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1st year as a PA-C... reactions/thoughts/advice wanted from your experience


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I’m 6 months into my first year out of PA school of being a PA-C in a Family Practice. I want to get some advice and reactions to the first year experience.

 

I’ve generally found the first year to be much harder than expected. I still feel there is so much to learn, and that most days are stressful. I believe the misconceptions that I had about the first year came from being treated in school that we would be able to treat anything that came our way right out of school. I still don’t feel comfortable dosing insulin, for example, and patients with multiple comorbidities and many medications can also be very tricky to manage obviously.

 

The office I’m in has never had a PA before, so I believe they realized that since I’m a new graduate, I should be seeing more acute visits rather than also trying to manage patients with chronic illnesses. The practice has tailored my schedule to be used more like what would be seen in Urgent Care, which has definitely made my days more manageable for me at this stage of the game.

 

The practice that I’m in has 3 doctors, all of which are helpful to me when I have questions about treating patients. I feel that I’m having to ask questions regularly, although it does seem to be getting a little less frequently, and varies day by day. They seem to appreciate the job that I’m doing, but since none of them have worked with a PA before, they may have been thinking that I would need less help on a day to day basis. On top of all of this, we are going through conversion to electronic medical records, that is posing a challenge itself.

 

I’ve also found that even when I follow what any resource (such as CMDT) says to do for treatment, the docs may say something like “Well, that’s OK, but here’s how we really do it in the clinically world.” I feel that I got a good education, and that there were no huge gaps, but am just finding some disparities from the academic world to the clinical world. Someone once told me they feel that they learned everything on the job, not so much in school… and some days I can see their point, even though I would not be where I’m at knowledge wise without the base of the education that I’ve had.

 

Having said all of this, I’m curious what others have experienced, as well as any reaction to any of the following:

 

  • How often in your first year were you having to get guidance from your supervising physician?
  • At what point did you feel more comfortable treating chronic illnesses, and how did you develop the skills to treat these patients?
  • Other than CME, do you study outside of the office in your first year, and if so, how much?
  • I know that pharmacology is huge in and of itself, but any tips you would offer in tackling that wild beast?
  • Other than Dubin’s EKG book, are there any other training resources you would recommend for getting a better handle on reading EKGs?
  • I also have to take call at times, so and reaction on how this was for you in your first year and how you handled it in general would be helpful.

 

Sorry for the long post, but I’m sure you understand where I’m coming from.

 

Thanks for any input!

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Take a deep breath! Sounds like ur a tad overwhelmed.. I still consider myself a new grad - graduated 01/2011, been practicing over a year now. I did 6 months of emergency med, then moved to general surgery. The first thing I learned when I started working was how much I didn't know. You're going to learn on the job, and don't worry about what the book says vs the docs telling u "this isn't how u do it actually in clinic" - this is when you learn and figure out what we are actually meant to do. I too joined a team of docs who have never had a PA before.. so there's def growing pains.. but prob 6 months into it, it's getting much better.. I've been able to carve out my own niche during that time. Enjoy the ride!

-i ask for guidance all the freaking time. in fact one of my sp's came up to me (in ER) and asked if i was reading outside of work, and said i wasn't b/c everyone's so great at answering all my questions.. hehe. I barely had time to read, but I had time to stop ppl in the halls and ask them tons of questions during work.

-theres no finite amt of time before you feel comfortable... it comes gradually

-I do CME, I barely read outside of work.. just a little bit here and there before surgical cases. I'm trying to make an effort to do more reading these days tho.

-there's tons of meds.. you will find certain ones you will like to give more often than others. You will also find there are certain ones that your sps like to give more than others.. probably will gravitate towards giving those more. you don't have to swallow the whole apple dude.. take it slow. sometimes insurance or what's cheap in the community will dictate what you give

-EKGs.. what else do you need to know about them outside of Dubins? Takes practice.. look at as many as you can

-don't take call luckily..

Best of luck!

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What you are feeling is completely normal. Try not to worry about the MDs thinking you need too much help. I guarantee that they appreciate your conscientiousness and would much rather you ask a question than not. It takes time. You'll get there. You are certainly right that the real learning is on the job

 

Insulin just takes practice. It's the art of medicine. For some objective stuff:

-read about the 1800 rule. Essentially, if you add up a patient's total daily insulin requirement and divide it into 1800, that is how much his/her blood sugar will drop with 1 unit of aspart. This is useful for prandial insulin or making a sliding scale.

