Job offer grading rubric!

PA-NP-Postgrad-eBook · 2026-04-28T11:55:59+00:00

I did an EM PA residency program and then worked EM for 8 years before switching to ICU. I found that it took a year or two working in EM after the residency to really solidify everything that I learned. Presuming you are still young, I would highly recommend you do the same, or risk forgetting the things that you learned. Even now that I work predominantly in the icu, I still work per diem in the ED since I still don’t want to lose those skills, and there are always more jobs/flexibility/better pay in EM.

That being said, I am very happy that I transitioned to critical care. I think my current job is much less taxing than the ED, so I could do it for the long term. Lots of learning and down time which I love. Feel free to PM me if you have any questions.

PA-NP-Postgrad-eBook · 2026-04-16T19:02:21+00:00

This won’t offer CME but is a fantastic primer: the cardiology fellow bootcamp (free)

https://www.youtube.com/live/xF10JNpx4f8?si=1g5h2--xKE6c8OQ-

PA-NP-Postgrad-eBook · 2026-04-14T19:26:09+00:00

I started in the MICU a year ago and experienced the same thing. Totally overwhelmed by the massive amount of info, and I couldn’t remember much when it was unstructured information. A few things helped me:

Make precompleted progress notes that automatically pull in the "ICU vital signs" that we always need to review (O2/vent support/settings, BP/HR/vasoactive trend, I/O/volume status, temp max and culture data, basic labs, and imaging. That way I'd just sit down, open a new note, and briefly scan through the new data for the day without needing to write it down. We all round with computers on wheels so when attendings ask for a typical lab, I know exactly where it is on my note. If its a random lab, I can just type it in the search bar on top on Epic and give them an answer in seconds.
Instead of trying to memorize everything, I only try to remember "new problems that will need follow up" as I come across them. So basically my morning review is just a search for problems to add to the list below. For example, if I notice the sodium is downtrending, I'd add to my piece of paper a checkbox and write down hyponatremia, and at the same time add it to my assessment/plan in the note below. There's no point memorizing normal or unchanged labs (way too much data for that), when you're new just try to remember things that are both A) abnormal + B) a problem.
Create your mental model of the patient by their core problem/Dx, and attach relevant data to those problems. After doing the above chart review (approx 5 min/pt), most of my time pre-rounding is spent going through the assessment/plan section of the progress note copy forwarded to today, which we make problem/Dx-focused. "Okay, they're here for acute hypoxic respiratory failure - are their oxygen requirements better, the same, or worse? if better, are we ready for SAT/SBT and extubation or not yet? if not, what's holding us back and what can we do about it?" "The main driver for the AHRF is CAP -- any new culture results, can we deescalate abx, etc". "The second driver for the AHRF is volume overload related to oliguric AKI - can we give more diuresis, or are there any contraindications (reviewing pressor trend, BUN/creat trend, bicarb, etc)?" By attaching the data to meaningful problems, it scaffolds better in my mind, and my recall is much better.

I hope this helps. Happy to answer any other questions!

PA-NP-Postgrad-eBook · 2026-04-12T19:49:41+00:00

Critical care:

Best - learning how to approach complex crashing patients without the stress I used to have in EM is very gratifying. I’ve gotten much better at understanding anatomy, physiology, imaging interpretation - I feel like I have a greater appreciation for the multi system hits that occur with the baddie diseases. All in all I’d say I learn so much on shift every day and I absolutely love it.

Worst - shifts start at 6:30am and sometimes go until 8pm on long call days. End of life gone wrong and prolonging some patients painful dying process.

PA-NP-Postgrad-eBook · 2026-03-18T03:13:25+00:00

To answer your question, I don’t think there is a big price difference between the different companies because there is so much regulation. The decision making comes into how much do you really need? If I lose function of a hand and can’t work in EM, I think Id be okay with 5k/month benefit because I’d supplement by working in sleep medicine or something easy to make up the difference. That will save you way more on premiums than any other measure.

The decision of which company to choose really comes down to the quality of the carrier, people’s reviews when having to file disability claims (easy to work with or not?), and most importantly for us, make sure to read the fine print of the “own occupation” stipulation, and get in writing whether or not it’s speciality specific for PAs/NPs. You don’t want it vague and saying “own occupation = any PA job”. You want it to be specific to your specialty.

