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Any updates, people? I've been following this crap since someone posted it in my old residency group chat. This crap is one of the reasons I went onto do a critical care fellowship, though now i've learned that the ICUs have got the same thing coming to them. It's absolutely shameful that we aren't allowed to protect our profession. Has anyone talked to this PD at Yale? Does anyone know any Yale EM physician residents? (amazing that we have to make this distinction now). I can't imaging their residents are feeling good about this. A program cannibalizing it's own resident's training.
 

UrbanEM2

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So just to make sure I understand, would you all rather just not have PAs in the ER at all? If the answer is you're ok with them in the ER, wouldn't you want them better trained?

Sounds like you would rather call their "residency" training something else and ultimately want them referred to as something other than "providers" or "APPs".

But is anyone against the idea of PAs working in the ER?

Just trying to wrap my head around this is all.
 
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I’ve never even heard of such a thing. Is this really widespread in the US?!?
Mostly in the HMOs , like Kaiser. I was offered a position doing this more than 15 years ago in kaiser's colorectal clinic. I declined. The entire scope of practice was colonoscopies and banding hemorrhoids. No thanks. Their model at the time was six months of doing directly supervised scopes then independent performance of scopes with GI Physician review of images, so there were some safeguards in place. (and yes, a patient might end up getting a repeat colonoscopy if the PA didn't biopsy a suspicious lesion, etc, although I never heard of this happening).
If I was going to do a single skill all day long, this would be more fun (note, 20 year old study):
 

Emedpa

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So just to make sure I understand, would you all rather just not have PAs in the ER at all? If the answer is you're ok with them in the ER, wouldn't you want them better trained?

Sounds like you would rather call their "residency" training something else and ultimately want them referred to as something other than "providers" or "APPs".

But is anyone against the idea of PAs working in the ER?

Just trying to wrap my head around this is all.
As the most senior EMPA on SDN I can assure you that the vast majority of docs I work with are happy to see me when I show up for a shift. On the internet, there is a vocal minority of physicians in every specialty who would do away with everyone who is not residency trained and boarded in their specialty practicing in their specialty. The derm guys say a family med doc shouldn't do punch biopsies, etc. It is all about turf. I understand folks getting upset when PA/NP use the terms residency and fellowship, but they get upset even when the programs are called "postgraduate training for PA/NP in XYZ specialty". Many of the more vocal docs on this forum believe PAs either should not exist outside of primary care or should only do supervised scut work. Primary care docs say PA/NP should not do primary care. It is all about turf. You seem like a reasonable physician, just like most of the docs I work with. You realize there is a job to do and we are all here to make each others lives easier. Until there are both enough EM residency trained and boarded docs to cover every ED shift in every ED in the country and the EM physicians are willing to work in small rural facilities , non-physician providers will remain a reality.
 
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UrbanEM2

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As the most senior EMPA on SDN I can assure you that the vast majority of docs I work with are happy to see me when I show up for a shift. On the internet, there is a vocal minority of physicians in every specialty who would do away with everyone who is not residency trained and boarded in their specialty practicing in their specialty. The derm guys say a family med doc shouldn't do punch biopsies, etc. It is all about turf. I understand folks getting upset when PA/NP use the terms residency and fellowship, but they get upset even when the programs are called "postgraduate training for PA/NP in XYZ specialty". Many of the more vocal docs on this forum believe PAs either should not exist outside of primary care or should only do supervised scut work. Primary care docs say PA/NP should not do primary care. It is all about turf. You seem like a reasonable physician, just like most of the docs I work with. You realize there is a job to do and we are all here to make each others lives easier. Until there are both enough EM residency trained and boarded docs to cover every ED shift in every ED in the country and the EM physicians are willing to work in small rural facilities , non-physician providers will remain a reality.

So based on your read, the opposition on this thread would rather there just be no PAs and all ER shifts covered by ER doctors?

That would significantly hit a lot of CMG employed docs' pay.

I'm just confused. People complain that the PAs are no good. You give them extra training then they complain they get extra training. What is it that you want?
 
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Emedpa

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So based on your read, the opposition on this thread would rather there just be no PAs and all ER shifts covered by ER doctors?

That would significantly hit a lot of CMG employed docs' pay.

