PA PROFILE • BY CLAIRE , CCPA

Claire is a McMaster PA Graduate and currently works as an Oncology Hospitalist PA. We sat down and talked about her background going into PA school, how she became the first Canadian PA student at John Hopkin’s, how she fell in love with Oncology, and what she thinks would make a stellar PA!

I found out about the PA program from my relatives in the United States. I have an uncle who is a US Emergency Physician and an aunt  who is a US Nurse Practitioner. When I was graduating, I was telling them about I wanted to go into medicine in one form or another. They actually both recommended the PA program.

I had a general sense of what it was. Part of me was saying ‘yes’ to many things that year. Once I was in the interviews I realized how much I wanted to be part of the PA program.

Quality of life was the biggest thing my uncle and aunt recommended. My aunt coming from the advanced practice side, and my uncle coming from the physician both recognized that with PA you get best of both worlds. You practice medicine, but you can choose how much you get into it, the flexibility to switch specialties, choose to work call or not do call – whatever your preferences are. They know I am the type of person who has many different interests within and outside of medicine. For me, to be able to do something that allows me to maintain different passions was important.

You also have two years of schooling after your undergraduate work, and if you don’t like you can move onto something else. If you still want to do more schooling- you can. You are not investing a decade of your life into it.

I did a Biology-Psychology double major. This is called Exceptionality in Human Learning. It was a combination of disability studies and biology. I went straight into the PA program afterwards.

At the time, I had thought about behavioural therapy. I also thought about going into an MD program.

Going through the PA program. Out of the 6 years of schooling I had done after high school, those two years in PA school was my favourite.

In my first year, when I was doing my longitudinal placement (LP) experiences (half day observerships). I had met an oncologist who hooked me oncology. Since then I had kept in touch with her. Throughout clerkship I would try to do as much clerkship as I could. I did it in Sunnybrook, John’s Hopkins Hospital in the United States and did a one month elective there. Even in a surgical rotation, you get to choose a selective. I asked to be put in surgical oncology for at least two weeks.

Through that route I was exposed to different facets of oncology.

The oncologist I met in first year, I went back for more experiences with her which were completely optional. She was affiliated with John Hopkins. I told her how much I really liked Oncology. She not only set me up with a rotation there, she set me up with an Oncology PA. I got to know what PAs were doing in Oncology before they really existed here in Canada.

I was actually the first Canadian PA student to come there. That was a neat experience for John Hopkins as well.

There are ~14 Oncology PAs in Ontario.

This was a four week rotation, and all I required was a letter from John’s Hopkins acknowledging that I was coming there, and a letter from my PA school that I was coming there for elective and I showed at the border.

This was a good transition, because I did my last elective rotation before graduating. At that point they knew they wanted to hire me. Coming there, I had known everyone already. It was a transition from being ‘no longer a student’ to ‘the orders I write are valid’.

Most of my orientation came through my rotation. When I first met everyone on the Oncology Team – I explained what a PA was. My supervising PA was into it right away he was comfortable delegating things to me. He was good at seeing what I was comfortable with and what I was doing.

Once I started working there, I actually put together a small presentation and I did it for the nursing team, to the clinic – even though I don’t work in the Oncology Clinic just so the other Oncologists would be familiar with me. It certainly helped that they had experience with me as a student.

I had a few weeks I went to different Oncology Clinics in the beginning. Even though I haven’t gone back to Oncology Clinics since then, I go to each tumor site to see what their typical treatments are like, and what kind of cases they see.

Oncology is the treatment cancer. It can be done as an outpatient, as an inpatient. PAs can be in any of the settings, it just depends on what the needs are of the environment. I work primarily as an inpatient oncology hospitalist PA.

I look after cancer patients admitted to hospital. Any complications from their cancer or from their treatment is what our service sees. We were doing haematologic oncology up until about 6 months ago. We would see new leukemic patients and do their induction treatments.

Goals of Care in Oncology is when when you are trying to articulate whats important to a patient: What are their values? Trying to match that with their treatment plan. Seeing what is available. There are so many avenues that you can go down with Oncology. There are several lines of chemotherapy available, there is radiation and surgery might be possible. You also have to look at the whole picture. Not only in life span but also quality of life for patiens.

There are many patients who might go through treatment and get so sick that its not worth it to them to go through all of that if it means an extra few days or an extra month. Whereas for some patients, they might think that they want all the treatments possible even if there is a chance it actually makes life shorter for them. Its trying to figure out that balance and figuring out how far they want you to go. Would they want you to take them to ICU or do CPR? Its all of those tough conversations and trying to figure out what’s appropriate for a patient.

