No SP on-site = dealbreaker for a new grad?

[NewGradLyn]

Hello, I am a new grad and just interviewed at a new primary care clinic (it literally opened a month ago). Overall, it is the kind of opportunity I have been looking for (it would allow me to use my medical Spanish), but my big issue is that my SP will be in a different building that is about 7 minutes away. There will be another PA on-site with me but she is also entry level. The physician reassured me that he can be reached by phone or he could drive over to see a case that I need help with. But I would honestly hesitate to ask him to take time out of his busy day to drive over to the clinic and help me out. As a new grad, I would really prefer to have either an experienced physician or PA on-site.  

 

Should not having an on-site, experienced physician or PA be a dealbreaker for a new grad? I will appreciate any wisdom/advice anyone is willing to offer me. Thank you.

 

*EDIT: I would also be by myself in the clinic some Saturday shifts (it would be a 4 hour shift). 

[rev ronin]

I wouldn't take such a position as a new grad.  Three years in, I still really like having my SP around for primary care, even if I rarely ask him to see any of my patients.

[LT_Oneal_PAC]

Primary care where SP is seven minutes away and always available by phone with a second PA to bounce ideas off of? Wouldn't bother me.

[sas5814]

Hello, I am a new grad and just interviewed at a new primary care clinic (it literally opened a month ago). Overall, it is the kind of opportunity I have been looking for (it would allow me to use my medical Spanish), but my big issue is that my SP will be in a different building that is about 7 minutes away. There will be another PA on-site with me but she is also entry level. The physician reassured me that he can be reached by phone or he could drive over to see a case that I need help with. But I would honestly hesitate to ask him to take time out of his busy day to drive over to the clinic and help me out. As a new grad, I would really prefer to have either an experienced physician or PA on-site.  

 

Should not having an on-site, experienced physician or PA be a dealbreaker for a new grad? I will appreciate any wisdom/advice anyone is willing to offer me. Thank you.

I think you answered your own question. If the set up makes you uncomfortable you should probably listen to your gut. In the alternative you might ask...how many times a day can I ask you to come over before it gets to be a problem?

[UGoLong]

I'd say it's a personal decision.

 

In primary care, with another PA on-site (even another new one) is doable if you want to do it. 

[jmj11]

I can only speak for myself.  I could have gotten by, by myself when I first started. But I wouldn't have learned a lot and maybe have made some mistakes. I treasured the close relationship I had with my first SP as he taught me a lot.  Just had coffee with him a year ago (after 32 years) and I still appreciate his input into my life.

[Guest Paula]

I must have been really, really naive when I first started in FP without a physician on site.  My collaborator was 75 miles away in another state. I was on a reservation........oh, that explains it! 

 

 It was the best experience and the learning trajectory was straight up, but I managed it just fine.  Partly because it was a part time job to start 2-3 days a week and the other days I worked part time at an ER/UC.  The ER/UC experience taught me much and honed all the acute care and emergency skills I needed and the ER physicians (well....most of them....were fabulous).  The blend of the two experiences helped round me out and I could handle just about anything that came into the tribal clinic. ( Believe me, just about everything came to the tribal clinic).  I eventually went full time at the tribe and prn at the ER.  

 

I had plenty of time to look stuff up at the tribal job as the patient load was low initially ( 4 per day on average)  and I built the practice to about 14 per day by the time I left. 

 

All was good.  

 

It all depends on your comfort level, experience in life,  common sense and the ability to tell when someone really needed another set of eyes to see the patient. 

[cinntsp]

I think Paula makes a good point in that patient load should probably be a big part of your decision.  If you have 10 patients per day with plenty of time to look things up and run ideas by your colleague or SP, it could be doable.  If you're expected to see 25ppd then it's probably worth rethinking.  We like to think of ourselves as ready to jump into FP all gung ho right out of school, but the reality is that FP is not easy and there is still A LOT for you to learn.  

[winterallsummer]

Agree with above. In the non acute setting being forced to have autonomy early can be a great learning experience. However personally if the other PA is also fresh out of school I would look for another job.

[Miaow]

Don't we all have that one story about being a new grad, not having enough supervision and making a mistake that could have been prevented? Well, maybe not all of us but I do. Brand new, left to manage a mountain of patients and I didn't recognize the signs and sx's of a AAA when it first begins to go bad. He went home and died that day. I will literally never forget that and I am eternally grateful that his family didn't ruin me legally. They prayed for me and thanked me for trying my best - but not all of us get that lucky.

 

Now, will this happen to you? Probably not. You'll likely be fine. You'll have plenty of uncomfortable moments where it's abundantly clear that you have no clue and you're not the only person in the exam room who is aware of that fact.

