As intersession ends.

Last year's class apparently did really, really well on the neuroanatomy quiz which means that this years quiz got significantly harder. We had it this morning and it was rough! And long! It just kept going and going. It was scheduled from 9-10 am, but I didn't finish until after 10:30 and only about half the class had finished by that point.

I will say that the text assigned for it has been the most readable textbook ever. There were even moments of humor it, and like a James Patterson novel the chapters are only a page or two long which makes it a fairly quick read. It also has lots of diagrams, interesting case studies, and a bunch of practice questions in the back.

Last Friday the med students had their big final for Brain and Behavior (their intersession class). When talking to some of them about it I realized just how much I am enjoying our intersession and how I don't want it to end. But it must! Next week we start up again with the medical students for Body and Disease. It should be interesting... I am withholding judgement on the TBL format and am trying to be cautiously optimistic. There have been extremely mixed reviews from the Brain and Behavior format from the medical students and apparently working in small groups negatively impacts the intelligence of the people in the group.

Wednesday afternoons the med students have their practice course, and since we don't have to learn how to interact with patients we get to use that time for clinical rotations. Actually, this whole week they are practicing their patient interview skills. Meanwhile we're going to have a four and a half day weekend. I don't have anything fun planned but it will still be nice to have a break!

Last weekend was actually pretty good. Friday was strange. I really wanted to go out but my classmates were opting to stay in and be studious, so I went to hang out with some medical students. My husband was visiting so he went too. It was surprisingly fun to do something different. Saturday, my class went to the Duke lemur enclosure (the second largest population of lemurs in the world) and we got to see lemurs! And slow lorises and bush babies! I want to go back in the warmer months when you can walk through the areas where the lemurs are running free (in the winter they have indoor spaces). I'm glad my husband got to come since for the most part he comes on the weekends when I have tests and don't go out.

There were autopsies on Saturday that we could have gone in to see. I kept going back and forth about whether I should go or not, and finally decided not to go. The kids have basketball games on Saturdays and the autopsy staff don't have the luxury of time to do a lot of teaching on the weekends. And my group has been able to see autopsies almost every day that we've been on call over the past few weeks, so I already feel a bit ahead of the curve.

Sharing vs Anonymity

I am not particularly anonymous and I haven't been very secretive about what program I'm in; therefore, I've opted to be intentionally vague about decedents for autopsies. The chances of someone whose loved one has been submitted to Duke for autopsy doing a web search and stumbling on my blog are pretty much slim to none. But... there is always a chance. No one wants to read a gleeful account of someone eviscerating their grandmother.

So I will say things like I got to slice and examine lungs and kidneys last week (because I did, go me! My first little bit of autopsy cutting), but I won't say things like we got a 63 y/o male with a history of CABG (we didn't, honestly) with massive amounts of pleural effusion. There might sometimes be unique things that we see that would be interesting to write about, but I guess I would rather be boring than violate anyone's privacy.

Duke Pathologists' Assistant Class of 2014!

There are ten days left to get your applications in! Not that you should have waited until the last minute to get your application in, but I am fully aware of human nature and know that even if you, the applicant, were conscientious about getting everything submitted to Pam Vollmer the people writing your letters of recommendation might need a gentle reminder.

Now any year is a great year to get into a PA program and start your masters, but if you get in this year you'll get to be my class' first year students when we're second years. And we're fun to be around and will include you in outings. Also, by this time next year, you too will be getting to do fun things like breadloafing organs during autopsy rotations and doing smalls at Duke North and the VA. 

Dragon training, stomping and doing it old school

I have been meaning to discuss this for a while, but tonight seems a good time to do it: Dictation methods. Grossing needs a gross description after all, and it has to get written into the record some way.

In 2010 the practice where I worked made the decision to go from human transcriptionists to Dragon Medical. I got to be the guinea pig for it, followed a week or so later by the other two grossing techs I worked with. We had a miserable few months working out the kinks before they started rolling it out for the pathologists (the transcriptionists at our outlying hospitals were hospital employees not pathology employees so the hospital PAs didn't have to use Dragon). After three or four months (averaging just under a thousand dictations a month per person) it was mostly trained to recognize our speech and we were fairly comfortable using it.

