midlevels in community EDs

[Bostonredsox]

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how many of you guys have this?

My wifes cousin is in PA school, smart kid, spent a month shadowing me in residency and said F that to a residents life and decided to go PA, good decision knowing him. He is looking at different career options. Was an EMT/paramedic, really liked first responder stuff and then being in the ED. Hes not a huge fan of surgery where most of the PAs in my area tend to work. He asked about my field, told him I have not seen many midlevels in the hospitalist fields. sometimes I have seen NPs covering night ED admissions, but rare to see them rouding as attending during the day. We have only 1-2 PAs in our ed, dont really have a fastrack unit.

So in the various places you guys work, are PAs frequently utilized? Is it a good market for them in the EM field?

 

[deleted480308]

I've only spent time in a lvl trauma ED, their they had NP's staffing a "fast track" section for very minor complaints and the docs ran across the hall once an hour to double check all the treatment plans before they happened. Neither NP nor PA was ever treated like an attending...some states may vary

 

[Bostonredsox]

I am totally cool with this. I detest NPs and CRNAs and this idea they should be able to function independent of us. Thats why I endorsed his decision to be a PA, which is still supervised to a degree by us. But I think fastrack units in eds especially in flu season are great places for PAs. probably helps you guys alot to focus on the more sicker pts. we dont really have that in hospitalist medicine. everyone just gets a list pf pts. very little midlevel work that I have seen. All I have seen them in atleast with a respectable income is surgery or the ED, but most frequently assisting in ortho procedures and such while doing the preop historys. Im not sure how much he would care about running fast track units and being supervised/discussing any major intervention with his attending. he just wants to take care of people and from my experience has no problem taking orders/being taught things.

Just wondering if the ED is a good field for them in general.

 

[Hercules]

There are tons of mid levels being used in emergency departments in the community. My group has 30 hours of physician coverage and 18 hours of mid-level coverage every day. I can also tell you that hospitalists are using mid-level a lot as well. There are more mid levels than physicians in the hospitalist group at my hospital.

 

[Apollyon]

In the real world (non-academic, community, non-leveled ED), I work with mid levels - the PA is more helpful, because the NP is an adult NP only - can't see any pts under age 18. However, when it is busy, they can pick up the next chart. I try to steer the lower acuity to them, but sometimes you gotta do what you gotta do. At my last job, there was a DNP that was as good as any doc with which I've ever worked - he was thorough, knew what he didn't know, and was NOT a cowboy. And he did not introduce himself as "doctor".

And, in an academic place I know in upstate NY, and at one of my jobs in Hawai'i, rural, the PAs just picked up the next undifferentiated chart, and it rolled like that.

 

[styphon]

I have been in a few ER's in upstate NY - during the days the NPs/PA's staff the fast track and the "chest pain center" - at night the fast track closes and they start doing level 3/4s (I did not see them pick any level 1/2 charts). In one of our rural hospitals the day is a 1 MD+1 PA and at night 1 MD only.

 

[Makati2008]

how many of you guys have this?

My wifes cousin is in PA school, smart kid, spent a month shadowing me in residency and said F that to a residents life and decided to go PA, good decision knowing him. He is looking at different career options. Was an EMT/paramedic, really liked first responder stuff and then being in the ED. Hes not a huge fan of surgery where most of the PAs in my area tend to work. He asked about my field, told him I have not seen many midlevels in the hospitalist fields. sometimes I have seen NPs covering night ED admissions, but rare to see them rouding as attending during the day. We have only 1-2 PAs in our ed, dont really have a fastrack unit.

So in the various places you guys work, are PAs frequently utilized? Is it a good market for them in the EM field?

As a former PA, the market is VERY good in EM. With his background he will do well I assume. Also he does know PAs get treated like residents our entire career right? Even in rural EM there have been times to call for a Physician because they only want to speak to a doc not a midlevel.

 

[SoCuteMD]

how many of you guys have this?

