Interview with a PA fro Interventional Radiology

Here's an interview with a PA working in IR.

1) Why did you choose to be a PA? 

After college I worked as a health education researcher and teacher for several years and I really loved what I did. But it became frustrating when my students would come to me for health concerns and I didn’t have any means to provide immediate medical help. Many didn’t have access to regular check-ups and/or they did not trust their health care provider. I felt that being a PA would allow me to provide comprehensive medical care AND the education to help make good healthcare choices in the future. 

2) How did you pick UTSW? What was your interview process like? 

I honestly applied to all the Texas schools because I knew how competitive the process was. What I really liked about UTSW was naturally how highly ranked it is, that it had a 100% PANCE rate, the option to do a study abroad rotation (though I unfortunately wasn’t able to do so while in school) and because it seemed like a school that was genuinely invested in helping me to succeed. 

3) What was your biggest surprise once you started working as a PA-C? 

I think one big reality check for me was realizing working in the American Healthcare system isn’t necessarily just diagnosing and treating diseases. A large amount of time is spent navigating insurance systems, making sure that the patient has support outside of the hospital to help with follow-up care, and assessing transportation status is huge! Plus every single field of medicine deals with mental health issues so you have to be able to evaluate your patient holistically. 

4) What area of practice are you in now? What does a week look like for you? 

I currently work in an interventional radiology private practice that is contracted out to several major hospitals in the Dallas-Fort Worth area. I work Monday-Friday 8-5pm. We have the option to do weekend call but for the first two years, I chose not to. We are split between working interventional radiology (performing surgical procedures with imaging such as ultrasound, CT or x-ray), diagnostic radiology (putting contrast in any hole and barium studies), and outpatient clinic. We get a lot of variety within a day because you can switch between doing OB-GYN, orthopedic, oncology, GI, and endocrine procedures with each appointment. I rarely feel bored and most procedures last 20-30 minutes. I feel like IR is a lot like general surgery; you learn a lot about every specialty. 

5) Can you tell us about your involvement with TAPA as a student and now a practicing PA? 

I actually didn’t know about TAPA prior to PA school but after a presentation during one of my classes, I saw the importance of joining. TAPA is the only organization that fights and works solely for Texas PAs and honestly, any ability for us to practice is medicine is only because of them! I then became the student rep for UTSW and served in that role for two years. As a student I attended all the conferences, which was a great opportunity to network. Even if you’re not an officer, you can meet other students, professors and even practicing PAs who could be your link to a job when you graduate. I also liked the workshops and lectures which helped with upcoming exams. As a practicing PA, I served as the TAPA membership chair for two years. I really wanted to make sure that we got as many PAs as possible to become TAPA members. I have also been very involved in legislative issues that had the potential to greatly limit our scope of practice. It’s hard to believe, but there is always “someone” out there that wants a piece of your “pie” or scope so we have to constantly be vigilant. Recently there were two TMB rules that could have had broad implications to how we practice medicine so I personally went out to the meetings in Austin and testified. It was intimidating but I think by showing that we are competent providers who work in collaboration with our physician and that should be able to do what our prescriptive authority deems as possible really made a difference. Making arbitrary restrictions actually harms patients in the long run. As a result, the troublesome rule was dismissed and we got reinstated protection to continue to work in radiology. I’m really proud of that!

6) Any advice for aspiring PAs?

If you’re a pre-PA I would say to take as many opportunities as you can to see different PA roles. Being a PA is an awesome job but it is very difficult at times to both your mental and physical health. You have to have an inner drive to motivate you otherwise you can get burned out. For PA students, I’d say to hang in there! The semesters will soon end and the light at the end of the tunnel is much closer than you think. You were selected because you are the best! So keep that in the front of your mind when you have challenges. Doing poorly in a test does not translate to being a poor provider. There are many people counting on you to finish! And finally keep an open mind. I really thought I would be an OB-GYN PA when I was in PA school and never once imagined I’d do IR. Now, I can’t imagine doing anything else! Try to shadow during your holidays while you’re a student. Those opportunities are easier to come by than when you are out of school and in that weird limbo. I look forward to working with you in the future!

Finding a good fit

As a recruiter, I would often talk to people about what makes a good fit. Even people who had been working for years would have trouble answering this question. Knowing yourself and how you fit into the positions out will help you stand out whether interviewing for another job or trying to explain why you should get into PA school. As you consider different avenues available to you, here's some things to keep in mind:


1) What do you like to do - What kind of things excite you about a job? Working at the bedside with a patient, working in a close knot team towards goal, solving a financial puzzle, research, supporting the team by digging into details. Skip past cliches like "I want to make a difference" and think about what kind of tasks make you feel engaged. Do you like working in big teams? Seeing new people every day? Do you like routine? Knowing these things about you will help you find roles that will keep you interested and satisfied long term.

2) What do you NOT like - What things would make you walk away from a good job? Repetitive tasks, smells, meticulous work, unsolved mysteries. Every job has aspects that are unpleasant, that's why they pay us to keep showing up. The fun parts of a job, those exciting things that first attracted you to that role, will become normal and boring over time. Finding a job with tolerable frustrations while avoiding unbearable issues will keep you satisfied long after the newness wears off.

3) Where are you starting from - still in undergrad, already have a career, working and haven't started college yet? When I decided to become a PA, I already had a bachelor's degree, family, and a mortgage. That shaped how I needed to pursue my dream. Taking an honest look at how long you have to prepare, what steps you need to accomplish, and what resource and support you have will clarify some of the option in front of you.

4) Know your financial wants and needs - No one works with patients just to make tons of money and not care about the patient. None of us do this for free either. Be aware of your obligations, plans, and expectations for compensation because the position you love may not pay as much as one you could force yourself to do.

5) Test your theories - The best way to truly see what kind of role fits you best is to gather evidence. Go shadow someone dong these jobs. Talk to them, read up on the positions on a blog like this, and try to find some opportunities to work or volunteer.

Considering a Position, whether future, first, or further

Before I started this journey, I worked in recruiting. I helped people hire and get hired, walking through the steps of making a decision on a job. One of the key contributions I would make was helping people define what would make an excellent "fit." We usually think about money first, and then turn our attention to comparing exciting parts of different jobs. This can be a dangerously short sighted way to look at different positions, especially in your career as a PA. So, whether you have been a PA for decades or if you're nearly finished with school and want to look forward to something other than tests, here are some things to consider when considering a new position.

