Specialty CAQs- Thoughts?

[True Anomaly]

I want to agree, I really do.

 

But the calculus of PA school, and residency as the new standard for basic PA, and I will no longer be able endorce PA over MD pathway when asked.

The payback simply isn't worth it

 

I'm starting to really agree with this sentiment. On a grossly generalized level, those of you who talked about the push towards "grades over experience" in regards to PA admissions who asked what the long-term effects of it would be.....well, this may be it.

[robidf]

I'm starting to really agree with this sentiment. On a grossly generalized level, those of you who talked about the push towards "grades over experience" in regards to PA admissions who asked what the long-term effects of it would be.....well, this may be it.

 

This feels like a very slippery slope.

 

Our profession is tied DIRECTLY to another profession: Doctors. Their experience with any PA, whether it be newer or older generation, is going to be the basis of their decisions and even the decisions of their colleagues. It is for this reason that I feel the push for "grades over experience" will be greatly detrimental to this profession. As our profession becomes diluted to an "elevated GPA and depressed HCE" younger crowd of students, we may find ourselves being greatly misrepresented and therefore being utilized more as "Advanced Medical Assistants".

 

We may no longer seen by the attending as "the 30 year old PA who worked as a paramedic/nurse/RT/RRT for 6 years"...the PA that in his prior career has intubated countless patients or performed ACLS on an ambulance countless times; but, more commonly, as the 23 year old who chose PA school because they had a good GPA and wanted to be out of school in two years.

 

Unfortunately, as Ventana has stated, I feel that this has already been set into motion and there is no stopping it. Our only hope is to push the new generation of PA's to act with dignity and honor: to treat this as a profession and not a job. We must strive to advance this profession and carry on the positive impression that the generations before us have made, even if it takes putting in twice as much work to earn the same amount of respect.

[NAP1986]

This feels like a very slippery slope.

 

Our profession is tied DIRECTLY to another profession: Doctors. Their experience with any PA, whether it be newer or older generation, is going to be the basis of their decisions and even the decisions of their colleagues. It is for this reason that I feel the push for "grades over experience" will be greatly detrimental to this profession. As our profession becomes diluted to an "elevated GPA and depressed HCE" younger crowd of students, we may find ourselves being greatly misrepresented and therefore being utilized more as "Advanced Medical Assistants".

 

We may no longer seen by the attending as "the 30 year old PA who worked as a paramedic/nurse/RT/RRT for 6 years"...the PA that in his prior career has intubated countless patients or performed ACLS on an ambulance countless times; but, more commonly, as the 23 year old who chose PA school because they had a good GPA and wanted to be out of school in two years.

 

Unfortunately, as Ventana has stated, I feel that this has already been set into motion and there is no stopping it. Our only hope is to push the new generation of PA's to act with dignity and honor: to treat this as a profession and not a job. We must strive to advance this profession and carry on the positive impression that the generations before us have made, even if it takes putting in twice as much work to earn the same amount of respect.

 

I think this generalization is unfair. I've shaded a neurosurgery PA, an urgent care PA, and a cardiology PA. All were outstanding clinicians in their mid-30's, and when they weren't around the docs often said they were as good if not better than most of the docs in that particular hospital. All of them, however, urged me to go to medical school and said they went to PA school because they were single parents at the time when they had to make decisions and medical school was not feasible to them. All openly expressed remorse for not going to medical school. By contrast, after having gone on interviews at some of the best PA programs (including Duke and Emory), and seeing most of the students age 25-30, all said they were passionate about the PA profession and had very strong reasons for wanting to be a PA rather than an MD/DO or NP. Most wanted to work in primary care and had a strong desire to work with underserved populations. Most wanted to be involved in healthcare policy and legislation, which I see more of the older PAs complaining about but not doing. None of them saw it as just a job or a quick way to get into the workforce. Most talked about flexibility to change specialties, more time with patients, less liability, better working hours, etc. relative to MD/DOs.

 

Who is going to be a better advocate for the profession and help it move forward? Someone who felt forced to enter it because "life happened" and tells people who shadow that they regret it, or a relatively youthful person who is passionate about being a PA and it has been their first career goal? I felt depressed after shadowing these older PAs. I can hear the naysayers saying those younger people will regret it and outgrow the role, but that varies so much by individual I feel it is not fair to make such generalizations. I had a good number of group interviews where multiple interviewers were extremely aggressive about my personal reasons for not going MD/DO.

[Just Steve]

Would you expect a sample of applicants, surveyed at an interview, to be anything less than textbook "I love primary care" and full of pro PA love? Of all days in the PA career, there are a few days where you put your best foot forward...those would be days of interviews and lawsuits.

