Should I be wary of sites that have PA/NP residencies?

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StephenMaturin

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Getting my ROL ready and wanted to hear people's experience with this. Should I be wary of sites that have PA/NP EM "fellowships", like this (https://www.carilionclinic.org/emergency-care/fellowship)? It sounds like they're advertising the same educational and procedural experiences that the residents are looking for. Will this dilute the resident experience, or is it really not a problem?

I'm just a little nervous, because at my medical school we're always so low on the totem pole in terms of priority for teaching. I really want to go to a place at which there is no question about who gets priority for these opportunities.

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Do you have the contact info for any residents? I'd try emailing them and asking. Ask specifics, and don't settle for a a generic answer like 'we get plenty of procedures'. Ask if they ever let mid level fellows intubate, if so dump em.

I general I'd be suspicious about this kind of thing, but the website linked seems to suggest that only one block of the mid level "fellowship" is actually spent in the ED, so likely not a big deal but you should ask someone familiar with the program. Residency rank lists are in, so you're not risking anything by asking.
 
I know quite a bit about the em pa residency/fellowship/postgrad programs. There are 27 now. Most are modeled after the em md/do pgy-1 year with lots of off-service rotations in critical care, trauma, anesthesiology, u/s, etc. . At all of them PAs (and NPs at 2 or 3 that accept both) do full scope em including all procedures. These are all busy places and many use the programs to attract em pas who may wish to stay after completion of their programs. Most grads of these programs end up in rural practices that can't afford an em residency trained/boarded physician. I have worked with several of these folks from the various programs and been impressed with all of them. I would have done one of these programs if one were available when I graduated pa school. I still might if there were one in my home town. There are a few new ones every year. ACEP is very much in favor of these as EM physicians set the currriculum and provide all the training. If you are going to work with PAs (and sign their charts) , don't you want them to reflect well upon you and the specialty of emergency medicine? Not using PAs is not an option financially at this point for most departments so having the best PAs you can only makes sense.
here is a complete list at present( if anyone knows of others please let me know so I can update the list):

EM PA RESIDENCIES/FELLOWSHIPS/POSTGRAD PROGRAMS
(27)

Albert Einstein Emergency Medicine PA Residency (PA): http://www.einstein....-assistant.html

Johns Hopkins Emergency Medicine PA Residency (MD): http://www.hopkinsba...org/emresidency

University of Iowa Emergency Medicine PA Residency: http://www.uihealthc.../emparesidency/

US Navy Emergency Medicine PA Fellowship (CA): http://www.napasite....?pageId=1148479

Upstate Medical University Emergency Medicine PA Fellowship(NY): http://www.upstate.e...mergencymed.php

NY Presbyterian Weill-Cornell Emergency Medicine PA Residency (NY): http://www.weillcorn...aresidency.org/

Staten Island Hospital PA Residency In Emergency Medicine (NY):
http://www.statenislandem.com/pa/

Baylor University/Ben Taub Hospital PA Fellowship in Emergency Medicine(TX

https://www.bcm.edu/...tant-fellowship

Baylor University/U.S.Army Emergency Medicine PA Postgarduate Doctoral Residency Program (TX) :http://www.bamc.amed...lth/empa/[/URL]

Regions Hospital Emergency Medicine PA Residency(MN): http://www.regionsem.org/pa-residency

Cook County Hospital PA Postgraduate Emergency Medicine Residency Training Program (IL.): http://ccparesidency...cialties_4.html

St. Lukes Hospital Emergency Medicine PA Postgraduate Fellowship (PA):
http://www.mystlukes...ship/index.aspx

East Virginia Medical School Emergency Medicine PA Fellowship (VA):
http://www.evms.edu/....nt_fellowship/

Arrowhead Medical Ctr Emergency Medicine PA fellowship (CA): https://www.arrowhea...ault.aspx?id=70

Marquette University Postgraduate Emergency Medicine PA Program( WI):http://www.marquette...tgraduate.shtml

Carilion Clinic Emergency Medicine PA Fellowship Program (VA):
https://www.carilionclinic.org/emergency-care/fellowship

Albany Medical College PA Postgraduate Program in Emergency Medicine (NY): http://amc.edu/Acade...ship/index.html

San Joaquin Valley Hospital Emergency Medicine PA Residency(CA): http://www.emparesidency.com/

Rhode Island Hospital PA Emergency Medicine Development Program (RI): http://brown.edu/academics/medical/about/departments/emergency-medicine/emped

Team Health EMPA residency in Oklahoma. https://thma.co/providers/

Baystate medical center EMPA residency (Mass.): http://www.baystateh...idency Overview

Northshore NP/PA EM residency (IL): http://www.northshor...gency-medicine/

Yale/New Haven PA/NP Residency (CT): http://www.physician...cine-residency/

Livingston & Brighton (MI):

www.livingstonbrightoned.com/pafellowship.htm

Mayo Emergency Medicine Fellowship (MN): http://www.mayo.edu/...wship-minnesota

Long Island Jewish (NY)- 24 month program: http://www.lijed.com...em-fellowship-0

UT San Antonio (TX) In Development: http://emergencymedi...a.edu/pa-np.asp
 
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If there are X number of procedures and PA/NP fellows do any of them then in fact it is diluted.

