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Disillusioned New Grad


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New grad here - I am convinced every PA I talked to before PA school painted a false picture of what it would be like.
 

I am 6 months into FM and find myself trying to plan an exit strategy from medicine entirely. PA school was hard, but I put my head down and learned everything I could and was in the top of my class. I loved most of my rotations and didn’t see this feeling coming at all. 
 

I am not just struggling but completely miserable. I don’t really know what to do from here. 

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I am admittedly a hopeless perfectionist - which I understand is my own hang up.

Nevertheless this manifests in constantly looking things up and researching and learning throughout my work day above what is feasible in a 9 hour day. This means I go home exhausted with 8-12 unfinished notes, only to do it all again the next day. I agonize over anything I am not confident on or “get wrong” and carry it with me for the rest of the day.

Reviewing labs, following up on messages, answering curb sides from the clinical staff takes me 10 times as long as the other providers because I research everything I don’t know. 
 

I am SO burnt out and I can’t imagine spending one minute on CME or learning more outside of work which makes me feel like a huge failure. Because I KNOW I don’t know enough and I’m terrified of being responsible for poor patient outcomes and inadvertently hurting someone

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The "Good" news is that in family medicine, most problems aren't severe enough to benefit materially from that level of care.

I recommend cutting back to half time, regardless of the impact on your finances, loans, or benefits, and doing that half-job well enough for your own personal satisfaction, while spending the freed-up time on two things 1) self-directed study, and 2) mental health care.

Last first, you have an anxiety disorder.  Properly managed, you're going to be an awesome clinician.  Not properly managed, you're going to be burnt out before you can get there.

As far as self-directed study goes, Family Medicine is a huge field... but you don't need to know everything about everything, just something about everything. You NEED to be into online CME, into UpToDate, and remedying your self-perceived deficits.

You also haven't told me about how your SP(s) are supporting you through this time.  They should be, but if they had been, you wouldn't have gotten to this point.

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I agree with rev that you may need to see a therapist or psych provider about anxiety disorder or even OCD tendencies. 

 

The good news is that we ALL went through that to start. Physicians do it during residency with their 80+ hour work weeks, and we do it on the job for the first year or so. Every single day you will spend less time looking things up until you've finally looked up and memorized 99% of what you see in a typical day. At that point everything will be second nature and you'll know labs, medication, dosing and symptoms like the back of your hand. 

 

If you can stick it out it will get much better soon!

Edited by Komorebi
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lots of great advice above

 

my own addition is to realize most new grads feel this way at some point.  It is overwhelming to enter the primary care fields as a new grad.  Hardest field to enter in my opinion - literally anything can be your next apt and you are supposed to know something about it.  

 

I got though it by learning as I went (yup considered leaving medicine as well). For a month I would read and learn on DM management and then when I got comfortable it was onto the next topic, ie Asthma.  Just keep expanding your knowledge base.   You doc's and senior PAs need to be helping you as well - is hugely helpful just to talk things out.  might only take 5 min, and you likely already have the answer - but helps to talk it through with someone.

Also don't hesitate to tell patient "I don't know but I will research it"

Hang in there, most of us have been there and it does get better.

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It takes time and some seasoning to figure out how to strike a balance between perfectionism and reality. One of the PAs I worked for when I was a medic said "it takes about 3 years for you to get your head out of your ass and practice good medicine." I think that is pretty close to the truth.

I've been at this for 32 years and every day I bump up against something I don't have any experience with or, sometimes, just something I haven't done in a long long time. I just had to write the first prescription for hormone replacement therapy I have written in probably 10 years. I had to sit down and read for about 10-15 minutes to make an adequate choice for what I needed it to do and now HRT is on my reading list. You'll note I said adequate. I THINK it was the best choice. Time will tell. I KNOW I haven't caused any harm and my choice will help the patient. That is all you get some days.

Get some therapy. We all need a tune up from time to time. Sit down and figure out what you actually have some control over and things you have no control over. Understand the difference and get comfortable with it.

My late career job is in primary care in the VA. I have no control over anything except me. 6 months in I'm finally getting used to the idea and my neck hurts from me shrugging so much. What can I do about (problem)? Nothing. *shrug* Move on to the next thing.

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17 hours ago, PAfocus said:

I am admittedly a hopeless perfectionist - which I understand is my own hang up.

