Why do a residency?

[andersenpa]

Second, the value of residencies to is to teach those without prior experience before coming to PA school the skill set necessary to perform OTJ. This is applicable across all specialties but is meaningless in the realm of primary care. For example, the average medic with 5 years of SOLID 911 experience has the skill set, sans U/S and central lines, to be dropped into any acute care setting and start taking care of people. Add the primary care training of PA school and you have a solid knowledge base from which to spring into an EM slot. This is not so for the current crop of young 20-somethings right out of college and into PA school. They need a year to garner the necessary skills to work in a specialty environment. In an environment where medical dollars are at a premium, wasting a year to teach a newbie who is going to leave after 7 months is valuable to no one.

 

Also, the average residency trained PA, at best, has 4-4.5 years of post-bac training that is directly applicable to the clinical arena (24-30 months PA program, 1-1.5 years residency - yes, I know there are two year residencies out there...). This is still not enough to warrant the granting of independent practice when one considers that in the medical model, the average doctor (the standard for independent practice) has 4 years of medical school and AT LEAST 3 years of residency training (more likely 4-7) + fellowship. It is still apples and oranges when comparing the professions. Demanding parity as a "buy-in" to doing a residency is farcical on its face.

 

Finally, the reality is that the average student entering PA school is getting younger, experience is less common, and a lot of the outside realities of practicing medicine independent of PA practice have not changed. Litigation continues to be a major problem, PA programs are pumping out, IMHO, a less-polished product compared to even 10 years ago, and the docs are noticing it. Residencies will continue to expand as the market forces dictate it. It would behoove us as a profession to harness this now, standardize it, and put out a superior product. When that happens, you have a chip at the table to play. Otherwise, we DO leave our future in the hands of others and that does not give me a warm and fuzzy feeling...

 

G

 

G-

 

I've thought a lot about this and I think PAs with previous medic experience really are in a class by themselves. I can't think of any other type of HCE where the individual is practicing medicine to that level. This probably accounts for the success of PAs in EM.

 

However I don't see this same model applicable to other PA specialties. For these fields (surgery, ortho, neuro, ENT) there isn't a pre-PA HCE equivalent that puts the PA in the same position to hit the ground running. To generalize, it doesn't seem accurate to say that the purpose of residency is to supplement the lack of knowledge in the current crop of lesser HCE PA applicants.

 

The goal of residency is to provide more intense postgrad specialty training not available in generalist PA education. Look at CT surgery. There is no mandatory CTS in 2nd yr; electives are the best bet and then it's 4 weeks. Previous HCE or not, all PA grads looking to get into CT benefit from residency.

 

To restate though, I agree that the EMS-EM PA transition is much smoother with experience and residency may not be as much benefit for a seasoned medic.

[navyflyPAC]

Good stuff here guys. I'm the OP btw. This thread seems to have grown its own legs :). Anyhow, one more question for all of you. Are PA residencies more or less done with physician residents? Meaning, are our training programs arranged throgh Physician residency coordinators? Are we in the same room with physician residents/duties/training? How does this all work? Reason I'm asking is because I kind of know the Fellowship and Residency coordinator for a very promiment CT surgeon in my area. I believe they only train physician residents, but it would be nice if I could start working something out for PA's to benefit from another opportunity (especially me right now).

[kargiver]

Damn, that may be the best post ever written on the pa forum. you should run for some kind of office....

 

I'll have to give it some thought... :)

 

Matt, I think that there is significant validity to the agrument about medics transitioning to the EM PA role. But also, a well trained RT or an experienced RN can transition to other fields with a lot more knowledge base compared to other, less experienced new grads. I do see your point about the surgical specialties (really, what pre-PA experience will prepare you for opening a chest or harvesting a vein or putting a rod in someones tibia) but learning the medicine can be achieved. At least once upon a time it could...

 

We now accept CNA as valid experience. Although invaluable (thank you to those who do it) it still isn't the same...

