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Practice-based autonomy and OTP


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My question is for any state that passes  practice- based  items for OTP.  

 I remember as a new to practice PA (about a 1-2 yrs in) going to a conference.  I looked at an older gentleman next to me, and asked him “When do I quit having to prove myself?” 

  With an down-trodden look he responsed, “Kris,  every time a new (and/or younger) phyisican starts at the clinic, I have to start all over proving what I know!” 

So when one switches positions/practices, would one have to start over by proving themselves....again? 

 With OTP rules set at the practice level (vs state) would one  have to prove and attempt to regain the same autonomy that one had at the last place of employment?  Or when a new physician arrives? 

 ........ Because this does not sound any different than what we have now ...

 Interested in hearing your thoughts   

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(shrug) all of life is about having to prove one's self.  Sometimes, it's formal, in terms of credentialing, where a third party looks at what you've done.  Other times, it's not.  I don't think anything short of a CAQ or maybe a residency actually significantly shortcuts that for PAs, but I've never found myself unduly restricted by new docs in a primary care setting.

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Perception is 90% of the battle....

 

we are "assistant" now so "we have to prove we are better then assistant" every single time....

 

Add into this that HR and small practices sometimes is so short sighted that they can not (will not/refuse to ) grow with a provider as the skill set increases that they just loose employees.

 

 

So if we are "providers" and do not stupid, useless meaningless supervision meetings and feedback then they doc's will not get the opportunity to look down on us....

 

 

Funny story lately

 

At my primary job the SP is just administrative, does not have clinic, does not see patients.....

 

He refused to back me up on a policy issue where the medical knowledge is changing and we should change protocols.....

He said it was not worth it, we don't want to piss off admin, and it was his call..... ahhh no, not on my watch,  I will advocate for my patients and what is right medically.   Meet with Admin and they appear to have sided with me.  And are scheduling a meeting with he and I.  I simply can not wait to see the look on his face when he realizes not only was he wrong, but admin is serious about trying to do good medicine and will not likely appreciate that he was unwilling to advocate for the patients.......   I might get in more trouble, and I have already contact my own PA Board to make sure I am stepping very carefully.   But really, why on gods earth do I need to do this BS?  it is a waste of my  time and efforts.......  (every specialist I have spoken with sides with me)

 

 

OTP and name change can change this......

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Doesn't want to piss admin off? Is that what we have come to where physicians are actually afraid of administrators? My how the worm has turned.

 

As for increased autonomy OTP doesn't guarentee that. It just means the rules will be decided at the practice level and not mandated by the state. Some places that will mean autonomy. Some places will want to keep a tight leash on everyone. The fun part will be how the market forces drive things. If your organization wants to keep a choke hold on PAs you aren't going to be able to hire any. When that reality sets in then the reigns will be loosened.

Its an interesting time for the profession right now despite all the teeth gnashing and angst.

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1 hour ago, sas5814 said:

Doesn't want to piss admin off? Is that what we have come to where physicians are actually afraid of administrators? My how the worm has turned.

 

As for increased autonomy OTP doesn't guarantee that. It just means the rules will be decided at the practice level and not mandated by the state. Some places that will mean autonomy. Some places will want to keep a tight leash on everyone. The fun part will be how the market forces drive things. If your organization wants to keep a choke hold on PAs you aren't going to be able to hire any. When that reality sets in then the reigns will be loosened.

Its an interesting time for the profession right now despite all the teeth gnashing and angst.

 

 

 

Hummmm  but from my perspective I would NEVER work for an agency which would mandate anything beyond independent practice, and I would hope others that are experienced would do the same.  As well I don't think that people (or admin) want to supervise PA's, but instead just want to hire a highly skilled professional medical provider that wants to help his patients......

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yea I agree but it will take a while for employers to catch on and there are enough administrator/physicians in some places to keep a choke hold (or try to) on the PAs. Right now my organization is having a long involved conversation about increasing chart reviews. Wanna guess how many PAs are involved in the conversation? If you guess none you win the prize. 

Bean counters, nurses, physicians all discussing our profession with no input from us at all. The fun part is none of them seem to understand what the state law mandates and the vast majority of their opinions are wrong. Once OTP come to Texas in say....40 years or so ..things will change.

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On 4/13/2019 at 6:41 AM, KpsPac said:

My question is for any state that passes  practice- based  items for OTP.  

