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Struggling in the ED. Any suggestions?

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Recently started my first EM job in a very busy inner-city hospital fast track.   At first, things were great, but once the very short "training" period was over (about a month), the poop hit the fan. Feel like I am drowning, and I am looking for any advice.


Essentially, I am struggling to see enough patients and get them out in time to satisfy the attendings.  If I can squeeze in 16 patients in a 12 hour period in the fast track section, where I usually work, and get them out in under 3 hours, that is quite a miracle.  Before anyone thinks those numbers are rather low, consider a few things:


(1) At this ER, there is NO independent PA treat-and-release.  Every, yes EVERY single patient must be presented to an attending.   Many of these attending demand a full, OSCE style presentation of the patient, in full medical-terminology-only glory, and will pimp and nitpick the living hell out of you, just like back in rotations, even for a 20 year old with sniffles. Often there is just one attending balancing 20-30 patients at once in the fast track, which means that sometimes I must wait half an hour or more just to present to the attending, then get torn to shreds for a while by their mind games, delaying the process, especially if the docs then decide to order every test in the book. Of course, I get yelled at for the final delay.  I can't recall a single case where I was wrong in my assessment and treatment plan, and I could have had the patients out the door in 25 minutes, but instead that number shoots to three hours.  When the atendings themselves see patients, they do the same wokup, with the same gut hunches as me, and have the patients out in ten minutes, I am simply not allowed to do that.


(2) I am new at this, and have so much to learn, and often do not know the best course of action with a given patient;  as we are busy, the other PAs and residents are busy too, and can't always offer advice, and when I don't know what to do with a patient, I stall and grind my wheels trying to figure the next step, with no one to ask.  Sometimes even the nurses are busy, and I have to do nursing tasks myself, or go looking for someone; both of these burn tons of precious time.


(3) Documentation is very heavy; for each patient, there is about 10-15 minutes of EMR documentation, and when scribes aren't around, the onus is on me.


(4) Very few of our fast track patients are "simple" cases; we get a lot of psych, homeless, addicts, and so on, as we are an inner city hospital, and trying to work with them to interview and treat them can be a time consuming, painful mess. 



I am aware that several of the attendings are unimpressed and disconfident with me because I

  -ask too many questions (not sure how else to learn?)

  -seem uncertain of the course of treatment at times (duh! I'm completely new at this, shall I fake confidence?)

  -sometimes miss small things here and there (again, new at this, I am learning)

  -are furious that I did not learn the first time around (again, I am new at this, and I take plenty of notes, but things slip through if I don't see a particular illness in a while).

  - I'm naturally a quieter person, not as "loud" and "in your face" nor as cocky and BS-conjuring as some of the other PAs, and the attendings' impression due to this is, wrongly , as I have gathered, is that I am not capable and confident.  This is simply not true, I just don't pretend to cockily know as much,. and with as much faux-bravado as some of the other PAs.


To make matters worse, the attendings are under tremendous pressure from above to get their time metrics down, and they pass on this frustration to the PAs...and are always down my throat, to the point that I don't have time to even complete a task before they are already yelling at me for not completing that and the two things they haven't even asked me for yet, further destroying their confidence in me in a vicious circle.  I often hide in corners to use computers out of their view, so I may have 2 minutes to thing and formulate a plan.  It is my only break from their hounding, and having to constantly defend myself for being newer.


I am trying to ascertain if this is a typical ER situation, and I am just not getting with the program, or if this sort of setup is a bit unfair and ridiculous.


I used to go to work eager to learn and help and treat, but now I dread every shift, walking in to see which attending is going to bite my head off that day and make me dance on my my head so that I can prescribe a few measly Z-packs, which patients will make my life miserable by changing their story every two minutes in a heroin-fueled stupor and making me look like an idiot in front of the attending, and by day's end I am stressed, exhausted, frustrated, and my morale, confidence and soul are just beaten down.  I used to think I wanted to do EM, but...not like this.



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What you're experiencing sounds dysfunctional - and I'm not sure which personalities sound more pathological to me, your homeless heroin-addicted patients or your attendings?!?  


While your patients sound potentially more problematic and risky than your average Fast Track patient population, as EMEDPA said you should not have to present every single patient to an attending if they are truly ESI Level 4-5 and fast-track-appropriate.  If they truly want to get the times down, they should allow you to TX/dispo the ones that you feel comfortable handling and aren't mistriaged/potentially sicker.  That at a minimum (and much more with time and experience...) is well within your scope of practice as an EM PA-C.


