Don't Do It

[8744]

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You so do not want to go read the latest article on my blog. Trust me. Better that you just move along. Nothing to see. Sorry I mentioned it.

 

[deleted6669]

panda-mostly a fair and balanced entry as always. what you wrote seems true regarding the newer generation of pa's(younger, less experience, etc).
I think to some extent you marginalize the benefit of prior experience in the "traditional" pa applicant pool. someone who has been an rt, rn, paramedic for years will still be ahead of the ms4 in many regards.
I do agree with you that by the end of residency there is no comparison.
a residency trained em physician with 5 yrs experience is way ahead of an em pa with 5 yrs experience. that pa however is way ahead of the typical fp doc with 5 yrs experience with regards to em practice.

 

[8744]

panda-mostly a fair and balanced entry as always. what you wrote seems true regarding the newer generation of pa's(younger, less experience, etc).
I think to some extent you marginalize the benefit of prior experience in the "traditional" pa applicant pool. someone who has been an rt, rn, paramedic for years will still be ahead of the ms4 in many regards.
I do agree with you that by the end of residency there is no comparison.
a residency trained em physician with 5 yrs experience is way ahead of an em pa with 5 yrs experience. that pa however is way ahead of the typical fp doc with 5 yrs experience with regards to em practice.

You know I like and respect PAs. I'm actually just trying to drum up some hits on my blog. I get around 500 a day now (and have had about 120,000 in the year as well as close to 400,000 page views) and I hope to get some advertisers eventually.

The "prior experience" is the wild-card and I think where some people, including PAs, get confused. A lot of doctors have prior meaningful medical experience but it is not really required for medical school while it almost always is for PA school.

I think even my critics will agree that I have a lot of good content on my blog and I just don't bang out short posts about what I had for dinner or the state of my bowels.

 

[deleted6669]

agreed- I like your blog and have read a lot of it already.

 

[Faebinder]

A PA with 5 years of experience in Neurosurgery SHOULD know more about neurosurgery than an EM doc with 5 years of EM experience I don't think we argue this...

BUT the important question.... does he/she know enough to BE ON THEIR OWN? And lets make the question even more dangerous...

Is a PA with 20 years of EM experience equivilant or better than a physician out of EM residency?

MY answer to you is... NO Not all ZEBRAS are seen in practice and yet they should be KNOWN because THEY CAN SHOW UP!

Now with regards to PAs making more than physicians..... this is the result of the imbalance of physicians payments to primary care.... I dont blame the PAs for it... I actually blame the government for it... they dont see the importance of primary care because if they did.. they would not be paying for those codes less than they do for the other codes.....

I believe however, the market will correct itself.... as less and less physicians go to primary care. (Personally, I am surprised the mid levels haven't required residency yet of all mid level graduates... might happen in the future as more competition comes out.)

 

[deleted6669]

"BUT the important question.... does he/she know enough to BE ON THEIR OWN? And lets make the question even more dangerous...
Is a PA with 20 years of EM experience equivilant or better than a physician out of EM residency?"


does a moonlighting 2nd or 3rd yr fp resident know enough to BE ON THEIR OWN in a rural ed? I don't think so....I orient these guys when they work in my dept....scary......they know A LOT LESS em than I do and yet when we don't have enough em pa's to staff the dept we use these guys.....I have saved some of their backsides bigtime at shift change time when I walk in to find them fumbling their way through a critical pt......

lots of pa's work solo in rural e.d.'s and have for > 30 yrs with similar outcomes to md's, so yes, they know enough to be on there own in this setting. any truly emergent medical or trauma pt will be stabilized and transfered by the pa just as they would be if a doc were there.
the md who would likely be working in the rural ed if the pa were not there is an fp doc, not a residency trained em doc. an experienced em pa knows more em than an avg fp doc and is a better fit in the rural hospital setting for this reason.
obviously the best situation would be a residency trained/boarded em doc in every ed in the country. not going to happen anytime soon.....
do we really need to have this discussion every month here at sdn?
it always comes down to the same conclusions:
em docs are best at em and in an ideal world should staff every ed.
after em docs, em pa's are the next level of expertise in the profession ahead of non-em docs and are a reasonable alternative until there are enough em docs to staff every facility.
em pa's are a safe and effective way to get pts seen. they are not killing pts left and right.
without em pa's many rural communities would have no emergency medicine providers at all

FOR INSTANCE THIS JOB.....
The City of Fossil, Oregon is Desperately Looking for a PA-C interested in Practicing Solo in their community Funded Clinic. Clinic is Freestanding and fully staffed.The current PA has been there for 3 years but now has to move due to ailing parents. This is a ranching community. The nearest Hospital is 90 miles away but a helicopter will land 40 feet from the front door of the clinic if needed.
The PA is the only medical provider on site: FP, UC, EM, Trauma...routine OB is contracted out to a clinic 45 miles away. The PA also serves as "medical control" to the 4-6 volunteer EMTs. The clinic is beginning to implement an EMR. The clinic has 3 exam rooms and 1 large treatment room for traumas and codes, has limited x-rays, lab, the usual stuff. Pay range is $58,000 to $68,000.

