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I've never been in favor of PA's, except in rural areas where health care access is minimal. What is the role of PA's in the EM department, and what threat if any will they pose to physicians?
EM physician assistants
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i worked as an ED tech in a community hospital in a major city before med school. they usually had an NP and PA (or two PAs) with one doc overseeing them on the acute care side of the ED only. they took care of the common colds and lacs and stuff of that nature. one doc i talked too loved the idea since PAs were competent in what they were doing and got paid less than the docs. that way all the partners in the group made more money.
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I have worked side by side with PAs. It frightens me when a PA asks an intern for help interpreting a CXR. Cut costs where you want, but don't send the PA in to see me.
D
deleted6669
ACEP Survey
The most recent data available from ACEP comes from a 1999 work force study. Of approximately 900 responding hospitals, a third indicated that they utilize physician assistants in their EDs. The results were published in the July 2002 Annals of Emergency Medicine, Vol. 40, No.1. (www.acep.org/1,5327,0.html or www.mosby.com/scripts/om.dll/serve?article=a124754)
Literature Reference
Hooker, R.S. & McCraig, L. (1996). Emergency department uses of physician assistants and nurse practitioners: A national survey. American Journal of Emergency Medicine, Vol. 14, pp. 246-249.
Question 8 What determines how PAs are utilized in the ED?
Answer 8 Four parameters determine how PAs are utilized in the ED: (1) The first is PA education and training. A new graduate may have a somewhat basic scope of practice, which expands as supervised practice and additional training in the clinical setting increases the PA?s experience and skill level. (2) The second determinant of PA utilization is state law. In general, state laws define the PA?s scope of practice as those tasks a PA has been trained to do that are delegated and supervised by the physician. However, some state laws have specific restrictions or requirements. (3) The third determinant of PA utilization is the hospital?s bylaws or policy regarding PA practice. (4) Last, in EDs, PAs work as members of physician-directed teams and derive their scope of practice from physician?s delegation. Supervising physicians determine PA utilization through their decisions on delegation and supervision.
Question 9 What are the practice models for PA use in the ED?
Answer 9 PAs are utilized in all areas of the ED and in all settings, from being the solo provider in a rural ED to providing patient care at a Level I Trauma Center. In each situation as part of the physician/PA team. When staffing the ED, a PA typically sees the same patient acuity mix as the physicians they work as a part of a physician-PA team
Question 10 Are PAs cost effective in the ED?
Answer 10 Utilizing PAs in the ED has proven to be both cost effective and efficient. PAs provide similar, and in most cases identical, medical services that are being provided by their supervising physician, but at a much lower cost. By adding a PA program to the ED, more patients can be seen faster, reducing patients waiting times and improving patient satisfaction. PAs can be utilized to see lower acuity patients and those patients most likely to be discharged home from the ED, giving the physician more time to care for critical patients.
Question 11 How can I recruit a PA? Should I recruit a new graduate or an experienced PA?
Answer 11 An emergency department should consider its needs when recruiting physician assistants. Providing rotations for PA students in an ED is an excellent way to recruit new graduates; the physicians have a chance to work with the PA student before making a hiring decision. Any organization hiring a new graduate should be mindful that newly trained PAs require more mentoring and closer supervision than experienced PAs. A seasoned PA with emergency medicine experience will be more likely to hit the ground running, may work at a more rapid pace than a new graduate and be able to handle a higher volume of patients, but an experienced PA will command a higher salary and possibly a richer benefits package.
When looking for ED candidates, employers might wish to consider individuals with previous ED experience, either as a PA or in a previous career as a technician, paramedic, or nurse, for example. Very often, PAs who are drawn to emergency medicine have worked in emergency medicine in some capacity
before they became PAs.
The PA Role
As members of health care teams headed by physicians, PAs provide medical and surgical services that would otherwise be provided by physicians. Each PA's responsibilities depend on the type of practice, his or her experience, the working relationship with the supervising physician, the physician's or institution's decisions about what can be delegated, and state law. Though by law PAs are dependent practitioners, typically they exercise a considerable level of autonomy in clinical decision making. The relationship between the physician and PA is one of mutual trust and reliance. The physician trusts the PA to provide physician-quality care to patients seen by the team and to consult with the physician on those cases that are outside of the PA's scope of practice. The PA trusts the physician to be available for supervision, to provide learned advice, and to accept the care of patients with serious or complex problems.
