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Hi all,

 

I graduated in August 2015 and have recently begun working full time at an urgent care (that always has an on-site attending phys) about 3 days ago. I have been feeling extremely nervous about my poor performance so far as a Physician Assistant, so any advice, criticism, encouragement, and similar experiences might help. I have lurked here for a long time, so I know how honest and helpful the PA community is.

 

At this urgent care, you get 3 days of EMR training. The urgent care I work at sees ~60-80 patients a day and I've been feeling pretty rushed/stressed trying to keep up with the pace while still learning the system. I have figured out the EMR system pretty quickly but patient interaction/decision-making wise, I have been such a mess. I have realized that I am not very confident in my knowledge besides the simple diagnoses, like OM, fractures, sprains, sinusitis, etc. Even when I talk to patients, they seem to catch on that I am unsure of myself. About half of my patient interactions have gone OK. I ask my attending phys questions and I go on UpToDate/Medscape to read up when I'm unsure, but most of the time I still don't even know what I'm doing. I have forgotten to mention some SE to patients about their meds, or forget to do something during the physical. I haven't been able to sleep at night because I'd been worrying about that patient I should have sent to the ER immediately, or if those meds will actually help that guy's cough that he's had for 2 weeks. I have been praying so far that I won't get a call next week from a lawyer suing me for something.

 

I wanted to go into urgent care because I wanted to keep myself well-rounded and I believe I could learn so much in this field. I'm starting to wonder if I was too ahead of myself when I applied and should have taken that pain medicine job where I would have done knee/trigger finger injections all day. I know that I'm only on my 3rd day in, but my anxiety level has sky-rocketed, making it even worse to focus.

 

Again, any advice, criticism, encouragement, and similar experiences will help. Thanks for reading!

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I'm fairly new to a complex field and I was pretty anxious when I first started too. Someone gave me some fantastic advice and it changed my stress level immediately. She told me that there is nothing wrong with telling a patient, "I don't know" Followed by something reasonable like I will find out, let me consult with my colleagues, etc. The person who gave me this advice has been practicing in my field for a long time and she still has to look things up or check details out sometimes. It allows you to keep your confidence if you realize that there is nothing wrong with not knowing everything. My patients don't mind at all if I need to go check on something for them as long as I am taking good care of them and get answer for them before they leave. My anxiety level is so much lower now and I am able to think more clearly when I am not constantly stressing about how much I don't know.

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As noted above, your feelings are normal. If you didn't worry about your impact on your patients, THAT would be abnormal. You will learn as you go. Eventually you will see patterns and react instinctively, but not in the third day, or third week, or maybe third month.

 

You work in a busy field. The best advice I got was from my SP, who said: "Go as fast as you can, but know when something comes along that you need to slow down for." 

 

Take a breath; you can make this work.

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General advice for new PAs:

 

1) whatever your field, it is normal to feel overwhelmed and ill prepared. That fades with time (6-12 months to begin feeling comfortable).

2) read and learn on your own. Search the forums or get on Amazon for some good books. Download medical apps (I like agileMD and also Omnio has free access to Merck Manual, which is also free online).

3) many patient complaints are trivial. You cannot cure most viruses, headaches, chronic pain etc. often the most important thing to your patient is they feel they had your undivided attention and care for some period of time even if only a few minutes.

4) people die and early diagnoses are missed. When in doubt, emphasize the need for follow up. Remember that patients health is also in their own hands. If you can't figure a case out, get some labs and have them return in a week or two and see how things are progressing.

5) patients do not go to medical or PA school. All they know is what you project. If you show care and confidence (even when faking either or both), that is what your patients go off of. This improves with time.

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Also a new grad about six weeks into my first job at an ER. I have felt all the things you described and have already had a lot of sleepless nights, waking up many times remembering things I should have done differently! It is totally normal. If you didn't feel worried and like you don't know anything it would be concerning. You know you're becoming more competent when you recognize when you know what you don't know - sounds like you're at that spot - rather than not knowing what you don't know, which is a dangerous thing. On one of my first days at the ER an experienced doc told me, "Every day for the first few years that I was a doctor, I felt like a fraud. I would wake up in the morning and go to work and wonder why anyone trusted me because I truly was unsure of what I was doing." In short it's normal to feel like a fraud! Even the top PANCE performer in our class took an urgent care job and texts me regularly freaking out about things she messed up on. It is okay! Don't be afraid to ask questions, because your learning and your patient's safety depends on it. Also - I recommend you get two resources, as they are fun to read and saved my butt a few times and provide straight forward info -- do the EM Bootcamp by the Center for CME, and buy Minor Emergencies by Buttaravoli, then put the free Inkling app that comes with it on your phone. You will be so grateful to have both resources in urgent care, especially the second!