I'm just confused. People complain that the PAs are no good. You give them extra training then they complain they get extra training. What is it that you want?
Either 100% physician coverage or PAs just doing scut with 100% doc supervision without liability. They complain that they don't want to sign our notes, so we do away with doc signature requirements while maintaining a supervisory relationship and then they complain we are working without oversight. As a PA, I can assure you it is incredibly frustrating. That is why I only work places I am appreciated now. 100% rural, critical access hospitals.
 

UrbanEM2

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Just seems like the goal posts keep moving. I just want to wrap my head around what people actually want.

I agree, I wouldn't want people with less training taking over my job. But no one here is proposing any solutions. No one has said get rid of any midlevels working in the ER, but that seems to be what some people are skating around. I can't imagine that's a good solution either.

Maybe the reality is all that training we go through to become board certified doctors isn't really all the necessary? I always felt that the often prohibitive training to become a physician was just a way to thin the ranks and keep barriers to entry high. Society has decided the baseline level of competence they demand from the medical profession and if society is ok with midlevels taking care of people, then maybe society has spoken?

Again, easy for me to say as someone who hasn't seen a patient in over 10 years and I'm sure I'd be threatened if my shifts were being filled by non-MDs. It just seems to me people are frustrated but don't have any solutions.

Based on other threads here, there are total garbage MDs working in ERs. There are great PAs out there too. Would you rather that garbage MD fill a shift and see patients more than a supervised PA?
 
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Emedpa

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Spoken by a guy who has been sued for a negligent PLP mistake, never saw the patient, and was forced to sign the chart.
This should not have happened obviously. The goal of current legislation is that PAs will be responsible for their own actions unless a physician was directly involved in the care of the patient. In Michigan this is now reality. Physicians still are the captains of the ship as "Participating Physicians", but decide oversight at the practice level and are specifically not liable for PA errors.
 

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Maybe if the vast majority of PLPs didn't suck, and actually did what they were told to do when given direction instead of throwing a tantrum, this wouldn't be a problem.

Spoken by a guy who has been sued for a negligent PLP mistake, never saw the patient, and was forced to sign the chart. Oh, and that petulant PLP... had failed all attempts at education, yet couldn't be "fired".

"Vast majority" seems like hyperbole. You don't know all PLPs to make that claim.

Seems like in that case, the need to shift liability and the ability to fire incompetent PLPs is the solution.
 
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UrbanEM2

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I know some of their faculty, they're actually pretty nice people

It's incredible what people will say on an anonymous forum. I wonder how many would tell the attending in the Yale ER that if they ever ended up getting good care there.
 
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UrbanEM2

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With great power comes great responsibility.
Seems like the admins and PLPs want all of the power, but none of the responsibility. They can hide behind their liability shields and pack their golden parachutes into their backpacks.

The emporer is not wearing new clothes.

On this I will agree with you. The autonomy/accountability split in EM is off.

I would argue that's because physician arrogance basically locked MDs out of any real decision making meetings over the last 30 years. Now everyone else has taken over. Good behavior is generally rewarded in the long term. Short game tantrums never win.
 
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doctalaughs

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On this I will agree with you. The autonomy/accountability split in EM is off.

I would argue that's because physician arrogance basically locked MDs out of any real decision making meetings over the last 30 years. Now everyone else has taken over. Good behavior is generally rewarded in the long term. Short game tantrums never win.

You have an interesting perspective being in an industry that has sort of driven the shift from physician care to midlevel care in the USA (sounds like you work for a hedge fund that does medical investments; not sure in direct patient care companies or not).

Usually the argument has been that we “need” midlevels because we can’t provide enough care with physicians only, and they are cheaper.

The problem is that “cheaper” doesn’t mean patients ever see this money. As everyone knows healthcare costs in the USA are way higher than any other first-world country, most of which provide their citizens with largely physician-level care. So where is all that extra money going?? Probably to the admins and investor class (ie siphoned off by vehicles such as hedge funds and PE).

You well know that one of the major ways large PE firms can pocket that money is taking over a physician group, move the “provider balance” to less physicians and more midlevels - and pocket the salary difference.

Do the patients pay less? No, of course not. Do they get inferior care? Hard to prove, and while you use the common argument “well, there are incompetent physicians just like incompetent PAs/NPs” we ALL know there is a bell curve. Common sense would say that on AVERAGE more/higher intensity training (and higher caliper initial intellectual talent bar on average to start) would result in a better qualified caregiver.

