How do we get our PAs more job satisfaction?

europeman · Jul 21, 2012

I'm very concerned about this. As a chief resident this year, I am actually very invested in my PAs which started working at our institution in a much bigger role once the 16 hr work week began.

Most of them are VERY smart and young and motivated. But Inherent in their roles, essentially as perpetual interns, I see the life slowly getting sucked out of them.

I know they can do so much more too! Our cardiothoracic service at my institution is completely run by PAs. Some are in the OR all day doing saphenous harvests, and others totally run the floors and round with the attendings or fellows. Some of the big shot attendings on vascular surgery or general survey ( ie division chiefs and such) have their own personal PAs or NPs which see patients in clinic, follow up on patients in and out of the hospital, take part in research studies, etc. In short, they are true professions and are invested in their patients and such.

But my poor PAs basically are assigned to function in a role to fill the gap of the 16 hour intern work week. And worse.... They never operate.

Take our acute care surgery service at night. We have to have someone responsible for the floor and someone responsible for ER consults. When a small case comes like an appendectomy or perirectal abscess or something.... I can't do it with the pA if I have an intern.... My interns are already behind the 8 ball since they are never there to begin with.... So any opportunity I get to get them into the OR I have to take.

But the pAs are left out to dry.

Now u could say... Oh this job is a stepping stone for these PAs.

Well that sucks cuz then we just have high turnover.

Something needs to change

SLUser11 · Jul 21, 2012

europeman said:
I'm very concerned about this. As a chief resident this year, I am actually very invested in my PAs which started working at our institution in a much bigger role once the 16 hr work week began.

Most of them are VERY smart and young and motivated. But Inherent in their roles, essentially as perpetual interns, I see the life slowly getting sucked out of them.

I know they can do so much more too! Our cardiothoracic service at my institution is completely run by PAs. Some are in the OR all day doing saphenous harvests, and others totally run the floors and round with the attendings or fellows. Some of the big shot attendings on vascular surgery or general survey ( ie division chiefs and such) have their own personal PAs or NPs which see patients in clinic, follow up on patients in and out of the hospital, take part in research studies, etc. In short, they are true professions and are invested in their patients and such.

But my poor PAs basically are assigned to function in a role to fill the gap of the 16 hour intern work week. And worse.... They never operate.

Take our acute care surgery service at night. We have to have someone responsible for the floor and someone responsible for ER consults. When a small case comes like an appendectomy or perirectal abscess or something.... I can't do it with the pA if I have an intern.... My interns are already behind the 8 ball since they are never there to begin with.... So any opportunity I get to get them into the OR I have to take.

But the pAs are left out to dry.

Now u could say... Oh this job is a stepping stone for these PAs.

Well that sucks cuz then we just have high turnover.

Something needs to change

Interns get to go to the OR because they are there to learn how to operate independently. There's no reason to train a PA to do anything more than just assist in the OR. Since you are at a training program, the PAs will have less of a role in the OR naturally. That's why the more desirable PA jobs are in other environments.

What exactly do you want to have the PAs doing during your appys?

Like you said, scutwork is inherent into their roles...they function at the level of an intern because their education is not meant to create an independent practitioner. If they wanted a different inherent role, they should have gone to medical school.

SouthernSurgeon · Jul 21, 2012

IMHO the satisfaction has to come from being in a stable work environment with predictable and good hours, good pay, and the benefits package that you'd expect as an employee at a major university hospital.

Treat the PAs well, hope they like the work and the people they are working with, and hope they stick around.

Our general surgery PAs are very explicitly told that they will not be operating because the department's mission is to train residents. They should know and expect that coming into the job.

Now that said, there are lots of procedures a PA can do and bill for, and they can see patients independently in clinic in a lot of circumstances, adding to the department's revenue stream, because they don't have the same requirements for supervision that a resident does. Those tasks should be identified and maximized and can help be an outlet for PAs so that they aren't just stuck on the floor 100% of the time.

deleted6669 · Jul 21, 2012

also you need to do something to reward loyalty for those pa's who don't leave after a year. a bit more money or vacation hrs, a slightly better schedule, more cme money, u/s training etc.
as mentioned above identify which procedures they can do with a greater degree of autonomy and allow those after adequate training. many floor and ICU procedures like central lines, paracentesis, thoracentesis, chest tubes, etc are nice for a surgical pa to add to their skill set once the interns and residents feel comfortable with these.
Thanks for looking out for the pa's on your service. too often this doesn't happen and depts like yours become a revolving door where new grads train for 1 year then leave for a job which treats them better. This is not unique to surgery. there are em, ortho, hospitalist, etc pa jobs like this out there as well.

ESU_MD · Jul 21, 2012

Very good topic, think about it alot.

