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kargiver

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kargiver last won the day on February 2 2018

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About kargiver

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    Just an old school EM guy...

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    Physician Associate

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  1. I live and work in rural VT. The area in which I work is economically depressed, but that is just where I work. I am in the middle of ski country, hiking, camping (pick the outdoor event), live on 30+ acres, have a river running though my property, can hunt if I want (the wildlife is ridiculous where I live), play drums at 3 in the morning, and do whatever I want at my job. I work for a small hospital as a solo ED provider, am treated very well and make more than enough to live what I think is my best version of life. Most important, VT is home to some of the finest beer brews in the world, and they are all within an easy drive to get. I know you want to get away from the cold, but there is a huge difference between coastal cold weather and mountainous cold weather. Not sure it matters for you but its one of the reasons I haven't gone south... Boston is 2 hours away, NYC is 4, Montreal is 3, and the ocean is 90 minutes. Growing up a city kid and working EMS for 2 decades in the Boston area made me think I would never like rural living. Now - I would never go back. G
  2. Best book about how to deal with life... sits on my nightstand and gets read often. Highly recommended. You have a lot of options. You are just too beat down to see it. Lots of great advice here though. - VA (or a job that is not insurance for profit i.e. urgent care) - Teaching - Family Medicine (you'll see a panel and throughput will be expected, but its a different kind of environment. At least everywhere I have worked and overlapped with the FP folks - they all love it, even during the height of cold and flu season - Hospitalist positions You got options... let the book be your guide If you are willing to move you have a lot more options than you think. G
  3. If you don't mind my asking - why the tPA in a massive embolic stroke? These are known to cause significant vasogenic edema, are prime setups for hemorrhagic conversion, and lytics are generally not recommended in these patients... was it a stroke that evolved? Just curious, G
  4. Why doesn't TAPA retain legal representation and send a "Cease and Desist" order for Restraint of Trade to the TMA? They are clearly not friends of the profession and what they are trying to do is tantamount to a restraint of trade. G
  5. Borderline Patients. All else pales compared to them. G
  6. Working solo in a rural ER isn't the relevant issue - we practice medicine. All of us. Doesn't matter who supervises you, collaborates with you, or anything else - your decisions are your own. If you think you cannot be named in a lawsuit because you ran something "past your SP," think again. The OP is making a case for "Medical Practitioner." I don't think initials that are reminiscent of "Mid-Level Provider" - M.P. are the answer...along with the other reasons mentioned. APP was chosen for a very specific reason when it came up within our specialty organization. MP is not the way to go. But, like all things... just an opinion. G
  7. You are right where you should be. Some days you know stuff, some days you don't - you are still learning what is sick, not sick, how to differentiate the subtleties of what is what, and when you need physician involvement and/or consultant involvement. Expect this until about year 5 - when you have seen enough to know what is normal vs. not normal, and how to differentiate it. It's not by accident EM residencies are 3-4 years in length and most EM residents are doing fellowships as well. There are things you should be comfortable seeing at this point - but the most important thing to know is what you don't know. That pool shrinks over time - but it never goes away completely. G
  8. I remember the last time this came around, about 5-7 years ago, when I was in the HOD, NPs were the threat then too, just as they are now - except they are not - and this got nowhere. It was pawned off for study in committee for a year to placate those who wanted the name change but in the end - nada. I expect the same will occur - regardless of what is spent. If folks wish to spend their time and energy on something like a “name change” that somehow will grant us greater autonomy, open up greener pastures, and make the world a happier place - have at it. But that’s not reality... we are governed not only by AAPA, NCCPA and ARC-PA, but by federal and state statute. Want to make change - you have to change it there first. The name isn’t the issue... being a generalist is. Money moves the world - not titles. For a rose by any other name is still a rose. And my license to practice medicine says that - I practice medicine. I’m held to the same standards as MDs, DOs, other PAs, NPs, name it... whether I am an “assistant” or not - I have to practice to the gold standard that is the standard of care. Politicians know this, lawyers know this... and amazingly, patients know this. My patients don’t care that “assistant” is in my title - they can’t see a doc if they wanted to - unless they want to travel quite a distance further. As for the NPs - good luck with that... CMS and other federal entities see them as gateway keepers in primary care medicine. The logical approach is to join them - they are an overwhelming force to be reckoned with - ask members of the BODs of the AMA behind closed doors. No wall you build will hold back that current - use it to our advantage. Or not. They won’t care either way. G
  9. Well, opinions vary... but your assertion is factually incorrect. Their training, by definition, is specialty based. If they are family practice NPs, they are, by definition, limited to that field. If they are acute care NPs, they are limited by training in the patient population they see. What they have done with it politically in their respective states of practice after the fact is another matter for debate (and the point of yours). But the fact remains - they can claim they are specialty trained in a specific area of medicine - we cannot. I'd like to think I have some insight into what NPs are doing at the national level and what their political activity is... G
