Debates of the Orthopedic PA

Every week as orthopedic PAs, we're faced with decisions that don't have a perfect answer. Some are serious, some are fun, all are things we've encountered.

From ethical dilemmas and clinic management challenges to difficult patient interactions, career decisions, orthopedic hot takes, and some of our biggest pet peeves, nothing is off the table.

There isn't always one "correct" answer—but there is always something to learn from hearing both sides.

If you've ever had something crazy happen and thought What would Beth/Hannah Do? Hopefully this answers it!

Transcript

SPEAKER_02 0:00

Welcome to Joint Effort PAs, where two orthopedic surgery PAs get real about life in medicine. From tips and tricks to professional growth, work-life balance, and everything in between. We're here to share what we've learned and what we're still figuring out. Let's get into it. Okay. We're just gonna dive in. We're gonna dive in. I don't know. That sounds dumb. All right. So more of like a how would you handle certain scenarios? Yeah, what would Hannah do? Yeah, exactly. What would Hannah do? What would Beth do? There you go. In various scenarios. So, um, well, I mean, we can go over how our weeks were, but Yeah.

SPEAKER_00 0:44

Um, yeah, okay, I guess quick, I guess do a little quick coming off of like the holiday week last week, clinic was full Monday, um, decent cases on Tuesday, um, clinic Wednesday, Thursday, and then we had a uh return to full day OR day on Friday. So um the doc I work with, he had taken off the Friday before last Friday. So I'm giving him a little bit of a hard time that he's like immune to operating on Fridays. Yeah, and that's okay. That's directly affecting me. Yeah, yeah. Um, but you know, it it is what it is, but it felt good to get back uh in the OR on Friday. Um again, I this is like a repeat of last week. I had a lot of tough conversations this week. Um I'm looking for a medical assistant. My medical assistant's last day was yesterday. So we had a you know, going away, slash the other medical assistant's birthday, slash slash you're a little bitter about it, slash a little bitter about it, slash another one person on my team's leaving. So I'm like, don't think you're getting a party when you leave. Um it's the opposite.

SPEAKER_02 1:44

Throwing a party when you leave.

SPEAKER_00 1:46

Yeah, but I I felt like a master scheduler this week. I have like Game of Thrones. I have like a Game of Thrones thing going on. Like I have like you were sitting here. Well, this project, I'm making allies with this, and then this project, I'm you know, making some chess moves over here. Anyway, we had an urgent care um sports physical kickoff meeting. So it's very important for me as I kind of hand the torch over to our injury express director. So that was kind of a last hurrah there. Yeah. Um, so yeah, it was it was a busy week, I guess.

SPEAKER_02 2:21

Emotionally exhausting. It wasn't weird.

SPEAKER_00 2:24

Yeah, but um no, it was it was uh for a summer week, which sometimes the summer weeks are dead. It was it was a good week. What about you?

SPEAKER_02 2:31

Yeah, it was good. I mean, not uh not nearly as uh chess gamey as yours was. They felt very gamey, um, but had a lot of good cases. We did a I think two of the thumb replacements this week. Oh, you know how I feel about those? I love them. Yes. Um, so we had a couple of those and I saw a couple post-ops for it that we're doing fantastic and made me super happy. And yeah, overall, that was enough to make it a good day for me. So definitely I was looking forward just to that day. And after Thursday passed and was over with, I was like, I'm done. Friday came and I was like, I can't like I'm already now. I want to go back in time to when things were good yesterday. I know what was happening.

SPEAKER_00 3:16

I know, I know Friday, Friday was so busy. I leave a lot of things to do on Friday because I think I'll have more time than I do. I had no time yesterday to do any of the things that I left myself to do, which is slightly concerning when it comes to like notes.

SPEAKER_02 3:29

You're about to be off an entire week.

SPEAKER_00 3:30

Yes, yeah. Um, but as you know, like at least at our um company, all of our APPs get um quarterly bonuses. Oh yes. Oh my god, I do know because I know you know. So I it's a formula now. So payrolls on the 10th, yeah. On the 7th, all your notes needed to be closed on the 7th. I sent an email this year saying, hey, you guys, or this year, this quarter, right? This needs to be done. The one thing you were missing was a click like in a box. A box click. The the thing was done, and no one could say that to you.

SPEAKER_02 4:05

Yeah, you know what I mean? That's the annoying part because I'm like why.

SPEAKER_00 4:08

It's a withhold the bonus until you're gonna be able to do it.

SPEAKER_02 4:10

I clicked a box that said it was reviewed, even when the stuff was put in.

SPEAKER_00 4:14

So okay, so this is how we handled it. I went in and I was like, there's no way, because I looked, you had no missing slips. I went in and saw, and I clicked the box, and I responded to the email of like this required a box click, like intentionally, not to say you couldn't do it, but just to say this like why was this the withholding thing? And for you to stop in clinic to click a box really irritates me. It was like it was super annoying. But anyway, I was very happy for all my APPs that everybody except one who always has his open got them done. So that was that was kind of cool.

SPEAKER_02 4:45

And I yeah, I appreciated the update email because I let those things slide by. I remember like last quarter, it was like two hours before I got it done. And I lay down to take a nap and I got this email. It like heard the ding, and I read it, and I was like, oh, disheveled and got up and started.

SPEAKER_00 5:02

So I I had a provider who let that same thing happened to him last time. He was like, I'm traveling, I'm out of town. What is this email? I have two hours, I can't get to my computer. I was like, I'll just do it for you. I've just sent the email to let you know. So I sent the email three days earlier and he wrote me. He goes, Hey, I got your email. I checked everything. Like now I'm super paranoid. I don't see anything undone. And I was and and I wrote him, I said, You've done all your stuff. And he goes, Well, then why the emails? Like, because to remind you. To make you paranoid. I was like, this did exactly what I needed to do.

SPEAKER_02 5:28

That was the goal of it. Yeah. Yeah. Which I, yeah, that's a story for another time. But I that's it's so silly. I mean, I get the concept of it, like, yeah, you can't have outstanding notes forever. But like, say you work in urgent care and you saw like 40 people the day before, and then it's the cutoff day the next day, and you're like up all night doing whatever. I know, yeah, yeah. Or your bonuses withheld. Yeah. Whatever. Things happen. That is what it is. That's right. All right. We will get into the great debate.

