PAs in EM

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What are your thoughts on the role PAs play in an ED? When it comes to seeing patients, which ones do they participate more in? Lets say, Traumatic patients? Are PAs pretty involved in critical cases or are they given all the non-life threatening pts?

Thanks
 
It varies. Many shops use PAs to run fast-track, some use them to see a general mix of patients. I have not seen a job were PAs saw critical patients (unless they were mistriaged) but there may be a place where a specific PA does see their share of "sick" patients. In general the philosophy in most EDs is to use the PA to deal with lower acuity patients so that the EP can deliver effective care to the critical patient.
 
Calling EMEDPA....Calling EMEDPA...
 
yeah from what i have seen PA's take the lower acuity, and EP get higher acuity. I'm sure they can help in traumas if there isn't a lot else going on but that will depend on where you work and volume. Mostly I see PA's doing stuff that could be done at an urgent care center if that gives a better idea of their scope in EM.
 
really depends on the setting. I work a couple jobs:

rural facility: alternate pts with md. if everyone is sick I see my share of the critical traumas and icu pts. if there are very few sick folks the doc sees those and I see lower acuity.

small inner city dept: I work solo coverage nights in an 11 bed dept and see everyone that comes in the door. I run the codes, intubate, cardiovert, etc
I treat and street those that I can and stabilize and transfer those that need more resources.
this facility is staffed 24/7 by pa's with a doc on day shift only.

trauma ctr:
day shift: mostly fast track and intermediate complexity pts.
night shift: similar to rural facility above

10 years from now I would like to be doing solo rural emergency medicine full time. lots of those jobs out there for folks with experience. it's just a matter of convincing the wife to leave the big city....
 
With a relatively small sample size (maybe 10 hospitals) I've never seen a PA doing anything other than fast-track or its equivalent.

That said I sure as heck have seen PAs doing critical care on other services so I don't see anything inherently wrong with their working on sick ED patients.

I think the trickiest questions would be those of liability e.g. it's one thing for a PA to be working under you sewing up lacs and ordering ankle films, quite another when they are doing critical care.
 
Do people think that PAs working solo coverage is going to continue as there are more and more EM graduates? Considering that the trend seems to be pushing out MDs who were trained in FM or IM, that would be expected to affect PAs too. I understand that there are rural places that have trouble holding an MD, but I think it would be a mistake for someone to go into PA school expecting that they are going to be working running their own ED somewhere by themselves. It sounds like those situations exist but it's like going to EM residency planning on being the Everest base camp doc, not that many spots.
 
jbar said:
Do people think that PAs working solo coverage is going to continue as there are more and more EM graduates? Considering that the trend seems to be pushing out MDs who were trained in FM or IM, that would be expected to affect PAs too. I understand that there are rural places that have trouble holding an MD, but I think it would be a mistake for someone to go into PA school expecting that they are going to be working running their own ED somewhere by themselves. It sounds like those situations exist but it's like going to EM residency planning on being the Everest base camp doc, not that many spots.
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actually at this point there are still lots of spots in almost any rural state where a pa can find an opportunity to do solo coverage. states with the most are probably vt and maine, the 2 places I would most like to live for a variety od reasons.
 
I understand that right now there are still rural places, but I think someone going into the field as a PA should think about

1: What will the situation be in 10 years

and 2: key word being rural, ie is it reasonable to expect to be in a solo coverage situation in an city?

Yes there are PAs who right now are in such a situation, but it may not be a great idea to base your career plans as a PA student around such a situation which seem to be the exception rather than the rule.

As an aside I wonder about liability issues for hospitals that set up this sort of single coverage with just a PA. How do they decide who has had enough experience? To graduate from EM residency my understanding is that residents have to do so many chest tubes, so many LPs etc. Are there rules about what procedures a PA must have mastered to be able to be solo practice? Is it up to the state or just the hospital?
 
