Why PAs and NPs Don't Help
I've worked with an assortment of physician assistants and nurse practitioners in various ERs, and while some of them were wonderful clinicians, I found that they weren't all that beneficial to the cause. Our group no longer employs them.
These midlevel providers are typicallygood competent at procedures, so having them sew up a laceration or drain an abscess while you crank through a few patients can be helpful in clearing the waiting room. But procedures are big money-makers in the ER, so unless the doc personally supervises the assistant, he is losing money if the PA does the procedure. Many docs commit fraud by saying they personally supervised the procedure when they really just looked at the results afterward (if that). And it's uncomfortable to me to make a paying patient settle for the services of a PA when they are paying for my services. And it's REALLY uncomfortable when their results are suboptimal.
Instead, you could use the assistants to see the minor stuff while you do the procedures. So when you get done with the laceration repair, maybe you have the PA ready to present two or three kids with colds. But when you look at the census, you see that you have a septic nursing home resident that needs to be seen NOW, and a drunk guy on a backboard that needs to be seen next. So either you are going to have to commit fraud by signing the charts of the kids with colds so you can get them out the door (and bill for their visit) without personally evaluating them, or you could make them wait until you have seen the sicker patients first before doing a quick evaluation on them (like you would do without a PA), or you could delay your evaluation of the sicker patients in order to move the meat (not likely).
Instead, you see the septic NH resident, you let the PA see the drunk guy on the backboard, and the kids with colds wait longer, like they would without a PA. But you still have to go around and see everyone anyway, and if you are a good doctor it won't take you much longer than it would have without a PA. The door to caregiver time for the minor stuff is decreased, but the time in department often isn't. And the annoying interruption factor is significantly increased. When you've got a department stacked with sick patients, the last thing you want to deal with is a PA standing there trying to present a kid with a sore throat to you.
That's why PAs and NPs don't really help.
These midlevel providers are typically
Instead, you could use the assistants to see the minor stuff while you do the procedures. So when you get done with the laceration repair, maybe you have the PA ready to present two or three kids with colds. But when you look at the census, you see that you have a septic nursing home resident that needs to be seen NOW, and a drunk guy on a backboard that needs to be seen next. So either you are going to have to commit fraud by signing the charts of the kids with colds so you can get them out the door (and bill for their visit) without personally evaluating them, or you could make them wait until you have seen the sicker patients first before doing a quick evaluation on them (like you would do without a PA), or you could delay your evaluation of the sicker patients in order to move the meat (not likely).
Instead, you see the septic NH resident, you let the PA see the drunk guy on the backboard, and the kids with colds wait longer, like they would without a PA. But you still have to go around and see everyone anyway, and if you are a good doctor it won't take you much longer than it would have without a PA. The door to caregiver time for the minor stuff is decreased, but the time in department often isn't. And the annoying interruption factor is significantly increased. When you've got a department stacked with sick patients, the last thing you want to deal with is a PA standing there trying to present a kid with a sore throat to you.
That's why PAs and NPs don't really help.
Labels: ER, health care crisis, physician assistants
posted by scalpel at 2:50 PM
69 Comments:
This is not helping my deliberation: to continue on my pre-PA school path or to stick with the original plan: go to med school.
Aren't most PA's settling because they do not have the resources to become physicians?
My advice: if you can get into med school and have the additional requisite resources to complete the program and training then do it. If you cannot, but aspire to be a clinician, become a PA-C.
I am in and out of a lot of hospitals (at least when I'm on two feet and able to work) and it seems like there is a lot of variation present with respect to how PA's and NP's function. Seems like in one hospital the mid-level folks do what you describe near the beginning of the post and in another they work "a la part deux." Yet in another set of hospitals (specifically the teaching hospitals in the Longwood section of Boston) I go into there are no PA's or NP's to be found because there are MD residents working. When I ripped my Achilles I was seen in the ED at the hospital we contract with, and while I was there I was seen by a resident (third year, I think) and an attending. The care was decent; not great, but decent.
On the other hand, my wife had to be seen for a migraine recently, and we went to the Urgent Care facility affiliated with the hospital our PCP is part of. She was seen by a PA, and the PA really sucked! The level of care she received was poor enough that two things happened: I took her to the ED to continue her care (which was a good move) and I filed a complaint with the director of medical staff affairs.
Thanks for the post, Scalpel - it's a good one.
I just read what I wrote, and I have to clarify something: I know a number of really good PA's. This particular one that treated my wife just happened to be a donkey on two feet.
Either things are really different in texas, or you're missing a major point here.
We pay our PAs somewhat less than half what the doctors are paid; they bill at the same rates we do, and generate almost the same amount of revenue per hour worked. So for every hour they work, the physicians get to keep more than half the revenue generated, which goes to support the physicians' income.