 

We should never be seen as the "go between" or give the impression that we need to "go ask." Even after 13 years, or should I say, especially after 13 years I love the process of collaborating with all my collegues. Good medicine isn't a "lone ranger" situation it's a team and it works best that way.

 

Make sure you have enough support so that you don't feel like you're not safely providing care to the patients who trust you and depend on your judgement. Also, the first years are all about learning so make sure you're in a good environment for that too.

 

Best of luck!

 

-Laura

[shani26]

I am just about to leave my first job that ended up being this almost exact situation: In a federally qualified underserved office- the reason why I left is because I ended having little to no supervision d/t my doctor leaving.

I was basically running a patient panel on my own and ended up burning out.

My advice: don't take it.

[cbrsmurf]

Don't we all have that one story about being a new grad, not having enough supervision and making a mistake that could have been prevented? Well, maybe not all of us but I do. Brand new, left to manage a mountain of patients and I didn't recognize the signs and sx's of a AAA when it first begins to go bad. He went home and died that day. I will literally never forget that and I am eternally grateful that his family didn't ruin me legally. They prayed for me and thanked me for trying my best - but not all of us get that lucky.

 

Now, will this happen to you? Probably not. You'll likely be fine. You'll have plenty of uncomfortable moments where it's abundantly clear that you have no clue and you're not the only person in the exam room who is aware of that fact.

 

We should never be seen as the "go between" or give the impression that we need to "go ask." Even after 13 years, or should I say, especially after 13 years I love the process of collaborating with all my collegues. Good medicine isn't a "lone ranger" situation it's a team and it works best that way.

 

Make sure you have enough support so that you don't feel like you're not safely providing care to the patients who trust you and depend on your judgement. Also, the first years are all about learning so make sure you're in a good environment for that too.

 

Best of luck!

 

-Laura

 

damn.  thanks for sharing that story.

 

if you had been more experienced or a SP was on site, would that have changed the outcome?

[Miaow]

You ask if the SP was there would the outcome have been different and my answer is, maybe.

 

We were 30 - 45 minutes out from a major medical center. My patient was a Caucasian male about 55-60 years old, normal weight, hypertensive but controlled on medication. His BP was slightly elevated that day (150/90) but he said he hadn't taken his medication yet. He complained of new onset pain in both legs but denied low back pain as the cause. I'm not sure at the point that I would have known what a pulsation mass felt like or what a bruit sounded like but I must have missed both.

 

Would my SP have known? Maybe. Although anyone who leaves their entire practice to a brand new PA to go do whatever else she was doing that day ... makes you wonder how much attention she would have been paying

 

So, someone with more years of experience who had encountered this at least once before and not just read about it once during their cardiology block (and never saw it on rotation) might have sent the man by ambulance for more evaluation that day. I'll never know but hindsight is a b*tch and it truly is 20/20.

 

-Laura

[Boatswain2PA]

It is standard of care to miss a AAA/dissection.  B/l leg pain as only sx?  Nope, not gonna really think about AAA/dissection. 

[LT_Oneal_PAC]

It is standard of care to miss a AAA/dissection. B/l leg pain as only sx? Nope, not gonna really think about AAA/dissection.

Right? I would miss that every AAA every day of the week and twice on Sunday with the only complaint being leg pain and a mildly elevated BP.

[Miaow]

Yep, you guys probably would miss every single one. Just like I did. Funny, I've told that story over the years to plenty of friends who called it before I got to the end. Must be in the telling. :-)

 

-Laura

[Boatswain2PA]

Retrospectroscope selection bias.  If I already know it's gonna end badly, and THEN you tell me about b/l leg pain, and hypertension.....I'll get that one..  

 

Guy sitting on the exam table looking fine but saying b/l legs hurt....nope, gonna miss the AAA every time.  

[Miaow]

13 years out its hard to know what made it so obvious to everyone else. The records were reviewed and that decision was made. Likely there were some vague abdominal complaints with pain radiating down into to groin and the legs.

 

Anyhow, I know that it is easy to contradict someone here at every turn, "I would have never missed that!" or "No one could have ever known!" So if you're trying to make me feel better, I appreciate it. It you're trying to take apart my story to disprove my point, that's fine too.

 

The point I was making, if you're a brand new PA don't get in over your head because bad sh*t can happen and you don't want to look back years later and wonder if someone would have lived if your SP was onsite and could have consulted.

 

Edited to add: From a more pragmatic standpoint, do you really want to be in a bad situation and be the only person that people can blame? Safety in numbers!! ;-)

[GetMeOuttaThisMess]

Different perspective here. Bilateral leg pain, even assuming neurogenic etiology, should warrant a quick belly listen and quick hands on for pulsatile mass. I don't know why I always did so in my ED years but I did for just this reason. I always inquired about recent spinal injection, fever, and traumatic event as well. Maybe it just goes back to my spine days in early 80's. Not making statement to sound like "look at me" but rather to plant seed for others still in EM/UC/FM. Legal Monday morning QBing is a bit@h.

