4 years in, still regretting becoming a PA

[ajnelson]

Kargiver...

I couldn't have said it better myself. As I've progressed through my PA career so far, jobs I now look for are more focused on the scope of practice and the system in which I'll potentially work. I've worked in a few 'broken' systems. And sadly, no matter how much you love what you do, it makes you miserable.

[EMEDPA]

I'm at a point that I only look at rural jobs, and typically only rural solo coverage. starting next month I have privileges at 6 places, 3 are solo coverage, 1 is double coverage , 1 is urban trauma ctr, and 1 is community hospital. A year from now I hope to be out of the urban trauma ctr except for perhaps an on call position(it currently is primary job, I would keep it only for social reasons-many friends there).

[BruceBanner]

I would take it a step further and say that if you don't like dealing with people at their worst (feeling bad, argumentative, short-tempered, demanding, i.e.-have the patience of Job) DON'T go into this field.  I'm finding that the older I get the less patience I have for folks in general and that getting out in the next 5-6 years will have been about right (38-40 years total).  The medicine/science part is fine, it's the human interaction under these circumstances I would argue that wears folks out.

 

I wholeheartedly agree.

 

Like kargiver said medicine is a service profession, one in which you are expected to not only fix people's problems but also give them what they want much of the time. This is something I didn't fully grasp when I got into it. I thought i would mostly be giving people my expert opinion and telling them what I think we should do---which I do sometimes---but I also feel like a glorified order and Rx signer more often than not.

 

Setting and practice environment make a big difference, but no one man is bigger than the machine. It always corrects itself towards the bottom line, and that bottom line is dollars.

[jmj11]

I think I am suffering from a disillusionment with medicine in general, not in being a PA.  I am just completing my first month as an employee again (after being an owner). Since the transition, the demand for my services have gone through the roof (my old patients + all the new patients of the new system that I am in).  So, I have worked 10-hour+ days, no breaks and have billed out over 60K for Feb. I get 1/2 of collections. Yesterday the accountant notified me that almost nothing has come in for me because we are in high deductible season and virtually all claims, once rejected by the insurance, are turned over the patient. It may take months or a year for the patients to pay their share.

 

But yesterday I came back to work after being down with influenza (yes I did get a flu shot) and having to miss last Friday. I had been on my back for four days, until I got up to go to work yesterday. It was a very bad day for me. I felt horrible and had twenty very complex headache patients on my schedule. I took no pause for lunch and worked until seven PM. It was then I learned that my paycheck will be lean to nothing for the month (strict productivity). This was what I lived with for the past five years in the practice that I owned. Based on my prior production, we estimated that my income would be well over 150 K in this new position.  It may easily end up there by the end of the year, but for now, it seems like we have become the "coal miners" of  health care.  I don't mean PAs but all providers. We work very, very hard and then have to fight with insurance companies to get paid in this post-ACA high deductible, high paperwork-prior auth-denial, age.  Insurance executives don't work like this. My wife is a hospital administrator and their (the executives) job this afternoon, literally, is to taste wine for three hours to pick the best bottles for the annual fund-rasing gala. 

 

I spoke to a friend of mine a couple of weeks ago. She started a retail business about the time I started my practice five years ago. She went bankrupt and got out. She is now a realtor and LOVES it. I know that there is no easy business as my sister has been a realtor for thirty years. But this friend said that she has a very light schedule, that is not hectic. She loves showing houses AND she got paid more in the past month than in the past five years (our average house cost on my island is over $750K).

 

My point being, as much as I love caring for patients, I would leave medicine tomorrow if I could find a way to support myself. Medicine is NOT what it use to be . . . or maybe I'm not who I use to be.

[Acebecker]

JMJ - so sorry to hear about the misfortunes that you have had to deal with.  I am no psychiatrist, but this sounds like classic provider burnout to me. 

 

Everything you say is true, but we as a collective have not necessarily prized the tangible rewards as highly as the intangible ones.  Yes, the tangibles are awfully nice, but what about that college student who goes from Cs to As because you have taken care of their chronic daily headaches (hypothetical example - I'm willing to bet you have done this)?  Their benefit is your reward because you see the long term.  The people we help and the people we save are going to go on to do great things, for the most part.  And even if they become used car salesmen, their children will have a future because of us. 

