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Hey all - 

I was wondering what the work dynamic between you and your attending physicians is? For instance, do the attendings see all the patients you see? Are some places more autonomous and the attendings will only see the really sick patients? How many patients are you expected to see in a shift? How many patients are you expected to manage at a given time? 

 

I have been doing EM for about 18 months and had one month of orientation. This is my first job out of school. During a fast track shift, the attending will not see any of my patients unless I have a question or concern about a particular patient. The clinical shifts vary - there is a supervisory shift where the attending will see all your patients. Whereas some of the other shifts are set up more like a fast track shift, that is the attending will only see the really sick ones or a patient I may have a significant concern about. We work 8 hour shifts and are expected to see at least 13 patients per clinical shift, more for fast track. At times one midlevel may be managing up to 9 clinical patients, many of which could be high acuity cases. Furthermore, during a fast track shift we are managing 9 rooms and at times this may include multiple lacerations, I&Ds, and other types of similar procedures.

 

Sometimes I feel like I'm being stretched too thin, but that may also be because I only have 18 months of experience. I'm just curious how other EDs compare...thanks in advance. 

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Midlevel provider, i.e. physician assistant or nurse practitioner.

It was sarcasm. 

He's not asking an actual question. 

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To the OP, I'll try to answer your initial question (take into account that I've been out of the ER for about 10 years).  Something seems odd with regard to the bases that you covered.  One is expected to see 13 minimum over an 8 hour shift (I didn't like 12's since I was brain dead after 10 hrs.), yet some are balancing up to 9 at any one time?  The 13 seems low to me and the balancing of 9 at a time seems for lack of a better description, dangerous.  I used to take a progress note sheet and put a patient label on the sheet just to keep from losing folks and to serve as a reminder as to what I had pending.  For a FT setting, depending on how much assistance you receive from the staff, I think 2.25 to 2.5/hour average is somewhat reasonable.  If you actually have help (suture trays setup for you with lido on the mayo or already drawn up, splinting performed by techs, etc.) then 2.5-3/hour would be acceptable to me.  I am assuming that the 13 figure is for the main ED?

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I work at 3 places. at 2 I am solo seeing all comers at the other I am double coverage with a doc alternating charts from the same rack regardless of acuity. They only see folks I ask them to see, maybe 3-5% of pts. I just worked 3 days in a row there, saw 75 pts and asked the doc to see one of them. he asked me to see 2 of his.

if low acuity I can crank out 5-6/hr. If high acuity or more procedures 2-3/hr is more reasonable.

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To the OP, I'll try to answer your initial question (take into account that I've been out of the ER for about 10 years).  Something seems odd with regard to the bases that you covered.  One is expected to see 13 minimum over an 8 hour shift (I didn't like 12's since I was brain dead after 10 hrs.), yet some are balancing up to 9 at any one time?  The 13 seems low to me and the balancing of 9 at a time seems for lack of a better description, dangerous.  I used to take a progress note sheet and put a patient label on the sheet just to keep from losing folks and to serve as a reminder as to what I had pending.  For a FT setting, depending on how much assistance you receive from the staff, I think 2.25 to 2.5/hour average is somewhat reasonable.  If you actually have help (suture trays setup for you with lido on the mayo or already drawn up, splinting performed by techs, etc.) then 2.5-3/hour would be acceptable to me.  I am assuming that the 13 figure is for the main ED?

 

My apologies, I should clarify. We are expected to see about 2 patients per hour during a clinical shift, and 2.5-3 patients/hour during a fast track shift. I don't pick up any patients during the last hour, so this averages about 14 patients per clinical shift and more per fast track shift, all of which are 8-hour shifts. It is not unusual to have seen 22+ patients in a single fast tract shift.

 

As far as managing up to 9 patients at a time, this is not always the norm. This only occurs on days where we have very high volumes and during peak hours. At my facility we use Cerner firstnet, so keeping track of patients and pending studies are not as difficult as it would be compared to paper charting. But the sheer volume and higher acuity of patients at a given time is what's most challenging to me, especially when the attending physician has his/her own 8-9 patients to look after and may take any priority 1 traffic that comes through.

 

So, I was just curious how midlevels are utilized in other EDs. 

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Again, going back to the early days of PA's in ED's, I found that many of my physicians would sit and chat while I saw the patients, unless a high acuity case came through the door.  Why do the work yourself if you can have someone else do it for you and still get paid for it?  To clarify my earlier post regarding volume per hour, this also included manually typing out discharge instructions as well as hand writing notes (T Systems notation the last 3-4 years) and prescriptions.  We're talking the days of x286 microprocessors and dot matrix printers.  Efficiency really took off when we were allowed to dictate the visit, especially with defaults thrown into the dictation.  There was no formal fast track until the last 3 years or so of my time in the ED.