That’s why I find your arguments so.... disconnected with reality on the ground.

No one is arguing against better midlevel training. We are arguing against blurring the lines between physicians and midlevels. And the continued vested interests to blur these lines (with likely harm to patients in the name of corporate profits).
 
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KGflyboy

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My personal experience is that most of us, not just the ones on SDN, feel that every patient in the ED should be managed by a physician. That's not an option anymore, so we work with our PA and NP colleagues and maintain mostly good relationships. But don't let that mislead you into thinking we actually think the quality of care is sufficient. It is not. I cringe reading notes sent to me for cosignature. It's bad. Patients deserve better. They deserve physicians.

I support PPP.

 
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Emedpa

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No one is arguing against better midlevels training.
except that several folks in this thread ARE doing this by saying we need to hold onto our turf and not train PAs to do our job...PAs in the ED are a reality that is not going away. There is no downside to having PAs getting additional training.
 
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Emedpa

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My personal experience is that most of us, not just the ones on SDN, feel that every patient in the ED should be managed by a physician. That's not an option anymore, so we work with our PA and NP colleagues and maintain mostly good relationships. But don't let that mislead you into thinking we actually think the quality of care is sufficient. It is not. I cringe reading notes sent to me for cosignature. It's bad. Patients deserve better. They deserve physicians.

I support PPP.

would you prefer an FM physician 6 months out of residency staffing a rural ED or a PA/NP who had been doing just that for > 20 years. I won't argue against the concept that an EM residency trained and boarded physician is ideal, because that is in fact the case.
 

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except that several folks in this thread ARE doing this

They are arguing against how Yale is doing it (calling it a residency, claiming the PAs in this program have exactly the same experience, objectives and standards as the physician residents who went through medical school and internship).

If Yale had a PA “em certificate” program where they did NOT claim the same training/ curriculum/ standards as physicians and did not attempt to blur the lines between docs and midlevels I doubt anyone would object.
 
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UrbanEM2

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You have an interesting perspective being in an industry that has sort of driven the shift from physician care to midlevel care in the USA (sounds like you work for a hedge fund that does medical investments; not sure in direct patient care companies or not).

Usually the argument has been that we “need” midlevels because we can’t provide enough care with physicians only, and they are cheaper.

The problem is that “cheaper” doesn’t mean patients ever see this money. As everyone knows healthcare costs in the USA are way higher than any other first-world country, most of which provide their citizens with largely physician-level care. So where is all that extra money going?? Probably to the admins and investor class (ie siphoned off by vehicles such as hedge funds and PE).

You well know that one of the major ways large PE firms can pocket that money is taking over a physician group, move the “provider balance” to less physicians and more midlevels - and pocket the salary difference.

Do the patients pay less? No, of course not. Do they get inferior care? Hard to prove, and while you use the common argument “well, there are incompetent physicians just like incompetent PAs/NPs” we ALL know there is a bell curve. Common sense would say that on AVERAGE more/higher intensity training (and higher caliper initial intellectual talent bar on average to start) would result in a better qualified caregiver.

That’s why I find your arguments so.... disconnected with reality on the ground.

No one is arguing against better midlevel training. We are arguing against blurring the lines between physicians and midlevels. And the continued vested interests to blur these lines (with likely harm to patients in the name of corporate profits).

You bring up several good points. I have in the past used midlevels in companies I've owned. They have all been outpatient focused companies and the doctors were all in favor since the NP/PAs worked under them and their clinical guidelines. We would always bring the docs in to set the midlevel policy and decide how they would be used to increase throughput. In these settings, we poured over outcomes data to see if there was any impact on outcomes to have midlevels working in this capacity and there wasn't.

EM is different since they are basically functioning in the same capacity as the ER attending. So I understand the frustration. I've been burned myself, albeit many years ago. That's why I asked what the solution is in much the way I'd ask what the solution is to the physician leaders at a company I owned. If someone had asked me when I got burned by a PAs management, I would have said better training. Training programs, maybe even PA residencies. That's why I'm so confused by the outrage here. This is the exact solution I would have proposed.

Many on here have in fact argued against better midlevel training so I don't really understand what the solutions being proposed here are.
 