agree with above post. someone going into the profession now can't plan on anything except a job when they get out.
most of us working solo were former medics, er rn's, or rt's who have taken additional critical care, trauma, difficult airway, burn management, and peds em coursework. I have 2 postgrad educational credentials in em(one is from a post pa school masters fellowship in em and 1 a postmasters certificate in adv. clinical studies in family and em that took an additional yr so all told I have almost a decade of post high school education to do my current job).
we do need to get credentialed for individual adv. procedures by the hospital before working alone. at my current solo gig we all had to work with one of the docs for a few yrs on day shift before working alone. all of our charts are reviewed by the day doc within 24 hrs.
many of the pa's going into critical care today are doing a postgrad residency. these are becoming more common and I wouldn't be at all surprised if they were required for practice in any specialty field 10 yrs from now.
see this link for pa residencies:
http://www.appap.org/prog_specialty.html

in these residencies pa's typically train alongside md residents with the same requirements and responsibilities(call, procedure logs, rounding, conferences, off service rotations, etc).
 
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I think for any PA position, both pay and responsibility are commensurate with experience.
 
emedpa said:
agree with above post. someone going into the profession now can't plan on anything except a job when they get out.
most of us working solo were former medics, er rn's, or rt's who have taken additional critical care, trauma, difficult airway, burn management, and peds em coursework. I have 2 postgrad educational credentials in em(one is from a post pa school masters fellowship in em and 1 a postmasters certificate in adv. clinical studies in family and em that took an additional yr so all told I have almost a decade of post high school education to do my current job).
we do need to get credentialed for individual adv. procedures by the hospital before working alone. at my current solo gig we all had to work with one of the docs for a few yrs on day shift before working alone. all of our charts are reviewed by the day doc within 24 hrs.
many of the pa's going into critical care today are doing a postgrad residency. these are becoming more common and I wouldn't be at all surprised if they were required for practice in any specialty field 10 yrs from now.
see this link for pa residencies:
http://www.appap.org/prog_specialty.html

in these residencies pa's typically train alongside md residents with the same requirements and responsibilities(call, procedure logs, rounding, conferences, off service rotations, etc).
Click to expand...

didn't know they had PA residencies. Does anyone think if they do a full residency and have the same requirements as MD's during residency what would really make them any different from MD's besides 1 yr of school? Just saying at some point if residencies are mandatory than I could see pay and position being comprable and pushing on doctors. Just a thought for some new discussion.
 
My wife is a PA at an urban hospital that uses a doctor in triage. The triage doctors are mostly FM residency trained and see patients out in triage. They will do a quick H&P to triage patients to the emergency medicine trained docs or the PAs. Anything that can be handled out in triage will get a more thorough H&P, some simple labs/x-rays, and be discharged from triage without ever making it back to the ED. This means that all the earaches, sore throats, simple flu, sprained ankles, etc will get discharged from triage. Then my wife will get stuff like otherwise healthy people (as in not a lot of comorbidities) with belly pains, back pains, hematuria, some chest pains, more complicated fractures, low to moderate speed MVCs, lacerations, and once the main ED gets full up she starts getting some of the overflow. She likes this system because it lets her work in a busy department and see more than just the fast track type of stuff.
 
DoctorMedic said:
didn't know they had PA residencies. Does anyone think if they do a full residency and have the same requirements as MD's during residency what would really make them any different from MD's besides 1 yr of school? Just saying at some point if residencies are mandatory than I could see pay and position being comprable and pushing on doctors. Just a thought for some new discussion.
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PA em residencies(at least for now) are all 2 years or less so pa's never get the pgy-3 chief resident role that docs do. the several pa residencies I know of are quite good and have pa's training alongside docs at the pgy1 and 2 levels but I don't think you have to worry about pa's being given full md slots and chief duties.
( if they did I would do 1 in a heartbeat just for the increased knowledge base in my field).

these are the current em pa residencies. not exactly slacker institutions:


EMERGENCY MEDICINE
Albert Einstein Medical Center Physician Assistant Emergency Medicine Residency
Johns Hopkins Bayview Medical Center Emergency Medicine Residency
U of Iowa Emergency Medicine Physician Assistant Residency Program
U of Texas Health Science Center San Antonio
U.S. Army Medical Department Emergency Medicine Physician Assistant Programs( grants DHSc)
Wright Patterson Emergency Medicine Physician Assistant Fellowship
 
DoctorMedic said:
didn't know they had PA residencies. Does anyone think if they do a full residency and have the same requirements as MD's during residency what would really make them any different from MD's besides 1 yr of school? Just saying at some point if residencies are mandatory than I could see pay and position being comprable and pushing on doctors. Just a thought for some new discussion.
Click to expand...

