Sage Advice for New Graduates
Robert M. Blumm, PA-C Emeritus, DFAAPA
Congratulations! Many of you will be graduating from your PA & NP programs in the coming months. You are about to set out on a clinical career journey that could be as long as forty years. A few years ago, my wife and I planned a trip to Italy where we would visit all of the sights of Rome and Florence. Twelve days in Europe was a gift to ourselves - for me after many years of practice and for her, a lifetime of teaching Humanities to high school students. Our journey started six months before when she, as my task master, gave me several books earmarked with all of the relevant sights we were to experience. This homework was an invaluable crash-course on the art, architecture, poetry and history of all of the places we were to visit. Had she not crafted our course of study, I would have been like a child awakening on Christmas morning to twenty gifts which I could not open, let alone understand.
You have just completed an arduous course of study which has demanded a lot of sacrifice: study, financial cost, neglected friendships and delayed marriage plans. The initial goal was just to graduate; now you are required to take a certification examination to determine if all of your hard work was fruitful. When the large envelope arrives with your certification you are then ready to start. Correct? No! Now you will now need to make more decisions that determine your future. And these decisions are just as complex as your clinical training. Just like our trip to Italy, you will need to weigh many options and choices whose decisions will impact your success as a new PA or NP. My graduation present to you is this article which has the potential to better prepare you for your new journey as a professional clinician. It’s advice from me and my colleagues in business, administration and professional practice and will likely make your career journey safer and more satisfying. Like any advice, you can heed or disregard it – but hopefully, it will be a helpful component of your career blueprint for success.
These suggestions come from a variety of sources such as well-known PAs, like EMEDPA, a senior moderator on PhysicianAssistantForum.com, many of your PA Colleagues, myself included, Personal Liability Experts such as those from the AAPA endorsed provider and years of observing the pains and rewards of those who have provided healthcare to our nation in their professional capacity.
Ø Your first job is about learning your clinical skills, not about money.
Ø If you can afford to do a residency in your field of choice, do it! see #1 above.
Ø As a new grad you can have two of the following, three if you are lucky: location, specialty, salary. Choose wisely.
Ø Read your contracts thoroughly before signing them. Look for hidden details, such as mention of a non-compete clause. [A non-compete clause is a legally binding contract whereby the employee agrees not to work with a rival company or start a similar trade or profession for a specified period of time after leaving his current employer.]
Ø Choose a favorite maxim and then try to live by it. Mine remains: “Tis far better to show what you know than to say what you know”. Equally important: “Say, rather than show, what you don’t know.”
Ø Join your professional organizations and support them so that you will be empowered to make changes that the first fifty years of PAs were unable to accomplish.
Ø Don't take the first job you are offered unless it's ideal. Don't settle for mediocrity, ever.
Ø Don't accept a position in a specialty that you detest just because “it’s a job”. You will be miserable in a job that you dislike and you will never achieve excellence.
Ø Don’t accept a position that does not offer CME and vacation time that is adequate for you and your family. Do not accept call without pay, weekends without pay and no more than two weekends monthly.
Ø Do not work in a critical care setting immediately out of school. Hospitalist, ICU, CCU, pediatrics are all specialties for experienced providers. Spend at least two years of non-critical care clinical work so that transitions to other specialties can be accomplished more effortlessly.
Ø Don't work in a very narrow field right out of school unless it is your dream job and you never intend to leave the specialty. I know lots of folks stuck in jobs they hate who can't leave them.
Ø If you are getting burned out, consider the following: work fewer hrs./mo., see fewer pts/shift, switch specialty, switch location. Find something new where you are appreciated.
Ø An essential lesson that I learned which I discovered after working too hard for others. Your husband/wife/significant other and children should be your first priority, yourself your second, your practice third, and professional politics last. No one will ever care for you like your family. Jobs expire, positions fail to exist beyond their time limits and then you will be forgotten. You can never recoup the time you have lost working for others. I have served this profession as a leader for about thirty years. But I paid a price: my kids placed a photo of me at the dinner table at a certain time in our life. Sad commentary.
Ø Don't take a job where your clinical supervisor is an RN or office manager. We are not medical assistants.
Ø Don't refer to yourself as Dr Smith's PA. They don't own you. Say instead, “I'm John Doe, one of the PAs here." Or "I'm John Doe, I work with Dr Smith on the surgical service.” Words matter. Don't let yourself be treated like an assistant. Don't regularly take out trash, take your own vitals, room patients, etc. unless the docs in the group do so, too. I can see this in a small office, but there is no excuse for it elsewhere.
Well, we have covered many of the rules and suggestions but now let me conclude and write about the most important task on your new medical journey. Remember my trip to Italy which I spoke about earlier? Your excitement as you begin your career is comparable to the thrill and anticipation one feels as they set off to explore the Renaissance. But unforeseen events can destroy that cherished vacation: robbery, an injury to you, a crisis at home. So, as your journey begins, a critically important item to secure is a professional liability insurance policy, better known as a malpractice policy, and it is never more affordable than when you first graduate. The AAPA, your professional organization, has endorsed an excellent provider and secured special rates for you, the new PA.
