Solo UC with 1 year of FP experience?

[UpRegulated]

Graduated as an FNP last December, working in primary care since January.  I’ve learned a ton, and have been somewhat autonomous since day one, but with plenty of backup support. At first my SP didn’t want me taking any complex patients, but have done well enough that he now doesn’t care.  I pretty much take any new patients that walk through the door.  The problem is, volume is just too low to be sustainable.  It was projected that I’d be seeing 14-17 patients a day by now, most of which were expected to be from my SP’s overflow acutes.  I am seeing 6-8 a day, most of which are from my own panel – I’m getting very few of my SP’s acutes as projected.   At some point, I’m expected to turn a profit, but I just don’t see it happening, and 3 new FP providers have or will be coming into my area.

 

So…I am looking at two UC opportunities. One would require me to be solo all the time with backup via phone, and overreads on all my x-rays, nearest ER 10-15 minutes away (not affiliated with the clinic)., volume of 2-4 patients per hour.  The other would require me to be solo 1 day a week, and from 5-8p 2-3 shifts per week, but only 3-4 patients in 12 hours (it's a brand new clinic) to start. Doc onsite 8-5p M-F who supposedly loves to teach.  Unaffiliated nearby ER as well. Around 4 weeks “orientation” at both places.  Pay and benefits are very good at both places

 

The big question is, I’m not sure if I’m ready for solo.  I spent some time at an UC clinic during my NP training, and felt fairly comfortable with 75-90% of the patients as saw as a student, and I’ll have a year of PC under my belt by the time I start.  I have 1000 hours in the ER as an RN, and 2000+ hours in the ICU as an RN, but as an FNP I didn’t get an EM rotation.

 

If I devour a couple of good EM/UC books, brush up on procedures (I do some, but not a lot now), maybe try to squeeze in a bootcamp, and do the 30 days of orientation, is it possible I could be ready?

[EMEDPA]

if you can manage an emergent pt with minimal assistance by yourself (intubate, cardiovert, run a code, deliver a breech presentation, etc) for 10 min until medics arrive you should be ok. if you are not ready to run a peds code or crich an unstable airway right now you aren't ready yet. some folks are ready day 1 out of school, some never are. only you can answer that question. too many people think urgent care = ER services at 1/2 price. they are not always right. I do some solo UC shifts and in the last week have emergently transferred lots of folks for trauma issues, MIs, CVAs, ALOC, sepsis, etc.

[UpRegulated]

if you can manage an emergent pt with minimal assistance by yourself (intubate, cardiovert, run a code, deliver a breech presentation, etc) for 10 min until medics arrive you should be ok. if you are not ready to run a peds code or crich an unstable airway right now you aren't ready yet. some folks are ready day 1 out of school, some never are. only you can answer that question. too many people think urgent care = ER services at 1/2 price. they are not always right. I do some solo UC shifts and in the last week have emergently transferred lots of folks for trauma issues, MIs, CVAs, ALOC, sepsis, etc.

 

I doubt any of that occurs in these clinics/communities except perhaps very rarely. These are more walk-in/convenient care clinics.  Admin at both places has grilled me thoroughly about my skills, and never once did any of these come up.  In fact, one of the clinics doesn't even require ACLS or PALS (I have both) let alone the ability to do a crich.  Furthermore, they only have AED's, which would all but prevent running an ACLS code. 

 

At my FP clinic where I currently work on the other hand, we seem to have to call EMS every couple of weeks and out of four providers there, I am the only one with PALS and ACLS.  We have two physicians in that clinic, and only one would ever attempt an intubation, and he hasn't intubated a patient since his residency years ago.  

[Acebecker]

I have been doing UC for almost 4 years and as EMED said - it's possible that you'll need to manage a crashing patient who walks through the door and crumps while checking in.  I have not had that experience, but I have sent many many patients to the ER for "belly pain," "acid reflux," "I just bumped my head a little," etc. who turned out to have bowel perforations, MIs, and head trauma with LOC in LoLs on anticoagulants. 

 

I had never thought about the potential need to crich someone and thankfully I haven't needed to do so.  But yeah, that is something you may face. I have not had to, it *is* highly unlikely.  But mom brings a kiddo in for stridor and you bring them back and find out they swallowed a bouncy ball.  That ball dislodges during exam and Pt can no longer breath.  You aren't going to wait 10-15 minutes for EMS to show up...  You're going to grab a blade, an ETT, and get to work. 

 

It sounds like the second option might be better - the 3-4 pts in a day would be a good way to work yourself into the higher volumes and acuities. 

 

And yes, reading would be very beneficial.  I suggest "Minor emergencies: Splinters to Fractures," and the "Emergency medicine handbook." 