The Society of Emergency Medicine Physician Assistants (SEMPA) offers guidelines on the role of PAs in emergency departments.4 According to SEMPA's guidelines, PA practice commonly includes, but is not limited to, taking patient histories and performing physical examinations; recording or dictating the information; ordering, performing, or assisting in the performance of laboratory and patient screening procedures; initiating basic and advanced life support; and initiating IV therapy by peripheral, central, intraosseous routes, and venous cutdowns.
The guidelines note that PAs commonly perform injections; arterial puncture; venipuncture; arterial line insertion; thoracentesis; lumbar puncture; wound care, including debridement; suturing; incision and drainage of abscesses; reduction of closed dislocations and fractures; application of casts and splints; nasogastric intubation; removal of foreign bodies (including sutures); EKG; urethral catheterization; arthrocentesis; endotracheal intubation; local, digital, and IV regional nerve blocks; administration of medicines; referring patients to appropriate follow-up care or community resources; and other interventions and procedures as directed by the supervising physician.
In 1999 the American College of Emergency Physicians surveyed PAs to identify their work environment, their postgraduate needs, and the procedures PAs perform. George Molzen, M.D., ACEP board liaison to the task force conducting the survey, concluded that the PAs are in emergency departments "side by side with the physicians, picking up the next patient." The ACEP report showed that patients usually are randomly assigned to PAs (see Chart 1). A high percentage of PAs performs endotracheal intubation and reduces fractures (see Chart 2).
Hospital Issues
In general, PA practice is not delineated by detailed treatment protocols. Emergency departments may be an exception to the rule, because physicians commonly use protocols and clinical guidelines in emergency practice. When physicians use protocols or clinical guidelines, it is appropriate for PAs use them, too. What is not appropriate is defining PA practice by the use of detailed protocols specifically written for PAs. PA education, like physician education, promotes the development of practical skills in clinical problem solving and decision making. It is more practical and establishes better teamwork and communication when the PA and physician work together under a broad practice agreement that allows the PA to exercise his or her clinical judgment while consulting the supervising physician as appropriate and necessary.
Cost-Effectiveness and Efficency
Utilizing physician assistants in emergency departments has proven to be both cost-effective and efficient. The state of the current health care system is such that many emergency departments are facing severe budget restrictions. Physician assistants can perform many of the tasks traditionally performed by physicians, but at lower cost. In rural areas in particular, PAs often provide access to care that otherwise would not be available.
Further information also is available from the Society of Emergency Medicine Physician Assistants, 950 North Washington Street, Alexandria, Virginia 22314-1552. Phone: 703/519-7334; Fax: 703/684-1924; E-mail: [email protected]. Web site: http://www.sempa.org.
Issue Brief: Physician Assistants and Emergency Medicine
4/02
--------------------------------------------------------------------------------
References
2001 AAPA Physician Assistant Census Report. American Academy of Physician Assistants. Alexandria, Virginia. October 6, 2001.
2001 AAPA Physician Assistant Census Report for Physician Assistants in Emergency Medicine. American Academy of Physician Assistants. Alexandria, Virginia. October 6, 2001.
Simon AF, Link MS, Miko AS. Seventeenth Annual Report on Physician Assistant Educational Programs in the United States, 2000-2001. Association of Physician Assistant Programs. Alexandria, Virginia. August 2001.
SEMPA News. "EMPA Guidelines." Summer 1994;4:6,7. www.sempa.org/sempa_guidelines.htm
Hughes N. "ACEP Survey Provides Statistical Information on Utilization of PAs in Emergency Medicine." AAPA News. November 1999;20(20):1.
