Doing work

[Acebecker]

All -

 

I think I'm noticing a trend among new docs and PAs who are younger wherein they do not want to work hard.  Is this a common thing that y'all are noticing?  Am I just of an old school mindset? 

 

Here's the setting - I worked urgent care for a few years.  Averaged 25 pts/day throughout the year but during peak seasons we'd be >33/day, solo coverage.  We worked to increase this and added another PA so we had double coverage.  However, our volume has not increased as much as projected but the new providers we hired to help double cover are complaining that it's too busy when we have asked them to cover part of the day by themselves.  Same with one of our newer grad MDs - she's doesn't want to add in patients.  The other thing that I'm seeing is that our urgent care guys don't want to take on anything remotely complex (pneumonia in an elderly person gets sent elsewhere).  I don't want to second guess these providers - freedom to judge what is and what is not appropriate is important, but these are patients who belong to our clinic.  Taking care of them seems to me to be our duty whether their illness is easy or hard to take care of. 

 

Am I myopic?  Or is my experience representative of medicine in general?

 

Andrew

[Katera]

UC is treat'm and street'm. If you mean they won't even see them initially then that could be a problem. If you mean treating and following them? No way, not in UC. That is not the place for following a high risk issue. Liability is just too great.

[Reality Check 2]

I have worked with new grad docs and PAs and old timers alike.

 

Some of the newer folks seem to want to cherry pick. I had a new doc tell me "I don't want to see that. I have seen it. I want to see new things."

 

My blank death stare and silence made him uncomfortable. I told him it didn't work that way and he saw whatever came down the pike. So, see 500 UTIs - practice makes perfect - big cheesy smile.......................

 

Every ER and UC will have the slug who spends a lot of time in the break room and never seems to be around when stuff comes in. I have yet to come up with adequate and legal ways of dealing with those folks.

 

As far as UC - if CPR is in progress in the parking lot - better not check them in.

If someone is SOB and still conscious - assess, stabilize, treat, and transport if indicated. You didn't tell that patient to come see UC instead of ER but once in the building - do what is needed to deal with them. I don't think turning them away before assessment if very legal or ethical. 

 

Folks have different comfort levels with what they will handle - not fair but it exists. 

Some of us are way more comfortable with exposed bone or that funny color that indicates something bad is happening.

UCs should, in my opinion, have levels of assessment that give providers in general an idea of what is ok and what is not. Some folks get turfed because they take up time and make folks actually work. Some folks should be turfed sooner than later. 

 

If there were a way to set criteria - say - O2 sat still 89 on 4 L or nonrebreather - yep, let's get that one to a larger facility.

But, the migraine without neuro changes who is a bit of a baby - suck it up - it comes with the territory.

 

If we expect our patients to not treat medicine like Burger King then we should certainly not act like Burger King employees.

 

If a provider never removes their hand from the doorknob while assessing the patient - bye bye provider.

 

So, nutshell, I would agree Ace - there seems to be a sense of entitlement and cherry picking coming out of schools recently with a desire to limit exposure, make visits short and probably insufficient. I see it. Those folks should have gone into data entry and punched a clock.

 

Cranky old 2 cents

[LKPAC]

To answer your question: Yes, newer generation providers are (generally) lazier.  They don't want call, they don't want to be too busy, and they don't want to handle difficult cases.

[Acebecker]

UC is treat'm and street'm. If you mean they won't even see them initially then that could be a problem. If you mean treating and following them? No way, not in UC. That is not the place for following a high risk issue. Liability is just too great.

 

Yup, worked UC for 4 years so definitely get the treat and street mentality.  That mentality is what is most appropriate because there should be no follow-up in UC - all following of patients should be with PCPs.  Liability is terrible. 

 

What I'm talking about is the elderly male who has a mild cough, fatigue, SOB but is satting ok; was not seen because the provider of the day did not want to do the work.  And I'm talking about this more broadly - people are not evaluating any abdomens and sending them all to the ED.  Our IM docs are not adding on their own patients for quick visits between their regularly scheduled visits.  It's not a UC issue, I don't think - it's a work ethic issue. 

