My PANCE exam is set for early February, giving me approximately 8 weeks to prepare. The question banks that were most beneficial during my clinical year and that I intend to stick with for the PANCE are Kaplan, Rosh, and UWorld. After assessing my performance evaluations and my Clinical PACKRAT scores, I’ve identified my weaker areas to be Endocrine, Hematology, Infectious diseases, and MSK. While focusing on these subjects, I aim to also strengthen my confidence in lab and diagnostic imaging skills, along with mastering third-order questions. 

I find that completing practice questions is the most effective way for me to learn. My goal is to tackle at least 100 questions daily in the specific subject I’m focusing on that day. I plan to utilize SmartyPance and PANCE Prep Pearls as knowledge resources. In preparation for the EOC exam, I’ve been working on enhancing my testing endurance; however, I did experience some fatigue towards the end of the fourth section and therefore, in preparation for the PANCE, I intend to gradually increase from 120-question timed tests per week to 240 questions and then to 300 questions.

Given that Cardiology and Pulmonology constitute the highest percentage of the test, I will allocate more dedicated time to those subjects, supplementing with smaller reviews throughout the eight weeks. Consistent exposure to various conditions and question types is crucial to me for better retention, especially for material covered early in my study period. I plan to cover 2 topics per week with a 120-question test on those two specific topics followed by a 240 test the next day on all the topics covered thus far. In the final 1-2 weeks leading up to the exam, I intend to focus on comprehensive reviews, creating mixed-subject tests, and completing timed tests ranging from 240 to 300 questions.

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Similar to my experience in Internal Medicine, my Family Medicine rotation further solidified my fundamental understanding of prevalent conditions like diabetes and hypertension, crucial knowledge for any healthcare professional. What distinguished this rotation to my internal medicine one was its outpatient focus, allowing me to actively engage in more routine care. One aspect I found particularly appealing was the different services provided at the office where I was stationed, including Spirometry, “brain checks” or cognition testing, and TM flow – offerings that were new and intriguing to me.

Continuity of care is essential to foster a consistent and trusting relationship between healthcare providers and patients and I got to see it in this practice. Throughout the five weeks, I witnessed patients returning for multiple visits to discuss lab results, follow up on high blood pressure, and adjust medications. At the beginning of the rotation I didn’t really understand why patient’s were coming in so often or why they were asked to come in for results that were normal, but now I can see the benefit it has on patients as it encouraged  more engagement with them, facilitating more of a collaborative discussion on next steps and ensuring clearer comprehension of the information provided. The doctor was also knowledgable in holistic approaches to medicine and would teach people how to implement such approaches like meditation. There was one patient that suffered from extreme anxiety and depression and the doctor had not only performed a 5 minute meditation session with the patient in that moment but offered for the patient to follow up the next week after hours for a better teaching on how to properly meditate. 

Many patients came into the office for referrals to various other services and if we didn’t have the notes from the specialty doctors, the doctor would often just call or text the specialty doctor to discuss the patient in that moment. One patient that was especially memorable to me because it not only emphasized the importance of communication between healthcare providers but the significance of the primary care physician and the trust patients have in them. The patient had come into the office to have his pre-op paperwork filled out for robotic colectomy. The doctor had received the initial colonoscopy results but had not received the pathology results, which had reported hyperplasia. The patient verbalized his upset over the lack of communication between the doctor and his GI doctor especially for something so serious, as he had wanted to discuss the results with his primary care doctor before scheduling the surgery as he trusted his opinion. Communication of results should be a priority as the the lack of it increases the risk of errors and improper care. 

Though the office was small, they cleared a room for me to triage patients before the doctor came in. The doctor gave me adequate time to gather the HPI, make sure the patient was up to date on screenings and immunizations, and review the patients medications, previous lab work, and any recent diagnostic test results. I would then present to the doctor. I really appreciated this experience because it gave me a taste of what I would be doing in a couple of months from calling the patient into the room to the end of the patient’s visit. An area that I am a bit weaker in is my knowledge on medications and I felt that since I was going over so many medications, I really got to grow my knowledge and familiarize myself with common medications for diabetes, hyperlipidemia, hypertension, etc.

