North Dakota Closer to OTP

[ProSpectre]

1 hour ago, Kaepora said:

Are you people telling me that you haven't precepted students where you were glad they had to be supervised?  I practice in an area with *three* BS to MS programs - I precept these kids all the time.  The last student I had was 23.  It was her final rotation.  She was incredibly immature.  Great grades, but my goodness.  She had so much growing up to do.  I wouldn't want her practicing unsupervised.  She certainly wasn't the first or only in my experience.  

Kaepora, I think you are conflating the issue a bit here. The lack of a legal document tying a PA to a specific supervising physician is not the same as turning new grads loose unsupervised. New grads will still be working closely with the physicians (or experienced PAs and NPs) in their practice, just like they do now. I honestly doubt much will change in the way PAs practice, but it will be easier to hire PAs (less paperwork), and there won't be threat to a PA's livelihood if their supervising physician moves, retires, dies, or loses their license. 

I don't think anyone here is advocating for turning inexperienced clinicians loose to work unsupervised. Like mentioned above, the medical board (which still regulates PA practice) would still require PAs to work in established practices, so new grads won't be graduating one week and opening a new clinic all alone the next.  

[Boatswain2PA]

12 hours ago, ProSpectre said:

New grads will still be working closely with the physicians (or experienced PAs and NPs) in their practice, just like they do now

Where is the safety built in to ensure that?

What's to stop an adminiscritter from hiring said young new PA and throwing them to the wolves?  Its already happening with the doc-in-a-box shops like CVS, along with CMG owned EDs everywhere who force EPs to "supervise" them.

[ArmyVetDude]

1 hour ago, Boatswain2PA said:

Where is the safety built in to ensure that?

What's to stop an adminiscritter from hiring said young new PA and throwing them to the wolves?  Its already happening with the doc-in-a-box shops like CVS, along with CMG owned EDs everywhere who force EPs to "supervise" them.

"OTP" is not going to be stopped. It will soon get passed in numerous states starting with North Dakota. Stop trying to deter the enviable and just enjoy the ride. Also there is nothing wrong with PA's being allowed to operate their own primary care clinics. That is one of the goals of new  PA leadership. 

 If NP's could do it so should PA's. We would likely do it better. 

[Boatswain2PA]

Can you stop cheerleading long enough to answer the question?

Where is the safety net to ensure adminiscritters dont put such new grads in untenable positions simply to make money (like they do with NPs at CVS and other doc-in-a-box places)?

 

[EMEDPA]

11 minutes ago, Boatswain2PA said:

 

Where is the safety net to ensure adminiscritters dont put such new grads in untenable positions simply to make money (like they do with NPs at CVS and other doc-in-a-box places)?

 

have you ever looked into what those CVS jobs entail? it is 100% algorithmic.

" we only see the following a,b,c. If you have xyz(abnl vs, cp, abd pain, etc) we can not see you"

UTI macrobid

strep pcn

want a td. give it

want a flu shot. give it.

want a pregnancy test. do it

etc

I agree a peritonsilar abscess, etc can and will get missed at these types of places. having a doc read the note 3 days later that says "nl pharynx exam" though does nothing to assure pt safety. all it does is spread liability around to someone uninvolved with the actual pt care. how does this "supervision" improve patient care if you have a doc reading charts days later who is never on site and might never even meet the new grad pa in question? honest question. 

honest question #2: would you rather be seen by the guy who graduated last in his pa school class and barely passed pance or an online np who barely passed her np boards? Neither is supervised in real time.   those are your only 2 choices. 

[LT_Oneal_PAC]

6 hours ago, Boatswain2PA said:

Can you stop cheerleading long enough to answer the question?

Where is the safety net to ensure adminiscritters dont put such new grads in untenable positions simply to make money (like they do with NPs at CVS and other doc-in-a-box places)?

 

There will be no safety net other than people won’t want to be sued for having an incompetent employee. Same as now because delayed chart review or cosignature isn’t really supervising and there is no current law requiring a physician to teach a new grad PA, only just to rubber stamp charts.

I had classmates being asked to go run (literally operate and work clinically in) new satellite clinics in TN. Unscrupulous people will always skirt around safety. I imagine your against gun control (please not derail, it’s just an analogy) because you believe criminals will break the laws to get guns and it will only hurt law abiding citizens? Same here.

i haven’t looked back at your post history, but didn’t you start at a rural solo ED gig? I seem to recall that, but honestly I may be wrong.

