Merging fields with Nurse Practitioners.....It's time.

[PACali]

40 minutes ago, TexasPA28 said:

I can do crashing neonates and difficult airways just as well if not better than the MDs can.

PAs have proven time and time again that they can run all the different types of situations that occur in an ER, including major trauma without MD involvement.  Hell there are major ERs in urban Chicago, New York, Los Angeles that are run 100% by PAs RIGHT NOW with no MD involvement.  

The days of ER PAs only working in rural areas is over.  We can run ERs in major level 1 trauma centers with no MD involvement.  We've got the skills.

MDs provide nothing that we cant already do.  All they do is eat up unnecessary paycheck.  Like I said, eventually hospitals are going to figure out that it's stupid to pay ER docs 400k to sit around and do nothing while the PAs are doing all the work, and doing it better than the MDs can.

New grad PA definitely can't run the show by themselves and they require MD oversight. However, my dream is to have experienced PA like you training the new grad PA. I think it can happen but only with OTP (Im talking about collaborative agreement with experienced PA not MDs) or FPAR and a name change to get the word "physician" out of our name. As long as we have physician in our name, they going to be around us. 

[dfw6er]

On 4/3/2020 at 8:17 PM, jfmDNP said:

As a DNP (and yes, patients, staff and my physician colleagues do refer to me as doctor, with my credentials fully visible on my lab coat/fleece jacket) and having been a preceptor for MD, NP and PA students, I appreciate the history of each profession and the role they play in providing care for millions of Americans to the fullest level of their training and capabilities. 

I'm not sure what medical students you've been "precepting" but at my school they'd never. in. a. million. years. allow anyone but a physician to precept medical students.  Sure a NP/PA might be on the service the med student is clerking on that month and might help teach a med student, but credentialing bodies for med schools will not allow anyone but a physician to be the preceptor for med students.

On 4/3/2020 at 8:17 PM, jfmDNP said:

If anything, you might be able to take the family NP certification due to its breadth as PAs. And just to clarify, NPs need to recertify. However, they may decide between retaking the boards each recertification period or present a certain number of CME units in their specialty plus pharmacology units. But regarding merging, should that really be what needs to happen or should the entire PA community continue to work in unison to advance the profession, regardless of the challenges and length of time it may take?

See there's a difference b/w PAs and NPs.  PAs are following the medical model when it comes to CME and recertification.  I don't think it's enough to just maintain CMEs...especially when it's so easy to accumulate low-quality category 1 CME.   Having to recertify with periodic standardized exams makes sure the PA or physician has basic competency to practice safely.   If NPs are just doing easy nursing contact hour CEs, then what safeguard is in place for the public?

[dfw6er]

On 4/5/2020 at 1:16 AM, TexasPA28 said:

You should tell them to fire the MDs.  MDs cost a shitload of money.  You can replace all of them with PAs and split the difference in the savings.

Mark my words in 20 years there won't be MDs in the ER anymore.  The writing is on the wall.

You really can't replace BC EM physicians in high acuity ERs.  Low volume rural places maybe as many of them transfer out complex cases anyway. By definition, Level 1 and Level 2 trauma centers can't be staffed solely by PAs....they must have BC/BE EM residency-trained physicians on staff working there.  Heck Level 1 trauma center rules dictate that only BC/BE EM-trained physicians are allowed to run traumas....so FM docs who work EM can't see the traumas, let alone PAs.  

The amount of dedicated pediatric EM training EM physicians receive in residency is considerably more than any PA would receive in PA school and more than any EM PA would get on the job unless they worked in a dedicated pediatric EM....and most of those are constantly rotating in EM residents and have pedi EM fellows staffing them so the PAs & NPs don't get to do much of the high acuity care at those places. The amount of surgical critical care and intensive care training EM docs get in residency vastly outweighs what little EM PAs receive as well.  I really don't think anyone but the top 1% of PAs could come close to treating complex, critically ill/injured patients as well as a BC/BE EM doctor.

But there's too much complex stuff that regularly shows up in the majority of ERs to think that your average EM PA is as capable of evaluating and treating just as well as a EM physician.  You might like to think otherwise, but you're deluding yourself.  I was definitely a well-above-average EM PA, and my technical skills are on point, but after learning all I've learned in med school, I know now that I was woefully undereducated compared to the physicians I worked with in my shop.  

