Are we really ready to hang out our own shingle?

[Jofriend]

From PAEA website: 'Optimal Team Practice OTP is a new policy passed at the 2017 AAPA House of Delegates meeting that allows state chapters to seek changes in state laws that will, among other things, eliminate the “legal requirement for PAs to have a specific relationship with a particular collaborating physician in order to practice."'

This is a watershed movement that I predict will alienate our physician colleagues.  It represents a sea change and personally, I don't think it necessarily represents the viewpoint of most PAs.  I know there has been talk about this change on the PA forum but I was not aware this had been formally promoted by the AAPA.  No apologies about the care we provide.  However, I thought our role was by design to be a part of a team with the physician as the lead.   Thoughts? 

 

[EMEDPA]

There was a survey sent to all PAs about this and something like 70% were in favor. that is why they proceeded with the committee and formed the new policy. this does not take PAs out of the team environment. anyone can still get a consult. docs do it all the time. what this does is levels the playing field with NPs so folks stop losing jobs to them over the issue of mandatory supervision. we are every bit as good as NPs and should have all the same practice options open to them. If you want to work in a closely supervised environment, that option is not going away. just find a job set up like that. what this does is sets supervision at the practice level, not the state level, so if a doc/group wants to review 0% or 100% of your notes they can as a condition of employment. it gives the group you work for the option to let you do everything or a very limited scope. this will really help folks in rural environments, the VA, large HMOs, etc. that have been trending towards using NPs >>PAs over the supervision issue. there is a post on the huddle right now about a group that says they will hire no more PAs due to supervision. it is very common. I have seen it many times in my 21 years as a pa in 3 states. PAs in many states are already opening their own practices and paying a doc a lot of money for no real oversight, just minimal chart review within a month. that needs to go away as it actually has no impact on the care delivered in real time.

[ApolloPA]

43 minutes ago, EMEDPA said:

There was a survey sent to all PAs about this and something like 70% were in favor. that is why they proceeded with the committee and formed the new policy. this does not take PAs out of the team environment. anyone can still get a consult. docs do it all the time. what this does is levels the playing field with NPs so folks stop losing jobs to them over the issue of mandatory supervision. we are every bit as good as NPs and should have all the same practice options open to them. If you want to work in a closely supervised environment, that option is not going away. just find a job set up like that. what this does is sets supervision at the practice level, not the state level, so if a doc/group wants to review 0% or 100% of your notes they can as a condition of employment. it gives the group you work for the option to let you do everything or a very limited scope. this will really help folks in rural environments, the VA, large HMOs, etc. that have been trending towards using NPs >>PAs over the supervision issue. there is a post on the huddle right now about a group that says they will hire no more PAs due to supervision. it is very common. I have seen it many times in my 21 years as a pa in 3 states. PAs in many states are already opening their own practices and paying a doc a lot of money for no real oversight, just minimal chart review within a month. that needs to go away as it actually has no impact on the care delivered in real time.

So this policy is purely reactionary to NP autonomy?

[EMEDPA]

that is certainly a big part of it. I have lost jobs to MUCH less qualified NPs due to required supervision, so it works for me.

supervision for the most part is a joke. unless charts are reviewed in real time before the patient leaves, then they have no impact on pt care. I work in 2 states. 1 requires 0 chart review and 1 requires 10 charts/month. how does that improve pt care?

[Joelseff]

that is certainly a big part of it. I have lost jobs to MUCH less qualified NPs due to required supervision, so it works for me.
supervision for the most part is a joke. unless charts are reviewed in real time before the patient leaves, then they have no impact on pt care. I work in 2 states. 1 requires 0 chart review and 1 requires 10 charts/month. how does that improve pt care?

Will OTP allow us to, as the OP put it, "Hang out our own shingle?"

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[EMEDPA]

37 minutes ago, Joelseff said:

Will OTP allow us to, as the OP put it, "Hang out our own shingle?"

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if implemented as intended states could allow that, likely with a provision as is done with nps in some states that they practice for X years first.

[lkth487]

I am not an expert in this, so please excuse the naïveté. But I'm not sure what that means?  If someone wanted to do independent surgery to remove brain tumors, legally, they'd be allowed to open their practice without any formal training? 

[Joelseff]

if implemented as intended states could allow that, likely with a provision as is done with nps in some states that they practice for X years first.

I'm down with that.

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[Joelseff]

I am not an expert in this, so please excuse the naïveté. But I'm not sure what that means?  If someone wanted to do independent surgery to remove brain tumors, legally, they'd be allowed to open their practice without any formal training? 

It would have to be within the scope of training of the PA so independent surgery is not in our scope of practice. Family and internal med though, we should be able to do that esp those of us with time in. I think anyway.

 

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[EMEDPA]

11 minutes ago, Joelseff said:

It would be within the scope of training of the PA so independent surgery is not in our scope of practice. Family and internal med though, we should be able to do that esp those of us with time in. I think anyway.

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yup, pretty much all of primary care plus EM and a few subspecialties like Headache med, HIV, etc

[lkth487]

How would that be decided?  For example, would someone graduating right out of PA school able to open up an office and start treating HIV or headache patients legally?

