I don't know about you guys, but this whole transition from being a student to being a professional has been hard! I have yet to start work (also due to a problem with getting my license--Adam) and it seems like I'm losing more of the 2 years' worth of information that I crammed into with each passing minute. This article was encouraging, though. Hopefully it will be to you as well. I miss you guys and almost even miss GH5!
:)Kirstin
Sixteen Years of PA Experience
This article originally ran in the October 2007 print issue of ADVANCE for Physician Assistants.
With more than 16 years of experience in family practice, urology and emergency medicine under my belt now, and having attended a fair number of conferences, workshops and other events, I've had numerous opportunities to talk with PAs across the country. Almost universally, they have expressed great satisfaction with their career choice. I'm no exception. During those conversations, one of my favorite topics of discussion has been the many interesting experiences we encounter during the first year or so of practice as PAs.
A few years after graduating from the University of Utah PA Program, I was asked to present a lecture to PA students there on practicing in rural medicine. At the time, I had been working in eastern Utah at the Duchesne Valley Medical Center, about 90 miles east of Salt Lake City. The practice was a National Health Service Corps loan repayment site. My first job had been in Phoenix?rather urban compared with Duchesne, Utah, where I was the only health care provider in a town of about 1,300 people. My supervising physician was 30 miles away. I was on my own.
Fortunately for me, I had a year's worth of experience in Phoenix that was essential to my success in rural medicine. But the story begins long before that.
Early Health Care Experience
During my senior year of high school, I got a job as a radiology department orderly at a local hospital. The summer after my high school graduation in 1974, our local county fire department implemented paramedic services. It just so happened that I was working on the first day of service when the paramedics transported their very first patient to our hospital. As a 17-year-old, I was impressed! After all, I had been watching paramedics by the names of Gage and DeSoto on TV for a couple of years. Now, here was the real thing.
In 1980, I decided that I wanted to become a firefighter/paramedic. I began to prepare for that career by taking an EMT class. One of the instructors was a PA. I had never even heard of a PA before then.
During one training session, the PA asked several of us why we were taking the EMT class. When he came to me, I told him that I wanted to be a firefighter/paramedic. Later, during a break, he pulled me aside and offered me some advice. He encouraged me to pursue my dream with the fire service, but he promised that I'd become discouraged by the politics and many other aspects of the work. He then suggested that when I was ready to move on, I consider becoming a PA. He didn't know that that would be exactly what would happen. After nearly eight years in the fire service, I entered PA school.
First PA Job, First Physician Tantrum
Right out of PA school, I took a position in the ER at Phoenix Memorial Hospital. The physician who hired me said that the hospital had never before hired a PA right out of school, but that he thought I could handle the work with my experience. The ER docs for whom I worked were fantastic. I learned a lot working with them and the other PAs in the ER. It was a great experience.
My time at Phoenix Memorial provided my first experience seeing a physician throw a tantrum. One night, I had a patient with hand injury that required the services of a hand surgeon. I made the call and explained the situation to the specialist. He indicated that he was only a few minutes away and asked me to go ahead and place a digital block in each of the involved fingers. He was in a hurry and wanted to have the patient numb when he got there.
I did as requested, and no sooner had I taken off my gloves from doing the procedure, he walked through the ER doors. I introduced him to the patient, and I stepped away to see another patient. In less than a minute, I heard him in a very loud voice proclaim that his patient wasn't numb, and that the patient wasn't ready for any procedure. Instantly, instruments were being thrown across the minor trauma area of the ER.
I had been out of PA school about two months. I had performed a number of digital blocks, both as a student and in this job, and had never had a problem. Later, I learned that this was standard practice for this physician. Nothing done in the ER ever seemed to be up to his expectations. Somehow, my PA training hadn't quite prepared me for this. I was devastated.
More Surprises
A few months later, I started working one day a week in a very nice family practice in the Phoenix area, in addition to my ER job. The supervising physician had two offices. I was covering one office while he was at the other. One day, a man walked into the office in respiratory distress with severe COPD. He was a patient of a local pulmonologist but couldn't get in to be seen and asked if we could help him.
This guy was a blue bloater for sure-dusky gray-blue color, pursed lips and diaphoretic. His oxygen saturation registered in the 50 to 60 range. I knew he needed to be admitted somewhere. I called his pulmonologist's office, explained who I was and who the patient was and his situation to the receptionist. After waiting for what seemed like an eternity, Dr. Lung (name changed to protect the guilty) came on the line. I introduced myself to him and was promptly interrupted with the statement, "I don't talk to PAs." And the line went dead. Wow, I wasn't prepared for that. Needless to say, the patient was cared for, but not without some effort and a prompt call to 911.
In both situations, I'm happy to report that the physicians I worked for were there when I needed them. I had 100% support in both situations. In each case, my docs went right after the offending docs, stood right up to them, defended me and my care of the patients and gave me the confidence to continue. Although I wasn't prepared for the emotions at the moment, a good relationship with my docs went a very long way in helping me deal with feelings of inadequacy.
Practical Advice for Newbies
First and foremost, know your limitations. I know mine, and I don't pretend to go beyond them. I have now, and have almost always had, an excellent relationship with my supervising physicians. I have discovered that I still don't have to know all the answers. I can always tell the patient that I don't know, and then I can go and ask the doc. When I come to my supervising physicians with a question or looking for direction, it's very reassuring to me to often find them as puzzled about a diagnosis or condition as I am. That helps me know that I'm not as lost as I thought I was. If I don't know the answer and they don't either, I feel a lot better.
