Posting for feedback/input

[Acebecker]

All -

 

Let me first start off by stating that I love my job and love being a PA. But I need a little help or input on this situation.

 

I am working full time in UC and part time FP at another clinic. The clinic where I work UC is actually more of an ER minor care than just a family practice walk-in clinic. In fact, the local ER closed the minor care department because we have been taking all their minor emergencies. We take pretty much everything, but of course we're limited. Anything that I think will need a CT scan goes downstairs to the ER, anything that I think needs a chest pain w/u goes downstairs to the ER, any surgical cases either go to the general surgeon's office (down the hall) or to the ER, etc. The problem that I'm having is that within our practice there are a bunch of IM docs and one IM NP. These providers' patients are complex, sick people. When they come to see me, I have a high index of suspicion that they'll need a complex w/u to at least r/o some of the bad stuff. So I send them downstairs more often than I send the family practice patients. The family practice patients are on average a decade younger and with a problem list that is far shorter than the IM patients. Plus, I know all of the FP docs and the FP NP well - we share offices and I can pull them aside for a quick chat without them giving me grief for it. The IM guys I can't do that with for a couple of reasons - 1. they are geographically further away than the FP guys/gals which means I can't just pull them aside for a curbside really quick. 2. while they're generally approachable, there are times when they're too busy to take care of or help me take care of their patients; often I can't find them for 30-45 minutes. 3. one of them is an absolute pain - an old-school IM doc who doesn't like to give me the time of day.

 

The biggest issue is this: the IM crew are monday-morning-quarterbacking my triage decisions and they're butt hurt about the fact that I send more of their Pts to the ER than I do FP patients.

 

The second issue is that some of them are routinely sending f/u patients into the UC. They see someone for a cough and Rx and ABx without getting a CXR... 2 days later the Pt comes back and they want the CXR so they send them to me to have another exam and w/u with CXR included. An established Pt with PNA is treated for a week with ABx by his PCP; the guy improves and then gets worse again -- the PCP tells this guy to come to UC for repeated w/u of his PNA.

 

I need to open a dialogue with some of you to help me work this stuff out in my head before I lose it. I'm not their whipping boy and they have to get that. They also have to get that I see more Pts/day than any two of them combined and when I'm trying to see their established Pt's for a quick w/u for dyspnea (someone I've never seen before) I think it's completely reasonable to expect that they slide this well-known (to them) Pt into their schedule rather than have me try to fit this complex person with a w/u that takes at least 30 minutes into a day when I'm struggling to get everyone out the door.

 

Let me know if you have any thoughts or if I'm expecting too much of my IM docs.

 

Andrew

[PACProvider]

Where I have been for the last year in outpatient clinic seeing internal medicine patients, I see patients for acute care visits for every doctor in the clinic. Doctors in the clinic have no schedule openings ever for acute care visits. Waiting time for the internal medicine doctors is 3-4 months. Specialist wait times are 6 months. ER waiting times are 16 hours. So, any new problems or acute on chronic problems were mine. Doctors don't want to interrupted while they are seeing their paneled patients for "six month follow up visits." It got old quickly. As long as the doctors schedules are blocked our for 3 months with their own follow up visits, there is not going to be much collaboration with the doctors for THEIR patients. I have discovered that the doctors love the benefits that PAs provide (taking the acute care/urgent/ed visits) but they despise the responsibility that comes with it (collaboration, supervision). My SP (and medical director for internal medicine) complained in a staff meeting that he "doesn't get paid to supervise PAs."

[Acebecker]

That's kinda' my point... If they're too busy to collaborate, then they shouldn't be second guessing my decisions. I had one Pt who tried to check in with decreased hearing on one side and her face "felt funny." I sent her to the ER without seeing her as I was slammed with 30 other people who had problems I could fix. She complained to her PCP - one of our IM docs - that she got sent to the ER for a "little fuzziness in my ear." The IM doc was upset that I sent the Pt to the ER for evaluation of a BS complaint.

 

And she paid no heed to the fact that on the same day she was complaining about me, I had accepted an obese and hypertensive diabetic 62 yo male for dyspnea for a week. He turned out to have ST depressions in all of his lateral leads. I spent 45 minutes doing the full w/u only to turn around and send him to the ER anyway. But asking his PCP what he should do never even entered his mind. Instead he walked in for a "quick checkup."

 

Any other folks who have experience in family practice based UCs who have made things harmonize well?

[discogenic]

Where I have been for the last year in outpatient clinic seeing internal medicine patients, I see patients for acute care visits for every doctor in the clinic. Doctors in the clinic have no schedule openings ever for acute care visits. Waiting time for the internal medicine doctors is 3-4 months. Specialist wait times are 6 months. ER waiting times are 16 hours. So, any new problems or acute on chronic problems were mine. Doctors don't want to interrupted while they are seeing their paneled patients for "six month follow up visits." It got old quickly. As long as the doctors schedules are blocked our for 3 months with their own follow up visits, there is not going to be much collaboration with the doctors for THEIR patients. I have discovered that the doctors love the benefits that PAs provide (taking the acute care/urgent/ed visits) but they despise the responsibility that comes with it (collaboration, supervision). My SP (and medical director for internal medicine) complained in a staff meeting that he "doesn't get paid to supervise PAs."

 

Is this a reason why some places opt for a NP instead of a PA?

[EMEDPA]

Is this a reason why some places opt for a NP instead of a PA?

yup, although I would argue that a new grad np needs as much, if not more, supervision than a new grad pa.

[ventana]

My thoughts

 

1) treat every patient the same way no matter who their doc is

2) realize that some doc's don't like other doc's and some doc's don't like PA or NP and you should not care

3) realize some of them are not going to ever like you

4) take time to chart well and EXACTLY put why you are referring to the ER not the PCP in clear concise points - even bullet points are okay - ie CP in HTN, poorly controlled DM, 100+ pack yr smoker, unable to r/o MI here - sent to ER

5) stand your ground, tell them that if they would like to manage every patient they have would have to see them in their schedule

6) I think it is always and almost impossible for them to argue against the fact you do not know them, they are not 'your' patients, and you function more as an ER provider(urgent care) they a PCP

 

Just go about your job, do a good job and move on

 

 

not worth spending to much effort on this topic as you will never win unless you just do a good job and move on...

 

 

 

 

 

As for supervision of new grad NP or PA - honestly I think a PA might need more - but not for the reason you think - NPs are not taught enough to realize what they don't know and how ill prepared they are (especially a new grad NP that was never a practicing RN in the ICU or ER). A new PA for the most part knows they have to be careful, and this can be scary, and hence might need more "supervision" but likely less "teaching"