"Never give in, never give in, never, never, never-in nothing, great or small, large or petty - never give in except to convictions of honour and good sense. Never yield to force; never yield to the apparently overwhelming might of the enemy." - Sir Winston Churchill
If you are a new grad and you haven't nailed down a job yet, I don't doubt you feel like you have applied everywhere. You have scoured the internet's most popular resources: paworld.net, healthecareers, indeed, doccafe, craigslist, pajobsite, and even our own ADVANCE.
You get calls from recruiters daily. You have emailed all those weird friends of your parents who "might be able to help." By Facebook stalking friends from undergrad, you realized two of them live in the city you're trying to relocate to. "Will messaging them make me seem as desperate as I feel?" you wonder.
Maybe you got an interview offer but it was in bariatric surgery and you realized that you love tackling public health issues like obesity, but not when the issue is 400 pounds on the operating table with you assisting the surgeon.
Or your recruiters would love to get you set up with a practice "near" a major city which turns out to be in one of America's most rural counties and a two hour drive from a Target. All your colleagues somehow got their dream jobs, right? A cushy dermatology gig or a fellowship that pays off their loans; meanwhile, your credit card is maxed out for the tenth time since you started grad school and you're asking for a loan from your grandma.
Maybe you interviewed at three places but none of them called you back and you are on the verge of annoying the office secretaries into making the no-hire decision on you. How far is too far?
Perhaps you have woken up in the middle of the night in a panic and checked your LinkedIn app and realized that no one who would even know what "ACLS" is has endorsed your skill. Just your dad. "Maybe that's why I don't get calls back," you think.
You keep reminding yourself of all your friends who are Starbucks baristas because they got a master's degree in Medieval English; not you, and you chose a highly marketable skill. But no sooner do you think that until that causes you to doubt your ticking time bomb of student loans that are four and a half months from suffocating your budget.
And in long days of internet searching you find yourself Googling, "motivational quotes" and re-realize your love of Winston Churchill and think maybe your English major friend wasn't so crazy after all.
After what seems like months (because it was months), finally, you get a call back from a normal sounding human who asks if you will come interview with the cost of your travel covered even though the recruiter you applied through didn't even give them your CV (that you had spent countless hours polishing).
They ask you a lot of direct questions, "Well, don't you want to know how much you'll get paid?" And you answer, "Uh, yeah?" though everything you read on how-to phone interview weblogs said to never ask about salary during a phone interview.
You fly to the interview, end up getting a free $400 voucher from Delta (that will pay for your flight to your best friend's wedding), and you love the practice. Then you get hired at your dream job and you forget all the self-doubt you had about choosing your career.
You then spend the next month frantically filling out paperwork and calling a medical board that you are pretty sure has not realized that the internet exists.
Happy job hunting, friends!
I sat in the airport terminal in
November of 2012 and stared at my cell phone. I flicked the screen on and off as
I waited out another wave of anxiety. I was about to place a call that would
dictate the course of my life. At the time, I could barely comprehend the
changes that would take place over the next year.
It would be the year that changed
the way I looked at life. The year that changed the way I looked at patients
and at medicine. It would be the year that I learned to trust my gut ... that I
even had a gut to trust. It would be the year that I learned my own limitations
and how to first accept, then overcome them. It would be the year that I would
lose someone very dear, but help dozens of strangers overcome that same loss.
It would be the year that I befriended death but fell in love with life.
In 2013, I transformed from a
scared student to a slightly-less-scared clinician. I became a teacher and a
mentor before I even hung my diploma on the wall. I met some colleagues who
seemed bent on stopping my progress but many more who supported me like family.
I discovered that my passion mattered much more than my age and experience to the
patients and families experiencing their own personal hells.
I dipped my toe into the waters of
medicine and-without warning-someone pushed me into its depths. I coughed and
sputtered and kicked my legs just hard enough to stay afloat. But by the end of
the year, I swam.
And, perhaps most important of all,
I was privileged to share my experiences with you. This blog has served as an
outlet for my triumphs and failures. It has connected me to people around the
world who have felt the same fear and pain and elation in their own careers.
It, hopefully, can teach future clinicians a few lessons that I only learned
through sweat and tears and heartbreak.
The experiences of the first year
of clinical practice are invaluable and beyond replication. However, they come
at a cost. Like training for a race, the first day is always the hardest.
Remain dedicated and persistent. Surround yourself with supporters. Heed
helpful criticism. Mute those who detract for their own pleasure. And on the
days when you feel beaten down, exhausted and close to failure, just remember
that somewhere there is someone grateful that you entered his or her life.