 

Three things to say about this 1. The people who have picked our clinic for a primary care office should receive the care they need including same-day visits with their PCP for follow-up stuff or access to our UC as long as they are not actively trying to die. 2. our clinic is privately owned and all of us make a salary based in part on how many patients we see.  3. Our clinic doors stay open because we all work hard.  Our doors will not stay open if we do not all accept responsibility to see patients and generate revenue. 

[Reality Check 2]

"Three things to say about this 1. The people who have picked our clinic for a primary care office should receive the care they need including same-day visits with their PCP for follow-up stuff or access to our UC as long as they are not actively trying to die. 2. our clinic is privately owned and all of us make a salary based in part on how many patients we see.  3. Our clinic doors stay open because we all work hard.  Our doors will not stay open if we do not all accept responsibility to see patients and generate revenue. "

 

TOTALLY AGREE

 

If you go to work - WORK. See patients. Treat patients. Send patients to ER IF THEY NEED IT.

 

I can't do Lazy - just isn't right.

[rev ronin]

The flip side of this is that quality of care suffers when providers are rushed.  One Group Health senior doc--as in, one of the medical directors--was just admonished by the Medical Quality Assurance Commission for something that sounds quite trivial to have spotted, and the plain-as-day signs are right there in the patient's electronic communication to the provider.  So what happened?

 

Too many work-ins. Too much email.  Too much paperwork.

 

When I want to see 2 patients per hour, it's not because I'm lazy.  It's because if I want to make money, I'll go be a HIPAA consultant.  I don't see patients to make money, I see patients to meet THEIR needs, listen to THEIR concerns.  Can't do that when we're maxpacking patients to increase profit margin because the malpractice premium is just a cost of doing business.

[BruceBanner]

I think people have different ideas of "working hard". But yes there is probably a generational difference. The current generation is getting into the profession more for lifestyle I feel.

 

Also there is a tendency in all primary settings--FM, UC, EM--to pass the buck whenever possible. UC hates it when we send them overflow patients, EM tries to keep people in clinic if they can, and FM tries to boot things to specialists and urgent/emergent care whenever possible. We're all busy, and no one wants to be more busy, because there is an inverse correlation between job satisfaction and patient volume.

 

And like Rev said, patient care really does suffer above a certain volume threshold.

[sk732]

I had a referral a couple weeks ago - started with a phone call because the NP at the "Quick Care Clinic" (a misnomer at best, oxymoron at normal) had a lady with high blood pressure and vertigo...wanted her started on labetalol.  I asked a routine question - how was the neuro exam?  "Well, I didn't do one".  WTF???!!!  I suggested they do one and call me back - since it sounded like BPPV causing the HTN vs the other way around.  "But she has high blood pressure!!"  "I've had BPPV - it's pretty stressful, making your BP go up - do a neuro exam."   Sounds like all they did was a Rhomberg, since it was apparently positive, so I said send her over...and her exam was positive for only a rapid horizontal nystagmus to the affected side. Turns out the lady had a PHx of, you guessed it, BPPV...and a resoling URTI.

 

The things I've  noticed from some of the doc in the boxes (or NP in the trees) of late is that nobody wants to make a clinical decision about even simple things...or even rule out the easy stuff before panicking over the not so easy stuff.  Frig, I had an appointment only family med practice where I would see walk in's for things like eye FB's, minor suturing, SOB's and the such - I was rural, was trained in the military, so used to nobody being around, and so did what had to be done to either sort it out or get it out - but do the necessary stuff FIRST before getting it out.  Three letters come to mind - D, U, H...and add as many exclamation points after as needed. 

 

I'd have to say there is a lot of lazy combined with propagation of Doltus Erectus.

 

$0.02 Cdn

 

SK

[Katera]

^^^ High BP with Vertigo will virtually always be referred to the ED in the UC clinics I work in.

 

Liability. Simple as that. Not worth the risk when you have no serious lab/testing capabilities. I know the ER guys hate it, I know I did. It's just the way it is though. They can cry about it, but it won't stop the referrals from pouring in.

 

One other little tid bit, unlike the ER folk, the doors of UC close at a certain time. There is no way most providers I know are going to stay uber late to work up a high liability visit...Truthiness!

