IER Placement: Urology

As part of the McMaster Physician Assistant Education Program curriculum, each student shadows a professional in the field relevant to the unit being studied that month. These are called IER placements and students are assigned a half-day shift at a hospital/clinic in Hamilton. IER stands for Interviewing, Examining, and Reasoning.

For this IER Placement:

  • Medical Foundation Unit: Renal
  • Professional Shadowed: Urologist/Surgeon
  • Date of Placement: Monday, March 23, 2015
  • Where: Juravinski Hospital – Clinic

Read more about what I learned in my placement!

Seeing Patients

The first thing the physician told me was that he’s very encouraging to learners, that the best way to learn is by doing it. With that, he handed me a patient file, told me that I can write on the patient chart and sent me off to see a patient. I was so happy that he gave me a chance to practice history taking. I would go in first to talk to the patient, ask them for their history or if it’s a follow-up appointment, I would ask them about any urinary problems. Then I’d come out of the clinic room to talk to the physcian about what I learned from the patient. We would go back in together to discuss plan and management.

The Urinary Symptom Assessment Mnemonic

The mnemonic FUND SHID helped a lot when a patient presents with urinary problems. FUND asks about urine storage or bladder problems. SHID asks about voiding or urethral/pelvic floor problems. I have this mnemonic memorized by heart!

  • F – Frequency
    • Caused by urgency
  • U – Urgency
    • Bladder irritation can cause the patient to feel like they need to pee all the time
  • N – Nocturia
    • Waking up in the middle of the night to urinate. Some patients have to wake up 3-5 times a night to void
  • D – Dribbling
    • When the bladder is overfull, some urine dribbles out of urethra. Another situation is when after peeing, the patient notices that some urine comes out as they walk away. This may be a sign of incomplete voiding
  • S – Strain and Stream
    • If there is a blockage, stricture in urethra, or enlarged prostate that is compressing the urethra (which is common in men), patients may need to push really hard to start voiding. Their stream may be weak or intermittent rather than constant
  • H – Hesitancy/Hematuria
    • Always important to ask about blood in urine!
    • Blood in urine is bladder cancer until proven otherwise!
  • I – Incontinence (urge and stress)
    • Urge incontinence – once you get the sense that you need to pee, you pee on the spot. No control over bladder. May be a sign of neurogenic bladder
    • Stress incontinence – common in women who had childbirth. With pregnancy and vaginal child birth, the pelvic floor muscles may become weak and cannot control the bladder sphincter as well as before. Then there is increased abdominal pressure, such as coughing, sneezing, laughing, etc, some urine will leak out. Men can get this too if they had a prostatectomy (prostate removed).

  • D – Dysuria (pain when urinating)
    • May be straining too hard from stricture or enlarged prostate. Or may be a sign of an infection (urinary tract infection, sexually transmitted infection, etc)

What I Learned from the Patients I saw

The first patient I saw on my own had spina bifida. Spina bifida is birth defect caused by incomplete closure of the spinal cord. Often, these patients have neurogenic bladders – problems holding urine. The patient I saw did not have a neurogenic bladder. He was able to control his voiding but with the help of a prosthetic bladder sphincter. This was a follow-up appointment to see how he was voiding with the prosthesis. I also got the chance to ask him about his congenital condition. He said that most people with spina bifida are not able to walk. He was fortunate that he does not have that and can walk on his own, that his biggest fear is to be in a wheel chair.

The second patient I saw with a resident. The patient is a 55 year old woman with stress incontinence. There are two treatments for stress incontinence: 1) do kegel exercises to strengthen the pelvic floor muscles (results in 2-3 months) or 2) have surgery. With this patient, I learned about how to go about picking the best treatment option with the patient. The resident explained to the patient the treatment options, the pros and cons. Then he asked her how symptomatic or how bothersome her symptoms are. She was not that symptomatic so the resident suggested to try the kegel exercises first, follow up in 3 months. My tutor always said, “A chance to cut, is a chance to kill!”. Surgery is always an option but it comes with its own risks. It should be reserved for very symptomatic patients and as a last resort.

The third and fourth patients I saw with the physician and the resident, both had suprapubic catheters. It was my first time seeing one. Instead of the catheter (a tube) going up the urethra, it goes directly into the bladder. A bag is strapped on the side of the thigh, where the urine flows into. The patient drains the bag him/herself when it gets too heavy but the catheter gets changed every week at a hospital/clinic or by someone from home care.

Overall Experience

This is by far the BEST IER placement I have done. My rating is based on the fact that the physician is  a very encouraging preceptor who pushes his students to learn by seeing and practicing. Coincidently, the day after my placement was SP (Standardized Patient) day and I was assigned to take a history from the patient. Let me just say that I rocked it 😉 from all the practice I had at the placement! (very proud of myself haha)

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