APP Coverage

[2021Doctor]

Emergency Medical Associates (EMA), an Envision Physician Services Provider, is seeking an experience Full Time Nurse Practitioners/Physician Assistants to staff the Emergency Department at Ellenville Regional Hospital located in Ellenville, NY. *Must have previous EM experience as an APP*

Emergency Department Profile:
Under 15,000 annual patient volume
7 ED beds
APP Coverage: 24 hours daily
Scribe coverage: 12 hours daily
PACS
Senior Friendly

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[southerndoc]

@2021Doctor What is the purpose of your post? You've created a few threads like this without any other content.

 

[RustedFox]

@2021Doctor What is the purpose of your post? You've created a few threads like this without any other content.

Let it slide, I say.

The silence is part of the post.
It's pretty clear he's not advertising the positions.

 

[drerp88]

This scam of an ED is staffed by mid levels 24/7 with no physician coverage. Someone I know worked at a hospital who routinely took transfers from there and said it was a disaster.

 

[2021Doctor]

@2021Doctor What is the purpose of your post? You've created a few threads like this without any other content.

Is it a new trend for hospitals to advertise 24/7 APP coverage?

 

[southerndoc]

Let it slide, I say.

The silence is part of the post.
It's pretty clear he's not advertising the positions.

I'm interested to hear his/her side of the story. Don't just post a link and let it be. Comment on it. I realize this wasn't posted as an advertisement.

 

[AlmostAnMD]

Dude, the post speaks for itself

Living in a world where ED staffing is fully staffed by MLP

Hits the "well I'll just go work rural" argument pretty hard

 

[EctopicFetus]

Dude, the post speaks for itself

Living in a world where ED staffing is fully staffed by MLP

Hits the "well I'll just go work rural" argument pretty hard

But man acep said it’s fine. Their assumptions include all eps and none of this. Will be way worse in reality. I wouldn’t hire a new grad over an FP guy who worked for me and did a good job reliably for 7 years. Would you?

 

[southerndoc]

Dude, the post speaks for itself

Living in a world where ED staffing is fully staffed by MLP

Hits the "well I'll just go work rural" argument pretty hard

I don't agree with staffing with non-physicians only, but currently this is the reality in a lot of very small ER's. Should be interesting to see what plays out with an oversupply of graduating residents and oversupply of nurse practitioners. Hopefully not a race to the bottom "will work for peanuts" kind of situation.

 

[thegenius]

Wonder why the two MD's above in the original post want to work in that environment?

 

[Rekt]

I'm interested to hear his/her side of the story. Don't just post a link and let it be. Comment on it. I realize this wasn't posted as an advertisement.

"What the **** is happening to medicine?"

Did it for him.

 

[deleted6669]

"What the **** is happening to medicine?"

Did it for him.

You guys know that jobs like these have been around for almost 40 years, right? This isn't new. Lots of small critical access depts have had solo PA coverage forever. I've been working at a place like this since 2001 and I am not the first to do so. The guy I replaced was there for 20 years before he retired.

 

[Rekt]

You guys know that jobs like these have been around for almost 40 years, right? This isn't new. Lots of small critical access depts have had solo PA coverage forever. I've been working at a place like this since 2001 and I am not the first to do so. The guy I replaced was there for 20 years before he retired.

Things are much different now than before. Should not allow yourself to be called an ED unless you have 24/7 BCEM staffing.

 

[deleted6669]

Things are much different now than before. Should not allow yourself to be called an ED unless you have 24/7 BCEM staffing.

We staff a mix of PA, FP, and BCEM coverage. There is no difference in outcomes between these groups.

 

[skougess]

We staff a mix of PA, FP, and BCEM coverage. There is no difference in outcomes between these groups.

Based on…..

 

[Rekt]

Based on…..

Completely made up data. As usual SOP for mid-levels.

Even if your adverse outcome rate was 1% worse than mine (can garauntee it's much higher), that's easily one poor outcome per week as I easily see 100pts a week. Realistically it's closer to 15-20 negative outcomes per week. Easily 25-40 for NPs.

