Why are we making nice with NPs?

[physasst]

physasst: (below taken from another thread on health policy, but the following questions fit well here) Did the topic of the professional title of physician assistant vs. physician associate come up during the course of your conversation with Timothy Johnson? Did he mention any comparison of PAs to NPs? Also, how do you think he perceives the PA profession? And, any hope for a plug on ABC World News?

 

"On a bright note, I had a 30 minute conversation with Tim Johnson, MD from ABC news about PA' s and our contributions to healthcare...It was a great talk. I actually talked with him for about 3 hours, but only 30 minutes on PA's.....better than nothing...."

 

 

The topic of our professional title did not come up. We spoke primarily about changes to reimbursement mechanisms, primary care workforce, and ACO's, and how PA's fit into those scenarios...We spoke primarily of PA's and our history of working in primary care. I got the sense that he's not really worked clinically with any PA's, and therefore is sort of neutral on the use and deployment of PA's. I don't think that he is necessarily against PA's, but he's definitely still old school. My impression was that he thinks PA's and NP's need supervision, and should be primarily seeing lower acuity illnesses, although he never came out and said that exactly. Our discussions were more of the bigger picture "How will PA's and NP's fit into new models like the ACO" type of thing.

 

I wouldn't count on any plug on ABC News, but I am working on a possible story on PA's with CNN. In fact, you just reminded me, I need to talk to my friend there again. We had started some preliminary talks, and then the holidays hit, and we haven't talked about it again......Sending email tonight....

[physasst]

You're saying two different things. The argument was losing primary care workforce. More PA matriculants does not mean more PAs and it certainly doesn't mean more primary care PAs; the trend is toward specialization.

 

No matter what level of education or degree people attain, they will go to where the security and jobs are; specialties.

 

I agree with you Andersen, my point was that establishing a PA doctorate won't change that.....PA's are following specialty trends mirroring that of our physician colleagues. In fact, I am in the process of doing a large, national representative study of PA's...(HINT, many of you on here may recieve an electronic survey, PLEASE fill it out) to try and examine the factors behind PA specialty selection.

 

Everyone says money, but many of the studies done on the physician workforce have revealed that money is NOT the primary factor behind specialty selection.....I think we need to better understand what is motivating PA's....

 

SO, if you get a survey....please help our profession, by helping to better understand what made you choose whatever specialty you are in.....

[physasst]

Cabkrun

The humanitarian types will go to rural and inner city clinics if they TRULY believe in the humanitarian cause. A difference of 25k in student loans shouldn't shake your foundation of altruistic beliefs.

Do not respond so flippantly with "If a PA wants to get a doctorate then why not just become an MD". Shows a lack of understanding of the argument, the topic and what is at stake for PAs. This is about market viability and competition against the DNP and we are losing.

 

I'm curious as to where you are getting "A difference of 25k in student loans".....

 

I don't know the answer, but if you are making the schooling twice as long, you cannot have a fractional increase in tuition, right?

 

I mean I haven't looked up tuition rates for PA school, or for the DNP programs, but that certainly doesn't sound right....

[Grinder993]

Well physasst how do you figure that PA school would be TWICE as long?? The DNP program adds only 6 months. My residency program added 1 year. My PA program cost me 25k per year. So you do the math.

[physasst]

Well physasst how do you figure that PA school would be TWICE as long?? The DNP program adds only 6 months. My residency program added 1 year. My PA program cost me 25k per year. So you do the math.

 

 

A doctoral degree should be 4 years in length after your baccalaureate....If PA school is typically 2 years, than that would add an additional 2 years. Heck, many PhD's are 5-6 years in length to complete. I'm not sure which DNP program you are referring to, but a quick google search showed programs ranging from 3-4 years for those without their NP, and 1-2 for those who are just looking for degree completion and already have their NP.

 

Adding 1 year onto PA school and then calling it a doctorate is a farce, nothing more than a shell game....but, I at least understand your logic now....