In gen surgery program with residents, I really cant see anyway to build up a PA who is interested in getting operative skills. The training of residents come first. This can lead to resentment on both ends. Low level residents are insecure and some have a hard time interacting with midlevels who often are more experienced. The best way i see to retain gen surgery PAs is with consideration to favorable work hours and money. The best gen surg PAs tend to be moms who need the stable hours or those who are content with floor work.

The young guns tend to gravitate towards ortho or cardiac where they are expected to do alot in th OR, or the rare private practice PA in gen surgery, but the lifestyle sucks.

As a cardiac surgeon, i like working with our PAs and am helping them learn how to open chests, dry up and close as well. It makes them happy and makes our team more productive as well.

europeman · Jul 21, 2012

Granted, for general surgery where i am at, there is absolutely no reason for a pA to go to the operating room when I have residents. I totally get that. Cardiac surgery with their vein harvests is sorta a unique field/ situation.

I just feel since PAs are licensed health care providers, their role shouldn't be that of an intern. I don't mean they should have a higher or lower role... I just think different. So the way we have them filling in the gaps of intern work because of work hours just doesn't seem efficient.

For example, at our city hospital, at night it unfortunately necessary for someone on the team to physically transport patients to operating room from floor or to OR from ER. It's just how it is. Now I NEVER felt bad asking my intern to do that cuz he is an intern and once he got the patient up I'd show him something in the operating room.

Well..... Asking the pA time and time again to get my patient transported as if he is my intern just isn't right.

It's not utilizing his skills/ability/education in a way which makes sense.

It's inefficient.

The obvious solution is hire more transporters at night. Duh. But administration doesn't look at it that way.

I'm SURE one experienced PA could handle BOTH our floor AND ER consults if we had a tech or something we could have do our real scut (transport patients, draw emergency labs, maybe even place ngts) which would free up a PA to actually practice medicine.

Do I trust an intern to cover floor and ER? Absolutely not. Do I trust one of the pAs who has 2 years experience with me to? Of course! But instead that pA is just being scutted out half the time with things that aren't even appropriate scutt.

Appropriate scutt in my opinion for a PA is: initially seeing patient, placing orders, responding to nurse pages, writing H&Ps.

Socrates25 · Jul 21, 2012

The best solution is to have the attendings work out a deal with the PAs.

the PAs get to do the "easy" cases solo and the attendings get to bill for their services.

Its a win-win situation! The PAs get to do their own cases and get plenty of OR time, and the attendings get to triple their income because they can run multiple ORs simultaneously while the PA-surgeon does all the work!

Sounds like a great plan to me!

deleted6669 · Jul 21, 2012

Nice sarcasm above. this is meant to be a thread about working with pa's as opposed to bashing them, your favorite topic. at some point you really need to change your signature misquoting me talking about PA residencies on a different board.....

europeman · Jul 21, 2012

C'mon Greek philosopher.... That's not cool

Poetic Silence · Jul 21, 2012

I love shadowing PA's and talking with them about their philosophies in medicine. I know PA's at OHSU in the cardiothoracic department, orthpaedic department and neurosurgery department get to assist in the OR. I know they enjoy it too.

europeman · Jul 21, 2012

I should have rephrased my statement.

Given our pAs can't go to OR, what are some ways people have found to utilize their skills and have them have job satisfaction on a general surgery service?

ESU_MD · Jul 21, 2012

Probably the best way to improve morale is to just be cool and not treat people like crap. It goes a long way, a few kind words and genuine appreciation will pay big dividends. The vast majority of PAs know they will never have the same autonomy as docs and are ok with it. Treat them nice and they will go down with ship for you.

deleted6669 · Jul 22, 2012

ESU_MD said:
Probably the best way to improve morale is to just be cool and not treat people like crap. It goes a long way, a few kind words and genuine appreciation will pay big dividends. The vast majority of PAs know they will never have the same autonomy as docs and are ok with it. Treat them nice and they will go down with ship for you.

Great advice. Thanks. none of us expect to be doing heart transplants but we wouldn't mind the chance to do a few central lines/chest tubes/etc here and there. all scut and no fun = folks looking for jobs where they will be appreciated more. every time I have left a job it has been over scope of practice, not pay.

Thanatos · Jul 22, 2012

I find this thread a little disturbing.

Maybe I am misinterpreting, if so feel free to let me know. But are you basically saying that you feel bad for the PA's when you scut them out, but scutting out a resident is okay. PA's (like nurses and other support staff) are paid very well after only a few years of education for working 40 hours a week with minimal liability and beyond excellent job portability. The role of the physicians assistant is to assist. We don't need assistance in the OR or with procedures, which are what we put up with all of this other bull**** to have the privilege of finally getting to do. We need help with the neverending amount of scut work, which are what these guys and gals are brought in to do. I'm not going to feel sorry for them when they come in to work 3 hours after I do, leave 3 hours before me, and make twice my salary.