 

[deleted6669]

Based on…..

Quarterly outside review performed by a well-known EM physician. All charts are reviewed for departures from the standard of care. Those cases in which something could have been done differently/better are discussed between all the clinicians in the department so everyone can learn from one provider's experience. Last quarter the 2 providers with the best overall scores were PAs. One of the EM physicians was advised to spend more time in the OR working on his airway skills.

 

[skougess]

Quarterly outside review performed by a well-known EM physician. All charts are reviewed for departures from the standard of care. Those cases in which something could have been done differently/better are discussed between all the clinicians in the department so everyone can learn from one provider's experience. Last quarter the 2 providers with the best overall scores were PAs. One of the EM physicians was advised to spend more time in the OR working on his airway skills.

You must have exceptionally strong PAs and exceptionally weak physicians at your shop, which to be honest kind of fits with the staffing setup you described.

I would also posit that for a great deal of encounters it would take a room full of physicians a 30 minute discussion to go over how well a case did or didn’t go (exactly what M&M conference does). This chart review process is more likely just “did they get an EKG within 15 minutes for chest pain chief complaint?” Hardly critical thinking action items.

 

[deleted6669]

You must have exceptionally strong PAs and exceptionally weak physicians at your shop, which to be honest kind of fits with the staffing setup you described.

I would also posit that for a great deal of encounters it would take a room full of physicians a 30 minute discussion to go over how well a case did or didn’t go (exactly what M&M conference does). This chart review process is more likely just “did they get an EKG within 15 minutes for chest pain chief complaint?” Hardly critical thinking action items.

All the PAs are very strong. Avg experience > 20 years. Most (all but one) are former paramedics or military medics. The BCEM guys are really good. Mostly a younger crew. I have been working in the ED longer than some of them have been alive. The weak link in the chain is definitely the FP docs. Whenever one leaves, they are replaced by a BCEM doc (if they can find one) or an experienced EMPA if they can't. We are down to just 2 FP docs now. There were 5-7 when I started there. They generally call in the CRNA for every sedation and intubation. The rest of us don't.
The chart review also looks at time to transfer for critical patients. Most of us can get folks out of the dept fairly quickly with the truly important interventions done. A few of the older docs flog really sick folks for hrs when they really should be in the OR at a regional trauma center or with stroke neuro or in the cath lab.

 

[GonnaBeADoc2222]

Guys Guys Guys Guys Guys......

Listen to him. He's a DOCTOR and PROFESSOR of Global Health! ANDDDD he has 20 years experience on SDN!

 

[thegenius]

We staff a mix of PA, FP, and BCEM coverage. There is no difference in outcomes between these groups.

Is this nonsense? Are you serious?

 

[RustedFox]

@Emedpa and I have crossed swords a bunch on here. Though our duel remains active, I will say to him directly that the 2 PAs at my new job site are SOLID. Had to put that out there to be fair when I skewer the rest of the Jenny McJennyson lot, as I commonly do.

 

[thegenius]

You think they are solid because the buck doesn't stop with them?

I remember in residency that I thought I made excellent decisions all the time and I didn't realize the subconscious effect that I always had someone reviewing my work.

Once I became an attending and every decision was left up to me, and my name was on the chart, and administration would come down on me, it changed the way I practiced.

 

[RustedFox]

You think they are solid because the buck doesn't stop with them?

I remember in residency that I thought I made excellent decisions all the time and I didn't realize the subconscious effect that I always had someone reviewing my work.

Once I became an attending and every decision was left up to me, and my name was on the chart, and administration would come down on me, it changed the way I practiced.

I don't disagree.
I mean that as a reasonable evaluation of their medical knowledge compared to prior PAs.

 

[Porfirio]

Why do we assume the newly graduated NP/PA (hell even the just two years out grad) has the same expertise/outcomes as a NP/PA who has been in the ED for 20 years?

We should compare outcomes for a new grad PA/NP to new grad EM physician. I wonder what that data would show.

