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FUTURE VISION - Who's Responsible??


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FUTURE VISION – WHO’s RESPONSIBLE?

As President of PAs for Tomorrow, I’ve been in a great ideological flux.  I see a dramatic dichotomy for the PA profession.  On one hand, Forbes, USA Today and the New York Times often have the PA profession as one of the top 5 or 10 most promising fields.  On the other hand, there continue to be “issues” that loom over the profession.  Name change, antiquated state laws, reimbursement inequity, and competition for jobs all intermingle with greater clinical demands such as volume production, meaningful use requirements, EMR integration among other administrative demands.  I’ve found this dichotomy difficult to reconcile.  Do we have a hopeful and stable professional future as PAs?  Or do we have a profession that is losing ground because our greater majority is either basking in the apathetic glory of a Forbes article and our national leadership that seems frozen in time, fearful of disrupting a careful balance that is teetering on dramatic change anyway?   
 

I spent the first half of my career basking in the Forbes article.  The past five years, I’ve found myself acknowledging realities of limited regional job opportunities because physicians don’t want to “supervise” PAs.  I see AMA and AAFP leadership denigrate PAs despite the financial and quality of life rewards their majority reap by working with PAs.  I see the millions of legislative nursing dollars successfully lobbying for NP independence while PAs still practice with antiquated legislation passed 40 years ago.   And I’ve watched our national leadership do some good things and ideologically progress in some ways, make promises of action in other ways and seemingly stand still in a lot of ways that matter most. 

Some say break away, form a new, more progressive PA-centric organization.  And that may be a future reality if the AAPA, as the largest organization of PAs FOR PAs, continues to stand still on issues important to their membership.  That said, there is power in numbers – and the AAPA has numbers, lots of them.  They have the most members, the most money, the most manpower and the most established connections.  With all of that comes the most responsibility and accountability to this profession. 

Ultimately, I believe that the utility of the PA profession will succeed in moving our profession forward.  Our malleability as a profession is what makes us appealing. 

I believe that the solutions come from holding leadership accountable to future vision.  That accountability will come from you, me and others who take the time to communicate with AAPA leaders who either aren't interested in change or just don't have vision.  I have no doubt that any PA colleague who takes the time to run for any AAPA leadership positon has an altruistic motive.  However, not all have true vision to lead in times of change and flux.  This is a pivotal time for the healthcare industry.  Change is evolving rapidly from a multitude of directions - seemingly all but in the best interest of patient care.  The PA profession has historically been passive in its professional advocacy efforts - safe, don't ruffle feathers, don't upset organized medicine and for gosh sakes, don't upset physicians.  Some leaders seem to be finally accepting the harsh reality that present physician generations are NOT interested in supporting the PA profession's growth and maturity beyond the 1970 standard.  Though physicians speak rhetorically of teamwork, it hasn't been a respectful, genuine or most importantly, an inclusive conversation.  Organized medicine and physicians in general are struggling to define their own future.  They've accepted PAs in their realm as long as PAs were of benefit them financially or a quality of life perspective.  Medicine has shifted dramatically and, without a doubt, has more an "each his own" mentality.

And PAs are largely on our own except where it matters most - legislatively and administratively - and usually not in support of PAs.  Physicians aren't (and have rarely been, in my opinion) busting the doors down to support PAs locally, regionally or nationally.  To the contrary, those are the arenas where organized medicine loudly voices dismay if PAs stray into uncomfortable territory.  If you want physicians to appear out of the woodwork, propose changes to prescriptive authority, "supervision" language, co-signature, or practice ownership.   The same physicians who hire only NPs to avoid the pesky task of co-signature are the same physicians who stand on the capitol steps to block bills proposing legislation to eliminate or loosen those requirements for PAs.  For the record, I have had the great fortune to work with many great physicians and have fantastic microscopic relationships with physicians who respect me and call me their friend.  Organized medicine, however, is a disingenuous 'frenemy' to the PA profession and we would do ourselves well to finally accept that reality.  It's taken me 20 years to accept what I would "feel" but not say out loud, lest I’d have to acknowledge it.  It's time that the larger PA profession leadership accept that reality and start making future policy and strategic decisions for the PA profession with that in mind.  

