"APP-MD Bridge" Program?

[ohiovolffemtp]

20 hours ago, newton9686 said:

The problem with emergency medicine is 80% is relatively routine care that can be managed by your average PA or NP. As most MDs and DOs want to work with PAs and NPs who can help with less acute patients so they can focus on the sicker patients. The challenge comes from being able to manage that last 10-20%. And as a lot of our Solo PAs on this board will tell you, those PAs and NPs are not a dime a dozen. We’re talking bad asses with at least 5 years experience at a minimum, with the majority 10+.

That's probably right.  However, even for the majority of PA's who work in larger ED's where there are docs present, there are often barriers in state law that prevent them from doing things that they're very capable of: signing mental health holds (Ohio), prescribing controlled substances (KY), doing procedural sedations (Ohio), etc.

Not all PA's want to work solo, I am one of the ones who does.  Still, I believe that we need to remove as many glass ceilings as possible so that PA's can grow as much as they can.  There's nothing wrong with using the EM doc as a consultant when you need them just like you use hospitalists, surgeons, cardiology, ortho, OB/gyn, etc and doing as much as you can yourself.

[TeddyRucpin]

On 10/5/2022 at 4:34 AM, ohiovolffemtp said:

That's probably right.  However, even for the majority of PA's who work in larger ED's where there are docs present, there are often barriers in state law that prevent them from doing things that they're very capable of: signing mental health holds (Ohio), prescribing controlled substances (KY), doing procedural sedations (Ohio), etc.

Not all PA's want to work solo, I am one of the ones who does.  Still, I believe that we need to remove as many glass ceilings as possible so that PA's can grow as much as they can.  There's nothing wrong with using the EM doc as a consultant when you need them just like you use hospitalists, surgeons, cardiology, ortho, OB/gyn, etc and doing as much as you can yourself.

How are the barriers in the other states you work in EM?

[EMEDPA]

3 hours ago, TeddyRucpin said:

How are the barriers in the other states you work in EM?

Pretty much nonexistent in rural settings and oppressively intolerable in urban settings

[ventana]

I have to get permission to be precepted to do a Bx or nitrogen therapy, then have to have 5 witnessed procedures, then go back before credentialing to get approved.  I have done them for 20 yrs but it is not considered a "core" skill for PA so I have to jump through all these hoops.....   just plain and simple waste of time.   It is illogical and needs to stop.  

 

I am against anything that ADDS time to our training so not even be equal to an NP.  We are already trained WAY more and we need to become politically savvy

[roundabout]

On 9/26/2022 at 11:50 AM, newton9686 said:

As someone in the process right now I do think it would need to be 30-36 months. There is just too much red tape and opinions to make it work otherwise.

However there is A TON that we could do to make this more doable for PAs

1)  Remove the MCAT. PAs are too far removed form basic sciences and they are at an obvious disadvantage from a 20 something year old living with their parents with no other responsibilities who can study for 3 months for a test that has nothing to do with becoming a physician. If you want to see how well someone is at taking test use their PANCE score and this would provide more than enough info.

2) Make the majority of the basic science courses online with non synchronous learning. I can process a full day of lectures (4 classes)  in less than 2 hours. From there more clinical lectures I need an additional 30 minutes to 1 hour to study before testing. More PhD courses require more studying but again its doable while still picking up enough shifts to pay the bills and put a little towards tuition too.

3) Make clinical skills more check off or perhaps a 1 week boot camp to prepare you for any practical examination requirements with again a lot of online learning. I think anatomy lab could be done online as well. Likely synchronous, but the online lab we did during the Delta surge was actually more informative and efficient than the traditional cadaver lab because there is no questioning what you are looking at and how it relates to everything else. Plus, you are not spending hours “cleaning things up”. Not to say I recommend  online lab for those who have never done a cadaver dissection, but for most PAs who have already done the full dissection in PA school I think there’s an argument that online anatomy labs would be more beneficial

4) All testing could be done remotely with new monitoring programs.

5) Obviously would need to be done MD, possible DO if they turned OMM into 1 week boot camps focusing on the minimium requirements to pass boards, but honestly the best bet would be MD because it is just an unnecessary burden for the vast majority of DO students that MDs and PAs have shown is not necessary or realistic  for clinical practice and most DOs do nothing with once they start clinicals other than try to remember enough to pass boards. 

I believe by doing these 4 or 5 things PAs could still do the full first 2 years more in a way that is way more conducive to peoples lives, meets all requirements for the first 2 years of medical school  and attainable with a significantly lower the barrier to entry by removing the MCAT since it does not accurately predict PA’s ability to succeed in medical school. If there was one good thing about COVID is it has shown that all of these things can already be done. There is just needs to be a program that puts it all together.