 

I think burnout is essentially when you can no longer see outside of the trench that you're fighting from and you are so enwrapped in your day-to-day struggles to see beyond what is right in front of you. 

 

Perhaps you need some time off.  Maybe a reset will be of benefit - and hopefully this new job allows you a minute to get that.  I doubt that it's because you have changed.  It may be because medicine has changed.  But the one thing about medicine that has not changed is that we are still privileged with taking care of people.  Human beings put their minds and their brains (not literally) in your hands and you fix them.  There is nothing more motivating than that.

[GetMeOuttaThisMess]

I'm telling you folks, employer based healthcare where it is considered a bennie and there is no insurance filing is the way to go.

[Guest Paula]

I'm telling you folks, employer based healthcare where it is considered a bennie and there is no insurance filing is the way to go.

 

^^^^^^Where do we find these type of jobs?  They don't exist in small town America. 

[GetMeOuttaThisMess]

I found this one on Indeed.com (they had trouble finding a second provider even!).  Great situation thus far.  I did a very similar job with another governmental entity for over eight years until I had to leave to care for an elderly parent.  We had another local school district stop by several months after opening looking at doing the same thing.  The key with this one is you are NOT the PCP.

[Febrifuge]

I'm telling you folks, employer based healthcare where it is considered a bennie and there is no insurance filing is the way to go.

...except back before I switched careers, I was already bothered as a patient by the idea that my health coverage had to be linked to my employer. I had some meetings about a job like you describe in my organization, and really liked the idea of supporting and adding to the care people's PCPs were giving. It fell through after the employer announced that they wanted the in-house clinic to *be* the primary care.

 

It's one thing to have a clinic on-site so people can have BP monitored and get treated for sniffles and work injuries without having to take half a day off. But to pressure patients to go to a specific provider, even if that provider is me? No thank you. To me, that's just way too much control on the employer's side. Reminds me of the days when coal miners were paid in company scrip that could only be spent at the company store, and not in cash.

 

Besides, those clinics, in our system anyway, can be sooooo sloooooowwwww. Like, fewer than 30 patients a week. Maybe if I were writing a novel...

 

EDIT:

 

The key with this one is you are NOT the PCP.

Haha! So we do agree. Awesome. Yes, if you're not meant to be the PCP, and employees/ patients retain their free choice, then they can be pretty great. Like being a small-town GP of olden days.

[jmj11]

I'm telling you folks, employer based healthcare where it is considered a bennie and there is no insurance filing is the way to go.

I passed on a job like that (nearby oil refinery) a little over a year ago, when I was still trying to save my clinic. The appeal was as you have stated.

[True Anomaly]

^^^^^^Where do we find these type of jobs?  They don't exist in small town America. 

 

Oh they will be, and already are in some areas of the country.  As hospital systems combine and merge with outpatient services, it will not be hard in the future to find a large system that plants a clinic in a small town as a feeder to the larger hospital or even the tertiary-care center miles away.  Baylor Scott and White in Texas is very much embracing this model

[Febrifuge]

Oh, but it's not even just that. A small-town clinic as a feeder for a larger hospital system is cool, but the subject here is a clinic physically located at the employer site. So in your small town example, if 4000 people work for the Dell computer factory, there would be a clinic right there in one of the buildings on Dell's local campus. Instead of using sick time and driving to the clinic, an employee would just go talk to their boss, say "I'm coughing up green crud now, I'm gonna walk to Building B and get checked out."

 

It's a very cool option, provided it really is an option. The company saves a bundle, because of so much less lost work time, not to mention no billing of insurance plans whatsoever for services provided by the in-house clinic. It's obviously much more convenient to the employee. Add in spouses and kids of employees, and it can basically turn into a small-town clinic.

 

The drawbacks are a question of whatever lab or imaging you have or don't have, and how much the employer does or doesn't trust and respect you when you say the patient needs to go elsewhere for something.

[GetMeOuttaThisMess]

Oh, but it's not even just that. A small-town clinic as a feeder for a larger hospital system is cool, but the subject here is a clinic physically located at the employer site. So in your small town example, if 4000 people work for the Dell computer factory, there would be a clinic right there in one of the buildings on Dell's local campus. Instead of using sick time and driving to the clinic, an employee would just go talk to their boss, say "I'm coughing up green crud now, I'm gonna walk to Building B and get checked out."

