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AOA Warning on PA "Independence"


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24 minutes ago, SHU-CH said:

I don't think anyone is opposed to this - given your scenario, I think everyone would make the same decision. But again, admissions situation are never this cut and dry. More likely we are comparing:

a 4.0 candidate with experience you'd regard as weak

versus

a medic that had to repeat multiple courses to clear the minimum acceptable pre-req GPA

 

I think we can find some middle ground here for both experience and gpa. a 4.0 gpa does not make up for zero/low quality experience and being a medic does not make up for a 2.0. The 4.0 student who is 22 years old likely lived with their parents , did not work, and was able to fully commit to school. what is wrong with a 3.4 paramedic, working full time and raising kids while going to school?  who do you think can handle life(and being a PA) better?

I would be happy as a first step to see an age requirement to apply so that folks at least have some life experience...I am not talking about 30 here, I would be fine with 24. Straight from undergrad to PA school implies you likely have never had a real job or paid your own bills or dealt with many life stressors aside from academics. Of course there could be exceptions if someone met exclusion criteria(graduated HS at 16, worked in health care for 4 years while attending college, etc).

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I don't think anyone is opposed to this - given your scenario, I think everyone would make the same decision. But again, admissions situation are never this cut and dry. More likely we are comparing:
a 4.0 candidate with experience you'd regard as weak
versus
a medic that had to repeat multiple courses to clear the minimum acceptable pre-req GPA
Experience is great because it can help provide evidence of intangibles, like a history of good people skills, flexibility, creativity and the ability to manage stressful situations. It can also develop some assessment and procedural skills, although these will be rudimentary compared to those needed in PA school. Most of these allied health experiences don't speak one iota toward a candidate's ability to handle the type of science courseload PA school will throw at them. 
Did you know that during the accreditation self-study process, PA programs have to explain to the ARC-PA every grade of "C" or lower that has occurred in the last three years?


I think it’s fair to say that an exceptional student who can translate this information into a clinical situation, and has demonstrated same, is the ideal student. The second example given is a no go for me.


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3 hours ago, karebear12892 said:

Have you ever worked with scribes from a reputable company? If not, you may not realize that we aren't simply transcriptionists.

The providers aren't telling us what to say word-for-word. We are typing HPI's in real time, in our own words, and determining what content is pertinent and what isn't. We complete the ROS and document physical exams with hardly any prompting from the provider. Obviously we can't hear heart and lung sounds, but everything else we identify and describe entirely on our own, as if we were performing the exam ourselves. We are tested on our ability to document appropriate PE findings (ex: neurovascular status in extremities, GCS, appendicitis signs, etc.) by watching the patient's response to the provider's exam - and if we do not pass this written test, we have to repeat our training program (which is several weeks long and includes multiple exams). It is up to us (not the provider) to come up with a list of differentials based on the H & P and then modify that list according to the orders entered by the provider. We compose MDM's in our own words - it is our job to be the provider's peripheral brain and document the relevant information. For example, if a D-Dimer is ordered, we are trained to calculate Wells/PERC. We are expected to calculate a HEART score for chest pain work-ups. And we exercise our judgment in describing why patients are being admitted/discharged, why a test is being ordered, any shared decision making that takes place, risk vs. benefit discussions, etc. When a patient is discharged, it is up to us (not the provider) to come up with a set up discharge instructions appropriate for each patient based on their diagnosis and any medications being prescribed. At the end of the shift, the provider will proofread the charts before signing, but an experienced scribe's chart typically doesn't require too many modifications. 

I'm finishing up PA school now and I've been offered ER jobs that supposedly don't take new grads, but exceptions are being made on my behalf because of my ER scribe experience. 

I'm not by any means putting down other types of HCE. But I am saying that you don't need to touch patients in order to learn. Paying attention to what is happening around you and asking questions can go a long, long way. In my case, working with ER doctors who were phenomenal teachers made all the difference in the world. Just like any other job, you get out of it what you put into it. 

 

Oh come on.  That's so inappropriate.  You are acting as a provider in these circumstances.  You can't do an H&P.  You can't come up with differentials as a scribe.  

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3 hours ago, karebear12892 said:

Have you ever worked with scribes from a reputable company? If not, you may not realize that we aren't simply transcriptionists.