The real compliment is when my doc comes to me and asks my advice or input on a patient he is seeing. Not only does this help me stand a little taller, it also really strengthens the relationship of trust and respect between us.
A Peripheral Brain
My first recommendation is to get a peripheral brain. Before personal digital assistants were common (or available, for that matter), I began collecting charts and graphs and teaching aids that I found helpful for patient education. I put them in a binder with plastic sheet protectors. I was able to find a binder that was only half an inch thick, with the sheet protectors already bound into it. That way, when I dropped it, everything didn't fly all over the place. This became a very useful tool?so much so that I added charts that I created for dosing of various medications, such as liquid antibiotics (based on weight) and others I commonly prescribed. I can't tell you how much time that saved in calculating doses every visit. The inside pocket of the binder was a perfect place for my prescription pad, too.
I had other reference information in my peripheral brain, too. An outline of required elements of charting for dictation in the ER I worked in. Diagrams of the anatomy of the skin, inner ears and coronary artery disease. Treatment outlines for acne, irregular menstrual cycles and anything else I needed. A few years ago, I added some charts that outlined the areas in my community where natural fluoridation is adequate and those where it isn't. That was a great tool for teaching and counseling.
I've added and removed a lot of things from that original peripheral brain, but I still have it, and I still use it. I think it works a lot better than a PDA, but the students who work with me often argue that point.
A Personal Library
I also recommend that every PA have a decent library of good books. I remember the first day of PA school when we were handed a list of required textbooks. Dutifully, I went to the bookstore and bought every single one. It cost me a hard $1,000 to buy all those books. I used about 40% of them during my education.
I found that the recommended books weren't always the best books, nor were they all necessary. Here are some of the texts I find useful in my practice today, and most of them weren't on the "required" list for my program.
Because pharmacology is such a big part of my daily practice, I have found the most used item in my library to be the Monthly Prescribing Reference (MPR). I call this amazing reference my "Reader's Digest" version of the Physician's Desk Reference. It contains a list of more than 2,300 commonly prescribed drugs, all arranged in therapeutic categories. I get a new copy every month with invaluable information on new drugs, changes in indications, dosages and other great stuff. There are tables for management of hypertension, lipids and ADHD, and a host of other information. I use it multiple times every day. (My PA students prefer Epocrates on their PDAs. Personally, I find it totally frustrating to scroll back and forth to find what I am looking for.)
The AAPA provides a free subscription to the Physician Assistants' Prescribing Reference (PAPR), which is published by the same company as the MPR. It comes out quarterly versus monthly. You also can purchase a similar product from the publishers of the PDR. In any case, they are all indispensable in daily practice.
My next most often used book is a tossup between The Merck Manual and The Sanford Guide to Antimicrobial Therapy. Although I don't use them daily, when I need information, they are excellent sources.
Generally, if you're in family practice, a good pediatrics text is invaluable. And, good books on orthopedic exams, dermatology, laboratory tests and values, office procedures and physical exams are important.
A library of books is only as good as the person using them. They may look impressive on the wall behind your desk, but if they aren't used, they are of little benefit. Many of the books I purchased as a student are stored in boxes in my garage. That is how useful they have been. What an investment.
More Advice
As I hinted at earlier, you need to know your referral sources. Those two docs whom I failed to connect with early in my career never got any referral business from me. I doubt that it bothered them much, but I learned early on that when I referred patients to specialists, I was and still am most likely to refer to someone who appreciates my referral, who respects me and who doesn't feel threatened by me. I can also generally assume that my patients will be treated well, too. If not, I find someone else.
When I worked in rural medicine, finding another referral source often meant that patients had to travel an hour or more to see the appropriate specialist. I found that some of the surgeons and specialists I met as a student were very willing to talk to me on the phone and were very appreciative of my referrals. One of the cardiologists I called occasionally often asked me how the fishing was in Duchesne before we talked about the patients.
One of the struggles I still deal with is getting the specialists to address me when they send letters to our practice detailing what they have done for my patients. It always amazes me that I see a patient, do the initial workup and make the referral. When a specialist sees a patient, he or she often sends a letter outlining findings, treatment and recommendations-addressed to my supervising physician, not to me. I find that to be a small source of frustration. It does seem to be getting a little better now.
No matter where I work, I try to get to know what emergency medical services are available when I need them. As a former firefighter/paramedic, I'm not uncomfortable with finding the nearest fire station or paramedic service. I'll go visit them once in a while, swap some stories and thank them for their service. I make sure that they know where my office is, and I determine the level of care they can offer?advanced life support versus basic life support, for example. In a rural situation, making nice with the local EMS can make a big difference in a critical situation.
I have learned that the career I have chosen has rarely led down a straight and level road. More often, there are curves and hills where I never knew just what was around the next bend or over the next hill. It has always been an adventure.
This is a great career. There are challenges and disappointments all along the way, but when all is said and done, I love taking care of my patients. When they thank me for that, my day has been made.
And I still don't know everything.
Jim Meeks is a family practice PA who works in Orem, Utah, and is the founder of Medical Professional Education and Consultation Services (MPECS). He is the president of the Association of Family Practice Physician Assistants.
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