AOA Warning on PA "Independence"

[ohiovolffemtp]

Quote

There was this study (https://www.ncbi.nlm.nih.gov/pubmed/27228045) that looked at prior experience and clinical year outcomes, and the study "did not support the hypothesis that healthcare experience is associated with improved clinical year outcomes." It would be interesting to see a similar study that looked at first few years of practice rather than just the clinical year. 

I acknowledge that this is purely my opinion, but I believe that my 3+ decades of EMS experience really provided value not as much in my 1st 1-3 years of being a PA when I was really focused on learning the medicine, ED work flow, etc but rather afterwards when I was managing more critical patients and coordinating ad hoc teams of RN, RT, techs etc in the room and dealing with tense patients and their families.

[SHU-CH]

17 hours ago, sas5814 said:

My point is people with solid expert experience in a subject matter can have credible opinions. People who disagree then , all too often, start banging the "evidence" bell.

I guess my expert experience is different. I have been in PA education for 15 years. I have not observed a significant difference in outcomes among our students based on their experience level. I've been involved in EMS for 25 years. Students who come in with this type of background are generally initially more comfortable working with people, but the differences disappear during the first semester. 

If anything, it has sometimes proven difficult to teach up and coming, former EMS students the difference between an ambulance report and a history and physical write up. They are good at managing some things, like CHF, but they can anchor on a diagnosis, develop tunnel vision, and fail to identify subtle findings. Some "experience" can lead people to think they have much better skills than they really have. If you are not humble, medicine will humble you. 

16 hours ago, EMEDPA said:

Agree- I would like to see a study that examines first year competence as determined by collaborating physicians based on a set criteria for what determines "good" (# of bounce backs, frequency of needing to be bailed out, med errors, etc) examined solely based on years and intensity of prior experience. My N= probably around 200-250 now for PA students precepted is that 95% of the time intensive/high level experience(Paramedic/RN/Resp therapist) > gpa or pance score as a marker for ability to actually practice safely and effectively with minimal oversight. I know many folks who struggled through PA school in the didactic year, shined in clinicals, and can run circles around the 4.0/700 pance former scribes out there.

My N is 450-500. Our employer surveys do not indicate a difference.

[GetMeOuttaThisMess]

1 hour ago, mcclane said:

Generally speaking, individuals who inherently agree with a statement don't bother asking for more evidence. I'll take the evidence bell over whatever you are trying to sell here any day.

Nevermind, it's too late in the game for me to argue anymore.

[SHU-CH]

2 hours ago, mcclane said:

Generally speaking, individuals who inherently agree with a statement don't bother asking for more evidence. I'll take the evidence bell over whatever you are trying to sell here any day.

PA programs really do make a concerted effort to turn out the best possible graduates. We are well aware that we play a serious role in the future health of our profession. We also all puzzle over the incoming characteristics that best identify someone who will be an exceptional student and eventually an exceptional PA. If someone can show me decent evidence that experience is of paramount importance, I can change our requirement basically overnight for our next admission cycle and I'm happy to do so. 

Having looked at a ton of data, articles and graduates, I hate to say it but there is no formula that works well. There is no such thing as an ideal GPA or ideal type/length of experience that predicts a solid clinician. There are just a wide variety of individuals who apply to PA school and we select and work with them as best we can. Most turn out great, some are shaky, and there is not a lot to tell who will be who coming in the door. 

[MediMike]

On 11/5/2018 at 9:03 AM, HanSolo said:

The appeal to ignorance logical fallacy doesn't really work in this scenario. Data would be helpful because the answer isn't clear. We didn't ask if unicorns exist...

 

Is that because WE KNOW THAT THEY DID?!

https://www.sciencealert.com/were-unicorns-real-fossilised-skull-reveals-siberian-date-last

[EMEDPA]

5 hours ago, SHU-CH said:

There is no such thing as an ideal GPA or ideal type/length of experience that predicts a solid clinician. There are just a wide variety of individuals who apply to PA school and we select and work with them as best we can. Most turn out great, some are shaky, and there is not a lot to tell who will be who coming in the door. 

I think it is fair to say that the ideal student will meet all of the criteria we have been discussing: high gpa, good community service/shadowing/volunteering/PA exposure, and significant medical experience. Take any of those away from a given candidate and they will likely not do as well in part of the program. 

Stated another way: twin brothers attend the same university, both attend the same courses and get the same grades. Both volunteer and shadow PAs together.  One attends night school to become a paramedic and works as a medic for 2 years while in school without hurting his grades. he learns the language of medicine, multitasking, sick vs not sick, etc both apply to PA school for the same spot. who would you anticipate to be the better student, and more importantly, which student will hit the ground running day 1 at job 1 after passing pance. ? 

