When does taking it for the team become taking it up the you know what?

[deleted836128]

I am sure you guys have all dealt with some pretty dramatic changes with your jobs due to the pandemic. We’ve all had to be flexible but when is enough ENOUGH?

These are some of the things our group of PAs (and sometimes the docs) are going through and it’s hard to know if it’s bordering on disrespectful or if we need to suck it up because we are lucky to have jobs right now... my gut is that all the things I mention below should NOT happen to a professional but this has become the new norm and our ER directors don’t seem to bat an eye. I wonder if any of you are also experiencing the same...

1) Last last last minute schedule changes - being told that starting tomorrow, this shift or that shift is now going to be four hours longer, or will be shifted up two hours earlier, even when the schedule has already been out. We’ve all been able to accommodate this but I would think this would be a nightmare for people with other jobs (yikes) or small children. Not only schedule wise but hours wise - maybe someone was planning on working 110 hours this month and just like that now they’re on 140, for example.

2) Last minute requests to stay late - our shifts were cut substantially causing us to lose hours, but then what they do is ask us to stay late sometimes “on demand” depending on if it’s busy that day. So they don’t want to “commit” to giving you a full shift in case it’s not busy but have no qualms with asking you to stay late (for pay of course) when it is busy.

3) Taking a handful of days to be “on call” without pay “just in case someone gets sick”... this one I pushed back on but was encouraged to do so “for the good of the group”

4) Being required to work at a different hospital when you weren’t hired for that hospital - asking us to get credentialed so we can help out if needed at a hospital that is for many of us 25-40 miles away which is not what we signed up for (we agreed to work at the three hospitals in town, not a hospital that is in another town!). This one bothers me the most. Has this ever been asked of any of you, and is it reasonable?

5) Being furloughed, unfurloughed for a short time, then refurloughed - this has happened to some in our group

6) Getting our productivity bonuses months late and they’re half the usual amount “because we got a bad billing company... next month it’ll be better because we are switching companies”

7) Breaking contractual obligations for hours - being contracted to be paid a salary to work a certain number of hours and getting your salary docked when those hours aren’t available, even when you’re willing and able to work (uhhh... this one is illegal)

8) And just day to day CRAP - working in an ER in which you’re not set up for success due to lack of support staff (or lack of SKILLED support staff). Having to see an eye pain without a slit lamp because it’s broken. Having to make your own pages to specialists because there is no clerk. Suture carts never stocked requiring an annoying search for stuff in multiple places in the middle of a busy work day. Seeing a pelvic pain with discharge patient in an internal waiting room with other patients and trying to figure out a place to do a pelvic exam. Seeing a back pain patient wearing a leotard and skinny jeans out in the hallway and being barked at by the charge nurse when you say they need to be gowned and therefore roomed.

Can you guys tell I am getting burned out on the ER?

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[BoardingDoc]

I am sure you guys have all dealt with some pretty dramatic changes with your jobs due to the pandemic. We’ve all had to be flexible but when is enough ENOUGH?

These are some of the things our group of PAs (and sometimes the docs) are going through and it’s hard to know if it’s bordering on disrespectful or if we need to suck it up because we are lucky to have jobs right now... my gut is that all the things I mention below should NOT happen to a professional but this has become the new norm and our ER directors don’t seem to bat an eye. I wonder if any of you are also experiencing the same...

1) Last last last minute schedule changes - being told that starting tomorrow, this shift or that shift is now going to be four hours longer, or will be shifted up two hours earlier, even when the schedule has already been out. We’ve all been able to accommodate this but I would think this would be a nightmare for people with other jobs (yikes) or small children. Not only schedule wise but hours wise - maybe someone was planning on working 110 hours this month and just like that now they’re on 140, for example.

2) Last minute requests to stay late - our shifts were cut substantially causing us to lose hours, but then what they do is ask us to stay late sometimes “on demand” depending on if it’s busy that day. So they don’t want to “commit” to giving you a full shift in case it’s not busy but have no qualms with asking you to stay late (for pay of course) when it is busy.

3) Taking a handful of days to be “on call” without pay “just in case someone gets sick”... this one I pushed back on but was encouraged to do so “for the good of the group”

4) Being required to work at a different hospital when you weren’t hired for that hospital - asking us to get credentialed so we can help out if needed at a hospital that is for many of us 25-40 miles away which is not what we signed up for (we agreed to work at the three hospitals in town, not a hospital that is in another town!). This one bothers me the most. Has this ever been asked of any of you, and is it reasonable?

5) Being furloughed, unfurloughed for a short time, then refurloughed - this has happened to some in our group

6) Getting our productivity bonuses months late and they’re half the usual amount “because we got a bad billing company... next month it’ll be better because we are switching companies”

7) Breaking contractual obligations for hours - being contracted to be paid a salary to work a certain number of hours and getting your salary docked when those hours aren’t available, even when you’re willing and able to work (uhhh... this one is illegal)

8) And just day to day CRAP - working in an ER in which you’re not set up for success due to lack of support staff (or lack of SKILLED support staff). Having to see an eye pain without a slit lamp because it’s broken. Having to make your own pages to specialists because there is no clerk. Suture carts never stocked requiring an annoying search for stuff in multiple places in the middle of a busy work day. Seeing a pelvic pain with discharge patient in an internal waiting room with other patients and trying to figure out a place to do a pelvic exam. Seeing a back pain patient wearing a leotard and skinny jeans out in the hallway and being barked at by the charge nurse when you say they need to be gowned and therefore roomed.