[EMEDPA]

27 minutes ago, dfw6er said:

I'm not sure what medical students you've been "precepting" but at my school they'd never. in. a. million. years. allow anyone but a physician to precept medical students.  Sure a NP/PA might be on the service the med student is clerking on that month and might help teach a med student, but credentialing bodies for med schools will not allow anyone but a physician to be the preceptor for med students.

Not entirely true. I precept med students regularly and at a prior job(which had an FP residency)  had FP interns assigned to me for an EM/UC procedures rotation. They spent a month with me and I wrote their evaluation. It is rare, but it happens.

I agree with most of your statements above, but I think an EM PA with a residency or years of experience can deliver excellent care to anyone presenting to the emergency dept. Sure, they transfer patients, but generally to surgical or medical specialists, just like an EM physician would. Don't know too many EM docs who will do a chole or a carotid endarterectomy.....

[dfw6er]

9 minutes ago, EMEDPA said:

Not entirely true. I precept med students regularly and at a prior job(which had an FP residency)  had FP interns assigned to me for an EM/UC procedures rotation. They spent a month with me and I wrote their evaluation. It is rare, but it happens.

I agree with most of your statements above, but I think an EM PA with a residency or years of experience can deliver excellent care to anyone presenting to the emergency dept. Sure, they transfer patients, but generally to surgical or medical specialists, just like an EM physician would. Don't know too many EM docs who will do a chole or a carotid endarterectomy.....

Our school admin told us COCA (regulatory agency for DO schools) mandates that only a physician can precept us on clerkships.  IDK if the same is true for allopathic students or if my school was lying and it's really just my school's policy.  I do know that my physician preceptor may elicit feedback from anyone I had interactions with during my clerkship, but each and every clerkship evaluation must be completed by the physician preceptor....and the preceptors are identified ahead of time and are known to my school's clinical education department.  We are told to notify school if we're not getting supervision from a physician on rotations so they can remove that site from their clerkship list.  

Yeah, I agree that a very experienced PA (15-20+ years) can deliver excellent care to the vast majority of ED patients, but that's the exception, not the rule.   I think all but the very rural, hard-to-recruit-physician ERs, benefit from having boarded EM docs on staff.  I don't think EM PAs will replace EM physicians in most ERs as one person posted in this thread....if anything you'll be seeing more and more BC docs in the future as more and more EM residencies are popping up all over the place (CMG-administered like Kaiser and HCA). And again, I'm a huge fan of the PA profession and will continue to advocate for PAs....this is just how I'm seeing things now having been through both PA school and now about to graduate med school in the spring.

[EMEDPA]

I agree that residency trained EM docs should run every dept. I don't see them taking over all the provider slots, however, as small hospitals can't afford them. At my primary job we staff a single provider, either an EM PA, an FP MD, or an EM MD. To make the budget work, they can only staff EM docs 1/3rd of the time. The EM docs make about twice what the EMPAs make. The EMPAs make $15/hr less than the FP docs. I think I deliver better care than the FP docs on staff there. It's all about exposure to different types of cases and procedures. With 33 years working in the ED, I have seen and done more than an FP doc a few years out of a primary care residency. I agree that the vast majority of em boarded docs bring more to the table than the vast majority of EMPAs. Hard to beat that EM MD internship experience with all the dedicated off-service rotations.

The program at which I precepted FP residents was an FP MD program 20 years ago. Things may have changed since then.

[sleepingbeautyyyyy]

 

[rev ronin]

4 minutes ago, sleepingbeautyyyyy said:

 

Great.  Someone took a post from April, and posted it to Reddit a few hours ago.  Obviously, it had a huge impact.

For anyone from Reddit who may decide to come here and see what the kerfuffle is about, be aware that we are not limited only to PAs, but expect those who're coming to tell us specific posters are FOS to please be at least as polite as we are to each other.

[ANESMCR]

22 minutes ago, sleepingbeautyyyyy said:

 

While I don’t agree with this post, there are some twisted minds on that residency forum I wouldn’t let touch my family with a 10 foot pole. I had to stop reading after just a few replies in disgust.