[SHU-CH]

2 hours ago, EMEDPA said:

Stated another way: twin brothers attend the same university, both attend the same courses and get the same grades. Both volunteer and shadow PAs together.  One attends night school to become a paramedic and works as a medic for 2 years while in school without hurting his grades. he learns the language of medicine, multitasking, sick vs not sick, etc both apply to PA school for the same spot. who would you anticipate to be the better student, and more importantly, which student will hit the ground running day 1 at job 1 after passing pance. ? 

Impossible to say, unless you tell us what the other guy was doing for those 2 years.

[EMEDPA]

2 hours ago, SHU-CH said:

Impossible to say, unless you tell us what the other guy was doing for those 2 years.

just being a student getting his bs in biology like his twin brother. in my scenario the only difference is one is a medic and the other is not. you can assume twin brother #2 spent his extra time watching game of thrones reruns if you like. 

[Guest HanSolo]

[GetMeOuttaThisMess]

2 hours ago, EMEDPA said:

just being a student getting his bs in biology like his twin brother. in my scenario the only difference is one is a medic and the other is not. you can assume twin brother #2 spent his extra time watching game of thrones reruns if you like. 

Or on a forum looking through data to see what their chances are to be approved/accepted based on GPA and test scores instead of being out there seeing if they even like what they think they like.  I had one in my class.  Within the first week deciding they’d rather go to vet school, or attempt to.  Wasted slot for someone else.

[ProSpectre]

A lot of this discussion is still not much more than an interesting but rather meaningless thought-experiment that provides no real evidence of what type of applicant makes for a better or worse clinician. 

There seems to be mild disdain from some on this board for students that don’t follow the traditional pathway to becoming a PA, despite being academically gifted enough to pursue any other career (and often foregoing medical school to join our profession instead). In my mind, we should embrace that there are multiple valid pathways to becoming a PA -- unless and until there is valid evidence that the current methods of selecting applicants are producing an inferior clinician. 

Maybe the 24 year old student that learns quickly, studies hard and does well academically will make just as strong of a PA as the 28 year old paramedic with years of experience. Maybe intrinsic characteristics such as compassion, perseverance, humility and resilience are just as important to becoming a great PA as whether you were an EMT or an RT. Maybe there is no one-size-fits all applicant that is guaranteed to make a strong PA.  

 

Regardless of the prevailing dogma that is pervasive on this board, the PA profession continues to grow in both size and reputation, despite the shifting trend in admissions over the last decade or two. I have full confidence that the generation of PAs currently in the making will carry the torch just as well during the next 30 years as many on this board have over the previous 30, despite these changes. 

[CAdamsPAC]

14 hours ago, SHU-CH said:

PA programs really do make a concerted effort to turn out the best possible graduates. We are well aware that we play a serious role in the future health of our profession. We also all puzzle over the incoming characteristics that best identify someone who will be an exceptional student and eventually an exceptional PA. If someone can show me decent evidence that experience is of paramount importance, I can change our requirement basically overnight for our next admission cycle and I'm happy to do so. 

Having looked at a ton of data, articles and graduates, I hate to say it but there is no formula that works well. There is no such thing as an ideal GPA or ideal type/length of experience that predicts a solid clinician. There are just a wide variety of individuals who apply to PA school and we select and work with them as best we can. Most turn out great, some are shaky, and there is not a lot to tell who will be who coming in the door. 

 

I'd like to know the data on the "Money Axis" of selection for PA School admissions. I've watched the marked increase in the number of PA Schools along with the "Degree creep" and the concurrent increase in costs to attend PA School for the past 20 years. Views or data please?

[SHU-CH]

16 hours ago, EMEDPA said:

just being a student getting his bs in biology like his twin brother. in my scenario the only difference is one is a medic and the other is not. you can assume twin brother #2 spent his extra time watching game of thrones reruns if you like. 

It seems like you are suggesting that being a medic is the utter pinnacle of experience for a future PA? Is this for all PAs, or just for PAs who ultimately intend to go into emergency medicine? Do you know any incapable paramedics (I have met a few in my travels)? What of their experience? 

What if his brother became a respiratory therapist? Or if his brother was a scribe in an ER, don't you think he would have been exposed to a lot more treatment algorithms for a lot more conditions than a medic is typically exposed to? This is much more complex than people are making it out to be.

As for Game of Thrones, I'll have you know I went to high school with Tyrion Lannister (albeit not in the same class). Beat that!

