This week in frozens

This is my third week at Duke North on this rotation, which means I'm doing triage/frozens.

Pinned specimen from this site

Triage varies by specimen, but almost everything gets weighed, measured, or both. Margins may be taken, specimens may be inked for orientation, and opened up or bread loafed (sectioned but not cut all the way through) to allow better formalin fixation. Some specimens may be pinned out on cork boards so they fix in the shape they are pinned into (useful for things like an esophagogastrectomy). And everything gets put into adequate formalin. Larger specimens are held until the next day for grossing, which is nice when you're a student picking out the cases you'd like to do for the next day.

Where I worked before didn't do that much with triage. Sometimes we would open the colon specimens, and sometimes we would ink mastectomies for orientation and bread loaf them. Colons and breasts were held until the next day, but everything else was grossed the day we got it. Most of our specimens were received in formalin, but larger things like spleen and liver were usually not. And being in formalin isn't the same thing as being received in enough formalin! Sometimes there was so much specimen crammed into a container that there was just a splash of fixative on it and most of the tissue was still unfixed. So I can appreciate that the PAs or residents doing triage at Duke are the ones ensuring there is enough fixative, and that there is enough flexibility on the the turn around time that things can be held for a day.

Frozen sections are interesting. We go with the staff PA or resident to the operating room and are handed the tissue of interest to take back to the gross room. Then we triage the specimen and whatever section(s) we need are taken and given to the techs. The techs section the tissue and stain the slides. The staff PA works with the tissue bank/research folks to provide needed tissues at that time as well if they can. The pathologist reading frozens that day may see the specimen or ask for additional sections, but once they are done the specimen is put into formalin and accessioned.

It has been nicely steady and I've gotten to work with one of the staff PAs that I haven't worked with before. Plus, I've worked with several residents which isn't something that happens often when we're at Duke North. It is good to get to learn from so many different people.

In other news, today is my dad's birthday! We had a small family celebration at home. 

Hilarity ensued

We're doing a lunchtime lecture course, and part of today's lecture involved what not to do when giving a powerpoint presentation. It involved our course director dressed as a pirate (more or less) giving an intentionally horrifically uninformative presentation that demonstrated all the things you shouldn't do while giving a presentation. It had sound effects, excessive animations, delightful color combinations like light lime green on a busy orange background, and the sort of disorganized rambling instruction you get from someone who isn't exactly prepared for the talk they are supposed to be giving. It was great, lots of smiles all around.

We also had some much more serious information imparted. I really feel that most people would benefit from a quick what not to do when it comes to powerpoint presentations. Some of it is common sense, but I think almost everyone is guilty (at one time or another) or putting way too much information on a single slide.

In other news, we got our fall portfolios back along with our evaluations from all of our rotation sites. I received some nice positive feedback, which is always a great way to start a new semester.

My first day back at North after the break was pretty good. We got a late start as always because of photography, but still managed a productive morning. It was funny though because even somewhere as busy as Duke can get things in waves. It was something I noticed where I worked before, all of a sudden, out of nowhere it would be spleen week or one digit amputation after another or massive sutured skin ellipses. Some days it seems like the tonsil folks are offering surgeries two for one and you have set after set, and other times you might go several days without any. Same thing today at Duke, although not with tonsils. I did several different specimens, but it seemed like there were only two types of surgeons working and they were either one type or the other. It was odd! But not bad, it was actually something I enjoyed practicing on.

So overdue for an update...

I'm winding down three weeks at the VA. It has been a productive few weeks, and I've had lots of chances to do frozens. It is always interesting when I've been away from the VA and haven't been doing them... It is inevitable that my first case after being away is one where the surgeon walks it down to the gross room and sits there waiting for the frozen to be done. Ah, stressful! But it is fine. After being back in the swing of things for a while, I feel comfortable that I can churn out some decent sections.

Plus, it is a useful rotation to be on for a while. I get to see the slides that my sections get turned into and pick up bits of knowledge from the attending pathologists and residents--and we're there with one of the nicest residents (most of our residents are pretty awesome, but she is just really exceptionally pleasant). The VA is a lot more like a regular hospital than Duke is, so it is good to get a mix of smalls and complex specimens instead of the high concentration of complex specimens that you get at a major academic medical center. 

