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I may be wrong, but I believe there was a "call" from physician groups years ago for NPs, back when they were starting to push for independence, to take the Step 3 if they wanted to practice independently.  

In response to this, and in an attempt to prove their worthiness, there was a group of NPs who took a "watered down" Step 3 test, and did terribly on it.  I can't put my finger on that study right now, but I'll look for it later.

For those PAs who think they should be able to practice independently, would you be willing to put your money where your mouth is and take either a (non-watered down) Step 3 test, or (even better yet) board exam for your specialty?

Perhaps, instead of independent practice for PAs, we should be pushing for PA to be an alternate way of achieving medical board certification (pass step 3 and specialty exam).  

.....just an idea....

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....For those PAs who think they should be able to practice independently, would you be willing to put your money where your mouth is and take either a (non-watered down) Step 3 test, or (even better yet) board exam for your specialty?

 

Perhaps, instead of independent practice for PAs, we should be pushing for PA to be an alternate way of achieving medical board certification (pass step 3 and specialty exam).  

 

.....just an idea....

Because isn't that what the DO profession did?  Didn't the DO's bring their educational level up on par with the MD profession, and took the same tests proving they were "equal"??

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Because isn't that what the DO profession did?  Didn't the DO's bring their educational level up on par with the MD profession, and took the same tests proving they were "equal"??

 

Not quite.  DOs are able to take the COMLEX and USMLE and apply to DO residencies or MD residencies, respectively.  MDs are only able to take the USMLE and apply to allopathic residencies.  Ask an MD if they feel like DOs are on the same level as they are sometime.  For all intents and purposes, yes, they are equivalent.  But allopathic pathways are still regarded as more prestigious.  

 

Here's a link that talks about it. I wasn't aware they had done this. Must've been during my dark period. http://allnurses.com/doctor-nursing-practice/dnps-failing-the-375228.html

 

From what I can tell, since NPs specialize, the 50% that failed could be d/t the fact that the USMLE step 3 tests adults/peds, etc.  So an adult np, or pediatric np, or women's health np, wouldn't do very well on this type of exam.  Watered down or not.  

 

Just a few days ago I had a very "experienced" NP walk a patient over to my ED (where NPs are not allowed to staff) asking if I could clear him and send him for psych.  He had eaten 60-100 hydralazine tablets over the past 12 hours.  You could see the cholinergic toxidrome from across the room!

 

 

Ok.  Do we really want to get into telling stories about horrible decisions we've seen providers make?  Because I have multiple for MDs, PAs and NPs.  Like the provider who asked me if we should start compressions on a patient with a paced rhythm because he diagnosed it as v-tach on the monitor.  Everybody says and does stupid things now and then.  When the pacer spikes were pointed out he said "oh duh" and we moved on.  I won't divulge what type of provider this was.

 

We can debate whether or not NP education is lesser than PA education all day long.  I know in my neck of the woods, NPs dominate in most specialties, save surgical areas.  I have worked for 2 larger health systems in this area as well, and the hospitalist groups and intensive care units hire NPs much more than PAs.  Like it or not NPs are gaining independence (deserved or not) and PAs are remaining stagnant.

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I may be wrong, but I believe there was a "call" from physician groups years ago for NPs, back when they were starting to push for independence, to take the Step 3 if they wanted to practice independently.  

 

In response to this, and in an attempt to prove their worthiness, there was a group of NPs who took a "watered down" Step 3 test, and did terribly on it.  I can't put my finger on that study right now, but I'll look for it later.

 

For those PAs who think they should be able to practice independently, would you be willing to put your money where your mouth is and take either a (non-watered down) Step 3 test, or (even better yet) board exam for your specialty?

 

Perhaps, instead of independent practice for PAs, we should be pushing for PA to be an alternate way of achieving medical board certification (pass step 3 and specialty exam).  

 

.....just an idea....

YES, I would take the FP boards minus OB. 

I would love to have AAFP  let me take the boards and see what I do after 25 years of doing this.

If I pass and I have all these years, then I should be able to practice independently.

 

If a new grad wants to do FP then I believe the grad should be aligned with a long experienced PA for 5 years and then do the same - take a version of the board test.

I don't think new grads should be set loose without training wheels.

 

PAs can't realistically function independently in surgery specialties since I doubt you will find a PA doing a total knee solo or bowel resections in general surg. Some types of practice are still going to be the somewhat dependent PA/doc team thing. I just don't see getting around that.