 I remember as a new to practice PA (about a 1-2 yrs in) going to a conference.  I looked at an older gentleman next to me, and asked him “When do I quit having to prove myself?” 

  With an down-trodden look he responsed, “Kris,  every time a new (and/or younger) phyisican starts at the clinic, I have to start all over proving what I know!” 

So when one switches positions/practices, would one have to start over by proving themselves....again? 

 With OTP rules set at the practice level (vs state) would one  have to prove and attempt to regain the same autonomy that one had at the last place of employment?  Or when a new physician arrives? 

 ........ Because this does not sound any different than what we have now ...

 Interested in hearing your thoughts   

I will risk being shadow-banned by a certain moderator here (again) by giving a politically-incorrect answer (meaning one that people don't like, but that doesn't mean it's not true).

It's all about standards.  And if you talk standards, you HAVE to talk about MINIMUM standards.  

You can have certain credentials that prove you have met minimum standards of competence.  Like Board Certified Emergency Physician (or Board Certified **insert specialty here**) means you are at the top of the game in Emergency Medicine (or other specialty), so it is reasonably safe for everyone to assume such a person is competent in their specialty.  With that credential we know that the person graduated medical school and has (with rare grandfathering rules) completed an Emergency Medicine residency and passed Emergency Medicine boards.

The MINIMUM standard for being a PA is passing a 26 month intense program of medical education and passing a test that virtually everyone passes. 

That is a big difference.

Oh, and that experienced 20 year PA could have worked in urology for 19.5 of those 20 years, and now that he's in your ED doesn't really know how to manage an unstable arrhythmia.  Likewise, that experienced 20 year PA who worked in the ED for 19.5 of those years wouldn't know how to reconstruct a bell-clapper deformity.

The MINIMUM standard for being a NP is being a nurse who passes 24 months of part-time online classes, and shadowing a friend in clinic for 500 hours, then passing a written test.  

That is a HUGE difference.

But, like it or not, those ARE the standards.

So, if you are a physician/midlevel/APP/RN/RT/CNA/adminiscritter or ward clerk, how do you know if someone you just meet is competent in their job?  

If the MINIMUM for their credentialing means that they passed their specialty boards in medicine, you can assume they are indeed a specialist.  If their MINIMUM standard is a 26 month program that lets them move between specialties...yeah, I'm not going to assume they are competent until they prove it.

Will practice based OTP change this?  nope.  It's human, and protective, in nature.

As we continue toward specialization (CAQ's) I think this will improve, but that will be a long road.
 

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I actually totally agree with the above. There may come a day when the need to prove yourself won't be there, but that will either come with a significant amount of time in the same area or some sort of "board" certification.

Or med school.

I know too many people from my class who passed the PANCE to be comfortable with just anyone treating patients.

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11 hours ago, Boatswain2PA said:

I will risk being shadow-banned by a certain moderator here (again) by giving a politically-incorrect answer (meaning one that people don't like, but that doesn't mean it's not true).

It's all about standards.  And if you talk standards, you HAVE to talk about MINIMUM standards.  

You can have certain credentials that prove you have met minimum standards of competence.  Like Board Certified Emergency Physician (or Board Certified **insert specialty here**) means you are at the top of the game in Emergency Medicine (or other specialty), so it is reasonably safe for everyone to assume such a person is competent in their specialty.  With that credential we know that the person graduated medical school and has (with rare grandfathering rules) completed an Emergency Medicine residency and passed Emergency Medicine boards.

The MINIMUM standard for being a PA is passing a 26 month intense program of medical education and passing a test that virtually everyone passes. 

That is a big difference.

Oh, and that experienced 20 year PA could have worked in urology for 19.5 of those 20 years, and now that he's in your ED doesn't really know how to manage an unstable arrhythmia.  Likewise, that experienced 20 year PA who worked in the ED for 19.5 of those years wouldn't know how to reconstruct a bell-clapper deformity.

The MINIMUM standard for being a NP is being a nurse who passes 24 months of part-time online classes, and shadowing a friend in clinic for 500 hours, then passing a written test.  

That is a HUGE difference.

But, like it or not, those ARE the standards.

So, if you are a physician/midlevel/APP/RN/RT/CNA/adminiscritter or ward clerk, how do you know if someone you just meet is competent in their job?  

If the MINIMUM for their credentialing means that they passed their specialty boards in medicine, you can assume they are indeed a specialist.  If their MINIMUM standard is a 26 month program that lets them move between specialties...yeah, I'm not going to assume they are competent until they prove it.