That's not the question. The real question is if you get an adequate number even with the dilution.

After a certain point you probably would rather spend your time doing other things. If you get to do 40 central lines during residency, is doing another 10 going to really make you much more proficient?

Now if you lose 1/2 or 1/3 of your lines as an intern to the 'fellows' then it is probably not helping your education.
 
If there are X number of procedures and PA/NP fellows do any of them then in fact it is diluted.

That's not the question. The real question is if you get an adequate number even with the dilution.

After a certain point you probably would rather spend your time doing other things. If you get to do 40 central lines during residency, is doing another 10 going to really make you much more proficient?

Now if you lose 1/2 or 1/3 of your lines as an intern to the 'fellows' then it is probably not helping your education.
most places that have these programs schedule either an md/do resident or pa fellow on the specialty service at one time so , for example, on your icu block you would be the only one there doing central and A-lines and the next month a pa would be the only one there.
 
most places that have these programs schedule either an md/do resident or pa fellow on the specialty service at one time so , for example, on your icu block you would be the only one there doing central and A-lines and the next month a pa would be the only one there.

Maybe at smaller places. If you are at a big tertiary care center you might have multiple teams on a single unit. During my ICU blocks there were 2 interns/PAs per team (and there were 2 teams on the unit).

I have definitely lost procedures to new PAs in the ICUs. Albeit it wasn't too common and rarely presented an issue where I'm at. It all comes down to the ratio of learners to opportunities.
 
Rank lists are by no means in. We haven't even met to discuss our list yet...
 
I was a med student at a place with pa fellows and now at a residency with pa fellows. Yes they do take procedures, it really depends on how aggressive they are, ive had some pa fellows who definstely took away learning experiences from me as they did 30plus lines in 1 yr. Though the current crop 6 months in has done 1 to 3 lines, and arent really taking anything away. Its so depends. We still get plenty of each type and now as a senior i don't look back and wish u had more x or y. Id not take pa fellowship into your residency choice equation

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If there are X number of procedures and PA/NP fellows do any of them then in fact it is diluted.

That's not the question. The real question is if you get an adequate number even with the dilution.

After a certain point you probably would rather spend your time doing other things. If you get to do 40 central lines during residency, is doing another 10 going to really make you much more proficient?

Now if you lose 1/2 or 1/3 of your lines as an intern to the 'fellows' then it is probably not helping your education.
Most of these places only take 2 or three fellows per year. With all the off shift rotations they end up only amounting to one extra body. When you consider that ED utilization has skyrocketed and most of these places have had their number of EM residents frozen for years, it's pretty easy to extrapolate that you'll have plenty of procedures.
 
Yeah. That's a nonstarter for me. You will be competing with other services for many procedures too. Don't forget that.
 
Shrug, I learned most of my procedural skills on my own ED patients. They're not gonna steal procedures from you on your own patients, only in off service rotations where they're shared patients. And those are not necessarily the most important ones.
 
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I know quite a bit about the em pa residency/fellowship/postgrad programs. There are 27 now. Most are modeled after the em md/do pgy-1 year with lots of off-service rotations in critical care, trauma, anesthesiology, u/s, etc. . At all of them PAs (and NPs at 2 or 3 that accept both) do full scope em including all procedures. These are all busy places and many use the programs to attract em pas who may wish to stay after completion of their programs. Most grads of these programs end up in rural practices that can't afford an em residency trained/boarded physician. I have worked with several of these folks from the various programs and been impressed with all of them. I would have done one of these programs if one were available when I graduated pa school. I still might if there were one in my home town. There are a few new ones every year. ACEP is very much in favor of these as EM physicians set the currriculum and provide all the training. If you are going to work with PAs (and sign their charts) , don't you want them to reflect well upon you and the specialty of emergency medicine? Not using PAs is not an option financially at this point for most departments so having the best PAs you can only makes sense.
here is a complete list at present( if anyone knows of others please let me know so I can update the list):

EM PA RESIDENCIES/FELLOWSHIPS/POSTGRAD PROGRAMS
(27)

Albert Einstein Emergency Medicine PA Residency (PA): http://www.einstein....-assistant.html

Johns Hopkins Emergency Medicine PA Residency (MD): http://www.hopkinsba...org/emresidency

University of Iowa Emergency Medicine PA Residency: http://www.uihealthc.../emparesidency/