Christmas trees make me happy!

Today was the Christmas party for the clinical labs and there was an enormous amount of food brought in. We snagged some on our way to our lunch time lecture, which was our penultimate class for this course. It has been one of those long weeks where we've had a morning class every morning and a lunch time lecture each day (except Monday). There's been a lot of going from the Duke clinics to the VA back to the clinics and then back to the VA. We take this walkway between the clinics on the way through Duke North when going between the clinics and the VA across the street that is lined with windows. One side looks out over the new center for medical education, the other is the Duke Medical Pavilion--both of which are under construction. Every day, every week, we can see it change. I like the idea of it... things have grown and evolved during our time at Duke and will be in their semi-final state by the time my class graduates (I say semi-final because it seems that hospitals are always changing, but I think they will be happy with the way things stand for a while after this construction wraps up. Although... I'm sure there's someone somewhere in the organization that is already projecting the needs of the hospital system for the next decade that's drafting a whole new set of blue prints for future classes to watch be erected.).

The Christmas party did take me off guard though. This year has just gone zipping past! Our fall semester is going to be wrapping up in just over a week. I feel like I've gotten to gross everything that I've wanted to do, which leaves the spring for refining those skills.

Second year is just so different from first year. I don't get to see our first years much unless I'm on autopsy, but I hope that they're doing well. They have another few days before their exams, but they are coming up quickly! And then they will get to be on rotations with us in January, everyone is looking forward to it. It will be good for them as well to get some hands on experience. January was really a high light of my first year and I think that is a pretty universal opinion. 

What I did on my summer rotation

I thought it might be interesting for folks considering a pathologists' assistant program to see the types of specimens that I encountered and grossed during my first rotation (it was summer so it meant only one pass through Duke surgical pathology and the VA surgical pathology, and that we were brand new students so the complexity is not what it will be). This is not a comprehensive list, since I am not including specimen number counts and it doesn't include autopsy at all. Also, I'm not breaking it down by location to keep things vague since these are specimens that could be received on either rotation and I tend to overcompensate when it comes to not violating social media policies.

Summer rotation specimen list:

Lumpectomies
Radical mastectomies
Reduction mammoplasty
Sentinel lymph nodes/node dissections
Foreskin
Nephrectomy (partial and radical)
Prostatecomy (radical)
TURP (prostate chips)
Vas Deferens
Thyroidectomy for neoplasm
Liver wedges
Hepatectomy (total and partial)
Amputation specimens
Lipomas/Hemangiomas/lymphangioma
Assorted orthopedic specimens
Appendix
Colon resection (with and without anus, with and without appendix)
Gallbladder (routine and for suspicion of neoplasm)
Small bowel resections
Stoma takedown
Fetus
Hysterectomy (for fibroids and neoplasm, simple and radical)
LEEPs
Ovaries (benign and neoplasm)
Placentas (singletons and multiples)
POCs
Pneumonectomies (native lungs for transplant patients and neoplasms)
Pneumonectomies (wedges/partial)
Tonsils
Assorted smaller specimens of varying types/complexity

It feels like a pretty solid start to my clinical year! The fall semester has already had some interesting specimens pop up, but I'll save those for later.

The coolest thing I saw last week...

So Friday wrapped up my week in imaging, which was mostly getting the opportunity to see how tests I've heard of before were actually performed. It was neat, especially with some of the FISH stuff where they are working on being able to detect extremely low percentages of positive cells. But, by far, the coolest thing I saw was the process that allows them to count circulating tumor cells (CTCs) from patients with tumor metastasis.

It is one of those things I've never heard of before, and I don't think I'm alone in that. The patients come in approximately every six weeks and their levels of CTCs are counted. It allows their doctors to see how the patient is responding to treatment very quickly and to be able to track the extent of metastatic disease in the blood. They can even directly visualize tumor microemboli, as in they can count the number of cells in a microemboli. It was such a cool technology and I was able to see some sample data that really showed how effective it was in practice. I sat with the tech who has been the one to get the process up and running at Duke (it isn't a wide spread technology yet, there is one at Duke and then the next closest one is in Tennessee) with the results of a test up on the screen in front of us and he did his count of cells with me, quizzing me on which cells I thought were positive, negative, or borderline. It was a lot of fun.

