Going Midlevel Midlife: Michelle’s Story of Becoming a Physician Assistant in her 40’s

After 16 years of teaching high school wellness, Michelle Roush felt ready for a greater challenge to leverage her interest in health. After much planning and preparation, she is now studying to become a physician assistant, and loving the journey.

Tell us a little about your background…

I am a married, 41-year-old mother of two boys, ages six and eight. I received my BA in health and physical education in 1996 from Ohio Northern University (Ada, Ohio) and taught in the greater Cincinnati area for four years before moving to Chicago.

I finished my Master’s in Education in 2002 and taught at New Trier High School in Winnetka, IL for 12 years. I taught in the Kinetic Wellness department, which, in most schools, is better known as health and physical education.

My primary teaching assignment was health education (sex education and personal fitness) but I also taught team sports and women’s health and fitness. In addition, I was very active in departmental activities: I was the sophomore health course coordinator, sat on the hiring committee and the policies and procedures committee, and more.

When did you start to think about making a career change and becoming a physician assistant?

PA School Age-Related Statistics

First-Year Class: Age	M	SD	Mdn	n(P)
Age of first-year PA student	26.1	2.51	26.0	170
Age of youngest first-year PA student	21.4	1.23	21.0	168
Age of oldest first-year PA student	44.1	7.57	44.0	168

When each of my sons was born, I took a leave of absence from my job to spend time with them in their infancy months. With my second child, I did not feel that magical “pull” to return to work. Teaching had started to feel like Groundhog Day, every day; I could do anything and everything on autopilot. While this made work quite easy, it also made it exceptionally boring.

Compounding this issue, I often felt like a second-class citizen at my high school because I did not teach what they considered a “solid” class, like English or math.

I am very curious about health, wellness, and disease, and if I couldn’t use my skills and talents in the classroom, I felt I should find other avenues where I could make a difference. It doesn’t help that I don’t have a lot of confidence in our state and federal government when it comes to public education—be it classroom funding, standardized assessments, or funding pensions. It was clearly time for me to leave teaching.

What is your next act?

I am a member of the 2017 Rush University Physician Assistant Studies cohort. Upon completion of the program and after passing the licensing exam, I will be certified as a Physician Assistant (PA) and will be able to practice medicine as a member of a collaborative team of healthcare providers.

I will become a PA-C, which stands for Physician Assistant-Certified. In every state, to practice as a PA, one must take and pass the PANCE (Physician Assistant National Certifying Exam) for initial certification and take and pass the PANRE (Physician Assistant National Recertifying Exam) every 10 years. Additionally, to maintain their license, a PA must accumulate a specified number of continuing education hours each year, as defined by their state licensing board.

Rush’s program is 30 months to complete as it has the unique 6-month advanced practice rotation. Participating in a program structured like this, the graduate is prepared with both strong generalist skills and proficiency in an area of advanced practice. Most other PA programs are 24-27 months (Northwestern is twenty-four, Midwestern is twenty-seven, Rosalind Franklin is 24 months).

Despite having very intense academic demands, I can honestly say that I am so happy I made this decision. I love studying medicine and science, learning how disease processes work, using critical thinking and reasoning to arrive at potential diagnoses, and beginning to formulate treatment plans. On the downside, there are days where all I feel I do is study, go to class, eat, study, then pass out from exhaustion – but I realize that this stage is temporary and so worth it!

The volume of information and the speed at which it is disseminated is completely unreal; for example, our dermatology unit lasted one week where we spent five days in the classroom, had six PowerPoint sessions with over 650 slides, then had our exam. And keep in mind that was only for one course!

The volume and pacing are just brutal, and, at times, I think to myself “how on earth am I going to remember all this?” but then I do review sessions for my certifying exam (two years down the road) and surprise myself with how much I know!

There has been a huge growth in demand for PAs and in applications to PA schools. Why is that?

Implementing team-based, collaborative care coupled with the influx of more patients to the health care system (due to the Affordable Care Act) has emphasized the need for flexibility in care delivery to best meet the needs of patients.

PAs are utilized in many areas of healthcare: seeing patients in the clinic for routine or acute needs, rounding on patients in hospitals, assisting in surgery, performing various procedures, and providing patient education – often autonomously, but with collaboration from their partner physician.

