Just waiting for a "it's probably nothing"-fast track disasters

[ventana]

The thread "it's probably nothing"-fast track disasters scares the living crap out of me!

 

The problem that I am facing is that this is a COMMON occurance in my local ER Urgent Care and they do not get caught......

 

Why?

 

The local ER seems unable to hire anything but new grads - yup you guessed it - NEW GRADs working in a high volume pressure cooker with minimal support. I have seen patients d/c home that I sent for a DVT R/O or PE R/O that never had a work up for that item - I have talked to the PA's on the phone and the common answer is "geez I didn't think of that". This is NOT the PA's fault, they are newer PA's and young and wet behind the ears. Problem is that they really suck at their jobs. IE IDDM with a typical viral syndrom of 2 days length, normal exam except for some redness of the throat - no swelling, strep never tested (swab got lost) no culture done, fever to 101, treated with Rocephin and keflex and Prednisone 40mg x 5 days (but at least the PA told the patient his BS might go high from the pred and if it do to see PCP) the throat was "sore" per the patient but no exudates, soft palate petechia, no cervical nodes and had A TON of sinus symptoms. I saw him 3 or 4 days later and his BS was 400+, he still has ST, fever broke a few days before, was coughing, myalgias, arthalgias.......... IT WAS A VIRAL INFECTION and this ER PA had used a broad spectrum huge gun ABX, then prednisone (which is only used for mono or dangerous tonsilar swelling - of which he had neither) Now the patient is pissed and asking me what to do as he 'should' be all better from teh ABX - I get stuck holding firm with the viral Dx, explaining the crappy care he got, counseling on the use of ABX for a viral infection, and trying to calm him down on his BS.

 

I am not good enough 'friends' with the ER director to bring this up - my doc's just say the ER sucks and they would never go there

 

How do we get ER directors to realize that $80k for a new grad is not a deal when the perform horrible medicine and the doc's never do any case review - the ER is to busy and the ER doc's just seem not to care (I have called down and spoken to the SP fo the ER PA's and they just don't care)

 

 

sorry for my rant - but it is just giving PA's a bad name......

[physasst]

You have to be careful with judging another providers care from 3-4 days earlier. You are relying on a patient report (an unhappy patient I might add) and you are second guessing what these other providers are doing. Rather than rant, perhaps try to set up some continuing education for this group.

[David the Nome]

I'm a new graduate EM PA in exactly the situation described above. Needless to say, it sucks-and I hate going into work everyday. I work half time in urgent care (unsupervised) and half time on the main side on nights (rotating charts with the MD-whatever is up next, I see). I was promised three months of training prior to starting but was only given two days of EMR training, then told to go work. I know i can't handle the complexity of these patients as a new grad. And in the urgent care, I often wonder how much I am missing.

 

ANother issue is, when actually working with a doc, they are to busy to really ask any questions-so no learning takes place and no feedback is provided. For example, if i ask the doc to look at an ECG, they may glance at it for a second and say "it looks fine"....or something along those lines. It makes me sick because I know that at this point in my career I am not able to provide the quality of care that patient's deserve, and am in constant fear of making mistakes and missing things.

 

Though I like EM, I find this situation unacceptable, so next week I'll be interviewing for two other jobs. In EDs with little physician oversight, either hire experienced PAs or actually invest time into training the new grads. Apparently, the department I work at has had a huge PA turnover over the past several years, and still they have not learned.....

[ventana]

You have to be careful with judging another providers care from 3-4 days earlier. You are relying on a patient report (an unhappy patient I might add) and you are second guessing what these other providers are doing. Rather than rant, perhaps try to set up some continuing education for this group.

 

I understand that, but I review the notes of the ER provider and they just don't make sense - I get that second guessing is not good and that is why I call them to discuss on phone......

 

their answer "geez DVT never came into the DDX ..... 56yr old female obease RA patient with unilateral calf swelling."