The PA residencies that I've heard of tend to be much shorter than the MD residencies in the same field. Like the one year surgical PA residency vrs the 5-7 years of general surgery residency.

I don't think the two are going to end up with training that is too similar in length because the advantage starts to vanish for both the PA who has to stay in school longer and the hospital who likely has to pay more to someone with more training.
 
emedpa said:
EMERGENCY MEDICINE
Albert Einstein Medical Center Physician Assistant Emergency Medicine Residency
Johns Hopkins Bayview Medical Center Emergency Medicine Residency
U of Iowa Emergency Medicine Physician Assistant Residency Program
U of Texas Health Science Center San Antonio
U.S. Army Medical Department Emergency Medicine Physician Assistant Programs( grants DHSc)
Wright Patterson Emergency Medicine Physician Assistant Fellowship
Click to expand...

Did Medical College of Georgia drop their PA residency program?
 
southerndoc said:
Did Medical College of Georgia drop their PA residency program?
Click to expand...
Yes they did. and it was a solid program so it's a shame.
it came down to a funding issue much like the LA county/USC em pa residency that closed in 1996. that was the model for all later em pa residencies. I work with a few of their grads. that truly was a solid educational experience for the aspiring em pa.
 
jbar said:
The PA residencies that I've heard of tend to be much shorter than the MD residencies in the same field. Like the one year surgical PA residency vrs the 5-7 years of general surgery residency.

I don't think the two are going to end up with training that is too similar in length because the advantage starts to vanish for both the PA who has to stay in school longer and the hospital who likely has to pay more to someone with more training.
Click to expand...

I was talking more so for EM. Seems like PAs in medicine could very easily hit that point if they already do 2 yrs. 1 more and they do the exact same residency as most EM MD/DOs. I do agree that at some point they might as well as gone to medical school, but some don't have the grades or don't want to make that commitment at the time. Seems like a way to make up for that somewhat. Not to mention those Residencies are at some good institutions.
 
DoctorMedic said:
I was talking more so for EM. Seems like PAs in medicine could very easily hit that point if they already do 2 yrs. 1 more and they do the exact same residency as most EM MD/DOs. I do agree that at some point they might as well as gone to medical school, but some don't have the grades or don't want to make that commitment at the time. Seems like a way to make up for that somewhat. Not to mention those Residencies are at some good institutions.
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I think the answer there, if I may step in as an interested third party, is simply to foster the development of PA-MD/DO transitional programs. Most PAs don't, at this point, complete residencies, and if you had a PA in practice for a few years then why not let them become physicians with the added coursework. I happen to think a PA would probably be amongst if not the top students in medical school, and I would suspect that most PAs would either specialize in the area they were previously engaged in, many of which seem to be in primary care, and the remainder would likely pursue traditional primary care residencies, i.e. FP, IM, etc.

At some point medical schools in the U.S. should really examine their admissions requirements and decide if their selection criteria is in fact efficacious. Programs such as PA to MD or PA to DO would really help this purported shortage, in my opinion for whatever it's worth.
 
bridge would be nice but as far as i know PA's have to repeat all 4 yrs of medical school. The point is if they are allowed/expected to practice equivelent to MD/DO's during residency why should they have to go back to school. Kind of like putting the cart before the horse so to speak.
 
I don't really see how you can transition, because you can't fill the holes of the stuff that the PAs didn't cover from medical school. The PA neuro anatomy class was about half the time of ours, but it isn't a matter of giving the missing lectures, because each lecture was missing about 15 minutes worth of detail. The same went for many of the classes. And on rotations PAs often aren't held to the same standard as the medical students in terms of knowledge, the just aren't pimped as hard and with the same level of detail. Their rotations were different, often being on a service for two weeks when we were there for four. They just had a different experience.

