The Decision to Become a Physician Assistant

Ironically, whether we choose to look at it this way or not, PAs all become personal experts on stress as part of their medical education. The consideration of any medical career creates stress. The prospect of long hours; personal sacrifice; a commitment to care of patients, sometimes at the expense of family; and the recognition of the intensity of a medical career demand serious consideration. Many PAs at some point considered becoming physicians. This consideration was at least understandable to our teachers, mentors, family, and friends. Becoming a nurse also made some sense (“You’ll always have a job”). Although the Affordable Care Act has brought new visibility to the PA career, it still may not be fully understood or supported by family and friends. Historically, the admissions process for most PA programs has favored the selection of risk-taking and pioneering individuals who see the PA profession as a unique opportunity. One of the best ways to understand this is to spend time with practicing PAs who are willing to provide firsthand exposure to the PA profession.

Nevertheless, the first stress for many successful candidates to PA programs has been the job of answering the question, “You’re going to become a what!?” Even the most understanding friend may still ask, “When will you be a doctor?” The most supportive friend, employer, or parent may still not understand why being a PA is a separate and different career with its own satisfactions and rewards.

Experience of Stress in Training

Next come the adventure and stress of PA training. Asked about the difference between PA and physician training programs, many of the founders of PA education are quick to point out that both PA and nurse practitioner (NP) programs, although designed to train new types of primary care providers, were also intended to be a proving ground for new concepts in medical education. Problem-based learning, the use of simulated patients, videotaping to teach patient interviewing skills, and new types of clinical training experiences were used early on in PA and NP programs before their more recent appearance in medical schools. Objectives and competency-based learning also were used to make PA training extremely efficient. As a result, the curriculum of most PA programs is intended to present a large amount of information in a short time. PA program directors often say, “It’s not that the material is so hard but that it comes in truckloads.” Students often say the intensity of PA classroom training is “like drinking from a fire hydrant.” As programs have moved to the graduate levels, PA curricula have also added significant research and management content, which places further demands on every PA student.

In addition to simple acquisition of information, the relatively short duration of PA training, compared with that of physicians, demands that PA students quickly develop a professional identity in an extremely responsible role. This rapid role transition actually accounts for much of the stress PA students’ experience. Students entering the PA profession as a first career choice generally have a successful college career as a foundation for their PA training but may have had little exposure to patient care. Thus, the stress for these students is often that of developing a way of relating to patients and seeing themselves as decision makers on the health care team. People who enter PA programs as second-career students; former registered nurses (RNs); licensed practical nurses (LPNs); military corpsmen; paramedics; surgical, respiratory, radiology, or laboratory technicians; and other allied health personnel may have had identities as members of the health care team but generally find that they have to relinquish their former identities to assume their new role of PA.

Recognizing these concerns, PA program admissions committees often seek and choose applicants who are flexible, trainable, proactive, and proficient in multiple tasks. Students who are less adaptable to the extremely rapid didactic and clinical experiences required of them in PA training may become alienated from classmates who are enthusiastically moving ahead on an exciting career path.

Another unique aspect of PA training that often creates some short-term stress—but may actually decrease long-term stress—is the emphasis on sensitive issues and interpersonal skills as part of training. Training includes extensive small-group work with faculty feedback to teach interviewing and physical examination skills. Course work is also required to include primary care topics dealing with sexuality, parenting, death and dying, cross-cultural issues, and family dynamics. In studying these topics, students are forced to confront their personal opinions and biases as they apply to interactions not only with their colleagues but also with their future patients.

Current trends in health profession education include an emphasis on professionalism and opportunities for interdisciplinary education. Giving and receiving feedback are critical skills in new educational environments. Although stressful at first, these new skills are designed to increase clarity regarding expectations and performance. As a result, minimizing misunderstanding and confusion can decrease stress.

One “solution” for stress in the didactic year is to focus on planning for the future in the clinical year. This diversionary tactic is probably most appealing for students with prior clinical experience, who may believe that they are “just putting in time” in the classroom until they can “really perform” in the clinical setting. In contrast, students with more extensive academic experience and less clinical identity may approach the clinical year with increasing anxiety. Regardless of each group’s anticipatory viewpoint, the clinical year brings certain predictable stresses:

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  No matter how well the program has prepared the site and used it in the past, some members of the physician, nursing, and administrative staff, in at least some sites, still will not know what a PA is or does.

  
  
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  Medical students assigned the same clinical placements may not understand the PA role and may at first perceive the PA student as a threat.

  
  
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  The process of relocating from site to site is disorienting. The health care system may, for the first time, appear extremely fragmented to the PA student, who may not have realized that medicine is practiced so many different ways in so many different settings.

  
  
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  The demand for documentation (charting) as to both detail and timeliness is much greater than the student had expected. Electronic health record systems are still being adopted in some clinics and hospitals, and the transition to these new processes creates stress for all clinicians—but especially for students who may be called on to master an entirely new system for each rotation.

  
  
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  Other health care workers question PA students aggressively about their career choice. What seem like “attacks” are often discovered to be the questions of individuals who are considering PA training for themselves or other colleagues.

  
  
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  When required to make complex decisions about patient care, the student realizes how judgmental he or she has been about other health care providers in the past.

Throughout the process of didactic and clinical training, the impetus is toward greater recognition of how much there is to know. Other providers may make disparaging comments about the limited knowledge base of the new PA, with little recognition of past experience or of the serious decisions he or she may have been required to make in previous employment settings. It is important to have a ready and nondefensive answer to the questions, “What is a PA, and what is your training?” Fortunately, more and more medical students and residents are familiar with the PA concept and see PAs as allies in optimizing patient care.

The increasing cost of higher education also creates significant pressure on students, especially those who have incurred significant debt in their undergraduate years. Although PA students incur significantly less debt than medical students, it is still unclear how this debt influences the employment choices of new PAs.

There is always concern that employment choices of the higher paying procedurally based specialties will move us as a profession away from our original primary care mission. Chapters elsewhere in this book discuss negotiating for the first job; however, it is fair to say that most clinical year PA students are experiencing significant stress as they consider salaries and job responsibilities for their first PA employment.

Excellent resources on the topic of coping and stress reduction during medical training can be found on the website for the American Medical Student Association. These include self-assessment tools, as well as specific stress reduction activities ( http://www.amsa.org ).