Ask an emerg PA

[A-Stark]

I could be mistaken but my understanding is that PAs operate solely on the basis of acts delegated by a supervising physician. From the Ontario statement:

 

The PA profession is not regulated in Ontario. As such, medical care provided by the PA must be supervised by a registered physician and follow a recognized process of delegation. The PA is not an autonomous health care provider, and cannot act as the principal medical decision maker.

 

I'm not sure how this would be compatible with solo emerg (or any) practice, but of course in the US the situation is quite different.

[PAstudent]

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).

 

 

 

You are correct. This friend of mine works in the USA (though there are PAs in Canada doing solo emerg, I don't know any of them well and am not familiar with their practice). Your understanding of the situation for PAs in Ontario (though not Canada wide) is correct and so we must have medical directives in order for us to order anything without a cosignature.

[PAstudent]

I could be mistaken but my understanding is that PAs operate solely on the basis of acts delegated by a supervising physician. From the Ontario statement:

 

 

 

I'm not sure how this would be compatible with solo emerg (or any) practice, but of course in the US the situation is quite different.

 

 

 

Yes, you are correct. Not being regulated is a problem here and it is something we are working to correct as soon as possible.

 

In the USA PAs are regulated by State medical licensing boards and have a license to practice medicine under supervision.

[iamarealdoctor]

Yes, you are correct. Not being regulated is a problem here and it is something we are working to correct as soon as possible.

 

In the USA PAs are regulated by State medical licensing boards and have a license to practice medicine under supervision.

 

When you say that "we" are working to correct as soon as possible, how soon do you expect regulation to happen?

 

It could be many years before physician assistants are regulated.

[PAstudent]

When you say that "we" are working to correct as soon as possible, how soon do you expect regulation to happen?

 

It could be many years before physician assistants are regulated.

 

This thread is for me to answer questions about my day-to-day practice as an emergency medicine PA. This is not the appropriate place for your post. If you wish to discuss this issue, in a respectful and professional manner, I would be happy to do so in a different thread.

[iamarealdoctor]

Okay, fair enough.

 

What can't you do that a senior resident and staff can do in the ER?

[PAstudent]

Okay, fair enough.

 

What can't you do that a senior resident and staff can do in the ER?

 

Depends on what you mean by can't. Legally? In terms of my knowledge and skills? In terms of hospital policy? What do you mean?

[rswim]

Depends on what you mean by can't. Legally? In terms of my knowledge and skills? In terms of hospital policy? What do you mean?

 

i think it is great that we are getting more nurses, PAs, PT, OTs to expand their roles in the hospitals. As medicine continues to progress and evolve physicians need to relinquish some of their responsibilities to mid levels.

 

It doesn't make sense to be paying an ERP >$200/h to be suturing the simplest of lacs, putting in coude tip catheters or uncapping NG tubes just because it is in some hospital policy that is "outside the scope of practice" of the nurses/other midlevels.

 

I find myself questioning policies that prevent experienced nurses and others from performing tasks that the most junior of medical students are often asked to do (DREs, coude catheters, suturing simple lacs) --- If they are simple enough for a 3rd year med student to do indecently then certainly experienced mid levels should be able to do them to --- yes event he simplest things have the potential to get complicated and go south quickly --- but that is why the physician will always be there to step in.

 

I think it is great that you (PAstudent) are pushing the boundaries a little bit - stay safe and practice within reasonable limits and you will undoubtedly help streamline the system and save a lot of healthcare $ by freeing up MD time to do more complex tasks.

[PAstudent]

 

I think it is great that you (PAstudent) are pushing the boundaries a little bit -

 

I'm not sure what you mean as I am not pushing any boundaries.

[rswim]

I'm not sure what you mean as I am not pushing any boundaries.

 

I meant it in a positive way - more your profession (PAs) are trying to break down some eclectic rules that limited mid-levels for no good reason. Aka - red tape policy.

 

We are all on the same team and the more the more responsibilities that allied healthcare are able to take on the more the field of medicine will be able to continue to progress and innovate.

[iamarealdoctor]

Let's say that you have worked 20-30 years as an emerg PA.

 

If PGY1 was the only physician available to supervise you, would you be limited to what that particular PGY1 could do?

[PAstudent]

Let's say that you have worked 20-30 years as an emerg PA.

 

If PGY1 was the only physician available to supervise you, would you be limited to what that particular PGY1 could do?

