Episode 35: Shadowing an Oncology Physician Assistant, Part 1

[00:00:00] Intro: We are a resource for learners, including every member of the Livestrong Cancer Institute’s on track educational pipeline from middle school to residency. We are a growing collection of interviews, talks, and experiences that uncover the myths and the uncertainties of cancer and careers in cancer in order to empower and inspire generations of thinkers and leaders.

This is Cancer Uncovered, an education and empowerment podcast by the Livestrong Cancer Institutes.

[00:00:44] Kristen Wynn: Welcome back to Cancer Uncovered. My name is Kristen Wynn, and I am the program manager of the Livestrong Cancer Institutes at the University of Texas at Austin’s Dell Medical School. What I love about this podcast is highlighting the work of the many people it takes to defy cancer with the hope that we spark some inspiration for you to join us in this important work or just to learn something new about health care and science that you can brag to your friends about.

We’ve talked to researchers, social workers, dieticians, nurses, physical therapists, nonprofit organization, presidents, pharmacists, clinical trials, leadership, teachers. Students, cancer survivors, caregivers, but we haven’t talked to a physician assistant. There is a really good chance you’ve seen a physician assistant or a PA at some point if you’ve received medical care in the USA.

Let me invite you to dig deeper today and hear more about the work of a PA in oncology. Not to brag, but our PA at the Livestrong Cancer Institute’s clinic, Lindsey Kozicz, is an incredible clinician and human. I have the pleasure of shadowing her for just a few hours and record moments of her typical work day throughout the day.

Before we release that episode, we wanted to give you a little background on Lindsey and get really clear about the role of a physician assistant in clinical care, particularly cancer clinical care. Please enjoy.

[00:02:18] Lindsay Kozicz: My name’s Lindsey Kozicz. I’m a physician assistant. I work at Livestrong Cancer Institutes currently in the oncology department.

[00:02:25] Kristen Wynn: How did you arrive here? How did you get to what you’re doing now in Austin? With Livestrong Cancer Institutes, how

[00:02:33] Lindsay Kozicz: did you get here? I think that’s such an interesting question to reflect on because I don’t think looking back that I ever would have thought that I would be where I am right now.

If you asked me, I don’t know, 12 years ago, 13 years ago when I graduated from PA school. So it’s kind of been an interesting journey that I have really let kind of. Life free flow and bring me where I guess was meant to end up. And so when I graduated from P. A. school, I was living in Connecticut and New Haven.

Um, that’s where I did all my training. I had vowed that I was not going to stay in the Northeast just Because I had been so over the winter weather and I’m kind of a beach bum. So I ended up actually taking a job right out of PA school and staying in the Northeast and working at Yale as a hospitalist PA for four years.

And that was a really incredible launch pad for. A base of knowledge to help me with my career, like, even now, but after 4 years of doing that, I really got sick of the winter weather and I ended up moving to Southern California. That’s actually how I got into oncology was that the job that was available.

Was an oncology job and I had not a lot of interest in specializing to do bone marrow transplant, but that was the job that was available. And it turns out that, um, I ended up taking the job and I absolutely loved it. I fell in love with the place, the people, um, the subspecialty. I loved doing oncology care.

And then I never really looked back from doing oncology care. I never really looked back. And thought about whether or not I really wanted to change what I was doing, just because I really, really felt like oncology was the subspecialty that was kind of like made for me. Um, and so I stayed in Southern California for about seven years and had moved around a little bit from San Diego.

To Los Angeles and I was running a PA program at the time in, um, 2016 and just feeling really burnt out. So looking back over the prior 10 years of my career, working 60 to 80 hour work weeks and just not really prioritizing myself. And so I thought about, you know, what do I really want to do? And I took time off basically.

And I traveled internationally for six months. Um, and part of the focus of that trip was really learning about, um, Western and Western birth of Eastern medicine and exploring some, you know, um, what we would consider like non allopathic modalities for medical care and, um, outside the U S. And during that trip, I just decided I wasn’t going to really think about what was my next.

