What You Should Know About the First Year of Clinical Practice


Starting your first PA job is incredibly exciting. After many months of intense training with manikins, practice patients, and (with supervision) real patients, you'll feel ready to be released into the "wild." 


But, while it's exciting and new, the start of a career in medicine is pretty strange. Once you stop being a student, no one high fives you anymore for guessing the right diagnosis. In the real world, when you get ten things out of 100 wrong, you don't get an A. You just made ten mistakes.


While you may feel so so ready to start practicing in those last days of PA school, the first three months of working as a PA will make you wonder if you learned anything while you were there.  


When I started my first PA job, I wasn't prepared for what to expect in those early months. You learn a lot in PA school, but there are some aspects of starting out as a new PA that are difficult to know until you're handed the reins and given responsibility in caring for patients. 


If you want to be ready for the most common "surprises" of starting a new career in medicine, here's what you should know. 


There will be many things that make you feel stupid.

Even if you graduate at the top of your PA school class, the first year of clinical practice will involve moments that make you feel like a dunce. 


If you don't have those moments, your job is too easy, and you're not learning enough to justify staying in it. 


Patients will ask you simple questions that you won't be able to answer. You may be well versed in their diagnosis and treatment plan, but when you don't know how their insurance will approve the recommended medication, you'll feel foolish. 


When a nurse asks you for an order clarification because your order doesn't make sense, you'll be quietly praying she has a suggestion for one that does.


But, if you try to fabricate an answer because you're too embarrassed to say, "I don't know, let me check and get back to you on that," you're losing opportunities to learn. And not just to determine the right answer, but to learn how to ask your colleagues for help and advice and how to interact with patients in a way that builds trust. 


So, if you want to get better, accept that you will often feel (and sometimes look) like a fool as a new PA. The frequency at which this occurs will lessen over time. 


However, you should start acknowledging what you don't know in the early part of your career. Not only will it help you get better faster, but becoming comfortable with admitting your limits will lower the threshold for you to speak up when you're even further along in your practice. 


Patients are way more complicated in real life than the cases you've practiced.

In PA school, when a patient walks in with a fever, swollen cervical lymph nodes, and tonsillar exudate, you figure out quickly that they have strep throat. If you say you'd send them home with some penicillin-based treatment for a 10-day course, you nailed it!


Except in the real world, the patient has a bit of a cough. And gags when you try to do the culture and refuses to let you try a second time. And he has a penicillin allergy. And hates pills. Also, he forgot to mention he has diabetes. 


In practice, patients are not like the cases you've prepared for. They are far more complex and often are missing a symptom or have an extra one that doesn't quite line up with the classic presentation. 


What It's Like in Your First Year as a PAlBe a Physician Assistant

You may have trained on conducting a visit in a particular order: chief complaint first, then HPI, the rest of the medical history, followed by an exam. But patient's don't know that. They may want to show you a weird rash or have you press on a new lump as soon as you walk in the exam room. 


As a new PA, it's disorienting to have your expected visit order disrupted. You might forget to ask relevant questions or skip over parts of a patient's history that are necessary to make decisions. 


But over time, you'll get more comfortable with going out of order and may even enjoy the challenge that a patient with 11 allergies brings to your day. 


Adapting to what patients need is an integral part of what we do, but it will take some time and experience to get comfortable with handling non-textbook cases and visits. 


You will need to lean on your colleagues — a lot.

The PA profession is built upon a foundation of collaboration; the position was designed for practicing medicine as a team. Once you start practicing, you'll need to rely heavily on that team, especially in the early years. 


Having a collaborating physician to learn from is great, but, as any medical resident can tell you, the real treasure trove of information will come from the nurses you work with. 


They'll know who to go to in order to get something done, how to work with an insurance company for drug coverage, what's a realistic timeline for getting a test completed, and whether something you want to do for a patient is feasible. 


If you're incredibly fortunate, as I have been, you'll also have the benefit of having PA colleagues who are happy to work with new graduates and bring you up to speed in your newly appointed medical discipline. This is particularly helpful if you work in a specialty that you may have only touched the tip of the iceberg of in your PA school training. 


Don't be afraid of using your colleagues as a resource. If you choose your position wisely, you'll be surrounded by those who want to help you and encourage your success. 


No one wants to work with a know-it-all, and no one expects someone who's in a brand new role to have all of the answers. If you ask your coworkers for their help or expertise and acknowledge your limits, they will grow to trust you. And by learning from them, you'll begin to believe you also know what you're doing. 


You'll screw things up.

When I was a baby PA, I once calculated a dose of chemotherapy based on a patient's English units of height and weight, instead of using metric. Yes, it was a big mistake that I would have caught in a millisecond if I had made it months or years later. 


But, I was inexperienced, so the insane quantity of drug I calculated did not seem out of the ordinary to me. Luckily, it jumped out to Cindy, the nurse who caught my rookie error long before it would have put a patient in danger. 


I've never made that mistake again. 


You screw up plenty of things as a new PA, and a few as a seasoned PA too. But you'll also learn lessons from your mistakes that will help prevent you from making bigger ones down the line. 


When you inevitably do make a mistake, you need to own up to it. It's okay to make a mistake, but it's not okay to pretend you didn't. 


You'll be forgiven or at least respected by admitting your mistakes. I once accidentally gave a patient the CT results from her prior scan, which were good, instead of her most recent scan, which were not so good. I then had to go back to her room to admit my mistake and break the bad news. 


One time, I scheduled a patient for a visit with my collaborating physician, who I forgot was out of town on that date. The patient had flown from Missouri to Texas for just that appointment. The list goes on. These patients along with others have forgiven me in nearly every case. 


Patients and colleagues will give you a lot of grace if you own up to your mistakes. But only if you own up to them. 


Blaming someone else, even when it might be a little or a lot their fault, does not have the same conciliatory tone as an apology. 


No one expects you to do everything perfectly, but they do expect you to take responsibility. 


You'll be exhausted.

When you're finishing PA school, it's easy to envision working as a PA as an oasis that is nearly within reach. But, when you finally have the opportunity to work as a PA, you'll be exhausted.


At first, it will be very similar to starting PA school—tons of new information coming at you at what feels like warp speed. And it's mentally and physically exhausting. But, it will get better after the first three months, and things will normalize around 6-8 months. 


As you get more comfortable in your role, things will come more naturally to you. You won't have to spend mental energy figuring out how to do each little thing that goes into taking care of a patient. With practice, some tasks that were once a challenge will be easy, and you'll start doing them without even thinking about it. 


Becoming proficient, or even adequate, takes time though. It's totally normal to be mentally and physically exhausted at the end of each and every day for the first few months.


You may find yourself ignoring invites from friends so that you can spend your Saturday holed up at home to recoup from the week. But, just like the frenzy of PA school, you'll get more comfortable over time, and this phase will pass.  


And, life is pretty great once it does. 

Some of these aspects of a new PA career may not sound so appealing. It's an exciting time, but it's a tough period too. 


Going through these growing pains of working as new PA are worth it, though, as long as you're in it for the long run. 


But consider these aspects of working as a new PA when you're deep in the hunt for your first PA position. You want to choose a place that will help to support you as a new provider with colleagues who will welcome and encourage you as a new member of the team. 


There's nothing like the first year of practice, so choose a place that will help you flourish to become the PA you want to be.