[Guest JMPA]

N please

[sk732]

Where I come from and where I trained, you make the effort to at least properly examine the person before firing them off to the ER - there is actually a doc in one of the health regions nearby that's being disciplined by the College for just that reason - failing to send proper referrals and failing to send proper referrals due to failing to examine the patients AND sending them to the ER for primary care problems.  Add to that stupidity, IIRC, they're also being disciplined for fraud for billing for the visits that never really were...

 

SK

[Katera]

Where I come from and where I trained, you make the effort to at least properly examine the person before firing them off to the ER - there is actually a doc in one of the health regions nearby that's being disciplined by the College for just that reason - failing to send proper referrals and failing to send proper referrals due to failing to examine the patients AND sending them to the ER for primary care problems.  Add to that stupidity, IIRC, they're also being disciplined for fraud for billing for the visits that never really were...

 

SK

 

 

That's where you get into trouble, billing for doing nothing.  Unfortunately every corporate owned UC or retail health chain is adamant that any patient who walks in the door gets a nice fat charge.  Talk about adding insult to injury....

[jmj11]

I haven't worked in UC for 20 years but I can comment on the trend in general for the past 35 years. Two things are at play. One, quality of life issues are more important for this generation than in the past. I know many 20-30 year old that say they only want to work enough to buy their experiences (travel, rent, food) and toys. I can't blame them too much for that. The second thing is that it now takes more energy to see the same amount of patients. Maybe double, than it did 35 years ago. Now, I waste so much time and energy with insurance companies, ACA etc. It was easier to see 30 patients per day when the note was a short scribble than now where I have to enter 10 minutes of data to satisfy all the parameters. Then there are things like PAs (prior auths, not PAs as in PA-C). This was unheard of in the early 80s. Even the DRGs were new and highly offensive. Now the insurance companies are treating the patient, we only are acting as their surrogates. 

[SHU-CH]

I have tried to warn students that they are going into an intense work environment but they do not always believe me. I have seen a few graduates switch jobs 2 or 3 times in the first several months after graduation. I think by the third job they finally realize, "Wow, this is what the real world is like!"

 

Most students with a serious work allergy will get selected out by PA school. But It seems to me like each year in the applicant pool the GPAs are getting higher and higher while the student capabilities are deteriorating. Undergrad institutions are giving an "A for effort" and not for proven ability in many cases. Students come to PA school never really having received negative feedback or having had to expend serious effort on their studies. We are coddling people and doing them a disservice.

 

I guess I am getting old and grouchy and this is is all nothing new. Eugene Stead himself said, " It has always been of interest to me to see how students run a collective protective society and avoid what they came to school for."

[Reality Check 2]

I hear two issues in the posts - provider effort, desire and expectation and then the UC/ER dogma, metrics, business aspect.

 

It doesn't necessarily mean these two concepts can mesh.

 

I agree with Christopher above - students are different in each generation and we shouldn't be coddling them. A high GPA does NOT imply any form of common sense, work ethic necessarily or team capacity, muchless patient confidence or bedside manner.

 

A Zombie Loving Friend likes to make students pretend it is the Zombie Apocalypse and they have ZERO technology - use your eyes, ears, stethoscope, and intuition to diagnose the patient based solely on history and exam. Some students kind of freak out and want to consult their iPad or phone or epocrates or emedicine. He won't let them. They get frustrated and say he is restricting them. I laugh - he is making them use SKILLS and go to an uncomfortable place. 

 

I went to school before the internet and before digital xrays and before WebMD. We actually had to lay hands on the patient or flunk a rotation and we had to make a differential BEFORE the MRI, CT, lab, etc. 

 

There is work/life balance that involves actual real and often HARD work. I get tired of folks who want to work the bare minimum, make top wage and not take their place in the totem pole as far as those of us with experience and tenure. There is truth to "do your time, earn your stripes". 

 

Perhaps we need to do an even better job with new students making sure they know there is no technologic substitute for actual skills and hands on patient exam AND make sure they know they will be expected to actually work upon graduation. There is no such thing as a free lunch. 