The whole point of having medical schools accredited is so you can say "if someone has graduated a US medical school they have done X Y and Z and passed these test. It would be a nightmare to try to substitue clinical experience for that. How would you figure out how PA # 1's experience matched up to PA #2? One worked in a cardiology practice and the other in primary care. Do they have to take different classes to be an MD?

Finally it's not just the time in school or on the wards but the mindset. There were plenty of times during my third year in medical school where I said "I should learn how this works because I will have to do this in residency." I would expect that PA students come across plenty of things during their training that they say "I don't need to know that or how to do that." There is a reason that it is called PA school, because they are learning to be PAs. Which is great, I really respect PAs and they tend to know a lot about the field in which they are working. But I think it is crazy to say that PA school plus a few years working should be the same as medical school.

Also as a manpower issue turning a PA into a doc doesn't really get you more patients seen. You would have one less PA and one more doc but they'd be seeing about the same number of patient's per week. If you want more docs you have to put more people into the system, have more med school spots, more residency spots. It's not like there aren't people who want them.

I also wonder if there are really PAs who want to do this. These are people who chose to go the PA route for a reason in the first place. Many of the PAs I know did so because they were a few years older and didn't really want to spend the next seven or eight years in school. I don't think that these guys would be psyched to go back in to a residency after being even further down the road. And from a system standpoint it makes more sense to be putting 26 year olds into residency rather than 36 year old PAs who have been working a few years, you get more MD work years out.
 
I could still see some feasibility in putting PAs in an MD transition (if they existed), i.e. a two year program perhaps emulating the first and fourth years of medical school with a reiteration of perhaps pathophysiology along the way. I've never been in either position to judge the merits of such a program. I was just thinking of yet another way to try to increase the number of physicians in practice. Granted, this probably wouldn't be the most popular avenue, but I think it could be doable.
 
again, what's the advantage to the system? You are taking people with 2.5 years of training, giving them another two years of training to get them to roughly the same point as someone with 4 years of training, while losing a PA in the process. If you really want more docs you could just make it easier to international grads to work in the US and open up more residency spots for them.

The real problem right now isn't really that there aren't enough MDs, but that there aren't enough in primary care. Not sure that making PAs into MDs would help this, most of the PAs I know are just as gung ho as med students about going into neurosurgery, ortho, surgery etc. Don't know numbers but they don't seem to be any more interested in primary care than the average med student. So you potentialy would just have more people fighting for the same limited number of specialty residencies. And if you want good primary care docs you need to recruit people into med school who want to do primary care, not take the angry rejects who didn't get into optho or derm.
 
jbar said:
again, what's the advantage to the system? You are taking people with 2.5 years of training, giving them another two years of training to get them to roughly the same point as someone with 4 years of training, while losing a PA in the process. If you really want more docs you could just make it easier to international grads to work in the US and open up more residency spots for them.

The real problem right now isn't really that there aren't enough MDs, but that there aren't enough in primary care. Not sure that making PAs into MDs would help this, most of the PAs I know are just as gung ho as med students about going into neurosurgery, ortho, surgery etc. Don't know numbers but they don't seem to be any more interested in primary care than the average med student. So you potentialy would just have more people fighting for the same limited number of specialty residencies. And if you want good primary care docs you need to recruit people into med school who want to do primary care, not take the angry rejects who didn't get into optho or derm.
Click to expand...

There is no advantage with regard to time or money. It's only an option for those interested who wanted to further their career. It could be such that a program was a direct funnel, if not requirement, for training in primary care perhaps with a two year rather than three year residency or something thus IF a PA wanted to be a PCP then rather than seven years you'd have four. Four years is still along time, but that's much better than seven in my book on top of whatever highly specific premed prereqs the PA might be lacking. Just spitballing here. I'm with you on bringing in students interested in primary care as I think you and I have bantered back and forth about in another forum. That's me for example. I could care less about highly specialized fields. After reflecting on the course of my life it's obvious to me that the generality of an FP brings about much more appeal than the specialization of say opthalmology. U.S. history, for example, is interesting, but spending say a semester taking a U.S. history overview is much more palatable and exciting than a semester of something like Civil War...which I did. 😴
 
I'm sure the PAs would like it if they could do what you are suggesting, but so what? I would love it if I could take a one year course and get paid as a lawyer, but most people would argue that I wouldn't be as well trained as a three year lawyer, and the Bar, the courts, congress etc aren't going to approve of such a class unless it is in their interest or societies interest.

