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physasst last won the day on September 28 2013

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  1. At this point in my career, I function exactly like my physician colleagues. I practice in a non operative Spine Center under the division of PM&R. I see referrals from all over the world. I frequently get referrals from all over the country to see me. I cannot remember the last time I had to run a patient by one of the physicians. I work them up and manage them completely on my own. There is a physician...usually a different one every day, that is "assigned" to be my resource, but after years of experience.....it is rare that I talk to them. They don't even know about 95% of the patients I see. Some of the higher profile ones, including a President of a foreign country, as well as some Fortune 500 executives that are on my panel they are aware of. YMMV. Mike
  2. Great discussion John. I agree with you. Hope you are well. Give your wife a hug from me. Kindest, Mike
  3. We get our DEA reimbursed by renewing it with our corporate credit cards. Then we submit for re-imbursement, which means it is not taxed. It's interesting, they will pay for DEA, but NOT for state license renewal or NCCPA renewal. Those are on the individual PA to take care of. Mike
  4. This is not as uncommon as you might think. My first job was this way (one of the reasons I left)...but I also know of many, many PAs with similar workplace environments, where the PA captures the H&P, presents to the physician, and then the physician goes in, verifies the H&P, formulates a treatment plan, and then asks the PA to do the orders and scheduling.... Basically a glorified secretary. It sucks, but I would caution people against thinking that this is rare...it is more common than many believe. FWIW, many PAs are okay with this. Many PAs look at being a PA as a job.....not a career or a passion, and they don't mind the comfort and security that this arrangement provides.
  5. http://networker.paeaonline.org/wp-content/uploads/2014/08/RGC-Impact-Debt-Load-on-PA-Exec-Summary.pdf Heavy Education Debt May Discourage Physician Assistants From Practicing in Primary Care or Underserved Settings Washington, DC, August 18, 2014 — Given the recent concerns about the ability of the future primary care workforce to address the health care needs of the nation, factors influencing career decisions are vitally important. Nearly nine out of 10 physician assistant (PA) students owe education debt that could influence the primary care PA workforce of the future. That’s a conclusion that could be drawn from a Robert Graham Center study funded by the Physician Assistant Education Association (PAEA), The Impact of Debt Load on Physician Assistants, released today. The study analyzed results of a series of focus group discussions with second-year PA students and the 2011 American Academy of Physician Assistants (AAPA)–PAEA Graduating Student Survey on career choices, education debt, and demographic characteristics of PA students. Robert Graham Center researchers found that the median reported debt load of PA students in 2011 was $88,000. Of those with education debt reported, nearly 60 percent of PA students graduated with more than $50,000 in PA education debt, and nearly one in four students owed more than $100,000. Students from urban and suburban settings were less likely to plan a career in a rural practice setting. Students with minimal or extremely high debt were most likely to seek a career in a rural or underserved area. Although more data analysis is needed to pinpoint the reason for these associations, “There is some speculation that students with smaller debt can afford to go into primary care, and people with high debt are looking for loan repayment options that are more available in primary care and rural or underserved settings,” said Miranda Moore, economist and health services researcher at the Robert Graham Center, and lead author of the study. PAs working in primary care earn an average of $85,000 a year, compared to those who earn $105,000 for other specialties. “Given that the median debt load of PA students in 2011 was $88,000, this $20,000 annual difference could have a substantial impact on the specialty decision of a PA student,” the researchers wrote. Focus group discussions held with second-year PA students also revealed that the majority of students are undecided regarding specialty choice when they matriculate to a PA program, but are open to working in primary care specialties. “A good preceptor was