I have no desire to be adversarial.  I have no desire to create conflict.  But I do believe we each have a responsibility to more progressively and aggressively promote the PA profession to do good for patients.  I believe we also must do this to secure a viable and stable future for the PA profession.  This means we WILL ruffle feathers, we will be professionally adversarial when necessary and there will be conflict to resolve.  So be it.  Organized medicine will not quietly accept a progressive PA-centric platform and physicians won't collectively have an epiphany, welcoming us into the fold.  But those things haven't happened in 50 years despite our profession’s teamwork and our submission to organized medicine’s control anyway.  And the structure of the healthcare industry today is demanding a different framework that is even less conducive to respectful PA/MD relationships.  Most importantly, organized medicine hasn't been receptive to most policy and statute changes PAs have fought to achieve during our 50 year existence – it’s always been challenging, even when we’ve been perfectly compliant.  We should accept that and move forward regardless.  What were once perhaps logical laws, language and policies necessary for a young professional workforce are now unsubstantiated and often unfounded restrictions.  If a policy or statute does nothing to enhance access to care, foster true team framework or isn't a cost effective use of manpower, it needs to go away no matter who’s feathers get ruffled.   

The passivity and lack of willingness of our own to see these things is troubling.  The PA profession will need to step outside the policy box of the past and let the fear and reluctance go. We can create new vision for our future viability.  It's just simply time.  Pick up the phone, call your state AAPA HOD representative and have a talk about what the vision for the future really looks like.  They ran for office to lead.  They are responsible to do that. 

Nichole Bateman, MPAS, PA-C
PAFT President

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nice summary. I think the pa profession will need to take several bold steps over the next decade to advance the profession:

1. pursue the model legislation in all 50 states and territories. that is the biggest thing to come out of aapa leadership EVER. I'm surprised it isn't getting more press.

2. get behind the transition to doctoral programs. don't require them, but make them an entry-level option for those who see their value when faced with a DNP saturated market.

3. expand the postgraduate opportunities for PAs to gain additional training and responsibilities in all specialties.

4. improve funding for loan repayment for those pas willing to work in underserved areas and/or primary care fields

5. go after EVERY SINGLE THING NPs have been able to get through legislatures. We are at least as qualified as they are to do what they do.

6. and finally, name/title change is still an issue. assistant drags us down and always will. when new bills come up, riders need to be added that after XYZ date a clinician trained and licensed as a physician assistant may call themselves a physician associate or physician assistant. bang, done.

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nice summary. I think the pa profession will need to take several bold steps over the next decade to advance the profession:

1. pursue the model legislation in all 50 states and territories. that is the biggest thing to come out of aapa leadership EVER. I'm surprised it isn't getting more press.

2. get behind the transition to doctoral programs. don't require them, but make them an entry-level option for those who see their value when faced with a DNP saturated market.

3. expand the postgraduate opportunities for PAs to gain additional training and responsibilities in all specialties.

4. improve funding for loan repayment for those pas willing to work in underserved areas and/or primary care fields

5. go after EVERY SINGLE THING NPs have been able to get through legislatures. We are at least as qualified as they are to do what they do.

6. and finally, name/title change is still an issue. assistant drags us down and always will. when new bills come up, riders need to be added that after XYZ date a clinician trained and licensed as a physician assistant may call themselves a physician associate or physician assistant. bang, done.

 

Number 3 seems to be a problem with some PAs and faculty members of PA programs. I have no idea why. The folks at my university say its not as beneficial as one might think and that it may potentially put PAs in a position where it removes the ability to switch specialties w/o a residency. Yet on the other hand they talk about the desire to possibly have a EM PA residency. I agree with every single point you make. 

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lasteral mobility is going away on it's own. the joint commission and hospital credentialing bodies are seeing to that....many of the better jobs today say "experience required". in many markets the only way to get quality surgical or em experience is to do a residency. I think you would be hard pressed to find someone who had done a residency who wished they hadn't. I know 2 folks who have done 2. they both started out in surgery, did it for a few years and wanted to transition to something else. one did em, the other did rural medicine(this residency in WV no longer exists, unfortunately).

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The folks at my university say its not as beneficial as one might think and that it may potentially put PAs in a position where it removes the ability to switch specialties w/o a residency. 

 

It's quite a leap to think that because some PAs want to be better educated that others won't be able to switch between specialties.