US Navy Emergency Medicine PA Fellowship (CA): http://www.napasite....?pageId=1148479

Upstate Medical University Emergency Medicine PA Fellowship(NY): http://www.upstate.e...mergencymed.php

NY Presbyterian Weill-Cornell Emergency Medicine PA Residency (NY): http://www.weillcorn...aresidency.org/

Staten Island Hospital PA Residency In Emergency Medicine (NY):
http://www.statenislandem.com/pa/

Baylor University/Ben Taub Hospital PA Fellowship in Emergency Medicine(TX

https://www.bcm.edu/...tant-fellowship

Baylor University/U.S.Army Emergency Medicine PA Postgarduate Doctoral Residency Program (TX) :http://www.bamc.amed...lth/empa/[/URL]

Regions Hospital Emergency Medicine PA Residency(MN): http://www.regionsem.org/pa-residency

Cook County Hospital PA Postgraduate Emergency Medicine Residency Training Program (IL.): http://ccparesidency...cialties_4.html

St. Lukes Hospital Emergency Medicine PA Postgraduate Fellowship (PA):
http://www.mystlukes...ship/index.aspx

East Virginia Medical School Emergency Medicine PA Fellowship (VA):
http://www.evms.edu/....nt_fellowship/

Arrowhead Medical Ctr Emergency Medicine PA fellowship (CA): https://www.arrowhea...ault.aspx?id=70

Marquette University Postgraduate Emergency Medicine PA Program( WI):http://www.marquette...tgraduate.shtml

Carilion Clinic Emergency Medicine PA Fellowship Program (VA):
https://www.carilionclinic.org/emergency-care/fellowship

Albany Medical College PA Postgraduate Program in Emergency Medicine (NY): http://amc.edu/Acade...ship/index.html

San Joaquin Valley Hospital Emergency Medicine PA Residency(CA): http://www.emparesidency.com/

Rhode Island Hospital PA Emergency Medicine Development Program (RI): http://brown.edu/academics/medical/about/departments/emergency-medicine/emped

Team Health EMPA residency in Oklahoma. https://thma.co/providers/

Baystate medical center EMPA residency (Mass.): http://www.baystateh...idency Overview

Northshore NP/PA EM residency (IL): http://www.northshor...gency-medicine/

Yale/New Haven PA/NP Residency (CT): http://www.physician...cine-residency/

Livingston & Brighton (MI):

www.livingstonbrightoned.com/pafellowship.htm

Mayo Emergency Medicine Fellowship (MN): http://www.mayo.edu/...wship-minnesota

Long Island Jewish (NY)- 24 month program: http://www.lijed.com...em-fellowship-0

UT San Antonio (TX) In Development: http://emergencymedi...a.edu/pa-np.asp

Certainly you can't know that all of these programs they do all procedures...
 
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I don't really have interest in "super midlevels" putting in lines and intubating people in the ER.. as most of you know from working with off service residents someone who has done 5 central lines and 5 intubations is more dangerous than someone who has done none at all.

that said we have one fast-track midlevel at our lvl 1 ED who refuses to see rashes/lacerations/I+Ds because he doesn't know how to manage these conditions. guy can see like back pain and dental pain that doesn't need I+D/block and that's it. No idea how he still has a job.

so it would be nice if these programs train people how to suture.

we frequently have paramedic students and flight RN's/medics who need intubations in the ED. It's always up to the resident to give up. I hardly ever give intubations away unless it's to an EM intern because if I'm the one doing the chart and managing dispo I'd like to do the one fun part of the encounter. am always happy to give lines away cause they are boring after doing a hundred or so.
 
Certainly you can't know that all of these programs they do all procedures...
I'm sure it's a requirement...I helped write the rules for credentialing these programs...
http://www.sempa.org/Content.aspx?id=360
from link above:
Have documented procedural experiences to minimally show understanding of:
    • Intubation and difficult airway management
    • Emergency criccothyroidotomy
    • Chest tubeinsertion
    • Ventilator management
    • Procedural sedation and rapid sequence intubation
    • Fracture and dislocation management
    • Slit lamp and tonometry
    • Additional skills as determined by preceptor or program
    • Intra-osseousplacement
    • Central line placement
    • Capnography
    • Advanced EKG interpretation
    • Radiographs, Computerized Tomography, Magnetic Resonance Imaging,ultrasound basic interpretation
    • Simple andadvanced wound closure
    • Cardiacresuscitation (to include cardioversion and cardiac pacing)
    • Arterial access for blood gas and monitoring
    • Lumbar puncture
    • Use of bedside ultrasound
    • Joint aspiration and injection
    • Additional skills as determined by preceptor or program
    • Skills should be obtained through patient, cadaver or simulation laboratory teaching.
5. Demonstrate and document team leadership knowledge and skills in the management of:

    • Cardiac arrest
    • Shock
    • Respiratory arrest
    • Traumas
    • Unresponsive patient(s)
    • Overdose patients
    • Diabetic ketoacidosis and other endocrine emergencies
    • Obstetric and gynecologic emergencies;
    • Pediatric emergency
    • Oncologic emergency
    • Hazardous material exposure
    • Mass casualty events
    • Other situations as determined by preceptor or program
 
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that said we have one fast-track midlevel at our lvl 1 ED who refuses to see rashes/lacerations/I+Ds because he doesn't know how to manage these conditions. guy can see like back pain and dental pain that doesn't need I+D/block and that's it. No idea how he still has a job.
.
this guy should not have graduated PA school...You need to find a new PA
those are core skills taught in PA school....all my students suture(simple and complex), I+D, use slit lamps, learn local and regional blocks including dental blocks, fx reduction, control of epistaxis, ingrown toenails, removal of FBs, etc. PA school has a strong focus on procedural skills for primary care and urgent care. Students with an em interest can do extra rotations, peds em, trauma surg, etc. I teach FP residents as well and I teach them the same skills I teach the PA students.
 
I don't really have interest in "super midlevels" putting in lines and intubating people in the ER.. as most of you know from working with off service residents someone who has done 5 central lines and 5 intubations is more dangerous than someone who has done none at all.
.
Many/most of these folks are going to end up working in rural facilities either as solo providers or alternating charts with an fp doc who may have less em experience than they do. They will work places no em physician and few fp physicians will because the facilities pay 70-90 dollars/hr....any of you willing to work for that in a 7 bed facility working 24 shifts in which you see fewer than 20 patients? The em pa residents I know (and I know many, including folks who run the programs above) get plenty of procedural experience (most get #s similar to pgy-1 em md/do residents). You want these folks to be good. they will be stabilizing critical pts in the middle of nowhere and transferring them to you. I work in 2 rural facilities; one as a solo provider and 1 alongside an fp doc. we see it all in the rural setting. most of the time our goal is to stabilize and ship to places with trauma teams, cath labs, etc, but we need to be able to handle that first 30-60 minutes, including all the critical interventions. On one of my recent rural shifts I was intubating a polysubstance OD while the doc I was working with that day was seeing a kid with the flu. They ducked into the room after I had the pt stabilized, said "nice job" and walked out.
 
I'm sure it's a requirement...I helped write the rules for credentialing these programs...
http://www.sempa.org/Content.aspx?id=360
from link above:
Have documented procedural experiences to minimally show understanding of:
    • Intubation and difficult airway management
    • Emergency criccothyroidotomy
    • Chest tubeinsertion
    • Ventilator management
    • Procedural sedation and rapid sequence intubation
    • Fracture and dislocation management
    • Slit lamp and tonometry
    • Additional skills as determined by preceptor or program
    • Intra-osseousplacement
    • Central line placement
    • Capnography
    • Advanced EKG interpretation
    • Radiographs, Computerized Tomography, Magnetic Resonance Imaging,ultrasound basic interpretation
    • Simple andadvanced wound closure
    • Cardiacresuscitation (to include cardioversion and cardiac pacing)
    • Arterial access for blood gas and monitoring
    • Lumbar puncture
    • Use of bedside ultrasound
    • Joint aspiration and injection
    • Additional skills as determined by preceptor or program
    • Skills should be obtained through patient, cadaver or simulation laboratory teaching.
5. Demonstrate and document team leadership knowledge and skills in the management of:

    • Cardiac arrest
    • Shock
    • Respiratory arrest
    • Traumas
    • Unresponsive patient(s)
    • Overdose patients
    • Diabetic ketoacidosis and other endocrine emergencies
    • Obstetric and gynecologic emergencies;
    • Pediatric emergency
    • Oncologic emergency
    • Hazardous material exposure
    • Mass casualty events
    • Other situations as determined by preceptor or program

The policy linked has a bunch of recommendations and no firm numbers for procedures, real vs sim, etc. Many of those things can be accomplished, as written, without providing those opportunities to the PAs. So you can't know that PA fellows are getting the training you think they are getting.
 
emedpa from reading your posts over the years you obviously have great training and are a competent solo provider. In my experience that is the exception rather than the rule. There certainly is a place for specialized PA training in EM. I was speaking solely from my perspective as a resident at a trauma center who will be supervising midlevels in a community ED. In my practice I don't see the use for midlevels managing critical patients independently because there is always an EM trained physician running the show.

However, completely agree that solo EM practitioners need to be well prepared. If you want to work solo by all means do a fellowship and get all the experience you can. All the PA friends I know from med school (n=4) who did EM "fellowships" work in urban/suburban EDs alongside EM physicians.

It would be great if some really well trained midlevels could staff some of the rural EDs in our catchment area.