-weight based insulin: body weight in kilos divided by 2= anticipated daily requirements. Half of this is usually in basal form and half in prandial

- Yale DM guidelines are free http://endocrinology.yale.edu/patient/50135_Yale%20National%20F.pdf

 

For EKGs, I swear by Garcia and Holtz's 12-Lead ECG: The Art of Interpretation.

 

I recently transitioned from hospitalist medicine to primary care after 3-4 years. A couple months in, I'm still asking questions everyday... Sometimes multiple questions per day. You are not alone.

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  • Other than CME, do you study outside of the office in your first year, and if so, how much?

One of the best pieces of advice I received during PA school was from an anesthesia attending; you should treat your first couple of years out of school as if you are in residency. Make reading a priority while you are learning to be a practitioner, and it will give you a much better base as your career progresses. If possible, buy a couple of great reference books (sorry, I work in EM so I don't know many medicine texts outside of Harrison's and Cecil's from PA school). Make a point of going home after every shift and reading all you can about a particular condition you saw that day at work. I found this to be a great way to make the information stick.

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One of the best pieces of advice I received during PA school was from an anesthesia attending; you should treat your first couple of years out of school as if you are in residency. Make reading a priority while you are learning to be a practitioner, and it will give you a much better base as your career progresses. If possible, buy a couple of great reference books (sorry, I work in EM so I don't know many medicine texts outside of Harrison's and Cecil's from PA school). Make a point of going home after every shift and reading all you can about a particular condition you saw that day at work. I found this to be a great way to make the information stick.

 

This is exactly how I am treating last year and the next 2-3 yrs. This was sound advice a NP friend gave me when I got accepted to PA school. I still read up even on routine things as well as the interesting things I see. I by no means got it down, and still have A LOT to learn, but taking things one day at a time and asking the SP LOTS of ?'s really help build up the knowledge base and believe it or not your confidence.

 

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congrats on realizing being a PA is really hard!

 

 

I said I was going to do 1 yr in internal med to "learn medicine" ...... 5 years latter I felt like I had a good hand on it and tried subspeciality medicine for 4 years before I returned to primary care realizing that is what I loved

 

 

 

I had over 400 hours of cat1 CME in my first 2 yr renewal - I read all the time at home - not as much as in school (falling asleep in the books everynight in a puddle of drool....) Asking people for answers should only be after you have read about the condition and tried to answer teh question yourself

 

a few pointers

Don't try to learn all the drugs out there - if you actually stop and listing to the doc's they all have maybe 20-30 drugs that they are comfortable writing - outside of this they are grabbing references and looking it up. Instead learn a few drugs for each thing you are trying to treat and learn them inside out and up side down and every which way so you know everything there is to know about these few drugs - then slowly expand out from there. FORGET all the name brand drugs and just learn generics initially - learn the ACE, ARB, Betablockers, the very simple DM oral meds, and some basic antibiotics

 

GET epocrates on an Itouch and use it all the time to look up drugs, cost, and most importantly the drug-drug interactions (these are really not looked at by most and I continue to learn things, just last week I pointed out an absolute contraindication on a med list that a very senior psychiatrist was un aware of)

 

Don't think that you have to "do everything that the real world says" I have repeatedly seen that used as an excuse for subpar medicine - following the guidelines is the best thing we can do as long as you are comfortable in your assessment - on this thought don't get lazy in PE skills (and I am guilty of this now) fine tune everything you learned in school, listen to bruits, look at HGJ, test the CN's, listen to murmurs with a valsalva and all the esoteric crazy stuff you can think of. Slow days when I was learning were times I would branch out and do a very detailed exam for even a simple complaint (keep it quick though..)

 

 

 

 

my final plea on writing drugs

1. narcotics/benzo's are poisons yet you make your patients VERY happy by writing them - we are not in the business of making patients happy but instead practicing medicine - be very very careful on giving any scheduled meds when there is no tangible evidence of pain. I give perc's to fractures (proven on xray) as they hurt - but only 10-20 tabs with a basic motrin script as well - but for back pain that has not findings they get high dose motrin, cyclobenziprine and PT. Remember "first do no harm" and making addicts, allowing people to sell the drugs, and getting people dependent on opiates/benzo's is doing harm.