 

I'm still completely and utterly opposed to the idea, and will definitely advocate and speak against it at the national and state levels, but I understand your post about 25k now.

 

If you believe in it, then you should advocate for it. You should always push for what you believe in, but there will be many, many PA's who will speak out against it.

 

Good Luck Grinder.

[bobuddy]

I'm still completely and utterly opposed to the idea, and will definitely advocate and speak against it at the national and state levels

 

I dont get it. Why are you so opposed to the PA's progressing (or rather staying competitive in today's market) and the PA path evolving into a better opportunity for most of us? Its great that you work in the sheltered halls of the Mayo Clinic - but for the rest of us - we NEED this. JMJ is opening his own clinic - WOW - great for him. Why would you want to stand in the way of that for the rest of us????

[physasst]

I dont get it. Why are you so opposed to the PA's progressing (or rather staying competitive in today's market) and the PA path evolving into a better opportunity for most of us? Its great that you work in the sheltered halls of the Mayo Clinic - but for the rest of us - we NEED this. JMJ is opening his own clinic - WOW - great for him. Why would you want to stand in the way of that for the rest of us????

 

Where did I say I was opposed to PA's progressing? Wow, I never said that. Mike is opening his own clinic and that is awesome. I have really happy for him, and not just because he's on this board, but because I know him personally, and I consider him a friend.

 

I stated earlier that I support removing barriers and restrictions to increasing PA autonomy and practice. I think PA's SHOULD be able to own their own clinics, and should be able to see their own patients, and practice with a high degree of autonomy. I think that a LOT of our states laws need to be revised, and revisited to make the employment of PA's easier for physicians, groups, and hospitals. I want to see the PA profession flourish....I want to see it grow....

 

I am only opposed to COMPLETE independence, and/or having a mandatory doctoral degree. Those are my feelings. I practice pretty much on my own now, and in one ER I moonlight in (rarely now, cause simply no time) there are no physicians on site, it is staffed and run completely by PA's with a physician always on call as backup.

 

I think we need to work on the Medicare language, work with CMS, work with our state medical licensing boards, continue to work with HHS regarding regulations pertaining to ACO's and PA involvement and utilization. We need to work on increasing the PA supply to primary care, and in particular to rural and underserved areas. We need to develop a standardized practice, or utilization privileges that should be adopted by ALL States, so that utilization and prescribing rights are not variable from one state to the next....We need to work on our recertification process, and make that easier...we need to ensure dialogue with the AMA, ANA, and other national organizations, not as subordinates, but as colleagues.

 

I've long, long believed that PA's, and our national organization need to move away from the subordinate positions that we sometimes either put ourselves, or find ourselves in with respect to physicians, and establish a more collegial attitude of teamwork and partnership.

 

I support the name change, and was one of the first 50 PA's to sign Dave's letter.....

 

You're assuming that because I oppose an entry level doctoral degree for the profession, that I oppose us progressing and maturing. Quite the opposite actually. I do oppose complete independence, because, even if it only involves a radio or phone call, I think PA's should have some ongoing dialogue at times about their patients. We should have that safety net.

 

I am opposed to the doctoral degree, cause, well, it doesn't make sense from a workforce perspective, and in my humble opinion, there are FAR, FAR too many other things for our profession to dedicate our limited resources to.

 

I hope that helps to clarify.

 

Mike

[Moonwalk]

I agree with Marilyn - here in KY, NP's have the ability to practice independently and have their DEA. I overhear docs talking on a regular basis about "why hire a PA because we are a PITA to supervise when they can hire a NP and not have to worry about the supervisory regulations". More and more job listings are for NP's ONLY. Even at UK where we have a PA program - lots of NP listings for jobs and nothing for PA's. Face it, NP's are just as good as us - salary is the same, but less "work" for the docs. Why even hire a PA then?

 

I will repeat what I said in a different thread - PA's as dependent practitioners need to be a thing of the past. Sure, the PA's were initially supposed to compliment the MD's but isn't that what the nurses were supposed to do also? Come on, times are changing and we need to either get with the program and be part of the future or hang it up and kiss our jobs goodbye.

