North Dakota Closer to OTP

[weezianna]

Big News for OTP in North Dakota

Posted about 12 hours ago by Jay Metzger

NDAPA Members,

The ND Academy of PAs Board of Directors is thrilled to pass on some important news from our meeting with ND Board of Medicine (NDBOM) last Friday. The NDAPA has been working with the NDBOM on achieving Optimal Team Practice (OTP) for PAs and at their meeting on Friday, the NDBOM unanimously approved to support PAs in the upcoming legislative session in our efforts! Specifically, the NDAPA is pursuing the following:

• Supervisory agreements currently mandatory for licensure in North Dakota will no longer be required. This means that PA’s will be responsible for the care they provide and the need to have a supervising physician will no longer be necessary.
  • This is a HUGE change for our practices and profession. It better aligns us in practice for those employers that don’t even consider PAs due to supervisory issues.
  • The NDAPA and PAs in North Dakota will still do what they have always done and practice in the team model. We are not looking to be “independent providers”, rather we want to be able to practice where we are needed.
  • One concession that was a deal-breaker for the NDBOM was that PAs would need to practice at clinics, hospitals and physician offices that are established or meet certain criteria. The NDBOM concern was that PAs would pursue privately owned clinics for things such as cosmetic dermatology, medi-spas, etc.
    • A PA may still be able to operate a clinic or practice of their own but would need approval from the NDBOM to do so.
    • This concession was felt to be a reasonable request as we are trying to get PAs in areas that need providers in primary care.
  • If we are able to get this legislation passed through the legislature, North Dakota will be the first in the nation where a PA can practice medicine without a supervisory or collaborative agreement with a physician.

So what it is next?

• We are waiting to hear back from the ND Medical Association on whether they will also support us in our efforts. Their board meets at the beginning of December. Their support would be a phenomenal step towards our end goals.
• We are finalizing the proposed legislation and are seeking sponsors in the ND Legislature. We have a few names that will likely be willing, but if you know of any legislators that would be willing to do so, please let us know.
• In the next week or two, we will be sending out a form for signatures of support from physicians in ND. This form will be sent to all PAs in ND. This is where we need your help: find physicians that are in support of these changes and have them commit to their support by signing the form.
• Once we have a submitted bill, we will need all PAs to contact their local legislators and let them who we are and what this legislation would mean for the people of their districts and PAs in ND.

We will keep you informed of our progress and please let us know if you have any questions or ideas (jay.metzger@med.und.edu or cell #701-361-4074) .

Have a great week and Happy Thanksgiving!

Jay R. Metzger, PA-C

President, NDAPA  

[EMEDPA]

Strong work!!! 

[ArmyVetDude]

For Primary care and urgent care clinics, experienced PAs should practice without supervision, especially in rural or inner city areas.  This message needs to spread.  Seriously, I am a sole provider for an urgent care I work for. I have not spoken to any physician here for over a year... just with a senior PA once for advice on management.

 

[EMSGuy1982]

47 minutes ago, ArmyVetDude said:

For Primary care and urgent care clinics, experienced PAs should practice without supervision, especially in rural or inner city areas.  This message needs to spread.  Seriously, I am a sole provider for an urgent care I work for. I have not spoken to any physician here for over a year... just with a senior PA once for advice on management.

 

My thoughts exactly. I also work in a rural urgent care and am solo on weekends. All 4 of the providers in the clinic are PA’s. Our “ supervising physician” hasn’t communicated with me in about a year (chart review feedback). Most of the MD’s out here in the Primary care clinics are supportive of PA’s being independent. I imagine it’s partly to lessen their loads of doing chart reviews though. 

[corpsman89]

The first state will be the hardest. If this gets passed we will have reached a MAJOR milestone and each subsequent state will be easier and more achievable. 

[Guest Paula]

GO!!! NORTH DAKOTA!!! This is good news.  Wisconsin is cheering you on even though we were hopeful to be the first state for true OTP.  WE hope to overcome our roadblocks.    I am a graduate of NDSU under my first degree in 1978 so still have a place in my heart for North Dakota. 

I work rural and was just assigned a new SP (of whom I've never met and likely won't ever meet).  My previous SP ratio became exceeded and I agreed to the new SP.  It's ok cuz I never consulted with the previous one either....she was off site and no need.  I just do my work and consult with whomever I need to consult with....and it's rare to be the SP who is my go to person.. 

 

[Hope2PA]

Great news for ND and PA in general, The profession appears to be moving into adult hood. Will still rely on others for consultation, advice etc, but be responsible for yourself. 

I did think it was ironic that the concession was to not do cosmetic med spa type work. so many remarks I could add, however, I'm sure you can guess where I was going with thoughts. Have a great day and much to be Thankful for, past, present and future,

[Boatswain2PA]

So the 25 year old new PA graduate who has never been responsible for anything in her life beyond getting straight A's can practice without any supervision.

