What patients can expect from a PA in Infectious Disease
I mean, I think that they can expect two things. They will see me almost every day and follow me along, but they will also, have met the physician who supervises me. So that’s something we always do on the first day. The physician will be there to answer their questions, but they know that when they see me after that, if they have a question that I don’t have the answer to right off the bat, I’ll speak to my physician and get back to them.
A lot of times they will ask me questions that have nothing to do with their infection. A lot of times it’s, “and so do you think they’re going to take the gallbladder out during this admission or are they going to make me wait?” And I explain that I have no idea and have no control over that. So a lot of it is just educating the patient about what I can do, what I have control over and what I don’t. Because remember we’re seeing patients, yes, for their infection, but sometimes that’s not all that’s going on with them. They have a lot of other reasons to be in hospital.
And then one other thing I want to add about me that’s maybe different from other PAs as I do in infectious diseases.
You wouldn’t think we see a lot of patients who are palliative, but sometimes we do see patients in that transition from active treatment to palliation and they may have an underlying infection going on that has nothing to do with whether or how soon they’re going to die. I let them know that I’m okay to talk about their death and their goals of care and things like that, even though it’s not really my bailiwick.
If they have questions around that, because I have an interest in palliative care in and dying, I let them know that it’s okay to talk to me. And you can talk frankly to me about your fears because I’ve been there myself. And so maybe that’s something that I’m adding to my practice that really has nothing to do with my role as an ID/PA.
Benefits and Challenges of Working in Infectious Disease
Yeah, as I said, I do enjoy figuring out how this infection came to be for things that aren’t obvious. There’s epidemiology involved sometimes. So, you know, especially in the hospital when we have an outbreak on a ward trying to track, I don’t have that much to do with that sort of thing, but my bosses do. So I listened in on that and that’s, that’s fun. I obviously enjoy the part where we tried to choose the best antibiotic with the narrowest spectrum.
If people know what that means, because otherwise, why not just put everybody on Ertapenem? But there are good reasons not to, and I take cost into consideration as you know, I have a long history of supporting a universal healthcare system in Canada and I know that this is in jeopardy, that we’re not going to be able to afford it if we keep going at this rate.
So I’m a big fan of Choosing Wisely. So that’s what I enjoy.
Following Infectious Disease topics onTwitter
Twitter is great. So what I do is I follow journals and infectious diseases and I follow a smart micro ID people and when I wake up first thing in the morning before you even get out of bed, I’m running through the twitter feed and if there is an article that I think I need to read, I flag it for later. So I say that’s mainly how I stay on top of things. But also, you know, we’re able to access grand rounds in ID throughout Toronto. So we try to make time in our busy day on Tuesdays to do that. But it’s hard. Yeah. And then just in talking to my physicians about these things all the time.
Tips for PA students studying Infectious Disease
So this is what I tell the students who do come to me and seemed scared because I know how little you get in ID in your training. I don’t expect people to, know antibiotics. So right off the bat that’s, that’s not going to be their job. But I would like them to know the difference between for bacteria anyway, gram positives and gram negatives and just be able to name a few. Right, that’s fairly easy to get through viruses you’d be surprised, we don’t actually in hospital end up treating viruses as much as we end up treating bacterial infections. That’s just because there’s not that much for viruses. Right?
A lot of time it’s just supportive care. So I tell them, don’t worry too much about viruses, but bacteria gram positives and gram negatives and come prepared to name a couple and the diseases that they cause. And I think from there you’re going to go out and see patients on your rotation and it’s slowly going to dawn on you. Which ones that are kind of like, we call them above the waist and which ones generally below the waist. That is over simplifying, but it’s certainly enough for a student to get started.
The Impact of Adding a Physician Assistant to an Infectious Disease Service
This is all the work done before I got there by Melissa and the team. But they actually look at the data and collected the data, and I’m not going to know the study as well as Melissa would, but the gist of it was that they could show that when they got the PA in ID, the patient time of admission and the time to being discharged home was decreased by, I think a couple of days at least. And this is the physicians will tell you in plain language before they had a PA, physicians would put in an
Commentary on the Effect of a PA on an Infectious Disease Consult Service
ID consult and it might sit there more than a day before they could get to your patient. So this is one extra day of you maybe not knowing whether to start antibiotics, which antibiotics to start, right? But now with the PA that never happens.
We’re able to see all of the consults if they come, you know, that come in between eight and five 30 at night and you know that we’re going to come up with a plan by the end of that day for your patient.
