AAPA's Push for Full Practice Authority

[sum dude]

You seem to say it's professionally frustrating and dangerous for patients to watch someone lobby for scope and autonomy beyond their training....but then simultaneously do the frustrating and dangerous thing

Can I do a Derm Fellowship, ala NP's? I swear I have more training than NP's. Botox and Acne meds here I come!

---

Members don't see this ad.

 

[feargift]

Spot on. I had a pre-PA that worked in our ED acting so cocky it's sickening. I'm like I've been where you are going and if you think PA school is hard try medical school.

Also I wouldn't put a "number" on how close we are to being physicians. It's more about depth of knowledge.


A green PA might see a sore throats and think strep or viral pharyngitis but forget the more deadly presentations that these can mask around as. This is taught to us from day 1 of residency.


Sent from my iPhone using SDN mobile app

That is getting very petty.

 

[MSmentor018]

That is getting very petty.

let's pull it back on track and stir the pot to get the conversation going
if this authority thing goes through, what's the worse that could happen?

 

[Boatswain2PA]

I'm not a member of the AAPA, and very few PAs are. The AAPA is about as representative of all PAs as the AMA is representative of all physicians. For years they were more concerned with political gamesmanship than they were of advancing the profession.

So who "represented" PAs? Well, like SB's "Et tu Brute" inference above, many of us just assumed that since we were Physician ASSISTANTS, we would be represented by physicians. But we really weren't. Furthermore, physician organization influence (hiring, credentialing, political, etc) continues to erode, leading to even less representation for us. Meanwhile we see the nursing lobby get independent practice in more and more states, and this leads to the C-suites preferentially hiring them over us (despite their grossly less education/training).

A few years ago another PA organization was created (PAs For Tomorrow (PAFT)) who began pursuing necessary actions (fighting back against the NP lobby, terrible media coverage, etc) and led to rapid growth of the organization, and drawing in the small number of politically active PAs. A but unfortunately they also began pushing for independent practice. With their rapid growth, and the collection of politically active PAs, PAFT was able to recently exert a large influence over the AAPA....and suddenly we have this over-reach.

My preference would be for physician groups to stand up for MEDICINE and define what it means to practice medicine, and then ensure nobody practices medicine unless they are under the purview of the Boards of Medicine (BOM). No more naturopaths injecting turmeric for eczema or diagnosing "liver parasites" and prescribing expensive vitamins to "cure" said disease. No more nurse practitioners opening their own practice after 2 years of part-time (mostly) online "doctorate" education and 500 hours of "clinical training" in their friend's clinic. This would ensure patients always have a physician, the top-dawg of the field, somehow involved in their care.

But this didn't happen, and I think the boat's left the dock on ever happening. The nurses have far more political power than the AMA and they will soon have independent practice everywhere. No chart review required by law, no supervising/collaborative physicians...nothing. The C-suites who now run everything would rather hire an NP because "they are independent"...not realizing that the med staff rules still require physician oversight.

So...what should PAs do? Keep begging for scraps from physicians? Looking at some of the derogatory comments here, even I think that's looking less and less beneficial.
Fight against NP independence? There are about 100K PAs, there are millions of nurses; no chance we could match that political power.

I think "independent practice" is coming to the PA world. I don't like it (and I'm in a very independent practice environment), but it's coming. It won't be a perfect fix for the problems, and it will certainly add new problems, but independent practice is coming.

Hopefully we can get this changed so that PAs maintain their position under the BOM and not creating an entire new bureaucratic licensing organization, but I think that will depend on whether the BOMs support the move toward independence. Unfortunately I doubt that will happen, but I hope I'm wrong.

 

[RustedFox]

let's pull it back on track and stir the pot to get the conversation going
if this authority thing goes through, what's the worse that could happen?

Like I said; they get the rope with which to tie their own nooses.
They can have fun being sued and regulated right back to where they should be.

 

[deleted480308]

I'm not a member of the AAPA, and very few PAs are. The AAPA is about as representative of all PAs as the AMA is representative of all physicians. For years they were more concerned with political gamesmanship than they were of advancing the profession.

So who "represented" PAs? Well, like SB's "Et tu Brute" inference above, many of us just assumed that since we were Physician ASSISTANTS, we would be represented by physicians. But we really weren't. Furthermore, physician organization influence (hiring, credentialing, political, etc) continues to erode, leading to even less representation for us. Meanwhile we see the nursing lobby get independent practice in more and more states, and this leads to the C-suites preferentially hiring them over us (despite their grossly less education/training).

A few years ago another PA organization was created (PAs For Tomorrow (PAFT)) who began pursuing necessary actions (fighting back against the NP lobby, terrible media coverage, etc) and led to rapid growth of the organization, and drawing in the small number of politically active PAs. A but unfortunately they also began pushing for independent practice. With their rapid growth, and the collection of politically active PAs, PAFT was able to recently exert a large influence over the AAPA....and suddenly we have this over-reach.

My preference would be for physician groups to stand up for MEDICINE and define what it means to practice medicine, and then ensure nobody practices medicine unless they are under the purview of the Boards of Medicine (BOM). No more naturopaths injecting turmeric for eczema or diagnosing "liver parasites" and prescribing expensive vitamins to "cure" said disease. No more nurse practitioners opening their own practice after 2 years of part-time (mostly) online "doctorate" education and 500 hours of "clinical training" in their friend's clinic. This would ensure patients always have a physician, the top-dawg of the field, somehow involved in their care.

But this didn't happen, and I think the boat's left the dock on ever happening. The nurses have far more political power than the AMA and they will soon have independent practice everywhere. No chart review required by law, no supervising/collaborative physicians...nothing. The C-suites who now run everything would rather hire an NP because "they are independent"...not realizing that the med staff rules still require physician oversight.

So...what should PAs do? Keep begging for scraps from physicians? Looking at some of the derogatory comments here, even I think that's looking less and less beneficial.
Fight against NP independence? There are about 100K PAs, there are millions of nurses; no chance we could match that political power.

I think "independent practice" is coming to the PA world. I don't like it (and I'm in a very independent practice environment), but it's coming. It won't be a perfect fix for the problems, and it will certainly add new problems, but independent practice is coming.

Hopefully we can get this changed so that PAs maintain their position under the BOM and not creating an entire new bureaucratic licensing organization, but I think that will depend on whether the BOMs support the move toward independence. Unfortunately I doubt that will happen, but I hope I'm wrong.

