Emergency NP & PA Workforce

John Canion - 00:00:04:

Which type of NP is supposed to work in the ER? That's one question where you start. Is it family? Is it acute care? Part of what we do as leaders in this, is trying to match the right person, too. Because sometimes you can get somebody you can train who doesn't necessarily have the knowledge but has the appropriate, let's say, personality traits that would make them successful in the Emergency Department.

Omar Nava - 00:00:29:

Welcome, welcome everybody. Welcome to the Emergency NP and PA Workforce Podcast, the Workforce Podcast for EM, NPs and PA. What do we do here? Well, here we navigate the EM labor market, the role of the EM, NP and PA. The relationship between clinicians and facilities, and all the financial issues that come with it. What's our objective? Simply to share and inform. I am your humble host Omar Nava and I am an emergency medicine PA who's been in the business for 20 years and I'm excited to bring you this podcast. all the emergency medicine clinicians out there. We know what you go through and we appreciate you. Today I'm very happy to bring you our guest, John Canion, Emergency Medicine NP. Hello, John.

John Canion - 00:01:16:

Hello, Omar. How it’s going, buddy?

Omar Nava - 00:01:18:

It's a good day today. I'm very happy that we were able to snag you for this podcast and share in the contributions you have for the workforce. Before we get going into the questions, John, can you just tell our listeners a brief story of your journey to becoming an emergency medicine NP?

John Canion - 00:01:40:

I worked as a nurse and I did travel nursing for a long time and worked in a variety of areas from ICU to ECU to Telemetry to Med Surg to Pediatrics. I mean, the only areas I didn't work as OB and L&D. I ended up in the ER, loved the ER, and I was working in the ER. As an agency nurse, I realized that I had maxed the potential for my income for my career and I was still mid-twenties. So early 20s, so I decided that it was time to go on. Actually, there was PA students rotating through our ER at the time, and I thought, man, I know most of what they're. Most of the questions are being asked and I know the answers to. I thought, man, I can do this. So as I was applying to PA Schools, one of the nurses was like, why don't you become an NP? I don't even know what that is. We didn't have any, there was none around where I was. There was none. So I was like, okay, well, I'll apply to both. Whichever one I get in first wins. And as you can tell, I went to NP Schools, to the PA Schools, I got into that one first, so. And then I got out, started working in emergency medicine. Since then, I've worked, probably 55 ERs and I've done Family Practice, Critical Access, Hospitalist Medicine and quite a bit.

Omar Nava - 00:02:54:

Thank you for that intro. Some of that is going to lead into some of our questions. And so I'll snag one of the things that you talked about. I mean, you talked about here, you'd been in the workforce already, and you realize that you had a pretty good handle on nursing and you're watching these PA students, these Physician assistant students, and you're recognizing, gosh, I could probably, not only do I know most of us, probably teach these guys a lot of the stuff. And then someone tells you about this NP gig, and you're like, well, what is that? I've never even heard of that. So now we're talking about somebody who's been in the business for a few years, you have your rhythm as a nurse, and even you with that years of experience hadn't yet heard of an NP. The reason I bring this up is because I think this is what's unique about the, certainly in emergency medicine, but in all specialties too, regarding NPs and PAs. We're a relatively young couple of professions. Back then, at that time, when you were looking into it and said, hey, I might give this a stab, everybody knew what a doctor was. You wouldn't say, hey, here's a doctor, and nobody would say, well, what is a doctor? But you throw the word NP at, and even if you describe it to them, or you went to go work with a doctor, I would imagine there's a handful of Doctors that didn't know what to do with a PA or NP. So that'll bring us to our first question here. In my experience over the past 20 years, this is some of what I've witnessed, either firsthand or indirectly, and I've worked in multiple states. There were some NPs that had great valuable experiences, EDRNs, before they went to NP School. Some of them were even ED charge nurses. So much of their experience and their knowledge and their skill were transferable, and very complimentary once they transitioned to the NP role. If they were appropriately matched with patient acuity and good supervision, a good model, and a good positive experience, then good things could be expected. However, if they were mismatched with the wrong acuity, not sufficient supervision, or thrown into deep waters with wrong expectations, unfortunately, sometimes that leads to bad experiences. So we'll start with the first question. Do you think that 10, 15 years ago, John, EM NPs contributed to increasing patient access to quality emergency medicine care?

John Canion - 00:05:11:

Yeah, I was the only one I knew of. So I don't, they really can't save 20 years into it. It's been, it's 2005 since I got out of school. So almost 20 years ago, there weren't any. And did we increase access to care? Absolutely. Quality is another issue, right? That's something that, and still to this day, varies wildly from NP to NP because of lack of standardization of education, you know? So you get somebody who's... going straight through school and doesn't ever work as a nurse and comes out and struggles mightily. You get somebody who's worked for a long time, who comes out and still struggles mind. You get somebody who works for a long time, like you said, gets appropriate support and does well. People have to understand that, I mean, I know you guys get a better, well-rounded education than we do from a clinical perspective, but when we get out, for EM is not a great place for somebody to work if they don't have a lot of support. You've got to have a lot of support, a lot of education to get them caught up to speed so they can take on the EM role.

Omar Nava - 00:06:12:

Would you say that the role of the EM NP has expanded over the past 15 years? And if you do think so, how so?

