PAFT responds to SEMPA letter

[EMEDPA]

how about PA oversight by the medical board and not a named physician? I like that idea better than a formal relationship with a named physician. every quarter or Q 6 months a committee of the medical board made up of PAs and docs reviews a small % of PA charts and gives constructive feedback. I don't think every chart or even a majority of charts need to be reviewed. many states are already at 0-10% chart review, so in reality the SP doesn't know what's going on most of the time in these states anyway. they are not providing feedback on every case. even when I worked at  places(several) that required 100% chart review the docs just rubber stamped every chart and only read admissions.

[PAFT PRESIDENT]

PAFT does not advocate severing the PA/Physician relationship as you continue to assume.  Autonomy clearly conjures a vision of what you think that means....so much so that I'm not sure you even read the white paper or gave consideration to anything else I've tried to convey about PAFT's views.  If you had, you'd realize we are largely talking the same language and the same concepts.  

 

Autonomy, Full Practice Responsibility, Independence - and a few other terms we've all heard over the past few years - are concepts PAs should explore to decide how they can, should and are likely to be applied to PAs.  PAFT is an organization committed to openly exploring which - if any of them - hold value for our future.  How that ultimately comes to pass is largely unknown but is being explored by multiple individuals, COs and organizations (including physicians btw) across the US.  PAFT is only one of them.  The military braches have truly been at the forefront - nearly ALL branches use terms like autonomy, independence, collaboration, professional responsibility in their descriptors for PAs and some have since the early 2000s - long before the AAPA HOD accepted collaboration language as AAPA policy and long before AAPA model legislation of 2015.  In NONE of our military branches is "supervision" the only term used to describe how PAs function. 

 

All of these terms mean different things to different people.  @Boatswain2PA - I hope you will expand your vision of autonomy as some of these other terms might come into play in the future -  they all mean other things than severing the PA/Physician relationship as you believe.  If hearing a personalized, narrowly defined term causes you to exclude the bigger picture, I think that's an unfortunate thing.  There are no perfect terms or perfect circumstances - only the best of all options for a given time.  

 

Clearly "supervision" language is imperfect, often frankly detrimental to our profession and is no longer serving PAs well.  Whatever it is called and however it looks, "supervision" language needs to change legally for our own professional needs if we are to continue to serve patients efficiently.  That's what PAFT advocates for in the PA profession's future.

[EMEDPA]

Agree with above- we are talking about autonomy and practicing to the top of our license, not completely separating ourselves from organized medicine. "supervision" as a concept needs to go away. call it something else, almost anything else. collaboration works, "under the oversight of the medical board" works.

The word "assistant" is , and will continue to be, a problem. Do I assist a physician when I never work with them and they never see my patients? no, I practice medicine with available backup. big difference. docs have backup too. it's called a specialty consult.

[Boatswain2PA]

PAFT Pres - I asked: "Is it your personal position, or PAFT's position, to remove the need for a supervising/collaborating physician?"

You replied "Yes". 

 

That was pretty clear.

 

But now you say "PAFT does not advocate severing the PA/Physician relationship"

 

I'm a pretty simple guy, but if it is your position to remove the need for a SP, then that pretty much severs the SP/PA relationship.  Hard to have a relationship with a SP if you don't have one. 

 

You are starting to muddy the waters again with your semantics.  Yes, we can change it to "collaborating physician" if you wish, it is still a designation physician responsible for some sort of oversight. 

 

EMED:  I think oversight by a med board would be just as bad as we have now. How would they differentiate between a 24 yo new grad who had never truly cared for a patient, from a 40 yo new grad who had been a paramedic or RT for 15 years, from a 40 yo with 15 years of experience as a PA in critical care?

 

Better to have a designated SP, and have the SP and PA define what the supervisory role is.  This may be "available for consult if needed" for that 40 yo with 15 yrs experience, it may be occasional chart review for the 40 yo new grad with heavy experience, and be physician contact for every patient for the 24 yo new grad.

 

Agree with the name change...but I don't know any name that wouldn't also have some problems. 