We justify that by the fact that a) the PAs are working under our licenses, and b) we are tasking the PAs with the most profitable but lowest-risk patients, and this frees up the docs to see the lower-paying higher-risk sick patients.
In short, if we got rid of our PAs, the physicians' income would go down by 25% due to the loss of that cross-subsidization.
And yes, PAs only get reimbursed 85% for medicare patients. But all the private payers pay the same rates for our PA-seen patients, so it's a small loss for a big gain in the end.
Also, our PAs do not need to present the patients to us, so the patient flow in the ED is greatly improved by having the PA run the fast track solo.
I don't think I missed anything. I do understand how the PA/MD relationship works, at least with respect to insurance reimbursement. And I understand the licensing responsibilities all too well because as a Paramedic I also work under an MD's license.... All I was pointing out is what I've seen, at least how PA's work in two hospital in NH that I frequently transport to. And I never said anything about getting rid of PA's or NP's; I know they fill a vital niche in the hierarchy of care, and I do like dealing with them for the most part. Most of the ones I know are good clinicians, and over the years they have learned to trust most of us pre-hospital types.
I just think it's interesting that in the Boston hospitals I transport to I've never dealt with a PA in them, and dealing with an NP is actually quite rare. The traditional model of resident/attending MD is still pretty unchanged in their ED's. It's not to say that mid-level providers aren't present elsewhere, just not so much in the ED.
As a PA who works in an ER... this is very offensive.
At least in MN I don't have to run every patient by my supervising MD. And I know PA's who are just as good if not better at procedures than the ER MD, so generalizing that PA's are only competent at these procedures in inappropriate.
And if you're worried about letting PA's practice under your license... think about this. The PA you work with is just down the hall. And you know what? The paramedics and EMT's are also under your license, and they are 20 miles down the highway with less training than the PA down the hall.
And no, I did not go to medical school, but it was my CHOICE to be a PA, not because I "couldn't get into medical school" but because I couldn't justify the time and debt of medical school, but I sill wanted to work in medicine.
Uh, somedood that I know that runs an ER says "the PAs [in Fast Track seeing easy patients] make the group $160 per hour on average and we pay them $50/hr". So...group makes $110 straight profit each hour which goes to...the docs like Shadowfizzle said. The PAs only ask the docs questions when it's absolutely necessary. No need to have docs eval every single patient. Silly.
We use PA's and since they are paid about half of what we make but see much more volume (ie the fast track stuff), it more than makes up for the lost income we would make supervising them doing procedures and what not. They are very good and obviously this model does not work if your PA's are having to ask your help all the time.
I wonder if things are different in the states, because in Canada - at least my part of Canada, the NP's can just see patients in the er, write stuff up, and discharge them. I've had awesome experiences with them, and it frees the doctors up for the major stuff...
Hi Scalpel - sorry off topic but I left you a comment on your tampon post and just want to say that I have a tiny surprise for you next week and the hint is in my comment.
Second hint... now I know Santa Clause is real. ;)
Shoot! I didn't write it yet... now I am going to have to get creative!
Okay..fine! 3rd hint...a picture is worth a thousand words. :)
In UK ENP's will see, examine, request X-ray, diagnose, treat, prescribe if required and discharge patients without any recourse to a doctor. Doctors are available for advice if required. ENP will see anywhere between 10 and 20 patients per day, sometimes more.
Anonymous: I believe I can get into med school if I do the work. It's the cash to pay for it I am worried about and, you know, the years of my life that it will take up.
Honestly, my spidey sense is telling me that PA school (around where I am) is damned competitive and isn't the easier route in comparison to med school. For me, the decision comes down to time and money. My academics need to be stellar no matter what I choose.
--Alicia (sorry, I changed my avatar/nickname a bit)
I've worked for three separate organizations that employed PAs or NPs, and none of them allowed these providers to independently practice medicine. We still had to sign every chart and see every patient.
The business model you describe is intriguing to me, however. Charging full price for something less than full service sounds like a great scam.
My understanding (as I was researching this trying to decide between NP and PA) is that NPs are independent of docs, but PAs are not. So your practice may be unique in their quality controls with NPs or it could be a peculiarity of your state.
With regards to 'just go to med school'...I am too old, too tired, and too poor to do med school. If I had understood myself better and had been identified as learning disabled earlier I would have made different choices when I was in college the first time. Now I'm older and wiser, but that patina limits the economics of my options. So it's PA school for me, assuming I can slog through the 7 chemistry classes that are required before applying.
But no worries for you, I want to go into primary care.
M
I'm not disparaging PAs or NPs in the least, by the way. I think they will play an important role in the future healthcare needs of our country, but if they are going to practice independently, then they shouldn't command the same charges as physicians. That sort of defeats the purpose, imo.
Let them go into practice on their own and charge less. It sounds like the Northerners aren't really supervising their assistants anyway, just pimping them out and siphoning money off the top.