[Joelseff]

How would that be decided?  For example, would someone graduating right out of PA school able to open up an office and start treating HIV or headache patients legally?

I hope not. I think there was a provision mentioned for 3-5 years or something but I think the last update my state chapter gave on OTP last year said that it would be up to the provider which I disagree with because new grads don't know what they don't know yet for the most part

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[lkth487]

23 minutes ago, Joelseff said:

I hope not. I think there was a provision mentioned for 3-5 years or something but I think the last update my state chapter gave on OTP last year said that it would be up to the provider which I disagree with because new grads don't know what they don't know yet for the most part

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Yeah my only concern would be that I can't do a headache clinic for a few years and call myself a headache specialist.  There is value and improtantance in going through a formal training process - not just didactically but some national body that ensures that the training was comprehensive - the off service rotations, acuity, the variety of pathophysiology etc - that you got enough time and patients to know the zebras.  Also some formal process that ensures your preceptors are qualified and get evaluated on teaching etc etc. 

It used to be in medicine where you just followed some doc for an x amount of time and could call yourself a specialist.  I think it's much better now. 

Thats is the reason I advocate opening up the STEPS and residencies to PAs.   

[Joelseff]

Yeah my only concern would be that I can't do a headache clinic for a few years and call myself a headache specialist.  There is value and improtantance in going through a formal training process - not just didactically but some national body that ensures that the training was comprehensive - the off service rotations, acuity, the variety of pathophysiology etc - that you got enough time and patients to know the zebras.  Also some formal process that ensures your preceptors are qualified and get evaluated on teaching etc etc. 

It used to be in medicine where you just followed some doc for an x amount of time and could call yourself a specialist.  I think it's much better now. 

Thats is the reason I advocate opening up the STEPS and residencies to PAs.   

I agree. We do have CAQ testing as PAs and I think anyone looking to go into practice for themselves need some accountability. I would not mind being subjected to such scrutiny. I never have. Now we are getting the cart before ether horse because as I understand it OTP is not a call for independence per se. But to reduce limitations on PAs by eliminating the need for collaborative relationships strictly mandated for employment. I don't know if the whole "Hang out your own shingle" thing is actually part of it. But like I said, I am for an avenue for that for the willing (and capable) PA even if it means extra schooling or testing within reason.

 

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[LT_Oneal_PAC]

3 hours ago, lkth487 said:

Yeah my only concern would be that I can't do a headache clinic for a few years and call myself a headache specialist.  There is value and improtantance in going through a formal training process - not just didactically but some national body that ensures that the training was comprehensive - the off service rotations, acuity, the variety of pathophysiology etc - that you got enough time and patients to know the zebras.  Also some formal process that ensures your preceptors are qualified and get evaluated on teaching etc etc. 

It used to be in medicine where you just followed some doc for an x amount of time and could call yourself a specialist.  I think it's much better now. 

Thats is the reason I advocate opening up the STEPS and residencies to PAs.   

There is nothing legally preventing you from opening up a clinic and seeing only headache patients. After you pass step 3 and complete one year of residency (or 2 depending on the state) you are licensed as a independent practitioner. There was a case of this in Arizona where this guy was taking cash from illegal immigrants and doing cholecystectomies in his clinic. That was until he killed some people. My father, an IM physician, will readily admit that legally he could do heart surgery tomorrow. But you do not see these things happening rampantly in the US with physicians because of the civil liability imposed. We are a very risk averse people. Just look at the independent NPs. They actually do not own clinics in a much greater percentage than we do.

 Further:

 Would CMS reimburse you for something outside your scope? No. Would people refer you patients? No. Would the hospital credential you to use their facilities? No. Would you get sued doing something you couldn't back up training in? Yes.

Though I agree in with you in principle.

 

[lkth487]

You're right - legally I can. But that's a historical anachronism.  Practically, I really can't and shouldn't be allowed to. 

[LT_Oneal_PAC]

4 minutes ago, lkth487 said:

You're right - legally I can. But that's a historical anachronism.  Practically, I really can't and shouldn't be allowed to. 

I think you'll see the same would apply to us. With our own PA boards through OTP as well, we would police our own as to not ending up looking like homeopathic quacks or like this guy in the article.

http://www.phoenixnewtimes.com/news/doctor-faces-potential-suspension-after-new-times-investigation-6645789

[lkth487]

Yeah I have no doubt. I was just making that point - that there should be a standardized pathway for people to pursue so that there's structure and accountability!  Ideally a national set of standards that would vet each place offering experience to make sure it's adequate and not just "hey I worked in this hiv clinic shadowing this dude so now I'm all set". 

[LT_Oneal_PAC]

3 minutes ago, lkth487 said:

Yeah I have no doubt. I was just making that point - that there should be a standardized pathway for people to pursue so that there's structure and accountability! And it just "hey I worked in this hiv clinic shadowing this dude so now I'm all set" 

You won't hear any arguments from me. I'm very much pro-residency or testing for those past that stage.