FWIW the midlevel I referenced in your other post was an NP..
 
The policy linked has a bunch of recommendations and no firm numbers for procedures, real vs sim, etc. Many of those things can be accomplished, as written, without providing those opportunities to the PAs. So you can't know that PA fellows are getting the training you think they are getting.
you could say the same of md/do residents. how many go through residency without doing a crich on a live patient? I would wager most.
The guidelines are there to outline what an ideal program should look like, just like the guidelines for docs. programs try to follow these guidelines. There would be no reason for a pa to work for 40-50 k/yr (pa fellows get pgy-1 pay) when they could get 90k+ at a job if they were not getting good training. Folks interested in these apply to several, interview with current fellows, etc. Why would anyone go to a program that didn't guarantee access to the full range of procedures? A few programs opened and were discovered to basically be scut factories where the fellows didn't get good off-service rotations, etc. All those programs closed because no one applied once word of mouth got around. of the 27 sites above I can personally vouch for 10 that I have direct knowledge of. Most of the others I have heard word of mouth about. A few are too new to have any grads yet.
There are a number of em pa fellows who post blogs about their experiences and none of them gripe about too few procedures.
 
emedpa from reading your posts over the years you obviously have great training and are a competent solo provider. In my experience that is the exception rather than the rule. There certainly is a place for specialized PA training in EM. I was speaking solely from my perspective as a resident at a trauma center who will be supervising midlevels in a community ED. In my practice I don't see the use for midlevels managing critical patients independently because there is always an EM trained physician running the show.

However, completely agree that solo EM practitioners need to be well prepared. If you want to work solo by all means do a fellowship and get all the experience you can. All the PA friends I know from med school (n=4) who did EM "fellowships" work in urban/suburban EDs alongside EM physicians.

It would be great if some really well trained midlevels could staff some of the rural EDs in our catchment area.

FWIW the midlevel I referenced in your other post was an NP..
thanks. I agree that when residency trained/boarded em docs are around they should get first pick of the really sick folks. it makes sense for the pas to start with low acuity in this setting and work their way up and em docs to start high and work down. That is a fair and appropriate division of labor. the only exception to this is the shop with coverage with only 1 doc and 1 pa that gets multiple critical pts at once. It's nice if the pa can run a medical code while the doc is running another or doing a critical intervention elsewhere in the dept.
I have actually been in the position of working with a doc with multiple codes on opposite ends of the dept. doc ran one, I ran one. it was a good day they both lived. husband and wife. husband coded pushing wife with chest pain in a wheelchair to the door. wife then coded. both in their 90s.
regarding your NP: fire her a$$ and hire a competent PA!
 
I have actually been in the position of working with a doc with multiple codes on opposite ends of the dept. doc ran one, I ran one. it was a good day they both lived. husband and wife. husband coded pushing wife with chest pain in a wheelchair to the door. wife then coded. both in their 90s.

Maybe they should include some theology in PA school. This was clearly an act of God. Why would you want to intervene?
 
wait you had two 90 y/o patients code at the same time and both lived?

hope you bought a lotto ticket on the way home!
 
I'm all for a year of EM fellowship for PAs. But I see little reason to try to get them enough lines, intubations, codes etc to be competent. I need them to be good at what THEY do. They're not good coming straight out of PA school. If I need someone to run codes, intubate, place lines, or see complex patients, I hire a doctor. The EM fellowship trained PAs I've worked with still do the fast track, and I think that's exactly the way it ought to be. I don't need them to spend time in the ICU in their fellowship. I need them to learn how to do I&Ds, suture, take care of back pain/dental pain/toddler fevers etc etc etc, learning the red flags for when they need to bring the case to me. I could care less about how many intubations they've done. I don't even let them do LPs. It's not that I couldn't train them to do them safely. It's that there aren't so many of them that I can't do them all myself. When you go to the ED, who do you want doing your LP?

If you're stuck in podunkville and can't convince a doc to come work in your ED with any reasonable sum of money, then sure, get the best trained PA you can find. But in my experience, PAs don't want to work in rural places any more than physicians do.

I do know one PA who spends time every year workings olo in the Aleutians in a place where he may be stuck alone with a critical patient for days. But he's the exception more than the rule. It's hard to justify additional training for something that only once a year may make a difference for a patient. Just like it's hard to justify paying for a doc to be there. I have no idea how what he is doing is considered "supervised by a physician" but that's the way life is in "The Bush."
 