We don't charge the same if we don't personally supervise the procedure or personally see the patient. Honestly, unless the patient is sick or complicated it is not worth it (at least in terms of the extra billing). We make more by letting them see and discharge patients - usually just telling us about them and then we cosign the chart stating that we agree with the plan. This frees us up to see more ourselves.
but a part of having the pa do the work is to keep medical costs down, right?
Unfortunately for us, my son has had too many opportunities to be stitched up- both planned repairs and sharp coffee tables. As such, I have become a fair judge of lac repairs. Obviously, the pediatric plastics are the best, but recently he was stitched by the PA at the ER, whom I was told pretty much does nothing but these, and the results were phenomenal (and in the middle of the forehead) - perfect, tiny stitches and a now very flat fine line scar. I have been to another ER and actually asked the ER doc to redo a couple of stitches because I could tell that even when the swelling went down it was going to pull. I think experience in a simple procedure would be EXACTLY the kind of thing that PAs should be used for.
Now, when we went in because my son had a post surgical complication I definitely wanted the MD to take a look.
I really don't know how the fees work for NPs in Canada (or my province or whatever) because we have public health care anyway. The wouldn't be making the same thing as the MD's so I'm sure the province would be billed less for it even if they did the same procedure... but I could be wrong. I do social work, not medicine. I also know my c/n's get super grumpy because the NP's can't prescribe their narcotics (which is probably half the reason they get routed to them for suspected drug seeking anyway)!
I thought I qualified my remarks well: "if you can get into med school AND have the additional resources to complete the program and training then do it"
Things I consider to be additional requisite resources: time, money, importance, value, etc.
So when you say I can get into med school but the loans aren't worth it, or the 10 years spent training aren't worth it, or I'm too old to do all of that -- those are necessary resources one has to be willing to commit to the career. I know more than one person who went pre-med and were accepted to med schools to ultimately go into a different profession. I'm also good friends with a guy who went to med school and now teaches 8th grade math.
I also am not disparaging PA's or NPs. I wanted to be a physician my entire life but I wasn't blessed with a number of resources required so I sell used cars. And I'm sure all of those potential patients of mine are very happy I ended up in a different career.
I gave my take
Happy's Take
Like many blogs, this one plays fast and loose with facts. Please, do some true fact checking before posting! And remember that fact-checking means actually going to a proven source - not "this guy/gal I know sez" or "because I worked with 1 NP/PA/ERMD I know everything about them." Absent this, I wouldn't want the authors to wield either scalpel or sword - they're really wielding a scattergun.
In Michigan, PAs do not have to present every patient and every chart does not have to be cosigned. As a matter of fact, no patient needs to be presented unless the PA/doc so desires, and no chart needs to be cosigned. Where the heck do you work? No wonder you are in such a bad mood all of the time.
The laws vary from state to state. Texas reportedly has among the most restrictive environments for PAs and NPs, but I've reviewed the pertinent statutes from TX, WA, and MN, and they seem similar to me.
Why should the legal (or ethical) requirements for supervising a PA be less than those for supervising a third year resident physician?
Well, shadowfax works in Washington and he doesn't have the PAs present every patient. Actually, having the patient seen by a doc as well has more to do with billing (100% vs. 85% for Medicare and blue cross blue shield here) than the legal requirement. As far as legal requirements, they (all states) all require supervision for PAs, but no state requires the physician to see every patient. In Michigan we have critical access hospitals where the EDs are staffed only by PAs.
I've been a PA for over 30 years and we didn't even have such a requirement back then. Thousands of fast tracks are staffed by PAs only.
My take:
I was in my thirties without significant resources in the bank (or wealthy family) when I started med school. There ARE resources available out there if that is what you want to do. I did it. Yes you will be in debt equal to owning a middle class house (outside of California). It is a personal decision of course. I thought (and still think) it was worth it. But remember a 2 year PA (or NP, and yes I now they are RN's already) is not the same thing as 7-12 years of med school/residency/fellowship. The knowledge base is not the same. I also am of the opinion that midlevels have a signicant place in american medicine. But to think they are essential the same thing as an ER doc or PCP is just plain stupid. I hear those statements fairly regularly. Ignorance is bliss.
My employers required me to see every patient even if the state did not, and often I was glad that I did.
Having been a hospital administrator and a director of medical education for various residencies this is an interesting yet very misleading post. First of all if we as a society would first focus on "the right person for the right reason for the right job" then a PA or NP would easily work out in the ER. Anyone visiting an academic ER the first week of July understands chaos theory only all too well. PA and NPs play a vital role as clinicians if used the right way - in addition they add revenue value being able to bill and often replace an MD/DO more than 90% of the time in the ED and more in "fast track or triage areas" Sadly many MD/DO still think they are irreplaceable but have not yet realized they are only part of a team especially in an ED situation. ED do what they do best they triage and PA/NPs working in that area do the same. The key is knowing the limits regardless of the fact of what your license tells you, would the ED doc single handle a NS patient not ever. Regarding becoming a PA or NP = its a personal decision based on time, focus of career and ability to pay. Funny being in a country that faces a health care crisis in primary care and general internal medicine and we are talking about the concern with over 100,000 PA/NPs that make a difference in quality daily. Ok so give me a break and do your job!