I get the self preservation move for PAs to push for indepent status if professional gamesmanship is the priority

I don't get the justification of it if we're at all pretending that patient care is still the priority. I don't get the claim of "but the nurses are being inappropriate so we will too". I don't understand disappointment that the the BOM doesn't want to license PA independant status...they shouldn't. I share your frustration at people who don't really represent your feelings speaking for you (some of the crap put out by student organizations is mind boggling) though, but the "we're about to do something bad so you should get on board" isn't likely (or shouldn't be) an appealing argument to a BOM.

I share your opinion on the nurses out playing us legislatively

 

[Brahnold Bloodaxe]

I am really regretting ever setting out on this path, it feels more and more like climbing onboard a sinking ship with every passing year.

It is easy to see where this is going. The government healthcare system is broke, the transition of the healthcare industry into a fully corporitized model is almost fully complete, and the onslaught of assorted "providers" is increasing in both numbers and scope.

And all these forces want the same thing: cut doctors down to size.
-The government wants to pay us less
-The hospitals and CMGs want to pay us less
-The insurance companies want to pay us less
-Tech wants to muscle in on the field and get their slice of the pie
-The provider alphabet soup wants to replace us

It is in the interest of all the above parties to do away with the very concept of a "doctor."' Supply and demand baby, the more interchangeable "providers" there are the less negotiating power they have and the worse are the terms they can procure for themselves.

I am really wishing I stayed in corporate.

 

[Venko]

You say that if PHYSICIANS would hire PAs instead of NPs, then this would obviate the issue.

Sure, let me do the hiring/firing. Oh, wait... I can't. That's the CMG's turf. Another reason why CMGs need to die.

You seem to make the assertion that PA >>> NP frequently.

I gotta say, I've worked with a lot, and only very few of them are half-decent at medical decision making, documentation, etc.

If the general attitude of the Physician assistants was to... assist physicians, then I wouldn't be so critical. But instead, many of them seem to be more interested in arguing with me as to why they're just as good or better, or "right" when it comes down to the management of this patient, or why "they do it this way."

I would love to work with a true physician assistant. I want them to do what I want them to do, how I want it done, and document it how I want it written. No arguments.

I haven't seen one of those yet.

My experience has been that PAs have a better understanding of the why we do things and pick up the nuance better than the NPs I have worked with. This could be just a reflection of the specific NPs and PAs i met though.


Sent from my iPhone using SDN mobile

 

[RustedFox]

My experience has been that PAs have a better understanding of the why we do things and pick up the nuance better than the NPs I have worked with. This could be just a reflection of the specific NPs and PAs i met though.


Sent from my iPhone using SDN mobile

I am inclined to agree. The PAs seem to have more cerebral horsepower than the NPs. That doesn't mean I think either should have independent practice rights unless they're greet-to-dispo ready. That takes time, and you know what we call those who spend the time to be greet-to-dispo ready?

Graduating Senior Residents.


I had another shift today where I got peppered by two voices, each saying "Hey, I got one for yah." It's amazingly agitating that they can't dispo a passed kidney stone, but they're ready to send that old guy with dyspepsia home. After all... He was all sweaty and gross and he smelled like cigarettes. Eww.

 

[Overthehorizen]

All of this thread is for naught. Given the influence of NPs and the overgrowth of PA programs without any infrastructure, the profession of the PA will cease to exist in ten years. No undergraduate today should give a moments thought to going to PA school. The choice is Med School first. If that cannot happen, go to NP. Remeber, if you are foolish enough to go to PA school now, by the time you finish paying off your exorbitant loans you won't be able to get a job. The PA profession is in utter chaos and they are in a death spiral. Emed and Boatswain like to paint a rosy picture because they benefit professionally from unsuspecting new entrants into this dying profession.

 

[Makati2008]

All of this thread is for naught. Given the influence of NPs and the overgrowth of PA programs without any infrastructure, the profession of the PA will cease to exist in ten years. No undergraduate today should give a moments thought to going to PA school. The choice is Med School first. If that cannot happen, go to NP. Remeber, if you are foolish enough to go to PA school now, by the time you finish paying off your exorbitant loans you won't be able to get a job. The PA profession is in utter chaos and they are in a death spiral. Emed and Boatswain like to paint a rosy picture because they benefit professionally from unsuspecting new entrants into this dying profession.

You have any proof of these claims?


Sent from my iPhone using SDN mobile app

 

[Boatswain2PA]

I am inclined to agree. The PAs seem to have more cerebral horsepower than the NPs. That doesn't mean I think either should have independent practice rights unless they're greet-to-dispo ready. That takes time, and you know what we call those who spend the time to be greet-to-dispo ready?

Graduating Senior Residents.

I had another shift today where I got peppered by two voices, each saying "Hey, I got one for yah." It's amazingly agitating that they can't dispo a passed kidney stone, but they're ready to send that old guy with dyspepsia home. After all... He was all sweaty and gross and he smelled like cigarettes. Eww.

Many experienced PAs are also greet-to-dispo ready. There are many of us that practice EM under the same standard of care that you have. I'm not saying there is an equivalency in education, experience, or value, just that the same standard of care applies to us.

Regarding the "Hey, I got one for ya." If it's an experienced PA then that SHOULD be the same approach that you take with a specialist, or with another EP. There's nothing wrong with bouncing something off of someone. I'm sure you do it with specialists all the time.

As for sending home your described patient....then that PA isn't getting enough supervision. You can either relegate him to the cough & snot hall, or if you think he's worth spending your time on you could help him grow into a competent EM provider to help you carry the load later. Your call.

Emed and Boatswain like to paint a rosy picture because they benefit professionally from unsuspecting new entrants into this dying profession.

You are off your medicine again....

 

[Fox800]

Many experienced PAs are also greet-to-dispo ready. There are many of us that practice EM under the same standard of care that you have. I'm not saying there is an equivalency in education, experience, or value, just that the same standard of care applies to us.

Regarding the "Hey, I got one for ya." If it's an experienced PA then that SHOULD be the same approach that you take with a specialist, or with another EP. There's nothing wrong with bouncing something off of someone. I'm sure you do it with specialists all the time.

As for sending home your described patient....then that PA isn't getting enough supervision. You can either relegate him to the cough & snot hall, or if you think he's worth spending your time on you could help him grow into a competent EM provider to help you carry the load later. Your call.



You are off your medicine again....

No reason to train your replacement. You make it sound like EM attendings are bouncing dispos off each other regularly during every single shift. That's not how this works and you know it.

If you want out of the minor acuity side of the ED, go to medical school and complete an ACGME-accredited emergency medicine residency program. Period.

