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EM PAs

Discussion in 'Emergency Medicine' started by ER PA, Aug 17, 2015.

  1. ER PA

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    What do you guys expect from a good EM PA? I'm interested to hear responses as most MD's preferences of PA scope/duties vary.

    Been doing EM for 5 years. Not a whole lot of feedback from the (fairly small democratic) group I'm in.

    (How things work in the group: pretty 20-something-y/o female PAs get hired (with little/no experience.) If she sucks at EM our docs (15 male docs) do very little at addressing the situation. PAs that suck get ostracized by nursing staff, nurses make their life hell and they eventually resign after 6-12 months. This has happened to 3 PAs since I've been with the group...)

    I receive no feedback from the docs and every 12 months my eval (required by hospital credentialing) automatically reads "excellent" at all the checked options. No feedback other than that. I'm one of the top RVU earners so must be doing something semi-right. But input would be nice.

    Anywho, Just wondering what you guys look for in an ideal PA colleague? What do you hate/dislike?
     
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  3. Daiphon

    Daiphon Semper Ubi Sub Ubi
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    Ideally, one who's confident in his/her skills, and knows what he/she doesn't know.

    That's the key. I'm happy to see anything mine bring me, because they know their limitations & I'd rather see a borderline case in real time than have to call them back, deal with a bounceback, or get a summons.

    -d
     
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  4. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD
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    I think there are a few things to know.

    First, you were hired for one of two reasons. Either no docs will come and work there or you were hired to make somebody money. If it is a small democratic group like mine, you were hired to make me money. If it is a hospital or contract management group, you were hired because you're cheaper than a doc. Given the choice, most docs would prefer to work side by side with a doc than a PA and most patients would rather be seen by a doc than a PA. I think remembering the business of PAs is important in keeping in mind my expectations of you.

    So, if you're my employee hired to make me money, I want you to go generate money while minimizing customer complaints, my work, and my liability. That means seeing lots of patients without requiring me to hold your hand, treating the patients nicely, and most importantly, not missing stuff that really isn't fast track in the first place.

    If you're not my employee, and you're making someone else money but I still have to supervise you as part of my job, it becomes doubly important to do the above.

    The key is finding the balance between not bugging me for dumb stuff and making sure you do bug me for the not-dumb stuff. Personally I'd rather have you err on the side of bugging me more often. In our group, our new PAs present every patient until we say they don't have to any more.

    As a general rule, no feedback is good feedback. Newly hired docs and PAs that we're having issues with are getting feedback very frequently.
     
  5. Makati2008

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    Agree with this. Being a PA that is now a Physician, I have seen some MLP make comments like they don't need a supervising doc, too cocky to ask for help, which has led to very critical errors such as missed SAH and PTX. A good PA/NP knows his or her limits, and is willing to change practices patterns as medicine evolves.
     
  6. Boatswain2PA

    Boatswain2PA Physician Assistant
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    We work in much different environments....but my job as an EM PA is to give the exact same level of patient care that a boarded EM physician would give in my environment.

    I'm not saying that I'm as good as a boarded EM physician, but the standard of care is the same. That just means I have to work harder.

    Oh, and get paid 1/3 of what an EM physician would make.
     
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  7. emedpa

    emedpa GlobalDoc
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    DITTO. at one of my jobs it's either me or an fp doc at a rural/critical access hospital. all the em pas there are generally regarded as being better at em than the fp clinic docs who cover the er if we are not there. I have had the experience twice now in the last year of arriving at shift change with a code just arriving and the fp doc asking me to run it as he knows I am more comfortable running codes than he is.
    agree w/ Boat that a residency trained/boarded em doc is the gold standard. I would argue that a good em pa is second best.
    PS we get 2/3rds what the fp docs get to do exactly the same job.
     
  8. deltamed

    deltamed Member
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    And you also take 1/3 the liability.
     
  9. emedpa

    emedpa GlobalDoc
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    NOPE, we are expected to get a consult as needed. if we don't it's on us. the collaborating doc sometimes doesn't even read the charts for a month and is acting within the legal requirements when he does so. several recent legal precedents have held off-site physicians not responsible for PA mistakes unless they were consulted.
     