Then it just comes down to clinicals which we have already seen can be done in an accelerated fashion in just 1 year. Thus the result is PAs would only have to really give up 1 year of salary to complete all clinical requirements (and perhaps even here something could be worked out where PAs could earn a stipend because of the value they would bring to the team).  

The key to making this pipe dream a reality is you are still have PAs fully jumped through all the hoops to become a physician. But you doing it in the most efficient way possible and in a way that gives credit to those who completed PA school and already sacrificed so much to get to where they are. 

I would love to see something happen like this where as a PA you can complete a schedule friendly medical school as an already proven student and provider. Medical education is already speeding up for undergrad students with 25+ medical schools offering accelerated pathways to MD. There's absolutely no reason why a PA with experience shouldn't qualify for some sort of reduction in time. I agree with you that residency has to be apart of the package. You'll never be seen as equal without a residency (not to mention AMA would never allow such a program) and unless you've been a PA for 10+ years in the same specialty you likely won't have the same experience and knowledge as the physician provider. There are tons of amazing talented PA's out there, but a formal medical residency programs is a non-negotiable supplement to becoming a physician IMO.

[LT_Oneal_PAC]

Residency is where the real learning is. If the pathway doesn’t  lead to a ticket into formal physician residencies and be able to pick our specialty, then I say don’t bother and do as Ventana says. Just work on establishing our own independent scope of practice based on education and experience to the individual.

i think @newton9686 has the right idea. Remove all the MCAT and class requirements for acceptance into Med school for PAs with an acceptable PANCE scores. Make the first 2 years friendly to working part time and not having to live locally with online course. Most Med students don’t show up to class anymore and every premed is looking for non-mandatory class attendance.

[PAtoMD]

1 hour ago, LT_Oneal_PAC said:

Residency is where the real learning is. If the pathway doesn’t  lead to a ticket into formal physician residencies and be able to pick our specialty, then I say don’t bother and do as Ventana says. Just work on establishing our own independent scope of practice based on education and experience to the individual.

i think @newton9686 has the right idea. Remove all the MCAT and class requirements for acceptance into Med school for PAs with an acceptable PANCE scores. Make the first 2 years friendly to working part time and not having to live locally with online course. Most Med students don’t show up to class anymore and every premed is looking for non-mandatory class attendance.

We probably aren’t far from removing “prereqs”. Plenty of schools have move passed them and have recommended classes. I’ve seen anecdotes that age of class is subjective and a good MCAT score voids the age of classes. 
 

Heck, we may be close to ridding the MCAT for normal premeds. A handful of west coast schools have dropped it. Step 1 is P/F. Wouldn’t be surprised if step 2 is P/F by the time I’m leaving school. 
 

I can get behind dropping MCAT and prerequisites for PA students make sense. An odd tidbit is our PA classes don’t even count as science courses for AMCAS applications which I thought was absurd. 
 

Lastly, med school should be trimmed down but my state med school recently trimmed their preclinical to shorter and their students did not do well on step 1 and subsequent shelf exams. But that may be a rumor.

[hm2paharris]

Thoughts:

https://www.tandfonline.com/doi/epdf/10.1080/0142159X.2023.2271153?needAccess=true

Advancing primary care Doctoral program for physician associates and nurse practitioners.pdf

[ventana]

32 minutes ago, hm2paharris said:

Thoughts:

https://www.tandfonline.com/doi/epdf/10.1080/0142159X.2023.2271153?needAccess=true

Advancing primary care Doctoral program for physician associates and nurse practitioners.pdf 672.12 kB · 1 download

Only read the abstract but 

we don’t need a ton more training (NP’s need a lot more clinical training/education).  We all should have a doctorate and staged independent practice.   

[Hope2PA]

Didn't LMU attempt this. They made a clinical doctorate to help to help experienced PAs gain more education in Primary care, internal med or Emerg med. taught by physicians. Unfortunately PAs were against the idea. Plus nurses lobbied heavily against it.  
The DMS or DMSc should be worthwhile standardized degree for all programs. 

[iconic]

Get the dinosaurs out of PA leadership. At this point I would prefer visionary nurses to lead our profession over SP-obsessed PAs

[ventana]

In this case I think the solution is simple and tight in front of us 

1) all PA degree should be DMSc 

2) immediate move to push hard for full staged independence.  (Think 10,000 hours supervised by doc or senior PA)

3) Senior PA status at passing 10,000 hours in your speciality.  
 

Cut all ties to MD/DO/NP 

we are our own profession. 
 

this would take new leadership at NCCPA and a refocusing at AAPA. 

[sas5814]

8 hours ago, ventana said:

immediate move to push hard for full staged independence.  (Think 10,000 hours supervised by doc or senior PA)

I just licensed in Utah. Full autonomy after 10k hours of practice. I'm not sure what I'm going to do with it exactly since I don't practice in Utah but I'm hoping 2024 will see the VA change their rules to something like "practice according to your state licensure."