 

Great discussion. I've been away for too long. The nature of politics I suppose...

 

G

[kargiver]

I would like to see them developed independently but intertwined with physicians during residency. It is important that if we do not the "independent route" we are intertwined as much as possible to enhance our value. Making ourselves the provider of choice will only occur by making us indispensable...

 

G

[whimsygirl]

Making ourselves the provider of choice will only occur by making us indispensable...

 

I agree. I also appreciate the proactive stance as opposed to woe is us.

[foley08]

 

Second, the value of residencies to is to teach those without prior experience before coming to PA school the skill set necessary to perform OTJ. This is applicable across all specialties but is meaningless in the realm of primary care. For example, the average medic with 5 years of SOLID 911 experience has the skill set, sans U/S and central lines, to be dropped into any acute care setting and start taking care of people. Add the primary care training of PA school and you have a solid knowledge base from which to spring into an EM slot. This is not so for the current crop of young 20-somethings right out of college and into PA school. They need a year to garner the necessary skills to work in a specialty environment.

G

 

I think the value of residencies is the structured learning environment that allows a clinician to receive constant feedback from those more senior and grow in a step wise fashion. We've all been around physician residency programs as students and there are probably few, if any, jobs that could offer OTJ training to even come close.

 

Medic is a high level job and that's great but not all PA students are medics and not all former medics go into EM/critical care. I have a feeling that a former medic would have a lot to learn in an EM residency.

 

Anyway, it's all sort of a moot point at this stage. What percentage of PAs (lets say 1st and 2nd year PAs) in a given year are in a residency? It must be less than one percent. That's a lot of slots to come up with before residency is even a viable option for most new PAs.

[foley08]

I would like to see them developed independently but intertwined with physicians during residency.

G

 

I agree 100%. When I looked into EM residencies, at least the ones near me were all pretty much carbon copies of the intern year. I then found an EM "fellowship" (I'll try to find the curriculum) which looked to me like someone sat down and said how can we maximize a PAs time and exposure to EM over the course of a year.

 

I think given the time constraints and the fact that the end goal of a PA residency is not to put out a residency trained physician we need to tweak residencies to maximize the benefits to us.

[Gonadometrics]

 

PA programs are pumping out, IMHO, a less-polished product compared to even 10 years ago, and the docs are noticing it.

 

G

 

Thank you for qualifying your remarks with the IMHO. I am going to offer a counter point. PA programs are pumping out a MORE polished product today compared to 10 (or 30) years ago. Today, admissions are far more competitive so only the brightest get accepted. Also, the admission requirements (academic) are far more stringent. IMHO, many of the PAs who went to PA school 30 years ago would not be able to compete academically against today's PA applicant. PAs today enter PA school with tremendous biology and chemistry backgrounds. In most cases, they have physics and strong math/statistics education as well. They are moving the profession forward by increasing the intellectual power of the Physician Assistant. PAs graduates todays will become leaders in the Health Care industry in 5, 10 or 20 years. Many of the critiques we read here are rooted in attacks on academic endeavors....IMHO.

 

You also mention that "Docs are noticing." Obviously this is your opinion based on anecdotal evidence. No double blinded, randomized controlled studies have been done to show a less favorable view today versus ten years ago. If so, I am interested in reading them. Also, one may hear more "complaints" about Physician Assistants today for two reasons. First, there are simply more of us. If the percentage of complaints remains the same but the base grows, the absolute number of complaints increases. Second, Physician Assistants have made major inroads (thanks to hard work of older PAs) such as prescribing, more priviledges, limited solo practice, practice ownership (restricted of course). The physician population may see that as threatening and disparage PAs to advance their own professional interests.

 

Finally, everything I have said is "In my humblest opinion."