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What you are writing sounds exactly how I'm feeling!

I also graduated end of summer. I just started working in a FM practice 2 days ago and have no idea what I'm doing.  I shadowed my SP for only 3 patients and they started assigning me patients to see and treat SOLO. My SP is super busy so I can't always ask him. I'm asking the NP, MAs for so much help and they can definitely see my insecurities and lack of confidence. I have no idea how to use the EMR (after only 1 day of EMR training), how to place orders/referrals, and how to choose in regards to whatever type of insurance (so MANY). I didn't even know how to pull up vitals for the patient. I feel like a nervous wreck since yesterday. My nervousness is causing me forget things and do incomplete physical exams. I tried to convince my wrist fx patient to go to ER but he refused, and didn't try further. Since we don't splint in the office all I could do was put him in a sling and wrap him with ace bandage and told him I'll refer him to ortho. I was later told seeing ortho would take weeks, the sling might worsen the problem and he shoudlve gone gone to ER. Now I'm worried sick that I might have caused him more harm than good. I'm also worried for malpractice. I tried calling the patient but could only leave a voicemail. I only saw 3 patients but I spent 11 hours trying to figure out how to navigate through this EMR. I teared up after work wondering if I'm going to be a good/efficient PCP and if I made the right choice choosing this job with such limited training.

 

FM rotation went so well. During rotations, I had a preceptor who mentored me and followed up with me on every case. I knew I could ask him anything. I grew pretty confident and even if I had no idea what to do, I could tell my patient comfortably that I will consult with my preceptor. But it was over a year ago.  Now  I'm on my own. It is hard to hunt down someone for guidance. I've forgotten everything from FM rotation. I'm freaking out. Not enough training and a mentor who not always accessible.  I have to review when vaccines/special tests should be given, BIRADS, interpreting labs (When is low too low or high too high?) It only been 2 days at work, but I have so much catching up, learning, and calming down to do! People are saying to fake it till you make it, be an actor, make a first good impression. But heeding to that advice is always hard for me when I don't know the system.

 

Good luck to all us noobs. Glad I'm not the only one on this boat.

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What you are writing sounds exactly how I'm feeling!

I also graduated end of summer. I just started working in a FM practice 2 days ago and have no idea what I'm doing.  I shadowed my SP for only 3 patients and they started assigning me patients to see and treat SOLO. My SP is super busy so I can't always ask him. I'm asking the NP, MAs for so much help and they can definitely see my insecurities and lack of confidence. I have no idea how to use the EMR (after only 1 day of EMR training), how to place orders/referrals, and how to choose in regards to whatever type of insurance (so MANY). I didn't even know how to pull up vitals for the patient. I feel like a nervous wreck since yesterday. My nervousness is causing me forget things and do incomplete physical exams. I tried to convince my wrist fx patient to go to ER but he refused, and didn't try further. Since we don't splint in the office all I could do was put him in a sling and wrap him with ace bandage and told him I'll refer him to ortho. I was later told seeing ortho would take weeks, the sling might worsen the problem and he shoudlve gone gone to ER. Now I'm worried sick that I might have caused him more harm than good. I'm also worried for malpractice. I tried calling the patient but could only leave a voicemail. I only saw 3 patients but I spent 11 hours trying to figure out how to navigate through this EMR. I teared up after work wondering if I'm going to be a good/efficient PCP and if I made the right choice choosing this job with such limited training.

 

FM rotation went so well. During rotations, I had a preceptor who mentored me and followed up with me on every case. I knew I could ask him anything. I grew pretty confident and even if I had no idea what to do, I could tell my patient comfortably that I will consult with my preceptor. But it was over a year ago.  Now  I'm on my own. It is hard to hunt down someone for guidance. I've forgotten everything from FM rotation. I'm freaking out. Not enough training and a mentor who not always accessible.  I have to review when vaccines/special tests should be given, BIRADS, interpreting labs (When is low too low or high too high?) It only been 2 days at work, but I have so much catching up, learning, and calming down to do! People are saying to fake it till you make it, be an actor, make a first good impression. But heeding to that advice is always hard for me when I don't know the system.