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SP - who is that?

 

I now only do per diem in the fast track side.... so not the best resource of info

 

But - I  honestly don't remember who my SP is, and if I have a question I grab any available doc, but no case review or training.  In fact I try to mentor the younger PA's a little if I find something interesting - which is seems to be very much lacking..... since exposure is the key to learning and knowledge I think it is my responsibility to share the interesting cases with the full timers that are new....

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^^^ Amen to that.  I used to even grab the nursing staff to point out interesting clinical findings, as long as the patient didn't mind (they never did because of course "I had something interesting").

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As was suggested above

DON'T USE THE TERM "MIDLEVEL"!!!!!

 

Are you practicing "mid"-medicine?

Or are you expected to meet the same gold standard as the docs in your group?

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As was suggested above

DON'T USE THE TERM "MIDLEVEL"!!!!!

 

Are you practicing "mid"-medicine?

Or are you expected to meet the same gold standard as the docs in your group?

 

Please forgive me - I did not know there was such strong animosity towards the term "midlevel."

 

You do bring up a good point though about practicing "mid"-medicine.

 

STILL - I've had 2 responses about how I shouldn't use the term midlevel, and only 3 responses to my actual questions, which is unfortunate in my opinion.

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I haven't worked in EM, so all I can give you is my experience from clinical rotations. I worked at a rural hospital between Targhee in Idaho, and Jackson, Wyoming. It was great. PAs and NPs soloed the ER, with MD/DO on call if needed.

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Hey all - 

I was wondering what the work dynamic between you and your attending physicians is? For instance, do the attendings see all the patients you see? Are some places more autonomous and the attendings will only see the really sick patients? How many patients are you expected to see in a shift? How many patients are you expected to manage at a given time? 

 

I have been doing EM for about 18 months and had one month of orientation. This is my first job out of school. During a fast track shift, the attending will not see any of my patients unless I have a question or concern about a particular patient. The clinical shifts vary - there is a supervisory shift where the attending will see all your patients. Whereas some of the other shifts are set up more like a fast track shift, that is the attending will only see the really sick ones or a patient I may have a significant concern about. We work 8 hour shifts and are expected to see at least 13 patients per clinical shift, more for fast track. At times one midlevel may be managing up to 9 clinical patients, many of which could be high acuity cases. Furthermore, during a fast track shift we are managing 9 rooms and at times this may include multiple lacerations, I&Ds, and other types of similar procedures.

 

Sometimes I feel like I'm being stretched too thin, but that may also be because I only have 18 months of experience. I'm just curious how other EDs compare...thanks in advance. 

First job out of school in the ED is tough, steep learning curve. 13 pts in an 8 hr shift is very doable. Managing 9 pts at once with varying levels of acuity is difficult for even the most experienced clinician regardless of position and training though. Unless the attendings are managing the same # during this time, I think you are being taken advantage of. I have personal experience early in my career of seeing nearly all pts in the dept while an attending mucks around with one. I specifically remember evaluating a TIA and chest pain that came in at once while the attending saw a sprained ankle of a young lady who was getting married and thought only a dr should see her due to the importance she be fully recovered to walk down the aisle. Good luck with that one buddy.

 

After a year or 2, I got rather sick of this. We essentially picked up next chart. I worked with some attendings that were fair and liked to work and we shared the load equally. They usually would see more patients than me by about another 25% but they were also being paid over twice what I made. Others were satisfied with cherry picking charts and leaving the rest for me. I knew it was likely I would not stay there forever, looked at this time as a mini residency and worked it for all I could get in terms of experience. I left at the 3 yr mark because it was obvious to me that the dynamic would not change with the cherry pickers so I changed it. It may be good advice for you.

 

I think if the root of your question is if you feel stretched at times then you likely do. Your attention will fracture and you will make a mistake. If there are times you feel like this then professionally you need to make a statement to that affect. Too many pts, cant focus, mistake will be made, need help. If you are adhering to dept guidelines in terms of how many you see per shift (13 in 8) then you are meeting the standard they have set. 

 

Several things to take into consideration:

 

Is this a contract group or is everyone employed by the hospital? If the first then the bottom line issue is money and you need to understand that. Your salary is dependent upon moving the meat. If you work for the hospital, then there is a different dynamic. I dont encourage a work slow down but you likely will not be rewarded substantially for working your tail off unless your compensation is based upon RVUs and such.