SPEAKER_00 5:57

Our great debate. So WWHD, what would Hannah do? All right.

SPEAKER_02 6:02

What we can do for number one, let's talk about um ambush visits slash curbside consults. We'll also we'll call them curbside consults. Now, these can come from um a patient that has a family member in the room. They can come from co-workers, co-worker ones or just like, you know, family friends or something when you're out and about. So if I am in a room, so our scenario one is, you know, you're seeing maybe the wife is a patient, the husband interjects and is like, hey, you know, while I have you here, can I ask you a question? And in my mind, I'm like partially assuming it's gonna be a question about his wife, but in the back of my mind, I know I'm like, this is a personal question about you. You have taken over the visit. Um and they want you to look at their body part, whatever. Um, it depends. I try to be a very accommodating provider because I want to keep the business drumming up. I want them to be happy. I want them to come back and keep seeing us. I want us to be the family providers, like, oh, your kid broke their wrist and we saw him for that, and we're gonna replace your thumb and grandma's, you know, whatever. So if I have time, I will 100% say, hey, let's get you at it on the schedule and do it.

SPEAKER_00 7:25

This is this is a tough one for me. I also will most of the time say yes, but I will complain about it. I will complain about it. It really irks me, and I know I have the power to say no, and you know, I should feel the ability to to um create boundaries, but like I I blame other people, and I'll tell you why. So I had this one patient and it was a husband-wife team. The husband, it was his visit. The wife had a $3,000 balance. She has been trying to get in for me to see her for her shoulder. And I said, Hey, I know this lady, she's sneaky AF. When she checks, when husband checks in, she's going to try to sneak in. Please do not let her come back. Now I know that that puts like stress on the front desk, saying, like, Oh, you can't come back, you can't come back, right? You know, um, or my medical assistant, something like that. So here's here's what happens. Go in the room. Now it's a closed door situation. And then she immediately hijacks his visit and says, Hey, listen, I don't know what the issue is. You're billing people, keep calling me. Um, I just want to be seen from my shoulder. You know how much it's been bugging me. So now I'm forced to I'm forced to decline. It's not like, you know, our company's policy. It's I have chosen when she is pleading with me that I can't, uh my hands are tied, even though I'm about to do something for her husband. Yeah. So did I see her? Yes. Did I write a scathing email? Yeah. Like, why make her husband an appointment? I'm sorry. Yeah. Also, he had a balance, which he paid his off. Can he not just pay her? And did nobody ask that question?

SPEAKER_02 9:08

Yeah, like I know a lot of questions. And it makes you wonder like, is anybody even trying to do anything else about this? Or are they leaving it all? It makes you feel like you're on a lonely island.

SPEAKER_00 9:19

So, ambush visit, I did that. The second one is like, as you said, you see the wife and the husband's like, Hey, can I ask you a quick question about my shoulder? Next thing you know, you're examining the shoulder. Next thing you know, you're giving him advice. You know, I will do that, and then retrospectively, when they leave, put them on the schedule and document the whole thing. Um, the other thing that bothers me is the workers' comp only approved for their right shoulder. They come back, they want to talk about their left knee. And I'm like, listen, can't can't not approved. And then they will say, No problem, I'll just use my personal insurance. Which now is a second visit because now it's a different encounter. She have to document that under a different encounter, and now that turned into a whole thing. So I'm not gonna say no to that, you know. I should because they know the rules for the workers' comp stuff. Third scenario, and actually fourth scenario. Out socially, see my friend. It's like, hey, so my shoulder's been bothering. Next you know, I'm in the pool examining my friend's shoulder. In the pool? Yes, it's like on July 4th. Hanging up with my friend. Just like I'm just gonna take a look at my shoulder. And I was like, Do you want me to like talk to you about your shoulder or like dive in and look at your shoulder? Like you're now you're forcing me. Physically dive in your pool. Well, now you're forcing me to casually talk about a hypothetical shoulder where you're standing in front of me and you're kind of begging me to examine you, or do I take off my fourth of July hat, put on my PA hat when I didn't want to and look at your shoulder? Like, I will do that. But you know, at the back of my mind, it irks me like a little bit.

SPEAKER_02 10:53

Yeah, because those are different hats. I mean, if I am talking to somebody in a casual scenario and they're like, oh, what should I do about my shoulder? Like Fourth of July Hannah wants to be like, don't fucking use your shoulder if it hurts. Don't do that.

SPEAKER_00 11:04

You know, like no Fourth of July Hannah doesn't get to be. Why do we need shoulders? You can't though. Um, and then the last scenario is the coworker.

SPEAKER_02 11:13

Those are because I I love all my coworkers. I do too. I want, I obviously like I love that people want to ask for help with things because that means that they trust me to do those things. Um, but I think you just have to be good at reading the room of like when is the appropriate time to do that. Uh, because I'm sure you've been in this scenario where maybe you push put yourself in that situation where you've said yes and before you know it, it's a snowball effect and it's way out of control. And you're like, how did I get here?

SPEAKER_00 11:44

Yeah. So it's like, hey, like I was at a concert and I tweaked my knee. Do you mind looking at it? Sure, no problem. Versus, hey, can you order an MRI scan? Now I'm like, ooh, now I gotta document the visit. Are you gonna use your insurance? Do you think that I'm doing this for free? Now I have to have the conversation. I would much rather you go to the front desk and like do it formally an appointment.

SPEAKER_02 12:04

Yeah, yeah.

SPEAKER_00 12:05

Like I would much rather that because then it clearly defines what it is. Yeah, versus like, you know, someone who dropped a weight on their foot, like, hey, does this look broken? I'm like, uh yes. And then that that's all that they want to know. Yeah. Should I get an x-ray? And then yeah, and then they go handle it. Yeah. But when they ask your advice and then you give it a little bit, and now you're stuck in, oh, we're in a visit that I didn't realize. So I I say yes to all the things.

SPEAKER_02 12:27

Yeah, I I never say no. And then I, like you said, I just complain about it later. Yeah. And I mean, is that that's a form of insanity, right? I'm just complaining about my own doings.