Can you guys tell I am getting burned out on the ER?

You clearly work for a CMG of some sort, and this job sounds terrible. In general, have I been subjected to what you're describing?
1: Absolutely not
2: I'm RVU based and work in a small group so if staying late is helpful, we generally do it. If we can't, that just means that the next doc gets paid more for seeing more people.
3: Some groups have this as part of their scheduling. If everyone is doing it a proportional amount, it's fine. Otherwise, no.
4: Absolutely not.
5: We did not furlough anyone.
6: Late? Yes. Wrong amount? No.
7: N/A
8: This could either be that you work in a crappy ED, or work in a normal ED and are just fried and venting. All of the things you described have happened to me at one time or another. Frequency of these occurrences dictates whether or not it's a crappy dept.

 

[dadaddadaBATMAN]

I am sure you guys have all dealt with some pretty dramatic changes with your jobs due to the pandemic. We’ve all had to be flexible but when is enough ENOUGH?

These are some of the things our group of PAs (and sometimes the docs) are going through and it’s hard to know if it’s bordering on disrespectful or if we need to suck it up because we are lucky to have jobs right now... my gut is that all the things I mention below should NOT happen to a professional but this has become the new norm and our ER directors don’t seem to bat an eye. I wonder if any of you are also experiencing the same...

1) Last last last minute schedule changes - being told that starting tomorrow, this shift or that shift is now going to be four hours longer, or will be shifted up two hours earlier, even when the schedule has already been out. We’ve all been able to accommodate this but I would think this would be a nightmare for people with other jobs (yikes) or small children. Not only schedule wise but hours wise - maybe someone was planning on working 110 hours this month and just like that now they’re on 140, for example.

—-Not that there’s a ton of pickings out there but I would start looking for another job If this became a regular thing. I have to know when I’m working and when I’m not. It’s pretty much the only real schedule perk beyond lower hours in the ed.

2) Last minute requests to stay late - our shifts were cut substantially causing us to lose hours, but then what they do is ask us to stay late sometimes “on demand” depending on if it’s busy that day. So they don’t want to “commit” to giving you a full shift in case it’s not busy but have no qualms with asking you to stay late (for pay of course) when it is busy.

—-sure if you pay me an overtime rate. Same reasons as above, and same response as above if no overtime. I need to know when I’m working and when I’m home. I would bluntly say “no” if this happened regularly.

My last two hours on shift are probably when I am highest risk. It’s the reason I avoided jobs that work twelves. I am just point-blank worse at being a doc at hour 11 than hour 7, much less hour 14.

3) Taking a handful of days to be “on call” without pay “just in case someone gets sick”... this one I pushed back on but was encouraged to do so “for the good of the group”

—-I object to this the least, and it seems reasonable in a pandemic to have this be a culture shift. My group has about two days a month where you are first call for sick stuff. Gets used like 5 times a year, and if it’s more than that there would be problems.

4) Being required to work at a different hospital when you weren’t hired for that hospital - asking us to get credentialed so we can help out if needed at a hospital that is for many of us 25-40 miles away which is not what we signed up for (we agreed to work at the three hospitals in town, not a hospital that is in another town!). This one bothers me the most. Has this ever been asked of any of you, and is it reasonable?

—-it’s preferable to looking for a new job in my estimation. Our system is asking for this, but it’s volunteer for now.

5) Being furloughed, unfurloughed for a short time, then refurloughed - this has happened to some in our group

—-this is horse****, and if furloughed I would treat it as “fired”

6) Getting our productivity bonuses months late and they’re half the usual amount “because we got a bad billing company... next month it’ll be better because we are switching companies”

—-another indicator to look for a new job. They aren’t financially stable. They are not being transparent. This is a bad thing. If it was communicated clearly why ( “we don’t have any more money”) in advance it’s different though.

7) Breaking contractual obligations for hours - being contracted to be paid a salary to work a certain number of hours and getting your salary docked when those hours aren’t available, even when you’re willing and able to work (uhhh... this one is illegal)

—-another good reason to look for a new job, but this is kind of to be expected

8) And just day to day CRAP - working in an ER in which you’re not set up for success due to lack of support staff (or lack of SKILLED support staff). Having to see an eye pain without a slit lamp because it’s broken. Having to make your own pages to specialists because there is no clerk. Suture carts never stocked requiring an annoying search for stuff in multiple places in the middle of a busy work day. Seeing a pelvic pain with discharge patient in an internal waiting room with other patients and trying to figure out a place to do a pelvic exam. Seeing a back pain patient wearing a leotard and skinny jeans out in the hallway and being barked at by the charge nurse when you say they need to be gowned and therefore roomed.

Can you guys tell I am getting burned out on the ER?


—this is fundamental to em. While I commiserate, it is not changing. However as a pa you do have other options.