Every PA should carry personal liability insurance for all time periods during which they have practiced. A malpractice suit can be brought against you at any time after seeing a patient (days, weeks, months or even years). And a malpractice suit can jeopardize your professional reputation and impact your credentials with the potential of losing your license by suspension or revocation. Your malpractice history is a matter of public record and your NPI number creates a profile of your lifetime practice. Your ability to secure employment will be decided partly upon this information. New graduates have a one-time opportunity for securing discounted insurance premiums for five years which offers comprehensive protection. Congratulations on your graduation and best of luck!
Future Standards for PAs and NPs
Bob Blumm, PA, DFAAPA, PA-C Emeritus
Standards: it seems as if everyone is talking about them today. We are either creating standards, improving standards, setting new standards or raising standards. Ultimately, as decades pass, standards grow, and this seems appropriate considering the health care needs in the United States and our world standing in that sphere. Like most Americans, I had always assumed that we were naturally - Number One - but was disheartened to discover that my assumptions were grounded in my patriotism and not in evidence-based studies. Depending upon the source and the year, the US typically ranks in the top 20 or 30% and shockingly behind all other nation members of the G-10 (including many smaller countries). This surprising revelation gave me pause to reflect on our “standard of care.”
What does the word “standard” connote to the average PA, NP, or patient in terms of academic achievement? It might be interpreted as an entry-level bachelor’s or master’s degree - or perhaps even a doctoral degree. Many of these advanced levels could never have been imagined in the past but are now very much a part of the 2021 working world for PAs and NPs. How quickly times change with more and more clinicians earning doctorate degrees – spurring insurance companies and administrators to establish yet even newer benchmarks based on this academic proliferation. If we as a profession do not set our own standards, someone else or another profession will surely try to do it for us. If ever we needed cohesive leadership, it is now! Maybe you are the person who can lead us into the future?
What do I personally think of standards? I believe that standards are a very positive modifier of our practice protocols and approaches to medicine. I see the patient as the ultimate winner when a profession has high standards. Standards lead to increased study and competence. Standards are set and maintained by academia, education secured at conferences, and CME provided by associations. They are enhanced by experience and certified by procedural attestation such as those through residency rotations. There will, in the near future, be a mandated procedural attestation required within all institutions of medical care. When looking at medical specialties, we note that either a residency or a specialized track of education and experience defines what an institution requires for an NP or a PA to be hired.
Most of the specialty areas need highly experienced, highly motivated, and extremely well-educated PAs and NPs and are willing to provide a mini residency. Some of these specialties require additional education, CME, preceptorship, and a specialized curriculum in addition to an advanced degree. I will repeat a sentence that I wrote ten years ago: “The time is quickly coming upon us that will no longer place on a resume ‘PA seeking a hospitalist role, ---- willing to learn, seeking physician willing to teach.’” That time became a reality more than five years ago. Physicians are engaged in their own fight for survival, focused on issues which affect their profession, leaving little time for the altruism of the past when they sought to be the “teacher” to a nonphysician. The economy, new health care laws, insurance mandated reimbursements, malpractice issues, and the huge financial debt incurred while becoming doctors have caused them to protect their own turf and areas of responsibility.
What will possibly be the standard for the PA in the next few decades? PAs will be a graduate of a doctoral program, be highly intelligent, and have the interest to further their education by means of residencies of various lengths to best prepare for the arduous task of caring for an additional 31 million patients in a decade with decreasing numbers of physicians. The PA will be a team member that possesses a team attitude and team spirit as the care of patients will be delivered by highly trained team members. Personally, I see this as a positive move and will be comforted as a patient to realize that all of the medical personnel with whom I have a relationship share a unified approach and attitude that will enhance my treatment, wellness and outcome. I think that the nursing profession will continue to grow in this same direction as they are recognized experts in so many specialties today.
This shared approach to patient care will require many signatures and notes on the EMR which can become tricky for many clinicians. With a team approach, opportunities for medical error will require heightened vigilance. And when errors occur - who is responsible - the institution, or the clinician? It is and has always been the clinician, and these errors are often due to the exhaustion felt by providers: reading every note, reviewing every test, and reconciling every new medication order. Prior to my own retirement, I began to feel the exhaustion of doing the detective work and realized that I was becoming a relic. As malpractice exposures rise, so too the need for a personal malpractice policy. Younger clinicians are much better suited to the demands of this ever-increasing administrative multi-tasking than those of us from an earlier vintage. This new era makes a malpractice instrument essential, now more than ever. Be careful and refrain from choosing based on cost alone, without fully understanding the policy terms and the provider’s history in the healthcare market. “New” companies with new perks come and go and may not exist in a few years, when you might need them. Make your own educated decision to prevent hardships in the future.
What’s In A Spoonful?