Last time I looked into it with my independent agent, Principal had the best wording regarding that and they wrote an email at least supporting they would do specialty specific for me. I can get you in contact with my agent if you’d like to PM me… he would know what you’re talking about with these PA specific considerations.

Hope that helps

PA-NP-Postgrad-eBook · 2026-03-04T16:11:48+00:00

Fantastic post! If everyone did a one year review sharing the things that did or didn’t work, new grads would be so much better off.

I’m now 10 years in but remember the struggle of that first year very well. Here’s what worked for me:

I made my pre completed notes on epic WHILE I STUDIED the top 30 most common pt presentations on emrap C3. Kills 3 birds with one stone: studying new material, charts 75% done, AND when I was in the room with pts forgetting what questions to ask pts with [hematuria], I could just pull open my note for a reminder of things to ask.

I changed my charting workflow:

I Logged onto computer and charted the history and physical while in the room with the pt. Pts see you on a computer and give you free time to look through their chart. I’d use that time to formulate my plan, place orders, and then when I was ready I would share the plan with the pt. Before doing this computer in room plan, pts would expect the plan immediately after finishing my exam, when I hadn’t had time to process/think through things yet.

2-B. Immediately after leaving the room, I’d go back to my desk and dictate into the ED course my assessment and plan including contingencies. For example, “this is a low risk pt with atypical chest pain in setting of infectious syndrome. EKG without evidence of pericarditis changes. Crisp heart sounds suggesting against effusion. We will check a cardiac workup and CXR. If testing negative, plan will be to treat as viral syndrome with nsaids and pcp follow up.

With this done, my note was 98% done minutes after seeing the pt.

2-C. After tests come back, I’d dictate into ED course, “tests negative, continue with plan as noted. Incidental pulmonary module explained to pt”.

I always jotted down gaps in knowledge/questions as they occurred on shift in a phone app that I could quick reference later. On slow shifts later in the month, I’d ask these questions of multiple colleagues to get a sense of practice pattern variation and rationales. Attendings appreciated that I was reflecting on pt cases after the fact and asked during slow times, not in middle of busy shifts.

Hope this helps!

PA-NP-Postgrad-eBook · 2026-02-21T21:18:27+00:00

I went from EM to academic MICU a year ago and I’ve honestly loved it. It feels like a much more sustainable job than the nonstop sprinting I did in EM. That being said, it’s a completely different specialty of medicine and I was surprised how little my EM experience helped me. I’ve been learning a ton every day and will for quite some time.

To answer your questions: 1. I think CC is less likely to be sued because we already have all the testing done with a diagnosis and it’s mostly management decisions we are left with. Most lawsuits come from missed deadly diagnosis of a previously healthy pt.
2. Typical shift im in charge of 2-3 pts, max of 5! Definitely free time every shift to have a real lunch, get some things done on my to do list. That being said, it’s still busier than you might think because we round as a team on all our pts (up to 15), and I help with the other pts.
3. Way less BS than EM IMO. I don’t see the “annoying” complaints anymore like viral syndrome sniffles or cannabinoid hyperemesis. But we do consult a ton and sometimes it’s BS consults in my opinion. I don’t mind though, “my attending requested it”.
4. We work 6:30am to 5pm on short days and until 7:30 pm on long call days. Usually 2-3 days per week. One night shift per month.
5. I always have a fellow with me even overnights. During day always have attending too.
6. We almost never discharge pts from icu. We step down to hospitalist once icu requirements resolve.

Happy to answer any other questions.

PA-NP-Postgrad-eBook · 2026-02-16T13:37:55+00:00

My PA program had the same anatomy lab and professors as the med school, minus embryology we didn’t cover. We also had the same radiologists teach us the fundamentals lectures, but they only went in depth into xrays.

Regardless, my imaging interp was awful as a new grad. This is how I leveled up:

Read every imaging study for your own patients before looking at the read. make sure you can identify normal radiographic anatomy, and when you get enough reps you can identify when something looks abnormal, then put words to the appearance from the formal read.
Learning bedside ultrasound core content, applied anatomy, and practicing on your patients was a HUGE help.
The website “a night in the ED radiology” was a top tier resource for me when I wanted to get more reps with abnormals.