So I would say that this just removes admin burden and does not enhance or detract from safety. 

You can look at the malpractice data from before and after NPs were granted independence and see no change, and yet we are still being more restrictive here saying we agree to work at established clinics.

[ventana]

Safety net.  Require new grads to do 1 yr residency in hospital based setting rotating through specialties just l8ke interns   Burns in basic knowledge

 

[vb315]

15 hours ago, ventana said:

Safety net.  Require new grads to do 1 yr residency in hospital based setting rotating through specialties just l8ke interns   Burns in basic knowledge

 

The problem with this is creating enough spots and enough funding.

[mmiller3]

Some people here seem bound and determined to watch our profession fade away due to an unwillingness to welcome change.

You don't want your grandchildren being treated by an unsupervised PA? Do your homework before they see that provider. 

Some of the reasons against this are unreal.

 

 

[Boatswain2PA]

On 11/27/2018 at 11:43 PM, EMEDPA said:

how does this "supervision" improve patient care if you have a doc reading charts days later who is never on site and might never even meet the new grad pa in question? honest question. 

As we all know, there are poor supervisors, leaders, managers, etc.  If a doc hires a new PA grad, is never on site with them, and never meets them in person, then that doc is a very poor supervisor and is setting the new PA up for failure.  Does poor supervision improve patient care?  No, of course not.

But continuing a legal supervisory role, to be determined between the Doc and the PA, at least requires there to BE some sort of supervision.  If the Doc/Supervisor sucks at it, then he is on the hook for the results of it.

Meanwhile, requiring supervision would continue to force the average-to-excellent supervisors to continue doing what they are doing.

Another way of looking at it.  Would you rather be supervised by a physician, or an administrator?  Many of the arguments made for the removal of supervisory requirements point out that everyone is supervised, usually by the bureaucracy.  But is that bureaucracy going to actually supervise those who NEED supervision?  No, they are not.

On 11/27/2018 at 11:43 PM, EMEDPA said:

honest question #2: would you rather be seen by the guy who graduated last in his pa school class and barely passed pance or an online np who barely passed her np boards? Neither is supervised in real time.   those are your only 2 choices. 

PA education >>>> NP education, we all know that. 

Good, and even GREAT, supervision doesn't need to be in real time.  It should start before patient contact when the Doc/PA get to know each other so the Doc knows the PAs strengths and weaknesses, and the PA knows what makes the doc nervous.  Parameters are agreed upon and set, and then on to see patients.  

I am not, and have never, advocated for a need for direct (ie: in room/house/hospital/city) supervision of PAs, even new grads.

On 11/28/2018 at 6:05 AM, LT_Oneal_PAC said:

There will be no safety net other than people won’t want to be sued for having an incompetent employee. Same as now because delayed chart review or cosignature isn’t really supervising and there is no current law requiring a physician to teach a new grad PA, only just to rubber stamp charts.

Most malpractice isn't litigated.  Most terrible medicine never rises to that point.  But with physician-led healthcare team the guy in charge of the team knows medicine.  Without it, you put an adminiscritter in even more charge of it, and that's never a good idea.

On 11/28/2018 at 6:05 AM, LT_Oneal_PAC said:

i haven’t looked back at your post history, but didn’t you start at a rural solo ED gig? I seem to recall that, but honestly I may be wrong.

So I would say that this just removes admin burden and does not enhance or detract from safety. 

Yes, still do.  But very atypical new grad.

I'm all for removing administrative burden.  Get rid of cosignatures, mandatory chart review, etc.

Just one simple document saying who the supervising physician is.  Beyond that all administrative burdens are between the Doc and PA.

On 11/28/2018 at 6:05 AM, LT_Oneal_PAC said:

You can look at the malpractice data from before and after NPs were granted independence and see no change,

Looking at malpractice data as an indicator of patient care is useless, just like patient satisfaction scores.

No NP should ever practice independently.

On 11/28/2018 at 7:22 PM, ventana said:

Safety net.  Require new grads to do 1 yr residency in hospital based setting rotating through specialties just l8ke interns   Burns in basic knowledge

And what about changing specialties?

9 hours ago, mmiller3 said:

You don't want your grandchildren being treated by an unsupervised PA? Do your homework before they see that provider. 

I didn't write that very well, please forgive me for being unclear.

