Interesting Nurse Practitioner Document

[deleted6669]

all of the fp interns did their first er rotation with a pa and later rotations with a doc.
as 1st yrs they don't have a license yet and we do so for all intents and purposes an intern is an ms5. after they pass step 3 of the usmle they can get a state license and sign their own charts without cosignature.
we basically spent a month teaching them how the e.d. works and how to work up common problems and do basic procedures such as suturing, fb removals, I+D's, epistaxis management, ent/ophtho complaints, fx/dislocation management, etc
the second and third yrs would ask the pa's for help with cases that they were not comfortable with and we would give direction as needed. if we precepted a case or procedure we signed the chart.

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[deleted6669]

You have a supervising physician under whose license you practice.

actually as a matter of semantics I have my own license and dea# but must have a sponsoring physician in order to use them so I can't work independently of a physician although they need not be present when I work but must be aware of my practice patterns.

 

[oldpro]

actually as a matter of semantics I have my own license and dea# but must have a sponsoring physician in order to use them so I can't work independently of a physician although they need not be present when I work but must be aware of my practice patterns.

What state? I would like to read the laws and rules for PA's in that state.

I doubt that the license read's "To Practice Medicine"

I doubt the laws in your state say that PA's can practice 100% autonomous

As far as Having a License, So do drivers, so do MA's so do Barbers, so do Nurses and Nurse practitioners............... I have a license as a RN so what?

DEA is to track you BTW, it was not required at one time. It became required when the Gov wanted to control who writes for narcotics and to track them, it does not make yo a Doctor.

 

[oldpro]

all of the fp interns did their first er rotation with a pa and later rotations with a doc.
as 1st yrs they don't have a license yet and we do so for all intents and purposes an intern is an ms5.

What planet are you on? No it is not MS5, they have graduated from medical school and are Doctors, they also have training License, You know this right?

after they pass step 3 of the usmle they can get a state license and sign their own charts without cosignature.
.

Uh FMG Docs cannot get a License in 1 year, it takes 3 years in most states, 3 years of residency, Of course you know that right? Thats why they are given a training License.

Just because things are messed up at the place you work does not make it correct, many places do things that are not correct.

 

[AwesomO]

Wow I would not even rank a program that required that I have all my orders signed off on.

 

[oldpro]

Wow I would not even rank a program that required that I have all my orders signed off on.

I really want to know what state this is in, I really want to look at the laws and rules and see that there are no training license for residents and that PA's are Licensed to sign off Docs..........................

At this moment I personally do not believe this. ( Of course I could be wrong)

 

[deleted6669]

At this moment I personally do not believe this. ( Of course I could be wrong)

what's the chance of that? a DOCTOR being wrong?
I'm sure it's never happened in the history of medicine.......

 

[deleted6669]

I really want to know what state this is in, I really want to look at the laws and rules and see that there are no training license for residents and that PA's are Licensed to sign off Docs..........................

of course the residents have a training license.
it is a hospital requirement not a state requirement that their notes are cosigned until they have an unrestricted license at which time they can also moonlight..

 

[deleted6669]

Uh FMG Docs cannot get a License in 1 year, it takes 3 years in most states, 3 years of residency, Of course you know that right? Thats why they are given a training License.

.

who is talking about fmg's? I'm talking about us medschool grads.
medschool + 1 yr of internship+ pass step 3 = unrestricted license.

 

[Tired]

actually as a matter of semantics I have my own license and dea# but must have a sponsoring physician in order to use them so I can't work independently of a physician although they need not be present when I work but must be aware of my practice patterns.

I checked out a couple websites, looks like there are more than a few community FP programs that have PAs and NPs on their clinical faculty. Never would have thought that possible.

Oh well, learn something new every day.

 

[oldpro]

of course the residents have a training license.
it is a hospital requirement not a state requirement that their notes are cosigned until they have an unrestricted license at which time they can also moonlight..

With a Training License they can sign their own notes and write prescriptions, they do not have DEA numbers yet though.

 

[oldpro]

who is talking about fmg's? I'm talking about us medschool grads.
medschool + 1 yr of internship+ pass step 3 = unrestricted license.

Not all programs allow Moonlighting
This is not true in every state
A FMG does take step 3 in year one
Many programs have FMG and IMG's

Moonlighting as what anyway? You are not board certified yet.