 

Good luck.

[winterallsummer]

Not to be rude or start Any arguments. But I don't think most PAs would be ready after one year and even less likely NP would be. I would recommend against it. Wait a few years then revisit. UC is becoming the McDonald's of medicine and they easily will hire someone new to save money. When you realize you missed cancer diagnosis, didn't refer that atypical appy to the ER, etc, they won't be there to defend you in court. And if the lawyer asks what made you think you could handle such autonomy so early in your career it will be hard to justify with an answer. I hear of some PAs doing solo on weekends but with close SP back up via phone and referring to ER when unsure. But my final answer is for the safety of your career I would advise against it.

[winterallsummer]

Addendum to above: I have heard of Pa doing solo EARLY in their career.

 

By all means once you have several years under your belt and you have been keeping up with reading lectures workshops etc you would be ready to do solo. We have at least two PAs on this form doing solo ER.

[EMEDPA]

if you are a former medic and comfortable with your skills it's not the crashing pt that is a problem, it's the atypical presentation of something that will look really bad in an hr or 2 but looks ok now that is a problem as a new grad if you don't ask the right questions.

working some urgent care shifts (granted 24 hr facility, rough neighborhood, locals think it's an ER) I have taken care of/stabilized/transferred far sicker folks than what PAs see at either of my trauma ctr jobs. several codes, several significant  traumas(GSWs, stabbings, etc), ODs too numerous to count, ditto pts with unstable arrhythmias, delivered a baby a few years ago, had an adult pt last year with epiglotitis from free basing cocaine, etc

this particular facility sees around 75-100 pts/24 hrs and transfers probably 10/day with 1-2 emergently. we have 24/7 PA coverage with a doc on day shift only as double coverage.

[winterallsummer]

Agree with above. It is not the terribly sick pt who you will get into trouble with. Those patients are easy to spot and call EMS for ED transfer.

 

It is the atypical insidious cases or early presentation of disasters that make solo coverage dangerous for the clinician early in their career. It is the pt with occult malignancy that you treat symptomatically twice and two months later is found to have malignancy that you missed. It is the early atypical L sided appy that you reassure and tell to see their family doc on Monday whose family sues when the next day that appy perfs. It is the asthmatic that seems to do well after a breathing treatment that six hours later decompensates from WOB you failed to appreciate and ends up intubated after subsequently going to the ER after you sent them home. Or the elderly liver patient whom neither of you know is a cirrhotic that you send home with an antibiotic and later has fulminant sepsis and decompensates at home. Think you get my point here... These cases pose a much higher medicolegal risk than someone who obviously should've gone to the ER not UC. Those patients are easy to recognize and transfer. So just because you can or cannot trach someone etc is not the only issue here.

[UpRegulated]

if you are a former medic and comfortable with your skills it's not the crashing pt that is a problem, it's the atypical presentation of something that will look really bad in an hr or 2 but looks ok now that is a problem as a new grad if you don't ask the right questions.

 

Not a former medic and honestly, crashing patients are not my concern as much.  It's what you (and winterallsummer have said), it's the atypical.  If anything, I tend to overthink, do too thorough of a history, order too much, etc. which is a reflection of my lack of of experience (and perhaps my personality and background).  Then again, my SP is the same way and he is 5 years out of residency (and was chief resident). :)  

 

But let me ask you this.  Are you overestimating the skills required for a walk-in environment given your significant EM experience and the lessons you have learned over the years?  There are always zebra's, and per what you have mentioned, many FP physicians could easily miss things in an UC/walk-in setting and/or not be able to manage emergent patients in an outpatient setting, esp. if it requires the utilization of the skills you enumerate.

[UpRegulated]

It is the pt with occult malignancy that you treat symptomatically twice and two months later is found to have malignancy that you missed. It is the early atypical L sided appy that you reassure and tell to see their family doc on Monday whose family sues when the next day that appy perfs. It is the asthmatic that seems to do well after a breathing treatment that six hours later decompensates from WOB you failed to appreciate and ends up intubated after subsequently going to the ER after you sent them home. 

 

But isn't that primary care?  You don't dial up $5000 worth of diagnostics for everyone with LLQ pain.  Does that approach cause you to miss 1 left sided appy in 10 years?  Maybe.  But you use clinical judgement, empirically treat, and then follow up.  That is the essence of primary/outpatient care, is it not?  It is forming a hypothesis, then testing it.

 

The occult malignancy?  You don't dx that in a walk-in clinic.  That's a primary care thing.  That is true with any malignancy, and certainly an occult one.  And in 10 months, I've "caught" 4-5 malignancies in PC, BTW (still waiting on definitive path reports on the 5th).  

