New grad with first job feeling lost...thoughts please!

[FamilyPAC]

Hey all, really looking to hear if my feelings are typical for a new grad or I really am just that unprepared. New grad with first job in rural family practice. Been here for about 2 months now with pt load really picking up. SP in practice site but he is busy and really not too welcoming.

 

I feel unprepared and sometimes not trained well enough to take care of come of the elderly patients with a million different chronic problems going on. I'm very uncomfortable and constantly worrying if I did the right thing. I look up everything I can and ask questions when I'm really doubtful but feel like I should be able to make more confident and competent decisions. I'm really starting to doubt the PA curriculum has trained me to do what I need to for this position....which is act as a fp physician when I have half the training and no experience.

 

I did well in PA school and my boards but real life is just bumming me out. Anyone else have these feelings? How often did you consult with your SP in the beginning? I don't want to get burned out this early.

 

Thanks in advance to anyone that can comment.

[primadonna22274]

So sorry to hear this. I got very lucky in my first job because my SP made it her mission to mentor me very closely the first 6 mos we worked together, and we had dedicated teaching time built into our schedule once a week. It was fantastic. IMO FM and EM are some of the hardest places for new grads to start because the knowledge base is SO broad and it's just not possible to know enough.

You are doing right by looking things up and reading. I am sorry to say your SP does not sound supportive and this is a red flag. You are smart enough to know you are in over your head and to ask for help. It sounds like you are a conscientious PA who wants to take good care of patients and not do harm--I would approach your SP from this perspective and request a meeting to sit down and discuss realistic expectations and devise a plan to address your concerns.

Make a list of top 20-30 dx you see. These should be your priority to address with your SP. If you have a solid plan for most common problems you can tweak it as needed. Understand this process will take at least several months and maybe a couple years to get comfortable. Your SP should see you as an investment, not a cheaper version of a FP partner.

For geriatrics especially pay attention to functional status, mobility, cognitive impairment and polypharmacy. Know your most commonly used drugs in and out, especially the metabolism and major interactions and adverse reactions. You and your SP will take much better care of your patients as a team if you can learn to work together, but of course he has to be wiling to make the investment in your education as well. I think some physicians forget how much they learned in residency and have an unfair expectation that a fledgling PA should be fully capable right out of training. That's a ridiculous notion and dangerous.

Good luck to you. And P.S. what you are feeling is entirely NORMAL.

:)

[FamilyPAC]

Thanks so much for the suggestions! Well worded and a good way to approach this topic with my SP. It's nice to hear feedback from others and know I'm not alone!

[GeneValgene]

i work in a different setting, but know how you feel. school is nothing like real life. i just graduated too, and have been only working two months.

 

there are days i am scared out of my mind at work because i feel so clueless - so i still staff EVERYTHING with my attending. i feel for you, because your situation stinks that your SP isn't accessible to you. my encouragement is to never make decisions beyond your means, and always ask for help if you need it-which sounds like what you're already doing. i tell myself it's better for me to look like an idiot or be annoying than to ever put a patient in harms way. any way you can sit down and talk with your SP to let him know how you're feeling?

 

just know you are not alone in feeling completely unprepared and terrified at times. what keeps me going is that i look at other midlevels who have been at it for 5 years and they are rocking it. i think we'll all get there eventually...sucks that the first few years are so painful

[ventana]

relax - you are a new grad

 

 

90% of your job is getting an H&P and good exam - you are well trained for this

read everything you can and don't try to go fast

on EVERY patient develop a Ddx of at least 5 things and research them at night

 

 

YOU WILL SUCCEED! scared and continuing to read every night will serve you well!!

 

 

As you are learning - primary care is one of the hardest fields because the of the knowledge you need to have

It took me 4+ years to really get comfortable...

[Guest Paula]

I agree with all of the above. My first job (8 years ago) was in rural health care as the sole provider on a reservation. It was a nail biting experience at times. My SP was at another reservation, so I was in contact by phone and he came once or twice monthly. He liked to teach, but we did not spend much time going over charts, just sign off as needed according to the state laws. My saving grace was my patient load. It ranged from one per day to about eight at the most initially. As I built up the concept there would really be a provider that could be counted on, my patient load increased to 8-20 per day. The first year I had much time to pull out my books, use uptodate and other resources to learn. I spent the first couple of years having sleepless nights worrying about if I made the right dx, gave the right drug, ran the right tests, or missed something really big. I probably referred to early but since it was just me, I felt it was on the side of caution. I also spent some time working at an ED/ walk-in clinic part-time in a larger facility with a Dr. always on staff and learned so much about urgent care/emergency medicine that helped me at the tribal clinic. Looking back....wow....it almost scares me!

