Is 2 years enough to become a competent clinician?

[Hemegroup]

caution - - - -

 

murmurs can come and go - don't be overconfident on a single exam

 

surgery can be a very stressfull time on the heart - and to have a flow murmur that is not heard at rest would be of concern - why not order a simple transthoracic US to put the issue to rest - after all another provider did indeed hear a murmur (unless you think they were lying about what they heard) and the cost of missing something as sig as this is pretty high in a peds patient

 

again - experience counts..... if it were me (and it is not) if a NA or other provider heard a murmur I would do more then listing a single time in the office and rule it out. Especially as a fairly new PA versus a likely very established anesthesia team......(guess on my behalf)

 

 

high morbidity/mortality and settlements on missed murmurs when sudden death follows in peds - read the medical legal journals to see this.

 

 

 

 

excellent example of how experience really is highly valuable.

 

interesting. i did listen in 3 different positions ... maybe i'll do that, thanks for the advice. it wouldn't be an issue of suspecting lying lol, i mentioned my stethoscope. but i'll do that. i had been considering asking them back for the doc to listen to, although he would trust my stethoscope. the transUS will put the issue to rest finally and for all. and we'll see who wins ... the lowly PA or the very established team. either way, i would hold no ill will (think they were lying? no ... unless i guess maybe the guy had something to do for the day and he needed to skip out?) ... i do have an advanced stethoscope so i wouldn't hold it against someone (barump pshh) ... respiration and busy rooms can confuse things a bit ... i will never go back to using anything else

[Hemegroup]

ventana, may i ask what stethoscope you use?

[Guest JMPA]

"advanced" stethoscopes are ridiculous for people without hearing loss. Listen in multiple areas and in multiple positions and also while bearing down with both the bell and diaphram. Cardiology 101. If a murmur is heard by any licensed/credible clinician than a harmless TTE is the minimum that should be done.

[chickitabanana]

This is not true. It was true 10 years ago, but this is no longer the case. PA schools by and large have abandoned the idea of only accepting students with significant HCE. I precept both MD and PA students and 3 different schools and neither group has significant HCE

 

It's not necessarily false, though. It depends on the program. There are still programs out there that require MINIMUM 1,000-2,000 hours HCE before they'll even look at your application. When asked what I did between undergrad and PA school some MDs I have interviewed with are surprised to find out the number of HCE required before even applying to PA programs when I explain my work/HCE. I know there are a number of programs that only require 100 or so hours, but I think we'd all agree on a list of some of the "best PA programs" and all of those schools still require the hours.

[EMEDPA]

and the top of that list includes programs that require 4000+ hrs....

[Hemegroup]

"advanced" stethoscopes are ridiculous for people without hearing loss.

 

I could not disagree more. What a ridiculous thing to say.

 

If a murmur is heard by any licensed/credible clinician than a harmless TTE is the minimum that should be done.

 

That part sounds good. I caught a murmur in a 9 year old that had apparently been missed by every licensed/credible clinician who had seen him before, so have to agree there.

[physasst]

"advanced" stethoscopes are ridiculous for people without hearing loss. Listen in multiple areas and in multiple positions and also while bearing down with both the bell and diaphram. Cardiology 101. If a murmur is heard by any licensed/credible clinician than a harmless TTE is the minimum that should be done.

 

The only thing that I would argue is that a TTE is not harmless. It may not risk physical harm, but what about cost? A lot of the research that some of my colleagues are doing is focused on cost and necessity of testing.

 

I can tell you that I personally think of cost every time I order a test now. I ask myself three simple questions.

 

1. Do I really need this test, or can we simply wait and observe? Case in point, a patient I saw the other day came in for further workup of arthritic, facet mediated back pain. I also noticed an early, incomplete peripheral neuropathy. We discussed further testing, and we did decide together to get an EMG, mainly to satisfy his curiousity, to rule out any large fiber PN's. We also discussed the fact that small fiber PN's won't show up on EMG studies. When the EMG came back negative, we discussed QST testing, thermoregulatory testing, etc. We decided however that his symptoms were mild and early, and at this point, it might be best to simply watch. The patient agreed with that plan. We'll talk by phone in six months.