--------------------------------------------------------------------------------
The most recent data available from ACEP comes from a 1999 work force study. Of approximately 900 responding hospitals, a third indicated that they utilize physician assistants in their EDs. The results were published in the July 2002 Annals of Emergency Medicine, Vol. 40, No.1. (www.acep.org/1,5327,0.html or www.mosby.com/scripts/om.dll/serve?article=a124754)
Literature Reference
Hooker, R.S. & McCraig, L. (1996). Emergency department uses of physician assistants and nurse practitioners: A national survey. American Journal of Emergency Medicine, Vol. 14, pp. 246-249.
Question 8 What determines how PAs are utilized in the ED?
Answer 8 Four parameters determine how PAs are utilized in the ED: (1) The first is PA education and training. A new graduate may have a somewhat basic scope of practice, which expands as supervised practice and additional training in the clinical setting increases the PA?s experience and skill level. (2) The second determinant of PA utilization is state law. In general, state laws define the PA?s scope of practice as those tasks a PA has been trained to do that are delegated and supervised by the physician. However, some state laws have specific restrictions or requirements. (3) The third determinant of PA utilization is the hospital?s bylaws or policy regarding PA practice. (4) Last, in EDs, PAs work as members of physician-directed teams and derive their scope of practice from physician?s delegation. Supervising physicians determine PA utilization through their decisions on delegation and supervision.
Question 9 What are the practice models for PA use in the ED?
Answer 9 PAs are utilized in all areas of the ED and in all settings, from being the solo provider in a rural ED to providing patient care at a Level I Trauma Center. In each situation as part of the physician/PA team. When staffing the ED, a PA typically sees the same patient acuity mix as the physicians they work as a part of a physician-PA team
Question 10 Are PAs cost effective in the ED?
Answer 10 Utilizing PAs in the ED has proven to be both cost effective and efficient. PAs provide similar, and in most cases identical, medical services that are being provided by their supervising physician, but at a much lower cost. By adding a PA program to the ED, more patients can be seen faster, reducing patients waiting times and improving patient satisfaction. PAs can be utilized to see lower acuity patients and those patients most likely to be discharged home from the ED, giving the physician more time to care for critical patients.
Question 11 How can I recruit a PA? Should I recruit a new graduate or an experienced PA?
Answer 11 An emergency department should consider its needs when recruiting physician assistants. Providing rotations for PA students in an ED is an excellent way to recruit new graduates; the physicians have a chance to work with the PA student before making a hiring decision. Any organization hiring a new graduate should be mindful that newly trained PAs require more mentoring and closer supervision than experienced PAs. A seasoned PA with emergency medicine experience will be more likely to hit the ground running, may work at a more rapid pace than a new graduate and be able to handle a higher volume of patients, but an experienced PA will command a higher salary and possibly a richer benefits package.
When looking for ED candidates, employers might wish to consider individuals with previous ED experience, either as a PA or in a previous career as a technician, paramedic, or nurse, for example. Very often, PAs who are drawn to emergency medicine have worked in emergency medicine in some capacity
before they became PAs.
The PA Role
As members of health care teams headed by physicians, PAs provide medical and surgical services that would otherwise be provided by physicians. Each PA's responsibilities depend on the type of practice, his or her experience, the working relationship with the supervising physician, the physician's or institution's decisions about what can be delegated, and state law. Though by law PAs are dependent practitioners, typically they exercise a considerable level of autonomy in clinical decision making. The relationship between the physician and PA is one of mutual trust and reliance. The physician trusts the PA to provide physician-quality care to patients seen by the team and to consult with the physician on those cases that are outside of the PA's scope of practice. The PA trusts the physician to be available for supervision, to provide learned advice, and to accept the care of patients with serious or complex problems.
The Society of Emergency Medicine Physician Assistants (SEMPA) offers guidelines on the role of PAs in emergency departments.4 According to SEMPA's guidelines, PA practice commonly includes, but is not limited to, taking patient histories and performing physical examinations; recording or dictating the information; ordering, performing, or assisting in the performance of laboratory and patient screening procedures; initiating basic and advanced life support; and initiating IV therapy by peripheral, central, intraosseous routes, and venous cutdowns.
