Does it get better?

[Acromion]

So I'm 2 months away from my 1 year anniversary as a practicing PA in ER. I've been mostly slogging through the fast track trenches in a semi-rural ED. I frankly sucked at first and my practice was frustrated with how slow I was (although I haven't made any major mistakes, thank God). The recruiters and the docs who interviewed me assured me that it would be a perfect place for a new grad, which turned out to be total BS - they just needed someone to fill the position stat. When I was hired, I was under the impression that I would be working with another PA at all times so I wouldn't have to escalate every scenario directly to the attending. Well that was the PLAN at least, but they just couldn't find another PA. Most of them were understanding but they were frustrated with the situation since they were used to working with experienced PA's who could really lighten their workload with minimal oversight.

 

Well, I decided to show them that I was capable of this job no matter what lengths I had to go. I made some changes, got help, and I'm now churning through patients, staying late and coming in early to finish charts. I've established a really great relationship with the nursing staff and I will often go to them to answer my questions or get input before bothering the doc. In september I saw 440 patients and I think there's a sense now that I'm really pulling my weight and they want to keep me around. The hospital is looking into me picking up shifts with the hospitalist team because they are short staffed and need a PA. I think that could be a really great opportunity.

 

My question is, now that I've earned the trust of my physician partners, where can I go from here to become the PA I want to be? I keep hearing about these PA's who run codes, lines, intubate, and all the cool stuff. I don't want all the knowledge I struggled to acquire rot on the vine while I see endless back pains, URI's, ankle sprains, and abdominal pains. I've been slowly picking up higher acuity patients and doing a competent job with them. I've had about 10 admissions/transfers per month in the past few months and one level 1 patient. I've been spending several hours a week on my off days studying. I listen to lectures during commutes. I know there is the option of residency, which is most likely not a financially realistic option and I understand they usually look for students fresh out of school. I know there's a lot of high functioning PA's out there who didn't do a residency. 

 

 

[SocialMedicine]

there is a reason MDs do a several year ER residency before they run codes and emergency critical care.  It sounds like you are advancing if you are getting exposure to some sick patients in the urgent care. It sounds like taking on a hospitalist per diem or perhaps main ED per diem role could be useful. Even if your ER does not utilize PAs in main ED you could perhaps argue for a 1 day a month experience basically working as a resident or intern. If you have a CME budget consider advanced airway mgmt coursework and other skills you can bring to the table. 

[cinntsp]

 I know there is the option of residency, which is most likely not a financially realistic option and I understand they usually look for students fresh out of school. I know there's a lot of high functioning PA's out there who didn't do a residency. 

 

This is the best option to really accomplish what you're looking for.  Most residencies pay 50-55k. That's easy to live on, especially if you're somewhat frugal.  Loans can be deferred if necessary.  These programs are not looking solely for fresh new grads.  When I was interviewing at several programs there were quite a few PAs with 1, 2, 5+ years of experience that were either looking to take their education to the next level or make a career change. This route will provide you the best environment to do what you're looking to do in the shortest time possible.  If you read some of the posts on here, like from EMED, you'll see that the standard approach can take 10+ years working your way into a position with the scope of practice you desire and it may require some sacrifices along the way(location, pay, etc.)

[EMEDPA]

This is the best option to really accomplish what you're looking for.  Most residencies pay 50-55k. That's easy to live on, especially if you're somewhat frugal.  Loans can be deferred if necessary.  These programs are not looking solely for fresh new grads.  When I was interviewing at several programs there were quite a few PAs with 1, 2, 5+ years of experience that were either looking to take their education to the next level or make a career change. This route will provide you the best environment to do what you're looking to do in the shortest time possible.  If you read some of the posts on here, like from EMED, you'll see that the standard approach can take 10+ years working your way into a position with the scope of practice you desire and it may require some sacrifices along the way(location, pay, etc.)

 

 

you'll see that the standard approach can take 10+ years working your way into a position with the scope of practice you desire and it may require some sacrifices along the way(location, pay, etc.)

yup, this.

when you max out your scope of practice at your current shop you need to find a new job which lets you see sicker pts. repeat q 2 years until you are where you want to be. took me > 15 years and 6 job changes but I've finally arrived at a place I could have been with a 1 yr em residency right out of school.

[Boatswain2PA]

What was your background before school??

[EMEDPA]

me or acromion?

[Acromion]

Before school I worked as a CNA in a memory unit (diaper changer), then a Pharmacy Tech and Medical assistant.