Of course, you will have to figure
most of this out for yourself. Because a year ago even this blog would not have
prepared me for what lay ahead. I sat in that airport staring at my phone, took
a deep breath, hit the "Call" button and waited for the voice on the other end.
"About that job offer," I told the
recruiter, " I'll take it."
I'm too young for this. That's what everyone says-or at
least thinks, the way their eyes track across my features, down to the name on
my coat, then back to my face. It's OK. I tell myself that I can earn the
respect automatically granted to someone with a few gray hairs. Besides,
there's a difference between age and maturity and these days I don't feel young.
It's not that I'm jaded. Far from it. I still care about
every patient that rolls into my unit and every family member that shuffles out
of its doors. But I watched a man die on Thanksgiving Day. I wrapped my arm around
his wife's shoulders-a woman my mother's age-while I switched off his life
support and bid farewell to my innocent youth.
Don't feel bad. I know what I write can be a depressing but
that's not what I want. Most days I don't even leave work sad. Because every
time I see someone die I get a little closer to learning the secret of life.
I've already told you that, in the ICU, the scoreboard
is rarely in our favor. I've shifted my goals away from "saving lives,"
though my mom still thinks that's my job. If it was, I wouldn't be very
satisfied. People will die. I've decided to worry less about the existential
question of "why" and focus on what I can control, the "how."
I think everyone has some idea in their head about how they
would like to die. They might say "in my sleep;" that's always a popular
answer. The lack of awareness brings comfort. Most people would choose
"painless" and in modern medicine that's easy enough (though the application is
often botched). But these answers are reflexive, generated by fear and aimed at
avoiding the physically unpleasant.
The next response will be some variation of "surrounded by
those I love." Children and grandchildren are often mentioned as well as the companionship
of a long-wed spouse. Ah, now they are
starting to get it. These answers aren't offered impulsively for a sense of
protection. They come to mind because they represent something else: a sense of
accomplishment in life, a completion of purpose.
In a fantasy death, most people are 80 or 90 or even 100
years old. And from what I've seen, the older someone is, the more accepting
they are of death. I don't think that the age itself is a comfort or that the
number on your birth certificate matters. But even the most deliberate person
figures 80 or 90 years is enough time to accomplish the things that matter.
But what about the others? What about the globetrotting
businessman in his 60s or the 54-year-old mother of two college students or the
32-year-old who hasn't sent her first daughter off to kindergarten? Surely
their greatest deathbed fears revolved around unfinished business. The same
reason I had a lump in my throat when they passed.
Now you remember that this wasn't supposed to be a
depressing blog and I promised some bigger lesson. Here it is: death will
happen and there is no telling when. You can't be angry about death just like
you can't be angry about gravity. There is no debate. So don't ask what we will
do about death. The real question is: what will we do about life?
The daily brush with mortality has had a strange effect on
me. It didn't make me sad or scared or even pessimistic. If anything, it
produced the opposite effect. I've started to take a few more risks, have a
little more fun. I spend a little more money and eat a little more dessert. I
skip the gym on occasion for the opportunity to try something new. And if
something scares me, I do it.
If you believe age matters, maybe I really am too young for
all of this death. But I'm not afraid of it. I've seen it enough; we are old
friends. The only thing I am truly afraid of is not having lived.
"There's no way you should look so calm doing that."
during the first year of PA school a handful of my classmates had met at the
gym before our lectures. One of them looked over the numbers on the display of my
treadmill and shook his head.
"If I was
doing that right now, I would be in serious pain."
turned up the corner of my mouth in a smile. He couldn't tell but, with the
machine set at my race pace, my legs screamed with every stride. My lungs
burned. A little stab of pain jabbed my side once and then again. But none of
this showed on my face because of one key factor: experience.
I had been
there before, hundreds of times. Years of running and dozens of races meant I
know how to flirt with the edge of exhaustion. My body could shout at me, warn
me of the danger, but it wouldn't cause panic. I knew when to press my pace and
I knew how to rest in motion. I knew my abilities and, more importantly, I knew
often start too fast. They are excited and confident. They haven't failed
enough, haven't smacked into a wall down the stretch and watched the
competition speed past. And when they near that limit, they panic. They waste
the last of their energy and stop in their tracks.
New runners haven't mentally
overpowered that physical limit, so they don't know that they can. They don't
recognize the positive signals, sensations of "Yes, this works," because they
haven't crossed enough finish lines. They can't predict a mistake because they
haven't lost enough races.
this first year of my career like a new runner. I jumped at the blast of the
starting pistol, ignorant to what lay ahead. Far too soon, I encountered
obstacles that left me gasping for breath. Some were professional, the gaps in
knowledge and expertise. Some were interpersonal, the potholes of workplace
politics. Some were emotional, the search for satisfaction in daily tragedy.
several months I still doubted if I would make it as a critical care clinician.
