Not a New PA, but still inexperienced. How do I fix this?

[PitouPAC]

Hello, 

 

I am new to this forum (today), but I have been lurking for awhile now

 

I am in a position now, where I feel inferior to other PAs, including some of you guys on the forum

I just feel like I do not have the experience or clinical knowledge that a PA that has been practicing for 3.5 years should have.

 

Granted, my first job wasn't the best (for me):

 

I worked x 1 year in an allergy/asthma/immunology practice, became bored ( I didn't learn much and was essentially a glorified scribe) so I left.

My second job was much better, privately owned Fam. Medicine Clinic x2.5 years. I was paid about $30K more per year and had way more autonomy.  I did gain more experience with the routine things, DM, HTN, cholesterol etc.  But we very rarely did procedures and the docs were too busy to teach me the few that we did. I also didn't have much experience with EKGs 

 

So here I am 3.5 years out with no procedural experience and just basic family medicine experience and weak EKG interpretation.  I also have a bachelor's and am finding it somewhat difficult to find PA jobs in TX with a bachelor's degree. ( to clarify, i quit my fam. med job because i felt that i had hit a plateau in terms of gaining experience and we were too busy as a clinic for my SP to mentor/teach me any new skills).   I try to read journals and reference texts, which helps. But I am a visual learner and if I don't have clinical experience/application with what I read, I tend to forget the material.

 

I'm currently frustrated and in need of advice, if there's any to give.

many thanks

[Boatswain2PA]

Amal Matu's "EKGs for the Emergency Physician" Vol 1 & 2. Go through that a few times and you'll be competent on EKGs.

Did you quit the FP job without having another job lined up??

[PitouPAC]

Hi, thanks for your response.

 

No, I had (or so I thought) a locum position.  It was confirmed and I was to start in December, but the client cancelled the assignment offer at the last minute due to billing issues with their current locum provider.

 

So unfortunately, I am now searching for employment again. 

[GetMeOuttaThisMess]

PA training should prepare you with basic resources, enough so as to allow you to know where to look further for greater depth in understanding topics of interest. Most PCPs I would venture can't accurately assess electrocardiograms in depth. If you were trained to comfortably treat the most common of conditions then I would say that they did their job. What procedures are you wanting to perform that you don't feel you were trained on? Take specific training classes as part of your CME allowance in areas of interest. When you're hired on and experienced they shouldn't have to walk one through different scenarios. Its a constant learning process. Bet most FM docs couldn't tell you criteria for Brugada Sx without looking it up. Try IR if you want procedures, plus they'll have to train you.

[EMEDPA]

Also , consider a residency in field of choice

[Boatswain2PA]

Wanna learn basics of procedures?  Start with youtube.

[ventana]

procedures - first you have to be in a job that does them - think UC or ER or Surgery or pain management 

Knowledge base - don't be to hard on yourself - you are in the perfect position - you have a good grasp of IM (I hope anyways) and now are HIGHLY marketable to specialty medicine.  I did 5 years in a small PCP/UC/Occ Health then did about one year each in IR, Chronic Pain, ER with per diem position in hospital in addition.  Then realized I am an internist at heart and returned to my love.  In doing this I gained a HUGE amount of real world knowledge of these other fields and made myself a better PA. 

 

You might consider a residency - but that points you in one direction

 

Or just look for a job locally that sounds "fun" and commit to it for a year and see.

I honestly wish hospitals had a "coverage PA" or something like that which would send you through many different departments for this learning curve - while paying you real money - ie 100k/year with a reasonable schedule

Everyone wins.....

 

 

you have the world at you feet - take advantage of it.....

(I would shy away from traveling, as this can be fraught with challenges - as you have learned - instead approach local hospital HR departments directly...)

[GetMeOuttaThisMess]

procedures - first you have to be in a job that does them - think UC or ER or Surgery or pain management 

Knowledge base - don't be to hard on yourself - you are in the perfect position - you have a good grasp of IM (I hope anyways) and now are HIGHLY marketable to specialty medicine.  I did 5 years in a small PCP/UC/Occ Health then did about one year each in IR, Chronic Pain, ER with per diem position in hospital in addition.  Then realized I am an internist at heart and returned to my love.  In doing this I gained a HUGE amount of real world knowledge of these other fields and made myself a better PA. 

 

You might consider a residency - but that points you in one direction

 

Or just look for a job locally that sounds "fun" and commit to it for a year and see.

I honestly wish hospitals had a "coverage PA" or something like that which would send you through many different departments for this learning curve - while paying you real money - ie 100k/year with a reasonable schedule

Everyone wins.....

 

 

you have the world at you feet - take advantage of it.....