It is a quick entry, I just wanted to get that down while I was thinking about it (I still have three things from autopsy I haven't written!). Some days technology just amazes me, I'm so lucky to be able to see things like this.

Autopsy, special cuttings, and histology

Paraffin tissue blocks (not mine though!)

In deference to the Duke social media policy I will continue with my (maddening to some, apparently) tendency towards vagueness.

Duke's autopsy service is pretty busy, some cases come from outside hospitals and some from Duke itself. Autopsies happen and I will be present for some of them (some as the person eviscerating, some assisting a resident or staff PA, and some as the lead prosector). We have three diener's (known collectively as "The guys") who do most of the eviscerations, prep work, lung inflation, and clean up. It is very helpful to have such experienced techs, especially considering how much time the autopsy services spends training residents, med students, and PA students.

I like autopsy, in general (although the smell can be very noticeable at times)...the schedule can be irregular though. In addition to the actual autopsies, which can start any time between 8 am and 1:30 pm, there are the slide sign outs (going over the slides with the attendings). Some sign outs have more of a set schedule, but other times it is when the residents have had a chance to look over their slides and can grab an attending. There are also the special cuttings (brain, eyes, and sometimes heart if there is a reason for it) which may or may not have a regular schedule (brain definitely does) and may or may not be mandatory (eyes aren't). It just makes me worry that I'm going to miss something. But the autopsy PAs are fantastic and the residents I was with last week were so great to work with, so it was a really amazing first rotation.

This week is histology! They set aside sample tissue during preceptor week and I took my blocks down for processing on Friday. I embedded them this morning (with a break to go to a special cutting) and spent the afternoon cutting slides. I've embedded before, but this was my first time making slides. Oh my goodness, I would be the worst histotech ever! Or at least the slowest. And paraffin shavings get everywhere! The rest of the week will be spent doing special stains and studying the histology textbook.

Keeping a log...

As second years (yay second year!) we are supposed to keep a portfolio of specimens that we gross for a couple reasons such as being able to tell future employers what we've done, ensuring that we're not missing out on any particular specimen type, etc. My first day of preceptor week was at the VA (my second day will be there too!) and I know that I grossed things... but neglected to write down how many of what. Tomorrow I will do better with that!

At some point I tried to figure out ballpark numbers of specimens that I did in my previous job. "A lot" probably isn't a very useful unit of measurement. I know that the last full year I worked we did around twenty nine thousand accessions. Approximately five or six thousand GI (and I know that about a third of them had multiple sites, so figure between seven to nine thousand actual specimens in a given year). Skins and small surgicals were each around nine and half thousand accessions (say eleven or twelve thousand individual specimens for each type) and large surgicals that the techs did were maybe five thousand (mostly not multiples but maybe six thousand actual speciments). There were only two of us for the first year and a half that I worked (although during that time I did mostly GIs, some small surgicals, and almost all of the large surgicals), and then three of us for the last two years I worked when we started added more derms, larger smalls and larges. So... "a lot" seems to sum it up. It sounds weird to say that I've done thousands of anything, but realistically I've done thousands of GIs, thousands of skins, thousands of small surgicals (so many cervical biopsies, tonsils, etc).

But! Those specimens weren't officially supervised educational specimens so while I've done them and I should hope they count in my favor when it comes time to interview (although most positions do mention that they welcome new graduates!), they won't be part of my tally this year. I hope I get a decent number of specimens documented though since I'd feel silly just having a list that says I've only done a handful of something common.

Orientation today!

This week is preceptor week, but before that starts in earnest we have orientation! More chapters will be added to our PA student manual and we will find out more specifically what we will be doing day to day.

We're transitioning from the predominantly classroom first year to the predominantly clinical second year, but not really feeling like we're really almost second years yet. Of course our second years are still here but they are all thinking about taking the certification exam, moving and starting their new jobs. I can't believe that will be us in a year! I can't believe they were us this time last year... they seemed like old pros by the time we arrived in August!