The providers aren't telling us what to say word-for-word. We are typing HPI's in real time, in our own words, and determining what content is pertinent and what isn't. We complete the ROS and document physical exams with hardly any prompting from the provider. Obviously we can't hear heart and lung sounds, but everything else we identify and describe entirely on our own, as if we were performing the exam ourselves. We are tested on our ability to document appropriate PE findings (ex: neurovascular status in extremities, GCS, appendicitis signs, etc.) by watching the patient's response to the provider's exam - and if we do not pass this written test, we have to repeat our training program (which is several weeks long and includes multiple exams). It is up to us (not the provider) to come up with a list of differentials based on the H & P and then modify that list according to the orders entered by the provider. We compose MDM's in our own words - it is our job to be the provider's peripheral brain and document the relevant information. For example, if a D-Dimer is ordered, we are trained to calculate Wells/PERC. We are expected to calculate a HEART score for chest pain work-ups. And we exercise our judgment in describing why patients are being admitted/discharged, why a test is being ordered, any shared decision making that takes place, risk vs. benefit discussions, etc. When a patient is discharged, it is up to us (not the provider) to come up with a set up discharge instructions appropriate for each patient based on their diagnosis and any medications being prescribed. At the end of the shift, the provider will proofread the charts before signing, but an experienced scribe's chart typically doesn't require too many modifications. 

I'm finishing up PA school now and I've been offered ER jobs that supposedly don't take new grads, but exceptions are being made on my behalf because of my ER scribe experience. 

I'm not by any means putting down other types of HCE. But I am saying that you don't need to touch patients in order to learn. Paying attention to what is happening around you and asking questions can go a long, long way. In my case, working with ER doctors who were phenomenal teachers made all the difference in the world. Just like any other job, you get out of it what you put into it. 

 

That’s insane. This is not appropriate practice. 

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11 hours ago, SHU-CH said:

The explosion in programs is most likely due to the exposure our profession has gotten in the last decade. Pretty much every year we have made the "Top 10 Best Professions" in some big-name media outlet. Administrators read this stuff and all of a sudden they are putting a program together for provisional accreditation. 

I was at the PAEA conference last month, and ARC-PA spoke and rightly noted they don't have an ability to keep new programs from opening. As to what will happen in the future, I believe they used the term "natural selection." Programs will go out of business. Some of these will be newer programs, and some will be programs that have been long established. 

Believe it or not, degree creep might not originate from academia. PAEA didn't originate OTP - that primarily came out of AAPA. It seems like there is a boatload of PAs around looking for a fancy title. If it gets traction, universities will happily start to supply a route to a fancy title.

No one is happy about costs. I have about as much control over rising tuition costs as you do over rising healthcare costs. The only thing that will stop spiraling costs is people deciding they are not going to pay it any more. I love being a PA but if I was young and knew what I know now I would seriously look into a building trade. 

So your position is "The Academics" are not behind these circumstances, but are trapped by the external forces in my stated concerns? I find it hard personally to accept the idea that there is not an incestuous cabal of Administrators, Academics/PAEA, AAPA  whose actions enhance their standings and agendas by pushing Degree Creep, higher tuitions, expanded numbers of programs? Just the PA worldview of an old guy PA.

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If there exists such a cabal, I am deeply sorrowed to report that I have not derived any benefits from it. Nor have any faculty members I know. Maybe we missed the sign-up meeting.

I do know I could be making a shizzle ton more money in clinical practice than I am making trying to train the next generation of PAs, so hopefully the cabal kicks things into overdrive soon. 

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17 hours ago, EMEDPA said:

A good scribe is a great resource. a bad one doubles your work as you need to rewrite their notes. 

Definitely agree with this. No scribe is better than a bad scribe. ?

17 hours ago, EMEDPA said:

Our notes had to be read by us and signed before the patient could leave the dept. 

The providers would always read our notes before the patient left the department. Some would sign as well, others would wait until the end of the shift, depending on the provider. 

17 hours ago, EMEDPA said:

Nowhere that I have worked allows scribes the kind of scope of practice you describe above. We literally tell them which template to use and dictate to them what to write. they serve only as mobile transcriptions in the 2 trauma centers in which I have worked with them. Often they are not even in the room with the patient, but waiting at the desk. 

Wow. That's not the way we did things at all. What's the point of having a scribe if they aren't going to come into the room and listen/watch? Now I understand why the scribes you're working with don't meet your expectations in terms of preparation for PA school. I'm not sure how you're supposed to learn anything by sitting at a desk and waiting for the provider to tell you what to type. You (as the provider) might as well be dictating your notes using a Dragon device at that point. I don't see how using scribes in this way increases efficiency compared with a dictation device (not criticizing you, I'm assuming this is an administrative decision). 