 

Then we can broach the next subject of too many PA schools, too many graduates and our profession not quite being in an advanced enough place to handle all this for the future.......

 

another thread perhaps.

 

cranky old 2 cents

[mgriffiths]

In regards to students being coddled...I was a high school teacher before deciding to go back to school - quick story that was one of the final straws that sadly pushed me FAR AWAY from education.

 

I taught mostly juniors and seniors in chemistry/biology.  In my remedial chemistry class I had multiple seniors who literally could not read.  No, I don't mean they struggled with their textbook.  I mean I purchased elementary level books (think Dr. Seuss and similar) and actually worked on reading in the back of the classroom with them while their classmates completed labs, practice problems, etc.  Obviously there was no possible way these students were going to pass chemistry class, let alone their literature, history, or math classes.  About halfway through the first semester I was called into the principal's office to discuss why so many of my students were failing.  I found out these students who could not read were magically passing all of their other classes.  When I brought up the question of how we planned to graduate these students who couldn't read, the answer was that it was my job to make sure they passed - TRANSLATION: their performance did not matter, their graduation was required.

 

It does not take long for students to figure out when their success does not hinge on their work ethic, and this has grave consequences.  If they can get by doing the minimum and still "progress" then that is what will happen.

 

NOTE: obviously this is a much more complex issue than how I presented it, and honestly I don't have the perfect answer, but I could not continue in a profession where students were rewarded with high school diplomas when they literally could not read.

[jwells78]

Undergrad institutions are giving an "A for effort" and not for proven ability in many cases. Students come to PA school never really having received negative feedback or having had to expend serious effort on their studies. We are coddling people and doing them a disservice.

 

- and I think you just stumbled upon an enormous problem in this country. You could have added common core to the fray and I would have posted a giant gif of Maverick giving Goose a high five.

 

Trophies for 8th place, three sticks and a watermelon with three hashmarks equal 6, stress cards in bootcamp so Drill Instructors can't smoke you for mistakes, hurt feelings reports...

 

We are hard-wiring our youth to have no coping mechanisms or work ethic.

 

... sorry, tangent

[SHU-CH]

We might be here already; if not, it isn't far off...

 

[newton9686]

This is why I have a problem with the applicants who come in talking about work life balance. To many people my age have no appreciation for a hard days work. It's all about 4 day weeks, closing up shop at 3pm and referring (but don't forget to swipe your visa on the way out.)

[WeBuyAndSellJunk]

This thread is ridiculous. You could post some the same mumbo jumbo from 20-30 years ago about the youth.

[Guest GoyaHoya69]

Unfortunately this is something I've seen quite a bit as well, and I'm only in my mid-20s. I grew up washing dishes and mopping floors for a father who HATED lazy people (he was an immigrant who worked his tail off since he was a child). Though I'm not in PA school yet, I've been on several interviews, including one yesterday, where people are fed up with not having gotten accepted anywhere "good" yet. They seem to blame the system instead of asking themselves what they can do to improve their interviewing skills or overall application. They seem to feel entitled to get into PA school and, frankly, it's annoying. It also slightly worries me because people like that are going to be my colleagues someday.

 

 

Sent from my iPhone using Tapatalk

[LT_Oneal_PAC]

"Never has youth been exposed to such dangers of both perversion and arrest as in our own land and day. Increasing urban life with its temptations, prematurities, sedentary occupations, and passive stimuli just when an active life is most needed, early emancipation and a lessening sense for both duty and discipline, the haste to know and do all befitting man's estate before its time, the mad rush for sudden wealth and the reckless fashions set by its gilded youth--all these lack some of the regulatives they still have in older lands with more conservative conditions." Psychologist Granville Stanley published in The Psychology of Adolescence, 1904

[LT_Oneal_PAC]

"...a fearful multitude of untutored savages... [boys] with dogs at their heels and other evidence of dissolute habits...[girls who] drive coal-carts, ride astride upon horses, drink, swear, fight, smoke, whistle, and care for nobody...the morals of children are tenfold worse than formerly."

Speech in the House of Commons by Anthony Ashley Cooper, 1843

[LT_Oneal_PAC]

"The children now love luxury. They have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise."

 

-Socrates