It is an exciting period. We'll bid farewell to our second year's, welcome our incoming first years, some of us will start work study positions (I won't have one, in large part due to not knowing what the children's schedule will be with sports and how much I will see them just with rotations, etc), and we'll try to make our way through our first experience in each of our rotations.

I still really need to practice frozen sections... I'm sure that'll happen this week sometime.

Also, my laptop has another virus... I've lost count. I really wish I could have had a Mac, but at least the incoming students seem to have been given the choice. Hopefully it means fewer visits to the IT department for them. 

First year done!!

We had our cumulative final this morning. I spent yesterday studying (with a two hour break around dinner time to see a friend and grab something to eat) and woke up around 6 this morning to go back over the most important things. I feel like I did well... for the most part the answer I was thinking of was one of the options I had to choose from, which I feel like is generally a good sign.

I still feel like laying down and having a good cry though. Just to purge some of the stress from the last week. Not that it has even been that horrifically bad... It always gets built up worse in my mind than it actually is. 

I called my husband on the way back to my car and gave him the report. He said congratulations and then dropped a bit of a bomb on me. Apparently the screening medical procedure my mom had done a few weeks ago had yielded a positive result and she'd gotten the results last week. And everyone in my family decided, what with everything else going on, that they wouldn't tell me until after my exams were over.

Which, while it shocked me, was probably the best course of action... especially considering that our Monday exam covered relevant material and crying makes studying harder. The good news is that as far as prognoses go, she has a really, really good one. Hearing medical news is a lot easier when you know what all the words mean and have a solid understanding of what is going on. And finding out about everything later meant that by today my sister already had a copy of the pathology report, and my mom and dad have had follow up appointments and a plan is already in place.

Senior Seminars and Oral Done

I opened my email to see an invitation to the class of 2012's senior seminar. I've seen facebook statuses saying how they're down to their last 30 days and while studying in the PA room yesterday they were all discussing their cases for their seminar talks. People are getting ready to move and looking forward to being employed and starting that phase of their lives. It is exciting for them, but hard not to be jealous!
 
I can't complain since it really doesn't seem like a year since I got last year's invitation for 2011's seminar! Time flies and it will be our turn soon. I was thinking about that last night, how this time last year I was insanely excited and very impatient to finish up my last month of work and start on this adventure. And now here I am, on the cusp of being a second year student!

I took my oral exam yesterday and passed! I don't know what my score was but after everyone finished taking it we received an email from our course director saying we all passed. I'm good with identifying organs and identifying the disease process... I am less good with symptoms/complications but not horrible. And with cirrhosis I couldn't remember a complication (spontaneous bacterial peritonitis) but knew that I knew it and my brain did that thing where it hung up on that one fact and couldn't move past it. Not horrible though.

And even though it was an oral exam and those are particularly stressful, I didn't have an awful time with anxiety. It wasn't completely absent but I could still function, which is a vast improvement over the way things were in December. I was able to push past the part of my brain that was freaking out and pay attention to the organ in front of me. It helped a lot that as soon as I looked at the specimens on the grossing table I knew what all four of them were. I was scared to look at the table while I was getting dressed because I was worried that they would all look foreign (which is, I know, an irrational fear), but once I did I was reassured. If nothing else I can sight identify organs. 

Pathology Oral Exam Upcoming!

We are heading into the stretch of final exams. Wednesday is the PA Pathology Oral, Friday is the Pathology Small Group, Monday is our final unit test, and the following Wednesday is our cumulative final (which is extremely terrifying!).

The oral is probably the most intimidating, because in addition to being an important part of my grade it is also the opportunity to look completely ignorant in front of our course director. I'm allotting time this weekend to write out the major pathologies of the various organ systems. Thankfully this week's lectures have included both GI pathology and liver/pancreatic pathology so it'll kill two birds with one stone (pathology oral and test 10 studying). I really feel like I need to go back and re-study the renal pathology lectures though because it has been a month since we had those lectures and there have been soooo many other topics covered between then and now. There are other organ systems to review as well, but I just feel strongly about needing to do renal since I don't feel like my retention was particularly good on those. Lungs too, it feels like forever since we've had to study lungs...

