Sandy, Gynecologic Oncology PA
Sandy Vuong is a McMaster PA graduate who now works in Surgical Oncology. She first contacted me in my early days of blogging asking about the PA program. Sandy blogs at Sandy the PA.
She has previously worked in Juravinski Cancer Centre in Hamilton, Ontario prior to moving back to her hometown in Toronto, Ontario, currently working at Princess Margaret Cancer Centre. She holds a Bachelor of Science in Psychology Biologist prior to entering the Physician Assistant program at McMaster University.
Working in Surgical Oncology
What is Surgical Oncology?
As the name implies, surgical oncology focuses on surgical management of cancerous tumors. The full spectrum of management of patients with cancer include detection and screening, diagnosis and staging, surveillance and palliation. Gynecologic oncology is the only subspecilaty of oncology where the surgeon performs the surgery and also administers the chemotherapy.
Why I picked Surgical Oncology
This may resonate with many people – I never envisioned that I would be where I am now back when I first started my training. I always thought I would be working in Family Medicine or Emergency Medicine. However, during my clerkship rotation, what sparked joy for me was my surgical rotations. One of my electives was in Gynecologic Oncology. I saw a variety of patients with gynecologic malignancies in clinic. I saw patients undergoing chemotherapy and patients on surveillance. I observed how the oncologist break bad news and how the patient responded. I participated in the OR and especially enjoyed the laparotomy cases (open abdomen versus minimal invasive surgery with the laparoscope). I had a very positive experience during my rotation and when the service was looking to hire a PA, I applied. Surgical oncology serves a vulnerable population and it’s been humbling to be part of their care.
How I was trained for my position
There was definitely a steep learning curve when I first started in Gynecologic Oncology. Since Physician Assistants are trained as generalists, our program probably only had 2 week’s worth of dedicated oncology cases and one half day observership with a medical oncologist. I completed a two week rotation in gynecologic oncology during clerkship which was what initially exposed me to this field.
There was a lot of self-learning and me taking initiative to advance my skills. I used Toronto Notes for a general overview and also acquired teaching slides from my supervising physician. Then, I went into the specifics/details with the textbook the residents are using for their gynecologic oncology rotation. If I started with the textbook instead, I would have felt super overwhelmed. For the patients I saw in clinic, I take a minute to understand their diagnosis and treatment. For example, what does“Stage 3C high grade serous ovarian cancer” mean, why is she on this type of chemotherapy, and why is she having these symptoms. Everyone is different in terms of their learning trajectory – to be honest, it took me at least 6 months to start feeling comfortable. It helps a lot when my staff nurtures my knowledge by asking me questions around patient cases. I shadowed a radiation oncologist for two days observing how vaginal brachytherapy and cervical brachytherapy is administered.
There are small procedures I can do as a Physician Assistant and I get this training through the physicians themselves. Like everything else when starting, my physician supervises me and once we both feel comfortable with my skills, I do them unsupervised. Procedures I am doing include paracentesis, endometrial biopsies, vulvar biopsies, etc.
I second assist in the OR, mostly in laparotomy cases. My main job is to create the optimal view of the surgical site and the key is knowing what your surgeon likes. This comes with time and experience. Eventually I was able to anticipate what my surgeon will be doing next and have the tools in the my hand already for that next step. Slowly I also started tying knots, suturing, and closing. I also like being there as a second assist and learning all the tips and tricks the surgeon is teaching the residents .
Common Conditions in a Surgical Oncology Service
Pelvic mass suspicious for malignancy (MOST COMMON REASON FOR REFERRAL TO OUR SERVICE)
Endometrial cancer
Peritoneal carcinomatosis/Ovarian cancer
Cervical Cancer
Vulvar Cancer
Rare Conditions I’ve seen
Gestational Trophoblastic Disease – Cancer arising from abnormal proliferation of the placental trophoblast. It often arises after a molar pregnancy but can theoretically arise from any pregnancy (miscarriage, term pregnancy). Age group usually runs < 16 years old or > 40 years old. Incidence of molar pregnancy is 1 in 1000 pregnancies, doubled if previous molar pregnancy (1 in 100). Risk of progression to malignant gestational trophoblastic disease can be up to 40% with certain risk factors. These cancers are very sensitive to chemotherapy which allows curative treatment while preserving the patient’s fertility.
My Current Practice Setting
I worked in two cancer centres now and it’s nice to see how different the PA is used based on what the service needs.
My first job was at the Juravinski Cancer Centre in Hamilton, Ontario, which is an academic hospital. I worked alongside five gynecologic oncologists, residents, oncology nurses and one to two medical students who rotated with us. There is less help available for a busy service, so the PA was able to fill in different roles (clinic, OR, inpatient).