SPEAKER_00 12:38

But here's the thing if I were educating you as a brand new provider, I would tell you to not practice medicine without documenting it, Hannah. Yeah. Well, but guess what? Yeah, I do that. I'm a hypocrite. Yeah. And you would probably get like all fives for patient service, and I'd be like rewarding you for that. Yeah. Because of the things that you do. That I basically told you not to do that.

SPEAKER_02 12:59

Yeah, they're so happy that you're not going for the book.

SPEAKER_00 13:02

Um that's annoying. Now, whatever. To bring in the next topic. Now, this unfortunately, this unfortunately turns my stomach. Accepting gifts. It's not illegal. It's not illegal. Patients bring gifts. And you do, it's sweet most of the time. Over the years, I've had blankets, homemade scarves, right? Scarves. Cookies, um, uh, a bottle of wine. Like it's usually when I think it's nice, it's after the service is provided. Yeah. And it's a thank you, token of my appreciation. What I don't like is in the middle of treating the patient, they're gifting you because you know they're doing that to get something on the back end.

SPEAKER_02 13:49

Or they're gonna be like I now feel indebted to them in a way. Like, oh, they were nice. Okay. So now I have to be extra above and beyond.

SPEAKER_00 13:58

Okay, so the run-of-the-mill stuff, right? The cookies and the whatever, whatever. What are some weird ones that you've gotten? Some gifts?

SPEAKER_02 14:05

Weird ones? Well, I have a weird one. The weirdest one I've ever gotten is sitting next to me right now. And I don't know how to describe it.

SPEAKER_00 14:14

It is a Hannah, that looks like a gag. It's a gag. It's a gag. Okay. So to help our listeners and see how descriptive you can be, let's talk about what we're looking at.

SPEAKER_02 14:27

Yeah, it is some sort of rubber gag tool. That's what it looks like. Exercise your jaw.

SPEAKER_00 14:34

No, it it is. The the gift is legit. It's a it is an exercise piece of equipment.

SPEAKER_02 14:40

It is an exercise equipment. That was how it was described to me, and it is truly that. Um the the picture on the box is very interesting.

SPEAKER_00 14:49

It makes you sick.

SPEAKER_02 14:50

Yeah. So that is probably the weirdest gift that I've ever gotten. Um, do I still accept it? Yes, I'm so awkward. You know, I'm I'm not sure.

SPEAKER_00 14:57

But to be clear, this is from a patient who is, I guess, promoting their family's business or something like that. So it is an a piece of exercise equipment. You put this rubber ball in your mouth and it's meant to tone your neck and your face. It is going to tighten all those facial muscles and strengthen. So someone gave that to Hannah because they think your jawline needs improvement. But when they give it to you, your gowls, when they give that to you, and that is like literally the craziest thing I've ever seen. Yeah. When they give it to you, you're just like, Oh, thanks. Like, I can't wait to use this.

SPEAKER_02 15:37

Yeah, yeah. They wanted me to take a picture using it, and I'm I can't do that. I feel like that's crossing some sort of boundary that I'm not ready to cross yet. Yeah. Because I might get fired.

SPEAKER_00 15:48

But um, I have gotten a tremendous amount of religious gifts. Yes. I got a lots of crosses. I got a glass angel one time that the patient told me they got a goodwill.

unknown 16:01

Okay.

SPEAKER_00 16:02

I was like, okay. Yeah. So I placed it on the counter where we do, you know, we work, and everyone's like, Why did you bring a glass angel to work? I'm like, no, this is a angel. This is our guardian angel. I've gotten a Christmas wreath before. Okay. Um, bottle of wine, cards, gift cards, like a thank you or something like that. And I think that's all at the end of the patient service. I think it's a very nice thing to do. Um, I had one patient one time booked a massage for me. Prepaid. Booked it. Yeah.

SPEAKER_02 16:34

However, a little odd, but like, no, no.

SPEAKER_00 16:37

So, but here's the thing it it should you you should have that reaction because that patient continues to ask me inappropriately to sneak around the schedule and to see her. But now we have this. I'm indebted to her.

SPEAKER_02 16:52

Yeah, because she got you one massage.

SPEAKER_00 16:54

But I didn't ask for it. Right. Yeah, no, that's it. If I canceled it, it would have been weird. Yeah. Like she pre-booked it. Yeah. So she would know if I canceled it. So now I'm indebted to her, but I think she did it's it's totally contrived. Like she did it to get that.

SPEAKER_02 17:10

And I like Would you ever do that? I wouldn't because I have a weird thing about like being indebted to people because I don't want to feel like I owe them something. And I don't want them to feel like they owe me something either. Now, granted, I will do whatever for people because like I if I want to, but I don't want to feel like there is something, some reason that is driving it.

SPEAKER_00 17:32

Do you feel a different way about like food, like homemade things? Do you would you eat a homemade thing that someone made you? It depends right.

SPEAKER_02 17:38

It much depends. I mean, usually not because like I It's like a break room thing. Yeah, I remember we had a patient once, she's super sweet, but I just don't know that I would eat something homemade from your house.

unknown 17:50

Yeah.

SPEAKER_02 17:50

And made us like all these really nice homemade pies.

SPEAKER_00 17:53

But that's that's so much of like an old school gesture. Like I spent the time to make you some that's so my doc will eat them though. He will, no problem.

SPEAKER_02 18:01

Yeah, zero, zero concern.

SPEAKER_00 18:03

Yeah, I've gotten like a cake, cookies. Um, I got last week a dairy-free, gluten-free rice crispy bar.

SPEAKER_02 18:11

Oh, that's nice. It would take it. Did they homemake it?

SPEAKER_00 18:13

I had to try it.

SPEAKER_02 18:14

Yeah. Yeah. Homemade.

SPEAKER_00 18:15

Homemade, yes.

SPEAKER_02 18:17

Um, I got some tequila. That was a big thing. That's a great gift.

SPEAKER_00 18:21

That's a great gift. Um, that's I but I think like that's that's a token of thanks. Like, I don't know. I feel like that's if patients want to do that, that's fine. Do I expect it? Absolutely not. Does it warm my heart a little bit when they make me homemade stuff, like a knitted something? Yeah. That's really nice. It's nice, but they thought enough to do that.