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It's quite a leap to think that because some PAs want to be better educated that others won't be able to switch between specialties.

I think eventually postgrad programs will be required. the docs went through the same paradigm shift 100 years ago:

medschool required, then medschool + internship, then medschool + full residency, then medschool + full residency+ specialty board exams.

we took the first and last step already. the middle step (extra training) is coming. probably around the same time all programs become doctoral programs. ? 20 years from now?

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I think eventually postgrad programs will be required. the docs went through the same paradigm shift 100 years ago:

medschool required, then medschool + internship, then medschool + full residency, then medschool + full residency+ specialty board exams.

we took the first and last step already. the middle step (extra training) is coming. probably around the same time all programs become doctoral programs. ? 20 years from now?

 

It seems that postgrad programs are gaining major traction, at least in the EM and surgical world. As we've seen, there are more than enough new grads (more than enough being just ONE) being offered solo coverage in certain shops and clinics without postgrad experience. This just seems crazy. To stand in the way of those people getting/requiring postgrad training, I think, is irresponsible and dangerous. Not to mention it just stands in the way of progression and you'll eventually look like a fool.

 

I don't meant to flip this thread into a postgrad campaign, I think the OP has some truly great concerns and desires for our (my future) profession. We don't get exposure to this stuff at my program so I'm thankful this forum exists so I can at least get a look at the issues that professional PAs are currently facing and will face in the future. 

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The PA profession will only change when "you" (meaning whoever reads this post) gets involved in the local, state and national levels to advocate for advancement and regulation change.  We must forge forward as Nichole stated and ignore the detractors who say it can't be done. 

 

AAPA needs to step up to the plate to advocate fiercely for us.  When AAPA leads the way and sends a strong message to the state chapters that they will support every legislative issue change, then and only then, will the PA profession become one of recognizable worth to patients, employers, government entities, insurance companies. 

 

Is AAPA up for the challenge?  If not, then we need a sea change of leadership at the top of the organization, including all the BOD and HOD. 

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The PA profession will only change when "you" (meaning whoever reads this post) gets involved in the local, state and national levels to advocate for advancement and regulation change.  We must forge forward as Nichole stated and ignore the detractors who say it can't be done. 

 

AAPA needs to step up to the plate to advocate fiercely for us.  When AAPA leads the way and sends a strong message to the state chapters that they will support every legislative issue change, then and only then, will the PA profession become one of recognizable worth to patients, employers, government entities, insurance companies. 

 

Is AAPA up for the challenge?  If not, then we need a sea change of leadership at the top of the organization, including all the BOD and HOD. 

 

I guess I don't understand the lack of motivation from the AAPA to back the profession and move it forward. Are they afraid to piss off the docs and NPs? Does that show we have a lack of muscle in the medical community?

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Number 3 seems to be a problem with some PAs and faculty members of PA programs. I have no idea why. The folks at my university say its not as beneficial as one might think and that it may potentially put PAs in a position where it removes the ability to switch specialties w/o a residency. Yet on the other hand they talk about the desire to possibly have a EM PA residency. I agree with every single point you make. 

 

You probably already know this, but remember that it's just their opinion on post-grad programs.  I had a faculty member I trusted greatly who tried to talk me out of doing a residency, but it seemed to be because it fit more in line with how they saw the profession going, not what I felt was best for my own individual career.  I chose to do a post-grad program, and as you might imagine I am a huge proponent of that option being available to whoever wants it.  We should always promote PA's wanting to further educate themselves to be better clinicians.

 

FWIW, this faculty member was an AAPA board member at the time

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No offense to anyone but I am exhausted just trying to do my job and stay afloat on a daily basis.

I cannot imagine being involved in anything political - I REALLY hate politics.

I hate lobbyists and hate the whole PAC system.

 

I have been on committees before - NOTHING EVER HAPPENS.

We talked about things, proposed things and nothing came to fruition.

I am a DOER - I DO THINGS.

Committees and boards and all are just lengthy processes that make me insane and more frustrated than I was before and rarely see any type of beneficial outcome.

 

My employer doesn't support PAs politically and wouldn't do anything for our profession - they have even shut down PA applications to family practice and will only entertain NPs.

Same with the local VA - no PA positions at all - just NPs. That makes me crazy since the first 6 PAs ever on the planet were Corpsmen from VietNam......................................

