zeusfaber Posted May 22, 2014 Share Posted May 22, 2014 Hi everyone, Well, I've gone and done it again. I had previously written about my first job out of school, at a crazy busy ED for which I was clinically unprepared and it was mutually agreed that I should leave the position. I was there 6 months. I got another job with a surgical specialty private practice, started in December and just got fired this week. They wouldn't tell me exactly what the issues were, only that it was "in the best interest of the practice" to terminate my employment. Some issues which probably had to do with it: I was really behind on billing and documenting. I was never trained in billing, and it took me a couple months into the job to even understand the concept. Was really behind and still learning it but never had a good chance to catch up. Documenting was tough, they got a new EMR, which I tried to learn but it was pretty user-unfriendly, the doc agreed and we went back to dictating, then we were going to get a new EMR. Overall, they just didn't have an efficient system in place and I was expected to compensate and keep track of everything. If I knew this was such a big problem, I would have come in on a Saturday and caught up on everything, but I always thought I'd get to it. In retrospect, I absolutely should have done that. The other thing: I joined with the impression that there would be another PA for support. She ended up going on maternity a few days after I started and had not returned at the time of my firing. I never really got to observe how she did things, and a large part of the job was admin tasks. I was figuring out office procedures as I went along, since no one else knew exactly how the other PA did things. I had a really big problem with admin, not figuring out that I had to do something until mistakes happened, and not feeling like I had time to address all of the tasks. The practice didn't have an MA, so the PA role was actually an MA/PA combo. I was only in the office 2-3 partial days a week (at the hospital rounding or in the OR other days) so this became really challenging. Last thing: I think there was a deficit in my training in terms of hospital rounding, which is something I never got great experience in. I did not know how systems/procedures worked at a hospital and was learning by making mistakes. Overall, I totally failed because I was extremely slow to learn and then didn't devote myself to organizing and completing all the tasks that I needed to. I took a little too much of a lackadaisical attitude when I was falling behind but at the same time I felt like I was handed a ton of responsibilities without an idea of how exactly to handle them all or how to approach things. Also didn't realize it would lead to my termination. Now, I feel totally incompetent and like an utter failure. Two jobs that didn't work out, that looks horrible. No one really that I can ask for a professional reference. I don't know if being a PA is the right thing for me if I can't manage admin tasks or take the initiative that I need to in order to meet my obligations. I think my patient care is good, but it seems like that's not the only important thing about being a PA. I'm actually going to get medically evaluated to figure out why I have such a problem with admin and organization (adhd, or whatnot). What should I do? Should I just go into teaching or find an office career? How do I find a job I can actually perform well? I feel like I somehow got into and got through PA school without being completely qualified and now I'm feeling the consequences. I also don't know why I let laziness get the better of me and didn't think it was essential to catch up on billing/charting. But again, not sure if that was the reason. Could have been anything. Any advice is appreciated. Link to comment Share on other sites More sharing options...
Z PA-C Posted May 22, 2014 Share Posted May 22, 2014 Do you mind PMing me what program you attended? I am concerned how you went through PA school and have never heard of a discharge summary...Yes, billing and charting is pretty important... Link to comment Share on other sites More sharing options...
cinntsp Posted May 22, 2014 Share Posted May 22, 2014 Did you ever ask the doc to spend a little time walking you through these processes so you could take notes? Link to comment Share on other sites More sharing options...
Guest jb555 Posted May 22, 2014 Share Posted May 22, 2014 I only have 2 years of actual work experience, so take my advice with a grain of salt, but next time you have an interview, it would probably be a good idea to get a firm idea on how they plan on training you. I was extremely lucky that my SP wanted a new grad to "shape" and had planned on a minimum of 6 months of shadowing. Now it didn't take me that long to actually start seeing patients, but just knowing I had that amount of time to get used to the patient population, administrative work, etc was such a relief. I wish during my clinical rotations my preceptors had actually let on about how much paperwork they actually do because it was quite a shock when I started too. Did you have any preceptors from clinical year who would be willing to be references? While it wouldn't look quite as good, you could also use past managers from non-PA jobs who can vouch for you. Link to comment Share on other sites More sharing options...