That's stupid.  Almost as stupid as NPs having independent practice rights.

[PA-C]

25 minutes ago, Boatswain2PA said:

So the 25 year old new PA graduate who has never been responsible for anything in her life beyond getting straight A's can practice without any supervision.

That's stupid.  Almost as stupid as NPs having independent practice rights.

I’d like to think that even new grad PAs have the maturity and self-awareness to know when they need to ask for help. OTP doesn’t mean PAs can’t or won’t “collaborate” when needed

[Boatswain2PA]

A 25 year old who has never done anything in life beyond school (ie: typical new PA grad) with maturity and self-awareness?

Doesn't exist.

[ventana]

GREAT NEWS!!!!!!!

 

Come on MASS!!!!  Get on with it!!

[EMEDPA]

55 minutes ago, Boatswain2PA said:

A 25 year old who has never done anything in life beyond school (ie: typical new PA grad) with maturity and self-awareness?

Doesn't exist.

the system will chew them up and spit them out if they attempt to practice beyond their competence. I've seen this happen to FP docs who thought they could work solo coverage in the ER with no ER training. They lasted about a month. I've seen this happen to PAs who thought their 2 years of low acuity UC was enough to do solo ER. lasted 4 shifts. I've seen the same with NPs. We had 1 with 2 years of fast track experience who was hired only because she was a friend of the director. gone in less than a month. If your colleagues and your patients and the hospital administration realizes you are not up to the task, whatever that task is, you won't last long.

I would hope that every new grad would seek a residency or first job with mentorship and everyone hiring PAs would know not to put them in inappropriate settings. we both know "supervision" unless in real -time is BS. reading a chart 24 hrs after the pt has been discharged does nothing. most docs don't even read them, they just stamp them to collect their $. Also , recognize that OTP only removes state barriers to practice. An ER director could still tell a new grad they will review 100% of their charts before the pt goes home. OTP shifts oversight responsibility to the practice level. You and I don't need it, so we would not have to have it. A new grad does, and hopefully that would be recognized.

[ak004]

So the 25 year old new PA graduate who has never been responsible for anything in her life beyond getting straight A's can practice without any supervision.

That's stupid.  Almost as stupid as NPs having independent practice rights.

I think it’s a little unfair to characterize all young, new grad PAs as being so irresponsible and power hungry that we would do something so unsafe like taking a job with no supervision. I know my limitations, and as a new grad will actively look for a job that provides the supervision and mentorship I need to become a competent provider. I understand where your concerns come from, but lately I’ve seen so much animosity coming from the older generation of PAs towards the new generation. It makes me incredibly disheartened about the senior PAs I may work with in the future if this is your attitude towards us younger generation.

[EMEDPA]

8 minutes ago, ak004 said:

I think it’s a little unfair to characterize all young, new grad PAs as being so irresponsible and power hungry that we would do something so unsafe like taking a job with no supervision. I know my limitations, and as a new grad will actively look for a job that provides the supervision and mentorship I need to become a competent provider. I understand where your concerns come from, but lately I’ve seen so much animosity coming from the older generation of PAs towards the new generation. It makes me incredibly disheartened about the senior PAs I may work with in the future if this is your attitude towards us younger generation.

This is the right attitude. You will do fine.

[Boatswain2PA]

5 hours ago, ak004 said:

I think it’s a little unfair to characterize all young, new grad PAs as being so irresponsible and power hungry that we would do something so unsafe like taking a job with no supervision. I know my limitations, and as a new grad will actively look for a job that provides the supervision and mentorship I need to become a competent provider. I understand where your concerns come from, but lately I’ve seen so much animosity coming from the older generation of PAs towards the new generation. It makes me incredibly disheartened about the senior PAs I may work with in the future if this is your attitude towards us younger generation.

I'm not characterizing all that way, but there will be some.  The law isnt there to protect people from responsible people, the law is there to protect people from the IRresponsible.

Currently PAs need "supervision" because our base education is less than half of that of a board certified physician. Kind of common sense.  It sounds like the OTP in ND completely obliterated that, thus clearing the way for the overly-eager 25 year old straight-A new grad to open her own clinic.

 

Worse yet, the corporate interests running more and more of healthcare will push to hire such new grads and other inexperienced people because they can get them cheap....and then put them in unsupervised positions to save money.

I have no animosity toward youth.  I think today's 20-30 year olds are the next "greatest generation"...although like the last generation they will have to pay the price for such honor.

[Kaepora]

This doesn't sound like "OTP".  It sounds like complete independent practice.  Something I don't agree with for NPs or PAs.  There are many states with independent practice for NPs that have a caveat of at least 3-5 years of supervised practice by a physician.  That at least lets a new grad get their feet wet and their bearings before practicing, unknowingly, outside of their scope.  I have seen soooooo many new grad NPs and PAs that needed that guidance for at least the first year or two.