If anyone is interested they have a sort of reciprocity agreement where if you are licensed in any of 42 states you are presumed to meet their criteria. I applied in the morning and got my license at 1700 that afternoon. That, boys and girls, is how things should work.

[iconic]

I'll take 10k hours, although I'd argue that 4-6k would be sufficient 

[rev ronin]

On 12/6/2023 at 8:43 PM, iconic said:

Get the dinosaurs out of PA leadership. At this point I would prefer visionary nurses to lead our profession over SP-obsessed PAs

Are you able to vote in AAPA elections?

[rev ronin]

On 12/7/2023 at 2:05 PM, Hemmingway said:

I just licensed in Utah. Full autonomy after 10k hours of practice. I'm not sure what I'm going to do with it exactly since I don't practice in Utah but I'm hoping 2024 will see the VA change their rules to something like "practice according to your state licensure."

If anyone is interested they have a sort of reciprocity agreement where if you are licensed in any of 42 states you are presumed to meet their criteria. I applied in the morning and got my license at 1700 that afternoon. That, boys and girls, is how things should work.

Just did this too. Let's see if I can do telemedicine for my existing patients who move there...

Jonathan

[ventana]

On 12/7/2023 at 5:05 PM, Hemmingway said:

I just licensed in Utah. Full autonomy after 10k hours of practice. I'm not sure what I'm going to do with it exactly since I don't practice in Utah but I'm hoping 2024 will see the VA change their rules to something like "practice according to your state licensure."

If anyone is interested they have a sort of reciprocity agreement where if you are licensed in any of 42 states you are presumed to meet their criteria. I applied in the morning and got my license at 1700 that afternoon. That, boys and girls, is how things should work.

Doing Montana as I have family there but excited to finally be free of physician supervision....

[TeddyRucpin]

Not to hijack this thread; however, can anyone comment on what "life is like" when practicing in these states with independent practice? Do your hospitals still have stronger requirements than what the state may be? I'd like to know what life is on the ground level. TIA.

[sas5814]

12 hours ago, TeddyRucpin said:

Not to hijack this thread; however, can anyone comment on what "life is like" when practicing in these states with independent practice? Do your hospitals still have stronger requirements than what the state may be? I'd like to know what life is on the ground level. TIA.

I don't practice in Utah. I work for the VA and they, generally, make their own guidelines. We are currently bound by our state guidelines if they are more restrictive than the VA guidelines but there are a couple of moves afoot to change that. For instance there is a claim under the supremacy act that the VA, as a federal institute, can make rules that supercede state requirements. I'm not sure that will gain traction. There is discussion of not having uniform rules for PAs but each of us working according to our states requirement and restrictions. If that were to become the case then those of us with fully autonomous licenses would, in essence, be independent practitioners. That was the drive behind my getting licensed in Utah.

[iconic]

Nothing is more absurd than PAs working at the same institution working under different rules based on the state of their licensure 

[CSCH]

Currently in med school, so I'm strapped in for the full ride.

I can say that there is absolutely no way that I would have signed up for a process that didn't get me the right to apply for the exact same residencies and fellowships any MD graduate can apply for. No way I would have signed up for a program where my PA training was treated a equivalent to an NP's training. Also no way I would accept some other random letters after my name. It's already political bullshit that there's still such a thing as a DO, and despite them getting the same exact training they're still second class citizens when it comes time to apply for residencies. MD or bust, I'm not hopping into the third class.

Finally, y'all got mad at me last time but I'm going to say it again. We shouldn't be doing anything that an NP would do, and we shouldn't be acting just with the motivation of beating the NPs at their own game. PA training is amazing but it is not equivalent to that of a physician, and years of practice don't make up for what happens in school, residency didactics, etc. Living under an attending's thumb for years is annoying but effective at molding real experts, and I'm not okay with my patients getting fully independent care from anyone who hasn't undergone that process. If you want to have doctor-level responsibilities, you need doctor-level training. I am very, very much in favor of making a better way for PAs to get into and through med school, but after that I want full equivalency.

[ventana]

10 hours ago, CSCH said:

Currently in med school, so I'm strapped in for the full ride.

I can say that there is absolutely no way that I would have signed up for a process that didn't get me the right to apply for the exact same residencies and fellowships any MD graduate can apply for. No way I would have signed up for a program where my PA training was treated a equivalent to an NP's training. Also no way I would accept some other random letters after my name. It's already political bullshit that there's still such a thing as a DO, and despite them getting the same exact training they're still second class citizens when it comes time to apply for residencies. MD or bust, I'm not hopping into the third class.

