PAFT responds to SEMPA letter

[andersenpa]

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.  

At this point (50 yrs in) proof needs to be demonstrated that supervisory relationships are necessary. PAs have been around long enough to merit an investigation into that. Furthermore docs (real world docs, not those on the board of societies and organizations) don't want or need the supervisory hassle. Finally the competition between NPs and PAs is only magnified by supervisory requirements as it is perceived as a barrier to hiring by the (often ignorant) HRs and managers of the world.

 

The team based model is so prevalent that the idea of a rogue PA is no more a concern than that of a rogue doc. 

[PAFT PRESIDENT]

@Boatswain2PA - PA Autonomy does not replace or supercede our physician colleagues. Layers of compliance in the delivery of healthcare (not to mention how services are reimbursed to any given provider for any given service) would never allow such a change in your example.  I'm surprised you would suggest something so random.  PAFT's support for autonomous practice and/or full practice authority means that we advocate for more accurate reflection of what PAs already do everyday across the US. 

 

State statute, federal law and institutional policy should reflect what PAs do in the delivery of healthcare and should be responsive and reactive to the needs of patients and the system.  There should also be some flexibility for the well-trained professionals they govern.  There are PAs all over the US who have had the unfortunate experience of losing their livelihood the moment their SP dies, goes to rehab, or randomly elects to suspend their supervisory responsibilities, etc. simply because their SP was no longer "supervising" them.  Efforts in most states to create language offering basic practice protection to PAs is ALWAYS fought and defeated.  Autonomy protects PAs from those circumstances legally.  There are many significantly underserved regions of the US where basic primary care services are lacking - regions where PAs would voluntarily choose to autonomously practice but cannot because there are no physicians there to "supervise" them and fulfill state statute.  Autonomy opens those opportunities to PAs and offers provider access to patients.  PAs all over the US are, largely by attrition, being replaced by an "independent" NP workforce who does not require time and tasks to fulfill "supervision" responsibilities - whether those things are real or perceived in a given practice setting or state.  It's real.  One only needs to take a look at VA PA workforce changes in the last 20 years.  In the past, PAs outnumbered NPs in the VA system 2:1 and was, historically the single largest employer of PAs in the US.  That ratio is now reversed.  I'm sure the reasons are many, but have no doubt that "independent" NP practice is significant, even though PAs and NPs in the VA system practice almost exactly the same and are utilized almost exactly the same.  Autonomy levels that playing field with our NP colleagues.

 

The majority of PAs already practice very autonomously in their roles - if we didn't, physicians wouldn't employ us.  Most physicians have neither the time, nor the patience to micromanage how PAs deliver care.  They have the confidence that we understand our scope of practice for a given setting and would seek appropriate guidance when necessary.  Being autonomous doesn't mean that a provider cleaves themselves from other clinicians.  PAs have historically successfully built mutually respectful PA/physician relationships that hold great value for us professionally.  PA autonomy does not have to be mutually exclusive of good and positive relationships with other members of the healthcare team.  To suggest that's what it would mean is shortsighted and undermining of all PAs.   If PAs present a unified vision of how PA autonomy is a very real benefit to physicians for these and many more reasons, we can be successful in doing what we should all be vested in doing - providing quality and safe medical care to the patients who need us. 

[cinntsp]

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.

 

 

 

I'm sure this is the same argument that gets made about PAs prescribing schedule II drugs.  Those silly ol' PAs will surely go crazy with those prescription pads and start killing patients left and right with narcotics.  Someone will always do anything.  That doesn't mean the other 98% should be held back for it.

[Guest Paula]

For one day my clinic closed down because the SP's contracted was not renewed on a timely basis.  He refused to work until it was signed.  It took a day so I could not work that day.  Then a year later the tribe decided to hire a different medical director (an Internal Medicine physician) who assured the council he could see all ages.  (NOT, he was not board certified FP), so therefore, eventually while trying to make the corrections, and unsuccessful, I was out of a job for fear the state would audit and find out I was practicing outside of my scope, per state laws.  An NP was hired. 