John Canion - 00:06:20:

I don't know that the role has really changed much. I'm pretty much doing the same thing I was 20 years ago. I mean, when we came out, we were trained to do everything. So we went everything from the not sick to the critical and you had to see those patients. And so it really hadn't changed a whole lot. Depends on, I would say it really depends on location. As I've worked in some places where they just want me to do fast track, some places where they just want me to do a pit model, some places where I do everything, and then some places where I do a mix of whatever that particular doc on that shift wants me to do. So you have to be able to be pliable in your practice and work according to the comforts of whichever Physician you're working with sometimes. And then I've worked out in a little bit critical access place where I'm the only guy in the whole county.

Omar Nava - 00:07:02:

things that I picked up on that you talked about. One of the keywords was being pliable, which I would say absolutely is a key characteristic for NPs and PAs. If for no other reason you'd mentioned something earlier that there isn't this universal rigid standardization, and because of that, not only does every site have different needs of you just went through examples, what do they need from you? But then every supervising Physician either A may have a different need or B, they just have a different fundamental of understanding of how can John best help me knock out that waiting room and all the patients in the waiting room? And sometimes they're very well versed in what NPs and PAs can do, but they just have certain thoughts of how they should function. And that's cool. There's a supervising Physician. But I think in a lot of cases, especially the younger, new post residents, they just don't know the full capability of what we can or cannot do. Do you think that supervising physicians are challenged, that this is a challenge with providing the best optimal supervision at times, either because they're getting run over by patients in the emergency department or because emergency medicine has changed, that this is a challenge for supervising Docs to say, I don't know what kind of supervision exactly Omar needs or what John needs. I guess I'll just leave it to them to let me know when they need something. Does that sound familiar to you?

John Canion - 00:08:28:

100%. I mean, there's no way to know what anybody needs individually as we don't have standardization of training. And that's the problem. I walked into one ER. First day I sat down with his doc and he's like, you're a nurse practitioner? I said, yes, sir. And he said, we should never hire you. We should only hire PAs. Nurse practitioners are garbage. And I said, well, I don't know who you work, have been working with, but it wasn't me. And then a month later, he was requesting to work all the shifts with me. So, and now he's one of my best friends, but it's one of those things where there's some internal bias too. So if you work with somebody from either side and you think, oh, well, they're garbage. Well, I don't want to hire anymore of those guys anymore. It must be all of them. You attribute one person's lack of knowledge or lack of understanding of emergency medicine to everybody in that field. And it's just not that way. The problem is, again, lack of standardization of training. So we don't have a specific set way to train our ERs, NPs and PAs. And a lot of groups are now addressing that by coming up with training mechanisms for ERs and NPAs and NPs as they onboard them. They have extensive, extensive training. They want them to go to the EM bootcamp or get a post-master's EM NP for us, or a CAQ for you guys, you know, and they want you to have that. So at least they know you've got some NP training at all. Again, it's just a complete and utter lack of understanding what they do. And then there's a comfort level thing where some people say, well, I'm not comfortable. I'm not comfortable taking care of sick people. I only want to take care of not sick people. Well, the not sick people can be sick too. I picked up two brain tumors and one shift in a fast track, back to back, you know? I mean, you see them everywhere. And they come in, you gotta be aware of all the options. If you're not, you're going to miss it, and then you get in trouble. Funny on that story, I had the neurosurgeon called me that night. I sent him one and I called him back 10 minutes later. I'm like, hey, I got a brain tumor for you. He's like, yeah, John, I know, you just called me. I'm seeing him right now, I'm like, no, no, no. I got another one. He's like, what? Like, yeah. So about four hours later, right before I go, Sohmi calls down to the ER. He's like, hey, John. Did you find that third brain tumor? It's like nah man, but two out of three ain't bad, right?

Omar Nava - 00:10:34:

Yeah, that's a pretty good record. 100% true on that last point. You know, it's arguable over a cup of coffee or over good bourbon or beer that relegating oneself only to fast track, at least when they're bringing somebody in a truck, lights and sirens and everybody's gathering, then everybody has a fundamental understanding that patient is probably sick, let's pay close attention. But I'm with you, brother. I worry about the grenade with no pin that's hidden underneath all the boxes that nobody knows about because they were triaged as a level four and they say, oh, they look okay, it's probably no big deal until you just ask a few questions, get a little bit of their history, do a skosh of an exam, you're like, hey, get this guy in a bed right now. guy is not a level 4.

John Canion - 00:11:16:

What's worse than that is when you're on shift with a Doc and the Doc goes down and codes. Then what? And you're out in an area where there's no backup. There's no hospice. There's no anesthesia. It's just you and a doc. And the doc goes down while they're putting in a central lining codes. What do you do? If you're not comfortable doing that, then you put you in a really, really bad situation. And then you've got to get a doc in there to help cover the ER while this guy gets shipped out. And the closest Doc is 400 miles away. So then you're sitting in a situation, a really bad situation where if you're not comfortable seeing at least seeing and taking care of sick people, it puts you in a really, really, really bad situation where you have a chance for a whole lot of negative outcomes instead of just one.