  10. I hope you didn't cut the benzos in half... this will precipitate a benzo withdrawal. If you are intent on weaning patients of this nature, you need to understand, cold, the pathways involved, what interacts with what, the timeframes for proper weans, what is "en vogue" in the FP/IM community to "replace" narcotics, and the best way to get from point A to point B. If the PATIENT is the focus - treat them as such... or you do a disservice to both of you. There is a stigmata emerging (already has emerged) about "controlled substances" and the people who take them. I see this in new grads as they come into our group and with students who rotate through with us. Everything we prescribe is "controlled." The only difference is where it works and its potential to cause harm. The reality is the most dangerous drugs do not fall on the DEAs controlled substances list at all - the idea of pulling people off of regimens they have been on for years, their body is now physiologically dependent upon, causes a lot of strife unless done carefully, methodically, and with buy-in from a patient. You wouldn't abruptly stop someone on high dose beta-blockers... why would you abruptly stop their clonazepam? Food for thought... G
  11. I don't think any of this really matters... there is a reason why it hasn't changed in the last 20 years and isn't likely to anytime in the near future. The nature of NPs and MDs do is vastly different than what we do, with the exception of family practice and IM docs, who by design see a wide spectrum of illness and farm out a lot to specialists. NPs specialize from the get-go in whatever field they wish to pursue. Docs do fellowships in certain fields and maintain boards in those specific fields. We don't. The closest we come is specialization via the CAQ, which just shows a "mastery" of a specific area of medicine - but the core does not change - we are still generalists. The only way this changes is when Congress mandates it based on Medicare and Medicaid re-imbursement issues or we collectively sue, the AMA, using the FTC route. Until the field accepts specialization outside of the NCCPA mandated generalist curriculum and/or we extend our education (which is self defeating), I see no reason to change the name except to either APP or Physician Associate. Medical Practitioner is even further confusing I suspect to the general population and requires a rebuild from ground zero - a battle not worth fighting. G
  12. Caribbean patient plus swollen knee is infectious until proven otherwise. Besides the usual culprits that cause this that are infectious (was this person from the Caribbean or did they visit?), there are lots of bad bugs that circulate there that we don't see in the states, and the spat of hurricanes last year also drudged up other microbes that are usually kept at isolated levels. You have elevated PMNs, no crystals, a WBC greater than 25K (that's my magical cutoff if one exists) and the potential loss of limb isn't worth the risk of assumption of inflammatory etiology without at least an ortho consult. Curious - sexual history? Cultural hx? Native or visitor? Prior infections? All play a role here... G
  13. Two things - a bit redundant but worth repeating: 1 - several drugs do cause false positive results in urine tests for cocaine. Specifically, the aminopenicillins are notorious for this. If you have positive cocaine results in urine and are making decisions to stop benzodiazepine therapy in a chronic user, you MUST do confirmatory testing by GC-MS first. 2. If the person is actually positive for cocaine by GC-MS, you cannot abruptly stop the benzodiazepine if they have been on it for any prolonged period (the literature in psychopharmacology and pain management considers this 4-6 weeks or greater). Once GABA receptors and ligands are upregulated in response to the presence of benzodiazepines, it takes literally, months to years to perform a proper wean. This is of course, dose dependent, but something even as small as 0.5 mg of Ativan PRN once a day requires a solid 6-8 weeks to properly wean. Anything less puts a patient at risk for withdrawal seizures and guarantees a prolonged benzodiazepine withdrawal syndrome complex that is debilitating for most people. We all want to write off people who we think don’t somehow “deserve” these medications because we have “found” a reason to not give it to them. However, we have an ethical and moral responsibility to confirm what we see and find - not assume - when we are looking to withdraw psychotropic drugs that people have been taking for, in some cases, decades. The body seeks homeostasis as it’s the lowest form of free energy in whatever psychopharmacologic milieu we have created in patients. If one isn’t comfortable writing the Rx, as others have said - this is what your SP/CP is for. It’s their patient to begin with... you can always pass it along. But understand completely why something works (or doesn’t) first before making a life-altering medication change to someone that can have devastating consequences. As this political pendulum is swinging back and we are withholding more and more scheduled drugs, the pharmacological reality of what we have created, what we are doing to people, and what they in turn will do to feel “normal” when we decide to improperly wean people or deny them their medications, is becoming apparent - the illegal drug trade is booming. Washing our hands with a patient based on bad data starts far too many people down a road that we can prevent them from going down... and I’d argue we have the moral obligation to prevent them from doing so - particularly if we were the ones who started them on these therapies in the first place. G
  14. This is correct - when I was clinical education coordinator for one of the Boston programs this was part of my job and part of the ARC-PA standards we had to meet to maintain accreditation.
  15. Sorry Eric - I have to disagree here. the PA program on campus has a full dissection that is roughly a 1/3 the time of the medical students while covering the same material. The fact that they are even bringing them to campus to do a dissection in the first place is far better than what most programs are doing for those students at traditionally based schools. This dissection sounds similar to what the on-campus students do. And we both know there are no issues with the in-class curriculum... Additionally, the H+P class is 10 classes total for the on-campus class then write-up after write-up after write-up. Mine varied from clinics to the ortho floors at the VA (those were interesting) to standard IM write-ups. No reason this cannot be done elsewhere. All I am seeing on this thread is people complaining about how this will drag down the profession. What will actually drag down the profession is the continued proliferation of crap schools that cannot find clinical sites, force students to do all the legwork, cannot maintain accreditation on a consistent basis, and while going through their initial probationary period for provisional accreditation, fleecing students for as much as they can. This is not the case with this online program. As I stated earlier, I do not support it for political reasons - but as far as content and connections for students: it is well covered. G
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