It is trainable, it just takes a while

It does have the advantage that it is easy to create your own customized quick text (aka speed phrases aka macros aka a dozen other things). For instance I set mine up so that when I dictated "start" it typed out the text "A. Received in formalin, labeled "_____"" which saved quite a bit of repetition. And when Dragon is well trained you can speak very fast and it can interpret it, which sometimes meant that just doing a straight dictation was faster than using the text short cuts. It also allows for hands-free dictation, even allowing verbal corrections of things it has incorrectly transcribed. Also, you can see the transcription on the screen in front of you, which allows you to proofread your dictations before they are saved.

There are disadvantages as well. It is a lot of work to get Dragon trained well and some things it refuses to be trained on no matter how many times you try to teach it (every time I dictated the word "yes" it typed out "gas" which made verbally navigating through CoPath's menus ridiculously difficult). Dragon requires you to dictate everything and only transcribes what you dictate, which can be frustrating. A good transcriptionist is great to work with, they know what you should have in a dictation for common specimen types and can fill in the blanks when things are inadvertently left out. Dragon doesn't do any of that. The start up cost can be high and you really have to have a computer screen at each grossing station.

Also, in cases where you have people on rotations (any academic or training facility) the time required to train Dragon to a useable level is longer than the time the residents or students would be spending on the rotation. That is also the sort of situation where you want to have the well trained ear of a practiced transcriptionist proofing anything they dictate.

Before Dragon Medical came along we had human transcriptionists and foot pedals, similar to the set up at Duke. I loved this set up! It allowed for hands free dictation, so like Dragon, you could be finishing your dictation while sectioning/filtering/closing up the cassettes. It was efficient. The disadvantage was that if you had to go back and make a correction you had to rewind and listen to your dictation to see what you had already said, which wasn't bad on a one line GI dictation and awful on a three minute long kidney dictation. And, there is the recurring salary cost of transcriptionists that you don't get with Dragon.

And before Dragon and before foot pedals there are the old school methods. Before my old company got foot pedals we had hand held voice recorders. It also relied on transcriptionists so it had the advantages of having a live person going over the dictation and didn't require a computer to be dedicated to each grossing station. It was clunky, did not allow for hands free dictation, and the dictation tapes had to be physically delivered to our transcriptionists (who worked from home). It did seem to rewind faster than the foot pedals though, which made doing corrections easier. There is also the option of typing or writing our your dictation but I've never really used those methods so your idea of the pros and cons is probably as valid as mine is.

Day in the life: Rotations

Appendix of the testis slide from webpathology.com

Yesterday morning my group went to a conference with one of the staff PAs and the second years where the second years presented interesting cases they've had recently and gave background information on the disease associated with the specimen. It was very interesting and we learned some things we wouldn't have learned otherwise (I can't be the only person surprised to learn about the appendix testis, right?). And while we didn't have an autopsy we saw a case signed out, and one of the autopsy PAs let us see the organs from the case from the day before which had some interesting findings.

Today we had brain sign out, medical terminology and rotations. Surgical pathology is fun and honestly learning the format for dictations here at Duke is the hardest part of doing smalls so far. For some reason I'm trying to say one word (like quote) and another one pops out of my mouth (colon). No idea why, but it is driving me batty! At least we're picking up speed and getting to do a wide variety of small specimens.

Derms are done in a way completely different from what I am used to, which means that so far the only advantages gained from three and a half years of grossing are 1. I can pronounce the word nevus correctly without thinking about it and 2. I know when to call something a macule and when to call it a papule. In the future I may also demonstrate some decent knife handling skills, but for right now this is what I've got :-)

Rotations, Autopsies, and a bit of a social life.

January has been such a fantastic month so far! Rotations continue to be great, and I'm looking forward to another day of surgical grossing at Duke North. I am getting used to their format for dictations but more practice is always welcome!

Last week we finally got to see some autopsies, including one where we got to see a second year student do the evisceration. That is what I'll be doing this time next year, so exciting! We also got to see the autopsy technicians (dieners) do some evisceration and it is impressive how quickly they get everything done.

