Swallow It


As I sit here with an ice pack and foot propped up, it occurs to me that the old adage that doctors make the worst patients should be amended to include all medical providers.  In my work, on a daily basis I dispense medical advice that I frequently ignore.  Not because I think I’m ten foot tall and bullet-proof, but because I’m busy running around taking care of other things before I realize that I haven’t had a single thing to drink all day (hence the three kidney stones), or busy running around and not watching where I’m going (hence the three sprained ankles in three years).  Is it any wonder my mother is always admonishing me to slow down?

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I am a firm believer in the mind-body connection.  Since I started practicing medicine, I’ve seen what stress can do to our bodies.  Like most women I know, I carry all of my stress in my neck and shoulders, the non-ergonomic office chair and computer set-up, of course, contributing to the problems.  My husband, on the other hand, feels his stress in his stomach, having difficulty eating when he feels stressed out (I wish I had that problem!).  The brain is the most powerful organ in our body with its ability to effect changes which may seem magical to those not confronted with these cases every day.

Though both branches of my family have survived wars and strife, my recognition of PTSD has grown by leaps and bounds through my work with veterans.  Time after time, I am struck by the stories my patients tell of how ill-equipped they were psychologically to deal with what they saw and did.  Many veterans came back from Vietnam or Korea, and stated that they had no problems with “shell-shock” like other veterans they knew, raising families and working steadily at jobs that built this country, until they retired.  Then suddenly, they find themselves experiencing palpitations and sweaty hands in crowds, nightmares/vivid dreams of people and places they have not thought of for years.  They come in genuinely confused, some of them undergoing cardiac testing for these symptoms which make no sense to them.  After years of looking forward and striving for the next thing, retirement affords them space and time to look backwards, and they find their past is catching up with them.

One veteran told me that shortly after he arrived in Vietnam, he spoke to his supervising officer about his doubts that he could deal with all of the death he was seeing.  This was a man whom he respected, a grizzled veteran of many military maneuvers, and so he took the man’s advice to heart.  “Swallow it,” the young soldier was told.  “If you don’t, it will eat you alive, so swallow it, because we don’t have time for it now, and your job is to stay alive.  Just stay alive.”  I am not a psychologist or expert on PTSD, but I found it interesting that the veteran’s main complaint was debilitating stomach pain with extensive gastrointestinal testing over many years which has been negative.

I’ve had other patients come in with complaints of dizziness.  In medicine, a complaint of dizziness needs to be further clarified in order to narrow the differential diagnosis.  My question to patients with dizziness or lightheadedness is usually asking them if they have a sensation of feeling woozy like they are about to pass out, a spinning sensation either of the world spinning or of themselves spinning, or a feeling of being off-balance.  I’ve learned that besides trying to figure out all of the medical reasons for a patient’s symptoms, it is important to ask questions about how the rest of their life is going as this will have an effect on their symptoms.  It never surprises me that the patients who will share that they are feeling lost or confused, will also describe their dizziness as a feeling of being off-balance, often times associated with blurry vision or tunnel vision.  Is it any wonder that those who most feel out of control emotionally have symptoms that mimic having lost sight of where they are going or where the ground is? Some have literally used the words, “I don’t know which way is up.”

The words that people use when describing their symptoms and telling their stories can be revealing.  Perhaps because I love words so much, I think they are important and I try to pay attention to how people describe their pain.  In our training as PAs, we are asked to be very specific in how we document pain.  Some patients will laugh a little at my question, ‘Would you describe the pain as sharp, stabbing, squeezing, pressure, aching, burning or something else?’ but it helps people to find the word that best describes their pain.  As medical providers, we have a lot of experience dealing with pain, and though I cannot truly “feel” their pain, I always feel that if I can help them name it, it will have less power over them.

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One method frequently used to help patients categorize their sensation of pain.

