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Am I a failure as a PA / In the wrong line of work?

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Sorry all for what might be a rant.  Just trying to figure out if my career in medicine is just a failed fantasy.

Unfortunately, my school clinicals were pretty crappy and disorganized,  from the top down, due to a combination of factors...didn't learn a whole lot about the business of medicine.

After graduating and spending a long while in an inane diagnostics specialty (an MA could do my job), I made the jump to emergency medicine.

Worked in a busy, transitioning inner-city ER, and It was a complete, utter shit-show.  Horrible leadership, no mentoring, no help for the other PAs, overall toxic ER.  After a while, I was asked to leave because I just wasn't "catching on"...like, yeah, of course I wasn't, as somehow 4 weeks during school wasn't enough to fully engrave the entirety of emergency care to into my brain.  But I digress.  But the abuse was...exceptional, and the trauma remains.

I had a brief good run early in Urgent Care, with a very supportive doc, and a moderately paced practice that had, max, 3 patients per hour on a busy day...4 per hour only on an insane full-moon, exceptionally rare occasion.  Unfortunately, the place downsized one location, and I was the last in, so first out.

Since then, I have been struggling.  The PTSD from my time in the ER has never faded, and has bled through into my work.   My last job was a monster of a corporate behemoth, with about 30-40 demanding, wealthy, multiply-comorbid, talkative, "oh yeah I forgot to mention this chronic problem" patients per 12 hour shift, with a consistent 3-4 patient per hour load for those 12 hours, with back-to-back 12 hour breakless, lunch-less, bathroomless shifts....and a whole cast of backstabbing, lie-to-your-face, cold-hearted ER docs staffing the place.   It did not go well, and I was unceremoniously thrown out the door after a few months for failure to adapt to the kiss-ass environment, while solving all of the patient's problems and managing all their comorbidities and referring them out to all our associated providers, every shift, all by myself, within a sufficient time...and failure to avoid asking the supervising docs an occasional question on a complex patient. They made clear I was there to sink or swim, not learn, and that I was excess weight they were glad to be rid of.

Now...I feel like a failure.   I failed to hack the ER.   So many PAs can manage it seamlessly..yet I was an utter failure at emergency medicine.  And Urgent care? my peers are like "sure, 6 patients an hour for 12 hours is a breeze, why can't you get your shit together and handle 4?   

As I've long passed my high-speed teens, and after the abuse in the ER, I've slowed. I want to help the patients, form a bond, address their needs, and not have to shove them out the door because they are slowing me down.  I have decision anxiety, comorbidity anxiety, time anxiety...all borne of an unguided, mentorless career.  I hate the rush of 10 minutes to see a patient, discuss their (usually) complex situation with my sup, make a plan, answer their myriad questions and "oh also"s, push them out the door, and fully document and lock that chart...and do so, hour after hour after hour.   This is not why I got into medicine.    Yet I am aware that ALL my peers in Urgent Care and the ER are seeing 4 patients per hour with ease, juggling 8 rooms or beds at a time, and have the equivalent of pure cocaine running though their veins and adderall coursing through their brain...perfect recall, no questions, all knowledge, pure confidence, and endless energy.   I feel like an utter failure for feeling like, "heck, why can't I just see 2-3 patients per hour and actually practice humanistic medicine." I feel like a failure at Urgent Care, at Emergency medicine, and a failure as PA...as this is the business we are in, and I just can't hack it at the speeds necessary to stay hired.      I'm not a dumb guy, and when I am given plenty of time, I am an excellent diagnostician and planner, technically adept, and am great with the patients on a personal level...but this is not medicine anymore. No one wants to hire someone to see patients at 2-3 an hour.

I feel like....maybe it's time to apply to Home Depot, or get my CDL truck driving license...somewhere with few decisions, somewhere I can excel, and not have to live with the way medicine is today.

Sorry for the rant.  Thanks for listening.

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You are normal.  

 

Sounds like your jobs have stunk at this point.  

 

Dont get discouraged.  Try primary care.  You have time to read up and figure it out.  Max 16 pts in a 8 hr day (otherwise it is just assembly line)

 

 

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No two jobs are exactly the same. Find one that fits for you.

Be adaptable but don't let the turkeys you may meet along the way convince you that you're the problem.

Sent from my XT1254 using Tapatalk

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Maybe you just need to try a different speciality of medicine. 

Like Ventana was saying, I think primary care would be great for you, especially if you want to sit down and really spend time with patients. It's not so fast paced. Also consider specializing if there is a particular field you're drawn to.

I've worked as a PA for 5 years (mostly EM) and still think I suck. I just take everyday as a learning day. 

I don't think you should give up yet.

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I'm not exactly sure of your timeline- you had a bad experience in the ed, tried urgent care, then went back to the ed?  You want to form long lasting relationships with patients?  Your perceived failures at two aspects of care are leading you to abandon everything?

Two ideas- look for a primary care job that will slowly ease you into a full schedule.

and some counseling wouldn't hurt either.