2. 90% of uri's are viral - sinusitus is viral almost 100% of the time - interesting study recently with 125 patients who were seen by ENT for chronic sinusitus - only 18 had a confirm bacterial pathogen and the more the patient complained of "sinus pain" the less likely they were to have true bacterial sinusitus..... we write something like 16X's more ABX then europe - europe is not missing all the bacterial infections for colds - instead they are not giving ABX to every head cold that comes through.

 

 

 

parting thought for starting chronic meds - (and all meds for that matter) - medications are poisons with good side effects... do you want to be taking a poison?

 

 

 

sounds like you are on the path to becoming a great primary care PA !! keep hitting the books and learning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

my first few year resources (and still use them daily)

On a mobile PDA/Itouch (yeah mine was on one of the first Palm PDA almost ancient history now....)

Epocrates

Five Minute clinical consult

Five minute Emergency

There was a great (now outdated) book produced by a NP organization that was about 3 inches thick and gave all common conditions with treatment guidelines that was simple, easy to read and invaluable to me - look around and talk around and try to find a new book on primary care that does this. http://www.amazon.com/Clinical-Guidelines-Family-Practice-Constance/dp/0964615169/ref=sr_1_1?s=books&ie=UTF8&qid=1333975193&sr=1-1

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I went from 2 years diagnostic radiology(worst job in the world for a PA) to CT surgery. My CT job had one fellow and the surgeons stayed in the OR. Nobody wanted to teach and I truly was on my own. Fear was gone and only anger and drive existed. Needless to say it was the best experience for me. I read my way to confidence. I learned prioritizing and multitasking. Most of all I realized never to hesitate doing somthing new. I feel now that I can do any field with confidence after learning how to learn. Good luck and never give up.

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Uptodate is an excellent resource to use in your first couple of years.

 

Up-to-date is a life saver! I also use my Medscape app on my phone and pubmed quite frequently.

 

And i agree with focusing on class of drugs vs trade names. Most adverse effects are class effects but lookout for the outliers.

 

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Ventana- I just read through your response here and on the facebook post thread, and I just want to say- I want to practice medicine like you! Any chance you are in NC and willing to precept :=D:?

 

Sorry Western MA and currently my job does not let me precept - they are too concerned with lost productivity...... not a good set up for me....

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What you are experiencing is normal...

 

Just keep reading... reading... reading... reading.... IQRAA...!!!!!

You should be surrounded by books for the next couple of yrs, EVERYWHERE you go.

 

Before I responded to this thread, I did a "medical text" count:

 

6 books on my bedside table

3 books in my bathroom near the "Throne"

Epocrates Essentials, Medscape Mobile, SkyScape Consellation, 25 Current Clinical Strategies texts, 5MCC, DeGowins Harrisons, Residents Manual of Medicine, WM Internists Survival Guide and Tarascons Primary Care is on EVERY device (phone & Tablet) I own which means that these references are never further than arms reach. Whenever I have down time... I read. Waiting in line... I read, at the DMV... I read, airport... I read, shopping with the wife and/or daughters... yep... usually within a few minutes, I'm looking down at my phone or tablet reading.

 

Hint: If you buy one Current Clinical Strategies Book, the publisher gives you a password that allows you to download ALL 25 texts in PDF format. These work GREAT on smartphones and tablets...

 

Also download or get the hard copy of "The Common Symptom Guide" 6th edition... (John Wasson)

 

Its basically a "to-do-list" with differentials organized by a patients presenting complaints.

 

 

The the 4th edition was GREAT when I was in training... so much so that over the yrs, I have always updated this text. I now have the 6th edition on my bookshelf and on every electronic device I own (Smartphone, Xoom Tablet, Ipad, Nook Tablet). Its a great resource for a newbie...

 

The actual hard copy book can be secured on Amazon or B&N... and the electronic version for Android and Iphone/pad is available on ebooks.com. B&N also has a Nook book version.

 

 

This quick-reference guide to over 100 commonly seen symptoms in adults and

children allows you to quickly and accurately evaluate and treat a patient’s

complaint.

 

Thoroughly cross-referenced, The Common Symptom Guide includes insightful guidelines on:

 

* Patient and family history

* Physical examination

* Diagnostic considerations

* Medications

 

NEW IN THIS EDITION:

* Geriatric considerations

* Updated medications section

* New information of health assessment website

This quick-reference guide to over 100 commonly seen symptoms in adults and

children allows you to quickly and accurately evaluate and treat a patient’s

complaint. Thoroughly indexed and cross-referenced, The Common Symptom Guide

includes insightful guidelines on:

* Patient and family history

* Physical examination

* Diagnostic considerations

* Medications

* Measures that matter to patients

 

 

IQRAA...!!!!

