Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

One Provider's Professional Journey through the Acute Care Continuum

4/26/2016 7:12:16 PM | 10 comments

We often discuss patients’ experiences through the Acute Care Continuum. Achieving seamless transitions from setting to setting is both a marker of quality and a patient satisfier.
Much less has been written about the journey of providers whose careers take them through a variety of settings. As a PA with a multispecialty group, I'd like to share how the Acute Care Continuum has enriched my practice — and how it can benefit providers in all disciplines.
From the Wilderness to the ED
My first six months as a physician assistant were spent in a remote Alaskan clinic. It was the only medical facility on the island, and the staff consisted of a secretary and two PAs. In this role, I was the primary provider, lab tech, RN, pharmacist, and ED tech for roughly 400 people. (We joked that the other PA had the other 400 in town). The only thing I didn’t do was fly the lab samples to the lab facility in Juneau, 40 miles away by air.  I would however call patients back for redraws several days in a row when the weather had not permitted flying.
Our physician flew in for one week a month to manage chronic ailments and complicated cases, and was available by phone the rest of the time.  However, we usually had to call the ED in Juneau or Sitka to coordinate immediate transfers. We sent other patients by plane or ferry for any specialist appointments — which were only available quarterly.
Ideologically, I knew I was in the correct field, but something about the job didn't quite fit.
One day, I saw a patient with a stubborn cough. “I went to the ED for this, and they couldn’t figure it out," he said. "But they said you would.”
I'd heard this before from more patients than I could count. But on this day, the proverbial light bulb finally went off. While my current job had its rewards, I was hungry for intensity, variety, and teamwork.
Thus began my transition to a rewarding eight-year career in emergency medicine.
And how I loved it. I threw myself into it, racked up an alphabet soup of certifications (ATLS, CAQ in EM, even WALS for good measure). I cut my emergency teeth in remote Wyoming, gained confidence in rural Oregon, and jumped into leadership in northern California. Upon my return to Oregon, I felt capable and strong, and at home.  "Now be sure to follow-up with your family provider," I'd tell patients at each location, secretly relieved to no longer be that provider.
Life was good. I had a great job and a wonderful home in a town I loved. When I looked forward, I saw myself in the ED forever.
Back to the Wilderness?
Life has a funny way of changing our perspectives.
Last year, after several life-altering events, my family and I mournfully decided to relocate from the West Coast to Eastern Pennsylvania.
The only job available in the right place at the right time was in a rural urgent care center. This adrenaline junkie EMPA verbally accepted the offer, then started to sob the moment I hung up the phone. I felt like I was going back to the wilderness — a wilderness of colds, coughs, and crying babies.
Fast-forward nine months. I'm talking to a patient who I'm concerned might have transverse myelitis. He wants to be treated at a nearby community hospital. I’m convincing him to travel an hour away to a facility that can perform an emergent MRI. 
To bolster my credibility, I tell him about caring for neurological patients in the ED. We'd have made sure he got that MRI stat.
Finally he nods his assent. Then he asks if I miss working in emergency medicine. 
To my complete surprise I answer, "Not really." Then I add, “I loved it while I was in it. But now I love that I’m not.” 
The little clinic where I work is a calm place, and that initially terrified the type-A in me. It operates at a slower pace and affords me the luxury of educating my patients for an extra few minutes without worrying about the sicker patient next door or the guy about to code in the lobby. My rural patients tend to be down-to-earth and practical.
Transferrable Skills
When I took this position, I was concerned that my skills and experience would be wasted. But that's far from the case. I learned that urgent care patients improperly self-triage all the time, making my ED experience immensely valuable. 
Without seeing numerous children sent to the ED for unnecessary IV hydration, I would not feel comfortable keeping them in my clinic. But I do.
My time in rural Alaska comes in handy as well. By understanding the mindset of a failing man who barely left his mountain home for the last 60 years — let alone went to the doctor — I can help coordinate his acute care to minimize hospitalizations.
And when a postictal toddler with prolonged cyanosis was handed through our registration window to the RN — the only other staff member in the building — we did not panic. I grabbed a mask while she put down the child. Then she ran for the O2 tank while I bagged the patient and called 911 from my Bluetooth headset.
The little girl was febrile and had returned to near baseline mentation by her arrival at the hospital. I knew she would present like a classic febrile seizure patient and likely be treated accordingly. But I suspected an underlying issue and discussed it with the ED physician. Several consequent tests returned abnormal, and the patient was sent to a children’s hospital for evaluation and treatment. 
Room to Grow
While experience in a single discipline could account for some of the benefits I have described, I believe it is the diversity of situations and multilayer approach to my career that has benefitted my patients the most.
By navigating the Acute Care Continuum as providers, we become better equipped to guide our patients. The more open we are to changing and sharing skills across fields — thus making everyone on the continuum one giant team — the more we all benefit.
Another potential benefit of traversing the continuum is career longevity. Having the chance to integrate our skills and experiences in a new setting can be a source of renewal and resilience.
Variety is a major benefit of working for a multispecialty group. CEP America providers practice in EDs, urgent care centers, inpatient units, ICUs, skilled-nursing facilities, detention centers, psychiatric emergency units, community clinics, and via telehealth. No matter where your circumstances and interests take you, there are plenty of options.
I'm also pleased to see our Partnership supporting these career transitions. Several CEP sites offer internships and fellowships to help PAs and NPs transition to the ED. Many of our hospitalist Partners are exploring opportunities in post-acute care. And we just launched a fellowship that prepares family medicine physicians to work in the ED.
Not everyone wants or needs experience in multiple disciplines. But to those considering change, my advice is not to let fear stop you. We fear the unknown. We enjoy the status that comes with certain roles. We feel a sense of obligation to our current patients and colleagues.
But sometimes it's exactly what we need. Sometimes change means falling back in love with practicing medicine — something I hadn’t realized I’d drifted from until it found me again.