I posted this example a while back(it still is open-probably because the pay sucks) and mcgyver was quick to point out that there is a licensed physician of record somewhere in the county. apparently the guy does not see urgent or emergent patients because this job is still open.....

 

[zenman]

I think even my critics will agree that I have a lot of good content on my blog and I just don't bang out short posts about what I had for dinner or the state of my bowels.

Yes, but could you shorten the posts a bit? I'm still waiting for that post on what you do when the Vanco and double strength Dopamine are not working and the lungs are turning into clouds and the kidneys to raisins.

You know many old people are very bowel oriented. Might pick up more hits if you did write some crap.

 

[8744]

Yes, but could you shorten the posts a bit? I'm still waiting for that post on what you do when the Vanco and double strength Dopamine are not working and the lungs are turning into clouds and the kidneys to raisins.

You know many old people are very bowel oriented. Might pick up more hits if you did write some crap.

I don't know what you're asking me here. Surely that patient is going to die.

 

[soonereng]

I believe however, the market will correct itself.... as less and less physicians go to primary care. (Personally, I am surprised the mid levels haven't required residency yet of all mid level graduates... might happen in the future as more competition comes out.)

The market probably won't correct itself with more physicians entering primary care or with higher reimbursement for those that do. Midlevel-run clinics are entering the market to take the place of those who want to make more money for 7 yrs of training.

This trend will likely continue as both PAs and NPs have multiple studies showing that their patient outcomes are equal to or better than physician outcomes when within their scope of practice. Also there are studies that show that midlevels can competently treat 80% of what a primary care physician does.

As physicians continue to move up the payscale ladder, we may see a new primary entry point into the healthcare system in these midlevel staffed clinics, who are happy with 80% of physician reimbursement, rather than physician staffed clinics. For those who would want to learn more about the market dynamics involved in this, might I suggest The Innovator's Dilemma and Chapter 8 of Seeing What's Next both by Clayton Christensen, a Harvard business professor.

 

[8744]

The market probably won't correct itself with more physicians entering primary care or with higher reimbursement for those that do. Midlevel-run clinics are entering the market to take the place of those who want to make more money for 7 yrs of training.

This trend will likely continue as both PAs and NPs have multiple studies showing that their patient outcomes are equal to or better than physician outcomes when within their scope of practice. Also there are studies that show that midlevels can competently treat 80% of what a primary care physician does.

As physicians continue to move up the payscale ladder, we may see a new primary entry point into the healthcare system in these midlevel staffed clinics, who are happy with 80% of physician reimbursement, rather than physician staffed clinics. For those who would want to learn more about the market dynamics involved in this, might I suggest The Innovator's Dilemma and Chapter 8 of Seeing What's Next both by Clayton Christensen, a Harvard business professor.

I don't necessarily disagree with you at all. Like I said in my article, it does not take a medical degree from Johns Hopkin and Duke residency training to manage garden variety hypertension. But as one of my readers said, the current crop of PAs are not as strong as they used to be when it comes to prior medical experience and we certainly don't want to foist a bunch or poorly trained poseurs on the public. Not everything is garden-variety, even in primary care.

 

[core0]

I don't necessarily disagree with you at all. Like I said in my article, it does not take a medical degree from Johns Hopkin and Duke residency training to manage garden variety hypertension. But as one of my readers said, the current crop of PAs are not as strong as they used to be when it comes to prior medical experience and we certainly don't want to foist a bunch or poorly trained poseurs on the public. Not everything is garden-variety, even in primary care.

To some extent the programs are responding to this by extending the coursework and clinicals. I think the average is now 25 months from 22 months several years ago. I also think that the current crop theory remains to be proven. I know that there are several posters that disagree, but the only measureable method we have of ranking PA's - the PANCE pass rate has not changed. What has changed in the last five year that I have been working is the willingness of supervising physicians to train the PA's. The PA that comes out of PA school is raw and needs additional training. It is a relationship that needs to develop. Too many SP's are hiring PA' because their business manager/accountant told them they could make money doing this. If you do not invest the time and energy to make this work everyone is unhappy. I think that with the reimbursement rates, you are going to see more mid-levels in primary care. I don't think this is a bad thing as long as it is done properly and with proper supervision (for the ability and experience of the PA) (or NP for that matter). I also think that with the increase in chronic disease (DM for example) there is ample opportunity for mid-levels to manage these chronic conditions either in a specialty setting or as part of primary care.