At Princess Margaret Hospital in Toronto, Ontario, this is a bigger academic hospital. I work with six gynecologic oncologists, clinical fellows, residents, clinical associates and oncology nurses. I do notice a larger volume of patients being seen in clinic (upwards of 40 patients a day). The busiest part of the service is clinic and this is where the PA’s help is needed most. Many are actually younger than the demographic range I was use to in Hamilton. Therefore I have seen more cases where we have to consider fertility sparing treatment.
What patients can expect when seen by a PA
When patients visit the gynecologic oncology clinic for a scheduled appointment, I will meet with the patient and obtain a history and review of systems. Depending on the reason for visit, I may do the physical exam including a pelvic exam. I review imaging and pathology with the patient. I will also address any other concerns the patient may have (questions about their symptoms, counselling, prescriptions and referrals). I always review the patient with my staff but depending on the reason for visit, my staff may or may not come in the finish off the encounter.
Working with Medical Directives
I work under direct supervision and my staff is always available in clinic. However, having medical directives would be nice to allow me to write orders if patient is getting admitted or going to urgent care for management. As I was the first Physician Assistant at the Juravinski Cancer Centre, I started my medical directives from scratch, using templates from PAs in other specialties. I did not know how much work it took to work on it! It took me about 8 months to complete it and have all the right persons to review it (supervising physicians, nurse managers, pharmacists, directors, etc).
Currently, there are actually quite a few physician assistants practicing at University Health Network (UHN). There is a general medical directive for all physician assistants however, a specific one for gynecologic oncology physician assistant is still in the works.
Week in the life of a PA in Gynecologic Oncology
Monday – Clinic + Multidisciplinary Case Conference (Tumor Board)*
Tuesday – Clinic
Wednesday – Clinic
Thursday – Clinic +/- resident teaching
Friday – Clinic +/- surgical rounds
*The Gyne Onc Multidisciplinary Case Conference, or Tumor Board for short, consists of gynecologic surgical oncologists, medical oncologists, radiation oncologists, and pathologists who’s special interest is in gyne malignancies. We also have a radiologist who can comment on imaging. At Tumor Board, we discuss difficult patient cases whom we want opinion from other members regarding the best management in the patient’s interest.
My Typical Day
In my current position, I usually arrive 15-20 minutes before clinic starts. I stop by our office area to pick up new referrals for triaging. Whenever a patient arrives and is put into a room, our wonderful nurse would put out the patient’s chart to let us know they are in the room and a quick one-liner of what the patient’s main concern is (or sometimes, no concerns). I would then go into the room and assess the patient which includes a history and physical exam (if appropriate). I review with the patient their bloodwork and imaging results if available. I generally have a plan for the patient after this and review with the staff. My staff would join me to discuss the plan and answer any further questions. I would dictate/write a full clinical note for the encounter. If any tests are ordered, I would follow-up on those.
I see a combination of new patient consults, chemotherapy followups, post-operative follow-ups and surveillance followups. I also participate in consenting patients for surgery, helping them understand what the surgery would entail and answering their questions.
In between seeing patients or at the end of the clinic, I work with the clinical associate to triage the referrals I picked up in the morning. She has been working with the gynecologic oncology service at PMH for over 12 years and have a wealth of experience. She is very lovely to work with and often guides me whenever I have questions.
PAs & Team Based Care
Working with a Supervising Physician
I work closely with my supervising physicians. In clinic, I see patient’s on my staff’s clinic list and review each patient’s case with them before sending the patient home.
Benefits of Adding a PA to Surgical Oncology
In my last position, one of the feedbacks I received was that the physician assistant is a constant on the service. Between residents rotating through the service or when one of the doctors is covering another doctor’s clinic, the patient will still see a familiar face. Since I worked with all the staff in clinic, I am familiar with many of the patients. Secondly, I was very flexible in my role and able to fill in gaps in patient care. When there was an extra OR running or when there is a big surgery going on, I was the extra pair of hands needed. When there was a large number of patients on the ward or when there was a shortage of residents on service, I assisted the residents in managing ward issues. It is nice for the service to have someone available at anytime. Lastly, as the staff is often busy, I was the one orientating the learners on the service. I created an “Unofficial Guide to Gyne Oncology” for the Juravinski service with the goal in helping learners get the best out of their two week rotation with us.
Working with other health care providers
I work alongside two clinical associates, oncology nurses and patient flow coordinators.
Tips for PA Students & PAs in Oncology
Completing a Clerkship Rotation in Oncology
I think gynecologic oncology is a great oncology rotation to partake in (2 weeks is about right). I find in gynecologic oncology, you get exposed to both the surgical and the medical aspect of oncology. On the surgical side, you will participate in quite complex and extensive surgery (such as ovarian debulking) and also management of any post-op complications. From the medical side, you will see patients undergoing chemotherapy treatment and see patients on surveillance. You will see patients at different stages of her journey with cancer – from diagnosis, surgery, undergoing chemotherapy, surveillance, recurrence or palliation.
Favourite Resources for Oncology
For general oncology information, the following are good starting points:
Toronto Notes for overview of oncology
Pubmed/UpToDate
