The Politics of a Professional Name Change: Dave's Blog

[jmj11]

From Dave Mittman's Blog:

Too Many Unhappy PAs

 

Posted 20 hours, 39 minutes ago.

My thoughts below are not about a title change for PAs which I will again say is the single most important thing the PA profession must eventually do to elevate itself and its image. This blog is about thoughts on leadership and how the grassroots PA is represented. Please read on. Let me know if you agree.

My friend sent me a copy of the House of Delegate statements from the people running for House of Delegate seats from Florida for the upcoming AAPA conference. He warned me that it was already creating a “ruckus” with some Florida members. I wondered why before reading. As a HOD veteran of over 20 years representing NY, I thought I had seen it all. As I suspected the problem was that the people running for delegate seats were asked to answer a question about the “name change”. And yes, I was shocked. To read the platforms you would think there are two different PA professions. Maybe there are and its time to admit it? Or maybe there are the people who believe and the people that don’t believe and want to spread reasons that make little sense so that the problem with our name magically goes away. Problem is it won’t. Second problem is they are not representing the wishes of the PAs they hope to represent.

 

Last spring the AAPA census asked PAs in every state in the USA if their name (physician assistant) represented them. The majority of the PAs who answered each of the three choices they could choose (yes, no and unsure) answered that it did not. In Florida 50% answered that it did not and another 17% answered that they were unsure. So even if we split the unsure, that’s 58.5% of all PAs in Florida feeling that their name holds the profession back. In my book that wins the election. Even 50% does. Clearly anyway you spin it a considerable problem for the PAs in Florida and across America.

 

So this year when given a chance to think about those numbers when one read these delegate’s platform responses to the question “ Do you feel that the name change is an issue we should do something about?”; all seven people answered no. The fact that 100 long standing PA leaders asked the AAPA to do something about this problem years ago had no impact on the people running. More significantly, the fact that 6,500 PAs and PA students sent an email to the AAPA asking them to deal with this and it followed up by another leadership letter with the first PA General, the first PA Admiral, the FIRST PA EVER and many other dignitaries obviously did not matter at all. Even 50% of their state asking. A resounding “no”.

One would-be delegate said that “This alleged name change is just not worth it. We PAs are a dependent Team player with the physician and patient and these unhappy PAs should learn how to accept their profession and their professional title they earned.” Could someone really say that in public about thousands and thousands and thousands of PAs? Really......., 50% of the PAs in his own state who did the AAPA Census are just “unhappy”? The first PA to graduate from Duke. Unhappy I guess? And a PA Admiral and General, just plain unhappy folks? Many, many, many Paragon Award winners; unhappy. Former AAPA Presidents and chairpeople; unhappy? And poor me, past chapter president and “physician associate” graduate, PA Lifetime Achievement Award winner in two states-totally depressed? If that is really the case, we need more than what’s on the platform statements to fix the profession.We need a bunch of psych PAs fanning out across the nation. But we all know it is not the case. I shudder to think that people actually believe it is. Do you think so? The real unspoken problem is that the AAPA refuses to put an impartial board together to look at our title and the delegates refuse to ask them to, even though the PAs of America have asked them in a number of ways multiple times. Maybe it’s just easier, chalk it up to unhappiness. Maybe it will go away? Maybe we will all grow out of it?

Another would be delegate said “by changing the name, all states’ legislative bodies in the USA and the US Territories would have to agree on changing this name and then all would have to agree to change their statutes and policies. This would not only waste a lot time of the legislators but would also waste a lot of funds coming from the taxpayer to make this happen. Another reason is there has not been one poll that has represented every PA in the USA and US territories (whether they are a member of AAPA or not) to show that this name change is supported by the majority of PAs”. Wow, where did that come from? Really? How about the VA PAs agreeing on a title change or the PAs in New Mexico or Montana? Did we all agree to drop the apostrophe ‘s together at one time in every state? No. And now we worry about the huge amount of taxes it would take to change one word in a law? And by the way, just to set the record straight, we had a national poll; the 2012 AAPA census. The AAPA even left it open months longer than planned and you know what......more PAs said that their name did not represent their vision of the profession than any other choice. In NY, our largest state, 53% were pro name change 27% said no. In California, 57% were pro name change and 25% said don’t change. Add that to Florida’s 50% and 33 no and you have close to ONE QUARTER of the profession asking for change in only three states.