 

I'm great at pharm as a result of my experience. Did I learn much from changing diapers? No not really, but it build character I guess.

[Acromion]

yup, this.

when you max out your scope of practice at your current shop you need to find a new job which lets you see sicker pts. repeat q 2 years until you are where you want to be. took me > 15 years and 6 job changes but I've finally arrived at a place I could have been with a 1 yr em residency right out of school.

 

At my current shop, I think I have plenty of opportunity to grow yet. Most of my attendings give me leeway to see patients I'm comfortable with. I just have to find the opportune moments, when it's not too busy, and tell the attending "hey, do you mind if I pick up this chest pain?" I think most of them would be pretty cool with that.

[gbrothers98]

I think you are in a good spot right now. If you can keep up your work load and also engage the attendings on higher acuity cases, you essentially have a well paid residency. There is a lot of self learning in residency, you can use either the EM CAQ blueprint or the ABEM core of EM structure to guide your studies. The only thing missing is that after a few years you wont have a certificate declaring you a resident or fellow grad but you will have some hard earned experience and a number of references attesting to your competency. That is just as important as graduation from an ED fellowship, in fact if I looked at your resume as an applicant, I would rate it higher vs a fellowship.

 

You are doing the right thing which is being engaged and pursuing more knowledge and experience.

I understand the desire to climb up that ladder of more responsibility and autonomy but in real life it is not a clear pathway.

 

Here are my suggestions:

 

1. Start working on the badges, ie PALS, ATLS, airway course, ultrasound course.

2. Conferences ie Bootcamp, ACEP/SEMPA conferences, Essentials of EM, Resus, Critical Points, etc. See if you can go with one of your physician colleagues.

3. Is there an attending or more experienced PA there that you can use as somewhat of a mentor?

4. Apply for and obtain the EM CAQ.

 

Your situation sounds very much like mine when I got out of school. I was in my early 30s, started in an ED where I saw a mix of patients. In retrospect, there is not much I think you can do to make things better quickly, this is also a process, similar to PA school. In the end, you will appreciate the time that is needed and realize that patience and consistency will get you places, places right now you may not know you want to go. My life is much different from what I ever thought it would be and the route getting here was not a result of overt planning but rather hard work, consistency and taking opportunity when it appeared.

 

Good luck to you.

G Brothers PA-C

[Boatswain2PA]

Acromion - If you had a strong EMS background then I would recommend you do some locums in more rural areas.  They can pay VERY well, and you are the sole provider so you will see everything that comes in the door.  Trauma, sick & crashing, kids...everything.  The downside to that is the numbers you see is much lower, however knowing that "you're it" in the ED makes you study and prepare yourself even harder (at least it does for me).

Overall it sounds like you're doing very well.  Concur with what Emed and Brothers said, but I would add a healthy dose of things like EMRAP not only for the actual knowledge, but just as importantly to get you to think like an emergency physician. 

[True Anomaly]

Agree with just about everyone- so long as the physician group you are with has some avenue that allows you to progress further in seeing patients of higher acuity AND allows you to do advanced procedures, then you will be able to grow with them.  gbrothers gave you good suggestions on outside learning/credentials that will help your practice, and as EMED and boatswain suggested, you may have to seek outside opportunities that will challenge you further.

 

The hospitalist opportunity would be good if you're interested in transitioning to an inpatient style of medicine down the road, OR if you want to have a variety of positions.  I think doing observational/hospitalist-type medicine does help with practicing in the ER as you know exactly how patients are handled after you admit them and what patients actually need to be admitted- a helpful thing for new grads to know.

 

FWIW, I would only rule out the residency if it's financially un-feasible for you; my old program has a history of interviewing several PA's who've had actual work experience, and I'd say the "new grad/experienced PA" ratio of the residents who have gone through the program is 50:50.

 

440 patients/month is great!  I'm averaging 300-400 month at this point, but only because I rarely do 12-hr shifts anymore at my new job.

[polarbebe]

In addition to the excellent advice above, experience in critical care can open many doors in emergency medicine... ICU experience translate well into emergency medicine.  

 

Codes are not uncommon and many procedures are performed in the unit (intubations, CVLs, Swans, a-lines, thoras, paras, chest tubes, LP, etc.).

