OTP and removal of supervising physician relationship/agreement

[Gizmo]

Hi there everybody! I’ve been a PA for 6 years now and have worked in CT surgery and Neurosurgery and am about to begin a role in the ED of a busy Level 2 trauma center. I basically wanted more autonomy with medical decision-making; and then the ability to come to work, do my job and be paid for my time and skills (versus salaried where the hours were long, diluting what I was actually getting paid for my time) and then go home and have some semblance of a life outside work. My research led me to the ED as the place I could achieve those goals.

More than anything, when I am at work, I want to be able to provide high-quality, evidence-based care to patients. The absolute worst is having to “ask permission” from a physician colleague to do something I know is the right thing to do, etc… and then be instructed to do something else. (Example: Me —“I’m giving ceftriaxone 1g qD x 5 days d/t black box for quinolones.” Doc — “That warning doesn’t matter. I’ve never seen it happen. Give them ciprofloxacin for 10 days for their UTI.”) Professionally, the ability to NOT have things like this happen and to deliver what I know to be the best care for patients — while still collaborating with physicians when I do need help / feedback — is possibly the *most* valuable thing to me… and, again, is one of the reasons I am excited to work in Emergency Medicine. 

So that’s the background info to set the stage for why I’m posting…

I’ve been following — as best I can without a lot of background knowledge of politics — OTP and the hurdles that our profession is trying to overcome. 

I am in a state that only ticks 2 of the 6 boxes for “elements of a modern PA practice.” (Shockingly, no one walks with their knuckles dragging the ground, and we *do* use EMR vs stone tablets.) Sometimes I wonder if my past experiences with these more frustrating aspects of collaboration are specialty-specific, or possibly more as a result of the red tape in place due to my geographic location. So I figured it might be good to ask my colleagues.

Specifically, I am curious to hear from PAs who practice in those few states where the supervisory requirements have been removed. States like Utah and Wyoming (and maybe North Dakota and Oregon? I’m not sure about these two…I tried to research all the states, but I may be wrong. Anyone who knows all the states where that supervisory requirement has been removed — please correct me if I’ve got them wrong!).

I know it’s early days with a lot of these gains, and I think that in one of the states, it’s not going to take effect until January 2022, but still… I figure at the very least, the mentality in those states must be different. In daily medical practice, how are things different for those of you who work in states which have removed that PA-supervising physician tether with the goal of improving access? What is that like day-to-day when treating patients? How does that translate into your earning potential / is your compensation arrangement different with the physician-PA supervision requirement severed? Overall job satisfaction? Has it affected your working relationship with your physician colleagues? Other things I may not be asking but you feel are pertinent to share…?

I hope everyone is doing alright out there with everything going on, and thank you for letting me pick your brain and for taking the time to read this and respond!

Cheers,

Erika

Edited November 10, 2021 by Gizmo
Poor grammar.

[sas5814]

Great post! Nice to see you chasing a better professional and personal life. I hope things work out well. I'm in Texas (and have been since I retired from the Army) and all my experience has been in a backwards physician controlled world so my experience here isn't of much value I'm afraid.

I did practice at a remote site in Alaska for a while during the height of COVID. Being autonomous, having your skills and knowledge not only respected but appreciated is a pretty big deal.

Good luck!

[ventana]

two things going on here for you

1- you are no longer a new grad and have a brain

2- you are new to EM

 

I would say a little supervision is okay as you enter a new speciality - formal or informal (in our case it always formal due to dependency)

 

Yup you are seeing the real negative so dependency (And the fact that ER Doc has never seen a S/E from quinolone means they are not looking!!)  It will take a paradigm shift for the PA's in the trenches to enmass realize, support, and demand OTP and severing the cord to organized medicine.....    So far I am seeing glimpses (at least AAPA and NCCPA are not actively working to stop OTP and AAPA is trying - but I am unsure of this new President Elect)

 

Sorry you are experiencing it - it is a fact of life in most jobs - I have personally found that I I don't ask questions, and get a bristly when I am challenged and have good justification for doing what I do - even when I am talking to specialists - whom seem overworked and not putting the time into their patients (especially in our local Cards office where I have had to have frank discussions with the PA/NP about volume status management ARF/diuretics on more then one occasion.....  once again I am getting a little prickly in my old age....)

 

OTP and solely responsible for our decisions would indeed help - then there is no need to go ask the blessing of the almighty doc.....  But we still are part of a team and need to play nice in the sand box.  BTW I have a few specialists who are absolutely amazing and I do what they ask almost with out question.  They are that good!

[Gizmo]

In response to Ventana:

 

The quinolone thing didn’t happen in the ED. It happened while working in one of the specialties. Overall, I had a great experience working in previous roles — especially in Neurosurgery. The physicians were great…exceptional surgeons. It was just time for a change. But yeah, I haven’t even worked Day 1 of my ED job yet! I have no idea how it’ll go, but my fingers are crossed it’ll be good. It’s in the same hospital where I worked in Neurosurgery, and from a collaborative experience while in Neurosurgery, I had a lot of positive experiences and an overall favorable impression of those docs (the ED physicians). And the feedback from the PAs and NPs who work there make it seem like it’s a place where I’ll have a little more freedom. I’m not looking to not be supervised or not have to answer to anyone — that’s not how I roll at all. I know what I know, but I also know what I don’t know and when to ask questions. And if I *think* I know something but it turns out somebody knows better/different, then that’s cool too and I’m glad to learn from them. Also, God bless peripheral brains. I got scrubs with 11 total pockets to fit more of those mini books my aging eyes probably won’t be able to read for much longer. 