Nevertheless this manifests in constantly looking things up and researching and learning throughout my work day above what is feasible in a 9 hour day. This means I go home exhausted with 8-12 unfinished notes, only to do it all again the next day. I agonize over anything I am not confident on or “get wrong” and carry it with me for the rest of the day.

Reviewing labs, following up on messages, answering curb sides from the clinical staff takes me 10 times as long as the other providers because I research everything I don’t know. 
 

I am SO burnt out and I can’t imagine spending one minute on CME or learning more outside of work which makes me feel like a huge failure. Because I KNOW I don’t know enough and I’m terrified of being responsible for poor patient outcomes and inadvertently hurting someone

lots of excellent advice here. Take all of it to heart. Realize you aren’t alone.
 

I could have written this exact same thing my first few years in FM. Staying late everyday to read, often staying until 7-9 at night, looking tons of things up, calling all my patients with their lab results, coming in on weekends to finish notes and call patients to check on them making sure they were doing better, double checking everything I told people. Anxiety everyday on the drive home from work. Praying to God every morning that I would do good and not screw up. I took being the manager of my panel very seriously, answering patient calls even on vacation. I listened to a half hour of primary care RAP CME every morning before work. Any mistake, no matter how small or insignificant, would make depressed and feel worthless.

I’m happy you too take it very seriously, but it’s unsustainable for people like yourself. Family medicine is the hardest specialty to be good at because of the massive amounts of knowledge you feel you need to know. 
 

my first piece of advice is learn to be okay with referring more in the beginning. I took my more complicated cases on in phases. For example, I had several patients with prolactinomas. I would take one that was the simplest, established their routine, then I would learn all about it. When I felt comfortable I took on more complex ones, new diagnoses, etc. after I felt solid with these I would take on other complex diseases, adding atrial fibrillation patients, then managing thyroid nodules, then managing heart failure, etc. By my 3rd year in, I had the lowest referral rate in clinic. This didn’t help my anxiety though, as I was always increasing my cognitive load.

I’ll give you the best advice my dad gave me. He’s a IM physician, who was also a workaholic. He would see me on vacation together taking calls and the stress all the work was putting on me. Finally he said, “primary care is not for you, Oneal. It’s not that you can’t handle it. It’s not that you aren’t good either. But you can’t ‘turn it off.’ You need a specialty where you can clock out, and when you’re not at work you know someone else is caring for the patient. A specialty where you help them answer a specific question or problem, then your job is done and where it’s not even really your place to get involved in other aspects, because if its allowed you’re going to do it and you’ll still just burn out.” I think he was speaking a little from personal experience and things he wish he had done.

if you can’t turn it off, then I suggest you narrow your specialty so that way you only compel yourself to know a lot about a small section of medicine, rather than trying to learn everything about everything. 
 

oh, and don’t be like me trying to power through. Get some therapy.

if residency is ever an option for you, it’s great having that structured experiential learning to boost confidence. 
 

 

 

 

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I agree with what everyone has said.  You're at the early steep end of the learning curve, one that's probably at least 3 years long.

There's no substitute for experience, and there's no way to get that experience other than lot's of patients, which means lots of time.  Some of the things that you'll learn, that PA school certainly can't teach and probably didn't even mention:

  • there are LOTS of variations on normal, especially in individual patients' baselines.  Those can be outside of the usual normal limits we were first taught and had to memorize.  You WILL get to know those patients & presentations/labs/imaging that is just their variation on normal - for them.
  • the patient's report of their symptoms may or may not represent a can of worms that needs to be opened:
    • 32 y/o/f with "chest pain" reported as 10/10 but has positive cell phone sign, normal vitals, and no risk factors probably only needs 1 EKG, 1 troponin, 1 CXR, and a CBC, BMP, and mag vs the serial cardiac workup
    • motor cycle wreck patient who's only complaining of "back pain" and is alert and oriented, good PMS x4, but has new flank bruising and is tachycardic and tachypneic is trying to die on you
  • as a new PA, it's hard to feel comfortable deciding the odds of something being important are small and you can either not look into it or give it a 1st pass most probable dx and move on.  After 1000's of patients, you'll have the confidence to know that you're probably missing things, but almost certainly nothing important.