Your lack of bluster and false bravado shouldn't cause them to think you're incapable, either - a healthy measure of caution as a new grad starting in the ED is exactly what you should have right now.  Attendings should welcome/expect that in a new grad.  Those other PAs are faking it 'til they make it - right into their first court deposition/lawsuit because they didn't know what the hell they were doing and were too afraid to tell anyone!  With that said, you still need to present yourself in a composed fashion and with confidence (have your presentations down cold and at least propose a differential/treatment plan, even if you're uncertain of it) but they should not treat you the way you're describing above.  Sink or swim is one thing, try to swim while I'm tying weights around your ankles and pushing down on your head is another thing entirely!


My guess is you have limited options if you're in an urban area where competition for jobs is tough and people put up with this kind of crap to get their foot in the door for an ED job - but I would look elsewhere if at all possible as this environment sounds toxic.  Work on shoring up your core knowledge as fast as possible so your own confidence/competence will improve as well.  EM Basic podcasts/show notes are a good starting point, as are a CME course like the EM Boot Camp below?  Minor Emergencies is probably the one Fast Track text I'd recommend.  A new setting plus a good foundation will likely change your opinion on what it's truly like to work in EM. 









(Minor Emergencies is cheaper elsewhere, for some reason this site is not letting me post an A**zon link though!??)


Best of luck, let us know if we can help in any other way...

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I disagree with the above posts! I am a new grad and I am so thankful to present my cases to the docs - I am barely out of school so I view it as an incredible learning experience. How terrifying would it be to miss something? I agree that eventually you should not have to present cases to the docs but I don't think it should be seen as a negative thing this early on. Look at the fast track disasters thread for an idea of some of the crazy stuff that can be missed. If you're still presenting everything in a year then sure, be mad but for now I would think it would be wonderful to have the support and opportunity for reassurance that you are doing the right thing rather than like some of my classmates who went into EM and have to just "figure it out" all on their own. I don't know about you but as a new grad with no prior ER experience I don't want to be up all night wondering if I screwed up. Having the docs around is peace of mind for me.


That said it sounds like you're in a high pressure environment. Are you putting these pressures on yourself or are the higher ups pressing you to see more and more? Sounds like you're seeing an appropriate amount of patients for a new grad... It's hard to get fast especially when you're terrified of missing things and it'll just take time.


You say you are being subjected to nitpicking and mind games. And yelling. If it is the way you are truly presenting it then I agree, it sounds high pressure and awful. But consider the fact that it may be only your perception. Are the doctors challenging you and trying to expand your mind and you're being insecure and sensitive, and interpreting this as threatening? Or are they truly being disrespectful and demeaning? If they are truly yelling at you and don't welcome the opportunity to discuss patients with you I would say get out!


Secondly - EHRs suck for everyone. If you have scribes to do the charting for you, that's awesome, but if they're not around no wonder it's taking you 10-15 minutes to do a chart! I am in the same boat. We don't have scribes so I am getting faster as I have to do charts myself every day. Practice makes perfect.


Thirdly - not knowing what to do sometimes is the name of the game. You can't go to the attending a for everything bedause yes, that is annoying. I do ask the NPs and nurses stuff all the time, but other times I refer to my Minor Emergencies book and my notecards I made from EM Bootcamp lectures and EMBasics podcasts. I must have 300 notecards! Do you have awesome resources you can refer to at work? Uptodate? Minor Emergencies by Buttaravoli? Have you done the EM Bootcamp by the Center for CME? Surviving EM and loving it means having the motivation to study after work and use your resources when you're on the job.


Last - fast track patients being really complicated sometimes is also the name of the game in ER. To be frustrated with that is wasting your time because it's always gonna be that way.


It's hard to know if a) EM isn't for you, B) this environment is truly hell and wouldn't work for anyone or c) you have a negative slant on things? Only you will know that!


I have been trying to adopt these traits as a new PA in ER and so far the docs have been very happy with me a) take initiative to learn new things, b) be excited and enthusastic about being in EM - not all new grads can get in! c) don't get knocked down and complain when things get bad, d) do EM courses like EM Bootcamp on your down time, e) look at challenging situations as opportunities to learn, not threats and f) be respectful and friendly and appreciative to those you work with... Anyone from techs to RNs to pharmacists has something to teach you!