often cited as the key influencer in a student’s specialty choice decision,” according to the study. The study’s authors lay out steps to help reverse the downward trend in primary care PAs. Among them are: Increase PA student interest in primary care by developing curricula that distinguish primary care as a defined specialty with its own specific body of knowledge and skills. Encourage payers to address the PA salary differential between primary care specialties and subspecialties. Increase interest in rural and underserved areas by targeting rural-born and educated students and increasing opportunities for training exposure in rural and underserved locations. Groom highly qualified and well-prepared preceptors and mentors who provide patient care in team- and information technology-driven, patient-centered medical homes. “The PA education community has opportunities to encourage undifferentiated PA students to choose a primary care specialty and to practice in a rural or underserved area,” said Moore. “They can take those opportunities—such as increasing clinical rotations in primary care settings—into consideration as they make educational changes now and in the future.” PAEA Chief Policy & Research Officer, Anthony Miller stated: “One of the Association’s chief priorities is to encourage the deployment of PA students to primary care practices, particularly those in underserved communities. This is imperative in order to ensure access to quality health care for everyone in the nation. We were encouraged to see that while rising PA student debt is a concern, it is not the primary motivator for specialty choice. This report provides a foundation for planning our continued efforts in this area.” The Physician Assistant Education Association (PAEA) is a not-for-profit association representing accredited physician assistant educational programs in the United States. PAEA provides services for faculty at its member programs, as well as to applicants, students, and other stakeholders. Additional information about PAEA is available at PAEAonline.org. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care works to improve individual and population health by enhancing the delivery of primary care. The Center staff generates and analyzes evidence that brings a family medicine and primary care perspective to health policy deliberations at local, state, and national levels. Founded in 1999, the Robert Graham Center is an independent research unit affiliated with the American Academy of Family Physicians (AAFP). The information and opinions contained in research from the Center do not necessarily reflect the views or policy of the AAFP.
  6. Sure, of course, that study cost the RWJF and the nursing associations over 3 million dollars. Just for clarification. IOM isn't cheap.
  7. A Kernel in the Pod......Mike Jones. BTW, a PA forum member. Good Read. Mike
  8. Yep....I got heavy over the past ten years....too much work, research, school, etc. I got up to 248 this winter. I've lost 28# since April 1st, and looking to lose another 30... Mike
  9. Yep, LP with elevated OP, and elevated protein at 58 with 11 oligoclonal bands. ANA, CMV, RPR, EBV, and NMO all negative. TSH normal. Sed rate WNL. Both outside MR and internal MR with Gad showed lesions. Our Neurologists decided against steroid burst as primary complaint was neuropathic pain. Very cool case. Mike
  10. The hallmark in this history was the left sided numbness and weakness that occured back in January with the cord signal changes noted on the MRI. No spasticity on exam, and CN exam was normal. We typically do not use gadolinium for spine MRI's if the suspicion is nerve root impingement/radiculopathy etc. However, we also have a neuro radiologist review every brain/spine MRI before the patient is allowed out of the room. If there is an indication for gadolinium we do it. This was an outside MR, and not sure what the procedure was where this patient had it done. My working differential was: tumor, infection, or demyelinating process (Transverse Myelitis, Neuromyelitis Opticans, Multiple Sclerosis, etc.) as you can get isolated extremity neuropathy with MS. Got NMO antibodies, EMG, and MR with contrast of both cervical and thoracic spine. MR confirmed demyelinating disease in both cervical and thoracic spine. NMO antibodies negative. Final diagnosis was MS. Started on gabapentin for pain control. Follow up with Neurology confirmed this, pain still poorly controlled, primary progressive multiple sclerosis. Interesting case. Remember, radiculopathy is not always radiculopathy.
