To Whom It May Concern:

As an upcoming Physician Assistant, I am excited to apply for the GYN PA position at Woodhull Medical Center. As a dedicated and compassionate student, I am eager to contribute my clinical abilities and provide patient-centered care.

During my OB/GYN rotation at Woodhull Medical Center, I discovered a true passion for Women’s Health. I worked with multiple members in the department who guided me in honing my skills, enabling me to feel confident in counseling patients, performing  pelvic and bimanual exams, and collecting specimens for routine and non-routine screening tests. I worked directly PAs during my clinic and GYN on-call weeks, which further confirmed that I wanted to pursue a career in this field. I gravitate towards Woodhull’s mission statement which is “To extend equally to all New Yorkers, regardless of their ability to pay, comprehensive health services of the highest quality in an atmosphere of humane care, dignity, and respect”. These values reflect my very own.

In addition to my clinical training, my previous roles have strengthened my ability to communicate effectively and remain organized.  Prior to PA school, I was exposed to the daily life of healthcare providers as a patient support volunteer. I assisted patient care technicians with caring for patients and was responsible for retrieving equipment from the central supply unit for our nurses, such catheterization, douche, bladder, and intravenous trays.  As a medical scribe I documented patient encounters in an electronic medical record, assisted in minor procedures, and performed point of care tests in a fast-paced outpatient setting.

In my current position as a PA student, I engage in rigorous academic coursework and my clinical rotations provide me with hands-on experience that has allowed me to develop sound clinical reasoning. I can evaluate my patients, develop a list of differential diagnosis, and create an assessment and plan tailored to what I believe will provide the best patient outcome.

Through these years of experience, I have developed responsibility, patience, and a passion to help others. Thank you for considering my application. I look forward to the possibility of contributing to the exceptional care provided at Woodhull Medical Center.

Sincerely,

Arianne Diaz

Clinical Scenario:

            A.R. is a 51-year-old Hispanic male with PMHx of uncontrolled Type 2 Diabetes Mellitus who presents to his PCP complaining of fatigue and bilateral lower extremity pain. A.R. immigrated to the United States from the Dominican Republic about two years ago with his wife and three children. He was born and raised in a rural village in the Dominican Republic where herbs are used as the primary means for managing medical conditions. A.R.’s symptoms started around 5 months ago, but he did not seek medical care until his wife insisted. Prior to this, A.R. was self-medicating by consuming a tea made of nettle, ginger, and dandelion.  He tells his PCP that he works 60 hours a week as a butcher at their local meat market, but he cannot take time off work because he needs to take care of his family. He states that it is his duty to be strong and continue “pushing forward”. A.R. speaks some English, but he is not fluent, so he prefers Spanish.

Cultural Factors:

Use of Herbal Medicine: Traditional herbal remedies are significant in Dominican culture. Medicinal knowledge is passed down from one generation to another, and it is common for villages to have traditional healers who use herbal remedies to help others manage their chronic conditions. Traditional healers possess extensive knowledge on the herbs, plants, flowers, and roots that grow on the land and are well-respected figures in their community. A.R. may have consulted a highly regarded healer from his village in the Dominican Republic about his symptoms.

Language Barrier: A.R.’s preferred language is Spanish. To effectively communicate with his PCP, interpretation services must be available to him if his PCP does not speak Spanish.

Unique Beliefs/Considerations:

Machismo: Machismo is a value which emphasizes  the importance of masculinity, strength, and responsibility as provider. A.R. admits to engaging in 60-hour work weeks to provide for his family which may have led to a delay in seeking care. There is a strong sense of pride in men who practice machismo, specifically that they must be brave and self-sufficient even when they do not feel well. A.R. expresses that he feels he must “push forward” despite his symptoms because it is his obligation to do so as a man.

Financial Situation: A.R. immigrated to the United States about two years ago. It is possible that he is working extensive hours not only to support his immediate family, but to help his family in the Dominican Republic as well. It is common in many cultures to “send money back home” to help with necessities such as food, electricity, and water. The U.S. dollar is more valuable in the Dominican Republic, and it is possible that A.R. allocates some of his money towards relatives who live there.

Areas of Potential Conflict:

Medical vs. Herbal Management: A.R. has uncontrolled T2DM and new onset fatigue and lower extremity pain. It is important to explain the benefits of lifestyle modification and possible pharmacotherapy without discounting A.R.’s beliefs on traditional medicine. Completely dismissing his cultural practices may discourage him from adhering to medical advice.

Work Demands vs. Health Needs: Because A.R. has such a strong belief in his duty to provide for his family, he may not prioritize his health. The clinician can initiate the conversation by acknowledging and even commending A.R. for his stellar work ethic then transition into the importance of resting and taking time off to recover when needed.

Machismo vs. Vulnerability: A.R. may oppose medical intervention because it opposes his machismo views.

Expected Skills:

Language Access: The clinician should offer interpreter services once A.R. confirms his preferred language. This is done to facilitate effective communication between A.R. and the medical team. Interpretation services may be provided over the phone or via video on a tablet or other smart device.