Okay, so maybe it would just be safer to start at the head and work my way down! It can't hurt and will hopefully make cumulative final studying that much easier...

Thankfully my kids are with my parents so my out of class obligations are significantly lessened. It is amazing how much easier it is to study during the day when it is quiet and you don't have to take anyone to soccer practice or feed everyone. I'm going to have to take a study break on Sunday though because there is a food truck rodeo! Socializing is important and so is eating lunch!

Test 8 tomorrow!

I took a study break and had dinner out with the kids. Amazing burgers and fries one place and frozen yogurt two doors down. It rained during dinner. As in the bottom fell out of the sky and the asphalt warmed by days of southern heat steamed in the aftermath. My children were well behaved and said appropriate thank yous and everything. It was a good hour and a half.

Then back home... to study, back to my laptop that has been my near constant companion for the weekend.

I saw my best friend's girlfriend (as well as my best friend) for a little while last week since they were in town for a show, and she is in medical school doing the normal two year curriculum. We shared frustration about studying and being tethered to our laptops. Some times I dearly hate my laptop, I would like to close it and leave it alone for a few days... but I can't. Not right now. Maybe in a month (which is an exciting and terrifying thought! I must survive June first... I try not to get too ahead of myself).

I am mentally saturated today. And I may have halfway diagnosed myself with a handful of different random parasitic infections and leukemias.Thank goodness I don't have a prostate or I'd be worried to death about it! Studying diseases makes you paranoid!

I'll have four solid hours in the morning between the time I drop the kids off for school and the time the test starts to go over the IRA questions and Robbins review. It is good to have that type of question fresh in my mind right before tests.

Then... I'll have a fairly social rest of the week (at the moment I have plans with my Durham friends every night except Wednesday...hm, by the weekend they might be tired of being around me lol) and a weekend with not too too much new material to study. I expect by this time next week I should be much more relaxed!

PS: After the test I have to take my laptop to the IT guys again...because it has spyware again (I swear I am not going to sketchy websites!). I've lost count of how many times they've had my laptop. 6 maybe?

Success!

The bake sale went well! There were some pretty impressive offerings (the cake pops looked very yummy!), some folks just donated money, and others came down and got treats for their whole staff. It is nice to be supported by the community! (Yes, yes, I know... no one is surprised that I'm saying Duke is awesome yet again, but I do love it!).

Classes have continued to evolve, but overall the structure relies heavily on student guided learning. But at least immunology is over and we're focusing much more on pathology (and pharmacology but that is more of a med student concern).

We have had sessions with patients coming in to discuss their experiences and those are always interesting. I like the idea that the future doctors in our class get this exposure to the human aspect of medicine. We had one patient who had a doctor elsewhere tell her that her medical condition was all in her head, and it was good for the med students to hear how something like that impacts a patient.

Happy Birthday Blog!

Soooo, around this time last year I was at work and thought it would be a super good idea to start a blog to document this whole PA school experience.

In one year I've posted (including this one) 96 entries, but have written 102.

I've had 16,187 total visitors.

My highest number of visitors for a 30 day period was 3,268 and my highest in a single day was 237 (application season was a particularly busy time for blog traffic). It used to tickle me when I broke 25 viewers a day, so while I don't know who all of the readers are I think you're all awesome and I'm completely amazed that you are out there reading.

This post on interviewing at Duke is my single most popular with 986 views, followed by the posts on TBLs.

I'm glad I started the blog, I hope prospective students have found it helpful and the random curious folks have at least managed not to be too bored :)

I hope you all hang around until we finish up our didactic year in June and can start in on the very exciting clinical rotation year. :-D  Thanks for a great first year!

One test stands between me and a week of (relative) relaxation

I reconnected with a friend I hadn't spoken to in ages and he said that he'd recently thought about a project he critiqued for me and asked me how it was going. And it isn't going. It is on pause. I miss having a creative outlet sometimes but the trade off has been worth it. I knew going into school that it was going to take priority over hobbies, but that the is nature of higher education not just this field of study.