 

So, I don't know exactly what to do.

I am 25 yrs in. but a long way from retirement.

I feel strongly about the profession but struggle to function every day much less try to advocate.

 

Any thoughts?

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No offense to anyone but I am exhausted just trying to do my job and stay afloat on a daily basis.

I cannot imagine being involved in anything political - I REALLY hate politics.

I hate lobbyists and hate the whole PAC system.

 

I have been on committees before - NOTHING EVER HAPPENS.

We talked about things, proposed things and nothing came to fruition.

I am a DOER - I DO THINGS.

Committees and boards and all are just lengthy processes that make me insane and more frustrated than I was before and rarely see any type of beneficial outcome.

 

My employer doesn't support PAs politically and wouldn't do anything for our profession - they have even shut down PA applications to family practice and will only entertain NPs.

Same with the local VA - no PA positions at all - just NPs. That makes me crazy since the first 6 PAs ever on the planet were Corpsmen from VietNam......................................

 

So, I don't know exactly what to do.

I am 25 yrs in. but a long way from retirement.

I feel strongly about the profession but struggle to function every day much less try to advocate.

 

Any thoughts?

 

A couple thoughts:

 

I like to think that most people who are involved politically understand that the majority of working PA's have many things on their plate other than their career- at the very least, you want time to be able to actually enjoy the fruits of your labors and not just have your life be one constant giant ball of stress you can never seem to overcome, but unfortunately many working people live that life day-to-day.  Representative organizations try to simplify that by asking for membership in their organization because the more members an organization has, the louder voice it has- believe it or not.  

 

The other way to simplify political involvement is PAC donations.  I know that PAC has become a truly offensive term in the last several years, but the reality is that our political system unfortunately takes money to make things happen.  We cannot change our political system- we can only work within the confines of the system to get what we believe is best for our profession.  Organizations have to use lobbyists because they know the system better than the working PA, and their job is knowing the ins and outs of the political field in order to serve their client.  Lobbyists are not evil, although I won't doubt there are those who are shady.  But a lobbyist who knows how to navigate a state legislature or Congress in order to do the best for their client is invaluable- and trust me, those people do exist.

 

Asking for $25, $50 or $100 may seem like a lot of money.  The reality is that on a state level, you don't have to garner hundreds of thousands of dollars in order to make an impact to help gain access to the system to help advance your agenda.  Your money helps to get legislators to write or sponsor bills that can truly improve your ability to practice.  But it's not just throwing money around indiscriminantly- there's a smart way to use the money, especially compared to those groups who have FAR more dollars than we do.  $25, or even $100, in the moment seems like a lot of money to donate at once and not see immediate benefit, but in the grand scheme it's a small sacrifice for your representative organization to continue to fight for your professional existence in the face of many other groups who would just as soon see us all go away.

 

The bottom line is:

- We cannot change the fundamental function of our political system as PA's

- There is NO ONE out there who will advocate for us politically outside of our own PA organizations

- The only sure way to get nothing done politically is to do nothing

 

The best phrase I ever heard when it came to politics is "If you're not at the table, you're on the menu"

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Thanks for the comments - 

I still need to KNOW what the lobbyists are peddling and if I really believe in it.

I don't even know where to start to understand what is being peddled at a state level much less nationally.

 

As in patient education, the legislation needs to be written in non-legaleeze. 

I would like to know how certain things will impact me on a daily basis or what it might cost me.

 

I have unfortunately found that most of the journals tend to put things in cheerleader mode and only tell you the slightly positive slant but not what is really happening.

 

Action words and actual implications would help too. I find it hard to wade through the pretty and flowery words to get to the meat and potatoes of what it really means.

 

Any suggestions before I even consider giving money to a lobbyist? P.S. I still don't like them

 

Sorry to be a bummer but this is how it is with me. A shovel is a shovel, etc.............. If it needs to be done - JUST DO IT

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Nice letter Nichole and well-articulated.

 

The time has long passed for us to just standby and wait for the AAPA to make meaningful changes, or wait for any one entity to make meaningful changes for that matter. I think PAFT is a great spearhead for the new paradigm we face and the newer generation of PAs as well.

