New grad Started a job in urgent care. Any resources to help me gain confidence/understanding?

[LonguylandPA]

I will be training for the next 2-3 months with an awesome PA but I still feel that I need a deeper understanding  to follow/ learn from

 

My review books are too abstract and not practical for life scenarios. for example. management of children and infants with fever with confirmed/unconfirmed source is something im not comfortable with and cant seem to get a grasp on it. 

Is there any resources out there: audio/video/text that are high yield for urgent care scenarios?

 

thank you

[SoCal_PA]

Ditch the books and learn on your feet. Gotta cut the cord as hard as that seems

[newton9686]

Not all the cases are applicable, but as a new grad PA waiting to credential I've been studying Case Files Emergency Medicine. They go over FUO really well. Just remember <90 days old + fever (even if mom took it and they don't have one now in clinic) = hospital admission and work up. Everyone else in peds assuming they dont a significant PMH such as sickle cell depends on how sick they look and associated symptoms (HA, abdominal pain, URI, GU symptoms etc)

[LonguylandPA]

1 hour ago, newton9686 said:

Not all the cases are applicable, but as a new grad PA waiting to credential I've been studying Case Files Emergency Medicine. They go over FUO really well. Just remember <90 days old + fever (even if mom took it and they don't have one now in clinic) = hospital admission and work up. Everyone else in peds assuming they dont a significant PMH such as sickle cell depends on how sick they look and associated symptoms (HA, abdominal pain, URI, GU symptoms etc)

are you sure? from my sources its <90 days old + fever with abnormal general appearance warrant hospital admission 

[Cideous]

I feel for you.  I shat myself the first time I worked independently in the ER.  I had a doc tell me I had no business being there and he was prob right.  I was way to inexperienced, but I was also young and stupid.  I didn't know what I didn't know....After a few hours, I thought I was going to have a nervous breakdown lol.  Urgent care is sneaky.  You let your guard down because we are supposed to be low acuity....until we're not.  A wise doc in the ER told me once after noticing me obsessing over every pt, he said "This is the ER, we are not here to fix everyone, just make sure they don't die on our watch".  That is the mentality you should have for UC as well.  You will be faced everyday with stuff you won't have a clue what to do with, and with CLIA waved testing, you won't have much lab or imaging help.  So make sure you simply cover the bases.  Put in writing to follow-up and learn to end with this phrase on every chart.  "Strict ER precautions discussed.  Understanding verbalized."  Just those 6 words can make a huge difference should something go wrong.

You're not going to like what I will say next, but whatever.  If you just graduated, and you are new to medicine (not a previous EMT, Nurse, Respiratory Therapist etc), then you are asking for trouble going it alone after only 3 months.  You can not possibly get comfortable flying solo in 3 months.  It's just a bad idea.  If it's a busy UC, even worse, because you will have a devil of a time sifting acuity AND volume.  My advice is to work with another provider at least double that.  Run almost everything by them and start making mental notes of what he/she does on the borderline cases.  I just got off a shift and saw a crap-ton of kids with fever.  Some positive for the flu, some neg.  Hundreds of little decisions that need to be made. Who get's treated? 

Anyway, I wish you the best.  Just remember, you can't fix everyone, but you can make proper referrals to those specialists/PCP's that can.  Oh, and be nice.  UC lives by Yelp reviews.  Start getting bad reviews online and most UC's will drop the hammer.

..Oh and any kid less then 3 months old with a fever >100.5 get's a septic work-up, which means ER.  

[LonguylandPA]

56 minutes ago, Cideous said:

I feel for you.  I shat myself the first time I worked independently in the ER.  I had a doc tell me I had no business being there and he was prob right.  I was way to inexperienced, but I was also young and stupid.  I didn't know what I didn't know....After a few hours, I thought I was going to have a nervous breakdown lol.  Urgent care is sneaky.  You let your guard down because we are supposed to be low acuity....until we're not.  A wise doc in the ER told me once after noticing me obsessing over every pt, he said "This is the ER, we are not here to fix everyone, just make sure they don't die on our watch".  That is the mentality you should have for UC as well.  You will be faced everyday with stuff you won't have a clue what to do with, and with CLIA waved testing, you won't have much lab or imaging help.  So make sure you simply cover the bases.  Put in writing to follow-up and learn to end with this phrase on every chart.  "Strict ER precautions discussed.  Understanding verbalized."  Just those 6 words can make a huge difference should something go wrong.