Edited July 26, 2020 by ANESMCR

[ohiovolffemtp]

Like EMED, I believe a board certified EM physician should supervise every ED.  However, the vast majority of ED patients can be managed by an experienced and/or residency trained EM PA.  From what I've seen, probably 95+%.  It's the most complicated, not necessarily the most acutely ill, patients that really need the EM doc's additional training.  Depending upon the EM PA's procedural skills, the EM doc may also be needed for some procedures.  I really value having my doc available as a consultant.   I probably call them ~ once every 2 weeks.   This includes cases where they have to come in: codes and thrombolytics. 

[TexasPA28]

3 hours ago, ohiovolffemtp said:

Like EMED, I believe a board certified EM physician should supervise every ED.  However, the vast majority of ED patients can be managed by an experienced and/or residency trained EM PA.  From what I've seen, probably 95+%.  It's the most complicated, not necessarily the most acutely ill, patients that really need the EM doc's additional training.  Depending upon the EM PA's procedural skills, the EM doc may also be needed for some procedures.  I really value having my doc available as a consultant.   I probably call them ~ once every 2 weeks.   This includes cases where they have to come in: codes and thrombolytics. 

Disagree.  I've seen PAs in the ER do absolutely EVERYTHING that the MD can do.  PAs are very capable of running a busy ER urban trauma unit with no MD involvement. 

At University of Maryland Shock Trauma Center in Baltimore, the lead trauma PA supervises trauma calls over the PGY-5 chief surgery resident.

 

[turnedintoamartian]

This is going to be an extremely rare situation and not broadly applicable. There are going to be locations where a highly trained/experienced PA is going to be integral to the facility even being open. Mostly though we’re really going to fill a different role.

Man that reddit response was something.

[HMtoPA]

On 4/5/2020 at 9:56 AM, TexasPA28 said:

I can do crashing neonates and difficult airways just as well if not better than the MDs can.

PAs have proven time and time again that they can run all the different types of situations that occur in an ER, including major trauma without MD involvement.  Hell there are major ERs in urban Chicago, New York, Los Angeles that are run 100% by PAs RIGHT NOW with no MD involvement.  

The days of ER PAs only working in rural areas is over.  We can run ERs in major level 1 trauma centers with no MD involvement.  We've got the skills.

MDs provide nothing that we cant already do.  All they do is eat up unnecessary paycheck.  Like I said, eventually hospitals are going to figure out that it's stupid to pay ER docs 400k to sit around and do nothing while the PAs are doing all the work, and doing it better than the MDs can.

You do have a flair for hyperbole ("I can do...better than the MDs can."), but do you have anything factual to back up your claims? For example, where exactly are these "major ERs in urban Chicago, New York, Los Angeles that are run 100& by PAs?" I mean, which facilities precisely? Some of us may want to know for career purposes. And you must know that we most certainly cannot, by definition, run ERs alone in "major level 1 trauma centers."

[ScullyAMA]

I wanted to jump in on this convo and say how disheartening reading all of this is. I'm also an HM hoping to be PA @HMtoPA. I appreciate you making a point to discern between md & pa.

I have to say, these threads end up on reddit, specifically r/residency (as @ANESMCR pointed out), and on #midlevelrant, and it really has made me think twice, even thrice, about choosing to pursue the PA route. It just seems like there is no solidarity in the PA community, and it makes it easy for NPs and MDs to gang up and even dismiss PAs as a whole. I'm not sure what I'm looking to gain out of saying this, but it stinks to feel this way when I really should be so excited to jump in and get to work.

Edited July 26, 2020 by ScullyAMA
clarity

[EMEDPA]

3 hours ago, HMtoPA said:

You do have a flair for hyperbole ("I can do...better than the MDs can."), but do you have anything factual to back up your claims?

There are some studly PAs out there doing amazing things:

https://columbiasurgery.org/joseph-costa-dhsc-pa-c

https://pahx.org/assistants/stone-shepard-b/

https://pahx.org/assistants/elizondo-epifanio-epi/#:~:text=Epifanio (Epi) Elizondo%2C Ph.D.%2C PA-C Before he retired%2C,and reported to the Assistant Secretary for Health.

[HMtoPA]

33 minutes ago, EMEDPA said:

There are some studly PAs out there doing amazing things:

https://columbiasurgery.org/joseph-costa-dhsc-pa-c

https://pahx.org/assistants/stone-shepard-b/

https://pahx.org/assistants/elizondo-epifanio-epi/#:~:text=Epifanio (Epi) Elizondo%2C Ph.D.%2C PA-C Before he retired%2C,and reported to the Assistant Secretary for Health.