  10. d2305

    d2305 SDN Gold Donor
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    Physician liability for PA malpractice is state dependent.
     
  11. deltamed

    deltamed Member
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    Somehow I doubt that. There are literally thousands of cases where midlevel messed up (and didn't consult the supervising physician) and the physician typically takes the majority of the liability for "failure to supervise." This is well established. Why is your situation any different?
     
  12. Psai

    Psai Snitches get zero vicryl
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    since when are mid levels allowed to see patients without physician oversight/responsibility?
    if that's going on, that's unethical and dangerous and i can't see a lawyer going after the pa and not the physician whose malpractice coverage is sure to have much deeper pockets
     
  13. Birdstrike

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    Uhh...are you joking? Since...forever.


    But really, depends how you define "oversight" and "responsibility."

    "Oversight" could mean simply signing a stack of charts never having actually seen 30 PA patients, and only theoretically being available to advise the PA as needed, in person or by phone, even. By that definition of oversight, PAs have been able to work essentially without oversight, for decades. This goes on all the time, in EDs all over the place.

    The responsibility part is always there by making the MD the fall guy, when something goes wrong, because he also has an insurance policy. Ultimately any PA, even if working 100% alone, has a default supervising physician on paper somewhere that fills this role. That way, if a PA misses a diagnosis and there's a lawsuit, he gets named, as does the supervising doctor for not doing his duty to make sure the PA doesn't miss diagnoses. In fact, depending how your PA program is set up, it's feasible you could be the default supervising physician of a PA and not even know it, and be liable for patients you've never seen, never been told about by a PA or never signed the chart of.

    For that reason, I don't really like the PA set up in Emergency Medicine. I personally think the arrangement works better when a PA and physician work closer together, one on one, in a surgical or outpatient private practice setting. Having to supervise PAs without choice, that you had no role or responsibility to hire or fire, is not ideal in my opinion, especially considering your CMG employer is increasing your liability by putting you with a mid-level and may not be sharing in the excess revenue generated by the midlevel, if there is any. If I'm going to get paid the same, I'd rather work alone or with an independently practicing NP who isn't required to hang the hat of malpractice safety net on me.

    In an outpatient office, private practice setting I think having a PA has the potential to work out great. You get to pick who you want to work with, you get to know them and can choose to keep them with you or not. You take on the liability of working with them, but benefit by being able to have a bigger practice, have more free time and/or greater revenue which you can keep if desired.
     
    #12 Birdstrike, Aug 18, 2015
    Last edited: Aug 18, 2015
  14. deltamed

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    I will echo this. I wish that the supervising doc only was held liable if they were consulted by the PA (sounds like a fair system to me) but that is NOT the case. I'm in a different specialty and was sued for a patient that I never saw, for a PA that I barely had any role training (ie was there long before I joined the large system and really is their employee not mine). However Im the supervising physician of record. Court found me 90% liable and the PA 10%. How fair does that sound for a patient you never saw or heard of?
     
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  15. Birdstrike

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    I don't know how fair it is, but it's definitely not a good arrangement unless you benefit in some way. It sounds like you took on the liability, for the benefit of the "large system." You probably didn't even realize that was the arrangement until the process server showed up to serve you your subpoena.

    This is part of a larger trend of physicians losing or giving up autonomy. Doctors might be better off to start moving back to private practice, which still can be done nowadays in medium-sized physician-owned groups, without the burden of being solo, yet much more autonomy than if reporting to non-physician employers. That's my opinion.
     
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  16. Boatswain2PA

    Boatswain2PA Physician Assistant
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    Two points.

    1st - the bloodsuckers are going to go after anyone with an insurance policy who can be remotely tied to a malpractice case.
    2nd - the organization you describe is not how PAs should be utilized. Instead, you describe an organization that is completely run by administrators instead of providers. Why would any Doctor/PA/NP want to work for such an organization? There are lots of EM jobs out there, find one who uses PAs appropriately without hanging you out to dry.