[kargiver]

Thank you for qualifying your remarks with the IMHO. I am going to offer a counter point. PA programs are pumping out a MORE polished product today compared to 10 (or 30) years ago. Today, admissions are far more competitive so only the brightest get accepted. Also, the admission requirements (academic) are far more stringent. IMHO, many of the PAs who went to PA school 30 years ago would not be able to compete academically against today's PA applicant. PAs today enter PA school with tremendous biology and chemistry backgrounds. In most cases, they have physics and strong math/statistics education as well. They are moving the profession forward by increasing the intellectual power of the Physician Assistant. PAs graduates todays will become leaders in the Health Care industry in 5, 10 or 20 years. Many of the critiques we read here are rooted in attacks on academic endeavors....IMHO.

 

You also mention that "Docs are noticing." Obviously this is your opinion based on anecdotal evidence. No double blinded, randomized controlled studies have been done to show a less favorable view today versus ten years ago. If so, I am interested in reading them. Also, one may hear more "complaints" about Physician Assistants today for two reasons. First, there are simply more of us. If the percentage of complaints remains the same but the base grows, the absolute number of complaints increases. Second, Physician Assistants have made major inroads (thanks to hard work of older PAs) such as prescribing, more priviledges, limited solo practice, practice ownership (restricted of course). The physician population may see that as threatening and disparage PAs to advance their own professional interests.

 

Finally, everything I have said is "In my humblest opinion."

 

All valid points. Can't argue with this logic as it too is opinion... I will say this, sitting on 2 program admissions committees, one highly ranked and one a newer program, the caliber of appicants is vastly different. One can suppose many reasons for this and there is no real way to study it, but the newer program has inferior applicants relative to the older, highly regarded program. The number of applicants aren't different, but the pool make-up is. When I refer to the current pool being "less-polished" this is to what I am referring... there are more programs and more people wanting to be PAs. This will invariably bring in more people with a wider range of academic and prior clinical abilities. The "lesser" schools still need to fill slots with warm bodies and in the end, these people still come out practicing medicine. But it is a reflection on all of us. Hence the perceived changes...

 

But again, you make many valid points.

 

G

[jdtpac]

I have been reading all the previous posts with great interest. I think there has been some very valid and thoughtful points made. But I'm having a problem with trying to grasp this concept of an independently practicing PA in a specialty. I can vision how a PA in primary care could practice independently. We “Boomers” remember there once was a provider that would have worked in a similar manner and we used to call then “General Practitioners” or GP’s for short. Many of us remember them as our family doctors. My question to those of you that believe we should be working towards independence practice is, “how would a PA that finished a residency in orthopedics practice independently in that specialty”?

Did not think that I do not agree with what you are espousing to, I just don't understand how we are going to achieve this goal.

[andersenpa]

I have been reading all the previous posts with great interest. I think there has been some very valid and thoughtful points made. But I'm having a problem with trying to grasp this concept of an independently practicing PA in a specialty. I can vision how a PA in primary care could practice independently. We “Boomers” remember there once was a provider that would have worked in a similar manner and we used to call then “General Practitioners” or GP’s for short. Many of us remember them as our family doctors. My question to those of you that believe we should be working towards independence practice is, “how would a PA that finished a residency in orthopedics practice independently in that specialty”?

Did not think that I do not agree with what you are espousing to, I just don't understand how we are going to achieve this goal.

 

When I think about greater PA autonomy/independence (or whatever you want to call it), I am always thinking of primary care; the model we are trained in during our generalist PA education. They really are two separate tracks, primary care and specialty practice. I think most PAs who have been in the field for a while or keep abreast of these issues think similarly. As a CTS PA it's not even in my most peripheral thoughts to enter any "independent" practice.

 

This is why the awarding of special independent designation for residency PAs seems misguided.

Instead, we should honor the tradition of PA training- to meet the public health need- and train PAs who can maximize access in primary care. Less restrictive oversight/supervision, eliminating chart review mandates etc should be the first steps down that pathway.

[jdtpac]

This is why the awarding of special independent designation for residency PAs seems misguided.

Instead, we should honor the tradition of PA training- to meet the public health need- and train PAs who can maximize access in primary care. Less restrictive oversight/supervision, eliminating chart review mandates etc should be the first steps down that pathway.

