Last Week at UPMC Presbyterian Autopsy

These three-week rotations sure do fly by fast. I would like to thank everyone working at the autopsy suite for showing me a different way of approaching the autopsy process. When and if I perform autopsies in the future, I'll be able to use the best methods that I've learned from both places.

The next place that I'll be heading off to is UPMC Children's Hospital. It will give me the chance to become exposed to some of the unfortunate pathologies that primarily occur during childhood. Once again, my time will be spent in the gross room and hopefully I will become more proficient and efficient in my grossings.

I have a small side project that I've been working on to assist me while I am grossing. The inspiration for this work came from my time spent at Allegheny General Hospital. They often have us students and other residents rotate through their gross laboratory and they have kindly prepared for us a dictation template for a wide variety of specimens that enter into the laboratory. The dictation templates offer a basic skeleton of a dictation and the dissector only needs to fill in the blanks and amend their dictation to suit the specimen. Having a template such as that is of great help for beginning PAs, but I would quickly like to move from using a template to being able to naturally say a dictation from memory and experience. To help me I've created a kind of a stepping stone. Instead of creating my own templates, I've merely printed my past dictations and encased them in plastic sheet covers. (Of course the personal identifying information has been removed.) The result thus far is a 30 or so page, easy-to-access booklet that will allow me to flip to some of my previous dictations to see what cassettes I need or how to describe a certain specimen.

Another problem that I sometimes come across while working on a dictation is how to describe something. Some specimens seem so 'out of this world' that one is at a loss for words. For example, if you were to see the following specimen, how would you describe it in words?

Picture taken from: http://radiographics.rsna.org/content/29/3/907/F51.expansion.html

Describing this would be a daunting task for beginning grossers and often I too admittedly have some trouble with descriptions. I spend far too much time finding what words to say and if I were to be able to smoothly say my descriptions, then I could easily cut my time down by 1/4 to 1/3. Interestingly enough, on Google, I have found a website from the University of Pittsburgh Medical Centers Pathology Department that has literally hundreds of cases that provide gross pictures, microscopic pictures and their associated gross dictations, microscopic dictations and final diagnoses. This great resource can be found here:
http://path.upmc.edu/cases/index.html

I have been using this site as a practice guide. I love it and have been accessing it whenever I have some extra time. My eventual goal is to make a booklet of sample dictations and 4x6 color printouts. Who knows, if I can produce enough of my own dictations and pictures I might even be able to market it.

In one last bit of news, I'm happy to say that I've finally been able to get my total cholesterol down under 200 for the first time in my adult life! It's an important milestone for myself, so I figured I'd write it down for posterity when I look back on this blog in some years in the future. I had to drastically cut down my sugar and processed foods, increase my jogging to 20 minutes everyday and get more sunlight. Hopefully, this cholesterol reading was not a fluke and I'll be able to continue this healthy lifestyle for as long as I am able. In a few months time, if my cholesterol is still down, then I know that these changes are for real.

Where To Find Employment After Graduation From PA School

Although us second year PA students are busy learning and experiencing all that we can on our rotations, each of us must eventually confront the question of "Where will I work?" It is perhaps a decision that will influence the rest of our lives and should not be undertaken lightly. Our graduation date is set in December, which is a mere six months away, and for those of us who have been able to find a place of employment already the burden has been lifted. For the rest of us, including myself, the search continues.

The demand for pathologists' assistants has continued to be strong, but how long this will last is questionable. A greater and greater number of new graduates are meeting the demand to fill positions, but a disturbing new trend is emerging. I have heard that the average age of pathologists' assistants is actually decreasing year-by-year. If this continues, there will be an excess of new graduates and not enough job positions available for them. I am optimistic for the next number of years, but eventually, this potential issue must be addressed.

