"so, you are going to be a doctor?"

[andersenpa]

I understand, and we all understand... but it's so hard to get patients to understand that I even wish that there was some sort of "universal" pamphlet that we can hand out to identify our role in healthcare.

 

Again, I use the medical resident as an easy analogy because I feel that a resident is equivalent to a mid level practitioner until they graduate to attending. Of course there are senior and chief residents that may know more then some attending physicians, but that doesn't mean their role is any different, they still have to report to, and have an attending physician have the final say... where I see the same as a PA - even though after years of seasoning we can be more knowledgeable then Physicians, it still doesn't negate the fact that we are still mid-level practitioners regardless of our extensive training in a particular field.

 

So although after years of experience we develop a sense of autonomy and a respect from seasoned attendings, it doesn't make us autonomous - they still need to agree with out decisions.

 

There are two arguments against this:

 

1) As I mentioned earlier, our training is complete. To the patient, a resident's (even chief!) knowledge level is not fully established. To put PAs on that level implies a fact that simply isn't true. There are tons of PAs on this forum who can attest to that, including those that teach med students and residents.

 

2) Different practice environments have PAs making many decisions independently and without "clearance". The majority of my care in the ICU is performed without any discussion w/ the attendings; we notify them later of issues and handle it oursleves. There are many flavors to the SP-PA relationship, and lots of them don't have regular "clearance".

 

Enjoying the discussion..............

[Guest tmarkie]

I am also enjoying this discussion, but I'm starting to feel a little like a peeping tom (pun intended), so I thought I'd throw my .02 in. I can definitely see both sides of this PA is/isn't like a resident debate. For years, I have jokingly referred to myself as an eternal resident to some of the Orthopods I work with, but in reality I do a whole lot less "scut work" than any resident I know. However, the fact still remains that true residents will go on to become full fledged surgeons and no matter how much experience and expertise I gain, unless I go to Medical school and then residency, I will always be a PA - But that's OK with me, (most of the time).;)

(but I do like the analogy of resident better than NP)

 

Tom

[ssiegelpa]

I like both the NP and resident analogies. However, when making either analogy you must be able to tell the person you are talking to what the different is between a PA and NP or resident. I think it would be best to use one analogy, but make sure to add in that PA's are similar to them (whichever analogy you use) "except for...."

[Guest JDM ER PA]

There are two arguments against this:

 

1) As I mentioned earlier, our training is complete. To the patient, a resident's (even chief!) knowledge level is not fully established. To put PAs on that level implies a fact that simply isn't true. There are tons of PAs on this forum who can attest to that, including those that teach med students and residents.

 

2) Different practice environments have PAs making many decisions independently and without "clearance". The majority of my care in the ICU is performed without any discussion w/ the attendings; we notify them later of issues and handle it oursleves. There are many flavors to the SP-PA relationship, and lots of them don't have regular "clearance".

 

Enjoying the discussion..............

 

 

I disagree with both:

 

1. Our training is never complete. Medicine is a part of lifelong learning. I think it is unfortunate that you feel that PA school completes our training. Just because we can land a job immediately and do not have an "additional training phase" does not suggest that our training has ceased. I think you are not appreciating that I am comparing the "role" of a resident to a PA and not the lifestyle or level of training.

 

2. Supervision and Independence are 2 different words and 2 different concepts. I never said nor implied that every decision that a PA makes has to be "cleared" by an attending. Regardless, our work must be reviewed and signed off on at some point.

 

A PA is never truly autonomous, and for some strange reason I think you feel differently. I never implied that each decision made must be cleared by a physician and understand that we can see patients independently of a physician. Regardless, our work is still reviewed - whether before a final decision is made, or after our decision is made and followed through - and the physician's word/decision is final. In my work the level of "supervision" rests on the severity of the patient. Many patients can be discharged without a physician's approval, while other cases require review prior to beginning treatment or forming a plan.

[1ORTHOPA]

It's seems this question will always be asked, regardless of what any organization does for our profession. Anytime I get asked this question. I just tell them that I can do just about the same things that an MD can (meds, labs, tests, dx, etc.), except I can only assist on the surgeries and don't see any of the really complicated cases. This usually works for me, but you will always get those patients who "only want to be seen by a doctor", which I happily agree to because if they don't have any trust in my abilities, then I wouldn't want to treat them anyway. This whole NP vs. PA thing will never end either. I'm in Southern Califiornia, and from what I've seen and heard through my PA friends as well as some of the MD's that I know, a majority of the MD's feel more comfortable with a PA vs. a NP. I'm not trying to say that NP's are inferior to PA's, but one MD told me that NP's, regardless of their training/education, NP's will always have "that nurse tag" on them.