 

[RustedFox]

I don't disagree.
I mean that as a reasonable evaluation of their medical knowledge compared to prior PAs.

For as much hell as I give the PLP crowd on here, I figured the right thing to do was to say so when have now encountered two PAs that are serviceable with strong experience.

 

[Rekt]

Why do we assume the newly graduated NP/PA (hell even the just two years out grad) has the same expertise/outcomes as a NP/PA who has been in the ED for 20 years?

We should compare outcomes for a new grad PA/NP to new grad EM physician. I wonder what that data would show.

This may be shocking to hear but they have no formal EM training. It's very possible for someone to practice incorrectly for 20 years.

 

[thegenius]

For as much hell as I give the PLP crowd on here, I figured the right thing to do was to say so when have now encountered two PAs that are serviceable with strong experience.

We have good ones too. When used appropriately they can be helpful. Remember that the ER is not really used for medical emergencies. 3/4 of people who use it could just as easily stay at home and do nothing with respect to their complaint, and they would be fine. Their outcome would be the same as if they came to the ER.

 

[deleted6669]

@Emedpa and I have crossed swords a bunch on here. Though our duel remains active, I will say to him directly that the 2 PAs at my new job site are SOLID. Had to put that out there to be fair when I skewer the rest of the Jenny McJennyson lot, as I commonly do.

Thank you for confirming that we are not all out to "assassinate patients".

Why do we assume the newly graduated NP/PA (hell even the just two years out grad) has the same expertise/outcomes as a NP/PA who has been in the ED for 20 years?

We should compare outcomes for a new grad PA/NP to new grad EM physician. I wonder what that data would show.

A new grad PA/NP requires a lot of oversight. No argument there. New grad PA/NP should not be working unsupervised in an emergency dept. I worked as a paramedic in busy systems and as a PA at busy trauma centers for years before ever working solo. Despite already being comfortable with airway management, I was required to spend 30 hours in the OR doing LMAs, both direct and video assisted intubations, etc before I was signed off to work solo shifts. Not that it means much, but I also need to maintain ACLS/ATLS/PALS/DIFFICULT AIRWAY/FCCS/NRP, u/s, and ALSO certifications.
By no means am I saying that any PA/NP can do this work. Only 2% of EMPAs do nationally. Maybe 250 of us all told.
My only purpose in responding to this post initially was just to point out that this is not some startling new trend. PAs have been staffing EDs for a long time. Feel free to disagree with that staffing model. My only point is that this is not new and the sky is not falling.

 

[Lexdiamondz]

This may be shocking to hear but they have no formal EM training. It's very possible for someone to practice incorrectly for 20 years.

This.

Expertise comes from education + experience. Memorizing Rosen's doesn't matter if you've never seen a patient. Neither does practicing for 20 years when your differential for abdominal pain is essentially "scan or don't scan".

I work with a couple FM/IM guys who have been doing this nearly as long as I've been alive. They aren't good. Practicing internal medicine from the 90s doesn't make you a good ER doc.

 

[deleted6669]

Expertise comes from education + experience.

Could not agree more. I would be the first to say how much I respect a residency trained and boarded EM doc.
Saying an experienced EMPA has no training, however is blatantly false. Most of us set on EM as a career have a background similar to this:
Paramedic/resp therapist/ER RN x many years
rotations in school in em, peds em, trauma surgery, icu, psych, ob, etc. At my program at a major east coast medical school the PA students and med students were scheduled interchangeably. The slots were PA2/MS3.
Without the benefit of dedicated EM residency we work our way up from fast track(learning procedural skills) to community hospitals(getting comfortable with level 3-5 cases) to trauma centers (sicker patients) to solo coverage. Along the way we have to have 100 hrs of EM CME every two years to maintain our licensure in addition to all the alphabet soup courses.
You guys are not my competition in the market. you win every time. You should and I get that. My competition is fp docs with less training and experience than I have(and that is most of them unless they have dedicated their lives to EM or done a fellowship, etc). I've been doing this for a long time. Chances are I have done more procedures than many on this forum. I understand that procedure monkey skills do not make an EM doc, but repetition, on the job training, and exposure to other folks doing things over the years counts for something. Various ways are used to describe an expert. "10,000 hours in the same field" is often used. I prefer "an expert has seen or made every possible mistake in a narrow field and learned from them".