My responses are above

 

[deleted6669]

You need a new job where you are valued, my friend. Make yourself irreplaceable.
In the course of the last six months, I have been offered essentially unlimited hours with a significant raise. If not for the whole pandemic thing I would be loving this. I am working a lot more and my wife hates it, but will likely pay off almost all my debt this year, including the new car I just bought myself.
The key to this is only working at small rural hospitals. I did the urban trauma center meat market thing for almost 20 years. Never again. Low volume, high acuity single or double coverage is where it is at. Few people can(or will) do this kind of work without a safety net of every specialist imaginable immediately available. If you are one of them, you will always have a job. I am making double my prior trauma center hourly rate seeing 10-15 pts/24 hrs as opposed to 30 pts/12 hrs.
One of the docs I occasionally work with still works at a big academic ctr and says he only feels like a real ER doc when he works rural, because he actually works to his potential instead of having ortho do all the reductions, anesthesia do all the intubations, etc
Also, you need to find a job that is not RVU based. You are paid to be available to deliver the services you are trained to do whether that is 10 pts a shift or 20. Straight hourly rate keeps you honest. No BS workups. No crappy notes to see more patients. FWIW, the consultants at the small hospitals tend to be a lot more mellow. If you only have two hospitalists and they are friends of yours an admit is as easy as "Hey John, I have a 74 yr old lady with pneumonia who needs to come in" as opposed to push back from some random stranger in a group with 50 hospitalists who you have never met on every reasonable admit. Rural surgeons actually come in and evaluate surgical patients. It is kind of wonderful.

 

[deleted6669]

I am an emergency medicine PA and a former paramedic. I work mostly single coverage, rural critical access hospitals at this point. I have worked in EM since 1987 in every setting you can imagine on both sides of the country. I have worked with a lot of the big names in EM and learned from the best. My last job was at a busy trauma ctr where the EM physicians were often just glorified triage nurses unfortunately: Stemi, stabilize and call cards. Bad airway, call anesthesiology, bad fx or dislocation, call ortho, sick kid, call the peds intensivist, etc. I may have just lucked out with my choice of jobs, but I now see far higher acuity and much lower volume than I ever did before . Having fewer specialists available means YOU get to do the procedures. You deliver the teenaged kid with no prenatal care who didn't even know she was pregnant. You are the guy injecting phyenylephrine into the priapsim at 3 am because there is no urologist within 3 hrs. You look at the ugly fracture dislocation and say I will give it a try. the 400 lb pt on the floor crashes at 2 am and they call you to do the difficult intubation BECAUSE THERE IS NO ONE ELSE.
I say that I am irreplaceable here because I have a much better skill set than the vast majority of non-em boarded physicians and no em boarded folks will drive to the middle of nowhere to make 1/2 what they can in the city. I highly respect the training and dedication of residency trained and boarded emergency physicians. Very few of them are willing to come work out in the sticks without a safety net of consultants. The ones who do are super heroes.
The hospital has a choice of me or folks like me, or 30 yr old family medicine physicians right out of residency. They choose me every time. And they should.
I respect your right to your opinion about salary vs hourly, but disagree. People work better and smarter when they have the time to do what is right for the patient and don't have to move the meat. No one does their best work at 3-5 pts/hr.

 

[deleted6669]

The OP is a PA and I was responding to them as such. I agree that many/most PAs are not ready to do this kind of work. I meant no offense to any EP. The new trend in PA legislation is for us to assume full responsibility for our actions. See the new laws in Michigan and North Dakota as examples of this.

Major PA Victory in Michigan - AAPA

PAs in Michigan are applauding the enactment of House Bill 5533, which increases patient access to healthcare by modernizing and updating how PAs practice.

www.aapa.org

PAs Across America Celebrate First State with Key Components of Optimal Team Practice Following the Legislative Victory in North Dakota

Newly signed North Dakota legislation eliminates the requirement that a PA have an agreement with a specific physician in most settings for nearly all PAs in the state.

www.aapa.org

I am fully in favor of this as well. My state does not require chart review and although I have a sponsoring physician of record, it is essentially an administrative requirement only as he never is involved in the care of any of my patients. I don't think my patients receive substandard care. As I mentioned, I have been doing this for a long time and have probably seen over 150,000 ED patients of all acuities at this point in my career. I am certainly more qualified to to this work than a 30 yr old FM physician who has spent 3-6 months in the ED during their entire training. If a residency trained and boarded EM physician wants my job for $100/hr I am willing to step aside and let them have it. Until then, folks like me are what keeps rural EDs open.

 

[EctopicFetus]

It’s worth visualizing the long term implications. Increased unsupervised autonomy on top of a background of an inferior level of training will result in ‘practicing’ medicine below the standard level of care potentially leading to patient harm and increased litigation. This will result in PAs training more, ultimately realizing what it takes to become a physician versus the alternative of reverting back to being assistants to physicians. There is a standard for practicing medicine, not multiple pathways. If you don’t meet that standard, it’s substandard. EPs bring incredible value. You may offer some value, and more than some PAs, but you don’t bring the same thing to the table as an EP. I don’t say these things to create controversy, but to defend what it takes to become and practice as an EP amidst the constant unnecessary encroachment by midlevels.

This this and more this. I love my mlps but solo practice nfw.

 

[deleted6669]

I love my mlps but solo practice nfw.

I love my EPs, but when they are asked to do solo practice in very rural environments most of them say NFW. Until this changes, rural EDs will be staffed by PAs/NPs/Family medicine physicians. I respect all you folks and know you are protecting your turf. I get that, but you all lose credibility when you both criticize me and refuse to work where there is a legitimate need. Someone has to do it and after 33 years, I am more qualified for this than most family medicine physicians.

