Sahand, Emergency Medicine PA

Sahand is a McMaster PA grad graduating from Class of 2013. He served as the McMaster PA Student Association (MPASA) President for his class, and has been an advocate for the PA Profession. He now works in Emergency Medicine at University Hospital Network (UHN) in Toronto, Ontario. Sahand teaches at the McMaster PA Program covering Interview Examination and Reasoning Skills (IER). He is also involved in the PA student mentorship program and precepts for students completing clerkship rotations in Emergency Medicine at UHN.

Working in Emergency Medicine PA

Work Hours in the ED

I work 16 shifts a month. This is a total of 6 – 10 hour shifts and 10 – 9 hour shifts. My shifts are all mid-day (as this works for me). So they are either between 11am – 8pm or 10am – 8pm. As I don’t have a family yet – I can sleep in, I miss traffic going downtown and I get home at a reasonable hour.

I also try to work 2 weekends a month. Within the above constraints, I make my own schedule which is awesome as well, because I can just schedule around things without taking unnecessary vacation time.

I find that I have a great work-life balance. Given I have 3 days off per week, I have time to catch up on other things that I do on the side while I am off. I also teach part-time at McMaster and University of Toronto’s PA program which is also a great opportunity.

Procedures I perform in the ED

Procedures that I do in the ED include:

• Suturing

• casting, reducing fractures/dislocations

• lumbar puncture

• paracentesis

• thoracentesis

• Incision and Drainage

• assisting during resuscitations

• We are starting to explore the option of getting certified for point of care ultrasound but we are not formally trained to utilize this yet (although we still use it to guide us for certain procedures).

Benefits of working in the ED

As a PA I have the ability to affect both the lives of the patients that I see and the Physicians with whom I work. This is a very unique aspect of my job that I enjoy. There is nothing more rewarding than treating a sick patient coming into hospital (who may have died otherwise) and seeing them make it to discharge 4 weeks later – all because of your initial diagnosis and management in the ER. The ER is an extremely high-stress area of medicine filled with chaos. We often take fore granted how much a correct (or incorrect) diagnosis can change someone’s life.

In terms of the Physicians – it is always nice coming onto a shift where the department is overwhelmed with high volumes and seeing your colleagues brighten up and say “thank god you’ve arrived!”. It makes you feel very appreciated.

Challenges of working in the ED

Despite those life saving diagnoses that happen every once in a while, the ER is often a disappointing place for patients. Many come in with chronic problems that have been poorly managed for a long time – looking for answers/a quick fix. What they don’t understand is that the ER is a place for Emergencies – Heart Attacks, Strokes etc. And often, when you tell these patients that there is not much more that you can offer them – they can be quite disappointed.

Benefits of adding PAs to an Emergency Department

Having the PAs in the ED has not only helped to improve flow and patient throughput but most importantly has allowed the PA/NP team to work collaboratively with one another in order to optimize our coverage of “advanced practice providers” in the ED during the busiest times of the week.

Also, by working with one another we can also reduce stress/burnout amongst our team as prior to this it was much more difficult to arrange for time off (as specific days required coverage with a PA or NP). I think this ultimately helps to improve physician workload but also improves patient care. Both the PAs and NPs in our department have the ability to take the time necessary to complete thorough assessments in order to provide thorough and exceptional care to the patients whom we assess (e.g. ensuring subtle abnormalities in labs/imaging as well as in the patients story are not overlooked etc). I think this is the ultimate advantage of having us as a part of the team – in order to not only improve wait times but to provide both timely and exceptional care to the patients whom we are responsible for.

Choosing to Pursue PA

I always knew that I wanted a career in medicine. However, I always knew that the MD route was not something I wanted to do. The main reason for this was the length of time it takes to do it. I always excelled in school but didn’t enjoy classes, tests, the stress etc.

I wanted a clinical career – one where I would be able to practice medicine but not have to be in school for 12 years to do it.

Long story short – one day I ran across an article about PAs in the states. I immediately fell in love with the idea. The career outlooks were great, you take on a clinical role and the schooling was something that I could handle. Doing a strenuous 2-year program followed by on-the-job training was exactly what I had been looking for. Needless to say, I chose to take a leap of faith and decided to pursue a career as a PA.