[EMEDPA]

the problem with a designated sp is that they can die, retire, etc. we need a fix for that.

[PACdan]

EMED:  I think oversight by a med board would be just as bad as we have now. How would they differentiate between a 24 yo new grad who had never truly cared for a patient, from a 40 yo new grad who had been a paramedic or RT for 15 years, from a 40 yo with 15 years of experience as a PA in critical care?

 

Better to have a designated SP, and have the SP and PA define what the supervisory role is.  This may be "available for consult if needed" for that 40 yo with 15 yrs experience, it may be occasional chart review for the 40 yo new grad with heavy experience, and be physician contact for every patient for the 24 yo new grad.

 

Agree with the name change...but I don't know any name that wouldn't also have some problems. 

 

 

the problem with a designated sp is that they can die, retire, etc. we need a fix for that.

 

 

How about a named, designated SP for the first 6 years of full-time practice in a given speciality? Afterwards the PA can move under the general purview of the state BoM and work uninterrupted for the rest of their career as long as they continue to work in the same field. That removes the burden on established PAs pertaining to SPs that die, ditch, or retire.

[Boatswain2PA]

the problem with a designated sp is that they can die, retire, etc. we need a fix for that.

Agreed. There are easy fixes for that though without throwing away the SP/PA relationship that our profession was FOUNDED upon.

[Boatswain2PA]

the problem with a designated sp is that they can die, retire, etc. we need a fix for that.

Agreed. There are easy fixes for that though without throwing away the SP/PA relationship that our profession was FOUNDED upon.

[EMEDPA]

How about a named, designated SP for the first 6 years of full-time practice in a given speciality? Afterwards the PA can move under the general purview of the state BoM and work uninterrupted for the rest of their career as long as they continue to work in the same field. That removes the burden on established PAs pertaining to SPs that die, ditch, or retire.

I like this idea. probably less time though. 5 years or completion of a residency + 2 years.

[EMEDPA]

Agreed. There are easy fixes for that though without throwing away the SP/PA relationship that our profession was FOUNDED upon.

Dr Stead thought PAs would be able to easily bridge to full fledged physicians in the future...not all concepts of the founders have worked out as planned...the founders all thought docs liked to teach and be mentors....doesn't happen much outside of a residency these days...

[andersenpa]

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.  

I agree with some of the sentiments in your post- eg, not all PAs are ready for complete freedom from supervision. Some will never be. There NEEDS to be ultimate flexibility in the relationship, such that those PAs that truly need no supervision can work as such.

 

Furthermore the licensing issue is not straightforward. I recently spoke to my state licensing board (WA). A PA can get licensed without an SP, they just can't PRACTICE without one. I honestly don't know how different it is in each state- I hope others post how it is for them. For WA, the licensing process and practice plan are separate (but interdependent).

 

We are at a strange place in our profession, in that 1) PAs have CLEARLY demonstrated that the old supervisory model is no longer applicable, 2) we have not determined how to describe the physician relationship that is necessary,a nd 3) providers with less training (NPs) are lapping us in the race for professional freedom. 

[PAFT PRESIDENT]

I've re-read the string...tried to decide if I'd answer any differently in the light if day rather than in the middle of the night.

At the risk of being accused of "semantics" again, I'll clarify and say that PAFT absolutely advocates severing terms like physician supervision and the unnecessary things that embodies. The PA/physician RELATIONSHIP has never been functionally built on legislated mandates. Cosigning charts, being onsite a minimum of 4 hrs per month, signing a scheduled script and on and on are not what creates a respectful symbiotic relationship between a PA and a physician. If it takes changing legislative language to autonomy or practice responsibility or the like to accomplish change of things like that, PAFT supports that. Physicians have historically fought changing/elimating useless PA statutes in every state for years for unfounded reasons - even when it creates "more work" for them in the trenches. If there were reasonable avenues for PAs to accomplish these things without taking 30 years to do it, we wouldn't be having this conversation. The PA profession does not have another decade or two to remain competitive.

Oversight, mentoring, competency development and assessment and the things we seem to be on the very same page about are determined at the practice level - not by mandated supervision.