Omar Nava - 00:11:58:

You've just touched on something that we're going to visit here in a little bit and it's what I call the mismatch problem. Making sure that the grownups in the room and the leaders and those with experience are matching the right person for the right environment and thinking about this one step ahead scenario that you just described and not only thinking about, I just need them to knock out fast track, but thinking about this next level of what is it. We'll visit that here in a little bit. John, would you say that over the past 15 years, you've seen an increased frequency of NPs performing more procedures where they get called and say, hey, we need you to be to help us out more with procedures in the ED?

John Canion - 00:12:37:

100%, yes. I think for both of us, just mix us both in the same group from that perspective. Yeah, a lot more. And honestly, procedures from a technical standpoint are not difficult to perform most of the time. Not real difficult. It's just a matter of training and repetition. I mean, it's just like in the, what is it, 1940s, Docs were the only one who could put IVs in. And now the nurses are doing it, right? So, I mean, it's a matter of risk and benefit and training and repetition. And if it depends on the shop too, right? And the busier the shop is, the higher acuity. Well, there's one place where the Docs are all RVU-based. And it makes more sense from an RVU perspective for them to see another patient than to put it in a central line because they make more RVUs. So they have us put in there, do all their procedures, and they go on and see the next patient. So they miss out on the RVUs from the procedure, but they generate more overall by seeing more patients.

Omar Nava - 00:13:31:

Totally been involved in those scenarios, the RVU full, RVU partial, shared RVU and non-RVU. We'll talk about that one as well here in a little bit. Let's talk about the relationship, and we hit on it a little bit already, John, relationship between EM, NPs, PAs, and their supervising Docs. I think all across the country, NPs and PAs and emergency Docs, they're getting along just fine and they're working together well, by and large. I think as a team of providers, we're at our best when we're united. I would like to keep it that way. Unfortunately, in society, there's always going to be people with dissenting opinions, and that's cool. That's what makes us diverse. There's some number of considerable voices that have expressed concern over the scope of practice of EM, PAs and NPs. I think all professions, Lawyers, Carpenters, Electricians, Engineers, PAs, NPs, and Doctors, there's always going to be room for improvement somewhere in that profession. However, I think that there have been instances where one or two anecdotes have been used to characterize all NPs and PAs. You just gave us one example of when you met up with one of your supervising Docs who you ended up being a good friend with. I don't believe that these characterizations have been accurate in a widespread fashion. Can you share your thoughts on this?

John Canion - 00:14:48:

The problem is, I think it goes back to lack of standardization and training for what we're doing. The problem is, if you get a residency training board certified EM doc, you know what they can and can't do. For instance, which type of NP is supposed to work in the ER? That's one question where you start. Is it family? Is it acute care? I can go on this rabbit soap box all day long. It's one of my favorite topics, but you get a PA who's fresh out of school. Are they appropriate to come into the ER? You get a PA who's been in General Surgery for 10 years. Are they appropriate to come to the ER? You get a PA who's been working in Family Practice for 10 years. Are they appropriate to come into the ER and see sick people? Part of what we do as leaders in this is trying to match the right person, too, because some times you can get somebody you can train, who doesn't necessarily have the knowledge but has the appropriate, let's say, personality traits that would make them successful in the Emergency Department.

Omar Nava - 00:15:39:

Sure.

John Canion - 00:15:40:

That makes sense. And then the coordination between us and Docs, it's all on the individuals, I think. I don't think there's any place I've worked that's been overtly hostile. Never worked in a place that's been overtly hostile. I've never worked in a place where I've felt uncomfortable talking to my Docs. I've never worked in a place that I've felt uncomfortable talking to my colleagues at all, NPs, PAs, never felt uncomfortable going to anybody. And I would never want anybody feeling uncomfortable coming and talking to me. There's been some people I don't like. Yeah, sure. But that's more a personality thing than anything else. You don't get along with everybody in this world. No matter how nice you are. There's going to be people that don't like you, people you don't like. That part doesn't bother me too much. But it's me, it's more about independence of practice. When I go to a place and I can't practice independently, if they want me to act like a resident or a student, I'm not going to work well in that environment. Because I'm not going to agree with how you skin the cat, necessarily. Like I may do it a little different. Like I do one thing that's interesting on the pediatric head injuries that are PECARN negative. I order two view skulls on the mom, on the patient. And then I go in and I tell mom, that actually looked great. I didn't see anything bad and go home. I don't even discuss PECARN with them because they don't understand all they're going to hear is, Oh, you just don't want to do what's right for my, my baby versus me going in and going, Oh honey, that actually looked great. I didn't see anything bad. And then let them go home. Now they feel comforted that I quote did something, you know? And the radiation exposure is negligible. Now you and I know that fighting a skull fracture on a two view skull is what one in 150 bazillion or whatever. But I mean, it's just, you, it's chance for you finding it as non-existent, but it makes them feel better. It makes them feel like we've done something for the patient. And sometimes we have to practice that art as much as we do the science and the business side of medicine.

Omar Nava - 00:17:30:

And to that point, before we move on to the next question, I think that all players. NPs, PAs, Docs, if they've traveled around the country, they would have to admit. that there's a standard of care. Absolutely things should be science-based, but to practically take care of a community, I think all folks would agree that your practice is also shaped by where you work and what part of the country, what community. There's different expectations, because as you said, you could easily be seen as somebody who doesn't give a damn, doesn't care, or you could be seen in any other dimension. But I'm actually glad that you mentioned that, because I have found working in different parts of the country that practice is shaped by where you work and what community you serve.