 

Since FP is so underserved, we should be building an independence test to overcome the barriers to putting PAs into Primary Care even in urban areas to fill the need.

 

My old 2 cents

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In reading over all these comments. (And I thank everyone for thoughtful deliberation and keeping it professional) I think one common thread is coming thorugh

 

New Grad PAs need supervision for X number of years to protect society

 

Old crusty, established PAs might and probably should be independent

 

I would point out that FPR does not eliminate or advance any of this - and in fact might well help the case for direct supervision or residency competition as corporate employers will realize that new grad PAs are not the same as 10+ year PA (or even 2+ year PA's)

 

 

 

So where do we go from here?

 

I totally encourage folks to think more about this topic and let the PAFT and AAPA know your thoughts and feelings in a professional way. They are representing all of us, and although I strongly support FPR I think it is of upmost importance to have a discourse on it, and let our agencies know of feelings. As a part of this is also realizing that we are in a democracy and the majority rules - and we can all still get along and respect each other.

 

 

 

 

 

I do think the idea of having formalized supervision, or mandatory one year residency a key issue for societal safety.

i still believe that if a PA builds up enough "crust" and wishes to go independent then there should be a simple pathway for that whether it be a bridge program, exam, or time limit. I do not feel that it should be mandatory. For those that wish to remain dependent ( or need the continued supervision) than i am all for allowing that option. As a seasoned PA i can honestly tell you that many physicians that i have been exposed to in outpatient practice have a fraction of the understanding that many Pas have gained that blows away residency trained physicians do to the self drive and years of experience. If they could take the board exam to show their competency they would far excel the newly trained resident. You hit the nail on the head with the "crust".

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some more great posts here

 

 

I think one thing to point out is that FPR DOES NOT equal being a doc - no PA out there will perform across the entire speciality like a doc in surgery.  They are the top of the pile - they can do everything they want....

 

 

What i envision FPR doing is removing the handcuffs to Doc's - it is not authorizing us to do TKR solo - or orther major surgery - that is where a surgeon comes in.

 

It does allow us to stand on our own two feet

 

 

Another recent example of this hurting us

 

I am thinking of volunterring in a free clinic - across state line in VT

looking encouraging, free med mal, and I would be the first PA they have.

 

then I go look at the VT PA license application  - says I have to have have a job and the CP sign off on my application - 
WTH??

 

How on earth does this in any way reflect on my ability to practice medicine, or volunteer in a clinic (giving my time for free!)

 

It is just illogical to be handcuffed to physicians.  We should stand on our own professional feet.

 

 

It is interesting to point out that FPR   DOES NOT mean we will take the positions of specialists.  I can see how that would be less then desirable for most if not all PAs.  Instead I want to be able to do everything I was trained to do as a PA with out some doc also being on the hook. 

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I am really enjoying reading all the thoughtful comments in this thread. To a degree I even enjoy the more passionate ones because it makes my dried up old heart beat a little faster just to hear some passion about the profession. In the greatest numbers we have historically tended to be blase about the nuts and bolts of the profession until something happens that affects us directly and the we want it fixed NOW.

20 years ago when we were working on getting scheduled drug privileges here in Texas I participated in a mediated discussion between us, NPs and physicians. There were 5 from each drawn from our representative organizations. The first thing I was asked (with a finger wagging in my face) was "are you trying to be independent?" My answer that day was "we don't even have a lunatic fringe that talks about it." Now I am the lunatic fringe.

I support FPA but don't see it as an all-or-none proposition. I currently am working what will probably be my last job and I have enjoyed as much autonomy and respect from my physician colleagues as anyone could ask for. I don't really have any skin in the game beyond wanting to see the profession advance. 

I don't think anyone really believes that with the stroke of a pen all restrictions for either profession should just be swept away. Big changes need to be done in a measured and thoughtful way. I also hope nobody thinks FPA would suddenly allow a PA or NP to be any kind of specialist. It isn't true for physicians so obviously it wouldn't be true for us. What FPA is and should be is a mechanism to remove piles of needless regulation about supervision that doesn't really serve anyone. It doesn't make patients safer and it doesn't improve access to care so it needs to be done away with.