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I just wanted to reinforce some very excellent observation and advice here:



Your lack of bluster and false bravado shouldn't cause them to think you're incapable, either - a healthy measure of caution as a new grad starting in the ED is exactly what you should have right now.  Attendings should welcome/expect that in a new grad.  Those other PAs are faking it 'til they make it - right into their first court deposition/lawsuit because they didn't know what the hell they were doing and were too afraid to tell anyone!  With that said, you still need to present yourself in a composed fashion and with confidence (have your presentations down cold and at least propose a differential/treatment plan, even if you're uncertain of it) but they should not treat you the way you're describing above.  Sink or swim is one thing, try to swim while I'm tying ankles around your weights and pushing down on your head is another thing entirely!



My first job out of school was one like this. I was already a bit older, a non-traditional student (actually something of a throwback to PAs of an earlier vintage), and came out of school with plenty of life experience and decent training, but a VERY healthy respect for how much I had yet to learn. I had to deal with a group that had some very strong personalities, some of whom enjoyed pontificating and pimping, and some of whom appeared as though they wanted to be anywhere else. I had to try and adapt my practice style -- which didn't yet exist as a cohesive thing -- to each of these charming individuals, and like the OP I was held to some fairly insane standards of speed and productivity. It was, to put it nicely, a bad scene.


My unconscious response was to slow down, question EVERYTHING, and basically push against the boundaries of just how stupid they thought I must be, and how hard they were willing to work someone they clearly didn't seem to trust. It was an immature reaction, brought about by stress I didn't know how to deal with, and it made me look bad more than once. But looking back, it was really illuminating and helpful. I learned a TON about how much the dynamics of personality and working style affect the things we think of as fixed quantities, like your fund of knowledge or your fundamental ability to problem-solve.


There's a statistic out there -- someone please chime in if they have it handy -- about the percentage of new grads who end up leaving their first job within 1 year. It's a shockingly high number. I'm convinced that part of the reason for turnover is that new grads simply don't have the perspective to recognize the toxic, obstructive style of working until it's too late. Most of this sounds like it's NOT YOUR FAULT, and LoRez has nailed the diagnosis.


But take the advice, too: work on your presentations, get them short and slick and don't let yourself be purturbed by the fact that you need to do them. Do it for the patients, because they deserve better than the weird system you've found yourself in. Work to mentally separate your practice, your clinical acumen, your career from the specifics of this job. Meanwhile, look for a new one because this one is broken.

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There is risk being a new grad in the ED. Where I used to work, there was a continual rotation of new grad PAs into the ED (low pay, PA school in the area) so the attendings were constantly training new PAs. Once they got comfortable with where one of the PAs were at, the PA would announce that they were moving on to greener pastures.


I took that job because I would learn a whole lot and more or less treated it like a residency. There was lots of stress, but I am a lot more capable than some of the other PAs that I now work with.



In some states like Virginia, you are required by state law to present every patient prior to discharge. I still do even though I have been working for 6 years. It sucks...


If you are a new grad, prepare to be pimped. How else is the attending supposed to figure out whether they can trust you?

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Start looking for a new job.  As a new PA I was hired into a small community ED; I took the first job that was offered to me.  The docs hated PAs, were hostile, offered no help, sabotaged.  After a few weeks, I started looking for different jobs.  I ended up at a competing, inner city ED and have loved my job for the last 10 years.  So much of being a new PA is not only learning the medicine, but finding an environment that works for you.  It doesn't mean that you are a bad PA; just means that this is not the environment/group for you.



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Thank you all for your responses.  Some thoughts:

I am very apprehensive about searching for a new ER job...this job took me, no joke, five years to land.  Nearly ever hospital in my metro area demand a minimum 1-2 years ER experience for ER PAs, sometimes even more.  My measly few months of experience, despite their intensity...I can't imagine that would count for much. Especially when other EDs in the area are probably about the same.  It took me five years after school, five years of fairly consistent applications, working back channels, networking and downright begging to land an ER job, and I can't imagine the next is close on it's tail.  I'm fairly certain it's this job or none.  As for moving outside the beltway, so to speak, is tough due to family.  Not to mention how I would explain to a hiring manager, in the event I do get fired from this job, the circumstances of why I didn't make it.  Not what employers like to hear.   

LoRezSkyLine:  I know, it's unusual, but apparently with circumstances with my hospital and various corporate and logistical factors, this is how the setup is now.  There is no treat and release for anyone. Sometimes close to it, but never quite, and usually far from it.  Depends on the attending.  As for knowledge, good tips. I already use EM Bootcamp, which is great, and some of the others you recommended are great.  As I understood, the powers that be are not concerned with my knowledge or clinical acumen...the want me to be faster, less human, care less for the patients, and be more interested in moving the bodies through...and to get every decision right, the first time, every time.  My feedback is that, the fact that I am not constantly, consistently super-confident, and sometimes tell the attendings "I really don't know here, what do you think is the best course of action?" is a big no-no and is costing me all confidence of the attendings.  I suppose several months on the job should be enough to know everything, always, and I suppose that attendings are there to work, not to teach.  Neither works well for me.

