What is being a Physician Assistant really like? Now that I am licensed and working, I will begin to tell you as I have wanted to for some time now - from the inside…

Background

If you’re new to Inside PA Training, this paragraph should get you up to speed. I graduated from UC Davis School of Medicine’s PA program 6 months ago, passed my licensing exam, and found a job, where I’ve been working for the past 4 months. Four months isn’t long, but that’s why this is Part I - there is more to come. Since starting work, I’ve been immersed in my new profession. No more studying for exams, completing assignments, rotating through hospital departments. I’m working in a busy clinic as the only full time PA. But more about that later…

The clinic is in a busy suburb of Sacramento, California. Five days per we provide urgent care, primary care (general medicine), and industrial medicine (workman’s compensation) services to between 70 and 95 patients per day. We do a lot of workman’s comp - about 60% of our clients come to us for help with illnesses and injuries sustained in the workplace.

My Typical Day

My day begins at 8 AM. After arriving and throwing on my stethoscope and long white coat filled with little booklets of reference materials and a reflex hammer, I log into the computer system and review correspondence. This involves reading results of labs and imaging studies I have ordered on my patients, along with reports from various specialists. I print out any that are concerning so that I can review the patients’ charts and call them if necessary, and sign the rest off. I spend a few minutes going through chart errands - approving prescription refills, completing forms sent by insurance companies and pharmacies. I am blessed to work in a clinic that has a large support staff that keeps my paperwork to a minimum. It’s not uncommon for me to sign a form and ask a staffer to fill it out for me as I indicate. This leaves me free to do what I’m there to do: see patients.

Seeing patients is mostly fun, but I see more patients than most PAs - as many as 30 in a day, no problem. I move from exam room to exam room talking with patients, examining them, discussing my recommendations, ordering tests, and prescribing. The tricky part is knowing how to divide my time. Some patients need 3 minutes, and some need 30. My average is about 15 minutes per patient. My boss would like me to get down to 12 (he calls this “the magical 4.5 patients per hour”), but I figure for now, I need to go at a speed that works for me, so I don’t push myself too hard.

If a test or injection needs to be performed while the patient is in the office, I make a note on the paper version of their chart (we are stuck in the limbo between all paper and all electronic charts, which means both), and leave it for one of the medical assistants to perform while I move to work with someone else. When I’m done, I come back to find out how the test (a urinalysis, for example) turned out, and to decide what needs to happen. It’s possible to work with as many as four patients at once this way, but that’s hard, and try to stick two or sometimes three at a time. Some of my biggest blunders have been ordering a test on a patient A, then seeing patients B and C and forgetting all about patient A, who then sits around waiting. But I’m getting better at this.

I usually stop to eat lunch for about 15 minutes. Sometimes food is courtesy of a drug rep, sometimes my employer, and sometimes take out from a nearby restaurant or sandwich shop. When the pharma reps bring lunch, they wait to speak with you, which is a little awkward - they show me all kinds of graphs and visuals on their iPads while I try choke down a ciabatta sandwich and work in my questions.

I see patients until the end of the day, and once the last one is gone, I hang my white coat and stethoscope until morning. Some places allow casual attire, others scrubs. At my clinic it’s necktie M-Th. I work 40-45 hours per week and have Saturday, Sunday, and Monday off.

The Doctor & PA Relationship

How closely do I work with the doctor?

Not very closely at all, and where once I fantasized about that, now I don’t. I handle the vast majority of my patients without speaking to my boss, who is the owner of the clinic, an MD, and an Assistant Professor of medicine at a medical school.

Since graduating I’ve come to a (sometimes painful) realization: I will be speaking with the doc far less often than I would like. I’m one of those people who is hungry to learn, to do a great job, and to make true progress with patients. Most of the time I handle things with total confidence (say, 80% of the time). Less frequently (say 15% of the time) I wish I could speak with my doc to make sure I’m not missing something, but don’t have that luxury, and need to do my best without it. And about 5% of the time I either have no confidence in my direction, or feel the stakes are high enough that I need him involved. My doc is a hard working guy with a great sense of humor, who knows how much I want to learn and he tries (when there is time) to teach me what I need to learn. But there are times when it just isn’t possible. On one busy day, to one of my questions, he answered flatly, “Dude. Just figure it out.” So I did.