Robert M. Blumm, MA, PA-C Emeritus, DFAAPA
Being a grandfather or grandmother is one of life’s most rewarding experiences. While reliving the early stages of life with our grandchildren we can enjoy their movies and get a second chance at some which we may have missed. I was recently watching Mary Poppins with my grandkids and found it delightful and uplifting. For days, I was rehashing that famous song in my head, “just a spoonful of sugar helps the medicine go down.” As a clinician, I paused with some concern as I had to ask myself: What, actually, is a spoonful?
It is in the purview of physicians, NPs and PAs in pediatrics, family practice, internal medicine, urgent care, emergency medicine, retail health care and geriatrics to examine their patients who present with symptoms of a cold, allergy symptoms or a cough, resulting with a note recommending some form of OTC medicine. We commonly use the phrase “one or two teaspoons” and either document (or fail) to document this dosage. Either way, the potential for creating an iatrogenic poisoning or a drug reaction is quite high. It is always important to know what medications your patient may be taking - a critical practice which should accompany every patient encounter, whether new or not. Most PAs and NPs enter healthcare with the idea of working for 30-40 years but prudent attention to malpractice prevention can never start too early. Thorough, thoughtful practice can illuminate cross-sensitivity to prescribed OTC drugs. We need to look at OTCs as carefully as we would any prescribed medication, and it is equally important to know the age and weight of your patient, as a spoonful may be too little or too much. If the patient is a pediatric patient, the parent may be confused by the description of a spoonful and give a tablespoon, a teaspoon or a pediatric feeding spoonful. Children who are taking a drug, particularly an OTC drug, have a much greater possibility of a reaction.
For many of our senior citizens on polypharmacy, there are many potential drug-drug-interactions that will increase or decrease the effectiveness of their other medications making way for hypertension, severe hypotension or rhythm changes related to their cardiac drugs. For a moment, consider the patient on Coumadin. This drug has restrictions on other medications, as well as foods and alcohol which can greatly affect the INR and create a life- threatening bleed in the brain or in the GI system. I was scolded by my cardiologist a few years ago for taking a class lll antiarhythmic with herbal drugs or vitamins and minerals. He made me wait an additional hour in his office, then had me step into his private room and asked me, “What is it that you don’t understand about taking NO additional supplements or herbs?” As a healthcare professional, he was shocked at my actions. These substances can interact with my prescribed drug regimen to the degree that I could have developed Torsade’s De Pontes. He asked me if my need to take supplements - including fish oil, glucosamine and chondroitin - surpassed my need to live. His direct approach about my nonchalant attitude regarding supplements certainly got my attention!
Being careless can lead to a poor outcome for the patient, as well as a possible lawsuit. What can the collective “we” do to prevent a patient incident that is negative or life threatening? Check for other medications, review current drugs, look at age and weight and be cautious to write an OTC medication unless aware of all of the possible reactions. Is there anything else to glean from this? Another related concern is failure to document the other medications and to cross reference all contraindications, which are frequent causes for litigation involving PAs as well as NPs and particularly in the setting of the Retail Healthcare Clinic or Urgent Care Center. The same focus should apply to Telemedicine since it has become particularly popular during the pandemic. These concerns should encourage clinicians to consider how to best protect themselves, their professional futures and their families from litigation due to negligence.
Accuracy is the name of the game and is the mandate for all healthcare professionals but owning proper professional liability is the safest solution for potential error. It is not a coincidence that you are reading this today, but a heartfelt concern of a colleague who wishes all PAs and NPs a long and successful career. You do not want to create a life-threatening situation or worse. Our ultimate goal is to retire with professional pride and satisfaction – with NO history of careless nonchalance or, pardon the expression, “sloppiness”. Perhaps this “spoonful” of advice might help…
I just moved to NoCal (Silicon Valley) area due to my husband's new job. My attending in Florida contacted his friend at a major university here and got me my dream job. I have five years of pediatric surgery experience and have been told that I am expected to train the other NPs in the group (who all have less than or around one year of experience in the subspecialty). I am less than one week into my job and today I found out that one NP (who has just over one year of experience) is being paid slightly more than me. Apparently this institution counts nursing experience as part of their calculations in salary. She told me what her starting salary was which was about 8k lower than me. She has since received a raise and her salary is now just a hair above mine. Part of this is because she was the only one running the show for awhile so they may have been given a performance bonus of some sort.
This was very deflating to me given that I have five years of experience being a provider, have an entire OR skillsket, and have been asked by the NPs to proctor them to first assist only to find out that they are being paid more than me.
Anyone else run into these situations in this area? From what I have read on this forum the nursing unions are very strong here in NoCal. Does this apply to NPs as well? When I received my initial offer from HR I asked if there was any room for negotiation and was told no because it was based on a scale for my clinical background.
I currently work in a psychiatry practice, they told me that it was hard finding ARNP's to fill the role because they look for PMHNP certification in particular. ARNP's are a dime a dozen but PMHNP are not.
My 1st job out of PA school was with a Primary Care practice and there was an ARNP that was on her way out. She told me she took a job in psychiatry. So I wasn't sure if she was PMHNP certified because she was already working 1 year with us (the primary care practice).