You're not going to like what I will say next, but whatever.  If you just graduated, and you are new to medicine (not a previous EMT, Nurse, Respiratory Therapist etc), then you are asking for trouble going it alone after only 3 months.  You can not possibly get comfortable flying solo in 3 months.  It's just a bad idea.  If it's a busy UC, even worse, because you will have a devil of a time sifting acuity AND volume.  My advice is to work with another provider at least double that.  Run almost everything by them and start making mental notes of what he/she does on the borderline cases.  I just got off a shift and saw a crap-ton of kids with fever.  Some positive for the flu, some neg.  Hundreds of little decisions that need to be made. Who get's treated? 

Anyway, I wish you the best.  Just remember, you can't fix everyone, but you can make proper referrals to those specialists/PCP's that can.  Oh, and be nice.  UC lives my Yelp reviews.  Start getting bad reviews online and most UC's will drop the hammer.

..Oh and any kid less then 3 months old with a fever >100.5 get's a septic work-up, which means ER.  

thank you. this is what I needed to read

 

its a busy UC. we see on average 90-120 patients a day during a 10 hour shift. is it realistic to expect a new grad to be solo within 2-3 months to handle that?

[beattie228]

I really like the Urgent Care podcast from Hippo (Called Urgent Care RAP). It's like $200 a year, but you answer 10 questions a month for up to 3.5 cat 1 CME a month and it's been very high yield for the stuff I see day to day in UC. Plus, the podcasts are available in PDF format, which is great for reading on the job or just plowing through the material faster. There are chapters from a MD who is also a lawyer, and his pieces on the 'Don't Miss These Things' and 'Chart Like This' have changed the way I approach certain patients. I've been practicing for a few years in UC and I still learn something new from the monthly episodes.

 

Also, being solo in UC as a brand new grad is a recipe for disaster for you, your patients and the UC you work for. If your shop truly sees 90-120 patients a day and you're expected to hit the ground running in 2-3 months time, you should think long and hard about whether that gig is a position for you in 5 years time rather than being 5 days out of school. My shop sees 50-60 in 12 hours and it's always a PA + MD team. 

[newton9686]

Yeah unfortunately most urgent cares, at least the ones around here do not have you working side by side with an MD, even early in your career. While it is true that it is less than ideal for someone to be solo in an UC early in your career, its the way most places (at least around here operate). Thats why you have to have the fear of God in you, which means you are constantly looking for a reason to send a person to the ER. What if that cough is a PE? What if that generalized abdominal pain is early appendicitis, mesenteric ischemia or a MI? No one can catch everything working urgent care or ER, but you sure as hell missing a couple if you are constantly diagnosing everyone with bronchitis and gastroenteritis. And like someone said. And as someone mentioned always put the ball back in the patients court and document your instructions to seek further medical attention if symptoms do not improve. Also if you tell patients you are 90% sure this is not something life threatening, but the only way to rule it out is a CT scan, most will respond, "I don't think that is necessary right now". Document "patient was offered a CT scan and declined at this time, patient agreed to seek further medical attention if symptoms do not improve or if they develop any additional symptoms." Because no one, including seasoned PAs and MDs make the correct diagnosis every time. The ones that get sued are the ones who do not talk about the possibility of a life threatening condition with their patients or make mention of it in their notes. 

[GetMeOuttaThisMess]

Never diagnose “gastroenteritis”. It’s always abd pain, N/V/D as applicable, or something else vague. Nothing wrong with using symptoms for a diagnosis.

As noted above, at some point GE becomes a missed appendicitis, even though it actually was just GE when you saw the pt..

[LonguylandPA]

5 hours ago, beattie228 said:

I really like the Urgent Care podcast from Hippo (Called Urgent Care RAP). It's like $200 a year, but you answer 10 questions a month for up to 3.5 cat 1 CME a month and it's been very high yield for the stuff I see day to day in UC. Plus, the podcasts are available in PDF format, which is great for reading on the job or just plowing through the material faster. There are chapters from a MD who is also a lawyer, and his pieces on the 'Don't Miss These Things' and 'Chart Like This' have changed the way I approach certain patients. I've been practicing for a few years in UC and I still learn something new from the monthly episodes.

 

Also, being solo in UC as a brand new grad is a recipe for disaster for you, your patients and the UC you work for. If your shop truly sees 90-120 patients a day and you're expected to hit the ground running in 2-3 months time, you should think long and hard about whether that gig is a position for you in 5 years time rather than being 5 days out of school. My shop sees 50-60 in 12 hours and it's always a PA + MD team. 

A question thats prominent in my head is this: why would the urgent care (3 branches and growing) allow me to do this then if its deemed unsafe?

