Last Week at UPMC Chilren's Hospital and First Day at Thomas Memorial Hospital

It has been a busy weekend what with the move that my classmate and I have made from Pittsburgh to Charleston, but it has come as a welcome change. I highly value my time spent at Children's Hospital and got to do a lot of good specimens that I had never done before. There are a lot of things that I would like to talk about while at Children's, but for the sake of privacy I will have to show restraint.

In addition to the interesting specimens that I was able to do at Children's I learned to think more carefully about what I write down in my dictations. There are small nuances that were pointed out to me and I was very grateful for it. For example, in my dictations I would often say, "The serosa is..." and go on to describe the external surface of the specimen. However, the reality is that the serosa is a thin, transparent membrane and usually has no color of its own. So I have changed my dictations to "The serosal surface..." instead. Other small things include giving internal and external diameters to tubular tissues. If I say that, "The diameter measures 0.6 cm" then the reader still won't know whether I am talking about the outer tubular diameter or inner lumen diameter. Also, people interpret words differently, so it's best to be careful with words such as "multi-cystic" or "multiple" because for one person it may mean four while for others it may means hundreds. Grossing is as much a science as it is an English lesson.

The move to Charleston, although initially rainy, turned out to be smooth in the end. On Sunday, I had the opportunity to explore the town a little bit and I already like the atmosphere better than Pittsburgh. I was never much of a city person in the first place because of the cramped roads, the pollution, the noise, the high cost of living and the lack of privacy. Despite Charleston being smaller than Pittsburgh, I was pleasantly surprised while driving around Charleston to see the four lane freeways that are so desperately needed in Pittsburgh. I am already certain that I will thoroughly enjoy my seven-week stay here.

On top of that, the pathologists here have been extremely kind to lend us a whole house of our own while we are here for free. The house is very comfortable to live in and has already come with all of the amenities needed for daily living. Even dishes, silverware and washcloths are provided. I only wish that we had the same housing boon while living in Morgantown and Pittsburgh.

The first day at Thomas Memorial has gone well enough. It stayed busy throughout the whole day, but that may be partially due to being unaccustomed to the dictation system. Similar to Allegheny General Hospital in Pittsburgh, grossers use a voice recorder and transcriptionists physically type out the gross pathology report. My most common blunder was forgetting to say "period" or "comma" or "new paragraph" and I lost some time going back and correcting myself. I'm sure that the transcriptionists will be kind enough to forgive our small mistakes this first week at least.

Week Three at UPMC Children's Hospital

Things are busy as usual and I can't believe that it's almost time for me to move again. Just when you think you've gotten something down it's already time to move on. In preparation for the move to Charleston, Prashant and I have switched off our internet at home. I don't usually make blog posts from wifi spots, but Einstein Bros will have to do this time. I can't complain about their bagels.

I've once again learned a lot while at Children's Hospital. To me, the most fascinating protocol that I've seen and participated in over there is 'tumor mapping'. It's actually much simpler than it sounds. I think that it makes a pathologist's job much more easy.

For larger cases at Children's Hospital, they take their normal photographs of the specimens, but then they add to the picture using photoshop. "What do they add?" you might ask. The PAs add lines and squares to indicate exactly where they took each section. The pathologist no longer has to struggle in their mind where each section came from. All they have to do is look at the picture and it will tell them, "Alright, slide 3F came from this part of the tumor. Ah, I see." Tumor mapping certainly takes more time to do, but if a pathologist's assistant has the time to spare, then it could really make the pathologist's life easier. That's what were here for!

Unfortunately, I will have to cut my post short this week. Take care everyone and keep on working hard.

How Obamacare Could Affect Laboratories and PAs

This past Thursday the Supreme Court made a landmark decision to uphold the individual mandate of Obamacare or more formally known "The Patient Protection and Affordable Care Act." Although I have my own opinions about the moral implications of this ruling, I will try to leave aside the politics and analyze how the Affordable Care Act could affect the future of the field of pathologist's assistants as well as its affect on clinical laboratories.

Of course, this is all contingent on President Obama becoming reelected in November. Mitt Romney has vowed to repeal Obamacare if elected, so all of these musings by myself could be for naught.