Should a new grad have FPA? Probably not. Should there be a test to have full practice authority? No... It is about everyone staying in their lane and using some common sense. Strip away the hysteria and the name calling and create systems that improve access to care without hurting quality of care. If you want supervision make an argument for it that is based on measurable evidence and not hysteria. If you don't think supervision of any kind is necessary make that argument with facts... measurable verifiable facts. "I'm better than most of the physicians I know" might be true but isn't the kind of broad historical or measurable evidence that advances the argument. Neither is "people will die" which I heard so much over the years I was pretty sure it was on the flag in front of the Texas Medical Association. 

What we have now is outdated and not needed. It is time for things to change. Keep the conversation going! Let your legislators know what you think. Let your associations know what you think. But hey.... keep your passion pointed at the issue and not the folks who disagree with you.

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NPs are kicking sand in our faces again. PAs keep saying, "it's not so bad" and "let's move our beach towels" and "I like the taste of sand in my teeth"

 

Seriously, NPs will have a clean sweep of all 50 states and PAs will still have zero states with independent practice. This is like being in a battle for your life and your position has been overrun. Instead of fighting, the PAs just give up and pull out pictures of their wives and children and think fondly of better times while they get skewered. 

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NPs are kicking sand in our faces again. PAs keep saying, "it's not so bad" and "let's move our beach towels" and "I like the taste of sand in my teeth"

 

Seriously, NPs will have a clean sweep of all 50 states and PAs will still have zero states with independent practice. This is like being in a battle for your life and your position has been overrun. Instead of fighting, the PAs just give up and pull out pictures of their wives and children and think fondly of better times while they get skewered. 

(moderator hat on) Can we please turn down the rhetoric a notch or two?  You're entitled to think less of those who disagree with you, but you're bordering on being rude here.

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Vent - nobody should be forced to precept. If you or OTH want to decline precepting because of their desire to retain the status-quo, then that's your call. Or you could take students and expose them to your thoughts on the profession. But to suggest purposefully giving them a poor educational experience is uselessly damaging.

 

JM - push for self destruction? Come on....just because I don't see the doom and gloom "NURSES ARE GONNA PUT US OUT OF BUSINESS!!!!" that OTH screams incessantly doesn't mean I'm pushing for self-destruction.

 

There are areas where NPS predominate. There are areas where PAs predominate.

 

I completely understand the arguments for independent practice.

 

However I wouldn't want my wife, kids or grand kids to see an inexperienced PA (or especially NP) who didn't have some kind of medical oversight by a physician.

Boats, I understand your argument. You and I work in similar ED's (CAH's, solo coverage) Playing the devils advocate, We ( as many other PA's), make independent patient care decisions every day without physician input. By that I mean, we make the decision how to best treat the pt, and the physician reviews the chart later. Is that not, in a since independent practice? In the ED we make a  dispo. on a pt and the doc doesn't review the chart until later, unless you consult the doc for every pt? Do you? Again a form of independent practice.

 

Regarding solo ED coverage, to the best of my knowledge Montana is the only state to enact a rule that any PA must have at least 1 year of "acute care experience" before they can work solo coverage. And even that ARM is loosely interpreted.

 

My question is; What government agency/law/bill/ARM is protecting your family from these providers now (given the fact that they make independent, point of care decisions) that would not protect them from the same provider if said provider had independent practice?        

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...My question is; What government agency/law/bill/ARM is protecting your family from these providers now (given the fact that they make independent, point of care decisions) that would not protect them from the same provider if said provider had independent practice?        

The law that states PAs must be supervised by a MD/DO.  

 

The level of supervision varies greatly.  Some PAs run very independently and never call the Doc for help, other PAs are required to call the Doc for the more seriously ill patients.  With some PAs the Docs will come into the ED more often, while with other PAs the Docs know they should probably just stay OUT of the ED and let us handle it.

 

The requirement for supervision allows the MD/DOs to give, and adjust, this level of supervision more easily.

 

I understand this level of supervision can also exist in legally "independent" states, existing as hospital policy instead of legal requirement.

 

Bottom line for me is this:  We all knew PA was a dependent provider when we chose this profession.  Our education and training is no where near the level of a board certified physician.  And it seems that many of us are pushing for PA independence now simply because the NPs are doing it.  I think that's doubly wrong...NPs CERTAINLY shouldn't be independent, and instead of jumping on that $hitwagon we should be working with physician groups to shut that down.

 

Unfortunately I don't see many physician groups doing that.

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  • 2 weeks later...

This is a great thread and topic, and is an important discussion to have for the profession. In the end, the majority of PAs believe that FPAR is a good thing and should be pursued (according to the recent AAPA study). 