Confidentiality: The clinician should emphasize confidentiality. Confidentiality should be emphasized at the beginning of each visit.

Respect for Cultural Practices: If the clinician is not familiar with the health benefits of the herbs that A.R. is consuming, this is a great opportunity to establish rapport with the patient by asking questions and actively listening. Engaging in this manner can make A.R. feel more comfortable and he will be more agreeable to adhering to medical advice. If possible, the clinician can try to develop a treatment plan that allows A.R. to use his herbals as a supplement for disease management.

Empathy: When addressing A.R.’s health needs, the clinician should acknowledge his hard work and dedication to his family. By doing this, the clinician is addressing A.R.s cultural beliefs which strengthens the patient-provider relationship.

Collaboration: If necessary, the clinician should not hesitate to reach out to other health professionals.

Patient Education:

Type 2 Diabetes Mellitus: T2DM is an endocrine disorder in which the body’s cell become less responsive to insulin, leading to increased blood sugar levels. First-line treatment for T2DM is lifestyle modifications such as improvement in diet and exercise. Pharmacotherapy with Metformin may be initiated if lifestyle modifications are unsuccessful.

Herbal Remedies: Herbal remedies can be used as adjunct therapy to pharmacologic treatment so long as there are no interactions. Many times, patients are under the impression that taking herbal supplements in conjunction with their prescription medication is harmless. This, however, is not true. A common plant that is used for a wide variety of illnesses is St. John’s Wort. This medication possesses serotonergic properties and can induce serotonin syndrome if taken with another serotonergic drug such as citalopram. The clinician should make A.R. aware of any interactions that may arise if he initiates pharmacotherapy and wants to continue drinking herbal tea.

Importance of Seeking Timely Care: Although it is important for A.R. to provide for his family, it is equally as important to take care of himself. The clinician can suggest a treatment plan that is tailored around his work schedule and encourage him to seek care in a timely manner. 

BACKGROUND: Acute urinary retention (AUR) is a common urological emergency. In this article, we review the current literature and present a structured summary in management of AUR.
METHODS: A systematic review was conducted using the keywords ‘acute AND retention AND urin*’ within the title in search engines including Medline, EMBASE and EBM Review. The obtained literature was manually reviewed by the primary author (PDY) and was further refined by confining the subject to management of AUR. Exclusion criteria included pediatric and female population studies, case reports, reviews, surveys, economical assessment and articles on AUR in prostate cancer and post- operative patients.

RESULTS: Total of 54 articles met our inclusion and exclusion criteria. The trial without catheter (TWOC) post-immediate catheterization is widely practiced although there remains a significant variability in terms of type and duration of catheterization required, use of concurrent medical therapy or post-catheterization management. Our systematic review and subsequent meta-analysis has shown superiority of α1-adrenergic receptor blockers over placebo in achieving successful voiding in patients with AUR. Suprapubic catheter (SPC) is an alternative to urethral catheterization (indwelling catheter (IDC)) and may provide several advantages. Clean intermittent self-catheterization may be a safe and useful option for patients with AUR until their definitive management. The overall long-term outcome of in-and-out catheterization remains promising in selected patients. Surgery
is an end point in patients with unsuccessful TWOC as well as in those with significant lower urinary tract symptoms post-successful TWOC.
CONCLUSIONS: We recommend use of α1-adrenergic receptor blockers before TWOC and discourage emergency operative management. Use of SPC over IDC in AUR is debatable. Duration of catheterization is controversial but o3 days is a safe option in avoiding catheterization-related complications. Although TURP remains the current gold standard, there has been an emergence of newer operative management utilizing laser techniques.

Type of Study: Systematic Review and Meta-Analysis

Summary:

            This article goes over the etiology and management options for acute urinary retention. Acute urinary retention is a urological emergency characterized by the inability to fully empty the bladder. It is most common in older men and can be classified into two categories: spontaneous acute urinary retention (sAUR) and precipitated acute urinary retention (pAUR). sAUR occurs secondary to BPH while pAUR may be due to  surgery, medication, alcohol intake, or infections. Acute urinary retention is multifactorial and thought to be due to combination of mechanical and dynamic obstruction as well as a neuropathic issues. Examples of mechanical obstruction include BPH, urethral strictures, urinary tract stones, or cystocele. Dynamic obstruction includes things such as increased alpha-adrenergic activity, and prostatic inflammation. Immediate management of AUR involves bladder decompression via catheterization to relieve discomfort. Decompression must be performed carefully to prevent profound hypotension. For instance, in a patient that has not voided in a few days, 1 liter of urine should be removed before the Foley is tied up. Further decompression to remove the remaining urine may take place after an hour. There are various catheterization options such as urethral catheterization, suprapubic catheterization, and intermittent self-catheterization. In the emergency department, indwelling catheters such as foley catheters are used unless there is an inability to do so such as in cases of urethral trauma. In this case, a suprapubic catheter may be used. In patients with AUR due to BPH, medications such as alpha blockers and 5-alpha reductase inhibitors may be used as adjunct therapy. Surgical intervention is indicated in cases of failed trial without catheter (TWOC) or significant lower urinary tract symptoms.