1) What is actually important to you? Our instant answer is money, but if you work 100 hours a week for it with no time off, you'll never get a chance to spend that money. Consider things like schedule, field, location, and team. Do you want to have more time off - maybe shift work is better. Does everyone else in your world live on a Mon-Fri 9-5 schedule? Maybe you should too. Do you really want to work in Neurosurgery? Do you want to be in pediatrics? Or do you just want to find a position near your family? Really figuring out what your priorities are will help you focus your choice.

2) Team - this is really critical. Finding a team that is right for you means you need to understand what kind of group you work well in. We often take for granted that everyone wants the same things, but there is a variety of nuance when considering who you work with. Do you function with more oversight? Do you need lots of clear expectations? Do you prefer more autonomy? Doe workplace humor help you or frustrate you? Culture and group fit are very personal, so consider what kind of mix works best for you.

3) Experience - as PAs, building good clinical experience is essential to having a strong career. When looking at positions, consider how much learning it will provide to you. Does this help you expand your portfolio of skills? Will you be exposed to different disease processes or patient populations? More importantly, does this experience help you build towards your future career goals? As PAs we can move from one area of medicine to another, so having solid experience can give you more flexibility in the future.

4) First Position - If you are making a decision about your first position, there's needs to be a few extra considerations. Have they trained a new hire before? What are the training and production expectations? Are there other PAs to help mentor you as you navigate they clinic or hospital? I have known some new grads who have successfully worked as the first PA in a clinic, but unless you are determined to do this I would focus on positions that have successfully trained new grad PAs already.

What job tips do you have? Any words of wisdom you've come across or had to learn the hard way? Let us know in the comments!

PA Life: Night Shift

Working night shift can seem daunting, but it has its advantages. Many PAs working shift work, especially newer graduates, end up working their share of nights. I've spent 6 years on nights, half as a PCT while getting my prereqs and half as a practicing PA Hospitalist. In that time, I've come to appreciate working nights. Below are some highlight and pits falls of working night shift.

Pro:

1) More Medicine, less bureaucracy - During a night shift, ancillary services like social work, case management, physical therapy, and to a degree administration are typically less available if at all. Trying to learn and navigate the complicated bureaucracy of medicine is less of an issue over night, allowing you the chance to focus more on evaluating, diagnosing, and treating the patient.

2) Flexibility - Shift work allows for some flexible schedules, and night shift can have even more. Often time, night shift is either required to work less shifts, get more compensation, or both. The trade off of working some weekends and holidays can give you long stretches of time off without using PTO.

3) Camaraderie - There's an inherent closeness amongst the teams at night, a sense of being "in the trenches" that develops. With some exceptions, you will find the common thread of working with less resources, less backup, at odd hours, helps unite the everyone.

4) Urgent and Emergent issues - You'll see plenty of this during the day as well, but over night you'll likely run into more if it. Decisions that need to be made quickly, interventions that need to be started, all with less support structure that day shift. If you're an adrenaline junky, night shift might be for you.

Con:

1) Sleep - The sacrifice you make from your sleep schedule will take a toll. There are studies showing the health effects you could suffer from working night shift. But even if you avoid these, your sleep will not be the same.

2) Social - While you might have time off work, most of your friends and family do not. Few of them will be off work when you do. Trying to schedule around nights, holidays, and weekends can be challenging.

3) Intangible - While you will be more connected to your nightshift team, you will often seem disconnected to the larger workings of your facility. You will miss meetings, you will struggle to make training sessions, you will be apart from much of the decisions made about your practice.


I don't want to end on such a negative note, because Night shift can be a wonderful fit for many PAs. On an upcoming post, I'll go over some of the ways to address these short comings and make the most of these benefits.

Do you work night shift? Any tips, thoughts, or hard learned lessons? Let us know in the comments!

Interview with PA-S from UNTHSC

Here's an interview from a PA student at UNTHSC who just graduated!


1) What made you decide to be a PA? I’ve always looked up to my own pediatrician growing up and truly appreciated how he treated my family and I so graciously. I aspired to serve others in that way and instill hope and confidence in children and their parents. I didn’t actually know what a PA was until I was in my second year of college and another student told me about it, sparking my interest. After some research into the career, I decided that this career path would fit my lifestyle better than going to medical school to be a physician. I would still have the wonderful opportunity to serve in pediatrics in the way I dreamed, however I would finish school faster and be able to have the family life I always envisioned for myself before the age of thirty. Felt like the perfect dream. 2) How did you choose UNTHSC? What was interviewing like?
Choosing UNTHSC was easy for me. My family is based in Fort Worth, so I was incredibly blessed to get in. I also thought the campus was pretty and nicely located in the middle of Fort Worth. The people had such a friendly vibe and I felt like it was easy to connect with everyone. Interviewing at UNTHSC was a little more intense than the interview at UTMB, but at the same time I felt more comfortable with the faculty. I remember I was in the afternoon interviews, so we had a quick bite to eat while sitting with faculty and other applicants. Then there was some sort of essay to write in a given time, a one on one interview with the faculty, and a team exercise with other applicants. It was stressful, but I tried to maintain my cool! That’s pretty much how everything went! It was all stressful, but then again I’m a worry bug. 3) What has surprised you about PA school?
Looking back on PA school, what surprised me was how hard it actually was. What also surprised me was how much you realize you are capable of learning! The learning curve applies to learning how to learn. Once you get your study habits on track, it goes much smoother. 4) What study strategies worked? Did that change on rotations?
During didactic, I realized quickly that my old study habits of making flashcards and reading were not going to cut it. I turned to my classmates for help and quickly realized that I needed a study buddy. I needed to review things out loud with someone to ensure that thought processes were correct and test one another to see multiple perspectives of the same material. I needed to see how the same information could be asked in different ways. I also used test banks like ExamMaster and books like PANCE Prep Pearls to figure out what were the main highlights and must knows within a topic. On rotations I had to fend for myself. I mostly used PANCE Prep Pearls book and ExamMaster to review material and topics. I also reviewed over old notes from didactic occasionally.
5) Tell me about your involvement and experience with TAPA.
TAPA was a great opportunity to do something outside of school with my classmates while also benefiting my career. My classmates and I always made a fun trip out of it and we got to see and meet students and alumni from other programs. It gave me a chance to learn about different career opportunities and practice communicating with other professionals. I think I went to at least one conference each year, if not two! It was fun to go to different cities and also to learn about what our career had to offer and what changes were being made. 6) Any plans for after graduation?