 

Bravo, Bravo, Bravo! This is probably one of the most profound statements I have ever read on this forum. For someone who has been in our profession since 1972 I can say the following statement unequivocally : ”Over the past 40+ years the physician assistant profession has proven without a doubt that it doesn't take 4 years of undergraduate, 4 years of medical school and 2-3 years of a residency to be qualified and competent to provide high quality primary care services."

I have been outspoken about this in the past in the Academy. I have also written 2 articles within the last 10 years addressing Medical Education Reform , one was sent to JAAPA and the other to the AMA news, both of which were turned down. All I was suggesting was that the AAPA, AMA and the medical education establishment enter into a dialogue to investigate the possibility of a greater role for PA’s in the delivery of primary care services in this country.

I also agree with you that the individuals whose vision of increasing PA postgraduate residency training is misguided. I do believe there is a very important role for PA’s in subspecialties, however, what we are turning into are ”lifelong residents”. And I also believes that their supposition that awarding a doctorate degree to individuals who have completed a postgraduate PA residency will give them greater autonomy in a subspecialty is also misguided.

I am overwhelmed and glad that you made the above statement and hope we can move away from this topic of postgraduate residency programs and dialogue more on the potential future for physician assistants that you have suggested. Thank you!

[andersenpa]

Bravo, Bravo, Bravo! This is probably one of the most profound statements I have ever read on this forum. For someone who has been in our profession since 1972 I can say the following statement unequivocally : ”Over the past 40+ years the physician assistant profession has proven without a doubt that it doesn't take 4 years of undergraduate, 4 years of medical school and 2-3 years of a residency to be qualified and competent to provide high quality primary care services."

I have been outspoken about this in the past in the Academy. I have also written 2 articles within the last 10 years addressing Medical Education Reform , one was sent to JAAPA and the other to the AMA news, both of which were turned down. All I was suggesting was that the AAPA, AMA and the medical education establishment enter into a dialogue to investigate the possibility of a greater role for PA’s in the delivery of primary care services in this country.

I also agree with you that the individuals whose vision of increasing PA postgraduate residency training is misguided. I do believe there is a very important role for PA’s in subspecialties, however, what we are turning into are ”lifelong residents”. And I also believes that their supposition that awarding a doctorate degree to individuals who have completed a postgraduate PA residency will give them greater autonomy in a subspecialty is also misguided.

I am overwhelmed and glad that you made the above statement and hope we can move away from this topic of postgraduate residency programs and dialogue more on the potential future for physician assistants that you have suggested. Thank you!

 

I think there's room for both, and it will be exciting to see how the change in the specialty landscape (which will probably be a direct result of how specialty care is paid for) will influence postgrad training for PAs. Even the most bada$$ pre PA with 10,000 hrs of intense HCE will benefit from residency if they intend on entering the top specialty fields for PAs (CTS, neuro, derm, ortho, and even EM). I don't think it is misguided to say that postgrad training should grow for PAs...I just don't think equating it with a doctorate/etc is the way to go. As far as I can see, PAs are still the "away team" and docs have home field advantage on this.

 

I too have been saying on this forum for several yrs now that we have found another way to make a primary care provider. I'm a bit removed from PC so it's hard for me to say emphatically, but I think as PAs we're damn close to producing independent PCPs outside the MD 4+4+3 route.

