Is Being a PA Stressful?

The beeper. I know that sounds like a joke, but it's 2026 and I carry a pager. The hospital uses Vocera for most communication but CT surgery still pages. I'm on call every fourth night, and on those nights the pager goes off an average of 11 times between 6 PM and 6 AM. Chest tube outputs, blood pressure parameters, post-op fever workups, a nurse who needs an order for Tylenol because the one I wrote six hours ago has expired. Each page is a decision. Some of them take 30 seconds. Some of them take an hour. And none of them come with context. The pager just shows a callback number. So every single time it goes off, there's a two-second window where I don't know if it's a Tylenol order or a patient who's coding.

I've been on call nights where I sleep in 40-minute increments. I set an alarm for the last possible minute before I have to round, which is 5 AM, and I'll have slept maybe three hours total in 20-minute fragments. The next morning I first-assist in a six-hour cabbage, which is open-heart bypass surgery, and my hands need to be steady and my brain needs to be sharp and I've had three hours of broken sleep. The attending surgeon, Dr. Pelletier, sleeps in his own bed on call nights because his calls get triaged through me. I handle the routine stuff so he can be rested for the OR. That's rational. That's the system working as designed. But the system is designed around the surgeon's rest, not mine. I'm the buffer, and the buffer absorbs the damage.

The production pressure. My compensation is partly based on RVUs, which are relative value units, basically a measure of how many patients I see and what I bill for each visit. My base salary is $118,000 but I have a bonus structure that kicks in above a certain RVU threshold. Last year my bonus was $22,000, which is significant. But to hit that number, I need to see 28 to 32 patients a day. Each visit is scheduled for 15 minutes. Some of them are simple: acne follow-up, medication refill, mole check. Those take 8 minutes. But then someone comes in for a "mole check" and I find an irregular lesion on their upper back that needs a biopsy. The biopsy takes 10 minutes. The documentation takes another 10. I'm now 12 minutes behind schedule and it's 10:15 AM.

The stress isn't the pace itself. I can move fast. The stress is knowing that the pace is determined by a financial model, not a clinical one. If I spent 20 minutes with the patient whose irregular lesion turned out to be a melanoma in situ, that's 20 minutes well spent. Melanoma in situ caught early is a cure. But the RVU model doesn't reward thoroughness. It rewards volume. My supervising dermatologist, Dr. Huang, sees 36 patients a day and makes $440,000. She's faster than me and she's been doing it longer. She also told me once, at the Christmas party after two glasses of wine, that she missed a melanoma in 2019 because she was rushing and the patient didn't come back for the follow-up biopsy. She thinks about that patient. She doesn't know the outcome. That's the cost of 36 patients a day, and nobody puts it on the productivity report.

I work alone. That's the stress. The clinic is a standalone urgent care, the kind you see in strip malls next to a Panera. There's me, a medical assistant named Trish, and a front desk person. The supervising physician is a doctor named Dr. Okafor who oversees four clinics. He's physically present at one of them at a time, rotating. Most days he's not at mine. If I have a question, I call him. He usually picks up within ten minutes. Usually.

Last month a 68-year-old man came in with abdominal pain that he said started the night before. He was tachycardic at 112 and his belly was rigid on palpation. That's a surgical abdomen. That's "call 911 and get this person to an ER now." And I did. But for the 14 minutes between when I recognized what was happening and when the ambulance arrived, I was the only clinician in the building with a patient who might have a perforated viscus. Trish was incredible, she got the IV started and drew labs while I was on the phone with the ER. But Trish is an MA, not a nurse. She can't push meds without my order. Dr. Okafor was at the Marietta clinic, 40 minutes away. I managed it. The patient got to the ER and went to surgery within the hour. He was fine. But for those 14 minutes, the entirety of this man's medical care was on me, a PA with one year of experience, in a strip mall clinic with one MA and no crash cart. The system puts PAs in these settings because we're cheaper than physicians and we can see patients independently. That's a business decision dressed up as a staffing model.