And I think that by having a PA on, the way, the reason they were able to get them out of hospital quicker is we come up with a plan for what are you going to go home with an IV in a PICC line, “who’s going to follow you up? What imaging are you going to need?”
And I helped arrange all of that. So I think that those are the reasons that I know that if I had to quit the job tomorrow, they would definitely be advertising for another PA to take my place. It’s the kind of thing that they’ll never be able to live without now.
Working with Residents
We actually don’t have as many residents right now as we used to, but when we had the fourth year general internal medicine residents, I would say to them, you know, if you have anything to teach me about, especially patho physiology and stuff like that, I’m happy to learn. I used to say that more in the beginning than I do now. Now when I work, the people I work with most, from time to time, our fellows in ID. So these would be our fives basically. So they’re already very knowledgeable. They’re about to write their royal college exam. They are up to speed on all of these drugs and bugs and everything. And so I learn from them. I don’t have the clinical clerks and medicine or the R1’s that I have to teach, but I do get PA students obviously.
Change in Scope of Practice
There was a very obvious change in scope of practice when switching PA jobs, especially starting off in emergency medicine that you weren’t going to be able to walk in the door right after graduation and be able to start, ordering imaging. Like you’re not going to be able to order an MRI or a CT with contrast right away. I mean those are things that you want to be careful and know what the right indication is. And then all the PA students when they graduate, they want to know what procedures you’re doing. Like everybody has very procedure oriented when they come out of school. So it’s going to be gradual.
The physicians are going to have to watch you do a couple and then they’re going to be comfortable letting you do it. We didn’t at SunnyBrook, have official sign offs. Like I need to see you do three and then you can do one alone. It was just sort of a discussion between you and the physician. But your scope of practice definitely grew as you gained more experience and more confidence.
Now I’m over in Infectious Disease and really for me what would be a little beyond my scope of practice would no longer be, am I going to put a chest tube in because I’ve got to tell you I don’t do that. We have people way better at doing that. My ID physicians don’t do that. The procedures that we do, we might do a little abscess draining here and there and then I guess obviously the fecal transplants. But for me, scope of practice would be, when am I going to be able to be confident enough to know when we have to pull out Ivermectin for example, or Colistin, which is the antibiotic of last resort and is terribly toxic, you know, so we have ID pharmacists we work with as well.
And what I noticed with my physicians is they wouldn’t even start those things without first talking to the ID pharmacists and discussing, yeah, do we really want to pull this out? What do we got to look for? So that’s scope of practice in the ID world, which students are probably listening and going, well that’s kind of boring, but really for me it’s not. Those are, those are the exciting things. So scope of practice hasn’t really, is not as much of an issue for, I think, someone in a consult service like me as it would be where you’re doing a lot of procedures in like an emergency medicine scenario.
Steps to Hire a PA in Infectious Disease
My boss, having already had Melissa before me, told me that he would like to send me to our microbiology lab, which has way uptown, for a week of just watching how microbiology works at the bench side. So I went for a week and watch them, you know, take the plates with the agar and put the specimen on it and put it in, you know, the different machines that they have and how they get answers.
I have to say in retrospect if they have to do it over again, I think I went too soon, I had really just started. And what would probably have been better would be for me to become more familiar with the different, organisms that we would be dealing with and the different antibiotics that they use to see what susceptible and what’s not. Because that’s how you find out what’s resistant and then go. So it almost would have been better a year into things. So that would be one thing. Yes. They, they’re going to need to learn more about microbiology.
But first give them some practice just with the simple kinds of infections that you’re going to run across in the hospital and get comfortable ordering the drugs. It was a long time before. Like now I don’t have to look up the dose for very many antibiotics anymore. They are there.
But if you ask me now what dose we used to give even for, you know, tylenol threes when we send people home, I don’t know if I remember that. It’s amazing how the brain takes out the superfluous information that isn’t needed anymore. Cause I don’t order Tylenol for people anymore. So, that’s what, I would say to them, your PA, it will take time, but eventually they’ll get very comfortable doing that.
And I can’t reiterate enough, if an Infectious Disease doctor has ever had a resident like an R4 who really took to ID and they were wishing they could stay around because it was so nice having them see patients and making your life easier, that’s what a PA could do for you.
So I would encourage, and that’s really all there is to it. It’s not rocket science.
Working with Medical Directives
Yes, we have medical directives and the ones in ID have just been adopted from the ones that were already done for the, general internal medicine, PA. So we just have a few days. Obviously the drugs would be different and we updated them a little while ago and that’s actually the last time I had to look at them.
