/her plan of care, the documentation isn’t finished quite as quickly. Some of the documentation is done in the room while talking to the patient, at least enough to remind you when you sit down to finish the chart later. The rest of the documentation is often done during lunch, after the last patient of the day, or the next morning.

She told me that a provider trains his/her mind to remember what happened in the visit when it is time to finish documentation.

She had her schedule printed out before the day began and gave it a cursory glance to see what the day’s patients were coming in for. She could then look up past visits, if necessary, to remind her of the patient’s history and where she had left off with them. For the most part, when she entered the room with the patient, she was able to let the patient know that she remembered the last visit and what direction they were heading in.

I noticed that the patients really trusted the PA and wanted to know her opinions about everything related to their healthcare. One patient was schedule to see two MD specialists, but wanted to come back and see the PA to get her opinion on the matter before following the specialists’ advice. Another patient kept expressing her anxiety and stress due to her work situation. This patient seemed to want to talk about that a little more than she was able to during the office visit. The advice of the PA was important to both of these patients.

A 16 year old patient came in with a rash that her mother thought may be an allergic reaction to antibiotics she was taking. As the facts were investigated, it was found that the patient had been on the same antibiotic relatively recently with no side effects, plus the rash didn’t fit the typical allergic skin reaction pattern. She had, however, been swimming multiple days in the row, reusing the same damp swimsuit. In the end, the PA didn’t unnecessarily diagnose the patient with an allergy to a medication she may need in the future when there wasn’t conclusive evidence to do so.

Another of the acute patients was someone that I thought could have been treated over the phone if the PA had known the extent of the problems at the time. The patient had been seen for a similar problem in the past, had somewhat of a history actually. The patient had all the medications prescribed to her earlier in the year for a skin irritation but hadn’t needed to use the entire prescription. The patient didn’t have a new problem or need a new treatment plan, but just needed confirmation from a provider that it was OK to use the medication for what seemed to her to be a different incident. The PA was able to recognize the symptoms from earlier visits and recognize the medications from the EMR and assure the patient that it was appropriate to use them.

The last patient of the day told me she liked the PA because the PA was thorough. Right away, the PA started asking questions that didn’t seem to have to do with the chief complaints at hand. Through further probing, it was found that the chest discomfort and weakness the 38 year old patient was feeling was probably due to a new onset of hyperthyroid rather than any kind of cardiac problem, which she had been worried about. That patient had been good natured and making jokes, but deep down she was worried that her unhealthy lifestyle might be catching up to her. The PA was able to calm the fears significantly before the patient left.

I noticed that for every medical decision the PA made, there was another consideration that had to be followed up. For instance, when prescribing one medication to a patient, the PA then had to make sure to follow up with blood work afterward to check the liver. She also had to follow up with the prescription to make sure it didn’t cause a cough, which is the most common side-effect. No medical decision is an island. Medicine is an interconnected discipline and has to be practiced in that manner. That is often a challenge for an urgent care or emergency facility treating a patient they don’t know. The patient can be on other medications, have other allergies, and have other diagnoses that are going to affect medical decision making, however the provider doesn’t always have access to this information. In this regard, family medicine can be a little harder – you have to keep up with the patient’s entire medical history – but also a little easier because you have the medical history available when making decisions.

I realized a couple things from the experience I had today that I hadn’t thought of before. First, family medicine gives you a wide range of patient care opportunities. I like the thought of a challenge, as in the situations that present in an emergency department when someone’s life has to be saved and you might not know that much about the life before having to save it. Family medicine hints at this challenge with acute visits in a multi-provider practice. A patient you are unfamiliar with comes in to be seen for a problem you haven’t been following.

On the other hand, I like the thought of following up with the patient and seeing where my medical decisions brought them. Is the patient better off in the long run because of how I handled his/her care? Am I able to make the slight alterations in the care plan in each successive visit that ultimately lead to a healthy, enjoyable life for my patient?

Secondly, I was told that a provider trains his/her mind to remember what happened in the visit when it is time to finish documentation. I believe I would have the ability to see a patient at one point and document the visit later if necessary. Even now, hours after I have left the office, I can remember what the patients were seen for and how the PA treated them. Beyond the chief complaint and main reason for the visit, I remember many of the secondary diagnoses and other medications the patients were on that we saw today.