You continually and repeatedly cite "experienced PAs" in your arguments while ignoring the fact that the push for PA independence means 25 year-old just-graduated PAs will be set loose on the public.

 

[RustedFox]

No reason to train your replacement. You make it sound like EM attending are bouncing dispos off each other regularly during every single shift.

If you want out of the minor acuity side of the ED, go to medical school and complete an ACGME-accredited emergency medicine residency program. Period.

You continually and repeatedly cite "experienced PAs" in your arguments while ignoring the fact that the push for PA independence means 25 year-old just-graduated PAs will be set loose on the public.

You beat me to the punch.

The experienced PA should be regularly showing me that he/she needs guidance and supervision, but now the inexperienced PA should be given full practice authority???

*Buzzer*

 

[Boatswain2PA]

Wasn't trying to infer that you, or anyone, regularly bounces dispos off each other. But I'm sure you occasionally do if you work double coverage shop. It's good medicine.

ACGME resident grads are at the top of the game. Nobody is arguing against that.

But there are too many patients to be seen for everyone to be directly seen by an ACGME grad. Many of the places I work are struggling to pay MY wages, and could never afford to pay what you rightfully demand.

I am fortunate to work part-time at a busier ED alongside ACGME grad EPs who use PA/NPs right. Some of us can be left alone to see anyone who walks in, while others of us self-select to the lower acuity and need frequent guidance. These EPs are not only terrific physicians, they are good leaders, teachers, and managers.

Back to the OP, and the discussion of PA certification. As discussed on the other thread, there IS a relatively new certification for PAs, and ACEP has worked with SEMPA (Soc of EM PAs) to build the framework for that. Unfortunately it is administered through the NCCPA (the national PA certifying body) which is a mess.

I would prefer to do away with NCCPA in it's entirety and have PAs do a mini-residency (like we do mini-medical school) and then get board certified by the respective medical college, in this case ABEM. That would maintain the primacy of the physician-led team, establish clear-cut specialty training/education guidelines (so EPs would know what EM PAs are/are not capable of), and could work well for the different specialties. Of course, this would limit PAs ability to jump between specialties, but I don't think that's a good idea anyway.

But, that would require not only fealty to the physician led specialty groups, it would also require those specialty groups to stand up for their PAs. Haven't seen that happen so much, which leads us to the mess we are in now with a vocal minority of PAs beginning to push for independent practice.

 

[RustedFox]

Wasn't trying to infer that you, or anyone, regularly bounces dispos off each other. But I'm sure you occasionally do if you work double coverage shop. It's good medicine.

ACGME resident grads are at the top of the game. Nobody is arguing against that.

But there are too many patients to be seen for everyone to be directly seen by an ACGME grad. Many of the places I work are struggling to pay MY wages, and could never afford to pay what you rightfully demand.

I am fortunate to work part-time at a busier ED alongside ACGME grad EPs who use PA/NPs right. Some of us can be left alone to see anyone who walks in, while others of us self-select to the lower acuity and need frequent guidance. These EPs are not only terrific physicians, they are good leaders, teachers, and managers.

Back to the OP, and the discussion of PA certification. As discussed on the other thread, there IS a relatively new certification for PAs, and ACEP has worked with SEMPA (Soc of EM PAs) to build the framework for that. Unfortunately it is administered through the NCCPA (the national PA certifying body) which is a mess.

I would prefer to do away with NCCPA in it's entirety and have PAs do a mini-residency (like we do mini-medical school) and then get board certified by the respective medical college, in this case ABEM. That would maintain the primacy of the physician-led team, establish clear-cut specialty training/education guidelines (so EPs would know what EM PAs are/are not capable of), and could work well for the different specialties. Of course, this would limit PAs ability to jump between specialties, but I don't think that's a good idea anyway.

But, that would require not only fealty to the physician led specialty groups, it would also require those specialty groups to stand up for their PAs. Haven't seen that happen so much, which leads us to the mess we are in now with a vocal minority of PAs beginning to push for independent practice.

You're correct in that I occasionally ask for a second set of MD/DO eyes to look over a situation. That's generally a good idea.

Your argument of "relegate that PA to the snot hall" doesn't hold water in the real world, and is incongruent with the "push for independence".

Relegation doesn't work when the PA/NP is too busy arguing with you as to why "you're wrong and they're right".

Just last night. 10pm. Quittin' time for one of our PAs. I look thru his 28 year old with vertigo chart before he leaves. Guy notoriously sucks at charting. When he presents the case to me, he tells me of right-sided nystagmus and classic BPPV symptoms.

Nothing is in the chart about any of that. Just a normal neuro exam.

"Hey, bro. You gotta fix this. No nystagmus is charted. There's also nothing about a normal cerebellar exam, lateralizing signs, etc."

"Oh, Okay. Thanks, I'll fix it."

He "fixes" it.

The only thing he added were the words "right sided", somewhere in the neuro exam; not even the word "nystagmus".

"Dude! You gotta fix this. Right-sided what, exactly? Pronator drift? Ataxia? Cerebellar signs? Also, there's no repeat assesment, just: "Improved. Discharged.""

"FINE! Whatever; just send it back to me and I'll fix it later." He walks off in a huff.

If I did that during residency, I would find myself staying another 1-2 hours to "do it all again, and do it right". I'd also have to explain myself to the PD.

Sadly, this is the attitude that I've encountered from the majority of MLPs out there. Its not "teach me" at all.... instead, its "Why are you like this?! You can't tell me what to do, dad."

For the record, homebody has the nystagmus incorrectly labeled, even when fixed. Its the reset, not the snap... the "fast phase".

 

[Fox800]

Wasn't trying to infer that you, or anyone, regularly bounces dispos off each other. But I'm sure you occasionally do if you work double coverage shop. It's good medicine.

But there are too many patients to be seen for everyone to be directly seen by an ACGME grad. Many of the places I work are struggling to pay MY wages, and could never afford to pay what you rightfully demand.

But, that would require not only fealty to the physician led specialty groups, it would also require those specialty groups to stand up for their PAs. Haven't seen that happen so much, which leads us to the mess we are in now with a vocal minority of PAs beginning to push for independent practice.

Change "occasionally" to "seldom". I mean, it's cute that you liken EM PAs presenting patients to staff to what attendings do on unusual/complex patients. The former happens multiple times a shift at most ERs. Attendings aren't running things by other attendings for help with management decisions very often.