 

[oldpro]

what's the chance of that? a DOCTOR being wrong?
I'm sure it's never happened in the history of medicine.......

LOL and PA's and NP's are always right too? LOL give us a break.........

 

[Tired]

With a Training License they can sign their own notes and write prescriptions, they do not have DEA numbers yet though.

Has it occurred to you that he may know a little more about this than you?

 

[deleted6669]

Moonlighting as what anyway? You are not board certified yet.

I think you might want to research the concept of resident moonlighting a bit....

 

[oldpro]

I think you might want to research the concept of resident moonlighting a bit....

LOL I love the way you argue, I know about it, I just made a statement that a resident has not finished training yet, and some programs do not allow moonlighting.

 

[oldpro]

Has it occurred to you that he may know a little more about this than you?

LOL yes I'm getting tired, been on call all weekend and have to go back up to the floor, in fact now.

LOL I'm TIRED now................

Can't wait till residency so PA's can sign my charts.

 

[Tired]

Can't wait till residency so PA's can sign my charts.

I've never seen it anywhere I've worked.

I did have one rotation in a burn clinic where the NP said, "Oh, you can just present to me and I'll sign the chart." I said thanks but no thanks, and waited for the attending.

As an intern, I got irritated enough presenting to junior residents. Cold day in hell when an NP approves my treatment plans.

 

[ForbiddenComma]

I think the key here is that emedpa is shepherding *FP* residents. Presumably, an emergency PA with decades of experience will be better at ER patient care than an off-service intern, even if the intern's degree "outranks" his.

It should also be noted that, unlike NPs, PAs are not presenting themselves as the future replacements of physicians. As is endlessly pointed out by NPs, the PAs follow the "medical" tradition instead of their own "nursing" model and are therefore suspect. In other words, the NPs will not be making room at the table for PAs, and I think the mighty nursing lobby easily outweighs whatever lobby PAs have (not sure if they even have one).

Let's not catch them in the crossfire.

 

[oldpro]

I think the key here is that emedpa is shepherding *FP* residents. Presumably, an emergency PA with decades of experience will be better at ER patient care than an off-service intern, even if the intern's degree "outranks" his.

It should also be noted that, unlike NPs, PAs are not presenting themselves as the future replacements of physicians. As is endlessly pointed out by NPs, the PAs follow the "medical" tradition instead of their own "nursing" model and are therefore suspect. In other words, the NPs will not be making room at the table for PAs, and I think the mighty nursing lobby easily outweighs whatever lobby PAs have (not sure if they even have one).

Let's not catch them in the crossfire.

Then a PA should not get in the crossfire, MD's and DO's answering to a PA?
I think a PA can work with a MD or DO and "show them the ropes" Just as a Nurse does at times in the ICU or even on the floor, we can all learn something from one another, But the way the above posts are, it seems that at this Hospital this particular PA works at, the PA is acting like an Attending, or Chief Resident, to me that is not Kosher, and not sure its Legal.

If I and others question the practice, I think its expected.

 

[deleted6669]

the PA is acting like an Attending, or Chief Resident, to me that is not Kosher, and not sure its Legal.

If I and others question the practice, I think its expected.

the job of pa is often described as "permanent resident" because we are never truly independent but within that structure can help with teaching those who know less about a subject area than we do. after 22 yrs+ doing this I know a lot more em than any med student or fp intern. there are things I learn from them as well so it goes both ways.
this is not an uncommon set up. many residency programs of many types incorporate staff pa's into the teaching structure on surgical floors, icu, ortho, etc
we're not the competition. we know that in a few yrs we may work for you. we're just trying to do our part to help educate the next generation of clinicians, regardless of the titles after their names. in addition to med students and residents we have pa and np students rotate through the dept as well

 

[oldpro]

the job of pa is often described as "permanent resident" because we are never truly independent but within that structure can help with teaching those who know less about a subject area than we do. after 22 yrs+ doing this I know a lot more em than any med student or fp intern. there are things I learn from them as well so it goes both ways.
this is not an uncommon set up. many residency programs of many types incorporate staff pa's into the teaching structure on surgical floors, icu, ortho, etc
we're not the competition. we know that in a few yrs we may work for you. we're just trying to do our part to help educate the next generation of clinicians, regardless of the titles after their names. in addition to med students and residents we have pa and np students rotate through the dept as well

The doctors I have been with, one of them has both a PA and NP working for them, have all expressed that these people are knowledgeable and they have respect for them but also said that these professionals go too far at times thinking they are Doctors and that "the line gets crossed" at times. One doctor in particular has expressed a dislike of some PA's who allow patients to call them a Doctor and has expressed that this PA should be reported.

