|Author: Michael Samsot|
|PA's Career Influenced by World Travel|
|Deeply committed to his work in general adult internal medicine, HIV/AIDS healthcare, gay healthcare, and preventive medicine, Physician Assistant Carl Stein seemed an unlikely candidate for a healthcare professional when he graduated from college in 1982.
In 1985, Stein was armed with a Bachelor's degree in history and a few years of job experience as a writer and copy writer in Washington, D.C. -- but "I was bored out of my mind and decided to travel," he says. "Then, when I ran out of money or got exhausted, I came home, saved up money and went off again." He wound up traveling off and on for more than five years.
Stein had grown up in New York and Michigan, but began working in Washington, D.C. out of college. "When I was in D.C.," he says, "I worked as a volunteer at the Washington Free Clinic, and at the Whitman-Walker Clinic. I still had an interest in journalism and was thinking that I might go into healthcare journalism. I thought the clinic experience would give me a better feel for that kind of writing.
"Instead," he recalls, "it switched my whole career. As a volunteer at those two free clinics, I realized that my work there was the only work I had done that I truly enjoyed. I decided to learn to do more and then to work in healthcare full time, first considering becoming a health educator. Additionally, I was driven to want to help people with HIV and AIDS by my outrage at how our society was treating them. At the clinics, they first needed me to do STD [sexually transmitted disease] exams and treatments. I enjoyed the work and the people I was working with. Then, when HIV became more prominent, I worked with those patients." Stein also worked in a volunteer program as a buddy for AIDS patients.
Both Stein's volunteer clinic work and his love of travel pointed him in the direction of the PA profession, he says. While he's traveled all over the world -- to six continents, 43 countries, and 48 states -- it was "an incident in the Dominican Republic [that] convinced me that I wanted clinical skills. I was visiting a friend, Michael Seidman, who was working there in the Peace Corps; I had met him at the Washington Free Clinic. Michael was doing health education and took me with him into the different communities."
But health education is not healthcare practice--and Stein realized that he wanted more. "A woman with her sick baby came up to Michael and asked for help," he says. "When all Michael could do was to send her to the nearest clinic or doctor, it hit me that if I was going to be working in far corners of the world, I needed to have some clinical skills." It was after this series of happenstances that Stein eventually decided to apply for admission into a PA program. (Seidman, too, apparently felt a greater pull toward the medical field; "He has since gone to med school and is now an M.D.," Stein says.)
After a bit more traveling, including a trip to Southeast Asia, "I began in 1991 taking the undergrad science courses that I needed at UDC [the University of the District of Columbia]." Talking to PAs he met during his volunteer work led Stein to apply to Duke University Medical Center in Durham, North Carolina.
"Duke is where the PA profession was created, and they were offering a Master's degree in the program," he says. "I was accepted and got a rock-solid education that I am very grateful for. The faculty was terrific, the support from the faculty was very helpful, and the Duke name has opened a few doors for me."
Looking ahead to his post-graduate employment and networking through a Duke PA alumnus, Stein was contacted by and hired by Dr. William F. Owen, Jr. of San Francisco in 1994. Still there today, Stein has developed a growing interest in preventive medicine. "I enjoy helping patients learn to make choices that are consistent with good health -- choices about diet, contraceptive needs, smoking, alcohol, recreational drugs, sexual practices, exercise habits," he says.
Stein has two patients whose cases illustrate dramatically how making or not making behavioral changes can affect the health. "The first patient was new here in 1997," he says. "He had a history of tobacco smoking, had COPD [chronic obstructive pulmonary disease], and needed to use three different inhalers. He also had high blood pressure, which was probably connected. I talked to him often about the need to stop smoking and had tried several times to refer him to a stop-smoking support group."
During this time, the medication Zyban, which had been approved as an antidepressant, began to attract attention on another front. "Glaxo found that people on this drug also seemed to have an easier time stopping smoking," Stein continues. "My patient had smoked two and one-half packs of cigarettes a day for 33 years, but was put on Zyban in June, 1998, "and he has not smoked a cigarette since. He no longer needs his inhalers, is not getting respiratory infections, and has no more shortness of breath. He is coughing less, is feeling fine, and is happier. At 52, he is also an ardent anti-smoker."
The second case, unfortunately, shows the dangers of not changing life-threatening behavior. "This is a patient I've known for about two-and-a-half years," Stein says. "He's 33 now, and when I first met him was a healthy, happy guy. I saw him for various different things -- sore throats, check-ups. I began to notice, though, that there seemed to be a pattern: every few months, he wanted to get tested for HIV, after what he said was unprotected or anonymous sexual contact. Each time he'd come in, we talked about risk and what sort of behavioral changes would be advisable -- but there would always be a lapse.
