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UpRegulated

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UpRegulated last won the day on May 1 2016

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  1. I wholeheartedly agree. But that's hard to pull off. Why? Because if you introduce a doctorate (wide spread) that adds something like a residency, or additional clinical hours, or more sciences, etc. then you simultaneously undercut and undermine all practicing PA's who have "only" a master's degree. It's sends the message, unintentionally or not, correct or not, that existing PA's aren't adequately trained. It could very well be perceived as an admission that existing PA training is inadequate, which, of course, is false.
  2. We didn't start the fire. But we've at least fanned it a little. By "we" I mean PA's and NP's. For years, one could be a PA with an AS. Now an MS is required. Is the training really that much different? For all the whining, moaning, and nashing of teeth that the DNP just adds "fluff" hours to the MS in nursing, the same can be said of the transition of AS to MS for PA's. It's just degree creep. A doctoral degree is becoming the norm in healthcare and there's no stopping that. The DNP is nursing's answer. PA's need one too.
  3. Not sure if you are replying to me or not, but good point. A POC test should be part of the data like ROS, PE. When an older adult presents with FUO, with only body aches, chills, malaise and fatigue with a clear UA and a + flu, you have a reasonable idea of what is going on. Or at least a reasonable management approach. Hx is 90% of your diagnosis. PE and labs are to help confirm, so long as limitations are understood.
  4. That's kind of my point too. But any test based on the prevalence of a disease in the community relies on some other measure/test to measure/test the prevalence of a disease in a community. I too am the nerd that likes to look at the statistical validity of a given test, but that only has so much utility in a real-world clinical setting. My point being that we can get too wrapped up in the stats/"research" of POC tests. To me, they are on a practical level just part of the history. Flu + or -, Tamiflu or other antivirals do practically nothing. Combine that with the fact that I have little trust for POC tests given the inter-manufacturer lack of reliability, I fall back on clinical judgement, which is probably what we should be doing anyway. I agree with you on Centor, BTW. I rely more on Centor criteria than rapid streps at my facility, to the point I note "Centor criteria +" in my charts when I treat. And Centor is based on history and exam, not a POC test. Let me add that even the "perfect" POC test relies heavily on the ability of the person administering it, as do all diagnostics. There are too many MA's and nurses that can't adequately swab tonsils or a nasopharynx for us, as providers, to not take the results with a grain of salt. So you are right, why do POC tests at all? I'd be cool with not doing them to be honest with you, to a certain degree. But I order them to have a little more data along with my history and physical. I use them as part of my MDM, just as one would do with any lab test. But no test, POC or not, makes or breaks a diagnosis. It is sometimes too easy for providers to exclusively use diagnostics to rule in or out. Diagnostics tests are great and essential to good practice, some are so good as to offer "gold standards" for diagnosis, but we as providers need to understand the utility of one diagnostic test vs. another. POC RI/URI tests suck. Flu test included.
  5. The studies are based on predefined criteria, the patient is not. These studies are based on CDC criteria of ILI, but that in and of itself does not mean the patient does or does not have influenza. So...treat the patient not the test? Not being sarcastic at all, just that it's easy to tie onself in knots over a positive or a negative result of whatever POC test. I remind myself from time to time that there was a day when there were not rapid flu tests, rapid streps, POC mono's, etc. It forces me to rely more on my history, exam and clinical judgement. There are numerous studies on multiple POC labs, which are helpful, but there seems to be a lot of inter-manufacturer variability. Unfortunately, for example, my facility uses a rapid strep that I put zero faith in. We almost never get a positive, but when we do, it is inevitably in someone that doesn't even have a sore throat, or an intermittent sore throat at best (our MA's and nurses swab "sore throat" complaints before I see them most of the time). At the same time, many of the POC tests we do are for self-limiting illnesses. So I'm kinda "meh" on POC tests for acute illness. I use them as part of my clinical decision making, but certainly not the crux of it.
  6. Go to amazon.com, search for Botox, click on the product you want, then click "Add to Cart" then click "Proceed to Checkout." ;)
  7. $20K???? That's chump change over the life of a career and should have nothing to do with your decision. You are in school for 2-3 years. You are married for life. Your wife giving up seeing you for 2-3 years warrants listening to her opinion. She is making a greater sacrifice than you. If you pull your wife away from her family over a relatively minor school preference it will cost you. She will be left with no nearby family and no husband. The failure rate of marriages with students in medical professions is already extremely high. Taking her away from her family + you being in school all but guarantees the house will win. Lower pass rates? Your education is your responsibility as much as it is your school's. Actually more. If you can't learn what you need to learn on your own, then that is on you. You will have lifelong career after school and no professors to help you.