I found a job in primary care pediatrics! Start in August, so I have a couple months of lounging around and enjoying my last ever summer break!
7) What advice would you give an aspiring PA?
I would say that you should keep pushing through! All the hard work will pay off! Work hard to keep your GPA high in undergrad, volunteer, shadow, and don’t burn any bridges with anyone because you never know where a relationship will lead. Networking is key! I found my first job through my rotations! It is a great career and totally worth every moment of hard work!

Welcome Back

Welcome Back! 

We've been hibernating long enough. Time for some new posts! Stay tuned because we'll have new interviews from PAs and PA students, day in the life of snap shots, updates on the PA admission process, and more.

Have something you want us to cover? Any field of medicine you are curious about? Have a question about a particular school? Let us know in the comments!

TAPA Fall Conference 2013 Video Interview #1

Here is the first video interview from the conference. John and Alesha are UNTHSC alumni speaking about their experience.

Interview with an Othropedic surgery PA

Here's an interview with a PA-C who happened to be married to one of my classmates. 

1)  Why did you choose to be a PA? 

I chose to become a PA based on the lifestyle. I wanted to practice medicine and becoming a PA provided me that option without going through medical school. I was constantly searching for a field in medicine that would fulfill my career aspirations and never felt right about other fields. Once I found out about PA, I never looked back. 

2) How did you pick UTMB? What was your interview process like? 

I chose UTMB based on the academics and the student run clinic. There is a clinic in Galveston where care is provided to the underserved community. The patients there are so appreciative of the care that they otherwise, would not have received. The pass rates are outstanding. My class had a 100% first time pass rate on the PANCE. I did get into 2 other programs, which were good as well, but I felt that UTMB was the best fit for me. 

3) What was your biggest surprise once you started working as a PA-C? 

What has surprised me is how much I still have to learn. I have been at my position for 5 months now, and I still see something new frequently. PA school is good at providing a background for primary care, but going into a sub-specialty requires its own education. There is so much information in medicine, that it is hard to know it all. 

4) What area of practice are you in now? What does a week look like for you? 

I work in orthopedic surgery with a foot and ankle surgeon. I split my time between the clinic, OR, and the hospital making rounds on patients. Every week is different so it is hard to even come out with a typical schedule. I would say that I work around 50 hours per week with call once during the work week and every couple of months for weekend call. 

5) What is it like with your husband in PA school now? Do you give him study tips? 

I love that he is in PA school now to be honest. We are able to spend more time together now than we did while he was working full time and going to school part time. I actually let him do his own thing during school. I have tried giving him study tips, but we study so differently that what worked for me does not work for him. 

6) Any advice for aspiring PAs? 

My advice for aspiring PAs is to shadow a PA. This is when I truly decided that becoming a PA was what I wanted to do with my life. Then I would focus on getting some sort of hands on experience. I didn't have that much hands on experience and I wish I had. Get involved in your community and organizations in school. Once you do get into PA school, take a break and relax. You will never have time like that again! I definitely miss my days of just being lazy around the house, so when I get those days, I cherish them. Last piece of advice is to have fun!

New Bill passed in Texas

This spring/summer there have been several states passing new PA laws. This week, Texas passed a bill that will free up PAs working in hospitals and hospice, among other things. Below are the highlights of the bill and a quick word from a few of the TAPA legislative affairs committee explaining its significance.



1) What does this bill mean for Texas PAs?

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1. The LAC formed a task force to lead the negotiations for TAPA with the TMA and the Nurses Coalition. This task force included: Lauren Dobbs, Karrie Crosby, Todd Pickard, Melinda Moore, Jaime Capelo and Lisa Jackson. This group worked tirelessly over several months to ensure that the bill contains victories for the PA profession and moves our practice forward. The following summarizes the changes to current law that are included in this bill that represent MAJOR VICTORIES for PAs in Texas:

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• Reduces site-based language from 5 settings to 2 (community and facility-based).
• Delegation of schedule II medications to PAs working in Hospitals or for patients in Hospice.
• Increases the number of PAs that a physician can delegate prescriptive practice from 4 to 7.
• Allows for unlimited delegated prescriptive practice in underserved and rural areas.
• Clarifies language that allows for unlimited delegated prescriptive practice at Hospitals.
• Removes the limitation for physicians to delegate prescriptive practice only at one Hospital.
• Removes distance limitations for physician supervision.
• Removes the percentage of charts that a physician must review and co-sign.
• Improves PA Board collaboration with the Medical Board and Nursing Board.
• Removes requirements for a percentage of hours of operation that a physician must be present at a practice.


It means that there will be some simplification on the rules that govern how we practice with physicians. As of now there are complicated and confusing site-based rules that have 5 different sites. Moving to two simplified sites (hospital and community settings) will make it easier to understand the rules. It also eliminates distance limitations, physician chart review, daily logs and many other cumbersome administrative tasks. It also allows for a physician to delegate up to 7 PA. This is an increase from the current limit of 4. Also for the first time PAs will be officially recognized as Primary Care Providers and be able to Order DME for our patients. It is a big step forward. TAPA will continue to seek improvements in our practice act and this is part of that ongoing effort. 


2) How did you engage the legislature?

We negotiated with the TMA and Nurses Coalition for several months, met with the Senate Health Committee Chair, met with the House Public Health Committee Chair, held a PA day at the Capitol where more than 40 PAs and Students did 60 visits, canvassed the capitol and held additional visits with the legislators, and reached out to our membership to call their representatives in support of our legislative agenda. It was a lot of hard work and took many months. We also worked with the TAPA PAC to make key donations for the primaries and general elections held this past fall.

TAPA’s Legislative Affairs Committee (LAC) works with our lobbyist, Jaime Capelo, who assists us in staying, engaged legislatively.  As a result, we have developed relationships with key stakeholders and legislative committees in regards issues relevant to PA practice.   We have also partnered with physician groups who have interests in seeing the physician-PA team practice model work.


3) What can someone do to help out next time there is an important bill?

The best way to get involved and be a part of the bill making process and affect the next legislative session is to get involved with the Legislative Affairs Committee (LAC).  Students and practicing PAs are encouraged to sign up every June via the TAPA website to participate in committees. The state legislative sessions are every 2 years but planning and work for the legislative session begins the year prior.  TAPA also hosts a Legislative Day for PAs to discuss bills with legislators every legislative session and is an additional way to get involved.  TAPA also hosts a Legislative PA Day every session where PAs can learn about the legislative process and lobbying.  Then teams conduct visits to Legislative offices.