ERCat, good questions...I think the doctors are a mixed bag. Some truly challenge to help teach, some have no interest in PAs but still begrudgingly teach...some though, are just mean, and want to tear holes in whatever you are saying, and no presentation will ever be fast enough, good enough, medical-lingo-ey enough, perfectly formed enough...(as if it makes a damned of difference). Few yell, but many make you feel like an idiot with their eyes...and there seems to be this culture among the EMED docs, this game...it's the cold stare, the emotionless pimping...they will have an animated conversation with a patient, then sit next to you, and just with their eyes, make you feel like a fool...just stare you down, emotionless, as you share your thoughts on a patient, slowly eating away your confidence with their cold stare...it just feels like a whole game.  Not a word from them, not a hint of emotion, just....mind games, and a few words later you feel like a total fool for missing x,y or z.  It's almost like the culture of these Attendings is to grind away at students (or PAs, residents) resolves with this emotional game to drive us crazy and toy with our minds.  There are a few actual human attendings with whom I can interact like an actual living person, and I thrive when they are on.....but only a few.  The rest are just painful to deal with, and their pressure, antics and their own internal anxiety make me flustered, frustrated and tired soon enough.  And, I do review my notes, make more notes, and consult with others when I can, as often as I can...but a few months in, I understand I have lost some of their confidence, and I have an uphill battle to regain it....all the while, I don't know if I will be retained at this job.  

Febrifuge.:  I feel that way exactly. the emotional up and downs are insane.  I want to cry on an almost daily basis...am doing my best to adjust, Its going to take a huge amount of mental toughness to fight the constant emotional barrage.

To all the rest, thank you for your responses....

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I worked with very similar attendings in my first job (also ED).

A few things I learned from those experiences...

Don't ever go to them saying you don't know. Have a differential diagnosis and possible workup in place. Then ask if they think anything else should be done, or if you are on the fence about a test ask why/why not. If you go to them already 'thinking' they are going to be more likely to help you.

Also, learn each of your attendings styles. You'll have to adapt to each one. This is one of the hardest parts about being a new PA. But as you get more experience and confidence, many times you don't have to adapt any longer. You will have the knowledge to explain why you did or didn't do something (and that's the key).

As far as trying to make your time there better, learn as much as you can from everyone. Use the docs for all the knowledge they can give you. Make a list of some of your common chief complaints (sore throat, cough, abd pain, pelvic pain, etc) and start formulating what you'd want to do on exam, what tests and why. Keep reviewing these. Within each of these diagnoses, also review the 'bad' things each could be, as well as how you'd prove it is/isn't one of these diagnoses (this is something you typically would want to make sure is evident in your notes as well, that you considered these diagnoses).

If going to this job every day is truly that bad, it is important to start looking for another job. If you are unhappy in your job, your performance will eventually suffer. You worked way too hard to put your career at risk. In the meantime, use this job as much as you can to get yourself ahead, learn, absorb and get ready to move on

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  • 1 month later...

I find my docs appreciate it if I come to them with a specific question or plan in place that they can agree or disagree with


Example: I have a patient that came in with X,Y, Z and I did X,Y, Z - would like to treat for X - does that sound right to you? Anything I'm not thinking of that pops out at you?


Example: I might start it with: "my question is this"  - should this patient have a CT abdomen/pelvis with IV contrast, oral and IV contrast or skip the CT. Then present it. That doesn't always work if its not that easy of a question. But one attending said he liked that format because as he's listening to presentation he's listening for clues on how to answer the question.


Slow down. They won't fire you for a long time if speed is the only thing. 


Look stuff up. Use UpToDate


Also, as you see people check in for certain things and think to yourself "i dont want to see that" - follow up on the story, workup and diagnosis as a way of learning. Ask the docs if they have anything interesting (if it happens to be kind of slow), tag along with them when they see a patient (if theres time) as a way of learning.


Study. Keep reading. 


Once when I was new at the ER I had a 16 year old with abdominal pain that I couldn't figure out but didn't think needed a CT necessarily. I presented to the doc and he asked whats her lipase? I had forgotten to order it. Her lipase was in the 1000s and she had gallstone pancreatitis. 

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