[beattie228]

Business decisions aren't made with your best interest or the interest of the patient. It's strictly numbers driven for monetary gain. Solo, brand new PA seeing 90-120 patients a day gives you little to no time to tease out the subtle nuances for sick vs not sick. Also, being so new out of school means you don't have the exposure yet to know what you don't know, if that makes sense. That said, I'm just a stranger on the internet so do what you want with the above advice.

[beattie228]

Quoted from @CAdamsPAC from another UC thread. He hit the nail on the head for the point I was trying to make. 

51 minutes ago, CAdamsPAC said:

Adrenal crisis, Acute Renal Failure, Pneumonitis, Pulmonary Emboli are a few "Fast Track" patients triaged to me but again I was an experienced PA in the UC area. All new grads need to be in a good teaching environment with peers and MDs who want them to develop and work at making them better clinicians, not just another drone worker bee! Many ED have discovered that UC/Fast Track is where experienced PA need to be not new grads.

[LonguylandPA]

2 minutes ago, beattie228 said:

Quoted from @CAdamsPAC from another UC thread. He hit the nail on the head for the point I was trying to make. 

So what should I do in my position? im already liking the office staff and the pa whose teaching me. Im happy with the salary and the location. I really dont want to give it up. what are my options? 

[beattie228]

I'd continue with what you've got. Especially if you're doing side by side training with someone who's experienced. Ideally not getting thrown to the wolves once your training period is over. As long as your employment agreement doesn't have a Do Not Compete clause (which you should never sign, especially if you work in a Metropolitan area), you can always jump ship if you're not comfortable with the position once training is over.

UC as a whole is a great field for PAs. I have a ton of autonomy, pays well, and it works well for my personality. Just takes time to develop the skill-set, just like any other field of medicine.

[LonguylandPA]

Just now, beattie228 said:

I'd continue with what you've got. Especially if you're doing side by side training with someone who's experienced. Ideally not getting thrown to the wolves once your training period is over. As long as your employment agreement doesn't have a Do Not Compete clause (which you should never sign, especially if you work in a Metropolitan area), you can always jump ship if you're not comfortable with the position once training is over.

UC as a whole is a great field for PAs. I have a ton of autonomy, pays well, and it works well for my personality. Just takes time to develop the skill-set, just like any other field of medicine.

Thanks, I agree.

im training 20 hrs a week for the next 2-3 months and listening to UrgentcareRAP hippo ed (debating buying it now for $200) in my spare time 

[marktheshark89]

90-120 patients for a solo provider is insane, dangerous, and a recipe for malpractice. How could you even defend yourself in court if you made an error? I would not be risking my license working in an environment like this. Assuming roughly half your time is spent charting and with administrative tasks, seeing 120 patients by yourself in 10 hours would amount to a whopping 150 seconds on average spent with each patient. I work in an urgent care that sees a similar volume and is always staffed with 3 providers. Anything above 3-4 patients per hour for even experienced providers is challenging. 

I have found both Urgent Care RAP and PRimary Care RAP to be entertaining and valuable resources as well, as beattie and others mentioned. 

[newton9686]

90 patients over a 12 hour shift isnt even humanly possible is it? When I was an MA at a hand clinic we would knock out 55-60 in a day but that was follow ups and injections. But all your patients at an urgent care are new patients. A lot of it is simple, but life threatening conditions come into urgent cares every day.

[Cideous]

5 minutes ago, newton9686 said:

90 patients over a 12 hour shift isnt even humanly possible is it? When I was an MA at a hand clinic we would knock out 55-60 in a day but that was follow ups and injections. But all your patients at an urgent care are new patients. A lot of it is simple, but life threatening conditions come into urgent cares every day.

It’s not possible unless they are counting school physicals and/or drug screens which a lot of UC’s count in their daily numbers.  Other then that, not possible.

[LonguylandPA]

42 minutes ago, Cideous said:

It’s not possible unless they are counting school physicals and/or drug screens which a lot of UC’s count in their daily numbers.  Other then that, not possible.

90-120 patients in 10 hours

[marktheshark89]

Run, fast

[thinkertdm]

100 patients in 10 hours, that's 10 an hour.  That's 1 every 6 minutes, including introductions and hand washing. 3 minutes history, 2 minutes physical exam, and one minute explaining what they have and their meds.  You also need to chart defensively.

Try this- 70 yo, cc "cold" x 3 weeks- time yourself to list worst case ddx, and physical exam findings.  Was it under a minute?

4 year old with fever of 103 dx strep via rapid swab, allergic to amoxicillin, but has taken cephalosporins without problem-solving just last week for aom.  What's your next choice?