I look at the employment dilemmas of my friends who are making it on their own and am extremely grateful to be studying in this program. I'm grateful not just from an educational perspective, but also from an employment perspective. As far as the PA Program at West Virginia University is concerned, I am happy to say that thus far all graduates of our program have found work either before graduation or upon graduation. The field of medicine has been largely shielded from the effects of the 'economic recession.' However, nationwide, college graduates of my generation have been hit especially hard and as many as 53% are either unemployed or underemployed.
http://news.yahoo.com/1-2-graduates-jobless-underemployed-140300522.html
Being able to graduate from an accredited program will enable me to achieve my goals inside the profession and outside the profession. The recession is hitting young adults the hardest because the rest of their lives will be stunted. Their decisions to climb the career ladder, to buy a home or to raise a family will inevitably become delayed or possibly never materialize.

Fortunately, for my classmates and myself, the 50 states of our union are ours for the taking. There are job opportunities that continue to open themselves all across the country. I have seen job openings from West Coast to East Coast. The question for us is not whether we can find employment, but rather, where should we choose to work?

There are a variety of factors to consider when choosing a place of employment. Although each job position usually has a few applicants I will assume for this article that the competition nationwide is fairly constant. Also, I will not compare the working facilities themselves (small community hospital vs private high-volume lab.)

1. How close is it to family?
For myself and many of my classmates, this is actually the largest factor in choosing a place of employment. I believe that my classmates who have already found employment have found it close to home. My family is located in Clovis, California, so my hope is to find employment back in California. Fortunately for me, California is a large state and lacks a local pathologists' assistant program. The majority of the PA programs are located on the eastern side of the US and one is located in Canada. Generally speaking, this creates a greater demand for PAs in the west, mid-west and southern states.
Moving back in with family has a number of advantages and disadvantages. By moving in with family you are accepting an opportunity cost. Perhaps a different hospital would have paid more than a local hospital or perhaps the weather is nicer in a different state than your local state.
Also, if you are moving back closer to family, you might be doing so because you want to move back in! I hate to sound like a parasite, but that is what my goal is. I have always praised cultures in which there are three or perhaps even four generations all living under the same roof. American individualism and entrepreneurship are admirable qualities to have, but they are not practical when you are a new graduate and have tens-of-thousands of dollars in student loans to pay off. As soon as I am able to pay off my debts and save up enough for a house of my own, I will be happy to move out, ideally next door. My parents worked hard to care for me when I couldn't do so myself as a child and I want to repay the favor by taking care of them.
Besides, Hanako said that she doesn't want to live in any other city besides Clovis and at my parent's place. I'm stuck between a hard spot and a rock.

2. What is the cost of living?
One reason why I am not enthusiastic about accepting a position in a large metropolitan city is because of the high cost of living. Whether it be San Francisco or New York, the larger check that you receive will be taken care of by the high cost of food, energy and taxes.
There is a great website that has a list of tax burdens according to each state. Each state can entice new migrants or retain long time residents by changing their tax codes. There are some states that have no sales tax and others which have no income tax. Even among the states that do have taxes, their levels will vary. There is a great resource here: http://www.retirementliving.com/taxes-by-state, that breaks down each state and how much it costs to live in that state. Sure, we all want to live in Hawaii, but can we even afford a condo there? Which brings me to my next factor...

3. What is the climate like?
I have seen a job opening for a position in North Dakota before. I'm sure that the summers are beautiful and mild, but a cold intolerant person like myself would not be able to survive the winter. Likewise, I don't believe that I would be able to survive hot/humid weather. I much prefer hot and dry weather as in California, Nevada, Arizona, etc... We are fortunate that job positions are still available across the country because it gives us the ability to choose our weather. Believe it or not, weather plays a big role in our mood and mental health. Most people in the US don't have that luxury.

