jmj11

I saw this coming over twenty years ago, when ARNPs started to differentiate themselves as a tier higher than PAs and as nurses, such as my wife, started to move into health care system administration roles (beside nursing directors). There was also the strange culture (in my opinion) in the AAPA back then, which I never understood, that was resistant to change. As an example, it was twenty years ago when one of my patients (politically active RN) pointed out that in the Mayo System, the official policy was that MDs, DOs, Chiropractors, AND ARNPs can sign FMLA paperwork. The policy added, that medical assistants, nursing assistants and PAs could also sign it if any of the previous named people (including ARNPs) countersigned it. I was really upset and sent out an email to the 50+ PAs that this is a very important issue and I will take the lead in addressing this at the highest level. Then, strangely, I got a personal email from one of those PAs who happened to be the president of the Minnesota Academy of PAs. It was a threatening letter telling me that I better watch my back because he did not authorize me to get involve and he could cause me "professional damage" if I don't back off. It was one of the most bizarre things I had encountered in my career. I saw him about a year later in the Mayo gym and he asked me, "Does that FMLA thing still bug you?" I'm glad things are different now, but there is a lot of catching up.

The best way to get any job is networking. So, talk to people while you are there, building relationships, people who would be in the position to ask for you or pull for your hiring. Keep them updated on your progress. Set up an elective rotation at your hospital during the clinical year, then you might beat out experienced PAs for the same position.

I think this is one of the most difficult things in medicine. I had a patient who was #1 in my panel for both drug seeking and somatization disorder. She also had habit of lying about many things. She was (hate to use the past tense) only 35. She seemed to disappear for a while and came back to see me. She told me she had metastatic cancer ( I won't say which type because I don't want her family connecting the dots to her case here in the webosphere) and had weeks to live. I was doubtful and had her records sent to me (after her approval). I read through them, from her first complaint of new pain, to her final diagnosis, to chemo failures and turning her over to hospice. She was telling the truth this time. But the pattern I saw was that she was not taken seriously at first because she was always in some clinic, ED, urgent care, etc. looking for benzos or narcotics and with bizarre complaints and fears of disease. I was not in this loop as I see her just for her migraines. I suspect those in the loop, who dismissed her early complaints, will be sued. But sometimes there is a woof, but, on the other hand, you simply cannot run extensive tests on everyone with every new complaint, especially when they are histrionic.

In practice I never used the term, "I have no more ideas," or I never just said, "I don't know." I would say, "I don't know but you deserve an answer" and I would either research it myself, it was remotely related to my area, or set up a referral to someone who would know. There is nothing worse than saying "I know you are struggling" then shugg your shoulders and add, "But have a good day," and walk out.

I worked with a neurologist once, who was privately verbal that he didn't like patients, any of them. He was a very high producer, seeing new consults in 15 minutes and billing for 90 all day long. When I saw patients that he had seen, they told me that he never touched them during their new patient consult. That didn't seem possible and I thought they must be embellishing. Then one day (long story) I left all my medical equipment in another office in another city and this neurologist was not there that day. I borrowed his equipment, reflex hammer, ophthalmoscope, stethoscope and etc. Then the cleaning person had put them all in a drawer in MY exam room, where I was using them, at the end of the day. This neurologist came back to work and it was weeks later that I discovered his equipment still in my drawer. He had never used them or even missed them. Then it dawned on me that the patients were telling the truth. But the system loved the guy because he brought in the most $$$.