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UrbanEM2

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They are arguing against how Yale is doing it (calling it a residency, claiming the PAs in this program have exactly the same experience, objectives and standards as the physician residents who went through medical school and internship).

If Yale had a PA “em certificate” program where they did NOT claim the same training/ curriculum/ standards as physicians and did not attempt to blur the lines between docs and midlevels I doubt anyone would object.
Finally a solution! The only thing here is it's literally just semantics. Let's just call it something different but keep the actual training the same. Let's have the PAs do the same training but call it something else so the doctors are less hurt. If what you're holding onto is that you did a "residency" then you really need to rethink where you are in your career.

I find when people are pulling at semantics as solutions, there are really at the extreme end of desperation.
 
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Emedpa

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They are arguing against how Yale is doing it (calling it a residency, claiming the PAs in this program have exactly the same experience, objectives and standards as the physician residents who went through medical school and internship).

If Yale had a PA “em certificate” program where they did NOT claim the same training/ curriculum/ standards as physicians and did not attempt to blur the lines between docs and midlevels I doubt anyone would object.
Except that Yale and many other postgrad programs ARE doing exactly this. If a PA is the student of the day they do XYZ. If a physician is the student they do exactly the same things. Both are required to be supervised by an attending, etc. I know quite a bit about this program and most of the other EMPA postgrad programs. I know grads of most of them and directors of several of them. A few are run by physicians who themselves used to be PAs. What is "blurring the lines" is that medschool programs are getting shorter and PA programs are getting longer. There are already bridge programs that credit PAs for their entire 3rd year when attending medschool. At my Medschool-based PA program 25 years ago the rotation slots were called PA2/MS3. We did the same stuff, took the same call, had the same patient loads, etc.
 
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greatnt249

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I think the real issue here is that the very nature of medicine can be very unforgiving to those who "don't know what they don't know," and it frustrates us when even our own physician colleagues can't admit to this. When someone with far less training has this same attitude and thinks we're just "not being good team players" yet we're still liable for the decisions being made, it takes that insult to a different level. It's not the level of training that is necessarily bothersome; it's the inability to recognize that you don't know what you don't know and at the same time lobby to be on the same playing field.
 
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I know their EMPA program director. Also a very nice guy.
It's funny, the whole reason that going to med school ever came to mind for me was one of higher ups in the EM program. On me saying I was planning to go to PA school, she asked "but why?" "Well, if I go to med school I won't be done with residency until I'm 36..." "You're going to be 36 someday anyway, why not be 36 and a doctor?" They were all, at least back in those days, pretty good to work with, though I've got no clue how many of them are still around. Turnover was never really that high, so I'd imagine most are the same old faces.
 
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greatnt249

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Ha! Do you call the PAs you work with "low level providers"? I'd love to see that and the kind of treatment you get after that. What if one of your kids goes to PA school or marries a PA? Would you call them a "low level provider" at the dinner table? The level of arrogance is sickening.

Also to your point about confrontation, I've been on the receiving end of physician bad behavior for over a decade and always confront it when I see it. Repeated arrogance and abuse, such as calling someone a "low level provider" more than once would probably get someone fired pretty.

Just be kind and and not disrespectful.

I think it's important to not conflate being kind/respectful to being on the same experience/training level.
 
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doctalaughs

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Finally a solution! The only thing here is it's literally just semantics. Let's just call it something different but keep the actual training the same. Let's have the PAs do the same training but call it something else so the doctors are less hurt. If what you're holding onto is that you did a "residency" then you really need to rethink where you are in your career.

I find when people are pulling at semantics as solutions, there are really at the extreme end of desperation.

Except it’s not semantics.

Midlevels did not go to 4 years of med school so Yale’s claim that they can achieve the same proficiencies and training is not only lying to the PAs, it’s intentionally blurring the lines to patients.

No one would create a “equivalent training program” for new lawyers and paralegals and try to train them side by side with the same material. Sure, you could do that but it would be both illegal and immoral if the paralegals used the program as justification to practice law independently when they finished.
 
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doctalaughs

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You bring up several good points. I have in the past used midlevels in companies I've owned. They have all been outpatient focused companies and the doctors were all in favor since the NP/PAs worked under them and their clinical guidelines. We would always bring the docs in to set the midlevel policy and decide how they would be used to increase throughput. In these settings, we poured over outcomes data to see if there was any impact on outcomes to have midlevels working in this capacity and there wasn’t

Glad you are trying to insert ethics in those decisions. As you know, many making these decisions are absolutely not (only looking at the bottom line).

