As part of physician assistant (PA) training, students receive extensive information about stress. PAs learn that almost all change creates stress, and most clinicians optimistically believe that stress can be “managed.” Typical classroom presentations include the concepts of “good” and “bad” stress, the Holmes-Reye Stress Scale as a teaching and evaluation tool for patients, and recommended treatment plans (exercise, decreased caffeine intake, improved nutrition, meditation, and even short-term psychotherapy) for patients with stress. This chapter does not attempt to duplicate that information. Rather, the focus of the chapter is to identify and discuss the specifics of stress and burnout as they apply to PAs, recommend strategies for prevention, and suggest a range of treatment interventions.
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:
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.
Medical students assigned the same clinical placements may not understand the PA role and may at first perceive the PA student as a threat.
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.
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.
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.
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 ( www.amsa.org ).
Stress in Choosing the First Job
As the student approaches graduation, the job decision becomes the next developmental obsession. Students who enter PA training with a well-defined idea of their employment choices may suddenly see other variables often as a direct result of their clinical training experiences. Opportunities to pay student loans in exchange for service to specific populations (rural or underserved inner city) may significantly influence a student’s employment choice.
Program faculty members describe new episodes of stress for recent graduates who face an extremely wide range of employment choices, many of which offer salaries and “perks” that have rarely been paid to practicing PAs in the past. In contrast to the employment scene in the mid-1980s, when the number of new PA jobs roughly equaled the number of new PAs entering the job market, the current market offers multiple positions for each graduate. In addition, the expanded access to care provided by health reform and the limitation on work hours for medical residents is forcing the creation of new PA jobs that never would have been considered in the past. Each graduate is now faced with the task of avoiding jobs that are inappropriate, as well as seriously considering offers that provide the best short- and long-term opportunities. The choice of the first PA job also shapes each PA’s ultimate view of his or her new profession. Much of the initial stress for new PAs in their first job is directly related to the acceptance of PAs in the specific employment setting. This is a particular concern if other members of the health care team are not informed about PAs. It is difficult to adjust to a new role and employment setting while also being called on to educate administrators, nursing and medical staff members, credentials committees, and billing clerks about PA issues. This stress can be significantly reduced by negotiation of an orientation process as part of an employment contract, seeking the assistance of PA program clinical coordinators to provide technical assistance to new PA employment sites, or enlisting the assistance and support of other PAs practicing in the institution or community.
Some PA graduates believe that one criterion of the “perfect PA job” is current or recent employment of a PA at the site who has enthusiastically and proactively pioneered the PA role. Other graduates deliberately seek sites where there has not been a previous PA role model. They see the opportunity to be the “first PA” as one of great potential, stressful though it may initially be.
Educating Patients and Their Families
New graduates are often unprepared for the number of patients and health care professionals asking “What is a physician assistant?” It is important that PA programs train their students and graduates not only to expect these questions but also to regard them as opportunities. Unfortunately, some PAs stressfully view each such encounter as further proof that PAs are still not accepted and that the profession, state and national PA organizations, and PA programs are not doing their job of public education. In fact, health care consumers are frequently confused by the wide diversity of careers represented in any clinic and should be encouraged to ask about the training and credentials of those providing their care.
Relationships With Preceptors
The supervised nature of PA practice makes the relationship between PA and preceptor a potential source of both satisfaction and stress. Here again, the messages given to new PAs by PA training programs about the relationships between PAs and preceptors set the stage for collaboration or dysfunction. Similar to all other relationships, the preceptor–PA collaboration requires work. The preceptor needs to be well informed about the background and current clinical expertise of the PA. This may appropriately require frequent observation and supervision early in the employment period. In fact, little or no supervision from a preceptor at the start of a PA job, especially for a new graduate, should be seen as a “red flag.”
Appropriate support from the supervising physician is one of the greatest stress relievers for a PA. Similarly, the physician may have chosen to work with the PA because of the opportunity that the relationship provides for sharing the challenges and frustrations of medical practice!
The fact that there is a formal backup for knowledge, decision making, and consultation makes the PA profession particularly attractive for many potential PA candidates. PAs however, need to learn to use this collaborative relationship for teaching and support. Each new job requires a renegotiation of this communication. An important stress reduction tool is to plan on regular case review and journal assignments in addition to whatever chart review is required by state law. Insistence on a theme of “lifelong learning” early in an employment setting fosters communication and decreases stress. The intense and emotional demands of medical practice are most easily shared with those who are there at the same time seeing the same patients. The opportunity to review individual cases and specific encounters often allows the preceptor and the PA to leave these cases at work and to make the transition to personal and family time more efficiently.
Relationships With Administrators
With health care increasingly being provided by large systems, the relationships of PAs who were primarily centered with physicians now include health care administrators. Although the physician may provide clinical supervision and oversight, the administrator may develop and negotiate jobs, supervise and evaluate personnel, and manage patient scheduling and follow-up. Thus, whereas PAs in the past were required to speak the “language of medicine,” they now must also be able to speak the “corporate language of business.” A lack of understanding of concepts such as productivity, quality improvement, supervisory relationships, capitation, per-member-per-month costs, and risk sharing will put a PA at a disadvantage.
In addition, the communication styles of administrators may vary vastly from PAs who are accustomed to working with physician preceptors. Notes on charts and hall-side consultations may be replaced with memos requiring written responses. Written evaluations of clinical performance may involve complicated spreadsheets and graphs. Electronic communication skills will soon be required for all providers.
Although some PAs and PA students may initially think that the best coping mechanism is to avoid the transition to administrative relationships, a better strategy would be to quickly acquire the skills to interact effectively with health care administrators in these new and evolving relationships.