Confessions of a First Year PA

Now you’ve finished school, passed the PANCE, and landed your first job. It’s time to relax and be the PA you’ve always envisioned yourself to be, right? There is still a lot to learn. Here’s what I have learned about medicine and life in my first few years as a PA.

You nailed the interview and they have given you the position. Now comes the waiting! Starting your job requires licensing in the state you plan to practice in, DEA licensing, malpractice coverage, and for most places credentialing. I wish I had thought about just how long this would take during my second year of school and made more of an effort to save. I thought I would be able to start within a month of passing boards. In my experience, this process takes a few months, if not longer. Budgeting through PA school so you have 3-6 months of living expenses in savings will make sure you get to your start date without big credit card debt.

Take my advice and make sure you take some of this down time to relax. It’s easy to get caught up in the excitement of your first job, but once it starts it will be some time before you are able to take vacation. Also, take some of this time to brush up on the bread and butter of what you will be doing at your new job. Rotations may have ended with Pediatrics and Surgery, while you plan to go into Family Medicine.

Nervous is normal. Looking back it was terrifying , but honestly, I learned that the nerves come from wanting what is best for your patients. Don’t let fear cripple you. PA training by nature leaves room for on job training and a need to gain experience. That complex condition you read about in a book and have never seen on rotations is sitting in front of you in the flesh. Early on, it’s hard to remember that people aren’t books. Patients don’t always fit into the neat boxes in your head of what a diagnosis entails.

Ask questions. We in the PA profession pride ourselves on being proficient. There is a line between growing as a provider and gaining independence and knowing when it is best for the patient that you ask. It also takes balance to foster trust and confidence in your ability from the patients while being honest about needing help. It’s important to remember amid the colds and musculoskeletal problems that we have patients’ lives in our hands.

First, there is the technology. The word Epic still makes me cringe a bit. Your first day with Epic may feel like an epic fail. Students in school are more and more exposed to Electronic Medical Records (EMR), but navigating them on the level of a provider is a different story. No two records are the same and it takes time to get the hang of them and that is OK!

Then there’s the billing. If your program didn’t emphasize this, then my recommendation would be to take some time before starting work to take a billing course. If you work for a group practice that has a billing department, ask for help and input. Ultimately, you are responsible for the way you code and bill. It impacts how your employer gets reimbursed and impacts what patients’ cost will be.

After learning to navigate the EMR and code accurately, familiarize yourself with the resources in your office and community. Patient’s come in with a lot of social issues that impact their view of their wellbeing and care. Have you spoken with the Care Coordinator or Social Worker? They can make your work and your patients’ level of satisfaction much better. You care for the whole person, and not just their medical conditions and these team members can best help you achieve that!

Your office doesn’t run with just you. The truth of the matter is that the office dynamic depends on a number of personalities, which all contribute. This can be tough, but at the same time is what makes a strong practice. As a provider, you don’t have to shoulder all of the work. It may take time to get good at delegating. There is a line between everyone working together to get the patient what they need and putting work off on others. In a practice that truly functions smoothly everyone has to know their role and you truly have to be a team. Providers can’t be loners!

Patients expect you to understand their insurance. They will ask you questions about what things will cost. 5/10 of them will tell you that medicine you prescribed was too expensive and they expect you to know a cheaper alternative. The medication you prescribed them may be the very best thing for them, but if they can’t afford it, they aren’t likely to take it. As providers, we want to give the patient the very best care, but sometimes they have financial factors, or past experience that influence their thinking. We have to meet patients half way and need to balance when it is imperative to stick to our guns and when we can bend a bit so that the patient buys in to treatment. There are often a bunch of ways to skin a cat, and just like patients can get stuck in their ways, so can we.

You can’t always scare patients into doing what you want. You can’t always convince them with science. What is important to one patient isn’t always important to the next. Along those same lines, what is important to you is not always important to the patient. We have to help people set goals for their health that matter to them. We have to balance pushing them to be healthy, and giving them reasonable goals that fit with what they want from their quality of life. Once we leave the office, life happens. This is true for both you and the patients. Remembering this is key.

- Breathe. Sometimes you need to take a deep breath, go get a drink of water, walk for 10 minutes at lunch, or stretch in your office. You can’t take care of your patients if you don’t do things for yourself.

- Ask! Even though you are out of school, you will still have questions. Medicine is becoming more and more collaborative and in the end we all have to work together. Not all diagnoses are created equal and what works for one person may not work for another. Our diagnostic and treatment strategies are ever changing and it is important to use evidence based medicine, but not get stuck in a Clinical Medicine textbook.

- Not all patients are created equal. Patients can be difficult. They get angry. They feel scared. Our goal is to care for them as best we can. That means being empathetic and not letting one visit influence how you interact with the next patient. Thinking back to a time when you felt that way can bring things back into perspective.

- No one is perfect. This has been a hard lesson. We are human and while we as PAs, or even providers in general, pride ourselves on being intelligent, caring, and right, we all have bad days. Patients expect us to be at our best and sometimes it means taking a step back and admitting you are human, sometimes is means taking time away for yourself, and sometimes it means being able to put aside your personal life, or biases to care for someone.

- You’re not alone. You graduated PA school with a class of fellow students who shared your ups and downs. They shared your fears. Now that you have graduated, it is easy to feel isolated. There are a number of organizations and forums to help you stay connected. You may have other PAs in your practice to reach out to. The American Academy of Physician Assistants (AAPA) hosts conferences each year. The PA forum provides an online platform to reach out to other PAs. I recently learned about a new online platform called the Huddle, which is closed to the public and only providers can see its content.

- Don’t forget about your CME! Particularly the first cycle. With everything there is to learn getting up and going, it is easy to get behind with CME. Currently, you need 100 hours every 2 years, 50 of which must be category 1.

- You’re not going to love your job 100% of the time. You will have days that are hard. You will have days that are mentally trying and you will go home feeling like your brain has run out your ears. Then you will have days you catch something big, or help a patient reach a goal. The first few years, there will be lots of ups and downs. You are caring for people after all.

- Life happens. In order for you to take care of your patients you have to remember this. It happens for them and gets in the way of well thought out plans and best intentions for their health. It happens for you and it is OK to take time when you need it. It is OK to admit your too are human and you too are sometimes a patient. Make sure you sleep. Make sure you take pictures, go to the beach, or run. Your patients will still be there and you will be better able to care for them.

- Smile. Even better, laugh! It makes you feel better. It makes the staff feel better. It makes patients feel better.

- Life ends. This was an even harder lesson. Patients die. It’s not always a function of your ability as a provider. Death is a part of life. You aren’t weak for feeling sad.

We got into this profession to care for people. We signed up to be life long learners. We are human and we can’t learn everything in a year, 5 years, 10 years. We will laugh. We will get frustrated. We still have a lot to learn and our work is never done.