LonguylandPA Posted March 2, 2018 Share Posted March 2, 2018 Have been training in an Urgent care now for the past 6 weeks. training involves another 2 months before I "fly solo". I love the staff and I trust the supervising PA. I am picking things up nicely and see about 70-80% of the patients on my own. out of the 70-80%% I see, I usually consult/have the other PA come into the room for about 20-25% of those. the reasons il have him come in the room range from: to double check a kids ear to get his opinion on if it looks infected (still getting a feel for that visual skill), clarify treatments in a pregnant/nursing patient, dosing questions, and of course x ray interpretation (im picking up on this skill nicely) Heres the "bad part" that makes me double guess things.. eventually I will be expected to fly solo and see anywhere from 70-100 patients a day (I know what youre thinking, what the hell man thats insane) HOLD ON... 80% of our patients are unremarkable and come in for a flu/strep culture because they "feel strep x <1day".. out of those 80%, we rapid and overnight culture them and send about 70% home without a script for anything (these patient consults take less than 3 minutes) the other 30% will get either an x ray next door, or a script for z pack if they're obviously high risk or have constitutionally alarming symptoms/prolonged course of sx (Proud to say I am being trained to cut down on innapropriate abx use and usually end up prescribing about 1-3zpaks a day for URI out of the 60 patients that come in for "URI" So yes, although I will be responsible to see 70-100 patients a day... only 30% of them are really Non URI issues ranging from fractures, to asthma, allergic reactions, and suturing.. Also of note: once flu season is over, the practice expects to see 50-65 patients a day. Suturing I have down, just need to pick up speed slightly. Asthma and oxygenation issues I have down as well and know when someone needs to be sent to ED. So far I have not seen a case where I felt scared or wouldn't know what to do. out of all the patients we have sent to the ER (less than one per shift), I feel that I would have easily picked up on these patients and sent them to the ER myself Is this a recipe for disaster? Or is this just part of growing into your profession? Thank you Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 2, 2018 Moderator Share Posted March 2, 2018 recipe for disaster. 70-100 pts/day is insane. even if every single one is minor. this is a recipe for burnout. before EMRs, the most I ever saw in 1 day was 60 during the height of cold/flu season and that was with a simple check off sheet with tear off rx at the bottom and 100% of those had already been seen by a triage nurse and sent to me because they were obviously flu. would not want to do that every day. 6-8 pts/hr means you don't spend any time with anyone. high liability. someone is making a lot of money off you. run away. this is an easy way to lose your license. what if just 1 "simple sore throat" is a (missed) peritonsilar abscess. you are screwed. or 1 "bronchitis" is really a PE because a 16 yr old girl didn't admit she was on birth control in front of her dad. In Haiti I frequently see 60-80/day on medical missions, BUT NO EMR (charting on single piece of paper, very basic soap note) NO LIABILITY LOTS of folks around to bounce weird stuff off of/get consults Old charts available with good hx on the majority of pts. Link to comment Share on other sites More sharing options...
LonguylandPA Posted March 2, 2018 Author Share Posted March 2, 2018 1 minute ago, EMEDPA said: recipe for disaster. 70-100 pts/day is insane. even if every single one is minor. this is a recipe for burnout. before EMRs, the most I ever saw in 1 day was 60 during the height of cold/flu season and that was with a simple check off sheet with tear off rx at the bottom and 100% of those had already been seen by a triage nurse and sent to me because they were obviously flu. would not want to do that every day. 6-8 pts/hr means you don't spend any time with anyone. high liability. someone is making a lot of money off you. run away. this is an easy way to lose your license. what if just 1 "simple sore throat" is a (missed) peritonsilar abscess. you are screwed. or 1 "bronchitis" is really a PE because a 16 yr old girl didn't admit she was on birth control in front of her dad. In Haiti I frequently see 60-80/day on medical missions, BUT NO EMR (charting on single piece of paper, very basic soap note) NO LIABILITY LOTS of folks around to bounce weird stuff off of/get consults Old charts available with good hx on the majority of pts. I hear you EMEDPA, I respect your posts. a few questions if you dont mind answering 1) "simple check off sheet with tear off rx at the bottom" sounds like my situation.. whats wrong with this? assuming its clearly some sort or viral pharyngitis/positive flu 2) 6-8 pts/hr means you don't spend any time with anyone. how many patients should an urgent care PA see a day max? 3) what if just 1 "simple sore throat" is a (missed) peritonsilar abscess. I check everyones throats. how else would one be able to definitely rule this out? couldn't this happen to anyone? 