Ken is a Canadian Certified PA and graduate of the Consortium of PA Education (University of Toronto, Northern Ontario School of Medicine (NOSM) and Michener Institute) Class of 2015. He now works in North Bay Regional Health Centre, where he is based out of the Critical Care Unit (CCU) and works with Internal Medicine Specialists. You can follow him on twitter @ken_crosby.
What is Internal Medicine?
What is Internal Medicine?
Internal Medicine (IM) is a specialty within medicine. The simplest definition I can come up with is Internal Medicine covers all aspects of adult health that are non-mental health and they don’t perform surgery. So it’s a very broad field of expertise.
To qualify as an Internal Medicine physician individuals complete 3 years of residency and a pass a Royal College exam (one of my supervisors Dr. McKenna runs a famous exam prep course). After third year residents branch off to complete a fellowship in either a sub-specialty (ie. Cardiology, Respirology, Nephrology…) or complete a General Internal Medicine (GIM) specialist fellowship.
What is the difference between Internal Medicine and Critical Care?
In hospitals Internal Medicine will often perform several functions: Internal Medicine consultation service where patients admitted under hospitalists, or surgeons can request an Internal Medicine consult. Internal Medicine also often assumes responsibility and becomes the main physician for patients admitted to hospital including step down units, or in some cases critical care units.
In tertiary centres physicians working in Critical Care often have completed a Critical Care fellowship. However, in community hospitals the frequency of critical illness is lower and patients can be transferred out when needed so critical care units are staffed by Internal Medicine, Anaesthesiology, or General Surgery. This is the case in North Bay. Internal Medicine is responsible for the majority of patients in the Critical Care Unit, but Anesthesiology plays a major role especially with mechanically ventilated patients. Often there is co-management with IM, Anesthesiology, General Surgery, or other surgical specialties. We also have access to consult tertiary centre Critical Care specialists through a program called Virtual Critical Care.
My PA Career Pathway
I’ve always been interested in a career in healthcare. I completed a degree in Human Kinetics from the University of Ottawa, then became certified as an Exercise Physiologist and Clinical Exercise Specialist. I worked in a clinic that did mostly preventative and occupational health, and volunteered at hospitals on the side. After several years in the clinic I was looking to expand my knowledge and scope. I discovered the Physician Assistant program which addressed my goals and career aspirations perfectly.
What drew me to Internal Medicine & Working in Critical Care
My past experiences certainly played a role. My introduction to Critical Care was as a hospital volunteer. Prior to applying to PA school I volunteered for a year at St. Mike’s in Toronto in the ICU. In PA school I really enjoyed acute care medicine and choose an elective in Critical Care. I also had past experience relevant to Internal Medicine with having performed thousands of exercise stress tests in my previous career.
Benefits of working rurally
In a community hospital like ours you get to know almost everyone that works at the hospital. People say hello to each other in the hallways, it a great work atmosphere. I love North Bay.
I’m originally from Mississauga and lived in Toronto for many years; I have no interest in going back to a big city. Here it takes 10 minutes to commute to work no matter where you live in the city, there are many outdoor recreation opportunities, beautiful natural scenery, and yet the city is big enough to have everything you need.
Walk Through of a typical day in Internal Medicine and Critical Care
First thing in the morning I’ll meet with the Charge Nurse and my supervising physician to discuss any new admissions or developments overnight. We will come up with a loose plan for the day (who will be transferred, discharged etc.). Our patient list is divided up and assigned to either myself, a learner, or the staff physician. I then assess and create a plan for the patients assigned to me; which involves history, physical exam, reviewing investigations, and preparing order sets. By late morning we do bedside rounds as a team where my role is to give a case presentation with plan for patients assigned to me. At rounds I also give input for patients assigned to other team members. After rounds there are often new admissions consults to do. Other daily responsibilities include: documentation including dictations, handover patients to receiving physicians, assist procedures, update patients and family, following up on results or response to therapy.
In our department the Internal Med PAs work 8, 10, or 12 hour days. The shifts are designed to extend into the evening to cover peak times for consult and admission. Our IM PAs work weekends. On average it works out to be 40 hours a week. There are no nights, and no true call.
The patient population I encounter ranges from hospitalized patients who are stable and feeling well but requires monitoring, to critically ill requiring resuscitation. North Bay also serves Francophone and Aboriginal populations.
We are a community hospital but also a teaching site for Northern Ontario School of Medicine. I work closely with residents and medical students as they rotate through CCU for their Internal Med blocks. PA students are rare, but there has been one or two shadow me for a day (one of whom ended up coming to work with us).
Our hospital also has two excellent Nurse Practitioners. I rarely work directly with them as we are involved in caring for different patient populations.
I have developed skill in bedside ultrasound, and continue to improve in this area. There hasn’t been a need for the PA to do invasive procedures due to excellent support from our Interventional Radiology and Anesthesiology colleagues.
PA/MD Supervision in Internal Medicine & CCU
The model of care in our CCU is we write orders as a team during rounds. The staff physician, charge nurse, pharmacist, PA, learners, patient, and the patient’s bedside nurse all involved in the creation of orders which are transcribed during rounds then approved by the staff physician. This is how most Critical Care units function regardless of weather they have PAs.
We do have PA medical directives for investigations. The PA medical directives were originally developed by another staff member, then I completed the most recent revision.
Advice for PA students aspiring to work in Internal Medicine
Work on your case presentations. The patient population Internal Medicine serves often have multiple morbidities and many active medical issues. Efficiently communicating to your supervising physicians this type of patient is an art and a skill. I’ve found that reading case presentations such as the Case Files series of books, or watching well performed OSCE scenarios (case simulations) has helped me develop in this area.
With our residents and students we stress the importance of breaking down the complex patients into issues and coming up with an assessment and plan for each issue.
The Impact of PAs in Internal Medicine and CCU
Some of the anecdotal impacts I have heard of incorporating a Physician Assistant into the Internal Medicine team include: I have heard are:
- Improved documentation
- More consistent and timely assessments
- Improved medication reconciliation
- More consistent use of protocols,
- Improved continuity of care
- Reduced physician stress
- Fewer patients deteriorating upon leaving our unit
- Improved patient flow
- Improved patient communication upon discharge
There is currently a retrospective matched cohort study underway in our hospital to empirically evaluate some of these and other potential impacts of adding a PA to a community hospital critical care unit.
Any questions or comments? Let us know in the comments below.
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