How to become a "great" Emergency Medicine PA.

[Superfundee]

Hi I've been lurking some time reading some previous post on student doc and PA forum, and I have come across many topics on good doc bad doc, better MD than DO, good PA, bad NP..etc.

 

So what exactly does this mean? How about those who practice Emergency Medicine? Being a great EM doc or Being a great EM PA??

does it mean you are House MD who lacks bedside skills?

does it mean you are capable of making quick decision and right diagnosis?

does it mean you have ADHD, risk takers?

Or does it mean you are hard-worker w/ good interpersonal and communication skills?

Does it mean that you are just well-rounded person?

OR does it mean all of the above?

Or what about those top-notch clinician turn into worst clinician (real story of a surgeon) Best clinician can turn into bad clinician.

 

Well, we all strive for the best. None of PAs here want to be just "okay" PA. Sometimes "good-enough PA" maybe okay to some but you don't want to admit to yourself that you are a mediocre clinician.

I'm bringing this up because I want to be one of the good ones or even great ones.

 

My weakest point is sometimes, when everything goes well- you diagnose difficult cases, order right med/labs/imaging, work fast and efficiently plus get along with all nurses and doc, receive tons of compliments from your co-workers and physicians, suddenly you make stupid mistake.

I think there's this fluctuant cycle in my performance. 2-3 months of good work, a few stupid mistakes... then the cycles repeat

 

Just yesterday that mistake was done when I was working with this one ER doc who is extremely nice until you make mistake (such as not telling one important history when presenting a case; yes that is bad) This one particular ER attending happened to be walking around, then she sat next to me, we chit chat and laughed about something, then suddenly she ask me "so what you got?"

 

Case: 62 year male patient with CAD w/ recent stent 5 days ago, HTN, HC c/o new different type of "chest pressure" on and off for 4 days.

associated with a deep breath w/ brief sob. worsening with lying down and better with sitting up. He also noticed some black stool this morning.

no etoh abuse no unusual recent stress, no tobacco hx (never), n/v, fever or chills...

 

VS: normal BP, HR about 79 sat 98%, afebrile

on exam: diffuse anterior chest wall tenderness to palpation and guag negative

Chest/lung: RRR clear

abdomen: NTND

labs/imaging:

ekg normal w/ no signs of pericarditis,

trop x2 neg, chest neg. cbc/chem normal

 

So I figured is this pericarditis or just costochondritis?? I wasn't suspicious of PE at all.

 

Prior to presenting to case ER attending, pt's cardiologist showed up in the ED telling me that the patient has been taking prednisone recently for the last 2 weeks for possible temporal arteritis. I went to the patient, re-examined and pt told me now he still has chest pressure with now new "stomach cramps" and not heart burn.

Hmm,so I was thinking ' but why his chest is so tender?? I have my long hx of heart burn with PUD, acid reflux, GERD but chest pressure with chest tenderness?'

It really blurred my decision making process to think outside the box at that time. so I waited for my attending to come check and presented the case and completely forgot her that pt has been taking prednisone recently.

 

She comes back after examining patient, and said "well i think it's stomach, give pepcid." So I ordered maalox and pepcid IV

Few hours later, pt felt better with maalox and pepcid. I felt like an idiot. I knew prednisone can cause gastritis and have seen some chest pain who turned out to be gastritis, but this one I let my inherent characters just let loose (ADHD, lack in detail and impatience).

Oh well but usually patient tell more story when the second time attending checks patient!

 

However, this ER attending was sorta irritated and asked me "You did not tell me about that history of prednisone he took for temporal arteritis!"

So what is this? does this mean I'm a bad clinician? why is that this only attending gives you hard-time? I have only 21 months of PA experience still.. I felt horrible although I did NOT appreciate she expressed her in a way without giving me constructive criticism.

Isn't it great learn from self-reflection when you make mistake? I tend to self-criticize too much sometimes but I learn. I'd rather recognize my own mistake and learn than somebody blaming in not so diplomatic way.

 

We all have made so many mistakes in our life and in our practice, but I wonder if we ever reach to a point we are completely perfect never-make-mistake clinician? OR do you have to be 100% vigilant, thorough, completely anal at all time to become a great EM PA?

What can be done to improve yourself to be a great EM PA? In the ED, there's tons of factors that can blur your decision making process- the noise, pt's atypical presentation, your mood at that moment, how busy it is...etc.

 

 

 

Well back to ACLS instructor course prep.

[EMEDPA]

a 62 yr old with a complaint of black stools gets a rectal exam and gi workup. live and learn.

[Superfundee]

of course rectal was done: no black stool. guag neg.

[EMEDPA]

not meaning to harsh on you but it's guaiac, not guag.

http://en.wikipedia.org/wiki/Stool_guaiac_test

tough word to spell. I usually just say and document"heme neg. rectal exam".

[EMEDPA]

 

 

What can be done to improve yourself to be a great EM PA? .

 

just keep at it. consider a residency if that is a viable option but the main thing is keep at it. do lots of cme. join sempa and go to their excellent yearly conference. take atls/pals/difficult airway/apls/fccs/etc courses.

I don't think I am a great em pa. good, sure. better than avg? probably.

RCDavis is a great em pa. I want to be him when I grow up.

[Superfundee]

Thanks I knew it was misspelled. It's hard now everything is in electronic. All I do is click that box.

Anyhow I figured everyone understood what I meant in this informal forum. As ESL person, I hope no one judge.