[wookie]

7 hours ago, Joelseff said:

I hope not. I think there was a provision mentioned for 3-5 years or something but I think the last update my state chapter gave on OTP last year said that it would be up to the provider which I disagree with because new grads don't know what they don't know yet for the most part

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3-5 years, IMO, isn't enough. At the bare minimum, it should equate to MD/DO residency hours. 80 hours/week x 3 years for residencies to a new grad PA working 40 hours/week should be 6 years minimum. Some ER residencies even push 4 years for DO's, which would make 8 PA years. You also need to consider that PA's in ER do more fast track than docs. I can see a PA with 20 years of experience not having intubated a patient or ran a code.

[Joelseff]

3-5 years, IMO, isn't enough. At the bare minimum, it should equate to MD/DO residency hours. 80 hours/week x 3 years for residencies to a new grad PA working 40 hours/week should be 6 years minimum. Some ER residencies even push 4 years for DO's, which would make 8 PA years. You also need to consider that PA's in ER do more fast track than docs. I can see a PA with 20 years of experience not having intubated a patient or ran a code.

Fine 6 years...

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[Jofriend]

I did not see anything on the AAPA website re. PA surveys suggesting that 70% of us want this.  Rather, I do see information about competition with NPs and that hiring PAs is seen as more complicated than hiring NPs.  I understand promoting a situation where we are personally accountable rather than having everything falling back onto our supervising MDs.  But the complexity of changing state legislation around this boggles my mind.  And, as I said in the initial post, it is hard for me to think that in promoting this, once more, physicians will see yet another competitor for their business that has somehow short cut their way into practice.  Caution please, AAPA.  

Here's the AAPA link for FAQ around the issue:

https://www.aapa.org/advocacy-central/optimal-team-practice/

[DLane]

8 hours ago, wookie said:

3-5 years, IMO, isn't enough. At the bare minimum, it should equate to MD/DO residency hours. 80 hours/week x 3 years for residencies to a new grad PA working 40 hours/week should be 6 years minimum. Some ER residencies even push 4 years for DO's, which would make 8 PA years. You also need to consider that PA's in ER do more fast track than docs. I can see a PA with 20 years of experience not having intubated a patient or ran a cod

As a PA resident in EM and having worked prior in a FM residency, I assure that they are not working 80 hour weeks except a few months when they are in the ICU or on surgical rotations. Average more like 60. 

[LT_Oneal_PAC]

9 hours ago, wookie said:

3-5 years, IMO, isn't enough. At the bare minimum, it should equate to MD/DO residency hours. 80 hours/week x 3 years for residencies to a new grad PA working 40 hours/week should be 6 years minimum. Some ER residencies even push 4 years for DO's, which would make 8 PA years. You also need to consider that PA's in ER do more fast track than docs. I can see a PA with 20 years of experience not having intubated a patient or ran a code.

No hospital would hire someone to staff a solo ED or credential them for high level procedures that they haven’t done. So your point is moot there. 

We also still need to relieve the administrative burden on MD and PAs working in fast track and urgent cares as well. 

NPs have been independent in 22 states, some of them for a long time. In North Carolina PA supervision is a 30 minute meeting every 6 months after 2 years of practice and there are more PA owned clinics there than anywhere else. Please point out any data that shows people in those areas are practicing beyond their scope in any greater number than we or MDs already do. 

[LT_Oneal_PAC]

2 hours ago, Jofriend said:

I did not see anything on the AAPA website re. PA surveys suggesting that 70% of us want this.  Rather, I do see information about competition with NPs and that hiring PAs is seen as more complicated than hiring NPs.  I understand promoting a situation where we are personally accountable rather than having everything falling back onto our supervising MDs.  But the complexity of changing state legislation around this boggles my mind.  And, as I said in the initial post, it is hard for me to think that in promoting this, once more, physicians will see yet another competitor for their business that has somehow short cut their way into practice.  Caution please, AAPA.  

Here's the AAPA link for FAQ around the issue:

https://www.aapa.org/advocacy-central/optimal-team-practice/

The AAPA is not forcing this down anyone’s throat. They are offering it as support to any state that wishes to pursue it. If you do not like it, talk with and join your state chapter because the ship has sailed at AAPA.

I’m curious why everyone is still worried about offending physicians. It hasn’t affected the NPs at all and being physician’s “competition” (I don’t think most rank and file MDs see it this way) hasn’t prevented NPs from being hired over us by either physicians themselves who want to do less paperwork with less responsibility for clinical care they didn’t provide nor by admin who have physician staff that don’t want to supervise without compensation. 

 

As for the survey results, ask and ye shall receive. Before you mention the 12,000 respondents, this is the greatest number of respondents we’ve had for any survey and it was sent to members and nonmembers:

Survey results are in from more than 12,000 PAs, retired PAs, and PA students regarding Full Practice Authority and Responsibility (FPAR) as proposed by AAPA’s Joint Task Force on the Future of PA Practice Authority. Overall, 72 percent of respondents expressed support for it. Read the report(s), complilation of respondant comments, or view slides to see what PAs had to say.

https://news-center.aapa.org/wp-content/uploads/sites/2/2017/03/fpar.report.state_.FINAL_.pdf