The guidelines note that PAs commonly perform injections; arterial puncture; venipuncture; arterial line insertion; thoracentesis; lumbar puncture; wound care, including debridement; suturing; incision and drainage of abscesses; reduction of closed dislocations and fractures; application of casts and splints; nasogastric intubation; removal of foreign bodies (including sutures); EKG; urethral catheterization; arthrocentesis; endotracheal intubation; local, digital, and IV regional nerve blocks; administration of medicines; referring patients to appropriate follow-up care or community resources; and other interventions and procedures as directed by the supervising physician.
In 1999 the American College of Emergency Physicians surveyed PAs to identify their work environment, their postgraduate needs, and the procedures PAs perform. George Molzen, M.D., ACEP board liaison to the task force conducting the survey, concluded that the PAs are in emergency departments "side by side with the physicians, picking up the next patient." The ACEP report showed that patients usually are randomly assigned to PAs (see Chart 1). A high percentage of PAs performs endotracheal intubation and reduces fractures (see Chart 2).
Hospital Issues
In general, PA practice is not delineated by detailed treatment protocols. Emergency departments may be an exception to the rule, because physicians commonly use protocols and clinical guidelines in emergency practice. When physicians use protocols or clinical guidelines, it is appropriate for PAs use them, too. What is not appropriate is defining PA practice by the use of detailed protocols specifically written for PAs. PA education, like physician education, promotes the development of practical skills in clinical problem solving and decision making. It is more practical and establishes better teamwork and communication when the PA and physician work together under a broad practice agreement that allows the PA to exercise his or her clinical judgment while consulting the supervising physician as appropriate and necessary.
Cost-Effectiveness and Efficency
Utilizing physician assistants in emergency departments has proven to be both cost-effective and efficient. The state of the current health care system is such that many emergency departments are facing severe budget restrictions. Physician assistants can perform many of the tasks traditionally performed by physicians, but at lower cost. In rural areas in particular, PAs often provide access to care that otherwise would not be available.
Further information also is available from the Society of Emergency Medicine Physician Assistants, 950 North Washington Street, Alexandria, Virginia 22314-1552. Phone: 703/519-7334; Fax: 703/684-1924; E-mail: [email protected]. Web site: http://www.sempa.org.
Issue Brief: Physician Assistants and Emergency Medicine
4/02
--------------------------------------------------------------------------------
References
2001 AAPA Physician Assistant Census Report. American Academy of Physician Assistants. Alexandria, Virginia. October 6, 2001.
2001 AAPA Physician Assistant Census Report for Physician Assistants in Emergency Medicine. American Academy of Physician Assistants. Alexandria, Virginia. October 6, 2001.
Simon AF, Link MS, Miko AS. Seventeenth Annual Report on Physician Assistant Educational Programs in the United States, 2000-2001. Association of Physician Assistant Programs. Alexandria, Virginia. August 2001.
SEMPA News. "EMPA Guidelines." Summer 1994;4:6,7. www.sempa.org/sempa_guidelines.htm
Hughes N. "ACEP Survey Provides Statistical Information on Utilization of PAs in Emergency Medicine." AAPA News. November 1999;20(20):1.
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My hospital employs PAs and NPs in the ED fast track area. The ED attending physician co-signs all the scripts they write, and helps them as needed. They are quite competent at handling most of the minor cases that come in, and usually know when they are in over their head.
On a slightly different note, when I was working at another hospital, one of the orthopedic surgeons had a PA that would be the first to respond for consults on certain days. It was no different than a mid-level resident seeing a patient and reporting back to the attending. He knew quite a bit about orthopedics and splinting, and taught me a thing or two.
On a slightly different note, when I was working at another hospital, one of the orthopedic surgeons had a PA that would be the first to respond for consults on certain days. It was no different than a mid-level resident seeing a patient and reporting back to the attending. He knew quite a bit about orthopedics and splinting, and taught me a thing or two.