[SocialMedicine]

Does not sound like a great situation. 

What if you want someone to look at a rash or ECG ? Do you send photos to the SP ?

I learned a lot discussing patient presentation and bringing colleagues into the exam room for a second look. 

Unless you were an RN or military medic for 20 years I would have very strong hesitations about this. 

Has the physician operated like this before? he may not even recognize all the barriers which could come up this way. 

[Miaow]

At 13 years out I would maybe finally feel comfortable managing a clinic in my specialty alone. I have plenty of times where I am the only provider in the clinic and that's fine. Always glad to have a colleague around especially in those moments where your patient is hemorrhaging and they knew to shove a Foley catheter inside the uterus to tamponade the bleeding so you can transport to the ED!

[EMEDPA]

At 13 years out I would maybe finally feel comfortable managing a clinic in my specialty alone. I have plenty of times where I am the only provider in the clinic and that's fine. Always glad to have a colleague around especially in those moments where your patient is hemorrhaging and they knew to shove a Foley catheter inside the uterus to tamponade the bleeding so you can transport to the ED!

interesting approach:

http://www.ncbi.nlm.nih.gov/pubmed/3900389

[UpRegulated]

Don't we all have that one story about being a new grad, not having enough supervision and making a mistake that could have been prevented? Well, maybe not all of us but I do. Brand new, left to manage a mountain of patients and I didn't recognize the signs and sx's of a AAA when it first begins to go bad. He went home and died that day. 

 

OK.  Several things here.  I'm a newb (and an NP to boot), so take anything I say with a grain of salt I guess.

 

One, everyone misses things. Everyone.  Why is this such a taboo topic on discussion forums?  We love to pat ourselves on the back when we "catch" something the PA/NP/MD/DO missed (it's awesome to be the 2nd or 3rd person to evaluate a problem!), but never admit when we miss.  The presentation you describe is crazy unusual, and a rare condition to boot.  DON'T beat yourself up over it.  Missing a dx is an awful but inherent part of medicine.

 

Two, you were/are trained well and sufficiently.  It's like we crap on ourselves for being PA's (and NP's) thinking if we were MD's these things wouldn't happen.  That's a load of crap.  I work with 2 MD's.  I am a baby NP and have already "caught" things they didn't catch a couple of times in my (only) 10 months out of school, and they have a combined 20 years of experience and one was a chief resident.  Does that make me brilliant?  No!  Does that make them dumb? No!  I'm learning how to not brag for my "catches" because I know tomorrow I just my F* it up and one of them, or the other NP I work with, just my save my a**.  One already has saved my a** just one week after my saving his.

 

Missing sucks, but it is not limited to "mid-levels" - it happens to EVERYONE.  Don't blame it on your training or perceived lack thereof.  1 month out of RN school, I had a patient code in the ER two minutes after pushing the insulin ordered by a doc for a suspected DKA (the pt was a type I diabetic and in severe respiratory distress and had an extensive hx of cancer).  I spent weeks turning it over in my head thinking I had done something wrong, and literally losing sleep, despite the fact I verified my insulin dose with 2 nurses prior to pushing it.  I even went so far as to take a syringe home with me to draw up water into it to confirm what I visualized when I pulled up the insulin because I questioned myself so much.  The fact is, the dude died from a PE (which ended up being his final dx), and was misdiagnosed as a DKA by the ER docs and had nothing to do with my actions, but it still really bothered me.  When something is missed - even if you aren't the one who missed it - it sucks.  You feel like there is something you could have done better.  That is human. And honestly, we probably should feel that way because it shows we care.

 

But sometimes we do miss. Truly miss.  Sometimes on obvious things.  Sometimes on not so obvious things like with you.  That does/will happen no matter who you are and no matter your training, experience, or intelligence. We are humans. It sucks, but it's part of it.  Don't beat yourself up over it, as hard as it can be not to.

[EMEDPA]

nice post upregulated. totally agree. we do all miss things and we do all catch things. there is an em doc named Billy Mallon who does the em lecture circuit. he used to run the usc em md residency program. he talks about different diagnoses as a dart board. most of the board is common things presenting commonly. everyone catches these. as you get closer to the center of the board you have uncommon things presenting commonly. most of the time most people catch these. the center circle(the bullseye) is uncommon things presenting uncommonly. almost everyone misses these on initial presentation no matter how good you are. his lecture was on not missing these the second time when you are seeing the bounceback and a discussion of uncommon presentations of uncommon things once the more common had been ruled out.

[Miaow]

Awesome post,UpRegulated! Thank you for putting time and heart into that. I appreciate hearing about your own experiences. Always a good reminder how none of us are perfect.