 

So, what you are saying is that the NP's are perceived as the better hire because the PA is too much trouble to supervise. So how do we level the playing field?

 

Obviously, the state laws need to be made equitable for both PA's and NP's--otherwise you are in a losing battle. Some PA's choose to move to states with a favorable practice climate for PA's, and avoid those with an unfavorable one. In terms of eliminating the supervisory hassle for physicians, consider what the various options might be:

 

1) becoming such a competent PA that the doctor really doesn't need to do much of anything

2) pushing for independent practice (completely autonomous)

3) developing a transitional pathway to independent practice

 

There are some other issues regarding the perception of PA's and the perception of NP's in the job marketplace.

a) public relations. The name change to something other than assistant. Most of the profession favors the Physician Associate name.

b) the degree. The DNP degree does not add a whit of clinical competence or expertise to an NP education, unfortunately. The DNP degree is not about medicine, nor is it a medical degree. My understanding is that it is an NP program with added courses on health care delivery systems. However, if it leads to the PERCEPTION that an NP's education and training is superior to that of a PA, then perhaps we need to counter with a comparable degree/prestige for PA's in order to be competitive. Could be a PA-to-MD bridge program. Could be a formal residency that leads to a clinical doctorate, along with an upgrade in professional privileges and status, such as Senior PA. Only our program/degree would actually have clinical meat in it, instead of being more fluff about nursing theory or the health care delivery system.

 

If we're going to compete, we need to consider what all of our options might be. And lastly, there is the option of daily demonstrating excellence and competence in everything we do as PA's, gradually winning the respect of the medical profession and of patients. Another option is a massive PR campaign to promote PA's and the PA-MD team concept.

 

Seriously, if I were a nurse (which I am not), and wished to advance as a clinician and had to choose between investing four years of my life pursuing a DNP degree or investing that same four years of my life into medical school, which do you think I would choose? Which do you think most nurses would choose? Or are they choosing DNP school because they never got the basic prerequisites required for medical school, or can't score well enough on the MCAT to be accepted in medical school? I had many nursing friends when I was an undergraduate. Some went on to become NP's, but at least two of them ultimately decided that medical school was a better investment. One became a pediatrician and one became a plastic surgeon. However, they were also serious pre-med nursing students as undergraduates--they took the premed prerequisites (organic chemistry, etc. premed bio, chem, & physics) and made high-enough GPA's to be competitive for medical school.

[Moonwalk]

Or are they choosing DNP because they can do it online, while continuing to work full or part time with "arrange-your-own" clinical rotations?

[bradtPA]

The problem is not the NPs, but their lobbying organizations. You need to fight fire with fire. In NC, we have lobbied extensively for the rights that we have as PAs. I enjoy the rights to practice without cumbersome restrictions because of the work that has been done by some dedicated folks over the last forty years.

 

And the clinical doctorate is not the answer to your lobbying problem. It's a lack of funds in your state organization holding you back....

[physasst]

The problem is not the NPs, but their lobbying organizations. You need to fight fire with fire. In NC, we have lobbied extensively for the rights that we have as PAs. I enjoy the rights to practice without cumbersome restrictions because of the work that has been done by some dedicated folks over the last forty years.

 

And the clinical doctorate is not the answer to your lobbying problem. It's a lack of funds in your state organization holding you back....

 

+1...nothing more to add.

[Grinder993]

+1...nothing more to add.

 

Wow...childish.

 

You keep beating your drum about "entry level Doctorate" clearly you didn't read my earlier posts I have made it clear that I am willing to keep the Masters but we should have a Doctorate option.

And why do you think that getting a Doctorate degree = complete independence?? Have I ever said that PA's should have no collegial relationship with an MD?? I have not said that at all, yet you just don't get it and you never will. Fortunately you are likely at the end of your career because you are so entrenched in the old mindset that you cannot listen to reason.

