Guest ERCat Posted October 25, 2015 Share Posted October 25, 2015 Excuse my barrage of posts this week. Just started a new job and have millions of questions... I started a position in a rehab doing medical (not psychiatric) care. I am "per diem," covering for the full time PAs when they can't work. I am responsible for doing H+Ps on new patients and medically clearing them for treatment, and then taking sick call for residents. To be honest I feel in over my head -- I am responsible for knowing the ins and outs of inpatient management and knowing how to "detox" patients (protocols were given but otherwise nothing else). Some of these patients are super sick. I was told today that I would get a few days of shadowing the PA, and would then be on my own as they "can't afford to pay two providers." That would be fine except, the only medical provider for the entire facility is the PA who happens to be working… there are NO docs in the medical side, only PAs and they only work one PA at a time. Therefore when I work I would work alone... No one to bounce ideas off of or check in with. I am very uncomfortable about this, especially in this inpatient setting. I could maybe handle family medicine or urgent care more autonomously but...I mean, patients are withdrawing from alcohol and benzos... They come in with all sorts of issues I don't fully understand as a new grad. We aren't really trained in addiction medicine in PA school. My "supervising physicians" are basically 3-4 psychiatrists... And I am not even doing psych; I am doing medical...To be honest I haven't met any of them and have been given the message from one of the PAs that if I ask a question they will say "I don't know, I am a psychiatrist, and I am not in charge of medical." I haven't even spoken to them and if I texted one of them I assume the text back would say "Who is this?" I guess I could text one of the PAs but a) it isn't their responsibility to be my supervising physician and b) MALPRACTICE ("I consulted with my fellow PA" probably wouldn't hold up in a court). I kind of want to talk to my boss and let her know that I don't feel the situation is appropriate. I feel that a) as a new grad in this complex environment I shouldn't be a solo provider for at least a few months (not a few days) and b) if they are going to throw me to the wolves they need to provide really great resources and a really great SP who will be available at all times to answer my questions. Am I being idealistic? Because if I am not I need to find a way to get my message across. If they don't take me seriously in terms of "I need more help" maybe they would take me seriously in terms of "this is not a great situation for any of us legally." Are there any rules anywhere that a psychiatrist couldn't oversee my work as they are not doing internal medicine? I need to try to convince my employer that the situation is not ideal. Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted October 25, 2015 Share Posted October 25, 2015 This is no good for a new grad. Honestly, its dangerous if you truly have that little support. You said this is per diem.... Do you have a full time gig? If so, drop this. Even if you don't.... I would really consider if this is appropriate before I started. Link to comment Share on other sites More sharing options...
Guest ERCat Posted October 25, 2015 Share Posted October 25, 2015 I tend to agree. It is hard to distinguish between first job nerves plus my obsessive personality, and this being a bad situation but overall, as a new grad to be expected to take care of all medical issues for the entire facility with no support or oversight especially in light of all these complex issues they bring in (suicidal ideation, alcohol withdrawal, complex medical issues -- we had a patient with paroxysmal nocturnal hemoglobinuria the first day... How, as a new grad, would I feel comfortable managing that and even knowing to schedule him his IV infusion?) Not sure how to broach this with my boss. I feel stupid and a little bit guilty for speaking up because they desperately needed someone to cover their shifts -- I am already scheduled to cover a one day shift and then a seven day shift. The one day shift I could swing but seven days? That's long enough to miss something or make an error and not have it caught by the other PA. In the interview I definitely teiterated multiple times that I am a new grad and would need more support, and they assured me that I would have my hand held for a long while before I was expected to do anything on my own. By that I thought they meant weeks or months of training and I thought at the very least I would actually have access to a real SP. But one of the actual PAs working there told me day one "This is actually an autonomous position." I feel bound to miss something -- either from a medical aspect or even just from a responsibility aspect. Being the medical provider for the whole facility involves a lot of different tasks... Link to comment Share on other sites More sharing options...
