Failed at my first job, now what? Follow up to prior post...

[zeusfaber]

For reference, please see my previous post.

 

Hello all,

 

I posted previously about being a new grad in a crazy busy ER and being completely unprepared to handle my patients and work with the level of independence that's expected of me. It's definitely a tough first job and my supervisor recognizes that. She said that she herself would not have been able to handle it if she started now (vs when the hospital was smaller and lower volume). In any case, I have failed. I am not able to keep up, I don't feel safe seeing patients, and it has been mutually decided that I should not work there anymore as of the end of this month.

 

My problem, to sum up, was a lack of clinical experience prior to PA school, being an average student, and not working well under pressure. I can't think on the fly. I can't see a patient that is completely new to me, digest all the HPI, PMH, lab results and pick out what is relevant to make a plan. I have a really hard time going back to my desk, keeping track of everything I just learned about the pt, and then reaching into the back of my brain for differentials. Sometimes I don't even know what tests I want or why. Every attending I work with has a different style and this further confuses me and makes me nervous about presenting the pt. Basically, I feel like I am bumbling through each patient, having to rely way too much on the attending, either doing way too much workup or not enough, or sometimes just not even getting a good clinical idea of what the patient is actually there for. I look stuff up on uptodate and it still ends up being the wrong thing to do sometimes.

 

This all has made me feel like I don't know 'how' to be a PA. I'm not clinically savvy, and I still feel like a student who has to ask about everything. I feel like I got this degree without really having the skills that are supposed to come with it, and I don't know why that happened or how to fix it. Others in a similar situation experience-wise are doing just fine.

 

I don't know where to go from here. My confidence is shot. I don't know what to look for in a job, other than less chaos and more training. How can I do my best not to get into this situation again? I am considering a residency but I don't know what specialty I would want. Definitely not ER! I don't know what kinds of jobs to look for. I just know I cannot handle failing again.

 

Thank you for being a place where I can talk about this, I really have nowhere else to turn. I really appreciated everyone's feedback last time and I hope that anyone with words of advice, any thoughts, anything at all to say will tell me because I can use it.

[skyblu]

I'm so sorry you had to go through this. I can totally see how it would have you doubting yourself.

 

I'm an E-Med PA, started right out of school at a busy ED with lots of critical patients. I understand that you either have the personality and confidence to do this, or you don't. But a lot of the skill can also be learned.

 

For me, I had 5 years of EMS experience so I did learn a lot of rapid assessment from that job (are they sick? Not sick? When I was a basic EMT, do we need ALS? Do we just go?). I also was fortunate enough to do a full 15 weeks of EM rotations in PA school, at a Level I academic trauma center where I worked alongside medical residents in complicated cases. I learned A TON there, too.

 

The multi-tasking is always going to be there. Some people are just not great at it, and that is okay. My husband, for example, is a very methodical individual who likes to see one project at a time and see it through from beginning to end in an orderly approach. He is INCREDIBLY smart. Clearly, while he would be a great surgeon, he would suck at EM! (He's a software engineer, though.)

 

If your biggest problem is clinical acumen, the gestalt of knowing if a patient is sick or not, and the interpretation of labs and putting the picture together, that can be learned. Probably not best be learned in a sink-or-swim way, but it can come with time.

 

If your biggest problem is that you don't do well with chaos, multi-tasking, thinking on your feet, and being distracted by a million other thins needing your attention, then your personality is not suited to EM. Again, that's totally okay! You might totally thrive in a controlled environment where you see a case at a time, have time to do a little research, and have time to sit down and think before taking action or formulating a plan.

 

Primary care might be a good first step. It would expose you to a variety of body systems, rather than if you are specialized and then your focus is narrower. And you can work in an office, see one patient at a time, and be able to interpret results at your own pace, maybe even while sitting in a quiet office with lots of reference books and support staff.

 

I agree with you, less chaos and more training sounds like a good place to start. You don't necessarily need a residency to get training. You just need a place where the pace suits your own pace, where there are more experienced clinicians who are willing to take you under your wing, and where you have a supportive environment that doesn't require the on-the-spot decisions that EM does.

 

So this wasn't a good fit. It doesn't mean anything bad about YOU as a PA or certainly as a person. I saw in your previous post you called yourself "an average human being." You are not! You are someone who chose a hard career where you could help the sick and keep people healthy. That's way, way above average, in my opinion!