 

Maybe I wasn’t clear as to why I was posting. I provided all that background info in an effort to convey where I’m coming from and where I’m going just to give context. I guess I was just pondering this career change…why I made the change, the clinical abilities I’ll hopefully get to develop while in the ED, the working relationship I’m hoping to have with the docs there, etc… And the natural progression, in my head anyway, was to wonder if the opportunities I’m hoping to be able to realize practicing in the ED are ones that other PAs have been able to realize, just by virtue of the fact that they are in one of those very few states without that supervising physician-PA requirement.

 

There’s a lot written on various forums about what the PA profession is trying to achieve, and it’s great. I’m just curious how it plays out clinically/in practice in places where some of those achievements have been realized — what it’s like “on the other side.” I’m in my own head a lot and I don’t have a lot of folks I routinely communicate with about stuff like this, other than my husband (who isn’t in medicine). I figured I would just toss a line out here on this forum because I am genuinely interested in my fellow PAs’ experiences.

 

I’ve just sort of been wondering what PAs who are in states without that supervising physician-PA requirement have experienced. I’m not looking to move anywhere or do anything different — heck, I have to see what this ED thing is all about first! But yeah, the “dependency” you referenced, Ventana — that’s exactly what I’m wondering about…Whether having that formal supervisory relationship waived on the state level translates into any meaningful/perceptible change in the “feel” of what it’s like to practice in those places. 

 

In response to SAS:

That sounds awesome (re: working in Alaska)! I somehow ended up down a rabbit hole and stumbled upon some photos of Kodiak Island last week. I said to my husband, “Wow! Too bad we aren’t crazy about the cold! Wonder what it’s like to practice in Alaska…”      And yeah, you hit it on the head — kind of getting to be the one who’s there to help patients, and they’re just glad for the care. That’s a beautiful thing! To me, that sounds like practicing medicine in a very pure form. I’m just getting started in the ED, so…who knows what’ll happen, but I sure hope that one day I’ll be able to do something like that — or at least have enough experience so that it would be an option. 

Edited November 11, 2021 by Gizmo

[ohiovolffemtp]

I've done EM and found that the amount of actual "supervision" varies tremendously by state, site, and individual doc.  I work PT at one site where the doc who owns the group intrudes himself on every patient seen by the PA's and pushes the other docs to do so, mostly for the extra 15% reimbursement for incident to billing.  Some of the other docs trust us to approach them when we need them but otherwise leave us alone.  At my last FT job we were usually very busy and I worked primarily with 1 doc.  His usual question was "do I need to see any of your patients?".  Now, I do solo overnight coverage at a rural critical access hospital and pretty much only have the doc come in for codes and thrombolytics.

[GetMeOuttaThisMess]

13 hours ago, ohiovolffemtp said:

I've done EM and found that the amount of actual "supervision" varies tremendously by state, site, and individual doc.  I work PT at one site where the doc who owns the group intrudes himself on every patient seen by the PA's and pushes the other docs to do so, mostly for the extra 15% reimbursement for incident to billing.  Some of the other docs trust us to approach them when we need them but otherwise leave us alone.  At my last FT job we were usually very busy and I worked primarily with 1 doc.  His usual question was "do I need to see any of your patients?".  Now, I do solo overnight coverage at a rural critical access hospital and pretty much only have the doc come in for codes and thrombolytics.

This is how it was for me when I became the first PA at my Dallas hospital in the ED ( I had already done same in cardiology at the same facility), and then later at a suburban hospital whose group had used PA’s at its central campus.  Only the ED director said hi to everyone while the others left me alone at the first location.  It varied initially at the second until a novel idea called fast track came into being.  After that, they wouldn’t be caught dead back there unless i asked them to look at someone.

[Febrifuge]

I’m in MN, which on my reading of the Barton & Associates chart (Link here) is one of 8 states that hit 6 out of 6. It’s pretty great. I report to my clinic’s medical director, and so does my NP colleague. Before the current boss, an MD, the previous clinic medical director was a PA. 

I’ll be starting a new job elsewhere in the same clinic system next year, and was just asked to sign the practice agreement. It took me a second, but since summer 2020 we no longer have a ‘supervisory agreement’ or anything that ties me to a specific MD, legally or clinically, for day-to-day work. My understanding is that you need to designate an MD within the clinic system and formalize that you have someone to collaborate with as needed. This is filed at the practice level, not with the state. Practically speaking, my new boss works fine for that. 
 

 

[ohiovolffemtp]

The Barton & Associates chart is good, but doesn't tell the whole story.  States can have other barriers, e.g. being unable to sign mental health holds, being unable to pronounce death/sign death certificates, etc.