Donate to the TAPA PAC and come to the PA Day at the Capitol. Calling your representative’s and senator’s office to voice support for the TAPA legislative agenda and bills is also crucial. It takes time and money to get the message out and get support for the PA Profession.

TAPA 2013 Video Interview #4

Here's an interview I did with a PA-C working in Hormone Replacement Therapy. 

TAPA 2013 Video Interview #3

Here's an interview with Jack Runyan PA-C, PhD. He is faculty at UT Pan America, a Physician Assistant since 1977, and founder of Mercy Trips non profit healthcare outreach organization.

Interview with a Rural Medicine PA-C

Here's an interview with a PA who practices Rural Medicine in North Texas.

1) Why did you become a PA?

 I spent quite a bit of time in my undergraduate career trying to decide between medical school and physician assistant school.  I had the opportunity to work as a medical assistant at a Christian family practice office where I feel like I was introduced to excellent medicine and a great example of a physician/PA team. One of the physician assistants I met there had trained at Duke during the first few years of that start up PA program in the 1960's, so coming to know him and hear his stories of training was truly a dose of PA history! The other physician assistant at the practice was a new graduate and offered a fresh perspective on the process of applying to PA school, and the up and coming advances in the PA profession. It was through coming to know these excellent physician assistants that I realized the value of the profession and began to learn more and more about PA's and their patient centered focus.

2) How did you pick UNT HSC? What was your time like there? What strategies helped you?

I picked UNTHSC because of the warm welcome I received during my interview period.  I had taken a few days to talk candidly with students at several of the Texas PA schools, and the UNT students were honest about the difficulty of PA school but spoke highly of their program, and felt like they had the support of their faculty and student peers.  I also knew I wanted a longer PA program, so the length of UNT's program was very attractive to me.

I had an excellent time at UNTHSC.  Looking back, it was very challenging, but also a time of great personal and academic growth.  Our class of PA students operated like a family, we all worked together to take complete notes, and shared study materials; the fact that competition between classmates was not a hindrance was something that helped all of us navigate the three years of PA school.  Taking one day or part of a day off from studying, a "day of rest" if you will, was another vital part of maintaining a balance in school.  There is a "buddy system" in place where you will be assigned an upper class PA student to help you with tips and strategies during the first few weeks of school, and I would recommend taking full advantage of their experience and knowledge.  

3) How did you get into Rural Medicine? Did you do a rural rotation in school?

I did not complete a rural medicine rotation, and would not have initially seen myself practicing in a rural setting.  I knew I wanted to gain experience in primary care with my first job after graduation. To be quite honest, when I interviewed for my current position, I didn't fully realize how rural a setting it was until I arrived at the job interview!  Once I met my supervising physician, and saw the practice setting, I was intrigued  and impressed; I decided I was up for a challenge and an adventure in rural medicine, and I have not regretted that decision.

4) How has your perception changed about Rural medicine since you started practicing?

My perception has changed in several ways.  My perception of the PA/physician team started off as something fairly standardized, but now I realize that that relationship is unique to the individual physician and physician assistant, as well as variable by practice setting.  The scope of practice of rural family physicians and by extension, that of rural physician assistants, is still fairly extensive.  

My perception of work/life balance has changed quite a bit; in the rural setting, your job and involvement in the community doesn't end at 5:00 pm.  You become an integral part of the community, and people come to know you as a leader, and will ask you to commit to various voluntary or appointed positions.   I've had patients call me in the middle of the night, with a health emergency or question.  You see people at the local meat market or grocery store and they will ask you their medical questions with bold (and sometimes amusing) honesty; they will often introduce you to family and friends and say "This is my PA, they take care of me".  

Finally, my perception of the medical community overall has changed since I began working in a more rural area.  We do have limited specialist coverage, and all of the family physicians rotate call for any patients that are admitted to the hospital.  There is a spirit of teamwork between the family doctors, their physician assistants, and the specialists we have covering our local hospital which I have not witnessed anywhere else in my training, and this is something I will always remember about rural medicine.  The medical staff here truly do rely on each other for personal and professional support, and everyone collaborates very well to help patients receive the treatment they need, even if it means staying late or taking on an patient consult. For example, I frequently contact our orthopedic surgeon and cardiologist on call for our area hospital on their personal cell phones when I need advice on a patient I have in the office.  

5)  What kind of patients do you see?

I see a range of patients in the family clinic, infants to geriatrics, for anything from preventive exams to chronic disease management, to walk in visits for sick patients and minor injuries.  My supervising physician and I also see patients at the local nursing home, so I round on those patients at least one per month. I am the provider on call for the nursing home, so take 24 hour telephone call for any situation that may come up with our patients there.  After building my skills in the clinic and nursing home my first year in practice, I have had the opportunity to gain some experience with inpatient medicine; I essentially pre-round on any patients my physician or I admit to the local community hospital, and work closely with my supervising physician to coordinate hospital orders and discharge planning.

What does a typical week look like for you?

My days start at around 06:30 when I call up to the local hospital to check on any admitted patients.  If we have patients in the hospital (usually anywhere from 1-5) I head up to the hospital around 07:00 and start rounds and progress notes.  My supervising physician usually meets me on the inpatient side and we wrap up discharge planning or further hospital orders together.  Clinic starts at 8:00, so I head to the office after hospital rounds, and see patients from 8-5.  If anything comes up for our nursing home patients during the day, or if I received an overnight call for any problem, I will drive by the local nursing home during lunch of after office hours to make a nursing home visit for any sick patients. I don't typically take call at the hospital or round on patients over the weekend, although I am still on call by telephone for the nursing home;  If our nursing home patients get sick over the weekend and I am in town I usually will pay a weekend visit to them.  The providers at our office number seven (three physicians and four physician assistants) and we alternate shorter weekend clinic hours, so we each work one out of every seven weekends.

6) What is your favorite part of your practice?

My favorite part of my practice is the long term relationships I have had the opportunity to form with patients.  It is common to build relationships and take care of several generations of a family.  It is rewarding to see patients back for follow-up over an extended period of time and mark their progress.

7) Any advice for future PAs?

I think my advice would be to remain open to career changing opportunities, but don't be a afraid to take that first job in primary care, for those who are so inclined. I believe it has been a really valuable experience, and I think that physician assistant scope of practice can really be utilized to its full extend in that setting.  Second, I would say to make sure to try and maintain a work/life balance that will help you stay grounded and prevent burnout, especially during the first few years of practice. 

