non-so-great review

[Road Runner]

Hello to all PA's out there,

 

Short version: I am wondering if the ED is where I need to be after a not-so-great review.

 

Long version:

So I am a new-ish ED PA. Been working for 1 year now. I work in a small ED (less than 10 bed ED). It's me and another physician. I usually pick up the "fast-track" stuff, but often can pick up higher acuity patient (chest pain, SOB), especially when the doc is busy with other patients. I finally had a review (they forgot to do one at 6 months). The ED medical director told me that my positives/strengths: I well-liked by the staff and patients, and that I am not medically "dangerous". He said that I am quick to let the ER doc know if it is a patient is sick and I appropriately get help. He said that that was 60-70% of my job.

 

The things he thought I needed to work on was being more efficient. He also said he wanted me to attend an EM CME course (I have done 3 already in 2010) and to work with a more seasoned PA outside of my normal shifts. He felt I was on the bottom half of PAs in our group in terms of efficiency. During the review, I was agreeable and nodded my head, and played it cool.

 

This was a mixed review for me. I was happy that he saw my strengths, but bummed (really bummed) about about the efficiency part. I am pretty hard on myself (aren't we all?). I came home and started to brood over the review and my whole EM career.. and was starting to second guess my current ED position...

 

I started to question myself like:

Is this the right field for me?

Should I do an EM residency?

Do I take too long in the room? Am I just too slow?

Am I not seeing enough patients (my best day was 28 patients)? Is that what he really meant?

 

I am trying to remain positive. I try to reading one chapter in an EM book every other day. I am trying not to feel bad/sad/down/upset. But I feel like I am the "slow" PA or something.

 

Gosh there are many days I do feel inadequate. I want to be optimistic. I pray for strength to learn from this. I pray that if this the place I need to be, that I would know it. I consider it a privilege to work in the medical field, and serve my patients as a PA. I want to be a better PA. But reviews like this, I wonder -- is the ED for me?

[Neup]

Is it possible to follow up with the director to see if there are certain goals or specifics he would like to see improvement in? Maybe hit up some of the senior PA's to see what he's referring to. Likely, someone else has been in the same boat. My two cents is that if it took an entire year to hear criticism from him, you're doing well. As a patient, I look for three things: you care, you want to fix me, and if you can't, you're going to find someone who can.

 

However, I'm not a PA, so enjoy a few grains of salt with my opinion. :)

[unewillow]

Personally, I wouldn't take it too much to heart. You've only been there a year, and I assume this is your first PA job? Of course there's no way you are going to be as effieicent or as fast as some of the PAs who have been there longer. With time you will learn how to better manage your time with patients. If you like what you do and you like where you are stick it out.

[EMEDPA]

Sounds like you are doing ok because you aren't considered unsafe and you are well liked. an er residency is a good idea for anyone and if you could make it work I would certainly recommend one. speed comes with time. my first yr I saw 2-3 pts/hr.

by the end of my second yr I saw many more/hr with my fastest day 52 pts in 12 hrs, all very minor.

follow some other folks around and see how they do things differently. you don't really need a huge hx, fh, social hx for example on many minor medical and trauma presentations. most fast track pts can be in and out in 5-10 min unless you need to do a procedure. you can catch up on charting after the pt leaves. just write enough on the chart initially so you will remember the c/c, exam, and your tx.

[LESH]

Was your past health care experience before PA school in the ER? If not then really I don't think that was a bad review. Maybe a brutally honest one but its not like you are killing anyone or present a major malpractice risk. The ER can be a hard place to practice for anyone especially a "newish" grad IMHO. I agree with EMED.

[ventana]

no worries - if you are not in the bottom 10% you are doing fine.

 

ER is not really the place for a new grad and the fact that you are not a danger is the biggest issue.

 

Productivity - who gives a S### - do good medicine - treat patients the way you would want your family member treated. As long as you are not the very bottom of the pile don't sweat it......

 

I got very tired of the whole productivity thing - our benchmark was a PA that clicked comprehensive exam on every patient and was consistently the highest RVU generator in the entire ER (sometimes as high as 8 RVU's per hour)

 

 

I saw her never touch a patient and make many mistakes on Dx...... but the mngt lover her due to her numbers....

 

 

 

I would actually be encouraged with a review like you had - one year out and surviving in an ER where you are helping with very sick patients is great!!!

[Road Runner]

Neup,

 

Thank you for your comment/suggestions. I appreciate it.

 

I am going to meet with the med director for a follow-up on my review in ~3 months. I realize that during the initial interview, I should have asked what he meant by "efficient". I think that means how well I juggle patients and getting them seen, work-up, etc, in the most timely manner. It think there is an numbers element to it.. (I did asked the other seasoned PA who works there when I don't work how many pts he sees -- and he said he usually sees about 20-24 pts a day. I keep a log of how many patients I see. I see an average of 18-22 pts in 12 hours. My goal is 24-30 a day. Like I said, my best day was 28).

 

Yes, I will be hanging out with another PA who has been practicing a long long time. I hope to learn tips/tricks and become more efficient.

 

And finally, thank you for the reminder on what matter to pts. I wish you well on you becoming a PA!

[Road Runner]

Thanks unewillow for your post.

 

In regards to what I do, I enjoy my position as a whole. The ED is a fast-paced environment, and sometimes staff (and me!) can be on "edge" when our ER waiting room is full, and all beds are full and nothing is moving. That's can be stressful! But all in all, I do enjoy EM and I enjoy my interactions with patients and their families. But I also want to know that if this is not where my skills/strengths are best served (aka I am too slow), that I find that position that best suits my skills.

 

(It's my first EM job, did 1 year in FM.)

