What Being a Physician Assistant Is Actually Like

When you tell people you're a PA, what do they picture?

A doctor's helper. Like an assistant in the literal sense. Someone handing instruments over. And honestly, that's not entirely wrong for my specialty, because I do first-assist in the OR, and part of that job is literally holding a retractor for two hours while Dr. Kaplan drills hardware into someone's tibia. But it's also not right, because the other half of my day is me seeing patients alone, making clinical decisions, writing orders, and managing post-op care for about 14 to 18 patients on my own panel. Nobody's standing behind me checking my work in real time. Dr. Kaplan is usually in the OR or at the other campus. I text him when I need him. Most days I don't.

The assistant in the title does real damage to how people perceive the role. I had an athletic training degree from Northern Arizona, worked four years on the sidelines at a Division II school in Flagstaff. Taped ankles, managed concussion protocols, stood in the rain during football games with a first aid kit and a walkie-talkie. I loved the athletes, I loved the game-day energy, but I kept hitting this wall where I'd identify a problem and then have to send them somewhere else. Torn ACL? See the orthopedic surgeon. Stress fracture? Radiology and then the surgeon. I was the middleman. PA school was my way out of the middle.

Walk us through the screw thing. That came up in our notes.

OK so this was a Wednesday, about three weeks ago. I was in our outpatient clinic, which is across the parking lot from the main hospital. Mornings in clinic I see post-op follow-ups. A patient named Mr. Devereaux came in, nine days post-op from a distal femur fracture repair. Dr. Kaplan had put in a plate and seven screws. Routine fixation. The patient was doing fine clinically, weight-bearing as tolerated, pain was manageable, incision looked clean. I ordered the standard post-op X-ray, which we do at every two-week follow-up.

The X-ray tech is a guy named Ronaldo, and he's fast, usually gets me the images within 20 minutes. I was eating a protein bar at my desk and the images popped up on the PACS system. I pulled them up and immediately noticed one of the proximal screws was about 2 millimeters proud of the plate. Meaning it had backed out slightly. On the intra-op films from the original surgery, that screw was flush. Now it wasn't.

Two millimeters doesn't sound like much. But in hardware fixation, a screw that's migrating at nine days is a screw that's going to keep migrating. And a loose screw in the distal femur can irritate the IT band, cause pain, or in a bad scenario compromise the whole construct. I texted Dr. Kaplan a photo of the X-ray with the measurement. He was in the middle of a total knee on the other campus. He called me between cases, which means he was standing in the hallway still in scrubs, and we agreed Mr. Devereaux needed to go back to the OR for a screw revision. Not urgent, not today, but within the week.

I had to tell the patient. That's my job. Dr. Kaplan does the surgery, I manage the relationship. Mr. Devereaux is 58, a retired firefighter, and he was not happy. He'd been told the surgery went perfectly. And it did, at the time. Hardware migration isn't a surgical error. It's a known complication. But try explaining "known complication" to a 58-year-old man who was told he'd be walking normally in six weeks and now needs another surgery. He asked me three times if the surgeon made a mistake. I said no three times. He believed me on the third time, I think.

You caught it, though. That's a lot of responsibility for someone the patient probably thought was the doctor's helper.

Yeah. And that's the thing about this role in surgery. I am, functionally, the eyes on most of the post-op care. Dr. Kaplan operates. I manage everything before and after. The pre-op workup, the medical clearances, the post-op visits, the imaging review, the physical therapy orders. If I miss the screw, it doesn't get caught until the next visit, which might be three weeks later, when it's migrated 5 or 6 millimeters and the patient is in real pain. The catch is that I'm trained to see it. Athletic training taught me to look at body mechanics, to notice when something is off by a small amount. In ortho, small amounts matter. A 3-degree valgus shift in a knee alignment on a post-op film can mean the difference between a good outcome and a revision in two years. I was trained to look at alignment on a football field. Now I look at alignment on X-rays. Different substrate, same eye.

What's the OR like for you?

I first-assist about three days a week. That means I'm scrubbed in, gowned, gloved, standing across from Dr. Kaplan with my hands in the surgical field. For a total hip replacement, which takes about 90 minutes, I'm retracting tissue so he can see the acetabulum, I'm irrigating the surgical site, I'm handing him the femoral component when he's ready to press-fit it. During the approach I'm cauterizing small bleeders. During closure I'm suturing the deep layers while he closes the superficial ones.

It's physical work. After a long case, a revision hip that takes three hours, my shoulders ache. My lower back is tight. You're standing in one position, leaning slightly forward, holding tension on a retractor, and you can't shift your weight or scratch your nose because you're sterile. The scrub tech, a woman named Delia who's been in that OR for 19 years, told me during my first week that the trick is to do calf raises inside your shoes during the case. I do them now. She was right.