Interview with an Admiral

This past fall I had a chance to meet with Rear Admiral Epifanio “Epi” Elizondo, Ph.D., PA-C, the Regional Health Administrator for Region 6, Department of Health and Human Services. You can read an excellent article for more on his position and background, and here to see his most recent distinction in the PA world. Since we met in his office (a federal building) I didn't get to video our conversation. I made furious notes the whole time we spoke and, afterwards, had a difficult time putting them into a coherent post. Below are, in no particular order, some thoughts about our conversation. 


Remember where you come from - Admiral Elizondo showed me around his office and pointed out several notable items: a picture with Janet Reno, a flag given to him by the First Lady, several awards for his service and work, etc. We came across a black and white close up photo of a women working in a field. "That's my mother." He told me how he keeps the photo to remember where he came from. His mother worked hard to provide him with opportunity so that now he may help others. It's humbling to remember, and it's important. 


Public Health = Population Perspective - Starting in clinical medicine, Admiral Elizondo worked directly with patients. While he was able to make a great impact on each person, he told me how public health let him reach many people at once. Cleaning up a water supply means a whole population doesn't need to keep making trips to a clinic. For him, it was a chance to have a broader impact and help more people with his time.  


Think Career - As he walked me through his career, he described an incredible amount of intention during each step. Moving from the Air Force to the Public Health Service not only opened up new avenues of practice, but allowed quicker advancement for a new officer his age. Making the most of a position in correctional medicine meant taking on extra projects, but it also let him learn new leadership skills needed to advance. Admiral Elizondo didn't just work hard; he worked wisely to make the most of his career. 


Always another way to help - I had not heard of Operation Lone Star, but in talking I learned of this initiative to address health disparities along the Texas border. I was fascinated to know that a) there was a coordinated effort that occurred regularly to intervene in this massively under served area b) even though I've spent tons of free time trying to learn all the ways to serve locally, I had no idea this existed since 1998.


Take the time, take the opportunity - I emailed the Admiral's office to see if I send a few questions to share on this blog. It was a great surprise to be invited to his office to speak with him in person. Hearing his journey showed me countless times that he learned to make the most of what he was given. Being able to talk one on one with him about his career was an amazing honor and one that I would not have come across if he wasn't eager to help out an aspiring PA. In this field more than any other, I consistently find people who are excited to help anyone interested in the profession. Be sure to take the opportunity and reach out. 

Interview with a PA-C in Neuro

Here's an interview witha PA who works in Neurosurgery. 

1) Why did you become a PA?

I became a PA in a roundabout way.  I suppose the same way a lot of people do.  I already had a Master's degree in Anthropology and was burnt out on academics.  I knew I wanted to do something practical with my training and experience.  Initially, I was taking pre-med prerequisites thinking I'd become a physician, but I met someone who was applying to PA school who was taking a class with me.  I did some investigating and realized that becoming a PA would be a better fit for me over all.  I wasn't wrong.

2) How did you pick BCM? What was your application and interview process like? 

I lived in Louisiana at the time I applied to Baylor College of Medicine in Houston.  Louisiana only had one PA school available and it was a Bachelor's program.  Baylor was relatively close to home and I didn't have to meet any residency requirements to go to Baylor.  I loved it there.  Great school and amazing experiences at the Medical Center there.  The application process was easy.  This was 1998-99 so I think it was an individual application process, not a centralized process.  The application process was enjoyable actually.  We all toured the campus and part of the Med Center.  We were assigned to interview with PAs and MDs.  It was pretty relaxed overall even though we were all stressed out.

3) What was your strategy for succeeding in the didactic phase? How did that change in clinicals?

I learn visually and I just remember reading and re-reading and re-reading and talking things through with classmates.  For me, re-writing my notes was really helpful.  Clinical phase was markedly different.  You learn on your feet, helping take care of patients and then reinforcing what you saw and learned by reading more whenever possible.

4)  What do you do as a neuro PA? What does a normal day/week look like for you?

As a neurosurgery PA I see patient's in my own clinic, assist my physician in his clinics, order and interpret tests, assist in surgeries in hospitals and in our surgery center.  I also take call after hours and round on the weekends as needed.  I also field phone calls from patient's and deal with disability paperwork and refill requests.  I also see patients in pre-op clinic and discuss their upcoming surgery and answer their questions.  A normal day starts at its earliest around 7 am and ends around 4:30-5.  I work Monday through Friday and, if on call, round on Saturdays and Sundays.  Occasionally, we do have emergency surgeries that happen after hours.  Occasionally we have to see patients in the hospital in consultation after hours too.

5) How did you get connected to your current practice? Have you worked in other areas of practice?

I actually interviewed with my current employer 9 years ago but accepted another job offer.  I was looking for a new position several months ago and answered an advertisement for a Neurosurgical PA on the TAPA website.  I have also worked in general orthopedics, neurology, orthopaedic spine and orthopaedic trauma surgery.

6) I've heard that the critical component of any PA position is the relationship with your supervising physician. What do you look for in that relationship?

Finding the right "fit" with your supervising physician is very important.  You have to mesh well intellectually and emotionally.  Working with surgeons means that you have to respect and appreciate that your employer may do things differently from other surgeons, but your employer's way is THE right way when you work for him/her.  You are second fiddle to your boss.  If you can't accept that, don't become a PA!  For me, I need to work with someone who is respectful of me, my life and my opinions, and is honest about the expectations.  Some employers will try to win you over with money and benefits but then have no respect for your time outside of work.  I can take working long hours as long as I know that's what is expected of me.  I've been led down primrose paths before thinking that I would work "normal" hours (ie, 9-5) only to be in clinic until 8pm routinely and in the operating room until 11pm all too often.  With no extra compensation for all that time mind you.  If your employer works as hard as you do that's the exception to the rule.  That's how things are for me now.  Not always.  I used to work with ones who took their dedicated time off during the week but expected you to work your 40 hours and more.  

7) You've been practicing for 10 years now [ed: I think I remember that from our conversation, feel free to correct me] How has the role of a PA evolved in that time? 