As medical providers, sometimes we can be so focused on the disorder, we forget that mind-body connection.  No matter how many times we read the study about how pretending to smile actually improves a person’s mood, we point the arrow from body to mind, and forgot the power the mind has over the body.  One of my most memorable patients during my psych rotation was a woman who had been diagnosed with somatization disorder (which in the DSM-5 has now been replaced with the broader category of somatic symptom disorder in order to “remove the mind-body separation that is implied in DSM-IV”). She reported paralysis and loss of feeling from the waist down, though all testing and imaging was normal, and there was no report or sign of injury or external trauma. She had been there for weeks undergoing test after test before she was moved to the psychiatric ward. Other patients have reported blindness, others deafness. She would speak cheerfully of everything but the broken engagement that had occurred just prior to her hospitalization, that event a black hole into which all memory had vanished. Was it chance that this woman had lost half of her body, her better half perhaps? Or that she was numb, and paralyzed to the point that she could not move forward or backward?

At the time, though, I was in my first rotation in my second year of PA school. My job was only to learn everything I could about somatization disorder which was thought to be very rare in order to prepare a presentation for the rest of those in our consult service, round on this patient every morning, as well as attending to any new consults that came in that day. My job wasn’t to diagnose this woman with heartbreak, though I thought most likely it was true.

As a PA working in cardiology many years later, I would learn about Takotsubo cardiomyopathy aka stress cardiomyopathy or broken heart syndrome, in which the heart muscle function is dramatically affected in approximately 85% of cases by an emotionally or physically stressful event. Patients normally arrive at the hospital with symptoms mimicking a heart attack, including chest pain and difficulty breathing. Actual visualization of the coronary arteries usually reveals no evidence of significant atherosclerotic plaque to explain the dramatic change in the heart’s ability to pump efficiently or the change in the actual shape of the heart muscle itself.  In most instances, the heart muscle function returns to normal by the time of the patient’s discharge (usually within a week).

Figure 2.

Called Takotsubo after a Japanese ceramic pot used to trap octupi, this is a dramatic change in the normal shape of the heart (Credit: Circulation 2011; 124)

The more we learn though, the greater distance we put between ourselves and our patients.  We think we learn enough to make a difference, gaining the tools and knowledge to ease suffering and effect cures.  We gather information, nod sympathetically, lay hands on our patients, and dispense knowledge and prescriptions with impunity, doing our best with what we know. Our patients get better, mostly, but sometimes they do not, and we blame ourselves. We want that distance because we want to believe that we can help our patients. We want to believe we do know enough to make a difference. We forget though, we are ourselves human as well. It is a bitter pill to swallow–“Cure thyself!” we are told and tell ourselves, though we no more listen to our own advice than our patients might. We stumble, and curse the ground, and forget that perhaps,  our mind wants us to listen, and slow down. We learn again, what bruising, pain, and heartbreak can do, and in doing so, close the gap between us all again.

 

 

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The Final Frontier


A snapshot into the crazy world of what being married to me is like, based on an actual telephone conversation I had with my husband today:

“Ok, I need to tell you something really big,” I said.

“Big, as in I need to sit down, or maybe just lean on something? Or are you joking?” he said.

“No, I’m not joking, it’s not bad, but maybe you should lean on something,” I said excitedly.

“Okaaaay, well, what is it?”

Now keep in mind that not only was I over-the-moon excited about this news, I had also had a whole handful of chocolate-covered espresso beans which for someone like me who generally avoids caffeine, made me talk even faster than I normally do, so it came out something like this: “NASAistakingapplicationsforastronauts, and I want to apply!”

“What?! Are you serious? No way! Do you know how many space shuttles or rockets have exploded in the history of space flight?”

Silence on my end, then “I can’t believe you’re not supporting me in this.  You’re supposed to help me achieve my dreams. They’re going to go to MARS!!!”

“But, honey, don’t you know how dangerous that is?”

“Um, hello, firefighter/SWAT medic? Seriously?!”

“Uh, right. Point taken. ”

Big sigh on his end of the line, then “OK, fine. I didn’t even know you wanted to be an astronaut.” (Really, he’s such a good guy, isn’t he?)

“I’ve only wanted to be an astronaut my whole life.  It’s SPACE!  Who wouldn’t want to go to space?  How cool would that be?!”  Actually, it was one of several things I’d considered.  Almost a year ago, I posted my dream list of future occupations when I was a kid which included “Supreme court justice, Shirley Temple stand-in, crime-fighting assassin/journalist, astronaut, and finally, Nobel Prize-winning brain researcher.”