  8. Wunderlist!!! It has nothing to do with medicine, but it rocks for groceries and what I need at Home Depot! Having said that...UpToDate is awesome in a desktop browser, kinda "meh" on a smart phone. Epocrates for smartphone (I know those were excluded from your question). Medscape is increasingly not my go-to, though I used to like them. Bugs+Drugs was great, but is no longer supported. MMIT is OK for getting a ballpark on insurance drug coverage, but only a ballpark. I've tried/used a few lab reference apps, but haven't been impressed and they don't offer anything Epocrates doesn't offer. Sanford is nice and is considered the gold standard by some, but they don't seem to offer much that you can't get elsewhere from UpToDate or Epocrates, and I assume they don't have the research resources that UpToDate or Epocrates has. Same with calculator apps. Epocrates has plenty of calculators too and they are usually better. 3 years post-grad and all I use now is UpToDate (desktop) and Epocrates (mobile). Medscape from time-to-time, but I'm using them less all the time. Just don't see the benefits of anything else.
  9. In a year or two, when I rule the world, :) there will be three titles: MD, DO, MP. The latter being a "medical provider" and used by both PA's and NP's in areas of general medicine (family, peds, adult/IM, urgent care, women's health, ED) after 3-5 years of experience and passing a rigorous specialty national examination respective to each specialty. Physician Assistant does not accurately reflect the advanced training and abilities that PA's have. Too many patients see "Physician Assistant" as "nurse" or even worse, "medical assistant." How is a PA "assisting" a physician when they have been taking care of a patient for 2 years that has 8 different chronic issues when the "SP" has never even laid eyes on them? The PA title makes sense historically, but not now. I don't think Physician Associate works well either. Isn't a physician associate a physician?
  10. (1) Try to get some perspective on age. It cracks me up when people say something like "I'll be 25 before I finish my bachelors!" GASP. 25? Isn't that when you start getting letters from AARP? :) In your 20's, you are not even close to your peak abilities. You won't hit that until at least your 30's, 40's or 50's. That is why many change careers during those decades - it takes that long to learn who you are and what you are truly good at. In that regard, there is no difference in a 19 year old or a 29 year old. But in the mind of many 21 year olds, 27 year olds are old people. That's very typical, and not a criticism at all. Just keep that in perspective as you join your group as the youngest. (2) Don't go into it with a chip on your shoulder. If you go in assuming that when you are treated differently than others that it is because of your age, then you are setting yourself up for problems. Every single human being on the planet will be a "minority" at some point in their lives. That may be due to age, sex, race, education, geography, economics, whatever. It is human nature to attribute problems we face to being due to our "minority" status, whatever it may be in a particular job or situation. That prevents us from honest self-reflection and growth, even if the adversity that we are facing really is because of our status in a given situation. (3) Realize that your youth and inexperience can be and often is an asset. You bring fresh ideas and perspectives, as you will be untainted by enculturation. But that can cut both ways. Your relative lack of knowledge and experience compared to those far more experienced than you means you can make a butt of yourself if/when you express an opinion. At the same time, you are untainted and can see things freshly and differently. In the business world, from which I came before changing careers as an "old dude," a frequently mentioned adage was that new employees were most productive in their first 2 years of hire because of their fresh perspectives. That certainly applies to you not only being a young and new PA, but a young and new professional. (4) All of the above is a delicate balancing act. You've asked for advice, which suggests that you have a healthy sense of awareness. Nurture that. And go into to your new career with a relentlessly positive attitude. Be humble, seek opportunities to learn constantly, develop friendships and relationships, find mentors, and work your butt off. Everything I said above is not all at specific to being a PA, BTW. It applies to everything in life, especially those new to professional careers.
  11. Extended fixation? Seems to me that my "fixation" is quite relevant to this back and forth discussion. Glad you are sorry the OP didn't mention edema. Me too. It seems like an important factor in light of the discussion. As previously mentioned, Homan's sign is pretty much useless, regardless of what vein(s) a potential thrombosis is in. Discounting the varied experiences of PA's? Hardly. A CNA with 3 months of experience prior to PA school matriculation needs to learn how to adequately take vital signs (they didn't get in CNA school, and likely just doubled down on bad habits in practice). The RT in PA school, on the other hand, is comfortable using a stethoscope. The varied experience of NP's and PA's is sort of my point. Compare an RN with 5 years of ER experience going into family practice as an NP vs. a physical therapist with 6 months of experience prior to PA school going into family practice. We all have varied experiences, which is precisely why none of us should be stereotyping, which, as you mention, hampers collegiality.
  12. This coming from a poster that has NO profile pic? How would posting a real picture of me change anything? As for being "thin skinned," read my posts. I am quite complementary of and supportive of PA's, and I ignore most of the anti-NP posts that appear here from time to time.