By having the attitude that you are equal to Doctors and spreading this is creating problems for your profession, just as Nurses who are trying to make DNP's equals to Doctors and want the Title in the clinical setting Doctor.

If you want to be a Doctor so bad then do what I did, Go to medical school,
otherwise be proud of being a PA, do not go around telling others that you are "Just like a Doctor, on the same level as a resident" You are clearly not, not in license and not in the education, experience counts, it can make you an expert, but you are an expert in the Practice of EM at the PA level, not the Level of Physician, a physician with 20 plus years as a Board certified Emergency Medical Physician I bet has even more knowledge and skills, and some are Trauma Docs.

You can think you are the same but I can see where you are not.

 

[deleted6669]

dude, what's up with the hostility?
I clearly know more em than anyone except an em boarded physician and am willing to help train others. what is your problem with that?
if you rotated at my facility you could choose not to interact with the pa staff and wait around for attendings. you would get a substandard learning experience because you would see far fewer pts and do far fewer procedures but if that's your choice than by all means run with it. most likely my attendings would also direct you to see the pa's about any procedures.
fyi- when the family members of my attendings need procedures done in the e.d they prefer the pa's to do them because we do them a lot more frequently than they do. some of my attendings haven't sutured in years.
I have sutured up the faces of several of my attending's kids at this point.

 

[psy]

I think oldpro's problem with this is for the PAs to be able to have independence from docs. This thread has set a tone of hostility between docs and midlevel providers since the start. So far it's been getting worse. I would hope that when it's time to caring for the patients we won't be so hostile towards each other.

emedpa,
I didn't know PAs were such a valuable source of info. I'll make sure to grill you guys with questions when it's time for me step into the hospital. Every source of knowledge is welcomed here.

 

[oldpro]

dude, what's up with the hostility?
I clearly know more em than anyone except an em boarded physician and am willing to help train others. what is your problem with that?
if you rotated at my facility you could choose not to interact with the pa staff and wait around for attendings. you would get a substandard learning experience because you would see far fewer pts and do far fewer procedures but if that's your choice than by all means run with it. most likely my attendings would also direct you to see the pa's about any procedures.
fyi- when the family members of my attendings need procedures done in the e.d they prefer the pa's to do them because we do them a lot more frequently than they do. some of my attendings haven't sutured in years.
I have sutured up the faces of several of my attending's kids at this point.

I'm not the one who is the PA saying they are the same as a Resident, you can candy coat what you said but that is the intent of the statement,

You misunderstand my post, I said be proud of what you are and stop trying to be something you are not.

DUDE! I'm not a kid either. Some residents are not Kids, Plus you are not going to be at my Residency, I'm going into Family Medicine, As a medical student I was told not to accept directions from PA's and NP's by the Docs here, they said to bring it to them.
Your so desperate to have us agree that PA's are equal to MD and DO residents that you have to post in this way and be upset.

Also funny you mentioned suturing, time consuming and really not a hard skill, the Doctors may not want to spend the time to do it, in the OR the Surgery techs did the closing at times, not PA's or Nurses but surgery Techs.

I would not go around defining myself because I can do one skill.

As far as fewer procedures, well even as a Medical student I have already assisted with over 200 surgeries and have done daily rounds on hundreds of patients. I have not lacked any experience because I have not worked with PA's

 

[deleted6669]

You misunderstand my post, I said be proud of what you are and stop trying to be something you are not.

I am proud of what I am and what I do. I just have a better idea of what it is than you do.
over the years I have worked many jobs in emergency medicine and know my role quite well as it has been essentially the same in every facility I have trained and worked at.
let's end this side issue here and let the thread return to its original intent.

peace-emedpa

 

[oldpro]

I am proud of what I am and what I do. I just have a better idea of what it is than you do.
over the years I have worked many jobs in emergency medicine and know my role quite well as it has been essentially the same in every facility I have trained and worked at.