David Carpenter, PA-C

 

[core0]

This trend will likely continue as both PAs and NPs have multiple studies showing that their patient outcomes are equal to or better than physician outcomes when within their scope of practice. Also there are studies that show that midlevels can competently treat 80% of what a primary care physician does.

I agree with you on the primary care portion. The part that I disagree is that there are any well done studies that show a PA or NP have better or equal outcomes than Physicians (not residents). There is a paucity of data and I would dare you to show me any study that shows this (and doesn't have major design flaws). I think this is a major failing of both the PA and NP professions. The data is actually out there, it is difficult to access though and hard to seperate from the physcian due to the interdependence between the professions.

David Carpenter, PA-C

 

[zenman]

I don't know what you're asking me here. Surely that patient is going to die.

Just wondering what you do when everything is going downhill...give up...pray, beg, etc..

 

[deleted6669]

"the only measureable method we have of ranking PA's - the PANCE pass rate has not changed"

YES...but...they made pance a lot easier....I know this was before your time but pre-1996 pance was a week long exam with 3 written and 3 practical components....a LOT harder than the current single 3 hr computer based exam...also the increase in pa program duration is in the didactic portion, mostly in research methodologies to meet grad school requirements, not extra clinicals which is what younger, less experienced students need.....a 27 month program with 12 months of didactic and 15 months of clinicals would be a better fit for the current crop of students, not the other way around.....

 

[soonereng]

I agree with you on the primary care portion. The part that I disagree is that there are any well done studies that show a PA or NP have better or equal outcomes than Physicians (not residents). There is a paucity of data and I would dare you to show me any study that shows this (and doesn't have major design flaws). I think this is a major failing of both the PA and NP professions. The data is actually out there, it is difficult to access though and hard to seperate from the physcian due to the interdependence between the professions.

David Carpenter, PA-C

I can't argue whether these studies are or are not well done, as it is fairly relative. I might think that they are well done, but you may not agree; however, we both agree that studies have been done.

My point was that both NPs and PAs (and the gov't) have conducted these studies (flawed though they may be) and use them as evidence that their respective professions are valid.

Probably the only study that matters in the eyes of the gov't was OTA-HCS-37.

 

[core0]

I can't argue whether these studies are or are not well done, as it is fairly relative. I might think that they are well done, but you may not agree; however, we both agree that studies have been done.

My point was that both NPs and PAs (and the gov't) have conducted these studies (flawed though they may be) and use them as evidence that their respective professions are valid.

Probably the only study that matters in the eyes of the gov't was OTA-HCS-37.

The problem is that this is a 20 year old study that essentially repeated the same mantra that was previously evoked. The problem with these studies is that they either:
1. Involve a comparison of NP/PA with residents not practicing physicians
2. Are too short in duration to see if the effects are sustainable
3. Are too small to provide proper power

I will say that as a PA I don't believe PA's provide poor care, but that is different from saying that we provide compareable care. I believe that, but that is a long way from showing this in a scientific manner. There were several important studies done in the late 70's and early 80's, but there have been very few done lately despite the tremendous changes in the medical community. Notice the reference in OTA-HCS-37 to HMO's. Now try finding many HMO's in the manner they were run in the eighties.

There are two problems with doing studies on NP/PA effectiveness. The first is seperating them from their supervising physicians. In today's health care environment a patient may be seen by multiple providers. Who do you give credit or blame for the outcomes? The second is that while the data is probably available through malpractice information and large databases such as those at Kaiser, access is difficult if not impossible.

As medical records move into the electronic age we will hopefully see some of these studies done. The study on osteoporosis and PPI's in JAMA is such an example. From a PA perspective the move toward the Doctorate for PA educators will hopefully spur such research.

David Carpenter, PA-C

 

[8744]

Just wondering what you do when everything is going downhill...give up...pray, beg, etc..

Inform the family of the poor prognosis, make the patient comfortable, ask to make him a "no code," and leave it to the infinite wisdom and ultimate mercy of God. On the other hand we oftentimes keep people like this going and going and going.

Who would we beg? Some people die. They die pretty dead in the third world even with all o' dat' shamansim you all got down dere'. I have seem people die in the third world of things we treat routinely in urgent care.

Oh, some people reach for the $10,000 per dose Xigris but I understand the studies on this are equivocal and at this stage we may as well just withdraw 10 grand from the bank and flush it down the toilet.

 

[MacGyver]

panda bear,

good blog post, but I take issue with one statement you made.

You said PAs work under phsyician "supervision"

i'll let emedpa chime in with what the "supervision" requirements are for states like North Carolina.

The bottom line is that "supervision" is a total sham. The sad part is, it was doctors themselves who continuously weaken the supervision rules. Why bother with close supervision of 1 PA on site when you can change the rules into sham supervision and "supervise" 5 PAs all on remote sites, while never setting foot in their clinic? Once again, its the greed of physicians at work here.

 

[Beau Geste]

Panda, you need to post a new entry 🙂