 

2. Will the test change my management? Often times that answer is no. I have several cervical myelopathy patients that I am simply following. They have mild myelopathic findings, and known cervical myelopathy. Unless I see something on exam, there is no need for additional testing. Same with radiculopathy patients. I see obvious lumbar radics all day long. Usually I'll get an MRI, mainly for interventional reasons, but sometimes I don't even get that if we decide on therapy. I rarely ever get an EMG in these patients because my exam already told what they have.

 

3. Am i ordering the test for the patient? Or myself? In medicine we are way, way too guilty of the latter. We tend to order tests to satisfy our own curiosity. Case in point, I was precepting a resident the other day, and he saw a patient with arthritic back pain. The PCP had ordered an MRI (overkill really), and there was some question of a compression fracture at T8 on the scout films. The radiologist recommended a "bone scan if clinically indicated". The resident was ordering the bone scan. I asked why? Well, he wanted to know if the compression fracture was new or old. I said, Does it matter? Does he have pain there? Even if he does, we aren't really wild about vertebroplasty as the results aren't really that good. His main complaint was arthritic LOW back pain right? Failing physical therapy? What if we tried L4-5, L5-S1 bilateral facet injections to manage his pain instead? You could see his face start contorting.....but, what about the fracture.....I'll just say, we didn't order the bone scan. It wasn't needed. He was ordering it for himself, and not the patient.

 

Another patient has an old cervical myelopathy with altered AMRs, complains of "tripping", and has a chronic L5 radic with active denervation on EMG. However, on exam, his weakness is really mild. A -1..(Mayo uses a completely different neurologic scale than everyone else). He feels it has progressed a little, but not a lot. So now we have a real quandry, a patient with active, uncompensated denervation, some mild weakness, but no pain. Many providers would send him to a surgeon for discussion of a decompression. I discussed that with him, but recommended that we simply watch this. I'll see him again in 3 months and will re-examine him. If his weakness has progressed, he'll see a surgeon, if not, we'll continue watching.

 

The point is, costs matter, and every provider needs to be thinking about them when they are ordering tests and caring for patients.

 

Just some thoughts.

[ventana]

ventana, may i ask what stethoscope you use?

 

 

Litmann Cardiology III - 11 years old and love it - have tried many others hoping for a better cheaper alternative - never found it

 

The only thing that I would argue is that a TTE is not harmless. It may not risk physical harm, but what about cost? A lot of the research that some of my colleagues are doing is focused on cost and necessity of testing.

 

I can tell you that I personally think of cost every time I order a test now. I ask myself three simple questions.

 

1. Do I really need this test, or can we simply wait and observe? Case in point, a patient I saw the other day came in for further workup of arthritic, facet mediated back pain. I also noticed an early, incomplete peripheral neuropathy. We discussed further testing, and we did decide together to get an EMG, mainly to satisfy his curiousity, to rule out any large fiber PN's. We also discussed the fact that small fiber PN's won't show up on EMG studies. When the EMG came back negative, we discussed QST testing, thermoregulatory testing, etc. We decided however that his symptoms were mild and early, and at this point, it might be best to simply watch. The patient agreed with that plan. We'll talk by phone in six months.

 

2. Will the test change my management? Often times that answer is no. I have several cervical myelopathy patients that I am simply following. They have mild myelopathic findings, and known cervical myelopathy. Unless I see something on exam, there is no need for additional testing. Same with radiculopathy patients. I see obvious lumbar radics all day long. Usually I'll get an MRI, mainly for interventional reasons, but sometimes I don't even get that if we decide on therapy. I rarely ever get an EMG in these patients because my exam already told what they have.