 

Dust yourself off. This was a stumble, not a fall. It takes a very specific set of skills and personality to thrive in EM. And those of us who have them, we lack a bunch of other skills that might make us thrive in other situations! For example, I would SUCK at surgery. Or anything where I have to follow a patient for months. I just don't have the attention span or honestly, the interest. I like the fast pace, the chaos, the noise, the adrenaline rush. It makes me a little crazy to work in an orderly surrounding. It doesn't make me better or worse than you, it just makes me better suited for EM, and you better suited for something else. It takes all kinds of people to make this amazing world of ours. If we all had the same skill set, the world would be a very boring and limiting place!

[GreatChecko]

Ever thought about a PA residency program? Might be a good way to beef up any areas you feel weak in and increase your confidence.

[cbrsmurf]

I was thinking residency as well

 

Or mabye something slower and less acutely critical like ortho, derm, psych, endocrinology or something completely surgical (no offense to those working in those specialties)

[skyblu]

I think though that working in a specialty, if you want to eventually go back to something more global like EM, is not going to help hone your clinical "big picture" skills. If you work in a dermatology office, you're not going to learn how to get that 2-second impression of a patient with labored breathing.

 

This is in no way meant to offend specialty practice. I am dumb as a rock when it comes to rashes, for example. I see rashes in the ED and I tell people: "Look, I know bad rashes. I know common rashes. Everything else is just a rash to me." So if you have Stevens-Johnson, I got it. If you have zoster or poison ivy, I'm totally okay. If you have erythema multiforme? Yeah, I'm out of my depth.

 

Surgery requires incredible skill, concentration, and knowledge. But the environment is a lot more controlled, and you focus (especially in the OR) on one patient at a time. I would SUCK at this.

 

It's ll about knowing yourself, and learning about the reality of practice of various specialties and then figuring out which one suits your strengths. This is why a key part of choosing a PA program is the availability of numerous clinical rotations, so you can "try your hand" at what you think you like, and see if the reality fits your idea of it.

 

Did you do lots of clinical rotations? What area did you find then that felt comfortable and like it would be a good fit?

[zeusfaber]

Smurf and Checko, I did consider a residency, but like I mentioned I'm not sure what I would want to do it in. After this experience, definitely not ER. I don't know what I'd be looking for to be honest. It is a consideration though.

 

I just went on an interview for plastic surgery. Great office and people that would definitely train me, but don't know if I want to get sucked into the world of boob jobs and tummy tucks and have to get all gussied up every day for the customer service aspect. Today, I applied to jobs in heme/onc and bone marrow transplant. I don't know what those jobs entail and I don't know how to tell if it would be a better fit.

 

I feel like I need to be in an environment that's a little more repetitive and lower acuity and where, like you mentioned, I will have a moment to sit and think about the patient and the plan, where I can receive adequate supervision, support and training, and where I can feel prepared for the patient before I walk in the room. I want to slowly build up my skills rather than being thrown into the fire pit. I'd even be okay being "underutilized", for example doing pre-procedure H&Ps by rote, if it meant I wouldn't be panicked and floundering every day.

 

In my rotations, I really liked my peds allergy/immunology rotation and felt that was the best fit. Learned a ton, it was repetitive in a good way (scratch testing, refill/step-up/step-down asthma meds, rx epipens/atarax/HC, counseling, food challenges), and I felt like I could handle most patients on my own by the end of the rotation. If I could find an allergy/immunology job I would take it in a heartbeat. I liked derm because of the preceptor but didn't love the patient population and thought it would get boring after a while - seemed like derm is more about being an income-generating machine and with a few exceptions I never felt like I was actually helping to heal people. I liked my surgery rotations and being in the OR. I actually loved my ER rotation, but I see now that it did not paint an accurate picture of what an ER PA actually does. I liked my psych rotation, too. I didn't like the inpatient rotations. For some reason, I never was able to figure out how to make plans for patients in the hospital and I don't "get it" when it comes to inpatient stuff. Again, possibly a problem with "putting it all together" and seeing the big clinical picture.

 

Thanks for your very thoughtful responses. I'm trying not to be too hard on myself but it's been very difficult and I am scared to death of something like this happening again at my next job.