The occasional awkward stomp of my foot resonated louder than the more frequent
precise ones. As my lungs burned from the steep learning incline of this first
year the temptation to stop moving, to flop to the ground and attempt some
easier path, nearly overpowered me.
Doubled over, hungry for air, I wondered
where the finish line stood or how far I had come. I watched more experienced
clinicians run past with ease. I thought I was in great shape, smart and
well-trained, but they had something I lacked: experience.
I had forgotten a painful lesson I learned as
a runner many years ago: the first race
is always the hardest.
though, a strange thing happened. I struggle a little less. Small tasks that
once baffled me became just a bit smoother and more natural. I stumbled less
and found a better pace. I started to recognize the patterns before me, steered
toward the successes I previously found and avoided some of my old mistakes.
This somewhat more graceful stride reminded me of another lesson that I had
taken for granted: you conserve more energy when you relax.
to become familiar with my route. Soon, the ominous twists and turns became
more friendly territory. The role of perpetual newcomer I had played as a student
in clinical rotations changed. Strangers knew my name. Some of them even asked
for my advice and, inexplicably, took it. The road, once crowded with
competitors, now seemed packed with teammates.
I know that
I am still a novice and the real race is far from over. I have miles and miles
to cover before I will feel comfortable with my role. But even the slightest
wisp of experience is a wonderful gift. Because if, like my first race, I cross
this first-year finish line with sore legs, burning lungs and bleeding knees, I
will have passed the hardest miles of my career.
I used to be afraid
Cold sweat across my brow
Cotton mouth and tremble legs
My voice could not be found
I used to fear the sick
Such fragile flesh and bone
Their mist of breath dissipate
And they are taken home
I used to fear mistakes
Until I made a few
The sun still rise, globe intact
No matter what I do
I used to fear my path
Pure darkness leads the way
Tangled weeds that reach for me
A toll for all to pay
I used to fear myself
Clear hurdles set so high?
The doubt and hate replicate
No ceiling but the sky
So yes, I'm still afraid
Respect my mortal bounds
But I gaze celestial
With feet firm on the ground
The first year of clinical practice can chew through the
toughest skin right down to the marrow of your bones. Doubt creeps into the
crevices of your brain, the dark recesses that you never knew existed. The
early challenges of your career can force you to examine the biggest decisions
of your life. Fortunately, there is one I have never doubted.
People have questioned my decision to become a physician
assistant throughout my career. The inquiries are usually based on innocent
curiosity. Many of my coworkers have had limited exposure to PAs or grew up and
trained in countries where we simply don't exist. My position at a large,
globally recognized academic center has, in a way, turned me into an
international ambassador for the profession.
Occasionally, less respectful (though often
well-intentioned) comments require a response as well. As a student, I cringed
the first time a respected preceptor told me "You are really competent, you
totally could have gone to medical school." While the influx of young, talented
students to the PA profession seems to have baffled some outsiders, these (now
frequent) comments merely serve as a reminder that our ranks are still
I'm known to delve into lengthy, animated rants on the
virtues of the PA profession, but I try to limit the number of people I expose
to that treatment. Instead, I prefer to distill this tirade into some key
The Top 3 Reasons to
Love the PA Profession:
- Ultimate Career
Flexibility - The PA profession
is the slinky of healthcare. It offers flexibility beyond any other career. Our
chameleon-like ability to adopt the practice scope of our supervising
physicians means we can transition from prescribing outpatient medications to
managing an ICU ventilator to opening an abdominal cavity in the operating
room. We aren't limited by specialty certifications or required residency; we
can collect an eclectic mixture of experiences and skills over the course of a
- An Emerging
Healthcare Force -The PA
profession hasn't turned 50 yet. That youth offers some great advantages. PAs
are not hampered by centuries of outdated tradition or insurmountable political
hierarchy. Like a hot piece of metal, the profession is malleable to the
changing forces of the healthcare landscape. It is wide open for young leaders
and pioneers to offer new ideas and leave an immortal impression. You can
pretty much be the first PA-anything.
Just ask PA Karen Bass; that is, if she isn't busy representing her district in
- Return on Investment -Money
should never motivate someone to enter the healthcare industry. However, if you
decide to dedicate your career to serving others, there is nothing wrong with
getting a bargain. Based on the initial time and economic investment, PAs receive
outstanding compensation, job security and career options nearly anywhere in
Much more importantly, the job satisfies those who wish to
impact the lives of others in a deep and meaningful way. It's hard to find another
master's degree that offers the same career rewards.