 

3. Am i ordering the test for the patient? Or myself? In medicine we are way, way too guilty of the latter. We tend to order tests to satisfy our own curiosity. Case in point, I was precepting a resident the other day, and he saw a patient with arthritic back pain. The PCP had ordered an MRI (overkill really), and there was some question of a compression fracture at T8 on the scout films. The radiologist recommended a "bone scan if clinically indicated". The resident was ordering the bone scan. I asked why? Well, he wanted to know if the compression fracture was new or old. I said, Does it matter? Does he have pain there? Even if he does, we aren't really wild about vertebroplasty as the results aren't really that good. His main complaint was arthritic LOW back pain right? Failing physical therapy? What if we tried L4-5, L5-S1 bilateral facet injections to manage his pain instead? You could see his face start contorting.....but, what about the fracture.....I'll just say, we didn't order the bone scan. It wasn't needed. He was ordering it for himself, and not the patient.

 

Another patient has an old cervical myelopathy with altered AMRs, complains of "tripping", and has a chronic L5 radic with active denervation on EMG. However, on exam, his weakness is really mild. A -1..(Mayo uses a completely different neurologic scale than everyone else). He feels it has progressed a little, but not a lot. So now we have a real quandry, a patient with active, uncompensated denervation, some mild weakness, but no pain. Many providers would send him to a surgeon for discussion of a decompression. I discussed that with him, but recommended that we simply watch this. I'll see him again in 3 months and will re-examine him. If his weakness has progressed, he'll see a surgeon, if not, we'll continue watching.

 

The point is, costs matter, and every provider needs to be thinking about them when they are ordering tests and caring for patients.

 

Just some thoughts.

 

 

Don't disregard your thoughts at all - in fact in the Neurosurg world this is a HUGE topic. serial MR's or CT's are usually just a waste of money. Also neuro imagining is in an entirely different catagory then Cardiac US - think false positives to understand more. (axial spine imagining tends to over read pathology and with out supporting Physical Exam is a huge cause of unneeded additional testing.) However, in this case we are talking a peds patient that has anywhere from 50-100 years of life and the heart is not something that tolerates being ignored (not that the spine does, but it tends not to fail as dramatically as a heart.)

 

The cost of exams is huge - look at the facility fee for CT's and MRI's and how many are ordered - look at the massive expansion that organized health care (think big hospitals that are putting millions into redo or facilities.) But trying to make sure we are doing the right thing for our patients and a known murmur in a peds patient deserves an US. I know that in school or sports physicals if i hear a new murmur I get and US.

 

Now the disclaimer - Peds is not my strong point (other end of the spectrum is) any peds specialists that are reading this that can pipe in??

[Guest Paula]

We are a bit off topic but in response to physasst: I agree costs matter and we need to be thinking about them when ordering tests. I have 2 recent interesting cases: Two men came in to see me the same week, at different times. Both about the same age (65), both with left sided sciatica symptoms. One responded better than the other to conservative treatment. One came back for the fourth time in 5 months. At the 4th time I decided to order the MRI. He had a large 6x6x6cm mass at L5-S1 and into the SI joint, with severe impingement of the nerve at L5. What was interesting to me is that his symptoms were intermittent. He and his wife went to California for a 2 week vacation and he had no symptoms at all, no leg pain, no back pain and he hiked every day. But once he got off the plane and picked up his luggage, he had acute pain that started. Then it became intermittent over a week or so, and prompted him to come back. I even had my SP see him on the third visit and he agreed with me that the patient had sciatica. I was thinking of the cost of the MRI and rarely order one unless the patient is very symptomatic and fails conservative treatment. This patient in particular started developing a little neuropathy of the left leg. Ultimately, after he was referred out, he was found to have a softball size tumor on his left kidney, lung cancer and liver cancer with mets to the bone. The oncologist told him he had this for a long time, not just a recent 4 month growth. I was glad I ordered the MRI. (THe other patients is doing well in PT, but I ended ordering an MRI on him too, spinal stenosis with mild impingement at L5.