Finally, y'all got mad at me last time but I'm going to say it again. We shouldn't be doing anything that an NP would do, and we shouldn't be acting just with the motivation of beating the NPs at their own game. PA training is amazing but it is not equivalent to that of a physician, and years of practice don't make up for what happens in school, residency didactics, etc. Living under an attending's thumb for years is annoying but effective at molding real experts, and I'm not okay with my patients getting fully independent care from anyone who hasn't undergone that process. If you want to have doctor-level responsibilities, you need doctor-level training. I am very, very much in favor of making a better way for PAs to get into and through med school, but after that I want full equivalency.

yet another doc (wanna be to be) that thinks the only thing that matters is the MD after your name.  

Yes you came through the PA ranks but you clearly missed the boat.

Please show me even one valid study on PA that shows different outcomes?  crickets -  yup there is none.

I am a medical professional some 20+ years out of school.  I work besides wonderful docs, but I am totally responsible for my patients and I am comfortable with this.  (I am not comfortable with < 5 yr out PA's having this same freedom)  I will not go into the countless patients whom I have taken over from doc's over the years that were very poorly managed....

 

Once again by your logic only a cardiologist should treat HTN, only an GYN should do a pelvic...... and so on.  

WE ALL HAVE A PLACE at the table, and yes Docs get more education, but don't get such an inflated view of yourself that you think a PA can not manage a highly complex patient in the pcp realm.  (fyi I am Primary care and would want a boarded surgeon overseeing  my major surgery - not a PA).  

 

 

Congrats on Med school, but you still put pants on one leg at a time, and your poo still stinks just like everyone elses....

 

[rev ronin]

On 12/16/2023 at 5:18 AM, CSCH said:

Living under an attending's thumb for years is annoying but effective at molding real experts, and I'm not okay with my patients getting fully independent care from anyone who hasn't undergone that process. If you want to have doctor-level responsibilities, you need doctor-level training.

I think there's a false dichotomy here.

First, NO ONE is ever fully independent in medicine, and the ones who try to be are idiots. Even attendings who have been attendings for decades have friends to call, and their social networks take the place of formal supervisory relationships.  Each of us in medicine, from the CNA to the subspecialist full professor, should have a set of things we know "cold", another list of things we're quite familiar with, another of things we know a bit, and another of things we know we don't know. When we're asked to do or answer outside of our personal competencies, the most important medical skill for everyone is knowing who else to call.

Everyone has these lists of competencies and should mentally maintain theirs. I get patients referred to occ/family med for smoking cessation because surgeons won't touch it. Wait, aren't the surgeons higher up on the food chain? Sure they are, but it's not a matter of hierarchy, so much as it is a matter of what people do all day, every day. Using a board certified spine surgeon--or even a surgical PA--to manage smoking cessation as a barrier to curative surgery secondary to a workplace injury is a bad match: again, not because it's "beneath" them, but because surgeons don't develop relationships with patients the way that I, as a family medicine PA, love to.

Second, being a good scientist and being a good clinician are entirely separate things.  I'd add in a third one, which doesn't have a pithy term but involves being a good resource and risk manager. Going to medical school in America or Canada absolutely equips one to be among the best medical scientists in the world, especially with the relative ease one can get into fellowships and academic medicine compared to the rest of the world. If you look at SDN and other such places, you find there are a lot of presumably excellent medical scientists who are (or at least "behave like when essentially anonymous") reprehensible human beings, and the residency system is designed to bring out the trait of ambivalence towards patients in the name of logic and detachment.

It is a real possibility that medical school, through inflating ego and deflating compassion, can take a PA and make him or her a worse clinician and a better scientist at the same time. Make avoiding that your goal: remember that the best MDs are the ones who have all the science down but still see each patient as a human being rather than thinking of each as a disease process.

[sas5814]

On 12/6/2023 at 10:43 PM, iconic said:

Get the dinosaurs out of PA leadership. At this point I would prefer visionary nurses to lead our profession over SP-obsessed PAs

While I have been unplugged for a few years now I spent years in PA politics and policy at the state and national level. You might be surprised that the "dinosaurs" were the progenetors of title change and autonomy which are the 2 biggest changes to the profession in 30 years. The AAPA HOD, who screwed the pooch on title change, is mostly filled with young and mid term PAs.

We have, collectively as a profession, lacked long term vision and been mired in "everything is just fine" for as long as I can remember. There is plenty of responsibility to be spread throughout the generations.

[thinkertdm]

Last week I went to see my endocrinologist and saw a dnp.  There is an np at my va working solely in Pulmonology.  Pas have the knowledge base and ability to function as a medical provider.   Independently.  However, I also feel that in the grand scheme, pas have lost.  We have been relegated to “allied health personnel” and will never regain what we could have been.  Pas aren’t med school applicants, we are autonomous (or were) medical professionals.

i gladly would see an np or pa- and would prefer to see a pa over an md, even knowing they lack the extra training mds have.  There are many on this forum who I would have no problem sending my family members to.