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winterallsummer

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winterallsummer last won the day on November 17 2015

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  1. Have you considered getting a healthcare administrative degree or MBA and going to admin health care? Then your PA degree won't be wasted. I'd say if you're unhappy change now not later. But learn from your mistake and thoroughly research whatever field you go into. What's your student loan burden like at this point? I don't think anyone
  2. Another way to increase RVUs is include your own read on all imaging studies (eg XR and CT) and also denote that you reviewed all labs yourself. We assume this is done as clinicians but it increases your RVUs to chart it.
  3. There is NO benefit of IV over PO steroids this also applies to COPD and asthma. This has been proven to the extent it is basically a moot point. If you are giving a single dose of an IM steroid then give a single dose of the PO equivalent. If patients are not happy with this then tell them you are not happy to give an injection with no evidence behind it when the pill works just as well and is cheaper and less labor intensive. We are only encouraging "fast food medicine" when appeasing patients like this. Yes I know choose your battles and sometimes you just gotta give the damn shot but those situations should be few and far between. On the flip side some patients should be happy tO avoid the shot or even begin to store badgering you for this. If they used daily intranasal steroids and saline they probably wouldn't even "need" steroids half the time. Unless there is some new literature I'm unaware of...
  4. Absolutely no reason to use IM over PO steroid. Some ENTs will use high dose PO steroids for nasal polyps and some data supporting this as alternative to surgery. As far as ER or FM using PO steroids for allergies - okay if pt understands risk. It's symptomatic tx obviously the allergies won't kill the pt. I would not give any shot however. PO is the way to go. Remember in addition to harming sugars steroids also increase risk of VTE although otherwise are often self limited in ADRs with infrequent use.
  5. Number of ROS and exam findings determines level billed. Agree there is much more going into RVU but if you don't hit enough ROS and exam then you will never hit that higher level.
  6. Boatswain hit the nail on the head. Key is to have enough ROS and exam findings. Don't have to lie. A quick press on abdomen can reveal non distension and no guarding. Looking at the head and face can show its non traumatic and normocephalic. Listening quickly to chest can reveal RRR without M and clear lungs without wheezing. Skin can be warm and dry. No need to lie. Same thing about a brief but broad ROS. In school I had a PA who worked in the ER. Young kid came in for some ear issue. The PA also listened to the heart and heard a murmur - turns out the kid had hypertrophic cardiomyopathy. So we were taught "everyone deserves a heart and lung exam at least a quick one."
  7. Varies by state and also experience 90k likely as average Above mentioned report will give beat numbers
  8. I recommend using whatever antibiotic is best regardless and having them follow up sooner for an INR check. I wouldn't lose a ton of sleep over picking the abx that will interfere least with their Coumadin. Pick the right abx for the bug you are treating. Also doxy can interact with Coumadin. That being said quick teaching point: if the CXR was read as bilateral patchy infiltrate and you felt they had pneumonia (cough, fever, white count etc) then this was more likely an atypical pneumonia such as mycoplasma which rocephin DOESNT cover for and you should've instead gone with doxy, zithro, levaquin (if pt has comorbidities) etc. also you have them a dose of rocephin so that covers them 24 hours - then what? If they really do have PNA and get sick and don't have a PCP or can't be seen the next day (pretty dang hard to get next day appointment) they're going to come back and then what's the plan? Assuming this wasn't an atypical (in which case the CXR wouldve likely had a more classic lobar opacity) are you gonna have them return daily for a shot? Totally impractical. So you have to get comfortable giving an abx that will alter their INR and its on them to follow up on this. I would not personally advise telling them to skip any Coumadin doses (unless you decided to check INR on that visit and it was high - but NO need to do this). Totally respect UGoLong opinion but he is a cardiologist PA and I personally would not feel comfortable altering their Coumadin dose from an ER perspective. If they have a stroke (unlikely but possible) and you cut their dose that could lie on you from a medicolegal perspective. Giving the right abx and having them follow up for an INR in 3D - certainly within standard of care. All that being said UGOLong certainly knows more about Coumadin than me but that's just my opinion. May be safe to have them half the dose or something but I personally would not mess with this, and if I were, I'd want an INR to see if they're even in range beforehand. Everything in medicine is a risk benefit. Risk of them having ICH is not as high from dying of a true PNA (unless this wasn't a true PNA in which case why even give abx?). So you HAVE to get comfortable with assuming risk. The best way in this case to manage that risk would be write for the right abx (in this case something with atypical coverage) and have then have their INR checked in 72h. If you want to have them half their dose until then (which I wouldn't) you probably should check an INR there. As far as giving an antibiotic or not... If you think they have PNA they need abx. Most PNA pts don't look septic. If they have a fever a white count a cough, especially if elderly and with comorbidities, probably needs treatment. If they came in for a cough for a day, no fever, pristine vitals, no white count - probably viral and PCP recheck with good ER return precautions is the right way to go. If the ONLY sign of PNA is the CXR read and clinically you don't think it's PNA - probably fine to not give abx. Final option is check a CRP (cheap) or pro calcitonin (better but more expensive) and use this to guide therapy.