(I would shy away from traveling, as this can be fraught with challenges - as you have learned - instead approach local hospital HR departments directly...)

 

 

Bless you for being an "internist at heart".  If I were younger, knew what I know now, and had it to do over, I'd be all over sticking needles in folks or being the PA equivalent of YouTube "Dr. Pimple Popper".  I'd almost do the latter for free.

[PitouPAC]

Hello, all thanks for your input.

 

The private practice I worked with 3 other MDs.  I asked for their opinion on my performance at various times throughout working there, and they all said that I did an outstanding job and were please with my performance.

 

I think my problem is comparing myself to other PAs, specifically my former classmates.  Everyone, but me seems to have found the "perfect" job. 

I would really love to do urgent care and/or ER, but a few of the local UCs/ERs only want PAs with prior ER/UC experience or a Master's Degree.  

I'm looking in to getting my Master's from an online school-Touro was one of them.

 

I know that I can sometimes be too hard on myself, but i doesn't help that my previous SP( the allergist) told me that I "didn't know anything" and that I reminded him of his 5 year old daughter.  I also wasn't  allowed  to do anything aside from signing his charts. What he said has stuck with me and I feel like Im still trying to prove him wrong. 

[PitouPAC]

to GetMeOuttaThisMess- I wasn't necessarily looking for my SP to re-teach me PA school, just offer some guidance or pearls of wisdom from his experience.  Some things that I was taught in school, he doesn't do.  So I wanted to know why he prefers X over Y.  I haven't thought about IR, but it definitely sounds like something that would interest me.  Thank you. 

 

Boatswain2- thanks, i look at a lot of youtube.  it definitely helps.

 

EMEDPA/Ventana- there is a residency program offered by Texas Childrens Hospital that actually does take you through their different specialties and sub specialties over the course of about a year, but they too require a Master's Degree.

[3GeronimoPA]

If you're willing to move the world is at your fingertips.  PM me where you are looking to work.  With a Bachelor's you are still employable.  Procedural experience comes with experience.  If I were hiring a PA for a procedure heavy job and willing to entertain new grads, I'd rather have someone with 3+ years of experience in medicine that needs to be taught procedures than I would a new grad that needed to be taught procedures.  Human Resources offices scrutinze degrees but you just need to be aggressive about getting yourself an interview.

 

Don't compare yourself to your peers as far as they can do this or that.  Do however compare yourself in happiness because an unhappy PA is a PA who hasn't put out enough job applications.  Our profession is too broad for that.  I have classmates who are providing medicine to troops in Syria and classmates who have done occupational medicine for 6+ years and failed their PANRE (twice).  My study buddy from PA school went to DO school and is an anesthesia resident.  I'm just a lowly transitioning military PA working Trauma at our Level II.  Sure, I can do procedures all day, chest tubes, perc trachs, and sew like Isaac Singer himself, but I don't know the first thing about JNC7, 8, 9 10 or whatever you're on.  I don't know anything about cholesterol except when the lab puts a big "H" next to the LDL line on my Trauma ICU patient that it's a risk factor for heart disease.  When I ask people about SI/HI I'm really asking them if they need chemical and physical restraints until someone with the clinical sense to deal with behavioral stuff can come talk them off the ledge.  Minus some ICU work and procedures, I'm a blunt instrument of medicine but I love my job.  We come with all sorts of skills and family medicine is a super important skill.

 

I met a PA the other day who was one of the first 5 people in the world to ever do endoscopic vein harvesting.  She was trained up North and then went around the globe training surgeons the technique.  Now she does something completely different.  I'll tell you what I was once told by an ER doc precepting me, "there are tons of you PA types coming out of the woodwork.  Find your niche and master it".  If family medicine wasn't your niche, that's perfect.  It's a great background to go into anything you want to do.  PM me that info and I'll send you some jobs I can shake down.  Also, what does your Resume/CV look like?

[electric130]

I totally agree with the advice above.  I really think you are being too hard on yourself.  Being able to manage the basics of family medicine is a huge skill and not to be discounted.  Big admission here....I am 14 years in to practicing and have not done procedures or read an EKG for the last 10 years.  (except for taking panre)...  I would honestly suck big time at both of these.  I did do ER and UC very part time for a few years when I first was out of school.  Honestly I did not enjoy either, have happily settled into a specialty and that is that.  I know my specialty very well, have physicians that call to talk to me about their patients with GI issues and enjoy my large base of knowledge in this field.    This is just to say that being really good at one area of medicine is ok.... At one point I was able to read EKGs and do procedures , very basically but at this point I am not using that knowledge at all in daily practice.