[Boatswain2PA]

How old are you Zeus? And what experience did you have before PA school?

[UGoLong]

I recommend that you find a place with one good supervising physician that you will be working with. It almost doesn't matter what the practice area is. Some SPs are good at training and are easy to work with. After some time working with someone like that, your confidence with probably return.

 

A successful position is a mix of good people to work with and a setting that matches your interests. Don't give up.

 

Good luck!

[jwells78]

Dude- take a deep breath. You came out of the gate running and tripped. Its OK! Pick yourself up, dust yourself off- use this experience to find your strengths and realize your weaknesses! Capitalize on what you have and adapt. I would look for a clinic with an SP that can mentor you; read up on Patho/evidence based medicine; look into residencies; but FIRST- go to your mirror with a big red erasable marker and write at the top the following words: I AM A PA. THIS AIN'T NOTHIN BUT A THING. PUSH THROUGH IT. You had to know that the tough part was the first few years out, no? One foot in front of the other bro... J

[zeusfaber]

How old are you Zeus? And what experience did you have before PA school?

 

I'm 31, and I'm a career-changer. I started doing prereqs in 2008 and went to school in 2010. Also worked at a Family Med clinic for about a year before school started. Had some hospital volunteer and other community service hours accumulated over the years.

 

There were people in my class straight out of undergrad with less experience than me, and they're doing fine. So I can't figure out what my problem is...

[zeusfaber]

ugolong, jwells - Thank you so much for your kind words. It is really rough right now, especially with the uncertainty of finding something else and possibly having to relocate. Also since I graduated 5/2012 I've only worked for 6 months. I feel like that looks terrible and I'll need to explain it somehow. No idea how to start looking for work again, it was not easy the first time around.

[Guest JMPA]

ugolong, jwells - Thank you so much for your kind words. It is really rough right now, especially with the uncertainty of finding something else and possibly having to relocate. Also since I graduated 5/2012 I've only worked for 6 months. I feel like that looks terrible and I'll need to explain it somehow. No idea how to start looking for work again, it was not easy the first time around.

may i suggest inpatient medicine. it is at a slower pace with less critical patients and greater exposure to multiple diseases. once you feel comfortable with your base knowledge and learning how to learn than all fields will seem much easier to you, don't give up

[rev ronin]

Alternatively, family medicine is often more repetitive and reasonably lower acuity. I put myself there on purpose, because I didn't think 5 years as an EMT-B prior to PA school was enough to dive into EM right after school.

[peaceloveandPA]

First and foremost, you are not a failure. And with being a recent grad I do not think u will have any problem finding a new job. All u have to say is that You realized EM is just not ur thing. Many new grads go Into specialties they think they will love and change their minds. Nothing wrong with that. I'm a recent grad with about 10 months experience in primary care, and most days I don't know what I'm doing but my patients keep coming back and I've gotten many good reviews on my care. I think u would do great in family medicine or peds, outpatient. You get to spend more time with the patient... Get a FULL history and understanding of them, it's not rushed or life threatening (usually), And u develop a rapport with them. perhaps u would like that! Yes, u do have to formulate an assessment and plan right there with the patient in the room (no presenting of the case to ur SP, unless ure really not sure), but u order labs and imaging, which comes to ur computer when the patient is at home and u can research, formulate a plan, or discuss with ur SPs BEFORE u have to call the pt with results or they come in for a follow up appt. This gives u a lot more time than u would have in EM. I throw words like this to my SPs "I have a patient with a, b, c... Here's what I'm doing. Would u do anything else?" Or "I'm working up this patient for RA... Here's what I'm ordering. Am I missing anything?" I agree, u need an SP who is willing to work with u and train u. Mine are great for the most part and easily accessible when they're not in the exam room with the patient. What I have done in the past when I first started is "give me 5 mins... I'm gonna print out/transmit ur labs/scripts and Ill be right back to talk with you." That way I can confirm with the SP that I'm doing the right thing or look up something real quick if I need to. Also I look at the schedule for the next day to see if there's anything I need to brush up on research the night before... Common chief complaints like "knee pain, heel pain, rash, chest pain, etc" you can then research those things, begin to formulate a differential in ur head and know which questions to ask before the patient steps in ur office.