We have recently hired a bunch of PA's to help with the workload so our interns aren't violating the **** out of their work hours. They are very pleasant and knowledgeable and are helping out with the work, which we all greatly appreciate. I have a hard time integrating them into our services though because they only work 8 hour days 5 days a week, no holidays/weekends. They won't come in early for rounds so the interns have to stop for 15 minutes when they come in to get them up to speed, and they won't stay late so we can send the interns home any earlier. They don't take overnight call or work weekends....so they help the interns have a more pleasant day I suppose but I'm a little lost on how this will help us stay under hours but whatever.

But under no circumstances am I going to do any procedure with a PA when any resident is available based on principle alone. Of course PA's are capable of learning these things and doing them well, and I'm sure they would like to do lines and chest tubes because it is kind of cool. It seems like what happens gradually is that a PA with a lot of experience will start doing all the chest tubes while the interns are writing orders for zofran and transporting patients to xray, and I have a real problem with that.

Dwindlin · Jul 22, 2012

Thanatos said:
I find this thread a little disturbing.

Maybe I am misinterpreting, if so feel free to let me know. But are you basically saying that you feel bad for the PA's when you scut them out, but scutting out a resident is okay. PA's (like nurses and other support staff) are paid very well after only a few years of education for working 40 hours a week with minimal liability and beyond excellent job portability. The role of the physicians assistant is to assist. We don't need assistance in the OR or with procedures, which are what we put up with all of this other bull**** to have the privilege of finally getting to do. We need help with the neverending amount of scut work, which are what these guys and gals are brought in to do. I'm not going to feel sorry for them when they come in to work 3 hours after I do, leave 3 hours before me, and make twice my salary.

We have recently hired a bunch of PA's to help with the workload so our interns aren't violating the **** out of their work hours. They are very pleasant and knowledgeable and are helping out with the work, which we all greatly appreciate. I have a hard time integrating them into our services though because they only work 8 hour days 5 days a week, no holidays/weekends. They won't come in early for rounds so the interns have to stop for 15 minutes when they come in to get them up to speed, and they won't stay late so we can send the interns home any earlier. They don't take overnight call or work weekends....so they help the interns have a more pleasant day I suppose but I'm a little lost on how this will help us stay under hours but whatever.

But under no circumstances am I going to do any procedure with a PA when any resident is available based on principle alone. Of course PA's are capable of learning these things and doing them well, and I'm sure they would like to do lines and chest tubes because it is kind of cool. It seems like what happens gradually is that a PA with a lot of experience will start doing all the chest tubes while the interns are writing orders for zofran and transporting patients to xray, and I have a real problem with that.

Thank you.

deleted6669 · Jul 22, 2012

Thanatos said:
It seems like what happens gradually is that a PA with a lot of experience will start doing all the chest tubes while the interns are writing orders for zofran and transporting patients to xray, and I have a real problem with that.

actually what starts happening is that these experienced pa's start helping in the teaching of med students/interns/residents when senior residents and attendings are not around vs the intern stumbling through the procedure alone....we have residents at my shop and I have taught a lot of them procedural skills when the senior residents and attendings aren't around or don't have time to teach. I understand that in a perfect world interns learn only from senior docs. I get that. in the real world senior residents and attendings don't always make time for interns. it shouldn't be that way but it is. Some places formalize pa's helping in the teaching of residents. at a previous job I was asked to run a minor er procedures rotation for incoming fp interns. it made sense as I had more procedural experience than any of the senior residents. it was very well received by the interns, senior residents, and attendings.
If the pa's only work 8 hrs that is the fault of the system, not the pa's. many jobs are posted for pa's as 12 hr shifts, all nights/weekends/holidays to help out when they are most needed. my job is full time nights. most of my shifts are fri/sat/sun/mon. don't blame the pa's for their cush schedules, blame the folks who created the jobs to be like that. if you need pa's at night, post a nocturninst position. if you need them at 5 am, make the shift 5 am to 5 pm. there are enough pa's out there who want to get into surgery that someone will take that job.

Apollyon · Jul 22, 2012

europeman said:
I'm SURE one experienced PA could handle BOTH our floor AND ER consults if we had a tech or something we could have do our real scut (transport patients, draw emergency labs, maybe even place ngts) which would free up a PA to actually practice medicine.

So you are advocating for a PA-....A? A physician assistant's assistant? And then, for the really, really mind-numbing or trivial stuff, would the assistant get an aide - so now there's a PAAA?

Poetic Silence · Jul 22, 2012

Apollyon said:
So you are advocating for a PA-....A? A physician assistant's assistant? And then, for the really, really mind-numbing or trivial stuff, would the assistant get an aide - so now there's a PAAA?

Oh, c'mon now. A medical assistant or an LPN would suffice.

badasshairday · Jul 22, 2012

emedpa said:
actually what starts happening is that these experienced pa's start helping in the teaching of med students/interns/residents when senior residents and attendings are not around vs the intern stumbling through the procedure alone....we have residents at my shop and I have taught a lot of them procedural skills when the senior residents and attendings aren't around or don't have time to teach.