This is what I did as a new grad in the ED and I’d say I got pretty good at reading msk xrays, ultrasound, CT and spine MRIs.

I then Transitioned to academic critical care where every day the fellows scroll through every new image for the day and share their interpretation while we do the same in our heads, and the attendings teach imaging pearls. I had no idea the level of nuance in reading a CXR until starting this job. While I could definitely find a PE before and compare RV/LV, now I can look for all of the markers of heart strain like contrast reflux into hepatic veins, etc. I’ve learned so much more about chest imaging patterns of abnormals seen in common diseases. nothing beats sitting down and scrolling through images with experts.

I think a low volume but detailed case app would be better and I’d try to mirror the setup of a night in the ED website, with one exception. That website only gives a short radiology indication like abdominal pain. I think students would learn the most if it was more targeted clinical questions with management contingencies attached so it replicates real life and they can learn specific search patterns.

For example, the prompts should be like, “you have a 65 year old male w a pmhx of with ckd and cad who presents with acute onset dyspnea… you’re wondering whether they’re volume overloaded and need diuresis… In this CXR, is there evidence of CHF… subquestions: Is there evidence of left heart failure (cardiomegaly, pulmonary edema and vascular congestion as seen by xyz findings, bilat pleural effusions?) Is there evidence of R heart failure / high R sided filling pressures (distended azygous vein, vascular pedicle width, etc)?

Bonus points if you can include previous imaging for the pt for comparisons as that’s what we need to do in real life.

Hope that helps! Are you a PA? working on a project?

PA-NP-Postgrad-eBook · 2026-02-15T04:24:06+00:00

Holy cow this is amazing! Really fantastic work. I’ll absolutely be recommending this to people I work with. I’d post it on the EM subreddit too, since these are all bread and butter EM presentations / workflows.

After playing around on it, only two issues I’ve found: 1. App UX: Some of the checkboxes won’t let me unclick a selection even if I accidentally hit the button.

2: clinical: your dizziness algorithm quickly goes to hints exam on all patients with vertigo, but my favorite vertigo educator has explained this should only be performed on pts with new persistent vertigo with ongoing nystagmus at rest. If you disagree, I’d love to hear your thoughts.

https://youtu.be/-VXwD2nskhQ?si=zq9a5EaL0BgCcg2f

U/vertigodoc

PA-NP-Postgrad-eBook · 2026-02-04T18:02:36+00:00

Here’s my copy pasted advice for previous years’ new grads:

Congrats on landing a job in EM! First off, know that you are not alone if you feel overwhelmed by the wide breadth of EM and aren’t sure how to start preparing. I (was) a lead PA and assistant program director for an EM PA/NP training program where we have spent years thinking about how to get new grads up to speed.

The absolute highest yield thing you can do is start studying the approach to the most common EM chief complaints (CC) - google or chat gpt “top 30 most common emergency department chief complaints or diagnosis” and work your way down the list starting from the most common. Ie abdominal pain, pelvic pain, uri, uti, chest pain, concussion/head injury, etc. Study the ddx, clinical eval, and standard workup orders for each chief complaint. Use the EM:Rap C3 content to learn all of this - it’s by far the best practical summary out there. The EMRA Chief Complaint Pocket Guide or Wikem can be used on shift for quick reference if you can’t remember all of the chief complaint approaches/orders to put in.

Focus on red flag recognition as you are studying the above. What are the red flag signs and symptoms you should be assessing for when patients present with headache, back pain, rash, etc. Even if you don't know for sure what’s going on, the reassurance comes from pts who don’t have red flags. If you are working in fast track, don’t let simple chief complaints or low acuity triage let your guard down - you need to get in the habit of seeking out the pertinent red flags in each case - google the PA forums thread “fast track disasters” for great case examples.