Similarly you aren't going to see the AMA or most of society getting behind such a short cut to being an MD/DO. If it doesn't save money or improve care or increase the number of providers then why do it?

Furthermore, calling such a PA an "MD" doesn't really raise the PAs up, it brings down the standard of what an residency trained MD is. It's like a PA saying that the graduated medical school because they go to a school that teaches medicine.

Now it is a whole different question to say "can PAs do a PA residency for a year or two years or whatever and practice more autonomously, still having the option to refer more complex patients to MDs for their primary care." That is something very different and I think better for everyone than taking those PAs and calling them MDs.
 
jbar said:
I'm sure the PAs would like it if they could do what you are suggesting, but so what? I would love it if I could take a one year course and get paid as a lawyer, but most people would argue that I wouldn't be as well trained as a three year lawyer, and the Bar, the courts, congress etc aren't going to approve of such a class unless it is in their interest or societies interest.

Similarly you aren't going to see the AMA or most of society getting behind such a short cut to being an MD/DO. If it doesn't save money or improve care or increase the number of providers then why do it?

Furthermore, calling such a PA an "MD" doesn't really raise the PAs up, it brings down the standard of what an residency trained MD is. It's like a PA saying that the graduated medical school because they go to a school that teaches medicine.

Now it is a whole different question to say "can PAs do a PA residency for a year or two years or whatever and practice more autonomously, still having the option to refer more complex patients to MDs for their primary care." That is something very different and I think better for everyone than taking those PAs and calling them MDs.
Click to expand...

Geez, lol. I'm not really concerned with what the AMA thinks. Don't take that the wrong way, but why let a singular organization, a society, dictate what an entire profession allows. An anecdote here. I once worked with a national board certified teacher. To earn such a credential is a rather arduous and time consuming process from what I gather. A presumption is made that those teachers are on top of their game and the best in the field. However, it could also easily be suggested that such a teacher who earned that credential did exceptionally well at preparing the documents and presentation necessary. That said, an organization is make claims that a person belonging to their "group" is going to be better than others when in fact that may not be the case. I'm sure it's normally true, and she was an ok teacher. However, her students often complained about her abilities to me as well as her attitude. End of anecdote.

There's no reason for a PA to be autonomous due to two reasons 1) they are physician assistants not associates, soloists, or any other such term, and 2) I don't feel, again as an outsider, that the profession as a whole is prepared to assume such a role. I'm confident that there are competent providers out there, but once that door is opened it's going to be hard to regulate the flow moving through it.

How can you be so certain of what I quoted below? How do you know a plan such as what I spoke of wouldn't provide clinicians demonstrating the requisite efficacy?

"Furthermore, calling such a PA an "MD" doesn't really raise the PAs up, it brings down the standard of what an residency trained MD is. It's like a PA saying that the graduated medical school because they go to a school that teaches medicine."

I respect your statements, by the way. I'm just enjoying the banter. I should also note that I'd be quite happy as a PA, and I exude respect for that profession.
 
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ArkansasRanger said:
That said, an organization is make claims that a person belonging to their "group" is going to be better than others when in fact that may not be the case. I'm sure it's normally true, and she was an ok teacher. However, her students often complained about her abilities to me as well as her attitude. End of anecdote.
.
Click to expand...

It isn't a matter of MDs as a group saying that they are better than another group. It's a matter of MDs or DOs as a group can say "if you want to be recognized as an MD/DO, here are the requirements (go to an accredited 4 year med school, pass the boards etc.) If someone else wants to be a part of that group they either need to follow those rules or convince the group to change the rules.

Since it doesn't seem to be in the interest of MDs to permit PAs to "bridge" to MD it won't happen. And if it isn't in societies interest or the medical system's interest there won't be outside pressure either.
 
jbar said:
It isn't a matter of MDs as a group saying that they are better than another group. It's a matter of MDs or DOs as a group can say "if you want to be recognized as an MD/DO, here are the requirements (go to an accredited 4 year med school, pass the boards etc.) If someone else wants to be a part of that group they either need to follow those rules or convince the group to change the rules.