It is great that you do that, but other PA/NP's don't do the same. The program I went to med school at had a high powered IR program, obviously the fellows were doing big cases and were super busy. There was an NP who did a lot of consents, pre procedure H&P's and a lot of procedures (paras, thoras, chest tubes, ports, piccs, mahukars) and he was really good at these procedures. He was lightening fast having done so many over many years. Sometimes he stole procedures from the residents on service... who only had opportunities to do low end procedures due to the fellows.

He never taught me anything. I remember resenting him so much because of that, especially when I saw the NP student with him trying a PICC.

Luckily one of the fellows was very nice and even though he was super busy let me try a few things.

I understand that in a perfect world interns learn only from senior docs.

And there lies more resentment. Because the midlevels learned from the attendings. There was an attending at some point who walked them through each procedure. For us residents, we are to be taught by the PA/NP?

Again, I have nothing against PA/NP, in fact I'm marrying one. I am just with others who doesn't understand why the OP has concerns. We are the ones going through all this training, education, time, to get to where we want to be, so resident satisfaction should be the most important. The PA/NP already get to do so much and get paid a ton relative to residents without nearly as much sacrifice.

deleted6669 · Jul 22, 2012

"Sometimes he stole procedures from the residents on service... who only had opportunities to do low end procedures due to the fellows. "
I see that as a failure of leadership. pa's/np's shouldn't be taking cases/procedures away from residents. they should be doing overflow that the house staff can't keep up with.

"And there lies more resentment. Because the midlevels learned from the attendings. There was an attending at some point who walked them through each procedure."
Many of us learned how to do procedures from attendings at places that didn't have residents. my best learning experiences have been at small depts where it's just me and 1 doc. In a place like that I can be involved in every case. the docs like me doing some of the work. the more they teach me, the more I can do when it gets really busy.

"I am just with others who doesn't understand why the OP has concerns."
the residency program needs warm bodies to see pts.
residency hr restrictions mean the residents can't do them all so they hire pa's to deal with overflow admissions, dicharges, procredures, clinic, etc
. if the pa's are all miserable they will all quit making the residents experience more about scut than learning. that's why it's important to throw the pa's a bone every now and then so they feel like they are also learning and doing meaningful work. most of us change jobs every few years because we have maxed out what we can learn at the current place. if you keep us learning and enjoying our jobs we will stick around longer. senior pa's are more efficient than new grad pa's. they make your residency service run more smoothly. The op understands that. we offer yr to yr continuity which contributes to hospitals remaining safe places for patients every July. new grads, whether pa's or md's, shouldn't be set loose on pts without some experienced folks around to back them up. in the past attendings took this role. now many attendings prefer to not work nights/weekends/holidays/etc. they want lives outside of medicine.
it's a different world than it was 40-50 years ago. my dad was an "old school doc" and was available to the hospital 24/7/365. he was a great doc( and a great teacher), but as you might imagine not the best family man. not a lot of folks like that around any more to teach the next generation of physicians.

adenocard · Jul 22, 2012

Thanatos said:
I find this thread a little disturbing.

Maybe I am misinterpreting, if so feel free to let me know. But are you basically saying that you feel bad for the PA's when you scut them out, but scutting out a resident is okay. PA's (like nurses and other support staff) are paid very well after only a few years of education for working 40 hours a week with minimal liability and beyond excellent job portability. The role of the physicians assistant is to assist. We don't need assistance in the OR or with procedures, which are what we put up with all of this other bull**** to have the privilege of finally getting to do. We need help with the neverending amount of scut work, which are what these guys and gals are brought in to do. I'm not going to feel sorry for them when they come in to work 3 hours after I do, leave 3 hours before me, and make twice my salary.

We have recently hired a bunch of PA's to help with the workload so our interns aren't violating the **** out of their work hours. They are very pleasant and knowledgeable and are helping out with the work, which we all greatly appreciate. I have a hard time integrating them into our services though because they only work 8 hour days 5 days a week, no holidays/weekends. They won't come in early for rounds so the interns have to stop for 15 minutes when they come in to get them up to speed, and they won't stay late so we can send the interns home any earlier. They don't take overnight call or work weekends....so they help the interns have a more pleasant day I suppose but I'm a little lost on how this will help us stay under hours but whatever.

But under no circumstances am I going to do any procedure with a PA when any resident is available based on principle alone. Of course PA's are capable of learning these things and doing them well, and I'm sure they would like to do lines and chest tubes because it is kind of cool. It seems like what happens gradually is that a PA with a lot of experience will start doing all the chest tubes while the interns are writing orders for zofran and transporting patients to xray, and I have a real problem with that.

Apollyon said:
So you are advocating for a PA-....A? A physician assistant's assistant? And then, for the really, really mind-numbing or trivial stuff, would the assistant get an aide - so now there's a PAAA?

anonperson · Jul 22, 2012

europeman said:
I'm very concerned about this. As a chief resident this year, I am actually very invested in my PAs which started working at our institution in a much bigger role once the 16 hr work week began.