SPEAKER_02 18:41

And enough patients come back unhappy for some reason, or like you get enough not pleased people throughout the day and throughout the week that if somebody thinks enough of you to even like I don't know, I've had people like old ladies get like hard candies out of their purse and hand it to me, and that is like it makes me day a little bit. It does, it does.

SPEAKER_00 19:00

A handwritten note, that's so nice. I love those. Yeah, that's just like a really nice gesture, but it's so funny because again, it brings up that the like is accepting every gift inappropriate this one might have been. This is borderline is refusing it rude. I mean, in my mind, yeah. Okay, and is there a dollar amount that is like okay? Speaking of which, I had a patient one time. So uncomfortable. Take a $100 bill and put it in my front scrub pocket. Yeah. Almost like down your shirt. Like inappropriate. And I immediately was like, no, thanks. This is not why I do it. They had to go into my personal space to do that. And when the hand was reaching, I like, I like froze. I was just kind of like, I turned it because you don't want to make it uncomfortable. But I turned and then like my foot hit the stool and then I lurched forward. Like, you know, it was one of those things where I was like, oh, my hand is like so anyway. So I like, you know, he refused to take it back, and I was like, This is so inappropriate. Um, yeah. So I took it home and I tipped my cleaning lady.

SPEAKER_02 20:13

That's nice. Yeah, that's like I had to get really good.

SPEAKER_00 20:15

It was dirty money. I had to make it clean.

SPEAKER_01 20:18

Something else is that's like take yourself out to dinner with that money. Ugh.

SPEAKER_00 20:22

You cannot, yeah. Um, gifts are gifts are rich.

SPEAKER_01 20:26

So so you would accept I will accept even the gagball. The gagball is.

SPEAKER_00 20:31

I cannot believe we're staring at that right now.

unknown 20:33

Yeah.

SPEAKER_00 20:34

And the worst part was, and I don't even want to say this because I'm gonna have to re-listen to this. The patient wants you to take a picture of you using it.

SPEAKER_01 20:42

Yeah, and be on the internet.

SPEAKER_02 20:44

So inappropriate. So I can't do that because now I'm saying it here and and people will go looking for it. Oh, yeah. Now my identity is blown.

SPEAKER_00 20:56

Dude, if that picture of you is what it makes the internet, like that's what takes off your career.

SPEAKER_01 21:01

I mean, like, I don't know. Could that be could this actually be beneficial to us? What if that's your one for the TV?

SPEAKER_00 21:06

That's your golden ticket right there.

unknown 21:08

It's terrible.

SPEAKER_02 21:09

Wow, watch joint efforts explode after this.

SPEAKER_00 21:12

That's right. God. Um Facebook friend request. And I might be dating myself. Like, does anybody use Facebook? I don't know.

SPEAKER_02 21:20

I mean, I still have it and I log on.

SPEAKER_00 21:22

What do you think follow?

SPEAKER_02 21:24

I don't think I've ever had a patient follow me on Instagram.

SPEAKER_00 21:27

I have. Really? I have yeah, I have those like requests that are just sitting there and they've been sitting there for like two years. And the gamut runs everything from the teenager, which is inappropriate, to the 86-year-old person. I had an 86 year old Facebook request me. I know.

SPEAKER_02 21:43

I don't know. I mean, I feel like if it is somebody that I knew kind of like through other routes, not just as a patient, yeah, then yes.

SPEAKER_00 21:53

Yeah.

SPEAKER_02 21:54

After I'm maybe done treating them. Yeah. But yeah, I don't know. That's a weird one. I also don't really know. Facebook that much anymore.

SPEAKER_00 22:01

So But I think like they I think it's their desire to kind of want to know you socially, but also it's hard because I mean I want to draw that line.

SPEAKER_02 22:12

Yeah, I mean I feel like this is the difference between like small town versus big town. I think of like the big city provider, right? That has the strict boundaries and and people would never try that with them. And we're somewhere in between where like we also exist in a small town community, private practice, like we try to make ourselves very friendly with the patients, and like I try to make myself seem interested in their lives and in their day. It's not fake, but like that doesn't mean that does it come across like oh, we could be Facebook friends. Am I being fake to them now? Is it almost like when you think somebody's like they're so nice that you assume they're flirting with you and they never were? Yeah, it's the same thing. Yeah. It's the same thing. Yeah.

unknown 22:57

Yeah.

SPEAKER_00 22:57

But you don't know their motivation. Like, why are they trying to be friends with you? Because they want to see socially what you do. They want to just they just want to be nice. They want to expand their network. I don't know. I don't know. It's weird.

SPEAKER_02 23:10

Yeah. Um that's that's mostly a decline. Yeah. Well, that is not decline. Ignore. Mine is ignore. I don't decline it.

SPEAKER_00 23:15

I will say they refused your whatever. I will just let it sit there in the in the like, oh, I never saw it. Yeah. Never saw it. I don't know how to work Facebook. I don't know how to work Facebook Facebook. I never won there. Yeah.

SPEAKER_02 23:26

Um, number four. Um the what do we call this? Your your hand on the door question situation. Like I've slowly stood up from the stool and then there's another question, and then I put my hand on the door, and we've already kind of like made the goodbye exchange, and they're like, oh wait.