4) or 1 "bronchitis" is really a PE because a 16 yr old girl didn't admit she was on birth control in front of her dad. Now this situation does scare me. but that would have to mean that you ask about PE risk factors to every single patient with bronchitis like symptoms..? is that what is standard in a low risk patient with chief complaint "dry cough x2 days? +/- trouble breathing" Thank you Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 2, 2018 Moderator Share Posted March 2, 2018 1 hour ago, LonguylandPA said: I hear you EMEDPA, I respect your posts. a few questions if you dont mind answering 1) "simple check off sheet with tear off rx at the bottom" sounds like my situation.. whats wrong with this? assuming its clearly some sort or viral pharyngitis/positive flu 2) 6-8 pts/hr means you don't spend any time with anyone. how many patients should an urgent care PA see a day max? 3) what if just 1 "simple sore throat" is a (missed) peritonsilar abscess. I check everyones throats. how else would one be able to definitely rule this out? couldn't this happen to anyone? 4) or 1 "bronchitis" is really a PE because a 16 yr old girl didn't admit she was on birth control in front of her dad. Now this situation does scare me. but that would have to mean that you ask about PE risk factors to every single patient with bronchitis like symptoms..? is that what is standard in a low risk patient with chief complaint "dry cough x2 days? +/- trouble breathing" Thank you 1. all my patients with "flu" were prescreened by a triage nurse. they could only have runny nose, cough, and body aches. low grade fevers were ok, but there was a max cutoff for the flu fast track. also this was at a major HMO and all of these patients were previously known and had established histories, pcps for f/u , etc Keep in mind that just because you have a + flu swab doesn't mean you aren't also actually pretty sick. I admit folks with influenza every year for a variety of reasons. 2. 4/hr is pushing it with no procedures. 3/hr if you are also doing suturing, I+Ds, etc I used to work some shifts at a 24 hr urgent care where the expectation was 3/hr. 3. more than just looking at the throat. do they have stridor, can they not handle secretions, do they have hot potato voice, etc? One of my very experienced colleagues just missed a huge retropharyngeal abscess that required ent to drain. 4. any female who tells me she has chest tightness gets questioned about birth control. if she also happens to be tachycardic, tachypneic, or does not have a nl sat they get a cxr and a d-dimer in the absence of an obvious pneumonia. any pleuritic chest pain should get a cxr. easy to miss a small pneumothorax. I have done it. See perc, Geneva, and wells criteria at mdcalc site for risk stratifying for PE. Any abnormal vital signs in anyone with any complaint should give you pause to consider. why is their pulse 120? why is there sat 93% when they don't smoke? why is their resp rate 26? etc. Not trying to scare you, but that volume is just crazy, even for a very experienced provider. I don't think anyone on this forum with > 5 years experience would consider the job you describe. I would not do that job for $100/hr. Link to comment Share on other sites More sharing options...
cbrsmurf Posted March 2, 2018 Share Posted March 2, 2018 You are going to hurt yourself and you are going to hurt patients with that kind of workload. Link to comment Share on other sites More sharing options...
DogLovingPA Posted March 2, 2018 Share Posted March 2, 2018 Run. And run fast. That volume is insane and a terrible idea. It is unsafe and you will hate your life. I saw 62 the other day in 12 hours (not my norm, just a shitty co-worker and an insane flu season) and I wanted to die. And I've been doing this 5 years. Going that fast you WILL miss something. The more I think about it, I don't even know how it is physically possible to see 70-100 patients in a day (even a 12 hour day). I agree with emed on 3-4 an hour but even at 4/hr that means 48 patients/12 hours and a day like that in UC is a BUSY day. Too many of those days in a row and I start to question my life choices and my sanity. A new grad should be more at 2/hour. I also work in an UC where in general things are pretty low acuity but that doesn't mean bad things don't walk through that door. Just off the top of my head in the last couple weeks (not all mine, but seen at our UC): "UTI" = new onset DM I in a kid "Fall/shoulder pain" = clavicular fracture and a left temporal fracture with SAH and subdural "Rash" = petechia with platelet count of 9 "kidney stone" = rhabo with K 6.7 "headache" = SAH "sore throat" = PTA "cough" = heart failure "flu" = any number of things that aren't the flu including sepsis, pneumonia, AMI "leg pain" = tibial abscess Link to comment Share on other sites More sharing options...