[Justeco]

I don't mean to be a concern troll... but why would I want to become a physician assistant if residencies are required in order to do a specialty? It seems to make more sense, financially and time wise, to simply become an advanced nurse.

[ATCLATEMTB]

This is a small aside....but I have to make it.

 

First, I am VERY tired of talking with PA students / applicants who say they want to be a PA for x,y,z oh and better working hours. I don't know a single PA that works less hours then their doc. Maybe its my hospital system, or practice, or where I trained at Emory....but I don't see it.

 

Secondly, this on-going chatter about less liability irks me. We are held to the standards of physicians, as well as standards of care for particular disease processes / guidelines ect. I have my own license, DEA, malpractice....I have liability and a career to protect. My physician has EXTENDED his liability as a provider by choosing to work with me. Something I don't take lightly. I don't like the message and attitude it conveys when Pas / students say less liability. You want to practice medicine and make decisions BUT you don't want all the responsibility for the decisions you make. Obviously, by construct there is a shared liability......but seriously folks what kind of message do we send we we say that?!? Not one that lends itself well to advancing our profession, autonomy, and respect. I can't say I have ever heard an NP say less liability...then again that may not be a talking point.

 

I guess I just expect people to take responsibility for their actions and decisions.

[ventana]

I don't mean to be a concern troll... but why would I want to become a physician assistant if residencies are required in order to do a specialty? It seems to make more sense, financially and time wise, to simply become an advanced nurse.

 

 

Not so

 

NP's are likely going to loose some ability to work in the specialities as they advance for more independent practice. By their training standards a FP nurse should NOT be working in the ICU or OR - - in past this has always slipped by but I have heard of a few cases where the hospitals are saying that unless the nurse is acute care they can not be in the hospital.... ie a Peds NP can't work Geriatrics.... only makes sense....

 

 

If however you want to be a PCP and work peds or IM or FP I would suggest NP instead of PA in the current setting, but your quality of education is far less as an NP - only about 400 clinical hours versus 2000+ for a PA. I have meet some NP's that managed to get the degree and never step foot in the hospital or OR ----- sort of scary in my mind, as they were taking an online NP degree

 

As for Doc versus PA

It is not so much about the hours worked (although I suspect the true data does support some doc's work a lot more) it is the duration and cost of training.

 

MD/DO is min of 7 years post bachelors degree

PA is min 2 years post bachelors degree - even with a one year "residency" it is still less then half the training......

 

Used to be able to say PA school was cheaper, but I think the MS degree and cost creep has pretty much done away with that.... ie debt load on graduation is a lot less as the # of years training is less, but the per year expense is probably pretty equal.....

[CoastalPalm]

Not so

 

NP's are likely going to loose some ability to work in the specialities as they advance for more independent practice. By their training standards a FP nurse should NOT be working in the ICU or OR - - in past this has always slipped by but I have heard of a few cases where the hospitals are saying that unless the nurse is acute care they can not be in the hospital.... ie a Peds NP can't work Geriatrics.... only makes sense....

 

 

If however you want to be a PCP and work peds or IM or FP I would suggest NP instead of PA in the current setting, but your quality of education is far less as an NP - only about 400 clinical hours versus 2000+ for a PA. I have meet some NP's that managed to get the degree and never step foot in the hospital or OR ----- sort of scary in my mind, as they were taking an online NP degree

 

Does having independent NP practice affect those NPs that work in the hospital setting? I mean, it's clear how independent practice works in primary care, but what about in specialty practice/clinics/hospitals? Would there be any difference compared to PAs working in the same setting? Would hospitals still require physician supervision/collaboration?

[drholmes]

Would there be any difference compared to PAs working in the same setting? Would hospitals still require physician supervision/collaboration?

 

My observations (as an ED scribe) are that it works both collaboratively and supervisory. The style of practice depends upon a mix of PA confidence/abilities and the perspective of the physician/physicians worked with. There are others, much more qualified than me, that can comment from an actual practice perspective.

 

In general, it really comes down to the individual PA who asserts themselves and there demonstrable abilities as they move forward to practice medicine. PA/MD/DO education being similar (not the same) it comes down to confidence and assimilation of experience that sets the better medical providers apart (litmus test works for NPs as well but we're talking medical model of training here). The schools will do what they need to do (for the PA - get through it). Regulators will do what they feel the need to do (deal with it - they have a say in this). Fellow professionals will continue to test you (that is the way it works). Show them all up by showing up and showing what you've got. Humility is still a great thing because it allows you to learn and considering we're entering medical practice; I assume that residencies and CAQ's are part of the larger animal of becoming a better practitioner. If the arena of medicine you choose to work in overwhelmingly requires such measures to "show" that you have the stuff - then maybe you need to consider it. By initial training, like the physicians, we are trained as generalists. Having passed the PANCE we should have fulfilled all the necessary requirements for that type of practice.