Most of them are VERY smart and young and motivated. But Inherent in their roles, essentially as perpetual interns, I see the life slowly getting sucked out of them.

I know they can do so much more too! Our cardiothoracic service at my institution is completely run by PAs. Some are in the OR all day doing saphenous harvests, and others totally run the floors and round with the attendings or fellows. Some of the big shot attendings on vascular surgery or general survey ( ie division chiefs and such) have their own personal PAs or NPs which see patients in clinic, follow up on patients in and out of the hospital, take part in research studies, etc. In short, they are true professions and are invested in their patients and such.

But my poor PAs basically are assigned to function in a role to fill the gap of the 16 hour intern work week. And worse.... They never operate.

Take our acute care surgery service at night. We have to have someone responsible for the floor and someone responsible for ER consults. When a small case comes like an appendectomy or perirectal abscess or something.... I can't do it with the pA if I have an intern.... My interns are already behind the 8 ball since they are never there to begin with.... So any opportunity I get to get them into the OR I have to take.

But the pAs are left out to dry.

Now u could say... Oh this job is a stepping stone for these PAs.

Well that sucks cuz then we just have high turnover.

Something needs to change

I don't get why doing procedures and being in the OR means being more appreciative of a PA. If they wanted the opportunity to be in the OR on a legitimate basis then they should take the route that thousands have taken before them which is going to medical school and applying to a surgical residency.

The role of a PA is to assist. If that means scut, then so be it. That doesn't mean you should treat them like crap, but mainly that their role is to fill in gaps.

I know having a PA or NP do a bunch of procedures will get them very proficient, but what ends up happening is they end up taking these procedures from residents. Resident training is more important than getting PAs a couple of extra procedures. They are the ones who will end up being independent and need to know the nuances of doing a procedure, even if it is routine.

Chirurg · Jul 22, 2012

thanatos said:
i find this thread a little disturbing.

Maybe i am misinterpreting, if so feel free to let me know. But are you basically saying that you feel bad for the pa's when you scut them out, but scutting out a resident is okay. Pa's (like nurses and other support staff) are paid very well after only a few years of education for working 40 hours a week with minimal liability and beyond excellent job portability. The role of the physicians assistant is to assist. We don't need assistance in the or or with procedures, which are what we put up with all of this other bull**** to have the privilege of finally getting to do. We need help with the neverending amount of scut work, which are what these guys and gals are brought in to do. I'm not going to feel sorry for them when they come in to work 3 hours after i do, leave 3 hours before me, and make twice my salary.

We have recently hired a bunch of pa's to help with the workload so our interns aren't violating the **** out of their work hours. They are very pleasant and knowledgeable and are helping out with the work, which we all greatly appreciate. I have a hard time integrating them into our services though because they only work 8 hour days 5 days a week, no holidays/weekends. They won't come in early for rounds so the interns have to stop for 15 minutes when they come in to get them up to speed, and they won't stay late so we can send the interns home any earlier. They don't take overnight call or work weekends....so they help the interns have a more pleasant day i suppose but i'm a little lost on how this will help us stay under hours but whatever.

But under no circumstances am i going to do any procedure with a pa when any resident is available based on principle alone. Of course pa's are capable of learning these things and doing them well, and i'm sure they would like to do lines and chest tubes because it is kind of cool. It seems like what happens gradually is that a pa with a lot of experience will start doing all the chest tubes while the interns are writing orders for zofran and transporting patients to xray, and i have a real problem with that.

thank you!

Poetic Silence · Jul 22, 2012

I cannot believe the lack of empathy I am seeing here. Well, actually I can. I mean, this is SDN after all. But still.

I think we as medical professionals and future medical professionals owe it to nurses, NP's and PA's to provide an environment where they feel intellectual challenged and are able to observe growth and maturity in their work. Everyone deserves to feel pride in their hard work.

Kudos to the OP. He's the kind of doctor I hope to become.

diagonal · Jul 22, 2012

Poetic Silence said:
I cannot believe the lack of empathy I am seeing here. Well, actually I can. I mean, this is SDN after all. But still.

I think we as medical professionals and future medical professionals owe it to nurses, NP's and PA's to provide an environment where they feel intellectual challenged and are able to observe growth and maturity in their work. Everyone deserves to feel pride in their hard work.

What on God's green Earth are you talking about?

deleted6669 · Jul 22, 2012

Poetic Silence said:
I cannot believe the lack of empathy I am seeing here. Well, actually I can. I mean, this is SDN after all. But still.

I think we as medical professionals and future medical professionals owe it to nurses, NP's and PA's to provide an environment where they feel intellectual challenged and are able to observe growth and maturity in their work. Everyone deserves to feel pride in their hard work.