 

And yes, the University of TN NP program added 6 - 12 months to the existing curriculum to do an online at your pace "research" project and they call it a Doctorate. Again though, you don't understand. The legitimacy of such a degree to you and I means NOTHING!! It is only what the public thinks!!! Please understand that public perception means everything and we are LOSING!! The public thinks a Doctorate is better than an Assistant!!!

[bobuddy]

I stated earlier that I support removing barriers and restrictions to increasing PA autonomy and practice. I think PA's SHOULD be able to own their own clinics, and should be able to see their own patients, and practice with a high degree of autonomy. I think that a LOT of our states laws need to be revised, and revisited to make the employment of PA's easier for physicians, groups, and hospitals. I want to see the PA profession flourish....I want to see it grow....

 

I am only opposed to COMPLETE independence, and/or having a mandatory doctoral degree. Those are my feelings. I practice pretty much on my own now, and in one ER I moonlight in (rarely now, cause simply no time) there are no physicians on site, it is staffed and run completely by PA's with a physician always on call as backup.

 

I think we need to work on the Medicare language, work with CMS, work with our state medical licensing boards, continue to work with HHS regarding regulations pertaining to ACO's and PA involvement and utilization. We need to work on increasing the PA supply to primary care, and in particular to rural and underserved areas. We need to develop a standardized practice, or utilization privileges that should be adopted by ALL States, so that utilization and prescribing rights are not variable from one state to the next....We need to work on our recertification process, and make that easier...we need to ensure dialogue with the AMA, ANA, and other national organizations, not as subordinates, but as colleagues.

 

I've long, long believed that PA's, and our national organization need to move away from the subordinate positions that we sometimes either put ourselves, or find ourselves in with respect to physicians, and establish a more collegial attitude of teamwork and partnership.

 

Yes, I agree to most of this. Starting with the name change. Thank you for clarifying your position on these issues. I think we are more on the same page than not.

 

As I have stated before, my doctorate has done NOTHING for me as far as getting a job or better pay. However, when a patient/MD/co-worker hears that I have a doctorate, you can see their faces change. Somehow, I know more now than I did a minute ago. Their perception of me has changed. That is what the DNP is doing for the NP profession. Yes, their doctorate may be "fluff" but public perception is that they ARE better than the Physician ASSISTANT. I do agree that we have bigger battles to fight - but I think ultimately we may be fighting that one too. The ANA is doing a fine job promoting the DNP - how is the AAPA promoting us in that regard?

 

So, what you are saying is that the NP's are perceived as the better hire because the PA is too much trouble to supervise. So how do we level the playing field?

 

Obviously, the state laws need to be made equitable for both PA's and NP's--otherwise you are in a losing battle. Some PA's choose to move to states with a favorable practice climate for PA's, and avoid those with an unfavorable one. In terms of eliminating the supervisory hassle for physicians, consider what the various options might be:

 

1) becoming such a competent PA that the doctor really doesn't need to do much of anything

2) pushing for independent practice (completely autonomous)

3) developing a transitional pathway to independent practice

Yes to either 2 or 3. Number 1 option doesn't deal with the obstacles in the way of PA's. My competence (or incompetence depending on which day you ask me) level has nothing to do with the baggage that I carry with me to a hiring physician/hospital/clinic - signing charts, signing prescriptions, supervisory rules, etc. I do think we need to push for independent practice - completely autonomous. Without that, we won't hold a candle to what the NP's can already do. I would also support a transitional pathway to independent practice - but I still think that slows us down and puts us behind the eight ball when a PA applies to the same job that an NP can do on day 1 of graduation.

[Fairmeadow]

Speaking of lobbying efforts, I would like to know how PA's came out to be optional providers with CMS, and NP's, along with physicians, came to be mandatory providers. How was the AAPA involved in that? What were their lobbying efforts compared with the nurses' lobby. I don't think that money or numbers had much to do with it. That would not make any difference in whether 2 or 3 people from AAPA vs. 2 or 3 people from ANA were constantly hammering CMS. Was it that they tried harder? Does anyone know the story behind the lobbying efforts?