    The same thing can happen in EDs. Know your team member's strengths and weaknesses. If PA Smith is a new grad with minimal pre-PA experience then you know you gotta watch over his shoulder a lot more. But if PA Jones did 20 years as medic before PA school, and has been an EM PA for another 10 years, you can probably rest easy that he will appropriately intubate & treat that 70 year old in septic shock.


    I suggest NO physician sign the supervisory agreement without knowing the PA, and establishing what level of supervision that PA needs.

    Physicians should lead our healthcare system. Unfortunately, physicians are losing this role to bureaucrats.
     
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  17. deltamed

    deltamed Member
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    Its easy to say "find another job" but harder in real life in todays healthcare system. The job market dictates what opportunities you have and the truth is that a large proportion of physician jobs now require supervision of a PA whether you like it or not. Its great if you benefit from the PA, but many jobs you do not- 1) if you are at a private group but not yet a partner are you going to tell your boss, no, I'm not a team player and I wont supervise? 2) if you are employed by a hospital or large system it may be a requirement of employment. Unfortunately I would say those two situations are now the overwhelming majority of jobs (for new physicians in the vast majority of specialties).

    Its also easy to say the system is "not using PA's appropriately." The truth is that in MOST situations PAs are quickly seeing their own patients independently and consulting you for a small minority of cases. Unfortunately PAs- no matter how experienced- are NOT generally good at picking up the zebras. In my case, the PA was actually quite good overall and very "experienced"- had been in my field twice as long as me. However, if he had consulted me on this case It would have taken me 20 seconds to arrive at a diagnosis. Instead there was a bad outcome (patient died) which I was was completely unaware of until papers were served over a year later.

    Here's the bottom line: if you supervise a PA- no matter how experienced they are- you ARE a liability sponge. A single piece of BAD luck which you have ZERO control over can lead to a multimillion dollar lawsuit. Unfair but true. So like birdstrike said- make sure you are benefitting financially (which unfortunately is easier said than done in todays system)
     
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  18. exsanguination

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    Man, experienced PA tubing and resuscitating septic shock patients. Honestly I don't see why hospital admins haven't replaced EM docs fully with more experienced PAs

    It's only a matter of time...
     
  19. emd123

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  20. Birdstrike

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    I wouldn't worry about total replacement. Docs and PAs will work side by side. Neither is going away. Though they might like to eliminate docs totally to same money, the administrators still need plausible deniability that bad outcomes were not their system's and therefore their fault, in the form of a fall guy to blame when something goes wrong. That is the MD/DO. They also want to balance the marketing and customer satisfaction aspect of being able to advertise "all board certified doctors!" even if it's only a board certified doctor supervising someone who's not a board certified doctor.

    Again, if a bad outcome occurs? "We hire board certified doctors to make sure the PAs provide the same standard of care a board certified physician would." Therefore it's always one of two explanations, either 1-The supervising doctor failed to provide standard of care along with the PA, or 2-The MD/Do failed to supervise the PA close enough to ensure the PA met standard of care.

    Also, when the hospital is sued, they're never named personally as we are, the nebulous "hospital" is named and they'll put various low level staff up there as witnesses but rarely if ever do the decision makers (CEO, CFO, board of directors) have to do depositions, testify or personally be sued. Administrators are not stupid. They're very smart. They're lawyered up to the gills, have thought this all through long before you and I have and the result is that they've got their end covered very, very well. To them it's not personal, it's "just business."
     
    #19 Birdstrike, Aug 19, 2015
    Last edited: Aug 19, 2015
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  21. BruceWilly

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    A common misconception when it comes to intellectual work. You can't read minds.
     
  22. deltamed

    deltamed Member
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    This is very true. The hospital admin loves midlevels - makes them money with no increased liability (for them). The truth is that PAs/NPs are not board certified physicians and cannot provide the same standard of care despite all the hand-waving everyone does. I actually think they are an integral part of our system and can be great- however, I wish people would just admit they are largely seeing patients independently and "supervision" is really a myth that the admins and lawyers have made up. No matter what I do I cannot take responsibility for a patient I never saw or even heard about. MOST of the time, physicians and systems aren't egregious in misusing or under-training PAs. Its a simple matter that you cannot triage everything, and undifferentiated patients with life-threatening problems can masquerade as "simple" issues. There is no substitute for a trained physician.