SPEAKER_00 23:46

Yes. You know? Now, oh wait is sometimes I forgot to ask a question, can I drive? And that's fine. I can answer that with my hand on the door. Do you sit back down? It depends how many follow-up questions there are. When I sit back down, it means, well, one, it means I'm annoyed to the point where now I'm going to engage in a conversation with you. Like if they want advice as I'm, I've wrapped up the visit, right? Okay. So we'll see you back in a month. Do you have any other questions? No. And I get up, hands on the door. Oh, wait, but can I drive? Sure. Yeah. I'll go, you know, I will go get your slot, whatever, I'll be back. Then it's wait, do you think this is related to my um car accident 30 years ago with my neck pain because I have numbness and tingling in my leg? And then I will sit down and be like, listen, like this is not, yeah. I'm not, I wasn't ready to I this just happened this week. I had it happen this week. Again, one of these patients who's been a patient for 10 years, I will not give my phone number out, which again, I guess we can talk about that too. Email, work email. She emails me. It's like she has a radar. She knows when I'm full, when I'm going out of town. She says, Hey, can you see this is specifically? Can you fit me in for my elbow before the end of the week? And PS, this is Wednesday. Before the end of the week, there's one day of clinic. So I was like, fine. And I, you know, I didn't write back any like whatever. I just wrote back 9:30 or 1 on Thursday. It wasn't like, hey, thanks for no. I was just like 9:30 or 1. She said, 9 30, I say then. So I go in the room and it's her left elbow, which we saw for maybe like a year ago, something like that. She's got some media kindolitis. So she says, okay, so my elbow, blah, blah. Now let's talk about my shoulder. And I did the whole, she goes, Well, what do you think I should do? And I was like, I was not prepared to talk about your shoulder today, which I feel because a very easy way of saying you asked me for a fit in. You specifically said for your elbow, and now you're turning it into something else. And I just go, I wasn't prepared to talk about your shoulder, so I really can't answer that question. Yeah. Which means if she wants me to, I have to go get my computer, look up when we saw her shoulder, what it was. I mean, so she was like, Oh, did I not tell you this was a twofer?

SPEAKER_02 25:53

Oh how you have to say it like that, did I not tell you this was a twofer? Oh my gosh.

SPEAKER_00 25:57

But here, now the choice is I get up and say, You didn't. This was a one fur, and this was a you know, actually one furs are the only things that really should exist. Yeah, I know, but like you do realize this was a if you wanted to do this the right way, you'd have called the front desk. But this one I did because I thought it was like immediate and I was trying to be nice, and now you're you're abusing my time. So I ended up, you know, I ended up saying to her, like, again, and I I haven't been that blunt. Like recently, I was like, I wasn't prepared to talk about your shoulder. And I just looked at her. And she was like, she was like, okay, well, can we? And I was like, what do you want to talk about? Literally, you know, he's like, how again, am I sitting? I'm sitting at this point. I was like, how much how without saying this, how much time is this gonna take? Like, you know what I mean? How in depth are we getting? How in depth are we gonna? And it was it was a whole surgical conversation. Yeah, but that that is like the just one more question patient. They know what they're doing. The no good deed goes unpunished. No good deed goes unpunished, yeah. So when I hand on the door, okay, do you have any questions? No, and then they have a question, then they have a follow-up question. When I sit down, I feel like it's reasserting dominance of like this is what we're gonna do, this is what we're not gonna do. Yeah, you know, whereas if I'm standing, I'm art, I'm done, like we're done. If I have no intention of sitting down and my lean is toward the door, like we're not going into this. Sometimes I'll even start opening the door. But don't you think, but don't you think, okay, but here's the other thing Doors open, and on the doors open, they continue to ask, now I have to shut the door. Yeah. So that implies that, like, oh, we're gonna continue.

SPEAKER_02 27:27

Yeah. It's like a power move. It is a power move, but it also then sometimes I feel like, oh, did I like am I making myself look bad because like did I look like I was too ready to get out, and now I'm like having to sit myself back down? No. It's on them.

SPEAKER_00 27:40

What do you say to the patient though, like that's a great question? I want you to schedule a visit to discuss that, or I don't have the would you would you say, because it admits defeat, I don't have the time to discuss that today?

SPEAKER_02 27:52

I have never said it like that. I have said, Hey, like, if you have extra time today, we will separately talk about that. Like, let me go review stuff or like we'll get x-rays of this other body part that you're now mentioning. Um, but I have some other people I have to see. So, like, if you don't mind waiting forever, then I can come back and talk about it. And then they're like, Yeah, no, sure, no problem. And then forever, which is 20 minutes goes by, and they're like out of the room. They're like, Are you did you forget about it? I need to be somewhere at 11. Did you forget me?

SPEAKER_00 28:29

And I'm like, no, we had this conversation. Well, or they say, or they put parameters on you. I need to be somewhere at 11. I'm like, wait, but you asked me you asked to extend this visit. All right, so those are the like, those are the non-clinical scenarios. I don't know. Those are the awkward things we live every day. But I think we're on the same page with the level. We're on the same page. Um, let's talk about like ways we treat stuff. And again, without getting into like that's right, that's wrong. Yeah.

SPEAKER_02 28:56

Just the thing. Yeah, the quick overview of it. All right. Neo A. Or any OA. Any OA, anyway. Comes in with shoulder, knee, hip CMC. I mean, I don't do a lot of hip, but well, yeah, let's talk about, you know, shoulder knee specifically. Um, no treatment in the past, you get an x-ray, it is moderate.

SPEAKER_00 29:16

Yeah. It's it's like a slam dunk. This is arthritis. Yeah. This is not like it might be, or there's a little arthritis, and let me then examine you. It's arthritis. It's like CMC is obliterated. Yeah. Okay.

SPEAKER_02 29:26

And that's the only place they're having pain.

SPEAKER_00 29:28

Only place they're having pain. So will you algorithmically take your patients through what the boards will say to do? Like anti-inflammatories, bracing.

SPEAKER_02 29:39

I do talk about all of those things. I I, for any OA, this includes knee, shoulder, whatever. Yeah. This is the most conservative we could be, topicals, you know, therapy, blah, blah, blah. Or we can do injections, which is the most aggressive we're going to get today at least. Injections will carry you through X amount of time. We can't predict that all the way up to surgery eventually. Now, at my first visit meeting them, I only very, very briefly discussed surgery because I've had patients tell me in the past that they were told by previous providers that nothing could be done for their arthritis. Correct. And I'm like, that is not true. Something can be done down the road, but we're not gonna, we're not really gonna entertain that yet. We're gonna start somewhere on the spectrum here. Um, so pretty much always injections at their first visit with me. I would say maybe like 20% of the time somebody's not quite ready even for an injection yet. Most of the time, though, if they have taken the time to schedule a visit, they have tried some things on their own and they want injections.

SPEAKER_00 30:40

So what about the patient, though, that comes in and they know to some extent they have arthritis and they want um a replacement. They want a CMC replacement, they want a shoulder replacement. Will you go right to that? Or do you have the courting phase where you have to get to know the patient to see it depends.