 

Good luck. You will be fine and keep us updated on ur progress!

 

 

Let food be thy medicine

[Guest Paula]

^^^^^^ I agree with all of the above. You are not a failure. I worked 3 years as a locum in ER/Urgent Care on a part-time basis. I learned a lot but realized the ER part was not for me. I am a reflective thinker and did not like some of the cases that came in that needed QUICK thinking. So, ultimately I returned full-time to family medicine/urgent care, which I absolutely love. You mentioned you liked your peds allergy/immunology rotation. Have you thought about going to that clinic and asking them if they have any openings? One never knows what you'll find if you ask. If you had a good review from them as a student they might keep you in mind if a job opens up. Good luck and keep us informed.

[jwells78]

may i suggest inpatient medicine

. <----This. Learned more on that rotation than almost all the rest combined.

[whoRyou]

[Annika]

I did the same- started into EM and boy...what a MISERABLE experience it was for the first 6 or so months....but also, Damn am I glad I did it! ;)  I moved onto UC and possibly more  FP as the practice grows after having to relocate (divorce...) and UC is okay- and I like PCP work.  I did not like the nights at ED work, but boy, did I learn a lot.  

Your attendings make all the difference in the world to me at a novice EMPA.  I had great attendings...the hours...they were tough. But I would do EM in a heartbeat again...

You are Not a Failure.  It takes time, and tears and doubting yourself.  I worked with 2 PAs that started in EM and were fired after a short time.  They are back in EM and loving it.

[Derbingle]

Completley agree you are not a failure, at all. starting as a new grad into ED even with good HCE is very (and I mean very) challenging. Recipe for success is determined by type of attendings, fellow PA/NP support, number of patients, how sick. Not just the PA skill. Docs do a residency and they back each other up as they learn codes, trauma, scary stuff etc! The attending hangs out/watches the senior resident, who watches the jr, they layer the learning. PAs start and are expected to produce immediately. And im learning it just takes time. As in experience.

 

I started in ED just 10 months ago. Its been a life changing experience. I havent decided yet, whether or not its for the better. Good and bad days, self doubt, self success, feeling stupid, feeling smart. First 6 months were hard! Second 6 months...still hard. Better, getting faster. (This forum has helped a lot regarding coping with the stress). An attending said tonight, if this job wasnt this challenging, you wouldnt be questioning, reflecting, breaking mental boundaries, becoming better as a person. Like working out, only its your brain! Several new people have started in this inner city ED along the way while I learn, compare myself, and Ive watched some with experience, some not. Its been kind of a barometer for how I am really doing. it seems in ED "no news is good news" and you just keep working. Its been tough on all of them too.

 

Keep the faith, and as stated above, dust yourself off. Allow your self a week of self pity, crying and doing only what you want ;) then look forward to your future.

[Febrifuge]

Sorry I missed this when it was fresh. There's a lot of excellent advice on here already, so I have little to add.

 

I was VERY similar. Career-changer, surrounded by bright young Bio majors with little experience, and they all went out and did great while I suffered through months of trying to be a hospitalist. If there was a worse fit for my brain and temperament, I'm not sure what it would have been. The group failed to hold up their end of the "oh yeah, we'll totally teach you everything" bargain, and I held up my end which was "I am going to pester you for clarification and act like a total newbie because I have confidence in myself, but not to the point where I want to maybe kill someone." We mutually decided it wasn't working out.

 

What was nice about my situation was they didn't give me the boot during my 90-day no-fault probation period; they instead waited an additional month and a half, and paid me four months' salary as a lump. It still felt like a kick in the gut when they let me go, but the big check made things feel a little better right away.

 

Then I got to stay home for a while. It was impossible not to feel like a failure, but that wore off. Today, it's more than 3 years later and I basically laugh about it. Still, there's that sting...

 

Just know, it wasn't a matter of you failing, it was a matter of the situation being wrong. Some ridiculously huge proportion of PAs change jobs within their first two years out of school; I don't have the statistic handy but it's something like 30 or 40%. Let yourself feel the pain, but then work through it, and put it behind you. Honestly, in just a few months all you'll need to tell anyone is "it just didn't work out" or "it wasn't a good fit." And that won't be an evasion, that'll be the truth.