[physasst]

We are a bit off topic but in response to physasst: I agree costs matter and we need to be thinking about them when ordering tests. I have 2 recent interesting cases: Two men came in to see me the same week, at different times. Both about the same age (65), both with left sided sciatica symptoms. One responded better than the other to conservative treatment. One came back for the fourth time in 5 months. At the 4th time I decided to order the MRI. He had a large 6x6x6cm mass at L5-S1 and into the SI joint, with severe impingement of the nerve at L5. What was interesting to me is that his symptoms were intermittent. He and his wife went to California for a 2 week vacation and he had no symptoms at all, no leg pain, no back pain and he hiked every day. But once he got off the plane and picked up his luggage, he had acute pain that started. Then it became intermittent over a week or so, and prompted him to come back. I even had my SP see him on the third visit and he agreed with me that the patient had sciatica. I was thinking of the cost of the MRI and rarely order one unless the patient is very symptomatic and fails conservative treatment. This patient in particular started developing a little neuropathy of the left leg. Ultimately, after he was referred out, he was found to have a softball size tumor on his left kidney, lung cancer and liver cancer with mets to the bone. The oncologist told him he had this for a long time, not just a recent 4 month growth. I was glad I ordered the MRI. (THe other patients is doing well in PT, but I ended ordering an MRI on him too, spinal stenosis with mild impingement at L5.

 

Well, and that's a legitimate indication. When someone is not improving and developing neurologic symptoms, then an MRI is appropriate.

 

The problem is, I see too many PCPs who order MRIs for back pain without neurologic deficit or symptoms. Too many who haven't even really tried treatment, IE; failed advil, who go in, and then get an MRI.

 

The best was the patient I had last month. Made me angry at the time....

 

Elderly female with severe low back pain extending into her right buttock x 1 month. Had an MRI, 2 series of lumbar plain films, and comes in to see me for "Mechanical back pain".

 

Apparently NO ONE had examined her.....or more precisely, no one had examined her hips. I did and thought well....that's odd. Her

right leg is shortened and rotated and she guards against any movement. Got an xray of her pelvis and she had a completely displaced femoral neck fracture. Which had callous already forming and had been there for several weeks.

 

I just shook my head.......sad. Then I called our Ortho Trauma surgeons and had her admitted to their service.

 

I see at least 1-2 patients per month who come in for low back pain, some with multiple MRIs, (even had one they did a discogram too---shudders), multiple xrays of the spine, and they have positive hip findings. Most with advanced hip DJD. I'll usually do an intra-articular hip injection under US in the office, and then have them come back in 1-2 hours. The majority (not all) will have resolution of their back pain.

 

This is kind of what I was getting at initially about wisdom, and experience guiding judgment. I had one patient recently who was sent for a cervical myelopathy, but no one could figure out from what (including me, but I didn't call it myelopathy, and while there were upper motor neuron findings, nothing consistent with a cervical origin). Got a neuro consult and it was MS.

 

Patients didn't read your textbooks. They don't know that they are supposed to present a certain way. It takes a while to see the different permutations of presentation, and to understand how to put what is often a complex mix of various symptoms together.

[Gordon, PA-C]

That part sounds good. I caught a murmur in a 9 year old that had apparently missed by every licensed/credible clinician who had seen him before, so have to agree there.

 

Cmon man, dont get cocky. Without knowing you I can already guarantee you that you've missed murmurs in patients that other people have picked up.

 

Murmurs, ESPECIALLY innocent murmurs in kids, come and go -- they arent present on every physical exam, even for the same examiner.

 

Just because you heard a murmur that wasnt documented previously doesnt mean that the other guys "missed" something. Good chance it wasnt there at the time.

[Guest JMPA]

The only thing that I would argue is that a TTE is not harmless. It may not risk physical harm, but what about cost? A lot of the research that some of my colleagues are doing is focused on cost and necessity of testing.

 

I can tell you that I personally think of cost every time I order a test now. I ask myself three simple questions.