[EMEDPA]

Acromion - If you had a strong EMS background then I would recommend you do some locums in more rural areas.  They can pay VERY well, and you are the sole provider so you will see everything that comes in the door.  Trauma, sick & crashing, kids...everything. 

agree with Boat here. This is really only for folks with strong prior backgrounds. If you can't run a trauma or medical code with 1 nurse and 1 tech you SHOULD NOT be working solo. If you can't manage all the ACLS scenarios, deal with DKA, ODs , etc without calling a doc you are not ready for this.

[FriarMedic]

where do you find solo positions? I'm a new grad so not interested now, but I envision this many years down the road when I feel the time is right. I'm in the lower new england area. 

[EMEDPA]

where do you find solo positions? I'm a new grad so not interested now, but I envision this many years down the road when I feel the time is right. I'm in the lower new england area. 

word of mouth mostly. there are probably <100 in the entire country. I think I work at the only 1 in a 3 state area. I sent them a CV every year for a decade before they even interviewed me.

[cinntsp]

If you can keep up your work load and also engage the attendings on higher acuity cases, you essentially have a well paid residency. There is a lot of self learning in residency, you can use either the EM CAQ blueprint or the ABEM core of EM structure to guide your studies. The only thing missing is that after a few years you wont have a certificate declaring you a resident or fellow grad but you will have some hard earned experience and a number of references attesting to your competency. That is just as important as graduation from an ED fellowship, in fact if I looked at your resume as an applicant, I would rate it higher vs a fellowship.

 

I think this is understating the value of a residency/fellowship somewhat.  In addition to my patient care duties that include working with docs/PAs/NPs that like to teach, I have both a core curriculum and a specialty curriculum that includes hours of weekly lectures, sim labs, required case presentations and discussions, journal club, etc.  For example, my last lecture/lab for my core curriculum was on mechanical ventilation and respiratory failure. This week is u/s-guided central line placement.  Can these things be accomplished outside of a residency? Sure - PAs have been around a lot longer than residencies have.  However, there is a lot to be said for an environment that is built solely for your learning experience versus an expectation that you are there to make a practice money first and foremost.  It's a lot easier to focus on learning with time carved out for educational activities and I think this whole concept speeds up the learning process considerably.  I have to imagine if new grads 1 year out were compared(residency vs. not), there would be a measurable discrepancy. This gap may close over time, but maybe never level out if the non-residency person was never afforded the opportunities to increase scope of practice or get credentialed in procedures. So while not the only way to skin a cat, it's probably the most effective.  I'm not doing EM, but I have to imagine the situation is similar.       

 

/edited to add - I forgot to mention off-service rotations. These can also be an invaluable component to one's training.

[Boatswain2PA]

What type of residency are you in then Chris?

[cinntsp]

What type of residency are you in then Chris?

 

Hospitalist

[Boatswain2PA]

Sounds like it's a great residency.  I would have loved to be able to do one, but I'm too old, and there simply isn't a need for that in my environment. 

[gbrothers98]

I think this is understating the value of a residency/fellowship somewhat.  In addition to my patient care duties that include working with docs/PAs/NPs that like to teach, I have both a core curriculum and a specialty curriculum that includes hours of weekly lectures, sim labs, required case presentations and discussions, journal club, etc.  For example, my last lecture/lab for my core curriculum was on mechanical ventilation and respiratory failure. This week is u/s-guided central line placement.  Can these things be accomplished outside of a residency? Sure - PAs have been around a lot longer than residencies have.  However, there is a lot to be said for an environment that is built solely for your learning experience versus an expectation that you are there to make a practice money first and foremost.  It's a lot easier to focus on learning with time carved out for educational activities and I think this whole concept speeds up the learning process considerably.  I have to imagine if new grads 1 year out were compared(residency vs. not), there would be a measurable discrepancy. This gap may close over time, but maybe never level out if the non-residency person was never afforded the opportunities to increase scope of practice or get credentialed in procedures. So while not the only way to skin a cat, it's probably the most effective.  I'm not doing EM, but I have to imagine the situation is similar.       

 

/edited to add - I forgot to mention off-service rotations. These can also be an invaluable component to one's training.

You have me with that description.  

Now if this could be an readily available opportunity for the multitudes that seek and need it after graduation?

Until then, I think more often many new grads will be served best by on the job training in a supportive environment. 

GB PA-C

[Randito]

Wutthechris, I'm curious as to which hospitalist residency you are in?

[EMEDPA]

Now if this could be an readily available opportunity for the multitudes that seek and need it after graduation?

Until then, I think more often many new grads will be served best by on the job training in a supportive environment. 

GB PA-C

sometimes hard to find, especially on the west coast....