PA Students On Rotation Learn to Trust Their Instincts

Unlike most PA students around the country, students in RVU’s PA Program complete their clinical rotations in 15 months (as opposed to 12 months). For second-year PA students Alison Hart and Maria Hipp, the additional three months means more hands-on experience with patients in multiple specialties such as Women’s Health, Pediatrics, and Behavioral Health.

Alison Hart, PAS II, on her Surgery rotation –

A little after midnight, a call came through for Alison. It was her preceptor and they were needed for an emergent ischemic bowel resection for an elderly female with stage three colon cancer. “[The patient] had decided to fight [the cancer] and was now faced with part of her bowel dying off,” Hart remembers.

When Hart arrived at the hospital, the patient was sitting calmly in the pre-op area, which gave Hart pause. “She wasn’t confused or scared, as I would have been in that situation. [Instead], she was calm, trusting of us and ready for the surgery.”

Once in the operating room (OR), Hart saw that the patient had numerous adhesions due to the cancer that would make the surgery more difficult. After some time, the OR staff were able to isolate the section of the bowel that needed resecting. Hart stapled the patient’s bowel together and closed up. “The procedure took about three hours and was a testament of the surgeon’s determination, the patient’s state of mind, and the abilities of medicine to overcome situations that sometimes seem insurmountable.”

“The most challenging, but rewarding, lesson [for me] has been about my own confidence and abilities,” said Hart. “At first, I felt lost and confused and supremely overwhelmed. But I have learned that there is much to be said about self-confidence in situations where you don’t feel confident.”   

Clinical rotations test students in unexpected ways. Some of the most important lessons come from interactions with patients and with preceptors. “A preceptor can make or break your rotation,” said Hart. “I have had some wonderful preceptors who have shown me kindness and have taught me so much about the world of medicine.” However, patients are the reason why students put themselves through the trials of school and step into the unknown. “[On rotations], they are no longer standardized patients, but real people with real problems that are trusting you to figure it out. It leaves a mark.”

In the end, Hart says she “has been exposed to things I never thought I would get the chance to see and I have learned that I am much more capable than I originally believed.”

Maria Hipp, PAS II, shares a case from her Internal Medicine rotation –

As part of her Internal Medicine rotation, Hipp dealt with a patient who had presented in the Emergency Department (ED) with a urinary tract infection (UTI). He also exhibited confusion and inability to walk which. He was admitted and treated with intravenous antibiotics, but after 24 hours, his mental status and inability to walk were unchanged.

The wife reported that her husband had gradually lost the ability to stand upright and to walk for the past few months, and that his mental status had evolved to dementia-like symptoms for at least a month. “I sat down with her for thirty minutes to hear her story.” During the conversation, Hipp learned that at a previous visit to the hospital, a neurologist had told the couple that they needed to follow up for treatment.

This was a game-changer for Hipp. “The patient had previously been diagnosed with Normal Pressure Hydrocephalus – also known as ‘WET, WOBBLY, and WACKY’ – and the couple was supposed to follow up with neurology for the placement of ventriculoperitoneal shunts or the condition would be recurrent,” said Hipp. But they never did. His wife had not connected the current UTI to the previous condition until Hipp had conversed with her. Hipp recommended an MRI and the patient was flown out that night for treatment.

The case was a comprehensive learning experience for Hipp. “Never underestimate the power of a thorough history,” said Hipp. “His wife was never asked about previous hospitalizations [in the ED].” In this case, a more thorough history would have sped up the patient’s treatment of the real underlying cause for his symptoms.

When it came time to recommend a course of action for treating the patient, Hipp was a bit nervous. But she also learned the next lesson of her rotation: “Do not underestimate yourself as a student.” After learning the patient’s hospitalization history, Hipp was confident of the diagnosis for Normal Pressure Hydrocephalus, but she had not confirmed it with records from neurology. “I knew we needed an MRI to confirm, but it was only my second rotation.” She presented her case to the hospitalist regardless and he did not hesitate to order the MRI.

The most important lesson, however, was that of compassion. “The wife was exhausted. Her husband had turned into someone she did not know and was helpless,” said Hipp. For months, his wife had been helping him with basic tasks like eating – all while listening to incoherent speech. To the wife, all signs pointed to rapid onset Dementia. “By taking thirty minutes to hold her hand, letting her cry and talk, I discovered the piece of history that explained all of his symptoms. She had been so exhausted from taking care of him, that she had forgotten about the previous neurologist’s recommendation and guidance.”

In the end, the patient received the ventriculoperitoneal shunts and is walking upright and making sense of words. “The wife tells the nurses at the hospital to tell me ‘thank you’ every time she goes in for something. Hearing her praise is the most empowering thing I have ever felt. It is confirmation that I am in the career I was meant to be in.”