PA STUDENTS • BY ANTHONY DESLOGES, CCPA

Second year of PA school is also known as “clerkship”. Here PA students function as clinical clerks (similar to 3rd or 4th year medical students) where you complete core and elective rotations in different areas of medicine – family, emergency, psyhciatry, internal medicine, surgery, paediatrics, OB/GYN, and more!

Anthony is a 2nd year Canadian PA student who provides insight into what its like to be a PA student during the clerkship year!

My name is Anthony, and I am a second year physician assistant student at the University of Toronto, and the president of the UofT Physician Assistant Student Association. I was first introduced to the profession while working as a clerk in a hospital in Ottawa. After hearing about the profession, I did some research and quickly realized how valuable the profession was in a struggling healthcare system. I could see how the profession would grow in the coming years with Canada’s aging population. I liked how the profession was interchangeable with other specialties, with on-site learning without the need for a full fellowship. The accelerated 24-month program was also very appealing as I had just completed a 4-year undergraduate degree. Since graduating from health sciences, I knew that I wanted to gear my career towards one with more hands-on patient interaction, and the PA profession seemed like a great fit! My experience at UofT as a student and a member of the association has been great, and it sure has kept me busy!

In the first year of the program, it is didactic with both lectures, self-study and Longitudinal Clinical Experiences (LCE). This year is heavily weighted to lectures and self-study with one LCE per week in the area of your choosing. This allows students to gain an understanding of basic medical concepts, examination skills, and conditions/disease states, then further apply learned concepts in a more controlled setting.

Different from didactic year, PA Clerkship consists of both core and elective clinical rotations, much like resident physicians. We still do have lectures and courses, but they are far fewer than in first year. The primary focus of second year is clinical experience in rotations, with knowledge testing through End Rotation Examinations (comparable to Shelf Exams) from PAEA (US). Students complete 8 core rotations and 2 electives.

During these rotations you are present on-site with a designated preceptor or group and perform duties comparable to an MS3/Junior Resident. The schedule of your rotation will be decided by the preceptor and can include days, overnights, call-shifts, clinic days, OR days as an assist, etc. Shifts/On-call can vary in lengths and can range from 8, 15, and 24+ hours.

As a clerk (PA-S2), you are expected to perform in a comparable manner to an MS3 and in some locations comparable to a Junior Resident (with restrictions of course). Your duties can range from any of the following:

• Patient History – including assessment, treatment plan and prescriptions (co-signed by your preceptor). Most preceptors will expect you to have not only assessed your patient at this point, but also have come up with a written plan for management prior to orally presenting your case.
• Physical Exam
• Minor procedures (suturing, minor debridement, chest tube removal, casting and splinting, etc.)
• Surgical Assist/Pre-op care/Post-op care
• Rounding on in-patients
• Medication administration

Interaction type with the MD, residents and nurses will depend highly on the setting and the amount of team members.

If you are on a service with many resident physicians, you would treat them as your seniors. If you are alone with the physician, you are his or her extension of services and would report directly to them.

Interaction with the nurses will depend highly on whether or not they are familiar with the PA profession.

As long as you are helpful, respectful and outline your scope, you’ll be able to develop a good rapport. The nurses I have interacted with have always been great, and good teachers with helpful hints and tricks!

Knowledge expectations vary quite a bit from 1^st year to 2^nd year. In the first year, your expectations are more focused on pathophysiology, physical examination skills, investigations and knowing when something is abnormal. Towards the end of the second year your knowledge expectations shift to knowledge about certain conditions.

Preceptors understand that you are a learner and that no, you are not an expert in their field. They do, however, expect that you know the basic disease concepts that pertain to their specialty, so review is necessary prior to rotation and on an ongoing basis.

As you progress in your rotations, they will expect that your basic knowledge solidifies and that you are able to understand more complex pathophysiology. Preceptors will frequently ask you “pimping” questions to test your knowledge, and if you are wrong, they will usually ask you to explain your basic understanding before explaining.

