MD supervision

[slolar]

Background:

 

We are a small 5-8 PA group (100 MD group), PAs staff 2 hospitals, MDs 4 hospitals.  Mainly Fast Track, Main Ed when residents away and as a "float" shift.  This is our current role, it has always been in flux over the last 10 years.

We have had some bad hires recently.  Experienced PAs from IM or Cards, new grads that don't quite live up to the snuff.  Sigh, an NP.

As a group, we want to actually expand PA roles.  Solo in the urgent care part (we currently work pretty independently but alway with an MD), more staffing in Main ED.

Sooo, we are trying to establish clear guidelines, including training and advancement.    I'm in agreement with this.  

 

Buuuttt...

 

this article is a big part of the MD/PA/Board discussion:

 

http://epmonthly.com/article/pa-training-oversight-model-worth-copying/?utm_source=February+25th%2C+2016+Ezine&utm_campaign=EPM+August+27+2014&utm_medium=email

 

 

Sooo, I'm good with a lot of it...However, I'm losing the argument for a "senior" PA (ie me) needing to staff EVERY ESI 2-3 case in the main ED.  I don't need to staff every vaginal bleed, simple asthma attack, PID patient etc.  I propose automatic consult for unstable vital signs, critical lab values etc.  There is reference a lot to residents messing up and I have to remind them I have >7 years experience over a resident ( as does the PA in our proposed training alogorithm to act as a senior PA).  

 

But most MDs are reflexing to agreeing to total supervision for ESI 2 and 3. (And I know a lot of these MD's and they will NOT provide supervision, just on paper)

 

So how can I argue this? 

 

Sara

[ventana]

Exactly as you are doing

 

Also bring up the solo coverage in remote ED's

Get your CAQ (residents can't earn that title so it helps you!)

Take all the classes

 

Slowly keep advocating for advancement

 

I have watched my own hospital system slowly learn that PAs are providers, and valuable (mostly precipitated by need after a residency program closed) and with increasing responsibility comes increasing need to prove we are worthy.

 

And it is a SLOW process.....

 

Take every course and certificate you can

 

Continue to advocate.

[piteog]

Really curious how this turns out.  Background:

 

I supervise a very large group of PAs (and a few NPs) in an urban EM group.

We have been trying to revise and simplify our scope of practice agreement.

Unfortunately, we have two buckets of doctors: the risk tolerant and the risk averse.

 

Meetings about the scope of practice are naturally dominated by risk averse doctors who force the risk tolerant doctors to capitulate.  There's such a strong emotional response in risk averse doctors as they feel a real stress when PAs or NPs evaluate patients.  Some of our doctors are true "helicopter doctors" who insists on evaluating everything, even in patients with obviously benign presentations.  

 

I agree with Ventana.  Demonstrating your competency will change minds over time.  This requires substantial patience on your part, but if they are open minded, things will change.  If they're not open-minded, you'll find another job.  One thing you could do is propose that they evaluate your performance with respect to specific patient presentations.  Ask for critical feedback in 6 months about managing patients with chest pain, or DKA for example.  Then, make sure you know the algorithms, how to interpret the blood gas, etc.  When you knock their socks off, ask them to loosen the reigns.

 

On the other hand, I was going to post a question about how YOU all deal with "helicopter doctors" since some doctors won't change and are difficult to manage for their doctor colleagues.  The reality is that most people will approach these things with common sense.  Once you show you're capable, they'll let you do more.  

[EMEDPA]

I refuse to work with folks who don't respect my background and experience. it's ok to ask reasonable questions, but armchairing every minor case is ridiculous when working with PAs with 10+ years of experience seeing critically ill pts. One place I work the PAs complained about a per diem doc who wanted a presentation on EVERY pt and wanted to then see them himself. he doesn't work there anymore...

[piteog]

From a scope of practice standpoint, though, what would think if the scope of practice was vague and allowed broad discretion in PA-led care but also included a caveat allowing individual doctors to "tighten" the scope off practice when PAs in the practice specifically work with those physicians.

 

I think it could be problematic, but I'm looking for a way to throw a bone to some of our more conservative doctors.  As I noted, conservatism isn't always rooted in a lack of trust in PA-led care but rather in an anxiety about risk-management.  Do you think it would be possible to follow something like that?  I think it may be difficult but essentially just codifies what is already routinely done.  For example, say you're training a new PA.  You might say, "Dr. Jones is a heavy admitted of low risk chest pain and wants to hear about all those cases before disposition unlike Dr. Smith . . ." or whatever.

[EMEDPA]

if you have different expectations for each doc it is not workable. at one of my jobs I work with 35 different physicians. if I had to remember to tell dr smith about chest pain, dr jones about pediatric belly pain, dr green about bad headaches, etc it would not be workable. you need to have PAs you trust and a few rules like "discuss potential admissions and potentially septic patients with the following VS or presentations". most good em pas know when to seek a consult. it's not the folks we are thinking about admitting, it's the folks who got a workup and are potentially going home. "hey, I've got this 90 yr old with abd pain and a completely negative workup for cardiac dz, a nl ct scan with iv contrast, and no worrisome comorbidities who I am thinking about sending home. would you take a quick look and make sure I'm not missing anything? thanks".