Lemon Bars Posted July 17, 2014 Share Posted July 17, 2014 Where did your post go, EMEDPA? You made some valid points regarding my post and I was going to say that I respect your experience and your perspective. Link to comment Share on other sites More sharing options...
primadonna22274 Posted July 17, 2014 Share Posted July 17, 2014 I don't necessarily dislike the utilization of APs as a stopgap to HPSA needs...on a short-term basis. I can see that it might help with re-applying to residency...although numbers are still the name of the game (board scores etc.) My major objection to this pathway is the absolutely inadequate dose of supervision. Come on, 1 month?! As a new PA I had regular weekly meetings with my SP and she was always available when I needed help/guidance. These guys won't get this. As a new PGY1 physician I have even closer supervision the first few months (must staff all patients with an attending). Graduated autonomy is somewhat resident-specific, but by the end of intern year most of us are considered "safe" to practice at a high degree of autonomy, but not independently until completion of R3. (This is somewhat arguable as we can moonlight with a permanent license in PGY2.) Link to comment Share on other sites More sharing options...
andersenpa Posted July 17, 2014 Share Posted July 17, 2014 This actually doesn't sound all that crazy to me. 1) Medical school is typically four years long and includes clinical rotations while PA school is only typically only 2.5 years long including rotations. Therefore a medical student before residency should be as well trained as a PA. I know some (and not all) physician assistants had many years of prior health care experience, but so did some doctors. 2) I'm sure at least some foreign medical graduates are qualified to practice medicine. It's BS that they would have to redo three years of residency if they already did that in their home country. They should have to pass the normal medical school tests, though, I think, as well as some sort of supervised rotations, to weed out those who don't know their stuff. 3) The current three year residency requirement for primary care doctors is not working out very well. Primary care does not pay enough to compensate doctors for their time and pay back their loans. That's a big reason why there is a shortage of primary care doctors. Turning MD's into PA's frees them from being underpaid for three years. Personally I like the idea of a stepped system where all providers (MD/DO/PA/NP) are referred to as Physician I, Physician II, Physician III and have the opportunity to move up the ladder with additional schooling and training, gaining more privileges with experience and training. We should all be mentored by more experienced providers, as happens normally in most professions. All these arguments just sound like turf wars to me, probably motivated by money more than patient care. I get what you're saying and I don't totally disagree with some of the comments on the linked SDN thread. In philosophy med school is preparation for residency while PA schools prepares for collaborative practice (I can't really use the word supervised with good intent anymore). One of the flaws is all the "maybes" in your points. I honestly don't know how MS and PAS clinicals compare- Lisa can comment on this- but do the MS clinicals prepare for our concept of initial PA practice, and losing supervision at 1 mo? We also can't assume how ready these non-residency docs are to practice. Perhaps some have int'l credentials, but that won't apply to them all, and the system has to be organized to address all comers. Point #3 could easily be read as an argument to open up PA practice. The same financial forces the route docs away from PC also do so for PAs. PAs have (theoretically) less debt burden and, with the explosion of PA programs, this is fertile ground to meet the shortage. The graduated level of physician practice is a great idea, we've discussed it here before. Basically to good an idea to happen! Link to comment Share on other sites More sharing options...
primadonna22274 Posted July 17, 2014 Share Posted July 17, 2014 Matt, just my observation: when you and I and (I suspect) most of the >10 yr postgrad PA folks were in PA clinical rotations, we were allowed to do almost everything ("Here Lisa, hold the heart"..."Cut"... "you done harvesting that vein yet?!" "Do I need to see that patient before they go?" ????) A decade and a half later, on med school rotations, I was VERY restricted in about half of these. It was exasperating. I really think many PA students are experiencing this too. I just don't think folks are getting the same preparation we used to get. This is a byproduct of the severe Medicare payment restrictions and hospitals significantly restricting student experiences for "risk management" since the mid-2000s. I find it frustrating all around and worry that we are not encouraging and in fact are actively limiting PA and medical students' growth in the all-important medical decision making skills. Would like to hear from any recent (<5 yr) grads and current clinical PA students on this. Would also concede that some of this phenomenon may be an East Coast vs. Best Coast phenomenon.... Link to comment Share on other sites More sharing options...