I think we ask the question often, like, what’s next? What’s next? And I just decided, like, I’m not doing that. I’m just going to go. I’m going to enjoy this time. And then when I get back, I’ll figure out what’s next. So I came back to the States right before COVID hit in December of 2019, and I started really thinking about what I had from a career and the pillars of a career that were really important to me, which included being able to be in, um, clinical medicine, being able to have a possibility of being in a leadership role.

Um, working with really like minded individuals who had a growth mindset and being able to continue to have a part in medical education. So I started applying and looking for jobs and I found this job hosting for the calm clinic. And one of the reasons why it really enticed me was they were doing, y’all, y’all were doing medicine and oncology care in a way that Felt like all of the things that were lacking in the oncology care I had provided previously, a holistic model, supportive care services, mental health support, y’all were doing it.

And so I said, you know, this sounds really interesting to me. I want to check it out. So I submitted a bunch of applications. I ended up actually emailing my application and my resume to Gail directly. And she emailed me back immediately saying, like, we’re super interested, we want to interview you ASAP.

And so I did a Zoom interview, and within 30 minutes, I was like, wow, these people are special, they’re different, um, they’re all women. Bill Matsui, which is like one of our, the male physicians in our department, was not there at the time. It’s all a bunch of women and they said, we want to fly you out for an interview in person.

And so I accepted that and came out for an interview just from like moment one walking into that interview. I just felt like everyone was genuine, authentic, mission driven, honest, and warm. You know, like, uh, I heard somebody say like, you know, does it feel, does it feel like a warm hug? You know? And if it does, that’s a yes.

And that’s what, that’s what this place felt like for me. And that’s how I ended up here. I love that. Thank you so much for sharing that.

[00:07:45] Kristen Wynn: That’s great. Um, as a kid, what did you want to be when you grew up?

[00:07:51] Lindsay Kozicz: From what I can remember, I always wanted to do medicine. And so back when I was a kid in the eighties, I feel like there weren’t, it wasn’t as well known that there were so many options.

It was kind of like you either were going to be a doctor or a nurse. Yeah. My, my mom happened to be. a nurse practitioner at the time and had 17 years previously of nursing experience. So also in my own family, everyone was nurses. My dad’s sisters, my mom, my mom’s sister, my grandmother were all nurses.

Wow. And so I felt like I had two options, either become a nurse or become a doctor. And so, um, I decided I wanted to become a doctor, but when I, when it actually came down to it and I was in high school and choosing a career path, um, choosing, you know, a major for college, I really felt like going to med school and going the route of being a physician was going to take too long.

Um, and that I was going to be compromising wanting, um, a family at the time. And I felt like I had to choose. A career that was going to allow me to have a family and children and earlier, um, which is hilarious because I’m 38 and I am not married and I don’t have any children. Um, but at the time, um, the people that were guiding me to that decision, that was their life path, right?

So that was what I had as a role model. And so when I was talking to my mom and dad about, well, what, you know, what am I going to do? Um, my mom said, well, what about a physician assistant? And I hadn’t even ever heard of it before. So I was 17, like us, probably a little young 17 year old. And so she set me up at the, at the time where it was a lot easier to get into a hospital or clinic system.

And I spent the day. With a PA in plastic surgery at the hospital that my mom worked with and I was sold. I was like, this is amazing. You know, he was doing procedures. He was making medical decisions in practice. There was, it didn’t appear that there was a whole lot of difference between what he was doing and the physicians that he was working with were doing.

And so I said, sign me up for that. And so I actually. Applied into what was called an entry level master’s position assistant program from high school. And so it was six and a half year tracked where you basically go into undergrad. You have pretty much a pre med curriculum to keep a certain, a certain GPA.

Okay. You have to take many credits a semester. Like I wasn’t allowed to study abroad. And, um, and then I had 10 days off between my undergraduate. graduation and starting PA school. Wow. Wow. So I went straight through it.

[00:10:43] Kristen Wynn: Yeah. Okay. Okay. Is that common or is that something like super special and rare that

[00:10:48] Lindsay Kozicz: you know?

So right now, um, there is many more PD schools now than there were when I was applying. When I was applying, um, to this entry level program as a high school student, there was only two programs, actually three programs. In the entire Northeast that did this. So I applied to all of them. Decided to go to Quinnipiac.