My wifes cousin is in PA school, smart kid, spent a month shadowing me in residency and said F that to a residents life and decided to go PA, good decision knowing him. He is looking at different career options. Was an EMT/paramedic, really liked first responder stuff and then being in the ED. Hes not a huge fan of surgery where most of the PAs in my area tend to work. He asked about my field, told him I have not seen many midlevels in the hospitalist fields. sometimes I have seen NPs covering night ED admissions, but rare to see them rouding as attending during the day. We have only 1-2 PAs in our ed, dont really have a fastrack unit.

So in the various places you guys work, are PAs frequently utilized? Is it a good market for them in the EM field?

The hospitalist service where I am employs a lot of midlevels.

 

[namethatsmell]

One of our shops has PAs in the fast track with a doc there to staff.

There are also multiple inpatient teams in the hospital where patients go when they are medically stable but have social/insurance dispo issues and midlevels pretty much exclusively staff them. While it's probably not the most interesting work it seems like a super cush gig.

 

[fahimaz7]

We have PA's seeing level 3-5 patients in our fast track unit. They don't see the sick side of the ED and they don't do any of the trauma/resuscitation work. Overall though, they seem happy and do get to see some quite medically sick patients.

 

[primadonna22274]

Another PA here and almost-DO 🙂
I have worked in 3 community EDs as a PA, two of them Level 3 centers. I've had fairly broad experiences from one dept that mandated each patient be presented to the attending and "blessed" before discharge--some of them even more constricting, requiring staffing before the PA ordered any tests or treatments. I was six years into my career at this point. It got old and I moved on--but I did learn a LOT about EM! Another had almost too much autonomy and lackadaisical attendings who could barely be bothered to back me up when I needed their help. (Ironically I still work that job part-time...2 more shifts remaining of my PA career before med school graduation). Another was just meh.
The future is VERY bright for your cousin as an EM PA. Tell him to join SEMPA, be willing to work his way up from lower acuity parts of the ED to the main side, and he might do well to consider an EM residency for PAs.

 

[alpinism]

Basically what everyone else has said. At the 2 community hospitals I've worked at the PAs ran the fast track section (low acuity pts) with MD oversight during the day then helped with whatever came in at night. If we got slammed they'd also grab some higher acuity pts from time to time.

Besides EM I've seen many working in subspecialty clinics (neuro/ENT/ortho/plastics/derm) or just doing outpatient primary care.

 

[@JackShephard]

I am totally cool with this. I detest NPs and CRNAs and this idea they should be able to function independent of us. Thats why I endorsed his decision to be a PA, which is still supervised to a degree by us. But I think fastrack units in eds especially in flu season are great places for PAs. probably helps you guys alot to focus on the more sicker pts. we dont really have that in hospitalist medicine. everyone just gets a list pf pts. very little midlevel work that I have seen. All I have seen them in atleast with a respectable income is surgery or the ED, but most frequently assisting in ortho procedures and such while doing the preop historys. Im not sure how much he would care about running fast track units and being supervised/discussing any major intervention with his attending. he just wants to take care of people and from my experience has no problem taking orders/being taught things.

Just wondering if the ED is a good field for them in general.

If I were advising someone to get into medicine as a midlevel, I would advise them to get an NP.

For the same reason you like PAs. NPs are governed by someone else. They will progress much faster because their leadership wants to push for equal practice rights in many areas. They will be given more $ and responsibility because they have independent leadership.

 

[Makati2008]

If I were advising someone to get into medicine as a midlevel, I would advise them to get an NP.

For the same reason you like PAs. NPs are governed by someone else. They will progress much faster because their leadership wants to push for equal practice rights in many areas. They will be given more $ and responsibility because they have independent leadership.

So I am confused you want to risk patients safety by having someone go through a NP program where I can say they are sorely lacking.

Also you want these providers to gain independent practice without a residency to back it up(if I interpreted your equal practice rights comment correctly.)

Call me selfish but I would hope most doctors would want to slow this proliferation of NP SOP not only for themselves but future docs?

