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Acebecker

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Posts posted by Acebecker

  1. Rev said it well.  

    My wife is concerned about me as well, but the truth of the matter is that it is my job to take care of people.  I signed up knowing that was the case even if they have Ebola and there's a 50% chance of me dying if I get it.  

    Not everyone went to school with this commitment, but most did.  I'd bet you did as this is your dream job.  It's hard to say to your wife, "I'm sorry, but this is what I signed up for."  But sometimes that's what we have to say. 

    • Like 2
  2. Heavy advice to consider.  I appreciate it.  It's taking a lot for me to say no.  I like this model and how much this model can serve the underserved population in our area. 

    Would it change any of your opinions if the offer was not a job but a partnership in the clinic?  That is on the table here. 

    Andrew

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  3. 4 hours ago, BruceBanner said:

    Do you mean DPC as in concierge primary care?

    A lot of my current colleagues to refer to it as concierge primary care.  I actually am not certain if that is the accepted nomenclature or not. 

    What this guy does is to offer a subscription to his clinic - a flat monthly fee.  For that fee, you get as many visits as needed and most procedures are included.  If there is something above what would be included, the costs are transmitted to the Pt without markup.  He does not accept insurances.  He also has been able to get medications at markedly reduced cost such that they are cheaper through him than through pharmacies and with insurance.

    I would not be billing for my time and would not be on a production basis.  It would be a flat hourly rate. 

     

     

  4. All - 

    Is anyone working under this model at this point?  If so, I'd love to PM a bit back and forth. 

    Here's my situation: currently in private practice, internal medicine.  Made $120k last year.  Love my job, love my patients.  

     I have a physician friend and colleague who wants me to work in his DPC practice.  The only problem at present is that he doesn't know what PAs in DPC make, so the job offer is a little poor.  Can anyone point me in a direction for PA salaries/benefits in direct primary care?  

    Thanks!

     

     

     

     

  5. I wear one sometimes, mostly when I'm cold.  Here's the thing - docs don't own the "graduated medical professional" status.  We are graduates and if you elect to wear a white coat, do so.

    That said, they are a huge infectious disease vector.  I guess if physicians want to be sole owners of that, they can be my guest.

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  6. I gave a little old lady with a UTI some Keflex and she went into anaphylactic shock, ended in cardiac arrest.  Protracted resuscitation and she was discharged from the hospital neurologically intact.  I have seen her for several UTIs since then and I am still gun shy.  She had had Keflex no fewer than 5 times prior to that day and had never had any sort of reaction.

    I've had several other 1/1,000,000 zebra misses.  I hate all of them and I have learned a lot from each one.

     

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  7. So you've said you don't mind doing paperwork.  Start there - is there any room in your practice for someone who fills out paperwork for patients?  I mean, there are a million face-to-face visits required for walkers, wheelchairs, CPAP, etc.

    Is there anything about medicine that you *do* like?  What made you go to PA school in the first place?  Maybe start there and work your way up.....

  8. I would not do a purely online course for your initial certification anyway - there is a lot that you learn from interaction with your instructor and other students.  ACLS is as much about personnel management as it is about information intake, processing, and decision making.  Otherwise you'll get to a code and just assume that the information will come to you.  You have to direct the interventions and assessments being done.  If you don't, you'll miss something.

     

    My $0.02.

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  9. Urgent Care (did this for 4 years)

    Pros - can make a lot of money.  variety of cases.  12 shifts/month, which allows a fair amount of time off. 

    Cons - Can be high stress - lots of "move the meat" mentality.  Pts upset about wait times.  Got to be on your toes - cannot miss the MI that presents as jaw pain or heartburn. weekends.

     

    Internal medicine (2 years worth)

    Pros - sick people, complex cases - very cerebral medicine.  I do most of the procedures for our IM group.  variety of opportunities - inpatient, SNF, outpatient.  good hours.  continuity of care.

    Cons - call, occasionally.  lower salary.  pain medication management.  psych management.