The part I didn't expect is how quiet the OR is during the critical moments. When Dr. Kaplan is reaming the femoral canal, nobody talks. The only sound is the drill and the suction. It's almost meditative, which is a weird word to use about a room where someone's femur is exposed, but it's accurate. Then the component goes in and Kaplan says "good" and the whole room exhales at the same time. You feel that collectively. It doesn't get old.

What's yours?

The identity confusion. Not mine. Everyone else's. I'm not a doctor. I'm not a nurse. I'm not a medical assistant. I'm in this space between all of those roles and nobody outside of healthcare knows what that space is. When I introduce myself to patients, I say "I'm Tamsin, I'm Dr. Kaplan's physician assistant, I'll be managing your post-op care." About 60% of the time, the next sentence out of their mouth is either "so when will I see the doctor?" or "thanks, nurse." The ones who call me nurse aren't being rude. They genuinely don't have a category for what I am.

My boyfriend teaches high school chemistry in Tempe. When his friends ask what I do, he says "she's like a doctor but not." Which is, I mean, he's trying. But "like a doctor but not" is exactly the problem. The profession has a branding issue that nobody has solved, and it lives in that word "assistant." There's a push to change the title to "physician associate," which some states have adopted. I don't know if it'll fix anything. The confusion isn't really about the word. It's about the fact that most people think healthcare has two categories: doctors and nurses. Everything else is invisible. I'm in the invisible category, doing real clinical work, making real decisions, and explaining what I am roughly four times a day.

You were an EMT first. How does that shape what you do now?

When you're an EMT, you see the crisis. You show up, you stabilize, you transport. Then you drive away. I did that for five years in Lincoln and the thing that ate at me was the not knowing. I'd pick up a guy having a STEMI, a heart attack, in a parking lot at 2 AM, run the 12-lead, push the aspirin, call ahead to the cath lab, and hand him off at the ER doors. That was my entire relationship with that patient. Fifteen minutes, maybe twenty. I never knew if he lived. I never knew if the stent worked. I never knew if he went home to his family or if his family got a different kind of phone call.

Now I'm the person on the other end of that. I manage the follow-up. The post-discharge appointment. The medication reconciliation. The long conversation where I explain that the triple bypass you had three months ago does not mean you're fixed, it means you bought time, and what you do with that time determines whether I see you in this chair at 70 or in a hospital bed at 62. I see the whole arc now. I like the whole arc.

Grand Island, Nebraska. That's not exactly a major metro.

About 53,000 people. The clinic is part of a regional health system. Four providers: two physicians, me, and another PA named Gretchen who started last year. Between us we serve about 4,200 active patients. My panel is roughly 1,800 of those. In a city, a primary care PA might see 18 to 22 patients a day. I see 20 to 24 because there are fewer specialists within driving distance, so I handle more of what might get referred out in a bigger market.

Last Tuesday is a good example. I had 22 patients scheduled. The first was a well-child check for a four-year-old. Standard developmental screening, vaccines, talked to the mom about the kid's speech delay and when to worry versus when to wait. Second patient was a 67-year-old farmer named Lyle who came in for a blood pressure follow-up. His lisinopril isn't controlling it. I added amlodipine 5mg and asked him about his sodium intake, which went about how you'd expect with a farmer in Nebraska. He said "I eat what I eat" and I said "what you eat is keeping your blood pressure at 152 over 94" and he laughed and said he'd try. He won't try. I'll see him in three months and his pressure will be the same and we'll have the same conversation. That's primary care. You plant seeds. Some of them take years.

Tell us about the ankle sprain that wasn't.

A 16-year-old girl, I'll call her Patient K, came in as a same-day add-on. Chief complaint: left ankle sprain from volleyball practice. Her mom was in the waiting room. I walked into the exam room and she was sitting on the table looking at her phone. Normal teenager. I asked about the injury, she said she rolled her ankle going up for a block. I examined it. Mild lateral swelling, no ecchymosis, negative anterior drawer test. Classic Grade 1 inversion sprain. In and out in 10 minutes. RICE protocol, ibuprofen, follow up if it's not better in two weeks.

But something felt off. Her affect didn't match. When a 16-year-old athlete hurts her ankle and might miss games, she's usually either upset about the games or annoyed at the inconvenience. This girl was flat. Not sad exactly, just, the light was off. EMT training teaches you to look at people's faces before you look at their injuries. So while I was wrapping the ankle, I asked how the volleyball season was going. She said "fine." I asked how school was going. She said "fine." And then she said, very quietly, "I don't really care about the ankle."