The hospital's you mention could pay fair wages to attract BCEPs, they choose not to. They cheapen our work by employing physicians from other specialties (FP, IM) and midleve providers without proper supervision. Patient care suffers at the hand of corporate greed.

Your "vocal minority" of PAs are getting press. You can throw smoke around like the majority of PAs don't want this, but how many would really vote it down? A scary proportion want to play doctor, bill similarly to a doctor, and not have to answer to those pesky doctors. They just get in the way.

 

[Fox800]

You're correct in that I occasionally ask for a second set of MD/DO eyes to look over a situation. That's generally a good idea.

Your argument of "relegate that PA to the snot hall" doesn't hold water in the real world, and is incongruent with the "push for independence".

Relegation doesn't work when the PA/NP is too busy arguing with you as to why "you're wrong and they're right".

Just last night. 10pm. Quittin' time for one of our PAs. I look thru his 28 year old with vertigo chart before he leaves. Guy notoriously sucks at charting. When he presents the case to me, he tells me of right-sided nystagmus and classic BPPV symptoms.

Nothing is in the chart about any of that. Just a normal neuro exam.

"Hey, bro. You gotta fix this. No nystagmus is charted. There's also nothing about a normal cerebellar exam, lateralizing signs, etc."

"Oh, Okay. Thanks, I'll fix it."

He "fixes" it.

The only thing he added were the words "right sided", somewhere in the neuro exam; not even the word "nystagmus".

"Dude! You gotta fix this. Right-sided what, exactly? Pronator drift? Ataxia? Cerebellar signs? Also, there's no repeat assesment, just: "Improved. Discharged.""

"FINE! Whatever; just send it back to me and I'll fix it later." He walks off in a huff.

If I did that during residency, I would find myself staying another 1-2 hours to "do it all again, and do it right". I'd also have to explain myself to the PD.

Sadly, this is the attitude that I've encountered from the majority of MLPs out there. Its not "teach me" at all.... instead, its "Why are you like this?! You can't tell me what to do, dad."

For the record, homebody has the nystagmus incorrectly labeled, even when fixed. Its the reset, not the snap... the "fast phase".

I see this attitude a lot from the PAs at our residency program. Super casual, too cool for school presentations to the senior residents. Some of them subvert the senior residents and go to the attendings. Think they're smarter than the EM residents at our tertiary hospital because they've been a PA for a year at a dinky urgent care place straight out of school.

They claim they're "just as good" as our residents but run to mommy/daddy attending when the **** hits the fan when the residents are all away at didactics.

 

[Boatswain2PA]

You're correct in that I occasionally ask for a second set of MD/DO eyes to look over a situation. That's generally a good idea.

Your argument of "relegate that PA to the snot hall" doesn't hold water in the real world, and is incongruent with the "push for independence".

Relegation doesn't work when the PA/NP is too busy arguing with you as to why "you're wrong and they're right".

Just last night. 10pm. Quittin' time for one of our PAs. I look thru his 28 year old with vertigo chart before he leaves. Guy notoriously sucks at charting. When he presents the case to me, he tells me of right-sided nystagmus and classic BPPV symptoms.

Nothing is in the chart about any of that. Just a normal neuro exam.

"Hey, bro. You gotta fix this. No nystagmus is charted. There's also nothing about a normal cerebellar exam, lateralizing signs, etc."

"Oh, Okay. Thanks, I'll fix it."

He "fixes" it.

The only thing he added were the words "right sided", somewhere in the neuro exam; not even the word "nystagmus".

"Dude! You gotta fix this. Right-sided what, exactly? Pronator drift? Ataxia? Cerebellar signs? Also, there's no repeat assesment, just: "Improved. Discharged.""

"FINE! Whatever; just send it back to me and I'll fix it later." He walks off in a huff.

If I did that during residency, I would find myself staying another 1-2 hours to "do it all again, and do it right". I'd also have to explain myself to the PD.

Sadly, this is the attitude that I've encountered from the majority of MLPs out there. Its not "teach me" at all.... instead, its "Why are you like this?! You can't tell me what to do, dad."

For the record, homebody has the nystagmus incorrectly labeled, even when fixed. Its the reset, not the snap... the "fast phase".

I'm not pushing for independent practice. Never have, never will. The BC physician is at the top of the profession, and all of my patients deserve to have a physician at LEAST nominally involved in their care.

If the PA in your example doesn't fix this, learn from it, and do MUCH better then he should be fired. I'm guessing in your shop the physicians aren't allowed to do that, which highlights the biggest problem in healthcare---physicians aren't in charge anymore.

Change "occasionally" to "seldom". I mean, it's cute that you liken EM PAs presenting patients to staff to what attendings do on unusual/complex patients. The former happens multiple times a shift at most ERs. Attendings aren't running things by other attendings for help with management decisions very often.

The hospital's you mention could pay fair wages to attract BCEPs, they choose not to. They cheapen our work by employing physicians from other specialties (FP, IM) and midleve providers without proper supervision. Patient care suffers at the hand of corporate greed.

Your "vocal minority" of PAs are getting press. You can throw smoke around like the majority of PAs don't want this, but how many would really vote it down? A scary proportion want to play doctor, bill similarly to a doctor, and not have to answer to those pesky doctors. They just get in the way.

I'm glad you find me cute, but I'm pretty sure you're not my type. Not that there's anything wrong with that....just not my thing.

No, most rural hospitals absolutely could NOT pay EP wages. Rural hospitals are closing at a pretty fast rate as it is, add another $1.5 million to their annual budget to staff a BC EP (making $250/hr) instead of a PA (at $75/hr) for 24/7 coverage would force many more to close down.

I understand the press they are getting. Like I said, I think independent practice IS going to eventually happen. We can bitch and whine about it all we want, but I think it's going to happen.

 

[RustedFox]

I see this attitude a lot from the PAs at our residency program. Super casual, too cool for school presentations to the senior residents. Some of them subvert the senior residents and go to the attendings. Think they're smarter than the EM residents at our tertiary hospital because they've been a PA for a year at a dinky urgent care place straight out of school.

They claim they're "just as good" as our residents but run to mommy/daddy attending when the **** hits the fan when the residents are all away at didactics.

I've five years out. It doesn't get better, in general. I can readily name ONE that doesn't have a 'tude. I miss working with him.

This is why, given the present situation, I propose a dichotomy. Either path will likely lead us back to Rome.

A.) Get back in line and do as you're told, or:
B.) YOYOMF. Don't ask me for help. Don't present a single case to me, and I'm not signing a single chart. Enjoy your lawsuits, and then after awhile, you'll get back in line and do as you're told.