 

1. Do I really need this test, or can we simply wait and observe? Case in point, a patient I saw the other day came in for further workup of arthritic, facet mediated back pain. I also noticed an early, incomplete peripheral neuropathy. We discussed further testing, and we did decide together to get an EMG, mainly to satisfy his curiousity, to rule out any large fiber PN's. We also discussed the fact that small fiber PN's won't show up on EMG studies. When the EMG came back negative, we discussed QST testing, thermoregulatory testing, etc. We decided however that his symptoms were mild and early, and at this point, it might be best to simply watch. The patient agreed with that plan. We'll talk by phone in six months.

 

2. Will the test change my management? Often times that answer is no. I have several cervical myelopathy patients that I am simply following. They have mild myelopathic findings, and known cervical myelopathy. Unless I see something on exam, there is no need for additional testing. Same with radiculopathy patients. I see obvious lumbar radics all day long. Usually I'll get an MRI, mainly for interventional reasons, but sometimes I don't even get that if we decide on therapy. I rarely ever get an EMG in these patients because my exam already told what they have.

 

3. Am i ordering the test for the patient? Or myself? In medicine we are way, way too guilty of the latter. We tend to order tests to satisfy our own curiosity. Case in point, I was precepting a resident the other day, and he saw a patient with arthritic back pain. The PCP had ordered an MRI (overkill really), and there was some question of a compression fracture at T8 on the scout films. The radiologist recommended a "bone scan if clinically indicated". The resident was ordering the bone scan. I asked why? Well, he wanted to know if the compression fracture was new or old. I said, Does it matter? Does he have pain there? Even if he does, we aren't really wild about vertebroplasty as the results aren't really that good. His main complaint was arthritic LOW back pain right? Failing physical therapy? What if we tried L4-5, L5-S1 bilateral facet injections to manage his pain instead? You could see his face start contorting.....but, what about the fracture.....I'll just say, we didn't order the bone scan. It wasn't needed. He was ordering it for himself, and not the patient.

 

Another patient has an old cervical myelopathy with altered AMRs, complains of "tripping", and has a chronic L5 radic with active denervation on EMG. However, on exam, his weakness is really mild. A -1..(Mayo uses a completely different neurologic scale than everyone else). He feels it has progressed a little, but not a lot. So now we have a real quandry, a patient with active, uncompensated denervation, some mild weakness, but no pain. Many providers would send him to a surgeon for discussion of a decompression. I discussed that with him, but recommended that we simply watch this. I'll see him again in 3 months and will re-examine him. If his weakness has progressed, he'll see a surgeon, if not, we'll continue watching.

 

The point is, costs matter, and every provider needs to be thinking about them when they are ordering tests and caring for patients.

 

Just some thoughts.

Are you really comparing a neuromuscular issue with a cardiac issue?

Heart murmurs can be signs of potentially serious/life threatening disease. To not follow up a heart murmur and confirm it with further testing is not only malpractice but also malfeasance. TTE is not only "harmless" but also extremely important to detect,qualify, and quantify murmurs and rule out potential life threatening causes. Cost has no place in this discussion. Please do not ever watch and wait a new murmur in a patient.

[mdebord]

Are you really comparing a neuromuscular issue with a cardiac issue?

Heart murmurs can be signs of potentially serious/life threatening disease. To not follow up a heart murmur and confirm it with further testing is not only malpractice but also malfeasance. TTE is not only "harmless" but also extremely important to detect,qualify, and quantify murmurs and rule out potential life threatening causes. Cost has no place in this discussion. Please do not ever watch and wait a new murmur in a patient.

 

Generally I encounter this situation doing sports physicals on kids. There's a very nice decision tree in Harrison's that I've found helpful. Grade <III, upper sternal borders, systolic, asymptomatic....highly likely it's functional. We do generally bring them back for another listen, but not every murmur needs a work-up.

[physasst]

Are you really comparing a neuromuscular issue with a cardiac issue?

Heart murmurs can be signs of potentially serious/life threatening disease. To not follow up a heart murmur and confirm it with further testing is not only malpractice but also malfeasance. TTE is not only "harmless" but also extremely important to detect,qualify, and quantify murmurs and rule out potential life threatening causes. Cost has no place in this discussion. Please do not ever watch and wait a new murmur in a patient.