Also, another major point of interest for me was the flexibility of the role. You are trained as a generalist and you can switch specialties as you please, you are not constrained to practice medicine in only one field. For example – as a physician, you complete Medical school followed by a Residency in a specific specialty (e.g. Orthopaedic Surgery) after you are done, you find a job in a hospital and can practice as a staff orthopedic surgeon independently. However, that surgeon can only practice orthopedic surgery. If one day they decided to switch specialties (even to go and do something like family medicine) they would need to re-apply and complete a residency for that specialty.

As a PA, you are a dependent practitioner (meaning you always work with a Physician). However, as a result, you do a lot of learning on the job (like a resident) but this also gives PAs a huge amount of flexibility and the opportunity to switch between specialties. For example, a Family Medicine PA can decide to switch to Ortho, general surgery etc as they please. Obviously – there will be a big learning curve for the first few months but they would not need to undergo formal training to do so.

PA Advocacy - Clarifying the PA Role

A PA is as a physician extender. We work in a team with a physician to provide medical care to patients. PAs practice medicine. This means that our training teaches us to approach patients in the same way as physicians

We are able to take histories, perform physical exams, order and interpret diagnostic tests and come up with a treatment plan for the patients that we see. We are able to work in all areas of medicine where there is a physician working and as long as we have been adequately trained; we can do anything that is within the scope of practice of the physician we are working with.

Being a dependent practitioner is sometimes misinterpreted. Depending on the setting – PAs function differently. Ultimately, as you are an extension of the Physician with whom you work – they are responsible for the patients that you see and treat. In some settings, this means that PAs will only review cases which are complicated for which they require a second opinion (e.g. family medicine). In other, high-risk/high-stakes settings, PAs will see patients, complete their history/physical/diagnosis and treatment but discuss the case prior to patient discharge to ensure that the MD does not want anything to be done differently (e.g. in ER).

It is important for a PA to have strong interpersonal as well as communication skills. As a PA, you are constantly interacting with patients and physicians (who can both be difficult to work with at times). As a result – communication and your ability to relate to and empathize with others is a critical part of your job.

PA vs. NP

As with many health care professions there is a lot of overlap between the two. I work with two NPs at UHN and have a great relationship with both. NPs are trained in the nursing model – that is they are nurses with specialized training to diagnose and treat illnesses. They (just as of a few years ago in Canada) can also practice independently. This means for straight-forward patients, they do not need to review with a physician and can send the patients home. They are also regulated (as they have been around for the last 40 or so years).

PAs are trained in the medical model and are dependent health care providers (as discussed above). As a result, we are always in a team with a physician (although in certain places we can also function remotely – with a physician available on call). In my mind an NP as a defined scope of practice as they are independent. So when they graduate from an NP program – they can do the things that they have been trained to do independently. A PAs scope of practice is variable depending on the setting that they are working with and who they are working for and the longer that the PA has worked with a physician, the more training they will have and the more things that they will be allowed to do. For example: when I began working at UHN 2 years ago, I wasn’t doing joint aspirations, central lines, and lumbar punctures. However now that I have been trained to do these highly invasive procedures – I can do them. The NPs however do not do these procedures and need to get the physician involved should they need to have them completed. Overall the difference is very vague – and both can function in similar settings. It comes down to what the hospital/setting is looking for and what role they need filled. Ultimately – there is a role for both and I can say that we work well together.

Patients appreciate being seen by PAs

The name PA is misleading but what people need to understand is that patients don’t care about titles. A lot of the time, even though I introduce myself as a Physician Assistant/Associate – they may not process exactly what I am and still end the interaction with “Thanks doc”. What I mean by this is: If you are confident and competent people will listen to you and respect your opinion. If you are not – then the opposite will occur. Regardless of whether you are a nurse, NP, PA or MD. If a patient sees a resident who is not confident with what they do they will ask to see the staff, if they see an attending who isn’t confident they will have bad reviews to give to the doc personally, the hospital and the royal college. It is also an issue that comes up with regards to patients wanting to see specialists, “Oh well you are just a family doctor, you aren’t an ophthalmologist so how would you know”. This occurs at all levels of the health care industry.