Thursday, May 27, 2010

What is all this about, anyhow?



I thought you might like to get a better glimpse into what's required of us as PA students. Most PA programs require prior coursework in the sciences which are equal in many respects to pre-med students, more or less. For example, PA students for most programs must have already completed a Biology series with labs, Chemistry series with labs, Organic Chemistry with Labs, Biochemistry, Microbiology with Lab, Anatomy with Lab, and Physiology. Pre-meds are not required to take Anatomy or Microbiology in undergrad, but PA students are. This is so they can jump you straight into deeper study of medicine from day one. The other main difference with undergrad requirements is that pre-meds are required to take Physics in preparation for the MCAT, but most PA schools don't require Physics. Of course if you're going for a Bio degree in undergrad then you'll probably have taken Physics regardless.

Medical school does still go deeper into physiology and pathophysiology, but PA students are nonetheless expected to handle a great deal of material. A great deal. Most make it through the first year, but alas some do not. We had an attrition of about 5 or 6 students this year. Some are trying a second time, some have moved on towards other careers. I think no less of any of them, the first year is a hard kick in the face and there is unfortunately little to no forgiveness offered for failure.

PA program accreditation involves representatives from quite a few Physician organizations, including the AMA, American Academy of Family Physicians, and the American College of Surgeons. 

In addition to the brutal first year of didactic coursework, the second year consists of training rotations in Surgery, Emergency Medicine, Psychiatry, Pediatrics, Obstetrics/Gynecology, and Adult Medicine. The student is taught and graded by a preceptor during each rotation, usually a MD or DO. I have had one rotation (Emed) where I was primarily taught by PAs. In addition to the preceptor's grade, each rotation ends with an exam (roughly half of the final rotation grade). 

I'm currently finishing up my Adult Medicine rotation in hospital Nephrology, here is the list of learning objectives that I'm expected to know for the exam. Remember, this is for only one rotation:

Cardiovascular

Category I: Coronary artery disease; AMI, angina, hyperlipidemia, valvular heart disease, dysrhythmias, congestive heart failure; hypertension (essential, secondary, malignant), orthostatic/postural hypotension, arterial/venous insufficiency, deep vein thrombosis, thrombophlebitis, peripheral vascular disease (venous and arterial)
Category II: Pericardial diseases / cardiomyopathies (dilated, hypertrophic, restrictive) rheumatic heart disease, infectious endocarditis, mesenteric ischemia
Pulmonary

Category I: Acute bronchitis, pneumonias (community & nosocomial, bacterial, viral, fungal,
HIV-related), pleural effusion, pulmonary edema, asthma, chronic bronchitis/ emphysema, pulmonary embolus, tuberculosis, influenza.
Category II: Abscesses, empyema, restrictive lung diseases related to environmental/occupational and connective tissue etiologies, carcinomas, sarcoidosis, pulmonary hypertension, cystic fibrosis, primary pulmonary hypertension, pulmonary fibrosis
Gastrointestinal
Category I: Peptic ulcer disease: H. pylori, gastric, duodenal; gastroesophageal reflux, esophageal spasm, esophagitis, gastritis/gastreoenteritis; hepatitis, pancreatitis, inflammatory bowel disease, irritable bowel syndrome, diarrhea (infectious, parasitic), constipation, diverticular disease, pseudomembranous colitis, cholelithiasis, cholecystitis, lactose intolerance, constipation, Nutritional Deficiencies ( Niacin, Thiamine, Riboflavin, Vitamins A, C, D, K)., Metabolic Disorders (Lactose intolerance)
Category II: Esophageal/gastric/colorectal carcinoma; achalasia, esophageal varices, malabsorption syndromes, biliary obstruction, cirrhosis, parasitic diseases, large or small bowel obstruction

Musculoskeletal
Category I: Rheumatoid arthritis, osteoarthritis, low back pain, gout, pseudogout, septic arthritis, osteoporosis, carpal tunnel syndrome
Category II: Systemic lupus erythematosus, progressive systemic sclerosis, psoriasis, vasculitis, Reiter’s syndrome, aseptic necrosis, polymyositis, polymyalgia rheumatica, fibromyalgia, osteomyelitis
EENT
Category I: Glaucoma, otitis media/externa, labyrinthitis, Meniere’s disease, acute/chronic sinusitis, allergic rhinitis, pharyngitis, conjunctivitis
Category II: Oral leukoplakia, orbital/periorbital cellulitis, retinal detachment, ocular herpes, oral carcinoma, cataracts, diabetic/hypertensive retinopathy
Endocrine
Category I: Diabetes Mellitus (types I and II), hypo/hyperthyroidism, Graves’ disease, Hashimoto’s thyroiditis, thyroid storm, Cushing’s syndrome, hypercholesterolemia, hypertriglyceridemia.
Category II: Hyper/hypoparathyroidism, acromegaly/gigantism, corticoadrenal insufficiency, pituitary adenoma, thyroid cancer, diabetes insipidus, SIADH