 

Having said all that, if the schools are not requiring the grades and the direct, clinical HCE (I tend to think that more is better - 4-5K sounds great) then we need to insist that they do. I don't care what age you are when you start or where your chronological age is when I'm looking at you from the gurney; treat me with dignity and competence and we'll be alright. All the players can't be addressed in one post but if you want to practice in a specialty arena with highly demanded CAQ and you are a urology Adonis then maybe you should consider burying the pride and taking the test to get the job.

 

Look, we have all seen/worked with PAs, MD, DOs, NPs that we would not send our worst enemy too. They will get what's coming to them (and, usually do).

 

In much needed summary, fiercely be all you can be, be damn good at it, and everything else works out.

[CoastalPalm]

My observations (as an ED scribe) are that it works both collaboratively and supervisory. The style of practice depends upon a mix of PA confidence/abilities and the perspective of the physician/physicians worked with. There are others, much more qualified than me, that can comment from an actual practice perspective.

 

In general, it really comes down to the individual PA who asserts themselves and there demonstrable abilities as they move forward to practice medicine. PA/MD/DO education being similar (not the same) it comes down to confidence and assimilation of experience that sets the better medical providers apart (litmus test works for NPs as well but we're talking medical model of training here). The schools will do what they need to do (for the PA - get through it). Regulators will do what they feel the need to do (deal with it - they have a say in this). Fellow professionals will continue to test you (that is the way it works). Show them all up by showing up and showing what you've got. Humility is still a great thing because it allows you to learn and considering we're entering medical practice; I assume that residencies and CAQ's are part of the larger animal of becoming a better practitioner. If the arena of medicine you choose to work in overwhelmingly requires such measures to "show" that you have the stuff - then maybe you need to consider it. By initial training, like the physicians, we are trained as generalists. Having passed the PANCE we should have fulfilled all the necessary requirements for that type of practice.

 

Having said all that, if the schools are not requiring the grades and the direct, clinical HCE (I tend to think that more is better - 4-5K sounds great) then we need to insist that they do. I don't care what age you are when you start or where your chronological age is when I'm looking at you from the gurney; treat me with dignity and competence and we'll be alright. All the players can't be addressed in one post but if you want to practice in a specialty arena with highly demanded CAQ and you are a urology Adonis then maybe you should consider burying the pride and taking the test to get the job.

 

Look, we have all seen/worked with PAs, MD, DOs, NPs that we would not send our worst enemy too. They will get what's coming to them (and, usually do).

 

In much needed summary, fiercely be all you can be, be damn good at it, and everything else works out.

 

Thanks for that. I guess when it comes down to it, I'm wondering if, in the inpatient and specialty settings (i.e. cardiology, pulmonary, endocrine, etc), would there be any difference between an independent practice NP and a PA? We know that in primary care, the independent NP would have advantages over the PA. However, in specialty and inpatient settings, aren't the physicians essentially "running" the show, i.e. ultimately responsible (not to take away of the autonomy of the APCs)? For example, even in a state with independent NP practice, you wouldn't see an NP as "attending NP" running an ICU, or a cardiology service, right? But, would an independent NP be able to open a cardiology private practice? So, would the independence confer any advantage over PA in that setting? I'm guessing not, but I'm just wondering how those more experienced view this. I'm guessing with CAQs and residencies, PAs obviously become more specialized, skilled, and knowledgeable within that area of medicine, however I'm wondering if, when faced with independent NPs, they would be able to practice to that same "top of the license", when there are restrictions.

[True Anomaly]

Thanks for that. I guess when it comes down to it, I'm wondering if, in the inpatient and specialty settings (i.e. cardiology, pulmonary, endocrine, etc), would there be any difference between an independent practice NP and a PA? We know that in primary care, the independent NP would have advantages over the PA. However, in specialty and inpatient settings, aren't the physicians essentially "running" the show, i.e. ultimately responsible (not to take away of the autonomy of the APCs)? For example, even in a state with independent NP practice, you wouldn't see an NP as "attending NP" running an ICU, or a cardiology service, right? But, would an independent NP be able to open a cardiology private practice? So, would the independence confer any advantage over PA in that setting? I'm guessing not, but I'm just wondering how those more experienced view this. I'm guessing with CAQs and residencies, PAs obviously become more specialized, skilled, and knowledgeable within that area of medicine, however I'm wondering if, when faced with independent NPs, they would be able to practice to that same "top of the license", when there are restrictions.