Becoming a physician assistant, versus an MD, requires fewer years of study while still allowing you to assume a lot of responsibility in the field of medicine and rewarding you with an attractive salary. In addition, job opportunities are plentiful. According to a recent Forbes article, physician assistant studies is ranked the number one best master’s degree for finding a job. Here is a link to the US Department of Labor Bureau of Labor Statistics regarding PA salaries, requirements, outlook, etc.

While I can’t speak for other institutions, the program director at Rush did tell us she typically receives six job inquiries from potential employers per student. Currently, 100% of Rush graduates are employed within six months of graduation. Many secure jobs even before they graduate.

Why did you choose to become a physician assistant?  What other options did you consider?

I knew I wanted to do something in medicine, so I initially considered medical school to become a physician. After doing some research and talking to MDs and PAs, it became quite clear to me that the role of a PA was best suited for me. Knowing I would want to start school when I was 41, had I gone the MD route, I would not have begun practicing medicine until I was 50 and then I would have spent the next decade (or more!) paying off medical school debt.

Also, having had the opportunity to gain work experience and learn about the roles various individuals play in team settings, I am very comfortable with assuming a great deal of autonomy within the medical setting but am also comfortable serving as an adjunct in various settings.

Knowing that admission to PA school would be extremely competitive, I had to consider backup options. In the event I did not get into PA school, I also applied (and was accepted) to the Generalist Entry Master’s (GEM) program at Rush University, which would have awarded me a Master’s of Science in Nursing (MSN) and allowed me to sit for the registered nurse (RN) licensure test. I could then choose to complete further studies to become a nurse practitioner (NP), an RN with advanced training in diagnosing and treating illness.

For me, there were three main drawbacks to this backup route. First, the didactic and clinical preparation for PAs and RNs is pretty different: PA school follows a medical model and approaches medicine as an organ-disease system, whereas RNs are trained under a nursing model and approach medicine as more of a lifespan issue. For the most part it means that PAs are trained like doctors and use basic sciences as a foundation for their diagnostic reasoning in the care of patients: They determine the workup, analyze how the patient presents (signs/symptoms), order and interpret various tests (labs, imaging, etc), create a differential diagnosis list (possible underlying causes for the chief complaint), then formulate a treatment plan. I mean no disrespect when I say this next part, but nurses are trained to care for the patients they receive while in the hospital. A patient is admitted to their unit and assigned to them. The nurse follows the orders as prescribed by the MD/PA/NP and takes care of the patient on a moment-to-moment basis.

Second, after completing the MSN program and becoming an RN, I would have to spend a bit of time as a floor/shift nurse before I could work toward becoming an NP. I was not so keen on this work. As a floor nurse, you work three shifts a week for 12 hours at a time and every other weekend. While the responsibility is great, the opportunity to actually make decisions regarding the care of the patient is pretty low. As a physician or a PA, you look at the data given and use your physical/mental assessments to make decisions about the workup and treatment plan. The nurse follows your orders/plans. If something should change in the patient’s status, you have to call the provider and await his or her decision to modify care plans, and sometimes they’re not so nice about this—especially when you’re calling them at 3 am! When I became a Certified Nursing Assistant to get the required patient experience, I learned that while the majority of the providers who saw patients on our unit were tremendously kind, there were some that were just rude and condescending.

The job of floor/shift nurse can be exceptionally grueling, both physically and mentally. I think nurses must possess a very special skill set of caring and compassion, above and beyond what is typically provided by the MD/PA. Nurses are absolutely brilliant caregivers and the best ones have a knack for knowing what to say, how to say it, and when to say it. I know, this sounds really “intangible” if you will. From my experience as a nursing assistant, I saw so many wonderful nurses be able to provide such wonderful care to patients and their families in this manner. I also realize that they do it so much better than I could ever do it!

All in all, in order to work in the capacity that I wanted to, PA school would ultimately be less expensive and take less time, not to mention give me the intensity and focus I was seeking.

How hard was it to take the plunge? How did you prepare?

By nature, I am a planner. I need to understand processes, chart a course to arrive at my destination, and do lots of preparation to stave off disaster or failure. Once I made the decision to go for it, I began researching, first figuring out which schools in the Chicago area offered PA studies and then learning what I would need to do to present a competitive application.

