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Everything posted by BrianR

  1. Agree with my colleagues that those jobs do exist, though you may have to search for them. You are correct that a teaching hospital will offer little autonomy, and the residents will be jumping up and down to do all the procedures. But there are plenty of hospitals, even in the cities, that aren't teaching sites and don't have EM residents. I spent 30 years in rural EM, mostly in critical access hospitals, where I was it. No attendings, no back up, just me and 1-2 RNs, maybe an RT if we were lucky. If the patient needed a procedure, I did it. But with all due respect, with 1.5 years of experience, those hospitals are probably not the place for you at this stage of your career. I think your best bet, if you wish to remain in EM, would be a community hospital where PAs are respected and allowed to practice to the full extent of their training and experience. My current hospital, where I am a critical care ICU PA, is a 500 bed city hospital. Our ED uses PAs (and NPs) extensively, and they do almost everything - intubations, codes, etc. I don't think there are any restrictions on what they can see. We do not have EM residents, so there are no battles over doing the procedures. Like MediMike, I am also an ICU nocturnist PA. While ICU is definitely more of a team approach compared to EM, I find I have plenty of autonomy. We are a 29 bed ICU, and we have no attendings on site at night; it's just the PA and a medicine PGY2. I enjoy the acuity, which is uniformly high compared to the ED, where I eventually tired of the low acuity nonsense and the rampant entitlement mentality. I either do the procedures overnight, or teach/supervise the residents, depending on the situation. And for those who say they can't find decent PA jobs...we have been looking for one since my nocturnist cohort left last year. We can't find one. The schedule is decent, the pay is above average, benefits are good, the medical director is extremely supportive, and the staff is great to work with. But no one wants to work at night, they don't want to work without an attending around, don't want to live in upstate NY, etc. I don't understand it. It's arguably the best job I've ever had. But I guess it's not for everyone.
  2. I think it's absolutely doable for the right job. I commute 1:15 three consecutive nights each week for 12 hour shifts. To me, it's worth it, as I like the hospital, the job, and my coworkers. And I like my home, and moving isn't an option. It's 90% rural driving, so traffic isn't generally an issue. Years ago I commuted 2.5 hours for two 24 hour ED shifts weekly. Didn't mind that either, as I loved the hospital. But staying awake on the way home could be difficult if I was unable to get any rest during the night, which was, fortunately, rare. I did some locums work a few years back, also 2.5 hours from home. But it was a difficult hospital in which to work, usually nonstop busy, and I didn't like much of the hospital staff. And they didn't pay all that well. So that just wasn't worth continuing. I use the commute time to listen to podcasts and relax. And it helps to have a comfortable vehicle!
  3. A result of the market saturation in some areas, and of NPs who are willing to work for ridiculously low salaries. I agree with Sed; try not to be the first to mention salary when talking with a potential employer. 32 years of experience here. I live in a rural area, but drive 75 miles one way to work. I don't work too hard, and I make what I consider a pretty good salary, but I was able to offer the employer a background and skill set that they wanted and needed. I could work closer to home, but wouldn't make near as much, or would have to work a lot more hours to do so. It's always a balancing act.