Pacing yourself and seeing yourself as a promising learner and valuing that vs beating yourself as inexperienced and not knowing - which there's no way you can be until you have that experience, is very important to your survival.

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On 7/19/2021 at 7:50 PM, PAfocus said:

New grad here - I am convinced every PA I talked to before PA school painted a false picture of what it would be like.

Heh, you should have spoken with me. I'd have advised you that most physicians are bitter narcissists with a high incidence of significant mental illness. And the vast majority of administrators make Dilbert's boss look like a kind, ethical, genius. 

If I saw my hospital CEO unconscious in the parking lot, I would not render aid. I might even put a plastic bag over his head if he was out of security camera range. 

Eunuch programmers

Edited by CAAdmission
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Welp...here goes.  People are going to hate what I say but I say it with no skin in the game concerning this poster.

 

Start planning your exit from medicine.

 

This career field has chosen dead man walking status for new grads.  Many of the "do this" or "do that" comments that you see here are from 20+++ year PA's who have had decent careers.  They simply entered this field at the right time.  Kinda like buying a house in So Cal in 1979 for $82k and now being able to sell it for 1.4 mil.  They love them some housing market but struggle to understand what young new homebuyers are up against....

If you are young, you can leverage your PA a little and perhaps grab an MBA and go into some form of healthcare related business.  Or, just leave medicine altogether and switch field completely.  

This recent name change cluster puck was our last chance to move to a name with practitioner in it and aggressively start trying to create some parity with NP's.  We were given a clear path lay up and right at the last second, our own team mates jumped up and blocked our shot at being Medical Care Practitioners.  Oh... and after we spent 1 million just to take that lay up shot.  Sickening.

 

So remember when you get advice from people who have seen the best of this field, they are going to look back with rose colored tinted glasses.  Anymore I despair for new PA grads.  I have lost count of the number that PM me here and other sites expressing frustration at being "duped" into going into PA school.

Plan your exit now, while you can.

Edited by Cideous
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OPs question had more to do with daily struggles with knowledge and confidence as a new grad than whether the profession is screwed or not. I

I have a pretty good grasp on the state of the profession and my years in it don't make me see things through rose colored glasses. It would seem you could make you point without disparaging other people who shared their opinion.

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7 hours ago, sas5814 said:

OPs question had more to do with daily struggles with knowledge and confidence as a new grad than whether the profession is screwed or not. I

I have a pretty good grasp on the state of the profession and my years in it don't make me see things through rose colored glasses. It would seem you could make you point without disparaging other people who shared their opinion.

You have always been the exception to what I described Scott, and I was not disparaging anyone, only telling the OP to understand that the advice given is coming from a demographic that has seen the best of this profession.  You likened it to a group of people that would not get it until the bus drives off the cliff, hits the ground and explodes and even then they would say all we need is a garden hose or some such.  An analogy I agree with 100% btw.

 

He/she also complained that He/She were given false information FROM PA's which painted a "false picture" of the PA field.  Their words, not mine.  Also that He/She is planning an exit strategy from medicine and is miserable.

Do you know how many new PA's I have talked to that have said the exact same thing?  PA's in the field painted this rose picture....and bam!  They are up to their eye balls in debt, can't find a job (or get some feckless position where they are treated like crap) and are miserable.  And you know how they feel?  Duped.  And it is not improving, far from it.  5 years from now after NP's finally finish running the table on us legislatively they are going to be hosed...and they are just now figuring that out.

Edited by Cideous
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Fair enough. I was not really focused on an exit strategy. OPs  problem in that regard is it almost too late because of school debt. Its hard to leave a fairly high paying field you have spent a lot of time and energy training for and find another job that will cover their nut. If that were easy I think a fair number of PAs would already be gone.

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^^^ Completely agree.  Especially with school loan debts today.  I did full PA school, apt, living expenses etc for almost 3 years for about $58k and it still took me 10 years to pay it off.  I can't imagine having $100k + now a days.  Uggh.

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On 7/19/2021 at 7:50 PM, PAfocus said:

New grad here - I am convinced every PA I talked to before PA school painted a false picture of what it would be like.
 

I am 6 months into FM and find myself trying to plan an exit strategy from medicine entirely. PA school was hard, but I put my head down and learned everything I could and was in the top of my class. I loved most of my rotations and didn’t see this feeling coming at all. 
 

