I was really excited to start my Psychiatry rotation because it offered a unique opportunity to delve into the complexities of the human mind and behavior. Through this experience, I gained a deeper understanding of mental health conditions and learned to provide compassionate care to patients facing various challenges. I primary was just speaking to the patient, as opposed to performing any physical exams, which helped me improve my communication skills and developing different approaches to the patient that considers both the psychological and physical aspect of their well-being. It was great to work alongside other experienced PAs, physicians, and nurses, and see the different approaches to these patients. 

I have never been in a type of environment where I was working with patients suffering from mental illness and substance use, and I think at the end of the rotation, it has made me more sympathetic towards them. Speaking to their families and reviewing their histories in their charts, gave the person more of a story and not just someone who was acting bizarre in public. It made me root for these patients, to be compliant with their medications and attend the outpatient services arranged for them to get better; however, it just highlights the difficulty in treating mental illness, that even if everything is set up for them, many still do not comply and end up back in the hospital. Speaking to the families and seeing them struggle was just as emotional as seeing these patient’s struggle. A handful of parents had expressed their wanting for their child to stay in CPEP overnight because they needed a break or felt unsafe with their child coming home. One particular situation that made me feel particular emotional was a case of 19 year old boy who had become increasingly aggressive and physical due to substance use. She wanted him to be admitted to inpatient as she felt unsafe with him coming home, but he didn’t meet the criteria to be admitted and the attending had decided he was to be discharged. We told her he could either go home with her or we could arrange for transportation to a shelter. After going back and forth a couple of times, she ultimately decided to take him home because she felt she was abandoning him by sending him to the shelter. The only thing we could do was tell her to call 911 if he became aggressive again or to become his proxy so she can make decisions for him. The patient ended up back in the hospital for being physically aggression the following week. 

Patience proved to be paramount in this field, as progress is not predictable. Not only throughout the day with patients that would be yelling the whole day, patients that would tap on the plexiglass every 10 minutes asking when they were going to be discharged, and patients that would refuse to talk to you, but with patients that were regular visitors to CPEP. There were a handful of patients that had come back multiple times during my 5 week rotation there. There was one lady who had stayed overnight in CPEP after being found in an apartment with a friend who had died from an opioid overdose. She left the following day with her mother, only to return a couple of hours later after overdoing again on opioids. Maintaining a nonjudgmental approach and providing consistent support can greatly enhance therapeutic relationships and contribute to better outcomes for the individual.   

One skill that I notably strengthened and I believe will be helpful in my future rotations is the ability to gather information based on observation alone. At the beginning it was unexpectedly difficult to concentrate on what they were saying, which was at times confusing, at the same time as noting their appearance and behavior. I was asked a handful of times to fill out mental status exam for the providers and would find myself unsure about certain parts, even if I was the one who interviewed the patient. As I started to get more familiar with the different parts of the mental status exam, it became easier for me to know what to look for and to note the patient’s thought process and content, their attentiveness during the interview, their affect, their mood, their body movements etc. The terminology also was becoming more familiar to me, such as what pressured speech, thought blocking, or flat affect meant, which helped me more accurately fill out the mental status exam. This exam is crucial in assessing a person’s cognitive, emotional, and behavioral function, which provides valuable insights into the patient’s mental health. In any medical field, it will help me be able to identify potential psychiatric disorder, gauge the severity of symptoms, and formulate accurate diagnosis, ultimately guiding the development of appropriate treatment plans to improve the patient’s well-being.

One aspect that I found particularly difficult was knowing what to believe when it came to what the patient was telling the interviewer compared to the parents stories, but I feel that it is a skill that comes with experience. There were a handful of times where the provider wouldn’t believe the symptoms that the patient was reporting, that was not obvious to me. I believe that as a healthcare provider, it is crucial to approach the patient’s story with an open mind and without preconceived biases, especially if they have a past medical history of mental illness. Believing the patient’s account is essential in establishing trust and understanding their unique experiences and needs, however, it is still important to stay cautious for malingering behavior. While considering the parents’ perspective is important, it is equally vital to recognize that the patient’s firsthand account can provide valuable insights into their mental health journey and help tailor the most appropriate and effective treatment plan.  

My Ambulatory care rotation was a nice change following my other 4 rotations as it was my first rotation that I was not in the hospital setting. What I really enjoyed about this rotation was that I got to work mainly alongside other physician assistants, some new graduates, who were often the sole provider during the shift and I was able to take a primary role in the care of the patient. I would gather the HPI and perform my physical exam before the provider went in and then present it to the provider. After their examination, I would be asked what my assessment of the patient is, how I would treat the patient (including if I would order any lab work or diagnostic tests.), and then deliver education on the diagnosis to the patient. 

During my time at the clinic, I was able to solely perform or assist in wound care, cerumen disimpactions, IM/SC/ID injections, throat or nasal swabs, nebulizer treatments, and removal of foreign bodies. What I liked about working at Nao Medical specifically was that the providers were certified to medically clear patients to work for NYC ACS. I was able to perform more of a comprehensive physical exam on these patients, was taught how to complete the fit test with the patient, and then was able to administer the PPD test afterwards. In addition to the procedures, one area that I particularly enjoyed was getting more practice on providing education to the patient following the diagnosis. It really tested my own knowledge in certain areas and showed me the topics that I needed to improve on. 