[corpsman89]

I would think most PAs wouldn't have wanted this sort of thing to happen. Many MDs/PAs see what NPs are doing and they don't think it safe or ethical, especially considering the many online diploma mills that NPs are completing. 

However, as a profession, this is our last chance to remain relevant in today's medical landscape. With more and more organizations saying the hell with PAs due to our supervisory agreements, we MUST eliminate supervision requirements in order to stay on par with NPs and stay competitive in the market. 

It's understandable to not like the current trend, but there is no stopping the nursing agenda. We wither keep up, or get left behind.

 

[weezianna]

The concession was not to forego "cosmetic" practice per se, but to work in established clinics.  From what I understand, this move helps level the playing field with NPs in ND (anyone seen the TV ad touting NPs?), and helps provide needed healthcare in the very rural underserved areas of North Dakota, of which there are many.

" One concession that was a deal-breaker for the NDBOM was that PAs would need to practice at clinics, hospitals and physician offices that are established or meet certain criteria. The NDBOM concern was that PAs would pursue privately owned clinics for things such as cosmetic dermatology, medi-spas, etc.

• A PA may still be able to operate a clinic or practice of their own but would need approval from the NDBOM to do so."

[Boatswain2PA]

10 hours ago, corpsman89 said:

With more and more organizations saying the hell with PAs due to our supervisory agreements, we MUST eliminate supervision requirements in order to stay on par with NPs and stay competitive in the market. 

I don't disagree with your premise, but I'm not sure about it either.  I know one hospital that seems to prefer NPs over PAs, but that is simply because of one nursing manager there.  I know several hospitals who prefer PAs over NPs because of our vastly better education/model.

I also don't see, yet, many NPs who are practicing independently.  I know one who started her own home-healthcare business, but most "independent practice" NPs I see are working at snot-clinics in CVS, etc.  They can have those jobs.

I think a much bigger problem in our profession is the explosive growth of schools, the dilution of good clinical rotation sites, and the lowering of prior healthcare experience requirements.  THIS is fundamentally changing our profession.  I see some new grads now who seem to act more as advanced scribes than practitioners.

Worked with new grad few weeks ago on their first shift.  Kinda came unglued on them when they asked the doc what antibiotic to give for a dental infection.  Of course the answer was already in their head, but this was the first adult decision they ever had to make and didn't know how to make it.

[slimjim2525]

As a PA of almost 30 years, I never thought I would see the day.  It is exciting and a little scary at the same time.

[corpsman89]

5 hours ago, Boatswain2PA said:

I think a much bigger problem in our profession is the explosive growth of schools, the dilution of good clinical rotation sites, and the lowering of prior healthcare experience requirements.  THIS is fundamentally changing our profession.  I see some new grads now who seem to act more as advanced scribes than practitioners.
 

I can't argue with this. I agree 100% 

But while PA schools are expanding, NP schools are a real problem. As I rotate through my rotations I am surprised to learn that nearly all the RNs that I am encountering are currently going to NP school (Online of course). 

[ArmyVetDude]

On 11/22/2018 at 11:00 AM, Boatswain2PA said:

So the 25 year old new PA graduate who has never been responsible for anything in her life beyond getting straight A's can practice without any supervision.

That's stupid.  Almost as stupid as NPs having independent practice rights.

PA's with some experience should practice independently in primary care and low acuity urgent care clinics.  I agree with not being able to indepdently operate specialty clinics though

For whatever reason, all of  your posts seem to be against OTP and PA's being allowed to practice without supervision. Are you from Texas or Rhode Island?

[ArmyVetDude]

On 11/22/2018 at 7:35 PM, Kaepora said:

This doesn't sound like "OTP".  It sounds like complete independent practice.  Something I don't agree with for NPs or PAs.  There are many states with independent practice for NPs that have a caveat of at least 3-5 years of supervised practice by a physician.  That at least lets a new grad get their feet wet and their bearings before practicing, unknowingly, outside of their scope.  I have seen soooooo many new grad NPs and PAs that needed that guidance for at least the first year or two.

No reasonable 25 year old new grad would go out and open their own clinic without having any experience. They are not that stupid. What OTP wants to do is establish supervision at a practice level. If practice feels that you are competent enough to practice independently tit should be allowed. On the other hand, if they feel you need supervision full time, it should also be allowed. A state or its archaic law should not be the one dictating your scope of work.

By the way, PA's are trained to be generalists. They are much better prepared to work  in primary care and/or urgent care fresh out of school than NP's. Also, I feel that PA schools should add additional six months of primary care training and rotations.