Since it doesn't seem to be in the interest of MDs to permit PAs to "bridge" to MD it won't happen. And if it isn't in societies interest or the medical system's interest there won't be outside pressure either.
Click to expand...

I thought that was implied, jbar. You're going to have to have policies and procedures in place for anything like what we're debating to transpire. I know a school can't just advertise a new "program" and two years later produce physicians or any other such professional. I recall a closed down deli that opened up a few years later as an "institute" awarding master's degrees in theology. That's not the kind of process I was talking about. This was all hypothetical. Obviously, the movers and shakers, in this case the physicians, are going to have to be on the bandwagon for a physician assistant - physican transition, by which one could bypass some of the already completed elements, to commence. Anyone reading this should have been aware of that. I guess you had the idea that I was suggesting that Old State U. somewhere should proceed with a transition program without any other planning, accreditation, and so forth. I don't see how the option could be outside of the medical system's interest though. I hardly agree that any negative outcomes could result in such a thing as we've been typing about. I would, however, speculate that a transition would be in society's interest because it would be yet one more avenue of creating physicians. Anyway it's all a moot point because I'm not in a position to make it happen nor am I all that concerned about it. I just like talking. Overall, you're right though in the assumption that to produce primary care physicians you need to recruite primary care - oriented individuals. However, how can you do that? People do change their minds, and medical school is four years long enough to stimulate a change of mind. For that same reason, although I'm of the primary care mindset now, if I had to sign a contract upon admission to medical school stipulating that I complete four years of school and three years of residency specifically in a primary care field or risk some sort of punitive action then I wouldn't go. That same reason is why I never joined the military because I find it very hard to make an eight year commitment (commissioned line officer's commitment) to anything particularly when I was just turning 20. Granted, it seemed ok, at the time, but I couldn't anticipate my view of it all eight years down the road. Likewise, a kid going to medical school can't fully anticipate that he might want to pursue internal medicine yet later find out that pathology was his true passion.
 
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If I could be a doctor, not have to go through medical school, not have the liability (or debt) I do now, and still be in my mid-20's when I started making attending money... that would be a difficult deal to pass up.

I think it will be successful in getting people into primary care, it just seems wrong somehow.
 
southerndoc said:
Why can't they just open and advertise to produce physician equals? The DNP program has done just that, and with due time, the DNP's will be requesting autonomous rights from the state medical boards.
Click to expand...

Because the boards of medicine would never allow it, just like they would never allow autonomous NP practice. The reason NPs have autonomy is because they are under the board of NURSING, which has (unsurprisingly) decided that the entirety of medicine is actually the practice of nursing so they can allow NPs to do it under their "supervision". PAs are stuck under the board of medicine. Much different situation.
 
dilated said:
Because the boards of medicine would never allow it, just like they would never allow autonomous NP practice. The reason NPs have autonomy is because they are under the board of NURSING, which has (unsurprisingly) decided that the entirety of medicine is actually the practice of nursing so they can allow NPs to do it under their "supervision". PAs are stuck under the board of medicine. Much different situation.
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Let's have this discussion again in 5 years when the DNP's are trying to get autonomous practice privileges.
 
thought the DNP was to be more of an academic position? I do know that if you confer the title of Doctor to them some of them will want the privledges. lastly how does a board of nursing seem to think they can just increase their privledges to be almost equivelant to the board of medicine? Seems like some oversight was missed.
 
jbar,

sorry been away for awhile. My point was that other people had posted PA's were already in residency right along side doing the same things as PGY1 and 2 MD/DO's. My point wasn't to make them MD/DO my point was if they are ALREADY TODAY not hypothetically but this is happening right now doing the 1st 2 years of residency and able to practice the same amount/equally to residents of their same year, than what is to stop them from saying add the last year and pay much closer to MD/DO's and give us more autonomy. That is the point I'm making. Again the whole cart before the horse. How can they allow PA's to practice as PGY 1 and 2 (i know they have attendings and Sr. Residents) practice equal to MD's of that level and than later say hey if you want to do what you were doing in residency go back to school)
 
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