Ok I can end it but my take on this is I have a good understanding of the laws and the roles of midlevel care givers, I doubt you have been called a resident at any of your jobs, compared to one possibly but out right job description with full responsibilities Just as a DOC? I doubt this, JACHO would have a field day.

 

[oldpro]

I think oldpro's problem with this is for the PAs to be able to have independence from docs. This thread has set a tone of hostility between docs and midlevel providers since the start. So far it's been getting worse. I would hope that when it's time to caring for the patients we won't be so hostile towards each other.

emedpa,
I didn't know PAs were such a valuable source of info. I'll make sure to grill you guys with questions when it's time for me step into the hospital. Every source of knowledge is welcomed here.

Naw I'm not hostile at all, "Arguments and Debates" are great ways to learn, Aristotle and Socrates practice this, the art has been lost by some in the 21st century.

In practice the upmost respect must be given both ways, it would be unprofessional otherwise.

In fact without really knowing emepda, I'm sure they are a very professional and knowledgeable care giver with a lot to teach and great skills. I would give them all due respect in person and professionally ( I think this is misunderstood)

That is not the points I was talking about and not the focus. PA's are not equals to Doctors, they are not residents, they are PA's. emepda has posted otherwise and I have counter posted my opinions.

 

[deleted6669]

That is not the points I was talking about and not the focus. PA's are not equals to Doctors, they are not residents, they are PA's. emepda has posted otherwise and I have counter posted my opinions.

you have misunderstood my post.
I was comparing the job duties of a pa to the job duties of a resident only insomuch as teaching and lack of independence go.
pa's practice with attending physician oversight. so do residents.
pa's teach junior residents, med students, and others. so do residents.
that is as far as the comparison goes. I never said I was a resident, called myself a resident or physician, only stated that our duties overlap.
FWIW- the following was written by a third yr em physician resident recently over at the pa forum. he also posts here and I can give you his pm if you wish to contact him to discuss his thoughts on this.
"Acutely off my final ICU rotation in EM residency and looking downstream to the light at the end of the tunnel. I recently gained a new respect for PA's in my ICU. My ICU is truly PA run, especially at night. I have no pride issue in stating that the PA's on this service taught me more about critical care medicine in a tertiary receiving center than the physicians. There are at least 6 full time PA's that rotate 3/3 nights/days where 3 always are on together and cover about 25-30 patients. Residents work under them and gain valuable thought processes. having been both a PA and a physician I was proud to see these autunomous PA's working in settings the way they were meant to perform. They kept continuity on the service and patient's gained because of it. Academic programs across all specialties should and must use PA's to keep continuity at a priority. PA's can also be involved in the residency teaching process, and rightly should be. I find this PA niche to be a new wave of the future. I hope to be involved with helping to develop it wherever I end up next year."

also for your consideration this study done on american pa's in england:
Role of Physician Assistants in the accident and emergency departments in the UK
Ansari U, Ansari M, Gipson K. Accident and Emergency Department; Warwick Hospital, UK
Published in 11th International Conference on Emergency Medicine, Halifax, Nova SCotia, Canada, June 3-7 2006 and Journal of Canadian Emergency Medicine, May 2006, Vol 8 No 3 (Suppl) P583

Introduction: The Accident and Emergency departments in the UK are under severe pressure to expand their staffing levels in a bid to try and comply with the 98% target for 4-hour waiting times set by the government. Increasing staffing levels is proving to be very difficult when a majority of Staff Grades have already left or are leaving to become General Practitioners for financial gains and better working hours. This combined with a limited number of FY2 doctors being allowed to work in Accident and Emergency departments poses new challenges to staffing within Accident and Emergency. The objective of this study was to evaluate the training requirements, GMC regulations and supervision required to perform a suitable role in Accident and EMergency following the appointment of two Physician Assistants at City Hospital, Birmingham. Methods: The activities of two Physician Assistants at City Hospital were monitored for two months. All case records were reviewed and the number and type of patients seen by the assistants recorded. These were then compared with the records of those patients seen by Senior House Officers. Monitored information included number of patients seen, type of patients seen as well as the quality of the notes. Results: On average, Physician Assistants at City Hospital treated 3-5 patients/hour compared to 1.5-2.5/hour seen by Senior House Officers. Physician Assistants were able to deal with most medical, surgical, orthopaedic and gynaecological problems with minimal supervision. The medical records revealed that documentation was better by Physician Assistants. Conclusion: Senior Physician Assistants from the USA are an effective way to improve staffing within Accident and Emergency Departments with the UK. Physician Assistants saw more patients and required less supervision than Senior House Officers. Physician Assistants proved to be a cost effective method of supporting Accident and Emergency doctors at City Hospital, Birmingham.

