Ask an emerg PA

[rswim]

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.

 

Sorry - I thought a little physician support of PAs and PA teaching medical students would be useful to the readers of your blog.

 

I'll refrain from contributing. Good luck with your career. Careful with the attitude that you have towards physicians.

[Guest Raj123]

PAStudent: Thank you for your continued feedback, really appreciate it!

[Guest Raj123]

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.

 

Very thoughtful and encouraging post! It's great to see some optimisim towards various health care professionals; including mid-level practitioners. The main thing is to accomplish the goal of working together, to provide the best care possible for patients.

 

Thank you for this!

[PAstudent]

PAStudent: Thank you for your continued feedback, really appreciate it!

 

No worries! I'm glad you appreciate it

[iamarealdoctor]

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.

 

And I encourage you not to lie.

 

I don't know if this is you in this forum, but here is a perspective of a PA student in Canada.

 

From:

 

http://www.physicianassistantforum.com/forums/showthread.php/37560-Meanwhile-in-Ontario

 

His username is PAstudentcanada.

 

Physicians can't really bill for what we do, we are unable to be responsible for our own actions, and we cannot order or prescribe medications (things that are necessary to do our job, indeed, this is part of our job description. NPs cant do all of these things and, indeed, many physicians have said to me "I would rather have an NP" for many of those reasons.

 

docs can't bill for what we do and now we're unable to be responsible for our own actions. This government has no idea what to do with PAs or any understanding of how we're actually working!

 

This is essentially making PAs work like Clinical Clerks which makes having a PA around almost pointless.

 

In my job as an emerg PA at a Toronto hospital I am essentially functioning just like I did when I was a PA clinical clerk. I have no actual authority. I basically take a hx and a px and then go talk to my SP who RARELY even wants to hear my plan. They usually grab the chart from me, write their own plan, then go see the patient and carry our their plan and d/c them /admit them and all without every talking to me about them again. At least I get paid now.

 

When I tell some of the docs in my group that the job of a pa is to practice medicine under supervision with negotiated autonomy they look at me like I am insane. When I tell them that in many places docs do not physically see the patients the pa treats they look at me in horror. When I tell them that in the USA there are experience pas who work with no doc on site they practically go into convulsions.

 

They see me as their assistant. They are my job as to collect data for them and do procedures for them. When I tell them that Yale has a physician Associate program they seem to be very uncomfortable.

 

When I told one of them that I intubated a pt the other day (while with a different doc) they told me PAs should not be doing that and she would never let me do that.

 

What PAs on Ontario do varies from place to place but, for the most part: histories, physicals, ordering/interpreting investigations, prescribing medications, and performing procedures.

Placing IVs is really a nurses job though you can certainly do it as a PA. Yes, you can intubate, I intubated a pt a few days ago.

 

Most physicians I meet don't have a clue what a PA is and just want a hx and px and for me to perform procedures for them. huge waste. Free government money is the key for most I meet.

[PAstudent]

And I encourage you not to lie.

 

I don't know if this is you in this forum, but here is a perspective of a PA student in Canada.

 

I have been completely open and honest and am trying my best to help inform the people who want to be informed about PAs and about my job in particular. I am, obviously, not that person on the PA forum as they seem rather unhappy with their job and with the lack of regulation for PAs in Ontario. Indeed, I have many friends who are not happy with things for PAs in Ontario right now and many friends who are unhappy with their jobs for various reasons.

 

While I also feel that regulation is a problem and feel that the MOHLTC has dropped the ball when it comes to PAs, I love my job and I trust that, as a pioneer of something new here, we simply must be patient with regard to regulation.

 

I'm not a liar and accusing me of such when I have been so kind to you as to offer to meet with you in person and introduce you to GTA physicians who work with and train PAs is rude and antagonistic. I am being nice and trying to helpful and you are going on the attack so to speak.

 

This is a thread that I started to answer questions people have about my role. If you don't like my answers that's fine but continuing to be antagonistic, seemingly trying to bait me into argument, and being out-right rude in spite of my sincere attempts to help you learn more puts you in a place here I no longer wish to help you. In fact, I question whether or not you are simply a "troll" as the people on this board use the term. For that reason, I will no longer respond to any of your comments or questions.