 

[Fox800]

I'm not pushing for independent practice. Never have, never will. The BC physician is at the top of the profession, and all of my patients deserve to have a physician at LEAST nominally involved in their care.

If the PA in your example doesn't fix this, learn from it, and do MUCH better then he should be fired. I'm guessing in your shop the physicians aren't allowed to do that, which highlights the biggest problem in healthcare---physicians aren't in charge anymore.



I'm glad you find me cute, but I'm pretty sure you're not my type. Not that there's anything wrong with that....just not my thing.

No, most rural hospitals absolutely could NOT pay EP wages. Rural hospitals are closing at a pretty fast rate as it is, add another $1.5 million to their annual budget to staff a BC EP (making $250/hr) instead of a PA (at $75/hr) for 24/7 coverage would force many more to close down.

I understand the press they are getting. Like I said, I think independent practice IS going to eventually happen. We can bitch and whine about it all we want, but I think it's going to happen.

I'm not sure where you were going with that part, but it was a little weird.

I bet the same hospitals can afford a general surgeon, right? You don't see PAs handling emergent surgical consults at 3:00 AM. They could pony up, they just won't. Gotta pad those wallets.

Modern medicine is the cheapest person in a white coat. Damn what's right for our patients.

 

[Boatswain2PA]

I've five years out. It doesn't get better, in general. I can readily name ONE that doesn't have a 'tude. I miss working with him.

This is why, given the present situation, I propose a dichotomy. Either path will likely lead us back to Rome.

A.) Get back in line and do as you're told, or:
B.) YOYOMF. Don't ask me for help. Don't present a single case to me, and I'm not signing a single chart. Enjoy your lawsuits, and then after awhile, you'll get back in line and do as you're told.

What do you mean by A? You want me to be your bitch boy? If so...I can understand why you only get the crappy PA/NPs working for you. The good ones would leave your shop for greener pastures.

And your option B sounds a lot like what AAPA is asking for.

 

[Fox800]

What do you mean by A? You want me to be your bitch boy? If so...I can understand why you only get the crappy PA/NPs working for you. The good ones would leave your shop for greener pastures.

And your option B sounds a lot like what AAPA is asking for.

Lol. You can't form an argument without referencing extremes. In your mind there is literally no middle ground.

If you want a BCEP to absorb your liability, you should do what they say and chart the way they say, without an attitude. Otherwise you would be canned. That's an ideal world.

If that makes you someone's bitch boy, then quit whining and go back to medical school.

 

[RustedFox]

-

What do you mean by A? You want me to be your bitch boy? If so...I can understand why you only get the crappy PA/NPs working for you. The good ones would leave your shop for greener pastures.

And your option B sounds a lot like what AAPA is asking for.

I explained option "A" earlier in the thread (page 1) when I said:

"Physician assistant... assist the physician. I want you to do what I want you to do, how I want it done, and documented how I want it written. No arguments."

If you're working for me, as my "extender", then you've got to do it the right way.... not some half-assed way (see example, above) and then argue with me as to why I'm wrong.

 

[Boatswain2PA]

I'm not sure where you were going with that part, but it was a little weird.

I bet the same hospitals can afford a general surgeon, right? You don't see PAs handling emergent surgical consults at 3:00 AM. They could pony up, they just won't. Gotta pad those wallets.

Surgical/specialty coverage at rural hospitals very. Some have a surgeon in town, others may have a surgeon/other specialist who comes for one day a week or so.

But these surgeons/specialists bring a LOT of money into the hospitals. For example, one hospital I frequently work at has a 1 room surgical suite. They do tonsils/tubes one day, minor laps another day, and pain management injections the other 3 days a week. The ENT and gen surgeons only come to town for that one day a week and do their own billing.

EDs don't make money seeing 10-12 patients a day. It would break these hospitals to pay your salary vice mine.

 

[Boatswain2PA]

-
I explained option "A" earlier in the thread (page 1) when I said:

"Physician assistant... assist the physician. I want you to do what I want you to do, how I want it done, and documented how I want it written. No arguments."

If you're working for me, as my "extender", then you've got to do it the right way.... not some half-assed way (see example, above) and then argue with me as to why I'm wrong.

I've got no problem with that. Of course, if your PA has to do it YOUR right way when they work for you, and then ANOTHER right way when working for someone else, and then yet ANOTHER right way when working for a 3rd EP.....I can understand why you can't keep good PAs there.

 

[Fox800]

I've got no problem with that. Of course, if your PA has to do it YOUR right way when they work for you, and then ANOTHER right way when working for someone else, and then yet ANOTHER right way when working for a 3rd EP.....I can understand why you can't keep good PAs there.

Option C: don't work at a place that makes you sign mid level charts.

 

[Fox800]

Surgical/specialty coverage at rural hospitals very. Some have a surgeon in town, others may have a surgeon/other specialist who comes for one day a week or so.

But these surgeons/specialists bring a LOT of money into the hospitals. For example, one hospital I frequently work at has a 1 room surgical suite. They do tonsils/tubes one day, minor laps another day, and pain management injections the other 3 days a week. The ENT and gen surgeons only come to town for that one day a week and do their own billing.

EDs don't make money seeing 10-12 patients a day. It would break these hospitals to pay your salary vice mine.

You and I both know that staffing these places with BCEPs wouldn't cause the hospital to close down. It's greed and bean counting.

 

[RustedFox]

I've got no problem with that. Of course, if your PA has to do it YOUR right way when they work for you, and then ANOTHER right way when working for someone else, and then yet ANOTHER right way when working for a 3rd EP.....I can understand why you can't keep good PAs there.

Thanks for demonstrating the attitude.

That's the words physician assistant mean... Assist the Physician. Sure, there's practice variance - but the core remains the same. When standard of care isn't met... And then there's argument as to why this is "right", then we have a problem.

 

[Boatswain2PA]

What's your background Fox800? Have you worked in a small hospital like this? Ever looked at the budget of a hospital in a town of 8000 people?

Even if they COULD afford BCEP (and the vast majority couldn't), there aren't NEARLY enough of you to go around.

 

[Boatswain2PA]

Thanks for demonstrating the attitude.

That's the words physician assistant mean... Assist the Physician. Sure, there's practice variance - but the core remains the same. When standard of care isn't met... And then there's argument as to why this is "right", then we have a problem.

Lots of "right" ways to do a lot of things. How many ways can you sedate someone to reduce a shoulder? You may want propofol, I prefer ketamine IV, yet one EP I work for over-rode me and made me use ketamine IM ("no need to start an IV").