The following predictions are my own personal hypotheses and if I have used incorrect information, then please correct me.

Predictions:

-Pathology Laboratories will receive more specimens.
The individual mandate of course means that there will be many more people required to have health insurance. It has been estimated that as many as 34 million new people will now gain health insurance through Obamacare. The rule of subsidies follows the slogan, "If you subsidize it, you will get more of it." With more people becoming covered, I expect that these people will want to have more tests done. Whereas before a person might have ignored that strangely growing brown spot on their arm, now they will be more inclined to get it checked and have a biopsy done. This will be a great step forward in preventative care. More people will be getting their diseases checked out early before they become bigger problems later on.
Effect on PAs: Slightly Positive. More specimens means that laboratories will be busier and there will be a greater demand for PAs. Laboratories may have to hire more PAs so the job market should be favorable.

-Pathology Laboratories will receive slightly more biopsies. The number of complex specimens should stay relatively constant. The type of complex specimens may change slightly.
Because more people will be able to get their ailments checked out early, I would expect the number of biopsy specimens to increase. If these biopsies lead to the early detection of disease then the disease can be managed before having to visit the surgeon. As more people become covered by health insurance, the cost of health care is shifted to the insurance companies who will in turn raise premiums. When individuals are not responsible for their own expenses, then they will utilize the service more. However, we have a positive feedback loop here. Because higher utilization will increase the costs to insurance companies and lead to higher premiums, people will be impelled to use the service even more to "get their money's worth."
Earlier detection of diseases will lead to fewer complex specimens, but it should be countered by the increased number of prophylactic complex specimens. Tumors and so forth that would have gone undiagnosed (but would most likely have stayed benign) will now be caught. (For example, think of all of the prostatectomies that are occurring due to prostate cancer as a preventative measure. Most people with small foci of prostate cancer will die due to other causes, but nonetheless many still undergo the prostatectomy procedure. Another example would be mastectomies and hysterectomies.)
Effect on PAs: Neutral. The beneficial role of having a PA work in a laboratory is that PAs are certified by law to perform high complexity testing. I expect that complex specimens due to patients ignoring their health to decrease (lung cancers, large skin cancers, etc...), but I expect the number of prophylactic and non-life threatening complex specimens to increase (prophylactic mastectomies, prophylactic prostatectomies, hysterectomies, etc...).  I expect biopsies to increase, so I would expect that the demand for laboratory technicians, who are cheaper to hire than PAs, will increase.

-Small Pathology Laboratories will struggle to stay in business. Hospital Laboratories and Large Pathology Laboratories will be able to weather the increased costs.
When I write 'increased costs' what I really am talking about is the decreased reimbursement that laboratories will receive under Obamacare. It seems that laboratories always bear the brunt of cuts. They are an easy, out-of-sight target and patients don't ever visit clinical laboratories. A letter written by the American Clinical Laboratory Association (ACLA) states that the combined effects of the Middle Class Tax Relief and Job Creation Act of 2012, Obamacare, and anticipated future sequestration cuts calls for a total 23% slash in Medicare reimbursements to clinical laboratories over the next 10 years. (Imagine what it will be after you account for inflation!) Clinical laboratories only make up 1.6% of Medicare spending but will bear 15% of the Medicare cuts.
In addition, most smaller laboratories aren't reimbursed the same as some large hospitals and laboratories due to Section 508 of the Medicare Prescription Drug, Improvement, and Modernization Act. It has been around for a while; it passed in 2003. But, it puts further strain on smaller laboratories that are not a part of the 'in-group'. You may have thought that reimbursement rates for Medicare specimens was the same throughout the country, but that is a fallacy. Larger hospitals and laboratories located in areas with high costs of living are reimbursed a greater percentage than smaller laboratories. Reimbursement rates are basically tied to a cost of living index. The already smaller reimbursement rates will cause small laboratories to buckle even more.
Effect on PAs: Negative or slightly positive. The effect will be largely dependent on whether you work at a small community laboratory versus a hospital laboratory/large laboratory. Lower reimbursement rates could cause many smaller laboratories to go out of business or refuse to accept Medicare patient specimens. If the smaller laboratory can weather the loss of reimbursements, then it will put a strain on laboratory personnel salaries. If the smaller laboratory can't weather the loss of reimbursements and chooses to refuse Medicare patients, a large percentage of their specimen volume will be gone, leading to lower demand for PAs. 
Of course, hospitals will be more than happy to take on the Medicare specimens that smaller laboratories don't take. Classically, tests done at hospitals cost more money and hospitals/larger laboratories are reimbursed more for Medicare specimens. If nearby smaller laboratories close, hospitals and larger laboratories could see an increase in specimen volume. 
It should be noted that the other people who will be hurt are unsurprisingly Medicare patients. Some nursing homes may no longer have access to their local, low-cost, small clinical laboratory and will have to rely on the more expensive hospitals which are farther away.