 

[ForbiddenComma]

I posted the following over at allnurses.com. The more I think about it, the more I feel this is close to the truth. Yes, there are a few arrogant NPs who declare that their education is equal to med school, but they are the extreme minority, and their claims are ridiculous on their face. There is little question that med school is the more elite school. But is such a high-level education really necessary for patient care in real life?

The far better argument, from the point of view of the NP, is that their model is better suited for the bueracracy of modern-day medicine, and that MDs are uselessly overeducated and overqualified. If it is indeed true that NPs produce equal outcomes in primary care as MDs, then they are not the poseurs after all. Instead, we med students with our massive debt loads and 3+ years of underpaid residency are the suckers.

I feel that it is primarily a difference of philosophy.

MD/DOs concentrate on evidence-based treatments to take care of their patients. Med school pays little attention to the bueracracy of medicine and the hospital... instead, it assumes that the physician may be practicing "in a vacuum" and encourages its students to be fully aware of medical problems in every field, from primary care to surgery to OB/GYN. The student's efforts are directed to scientific fields such as biochemistry, pharmacology and pathology. The student undergoes a rigorous and standardized series of brutal exams to become a physician, tests that examine the student's grasp of the science of medicine. Any lessons to be learned about how the hospital runs "in real life" are learned only informally during the student's third year of med school, and are not really tested. Medicine remains an elite profession with high compensation and requires top-notch qualifications and dedication from its applicants. Between school and the 3+ years of required residency, medicine demands many long hours of clinical experience before the physician may practice.

By contrast, the NP model makes the primary care provider as a "medical manager." The medical manager's primary purpose is to guide the patient through the vast, complex network of the medical system and oversee his/her interactions with specialists. Primary care consists of protocol-driven medicine, such as with the Minute Clinics, where individual deviation from the system is not allowed. This model takes note of the fact that difficult medical cases are handled by specialists. Considerable classwork is directed toward liberal-arts-type leadership-theory and systems-based practices as opposed to the hard sciences. Also, the qualifications necessary to enter NP school are much lower, and the coursework is far less demanding, in order to take account of the fact that NP students lead busy lives with jobs and children. NP school also requires very little in the way of clinical hours before the NP may practice.

So take it as you will. The schools are not the same... they just follow different philosophies.

 

[JLM]

Alright, so I try not to pipe up too much on here, but I think this is important. I would remind you that we have all endured endless hours of pathology class . . . ENDLESS. However, they were absolutely crucial to understanding and diagnosing of disease processes. Remember step 1 ?? Remember non-caseating granulomas, anti-topoisomerase I antibidies and trinucleotide repeat disorders?? I could have killed Dr. Legg, Dr. Calve, and Dr. Perthes (really, it took three of you to name that ***ing thing??)
I digress . . .

I still question the whole existence of a mid-level provider. Think about the depth of understanding you possess regarding these disease processes. Primary care physicians are the gateway to the medical system. So, guess who gets to sort out the horses and the zebras?? Mid levels dont get zebra training. WE ARE PUTTING PEOPLE INTO PRIMARY CARE WHO DONT HAVE ZEBRA TRAINING, FOLKS !!! I think that should scare you to some degree. How can you catch a zebra if you have never seen it, nor even told what it looks like.

And its gonna be that guy with 'the flu,' some pallor, and pale conjunctivae who gets an oseltamivir Rx instead of a peripheral smear that shall suffer in the end.

Please dont underestimate your knowledge. That is what they are paying you for . . . its not your degree, its how your brain works. You sat through the classes !! You molded that gelatinous blob inside your head tirelessly so that you could catch zebras. NOBODY SHOULD DO YOUR JOB BUT YOU !!! YOU ARE PHYSICIANS who understand pathology, physiology, anatomy, pharmacology, and equine species nearly to the limits of modern science. Physicians are diagnosticians. That is their role, especially in primary care.

You are the zebra catchers !!


Sorry for the lame rant. sweet dreams.

 

[Tired]

How can you catch a zebra if you have never seen it, nor even told what it looks like.

At autopsy?