jmj11

NWiH (as in "no way in hell") as a practice accident waiting to happen.

What prophylactic program is he on?

While I remember the days of paper charts and staying after work to complete them, in this day of EMR, I don't get why anyone would have to do charting after the end of the shift. I know it is different for inpatient, but in my outpatient setting, my charting is always done before the patient reaches the check out window. I am working a 4 day week, after working 5+ day weeks for most of my career. However, I'm seeing a lot of new docs and PAs working a 4 day (8 hour) work week from the beginning and is considered full time. I am the father of five, however, my wife was a stay-at-home mom for most of my career. Yet, as a father, I feel I missed out on a lot. But it doesn't have to be that way anymore.

Great case. Just got home and put the thinking cap on to work on this, and then your answer came in. How would you differentiate this from hepatic encephalopathy (10% with normal ammonia), induced by an acute (septic) renal failure? Or, are you saying the same thing? What is the mechanism of cognitive changes? I didn't see a (quantitative) benzo level. Hyperreflexia / clonus?

Let me just say, having been a PA for > 36 years and have left many jobs (more than I can count on one hand), I never left a job and then looked back with regret. The lesson I've learned, just like the girl or guy, that marries the abusive partner, you just can't fix them. I thought many time I could fix the attitude (once they see how great I am, wink) but social change comes in the speed of a glacier. On the other hand, I've worked with some PAs who came in, got frustrated and left in weeks. I tried to hang on to each job for one year (there was one except when I was working at a horrible job and got a great offer and left in six months). But, if you can't find mental peace and a happy place to work by the end of a year, it's not worth it. Your exit is also part of the pressure for the culture to change. If PAs keep leaving, finally the lights will go off for someone in the system. Life is short and there are better places to work (especially in this day). While salaries can be based on many factors, low salaries and low esteem toward the PA go hand n hand.

I will not do it again, for the reasons you stated. However, if I could do it as a cash-only business, I would consider it. When I ended my clinic, I took out truck loads of crap related to insurance companies, but virtually a back bag full of stuff for helping patients get well. (I orchestrated this narrative of the insurance company world into my novel, which is coming out in about a week). I know some who have done it, doing business with insurance companies, and succeeded well. But the insurance business world is like walking through the looking glass into a world where nothing makes sense any more.

This is a first for me, after a 36 + year career in neurology/headache. I have a patient I have followed for years for episodic migraine. Her migraines have been under control. Then, she had an experience a two months ago of confusion, aphasia and syncope. She did not seek medical help, for one reason her spouse is a provider. She feels, in some ways, her mind just has not returned to normal and her headaches have been much worse. There is a golden rule among headache specialists that if a migraine patient presents with new symptoms, not to blow them off. Everything she described could be accounted for by migraine. However, if a patient who never had headaches in their life, suddenly developed new neurological symptoms or suddenly worsening headaches, they deserve imaging, the same is true for those with a history of migraine. I was a bit concerned about a TIA or some vascular compromise Vs new migraine aura symptoms (which often can come on after age 60 and she is 60). The MRI I ordered was very surprising. She had rather large and bilateral, frontal subdural hygromas. Here is a brief description in the literature of non-traumatic, spontaneous hygromas. I will not use her MRI scans as I once posted MRI scans here and due to my poor technical skills, I posted it with the patient's id markers. Below is the best image I can find (her's looked worse, especially her sagittal view with severe frontal effacement). I've sent her off to the neurosurgeon and will be back with follow up and maybe her images if I can find a way and have the time to copy it without identifiers. Mike

I probably shouldn't have posted this, as I hate to kick someone when they are down, yet I was a bit befuddled.

This popped up on my news tonight. I hope this is rare. http://www.gainesville.com/news/20180802/physician-assistant-at-williston-clinic-accused-of-embezzlement

I've mentioned before that I (like all providers) get the Washington State quarterly newsletter from the Medical Quality Assurance board. They list all the MDs, and PAs who have lost their licenses. For physicians, it is mostly over sexual issues. For PAs, it is almost always due to writing Rx for friends and family without documentation.

I just got the noticed today, and to spend 1 mil for the research. Did hell just freeze over? For 30 + years I've heard from the old AAPA that hell would freeze over before they invest money in this.

Then there are the unknowns, things you would never have expected no matter how well you plan. Like, the business office building that you lease from, turns out the post office would not deliver mail to (dispute between the landlord and the post office) so you have to get a PO box in the meantime. Then all the insurances for the first six months denying payment because your clinic has a PO box instead of a street address. The other, as an example, the major insurance company refusing to do business with you because you are a PA owner. Then you enter a long legal battle with them (very draining). In the end, they contract with you, but then never make a single payment for the hundreds of patients because you were "not in their directory of practices." These kinds of things drive you mad. So I had retained lawyers, but it would mean spending up to 300K in legal fees and possibly getting nothing. Some days I wished I had taken them all to court, but my lawyers advice was not to (unless I was willing to lose 300K). My heart is with patients, not being consumed with fighting legal battles. This experience with the insurance companies became the watershed for my novel Waters or Bimini, which you will be hearing more about in a couple of weeks.

The hard thing with practice ownership (having been there for 5 years) is that the margin is so sensitive. If the debt/credit arrow moves 1-2 degrees to the positive, then the owner can do very well. Move the arrow in the other direction, and the owner loses their shirt, house and whatever they have. There are a lot of risks and rewards.

It would be interesting to hear stories of PAs who passed up large salaries to stay in or move to situations with less money but greater personal satisfaction.

I dreamt of living in Switzerland at one point. For a couple of years I looked at every angle I could, Red Cross in Geneva, Novartis in Basel, other relief organizations in the country (based but working other places) and none game me a second look. PAs could not practice there.