 

It's a very cool option, provided it really is an option. The company saves a bundle, because of so much less lost work time, not to mention no billing of insurance plans whatsoever for services provided by the in-house clinic. It's obviously much more convenient to the employee. Add in spouses and kids of employees, and it can basically turn into a small-town clinic.

 

The drawbacks are a question of whatever lab or imaging you have or don't have, and how much the employer does or doesn't trust and respect you when you say the patient needs to go elsewhere for something.

And this is where I'm golden. Only snot/cough/rash/UTI. No imaging on site but multiple FM referral options tied to our SPs, and their mega network. No MS c/o or injuries.

[adru373]

I'd recommend trying your hand at a specialty before writing off the profession as a whole.  The things that irritate you are worse than usual in general medicine.  When you're a specialist, you often get more respect.  

Best of luck to you!

[Reality Check 2]

The idea that specialty providers "get more respect" is not OK.

 

There are multiple issues at play here - 

 

1. Being a PA

2. Primary Care vs specialty

3. Medical dynamics in the US

4. Patients as patients or "customers"

5. REALLY practicing medicine instead of caving in

6. Corporate Medicine (is evil)

 

25 yrs in and I have worked rural and urban and for corporate and for nonprofit CHC and for independent - both specialty and primary care.

 

Primary Care is the least respected, hardest SPECIALTY there is - you have to know a lot about a lot ALL OF THE TIME. Figuring out medical symptoms, polypharmacy, psychosocial, mental health and then being reimbursed absolute DIRT for a HUGE amount of work.

 

As long as the ART of medicine is treated as a business with customer satisfaction surveys and "happiness" based reimbursement - we are completely screwed.

 

Patients have responsibilities and they won't take them and we don't hold them up to them. It might hurt their feelings or make them score us poorly. Never mind that we could kill them with drugs or negligence. Never mind that only one singular person can decide to take the meds or stop smoking or pay attention to the physical symptom.

 

I am living this at this very moment in clinic and worried about my boss's reaction as much as I am worried about the patient doing stupid things.

 

Remember that I inherited these patients from an retiring old doc:

 

49 yr old female renal transplant patient from 20 years ago. On crappy immune drugs - Imuran and prednisone. Takes 3 controlled substances - Fioricet and Ambien - so butalbital, codeine and zolpidem.

 

Takes Ambien EVERY SINGLE NIGHT FOR YEARS. Goes through Fioricet 30 pills in 40 days. 

 

Point blank tells ME today that she is NOT GOING OFF OF THEM. As though she controls my prescriptions.

 

I ask her to investigate her insomnia from a WHY standpoint - not interested.

 

I tell her about her addictive medicines and that Fioricet is not for migraines (muscle tension) and that she is using too many too often - she replies - It is the only thing that has ever worked. Hasn't seen a neurologist in over 12 years.......................

 

I have a lady taking 3 controlled substances in a manner not consistent with recommendations and unwilling to investigate her issues on immunosuppressant drugs with a creatinine over 1.5 on one borrowed kidney who is at risk for all kinds of issues.

 

My ONLY concern is her safety and well being and longevity. 

 

Yet, I am seen as uncaring and unwilling to help unless I blindly give her controlled substances without concern and keep her "happy".

 

My response - BULLSHIT -- I am not going to continue these rx's without further investigation and she has to take responsibility for these issues as well and make behavior changes.

 

She doesn't "like" me anymore and will complain to my office manager and boss. Should that reflect badly on me as provider - absolutely not - ever.

 

Does it make me loathe primary care? YES. These are the moments when I don't want to do this anymore. 

 

I can honestly tell you, though, that specialty patients were often more entitled and more demanding and more skeptical and more of a gigantic pain in the butt.

 

I don't always "know best" or "know everything" but there are guidelines and evidence out there and I am trying to keep people safe and alive. 

 

So, the quandary of doing what is right vs doing what is convenient vs doing what makes people "happy". 

 

My biggest question is - how do we handle the US Medical System with its screwed up visions of patient satisfaction, profit and micromanaging providers?

 

The ART of medicine is flying out the window - I do not want it to take our profession with it.