 

To practice in a hospital, you must be credentialed through the medical staff, which currently is still headed and run primarily by physicians (even if it's a "nurse"-run hospital). I can't forsee "independent" NP's being approved for medical staff in the near future. For that matter, I don't see it as well for PA's.

 

As far as "independent" NP specialty clinics...I don't see this happening either. Specialists get their clientele from one of two ways primarily- they are either consulted in the hospital by the internal medicine/hospitalist service or in the ER; or, patients are referred by a PCP's office to that clinic. Unless a primary care NP refers to a cardiology NP, both of whom may have "independent" practice, the likelihood of this happening is very slim. And no hospitalist service is going to consult a primarily NP specialist over a physician specialist, so that avenue is a dead-end. Sure, a patient can open up a phone book, pick a cardiology NP and make an appointment, but there aren't nearly enough of these types of patients to help support a practice like that.

[NAP1986]

 

In much needed summary, fiercely be all you can be, be damn good at it, and everything else works out.

 

Love this!

[Jbruskoski]

For anybody who has already taken the ED CAQ.

Any suggestions on what material to use to prepare for exam?

[kargiver]

If you see a wide spectrum of patients in the ED setting, just review basic stuff. Truly focus on stuff you don't see regularly (jelly fish stings, fish food poisoning) things like that and you will be fine...

 

G

[kargiver]

EM has, by far, the biggest turnout for CAQ takers by comparison to other specialties. This is borne out of a myriad of reasons, but the biggest one is that regardless of where you work in the ED, WE DO THE SAME EXACT JOB AS THE DOCs! This means needing the same knowledge base. It is the docs pushing for it, not necessarily the PAs (although SEMPA supports the CAQ for the above reason), and as the consequences of these actions play out, pay, autonomy level, skill level, even upward promotion will eventually be tied to whether or not you have it.

 

Is it degree creep? No, I don't think so... no one is saying you have to have it to be a PA. But if you want to be considered a highly competent PA in EM and show you have achieved a "masterly level" of knowledge that is only achievable by working in EM (the test is designed for those who work in EM, not just those who can read books about it), then the CAQ has relevance. Insurance companies are starting to move this way, and its only a matter of time until other policy makers do as well.

 

None of this affects lateral mobility for leaving the ER - it may affect the ability to get into the ER setting. But that will be the role of residencies, fellowships, and other products under development to get providers up to speed to play in the box. Fact is, PAs coming out of school are younger, much less experience, and they need the tools to transition to the environment where 50% of all hospital admissions are made (the ER). If they are going to play here, they need to know how to do it. Relying on past medical experience is just no longer a reality.

 

G

[3GeronimoPA]

I think in many ways there is far too much self promotion to say that it is the gold standard and the new drive is to get PAs to go to school, do a fellowship and take a certifying exam. It's not realistic. There are over 7,300 PAs working in Emergency Medicine (http://www.aapa.org/uploadedFiles/content/Common/Files/SP_PAs_EmergencyMed_v5-052611-UPDATED.pdf) as of 2010 an for sure more now. There are not enough fellowship programs out there for PAs to meet the desire of this concept. It is cool and all that you have your fellowships and you can argue with guys that did the OJT route and fight for jobs etc. but the fact of the matter is, there will be no way in the near future to churn out that many PAs in fellowship programs. There are fellowship programs that run parallel to residency programs for 12-18 months but these are programs that either use PAs for scut work ("PA so-and-so you have the left leg for this trauma patient" "PA so-and-so we need you to get 6 months of urgent care clinic(working up the same stuff you have done in general practice) to get experience doing what you are really going to do when you graduate") or they will be very open programs such as (but not limited to) the ones the military is currently running who abuse PAs like they do residents and make an excellent PA capable of working up whatever walks in the door. In my observations, there aren't enough residency sites out there that think enough of PAs to run these programs well. You can look at a new graduating doc's perception of PAs for evidence of this. Places that don't have Residencies running, have some PAs on staff, and want to bring PAs in for a fellowship under the agreement of cheap labor are likely the places that will give an aspiring PA the exposure and focus required to excel at a specialty. I just see there being limitations to a great degree in the US system's ability to facilitate the volume of PA training programs to make this happen. Also, rest assured, if these programs boom, we will be in direct competition for entry with NPs who dwarf our numbers and get legislature support to get independent ER credentials upon completion.

