Universal PA Career-related Stressors & Challenges.

         

        It is a given--all Physician Associates/Assistants (PAs) along their careers encounter "universal" stressors and occupational challenges. Herein in this post, a brief overview of the eight most common are discussed:

Burnout: The well-known demanding nature of medicine, with long hours and high patient volumes, can lead to burnout for PAs. This can manifest as exhaustion, cynicism toward their work, and often developing feelings of inadequacy in meeting their job responsibilities. For example, a PA working in an understaffed workplace might feel constantly rushed, unable to give patients the level of care they deserve, and eventually become emotionally drained and unconsciously disengaged. 

Burdening Workloads: Since the COVID-19 pandemic healthcare provider shortages have markedly increased, thus PAs are often expected to manage a significant workload. This can include seeing a high number of patients per day, performing administrative tasks, and trying to stay up-to-date on medical advancements. In this situation, a PA in a primary care setting might be juggling appointments, prescription refills, and managing complex cases, all while feeling pressure to keep wait times down and increase practice revenues. A reason why many leave medicine earlier altogether. 

Practice limitations: Depending on the state and their supervising physician, or practice protocols, PAs may have limitations on what they can diagnose, treat, or prescribe. This can be frustrating for PAs who are qualified to handle a wider range of cases but are restricted by outdated practice regulations. For instance, a PA in a state with restrictive practice laws might not be authorized to prescribe certain medications they believe would benefit their patients in managing their medical conditions. This creates unsatisfactory & unfulfilled sentiments for any practicing PA.

Heightened Emotional toll: PAs regularly deal with complex difficult situations, including litigious patients, deaths, and serious illnesses. This can take an emotional toll, especially without strong support systems in place or where work-life balance considerations are followed. As an example, a PA in oncology might develop close relationships with patients, making it especially difficult to cope with their passing, or an ER PA dealing with frequent devastating child abuse presentations. 

Poor Compensation Models: While PAs generally enjoy good salaries, some may feel they are compensated unfairly for the level of responsibility required and expected by their employers. This can be especially true if they are performing duties similar to physicians but earning significantly less. This naturally leads to a PA feeling very much undervalued. 

Unsupportive Employers: PAs generally would feel nonsupported when they feel/experience their organizational or practice concerns/issues are not heard or addressed for the common good or their well-being. This can be especially true if they have no voice or “representation at the table”. This has led to the rise of the unionization of PAs at large because they have felt professionally disrespected by their employer. 

Negative Workplace Politics: While PAs generally have good salaries, some may feel they are not being compensated fairly for the level of responsibility they take on. This can be especially true if they are performing duties similar to physicians but earning significantly less. 

Toxic Colleagues: While PAs generally are supportive of other PAs, not everyone conforms to this professional practice. Ego and personality differences sometimes cause or lead to professional tension and conflicts for a myriad of reasons. Among some of these reasons, one can always find distrust, envy, or even personal insecurities coming into play in these negative relational dynamics.

“Straight Talk" About Patients Handoffs Veiled Liabilities: The Signed-Outs & Bounced Backs–what you must consider.

As a hospital-based & former Emergency Medicine Physician Assistant (EMPA) at an urban inner city Level I trauma center, one of my biggest challenges was not only to spot the drug-seeking patients or rule out subtle life-threatening presentations but also to juggle & manage flawlessly two other high-risk types of patients: the “bounced-back” and/or the unimproved “signed-out” ones. Two potential med-mal time bombs waiting to happen most likely if not afforded the right clinical followed—through diligence or taken seriously on your watch, particularly when the liability factor was transferred to you by a recently graduated colleague or an intern (a 1st year resident) completing their work-related required shift. 

Why is that you ask? Well, simply because these two types of patients in some instances are usually either insufficiently or possibly improperly worked up. Thus, easily leading you astray in the already worked up supposedly ready-to-go “signed off” patient-shared presentation from the initial clinician. Especially when the clinical management or your partner’s clinical decision-making process was determined pending the patient sobering up or diagnostics results returning normal or “within normal limits” before you decide on the final disposition. Meaning you have the final say. But, before you discharge that patient, one question you must ask yourself is this: Do I have all the pieces of the puzzle fitting properly before discharging the patient? Again, does the presentation, hx, and findings fit the signed-out given to me? 