[EMEDPA]

"A PA is never truly autonomous, and for some strange reason I think you feel differently. I never implied that each decision made must be cleared by a physician and understand that we can see patients independently of a physician. Regardless, our work is still reviewed - whether before a final decision is made, or after our decision is made and followed through - and the physician's word/decision is final. In my work the level of "supervision" rests on the severity of the patient. Many patients can be discharged without a physician's approval, while other cases require review prior to beginning treatment or forming a plan."

 

true to some extent but some states allow for experienced pa's to have a lot less supervision. for instance I have to submit only 10% of my charts as chosen by me for review within 1 month so the vast majority of my pt care is never reviewed by an md and when it is it happens days to weeks later. some states have no chart review requirement at all. in north carolina a pa has to meet with his sp for 30 min every 6 months to "discuss their practice".

[Croooz]

EMED,

What do the majority of PA's do? No sense in pointing out the exceptions when the majority of PA's, I suspect, are less than senior providers.

"A PA is never truly autonomous, and for some strange reason I think you feel differently. I never implied that each decision made must be cleared by a physician and understand that we can see patients independently of a physician. Regardless, our work is still reviewed - whether before a final decision is made, or after our decision is made and followed through - and the physician's word/decision is final. In my work the level of "supervision" rests on the severity of the patient. Many patients can be discharged without a physician's approval, while other cases require review prior to beginning treatment or forming a plan."

 

true to some extent but some states allow for experienced pa's to have a lot less supervision. for instance I have to submit only 10% of my charts as chosen by me for review within 1 month so the vast majority of my pt care is never reviewed by an md and when it is it happens days to weeks later. some states have no chart review requirement at all. in north carolina a pa has to meet with his sp for 30 min every 6 months to "discuss their practice".

[Guest JDM ER PA]

true to some extent but some states allow for experienced pa's to have a lot less supervision. for instance I have to submit only 10% of my charts as chosen by me for review within 1 month so the vast majority of my pt care is never reviewed by an md and when it is it happens days to weeks later. some states have no chart review requirement at all. in north carolina a pa has to meet with his sp for 30 min every 6 months to "discuss their practice".

 

 

Then I must have a real misconception as to how the rest of the country works. In the north east this is a very collaborative process with the SP.

[JenGintheED]

The trend is away from state legislatures defining the PA/SP relationship, in favor of the parties deciding what is appropriate for them. In AZ (not where EMED is) we have no chart review and a weekly "discussion" with the SP. The board is working to change that to a monthly "discussion". As a new grad I'm on a shorter leash than the minimum supervision requirements, but my more experienced colleagues are granted more autonomy, as they deserve & the SP is comfortable with. It is still a collaborative practice environment, though.

[Guest lisnek]

I never get asked this question. I say who I am, that I work with their surgeon, and that's the end of it. Perhaps being in a surgical specialty, the patients see what I do, hands on every day, so there's no confusion as to the role. We practice medicine. We take care of them.

 

Although the training is different, we practice the same medicine the docs do- except in the decision to operate and the technical duties in the OR- different. To say we practice medicine to a lesser or similar degree is misinformation; it's the same!

 

as you know, i just started as a uro PA - i suggested the use of bactrim for a skin infx (vs. keflex d/t incr resistance and MRSA) and the SP looked at me weird and said, "is that a PA school thing?" i almost died - i NEVER have a problem with a comeback (EMED knows that is quite true-lol), but this time i was left speechless....i mean we don't have different pharmacology/medicine than MDs. i was so pissed! it is comments like that that will dissolve our relationship as PA and Physician. i won't stick around for any amount of $$$$ to deal with comments like that.

 

these first few mos have been hard in so many ways. a trauma attending told me once when he found out i was leaving to become a PA, "you don't have the personality for a PA." i think he was right. control? prestige? i don't know what i want but i sure know i don't want comments like, "is that a PA school thing?"

 

a question for us to discuss - does it take a certain personality (and i don't mean compassion, cultural sensitivity, etc) to become a PA vs. and MD? i think that is what i am struggling with....

[caldje]

in ohio there are no chart cosignature requirements anymore either. I agree with laughing. the TREND is that as the laws change they will change like ohio's did. Let the SP and PA what the best arrangement is for their own practice. You have two trained and licensed individuals who we have to trust to some extent to stay within their scope.