 

You are positing a hypothetical situation that is absurd. As a PA with just under a year of experience I regularly supervise and teach MD clinical clerks and many of my more experienced emerg PA colleagues at a major academic center supervise and teach PGY1s, 2s, and 3s on a regular basis. One particularly experienced emerg PA I know regularly supervises and teaches PGY4s and 5s in the RCPSC emerg program. The details of the legal arrangement of supervision for PAs is indeed different from place-to-place and, theoretically, there are places where, from a purely legal perspective, a resident physician could act as the supervising physician for a PA and, in some places, by-law, a PA many only operate within the scope of practice of their supervising physician (for e.g., let's say the PA has done a few hundred thoracenteses, but the supervising physician has never done one, from a purely legal perspective then the PA is not supposed to do them when working under that particular supervising physician in some places). This reminds me of a situation I had: I have an attending who, up until a month ago, had never done a paracentesis. I have done many and they asked me to teach them how, so I did.

[iamarealdoctor]

You are positing a hypothetical situation that is absurd. As a PA with just under a year of experience I regularly supervise and teach MD clinical clerks and many of my more experienced emerg PA colleagues at a major academic center supervise and teach PGY1s, 2s, and 3s on a regular basis. One particularly experienced emerg PA I know regularly supervises and teaches PGY4s and 5s in the RCPSC emerg program. The details of the legal arrangement of supervision for PAs is indeed different from place-to-place and, theoretically, there are places where, from a purely legal perspective, a resident physician could act as the supervising physician for a PA and, in some places, by-law, a PA many only operate within the scope of practice of their supervising physician (for e.g., let's say the PA has done a few hundred thoracenteses, but the supervising physician has never done one, from a purely legal perspective then the PA is not supposed to do them when working under that particular supervising physician in some places). This reminds me of a situation I had: I have an attending who, up until a month ago, had never done a paracentesis. I have done many and they asked me to teach them how, so I did.

 

Are your emerg PA friends in US?

 

Much of what you say doesn't sound like something that will happen in Canada anytime soon.

 

Here are my final questions. Thanks for your clarifications and answers btw.

 

Why are you allowed to teach MD clinical students?

 

Why aren't you teaching PA students instead?

 

Why aren't the residents teaching the med students themselves?

 

Do you want to become a MD if given the opportunity?

[PAstudent]

Are your emerg PA friends in US?

 

Why are you allowed to teach MD clinical students?

 

Why aren't you teaching PA students instead?

 

Why aren't the residents teaching the med students themselves?

 

Do you want to become a MD if given the opportunity?

 

 

1) The ones I was referring to in my last post are in Canada; Toronto to be exact.

2)Again, an absurd question. I am an emergency medicine PA, I practice emergency medicine. Therefore, when we have students in our department they are sometimes assigned to me.

3)I also teach PA students

4)The residents also teach the med students.

5) No. I was in an MD program before and left to pursue other interests and then decided to become a PA.

[iamarealdoctor]

1) The ones I was referring to in my last post are in Canada; Toronto to be exact.

2)Again, an absurd question. I am an emergency medicine PA, I practice emergency medicine. Therefore, when we have students in our department they are sometimes assigned to me.

3)I also teach PA students

4)The residents also teach the med students.

5) No. I was in an MD program before and left to pursue other interests and then decided to become a PA.

 

Thank you for your replies. Good luck with your emerg PA career!

[rswim]

1) The ones I was referring to in my last post are in Canada; Toronto to be exact.

2)Again, an absurd question. I am an emergency medicine PA, I practice emergency medicine. Therefore, when we have students in our department they are sometimes assigned to me.

3)I also teach PA students

4)The residents also teach the med students.

5) No. I was in an MD program before and left to pursue other interests and then decided to become a PA.

 

I agree - you don't need to be a physician to teach medical students/residents.

 

As a clinical clerk I learned a great deal from pharmacists, RNs, RTs etc. I think that just about every medical school in Canada integrates allied health professionals into their curriculum.

 

I would guess the majority of medical students learned how to to put in IVs from nurses on the wards. I'd also guess that most canadian medical students are taught how to (or at least given some pointers) on ABGs from RTs.

 

I think it is great that PAs teach all different levels of learners. Being a good physician requires that you learn skills from all different levels of providers so that you are able to captain the ship (pretty hard to be the captain if you have no idea about what the crew does).

 

I can't count the number of times I asked a nurse how to help me with my orders that he/she was unable to write. Yes technically I was writing and thus "supervising/taking on the responsibility" but the experienced RNs were able to give me guidance/confirm that what I was doing was right. Obviously this can get you into hot water and I think that medical students need to critically appraise what they are being taught by allied health and not necessarily take their word because ultimately the MSI(sort of)/PGY/MD Staff is responsible for the care of their patient and they can't just say "well the RN told me or the PA told me...." but I still think you can learn a great deal from others.

 

Again - it all comes down to the fact that we are on the same team and if PAs can practice within their scope and perform at a level where the supervising physician is comfortable taking responsibility for their work then the overall efficiency and hopefully quality of care will improve.

 

Its similar to the CRNA situation in the states... they are by NO MEANS anesthesiologists (despite some dangerous CRNA claims) but they do have a role in improving the efficiency of practice if they recognize their limitations and practice within them.

