Monte Posted March 29, 2017 Share Posted March 29, 2017 Hello! Briefly.. Started my new ER rotation. 11PM-7AM five days a week. It seems like i'll learn a lot, but I'm disappointed by a few things and wonder how common they are. 1.) The docs sit in a nice room with windows looking over the ER, the PAs are in a basic closet with a few computers. 2). The PAs keep calling themselves midlevels.. it does seem degrading the more I hear it. 3.) My preceptor has been working in this ER for 5+ years, yet they are reporting acuity level 3&4s to the attending.. very simple cases that I could even handle. At one point the attending literally went over all eight patients we were currently seeing. I'm in the northeast (small city) where I thought things were a bit more progressive. Slightly bummed.. what do you guys think? Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 29, 2017 Moderator Share Posted March 29, 2017 nope not common glorified scribes getting a healthy pay check Link to comment Share on other sites More sharing options...
Monte Posted March 29, 2017 Author Share Posted March 29, 2017 nope not common glorified scribes getting a healthy pay check I've done ER work before and it didn't seem to be common.. just wanted to scope these factors out elsewhere. Such a shame.. I want to work ER so I was hoping for a solid experience. Luckily my preceptor is a good teacher.. just have to get past the environment. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted March 30, 2017 Share Posted March 30, 2017 See if you can work with one of the EPs there so you can see the sicker patients. In past 2 days I've had 2 STEMIs, one where I pushed TNKase, a pregnant MVA, bunch of sick old people, reduced a neurologically compromised boxers fracture, etc, etc, etc. I did see my "attending" in the ED for a few minutes today as she dropped off one of the STEMI patients for me. Link to comment Share on other sites More sharing options...
moestown1016 Posted March 31, 2017 Share Posted March 31, 2017 Their group may require them to present every patient. Sometimes I do consults at a facility where every ER patient is seen by the attending (after the APP) so the group can get the 100% reimbursement. But where I work I only present a patient if I have a question. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Monte Posted March 31, 2017 Author Share Posted March 31, 2017 I found out that it's hospital policy that they report all acuity 3 or below to the ER docs. They are also not allowed to ever intubate, etc. It really bums me out.. the PA I'm with won't even order a CT scan before talking to the doc. Literally 2 out of 3 patients I hear them say to the patient.. okay well I'm going to go talk to my attending and get back to you. Link to comment Share on other sites More sharing options...
GreatChecko Posted March 31, 2017 Share Posted March 31, 2017 It really depends on the shop. At my last job, I had to have an attending see my ESI level 1,2,3 patients, that being said, once they worked with me a few shifts and were comfortable that I wasn't a complete idiot, I'd usually grab them once the workup was complete, so they could scribble a note and sign the chart. Of course, if they were really sick or complicated and I wasn't comfortable, I'd ask for help, run the case by them, etc. But as time went on, they were happy to have the help, and I was basically a "Set it and forget it" member of the team. Not a bad first ER gig. Link to comment Share on other sites More sharing options...
Monte Posted March 31, 2017 Author Share Posted March 31, 2017 It really depends on the shop. At my last job, I had to have an attending see my ESI level 1,2,3 patients, that being said, once they worked with me a few shifts and were comfortable that I wasn't a complete idiot, I'd usually grab them once the workup was complete, so they could scribble a note and sign the chart. Of course, if they were really sick or complicated and I wasn't comfortable, I'd ask for help, run the case by them, etc. But as time went on, they were happy to have the help, and I was basically a "Set it and forget it" member of the team. Not a bad first ER gig. Right.. I'm absolutely fine with that kind of oversight after graduation.. I just wouldn't be happy presenting all my 3,2,1 cases to an attending who is twenty years younger than me when I'm far into a career. Link to comment Share on other sites More sharing options...
GreatChecko Posted March 31, 2017 Share Posted March 31, 2017 Right.. I'm absolutely fine with that kind of oversight after graduation.. I just wouldn't be happy presenting all my 3,2,1 cases to an attending who is twenty years younger than me when I'm far into a career. Here's an article explaining how it worked. Perfect no, but overall, I was happy: http://epmonthly.com/article/pa-training-oversight-model-worth-copying/ Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 1, 2017 Moderator Share Posted April 1, 2017 I found out that it's hospital policy that they report all acuity 3 or below to the ER docs. They are also not allowed to ever intubate, etc. It really bums me out.. the PA I'm with won't even order a CT scan before talking to the doc. Literally 2 out of 3 patients I hear them say to the patient.. okay well I'm going to go talk to my attending and get back to you. Ugh So undermining... I would leave this position if they did not relent.... Link to comment Share on other sites More sharing options...
Monte Posted April 2, 2017 Author Share Posted April 2, 2017 I wish I could.. stuck for the rotation. I definitely feel like we are scribes collecting info for the doc when they say it every night. Link to comment Share on other sites More sharing options...
Monte Posted April 3, 2017 Author Share Posted April 3, 2017 So where do I have to go to not see things like this.. in the northeast states. It's not like I'm in a huge city or anything. (The presenting all cases 3+ acuity to "my attending" being mandatory, PA closets and being unanimously called midlevels by everyone) Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 3, 2017 Moderator Share Posted April 3, 2017 rural NY, VT, ME, CT, NH, preferably at a critical access hospital Link to comment Share on other sites More sharing options...
anewconvert Posted April 3, 2017 Share Posted April 3, 2017 So where do I have to go to not see things like this.. in the northeast states. It's not like I'm in a huge city or anything. (The presenting all cases 3+ acuity to "my attending" being mandatory, PA closets and being unanimously called midlevels by everyone) Get out in the sticks. The PA world in rural ERs is much more closely aligned to the type of medicine you want to experience. Link to comment Share on other sites More sharing options...