Your post hit a cord with me and I will try to summarize from the good and the bad from my saga. From a background perspective, I am 64 and have been in excellent health my entire life. As I've mentioned here before, on Jan 11th of this year, this all changed with it was discovered I was in severe renal failure (BUN of 165, Creatinine of 12.5 and K of 6.9). To make a long story short, I was admitted to ICU and after about a week a final dx was made of Multiple Myeloma with associated renal failure from the overproduction of light chain plasma proteins. I had to go on dialysis, did aggressive induction chemo and moved to Seattle in May for a stem cell transplant. I returned home in August. 1) Local Care Last Year: Now, with that background, I will say the old healthy me, I had a great relationship with my (MD) PCP. My wife picked him for me (she is in the local hospital admin and choose him as he was the chief of staff). He respected me and we "talked shop" and he respected my opinions. I would have been happy to have seen a PA if there was one available. 2) Summer Care at Seattle's Cancer Care Alliance: During my stay in Seattle, I had excellent care. Most the time I was seen by a PA, including during my stay in the hospital for several weeks. I had a deep respect for their knowledge, as for the "world class" attending (MD) and they respected my opinions and concerns. So, for about every 3-4th visit with the PA I would also see the MD. They would have me make many of the clinical decisions (which the choice was not clear) based on the papers written (and they would give me references if I had not already read them). 3) Back Home: This is where things get strange. I started to follow with a local oncologist as the Seattle program cannot do long-term follow up. He is very focused on the maintenance chemo, while I have many complicating factors from the disease and transplant. He refuses to discussed these and I am left on my own (for example my ANC dropped from 1700 to 200 in five days and then I developed a facial cellulitis. I had to call my Seattle doctor to get help as he didn't see what my concern was. She was very concerned and started me on Leaquin, saying that if I lived in Seattle she would have admitted me.) I've had several such issues including a HGB dropping to 8 and me calling and begging for transfusions. So, he doesn't show my clinical judgment much respect and dismisses my concerns and doesn't want to think outside his narrow box. I had made an appointment to go back and see my PCP before this time (late August). The main concern then was that the mega dose of steroids (95 MG of pred) was causing me to have hypertension. My Seattle PA had started me on carvedilol for this and it was not working (systolic 180-190 and diastolic 110+). It was a bizarre appointment back with my PCP. The last time he saw me, in Dec 2018, I was his best buddy, and in a great state of health. Now, with post stem cell transplant, cancer, renal failure, graft vs host disease, steroid dependent, hypertension, AND peripheral neuro-motor injury from uremia, he seemed pissed I was even coming to see him (suddenly I had become a train wreck, not of my own device.) He made me wait in his exam room for over an hour and came in with an attitude of why the hell are YOU here. I, in response to his attitude, said, simply help me with my blood pressure (I can't prescribe for myself) and I will not ask for anything else. He said no. He said it was outside of his expertise and he wasn't getting involved, then he left after calling me the wrong first name. Fortunately, once I tapered off the steroids, my B/P returned to normal. But I feel like I am on completely on my own now because I am so sick. My oncologist won't help me, my PCP doesn't want to get involved, and I can't go back to the great people in Seattle. If would love to have a PA or MD or ARNP who cares and is willing to give me some help but I don't think our system is set up for that anymore. That is my view of the health care system now as a patient. I think my present providers hope I die soon to leave them the hell alone. I can't imagine treating my own patients like this, but maybe I should have, to have make the big bucks with 4 minute appointments (not really).

I agree. It is somewhat better today, but I entered PA school way back in 1979 with the goal of living abroad for my whole career. I had a few gigs overseas, but finding opportunities took a huge amount of work and there is even fewer today. However, everywhere I went, they were lusting for American doctors . . . just not PAs. If I were a new graduate, I would try and get a job in the UK.

I’ve met with countless financial planners over the years. I can remember, so many times, sitting and talking about our goals. Mine was to retire at 65 and to move to the Mediterranean region and live a quiet and frugal lifestyle until the end. The planners always wanted to guarantee my 100 K income forever through my investments. They would estimate (based on my good health) that I would live to be in my 90s (as did my mother). Then, something that never showed up in any discussion with the planners, I get suddenly and profoundly ill before my retirement and have to quit work, then I look ahead, hoping to survive until I’m 65 or 66. What do I do with all the money? My kids are doing well. I may need an expensive, lifesaving, treatment later on. Forget the Mediterranean. My point is, do get too worried about it, but keep in the back of your mind that no matter how good your genes are (parents lived to be 105) and you live a very health lifestyle, you can become seriously ill with a terminal and incurable illness, that will profoundly change your dreams.