17 hours ago, EMEDPA said:

Frankly, the practice you describe sounds dangerous and reckless. I would rather write my own notes than have someone with a bs in bio and "several weeks of training" come up with a ddx and order tests, etc. Do you write their scripts for them too? this is not a personal attack in any way. this just sounds dangerous to me on many levels. I think both scribe and research experience are ok for folks who want to go to medschool as they will have an extra 2 years and a residency to learn the basics of medicine. A PA student day 1 of school should have a solid foundation in medicine already, and being a scribe or a researcher does not provide that foundation.

As a point of clarification, we do not order tests and we do not write scripts. The providers are expected to review the charts thoroughly and if they don't agree with what's documented, it is up to them to change it. The training process includes courses in pathophysiology, HPI elements, common chief complaints/work-ups, physical exam findings, appropriate use of diagnostic tests, pharmacology, and billing/coding. This is not because we are ultimately expected to do these things as as scribe but so that we have an understanding of what is happening around us and why. I can't speak for other companies but the retention rate in my region was about 50% due to many candidates failing the exams necessary to complete the scribe training program. 

Thanks to the fantastic doctors I worked with during my time between college and graduate school, I had a solid foundation in medicine on day 1 of PA school from being a scribe. You can disagree if you'd like, but my grades and preceptor/faculty feedback over the course of the year support this. That isn't true for all scribes, especially not under the model you've described at your facility, but it worked miracles for me and I would do it again in a heartbeat. 

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19 hours ago, EMEDPA said:

I have worked with scribes at many places from many companies. A good scribe is a great resource. a bad one doubles your work as you need to rewrite their notes. I had one who used a normal male/female template on every patient and then modified it. heme neg rectal exam on an ankle sprain? really?  Nowhere that I have worked allows scribes the kind of scope of practice you describe above. Our notes had to be read by us and signed before the patient could leave the dept. we literally tell them which template to use and dictate to them what to write. they serve only as mobile transcriptions in the 2 trauma centers in which I have worked with them. Often they are not even in the room with the patient, but waiting at the desk. Frankly, the practice you describe sounds dangerous and reckless. I would rather write my own notes than have someone with a bs in bio and "several weeks of training" come up with a ddx and order tests, etc. Do you write their scripts for them too? this is not a personal attack in any way. this just sounds dangerous to me on many levels. I think both scribe and research experience are ok for folks who want to go to medschool as they will have an extra 2 years and a residency to learn the basics of medicine. A PA student day 1 of school should have a solid foundation in medicine already, and being a scribe or a researcher does not provide that foundation.

Scribing is great experience; you're with the doc 24/7 and you're present during critical interventions recording measures. You'd be surprised at how much experienced scribes infer from their own experience rather than dictation from the doctor. If the doc knows you, there is a lot more trust involved, and a good scribe will make suggestions if the doc missed something (with a lot of tact). Plus they check your note anyway. I worked in a mid-sized E.R and the doc's trained us really well, and provided a lot of invaluable education. By the end of one year, I felt I could perform emergency medicine from an algorithmic standpoint. I felt much more confident the PA and NP students rotating at the emergency room at least. When I went to PA school everything clicked, and my emergency medicine rotation felt very easy.

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Paramedic was just an example. You may substitute RN or resp therapist if you like. Brother #2 still has no experience though.
As far as high school bragging rights, I went to high school with Robert Downey Jr, Rob and Chris Lowe, Zen Gesner(of Sinbad fame), and Charlie Sheen. Mel Gibson and Dick van Dyke were neighbors. I grew up in Southern Ca in the 80s. My first motorcycle(ok it was a vespa 200) was given to me by another neighbor, Rick Springfield of Jessie's girl fame.
E and his "Hog" lol

draft_lens14276631module126196971photo_1287066245Howard-red-Vespa-scooter.jpeg

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48 minutes ago, Joelseff said:

YOU come up with the differentials? I call BS... Or your Provider is in gross negligence

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Not really sure what is so controversial about this. Yes, we look at the tests that the provider has ordered and come up with a list differential diagnoses based on the presentation and work-up. Depending on the provider, it may just be a matter of uploading a template (i.e. "adult chest pain" or "elderly AMS") and modifying it accordingly based on the particular patient. If we have a question or we aren't sure about something, we always ask the provider for clarification. Before the chart is signed, the provider will always review the differentials (and everything else) and make changes if needed. 