Typically these patients can present already “diagnosed” or “labeled” by another facility healthcare provider or simply yet by one of your very own colleagues from a different shift. This “pre-packaging” can easily lull you into a false sense of security. And, therein lies the legal risks & challenge(s). Given these situations & unconsciously you’re more apt to engage in potentially perilous clinical activities or behaviors unlike your usual self-methodical approach when working up your very own patients. These faulty cognitive derailers like the following examples listed next can set you up for significant medical mishaps. Let’s dissect them & expose their perilous outcomes, to both, you the provider, and the patient, the recipient of your faulty or flawed narrow-framed medical decision-making “shortcuts” known as heuristics. Here they are: 

1. Overconfidence Bias. Beware and be careful of either you considering yourself or the other party as competently flawless as you think you are. Be always cognizant of this dangerous mindset because you or your partner may have acted on incomplete information, or hunches, or very limited obtained data for that matter. This type of delusion of grandeur (inflated opinion) may result in catastrophic outcomes if we tend to believe we know more than we do, especially if we never had the “right” information or re-analyzed/re-assessed the presentation and/or signed off the patient altogether.

Remember, even the best of us can have “off days”…no one is perfect…especially at the end of their shifts–when they are most tired, fatigued, and very likely disengaged. 

2. Diagnosis Momentum Bias. This mindset has fooled many clinicians and accounts for “missed diagnoses” simply because you have accepted what someone else or a few others have diagnosed the patient with. 

However, you may not realize or be aware that provider A, provider B, or provider C never objectively proved the patient’s recurring or for instance their unimproved symptomatology. For all practical purposes, you engaged in becoming a “clinical copycat” since the “dx” had already been made incorrectly and you went all along.  So why reinvent the wheel? Again, clinical syndromes are not static, they evolve possibly leading to clinical instability in which you could miss a window of opportunity if fixated with the “signed-out” presented to you. 

3. Search Satisfied Bias. Here the element of premature closure surfaces because either you found or didn’t find what you were looking for in the hx or physical exam. Or better yet, your cursory workup was “okay” or acceptable” at face value. Again, be aware not everything presents classically or the overlapping symptoms may be pointing to more than one condition. This phenomenon is very well known and documented in many trauma-related presentations. Patients can present with different ailments/conditions that can be masked because they have a “distracting injury” or presentation for that matter. Therefore, it's best to do a secondary survey after the first one if no relevant or critical information was obtained initially. The bottom line is that you must remain vigilant and suspicious if the patient’s condition is unimproved or worsening or if ETOH is involved too. 

4. Anchoring Bias. In this situation, your colleague may have simply latched onto thinking his/her “first impression” was right or the only plausible one, therefore holding firmly onto that specific diagnosis. A very detrimental perspective or path to take when a patient’s course begins to prove inconsistent with the first diagnostic impression. Again this undue exerted influence or progressive development if it were to remain uncorrected, can certainly lead to possible allegations of a) failure to dx, b) failure to treat; c) failure to refer, or even d) wrongful death in some cases. This clinical inflexibility is very significant in the eyes of a judge and/or jury when the outcome of care is disastrous in terms of the outcome if there was a foreseeable medical intervention. 

5. Availability Bias. In this situation the clinician simply latches onto thinking his/her “first impression” is right thus holding firmly onto a specific diagnosis. A very detrimental stance to take when a patient’s course begins to prove inconsistent with the first diagnostic impression. Again this undue exerted influence or progressive development if it were to remain uncorrected, can certainly lead to possible allegations of a) failure to dx, b) failure to treat; c) failure to refer, or even d) wrongful death in some cases. This clinical inflexibility is very significant in the eyes of a jury.