[concernedmedstudent]

And I encourage you not to lie.

 

I don't know if this is you in this forum, but here is a perspective of a PA student in Canada.

 

From:

 

http://www.physicianassistantforum.com/forums/showthread.php/37560-Meanwhile-in-Ontario

 

His username is PAstudentcanada.

 

Hey now --- clinical clerks can be useful for scut work!!

 

If a PA functions like an MSI/Clinical Clerk without the need for the residents/attendings to spend a lot of time teaching them then I feel like they could benefit the system.

 

As a senior medical student I agree that we use up more resources than we give back - but if a PA can do everything that we can do without requiring all of the teaching time then I definitely think they would have a net positive contribution.

[Mourning Cloak]

If a PA functions like an MSI/Clinical Clerk without the need for the residents/attendings to spend a lot of time teaching them then I feel like they could benefit the system.

 

Clinical clerks don't really do anything. They could all evaporate tomorrow (at least mine could) and no one other than the R1 might notice.

[rich10]

I would like to apply to medical school, but I know that less than 10% of applicants are selected each year. If I don't get in, I am thinking about applying to the Physician Assistant program at UofM and working in that field for the practical experience, before taking another crack at medical school. Does this seem like a logical course of action?

[PAstudent]

I would like to apply to medical school, but I know that less than 10% of applicants are selected each year. If I don't get in, I am thinking about applying to the Physician Assistant program at UofM and working in that field for the practical experience, before taking another crack at medical school. Does this seem like a logical course of action?

 

Please start a new thread in the forum for this. This thread is for discussing my position as an emerg PA in the GTA.

[ralk]

How does the delegation relationship work when you have different physicians overseeing your work? As I understand it, a PA's scope of practice depends entirely on the overseeing physician's scope and delegation discretion.

 

Do some physicians give you more latitude than others? Are there ever instances of a physician refusing to delegate tasks to you or another PA?

[PAstudent]

How does the delegation relationship work when you have different physicians overseeing your work? As I understand it, a PA's scope of practice depends entirely on the overseeing physician's scope and delegation discretion.

 

Do some physicians give you more latitude than others? Are there ever instances of a physician refusing to delegate tasks to you or another PA?

 

Excellent question! Thanks

 

For the most part, I have a lot of medical directives that cover the vast majority of what I do. Medical directives are different from place to place and range from non-existent to all encompassing documents that cover pretty much everything one might need to do so my situation is certainly not representative of any other. As I have said before there is far more variability among PAs and PA practice than among MDs in Canada.

 

Because of medical directives, the majority of what I do is pre-delegated so to speak. That is, all the physicians in my group, most importantly the Chief of the emerg, have signed-off on them.

 

That said, the way I work certainly changes depending on the physician I am working with at any given time. Just because I have a medical directive to do something does not mean I will go ahead and do that thing. The medical directives are a legal necessity in Ontario at the moment to allow a PA the authority they need to do their job. And that is the key point, the allowance of authority. Should a new-grad emerg PA be ordering, for example, a CT abdo/pelvis without running it by their SP first? No, I don't think so. And I never would. Nor would my colleagues I know who also have very good/complete directives. But should the PA have the framework to do so? Yes.

 

It is important to create the legal, administrative, and clinic framework for a PA to practice medicine. It is just as important that the PA not abuse the authority/autonomy given to them.

 

At my level, I feel it is important to review with my SP before ordering anything or performing any procedures 99 % of the time. There are certain physicians with whom I have worked a lot and who have told me already that they want me to go ahead and order certain things without speaking with them. Indeed, my Chief doesn't think I do enough of this.

 

I have run into the odd physician here or there that is not comfortable with the role of a PA or not comfortable with PAs doing certain things. With regard to the latter, a situation in my group did arise regarding where an SP told me they did not think it was appropriate for a PA to do a certain thing (I don't want to reveal what this thing is because it could actually identify the physician involved). I was surprised at this response because this thing was something I had been taught to do throughout PA school and something that the majority of my SPs want me to do. The end result was that our Chief told me to keep doing it and the Chief told this individual physician that I was to keep doing it and that they would have to be okay with that. Several other physicians in the group also told this particular one that they supported me doing this.

