First lessons from a PA clinical year

By Morgan Marin, PA Class of 2020

Morgan Marin
Second-year PA student Morgan Marin

The clinical year of the physician assistant program is a collection of stories—the experiences and lives of patients—through which we, as students, learn medicine.

Over the past four months of my physician assistant program clinical rotations, I’ve encountered dozens of patient stories during assignments in Pendleton and Eugene, Oregon. I’ve chased these stories during busy days on my inpatient internal medicine rotation at OHSU and silently waited for a patient’s words while working in behavioral health at Adventist. All of these experiences have changed the way I view patients as well as my approach to caring for them.

As students, we are tempted to put patients into boxes based on diagnostic criteria and the treatment algorithms we study in the classroom. But these people to whom we provide care are so much more than their demographics, lab values and risk factors.

Seeing more than metrics

On my first rotation in Pendleton, I worked with a highly-respected family medicine physician who introduced me to the concept of seeing patients first as people. When he presented a patient, he never described them as a “48-year-old female” or “65-year-old male.” Instead, he would send me into an exam room to see the “high school librarian” or another “local cowboy.” He would remind me to ask about their summer plans or their kids – and then to listen.

A month later, on my inpatient rotation, it was harder to come by the time and space to listen to patient stories. Early morning pre-rounding was followed by daily radiology rounds, formal team rounds and afternoon note-writing and discussions – most days felt like a blur. However, I found time outside of my daily commitments to re-visit my people and get to know them as such. I met their visitors, walked laps with them and learned which dining service foods they hated the least.

By week four, I’d exhausted my go-to line: “I know a lot of providers have come to talk numbers with you, but I’d really just like to hear how you’re doing.” Despite this overuse, there were always stories to follow.

Empowering patients to change

Returning to an outpatient setting in Eugene the following month meant revisiting the trends I’d started to see in common, chronic diseases. My new preceptor wanted to help people change their stories and promoted “food as medicine” lifestyle changes to slow or reverse the progress of the disease.

In contrast, I spent much of my didactic year learning about how to treat conditions with medications, procedures, etc. While lifestyle modifications were also discussed as “treatment,” there was always the caveat that diet and exercise would be more difficult for patients to change and often less favorable. Additionally, lifestyle changes were framed as disease “treatment” and never as modes of disease reversal.

At the end of my first week, I attended one of my preceptor’s free nutrition classes and was both astounded and inspired by what I saw. The one-room church where he teaches was packed wall-to-wall with people eager to learn about lifestyle changes, reverse their diseases and regain control of their lives. They wanted to take back the authorship of their stories. How can we help people change their stories if we don’t listen to them first?

Morgan Marin on an outing near one of her PA program rotation sites in Pendleton, Oregon,.

Listening to learn

My fourth rotation in behavioral health pushed me to flex my listening skills and find comfort with silence. My preceptor, a well-known psychiatrist at Adventist, quoted recent studies showing that providers only listen to patients for about 11 seconds before interrupting. As a result, patients’ concerns are often missed or misinterpreted. In his clinic, we spent at least 15 minutes listening to patients with minimal questioning and frequent bouts of silence. While I initially viewed the quiet as uncomfortable and unproductive, I learned to read the expressions of patients and interpret the comments that followed. I found that listening is more than just hearing – it’s observing both what people say as well as how and when they say it.

As PA students and providers during our clinical year, people are already coming to us with their experiences, concerns, victories, defeats, questions and observations – their stories. We are tempted to jump to diagnoses, treatment plans and well-rehearsed patient education. However, I’ve learned in just a few months that much can be gained if we first pull up a chair and listen.