That sentence changed the visit. I sat down. I asked if she wanted to talk about what she did care about. And over the next 25 minutes, she told me she'd been having panic attacks for three months. Couldn't sleep. Was skipping lunch at school because the cafeteria made her chest tight. Hadn't told her mom. Hadn't told anyone. She came in for the ankle because the ankle was a legitimate reason to see a doctor without having to explain the real reason.

I screened her with the PHQ-A, which is the adolescent depression questionnaire. She scored a 14, which is moderate. I talked to her about what that meant. I asked if she was safe, if she was having thoughts of hurting herself. She said no. I asked if she wanted me to bring her mom in. She said yes, but she didn't want to be the one to say it. So I brought the mom in and I started the conversation. The mom cried. The girl cried. I referred them to a behavioral health provider in Kearney, about 45 minutes away, because we don't have one in Grand Island. I also started her on a low-dose sertraline, 25mg, and scheduled a two-week follow-up to check on her.

That visit was supposed to take 10 minutes. It took 40. It pushed my entire afternoon schedule by 30 minutes. My next three patients waited. The front desk was not thrilled. But that girl walked in with an ankle sprain and walked out with a diagnosis and a plan for something that was actually eating her alive. That's primary care. The ankle is never just the ankle.

How does supervision work in your clinic? You said there are two physicians.

Dr. Fenn is my supervising physician on paper. In practice, I see my patients, I make my clinical decisions, I prescribe, I order labs and imaging. If I have a question, I walk down the hall and ask. She's available. She's not watching me. The chart review requirement in Nebraska is 10% of my charts per quarter, which Fenn does, but she's told me she mostly skims them at this point because in six years I've never had a finding she disagreed with. She said that once and then immediately said "which doesn't mean stop being careful." Classic Fenn.

The supervision model works well when the supervising physician trusts you. It works terribly when they don't. Gretchen, the new PA, her previous job was at an urgent care in Omaha where the supervising doc required her to present every patient before discharging them. Every single one. A 22-year-old with a sore throat and a positive strep test, she still had to present it. She lasted eight months. She told me her first week here that she felt like she was starting over, like those eight months didn't teach her anything because she'd never been allowed to make a decision. That's the dark side of the supervision model. The quality of your career depends enormously on the person whose name is on your collaboration agreement.

What's yours?

How much of primary care is performance. Not clinical performance. Social performance. I perform being unhurried when I have seven patients waiting. I perform being warm when I'm on my 21st visit and my feet hurt and I haven't eaten since a granola bar at 10 AM. I perform not being frustrated when a patient comes in for a sore throat and then, as I'm reaching for the door handle, says "oh and I've also been having chest pain for three weeks." The doorknob complaint. Every primary care provider knows it. The patient buries the real concern at the end because they're scared of the answer. And you have to turn around, sit back down, and treat it like it's the first thing they said, with the same energy, the same attention, even though you now have to work up chest pain in a 10-minute visit that's already 14 minutes long.

My fiancée, she manages a gym in Kearney, she says I'm different on work days. Not worse, not meaner, just quieter. Like I've used up all the words. And that's accurate. By 5 PM I've had 22 conversations that required me to be fully present, fully warm, fully careful with my language. The tank is empty. I go home and I don't want to talk about my day because my day was 22 small stories that each deserved more time than I gave them. The patients don't know that. They each think they got the full version of me. They didn't. They got a good version. But the full version left the building around patient number 16.

You came from respiratory therapy. Why the switch?

I was an RT at Hartford Hospital for seven years. Respiratory therapists manage ventilators, administer breathing treatments, respond to codes. When someone goes into respiratory failure, the RT is the person bagging them, the person managing the airway until the doc arrives. I was good at it. I liked the intensity. But in a code, the person running the show is the physician or the PA. The RT is executing the airway portion of someone else's plan. I was standing next to the bed, watching PAs call the shots, thinking, I know what comes next. I know the drug, I know the dose, I know why. But my job was to wait for the order.

One night, we had a patient decompensate on a med-surg floor. Severe COPD exacerbation. I got there before the PA, started bagging the patient, made the call to page the rapid response team. When the PA arrived, a woman named Trudy who'd been there maybe two years, she looked at the patient, looked at me, and said "what do we need?" And I told her. BiPAP first, then if the CO2 doesn't come down, we intubate with a 7.5 tube, rocuronium and etomidate for the RSI. She looked at me and said "you should go to PA school." I enrolled six months later. I was 29.

What does a Saturday night in the ER look like?

I work 12-hour shifts, mostly nights and weekends because I'm senior enough to choose my schedule and I actually prefer nights. Fewer administrators walking through. More real emergencies. Less "I've had a headache for six months and decided 11 PM on a Saturday is the right time to address it." Although we still get those.