Hopefully my children are paying attention and they notice how much work higher education can be some days so they can figure out that it is easier to do it when you go straight through... high school -> college -> professional school or whatever they end up doing. I can't even complain about my situation because this is what I am doing full time. I have friends who are working 40 hours a week, dealing with a lot more going on in their lives, and going to school. It would get psychologically exhausting but they keep doing it, they keep working every semester for years.

At least for us we have a finite time frame. We have the three major units of the didactic year (Molecules and Cells, Normal Body, and Body and Disease) which breaks the year up into more manageable chunks, as well as our January Intersession that gives us a taste of rotation. I'm glad that our program starts us out as early as it does with surg path and continues it through the rest of the first year.  It would be strange to have to wait through the entire didactic year to get to start grossing. I have to wonder how other programs handle it, I never thought to ask any of the PAs I worked with before. Any of my readers want to chime in? You can stay anonymous if you want ;-)

I had surg path yesterday afternoon, it always puts me in a good mood! Our group works well together and we managed to finish all of our specimens early, which is helpful in a week where we have two tests. I feel bad for the medical students this week! We only have toxicology (2 lectures) and environmental pathology (3 lectures) while they have those lectures plus 300 antibiotics to memorize and the chemotherapy lectures. Since we didn't have to worry about the antibiotics, etc we've been able to study ahead all week. At least everyone has all of today to study (there was only one class scheduled this morning but it is was a non-mandatory Q&A session) as well as tomorrow morning (the test starts at 11).

I did have a frustrating moment this morning. I've been focusing on my Robbins this week and finally got around to streaming the lectures last night (they were funny! But I am biased and always think the pathology lecturers are the best... although the chemo guy was pretty good too). I normally take my IRA right after I watch my lectures since everything is still fresh in my mind but wanted to do it this morning to kick start my early morning studying. So I took the kids to school, came home, looked over the annotated powerpoints and went to take my IRA about a half hour before it closed at 9 and found out my internet was down :( I've never missed an IRA before, especially not a pathology one! Sad. I thought about driving to campus and taking it in my car but I wasn't sure if I could get wifi in the parking garage and the drive to campus time + the get to somewhere I know I would have wifi time would have pushed me just over the time the IRA was cut off.

The Next 10 Days

We have ten days until spring break! Of course we also have two tests before that happens as well. The one next Monday is going to be rough, but this is a good week for me and I'm done at noon tomorrow and Friday. Conceivably I should have enough time on those days to study a lot. And I'm planning to go in a couple hours early tomorrow and Thursday. Whatever downtime I can scrounge up I will try to fit something into, except for Thursday night. I'm giving myself Thursday night off to relax because school/life balance is necessary for sanity!

The other test will be strange since there will only be three days of classes between it and the previous test, but they can cram a lot of information into three days. At least everything will still be fresh in our minds and our actual scheduled class time is pretty minimal that week.

My spring break plans consist of hanging out with my dog who will be visiting for the week, updating the unofficial guide for new students*, writing my autopsy report, and trying to study ahead. My plans would be significantly more fun if my children's spring break matched up with mine instead of being the week after. :( It is okay though, I think the time spent catching up on sleep, movies and life in general will be more beneficial long term than going somewhere. And my husband and I have already started planning a trip for the break we'll have in the summer between first and second year (it is close enough to our ten year wedding anniversary that we're considering it our anniversary celebration) so I don't feel completely cheated on fun trips this year.

Anyway, lab was interesting today. Our instructor is great and he's trying to teach us the keywords that go along with describing different disease processes, like shortened, thickened chordae tendineae indicates rheumatic heart disease. Yesterday's Clinical Pathological Correlation was good too since it focused on the effects of HPV and goodness knows HPV generates a ton of specimens for pathological evaluation!

So that's all for now, not too exciting. Study, study, study, night off, study, study, study lol

*We should get the official mailing list soonish, which means that the incoming first years can expect the deluge of welcome/congratulations emails to start up this weekend or next week sometime. :-)  I, for one, am really curious about them all!

Planning for test 2

There are advantages to having tests every other week. For one thing everything is still relatively fresh in your mind, for another you get every other weekend where you still study but you can decompress a bit and relax.