Overall it was a great rotation! 

Long-haul flights, edema, and thrombotic events: prevention with stockings and Pycnogenol® supplementation (LONFLIT Registry Study)

The association between immobilization and an increased risk of hypercoagulability is a critical concern. Prolonged immobilization decreases muscle contraction leading to decreased blood flow, blood stasis, and eventually the formation of blood clots. Majority of the time, any blood clot that is formed may resolve on its own; however, the longer the person is immobile, the greater risk the patient may be to serious medical conditions such as deep vein thrombosis (DVT) or superficial thrombophlebitis. According to the WHO, long distance traveling, defined as 4 hours or more either by ground or air, has been found to with increase the risk of DVT by 2-4-fold. Overall, the risk for travel associated DVT is small, especially in healthy people, and mostly occurs in people with other risk factors (e.g obesity, older age, recent surgery, estrogen contraceptives, pregnancy, varicose veins, active cancer etc.) Unless the individual is at risk for hypercoagulation and need to receive prophylaxis medical treatment, most individuals can benefit from graduated compression stockings. Studies have found that compressions stockings as substantially decrease the risk for DVT and reduce lower extremity edema. 

In a 2018 comparative study, researchers aimed to determine the effects of Pycnogenol on leg edema and thrombotic complications on long-haul flights, compared to compression stockings. 295 individuals flying in economy twice a week for a total of more than 8 hours were included and subdivided according to their DVT risk level (e.g low, moderate, or high). The 3 groups either received the control, Pycnogenol, or stockings. Any individuals that had severe bone/joint conditions, diabetes mellites, severe hypertension, obesity, recent thrombosis in the last 6 months, or an increased d-dimer level before the flight were excluded from the sample. Lower extremity edema was measured via Ankle circumference and d-dimer was used for thrombosis detection. Results showed that across all risk groups, individuals who received Pycnogenol had the lowest edema formation, compared to the control and stocking group, and no one had a positive d-dimer. Among the low-risk, the control had 1 positive d-dimer and the stocking group had 2 positive d-dimer. In the moderate-risk and high-risk individuals, 1 DVT and 1 SVT were seen in the controls. As a secondary outcome, researchers also measured jet lag and found that jet lag scores were lower in Pycnogenol subjects across all risk groups, compared to the other groups. 

Though a larger study is needed to further solidify the results of this study, these findings highlight the potential benefits of Pycnogenol, a natural compound from a French pine bark, and its comparable efficacy if not more to compression stockings in reducing edema of the legs, reducing the incidence of DVTs during long flights, without associated side effects. Other studies have also shown that it may have long-term protective efficacy individuals following a thrombotic event. Future studies should concentrate on how much supplementation is needed and if there are any long-term effects, especially among individuals with comorbidities and on other medications. 

Sources: 

• Belcaro, Gianni et al. “Long-haul flights, edema, and thrombotic events: prevention with stockings and Pycnogenol® supplementation (LONFLIT Registry Study).” Minerva cardioangiologica vol. 66,2 (2018): 152-159. doi:10.23736/S0026-4725.17.04577-7
• https://www.ncbi.nlm.nih.gov/books/NBK470215/#:~:text=Immobilization%20associated%20with%20prolonged%20travel,increases%20the%20risk%20of%20DVTs.
• https://www.who.int/news/item/29-06-2007-study-results-released-on-travel-and-blood-clots

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Site Evaluator: Fahim Sadat, PA-C