John Canion - 00:18:16:

Also changes your order sets too, man. Sure. I mean, you work in an area where there's a high specific type of population. Like I worked in one town where we never saw syphilis ever, ever. I mean, when we finally got a case, it was a big enough deal that the CDC came down and tracked it down. That's a big deal. Whereas first is if you work in other towns, syphilis is endemic to the area. So it's just part of your treatment for somebody that comes in. Anybody comes in with a lesion, you automatically assume. You're right.

Omar Nava - 00:18:45:

Following up on this issue about supervision, and we talked that so much depends on who the individual is. I think that the best supervisory model in an ED is one that's tailored to the experience and the skill level of that NP or that PA. You touched on that a little bit about it. The junior clinicians, they need to have easily accessible supervising Physician that's responsive, give them periodic feedback of their performance, and doesn't make them feel stupid for asking questions. The mid-grade and the senior APPs need to be given a little bit of room to flex what they know and have their advanced contributions taken into consideration. And then with the last group, the senior APPs, they need to be considered for possible leadership positions when there's some within the staffing group or the hospital or the hospital itself or the department. Examples of that are being on credential committee when they develop, well, what are the credentials that we're going to give APPs? I find it interesting that in lots of places, physicians only decide this, and there isn't any APP in there to just speak up and give a little bit of flavor, just give a little bit of input as to what should be on there, what shouldn't be on there, what should they explore for next year. What are your thoughts on this idea that I pose about different supervisory models for different levels of skill, experience, and knowledge?

John Canion - 00:20:03:

I think it's reasonable and it goes back to what most of the EM groups are doing right now where they're having onboarding processes for their new grads, which is 100% the right way to go. But I also think that there needs to be an onboarding process in the department where the newer people need to have their patients backed up, all of their patients, for at least three months. where they're followed up and seen, and that way they can discuss and go over and treat them like a resident. When I came out and I started practicing, that's what the guys I worked with did. They treated me like a resident. I saw every single patient, I did every single procedure, I did everything. And it was hard, it's hard work, man, because I had to see every patient that walked in the ER, was not expected to carry my own load, because they were expected to make sure I was doing the right job. So for the first three months, it was horrible. Saw every patient that walked in the ER. But the plus side of that is, once I started practicing on my own, it taught me efficiency, taught me how to see people in an efficient manner and still get the work done, and still rule out the by-threatening emergencies. So, I mean, that kind of thing is helpful. And then as you progress and experience, the amount of supervision you require should drop. But again, if we went back to standardization of education, going into emergency medicine, then that first part might not be necessary, right? But I think for sure the experienced people need to be sitting on credentialing committees, need to have roles in the EM groups. And most of the EM groups are moving that way. They have lead APPs, they call them, or lead PA/NP, whatever their terminology is, since there's not a great all-encompassing term right now that doesn't offend somebody. And those roles are necessary, because you get into things like, for instance, what can a family nurse practitioner do versus an acute care nurse practitioner, versus PA, you know, that kind of thing. And a lot of times, like for instance, I'm family trained. I did get my emergency certification a couple years ago, but up until then I was only family trained. So they would look at me and say, he's family trained. Well, this other guy's family trained and he wants to come into the yard. He should be able to do what John does. Well, not exactly, you know, there's significant difference in training and. experience there that you have to understand has value. And a lot of times we as leaders need to understand that and understand that there's significant difference in value. There's one group I know of that brings people in and pays them half rate until they pass their 90 day orientation period. I mean, they pay them to train them, but if they don't pass their orientation period, they fire them. I know several people who've been terminated at the end of it, because they just weren't cut out for emergency.

Omar Nava - 00:22:34:

One good thing that you mentioned just now in this response, and I made a note, you touched on this before in one of your previous responses. One of your previous responses, you talked about potential bias about being underqualified. I'd like to talk about the other side of the coin and you just touched about it now. You actually had mentioned it earlier before. You mentioned yourself, your years of experience and your family trained and a potential colleague that also has those initials after their name, but they don't have the experience that you do. There's a risk of a bias of thinking that everybody is overqualified, that just the same initials as I guess you can do everything that John does. No, no, no, no, wait a minute. John, what you don't see behind his name and his credentials is that he's been doing this for years. He shares the same letters behind his name, but somebody else and they just walked in from doing Family Practice Clinic. Same thing with PAs, do not make any assumptions. The reason I bring this topic up, John, I'd like to hear some commentary from you is because there's two spectrums that I look at on the spectrum of knowledge, skills, and ability. We talked a little bit about the seniors and the midrangers, but I'm very cautious over 20 years of practice, 19 of those years being an employer, looking after the younger generation that gets thrown into deep waters and they just assume, well, I guess a PA is a PA is a PA or an NP is an NP is an NP. And then it's a bad setup. They flounder. It's not their fault. Docs don't have the time for the supervision because, well, John's on shift. He doesn't need that kind of supervision from me. And then they may have a bad outcome or they're inefficient. So the patient's mad, the facility's mad, the staffing group is mad. The individual feels, look, I'm not stupid. You know, you threw me into this job. I'm just doing what you told me to. And it's just a bad setup for everybody. Can you talk a little bit about that, about some of the junior clinicians being thrown into waters? It's not fair to them. They don't belong there.