David Birdsall
Great article Rachel. What a wonderful career you have made. Thank you for sharing.
5/28/2016 1:36:35 PM

Great article. I work in an LTAC for CEP in Baltimore for the past 9 months. The LTAC was a my third stop in the continuum. I worked in private practice and as a Hospitalist before. CEP has allowed me to continue to grow!
5/2/2016 6:14:29 PM

David Carter
What a fantastic article! So many great points made. Your words (and experiences) are inspirational and a testament to why so many of us chose to be in medicine careers that give us opportunity and flexibility to change settings from time to time. It's the culmination of our experiences at each step of our paths that helps make us the patient care providers that we are. Thank you for your article.
4/29/2016 12:13:25 PM

Cyndy Flores
What a pleasure to read your article! CEP was lucky you found us and your patients are lucky to have you as their PA! Thanks for reminding us, as providers we too travel many paths.
4/27/2016 10:20:29 AM

Kevin Riggs
Thank you for sharing and for all you do as a PA! Keep up the great work.
4/27/2016 10:01:01 AM

Jon Brummond
Great perspective and story. Thanks for contributing!
4/27/2016 9:27:21 AM

Michael Neeki
That is an incredible story. Your skills, dedication in serving underserved communities and competency should be the core of our medical and humanitarian education.

Thank you for sharing your experience
4/27/2016 9:19:06 AM

Rachel Berros
Thanks Jessie, I miss working (and living) with all you guys in NorCal too. And Oregon!

I'm still picking up a few ED shifts a month, you know, just in case 😉. But who knows what the future holds for any of us.
4/27/2016 6:19:41 AM

Jessie Bugbee
You are amazing and I miss working beside you. So glad you are happy and there to provide the important every day care people truly need. Ugg come back though to northern ca are missed
4/26/2016 11:25:59 PM

Great article! I agree whole heartedly that multi disciplinary medical staff provide the best care. They have seen it all and from different perspectives. I've also travelled a diverse path starting in long term nursing and skilled nursing prior to the in hospital setting. While in hospital I've worked the greatest of my years split between ICU and ER, but have ventured to pick up shifts on Medical, Surgical and PCU as well. It's the diversity of our experience that sets us apart. Hearing of your journey reminded me of my own. It's been a pleasure working with you in Oregon. Hope we cross paths again.
4/26/2016 8:57:16 PM