I had a great first rotation with the QHC Surgery team. I’d heard a lot about this rotation going into week 1 and I was pleasantly surprised at the experience I had over the course of the 5 weeks. I was immediately engrained into the team and expected to participate fully and contribute to the group. I was anxious starting this rotation as I’d been warned how demanding the rotation was both physically and mentally. I was nervous I wouldn’t know enough, given this was my first rotation and I was with other students on their 6-7^th rotations, but I prepared each day and learned from other students’ experiences to make the most of this opportunity. I found I was more successful as a student when I made friends with the other students and collaborated with them. Given the amount of time we’d all spend with one another, having the support of the other students made the rotation substantially better.

During this rotation, in addition to the Operating Room, I worked in the general surgery clinic, the vascular clinic, the urology clinic and the breast clinic as well as with the ED consult physician. Over the course of the rotation, I saw differing techniques and approaches taken by various surgeons – the doctors and PAs took different approaches to closing patients at the end of a procedure they’d performed but also in treatment options for different presenting illnesses. What was consistent across the practice was the providers utilizing one another for opinions and advice. While they may not always agree with one another, this team consistently helps and pushes each other to be the best providers possible and that is something I will look for when I begin my job search.

The clinics were great opportunities to see things we’d learned about in the textbook in real life. On the first day, I joined the general surgery clinic and saw patients ahead of the PAs to interview the patients as well as alongside them to complete procedures. To my surprise, my preceptor had me remove staples from a patient’s scar following an exploratory laparotomy a few weeks earlier. While I had done this in the classroom setting, to do this on my first day to an actual patient was exciting and really reinforced my desire to work in the field. Vascular clinic truly helped me to differentiate between venous and arterial disease. Time and time again we reviewed the identifying details about venous stasis vs. arterial occlusion in our textbooks. However, seeing these disease states in person allowed me to solidify the diagnostic factors in my mind. Moving forward I will be able to use the skills and information I acquired on my surgery rotation to help diagnose vascular disease. I participated in Unna boot clinic and, after being shown the application process, was expected to apply them to all of the patients who presented for clinic. I truly appreciated the opportunity and respected the expectations the PAs had for me as a student. They set a high bar and wanted me to work towards it and in my opinion that will continue to benefit me as I move through this process.

I was expected to prepare for each surgery I would be scrubbing into and when scrubbing into a surgery, we were expected to not only know the anatomy but also know the anatomy in its relation to the procedure being performed. While in the classroom, I often wondered when learning about different landmarks if they really appear that way in the body and if they were really that important to a surgeon. This rotation showed me how anatomy truly helps to dictate approach and treatment during surgery. The cystic node overlies the cystic artery in most patients and the surgeons could use this node as a landmark to find and subsequently clip the artery in a cholecystectomy. In vascular surgery, the anatomy was important as it allowed me to understand how the surgeon would form an AV fistula and the physiology behind that process.

Given the patient population, the providers often had to deliver bad news. I saw this most frequently at the breast clinic, where patients follow up after having a mammogram and learn they have breast cancer. We learned about delivering bad news in Interviewing & Counseling but being a part of it in reality was something that took adjusting to being apart of in practice. Personally, I am a very emotional person and as a provider I need to have compassion and partner with these patients to help heal them medically but recognize my limitations in the emotional piece and ensure it doesn’t consume me as an individual.

The patient population seen by the surgery team, whether as patients or in consults, often didn’t have insurance. The medical knowledge and understanding of this population is limited and it is important for me to ensure my patients comprehend their medical issues and the different treatment options available. It was challenging when the provider would spend significant time with a patient and arrange relevant pre-surgical screening and evaluations, book the procedure and the patient doesn’t show up on the day of the surgery. What this rotation reinforced was that people have a lot going on and they do not always put their own health first and that is something I need to be aware of in reality. Patients may have children, jobs or other commitments that keep them from caring for themselves and I need to do a better job of understanding that point and continue to work with them to provide the care needed even if it is challenging at times.