[Boatswain2PA]

Dr Stead thought PAs would be able to easily bridge to full fledged physicians in the future...not all concepts of the founders have worked out as planned...the founders all thought docs liked to teach and be mentors....doesn't happen much outside of a residency these days...

I've read much of Dr. Stead's writings on the profession and I don't think he ever inferred that bridging would be EASY!  :-)   However you are right, his vision was to have much of our PA education count toward ME educational process.  The LECOM program is a blessing, albeit very late to the show.

[Boatswain2PA]

I've re-read the string...tried to decide if I'd answer any differently in the light if day rather than in the middle of the night.

 

At the risk of being accused of "semantics" again, I'll clarify and say that PAFT absolutely advocates severing terms like physician supervision and the unnecessary things that embodies. The PA/physician RELATIONSHIP has never been functionally built on legislated mandates. Cosigning charts, being onsite a minimum of 4 hrs per month, signing a scheduled script and on and on are not what creates a respectful symbiotic relationship between a PA and a physician. If it takes changing legislative language to autonomy or practice responsibility or the like to accomplish change of things like that, PAFT supports that. Physicians have historically fought changing/elimating useless PA statutes in every state for years for unfounded reasons - even when it creates "more work" for them in the trenches. If there were reasonable avenues for PAs to accomplish these things with taking 30 years to do it, we wouldn't be having this conversation. The PA profession does not have another decade or two to remain competitive.

 

Oversight, mentoring, competency development and assessment and the things we seem to be on the very same page about are determined at the practice level - not by mandated supervision.

 

Okay, you've clarified.  And we are in general agreement.

 

How do we ensure appropriate oversight, mentoring, competency development and assessment if we don't have SOME sort of proscribed supervision?  

 

I am against ANY written regulation for mandatory onsite time, chart review, script signature, etc because it is an imposition of an inflexible rule (MUST review 10% of charts) on a very flexible profession.  

 

However, simply stating that the SP and PA must have a collaborative supervisory agreement in place can meet all of our end goals.  

[PAFT PRESIDENT]

There are, at present, ZERO "easy fixes" for a PA who's SP dies, retires, goes to rehab, is found incompetent to practice, or chooses to dissolve the supervisory role suddenly - NONE.  There is likely a state or few who have some protective language for temporary emergency type situations but they are few.  Any attempt in the two states I've practiced in over the past 22 years to include some sort of language protective to the PA is defeated every single time by physicians - MD and DO organizations alike. There is example after example of how organized medicine has historically set the tone for PAs to have to look elsewhere to protect our profession.  It has taken me years to personally accept this reality.  This very situation was what prompted me, personally, to become far more involved and what led me to PAFT.  I had no recourse in a private practice setting, single physician/PA situation.  As he departs for his abrupt and unheralded 90 day vacation, there was NO assistance or protection from the BOM other than technical guidance of what I had to do to satisfy the law to avoid a BOM review or sanction.  There were 6 surgeries that week and every week thereafter, 20+ultrasounds weekly requiring review and countless other patient's who's care would have been completely left in limbo with no medical guidance and direction if I hadn't been able to scramble and provide some proof to the board that I had a reasonable SP lined up with at least a kind of similar scope of practice within 48 hours who would come and see patients onsite 4 hours per month.  I was lucky - I had existing relationships - built on things other than statute, btw - and was able to accomplish that.  Most would not have been able to do that.  The board told me I could be disciplined if I saw a single patient if that "supervision document" - not oversight - not medical competence - not quality care - was not in place for the safety and care of these patients who's doctor was abruptly incognito.  It didn't matter that I'd been practicing for 15 years in OB/GYN or that all of these patients knew me or that I was qualified by every other state law to guide them in making serious decisions about surgical procedures, inductions for delivery, oversight for Preeclampsia and other obstetric complications.  But if I didn't have the "supervision document",  all those patients were just out of luck and I was out of a job and an income for however long.  My learning curve was vertically abrupt.  And you want to know how many times the courtesy SP provided direct decision making and care to ANY of those patients?  NONE other than the 4 scheduled hours per month he saw patients to satisfy that statute, in which he mostly saw his own female patients for annual exams and well care during those hours.  And, I will forever be grateful to him for doing so, btw.   