A very tired VP having been in health care for 33yrs.
If you think that a PA or NP could "replace an MD/DO more than 90% of the time in the ED" then you are unenlightened, to put it nicely.
right person for the right reason for the right job. Tell me how does one define all three. Does a patient with just htn count? How about difficult to control htn? How about htn and a stroke? How about htn caused by adrenal tumor? Who's defining right time and right person for all possible medical conditions.
If everyone always knew their limitations, life would be easy, wouldn't it?
anon 3:38 here:
Dear academic VP having been a VP, hospital administrator and a director of medical education for various residencies tells me that you are most likely fairly ignorant of today's day to day medicine especially in the real world, especially if you think midlevels can replace MD/DO's more than 90% in the ER. They play a role but not that big of one (ie 90% plus). It is easy to say "the right person for the right reason for the right job" which is nothing more than an administator platitude. The reality is that knowing one's limitations is a very inexact science. Make no mistake MD's/DO's do it too just IMO less often do the added training and experience. Speaking of "doing your job". I recommend you dust off your MD and spend a little less time in the board room. You will sound a little less clueless.
Most PAs are NOT settling because they could not get into med school. Currently, PA school is more competitive than med school, and I know several students who have applied to both and have been rejected by PA school and accepted into numerous med schools. The pre-reqs are essentially identical, Im a junior in my undergrad with a 4.0 gpa and have been set on becoming a PA. Becoming a PA is not a fallback plan, and if it was that person would be miserable working as a PA.
Ironically, many surveys have shown that in various areas of medicine, people prefer the PAs to the MDs (family practice comes to mind, among others).
This article is misleading, opinionated, and in some cases a flat out lie.
People also need to do some research on the PA schooling. The pre-reqs are the same as med school. PA school is a masters level degree, taking a total of 6-7 years depending on the program one enters. There is no mandatory residency, but 1 year residency programs do exist for those who are willing. It is taught in the medical model just as med school is.
When you break down years in school it is misleading. In reality, PA students spend more hours in school per day, do not have summers off, must have 2000+ hours of paid healthcare experience, etc. When you actually break it down to credit hours, med students spend less than a year longer in school than PA students. The only true difference is the residency (which after 5-10 years of on the job training/experience, this becomes increasingly offset.)
A PA will never "be" a doctor and never "replace" a doctor, but they are highly competent healthcare providers.
Maybe if my previous employers hadn't required our PAs to be so heavily supervised, I'd have appreciated them more. I can only speak from my own experience, take it for what it's worth.
Then again, why should the requirements for supervising PAs be less than those for supervising third year residents? That never made sense to me.
what confuses me is why an ER doc is making billed income like a surgeon per procedure. I assumed he/she would be salaried or hourly since their shifts arent cut and dried on length.
and to the student on the fence -you dont have to be in the ER as a PA/NP
in family practice I have found most spent a better job evaling you that the actual doctors did
Scalpel, I think you need to do some basic research on PA reimbursement models. A 2005 survey on Physician Compensation and Production from the Medical Group Management Association states, "For those services which a PA or NP can handle just as effectively as a physician, a mid-level provider is a less costly investment for the group practice." The compensation to production ratio for a PA is .24 while it is .33 for a physician. Also, the three hospitals you worked at are hardly a representative sample size for you to make such sweeping generalizations about an entire profession. Stick to medicine... business isn't your forte.
I've worked with several PA's and NP's, and they've left me with a good impression. I guess I'm at a bit of a loss as to why the state requires a great deal of supervision- do NP's and PA's really need a doctor to confirm a simple sinus infection or suture a wound? I understand wanting and needing an attending for the more complex cases.
"Then again, why should the requirements for supervising PAs be less than those for supervising third year residents? That never made sense to me."
That statement speaks to some of the misunderstandings you may have about PAs (which is influenced by your exposure to them, which you mentioned is a highly restrictive PA environment).
I hesitate to make the comparison between a PA and MD/DO in terms of ability, but an experienced EM PA (say, >5yrs time served) could easily surpass a 3rd yr EM resident in terms of technical skill, experience, and likely EM knowledge base. This is dependent on the intensity of the PA's previous experience, but as others will attest to, PAs are doing WAY more than seeing kids with colds and suturing lacs. You are biased by your anecdotal experience; not exactly a scientific approach to your thesis, no?
-one more PA
You're preaching to the choir with your "practice track" philosophy. Too bad the EM leadership doesn't agree with us.