 

In Canada there is plenty of work to go around -- there is no turf war - there are and will continue to be clear boundaries - I think it is important that the MD community continue to support the expansion of mid level providers to take on more responsibility - there is simply not enough $$ to be paying physician wages for tasks that do not require physicians to be performing them.

[PAstudent]

Your post does not contribute to this thread. The point of this thread is for me to answer questions about my practice as an emerg PA, not for you to reply to give your opinion on things. Please refrain from doing so within this thread. If you wish to, please feel free to start a separate thread for this purpose.

 

 

 

I agree - you don't need to be a physician to teach medical students/residents.

 

As a clinical clerk I learned a great deal from pharmacists, RNs, RTs etc. I think that just about every medical school in Canada integrates allied health professionals into their curriculum.

 

I would guess the majority of medical students learned how to to put in IVs from nurses on the wards. I'd also guess that most canadian medical students are taught how to (or at least given some pointers) on ABGs from RTs.

 

I think it is great that PAs teach all different levels of learners. Being a good physician requires that you learn skills from all different levels of providers so that you are able to captain the ship (pretty hard to be the captain if you have no idea about what the crew does).

 

I can't count the number of times I asked a nurse how to help me with my orders that he/she was unable to write. Yes technically I was writing and thus "supervising/taking on the responsibility" but the experienced RNs were able to give me guidance/confirm that what I was doing was right. Obviously this can get you into hot water and I think that medical students need to critically appraise what they are being taught by allied health and not necessarily take their word because ultimately the MSI(sort of)/PGY/MD Staff is responsible for the care of their patient and they can't just say "well the RN told me or the PA told me...." but I still think you can learn a great deal from others.

 

Again - it all comes down to the fact that we are on the same team and if PAs can practice within their scope and perform at a level where the supervising physician is comfortable taking responsibility for their work then the overall efficiency and hopefully quality of care will improve.

 

Its similar to the CRNA situation in the states... they are by NO MEANS anesthesiologists (despite some dangerous CRNA claims) but they do have a role in improving the efficiency of practice if they recognize their limitations and practice within them.

 

In Canada there is plenty of work to go around -- there is no turf war - there are and will continue to be clear boundaries - I think it is important that the MD community continue to support the expansion of mid level providers to take on more responsibility - there is simply not enough $$ to be paying physician wages for tasks that do not require physicians to be performing them.

[mdfever]

I was wondering how do you get paid? Are you hired by the hospital and have benefits? Or you get paid from fees for services? Thanks.

[A-Stark]

Your post does not contribute to this thread. The point of this thread is for me to answer questions about my practice as an emerg PA, not for you to reply to give your opinion on things. Please refrain from doing so within this thread. If you wish to, please feel free to start a separate thread for this purpose.

 

That is an astoundingly rude reply to a thoughtful and well considered post.

 

But I suppose that isn't "contributing" either. l

[PAstudent]

I was wondering how do you get paid? Are you hired by the hospital and have benefits? Or you get paid from fees for services? Thanks.

 

I am a contract worker so no benefits. I get paid an hourly rate based on a yearly base salary with extra pay for working holidays or certain hard to cover shifts.

 

The way PAs are paid throughout Ontario varies a great deal though so my situation is not necessarily representative.

[iamarealdoctor]

As far as my understanding goes, PAs cannot get paid from fee for service in Ontario.

 

Currently, supervising physician cannot bill for PAs in Ontario.

[PAstudent]

As far as my understanding goes, PAs cannot get paid from fee for service in Ontario.

 

Currently, supervising physician cannot bill for PAs in Ontario.

 

 

This is not correct. All of my emerg SPs bill regularly for the services I provide as do the SPs of most PAs throughout the Province. There are also PA jobs where the PA is paid based directly on OHIP billings.

[iamarealdoctor]

This is not correct. All of my emerg SPs bill regularly for the services I provide as do the SPs of most PAs throughout the Province. There are also PA jobs where the PA is paid based directly on OHIP billings.

 

Somehow, I don't believe everything that you say. You seem to over-exaggerate the abilities of a PA and what can actually be done by a PA.

[PAstudent]

Somehow, I don't believe everything that you say. You seem to over-exaggerate the abilities of a PA and what can actually be done by a PA.

 

 

I encourage you to educate yourself on PAs. I assure you I have not exaggerated a thing. If you are in the GTA and are indeed a physician as you claim then I would be more than happy to meet with you and introduce you to multiple physicians who work with and train PAs.

[NutritionRunner]

Somehow, I don't believe everything that you say. You seem to over-exaggerate the abilities of a PA and what can actually be done by a PA.

 

In my limited experience with civilian PAs, everything PAStudent has said is accurate.