I mentioned before that Duke does a modified Letulle autopsy, removing the colon and then doing the rest of the organs en masse. I am used to Virchow autopsies, which is all done one organ at a time and doesn't require the prosector to visualize body placement/orientation. The en bloc method makes it much easier to examine the entire organ system at once and minimizes the time the body is open and exposed. I like being able to see the different styles.

Grave Digger at Monster Jam! Photo credit to April :)

In other news, we had a three day weekend for MLK and it was so relaxing! My class (and my husband!) went to Greensboro for Monster Jam! And since we were there, I finally got to take advantage of a friend's generosity and treated everyone to sushi courtesy of him. It was a really fun time.

Sunday I went to visit my favorite med students and one of my classmates and I took over their apartment and everyone made Filipino food together. Then we took a break where I went home and cooked American food for my family, and then I went to the movies with a couple friends (War Horse, which was okay but not as good as the company).

Yesterday was my dad's birthday, so the kids and I got him a card, some money, made his favorite dinner and baked a cake while I studied off and on for my autopsy procedure quiz and ignored the giant pile of laundry I didn't fold this weekend (I will do it tonight... probably).

Why am I in school?

Being on rotations I've gotten to talk to some of the second years that I haven't really had much interaction with up until now. Two different ones have asked me why I'm going through a PA program when I was grossing before. And I guess, looking at it from the outside, I can understand the question. I do think, though, that they will understand why I made the choice after they have worked out in the industry for a while.

Beyond what I'm learning in classes, I'm getting an opportunity to see a greater variety of specimens than I will ever see again. The thing about Duke is that it is a major medical center and there are surgeries and procedures commonly done there that rarely happen in other places. Just from an intellectual standpoint, it is a great place to be.

Not only that, after graduation I will have my masters and be eligible to sit for the board exam, which makes me much more marketable. Also, before I could only gross specimens that a pathologist had signed off on me for, which doesn't mean as much to a future employer than a solid year of documented rotations and dedicated training. Not to mention that board certified PAs earn significantly more money than a grossing tech, which helps offset the tuition investment.

And... I'm really enjoying the experience. Seriously, even with the horrific test anxiety and stress of being back in school after four years out of it and living apart from my husband, I enjoy it. It has given me a lot of perspective about the specimen types I've worked with and I know that Body and Disease is going to even more applicable. Plus, we're going to have microbiology and it has always been my favorite subject! I have great *classmates (yes, yes, I know I've mentioned it once or twice before, but they are!) and we have med students who have been amazingly inclusive. I walked from the parking garage this morning with one, got hugged by others who spied me in the food court at lunch and was joined for lunch by one of my absolute favorite med students. Our program directors are accessible and responsive, and while I'm not entirely sure how the TBL intensive spring semester will be the idea of it is interesting.

*No seriously, they do amazing things like share outlines they've made, send out information about resources, and are just great to work with in groups and on rotations.

Ugly side of medicine.

Today started with autopsy sign out, it wasn't on the schedule but as a class we are usually early enough to have significant time in the student room before we're due to be somewhere so we just tagged along when we heard it was happening. Just from conversation with one of the autopsy PAs it reminded me of some of the cadavers and specimens I have seen.

For many people, it is hard to imagine walking around with part of their body mummified or rotting off but for other people it is their normal life. I don't know how long you have to wear your clothes before they fuse to your body, but I've seen it at least once and heard of it from others often enough to know it happens more than someone outside of the medical field would believe.

Where I worked before some specimens made it into legendary status for their odd location, appearance or sheer size. I will never forget the enormous pedunculated skin tag that we dubbed the "back potato" for its shape, color and size. It was massive and I couldn't figure out how you could sit or wear normal clothes while carrying around something so large, and it had to be growing for ages.

Large crusted skin lesions, hoof-like toenails, gangrene going black, sloughing... things allowed to fester for years and years. It could be a matter of not having health insurance, a neglected geriatric patient or that deep seated human belief that if you ignore it long enough it might go away (ignoring the evidence of past experience, of course).

It can be heartbreaking to imagine living your life like that, especially for the elderly patients who aren't necessarily the one making the decision to go for medical care or not. For that, I am actually grateful that in pathology we won't have to see the patients whose specimens we receive and that the autopsy patients are beyond pain.