 

Crooz- you'd be surprised at how autonomously GOOD PAs are. The only thing is with PAs you have someone keeping the bad ones from doing too much harm. The bad MDs do all the harm they want until they lose their license. I think it is very prudent to point out the variations of PA practice just like one would point out the variations in MD practice. The majority of PAs do what they and their SP are comfortable with and are within state law. In many states that is zero chart cosignature and most of the others only chart cosignature when sch 2 drugs are written or on minimal charts.

 

chris

[Guest docmartin]

The fact is, though, to get the degree and MD does not have to go through residency.

 

Degree by itself is worthless. You can not find a job working as a doctor without a residency.

 

There are jobs out there for MDs who don't have residencies.

 

Not as a doctor, there arent. Yes there are a very few jobs such as consultants that are open to MDs without residencies. Simply put, no residency = no doctor. You are something else if you choose to work as a consultant without going thru residency.

 

I won't even get into the forth year. It has been the best year of all of my friend's lives who went to medical school. Mostly because it is fun and easy.

 

Med student rotations/electives in the 4th year are the same as PA students, they just dont have a structured schedule. YOu make it sound like people are taking off the entire 4th year for an extended vacation, but thats not what happens. AT most you might take off a couple of months out of the the year to go on residency interviews, but the rest of the time you are in electives and working just as hard as a PA student would on his clinical rotations.

 

I am glad you agree "90%" of NPs dont practice independently. Now when are you going to agree about the other 9%. Why do NPs CHOOSE to practice collaboratively when the salary figures show that NPs in private practice make much more money. Why do you lump all states together? In my state the laws are very clear that NPs are not independent and that is the way it is in MOST states. I have personally read the BONs laws in the states that do allow "independence" and every single one of those states has stipulations that include a physician's approval, consultation, and mentoring. There are PLENTY of things stopping them from being independent. plenty.

 

Thats flat out wrong. Some states do have "collaboration" regs for NPs, but many do not. As I said before, the reason 90% of NPs choose a group practice with MD collaboration is because its much easier to get a job that way than it is to take out a business loan and start up your own clinic. 90% of small businesses, including clinics, fail. Thats the ONLY reason why most NPs choose not to open solo clinics. Solo clinics are a lot more headache and responsibility and are much riskier than joining an already established practice.

[caldje]

Unfortunantly I just don't have the time to RE-DO the research I have already done. I have too many more important things to do but you should really research your opinion before speaking so strongly about what "simply isn't true." This one was easy to look up again so I'll just go ahead and show you one place you are wrong.

 

"Between 2003 and 2005, the percentage of nurse practitioners who identified themselves as practice owners doubled from 1% to 2% of survey respondents." http://nurse-practitioners.advanceweb.com/common/editorial/editorial.aspx?CC=65135

 

So I really wish you would at least let this 90% number go. As for going through the state nursing acts again and showing you where each state requires clearance and supervision from a physician PRIOR to allowing "independent" NP practice I simply don't have the time.

 

With regards to the med school thing. Neither of us have been to med school (yet). So I am not going to continue that discussion. I just know how many times I would go out for beers with my 4th year friends or be studying while they laughed at me and said "im in 4th year." Thats all Ive got and its not worth arguing with you over.

 

chris

 

 

Degree by itself is worthless. You can not find a job working as a doctor without a residency.

Not as a doctor, there arent. Yes there are a very few jobs such as consultants that are open to MDs without residencies. Simply put, no residency = no doctor. You are something else if you choose to work as a consultant without going thru residency.

Med student rotations/electives in the 4th year are the same as PA students, they just dont have a structured schedule. YOu make it sound like people are taking off the entire 4th year for an extended vacation, but thats not what happens. AT most you might take off a couple of months out of the the year to go on residency interviews, but the rest of the time you are in electives and working just as hard as a PA student would on his clinical rotations.

Thats flat out wrong. Some states do have "collaboration" regs for NPs, but many do not. As I said before, the reason 90% of NPs choose a group practice with MD collaboration is because its much easier to get a job that way than it is to take out a business loan and start up your own clinic. 90% of small businesses, including clinics, fail. Thats the ONLY reason why most NPs choose not to open solo clinics. Solo clinics are a lot more headache and responsibility and are much riskier than joining an already established practice.

[EMEDPA]

EMED,

What do the majority of PA's do? No sense in pointing out the exceptions when the majority of PA's, I suspect, are less than senior providers.