Kudos to the OP. He's the kind of doctor I hope to become.

at least somebody gets it....

deleted6669 · Jul 22, 2012

diagonal said:
What on God's green Earth are you talking about?

a team based approach to medicine....expect to hear more about that throughout your training, what with it being the future of healthcare and all....

diagonal · Jul 22, 2012

emedpa said:
a team based approach to medicine....expect to hear more about that throughout your training, what with it being the future of healthcare and all....

Oh, sorry. I was unaware that the future of health care is physicians providing a self-actualization service for mid-levels and nurses.

And guess what, we don't hear about any of that in medical school. And pardon me if I find tremendous humor in a PA telling me what to expect in my medical training. :laugh:

deleted6669 · Jul 22, 2012

diagonal said:
Oh, sorry. I was unaware that the future of health care is physicians providing a self-actualization service for mid-levels and nurses.
And guess what, we don't hear about any of that in medical school.

the future of medicine is physician lead teams caring for patients. ask any of your instructors if you don't believe me.
if you crap on folks throughout your career, even the janitor, your life will be a lot more difficult than it needs to be.
Do I occasionally grab a blanket or a glass of water for my patients? yup. is it my job? no. I do it to make life a bit easier for the techs I work with. in return they won't be passive aggressive about cleaning up vomit in one of my rooms. it's karma friend. what goes around comes around. treat folks as you would like to be treated. end of sermon.

diagonal · Jul 22, 2012

emedpa said:
the future of medicine is physician lead teams caring for patients. ask any of your instructors if you don't believe me.
if you crap on folks throughout your career, even the janitor, your life will be a lot more difficult than it needs to be.
Do I occasionally grab a blanket or a glass of water for my patients? yup. is it my job? no. I do it to make life a bit easier for the techs I work with. in return they won't be passive aggressive about cleaning up vomit in one of my rooms. it's karma friend. what goes around comes around. treat folks as you would like to be treated. end of sermon.

He didn't say "don't treat people like *******s." He said, it's the physician's job to build an environment that challenges mid-levels and nurses in an effort to bolster their intellect and esteem. No, it's not. That's the job of the individual to do for themselves. If you want a more challenging job, do what those ******* doctors did, and go to medical school.

SouthSideSteve · Jul 22, 2012

PA student here.

I get OP's point, but you ARE at an academic center. Residents should get OR time and procedures over PAs.

As a PA you are a PGY-1 for the rest of your career, scut is a huge part of that. Even more-so at an ivory tower. If those PAs want OR time and procedures they need to go to a private practice gig (which will also get paid significantly more).

I don't have any suggestions here, if they are unhappy they will leave. Though, it is refreshing to see you actually care about them.

FWIW, I want to do CV at an academic center for the opportunity to work with residents, fellows, and be involved in both the teaching and learning process.

Poetic Silence · Jul 22, 2012

diagonal said:
He didn't say "don't treat people like *******s." He said, it's the physician's job to build an environment that challenges mid-levels and nurses in an effort to bolster their intellect and esteem. No, it's not. That's the job of the individual to do for themselves. If you want a more challenging job, do what those ******* doctors did, and go to medical school.

Bro, that line of thinking is seriously flawed. Not everyone can become a doctor. And no, it's not because most aren't smart enough or hard working enough, it's because providing healthcare takes all kinds. If everyone was a doctor, healthcare would collapse. Nurses, medics, NP's and PA's are all vital organs in the body of medicine. It's time we started showing them that.

diagonal · Jul 22, 2012

Poetic Silence said:
Bro, that line of thinking is seriously flawed. Not everyone can become a doctor. And no, it's not because most aren't smart enough or hard working enough, it's because providing healthcare takes all kinds. If everyone was a doctor, healthcare would collapse. Nurses, medics, NP's and PA's are all vital organs in the body of medicine. It's time we started showing them that.

Non-sequitur.

The role of physician is not to custom-tailor an intellectually challenging and life-affirming day for their employees.

Where you got that I think mid-levels and nurses don't have a role, shouldn't be respected, and how I think they should all become physicians, is beyond me.

Poetic Silence · Jul 22, 2012

I got it from your completely original, "The should go to medical school," bit. Mad props for coming up with that one.

A physician's job is to serve as a leader in his or her workplace. Part of that is providing an atmosphere that motivates those who work under you to give you their best efforts 100% of the time. That can only happen when you take to heart their concerns and do your best to address them.

diagonal · Jul 22, 2012

Poetic Silence said:
I got it from your completely original, "The should go to medical school," bit. Mad props for coming up with that one.

A physician's job is to serve as a leader in his or her workplace. Part of that is providing an atmosphere that motivates those who work under you to give you their best efforts 100% of the time. That can only happen when you take to heart their concerns and do your best to address them.

You've never worked a day of your life in a hospital, have you?