I know many PAs working in remote and frontier settings hrs from the nearest physician. There are more of these jobs than you would expect...
The top 5%-10% of em pas in the country like to work in full scope settings. they probably should have gone to medschool. I know I should have.
using a fellowship trained em pa in fast track only is a waste of their training. Those folks must really want to work in that geographic area. I know if I did a fellowship there is no way in hell I would work with those restrictions. I won't now. Any place that won't let me do LPs, procedural sedation, fx reduction, airway management, etc is not a place I would consider working at this point. I put in my time with those types of jobs, maxed out the learning potential, and moved on and up. no way I'm going back.
re: supervision in "the bush":. I'm sure his charts are reviewed and a doc is available by phone or teleconsult as required by state law. I'm wondering if we know the same guy.
 
These folks would certainly benefit from a full scope em pa residency:
http://www.nxtbook.com/nxtbooks/aapa/paprofessional_201502/#/22/OnePage
I have several friends who do this. Most are ex-military or former civilian medics. I may do this someday as a bridge to retirement. PAs are senior medical officers working for the state dept at most of the US embassies around the world. They need to be able to stabilize folks with minimal facilities and under potentially austere and frankly unsafe conditions and get them transported to a higher level of care.
There are also many solo PAs practicing in rural ERs in ME, VT, WA, KS, MI, ND, SD, OK, MT. GA, WY and other states with large rural areas who benefit from this type of fellowship. A large % of PAs actually do tend to gravitate to rural areas more so than many other types of providers. A study a few years ago (posted here on sdn) showed the pattern was PA>DO>NP>MD.
 
As a current EM PA fellow myself, here is how I see it: I am not doing the fellowship so that I can be as skilled or knowledgeable as an MD. I am doing the fellowship so that I can be an excellent PA. Like emedpa said, if there is a super sick patient and an MD available, they should be the one to see them. But the fact of the matter is that there are a pretty significant number of PA jobs out there where there is at most one other doc in the ED. There is definitely a good market for PAs with the ability to perform LPs, intubate, put in chest tubes, etc... It may not be the majority, but is not insignificant. That's the kind of job I hope to one day have as a result of my fellowship program.

As to the OP: If you feel like having PA fellows doing procedures will inhibit your education, by all means look elsewhere. I can tell you that where I work, there are more than enough procedures to go around. If it's my patient, it's my procedure and the same goes for everyone else. I plan to use my skills down the road just as much as my MD colleagues do, and I think there is a pretty good mutual understanding of that fact. If you get the vibe that the PAs and MDs are fighting for procedures, you should definitely consider other options. It doesn't have to be that way.
 
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I'm just a little nervous, because at my medical school we're always so low on the totem pole in terms of priority for teaching. I really want to go to a place at which there is no question about who gets priority for these opportunities.

If this is true, then you should go to a place that does not have PA/NP residencies. Furthermore, you should give priority to places where you are rarely if ever getting elbowed out of the way for procedures by surgical residents, anesthesia residents, etc. Find a program where you do it all, don't share the airways with the surgery residents, and get more procedures than you can count, if you have the choice to do so.
 
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you could say the same of md/do residents. how many go through residency without doing a crich on a live patient? I would wager most.
The guidelines are there to outline what an ideal program should look like, just like the guidelines for docs. programs try to follow these guidelines. There would be no reason for a pa to work for 40-50 k/yr (pa fellows get pgy-1 pay) when they could get 90k+ at a job if they were not getting good training. Folks interested in these apply to several, interview with current fellows, etc. Why would anyone go to a program that didn't guarantee access to the full range of procedures? A few programs opened and were discovered to basically be scut factories where the fellows didn't get good off-service rotations, etc. All those programs closed because no one applied once word of mouth got around. of the 27 sites above I can personally vouch for 10 that I have direct knowledge of. Most of the others I have heard word of mouth about. A few are too new to have any grads yet.
There are a number of em pa fellows who post blogs about their experiences and none of them gripe about too few procedures.

We have mandated minimum numbers. Cric is a rare procedure, so simulation is considered okay.
 
If this is true, then you should go to a place that does not have PA/NP residencies. Furthermore, you should give priority to places where you are rarely if ever getting elbowed out of the way for procedures by surgical residents, anesthesia residents, etc. Find a program where you do it all, don't share the airways with the surgery residents, and get more procedures than you can count, if you have the choice to do so.

What does a surgery resident do with an airway?
 
What does a surgery resident do with an airway?

Great question. At many programs, surgical residents alternate with EM residents for trauma airways. Where I went to residency, surgery came nowhere near the airway. However, where I attend now the EM residents and surgical residents alternate trauma airways. My level of involvement would be described as full with the latter scenario.

The point is that you don't want to be sharing any procedures with anyone while you are in residency (if possible). If by graduation you have seen every possible body habitus and every possible combination of scenarios and indications and complications and you never even want to look at a central line kit again... then you've done enough.
 
Great question. At many programs, surgical residents alternate with EM residents for trauma airways. Where I went to residency, surgery came nowhere near the airway. However, where I attend now the EM residents and surgical residents alternate trauma airways. My level of involvement would be described as full with the latter scenario.