[sas5814]

I went to school with Daniel Boone.

he was no Tyrian Lannister but he had a great hat.

[SHU-CH]

11 hours ago, CAdamsPAC said:

I'd like to know the data on the "Money Axis" of selection for PA School admissions. I've watched the marked increase in the number of PA Schools along with the "Degree creep" and the concurrent increase in costs to attend PA School for the past 20 years. Views or data please?

The explosion in programs is most likely due to the exposure our profession has gotten in the last decade. Pretty much every year we have made the "Top 10 Best Professions" in some big-name media outlet. Administrators read this stuff and all of a sudden they are putting a program together for provisional accreditation. 

I was at the PAEA conference last month, and ARC-PA spoke and rightly noted they don't have an ability to keep new programs from opening. As to what will happen in the future, I believe they used the term "natural selection." Programs will go out of business. Some of these will be newer programs, and some will be programs that have been long established. 

Believe it or not, degree creep might not originate from academia. PAEA didn't originate OTP - that primarily came out of AAPA. It seems like there is a boatload of PAs around looking for a fancy title. If it gets traction, universities will happily start to supply a route to a fancy title.

No one is happy about costs. I have about as much control over rising tuition costs as you do over rising healthcare costs. The only thing that will stop spiraling costs is people deciding they are not going to pay it any more. I love being a PA but if I was young and knew what I know now I would seriously look into a building trade. 

[SHU-CH]

11 minutes ago, sas5814 said:

I went to school with Daniel Boone.

he was no Tyrian Lannister but he had a great hat.

I always mix him up with Davy Crockett.

[JMann]

On 11/5/2018 at 1:19 PM, sas5814 said:

Smart hard working people who continue to educate themselves and seek self improvement do well regardless of origins.

This is the crux of all the above hypotheticals. Work hard and you'll succeed. 

That being said, I was a medic and had to work to overcome some of the bad habits SHU-CH mentioned earlier. Given my background, I think all PA school students should have significant medical experience like RN, PA, RT etc. But that is my experience and bias and I'll own it... In my class, I had the most experience hours by a long ways. There were several 21-22 yo recent college grads who should have been in med school, but they chose PA school instead. They are doing fine with their shadowing and MA experience before school. It seems that selecting quality applicants regardless of experience is a tough job. A job I don't want!

I work in EM and chose to do a residency. Does everyone need to do that? Not yet, but I do agree with earlier comments regarding that being the wave of the future in certain specialties. This could be argued to death and funding will be the deciding factor. I can see a future in hospitalist medicine and EM, especially as budgets get tighter and medicaid reimbursement lowers, where physicians are simply the "supervisors" of the workforce and PAs and NPs are doing the "work." 

[EMEDPA]

2 hours ago, SHU-CH said:

It seems like you are suggesting that being a medic is the utter pinnacle of experience for a future PA? Is this for all PAs, or just for PAs who ultimately intend to go into emergency medicine? Do you know any incapable paramedics (I have met a few in my travels)? What of their experience? 

What if his brother became a respiratory therapist? Or if his brother was a scribe in an ER, don't you think he would have been exposed to a lot more treatment algorithms for a lot more conditions than a medic is typically exposed to? This is much more complex than people are making it out to be.

As for Game of Thrones, I'll have you know I went to high school with Tyrion Lannister (albeit not in the same class). Beat that!

Paramedic was just an example. You may substitute RN or resp therapist if you like. Brother #2 still has no experience though.

As far as high school bragging rights, I went to high school with Robert Downey Jr, Rob and Chris Lowe, Zen Gesner(of Sinbad fame), and Charlie Sheen. Mel Gibson and Dick van Dyke were neighbors. I grew up in Southern Ca in the 80s. My first motorcycle(ok it was a vespa 200) was given to me by another neighbor, Rick Springfield of Jessie's girl fame.

[karebear12892]

1 hour ago, EMEDPA said:

A scribe is a mobile transcriptionist. they don't even touch patients. they have no respresponsibility for pt care aside from typos. There is a reason many quality programs do not consider this as HCE. It is basically paid shadowing. It is watching other people work. It honestly sickens me to hear that programs accept this as experience today.

Have you ever worked with scribes from a reputable company? If not, you may not realize that we aren't simply transcriptionists.