4. Is it a place that fits what you like to do or believe in?
If you are going to work in a large city, you have the immediate satisfaction of being able to go out in your free time and enjoy all that the city life has to offer. If you are looking to raise a family then perhaps a more rural or suburban area will be to your liking. Do you like surfing? If you're living in Utah then don't expect to go surfing often. If you can't live without skiing, then Colorado might fit your bill. Despite having a small part of us offered up to the pathology textbook gods, we all have our own personalities and tastes.
One shouldn't forget that we don't live in a bubble and that our neighbors can make or break our home. A liberal person might not be able to stand living in a conservative county of Texas or vice-versa. Larger states such as California have both liberal and conservative areas. Wikipedia has an informative map of blue states and red states which can be found here: http://en.wikipedia.org/wiki/Red_states_and_blue_states.

5. What is your commute time going to be?
The average American spends 24.3 minutes driving to work one-way. http://usgovinfo.about.com/od/censusandstatistics/a/commutetimes.htm. That eventually adds up to over 100 hours per year! I can think of many better things to do than to spend 4 days in my car. The longest commute time, unsurprisingly, was in New York, where workers averaged 30.4 minutes. The shortest was in Montana at 16.9 minutes. If you're going to settle down, you might want to weigh the costs and benefits of living close to work. My ideal workplace would be right next door to my house, but the next best place would be a place which I could ride my bicycle to. That would take care of my exercise as well as save on gas.

I am certain that there are some other factors that one can think of. If there's anything which you would like to add, please feel free to tell me!

Week One at UPMC Presbyterian Autopsy

This last week was a good chance for me to become reacquainted with the autopsy process. I had learned many things from my time during the WVU autopsy rotation and I felt especially prepared coming here. Although there are a few differences between the way that autopsies are performed between here and at WVU the process is largely the same. WVU mostly receives medical examiner cases and a few hospital cases whereas here at Presbyterian they receive hospital cases almost exclusively. At this current rotation, I won’t get a chance to see some of the interesting forensic pathology related to traumatic deaths or drug overdoses, but I will be getting more experience related to chronic diseases. Most of the patients who sadly pass away here are elderly and have been battling their diseases for many years.

One more interesting aspect of being at this rotation at UPMC Presbyterian is that I also will be getting more exposure to fetal autopsies. These autopsies are performed at UPMC Magee Women’s Hospital, a rotation site where I received training in their gross room during January and February. It’s good to be able to see all of the familiar faces and although fetal autopsies are not assignments that I particularly look forward to, they are a necessary part of working as a PA. There are many diseases that can occur during development that unfortunately lead to the tragic demise of the fetus. Performing these autopsies helps to bring closure for the parents as well as epidemiologically track the incidence of different pathologies.

Recently, I have been doing even more personal research into nutrition and health concerning cholesterol and high blood pressure. I’ve just got to say that it’s great having a background in pathology so that I can understand fairly clearly all of the physiological processes that relate to our health. I love being able to use my professional knowledge and applying it to improve my personal life as well as being able to pass advice onto others. Last night I watched a great lecture on youtube given by a doctor at UCSF in 2009 called, “Sugar: The Bitter Truth”. I never had any idea that fructose metabolism played a role in blood pressure by inhibiting nitric oxide, an important vasodilator. There were a whole host of other detrimental things that I learned about fructose, so I’ve decided to make my diet as free of fructose as possible. I’ll still gladly eat whole fruit, but I’ve had to toss out all the items in my fridge containing high fructose corn syrup, including one of my favorite condiments since childhood, ketchup. Farewell my love. It was just not meant to be.

If any of you readers have the opportunity, I would highly recommend watching the lecture and taking notes while you’re at it. It can be found here:

http://www.youtube.com/watch?v=dBnniua6-oM

Last Week at Ruby Hospital Surgical Pathology Laboratory

This past week has been a bit busier than usual, but I've become inured to that by now. Ever since the start of this weekend however, I have had so much free time I didn't even know what to do. That's a good problem to have. So, this morning I decided to take a trip to downtown Pittsburgh and finally check out the Strip District. It might have a racy name, but what it is is an open market where people gather to sell their produce and crafts. There are all sorts of foods that you can buy and there are a lot of ethnic supermarkets over there as well. Also, I saw one of the most bustling fish markets of my life over there. It was an interesting break from the studying and presentation preparation that I had been caught up with.