John Canion - 00:24:24:

Well, I was very, very, very particular on who I hired and how I hired people. Very, very particular. There was one nurse that worked with us that was an exceptional nurse, very, very good. But as he was training, it was evident that he thought he knew emergency medicine inside and out. And it was evident that he did not. And so we didn't hire him, made him go do something else first. And then a couple of years later, we ended up having a slot open up and he came back and he's like, yeah, I'd really like to come back. And I said, well, all right, you have to go get your emergency certification in order for me to hire you. And for the first three months, we're going to watch you like a hawk. And I want you to ask questions on everything. And after that, he said, man, I'm really, really glad that you didn't hire me initially because I probably would have killed somebody. And that's the kind of thing you have to watch for is the initial training period when we brought in new people. We got all the Docs together and said, hey everybody okay with bringing in a new grad because we bring in the new grad, there's going to be extra work for three or four months while we try and get them up to speed You guys have to be on board with this and understand that you can't let anything slide while these guys are on shift And it goes same with the the PA/NP Group. We got to watch these guys. We got to protect them We got to help them out. And like I said before there's just some people who weren't meant for the Emergency Department you know, there's some people who from a from a personality standpoint or a efficiency standpoint are not they're just not designed for the kind of work that we do and it's not and it's not a bad thing It's not a knock on anybody. It's just they're not designed to do this. Just like I'm not designed to stay in family practice long-term. I can do a short term, but long term It's just not a good fit for me personality wise. I'm more of a Forrest Gump guy, you know like the ER What's the patient? It's like a box of chocolates. You never know what you're going to get when you walk in the room, right?

Omar Nava - 00:26:12:

Yes. Absolutely. Let me touch on a topic briefly. I'd mentioned before in my remarks, I truly believe this is sincere that by and large, all across the country, PAs and NPs and their supervising Docs, they're getting along just fine. They're working side by side in the trenches. They're happy to see each other. Oh, thank goodness John is on shift. We got a fighting chance today. You said you'd become good friends with one of your supervising Docs. I've been very blessed more than I deserve. Be really good friends with supervising Docs. Celebrate kids' birthdays together, weddings, vacation together, comforted each other through the loss of a parent or illness of a family member. About a year ago in the spring, ACEP, American College of Emergency Physicians, issued a white paper. And they talked about their position on the EM practice of NPs and PAs. And in it, what they expressed was that they thought that every patient that gets discharged from the Emergency Department should be seen by a supervising Physician. I usually find in life that when there's a difference of opinion on an issue, that the solution is going to be found somewhere in the middle. Maybe not at the 50 yard line, maybe at the 20 yard line of one side or the other, but it's rarely found on one extreme or the other. My first instinct when I heard that was, I'm not even insulted by that. I just don't see that as being possible. I could go through an entire shift and the only words I exchanged with my supervising doc is, hey, you want to go get coffee? And that might be all we talk about.

John Canion - 00:27:40:

Statistically, it's impossible though, right? Cause there's what, 10,000 ER Docs and 5,900 ER, or there's like, wait, no, there's enough ER Docs that cover one 12 hour shift for every ER in the country. That's it. So it's not statistically possible. And while I get peeing around your territory and trying to market, I understand that. I mean, I get it. And with our lack of standardization of training, I understand, I understand the concern. I understand the concern 100%, but man, the most patients I've seen in a shift is 77. So good luck seeing your 30 and then my 77 on top of it.

Omar Nava - 00:28:14:

That's a good point. And back to your point about standardization I mentioned in my earlier comments, there's always gong to be room for improvement. I'm never going to ever argue against education ever. It'd be stupid to argue, but I will say what 20 years has taught me is, education comes in many forms. It doesn't have to be didactic with a postgraduate degree that costs somebody another 30, $40,000. Sometimes education can come with targeted CME. And you mentioned it. A lot of groups are being smart about this. And they're saying, we're going to take you through E&B Bootcamp One, E&B Bootcamp Two. ACEP actually for about two years or a year and a half did a ACEP Academy of APPs, phase one, two, and three. And I was one of the nerds who did that. There's different avenues of getting this education. It doesn't have to be only in one way. If there was a goal or an objective to say, starting July 1st, NPs and PAs cannot work in the Emergency Department unless they have X standardization of care, whatever that looks like, John. It's going to take a while. It's going to take a while.

John Canion - 00:29:22:

Yeah, for sure.

Omar Nava - 00:29:23:

There's folks just trying to put their kids through college, paying off mortgages. And there's folks that say, I'm doing just fine. I don't know what's going on on the national debate stage. Me and my Docs are getting along fine. They don't tell me I need anything else. I do, I keep up on CME. I keep up on changes and I'm fine. So don't make me change. Give us some thoughts about the overall landscape of this debate.