Will practice based OTP change this?  nope.  It's human, and protective, in nature.

As we continue toward specialization (CAQ's) I think this will improve, but that will be a long road.
 

Your politically-incorrect comment is spot on!!!    While the opportunity for all PA’s obtaining a residency would not be possible,  expanding specialty (Derm, family med/ urgent care, ...etc.) CAQ for PA’s would be great. Either residency or a CAQ, with current standards, should be required in progressing toward independence. 

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17 hours ago, Boatswain2PA said:

I will risk being shadow-banned by a certain moderator here (again) by giving a politically-incorrect answer (meaning one that people don't like, but that doesn't mean it's not true).

It's all about standards.  And if you talk standards, you HAVE to talk about MINIMUM standards.  

You can have certain credentials that prove you have met minimum standards of competence.  Like Board Certified Emergency Physician (or Board Certified **insert specialty here**) means you are at the top of the game in Emergency Medicine (or other specialty), so it is reasonably safe for everyone to assume such a person is competent in their specialty.  With that credential we know that the person graduated medical school and has (with rare grandfathering rules) completed an Emergency Medicine residency and passed Emergency Medicine boards.

The MINIMUM standard for being a PA is passing a 26 month intense program of medical education and passing a test that virtually everyone passes. 

That is a big difference.

Oh, and that experienced 20 year PA could have worked in urology for 19.5 of those 20 years, and now that he's in your ED doesn't really know how to manage an unstable arrhythmia.  Likewise, that experienced 20 year PA who worked in the ED for 19.5 of those years wouldn't know how to reconstruct a bell-clapper deformity.

The MINIMUM standard for being a NP is being a nurse who passes 24 months of part-time online classes, and shadowing a friend in clinic for 500 hours, then passing a written test.  

That is a HUGE difference.

But, like it or not, those ARE the standards.

So, if you are a physician/midlevel/APP/RN/RT/CNA/adminiscritter or ward clerk, how do you know if someone you just meet is competent in their job?  

If the MINIMUM for their credentialing means that they passed their specialty boards in medicine, you can assume they are indeed a specialist.  If their MINIMUM standard is a 26 month program that lets them move between specialties...yeah, I'm not going to assume they are competent until they prove it.

Will practice based OTP change this?  nope.  It's human, and protective, in nature.

As we continue toward specialization (CAQ's) I think this will improve, but that will be a long road.
 

This is all so true. And its one reason I worry a bit seeing all these new programs entering the accreditation process. It seems that 90+% of them are not at academic medical centers and are just free standing little "universities" seeing to offer another degree. If the MINIMUM standard for PAs is to attend a program run out of a failing chiropractic school on an old high-school campus (https://en.wikipedia.org/wiki/Southern_California_University_of_Health_Sciences), we might be in trouble soon. 

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I don't think the CAQ (at least in EM) provides the same level of documentation of proficiency as does completion of a residency.  EM is a procedure rich practice environment.  No online test: PANCE, PANRE, CAQ can measure that.  However, procedure logs and LOR's from preceptors can document that and are much stronger evidence to use to support credentialing.

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7 hours ago, ohiovolffemtp said:

I don't think the CAQ (at least in EM) provides the same level of documentation of proficiency as does completion of a residency.  EM is a procedure rich practice environment.  No online test: PANCE, PANRE, CAQ can measure that.  However, procedure logs and LOR's from preceptors can document that and are much stronger evidence to use to support credentialing.

Of course not, but it will eventually show a stronger level of proficiency in the specialty as just passing the generalized PANCE.

The only people who will see procedure logs and LORs will be the adminiscritters, not the Docs who we work with (and we will always have to prove ourselves too).

It's just the name of the game of Life where, like Rev said, we are always working to prove ourselves to others, and we force others to prove themselves to us.

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11 hours ago, ohiovolffemtp said:

I don't think the CAQ (at least in EM) provides the same level of documentation of proficiency as does completion of a residency.  EM is a procedure rich practice environment.  No online test: PANCE, PANRE, CAQ can measure that.  However, procedure logs and LOR's from preceptors can document that and are much stronger evidence to use to support credentialing.

One way to change that would be to reframe the CAQ requirements to reflect procedural proficiency rather than knowledge of the procedure and when it should be performed or however it is phrased. That would of course limit the number of CAQ applicants and therefore cut into the profit margin sooo.... (Sorry, feeling a touch of nihilism today)

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