 

That left sided appy?  How rare is that? Extremely rare.  In a walk-in clinic, an acute abdomen goes to the ER, no?  You can't definitively figure out what side their appendix is on w/o a CT.  The decompensating asthmatic?  Do you not treat in outpatient until improvement/resolution, then discharge with instructions to return or go to the ER if sx return or worsen?  The examples you mention are diagnosed empirically, which is at the heart of outpatient medicine.

 

Take the 2 yo with fever of 103, normal CBC, no physical findings that is playful, alert, interactive.  Could they decompensate in 2 hours?  Heck yeah.  Do you send them to the ER?  Probably not.  You act empirically with good instructions to the parent.  Empirical treatment.

 

I'm not trying to be contrary, seriously.  I'm truly just trying to learn and understand and evaluate where I am professionally.  I think I get what you are saying in that what seems like a simple X, Y or Z is not always that.  But doesn't everyone both catch and miss zebra's?  And even if it isn't a zebra, but an unclear presentation (e.g. pediatric fever of 104 of unknown origin w/moderately elevated leuks, 20 YO with sudden onset DOE) for which you are not sure. Do you not send to the ED who has the facilities and diagnostics to r/o a life threatening condition?

[EMEDPA]

often it is the simple question that is missed that ends up in the bad dx/outcome. one of my newer pa partners asked me to eyeball someone they felt ready to d/c just because "something was off" last week. asthmatic, out of inhaler, got better with a few newbs, given steroids, ready to d/c. sounded ok, looked out. " so, what happened the last time you had an attack like this". "I ended up intubated for 6 weeks in the ICU". oh....., let's watch you a bit longer." sure enough, 10 minutes later crashing, required high flow 02 with inline albuterol, then bipap, almost got intubated.

if your clinic is truly walk in fp/ambulatory only, it's less of a problem. if folks mistake it for an ER alternative you will get walk in badness on a regular basis. it's why I work there. most FP would bore me to tears.

[EMEDPA]

if a doc misses something "it's a difficult case". if a PA/NP does "they should have known better". the sooner you learn that, the better...

[winterallsummer]

UpReg. I appreciate your reply and by no means do I take offense. Yes all of those things can and do happen in ERs and family Med clinics staffed with many physicians. However in court I think the patient who saw you, and you had your SP glance at because something was funny but you couldn't tell what (even if your SP also missed it), are more defensible. Also your clinic may be directing the "bounce backs" or toughies to your SP although I am not sure. If you go to court (God forbid, I am merely stating theoretically for anyone in this scenario) you better count on the jury shaking their head when they learn after only one year you felt confident enough to go it alone with no back up and minimal chart review. My point is not just that without an attending or senior APP to rely on you will miss diagnoses. My point is from a medicolegal standpoint that if you miss these diagnoses working solo after a year of experience you will be eaten alive.

 

I was actually offered a solo UC job right out of school. I ended up going elsewhere ER. Just looking out for you here.

[DogLovingPA]

I've been working in UC since graduation (2.5 years now) - we are always staffed with 1 PA/1 doc.  At this point in my career - some days I go the entire 12 hour shift and never ask for a second opinion on a patient, etc.... other days I may ask them to put their eyes on 5-10.  It all just depends on what walks through the door.  This will also vary by your prior experience as some complaints that I may not feel fully comfortable with may be your area of expertise.  My level of comfort with certain complaints also changes on a monthly basis as my experience grows (my current least favorite cc: dizziness). 

 

I like the CYA part of having a doc around right now and being able to document that I discussed patient x with them or that they also examined the patient.  Yes, as the time has gone by I utilize this less and less as I learn, but it's still nice to have right now in my career.  Could I handle the UC I work at solo?  Probably, 80% of the time right now..... but I think I have learned so much more as part of a team, and like being part of a team at this point. 

 

As for those crashing patients - whew, ya'll work at some scary urgent cares.  We are more FP acute care.  Yes, I have sent countless patients to the ER.  As for true life threatening emergencies - we've had 1 code and a handful of anaphylaxis, STEMI's, falls with bleeds, etc.  Those are easy (former medic)... it's those darn rashes that I still can't figure out ;-).   And as I work with 90% FP docs.... I can guarantee not one of them would ever crich someone.  A couple are even scared to do digital blocks (!)

 

But the biggest point is that I like working alongside another medical provider, especially so fresh in my career.  Even on days that I may not ask them a direct patient care question/second opinion we are constantly trading stories, things we've learned, showing off interesting rads we've taken, etc.  They may ask me to go look in on a patient they have.  As I have multiple SP's and they all practice differently - every shift I learn something new.  This has been invaluable to my growth and experience as a PA.  Every day I realize more and more how much more there is to know.  If I had worked alone, there is so much that I would have never learned.

