What role do PA's play in EM?

[WingsBelieve84]

---

Members don't see this ad.

Hey EM docs, I've been spending some time at my school's ED recently and noticed how many PA's present to attendings. Almost like a medical student. Where exactly do PA's fit into the system? Is there any concern amongst the doctors that they are taking some of the work away?

 

[southerndoc]

Where I trained during residency, PA's saw Fast Track patients and never presented to an attending unless they needed a narcotic prescription, had a question, needed to consult a specialty service, or the patient need admission.

Where I practice now, all patients seen by a PA must be presented to an attending and the attending must see the patient. I receive full reimbursement for seeing the patient, but then must pay back a percentage to pay for the PA's work. PA's only work a couple shifts each month, but this is increasing to a daily 12-hour shift where they will see level 3's and 4's in a separate area.

 

[Aloha Kid]

The PAs at our program run fast track. They fly entirely solo. The Doc only sees the patient if the PA has a question. Due to rules and regulations a physician must always be accessible to them. This is not a problem as we assign one physician who is working their own POD to the PA. In the end, the physician is responsible for the PA and all of their charts. Yes, many physicians do not like to be responsible for the PA charts. I hear my attending's whine and moan about this issue, but in the end, not many of them go back to at least spot check many of the patients the PA sees.

The interesting thing is when a 3rd or 4th year EM resident runs fast track, the attending is obligated to see every patient. Go figure. On the days the resident runs fast track the PAs go out to the main department and see the high acuity patients and report entirely to the attending.

 

[docjolly]

at my current emergency medicine rotation, the fast track is run by PAs on certain days, and by attendings on the other.

i asked one of the senior residents the function of a PA, and I was told that "s/he is basically a glorified intern."

all joking aside, i'm not certain of their function or utility, especially with respect to emergency medicine. however, if anyone can provide some further clarification, please let me know.

 

[southerndoc]

at my current emergency medicine rotation, the fast track is run by PAs on certain days, and by attendings on the other.

i asked one of the senior residents the function of a PA, and I was told that "s/he is basically a glorified intern."

all joking aside, i'm not certain of their function or utility, especially with respect to emergency medicine. however, if anyone can provide some further clarification, please let me know.

Are you kidding me? An experienced PA is worth a ton more than an intern! There were days during residency that I was glad to see a PA instead of an off-service intern.

 

[docB]

PAs can have various roles in the ED. Many groups utilize PAs in their fast tracks to see lower acuity patients. Other groups have PAs picking up the whole spectrum of charts though they will often need more oversight on complex cases.

Whether or not PAs present their cases to a doc is at the discression of the docs who employ the PA and the bylaws of the hospital. As Southerndoc alluded to a patient seen only by a PA is billed less (~70%) than a patient who is seen by the attending during their visit. That is one of the primary factors spurring many groups to have evey PA patient seen by the docs and the charts signed in real time.

Where I practice now, all patients seen by a PA must be presented to an attending and the attending must see the patient. I receive full reimbursement for seeing the patient, but then must pay back a percentage to pay for the PA's work. PA's only work a couple shifts each month, but this is increasing to a daily 12-hour shift where they will see level 3's and 4's in a separate area.

Just to clarify the money he's talking about "paying back" isn't going back to the payor. It's going back to his group so that they can pay the PAs.

 

[southerndoc]

Just to clarify the money he's talking about "paying back" isn't going back to the payor. It's going back to his group so that they can pay the PAs.

Sorry, the way I worded it was a bit confusing.

 

[docjolly]

you guys rock! thanks for the clarification 🙂 i honestly didn't know any of this. (i promise i'm not being facetious).

