EM PA Jobs City vs Rural

[ARinaldi3]

Hey all, I am currently 1.5 years into my career as an EM physician assistant working in the main part of the ED. I previously did my clinicals in Philadelphia at Temple University Hospital and will probably be headed back to the city in another 1.5 years as my girlfriend will be a headed to a residency in a city most likely. The biggest dilemma I foresee is finding a job comparable or better than my current job.

For the most part I have free range in my ED, mostly seeing ESI 2's and 3's though (very infrequently) running codes, intubating, chest tubes, fem lines. My objective/sight for my career is to essentially be at the level of a 4th year resident in EM--seeing/doing everything and bouncing stuff of docs very infrequently. I fear that going to a city where teaching hospitals dominate and residents are abundant that I will be relegated to the fast track. I would be content working in a community hospital setting and gradually growing my skillset but now that she's set on the city that's not possible. Do job's like I've describe exist? Do jobs like my current job exist even in the city?

Extra--

I've thought about taking the next year, getting my FCCS and switching to ICU/Critical Care in order to more frequently do central lines, intubations, chest tubes and manage more critically ill patients so that if that job does exist that I would be a good candidate, but that may require voiding half a year of my EM contract.

[LT_Oneal_PAC]

It’s not impossible. There are several residencies in that area if I recall. PAs certainly do all the things you’re talking about at our level one, but it’s more on Thursday when the residents are at conference. Your best best though is to find a job that is a commutable distance. You’d be surprised what you get at the really rural EDs. I’ve done more critical care per hour worked at my rural hospital than I did in residency. LVADS, epiglottitis, massive hematemesis. That was one 12 hour period weekend before last.

[EMEDPA]

Yup , at the rural places it is all you. I have 2 solo jobs, one double coverage job, and just interviewed for a second. All rural. all more than an hr for home. I could probably make more money doing fast track(due to RVU reimbursement) 5 min from home, but would hate every minute of it.

[ARinaldi3]

16 hours ago, LT_Oneal_PAC said:

It’s not impossible. There are several residencies in that area if I recall. PAs certainly do all the things you’re talking about at our level one, but it’s more on Thursday when the residents are at conference. Your best best though is to find a job that is a commutable distance. You’d be surprised what you get at the really rural EDs. I’ve done more critical care per hour worked at my rural hospital than I did in residency. LVADS, epiglottitis, massive hematemesis. That was one 12 hour period weekend before last.

 

11 hours ago, EMEDPA said:

Yup , at the rural places it is all you. I have 2 solo jobs, one double coverage job, and just interviewed for a second. All rural. all more than an hr for home. I could probably make more money doing fast track(due to RVU reimbursement) 5 min from home, but would hate every minute of it.

Well I'm glad it's not a crazy dream--you guys seem like awesome PA's and advocates for the profession from reading some comments and such. I had such a crappy view of our profession in a City based setting as Temple was very very light on APC's who were almost entirely outpatient, on wards, fast track, or second assist. I felt like they were utilized even less than students, far less than residents. My community hospital certainly rehabbed that image as it seems like docs and PA's are almost on equal footing--they are not only easily reached resources for us, but they seek advice from us as well regarding patient management, diagnosis and such. 

I can definitely imagine rural being like that, my hospital system does have a location much more isolated and I picked up shifts there in the next month to see if that is a more preferable setting for me. Still think I will do the FCCS and maybe some difficult airway courses, but fulfilling my contract is important.

[fishbum]

On 3/3/2020 at 1:01 AM, ARinaldi3 said:

I've thought about taking the next year, getting my FCCS and switching to ICU/Critical Care in order to more frequently do central lines, intubations, chest tubes and manage more critically ill patients so that if that job does exist that I would be a good candidate, but that may require voiding half a year of my EM contract.

If you want acuity, then obviously the ICU is the place to be. But if you're wanting autonomy, it's more difficult to find in critical care. Certainly there are exceptions (rural areas, overnight cross coverage, etc) but you should generally expect to have more attending involvement in the ICU vs. ED. I do lots of tubes and lines, but sometimes I think it would be nice to work up and dispo a patient without anyone else signing off on my work.