 

Your approach to attendings and directors can lead to a perception of you as a clinician. While you wont get many attendings to fully relate their opinions, I believe most look at PAs and NPs as less educated, less trained and less experienced regardless of the reality. They will think chain of command with their position at the top and you below. A concern about volume and acuity may be grounded in reality and fact but it may not be what they want to hear about given that it may directly impact upon them ie new PA says cannot keep up with volume now I have to go to fast track and actually see a few snot rockets myself. I also have encountered attendings who would rather displace clinical duties on others, focus on teaching, admin duties or just make sure the internet is working. Some are burnt out, some realize they should not be in medicine but are too far along to make any change, some are just plain lazy. 

 

Have you done some introspection to evaluate if there are workflow dynamics or knowledge base issues that would help you be more comfortable with volume and acuity? This may not be a situation you can do much about but you could make your life easier with adjustments to process and strengthening of know how. There are 2 books I encourage many people to read, The 1 minute manager and Multitasking is a Myth. They are business books but have some worthwhile direction essentially anyone can benefit from. 

 

This supervisory shift. Are you being truly supervised? First, supervision is a bad word. It means a critical watching and directing of someone. To many, that means being told what to do. I precept PA students quite a bit. Most want me to give them the answer. I on the other hand want them to figure out what they should do and why. Retention and growth come not from spoonfeeding but utilizing knowledge and experience and putting it to use. Taking ownership is important on your part. Conversely, if being supervised is being told to do something that is particular to the specific attending then I fail to see the benefit. If this supervisory shift is in place to get a signature of an MD on the chart to increase billing then this is just a boondoggle for the attending involved. Last, how long in one's career do these supervisory shifts last? Are they only for PAs beginning at your place and eventually peter out or are they a constant factor regardless of experience and longevity? That would be a hard pill to swallow over the long term.

 

My own situation. I work solo in a rural ED, usually telephone contact with SP if needed. I see everyone that comes in, assess and treat, consult as appropriate, disposition to home, admit or transfer. I honestly think I am ruined to work in the situation you describe. It is likely I have more work and world experience than some of your attendings. I dont tolerate being taken advantage of and am particularly resistant to my way or the highway supervision. But also at the beginning of a career, volume, acuity and mentoring especially are important. Eventually swim lessons are over and you have to dive into the deep end. 

 

 

Please forgive me - I did not know there was such strong animosity towards the term "midlevel."

 

You do bring up a good point though about practicing "mid"-medicine.

 

STILL - I've had 2 responses about how I shouldn't use the term midlevel, and only 3 responses to my actual questions, which is unfortunate in my opinion.

You have your 4th response.

The history of midlevel terminology is one that seems to be borne out of regulation and convenience. Changes to nomenclature will take both grass root efforts and state and federal political action.

I think the individual can help by avoiding the use of midlevel language. My personal tact is ID myself as a PA. I dont say physician assistant, some people ask if I want their insurance info. When I encounter my hospital admin and physicians using this, I also ask what level I am practicing at in their estimation? They get it, they are fully aware of my capabilities. This will be a generational change that occurs unfortunately but something that can be contributed to on a regular basis individually. 

Last, I never think of myself as midlevel. I think of myself as someone that has been trained to practice medicine. I took an alternative route to get there but it is what I do and I should be respected for that. It likely was a tougher route in some ways than getting an A in physics, a good score on the MCAT and toiling through med school and residency. On the other hand, I am debt free.

Good luck.

G Brothers PA-C

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Please forgive me - I did not know there was such strong animosity towards the term "midlevel."

 

You do bring up a good point though about practicing "mid"-medicine.

 

STILL - I've had 2 responses about how I shouldn't use the term midlevel, and only 3 responses to my actual questions, which is unfortunate in my opinion.

 

 

Words and terms make a difference - ask any marketing firm or advertising agency....

 

We are NOT midlevels

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I am 2 years out of school. I have been at the same ED since I graduated. My SP's have trained me well. Its a pretty small ED with 15 beds. Staffed in the am with 1 PA and 1 Doc, then 2 PA's and 1 Doc during peak hours (1pm to 8pm), then back to 1 PA and 1 Doc. 1 Doc coverage between 1am and 10am. There is no fast track. We all share the load, although docs generally see the most emergent patients (level 1's). PAs occasionally see 2's depending on what it is.

