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 This can be frustrating for PAs who are qualified to handle a wider range of cases but are restricted by outdated practice regulations.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.

Is it hard to be a PA?

     

      Like in all things in life, some things might be easier than others. But how about being a PA? That might be a little more complex to answer. Yet, simplistically speaking it can be both– hard and easy at the same time. In that vein, I will try to put it in perspective for you not so much from a clinical perspective but rather from an administrative one instead. 

      Personally, the way I see it is this: it boils down to individual and/or PA advocacy commitment level. So what difficulties specifically make it hard to be a PA? 

       For one, we (our profession) are constantly trying to prove ourselves over and over to the world that we are legit and belong in the healthcare playground like many other kindred professions. However, despite our rigorous training, and proven track record, we still fifty years later are by far more regulated, we are more unfairly scrutinized at every turn than anyone else. To make matters worse, even today, the Physician community and many nursing groups try to discount our role as healthcare team members or bring us down. 

      Another reason that it’s difficult is to accurately present our credentials to many misinformed or disinformed people inside and outside the industry when our title has “assistant” in it. Amidst this unfortunate conundrum, we [the PA community] have one thing going for us. We are a resilient group and started to move forward in our way of seeing ourselves. No matter how we are viewed or segregated, interprofessionally, whether minimized, or discounted, the patient community has started to realize and value our role and contributions. That’s what has been so hard in the past–the unleveled playing field. 

     Lastly, difficulties will always be present, however, we are starting to gain ground and be recognized, the industry generally speaking is becoming more tolerant and accepting of PA-led patient care, more so these days than when this author first became a physician extender in the late 80s. These days unsupportive employers are slowly vanishing, thus making PA practice less difficult.

      While some PAs are satisfied playing a subservient professional role in their careers, many PAs would argue that this is just setting too low a standard. It is time to assert ourselves and continue removing regulatory barriers or archaic restrictive statutory laws while continuing in our ascending trajectory. 

     In summary, from what I have seen & experienced throughout my career, the ease or difficulty of being a practicing PA while mostly multifactorial, it mainly would seem to stem from the level or degree of a PA advocacy commitment level. Professional passivity indirectly makes it more constraining to be a PA.

PA School Admission Essay Blueprint

        Through the years many practicing solopreneur PAs have launched their advisory services to pre-PAs contemplating a PA career. In addition, and specifically, a few books have been written on how to craft & tame that dreaded PA school admission essay--the subject matter to be tackled in this blog.

        Unfortunately, I don't have the coveted perfect template for this, however, I have a "blueprint" that will assist you in creating that complete essay for you. Upon completion, you should have a fairly good snapshot of yourself that the PA admission committee would extend an interview invitation to you.

        So to write a compelling piece, all you need to do is provide relevant details about yourself as it relates to the entry requirements, needed for that specific PA school program. Here are some suggestions to help you write your own best: authentic narrative

Template:

Introduction:

• Briefly introduce yourself and your previous or current academic background. Mention what interested you about the profession or experiences that led you to this career choice.
• State strongly your interest in this particular program--be specific or mention if their mission aligns with your values or focus in life.
• Briefly mention & explain what drew you into this program and how it aligns with your goals.
• Briefly summarize your skills, qualifications, and desire for a supportive environment.

Body:

Share & mention any specific social campaigns or drives, college community projects, or individuals (faculty)you admire within the organization. Also, share personal experiences or stories that shaped your desire to support a particular cause.

Conclusion:

• Again, reiterate your passion for the program and the organization's mission.
• Briefly summarize your skills, qualifications, and desire for a supportive environment.
• Express your gratitude for considering your application and look forward to discussing your potential contribution further.

Additional Tips:

• Keep it concise (500 words or less or the allotted length).
• Use clear and concise language, avoiding jargon.
• Proofread carefully for any grammatical errors.
• Be honest and authentic in your voice.
• Focus on your unique experiences and motivations.
• Research the PA Program thoroughly and tailor your essay to their specific needs and academic culture.

By incorporating your personal experiences and motivations, you can create a compelling essay that showcases your passion, and qualifications, making you a strong candidate for the applied program of your choice.

Beyond Deceitful Narratives

    Unfortunately, in this current world of media misinformation and/or disinformation, oftentimes it's very difficult to eliminate untruthful, deceitful narratives spewed by elitist social groups, or myopic organizations; specifically on the safety of patient care provided by The Physician Associate/Assistant community compared to other types of healthcare providers. As much as they try to obfuscate or veil the truth, most studies and collected data on PA-led patient care reveal a very different reality from the one usually presented about our inferior, unsafe care to the patient community.

Let's go beyond the quick glance & see what literature truly says about their false talking point:

1. Studies have shown that PAs perform at a level comparable to physicians in areas like diagnostic accuracy, patient satisfaction, and adherence to clinical guidelines. (Sources: JAMA 2009, Journal of General Internal Medicine, 2011)

2. Studies have shown no significant difference in patient safety outcomes between PA-led and physician-led primary care visits. (Source: Annals of Family Medicine 2014)

3. Healthcare System Integration:
The presence of PAs in healthcare systems is associated with increased access to care, particularly in underserved communities and rural areas. Several studies have highlighted the positive impact of PAs on healthcare costs, with their services often resulting in lower overall costs compared to physician-only care. (Sources: Health Affairs 2017, The Journal of Rural Health 2018)

4. Patient Satisfaction:
Numerous studies have demonstrated high patient satisfaction with the care provided by PAs, often emphasizing their communication skills, approachability, and patient-centered approach. (Sources: Journal of the American Academy of Physician Assistants 2012, Journal of Family Medicine 2015)

    The past and even current medical malpractice literature have consistently shown objective data positively showcasing PA practices' safe patient care outcomes. Case in point: a 2019 study published in the Annals of Family Medicine found no significant difference in malpractice claim rates between PAs and physicians in primary care.

    Based on these ( only a handful included) industry reports, PAs' patient-centered care approach makes them valuable members of the healthcare team, contributing significantly to improved access, affordability, and quality of care for patients across all socio-economic strata.

    I hope this information is helpful to you and gives you a comprehensive picture of the role of PAs in healthcare safety and quality. Invite others to go beyond the deceitful narratives.