I have a new book out, as of today, called Christina Athena: The Girl with the Headaches. It is actually a novel, but a collection of many stories that patients have told me, rolled into one character. It is to help others get inside the head and life of someone whose life has been ruined by the disease, but who finds hope in the newer treatments. I have created a very positive PA character as a role model for our profession. Read it and if you like it recommend it to your patients and write a review. Buy it on Amazon here.

I think we are loosing an art form in medicine. I can still tell a lot by listening to a heart and lungs. https://www.apnews.com/6cf7790448ee48b3a4844213c78e783b

Depending on the venue, it was from $500- $3000 per hour of talk. Once I spent a couple of hours on a talk, I could give it 10 times or more without much prep.

I was a spoke person for several pharmaceutical companies. It was good and easy money, but I quit when I was told what I had to say by one. In the beginning, I could create my own talks.

I've spent most of my career in neurology. You know the two, psychiatry and neurology used to have the same boards. But with that said, I don't think the adjustment would be harder or easier. You would bring some things to the table that those in surgery or FP wouldn't have and FP would bring some things to the table that you may not have. I don't see much advantage to having a surgery background unless it was neurosurgery. If it is your desire, you could navigate toward those disorders that have comorbidities of psych and neuro, such as dementia. I focused my career on headache, but also covered epilepsy, dementia, and a little stroke in my career. Headache disorders has a lot in common with psych. Not that psychological issues cause the headaches (a bad sterotype) but because it, like psych, is a disorder without a lot of objective findings and requires a very good history, great listening, and a lot of chronic management (like mood disorders). Neurology is such a broad area, if it were possible, I would pick 2-3 sub-specialties of neuro to focus on and try to know those very, very well.

I see that you didn't have any responders here. I owned a practice for 5 years, and it has been three years since we closed so I will give some general comments. My mentor told me (a PA who had owned a successful practice for 10 years), and I didn't listen, but I should have, to do my business plan the best I could and then cut in half my expected income and double my expected expenses. The hard lessons I learned were (and this does not correspond to your numbered questions); 1) Insurance companies drove me crazy and constantly looked for reasons to not pay us. It is a false notion to believe that if you just bill correctly you will get paid. For example, our business building did not have a mail box so we had to use a PO Box. It took six months to find out that no insurance company will pay for a visit that was seen in a practice that uses a PO Box (it is in their very, very fine print). We lost 65 K right up front and it could not be re-billed. I had to go to war with my landlord over this (he didn't want mail boxes in the building) which took a huge amount of energy and distraction. 2) Unless you are really lucky, personnel will disappoint you. I had five did different billers over 5 years, each one starting out doing a fantastic job and then doing a lousy job. 3) While suing injust insurance companies (who withhold payments for no reason) would make a good Hallmark movie, in reality, they are bullies. You can sue them, but it would cost you about 250K and you may get very little in return even if you win. 4) I had about 10% cash paying patients, most from Vancouver, BC. I loved them, because cash made it so easy. 5) I strongly recommend that you run a very frugal practice (based on what my mentor told me) until you are clearly doing well. My software because very expensive and failed us horribly. Between Kaiser rejecting payments (and it was ultimately based on the fact that I was a PA who owned the practice) and the software contract (which failed to bill correctly) I choose to close my doors although I was overwhelmed with demand. My fear, going into this, that there would not be enough demand but that fear was not realized.

It has been over 25 years ago when I had my short stent in student health and that may have been a different time. My memory may have been skewed as well. I had a terrible SP during that job and why I only stayed a year. It seems like there were several parents that called, but I do remember one couple from Chicago, both lawyers, who bugged the hell out of me when I would not give their daughter antibiotics for her cold. They were very angry and ended up calling my worthless SP, who completely folded and came down and screamed at me for not giving the students what they wanted. Otherwise, I would have loved the work.