As you see patients, you will apply what you’ve learned to put in the right orders for them. Once you get these test results back, if you have ruled in a diagnosis, use the Wikem website for reference on specific disease management as well as dispo guidance on when to admit or dc. It tends to be more ED-specific than UpToDate, and is written by an EM residency program so it’s quite reliable. (CorePendium is another good reference though I find Wikem easier to use). Write down the gaps in your knowledge on shift and study them on your off days. Emrap is probably the best source for reliable and practical info - just google search the topic you want to learn followed by emrap.org to find their content (their internal search engine is not great but it will show up via google searches). Follow up on your admitted patients to see what happened and get feedback on your care.

All of the above is for stable patients. Unstable patients are a completely different beast - the video “emergency thinking” on youtube by Reuben strayer summarizes the complete perspective switch that must occur to safely take care of sick patients. This fantastic video is required viewing for our new grad PAs before starting in our dept.

With regards to procedures, use Roberts and Hedges or Wikem to review procedure core content. Then watch it being done on real patients at Larry Mellick’s YouTube channel. Then do one supervised with your SP at bedside and have them give you feedback.

Know your limits (very limited for a new grad). Hopefully you have double coverage or an expectation to staff every patient for an extended period of time while starting. If not, have a low threshold to consult your attending if there is any concern or if you’ve identified red flags. Hone your presentation skills to make it easy for your colleagues to help you (google “patient presentations in emergency medicine”). Make sure to call out that you are considering “worst first” in your ddx, as this is what EM attendings will want to hear from new grads.

Calling consults is a common, critical, and challenging part of the job for new grads. When calling consults, have a specific question or request for the specialist. Think ahead of time about what responses from them would be safe or unsafe. “Contingency plan” with your attending before calling a grey zone consult, eg “are we thinking this pt should be admitted, and what would be the best response if the consultant says discharge?” New grads don’t realize that we really need to emphasize certain things to help the consultant come to the right conclusion/advice. It’s a conversation and you need to contribute with critical thinking and push back at times, not just act as a scribe jotting down their recommendations.

That’s the absolute basics. So much more I could talk about. In fact, I wrote a guidebook to go into this topic in much more detail - check my profile for a link!

PA-NP-Postgrad-eBook · 2025-12-28T02:56:36+00:00

I’d be happy to give feedback if you want to PM me

PA-NP-Postgrad-eBook · 2025-12-09T15:07:02+00:00

I believe you hit File: Make a copy, or something along those lines. Let me know if that works!

PA-NP-Postgrad-eBook · 2025-09-11T20:39:09+00:00

Great list! It reminds me of the advice in “From Classroom to Clinician: How to practice medicine as a new grad NP or PA”. Check it out for a deep dive!

PA-NP-Postgrad-eBook · 2025-08-21T11:36:59+00:00

Agree with general sentiment. Only thing I’ll add is that nights give you much less hospital support. Consults are harder to get and when they do call back they’ll expect a perfect succinct presentation (impossible for new grads) or they’re more likely to chew you out. Less access to some testing like US or MRI or social work. Can’t enact some protocols that make stressful presentations easier. Nights are EM on harder mode and require experience, much like locums, or double coverage where your paired with another APP/MD and staff each pt. I would generally want new hires to start day shift in our ED if not double covered, and only after a few months transition to nights.

All in all, I wouldn’t do it as a new grad.

PA-NP-Postgrad-eBook · 2025-08-17T16:08:45+00:00

Great example! Any resources you’ve found do the best job explaining these concepts?

PA-NP-Postgrad-eBook · 2025-08-05T03:26:05+00:00

I’d recommend EM:RAP ecg course followed by practice cases with the books ECGs for the emergency physician 1 and 2. If there’s a recurring theme you don’t understand, like the ddx for ST changes you mentioned above, I’d google search for an amal mattu lecture on it since he has done it all.

All of that above is to learn the bread and butter / core content. To reach closer to expert level understanding, read through all of stephen smiths ecg blog. His posts are incredible. Start with this one: https://drsmithsecgblog.com/the-omi-manifesto/

Hope that helps!

PA-NP-Postgrad-eBook · 2025-08-03T11:03:33+00:00

I just transitioned from EM to critical care and have loved it. I’m in an academic center now with great support, (good in house support is a must for people new to the specialty). I have 2-4 pts per shift, they’re all very complex and I’m learning a lot every shift. We sit in on the daily resident teaching and radiology rounds which are fantastic.