D
deleted6669
you would probably have the same experience if you worked with some of the better pa's who have extensive experience in em in addition to acls/pals/nals/atls etc.
there are really 2 kinds of pa's out there; those who learned the minimum in school to pass and don't really apply themselves after graduation and those who seek out learning experiences actively and try to learn as much as possible from their physician colleagues. I would ask only that each em physician on this site would evaluate each pa based on their knowledge and abilities and not judge all of us based on the poor performance of a few substandard clinicians.
there are really 2 kinds of pa's out there; those who learned the minimum in school to pass and don't really apply themselves after graduation and those who seek out learning experiences actively and try to learn as much as possible from their physician colleagues. I would ask only that each em physician on this site would evaluate each pa based on their knowledge and abilities and not judge all of us based on the poor performance of a few substandard clinicians.
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Lacs, Lacs, and more Lacs.
The problem we have had is the lack of identification of "Hello I am your Physician Assistant" or "Hello, I am your nurse practitioner"
AEM published an article a few years back that seems to state that if given the choice, patients (may have specifically been residents) would prefer not to be treated by mid levels vs residents and attendings. Makes sense.
AAEM held a position statement in "Common Sense" last month that clearly held that physicians must check EVERY SINGLE patient examined by a PA or NP. Stricter control for liablility and quality assurance.
The problem we have had is the lack of identification of "Hello I am your Physician Assistant" or "Hello, I am your nurse practitioner"
AEM published an article a few years back that seems to state that if given the choice, patients (may have specifically been residents) would prefer not to be treated by mid levels vs residents and attendings. Makes sense.
AAEM held a position statement in "Common Sense" last month that clearly held that physicians must check EVERY SINGLE patient examined by a PA or NP. Stricter control for liablility and quality assurance.
D
deleted6669
I know the survey you were discussing. all of the respondents were em residents.
regarding direct oversight of every pt,
it's never going to happen.....
the e.d. would come to a grinding halt if I had to present every single pt instead of the 5-10% that I currently do. with a new grad it is totally appropriate to present a majority of cases but after the docs are comfortable with an individual pa/np the scope needs to expand or there is no cost effectiveness realized. yesterday I saw 32 pts and prsented 2 of them( 1 icu admit and 1 tele admit).welcome back freeeedom. I hope your internship is going well.
regarding direct oversight of every pt,
it's never going to happen.....
the e.d. would come to a grinding halt if I had to present every single pt instead of the 5-10% that I currently do. with a new grad it is totally appropriate to present a majority of cases but after the docs are comfortable with an individual pa/np the scope needs to expand or there is no cost effectiveness realized. yesterday I saw 32 pts and prsented 2 of them( 1 icu admit and 1 tele admit).welcome back freeeedom. I hope your internship is going well.
I just got done doing another overnight shift with a PA and I have to say the good ones are worth their weight in gold. The bad ones you fire. The PA's I work with see somewhat fewer patients than I do and tend not to see as many of the really sick medical patients. However, most of them sew better than I do and many are better at reducing fractures. They don't do central lines or many intubations but they do LP's. I've done a few overnights without one and it wasn't pretty. If we had slightly more volume it might make sense to have two overnight docs but with our current volume one doc and one PA works pretty well
- Joined
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Emedpa,
Ouch...not an intern.
The AAEM article was very inciteful, I can't quote it as I gave it to another resident. All the PA's present their patients here...and we see 100k a year. It is the safest and best way to maintain quality. Granted, if you have pharyngitis on a non toxic adult, probably don't need to re-do the exam...but we have had a few case presentations with possible bad outcomes (psych vs medical cause of agitation or AMS) when a PA wasn't supervised.
This is NOT a criticism...not in any way. But presentation of patients by PA's will NOT cause the earth to reverse spin on its axis. It is quality assurance and part of accepted practice.
Remember, all PA's are NOT as good and experienced as you are Emed...the majority that I see now are 20-22 years old with little experience prior to PA school. The influx and new programs have thinned out all the typical/good candidates. I am sure you have seen them too.
We MUST act as if all PA's are new and inexperienced, even if they are not, and supervise...keeps you from being burned...which will happen.
Likely a 1 year internship in the field of their choice would alleviate concerns and increase quality.
Ouch...not an intern.
The AAEM article was very inciteful, I can't quote it as I gave it to another resident. All the PA's present their patients here...and we see 100k a year. It is the safest and best way to maintain quality. Granted, if you have pharyngitis on a non toxic adult, probably don't need to re-do the exam...but we have had a few case presentations with possible bad outcomes (psych vs medical cause of agitation or AMS) when a PA wasn't supervised.