Nobody's necessarily wrong.

 

[RustedFox]

Lots of "right" ways to do a lot of things. How many ways can you sedate someone to reduce a shoulder? You may want propofol, I prefer ketamine IV, yet one EP I work for over-rode me and made me use ketamine IM ("no need to start an IV").

Nobody's necessarily wrong.

Way to split hairs, dude. You know that's not what I'm referencing.

 

[Boatswain2PA]

Way to split hairs, dude. You know that's not what I'm referencing.

If your PAs are doing things WRONG, like the situation you presented earlier, then you & other EPs need to be able to either correct the problem, or fire the PA. Unfortunately you probably don't have that ability in your shop as it's run by suits instead of physicians.

But IF you are requiring your PAs to do it YOUR WAY, then that's a leadership failure on your part, and may be a reason you have crappy PAs.

 

[RustedFox]

If your PAs are doing things WRONG, like the situation you presented earlier, then you & other EPs need to be able to either correct the problem, or fire the PA. Unfortunately you probably don't have that ability in your shop as it's run by suits instead of physicians.

But IF you are requiring your PAs to do it YOUR WAY, then that's a leadership failure on your part, and may be a reason you have crappy PAs.

If you're not only not doing it my way, but also getting in the way of getting it done, then you're not assisting me much.

My name on the chart. My liability. Documented My way.

I'll elaborate more in a bit as to why too many cooks spoil the broth. I'm out to get needed Easter gear.

 

[Boatswain2PA]

If you're not only not doing it my way, but also getting in the way of getting it done, then you're not assisting me much.

My name on the chart. My liability. Documented My way.

I'll elaborate more in a bit as to why too many cooks spoil the broth. I'm out to get needed Easter gear.

These arguments are some of the best arguments FOR full practice authority for PA/NPs. Best way to remove your liability from what I do. Of course, you and I can both be named in lawsuits for what the nurse/tech/janitor does or doesn't do. The sharks will go after anyone with resources.

Have a happy Easter, and good luck in getting some better PAs in your shop.

 

[deleted480308]

These arguments are some of the best arguments FOR full practice authority for PA/NPs. Best way to remove your liability from what I do. Of course, you and I can both be named in lawsuits for what the nurse/tech/janitor does or doesn't do. The sharks will go after anyone with resources.

Have a happy Easter, and good luck in getting some better PAs in your shop.

But discharging liability isn't actually the primary goal. Primary goal is best treatment for the patient. That means no independent midlevels, the patients expect physician level care.

It should also be noted that finite supply of physicians isn't a valid argument because it isn't like the NPs and PAs are offering to relenquish independence if more docs show up.

 

[Boatswain2PA]

But discharging liability isn't actually the primary goal. Primary goal is best treatment for the patient. That means no independent midlevels, the patients expect physician level care.

It should also be noted that finite supply of physicians isn't a valid argument because it isn't like the NPs and PAs are offering to relenquish independence if more docs show up.

1) I agree. Like I've said, every patient deserves to have a physician at LEAST nominally involved in their care. However some EPs here have suggested they like the idea of PA autonomy if it frees them of the liability....kinda hard to argue against that.

2) The finite supply of BC physician was brought up with the discussion of preferring an experienced EM PA in the ED over most FPs. There aren't enough EPs to fill every ED, and many hospitals couldn't afford one if there were.

 

[deleted480308]

1) I agree. Like I've said, every patient deserves to have a physician at LEAST nominally involved in their care. However some EPs here have suggested they like the idea of PA autonomy if it frees them of the liability....kinda hard to argue against that.

i think the argument is more that if the doc is not going to get obedience out of someone they are liable for, they don't want to be liable for that person any more. It's nuanced but not quite the same as saying they really want PA Independance, what they really want is some compliance from those under their liability

 

[Boatswain2PA]

i think the argument is more that if the doc is not going to get obedience out of someone they are liable for, they don't want to be liable for that person any more. It's nuanced but not quite the same as saying they really want PA Independance, what they really want is some compliance from those under their liability

That is Fox's argument, others have argued that if autonomy frees them from liability they are all for it. Lots of different angles with which to look at it.

 

[RustedFox]

That is Fox's argument, others have argued that if autonomy frees them from liability they are all for it. Lots of different angles with which to look at it.

I actually make both arguments in my all roads to Rome post.

Cooks/broth argument to come, as promised. I'm in my pool listening to Van Halen.

 

[Mad Jack]

as mentioned in the other thread, if PHYSICIANS would hire PAs preferentially over NPs this would not be an issue.
we are doing this because PHYSICIANS don't want the liability of signing charts, so they hire NPs instead. a national survey of PAs found a vast majority losing job opportunities to NPs solely because of supervisory issues. this is not such an issue in EM as we are the non-physician provider of choice in the field, but in primary care PAs are losing out to NPs, despite the differences in our training.
this is a physician-created problem. you guys created the PA profession to work with you and then ignored us because supervision and signing charts is too much work.
Michigan has already enacted legislation reflective of this. physicians who work with PAs there are now known as "participating physicians" and specifically have no liability for the work done by PAs in their practices. physicians like this change.

Yeah, this is the same issue AAs are having versus CRNAs. AAs are unable to take independent call or do their own inductions, so bringing in AAs instead of CRNAs causes substantially more headaches for the hiring anesthesiologists.

 

[RustedFox]

As promised.

Can you spot the difference between the species above? HINT: One knows WHY it's doing what it's doing.


So, this actually happened with the MLP crew at my hospital system. Our MLPs go between two hospitals, one higher volume, "downtown" hospital with more subspecialties under one roof, and one smaller "suburbia" hospital. Our Docs are privileged at both, but generally stay put at one site. We have a "home team", but the MLPs do not.

Sometime last year, I noted two rather disturbing trends in the MLP practices. Now, they see a lot of these MVCs that need clearance, and have "head pain/back pain/neck pain" and other associated minor complaints.

1. There was no use or documentation of the New Orleans or NEXUS criteria (or any other CDM) in their charts, nor was there any decent head/neck exam commonly written.
2. Many of these patients had their c-spines "cleared" after 2 or 3 view x-rays. Collars removed, no follow-up exam documented... discharged.

I tried to engage the MLPs directly as to why they did this, when the overwhelming body of evidence states that c-spines cannot be cleared with x-rays, and how they were sure (or not sure) that there was no significant intracranial injury. This is something we all learned in month 1 of residency.