 

Then, next job, the medical directors contract was not signed.  I was in a different state, still at a tribe.  Again for one day, I could not work and the clinic closed until the contract was signed.  

 

Essentially, both state laws prevented me from seeing patients, putting patients at risk and loss of medical care.  Sure, only for 24 hours each time, but, it proves a point that it happens, and it was, in my case, the rural, underserved, disenfranchised patients who suffered. 

 

We have a huge job to do to define our terms.  Autonomy and autonomous practices means different things to different people.  To me, autonomy means my license is granted to me without having to legally name a collaborating physician (CP), but my CP is determined at the practice level, SOP determined at practice level, and that my license still allows me to work when the CPs contract goes unsigned.  

 

My current contract (I'm not tribal anymore) with a medical group clearly states if my CP retires, declines to be my CP, etc., I must immediately find another CP or not practice until a new CP is formally named with all the paperwork completed and submitted to the state.  This will hinder the care of patients and cause less access to care.  PAs keep saying WE ARE THE ANSWER to the shortage of physicians.  REALLY????   Not with our current laws, some states much worse than others. 

 

Plus, the model state legislation (MSL)that AAPA has approved is the model for each state to follow, and it clearly states that PAs are to be responsible for their own actions, CP is at the practice level and not necessarily named at the state level, etc.  Read the MSL.  Then re-read it.  Then contact your state chapter and start the process of the modernization of PA practice acts so we can BECOME the answer to the physician shortage.

 

P.S.  Today I found out that NPs are better trained and have higher credentials than PAs.  I did not know that.  Gosh, so glad someone informed me.  Unfortunately this information comes from an upper physician administrator............................Yup, physicians love us and understand who we are.......assistants, not capable of autonomous decisions, etc. 

 

I'm all for autonomy. Collaboration is fine with me, but not as a dependent clinician......my own personal opinion.

[LIPPER]

"....have practiced medicine with PHYSICIAN SUPERVISION ....nor do we foresee a change in the philosophy of our profession".....

 

Hmm... Might as well delete every post about "supervision"...glad this topic has been officially put to bed.

 

 

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[EMEDPA]

"....have practiced medicine with PHYSICIAN SUPERVISION ....nor do we foresee a change in the philosophy of our profession"..... Hmm... Might as well delete every post about "supervision"...glad this topic has been officially put to bed. Sent from my iPhone using Tapatalk

the official term per AAPA is now collaboration. SEMPA should have presented it in this light....

[LIPPER]

Ok, I believe I quoted the PAFT response.

 

 

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[PAFT PRESIDENT]

Ok, I believe I quoted the PAFT response. Sent from my iPhone using Tapatalk

No, Lipper - you quoted SEMPA's letter to ACEP Now. PAFT's response letter to SEMPA is attached to the original post.

[LIPPER]

Yes you're correct... I'm wrong. Still it's important to note a large swath of PA's feel this way.

 

 

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[PAFT PRESIDENT]

Feel which way Lipper?  It's difficult to tell if you support PA autonomy or if you believe that supervision - whether it's functional in the delivery of health care or useful in the oversight of PAs - should be left as is.  Help me understand your thoughts.

[Boatswain2PA]

I don't think anyone feels supervision should be left "as is". But many of us are against full "independence".

[PAFT PRESIDENT]

Why do you assume that's what PAFT believes should happen? So far, you are the only person in this conversation to use those words. I've only used the term autonomy. Maybe you are confusing PAFT with another organization or group.

[TWR]

For many years in New York City I owned my own clinic.  I practiced alone and my collaborating physician had his own practice 15 miles away.  I basically practiced "independently" and we met once a week to discuss any patient issues.  I of course could call him anytime with questions.  My point is that we collaborated.  The practice was mine  He received "Consultation" money monthly in the amount of $2000.  I was responsible for everything else that had to do with the practice.  It was quite lucrative as I worked hard (it was for me).  I eventually sold the practice to Episcopal Hospital for a 6 figured amount and stayed on for 6 years before moving to Houston.  So I am very happy with collaboration as long as I can practice "independently".  It was a wonderful arrangement for both of us.