[EMEDPA]

I wouldn't have a problem with granting a doctorate( DSc or something similar) for a residency program like the army baylor program does but I wouldn't try to tie that in with independent practice. lots of folks want residencies and lots of folks want doctorates so I could imagine 2 pathways for a given residency at the same site.

pathway 1 is 1 yr long and 100% clinical leading to a certificate. salary 45-50k/yr

pathway 2 would include the clinical yr but then would include a second yr with oversight/leadership requirements as well as some research, essentially a chief resident yr with 1/3 time clinical(mostly precepting 1st yr pa residents, med students and pa students), 1/3 time admin/leadership(hospital committees, interviewing new program applicants, etc) + a research project and coursework resulting in a certificate and a DSc degree. salary 60k/yr

[edwardcarter]

I believe the question should be refraised to Why Not do a Residancy

[Febrifuge]

I believe the question should be refraised to Why Not do a Residancy

Because if I'd wanted to specialize, I would have gone to four-year MD school and agreed to work as an indentured servant/ worthless slug making his way through intellectual boot camp in that paradigm? Because being a PA means being essentially the heir to the old-style GP tradition, and too much specialization could hurt the lateral mobility that is such an important part of what makes us unique?

 

Just as examples, of course, but I do think the onus is on the pro-residency side of the conversation to make the case. For EM or some Surgical specialties, it makes a lot of sense... but not for everything.

[EMEDPA]

MOST of the rsidencies at this point are em or a surgical subspecialty( ct, ortho, neuro, ob) with a few critical care, neonatology, and hospitalist.

there are no current primary care or outpt IM pa residencies that I know of.

[True Anomaly]

Having a primary care residency would basically be saying that our entire education paradigm during PA school is faulty.

[Febrifuge]

^ Yes, that, exactly. Thank you.

[Contrarian]

And so would a Primary Care CAQ...

 

Or more accurately... a Primary Care CAQ would be redundent to the PANCE/PANRE... but I'm sure some folks would take it cause they got a empty frame on their wall and subconsciously yearn for/need that external validation.

[EMEDPA]

I agree an fp caq would be silly.

pa school covers primary care well. no arguement on that.

hard to argue that you learned to practice nephrology in pa school well enough to be an "expert" at it though.

[Contrarian]

Naaaah....

 

Prior to being bamboozzzzled by the CAQ...

 

We were "experts" in whatever our SPs were "experts" in...

 

Soon... we will only be "experts" in what we paid NCCPA money to ... allow us to test in (must meet minimum requirements now)... then say we are "experts" in it.

 

The NCCPA now not only holds the key to the gates of initial clincal licensure and practice in all 50 states... but will soon be also able to limit what area of clinical practice a PA can function in.

 

Seems like PAs are becoming more and more like NPs every yr. (Actually... more like "NP-Lite" since PAs will never see independence)

Maybe someone should print some T-shirts that say, "I'm a PA-C... but when I grow UP I wanna be a DNP."

 

The way things are going... I seriously considering tabling the PsyD and just getting a DNP.

[OrthoSurgeryPA]

I get the argument that a fellowship/residency allows for ease of credentialing to be able to perform certain procedures. I was trained very well by preceptors on insertion/removal of IUDs. BUT, at my current hospital I do not have the supplemental hospital credentialing that would allow me to perform this procedure. I provided documentation validating the number of times I was observed and the extent I was trained, by a prominent MD no less, but it still a no-go. The lengths I would have to go through to get the supplemental are just to much of a hassle so I have to refer my empanelled pts to my DH and it is not well received at times.

 

This may be not be the best example as I can and do perform other procedures and see a higher level of acuity pts just based on me being a military PA, but I hear this argument all the time from my civilian counterparts.

[EMEDPA]

Maybe someone should print some T-shirts that say, "I'm a PA-C... but when I grow UP I wanna be a DNP."

 

The way things are going... I seriously considering tabling the PsyD and just getting a DNP.

dnp helps you own a primary care cash only practice, not really any advantage over msn np. hospitals still will not allow them to admit and insurance companies won't cover them doing advanced procedures. the only freedom as a medical provider today is rural/underserved/overseas medicine. in Haiti there is no one to say " a pa can't do that" for example.

[Contrarian]

For clarity...

I agree with residencies and do agree that credentialing is easier after having completed one.

I also think that residences are a great idea now since significant DHCE has gone the way of the do-do bird.

I don't think that they should be "required"... and I think the CAQ is "slippery slope" lathered with astroglide...