 

In some ways I feel like fellowship trained PAs saying, "I don't care how much experience you have you can't replicate the experience I received being treated like a slave in my 12-18 months of fellowship" is twin to MD/DOs saying, "I know you have 20 years of experience in Ortho but I'm a family medicine resident who actually went to medical school and I don't want to consult to a PA who I know more than" or "I know you have 30 years working in the Emergency Department but I am a Doctor (Family Practice Physician making some extra cash in the ER) and I will look at every chart and talk to every patient you see tonight". The "My school trumps your experience" argument is very condescending doctoresque. Don't be the kinda douche you don't like to work with.

[kargiver]

 

In some ways I feel like fellowship trained PAs saying, "I don't care how much experience you have you can't replicate the experience I received being treated like a slave in my 12-18 months of fellowship" is twin to MD/DOs saying, "I know you have 20 years of experience in Ortho but I'm a family medicine resident who actually went to medical school and I don't want to consult to a PA who I know more than" or "I know you have 30 years working in the Emergency Department but I am a Doctor (Family Practice Physician making some extra cash in the ER) and I will look at every chart and talk to every patient you see tonight". The "My school trumps your experience" argument is very condescending doctoresque. Don't be the kinda douche you don't like to work with.

 

I guess I'll respond to this aspect of your concerns as I think they are the most outlandish of what you write.

 

On what basis are you assuming that those PAs who go through residency are going to be comparing themselves in a superior context to those who have significant experience? That seems to me like a projected fear and a means of rejecting the concept out of hand without considering all of the facts.

 

I have no idea how long you have been a PA, what your background is, or the acuity of patients you see. What I do know is that the average PA student coming out of PA school is about 25 years old, has about a years worth of CNA or basic EMT work as their knowledge base going into school, and is woefully unprepared to staff an ER, let alone even a fast track. The facts are that there are not enough providers in EM, so we need more people doing it. How would you propose training them? 2 years of OJT? Or a sheltered, standardized residency program where they are paid to learn, not paid to move meat? OJT doesn't cut it anymore - there is too much to know, not enough knowledge base for those coming out of school to not have to start from scratch, and the demands on the ER setting are only increasing.

 

Everything starts somewhere. It is the great fallacy that if everything isn't in place right away, at the start, then what is being built or considered can never work. Yet, somehow, things get done. Why is that? 25 years after ACEP implemented it residency training requirements for physicians to become boards eligible, 50% of all practicing ER docs are still not board certified. Should they not have done it?

 

Again, EM is one of the few fields where our knowledge base needs to be on par with the docs. One way (note, not the only way) to get to that point is to have a standardized educational curriculum that PAs can go through to learn the tenets of EM. It will not be the only way to do it. For someone like me, I wouldn't do it at all. And woe to the person who tries to tell me they know more than me because they went through a residency. I have no problem taking BC/BE attendings to task over their attitudes; I certainly wouldn't tolerate it from my PA colleague(s).

 

What once made for a good PA no longer exists. In this new world, we can either define ourselves with better education and training, or let someone else define who we are and what we can do. I always opt for option A. By defining what we can do, we make a seat for ourselves at the table. It is only this way in which we can define our own future, not someone else doing it for us.

 

G

[LT_Oneal_PAC]

Excellent posts.

 

I guess I'll respond to this aspect of your concerns as I think they are the most outlandish of what you write.

 

On what basis are you assuming that those PAs who go through residency are going to be comparing themselves in a superior context to those who have significant experience? That seems to me like a projected fear and a means of rejecting the concept out of hand without considering all of the facts.

 

I have no idea how long you have been a PA, what your background is, or the acuity of patients you see. What I do know is that the average PA student coming out of PA school is about 25 years old, has about a years worth of CNA or basic EMT work as their knowledge base going into school, and is woefully unprepared to staff an ER, let alone even a fast track. The facts are that there are not enough providers in EM, so we need more people doing it. How would you propose training them? 2 years of OJT? Or a sheltered, standardized residency program where they are paid to learn, not paid to move meat? OJT doesn't cut it anymore - there is too much to know, not enough knowledge base for those coming out of school to not have to start from scratch, and the demands on the ER setting are only increasing.

 

Everything starts somewhere. It is the great fallacy that if everything isn't in place right away, at the start, then what is being built or considered can never work. Yet, somehow, things get done. Why is that? 25 years after ACEP implemented it residency training requirements for physicians to become boards eligible, 50% of all practicing ER docs are still not board certified. Should they not have done it?