  13. (1) The OP said NOTHING about edema. Venous blockages have no inherent effect on pulse amplitude. (2) Well aware of what and where the peroneal veins are. When I originally read the OP's post, I read it is as "perineal" instead of "peroneal" perhaps because he mentioned hip replacement and I was thinking regionally, so the whole post made no sense to me. I then (see my post edit done before anyone responded) mentioned that a peroneal, or any other venous blockage, does not inherently change pulse amplitude. Regardless, the points raised in my posts stand, regardless of switching an "i" for an "o." Drug reference sources often warn of look alike/sound alike drug names precisely because names have been confused, even in less subtle differences, so perhaps the OP should have given the NP the benefit of the doubt. Brintellix was getting confused with Brilinta, so its name was recently changed to Trintellix, for example. (3) The "thermometer comment" is in reference to how some PA's act like 3 years of science prerequisites and nursing courses as an RN are somehow irrelevant to being a provider, and that the NP's true education doesn't start until grad school (which many PA's would say is weak at that). In undergraduate nursing training, RN's are exposed to fairly in-depth physical assessment (I was trained with Bates), pathophysiology, and pharmacology in just their 1st semester of RN school. Vital signs are the first week only and we move on. Physical assessment, patho and pharm are covered fairly deeply in our first semester as undergrad RN students, all of which is subsequently integrated into remaining courses going even deeper every semester. Many PA's are first exposed to the basic measuring of vital signs in their first week of graduate school.
  14. The OP is either lying or confused. Period. Homan's sign is pretty much (no wait, IS) worthless regarding specificity and sensitivity and has NOTHING to do with the veins of the peritoneum, perineum or any other "neum" above the knee. IF the OP is telling the truth, then his "catch" is luck, not clinical acumen. But then, I am a stoopid NP that thanks that Homan's sign pertanes to them there vane thangs in the calf thang, rather than the crotch or belly thang. No wait, that's just the trooth. Homan's has NOTHING TO DO with thromboses in ANY vein other than those of the lower extremity. As a stoopid NP, to me that means that it has NOTHING TO DO with the peritoneal/peroneal veins, yet the OP rests his argument on it. And I'll await the OP's responses to my questions. Oh, and OP. Google all this. Take a selfie after your Google search and attach it to this thread. I'm sure it'll be priceless. Edit: please, anyone, explain this to me. The more I read the OP's post, the less sense it makes. How in the heck can a blockage in a peritoneal vein OR a peroneal vein cause DIMINISHED PULSES IN A DISTAL EXTREMITY????? I'm just a stoopid NP that believes that pulse amplitude is an artery thang, especially when several feet distal to a supposed venous blockage, which is several feet distal to distal the pedal pulses???? Surely anyone with a basic grasp of anatomy realizes that a capillary bed separates the arterial from the venous system peripherally, mitigating pressure differences, and sustaining the higher arterial pressure vs. venous pressures regardless of a blockage or not.
  15. Dude, you seem really smart. And you seem to love anecdotes. I could probably own you own those. But let's no go there. Instead, let's do this: (1) As an ortho PA, how would you manage/treat a resistant HTN patient on a beta blocker, a CCB, and an ACEI who is allergic to several diuretics (who has normal renal function)? (2) As an ortho PA, how would you manage/treat the recurrent intermittent rash on the bottom of one's foot x 3 years that has not responded to topical or oral antifungals? And what is your ddx? (3) As an ortho PA, how would you manage/treat the otherwise healthy young URI patient whose had symptoms x 14 days that suddenly worsened, has no cough, normal pulse ox, clear CXR, and who tested + for strep, - for flu but who didn't have a sore throat, and hasn't responded to Augmentin? And what is your ddx? (4) As an ortho PA, how would you manage/treat a 3 week old worsening sinusitis in an 80 yo/F uncontrolled diabetic on dialysis with an uncertain reaction to penicillins that takes immunosuppressants for breast CA? That's a weeks work for me. Or, truthfully, a day's work. But I'm just a stupid NP with barely 24 months of post-grad clinical experience who doesn't know one vein from another. You apparently have an expert grasp of vascular and orthopedic anatomy, all of which you undoubtedly mastered in PA school long before graduation, probably even in your first semester (while you were also learning how to hold and take a temperature with an oral thermometer). I'm certain your grasp of vascular and orthopedic anatomy has nothing to do with your post-grad experience, as your knowledge of such reached expert levels -- not by experience -- but strictly from your superior PA didactic and clinical curriculum vs NP's. And you certainly know much more than any stupid, poorly educated NP. So answer my questions above. Show me what else you know. -Signed: Stupid NP lacking in knowledge of vascular anatomy
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