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PAs For Tomorrow (PAFT) recently responded to the Society of Emergency Medicine PAs (SEMPA) organization's letter sent to the American College of Emergency Physicians (ACEP). 

 

In short, ACEP Now - a publication of ACEP - recently published an article including commentary by Dr. Stack, the AMA President. You can read that article by clicking http://www.acepnow.com/article/ama-president-dr-steven-stack-talks-physician-shortages-and-apps/.   SEMPA responded to that commentary with  the letter below.

 

 

 

 

Dear Editor,

This letter is in response to the article featured in the September 14, 2015 issue of ACEP Now with Kevin Klauer, DO, EJD, FACEP and Steven J. Stack, MD, FACEP, AMA President.

On behalf of the Society of Emergency Medicine Physician Assistants (SEMPA), the national organization that represents all physician assistants who practice in the emergency setting, we would like to offer supportive comments and some essential clarification of the PA role in a physician-led health care team.

As PAs, we wholeheartedly agree that physicians, by virtue of educational process, training and specialty certification, are the most highly educated and trained clinicians in the health care system. We also absolutely agree with the Truth in Advertising campaign that the AMA has spearheaded. As clinicians, who also have the patient’s greatest interests at heart, PAs by law, statute, and professional ethics, attempt to avoid any confusion or misrepresentation of our role, our title, and the profession. We feel that despite any advanced degree at the doctorate level, it is imperative that only a MD or DO be referred to as doctor in the clinical setting.

SEMPA, as the organization that represents emergency medicine PAs, would like to clarify that while we support the term of Advanced Practice Provider (APP) when referring to PAs and NPs collectively, PAs and NPs are two professionally independent groups, each with their own individual unique philosophy, educational/training model, and goals. PAs value being members of a team that provides excellent care for patients, and believe that the team approach serves the patient more completely. For nearly 50 years, we, as physician assistants, have practiced medicine, with physician supervision, as members of a physician led healthcare team. PAs have never sought independent practice, nor do we foresee a change in the philosophy of our profession.

In emergency departments across the country, PAs practice in a variety of roles to evaluate and manage patients and are proud of the work we do in emergency medicine. As highly skilled clinicians, we competently evaluate and treat a variety of emergency and acute care conditions with the clinical support and guidance of our supervising physicians and do not aspire to be perceived as physicians.

Our professional policies endorse our roles as members of the health care team, which recognizes the physician as the leader of that team, and we will continue to make clear and consistent efforts to communicate our stance, which does not include independent practice.

Respectfully Submitted,

The SEMPA Board of Directors

 

 

The BOD of PAFT feels there was an unfortunate lost opportunity by the SEMPA organization to clarify the expanded role that PAs play in the delivery of healthcare services as well as our role in medicine today - a role that has greatly matured and expanded over our profession's existence.  The reality for our profession - and all of organized medicine for that matter - is that the healthcare industry will demand many things from us all in the near future.  That means that we must have a progressive and enlightened vision of the PA profession beyond the 1970's era of PA practice.  The reality is that PAs practice medicine and we do it well.  Further, most clinicians with more than a few years of clinical experience practice quite autonomously, even in specialty care, including emergency medicine.  A great many of us have the desire to have statute and policy reflect what we really do in the delivery of the quality healthcare services we provide to our patients.  There really is no better time than right now to say that to the organized medical community and to advocate for ourselves professionally.  First though, it seems we must say those things to ourselves as PAs and enlighten our own.  

 

Attached is the PAFT response to the SEMPA President and BOD.  To date, PAFT has had no response from SEMPA.

 

Nichole Bateman

President, PAFT

SEMPA ACEP Response.pdf

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I read the article, and this line says it all:

 

 

You deliver a message with a significant amount of intellectual detail even when you have a limited amount of background information...

 

So, when other people make a statement without fully understanding, it's a guess, but when he does, it's an intellectual, detailed message.  I'm guessing you won't hear a response.

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The physician response and position in the original ACEP article are patent, typical and expected.  There is nothing unexpected about the context of that conversation between Dr. Stack and Dr. Klauer.  To be clear, most PAs embrace and respect their physician relationships and most have mutually respectful connections to the physicians they work with.  The point is that physician mindset will not change until how PAs view their own profession changes.  WE must be willing to step outside of our physician-led, subservient box.  We can do that without alienating our physicians colleagues but mostly we SHOULD do that to advocate for our own profession.