 

Again, EM is one of the few fields where our knowledge base needs to be on par with the docs. One way (note, not the only way) to get to that point is to have a standardized educational curriculum that PAs can go through to learn the tenets of EM. It will not be the only way to do it. For someone like me, I wouldn't do it at all. And woe to the person who tries to tell me they know more than me because they went through a residency. I have no problem taking BC/BE attendings to task over their attitudes; I certainly wouldn't tolerate it from my PA colleague(s).

 

What once made for a good PA no longer exists. In this new world, we can either define ourselves with better education and training, or let someone else define who we are and what we can do. I always opt for option A. By defining what we can do, we make a seat for ourselves at the table. It is only this way in which we can define our own future, not someone else doing it for us.

 

G

[True Anomaly]

So, I'm planning on taking the CAQ this September, and while it may be overkill, I'm using the ABEM board review and Peer VIII to study for it (only because they belong to my fiance :D)

 

But I wanted to say something about Geronimo's post-

 

In some ways I feel like fellowship trained PAs saying, "I don't care how much experience you have you can't replicate the experience I received being treated like a slave in my 12-18 months of fellowship" is twin to MD/DOs saying, "I know you have 20 years of experience in Ortho but I'm a family medicine resident who actually went to medical school and I don't want to consult to a PA who I know more than" or "I know you have 30 years working in the Emergency Department but I am a Doctor (Family Practice Physician making some extra cash in the ER) and I will look at every chart and talk to every patient you see tonight". The "My school trumps your experience" argument is very condescending doctoresque. Don't be the kinda douche you don't like to work with.

 

Are you actually finding this to be the case? Have you met many EM residency PA's who have given you the impression that this is their mentality? They constitute a VERY small percentage of the practicing EM PA's, let alone PA's at large.

 

I can tell you that MY experience, as a PA who went to an EM residency and has met residents from many different programs, that I have yet run into anyone who carried this mentality. I have, however, met "holier than thou" PA's who simply were that because that is just their baseline mentality, and they would have ended up like that no matter what field they went into- PA, MD/DO or NP.

 

In my observations, there aren't enough residency sites out there that think enough of PAs to run these programs well.

 

This statement confuses me- how many residency programs are you intimately familiar with? And what exactly about them makes you think they're not being run well? Out of the programs that I am familiar with, which is more than a few, the directors truly care about their residents getting first-class experience and education, and have gone to great lengths to ensure that in their institutions- and the institutions have given these directors the latitude to allow them to set up a program to get PA's this experience. And keep in mind that just about every one of these programs that has started up in the last 5 years or so has had to do so by basically trying to find what works for them uniquely- there hasn't really been much a blueprint laid out for how to set one up, hence why there are programs of different lengths and curriculums. As these programs age, the directors tweak what needs tweaking so that their residents can have a better overall educational experience and NOT be treated as slave labor.

[3GeronimoPA]

Are you actually finding this to be the case? Have you met many EM residency PA's who have given you the impression that this is their mentality? They constitute a VERY small percentage of the practicing EM PA's, let alone PA's at large.

 

Scan these boards for residency vs. OJT arguments and it's all over them. I've seen it on here.

 

This statement confuses me- how many residency programs are you intimately familiar with? And what exactly about them makes you think they're not being run well? Out of the programs that I am familiar with, which is more than a few, the directors truly care about their residents getting first-class experience and education, and have gone to great lengths to ensure that in their institutions- and the institutions have given these directors the latitude to allow them to set up a program to get PA's this experience. And keep in mind that just about every one of these programs that has started up in the last 5 years or so has had to do so by basically trying to find what works for them uniquely- there hasn't really been much a blueprint laid out for how to set one up, hence why there are programs of different lengths and curriculums. As these programs age, the directors tweak what needs tweaking so that their residents can have a better overall educational experience and NOT be treated as slave labor.

 

Look closer at my statements. I never said that the vast majority of PA fellowship programs weren't run well. I used examples of what a poorly ran program would look like. I said (1) there weren't enough programs and (2) that most Emergency Medicine Residency programs for MD/DO wouldn't be capable of running concurrent PA fellowships well. I have seen a few of these programs in action and the ones that do Docs and PAs in in training well are the one's who have an open opinion about the PA profession. That isn't the case at many institutions. I was listening to the director of EMRAP on a lesson from 2012 and him and his Residency Program Director and Chief of Emergency Medicine buddies flat out made comments to the extent that "midlevels can be trusted in the fast track, can be trusted to run ACLS algorithms because it's drawn step by step but shouldn't be working up the "ill" patients that walk in the door alone". Who wants to go train at a place and be told when the ill patient walks in the door, "grab another chart, you won't be asked to do this when you get out on your own?". Like I said, I have not met an ER Fellowship trained PA that I thought had a weak skillset and most were able to handle whatever came in the door. I don't think the existing programs are being ran poorly for the most part. I just don't think our medical system has the ability to expand that out and keep the same product. I also think that nursing lobbies will prevent major institutions from creating "PA Residency Programs" independently and give us an edge on NPs. They will probably get half of them to run "Mid-Level Provider" programs for PAs and NPs, and then badger the hell out of the others until they cave.