 

BACK to PAFT PRESIDENT MODE now......All the other discussion of autonomy, supervision, etc aside, the below is why PAFT penned that letter to SEMPA.

 

Microscopically, we have fabulous relationships with physicians based on mutual respect and human connection.  Macroscopically, we have had to fight to get reasonable legislation changes accomplished all-the-while organized medicine and physician organizations offer very, very little in the way of professional respect and support despite our historic connection to them.  This is no more glaring than the original ACEP Now article that started this entire string. 

 

Dr. Klauer, ACEP interviewer for the article - who MUST surely know ACEP's position on preference of PAs for utilization in ERs across America and the symbiotic ACEP relationship with SEMPA - did NOTHING to redirect and correct the AMA President on his incorrect and skewed statements about PAs.  The ACEP doc absolutely should have at least corrected and separated PAs from the generalized NP statements.  He did not. 

 

In response, SEMPA sends a public letter of "reassurance" to ACEP with a placating tone of subservience to the organization using terminology such as physician-led and physician supervision - terms that even AAPA has finally outwardly endorsed eliminating from our vernacular - all to reassure ACEP that PAs have "never sought independent practice, nor do we foresee a change in the philosophy of our profession."  At the very least among all of SEMPA's commentary should have been a reminder of ACEP's endorsement of PAs as the preferred provider.  It did not. 

 

Why wouldn't SEMPA simply inquire of ACEP why they didn't hold up their end of the relationship with SEMPA in a published article by publically voicing their support for the PA profession?  Is there no one in SEMPA leadership who sees that the largest ER doc representative body that you had to "fight" to get to say they prefer PAs just allowed the president of the largest physician organization in the US to disparage the entire PA profession?  And ACEP's Dr. Klauer said nothing, nada, zip.  And worse, SEMPA did not ask why. 

 

If PAs don't call upon physicians to offer at least accurate statements and perhaps basic professional respect publically when they should - like in that article - they will not do it on their own.  Aside from the occasional contemplative individual physician who does, organized medicine and physician organizations do not correct their own wrongs to PAs.  The past 50 years have proven that in large scale over and over and over.  Physicians have proven to PAs that we must do these things for ourselves.  There is nothing wrong with that and it can be done without being confrontational, dismissive or derogatory to our physician colleagues. 

[Boatswain2PA]

I agree we need to change things so that our licensure is not tied to a single physician.  We should be licensed to practice medicine, but I don't have a problem with having to have a signed SP document on file before practicing on a patient.  I'm sorry your physician dropped out on you and your patients, but that's on him and seems like that could be considered abandonment. 

 

About Dr. Stack's interview - what "incorrect and skewed statements about PAs" did he give?  i agree, he did kind of lump PA/NPs together, but it will be clear to any reader with ANY understanding of PA/NPs who he was talking about when he was referring to non-physician providers pushing for independent practice or trying to represent themselves as "Doctor".  

 

And that was pretty much what SEMPAs letter called them out on...that PAs are NOT the one's who are pushing for those things. 

I also wish that SEMPA had taken the opportunity to point out to ACEP and AMA that PAs are the preferred APP in the ED.  But my disappointment in that does not equate to the level of divisiveness that I read in your letter. 

 

[PAFT PRESIDENT]

So noted.   I'm glad we came to some mutual understanding.  We are of like mind for sure.

[Febrifuge]

I think one thing we can and should do, not only in these discussions off in our own little sanctuary here, but also in discussions with professional groups, state legislatures, and the public, starts with language. We need to clarify for ourselves, and once we get our intentions and goals straight we need to hammer away at, the difference between "independence" and "autonomy."

 

We need to make it crystal clear and blindingly obvious what we want, and what we don't. What we're asking for, and what we are not. What we believe needs to change, and what we feel already works the way it should. Until we can do that, we will always be at risk of tripping over our definitions, and arguing with people who actually agree with us.