As I was talking to him, I had been scrolling through NASA’s website, looking at the requirements in more detail.  The article I’d read said only a bachelor’s degree in a STEM (science, technology, engineering, or mathematics) field (CHECK!), at least 3 years of experience in that field (CHECK!), and the ability to pass the astronaut physical (Well, going to have to investigate that further). What I was looking for specifically was the one thing I knew I couldn’t overcome based on will alone:  The height requirement.

“Oh no! It says 62 inches, ” I said despairingly.

“Well, that’s probably based on–”

“Hah! Wait, that’s only if I want to be a pilot or commander, plus they need over 1000 flight hours as pilot-in-command.  But I only have to be 58.5 inches tall if I want to be a mission specialist, and I’ve got that beat by a whole inch and a half! I could be a mission specialist.”

“A whole inch and a half, huh?”

I was so elated, I pretended not to hear the gently sarcastic tone in his voice. Then, as I continued to read the requirements to him, I dropped back down to Earth. Vision was another requirement, and I’m famous in my family for having horrendously thick glasses starting from age 8, until the miracle of contact lenses came along.  I had been told by one well-known eye surgeon, “We have no surgical options for you. Perhaps you’ll develop cataracts early.”

“Oh no, there’s a minimum vision requirement. 20/200 or better uncorrected. Hmm, maybe I should look into getting Lasik done anyway. Oh wait! It says correctable to 20/20, each eye. Ok, I’ve still got a chance. Or I could be a payload specialist.”

He quietly listened to me as I continued on in this vein for another 5 minutes, up and down the spectrum of excitement, as I came to the realization as I read further, that the likelihood of actually getting picked to go to astronaut candidate school was only about 0.6 %.

“Well, it would be cool just to get a rejection letter from NASA, right? I’m going to apply anyway. You never know! I could be the first PA in space. My collaborating physician would be available. . .on Earth!”

My son’s reaction when I told him NASA was taking applications for astronauts, and that I was going to apply, was even cooler.

“You’re going to be an astronaut?  Wait, how?  Can you take me with you?  I want to go to Mars, too!”

“Sweetie, you’re not old enough yet.  But if you want to be an astronaut, see how important it is to get a college degree in one of the STEM fields?” (I know, I know, not everyone needs to go to college, but seriously, Tiger Mama training dies hard.)

We surfed the NASA website together, and oohed and aahed over pictures of rockets and astronauts.

“Do you think they get to keep the blue jumpsuits?”

“Yep, pretty sure they do.”

“I want one.”

“Me too, buddy.”

We read more in depth about the physical requirements with him saying “I could do that!” and me saying, “Hmm, not sure if I can pass the swimming test (I have this horrible fear of drowning) and my little guy saying “I can though!” and right there, I watched the dream blossom in his eyes, and saw the final frontier open up for him. No limits here on Earth.  Not if you think you can be an astronaut.  And who doesn’t want that for their kids?

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Here’s the actual description of astronaut requirements if you’re interested in one of those blue jumpsuits, too:

http://www.nasa.gov/audience/forstudents/postsecondary/features/F_Astronaut_Requirements.html

The Opposite of Tenebrific


A career in medicine is one that has many lures–the ability to touch lives,  fascinating medical phenomena, and the knowledge of the complexity that comprises the human body, among other things.  Yesterday, every single one of my patients reminded me again of why I became a PA.  One patient asked my advice on what to do about a lost love connection spanning over 20 years.  Another had such an intricate medical history, it had me stretching my brain for information I’d learned long ago in school.  One funny patient and I talked about our love of words, and I shared with him an app on my phone which gives me a new word to learn every morning. Every patient thanked me for being easy to talk to, and I was loathe to walk each of them to my door because I had enjoyed our visit so much.  It was a day sorely needed. Last week, the last patient of my day made me cry.