 

My overall point is, PA advocacy doesn't carry the weight to expand out a "school-PANCE-Fellowship-Specialty Qualification Test" system large enough to make it a requirement and exclude the OJT route. We will close out the majority of PAs in Emergency Medicine as most haven't done formal fellowships and then we will bow to the institution which is clearly dominated by the nursing community. I think we'll lose as a profession. If you want to push for an expanded scope for PAs who have passed the specialty cert by all means go ahead. Pushing for new state limitations on PAs scopes who haven't taken the specialty cert is very "eat your young"ish and trying to make the residency option a mandate is also going to blow up in our faces.

[3GeronimoPA]

I guess I'll respond to this aspect of your concerns as I think they are the most outlandish of what you write.

 

On what basis are you assuming that those PAs who go through residency are going to be comparing themselves in a superior context to those who have significant experience? That seems to me like a projected fear and a means of rejecting the concept out of hand without considering all of the facts.

 

I have no idea how long you have been a PA, what your background is, or the acuity of patients you see. What I do know is that the average PA student coming out of PA school is about 25 years old, has about a years worth of CNA or basic EMT work as their knowledge base going into school, and is woefully unprepared to staff an ER, let alone even a fast track. The facts are that there are not enough providers in EM, so we need more people doing it. How would you propose training them? 2 years of OJT? Or a sheltered, standardized residency program where they are paid to learn, not paid to move meat? OJT doesn't cut it anymore - there is too much to know, not enough knowledge base for those coming out of school to not have to start from scratch, and the demands on the ER setting are only increasing.

 

Everything starts somewhere. It is the great fallacy that if everything isn't in place right away, at the start, then what is being built or considered can never work. Yet, somehow, things get done. Why is that? 25 years after ACEP implemented it residency training requirements for physicians to become boards eligible, 50% of all practicing ER docs are still not board certified. Should they not have done it?

 

Again, EM is one of the few fields where our knowledge base needs to be on par with the docs. One way (note, not the only way) to get to that point is to have a standardized educational curriculum that PAs can go through to learn the tenets of EM. It will not be the only way to do it. For someone like me, I wouldn't do it at all. And woe to the person who tries to tell me they know more than me because they went through a residency. I have no problem taking BC/BE attendings to task over their attitudes; I certainly wouldn't tolerate it from my PA colleague(s).

 

What once made for a good PA no longer exists. In this new world, we can either define ourselves with better education and training, or let someone else define who we are and what we can do. I always opt for option A. By defining what we can do, we make a seat for ourselves at the table. It is only this way in which we can define our own future, not someone else doing it for us.

 

G

 

To answer your questions about me, I was a combat medic for 8 years with 2 deployments to Iraq and two deployments to remote outposts in Afghanistan with the Army. I have been working as a PA for 4 years in an Airborne Infantry battalion serving as a PCM for 1000 Soldiers and deployed a 5th time in January of 2011 to a remote trauma bay with myself and a few of my medics and provided initial stabilization of war trauma for my Soldiers and the surrounding Afghan military and civilian populace. I now work shifts in my local Emergency Department and on leave I fly up to the Arctic Circle at remote drilling platforms (sometimes on ships) in Alaska and provide initial management and coordinate transport for the aged population that runs those operations. I'm not a senior PA but I'm not new to medicine.

 

Don't assume that I made comments to the extent that all fellowship trained PAs have a superiority complex. Settle the feathers there. Please read my response to Anomaly about the political ramifications of this. I was always taught, don't let go of one branch until you have your hands firmly seated on another. Get a seat at the table and do what you must. I just think closing off the OJT route before there are enough fellowship options to meet the need in Emergency Medicine at the PA level is a bad idea. IF we fail to meet a need, rest assured someone else will fill it and then PAs will be standing in the back of the room looking at the table.

[EMEDPA]

no one is closing off the OJT training route (yet).