primadonna22274 Posted July 17, 2014 Share Posted July 17, 2014 Shoot not done. Recent grads <5yr and current clinical PA students would like to hear from you about your experiences. I would also be willing to concede that it may be an East Coast vs. Best Coast phenomenon as I trained PA school in west and med school in the east. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 17, 2014 Moderator Share Posted July 17, 2014 Matt, just my observation: when you and I and (I suspect) most of the >10 yr postgrad PA folks were in PA clinical rotations, we were allowed to do almost everything ("Here Lisa, hold the heart"..."Cut"... "you done harvesting that vein yet?!" "Do I need to see that patient before they go?" ) A decade and a half later, on med school rotations, I was VERY restricted in about half of these. It was exasperating. I really think many PA students are experiencing this too. I just don't think folks are getting the same preparation we used to get. This is a byproduct of the severe Medicare payment restrictions and hospitals significantly restricting student experiences for "risk management" since the mid-2000s. I find it frustrating all around and worry that we are not encouraging and in fact are actively limiting PA and medical students' growth in the all-important medical decision making skills. Would like to hear from any recent (<5 yr) grads and current clinical PA students on this. Would also concede that some of this phenomenon may be an East Coast vs. Best Coast phenomenon.... I agree, I just precepted a student for his last rotation and he told me that I was the first one to hand him a chart and let him just go see pts then tell me about them... Link to comment Share on other sites More sharing options...
dmdpac Posted July 17, 2014 Share Posted July 17, 2014 I've been out less than five years. For all of my rotations, with the exceptions of surgery and psych, I was picking up charts and seeing patients on my own starting day one of the rotation. I think this may have been the exception more than the rule based on conversations with my then classmates. I wonder if this is more an issue of individual self-motivation versus clinical site specifics or something else... I wasn't afraid to say/ask, "Hey, I can do that" or "Do you mind if I give that a go?". I was also older than most of my classmates and brought more than 10 years of paramedic level experience in 911, HEMS and critical care settings. So that may have influenced things, too. Link to comment Share on other sites More sharing options...
primadonna22274 Posted July 17, 2014 Share Posted July 17, 2014 I was an actively practicing PA for >12 yr during my M3/4 rotations. Those who respected my knowledge (and PAs overall I think) gave me quite a bit of rope. Those who were uncertain of their teaching ability and/or failed to respect maturity and prior experience were very restrictive and thus I learned almost nothing from them. Had nothing to do with my enthusiasm and motivation. Sadly ???? Link to comment Share on other sites More sharing options...
andersenpa Posted July 17, 2014 Share Posted July 17, 2014 I agree, I just precepted a student for his last rotation and he told me that I was the first one to hand him a chart and let him just go see pts then tell me about them... I've seen some of that with my students. Most have initiative but I have had more than a few where they are expecting me to tell them what to do on a daily basis. I ask them to "see the pt" and sometimes get a quizzical look in response, as if, "what does that mean"? I wonder what expectations are being placed on them be other preceptors. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 17, 2014 Moderator Share Posted July 17, 2014 Where did your post go, EMEDPA? You made some valid points regarding my post and I was going to say that I respect your experience and your perspective. I think it was too controversial and sounded arrogant so I deleted it a few min after posting it. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 17, 2014 Moderator Share Posted July 17, 2014 I've seen some of that with my students. Most have initiative but I have had more than a few where they are expecting me to tell them what to do on a daily basis. I ask them to "see the pt" and sometimes get a quizzical look in response, as if, "what does that mean"? I wonder what expectations are being placed on them be other preceptors. I think many preceptors of both md and pa students today just expect them to follow them around and maybe talk about cases but not actually do anything on the rotation ...totally worthless in my opinion. I didn't pay the big bucks for pa school to shadow someone... Link to comment Share on other sites More sharing options...