 

[WilcoWorld]

To my reading @emedpa is not bashing EP's. He's offering a direct response to @ERCAT and her frustrations by explaining how he found a practice environment that he likes.

I think this forum is much more valuable when people post about how they've shaped their careers into something they like doing than it is when people post about how the house of medicine is on fire, but they're unable to do anything about it because it's inconceivable to live on less than $350k/yr.

 

[deleted6669]

To my reading @emedpa is not bashing EP's. He's offering a direct response to @ERCAT and her frustrations by explaining how he found a practice environment that he likes.

I think this forum is much more valuable when people post about how they've shaped their careers into something they like doing than it is when people post about how the house of medicine is on fire, but they're unable to do anything about it because it's inconceivable to live on less than $350k/yr.

Thank you.

 

[Porfirio]

You are what you allow to happen. Take control of yourself and your life - find another job. You have the advantages of being able to switch jobs with ease, and most of all switch fields of medicine.

 

[WilcoWorld]

I think you’re right. However, I disagree with the idea presented further up above that a PA should move to a rural environment in order to have a better job. We have previously had disgruntled midlevels leave because they were unhappy that they couldn’t practice medicine in the ED like a physician. They wanted to be intubating, putting in lines, running codes, etc. I saw one leave to work in a rural hospital down the road where the hospital let them work in the ED overnight single coverage without onsite direct physician supervision. I then received some of their transfer patients who were train wrecks, including one where they tried to put a central line in an IJ that was kinked, half fallen out and not sutured into place. They didn’t have the training to do this as a PA and tried to learn on the job where someone would let them. They provided dangerous substandard care. I think society and EPs need to and will see this resulting in a backlash against people that want to practice medicine without the training. This is my issue with encouraging PAs to find employment like this.

I don't disagree. I shouldn't do appendectomies and the person you describe shouldn't be working single coverage.

It's more that I encourage people to share their individual success stories AND for readers to understand that one man gathers what another man spills. I suspect most posters on this forum would HATE my job. That's why it's good that it's MY job, because I probably wouldn't like theirs

 

[deleted6669]

I think you’re right. However, I disagree with the idea presented further up above that a PA should move to a rural environment in order to have a better job. We have previously had disgruntled midlevels leave because they were unhappy that they couldn’t practice medicine in the ED like a physician. They wanted to be intubating, putting in lines, running codes, etc. I saw one leave to work in a rural hospital down the road where the hospital let them work in the ED overnight single coverage without onsite direct physician supervision. I then received some of their transfer patients who were train wrecks, including one where they tried to put a central line in an IJ that was kinked, half fallen out and not sutured into place. They didn’t have the training to do this as a PA and tried to learn on the job where someone would let them. They provided dangerous substandard care. I think society and EPs need to and will see this resulting in a backlash against people that want to practice medicine without the training. This is my issue with encouraging PAs to find employment like this.

The right PA/NP can move to a more rural site to increase their job satisfaction, but not many do. Only 2.5% of EMPAs provide solo coverage nationwide, so less than 300 of us. The vast majority of those who do have gone out of their way to get the training and skills needed to do this well, either through postgrad training , on the job training, or both. I spent 15 years gradually working up the ladder from supervised low acuity to moderate acuity to high acuity settings before I ever worked solo and this was after years as a 911 and critical care paramedic in busy systems. You don't know me so you have no basis on which to evaluate my skills. I have put in time working at community hospitals and level 1-4 trauma centers as well as ED obs units learning the skills I need to be competent at my job. At my primary job we staff 1/3 EM docs, 1/3 FM docs, and 1/3 EMPAs interchangeably. Every time an FM doc leaves they are replaced by an EM doc if available or an EMPA if not. Most of the EMPAs have completed the Certificate of added qualifications (CAQ) in emergency medicine after being signed off on standard EM procedures by an EM physician, obtaining at a miniumum ACLS, ATLS, PALS/APLS, and a difficult airway course and passing an exam. It certainly is not EM residency and boards, but folks with this background are more prepared to staff an ED than a typical FM physician. I fully agree that in a perfect world every ED would be staffed by EM physicians, but there are not enough of you folks to go around and as mentioned before, many do not want to drive to BFE to work. I drive 1200 miles a month to and from work. I could land any number of lower acuity jobs within easy walking or biking distance of home but I would be bored to tears. If I had life to do over again I would have gone to medschool instead of PA school. I come from a long line of physicians and my father was fairly well known in his specialty. The reasons I did not are complex(not my grades) and outside the scope of this current discussion.

 

[Fox800]

The reason physicians do not want to fill those vacancies is because $100/hr is insulting. Even for a fresh-faced FM graduate. Your rural hospital could pony up and get BC/BE emergency physicians, but they've decided to pocket the difference because you're good enough. Sorry, but that's the way it is.

I work in a critical access hospital in "BFE", like you.

If they cared enough they'd pay appropriately. You don't see them hiring a PA to work as a general surgeon.

 

[deleted6669]

FWIW I am comfortable with fiberoptic intubations, vent management, and managing folks with symptomatic bradycardia. Sounds like you work with a group of NPs as you mentioned they are "independent". There is a significant difference between the typical EMPA and FNP working in EM. This has been recognized by multiple past presidents of ACEP. Somewhere I have a recorded lecture done by Dr Lawrence, who was ACEP president at the time, stating "emergency medicine PAs are the next best thing to emergency physicians in the ED". I have trained with many of the pioneers in the field of emergency medicine over the years and have learned my trade well. After 150,000+ patients with no litigation and no difference in outcomes between me and the docs I work with I think my safety stats speak for themselves. As a matter of courtesy, please say PAs or NPs, not MLPs. How would you like it if you were lumped in with chiropractors and podiatrists as medical program graduates (MPGs)? We have all earned our titles. Please use them.