I am sure that I have missed other important details regarding the effect that Obamacare will have on PAs. If there is anything else that you can think of or would like to add, please leave a comment!

------------------------------------

Update July, 4th 2012

------------------------------------

I have an additional prediction that I have thought up of.

-Laboratories will receive slightly more complex specimens. This goes in contrast to what I wrote above, that "the number of complex specimens should stay relatively constant". We know that with up to 34 million new people receiving healthcare and not a new doctor being trained to take on this increased load, waiting lines and appointments will take longer. How much longer it will take to see a doctor and how much longer it will take to see a specialist remains to be seen. However, the increased waiting times (whether it be weeks or months) could give certain cancers just enough time to become more invasive, metastatic or complex. It is a sad development for patient care, but a very real possible outcome of increasing patient load without increasing the number of doctors. A minority of Americans may be able to afford traveling abroad for instant healthcare (medical tourism), but the vast majority of Americans will have to compete with each other to be seen by the same number of doctors, or just give up altogether due to the increased waiting time.

Effect on PAs: Slightly positive. I would never want someone to develop a disease for the sake of providing a living, just like I would never want someone to pass away so that I could do an autopsy. A slightly increased load of complex specimens means that PAs will be in slightly higher demand.

Week One at UPMC Children's Hostpial

My first week at Children's Hospital has passed and it has been surprisingly busy. As expected, the gross room at Children's Hospital receives a multitude of specimens related to pediatric and children's issues. If you can just imagine the types of ailments that commonly afflict children (appendicitis, tonsillitis, etc...), then you will have a firm grasp of the types of cases to expect. Nevertheless, it is always the more unusual cases that stick out in your mind.

My first impression of the laboratory was, "Wow! This place is really well built!" The lab is the most spacious lab that I have ever seen. All too common, labs are crowded with narrow corridors and there is little room to move. Not so at Children's. The hallways are the largest I have ever seen and the distance between each bench is fit for a king's reception hall. It makes working in the laboratory much less claustrophobic. On top of that, the facilities are all new, clean and have a professional look to them. I'm very impressed with their facilities.

It seems that almost every laboratory that I go to, the pathology laboratory is relegated to the basement. It makes sense from a cost perspective, but there is something psychologically dour about heading "down" to work as if one is entering into a dungeon. I very much enjoy nature and being inside all day makes me a little restless, so at least during my lunch break I try to get outside and get some fresh air and sunshine. I suppose that if I want to work in a ergonomically pleasing zen-like work environment that is attuned with nature, I'll have to start my own laboratory.

Thus far the PAs at Children's Hospital have been easily available for my questions. Since this was my first week, my questions basically consisted of things like "Where are the plastic buckets?" and "My key card won't give me access downstairs. Could I borrow yours?" So far so good. The dictation system for "voice over" has been mistranslating a lot of my words and the PAs are still helping me with it. It seems that the voice over system for UPMC doesn't understand my words as well as when I was training at Ruby Hospital. I certainly hope that my future work place uses a software that easily understands my words. It can be frustrating when you need to spend more than half of your time correcting mistakes due to the incorrectly set software.

This Friday there is another monthly test that is coming up, so I'll be busy studying for that. It seems that employers don't really care about your grade in graduate school so long as you have the graduating degree. Nevertheless, for my own sake, I'll still be studying as much as I can.

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