For my site visit, the H&P I presented was of a 71 year old female who had come into the office complaining of a swelling in her right lower leg that started 4 days ago. She had a past medication history of HTN and HLD and a 20-pack smoking history. The patient had reported a constant, dull achy pain in the area, aggravated when she walked. She also said that the area look a little more red than the left side and felt warm. A key piece of information she noted was that she had come back from a trip to Rome a week prior to symptom onset where she did a considerable amount of walking and standing. The physical exam was consistent with the patient’s report of mild swelling of the right lower extremity with tenderness to palpation especially to the lateral and posterior aspects. The skin as warm to touch and mildly erythematous. No ulcers or traumatic injury were noted, negative Homan sign, and no pitting edema. An ABI was able to be done in office, which showed 1.13 brachial index of both the left and right ankle, ruling out peripheral artery disease. A STAT venous duplex ultrasound was ordered to rule out DVT vs superficial phlebitis/thrombophlebitis. There was low suspicion for pulmonary embolism at the time due to the patient’s stable vitals and absence of cough, sudden shortness of breath, chest pain, dizziness, or heart palpitations. Pending results, the patient was advised to use compression stockings, apply warm compresses to the area, and keep the legs elevated when she is sitting. If the results came back positive for DVT, the patient was told that she would need to be started on an anticoagulant immediately. I chose this case because I was given the opportunity to act in a primary role. Mr. Sadat agreed with my assessment and plan. It prompted a discussion on when a d-dimer would be ordered and red flag signs that would raise suspicion for a pulmonary embolism.  

The other H&P that I had written up was a 85 year old male who had presented to the office complaining of painless right eye redness that started a day ago. Given the patient’s medical history of HTN, HLD, DM2, atrial fibrillation, and CHF, and the absence of any visual disturbances or other irritative symptoms, the most suggestive diagnosis is spontaneous subconjunctival hemorrhage. Due to the patient being asymptomatic and no history of trauma, there is very low concern for corneal ulcer or other conjunctival injuries that require emergent ophthalmology care.  Treatment was symptomatic. 

During my internal medicine rotation, I found that it played a pivotal role in consolidating the foundational knowledge I had acquired during my didactic year of medical education. The real-world application of medical concepts and principles allowed me to bridge the gap between theory and practice. Working closely with experienced physicians, PAs, and other healthcare professionals provided me with valuable insights into patient care and complex decision-making processes. I really enjoyed the opportunity to collaborate with PAs in a primary role, as it greatly enhanced my understanding of team-based care and allowed me to witness the integral role PAs play in the healthcare system and the importance of interdisciplinary teamwork. I found Internal Medicine to be all-encompassing compared to the specialty fields I was in before, which allowed the providers to address and treat the entirety of a patient’s medical conditions. It highlighted the interconnectedness of various health issues, allowing for better management of complex cases and a more integrated and patient-centered care plan, including coordinating treatments and optimizing medication regimens. I enjoyed observing the consultations with other specialties and seeing how they will manage the patient. 

During my overnight shift, I had the opportunity to acquire a new skill – conducting handoff procedures to the day-shift team from the night. Handoff is a crucial aspect of patient safety and care continuity, facilitating the important exchange of vital patient information including their condition, recent developments, pending tasks, and potential concerns. During my initial attempt, I realized I was overly detailed, presenting like I would in my site visits, and then learned that handoff presentations should be more informal while still effectively conveying essential information to the day-shift team, as it helps to reduce errors, prevent misunderstandings, and ultimately ensures a seamless and efficient delivery of healthcare services.

One of the standout weeks during my rotation was when I joined the stroke team. It provided me with a taste of the fast-paced environment of trauma care, which was entirely new to me. I found the experience invigorating, having to work urgently while maintaining a sense of order, especially when a patient was still within the time frame for potential tPA administration. I distinctly remember a patient who arrived with suspected head trauma and stroke-like symptoms. The stroke, neurology, and surgical teams gathered around the patient, rapidly gathering vital information from both the patient and EMS, while a nurse swiftly inserted an IV. The scene was initially chaotic, but it felt oddly quiet once the teams left, having ruled out a hemorrhage. It was during that moment that I first contemplated the possibility of working in such a dynamic healthcare setting.

Overall, my internal medicine rotation was a great experience that solidified my medical knowledge and emphasized the significance of collaborative healthcare practice.