My grandkids are the most precious thing I have in my life (next to my wife).  An "unsupervised PA" (using whatever definition of that you want) may very well be the best practitioner in the needed specialty that can be found.  However how does one know that?  You say "do your homework", but how does a consumer do such homework?  How would a consumer know if the PA they see is extraordinaire in their specialty, or is their 3rd day in the pediatric ward after quitting their job in geriatrics?

However if you go see a pediatric PA (even the one who quit their job in geriatrics 3 days ago), and they are supervised by a board certified pediatrician, there is at least some promise that the pediatrician will be involved (directly or indirectly if appropriate) in the care.

That make better sense?

I am ALL FOR PAs working independently.  I work very independently, and when I see PAs ask docs stupid questions I get on them about it because it makes us ALL look bad.

But I'm also a big believer in meritocracy.  Want to be the top dawg in the medical profession?  Pay the price by going to medical school.

Hope that clarifies things.

[LT_Oneal_PAC]

@Boatswain2PA

Perhaps we can stop discussing it because I feel we may have an impasse. I’ll try again once more.

You want to remove co-signature, chart review, and other admin burden, but keep a physician listed as the supervisor to legally force them into being a leader, but no stated requirements to do anything? So how does this improve safety? This just seems to put them on the hook for litigation, but you don’t believe that most malpractice leads to litigation which would suggest bad supervisors would continue their current status quo, so I don’t understand. Wouldn’t it be better to put the PA on the legal hook so that those of us with experience can practice how we want and those without will work at shops with good supervision and learning? I think part of the reason that PA take these dangerous solo positions is because they do think someone else is on the hook for them.

Further, it’s okay for you to have been at a rural solo position because you’re atypical? What made you different? As a ICU RN and family med/ military PA before residency, I can tell you it would have been dangerous even for me to go to a rural solo position. I’m not chastising you, but I think it’s pretty unfair for you to worry about new grad PA working independently when that is what you did. Unless it is about age, which again I think is unfair because I’ve known some pretty mature and brilliant 25yo. The rest were nervous as hell and wouldn’t think of such a position.

as far as meritocracy, that is a system based on ability, not training, which I strongly believe in.

 As far as data, I feel whatever evidence I could present you would say is hogwash. But I would welcome any data from you that would prove your theory. You can just tell me about it and I’ll find the research 

[JMann]

I seem to need a refill on my popcorn for this discussion...

I'm for improved supervision rules and removing barriers to PA practice. I'm not opposed to independent practice, but I'm not sure what opening that can of worms will bring down the road. Guess it can't be worse than what we have now and falling behind NPs further. 

[rev ronin]

I don't want independence.

I want to be able to not immediately lose my ability to practice if my collaborating physician gets hit by a bus.

I want my own license to be enough to order DME for medicare.

I want to be able to practice things I've mastered, even if my SP doesn't do that. I want to have non-physician board recognition from every specialty society that I wanted to specialize in.  I don't care if it's CAQ (NCCPA) or board sponsored.  My specialty is not "physician assistant"--that's my training level.

I want to be able to bill insurance on a level playing field, even if it's not at 100% (If it's less than 100%, then I want to be able to keep all of it, though)

I want to have all the rest of "my" team be able to initiate patient care based on my orders.  This means making the most of all the specialists--physicians, allied health, other PAs--in my area.

I want to be so useful to a physician, both in terms of clinical throughput and earning power, that they will be knocking on MY door, rather than running away from the paperwork and malpractice burden.

[Boatswain2PA]

On 11/30/2018 at 9:07 AM, LT_Oneal_PAC said:

So how does this improve safety?

It doesn't.  It just keeps physicians in charge of healthcare, which I think they should be. 

On 11/30/2018 at 9:07 AM, LT_Oneal_PAC said:

Wouldn’t it be better to put the PA on the legal hook so that those of us with experience can practice how we want and those without will work at shops with good supervision and learning?

I think we already ARE on the hook, with our own malpractice, reputation, and personal net worth.  
 

On 11/30/2018 at 9:07 AM, LT_Oneal_PAC said:

I think part of the reason that PA take these dangerous solo positions is because they do think someone else is on the hook for them.

I don't think PAs take "dangerous" solo positions because they think someone else is "on the hook."  But I think some of us took them because we knew we had a doc there for backup if we needed.  Remove every element of physician supervision and the only backup you will have is an administrator.  Scary thought.

