I recently finished the most difficult and rewarding year of my career in medicine. It was not PA school or my first year of practice as a PA; it was residency. I completed the US Army Physician Assistant Emergency Medicine Residency at Brooke Army Medical Center (BAMC) in San Antonio, Texas (see http://www.bamc./ for more details). In conjunction with the emergency medicine residency program for physicians, the army conducts a program for selected PAs in San Antonio and at another army medical center in Tacoma, Washington.
A year that was well worth it
In my second year of PA school, which I began while I was a medic in the army, I knew that I wanted to specialize in emergency medicine. At the site where I trained during phase II of PA school, we were required to work in the emergency department (ED) every third night except during an on-call rotation. I enjoyed the pace and diversity of patient presentations, so soon I was working extra shifts over the holidays and during my elective rotation. I graduated from PA school in 1996 and spent the following years working with deployable units, including tours in Korea, Kuwait, and Iraq. In 2002, I was accepted into the residency program, and I looked forward to the upcoming training. But in 2003, Operation Iraqi Freedom started, and instead of going to San Antonio, I found myself in western Baghdad caring for wounded soldiers and Iraqi nationals. Finally in September 2003, I was released by my unit and allowed to return to the states to start residency.
Now that I was about to realize my dream, I was having serious second thoughts. After my time in Iraq, I really wanted to relax and spend time with my family. I was 3 months late for the start of the residency and had missed out on the classes that are given for the new arrivals. And after 7 years of relatively autonomous practice, often in remote locations, I now found myself presenting each patient again to a third-year medical resident, a fellow, or an attending physician. During the first couple of weeks of the program, I had serious doubts about my decision, and I debated dropping out completely.
Somewhere over the second month, though, those feelings began to fade. I was acquiring many new skills, and I had passed my first written examination. I soon became accustomed to the pace—long hours of work followed by several hours of study. Then it was time for off-service rotations, and just as I was becoming comfortable in the ED, I found myself working in various specialty clinics with other residents and staff. This gave me a whole new perspective on how the consultants handled patient care and what I needed to accomplish in the ED before consulting them. Next was my first rotation at another facility: the ED in the Children's Hospital in downtown San Antonio. Now I found myself completely out of my element, as this was a non-military facility in an inner-city environment. I quickly learned which medications Medicaid covered and how to arrange follow-up for a patient with no insurance and no primary care provider. I also learned how to examine patients who didn't speak English, and my knowledge of medicine and Spanish were rapidly expanding. Just as I was getting comfortable at Children's Hospital, it was time to go back to BAMC and start the dreaded ICU rotations, about which I had heard so many horror stories.
My first day on the medical ICU lasted 18 hours, and my first patient, who had stage IV small cell lung cancer, died 6 hours after being transferred to the unit. I found myself writing the most meticulous notes of my life, and I endured rounding on patients in a session that never seemed to end. But in a perverse way, I was also enjoying it. I was managing the most complicated patients I had ever encountered, and I was holding my own with the physician residents.
Next came the surgical ICU and more of the same. We had soldiers wounded in Iraq, victims of gang violence, and the unfortunate souls who partied too hard at the Fiesta celebrations downtown. I learned that a patient can still have a pulmonary embolism with a Greenfield filter in place, and I learned how to utilize high-frequency oscillatory ventilation to manage a trauma patient with diffuse alveolar hemorrhage. I had never imagined that I would find it difficult to get all my work done and still keep my work hours to less than 80 per week. But it was.
The time passed quickly, and the ICU was soon behind me. Now it was on to the major leagues—3 months in the ED at University Hospital. Like any inner-city trauma center, this was controlled chaos—just like a TV show, only this time for real. One of the first pieces of advice I got proved to be the most useful: “All these patients are sick. If you don't find anything wrong, look harder because you missed something.”
The first month was the hardest because no one knows you or really cares; you are just another rotating resident whose ignorance of the system makes life harder for the nurses and the staff. As I got into the second month, things began to gel, and I found myself actually doing things because I really understood the pathology, not because I was blindly following the staff's orders. I even found myself supervising medical students as they performed procedures. By the third month, I was a seasoned hand, even helping to orient new physician residents as they started their rotations. Intubations, lumbar punctures, and central lines, which previously caused me chest pain, nausea, and diaphoresis, were now just part of the job.
Now I have graduated and am working in the ED of an army hospital. I look back on my year of residency with a mixture of pride and nostalgia. Despite the long hours and constant pressure, I really enjoyed it. My knowledge and skills improved dramatically. Quite simply, I am not the PA I was before I entered the program. And now, as I work with the emergency medicine physicians in our department, my perspective and interactions with them are completely different. We have trained at the same places and worked under many of the same attendings. Now I intimately understand the differences between interns, second- and third-year residents, chief residents, fellows, and attendings. I know what it is like to sit through Grand Rounds—“death by lecture”—after a late night in the ED. And I know what it is like to go for months with too little sleep, too much work, and the realization that you see more of the other residents than you do of your family.
Strengthening our ties to physicians
Because of my experience, I believe that our profession has matured enough for us to consider a greater emphasis on formalized residency training for PAs. Many in our profession worry that the proliferation of such residency programs would take us away from our primary care focus. But the majority of physicians we work with today have completed a residency, including those who want to practice in primary care, and the days of opening up a general practice fresh out of internship are history for physicians. As members of the physician-PA team, we should have training programs similar to those used for physicians, to further complement our joint efforts. PA residencies should preferably be in conjunction with an established physician residency program. We should also strive to have these programs accredited by the Accreditation Council for Graduate Medical Education to promote standardization and professionalism.
Specialty certification has been another worry of those opposed to residency programs for PAs. Some have suggested that PAs might end up seeking certification from another body—for example, the American College of Emergency Medicine for those who completed a residency in emergency medicine—and that this would diminish the importance of the National Commission on Certification of Physician Assistants (NCCPA). But there is a simple solution that would satisfy all sides: The NCCPA should continue to offer basic certification to PAs, but it should also offer specialty certifications to PAs who have completed a residency. Examinations leading to specialty certification could be designed under a coordinated effort between the NCCPA and the body that certifies physicians for that specialty. When PAs pass the additional examinations, they could be granted an associate membership in the physician organization; this status could be recognized on the PA's NCCPA certificate, just as we used to receive a gold seal after passing the additional examinations for primary care or surgery. An arrangement like this one would serve to strengthen the NCCPA and the PA profession as a whole and bring our training closer to that offered to physicians. It might also ease the “degree creep” concerns we have experienced with the nurse practitioner profession. Ultimately, with residency programs for PAs, we will be producing better-quality clinicians with a higher level of training. JAAPA
The author practices emergency medicine at Evans Army Community Hospital, Fort Carson, Colo, and is currently serving in Iraq. He has indicated no relationships to disclose relating to the content of this article.