 

[sylvanthus]

FWIW I am comfortable with fiberoptic intubations, vent management, and managing folks with symptomatic bradycardia. Sounds like you work with a group of NPs as you mentioned they are "independent". There is a significant difference between the typical EMPA and FNP working in EM. This has been recognized by multiple past presidents of ACEP. Somewhere I have a recorded lecture done by Dr Lawrence, who was ACEP president at the time, stating "emergency medicine PAs are the next best thing to emergency physicians in the ED". I have trained with many of the pioneers in the field of emergency medicine over the years and have learned my trade well. After 150,000+ patients with no litigation and no difference in outcomes between me and the docs I work with I think my safety stats speak for themselves. As a matter of courtesy, please say PAs or NPs, not MLPs. How would you like it if you were lumped in with chiropractors and podiatrists as medical program graduates (MPGs)? We have all earned our titles. Please use them.

This is exactly why I absolutely loathe being called a "provider." That **** has to stop.

 

[Fox800]

FWIW I am comfortable with fiberoptic intubations, vent management, and managing folks with symptomatic bradycardia. Sounds like you work with a group of NPs as you mentioned they are "independent". There is a significant difference between the typical EMPA and FNP working in EM. This has been recognized by multiple past presidents of ACEP. Somewhere I have a recorded lecture done by Dr Lawrence, who was ACEP president at the time, stating "emergency medicine PAs are the next best thing to emergency physicians in the ED". I have trained with many of the pioneers in the field of emergency medicine over the years and have learned my trade well. After 150,000+ patients with no litigation and no difference in outcomes between me and the docs I work with I think my safety stats speak for themselves. As a matter of courtesy, please say PAs or NPs, not MLPs. How would you like it if you were lumped in with chiropractors and podiatrists as medical program graduates (MPGs)? We have all earned our titles. Please use them.

The term "mid-level practitioner" is codified into federal law, just FYI. As is "physician". I'm sorry that may upset you.

Also n=1 does not make your experience applicable across the field of emergency medicine. Neither does one doctor's opinion of how good physician assistants can be. I'm glad you've carved out your niche, but your experience is not typical, nor should it be, for the sake of our patients.

Emergency medicine requires physician-led care. It's literally insane that the rest of the developed world (Canada, UK, western Europe, NZ, Australia) has this figured out, but we allow this kind of thing. Surgery departments aren't letting NPs do ex laps. Stroke centers aren't letting PAs see stroke alert patients solo and order tPA. Shortcuts mean big bucks for hospitals and staffing companies.

 

[AlmostAnMD]

FWIW I am comfortable with fiberoptic intubations, vent management, and managing folks with symptomatic bradycardia

I've never seen anyone group those together

I don't have a comment either way

I'm just saying one is not the other two

EDIT: I would like to say I am trained in perimortem C-sections, lumbar punctures and using a woods lamp

 

[Fox800]

This is exactly why I absolutely loathe being called a "provider." That **** has to stop.

I didn't complete four years of provider school, thankyouverymuch.

 

[PikminOC]

I think everyone is scrambling during this covid situation so there has to be flexibility in hours and things that are asked of people. This is unprecedented

 

[Lexdiamondz]

FWIW I am comfortable with fiberoptic intubations, vent management, and managing folks with symptomatic bradycardia. Sounds like you work with a group of NPs as you mentioned they are "independent". There is a significant difference between the typical EMPA and FNP working in EM. This has been recognized by multiple past presidents of ACEP. Somewhere I have a recorded lecture done by Dr Lawrence, who was ACEP president at the time, stating "emergency medicine PAs are the next best thing to emergency physicians in the ED". I have trained with many of the pioneers in the field of emergency medicine over the years and have learned my trade well. After 150,000+ patients with no litigation and no difference in outcomes between me and the docs I work with I think my safety stats speak for themselves. As a matter of courtesy, please say PAs or NPs, not MLPs. How would you like it if you were lumped in with chiropractors and podiatrists as medical program graduates (MPGs)? We have all earned our titles. Please use them.

We get it, you are a good PA. Nobody is talking about you though, and you are decidedly not the norm when it comes to midlevels.

The average PA hasn't been in the game 30 years and can't say they've seen 150k ESI 1s and shouldn't be staffing an ED alone.

Even after completing post- graduate training in Emergency Medicine (usually only 12-18 mos) the average PA is still nowhere remotely ready to perform the duties of an independent EM physician unsupervised. Saying "I hate my job, I'm going to run to the forest where there's no oversight" isn't a safe or viable option for most PAs and isn't always the best setup for most patients.