 

I have "been around the block" enough, including working in a rural ER, inpatient medicine, chronic pain, ortho, Radiology, and years in primary care to finally feel comfortable in medicine, but these PA's quite literally have no idea what they are doing. No supervision, no guidance - not their fault. How about a lady with classic renal colic, CT shows stone - they give her Dilaudid 4mg!!! with out an NSAID - she was drugged for two days but still complained of pain..... just poor medicine

 

 

I truly feel bad for the PA's as they are getting chewed up and spit out - the hospital still bills for the services, the doc's don't care, the department still makes money but the poor PA is left out in the cold. My first job I kept for 5 years as I wanted to really learn and I had a great doc - that is not the case with this place and it just makes all local PA's look bad when a simple renal colic or viral URI is totaly mismanged in the ER.

 

Also, reflection on others performance after the fact is a reasonable strategy of teaching (and I have tried to call down and talk to the PA's to get them to think of a broad based Ddx when I have problems with the management but this is in ineffective way to teach)

 

It hurts all of us to have unsupported PA new grads in the ER

 

David the Nome gets it - I get it (I was thrown to the ER wolves as an 8 yr clinician and realized my own limitations clearly - would manage anyone walking through the door but with help of the attending)

 

 

 

David - what part of the country are you in?

[Febrifuge]

I'm a new graduate EM PA in exactly the situation described above. Needless to say, it sucks-and I hate going into work everyday. I work half time in urgent care (unsupervised) and half time on the main side on nights (rotating charts with the MD-whatever is up next, I see). I was promised three months of training prior to starting but was only given two days of EMR training, then told to go work. I know i can't handle the complexity of these patients as a new grad. And in the urgent care, I often wonder how much I am missing.

 

ANother issue is, when actually working with a doc, they are to busy to really ask any questions-so no learning takes place and no feedback is provided. For example, if i ask the doc to look at an ECG, they may glance at it for a second and say "it looks fine"....or something along those lines. It makes me sick because I know that at this point in my career I am not able to provide the quality of care that patient's deserve, and am in constant fear of making mistakes and missing things.

 

Though I like EM, I find this situation unacceptable, so next week I'll be interviewing for two other jobs. In EDs with little physician oversight, either hire experienced PAs or actually invest time into training the new grads. Apparently, the department I work at has had a huge PA turnover over the past several years, and still they have not learned.....

dude, I'm sorry; that sounds a lot like my experience as a Hospitalist, my first job out of school. Promised training; never got it, because it was all about moving as many patients as possible.

 

My only advice would be to look around (quietly) for a new gig, but nonetheless, BE FIRM about getting what you need in order to do your job well. The MDs got it; it's called residency. Ask one of them if s/he would trust his/her PGY-1 self to do half of what they do in a typical shift now. As PAs, we like to think we're a little more grounded or prepared but no one in their right mind would send an intern out into the wilderness like they've done you.

[PACali]

We need more PA residencies. I think most of new grads are willing to do a residency if there are enough spots.

[Just Steve]

We need more PA residencies. I think most of new grads are willing to do a residency if there are enough spots.

 

I really hope residences do not gain traction in being a requirement to be hired. PAs have enjoyed lateral mobility within the medical field for many years without having to go through another training program. That is one of the key draws to this profession. If we start pushing for residencies, we'll lose that some of that mobility, thus placing our own fences around us.

 

I feel the PA profession has done itself a disservice by expanding at such a rate where PA school applicants can get accepted to school with little to no direct patient care prior to applying. It has reduced the overall exposure PA graduates have to the world of medicine, making their learning curve AFTER school a fairly lengthy one. The best studies I have seen reporting that PAs with no previous medical experience take two years of active practice to catch up to those who came to school with medical experience. I'd be willing to bet this two year learning curve is one of the key reasons why so many jobs do not want to hire new grads.

 

So instead of trying to create non/low paying residencies, I'd much rather see the PA profession go back to it's roots of expanding the education of previously experienced medical providers.

 

disclaimer...I am biased. I spent over 2 decades working as first a navy corpsman, then a paramedic, now a PA student with Medex. I wish more schools followed their model.

[andersenpa]

I really hope residences do not gain traction in being a requirement to be hired. PAs have enjoyed lateral mobility within the medical field for many years without having to go through another training program. That is one of the key draws to this profession. If we start pushing for residencies, we'll lose that some of that mobility, thus placing our own fences around us.

