Is this what I should expect?

[EDDinoh]

Hey guys,

I'm having some issues with my job and I need a little tough love. I'm not sure if this is what I should expect from all ER jobs and maybe I'm in the wrong specialty, or if this is just the wrong job for me.

This is my 3rd year practicing, all ER, going on 1.5 years at this facility. I'm working at a very busy Level I Trama Center where I can see everything that walks through the doors and I get to do most of my own procedures (some things are farmed out to the residents in other specialties). Docs see the trauma patients, but we do mostly everything else. We have NP/PA coverage 50 hrs a day and 40 hrs of Doc coverage. For the past year I have loved the position and feel like I'm adequately compensated with a wide scope of practice. However, we have had A TON of turnover lately which resulted in hiring 3 brand new grad NPs and 2 fresh out of school PAs.  They are all great and trying their best, but this is not a position for a new grad. We have no training systems in place and it's a sink or swim mentality. This has put me in a position where I'm seeing 30 patients in a 10 hour shift with basically no physician oversight. The new grads just can't manage the acuity of patients that we see in a timely manner, and frankly, no one should expect them to. The docs will sit, watch tv, eat and occasionally come see a patient if one of us asks for help. 

 

Its gotten to the point where I don't feel like I can safely manage the number of sick people that I am seeing and I am not getting any physician support. I have been speaking with other people and they all feel like that's the way ER is now, that PAs run themselves ragged while the docs sit back and relax. Is this true? I've started looking at other positions, both ER and other specialties. I love the ED and have developed so many skills I don't want to lose,  I just don't want to find myself in the same position in a year.

 

Thanks!

[EMEDPA]

I have had that experience at many facilities in the past. I left one place when I saw 56 pts in 12.5 hrs to the docs 8...pulling from the same rack regardless of acuity.

now I work solo/rural and those issues are nonexistent. I won't go back.

[GetMeOuttaThisMess]

9 hours ago, EMEDPA said:

I have had that experience at many facilities in the past. I left one place when I saw 56 pts in 12.5 hrs to the docs 8...pulling from the same rack regardless of acuity.

now I work solo/rural and those issues are nonexistent. I won't go back.

I had this experience during my ED days.  One guy would literally sit at the desk with feet propped up on the counter and tell me "You're doing a great job" as I'd grab a couple of charts instead of just one.  When the "fast track" concept came into play I'd get slammed and never have any of the ED docs see one of mine yet if I was slow and they were busy then it was all hands on deck.  Note how I mentioned my ED experience in past tense.  Again, this was in the earliest of days of PA's in the ED in Dallas and I was the initial one at each of my two primary locations so I didn't want to burn any bridges.  I left that to those who later came onboard at each and performed the bridge burning for me.

[GreatChecko]

No its not like that everywhere. Some places, everyone shares the load or in some cases the MDs are way too involved. It really depends. I've worked in 3 EDs and in each one the docs are expected to pull their load or were overloaded themselves.

That being said, every ED has its issues. So, you'll likely find something that will peeve you about your next job, regardless of how the PA/MD relationship works. For example, I work with docs that are supportive and will teach when they get a chance. However, its a contract/corporate shop, so there are many of other pressures and annoyances that have nothing to do with taking care of the patient sitting in front of you.

 

[eighthnote24]

I have had this issue the majority of my ER career.  You have to stop letting yourself pick up so many patients.  This is really hard for me because I am all about efficiency and I HATE seeing a gridlocked ER or a full waiting room.  But you have to stop letting yourself be taken advantage of.  Those attendings are getting paid very well and damnit, they can pick up some patients. 

If you're at a level 1 trauma center with residents around....you are in a much better position to do this than if you were at a critical access ER.  Trust me, it gets so much worse in those smaller ERs.  For some reason administrators tend to think that less experienced or retirement-aged docs are more appropriate to staff those ERs and that couldn't be further from the truth.  You will work wayyyyy harder and the differential in number of patients seen between you and the doc in a smaller ER will be MUCH wider.  Let those residents and attendings pull their weight in that level 1 trauma center.

If you trust the nurses you work with.....you can fight the issue this way.  Leave the patients without anyone assigned to them and just let the nurses know that you have hit your limit, and they should go ask the physician what orders they want on the patient. After a while the nurses will just do this automatically when they see you already have several patients assigned to you.  Then the physician essentially has no choice but to accept responsibility and see the patient.  

Alternatively, you can just disappear for a while.  Extended bathroom break.  Whatever.  

 

 

[EMEDPA]

the opposite of this is the RVU driven shops where the doc either wants to see each pt or write a note on all of yours so they get their share of the bonus money. you spend 2 hrs with a pt. they introduce themselves and write "seen by me, agree with pa assessment and plan" on the chart and take 50% of the RVUs....greedy bastards....

[Boatswain2PA]

What others have said.  Simply stop doing what you're doing.

I'm guessing everyone is paid hourly.  You will get same pay if you see 1.25 pph or 5pph, so see 1.5.  Once the c-suites see the door-to-doc times are increasing they will start looking at where the problem is.

And you can flex it.  If there are some docs who work hard alongside you, then work hard alongside them.  Their DTD times will look stellar compared to Dr. Lazya$$.  

There's a term in the military:  "Drive it till it breaks".  Usually used for when some REMF/bureaucrat/E-mailocrat mid-grade Officer comes up with a policy that the operator's KNOW is stupid and will cause problems.  Okay, we will just make sure this problem crashes HARD.

So make it crash hard on Dr. Lazyass. If he sees .75 pph, then YOU see .75pph.  Go to the bathroom a lot.  Document exquisite notes.  Spend extraordinary time in the patient rooms asking the LOL about her grandkids.  Get your patients coffee....You may even improve your press-ganey scores and be the administrator's favorite!

[EMEDPA]

If you work in a group in which all the docs are partners and buddies and all the PAs are not they don't care if Dr lazyass is lazy, because he is their golfing buddy. they care if you are lazy because you are not a partner. dealt with that at last job for 15 hrs. lots of great docs, but also lots of docs I wouldn't take my dog to.

[Guest ERCat]

Sorry you are dealing with this. I agree with the above advice

This is not the case in my ER group, generally. We work in various locations. In the big ER, doctors have their own "wings" that they are responsible for. The PA's job is to help out in all the pods as needed. Here t is not uncommon for the doctor to have ten patients and the PA to have five. In the slower, smaller ER we work at, there is NO "wing" system. Most of the doctors realize they have scribes and we don't, so they tend to see more patients. A few doctors expect we pick up as much as they do. I only know of one doctor in my group out of maybe 40 that continually takes advantage of the PAs and sits there on two patients.