The point is that you don't want to be sharing any procedures with anyone while you are in residency (if possible). If by graduation you have seen every possible body habitus and every possible combination of scenarios and indications and complications and you never even want to look at a central line kit again... then you've done enough.

Surgery residents on the airway? That sounds terrifying. I get a little uncomfortable when our trauma patients, already intubated, go to CT with the surgery team.
 
My answer is - yes, you should be wary. It might be OK, but you should be wary.
 
This concern is quite a bit exaggerated. Are you concerned about the institution having residencies from other specialities? Because there are only so many chest tubes to go around, so I guess you shouldn't rank any place with a surgery residency then, cause that will dilute your numbers.

But seriously, how is having a PA 'competing' to do a procedure different than having residents from other departments who are rotating in the ER wanting to do a procedure? Or are you just not going to let any off service residents do any procedures?
 
This concern is quite a bit exaggerated. Are you concerned about the institution having residencies from other specialities? Because there are only so many chest tubes to go around, so I guess you shouldn't rank any place with a surgery residency then, cause that will dilute your numbers.

But seriously, how is having a PA 'competing' to do a procedure different than having residents from other departments who are rotating in the ER wanting to do a procedure? Or are you just not going to let any off service residents do any procedures?

It's not different. I recommend going somewhere where the competition from any source for procedures is as minimal as possible, all other things being equal.
 
using a fellowship trained em pa in fast track only is a waste of their training. Those folks must really want to work in that geographic area. I know if I did a fellowship there is no way in hell I would work with those restrictions.

I get the sense you haven't worked with a PA straight out of PA school in the ED lately. They're worse than useless, they're dangerous. I have to spend at least the first year training them to do their job. I feel the fellowship steps them up to useful right off the bat. Someone else does that year of on the job training for me. Well worth hiring them over someone else or paying them more to me. But I don't need them trained to intubate. If the fellowship wants to do that, fine, as long as they teach the rest of the crap I need them to know when I hire them. Sorry, you've got to drive at least 2 hours from here before you're going to find a facility where a PA is doing any intubating. PAs are hired here to boost income. The bottom line is the bottom line. I'm going to pay you 1/4th of what I'm making, and bill patients the same (or for Medicare 85% of the same) and I'm going to put the difference in my retirement account. Without that arbitrage, I'll just hire more docs and enjoy less liability.

I don't blame you for wanting to do fun stuff and if you can find a place that will hire you to do it, great for you. I also wanted to do fun stuff. I wanted to do fun stuff, get paid well for it, and live in a desirable area. I was lucky enough/smart enough to go the MD route so I didn't have to backdoor in.

On a side note, I'm always a little hesitant to train my replacement a la the CRNA/anesthesiologist situation. If there are too many PAs trained to do everything I do running around, why would anyone pay for a doctor?

And of course there is always the relevant philosophical issue. At a certain point, you've got to ask yourself is it better (for you, the patients, and society) to do a little education and lots of on the job training, or lots of education and less on the job training. As I think we've discussed before, I don't think you realize how rare your interest/skill set/experience is among PAs. It is not nearly as reproducible as your writing would lead some to believe, and a one year fellowship certainly isn't the same thing.
 
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This concern is quite a bit exaggerated. Are you concerned about the institution having residencies from other specialities? Because there are only so many chest tubes to go around, so I guess you shouldn't rank any place with a surgery residency then, cause that will dilute your numbers.

But seriously, how is having a PA 'competing' to do a procedure different than having residents from other departments who are rotating in the ER wanting to do a procedure? Or are you just not going to let any off service residents do any procedures?

Depends on the procedure...
 
As a current EM PA fellow myself, here is how I see it: I am not doing the fellowship so that I can be as skilled or knowledgeable as an MD. I am doing the fellowship so that I can be an excellent PA. Like emedpa said, if there is a super sick patient and an MD available, they should be the one to see them. But the fact of the matter is that there are a pretty significant number of PA jobs out there where there is at most one other doc in the ED. There is definitely a good market for PAs with the ability to perform LPs, intubate, put in chest tubes, etc... It may not be the majority, but is not insignificant. That's the kind of job I hope to one day have as a result of my fellowship program.

As to the OP: If you feel like having PA fellows doing procedures will inhibit your education, by all means look elsewhere. I can tell you that where I work, there are more than enough procedures to go around. If it's my patient, it's my procedure and the same goes for everyone else. I plan to use my skills down the road just as much as my MD colleagues do, and I think there is a pretty good mutual understanding of that fact. If you get the vibe that the PAs and MDs are fighting for procedures, you should definitely consider other options. It doesn't have to be that way.