SPEAKER_02 30:59

You can get a vibe on somebody if they're if they're a little off or not by the first visit. And if I have, if they have tried a reasonable amount of things or there's a reason they can't have an injection or don't want injections, sure.

SPEAKER_00 31:11

But do you think patients though who come in, and I'll see this, it's mainly for um I mean, I don't do a lot of joint replacement, but in the past it would be someone who come in and say, Listen, I just want my knee replaced. And I would argue, like, if you look at the picture, like, well, they're like, maybe they're 50, they still work full time. Arthritis is not terrible.

SPEAKER_02 31:31

Yeah, you're like, you're not gonna be as happy as you think you are after.

SPEAKER_00 31:34

Yeah, but the visit is specifically for consultation for surgery. So it's not that I try to talk them out of it, but like it's such a double-edged sword because that's why we're here. I want people to come in for surgical consults, but I want to do what's right for the patient. But if that's what they want, they don't want anything else. I feel like I'm just kind of like giving in to their will. Yeah, like it's Burger King.

SPEAKER_02 31:53

I know you ordered the knee replacement surgery today. Like, let me deliver it. But I cannot.

SPEAKER_00 31:58

And again, it is not true for physicians I've worked in the past. I cannot just say, no problem, we provide that service. We can do that. I will launch into without trying to sway them, yeah. Like the things I think that they should try first. I really think that they should.

SPEAKER_02 32:11

Yeah, no, and I mean, if somebody has never tried anything and there's not a reason that they shouldn't try an injection first, I always make them do at least one injection. Yeah. Because I'm like, hey, I need some sort of definitive data that this is definitely your problem and you're gonna get better with it. So I need to inject your CMC joint. Yeah. And if you tell me that it felt 100% better for three months, yeah, fantastic. In three months, we can replace it if you really don't want to repeat injections. And then sometimes they come back and they're like, hey, the injection wasn't that bad. And like, I felt great. Let's just do that. And so now I have convinced them that there is a another silver lining option. Yeah.

SPEAKER_00 32:47

And I first temporarised them. The first time visits, if they come locked and loaded with like I, you know, let's say me, I had minus cyste abreamant, you know, three years ago. I went back and I had a repair. I've done Visco at another practice, they just did an injection recently. Like, I want to talk about how we definitively fix this. Perfect. Love that. They literally have walked that timeline for me, right? And that's a great visit. But the patient who's had no treatment and either slam duck meets your uh criteria or doesn't, I still like to feel them out a little bit just to see like what they're yeah, are they compliant? Yeah, you know, like um, I don't know, for their lifestyle, is that gonna work out or not? I just feel like you can't get in a 15-minute visit without having all the details. Yeah, I don't like signing people up for surgery on that visit. Unless they come like teed up. Yeah. I fell, yeah, I tore my rotator cuff, here's my MRI scan by my primer. I can't sleep, I've had therapy. I'm like, all right, good, well, uh, let's fix it.

SPEAKER_02 33:43

I mean, like it it's so highly dependent, but I agree. If it is a never tried anything before, they don't, you know, unless they come in with like their shoulders completely obliterated, and uh I still will offer them the injection, but I know most of the time I want them to try something else at least once before.

SPEAKER_00 34:03

So agree. Um this one I'm gonna change this topic a little bit. Okay. PT. If someone wants to go to your PT specialist, the one that you want them to see, you're gonna do a reverse shoulder. You want them to see a PT that you know has done a good job, but they want to go to this one. Or my sister's a PT. Like, how do you do you do you comply and let them do what they're comfortable with? Or do you for a period of time?

SPEAKER_02 34:32

I say we can try it. I do too. We can try it, and when it starts going downhill, we're gonna switch it up.

SPEAKER_00 34:37

We have a PT place that's in a very, very rural location relative to us that has this weird subset of patients, and they love this PT. For run-in-the-mill stuff, fine. Post-surgical stuff, historically for 10 years, not good. And I will say, and again, say it without saying it, right? Um, this is convenient for me. It's like a half mile down the way, I can walk there. Okay, you can start there, but post-operative shoulder, let's say, is a totally different beast. Um, I do have specialists that we have trained to do things the way we like to do them. You can start at this therapist if things are going, you know, not accordingly, then I I might move you. And then it kind of like plants to seed. We have another therapist in the area that has this huge like religious following, like the church group always goes there. They're terrible for certain things. Just I've never gotten a good outcome. And now, what am I? So I'm gonna now say that I don't want them to go there because of they are your church friend and you do stuff with them, but they suck at PT. Like, yeah, it's just a very hard conversation to have. So, like, sometimes put them down, I will comply and let them do that and and roll the dice. And I hate doing that. Um, injections. Yeah, same, it's the same thing with injections. Someone comes in. I think people put a lot of faith in injections. Yeah. And I love having the conversation of like, this is the why. Yeah. If we don't fix this underlying problem, an injection will help you, but it's it's not gonna fix the underlying problem. And some people are like, that's cool. Can I just have my injection? Yeah. Like that's I and I I have a subset of patients that just come in for their injections. Yeah. And I every time I will say, like, hey, listen, if you start to get weak, we cannot do this anymore. Yeah. And I will not do this. Hey, it's been three months. Let's let's stretch it out to five. Yeah. You know, um, but it's almost like they think they need it to keep doing what they're doing. I have this one lady, this is interesting. This one lady who has medial OA, kind of. It's like, you know, Kale one or two. And she started getting this lateral knee pain. So it's her, it's her IT band. She does some cardio, whatever. So I had been injecting her knee and I was like, listen, your x-rays don't look terrible. Yeah, right? Like, I think it's your IT band. Why don't we try the therapy? And she's like, nah, I want to do an injection. It's like me injecting your knee though. So I tried one time IT band injection. She's like, Oh my god, that helped tremendously. So, what I've been doing over the past couple visits is I will IT band inject her and I'm titrating her knee injection down. She's basically at nothing for her knee injection. It's like 10 milligrams of catalog.

SPEAKER_02 37:03

And then at some point, do you tell her you're like, hey, I've been injecting saline into your knee?