  11. Here's a good case for those of you out there to think about.... HPI: 72 y/o right hand dominant male farmer presents to the Center with a 4 week history of severe unbearable right arm pain. He is unable to localize this pain, and states that it involves the entire arm. It seems to extend from the right side of his neck into his arm. He also complains of pain into the right jaw and face, and even extension into the anterior neck. Complains of significant balance issues, but feels that these have been present for several years, and cannot determine if they have worsened. Denies any history of trauma, infection, or prior surgery. States that in January, he had the sudden onset of weakness and numbness through his entire left body, including both upper and lower extremities. This is still present, but not as bad. He was evaluate locally at that time, and had a head CT, which his doctor said showed a "stroke, he said there some stuff in the white matter". After his symptoms started 3 weeks ago, he had a non contrast cervical MRI, and was told that he had a radiculopathy, but then there was confusion on that. He was started on methadone and vicodin which isn't helping the pain at all. Patient becomes concerned by lack of progress and presents to the ED who refers them to you. He states, "I can't live with this pain, I would cut my arm off if I could" PMH/PSH: CVA in January 2014, Borderline diabetes, CAD, OSA, COPD, history of MI 10 years ago, HTN, Hyperlipidemia, no spinal surgery history. Exam: Obese 72 year old male in mild distress, appears diaphoretic, in severe discomfort. A&O x 3, Mental status intact, affect normal. CN II-XII grossly intact, Weakness noted in finger extensors, first interosseous, and wrist extensors of -1 in RUE (our normal scale is 0-I know it's different) Reflexes are normal but did require significant reinforcement efforts, clonus is negative, toes are downgoing, hoffman's is positive. Sensory was intact to pinprick. Vibratory sense was diminished in RUE at -2 at both ulnar styloid and 1st MCP, and -1 at olecranon when compared to the LUE. Tinels and phalens are negative, ulnar tinels was negative. Wright's Test was negative. Gait was wide based, short strided, toe walking and heel walking are intact, heel/toe was -3, romberg was 0 to -1. Neck had normal ROM, no tenderness, no deformity noted. Shoulder provocative maneuvers are negative. Pulses are normal, Skin without rashes. MRI: non contrast image, no radiology report. Shows no evidence of compressive lesion. There are scattered degenerative changes with degenerative disc disease from C3 to C7, there is uncovertebral hypertrophy, and facet arthropathy noted throughout, worse at C5-T1. Mild multilevel neural foraminal stenosis, severe on the left at C5-6, but not impressive on right side. No central canal stenosis noted. However, at C2-3, and C3-4, there are cord signal changes in several locations without evidence of compression. Alright, so let's hear it, what's your differential, what are the next tests you want?
  12. Agreed with this, but the underlying notion that the diagnosis in a difficult patient cannot be made by anyone other than a physician is inaccurate. I practice in a complex spine clinic. I've made many diagnoses that others have missed, or more often, have to correct inaccurate an inaccurate diagnosis made by primary care. I've even came up with my own axiom....(stolen from the House of God)...."If the primary care provider thinks there is 'spinal stenosis' present, there can be no stenosis there". Mainly because I seem to see many patients with axial back pain with no pseudoclaudicatory symptoms who are sent for evaluation of their "stenosis". I end up explaining to them that spinal stenosis does not cause axial back pain ( I know, I know, there is some argument in the spine community that upper lumbar central stenosis, at L1-2, L2-3 might cause axial symptoms, but that is rather controversial, and no one can prove that). They are reluctant to believe me, because their primary doctor told them that it was their "stenosis".....I usually tell them that I am the specialist here, and that they were sent to see me by their primary doctor. BTW, I also see a lot of patients with stenosis, but they are sent in for "weakness" or "radiculopathy"....:)
  13. I was a corpsman in the Navy. That's when I met my first PA, but to be honest, I was going to school for economics. Worked as a framing and finish carpenter, painter, was a splicer's apprentice with the phone company for a while. All while I was finishing school. Back up career now would be working as an economist for consulting firm, academia-teaching, specifically, research methods to graduate students in any number of disciplines, or, possibly work in political circles, etc. I actually have a local candidate who asked me if I would run his campaign......LOL....so, there's always that.. I even think often of what it would be like if I just had stayed working as a carpenter. I miss that sometimes. There was a lot of happiness of a different kind with that job.
  14. Yep, Jack Welch so infamously used it at GE. I agree that team building is more important, as the other problem with vitality curves is that they promote perverse incentives in the top performers, altering the curve. That's sort of the point. This is going on...we need to be aware of it, and we need to be involved and have a seat at the table with these discussions taking place. Haven't seen you since the Academy. Trust you are doing well?
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