 

Just as how as a clinical clerk or a resident one finds working with different SPs to be different, so it goes for a PA. There are SPs who want to give me a great deal of autonomy and don't want to hear about or see my patients but are happy to sign-off on the chart and there are SPs who want to micro-manage and be involved with every small step. The majority of SPs are in the middle and I make a point of stressing my level and asking for teaching, guidance, and support from all of them.

 

I find that the physicians who are good and have confidence in themselves are the best to work with. They give me an appropriate level of oversight, seem to know just how to work with me, seem to know just how much autonomy to give or take, and they are always teaching me things. Because of this there is a harmony where we get things done. We see lots of patients, we give good care, and patient satisfaction is good.

 

 

Finally, to your point of a PA scope needed to be within the scope of their SP. I mentioned earlier in this thread an instance where an SP of mine had never done a certain procedure but I had done many of them. They asked me to teach them so we went in the room together and I taught them. So lines can be blurred sometimes. In fact, this type of thing has happened a few times.

 

Have I answered your questions? I hope I got to what you were trying to get at. If not, please let me know and I shall do my best to answer.

[ralk]

Excellent question! Thanks

 

For the most part, I have a lot of medical directives that cover the vast majority of what I do. Medical directives are different from place to place and range from non-existent to all encompassing documents that cover pretty much everything one might need to do so my situation is certainly not representative of any other. As I have said before there is far more variability among PAs and PA practice than among MDs in Canada.

 

Because of medical directives, the majority of what I do is pre-delegated so to speak. That is, all the physicians in my group, most importantly the Chief of the emerg, have signed-off on them.

 

That said, the way I work certainly changes depending on the physician I am working with at any given time. Just because I have a medical directive to do something does not mean I will go ahead and do that thing. The medical directives are a legal necessity in Ontario at the moment to allow a PA the authority they need to do their job. And that is the key point, the allowance of authority. Should a new-grad emerg PA be ordering, for example, a CT abdo/pelvis without running it by their SP first? No, I don't think so. And I never would. Nor would my colleagues I know who also have very good/complete directives. But should the PA have the framework to do so? Yes.

 

It is important to create the legal, administrative, and clinic framework for a PA to practice medicine. It is just as important that the PA not abuse the authority/autonomy given to them.

 

At my level, I feel it is important to review with my SP before ordering anything or performing any procedures 99 % of the time. There are certain physicians with whom I have worked a lot and who have told me already that they want me to go ahead and order certain things without speaking with them. Indeed, my Chief doesn't think I do enough of this.

 

I have run into the odd physician here or there that is not comfortable with the role of a PA or not comfortable with PAs doing certain things. With regard to the latter, a situation in my group did arise regarding where an SP told me they did not think it was appropriate for a PA to do a certain thing (I don't want to reveal what this thing is because it could actually identify the physician involved). I was surprised at this response because this thing was something I had been taught to do throughout PA school and something that the majority of my SPs want me to do. The end result was that our Chief told me to keep doing it and the Chief told this individual physician that I was to keep doing it and that they would have to be okay with that. Several other physicians in the group also told this particular one that they supported me doing this.

 

Just as how as a clinical clerk or a resident one finds working with different SPs to be different, so it goes for a PA. There are SPs who want to give me a great deal of autonomy and don't want to hear about or see my patients but are happy to sign-off on the chart and there are SPs who want to micro-manage and be involved with every small step. The majority of SPs are in the middle and I make a point of stressing my level and asking for teaching, guidance, and support from all of them.

 

I find that the physicians who are good and have confidence in themselves are the best to work with. They give me an appropriate level of oversight, seem to know just how to work with me, seem to know just how much autonomy to give or take, and they are always teaching me things. Because of this there is a harmony where we get things done. We see lots of patients, we give good care, and patient satisfaction is good.