The Not-Top List
While the above list is far from comprehensive, I
purposefully omitted several common (and erroneous) ideas I have heard over the
years. Responses like, "We work less/have a better lifestyle," or, "We get to
spend more time with our patients (than physicians)," or, "PAs are just better
at dealing with people," are impossible generalizations and, in nearly all
cases, are factually inaccurate. Anyone supplying these reasons, especially at
a PA school interview, should explore more hands-on opportunities with PAs in
the work force.
PA Week recently brought well-earned recognition to physician assistants across
the country. Our profession was featured in major publications, national
television spots and popular morning shows. The most powerful government and
industry leaders expressed their appreciation and countless breakfast, lunch
and dinner gatherings were held in our honor.
acknowledgement from the general public feels great. Our profession can
sometimes feel like the neglected middle child of the healthcare industry. A
little cheerleading boosts the morale that the daily work grind drains out.
But unsung praise resonates louder. I will
always remember the day I accidentally overheard one nurse tell another:
"You're lucky you are with Harrison today. He's a great PA."
even that praise can't outshine the recognition that comes straight from the
source: the patients. They don't always say it out loud in the Intensive Care
Unit. Some just ask for my name, smile and nod. Others grip my hand and give a
squeeze before I leave their room. After one particularly grueling day, a
patient's family sent me a present from the hospital pastry shop. "I don't know
what you did," the unit secretary said as she handed me a box, "but that is a
lot of cookies."
little appreciation can even change the course of your career. I sat in the
cafeteria of a Veterans Affairs hospital on one of my final rotations as a
student. My white coat and name badge were stuffed in a desk upstairs as I
enjoyed my meal in relative anonymity. Until an unfamiliar voice called out my
took me a moment to place him. Then it struck me: the last time I saw this man
he was sprawled across a hospital bed, a porcupine of lines and tubes. He had
never said a word to me-an endotracheal tube saw to that-but we had shared
conversations every day in the surgical ICU. Now he stood before me in jeans
and a t-shirt with an outstretched hand.
thanked me for the time spent with him while he recovered from cardiac surgery.
I was so taken aback by his transformation that I could only smile and shake
his hand. Seeing him walk out of the door that day, after being so close to
death, may have led to my eventual career in critical care medicine.
week a crowd of PAs gathered in my hospital to celebrate the PA profession. Someone
stepped up to a podium with a microphone and announced that my Medical ICU
colleagues and I were named the Best PA Team in our health system. Everyone
clapped and some of my coworkers accepted shiny plaques and took a bow.
what I imagine happened, anyway. I wasn't there.
was across the campus, several buildings away in a completely different world:
the ICU. I was busy arranging a last-minute procedure for one of my patients. It
meant I would stay late and miss the ceremony, but that is exactly where I
prefer to spend my time.
all, it seemed a little strange to accept an award while I am still working to
earn it. And while the praise of my employers was a generous gesture, my real
boss was the sick lady in that hospital bed.
We have carved deep into the second half of my first year as
a professional physician assistant. This is the perfect time for a Quarterly
Check-Up to examine some of the biggest lessons over the last three months
We learned that our
patient's beliefs can trump the strongest medicine and that our acceptance
of those beliefs makes us better clinicians. We felt the growing pains of a
young provider, the thousands of little
mistakes and the attitude it takes to overcome them.
We realized the strength
of our profession: the collaborative system that makes us the most flexible
professionals in healthcare. We accepted that our time as a student is over,
but our scattered
network of PAs brings a new sense of security and adventure. We finally
tackled some of that pesky
debt. And we taught ourselves a
lesson that could never fit into our textbooks.
Random Thoughts from This Quarter:
The single biggest breakthrough of my career may
have been earning the respect of my nurse colleagues. I have never been an RN
and won't be able to fully appreciate what they do, but it's clear that they
run the show. So here's a big thank you to all of the patient nurses who hung
in there while I figured out all of the little things.
On a not-so-unrelated note, discontinue rectal
Tylenol when we have oral access. Got it!
Working weekends has totally different consequences
during football season. Oh no, what have I done?
Show a spark of your personality on the job. In
a field that typically represses its own humanity, this can really improve your
environment. When people die every day, it's even more important to smile.
Many issues debated among our profession bring an
emotional payload. This is understandable, as a group that has dedicated an
enormous amount of time, money and energy to their craft has really invested a
portion of their soul. By expressing my views on a public forum, I occasionally
disagree with some of my more experienced and respected PA colleagues. One of
my recent blog posts in particular touched
off a debate.
