EM is NOT a specialty

[K Rider]

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Yep, found that out last night... Allow me to elaborate...

Out at a bar with a few friends. I, being recently single and still feeling a bit blue over the events, was in need of a few libations. A perceptive bro at the table decides to raise my spirits with some witty banter with our waitress.

This is what unfolded:

Friend: Hey, hey you there. Can I ask you a question?
Waitress: Sure.
Friend: What's your opinion of doctors? Wait, wait, I mean... What if there was a doctor at this table... Would you think to yourself, "Hey, that's a nice profession and clearly shows this person is going or maybe already is somewhere."? What do ya think? (I'm paraphrasing, but you get the jist.)

Waitress: Ummmmmmm 95% of doctors are real *******s. I mean, like, ya know, good luck finding an honest one of those. They're just like douchy.
Friend: (Face now pure white in color, jaw hanging)
Me: Hi!
Waitress: (Expressionless stare)
Me: Wow, we kinda got off on the wrong foot here... I'm K Rida, nice to meet you...

What follows now are basic and devoid of any meaning pleasantries... Then...

Waitress: So, umm, like, ya know, what kinda doctor are you? I mean, umm like aren't you going to have to do a residency or fellowship or something?
Me: Yes, I'm actually going to be an ER doctor. I start my residency training in a few weeks. I'm nervous, but it will be a great experience!
Waitress: Ummm yeah, but what specialty will you be doing?
Me: ER. It's actually Emergency Medicine. It's really neat.
Waitress: Umm that's not a specialty. Like, umm, neuro, or cardiology, or trauma, or like plastic surgery.
Me: (Smiling, nodding, takes sip of beer)

Thankfully, another table had a fresh horde of ogres so she had to scoot...

(Please bear with, the end is a must read for this story)

When we needed another round, another bro at the table, in a last ditch effort to assuage some of the awkwardness of the earlier fail asked the young waitress what she does besides waitressing....

The response...

Waitress: "Oh, I'm finishing up PA school."

Ladies and gentleman, no animals or waitresses were harmed in the filming of this comedic short.

Thank you for tolerating my vent!

 

[southerndoc]

I get paid well enough and enjoy my career that it doesn't bother me when people ask what I plan to do when I open my own office, why emergency medicine isn't a specialty, etc. I used to correct them, but now I just change the subject. Not even worth my time.

On another note, have you seen the new BMW X5? Niiice!

 

[EM2013]

"Finishing up" = 2nd year

Ask her how spending her life as the equivalent of a resident is gonna feel.

Seriously though, I have run into this a few times talking with family/friends about EM. Somehow we end up talking about how I like it because it's pretty general and you are a "jack of all trades" yada, yada. Then they say "Oh yeah that's great. And then maybe if you find something you really like you'll specialize in that???"

.......

uhhhhhhhhhh, no.

 

[survivordo]

Not to bash on PAs, most of them are pretty cool, but some of them seem to be totally ignorant about the medical field. How does this happen!? Don't they have to have some ridiculous amount of clinical hours before they can even matriculate? It scares me that she could potentially be starting her new job as a PA at the local Walmart's new health clinic next month with essentially no back up (true story of an acquaintance's first job as a PA)

Survivor DO

 

[Denatured]

My guess is the waitress above was finishing up her MA, as they like to say PA sometimes to either elevate themselves or from complete lack of knowledge, which she demonstrated. A significant number of PAs go into EM, not to mention there are multiple EM residencies for PAs, and all have to rotate through the specialty, so there is no way she didn't think of it as a specialty if she was truly a PA.

Survivor DO: it use to be that all PAs had huge clinical hours before school, and some schools still require 4000 hours with the average being about 8000, but prior HCE is becoming much less common. Hence the reason for proliferation of PA residencies.

- Denatured PA, RN

 

[RustedFox]

Not to bash on PAs, most of them are pretty cool, but some of them seem to be totally ignorant about the medical field. How does this happen!? Don't they have to have some ridiculous amount of clinical hours before they can even matriculate? It scares me that she could potentially be starting her new job as a PA at the local Walmart's new health clinic next month with essentially no back up (true story of an acquaintance's first job as a PA)

Survivor DO

I used to teach some of the PA school classes at my old University-related gig. One out of every 10 or 12 students actually demonstrated that they were capable of wrapping their head around some pathophys. The others... ad;sfklajdsc;acijoac

Clinical experience prior to starting is now a thing of the past with MLPs. People begin PA school and want to throw weight/clout around like they're a half-speed below an MD/DO. They like to say things like - "Well, its juuust like medical school." -- Sure, except that you know, its less hard and long and stuff. I watched as some of those newly minted PAs that I taught went to work in the same departments that I was finishing up being a resident in. Their lack of overall medical knowledge was staggering. I thought to myself on several occasions - "But I myself taught you how to (insert critical clinical thinking skill/interpretive skill here)!"

See my recent comments in the "respect for physicians" thread regarding an MLP or two that I work with. One of these days I'm afraid that I'm going to let it slip and say something like - "Why didn't you think about ____? Oh, they didn't teach you that in hurry-up school?"

 

[RustedFox]

Also, K-Rider... don't you ever change your avatar. 🙂

 

[K Rider]

Thanks for the comments everybody.

Pretty funny, right?

