Future Standards for PAs and NPs
Bob Blumm, PA, DFAAPA, PA-C Emeritus
Standards: it seems as if everyone is talking about them today. We are either creating standards, improving standards, setting new standards or raising standards. Ultimately, as decades pass, standards grow, and this seems appropriate considering the health care needs in the United States and our world standing in that sphere. Like most Americans, I had always assumed that we were naturally - Number One - but was disheartened to discover that my assumptions were grounded in my patriotism and not in evidence-based studies. Depending upon the source and the year, the US typically ranks in the top 20 or 30% and shockingly behind all other nation members of the G-10 (including many smaller countries). This surprising revelation gave me pause to reflect on our “standard of care.”
What does the word “standard” connote to the average PA, NP, or patient in terms of academic achievement? It might be interpreted as an entry-level bachelor’s or master’s degree - or perhaps even a doctoral degree. Many of these advanced levels could never have been imagined in the past but are now very much a part of the 2021 working world for PAs and NPs. How quickly times change with more and more clinicians earning doctorate degrees – spurring insurance companies and administrators to establish yet even newer benchmarks based on this academic proliferation. If we as a profession do not set our own standards, someone else or another profession will surely try to do it for us. If ever we needed cohesive leadership, it is now! Maybe you are the person who can lead us into the future?
What do I personally think of standards? I believe that standards are a very positive modifier of our practice protocols and approaches to medicine. I see the patient as the ultimate winner when a profession has high standards. Standards lead to increased study and competence. Standards are set and maintained by academia, education secured at conferences, and CME provided by associations. They are enhanced by experience and certified by procedural attestation such as those through residency rotations. There will, in the near future, be a mandated procedural attestation required within all institutions of medical care. When looking at medical specialties, we note that either a residency or a specialized track of education and experience defines what an institution requires for an NP or a PA to be hired.
Most of the specialty areas need highly experienced, highly motivated, and extremely well-educated PAs and NPs and are willing to provide a mini residency. Some of these specialties require additional education, CME, preceptorship, and a specialized curriculum in addition to an advanced degree. I will repeat a sentence that I wrote ten years ago: “The time is quickly coming upon us that will no longer place on a resume ‘PA seeking a hospitalist role, ---- willing to learn, seeking physician willing to teach.’” That time became a reality more than five years ago. Physicians are engaged in their own fight for survival, focused on issues which affect their profession, leaving little time for the altruism of the past when they sought to be the “teacher” to a nonphysician. The economy, new health care laws, insurance mandated reimbursements, malpractice issues, and the huge financial debt incurred while becoming doctors have caused them to protect their own turf and areas of responsibility.
What will possibly be the standard for the PA in the next few decades? PAs will be a graduate of a doctoral program, be highly intelligent, and have the interest to further their education by means of residencies of various lengths to best prepare for the arduous task of caring for an additional 31 million patients in a decade with decreasing numbers of physicians. The PA will be a team member that possesses a team attitude and team spirit as the care of patients will be delivered by highly trained team members. Personally, I see this as a positive move and will be comforted as a patient to realize that all of the medical personnel with whom I have a relationship share a unified approach and attitude that will enhance my treatment, wellness and outcome. I think that the nursing profession will continue to grow in this same direction as they are recognized experts in so many specialties today.
This shared approach to patient care will require many signatures and notes on the EMR which can become tricky for many clinicians. With a team approach, opportunities for medical error will require heightened vigilance. And when errors occur - who is responsible - the institution, or the clinician? It is and has always been the clinician, and these errors are often due to the exhaustion felt by providers: reading every note, reviewing every test, and reconciling every new medication order. Prior to my own retirement, I began to feel the exhaustion of doing the detective work and realized that I was becoming a relic. As malpractice exposures rise, so too the need for a personal malpractice policy. Younger clinicians are much better suited to the demands of this ever-increasing administrative multi-tasking than those of us from an earlier vintage. This new era makes a malpractice instrument essential, now more than ever. Be careful and refrain from choosing based on cost alone, without fully understanding the policy terms and the provider’s history in the healthcare market. “New” companies with new perks come and go and may not exist in a few years, when you might need them. Make your own educated decision to prevent hardships in the future.
I was recently accepted to a program in Florida! The school doesn't provide health insurance for their students so we are required to obtain our own health insurance. I currently have insurance through my employer, which I'll obviously no longer have once I begin school. Also, I can no longer be on my parents insurance.