As an aside, the doctors you speak with are complicit as they probably also stand to make a lot of money too as the decision-makers and practice owners. They are equally to blame. And there are PLENTY of outpatient situations now where the midlevels are acting like the attending physician, just like these setups in the ED.
 
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would you prefer an FM physician 6 months out of residency staffing a rural ED or a PA/NP who had been doing just that for > 20 years. I won't argue against the concept that an EM residency trained and boarded physician is ideal, because that is in fact the case.
That's a good question. There is no easy answer here. In theory, I would want an all physician team. There is no need for any PA or NP if there are enough physicians. It would probably depend on the training of each. In your specific example, it is easy to see how the PA might do better in many situations and the doc better in others.

The point is I would rather see a FM physician with 20 years experience than a PA with 20 years experience. Competing a fresh FM physician with a seasoned PA with many years of ED experience is not a good comparison because at that point individual differences in knowledge and skill will vary too much to consistently predict which is better.

The best option is physician only care in my opinion. The solution to a physician shortage is to produce more physicians... not produce people with less training and substitute them for physicians when a cheaper cog in the wheel is needed. My group has made a strong effort to minimize and eliminate midlevels in our group and staff everything with physicians as much as possible. Our patients consistently request this, and our physicians like it because we tend to see patient's much quicker and manage more patients at a time. It is great for throughput, patient satisfaction, and I think better for patient care.

I know examples of other countries utilizing midlevels has been cited already, but I really don't see any examples of other countries doing what we do. The drastic expansion of midlevels and shift of care from physicians to midlevels is not common in developed countries. We are kind of the "leaders" in this regard, and I don't think we should be proud of it.
 
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Emedpa

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The point is I would rather see a FM physician with 20 years experience than a PA with 20 years experience. Competing a fresh FM physician with a seasoned PA with many years of ED experience is not a good comparison because at that point individual differences in knowledge and skill will vary too much to consistently predict which is better.
what if the doc had 20 years in the FM clinic and the PA had 20 years all in the ED? This is a very real question and one that many rural hospitals deal with. In my neck of the woods, we got rid of the FM docs who would come dabble in the ED a few days a year in favor of EM docs and senior EM PAs with 20+ years of experience.
 

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what if the doc had 20 years in the FM clinic and the PA had 20 years all in the ED? This is a very real question and one that many rural hospitals deal with. In my neck of the woods, we got rid of the FM docs who would come dabble in the ED a few days a year in favor of EM docs and senior EM PAs with 20+ years of experience.

You are making irrelevant arguments. This is a fringe situation that doesn’t apply to 99% of hospitals and clinics across the country. Of course if you do something for 20 years you are probably going to be better (at that specific skill set) than someone who hasn’t regardless of credentials.

All across the country there are midlevels who DON’T have 20 years experience in a specific field making the end-point decisions for patients... with the tacit encouragement of corporate overlords, laws changed by lobbying (and greedy physicians).

There’s little we can do at this point but doesn’t change the fact that as a society this arrangement is not good.
 
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most of your colleagues would disagree with this. They think of medschool as some magic place that makes you better than everyone else.
Not morally better, but, more deeply educated, and technically better. There is nothing magic about it, although that snide statement is noted.

Or, to counter your statement - if you are sarcastic and mocking of med school, then, do you think that PAs are equal to doctors? Your example of "20 year experienced PAs" is, as was said above, vanishingly rare. The education - both classroom and clinical - is just not equivalent. There is just more to doctors. The PA residency is trying to close that gap a bit. Optimally, these PA residency trained providers would work with and next to doctors, but, the fear is (and you have said outright occurs) that these providers would desire to be in place of the doctors.

I can extrapolate my experience to literal thousands of EM residency trained doctors. Your experience has an N of 1. And what about a PA with, not 20 years, but, say, 15 or 10 years in the ED? Where is the "bright line" that one crosses to go from "not equivalent" to "equivalent"?
 