Thing is... As I'm sure you guys and gals remember, after going through 4 years of med school, I expect and have learned to handle being pooped on by everyone. Writ of passage. I get it. Might, just might even be character building.

However, being in a bar...

My guard was up for a random fist. NOT for EM bashing! Sheesh!

Anywho, in the words of Dirk Diggler: "Let's keep rockin' and rollin' [in EM] man!"

PS - RF, thanks brother. Avatar will stay put. The Hoff is my ride or die dog.

 

[Arcan57]

My guess is the waitress above was finishing up her MA, as they like to say PA sometimes to either elevate themselves or from complete lack of knowledge, which she demonstrated. A significant number of PAs go into EM, not to mention there are multiple EM residencies for PAs, and all have to rotate through the specialty, so there is no way she didn't think of it as a specialty if she was truly a PA.

Survivor DO: it use to be that all PAs had huge clinical hours before school, and some schools still require 4000 hours with the average being about 8000, but prior HCE is becoming much less common. Hence the reason for proliferation of PA residencies.

- Denatured PA, RN

One of our better scribes was trying to get into PA school and couldn't without 2 years of clinical experience (teching counted, scribe didn't). She ended up going into perfusionist training.

 

[Birdstrike]

Yep, found that out last night... Allow me to elaborate...

Out at a bar with a few friends. I, being recently single and still feeling a bit blue over the events, was in need of a few libations. A perceptive bro at the table decides to raise my spirits with some witty banter with our waitress.

This is what unfolded:

Friend: Hey, hey you there. Can I ask you a question?
Waitress: Sure.
Friend: What's your opinion of doctors? Wait, wait, I mean... What if there was a doctor at this table... Would you think to yourself, "Hey, that's a nice profession and clearly shows this person is going or maybe already is somewhere."? What do ya think? (I'm paraphrasing, but you get the jist.)

Waitress: Ummmmmmm 95% of doctors are real *******s. I mean, like, ya know, good luck finding an honest one of those. They're just like douchy.
Friend: (Face now pure white in color, jaw hanging)
Me: Hi!
Waitress: (Expressionless stare)
Me: Wow, we kinda got off on the wrong foot here... I'm K Rida, nice to meet you...

What follows now are basic and devoid of any meaning pleasantries... Then...

Waitress: So, umm, like, ya know, what kinda doctor are you? I mean, umm like aren't you going to have to do a residency or fellowship or something?
Me: Yes, I'm actually going to be an ER doctor. I start my residency training in a few weeks. I'm nervous, but it will be a great experience!
Waitress: Ummm yeah, but what specialty will you be doing?
Me: ER. It's actually Emergency Medicine. It's really neat.
Waitress: Umm that's not a specialty. Like, umm, neuro, or cardiology, or trauma, or like plastic surgery.
Me: (Smiling, nodding, takes sip of beer)

Thankfully, another table had a fresh horde of ogres so she had to scoot...

(Please bear with, the end is a must read for this story)

When we needed another round, another bro at the table, in a last ditch effort to assuage some of the awkwardness of the earlier fail asked the young waitress what she does besides waitressing....

The response...

Waitress: "Oh, I'm finishing up PA school."

Ladies and gentleman, no animals or waitresses were harmed in the filming of this comedic short.

Thank you for tolerating my vent!

I never thought I'd be giving dating advice online, but here I go...

You guys are all missing the point. This has nothing to do with PAs vs MDs or EM bashing. It has everything to do with drunk guys trying to hit on good looking waitresses and bartenders constantly by telling them they are a doctor and expecting the women to swoon, let alone even believe them.

Guys, look at this from the waitress's perspective. Assuming she was good looking (which is a fair assumption considering you were irritated she wasn't impressed) do you realize how many times on a Friday night drunk tools try to get her phone number with lines like, "I'm a doctor... I'm in a band...I'm in the CIA...I'm in acting school"? How many times do you think she comes back with, "95% of all (insert clichéd pick-up line profession) are a-s h-les"? Probably 10 times that night alone. This is taught day 1, in hot-chick school: How to Swat Away Drunk Guys with No Game 101.

I'm guessing if "friend" started out with more of a genuine interest in "waitress" and led with asking her name, a little bit about her, and what makes her tick it may have gone differently. Then after you've asked her what she does first, and she tells you she's a PA, naturally she asks you what you do. Then it's appropriate to tell her what you do. Chances are at that point she is a little impressed because you let her pull out of you that you have something in common. Leading with "Hey, hey, you there.....what's your opinion of doctors" translates into "I'm drunk, I want to get l---d, and the easiest way with the least effort is to tell you I'm a doctor and see if you're gullible enough to fall for the oldest line in the book."

Don't take it personally. As a PA student she probably thinks it's pretty cool that you're an ER doc. Just chalk it up to the fact that either you need a new wing man, or your wing man needs to step up his game.

 

[emergentmd]

Funny. Family and Friends still do not know that EM is a specialty. I think the show ER has helped and all of the other reality shows. I would be many do not know that radiology, pathology, etc are either.

I do know that all of my specialist friends greatly appreciate EM b/c we save them so much time. My ortho Chief even commented that his life is so much easier b/c he almost never comes in anymore b/c we can reduce almost anything that walks in the door.