 

 

Finally, to your point of a PA scope needed to be within the scope of their SP. I mentioned earlier in this thread an instance where an SP of mine had never done a certain procedure but I had done many of them. They asked me to teach them so we went in the room together and I taught them. So lines can be blurred sometimes. In fact, this type of thing has happened a few times.

 

Have I answered your questions? I hope I got to what you were trying to get at. If not, please let me know and I shall do my best to answer.

 

Thank you for the thorough response, that's quite helpful!

 

I'm just so used to the model of regulated health care workers with defined scopes of practice that it's difficult to picture how one would work with only delegated acts. I work in of these regulated health care professions and my role is clearly defined in legislation, and further by my provincial college. We have delegated acts too, but these comprise a small part of our practice - it must be quite a challenge when that's your entire practice!

 

As for teaching, as far as I'm concerned, knowledge is knowledge and it doesn't matter who transmits it to who so long as it's accurate. There's no legislation on teaching in health care (so far as I know ) only on practice.

[concernedmedstudent]

Clinical clerks don't really do anything. They could all evaporate tomorrow (at least mine could) and no one other than the R1 might notice.

 

Haha - wish that were the case - would make weekend rounding on CTU a lot easier when there is only an MSI/CC covering the team and writing all the notes... pretty sure the post call resident would be mighty pissed if we vanished

 

The point was more to say that if a clinical clerk didn't require teaching and just went around doing the difficult foley's, NG tubes, histories, physicals, simple (but annoying) orders for tylenol, zopiclone etc. they would be useful and this is a role that PAs can and should fill in non-teaching hospitals where there are no R1s and MSIs to do a lot of the scut work.

 

If i were in a community hospital 5 years from now as an attending i wouldn't want to be bothered by all the ward calls that the MSIs and jr residents handle in teaching hospitals and thus I think it would be a huge help to have PAs who aren't too burdened by red tape bureaucracy (like the many of the nurses are) who can order simple things and take care of problems on the ward that don't warrant waking up the staff MD.

[spontaneouscombustion]

I'm not sure I get it. So are PAs basically clinical clerks in non-academic hospitals?

[PAstudent]

I'm not sure I get it. So are PAs basically clinical clerks in non-academic hospitals?

 

No. I work primarily in a non-academic hospital.

[Talon01]

Does your PA degree carry over to the USA or do you have to rewrite exams, etc?

[PAstudent]

Does your PA degree carry over to the USA or do you have to rewrite exams, etc?

 

Currently, to work as a PA in the USA you have to write and pass the NCCPA exam which allows you to apply to a state medical licensing board for a license to practice in that state. The NCCPA does not recognize Canadian PA program graduates as eligible to write the exam. They only allow graduates of recognized USA programs to write the exam. Thus, as of now, the degree I have, from the Michael G. DeGroote School of Medicine, McMaster University, does not carry-over.

 

The Canadian Forces PAs, however, have been getting their degrees through the USA (though I understand this might change soon) since, up until the last several years, there were no other options (Canadian military has had PAs for 30 years). Thus, Canadian Forces PAs could qualify to work in the USA, though I don't know any who currently do.

 

Given that American-qualified PAs can work in Canada/take the Canadian certifying exam, there is hope that we can convince the Americans to do likewise for us. But, thus far, this has not happened.

[meeno]

Hi,

thank you for starting this thread and taking the time out to answer questions. I am considering the UofM Pa Program and I have the following question.

 

1) in terms of further studying, can a PA do further studying after PA school or is it that they learn on the job and move  up from there in terms of pay, benefits, job security etc? I am just trying to get a feeling of it as a career to start. 

 

2) Can Canadian PA's practice in the United States if they do the licensing examination or are they unable to practice there? Can they practice in the UK with their Canadian degree?

 

3) in terms of your medical education, what would you say that you got to study? for example: did you learn the pathologies of the systems in detail or would you say it was more focused on skill development over academic medicine so to speak? 

 

4) is there a white coat ceremony to the PA program at McMaster? 

 

I will have more questions later probably but these are all I can think of right now. 

 

Thanks for your time.