Jump to content

Why PAs should not have Autonomy


Guest Paula

Recommended Posts

I personally think the authors of the letter have Autonomy and Independence confused.   Autonomy does not mean we will sever ties with physicians.  Autonomy means the PA license is not tied to an SP and allows us freedom to not lose our jobs and be dependent on the physician for our sustenance. Graduated autonomy such as in the VA is a good thing and should lead to an autonomous license.  The team based care concept is the PA mantra but I do not hear or read about physicians who hail it as the answer to the problems of the American health care system (unless physicians are the leader of the team).  

 

Physicians do not mentor and train PAs in the practice setting.  I have not had one single physician who ever really mentored me in the way the authors project they do. Maybe in EM physicians mentor and train PAs in OTJ......I don't know.

 

Plus, have the authors heard of the CAQs and do they know they will be required eventually by insurance companies, employers, etc. for PAs to get hired? Our lateral mobility will not be so fluid in the future.   BTW.....I am not against CAQ.  I wish I could get one but am in the wrong discipline.......FP and IM. 

 

The article does not address the proliferation of the NP profession as the first go-to choice for many hospitals and clinics over the PA profession....at least that is the case in my neck of the woods.  

Link to comment
Share on other sites

I think between Hooker's letter and Cawley's that this is the start of a national conversation.

I think both author's have reasonable points of view with elements that I agree.

The difficult process will be developing a plan that will lift the herd up to the next level while not causing a detriment to the profession as a whole nor to significant constituents WHILE being amenable to the varied state agencies and other organizations our profession is held accountable to.

I recently was discussing this issue with a colleague whom has participated in PA national, state and specialty organizations for over a decade.

His thought process is that our profession has greatly benefited from our association with physicians throughout the decades and that this association should continue in order to benefit.

Conversely, he thought there needs to be better recognition of what PAs bring to the healthcare workforce as a solution. This recognition should extend to improved reimbursement, reasonable compensation, practice ownership opportunities, improved educational resources, standard posteducation training and specialization.

Likely this conversation is just the start, more to come in the future with plenty of effort to be exerted to move forward. 

G Brothers PA-C

Link to comment
Share on other sites

I personally think the authors of the letter have Autonomy and Independence confused.   Autonomy does not mean we will sever ties with physicians.  Autonomy means the PA license is not tied to an SP and allows us freedom to not lose our jobs and be dependent on the physician for our sustenance. Graduated autonomy such as in the VA is a good thing and should lead to an autonomous license.  The team based care concept is the PA mantra but I do not hear or read about physicians who hail it as the answer to the problems of the American health care system (unless physicians are the leader of the team).  

 

Physicians do not mentor and train PAs in the practice setting.  I have not had one single physician who ever really mentored me in the way the authors project they do. Maybe in EM physicians mentor and train PAs in OTJ......I don't know.

 

Plus, have the authors heard of the CAQs and do they know they will be required eventually by insurance companies, employers, etc. for PAs to get hired? Our lateral mobility will not be so fluid in the future.   BTW.....I am not against CAQ.  I wish I could get one but am in the wrong discipline.......FP and IM. 

 

The article does not address the proliferation of the NP profession as the first go-to choice for many hospitals and clinics over the PA profession....at least that is the case in my neck of the woods.  

 

Absolutely. 

 

Admittedly, the authors do paint an appealing picture of an ideal PA-physician relationship.  I think there is merit in the concept of an SP functioning as a type of built-in consultant that allows the PA to provide a higher level of care, especially when contrasted against a now largely independent NP movement.

 

The problem with their argument, IMHO, is how conditional the entire house of cards is.  IF the practice values PAs, IF the physician is willing to mentor and teach, IF the physician is amenable to the concept of graduated autonomy and advanced practice.  These are HUGE question marks that directly influence our professional direction not to mention our day-to-day job satisfaction.  And, as many of us have unfortunately experienced, not all of our physician colleagues are willing to play ball.  We need more control over our own profession, plain and simple.

 

So, how do we mitigate (or  at the least address these variables) without a little push back.  I echo the statement above by G. Brothers in that I hope this leads to a larger national discourse on the subject.

Link to comment
Share on other sites

  • Moderator

Mr. Cawley is an academic and out of touch with the realities of clinical practice. In his world, SPs are benevolent teachers trying to make every PA the best they can be, but in the real world most docs have no time for teaching and think of PAs as a burden requiring supervision. 15 years ago he and I exchanged several letters to the editor in one of the PA journals about the coming reality of doctorates for PA faculty. I took the position that it was the future and training programs would arise to meet that need. This was before the rise of the DHSc programs when very few PA faculty had doctorates. I pointed out that it happened to every other similar profession. He disagreed and said PA faculty would never need doctorates...he was wrong then and he is wrong now....PAs need more autonomy AND independence in order to compete with the NPs. we are losing ground to them in outpt settings and if they really want PAs to work in primary care they need to make it as easy for us as it is for them. Along with autonomy and independence will likely come requirements for more education and testing in the form of mandatory residencies/fellowships and CAQs/exams. I am ok with that. that trend also has already played out for others(docs) and it will do so for us as well.