As anyone who knows me will tell you, making me cry is not actually difficult. I confess to a small sob while watching the movie Aladdin (which is a cartoon I know, but that Genie gets me every time).  aladdin genie

Someone else crying causes me to tear up.  Even writing a sentence about crying will cause what my son calls my “shiny eyes.” I’ve cried with patients numerous times, with a touching story or in shared grief. But this time, it was different.  I was crying tears of anger.  I am cursed with full-on waterworks if I’m extremely angry, which I would love to be able to control. It’s hard to be taken seriously if you’re wiping away tears while trying to make a point, and even harder to carry on a patient evaluation when you are doing everything you can to remain professional in the face of hostility.

This patient began our encounter angry before he had even met me because his appointment had been rescheduled with another provider. Where I work, I’m used to dealing with angry patients on an almost daily basis.  To some of them, solely on the basis of where I work, I am the face of all of the bureaucratic bean-counting, soul-sucking paper-shuffling nonsense that prevented them from seeking care in the first place. I am part of the system that denied them benefits, told them PTSD did not exist, and denied their right to be seen as a person, and not a number. So I understand the frustration and the anger that comes as part of the baggage of just getting to the appointment.  I understand that part of my job is to lift that burden of frustration, and make them feel like they are seen, and heard.

As patients, we come to our appointments carrying the invisible baggage of our history–the memory of an aunt who died on the operating table, medication reactions, a fear of bad news-“What if it’s cancer?” As providers, we know this, and try our best to gauge those worries and try to alleviate them if possible.   Sometimes though, the actions brought about by those fears and worries are inappropriate, and other times, even criminal.  Fears have been running high in our department because one of our sister facilities suffered a tragic shooting.  A patient shot and killed one of the providers at the hospital in El Paso.  He worked in the same type of department in which I work.   Meetings about safety measures, active shooter scenarios, and how to deal with violence in the workplace have been laced with tension-filled voices.  One of our police officers tried to help us dial back the emotions.  “Let’s not call it a panic button. I prefer the name duress alarm. We don’t want to have panic,” she said.  I’m not sure that changing the name makes a difference, though I do advocate for the power of words.

But the words I mean are those we use when dealing with patients.  As peace-loving as I try to be, I am not immune to the effects of violence. I trained in the city of Detroit and saw the ravages of drugs and violence on the faces and bodies of our patients, treated gunshot wounds and stab wounds, and saw families ripped apart by random acts of killing.   People argue that our patient population is more dangerous because as veterans,  our patients have all been trained on how to use weapons.  I argue that if anything, that makes us safer, because they were also trained in how to defend those in need, in how to stand and fight for those who could not or will not because of an oath to heal or religious convictions or even conscience alone.  I will defend our veterans as patients just as worthy of our compassion as any other patients, if not more, and not to be considered a source of fear.

Last Friday though, I was afraid, and if I were a superstitious type, might have seen the word of the day, “tenebrific,” as a portent, as it means producing darkness. My patient arrived upset, out of control, and angry with me and everyone else in his vicinity.  I stand a whopping 5 foot nothing, and so to me, everyone is tall.  This man though, stood a good foot taller than me, and weighed over 2 times what I weigh.  I tried every tactic I had ever used to deal with a difficult patient, but I could not connect with him.  The power of words failed me.  He kept standing up while I was attempting to gather his history, and the sight of this very large man gesticulating wildly between me and the door gave me a qualm every time he stood up.  Between his wife and I, we tried to calm him down, but nothing seemed to work.  He alternated between insulting me and denigrating the system, and I bit my tongue and tried to smile pleasantly until it reached the point that he started to use expletives.  I firmly told him that this kind of language was unnecessary.  At this point he demanded to see someone else because he thought I was “belligerent and argumentative.”

My hands shook and my heart was pounding as I escorted him to the appointment desk to be rescheduled, and then I returned to my office and promptly burst into tears. I was angry and upset, mostly at my inability to control the situation and at the fact that I had not been able to get him to see beyond me as the face of an organization, to see me as someone who cared about his well-being, and at myself for feeling intimidated by a patient.

I believe strongly that all patients deserve good health care, the best that I can provide if possible.  To come to a point where I could not do so, made me realize that as providers we also have the right to be treated with dignity.  When we in good conscience have done all we can to do right by our patient, we also deserve to be seen and heard. We deserve, as our patients do, to work in a place where we should not fear for our lives for doing our jobs.  My heart goes out to those in El Paso, and especially the family of the man who was killed trying his best to help others.