 

Good luck to all us noobs. Glad I'm not the only one on this boat.

 

It's not too late to do some post-grad training.

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I'm an oldster to practice but in my newest job (nearly one year ago) the EMR training consisted of 2 full time days and then for the 1-2 days  the EMR trainer actually sat with me at the end of each patient visit in my office and reviewed all the steps for ordering, documentation, etc.  After that, she was available for phone calls and the MAs and the doctor I shared an office with answered questions. 

 

It made for a smoother transition to a new job and new  EMR.

 

Ask for more EMR training.  There has got to be an easier way to navigate and it is not acceptable that there is no one to help you.  Plus 2 days of training with the SP is unacceptable too.  It will get better with each passing day.   

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  • 3 weeks later...

Sorry, but I'm going to offer a little different advice.  Not to offend, but the "you-are-new-it-gets-better-roll-with-it-cuz-it-will-be-fine" advice I can't help but disagree with.  The OP hasn't reposted since starting the thread, hopefully he/she is doing OK.

 

NO ONE should start medical practice without good, readily available, backup support right out of school, regardless of specialty, environment, GPA, test scores, prior experience, confidence, graduation percentile, IQ, etc.  Your first year out of school should be about learning to practice at a basic level -- readily available backup is not a luxury, it is mandatory.

 

New grads have sacrificed a ton of money and time, and you should never jeopardize that and your license, even it it means unemployment for a while.  

 

The OP's problem was not the EMR.  The OP's problem was about being ready to practice. 

 

I'm not a PA.  I am an NP, posting to a PA forum.  But I graduated with highest honors not just for my BSN, but for my entire college within my university.  I previously had earned a BS degree with a 4.0 GPA from a respected private school with a 6 point grading scale.  I earned my master's degree from a fairly elite private school who has a highly respected major medical campus whose research is used daily in clinics all across the continent, and earned the graduate school clinical excellence award upon graduation from that school, and finished with a 3.7+ GPA.  Meanwhile, I worked as an RN in the ER as well as in the medical and cardiothoracic ICU at a major regional hospital with a level II trauma center while doing all of that.  I had 2 job offers months before graduating without even applying.  I've been inducted into multiple honors and leadership societies, both at the undergraduate and graduate levels.  I then scored in the highest percentiles on my board exams, with little studying.  

 

Am I bragging?  Dang right I am.  I worked my butt off.  But my point is that no one is ready to work with little support day one. I certainly wasn't, and the EMR was the least of my problems.  My "SP" was a chief resident in family practice, and was scared to death his first few months of practice, spending time on the phone with specialists fairly often.  And that's after 3 years of supervised training post MD school in residency.  Don't fool yourself into thinking you are the exception.

 

I knew none of this when I graduated.  I chose the job that I felt like had the most support, which was a key priority for me, but I was clueless as to how critical having that support in my first job actually was.  I'm the cocky type-A dude that readily points to my accomplishments, but my first year of practice has been humbling regarding the complexity of medicine.  No two cases are ever the same.  Ever.  Twice now I've been offered an UC position in my young career and backed off both because I wasn't certain that support was adequate for my level of experience.

 

If you are a new grad, or in a new specialty, make your SP help you and/or reduce your load to give you time to research your cases.  Don't give them an option.  If that means a backed up schedule, p** off patients or a pi** off SP, so be it.  That's not easy, but it is your best option even if it sucks.  You'll gain yourself time to learn while things get figured out in your clinic and/or give yourself time to find a new job.  

 

If you are a new grad, or about to be, run from offers for which you do not have great support. Stay unemployed if you have to until you find something better. And don't think that because this advice is coming from an NP makes you, a PA, any different. Newly independent physicians need the same thing and that's with 3 years of supervised transition to practice. 

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I completely agree with UpRegulated except I'm not as smart as him/her. I just left a job where the idea of a long, 3 month orientation was a great theory but it wasn't a reality. The reality was me finding someone to shadow and getting conflicting ideas for how to manage patients when I asked for advice. Once I was independent, I worked in geriatric facilities with access to my SP by phone or text with the worst EMR known to man. My SP went to one of them but I was a solo provider in the others. Eventually I figured things out, pulled together lots of resources (UpToDate, Micromedix, EMRA Antibiotics) and developed skills and confidence. I left that job after 1.5 years for one that is better organized and supported.