There were also some things from my shadowing experience today that I have further questions about. First, I understand the wisdom of looking at the schedule to know what to expect during your workday, however I wonder about planning the encounter before entering the room and the prejudices that come with it. From what I experienced the facts the patient gives, as they give them, influence the provider, but assumptions the provider researches before the visit can influence medical decision making before even talking to the patient. The patterns we see in healthcare can become ruts if we think that every patient with problem X can be treated the same or every patient with insurance Y abuses the system. It seems like it might be wise to mentally prepare oneself but be open-minded enough to not miss anything out of the ordinary.

Also, I think it is important for a PA, or any practitioner, to know the EMR well enough to be able to glean all the useful information from it. Healthcare may have been around a lot longer than the computer, but the computer can help in so many ways…if you know how to use it. Knowing how to access all the documents you want, and need, is key.

Lastly I’m concerned that some of the repetitiveness of the job might cause a provider to not fully listen to everything the patient is saying…and suggesting. I’d like to think that a PA is following up with a patient’s explicit and implicit anxieties instead of just focusing on prescribing a medication. There is an enormous link between a person’s mental well being and his/her physical well being, and that link works in both directions. If one is down, it can bring the other down. If one is up, it can bolster the other. Hopefully the practitioners of medicine aren’t just skimming the words coming out of the patient’s mouth for key terms and phrases, but are truly listening and taking into account everything the patient communicates to them. From just one morning in a family medicine office, one morning of listening to patients talking to a PA, I believe in a holistic approach to practicing medicine. This entire body of ours is inter-connected and it seems like it should be treated appropriately.

Requirement: Anatomy and Physiology needs to be 8 credits taken within the last 7 years. The anatomy I took was Comparative Anatomy in the fall of 1996. I needed to get a B or better, and I got a C+.

Plan: I am signed up for A&P I (4 credits) this coming semester. I will get an A. I will take A&P II (4 credits) next semester and also get an A.

Requirement: 250 hours of direct patient care (CNA, CMA, EMT, RN, etc.). I have zero hours of direct patient care, though many years of working in healthcare.

Plan: I am signed up for an EMT course. I will pass with a high grade and start working as an EMT. This line of work actually interests me and is not just something to pad my resume, so that helps. Incidentally, this class requires an up-to-date Basic Life Support (BLS) certification. I have signed up for the course on the 25th.

Requirement: My Biology-Chemistry-Physics (BCP) average needs to be over 3.0, with more competitive applications being closer to 3.2 or 3.5. Mine is currently a 2.75 (and that’s what you get for slacking off in college, my supposedly smart friends).

Plan: An A in both A&P semesters will bring this BCP average to a 2.9. I need to get an A in another BCP class next semester. If that’s not enough, I may need a summer class in the May term (a human-related biology was suggested…I have lots of animal classes). If 8 credits worth of A’s brings me to 2.9, another 8 credits worth should bring me to 3.05.

Strongly Required: Shadowing a PA to know exactly what a PA’s roles and responsibilities are. Now, I have worked with Pas for 9 years now but have never officially shadowed one.

Plan: I want to shadow as many PAs as possible between now and my next application. My employer has a shadowing program. I just need the approval of a department head to shadow within their department. I have sent off some emails and I already have one PA willing to let me shadow him. I plan on typing up a paragraph or two of each experience after I have done it.

Other Suggestions:

Work on my essay for the application. Let them know why I’d be a good choice.

Come to the spring open house. Meet the staff. Make myself known.

Explain in more depth on the application exactly what my healthcare experience is. I guess I was rather Spartan on the info, figuring they’d ask more, in-depth questions at the interview. Ooops. I didn’t get an interview.

I also feel I should look up the requirements of a few other PA schools around and make sure I meet their specific prerequisites. I can’t put all my hopes in one school; it has burned me twice (by my own fault, yes).

So, I have a plan and I’ve gotten right on top of signing up for things. Let’s see how it goes.

Let me say, I am 3 books behind at the end of July, but that’s not why I’m stopping. I fully believe I could catch up those three books, though I do tend to read long books. I’m stopping the goal due to the fact I have just signed up for 9 credit hours of classes next semester.

My knowledge is rusty, and I’m really going to need to read up on my subjects. As a matter of fact, I’m starting rather soon. I pulled out my BLS for Healthcare Professionals books yesterday so I could start reviewing. BLS is a prerequisite for my Basic EMS course starting in September. I have a feeling I’ll also need to review my first aid hand book that I also pulled out yesterday.

