Ask an emerg PA

[PAstudent]

I have been in practice now for almost a year and I get a lot of private messages, emails, and, other types of contact with questions for me about being an emergency medicine PA in the GTA. While many of the queries I receive come from people considering a career as a PA, I have also been fielding a lot of questions from physicians. I figured then that it might be nice to make a thread here where people can ask me questions and I will do my best to answer.

[maritimer]

Great Idea!

 

Finishing up my first year of PA School and just wondering what I may expect during my ER rotation in the upcoming year in terms of responsibility and experiences we will partake in!

[PAstudent]

Great Idea!

 

Finishing up my first year of PA School and just wondering what I may expect during my ER rotation in the upcoming year in terms of responsibility and experiences we will partake in!

 

That depends highly on where you are doing your emerg rotation; what school do you go to and where will you do your rotation?

 

In general, this might be helpful: http://mcmasterpa.weebly.com/emergency-medicine.html

[maritimer]

That's true. I'm a student at the UofM-most of my rotations will be in Winnipeg. Thanks for the link!

[Lunasly]

Do you mind providing us with the average salary for someone in your position? Also, what are the hours like? How often do you work each week?

[PAstudent]

Do you mind providing us with the average salary for someone in your position? Also, what are the hours like? How often do you work each week?

 

There is no established average for emerg PAs in Ontario because there are not enough of us to provide a good sample size nor are there much published data on this. Here is some data from the USA: http://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/Articles/National-Salary-Report-2011.aspx

 

I will say I am happy with my compensation and feel it is appropriate for me as a new grad emerg PA in Ontario. Most of my PA colleagues (most of whom are not in emerg) with whom I have discussed this are also satisfied. Our pay ranges greatly depending on our positions (whether or not a PA takes call, works unusual hours, has teaching and research responsibilities etc., etc.) and I know of a broad range from about 80k-160k. Again, this is from personal knowledge and word of mouth, not from any valid data.

 

As for my position: I work about 4 shifts per week and am scheduled the same way the docs are, taking different shifts all the time.

[hexonu]

Do you practice under a physician? Are you happy with your autonomy?What's the main difference between a PA and NP? Does the NP role seem redundant now than you're a PA? What's your opinion on NPs?

[PAstudent]

Do you practice under a physician? Are you happy with your autonomy?What's the main difference between a PA and NP? Does the NP role seem redundant now than you're a PA? What's your opinion on NPs?

 

In order:

1. Yes (by definition that is what a PA does)

2. Yes

3. That has been answered already on this forum, please use the search function

4. No, they are completely different professions with different training.

5. That's a broad question; my opinion with regard to what about NPs? Also, the point of this thread is to inform people about being an emerg PA in the GTA, not to get my opinion about NPs.

[VCanucks]

PAstudent, can you briefly elaborate on what you do on a day to day basis, from the start to the end of your shift.

Thanks

[PAstudent]

PAstudent, can you briefly elaborate on what you do on a day to day basis, from the start to the end of your shift.

Thanks

 

Sure,

My emerg is sectioned-off into three zones: main (acute), the middle acuity (the majority of patient funnel through here), and minor. I show-up, sign-into my hospital phone, log-in to the computer, and look at the tracker to get an idea of the condition of the emerg. If one area in particular has a great deal f volume (patients waiting to be seen) I will go there. Otherwise, I usually start my shifts by seeing main/middle patients (pts) for the first 1/2 to 2/3 and then I see minor pts for the last half/third. Most of my shifts are 8 hours in length but I sometimes work longer and sometimes shorter. I also check-in the the docs who are on when I show-up to ask if there is any particular need for me somewhere (for example, of there are many time-consuming procedures to be done or if concious sedation is needed or we have clinical clerks/residents who need teaching, etc., etc. then I might be directed for those things).

 

I pick-up patients according to CTAS scoring and time waiting to be seen. There is a big emphasis on reducing physician initial assessment times (PIA) because the Ministry of Health and Long Term Care uses these times to decide how much funding we get. Having a PA see a pt counts as a PIA.

 

Going to see a patient: I sign-up for them on our tracker and pick-up the paper chart. I will read the tracker info (triage notes, vitals, and often historical stuff on our system from previous visits and admissions). Then I go see the pt, take a history, do a physical, order investigations, treatments, perform procedures, talk to consultants if needed etc., etc. Sometimes I feel I need to get a physician involved right away and, if so, I find the physician and present the pt.