On 11/30/2018 at 9:07 AM, LT_Oneal_PAC said:

Further, it’s okay for you to have been at a rural solo position because you’re atypical?

I never said that.  I don't have any problem with PAs taking solo positions.  Yes, I took one right out of school, which is not generally recommended, but I was atypical.

But in every solo position I have had, which has been every single one of them but ONE, I have had a doc whose job it was to ensure I knew what I was doing.  Some of those docs did their due diligence, some didn't.  It's an imperfect world and always will be. 

 

On 11/30/2018 at 9:07 AM, LT_Oneal_PAC said:

As far as data, I feel whatever evidence I could present you would say is hogwash. But I would welcome any data from you that would prove your theory. You can just tell me about it and I’ll find the research 

I don't think there will ever be any good evidence for either of our positions.  Lots of things are simply impossible to study scientifically.

[LT_Oneal_PAC]

21 hours ago, Boatswain2PA said:

It doesn't.  It just keeps physicians in charge of healthcare, which I think they should be. 

I think we already ARE on the hook, with our own malpractice, reputation, and personal net worth.  
 

I don't think PAs take "dangerous" solo positions because they think someone else is "on the hook."  But I think some of us took them because we knew we had a doc there for backup if we needed.  Remove every element of physician supervision and the only backup you will have is an administrator.  Scary thought.

I never said that.  I don't have any problem with PAs taking solo positions.  Yes, I took one right out of school, which is not generally recommended, but I was atypical.

But in every solo position I have had, which has been every single one of them but ONE, I have had a doc whose job it was to ensure I knew what I was doing.  Some of those docs did their due diligence, some didn't.  It's an imperfect world and always will be. 

 

I don't think there will ever be any good evidence for either of our positions.  Lots of things are simply impossible to study scientifically.

Sorry, I didn’t mean to put words in your mouth. I was making assumptions.

okay, I’ll stop. If I understand correctly you strongly believe in the military style system (reasonably for a retiree) where rank trumps experience and supervisors are responsible for every positive and negative action of subordinates. Personally I hated that when I was in, and if that’s the reason you support a physician being legal tied to a PA, then we’ll never agree, but I’m glad we agree it’s not a safety issue.

[Boatswain2PA]

On 12/3/2018 at 10:20 AM, LT_Oneal_PAC said:

Sorry, I didn’t mean to put words in your mouth. I was making assumptions.

No apologies necessary.  

 

 

On 12/3/2018 at 10:20 AM, LT_Oneal_PAC said:

If I understand correctly you strongly believe in the military style system (reasonably for a retiree) where rank trumps experience

Nope.  Rank means nothing to me.  I retired as a very senior enlisted operator.  Didn't give much of a damn about what an O-3 wanted.

Conversely, I understand that medical school, and then a residency program, gives a physician a MUCH greater learning EXPERIENCE than we get.  Can a PA be just as good as a physician?  Yeah, but the STANDARD is different.  That's the meritocracy.

 

On 12/3/2018 at 10:20 AM, LT_Oneal_PAC said:

you support a physician being legal tied to a PA

I don't even know if that's the right way to say what I "support".  I really don't "support" anything except for decrease bureaucratical requirements, and keeping physicians in charge of healthcare.  

 

On 12/3/2018 at 10:20 AM, LT_Oneal_PAC said:

then we’ll never agree, but I’m glad we agree it’s not a safety issue.

It's okay to not agree.

But this ND plan IS a safety issue as it allows new grads to be totally unsupervised by physicians.  

[LT_Oneal_PAC]

@Boatswain2PA

 

but we’ve established that you’re plan provides no safety net, real time supervision, or teaching requirement, so where is the enhanced “safety” other than for those who would do it anyway?

lets be real, you practiced totally unsupervised as a new grad in a rural solo environment.

[Boatswain2PA]

I disagree.  I had worked with my SP before so he had confidence in my decision making, and he (or an alternate) was available 24/7. I also had indirect supervision via continual discussion from my SP about improvements.

Supervision doesn't mean running everything by the boss.  In the maritime services we have a Commanding Officer of the ship, and Deck Watch Officers/Officers of the Deck who run the ship when the CO isnt on the bridge.  The CO is responsible for the ship whether he is on the bridge, or in the rack.