I do not see how any other specialist could take our space given our knowledge of everything. I rarely have days that something is new to me.

 

[WilcoWorld]

First of all, as usual, BS hit it on the head.

Second of all, the general misunderstanding of our specialization is pretty understandable when you think about it. Most "specialists" focus on systems, organs, or parts of organs (right heart failure specialists, hand surgeons, neurosurgeons who only do spine, etc). However we specialize in a temporal realm (acute presentations). This is a hard concept for people to wrap their heads around, and we make it harder when we handle all sorts of non-emergencies with a smile.

Our specialty used to be well-defined (EMERGENCY), it becomes less well-defined with every chronic complaint you treat rather than swiftly discharge. Is this a bad thing? I don't know. Perhaps the pragmatic approach of the EMP is what the US medical system needs. But I do know that such an approach wont work unless it's unmoored from the constraints of satisfaction metrics.

 

[K Rider]

Bird, love all your stuff, but come on! You honestly believe there was no friend and I'm just looking for some interweb shoulders to cry on? Damn... That said, what you mentioned about anyone pompously flaunting title/money/whateve being stale is absolutely true.

However, geeeezzz... I'm operating under anonymity here. What's my motivation to lie and concoct story of said "friend"? I'll come right out and say, K-Rida has gotten turned down many a time. My ego can take a hit.

My buddy was truly, although awkward, altruistic with his intention of attempting to lift my spirits. This broad smelled blood in the water. Once she knew I was/am more or less basically a med student, the knives came out.

Perhaps I didn't articulate it clearly. If I had an aim with the post it was this: I was caught off guard when it came to defending my chosen profession. It will likely happen again. However, I will be looking for a new wing joint.

 

[Apollyon]

The PA student craps on EM because her preceptor does. We saw this as residents when I was at Duke - the Duke med students crapped on EM, because Duke IM and surgery residents crapped on EM - "they say you suck, so I say you suck, too". It's a learned behavior without an actual personal experiential component.

 

[VentdependenT]

Egomaniacs with inferiority complexes: welcome to the world of physician interaction. Whatever, i say f:$k it and do what needs to be done without being an a-hole to others. Every now and then I go on a self indulgant tirade though.

 

[Birdstrike]

You honestly believe there was no friend and I'm just looking for some interweb shoulders to cry on? Damn...

No. Wasn't implying that

 

[Procyon]

Not to bash on PAs, most of them are pretty cool, but some of them seem to be totally ignorant about the medical field. How does this happen!? Don't they have to have some ridiculous amount of clinical hours before they can even matriculate? It scares me that she could potentially be starting her new job as a PA at the local Walmart's new health clinic next month with essentially no back up (true story of an acquaintance's first job as a PA)

Survivor DO

It seems like some of the newer schools have a way around that requirement or something. There was one girl at my school this year who got into PA school, and she really struck me as someone who didn't deserve it, not only because she cheated her way through every class I was in with her, but because she had next to no clinical experience, and decided she wanted to apply for PA school in like, December. Meanwhile, my best friend at school has been slaving away in the ambulance and the ED for the past couple years and he still didn't get in.

In any case, sorry about her and that you were feeling blue OP. Just look on the bright side though. You've got residency ahead of you, maybe the love of your life is waiting for you there. 👍

 

[RustedFox]

Procyon: Nice avatar/location. Think I'll watch the whole thing again this week (I have a couple days off).

 

[BJJVP]

I am board certified in EM and while I definitely agree EM is technically a specialty, I don't make a fuss about it or try to convince people that it is a specialty. I understand why the general public and some med professionals feel that it it isn't. We are generalists in the sense that we see everything, do a little of everything, and don't spend all of our time on one body system or one type of pathology. Nobody ever formally consults us in the traditional sense (although I occasionally see a patient who was sent to the ED for a "second opinion").

Instead, when someone asks if I will ever open my own office or choose a specialty or if I will "just work in ERs," I tell them no, no, & yes and move on.

I try to be happy that I can read an EKG but I'm not a cardiologist, I can look at plain films but I'm not a radiologist, I can sedate pts but I'm not an anesthesiologist, I can put in lines, chest tubes, cric, crack a chest but I'm not a surgeon, use a slit lamp and burr a rust ring, but I'm not an ophthamologist, reduce a shoulder but I'm not an orthopedic surgeon, etc.

Most people (non EM doctors included) don't see us that way...but if I wanted respect from pts and others, I should've chosen some other "specialty."

I find that when I don't remind myself of the above, feelings of burnout creep in really fast.

I think that continuously trying to force people to call it the ED and not the ER, calling the field EM instead of ER, forcing others to consider us specialists vs not a specialist is a waste of energy. Also, I think it kind of makes us look like those guys in the hospitals that are non MDs with long white coats and a million letters after their names. If you want others to respect you, thenstart respecting yourself and don't allow others to determine your own worth.

We need to be just be proud of what we do, ignore the haters and just know that if someone else could do it better, then they would because on an hourly basis, we get paid more than a lot of the hospitalists, pediatricians, even some surgeons.

 

[Arcan57]

I am board certified in EM and while I definitely agree EM is technically a specialty, I don't make a fuss about it or try to convince people that it is a specialty. I understand why the general public and some med professionals feel that it it isn't. We are generalists in the sense that we see everything, do a little of everything, and don't spend all of our time on one body system or one type of pathology. Nobody ever formally consults us in the traditional sense (although I occasionally see a patient who was sent to the ED for a "second opinion").

