Paul's DeskToday is the start of an article series about what I do.  Not about being a PA so much as about me being a PA.  (Hey, I can’t be anybody else).

Calling it “Paul’s Desk” is an inside joke, because at my clinic, I have no desk.  In fact, I have no office!  What I do have is plenty of patients and experiences with them. Only my supervising physician, who I call “The Fatman,” has an office with a desk at my clinic.  I call him the Fat Man as a nod to the book I’m always recommending to pre-meds and pre-PAs — The House of God, by Samuel Shem.  If you’ve been reading this blog for long enough, you may remember my pre-PA mentor, whom I called the Thin Man for similar reasons.  The Fatman — my current boss — is a family medicine physician, associate professor of medicine at a well known medical school, and the owner of my clinic.

There’s a good reason he has the only desk: I don’t do as much paperwork and legal work as he does.  The Fat Man is a certified disability evaluator, which has him dictating many foot-thick reports on patients’ work injuries, and participating in depositions on them.  I on the other hand, see more patients than he does.  That’s right.  I probably see 30 a day on average, 4 days per week, and he 15 on average, 3 days per week.

What is the Fat Man like?

You can guess that he’s fat.  But he’s also tall, so he’s a bear of a guy.  He has ginormous sausage fingers. Fingers that make you feel for any man who gets a prostate exam from him.

I’d love to say with a grin that he’s “warm and caring and the best mentor any clinician could have!” 

But the truth is always more complicated.

He is a nice guy, if you know him.  But warm?  Hell, no.  He can be gruff.  Usually with patients.  Sometimes with staff.  Not usually with me because I’ve trained him (as much as he can be trained).  He admits that he’s narcissistic, and it helps to remember that in my dealings with him.  If you imagine him as a giant temperamental 2-year old, then you’re close.

Crazy and funny things that he sometimes has been known to say:

“Bring me the employee who did this!”

“Am I the only one who works around here?  I can’t do everyone’s job for them.”

“At this juncture…” (His favorite thing to dictate into a patient’s chart.  He uses this phrase like ten times a day.  It makes him feel smart).

“We’re not going to get reimbursed for that.  The money we spend on that will come out of all of our Christmas bonuses!”

But after 3 years with him, I know that it’s a lot of hot air.  It’s just who he is.   He’s far from perfect, but he is a very strong clinician.

My Relationship with The Fat Man

It’s not terribly complicated.  He trusts me — enough to leave me alone until I really need his input, which can be good and bad.  He has taught me to focus on what matters — getting the important things right, and keeping the office moving.  Yes, he does pressure me to go faster at times, but no faster than he goes himself.  Get used to it people — time pressure is a part of medicine that’s here to stay.

When I need his input, 2/3 of the time it is grudgingly given.  He might reply to my question with a HUGE SIGH and “Dude, I’m 40 minutes behind.  What is it?”  He then gives the briefest responses, and acts like I have wasted two hours of his time.  The other 1/3 of the time he will be brief, but his reply will be neutral or even supportive.  How often do I ask for help?   Not often.  You can imagine how this type of supervision discourages frequent consultation and lengthy discussion.  So there are many times when I need to figure things out for myself.  When I was a new clinician, a continual source of stress was not quite knowing how to handle some things and having to figure them out by myself.  I worried that I would kill a patient.  This is not always the best recipe for learning.  You’d think that  having a supervising physician who is an associate professor of medicine would be very instructive, particularly because, as the Fat Man says, “I love to teach.”  But remember how I said he’s narcissistic?  He doesn’t really love to teach — he loves to be professorial and important, which is something very different.

Some who read this will say, “Geez, is that what it’s like being a PA?  Working for a doctor who is full of himself and not a lot of help?”  And to them I would say that it is for me, but every supervising doc is different.  And I have learned a ton from this giant, fragile, overinflated man.  I’ve learned not to take the giant 2-year-old’s words personally, to trust my ability as a clinician, and not to be afraid of him.  Once he got snarky with me and I immediately asked to talk with him.  I brought him into his office to give us some privacy, and said simply, “I need you to talk to me as a peer.”  He apologized and we moved on to more important matters, and I know he respected me for it.

Although he doesn’t like being asked a lot of questions, when I know it’s time to include him, I do and he always has my back.  About a year and a half after becoming a PA, I worked with a patient who was very sick.  This patient was obese, had heart failure, stage III chronic kidney disease, diabetes, and infected open wounds on his legs.  I went to the fat man and said plainly to him “this is the first patient I’ve worked with who is truly out of my scope of practice and I need your help.”  So he came in and met the patient with me.  He listened to my summary, my plan, and said simply, “You’re doing fine.”

I wasn’t sure if I should feel angry, worried, or proud.

So I felt all three.