swooshie1 Posted July 17, 2014 Share Posted July 17, 2014 I'll just add my .02 as a soon to be graduating PA-S. During the first month of my FM rotation my preceptor allowed me to see seven (7 !) patients. Not for my lack of motivation. Every day I was prepared (having reviewed the coming day's schedule and every pt's chart ahead of time the night before) with at least 4-6 pts highlighted that I thought would be great learning cases for me. I specifically pointed these out to my preceptor each morning and told him "I'd like to see these pts" .... he would nod his head and say "ok" - when those pts came, it was the same old sh*t .... followed my preceptor in to the appt and after introducing me he would just sit down and start in on the appt. I repetitively told him I felt I could do more and his response: "oh, no, you're doing just fine. Don't worry about it." I spoke to my school. They said I needed to be seeing a LOT more. Reported this to my preceptor who said "Well, they've never made that clear. This is how I do it." My program had NO contingency plan for me. Part of the problem (I think) is that while my preceptor was a grad from the same program (6 years out), he had immediately gone into specialty (neuro) for several years; was back now in FM for only ONE year prior to taking me as a student. Not sure my program understood this or if it even matters to them; the bigger problem is that they are struggling to get preceptors, so they take what they can get, and they are not going to piss off a preceptor by telling them how they think they should be precepting students. My program has been around for decades, so it is not a "new program having difficulty organizing their clinicals" type of thing. By the end of my rotation I was seeing 2-4 pts each day, tops; about 50% of that time my preceptor would barge in after 10 minutes before I had even finished the PE. I did NO procedures start to finish, little bits here and there. Freezing warts? oh, sure. Biopsies? Toe nail removals? noooo way. In the end, I have a job secured in family practice with a great group who I've been honest with as far as my clinical year experiences, and my concerns. Bottom line is that we jive in philosophy of care. I feel very lucky. Link to comment Share on other sites More sharing options...
LESH Posted July 17, 2014 Share Posted July 17, 2014 Shoot not done. Recent grads <5yr and current clinical PA students would like to hear from you about your experiences. I would also be willing to concede that it may be an East Coast vs. Best Coast phenomenon as I trained PA school in west and med school in the east. "East Coast vs. Best Coast phenomenon" lol Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 17, 2014 Moderator Share Posted July 17, 2014 "East Coast vs. Best Coast phenomenon" lol or as my colleagues on the east coast say "east coast vs left coast". ok by me. Link to comment Share on other sites More sharing options...
jsfelder0417 Posted July 17, 2014 Share Posted July 17, 2014 I had good experiences during rotations in rural Idaho. I reduced fx's, splinted extremeties, controlled hemorrhage, removed nails, moles etc. Ordered and interpreted my own images and labs to my preceptor, intubated, injected joints, first assisted in Ortho and Gen Surg etc. My rotations were solid. My proudest moment was a skier that had fallen and came in on a back board. Peripheral pulse, motor, and sensation intact. Pt asked to get up. I said no, of course. When pt was log rolled I palpated the spine and elicited exquisite focal tenderness in the thoracic region. Voiced my concern for a fx of T5. Ordered the CT and presto, compression fx of T5. Pt was life flighted to closest Level 1, and is now back to competitive skiing. Link to comment Share on other sites More sharing options...
Acebecker Posted July 17, 2014 Share Posted July 17, 2014 I have been out 3 years. I have precepted several students. My best preceptors were the ones who would show me the schedule and say, "Go get 'em." Of course, this was generally because it meant their day was easier. My first rotation, 2nd day, general surgery: Preceptor says, "The ER called me for a consult on a gallbladder. Do you know where the ER is?" I found the ER, found the patient, finished the workup, read the CT, wrote admit orders, preceptor co-signed, dictated the note, patient admitted for obs as there was no significant cholecystitis and her white count was elevated by a couple of hundred cells. Improved on IV ABx and DCd home in 2 days. That's how that whole rotation went. It was crazy awesome. I treat my students much the same with the exception of observing them for the first few patients. We walk in together I say, "this is my student, she's going to get started and I'll watch." Students hate this, but it actually teaches them a lot. After 5-6 patients done that way I hand them a chart and say, "Go get 'em." By the end of their rotation with me I expect they can see easily 10-12 patients/day (I work in urgent care and do 11 hour days). Some students have struggled with this. Others have not. It's students who can see a fair number of patients who are ready to go on to practice in collaboration with a great deal of autonomy. A few months after I graduated we hired a doctor in clinic who had not completed her residency. We got along well but she was a total slacker. I got the distinct impression she was more comfortable with my level of knowledge and skill than her own. Nice lady, though. Got fired after about 9 months. ETA: Trained in metropolitan Washington and rural Idaho. Link to comment Share on other sites More sharing options...
DissentingVoice Posted July 18, 2014 Share Posted July 18, 2014 After briefly reviewing a few posts on SDN, they kinda sound like me. Except I try to be less of a jerk.... And we train people way too slowly without any evidence that it creates better physicians or safer care. Hell, medical students way back when used to do things that require fellowship training now. Everyone survived. The old saying was "see one, do one, teach one" I had preceptors in medical school that really trusted me and let me do lots of fun stuff. Minor surgeries, bronchoscopies, anesthetics, etc. They just stood back, gave me tips, and watched. Nobody died. Nobody got hurt. Then some preceptors were afraid to let me take a history/physical. It's not that I was any less capable when working under them. They were just more fearful. As the old adage goes - you reap what you sow. I put a lot in; I got a lot out. Maybe some people are just being wallflowers. Link to comment Share on other sites More sharing options...