[Boatswain2PA]

PAFTPresident:  Perhaps you should re-read these letters, because you clearly opposed SEMPAs acceptance of the long-standing premise of our profession.  

 

The purpose of SEMPA's letter was clarify some of the differences between PAs and NPs, The biggest difference is that NPs are pushing for independent practice.  They clearly state "PAs have never sought indepedent practice, nor do foresee a change in the philosophy of our profession."

Meanwhile your letter said you were "disappointed" with their response, and your letter specifically quotes that particular sentence that you disagree with.  If you disagree with not seeking independent practice....those double negatives mean that YOU ARE SEEKING INDEPENDENT PRACTICE.  

 

You continue saying that "In reality, there is a largescale effort to propel the PA profession toward autonomous practice in the near future." 

 

So you disagree with SEMPAs statement that PAs have never sought independent practice, and don't see that changing in the future.  And then you continue that there is a push toward autonomous practice.

 

Reading between the lines, you (and whoever else approved this ill-advised letter to SEMPA) want us to follow the NPs and have begun the push for independent, autonomous practice.

As for Paula, and everybody else who has stories about losing jobs and licenses because of politics and/or losing a supervising physician - those are problems that we need to work on, and SEMPA is actively working on those issues.  I have been working on a similar issue over the past week with a hospital I work at who hired all NPs in their ED because they erroneously thought the physicians were limited in number of PAs they could supervise.  These issues, and restrictive state laws/regulations that  that AAPA and PAFT, along with the specialty PA organizations, should be working on TOGETHER, not sending divisive letters stating how "disappointed" we are with each other's actions.
 

[Boatswain2PA]

Some of the confusion of this conversation is semantics - what is difference between independence and autonomy, what do these terms mean, etc.  

 

But some folks are hiding behind the semantics of these terms.

 

Everyone wants to reduce unnecessary restrictions on practice.  Both AAPA (of which I am not a huge fan of, and am not a member of) and SEMPA (I am a huge fan of, and I am a member) call for a removal of such unnecessary restrictions.  Both organizations say any restrictions should be collaboratively implemented between the supervising physician and the PA.

So, each PA should have (at least one) supervising physician, and between the two they determine the scope of practice for the PA.  Doesn't mean the PA license has to disappear if the SP dies, doesn't mean the PA can't own their own clinic, etc, etc, etc....just means that the SP has to be involved.  Some SP/PAs will require close supervision, other SP/PAs will allow complete autonomous practice, with the SP available for consult.

 

This is what we should ALL be pushing for.

[newton9686]

Boats, you are so caught up in the need for a designated supervising physician. Why? Like many have said insurance and protocols have made the ability to go rogue nearly impossible plus nearly everyone already practices in a team based approach. Nothing would change. I myself have no problem working with Physicians. I value their collaboration. i just do not wish to have my license tied to one particular provider and I will support any law that values my education and training enough to remove the need for a designated physician to co-sign for my license. It's not a matter of practicing independently, it's a matter of being licensed independently. That is what PAFT is fighting for and the vast majority of PAs on this board support.

[Boatswain2PA]

For the same reason I don't think NPs should practice without some sort of physician oversight.  MD education >>>> PA education.  

If you want to practice independently, go to medical school.  You chose the PA profession knowing full well that you would always have to be working with a SP, nothing has changed except the reduction of overly restrictive regulations/laws.

 

Now, I agree that we should be able to be licensed independently.  That would reduce some of the unnecessary burdens we experience, like Paula's example (and others).  We shouldn't have to have an SP to get our license.

 

However we should have to have an established SP/PA relationship.  Call it collaboration, call it supervision, whatever.  But we should have a physician who is designated to supervise us in a manner deemed appropriate by the SP and PA.  