 

Most attendings just want us to give them a heads up when we d/c a person, quick 2-3 word summery if its something straightforward ("a rash," "a benign belly", "20y/o muskuloskeletal CP", "negative wrist", "COPD exacerbation").. if its something more involved, like a chest pain or SOB then i'll give more info if necessary. Occasionally they will lay eyes on a patient if it is someone that I am unsure about or on the fence about (d/c vs admit). Some attendings don't want to hear about the patient unless it is someone I need them to see. I prefer this because it lets me work faster, without having to wait on the doc to be available before d/c'ing someone.

 

I see an average 20-22 during a 10 hour shift. Sometimes more, sometimes less depending on how busy we are. On average I have 4-5 patient's at a time. Usually 2-3 higher acuity, then while their stuff is pending I see some lower acuity patients.

 

Let  me know if you have any more questions

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Again, going back to the early days of PA's in ED's, I found that many of my physicians would sit and chat while I saw the patients, unless a high acuity case came through the door.  Why do the work yourself if you can have someone else do it for you and still get paid for it?

 

We have a few docs that do this. the PA's see most of the patient's while the doc is "busy" with their 1 patient, which is usually a psych patient that has been there (asleep) for 6 hours awaiting inpatient placement

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at my last job( and one of the reasons I left...) there was a particular shift in which I was alternating charts from a single rack with a doc. in 12 hrs I saw 56. I assumed it was a super busy day as the doc always seemed to be doing something. when the #s came out if turns out he saw 8 to my 56. and his were no sicker than mine....and this happened often...

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at my last job( and one of the reasons I left...) there was a particular shift in which I was alternating charts from a single rack with a doc. in 12 hrs I saw 56. I assumed it was a super busy day as the doc always seemed to be doing something. when the #s came out if turns out he saw 8 to my 56. and his were no sicker than mine....and this happened often...

See this happen many times. At the end, we gets called an "assistant" We drive Honda & they drive BMW. I'm sure he was doing administrative related work + seeing patient; a very legitimate reasons for seeing 8 pts in a 12 hours shift. Isn't that what they always blame it on? Glad you left E!

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See this happen many times. At the end, we gets called an "assistant" We drive Honda & they drive BMW. I'm sure he was doing administrative related work + seeing patient; a very legitimate reasons for seeing 8 pts in a 12 hours shift. Isn't that what they always blame it on? Glad you left E!

nope, he was day trading his stock account(seriously).

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We have a few docs that do this. the PA's see most of the patient's while the doc is "busy" with their 1 patient, which is usually a psych patient that has been there (asleep) for 6 hours awaiting inpatient placement

 

We would occasionally get a new attending in our satellite ED who was used to working in our academic medical center.  Rather than picking up patients equally, they would sit on the computer, waiting for the PA to see every patient and then come present to them (just like they were used to with the residents).  Our PA's were very quick to correct them and get them with the flow; the ones that didn't pull their weight were quickly disinvited from rotating out the the satellite ED and were sent back to the main hospital.

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At my last job (still in between jobs because of bastard credentialing!), on a 12-hr shift I was seeing about 20 patients of all levels of acuity.  The docs didn't require presentations of certain patients as they knew that I knew when to get them involved if I was in over my head.  When I would cover the fast track/mini clinic at our main facility, I would average 30-40 without too much effort over 12 hours- and seeing 50 was not unheard of.

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.... During a fast track shift, the attending will not see any of my patients unless I have a question or concern about a particular patient. The clinical shifts vary - there is a supervisory shift where the attending will see all your patients. Whereas some of the other shifts are set up more like a fast track shift, that is the attending will only see the really sick ones or a patient I may have a significant concern about...

 

Most attendings just want us to give them a heads up when we d/c a person, quick 2-3 word summery if its something straightforward ("a rash," "a benign belly", "20y/o muskuloskeletal CP", "negative wrist", "COPD exacerbation").. if its something more involved, like a chest pain or SOB then i'll give more info if necessary. Occasionally they will lay eyes on a patient if it is someone that I am unsure about or on the fence about (d/c vs admit).

 

Sounds like a lot of us don't practice the "same" medicine as the physicians we work with since they often take the higher acuity patients and/or often require a brief heads up about our ED patients.

There is nothing wrong with the term "mid-level provider".  Don't let anyone bully you away from using the term if you choose to use it.  However, if you don't think it applies to you, then feel free to not use it. 

To answer your question:  At the two local tertiary centers the mid-levels do much the same that you are doing.  However many of the surrounding rural hospitals have family practice docs and PAs provide single coverage for the EDs.

 

****I tried to multi-quote the above, but apparently I my computer is smarter than I am*****

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