     

    Wound care (2.5 years part time)

    Pros - weird stuff comes in.  being able to get things healed that other people believed would never heal. good pay.  lots of procedures.  no call, no weekends. 

    Cons - outliers - people who don't heal but still hope you can work a miracle.  noncompliant patients.  hard cases with bad news. 

  10. Weekdays I was up at 0700.  Headed to class at 0800, study until class starts at 0900.  Lunch at 1200, studied while I ate.  Back in the seat at 1300 and in lecture until 1600 or 1700 dep on the day.  Usually home by 1730.  I had a rule - no homework until kids in bed.  Kids (I had 2 at the time - 4 yo and 6 months) to bed at 2000.  I'd study from 2000-0000 almost every day.  Those were the weekdays.  Saturday I'd walk to the library at 0830 and study there from 0900-1700 then walk home.  I would take about 24 hours off and then pick back up studying from 1800-0000 on Sunday.  I had a supportive wife who did a great job of working hard alongside me so I could do all of this.

     

    It got a little more intense toward the end of didactic year - studied til 0100 every morning for the last 1.5 quarters.  Mid-terms and finals week were much more insane; the school is no longer set up the same way.  It was essentially 80 hours of study or testing in 4 days, but this was only twice each quarter. 

     

    There was a comment above about people like me not knowing how to study for my learning style; either that or people like me have ADHD.  Neither is correct.  I studied that hard because I wanted to do the absolute best I possibly could.  I wanted 100% on every exam and quiz.  This is what I expected of myself.  It is not what I expected from everyone in my class.  I knew that any less studying would not be my absolute best and I had to give my absolute best. 

     

    It is certainly not required to study "24/7."  I think if you study 3 hours each day after 7 hours in class, you're doing just fine.  That leaves a lot of time for ancillaries.

  11. attachicon.gifTPACODESTEMI.jpg

     

    have not given tnk in a code before, but figured with this rhythm before the pea arrest there was no downside. seemed to work ok. should know in a few days what neuro function is like...

     

    Cannot overstate the value of a bedside 12-lead.  I have not read the recent literature on thrombolytics during arrest, but if they're low risk for hemorrhagic cause (no Hx leading to aortic aneurysm rupture, ICH, trauma, etc.) then it makes sense.  I was just thinking of a case I'd heard about - young lady on exogenous estrogen with pleuritic CP on the way to have CTPA codes.  With this Hx, why not try thrombolytics?  Thoughts?  It seems too simple. 

  12. Here's the latest from Idaho:

     

    I am still an EMT (previously EMT-B, now EMT 2011) with additional skills.  I have IV/IO, Subcu/IM (specifically epinephrine for anaphylaxis), King airway (won't let me do ET intubation), and a couple of other things.  I can push fluids, I can give D5 if truly emergent or do IM glucagon if diabetic crisis.  These are all my pre-hospital allowances.  These are skills offered to every other EMT as well, I just didn't have to do extensive training to obtain them - I only had to show that I'd done them in my training during PA school and that was sufficient, then demonstrate competency and pass the skills test. I have been on some good runs - last night was an 88yo male with acute cognitive impairment and labs from the nursing home showing Creatinine of 9 and NA of 173. 

     

    I am also what we call and EMT with advanced practice privileges if I transport a patient from one hospital to another.  This is a huge confusing thing for some people.  It means that I can practice full scope medical care on a patient who is being transferred from our local hospital to an outside facility - I can give meds, manage drips, manage an airway, give an airway, etc.  It's interesting but I have not done many transports this way (mostly because I'm busy with my paying jobs). 

     

    It's not too bad, actually.

  13. Age certainly does not dictate maturity or professionalism.  However, a greater portion of experienced individuals are professional/mature vs. fresh-out-of-college graduates.  I have no data to back that up but it is my experience and the experience of...  I would bet...  Pretty much everybody who knows a lot of college graduates and a bunch of 30-somethings who have been in the professional work force for 5+ years. 