 

The reality is that by speaking honestly about how PAs deliver care in organized medicine today and asking that the law accurately corresponds to that, we are only saying aloud what physicians already know.  Physicians are increasingly choosing to work with NPs simply because of the perceived/real "supervision" requirements.  Physicians don't want the extra administrative tasks that supervision entails, particularly because those tasks (co-signature, onsite time, MD/PA ratios, etc. depending on each state's statutes) offer little that enhances patient care, safety, patient satisfaction or their bottom dollar.  However, physician organizations in most states oppose legislative changes removing those barriers to PA practice though clearly, they are not clinically important or relevant in the real life delivery of care.  What is the problem with taking opportunities to ask these relevant questions to our peers in organized medicine and move to change things that keep us from doing what we are trained to do?

 

And when PA organizations offer a response so dismissive of the true autonomous PA role, it is increasingly puzzling.  PAs often work autonomously in a variety of settings - and have for years.  We are often the leaders of teams, particularly in primary care.  Patients see PAs as their PCP - because that's our role.  Advocating for policy, regulation and conversation that accurately addresses how we deliver care should not be alienating to physicians. Mostly, it should not be alienating to PAs. 

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It is statements like this that lead to policies that we have in Virginia.

 

In the ED, I must present every patient that I see prior to discharge. 100% verbal reports prior to discharge.

 

Every URI, every strep.

 

We clearly cannot function on our own without physician masters (sarcasm).

 

I agree with PAFT. We need physicians at times. Sometimes, physicians need us too, but policies like this are stifling.

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It is statements like this that lead to policies that we have in Virginia.

 

In the ED, I must present every patient that I see prior to discharge. 100% verbal reports prior to discharge.

 

Every URI, every strep.

 

We clearly cannot function on our own without physician masters (sarcasm).

 

I agree with PAFT. We need physicians at times. Sometimes, physicians need us too, but policies like this are stifling.

this was suggested by some new attendings at one of my jobs and all of the senior PAS threatened to quit. it didn't happen. we only have to present admissions, which is not unreasonable as we don't have admitting privileges. most of them are ok with this " 35 yr old female with cholecystitis and a positive u/s, surgeon is on their way in". The future for PAs is more autonomy, not less.

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Moving towards autonomy/independence is certainly a controversial topic that has been discussed over and over again on this forum.  I have yet to hear a consensus for how we'd go about this.  Are we advocating for immediate independence straight out of PA school (awful idea), or a tiered approach where PAs gradually get more autonomy with time?  How exactly would the tiered process take place; what criteria, checks and balances?  What would it take to legally make this happen?  The PAFT website is great but again doesn't show any concrete details or tangible plans underlying the general principles they believe in.  If such details or plans exist, could someone post a link to them?  

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If such details or plans exist, could someone post a link to them?

 

Here's the platform and white paper for legislation that is in the works in Nevada for an Optional Autonomous Pathway for PAs in Primary Care.

https://m.box.com/shared_item/https%3A%2F%2Fapp.box.com%2Fs%2F6f6567b1fobkvvo1g7egfd2gq6ir1jx7

 

 

And here's a link to a facebook page if you want more info:

https://m.facebook.com/primarycarepa

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yup, as above, no one should be autonomous right out of school. completion of a residency or 3-5 yrs in practice would probably be a good place to start. you could add some didactic requirement like a CAQ or passage of a panre like exam as well.

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Thank you PAFT. It is awesome that the PA profession has an organization that isn't afraid to push the envelope. Your hard work in combination with the excellent medical care provided by PAs all around the world is why one day we will have our independence!

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yup, as above, no one should be autonomous right out of school. completion of a residency or 3-5 yrs in practice would probably be a good place to start. you could add some didactic requirement like a CAQ or passage of a panre like exam as well.

I'm clocking ~135 Cat 1 CME hours (and 80+ Cat 2... but I don't even track that all that closely) every year, in a bunch of different specialties, vs. the 25 that are required.  It would be nice if that counted for something other than my own personal satisfaction.

 

Do I think I'm capable of functioning independently at 3 years, 1 month into family medicine practice?  Within the scope of my experience, sure, but I don't see any compelling need to do that yet.  I'd just as soon be better than the minimum necessary, however, and I like bouncing things off of my teammates--not just the practice owner/SP, but the other PAs and NPs I work with.

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I'm clocking ~135 Cat 1 CME hours (and 80+ Cat 2... but I don't even track that all that closely) every year, in a bunch of different specialties, vs. the 25 that are required.  It would be nice if that counted for something other than my own personal satisfaction.