 

Another candidate said “Worst of all would be the prospect of opening up every state and federal statute pertaining to PAs and PA practice. The prospect of a name change has been so troublesome to the majority of us in the House of Delegates that we have repeatedly voted down any such measures. “

So the attitude seems to be, never mind what the nation’s PAs want. We have spent too much time on this already it’s not worth our trouble.

I find it amazing. Really I do. What I find most amazing is that not one out of the seven people running for delegate in Florida sided with the 50% of their constituents that want a change or at least want to see it fairly studied and reviewed. Remember that those 50% are the ones who still care. Add in all the others who won’t participate in the AAPA census. Those who feel they will never be heard. Those who have left the building for good. Equally amazing is that fellow PAs would dismiss the founding fathers and mothers of the PA world-people who have done so much and upon whose shoulders they stand as “unhappy people” when it is clear the profession has a problem that the MAJORITY of PAs passionately feel.

 

I know how important it is to listen to membership. Members are the blood, life and the future of any organization. We all know that. We all feel it. But sometimes leaders mean it when they say that members are important and sometimes they think they mean it. Silly me, I thought what people felt and were polled on should at least be respected. Maybe even paid attention to. It’s not just Florida that is turning their heads. It’s most of the delegates. Again, it’s not just Florida, please I do not mean to say that at all. If you are a delegate please listen. Too many people have spoken to dismiss them. And if you think they forgot they were dismissed, you are mistaken. In NY and in California almost six out of ten (and if you split the unsure voters) SEVEN OUT OF TEN PAs in their states voted pro-title change. Will their delegates be representing them? Seven out of ten? I don’t think those states will differ much from Florida. I guess some people would rather feel that we PAs are “unhappy” or troublemakers than admit that we represent real committed feelings their colleagues have. And people wonder why members stop joining. Remember, we never asked for a wholesale overnight change. We asked for a committee to study the problem. We asked for a plan to see how we could achieve this. We asked to be heard. Texas listened, AFPPA listened. We think we know how to neutralize the people who would oppose us, but then again, no one asked.

Wait, maybe we ARE unhappy..............

Or maybe just sad.

[jsfelder0417]

Thanks for the post. I really enjoyed it. Others have suggested a cosmetic name change, which would negate the need to reopen practice legislation, allowing one to use the title Physician Assistant and Physician Associate interchangeably. Sounds like a good route to me. Anyone else's thoughts? I don't have legal experience, so there may be some obstacles to that I am unaware of.

[Groovepie]

Great post Dave. I am a RN heading into PA school and I am honestly concerned about the future of the PA profession. I am shocked at the difference between how much the nursing associations advocate for the nursing profession while the AAPA gives their tacet approval to these types of measures. With the education changes the NP's are going through (DNP), at this rate the AAPA may agree to let them supervise PA's ;)-

[Acromion]

I agree the title Physician Assistant isn't a fair representation of our education and duties, but is the alternative any better?

 

The entire health care industry is undergoing a massive shake-up right now, and no one knows where the cards will fall. The only thing that everyone can agree on is that our health care spending is out of control and simply unsustainable. In the next few years we will see a massive influx of patients into the system from the opening of insurance exchanges and the expansion of Medicaid, not to mention the wave of boomers who are expected to bankrupt Medicare as early as 2018. The pressure to cut costs in the coming years will be intense and coming from all directions. Meanwhile, MD's and DO's have all but abandoned primary care, which is precisely the sector of health care that is most in need of providers, and it's the role we as PA's are naturally designed to fill. It won't be long before more people will realize that PA's can perform much of the same duties of MD's except cheaper. In this context, whether PA's are called Assistants or Associates may hardly matter.