I understand the impulse to dismiss
the insights of younger and less experienced members of the profession. But
there is value in a fresh pair of eyes on an old set of problems. Progress is
rarely jump-started by strictly following the ideas handed down before you.
Some "unpopular" viewpoints from the new blood of this profession may be
exactly what it needs.
I've tried to take you as far into the ICU as possible
without violating HIPAA or the privacy of those around me. The next three
months will end my first year as a practicing PA. The best may be yet to come.
But if there's one thing I have learned in the ICU so far, it's that you can
never predict the future.
I remember all of my great
preceptors: The ones who reaffirmed my choice of career or mentored my special
projects or were less of a taskmaster and more of a friend. As a student, I
pictured myself in their position, guiding some wide-eyed student through the
treacherous surf of clinical rotations. I imagined that sage, professorial
Harrison would have years of experience and a few gray hairs to prove it.
wrong. That first PA student bounced into my office during my first year of
practice. She arrived to glean some wisdom from a veteran intensivist and
instead found a fresh clinician still kicking the tangled graduation robe from
around his feet. I've heard some cliché about faking things and making things
and luckily, in this ICU, even just six months provides plenty of stories.
PA student was sharp. She sat on the unit and dove into chart reviews. She tore
apart the history and performed her exams on our sickest patients. She tackled
ABGs and dissected the most complicated acid-base disorders. She was
overwhelmed, she said, but then again, who wasn't? Perhaps the biggest
difference between her and I was a diploma and a paycheck.
also lucky. Her first day with me in the ICU produced a shocking finish. A
previously stable patient began to crash. As his heart rate soared and his
blood pressure dropped and we slapped the pads on his chest to cardiovert him,
my student witnessed a real critical care emergency. She stayed late to watch
his intubation and by the time she left she had finally seen a truly sick
student missed something. It is something I also missed as a student but it has
defined my career in critical care. While the ventilator puffed its breaths and
the vasopressors dripped and the million-dollar work-up cooked in the lab, we
performed a different kind of task.
the long bedside talk with my patient's wife, the tears and the hugs and the
promises to not give up. As my patient slipped into death that night, there was
a phone call that left the base of my skull tight.
The next morning, another phone
call, this one to my patient's daughter. It left a lump in my throat after all
of the apologies and condolences had escaped. That afternoon, more phone calls:
An angry brother who wanted answers-a conversation that left my head
pounding-and a depleted widow who extended her thanks and broke my heart.
later if my student had missed out on the most important part of critical care.
I wondered if I should have told her that the medicine was easy but the
humanity was backbreaking. I wondered if it would turn her away.
I think she saw what she needed: the excitement and the glamour. After all,
it's what draws us to critical care. That other part, the part when we tear off
a little corner of our soul and hand it to each family, is reserved for us.
Those brave or stupid enough to enter the ICU day after day may be driven away
by the burden. Or they will stay because it is the only weight that feels real.
You saw it coming, but there was nothing you could do to
stop it. It sat in the back of your brain during school and, as graduation date
approached, it grew. While you battled the more horrifying demons -- exams,
clinical rotations, sleep deprivation -- this little gremlin lurked in the
shadows and waited for its turn to terrorize. Now that you are certified and your
dream job is secured, you must face what has grown into a true monster: your
sours the taste of those first, glorious paychecks like a fat bill from the
Federal Loan Service (or, heaven forbid, a private loan source!). Never fear.
As a professional in one of the most in-demand fields, there are plenty of
sources to help relieve your debt. Here are five that you may not have
- National Health
Service Corps (NHSC) Loan Repayment Program: NHSC is by far one of the best
options to quickly repay your debt while serving a population in dire need of
medical providers. Clinical sites nation-wide are graded based on their need
for medical providers; the highest-scored locations will give up to $60,000 of
loan repayment for a two-year commitment from full-time clinicians. Smaller
sums are offered for part-time commitments and candidates can extend their
contracts beyond the initial two years. Sites are typically primary care
clinics in rural or inner city areas. If your prospective employer is not
listed as a rated site, you can submit an application and make them an eligible
This option is often viewed as a
"primary-care-only" opportunity. However, many people forget that all Indian Health
Services (IHS) and Federal Bureau of Prisons (BOP) sites are also eligible, including
hospitals and the larger Federal Medical Centers. Be sure to apply if you work
at any of these locations.