The response that I got for head injury was "if they didn't lose consciousness, I don't CT them" (nevermind that 2/3rds of our patients are 60 and older, and on lots of narcs to begin with, or "can't tell if they blacked out or not").

The response that I got for x-rays and c-spine clearance being an acceptable practice was "That's not how they do it at OtherHospital".

I dug deeper. "Who does it this way at OtherHospital?"

"Doctor XX does. Does it all the time. Says it okay."

This struck me as bizarre. Doctor XX is the site medical director at OtherHospital, but... any BCEP knows how to use a CDM rule.

I was not comfortable with this practice, especially in our patient population who is elderly, unreliable, narc'ed up, and frequently anticoagulated.

This was not going to fly with any chart that had my name on it. I engaged each MLP in real-time regarding using and documenting the CDMs, and that c-spine films are clearly inferior, and below the standard of care.

The pushback was outstanding. I asked, given the scientific data that I had provided... why this practice change was not adopted.

The response was the same: "Doctor XX says so."

That's it. That was the depth of their understanding of the matter. Not a one of them could tell me the sensitivity/specificity of plain films vs. CT, or the limitations of plain films, or any of that. Why? Because science is hard, and they found a way that was easy, and they liked, and they got a doc to say that this was okay. I can't even verify that this was Doc XX's practice pattern.

I had to push harder. "Okay. You're not working as Doc XX's MLP now. You're working under me. You'll do as I instruct you to do."

Pushback was even worse. Doc XX's name got tossed around harder and harder. How dare I act like I know more than Doc XX?! Doc XX has been practicing emergency medicine for twice as long as I have been alive.

Maybe Doc XX does practice like this. But I don't. Maybe he or she needs to be updated. I suspect that he/she is up to date, and that this little bit of local culture has just been hanging on since before 200X, before the CDM rule really made it to prime time.

It took me to engage my site director and to enact a departmental policy regarding how to handle imaging in trauma to get any change in the practice pattern. EVEN STILL, I get fallouts all the time... and when I call them on it, I get the glare and scowl from the MLPs, because I upset their little world, and they want to somehow prove to me that they're RIGHT.

That's the thing. They weren't interested in what was best for the patient. They were only interested in being right. Scientific data? Pfft. No interest in that... its too hard to understand.

Hence my attitude. If you're working for me as an *assistant*... then you do as you're told. No talkback. No excuses. You want independent practice rights? Buckle up, and at the very least... be able to know WHY you are doing what you are doing. Don't ask me for help if you don't want direction.

Its much easier to be a mimic.

 

[WilcoWorld]

I'm not sure where you were going with that part, but it was a little weird.

I think it was meant to address this thread's paucity of gay jokes.

 

[WilcoWorld]

I've got no problem with that. Of course, if your PA has to do it YOUR right way when they work for you, and then ANOTHER right way when working for someone else, and then yet ANOTHER right way when working for a 3rd EP.....I can understand why you can't keep good PAs there.

I'll grant that you have a point here - I have different practice patterns from many of my colleagues. This can certainly be a source of difficulty and frustration for APP's. On the other hand, I've worked with some great PAs who were perfectly capable of learning each doc's practice style and adapting that style when working with those docs. This becomes increasingly difficulty as the group size grows. PAs with such skill should be held onto with care.

However, this practice variation is NOT a justification for giving the current doc a hard time after you've involved them in the case, and I think that this is what @RustedFox is bothered by. If Doc A wants a d-dimer on every chest pain that isn't PERC negative it is completely immaterial that Doc C never get's a d-dimer on patients who endorse chest wall tenderness. Please just order the dimer so RF can go see the LOL who is more altered than usual after she FDGB.

 

[WilcoWorld]

Lots of "right" ways to do a lot of things. How many ways can you sedate someone to reduce a shoulder? You may want propofol, I prefer ketamine IV, yet one EP I work for over-rode me and made me use ketamine IM ("no need to start an IV").

Nobody's necessarily wrong.

First, see my above post. But also... sometimes some people are necessarily wrong.

 

[RustedFox]

I'll grant that you have a point here - I have different practice patterns from many of my colleagues. This can certainly be a source of difficulty and frustration for APP's. On the other hand, I've worked with some great PAs who were perfectly capable of learning each doc's practice style and adapting that style when working with those docs. This becomes increasingly difficulty as the group size grows. PAs with such skill should be held onto with care.

However, this practice variation is NOT a justification for giving the current doc a hard time after you've involved them in the case, and I think that this is what @RustedFox is bothered by. If Doc A wants a d-dimer on every chest pain that isn't PERC negative it is completely immaterial that Doc C never get's a d-dimer on patients who endorse chest wall tenderness. Please just order the dimer so RF can go see the LOL who is more altered than usual after she FDGB.

Smart. I don't order a dimer on every CP that doesn't PERC-out, but I document why I'm not pursuing it (most commonly: tachycardia of 103 resolved without specific intervention).

Asking the MLP crew to set up an AutoText for that would be asking too much.

 

[KanyeWes]

This is a nightmare.

Does the hosp pay for punitive damages with the typical med mal insurance? This is my biggest concern with using mid levels. And are major cities using mid levels in the ED in like NY, LA, Chicago, etc?

 

[Boatswain2PA]

As promised.

Can you spot the difference between the species above? HINT: One knows WHY it's doing what it's doing.


So, this actually happened with the MLP crew at my hospital system. Our MLPs go between two hospitals, one higher volume, "downtown" hospital with more subspecialties under one roof, and one smaller "suburbia" hospital. Our Docs are privileged at both, but generally stay put at one site. We have a "home team", but the MLPs do not.

Sometime last year, I noted two rather disturbing trends in the MLP practices. Now, they see a lot of these MVCs that need clearance, and have "head pain/back pain/neck pain" and other associated minor complaints.

1. There was no use or documentation of the New Orleans or NEXUS criteria (or any other CDM) in their charts, nor was there any decent head/neck exam commonly written.
2. Many of these patients had their c-spines "cleared" after 2 or 3 view x-rays. Collars removed, no follow-up exam documented... discharged.

I tried to engage the MLPs directly as to why they did this, when the overwhelming body of evidence states that c-spines cannot be cleared with x-rays, and how they were sure (or not sure) that there was no significant intracranial injury. This is something we all learned in month 1 of residency.

The response that I got for head injury was "if they didn't lose consciousness, I don't CT them" (nevermind that 2/3rds of our patients are 60 and older, and on lots of narcs to begin with, or "can't tell if they blacked out or not").