One area that I felt weak in was explaining the pathophysiology behind abnormal lab results to a patient. A handful of patients would come to the clinic to have their blood work results interpreted, even if the orders were not necessarily from this clinic. One of the providers really took his time to explain the significance of each abnormal value with me and then we would discuss possible underlying causes and what follow up questions needed to be asked. One helpful resource that was recommended to me was the  “Clinician’s Guide to Laboratory Medicine.” It gives an overview of what each component represents and then provides a clear step-by-step approach to interpreting lab results and what conditions or patient behaviors to consider when a value is of a certain level. 

One thing that I took note of during this rotation was that patients do not want to go to the ER. It is important as an urgent care provider to be able to determine if the patient can be managed in the outpatient setting or if the patient should be referred to the ER. Two patients in particular that come to mind, one being a 50 year old male who presented with chest pain accompanied with shortness of breath and a productive cough with rust colored sputum, and the second one being a 70 year old female who presented with severe abdominal pain accompanied with bilious vomiting. Both patients were strongly advised to go to the ER, the women went via ambulance and the man decided against going. All patients who presented with chest pain and abdominal pain, the providers treated with caution and examined thoroughly because the clinic was very limited in the diagnostic testing they could do.   

Overall, my rotation was a great experience to see conditions that I otherwise may not have seen in another setting such as tick bites or hordeolums and to practice educating my patients on URI management, on lab work results, on the transmission of sexually transmitted infections, on wound care etc.  

According to FAIR Health, Lyme disease diagnoses have increased significantly in the U.S from 2016 to 2021, reporting a 60% increase within rural areas and 19% increase within urban areas. If a patient seeks medical care for a suspected tickborne disease, treatment with antibiotics should be initiated as soon as possible. For patients with early localized disease, the treatment is Doxycycline 100mg tablets twice a day for 10 days. However, depending on symptoms and days after exposure, prophylactic treatment with Doxycycline 200mg x 1 dose may be initiated if the tick had been attached for more than 36 hours and it has been less than 72 hours since removal. 

In this 2014 experimental study, researchers sought out to determine if prophylactic application of Azithromycin cream would have similar efficacy to a topical Doxycycline cream. They also wanted to determine if the timing of applying the cream post-removal of the tick influenced the drug’s efficacy and if the cream will have both a systemic and transdermal effect. This study was performed in the lab setting with female Nymphal I. Scapularis ticks collected from New Jersey and Connecticut. The mice used were 4 weeks of age and bought from the Charles River Laboratories in Massachusetts. The Nymphal I. Scapularis ticks were infected with a strain of B.burgdorferi, and then the ticks were allowed to feed on the mice for about 72 hours before being removed. A PCR assay was used to confirm positively infected ticks; any PCR-negative ticks were removed from the study. Borrelia culturing and Xenodiagnoses were used to determine infection patterns in the mice. 

There was a total of 4 groups being studied: mice treated with 4% Azithromycin cream vs cream without an antibiotic, and mice treated with 4% Doxycycline cream vs cream without an antibiotic. The experiment was conducted in 2 phases. In the first phase, the researchers wanted to directly compare the protective effect of Azithromycin cream compared to Doxycycline cream. Either Azithromycin, Doxycycline, or a no antibiotic containing cream was immediately applied after the tick was removed. The second phase of the experiment was dedicated to determining if Azithromycin cream would only be effective if applied directly onto the site of the tick bite or if it had any benefit if applied to a distal site, as well as if ingestion of the cream provided any protection.

Results of phase 1 showed that none of the 12 mice (100% protection) who received Azithromycin cream developed spirochetal infection, compared to the 11/12 mice (8% protection) who developed spirochetal infection with the Doxycycline cream and 11/11 mice who were in the control group. The researchers also found that Azithromycin cream provided the mouse with 100% protection up until 3 days after first noticing the tick and removing it. Protection dropped to 74% after 3 days but remained at that efficacy at 2 weeks. 

Results of the second phase showed that among the mice that were allowed to groom themselves (ingesting some of the cream), no spirochetes were found whether the cream was placed at the tick bite site or at a distal site. Among the mice who couldn’t groom themselves (not ingesting any of the cream), 1/18 tested spirochete-positive when the cream was applied at the bite site (92% protection) and 0/12 mice test spirochete-positive when the cream was applied to a distal site (100% protective). None of the mice who were protected against spirochete infection seroconvert, which was confirmed through xenodiagnoses on the 10^th day post-tick removal. 

Overall, the study found that Azithromycin has the potential to be an effective prophylaxis against Lyme disease spirochete infection in the cream form. Results showed that it provides 100% protection if applied in the first 3 days following tick removal, and then 74% in the following 2 weeks. This can be very beneficial among individuals who cannot tolerate oral antibiotics and among residents who live in regions where Lyme disease incidence is high, and they may not have immediate access to a provider to get a prescription for Doxycycline. Residents will be able to self-apply a small amount of this cream immediately after removing a tick. Future experimental studies need to be performed on larger hosts to determine if the transdermal effects will be adequate for protection.  

Sources:

• Piesman, Joseph et al. “Efficacy of an experimental azithromycin cream for prophylaxis of tick-transmitted lyme disease spirochete infection in a murine model.” Antimicrobial agents and chemotherapy vol. 58,1 (2014): 348-51. doi:10.1128/AAC.01932-13
• https://www.cdc.gov/lyme/resources/FS-Guidance-for-Clinicians-Patients-after-TickBite-508.pdf
• https://s3.amazonaws.com/media2.fairhealth.org/infographic/asset/Lyme%20Disease%20Infographic%20-%20Final.pdf
• https://www.fda.gov/consumers/consumer-updates/ticks-and-lyme-disease-symptoms-treatment-and-prevention