 

I think the bottom line here is that the PA profession MUST stand up and defend itself from NPs ever-so gaining political power. Yes it is happening! It depends on where you live but I believe that overtime if PAs do not fully embrace FPAR we will see more threat from independent NPs.

 

With that being said, I do think we have other issues as a profession. One major threat I have seen first hand while interviewing with different schools, is the relatively recent evolution of PA programs accepting students who are not nearly qualified. As we know the PA profession was created to build on a solid foundation of experience (RN, RT, Corpsman, EMT-P, etc.). This doesn't matter much after 5 years practice as a PA, but it certainly does in those first 5 years, which makes us more competitive against NPs.

 

Lastly, and probably most importantly is the huge oversaturation about to happen with both PA programs and NP programs. This may be more of a threat to NPs as I see more and more NP programs that seem to be churning out really poor graduates.

 

But don't get me wrong, even with 5 years experience (Combat, Emergency, and Primary Care) as an FMF Corpsman, and as a medical technologist after my service, I wouldn't dare to say that I would be ready to practice fully independent out of school. I personally think FPAR is more about enabling PAs to be viewed not as assistants, but as competently trained and educated providers--FPAR would prove it!

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With that being said, I do think we have other issues as a profession. One major threat I have seen first hand while interviewing with different schools, is the relatively recent evolution of PA programs accepting students who are not nearly qualified. 

 

 

Do you believe that this is one reason for Pre-PA students to favor well-known programs with high patient care hour requirements? For example, in the past two years working at a large level 1 hospital in the midwest, I have witnessed the PA program affiliated with the hospital raise their PCE hours from 100>500>1000>2000. Yes, in the grand scheme of things 2,000 hours doesn't amount to more than ~ 2 years of full-time experience, however, considering the fact that other programs in the area "suggest PCE," or require "at least 100 hours," I think this is a key distinguishing factor.

 

Similarly, does anyone get the sense that the PA profession is playing the same dangerous game that Law did? Many (new) programs, over-saturation of the work force (which continues to be an issue), new graduates from WELL ESTABLISHED/PRESTIGIOUS programs easily gaining employment, while other students struggle after graduating and passing the necessary exams.

 

Food for thought...

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The law that states PAs must be supervised by a MD/DO.  

The level of supervision varies greatly.  Some PAs run very independently and never call the Doc for help, other PAs are required to call the Doc for the more seriously ill patients.  With some PAs the Docs will come into the ED more often, while with other PAs the Docs know they should probably just stay OUT of the ED and let us handle it.

The requirement for supervision allows the MD/DOs to give, and adjust, this level of supervision more easily.

I understand this level of supervision can also exist in legally "independent" states, existing as hospital policy instead of legal requirement.

Bottom line for me is this:  We all knew PA was a dependent provider when we chose this profession.  Our education and training is no where near the level of a board certified physician.  And it seems that many of us are pushing for PA independence now simply because the NPs are doing it.  I think that's doubly wrong...NPs CERTAINLY shouldn't be independent, and instead of jumping on that $hitwagon we should be working with physician groups to shut that down.

Unfortunately I don't see many physician groups doing that.

I did know we were dependent when I went to PA school. Now, five years later, I have discovered that I am more intellectually enabled than half of the doctors I work with. I have surpassed at least one third in my capabilities to an extent that I cannot trust them for consultation on a patient. I want independence to unshackle myself from the brainless deadweight who suck money out of my wallet but offer nothing in return for supervision fees.

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This is a great thread and topic, and is an important discussion to have for the profession. In the end, the majority of PAs believe that FPAR is a good thing and should be pursued (according to the recent AAPA study). 

 

I think the bottom line here is that the PA profession MUST stand up and defend itself from NPs ever-so gaining political power. Yes it is happening! It depends on where you live but I believe that overtime if PAs do not fully embrace FPAR we will see more threat from independent NPs.

 

With that being said, I do think we have other issues as a profession. One major threat I have seen first hand while interviewing with different schools, is the relatively recent evolution of PA programs accepting students who are not nearly qualified. As we know the PA profession was created to build on a solid foundation of experience (RN, RT, Corpsman, EMT-P, etc.). This doesn't matter much after 5 years practice as a PA, but it certainly does in those first 5 years, which makes us more competitive against NPs.