[physasst]

Yes, I agree to most of this. Starting with the name change. Thank you for clarifying your position on these issues. I think we are more on the same page than not.

 

As I have stated before, my doctorate has done NOTHING for me as far as getting a job or better pay. However, when a patient/MD/co-worker hears that I have a doctorate, you can see their faces change. Somehow, I know more now than I did a minute ago. Their perception of me has changed. That is what the DNP is doing for the NP profession. Yes, their doctorate may be "fluff" but public perception is that they ARE better than the Physician ASSISTANT. I do agree that we have bigger battles to fight - but I think ultimately we may be fighting that one too. The ANA is doing a fine job promoting the DNP - how is the AAPA promoting us in that regard?

 

Yes to either 2 or 3. Number 1 option doesn't deal with the obstacles in the way of PA's. My competence (or incompetence depending on which day you ask me) level has nothing to do with the baggage that I carry with me to a hiring physician/hospital/clinic - signing charts, signing prescriptions, supervisory rules, etc. I do think we need to push for independent practice - completely autonomous. Without that, we won't hold a candle to what the NP's can already do. I would also support a transitional pathway to independent practice - but I still think that slows us down and puts us behind the eight ball when a PA applies to the same job that an NP can do on day 1 of graduation.

 

 

Well, just to put this out there. How do we achieve "independent" practice? We, like it or not, are regulated, licensed, registered, etc, by our State's Medical Boards.....We would have to convince all 50 of them to allow this.

 

NP's are under the Board of Nursing instead...(Something I disagree with, but alas, they don't listen to me), with the lobbying power, and money that comes with 4 million nurses, and being under a different regulatory body, independence was something that was easier for them to achieve than us.

 

The AAPA could come out and support independent practice tomorrow, and it wouldn't make a bit of difference. Until you can convince 50 state legislative sessions, and 50 state medical licensing boards...it's never going to happen. And you'd better have a lot more money than the AAPA currently has to even consider it.

 

As far as me....nah, I got another 15-20 years left in practice....I'm going to be around for a LONG time....even then, I might work until I'm 70 or 75.....I really can't imagine ever retiring.

[archerry]

Another win for NPs orginated via the use of the term "collaborative agreements". Although this is essentially a supervisation agreement not unlike the rules and regs that PAs are subject to, but it sounds a lot more like "we agree to work together - me, independently within scope bounds and oversight mutual agreed upon with you, a physician".

 

This, I think, is the way to go, rather than full independence. Three reasons: a) I think full independence is an arrogant overstep; b) it would be politically more appealing than full independence (big pushback here from the MDs) and has precedent in most State laws; and c) we may see the pendulum swing our way (with support from the MDs), as we are still working "inside the system" together with the MDs, shaping on a practice-by-practice basis the scope of independence, while the NPs may be perceived as going rogue.

[Fairmeadow]

I agree that fully independent practice is not the way to go. No one truly practices independently these days, not an MD, or anyone else. Medicine is too complicated for that. What we PA's need is the ability to control our own destinies. It is unAmerican and immoral for the MD profession to be able to decide whether they are going to let me practice my profession and to decide how they are going to let me do it. When I am dependent on them like that, I am nothing more than a slave. I have no problem with collaborative agreements that provide for consultations and referrals to optimize patient care.

[Joelseff]

Archerry Has a good point! hmmm, but I think this would require a HUGE effort by the state legislative bodies to convert our "Supervisory" Relationship to a "Collaborative" one. Heck we cant even get a name change passed! LOL

[archerry]

Archerry Has a good point! hmmm, but I think this would require a HUGE effort by the state legislative bodies to convert our "Supervisory" Relationship to a "Collaborative" one. Heck we cant even get a name change passed! LOL

 

How do you eat an elephant? One bite at a time.