 

crooz- in my state the majority of pa's fall under the 10% of charts rule. to get this you have to have the same sp for 6 months. anytime you get a new sp who has never been an sp before the oversight requirement is:

50% for 3 months

30% for 2 months

20% for 2 months

10% thereafter

 

as an experienced pa if you switch to an sp who has been an sp before it stays at 10%

what sucks is if you get a new sp who has never done it before. then you have to start at 50% again. this happened to me a while ago when my sp quit to take a job overseas.

[EMEDPA]

as you know, i just started as a uro PA - i suggested the use of bactrim for a skin infx (vs. keflex d/t incr resistance and MRSA) and the SP looked at me weird and said, "is that a PA school thing?" i almost died - i NEVER have a problem with a comeback (EMED knows that is quite true-lol), but this time i was left speechless....i mean we don't have different pharmacology/medicine than MDs. i was so pissed! it is comments like that that will dissolve our relationship as PA and Physician. i won't stick around for any amount of $$$$ to deal with comments like that.

 

these first few mos have been hard in so many ways. a trauma attending told me once when he found out i was leaving to become a PA, "you don't have the personality for a PA." i think he was right. control? prestige? i don't know what i want but i sure know i don't want comments like, "is that a PA school thing?"

 

a question for us to discuss - does it take a certain personality (and i don't mean compassion, cultural sensitivity, etc) to become a PA vs. and MD? i think that is what i am struggling with....

 

that really sucks. I'm sorry.

next time tell him "no it's a mrsa drug resistance thing".all of the I.D. docs in our area would back you on the septra call. maybe you could suggest he calls one next time he gets snippity.....

if you get too burnt out doing uro remember we might have a spot for you at some point...-e

[jmj11]

I'm sorry to come into these discussions late (been busy and power has been off at home -thus no Internet-for almost a week) and try to make an intelligent comment (without reading the old posts) and without saying something that someone else hasn't already said.

 

I think there is a different personality between MDs and PAs in a vague and sterotyping kind of way. There are plenty of really nice people who have goine to medical school. I could name about 10 docs who are some of the nicests, most humble people I've known. However, I have noticed a general real difference.

 

I have noticed this the most when (several years in a row) I went directly from the AAPA cme conference to a major subspeciality conference attended by 500 MDs and about 3 PAs.

 

I don't know if med school teaches you to be an insecure narcistic person or it attracts them. But when I have hung out with only MDs, there is this strong tendency for all the docs to dress really nice (try to impress each other), compare notes of who has the most money, who's written the most papers, who has the best kids, biggest homes, biggest boats etc. To someone from another planet they would seem like a very insecure (but bright) group of people.

 

When I hang out with PAs, they seem like real people (and also bright). Most are very nice. They have lives outside of medicine. They don't have to constantly put others down and brag about their accomplishments (there are exceptions to this rule).

 

That's what I've noticed.

 

Mike

[MadelinePAC]

For you all that have no or little chart review:

 

Do some insurance providers require more supervision than state law? Do any require co-signature for re-imbursement. In PA we still have 100% chart signature and insureres don't even ackowledge us, except medicare. All services rendered by us goes in under the Docs name. I was always curious about insureres in other states. What percent of the dcotor bill do they reimburse at (80% for medicare)

[caldje]

good question, and I (obviously) dont have the "answer." BUT, I can say that this has been discussed within the OAPA in ohio because it seems insurance reimbursement by ohio companies for PA services that dont have cosignature will at best cause controversy. It is possible that state law will override this issue but it is certainly as concern. MOSTLY in inpatient settings where acute patients are being seen by PAs and the chart is not being signed by an MD. but its already started happening so I'll keep an eye out when the first audit happens and PAs and their SPs get in trouble.

 

chris

 

For you all that have no or little chart review:

 

Do some insurance providers require more supervision than state law? Do any require co-signature for re-imbursement. In PA we still have 100% chart signature and insureres don't even ackowledge us, except medicare. All services rendered by us goes in under the Docs name. I was always curious about insureres in other states. What percent of the dcotor bill do they reimburse at (80% for medicare)

[tool man]

Lisnek,

Don't go by what you were taught in school. Don't go by what you heard on rotations. Generally, go right to Sanford's. It gives 1st, 2nd, 3rd choice of drugs. If someone gives you sh*t...tell em to look it up in Sanford's themselves. That usually shuts people up.

 

Exception is if you know your SP prefers one drug or another for common things, I always tailor which drugs I write for by which doc is going to review the chart. One doc I work with doesn't like Hydralazine, the other doc likes hydralazine.