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Hello fellow new-grad! I'm also in my first year out from school and also the first PA on my team, while I can't offer that much advice I just wanted to give you some solidarity in that you're not alone. I'm lucky enough to be in a position as a hospitalist where our team works very closely together, I have as much time to examine the patient as I need on most days, and I have access to a large teaching hospital online library as well as grand rounds and case presentations if we have time to go. It's definitely a steep learning curve, I'm amazed daily at how much I don't know, we have some insanely complex transplant patients and rare diseases coming through, but it's been a fun ride. It's interesting how almost every provider in our group has their little "niche", so if I have a renal question we all ask one doc, have a heme question ask another, (I'm starting to pave my way as the "ID" question person :)). Don't feel bad about asking questions, I try and look something up first if the doc is busy, most docs say they would much rather you ask, sometimes you'll have to look it up together and both end up learning something. Hospital medicine is a good fit for me, I did pretty much internal medicine patients (HIV, Hep C, CHF, DM) before PA school, but I still have to look up so much every day. I use "Pocket Medicine" and "Sanford" like it's going out of style and I come home and read about whatever I've seen that day. I also like Medscape and Cleveland clinic CME (cleveland has some great primary care CME).

 

One thing that has been helpful for me is getting the basic work-ups down cold for everyday problems and making "cheat sheets" (while I do this for hyponatremia, acute renal failure, CHF, I'm sure this translates to outpatient medicine) then quickly being able to fix the problem once you know the answer or the best ways to do "damage-control" until you know what's going on. Our ED is pretty keen on "moving the meat" so we get a lot of folks coming upstairs with a lot of work-up left to go (which is the fun part). The best way to get good at EKGs is practice, practice practice, ask other providers to hold onto interesting EKGs for you to interpret. http://hqmeded-ecg.blogspot.com/ The "Dr. Smith's EKG blog" is also great.

 

Our team is part of the glycemic control research project, our endocrinologist made us a packet on how to initiate insulin and what the best evidence-based methods are for adjusting. We use the Hopkins protocol http://hqmeded-ecg.blogspot.com/ though the Yale as you were linked to is great too.

For weight-based dosing, we start at 0.4-0.5u/kg/day, 0.2-0.3 if they're elderly, heart/renal/liver failure, malnutrition or type 1's, 0.5-0.6 if they're on glucocorticoids and/or very obese. I divide this total daily dose in half, half basal as Lantus (or BID as NPH if their insurance won't cover lantus), and the other half split between meals with lispro or humalog, along with a correctional scale. I adjust my insulin based on how much correctional lispro they are needing on average in a 24-hour period. Say they use a total of 8u correction on average per day. I add 4 to their basal and 1u of lispro to each of their meals. If their fasting looks good and they get high at dinner and bedtime, I add more lispro to lunch and dinner and add a "PRN" snack dose of a few units. You have to look at where they're running into trouble and adjust there. If you have say a COPDer on am glucocorticoids, I do NPH in the morning which covers them when they get high at lunch and dinner.

 

Another way we start people on insulin who haven't required it previously is the lantus protocol designed by our endocrinology department. While I'm not at work and can't pull up my exact protocol, it works like this. Start a Lantus dose based on their weight, I start pretty conservative depending on their A1c and the fasting CBGs. I then tell them to give this at HS (start with say, 8u) and give them a protocol to self-adjust based on their am blood glucose for three days. My apologies, this is not entirely accurate, but for example:

AM fasting:

50-70- decrease lantus by 5 units

71-80- decrease lantus by 2 units

81-110- no change

111-150- increase lantus by 2 units

151-200+ - increase lantus by 5 units

 

Like I said, this is not exact, I think the Yale has one in their PDF

http://endocrinology.yale.edu/patient/50135_Yale National F.pdf , but just an example of ways we give patients to self-adjust their own regimen until their next appointment. Managing diabetes can be almost an art form, our NP is becoming our diabetic wizard, I always curbside her if I have a tricky one. It just takes practice. Check out the Yale and Hopkins guidelines on diabetes too.

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  • 2 weeks later...

@ Contrarian- thank you for such great resource advice! I'll have to revisit the common symptoms guide, of which I have an older edition. It's also hard at times to look things up when I'm with patients sometimes due to time crunch, but that's where reading and experience will come into play like you said so eventually I'll just know the information. Thanks again!

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