Instead, when someone asks if I will ever open my own office or choose a specialty or if I will "just work in ERs," I tell them no, no, & yes and move on.

I try to be happy that I can read an EKG but I'm not a cardiologist, I can look at plain films but I'm not a radiologist, I can sedate pts but I'm not an anesthesiologist, I can put in lines, chest tubes, cric, crack a chest but I'm not a surgeon, use a slit lamp and burr a rust ring, but I'm not an ophthamologist, reduce a shoulder but I'm not an orthopedic surgeon, etc.

Most people (non EM doctors included) don't see us that way...but if I wanted respect from pts and others, I should've chosen some other "specialty."

I find that when I don't remind myself of the above, feelings of burnout creep in really fast.

I think that continuously trying to force people to call it the ED and not the ER, calling the field EM instead of ER, forcing others to consider us specialists vs not a specialist is a waste of energy. Also, I think it kind of makes us look like those guys in the hospitals that are non MDs with long white coats and a million letters after their names. If you want others to respect you, thenstart respecting yourself and don't allow others to determine your own worth.

We need to be just be proud of what we do, ignore the haters and just know that if someone else could do it better, they wouldn't pay us so much.

The only issue I have with that is ignoring the haters usually means having the haters dictate our practice patterns. It is exhasting railing against other people's ignorance, but our specialty was carved out by people that weren't afraid to fight to increase our rep and our ability to take care of patients. Without them, you'd still be using morphine for procedural sedation and begging for admissions to your on call docs.

 

[Procyon]

Procyon: Nice avatar/location. Think I'll watch the whole thing again this week (I have a couple days off).

👍 Good call! I'm hoping to have a chance to watch it again with my little brother this summer before I move out/start med school. 😀

 

[winkleweizen]

Lol Birdstrike.....Idk why but this reminds me of something I heard the other day.

"Whats the difference bw a charming man and a creepy man?"

"One's good looking and one's not"

 

[BJJVP]

You are correct. Let me clarify...ignoring the haters does not mean laying down without standing up for yourself.

If someone doesn't think I'm a specialist, fine. But if they think we are not qualified to use propofol or succinylcholine, then we have to stand up for ourselves.

 

[la gringa]

You are correct. Let me clarify...ignoring the haters does not mean laying down without standing up for yourself.

If someone doesn't think I'm a specialist, fine. But if they think we are not qualified to use propofol or succinylcholine, then we have to stand up for ourselves.

we still can't use propofol for sedation in my hospital system - acutally, none of the 3 systems in which i've worked since residency have allowed it.

brought it up w/ an anesthesiologist the other day in casual chatter - he came down to be backup for a colleague who was intubating a pt with bad angioedema. dude INSISTED that propofol was GENERAL ANESTHESIA...?? i tried arguing otherwise based on how we used it in residency for sedation, to no avail.

heck, i'd be happy to have etomidate approved for "moderate sedation"... we're stuck with just ketamine, versed/fentanyl. leaves one wanting to avoid sedation at all costs due to long turnaround times!!!

 

[med2UCC]

Wow, that sucks. We have propofol, ketamine, versed, fentanyl, etomidate -pretty much whatever we want unless there is a shortage from the manufacturer. More and more I realise how lucky I am to work in a shop where these battles have been won already. Cheers,
M
Oh, and anaesthesia fought us on it, but eventually realised that it meant fewer calls and got on board.

 

[gman33]

we still can't use propofol for sedation in my hospital system - acutally, none of the 3 systems in which i've worked since residency have allowed it.

brought it up w/ an anesthesiologist the other day in casual chatter - he came down to be backup for a colleague who was intubating a pt with bad angioedema. dude INSISTED that propofol was GENERAL ANESTHESIA...?? i tried arguing otherwise based on how we used it in residency for sedation, to no avail.

heck, i'd be happy to have etomidate approved for "moderate sedation"... we're stuck with just ketamine, versed/fentanyl. leaves one wanting to avoid sedation at all costs due to long turnaround times!!!

start calling in anesthesia every time you want to use Propofol. maybe that will help change the policy.

 

[EM_Rebuilder]

I get paid well enough and enjoy my career that it doesn't bother me when people ask what I plan to do when I open my own office, why emergency medicine isn't a specialty, etc. I used to correct them, but now I just change the subject. Not even worth my time.

On another note, have you seen the new BMW X5? Niiice!

Amen!

I think about that fact that I was in Las Vegas last week and DC the week before that. And then in two weeks, my wife and I will be in Puerto Rico.

I figure I make more money that at least half the 'bashers' and probably make more with less time commitments than all of them.

Bash away; its Monday and almost 11AM. I just ate breakfeast, I am watching my kid play in his 'playhouse' on the back porch with my laptop in hand. I've said it before, but my biggest topic today is "Whats for lunch?"....

 

[Birdstrike]

Lol Birdstrike.....Idk why but this reminds me of something I heard the other day.

"Whats the difference bw a charming man and a creepy man?"

"One's good looking and one's not"

Right! I know. LOL.