More info here: http://nhsc.hrsa.gov/loanrepayment/
- U.S. Armed Forces
loan repayment programs: Most branches of the U.S. military offer loan
repayment in exchange for a service commitment. This option is also available
to the Reserve and National Guard components, though the amount of repayment,
length of service and other details can drastically vary. Clinicians with a
strong interest in military service should discuss these options with a
recruiter and ensure they are added to any recruitment contract.
information is available on the websites of the particular military branches:
- Public Service
Loan Forgiveness Program: This often-overlooked loan repayment option is
perfect for clinicians entrenched in debt for the long haul. The program is
geared towards graduates working in federal government positions or nonprofit
organizations (many hospitals are in this category) and forgives the remaining
balance of all loans after 120 payments are made. What does that really mean?
If you work for a qualifying employer, you need to make only minimum payments
for 10 years to wipe out your debt. Who says procrastination doesn't pay off?
More info: http://studentaid.ed.gov/repay-loans/forgiveness-cancellation/charts/public-service#what-is-the-public
- Perkins Loan
Forgiveness: You may have this in your back pocket and not even realize it.
Perkins loans are federally-sponsored loans that are awarded based on financial
need. Just fill out a Federal Application for Student Aid (FAFSA) prior to each
school year and accept the loan. After graduation, complete the appropriate
paperwork. The loan is deferred and a portion is cancelled each year for
graduates working in healthcare (just like you, PA-C or NP).
- Private employer
loan repayment: It's a job-seeker's market. Exceptional candidates, even
new graduates, are commanding excellent incentive packages, especially in
specialties with high demand (primary care) or high turnover (emergency
medicine, critical care). Employers are focused on retaining talent and will
sometimes offer loan repayment packages in exchange for a time commitment. This
is an excellent compromise during negotiations when employers can't or won't
budge on the base salary offer.
A Final Word
else, relax and have patience. You will make plenty of money during your career
and the burden of debt will eventually become a distant memory. While these
programs can certainly give you a boost, any PA or NP can easily manage their
debt with hard work and responsible spending. Don't forget to stash away a
portion for retirement from the beginning and allow yourself the occasional
The wind whipped around the rooftop
of the Philadelphia high-rise apartment building and tousled the hair of
perhaps the only person who knows exactly what I have experienced over the last
eight months. We sat overlooking the urban expanse and swapped stories of silly
daily events, gut-wrenching stress and, of course, death.
Like me, my
friend had left physician assistant school and accepted a job in one of the
most intense fields in medicine. And, just like me, she had left everyone she
knew to lay roots in a brand new city. Our mutual therapy session continued as
the sun disappeared and darkness settled over her new home. The conversation
inevitably drifted toward our days in school together and the friends we had
left to pursue our new careers.
scattered -- our old classmates, colleagues and friends -- to different corners
of the country, and even the globe. Their lives have already seen so many
triumphs: successful careers, engagements, weddings and even new babies. They,
no doubt, have also faced down many of the challenges that I encountered this
year. It's tempting to feel a bit disappointed, even sad, that such amazing
people are continuing their stories without sharing the daily encounters that
made our time together in school so special.
paths have diverged, but we may have gained something even better. Plants
survive by scattering their seeds far from the parent that produced them. In
order to grow and flourish, they need to escape the shade of the branches from
which they sprouted and find their own fertile ground. And even if the sun,
those environmental stressors we all encounter, can scorch us, it is exactly
what we need to grow.
So yes, we
came from that safe PA school tree and scattered like seeds in the wind. And some
of us ended up in places that seem more harsh and barren. But we are prepared
for it. Heck, we are made for it. We need it to grow to our greatest potential.
A few years
from now, you will see something truly impressive. We won't be scared little
seeds anymore, or even little saplings. When you look across the area that we
covered-from New York to Pennsylvania to Ohio to California and even Japan-you
will see a forest of strong PAs. And in an ever-changing healthcare
environment, our patients need that shade.
People always want to know the secret ingredient. And,
frankly, I can't blame them. In a lot of ways the physician assistant
profession seems too good to be true.
We study medicine for two to three years after obtaining a
bachelor's degree. We practice medicine without post-graduate training or
residency. We can switch specialties without recertification and our scope of
practice can change from one day to the next.
Naturally, people wonder how, in a complex and high-stakes
field like medicine, this amount of career flexibility is even possible.
Sure, we have great training programs. Plus, many PAs come
into their careers with years of related experience. And our skills are honed
as we gain experience on our jobs. But here's the real reason our profession
works: the supervising physician.