    It would make the most sense if all midlevels practiced under their own limited licensees and were responsible 100% for their own patients unless they consulted us. As I sadly discovered, this is not the case.
     
  23. Boatswain2PA

    Boatswain2PA Physician Assistant
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    There is a way to do this, it's called leadership.

    In my former career I was the Chief of two maritime search and rescue stations. I was PERSONALLY responsible for everything that happened at the these rescue stations, whether I was at the station or home asleep. If one of my 22 year old newly-certified boat captains launched a boat on a rescue, screwed up and got someone killed....I was responsible for that. Why? Because I had the authority to go with that responsibility. I was the guy who ensured that the boat captain knew what he was doing. I knew each of my boat captains strengths, weaknesses, and limitations. Weather going to be too crappy tonight and new boat captain on duty? Then the XO or I would stay on duty with him.....and we would go train some more. When some boat captains were on duty I would sleep well knowing they could handle whatever was thrown at them, meanwhile when other boat captains were on duty I they knew they had to call me more often. This is supervision, and leadership.

    The best Station Chiefs were ones who didn't really "do" much, but rather spent most of their time developing their "junior" people.

    This can directly apply to physicians in the ED, and likely every other specialty environment. Imagine if you saw less patients, but rather spent more time simply developing your "junior" people so they could see more and do more....under your supervision. It should be somewhat analogous to having permanent 4th or 5th year residents.....they know what they're doing, and they have their own license and malpractice, but never totally able to practice without some level of oversight by the attending.

    Of course, to do this would require the authority to along with this, which goes back to the loss of physician autonomy.
     
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  24. deltamed

    deltamed Member
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    As long as I can throw you into the brig and order the nurses to "get down and give me 20" I will gladly take this leadership role.

    But seriously, physician autonomy has been so severely eroded in the last 30 years that we should have a similar reduction in liability. We aren't calling the shots anymore and again "supervision" is a myth made up by the lawyers and admins.
     
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  25. deltamed

    deltamed Member
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    By the way, here what real "supervision" would look like: every single patient seen by a midlevel is then presented to the physician. The physician sees the patient personally, if only for a couple minutes. Modifies any plan. PA then does the orders, documentation and any procedure thats reasonable with the physician in close proximity or watching. Essentially, the same supervision that is given to a resident.

    Supervision is not seeing 1% of the PAs patients when they decide to consult you and signing off on 10% of the charts when you may or may not have even been in the building. That is an arrangement best for the admins and lawyers- not the healthcare team or the patients.

    Sure, we can keep doing things that way as long as we admit that's NOT supervision and therefore liability should be minimal.
     
  26. Boatswain2PA

    Boatswain2PA Physician Assistant
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    We agree that supervision must have commiserate authority. Without it there is no actual supervision.

    But supervision does not need to be "see every patient". If I worked for you under a good supervisory agreement then you would see that I am pretty darn capable of taking care of virtually all of OUR patients without you needing to see every one of them.

    But if that is the only situation you would be comfortable with, you would likely be a good SP for those 24 yo new grads in their first job!
     
  27. Birdstrike

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    There's no lack of leadership in medicine. "Leadership" has done a great job of getting things to function how they want. The system is the way it is because present "leadership" wants it that way. There's no lack of leadership, here. Follow the money and you'll find very simple answers to questions that formerly seemed mysterious. Medicine has become scarcely more than "Big Business" in today's day and age to those in charge, and that is not doctors. It's the hospital and insurance company businessmen along with politicians and bureaucrats. I'm not lamenting it. That's just the way it is.
     
  28. Boatswain2PA

    Boatswain2PA Physician Assistant
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    I respectfully disagree Bird. Big difference between leadership and administration. Physicians used to lead the team, now administrators set the rules and thus run the show. Big difference.

    I am fortunate to work in an environment where the physicians still do both: lead the team and run the show. It works very well, and the PAs get appropriate supervision.