 

Do I think I'm capable of functioning independently at 3 years, 1 month into family medicine practice?  Within the scope of my experience, sure, but I don't see any compelling need to do that yet.  I'd just as soon be better than the minimum necessary, however, and I like bouncing things off of my teammates--not just the practice owner/SP, but the other PAs and NPs I work with.

most of my learning over the years post graduation has come from senior PAs I worked with.

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Why would autonomous practice keep any practicing clinician from communicating and interacting with colleagues - including physicians - in the same fashion we do now? Being autonomous doesn't mean you are isolated from other professionals. Physicians, though independent, don't practice medicine alone. They do what any good clinician does when a situation calls for other insight. They seek out a trusted colleague, they pick up the phone and make a call, they refer to a higher level of care, they practice in their scope and they collaborate together. PAs would still do all of those things with autonomy just as we do now restricted by supervision parameters that do little to make us "safer" and do little to encourage meaningful, mentoring relationships between physicians and PAs.

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Emed - seems like a year ago (or so) you and I were discussing whether or not the fledgling PAFT was pushing for autonomous practice.  I remember saying that, reading between the lines, it appeared as though they were, and you said they were not.  It appears as though I was right.

 

Nichole - There are also many of us who exuberantly disagree with full autonomy for PAs.  

I had surgery on my knee yesterday.  The PA who was First Assist is a great friend of mine and classmate.  I'm sure he is an awesome PA, but I would NOT want him doing the surgery by himself.  He didn't go through 4 years of medical school, then 4 years of orthopedic residency, then a fellowship. 

If you want to be an autonomous provider, then go to medical school.  I'm pretty sure you knew that when you applied to PA schools.  

 

By the way, I suggest you not piss off ACEP.  They openly declare that PAs are the "preferred" APP in the ED - partially because we are the ones who are NOT pushing for independent practice.  If more PAs start openly pushing for independent practice, we are going to lose this physician support.

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Boat- no one is in favor of an ortho pa doing solo surgeries. we are talking mostly about outpt primary care and ER. you are a solo pa. do you feel the care is better on days they staff a doc than you? I think we are held to the same(if not a higher) standard than the docs who we work with. I think my care is BETTER than many of the fp docs who staff the rural ER I work at. they let me run the codes if they happen to be in house because they know I do them better, etc

my personal feeling on the autonomy issue is that we need more autonomy, but still should maintain some ties with organized medicine. I want the PA who works in a rural practice with an SP who dies to be able to continue working through collaboration with the state medical board, not a specific physician, basically what NPs have in states that require loose collaboration. I have no problem with someone occasionally reviewing my work for quality, but am opposed to 100% chart review requirements or md/do on site requirements.

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E - I agree that there are unnecessary, onerous, and often times harmful restrictions on our practice.  SEMPA has worked hard to remove these restrictions.  

 

I fervently believe that physicians should be, at least at some level, in charge of each patient's care.  What level of "being in charge" should be determined by the physician and their team, not by some bureaucrat at the state house.  Some PAs should be largely autonomous, many PAs need to be closely supervised.  Some specialties allow for greater autonomy, other specialties allow for less autonomy.  But, in the end, every patient deserves to have a physician involved, at least in some small way, in their care.

But when PAFT says: "In reality, there is a largescale effort to propel the PA profession towards autonomous practice in the very near future. It is a professional necessity, and it will happen.", it means they are working toward autonomous practice for the entire profession.  That is wrong-headed for many reasons.  

 

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Why would autonomous practice keep any practicing clinician from communicating and interacting with colleagues - including physicians - in the same fashion we do now? Being autonomous doesn't mean you are isolated from other professionals. Physicians, though independent, don't practice medicine alone. They do what any good clinician does when a situation calls for other insight. They seek out a trusted colleague, they pick up the phone and make a call, they refer to a higher level of care, they practice in their scope and they collaborate together. PAs would still do all of those things with autonomy just as we do now restricted by supervision parameters that do little to make us "safer" and do little to encourage meaningful, mentoring relationships between physicians and PAs.

 

Bingo.  Autonomy in my mind means not losing out jobs to NPs because they require less chart review. It means less paperwork that just wastes everyone's time.  Some people equate autonomy to thinking "well I'm autonomous now so maybe I'll just wing it if I don't know what this is since I don't need help."  That reasoning is nonsensical.  

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Why should the care of every patient revolve around a physician? Why can't that decision be between the patient and the PA. And you say you don't want a PA doing your knee surgery, but there are PA cath labs that's are essentially 100% autonomous at Duke. And the research shows they have the same, if not better outcomes than the physicians. Please do not get me wrong, I am not advocating for PAs performing knee surgery independently but i do not buy the need for physicians just for names sake. Medicine is medicine. It doesn't take an MD degree to oversee the care of a patient. It takes competent providers. You either are one or you are not.