Hi nurse, I'm going to make your job more challenging today, because I see a yearning in your eyes for something more. :laugh:

deleted6669 · Jul 22, 2012

diagonal said:
Where you got that I think mid-levels and nurses don't have a role, shouldn't be respected, and how I think they should all become physicians, is beyond me.

maybe when you said this:
"If you want a more challenging job... go to medical school."

diagonal · Jul 22, 2012

emedpa said:
maybe when you said this:
"If you want a more challenging job... go to medical school."

How is that incorrect? Most nurses don't want to be doctors. If they did, it's not my job to play pretend. It's their job to fulfill that destiny themselves.

deleted6669 · Jul 22, 2012

diagonal said:
How is that incorrect? Most nurses don't want to be doctors. If they did, it's not my job to play pretend. It's their job to fulfill that destiny themselves.

guess what? physicians aren't the only ones who are entitled to enjoying their jobs....

Poetic Silence · Jul 22, 2012

diagonal said:
You've never worked a day of your life in a hospital, have you?

Hi nurse, I'm going to make your job more challenging today, because I see a yearning in your eyes for something more.

No, you listen to their concerns and do your best to address them. Just like the OP is doing.

If your PA's come to you and say, "I don't feel challenged enough. I'd like to learn more procedures." Do your best to honor that request. A happy PA is a much harder working and more efficient PA.

diagonal · Jul 22, 2012

Poetic Silence said:
No, you listen to their concerns and do your best to address them. Just like the OP is doing.

If your PA's come to you and say, "I don't feel challenged enough. I'd like to learn more procedures." Do your best to honor that request. A happy PA is a much harder working and more efficient PA.

Ah yes, do what the anesthesiologists did for CRNAs. That worked out so well for them. You're blind to the realities of your utopia, my friend.

LucidSplash · Jul 22, 2012

Can I ask that the back and forth stop? The thread is getting hijacked a bit, and by non-residents/surgeons, which is a bit of a pet peeve of mine in this forum. I'm not a mod but for the love of Pete, if you want to have a personal snit session with another user's point of view, please take it to private messages. Watching pre-meds, medical students, and allied-health professionals piss on one another is not the reason I visit this forum.

/rant

europeman · Jul 23, 2012

I actually have found the comments and private messages from the non-physicians on this thread very informative. I'm happy they are part of the discussion since my thread is about their job.

I find it disburbing that there are actually physicians on this thread who are so arrogant they can't realize that better care of patients means maximizing utility of midlevels.

The reason so many private docs utilize midlevels is because the fact is, you don't need to be a physician to do a lot of the stuff we do! Therefore, it's much more efficient for them to hire a mid-level rather than a peer physician to help w/work burden. How you train and utilize that midlevel is obviously dependent on the local circumstances. The purpose of my thread was to get ideas how to do this better on my general surgery service 'cuz we have too much turnover... and it seemed to me that the PA's were capable of more than they were doing.

At our ER, PA's participate in trauma when the residents are in protected teaching conferences/electures and such. They intubate, put chest tubes, put lines, etc. They are good. As a trauma chief, I rely on them to help supervise lines and tubes for my own junior residents and ER residents so I can supervise other aspects of the trauma resuscitation. When I was a PGY-1 and 2 I learned how to do subclavians from the PA's in the ICU who were the best at them. In our CT-ICU, PA's are the only continuity the unit ever sees, and attendings recognize that and treat them accordingly. They help supervise and teach procedures and ultrasound to junior residnets... they are true professionals and part of the team - they are not stealing anything from the residents. Do I teach and supervise procedures as a chief resident (or have my senior resident do the same)? Of course. But the PA's are experienced, and if we are doing bilateral chest tubes and lots of stuff is going on, it's great having them around. They do nothing but add to the resident education actually.

My biggest problem is on our gen surgery service, I simply find the tasks we are giving our PA's to be ones that don't maximize their ability. Lots of them could instead be performed by a tech or LPN. i think our method of treating PA's like part time interns just inherently is inefficient. That's all. I can SEE on other services that they have more job satisfaction precisely because they have job descriptions which entail more responsibility than what we do on my service.... and coupled with the fact that we have a new PA quit every 6 months, I figured this would be a good place to get some ideas. Our ER and CT service, on the other hand, has PA's which have been there for years, and turnover is EXTREMELY low.

But me recognizing that hasn't helped me think of specific things I can do on my service to make it change. It's actually not so obvious. We have a general surgery busy floor. Interns have work hours. I'm in OR all day. PA's help. I get it. But our PA's are quitting and hate their job. On the CT service they love their job. There is something I'm not saying... and short of asking the CT pas at our hospital (maybe I should do this), I thought I'd start with this thread

plauto · Jul 23, 2012

People generally leave their jobs for these reasons:
#1 not being treated well
#2 overworked
#3 bad pay

Since you said that in other depts of your hospital turnover is low, I'd guess #3 is not the deciding factor here. On gen surg I'd venture out and say it's a combination of #1 and #2, mostly #1.

beefballs · Jul 24, 2012

Pgy 3 here. As for PAs a resident should never miss or time in favor of a PA. If that's happening you should lose resident coverage. The currency I trade in is OR time and if I am on the floor and e PA is in the or then the attending isn't holding up there end of the bargain. I have scrubbed with private plastics guys with there own RNFA or PA and they let me 1st assist with the attending because they aren't covering the attending at night etc. and they generally understand that, even though after 10-15 years of working with the boss they are more efficient than I am

debvz · Jul 24, 2012

anonperson said:
I don't get why doing procedures and being in the OR means being more appreciative of a PA. If they wanted the opportunity to be in the OR on a legitimate basis then they should take the route that thousands have taken before them which is going to medical school and applying to a surgical residency.