In the Coast Guard we have rescue/law enforcement stations with a CO who is responsible for everything that happens, yet we often launched boats on missions led by 22 year old boat captains.  How did I, as the CO, supervise the young boat captains?  Through ensuring they were trained, continual discussion and honing of their decision making, mutual understanding of their limitations, and following through on their missions.

I didnt have to launch with them on every mission to supervise them.  I was often at home in bed....but was still responsible for the mission, and yes, I supervised them.

[LT_Oneal_PAC]

1 hour ago, Boatswain2PA said:

I disagree.  I had worked with my SP before so he had confidence in my decision making, and he (or an alternate) was available 24/7. I also had indirect supervision via continual discussion from my SP about improvements.

Supervision doesn't mean running everything by the boss.  In the maritime services we have a Commanding Officer of the ship, and Deck Watch Officers/Officers of the Deck who run the ship when the CO isnt on the bridge.  The CO is responsible for the ship whether he is on the bridge, or in the rack.

In the Coast Guard we have rescue/law enforcement stations with a CO who is responsible for everything that happens, yet we often launched boats on missions led by 22 year old boat captains.  How did I, as the CO, supervise the young boat captains?  Through ensuring they were trained, continual discussion and honing of their decision making, mutual understanding of their limitations, and following through on their missions.

I didnt have to launch with them on every mission to supervise them.  I was often at home in bed....but was still responsible for the mission, and yes, I supervised them.

So you do believe in the military hierarchal structure. Okay officially done. Even if you don’t care what O3 thinks, and that’s fine because I didn’t care what senior enlisted thought. You still believe he/she with the most rank is ultimately responsible. This is always the Officer. I don’t like this because the navy times is littered with COs relieves for stupid stuff officers and enlisted below them did. Same with PAs. I don’t think a physician is on the hook for rogue PAs. I dont think knowing your supervising physician would help a patient be intubated in emergent situation, even if they were available by phone. This is now going in circles, so I’ll bow out. 

[Boatswain2PA]

Like most things....its relatively grey (or gray!).

Hierarchy is important, but not as much as experience, or training, or standards, or.......

Physicians are the highest trained medical professionals so should be in charge of healthcare.

[Boatswain2PA]

10 minutes ago, LT_Oneal_PAC said:

You still believe he/she with the most rank is ultimately responsible. This is always the Officer. I don’t like this because the navy times is littered with COs relieves for stupid stuff officers and enlisted below them did

Not with the Coast Guard who has enlisted in command of most of their operational units (both cutters and shore based rescue/law enforcement units).  

Most officers (in any branch) have no idea what true command looks like.

And if you dont care what your E8-E9s are telling you....you should reevaluate your military career.

[EMEDPA]

4 minutes ago, Boatswain2PA said:

Like most things....its relatively grey (or gray!).

Hierarchy is important, but not as much as experience, or training, or standards, or.......

Physicians are the highest trained medical professionals so should be in charge of healthcare.

what if your sp is a brand new FP doc and you are an em pa with far more em experience? It has happened to me before.

[Boatswain2PA]

1 minute ago, EMEDPA said:

what if your sp is a brand new FP doc and you are an em pa with far more em experience? It has happened to me before.

Great question, and one I dont have the answer to.  I believe I am better (and work hard at being better) at EM than most FP docs, some of whom have been my SP.

There is no easy answer to the problem we, as a profession, have!

[EMEDPA]

Just now, Boatswain2PA said:

Great question, and one I dont have the answer to.  I believe I am better (and work hard at being better) at EM than most FP docs, some of whom have been my SP.

There is no easy answer to the problem we, as a profession, have!

In some states your scope can not exceed that of your sp.  legally if your sp was not comfortable running codes, intubating, reducing fxs, etc then you could be restricted from doing this, or worse yet get in trouble with the medical board if someone complained(even if you made no mistake) and it was discovered that your credentialing exceeded theirs. tough situation. I quit a job over this about 10 years ago when an ER I worked in wanted to give me a brand new fp residency grad as an sp. told them(director of nursing, my admin boss) why it wouldn't work. they said" you are just an assistant. you can do anything a physician directs you to do". um, goodbye. right now. here is my pager. have fun replacing me. bitch.

[Boatswain2PA]

I've ran into that before with ultrasound.  One place I worked for a while I asked ti get credentialed in FAST so I could bill (just trying to help them stay open) but no doc felt qualified.  I just did them anyway for patient care. 

 

I would imagine any doc losing their DEA license would be removed from ED supervision role.