 

[Fox800]

This is a poor analogy. Physicians include MDs and DOs. Chiropractors are not physicians. None of these fields are in the same category. The term medical program graduates isn’t a common title. On the other hand, the term midlevel provider is widely used and encompasses PAs and NPs. I intentionally use that term as I find the title APP ridiculous. There is nothing advanced about midlevels in comparison to a physician. What are physicians - advanced advanced? I’m fine using the titles physician assistant and nurse practictioner. The commonality though with MLPs is that they are all providers of care and not physicians. We aren’t going to agree on this. If you want to discuss your preference for politically correct titles, you listing GlobalDoc below your user name is misleading and somewhat inappropriate on a physician forum. I believe I’ve heard your prior arguments regarding this and don’t need to hear them again.

You come across as defensive in your posts regarding your qualifications. Most of the comments made in this thread really aren’t directed specifically towards you. As others have stated, you probably aren’t very representative of most PAs. We overwhelmingly employ PAs in our group versus NPs. Even our most experienced ones should never work single coverage without onsite physician supervision.

I’ve more than shared enough of my two cents on these topics and will leave it at that as I no longer feel this discussion is relevant to the OPs post.

Very eloquently put.

I think physicians should be referred to as "super duper final boss mega providers". That is all.

All "APP" does is make PAs and NPs feel warm and fuzzy, and make CMGs look like their staffing models are better than they really are on paper or on their public-facing websites.

 

[avalon10]

I love my EPs, but when they are asked to do solo practice in very rural environments most of them say NFW. Until this changes, rural EDs will be staffed by PAs/NPs/Family medicine physicians. I respect all you folks and know you are protecting your turf. I get that, but you all lose credibility when you both criticize me and refuse to work where there is a legitimate need. Someone has to do it and after 33 years, I am more qualified for this than most family medicine physicians.

"I respect all you folks and know you are protecting your turf. I get that, but you all lose credibility when you both criticize me and refuse to work where there is a legitimate need"

It's irrelevant to doctors whether midlevel providers such as you "respect" them or not. And a doctor's "credibility" is certainly not decided by a midlevel provider.

And why does your username say GlobalDoc if you're a PA?!?! Intentionally misrepresenting yourself like midlevel providers tend to do?

 

[WilcoWorld]

Can you guys tell I am getting burned out on the ER?

Reading this thread, I can't imagine why a PA may be getting burned out in our current environment.

 

[turkeyjerky]

I think everyone is scrambling during this covid situation so there has to be flexibility in hours and things that are asked of people. This is unprecedented

A certain degree of flexibility is reasonable. But the OP (as are many of us) is getting screwed by the CMG they work for. The reason they need to stay late or put people on call is because they cut staff in the middle of a pandemic and have refused to staff back up according.

What's unprecedented is treating medical professionals like fast food workers.

 

[deleted6669]

I've never seen anyone group those together

I don't have a comment either way

I'm just saying one is not the other two

EDIT: I would like to say I am trained in perimortem C-sections, lumbar punctures and using a woods lamp

He mentioned those specifically as things PAs are not good at. That is why I responded the way I did.

 

[deleted6669]

And why does your username say GlobalDoc if you're a PA?!?! Intentionally misrepresenting yourself like midlevel providers tend to do?

I have a doctorate in Global health and teach global health at a doctoral program. I am not a physician. I am a "doctor"(as in I possess a doctorate). I do not use that title in clinical settings. SDN is not a clinical setting.

 

[deleted6669]

The commonality though with MLPs is that they are all providers of care and not physicians.

NPP (Non-Physician Provider) is also an established term and not considered insulting. If you have to lump us together please use that or say PAs and NPs. How hard is that?

 

[Fox800]

NPP (Non-Physician Provider) is also an established term and not considered insulting. If you have to lump us together please use that or say PAs and NPs. How hard is that?

Insulting based on your feels and your professional body’s highly politicized lobbying efforts. Again, it’s a widely accepted, legally codified term at the federal level.

Physician assistants and nurse practitioners aren’t at the top. So are you at the bottom, or somewhere in the middle?

 

[deleted6669]

Insulting based on your feels and your professional body’s highly politicized lobbying efforts. Again, it’s a widely accepted, legally codified term at the federal level.

Physician assistants and nurse practitioners aren’t at the top. So are you at the bottom, or somewhere in the middle?

so double boarded docs with a PhD are highest level providers? I work with a guy with 5 board certifications(FP, IM, Pulm, EM, Anes). Is he a super-uber level provider, because compared to you with just one board certification he is a demi-god.
I am just asking for common courtesy here. If I told you my birth name was John, But I go by Jack , you would call me Jack, even though legally I am John.

 

[PikminOC]

A certain degree of flexibility is reasonable. But the OP (as are many of us) is getting screwed by the CMG they work for. The reason they need to stay late or put people on call is because they cut staff in the middle of a pandemic and have refused to staff back up according.

What's unprecedented is treating medical professionals like fast food workers.

These places are hemorrhaging money. You can always vote with your feet

 

[PikminOC]

Not sure why we are pissing about md versus pa. Let's look at the original post and work from there

 

[deleted6669]

Not sure why we are pissing about md versus pa. Let's look at the original post and work from there

As a PA I answered a question about PAs in the ER and your colleagues felt the need to tell me how inferior they think we all are. That is what happened.