Um, but I would say that of the schools that were doing that at the time about 1 3rd of our class was what we called entry level P. A. S. that went directly from undergrad to grad school and about 2 3rd of our class were people that maybe had 2nd careers were out in the workforce for a while. Took took, like, some gap years.

Yeah. So I would say that that’s considered to be a non traditional path. So

[00:11:38] Kristen Wynn: can you give us some more information, Lindsay, on what it really is to be a physician’s

[00:11:44] Lindsay Kozicz: assistant? Yes. So that it’s actually a common mistake that people refer to the profession as a physician’s assistant, which is actually kind of timing us right as a, you know, it’s basically a physician with apostrophe S assistant is like, well, the physician kind of owns you.

And that’s actually, um, one of the misnomers in the profession is that the name of the profession is confusing. Yeah. So, um, You know, it, it makes us almost, I think it’s confusing for patients because it almost makes it sound like we’re the assistant to the physician, like a medical assistant. And I think it’s very confusing.

So the profession actually itself has tried to start, well, has adopted a new name for the, for the profession was just physician associate. I’m not sure if that’s that much better. Um, but, um, Basically, what happened was way back when, about, I don’t know, about 60 years ago now, um, the PA profession was created because there was a big gap when Medicare was approved.

After World War II, there was a huge population of people that were now insured that were previously non insured that needed health care. And they realized There’s a huge shortage of providers for these people. And so the profession was really built, um, out of needing to train people in medicine faster to be able to treat, uh, a larger population of patients.

And so the American Medical Association in, uh, collaboration with some physicians developed a medical training model for physician assistants, um, that was basically an abbreviated burden in a medical school. That could allow physician assistants to learn, uh, you know, a massive amount of material quickly.

And then it was initially, um, that the physician assistant would spend like, uh, internship with a physician, um, to kind of learn their, their. You know, practices as we do clinicals today, right? And that person would be able to provide care with more autonomy. The profession has really evolved over time.

And I think if you ask physician assistants all over the country, you know, what is their role and how do they practice? You’re going to get a variability between Specialties between individuals, between hospital systems. And what I have found personally in my practice is that it really is about the, the relationship that you develop with the people that you work with.

So I’ve worked in groups with, with, you know, 15 to 20 physicians. I’ve worked one on one with physicians. And I think it really, um, is that the relationship that you develop with the people that you’re working with really defines the scope of your practice. So we learn a lot in school. Um, but then there’s a lot of on the job training that happens when you choose to subspecialize, change, change careers, right?

So you’re, you’re, you can’t, you can’t possibly learn everything. You need to know necessarily while you’re in school for, for that period of time. And that’s the same is true for medical residents as well, right? Um, they have, that’s why they have a residency, you know, three years to, to get there, to get that hands on training.

And so PA school is, is much more abbreviated, but, um, for me in practice, I practice very autonomously. So, um, one of the things that’s really important for anybody practicing medicine. Is that we know the scope of our practice. So whether you’re a nurse, an NP, a physician assistant, a physician, it’s so important that we know what to, what do we know, what do we not know?

Where do we get help? So collaboration is so important in medicine, no matter what you’re doing, because there’s no way that all of us can know everything. Yeah. So there’s constantly asking each other for help and that goes in all directions. So, you know, there are times where I am not sure of something, or maybe I have made a decision about something, but I just want to run it by someone else to make sure that, you know, what I’m thinking and the way that I’m thinking that person also agrees with.

Yeah. Um, and I think that’s really, that’s what is in the best interest of the patient, right? If we’re working in a silo and making decisions all the time independently, it’s almost certain that there’s. information or experience other people have that can really improve that the decision making and the outcomes for patients.

For me personally, I see my own panel of patients in clinic. Um, you know, I, I see those patients, um, and then intermittently the physician sees them as well. We collaborate regularly to discuss the patient’s care plan when things come up. On a daily basis, we connect via either phone, text message, email to discuss more difficult patient cases or if a question comes up.

But I would say, you know, for the most part, I’ve, I’ve been a PA now for 13 years. And so the level of autonomy with which I practice now is different than when I graduated 13 years ago, where I needed a lot more support. And I think that that kind of just grows as you define, as you kind of have more experience throughout your career.

