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Heavy supervision, no continuity


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This is a vent/advise post. Be prepared for some rambling.

 

I am one year out of PA school working in EM. Although I am in my 20s, I did have 5 years of paid ems experience working for a very busy urban/suburban EMS service. Great experience and set a good foundation for PA school. I was hired by the EM group I rotated with while in school. This a small Ma and Pop operation consisting of about 10 members. All the partners are generally nice people...some with the touch of arrogance all too often seen in physicians. The PAs and MDs all pull from the same chart rack. ALL my patiets have to be seen by a physician. Herein lies the problem. At any given time I am working with 1-3 physicians at a time. It would be one thing if I gave my report and they went a waved to the patient but they all want to take complete ownership of the patient and want me to cater to their idiosyncrasies. This would be one thing if I worked with 3 physicians, but I work with 10. In short, I am constantly adjusting my practice style to cater to their likings. Despite this, I am always wrong because It is impossible to keep up with 10 different practice styles and I'm not always sure which physician is going to see a patient when I sign up and write orders. I often leave rooms ambiguous with patients because I'm not sure what the physician is going to want to do (I know what I want to do). This goes for the febrile 4 year old with the tonsillar exudates to the 40 y/o female chest pain that scores moderate risk on wells criteria.

 

If there is a silver lining, I am learning. I get to see how to practice medicine 10 different ways. However lately it has been weighing on me as the patients and nurses probably think I'm an idiot as I am always having to change my orders. I am also always being lectured to as to why I should do something "this way". "Hold off on that bicillin, we are going to do a rapid strep first", "Cancel the d-dimer, we are just going to do a cta", "get a UA on that 4 y/o girl with fever, red throat and red TM"...This is me all day long.

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They complain about it in private. The word "glorified scribe" is thrown around a lot. They both have families and view this as a job to support their family in a comfortable lifestyle.

 

I am told that it is in our hospital contract. I am not sure if that is true or not as I was also told by them that CMS requires patients to be seen by a physician for full reimbursement which is obviously not true.

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I have been in that boat with 15 Ortho Attendings in a teaching hospital. I actually felt schizophrenic. I would have to change my demeanor, approach and thought process for each of them AND deal with 25 residents a month.

 

It sucks.

 

It is not logical or realistic for them to continue in this practice of having every single patient seen by a physician. It is a waste of PA skills.

 

I would move on -- find someplace where you can blossom into an independent thinking, respected member of a team approach.

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they are clearly doing it to bill at 100% instead of the 85% a PA alone gets for govt payers. They are trying to do this at my primary job for any pt requiring a consult or admit. I am working very hard to only work solo at our satellite facility and never work at the big house to avoid this and other unpleasant situations there.

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It's the age old question of what a PAs purpose is to the healthcare system if we are relegated to being a glorified scribe due to money purposes. Doesn't employing a PA at half the cost of a physician make up for the meager 15% lost to one cohort of patients?

 

Advice-- get a better job, leave that one and give a clear reason why you are leaving to the other providers and to administration. We get nowhere as a profession when they just keep filling positions with warm bodies of unsuspecting PAs.

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Btw, this is another area where NPs are quietly killing us off (in my area at least).

 

Maybe if I wasn't an assistant... Med school or PA residency is looking better by the day. I know the old PA guard has seen how far we've come, I'm just afraid we are stalling and rolling back down the mountain.

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As a new grad I don't think it unreasonable to have you discuss your patients with a doc. I think this is a great way to learn and grow as a provider, especially during the first year. However this should be done to, 1. educate you as the PA in the ED, and 2. allow the docs to become comfortable with your knowledge, ability, and decision making, NOT to bill "full price". Also, if the above is/was the case you should have had one... and only one doc to "answer to" each shift, not several.

 

I agree with the reply's  above, its time to move on.    

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I am in the exact same work situation as you! I work with a (used to be up until a month ago) private ER group that hasn't even touched PAs/NPs until the last year. As of right now, there seems to be a general mistrust of "mid levels" and we are required to staff all of our patients with a doc. Usually the doc just goes in and quickly sees the patient and gives us advice on what we need to order or not order. As a fresh new grad, one month out, this is so incredibly awesome for me. It's a great learning experience. I feel safe to pick up complicated patients - one month out and yesterday I had a guy with a chainsaw to the forearm injury, an abdominal pain with a hemoglobin of 6.7 needing a transfusion, and a chronic pain patient who had (surprise!) a sodium of 116 and was an ICU admission. I would never feel comfortable picking up these kinds of patient if it wasn't for the doctor oversight. I know what you mean by having to cater to millions of different approaches. I think I've worked with about 15 doctors so far. The fresh out of residency doctors are ridiculously careful. I had one of the doctors insist that a urine dipstick was not enough in a 3 week pregnant vaginal bleed with no urinary symptoms; even though the urine was totally normal I apparently needed to order a microscopy and wait two hours for it. Other docs laughed about it. The new doctors are ridiculously OCD about their patients and expect to work up on the smallest things. And amongst the seasoned docs there are all sorts of stubborn opinions. One doc might be liberal with pain meds ("your job is to treat pain" and another might be more conservative ("why did you give a Percocet prescription for this knee pain"). One doc might be liberal about testing ("she has a sore throat, get a rapid strep" while others don't want any tests ("strep test isn't perfect; just assume strep based on clinical symptoms and treat if it looks like strep... Don't even get the test"). Is very challenging to adopt to the different neuroses of the different doctors, but for right now I'm in learning mode so I find it all fascinating as it is helping me to become the provider I'm supposed to be. However I see the downsides you are talking about. When I am one year out I can see it would be frustrating to have to present something as simple as a cold to a doc. And I can see that all of the different approaches might stop being fascinating, and just get plain annoying. It sounds like there was once a place for this type environment for you, but you have outgrown it. Instead of quitting and seeking another job, why don't you try create change within your organization? Let's show them what PAs can do - that we CAN work independently. Sit down with your boss, and explain your concerns. Explain how you are ready to see patients on your own, and having to have doctor oversight is inefficient and time-consuming. Give them data if you need to!

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Another thing. It's your license it's on the line. Each doctor probably adds some sort of addendum to your chart that says that they saw and evaluated the patient with you, but in the end, it's your patient. I think you have enough experience to be taken seriously if you have a different approach than the doctor you were working with. I know it's hard to change a system that seems set in stone, but maybe you can change it by speaking up. Even one month out, I've had things that I've disagreed with doctors about. You might laugh at that, because I'm such a fresh new grad and who am I to stand up to a doctor…but one example - we had a patient with a foreign body in the eye. He stated that he had been grinding metal all day. We removed the foreign body with a burr and then the doctor I was working with said "get him outta here." I had always been trained that we should always be concerned for intraocular foreign body with these kind of grinding injuries and we should get a CT in these cases. So I spoke up, and I showed him the evidence, and we all had a lively debate about it. I think he respected me for bringing it up. In the end, we did let the patient go without the CT, but I think if I had pushed for it he would've respected my opinion. There have been a couple other times when they told me a certain test isn't necessary, and I would just say "I just really want to get it." And they would say, "Okay, sure, it's not unreasonable." If you have the evidence to back it up, who can argue? Maybe it's the case with your docs, too.

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