The providers aren't telling us what to say word-for-word. We are typing HPI's in real time, in our own words, and determining what content is pertinent and what isn't. We complete the ROS and document physical exams with hardly any prompting from the provider. Obviously we can't hear heart and lung sounds, but everything else we identify and describe entirely on our own, as if we were performing the exam ourselves. We are tested on our ability to document appropriate PE findings (ex: neurovascular status in extremities, GCS, appendicitis signs, etc.) by watching the patient's response to the provider's exam - and if we do not pass this written test, we have to repeat our training program (which is several weeks long and includes multiple exams). It is up to us (not the provider) to come up with a list of differentials based on the H & P and then modify that list according to the orders entered by the provider. We compose MDM's in our own words - it is our job to be the provider's peripheral brain and document the relevant information. For example, if a D-Dimer is ordered, we are trained to calculate Wells/PERC. We are expected to calculate a HEART score for chest pain work-ups. And we exercise our judgment in describing why patients are being admitted/discharged, why a test is being ordered, any shared decision making that takes place, risk vs. benefit discussions, etc. When a patient is discharged, it is up to us (not the provider) to come up with a set up discharge instructions appropriate for each patient based on their diagnosis and any medications being prescribed. At the end of the shift, the provider will proofread the charts before signing, but an experienced scribe's chart typically doesn't require too many modifications. 

I'm finishing up PA school now and I've been offered ER jobs that supposedly don't take new grads, but exceptions are being made on my behalf because of my ER scribe experience. 

I'm not by any means putting down other types of HCE. But I am saying that you don't need to touch patients in order to learn. Paying attention to what is happening around you and asking questions can go a long, long way. In my case, working with ER doctors who were phenomenal teachers made all the difference in the world. Just like any other job, you get out of it what you put into it. 

 

[EMEDPA]

I have worked with scribes at many places from many companies. A good scribe is a great resource. a bad one doubles your work as you need to rewrite their notes. I had one who used a normal male/female template on every patient and then modified it. heme neg rectal exam on an ankle sprain? really?  Nowhere that I have worked allows scribes the kind of scope of practice you describe above. Our notes had to be read by us and signed before the patient could leave the dept. we literally tell them which template to use and dictate to them what to write. they serve only as mobile transcriptions in the 2 trauma centers in which I have worked with them. Often they are not even in the room with the patient, but waiting at the desk. Frankly, the practice you describe sounds dangerous and reckless. I would rather write my own notes than have someone with a bs in bio and "several weeks of training" come up with a ddx and order tests, etc. Do you write their scripts for them too? this is not a personal attack in any way. this just sounds dangerous to me on many levels. I think both scribe and research experience are ok for folks who want to go to medschool as they will have an extra 2 years and a residency to learn the basics of medicine. A PA student day 1 of school should have a solid foundation in medicine already, and being a scribe or a researcher does not provide that foundation.

[ProSpectre]

2 hours ago, EMEDPA said:

Paramedic was just an example. You may substitute RN or resp therapist if you like. Brother #2 still has no experience though.

I attend one of the oldest programs in the country, which is well respected and highly ranked (for what that's worth), and yet they accept applicants from all kinds of backgrounds with no firm requirement for PCE hours. Military medics, scribes, pharmacy techs, CNAs, MAs, athletic trainers, RNs, paramedics, RTs, and others are commonly accepted. When I first started PA school, I looked up to the military medics, paramedics and RNs as having "the best" prior experience (partly from opinions I saw on this forum), but I've consistently performed better than the ones in my class, despite my background. 

Out of the 2 paramedics and 1 respiratory therapist in my class, the RT and one of the medics were actually recycled from a previous year for failing, and are the only ones in my class that are there for that reason. The other paramedic has also struggled academically each semester, just not to the point of failing. I'm sure they will make fine PAs, but their background hasn't seemed to make much difference for them. 

To me, this solidifies that it is the individual, not the specific medical background, that determines success. Everyone has their strengths, but I can't seem to find congruence between past medical experience and the ability to perform strongly (academically or clinically), and there is currently no data to support it either. You can be taught medicine, but there are inherent characteristics that simply cannot be taught.  

[lemurcatta]

This is infuriating because the AOA is misrepresenting OTP. As it stands, the profession is not pushing to remove collaboration with physicians. The AOA’s statement says that is exactly what we are trying to do. But it’s in direct opposition the the positions and statements from AAPA on OTP. Unfortunately they are intentionally misrepresenting us and have signed up as another willing proponent of the facts-don’t-matter era we find ourselves in. 

[EMEDPA]

40 minutes ago, ProSpectre said:

I attend one of the oldest programs in the country, which is well respected and highly ranked (for what that's worth), and yet they accept applicants from all kinds of backgrounds with no firm requirement for PCE hours. Military medics, scribes, pharmacy techs, CNAs, MAs, athletic trainers, RNs, paramedics, RTs, and others are commonly accepted. When I first started PA school, I looked up to the military medics, paramedics and RNs as having "the best" prior experience (partly from opinions I saw on this forum), but I've consistently performed better than the ones in my class, despite my background. 