Should the provider fail to review the scribe's chart prior to signing - yes, this is negligence. Personally, I've never seen this happen, as the doctors I worked with were well aware that they are held responsible for any and all content within the medical record. 

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Not really sure what is so controversial about this. Yes, we look at the tests that the provider has ordered and come up with a list differential diagnoses based on the presentation and work-up. Depending on the provider, it may just be a matter of uploading a template (i.e. "adult chest pain" or "elderly AMS") and modifying it accordingly based on the particular patient. If we have a question or we aren't sure about something, we always ask the provider for clarification. Before the chart is signed, the provider will always review the differentials (and everything else) and make changes if needed.  Should the provider fail to review the scribe's chart prior to signing - yes, this is negligence. Personally, I've never seen this happen, as the doctors I worked with were well aware that they are held responsible for any and all content within the medical record. 

 

 

No, Kapoera stated "You can't do an H&P.  You can't come up with differentials as a scribe."

 

To which you replied "We can and we do."

 

YOU are NOT a provider and should not generate the ddx.

 

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I worked in an ER that used scribes. The vast majority of them were on the path of becoming some kind of healthcare provider. If the PAs and docs knew this, most of us would try to help them develop some clinical decision making skills and make sure they saw interesting stuff. 

I was in the habit of asking the scribes what they thought was going on, what they would do next. So in fact, anyone can come up with a differential diagnosis. There's a difference between generating "A" Ddx and generating "THE" Ddx (the one that eventually gets recorded in the documentation). 

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I worked in an ER that used scribes. The vast majority of them were on the path of becoming some kind of healthcare provider. If the PAs and docs knew this, most of us would try to help them develop some clinical decision making skills and make sure they saw interesting stuff. 
I was in the habit of asking the scribes what they thought was going on, what they would do next. So in fact, anyone can come up with a differential diagnosis. There's a difference between generating "A" Ddx and generating "THE" Ddx (the one that eventually gets recorded in the documentation). 


So what’s the point of what the scribe thinks with regard to a DDX if it doesn’t make it into the chart? Frankly, I’m not getting paid to mentor if it’s busy season and I’m trying to move the meat.
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1 hour ago, GetMeOuttaThisMess said:

So what’s the point of what the scribe thinks with regard to a DDX if it doesn’t make it into the chart? Frankly, I’m not getting paid to mentor if it’s busy season and I’m trying to move the meat.

 

Different strokes for different folks. Some of us have aspirations related adding value to people's lives beyond just moving meat. Did all of the mentors in your life get paid?

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2 hours ago, d-wade said:

 I don't understand why you think this is so dangerous compared to the plethora of dangerous things that for instance paramedics do everyday with a limited education out of necessity.

you don't understand the difference between 2 years of intensive emergency medical training done by folks who already have a prior 6 month course(emt-basic) and a minimum of 1 year of experience as basics and a 2 week course in EMR documentation done by bio majors?

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Anyone can simply put a list together, this is not a differential.  The differential is a living thing; I have a preliminary list in my head when I read the intake sheet, but another after I see the patient; this includes everything I see, hear, feel, smell...and think.  No one else can do this.  I use data from everyone around the patient, that would include nursing staff and any ancillary staff who might be present. 

It's nice to think someone with a few weeks of training sitting at the periphery who is watching me can adequately come up with a "differential", but its a false positive.  A foil.  Don't trust it. 

A paramedic, on the other hand, is a bit more than an observer on the edge of the action; they are the action. 

 

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23 minutes ago, thinkertdm said:

A paramedic, on the other hand, is a bit more than an observer on the edge of the action; they are the action. 

 

Made me think of this:

Yup. Folks- remember the worst day you ever had in the ER with all the labs down, the CT scanner broken, 1/2 the nurses out sick. This is still a more controlled environment than 2 medics on scene with someone actively trying to die. For those of you who think being a medic is start an IV and drive, you need to go do some ride alongs...

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1 minute ago, EMEDPA said:

Yup. Folks- remember the worst day you ever had in the ER with all the labs down, the CT scanner broken, 1/2 the nurses out sick. This is still a more controlled environment than 2 medics on scene with someone actively trying to die. For those of you who think being a medic is start an IV and drive, you need to go do some ride alongs...

Don't they start the IV while driving?

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