 

Hang in there. You have an SP on site. primadonna has a good idea to approach your SP to have sessions with you once monthly or whatever you can work out. You should be scared, it means you are conscientious and want to practice medicine correctly and not on the fly. I agree with Ventana, too, that primary care is one of the hardest specialties to be in. We have to know alot about everything. It has taken be 5 years to feel comfortable with the complicated stuff, and I will never be TOTALLY comfortable with complicated stuff...if you get my drift.

 

The PA curriculum prepares you for the generalist position ONLY if you have an SP who enthusiastically embraces you and wants to mentor you. Go put a pebble in his shoe. Rural care will continue to have these type of practice environments as physicians migrate away from the primary care focus. Learn all you can now and never stop learning.

[Contrarian]

Great advice and insight above... In 2-3 yrs, you will look back at these days and smile.

 

You will do fine as long as you keep a little of the fear and apprehension that you have now... use your resources, look up what you don't know and READ something medical everyday.

 

For example, I have the "Recall" series, the "Ridiculosly Simple" series and the "Currrents" series strategically placed (think bathroom and bedside table) around the house and/or at my two offices.

 

I have 1-2 pocket texts in my car. I also have Audio Digest Review MP3s downloaded into the memory of the hardrive in my car stereo that I listen to every morning on the way to work. For a change of pace, I also listen to "Reach MD" on Sirrius some mornings on the way to work.

 

I also carry my Tablet PC with me where ever I go so when I have to sit and wait on something or someone, I can use that time to browse Harrisons, Medscape, Tarascons Family practice, Epocrates Essentials and other references that live on the Tablet or I can connect the 4G tablet to the net and look up anything of interest.

 

I also have all of these audio CMEs and texts/programs loaded on my smart phone, so even if I am sitting in a restaurant waiting on a table or guests, or I have to make an emergency stop in a public bathroom stall... I can read 5MCC, Harrisons, Skyscape, Tarascons, Epocrates Essentials, etc. while attending to nature.

 

This is especially handy when on call.

I simply tell whoever is on the line to "Hold"... I mute the phone, then look up whatever I'm questioning/considering in Epocrates Essentials, 5MCC, or Harrisons right there on the phone. Unmute and give instructions.

 

As for the medically complex geriatric patiens with multiple comorbidities...

 

You just got to learn to s-l-o-w down... and "eat that pie one slice at a time."

 

Meaning... pick a problem and address it... then move on to the next problem and address it, then move on to the next problem and address it... all the while making sure that none of your recommendations for each successive problem exacerbate the previous problem.

 

 

Assessment:

 

1.) Hypertension

2.) CAD-S/p CABG with LIMA to LAD 2010

3.) Hypothyroidism- S/p Thyroidectomy

4.) Anxiety Disorder

5.) Herpes Simplex Virus II

6.) Type II DM (now insulin dependent for control)

 

Plan:

 

DX: Hypertension- poorly controlled on ACEII and low dose beta blocker

TX:

RX: We will D/C the Lisinopril and increase the Atenolol to 25mg po BID

Lab: We will send for renal scan since B/P acually increased when started on Lisinoprl

F/U: RTC x 2 weeks or sooner should problems issues or concerns arise

 

DX: CAD-S/p CABG with LIMA to LAD 2010 with stable Angina

TX:

RX: We will start Plavix 75mg po qd and continue ASA 325mg po q day

Lab: Will refer bac to Cardiology for possible Nuclear Scan/Stress Test

F/U: RTC x 2 weeks or sooner should problems issues or concerns arise

 

DX: Hypothyroidism- S/p Thyroidectomy (most recent TSH- Low)

TX:

RX: We will decrease the Levothyroxine to 50mcg

Lab: We will recheck in 10 days

F/U: RTC x 2 weeks or sooner should problems issues or concerns arise

 

DX: Anxiety Disorder- poorly controlled, has had a recent increase in general anxiety over last 2 weeks.

TX:

RX: The increase in Atenolol and the decrease in exdogeous Thyroxine should help with this. Continue Klonopin 0.5mg po BID.