 

That's basically it. If at the end of my shift I have pts that have not been discharged or consulted on my supervising physician, if they are staying, will take over all the care or, if they are not, we will hand over to the next physician.

[pedsPA]

Hi PAstudent,

 

Thank you so much for all your insight. I have recently become interested in pursuing a career in PA instead of medicine (also in the GTA). I was wondering what the job prospects are like for new PA grads. I've looked on career pages in hospitals across the GTA and postings seem to be few and far between. Are new grads often offered jobs privately following graduation? Is it probable to be offered a position in a certain subspecialty that you are particularly interested in? One concern of mine is being forced to take a position after graduation that I am not particularly interested in... just because that's the only thing available.

 

Thanks again!

[PAstudent]

Hi PAstudent,

 

Thank you so much for all your insight. I have recently become interested in pursuing a career in PA instead of medicine (also in the GTA). I was wondering what the job prospects are like for new PA grads. I've looked on career pages in hospitals across the GTA and postings seem to be few and far between. Are new grads often offered jobs privately following graduation? Is it probable to be offered a position in a certain subspecialty that you are particularly interested in? One concern of mine is being forced to take a position after graduation that I am not particularly interested in... just because that's the only thing available.

 

Thanks again!

 

Hi pedsPA,

 

Please post this elsewhere (start a new thread if you would like) and I will answer or, please see my answer to this question in other threads. This particular thread is to answer questions about my position, not to discuss PA job prospects in general; something I have already discussed elsewhere in this sub-forum.

[XIII]

Hi PAStudent,

 

When you work in emerg (or anywhere else), do you report to your supervising physician after every patient or do you report at the end of the day and have them sign the patient charts after looking over them? I guess this is a question of autonomy and I'm asking about the frequency you need your supervising physician's attention. Of course this excludes when you believe that certain patients should directly see the physician, in which case you would immediately need the physician's attention.

 

Thank you!

[PAstudent]

Hi PAStudent,

 

When you work in emerg (or anywhere else), do you report to your supervising physician after every patient or do you report at the end of the day and have them sign the patient charts after looking over them? I guess this is a question of autonomy and I'm asking about the frequency you need your supervising physician's attention. Of course this excludes when you believe that certain patients should directly see the physician, in which case you would immediately need the physician's attention.

 

Thank you!

 

This is highly dependent on the patient/case/individual SP. At my level (just finished school last year) I don't really feel it is appropriate for me to ever not review with an attending physician right away with very few exceptions. In truly emergent time-sensitive cases it is rare that I am alone in going to see the patient but, when this happens, I usually assess and implement life-saving/stabilizing orders at once and immediately grab the closest attending physician.

 

In less emergent cases, I will usually complete my assessment, write my plan/orders and review them at once with a staff if they are available. There are, again, some things I will order without speaking with them first (clear cut but not highly acute cases where the work-up is fairly routine). Indeed, most emergs have medical directives for RNs in place to start workups in these kinds of cases.

 

For the majority of lacerations without complications in healthy people I am comfortable doing the whole case and then letting the physician know after the fact. A big part of being a PA is knowing when to get help (also a big part of being a physician).

 

My autonomy has increased with time and this trend is likely to continue. That is just how PAs work.

 

As a recent grad, my level is similar to a PGY1 and PGY1s don't do a whole lot without consulting with a senior/staff first. There are experienced PAs, however, who have a great deal of autonomy and do solo emerg in some places.

 

I am acutely aware that I don't know what I don't know and my practice is fairly conservative. In fact, many of my attending physicians, including my Chief, think I should exercise greater autonomy than I already do. One of the great things about being a PA is always having that back-up.

 

Another issue is OHIP billing. If my supervising physician has not physically "seen" the patient they can't legally bill for the case. Thus, let's say a healthy 20 yo male, tetanus up to date, nkda, non-smoker, no rec. drugs, no ETOH, no PMH: superficial laceration to left index finger dorsal aspect sustained one hour ago with a clean exacto knfe, no actively bleeding, n/v intact. I do a digital block, suture him up, give him appropriate care instructions, then I tell him to stay put so he can meet my supervising physician. I then tell my SP about the case, they come say hi and bye, and the pt can leave.