zeusfaber Posted May 22, 2014 Author Share Posted May 22, 2014 wutthechris, I did. The main thing that would happen is he would give me a very brief rundown verbally. Then, when it came to actually doing the thing, I would be doing it wrong, or incompletely. Example, when we talked about discharge summaries, he said something like "Oh no one reads them anyway, you just put date of admission/discharge, d/c diagnosis, d/c meds, and a brief summary of their hospital stay". So I breezed through them or didn't do them in a timely manner, and then when someone else would try to read them (like a snf doctor), they would call him and say my dc summary sucked. He said he would go over it with me but we never got a chance to sit and do it. Same with hospital rounding. I told him specifically I don't have rounding experience. He said that we would round together and he would devote some time to training me in this. Either this totally didn't happen, or he thinks it did (we rounded together a few times when we were at the hospital together, but no specific training was given - it was more of a tag-team approach so we could finish and go home). At my interview, he said he would train me in billing. 2 months into my job, I was waiting for said training, when he said that I was so far behind in billing that it was affecting my performance. I told him I didn't understand it, and he got annoyed. Bought me a book and an online course (that ended up being not useful). (I even bought myself several apps and tried to read online.) So either he was not training me, or he thought he was training me and it wasn't sticking. Or, he was training me and I was so far behind where he was starting from that it didn't take. Link to comment Share on other sites More sharing options...
whoRyou Posted May 22, 2014 Share Posted May 22, 2014 Take this advice with a grain of salt, but you might consider residency that is if you can afford it, but then again can you NOT afford to? Speaking of which I recently read an article Are Med School Grads Prepared To Practice Medicine? I only have 2 years of actual work experience, so take my advice with a grain of salt, but next time you have an interview, it would probably be a good idea to get a firm idea on how they plan on training you. I was extremely lucky that my SP wanted a new grad to "shape" and had planned on a minimum of 6 months of shadowing. Now it didn't take me that long to actually start seeing patients, but just knowing I had that amount of time to get used to the patient population, administrative work, etc was such a relief. jb - You are lucky that your SP wanted to shape/mold a 'newbie' as yourself as I am sure this is NOT the norm, or is it? (FYI I am only a Pre-PA) That would be interesting to find out how many SPs actually mold newbies like yourself as opposed to others being thrown under the bus. Link to comment Share on other sites More sharing options...
cinntsp Posted May 22, 2014 Share Posted May 22, 2014 To be totally honest it sounds like you didn't take a real initiative to learn what you needed to learn. You say things like "He said it in such a way that it didn't seem serious. So I breezed through them or didn't do them at all." Wouldn't common sense dictate that discharge paperwork for a hospital patient is important? Did you spend your time outside of work searching for information on these topics to get up to speed? Did you read the book he bought you? Hopefully we can pinpoint the things you can address to make you feel more comfortable and be more successful in your next position. I really think at least one hospital-based rotation should be required for PA school. Link to comment Share on other sites More sharing options...
zeusfaber Posted May 22, 2014 Author Share Posted May 22, 2014 JB, I really thought that's what this job was going to be. He trained/molded his other PA and said he wanted to do the same with me. He seemed pretty serious and I think he was being sincere. I just think he had very little time, and it didn't end up happening, or at least not the way I thought it would, or I wasn't assertive enough. He's a super nice guy, very soft spoken, patient, etc. I think the practice was really busy and I didn't get the opportunity to learn/reflect because I was busy rounding/charting, then going back to clinic and seeing patients there. Meanwhile, multiple calls about order clarification, weight bearing status, rx refills, pt questions, pt needs a piece of DME covered by medicare (took me a few days to figure this out), calls from other physicians, etc. No other PA in the office to ask. No one else knows how to handle these things. Takes me much longer to figure out answers than it would someone with more experience, leaving little time for other tasks. Then I started to get frustrated and de-motivated bc I felt like I was just trying to get through the minimum daily requirements and was not really able to devote time to learning, and let some things fall by the wayside. Missed a few important paperwork/admin-related things. Most of these things are normal PA duties, but there was a built-in inefficiency as well as a necessity to "drop everything" and address issues when my SP had a spare moment or a phone call came in. Would get interrupted frequently and tasks would be incomplete by the end of the day, but I'd still be mentally exhausted. Not an excuse by any means. Just an explanation. Link to comment Share on other sites More sharing options...
Acebecker Posted May 22, 2014 Share Posted May 22, 2014 Per the ARC-PA inpatient medicine is a required rotation, as is at least one surgical rotation. You have to be very careful the line you tread here, OP. You are recognizing that a lot of this is your fault and was your responsibility, but you also seem to be poking at trying to find a way to blame your SP for your failings. I like that you understand it was in large part your responsibility. This is *huge* for your future success. Obtain a copy of scut monkey (aka "clinician's poket reference) and Maxwell's and be able to do those chart notes. These are the basics and you will need them for future success. While there were other cooks in this kitchen, you are the only cook who matters. If you want to succeed, you will succeed. You should have been in the office on off days getting your charting and billing done. This is a no-brainer. At this point, primary care in an office setting sounds about right for you. Get a job somewhere doing that, do it well for a few years and build your resume. Others have come back from worse. But remember - the care you provide is up to you, not anyone else. The way you function in the office is up to you, not anyone else. You know that and it comes through in your posts. Keep your chin up. Link to comment Share on other sites More sharing options...