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Again back to the bridge program idea.  "Physician" means two things:

1) 4 years of medical school followed by GME sufficient to become licensed and board certified: internship, residency, and fellowship(s) as appropriate.

2) The highest level of medical competence.

 

But the problem is that #1 and #2 are not 100% overlapping.  Look at the anti-vaccine doctors who still hold medical licenses--there are a few of them, and I daresay they meet 1 but not 2.  Contrast that to some of the PAs who've been at their jobs for decades, like many of the senior members of this forum (by experience, not necessarily posts).  They clearly meet #2, but not #1.

 

I hope no one wants to take away physicians' place as the top of the medical food chain--nor should anyone, because for all the hell they endure, it does make most of them the most competent practitioners available--but rather point out that #1 isn't the only path to #2, and there is a place to recognize that patients benefit from competent PAs practicing as best they can, without artificial guild-like limitations on who can provide care.

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Bingo.  Autonomy in my mind means not losing out jobs to NPs because they require less chart review. It means less paperwork that just wastes everyone's time.  Some people equate autonomy to thinking "well I'm autonomous now so maybe I'll just wing it if I don't know what this is since I don't need help."  That reasoning is nonsensical.  

 

But autonomy CAN mean "well I'm autonomous now so maybe I'll just wing it.".   And if we change the system so that it CAN happen, then it WILL happen.  You won't do it, and I won't do it, but someone will.

 

Better to have a system where APPs have to work with a physician.  Call it collaboration, call it supervision, call it whatever you want....but a physician is at least nominally involved in the care of the patient.  

 

Instead of following the very flawed NP scheme, we should be highlighting the flaws of THEIR scheme and the STRENGTHS of the Physician/PA team.  This is what SEMPA does, and SEMPA has managed to get ACEP to recognize PAs as the APP of choice in the ED

 

 

Why should the care of every patient revolve around a physician? Why can't that decision be between the patient and the PA. And you say you don't want a PA doing your knee surgery, but there are PA cath labs that's are essentially 100% autonomous at Duke. And the research shows they have the same, if not better outcomes than the physicians. Please do not get me wrong, I am not advocating for PAs performing knee surgery independently but i do not buy the need for physicians just for names sake. Medicine is medicine. It doesn't take an MD degree to oversee the care of a patient. It takes competent providers. You either are one or you are not.

 

The BEST method to ensure a provider is competent is 4 years of undergrad, 4 years of med school, and then 3-6 years of residency.  While this system isn't perfect (no system is), it is the best way.

 

The BEST method to ensure an APP is competent is to have a physician work with and evaluate that APP, and then let that APP work up to the level of their competence.  

 

I'm not advocating having every patient care episode "revolve around a physician".  In your PA cath lab example, the PAs are working autonomously, but not independently...because they have an established supervisor who is responsible for ensuring their competence.  

 

The PA model works, and it works well.  Just because the NPs have created an easier and cheaper model doesn't mean we should follow it.....cause it is deeply flawed.

 

..........t patients benefit from competent PAs practicing as best they can, without artificial guild-like limitations on who can provide care.

 

We can fight against such limitations without pushing for independent practice rights.  That has been the approach of the PA profession for 50 years.  Only recently has there been a small, but very vocal, minority of PAs who are pushing for independent practice rights.  

 

I applaud PAFT for pushing the stagnant AAPA into motion on many things, but on this topic they are off base.

 

 

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Here is what I can see happening if PAFT keeps sending out letters like this demanding independent practice rights, and predicting that "it WILL happen".

 

Our profession is already under attack by the NP profession.  We all know it, we know it comes from the large nursing academia groups, and they have buy in from many administrative types.  They have managed to lobby their way to legally independent rights, and used this as leverage to convince administrators/bureaucrats to hire them instead of us because "they are independent".

 

We try to team up with the physicians who generally prefer PAs because 1) our medical training is far superior to NPs, and 2) we aren't threatening their jobs by seeking independent practice rights.  If the movement for PA independence grows much louder, we will quickly lose much of our physician support....then our profession is going to be in serious trouble.  Without physician support of the PA profession, the NP profession will simply take over.  

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 The BEST method to ensure a provider is competent is 4 years of undergrad, 4 years of med school, and then 3-6 years of residency.  While this system isn't perfect (no system is), it is the best way.

 

You really have no way of knowing this is true. It is the most longstanding way, but there is no way of knowing if it is the best, as there would need to be a comparative model. PAs and NPs are still in the beginning stages (unfortunately) of validating alternatives.

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