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lamontPA

Integrating New Grad Into Practice

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Hello all,

 

My ER group just recently hired a new grad that spent 6 weeks with us during her ER rotation.  She is a sharp student and did an excellent job and is the first student that we have ever hired from rotations.

 

She is due to start working with us this June after graduation. I want to integrate her into the department slowly, so I was wondering if any of you had any ideas as to the best ways to bring her along.  I have told her that I would try to arrange for double coverage with close oversight for the first 3-6 months and then expand her role from there.

 

Our ER is moderately sized (37,000 visits per year) with separate fast track run by PAs with another PA shift seeing pts fairly independently along with ER doc.  Our oversight is excellent with a great, collaborative staff.

 

I am envisioning sort of a pseudo ER residency-type setup for her, so any help would be appreciated.  I'd like to write this up formally to hopefully use in the future with new grads or PAs new to EM.

 

Certain skills to know? How long before solo work? Certifications/CME prior to working solo?

 

Thanks,

lamontpa

 

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To the initial poster. How long have you being an ER PA? Not sure how much you're being paid to train the new PA. It's a huge undertaking & responsibilities. Particularly, if the MD/DO are not involve in training the new PA. I don't care how smart you are as new grad PA. Starting in the ED as a new grad is completely a bad idea. The only exception would be if one had prior ED work as an RN, EMT, or did a post graduate EM residency training.

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I've been an ER PA for about 7 years with several years in PA education. I agree that training a new grad is big undertaking. This is a trial for my group and docs and PAs will be involved in training. I get paid decently as lead PA to organize things.

 

This student does have an EMS background, but unfortunately, PAs these days are getting younger and younger with less experience. We've hired a couple of folks that have had a couple of years of ER experience, but we are finding so many that are poorly trained and even more dangerous than you would imagine.

 

This is not the norm for the group...we'd be crazy if it was.

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I like that you are providing a long period of mentorship. One thing I feel strongly about is that a new PA absolutely does NOT belong in fast track solo--seen too many disasters and near-misses that way (same goes with new NPs). I think the best place for a new PA is in the main ED alongside the attending/senior PA who provides close supervision with graduated autonomy as you suggest.

Let her know this is for her benefit as much as anyone else's--particularly the patients.

I also think coming up with a reading schedule and mini lectures/problem based scenarios would be a good idea. My first supervising physician did this with me the first 6 mos out of school--we even had dedicated teaching time built into the week. It was really a great thing that took me from a smart but unsure new grad to a smarter and well-honed clinician.

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Prima...with all due respect. New grad don't belong to the main ED. That's even more dangerous. Unless if you're referring to community hospital with low acuity if such a thing exist vs major academic Ctr w/ a vol ranging from 75-100k/yr.

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Prima...with all due respect. New grad don't belong to the main ED. That's even more dangerous. Unless if you're referring to community hospital with low acuity if such a thing exist vs major academic Ctr w/ a vol ranging from 75-100k/yr.

I disagree- in the main ED, coupled with an ER attending who is directly supervising the PA, is a great place for a new grad to learn, especially if it's at an academic center where you have ER attendings who also double as faculty members. Solo coverage in fast track, where an attending or senior PA is nowhere near to be able to overlook things as they are happening, can be much more precarious for a new grad. When our group hires new grads, we don't put them in the fast track setting until they have enough experience under their belt for precisely this reason

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I've been an ER PA for about 7 years with several years in PA education. I agree that training a new grad is big undertaking. This is a trial for my group and docs and PAs will be involved in training. I get paid decently as lead PA to organize things.

 

This student does have an EMS background, but unfortunately, PAs these days are getting younger and younger with less experience. We've hired a couple of folks that have had a couple of years of ER experience, but we are finding so many that are poorly trained and even more dangerous than you would imagine.

 

This is not the norm for the group...we'd be crazy if it was.

Too much HA. Current trend of newly grad PA is depressing to say the least. The new faces of PAs they called it.

 

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^^^. Has to present each case and review dx and tx options before implemented until both parties, but especially attending, are comfortable. I would even look (peek) at every wound/ closure to inquire as to why one technique versus another was chosen and inquire if an x-ray might be indicated based on nature of lac. Inquire as to eval of knee/ankle injuries (do they know about Ottawa rules). It's what they don't realize that they don't know that puts most at risk. Le Fort? What's Le Fort?

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Too much HA. Current trend of newly grad PA is depressing to say the least. The new faces of PAs they called it.

 

When I picture you saying this, I see one of the guys from the movie Grumpy Old Men.  I love it.  Keep 'em coming.

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Just a hopeful future EM PA here, but from what i have seen from my interviews and past experience as an EMT, the seasoned PAs are the ones heading up the fast track solo and the newbies are in the main ED with the docs at their side.  Makes more sense to me, but what do I know.