LKPAC Posted May 22, 2014 Share Posted May 22, 2014 I'd be very interested to know what PA program you attended. Also, what was your medical experience prior to PA school? Link to comment Share on other sites More sharing options...
gbrothers98 Posted May 22, 2014 Share Posted May 22, 2014 This is a horror show. Sorry to see you go through this. I read your post and also the post when you lost your first job. Here is some bitter medicine that is aimed at new grads in general. The disconnect with the PA world is that one is educated in a primary care model. This model does not translate well to the ED or surgery, especially specialties. Most program exposure to both is a rotation in each and a few weeks at best during the didactic year. Therefore a super busy ED or a solo specialist practice is the worst environment to find yourself in unless there is a well thought out plan in place to get one up to speed or preexisting significant experience in either of those venues. But be forewarned, all your ED tech experience made you a great ED tech, not a great EMPA. Sounds like both of your places set you up, sink or swim, there are other individuals they can hire till they get the one that survives. Here is your personal dose of reality. I think you need to ask yourself what you want to do in medicine and seek it out. Both of our posts lay the blame at the feet of lack of training. But you have graduated and passed the PANCE. On the job training has an expectation that you will do the job competently because you are getting paid while gaining experience. In both of your posts you relate some not very professional behaviors and attitudes that need to be addressed such as timeliness of work, attention to detail and taking responsibility to learn what you dont know. Relying on others, especially a solo surgeon or busy ED attendings to provide you with the answer, will get you hung out to dry, which is what these people did when you did not rise to the challenge. A residency may provide training and direction, but that is easier said than done. A general practice with a very supportive staff and supervising physician is similar. The loss of these 2 positions is going to be a concern for new employers. You are right about being evaluated. You have faced several significant life changes, graduation, new jobs, loss of those jobs. The most upbeat will be depressed and anxious. Counseling, activity, sleep, a good diet and perhaps meds may help. You are on a pathway that you need to divert to the positive. Finally, I would turn back to your program. Call your advisor/mentor/director up and have a chat. Ask if there is some help or assistance. You need a small success to turn in to a large success. Good luck, I feel for you. George Brothers PA-C Link to comment Share on other sites More sharing options...
cinntsp Posted May 22, 2014 Share Posted May 22, 2014 Per the ARC-PA inpatient medicine is a required rotation. There is no requirement for inpatient medicine as part of the standards of accreditation, It just defines it as "internal medicine." Surgery should provide some exposure for sure, though. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 22, 2014 Share Posted May 22, 2014 With regard to the discharge summaries, did you consider pulling one from a patient's chart and using it as a sample form to follow? You could have looked at one in the office and written out a format regarding what to include in the actual dictation. With regard to billing coding, I have never had to deal with that either yet I have a couple of free apps on my phone in case it were ever needed. Link to comment Share on other sites More sharing options...
zeusfaber Posted May 22, 2014 Author Share Posted May 22, 2014 wutthechris, Yes, you're completely right. I should have realized how important all of these things were but I just didn't at the time. Like I mentioned, it got to the point where I was just trying to get through the day and was so frustrated by the end of each day that I didn't want to think about work and had to attend to personal matters. I finally did find a colleague at the hospital to help me with discharge summaries. I would read up on procedures beforehand, but I felt like my weakness was not the medical stuff, it was all the administrative duties and keeping up with addressing tasks and phone calls as they would come up, then sign off on lab/path that came in, while seeing patients in the office, while checking which surgeries got added for the next couple days/week (seriously, how many times a day should I be expected to log into the schedule?) I'm not defending my procrastination on important things, which is definitely a serious issue. I was always so flustered and felt like I had way too many things to deal with and would almost "shut down" at the end of the day due to feeling overwhelmed. Billing/charting ended up taking a back seat and procrastination took over. I totally take responsibility for that. However, I am really concerned that I can't seem to handle the myriad administrative tasks that come with being a PA. I'm not a terribly organized person and that was a big problem here. If I had been able to handle the admin stuff, I wouldn't have been so behind on billing/charting, if that makes sense. Link to comment Share on other sites More sharing options...