 

My point isn't that PAs can't or aren't practicing at a high level. But I know EM docs and trauma surgeons with 30-40 years of practice under their belt with more humility than I saw displayed in that post. There's a reason it ended up as a screen grab on Reddit (clue: it sounded a bit ridiculous).

[PAinPenna]

2 hours ago, ScullyAMA said:

I wanted to jump in on this convo and say how disheartening reading all of this is. I'm also an HM hoping to be PA @HMtoPA. I appreciate you making a point to discern between md & pa.

I have to say, these threads end up on reddit, specifically r/residency (as @ANESMCR pointed out), and on #midlevelrant, and it really has made me think twice, even thrice, about choosing to pursue the PA route. It just seems like there is no solidarity in the PA community, and it makes it easy for NPs and MDs to gang up and even dismiss PAs as a whole. I'm not sure what I'm looking to gain out of saying this, but it stinks to feel this way when I really should be so excited to jump in and get to work.

If you are second -guessing your entire career path based on posts to the PA Forum and Reddit then you may consider avoiding medicine altogether . 

[Marinejiujitsu]

I would drop out of medicine before becoming a murse.

Sent from my SM-N975U using Tapatalk

[nikki386]

3 hours ago, ScullyAMA said:

I wanted to jump in on this convo and say how disheartening reading all of this is. I'm also an HM hoping to be PA @HMtoPA. I appreciate you making a point to discern between md & pa.

I have to say, these threads end up on reddit, specifically r/residency (as @ANESMCR pointed out), and on #midlevelrant, and it really has made me think twice, even thrice, about choosing to pursue the PA route. It just seems like there is no solidarity in the PA community, and it makes it easy for NPs and MDs to gang up and even dismiss PAs as a whole. I'm not sure what I'm looking to gain out of saying this, but it stinks to feel this way when I really should be so excited to jump in and get to work.

I am currently in PA school and I personally had to deactivate my Reddit account specifically because of the toxicity that would seep into the PA sub. What I surmise is that they are still very young and lack legitimate "real world" experience. Mommy and daddy probably took complete financial care of them, kissed their behinds and inflated their heads. The superiority complex is comical, really. Their entire 20s were spent in academia and they have never had the privilege of working on a team and eventually getting the sass beat out of them by upper management. You don't see that degree of hostility from working physicians with at least a few years of experience under their belt; or at least, I have not really witnessed it. 

Edited July 26, 2020 by nikki386
Clarity

[ScullyAMA]

Okay, yes, this. Thank you. I've been thinking about this and I believe that you're exactly right, @nikki386. 

Contrary to what @PAinPenna believes (because I brought up a valid point), I know what it is to be in medicine. I've been working in healthcare for a long time. And I know what I'm getting myself into.

But I think it is worth noting how the rhetoric effects current PAs and PA hopefuls. Who wants to go into a volatile field? Who wants to go into an environment where they know they'll be hated? What I really look for in mentors is consistency, dedication, and reassurance. You know, leadership. And the fact that there is so much infighting is concerning. IDK.

[nikki386]

1 hour ago, ScullyAMA said:But I think it is worth noting how the rhetoric effects current PAs and PA hopefuls. Who wants to go into a volatile field? Who wants to go into an environment where they know they'll be hated? What I really look for in mentors is consistency, dedication, and reassurance. You know, leadership. And the fact that there is so much infighting is concerning. IDK.

I had similar reservations reading all of it. The majority of negativity seems to come from medical students/residents, probably in an attempt to assert dominance because they have little control over anything else in their life or career. We are an easy target for abusive vitriol, online anyway. I’m sure there are some physicians out there that hold personal contempt for PAs/NPs but would never explicitly say anything. However, most physicians I’ve worked with have been easy to work with and generous with respect (and knowledge), even as a student. Interactions I’ve observed between physicians and PAs have pretty much always been friendly and professional. I don’t think that those forums are an accurate assessment of anything beyond the observation of petulant children feigning concern for patients by creating an imaginary turf war with their colleagues to bloat their self importance.