John Canion - 00:29:45:

Well, I think that long-term what it needs to be is like a grandfather thing, right? So you go to like at a certain point, I don't know, let's say what are we 23, right? Let's say by 2030, every new NPA or PA who comes into the Emergency Department has to have XYZ training. X number of hours in emergency medicine has to have X number of intubations, X number of chest tubes, you know, that kind of thing, X number of central lines, whatever. Whatever we're going to do for the training. So that way we can say, when I hire somebody who's has emergency medicine training, I know what I'm going to get. Now that also leaves options for the supervising Docs to utilize them in whichever capacity they feel like they need at whatever shop that they're in. But it also gives the comfort of knowledge because oftentimes the ER Docs are the responding to the codes in the hospital. So again, you have somebody who's not trained, you have an ER doc who goes to a code in ICU and the code walks in the door. What do you do? Do you not care for the patient? I mean, you're the most trained person there. Do you go, well, your honor, I just didn't feel like I could do it. I mean, how do you defend yourself from a legal perspective working in the Emergency Department and not being able to do basic ACLS protocols? Or ATLAs, if you've got a trauma that comes in, you have to be able to do that. Now, whether or not that care is directed by a doc or not, that's a whole different conversation. Most of the sick people probably should be seen by them for sure. But, you got to train your guys in order to be able to do this because as you know, it happens sometimes and it happens a lot. And you know, you get into a situation where you just don't have enough qualified people to take care of all the sick people who are coming in. So you have to get the next level to take care of them. And we're that army, we're the guys who are there to do that. And if we can't do that, then it puts the ER in an awkward situation as well. I like all of my guys to be trained to do that. I like all of them be able to put in central lines. I like all of them be able to intubate. Like all of them be able to do conscious sedation. I like all of them be able to reduce stuff. I like all of them to be able to put in chest tubes and help. If a major trauma comes in and the doc's busy doing procedures, he's not able to use his brain to work through the process because he's focused on a task. A task that can easily be achieved by one of us doing it very easily.

Omar Nava - 00:32:08:

Sure.

John Canion - 00:32:09:

And at the end of the day, their brains are the value, right?

Omar Nava - 00:32:12:

Yep, could not have said that better. I talked before about being very protective about the junior clinicians not being put in positions and we followed up with, you know, your commentary about standardization and saying, hey, if you're going to work in the ER, you want people to be trained in certain stuff. Now going to the other side of the spectrum, then I become very protective about people who are highly skilled, highly educated. So let's say we've waved our magic wand and we've converted everybody over. So now we have this army of these highly skilled NPs and PAs that can central line it, intubate it at a moment's notice. They can truly sincerely help out their doc in a trauma. Then for those folks, I want to make sure that they're getting compensated appropriately because they're doing that job. This army exists because for whatever reason anybody wants to opine, you can't get an emergency medicine Physician there. You can't get them there because they don't want to work there or because you can't afford to pay them to work. Whatever the case is, we exist because somebody else won't go do a job there. And that's a very, very value added attribute. And those folks should be getting paid differently than when you and I were coming up in the ranks.

John Canion - 00:33:26:

The one thing that we don't, that a lot of groups don't do now, is pay people differently. Because they feel like we're doing the same job. But are you? Are you really, if you're not on the same level, are you really doing the same job? Probably not. And again, there's groups that bring in people for the first three months and pay them at a half wage or whatnot as training. I think that's very viable. I think you should tier step people or pay them based on what their productivity is. I mean, it's very simple to come up with an RVU calculate based on someone's productivity and get an idea over the year what their salary should be. It doesn't even have to be a daily productivity or a monthly productivity or anything like that. You can just base it off of what their productivity is. And somebody who does more procedures has more value than somebody who does not. Somebody who sees sicker patients has more value than somebody who does not, unless the person who does not sees more volume. You know, it's all pretty easy, calculable based off of RVU rates and procedures and all that. Something's very, very, very simple to calculate. We've done it hundreds of times. I just got off a contract call before we did this.

Omar Nava - 00:34:30:

Yep, I agree. That's definitely an avenue that can be fully exploited. John, as we start coming to a close here, tell us some misconceptions and myths about NPs or things about them in the Emergency Department that you think most people probably don't know that would surprise them to learn.

John Canion - 00:34:48:

Well, again, the variation in training, right? It's just the problem from a Physician and even a PA standpoint is y'all's training is very standardized and very regimented. Your clinical rotations are set up for you for the most part, with the exception of exceptional rotations that you volunteer for. You guys have your rotations are set up. You go to your rotation, you do your month long rotation, you go to the next rotation, you do your month long rotation. Ours is not that way. Essentially, we have to beg people to train us. And there's no academic supervision of clinical training. So you really have no idea what you're getting when they come out. So you can't say one same credential equals another because they don't when they come out. Have to understand that if you're going to hire an NP, you need to ask clinical questions when you hire somebody, period. It needs to be part of your interview process as clinical questions. One of my favorite clinical questions to hire somebody in the Emergency Department is what's the most important question you need to ask somebody who has a punctuated on their foot. And as you and I both know, is were they wearing a shoe? Most people's first answer is diabetes because they don't know that Pseudomonas lives in the glue in the shoes and it changes what antibiotic you have to give. And then, if they don't understand that, they end up... The patient gets pseudomonal infection, osteo, and loses half their foot. So, you know, things like that. And there's a bunch of other ones. I'm going to give you all my interview questions, not online anyways. We can talk about that. You gotta get some of these tricks for people. They don't want to have all the answers before they come in to interview. But things like that are helpful. And the other thing is lack of standardization, understanding that we're not the same. We're not even close to the same. And there's going to be a wide variance in our clinical expertise, our clinical knowledge, and our clinical ability. And expecting them to be the same is not reasonable. If you're going to hire people, you need to have the expectation that there's going to be some training involved. Even with experienced people, unless I know them personally, I am very cautious when we hire somebody. And like I said, I do an extensive clinical interview that I want to know that they're able to actually care for my patients. And I don't have to stress about there being negative outcomes or complaints or they don't understand MIPS criteria or throughput times or door-to-dock times, things that are essentially essential knowledge in emergency medicine at this point. They're all things that we have to be aware of.