Monte Posted April 3, 2017 Author Share Posted April 3, 2017 It's not like I would even want crazy abilities.. just to not be monitored as mentioned like a student. I heard today that there are even teaching days where all PAs report their cases and are taught how to improve themselves. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 3, 2017 Moderator Share Posted April 3, 2017 yup, but you have to put in your time first learning your trade. solo coverage is not for new grads. I worked my way up from urgent care to community hospitals to level 1 and 2 trauma ctrs before ever working rural. my first rural job was dual coverage with a doc(great job, still there a few days/mo 10 years later) and now work 2 rural/solo positions. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 4, 2017 Share Posted April 4, 2017 It's not what you know that's dangerous; it's what you don't realize that you don't know (regardless of title). Link to comment Share on other sites More sharing options...
aty001 Posted April 4, 2017 Share Posted April 4, 2017 I currently work in an ER and recently the company that the docs work for changed how they get paid- now if they see more patients, they get more money. For the midlevels (we have PAs and NPs) they get paid the same no matter what. So the docs have started asking the midlevels to see higher acuity patients, do all the orders and work up and then sign them out to the doc so they get credit for seeing the patient. Not sure how the hospital you're rotating at works, but it could have something to do with reimbursement and the docs wanting to make more money Link to comment Share on other sites More sharing options...
Monte Posted April 4, 2017 Author Share Posted April 4, 2017 I currently work in an ER and recently the company that the docs work for changed how they get paid- now if they see more patients, they get more money. For the midlevels (we have PAs and NPs) they get paid the same no matter what. So the docs have started asking the midlevels to see higher acuity patients, do all the orders and work up and then sign them out to the doc so they get credit for seeing the patient. Not sure how the hospital you're rotating at works, but it could have something to do with reimbursement and the docs wanting to make more money Most likely that's a factor. The docs openly say oh thanks I'll just sit here and make money any time a PA presents a pt or does something. It's been quite disappointing since I was really considering working ER. Even as a new grad I wouldn't want to have to present every single patient.. and get permission for every single CT scan, etc. Link to comment Share on other sites More sharing options...
Guest ERCat Posted April 6, 2017 Share Posted April 6, 2017 Not like that everywhere at all. In my two ER rotations out in rural areas, the PAs basically ran the ER and the docs would sometimes even come in and ask this rockstar PA questions. The PA even had RESIDENTS working with him. In my ER currently it's a little different. We are comprised of mostly new grad so there is a lot of handholding like you described. But once they establish trust in someone, it's not so much like that anymore. I still do generally give a doc a heads up on each patient "Hey, I admitted this lady for appendicitis" or "Hey, I am sending home this pleuritic upper back pain who PERCed out and had a negative D Dimer." But usually I work up the patient from beginning to end without any assistance. If I have questions along the way though, they're great about answering them. This is the perfect happy medium for me in my stage. Link to comment Share on other sites More sharing options...
parnemt Posted April 10, 2017 Share Posted April 10, 2017 I work in an ER with 100% oversight. I'm three years out of school and this is my first job. I have learned so much but I'm fixing to quit for another ER job with more autonomy. I can't stand changing my practice style with every physician and getting lectured on why their way is right. It's also frustrating to sew someone up just to have them sit for another hour just so they can be seen by the physician. Link to comment Share on other sites More sharing options...
moestown1016 Posted April 10, 2017 Share Posted April 10, 2017 I work in an ER with 100% oversight. I'm three years out of school and this is my first job. I have learned so much but I'm fixing to quit for another ER job with more autonomy. I can't stand changing my practice style with every physician and getting lectured on why their way is right. It's also frustrating to sew someone up just to have them sit for another hour just so they can be seen by the physician. Sounds like a really good first job (with all the learning) but man it is frustrating to change how you practice based off who you're working with. I'm sure you're glad to be moving on! Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Monte Posted April 10, 2017 Author Share Posted April 10, 2017 I work in an ER with 100% oversight. I'm three years out of school and this is my first job. I have learned so much but I'm fixing to quit for another ER job with more autonomy. I can't stand changing my practice style with every physician and getting lectured on why their way is right. It's also frustrating to sew someone up just to have them sit for another hour just so they can be seen by the physician. Right.. I'm all for oversight in the initial practice. Precepting with someone who has 6 years ER experience, yet, has to prescribe certain meds depending on the doc working.. run decisions to order a CT by the doc.. present all cases, etc. is too much!! On the other hand I've been promised the next lumbar puncture.. gotta find some light in this rotation. Link to comment Share on other sites More sharing options...
parnemt Posted April 10, 2017 Share Posted April 10, 2017 A problem I've noticed with having 100% oversight is having to juggle patients in your head for longer. I can walk into a room, do my h&p and realize that the patient has a cold and know that I'm going to send them home with symptomatic treatment. But now I have to remember all the details of the encounter (sometimes 3 or 4 patients later) so I can present (and defend) my treatment plan when an attending is available. Adds a lot of useless clutter to and already busy ER shift. Link to comment Share on other sites More sharing options...
muchi Posted April 25, 2017 Share Posted April 25, 2017 At our ED (busy, metro area) PAs function pretty independently. I started as a new grad here and we had a 3 month "internship" where we ran every pt by an attending. After the attendings trusted me, I now see patients completely on my own, and discuss only admissions or weird cases with attendings. I love it, I have autonomy while also having an MD/DO available to bounce thoughts off of as needed. Link to comment Share on other sites More sharing options...
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