I am not just struggling but completely miserable. I don’t really know what to do from here. 

Just thought I'd get back to the OP's post before we all started reading stuff into it. And discussing all the things we don't like about our profession or how "you should have been here yesterday."  While medicine brings its unique challenges, being a perfectionist and getting burned out are definitely not unique. I felt that as a junior engineer.

Feeling dissatisfied is often your first clue that you're off course: never blow that feeling off! Maybe it really is the right job (for now) but you're not adjusting well. Maybe it's the right area of medicine but with the wrong setting/preceptor(s). Maybe it's the wrong area of medicine. Maybe it really is the wrong career. It could be any of those things. But an early career person who did well in school and liked most of their rotations feeling this way is a good sign that maybe you're not that far off-course.

The best piece of advice I ever got from a preceptor is to "go as fast as you can, but NO faster." When you start out, you've got to look things up and that takes time. As you see the same things over and over, you will have developed something like muscle memory. And you hopefully begin to enjoy helping your patients.

The best interpersonal advice I ever read was from a flight attendant who was asked how she stays calm with irritated passengers. "Oh, they're just screaming at my uniform. I'm safely inside of it." Try not to take criticism personally.

I would recommend that -- above all -- you cut yourself some slack. Take some time for you and don't assume that the way you feel right now is the way you will always feel. You will get better at your job just like you've gotten better at everything else you'd done in life. As you do, both you and your job will look like they're changing. If things move in a good way: fine. If not: then it's time to explore some options.

As you move forward, you will be presented with other opportunities. As you evaluate them, remember that it's often best to move towards something that attracts you, rather than just away from something that repels you.

Good luck!

 

Edited by UGoLong
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6 hours ago, CAAdmission said:

The way society is going, work will be the least of your problems. You should start stocking up on guns, ammo and booze. 

So, when I was doing my general surgery rotation at Madigan, we all (residents, med students, PA students) got to sit in on a "how to prepare for deployment" lecture from one of the attendings to the 3 soon-to-be-graduating chief residents who were all being assigned to either Iraq or Afghanistan, I forget which.

After he'd talked about the process for a while, he drew a sketch of an airliner seating chart, and then indicated all the seats were held by soldiers, and then left one empty in the middle of his diagram and circled it.  "This is your seat.  Do you think these people," indicating all the soldiers, "are going to let it take off without their surgeon?"

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On 7/19/2021 at 5:27 PM, PAfocus said:

I am admittedly a hopeless perfectionist - which I understand is my own hang up.

Nevertheless this manifests in constantly looking things up and researching and learning throughout my work day above what is feasible in a 9 hour day. This means I go home exhausted with 8-12 unfinished notes, only to do it all again the next day. I agonize over anything I am not confident on or “get wrong” and carry it with me for the rest of the day.

Reviewing labs, following up on messages, answering curb sides from the clinical staff takes me 10 times as long as the other providers because I research everything I don’t know. 
 

I am SO burnt out and I can’t imagine spending one minute on CME or learning more outside of work which makes me feel like a huge failure. Because I KNOW I don’t know enough and I’m terrified of being responsible for poor patient outcomes and inadvertently hurting someone

Best thing I was taught in my rotations by a hospitalist was “you don’t have to be right, but you have to make a decision. That is our job.” I think about that often. When it comes to EM I can hang with the best of them. When it comes to something I’m not sure about I get on a reference site, do a little 5 minute overview making sure to hit the killers and maimers and make a decision. 

I am also a new grad, about 7 months in. Granted I was a medic for many years so patients were nothing new to me. So while some have the “back when” stories, I am telling you from new grad to new grad, hang in there. You’re doing fine. 

Edited by deltawave
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It's so important to be okay with not knowing everything. I spent the first year (I'm currently year 2 out of school) constantly fighting imposter syndrome and feeling like an idiot because of all the things I didn't know that I expected I should know. I figured "I'm not a student anymore, so obviously I should know things now." I was so wrong. 

 

The best thing you can do be okay with the fact that you don't know everything, trust that knowledge comes with time, and be up front about what you do and do not know with your colleagues and even your patients.

 

Also: family medicine is insane. I seriously doubted my choice to go become a PA during my rotations in FM. It wasn't until I had a few rotations in specialties that I liked a lot that my original passion for medicine pre-PA school returned. Don't lose hope!

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