My presentation on the pituitary gland went as smoothly as possible. I modeled the style after our pathology power point lectures, introducing each pathology one-by-one and explaining them in turn. I believe that I covered the major pathologies associated with it and am satisfied that I created it to my own flavor. Each professor has their own 'feel' to their lectures and I hope to follow that mold.

While in the gross lab I have become quite good at completing biopsy specimens at a rapid and efficient pace. It's just the larger specimens that are still a stumbling block for me. I'm grateful for every big specimen that I can get, but I still need more practice to increase my speed. There are a variety of factors that are inhibiting the rapid completion of the bigger specimens that I do. My biggest problem is trying to find the right wording in how to describe an object. (eg. The renal medulla is comprised of... no... The renal medulla displays multiple tan-brown, pyramidal... no, that's not good... ah, screw it. The renal medulla is unremarkable.) Thank goodness I had the residents and the PAs to help me improve my dictation. I just need more big specimens. The people at Ruby have my sincerest gratitude.

I also recently went to go get my cholesterol checked and surprisingly it went up. In the winter or fall of last year I was surprised at my continued high cholesterol so I made changes to my lifestyle that included cooking with extra-virgin olive oil, not using margarine, limiting my meat, avoiding cheese, avoiding salt and sugar, eating whole wheat products, eating more fruits and vegetables, jogging every other day and so forth. Looks like that hasn't worked, so now I'm really pissed. I also discovered for the first time that I'm in the 'pre-hypertension' range. Before it had always been below 120/80. I'm going to conquer this cholesterol and blood pressure thing once and for all. For the next six months I'm going to absolutely not use any oil, sugar, or salt in my cooking, nor eat a single piece of chicken, pork, beef, hamburger or hotdog. Not a single scoop of ice cream, a single slice of pizza, a single piece of pie or cake, not even a measly cookie is going to reach the bottom of my stomach. (No, I'll not become bulimic.) Instead of jogging every other day, I'll be jogging at least 20 minutes everyday. I've done too many autopsies where people who don't look unhealthy have ended up dying from MIs caused by atherosclerotic coronary arteries. I'm not going to go out like that if there's anything I can do about it.

As you can probably see, working in the field of pathology gets you thinking about health issues a lot.

For the next couple of weeks I'll be starting an autopsy rotation again, this time at  UPMC Presbyterian. I'm really looking forward to it! I don't have any particular disliking of autopsies, but when compared to my classmates you could say that I'm a little more enthusiastic to preform them. Nevertheless, it's always important to approach the autopsy from a forensic perspective rather than a human one. I don't want people to pass away just so that I can do autopsies. But, if they are coming my way anyways, I'll do my best to shed the light that will bring comfort to their family and friends.

The back-way to the strip district. A lot of the shops on this side were closed and abandoned, so it must have been quite a bustling place in the past.

So many homemade delicious pastries to choose from. I soon left for greener pastures.

If you can make it by hand, you can find it here. There was a plethora of great food available for tasting as well.

Next to the costume shop was a haunted house! It won't be open until Halloween, but it would be a good diversion from studying for a night.

This place seemed to be the hot spot for brunches. Every seat in the house was packed and all the people outside were waiting to get in.

The legendary fish market. Your source of omega-3's for studying.

Lots of outdoor shops. It doesn't look crowded from these pictures, but it was really bustling.

Walking down the strip. There were a multitude of ethnic supermarkets to choose from.

Farmers selling their fresh and organic produce.

Test and Presentation

A test and a presentation on the pituitary gland on Friday are keeping me from writing a new post at the moment. Saturday can't come soon enough! Until then, take care everyone.