 

[EctopicFetus]

There are some decent MLPs. The issue is when you work in a low volume (and often low acuity ED) you will miss a ton of stuff and those patients wont ever come back to you to see you. The missed ascending cholangitis, it went to the big show an hour away. The missed meningitis did the same. Im not here to crap on all PAs but in my opinion there are 2 general breeds. The smart ones who realize there is a ton they dont know and the dumb ones who have hubris galore and think they know more than they do.

Same can be said for EM docs but our knowledge deficit is small and the numbers in category 2 of knowing it all tend to stick in academic centers and are pretty crappy clinicians.

 

[deleted6669]

There are some decent MLPs. The issue is when you work in a low volume (and often low acuity ED) you will miss a ton of stuff and those patients wont ever come back to you to see you.

I work in several departments, both single coverage and double coverage(with a physician). The double coverage places are a bit busier and expose me to other ways of thinking and doing things. They are all pretty collegial environments and we bounce cool stuff off each other and ask each other's opinions regularly. I wouldn't want to do just one low volume place because I would worry about skill atrophy. Fortunately I see a wide variety of cases between the various sites and I would like to think that I seek out expert opinions when I need to. I appreciate your respectful and well-considered response.

 

[turkeyjerky]

Lol. I've asked a midlevel for their opinion on a case literally zero times. Look, dude, most of us don't consider a place that has "double" coverage of a PA + doctor to be "high volume".

 

[betamale]

Emergency Medical Associates (EMA), an Envision Physician Services Provider, is seeking an experience Full Time Nurse Practitioners/Physician Assistants to staff the Emergency Department at Ellenville Regional Hospital located in Ellenville, NY. *Must have previous EM experience as an APP*

Emergency Department Profile:

Under 15,000 annual patient volume
7 ED beds
APP Coverage: 24 hours daily
Scribe coverage: 12 hours daily
PACS
Senior Friendly

PracticeMatch.com: The Opportunity 479913 is no longer available

PracticeMatch.com: The Opportunity 479913 is no longer available

www.practicematch.com

View attachment 345786

aw, I work with a new grad NP who does single coverage at a rural ER. The ER won't credential IM or FP in their ER. I used to do a bunch of rural sites including 24 hour shifts and it was brutal and can be a ****show. I admire the NP's courage though but this is what happens when docs turn on each other. I've worked with several exmilitary ER PAs who are not very good and need very frequent coaching. Some are very cocky and have to be shown that what they're doing or thinking of doing is unsafe...usually when the nurse refuses their order and turn to me. I've never asked a PA for help...though some have tried to "help" and made things worst. Same thing is happening in the military, civilian federal facilities...truely sad

 

[deleted6669]

Lol. I've asked a midlevel for their opinion on a case literally zero times.

Look, dude, most of us don't consider a place that has "double" coverage of a PA + doctor to be "high volume".

So you wouldn't ask a specialty PA/NP a question about a patient within their specialty? I can assure you that a PA/NP in GI or nephrology knows a lot more about their specialty than you do. Don't be afraid to ask anyone's opinion. Sometimes I get great advice from nurses and techs. To refuse to listen to someone solely because of the initials after their name limits your options. Medicine is a team sport. You will probably figure that out in a few years or stack up complaints from the staff you work with for being difficult and unpleasant to work with.

If you read my posts above, prior to my current job situation I spent > 10 years working at a very busy trauma ctr with > 50 beds. My current double coverage positions have me alternating cases regardless of acuity with a physician. There places see 40-60 pts/24 hrs. 20-25/provider in 12 hrs is reasonably busy.
I am done with this thread. You guys can continue to say the sky is falling.