    BTW - Please don't take my comments as bashing the personal leadership abilities of any individual physician, but rather the gradual loss of physician leadership in all of medicine, especially in large/urban centers.
     
  29. deltamed

    deltamed Member
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    So how long would you suggest physicians supervise new grad PAs like that seeing every patient? 3 months (what I have typically seen)? 6 months? 2 years? But wait - residents are supervised like that for 3-8 years, and have gone through medical school prior and see a more complex set of patients for more clinical hours.

    Or lets say as in my case I'm asked to supervise a PA with 15 years of "experience" in my field. I talk to him, see patients with him for a few months and review all his charts to be comfortable. He seems quite good and competent. But he's still practicing under my license. Given 3 months out of 15 years I contributed to his "training" in only a very small way by telling him my preferences. So I'm the fall guy if he messes up (as he did two years later). Am I a poor "physician leader" because I didn't supervise him more closely? Should I maybe have seen all his patients for 3 years? Was the system unreasonable? These are serious questions. Personally I dont know what I could have done differently - honestly I feel like he was 100% liable for not consulting me but what can I do.... Take the fall. As I said its a bizzare system setup for the admins and lawyers, not the patients.
     
    #28 deltamed, Aug 19, 2015
    Last edited: Aug 19, 2015
  30. Makati2008

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    So what field are you in? What was his "miss"? Was it esoteric?
     
  31. Birdstrike

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    Go into private, physician-owned practice. Stop working for administrators that are going to sell you down the river. Don't sell your soul to hospital-based Medicine, especially the ACO-hospital-monopoly, mega-system scam that is destroying our profession. The ACOs are going to fail by the way. Mark my words. Its easy to predict, because it's already happening.
     
  32. Boatswain2PA

    Boatswain2PA Physician Assistant
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    Totally up to you and the PA who works for you. You want to see every patient, forever....then see every patient, forever. But that's not a very efficient way of using a provider.

    Please don't extrapolate anything I've said about lack of physician leadership with anything about you personally. I am speaking about the generalized lack of physician leadership within healthcare organization. The bureaucrats are pushing the physicians out.

    About your suit; Our court system is no longer a "justice system", but rather simply a "legal system". The only people who win in such a system are the lawyers who run it.
     
  33. deltamed

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    Dermatology. Kind of. 47 yof with amyopathic dermatomyositis -> saw my PA with "photo-distributed" rash, treated with topical steroids->returned 1 month later rash is "somewhat better," labs normal (cr, UA, cbc, lfts, ck. Mildly positive ANA). DDX photoallergic vs cutaneous lupus. Treat with topical steroids, return in a year or early if systemic symptoms. -> year later saw an outside dermatologist, diagnosed with amyopathic dermatomyositis (ck still normal). Cancer screening -> sky high Ca-125, ovarian CA metastatic, died 8 months later-> delay in diagnosis suit filed against me (I never met or heard of the patient), PA and hospital system. 2 years of legal battles, suit was for 10 million dollars, judgement just shy of a million, 90% against me (thank god for tort reform state but economic damages not capped).

    So I can see what the PA was thinking... this is either a photoallergy or maybe cutaneous lupus. Labs are fairly normal so no end-organ issues- first-line treatment is appropriately topical steroids. Bring her back in a year, maybe start plaquenil if not better. Problem is that he didn't even consider dermatomyositis because he doesn't know it can present without muscle weakness or elevation in CK. He'd seen 1 case in 15 years of practice. I saw three dozen cases in residency alone (that's why tertiary academic referral centers and sub-specialty multidisciplinary clinics are key, and midlevels rarely get this experience). I think 8/10 dermatologists or rheumatologists would have nailed the diagnosis, 2/10 internists, maybe 1/10 derm/rheum midlevels and pretty much 0/10 in other specialties. I know for sure it would have been a 10-second "doorway" diagnosis for me if I had been consulted.

    The scary thing- I think I would actually been BETTER off with a newly graduated PA. A new grad would have been like "oh, this is a weird rash, I'll consult my doctor" or "oh, this might be cutaneous lupus and that's sort of unusual, maybe the doc should see this." But a PA with 15 years experience has seen skin lupus lots of times, and thinks he knows all about it. Even if he did a biopsy it would have "confirmed lupus" (the skin pathology looks identical to dermatomyositis), thus continuing to lead him down the wrong path. PAs in dermatology get zero training in pathology...