As an Oncology Hospitalist PA I manage some of the following common conditions:

• Febrile Neutropenia
• Hypercalcemia Malignancy
• Sepsis
• Bowel Obstructions
• Hyponatremia
• Related conditions secondary to immunotherapies patients going on (e.g. Colitis)
• Neutropenic Enterocolitis
• Spinal Cord Compression or Cauda Equina Syndrome

Because we are a tertiary care centre we see a lot of :

• neuroendocrine tumors
• Paraneopalstic syndrome
• refractory leukemias and lymphomas à This includes patients who go through multiple inductions and the complications.
• Aplastic Anemia
• Acute Promyelocytic Leukemia (APL)

I think it’s the combination of interesting medicine and the human side to it. I really enjoy we see complex cases, sometimes you are seeing the sickest people in the hospital. At the same time you really get to know them.

I love getting to know people’s stories, I think there is always something so authentic about going through the hardest moments of life with someone and making it easier for them. But also learning some really interesting medicine and interesting philosophies of life from patients. That is what drew me from the first day that I did that shadowing opportunity in first year of PA school, that is what kept me going since then.

There is nothing too different to expect from seeing a PA versus seeing one of the hospitalists. Because the way our program works we have several hospitalists who see the patients and there’s me as well. I am seeing the patients that my supervising physician would have been seeing, but he is also doing administrative work because he is the most responsible physician for the whole service.

If a patient is seeing me, they would expect:

• daily medical visits from me
• any diagnosis
• treatment and management plans
• initiating/continuing medications and discharge medications
• procedures (e.g. lumbar punctures, paracentesis, thoracentesis, bone marrow biopsies).
• We would discuss goals of care.
• We would talk about any discharge planning.
• Family Meetings – If it involves one of my patients, then I am running the meeting, or the social worker and I acting as a close right hand provider for medical updates.

All the things they would expect to see from a doctor on the team, they could also receive that from me.

Breaking bad news is not always at the later stages. If there is progression of disease, or there is a new diagnosis, that is a difficult scenario. Or if they lose function of their legs, they could live for another year, but if it means they’re not walking that’s may also be devastating for someone. I’ve definitely had to break bad news and I think that was one of the most overwhelming things during the first year of practice. I thought to myself, “I’m 23 years old, and I’ve been breaking a lot of bad news, and its very difficult”. One of the palliative care physicians I met actually actually said that her job makes her feel like she appreciates life even more. When you look at it from that perspective  sometimes it’s a job keeps you grounded.

Usually we start at 9 o’clock. I come and meet with the rest of the hospitalists and my supervising physician. He divides up the patients amongst us. Typically the hospitalist will see patients and I will see 8 patients per day.

We each go in for bullet rounds where we discuss our plans for our patients with the rest of the allied health team and team leader. Throughout the day, I am seeing patients in order of acuity. Whoever is least stable gets seen first.

I try to save any family meetings or procedures for the afternoon. I also started a research project in hospital. I am co-principal investigator within our own ward. I work with the research assistants and guide them along the process as well.

My schedule My job is 9 to 5. There could be option to do call. Typically we do have residents doing call.

My supervising physician is able to dedicate more time to administrative work. Typically he would have split his time between seeing patients, overseeing the whole service and having go back and do the administrative work.

He has been able to assign his patient load to me while he attends to everything else. This has really helped our group function smoothly. Our group has been able to evolve because of that.

There is a higher likelihood of burnout. I have found myself finding emotionally burnt out at times. That is where the you have to do a lot of self care and also really remember the moments you’ve made a difference in someone’s life.

It gets difficult if you feel attached to a patient or you meet someone who is young, just started their life and they are diagnosed with a very serious illness. Those can be difficult. I also feel that when you feel you’ve made a difference in their life, and you’ve made this horrible situation a little bit better for them, it’s also quite rewarding.

Someone who is optimistic, who is also very introspective and knows how to reflective. Those are the types of people that would do well with Oncology.

Also having a good sense of humor helps as well. Its interesting because even patients will have a really good sense of humor about things. Sometimes you think you are coming in and you’re feeling glum, but the patient will crack a joke that you may think is inappropriate for their situation – but that’s how you get through things.

If you can have a good a balance of being resilient, having a sense of humor, but also be introspective and be a sensitive person I think that’s a good fit for oncology.