Out of the 2 paramedics and 1 respiratory therapist in my class, the RT and one of the medics were actually recycled from a previous year for failing, and are the only ones in my class that are there for that reason. The other paramedic has also struggled academically each semester, just not to the point of failing. I'm sure they will make fine PAs, but their background hasn't seemed to make much difference for them. 

To me, this solidifies that it is the individual, not the specific medical background, that determines success. Everyone has their strengths, but I can't seem to find congruence between past medical experience and the ability to perform strongly (academically or clinically), and there is currently no data to support it either. You can be taught medicine, but there are inherent characteristics that simply cannot be taught.  

I'm not saying HCE alone is important. my point is that it adds significantly to the package. I am not in favor of accepting a bunch of medics/nurses/resp therapists with 2.0 gpas. what I am saying is that the medic, etc with a 3.75 is likely a better candidate than the applicant with a 3.75 and zero to no experience or low quality experience. how could they not be?  they are acadmically equivalent and have significant prior exposure to medicine. would you rather have a paramedic, etc who graduated top of their class from pa school caring for your loved one or the person who was a history major before pa school and worked as a receptionist in a medical office?

[SHU-CH]

5 minutes ago, EMEDPA said:

I'm not saying HCE alone is important. my point is that it adds significantly to the package. I am not in favor of accepting a bunch of medics/nurses/resp therapists with 2.0 gpas. what I am saying is that the medic, etc with a 3.75 is likely a better candidate than the applicant with a 3.75 and zero to no experience or low quality experience. how could they not be? 

I don't think anyone is opposed to this - given your scenario, I think everyone would make the same decision. But again, admissions situation are never this cut and dry. More likely we are comparing:

a 4.0 candidate with experience you'd regard as weak

versus

a medic that had to repeat multiple courses to clear the minimum acceptable pre-req GPA

Experience is great because it can help provide evidence of intangibles, like a history of good people skills, flexibility, creativity and the ability to manage stressful situations. It can also develop some assessment and procedural skills, although these will be rudimentary compared to those needed in PA school. Most of these allied health experiences don't speak one iota toward a candidate's ability to handle the type of science courseload PA school will throw at them. 

Did you know that during the accreditation self-study process, PA programs have to explain to the ARC-PA every grade of "C" or lower that has occurred in the last three years?

[GetMeOuttaThisMess]

Have you ever worked with scribes from a reputable company? If not, you may not realize that we aren't simply transcriptionists.

The providers aren't telling us what to say word-for-word. We are typing HPI's in real time, in our own words, and determining what content is pertinent and what isn't. We complete the ROS and document physical exams with hardly any prompting from the provider. Obviously we can't hear heart and lung sounds, but everything else we identify and describe entirely on our own, as if we were performing the exam ourselves. We are tested on our ability to document appropriate PE findings (ex: neurovascular status in extremities, GCS, appendicitis signs, etc.) by watching the patient's response to the provider's exam - and if we do not pass this written test, we have to repeat our training program (which is several weeks long and includes multiple exams). It is up to us (not the provider) to come up with a list of differentials based on the H & P and then modify that list according to the orders entered by the provider. We compose MDM's in our own words - it is our job to be the provider's peripheral brain and document the relevant information. For example, if a D-Dimer is ordered, we are trained to calculate Wells/PERC. We are expected to calculate a HEART score for chest pain work-ups. And we exercise our judgment in describing why patients are being admitted/discharged, why a test is being ordered, any shared decision making that takes place, risk vs. benefit discussions, etc. When a patient is discharged, it is up to us (not the provider) to come up with a set up discharge instructions appropriate for each patient based on their diagnosis and any medications being prescribed. At the end of the shift, the provider will proofread the charts before signing, but an experienced scribe's chart typically doesn't require too many modifications. 

I'm finishing up PA school now and I've been offered ER jobs that supposedly don't take new grads, but exceptions are being made on my behalf because of my ER scribe experience. 

I'm not by any means putting down other types of HCE. But I am saying that you don't need to touch patients in order to learn. Paying attention to what is happening around you and asking questions can go a long, long way. In my case, working with ER doctors who were phenomenal teachers made all the difference in the world. Just like any other job, you get out of it what you put into it. 

 

There is so much wrong with this. It’s a disaster looking for a place to happen IMO. No disrespect to your person inferred.

 

 

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