 

[Boatswain2PA]

3 hours ago, ArmyVetDude said:

PA's with some experience should practice independently in primary care and low acuity urgent care clinics.  I agree with not being able to indepdently operate specialty clinics though

How much experience?  And only FP, where they see and manage the widest spectrum of pathologies?

FP is a specialty, to not only physicians but to many PAs.  I often say I practice EM because I'm not smart enough to practice FP, simply because of the amount of knowledge a family practice SPECIALIST has to have.  There is no way on EARTH I could do RealityCheck's job.

3 hours ago, ArmyVetDude said:

For whatever reason, all of  your posts seem to be against OTP and PA's being allowed to practice without supervision. Are you from Texas or Rhode Island?

OTP is a nebulous term, see below.  I'm all for Optimal Team Practice, defined as a PA and a doc figuring out what level of supervision is needed..  I am against independent practice by MLPs (APPs, whateverUwannacallus).

No, not from TX or RI.

3 hours ago, ArmyVetDude said:

No reasonable 25 year old new grad would go out and open their own clinic without having any experience.

How about the unreasonable ones?  Again, the laws are not needed to protect the population from reasonable people.  Laws are there to protect from the UNreasonable ones.

3 hours ago, ArmyVetDude said:

They are not that stupid.

There will be a few.

3 hours ago, ArmyVetDude said:

What OTP wants to do is establish supervision at a practice level.

That's what some people say, but then this happens. 

I am all for "OTP" defined as "you and your doc figure out what level of supervision is needed."  But the ND "OTP" is independent practice. This isn't just "you and your Doc figure out supervision", this is "you don't need a doc".  

3 hours ago, ArmyVetDude said:

If practice feels that you are competent enough to practice independently tit should be allowed.

Who is "practice"?  With the ND "OTP", there is nobody who makes such judgements on competence.

3 hours ago, ArmyVetDude said:

By the way, PA's are trained to be generalists. They are much better prepared to work  in primary care and/or urgent care fresh out of school than NP's.

Generalists with 1 year of didactic, and 1 year of clinicals.  Compare this to 2 years of didactic, 1-2 years of clinicals in medical school, then 3 years of residency that a BC FP physician has.

Agreed we are much better trained/prepared than any NP program.

3 hours ago, ArmyVetDude said:

Also, I feel that PA schools should add additional six months of primary care training and rotations.

Why not just go to med school then?  Especially if your goal is independent practice.

[Kaepora]

10 hours ago, Boatswain2PA said:

How much experience?  And only FP, where they see and manage the widest spectrum of pathologies?

FP is a specialty, to not only physicians but to many PAs.  I often say I practice EM because I'm not smart enough to practice FP, simply because of the amount of knowledge a family practice SPECIALIST has to have.  There is no way on EARTH I could do RealityCheck's job.

OTP is a nebulous term, see below.  I'm all for Optimal Team Practice, defined as a PA and a doc figuring out what level of supervision is needed..  I am against independent practice by MLPs (APPs, whateverUwannacallus).

How about the unreasonable ones?  Again, the laws are not needed to protect the population from reasonable people.  Laws are there to protect from the UNreasonable ones.

There will be a few.

I am all for "OTP" defined as "you and your doc figure out what level of supervision is needed."  But the ND "OTP" is independent practice. This isn't just "you and your Doc figure out supervision", this is "you don't need a doc".  

Who is "practice"?  With the ND "OTP", there is nobody who makes such judgements on competence.

Generalists with 1 year of didactic, and 1 year of clinicals.  Compare this to 2 years of didactic, 1-2 years of clinicals in medical school, then 3 years of residency that a BC FP physician has.

Agreed we are much better trained/prepared than any NP program.

Why not just go to med school then?  Especially if your goal is independent practice.

I quite agree.  This is truly independent practice.  No APPs should have this ability.  And do you all really think there are no PAs who over judge their own clinical acumen and would attempt to practice without a physician right out of school?  Or even PAs who after multiple years shouldn't have that ability.  

PAs have one board exam.  Physicians have 3 USMLE step exams, then their board certifications.  It is much more difficult for a physician to be deficient and undeserving of independent practice, than an APP.

Family medicine is arguably the most difficult specialty.  You have to know a moderate amount of information about everything. If you don't want to be one of those over-referrers.  

And yes, PAs are better trained as generalists.  There are *no* generalist NP programs.  None.  But just to stir the pot a bit, I assert I was far better trained as an inpatient medicine provider.  I had 24 weeks of IM/Hospitalist, 24 weeks of critical care, and 30 weeks of surgery in my program - over 3000 hours.  Definitely not the norm, I'll admit.  On the whole, PAs have better training.

But again, I don't support this for NPs or PAs.  Only physicians should have independent practice.  This is just keeping up with the Jones' and it's a mistake.