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I'm a new grad working Fast Track at a smaller hospital, what has been working out well for me is that I was initially assigned to work shifts with the established PAs in Fast track for them to oversee me the 1st month, and I picked up the more straight forward cases. Once the PAs and MDs felt I showed competence and could keep up the pace, I was officially put on the schedule. With that being said, there is always another PA working in Fast Track. We have PAs scheduled 7a-7p, 10a-10p and 2p-2a, and 9p-7a. So I usually have a second eye/opinion in the fast track area.

 

In addition to that, I am required to present all my cases to the Attendings in the Main ED. Sometimes this is hard because if they are dealing with critical pt and I have to present something basic as a viral URI it distracts them so finding the right time to interject can be key. Not much you can do, besides be pleasant and apologetic and let them know when they have a free moment you have a simple case to discuss.  I was told to alternate which Attending I presented to, allowing me to get to know each of the Attendings, their specific style, and to gain their trust. I was also told to continue to present all routine cases until that specific attending told me it was unnecessary and just to come to them with questions. Some Attendings insist on spending face to face time with all my patients and others only if it is a more involved case or if I have questions.

 

As long as us (new PAs) know their limitations, ask questions, and can present a solid H&P with good reasoning/judgement I think they should be fine. 

I have seen some of my former classmates who were too matter-of-fact and overconfident, that in combination with the ED spells trouble.  I think the hardest part initially is adapting to a new environment, learning the hospital specific protocols, figuring out where materials are held, navigating the EMRs, and knowing who/when/where to refer to for consults as every hospital is different and is a learning process in itself. Having an orientation specific to the dept is great (which most places don't have and they throw you right in), but if they have been a student there, at least they know some of the basic ins and outs of that ED.

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I disagree- in the main ED, coupled with an ER attending who is directly supervising the PA, is a great place for a new grad to learn, especially if it's at an academic center where you have ER attendings who also double as faculty members. Solo coverage in fast track, where an attending or senior PA is nowhere near to be able to overlook things as they are happening, can be much more precarious for a new grad. When our group hires new grads, we don't put them in the fast track setting until they have enough experience under their belt for precisely this reason

New grad PA in the main ED? Very scary. I can't completely rule out a possibility but the question is how sustainable would it pan out? Yes. It's possible if the new PA is lucky enough to join a generous group willing and ready to train/build the PA to speed. I speak base on my personal experience. I prefer a model where the PA start in the UC but with oversight/working along side with senior PA & an attending, then, slowly move up to the main ED.

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Agree with TA above-I would schedule the new pa 50% in fast track and 50% in main. the PA should have a designated preceptor for every shift and should present every single pt until they are signed off on certain classes of pt.

I think limiting a new pa to fast track or urgent care only means that they won't recognize sicker pts when they get mistriaged to those areas(as happens every shift).

treat the new pa like a resident. let them see sick folks and do adv. procedures but always with a plan in place for an experienced provider(pa/md/do) to be involved with every pt and physically in the room any time they are doing a new procedure like an LP, etc. This is how physician em residents are taught and I think it just makes sense. having them work their way up from fast track to intermediate to main is one way to do it but I think early exposure to sick folks and adv. procedures is the better path and the one I would personally have preferred for myself as I am a "graduate" of the slow and steady advancement method, something which made me hate a lot of my first few years in practice as I often felt fast track was a step backwards from being a 911 paramedic.

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I am a new grad, hired on to train in a busy, well-staffed ED. Just started this month. My boss is an MD, and I will be assigned to work with an MD and have 100% cases presented and reviewed by my supervising MD every shift for 3 months. The majority of my cases will be fast-track, unless I am given permission to see a more complex case with my supervising. We will also be logging procedures performed in the ED. I agree that it would be good to have more sick-patient exposure to help me to recognize more. I'm going to try my best to learn what I can. I won't be seeing the extremely young or old.

At this point, I feel like a burden to the ED, and often humbled and humiliated by my lack of knowledge. But I am not the first to be trained as a new-grad here and I am hoping to become what they would like for me to be.

If you have any suggestions or advice for me, I will gladly accept. This has been an interesting conversation to follow as it is obviously so relevant to my situation.

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I'm a new grad in the ED as well. While I have ER experience in different capacities prior to PA school, still New as a PA.

 

My group has a model similar to what EMEDPA is talking about. I rotate between 3 hospitals. In 2/3 it is double coverage (me and a doc) and I focus on the lower acuity stuff mostly but as the docs become comfortable with me I have seen the sicker/higher acuity pts. I however always present these as a quick little heads up (just so they are aware of the pt really) and admit or not depending on the pt.

 

The other place I am fast track and depending on the day, I can, and seems often do, get things that are miss-triaged (most recently there was an MS pt with new acute onset hemianopsia...always fun when it is triaged as eye irritation). But, I feel like this is not so bad because of the acuity at the other places allows for me to be more comfortable in those scenarios.

 

A new grad in the ER is doable but it requires a specific situation regarding practice area and group as well as skill set on the part of the new grad. That being said, I won't lie and say that I am always acutely aware of my newness. Also I have no qualms about running the case by my doc to ensure I am doing the right thing when things get complicated at this point.

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Being humble and aware of how much you don't know is exactly the right approach. The prideful and overly confident newbies are very dangerous.