cinntsp Posted May 22, 2014 Share Posted May 22, 2014 Maybe you would fare better working for a large group or hospital system that is new grad friendly, has plans in place to get you up to speed, and has dedicated staff to handle billing. Link to comment Share on other sites More sharing options...
whoRyou Posted May 23, 2014 Share Posted May 23, 2014 I am just curious where is your mentor? Or perhaps the school can give you some insight? Perhaps where you did your clinicals maybe someone saw something, but didn't think it was an issue at that time. Someone should be able give you some answers. Here we are only guessing and grasping at straws. I am trying to be careful with my words because I do not know you, but you really need to look at things and take some responsibilities if you really want to continue to be a PA. Or one more thought and again take this with a grain of salt, but are you afraid to succeed (subconsciously)? The first step towards getting over the fear of success is to recognize it. To do this one needs to have a better understanding of the sources of their fears and discard their secret self-image as an unsuccessful, undeserving person. I hope I did not offend you, I just want to succeed and be happy. As the writer Ambrose Bierce said in The Devil’s Dictionary, “Success is the one unpardonable sin against one’s fellows.” I hope I did not offend you, I just want to succeed and be happy. As a mentor once said to me "sometimes you need to stop believing your own bullsh*t." Link to comment Share on other sites More sharing options...
zeusfaber Posted May 23, 2014 Author Share Posted May 23, 2014 Thank you everyone for your responses (and keep em coming). As for what school I went to, I don't want to say the name of the school because I already have a lot of personal identifying info here. I will say that I don't think this is at all my school's fault. None, zero, nada of my classmates have had this problem. I had one inpatient medicine rotation, but it was very "easy" and they did not challenge me at all. My surgery rotation was at the VA and my preceptor would really only first assist and then see clinic patients. The residents handled all the inpatient/hospital stuff. If he put in post-op orders and discharge summaries, I didn't know about it. He was kind of gruff and didn't really want a student (he was forced to by admin). My last inpatient component was with a bunch of residents who ignored me the whole time. I do think that a lot of this is because I didn't have a ton of health care experience prior to school. I was a career changer and worked in a primary care office for a few months prior. If asked, I would discourage schools from accepting people like me. I think it's doing the student and the profession a disservice. Billing/coding - I tried reading the book (it's huge) and also downloaded (and paid for) a few apps, but these were not really helpful due to the specialty, the apps and other resources were more for primary care type visits, and some other resources were for billers/coders, not providers. Was slowly getting it, but still needed to sit down with my rounding sheets and match my chart note to the right code. Really time consuming and didn't always get to this. I didn't realize how unprofessional my attitude about the above paperwork was. I was focused on leaving at the end of the day because I was mentally exhausted and frustrated. I was not staying as late as I could to finish my billing and catch up on documentation. I always thought I would get to it when I had a free moment, which rarely happened. I should have at least tried to prioritize this more than I did. However, even though they mentioned that I was behind in all these things and needed to catch up, I didn't realize I would be terminated for it (if that was even the reason). It wasn't like I never did them, I was just behind. I would have thought that if it had gotten to that point, I would have had a formal sit down or very clear warning. I just didn't take it seriously enough and I recognize that now. It could have been anything, since they didn't say. These are just the weaknesses I recognize in myself. I can learn from it and move on, but I want to make sure I don't fail a third time because I couldn't take it. Link to comment Share on other sites More sharing options...
bradtPA Posted May 23, 2014 Share Posted May 23, 2014 You desperately could use a residency program IMHO..... Link to comment Share on other sites More sharing options...
zeusfaber Posted May 23, 2014 Author Share Posted May 23, 2014 I think you are definitely onto something there. In reflecting on this, I do think that I have a subconscious image of myself as a lowly, unimportant person. I never compromise patient care, but I do see myself being lackadaisical about getting other work done on time because in my head, I feel like it's not important (if it were, they wouldn't have made me, a relatively dumb person, responsible for it). I do think that a lack of confidence underwrites all of this. I am not confident about doing dictations, so I put them off or don't do them. I am not confident about the accuracy of my billing, so I don't do it. etc. I can't possibly be successful if I tried, so I'm not going to try. I don't know why in the world I didn't see the problem with this thinking or link it to what was going on at work. You're totally onto something and I really appreciate you telling me this. I already have an appointment for therapy/evaluation to see if I have a learning disability, adhd, depression, or something else that makes me feel unmotivated. I'm going to remember this component too. Thank you. I am just curious where is your mentor? Or perhaps the school can give you some insight? Perhaps where you did your clinicals maybe someone saw something, but didn't think it was an issue at that time. Someone should be able give you some answers. Here we are only guessing and grasping at straws. I am trying to be careful with my words because I do not know you, but you really need to look at things and take some responsibilities if you really want to continue to be a PA. Or one more thought and again take this with a grain of salt, but are you afraid to succeed (subconsciously)? The first step towards getting over the fear of success is to recognize it. To do this one needs to has to have better understanding of the sources of their fears and discard their secret self-image as an unsuccessful, undeserving person. I hope I did not offend you, I just want to succeed and be happy. As the writer Ambrose Bierce said in The Devil’s Dictionary, “Success is the one unpardonable sin against one’s fellows.” I hope I did not offend you, I just want to succeed and be happy. As a mentor once said to me "sometimes you need to stop believing your own bullshit." Link to comment Share on other sites More sharing options...