Omar Nava - 00:37:23:

This is good information I meant to mention earlier. We have podcast listeners, this is crazy, in eight other countries other than the US that are listening. So this is good for them to learn. If they're thinking about coming here or they just want to know, hey, what's it like in the US? Lastly, what kind of advice would you give for junior EM NPs? They're going to inherit this landscape. You and I are likely on our last lap and younger folks, they just have a different world of emergency medicine than what you and I grew up and what kind of advice would you give them?

John Canion - 00:37:59:

Learn. Learn, ask, always ask. It's always better to ask than not to ask. Look at all your films. I can't tell you how many things I've caught that have been missed. You know, I've caught a brain tumor that was missed on two different head CTs within six months. You know, you have the distinct advantage of actually examining and just talking to the patient. To be able to see what's going on with the patient. So when you get a report back and it doesn't make sense, ask, look at the report, call the radiologist. It might be a benign finding that you see, but you'll never know if you don't ask. And you need to ask, you need to look at all your reports, everything that comes back, you're responsible for. So why would you not look at every single image that you're responsible for? It doesn't make any sense to me. So every single image I order, every single CT, every single MRI, every single ultrasound and ultrasound by far in a way is not my best ability. I'm getting better at it as it's becoming more pronounced in emergency medicine. It was like a Warshak test there for a little while, you know, where he couldn't, it looks like a butterfly. I can't really see what that is, but you know, I'm getting better at it as the time goes on, but I didn't grow up with it. So I didn't, I wasn't trained on it. So it's, this is one of my weaker spots as ultrasound. I'm getting better at it. I can do, I can do some stuff now that I couldn't do before and I'm getting better, but I'm not, I'm not great. Like I, I won't rule out a gallbladder with ultrasound. It's not something I'm good at. I won't rule out an NP, but I can, you know, I can see retinal detachments and I can do, you know, trauma, trauma evals and stuff like that, you know, and, and our thoracentesis paracentesis with ultrasound, ultrasound guided stuff is not a problem, but it just takes time and again, getting used to stuff. And if you're new to EM, read Tintinalli’s, it's the EM Bible or Rosen's if you prefer, even though Rosen’s got censored by ACEP. Oh, I go with Tintinalli’s because of that. A little bit of bias there. And I grew up on it. I was trained on it. So I've got a little bit of bias towards Tintinalli’s. I like the way it's laid out better. I like the format of the book a little better. The Rosen’s. It's a personal personal preference. If you like Rosen’s, learn Rosen’s. You need to know it front to back, cover to cover. There's a nice, I think Robert's, there's a EM procedure book, which is nice to know. The other thing is go to conferences, go to procedures, go to cadaver labs, learn this stuff, get used to doing it, get used to seeing the normals and not normals, right? The most important thing is recognizing abnormal. Not necessarily recognizing what it is, but recognizing that it's abnormal. Hey, this isn't right. I had a patient come in the other day with chronic back pain and she had pain that radiated down her sciatica and she says, when she stands up, the pain gets better. When she sits down, her entire leg goes numb. And I said, you mean down the back of your leg to your foot? She goes, no, the entire leg all the way around. It was like all the way around. I didn't make any sense. No nerve does that. Like you're like the whole thing? You're like, yeah, yeah, yeah. Whole thing all the way around. I didn't make any sense. So I CT8 her and she had a clot in her Aorta. So when she sat down, it was, you know, made a difference. So it's one of those things where you just, the patients are trying to tell you what's going on. It's your job to be able to translate what they're telling you and determine whether or not it's an emergency. And for them, the new people, remember, the goal of emergence in medicine is not final diagnosis. The goal is disposition, appropriate and efficient disposition. Worked Critical Access one time, had a hip fracture, transferred in eight minutes from arrival. So, she was same level mechanical fall. They came in short and rotated. I told Radiology, I told EMs, don't take her off the cot to shoot a picture. If it's broken, she's leaving. And sure enough, she had a hip fracture. I'm like, I'm not going to keep that here. What am I going to do with that? Is it what you're not going to do anymore work? No, it's a waste of time. Needs to get to the tertiary facility. Got them transferred in eight minutes. Once you have disposition, you're done. Dispo the patient. You know, whatever it is, as long as it's appropriate.

Omar Nava - 00:41:53:

Very like-minded. It's a little bit of a taste on standard language I would tell PA students and even for that matter junior ones and I would say listen there's many dimensions to our job. One dimension is you're a traffic cop and as soon as you click on a patient you're going to determine their disposition. They're either going home, they're getting admitted slash transferred, or they're going to the morgue. Let's discount the third one right now and hopefully not do that one. So you have two major tracks you have to decide and now you have to use your diagnostic skills, your physical exam, the history, what they're going to tell you to decide, which pathway they're going to go and along the way they get hugs and drugs and pictures but really the ultimate destiny here is a disposition and that's your job. So very similar take on your words. John, as we come here to the conclusion, I ask all of our guests, what book or movie would you recommend to our audience? It doesn't have to have anything to do with medicine at all whatsoever.