The role of a PA is to assist. If that means scut, then so be it. That doesn't mean you should treat them like crap, but mainly that their role is to fill in gaps.

I know having a PA or NP do a bunch of procedures will get them very proficient, but what ends up happening is they end up taking these procedures from residents. Resident training is more important than getting PAs a couple of extra procedures. They are the ones who will end up being independent and need to know the nuances of doing a procedure, even if it is routine.

A little different perspective practicing at a private hospital with resident rotators--

While my residents have first dibs on any OR cases, floor procedures are plenty, and whoever is available will take the procedure, whether it be a PA/NP/resident, or even myself. The goal is to get everybody seen and taken care of in the most time-efficient way.

An experienced PA who can perform procedures is worth their weight in gold. While some residents may feel left out by not doing every line, chest tube, lac repair, etc, it is imperative to keep my PA/NP's happy as well. It can become a major strain on a busy service to have an unhappy or bored midlevel leave for greener pastures, and to have to train a newly graduated replacement.

Poetic Silence · Jul 24, 2012

debvz said:
A little different perspective practicing at a private hospital with resident rotators--

While my residents have first dibs on any OR cases, floor procedures are plenty, and whoever is available will take the procedure, whether it be a PA/NP/resident, or even myself. The goal is to get everybody seen and taken care of in the most time-efficient way.

An experienced PA who can perform procedures is worth their weight in gold. While some residents may feel left out by not doing every line, chest tube, lac repair, etc, it is imperative to keep my PA/NP's happy as well. It can become a major strain on a busy service to have an unhappy or bored midlevel leave for greener pastures, and to have to train a newly graduated replacement.

Precisely what the voice of reason is trying to make known.

dilated · Jul 24, 2012

debvz said:
A little different perspective practicing at a private hospital with resident rotators--

While my residents have first dibs on any OR cases, floor procedures are plenty, and whoever is available will take the procedure, whether it be a PA/NP/resident, or even myself. The goal is to get everybody seen and taken care of in the most time-efficient way.

It's a little easier in your environment. You presumably don't have interns. The major issue where midlevels become a problem on an academic surgical service is that "midlevel appropriate procedures" are also by definition "intern appropriate procedures". I highly doubt there are any chiefs out there disgruntled that PAs are taking their Whipples or maxillectomies.

It is a problem, especially with the new intern hours. The only useful solution I've found is if there's time when the residents are unavailable due to didactics the midlevels can cover those cases and get OR time. Otherwise you've got to give the residents the cases, try to work the midlevels into the procedure rotation (in a fair way) and hope everyone gets along.

cpants · Jul 24, 2012

I think you need to recruit different people to make the relationship work well. You need midlevels who are not interested in going to the OR and you need to tell them up front that residents get first rights to all cases and procedures. We rotate at several different hospitals, and the place where it works the best runs this way. There really aren't any hard feelings when the roles are well defined like this, and there is still plenty to challenge people and keep them interested. Floor work and consults are still medicine and still making pretty important decisions. It's not like we have them making copies. There are also weekly PA didactics where an attending does stuff like take them through cases or go over interesting scans.

MiracleforMD · Jul 24, 2012

europeman said:
...which would free up a PA to actually practice medicine...

Yeah, this sounds reasonable.

badasshairday · Jul 25, 2012

cpants said:
I think you need to recruit different people to make the relationship work well. You need midlevels who are not interested in going to the OR and you need to tell them up front that residents get first rights to all cases and procedures. We rotate at several different hospitals, and the place where it works the best runs this way. There really aren't any hard feelings when the roles are well defined like this, and there is still plenty to challenge people and keep them interested. Floor work and consults are still medicine and still making pretty important decisions. It's not like we have them making copies. There are also weekly PA didactics where an attending does stuff like take them through cases or go over interesting scans.

Definitely need to define roles.

My fiancee and friends are all new PA's and they all look for different things. Mostly they are looking for high pay with minimal call and weekends. Who can blame them? But with that mentality don't expect to be treated like a physician. And I think they are okay with that. They went to PA school knowing that. So if a PA is not satisfied because they are not getting OR time in general surgery, then they chose the wrong career IMO.

How do we get our PAs more job satisfaction?

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