Meanwhile, I'm trying to plan out my studying for next Monday so that I don't end up cloistered in my study room this weekend. We are done with classes at noon tomorrow and on Friday, so I am going to try to utilize those afternoons to go over the material from last week. I am still trying to figure out if there is any advantage is streaming the lecture more than once or if I should just stream once and then just use the annotated slides.

The workload remains steady, consistently busy but not horrible. I'm still withholding judgement on the educational value of the team based learning exercises. Some are more useful than others, but overall I worry that I get more out of studying on my own. It is a strange shift in perception since I've always preferred classroom learning.


In other news I finally have access for the slides to my autopsy case! We're going over them on Thursday, and it should be good since it was such a complex case. My lab professor is actually presenting the eyes to some of the ophthalmology staff today but I'll have to miss it for class. I will have to check back in with him to find out if they were able to diagnose the anomalies they found (which were oddly enough, not the anomalies they were expecting to find). This was an amazing case to be able to see/be able to present.

Yet another Team Based Learning (TBL) update

Bluedocs screenshot from the instructional video someone posted

We've finished up another week since my last update and I have to say that I am a huge fan of doing the individual quizzes (IRAs) at home. They are still timed and closed notes, but just being able to do them right after I've finished studying (instead of 12 hours later in class) has helped immensely. And we can find out how we did/the correct answers right after we take our IRA through the same website where we do all of our school stuff (it is called Bluedocs, sort of like the blackboard program most schools I am familiar with use).

I am getting used to streaming the lectures online, which I was worried about in the beginning. I have always gone to class so the idea of just watching the lectures online and holding questions until the TBL exercise was worrying. I think it is working out okay though. One of the medical students said, and I agree, that the daily IRA is very helpful because it forces the students to keep up with the material to a greater extent than just going to class everyday did (because being present in class doesn't necessarily mean that you're paying attention).

And keeping up with the streaming isn't overwhelming. All the students except me* were done with classes at noon yesterday and we only had two lectures to stream (they run around 50 minutes but most people I know stream them at 1.5 times normal speed). Today we had morning lab which finished at noon and an option TBL session that only ended being half an hour in the afternoon. I watched one lecture while I ate lunch and would have gotten through most of today's lectures in the PA room before I went home except I somehow ended up reviewing the slides with a classmate's autopsy slides and the resident that assists in their path lab. 

Have I mentioned the autopsy requirement? All of the medical and PA students are put together in groups of four or five and have to go watch an autopsy**. They are given copies of the clinical history and the slides for the case. They have to go over the slides and present the case and results to the rest of the lab. Each student must also submit a written autopsy report as well. Our autopsy group went pretty early in the process but are still waiting for our slides, so I went along with my classmate to see if the resident had them/was going to be done with them soon.

The case my group observed was fascinating which is likely the reason the slides are still out. Also it was a complete autopsy so the brain and the eyes were held for special cuttings (brains are done on Monday, eyes on Tuesday), which would have delayed things as well. My lab instructor is the pathologist who does the eye cutting and he had found a few noteworthy things, so we spent some lab time today going over it as a class and postulating about the cause of some of the things noted on autopsy. It was an impromptu clinical correlation sort of thing--where everyone tried to trace the source of some blood clot (we had clot formation information on our last test). We had some decent theories, but we'll have to wait for the official diagnosis to find out for sure!



*We are still continuing our clinical rotations*** in surg path through the spring, with the groups alternating weeks. The rest of my group went home because the instructor was sick but I was scheduled for the VA hospital and wasn't effected. The VA is nice because we show up during case sign outs, which are interesting.

**I think it is more for the medical students than it is for us, since we spent January on autopsy rotation. Some of the medical students are a lot less comfortable with the idea of an autopsy than others (and none of the ones in my group seem nearly as interested in our case as I am, but that might also be because they don't realize just how much there is with this case to be fascinated with...) so it is probably good for them to have this experience. And we all get practice writing up an autopsy report, which I have never had to do before.

***Although Pam did give us the option of suspending them if we felt overwhelmed with the streaming/TBL class format. We unanimously voted to keep them, because PA students love grossing! Still, it is awesome that our administration gave us the option!