 

[primadonna22274]

I'm a PA who got a little burned out of family practice and changed into ED 6.5 years into my career. Talk about a change. I worked in a 50,000/yr semi-rural facility (we fly out emergent NS and interventional cards cases after stabilization). In our ED, every patient seen by the PA is also seen by the attending, although for the most part that consists of the attending MD/DO "blessing" the patient after the workup & dispo are essentially done. We don't do just fast track, but everything in the back too. Now, as a community-minded primary care PA, I never have been comfortable with trauma, but I'll start it off until the attending takes over. Unstable patients I always know the doc's got my back and will come in when I ask. I can't discharge a patient (even from fast track) without the "blessing" which is very frustrating on the fast track side (and why I went back to outpatient FP after a year and a half--to give up so much autonomy so far into my career was really difficult). I did learn an awful lot and feel much more comfortable managing office emergencies now--and punting them (appropriately) to the ED. I still pick up a shift or two a month for extra $$ and to work with some of my favorite docs & nurses but I have to tell ya, the entitlement of most ED patients wears me out. I think it's much better out there in private practice land, having done both.

I'm just representing one facet of the multitude of ways in which EDs utilize PAs. There are plenty of PAs working solo fast track and even solo night coverage. I wouldn't be comfortable as a solo night PA but I'm pretty comfortable solo outpatient which I do all the time. Bottom line though, I'm on this board cuz I'm applying to med school after 8 years as a PA, so I have a different perspective than the gung-ho PA.

😉 Lisa

 

[deleted6669]

As Southerndoc alluded to a patient seen only by a PA is billed less (~70%) than a patient who is seen by the attending during their visit.

It's 85% of the md rate actually.

see www.sempa.org for more on the role of pa's in em.
as mentioned above it varies all the way from fast track only to solo coverage of small depts with phone physician backup.

 

[bulgethetwine]

Are you kidding me? An experienced PA is worth a ton more than an intern! There were days during residency that I was glad to see a PA instead of an off-service intern.

The key word is here is experience --

When I was a resident, the PAs I worked with in the ED (big academic, ivory tower place) were awesome. I learned more about sutures and ortho splints etc. from them than arguably any attending.

But since being out in the community, I'm much less impressed. There are still some great ones, but having worked at two or three places, I've caught several near 'misses'... and now I'm finding myself reviewing and supervising their cases a whole lot closer. The problem is, the ones they're missing are the people that are teetering... like the guy sick and infected and potentially septic in 24h, but minimized as a kidney stone (it was pyelo). Or the guy with the "abscess" that was really a badly infected hand-now-turned-tenosynovitis.

I can't help but think the "PA Puppy Mills" are contributing... the market if full of so many nurses masquerading as PAs and RNs today.

So I'm not as big a fan as I was a couple years ago.

 

[primadonna22274]

The veteran PAs are concerned about this too. (I'm not so sure I'm a veteran only 8 years into the field, and I was not one with tons of experience prior to admission to PA school.) Prior health care experience is downplayed more and more; high grades and GRE scores are emphasized. Students are younger and lazier. I imagine this translates to medicine as well; the problem is, a PA can be turned out in 24 months and loosed on the public, licensed and all.
Supervision is key for the inexperienced PA. An inexperienced PA with appropriate mentoring and the tincture of time can become a stellar PA. So invest the time and mentor these folks. Near-misses are, at least, not misses, because there is an opportunity to intervene and change the course.
Keep the faith.

The key word is here is experience --

When I was a resident, the PAs I worked with in the ED (big academic, ivory tower place) were awesome. I learned more about sutures and ortho splints etc. from them than arguably any attending.

But since being out in the community, I'm much less impressed. There are still some great ones, but having worked at two or three places, I've caught several near 'misses'... and now I'm finding myself reviewing and supervising their cases a whole lot closer. The problem is, the ones they're missing are the people that are teetering... like the guy sick and infected and potentially septic in 24h, but minimized as a kidney stone (it was pyelo). Or the guy with the "abscess" that was really a badly infected hand-now-turned-tenosynovitis.

I can't help but think the "PA Puppy Mills" are contributing... the market if full of so many nurses masquerading as PAs and RNs today.

So I'm not as big a fan as I was a couple years ago.

 

[Aloha Kid]

Well said.