My other class is A&P. I’ll begin looking over my wife’s book as soon as I get the course syllabus. That and I’ll use A&P wallpaper on my computer to help study.

I won’t be giving up on reading; I’ll just be slowing the pace. It is healthy to know when to stop trying for your goals because of a life-changing event. It should be an interesting remainder of the year.

How I yearn to read
Out under the sagging elm
The book as my world

An escape calls me
Beautiful realms crying out
Touching upon mine

The grass grows so lush
A perfect seat beneath me
A padding for hours

My wife just graduated nursing school. She spent every week night and most weekends studying for years. She didn’t get out much. Her social life was smothered, going out with more of a whimper than a bang. But now she’s done.

She will be training and working some evening and overnight shifts coming up, however she is currently working day shifts. This means I can actually spend time with her after the work day. We can cruise the streets, wander around Wal*Mart for hours never walking the same hour twice, or chase squirrels with bottle rockets. The time is ours to enjoy!

So, I will see you again, and soon. The long after-work hours of braiding each other’s hair and whispering passive aggressive secrets about the imagined lives of unknown neighbors will end soon. Shortly I will return to your harsher embrace. Your free weights will bow me over like a 90 year old osteoporotic. Your leg extensions will cause me to strain and strain until I wet myself just enough to be embarrassing but not enough to inconvenience the next person on the machine. Your treadmills and I will spend long half hours in sweaty, tortuous bliss.

Until then.

Fantastic Caverns was a ride on a Jeep drawn cart through old underground caves. There are very few of these around that are accessible by Jeep.

The formations are pretty cool and provide a fertile imagination with many ideas.

Out of the natural beauty into the man-made scenery of Zio’s Italian Kitchen. I found the floorplan and decor quite interesting.

Krissy’s grandfather picked us up late in the morning and we headed back up to Springfield to the Fantastic Caverns, one of the few underground caves you can ride a Jeep through.

The tour was quite interesting. We were told about the rate of growth of stalagmites and stalactites, and were then told to approximate the age of the cave by the length of the stalactites. Using this equation, they are old.

The caves were quite historical, found during the Civil War (I believe) and kept from the government’s radar by the finder so they weren’t used by troops. They were underground storage areas, bars during prohibition, KKK meeting areas, and entertainment areas, with a full bar and stage. Yes, one cavern was actually that big!

We were quite hungry upon leaving the caverns, so we headed to Zio’s Italian Kitchen. The fare was probably Olive Gardenish, but the decorations were even better. It was an open floor, with Italian columns and ambiance. My salmon was a bit fishy tasting, but it was an overall enjoyable experience.

On the way home, we just had to stop and experience for ourselves the wonders of Andy’s custard. In our Bangor, Mainer minds, it was just a slightly different version of a Dairy Queen. The Blizzards are called Concretes. I had mine with peanut butter cup, and it was delicious.

Sunday night we just lazed around the room, which became our normal evening habit. This is when I got most of my reading done. I finished two books (one I had started before we left) and started another during the entire trip.

We dropped my car off at the Doughty’s house so we wouldn’t have to pay a week’s worth of parking fees at the Portland airport. Scoob brought us to the Courtyard by Marriott where we had one night in a beautiful room and only a couple hours, all said and done, when we were conscious to enjoy it.

Our checked luggage was 61 lbs, so Delta was going to charge us an extra $90 fee. We decided to juggle some items around and transferred 12 lbs into our carry on. The carry on became rather bulky.

The flights were perfect. I thought the first one, to Atlanta, was actually kind of roomy. I had an aisle seat and my wife sat in between me and a young man who has been in the Marines for about a year. There were a couple of his Marine buddies on the plane and an older man in fatigues. We were safe from terrorists.

We were starving and had a 4 hour layover in Atlanta, so we hit Popeye’s for a meal and Ben & Jerry’s for dessert. Popeye’s was at 10 AM, but we had already been up for 6 hours, so it didn’t feel like chicken and biscuits for breakfast.

Atlanta had wifi, but I couldn’t get a good connection. It had electrical outlets for the laptop, but I didn’t see it until it was almost time to go. I read while Krissy tried to nap. We were both rather distracted from our goals by everything that goes on in an airport. Plus, there was a Delta credit card booth by us and the workers were constantly trying to get passers-by to sign up. Sucky job.