  9. Wrist BP measurement is garbage. Throw it away. Automatic BP cuffs around the arm is way to go and if you doubt that reading then verify manually again around the arm. Oral temp or if sick ped then Rectal. Tympanic temp again garbage throw it away. No hospital would ever use tympanic (caveat - have seen done on psych setting where pts are relatively physically healthy) or wrist BP cuff. I don't work OP but I would never trust those. As a student during FM I had an old school practitioner and we ALWAYS had to do a manual BP and trusted it over the automatic read. That being said working in pt we never take our own vitals (I have a few times on special circumstance or checking pulse ox on someone crashing but obviously this isn't the standard). I worked as a tech through my undergrad so I will tell you from that perspective, rushing to take a ton of VS and write it on paper then key it in on a computer - mistakes happen. So when my RN calls me in a 'panic' with a high or low BP the first thing I do is have them recheck it especially if it's an anomaly compared to the other VS on that pt.
  10. In undergrad did a year of (paid) research. Not my thing. In PA school we wrote our thesis. That was the full extent of it. I'm not sure how involved PAs are in research. Obviously you can participate in clinical trial but to be the principal investigator etc you probably need a PhD. You should probably contact faculty at large schools to get a better answer than we have given you so far. All that being said even MD is typically going to get a PhD to be heavily involved in research. Or PhD alone. Either MD or PA can participate in a trial as far as a treating practitioner in which case a researcher would contact you or your institution but you would not be evaluating the outcomes. That's unlikely to be done by the MD either but probably someone with a PhD in statistics or bioengineering etc.
  11. I work in pt but primary and I am pretty confident specialists have it easier. Rarely primary on team, any pain or social issue they just say "ask your hospitalist", don't have to consult anyone with few exceptions, don't have to deal with disposition etc. that being said still wouldn't trade spots with them as I enjoy dealing with little bit of everything and otherwise love my job. But for those burnt out on primary I would suggest considering a specialty.
  12. Yea you can do everything with that license that you can with a normal one. Only thing is you still need your DEA to write out patient RX for anything scheduled. Have your manager call the state medical board if they don't believe you.
  13. Love my job. Work in an academic setting with high autonomy. Every day I learn something new. Group is great with mutual respect all around. Have a lot of loans but landed a competitive salary which is a blessing. Going to PA school was one of the smartest decisions I ever made no doubt about that.
  14. Sixteen 10s starting early in the morning. Anywhere from 3 to 6 in a row. One or two evening and one or two nights a month. More rounding than admission. Usually work half the weekends of a month. Yep for 7 on 7 off make sure you are well paid per above post. I have seen that true too for jobs out there (no PTO and pay not appropriately higher - unfair for providers.)
  15. In the hospital there are two main types of problem patients. The first are the complainer / drug seeker / gaming type. Others may not agree but this is my approach. Throw out all medical lingo. In fact if you know their slang, use it. I will be very frank with people. For pain "you are not getting anything extra from me" plain and simple, when safe to say. For the complainers, I let them vent briefly (do not let them go on forever), then explain I need the day to address their complaints. I try not to get into any confrontation with them as it is emotionally draining for me and time consuming. For the gaming type, I will sometimes just constantly steer the conversation back to the important topics (eg once had a PNA pt with chronic back pain who wanted dilaudid IV for said back pain - just keep steering the conversation back to talking about expected recovery time, importance of ambulation, etc). There's no one size fits all but the key is not to get worked up yourself or stoop to their level. The other problem patient is the one who has a family member in the room literally writing down names and taking notes, challenging everything, making uneducated demands and often wanting completely inappropriate code status for their family member. Often the pt themself is reasonable but family is not. For these, there are two approaches. One is sit down, hear them out, show compassion and give them a heart to heart. Sometimes they're just reacting out of pain. Other times they're truly nuts. In that case I will have the computer open and happily tell them lab results since they always ask, explain things sometimes somewhat vaguely so they can't later tie you down to something if it doesn't happen, and just make sure to cover myself medicolegally. I feel I practice good standard of care or (hopefully) above so I usually don't feel intimidated by these folks but it is nerve wracking. And I chart everything - always CYA. The hardest part of medicine isn't the science or procedures. It's dealing with difficult personalities of patients, their families, and of course our coworkers. If I worked in a clinic I'd probably recommend firing a patient if you ever felt unsafe. Why even risk it?
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