  4. Just goes with the territory. It's all well and good to be nice, have patients like you, and don't miss obvious pathology, but people can and do sue for anything with nary a care in the world about the effect it has on us. As someone else pointed out, you can be sued simply for coming to work that day. Patients/families expect 100% accuracy, nothing short of perfection is acceptable. God help you if you miss anything, no matter how trivial. For certain segments of the US population, it's like buying a lottery ticket - little cost, no risk, and a potential big reward. And there's no shortage of slime ball attorneys who will take nebulous cases in a heartbeat. It's a big reason I left EM after 30 years. Most of that was spent in single-coverage critical access EDs, and as the only provider seeing the patient, it presented a ready target for a windfall-seeking plaintiff. I was named in a few lawsuits over the years; a couple were settled for relatively small amounts, others were dismissed. The most infuriating case was a chronically-ill elderly patient who arrived already near-dead and the family actually said, before she was even transferred to the ED stretcher, "If she dies, we will sue you." She did and they did. The case was reviewed by multiple experts, who could find little about my care to criticize. The insurer settled the case, on the eve of trial, without my consent, which for several complex reasons, they actually didn't need. Although it was many years ago, it still makes my blood boil every time I think of this case, because I did absolutely nothing wrong, yet still lost. You just have to have the best malpractice insurance you can afford, and accept the fact that's what the premiums are for, and it's all about money. Nothing else.. Not that every lawsuit didn't cause significant stress, anxiety, and anger, and the cases usually drag on forever, but I eventually came to view lawsuits as virtually inevitable for anyone who practices long enough in a higher-risk specialty like EM. Nearly all of my EM colleagues, both PAs and physicians, who have been practicing for more than a few years, and are seeing sick patients, have been sued at least once. Interesting that the OP fears lawsuits as an ICU PA, since that's what I'm now doing, and I think it's far less risk than EM. The difference is that the patients I care for now in a tertiary ICU have so many people involved in their care, and generally have longer length of stays, that even if there's a bad outcome, it's tough for the families or the lawyers to narrow down whom to blame. It's also why I enjoy my other specialty of forensic medicine so much; dead people don't sue. As for the employers who won't even consider you if you've ever been named in a lawsuit, good luck finding experienced clinicians. As someone else said, sounds like a place that hires a lot of new grads. I did have one hospital tell me years ago that was their position, but they had other issues. Other than that, most employers, including my current one, just ask for a brief explanation of the case details, and seem to accept that it happens to good clinicians.
  5. CCM nocturnist, 3 consecutive 12s per week in 300 bed community hospital, PTO similar to Kaepora, plus cme time.
  6. Cuomo's a moron who never saw another onerous law he didn't like. I've been practicing in NY for 33 years and I don't know what the hell this even means. And doubtful the governor does either. A "lifetime" license? No idea.
  7. Not sure how much my experience will help you, but I've been a deputy county medical examiner in upstate NY for a few years. It's an appointed, not elected, position, and there are only three of us in the office: an IM MD, a nurse practitioner, and me. We don't share cases; whomever is on call gets the case. It's a rural county, so we only average a few cases each per month. We do it all - scene investigation, whatever additional investigation we deem necessary, decision on whether to refer for autopsy, coordination with law enforcement, pathologists and funeral directors, determination of cause/manner of death, and completion of the death certificate. I actually enjoy my forensic work much more than my clinical work, but it doesn't pay well. For the above (10 days of 24 hour call per month, plus 4--6 cases) I make about $15k per year. I consider it more as community service than a source of decent income. Obviously for a full time MLDI or coroner, depending on your state, it might pay more, but the forensic field is not known for good pay. I've maintained full time clinical practice, 30 years of EM, now critical care. If I'm ever able to retire from clinical work, I hope to continue the forensic position. However, if I could earn a decent living doing the forensic work, I'd do it in a heartbeat. As mentioned above, New York City OCME has long employed PAs as investigators, though they have recently started hiring non-clinician MLDI's from other jurisdictions. I actually interviewed with them less than a year ago. Had I been offered a position (I was not - they brought in four of us for interviews. I was the only PA; the other three were experienced MLDIs from large metropolitan areas) the low salary would have likely been untenable. If you're interested in the field, especially as a new PA, you'd be well served to get some education. The actual ABMDI MLDI exam requires that you be working in the profession for a time prior to sitting for the exam, so that can be a barrier to entry if you are just looking to join the profession. There is training available, but unless you're already affiliated with an agency, you'll probably have to pay out of pocket. The Cuyahoga County Medical Examiner's office in Cleveland, OH offers a well-recommended course, as does the University of North Dakota, as well as a guy named Darren Dake at ditacademy.org in Missouri. (I have no connection to any of these organizations, and have not taken their courses, but they are all highly recommended.) With some basic education, it does open some doors, but you'll still likely need to know someone, and be persistent if this is what you really want to do. If you live in a coroner state, you'd need to be elected, which is usually about how well known you are locally, not how qualified you are. However, many of the larger coroner offices in the US do hire investigators and deputy coroners, though again, the pay is usually dismal compared to clinical practice. Finally, if this is your preferred career, I wouldn't worry too much about your ability to do clinical work. You can always work part-time in clinical medicine to maintain those skills. I hope this answers some of your questions! Feel free to PM if I can be of further help!
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