The flight from Atlanta to Springfield was smaller, but I had a window seat. Unfortunately I was too tired to really spend much time looking out. I sorta, mighta barely fallen asleep a couple times.

The Springfield airport is rather small, so we had no trouble finding Krissy’s grandfather and our checked luggage. As far as we could tell, nothing was missing from the luggage. Success.

We were planning on being treated to Lambert’s, home of the Throwed Roll [sic], however the wait was almost an hour. We were driven to Branson and taken to Panera instead. I know people really like their Panera, but when you’re expecting Lambert’s, Panera just isn’t all that.

We got a bit of a road tour of hilly Branson before we made it to the resort. We unpacked and then were taken to Harrison AR to get the truck we were borrowing. The drive is through the Ozark Mountains and is quite scenic.

We got back to the resort, unpacked, and got comfortable. I tried to set up the internet connection, but the computer wasn’t playing nice (it does that sometimes, even when the internet connection itself is fine). I got tired of fiddling around and we read the rest of the night.

School is wrapping up (actually, today she takes her last tests), but there are few, if any, nursing jobs around. Hey, remember that nursing shortage we had and were told would last for many years? Well…not so much. Nursing shortage, meet healthcare crisis and overhaul. Meet hospital downstaffing, nurses staying put in their current positions, and therefore a lack of new positions to be had. Meet the State of Maine, where the state doesn’t pay its hospitals for taking care of its state-insured patients.

The job search is on. Until very recently, the only places she has been able to apply to were out of state. Will we be moving to Virginia? That would be nice, actually. Or, could she be hired at the Mayo Clinic in Minnesota? Cold, but acceptable.

School is wrapping up, but the future is extremely uncertain. It’s like rushing full tilt toward the edge of a cliff.

What’s over the edge?

We looked over the menu thinking there had to be something that would be the slightest bit appetizing. Well, there was: some kind of spinach and soy cheese wanton. However, that was an appetizer, and my wife seemed loathe to let me order only an appetizer and not a main dish. I might add a couple things at this point: 1) I am very good at choosing only a simple appetizer and enjoying it at a place where the menu seems a bit suspect to my tastes. One time I ordered only a bowl of clam chowder, and enjoyed it, while the rest of my dining party was nauseated with their dinner selections. I spent less money and had a better dinner. I trust me. This did not happen last night. 2) There was another person at the dinner last night, much smarter than I was allowed to be, who was allowed to not order anything at all. Nothing. He didn’t order only an appetizer. He ordered nothing. And he got away with it. I don’t know exactly how the birthday girl thought of him, but I didn’t hear anyone coming down on him for not ordering. Taking those two facts together, I should have just gotten an appetizer.

My steamed vegetables came to me covered in peanut sauce. I thought it would be pretty good and all I would have to do is pick out a few of my least favorite vegetables. Unfortunately, the peanut sauce was chunky not smooth. Also unfortunately, as of late my body has had a bit of a problem with chunky peanut sauce.

A couple weeks ago I was, what one would call, violently ill. The last thing I had eaten earlier in the day we some roasted peanuts. The taste of roasted peanuts stayed with me through the entire day as my stomach ached and caused the most nauseated feelings I have had in a decade or two. These feelings culminated in a grand, if not violent, outpouring of nothing other than chunky peanut sauce a few times that night. Flash forward that picture to the chunky peanut sauce I was staring at on my plate last night. I should have just gotten an appetizer.

We headed back toward home from the interestingly busy vegetarian restaurant and decided to stop at a Dairy Queen at the halfway point. The DQ in Augusta is a small little hole in the wall with no inside seating, though it does have inside serving. The pictures of the 25th anniversary Blizzards were deliciously tempting. I ordered a medium Tagalong Blizzard to make up for my dinner. The Blizzard looked great; the kid had even sprinkled some of the Tagalongs on top when he was done mixing it up.

The first few bites were not too bad. I was just enjoying the ice cream, a delicacy I don’t indulge in quite so much these days. After the first bites, I noticed the Blizzard was awfully soft. It was as if the ice cream was melting rapidly or maybe it wasn’t too hard to begin with. It also started tasting funny, and not a good kind of funny like a clown. It was definitely the bad kind of funny, like nauseating chunky peanuts.

I finished almost the entire Blizzard (hey, I paid for it), and drove home quite disappointed all in all.

Today I had a Mint Oreo Blizzard for lunch. It was awesome. The end.