Working in Research
I’m lucky in that the physicians I work with do, do some research. I wouldn’t, we’re not like one of the downtown academic centres where we’re involved in trials all the time. But they do do some, I’m a bit busy to be involved in all of it because, you know, my primary job is seeing the consults in hospital.
However, there was an issue where one of the ID doctors, Janine had talked our boss Jeff, into a trial where we looked at whether dogs could successfully be trained to smell C. Difficile. And we were thinking of this as a way to diagnose patients earlier because I don’t know if you know this, but once you collect the specimen and send it to the lab, it can take 48 hours to get a result. And in the meantime you don’t know should this patient be in isolation? Should we start Vancomycin, should we not?
Maureen’s Feature in Toronto.com
So Janine started the whole thing, found the dog trainer who found the dogs and they were starting just practicing in the hospital with specimens and going into real rooms. And then Janine, when they wanted to start the actual trial. Janine was on mat leave, her baby came early. So Jeff turned to me and said, “Maureen, I’d like you to take over. You’ll be the principal investigator, you’ll run the trial and then you’re going to write the paper”.
And this was amazing for me because I have written other papers that have been published before, but they’ve all been qualitative things, which more fits with my background as in journalism as a journalist. But this was quantitative data. And although I had lots of help, it was a great experience for me to run that trial and get it published in an infectious disease journal just a few weeks ago.
The final result, just to give it away as, the specificity and sensitivity are not bad, but the dogs did not have great inter-rater reliability. So probably not a way to go in the future.
Other Advocacy Initiatives
When I was one of the part of the graduating class, I saw myself as an advocate for the new PA profession, but now I think there are better people to do that now, younger people who are carrying that torch.
And because my late husband, Don Low died of a brain tumour in 2013 occurred around the time when the supreme court in Canada had not yet ruled on the legality of assisted death. And, so it’s a lot of people know that I’ve become an advocate for assisted death since then. Don died with palliative care and, conscious or sorry, yeah, palliative sedation, which was not how he wanted to die. So I made it one of my goals to see it not only legalized in Canada, but accessible.
I would say that, what we’ve had it for a couple of years now, things are certainly better and I’m really grateful we have the law, but you’d be surprised how many glitches there still are, not the least of which is people being able to access it in some religious hospitals and religious nursing homes and things. And just the whole idea of whether you should be able to use an advance directive to ask for Medical Assistance in Dying (MAID) as we call it now should you get a disease like dementia.
So I’m still doing a little bit in, in that front, but to be honest, the Infectious Disease job as a PA keeps me very, very busy.
I’m 58 now and I kind of am thinking of how I’m going to sort of wind things down maybe in three, four year – when my kids are finally launched and don’t require me as much anymore.
I’d like to, my goal would be to work part time in a job share in Infectious Disease and thenwind that down to retirement and do more travel.
What I use social media for
It’s hard to describe twitter to people who just think they’ve scrolled through it and don’t understand it.
There’s a community of people fighting for MAID (Medical Assistance in Dying), and we follow each other. Even people in Australia and England and Australia, right now they’re back where we were five years ago on the topic of MAID, where I was just starting on that journey.
So I’m in contact with those people, not providing them with anything important but mostly support and letting them know, “keep at it, it’ll happen for you. It was like that for us”.
So there’s Medical Assistance in Dying, there’s the medicine – infectious disease, and then there’s journalism. I still am interested in how the world works and especially politics in Ontario as it pertains to healthcare. And for all of that, there’s that community on twitter. People I agree with and don’t agree with. My kids are very impressed by how many followers I have. That’s how I use social media to stay connected, to stay on top of things.
I don’t use Facebook often – it’s not where I put my personal life out there. I’m not somebody who’s going to go on a trip and post a lot of photos for people to see and I’m never going to use twitter for that.
I consider twitter more professional and I actually following people who do too much about their personal life, although a little bit of is okay, but not too much.
And then Instagram is where I’ve see what my kids have been up to in the last 24 hours. So I like Instagram for photos, but, but I don’t use it very much for, you know, medicine and advocacy in that way.
Following People, Not Hashtags
The other thing about me on twitter is that I’m not a big hashtag follower. I’m more a person follower. I tell my students when I do one class at McMaster’s PA program Professional Competencies Class on this issue, I tell them that you should be following Andre Picard, and other health journalists like Kelly Grant, and Kelly Crowe from CBC.