[pawag]

There are days I feel like a great EM PA other days not so much. Press on and do as above. Through these experiences we (hopefully) become better at what we do. This can be said about every job. Let this bug you but only to the point of being a brief learning experience that will help another patient down the road.

[Superfundee]

There are days I feel like a great EM PA other days not so much. Press on and do as above. Through these experiences we (hopefully) become better at what we do. This can be said about every job. Let this bug you but only to the point of being a brief learning experience that will help another patient down the road.

 

Couldn't have said better. I think we have to be thick skinned to remain in this field.

[Superfundee]

just keep at it. consider a residency if that is a viable option but the main thing is keep at it. do lots of cme. join sempa and go to their excellent yearly conference. take atls/pals/difficult airway/apls/fccs/etc courses.

I don't think I am a great em pa. good, sure. better than avg? probably.

RCDavis is a great em pa. I want to be him when I grow up.

 

Thanks. I actually want to be EMEDPA when I grow up. :) Although I may end up applying DO program when I become 40.

I work at a big well-known academic hospital where we have huge EM residency program. PAs there have plenty of opportunities to learn, see resus patient and do critical procedures. We do everything what EM residents do here. I also lecture yearly CME PA conference in Manhattan, but that does not say much about your clinical skills overall.

 

However I think everywhere you go, there's always 1-2 ED attending bothers me if you ever make mistake. It's hard to please all attending's working style which is not very easy and sometimes blurs my own medical decision making.

[RetNavyPAC]

". . . fluctuant cycle in my performance. 2-3 months of good work, a few stupid mistakes... then the cycles repeat"

As long as the mistakes aren't the same ones. . .

 

It wasn't clear from your note if the cardiologist was called to the ED or was just strolling through, but in my opinion, any chest pain (new or different or same) five days after a cath & stent mandates at least a cardiology consultation to get his or her name & note on the chart opining that this is not cardiac etiology.

 

Yeah it could be prednisone-induced gastritis but, with his PMHX & recent PCI, that's a diagnosis of exclusion in my book.

[ventana]

good luck on learning the EM world - I tried but the facility I was in was horrible and the attendings had zero time to teach - even as an experienced PA with a broad based background in urgent care, internal medicine, interventional radiology, and chronic pain I still found it hard to swim with out a good mentor..... then one day that known bad doc just ripped into me on a highly confusing patient that I was asking for help with (in front of the entire ER). I will never again let someone talk to me that way. He made himself feel larger then life by putting me down (he is actually one year younger then me but a pompus jerk) but was a great life lesson for me.

 

For me I loved the ER and the challenges presented there - but so much of it is based upon the facility - I saw my ER turn many (likely over 100!) chronic pain patients into fulll blown addicts by always giving them 50 of benadryl and 2mg dilaudid x2 for stupid pain complaints..... in spite of trying to talk to the providers the management was purely focused on production and cleaning house.... even the doc's had a very tough time actually doing the right thing by their patients and many have left.... The PA hired to take my place (20+ yr highly experienced ER PA) lasted about 6 months before he up an quit....

 

Moral of this big long story..... if you want to be great, surround yourself with greatness - if you want to stink, surround yourself with crap.....

 

 

the more general advise - r/o the things that kill your patients, then look for the common things, then look for the zebra's - always remember the zebra's are out there and if they are not on your Ddx you will never find one.... on this thought - always have a Ddx of atleast 5 things, and always read read read to keep up to date on things...

 

time time time is what you need in a good experience place

[Just Steve]

I heard rumor that the last perfect person could walk on water and eventually got nailed to a cross. I'm not sure if I buy the whole story of that perfect person, but a lot of people talk of that same rumor.

 

When you get to work, check your feelings at the door. Especially in the ER. You can give compassion and show care for your patients and co workers, but be prepared to catch some heat (be criticized for mistakes) and learn from it. As an attending, they have quite a bit of responsibility and they want to know that their team is on point (performing at a top level)

 

"However, this ER attending was sorta irritated and asked me "You did not tell me about that history of prednisone he took for temporal arteritis!"

So what is this? does this mean I'm a bad clinician? why is that this only attending gives you hard-time? I have only 21 months of PA experience still.. I felt horrible although I did NOT appreciate she expressed her in a way without giving me constructive criticism."

 

What sort of constructive criticism would you like to receive? You are already acutely aware of where you made your mistake and I am quite positive that you know how to prevent that mistake in the future. This isn't a matter of not performing up to par or a mistaken diagnosis where some insight how to approach that situation can be beneficial...this is simply an unintentional omission. Do want a lesson from your attending in how to read from your notes? That would seem awful patronizing to me.

 

Roll on with your head up high. Everyone goofs. People with a bazillion years in any line of work still makes mistakes. It bears repeating from the previous posters...don't repeat the same mistakes. The moment you think you have everything dialed in perfect and are above reproach is the moment your next mistake kills someone. Approaching patient care with a healthy dose of due diligence and determination not to repeat mistakes is a prudent way to proceed.

 

If you get rattled by a little bark from an overworked attending perhaps it may be time to take a vacation and unwind a bit. Working in a pressure cooker (high intensity work setting) will cause anyone to crack. Take time to ensure you unwind and shake off the stress of work. Exercise, travel, family time, meditation, worship..whatever it takes...take care of YOU first.

[Superfundee]

Thank you for all your descent advice and input.