I do have an issue. Where are all of the doctors? It seems that where ever I go there are Physician's Assistants, and the medical facilities seem to want us to think that they are doctors. What I mean by this is there is never any mention that they are not a doctor that they are a PA. They said "Deb will be in to see you soon". Deb walks in and introduces herself as Deb and never tells anyone what her title is. Many times when making an appointment we patients are never told that the PA will be seeing us. I have gone to several appointments and was never told that the professional that would be attending to my medical needs was a PA. I am a stay at home mom and my family is fully insured through my husbands employer. We are not medicaid or anything like that.
I seems to me that an appropriate use for the PA's would be for routine issues like Strep testing, pregnancy testing, UTI's, stitching patients after the Doc has seen them, diagnosing earaches all under the direct supervision of an MD. I live in Nebraska and the PA's are seeing the lions share of the patients. Many times with no physician anywhere in the building. I had to take one of my infant twins to the pediatrician for a puzzling symptom. A PA came in (without telling us her proper title). I knew something was different about her from the other physicians in the practice. There wasn't the expert presence that I usually felt with the other doctors. She did procedures and ordered expensive tests that were way off base. I came home and looked her up and I saw that she was a PA. Later I went back and saw our physician and she looked at the symptoms and gave a very reasonable explanation about what was going on. Those tests that the PA ordered were not even close to being necessary. She also left the main cause untreated.
Why are PA's running the show. Where are all of the doctors? Why are we as consumers and patients being conditioned to accept a PA as a doctor. I am in a mom's group, and most of the moms think PA's are pretty much the same as doctors. Many think the PA's are as competent and knowledgeable as doctors. Then why don't we just call the PA's doctors? When my daughter cut her finger the doc saw her and the PA came in and did the stitching. That seems like an appropriate use of a PA. There are PA's in offices where the are no medical doctors in attendance. Aren't PA's suppose to be working under direct supervision of a physician? (I know the was no doctor there because I asked).
I am not a medical professional. I am a consumer and I am at the mercy of the medical community. They tell me what they want, I have to see who they want, and often I am given no information about the type of care I am going to receive.
Helen
You just earned a guest blog post.
anon 11:41
When I say: The only true difference is the residency (which after 5-10 years of on the job training/experience, this becomes increasingly offset.)
I fear for the safety of your patients. 5 years of clinical experience as a PA does not offset the training achieved in a residency. That's what makes a physician competent in their field. Not even close. It's light years of separation.
If in fact that statement was true, I have two responses.
1. All medial schools should be closed in favor of PA school.
2. 5 years of experience as a PA in a neurosurgeon's office should be allowed to perform surgery independently. Same with heart caths. Same with scopes. Same with diagnosing and managing all the diseases of specialty medicine.
That statement is just ludicrous. And that's the most frightening type of extender. One who believes that they achieve parity, or close to, parity of competence as a physician based solely on their clinical experience.
The difference in education, book work and clinical training is light years apart.
I fear extenders more not for what they know, but what they don't know.
Medicine follows the 80:20 rule. 80% of what I do is probably manage 10 conditions or less. 80% of those may be routine. BUT 20% of medicine is not routine and 20% of that 80% is not managed routinely.
That's what you learn as a physician that other much less intense training tracks don't train you. You learn the art of medical diagnosis and management.
The medical foundation to know when to recognize which is which is something I would only send myself and my family to a physician.
When I read comments that PAs see fast track patients really quickly, even faster than many physicians, I believe that the main reason that might be true is that they are perhaps not considering the long tail diagnoses.
One doesn't always have to order lots of time-consuming tests to exclude some of these potentially serious masqueraders, but one needs to be aware of them and know what questions to ask and what areas of the physical examination to include.
Even a seasoned physician can miss an SBE, an early sepsis, or a paraspinal abscess, but the extra training and experience we obtain in medical school and residency perhaps make it more likely we will identify these diagnoses.
And it only takes one missed case like that to wipe out any cost benefit of hiring a cheaper but less capable "provider" instead of a physician.
Scalpel. You hit the nail on the head. It's easy to ignore important disease processes in the differential diagnosis when you don't know they exist or how to evaluate them.
Like I said before, if PA school and some clinical experience was all that was needed, then all medical schools should close in favor of NP and PA schools.
I dont feel anyone here is trying to say that PAs/NPs can replace the physician. All of these comments about PA school replacing med school is something that the poster created, not something that was brought up or even implied in any posts in this blog. (Though it is interesting to note that med school applicants are down, and PA school applicants have been up in recent years.)
Also, all of the comments in this thread have been regarding EM and family practice. Bringing up a specialty such as neurosurgery which requires extended residencies and fellowships shouldnt even apply to this conversation.