 

[Boatswain2PA]

Similar to specialists seeing patients in the hospital, some "hospitalist" PAs will round and write the note, allowing the physician to rapidly see the patients and bill.

As to PAs in the ED. Seems like many of the bigger EDs have PAs do mostly fast-track. The smaller the ED, it seems the more the PA can do. Some have one Doc and one PA, while some of the smaller, especially rural ones, may only have a PA with a doc available by phone.

 

[deleted480308]

So I am confused you want to risk patients safety by having someone go through a NP program where I can say they are sorely lacking.

Also you want these providers to gain independent practice without a residency to back it up(if I interpreted your equal practice rights comment correctly.)

Call me selfish but I would hope most doctors would want to slow this proliferation of NP SOP not only for themselves but future docs?

I don't think jack shepherd was advocating for NP autonomy as much as predicting it


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[@JackShephard]

I don't think jack shepherd was advocating for NP autonomy as much as predicting it


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Exactly.

Why would any physician/medical student push for NP independent practice rights?

I'm just looking at the political climate, lack of healthcare resources, booming demand (especially elderly), lobbying power of nurses, alongside the general idea that physicians are paid a lot (forgetting that we spent a decade honing skills, foregoing income and borrowing 200k).

But the fact remains, if a friend of my wanting to be a midlevel asked me what to do, in their best interest I would tell them to become a NP. 40 hrs a week, increasing pay and independent rights in basic areas of medicine - much better than going into primary care as a MD considering all things. Anything more specialized? Then I recommend becoming a physician.

 

[@JackShephard]

So I am confused you want to risk patients safety by having someone go through a NP program where I can say they are sorely lacking.

Also you want these providers to gain independent practice without a residency to back it up(if I interpreted your equal practice rights comment correctly.)

Call me selfish but I would hope most doctors would want to slow this proliferation of NP SOP not only for themselves but future docs?

Doctors can't slow the proliferation of NPs. Only the government can.

If you can convince the government that higher quality is better than saving $, then go ahead. It's an interesting dilemma, but we already know how this plays out. Wherever the medicine is easy enough, they will give the NPs more $ and responsibility. When people start dying, then they will slow down. Unfortunately, in a lot of areas in medicine, mistakes can be made and they aren't seriously damaging and therefore unaccounted for.

 

[Makati2008]

Doctors can't slow the proliferation of NPs. Only the government can.

If you can convince the government that higher quality is better than saving $, then go ahead. It's an interesting dilemma, but we already know how this plays out. Wherever the medicine is easy enough, they will give the NPs more $ and responsibility. When people start dying, then they will slow down. Unfortunately, in a lot of areas in medicine, mistakes can be made and they aren't seriously damaging and therefore unaccounted for.

To your previous post, I do know of a few doctors that actually think that NP independence is fine( I will admit they are biased because they are usually a spouse or family member of the NP) but otherwise very valid point.

To this post you are correct about the government is only concerned about $ not quality which is disheartening but it's the world we live in.

I agree about the deaths probably also being the limiting factor but even then a lot of those deaths/ critical errors are swept under the rug.....

Also if Physicians were to stand up for this to stop I honestly think the public would label us as being "the greedy doctors" even more. It'll be interesting to see how this all plays out.

 

[RustedFox]

Exactly.

Why would any physician/medical student push for NP independent practice rights?

I'm just looking at the political climate, lack of healthcare resources, booming demand (especially elderly), lobbying power of nurses, alongside the general idea that physicians are paid a lot (forgetting that we spent a decade honing skills, foregoing income and borrowing 200k).

But the fact remains, if a friend of my wanting to be a midlevel asked me what to do, in their best interest I would tell them to become a NP. 40 hrs a week, increasing pay and independent rights in basic areas of medicine - much better than going into primary care as a MD considering all things. Anything more specialized? Then I recommend becoming a physician.

Funny that you should mention the elderly. I work where my average patient is a 73 year old female retiree, and "my average patient" takes every opportunity to decry the care that they get because "I never see my doctor; just the NP who never listens to me and has no idea what to do."