 

[GassYous]

So you wouldn't ask a specialty PA/NP a question about a patient within their specialty? I can assure you that a PA/NP in GI or nephrology knows a lot more about their specialty than you do. Don't be afraid to ask anyone's opinion. Sometimes I get great advice from nurses and techs. To refuse to listen to someone solely because of the initials after their name limits your options. Medicine is a team sport. You will probably figure that out in a few years or stack up complaints from the staff you work with for being difficult and unpleasant to work with.

If you read my posts above, prior to my current job situation I spent > 10 years working at a very busy trauma ctr with > 50 beds. My current double coverage positions have me alternating cases regardless of acuity with a physician. There places see 40-60 pts/24 hrs. 20-25/provider in 12 hrs is reasonably busy.
I am done with this thread. You guys can continue to say the sky is falling.

Absolutely not

 

[skougess]

I absolutely do not either. The midlevels are often clueless and it’s not legally defensible to say “I didn’t practice standard of care as a physician because this midlevel told me to!”

As physicians, we don’t have the luxury of pinning the blame on others when **** hits the fan.

 

[Kryptocoin]

15K volume and no MD? Yikes.

So you wouldn't ask a specialty PA/NP a question about a patient within their specialty? I can assure you that a PA/NP in GI or nephrology knows a lot more about their specialty than you do.

Is this guy for real? Specialty midlevels are GREAT in following protocols. That's about it. They can't design one or even know the WHY of what they're doing. Any deviation from the protocol and you can watch them start sweating bullets. That's why they are dangerous in the ER because a lot of ER patients don't read textbooks and present with atypical symptoms.

 

[d2305]

Now I'm worried how many transverse myelitis I've missed. I was alone in acute care for years, and that was stressful enough.

 

[doctalaughs]

15K volume and no MD? Yikes.


Is this guy for real? Specialty midlevels are GREAT in following protocols. That's about it. They can't design one or even know the WHY of what they're doing. Any deviation from the protocol and you can watch them start sweating bullets. That's why they are dangerous in the ER because a lot of ER patients don't read textbooks and present with atypical symptoms.

This is exactly right. I wouldn’t EVER let my derm PAs answer a “consult” from a primary care doc. They are extenders. I teach them to follow an algorithm for stuff I’ve already diagnosed. They can be taught skin biopsies, injections, accutane protocols even Botox injections etc. to help me out.

Why would a PCP ever want to hear from a PA who probably never had any formal sub-specialty training (and even if they did, or “practiced” in derm for 20 years barely scratched the surface). There’s a reason why we set standards for board certification — ie medical school then residency.

 

[Lexdiamondz]

So you wouldn't ask a specialty PA/NP a question about a patient within their specialty? I can assure you that a PA/NP in GI or nephrology knows a lot more about their specialty than you do. Don't be afraid to ask anyone's opinion. Sometimes I get great advice from nurses and techs. To refuse to listen to someone solely because of the initials after their name limits your options. Medicine is a team sport. You will probably figure that out in a few years or stack up complaints from the staff you work with for being difficult and unpleasant to work with.

If you read my posts above, prior to my current job situation I spent > 10 years working at a very busy trauma ctr with > 50 beds. My current double coverage positions have me alternating cases regardless of acuity with a physician. There places see 40-60 pts/24 hrs. 20-25/provider in 12 hrs is reasonably busy.
I am done with this thread. You guys can continue to say the sky is falling.

Dude. I admitted a patient for a tension PTX once as a resident and the CT surgery NP couldn't recognize the pneumo on the CXR.

Literally put two images side by side, one with a pigtail in it, and couldn't identify the emergent pathology staring her in the face.

Consults are a request for expert opinion. Jenny with an online certificate from CerealBox U is decidedly not an expert.

 

[EctopicFetus]

Ill just say this I agree. I sometimes speak to the MLPs. They usually just come and do notes. None have the ability to manage my patient. To think they can means they are either given way more responsibility than deserved or they are overstepping their bounds. Its a scary world we live in these days. The MLPs are becoming more powerful. Health care will become a joke (moreso than now). I am glad my group uses them appropriately. No thinking, straight forward cases and simple procedures. They do it well.