PAs should be given responsibilities based on their capabilities. This should mean a narrow scope to begin, and once they prove themselves competent, that should expand. After 10+ years on the job, in a field such as FP or EM, it isnt that far fetched that a PA could perform 85% or more of what a doctor can. A fresh grad cannot, and should not. The most critical patients should obviously be seen by an MD, there is no question about it. But restricting PAs to the most basic of patients wouldn't be utilizing their capabilities...
Anon that's scary. What makes surgery special? Honest question. If you are first assisting for 10 years, why do you not feel you could do 85% of that surgeons work? There is no difference when you apply your scary logic to a cardiologist or a family medicine doc. Your ability to not understand why is the reason why I would never send my family to you. Scary. Scary. Scary. You fail to appreciate what family medicine training is and why you aren't them. That's the scariest type of extended
I am not a PA, just giving my honest opinion. Here is a question for YOU. What are your thoughts on a CRNA? They surely do not have the training of an anesthesiologist, but they can do cases independently, and though I dont have any numbers in front of me, I would assume they are just as proficient and have around the same level of error as the MD equivalent. Is this "scary, scary, scary..." as well?
I have known PAs in cardiac surgery who have placed their on CABGs, and others in general surgery who have completed significant portions of surgeries with the MD in the room. The question is- if they are experienced enough, and have proven themselves to be competent to the MD, is there any reason outside of personal feelings of "thats something only doctor's could possibly do!" why they shouldnt be allowed to do it with the MD present?
Wow, just wow.
As a senior EM PA with many years of experience, all I can say is that your group truly does not understand how to utilize PA's/NP's. I work at possibly the most prestigious medical institution in the world here in MN, and I function with a HIGH level of autonomy. At our institution, we see all level 4-5 patients independently. We run a fast track hallway in the evenings, and on weekends/holidays. We also work in ALL other areas of the ED, including critical. Some of us that are more senior and experienced also see softer level 3 patients independently as our comfort level allows. I worked in surgery for years, and run a workshop on different suturing techniques for the residents and med students. I also lecture to them, and teach the med students how to perform LP's. I've written extensively, am involved in several research projects, I've published, and given talks at both MD and PA meetings, both at the state and national level. I precept med students, and function as a resource for the residents. I've done cardioversions, resucitations, and managed very complex patients with a minimum of supervision. HOWEVER, I have also done this for a long time, and have earned that autonomy. Most of our newer practitioners do not enjoy the latitude that I do.
Also, I moonlight at a small rural ER where there is NO phsyician on duty. It's just me. I'm it.
BTW, while PA's bill fully, we are only paid at 85% of the phsyician rate according to medicare guidelines. Since I am only making about 60% of a physicians salary, the department still makes about 25% income on all patients I see.
But perhaps I am the exception, although I think not.
I think when the shit hits the fan, I would much rather have an MD trained anesthesiologist than a nurse with anesthesia training.
Nobody has yet to answer my question. If in fact PA's and NP's are practicing medicine independently of physician oversight, why don't we just close all medical schools in favor of extender schools?
Less training, shorter hours. One tenth the hours of training. I"m sure most folks would opt for that. It certainly would make sense.
Your question is flawed to begin with... Nobody ever claimed that PAs work completely independently of an MD and without any supervision.
ah, but NP's are. And in many places in this country.
"Your question is flawed to begin with... Nobody ever claimed that PAs work completely independently of an MD and without any supervision."
Umm...MayoPA just did:
"Also, I moonlight at a small rural ER where there is NO phsyician on duty. It's just me. I'm it."
That does not mean that we are unsupervised. While there is no physician PRESENT. There is ALWAYS a phsyician on call, and someone that I can touch base with if I encounter a situation that is very complex, or something that I need help with. That is hardly "unsupervised".
Sorry but supervision is not somebody in bed 1-2 hours away when a patient is crashing and you don't know why no matter how you want to paint it.
BS.....Supervision does not mean that a physician needs to be there holding your hand. If that is your idea of supervision, than I actually agree with the title of PA's and NP's not helping. As far as a patient crashing...well there are one of two things that happen. If it is a trauma, or a patient crashing in the field, they are NOT brought to that smaller ER, they are automatically diverted to a larger facility, such as the one I practice at primarily.
TWO, if a patient DOES start to crash, or present with a serious illness, such as the posterior wall MI I had two weeks ago, they are stabilized, and transferred ASAP.
In the case of the posterior wall MI, I had heparin initiated (as per protocol), labs drawn, and had him on a chopper in 28 minutes after presentation to the ED.
Again, I did not try to finalize a diagnosis, or completely manage the patient....I am not a cardiologist. I recognized the event, proceeded with protocol, and transferred the patient.
As I said earlier, I am also heavily involved in health policy work, and am completing a doctorate in health sciences. I can tell you quite definitively, that based on recent studies, and the failing medical system as a whole, the utilization of PA's, and NP's will HAVE to expand.