[UpRegulated]

UpReg. I appreciate your reply and by no means do I take offense. Yes all of those things can and do happen in ERs and family Med clinics staffed with many physicians. However in court I think the patient who saw you, and you had your SP glance at because something was funny but you couldn't tell what (even if your SP also missed it), are more defensible. Also your clinic may be directing the "bounce backs" or toughies to your SP although I am not sure. If you go to court (God forbid, I am merely stating theoretically for anyone in this scenario) you better count on the jury shaking their head when they learn after only one year you felt confident enough to go it alone with no back up and minimal chart review. My point is not just that without an attending or senior APP to rely on you will miss diagnoses. My point is from a medicolegal standpoint that if you miss these diagnoses working solo after a year of experience you will be eaten alive.

 

I was actually offered a solo UC job right out of school. I ended up going elsewhere ER. Just looking out for you here.

 

Thanks for your (and emed's) feedback.  I too was offered an UC position right out of school and would have been given 3-6 months-ish to get my feet wet before I went solo.  I turned it down and went primary care and I'm glad I did.

 

To address another thing brought up earlier in this thread, on average I don't think NP training is as good as PA training.  Having said that, a rock-solid RN that makes the most of graduate training I think is as good (or even better in some cases) right out of school.  I don't fear my training, I fear my relative lack of experience.  I've caught a number of things that have "wowed" the other providers I work with (even things they have missed, and 2 are docs) and even caught an SIADH as an ICU RN, but I do have one near miss in my 11 months as an NP.  I am very confident in my skills given my experience and training, yet cautious if that makes any sense.  There are simply things I haven't seen.  Yet I feel somewhat good at managing well even in situations when I don't know what's going on for sure, which has/does/will happen to us all.

 

I've still have a ways to go before I decide.  I have a contract in hand from one place, and expect to get one from the other in the next couple of weeks, so I have a little time to think.  My focus throughout the process will be honing in on the details of how much backup I have, and if I can extend my "orientation" time - one place seems open and flexible about that.  

 

One place seems open and accommodating about the orientation period (perhaps it could be extended a bit?) and it is also the place that I would be solo only half the time or less (but with backup call and rapid rads overreads when solo).  It's also the place that supposedly that has a doc that loves to teach the PA's and NP's and the place that is slower, possibly meaning that the 1/2 time I am there could be getting even more supervised training.

 

If I can push my orientation to 2-3 months, get in a boot camp (which I definitely would do), devour a couple of books, and then have on-site backup and additional training 1/2 the time, I'm inclined to do it.  If there are type A and B personalities, I am an A- or B+ :)  I am bold and confident, and love a good challenge, but somewhat tempered with caution and have decent sense of knowing what I don't know. 

[UpRegulated]

I've been working in UC since graduation (2.5 years now) - we are always staffed with 1 PA/1 doc.  At this point in my career - some days I go the entire 12 hour shift and never ask for a second opinion on a patient, etc.... other days I may ask them to put their eyes on 5-10.  It all just depends on what walks through the door.  This will also vary by your prior experience as some complaints that I may not feel fully comfortable with may be your area of expertise.  My level of comfort with certain complaints also changes on a monthly basis as my experience grows (my current least favorite cc: dizziness). 

 

I like the CYA part of having a doc around right now and being able to document that I discussed patient x with them or that they also examined the patient.  Yes, as the time has gone by I utilize this less and less as I learn, but it's still nice to have right now in my career.  Could I handle the UC I work at solo?  Probably, 80% of the time right now..... but I think I have learned so much more as part of a team, and like being part of a team at this point. 

 

As for those crashing patients - whew, ya'll work at some scary urgent cares.  We are more FP acute care.  Yes, I have sent countless patients to the ER.  As for true life threatening emergencies - we've had 1 code and a handful of anaphylaxis, STEMI's, falls with bleeds, etc.  Those are easy (former medic)... it's those darn rashes that I still can't figure out ;-).   And as I work with 90% FP docs.... I can guarantee not one of them would ever crich someone.  A couple are even scared to do digital blocks (!)

 

But the biggest point is that I like working alongside another medical provider, especially so fresh in my career.  Even on days that I may not ask them a direct patient care question/second opinion we are constantly trading stories, things we've learned, showing off interesting rads we've taken, etc.  They may ask me to go look in on a patient they have.  As I have multiple SP's and they all practice differently - every shift I learn something new.  This has been invaluable to my growth and experience as a PA.  Every day I realize more and more how much more there is to know.  If I had worked alone, there is so much that I would have never learned.

 

LOL. Dizziness and rashes.  I hate both too, esp. dizziness.  Digital blocks?  Love 'em. :)