A faction of PAs reading this just cringed, though I'm not
sure why. There seems to be a perception that our required agreement to
collaborate with a physician somehow holds us back as providers. Calls for
increased PA autonomy inevitably lead to suggestions that we abolish the
supervisory agreement. While there are some instances where the MD-PA
partnership is a liability (and a largely logistical one at that), these views
The truth is, the PA-MD partnership is the single strongest
aspect of our profession. It is the reason I could apply for a job in any
specialty right out of school (and land one in a field like critical care).
It's the reason I didn't toil through a residency program with outrageous hours
and minimal pay. It's the reason I can place central lines and perform lumbar
punctures. It's the reason I can spend my evenings in the Emergency Room or the
Operating Room or any other room that chooses to hire me.
Our chameleon-like ability to adapt the scope of practice of
our supervising physicians is what attracted me to the physician assistant
profession. My supervising physicians aren't shackles around my ankles, they
are mentors and partners and friends.
However, navigating the PA-MD relationship is not always
easy. Last time I counted, I was contracted to 49 individual supervising
physicians. That group includes dozens of personalities, preferences and quirks
that factor into my clinical practice. Try
these tips to get the most out of your PA-physician collaboration:
Respect the Scope: Good
employers will allow PAs to practice at the top of their license at all times.
However, this must still fall within the scope of the supervising physician.
While PA independence is at an all-time high, make sure you don't find yourself
outside the limits of your physician's
scope of practice. That can be a very lonely place.
Close the Loop: After
you have worked with a new physician, reserve a few minutes to get feedback
about your performance. Almost every clinician will respect this proactive
approach. Often, this will also provide an opportunity to let the physician
know how they can help you grow in your practice. This form of "closed-loop"
communication will foster trust and a stronger clinical team.
Be Direct: If
there is an issue with a supervising physician, address it early and
professionally. You can brush aside small troubles, but a real problem will
eventually boil over into workplace conflict. Correct a misunderstanding as
soon as possible. If you set a high standard of respect in the workplace, the
PAs following behind you will benefit from your leadership.
Pick Your Battles: Unfortunately,
there are still people who do not want to work with PAs. Luckily, this minority
of physicians who oppose our profession shrinks by the day. Don't focus on
trying to convert the non-believers. If your professionalism, hard work and
clinical skills don't speak for themselves, that battle cannot be won. However,
you should still expect to be treated with courtesy and respect in the
At the risk of sounding arrogant (my close friends are
shaking their heads and thinking, "That ship has sailed, Harrison...") I must
confess something: I haven't made a lot of critical mistakes in life.
I'm not saying I am perfect. I am light years away from
that. But if you had to write the tagline for the story of my career thus far,
it wouldn't work as a long-shot-comeback or a gritty tale of redemption. For
whatever reason, I have avoided the minefield of pitfalls that often delay,
sidetrack or otherwise curtail professional progress.
Unfortunately, that also endowed me with a massive flaw. When
it comes to the development of certain skills, I have to admit I am late to the
party (and not in any fashionable way). You
see, I am still learning how to deal with setbacks. I am figuring out how to
step back from a situation, examine why it doesn't work and attack the problem
in a different way.
Through much of life we can rely on our strengths to compensate
for our weaknesses without ever really addressing them. But medicine has a way
of exposing those flaws anyway. The difference between success and failure is
not a matter of how many flaws we have, but what we do about them.
The last 6 months as a PA-C have shone a spotlight on every
hole in my professional armor. And sometimes I feel less like a clinician and
more like a slice of Swiss cheese. For someone who has cruised past a lot of
speed bumps in life, that is pretty terrifying. A part of me wanted to run and
hide from the adversity that a new PA faces every day.
But none of us chose this career because it sounded easy.
And every screw-up sears a vital lesson into my brain. The hard-knock education
that life delivers is the difference between knowledge and wisdom. One you can
acquire with training; the other just happens over time.
I'm lucky enough to be surrounded by people who care enough
to give me direct feedback. Their only agenda is molding a good clinician. If
you find those people throughout your career, keep them close. Often, your
flaws-those holes in your armor-are better seen from a distance.
It's tempting to look upon your own shortcomings with a
sense of disgust. Some people carry their mistakes as a lifelong burden, as
evidence that they aren't good enough for their relationships or their job.
They see the holes in their armor only as an imperfection and not an
But you know what else is full of holes? A sponge. And one thing
a new PA can do is use those flaws to soak up every bit of knowledge and wisdom
that comes his or her way. Because the only thing worse than making an error is
missing the lesson that it offers.
My first mistake was trying to shake my patient's hand. She smiled, looked at mine and shook her head.
"We like you," my patient's friend said with a smile. She was standing at the patient's bedside in the intensive care unit. "But we don't touch."