 

[chocomorsel]

I am an emergency medicine PA and a former paramedic. I work mostly single coverage, rural critical access hospitals at this point. I have worked in EM since 1987 in every setting you can imagine on both sides of the country. I have worked with a lot of the big names in EM and learned from the best. My last job was at a busy trauma ctr where the EM physicians were often just glorified triage nurses unfortunately: Stemi, stabilize and call cards. Bad airway, call anesthesiology, bad fx or dislocation, call ortho, sick kid, call the peds intensivist, etc. I may have just lucked out with my choice of jobs, but I now see far higher acuity and much lower volume than I ever did before . Having fewer specialists available means YOU get to do the procedures. You deliver the teenaged kid with no prenatal care who didn't even know she was pregnant. You are the guy injecting phyenylephrine into the priapsim at 3 am because there is no urologist within 3 hrs. You look at the ugly fracture dislocation and say I will give it a try. the 400 lb pt on the floor crashes at 2 am and they call you to do the difficult intubation BECAUSE THERE IS NO ONE ELSE.
I say that I am irreplaceable here because I have a much better skill set than the vast majority of non-em boarded physicians and no em boarded folks will drive to the middle of nowhere to make 1/2 what they can in the city. I highly respect the training and dedication of residency trained and boarded emergency physicians. Very few of them are willing to come work out in the sticks without a safety net of consultants. The ones who do are super heroes.
The hospital has a choice of me or folks like me, or 30 yr old family medicine physicians right out of residency. They choose me every time. And they should.
I respect your right to your opinion about salary vs hourly, but disagree. People work better and smarter when they have the time to do what is right for the patient and don't have to move the meat. No one does their best work at 3-5 pts/hr.

So why is it you make double what you made in the City but the ER docs make less?
I prefer smaller towns myself. Feel more appreciated. Obviously not completely rural as CRNAs have that s... on lock but more small town.
I hate the big city hassle.

 

[WilcoWorld]

I worry that we (the physicians here) are punching down here, when we should be punching up.

"Punching down" is bad because it makes you feel good, as if you've done something, but it doesn't actually address the problem.

If you could choose between:
1 - Reforming medical administration so that CEO salaries don't exceed the top-earning physicians at their hospitals, and their salaries were tied to patient outcomes, but you always had to call NP or PAs "APPs".
vs
2 - Calling PAs and NPs "midlevels" while allowing hospital administrators without any sort of medical degree to dictate patient care.
Which would you chose?

The answer's pretty clear to me. So I call NPs "NPs" and PAs "PAs" while I call administrators by their first name and educate them on how their decisions negatively impact patients every chance I get.

 

[deleted6669]

So why is it you make double what you made in the City but the ER docs make less?
I prefer smaller towns myself. Feel more appreciated. Obviously not completely rural as CRNAs have that s... on lock but more small town.
I hate the big city hassle.

EM boarded docs in my rural dept make the most, followed by FP docs, followed by PAs. EM docs in the city can make $250/hr, FP docs can't get EM jobs in the City and PAs make 50-60/hr. Here the EM docs get around 150/hr and the FP docs make around 100 and the PAs based on experience make 75-100/hr.
PS the highest paid employee here is not the CEO, it is the CRNAs who take call 24/7/365 and get their regular rate whether or not they ever come in.

 

[bravotwozero]

I worry that we (the physicians here) are punching down here, when we should be punching up.

"Punching down" is bad because it makes you feel good, as if you've done something, but it doesn't actually address the problem.

If you could choose between:
1 - Reforming medical administration so that CEO salaries don't exceed the top-earning physicians at their hospitals, and their salaries were tied to patient outcomes, but you always had to call NP or PAs "APPs".
vs
2 - Calling PAs and NPs "midlevels" while allowing hospital administrators without any sort of medical degree to dictate patient care.
Which would you chose?

The answer's pretty clear to me. So I call NPs "NPs" and PAs "PAs" while I call administrators by their first name and educate them on how their decisions negatively impact patients every chance I get.

While your point is valid, this is a moot discussion as nobody has the power to reform medical admin.

 

[WilcoWorld]

While your point is valid, this is a moot discussion as nobody has the power to reform medical admin.

You may be right, but I'm not entirely convinced that is the case.
However, if you're wrong and we still have a chance of reforming medical admin, our cause is certainly not helped by viewing APPs and Physicians as enemies. Rather, that plays right into the admin's hand.

(sorry for the delayed edit)

 

[Mr. D.O.five]

only read the title but can I get a "hoooo yeahhhhh"

 

[PikminOC]

I worry that we (the physicians here) are punching down here, when we should be punching up.

"Punching down" is bad because it makes you feel good, as if you've done something, but it doesn't actually address the problem.

If you could choose between:
1 - Reforming medical administration so that CEO salaries don't exceed the top-earning physicians at their hospitals, and their salaries were tied to patient outcomes, but you always had to call NP or PAs "APPs".
vs
2 - Calling PAs and NPs "midlevels" while allowing hospital administrators without any sort of medical degree to dictate patient care.
Which would you chose?

The answer's pretty clear to me. So I call NPs "NPs" and PAs "PAs" while I call administrators by their first name and educate them on how their decisions negatively impact patients every chance I get.

Admin doesn't care. They only look at money

 

[WilcoWorld]

Admin doesn't care. They only look at money

I don't disagree.

 

[chocomorsel]

EM boarded docs in my rural dept make the most, followed by FP docs, followed by PAs. EM docs in the city can make $250/hr, FP docs can't get EM jobs in the City and PAs make 50-60/hr. Here the EM docs get around 150/hr and the FP docs make around 100 and the PAs based on experience make 75-100/hr.
PS the highest paid employee here is not the CEO, it is the CRNAs who take call 24/7/365 and get their regular rate whether or not they ever come in.