Guest ERCat Posted October 25, 2015 Share Posted October 25, 2015 And yes - I have a full time job Set up but am still waiting on credentialing so I picked this job up to supplement, not knowing the level of responsibility it entailed... Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 25, 2015 Share Posted October 25, 2015 Sink or swim. This is a dangerous setup for a new grad. Now, if you truly have someone in active DTs, they belong in the ICU until stabilized and not on the psych floor. Who is your supervising physician of record? If it is in fact the psychiatrist then they ARE responsible for mentoring you. If they abdicate, then so do you. Truthfully the PAs should have medicine SPs as backup. I don't know how the hospital bylaws were interpreted to bless this setup which does sound foolishly risky. For an experienced medicine PA with quite a few years of managing sick people under her belt, this wouldn't be such a challenge, but you are a NEW GRAD. This first few years out in practice IS your residency. You deserve better. Sent from my SAMSUNG-SM-N910A using Tapatalk Link to comment Share on other sites More sharing options...
Guest Paula Posted October 25, 2015 Share Posted October 25, 2015 And yes - I have a full time job Set up but am still waiting on credentialing so I picked this job up to supplement, not knowing the level of responsibility it entailed... How long until your are credentialed at your full time job? Your situation for the per diem is not good and the employer is not doing right by you and putting all of you, your patients, and the facility at risk for a lawsuit............ I agree with prima donna.......If you had experience in IM/acute care/or hospital medicine for several years you probably could handle it.......but not now as a new grad. I would decline the job and tell the administration they have not provided adequate back up or direction on who you call for a consulting physician to discuss your treatment plans. Link to comment Share on other sites More sharing options...
Houstonian Posted October 25, 2015 Share Posted October 25, 2015 I agree-you need to resign this position. Don't know what state you are practicing in, but generally speaking if something is outside the scope of practice of your supervising physician, it is also outside your scope of practice. Look very, very carefully at your states PA practice laws. I'll bet you'll find serious violations regarding your practice. In the state where I work, the supervising physician is responsible for ensuring that the medical responsibilities assigned to the PA are appropriate to the skills and experience of the physician assistant. THIS IS NOT YOUR FAULT. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 25, 2015 Share Posted October 25, 2015 PLEASE get out quickly for your integrity. This situation is not your fault but you certainly should not be a part of it. It sounds to me like a private detox hospital in a for profit situation taking advantage of our miserable mental health situation in the US and doing whatever it has to however it has to in order to keep the medical billing flowing. If your SP is an Internal Medicine Doc then the PA shouldn't be seeing kids or peds since IM doesn't do that. If your SP is an interventional radiologist then the PA doesn't do Family Practice, etc. If a board certified Psychiatrist doesn't want to deal with HTN, DM, ulcers, thyroid, liver damage, etc then that facility should have a Board Certified IM or Hospitalist on the books as their Inpatient Medical Director to supervise the PAs. Or, someday in the future we, as PAs, could be independently functioning, but I digress. This is not a good job for a new grad under any circumstances. I know it pays some bills but it could lead to a lifetime of distress when something goes wrong and something will go wrong -- not a matter of IF but WHEN. I feel for the patents in this facility because they have big problems - the company running this place is doing them an injustice by not properly staffing but continuing to admit. My very old 2 cents…... Link to comment Share on other sites More sharing options...