 

[Birdstrike]

start calling in anesthesia every time you want to use Propofol. maybe that will help change the policy.

Agree, agree, agree. This is turf war BS inexcusable in the day and age of BC/BE EPs.

Nurses can push propofol. Nurses! but not a BC/BE EP. Call anesthesia every time you need a sedation or an intubation. Every single time! Fight fire with fire and show them how important their skills are by calling them in for every shoulder reduction at 3 am, and every single impending intubation on every holiday you work.

The problem will be fixed real soon. The entire profession of Anesthesiology felt it appropriate to train nurses to do their jobs (now severely regretting it) when it served their interests, but at your hospital they can't find the time to work with BC/BE residency trained EPs how to safely use propofol.

A sickening level of hypocrisy that needs to be called out for what it is-greed and turf protection at the expense of patient care.

 

[Tiger26]

Agree, agree, agree. This is turf war BS inexcusable in the day and age of BC/BE EPs.

Nurses can push propofol. Nurses! but not a BC/BE EP. Call anesthesia every time you need a sedation or an intubation. Every single time! Fight fire with fire and show them how important their skills are by calling them in for every shoulder reduction at 3 am, and every single impending intubation on every holiday you work.

The problem will be fixed real soon. The entire profession of Anesthesiology felt it appropriate to train nurses to do their jobs (now severely regretting it) when it served their interests, but at your hospital they can't find the time to work with BC/BE residency trained EPs how to safely use propofol.

A sickening level of hypocrisy that needs to be called out for what it is-greed and turf protection at the expense of patient care.

I'd raise you one and start calling them in for dental and digital blocks--but it's regional anesthesia!!!

 

[la gringa]

Agree, agree, agree. This is turf war BS inexcusable in the day and age of BC/BE EPs.

Nurses can push propofol. Nurses! but not a BC/BE EP. Call anesthesia every time you need a sedation or an intubation. Every single time! Fight fire with fire and show them how important their skills are by calling them in for every shoulder reduction at 3 am, and every single impending intubation on every holiday you work.

The problem will be fixed real soon. The entire profession of Anesthesiology felt it appropriate to train nurses to do their jobs (now severely regretting it) when it served their interests, but at your hospital they can't find the time to work with BC/BE residency trained EPs how to safely use propofol.

A sickening level of hypocrisy that needs to be called out for what it is-greed and turf protection at the expense of patient care.

actually i work in a HUGE hospital system, with a teaching hospital including an EM residency... which makes it even worse.

my previous gig, i worked at 2 community hospitals - 1 really "alone" but the other was also part of a larger entity including a hospital with some teaching elements.

at my county residency, we could do.... just about anything, which makes it even more frustrating.

 

[KLPM]

- I am going to be a radiologist ------> Don't all doctors do that?

- I am going to be a pathologist -------> So you are not a doctor?

- I am going to be an ophthalmologist ---------> An optometrist?

- I am going to be a psychiatrist ---------> I go to my school counselor. He is a nice guy.

- I am going to be a PMR --------> Is that what my chiropractor or physiotherapists do?

- I am going to be a general practitioner --------> So you are not going to specialise?

- I am going to be an anaesthetist ---------> So you are a nurse?


We all suck.

 

[shibby1111]

- I am going to be a radiologist ------> Don't all doctors do that?

- I am going to be a pathologist -------> So you are not a doctor?

- I am going to be an ophthalmologist ---------> An optometrist?

- I am going to be a psychiatrist ---------> I go to my school counselor. He is a nice guy.

- I am going to be a PMR --------> Is that what my chiropractor or physiotherapists do?

- I am going to be a general practitioner --------> So you are not going to specialise?

- I am going to be an anaesthetist ---------> So you are a nurse?


We all suck.

In subletting my apartment in order to move down to school, the new tenant insisted, "so what are you moving for?" "Well, I got into a medical school so that's what why I'm moving." "Oh so what are you going to be, PA, CRNA, nurse?" "No"

 

[DreamingTheLive]

Lol Birdstrike.....Idk why but this reminds me of something I heard the other day.

"Whats the difference bw a charming man and a creepy man?"

"One's good looking and one's not"

Truth.

 

[DeadCactus]

I don't know why anyone expects strangers to know or care about the intricacies of their career training and job title. Who knows how joining the clergy works or what the different jobs inside the church entail? How many people call SEALs Special Forces or refer to Marines as Soldiers? How many people think that an engineer drive trains, finance majors are the same as the guy with just a CFP certificate, or that lawyers only work in courtrooms?

It's not a lack of physician prestige thing, it's the simple fact that no one outside of a close circle of friends and family really gives any sort of a crap about the inner workings of your life...

 

[Boatswain2PA]

Not to bash on PAs, most of them are pretty cool, but some of them seem to be totally ignorant about the medical field. How does this happen!? Don't they have to have some ridiculous amount of clinical hours before they can even matriculate? It scares me that she could potentially be starting her new job as a PA at the local Walmart's new health clinic next month with essentially no back up (true story of an acquaintance's first job as a PA)
Survivor DO

The "legacy" PA model took experienced folks and taught them 2 years of medicine. Unfortunately this model has been bastardized by academia who pushed the master's level "education" and forced out many of the experienced paramedics/techs.