You will frequently have some research to do at the end of your days on concepts that were talked about that you didn’t quite understand. And make sure you do, because they will definitely ask you the next day to make sure.

All in all, the more you know and can demonstrate, the more you will develop a good relationship with your preceptor and have a great experience. If you don’t know something – no shame – let your preceptor know and tell them you will research it later. It shows that you care about patient safety and that you have good initiative. PAEA End Rotations Examinations (shelf exams) can be quite difficult and require a lot of preparation.

I am currently completing my rotation in General Surgery/ACS at Thunder Bay Regional Health Sciences Centre, under one physician.

My previous rotations have been as follows:

• Rotation 1: Primary Care – The Ottawa Hospital Academic FHT (Ottawa, ON)
• Rotation 2: Pediatrics – Central Park Medical Clinic (Ottawa, ON)
• Rotation 3: Women’s Health – The Ottawa Hospital/Harmony Health Centre (Ottawa, ON)
• Rotation 4: Primary Care – Superior FHO (Thunder Bay, ON)
• Rotation 6: Psychiatry – Thunder Bay Regional Health Sciences Centre/Private Office (Thunder Bay, ON)
• Rotation 7: General Surgery – Thunder Bay Regional Health Sciences Centre (Thunder Bay, ON)

My next rotations are:

• Rotation 8: Emergency Medicine – Thunder Bay Regional Health Sciences Centre (Thunder Bay, ON)

The final two are electives:

• Rotation 9: Thoracic Surgery – The Ottawa Hospital (Ottawa, ON)
• Rotation 10: Cardiology – University of Ottawa Heart Institute.

General Surgery is a very busy service, especially in Northern Ontario.

My days are usually booked as: Outpatient Clinic, Ambulatory Care Hospital, Endoscopy, OR, Rounding (when on-call).

Call Shifts – When I was on-call for one week with my physician preceptor, I would usually start my day with pre-rounds on the wards. I would usually arrive 30min-1hr prior to the physician (6am arrival for me) in order to go over blood work, vitals and nursing shift reports to get a good handle on what was happening. It is always challenging on your first day, because you are getting to know all the patients from scratch. After pre-rounds, I would meet the physician, and then we would visit select patients together. When on-call, we are also expected to handle all emergency room consults, and emergent surgical cases/endoscopies. Around 5pm the physician would leave the hospital and place me on-call overnight, where I would respond to emergency room and ward calls, and conference with them over the phone. If I found a complex case, I would page the physician to return to hospital. Call is very busy, especially in the north, as you are at times covering three inpatient wards with 40+ patients due to limited coverage. In down periods overnight I would catch-up on rest, eat, and study conditions from the previous day.

Endoscopy days would start around 7:30am. I would arrive 30mins prior in order to go over our patient list and greet the first few arrivals in day care. At first, I would wait for the physician to arrive to do anything. As I learned and developed a good rapport with the physician, I would bring in the patients, explain the procedure, handle any concerns and prepare the medications. When the physician would arrive, I would confirm the medication dosages and administer the medications to the patient. I was also responsible for all documentation for the endoscopic procedures.

OR days, I would arrive about 30mins prior to the first case (I would review the conditions and procedures the night before) and introduce myself to the patients in day care. It is always important to do this so there are no unfamiliar faces in the OR. After greeting the patient, I would go to the OR control room and grab my size gloves and gowns for the day and bring them to the OR. I would introduce myself to the nursing staff, write my name on the report and open my gloves and gown for the scrub nurse. Once the patient arrived to the OR, I would assist the attendants and anesthesiologists in positioning the patient and prepping. Most cases in Northern Ontario placements, I acted as the first assist.

Ambulatory Care Hospital days I would arrive close to the start time, about 8:00am. These days were for quick visits and minor procedures not requiring an OR- such as suture removal, anoscopy, hemorrhoid ligations, lipoma excisions, etc. These visits were mostly performed with the physician present.