How much are they making? But they are always touting about how much cheaper they are. Full of crap. Lies lies.

 

[deleted6669]

How much are they making? But they are always touting about how much cheaper they are. Full of crap. Lies lies.

>350k/yr

 

[12jas]

EM physicians were often just glorified triage nurses unfortunately

As a PA I answered a question about PAs in the ER and your colleagues felt the need to tell me how inferior they think we all are. That is what happened.

Don't act innocent. I am sorry but your attitude and some of the things you have said are insulting. Coming onto an EM physician board calling them "glorified triage nurses" is not going to gain you a lot of love.

 

[deleted6669]

Don't act innocent. I am sorry but your attitude and some of the things you have said are insulting. Coming onto an EM physician board calling them "glorified triage nurses" is not going to gain you a lot of love.

Fair enough. I apologize. I could have worded that better and said " at my last job the volume is such that the EM physicians end up handing a lot of the management of their patients over to specialists because they just don't have time to do a lot of procedures. . ". Once again, I do apologize.

 

[EctopicFetus]

I love my EPs, but when they are asked to do solo practice in very rural environments most of them say NFW. Until this changes, rural EDs will be staffed by PAs/NPs/Family medicine physicians. I respect all you folks and know you are protecting your turf. I get that, but you all lose credibility when you both criticize me and refuse to work where there is a legitimate need. Someone has to do it and after 33 years, I am more qualified for this than most family medicine physicians.

I am gonna say something unpopular with you and most FM docs who work In the ED. If they can't hire a residency-trained EP in 2020 then they shouldn’t be EDs. It’s real simple. Can you have a cath lab without an interventional cardiologist? No. Same thing. I get you don't like that. Some MLPs are better than FM docs in the ED I give you that. But both are far inferior to EM docs. That's my point. Keep those facilities, label them what they are which is urgent care with a CT scanner, and be done with the stupidity of the whole thing.

I don’t criticize MLPs for working wherever they are. I criticize the system. My criticism is of any doc or MLP who isn't equipped to do their job. My group staffs multiple rural EDs so let's stop there. You know what we did.. moved to as many EM trained docs as we could and got rid of the dead weight MLPs and brought on ones who both understood their role and were good at it.

Good docs and MLPs know and understand their limits. When I was a resident I cathed a patient, I did a PEG. I did a bunch of other stuff too. Today I don't do those things because I understand my limits. Many MLPs like to pretend they are equal to docs which is nonsense. MLPs often know how to do something but not the why. It’s that missing bit that leads to mistakes. You don't know what you don't know. EM docs spent 4 years in school and 3 years in residency to minimize what they don't know. MLPs spend maybe 15% of the time learning before they are set free.

 

[deleted6669]

Ectopic- I agree with most of what you say here. A good clinician regardless of the initials after their name is aware of their limitations and seeks to minimize those through ongoing education and training. We are able to get some EM docs at my primary facility, but none who are willing to be here full time or even half time. We are down to one FM doc at this point and when he leaves we will never hire another FM physician.

 

[EctopicFetus]

Ectopic- I agree with most of what you say here. A good clinician regardless of the initials after their name is aware of their limitations and seeks to minimize those through ongoing education and training. We are able to get some EM docs at my primary facility, but none who are willing to be here full time or even half time. We are down to one FM doc at this point and when he leaves we will never hire another FM physician.

Truly they "cant get" EM docs is a misnomer. It should say "they don't want" to get an EM doc. See if you pay enough you can get whatever you want. Pay $400/hr you will get an EM doc. If you want to be a chest pain center that can cath you CAN do it hospitals CHOOSE not to do it.

 

[chocomorsel]

Truly they "cant get" EM docs is a misnomer. It should say "they don't want" to get an EM doc. See if you pay enough you can get whatever you want. Pay $400/hr you will get an EM doc. If you want to be a chest pain center that can cath you CAN do it hospitals CHOOSE not to do it.

Is this what EM docs are making? $400 an hour? Is this the norm? In the city? I had read on this very forum that those days are gone.
I agree with you though that these rural hospitals often don't want to pay city prices. But it seems like they do for surgeons.
However, let me counter your question with this. Before the advent on the EM path, these rural hospitals still existed. Why is it back then, the FM docs were good enough to staff these same rural hospitals but now 30 years later (I am not sure how long EM has been a specialty) or so, they aren't good enough to be rural hospitals, but are glorified urgent cares with a CT scanner? Are they all supposed to close down their ERs?

Rural people need ERs too you know. I say this as a travel doc who sees how deficient smaller towns are in physicians while in the city they are climbing all over each other like crabs in a damn bucket and fighting for jobs/shifts. Makes no sense.

 

[chocomorsel]

Ectopic- I agree with most of what you say here. A good clinician regardless of the initials after their name is aware of their limitations and seeks to minimize those through ongoing education and training. We are able to get some EM docs at my primary facility, but none who are willing to be here full time or even half time. We are down to one FM doc at this point and when he leaves we will never hire another FM physician.

How small are these hospitals that can't find EM docs? In anesthesia, the CRNAs literally have it on lock with their pass thru money they get from government. So hospitals will just up and tell you that they don't hire MD/DOs. Just CRNAs.
Plus I can see how one could lose skills working in a very small 25 -50 bed hospital.