 

I feel the PA profession has done itself a disservice by expanding at such a rate where PA school applicants can get accepted to school with little to no direct patient care prior to applying. It has reduced the overall exposure PA graduates have to the world of medicine, making their learning curve AFTER school a fairly lengthy one. The best studies I have seen reporting that PAs with no previous medical experience take two years of active practice to catch up to those who came to school with medical experience. I'd be willing to bet this two year learning curve is one of the key reasons why so many jobs do not want to hire new grads.

 

So instead of trying to create non/low paying residencies, I'd much rather see the PA profession go back to it's roots of expanding the education of previously experienced medical providers.

 

disclaimer...I am biased. I spent over 2 decades working as first a navy corpsman, then a paramedic, now a PA student with Medex. I wish more schools followed their model.

 

Please provide a link to this study

[EMEDPA]

I feel the PA profession has done itself a disservice by expanding at such a rate where PA school applicants can get accepted to school with little to no direct patient care prior to applying. It has reduced the overall exposure PA graduates have to the world of medicine, making their learning curve AFTER school a fairly lengthy one. The best studies I have seen reporting that PAs with no previous medical experience take two years of active practice to catch up to those who came to school with medical experience. I'd be willing to bet this two year learning curve is one of the key reasons why so many jobs do not want to hire new grads.

 

So instead of trying to create non/low paying residencies, I'd much rather see the PA profession go back to it's roots of expanding the education of previously experienced medical providers.

 

disclaimer...I am biased. I spent over 2 decades working as first a navy corpsman, then a paramedic, now a PA student with Medex. I wish more schools followed their model.

 

totally agree.

I think it's probably more like 5 yrs to catch up on common stuff but for the less common many never catch up.

many of the em pa's I work with have never intubated/started an IO, etc and never will. they didn't know how before pa school, never did it in school and would never attempt it now.

[CAdamsPAC]

I really hope residences do not gain traction in being a requirement to be hired. PAs have enjoyed lateral mobility within the medical field for many years without having to go through another training program. That is one of the key draws to this profession. If we start pushing for residencies, we'll lose that some of that mobility, thus placing our own fences around us.

 

I feel the PA profession has done itself a disservice by expanding at such a rate where PA school applicants can get accepted to school with little to no direct patient care prior to applying. It has reduced the overall exposure PA graduates have to the world of medicine, making their learning curve AFTER school a fairly lengthy one. The best studies I have seen reporting that PAs with no previous medical experience take two years of active practice to catch up to those who came to school with medical experience. I'd be willing to bet this two year learning curve is one of the key reasons why so many jobs do not want to hire new grads.

 

So instead of trying to create non/low paying residencies, I'd much rather see the PA profession go back to it's roots of expanding the education of previously experienced medical providers.

 

disclaimer...I am biased. I spent over 2 decades working as first a navy corpsman, then a paramedic, now a PA student with Medex. I wish more schools followed their model.

 

 

Bravo Zulu!!!!!

[Febrifuge]

We need more PA residencies. I think most of new grads are willing to do a residency if there are enough spots.

Disagree, respectfully. We do often seem to need better training of new PAs, but I think it also needs to be practice- and setting-specific enough that a residency wouldn't solve all the problems. I'm quite comfortable with the present setup, now that my supervising doc and I are on the same page about how I am working to advance my skills and knowledge base.

 

EDIT TO ADD: ...and I had about three years' experience as an EMT/ ER tech before I went to PA school. I was a little discomfited to learn my approach was sort of a throwback. Many of my classmates were athletic trainers; a couple were also EMTs; and a lot were just people who were into medicine as an abstract idea. In four-year MD school, that makes sense, but I'm old-fashioned I guess. Having the background meant I knew how to contextualize and apply everything.

[Just Steve]

Please provide a link to this study

 

Well I tried...I recall a variety of studies posted by ColoradoPA aka: David Carpenter back in November of 2010. I searched back through the old archives and found the link but was unable to open the AAPA link. http://www.PhysicianAssistantForum.Com/forums/showthread.php/28730-facts-on-HCE-and-PA-school-success/page2

 

I am hoping David may chime in with a repeat on the link I am trying to find.