DogLovingPA Posted March 2, 2018 Share Posted March 2, 2018 ps. Even 50-65 patients per day for one person is not sustainable. I would not take that job for $200/hour. Link to comment Share on other sites More sharing options...
LonguylandPA Posted March 2, 2018 Author Share Posted March 2, 2018 2 hours ago, DogLovingPA said: "UTI" = new onset DM I in a kid "Fall/shoulder pain" = clavicular fracture and a left temporal fracture with SAH and subdural "Rash" = petechia with platelet count of 9 "kidney stone" = rhabo with K 6.7 "headache" = SAH "sore throat" = PTA "cough" = heart failure "flu" = any number of things that aren't the flu including sepsis, pneumonia, AMI "leg pain" = tibial abscess curious for the knowledge: so for UTI, im assuming he had other sx like fatigue, or a clean catch, non sexually active, that lead further investigation to a glucose stick? Fall/shoulder pain - he must have had admitted to head trauma ? Rash - how was this diagnosed? based on the appearance of rash? Kidney stone - weakness and toxic appearing? cough - was there an ECMO machine or some sort of clinical findings jvd/leg swelling/positive cxr/pmhx for HF? leg pain - atraumatic effusion/swelling? Link to comment Share on other sites More sharing options...
camoman1234 Posted March 2, 2018 Share Posted March 2, 2018 9 hours ago, LonguylandPA said: Have been training in an Urgent care now for the past 6 weeks. training involves another 2 months before I "fly solo". I love the staff and I trust the supervising PA. I am picking things up nicely and see about 70-80% of the patients on my own. out of the 70-80%% I see, I usually consult/have the other PA come into the room for about 20-25% of those. the reasons il have him come in the room range from: to double check a kids ear to get his opinion on if it looks infected (still getting a feel for that visual skill), clarify treatments in a pregnant/nursing patient, dosing questions, and of course x ray interpretation (im picking up on this skill nicely) Heres the "bad part" that makes me double guess things.. eventually I will be expected to fly solo and see anywhere from 70-100 patients a day (I know what youre thinking, what the hell man thats insane) HOLD ON... 80% of our patients are unremarkable and come in for a flu/strep culture because they "feel strep x <1day".. out of those 80%, we rapid and overnight culture them and send about 70% home without a script for anything (these patient consults take less than 3 minutes) the other 30% will get either an x ray next door, or a script for z pack if they're obviously high risk or have constitutionally alarming symptoms/prolonged course of sx (Proud to say I am being trained to cut down on innapropriate abx use and usually end up prescribing about 1-3zpaks a day for URI out of the 60 patients that come in for "URI" So yes, although I will be responsible to see 70-100 patients a day... only 30% of them are really Non URI issues ranging from fractures, to asthma, allergic reactions, and suturing.. Also of note: once flu season is over, the practice expects to see 50-65 patients a day. Suturing I have down, just need to pick up speed slightly. Asthma and oxygenation issues I have down as well and know when someone needs to be sent to ED. So far I have not seen a case where I felt scared or wouldn't know what to do. out of all the patients we have sent to the ER (less than one per shift), I feel that I would have easily picked up on these patients and sent them to the ER myself Is this a recipe for disaster? Or is this just part of growing into your profession? Thank you Wow...this is very scary. I would find a new job very soon. I have worked UC and FM, I always had 2-3 or 4 patients per hr, you will seriously have a lawsuit coming after you soon if you continue this job. I do not even know how one could see that many patients per hour. You mental health is MUCH more important than any money and plus you WILL miss something very serious if you see that many patients per hour (I would miss something as well). This is crazy for any provider to do and a set up for failure. Plus you have to think that you have to chart on these patients (yes I paper chart still and I still could not do it), you have to take a bathroom break, drink some water, eat lunch....RUN RUN RUN. Link to comment Share on other sites More sharing options...