Today I am thankful for work which allows me to be present in the lives of others in the midst of their pain and suffering. I pray for the strength to continue to be the opposite of tenebrific as much as possible.  And I am grateful for all of the wonderful patients I’ve met along this journey.

I would love to hear any of your stories of how you’ve either dealt with a difficult person or tactics on how to keep the tears from flowing when you don’t want them to.  I hope and pray that you have someone taking care of you with whom you can laugh and cry. Let them know you appreciate them if you do.  They might really need to hear it today.

Do What You Love: Top 7 Things You Never Knew About Physician Assistants


Growing up, my dream list of future occupations was varied: Supreme Court justice, Shirley Temple stand-in, crime-fighting assassin/journalist, astronaut, and finally, Nobel Prize-winning brain researcher. Alas, Sandra Day O’Connor took my seat, Shirley Temple grew up, being Catholic put the nix on the whole killing people gig (even if you only kill the bad ones, the Church frowns upon that–see Commandment #6), my 5 foot even height makes me too short to be an astronaut, and no matter how much I loved studying the brain, I found I really dislike research. However, I was blessed to work with stroke patients in my research work, and it turns out, I love people. So in 2003, I became a physician assistant (PA).

If you know any PAs, this is a logical conclusion. As a whole, PAs love people–helping them, taking care of them, and making a difference in their lives. I had never heard of the PA profession until shortly before I applied to PA school, when I met one while working with a surgeon who did not particularly like people (but that’s a story for another blog post).  That PA was, and is, a paragon of compassion and competence. She said and did all the things I had always associated with physicians, and her patients loved her and asked for her by name. Not by doctor but by Jennifer, because as she said, “If I cared about titles, I wouldn’t have become a PA.” Inspired by her quiet example, I researched the profession (all that time in research wasn’t wasted), and was astonished by what I learned.

1. PAs have been taking care of Americans since around the time of the Vietnam War.  The first PA class graduated October 6, 1967 from Duke University. In fact, PA training was based on the fast-track model of training doctors in World War II because of the health care shortage at that time, and the fantastic Navy corpsmen and their wealth of knowledge from the Vietnam War–necessity being the mother of invention and all. And in a time of civil unrest, one of the examples Dr. Eugene Stead used for the PA-physician team model was a white physician and his African American assistant, Henry Lee “Buddy” Treadwell, who capably managed the clinic while the physician was out of town, and whom “the richest man in town would rather have. . . sew him up than [the physician] because he can do it better. . .” as quoted by said physician.  As a female Asian American PA, I can’t think of any better testament to the founder of our profession than that he was progressive enough to recognize quality health care and not care who was delivering it, in a time when Jim Crow laws still existed.

2. PAs work collaboratively with physicians and other members of the medical team to provide quality health care in all fields of medicine. Yes, all.

3. PAs can write prescriptions for what ails you. And when there is no prescription, you can count on us to listen and be present, and fight like hell for you. I mean, advocate strongly for you.

4. PAs not only work in all branches of medicine, they can be found in a variety of settings. We don’t just deliver health care in hospitals, operating rooms, and private practices, we also teach at universities, work in prisons, practice in schools (not the same thing, no matter what you might recall about middle school), perform research (I suppose someone has to), lecture around the world, serve our country in the military and in the White House, own our own practices (in some states), publish in medical journals, care for nursing home residents, and work in industry. The sky is the limit in terms of opportunities available for PAs–literally. I’m still trying to figure out how to work the astronaut angle–first astronaut PA anyone?

5. PAs have to bring similar prerequisites for medical school to the table when applying to PA school, and to be competitive they usually need 2-3 years of healthcare experience to even be considered. My dual degrees in biology and neuropsychology from the University of Michigan were not sufficient. I had to go back and take more classes than I needed for a medical school application, just to be able to apply to PA school. Suffice it to say, I would have taken those classes in medical school if I had gone, but PA school expects you to come loaded for bear so you can be out practicing medicine upon graduation. The time I spent in the healthcare field before PA school was helpful in navigating through the intensive onslaught of information during PA school, and has made me a better PA now that I’m practicing because I had already worked as part of a healthcare delivery team prior to becoming a PA.  The PA who has helped clean patients in nursing homes before PA school knows to be on the lookout for decubitus ulcers from first-hand experience, just like the PA who was a paramedic before PA school is acutely aware of the possibility of tension pneumothorax in a patient with blunt chest trauma from an MVA.