[00:17:06] Kristen Wynn: I can see there may be a hierarchy problem sometimes, right? Like, have you experienced that as a PA or like, can you talk about that? Like, what is that like? What’s that dynamic like?

[00:17:19] Lindsay Kozicz: I would say that that’s been the most challenging thing for me. You’re, you’re hitting one of the things that’s been the most challenging for me in medicine in general.

So I think that things are changing. In a lot of different fields and and it’s been slow to change in academic medicine specifically, but yeah. Historically, there is a hierarchy, right? And there is a hierarchy of people that are making like what’s considered to be the most important decisions. And then below them, some decisions that maybe are important, but not quite as important.

And then below them, the people that are basically carrying out the orders of the people above. And I think it’s not really an ideal system for. Patient care collaboration job satisfaction. I think that 1 of the things that really drew me to live strong into this group is that it’s 1 of the groups. One of the few groups that I’ve worked with that really seems to be intending to break down the hierarchy, and I’ll tell you just some small examples of that is that we go by first names.

Yeah. So no one is referred to as Dr. So and So. Yeah. When we’re working together, we’re all on a first name basis and just that alone really can change the dynamic. Yeah. Um. feeling as though there’s not an additional barrier that you have to overcome to be able to communicate with somebody. The reality is, is there has to be someone in the decision making seat, right?

For specifically in oncology care, you know, the physician always makes the treatment decision about whether or not, what, what chemotherapy the patient is going to get and, you know, how that is going to be delivered. Okay. Um, The people that I work with, so the nurse practitioners, the nurses, then we decide, okay, then we’re taking that plan that the physician has proposed to the patient has been agreed upon and then we’re carrying that plan forward.

So, you know, there has to be some hierarchy because there are some decisions that are need to be made that require a certain level of training that not all of us have. Yeah, but a functional perspective in the clinic. It’s really nice to have a atmosphere that is that feels very open collegial. I don’t think we’re doing any favors by reinforcing the hierarchy in areas where we don’t necessarily need to.

So, yeah, I mean, I have, I would say that 95 percent of the people that I’ve worked with. Um, specifically physicians. I’ve had an incredible working relationship with where I really feel like there is a collaborative respect between both of us. And I have not felt that the hierarchy of them being a physician and me being a PA has negatively impacted me.

Occasionally it happens. And I had, there have been times where I’ve really considered whether or not I wanted to go back to school and become a physician for that reason, but I think like the 95 percent of the time really outweighs the 5 percent that I feel very challenged by the hierarchy of the medical system.

Um, and I do see that it is changing, but change is slow. And so I think that it’s just important to keep that in mind. I was

[00:20:48] Kristen Wynn: sort of like weighing in my head, like, the benefits of, for you personally, uh, being a PA versus a, a physician seems to allow for some flexibility too, right? Like, you’ve got some room to maybe do some other things, whereas like a physician may be sort of stuck doing X, Y, Z.

You see patients autonomously, so they’re yours, right? But you would still need to bring in someone like Bill to do certain parts of it? Or can you explain that a little more? Yeah,

[00:21:21] Lindsay Kozicz: so that’s a really good clarification. So Bill will always see the new patient. So Bill will see the patient first. Okay. And then Bill and I will together co manage a patient.

So I have my own clinic, meaning I will see those patients independently. But the patient will usually alternate between seeing me one month. Seeing bill the next month or see me for two months in a row and seeing bill generally our patients will see me You know as they’re going through their treatment if they need a treat change They have progressive disease that we need to change their regimen It’s always critical to ensure that the physicians coming back in on the plan The nice thing is about our clinic is that we huddle every single week to run the list of patients.

So even if the physician hasn’t seen the patient for a month or two, they know what’s going on and they’re touching base on that patient consistently. Um, because I’m reporting, hey, I saw this person, this is what’s going on with them. This is what I’m thinking, agree or disagree. And so we’re making decisions regularly together on the patients, even if I’m the one that’s seeing the patient at the time in clinic.

[00:22:32] Kristen Wynn: Cool. Okay. Is that typical for an oncology setup? Like as far as organization goes, do you think, or?