If it’s about something serious, I ask for him even if he is busy, in a hurry, in a mood, or giving me his patented looooong sighs. Even if his schedule is busy, when it really matters, I get his help, no matter how busy he is. This means there are frequently times when I come to the decision on my own that as much as I would like his thoughts on a case, I will need to do without them because it just doesn’t rise to that level. So I handle these and either 1) come home and read up on the topic at night, or 2) find him when he isn’t busy, tell him what happened, and see how I did. He has been very trusting in my ability and complimentary about my work. But the honeymoon is rapidly ending, and there are days when all he has time for is to tell me where I fall short. In his words, “You’re doing a fabulous job.” [fabulous is his favorite positive adjective.] “But you’re at the point where my job is to tell you whenever you f*ck up. Don’t let it get to you.” He said this with his arm on my shoulder.

“I know, John,” I told him. And I can take the feedback, believe me. It’s just hard being at that point in my work where I need to learn how to do some things as I’m doing them. No more shadowing. No more observation or instruction.” It feels a little like playing in a pro football game after only one season of pea-wee football practice. You go through this just about every time you prescribe a drug that you’ve never prescribed before, but that is how you learn. I have strategies to protect myself and my patients from my ignorance: 1) start only one new medication at a time, 2) start with a dose that is on the low end (particularly with the insulins), 4) have the patient come back to follow up soon, and 4) remember the edict: primum non nocere.

To my frustration of needing to learn while doing, my boss replied, “Yes. And it’s going to be that way for the rest of your career. Shit, I feel that way sometimes still. But that’s how you’re going to learn, and I wouldn’t have hired you if I didn’t think you could handle it.”

Okay, so I guess all I can do is trust in the process.

The Highs

• Finding an abdominal abscess the size of a grapefruit in a patient who “just didn’t feel right,” after she had been to the ER and released.
• My favorite bit of patient feedback: “You’re the first person who’s ever explained this to me before.”
• The first time my boss left the clinic early for the day, leaving me in charge [he was available by phone if I had problems]. It was a vote of confidence.
• Doing my first unsupervised surgical procedure (removal of a large, suspicious skin lesion. I made an elliptical incision, and closed with 5 interrupted sutures and one horizontal mattress stitch).
• Writing my first controlled medication prescriptions, like morphine, percocet, valium, ambien, methadone, etc. Pain management is a big part of workman’s comp cases.
• Being courted by drug reps (it actually gets old very quickly).
• My first paycheck. I was fortunate to find a job that pays very well, even right out of school.
• Getting a prescription pad with my name on it.
• My Christmas bonus. That was a very nice surprise.

The Lows

• Dealing with drug-seeking patients. They tend to walk in right before we close and say they are new in town from out of state and need their Xanax or Norco filled. I’m getting good at spotting them!
• Busy days when patients being irritated because they have had to wait for me, and I can’t seem to keep up no matter how fast I go.
• Prescription errors. Once I mistakenly hit the wrong button on the computer and transmitted an electronic prescription for a patient with high blood pressure that had the wrong dosage. The patient came in several days later to be seen for dizziness on standing. I was not pleased, and it started me double and triple checking my electronic prescriptions. My boss brought it to my attention and, and said simply, “Be more careful.” ( If this scares you, you should know that statistically, death rates in university hospitals rise every July when the new interns (doctors) arrive. No one wants to hurt anyone - that’s the opposite of why we are here. But as one preceptor in school told me, “Everyone learns something at someone else’s expense.”)
• Those inevitable days when frustration sets in and I get discouraged about all I still don’t know. There is so much to know.

Summary

All in all, I’ve had an amazing experience joining the field. I feel like I have found a professional home. I wanted work that makes a real difference in people’s lives. I wanted work that was challenging, but not tedious. I wanted to be compensated well for what I do, and I wanted a field that was broad enough that I would grow into it and not get bored.

So far so good.[subscribe2]