[PAFT PRESIDENT]

OK.  PAFT is involved in all of those things too

[Boatswain2PA]

Good.  But can you clarify your position on the SP/PA relationship.  Is it your personal position, or PAFT's position, to remove the need for a supervising/collaborating physician?  Your letter to SEMPA certainly makes it seem seem this way. 

[PAFT PRESIDENT]

Sure - am always happy to expound upon PAFT philosophy.  I appreciate the question rather than assuming you know exactly what PAFT is all about.

 

There's no doubt that PAFT, as an organization, is more progressive than most PA organizations. Not that long ago, the assumption was that the core founders were just heretic PAs who were on the fringes of the profession.  In truth, the things that the original founders started talking about 10-15 years ago as issues the AAPA and PAs everywhere should be concerned about are the very things that plague our profession today.  They were foreshadowing the issues that many PAs still think "someone else is taking care of for our profession."  In truth, many of the things that keep PAs from practicing a the top of our license (or whatever jargon you like to use), limit our job opportunities and impede full practice ability are the very things those original founders were ex-communicated for by the PA establishment.  The words that fell on deaf ears not that long ago are being acknowleged by AAPA leadership and a great many others as issues that SHOULD have been progressively addressed years ago.  Now, we're scrambling to adjust in a climate that is in flux. 

 

Now - to answer your specific question.  The short answer is YES, but not for the reasons that I assume that you assume...

 

PAFT has no desire to sever or disregard or minimize the physician in this effort.  There IS desire to accurately represent the function of the PA in the delivery of care today.  As I said in post #27 that you didn't acknowlege or respond to, I outline PAFT philosophy in greater detail.

 

@Boatswain2PA - PA Autonomy does not replace or supercede our physician colleagues. Layers of compliance in the delivery of healthcare (not to mention how services are reimbursed to any given provider for any given service) would never allow such a change in your example.  I'm surprised you would suggest something so random.  PAFT's support for autonomous practice and/or full practice authority means that we advocate for more accurate reflection of what PAs already do everyday across the US. 

 

State statute, federal law and institutional policy should reflect what PAs do in the delivery of healthcare and should be responsive and reactive to the needs of patients and the system.  There should also be some flexibility for the well-trained professionals they govern.  There are PAs all over the US who have had the unfortunate experience of losing their livelihood the moment their SP dies, goes to rehab, or randomly elects to suspend their supervisory responsibilities, etc. simply because their SP was no longer "supervising" them.  Efforts in most states to create language offering basic practice protection to PAs is ALWAYS fought and defeated.  Autonomy protects PAs from those circumstances legally.  There are many significantly underserved regions of the US where basic primary care services are lacking - regions where PAs would voluntarily choose to autonomously practice but cannot because there are no physicians there to "supervise" them and fulfill state statute.  Autonomy opens those opportunities to PAs and offers provider access to patients.  PAs all over the US are, largely by attrition, being replaced by an "independent" NP workforce who does not require time and tasks to fulfill "supervision" responsibilities - whether those things are real or perceived in a given practice setting or state.  It's real.  One only needs to take a look at VA PA workforce changes in the last 20 years.  In the past, PAs outnumbered NPs in the VA system 2:1 and was, historically the single largest employer of PAs in the US.  That ratio is now reversed.  I'm sure the reasons are many, but have no doubt that "independent" NP practice is significant, even though PAs and NPs in the VA system practice almost exactly the same and are utilized almost exactly the same.  Autonomy levels that playing field with our NP colleagues.

 

The majority of PAs already practice very autonomously in their roles - if we didn't, physicians wouldn't employ us.  Most physicians have neither the time, nor the patience to micromanage how PAs deliver care.  They have the confidence that we understand our scope of practice for a given setting and would seek appropriate guidance when necessary.  Being autonomous doesn't mean that a provider cleaves themselves from other clinicians.  PAs have historically successfully built mutually respectful PA/physician relationships that hold great value for us professionally.  PA autonomy does not have to be mutually exclusive of good and positive relationships with other members of the healthcare team.  To suggest that's what it would mean is shortsighted and undermining of all PAs.   If PAs present a unified vision of how PA autonomy is a very real benefit to physicians for these and many more reasons, we can be successful in doing what we should all be vested in doing - providing quality and safe medical care to the patients who need us.