     

    I want to add that in the "fresh-out-of-college" crowd I'm not talking about graduates of professional programs (nursing, MA, business, etc).  I'm talking about general college graduates.  Shoot, I graduated from a state university in kinesiology/athletic training and most of the people I graduated with were no more professional than an 18 year old college freshman who valued parties over studying. 

     

    I'll also add that as I have sat on the admissions committee for our local PA school I have also seen that the younger a person is, the more likely they are to be less professional than those who are experienced. 

     

    EDIT:

    Doug - I think you might be giving them too much credit.  I've had good experiences with new-grad experienced PAs working in our clinic, I've had not-so-good experiences with new grad young PAs working in our clinic (leaving early, refusing to see certain things/take care of certain people, etc.).  It's interesting. 

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  14. Pete - Nope, being humble enough to admit that you took things out of context is not what I was talking about.  Good on ya' for that one. 

     

    "Feel free to dive in past the intro if you need more convincing." - this is what I was referring to.  My apologies for not being more specific previously.  The reason I say this sounds disrespectful is because this is precisely the tone I use when I talk to insurance companies who are denying needed treatments for my patients.  :)  

    • Downvote 1
  15. You're telling me with the internet at my fingertips 24/7 that information acquisition has not changed...? Meh.

     

    If you read my post, attendance wasn't mandatory at my program, and I took advantage of that learning environment. It worked for me despite your claims that the mere thought of missing class makes me lazy, complacent, uncaring and arrogant.

     

    I agree that you should follow your school rules and be aware of them prior to applying. Further, I never missed a day of rotation; what we are talking about here is lecture; THE PRIMARY PURPOSE OF WHICH IS LEARNING. If I can learn better outside of the classroom, guess where you'll find me? 

     

    What I am not advocating for: skip every class, never participate, only read textbooks, be lazy, etc. etc. etc.

     

    I'm pretty sick of people attributing insults to previous posters without the previous posters actually saying those things.  Laziness, complacency, lack of caring and arrogance were not previously mentioned by anybody.  Typically I would let it go, but I'm feeling persnickety today, I guess. 

     

    It does lack commitment to fail to adhere to your program's standards.  It is disrespectful to miss lectures.  Pete - you have stated your program did not require attendance.  Glad you felt it was the program for you.  Glad you stepped up and took advantage of it.  

     

    There are two camps and we just need to have two program types to be honest.  You are not going to convince me or Reality Check 2 that attendance shouldn't be mandatory.  We're not going to convince you that it should be.  I'm glad you have done well, but there are a lot of people in your type of program that blow it off, get by with the bare minimum, and make terrible clinicians. 

     

    With regard to rotations - I think we can agree that this is where the rubber meets the road and unless you're dead or dying you ought not miss a day. 

     

    Finally, with regard to medical school - let's stop appealing to their model *specifically with regard to mandatory attendance*.  Keep in mind that once medical students are done with their formal didactics then they hit residency in which their real education begins.  In PA school, this is not the case.  We are (I've said this before and I'll say it again) expected to hit the ground running as much as possible on day one (not without supervision, but with as much clinical acumen as can be mustered).  After graduation from medical school, those students are expected to present every patient and they have several layers of built in supervision.  Additionally in residency there are a lot of mandatory lectures because at the end of residency these people *must* know the information. 

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  16. Agree with Reality Check 2. 

     

    You cannot put a value to the interactions that are available between you and a lecturer when you are learning medicine.  There are fine points and nuances that get discussed that you would miss if you only listened to lectures or read a book.  If you study ahead for lectures (which is the best way to be ready to absorb the information) then you will get a lot out of a live lecturer.  If you do not study ahead of time, it is less beneficial and overall you will retain less. 