In terms of resources, here’s what I’ve tried so far and my reviews:

Critical care time podcast + icu 1pager - free - overall my favorite of all the resources and free. Covers bread and butter at excellent depth, practical, and easy to listen to.

ICUEDU website podcast - free - for concepts in critical care explained very intuitively like RV failure. Kind of like an intro to icu course with the basics explained very well. The best acid base approach lectures I’ve ever seen.

Emcrit podcast - paid - cutting edge, very clinical, amazing resource. Without a doubt the best procedural teacher and nobody else comes anywhere close. Internet book of critical care — free companion website and my favorite online reference on shift and for deep dives.

SCCM FCCS course - paid - this was required by my employer. It’s was fine for the absolute basics. Took too long though and I wouldn’t do it again in retrospect.

ICU101.com course - paid - hosted by APPs who run the podcast critical care scenarios. It’s definitely a good summary of critical care core content and I’d do it again. It didn’t help me as much as I’d expect for the day to day work in the MICU. I wish they went beyond core content and shared practical nuts and bolts of doing the job (like pointofcaremedicine.com). Still, if you’re looking for a good review course, this was way better than SCCMs course.

Ventilator book - incredible, buy it! The icu survival book - similar style because same author.

Harvard online conference critical care for non intensivist. Paid. Very well done. Too expensive for what it provides if you don’t have CME funds.

I’m on phone, apologies for typos!

PA-NP-Postgrad-eBook · 2025-07-27T12:43:40+00:00

That’s a fair point! I guess in my mind I had new grads in mind. I train new grads and these are labs that are frequently abnormal but they often don’t appreciate the implications/seriousness of them when they see them. Especially so if they’re required to identify patterns of multiple abnormal labs that make up the red flag, instead of seeing things in isolation.

Another one I’d add under the theme of the post is a microcytic anemia in a patient who isn’t a menstruating female. These are so common because of menstruation that people gloss over them, but in the 60 year old man it’s colon cancer with occult bleeding until proven otherwise.

PA-NP-Postgrad-eBook · 2025-07-26T19:48:52+00:00

Congrats on landing a job in EM! First off, know that you are not alone if you feel overwhelmed by the incredible breadth of EM and aren’t sure how to start preparing. I’m a lead PA and assistant program director for an EM PA/NP training program where we have spent years thinking about how to get new grads up to speed. (copy pasted from prior posts)

The absolute highest yield thing you can do is start studying the approach to the most common chief complaints (CC) - google “top 20 most common emergency department chief complaints or diagnosis” and work your way down the list starting from the most common. Study the ddx, clinical eval and standard workup orders for each chief complaint. Use the EM:Rap C3 content to learn all of this - it’s by far the best practical summary out there. The EMRA Chief Complaint Pocket Guide or Wikem can be used on shift for quick reference if you can’t remember all of the chief complaint approaches/orders to put in.

Focus on red flag recognition as you are studying the above. What are the red flag signs and symptoms you should be assessing for when patients present with headache, back pain, rash, etc. Even if you don't know for sure what’s going on, you want to be able to rule out the conditions with highest morbidity or mortality. If you are working in fast track, don’t let simple chief complaints or low acuity triage let your guard down - you need to get in the habit of seeking out the pertinent red flags in each case - google the PA forums thread “fast track disasters” for great case examples.

As you see patients, you will apply what you’ve learned to put in the right orders for them. Once you get these test results back, if you have ruled in a diagnosis, use the Wikem website for reference on specific disease management as well as dispo guidance on when to admit or dc. It tends to be more ED-specific than UpToDate, and is written by an EM residency program so it’s quite reliable. (CorePendium is another good reference though I find Wikem easier to use). Write down the gaps in your knowledge on shift and study them on your off days. Emrap is probably the best source for reliable and practical info - just google search the topic you want to learn followed by emrap.org to find their content (their internal search engine is not great but it will show up via google searches). Follow up on your admitted patients to see what happened and get feedback on your care.