I have been a PA in practice since 2002.  Medicine has changed drastically.  I think that US medicine is evolving towards a more centralized system.  Not necessarily toward government centralized but more towards hospital centralized care.  I see more and more private practices having real difficulties because they're competing with other providers who are employed by hospitals.  Imagine that you work for yourself and have employees.  All the income you generate is because of your great reputation and hard work.  Then, right next to your name in the insurance directory is a provider who provides, by appearances at least, all the service you offer but their salary is paid for by a hospital system and that provider is expected to keep all their referrals and testing within that system.  That's what we're going to see more and more of.  Your boss may be a surgeon who is competing with other surgeons who provide the same services, but your boss gets paid based on the work that your practice performs.  A hospital employed surgeon gets paid no matter how much work he/she does because they get a salary from their employers - a hospital.  Your boss may need to do 40 surgeries a month to keep the business going, but that hospital employed surgeon....I'm not sure how hard that surgeon would work since they would get a salary no matter what.  I feel that this trend will affect PAs and NPs and more hospitals will employ mid levels directly.  Might not be a bad direction to consider.

8) Any advice for aspiring PAs?

Study hard.  Ask lots of questions.  Listen to the nurses.  They can teach you a LOT.  Don't take things personally if people look at you like you're "just a PA" and "not a doctor."  I'm amazed daily how few people know what PAs are and what we do.  Don't stop learning.  Most patients just want someone who actually listens to them.  Try to really listen to people rather than just waiting for your time to talk.  Do what you enjoy and enjoy what you do.

Interview with a Surgical PA-C

1)  Why did you choose to be a PA?

I graduated with  BS in biology from Wagner College in Staten Island New York.  For three years after graduation I taught Biology and Chemistry and at a local catholic high school.   As much as I enjoyed it, I wasn’t going to stay there forever.  Since Wagner had a PA program I had a handful of friends who were already practicing PAs.  The more I continued to talk with them the more I decided that becoming a PA would be a great fit for me.

2) How did you pick UMDNJ? What was your interview process like?

My undergraduate GPA was not good.  I want to say it was around a 2.5.  I went back at night to retake some prerequisites and I made sure I had a 4.0 in all of those classes.  With such a low GPA I applied to almost every school I could drive to.  Living between NYC and Philadelphia that was almost 10 schools.
I was surprised to be granted interview at the first two schools I heard from.

The UMDNJ interview was the first one.  I went early and dressed in a suit.  I remember waiting in the outlying room as other candidates went in for their interviews.  I went into the room and sitting behind a small table were probably two faculty members and one or two students.  They asked a lot of questions, but I only remember one.  They asked me what I would do if I were not accepted.  I remember the question because I told the truth and at the time I wasn’t sure that it was a good idea.  I told them that I didn’t know what I would do.  My wife and I were planning on starting a family and we may not want to wait another year.

I heard back from them a week later and I canceled all the rest of my interviews.

3) What strategies worked for you during your program? Did they change when you entered the clinical phase?

I changed study strategies hundreds of times throughout PA school.  I used piles and piles and piles of index cards for anatomy my first year. I wrote test questions and little study guides my second year.  Some classes i focused and took tons of notes.  Others I did crossword puzzles while only half listening.  It depends alot on the class and how much your brain can take.  It is a ton mental work.  It is exhausting and it is a marathon.  I studies in groups and I spent hours alone in a cubicle.  I found I don’t do well for focusing for long periods of time. I prefer the 25 minutes on 5 minutes off technique.  I find my brain works better that way.  In Stephen Covey’s The Seven Habits of Highly Effective People the seventh habit is called sharpen the saw.  The premise is that if you are going to be cutting down trees for a 8 hours you can get a lot more done if you stop and sharpen your saw for at a 4 hours.  If you just keep cutting you will work harder and accomplish less.  I noticed this strongly in PA school and I have brought it into every area of my life.

4) What was your biggest surprise once you started working as a PA-C?

The biggest surprise I had was that people started to trust me immediately.  Nurses would ask me questions as if I knew something.  Scrub techs stopped watching me like a hawk.  Nothing had changed since graduation, but somehow a lot had changed.  Don’t worry when you get there you will be ready for it.

5) What area of practice are you in now? What does a week look like for you?

I currently work for the department of surgery in a small community hospital.  I first assist on any case that a surgeon at our hospital needs help with.  I did a robotic prostate yesterday.  I have lumbar fusion case today.  I have a C-section scheduled for Monday.  I am lucky enough to have the job I went to PA school to get.  I am in the OR 5 days week with a huge variety of cases.  I don’t take call.  I don’t work nights, weekends or holidays.  It really is fantastic place to be

6) You have a great and thorough review website. How did that get started? What are your goals for PA Exam Review?

I got started producing content for Physician Assistant Exam Review because I couldn’t find what I was looking for.  I wasn’t in love with any of the review books out there.  I also really enjoy listening to podcasts and I couldn't find anything on medical review that I could use.  I decided to create what I couldn’t find.

I initially set out to write a review book, but I don’t think that's what I’m doing anymore.  I am building a place where PAs can go to feel like they are not alone when preparing for their exam.  The PANCE is one thing.  You are surrounded by a group of people in the same boat.  When you take the PANRE you are alone. Even if you work with other PAs you are still alone because their cycles likely don’t match up with yours.  So my biggest goal is to create a place for PAs preparing for their exams to feel welcome.

7) Any advice for aspiring PAs?

Get started now.  I put it off for three years debating what to do.  It’s a great job.  You may be worried about the three year commitment, but you will be three years older whether you go to school or not.

Follow Up Interview with PA-C Audrey Lively

My fist post was an interview with Audrey Lively, a newly graduated PA. Now that she's a year out, I was able to do a follow up and see what thought she had about her first year as a PA. Check it out!

1) What has your first year as a PA-C been like?

I work for the University of Texas as a PA in orthopaedic trauma at Memorial Hermann Hospital in Houston, Texas. We are a team of 6 attending surgeons, 2 fellows, 3 PAs, 1 NP, and 4 residents that rotate on a 4 month basis. My first year as a PA has been amazing. I am extremely fortunate to be working with a team of brilliant attending surgeons and supportive midlevel providers. The amount of information I have learned over the past year in my specialty surprises me daily. My basic job description is to arrive at the hospital by 6AM, when the team meets to cover all of our current inpatients and review the consults that came in over the previous 24 hours. We then disperse to begin rounding, prepping patients for surgery, and assisting in surgery. One day a week I am in clinic, where I see our hospital follow ups and new patients. When we are running short-handed or my physician is on call, I help with the consults that come through the ER.


2) What's different at work now compared to when you first started?