[00:22:40] Lindsay Kozicz: I would say for the most part. It really depends on the clinic and the disease state. So, for the most part, I would say that most clinics, um, new patients for malignant hematology generally see the oncologist for the physician first, um, because that plan needs to be Thank you.

put into action, right? We have to be able to say this person has this disease. This is the treatment that they’re going to get. These are the orders that are going to be placed. And then that person oftentimes will then be transitioned over to at least part of the time being seen by The APP or advanced practice provider, which may be a nurse practitioner or a PA.

I would say that, um, sometimes certain, um, cancer or oncology clinics have benign heme. A lot of times those patients may be seen by either, uh, advanced practice provider or a physician, but from a billing perspective for Medicare patients, they have to be seen by a physician first before they can. Before you can bill fully for seeing subsequently and like, especially Medicare, there is some reimbursement issues where we don’t get reimbursed fully 100 percent of what a physician would get reimbursed.

And that’s mostly not like private commercial insurance, but Medicare. And so it really depends on what the financial model is for the clinic as well. Um, so all of that really gets factored in like who sees who, but I would say generally in an oncology practice, the patient. Sees the physician first, the plan is put into place for whatever treatment is going to be administered, and then the, um, rest of the team takes that plan and carries it forward, um, and follows the patient through their treatment and the physician comes in.

As, as necessary. Um. Gotcha.

[00:24:34] Kristen Wynn: And are you specific to HEIM, right? Like do you work with Gail and everybody else as well or is it just Bill or like what does that look like for you?

[00:24:45] Lindsay Kozicz: So I was hired as the advanced practice provider for Phase one clinical trials and that was initially my right job. Um, but because that program has been growing and is small, I also was supporting the head and neck and lung clinic and the hemolygnency clinic.

Um, sometimes I work with other physicians because. Somebody was on a phase one trial, came off the phase one trial, but I now know the patient really well, so even though I don’t do a lot of GI, I have a few patients that I work with Gail, a few patients with Anna, um, predominantly now I work with Bill, and, um, we do heme malignancy, and that is, um, Um, and then because we don’t have a heme and head and neck clinic anymore, I don’t do that.

But right. Um, he is like my, my deepest love though. So

[00:25:35] Kristen Wynn: what is it about him that you love so much? Why? Why?

[00:25:38] Lindsay Kozicz: So it’s so interesting. Um, you know, the heme system of the body is just really, um, it’s integrated with so many other systems. It’s. Uh, complicated. Um, so once you understand it, I feel like it’s like kind of unlocking a puzzle.

Um, I’ve worked with a lot of brilliant people. I love Bill. He’s really fun to work with. So that, that also helps. Um, but even before I came here, I had kind of fallen in love with, with hemolygmency.

[00:26:09] Kristen Wynn: Yeah. Cool. Thank you for that. Can you tell us more about your work within clinical

[00:26:14] Lindsay Kozicz: trials? Yeah, so clinical trials have been part of my career for since I started oncology because clinical trials are important for cancer patients, for a lot of patients, but especially for cancer patients.

Um, and There’s different phases of clinical trials. And so different patient populations are, um, best suited depending on where they are in their treatment and what standard of care options they’ve had. But clinical trials are super important because that is how we get information. Um, about whether or not new treatments work, whether or not new treatments are toxic and how toxic are they and what is the right dose and, um, comparing them to standard of care regimens that maybe we’ve been using for many, many years to see what can we do better?

How can we make these outcomes better? How can we make patients live longer, have better qualities of life, have disease stay away for longer? Um. And so, when I was at UCSD, we had multiple clinical trials that were open, some which were investigator initiated, some which were larger phase 3 clinical trials, phase 2 clinical trials that we were involved with, um, that were multi center trials.

Um, and my role when I was there, um, You know, was to consent the patient, um, to make sure that they had a good understanding of what they were signing up to do to follow the protocol and make sure that while the patients were in the hospital, that they were getting the, um, treatments, lab work, whatever was necessary for the trial.

Subsequently to that, I worked at a phase 1 clinical trial center in Los Angeles, which is a very small clinical trial center working with cellular therapy, like cellular immunotherapy. Um, that was very interesting. And, um. I was functioning in a very similar capacity to the capacity that I’m functioning in now, which is working with, um, physicians in different disease areas of specialty, um, and following the patients, managing toxicities, seeing them regularly for their treatment visits, um, collaborating with the physician about changes and treatment plans, um.