 

Pick a single State that has pro-PA laws already in place, a strong State organization, good relationships/support with medical organizations, and access to a legislator. Get a commitment from the advocacy group to pursue moderate but significant changes. Have a special membership or donation drive to support the initiative.

 

For example, say NC (again, just an example); if the NC State PA organization will stand-up for the initiative, we could nationwide join this organziation or donate to the initiative to forward the cause in one single State. Many States copy legislation from other States, as it gains validity.

 

Any thoughts on candidate State organizations that could use the support of a few thousand new members?

[physio]

How do you eat an elephant? One bite at a time.

 

Pick a State that has pro-PA laws already in place, a strong State organization, good relationships/support with medical organizations, and access to a legislator. Get a commitment from the advocacy group to pursue moderate but significant changes. Have a special membership or donation drive to support the initiative.

 

For example, say NC (again, just an example); if the NC State PA organization will stand-up for the initiative, we could nationwide join this organziation or donate to the initiative to forward the cause in one single State. Many States copy legislation from other States, as it gains validity.

 

Agree 100%

 

I believe in Alaska, PAs work "in-collaboration" with physicians and from what I gather, it is the only state to have such wording. This would be a huge hurdle for PAs as once the ball gets moving, more and more states could be likely to follow. In many cases, supervision & collaboration mean essentially the same thing, but perception is key. To the lay man, supervision sounds like baby-sitting. Collaboration sounds like a mutual agreement. It doesn't matter if they mean the same thing medically speaking, but I believe the AAPA needs to pay more attention to public perception of our profession than it is currently is.

[Joelseff]

I believe the AAPA needs to pay more attention to public perception of our profession than it is currently is.

 

Bump!!! I know some may argue that AAPA IS working on PR but they aren't very effective. At least compared to other professions, namely the Nurses (I know, I know, The AAPA isnt as big or powerful blah blah blah...)

[Moonwalk]

So, in order to have "collaborative practice" as opposed to "supervisory relationship" we would need to define the "scope of practice" of a physician assistant (or Physician Associate); somehow that scope of practice would need to be distinct from that of a physician, I believe.

 

How do we define that scope of practice for a profession that covers umpteen different specialties? And does that mean that if your PA education did not include certain aspects of care, then you cannot practice in that arena? Is this truly an improvement over the concept of a scope of practice that is delegated by your supervisory physician? Or do we promote autonomy for minor illlnesses and preventive care, while accepting a different sort of responsibility for complex and/or acutely/critically ill patients? Should PA's have independent hospital admitting privileges?

[physasst]

Another win for NPs orginated via the use of the term "collaborative agreements". Although this is essentially a supervisation agreement not unlike the rules and regs that PAs are subject to, but it sounds a lot more like "we agree to work together - me, independently within scope bounds and oversight mutual agreed upon with you, a physician".

 

This, I think, is the way to go, rather than full independence. Three reasons: a) I think full independence is an arrogant overstep; b) it would be politically more appealing than full independence (big pushback here from the MDs) and has precedent in most State laws; and c) we may see the pendulum swing our way (with support from the MDs), as we are still working "inside the system" together with the MDs, shaping on a practice-by-practice basis the scope of independence, while the NPs may be perceived as going rogue.

 

 

I agree with this post completely....

[ventana]

just a comment to stress

 

it is all about the money and the lobby - I don't like that AAPA doesn't tend to jump into the fights but at the political level everything is about $$$ - if they do not have the $$ to lobby they will be ineffective - whereas the NP and nursing lobby is rich with cash and hence influence - you can be the best clinician in the world but with out an effective lobby you will get no where in politics

 

So - how does this apply to this thread? I am not sure it is good to boycott AAPA as they are really our only national agency - if you do not belong to them who do you belong to that gets (even a little bit) into the political areana? Not joining any one agency and then saying they all stink is ineffective......

[lizchao74]

@bcstout:

 

What state were you in where you encountered those restrictions on PA practice? Just curious.

 

Thanks,

Lissette