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Emedpa

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Or, to counter your statement - if you are sarcastic and mocking of med school, then, do you think that PAs are equal to doctors?
I think a specialty PA knows more about their specialty than the vast majority of physicians that do not practice that specialty. 99% of residency trained and boarded EM physicians are better at EM than any PA, EMPA or otherwise. I am not arguing that point. You guys are not my competition. FP docs thinking they can work one shift a month in the ED and be competent are my competition. Several of the larger EM groups in my area allow FP MDs to apply for specific PA spots.
From a local Ad:
The APP is an integral part of the Emergency Medical team and assists the flow and direct care of the patients within the Emergency Department. They can either be a Physician Assistant (PA) or Nurse Practitioner (NP) or a Physician not boarded in Emergency Medicine. PAs are dependent practitioners, and typically practice considerable autonomy under the supervision of a licensed Physician. NPs are independent medical providers, but within the XXX system they function under the licensed physician on duty. Non-Emergency Medicine boarded physicians may fill APP roles in the ED, practicing under their own license.
 
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I don't worry too much about the MLPs. Most of the ones we have are adequately competent as long as supervised. Most patients coming into the ER don't have an emergency, or life threatening condition (female abdominal pain), so their broad scattershot workups on everyone are usually adequate for catching badness. I make sure to review all their patients in real time, and intervene if I see anything concerning in the their vitals and labs.

Ultimately they'd better not argue with me about a disposition or treatment plan if I overrule them.
 
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doctalaughs

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I don't worry too much about the MLPs. Most of the ones we have are adequately competent as long as supervised. Most patients coming into the ER don't have an emergency, or life threatening condition (female abdominal pain), so their broad scattershot workups on everyone are usually adequate for catching badness. I make sure to review all their patients in real time, and intervene if I see anything concerning in the their vitals and labs.

Ultimately they'd better not argue with me about a disposition or treatment plan if I overrule them.

And this is how they are supposed to be used (and what they are trained for).

Honestly, they are used in worse ways in a lot of outpatient specialties where across this country you could see solely a midlevel (with no real-time physician review and no “real” supervision) for visit after visit from primary care to cardiology to neurology to dermatology. Maybe a few of these “essentially solo” practitioners have 20 years of solid specialty-specific training. But vanishingly few. There’s a reason board certification is the bar we should set (EM seems to be somewhat of anomaly allowing other specialties to masquerade as attendings in the ED).

Why is this? Greed/money (and not a dime of the “savings” seen by patients).

Sad really, as a society. We are specifically selling the American public an inferior product and charging them for the gold-standard (plus more).
 
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sylvanthus

Attending
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Aye always cracks me up when a midlevel spends so much effort stating their vast number of yeats of experience. Thats not the point. There are always outliers. The point is the “average” PA/NP vs the “average” board certified EM physician. Noone can argue these average compentency levels are the same. When midlevels are totally independent these averages will result in bad outcomes, poor workups, overuse of resources.
 
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jw3600

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Jan 7, 2013
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I just spent a lot of time catching up on posts. About 10 posts ago I started a draft of a post trying to diplomatically ask UrbanEm to get verified because literally everything they post...well does not sound like an emergency medicine doc. And then I saw the last couple posts and see I’m not alone. All I see is literally anti doctor (we’re too mean to each other; who would invite us to meetings 🙄) and pro EM PA comments. I understand it’s an online forum but if you’re going to project an air of attending-hood on an EM forum and try and let others know about how much better it is being out of clinical medicine maybe you should have to confirm your credentials.

edit: also for your viewing pleasure:

7899705F-B010-440F-9F6D-6CB0F4352B75.png
 
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TimesNewRoman

EM/CCM
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May 14, 2013
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It's incredible what people will say on an anonymous forum. I wonder how many would tell the attending in the Yale ER that if they ever ended up getting good care there.

I wonder how many retired ER docs would show up in a room full of ER docs and repeatedly tell them how they’re awful if it wasn’t an anonymous forum?
 
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southerndoc

life is good
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Jun 6, 2002
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Closing the thread as I think it's run it's course. Things are getting personal. Several posts were moved to the Off-Topic Forum. Feel free to go there to bash it out.

If you feel like I have inappropriately closed the thread due to lack of objectivity, then please contact an admin or another moderator. I try to be objective here, but I think the thread should be closed since this is now the fourth time I've moved or deleted posts that have gotten personal.
 
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