Last Saturday I came on at 7 PM. The board had 34 patients, which is high but not critical. We run three providers on a night shift: two physicians and me. I cover the acute side, which is the patients who come in by ambulance or who get triaged to a higher acuity. The docs cover the critical side, the traumas and the resuscitations, and the fast track, which is the low-acuity stuff.

My first patient was a 44-year-old man, came in by ambulance with chest pain. Crushing, substernal, started while he was watching TV. Diaphoretic on arrival. The paramedics had already done a 12-lead in the field and it showed ST elevation in leads II, III, and aVF. That's an inferior STEMI. Heart attack. The cardiologist on call was Dr. Virani, and the cath lab team was already being activated when the patient hit my stretcher.

My job at that point is to stabilize and confirm. I repeated the EKG, confirmed the ST changes, drew troponins, gave aspirin and heparin per protocol, started two large-bore IVs, and got a brief history from his wife who rode in the ambulance. No prior cardiac history. Non-smoker. Runs three times a week. She kept saying "he's healthy, he's the healthy one." I told her the cath lab team was on the way and that Dr. Virani would talk to her after the procedure. The whole encounter from arrival to handoff was about 18 minutes. He went to the cath lab and I moved to the next room.

Eighteen minutes is fast.

That's the job. In emergency medicine, speed isn't a bonus, it's the treatment. For a STEMI, the target is door-to-balloon time under 90 minutes, meaning the time from when the patient arrives to when the interventional cardiologist opens the blocked artery. Every minute of delay is dead heart muscle. My 18 minutes is part of that clock. If I take 30 minutes, we're already a third of the way through the window. I don't have time to be thorough in the way a primary care PA is thorough. I have time to be accurate and fast. Those are different skills.

The next patient was different. A 23-year-old guy who fell off a second-story porch. His friends said he'd been drinking. He was conscious, oriented, had a laceration on his forehead and was complaining of back pain. I ordered a CT of the head and a CT of the thoracolumbar spine. The head CT was clean, no bleed. The spine CT showed a compression fracture at L1, about 25% loss of height. Not surgical, but not nothing. He was going to be in a brace for 8 to 12 weeks. When I told him, he said "can I still go to work Monday?" He works construction. I said no. He looked at me like I'd told him something worse than the fracture.

How does the PA-physician dynamic work in the ER specifically?

It's more collaborative in real time than in other settings. In primary care, the supervising doc reviews your charts after the fact. In the ER, you're working alongside them, same department, same patients sometimes. The attending physician on my Saturday shift was Dr. Chu, who's been an EM doc for 20 years. When I'm managing a patient and I need a second opinion, I walk ten feet and ask. When a trauma comes in and it's all hands on deck, we're both in the room. He runs the resuscitation, I assist, I manage the airway if the RT hasn't arrived yet. There's no ego about it. In the ER, whoever's available and competent does the thing that needs doing.

That said, I can't run a trauma independently. That's the line. Level 1 traumas require an attending physician to be present. I can evaluate the patient, start the workup, order imaging, even intubate if the airway is compromised. But the final disposition, whether this patient goes to the OR or the ICU or home, that's the attending's call on a trauma activation. For everything else, the non-trauma acute patients, I'm functionally independent. I evaluate, treat, admit or discharge. Dr. Chu co-signs my charts but he doesn't review my clinical decisions in real time unless I bring them to him. After 11 years, the trust is built. The first two years were different. The first two years, the attendings watched everything.

What's yours?

The ones who die on your watch. Not the traumas, those are expected. The system is built for those. I'm talking about the ones who come in looking fine and then they're not fine. A woman, maybe 55, came in on a Thursday night last November with what she described as indigestion. Her vitals were normal. Her EKG was normal. Her troponin was pending. I put her in a monitored bed because something about the way she was pressing her fist into her sternum made me uneasy. Levine's sign, which is a clenched fist over the chest. It's a classic indicator of cardiac pain, not GI pain. Twenty minutes later, while I was seeing another patient, the monitor alarmed. V-fib. We coded her for 38 minutes. She didn't make it.

Her troponin came back elevated after she was already dead. The STEMI was in a territory that doesn't always show on the initial EKG. I did everything right. The chart was clean. The attending reviewed it and said "there was nothing else to do." My husband, he's a firefighter with Hartford FD, he told me "you can't save everyone." And I know that. Rationally I know that. But she came in talking to me. She told me she'd had Thai food for dinner and thought the green curry was the problem. She was making a joke about her husband not being able to handle spice. And then she was in V-fib and then she was dead and I was the last person she joked with. That doesn't go away. You learn to carry it, but it doesn't go away. The ER teaches you that you can do everything right and still lose. The people who can't accept that don't last in emergency medicine. The people who can accept it, well, we're still carrying it, we just learned where to put the weight.