 

If you want to be able to do more procedures see if you can get a side gig at a UC or ER, just to get your foot in the door.  If you want more experience in an area of medicine it can be done.  I am honestly at a point that I want to finish my career in my specialty, I do not have any interest in re learning those things, but you are much earlier in your career and have plenty of time to branch out and improve your skill set.

[BruceBanner]

Wanna learn basics of procedures?  Start with youtube.

 

 

Yep, not that I'd ever tell patients, but I've taught myself all sorts of office procedures with YouTube and a textbook. It's controlled "winging it". Dont be scared, just do it.

 

And I'm 4.5 years out and still dumb with EKGs. They just arent a big part of my job, so I rely on a combination of the computer interpretation, my own limited knowledge, and my attending if I'm unsure.

[3GeronimoPA]

Yep, not that I'd ever tell patients, but I've taught myself all sorts of office procedures with YouTube and a textbook. It's controlled "winging it". Dont be scared, just do it.

 

And I'm 4.5 years out and still dumb with EKGs. They just arent a big part of my job, so I rely on a combination of the computer interpretation, my own limited knowledge, and my attending if I'm unsure.

Yeah.  With a procedure book and youtube, you can get good enough but if you have a peer that has experience you can have them join you just to make sure things go smooth.  The textbook and youtube often forget to tell you how to get yourself out of a jam if you get into one.  If you can add some controls and back stops for yourself it'll be safer for your patient.

 

As far as the EKGs, if you aren't going into a job that requires you to read them, ACLS is about as deep as you need to go.  If you really want to get into EKGs, look no further than Garcia's Art of Interpretation (not the introduction but the actual book).  It has a Green, Yellow, and Red level of knowledge.  Read them in that order.  If you make it through yellow, the only people that will stump you at EKGs are people who work with EKGs on a daily basis and have mastered the art of it.  BTW, Dale Dubin is a pervert.  Don't support him by using his book.

[PitouPAC]

3GeronimoPA- thanks, I did PM you

ElectricPA- thanks for your advice

 

I don't mind being in a speciality at all. I just want to find a job that I genuinely like.  My Fam. Med job wasn't horrible and I didn't hate it, but I felt unfulfilled.  We also had a very high employee turnover in my time there ( 4 office managers, about 10 front desk employees, and I had 4 different MAs) and with each OM things got worse and worse. 

 

For now, I want to do locums to get a more experience in different areas of medicine and if I like it, I will stay. 

[GetMeOuttaThisMess]

Wait a sec.; if you were employed here in Texas how did you not have the opportunity to pic his/her brain during your mandatory monthly TMB chart review meetings (I understand about the procedures since none were apparently presented to perform)?  I present three case reports/abstract reviews with my two SP's each month just for comments and to keep us all current.  Please don't take my comments as critical.  If I'm not in a situation to utilize procedures then I don't fret about it.  I have a feeling that you're somewhat like me; the driving force is to not reflect poorly to your docs or other peers.

 

Addendum:  The reason that I ask about the monthly meeting is that I don't know how others have their meetings set up here in the state.  We're quite informal since the docs are off-site and so we meet at a local restaurant during lunch and review any pressing matters (hard to have with a snot/cough clinic), ask how their network/practice handles certain situations (ex.-baseline LFTs on pt's before initiating oral anti-fungal medication), and any specific pt. scenarios that might have cropped up since the last meeting (I always text same day with any issues so that they can review EMR from their location if need be).

 

Addendum #2:  I can relate to the BS only degree and it limiting doors opening for you.  With regard to an online MS, check out UTMB-Galveston and the cost of their program.  A couple of years ago it looked to be less than $5K.

[overthehorizen]

First, agree with comments posted about youtube training for procedures. Finding opportunities to learn these is a challenge for everyone so don't despair. Keep building relationships with people who could help you out. If your practice is part of a larger group that has other services (ER or ICU), see if there is a fellow PA who would teach you at night. Tell him you could come in any time to work with him or her to get skill training. When I was in PA school on a women's health rotation, I met a male 2nd year OB/GYN resident. He told me that he knew that OB/GYN admission would be tough being a male so when he was in medical school, he asked the ob/gyn residents to call him at home at ANY TIME so he could come in for L&D opportunities. When he got into his residency, he already had 30 deliveries that he was assisting on. Not bad. 

 

As far as getting your SP to train, I enjoy working with physicians who are team players who want to share their experience. However, I believe that the best experience comes from 1. seeing as many patients as you possibly can and 2. studying the right material.

 

People will argue here that you want to limit your patients per hour. In the long run, that is true because you don't want to burn out. When you are in the first few early years, I feel you should jump on every case you can find and work it. Even if you are tangentially on the case, you  can still learn. The studying part is my opinion is more ambitious because I believe PA school sucks. After PA school, I started studying things that were covered in MD programs that were never covered in PA programs. I completed over one thousand CME hours in one year alone (Category I). I feel that studying a minimum of two to four hours daily in the first three to five years is a minimum standard to see yourself progress intellectually. It won't do much for you professionally because the NPs will do little if anything and still progress past you. If you love medicine, just do it for that reason alone. 