As a part of this rotation we were assigned to work with the resident doing surgical consults in the ED. We saw patients that were very open with their drug history and spoke freely about the frequency in which they use illicit drugs. I was not necessarily expecting to hear these details from a patient. When we asked how often she used illicit drugs, she gave us the exact amount of heroin she used a day, told us about the needle exchange program she was a part of and why she was in the ED to be evaluated. She was very understanding about the negative effects of using drugs but did not want to stop at that moment. And while that is not something I can imagine for myself, I do understand the addiction of drug use and respect her openness allowing us to better care for her in practice and worked to provide the best care possible for her while she was in the ED.

In medicine, I think people can be disillusioned thinking every patient wants help and will take your recommendation for face value. In observing the way some providers practice it better allows me to shape how I want to practice in the future, whether its to avoid some of the habits they’ve formed or to adopt others. I know I want to treat each patient as if it were my family member or someone important to me – I want to spend the time with my patients to ensure they have full understanding and comprehension of what is going on with their care and are playing an active role in their treatment. I understand that there isn’t always a lot of time allocated to each patient but I want to use the time I do have to provide the highest level of care possible.

During this rotation I was able to practice my phlebotomy skills regularly, I closed wounds with staples and sutures and put in an NG tube in a patient. As I embark on my next rotations, I want to practice suturing and knotting because it is quite different doing it to an individual under anesthesia versus a silicon plate in the classroom. I want to work on my angles while suturing as well and must remember that the patient doesn’t move during the surgery/procedure so it is important to be able to manipulate my wrist to close the skin appropriately. During my Internal Medicine rotation I’m not sure how much suturing there will be; however, I’ve already spoken to one of my classmates who completed her Emergency Department rotation where I will be going for my 4^th rotation and learned we have multiple opportunities to suture, which I am excited about.

This rotation was extremely demanding from a time perspective and required a lot of its students. That said I learned an extremely large amount of information that will be applicable to all of my rotations moving forward. Surgery is rooted in understanding medicine and how the body works. I am hopeful I will be able to utilize the information I learned in the rotation and apply it to the patients I will see during my internal medicine rotation.

As a student on the QHC surgery team, we were responsible for doing the daily dressing changes for all surgical patients on the floor. Several of the patients were inpatient for a large majority of my rotation. One patient in particular stated although he hated having the dressings changed so regularly he looked forward to my coming to treat him and that stuck out to me as something I must be doing right.   On my last day with the team, I was working in the Urology clinic and I saw a previous surgical patient in the lobby waiting to be seen for another medical issue. As he saw me walk by he stopped me and asked me when I was going to see him. That question made me feel great because it meant he recognized me as a provider and felt comfortable with my providing him care, even if he wasn’t there to be seen by me that day.

Although I have a long ways to go in my rotations, I feel that my Surgery rotation is something that helped me to grow as a provider. I learned an incredible amount over the last five weeks and feel that this rotation made me step outside my comfort zone and challenged me to think in a different way than I’ve done before. The team often puts you on the spot and asks questions that are meant to make you think about the physiological process causing the issue. I think each rotation will continue to do this in its own way and challenge me to learn as much as possible. It was important for me to bring as much as possible to this rotation but also to take away experiences that I would have otherwise not had.

I’ve found a lot of medicine is learned by seeing a patient with a particular ailment, speaking with your peers to educate yourself and then researching the disease thoroughly. While providers are of course reading / studying the data to ensure their treatment techniques are standard of care, I was surprised how often students were told to go read up on something and follow up with the provider the next day. I, personally, have no issue with this approach but prefer to talk through the details with someone to ensure I have a sound understanding. I will continue to follow up with my assigned preceptors but also get comfortable using various resources (Surgical Recall, Up to Date) and incorporating them into my daily process. I have also found various PANCE sites that provide practice questions with explanations that help me to see a problem contextually and work to solve it as if it were a real patient. I will work to build my physical exam skills and ask questions that help to yield results by seeing as many patients as appropriate. I think seeing patients and observing different medical complaints will help me to expand my repertoire and to provide the highest level of care. I will continue to build trust with my patients and their families and work with my preceptors and push myself to grow as a PA student and future provider.

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