[GetMeOuttaThisMess]

"I'm getting congested and this always turns into an ear infection so I need something now to prevent it." Me: "Sounds like eustachian dysfunction since your ears are normal in appearance at this time." Pt. has unhappy look and says she won't use a NETI pot. Fine. Rx for nasal steroid, antihistamine, and decongestant (three separate med co-pays). I gave pt. a quarter for the lobby medication gum ball machine so she could get an antibiotic gum ball (we're out of antibiotic suckers at present).

[sk732]

So many stupid people, not enough live ammo...ooops, inside voice.

 

SK

[Boatswain2PA]

So many stupid people, not enough live ammo...ooops, inside voice.

 

SK

Oh geeezzz.....now you're going to have half the people on this board asking if you have any firearms in the house!  :-)

 

 

My last shift, in my quasi-urban level II ED --- BIBA with "Weak and dizzy for 2 years".

 

"What brought you into the ED today?" - "I was writing something down and the letters all touched together."

"Is that normal for you?"  - "Yeah for a long time."

"So....why did you come into the ED today?"  -  "I was walking and bumped into a wall."

"Do you normally bump into walls?"  - "Yeah, pretty much all the time".

 

Guy is on oxycontin and percocet for orthopedic pain, and washes them down with vodka.

 

Work up negative except mildly elevated LFTs.  Two hours & 1 liter of NS later he is remarkably better cause the narcotics have worn off a bit.

 

That's a couple grand of our tax money wasted (Medicaid of course)

[UpRegulated]

Oh geeezzz.....now you're going to have half the people on this board asking if you have any firearms in the house!  :-)

 

:) So...do you????

[UpRegulated]

The idea that specialty providers "get more respect" is not OK.

 

There are multiple issues at play here - 

 

1. Being a PA

2. Primary Care vs specialty

3. Medical dynamics in the US

4. Patients as patients or "customers"

5. REALLY practicing medicine instead of caving in

6. Corporate Medicine (is evil)

 

25 yrs in and I have worked rural and urban and for corporate and for nonprofit CHC and for independent - both specialty and primary care.

 

Primary Care is the least respected, hardest SPECIALTY there is - you have to know a lot about a lot ALL OF THE TIME. Figuring out medical symptoms, polypharmacy, psychosocial, mental health and then being reimbursed absolute DIRT for a HUGE amount of work.

 

As long as the ART of medicine is treated as a business with customer satisfaction surveys and "happiness" based reimbursement - we are completely screwed.

 

Patients have responsibilities and they won't take them and we don't hold them up to them. It might hurt their feelings or make them score us poorly. Never mind that we could kill them with drugs or negligence. Never mind that only one singular person can decide to take the meds or stop smoking or pay attention to the physical symptom.

 

I am living this at this very moment in clinic and worried about my boss's reaction as much as I am worried about the patient doing stupid things.

 

Remember that I inherited these patients from an retiring old doc:

 

49 yr old female renal transplant patient from 20 years ago. On crappy immune drugs - Imuran and prednisone. Takes 3 controlled substances - Fioricet and Ambien - so butalbital, codeine and zolpidem.

 

Takes Ambien EVERY SINGLE NIGHT FOR YEARS. Goes through Fioricet 30 pills in 40 days. 

 

Point blank tells ME today that she is NOT GOING OFF OF THEM. As though she controls my prescriptions.

 

I ask her to investigate her insomnia from a WHY standpoint - not interested.

 

I tell her about her addictive medicines and that Fioricet is not for migraines (muscle tension) and that she is using too many too often - she replies - It is the only thing that has ever worked. Hasn't seen a neurologist in over 12 years.......................

 

I have a lady taking 3 controlled substances in a manner not consistent with recommendations and unwilling to investigate her issues on immunosuppressant drugs with a creatinine over 1.5 on one borrowed kidney who is at risk for all kinds of issues.

 

My ONLY concern is her safety and well being and longevity. 

 

Yet, I am seen as uncaring and unwilling to help unless I blindly give her controlled substances without concern and keep her "happy".

 

My response - BULLSHIT -- I am not going to continue these rx's without further investigation and she has to take responsibility for these issues as well and make behavior changes.

 

She doesn't "like" me anymore and will complain to my office manager and boss. Should that reflect badly on me as provider - absolutely not - ever.