I have gained a lot more responsibility as my attending has trained me over the past year and come to trust my judgement on interpreting x-rays and making decisions regarding surgery. My surgeon's goal was that we become "one person who can be in two places at once," and I feel we have accomplished that. My comfort level has also greatly increased since starting one year ago as I have learned from other members of my team and attended conferences.


3) What surprised you about being a PA-C? What do you wish you had known when you graduated?

 I had this false idea going into PA school that when I graduated I would be a pro in everything and just have to stay up to date on topics, but otherwise know just about everything I needed to know. However, I quickly learned that this is not the case when you make the choice to go into a specialty. Every day is an opportunity to learn. The physicians I work with attended 4 years of med school, 5 years of orthopaedic residency, and at least a one year fellowship in orthopaedic trauma. I was surprised by how much I still needed to learn and continue to learn on a daily basis to keep up with them.


4) Do you see yourself staying in this area of practice? What do you like about it?

I do see myself staying in orthopaedics. I really enjoy the broad population with whom I work. We have treated patients as young as 2 weeks and as old as 98 years. It is also a great opportunity to learn and maintain knowledge in anatomy. PAs are able to do quite a bit in the field, including seeing clinic patients, ER consults, assisting in surgery, performing injections, reducing fractures, and applying splints and casts. Working in a hospital setting, I am also able to continue to use my medical knowledge in managing my inpatient's labs and chronic medical conditions. The knowledge learned in orthopaedics can always be carried over to urgent care, primary care, or emergency medicine as well if I ever did decide to switch fields.


5) Any advise for future PA students? What should we do to prepare for a program? What about preparing for the "real world?"

My advice to future PA students is to stay committed during the didactic year. It gets really tough trying to keep up with everything, but it will be worth it in the end. When students would complain about exams, my program director would always say "Every patient is a test." This statement could not be more true. The information learned in school will be vital later as your future patient looks at you and asks what is wrong with them. In preparing for a program I would suggest refreshing on your anatomy and physiology, which are the basis for what you will learn. Beyond that you will find out what you need to know in school. In preparing for the "real world," just remember that you should never stop learning. Medicine is a constantly evolving field and will pass you by if you don't keep up. Read journals and take the time to read a few of the emails with which your account will be flooded after graduation regarding new medications and treatments. Most importantly, keep in mind the reason you chose to go into PA school in the first place.

Neurosurgery PA-C Interview

Here's an interview with a Neurosurgery PA-C

1) Why did you choose PA as your career?

Initially, I was considering becoming a physician, and the more I looked into it, the PA field is much more portable.  I would not be tied down to a practice location, or specialty.  I also like the idea of having an attending physician available to me at all times to provide ongoing consultation, and education which continues to mold my clinical judgment.  


2) Where did you go to PA school? How did you choose?

I applied to probably 7 different schools in TX, NY, IL and FL.  The TX schools I chose because they were for the most part, "local".   The others, I chose because they offered entry within a few weeks of my completing my pre requisites.  So, I could start pretty much immediately.   The other thing I took into consideration was, was whether the program went year round with few breaks, versus on a traditional semester system.  For me it was important to start and finish and begin working as a PA in the shortest time possible.  And, for all those reasons, I chose Nova Southeastern University in Fort Lauderdale FL.  


3) What do you do as a neuro PA? What does a normal day/week look like for you?

Typically, I have 1/2 day clinic on Mondays, full day on Wednesdays.  OR cases are scheduled for Monday afternoon and Tues, Thurs and Friday.  We do 7-15 brain and spine cases per week, and I see 25-30 pt in clinic, then do rounds and consults at 5 different hospitals.  There is another PA who shares the patient burden with me, and he is a great asset.   I am "on call" every other weekend, which means all hospital rounds and cases, and I help 3 surgeons during those times.  Not all of them require assistance every weekend, though.  I always make myself available to the other physicians, nurses, and hospital staff at any time, and they all have my cell number.  In this specialty, it is critical that the communication be uninterrupted so problems can be taken care of quickly. There are no "normal" days in Neurosurgery!  Each one is full of new challenges, and I relish that.   The environment is fast paced and can be stressful, but I am part of a team and we trust and support each other tremendously and that makes all the difference in the world.


4) How did you get connected to your current practice? Have you worked in other areas of practice?

A "headhunter" contacted me about my current position.  In the past, I have used the healthEcareers webiste on the AAPA site.  I have worked in Neurology, Neuro Interventional Radiology and Physical Medicine and Rehab, as well as Neurosurgery. 


5) I've read some people in specialty practice would prefer a more specialty focused PANRE. Do you like reviewing the generalist helps you as a PA or would you prefer to focus further into your specialty?

My field is so specialized, that I like having to refresh myself with the generalist PANRE.  I refamiliarize myself with skills and treatments I do not get to use on a daily basis.  It makes me a more well rounded PA with skills and knowledge that cross over into to other areas.  If I can recognize a patient's acute cholecystitis, or UTI, it keeps me from ordering what may be an unnecessary MRI of the spine when I can treat and manage these other issues and get them the care they need. 


6) The PA profession is continuing to grow, with new legislation, more PAs in medical leadership, and practicing in new areas. What would you like to see happen next professionally?

I am pleased that the PA profession is growing and more recognized in communities, & branching into other practice areas in order to serve patients.  Going forward, I would like to see PAs more recognized as legitimate providers of high quality care by more of the medical community and lay people.  The more active we are with supervising physicians in promoting the field, the more receptive patients will be to our involvement.  Professionally, I would like to see more partnering and discussion with, and among mid-levels,  Independent practitioners NPs and PAs, regarding best practices and how to better serve patients and our supervising physicians to expedite the best and most cost effective care for patients.


7) In addition to shadowing and getting good grades, any advice for future applicants?

Remember PA school is a great experience but is just the beginning.  Being a PA is a commitment, and very fulfilling.  Getting good grades is important, but once out of school, thinking quickly about how to solve problems is extremely important, and the ability to do so under stress. 

PA-C running a business

Here's a unique interview: a PA who, after praticing clinically, started a health care related business: Medelita.

1) What made you interested in health care? Why did you become a PA? 