This is NOT a criticism...not in any way. But presentation of patients by PA's will NOT cause the earth to reverse spin on its axis. It is quality assurance and part of accepted practice.
Remember, all PA's are NOT as good and experienced as you are Emed...the majority that I see now are 20-22 years old with little experience prior to PA school. The influx and new programs have thinned out all the typical/good candidates. I am sure you have seen them too.
We MUST act as if all PA's are new and inexperienced, even if they are not, and supervise...keeps you from being burned...which will happen.
Likely a 1 year internship in the field of their choice would alleviate concerns and increase quality.
D
deleted6669
freedom....sorry, thought you were an r1. are you an r2 or an r3 now?
I agree that many of the new pa's coming out have very little prior experience and em skills. frankly, some of these folks are scary. I am fortunate to work with a group of pa's who all have > 10 yrs em experience, acls/pals/atls.the vast majority of us were civilian or military medics in prior careers. the docs are all boarded em with > 75% residency trained in em. they are always available for consults, so it works out ok here( 100 k volume trauma ctr). typical schedule is 3 docs and 3 pa's at a time. they handle 80% of what comes in by ambulance and the obvious cardiac cases and we do everything else. the pa's still pick up quite a few sick folks from the walk in traffic and the low acuity ems traffic. I had a pt c/o fatigue this week with a sodium of 106( checked twice because I thought it had to be lab error because they looked so good. they are still in the unit.I had another pt on a backboard triaged as" neck/shoulder injury from minor mva, needs c-spine clearance" who had a major liver lac and refered pain to the shoulder. I agree that post graduate training for pa's is a good thing and will probably become a greater trend at some point. about a quarter of our em pa group(myself included) did a 1-2 year post grad residency or fellowship in em.
happy new year-e
I agree that many of the new pa's coming out have very little prior experience and em skills. frankly, some of these folks are scary. I am fortunate to work with a group of pa's who all have > 10 yrs em experience, acls/pals/atls.the vast majority of us were civilian or military medics in prior careers. the docs are all boarded em with > 75% residency trained in em. they are always available for consults, so it works out ok here( 100 k volume trauma ctr). typical schedule is 3 docs and 3 pa's at a time. they handle 80% of what comes in by ambulance and the obvious cardiac cases and we do everything else. the pa's still pick up quite a few sick folks from the walk in traffic and the low acuity ems traffic. I had a pt c/o fatigue this week with a sodium of 106( checked twice because I thought it had to be lab error because they looked so good. they are still in the unit.I had another pt on a backboard triaged as" neck/shoulder injury from minor mva, needs c-spine clearance" who had a major liver lac and refered pain to the shoulder. I agree that post graduate training for pa's is a good thing and will probably become a greater trend at some point. about a quarter of our em pa group(myself included) did a 1-2 year post grad residency or fellowship in em.
happy new year-e
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I do not deny there are good PAs. Of course someone who has been practing for ten years will have picked up a lot. I do not deny that I will still be learning a lot when I finish residency, but that doesn't change the fact that medicine is taught through medical school and residency.
Now I hear people talking about post-graduate training for PAs. Why not convert all med schools to 2 years? Perhaps there is some benefit to those extra two years for someone who will be practicing medicine independently. If there isn't, abolish them for all of us, not just the PAs. Maybe the model we should be following is the PA model, but if it isn't, we can't be having PAs practicing medicine independently. If the doc doesn't see the patient, it's practicing independently.
Now I hear people talking about post-graduate training for PAs. Why not convert all med schools to 2 years? Perhaps there is some benefit to those extra two years for someone who will be practicing medicine independently. If there isn't, abolish them for all of us, not just the PAs. Maybe the model we should be following is the PA model, but if it isn't, we can't be having PAs practicing medicine independently. If the doc doesn't see the patient, it's practicing independently.