 

We rely on the clout of the physician lobby and the NP's rely on the clout of the nursing lobby. No getting around that. If you attempt to change the name of the profession to "Associate," thereby insinuating a more equal footing with physicians, they may drop us like a hot potato. Words have meaning and the word "assistant" implies a dependent role, which to be fair, is what we are licensed to do. Are you willing to risk biting the hand that feeds you? I know it seems unfair and all, but that's the politics of it, that's how the hierarchy works. If you wish to upset that hierarchy, you need the power and influence (aka money) to do it.

 

Mittman, your support of NP's is noble and all - I like NP's too and I even see one - but the NP's are sitting pretty. They don't need our help, nor do they seem particularly interested in helping PAs. Why would they? Their practice model and their education model is at odds with ours. Their political allegiances are different. Now they are using the term NPP, non-physician provider. How convenient... it's NP with an extra "P." Even the post you commented on over at KevinMD by Dr. Leng seemed perfectly willing to leave PA's out of the "NPP" discussion.

 

A recent editorial in the New York Times about non-physician health care providers or NPPs, has drawn more than 260 comments. Who are these NPPs and why do so many people care about them?

Historically, nurses have a long history of stepping in when there are gaps. For example, in the early 1900s anesthesia was given by med students and interns and everybody was unhappy, until nurses started doing it full-time, and then the surgeons were much happier. When surgeons are happy, everyone is happy, I’ll tell you that for free.

Most of my readers don’t know this, but I was an advanced practice nurse before I went to medical school. I was one of these NPPs. The thing about nurse practitioners is that they are trained under a nursing model, not a medical one.

The message is clear, and I've seen this over and over, an NPP = NP. Leng's conflating non-physician provider with NP and omitting PA's is deliberate and political. Surely she knows what PA's are, but what is left unsaid is often more revealing than what is said.

 

Basically, I think you are taking the wrong strategy, in my opinion. The question in the upcoming years won't be whether or not there will be an expanded role for midlevels. That's been settled already. The question will be what midlevels will be employed for what jobs? Who is more efficient and who delivers the most bang for the buck? Will the DNP degree pay off in terms of real dollars? Can med schools continue to justify their exorbitant tuition? Will entrenched institutions be able to reorient themselves to the changing health care landscape? These questions will be closely scrutinized in the coming years, and if we play our cards right, I believe PA's will do just fine, but I have a hard time seeing how an expensive and cosmetic name change is the best strategy right now.

[physasst]

I agree the title Physician Assistant isn't a fair representation of our education and duties, but is the alternative any better?

 

The entire health care industry is undergoing a massive shake-up right now, and no one knows where the cards will fall. The only thing that everyone can agree on is that our health care spending is out of control and simply unsustainable. In the next few years we will see a massive influx of patients into the system from the opening of insurance exchanges and the expansion of Medicaid, not to mention the wave of boomers who are expected to bankrupt Medicare as early as 2018. The pressure to cut costs in the coming years will be intense and coming from all directions. Meanwhile, MD's and DO's have all but abandoned primary care, which is precisely the sector of health care that is most in need of providers, and it's the role we as PA's are naturally designed to fill. It won't be long before more people will realize that PA's can perform much of the same duties of MD's except cheaper. In this context, whether PA's are called Assistants or Associates may hardly matter.

 

We rely on the clout of the physician lobby and the NP's rely on the clout of the nursing lobby. No getting around that. If you attempt to change the name of the profession to "Associate," thereby insinuating a more equal footing with physicians, they may drop us like a hot potato. Words have meaning and the word "assistant" implies a dependent role, which to be fair, is what we are licensed to do. Are you willing to risk biting the hand that feeds you? I know it seems unfair and all, but that's the politics of it, that's how the hierarchy works. If you wish to upset that hierarchy, you need the power and influence (aka money) to do it.