Also, if your acquaintance is a PA, he/she has a supervising PHYSICIAN who allows them to practice with "essentially no back up".

For physicians who are unhappy with PA's (like RustedFox?)– please keep in mind a that WE WORK FOR YOU! If you don't like how PAs are educated, then get involved in PA education. Don't just be a guest lecturer, use your physician organizations to push for changes in PA education. Become a Medical Director and change the admission criteria back to "significant experience required". Use your administrative clout at your hospitals to only hire PAs who show they had significant experience before PA school. Conversely, if you hire a PA right out of school, and/or one without significant experience before PA school, realize they will need much closer supervision than that 20 year paramedic, or the experienced PA.

And on the topic of supervising, keep in mind that we are NOT physicians. I am constantly astounded by how little I know in comparison to my supervising physicians. We are probably taught 60% of what you learn in medical school….but we don't have the 3-8 intense years of residency that you have. By no means does that make us useless, but it is up to YOU, as our supervising physicians, to make sure we are employed properly. We can make you a lot of money (or, in my case, I can let you go home and sleep in your own bed instead of being up all night), but it is up to you to supervise us.
The Supervising Physician/Physician Assistant model works very well, but only if both parties live up to their end of the deal.

 

[deleted109597]

For physicians who are unhappy with PA’s (like RustedFox?)– please keep in mind a that WE WORK FOR YOU!

Sorry, but in our field, that isn't true for many shops. The PA/NPs are hired by the contract manager, not by the docs working at the shop. Oversight can be minimal to none. Frequently I tell our midlevels what to do just to have them do whatever they wanted to do anyway.

 

[xenotype]

Can everyone just go ahead and admit that PA/NP is just a backdoor shortcut into medicine, and that all of this boils down to an argument of how much training is necessary to make safe providers? Few PA/NP programs require any real healthcare experience for admission, and the people going into them just want to avoid the hard work and long hours of medical school and residency. The supervision in most places is cursory at best, and nobody has any idea how much of an effect this has on patients.

The PA forum across the interwebs is full of PAs clamoring for independent practice with no supervision, jealous of the inroads NPs have made.

 

[Hercules]

Sorry, but in our field, that isn't true for many shops. The PA/NPs are hired by the contract manager, not by the docs working at the shop. Oversight can be minimal to none.

I know this is true in many places but it just sounds like such a bad arrangement.

 

[Siggy]

and change the admission criteria back to “significant experience required”.

There are a few problems with experience requirements. First, numerically, there's no difference between the person who has one years experience repeated 9 times, and someone with 10 years experience. "But but but interview" you might say, and you're right... except that interview is going to occur regardless of any experience requirement or not.

The second is the quality of the experience matters. Since you mentioned paramedics, does EMT experience count as well? Does someone with an undergrad degree and experience practicing at a level that requires 120 hours of training and essentially hands the person a NRB and an oxygen tank to play with (because, let's be honest, the vast majority of medical interventions that EMTs have available are rarely used... and no one is impressed with the ability to prime an IV line or connect a 12 lead) really have 10 years of useful experience? For paramedics, is 10 years of experience really "experience" if they worked in a state/region/county that relies on cookbook-ocols and online medical control for everything?

 

[Boatswain2PA]

Sorry, but in our field, that isn't true for many shops. The PA/NPs are hired by the contract manager, not by the docs working at the shop. Oversight can be minimal to none. Frequently I tell our midlevels what to do just to have them do whatever they wanted to do anyway.

That's a problem with management, but it is also a problem with the supervising physicians. You must have agreed to supervise these midlevels. Any degree of supervision must come with it a concomitant degree of authority. If you don't have enough authority in your shop to adequately supervise the mid-levels, then don't you have an obligation to change that? I'm not trying to be argumentative here, I am just a firm believer in the PA/supervising physician model. YOU are placed in the supervisory role because YOU have a much greater educational experience than I do. That means it's your job to supervise me. In return, I let you see more patients, let you make more money, and hopefully let you get a bit more sleep.

Can everyone just go ahead and admit that PA/NP is just a backdoor shortcut into medicine, and that all of this boils down to an argument of how much training is necessary to make safe providers? Few PA/NP programs require any real healthcare experience for admission, and the people going into them just want to avoid the hard work and long hours of medical school and residency. The supervision in most places is cursory at best, and nobody has any idea how much of an effect this has on patients.
The PA forum across the interwebs is full of PAs clamoring for independent practice with no supervision, jealous of the inroads NPs have made.

Sure PA/NP is a backdoor shortcut into medicine. But while "backdoor" means we don't have your (future) knowledge/experience base, it doesn't mean that we are useless. PA's are a part of YOUR STAFF that YOU can train to do anything you want us to do. The more YOU train your PA, the more they can do for YOU.
Yes, it seems like a lot of today's PA student's go that route because they want to do 2 yrs versus 7-11 years, and I agree this is a problem. It astounds me to see kids in early 20's applying to PA programs but not to med schools. But, again, use your role as a (future) physician to get involved in PA education and swing that pendulum back, or use the employment interview process to screen out the new PAs with no previous experience. There are still many PA students who have great experience. The one's who don't should be put in positions with much closer supervision (again, that will be YOUR JOB to do!)
And about the push for independent practice - I disagree with any form of mid-level independent practice. But, unfortunately, PA profession competition comes from the NP profession, which is pushing HARD for independent practice. If the Boards of Medicine would push back against this (perhaps by defining what, exactly, practicing MEDICINE entails and then establishing authority over it), the nurses wouldn't be able to practice medicine independently and PA's could stop barking up that tree.