 

When you approach the attending, make sure you have a plan for the patient. At least try to formulate one in your head. I've seen a lot of new PAs and interns present the HPI, ROS, exam and labs, then drop all decision making on the attending's lap. Figuring out a plan is the hard part about medicine, so train your brain for this. Your SP won't always agree with your plan, and that's okay, but at least you tried.

 

When I was starting out, I had trouble with people coming in for IV abx infusions, because I was never sure when they could stop IV and switch to PO. I hemmed and hawed about this for so long! Or even deciding whether to put them on IV. Eventually, my SP asked, "Well, what would you do if you were here alone? Would you give IV? Would you do PO?"

 

It seems silly, but that really helped me. Since then, when I'm unsure of a plan, I think "What would I do if I were flying solo?" And the answer presents itself. Which is not to say the answer is always the right one or the SP will always agree with my plan, but we're usually on the same page.

 

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I am a new grad, hired on to train in a busy, well-staffed ED. Just started this month. My boss is an MD, and I will be assigned to work with an MD and have 100% cases presented and reviewed by my supervising MD every shift for 3 months. The majority of my cases will be fast-track, unless I am given permission to see a more complex case with my supervising. We will also be logging procedures performed in the ED. I agree that it would be good to have more sick-patient exposure to help me to recognize more. I'm going to try my best to learn what I can. I won't be seeing the extremely young or old.

At this point, I feel like a burden to the ED, and often humbled and humiliated by my lack of knowledge. But I am not the first to be trained as a new-grad here and I am hoping to become what they would like for me to be.

If you have any suggestions or advice for me, I will gladly accept. This has been an interesting conversation to follow as it is obviously so relevant to my situation.

 

So IMO this is the way it should be. If the docs are going to "enjoy" the benefits of having a provider work for a fraction of the physician salary then it is important for them to take a very active role in the training of the PA. Some points:

  • Agree that the best place to get a new grad trained is from a pool of folks who rotated with you first.
  • We employ a "tier system" where we have stratified our group and it provides a pathway for advancement. The new grad must, therefore, prove mastery of certain basic EM concepts before being asked to do more.
  • We place no pressure on productivity on the new grad trainee for a least a good while (6 mo--1  yr).

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I am an EM PA-C that works in an ER in the suburbs of a major city. We see around 50,000 patients per year. I have been practicing for 2.5 years fresh out of school with little to no prior medical experience. We have 16 PA's in our group. Half of us do acute care (main side ED), the other half do Fast Track. All of the Acute Care PA's graduated in the past 3 years so we have a TON of experience getting new grad PA's going (including myself). With me, I was a student (first at a trauma center for my main EM rotation and then with this group as an elective) with the group and they threw me in with no orientation fresh out of school. Thankfully after doing that with a few of us, they have now implemented a 3 month transition period working side-by-side with a senior PA. Then you must continue to present each patient to your attending physician until they feel comfortable with you (seems to be around 1-1.5 years). Some in our group have not been "cut loose" yet even after 2 years and that is understandable. I agree that new grad PAs these days aren't what they used to be. I'd say at this point, the majority of us are GREEN. Boy are we green. I believe if you are going to hire new grad PAs that it must be the right group. Our attending physicians take GREAT care of us and it works well. They seem to appreciate the chance to mold us to their desire and not have to "retrain us" as they put it. Not every group has that mentality. Good luck!

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My group recently started hiring new grads and it has proven successful thus far. We do a 3 month mini-residency program which is structured based on the personality, experience and knowledge of the student. We staff three facilities with only one having fast track. The first month the new graduate will train alongside another PA to get them exposed to the basics and get them comfortable with doing simple procedures. Being that we are a large group, we also take the time to discuss the various personalities of each attending so there are no surprises. Month number two the new hire will now start to circulate with another PA at our other facilities seeing higher acuity patients. This provides them an opportunity to see sicker patients and learn more complicated procedures such as LPs, Reductions, Intubations, Bedside US, etc. Our 3rd month is pretty much an established PA following the new hire as if they were running the shift. This provides us with an opportunity to really so how far the new hire has advanced and to discern how much trust there is amongst the attending physicians. We've had one new hire that was extended to four months, but outside of that the system has worked well. 

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the only orientation I have ever gotten is "there's the chart rack".

a structured experience would definitely have been better.

When I was in UC/EM that was the extent of my training too.  Fortunately some of the docs were great and helpful and mentored.  Some were not at all willing to train or mentor.  Rather it was "I don't know the answer to your question, I'm not a gynecologist, or I'n not a urologist, etc."  Go call them.

 

And I did.  I learned alot on my own ( not always a good thing).   I'm back in FP where I belong and had great experiences in the UC/ER but felt like I did not have enough of the EM medicine training to be truly useful in emergencies.  My rural area hospitals do not allow the ACPs to do procedures that many of you do...no lumbar punctures, reductions, US bedside exams, run a code.   

 

I am all for PAs who want to make a career of EM to attend a residency under structured learning.  The days of OTJ training seem to be going by the wayside. 

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