 

I was certainly not ready to be independent in my first year. Besides the EMR, there were lung sounds and rashes that needed a quick "second look" and medication interactions that needed checking. I second guessed almost everything I did (or didn't do). Support is vital for patients and the new provider.

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#1  Stop trying to match the pace of seasoned, residency trained providers.  You won't be able to at this point. People can wait so that you have the time to provide safe care.  Don't get bullied into going too fast.

 

#2  No one is comfortable making decisions at day 3.  At a little over a year I have settled in to being comfortable 85% of the time when I am in our solo UC setting.  10 % of the time I am out of my depth to some extent and have to read (usually solves it...), ask a colleague or my SP by phone.   If the situation seems emergent and I don't have good backup/can't find what i want online or in a book I send them the ED.  UC is not the end of the line and it is better safe than sorry. I have good support so it is rare I need to make an ED referral blindly in that fashion, but I have done it because I care about the patient more than my ego. I even tell the patient that their situation is outside my knowledge base to treat safely, and they usually appreciate the honesty.  TL;DR: Err on the side of caution and by honest when you don't know. you are also much less likely to get sued if you are honest even if you royally *&@# up.

 

#3  Nervous about a patient?  Schedule a close follow up!  Call them the next day!  

 

#4  Realize you mis-diagnosed, didn't ask a question you need to know or want to change your plan?  Call the patient and tell them you were thinking about their case and came to a new conclusion. They will love you for it.

 

#5 Have a patient in the room that is non-emergent and you are not sure what to do?  Don't make something up.  Tell them you want to think about their case for awhile and that you will call them later in the day with your plan... They will love you for it.

 

#6  Not a day goes by that I don't forget something small. (should have asked this, should have inspected that) It is part of the self assessment and learning process to notice these things and work on doing them better.  When I catch something I think will significantly affect patient care or the quality of my DX (much less often after a year, but it still happens and likely always will) I call the patient and ask, add on the lab I forgot or have them come back.   It can be embarrassing, but they usually are graceful about it.  

 

#7 DO NOT LET A PATIENT BULLY YOU INTO DOING SOMETHING YOU FEEL IS UNSAFE.  They will try.  Tell them no. Stick to your guns.  If a patient needs to go the ED, they need to go there.  

 

#8 On the clinical side... never ignore screwy vital signs or weird neurological stuff..... 

 

To any new grads reading this thread, the most important thing you should look for in your first job is good support.  Everything else should be secondary.  You, your patients, and your license will suffer if you ignore the importance of this. You can go for pay, hours, etc with your second job.  Look for a place that has taken on new grads regularly  (and kept them!) and knows what they are getting in to.

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#1  Stop trying to match the pace of seasoned, residency trained providers.  You won't be able to at this point. People can wait so that you have the time to provide safe care.  Don't get bullied into going too fast.

 

#2  No one is comfortable making decisions at day 3.  At a little over a year I have settled in to being comfortable 85% of the time when I am in our solo UC setting.  10 % of the time I am out of my depth to some extent and have to read (usually solves it...), ask a colleague or my SP by phone.   If the situation seems emergent and I don't have good backup/can't find what i want online or in a book I send them the ED.  UC is not the end of the line and it is better safe than sorry. I have good support so it is rare I need to make an ED referral blindly in that fashion, but I have done it because I care about the patient more than my ego. I even tell the patient that their situation is outside my knowledge base to treat safely, and they usually appreciate the honesty.  TL;DR: Err on the side of caution and by honest when you don't know. you are also much less likely to get sued if you are honest even if you royally *&@# up.

 

#3  Nervous about a patient?  Schedule a close follow up!  Call them the next day!  

 

#4  Realize you mis-diagnosed, didn't ask a question you need to know or want to change your plan?  Call the patient and tell them you were thinking about their case and came to a new conclusion. They will love you for it.

 

#5 Have a patient in the room that is non-emergent and you are not sure what to do?  Don't make something up.  Tell them you want to think about their case for awhile and that you will call them later in the day with your plan... They will love you for it.

 

#6  Not a day goes by that I don't forget something small. (should have asked this, should have inspected that) It is part of the self assessment and learning process to notice these things and work on doing them better.  When I catch something I think will significantly affect patient care or the quality of my DX (much less often after a year, but it still happens and likely always will) I call the patient and ask, add on the lab I forgot or have them come back.   It can be embarrassing, but they usually are graceful about it.  