There are a few problems with experience requirements. First, numerically, there's no difference between the person who has one years experience repeated 9 times, and someone with 10 years experience. "But but but interview" you might say, and you're right... except that interview is going to occur regardless of any experience requirement or not.
The second is the quality of the experience matters. Since you mentioned paramedics, does EMT experience count as well? Does someone with an undergrad degree and experience practicing at a level that requires 120 hours of training and essentially hands the person a NRB and an oxygen tank to play with (because, let's be honest, the vast majority of medical interventions that EMTs have available are rarely used... and no one is impressed with the ability to prime an IV line or connect a 12 lead) really have 10 years of useful experience? For paramedics, is 10 years of experience really "experience" if they worked in a state/region/county that relies on cookbook-ocols and online medical control for everything?

So you will be expected to tease out of a patient whether they have a headache, a migraine, or a SAH; you will have to be able to tease out of a patient whether they have an exacerbation of their GERD, or if this is angina. If you don't already, I'm sure you will have the ability to tease out of a PA whether or not they have "significant" experience during a job interview.

 

[deleted547339]

thread successfully derailed....

 

[spyderdoc]

On another note, have you seen the new BMW X5? Niiice!

It sure is! I had a 2009 X5 diesel, and loved it. But it was the 1st year of the diesel engine in the US, so it had a few problems.... I picked up a Touareg TDI, and will keep it for a few yrs until the new X5 has had a few years to work out some of bugs, then pick one up.

 

[spyderdoc]

we still can't use propofol for sedation in my hospital system - acutally, none of the 3 systems in which i've worked since residency have allowed it.

brought it up w/ an anesthesiologist the other day in casual chatter - he came down to be backup for a colleague who was intubating a pt with bad angioedema. dude INSISTED that propofol was GENERAL ANESTHESIA...?? i tried arguing otherwise based on how we used it in residency for sedation, to no avail.

heck, i'd be happy to have etomidate approved for "moderate sedation"... we're stuck with just ketamine, versed/fentanyl. leaves one wanting to avoid sedation at all costs due to long turnaround times!!!

We just got done fighting a 4-5 yr battle with anesthesia, and finally just passed through a deep sedation policy that allows us to give all the good stuff. So painful, but I think that we just hounded them for so long that they finally just caved. It is a pretty strict policy, essentially requiring a second doc to be available, RT at bedside, ETCO2 monitor. NPO status was probably the biggest thorn. They wanted 6 hours, but we were able to but an urgency disclaimer to do it without waiting 6 hours.....We are just glad to have the policy and use the meds....

 

[RustedFox]

PA’s are a part of YOUR STAFF that YOU can train to do anything you want us to do. The more YOU train your PA, the more they can do for YOU.

You're confusing PAs and Pokemons again.

I feel like I should clarify my position. I don't "dislike" MLPs of any flavor. I work with three that are awesome at their job. Awesome. I work with three more that really think that they do "practice independently" and frequently "do whatever it is that they want to" despite my instructions. The first three MLPs did years of other clinically-relevant work. Some of the latter three frequently argue with me about what should be done. Argue with me; as in - "no, here's why I'm doing it this way." They don't seem to understand that this isn't a discussion; its an order - given from me to you.

You say "We work for YOU!"... and that just doesn't hold up a lot of the time in the real world; there's frequently an adversarial (rather than a collegial) attitude adopted by the MLPs, as the mantra increasingly becomes "we want independence and full practice rights!"

A lot of it has to do with the lack of a strong understanding of the BASIS of pathophys and its management. I frequently find a MLP presenting a case to me for "what's the next step here, doc ?" and I have to ask - "Okay, why did you order (lab X or imaging Y)?" ... and the response I get is a confused stare. That's not okay. In order to be 'able' to do something in the ED, you'd better know WHY you're doing it. I really think that a big part of the genesis of the problem is the method of learning. MD/DOs learn via "sit down and read Robbins pathology until you're blue in the face, and you understand it", while the MLPs are taught to learn via mimicry; "do as I do; its not important why."

I've taught PA classes by the handful at my old institution. A lot of these problems would be improved if the principles of disease and their management were taught.... but that would be time-consuming and difficult, unattractive for many a student.

As a final thought, there's the oft-thrown-around quote that goes something like: "With great power comes great responsibility." Those MLPs clamoring for full rights might be well-served to remember the "responsibility" part of that quote. Their songs for independence might change their tunes once there's no MD/DO around to serve as a liability offset.

 

[Boatswain2PA]

....

As a final thought, there's the oft-thrown-around quote that goes something like: "With great power comes great responsibility." Those MLPs clamoring for full rights might be well-served to remember the "responsibility" part of that quote. Their songs for independence might change their tunes once there's no MD/DO around to serve as a liability offset.

I agree with everything (well....except the pokemon thing ), although I only see the PA push for independence on the internet and a few people at the SEMPA conference. But again, their reasoning for PA independence is predicated on keeping up with the NPs.