DogLovingPA Posted March 2, 2018 Share Posted March 2, 2018 11 minutes ago, LonguylandPA said: curious for the knowledge: so for UTI, im assuming he had other sx like fatigue, or a clean catch, non sexually active, that lead further investigation to a glucose stick? Fall/shoulder pain - he must have had admitted to head trauma ? Rash - how was this diagnosed? based on the appearance of rash? Kidney stone - weakness and toxic appearing? cough - was there an ECMO machine or some sort of clinical findings jvd/leg swelling/positive cxr/pmhx for HF? leg pain - atraumatic effusion/swelling? UTI - looked great. Young 9 yo female who had some increased frequency, episode of overnight incontinence. Glucose in urine, which led to finger stick. Which led to a 20 min counseling session and explanation of DM while mom and daughter cried. So while a "simple/easy" pick up and diagnosis - definitely not a simple visit or case. Fall - nope. He said he "maybe" hit his head but his main complaint was his shoulder. No neuro signs. He did have some mild periorbital ecchymosis which clearly indicated that he did hit his head but he had zero neuro complaints. Rash - appearance. I then did a CBC Kidney stone - looked fabulous, laughing and joking. My colleague saw this one. It was a good pick up. Guy thought he was passing a stone because he had dark urine. Urine was clear on our sample. A lot of people would of just discharged him after a normal UA. But that's my point - you have to have TIME to ask these questions to make sure you aren't missing anything that would lead you to suspect your patient needs further work up. Cough - had been through 3 rounds of abx without improvement. Tachy and HTN. Minimal (and I mean minimal) ankle edema. I'm going to toot my own horn on this one because this one was my patient and a good catch. She was a female in her 20's. I was following her abnormal vitals (and the fact that she hadn't improved with previous treatment). Echo was done by cardiology later in the week, EF of 20%. Leg pain - this one I missed. Ecchymosis after a fall. Apparently must have had a small puncture that was not visible on exam and pt couldn't tell me because he didn't speak English. I diagnosed a contusion. Which is probably all it was at that point. But had I discovered the puncture I would of treated it much differently. 11 days later he was admitted for extensive I&D of his leg. I mean this very kindly..... but your questions indicate your knowledge as a new grad (example, you mean an "echo" not "ecmo" and my use of petechia is a description of a type of rash, etc). It's okay, you are a new grad!! You aren't supposed to know everything. No one is supposed to know everything. Every day I am constantly astounded by the amount I don't know. Medicine is a scary world out there. And you need to learn to ask questions, dig deeper, listen to those hairs on the back of your neck. That takes time to develop and there is no other way to develop those skills except by practicing medicine. And even the best clinician still misses things. But you can't be a good clinician and see 50-65 patients a day. You just simply can't. I don't care if you've been practicing for 2 months or 20 years. Working solo is also a very bad idea right out of school. I learned things by having my supervising physicians question me at first. You need someone who knows more than you to ask you "did you consider x, y or z?" Because right now, you don't even know "x, y and z" exist. Link to comment Share on other sites More sharing options...
DizzyJ Posted March 2, 2018 Share Posted March 2, 2018 Wowzers! Not safe and would not see 100 patients unless I was paid couple hundred an hour. Also, I would follow clinical recommendations for flu/strep tests as doing this on every patient presenting with these complaints just adds minutes of additional time spent on each patient that is likely not necessary, along with increased cost to patient. Link to comment Share on other sites More sharing options...
BruceBanner Posted March 2, 2018 Share Posted March 2, 2018 Agreed, patient mill. Get out as soon as practical. In college health, 70% of what I see is as you describe, super low-acuity, cold sx for 1 day, "sinusitis", minor rash, STI check kind of stuff. But even at that I only see about 20 ppd in 8 hours with a lunch break. This is with a modern EMR (Epic), MAs rooming and doing vitals, etc. I've done like 17 pts in 3 hours when I was really cruisin', but with very abbreviated notes. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 2, 2018 Moderator Share Posted March 2, 2018 70-100 patients a day! really? that is unsafe no matter how you do it and it is insurance fraud - there is no way you can see and manage 70 patients a day .... period.... no way no how Link to comment Share on other sites More sharing options...
sas5814 Posted March 2, 2018 Share Posted March 2, 2018 What everyone said.... I have been a PA for almost 30 years. I work in a UC that has some really unrealistic expectations about some things and our limit on a 12 hour shift is 45. Now that is optional...you can continue if you feel like your head is in the game and everything is going along smoothly. If not you are cleared to stop. I have seen 50 in a 12 hour shift and I realized I was making charting errors...wrong patients chart etc. It was nothing big but it was a big red flag that I was mentally fatigued so I stopped. Patient safety before all else. What you are describing is a malpractice claim(s) waiting to happen. It is a regulatory and insurance nightmare and will eventually implode. What is more it simply cannot be safe for the patients. To echo my colleagues..... run. Link to comment Share on other sites More sharing options...
lkth487 Posted March 2, 2018 Share Posted March 2, 2018 Don't do it. Remember, it's your license on the line too. Not to mention patient safety. Link to comment Share on other sites More sharing options...