 

#7 DO NOT LET A PATIENT BULLY YOU INTO DOING SOMETHING YOU FEEL IS UNSAFE.  They will try.  Tell them no. Stick to your guns.  If a patient needs to go the ED, they need to go there.  

 

#8 On the clinical side... never ignore screwy vital signs or weird neurological stuff..... 

 

To any new grads reading this thread, the most important thing you should look for in your first job is good support.  Everything else should be secondary.  You, your patients, and your license will suffer if you ignore the importance of this. You can go for pay, hours, etc with your second job.  Look for a place that has taken on new grads regularly  (and kept them!) and knows what they are getting in to.

 

Fantastic post.  I have had several times now that I've called a patient back after they left.  It's humbling, and even embarrassing (though it probably shouldn't be).  I can't say for sure, because I don't know, but I'm sure there has been a resident or two who's attending said "call them back now" after reviewing the case.  If you are < 5 years out of school, you are essentially a resident.  And as tao mentions, a lot of patients actually appreciate it. I have seen (in only 1 year of practice as an APP) providers (docs) screw things up, ignore it, and put themselves in situations of potential legal liability because they were too proud to do the right thing.  To the point of even firing a patient for complaining about their screw up!

 

I sometimes wonder if some providers get complacent in that they have practiced x number of years without getting sued, and thus think they never will no matter what.  At the same time, it seems too many PA's and NP's are too pre-occupied with the potential for a lawsuit, not recognizing that we all (MD's, DO's, PA's, NP's) fail at times and very few "mistakes" actually become lawsuits.

 

Where I am right now: It's always better to be humble and do the right thing than to do the wrong thing to save face.

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It has never bothered me in the least to call a patient back, even if they're out in the parking lot from just walking out the door if there is a relevant question that I need clarification on.  If answer is relevant, ask the pt. a second, third, fourth, however many times it takes to get a satisfactory answer.  Classic situation at current position, pt. denies on direct questioning any history of treatment for depression at present time, so when I go to order Bromfed DM up pops the warning between DM and Lexapro (risk for serotonin syndrome).  Call the pt. and clarify the discrepency and now I have to change to individual classes of meds as opposed to the all-in-one package.  Heaven only knows the number of pt.'s who put themselves at risk this time of year taking every OTC cold/cough med known to man, the best of which are marginally effective, well except for the alcohol in NyQuil; and run the risk of complication since no one ever told the pt. about the potential interaction.

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Hello all!!

 

Sorry for the delayed response, I've been repeatedly reading all of your posts throughout the month. I would go through this thread every time my anxiety was high, and I would always leave thinking about how I can improve and remember that I am not expected to be perfect (IT IS OK TO NOT KNOW).  After the first three days of training (when I wrote this post), I was feeling overwhelmed and helpless without my trainer, but I really underestimated how much support I would be getting from my supervising physicians and nurses. I am extremely grateful with the crew that I work with, they all have been so helpful and understanding. All of my supervising physicians love to teach.

 

Now I'm about 1 month in and have seen over 500 patients. I have done a lot of what you guys have suggested .. calling the patients back for follow up, if i'm not sure - always saying "i don't know, let me ask the doc/or double check", constantly referring to uptodate/medscape, having my SP take a second look at the patient, observing what my SP does through their physical exam, etc etc etc. Besides from the usual otitis medias or positive strep throats, I try to read up or ask the doc on almost all of my patients. I have seen so many usual cases so far that even leave the doctor stumped. (which honestly makes me feel a little bit better...)

 

I have learned so much in the past month about myself and medicine, and I'm still only 1 month in of my entire life. Every case that comes in is a constant reminder that I am still a student and that I am still learning. I am really grateful that I have this as my first job, where I could have been in a situation where I was the solo provider, or with a supervising physician who left me on my own.

 

Thank you all for your wonderful advice (and constructive criticism)!!! Your thoughts have definitely helped me and hopefully the new grads who have been feeling the same way.

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  • 2 weeks later...

Way to go, you are off the a fantastic start!  A couple things to ALWAYS remember in Urgent Care....   1) ensure a follow up plan and 2) Consider all worst case scenario's and DOCUMENT them or that you considered them.  If you do these two things it is almost impossible to get SUED!!!  These two things ensure you are "covering your ass" if you do make a mistake.  Best of luck! 

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