 

I agree with just about everything you said----while many of us have great personal relationships with physicians, our relationship with organized medicine and physicians as a profession is tenuous and antiquated, at best. The whole spiel about "collaboration" is really just rhetoric at the end of the day. There are plenty of physicians out there who still feel our sole purpose of existence is to make their lives easier. We are going to have to start stepping on political toes and making people uncomfortable in order to evolve. If we don't evolve we are going to be out-selected by the more numerous and lobbied cohort of NPs.

 

I also agree with some of the recs made above:

 

-PA leadership needs to aggressively pursue all rights and privileges given to NPs.

-Post-grad programs should be supported but not required

-EMED had a great idea about the riders on future bills addressing a title change. It does need to happen one way or another. Assistant has to go.

-Loan repayment for primary care fields will help disseminate more of us onto the front lines

-New program entrance requirements should NOT be getting easier (i.e. doing away with HCE requirements). I know this is probably more of an accrediting body issue rather than PAFT or AAPA.

 

I'm not sold, however, on the doctoral thing. I think it will come off as a farce, and frankly the title should be rectified first before we look like we are trying to take the back door into physicianhood.

 

And it is tough to get individual PAs to get involved politically. Most of us just want a good lifestyle, but we also want to be respected as mostly autonomous professionals. Part of the reason the nursing profession has advanced so far is their incessant vocality.

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Thanks for the comments - 

I still need to KNOW what the lobbyists are peddling and if I really believe in it.

I don't even know where to start to understand what is being peddled at a state level much less nationally.

 

As in patient education, the legislation needs to be written in non-legaleeze. 

I would like to know how certain things will impact me on a daily basis or what it might cost me.

 

I have unfortunately found that most of the journals tend to put things in cheerleader mode and only tell you the slightly positive slant but not what is really happening.

 

Action words and actual implications would help too. I find it hard to wade through the pretty and flowery words to get to the meat and potatoes of what it really means.

 

Any suggestions before I even consider giving money to a lobbyist? P.S. I still don't like them

 

Sorry to be a bummer but this is how it is with me. A shovel is a shovel, etc.............. If it needs to be done - JUST DO IT

 

A good place to start to understand what is being done at the state level is being a member of your state PA chapter.  There should be some mechanism where information is distributed to members about what bills are being sponsored in the state legislature by the PA chapter, or other legal news pertinent to PA practice in the state.  And, the best place to interact with those who work directly on PA legislation is at the chapter's conferences- every PA chapter I think has at least one state conference per year, and all board members and committees meet at these conferences.  Board members should be approachable and willing to talk about the issues being worked on, and also willing to hear about individual issues you may be encountering and seeing if it is possible to help clarify or change existing laws.  And, many times you can actually meet the state chapter lobbyist.

 

When it comes to the political field, personal relationships are still key.  And, relationships among locally-elected representatives still matter.  Who is your state legislature rep?  Have you ever interacted with them at any level- met them, gone to their local office?  The door is always open to constituents to at least meet staff and make an impression.  It sounds really silly, but say you walk in one morning with some donuts for the office staff and introduce yourself- do this a couple times, and believe me, impressions are made that make the staff and the rep remember you and make them more likely to care about the issues that you care about.

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I am a member of my state PA organization - still don't know anything about legislation and can't afford to go to any conferences out of town - most all CME online.

I have no idea who my city council folks are much less my state representatives - only to know that at least one national rep is well hated by anyone in medicine and wouldn't be the least approachable.

I really really hate politics and don't feel it does any good at my level.

Wish I was more optimistic or driven. I don't have time to go to anyone's office much less get a haircut or take the cat to the vet - so, priorities, I guess.

 

Thanks for the pep talk. 

I think I would be an awesome proponent of socialized medicine and the German and Northern European systems.........................

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I am a member of my state PA organization - still don't know anything about legislation and can't afford to go to any conferences out of town - most all CME online.

I have no idea who my city council folks are much less my state representatives - only to know that at least one national rep is well hated by anyone in medicine and wouldn't be the least approachable.

I really really hate politics and don't feel it does any good at my level.

Wish I was more optimistic or driven. I don't have time to go to anyone's office much less get a haircut or take the cat to the vet - so, priorities, I guess.

 

Thanks for the pep talk. 

I think I would be an awesome proponent of socialized medicine and the German and Northern European systems.........................

 

Get involved with PAFT if you aren't already..  See my sig for a link.

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