Guest ERCat Posted October 25, 2015 Share Posted October 25, 2015 Thanks, guys. I agree with all of you. :-( The facility has been under fire for having a few patients die in the last year… It's easy to understand why. Not only am I dealing with the lack of supervision and direction, it seems like half of the employees don't even know what they're doing and communication is lacking between all departments. I had a bad feeling during the interview, but I was later on pulled in by the fact that they really seemed like they would be caring and supportive and understanding of the process involved in being a new grad. THEY used the term "hand holding" describing the level of supervision I get so of course that really put me at ease. This is such an embarrassing situation… they've paid me for a week of training so far… So I feel guilty but… I guess there's actually no way I could've known it was like this until I started. I feel like the only reason I would stay is if they kept me on as a provider who is there to help do history and physicals alongside the other provider when they happen to have a lot that day. But even then, I just feel risky because of the lack of oversight and communication… Something I might be responsible for might slip through the cracks because of the lack of checks and balances and then I would be liable or a patient would get hurt. As far as medically managing these patients I'm just not comfortable doing it alone. Any words of wisdom about how I should approach this? I feel like I don't just need to tell them that I'm uncomfortable but that what they are doing is downright irresponsible and they probably shouldn't hire a new grad again. I kinda feel angry. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 25, 2015 Administrator Share Posted October 25, 2015 A week of training invested into you does not obligate for you to reciprocate by practicing in any way that is illegal or unsafe. The employer is the one who has the obligation to know this, and it's not your fault they paid you. As far as how to approach it, the PAs scope of practice is limited by the SP's. Make sure you have an SP who can do everything you are being asked to do, and verbally confirms to you that he or she will be available to you each hour that you are working... and if you don't, you don't work. If you have to say "I cannot work due to the lack of appropriate supervision", then you do. It's a pretty black or white thing. Don't fall for a guilt trip, and if they try to get you to work despite not having a good SP, get that in writing... and STILL don't do it. You just want to have ammunition in case they try and raise problems with you later, that they did in fact ask you to exceed your SP's scope of practice. Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 25, 2015 Share Posted October 25, 2015 Download your state practice laws and print them. Read them and understand them. Highlight, underline, etc. All the ways in which this practice situation violates them. Then write a well-crafted and referenced letter of resignation from the voice of a new and well-meaning PA who truly didn't know how risky the position was until you had been there training for a week. Tell them what you told us, that you worry for patient safety and for your own license and that you cannot in good conscience continue the position without strong MEDICINE backup. It may turn out the other PA finds herself in a dire position but that's not your fault. What they really need is to have their medicine residents moonlighting to cover hospitalist duties if they don't want to invest in a true PA-physician team practice. I was once told by a favorite psychiatrist attending "only bad psychiatrists forget their medicine training". I used to believe this to some extent, but patients these days are so sick. When you add up lifestyle disease and polypharmacy and throw in acute detox, then add poor communication and lack of teamwork, you have a recipe for disaster. Take care of yourself first. That's the only way you can take care of others. Sent from my SAMSUNG-SM-N910A using Tapatalk Link to comment Share on other sites More sharing options...
Guest ERCat Posted October 27, 2015 Share Posted October 27, 2015 Update -- I did more research on the laws in my state and they clearly state that the physician and the PA must be working within the same scope and doing the same kind of medical tasks... So the psychiatrist as SP thing truly doesn't hold up. That aside, there's no reason a new grad should ever be in charge of "all medical issues" for a facility of high risk patients who are on multiple psych meds and have serious mental health issues and other medical conditions, without a medical doctor directly supervising them and overseeing their work. The fact that I as a new grad was expected to take care of "all medical issues" without any physician doing the same is just weird, and clearly the patients' best interests were not at heart. I could see myself having several questions an hour and scrambling to get a hold of whatever psychiatrist was in that day hoping to get some kind of answer, or running into a major issue and needing a doc to take over but it would be a "too bad, you're the medical provider" situation. Yikes. So...after taking your kind advice I resigned from the position this morning. And I feel so much better. I am OK with turning down 55/hour as a new grad and instead being poor -- I want to start off my career with integrity and professionalism and most of all, the utmost concern for patients. I appreciate all of the help. You all have gotten me out of more than a few pickles as I start to navigate the world as a brand-new PA, and I really appreciate it. Link to comment Share on other sites More sharing options...
primadonna22274 Posted October 27, 2015 Share Posted October 27, 2015 Good luck. Any time you sleep better after making such a decision you can be sure it was the right one. Take care. Sent from my SAMSUNG-SM-N910A using Tapatalk Link to comment Share on other sites More sharing options...
winterallsummer Posted October 28, 2015 Share Posted October 28, 2015 You did the right thing resigning. Also unless you are in a very saturated state that is not a good hourly wage for per diem. Draw from your experience and take some time to de stress while you await credentialing at your new job. Link to comment Share on other sites More sharing options...
sas5814 Posted October 28, 2015 Share Posted October 28, 2015 Let me share a quote from Gen George Patton... fatigue makes cowards of us all. I remember that because I thought about giving up in PA school more than once and a friend of mine said that to me. I was in the Army program so not only were we doing all the didactic work but we had all the military stuff to deal with as well starting with PT at 5:30 every morning. When I got to clinicals it was a total change. I enjoyed my rotations and had great relationships with some great teachers and mentors. Would I do it again if I had to start over now? Probably not. Did it change and improve my life in many meaningful ways including improving things for my family? You betcha. Hang in there. Things only get better. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.