Week One at Ruby Hospital Surgical Pathology Laboratory

I've always preferred living in the countryside and moving back to Morgantown from Pittsburgh has been like a fresh breeze after a smoggy day. I'm back with my landlord who has been kind enough to create a special lease just for myself that covers only the few weeks I'll be here. One of the advantages to staying at a person's residence is that you can form a very cordial relationship with your landlord. Their family has made me feel welcome every time I'm here, going so far as to invite me to their family events. I'm more than happy to oblige. I don't mind solitude either, but it's a nice perk while studying in graduate school. I've become a part of this family so much now that I'm taking care of the house as if it were my own. Today, after they had treated me to a buffet for Mother's Day, I worked outside for a while gardening along the side of their property. You can't do something like that at a faceless rental management agency.

Work at Ruby has been surprisingly smooth thus far. At Allegheny I had become accustomed to the voice recording dictation system and assumed that I would have difficulty transitioning back into using CoPath for dictation. Within the first few days however, many of the things I had learned in CoPath at Magee Women's Hospital came flooding back to me. I have noticed that because of the headphone-dictation system the gross room is a bit more quiet than what I was used to at Allegheny. That hasn't stopped me from absentmindedly leaving my recorder on plenty of times while talking with the people around me. When I turn back to my computer I'm greeted with a novel of words which have transformed the screen into a blob of gibberish.

Another slight difference I have noticed is that the tools that we use differ between each site. For example, many of the biopsy specimens at Allegheny are submitted in biopsy cassettes which have holes that are small enough to prevent the specimen from leaking out. At Ruby, the normal cassettes are used more often which means that many biopsy specimens need to be placed in between a pair of sponges or placed in small biopsy bags. Also, over at Allegheny, cassettes had to be ordered from the accessioner directly because we didn't have access to a computer terminal, but at Ruby we can order cassettes directly though CoPath.

Ruby has also instituted an interesting system for inputting requisitions, containers and cassettes into their computers. Each case has a special square label/code that is assigned to it in the gross room and requires that you scan the requisition, container and associated cassettes into the computer before starting. I think that it's a good idea to prevent cassettes and samples from getting mixed up. Sometimes it can be a pain though when you have multiple containers and multiple cassettes for each container and they all must be scanned. Even though they are all scanned, I still spend the brief amount of time it takes to double check visually that I have the right containers and cassettes.

All in all, I'm looking forward to another week building more experience in the gross room. This rotation is especially short (only three weeks) and it's hard to believe that by Wednesday it will be half completed.

Just your average gross dictation.

Last Week at Allegheny General Hospital Surgical Pathology Laboratory

Last week I had intended to write another post about something practical, but time caught up with me and before I knew it I was busy just as before.

These rotations are really flying by, but I'm very grateful to the people at Allegheny who helped me while I was there on my rotation. I was introduced to a wide variety of specimens and wish that I had more time to spend there. Everyone was very helpful and I believe that I fit right in.

There were times when I made a few mistakes (and I also caught a few mistakes made by others) but it was a very instructive experience. I'm a very 'by-the-book' type of person and I follow textbook instructions almost religiously. At this rotation I learned that I need to be more accommodating. Each pathologist has their own preference in what they want to see in a specimen. For example, some pathologists just want representative sections from an appendix while others would prefer that you submit the appendix entirely. Some pathologists want you to separate the fat from lymph nodes in a cancer case whereas others want you to submit the lymph nodes and fat all together.

When you're just starting out at a new place, you don't have a good grasp of what the protocols are until you've spent some time there. It's for this reason that 'CYA' or 'cover your arse' is so important. I have been saved numerous times when a pathologist has requested more sections thanks to me saving and stocking every little bit of remaining tissue. Another thing that I have learned to 'CYA' or as it pertains to me 'CMA' is to ink multiple pieces from the same part into multiple colors rather than just use one color. (It ends up being a bit amusing when you're looking into a cassette and you think to yourself, "Why does it look like I'm submitting skittles in my blocks?")