John Canion - 00:42:48:

And my life has been upside down at the moment. I've not actually been able to do a whole lot of outside reading. I read for pleasure when I fly. And I watch for pleasure. I don't do any external studying unless it's CME related anymore. When I first got out and first started working, I'd Tintinalli’s every day until I felt like I had it memorized. And then it was after that, after the first six months of practice, I look stuff up if I don't know when I get home and that's about it. I don't only spend a lot of time on, you got to recharge, man. You got to recharge and let loose and get ready to go back for another hard shift because our jobs aren't easy. So anything you can do that's not self-help, top 10 ways to do anything, any of that stuff's okay. I watched this, there's a docu-series right now on Netflix on Chimpanzees. I've been watching that one. It was called Chimp Empire. It's okay. It's interesting. It's all right. I mean, I guess the last book I read was Dune. That was probably a couple months ago and I've been flipping through it on my plane rides back and forth to work. So you gotta recharge. So spend your time off work recharging. Don't spend your time going over cases. That's another thing for the new people. Drop your work at the door. When you walk out, you're done for the day. You don't pick that stuff up. Don't worry about it. Don't stress about it. Know that you did the best you could while you had the patient there and know that there's nothing else you could have done. And you did everything you possibly could for the patient is your best. Then you did, you did the right thing. And sometimes you're going to miss. You're not going to hit everything. You got to get about a thousand. Nobody does. It's impossible to even think that, but do the best you can and ask questions if you don't know and make sure you document your help. Remember, this is a specialty of medicine. It's not all of medicine. There's a reason there's specialists. Punt when you need to don't hesitate. We got help for all kinds of reasons. Punt ask. All it's going to do is help you. All it's going to do is help the patient every once in a while. You get some pretty good education from the specialist too. When you call him. They'll be alright, so don't worry about it, it's fine. Or, hey, this is a pretty interesting deal. You know, I mean, you get some, get some interesting educational points out of it, which is really helpful for your future practice. Cause you know, in two months you'll see that case again, and then you'll know what to do.

Omar Nava - 00:45:09:

Yep, that's for sure. You have extensive history interviewed, higher chain, develop people. If somebody would like to get a hold of you, how could they get a hold of you?

John Canion - 00:45:25:

Facebook is a good place, just John Canion. I’m in on all the Facebook groups, the ER groups. DM me, PM me, whatever you call it, it's fine. I do videos on YouTube occasionally, JC the NP. You can email me, jcthenp@yahoo.com. I'm very, very happy to help anytime. I'm happy to mentor people. I'm happy to give advice. I'm happy to listen to you, bitch, if you just want to complain to somebody who's outside your group, and you need somebody to listen to you. I'm happy to talk to anybody anytime. I think as a profession, we have to share our experiences and share our ups and downs. And sometimes you just need somebody who you don't know, who is outside your group, who you know won't say anything to anybody in your group because they live in a different state or a different time zone or whatever, and you just need to vent a little bit. And then you need another perspective on stuff. I'm happy to give those. I'm a nice guy, except on Tuesdays, you know, gotta have a day, right?

Omar Nava - 00:46:17:

I understand, man, I understand. Lastly, who would you recommend we interview next, John?

John Canion - 00:46:24:

Well, that's a really good question. I mean, to me, what's interesting is I would look for some of the residency developers, like these residency developers, and I would ask them, why? Why are you developing these residencies? And I think you're going to come back to the similar stuff that we talked about today, but I think it's very interesting. I think what would be an interesting thing, Omar, is interviewing a new grad, like their first month, and then probably six months later and see, see what they've gone through. It'd be an interesting one too, you know? I mean, it'd be an interesting one to do. I mean, that would be fun. But from a personal standpoint, man, there's just an absolute plethora of people you could use. I mean, there's a lot of people in, and Schumacher I've been with them for a long time, a lot of people in Team Health, a lot of people in InVision. I would talk to all the regional directors and just get them to talk to you and tell you about what's going on in their lives and how, how their lives are changing with MIPS criteria and how they're approaching the new hiring. Because in one of our groups, we fired 80% of the new grads because they just couldn't keep up. And that was prior to the introducing the training stuff. And then we started introducing the training stuff and I don't know what it is after that. I'm assuming they've studied it, but I don't have that personal information, but I'm assuming it's gotten better because they're continuing to do that, continuing to develop education, which is super helpful. I mean, you gotta get these people where they can work and not miss the bad stuff, you know?

Omar Nava - 00:47:52:

Yeah, totally understand. John, I want to thank you very much for joining us today. I think that you gave us a unique perspective, not just on your experience, number of years of experience, but what you've seen in your practice and how you see the landscape of emergency medicine. So thank you very much for joining us, John.

John Canion - 00:48:11:

Anytime man, anytime you want to talk again, just hit me up. You know how you're holding me?

Omar Nava - 00:48:15:

Yep, sounds good. Folks, we've been listening to John Canion, Emergency Medicine, NP extraordinaire. I would like to thank our podcast producers, the great team at Earfluence. And finally, a big thanks to you, the clinician. For over 20 years, I worked with you, I learned from you, I've been inspired by you. I know the sacrifices that you and your families have made. I know that challenges that you face, and more importantly, I know your value to the market. Thank you all for listening to the Emergency NP and PA Workforce Podcast. I am Omar Nava. We'll catch you at the next episode and don't forget to subscribe now to this podcast on your favorite podcast app.