So, let me ask all the med students and residents who feel threatened by PA's a question. Does your attending see and examine every patient of yours before you discharge them? I know they are supposed to but do they really see every single one? From what I've seen at multiple academic centers the answer is no. Some of the PA's I work with know more than a second or third year resident. Some know more than some new grads I've met. Asking me to double check their work on simple lacs, sprained ankles, runny noses, etc... is a waste of time. The key on their part (like for residents) is knowing when to ask for help. The key on my part is knowing who to trust and which diagnoses and chief complaints are red flags (that applies whether I am supervising residents or PA's)
If you feel threatened by PA's ask yourself why. I don't feel threatened because I know my depth and breadth of knowledge is greater than most of theirs and that there will always be a role for me in managing the sickest or more difficult patients. If I was less confident in my own education, training, and knowlegde I might feel more threatened
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I think the point of Freeeedom and emed is that PA training for EM should be of a HIGHER standard than those currently used in many institutions. As a resident, I can hardly imagine anything LESS than the current system of medical and residency education being adequate for patient care. I had graduate training prior to medical school, and I still learn each and every residency EM conference. Standards must ALWAYS remain high and increase. We have no choice but to maintain high standards for medico-legal reasons. PREVENTING BAD outcomes dictate practice...good outcomes do not dictate practice.
The discussion deals more with quality assurance and what the legal risk of signing your name and assuming responsibility for a patient WITHOUT thorough evaluation.
Do our attendings see every ankle sprain...yep every runny nose, nope. The point being, is that EVERY SINGLE patient is presented by residents and PA's as well. And while the PA's see lesser acuity patients, one must not trust the triage nurse to assign patients appropriately.
This is really a question of staffing. If there is too much independence given and the question is an ED "grinding to a halt" , then the real question is "are there more attendings needed to maintain appropriate standards of care in patient to physician ratios"...the answer is yes, more attendings are needed.
The discussion deals more with quality assurance and what the legal risk of signing your name and assuming responsibility for a patient WITHOUT thorough evaluation.
Do our attendings see every ankle sprain...yep every runny nose, nope. The point being, is that EVERY SINGLE patient is presented by residents and PA's as well. And while the PA's see lesser acuity patients, one must not trust the triage nurse to assign patients appropriately.
This is really a question of staffing. If there is too much independence given and the question is an ED "grinding to a halt" , then the real question is "are there more attendings needed to maintain appropriate standards of care in patient to physician ratios"...the answer is yes, more attendings are needed.
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There is a certain amount of "feeling threatened," best exemplified by the AAEM statement that EM is best practiced by EM residency trained and boards physicians. Its why they are against moonlighting too. If "anyone" can practice EM, why bother getting EM training? That applies to PAs, FPs, psychiatrists etc.
I'm not saying the attending needs to take a full history and do a full physical on each patient a PA sees. I am saying that just like with an EM resident, the attending should hear about each and every patient seen BEFORE the patient leaves the ED. That gives the attending the option of repeating history/physical points that he/she feels are pertinent. Not saying the doc has to repeat the work, just that the PA should be supervised on every patient. Obviously, just like with a resident, the longer the PA has been practicing and the better the PA is, the less often the supervising doc will go in and repeat things, and the later in the ED course that the doc can hear about the patient. That's the supervised practice of medicine, and PAs shouldn't be doing anything more. Just signing the charts 3 days after the patients are seen does not constitute "supervising." IMHO a PA should never be practicing at a level beyond what a senior EM resident practices at.
I'm not saying the attending needs to take a full history and do a full physical on each patient a PA sees. I am saying that just like with an EM resident, the attending should hear about each and every patient seen BEFORE the patient leaves the ED. That gives the attending the option of repeating history/physical points that he/she feels are pertinent. Not saying the doc has to repeat the work, just that the PA should be supervised on every patient. Obviously, just like with a resident, the longer the PA has been practicing and the better the PA is, the less often the supervising doc will go in and repeat things, and the later in the ED course that the doc can hear about the patient. That's the supervised practice of medicine, and PAs shouldn't be doing anything more. Just signing the charts 3 days after the patients are seen does not constitute "supervising." IMHO a PA should never be practicing at a level beyond what a senior EM resident practices at.