8 Days into Body and Disease

I said before that I was going to withhold judgement on the all TBL all the time format that we were going to be using for the five month Body and Disease portion of our didactic year, and I still am. Honestly it is still changing/being refined. The downside to being the first group doing anything is that all the kinks have to be worked out. I have no idea how many meetings have occurred between the students and the course directors, the students and the student leadership, the course directors and the administration, and the students and the administration. Then there have been the one on one conversations, the emails, and even the random run-ins in the hallway that turn into a feedback session.

The format started out with an IRA (individual quiz) followed immediately by the TBL groups discussing the questions to reach a group consensus. We got confirmation on the correct answers only after the group answers were submitted. Then there was an instructor guided Q&A session after that, some of which were more lecture-like than others, with a focus on addressing information related to the most commonly missed questions.

As of this morning we have moved to at-home IRAs (we are on the honor system to take the IRAs closed notes/book/online resources), no group quiz, and the class time being used for a clinical application problem (ie: a patient presents with these symptoms and test results so what is the disease, what causes it, what is the treatment, why would you run these tests, etc) in addition to the Q&A session.

The course material is from reading assignments and from previously recorded lectures (the 2010 and 2011 lectures are both available) that can be streamed online. The actual time in class is a lot less but that is balanced out by the time needed to stream lectures. I do like having the at-home IRA available the night before the TBL session since I was able go through the lectures, immediately take the quiz, and feel done for the day. With studying the night before and having the quiz the next day I felt like I had to use the time before class in the morning to go back over the material. Now I can use tomorrow morning to go to the gym *guilt free before heading to path lab.

Pathology lab has been interesting. My instructor is fantastic, he is funny and is good at reasoning through the case histories and questions. And he always has relevant information from actual cases to contribute.

Immunology has been so-so. I have to completely restudy the overview of immune response and inflammation for the test next Monday.

Meanwhile, I don't know if the microbiology lectures have just been really good or if I just really love microbiology... Hard to tell. But I want to say that they have been good overall and that microbiology being my favorite non-pathology subject has just made me more likely to enjoy them.

Oh, and interviews start on Friday for next year's class. It is exciting!

*I have honestly felt like **everything that I have done for the past week that wasn't studying was detracting from studying. But that sort of attitude is how you burn out... so yeah, not good. 

**Including blogging, sorry about that.

Guess who doesn't know everything?

You know who really doesn't know everything? You, me, anyone ever. Ever. And anyone who thinks they do is delusional.

Being a student means being humble. This is a thought I've had off and on over the past few months and was reminded of while studying for the quiz we had yesterday. There was a line that advised against telling future employers, "That's not the way they do it at Duke." There are people in PA programs who have years and years of experience and their instructors don't want to hear about how they are used to doing things, which is where the humility comes in. You have to be willing to take instruction and be flexible about doing things the way you are being told to do them. For people who have worked as traveling PAs or worked in a wide variety of places they are probably more used to adapting than others. Since all of my work experience comes from a single job I was used to doing things one way and only that way.

This past month we've had Pam watching over our shoulder during our surg path rotations to remind, correct, and direct us. When she tells us that we've done something wrong (or less correct, shall we say) we have to take that correction and do better next time. There is no room in this experience for ego. No one wants to try to teach someone who thinks they already know everything.

I have done thousands and thousands of small biopsies, but I haven't done them at Duke using their quick text/speed phrases with their guidelines (which are completely different from what I am used to!) and dictation format.  So I start over on fairly equal ground with my classmates except possibly with several ingrained habits that make Pam cringe (like picking up derms to measure them...).

It continues on well after graduation. I've previously blogged about the people I used to work with and we all used each other as resources. If something *different or unexpected came up we asked each other what they would dictate/what sections they would submit. If there was still a question then it went up the chain to a pathologist, either over the phone or by going to whoever was on call. At Duke the second year students ask the staff PAs, the residents ask the staff PAs, the staff PAs ask each other or the pathologists. Even the pathologists consult each other. Sometimes it is just a matter of making your best guess based on the collective wisdom of everyone's experience.

*And sometimes you call everyone over just to see the interesting thing you have, like the 8 kg liver mass or anytime there is a dermoid cyst because who knows what is going to be in there this time.