Then I noticed their similar dresses, long and plainly designed with only solid, dark colors for decoration. Their traditional clothes, next to the beeping alarms and flashing lights of our ICU gadgets, looked like the result of someone meddling with a time machine.
The embarrassment from my initial infraction kept me from asking any more questions, though I had many. Where are you from? What do you believe? What can I do to treat you? What can't I do? I wouldn't gather until later, as the Yiddish phrases began tumbling out, that she was an Orthodox Jew.
"Can I listen to your lungs?" I asked my patient.
"Of course you may," she said. "Touching for medical care is fine."
Ah, now I was getting it.
Patients have a variety of beliefs that guide their daily activities and interactions with the world. They hold these beliefs as sacred, sacrificing all kinds of pleasures and conveniences and even social acceptance in order to follow their cultural guidelines. But when it comes to health, to medicine, we can brush all that aside, at least for the moment. A handshake was too intrusive, but my physical exam-much more intimate-was allowed for the sake of survival.
To me, that made perfect sense.
I encountered something like this once before. Last summer, when the heat of the day scorched on for hours into the evening, my patient collapsed. No one really knew why, but since she was so dehydrated it seemed like an easy fix. But I had wondered why this woman, already fragile from age and comorbid disease, abstained from food or drink on a day like today. The answer is only simple if you ask.
She had fasted for religious purposes, from sun up to sun down. The Muslim holiday of Ramadan fell during the longest days of summer, but that didn't stop the devout from practicing their faith.
Intrigued, I met with Muslim leaders in the community and with chaplains at my hospital. I learned that, according to Muslim beliefs, there were plenty of exemptions from the fasting requirement. One of the exemptions allows the sick to skip the fasting ritual. While my patient saw herself as an able-bodied woman of even stronger faith, medical providers like myself could suggest taking advantage of the exclusion. We just needed to open the conversation.
Yet again, it seemed that faith was willing to take a back seat to the medical needs of the faithful. As medical providers, we can stand proud and know that our care takes priority over eons of established religion. As a testament to the progress of the modern age, our judgment truly comes first.
Except when it doesn't.
Except when the patient in question isn't an Orthodox Jew or a Muslim, but a Jehovah's Witness. Except when maintaining his faith trumps all, even life itself. Except when he looks at you with soft eyes and tells you "No blood products, ever," and thanks you for obliging. Except when his hematocrit drops and he becomes dizzy and falls over. Except when he vomits a cascade of bright red blood down the front of his hospital gown and the color drains from his face.
Except when the one thing that can save his life is forbidden.
Then we merely stand aside and bear witness to faith.
We are halfway through my first year as a professional PA.
You may stand up to stretch, run to the bathroom or refill your favorite snack.
But there is no halftime intermission for this PA. In fact, the intensity (and
excitement) of the PA-C life has just begun. As we pass the mid-point, let's
take a look back at what we've learned.
Onboarding Can Take a
Long, Long Time: The paperwork obstacle course constructed at the national,
state and local levels can leave you dizzy and nauseous. My onboarding process
stretched well into the second quarter of the year and, if the howls of my
classmates and colleagues are any indication, it appears I am not alone. Keep
calm and mail those documents.
CME: Pricey and
Priceless: One difference between a good
first job and a great first job: the
former teaches you to perform tasks; the latter expands your medical knowledge.
Nothing beats an investment in your own professional growth.
Try to take advantage of Continued Medical Education (CME) offered
by your employer. But beware third-party CME offered by other companies and
organizations; it often comes with a hefty price tag. Just make sure your
employer picks up the bill.
Find A (Work) Best
Friend: When you work 10- and 12-hour days, your job is like your second
home. That means-for better or worse-your coworkers are your second family. Try
to find at least one person at work with whom you can trust, confide in and
share a laugh. That work best friend serves as an extra support to unload the
weight of a new medical career.
The Bitter and the
Sweet: Working in medicine, particularly in the Intensive Care Unit, can
reveal the unfairness of life. I've cared for patients without hope of survival
and I have watched others defy expectations and walk away from the precipice of
certain death. Sometimes there is no way to predict or explain these ultimate
But I learned that death is far from the worst outcome. In
fact, it can bring relief to both the suffering patient and the loved ones they
leave behind. That sweet finality is sometimes the best care we can offer.
The Stories I
Couldn't Share: Readers of my previous work know that some experiences I
pour out as they happen and others take months to digest and share. The complex
and heart wrenching issues faced daily in the ICU often take the perspective of
time to place in the proper context. There have been rich, human experiences
over the last few months that deserve more than a hasty composition. They serve
you-and me-better as thoughtful lessons than emotional reactions. Stay tuned
and thank you for reading.