 

Cost ALWAYS has a place in EVERY medical discussion. The fact that we have not done that for years is why we have the problems we do now.

 

Not every murmur needs to be chased down.

 

Remember, even life has a defined value. VSL (value of a statistical life) is somewhere between 5 and 9.1 million dollars. Which is how we calculate whether a new technology is worth it. IOW, if you could save 10 people by using a new technology, but it would cost more than 100 million dollars, than it is not worth doing. If you could save 10 people and it would only cost 40 million, than it is likely worth doing. In economics, these discussions occur all the time. Sounds callous....but life does not have a limitless value.

 

Cost always matters.

[Hemegroup]

Murmurs, ESPECIALLY innocent murmurs in kids, come and go -- they arent present on every physical exam, even for the same examiner.

 

Wow, no offense but what is this, the very first day of Peds lecture? You need to work on your eye for sarcasm. The point already was, the Anethesiologist heard it, I didn't. Hence, innocent murmur. I listened beyond intently, with an electronic, in 3 positions. What more do you want from me? I'm supposed to send the kid for further workup because of something that I don't find? Is that in any way the same as the Senior PA AND Attending who both stood there telling me food poisoning never presents with fever? Or what about the overworked ER Doc who jumped in on a patient who had already had a full workup for her neck pain (recent ENT surgery), yelling that she had mastoiditis and to put her on antibiotics immediately. We all just sat there and stared at him because, well, she DIDN'T. Why does my opinion suddenly become secondary? The child was sent to me FOR a second opinion. I gave it. You know what I think? I think you guys should stop being cheap and kick down for one of those stethoscopes ;)

 

By the way, you might find it enlightening that my SP is a Board Pediatrician of 40 years. He read the chart. Next.

[NewbiePA-C]

I'm going in this year with 20,000+ hrs of previous HCE (long-term care medical case management and behavioral health case management) and I'm scared to death. What I do feel confident about and grateful for is the experience I have had, which includes some experience in healthcare settings, patient interaction time and maybe most importantly, life experience. Will it give me an edge, perhaps. I don't know necessarily that it'll make any better of a clinician than my younger, less-experienced counterparts. I believe that my program will prepare me with a solid foundation, with the necessary tools to get out there and learn and PRACTICE medicine (an imperfect science). I will always be learning and developing skills. Knowing my strengths and limitations will hopefully make me that competent clinician; a fine balance of confidence and humility.

[Guest Paula]

@LisaPhx: My health care experience before PA school was nearly 15 years in public health nutrition/dietetics/administration of public health programs/and "patient" contact with women, children and babies through the WIC program. That experience was helpful in classes like pediatrics, nutrition, OB/gyn, psychiatry, ethics, and a few other theory classes. I was petrified because I did not have the "medically focused hands on HCE". It all turned out ok. You will do fine. I studied my Petutty off. I still do after 9 years of practice. I learn every day. I know what I am good at and where I need more training and in-depth education. I believe I was hired at my first two part-time jobs because of my experience and maturity and was able to handle a clinic as sole provider (with good backup) for the first years of practice. Today, I run our diabetes program, see tons of patients with DM, see lots of kids and women, and have been designated the Maternal Child Health supervisor.

 

I also see plenty of complicated patients and handle a lot of medical issues. I fill in for our walk-in provider when she is gone, and take overflow if she gets slammed. It all comes with time, experience, and the willingness to continue to study and learn. Your last sentence is key for success and you will do fine.

[ventana]

to keep the topic off track..... (strange indeed)

 

1 - there is certainly "innocent murmurs" in kids, but i for one would not be content in writing it off to that as it was heard by someone else and TTE is a simple test

2 - costs do come into play in the areas where spending the money is debateable - ie back pain and MRI - but I don't think that applies in this area

3 - someone that missed a hip fracture and looked at back needs to focus more on their exam skills - yikes.... - just this week I put a lady through Xray CT and MRI is ordered for occult right hip fracture as that is the only thing that explains her s.s - awaiting MRI results - healthy ambulatory 65 yr old female who in 1.5 weeks is now using a walker and hurts to weight bear....