Neurologic
Category I: Alzheimer’s disease, CVA / TIA, tension/cluster/migraine headache, trigeminal neuralgia, giant cell arteritis, meningitis, diabetic peripheral and autonomic neuropathies
Category II: Multiple sclerosis, cerebral aneurysm, seizure disorders, encephalitis, Bell’s palsy, subarachnoid hemorrhage, epidural bleed, Parkinson’s disease, dementia, Guillian Barre, myasthenia gravis, SAH
Genitourinary
Category I: Acute and chronic renal failure, nephrotic syndrome, renal calculi, pyelonephritis, benign prostatic hyperplasia, acute and chronic prostatitis, cystitis, urethritis, incontinence, epididymitis, cystitis
Category II: Glomerulonephritis, Goodpasture’s syndrome, polycystic kidney disease, renovascular hypertension, tubulointerstitial disease, bladder/prostate carcinoma, renal cell carcinoma, testicular carcinoma
Dermatologic
Category I: Stasis dermatitis, venous stasis ulcers, tinea corporis/pedis/cruris, rosacea, onycomycosis, herpes simplex, cellulitis, decubitus ulcers, urticaria, herpes zoster, psoriasis, seborrheic/actinic keratoses, contact dermatitis, viral exanthum, gram positive and gram negative skin infections
Category II: Basal cell carcinoma, squamous cell carcinoma, melanoma

Hematologic
Category I: Anemias: iron deficiency, vitamin B12, folate, anemia of chronic disease, sickle cell anemia, anticoagulant use (warfarin, heparin, Lovonox, aspirin, clopidogrel)
Category II: Coagulation disorders, thrombocytopenia, VonWillebrand’s disease, acute and chronic lymphocytic leukemia, acute and chronic myelogenous leukemia, lymphoma, multiple myeloma, ITP, aplastic anemia, myeloproliferative disease, G6PD-deficiency

Infectious Disease

Category I: Candidiasis, gonococcal infections, salmonellosis, shigellosis, Lyme disease, HIV, streptococcal infections, staph infections, sepsis, Epstein Barr, cytomegalovirus
Category II: Pneumocystis, atypical mycobacterial disease, syphilis, histoplasmosis, cryptococcus, malaria

Miscellaneous

Dehydration, edema

Procedures
Given an adult patient, the PA student will observe and perform, where permitted, the following procedures: using proper technique and precautions; will identify the indications, contraindications and hazards for such procedures, and will appropriately educate the patient or legal guardian about such procedures and the meaning of the results. Including, obtaining the appropriate releases. The student will identify the age/gender appropriate “normal” values.
As indicated, with preceptor permission:

arterial blood gases urinalysis
electrocardiogram
urine pregnancy tests

foley catheterization
venipuncture / fingerstick

gram stain wet mounts
IV catheter placement
nasogastric tube placement
occult blood in stool
rapid strep tests
injections: intradermal, intravenous, subcutaneous
specimen collection:
culture/sensitivity of blood,
cervical, nasopharyngeal,
sputum, stool, urethral,
urine, wound

As indicated, under direct supervision and with assistance as needed:

thoracentesis
paracentesis
joint aspiration
proctoscopy
arterial puncture, other than radial artery
Removal of non-penetrating ocular foreign bodies

Principles of Monitoring/Therapeutics

The student will identify the indications, contraindications, hazards and management of the following:

intravenous fluid therapy
total parenteral nutrition
blood transfusions
arterial cannulation and catheterization
central pressure monitoring
pulmonary artery pressure monitoring

Diagnostic Studies
The student will demonstrate knowledge of normal values, and list common diseases, which may account for abnormal values, for the following laboratory tests:

complete blood count with white cell differential / anemia profiles
urinalysis
blood urea nitrogen, creatinine, electrolytes – Na+, K+, CL -, CO2
biochemical profiles: liver function, renal function, cardiac function,
calcium metabolism tests, glucose, lipid levels
hepatitis profiles
arterial blood gases
thyroid profiles
lipid profiles
rheumatologic disease profiles
pulmonary function testing
HIV/AIDS profiles
cardiovascular testing (cardiac enzyme profiles, echocardiography,
stress testing, cardiac catheterization, BNP, C-reactive protein)
spinal fluid analysis
microbiology: tests for infectious diseases
Radiographic Studies
The student will describe the indications for ordering radiologic studies such as radiographs; CT scans, MRI, nuclear medicine studies and ultrasound techniques, as diagnostic procedures, and will describe the health risks associated with radiologic procedures.
The student will:
Interpret PA and lateral chest x-rays for pneumonia, pneumothorax, pleural
effusion, CHF, cardiomegaly, solid tumors, fractures, hyperinflation.
Interpret x-rays of the extremities for fractures, dislocations and degenerative
joint/disc disease.
Interpret x-rays of the spine for scoliosis, kyphosis, and DJD.
Interpret the descriptive reports of radiologists concerning flat plates of the
abdomen, upper GI series, barium enema, IVP’s, skull and sinus films.


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