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Totally normal post and experience.  I would look to a sub specialty you find interesting, learn everything there is to know about it, get in with a good doc and be a rockstar at your pace.  ER and Urgent Care are two of the worst places for a new grad to go especially if they are not helping you.  Log some years in a specialty.  I hear psych is paying a lot more these days?  Just a thought.

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This kind of thing happens more than you might imagine. There are lots of bad jobs and employers, there are lots of OK jobs you may not be a good fit for.

You got your ass handed to you. Now you have to decide to pick yourself up and move forward wiser for the experience or quit. Life either bends you or breaks you. Most of the time its your choice.

Dust yourself off, evaluate the experiences for what can be learned, pick a new direction. You'll be OK.

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Nobody has ever really succeeded without failing first.  Those who look like they have, havent.

Btw - I'm pretty good at what I do, and I cant see 4 pph for more than an hour or two.

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My collaborating physician gave me some advice when I started that rings true after 13 years: be as fast as you can... but no faster. Know when you need to slow it down.


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8 hours ago, PAekgdude said:
This is how  many docs feel about and treat PA's. Even when you are right with some things  - especially backed by the literature - they will cast you as wrong, bold and dangerous. This is not all you. 

They think of us as worker bees that do scut works for them. We need OTP now and get the right to work with only those who respect us.  I still cannot believe some old PA's that think this type of crap is okay and physicians can judge and do whatever they want 

You had better stay out of my way. I may roll over your toes with my wheelchair and rap your knuckles with my cane. 😄

Edited by GetMeOuttaThisMess
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So much of what you’re describing is... my life. I have been doing ER for three and a half years and still usually feel like I am running around like a chicken with my head cut off because there’s six things to do (I need to discharge room six, close the laceration over there, and crap - I am getting a phone call from the orthopedist). It’s like that all the time. I stopped eating on my shifts and am lucky if I get one bathroom break or a drink of water. I also get very annoyed when patients perseverate. You have the ones who seek needy and hold you hostage with questions... and you swear they’re just trying to come up with inane questions to keep you there (“So... Um. Do I ice or heat?Um... Um... like is it normal that it still hurts? Um... like when will it get better?”) Or you have the ones with the positive review of systems and you want to rip your hair out. Or you have the ones who tell every single detail (“I got up, walked to the kitchen, ate a sandwich, sat on the couch, turned on Golden Girls. Then my right knee hurt so I got up, walked to the bathroom, openee the cabinet...”) These patients make me so anxious because I want them to STOP because I have a million other things to do...and I then feel like I am pushing them out the door rather than connecting with them. People always ask me why I walk so fast - because I don’t have time - and why do all of the others have time to eat lunch, chat about their weekend...AND LEAVE FIFTEEN MINUTES EARLY? I suspect that you may be like me, trying to be very thorough in your history, trying not to blow stuff off, making sure concerns are addressed AND making bullet proof documentation. Don’t have words of wisdom but uh... I am gonna say you’re not alone and you actually sound like a smart, dedicated and hardworking PA.

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Some techniques I use to help focus and shorten the H&P:

  • After the patient has talked about what happened I interject a question asking for more details about something they already mentioned, e.g. seeking more information about the pain.  That tends to put me in control of the conversation and I can begin asking more focused questions.
  • My standard response to "how long till I get better/how many days will I need to stay/etc. is "your body will answer that question".

 

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On 7/9/2019 at 11:07 AM, PAekgdude said:

We need OTP now and get the right to work with only those who respect us.  I still cannot believe some old PA's that think this type of crap is okay and physicians can judge and do whatever they want 

OTP wont be a panacea for any perceived lack of respect.

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I truly hate seeing these kind of posts, because it's a reminder of how broken the healthcare system is. 

 

1) If you were a diligent, hardworking student, which I'm going to assume you were, shame on your program for leaving you feeling unprepared. We'd do far better to have PA programs focus on turning out a few top-notch, well-prepared clinicians than throngs of programs looking to fill more seats and make more money.

 

2) You sound like me in many ways. I'm a sensitive person with a relatively low threshold for stress. I saw medicine as an investment with job security. Was it the right choice? Who knows. But being a thoughtful and often worrisome provider wears away at you. Find a place that can use your gifts -- you have them, whether you know it or not.

 

3) There is no universal provider experience. What you see, deal with, and stress over is different based on specialty, location, office setting, manager, supervising physician, and YOU! Just because ER and UC were great for someone else, doesn't make you less of a provider for not finding happiness and fulfillment there. It just means your talents have not yet found their niche.

 

I'm only a year out of school. Knew from the jump I wanted to do psych. First job was a lot of herding patients in and out like cattle. Pill pushing. Hated it. Not what I got into medicine to do. Left after three months, don't regret it one bit. I'm now doing overnight psych admissions from home and couldn't be happier. But that happiness required me to re-evaluate what it meant to be a good PA FOR ME. You'll find your place. If you made it through school and these past few jobs, you're smart enough for it.

 

Find your niche. 

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4 minutes ago, pa-wannabe said:

I'm now doing overnight psych admissions from home and couldn't be happier. But that happiness required me to re-evaluate what it meant to be a good PA FOR ME. You'll find your place...