 

 

now time to go outside on a spring March day that is heading north of 50 degrees in New England !!!! yeah!!

[Teasip]

Ped case, no prior knowledge of pt./family of the existence of a murmur, and in office for a sports clearance PE? TTE indicated. We all know what happens when one assumes something. The ONLY current day argument against this method of assessment is a low rate of positive findings (IHSS for example with secondary risk of lethal tachyarrhythmia) and cost. Italians mandate at least one TTE before clearance for athletics. What's the cost worth for peace of mind to the parent(s)? As with everything else, have an informed discussion with family, document, document, document, and respect their wishes. With regard to the MRI and subsequent mass finding; why the delay of four months before scanning (intermittent symptoms possibly)? If symptoms persist greater than a month without resolution then my old spine group always went looking (CT/MRI when it became available).

[ubergeff]

First post, woohoo. I am currently a PA student at IPAP, with no medical background. The argument whether a student is competent after 2 years depends on too many variables. At least 50% of our class has little to no medical experience, and has been true for previous classes. But, while the school has a limited pool to select candidates from and the remarkable lower standards for acceptance, IPAP still competes with the top 10 programs in the country. We have a 100% PANCE pass rate. What I'm trying to say is that it likely depends on what training you have received. It’s not what you don’t know that is going to more likely hurt a patient, it is what you THINK you know.

[EMEDPA]

pance rates measure how well individual students study, not the quality of the program.

some great programs have bad pance rates sometimes and some bad programs have high pance rates. it's all about the students in any given year.

[Alldaylong]

I keep hearing that you need(ideally) HCE prior to PA school and that the underlying tone is that you should get it before you go. Question becomes about time management/efficiency: What would make you a better clinician in 5 years time? A)Getting that 3 years experience prior to PA school and coming out as a new grad or B)Going now and having that 3 years experience as a post-grad PA.

[EMEDPA]

the issue is fairness to your first pt your first day in practice.

using model B proposed above you basically agree that your first 3 yrs in practice you are going to make more mistakes than someone with hce and those errors are ok. they aren't.

[GatorRRT]

the issue is fairness to your first pt your first day in practice.

using model B proposed above you basically agree that your first 3 yrs in practice you are going to make more mistakes than someone with hce and those errors are ok. they aren't.

 

I agree with the sediment of experience pre PA school, but is there a study backing this up?

[Guest Paula]

Ped case, no prior knowledge of pt./family of the existence of a murmur, and in office for a sports clearance PE? TTE indicated. We all know what happens when one assumes something. The ONLY current day argument against this method of assessment is a low rate of positive findings (IHSS for example with secondary risk of lethal tachyarrhythmia) and cost. Italians mandate at least one TTE before clearance for athletics. What's the cost worth for peace of mind to the parent(s)? As with everything else, have an informed discussion with family, document, document, document, and respect their wishes. With regard to the MRI and subsequent mass finding; why the delay of four months before scanning (intermittent symptoms possibly)? If symptoms persist greater than a month without resolution then my old spine group always went looking (CT/MRI when it became available).

 

The delay: He was a new patient and I saw him for the leg pain, determined it was sciatica. Treated, then in follow up (second visit) he was better. Third visit: symptoms back, after his trip to California, where he was completely symptom free, I saw him again, used the medrol dose pack and discussed the next step was MRI. He has diabetes, so didn't use medrol at first visit, and then we also discussed the diabetes as at this visit. The final visit was when the pain came back so severe it disabled him for a few hours, and i ordered the MRI. We are rural, so the length of time between visits is part of the reason for the delay, as he lives 45 miles away in another time zone, and it represents some of the challenges working in isolated places. Even getting appropriate care is a challenge and he now gets his chemo/radiation in a different state.