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Everything posted by jmj11

  1. I am happy to help when I can. I know that things are better now, but when I graduated it was a nightmare finding a job. I almost considered once scheduling myself to see a local physician as a patient, and then use the time to beg him for a job. I didn't. But here is one thing that I can't understand. I work in a hospital where my wife is an administrator, so I know a lot about recruitment here than most. They have had several jobs for PAs or NPs and they almost never get a PA applicant. They have given up on PAs and often only advertise with NP groups. I was frustrated when my own clinic partner said he wanted a PA and I just found out yesterday that he had about 5 NP applicants and no PA applicants, so now he is going to consider one of the NPs. We live in one of the most beautiful places in the country. It is hard to imagine why no PA wants to work here. I literally put a pin in a globe of the world trying to find the perfect place to live and it was here. Anyway, I'm just venting as I was looking forward to having another PA in the office.
  2. I really think there should be class action lawsuit against insurance companies over "credentialing." They claim that it is a tool for them to guarantee that the providers taking care of their subscribers are qualified. However, it is the responsibility of each state's medical board to make sure that the provider is qualified. The insurance companies use it as delay technique that saves them millions in payments. Seriously, I'm not just blowing a gasket, but we need a lawyer who could do that. I sense damage to providers and hospitals is in the billions.
  3. If you think Portland or Seattle are great, you should check out the San Juan Islands here i Washington. I know of a few jobs locally. My clinic is looking for a PA in interventional pain management.
  4. I have worked for most of the past 35 years in headache medicine. I did not study, I did not do a review course. It is just basic common sense stuff that all PAs should know.
  5. I just finished the 1s qt alternative exam. I think it took me 15 minutes. If you don't get 90%, in your sleep, you shouldn't be a PA. That's all I'm saying.
  6. 1) A functioning EMR and using it to its peak potential. 2) An excellent MA
  7. I will start it tomorrow. We have already been warned about not saying too much about the questions, but I can give you a general idea.
  8. I work on a 100% wRVU and it is a program that I created. No one else in our system works like this. I get paid well for the wRVUs, but when I take time off, and I can take as little or as much as I want, I do not get paid. I do have a generous benefit program (paying professional fees, retirement and health insurance) but no PTO, per my design.
  9. Dr. House does it well. I used to watch the British show Doc Martin, he had an episode where he reacted the same way (couldn't find it to show here). In the news this week there has been two young people who died of the flu, a conservative reporter and the Guatemalan boy. The latest issue is the person with measles flying into Newark Airport. So vaccines are relative to us all. I don't suspect a pandemic, but isolated cases of people dying who didn't have to.
  10. I hate to be the bearer of bad news, but it does not look promising. I entered the PA field in 1981 for the precise reason of working in the developing world. I was able to slip in under the radar for a few years, (Oman, UAE, Pakistan twice, Egypt, Cyprus, Nepal) but then things got worse for PA abroad, except for those countries that you listed. It is complicated but much of it is political and cultural. In most countries you are either an all-knowing doctor or a nurse who helps the doctor and being a PA is meaningless. The other problem is, since the US does not recognize foreign trained doctors (for example many of our language interpreters at Mayo Clinic were doctors in their home country) other countries are not open to having US trained anything, especially PAs, working in their countries, even the really poor and needy countries. Now, that is not to say that you can't find a job in almost any country, but those are usually US entities, such as State Department or Peace Corp. But in those situations you will be caring for Americans, not nationals. I know that UAE started their own PA program and I applied to be an instructor and never heard back. About 10 years ago the AAPA had a task force on introducing the PA profession internationally. I don't know where that stands now. I did everything in my power to be part of that. I went and met with the key person in charge (an unnamed PA program director). I called her, wrote her, emailed her, and begged her to allow me to be part of that on my own time and dime (pay my own airfare overseas). She never responded to me once after I met with her and told her of my deep interest in this issue. Eventually they treated me like some kind of deranged stalker. Maybe someone here knows something new as I've been out of the loop for a few years.
  11. Nice to see a major article like this that does not make errors. Good work Jonathan Sobel.
  12. To illustrate what I'm saying, I had to fill in for a vacationing family doctor. He was deeply loved by his patients. When I came in, for one week, I found a total disaster in the delivery of care. His patients were very obese and no one had ever addressed it. They smoked, but that was okay, because, believe it or not, the physician smoked too, right in the office. Many of his patients were on narcotics, often for the indication of things like "insomnia." But I remember seeing an obese, smoking, businessman with a blood pressure of about 180/110 and a A1C of >10. He told me that the good doctor was the best he had ever found, he said that was just the way he was and he promised the patient that he would never be on insulin. They loved this doctor and would pay more to see him, yet, the outcomes don't match what a good doctor could deliver.
  13. Competition works well for hardware stores. It doesn't work so easy for medical care, unless you are comparing the exact same (and simple) service, such as an MRI scan or maybe a hip replacement. But when you get to the complexities of primary care or general multiple system complaints it is hard to compare apples to apples. Patients would tend to pay for nice providers or providers with simple, confident answers (as some chiropractors give), even if those answers are wrong. The patient, at least at first, would not esteem providers that really changed the outcome of their disease based on hard work, staying informed on the state of the art care that changes outcome. It's complicated.
  14. So, this crossed my mind today. I was seeing a patient who is always unkempt and smell foul (BO, urine, possible feces) and in their 20s. They are applying for disability and I believe that they deserve it because of their mental health issues (not headache). They are brought in by their mother and rarely leave their bedroom (agoraphobia). In the old days you would make such objective statements at the patient smells of urine and is unkempt. I think it is relative to their over-all mental state and an important part of the exam. However, since the days of patient portals and reading their own records, this would really piss off (speaking of a urine smell) some patients.
  15. jmj11