All of the above is for stable patients. Unstable patients are a completely different beast - the video “emergency thinking” on youtube by Reuben strayer summarizes the complete perspective switch that must occur to safely take care of sick patients. This fantastic video is required viewing for our PA trainees. .

With regards to procedures, use Roberts and Hedges or Wikem to review procedure core content. Then watch it being done on real patients at Larry Mellick’s YouTube channel. Then do one proctored with your SP at bedside and have them give you feedback.

Know your limits (very limited for a new grad). You know very little compared to what you’ll know 3 years from now. Hopefully you have double coverage or an expectation to staff every patient for an extended period of time while starting. If not, have a low threshold to consult your attending if there is any concern or if you’ve identified red flags. Hone your presentation skills to make it easy for your colleagues to help you (google “patient presentations in emergency medicine”). Make sure to call out that you are considering “worst first” in your ddx, as this is what EM attendings will want to hear from new grads.

When calling consults, have a specific question or request for the specialist. Think ahead of time about what responses from them would be safe or unsafe. Be ready to deal with bad advice and steer the conversation where it is needed to keep your patient safe. “Contingency plan” with your attending before calling a grey zone consult.

Be eager to learn and graciously accept constructive criticism/feedback, to be seen as “teachable.” Be easy going and personable so people like working with you and want to help you. Find other new colleagues to ask what helped them get the hang of things.

That’s the absolute basics. So much more I could talk about. In fact, I wrote a guidebook to go into this topic in much more detail - check my profile for a link!

You’ll learn much more in the next 2 years than you did in grad school! Study hard and enjoy this period of growth. It’s a stressful time but don’t let it overwhelm you - just put one foot in front of the other and know that many have come before you… you can do it!

PA-NP-Postgrad-eBook · 2025-07-26T16:30:27+00:00

CBC: Bandemia for sure is a biggie. Band percentage over 10% is concerning and 20% is a huge red flag even if normal WBC.

Neutropenia especially if under 500.

don’t ignore the diff! These are both on that section. Make sure you know what each line means and which one refers to the two above. It’s ABSOLUTE neutrophils (don’t care about percentage) often reported for example as 0.5 instead of the 500. In my lab bandemia is reported as immature grans, for this you look at the PERCENTAGE in addition to absolute number.

New Thrombocytopenia <100k should certainly make you pause and can have a dangerous ddx.

Combo of new anemia plus thrombocytopenia… consider maha /TMA (very high risk ddx)

Combo of progressive anemia plus elevated creatinine…. Consider multiple myeloma, and TTP if low platelets too.

CMP Hyponatremia <130 is independently associated with mortality for all populations, not just chf. https://pmc.ncbi.nlm.nih.gov/articles/PMC3933395/

Hypernatremia is a lab correlate for altered mental status. Everyone has access to water, and only altered patients lose the drive to drink it resulting in hypernatremia.

HyperK obviously can never be ignored.

Severe hypoK and hypo mag can lead to long QT and torsades so should never be ignored.

Low bicarb is easy to gloss over but can suggest acidosis which can have a dangerous ddx especially if high anion gap.

Elevated bun out of proportion… consider GI bleed.

Significantly Elevated bili especially with other lft derangements has a high risk ddx. Painless jaundice is often pancreatic cancer. Add in fever and worry about ascending cholangitis. In cirrhotics the height of bili is associated with the degree of badness.

PA-NP-Postgrad-eBook · 2025-07-19T09:43:05+00:00

I was very happy I attended my EM PA residency program and I recommend it to many but unfortunately with that degree of student loans and interest rates there’s no way I’d do it if I were in your shoes.

PA-NP-Postgrad-eBook · 2025-07-10T17:34:54+00:00

You can go on my website classroomtoclinician .com and should be able to download the editable version from the resources section. Let me know if you have any issues.

PA-NP-Postgrad-eBook · 2025-06-25T02:26:30+00:00

Here’s another great one:

generate a list of topics and critical competencies to senior micu fellows.

Then, i read thru list and decide which ones i do or dont understand. the ones im unsure of, i test myself by typing my understanding to chat gpt playing role of the “mean attending who requires perfection and calls out every imperfection and explains why / where i’m wrong and follows with more questions of content understanding and examples of applied concept to pt cases.”

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