 

Lastly, and probably most importantly is the huge oversaturation about to happen with both PA programs and NP programs. This may be more of a threat to NPs as I see more and more NP programs that seem to be churning out really poor graduates.

 

But don't get me wrong, even with 5 years experience (Combat, Emergency, and Primary Care) as an FMF Corpsman, and as a medical technologist after my service, I wouldn't dare to say that I would be ready to practice fully independent out of school. I personally think FPAR is more about enabling PAs to be viewed not as assistants, but as competently trained and educated providers--FPAR would prove it!

I have to repeat myself. We are being overrun by NPs but we won't win the battle by attacking them or by trying to compare yourself to them. Doing that is foolishness because you don't understand the power of branding. NPs have a brand that is recognized and understood. You can try all day long to tell someone you are better than an NP but it doesn't matter. Their brand wins. Nobody in the AAPA leadership has ever thought about the PA brand which is why we will be extinct in ten years. The hype here is an attempt to milk a cash cow. The leadership of AAPA andNCCPA are old timers who are not invested in the future. They will retire just before the ship sinks.

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Do you believe that this is one reason for Pre-PA students to favor well-known programs with high patient care hour requirements?

 

 

YES.

 

There should be a 4-6 year HANDS ON prerequisite.

 

UW seattle class, 2009. Youngest person in our class was 24f- Army medic, fresh back from Iraq; least experienced was a 27f labtech with a masters (borderline genius I would say).

 

The labtech, despite her advanced degrees, struggled all the way through.

 

There is absolutely NO substitute for HCE and making it a notional prereq is diluting the strength of our greatest asset as PAs- diversity and depth of knowledge+ bedside manner.

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Do you believe that this is one reason for Pre-PA students to favor well-known programs with high patient care hour requirements?

 

 

YES.

 

There should be a 4-6 year HANDS ON prerequisite.

 

UW seattle class, 2009. Youngest person in our class was 24f- Army medic, fresh back from Iraq; least experienced was a 27f labtech with a masters (borderline genius I would say).

 

The labtech, despite her advanced degrees, struggled all the way through.

 

There is absolutely NO substitute for HCE and making it a notional prereq is diluting the strength of our greatest asset as PAs- diversity and depth of knowledge+ bedside manner.

 

 

The profession has gotten away from what made us unique and qualified to practice medicine after two years of training to begin with.  Medical professionals with experience but no legal way to utilize that training/experience.

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UW seattle class, 2009. Youngest person in our class was 24f- Army medic, fresh back from Iraq; least experienced was a 27f labtech with a masters (borderline genius I would say).

 

The labtech, despite her advanced degrees, struggled all the way through.

 

Holy cow, a 27f labtech with an MS struggled PA school.  The only possible conclusion I can draw from this is that the following individuals are poor candidates:

 

Individuals over the age of 27.

Individuals with graduate degrees.

Laboratory technicians.

Females.

 

Now we're getting somewhere.

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The profession has gotten away from what made us unique and qualified to practice medicine after two years of training to begin with.  Medical professionals with experience but no legal way to utilize that training/experience.

I seem to recall reading somewhere that the original PA program was based off of a trial program that was used in the US during the Second World War to train more physicians faster and get them out the door...guess the global "they" have forgotten that somewhere along the line.

 

SK

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There is one law that needs to be changed that would go a long way to helping our profession reach the heights that so many of you believe we should- make PAs able to do direct billing to Medicare.  

 

All this talk of full accountability and responsibility means nothing if you can't control your own ability to make money.  NPs can direct bill through Medicare, which has a trickle-down effect to private insurance and other payors.  

 

You really want to control your own destiny as a profession?  Get this one law changed, THEN work on states and implementing the aspects of FPAR.  To me, the effort is slightly misguided without putting all of our resources to this one endeavor

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Steve- how about a conclusion of:

 

Substituting academic achievement for HCE is a no go.

 

First and foremost let us not forget our roots-- Medics returning from war with tons of experience and unable to use it in the civilian world. The entire profession is based on building upon HCE that you bring to the table. The minute we stepped away from that, we were heading in the wrong direction.

 

You want to put FPR in the hands of a PA who was a pt sitter for 2 years, fresh out of school and we are going to look like a bag of d&&ks to our MD/DO counterparts.

 

We need to return to more stringent standards of entry to PA school, and IF the PA body as a whole decides to push this FPR, its going to have to have a requisite experience level and/or a boarding process.

 

Its ok Bannon- I'll get you there brother.

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