56 yo with urinary symptoms and lots of leuks on dip, loves her some Cipro.  No allergies, kidney function is fine.  (Time checking labs eats time).  What's wrong with Cipro?  Best choice?  How many days for macrobid?  Bactrim?  What if her gfr is 30?

That's your first 18 minutes right there.

I don't want to scare you to death, but it can be done- however, lawsuit, and knowledge of a medical error would live with me.  My advice, from random dude on the internet- take some time, learn medicine- you can even learn it fast, but in a place geared for making people better, not to make money.  

Here's two vignettes- first, my mil went to an urgent care for dysuria, was started on macrobid for probable UTI.  However, her kidney function wasn't checked, and it could have been, because it was the same hospital system.  Two days later, she was in the icu with renal failure.  Was the macrobid responsible?  I don't know.  The dose wasn't renally adjusted.  There was no mention of her kidney function on the note.

I saw a fellow for a post er visit; his throat was still sore.  I looked and found a mass in the back of his throat, easily found if you looked.  Look closely and you can see it's nicely vacularized.  Not strep, as written in the progress notes.

[MCHAD]

Ok, I’m hoping we all read this wrong.  Please tell me that ONE provider is not seeing 90-120 patients in a 10 hour shift. New or Experienced this is dangerous for both the patient and the provider.  

[LonguylandPA]

Hello id like to include an update on the position:

 

Turns out that the pa ive been training under is an experienced 17 year pa who did ER /ortho for a long time. he is completely knowledgable in every subject and basically on an attending level.

 

I am hired to work in the other two branches of the urgent care where theres always TWO PAs per shift. I will be one of two.

 

We currently see 100-110 patients per day because of flu season (80-90% of our patients complaints)

I was told that once flu season passes we will be seeng 60-70 pts a day.

 

So 2 pas with 60-70 pts a day seems way more realistic. thank you all for the advice though

[LonguylandPA]

On 1/27/2018 at 8:34 PM, thinkertdm said:

100 patients in 10 hours, that's 10 an hour.  That's 1 every 6 minutes, including introductions and hand washing. 3 minutes history, 2 minutes physical exam, and one minute explaining what they have and their meds.  You also need to chart defensively.

This is pretty much how its been run.

Also.. since when do we check GFR in urgent care setting..?

[LonguylandPA]

On 1/27/2018 at 8:34 PM, thinkertdm said:

100 patients in 10 hours, that's 10 an hour.  That's 1 every 6 minutes, including introductions and hand washing. 3 minutes history, 2 minutes physical exam, and one minute explaining what they have and their meds.  You also need to chart defensively.

Try this- 70 yo, cc "cold" x 3 weeks- time yourself to list worst case ddx, and physical exam findings.  Was it under a minute?

 

4 year old with fever of 103 dx strep via rapid swab, allergic to amoxicillin, but has taken cephalosporins without problem-solving just last week for aom.  What's your next choice?

56 yo with urinary symptoms and lots of leuks on dip, loves her some Cipro.  No allergies, kidney function is fine.  (Time checking labs eats time).  What's wrong with Cipro?  Best choice?  How many days for macrobid?  Bactrim?  What if her gfr is 30?

That's your first 18 minutes right there.

I don't want to scare you to death, but it can be done- however, lawsuit, and knowledge of a medical error would live with me.  My advice, from random dude on the internet- take some time, learn medicine- you can even learn it fast, but in a place geared for making people better, not to make money.  

Here's two vignettes- first, my mil went to an urgent care for dysuria, was started on macrobid for probable UTI.  However, her kidney function wasn't checked, and it could have been, because it was the same hospital system.  Two days later, she was in the icu with renal failure.  Was the macrobid responsible?  I don't know.  The dose wasn't renally adjusted.  There was no mention of her kidney function on the note.

I saw a fellow for a post er visit; his throat was still sore.  I looked and found a mass in the back of his throat, easily found if you looked.  Look closely and you can see it's nicely vacularized.  Not strep, as written in the progress notes.

 

70 year old cc cold 3 wks: get pmhx, already thinking pna, subacute bacterial sinusitis, r/o cardiac abnormalities as well. locate source of possible infection (took me two minutes)

4 year old w 103 fever: learned that cross reactivity between pcn and cephs are less than 10% and since he took one without problem last time for AOM, I would feel fairly fine giving keflex I think? maybe clinda or zpak to be extra safe (1 minute)

56 year old w uti: Id like to stay away from cipro if needed bc of black box warnings, physical exam r/o cva tenderness. r/o sulfa allergy and give bactrim for uncmplicated cystitis  (1 minute) I dont know the answer of what to give with compromised renal function though. 

 

How did I do?