 

If you're like some people here who get 1 out of 10 charts reviewed, then just go by Sanford's and it would be pretty easy to defend your position if you were every named in a law suit.

[bsady]

There is another thread that is talking about starting a new organization to address exactly what this thread is talking about. A lack of PA promotion and marketing. Check out "A modest proposal"

[andersenpa]

JDM- I think our difference in opinion has to do with the fact that I am talking about patient perception, not preception amongst ourselves as PAs. PAs are boarded pracitioners who have demonstrated a knowledge base in order to practice medicine. Residents have not completed their licensing exams (for the most part) and, in common knowledge- patient perception- not through with the educaiton process of becoming a practitioner.

 

I never indicated that PAs don't participate in a lifelong learning process; we all do, whether you're a PA, MD, police officer or dairy farmer.

 

I am appreciating your comparison of the role of a resident and PA; that's the basis of my disagrement. As a few others have posted before me, the degree of oversight/review/supervision is extremely limited for many PAs, with only a fraction of work being "signed off"- this speaks to their competency; MD residents are still in the process of proving their competency.

 

 

Regarding autonomy- this word requires interpretation. There are degrees of autonomy, and many PAs are highly autonomous while remaining dependent practitioners. Ask EMEDPA about remote site solo coverage. Autonomy in decision making vs. autonomy in licensure are two different things.

 

You will probably see on this forum that alot of the clinical decision made by PAs here is never seen by an SP.

 

The highly variable world of PA practice leads to many different takes on how we each work....

 

 

I disagree with both:

 

1. Our training is never complete. Medicine is a part of lifelong learning. I think it is unfortunate that you feel that PA school completes our training. Just because we can land a job immediately and do not have an "additional training phase" does not suggest that our training has ceased. I think you are not appreciating that I am comparing the "role" of a resident to a PA and not the lifestyle or level of training.

 

2. Supervision and Independence are 2 different words and 2 different concepts. I never said nor implied that every decision that a PA makes has to be "cleared" by an attending. Regardless, our work must be reviewed and signed off on at some point.

 

A PA is never truly autonomous, and for some strange reason I think you feel differently. I never implied that each decision made must be cleared by a physician and understand that we can see patients independently of a physician. Regardless, our work is still reviewed - whether before a final decision is made, or after our decision is made and followed through - and the physician's word/decision is final. In my work the level of "supervision" rests on the severity of the patient. Many patients can be discharged without a physician's approval, while other cases require review prior to beginning treatment or forming a plan.

[Guest JDM ER PA]

I better understand your thoughts now, thank you.

 

Rather then discussing this further, because it really could be more constructive, why don't we utilize this thread to create a "script"?

 

We could make a universal script that people can use, and continuously critique, so that that we are defining ourselves similarly.

 

And in doing that, make no comparisons to other practitioners.

[JenGintheED]

I better understand your thoughts now, thank you.

 

Rather then discussing this further, because it really could be more constructive, why don't we utilize this thread to create a "script"?

 

We could make a universal script that people can use, and continuously critique, so that that we are defining ourselves similarly.

 

And in doing that, make no comparisons to other practitioners.

 

I like that idea... and submit this from my earlier post, for your critique:

• PAs take the same classes as physicians, just not to the same depth of detail
  
• PA school is master's level and medical school is doctoral level (I say I have a master's in medicine, but not all PAs have masters degrees... even though the ARC-PA acknowledges that despite different degree levels, all PA education is graduate-level)
  
• after graduation, PAs work in partnership with physicians (encompasses the broad variety of autonomy between PA/SP pairs)

[Guest JDollison]

So as you can see there really is no 1 line answer to what we do exactly, which is frustrating for people who don't know anything about the profession, but true nonetheless

[Guest lisnek]

I like that idea... and submit this from my earlier post, for your critique:

• PAs take the same classes as physicians, just not to the same depth of detail
  
• PA school is master's level and medical school is doctoral level (I say I have a master's in medicine, but not all PAs have masters degrees... even though the ARC-PA acknowledges that despite different degree levels, all PA education is graduate-level)
  
• after graduation, PAs work in partnership with physicians (encompasses the broad variety of autonomy between PA/SP pairs)

 

why do so many of our "descriptions" say SUPERVISED, rather than PARTNERSHIP then?

 

i personally love your succint description and that is the one i have been using - however, in truth - i think supervision is more accurate (at least in written descriptions of our profession).