I was actually pre-nursing at Emory University (undergrad) and after volunteering extensively at Grady Hospital (the big, inner-city hospital in Atlanta) I realized that I wanted to be more a part of the clinical decision making process and that my personality was best suited for a clinical role.  I knew that I also wanted to someday be a mother, and I needed flexibility in my profession to allow me to do that.  And I was dead set on working in Emergency Medicine, and PA s have always had a strong, respected presence in ER.  I thought it was a great fit. 
 I wrote a recent blog post here that describes my first day of ER rotation with Larry Herman, president elect AAPA.


2) Tell me about your time in clinical practice. What did you like? 

My first job was at Mary Immaculate Hospital working in the Pediatric ER and Fast Track.  It was an inner-city hospital in Jamaica Queens (NY) and has since been shut down.  It was one of the best places in the country (perhaps I'm biased) to learn clinically at lightning speed with zero competition for good cases.  It was my number one goal to work in that ER under the direction of Larry Herman, RPA-C.  Only the brightest, most reputable and capable PA s worked in this ER.  The ultimate honor.  And it was the most difficult job I've ever had in my entire life.  There was very little (if any, honestly) physician support.  I would sometimes go to the main ER to ask for help and the response would be something along the lines of "look at me.  How could I leave this area now?"  It's not how the PA profession was designed to work, but I'm telling you – it is absolutely a great way to learn, for someone with the right clinical sense and drive.  The mentality of not being dependent on others in a very risky environment makes you learn super quickly, to say the least. 

It was wildly clinically challenging, in the oddest ways.  We were the receiving hospital for JFK airport, so we would regularly get people sent from other countries who were told "We cannot help you here.  Get on a plane to the US and they can help you with this medical problem."  So in the middle of the night I would see severe gigantism, uncontrolled seizures from head trauma (months prior) from a mounted water dispenser falling 2 stories onto my patient's head, etc.  Hmm . . .  It was always very interesting.  My very first patient as an employee/non-student was a seizing 2 year old coming in by ambulance as a "scoop and run", and while I was calculating the valium dose, I asked my nurse to put in a line.  She said "I don't put IV's in kids under 5."  So I said "well who does?"  And she said you do.  Ok . . . Well then I better get it on my first try.  Lots of miracles happened while I was working in that ER.  Getting lines in an actively seizing 2 year old just being one of them. 

I worked happily in that ER for 4 years, and then decided to move closer to family/re-prioritize my life after 9/11.  So I moved to Southern CA, without a job, in the summer of 2002.  My parents drove me to an interview a couple of days later in Mission Viejo, CA, and after 3 months of convincing them that I was the right hire – I got the job.  I worked at Mission Hospital/CHOC at Mission for 3 years, until I decided to get serious about Medelita.  My strengths clinically were anything related to Peds ER (most ER docs prefer not to deal with the parents, so I got really good at it), any ER procedure, especially complex suturing, and perhaps my biggest strength was my patience and skill at listening in combination with good clinical judgment.  Larry always said that the patient gives you the diagnosis 90% of the time, and I never forgot that.  It's so true, especially with children and parents.  A patient never complained about me, that I know of, in my entire clinical practice, and I feel really good about that.  My personality is such that I really do care, and I think people can feel/sense that.  It's common to lose that trait working in Emergency Medicine for a long time, but I was lucky not to.  It didn't mean I was especially popular amongst colleagues, or that I was the fastest at seeing patients.  I was just thorough and I listened, and could go home at the end of each day feeling good about my contributions.


3) What led you to transition to your new role founding Medelita? 

I'm not a fashionista or anything.  I just felt like I couldn't be the only female clinician that hated wearing boxy, frumpy, shapeless lab coats and scrubs that were absolutely not made for the female figure.  I simply bothered to brush my teeth, fix my hair, put on a tad of makeup before my shift, and why in the world would I want to put on something of lesser quality than cheap pajamas?  It just didn't make sense and seemed to be an issue, completely overlooked.  All other professionals of similar education and/or stature wore in upwards of $1000 business suits and carried expensive bags. But medical professionals should be stuck in horrendous quality ill-fitting garments, and expect to gain respect and trust in a matter of seconds?  Still to this day it baffles me that people are willing to accept this traditional norm.  Medelita is definitely changing that.  The original idea was based on fit/styling only, but I decided to combine the trend of using applicable performance fabrics, in a similar way that companies like Patagonia, Lululemon, Athleta, etc. have been doing to appeal to the buyer and improve the buyer experience and functionality of the garments.


4) Medelita has been in business for 4 years now. How has your experience as a PA informed the direction your business has taken? 

I think it's a HUGE advantage.  It gives us credibility and a level of understanding of our customers/colleagues that is unmatched in the medical apparel industry.  Everything that is written on the web site and/or guided by our customer service team, is catered toward the needs and personal attention of our clinician based customer base.  Almost all the other similar companies out there have focused on nurses, and surprisingly forgot about the growing clinician force – including physicians, physician assistants, nurse practitioners, dentists, veterinarians, chiropractors, podiatrists, etc.  This population has very different medical apparel needs v. nurses, and Medelita caters to their specific requirements for appearance, length of garments, quality of garments, and professional logos. 

Also, if you take a look at all of the professional organization logos that we offer, and the professional affiliations that we hold, it is testament to Medelita being a clinician owned and operated business.  It is a tremendous honor to have the trust from these extremely reputable, prestigious organizations, such as AAPA, ISAPS, and ASAPS, among others. 


5) Do you still work clinically?

Do you plan to re-certify when you license expires?
I'm not working clinically but I miss it terribly.  The combination of working (more than) full time and having a 2.5 year old daughter, as well as being almost 6 months pregnant with twins, would make it challenging for me to work right now.  I absolutely stay up to date by reading multiple journals and earning CME mainly at highly reputable conferences throughout the year.  Since we exhibit at the very best conferences in the country, it's been easier to travel with the conference team and attend CME lectures as well as help out in the booth when needed.  Main conferences we attend include AAPA, ACEP, AAD, ASRM, CAPA, etc.   My license is up to date and I have never lapsed in re-certification, after graduating in 1999.


6) What do you want to do next with Medelita? 

We are still very much in the beginning stages of the business.  So from that perspective, I simply want to do everything possible to help the business grow and to improve brand awareness to our target audience.  By hitting certain targets of growth, we will then be able to introduce new lab coat styles, new scrub colors, introduce additional sizing, and sponsor additional medically related events that show close unity to Medelita.  We also want to be at the forefront of fabric performance technology and being certain that we are testing and (in the future) utilizing the very best available technologies that are applicable to the wearer.  We do that now, but absolutely need to stay on top of developments and it is a very expensive, time consuming task.