 

With really sick patients who are stable I will see the, do a h&p, create my assessment and plan, write my orders and then run it all by a supervising physician. Different SPs have different approaches to working with me as well so that comes into play. Some want me to go ahead and order whatever I think necessary and they will see the pt later and some want me to speak with them first.

[XIII]

This is highly dependent on the patient/case/individual SP. At my level (just finished school last year) I don't really feel it is appropriate for me to ever not review with an attending physician right away with very few exceptions. In truly emergent time-sensitive cases it is rare that I am alone in going to see the patient but, when this happens, I usually assess and implement life-saving/stabilizing orders at once and immediately grab the closest attending physician.

 

In less emergent cases, I will usually complete my assessment, write my plan/orders and review them at once with a staff if they are available. There are, again, some things I will order without speaking with them first (clear cut but not highly acute cases where the work-up is fairly routine). Indeed, most emergs have medical directives for RNs in place to start workups in these kinds of cases.

 

For the majority of lacerations without complications in healthy people I am comfortable doing the whole case and then letting the physician know after the fact. A big part of being a PA is knowing when to get help (also a big part of being a physician).

 

My autonomy has increased with time and this trend is likely to continue. That is just how PAs work.

 

As a recent grad, my level is similar to a PGY1 and PGY1s don't do a whole lot without consulting with a senior/staff first. There are experienced PAs, however, who have a great deal of autonomy and do solo emerg in some places.

 

I am acutely aware that I don't know what I don't know and my practice is fairly conservative. In fact, many of my attending physicians, including my Chief, think I should exercise greater autonomy than I already do. One of the great things about being a PA is always having that back-up.

 

Another issue is OHIP billing. If my supervising physician has not physically "seen" the patient they can't legally bill for the case. Thus, let's say a healthy 20 yo male, tetanus up to date, nkda, non-smoker, no rec. drugs, no ETOH, no PMH: superficial laceration to left index finger dorsal aspect sustained one hour ago with a clean exacto knfe, no actively bleeding, n/v intact. I do a digital block, suture him up, give him appropriate care instructions, then I tell him to stay put so he can meet my supervising physician. I then tell my SP about the case, they come say hi and bye, and the pt can leave.

 

With really sick patients who are stable I will see the, do a h&p, create my assessment and plan, write my orders and then run it all by a supervising physician. Different SPs have different approaches to working with me as well so that comes into play. Some want me to go ahead and order whatever I think necessary and they will see the pt later and some want me to speak with them first.

 

Thank you for the insight! I absolutely love how as a PA, you gradually gain autonomy!

[PAstudent]

Thank you for the insight! I absolutely love how as a PA, you gradually gain autonomy!

 

Remember, this is not something that comes easily. You must learn and grow. I spend a lot of time reading around my cases, reading textbooks, uptodate, and other resources. I go back to my basic medical science books often to connect the clinical experience with my pathophysiology knowledge so that I can think through clinical problems. I am constantly asking for teaching from my attendings and for guidance and critical feedback. All of this takes work, effort, and a commitment to constantly grow and improve in both knowledge and skills. I do a lot of CME activities, not just because I have to to keep my CCPA, but because I want to/need to to be a good clinician.

 

I know PAs who don't do all these things and you know how autonomous they are compared to when they started? Not very.

 

As in most things in life, you get out of being a PA what you put into it. I want to do solo emerg one day and I know I won't get there by slacking.

[iamarealdoctor]

You're just a physician assistant with only 2 years of school (cookie cutter medical school?).

 

Even PGY1 residents (with 4 years of medical school) don't know that much. They require much guidance from upper level residents, fellows, and staff.

 

Why do you sound as if you're acting like a chief resident?

 

From reading your posts, it seems like you run the ER or something.

 

And who will let you run ER solo???

 

Maybe in Nunavut???

[PAStudentHopeful]

You're just a physician assistant with only 2 years of school (cookie cutter medical school?).

 

Even PGY1 residents (with 4 years of medical school) don't know that much. They require much guidance from upper level residents, fellows, and staff.

 

Why do you sound as if you're acting like a chief resident?

 

From reading your posts, it seems like you run the ER or something.

 

And who will let you run ER solo???

 

Maybe in Nunavut???