The caseload. I carry 340 active patients. In community mental health, we're serving a population that's largely uninsured or on Medicaid. Reimbursement rates are low. To keep the clinic funded, we need volume. My scheduled appointments are 20 minutes for follow-ups and 60 minutes for new intakes. I do about 16 patient encounters a day. Most of my patients have serious and persistent mental illness: schizophrenia, bipolar I, severe PTSD. These are not 20-minute problems. These are lifetime conditions that require ongoing medication management, crisis intervention, and sometimes just someone to talk to who understands their diagnosis.

Last week I had a patient, a man in his 50s I've been seeing for eight years, come in for a medication check. He's on clozapine for treatment-resistant schizophrenia. He's stable, which in his case means he's living in a group home, taking his meds, and holding a part-time job sorting donations at a Goodwill. That's a success story. Eight years ago he was homeless and psychotic. His appointment was supposed to be 20 minutes. He told me his group home was losing its funding and might close by June. He had nowhere else to go. His sister in El Paso doesn't have room. His case manager at the county is trying to find placement but there are seven people ahead of him on the waitlist. He didn't cry. He just sat there and said "I don't know what I'm going to do, Mr. Garrison." He calls me Mr. Garrison, not Garrison, because that's how he was raised. I spent 35 minutes with him, which put me behind for the rest of the afternoon. I didn't solve his housing crisis. I refilled his clozapine, confirmed his next blood draw, and told him I'd call his case manager. That's what I had to offer. Medication and a phone call. The gap between what my patients need and what I can give them is where the stress lives.

The ceiling. Not the salary ceiling, though that exists too. The scope ceiling. I've been in neurosurgery for eight years. I first-assist in craniotomies. I manage a 22-bed neurosurgery service. I run the post-op ICU rounds by myself every morning at 6 AM while the attendings and residents are in pre-op. I know this patient population. I know the complications, the medication protocols, the signs that a patient is herniating before the monitor confirms it. But I cannot operate. I cannot be the primary surgeon. I will never do a craniotomy on my own. The scope of practice has a hard wall and I'm standing at it.

For the first five years, that was fine. I was learning, building competence, becoming the person the residents called at 2 AM because I knew the answer faster than they could look it up. But somewhere around year six, something shifted. One of the neurosurgery residents, a woman named Dr. Sandoval, is in her PGY-4 year. She's four years into residency. I've been doing this for eight years. On a clinical level, in terms of managing the floor, anticipating complications, handling the families, I am better at those things than she is. I'm not better at surgery, she's getting more OR hours than I ever will. But in the hierarchy of academic medicine, she outranks me. She will graduate, become an attending, and make twice my salary. I will still be here, still excellent at what I do, still unable to go any further. The stress isn't that the ceiling exists. The stress is that after eight years, I can see every crack in it.

Telling parents. Not the diagnosis itself, usually. The moment right after, when the parent looks at you and tries to figure out whether they can trust you with their child's care, and then realizes you're not the doctor. I introduced myself to a mother in the ER last Tuesday. Her four-year-old had a febrile seizure. The kid was post-ictal, sleepy but okay, vitals stable. I told the mom what had happened, what febrile seizures are, that they're common in young children and almost always benign. She listened. Then she said, "Can we see the real doctor?"

She wasn't being cruel. She was scared, and scared parents want the most senior person in the building. I get that. I told her the attending would be in shortly and Dr. Yamamoto came in, said essentially the same things I'd said, and the mom relaxed. The medicine didn't change between my explanation and Dr. Yamamoto's. The credibility did. That's the part of being a PA that nobody prepares you for. You can be completely right, completely competent, and still not be enough for someone who needs a doctor in the room to feel safe. Three years in and I've stopped taking it personally. Mostly. My roommate is a PA in orthopedics and she says she doesn't have this problem because adults don't ask for the real doctor as often as scared parents do. Children raise the stakes in a way that makes the title gap feel bigger.