6. PAs can be found practicing medicine internationally. Besides those serving in the military for the United States, the PA concept has spread to Canada, the United Kingdom, the Netherlands, Ghana and South Africa. The Russian feldsher was a forerunner to the physician assistant profession dating back to the 17th and 18th century and introduced by Peter the Great to the Russian military in the setting of a physician shortage–not a new problem as you can see. PAs also work in disaster relief and with medical mission groups across the entire world, and many PA schools offer international rotations. One of the best experiences I had in PA school was going on a medical mission to Honduras. Nothing makes you more grateful or humble than knowing that patients have walked miles carrying their shoes just to see a medical provider in order to show up wearing their best clothes. Seeing ingenious providers treat patients in a clinic without reliable electricity inspired me to be more aware of how I allocate our health care dollars, and to hone my physical exam/diagnostic skills.

7. PAs are required to have both national certification and state licensure, and must recertify every 10 years by passing a national exam covering the following areas of medicine: surgery, pediatrics, cardiology, pulmonology, orthopedics, dermatology, psychiatry, neurology, infectious disease, hematology, genitourinary, gastroenterology, endocrinology, and otolaryngology (see #2 above).  In addition, we must remain up to date by earning 100 continuing medical education credit hours every 2 years. So even though patients ask us frequently when we are going to finish our schooling and become physicians, the answer is never, because we will never stop learning and we love being PAs.

National PA Week starts today. Even though I never did win a Nobel Prize, travel to outer space, or learn to dance like Shirley Temple, I am blessed to do what I love. Being a PA has been a more rewarding career than I ever dreamed possible. I am thankful for all the patients who have allowed me the privilege of caring for them, listening to their life stories, and sharing their journeys. I am humbled by the incredible trust they place in my hands, and strive like all in the medical field, to be worthy of it.

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Where Were You on 9/12?


Images of planes crashing into the Twin Towers flash behind my eyes, as I listen to the veteran before me haltingly describe his flashbacks from the IED explosion that changed his world forever. Years have passed for all of us, and nothing remains the same. It is the question of our generation: Where were you on 9/11?

I was a physician assistant student. As anyone who has survived PA school will tell you, there is no lower person on a medical team than the PA student. Scut work and long hours are the norm, and I had not yet even earned the privilege of standing in scrubs as the lowliest member of the team. I was still in that first long didactic year, where Socrates’ words held sway: I was learning all that I did not know. Navigating the streets of downtown Detroit, inhaling the acrid perfume that cadavers wear, and desperately memorizing the biochemical pathways that make us human, I despaired of ever knowing all that I needed to know to care for others.

Back in class on 9/12, a Wednesday, my helplessness multiplied. There were so many hurting, and in need, and I was a lowly student without the tools to help anyone. Like everyone else, I had spent the day before numbly watching the unlikely images of planes gliding into skyscrapers, gaping holes in the Pentagon, and ash-covered firefighters kneeling in prayer. I stared at my hands, pen in hand, aching to grasp the skills that could bandage or suture or make a difference, somehow. Laying my hand on my daughter’s head that night, I wondered what the world would bring for her, and for all of us. I resolved to learn all I could to make the world a better place for her and others.

The question we should ask of ourselves, and others today is this: Where were you on 9/12? If 9/11 was the day the world changed for us, 9/12 was the day each of us took stock of where we stood, and took the steps into a new future. What resolutions did you make that day? What changes did we make that have led us to where we stand now? And now, so many years later, I wonder at the journey that we as a nation have made, and look back at the person I was, and marvel. Since that day, my husband left his lucrative, but unsatisfying job to become a firefighter/paramedic, and I, like all firefighter’s spouses, lie in bed waiting for the call that he is safe. I know there is more innocence and laughter in the world, because I have brought two more children into it.