 

Here's the platform and white paper for proposed practice autonomy in Nevada for an Optional Autonomous Pathway for PAs in Primary Care.  There are many things within this paper that reflect PAFT philosophy.  This might help clarify things as well.
https://m.box.com/sh...7egfd2gq6ir1jx7

 

Many things shape a growing, evolving profession.  Laws, statutes and regulations that provided oversight for a new profession 40 years ago often impede care and limit PAs in todays world.  Medicine simply isn't the same animal it was 40 years ago.  PAs aren't the same as we were 40 years ago either - we've evolved tremendously.  Why shouldn't the language of our governing statutes. et al. evolve and change as well. Frankly, yesterday's language isn't palatable to physicians any longer either as they - on one hand - hire "independent" practitioners who are "less work" in deference to "better trained PAs" yet often the physician establishment opposes statute changes that loosen or remove the very things they don't want to burden themselves with in real life practice.  Are they not really necessary?  Are they not really important?  Are they of no benefit?  Apparently not to many physicians in real life as they'd rather not be bothered by pesky cosignature, onsite requirements, PA/physician ratios and the like.  And they don't really care if you are IMMEDIATELY unable to practice if they decide they no longer want to "supervise" you any longer.  RE:  the NP situation, you mentioned a similar situation at your institution in an earlier post I believe.  Whether you like it or PAFT likes that dynamic is frankly irrelevant - it IS the forward moving reality and it IS happening.  We cannot fault another profession for their successful self advocation efforts.  The only folks to fault for our profession not keep pace with necessary changes are ourselves.  PAFT believes change can, should and will come whether we believe it should or not.  We also believe we'd rather be a part of that change rather than letting others decide our fate for us.  If some of those things ring true to you, join us and get involved to help create forward motion. 

 

There are many ways to advocate and promote the PA profession and I have no doubt that if you and I personally sat down and lined up our respective sentiments, we'd have far more alike than not.  Any and all ways to successfully promote the PA profession are important, even those not always accepted by all - PAFT will move forward and adapt to the things that we can make meaningful progress with and adjust our direction to succeed in advocacy for the PA profession.  Sometimes if it means helping others of our own see that there's nothing wrong with doing the same, we'll do that too.

 

 

[Boatswain2PA]

PAFT President - I think PAFT has forced AAPA out of its stagnation and toward much greater action.  And for this I applaud the organization.

Thank you for clearly stating that you, and PAFT, are FOR PA autonomy (ie: no longer needing a SP/PA relationship).  Six or 12 months ago I got that impression, but others argued against me, challenging me to "find it in the PAFT bylaws" that they were pushing for PA autonomy.  I'm glad that you are clearly stating your goals.  It's the first time (that I know of) that anyone from PAFT has actually stood up and said this. 

 

However I disagee with the goal of dissolving the need for the SP/PA relationship.  Yes, healthcare and medicine has changed.  But one thing has remained, and that is MD/DO education >>>>>> PA education.  I feel that patients deserve to have someone with MD/DO level education involved in their care.  I wouldn't want my kids to see a NP who didn't have any physician oversight, and I wouldn't want my kids to see a PA who didn't have such physician oversight.    I practice very autonomously, yet nearly every shift I am confronted with how little I know compared to physicians. 

I am sure that you and I are more alike than different, and I certainly don't view you as any type of adversary....I just vehemently disagree with anyone but a residency trained MD or DO practicing medicine independently and unsupervised.  And I think your letter to SEMPA, who has been a TREMENDOUS advocate for advancing PA practice, was uncalled for.  How many specialty organizations have openly declared their support for PAs over NPs other than ACEP??  And you effectively told them their reply was crap because they support the SP/PA relationship.