I think in all likelihood the future will look something like this:

1. the majority of the better em pa jobs will go to those with experience who hold a CAQ 5-10 years from now.

next

2. hospitals will require the CAQ to get fully privileged as em pas to work outside of fast track (this already happened to me to get procedural sedation rights at a new job)

then

3. the number of residencies will increase and they will all have their grads take the CAQ

then

4. insurance companies will require the CAQ for full payment for services

then

5. Residency will become a requirement after a certain date to take the CAQ

then

6. all PAs working in any specialty outside of primary care will be required to do a residency and be board certified via CAQ.

 

this is the same pattern the docs took. apprenticeship used to be ok 100 years ago. I have a great, great grandfather who was a doc who never attended medschool but learned via apprenticeship(like the first folks who worked in a quasi-pa role before duke graduated its first class..) then graduation from a formal program was required. then an internship. then a specialty residency. then boards. the pa profession will take the same trajectory. it is unavoidable like the tide coming in. hospital credentialing committees and govt regulations will force it on us. like it or not lateral mobility is likely going away to anything but primary care. procedures logs will become the norm to do anything and everything. it is already in full swing. 10 years ago if you wanted to do LPs , central lines, and procedural sedation you just did them. now you have to show someone that you can and have appropriate training to do so.

[Guest Paula]

The original poster asked specifically about the pediatric CAQ. I was considering it or the psych CAQ but at this point both are impossible for me to attain because of the requirements. I thought naively the peds CAQ would be a breeze since i see lots of kids & babies...but in FP there is not opportunity to get the experience asked for before taking the CAQ. (at least not in rural practice). I would have to find a pediatric SP mentor first (my SP doesn't have the skills asked for either), get significant ER experience in peds, and on and on. Same thing for the psych CAQ. Even tho I see lots of psych patients I do not have a good avenue to get the prior hours of psych experience needed to take the CAQ. I was disappointed. It seems the ER CAQ or surgery CAQ will be the ones that PAs will be most successful at since residencies are offered in those specialties.

[nhpilot]

Just throwing in my viewpoint as a pre-pa....

 

I have ~26000 hrs of HCE, the vast majority of which is in the OR. Needless to say, my interest is in surgery, specifically CV.

 

I already have my residency program picked out for when I graduate from my PA program. To me the surgical residency at Norwalk Hospital is unparalleled and is the gold standard for PA residency programs. NO medical residents...no fighting for cases....the floors are staffed and run by PA's. My dream environment.

 

Now my reason for wanting to take a pay cut for the first year post grad is simple....I want to have what I perceive to be the best training available...I WANT to gain the skills I believe I need. Could I go the OJT route? ABSOLUTELY! But I don't want to, because when I go to my first job, I want to be able to do an EVH, do follow ups, run a cath, from the get go. Not for any monetary benefit, (tho' that would be awesome), but because I strive to be the absolute best I can be, and for me that is a residency. And after residency, believe me, I will be looking for the CV PA veterans to help me INCREASE my knowledge...because I will have the basics already in my arsenal, I will be ahead of the game and ready to absorb more advanced skills.

 

And yes....as soon as I can, I will be sitting for the CAQ. Again...It is because it is what I want...maybe and ego thing...but I like to know that I have the skills, knowledge and yes certifications to prove it.

 

I will be 50 when I start my program, and the year I will take for residency is much more than worth it to me.

[Boatswain2PA]

EM has, by far, the biggest turnout for CAQ takers by comparison to other specialties. This is borne out of a myriad of reasons, but the biggest one is that regardless of where you work in the ED, WE DO THE SAME EXACT JOB AS THE DOCs! This means needing the same knowledge base. It is the docs pushing for it, not necessarily the PAs (although SEMPA supports the CAQ for the above reason), and as the consequences of these actions play out, pay, autonomy level, skill level, even upward promotion will eventually be tied to whether or not you have it.

G

 

I'm not sure I agree with this. While I certainly don't claim to have the "big picture", it seems like the majority of the EM PAs that I talked to at SEMPA do a lot of fast track, or they see the lesser-acuity patients in the ER while the Doc's take the "sicker" patients. This is also what I experienced during my preceptorship at the biggest ER in the region. The PA/NPs ran fast track, and when working in the main EDs they handled the greens. If they took any yellows they had to be checked out by the attending.

 

I know of some ED's where the Doc's and PAs just alternate patients, but I think that is actually pretty rare if you are multi-coverage.

 

Plus, if you compare the education/expectations of a board certified EM physician to an EM CAQ PA, I think the differences are still pretty vast. Bottom line is they know a lot more than we do.