[Road Runner]

EMEDPA,

 

Thank you for sharing with me how in time, you were seeing many many patients. I will remember that "speed comes with time".

 

I so badly want to do an ER residency, but fitting it in is tough due to my family constraints. I really just want to apply to an ER residency, and do it. My significant other and I go back and forth over this. He feels that in time, I will get the experience I long for.

 

I agree, my hx can be trimmed down. I think by watching the seasoned PAs, I'll get some tips. I don't want to be sloppy with my physical exam, and rush the pts history, etc. And here's a question I haven't dared ask -- are the fast PAs/docs really doing cranial nerves/neuro exams? Sometimes I am amazed how fast some docs come in/out of patient's room!!!

 

(But I dream of being able to run the codes, chest tubes, intubations, etc. I do understand my current role as a "fast-track" PA, and I want to get better at that.)

[Road Runner]

Thanks, Lesh, for your feedback

 

My past HCE was not in the ER. No, I haven't killed anyone, but don't want it to come to that point! :)

 

I guess, I still feel newish at times. This can be frustrating after 1 year in the ED (Of course I can take care of the URIs, lacs, N/V/D, UTIs, FBs, etc) -- but when I take care of the higher acuity patients, I always wonder if I'm done enough, the right thing, etc. This is -- of course -- after presenting the patient, the ED doc sees the pt and dispo is done with their involvement. There have been so many different practice styles, based on the physician working in the ER that day. Some docs are EM trained, some our FM trained.

 

My medical director wants me to pick up the easy fast-tracky stuff, and leave the most acute pts to him. Some docs want me to picks up whoever is next in line (unless they are medicare). Some want me to pick up all the pelvics, some don't want to do headaches, some have me do their lacs/procedures, etc, etc. ah!!!!

 

One PA told me that it will take a good 2-3 years in EM minimum to feel "okay".

[Road Runner]

Ventana,

 

I am encouraged by your post. Really helped a lot. Thank you, thank you. I know that we define ourselves not by what people think, but in our belief in ourselves. I know that this review is not supposed to define me as a PA, but it is a objective-ish assessment for me to go by as EM PA.

 

Thank you for reminding me, that it IS about good medicine. I am more and more convinced that so much of what patients want is that we show them we care.

 

(From my review, he said I was in the bottom half, so felt like I was at the bottom...)

 

I want to move forward and keep my head up. I want to learn and continue learning. But if I am not "efficient" enough, than I really need to figure out what to do about that (aka watch other PAs, more abbreviated hx), or move on and find the right place/position for me.

 

Again, thank you.

[EMEDPA]

you can do a pretty good neuro exam in 2 minutes.

mental status: you should have this just by talking to them and seeing how they respond and a few basic questions to check orientation.

cn2-12 takes about 30 seconds

cerebellar: rams or romberg

motor/sensory: grips/pedal movement, lt touch. make sure to document motor exam for hand injuries; test radial(thumbs up), ulnar(wrist extension) and median(touch thumb to pinky).

dtr's only do the relevant ones( ie don't need upper extremity for low back pain)

low back pain: remember to have them walk on heels( L5), walk on toes(S1) and squat ( L4).

there is a great book I used as a student: the four minute neuro exam by goldberg

 

having staff set things up for you in advance really saves time(lac/I+D trays, pelvic setups, slit lamp, etc)

[rev ronin]

Remember: 50% of PA's will be in the bottom half, compared to their peers. Not everyone can be above average. :-)

[Road Runner]

Just an update from my original post. I recently had a follow-up review from my previous review. Long story short, the medical director was pleased with my improvements. I have learned to be more efficient in managing my patients and moving pts along.

 

I still have a lot to learn, but he stated I am no longer below average - heheheheh :)

 

For any new starting PAs out there in the ER, there is hope if you have not had the greatest review and been told you are slow-ish and need to see more pts. By observing efficient clinicians, reading/studying, having a good attitude, prayer, and what other PA forum experienced members shared helped me tremendously.

[Hemegroup]

Life is learning! Congrats on your strong start.

[Road Runner]

thanks hemegroup. :) small victories. one day at a time/one pt at a time.

[Just Steve]

When Thomas Edison was questioned about feeling like a failure for it taking him so many tries to build a light bulb he replied he now knows 2000 ways how not to make one..knowing your own weaknesses is the first step to improvement. Congrats on the improvement and for sticking with it.

[Road Runner]

just steve, thanks so much for your words. (sorry this is late too!)

 

so much to learn, and still learning. but striving to become better PA every day.

[Neup]

Glad to hear things went better this round!

[Road Runner]

Thanks neup. :)

[akb7]

Good work!

[janetlee]

Roadrunner, thank you for sharing! You have a great attitude! It's wonderful to have a supportive professional community like this!

[Road Runner]

Thanks akb7 :)

[Road Runner]

janetlee,

 

They say attitude is so important. I agree wholeheartedly. I am very thankful for the PA forum community and the support/suggestions.

 

Have a great day everybody. :)

[physasst]

Just an update from my original post. I recently had a follow-up review from my previous review. Long story short, the medical director was pleased with my improvements. I have learned to be more efficient in managing my patients and moving pts along.

 

I still have a lot to learn, but he stated I am no longer below average - heheheheh :)

 

For any new starting PAs out there in the ER, there is hope if you have not had the greatest review and been told you are slow-ish and need to see more pts. By observing efficient clinicians, reading/studying, having a good attitude, prayer, and what other PA forum experienced members shared helped me tremendously.

 

 

Be careful too though. Too much emphasis on efficiency results in things getting missed. It takes years to get really efficient. I'd be a little bit nervous about a group THAT focused on efficiency. My 0.02 cents at least.