And so it was a fairly seamless transition for me moving from there to here, although what I would say about my job here and based on clinical trials is that, um, our, our team is very small. And so there’s a lot, we do everything, you know, from beginning to end, including processing all of the samples, shipping our samples, you know, working directly with the sponsors, um, and then everything in between, including the patient care.

So. Um, when, you know, our, our program is still growing and but when we do have a patient on trial, um, I’m working really closely with everyone on the clinical trials team, um, to make sure that all the logistics, um, from the time that we meet the patient to consent, the patient to start treating the patient, all of the screening, making sure all of that gets done.

Reviewing it, um, managing the patient when they are on treatment, so managing side effects, making sure that, um, you know, their labs are up to date, that they’re, they’re scheduled for their infusion, so it’s really a very comprehensive job of every component that you can imagine from billing to documenting to consenting to the medical care to the scheduling.

[00:29:47] Kristen Wynn: Thank you for that. You also have a, a major role within educating. Others, right? So can you talk about your work in education previously and currently?

[00:29:59] Lindsay Kozicz: Yeah, so I have been involved in education really since like I hit the ground running out of PA school. And part of that initially was actually a requirement working at Yale.

We were required to precept PA students. And so after I was oriented to the job as a new PA, I was already precepting. PA students, which is pretty cool. Um, and I just really found that, um, I loved teaching. It was fun. I, I felt like when I was in school, I didn’t always have the benefit of consistently having people that were invested in teaching, excited about teaching, and good at teaching.

Right? So it takes a special Mind frame, I think, to be able to break something down simplest, like simply, simply enough to be able to explain it to somebody that doesn’t have any experience in that particular area. And so, um, I really enjoyed doing that in my, uh, initial job and then that kind of just grew from there.

So I was, I think that I really enjoyed it and I think that I was, I ended up realizing I was pretty good at it. And so I started to be asked to teach different classes for the university and so I was an adjunct professor there. I continued to take clinical students. I had a faculty appointment at UCSD where I would work clinically with medical students.

I trained the fellows that I worked with. Um, and I just really like the relationship that you can create between a learner and a quote unquote mentor teacher, however you want to refer to that. And so in my current job, I have kind of voiced my interest in teaching. I do a lot of teaching with the nursing staff.

Um, we have had some students that have rotated within our clinic. Um, and we just started a fellowship program last year, and so creating more teaching opportunities. In our tumor boards and multidisciplinary meetings, um, you know, for everyone, but specifically, um, with the, the lens of making sure that the, um, the learners in our clinic have a good experience has been something that I’ve been passionate about.

I love

[00:32:14] Kristen Wynn: that. Thank you for sharing that. Such a, uh, a wonderful way to state what we keep sort of coming back to on this podcast too is, you know, whole, whole person care, right? Is, um, there’s some creativity involved there. And I think so often we don’t use the word creativity, um, as far as I can tell with the way we talk about, um, the work that we do.

And I think, you know, I think to give physicians and PAs and everybody credit for having to be creative is a really important kind of note to make. I think as students kind of look at different careers and what’s possible within those careers and what it looks like and what you’re really up to and, um, on a daily basis.

So well said. I love that.

[00:33:00] Lindsay Kozicz: So cool. Okay. All right. All right. Thanks,

[00:33:03] Kristen Wynn: Lindsay.

[00:33:03] Lindsay Kozicz: Have

[00:33:05] Kristen Wynn: a good day. Thanks. You too. Bye. If you have questions for us or an idea about a future episode, please email us at Livestrong Cancer Institutes at delmed. utexas. edu. To find out more about the Livestrong Cancer Institutes, please visit delmed.

utexas. edu.

Please also follow our department chair, Dr. Gail Eckhart, on Twitter at sGailEckhart. Eckhart is spelled E C K H A R D T. This is Kristen Wynn with the Livestrong Cancer Institute and Cancer Uncovered, an education and empowerment podcast challenging you to keep asking questions and stay curious. Thank you for listening and learning with us.

We’ll see you next month.