 

My own humble take on it works something like this: we can draw a big thick line on the chalkboard, separating ideas that sometimes sound similar but are different in important ways. And the better we can place them in context, the more clear it becomes what things on one side of the line have to do with one another, and what the differences are from side to side.

 

This isn't about drawing battle lines, and it's not about putting anyone else down. That being said, there are probably going to be some battles, and having this kind of clarity will absolutely be useful at those times. C'est la vie.

 

You see where I'm going with this, right? On the AUTONOMY side of the chalkboard, we would have phrases like "working to the top of one's license" and "trained in the medical model" and "an important part of the patient care team." We'd add "consult and refer when needed" as well as "primary care provider" and "long-term patient care relationships" or "responsibility increases with experience and demonstrated competency." We would definitely add "respected as professionals." We could include "working with physicians" and depending on the mood in the room, we might put an asterisk by that, leading to "...not working FOR physicians," but there could be two asterisks going to "everybody working for the best possible patient care."

 

And what's on the INDEPENDENCE side of the chalkboard? That's a bit tougher to imagine, since we're trying to say that our goal isn't really to be completely independent, at least not in the way people tend to think. Right? So it's tricky not to just lump a bunch of straw-man type arguments over there like "replacing physicians" or "just do what the NPs want to do." I suppose independence would be a matter of not just "protect PAs from inability to practice if the SP runs away to live in a yurt" (which would be an autonomy thing), but maybe "no physician oversight whatsoever."

 

It's hard, because the INDEPENDENCE side of this exercise winds up being all about problems, and likely objections, and reasons why MDs or the AAPA might freak out, whereas the AUTONOMY side, if we do it right, would be all about solutions. Part of that is pointing out the problems that are extant in the current system, that's true. There are people who don't want to acknowledge those, but it's becoming increasingly important that we do, and as has been discussed above, things have been shifting in the past 10 years or so. I think they'll continue to shift, but we need to be smart, and we need to do our best to lead the discussion before some other group comes along and tries to take it over.

 

So I think we start by explaining what autonomy is, why it's important, why it's necessary, and why it's beneficial. Along the way, we explain the difference between autonomy and total independence.

[PAFT PRESIDENT]

PAFT is rolling a plan out very soon...your sentiments ring true - very, very true.  In fact, this exchange has crystalized a few things in my head as I craft a PAFT press release as we speak. 

[Marinejiujitsu]

The problem started with the NPs pushing more and more for independent practice. It has left us behind in a good chunk of jobs and states. I prefer us all to have physician oversight. PAs are retarded out of school and I do believe it's worse with the NPs. Quality medical practice is developed by practicing under guidance for a few yrs at least. For all. NP is the only medical providers that doesn't have this. That took medicine back unfortunately. 5 yrs in practice you should be a able to file for undependacy. That would be fair.

 

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[Boatswain2PA]

Feb - that's great, but another way of looking at it is that the autonomy side is what we want, but the independence side would be the side where we list the limiters.  If we don't limit the "autonomy" side by putting things (ie: defining things) on your "independence" side, we will find ourselves asking for completely independent practice. 

I like your idea, but we can't just fill in one side.  We gotta identify what we mean by autonomy, what we mean by independence, and, just as importantly, what we DON'T mean by those terms. 

[Marinejiujitsu]

Independence

 

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[Marinejiujitsu]

I think in order to get a head, NPS have to come back a notch with the legislation.

 

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[Boatswain2PA]

PAFT is rolling a plan out very soon...your sentiments ring true - very, very true.  In fact, this exchange has crystalized a few things in my head as I craft a PAFT press release as we speak. 

If you clearly state that PAFT's position still hinges on a physician having some level of responsibilty for the PAs practice, then I'll likely join your organization. 

 

AAPA, and it's subsidiary state branches, won't get me as a member until they change their politics.  It's funny...the guy who they disinvited from getting the Paragon award because liberals twisted his words on homosexual marriage is now a leading contender for POTUS.  :-)

[db_pavnp]

PAFT P,

 

I suggest doing your thing and not getting sucked into fruitless discussions with vocal, fringe minorities on message boards.