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  17. I work as a volunteer EMT still.  Our requirements are 10 runs/month.  Relatively easy to achieve.  On the trauma calls, the medics get my deference as they have much more experience than I do.  On the medical calls, everyone defers to me, esp the codes (which to me is really funny since I have only run a couple of codes).  I continue to work on obtaining new certifications such as supraglottic airways, intraosseous placement, etc.  I am a basic EMT for all practical purposes but because of the way Idaho works I can start IVs, given saline or D5W, do IM injections of epinephrine for anaphylaxis, place advanced airways (haven't gotten them to let me place ET tubes prehospital yet), etc.  I also have a special certification called "Ambulance Based Clinician" which allows me to practice full scope paramedicine on a transfer from one hospital to another.  I don't do a lot of critical care, but I feel very comfortable managing a drip line or two and pain medication (e.g. a complex fracture that needs care in another city). If the patient codes, I am expected to perform full ACLS protocols so I continually work at keeping those skills sharp. 

     

    It's a hoot.  I really love EMS.

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  18. peak -

     

    My experience was just as you described an ideal clinical year.  I was responsible for every patient I saw - their initial visit, their follow-up visits, making the diagnosis and determining treatment.  I had to consult with my preceptors of course, but that was - in my mind - how PA training is supposed to go. 

     

    At my school we had a 4 month family practice rotation - during that rotation I started at about 3-4 pts/day and progressed up to a full day.  That's ideally how it's supposed to work.  A good school, good preceptors, will arrange things as such. 

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  19. Out of curiosity, how much experience did you all have directly with PAs before you applied to PA school?

     

    From all reports, there was good prior healthcare experience - 15 years a medic, etc.  That's great. 

     

    Just wondering if everyone who is saying, "I shouldn't have gone to PA school because now I want out," had enough direct exposure to PAs before applying to PA school.  I've been sitting here, reading these and thinking, "We need to do a better job during the admissions process to help those folks who think they want to be a PA but really don't," but then the thought occurs to me, "Wait, is this the school's responsibility, or the student/applicant's?" 

     

    It makes me quite sad to hear my colleagues beleaguered and upset about this profession; I think it is a noble profession full of opportunities for growth, service, self-sacrifice, and with the potential for huge rewards but tangible and non-tangible.  I want everyone to enjoy it is much as I do.  Yeah, there are days when I don't want to hear another whiner and days when I just want to throw the chart in the air and yell, "52 card pickup!" and walk away.  But I take a step back and look at the overall trajectory of my life and the lives I have affected and realize that I - you, we - do good things for people.  Some days it's telling the chronic back pain patient who's addicted to narcs, "Hey, you realize you're addicted to narcs, right?"  Some days it's catching an acute appendicitis and getting them to a surgeon.  Still other's it's shocking a lifeless body back from the dead.  But think of all the patients you have seen in the past year - think that if you touched 20%, or maybe just 10% of them in a meaningful way - that ads up to hundreds of people you have done a good thing for.  Hundreds.  Those of you who have been in practice for a decade more...  Think of the *thousands* of people you have affected. 

     

    The impact we make is tremendous, whether we feel it on a daily basis or not.  The knowledge of that impact will carry you a long way if you let it. 

     

    FWIW.

    • Upvote 5
  20. So here's the latest update from Idaho: the state has made paramedic practice competency based. If you have an NREMT-P, you're good to go. PAs, such as myself, have to 1. prove what we learned in PA school regarding meds, medical issues, procedures. 2. take bridge courses to cover the rest that we don't know. Here's the problem: a bridge course for a single skill can take anywhere from 3-6 months to get approved and takes the educators hundreds of pages of proposals to write; then you have to find someone to teach it. There are barriers, but they're not insurmountable. I think that a few bridge courses for things like IOs, ET tubes, etc. will allow us to run codes in the field; our only restriction will be trauma - unlikely that we'll be able to do chest darts, surgical crichs, etc. This will obviously not qualify a PA from Idaho to take the NREMT-P exam, but allows a basic EMT with PA cert/license to practice more advanced medicine than otherwise allowed. It's not the best, but it will suffice for now. I'll keep you posted.

     

    Andrew

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