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PAofPlenty

Concerns with First Job

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Hey Everyone! 

New graduate with 6 months experience in inpatient psychiatry.  Hospital wanted a PA to "assist in overflow areas" child pysch, emergency medicine psych, consult and liaison psych,  geri psych, etc. Agreed to the job because I was told "varied scope of practice" and "we are in the business of teaching and training people" (Fiancee is a resident at said program and I know that was a factor in my employment).

Took the job and after a 2 week shadowing period was placed into the consult and liaison service (a toxic and moral injurious prone service that is notoriously detested and openly called "malignant") were I have been since then. Residents rotate in and out each month. Residents see new psychiatric consults and I take the (mostly) delirium follow ups and suicidal/homicidal (i.e. legal hold) patients. 

I asked my supervising physician 3 months ago about "varying my scope" of practice, but was told to stay put for the meanwhile. Salary $90,000 (M-F 8:30 - 5:00 pm with average of 6 patients/day. No weekend and no call). My problem is that my work environment is toxic (other hospital services do not respect us, psychiatric patients routinely neglected and not given the medical standard of care, morally injured supervising doctor), medical-legal dispositions are provided by not reliable social workers/risk management/case management, and I feel that I am not learning new information nor seeing different types of patients. I feel my medical knowledge is stagnating and that I am not advancing in my field.

I began applying to other jobs and the VA offered me a surgical PA position. I am guessing it will finalize with a contract in approximately 3-4 months. My current contract requires me to give a 90 day notice. 

Should I try to stick this out until I get a solid contract offer from the VA? I am a former veteran and loved surgery (honored my rotation and enjoy the service). I know the VA is far from perfect, but I regularly come home wondering if my notes/discharge planing/social work is going to cost me my license due to medical-legal grey issues. I document to hell-and-back, but with psychiatric patients and legal status' involved, I feel overwhelmed and undertrained to navigate the some-times very complex patients and mental health laws. 

Perhaps I am being too dramatic, but a few days ago, I was told by my attending to downgrade a patient's legal status to allow for them to get a surgery (which would not have been possible with their current legal status). I protested and transferred care over to that attending (and documented).  However, that situation left a foul taste in my mouth (they told me to write medical-legal words in my note that I did not know what they meant...and come to find out..they didn't quite know either as the social worker was ill-informed).

It sounds childish, but I like the positives of this job. However, the negatives are becoming incredibly glaring and feel that it would be better to leave with 9 months at my first job than continue in this place and try to milk out a year. I have been applying to other jobs, but feel that my resume screams "fired after 6 months." I feel like I was given the "bait-and-switch" and only now am I finding my voice as a new graduate.

Thoughts? 

Edited by PAofPlenty

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Keep options open until you have a formal contract, and start date, with VA.  That means keep sludging, AND keep looking for other jobs.

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man...tough spot. I don't envy you. 

Life is too short to keep a job that makes you miserable. You have put yourself at risk by documenting things that you don't understand even if your intent was good. The fact that such behavior is not only condone but encouraged should be a huge red flag. You are in legal jeopardy. Your mental and emotional health are in jeopardy.

You need to keep the lights on while you look but looking is what you should be doing. As soon as you have some place to go...be gone. As for serving your notice or not.... crap shoot. It is unlikely they will do anything about it and there is a good argument they failed to keep their side of the deal. I don't think anyone can give you great advice in that regard.

Find a place to go...and go.

As for the VA..it isn't for everyone but I have known lots of people over the years who loved it so I'd be inclined to see for myself if I were you.

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DO NOT rely on the VA coming through with an offer.... they are historically slow

I have tried for almost 17 years (Yup YEARS) to get hired

they offer a 50% pay cut

stay where you are at.... so much of the time I think new grads are overwhelmed and unable to see the positives of a position.  Branch out a little bit - see some other patients, do it on your own, wander around, ask questions.

NEVER change you notes based on someone telling you something

NEVER NEVER NEVER put legal words in you notes that you do not understand - EVER - you will be burned, hung out to dry, and eaten alive for this.  This is a tough lesson, but it is YOUR note and no one elses - be kind to your attending - he or she can sink you and the way of the world they are higher on the food chain... accept it, defer to them on medical decisions you disagree with (this can come in handy sometimes when you play it right) Document that you consulted with your doc and they wanted to do XYZ.  If anyone besides your doc tells you alter, edit or change you note - politely answer "no thank you"    I really mean it simply say that even it does not make sense in the conversation.  You are not to be bullied or influenced.  Period.

 

So hang out, collect a pay check, get to a year of work, still do the VA application process, hope you get that and you can simply move on painlessly - BUT DO NOT quit with out something lined up.  Meaning sign contract that outlines start date and pay irrelevant to credentialing process.  

 

Do you have your X number?  Ask to get sent to a CME to get it - it directly applies to your field, and gets you 3 days out, and a valuable knowledge base and an X number.  go to CME, call in sick, take your vacation, show up and leave on time, read a lot on shift.... you get the idea.  create your own realm of happiness while you look for something else.

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For the record, I have never written anything in my notes that I did not understand. When I did not understand, I have always written "Per Dr. Anonymous, the following recommendation were made. Leave final psychiatric consults at the discretion of the primary medical team responsible for the patient's disposition and this provider's attending physician. Patient was staffed, discussed and had recommendations made with Dr. "

The situation that irked me particularly raw arose last week. A social worker was telling my supervising doctor misleading information and the doctor believed her.  That same doctor told me to include that into my note. I suspected the information was wrong, did not write it, and wrote in my note that "This provider is transferring the care of patient to Doctor on this date at this time." My doctor proceeded and later was told by another senior psychiatrist on staff that social worker information was completely wrong and needed to be revised. It felt wrong "abandoning ship" on my doctor but my gut screamed and I listened to it and it saved me.

It was uncovered that the social worker was wrong but (thankfully) my note steered clear of the cluster fuck. It just made me wonder if one of my supervising doctors knew what he was doing. I work with 3 doctors who each are on-service for 1 week then rotate off. I was taken aback that this doctor would trust a social worker who was incorrect. The other 2 doctors steer clear of said social worker. 

As for rounding quickly and getting out ASAP, the whole psychiatric consult team rounds at noon to discuss all patients as a group. Most of the time I am done by 2:30 pm and there have been days were I see only 1or 2 follow-up patients. I know the pay is low, but I figured having inpatient psych experience on a resume would have helped across numerous services. 

I would like to thank everyone for their honest responses. I have always known never to place information into a chart that was not accurate nor words that were not understood by me. I will continue to apply for jobs, keep my head down, and defer to my provider in treatment plans that I don't understand/agree with.

Edited by PAofPlenty

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