LonguylandPA Posted March 2, 2018 Author Share Posted March 2, 2018 Thanks for your replies everyone. I will be bringing up this issue to my employer and will see if they are willing to staff me as a second PA on a shift. If not, It is clear that I will leave. Link to comment Share on other sites More sharing options...
KMD16 Posted March 2, 2018 Share Posted March 2, 2018 Thanks for your replies everyone. I will be bringing up this issue to my employer and will see if they are willing to staff me as a second PA on a shift. If not, It is clear that I will leave. Plz plz leave. So upset by how newer PA are treated this days. What a total disrespect and disregard for our profession. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 2, 2018 Moderator Share Posted March 2, 2018 leave fast and tell them why will not help you, but will help the next person Also would NOT go along with this plan while you are still there. When you sign a chart it says that you SAW AND EVALUATED the patient...... so do that with each one Other far better PAs have stated here that 40 is about the max (and that is with highly experienced PA) and you should likely only be 50-70% of that now...... so shoot for 30 patients a shit (still a HUGE number - about 20min each) and do that. No more, make sure you are seeing and evaluating everyone you sign for in a chart If they are making $100 a patient in receipts and you are seeing 100 patients - that is $10,000 per day income - they are defrauding the insurance companies and using your license to do so..... If you are put on the stand I can assure you your employer will say "geez if PA so and so felt that was to many patients they should have spoken up" speak up, do only what you can do, and leave... Link to comment Share on other sites More sharing options...
Boatswain2PA Posted March 3, 2018 Share Posted March 3, 2018 4 hours ago, LonguylandPA said: Thanks for your replies everyone. I will be bringing up this issue to my employer and will see if they are willing to staff me as a second PA on a shift. If not, It is clear that I will leave. By your screen name I assume you are on Long Island? NY seems to have liberal PA practice laws, but very low pay because of saturation of PA/NP programs. That leads to cases like this. Run away. Link to comment Share on other sites More sharing options...
ApolloPA Posted March 3, 2018 Share Posted March 3, 2018 hey man, shitty work conditions and endangering patients isn’t worth it soley for the NYC experience. Source: currently in NYC for PA school Link to comment Share on other sites More sharing options...
Cideous Posted March 3, 2018 Share Posted March 3, 2018 My limit in 12 hour shift is around 50-55. Anymore and stuff just becomes unsafe. Period. How many times do you take a quick second look at a patient, or a note and make a change? You simply can not do that with the volume you describe. You have to be 100% right, 100% of the time on the first glance seeing those numbers. That is a complete recipe for disaster. God help you if you get a few lac's or other procedures come in during that kind of volume... Link to comment Share on other sites More sharing options...
CAAdmission Posted March 3, 2018 Share Posted March 3, 2018 We need a “places that suck to work” sticky thread for situations like this.Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
Cideous Posted March 3, 2018 Share Posted March 3, 2018 7 minutes ago, CJAdmission said: We need a “places that suck to work” sticky thread for situations like this. Sent from my iPad using Tapatalk Agreed, but for the record, this is most Urgent Care work now-a-days. They are in such heated competition with each other that they just barrel in the numbers on one single provider. Some days it's ok...its the other days that make you question why you do it.... Link to comment Share on other sites More sharing options...
quietmedic Posted March 3, 2018 Share Posted March 3, 2018 Besides for the projected daily patient load, actually sounds like you are doing great....good self confidence, and nothing wrong with even 20-25% of help from other PAs at this point while you learn the "art" of medicine. Sounds like you are doing excellent. Working solo is definitely scary at first, but also is great ultimately as it forces you to start making decisions and judgements for yourself, for better or for worse, and living with those decisions. It's the natural next necessary step to build yourself as a competent practitioner. However, the 80-100 patients per day solo? Freak-no. Hell no. I wouldn't do it for any amount of money. I've been doing UC for a while, and even with a very very competent MA staff and easy charting software (meaning NOT eclinicalworks), more than 40-ish in 8 hours or 55-ish in 12 hours gets pretty heavy....throw in a few procedures and you are on the way to screwed. 80-100 is OUTRAGEOUS and a recipe for disaster, burnout, mistakes and lawsuits. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 3, 2018 Moderator Share Posted March 3, 2018 JUST FOR A LIST/DESCRIPTION OF EASY THINGS GOING BADLY SEE THE LONG-RUNNING THREAD IN THE EM FORUM HERE ENTITLED "IT'S PROBABLY NOTHING": FAST TRACK DISASTERS Link to comment Share on other sites More sharing options...
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