And today, I sit before this veteran who has served our country in the fight against terror, and the tools I use every day, are the tools I had then, though I did not know it. I did learn how to suture, and bandage, and administer medications that will heal and soothe, but what I have learned since 9/12 is this: The single greatest thing I, and anyone else privileged enough to be present in the healing process can do, is listen. Though these hands have finally acquired the skills I so longed for as a student, today they grasp the hands of the soldier in front of me, in gratitude, and somehow, it is enough.

Today, I also had the privilege of handing out awards to PAs from around the state. As part of my committee work for my state PA society, I learn about all the good work being done by PAs around the state through nominations by other PAs. It is humbling and gratifying to see all that others do every day, without thought of recognition. I am proud to be able to recognize all these paragons of our profession, and share their good work with others. Many are working in rural clinics, taking care of underserved populations, and making a difference merely by their existence. It truly is a blessing, and I am grateful to be surrounded by such inspirational people. It gives me hope for our world to be in the presence of all these good people. Our state PA conference honored them, as well as all those we lost on 9/11. All of us reflected on where we were on 9/11, and we had several PAs who are either veterans or are currently serving in the National Guard. Perhaps it is my own bias, but I feel blessed to work in a profession where serving others is our priority. Many tonight spoke of the same resolve to be part of the change to make the world a better, more peaceful place. Please feel free to share your story of where you were on 9/11, and what you changed on 9/12 that led you to where you are today.

7 Reasons Why I Love Working at the VA


If there is a word that means the opposite of a news hound, that would describe me. I get my news in small bits on my drive into work, but lately because I work at the VA, the news has been coming to me. People I barely know have been asking me with furrowed brows, real concern and almost prurient curiosity in their voices, “Sooo, how’s everything going at work?”

The funny thing for me is that not much has changed. I still listen to my patients’ stories and examine them with the same amount of care I always have. In fact, I would say, other than the comments I get from others because it is all over the news, there has not been much change in my practice. For everyone else I know that works at my facility, I would venture a guess that this is true for them as well. We are all doing the work we came here to do, despite news media reports, despite protestors, despite changes in leadership, despite insufficient staffing and budgetary concerns, because it must be done.

Coming from private practice, I will admit I had some trepidation about coming to work at the VA. As with any large hospital system, I was worried about fitting in after coming from a small community office. My fears were allayed on the first day of orientation. I knew very little about the military before coming to the VA even though my parents met on a US Army Base in Vietnam. I expected to get educated about rankings and how best to address people. In fact, none of this occurred. Instead the emphasis was put on serving veterans, those who have put their lives on the line for our freedom and our liberties. It didn’t matter where they served, in what capacity, what their rank had been, if they were a part of our military, they had in the (paraphrased) words I heard for the first time in orientation, “in effect, given the United States a blank check, payable up to and including their very lives.” Sobering, isn’t it? I have always admired those who were in the military, but after working here I have an even greater respect for them. As a PA, I owe my career to those who served in Vietnam and World War II. With the job market for PAs in its boom phase, I could get a job anywhere, so why do I work at the VA?

I work at the VA because:
1. There is nowhere else I’ve ever been where patriotism is not only seen everywhere, it is expected. I believe despite all the detractors, sarcastic comments, and negative reports, that this is still the greatest country in the world. There is a reason everyone still wants to come here, a reason why people risk their lives trying to cross borders and flee across seas filled with pirates and rapists to get to this country. Are there countries with less crime? Yes. Are there countries with better educational standards? Yes. Are there countries with less poverty? Yes. Is there any other country in the world, where we can have people protesting outside the gates of a hospital where we are taking care of our wounded warriors, and the only comment made by hospital administration is, please don’t stop to talk to the protestors as it will impede traffic through that gate. Why? Because these wounded of ours fought for our rights, including the right to free speech, even if it is to used to say they think you are wrong. As an immigrant, I am proud to call myself an American, and proud to serve our veterans.