Since I start school in January, how early should/can I apply for insurance in Florida? I am from Washington state. Also, does anyone have any tips/insight on which insurances are the most affordable for a student? Thanks in advance.
I have a new job offer and had some questions with regards to negotiating the malpractice coverage
The offer states that I would be covered under the group's malpractice policy using the group's standard policy and limits. I need to clarify the type of insurance policy but I am assuming it is a claim's made policy. The contract states that upon termination the employee "shall secure at their own expense malpractice insurance tail coverage if required."
This would be a dream job for me and I absolutely intend on staying with this position for the foreseeable future, but I am not comfortable going into a contract/position without any tail coverage guaranteed as it seems the cost is quite high to obtain this once leaving. While I know I could negotiate for a future employer to pay this I don't know how common or expected that would be.
I am thinking of negotiating for them to pay tail coverage OR negotiating for them to pay the premiums for my own occurrence-based policy (which would likely be through the AAPA) so that I would not have to worry about tail coverage if there comes a time I change positions. Thoughts on this? Should I not worry about the tail coverage issue and move forward with the contract if they decline my requests?
Communication and Dangerous Medical Errors
Robert M. Blumm, MA, PA, DFAAPA, PA-C Emeritus
Communication is as old as the human race and has always played a part in our lives: from early writing on the walls of caves in pictures, to smoke signals, the printing press, Morse Code, the welcoming of Alexander Bell's telephone and, of course, all of the enhancements that we have today, including that annoying cell phone with its robocalls. The purpose of communication is to share a message and to get a response. The key to communication is not mere hearing, but the focused act of listening, responding, and returning information. How often do we go to a store, give an order, only to have the clerk say, “What did you want?” They have not listened to what you ordered.
This is unacceptable in a medical practice. Just yesterday, as I began to write this article, I was informed of a medical error which caused a patient a greater morbidity risk because the message that was given was not relayed and the patient trusted the nurse who gave the response. We all know Mrs Jones; Mrs Jones called the gastroenterologist three days ago with the complaint of minimal left lower quadrant pain, severe bloating, gas, was afebrile and had unusual bowel movements. Mrs. Jones called her doctor when she realized that she was not healing spontaneously and needed the attention of a specialist rather than running to an Emergency Room. The nurse said the doctor was booked, but that she would double her up sometime that day or the next day and to wait for a call. The call did not come that day or the next. When the patient was finally seen as an emergency, she was beyond Flagyl and Cipro as she now had a perforated diverticulum. If the patient had been seen as she had been promised, the need for emergency surgical intervention might well have been averted.
This is only one of the hundreds of errors that can occur when employees in our offices drop the ball or when we do not have protocols in place. Every time that a PA or an NP orders blood labs, urine, radiological studies, special consultations or has a patient that has been discharged from the hospital, they should be notified by the provider or designated office person as to the results and what they may mean. Telling a patient that their WBC is 16,000 is not the same as saying that it is abnormally high and indicates an infection. When a patient reports a problem or calls to say their blood glucose is 50 or 350, these are examples of hypo and hyperglycemia and they will need to speak to a provider for directions and follow-up. All responses need to be placed in a log with the signature of the person making the call and what they told the patient. Hospital discharge patients require the same procedure to assure them that you are concerned and that they have had their questions addressed. These are written procedures and protocols and your health care system probably has forms for this for their own follow up. What if your office workers are not diligent to maintain this type of record? You, as the provider or owner of your practice are 100% responsible and, therefore, you need to have the proper liability insurance. You will also need to discharge that employee from your practice setting.
What is the best type of insurance to have for these potential problems as well as the many others that you may encounter as you practice medicine or nursing? My suggestion would be an occurrence policy, and not just any occurrence policy or one from your healthcare system, but a personal liability insurance policy that specifically names you as the covered and owner of the policy. What company would I choose? A company with a reputation for honesty, paying their claims, securing excellent attorney’s and having the ability to pay claims without bankruptcy. I would choose a company called CM&F, Personal Liability Insurance experts with a 70 year history of excellence and an A++ (Superior) rating by A.M. Best. Why this company? Because it is proven and has cared for nurses, PAs and NPs throughout its history and is a committed family-owned business.