If you wanted to be a doctor, should have went to doctor school
 
If you wanted to be a doctor, should have went to doctor school

Actually, seeing as how EM_PA_ is already a fellow, learning and applying full scope EM, with excellent job prospects that will utilize her in such a capacity, I would say she should have gone to PA school. Oh wait she did.
 
I get the sense you haven't worked with a PA straight out of PA school in the ED lately. They're worse than useless, they're dangerous. I have to spend at least the first year training them to do their job. I feel the fellowship steps them up to useful right off the bat. Someone else does that year of on the job training for me. Well worth hiring them over someone else or paying them more to me. But I don't need them trained to intubate. If the fellowship wants to do that, fine, as long as they teach the rest of the crap I need them to know when I hire them. Sorry, you've got to drive at least 2 hours from here before you're going to find a facility where a PA is doing any intubating. PAs are hired here to boost income. The bottom line is the bottom line. I'm going to pay you 1/4th of what I'm making, and bill patients the same (or for Medicare 85% of the same) and I'm going to put the difference in my retirement account. Without that arbitrage, I'll just hire more docs and enjoy less liability.

I don't blame you for wanting to do fun stuff and if you can find a place that will hire you to do it, great for you. I also wanted to do fun stuff. I wanted to do fun stuff, get paid well for it, and live in a desirable area. I was lucky enough/smart enough to go the MD route so I didn't have to backdoor in.

On a side note, I'm always a little hesitant to train my replacement a la the CRNA/anesthesiologist situation. If there are too many PAs trained to do everything I do running around, why would anyone pay for a doctor?

And of course there is always the relevant philosophical issue. At a certain point, you've got to ask yourself is it better (for you, the patients, and society) to do a little education and lots of on the job training, or lots of education and less on the job training. As I think we've discussed before, I don't think you realize how rare your interest/skill set/experience is among PAs. It is not nearly as reproducible as your writing would lead some to believe, and a one year fellowship certainly isn't the same thing.


"If there are too many PAs trained to do everything I do running around, why would anyone pay for a doctor?"

Cue the nervous laughter... Good thing you have been adding to that retirement fund.
 
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I get the sense you haven't worked with a PA straight out of PA school in the ED lately. They're worse than useless, they're dangerous..
Actually I precept PA student on a regular basis. I agree that some are better than others. The ones who were previously medics/rns/techs tend to be the better ones. we do hire some of the better ones right out of school at my urban trauma ctr job. we start them in fast track as double coverage with a second provider for the first year before they go anywhere near the main dept. they get lots of supervised training from senior pas and docs. when they work in higher acuity areas after a year they are presenting cases as needed and 100% of charts are reviewed at the end of the shift. all admissions need to be run by the doc and certain complaints need to be run by the doc before d/c. everyone has to learn some time.
 
Actually I precept PA student on a regular basis. I agree that some are better than others. The ones who were previously medics/rns/techs tend to be the better ones. we do hire some of the better ones right out of school at my urban trauma ctr job. we start them in fast track as double coverage with a second provider for the first year before they go anywhere near the main dept. they get lots of supervised training from senior pas and docs. when they work in higher acuity areas after a year they are presenting cases as needed and 100% of charts are reviewed at the end of the shift. all admissions need to be run by the doc and certain complaints need to be run by the doc before d/c. everyone has to learn some time.

So you give them a paid one year EM fellowship? Sounds about right.
 
So you give them a paid one year EM fellowship? Sounds about right.
More or less...but they are not learning chest tubes, u/s, a-lines, running medical codes and traumas etc like they would at an em pa fellowship. After a year with us they definitely are NOT ready to go work solo at places like some of my per diem jobs. They are ready for most of what they will see in fast track and intermediate level settings with physician consultation available.
An em pa fellow is ready for the low volume/high acuity rural setting, although many of them start out in rural settings with double coverage with a doc alternating charts for a few years before they make the jump to solo. I didn't do a fellowship(there were none in the 90s when I graduated PA school). I had 10 prior years in ems and worked my way up the acuity/responsibility/scope of practice/autonomy ladder over 15 years before I started working solo at a rural ER. I wish I had been able to do a fellowship and cut 10 painful years out of that ladder to fast track my way to the level I am at now. I think a day is probably coming when all pas in all specialties will probably have to do at least 1 post grad year before getting licensed. it's the way of the world to require more education, testing, and credentialing . docs went through it 50-100 years ago. It used to be a doc could learn by apprenticeship (my great-great grandfather did this by following his GP dad around from age 14-22). then a formal med school was required. then an internship. then a specialty residency. My grandfather did a general surgery residency, but practiced in all available surgical fields until the time of his death ( 1965ish).
initially one could do specialty residency and optionally take boards to practice (my dad went this route and practiced as a residency trained IM subspecialist for years without ever taking his specialty boards). now you have to jump through every hoop. we will too. probably more family hx than required, but it illustrates how requirements have changed since 1900 or so.
 
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