Essential Insights for PAs Navigating Their Critical First Year

Medscape

a day ago

While some healthcare professions have seen their numbers rise significantly in recent years, few jobs have experienced growth like physician assistants (PAs), or as they are now called in many states — physician associates.
The National Commission on Certification of Physician Assistants (NCCPA) reported that between 2013 and 2022, the number of PAs in the US climbed from 95,583 to 168,318.
At the end of 2024, those numbers had increased to over 189,900 PAs, according to the NCCPA.
To join their ranks, you need to complete a PA program — usually for 27 months or 3 academic years — which grants you a Master of Science degree.
After that, you need to pass the Physician Assistant National Certifying Examination.
Once on the job, PAs do everything from taking medical histories and conducting physical exams to diagnosing and treating illnesses, ordering and interpreting tests, prescribing medications, and assisting in locations ranging from operating rooms to research labs.
The first year as a PA can be filled with challenges, rewards, and lessons that can't be learned in the classroom. Alec Williams, an orthopedic trauma surgery PA at Stamford Hospital in Stamford, Connecticut, shared some revelations and insights from his first year after graduating from Quinnipiac University, Hamden, Connecticut.
On-the-job Education
Williams acknowledged that the 'drinking from a firehose' metaphor for PA school is an apt one, as students are expected to learn a vast array of skills and medical information in a short time.
He said PAs are able to come out of school as 'medical generalists,' equipped with tools to care for patient's health in a variety of clinical specialties.
'This being said, with only 27 months to master the art of medicine, the intricacies of various subspecialties are often neglected in some programs, while other programs take the time to focus on some and dismiss others,' Williams said. 'For example, in our orthopedic curriculum, we are taught about the many common orthopedic conditions related to overuse or acute injury, which may present in an office setting. Yet, that is only [one third] of the orthopedic world.'
Countless variables involved in diagnosis, treatment, and recovery add to the challenges faced by PAs in all types of specialties, Williams said.
More Than Patient Care
In addition to realizing how much there is to learn, Williams said a second major revelation was the amount of time that is needed for obligations beyond the actual practice of medicine.
'As PA students, we are bounced around every 4-8 weeks between a multitude of clinical practice environments, from large urban hospitals to rural outpatient mobile clinics and everything in between — including even some foreign countries,' Williams said. 'With this, we are exposed to a small sample size of various PAs' scope of practices. We rarely have the opportunity to fully appreciate the nuances of the extra-clinical responsibilities that PAs must be accountable for on a daily basis, like clinical documentation, administrative work, billing, leadership or committee work, and much more.'
Because many of these extra-clinical duties play such a large part in the care provided to patients, it is important that early-career PAs become proficient in many of these soft skills, Williams said.
Ask the Right Questions
Williams said it's important to understand that medicine is not black and white, but rather, it's full of gray.
'In PA school, we learn clinical guidelines and textbook presentations,' he said. 'But in practice, we quickly realize that no disease reads those same textbooks. Patients rarely present the way PowerPoints have said they will; so instead, we must master the ability to weigh competing priorities, make decisions with incomplete information, and adapt to the unique context of each patient.'
He recalled a young patient he encountered just a few months into his career. The patient was recovering from an ankle fracture but was experiencing posterior calf and knee pain.
An obvious response — a textbook response — would be to order a venous duplex ultrasound to rule out deep venous thrombosis.
But that consideration opened a host of new questions. Williams wondered, 'Would removing the splint for the ultrasound compromise the fracture reduction? Could we worsen the patient's pain or soft tissue injury by manipulating the leg? Could this be a Baker's cyst or referred pain instead? Will this impact the patient's surgery scheduled for today?'
Williams said he's learned that clinical reasoning becomes more conceptual and individualized the longer you practice.
'You stop searching for the 'right answer' and begin asking better questions,' he explained. 'Simply put, you look beyond just what the diagnosis is to see how that diagnosis will change management of the patient in front of you. To provide effective, patient-centered care, I would advise early career PAs, like me, to actively make the effort of moving beyond the student mindset and start thinking like a clinician.'
Williams suggested recent PA grads be 'relentlessly inquisitive' and ask questions — even if they think they should already know the answer.
'Clinical learning accelerates when you prioritize patient care over your own ego,' he said. 'Also, you have to communicate often with your team. Learn to rely on your fellow PAs, attendings, nurses, residents, and the many other healthcare professionals around you.'
One other piece of advice to PAs starting out: Give yourself grace, Williams said.
'Like any new graduate — whether an accountant, lawyer, or mechanic — you're going to make mistakes early in your career,' he said. 'That's part of learning. What matters is how you respond: take accountability, reflect, and lean on your team to grow from each experience. You'll feel behind at times, but with consistent effort, your clinical judgment and confidence will grow faster than you think.'
Making a Difference
Williams said his first year on the job reminded him not only of the responsibilities that come with being a PA but also of the opportunity to make a difference in people's lives.
'Never take for granted the deeply humbling privilege we've been given as direct medical care providers,' he said. 'Patients place an unequivocal amount of blind trust in us, despite being at their most vulnerable moments. The beauty of this profession lies in our ability to empower our patients to find strength and peace, even when the outcome isn't perfect. If that is your 'why,' hold onto it tightly.'
Along the way, PAs should also remember to prioritize their own health and strength.
'Your stamina and clarity will depend just as much on what you do outside of work: sleep, boundaries, hobbies, and a strong support system,' Williams said. 'Many of us became PAs because of the balance we will have, both in the workplace and in our personal lives. Protect that balance and be mindful of it always.'