 

Find your niche. 

 

That was a nice transition in jobs while still staying in the field of study you like.  Good on you.

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4 per hour for an entire shift is crazy. Things WILL be missed. No one I've ever seen is good enough to do that volume well. Not even the best or BC EM docs years out from graduation do a good job at that pace. I've seen really good, not lazy, docs quit jobs over having to see 18-20 a shift every shift in the main ED, saying its unsustainable. That's how I was scheduled in FM, 4 per hour, but I always ran behind to do a good and thorough job, so it was never really achieved. Sure if it was all 18 year old runny noses and coughs, it would be easy. I could crush 50 a day and make it home on time with a template note. Belly pain, dizziness, pediatric/geriatric fever, lacerations, vaginal bleeding, not to mention the sepsis, STEMIs, encephalopathy, drug seekers with pan positive ROS, traumas, take a lot of time. Is it possible these people are cherry picking cases? I've seen that. I wondered how some people always seemed to have a bunch and handle with ease or how they were always able to be free when that sick level one came in. I realized they were chart stalking. Looking at things before they signed up and if they saw it required transplant surgery or some other service that is known to take forever with tons of work, it would sit. They also had learned to time what they were picking up with the expected transfer list. 

  I can manage 8 beds at once, but that is as a senior EM resident with a over a year of training and off service rotations under my belt. Even so, it's usually because things in multiple beds are at a standstill because I'm waiting on specialty recommendations or a MRI that is taking 2 hours for the read to come back. I'm constantly running my list to make sure nothing is forgotten. 

I feel like a fraud all the time, especially in my first year. Everyone seemed so smart and fast. I still do sometimes when I watch certain people work. But then I catch a few of their bounce backs and realize nobody is perfect. 

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Get out of UC and EM. It is very hard for PAs without fantastic mentorship or a residency. 

Urgent Cares are meat-grinders and we see more PAs get used, abused and discarded by these than any other type of job. 

It's not you. You aren't incompetent. The problem nationwide is the system, not providers. It sets unreasonable standards for production, expects us to not make any significant mistakes, and on top of all that expects us to make every patient happy under penalty of our job. In no way is that fair or humane. 

The best advice I have is to A) find a more reasonable office-based job, or B) reduce your work hours, or both. Those are the only things that have kept me sane in this profession. 

I work in college health where the volumes are HIGH in the school year, but mostly super-acute sore throats, URIs, minor skin issues, minor injury, and STI checks. So it's super easy to keep my production high above the slow-poke IM docs and still be able to down-regulate enough to not get (too) burnt out. Dropping to 4 days a week was also a game-changer.

Edited by BruceBanner
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On 7/6/2019 at 2:01 PM, bike mike said:

Consider a residency

Yep. This.  Then go work somewhere rural where there is a manageable/enjoyable patient census.  Sure, I can manage 18-20 encounters per day as a hospitalist, but that sucks.  I much prefer to see 8-12 patients per day and have time to provide good care and actually interact with them.

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^^This. I hear a lot about residencies these days and see they are a growing thing but there are other approaches too. I spent the majority of my post military time in rural health clinics and under served areas. It was a much better pace. There was a great deal of challenging medicine because of the scarcity of resources. I was genuinely respected and appreciated by the patients and my physician colleagues. I was a voting member of the medical staff. The cost of living was much much lower than most places.

I know it isn't for everyone. Some folks need the amenities of bigger places but, if you want to try something different that has  much higher satisfation go somewhere where you are really needed. 

Edited by sas5814
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Now...I feel like a failure.   I failed to hack the ER.   So many PAs can manage it seamlessly..yet I was an utter failure at emergency medicine. 

I don't think that any novice PA can do ER seamlessly. There is so much to learn and so many experiences to participate in. It looks like there are many of your colleagues rooting for you. Do an EM residency. Think about that suggestion relating to your PTSD and move forwasd. You can do it!

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On 7/12/2019 at 8:55 AM, sas5814 said:

^^This. I hear a lot about residencies these days and see they are a growing thing but there are other approaches too. I spent the majority of my post military time in rural health clinics and under served areas. It was a much better pace. There was a great deal of challenging medicine because of the scarcity of resources. I was genuinely respected and appreciated by the patients and my physician colleagues. I was a voting member of the medical staff. The cost of living was much much lower than most places.

I know it isn't for everyone. Some folks need the amenities of bigger places but, if you want to try something different that has  much higher satisfation go somewhere where you are really needed. 

Why I work in remote Alaska sites!!!!

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Imposter syndrome is a reality for almost everyone, and if you don’t feel like you’re winging it, then maybe you are too confident? A little fear is a good thing. It helps you to not miss something.

You were in a bad environment. Really think about what you want to do. What drew you to ER in the first place? Procedures? Consider interventional rads. Variety? Consider primary care. There are lots of specialties out there. Lots of schedules.

You can do this. Medicine can be brutal, and you aren’t a failure. You aren’t broken. The system is.

Good luck.

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