BS Shmess. A phone call is NOT the same thing as laying eyes on the patient. Hell you should know that. Yeah I have received phone calls from PA's out in bumfuk ER. As often as not, it became evidently clear they didn't know what they were looking at. Especially in complicated situations. I don't argue, transfer the patient to me but PLEASE don't go spouting off your credentials as if you are the shit. I don't give a damn if you work at mayo. As far as crashing patients and traumas yes they end up in rural ER's for various reasons. I've seen it first hand more times than I can count.
My wife has had 2 brain surgeries, both life saving procedures.
Before each surgery the Neurosurgeon and a PA that works side by side with him consulted us about the details of the surgery. We were asked if we would object to having the PA tend to the sutures once the actual surgery was done. Perhaps it was bull headed of me, perhaps I'm too much the protective Husband but both times I insisted the stitches be done by the actual Surgeon.
I also asked that the Doctor be the one who came and updated my mother-in-law (who is a retired PA btw) and I on my wife's condition.
My wife now sees the Doc once a year and the PA once a year for her routine follow ups. The PA handles our questions just fine and if there is confusion he leaves the room and runs things by the Doc.
I'm not sure what my point is other than feeling that there is a time and place for both Doctors and PA's. I'm just glad that when my wife began to crash while being stitched up the neurosurgeon was there to save her.
Peace,
Dave
Of course a phone call is not the same as laying eyes on the patient. Sometimes I have simply consulted the attending with "I don't need you to come in and see this patient, but this is what I have________, this is what I am thinking________, SHOULD I be concerned about anything else?"
Other times, when I am in over my head, which of course does occur occasionally, I will say, "I need you to come in now, I have something that I need help with".
Now, I will agree with the point that it takes time to develop the understanding of what you do, and do not know. We have several newer PA's at my main job, and they are not afforded the same independence that myself, and one of the other senior PA's are. The job I moonlight at that is staffed by PA's only, will not under ANY circumstances hire a PA with less than 5 years experience. They usually, although not always, do not have the knowledge to know when to say when. Some PA's with more than 5 years exp, don't have it either.
Point is, PA's/NP's cannot be simply lumped into one category just as EM physicians cannot. Some have more experience than others, some are better at managing cardiac problems, etc.etc.etc.
EACH individual PA/NP needs to be evaluated and supervised, and then, depending on physician comfort level, allowed to see patients per their doc's decree.
Anonymous 12/24 11:41pm, Nice language! You are truly an inspiration and a tribute to your profession. You must be a nightmare to your HR department... you're a "hostile workplace environment" lawsuit waiting to happen.
I worked at a NP staffed family planning clinic. Our NP's were only trained in ob/gyn. They practiced under a clear and strict protocol. The NP's did paps, std testing, BC rxs. There scope was very limited. As an example, they did not insert IUDs. There was no legal restriction from performing them. In fact, a NP who wanted to insert them in our agency (as per the MD's protocol) could have after specific training and 6 successful MD supervised procedures. Very few of the NPs elected to be trained (for various reasons including a lack of financial incentive and increased malpractice risk). But mostly the Senior NPs felt that the high risk of complications for an IUD in an all midlevel practioner staffed facility was too great.
I think that since I have left, the clinic no longer had MD visits (The medical director did not see patients). At this point one of the NP became trained to do the procedure.
This is just a specific example, for this thread.
Our NPs were pretty great, However, they did not come out of NP school that way. (just as MDs entering internship year...) However there is no NP residencies. (although now pharmacists have a one year residency).
Just as a physical therapist is not a physiatrist...they all have their place on the rehab floor.
I think it's funny that a lot of you think all docs are competent just cuz they're docs. You're either in denial or totally clueless.
Scalpel, I had a 3.93 GPA and got into four medical schools. For many reasons I decided to apply to PA school instead; it was my choice. I was shocked when I couldn't get into PA school. After trying for three years, I was waitlisted and eventually got into Cornell. Afterwards, I completed a post graduate residency at Yale. I've been working 15 years and am highly respected in our department. I do consults on the floor and participate in training our surgical fellows. Maybe things are different in the ER, but I know we're being utilized well. I do not pretend to be a physician and know my limitations. And I certainly CHOSE to go to PA school over medical school.
I'm an ED PA, and work in a busy level1 trauma center. We have a great working relationship with the physicians. We only hire experienced PAs and after an initial credentialing process, the PAs are expected to handle patients on their own. That doesn't mean we don't consult with the physicians. Different states have different PA/NP restrictions. In some cases, it's the hospital that sets the restrictions.
This is an interesting post, but should be viewed as one physician's opinion. Taken at that, and after reviewing "Scalpel's" interests in his profile ("pushing buttons"), it follows that this should be read as a personal rant rather than a condemnation of the PA and NP professions.
There are 80,000 PAs working across the US, somebody is clearly finding a way for PAs to supplement their medical practice.