 

Edit:  2nd to last sentence didn't say what I wanted to say:  How many specialty PA organizations have managed to get the corresponding specialty MD organization to openly declare their support for PAs over NPs other than ACEP??

[Marinejiujitsu]

PAFT President - I think PAFT has forced AAPA out of its stagnation and toward much greater action. And for this I applaud the organization.

 

Thank you for clearly stating that you, and PAFT, are FOR PA autonomy (ie: no longer needing a SP/PA relationship). Six or 12 months ago I got that impression, but others argued against me, challenging me to "find it in the PAFT bylaws" that they were pushing for PA autonomy. I'm glad that you are clearly stating your goals. It's the first time (that I know of) that anyone from PAFT has actually stood up and said this.

 

However I disagee with the goal of dissolving the need for the SP/PA relationship. Yes, healthcare and medicine has changed. But one thing has remained, and that is MD/DO education >>>>>> PA education. I feel that patients deserve to have someone with MD/DO level education involved in their care. I wouldn't want my kids to see a NP who didn't have any physician oversight, and I wouldn't want my kids to see a PA who didn't have such physician oversight. I practice very autonomously, yet nearly every shift I am confronted with how little I know compared to physicians.

 

I am sure that you and I are more alike than different, and I certainly don't view you as any type of adversary....I just vehemently disagree with anyone but a residency trained MD or DO practicing medicine independently and unsupervised. And I think your letter to SEMPA, who has been a TREMENDOUS advocate for advancing PA practice, was uncalled for. How many specialty organizations have openly declared their support for PAs over NPs other than ACEP?? And you effectively told them their reply was crap because they support the SP/PA relationship.

I am perfectly ok with my kids seeing a PA independently of they have been practicing for 5+ yrs. New grad. Nope. Lol

 

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[Boatswain2PA]

I didn't say independently.  I said without any physician oversight.

 

ANY physician oversight.

 

This is what NPs are pushing for.  They used the exact same arguments that some people here are using in their push for independent practice.  Now in 20+ states a new NP graduate can start her own clinic the day after graduation.

 

Not the example that we want to follow.  

[PAFT PRESIDENT]

The thing the PA community has been reluctant to acknowledge is that PHYSICIANS don't WANT supervision responsibility any longer.

[Boatswain2PA]

The thing the PA community has been reluctant to acknowledge is that PHYSICIANS don't WANT supervision responsibility any longer.

 

I think there are a FEW physicians who don't want the SP/PA relationship anymore, and there are two reasons. 

 

A small percentage OF these few just don't want the responsibility anymore.  They are tired of the NP propaganda ("We went to 2 years of school part time and we are better at this than you are!") so want to drop any responsibility for mid-levels (yes, I used that term, don't start on me! lol).  These docs say "cut ties, let them sink or swim" . 

 

The majority of docs who don't want the SP/PA relationship anymore don't want it because of the burdensome laws/regulations tied to it.  They don't want the restrictions on how many PAs they can supervise, the chart review requirements for PAs that have been inpractice for years, etc, etc, etc.   AAPA had been lethargic in fighting these laws/regulations, and PAFT has pushed them into action.  State PA organizations, often specifically linked to AAPA (I won't join my state organization because I HAVE to be a member of AAPA to join) were sometimes just as bad.  But THIS is where we need to focus our energy.

 

We don't want to become NPs.  We don't need to hang a shingle and open our own clinic ("own clinic" meaning one without any SP).  Like many people have stated, even if we get independent practice rights the insurance companies and hospitals will maintain the need for physician oversight, so why are we wasting our resources and political good will (like sending that letter to SEMPA) fighting for independent practice rights?  Better to get rid of the burdensome rules/regulations/laws and simply say that PAs must have a SP to practice, and the SP/PA will determine the appropriate level of supervision for that relationship.