 

4 years of medical school is equivalent to roughly 32 months of formal education. All of the current Canadian PA programs run for approximately 24-26 months of formal education. With all of this in mind we see that the education for a Canadian medical student is roughly 8 months longer than that of PA - most of that being additional clerkship rotations/experiences. The PA pre-clerkship curriculum is identical to the medical school curriculum and only differs in that rarer cases or more advanced cases are not explored as much. In fact, at some Canadian schools PA programs have their students attend regular MD lectures.

 

You're right in that a PA technically only has 66% of the formal education a medical student receives. However, this does not mean that after many years of clinical practice and continuing education a PA cannot be as effective as an MD. The reason most medical schools are structured 50% pre clerkship and 50% clerkship (or more) is because most of what you learn about medicine you learn through practicing it.

[PAstudent]

I'm really not certain that your post, rude as it is, is deserving of response. I will say just this: it is unfortunate that you do not appreciate, understand, or value the training, functions, and role of a PA. If you are truly ignorant, I encourage you to endeavor to relieve yourself of this ignorance by informing yourself and, if you wish to make these efforts, I will gladly help in any way I can.

 

 

 

You're just a physician assistant with only 2 years of school (cookie cutter medical school?).

 

Even PGY1 residents (with 4 years of medical school) don't know that much. They require much guidance from upper level residents, fellows, and staff.

 

Why do you sound as if you're acting like a chief resident?

 

From reading your posts, it seems like you run the ER or something.

 

And who will let you run ER solo???

 

Maybe in Nunavut???

[A-Stark]

You're just a physician assistant with only 2 years of school (cookie cutter medical school?).

 

Even PGY1 residents (with 4 years of medical school) don't know that much. They require much guidance from upper level residents, fellows, and staff.

 

Why do you sound as if you're acting like a chief resident?

 

From reading your posts, it seems like you run the ER or something.

 

And who will let you run ER solo???

 

Maybe in Nunavut???

 

I disagree. It sounds pretty much like how I operated as a CC4 in Emerg, up to and including doing wound closures with little to no supervision on otherwise healthy patients. Running an "ER" solo would pretty much be limited to very small quasi-overnight-walk-in clinics.

 

4 years of medical school is equivalent to roughly 32 months of formal education. All of the current Canadian PA programs run for approximately 24-26 months of formal education. With all of this in mind we see that the education for a Canadian medical student is roughly 8 months longer than that of PA - most of that being additional clerkship rotations/experiences. The PA pre-clerkship curriculum is identical to the medical school curriculum and only differs in that rarer cases or more advanced cases are not explored as much. In fact, at some Canadian schools PA programs have their students attend regular MD lectures.

 

I'd say it's closer to 38-40 months, with 18-20 alone representing pre-clerkship, and not counting summer electives and research projects which almost every student does. I did about 5 weeks of elective after first year and 6 weeks after second year (when I also worked on some research and studied/wrote the USMLE Step 1). Otherwise, PA school really isn't comparable, and I would not for a second underestimate the importance of those extra 8+ months of clerkship.

 

You're right in that a PA technically only has 66% of the formal education a medical student receives. However, this does not mean that after many years of clinical practice and continuing education a PA cannot be as effective as an MD. The reason most medical schools are structured 50% pre clerkship and 50% clerkship (or more) is because most of what you learn about medicine you learn through practicing it.

 

A PA might be as effective as an MD with 1 or 2 years of residency training one day, but the issue is the lack of any graduated system for increasing autonomy. It's quite right to say that you only really learn with practice, but it's even more accurate to say that you only learn to make good decisions by making them with limited to no immediate supervision.

 

For example, as a resident, I have a senior in-house as backup, and if things get really sticky I can call the staff at home. But I rarely do and only for really significant stuff, usually at most once per night. Otherwise I make my own decisions without reviewing with anyone on 95% of issues that come up, typically with limited information and/or handover. A lot of it is simple stuff, but the trick is knowing when you need to come assess a patient instead of simply reordering a one-time breakthrough Dilaudid as the RN requests. The way my program works I'll be doing senior call in 5 months with the only backup being the staff in bed at home. That's maybe a bit scary but the only way you get comfortable with making "big" decisions is when you can't review them easily. I don't know if the PA model supports that paradigm very well (it's sort of designed to do so only very informally), though working in a smaller more peripheral centre would support it better.