Intersession Week 1

Tabs from our binder--awesome topics to cover this month!

It all started on Monday with getting to see all of my classmates again and play catch up on everyone's holiday break. We had an orientation to the schedule for the month and received the not unsubstantial binder containing lecture materials.

We had classes on neuroanatomy, medical ethics, lab safety, medical terminology (which is more fun than it sounds), autopsy and surgical pathology at Duke, as well as neuroanatomy lab. And, as I mentioned a bit in my last post we've been split into two groups for autopsy and surgical pathology rotations. It is fine, because our class is pretty close as a whole there have been no complaints about who is in which group. And being split up makes it fun to come back together and hear about what the other group got to do that day.

I really cannot being to say how excited/happy/jubilant I am about the rotations? Sadly there wasn't an autopsy Thursday afternoon (the one time my group has been on that particular rotation) but I'm holding out hope for tomorrow afternoon (and if we don't have one then it is extra time to read the neuroanatomy text, which is useful too). I am really interested to see an autopsy here because they do a modified Letulle (en mass organ removal) for their evisceration, while my experiences up until this point have been with Virchow (organ by organ removal).

Trimming knives

The surgical pathology rotations are pretty great so far. It is fun to be grossing (even just a little bit!) again! I tried to be good on Friday and use the scalpel instead of the trimming knife so I can be more proficient with using it. 95% of the time I've used the type of scalpel I posted in the last blog entry. Occasionally I used a regular scalpel with a #22 blade, so I have to get used to handling a regular scalpel with a much longer cutting surface than that. Trimming knives are fantastic and sharp but it would be ridiculous to try to cut up a little skin shave with one or bisect a little GI biopsy. I am sure that by the end of the month I will be much more comfortable using the tools available to me here, it is (like most things!) a matter of practice.

Also, if I can add another thing about how Duke is different from my previous experience? There is just so much more going on in the surg path department! Frozen sections are happening all the time; there are PAs, PA students, and pathology residents doing fixed tissues; and there are techs moving around through all of this as well. It is definitely a bustling environment! At my last job there were three of us in a brand new facility (built around the middle of my time there) with yards of open space between the grossing tables. It is fascinating to be somewhere where the pacing is so different and every where you look someone is doing something interesting.

Quickest blog post ever!

I love this style of scalpel <3

I will write more when I am less engaged in other things, but my class has been split into two groups for January and my group had surgical path rotation today. I got to gross my first specimen at Duke! It was exciting and made me realize just how very much I've missed grossing. It was good. It is funny though since so many things are different! It must be like this when a PA moves from one job to another... the basic tools are the same (scalpel, forceps, cassettes) but everything is not what you are used to and you have to let go of the way you have always done things. I am used to yellow cassettes being derm cases but those are stat cases at Duke, pinkish purple being GEs but those are surgicals at Duke, and green being surgicals which may or may not be small biopsies at Duke (it was a long day with a lot of information so forgive me for not remembering offhand). There are other little things like measuring with the top of the ruler instead of the bottom and using a different type of scalpel.

Tomorrow we have a neuroanatomy lab and my group is assigned to autopsy. I'm not hoping that a bunch of people die so that my January is more interesting, but I am hoping that if people are going to die anyway that they do it the days when I am on autopsy rotation.


Meanwhile I'm having a dinner party tomorrow night. I might have seriously underestimated the amount of work involved. I thought it would be fun to try making something I've never cooked before with my classmates and an assortment of med students as guinea pigs. I made a roux last night, I thought I had burned it but it turned out it was actually a pretty good brick roux. Unfortunately I didn't think to google what it was supposed to look like until after I let it cool down into an unappealing sludge in the bottom of my dutch oven. So tonight is my second attempt at making gumbo.

And I've gone insane with the whole cheese plate thing again. I don't think it is normal to have a monthly cheese budget... but I enjoy it so much.

Anyway, I have to go rearrange my living room furniture, make a chicken and andouille gumbo, slice lots of bread, and cut up even more vegetables. I promise to write a real blog entry detailing the awesomeness of this week so far this weekend!