What I wish I had known in my first year

I started my career in a high-volume spine and orthopedic practice in Southern California, first-assisting in the operating room and following the same patients through their recovery. It was an education I could not have gotten anywhere else. Since then I have trained more than fifteen new PAs and precepted more than ten students, and most of what follows is what I now try to give them in their first months.

It is written for PAs in their first year, or about to start it — and for the physicians and practices bringing them on.

Why does the first year feel so hard?

Because graduation certifies you as a generalist, and your first job asks you to be useful in one place, quickly. NCCPA's 2024 profile of newly certified PAs found that 94% felt prepared to practice — but only 40.6% felt very prepared. The larger group, 53.6%, felt somewhat prepared.

The research on the transition describes the same gap from other angles. A survey of new nurse practitioners and PAs, and of the physicians working with them, found the new clinicians describing anxiety, fear and a sense of inadequacy in their first year — and found the two groups disagreeing about how much physician support was being given, how long it takes to become fully functional, and how much independence is appropriate. A small study of PAs in their first two years found that those who described a partnership with the physicians they worked with reported few obstacles to putting their training into practice, while those who felt insecure reported obstacles both in themselves and in their surroundings.

The first year is supposed to feel like this. How hard it is depends on the place as much as on you — which is a reason to choose the place carefully.

You have more leverage than you think

New PAs are in demand. Of the PAs newly certified in 2024 who had accepted a position, 77.7% had at least two offers, and the median search took two months. It is easy to spend all of that leverage on salary and location. Spend some of it on the first year.

The evidence for onboarding programs is thinner than their popularity: a 2023 review of 216 articles on transition-to-practice programs for nurse practitioners and PAs found few that measured outcomes, and relatively few focused on PAs. But new graduates who have been through good ones describe the same useful parts, and the researchers who interviewed them suggest negotiating for those parts:

• A ramp-up schedule. Fewer patients at first, increasing on a plan you can see.
• Training on the electronic health record before you need it, not during your first full clinic.
• A named mentor, with time protected for them to actually do it.
• Expectations in writing — what you will see on your own, from when, and how the practice will decide you are ready.

Ask, too, how long the practice expects that to take. In one pediatric emergency department, PAs new to the department saw an average of 877 patients over their first year before being judged ready for independent practice, and most got there in the third or fourth quarter. The timeline in your job will be different. What matters is that you and the people supervising you agree on what it is.

What should you learn first?

Not more medicine — that comes with the patients. These are the habits I try to build in new PAs, and the ones I wish I had built sooner:

• An examination you do the same way every time. It is the thing a practice cannot easily teach a new graduate in the first month, and it is what protects you on the busy day.
• Your red flags, cold. Every specialty has a short list of things that cannot be missed. In spine surgery, it was knowing which post-operative complaints are expected at week three and which ones mean something is wrong. Learn your list before you need it.
• A plan before a question. Present your assessment and what you would do, then ask what you missed. It is faster for the physician you work with, and it is how you find out whether your reasoning holds — the same thing I ask of students.
• The system, not only the medicine. Who to call for what, how orders and referrals actually move, what the documentation has to show. It is rarely taught, and it decides how your day goes.
• A list of what you do not know. Write the gaps down as you meet them, and close one a week. A year of that is fifty things.
• A pace you can keep. Across the profession, 31.8% of PAs report at least one symptom of burnout. The first year is when your habits about staying late, charting at home and saying yes get set.

Is a postgraduate program worth it?

For some PAs, yes — but it is the exception. Only 5.8% of board-certified PAs report completing a PA residency or fellowship, most often in emergency medicine and surgery.

Graduates of these programs are enthusiastic about them. In one survey of 113, 97% felt more competitive in the job market, 74% believed it shortened the time to full productivity, and 95% would recommend it. That is self-report. Harder outcome data are thin, though one hospital medicine program cut its onboarding time for new hires from 25.4 weeks to 11 after starting a fellowship.

Nearly a quarter of newly certified PAs, 23.9%, plan further education or clinical training within three years. If you are drawn to a specialty with heavy procedural or acute-care demands — emergency medicine, surgery, critical care — a program can shorten the climb. If you are not, a first job with real onboarding does much of the same work.

Before you sign

Read the first contract slowly. These are the parts that matter later:

• Malpractice coverage. Find out whether the policy is occurrence or claims-made. A claims-made policy covers you only while it is in force; leave the job and you may need tail coverage, which AAPA warns can be very expensive. Ask who pays for it. Confirm you are named on the policy, and ask for the certificate of insurance every year.
• The onboarding you were promised. If it matters to you, it belongs in the offer letter, not just the interview.
• Non-compete and non-solicit clauses. They are standard in many PA contracts, and the details — which sites, how far, how long — matter more than whether one exists. More on that in changing specialty.
• Supervision or collaboration. Who it is, how available they are, and what happens when they are away.
• Time and money for CME. You will need both.

None of this makes the first year easy. It makes it the right kind of hard.