2. I love working at the VA because I am surrounded by others who love taking care of veterans. I am blessed to work in a place where people are happy to be here. Many of them will be even happier once we get more providers to help take care of the many veterans who are signing up every day to be seen, but even despite being overworked, patients tell me everyday that they can sense how happy everyone is who works here. These patients talk about the smiles on the faces of workers here, the friendliness of all the people who stop to ask them if they need help. It is bred into the culture of this hospital, from the very first day of orientation, that it is our job to take care of all veterans, whether they are sitting in front of us in an examining room or wandering looking lost in the hallways. Many of the employees here are veterans themselves, so patients feel a kinship with them, bonding over stories of boot camp and battles.

3. History comes to life at the VA. From World War II veterans who endured the Battle of the Bulge to Gulf War veterans who were there when they pulled down the statue of Saddam Hussein, I’ve met so many people who were part of history from patients to administrators. Just walking through our hallways is a history lesson. Though we have our fair share of generic abstract hospital artwork, these are far-outweighed by the pictures of veterans, memorials and other landmarks that commemorate their accomplishments. And if you are willing to listen, there is nothing like hearing first-person accounts of what really happened behind the scenes by the men and women who had boots on the ground

4. The world becomes more global at the VA. Hearing their personal stories of exposures to radiation on Bikini Atoll, trudging through days of pouring rain during the monsoons in Vietnam, and life on board ships in the Pacific brings the world into my little office. Most veterans have been stationed in places I’ve never had the pleasure of going, and just asking them their favorite place to be stationed always yields surprising answers. I’ve learned about clear cockroaches on Marshall Island, hamlets in Germany found intact after the bombing ended, and blinding dust storms in Iraq.

5. Good quality health care is given here. When I worked in private practice, it was my responsibility to keep countless algorithms and guidelines for clinical practice in my head. A 65-year-old man with any history of smoking? I had to remember to schedule his abdominal aortic aneurysm screening, EKG, and cholesterol check. Here at the VA, electronic alerts for recommended screening pop up to remind us. Providers with years of experience are coming to the VA, tired of the same dwindling fee for service, pressure to succumb to the almighty dollar, and rising malpractice costs that are driving people away from and out of medicine in general. People forget that innovative research and groundbreaking discoveries were done first at the VA, including the first implantable cardiac pacemaker and the first successful liver transplant. In the wake of all the negative media attention, I’ve had countless veterans making a point to thank me (!) for helping them. Two of these veterans shared their stories of how their lung cancer and colon cancer was diagnosed early here, after coming from private practice, essentially saving them from much worse outcomes. Our hospital is a teaching hospital, like the one in Detroit where I did my internal medicine rotation, and the one in Ann Arbor where I did my first undergraduate research with the University of Michigan. Everyday, eager students from nursing, medicine, OT, PT, psychology and countless other disciplines come here to learn from people who are taking the time to teach others how best to care for our veterans.

6. The electronic medical records system here actually helps me to get my job done as opposed to impeding it. That is not to say that I love EMR, but being able to easily access records for a veteran who is sitting in front of me makes my life and the patient’s life a lot easier. I get alerts about patients’ labs, imaging, and consultations sent directly to my account on my desktop. This is more efficient than keeping a list in my head of all the patient results I needed to check on throughout the day. Veterans also can sign up for a program called MyHealtheVet which allows them to look at their own labs, notes, and reports through a secure gateway, enabling them to take charge of their own health.

7. And most importantly, I get to help heroes every day. In the grocery store, you and I might walk by these men and women without a second glance as we run in to pick up a gallon of milk. Every day I have the privilege of meeting, talking, and hearing from people who though most of them would not call themselves so, are heroes. They have saved lives, built bridges both literal and figurative, done acts of diplomacy under scrutiny in foreign countries, and done this for those of us who get to sleep peacefully in our beds. I look at the world very differently, realizing there is a story inside every one of us ordinary-looking people.

I know there will be many, and have been many who say this system is damaged. My answer to that is that all of medicine needs to be revamped, and if closer scrutiny is what it takes to make our healthcare system more efficient, then it is a good thing and I am thankful for it. This scrutiny involves recognizing what works and fostering this, especially so those who are doing the work don’t lose courage to keep fighting for good healthcare for our veterans. What does not help, and will never help, is negativity without action. And so, I ask all of you to share your stories of what works and what does not, and perhaps then we can use those pointing fingers to lift the burden instead of making it harder to bear for those of us doing the best we can.