Link to comment
Share on other sites

The world is changing.  Fellowships, residencies, CAQs, doctoral degrees  for PAs etc.  No medical provider practices in a vacuum.  Defining autonomy that way is wrong for anyone, nurses, MDs, PAs.   Interdependence will be the rule and collaboration will be expected for everyone.  Linking licensure, though, does not make sense anymore.  Nurses carry out medical orders but their licenses are not linked.  For PAs,  it made some sense in the old private practice model, but less than 20% of physicians practice that way.    Licensees will be responsible for their own conduct (they are now) and if they fail as "effective" collaborators in any setting, they are responsible for that failure as well.  That will go for physicians, nurses, and all of us, because we are ultimately responsible together for care of the patient.  No more lone rangers, but no more servants either.   We all are responsible for pulling our own weight, but the effect will be always cumulative.   The weak link is the responsibility of all.   When a system fails, the burden will not necessarily be only on the physician, but will be apportioned out to members of the team.   It's that way now.  

Link to comment
Share on other sites

The concept of negotiated performance autonomy

 

I focus on this line. It is the ideal. But how often is it practiced ? At least once a month someone on this board feels their skills are being disrespected and under utilized. 

 

Both articles were well written and bring up useful points. Not sure there is a correct answer.

 

I am very cautious around autonomy because I have an OPINION that the profession is about to produce lower quality PA's due to student saturation. .

Link to comment
Share on other sites

As an EMT I have a state license. I cannot practice without working in an EMS system which a physician medical director. However, my state license is not contingent on working or being protocolled by that physician.

there is a big difference, where as you work off protocol we as PAs practice medicine.

Link to comment
Share on other sites

It's interesting to see these two duke it out publicly. They wrote a book together, remember (PAs in American Medicine, 1997). Rod Hooker was my teacher and I've had a beer with both of them and they are very interesting folks indeed...and both are careful wordsmiths, so I guarantee you that Jim Cawley chose "autonomy" deliberately (not independence).

I can't make sense of that myself because autonomy is generally considered among the rest of us working PAs as desirable, as something you work hard to attain.

Hmmmm. Food for thought.

Link to comment
Share on other sites

"We believe that the analogy between PAs and other types of health providers in terms of the pursuit of autonomous practice is not valid. Unlike other non-physician clinicians, such as podiatrists or optometrists, PAs do not typically have explicit limits on their scope of practice. These professions may be independent in that they do not practice collaboratively with physicians, but they actually have far greater legal limits on their practices than PAs do."

 

What are the explicit limits on the scope of FNPs in primary care, in states where they have independence? Just wondering...he kinda skips that.

Link to comment
Share on other sites

Plus PAs do have explicit limits on their scope of practice depending on the state they practice in.  I am moving from a state with great practice laws that are all determined at the practice site to a state that has specific things listed that a PA can do, which limits me to a degree.  

Link to comment
Share on other sites

So please notice folks that the former president of the PAEA said this:

 

"For PAs to practice autonomously, they would either require longer training or need to choose an area of specialty training (as NPs do) upon entry to the PA program."

 

That PAs don't have the necessary training (2000 clinical hrs) to practice autonomously in primary care, the basis of our generalist ARCPA curriculum, but NPs (500-700 clinical hrs) are more prepared. Maybe he needs some "why you should hire an NP" brochures to hand out, and finish off the process.

 

 

Yes the NP clinicals are specialty focused. But let's not kid ourselves or anyone else about the process. Enough PAs here have been involved with NP students and their clinicals to know that NP training is NOT de facto superior to PA.

 

Cawley had to go back over 200 yrs to give an example of....what? Physician turf mongering? An example that only proved that those physicians were restrictive and protectionist. He made NO mention of what those health officers were DOING.

 

"No one can seriously argue that the current model of training is sufficient to allow a newly graduated PA to practice on an autonomous basis."

 

I see the same in all providers, physicians and NPs included. PAs are prepared to work in a supportive environment just like a new psych NP or a new surgeon. We have a core of fundamentals and will encounter things we NEVER saw in training or only read about. 

 

This article is detached from real world PA practice and looks at the profession only in terms of how it serves health care at large; nothing about stewardship of OUR profession.