 

[Fox800]

So you wouldn't ask a specialty PA/NP a question about a patient within their specialty? I can assure you that a PA/NP in GI or nephrology knows a lot more about their specialty than you do. Don't be afraid to ask anyone's opinion. Sometimes I get great advice from nurses and techs. To refuse to listen to someone solely because of the initials after their name limits your options. Medicine is a team sport. You will probably figure that out in a few years or stack up complaints from the staff you work with for being difficult and unpleasant to work with.

If you read my posts above, prior to my current job situation I spent > 10 years working at a very busy trauma ctr with > 50 beds. My current double coverage positions have me alternating cases regardless of acuity with a physician. There places see 40-60 pts/24 hrs. 20-25/provider in 12 hrs is reasonably busy.
I am done with this thread. You guys can continue to say the sky is falling.

LOL, absolutely not. NPs especially so...they can jump from orthopaedics to a e s t h e t i c s to urgent care at the drop of a hat, with an online course. "Specialty" MLPs are there to gather information and feed it to their attending. That's it.

Weaknesses in midlevel training are readily apparent. That's where 15,000 hours of structured training (physician residency) come in to play. So I can discuss surgical management with a surgeon, or antihypertensive medications with the hospitalist, or a respectable neurologic exam with a neurologist (not a cookie cutter one sentence thing I see in MLP charts)...and know what I'm talking about.

Training matters. If a midlevel's half-baked plan sounds like BS I'm going to call them out on it, professionally. "Please have your attending call me to discuss this case." Nothing to get delicate midlevel feathers ruffled about.

Patient safety comes before midlevel egos. Medicine is a team sport, but each team has a captain. This is not an egalitarian society. Also, I love how calling out MLP misses and inadequacies automatically means someone generates a zillion complaints from staff - that's some strong ego protection there, home skillet.

 

[RustedFox]

Dude. I admitted a patient for a tension PTX once as a resident and the CT surgery NP couldn't recognize the pneumo on the CXR.

Literally put two images side by side, one with a pigtail in it, and couldn't identify the emergent pathology staring her in the face.

Consults are a request for expert opinion. Jenny with an online certificate from CerealBox U is decidedly not an expert.

I had to go back and find this post today because I can't like it enough.

Shift 2 days ago, similar thing happened.
I was gobsmacked.

 

[Matthew9Thirtyfive]

So you wouldn't ask a specialty PA/NP a question about a patient within their specialty? I can assure you that a PA/NP in GI or nephrology knows a lot more about their specialty than you do.

Dude, most of them don’t know more about their specialty than I do, and I’m just finishing MS3 lol.

 

[MechEDoc]

Asking for a consult from a highly subspecialized field and getting a half baked and half informed opinion from a PA/NP is super frustrating and high liability. I have had to ignore their "recs" so many times to avoid serious pathology.

E.g.
"you can send that chest pain home" Nope -> admit to medicine -> troponin went up 50x overnight while admitted.
"you can send home the renal transplant patient with a pyelonephritis and non-obstructing stone". Nope!

 

[turkeyjerky]

I recently left a semi-academic hospital that was overrun w/ midlevels. We had a pretty established EM residency program. It got to be soo exhausting trying to explain to residents that recommendations from a "consultant" who has less training in their field than they mean nothing. I really feel bad for the current generation of trainees, as well as future patients.

 

[doctalaughs]

I recently left a semi-academic hospital that was overrun w/ midlevels. We had a pretty established EM residency program. It got to be soo exhausting trying to explain to residents that recommendations from a "consultant" who has less training in their field than they mean nothing. I really feel bad for the current generation of trainees, as well as future patients.

The dumbing-down of American medicine is absolutely ridiculous.

Next, we should just start asking consults/opinions of the medical assistants working at various offices. Need a cardiology consult? go get a medical assistant working in a cards office- they MUST be an expert if they’ve been there 5+ years. Even better, the janitor from that office who’s been there for TWENTY years.

And the PAs/NPs TRULY, actually believe they are the experts in the field. It would be comical if it wasn’t so sad and scary where this country is going.