Maverick87 Posted May 23, 2014 Share Posted May 23, 2014 Dude, I realize that this is an emotional and sh*tty situation, but you need to get over these failures as quickly as possible and stop making excuses. I say take the Memorial Day Weekend and be mad, cry, or whatever....and then start the job search on Tuesday. Be committed to success. I've been (to some degree) where you are. My school did not prepare me well for practicing and I struggled when I started. I, like you, tend to be emotional and disorganized. BUT the major difference between us is that I started in primary care in a situation with VERY understanding and supportive mentors (I literally have 5 different mentors where I am now, which is my first job). After a year and a half, I am feeling more confident in my abilities, less emotional, and more organized than I was before. It WILL happen and you WILL get better.....as long as you don't give up. Now, I suggest you look for a primary care job, as another poster suggested with some good mentors. This is definitely a good place to start off since you see a little bit of everything and get an idea of what coding is like without drowning in it. Then if you want to transition to hospital or ER or surgery, you could get a per diem job in one of them and get your feet wet a bit. Or, as yet another poster suggested, you could do a residency. I don't see any other options that will lead to success besides those two, in your case. Good luck! Link to comment Share on other sites More sharing options...
KMD16 Posted May 23, 2014 Share Posted May 23, 2014 Residency training. Explore working in an underserve community through the NHSC. Link to comment Share on other sites More sharing options...
cinntsp Posted May 23, 2014 Share Posted May 23, 2014 My experience so far is that residencies are very, very competitive. It may be hard to sell this situation to the adcoms. Link to comment Share on other sites More sharing options...
CAAdmission Posted May 23, 2014 Share Posted May 23, 2014 I don't mean to sound (too) harsh, but you need to take some initiative. PAs are problems solvers. We make things happen. The inability to think "hey, let me look at another chart and see how someone else documents/dictates/writes X" shows a troubling problem with judgment. If you can't figure out simple issues like this I worry about your ability to see a patient who has a problem that does not fit a textbook presentation. Unfortunately I can;t tell you how to fix it. Link to comment Share on other sites More sharing options...
whoRyou Posted May 23, 2014 Share Posted May 23, 2014 I already have an appointment for therapy/evaluation to see if I have a learning disability, adhd, depression, or something else that makes me feel unmotivated. I'm going to remember this component too. Thank you. I think this is your best option and consider individual therapy would be my suggestion. Lastly find a mentor and consider a fellowship. I personally think you need some more training ... Best of Luck and keep us or me posted as I would like to hear what transpires. Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 23, 2014 Moderator Share Posted May 23, 2014 Dude, I realize that this is an emotional and sh*tty situation, but you need to get over these failures as quickly as possible and stop making excuses. I say take the Memorial Day Weekend and be mad, cry, or whatever....and then start the job search on Tuesday. Be committed to success. I've been (to some degree) where you are. My school did not prepare me well for practicing and I struggled when I started. I, like you, tend to be emotional and disorganized. BUT the major difference between us is that I started in primary care in a situation with VERY understanding and supportive mentors (I literally have 5 different mentors where I am now, which is my first job). After a year and a half, I am feeling more confident in my abilities, less emotional, and more organized than I was before. It WILL happen and you WILL get better.....as long as you don't give up. Now, I suggest you look for a primary care job, as another poster suggested with some good mentors. This is definitely a good place to start off since you see a little bit of everything and get an idea of what coding is like without drowning in it. Then if you want to transition to hospital or ER or surgery, you could get a per diem job in one of them and get your feet wet a bit. Or, as yet another poster suggested, you could do a residency. I don't see any other options that will lead to success besides those two, in your case. Good luck! could not have said it better myself... so I just posted this.... Link to comment Share on other sites More sharing options...
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