I had to retake some courses (anatomy and physiology, psychology) and take several for the first time (general chemistry, organic chemistry, biochemistry, microbiology, probability, and statistics). I completed these at City Colleges of Chicago and College of DuPage.

Since I hadn’t touched most of these subjects in 20 years, I didn’t mind having to do all this work. Furthermore, my undergraduate GPA was a 3.0 so these additional undergraduate hours (with straight As) would significantly strengthen the academic portion of my resume for my application. Because I had to fit these prerequisites into my schedule, which also included working full-time and being a wife and mom, I took these courses part-time. It took me from spring 2012 through fall 2014 to complete all these class requirements.

As part of the PA application, I also had to gain direct patient contact experience. While there are many ways to do this, I chose to become a Certified Nursing Assistant (CNA) and work at a hospital. Knowing that I decided to leave teaching in the spring of 2013 so I could acquire as many hours as possible since most schools really like to see 1,000 hours on the resume.

Shadowing physicians or PAs was another required activity for the application. I was able to shadow in internal medicine, infectious diseases, obstetrics and gynecology, and interventional radiology. It was easy to find MDs to shadow but PAs were virtually impossible, as most of the PAs with whom I am acquainted work for medical groups that do not allow shadowing. Ideally, one of the MDs/PAs you shadow should write one of your letters of recommendation. In any event, the experience should shed light on the role that the PA plays in the healthcare team.

Finally, I had to take the GRE, a graduate admissions test, which is basically a math and English test. I had to prepare intensively for the GRE because it had been decades (literally!) since I had done many of the math problems I would be required to solve. I spent 6-8 weeks with a Princeton Review manual to ready myself.

What was it like to go back to school to complete your PA school prerequisites?

Rarely did I have same-age peers in my classes. I think my background in teaching was exceptionally helpful in forming connections with my classmates. I was often the one organizing study groups outside of class. Also, since many of my peers were taking these classes for the first time, I was able to help them begin to develop good study habits such as creating/using mnemonics and making effective flashcards. I have kept in touch with several of my lab partners and study buddies from my courses.

The other students and my professors were very welcoming. Again, after being on the other side of the lectern, I understand the importance of building good (yet genuine) relationships with my professors. I’m still in contact with two of my instructors, and one even wrote my letter of recommendation.

When did you find time to become a certified nursing assistant too? Are there other ways to get the patient experience that’s required to apply to PA school?

I took an 8-week course in spring 2013 while I was still teaching AND taking anatomy and physiology two as well as organic chemistry. I’m not going to lie—it was BRUTAL. Fortunately, the CNA course wasn’t difficult at all; it was just time I had to spend to get it done and take the state certifying exam. You pay your $960 fee, buy your blood pressure cuff and stethoscope, pay for your background check, and state exam fee, and you’re done. It was super easy.

Some people come to PA school from another health field, such as being a registered dietitian, physical therapist, or pharmacist. In those cases, the individual has earned at least a BS and has had acceptable patient contact. Most people, however, take the “entry-level route” and pursue employment as an EMT or paramedic, phlebotomist, scribe, transporter, physical or occupational therapy aide, pharmacy tech, x-ray tech, etc. Each individual school has its own idea as to what they deem acceptable; it is certainly not uniform across the board.

Tell us more about the application process

Currently, there are over 250 programs that offer academic training to become a PA. I applied to four schools (Rush, Northwestern, Midwestern, and Rosalind Franklin). This is a small number when compared to other students in pursuit of the same degree; because of the competition for admissions, many students apply to 10-20 programs. For example, Rush received 1,200 applications, invited two hundred to interview, and offered admissions to 30 (in other words, a 2.5% admit rate). Midwestern, based on what I heard at open houses, receives about 3,000 applications for eighty-six spots.

All applications must be sent through CASPA.

It’s easy – demographic information, enter ALL your coursework (so your overall and science GPA can be calculated), enter your direct patient contact hours, your shadowing experiences, GRE scores, former work experience, etc. The application fee was about $290.

You must include at least two recommendation letters but no more than three. Most programs want one from an instructor who can speak to your academic abilities and one from a PA/MD. I got my first recommendation from the infectious diseases physician I shadowed. My second one came from my Anatomy and Physiology instructor who had previously worked in ultrasound/radiology and used to be the director of the radiology tech certification program at her school. My third one came from my manager at the hospital where I worked as a nursing assistant.