The response that I got for x-rays and c-spine clearance being an acceptable practice was "That's not how they do it at OtherHospital".

I dug deeper. "Who does it this way at OtherHospital?"

"Doctor XX does. Does it all the time. Says it okay."

This struck me as bizarre. Doctor XX is the site medical director at OtherHospital, but... any BCEP knows how to use a CDM rule.

I was not comfortable with this practice, especially in our patient population who is elderly, unreliable, narc'ed up, and frequently anticoagulated.

This was not going to fly with any chart that had my name on it. I engaged each MLP in real-time regarding using and documenting the CDMs, and that c-spine films are clearly inferior, and below the standard of care.

The pushback was outstanding. I asked, given the scientific data that I had provided... why this practice change was not adopted.

The response was the same: "Doctor XX says so."

That's it. That was the depth of their understanding of the matter. Not a one of them could tell me the sensitivity/specificity of plain films vs. CT, or the limitations of plain films, or any of that. Why? Because science is hard, and they found a way that was easy, and they liked, and they got a doc to say that this was okay. I can't even verify that this was Doc XX's practice pattern.

I had to push harder. "Okay. You're not working as Doc XX's MLP now. You're working under me. You'll do as I instruct you to do."

Pushback was even worse. Doc XX's name got tossed around harder and harder. How dare I act like I know more than Doc XX?! Doc XX has been practicing emergency medicine for twice as long as I have been alive.

Maybe Doc XX does practice like this. But I don't. Maybe he or she needs to be updated. I suspect that he/she is up to date, and that this little bit of local culture has just been hanging on since before 200X, before the CDM rule really made it to prime time.

It took me to engage my site director and to enact a departmental policy regarding how to handle imaging in trauma to get any change in the practice pattern. EVEN STILL, I get fallouts all the time... and when I call them on it, I get the glare and scowl from the MLPs, because I upset their little world, and they want to somehow prove to me that they're RIGHT.

That's the thing. They weren't interested in what was best for the patient. They were only interested in being right. Scientific data? Pfft. No interest in that... its too hard to understand.

Hence my attitude. If you're working for me as an *assistant*... then you do as you're told. No talkback. No excuses. You want independent practice rights? Buckle up, and at the very least... be able to know WHY you are doing what you are doing. Don't ask me for help if you don't want direction.

Its much easier to be a mimic.

Mimicry is often times the beginning step of learning. Children first mimic behaviors, then learn why. There are times we all simply mimic what we've seen done before.

If your EM PAs don't know Nexus criteria then fire them. Today. They should be working derm, not EM. Hell, they shouldn't even be working Derm because I'm 99% sure the Nexus criteria is on the PAEA/NCCPA blueprint for the PANCE/PANRE (the PA national certification/recertifcation examination).

If the "mid-levels" you are describing are NPs....then quit hiring NPs.

It sounds like you have realllly crappy mid-levels.

 

[Boatswain2PA]

I'll grant that you have a point here - I have different practice patterns from many of my colleagues. This can certainly be a source of difficulty and frustration for APP's. On the other hand, I've worked with some great PAs who were perfectly capable of learning each doc's practice style and adapting that style when working with those docs. This becomes increasingly difficulty as the group size grows. PAs with such skill should be held onto with care.

However, this practice variation is NOT a justification for giving the current doc a hard time after you've involved them in the case, and I think that this is what @RustedFox is bothered by. If Doc A wants a d-dimer on every chest pain that isn't PERC negative it is completely immaterial that Doc C never get's a d-dimer on patients who endorse chest wall tenderness. Please just order the dimer so RF can go see the LOL who is more altered than usual after she FDGB.

EM PAs should be able to do it their OWN correct way, and document their justification in such a way that if/when you (or anyone else) reviews their chart it is obvious WHY that way was chosen ("C-collar removed after clearing via Nexus criteria", or "Unable to clear via Nexus 2/2 distracting injury, head/neck CT pending"). I would argue THAT should be your goal in raising up good EM PAs.

I completely agree with not giving your attending a hard time, especially after you have asked for help. That's simply a no-brainer. If I call for help, whether it's to my FP attending at my primary gigs, it's an EP at my part-time job....or a specialist from anywhere....I shouldn't give them a hard time.

Unless the attending/specialist is WRONG! My personal worst-case example of this is when I'm working a PEA arrest, beautiful narrow sinus tach on monitor, EtCo2 of 48, and I've got good heart motion on US....guy's not dead yet. Attending walks into ED, says I "can't have contractility on US and not have a pulse", puts US somewhere on the chest (I can't see any landmarks on the screen), and declares patient dead.

I experience a W. T. F. moment and walk of resus bay. Attending has this now...right? Nope, nurses don't detach pads/turn off monitor. About 8 minutes later tech says "wow...that's still a great rhythm on the monitor" and checks for a pulse. Sure as $hit, we have a zombie with a pulse and a pressure.

Attending walks out of ED. I order norepi drip, abg and call for ice while starting central line, and call for aircraft wondering how the hell I'm supposed to chart THAT!

 

[RustedFox]

Mimicry is often times the beginning step of learning. Children first mimic behaviors, then learn why. There are times we all simply mimic what we've seen done before.

If your EM PAs don't know Nexus criteria then fire them. Today. They should be working derm, not EM. Hell, they shouldn't even be working Derm because I'm 99% sure the Nexus criteria is on the PAEA/NCCPA blueprint for the PANCE/PANRE (the PA national certification/recertifcation examination).

If the "mid-levels" you are describing are NPs....then quit hiring NPs.

It sounds like you have realllly crappy mid-levels.

Mimicry might be great for children and butterflies; but not so much for EM and critical actions in patient care. An understanding of why you're doing what you're doing is mandatory. Its this step that is generally missing from the MLPs that I have worked with between 4 hospitals.

With regard to your "firing" point. Once again, I can't hire or fire anyone. If I could, I would fire most of the MLPs (NP or PA) and have more MD/DO coverage. At present, our afternoon coverage model has one physician and two MLPs... sometimes, I just feel like the giant ape atop the EM skyscraper, swatting at the two MLP biplanes that circle me. I can't see and dispo my own patients because I'm too busy preventing them from steering their ships into the rocks. Its agitating as $hit to have 8-10 patients, each with a triage level of 1-3, and to hear "Hey, I got one for yah" every ten minutes.

It might sound like I have realllly crappy MLPs, but given the sentiments expressed by the number of people in this thread, it seems to me that the issue is more prevalent than you'd like to think.