SPEAKER_00 37:07

No, I told her, no, I told her last time. I said, I said, how about we start to wean down your knee injection? Or why not? No, I told her the first time, why don't we try your IT band and not the knee? And she was like, nah, I need both. And I was like, all right, but how about I lessen your knee injection, like the strength of the dose? And she was like, but like by a little, because she like need like I think she needs it. It's a um placebo effect. Yeah. So last time I told her, I was like, listen, you're you're now at about half the dose that you started with. Like, I don't think you need this anymore. She's like, You really think so? I mean, like, I think we, you know, we're not she's doing it behind her back. I kind of was like, hey, I think this is your issue, but she's so stuck on needing it.

SPEAKER_02 37:43

Yeah. But like as she sees gradually, like, oh wait, now I'm at like 10% of what I was, and I actually feel the same benefit from you just doing the other thing. But yeah, I don't know.

SPEAKER_00 37:54

Yeah, some people need it, which is weird. But but that with her, it's it's her IT band. And I'm like, Do you want to go to therapy?

SPEAKER_02 37:59

She's like, I mean, I injections are such a uh like we could we could have a whole episode on steroid injections and why they can be good, why they can be bad, when to use them, when not to use them, how to explain them to patients. And I think some people think of it just very algorithmically, black and white, like, oh, uh, you know, patient calls your team and is like, hey, uh, I want to get on the schedule for another steroid injection. And you go see the patient, and it's been two months since our last one and have to have that conversation. And or, you know, there's certain things that maybe you will re-inject repeatedly every three months forever, versus certain things that that's not appropriate for, certain things that are a one and done, certain things that maybe two or three. Yeah. And it it's all highly dependent. And people don't like to hear that sometimes. But I but that's you do a good job at explaining, like, hey, this is the why.

SPEAKER_00 38:57

Yeah. And yeah, and you again, like as our notes say, we discussed all you know forms of treatment. Patient elected to proceed with this. Yeah. Risks and benefits discussed, which, but I just feel like some patients are just like, nah nah, just do the injection. It's fine, do the injection. And then, you know, eventually when it doesn't work, they're like, Well, how come we didn't know that this was getting worse? I'm like, well, because you didn't want to like you didn't want to talk about that.

SPEAKER_02 39:19

Do you ever like have to truly scare somebody out of it? Say, like, yeah, if we do this, then this is gonna happen. Yeah.

SPEAKER_00 39:25

Yeah. Yeah. I have no problem doing that.

SPEAKER_02 39:27

Yeah. When somebody's had six trigger finger injections, and I'm like, if I inject your flexor tendon sheath one more time, it's gonna snap in half. And then you'll be fucked. Yes. And they're like, oh my god.

SPEAKER_00 39:40

Yeah, it'll be deformed forever. Never mind. All right. Lastly, let's do like a little career debate. Yes. And again, this is very interesting. As again, we're going through, at least I am in my life, where a lot of PAs are just kind of picking different career paths, and I always wonder. Like, I wonder where what their head is doing. Okay, so WWHD, what would Hannah do? Uh, would you rather? Okay, it's a would you rather question? I wish we were drinking, we're not. Um, surgeon A, super average. Okay, but they let you do everything. You get to pre-op, post op, close, inject, first assist. Um, you professionally grow tremendously, but you know that they're a very average surgeon. Oh God. Versus, versus world class, uh, has a great reputation, but doesn't teach you at all, has trust issues with you, and doesn't let you do anything.

SPEAKER_02 40:39

Yeah. You know what I'm gonna pick. I know what you're gonna pick. I am going to preface this because this is this is a loaded question. I feel like I'm being set up if my surgeon ever listens to this. No, I know. That's why I'm asking you. Yeah, yeah. Um and just say I'm lucky. My surgeon is not technically average. He's great. I I am getting the best of both worlds in my life scenario. This is this is the disclaimer, right? This is the disclaimer, but in a world where I did not have option C, um, I would I would probably go with option A. Because we're saying technically average, right? Not like below average. Oh, definitely not below average. Um so yeah, because I think, you know, for for me, obviously, I want to grow and I want them to have trust in me. I want to be first assist and I want to be involved in everything in this surgeon B that you're describing that is, you know, the uh God, Andrews clinic person. Yes. Yeah. Yeah. Like I'm not doing anything with them. I'm just a cog in the wheel and they don't even know my name. So yeah, I'm gonna choose A. Yeah. Um, but fortunately for me, there's an option C where I work with a very PC answer.

SPEAKER_00 41:46

I love it. I love it. I love it. It sounds it sounds like I'm gonna answer it now. Yeah. Okay. I would be crazy challenged by surgeon B. The person who would not let me do anything, I would get up every single day trying to let them have me do stuff.

SPEAKER_02 42:04

So I'm gonna become yeah.

SPEAKER_00 42:07

And again, disclaimer, do I work with a technically average surgeon? No. Do I work with someone who is great that also lets me do things? Yes. But I think that has gained I've gained that over time with trust and blah, blah, blah. But if I were faced with, hey, your doctor's sick and they're taking three months' leave, you can work with new guy who doesn't trust himself but lets you do everything. Or um, you know, this world-renowned surgeon. I think at this point in my career, yeah, knowing I could go back to what I had, yeah, I would choose B.

SPEAKER_02 42:35

Yeah.

SPEAKER_00 42:36

I would want to break those walls down. And I would be furious every day when I'm like, they didn't let me do anything today, but I would go back the next day until I cracked it.

SPEAKER_02 42:43

Yeah.

SPEAKER_00 42:44

I think. Um it's a challenge.

SPEAKER_02 42:45

It's a challenge.

SPEAKER_00 42:46

I worked with a foot and ankle surgeon like way back when, and she was a female. And I uh upon presentation, I was like, this can be great. I'm gonna love working with her. I've never worked with a female orthopedic surgeon that wasn't crazy, which spoiler what they all are, but um, she didn't let me do anything. I would go in, see the patient, then I would say, Hey, and it was the whole like, you know, you work up the patient, then the surgeon goes in, and then you pay back onto the next one. And she would redo everything, everything. Why am I here? Oh my God, it was so discouraging. But I was very early on in my career and I was kind of like, oh, this just might be me. Like I shouldn't have trust because who would trust me? Um, but now in my career, if it was more like they had to see everything, I I would, I don't know, I feel like I'd keep going back day after day trying to crack it. Yeah. Whereas when will I build that trust? When will I build that trust and why can't you give it to me? You know? Yeah. Um, but no, I've I have worked with surgeons that come out and they're brand new. And what's great about it is they they want to collaborate. And I don't know where that comes from. It's probably like you're their sounding board. They know what to do, but they just want you to be like, Yeah, no, that's what you should do. Yeah. Um, that's that's very fun.