The CASPA has one general essay: “Why do you want to be a physician assistant?” I hated it because it was so general and so open-ended. I also knew that initially, it would get about 2 minutes of eye-time, so I had to make sure my essay grabbed the reader immediately. Some schools require supplemental questions, like Rush and Northwestern. For Rush, it was asking, “Are you really serious about our school?”

You were called in for an interview at Rush. What was that like?

My PA school interview went from 8 a.m. to 2 p.m. The initial session was informational, with the program director. The twenty of us who had been called in were split into four groups, where our activities rotated.

My group started with a tour of the facilities, hosted by a first-year student. Next, we had a paperwork session where we had to submit a photo, unofficial transcripts of any outstanding coursework, and fill out a sheet indicating any change in our direct patient contact hours and shadowing since our application submission. Following that was a 30-minute one-on-one interview.

After the interview, we all reassembled for a Q&A session with students in the first, second, and third years. Next up was a 60-minute time slot allotted for a 70-question medical terminology exam.

Finally, we had a 60-minute time slot to type responses to two essay questions that we had received upon our arrival.

What kinds of things did they seem to be evaluating?

It was a little bit of everything. Even though the formal interview was only 30 minutes, I’m not naïve to think that the other parts of the day didn’t matter. Here is my take on what they were looking for during each part of our visit:

Arrival and opening session: How comfortable are you socializing with strangers who are all in the same boat as you? Do you seem like the type who might be a good fit for cohort work?

Three-on-one interview: I interviewed with the director of clinical education, a third-year PA student who was currently in her advanced practice rotation, and a second-year PA student who was doing her clinical rotations. All three of them had laptops and took turns asking questions, then immediately started typing once I began to speak.

Medical terminology test: I purposely took a medical terminology class so I could ace this. Luckily, I passed it. If you do not pass it but matriculate at Rush, you must retake it.

Essay: We had two essays and were given the prompts at the beginning of the day. They were both scenarios one might come across, one while in PA school, another once a practicing PA. During the breaks in the day, I started brainstorming and putting together my ideas. They are evaluating one’s ability to think critically about a complex problem and convey a thoughtful, coherent solution in a concise manner (considering we only had 60 minutes to write both essays).

Can you tell us more about the three-on-one interview? What kinds of questions did they ask?

Here are the questions anyone interviewing with a PA school should expect:

• Why do you want to be a PA?
• What do you think a PA does?
• Why do you want to study here?
• How have you prepared to deal with the rigors of this program (academically, emotionally, and do you have a support system in place)?
• What unique experiences have you had that you can apply to being a PA?
• The requisite ethical question (mine was: you believe your attending/supervising physician is under the influence of alcohol, what do you do?)
• Why should we pick you?

I was not terribly stressed out about this interview. In my role as a high school teacher, I was on the hiring committee so I spent a good four years on the other side of the interviewing table. I remember what I liked (and didn’t like) to hear and see and could tailor my approach to better read the needs of my interviewers and give them what they wanted. For example, I’d look at their body language: Are they looking away/yawning as if bored or disinterested or are they leaning forward in their chairs, nodding along with me?

I also made a playlist for my iPod and listened to music on the drive to Rush that morning; it really set the mood for me and got me pumped up. I also spent a great deal of time preparing for the interview by reading through the college catalog. I knew that I could drop keywords that demonstrated my knowledge of the school’s mission, tell stories that illustrated my skills using “their language,” and show enthusiasm.

I wanted to be a good “match” for the school, so I made sure to speak to their mission, values, and vision, all of which were clearly defined over and over throughout the catalog. I wanted to leave no doubt that I a) knew what a PA was, b) knew that I wanted to be a PA, c) knew that I wanted to matriculate at Rush, and d) knew that I would be both a great student and alumni.

How supportive were your family and friends?

I would never be able to do this without the unconditional support of my husband. He is my biggest cheerleader in this endeavor. When I was still teaching full-time AND taking my prerequisites prior to application, he assumed the bulk of the family responsibilities—sometimes four months would go by and I wouldn’t have done a single load of laundry. As a result, I was able to focus on my job and my studies without having to stress about the house or the family.