[PitouPAC]

GetMeOuttaThis MEss- my SP was on site almost every time I am there with the exception of when he is vacation a few times a year. We literally worked less than 5ft from each other in the same office.

 

Therefore chart review etc were kinda almost done daily.  When I had questions about patients, I asked and he would answer and then review/sign that chart. 

 

And no I don't take your comments as too critical.  And i'll def. look in to UTMB-Galv. Thanks

[PitouPAC]

Over the horizon and others: the reason I am concerned about procedures is because the primary care/Fam med positions I have been applying to want providers who can administer vaccines ( haven't done so since college), suture, splint, some even asked for casting ( I only did this once at a conference), toe nail removal, intra-articular injections.  I have familiarity with these, but have not performed them on a regular basis. 

 

i had tried the studying at home part.  But I became overwhelmed after a while.  My first job was at an allergy practice where we were "busy" with 7 patients on the schedule.  Then the Fam. Med job, I had to see upwards of 25 ppd alone(that was the goal I was told to try to meet daily, of course the more the merrier), sometimes more. And I also worked 2 Saturdays month, so I think I did burnout a bit.  And I always had a lot of charts to finish at the end of the day and had to start working at home to stay on top of them, so I felt like I never had any free time.  When I voiced my concerns, nothing was done about it. That and other things are what pushed me to finally leave.

 

However, I do feel better and have been using my "time off" to study my weak areas and look up procedures on YT.  And I finally have an interview on Tuesday, so hopefully all goes well!!

 

Many thanks to you all and Happy New Year!!!

[GetMeOuttaThisMess]

GetMeOuttaThis MEss- my SP was on site almost every time I am there with the exception of when he is vacation a few times a year. We literally worked less than 5ft from each other in the same office.

 

Therefore chart review etc were kinda almost done daily.  When I had questions about patients, I asked and he would answer and then review/sign that chart. 

 

And no I don't take your comments as too critical.  And i'll def. look in to UTMB-Galv. Thanks

 

 

Just to make sure that all are on the same page, make sure you guys have a formal documentation instrument in place should the TMB/TPAB come calling.  It has to show monthly discussion topics, etc..  TAPA used to have an example posted at their website showing how this can be done.

[Guest Paula]

To Cass:

 

The allergist was a dipstick for saying that to you, especially since you were "used" as a scribe.  Dispense with the words that hurt you and soldier on.  

 

I once had a physician tell me being a PA was like being a used car salesman.  While that  stuck with me for a while it didn't paralyze me either.  Just another opinion from an ill informed physician (who later lost his job for an undisclosed reason and had to move out of state, tee hee!)

 

Find something you are passionate about and all will be well with your soul.

[tmac12]

Never heard of a PA with just a bachelors. I always thought you need a masters to be and work as a Physician assistant? Btw how much did you make during your first job which was a glorified scribe at?

[3GeronimoPA]

Never heard of a PA with just a bachelors. I always thought you need a masters to be and work as a Physician assistant? Btw how much did you make during your first job which was a glorified scribe at?

There used to be PAs with Associates Degrees.  The Master's push from Bachelor's was to put more emphasis on research/writing and of course, the degree creep and competing for titles vs. NPs.  You've likely interacted with PAs with Bachelor's Degrees and didn't realize it because they are clinically no different (at least in my eyes). 

[OneDayAPA_Maybe]

Never heard of a PA with just a bachelors. I always thought you need a masters to be and work as a Physician assistant? Btw how much did you make during your first job which was a glorified scribe at?

 

There used to be PAs with Associates Degrees.  The Master's push from Bachelor's was to put more emphasis on research/writing and of course, the degree creep and competing for titles vs. NPs.  You've likely interacted with PAs with Bachelor's Degrees and didn't realize it because they are clinically no different (at least in my eyes). 

 

As mentioned above, you probably just didn't realize a PA you worked with had a Bachelor's. The hospital I used to work for had PA's who only had Bachelor's, but 25+ years of experience. You see a lot of schools offering bridge programs for Bachelor's to Master's. 

[rev ronin]

I completed over one thousand CME hours in one year alone (Category I). I feel that studying a minimum of two to four hours daily in the first three to five years is a minimum standard to see yourself progress intellectually.

Heh.  Here I thought I was overdoing it with ~150-200 Cat I CME hours per cycle.  I do wish there was something to distinguish those of us who do that much from those who do the minimum legally required.