[LT_Oneal_PAC]

Part of the problem here is everyone is speaking in absolutes. Are there experienced or residency trained PAs better than some BC EM physicians? I believe there are. It’s the same to me as saying all attendings are better than all residents. An extreme example is Dr Death. I’ll take a NSG intern over him. Some people are bad no matter what training you give them. I’ve certainly met even some EM R2s I would take over certain attendings. 
 

further, most of what makes one good is experience and drive to learn. so the question shouldn’t be is one profession better than the other, but are both capable of achieving the same level. I believe they are, but you have to look at them as individuals. Would I trust me to run an L1, no way. Would I trust some of my PA Faculty (yes, PA clinical professors in the ED), sure would. See them pretty much do it every time all the residents and other faculty are in conference.

this goes the same for this talk about “can handle CAH because they transfer most stuff anyway.” This is another generalization that is not always true. Lots of level ones don’t see OB because it goes right to the OB service. You have every service imaginable a stone throw away.MRI, CT, US available 24 hours a day. POCUS skills have to be on point working at night in a CAH. CAH May transfer a lot, but level one EDs see the code stroke for 5 seconds and the stroke team swoops in to manage. But your CAH PA is pushing that tPA (I am not required to have attendings present for this or codes and most live 20-30 mins away anyways). Your CAH PA is delivering that breech presentation. Guess who stabilized that variceal bleeder with a blakemore, your well trained CAH PA, your welcome GI. Who’s doing the skull trephination went that Head bleed goes from GCS 14 to 3 with a blown pupil. NSG is doing at your L1, but your CAH clinician is doing that or else the patient is going to die waiting 20-30 mins for air EMS, 20 minute load up at best, 30 minute travel time, 15 minute load out, 15 minute to OR. CAH ED is the ultimate test of skills. So let’s not hate on rural PAs and act like level ones do all the heavy lifting. Now we can make an argument that CAH Hospitalist only get the low hanging fruit. Now you may say oh that little CAH shouldn’t be managing that, but boy do level ones love to shit talk when they get a transfer that has had 90% of the work up done and act like it’s a dump. I know because I worked with those people, I used to be one of those people. I don’t say all this to boast that CAH are better, it’s to point out that they are equal in different ways. Certainly we aren’t as good as juggling 8-12 simultaneous patients, (usually just 5 in the shop) a skill I know I’ve let fade since residency. I also recognize that CAHs can be a safe harbor for otherwise terrible clinicians because they can’t recruit the best. Plenty of poor ones at L1s too that hide behind consultants and strong residents.

as for me, I don’t think I’m as good as a BC EM physician. My medical director agrees, describing me in my recent eval as “strong R3 level”, which I’m happy with. Right where I think I should be for my experience level. Though I’m hopeful to get there see more and more, and he agrees, which is nice to have that kind of support from a BC EM physician that I regard as very good.

[ohiovolffemtp]

I think the Lt said it very well.  Only thing I would add is that not all CAH are the same.  At mine, I do call in the attending for the codes and thrombolytics.  It's required where I work and easier: we all travel in and stay in a house whose front door is 115 steps from the front door of the hospital (yes, I counted them).   I don't see the very high acuity very often, but we do have codes.  I only intubate about 1 person/month.  However, it's often busy enough that I am often juggling 6-10 patients.  Thank heavens I can get my EMS crew and occasionally the inpatient nurses to help as I only have 2 nurses and no techs in the ED.

[GetMeOuttaThisMess]

11 hours ago, ohiovolffemtp said:

I think the Lt said it very well.  Only thing I would add is that not all CAH are the same.  At mine, I do call in the attending for the codes and thrombolytics.  It's required where I work and easier: we all travel in and stay in a house whose front door is 115 steps from the front door of the hospital (yes, I counted them).   I don't see the very high acuity very often, but we do have codes.  I only intubate about 1 person/month.  However, it's often busy enough that I am often juggling 6-10 patients.  Thank heavens I can get my EMS crew and occasionally the inpatient nurses to help as I only have 2 nurses and no techs in the ED.

How many beds in the ED?

[ohiovolffemtp]

6 hours ago, GetMeOuttaThisMess said:

How many beds in the ED?

8 beds, but when we're full, we open up 4 rooms used for exams by consultant physicians who come to the CAH on certain days of the week.  Assuming no "family plans", we can room 12 patients (and do so about 1/month).  However, usually during these time we do have "family plans" and have ~15 patients on the board.  Wait times go up, because even with deferred charting, it's hard to get more than 4 patients dispo'd/hour, and only can hit that if there's a fair number of ESI 4's in the mix.