 

[deleted480308]

Funny that you should mention the elderly. I work where my average patient is a 73 year old female retiree, and "my average patient" takes every opportunity to decry the care that they get because "I never see my doctor; just the NP who never listens to me and has no idea what to do."

at my primary care doc's office, I pretty much always end up seeing one of the NP's he has working for him. I'm cool with that, but I'm a healthy guy in my early 30's. If I was a less healthy 70yr old with multiple complicated issues, I wouldn't put up with less than the doctor.

 

[diphenyl]

Our PA's for the most part essentially work fast track (URI's, suturing, etc). This is in California. We do however make some exceptions. A few Pa's in the group are very experienced and competent. These few are allowed to pick up a little more complex patients when the fast track volume is low. One of the PA's splits his time between the ED and cardiology. I have seen him pick up some CP pt's but only because he knows more cardiology than the majority of the ED docs. They still will run treatment/ assessment by the attending though.

 

[Old_Mil]

We work alongside our PA providers and they pick up charts just like we do. If we didn't, there is no way we could hit our marketing and customer service targets.

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[Bostonredsox]

If I were advising someone to get into medicine as a midlevel, I would advise them to get an NP.

For the same reason you like PAs. NPs are governed by someone else. They will progress much faster because their leadership wants to push for equal practice rights in many areas. They will be given more $ and responsibility because they have independent leadership.

You realize that would mean advising someone who has a bachelors to go back and do 2 years of RN school, them two more to get a BS in nursing, hen two more to get Np right?....vs just a flat two to get his PA. Maybe starting from high school that make sense, but not after 4 years of college.

And thanks to all who responded that gave me a lot of info to forward to him. I think he would be good in the ED.

 

[@JackShephard]

You realize that would mean advising someone who has a bachelors to go back and do 2 years of RN school, them two more to get a BS in nursing, hen two more to get Np right?....vs just a flat two to get his PA. Maybe starting from high school that make sense, but not after 4 years of college.

And thanks to all who responded that gave me a lot of info to forward to him. I think he would be good in the ED.

I meant a freshman in college. And I was just talking about political climate and future opportunities more than the rigors or length of education.

 

[Old_Mil]

If he is a freshman in college it isn't too late for him to change his major, steer clear of health care and go do.something like petroleum engineering.

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[diphenyl]

You realize that would mean advising someone who has a bachelors to go back and do 2 years of RN school, them two more to get a BS in nursing, hen two more to get Np right?....vs just a flat two to get his PA. Maybe starting from high school that make sense, but not after 4 years of college.

And thanks to all who responded that gave me a lot of info to forward to him. I think he would be good in the ED.

Actually there are quite a few 1 year BSN programs for people who already have bachelors degrees. Nursing school is compressed into a 1 year full time program. Graduates come out with their RN and BSN.
I do agree with you though. If all the pre-req's are done in undergrad, take your bachelors and go to a maters level PA program.

 

[Corpsman]

You realize that would mean advising someone who has a bachelors to go back and do 2 years of RN school, them two more to get a BS in nursing, hen two more to get Np right?....vs just a flat two to get his PA. Maybe starting from high school that make sense, but not after 4 years of college.


There are also a large number of direct entry MSN programs that as long as he has a BS in any field and the prereqs done he can enter; with the trade off being a narrower focus/education than a PA at 1/3 the credit hours and 1/4 the clinical hours of any PA program.

 

[Bostonredsox]

If he is a freshman in college it isn't too late for him to change his major, steer clear of health care and go do.something like petroleum engineering.

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He graduated in dec, starts pay school at my med school alma mater, we have a pa school too, in august. I was a bit off though. He's in town for the weekend, apparently though he loves ems stuff, has not enjoyed his Ed time. He's leaning neurosurgery pa. Thanks for info though I showed him this thread and he was encouraged.

 

[NamasteBliss]

We have PA's and NP's that work in our community based EDs--mostly fast track and suturing.