My boys were two and five when I started tackling my PA school prerequisites and are five and eight now, as I’m starting PA school. This is “normal” for them. What I like the most is that I get to model hard work, focus, and perseverance in an academic pursuit; I hope they adopt my work ethic and drive. Although I was fortunate to have done well, this was NOT easy, and I’m proud of what I accomplished. I hope they can see that hard work can take you far in life.

My friends have been incredibly supportive of my desire for change and, I’ll be honest, it is exhilarating to share with my former colleagues that I indeed DID achieve my goal of getting into PA school!

What challenges did you encounter?

I tend to be a bit of a perfectionist and was unwilling to accept anything but an outstanding academic resume to present for admissions, so I probably put myself under a greater amount of stress than was necessary. In fact, now that I am in the didactic year of my program, I am finding that I am LESS stressed than when I was taking my prerequisites!

Another challenge was planning for a decrease in our family income. Rush’s program costs approximately $100,000. All the programs in the Chicago area are private institutions, so costs would be similar but lower since they are shorter in duration. I have taken out student loans to cover the cost of tuition. While they may seem daunting, I am in the fortunate position of having a spouse who works full-time (which means I don’t have to take out loans for housing or living expenses, etc.). This has meant that we had to modify how we live and how we spend, but the impact hasn’t been too great. It makes me feel a little better about paying them back, knowing that we’ve been able to keep the family afloat while I’ve had no income.

Were there times when you thought about giving up?

I’ll share a funny story here. Typically, most PA schools have wrapped up their interview and offer process around the beginning of the year. On January 5, 2015, when I hadn’t heard from the PA schools where I’d applied, I decided that I would contact the GEM nursing coordinator and let them know I’d like to matriculate in the fall.

I felt as if I had gone through the Kubler-Ross five stages of grief and decided I needed to begin moving forward with Plan B, nursing. I accepted that I could be happy with this decision knowing that I had done everything to try to pursue PA school. The very next day, I was invited to interview at Rush for a spot on the waitlist. Of course, I jumped at it—what did I have to lose?

I interviewed on February 6, learned I was on the waitlist on February 17, and got the call from the director on February 19 with the invitation to join their program.

What did you learn about yourself through this process?

Spending 16 years teaching has made me a better student than I ever could have imagined. I understand learning and how to learn, and it’s been a huge help.

I’ve also learned just how supportive my husband is. He is a great partner, father, and my biggest cheerleader.

What words of advice do you have for women seeking reinvention in midlife?

It can be very scary and risky, so be sure to have backup or contingency plans. That being said, don’t let your fear of the unknown stop you from pursuing something when you know it is the right decision. Before making the leap, grab lunch or coffee with people in the profession to learn as much as you can. Don’t be shy asking them about the grades, experiences, and finances involved. Put together a reasonable plan to accomplish your goals—many of you might have a family that also needs you.  Build a solid support network around you that includes people who are enthusiastic about your choices.

What words of advice do you have for those interested in pursuing your path?

Get good grades, pursue interesting and appropriate clinical experiences to earn the hours needed for the application, start networking with physicians and PAs who will let you shadow and perhaps eventually write your recommendations.  Get into a hospital and make sure you see some of the most disturbing things: newly amputated limbs, trauma sites, infected wounds, gushing blood – these are all things that will be commonplace in your future career so get used to them now.  I’m at the point where NOTHING surprises me anymore!

Find the right PA program for you. Currently, there are 217 programs that offer academic training to become a PA. A list can be found here. Clearly, some programs are stronger than others. Interested students should look for ones that offer a master's level of education. Also, the PANCE (Physician Assistant National Certifying Exam) first-time pass rate should be strongly considered as it sheds light on the rigor of the program.

Be certain to attend any open houses provided by the schools you wish to attend. Take your spouse or partner with you so they, too, know what you may be getting into.

What resources do you recommend?

• PA Education Association
• CAPSA or Central Application Service for Pas: This is where prospective students apply plus it has a wealth of other information
• Follow the American Academy of Physician Assistants.
• The Ultimate Guide to Getting Into Physician Assistant School by Andrew Rodican. I bought it and read it cover to cover numerous times.
• How to Write Your Physician Assistant Personal Statement

What’s next for you?

Right now, I’m focused on surviving my didactic (academic/classroom) year of PA school, which means being in class from 8 am to 5 pm daily for the next year. Once I get through the program and settled into a career, I think my next act will be retirement (in about 25-30 years!)