At the end of October

I'm glad to say that I survived making yet another costume (pictures possibly to follow since our class went out as a group and mostly dressed up) and like every other year I've made a costume I have vowed NEVER AGAIN. Of course in about eleven and a half months, I'm sure it'll seem like an excellent idea to make a costume again.

I've also survived two and a half weeks of my three weeks at Duke surg path. The second go-round has been much less stressful than the first time since I've already seen a lot of the specimens before. It is still a learning curve. Right now I'm working on making sure my dictations clearly cover everything they need to cover. It is good practice to do free dictations to figure out the cadence and descriptions that work best. So I practice.

I've also been forcing myself to use the normal scalpel since they have had trouble getting the blades that I love and not everything needs a trimming knife. And it can't hurt to learn to be more flexible about the type of equipment I'm used to using since different locations stock different things (or, like my favorite scalpels, they might go on back order).

Wish list...

I think I've talked about it before but when we're at Duke North we have a board where we can write down the specimens that we'd like to have first dibs on if one happens to come in. I always have a hard time trying to figure out what to want since I feel like I'm consistently getting a good cross section of organs and disease processes.

I have jotted down a few things though. I'm not ambitious enough to be asking for a whipple just yet, but I wouldn't be opposed to an esophagogastrectomy coming across my table or a laryngectomy. Which might be more about the fact that some of my classmates have done those specimens and I don't want to feel like I'm lagging behind, or I'm not where I should be.

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.

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.

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 :-)

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.

My day was cooler than yours

I don't want to come off as weird or morbid or gruesome, but I had the coolest day ever today at school. I got to cut our cadaver's head off! It was amazing. It just isn't one of those things that happens very often and I'm glad that I got to do it. Would I want to do it a lot? No, probably not, but it was still really cool to get to do it once (The dens is really hard to cut through, by the way.). I got to stick my finger through the foramen magnum while we were checking our position and it was just so neat to trace the path of the spinal accessory nerves, the spinal arteries, etc. It is not an experience that most people will ever get to have and I feel lucky to have done it. I will never again have the opportunity to dissect a body so thoroughly. And for everyone who didn't come to gross anatomy (I'll talk about this in a separate blog entry) they missed out on that. It is completely their loss because that has been the best gross anatomy lab so far.

Quick, name all the structures!

This week is strange. We're not having a lot more new information presented but we're having clinical case information given to us and by taking patient history we're supposed to be able to go through the differential diagnosis process to decide what to test them for. They are mandatory for med students (well, mandatory-ish, since they aren't taking attendance) but optionally mandatory for us. The one today did go over some of the material and we will probably remember that course material better than the things we didn't have in symposium, but for the time it took it wasn't high yield study time. Oh, and when you ask a bunch of PA students what tests to run on someone with abnormal uterine bleeding you get answers like "Let's do an endometrial biopsy!" in addition to the blood tests you're probably after.

It looks to be a fairly light week, which is good because everybody is in a state of semi-panic over the upcoming exams. It is a terrifying amount of information to be tested on in just one week. It should be doable. I keep telling myself that it is doable. I am hopeful, oh so hopeful... and yet so very scared at the same time. I spent this past weekend studying, I'll study tonight after I finish writing this, I'll study for two hours tomorrow morning before class starts, an hour over lunch, and all tomorrow night.

My kids started basketball week, but my dad is taking my oldest for practice tomorrow and my husband and my dad will take both kids to their separate practices on Saturday. I'm still trying to decide if I'm going to study on campus or holed up in my study room with headphones in at home.

Eyes - Thoughts on loss of autonomy

I grossed an eye last night. It was a veterinary specimen as are most of the eyes we receive where I work (While we do occasionally get human eyes for things like melanoma, it is much more likely that we get eye parts like corneal buttons, schlera and conjunctiva), so I grossed it. The important thing to remember is to use a brand new blade (so it is very sharp) and to--in the abscence of a large mass--make sure to submit the optic nerve. We get a bizarre number of specimens with absolutely no clinical history, I'm not sure if it is a case of "make the pathologist guess why we cut this off!" or what. The paperwork for this case just read "L. eye" which was not particularly helpful.

My days of relative independence are sharply numbered. Our veterinary pathologist trained me and for the past couple years I've had a fair amount of freedom in grossing her cases. Occasionally I do have to consult with her to find out what to do with a particular specimen but months can go by without that happening. With our human specimens, as long as it is something I am signed off to gross I will do it or one of the other two grossing techs I work with will.  Anything larger either gets the on-call pathologist called in or it is held for one of the hospital PAs to gross the next morning. Very rarely anymore do we ever have to grab a pathologist and ask them how to do something.

But I'm going to be a student.  I need to put aside pride and what I think I know how to do. I will have months of school before I ever start grossing anything, it is time enough to forget the rhythm and cadence of my dictations. I am not so old as to be set in my ways or think myself so perfect that I feel like I don't have anything else to learn. I'm pretty sure the first few months of didactic learning will be humbling enough to make me realize there is lots that I don't know.

I am going to be graded, I am going to be challenged, I am going to be tightly supervised. I will not be a relatively experienced grossing tech that can be trusted to do her job without direct supervision--I will be a student awaiting instruction because getting as much out of the program as they are willing to teach me is so much more important than my ego.

This is my new perception of self