Because I have a lot of interests, and I also had a desire to teach. The first thing that motivated me was teaching, but also I wanted to learn more about the health care system. This Master’s of Community Health is based off of the Public Health School, and the Family and Community Medicine Department at University of Toronto.

I learned a lot about public health as well, that uncovered another interest for me. I wanted to learn more about research in order to things like the research project I am doing now.

I did not have a lot of background in research in my undergraduate degree. When I found a topic that I was really interested in the past couple of years, I knew that I needed more skills to do something about it. The Master’s Degree helped with that.

Public Health  is looking at the social determinants of health. Looking at how poverty affects health outcomes of a person, how food insecurity affects people’s health outcomes, even how political instability can affect people’s health outcomes. The migrant crisis and refuges – its something that going to continue to progress in the next few years and just looking of undocumented people in our own city. Those are things I want to learn more about and take more of an activist role on in the near future.

The first is more of a teaching based project. I just complete Practicum or Capstone project where I design the framework for a course that I plan to propose in a PA program. It is about reflective practice and mentorship. PA, and really all health care professionals will need to be efficient,  self-directed learning in order to  flourish and continue to grow as professionals. For PAs in particular it is really important because PAs come out of school, get right onto the job and try to secure employment but also survive a steep learning curve. And you know because they are not doing residency there is no structured learning after you graduate.

To have reflective practice skills to be able to identify what are your learning gaps? Why was a case so difficult? And be able to go back and think about it later on. Figure out how you would approach a case differently next time. In order for PAs to grow, its important to have reflective practice listening. I saw a study that showed if PAs did not have as much self-directed learning skills, if they weren’t supportive a work environment there is a risk of leaving the career because they have trouble coping. I did design a framework that introduces reflective practice but in an interactive way that is attractive to students, and its been found to work in other programs. My hope is to start getting this developed or rolled out in the next few years.

I include the mentorship/interactive piece because I find that reflective practice alone is not attractive to students. There is systematic review that shows even just thinking about myself and interviewing others students, when you are trying to learn other things including medicine, clinical skills, then learning how to do reflections on the side becomes very difficult. When you add the mentorship component, it also brings the reflections to life. It gives context to it. You end up developing a relationship with a practicing PA and you are able to bounce your ideas off of them, and they can teach you where reflection comes into play.

We end up having to make a transition from our identify from being a patient, to being a student in health care, to then, being a health care professional. Having a mentor allows you to be more conscience of that process, and reflect more purposefully on that.

This is the one where I am currently a co-Principal Investigator. I am working with one of the psychiatrists in our unit. We are looking at meaning centered Psychotherapy and Existential Distress. Right now it’s the early stages, we are trying to explore the prevalence of Existential Distress in Oncology patients, and to see if it has any effects on health care outcomes, their own outcomes, hospital use, length of stay, quality of life for them. If we do have findings on this, perhaps we can take Meaning Centered Psychotherapy into the hospital, because at this time it is in clinics supporting more of the well patients.

Existential Distress is a loss of meaning in life. People can go through depression, anxiety, but existential distress is when you are typically suffering and you are not seeing meaning in the suffering. You have lost all meaning in life. That is what we are trying to explore in patients at this time.

If there weren’t any other considerations in life, I would say go for it.

I think its really flexible career, I think the possibilities are endless. I think that you get to practice, you are well compensated, but I also think that because its such a new career, at least in Canada that you could do anything with it. And I think that’s what fascinating.

I didn’t think I would be designing a course or doing research about Existential Distress while also treating cancer patients. I think its really unique evolution within the last 5 years of my career. I also think that its important that if you are considering it, you need to open to being advocate and being a trail blazer. There are a lot of challenges to that, but there are also rewarding things.

I also think if you are a PA student and you know the field you are interested in, be vocal about it.

When I was in clerkship, I think that there were well meaning people that suggested to me – ‘no matter what if anyone asks you say that you’re interested in Emergency Medicine, for example, because there are a lot of jobs there for PAs, and you need a job when you graduate’.

So when I was an Emerg, a physician asked me ‘What do you want to do when you graduate’? In my head I said, “I should say Emergency Medicine” but I decided to come out and say, “I want to do Oncology, I know it probably sounds strange and it sounds like there are no work for PAs there.” And The Emergency Physician said he would introduce me to some people, and he introduced me to the Oncologist who is now my supervising Physician.

I think that if you feel passionate about something, just go for it.