    Sorry to vent. By the way, I did subsequently move to a private practice. I supervise a PA - but they only get to see acne and warts. However, Birdstrike I disagree with you- I think private practices are dying and large systems are killing them off. I think ACOs are here to stay. Senior partners in all specialties are selling out to venture capital companies and large systems.
     
  34. Makati2008

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    All I can say is wow. I honestly hope my colleague was man enough to admit he had no ideal what the Dx was. It is my hope that MLP will take on more liability as we become more involved with complex cases. This would be beneficial to us all.
     
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  35. Boatswain2PA

    Boatswain2PA Physician Assistant
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    Vent away. You (and the PA) were hit by the liability lottery. That sucks.

    Why do PAs in derm get zero training in pathology? I would change that.

    If I were your PA and you limited me to seeing acne and warts then I would be up your butt every day learning more stuff until you trusted me to see more and do more. And, once I heard you say that "PAs get zero training in pathology" then I would get some training in pathology.

    Of course, that's never gonna happen, cause I hate rashes! :)
     
  36. Psai

    Psai Snitches get zero vicryl
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    Your attitude is pretty scary. You can't give the same level of care because you don't have the same level of training. You get paid more than your training deserves
     
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  37. Boatswain2PA

    Boatswain2PA Physician Assistant
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    Come talk to me when that wetness behind your ears dries off son.
     
  38. Doctor Bob

    Doctor Bob EM/CC
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    [​IMG]
     
  39. Psai

    Psai Snitches get zero vicryl
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    Hate me cause you ain't me
    you want to be a doc, go to medical school
    it's really that simple

    there's a world of knowledge that you just don't know about and that's because you're a midlevel
     
  40. Boatswain2PA

    Boatswain2PA Physician Assistant
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    Think the first attack was when the kid said I am overpaid. He would know that from his textbooks, right?

    I don't hate you, you're not worth that effort. You're all of about 24 years old. I was serving my country before you were born. When you are finished with residency you will damn well know more medicine than I do, but you won't have half the life experience I do.
     
  41. Psai

    Psai Snitches get zero vicryl
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    Good luck getting paid for life experience. I've forgotten more in the first year of medical school than you've ever learned
     
  42. Birdstrike

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    Stop.
     
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  43. Doctor Bob

    Doctor Bob EM/CC
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    Quit it you two. This isn't productive. "I'm better than you"-"nuh uh, I'm better than you" arguments don't do anything beyond derailing the thread.
     
  44. emememem

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    |Medical Student


    You are going to suffer if your real life persona is anything like what you project with this comment. Those are not appropriate criticisms coming from a medical student, or intern.

    Source: lowly intern.
     
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  45. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO.
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  46. Daiphon

    Daiphon Semper Ubi Sub Ubi
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    Agree.

    That said, the devolution took longer than I thought it would, so there's hope. d=)
     
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  47. tkim

    tkim 10 cc's cordrazine
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    Nothing to do with the *ahem* discussion at hand.
     
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  48. d2305

    d2305 SDN Gold Donor
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    Interesting, so she should have had a CT chest, abdomen and pelvis; & mammogram? Wonder what the ER do f/u with pcm?
     
  49. Birdstrike

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    You said mammogram. I'm out.

    (Wait! There's got to be a "you said mammogram I'm out" gif or meme that could have said that for me in 5 seconds or less...:headscratch: )
     
  50. deltamed

    deltamed Member
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    Fear not, mammogram not indicated. :). They rarely get breast ca. Pelvic ca and lymphoma are the biggies.

    Ct c/a/p , transvag ultrasound, cmp, ca125/19-9, pfts (can get insidious onset ILD) and full physical exam. Anything beyond guided by ros and exam.
     
  51. Old_Mil

    Old_Mil Senior Member
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    Know when to hold em...know when to fold em.

     
    #50 Old_Mil, Aug 28, 2015
    Last edited: Aug 28, 2015

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