But conversely, with the "great power" that physicians (deservedly) have comes the "great responsibility" to make sure they are supervising their PAs correctly. Some PAs, in some settings, need minimal supervision. Other PAs and other settings need much more.

Sorry for derailing the thread...

 

[WilcoWorld]

Any degree of supervision must come with it a concomitant degree of authority. If you don’t have enough authority in your shop to adequately supervise the mid-levels, then don’t you have an obligation to change that?

Some of us try, but as you said...

That’s a problem with management

The gap between is and ought is wide, and can be uncrossable (at least according to David Hume).

 

[NERDY]

If the MLP doesn't follow your request, what happens then?

You're confusing PAs and Pokemons again.

I feel like I should clarify my position. I don't "dislike" MLPs of any flavor. I work with three that are awesome at their job. Awesome. I work with three more that really think that they do "practice independently" and frequently "do whatever it is that they want to" despite my instructions. The first three MLPs did years of other clinically-relevant work. Some of the latter three frequently argue with me about what should be done. Argue with me; as in - "no, here's why I'm doing it this way." They don't seem to understand that this isn't a discussion; its an order - given from me to you.

You say "We work for YOU!"... and that just doesn't hold up a lot of the time in the real world; there's frequently an adversarial (rather than a collegial) attitude adopted by the MLPs, as the mantra increasingly becomes "we want independence and full practice rights!"

A lot of it has to do with the lack of a strong understanding of the BASIS of pathophys and its management. I frequently find a MLP presenting a case to me for "what's the next step here, doc ?" and I have to ask - "Okay, why did you order (lab X or imaging Y)?" ... and the response I get is a confused stare. That's not okay. In order to be 'able' to do something in the ED, you'd better know WHY you're doing it. I really think that a big part of the genesis of the problem is the method of learning. MD/DOs learn via "sit down and read Robbins pathology until you're blue in the face, and you understand it", while the MLPs are taught to learn via mimicry; "do as I do; its not important why."

I've taught PA classes by the handful at my old institution. A lot of these problems would be improved if the principles of disease and their management were taught.... but that would be time-consuming and difficult, unattractive for many a student.

As a final thought, there's the oft-thrown-around quote that goes something like: "With great power comes great responsibility." Those MLPs clamoring for full rights might be well-served to remember the "responsibility" part of that quote. Their songs for independence might change their tunes once there's no MD/DO around to serve as a liability offset.

 

[RustedFox]

Some of us try, but as you said...


The gap between is and ought is wide, and can be uncrossable (at least according to David Hume).

You hit it right there. The problem is "management". They have zero idea what works. Zero. And all of their prattle of: "We want to spend time with you and get to know you and gobbledy-gook, robble-robble-robble, McGurglePlex!" is equally as useless. We seem to be paying a lot of money to "management", to... do... nothing that helps us.

We had one of the CMG-vetted "spies" (a "nurse manager" for the record) recently come to the department and "spend some time walking in our shoes". The answers that she got were unsettling to say the least. I remember the exact conversation that I had with (him/her) one day:

Spy: "This patient has been out there in the waiting room for 12 minutes already! What seems to be the problem here?!"

Me: "Well, I'll tell you exactly what happened.The patient checked in with the triage nurse, who started the clock and took their chief complaint. The triage nurse began to do her job, then was interrupted three times in turn by the patient, who needed to 1.) tell her baby-daddy that she was here (which took three minutes), 2.) go outside and have a cigarette, because she knew she wouldn't be able to step-out once she 'got back', and 3.) text back at some people who might be able to get her a ride afterwards. At three minutes each, now we're at nine minutes, maybe more if that cigarette was really enjoyed down to the filter. The triage nurse (of course) dare not interrupt the patient, because that would be "bad customer service". Now that we've wasted another two minutes for redirection and whatever, we're at 11 minutes for the stay already. Give the triage nurse three whole minutes to take a decent history and some vitals, and we're at 14... 15 minutes. Now, your "door to doc" goal of 15 minutes is already blown.... and is in no part any fault of the staff."

She hated that. The underlying message (which, I'm sure that she refused to take back to corporate headquarters) is: STOP MEASURING THINGS WHICH DON'T MATTER AND HOLDING THEM OVER OUR HEADS.

My immediate boss showed up to the shop the other day to complain about the times and said something akin to "my OTHER shop is leading the district... so... hmm-HMM-hmm."

My immediate reaction was "Bull**** in. Bull**** out." Who cares if your shop has a door to doc time of 11 minutes as opposed to 18 ? You're not measuring anything useful. You might as well put your nose by my ass after I've eaten Mexican food and measure the raunchiness of my farts. The only thing that you'll conclude for certain is: "Farts are smelly. Some more than others, but... all, are undeniably nasty."

 

[RustedFox]

If the MLP doesn't follow your request, what happens then?

Request?

Its not a request. Its an order.


Once the MLP refuses to obey my order, I'm left to clean up the mess that's leftover. I explain why the PT/INR was not ordered on that surgical abdomen, or why there wasn't fluids ordered for hours beforehand, or why the magnesium wasn't replaced for that guy who's defibrillator fired eleventeen hours ago.

In short... its a freaking mess. And I'm left to explain it. And it negatively impacts my standing around the shop. And I don't like starting sentences with conjunctions.

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