SPEAKER_02 43:58

Yeah, it is fun. Yeah. Yeah. Lucky us. Lucky us. We don't have to choose between A and B. We have C.

SPEAKER_01 44:07

We have C. And that doesn't mean they're the the third option.

SPEAKER_00 44:10

No, this no, this C this C crawling my way out of whatever. No, this C is a surgeon who is great, who has trusted you enough with their patients that they let you do things.

SPEAKER_02 44:22

But it has grown over time. Oh my god. I don't want you know PA student Johnny to come out thinking like, oh, I'm just gonna like be with somebody that trusts me and I get to do all these things automatically. Like, I mean, I yeah, you have to earn all of those things. I mean, every day you have to earn them.

SPEAKER_00 44:40

Yeah. Yeah. Okay. Last one. Uh would you rather take the high salary job? We're talking like 200k. Okay. Um, but you can't go in the OR ever. No, okay. I already know. Okay. And there's other details, I guess, what I'm talking about. Or um average job, average salary, sorry, not average job, average salary. The surgeon's great, the team is great, room for growth. Like how much do you and I know the answer to this, but I guess this is more for our listeners. Like, it's not all about money. Um would you rather take the average salary job versus like this the job you're not gonna have to worry about? Money. Uh yeah. Yeah. And I'm gonna go with option B. And I'll tell you, after interviewing a lot of people and working with a lot of people and people come and go, whatever, I money, it's not about the money. Like, yeah, and I don't know if whoever is listening is gonna be like, well, I'm turning this off. Like, it really isn't.

SPEAKER_02 45:38

It's not because I mean okay, like, sure, you need a certain amount of money to have a livable salary, and like the economy's terrible, whatever. You it's hard to afford a house these days. So, like, I get the desire to make more money, um, but from a career satisfaction standpoint, it has nothing to do with money for me. It doesn't. Like, and I've I've made this, you know, actually, me and my doc have talked about this a lot extensively, because I think sometimes people assume like that that is a driver of success. For me, it's not. And for a lot of people, it's not. But I, if I can be technically proficient and growing and and trusted and um doing the things that I want to do, which for me are being in the OR and first assisting and you know going to or like continuing my education and being involved in like societies, that is way worth way more than an extra $80,000 a year.

SPEAKER_00 46:40

Yeah, I totally agree. I also think though, that if you demonstrate that you again, and they know, you know, I know when I'm offering someone a mediocre salary, I know that, right? And I almost also test them to say, like, hey, if you do this, if you take this on, let's see what you're worth, you know, and not knowing somebody and giving them a high salary, like that's also investing in a product. You don't know how they're gonna perform. Yeah. So I think at least what we do here is rewarding PAs who do a great job. Like you will see that happen if you provide a service that, you know, is great above and beyond. But I think to go home happy at the end of the day, taking a job that maybe is not at the top of the salary range, but gives you everything else, I would so much rather do that. And I advise that that's the better way to go. Um, because what comes with the higher costs sometimes are you got to sacrifice other things.

SPEAKER_02 47:33

Yeah. Would you ever risk, you know, risk isn't the right word. Would you ever um consider changing what you were doing if it like looked like a lateral exact same move just because the salary was higher? And I don't know. I haven't you know changed teams essentially because of that. I was offered that not too long ago.

SPEAKER_00 47:56

Yeah, maybe a couple years ago. Um I had a doc from another practice like literally text me and say, Hey, uh, my PA left. I need a good PA. I hear you're good. I will pay you this.

SPEAKER_02 48:05

Well, or their PA is also leaving again or recently did.

SPEAKER_00 48:08

So oh, I did know that. We did talk about that. Interesting. Well, apparently that only lasted five years. But um, no, he texted me and said, I will offer you this. And not gonna lie, like I was like, huh. Because I mean, I was flattered, right? How did you get my number? Who gave you my number? What's going on? You want me, whatever. But I mean, the other things like I'd have to start over. You start to know if that's gonna be a good relationship. And if I was dissatisfied of my role, again, I would be looking prior to that because then you're looking for something, but I don't think people look for other roles because they feel underpaid. I don't think it's that. I think what goes with that is you feel undervalued and you feel like you're not being appreciated. I think the the salary is just a confirmation of, yeah, you know. Um, but no, I don't I I would not leave lateral just for more money because I feel like, again, that's that's negotiable, right? Yeah, yeah. So it's much more important to but out of school when you're looking at the debt, it's hard to say no. Yeah, and I think New York Ph, you gotta make that mistake or not. I mean, you gotta try it on and see if it's gonna work for you, and it's not necessarily all about that.

SPEAKER_02 49:16

Yeah, that was good.

SPEAKER_00 49:17

That was good. I'll tell you what, after last week we did a very clinical one. I feel like we have to let loose a little bit. We have to let loose a little bit, but now we're probably gonna have to swing back next week, which is fine.

SPEAKER_02 49:28

We gotta go from not serious to serious and just keep ebbing and flowing. Although I'm trying to get one of our foot and ankle.

SPEAKER_01 49:34

Oh my god.

SPEAKER_02 49:35

Yes. That's gonna be that's gonna be great to come hang out with us. Um and then we also have a uh a duo PT and um PA talk about some uh like starting your own private practice or starting your own practice as a PA independently, which is an uncharted topic for us. I think that's gonna be great. Lots to talk about. All right, till next time. Have a good week.

SPEAKER_00 50:08

Thanks for tuning in to Joint Effort PAs. If you enjoyed this episode, be sure to subscribe, leave a review, and share it with a fellow PA or med-minded friend. You can also follow us on Instagram at Joint EffortPAs for updates and extra content. See you next time.