Link to comment
Share on other sites

  • Moderator

agree with Andersen above. what most folks don't realize is that many of us ended up with more specialty hours than the "specialist" NPs do. based on my clinical hours in school I could qualify for FNP, ACNP, RNFA, ANP, and ENP as I had > 500 hrs each in surgery, FP, EM, and adult medicine...so at 3000 hrs or so of training I'm not considered a specialist but an ACNP with 800 hrs is...

Link to comment
Share on other sites

  • Moderator

Mr. Cawley is an academic and out of touch with the realities of clinical practice. In his world, SPs are benevolent teachers trying to make every PA the best they can be, but in the real world most docs have no time for teaching and think of PAs as a burden requiring supervision. 15 years ago he and I exchanged several letters to the editor in one of the PA journals about the coming reality of doctorates for PA faculty. I took the position that it was the future and training programs would arise to meet that need. This was before the rise of the DHSc programs when very few PA faculty had doctorates. I pointed out that it happened to every other similar profession. He disagreed and said PA faculty would never need doctorates...he was wrong then and he is wrong now....PAs need more autonomy AND independence in order to compete with the NPs. we are losing ground to them in outpt settings and if they really want PAs to work in primary care they need to make it as easy for us as it is for them. Along with autonomy and independence will likely come requirements for more education and testing in the form of mandatory residencies/fellowships and CAQs/exams. I am ok with that. that trend also has already played out for others(docs) and it will do so for us as well.

 

 

So please notice folks that the former president of the PAEA said this:

 

"For PAs to practice autonomously, they would either require longer training or need to choose an area of specialty training (as NPs do) upon entry to the PA program."

 

That PAs don't have the necessary training (2000 clinical hrs) to practice autonomously in primary care, the basis of our generalist ARCPA curriculum, but NPs (500-700 clinical hrs) are more prepared. Maybe he needs some "why you should hire an NP" brochures to hand out, and finish off the process.

 

 

Yes the NP clinicals are specialty focused. But let's not kid ourselves or anyone else about the process. Enough PAs here have been involved with NP students and their clinicals to know that NP training is NOT de facto superior to PA.

 

Cawley had to go back over 200 yrs to give an example of....what? Physician turf mongering? An example that only proved that those physicians were restrictive and protectionist. He made NO mention of what those health officers were DOING.

 

"No one can seriously argue that the current model of training is sufficient to allow a newly graduated PA to practice on an autonomous basis."

 

I see the same in all providers, physicians and NPs included. PAs are prepared to work in a supportive environment just like a new psych NP or a new surgeon. We have a core of fundamentals and will encounter things we NEVER saw in training or only read about. 

 

This article is detached from real world PA practice and looks at the profession only in terms of how it serves health care at large; nothing about stewardship of OUR profession.

 

 

 

 

 

These two posts say just about all  of it

 

BUT

 

I find it strange BOTH these authors identify themselves as faculty and Educators?  

 

If you are not working in the field in the last 10 years I think you have no idea what PAs are living. 

Academics need to focus on teaching the basics - just enough to pass PANCE, but this by no means makes them experts, or even knowledgeable in what is going on in the trenches of medicine. 

 

It is disheartening to have otherwise highly educated people who are so far off the mark.......

 

 

 

 

No one practices independently - just this week I had contact with a surgeon, nephrologist, ER doc, geriatrician, and an IM doc.  We all function together..

 

 

 

What is stupid and illogical is that I can not sign the order for VNA or Hospice, I can not sign a death cert (what part of signing a form is medical practice?)  I just ask to be able to care for  my patients the way I know how with out the government putting up barriers to doing so.

Link to comment
Share on other sites

V what you're missing is that these 2 are the most prolific researchers and writers on the PA profession for the past 2 decades. When they publish anything it gets mention--and they publish prolifically. I'm not much of a name-dropper but when their names are dropped, people in the profession have generally heard of them and read their pieces.

Honestly this seems like quite a departure for Cawley...and a quizzical one at that. I can't help but think he's been out of the profession (the real actual boots-on-the-ground profession) so long that he really is out of touch in his GWU ivory tower.

Link to comment
Share on other sites

I've read Cawley's research and writing and never felt he was supportive of any progression of the PA profession.  Hooker's pieces have changed with the times. 

Link to comment
Share on other sites

We are starting to get some decent research on PAs.  Remember these citations when you advocate in your state for expanded practice rights and abolishing restrictions. 

Link to comment
Share on other sites

Archived

This topic is now archived and is closed to further replies.

×
×
  • Create New...

Important Information

Welcome to the Physician Assistant Forum! This website uses cookies to ensure you get the best experience on our website. Learn More