[MediMike]

14 hours ago, fishbum said:

If you want acuity, then obviously the ICU is the place to be. But if you're wanting autonomy, it's more difficult to find in critical care. Certainly there are exceptions (rural areas, overnight cross coverage, etc) but you should generally expect to have more attending involvement in the ICU vs. ED. I do lots of tubes and lines, but sometimes I think it would be nice to work up and dispo a patient without anyone else signing off on my work.

There is definitely a lot of range in regards to autonomy on the ICU side. I work in a nocturnist capacity and all but one of our docs are very hands-off..that one though...*shivers*

I've often thought about moonlighting in the ED, then my wife comes home and tells me about her nights and to be honest, it sounds like you guys work really hard. I'm more of a cerebral ponderer than a meat mover.

FCCS is decent, the virtual ICU rounds on SCCM are alright as well. Get Marino's, master shock and hemodynamics and you should be good. In my opinion the unit is all physiology, as long as you know how things work you can figure out how to fix it.

[dphy83]

Those jobs exist. The place where I did my EM residency was a large academic center and they had PAs in both zones in the main and in a way they actually had more autonomy than the residents (since the residents have to staff all patients with the attending). The PAs were treated well by the attendings and the residents loved having them there to share the load and were always happy to help out. PAs were involved in codes, traumas, whatever.

Ive also worked in a smaller community ED alongside a physician. I had free range as far as what I could see, though the docs almost always ran codes because, well, they want excitement too (probably provider-dependent but we had a very young group of ED docs so they wanted to have fun), but they would still let me do procedures if they were on my patient.

Current job is at a small-medium size hospital (about 250 beds) but the ED has very sick people since population is poor, underserved, comorbidity-ridden. Again, I have mostly free range as far as what I can see (this is partly a result of necessity as there are 30+ beds in the main with 3 day providers (usually 2 docs and an APP) at various parts of their shift to cover it all.

I have no experience in solo coverage gigs like the previous posters, but that would not be the place to grow your skill set - your skill set needs to be developed before taking one of this spots.

My point is that the jobs you want are there, in both urban and rural areas, at academic and nonacademic centers. Finding them may not always be easy, though. If you interview and are offered a position that you are unsure of I would ask if you can shadow a PA/NP for parts of a couple shifts to get a real feel of your autonomy.

[BrianR]

Agree with my colleagues that those jobs do exist, though you may have to search for them.  You are correct that a teaching hospital will offer little autonomy, and the residents will be jumping up and down to do all the procedures.  But there are plenty of hospitals, even in the cities, that aren't teaching sites and don't have EM residents.  

I spent 30 years in rural EM, mostly in critical access hospitals, where I was it.  No attendings, no back up, just me and 1-2 RNs, maybe an RT if we were lucky.  If the patient needed a procedure, I did it.  But with all due respect, with 1.5 years of experience, those hospitals are probably not the place for you at this stage of your career.

I think your best bet, if you wish to remain in EM, would be a community hospital where PAs are respected and allowed to practice to the full extent of their training and experience.  My current hospital, where I am a critical care ICU PA, is a 500 bed city hospital.  Our ED uses PAs (and NPs) extensively, and they do almost everything - intubations, codes, etc.  I don't think there are any restrictions on what they can see.  We do not have EM residents, so there are no battles over doing the procedures.

Like MediMike, I am also an ICU nocturnist PA.  While ICU is definitely more of a team approach compared to EM, I find I have plenty of autonomy.  We are a 29 bed ICU, and we have no attendings on site at night; it's just the PA and a medicine PGY2.  I enjoy the acuity, which is uniformly high compared to the ED, where I eventually tired of the low acuity nonsense and the rampant entitlement mentality.  I either do the procedures overnight, or teach/supervise the residents, depending on the situation.  

And for those who say they can't find decent PA jobs...we have been looking for one since my nocturnist cohort left last year.  We can't find one.  The schedule is decent, the pay is above average, benefits are good, the medical director is extremely supportive, and the staff is great to work with.  But no one wants to work at night, they don't want to work without an attending around, don't want to live in upstate NY,  etc.  I don't understand it.  It's arguably the best job I've ever had.  But I guess it's not for everyone.