 

Anyway, about the only thing I can recommend to emerg PAs is to strive to do better than their staff when it comes to making appropriate medicine consults.

[PAstudent]

Running an "ER" solo would pretty much be limited to very small quasi-overnight-walk-in clinics.

 

 

 

 

There are plenty of actual emergency departments, not "quasi-overnight-walk-in clinics" in rural and community hospitals in the USA where very-experienced PAs do solo shifts.

 

One emerg PA I know did, among the more mundane, all of the following during his solo night shifts last week: a cricothrotomy on a trauma patient with multiple facial fractures, running a cardiac arrest code, putting in bi-lateral chest tubes on another trauma patient, managing multiple septic patients, managing a PE, and pulled the STEMI button twice. Those are just some of the things he did over 4 shifts. Not very quasi-walk-in if you ask me.

 

PAs are not physicians. But PAs are qualified medical practitioners who learn on the job and work with varying degrees of autonomy according to skill and knowledge as assessed by their supervising physicians.

 

Everyone has something to give in medicine and there is always something new to learn. As much as I am a newbie and have lots to learn and probably won't be ready for solo emerg for many many years there are still plenty of times when I have taught an attending physician or a resident something, including knowledge and procedural skills.

[maritimer]

With that attitude, you're going to make a poor team player. Very ignorant response. Let's leave this thread not to debate PAs, but for PAStudent, as kind as he is for doing so, to answer questions for those that are interested.

 

You're just a physician assistant with only 2 years of school (cookie cutter medical school?).

 

Even PGY1 residents (with 4 years of medical school) don't know that much. They require much guidance from upper level residents, fellows, and staff.

 

Why do you sound as if you're acting like a chief resident?

 

From reading your posts, it seems like you run the ER or something.

 

And who will let you run ER solo???

 

Maybe in Nunavut???

[holiday1001]

i only found out PA program was 2 years a few days ago..

 

for reference at mac we have 70 hours of total clinical time. from the curriculum description, the pre-clerkship is also highly compressed compared to ours.

 

how often are in-hospital call in PA clerkship?

[PAstudent]

I took call on the majority of my core rotations as well as voluntarily on several electives. I had 1in4 call on IM, Gen Sx, and Trauma Sx, and psych I think I only did 1in7 but I don't recall for certain now. I ended-up doing about 3 months of IM, 2 months of Gen Sx (during which I was on call both for consults to the emerg and to the wards for all the surgical services except neuro surgery), and 6 weeks of psych.

 

Psych call was fairly easy, gen sx and IM were pretty heavy and I did them back to back (plus an IM elective at the end of my clerkship).

 

On any rotation an MD student would take call on a PA student would, generally speaking, do the same.

 

I, obsessed as I was with emerg, also picked-up a lot of emerg shifts during my other rotations and on holidays (instead of taking a break during Xmas time I worked more emerg shifts then than I did during my actual core emerg rotation!). I also fit in some good learning in an ICU where I got to become more comfortable with vent settings and central line placements. I did this by doing overnight ICU shifts, so not exactly on-call but got to do a lot.

 

I was also fortunate enough during my pre-clerkship time to do a lot of weekend emerg shifts including overnights and 24 hour rural shifts. This was through various physician connections I had made. Again, not exactly call but still, being in the hospital overnight afforded plenty of learning opportunities.

 

 

Also, I suppose it is worth noting that many of my IM and Gen Sx PA colleagues take call regularly as staff PAs.

 

 

how often are in-hospital call in PA clerkship?

[ACHQ]

 

One emerg PA I know did, among the more mundane, all of the following during his solo night shifts last week: a cricothrotomy on a trauma patient with multiple facial fractures, running a cardiac arrest code, putting in bi-lateral chest tubes on another trauma patient, managing multiple septic patients, managing a PE, and pulled the STEMI button twice. Those are just some of the things he did over 4 shifts. Not very quasi-walk-in if you ask me.

 

Was this is Canada or the U.S.?

 

From my understanding (in Canada) P.A.'s can't legally sign off on any orders/tests/meds/do procedures unless a physician has cosigned, or they have a medical directive/supervision. In a ER ran solely by a PA whose ultimately liable? Cause from my understanding when there is a supervising physician he's ultimately responsible if something were to go wrong/bad outcome (not saying this happens on the reg, but just asking).