 

Does it make me loathe primary care? YES. These are the moments when I don't want to do this anymore. 

 

I can honestly tell you, though, that specialty patients were often more entitled and more demanding and more skeptical and more of a gigantic pain in the butt.

 

I don't always "know best" or "know everything" but there are guidelines and evidence out there and I am trying to keep people safe and alive. 

 

So, the quandary of doing what is right vs doing what is convenient vs doing what makes people "happy". 

 

My biggest question is - how do we handle the US Medical System with its screwed up visions of patient satisfaction, profit and micromanaging providers?

 

The ART of medicine is flying out the window - I do not want it to take our profession with it.

 

'Nother perspective.  One that reinforces yours though, to a point.

 

I worked for 15-ish years in a corporate environment. Earned the corner office.  Had a "yuge" staff (Trump joke there).  Made lots of cash. More cash in my best year in corporate than what I make now, in fact.  Worked 8-6ish, 5 days a week with occasional travel. No call. Lots of vacation and all the benefits.  Then spent 6+ years training to become an NP after walking away from that white-collar office job.  Now a year out from finally graduating.  Already getting worn out from the non-compliant.  The herbalists hippies.  The anti-vaccers. The television-commercial-watching-that-medicine-will-kill-me-tin-foil-hat-wearers (a statin!!!!! Xarelto!!!!!).  The narc seekers.

 

Here's my thing.  Earning decent money IS NEVER EASY.  No matter whether you are an NP, a PA, a CEO, a realtor, a car salesman, a banker, an MD, whatever. There's a reason we are paid what we are paid.  It. Isn't. Easy.

 

Given that, I don't mind getting paid exceptionally well (compared to most) to explain how vaccines don't cause autism or that statins are quite safe, while occasionally giving out amoxicillin to the kid of a parent who insists on abx treatment when their kid doesn't need it.

[sk732]

Oh geeezzz.....now you're going to have half the people on this board asking if you have any firearms in the house!  :-)

 

 

 

:) So...do you????

 

To be frank, no I don't...I do have a fairly powerful crossbow, but it's not near as fast loading as I'd need to go US Postal on people (Canadian Postal just go on strike then beat up the scabs crossing the piquet lines).  I am in the Canadian Military still - a reservist - so there is a reason we don't have enough live ammo...all the stupid people make sure we don't have enough to make sure we can't light THEM up with it.

 

SK

[Evolute]

To be frank, no I don't...I do have a fairly powerful crossbow, but it's not near as fast loading as I'd need to go US Postal on people (Canadian Postal just go on strike then beat up the scabs crossing the piquet lines).  I am in the Canadian Military still - a reservist - so there is a reason we don't have enough live ammo...all the stupid people make sure we don't have enough to make sure we can't light THEM up with it.

 

SK

 

Canada has a military?

[EMEDPA]

Canada has a military?

you know, big hats, red uniforms, horses, gravy on everything....wait, I may have that wrong....:)

[sk732]

Canada has a military?

 

H

A

H

A

 

Yeah...the ones that helped burn down the White House in the War of 1812, took Vimy Ridge in 1917, singlehandedly advanced farther into France on D-Day than any Allied forces, helped stop a Chinese offensive in Korea in 1951, that in 2002 had the world's longest sniper kill in Afghanistan, helped lay the shoe leather to the Taliban and other asshats in the same place for a number of years AND ran the multinational hospital there up until a few years ago and just recently pulled back from putting bombs on ISIL.

 

After nearly thirty years of service, I find that joke in very poor taste.

 

SK  

[Boatswain2PA]

H

A

H

A

 

Yeah...the ones that helped burn down the White House in the War of 1812, took Vimy Ridge in 1917, singlehandedly advanced farther into France on D-Day than any Allied forces, helped stop a Chinese offensive in Korea in 1951, that in 2002 had the world's longest sniper kill in Afghanistan, helped lay the shoe leather to the Taliban and other asshats in the same place for a number of years AND ran the multinational hospital there up until a few years ago and just recently pulled back from putting bombs on ISIL.

 

After nearly thirty years of service, I find that joke in very poor taste.

 

SK  

Lighten up Francis.....never met anyone in uniform who didn't pick on someone wearing a different color uniform.

 

Look at the bright side, at least you weren't in the Navy!