I work in Vascular Surgery and there are certainly times when we get ER referrals and it is clear that the ER doc doesn't know how to workup ischemia any better than a box of rocks. Does that mean that the ER doc is incompetent? Maybe, but more than likely, they are just doing their best to evaluate patients to the best of their ability and knowledge base. Does this mean that there isn't a role for an ER doc to participate in the care of these patients. No, of course not.
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Well. I think almost all that can be said has been said. But I'm throwing my 2 cents in as well.
Firstly, I want to start off by saying that yes, I agree with Scalpel and Happy Hospitalist in principle. Some of their opinions are wrong, however.
I have an INCREDIBLE amount of respect for a good doc. The amount of time, emotional sacrifice, and years dedicated to their profession are irreplaceable!
Especially considering they are many times underpaid for what they do, get no respect from their patients, all while society claims how good they have it (even though I read a paper recently detailing how becoming an MD is actually a TERRIBLE financial desicion when you weigh out the debt/income ratio)
I am a Hospitalist PA and a darned good one. Especially with my level of experience. (2 years grad)
I work very nearly independently, but only because the physicians I work for trust me to come to them with any case that is above my level. Also, I realize that just because I CAN handle a case, doesn't always mean I should do it solo, 8 years of mandatory traing for a doctor beats out my 2 years with 2 experience, any day. Any patient that has the potential for instability is followed very closely by the phycisian, and the patient DESERVES that level of care!
Understand though that this doesn't mean I turn it over completely. The physicians graciously allow me to make the treatment decisions my patients, I run these decisions by them and WAY more often than not, my treatment plan is not changed! However, sometimes (less and less often as I continue working/learning) it is changed, and it points out to me why you are the DOC and I am the midlevel. The reason I am good at what I do is that GOD gave me a talent for it and a passion. When my treatment plans must change I tear apart my Harrison's (read cover to cover) and up to date and pub med. until I KNOW I won't miss it again and understand the physiology of applying it elsewhere.
So, while a good doctor can NEVER be replaced, the reason my team has time to discuss my medical decisions, and allow me to follow these complex patients, is that, when you consider 80% of what we see are "bread and butter" cases of COPD, CHF, R/O MI, DKA, pancreatitis. I can effectively cut my attendings work in half. I admit, follow and discharge my own patients with minimal need for observation. I make the hospital a lot of money and I get to learn. everyone is happy.
I know I'll get chewed out for throwing DKA ( an admittedly critical condition) in the bread and butter cases, but I've just seen alot of them.
also, guess what? I've caught a LOT of chronic diagnosis missed by the lazy PCP, because I have something to prove, namely, that I can do this job.
as follows:
-CREST (limited scleroderma) syndrome presenting as dysphagia and scleroderma
-Autoimmune hepatitis in a 19y/o female
-Disseminated UNENCAPSULATED cryptococcus in a 28y/o HIV negative patient (secondary to a MISTAKEN Diagnosis by A PCP who gave him 9 months of steroids with no follow up, the man had his spine eaten up with 3 paraspinal abcesses and presented as CP with a large pleural effusion) supposedly the CT surgeon I consulted will be putting it in CHEST Journal.
-Progressive multifocal Leukoencephalopathy in a previously undiagnosed AIDS patient (this was his presenting opportunistic infection)
-Lemierre's syndrome
-MULTIPLE SBE cases
-An EPIDURAL abcess in an IV drug user when the ER physician sent her home THREE times with FEVER, and Localized tenderness and only called me to admit her because she "keeps coming back" but she is a "drug seeker"
(i will admit I made the mistake of double ABX coverage for the MRSA cultured out, I was informed that I only needed vanco)
the list goes on. My point is not "oh, look how good I am"
but simply that, if you know the capabilities of your PA, and they understand their own, we can do more than you give us credit for, with appropriate supervision, which in many of these cases was "I agree with the PA, plan as above" signed MD
I personally became a PA as a "stepping stone" to Med school. I was accepted at 19 and graduated at 21. my plan was to use this degree as a "pre-med" degree and continue on. As I worked for a year however, I realized that the hell you are put through to become a doctor, 4 years of intense shcool (if you want to be good), the 3 years of no social life, never seeing your family, and the horrible hours after you are done with training, (and forget it if you want to specialize!) did not appeal to me.
Only a very special person can do that, and about 50% of the docs out there today are not that type. they are dissatisfied with their specialty and if you ask them "should I go to med school?" the answer is always "NO!" do something else.
Ask a PA the same question? the answer is "hell yes, love it, every day, wouldn't trade it for the world."
So with that advice I stayed a PA, and "Hell yes, I love it, every day, and I wouldn't trade it for the world.
I would love to hear what you have to say. I'm not sure it will be altogether nice though?
In your profile you have a section Interests: Pushing buttons...is one of those buttons marked "self destructed"?
"Off."
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