Lab:

F/U: RTC x 2 weeks or sooner should problems issues or concerns arise

 

DX: Herpes Zoster- active outbreak involving entire left lateral torso

TX: Apply Lidocaine topical 5% oint to affected areas with swab BID until resolved

RX: Valacyclovir 500mg 2 tabs po qd x 7 days,

Lab: Get CBC with Diff to assess immune status

F/U: RTC x 2 weeks or sooner should problems issues or concerns arise

 

DX: Type II DM (now insulin dependent for control)- poorly controlled with FSBG averaging 240, recent HgA1c- (8)

TX: Refer to Diabetes Education. Refer to Nutrition for diet education. Refer to Podiatrist for foot care. Refer to Opthalmology for Eye care.

RX: a.) Continue Metformin 1000mg po BID. b.) Start Lantus Insulin (290lbs= 132 kgs) 44units SC q hs. c.) FSBG check AC & HS (QID- 0630, 1130, 1630, 2130) cover with Novolog Insulin according to sliding scale below:

 

50-150- 0un

151-200- 2 un

201-250- 4 un

251-300- 6 un

301-350- 8 un

351-400- 10 un

401 or < 12 un and call PA-C.

 

Lab:

F/U: RTC x 2 weeks or sooner should problems issues or concerns aris

 

 

Moral of the story....

You apprehension is NORMAL.

READ daily and in a few years... it will simply fade and become background noise.

 

You will be fine.

[FamilyPAC]

thanks everyone, your advice definitely helps and is appreciated.

[EMEDPA]

"pick a problem and address it... then move on to the next problem and address it, then move on to the next problem and address it... all the while making sure that none of your recommendations for each successive problem exacerbate the previous problem."

 

great advice C!

 

the underlined is part of the art of medicine. lots of folks don't look at the big picture which is why you see pts with med lists with 26 drugs when they could use a lot less.....

prn means "as needed" not as it is used by many folks/facilities: "give everyday as written"

we see lots of folks in the e.d. for just this problem, overuse of multiple prn meds at the same time.

[paraguru]

Wow! There is certainly a ton of good information on this thread. Thanks guys for really spelling things out for new PA's such as my self and FamilyPAC. I graduated almost a year ago and have been practicing in a rural primary care/ED situation since September. I am sorry FPAC that your SP sounds so disjointed from you. I made it my priority to find a Doc that I could really jive with and who would school me on things I have problems with during my first PA job. That kind of worked out but my SP is pretty busy like yours. I have relied on the other Midlevels in the practice for advise too when it was needed. My SP and I have now decided to work 30 minutes a week into the schedule so we can sit down and chat about cases I am struggling with. I am hopeful this will lock some foundational items in as I move forward.

 

My limited 2 cents would be this: Get an online resource (I use UpToDate but there are others) that you have handy at ALL TIMES while you are seeing patients. Make the organization you work for purchase you a subscription. You can quickly search for just about anything with one of these and get to the information quickly. I cover the ER 10 days a month so I use my online resource and I also carry some clinical books with me just in case the network is down. I also like the Tarascon series because they are tiny and packed full of information.

 

Lastly, I can confirm that you and I are both feeling the exact same emotions and it is not uncommon. I asked all of my preceptors when I was in PA school how long it would take until I finally felt "confident with my self" and the average was 3-4 years. You are in good company so pay attention to those that have gone before us (EMEDPA and Contrarian are great examples). Stay motivated to help those you serve with your medical skills and realize you are going through the same thing WE are all going through as new PA's. God bless and if you every need to vent about your situation drop me an email at paraguru911@yahoo.com.

[SurferUF]

So glad I found others out there posting about experiencing the same feelings.

 

I just started my job in Family Med 3 days ago and feel completely overwhelmed.

 

On rotations, I wish my preceptors had given more independence to deal with dx/tx. There never seemed like there was enough time for them to hear what my thoughts were about a tx plan. Now, I feel totally under-prepared in seeing patients in real life and fretting about what i forgot to think about or if labs/xrays should have been ordered or spared. Wasn't it nice the the PANCE gave you text book presentations for questions?! Right now I'm really confused as to how the text books came to agree on a typical presentation since Im not seeing that at all!

 

Beyond taking care of my own patients for the first time...I have to figure out how to bill correctly and master the computer system. I also was handed the task of managing the coumadin log for all patients on the first day so needless to say I've been inundated with challenges.

 

Thanks for all of the support and answers you experienced PAs have provided! I'm printing this and going to read it whenever I feel like things are going out of control! Looking forward to year 3-4 of practice!!