"In June of 1999, he had an exposure that he was really worried about. At that time, we did post-exposure prophylaxis. This is not yet proven, but the theory is that if you get medicine on board immediately, you might prevent HIV infection from happening, if, in fact, exposure has occurred. Fortunately, again, the patient ended up testing negative. He was kept on the prophylactic treatment for one month, which is standard," Stein continues. "Then, he was back again in December and in March for more HIV tests -- and I kept talking with him about ways to change.
"This summer, in June, however, he came in again and did test positive for HIV. People knowing what to do and still choosing not to do it -- this is something we find that it is not atypical for some folks who test positive," Stein says. Much of the time these are conscious decisions [to continue making poor health-related choices]. I just wish we could find more effective ways to bring about better choices."
With each new patient, there's always a challenge, but sometimes the challenge is multi-faceted and the resulting problems require detective work to find solutions. "One of our patients, age 58, who was not HIV-positive, had a number of things that older men have: coronary artery disease [CAD], high blood pressure [HBP], benign prostatic hyperplasia [BPH] -- and he was developing diabetes," Stein remembers. "He was on medication for the HBP and the BPH, and he had had angioplasty for the CAD.
"I saw him in October of 1999 and he was doing fine; then I saw him again in November and his blood work showed very unusual chemistries -- a BUN [blood urea nitrogen] of 97 (25 is normal) and a creatinine of 8 (1.4 is normal). While he didn't feel particularly bad and his BP was controlled, his potassium level was high, he was somewhat fatigued, and he had shortness of breath and anemia. All these things suggested kidney failure, but we didn't know why it was happening. We consulted a nephrologist and did an ultrasound of the abdomen and kidneys.
"What we discovered," Stein says, "was that he had a huge, enlarged bladder, which was retaining an enormous amount of urine. This was happening because the urethra was blocked by the prostatic enlargement. The urine then backed up into the kidneys and was causing the kidney failure."
Once the diagnoses were made, there were multiple problems to correct. "First, we inserted a catheter and drained eight litres of urine," Stein remarks. "The catheter remained in for several months, until the kidneys recovered, and his heart and blood pressure were O.K. We then did a treadmill EKG, which was fine. At the same time, the anemia, which had led to the shortness of breath, had improved. Finally, he was improved enough that the urologist could do corrective surgery for prostate enlargement, and this patient is doing well."
While diagnosing, treating, and returning patients to health is very gratifying, Stein says, he considers his greatest challenge to be helping them to make behavioral choices in the first place that are consistent with good health.
"I think it's really important to work with all patients on these issues. The key is to have a good rapport with your patients so that you can get across to them that they alone are responsible for their own behavioral choices," Stein states. "Prevention is better than treating a problem after it arises -- and it is one of my particular interests, something I truly emphasize."
As for the traveling that influenced Stein's early career--is he still able to find time for travel? "Yes," he says. "I recently returned from my first trip to Africa, where I visited Tanzania, climbed Mount Kilimanjaro, did a game-park photo safari, and swam in the Indian Ocean off Zanzibar. I consider myself very fortunate to have had the opportunities I've had. I'm fortunate, as well, to be one of the very small percentage of people who can say that they live their life in terms of travel experiences. When I first chose this profession, I had thoughts of working internationally," Stein says. "That still may be something to pursue in the future."
Carl Stein earned his Bachelor of Arts degree in History from the University of Michigan, Ann Arbor, in 1982. He earned his Master of Health Sciences degree and Certificate in the Physician Assistant Program from Duke University Medical Center, Durham, NC, in 1994. He received the Health Promotion-Disease Prevention Project Scholarship from the American Medical Student Association Foundation/National Health Service Corps in 1994. He received Advanced Cardiac Life Support certification in 1996 and is affiliated with California Pacific Medical Center and St. Luke's Hospital, both of San Francisco. Stein is a member of the American Academy of Physician Assistants and of the San Francisco Community Consortium of HIV/AIDS Providers. He is a co-founder and steering-committee member of the San Francisco Bay Area Physician Assistants; he is on the Board of Directors of the Physician Assistant AIDS Network.
Michael Samsot is a freelance writer in Fairfax City, VA. She is on the Editorial Staff of NEWS-Line for Physician Assistants.