    cool derm case

    I know you have already solved this, and it was a fascinating case, but no one mentioned argyria, possibly from silver supplements. You know Oregon is world headquarters for crazy supplement use. Never heard of pseudochromhydrosis before.
  16. Knowing human nature, the Anti-vaxing movement will not go away until tragedy strikes. When a belief system is based upon an emotional belief system, reason and science do not matter. They will always dismiss it as the "The Great Western Medicine Conspiracy." But when disaster hits home, anti-vaxer looses a child, then they will "repent." I had a patient who her and her husband ran a health food and supplement store in Seattle. They were totally against western medicine. Then her 28 year old husband came down with AML leukemia. They were expecting to live to 100 because they only ate organic, etc. He died before turning 30. They both totally reversed their view of Western Medicine and she snickers when someone suggest taking a supplement for some magic health benefit.
  17. I think you make some very good points. I, too, am nearing the end of my career. Some bad cultural decisions were made early on. I understand why those decisions were made as we sprouted out of physician model and nurse practitioners came from a powerful and established nursing platform. But early on, our forefathers bet that physicians would oppose nurses who wanted more autonomy and embrace PAs who said we wanted to work together. But money talks. Nurse Practitioners are more lucrative for hospitals if they don't have the required supervising physician. They have a huge lobby to promote their profession and they play dirty. After working for my first years in support of the AAPA, I became disillusioned with them for the same reason as some have with Sears. They would not change and they would not listen to the rank-n-file. I left them for 15 years and continued working on my own issues. I met with insurance companies about reimbursement. I created and owned my own clinic and had to fight like hell against many powers to do that. I had to fight to keep PA-owned practices legal in Washington when an attempt was made to close us down (I had no help from PA powers that be). However, I do sense a final changing climate within the AAPA and PA culture. With Dave Mittman taking the helm next year (and he was always been on our side) I see hope of change. The only questions remain is it too little too late and will it be like Animal Farm, as soon as we get good people in the farmhouse, they become ruined by the same system. I'm betting that there will be change so I've rejoined the AAPA and am not losing hope.
  18. I work in a practice where vaccinations rarely come up. However, there are many other fake-medical information that I have to fight against daily. When someone says they don't "believe in western medicine," and have been using alternative treatments (and they are still suffering) I ask them, "So, how has the years of natural treatments working out for you?" But the anti vaccination really piss me off. The reason is, that early in my career I had the opportunity to work in the developing world where I saw great suffering as the result of the lack of vaccinations. I saw a kid die from tetanus and saw kids with measles. Stupidity kills. I was disappointed when the CIA used a vaccination doctor in the very town I had worked in, in Pakistan, to get DNA from Osama's kids. The reason is, I knew that the local paranoids would shut down the vaccination program there, and in many places of Pakistan, they did.
  19. So, I guess the other Jim W organized the climb and Wickwire s the one who made it to the summit. I watched this movie again last night after thinking about K2:
  20. This is a big problem and I feel your pain. While I've never been in this situation, I've had to bear the outcome of it many times. In my cases, the older-narcotic-happy doctor retires and the new provider says "Hell no I'm not prescribing oxycodone for your headaches I don't care if 'old doctor' has done it for 30 years. So, I'm sending you to the headache clinic and they will do it." Then I have the break the bad news that I might help taper them off ASAP, help them get dependency treatment, but I will not rx them for chronic use. Then they are pissed.
  21. I agree. I do undilated exams and it has been a godsend. I've used the I phone app, but never had good photos. Maybe that's my fault.
  22. jmj11

    Quick Case

    Bingo. That was easy wasn't it? I don't know why it was missed by the neurologist.
  23. jmj11

    Quick Case

    44 YO female has a sudden onset of left neck and jaw pain. Her husband notices that she starts to slurs some of her words. He rushes her to the ER. She had a CT and set up a brain MRI for early morning. Symptoms evolve to mostly left orbit pain. The MRI is normal. Rounded by a neurologist for 2-3 minutes. Told her she didn't have a stroke and to go home. The left orbit pain continues as does a Horner's syndrome (starting, they think, during the night at the hospital, prior to the neurologist's visit) and has persisted for the week. The pain is still focused in her left eye (8/10) and is a tearing sensation. Her husband brings her to our headache clinic. BTW, she feels a lessor pain still in her neck and left shoulder. What would do you think this is? (I have the answer but just wanted to know what you thought).
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