DissentingVoice Posted July 18, 2014 Share Posted July 18, 2014 So Primadonna, how do your first few weeks of residency compare to your first few weeks after PA school? Do your coworkers seem more or less qualified than new PAs? Do you think they can perform patient care duties under the supervision of another physician? Do they stand in the corner of the room and watch everything or do things? Everyone makes it sound as if new med school graduates can't do anything. What do you think? Also, do you take night call in a hospital? If so, how is your autonomy overnight? Link to comment Share on other sites More sharing options...
jsfelder0417 Posted July 18, 2014 Share Posted July 18, 2014 ^Great questions, DV. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 18, 2014 Moderator Share Posted July 18, 2014 So Primadonna, how do your first few weeks of residency compare to your first few weeks after PA school? Do your coworkers seem more or less qualified than new PAs? Do you think they can perform patient care duties under the supervision of another physician? Do they stand in the corner of the room and watch everything or do things? Everyone makes it sound as if new med school graduates can't do anything. What do you think? Also, do you take night call in a hospital? If so, how is your autonomy overnight? not really a fair comparison as her co-residents were good enough to match. all of the future APs weren't, they were likely the bottom 10% of their medschool class, the folks who got "pass" on all rotations and honors in none.. these folks are average or below average in every respect.sure, they are "doctors" just like yugos are cars. doesn't mean anyone wants to drive a yugo or be seen by an AP. maybe we should compare them to people who graduated from pa school but failed their national board exam or folks who passed pance but can't find jobs? compare your bottom of the barrel new grads to ours, not to those of us who actually succeed. Link to comment Share on other sites More sharing options...
primadonna22274 Posted July 18, 2014 Share Posted July 18, 2014 Lol I started residency on OB/peds night float ???? July 1, 6pm-7am, I was IT as the resident covering OB and peds services. Not NICU, but main peds admissions and floor, newborn nursery, L&D and antepartum. PGY2 and attending available by phone. 2 of my least favorite and least comfortable services. I'm less scared--quite a bit less lol. Trial by fire. Maybe I'm blessed to work with some pretty amazing residents, but they're all really bright and seem quite competent. Of course they will get much better--we are still in the first month. But I am really pleased. 8 of us, very diverse, we all get along and complement each other well so far. They're all 10-15 years younger than me but I don't look 40 either lol So, yes, definitely as competent as green new grad PAs. Deeper knowledge base but perhaps less comfortable with procedures. But some more procedurally competent than others. Actually interns at my program have quite a low amount of direct supervision. Plenty of indirect supervision and plenty of fallback. If we stood in the corner we would be called out immediately. This hospital has run on residents for 35 years and expects us to hit the ground running. We would be so fired if we thought we could stand by watching. Link to comment Share on other sites More sharing options...
jsfelder0417 Posted July 18, 2014 Share Posted July 18, 2014 ^That would be an awful small sample body on the PANCE failures, E Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 18, 2014 Moderator Share Posted July 18, 2014 ^That would be an awful small sample body on the PANCE failures, E Probably equivalent nationwide to the # of APs who will be hired? Link to comment Share on other sites More sharing options...
DissentingVoice Posted July 18, 2014 Share Posted July 18, 2014 not really a fair comparison as her co-residents were good enough to match. all of the future APs weren't, they were likely the bottom 10% of their medschool class, the folks who got "pass" on all rotations and honors in none.. these folks are average or below average in every respect.sure, they are "doctors" just like yugos are cars. doesn't mean anyone wants to drive a yugo or be seen by an AP. maybe we should compare them to people who graduated from pa school but failed their national board exam or folks who passed pance but can't find jobs? compare your bottom of the barrel new grads to ours, not to those of us who actually succeed. Um...there's a bottom 10% of PA school too. Link to comment Share on other sites More sharing options...
DissentingVoice Posted July 18, 2014 Share Posted July 18, 2014 Sounds like you're liking your program Primadonna. Enjoy it. Residency can be fun. Link to comment Share on other sites More sharing options...
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