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I agree with Desperado on this, and depending on the institution, I would argue that their scope of practice should not be beyond an EM R2. I feel the training of an R3 should also include learning to run the department as a future attending.
Desperado made a great point about the "supervising" which takes place days after the patient has been discharged. I am always amazed at the extra history or physical exam that can be obtained when the attending sees a patient compared to a resident.
The arguement here somewhat confuses me. Are PAs stating that they are just as capable of working in the ED as a residency trained EP? If so, as previously stated, why am I training for 7 years (possibly 8 depending on the residency)? I am going to stick to the AAEM stance that EM is best practiced by residency trained EPs.
Also, I do not feel threatened by PAs. I agree with what ERMudPhud said, I know my knowledge base is greater. I also do not scoff at experience, but that does not change whose name is responsible for each patient - the attending, not the PA. If there are PAs seeing patients without supervision, that is a risk that EP is taking. I would just hope that the patients are fully aware they are being seen by a PA and not a doctor. I mention this because I have seen several "misrepresentations" by PAs to their patients, not really explaining their role and allowing the patient to call them "doc".
Desperado made a great point about the "supervising" which takes place days after the patient has been discharged. I am always amazed at the extra history or physical exam that can be obtained when the attending sees a patient compared to a resident.
The arguement here somewhat confuses me. Are PAs stating that they are just as capable of working in the ED as a residency trained EP? If so, as previously stated, why am I training for 7 years (possibly 8 depending on the residency)? I am going to stick to the AAEM stance that EM is best practiced by residency trained EPs.
Also, I do not feel threatened by PAs. I agree with what ERMudPhud said, I know my knowledge base is greater. I also do not scoff at experience, but that does not change whose name is responsible for each patient - the attending, not the PA. If there are PAs seeing patients without supervision, that is a risk that EP is taking. I would just hope that the patients are fully aware they are being seen by a PA and not a doctor. I mention this because I have seen several "misrepresentations" by PAs to their patients, not really explaining their role and allowing the patient to call them "doc".
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As we slowly beat this topic into the ground...the underlying sentiment is that a PA requires supervision, PA's are not created equal and there is little quality control in place assuring EM PA #1 is trained equally as EM PA #2. For quality assurance, one MUST supervise. The role of residents is to gradually increase independence while seeing higher and higher patient acuity. This is NOT the role of a PA or NP. Physician extenders are defined as such, constantly under the supervision of the attending physician. If this is not possible, the appropriate action is NOT to allow increasing independence, rather change staffing to allow appropriate supervision. This view is similar to AAEM, ACEP and EMRA views.
I guess I misunderstood some of the previous posts that an attending must SEE every patient. For all patients my PA's do exactly what many of you as residents do. They see the patient, show me the chart and discuss the case, then its up to me if I want to physically see the patient. I don't sign charts three days later. (Actually, I do sign their dictation about a week later but I sign the chart when the patient is presented to me) I know who I can trust and I know what CC's are worrisome. I see almost all peds, all admissions, most chest pain, most abdominal pain. I sign off on all xrays. I don't see every lac, runny nose, sorethroat, etc... All of our PA's had prior clinical experience and do a 6 month probabtionary period in the ER prior to independent [semi-independent
] work. Its really no different from what I did when I superivised students, interns, and residents in an academic ER. Graduated independence based on experience and track record. Hopefully you all will have some similar experience as senior residents running and supervising the entire ER. We don't need a second attending as I easily see twice as many patients as the PA while generally seeing sicker patients.
If our ER's were truly only for emergencies than I could understand an attending seeing every patient. However, we are really the last safety net in a primary care system that is pretty near totaled. It's not all that different from what the PA's working in underserved areas are doing.
] work. Its really no different from what I did when I superivised students, interns, and residents in an academic ER. Graduated independence based on experience and track record. Hopefully you all will have some similar experience as senior residents running and supervising the entire ER. We don't need a second attending as I easily see twice as many patients as the PA while generally seeing sicker patients.If our ER's were truly only for emergencies than I could understand an attending seeing every patient. However, we are really the last safety net in a primary care system that is pretty near totaled. It's not all that different from what the PA's working in underserved areas are doing.