 

Mittman, your support of NP's is noble and all - I like NP's too and I even see one - but the NP's are sitting pretty. They don't need our help, nor do they seem particularly interested in helping PAs. Why would they? Their practice model and their education model is at odds with ours. Their political allegiances are different. Now they are using the term NPP, non-physician provider. How convenient... it's NP with an extra "P." Even the post you commented on over at KevinMD by Dr. Leng seemed perfectly willing to leave PA's out of the "NPP" discussion.

 

A recent editorial in the New York Times about non-physician health care providers or NPPs, has drawn more than 260 comments. Who are these NPPs and why do so many people care about them?

Historically, nurses have a long history of stepping in when there are gaps. For example, in the early 1900s anesthesia was given by med students and interns and everybody was unhappy, until nurses started doing it full-time, and then the surgeons were much happier. When surgeons are happy, everyone is happy, I’ll tell you that for free.

 

Most of my readers don’t know this, but I was an advanced practice nurse before I went to medical school. I was one of these NPPs. The thing about nurse practitioners is that they are trained under a nursing model, not a medical one.

The message is clear, and I've seen this over and over, an NPP = NP. Leng's conflating non-physician provider with NP and omitting PA's is deliberate and political. Surely she knows what PA's are, but what is left unsaid is often more revealing than what is said.

 

Basically, I think you are taking the wrong strategy, in my opinion. The question in the upcoming years won't be whether or not there will be an expanded role for midlevels. That's been settled already. The question will be what midlevels will be employed for what jobs? Who is more efficient and who delivers the most bang for the buck? Will the DNP degree pay off in terms of real dollars? Can med schools continue to justify their exorbitant tuition? Will entrenched institutions be able to reorient themselves to the changing health care landscape? These questions will be closely scrutinized in the coming years, and if we play our cards right, I believe PA's will do just fine, but I have a hard time seeing how an expensive and cosmetic name change is the best strategy right now.

 

I tend to agree with some of your sentiments. I am a pretty ardent supporter of the name change and was blogging about it well before the recent name change committee and AAPA meeting. However, there are some realities that we must face.

 

Everything right now from a national level is focused on medical teams, interprofessionalism, and decreasing healthcare costs through better teamwork. I'm just starting to write up a theoretical ethnomethodological/phenomenological paper on the sociologic foundation of medical teams from a sociologic theory perspective. Hoping to use that as the foundation for a big RO1 to study medical teams in the field. We're going to examine terminology such as collaboration, autonomy, supervision, dependent provider etc. What do they mean in theory, and what do they mean in practice? We don't know this.

 

I look at RFPs every day. All of them are focused on research that lowers cost through better teamwork.

 

We are lacking so much data on the PA profession that it is scary. The NPs not only have the support of the nursing lobby, they are decades ahead of us in infiltrating research and administrative ranks. There are hundreds of highly trained nurse researchers across the country.

 

In fact, I was at a recent international research meeting in early December, and one of the other US attendees is a HIGHLY respected researcher in knowledge translation, who is invited to present all over the world, and when I mentioned her name to some of the big dogs here in research, they not only knew exactly who she was, they had nothing but the highest respect for her.

I didn't know it at first, but as we were talking about some collaboration....I found out that she was not only an RN, but an NP as well prior to completing her PhD. She doesn't even list it in her credentials, but if she is asked to advocate on a national level for a provider..which one will she advocate for?

 

Mary Mundinger along with other NPs have been elected as members to the IOM..the most prestigious honor you can have. We have had ONE, and only one PA who is an affiliate and serves on the Graduate Medical Education committee as a non-elected contributor. Numerous NPs have done and completed the prestigious Robert Wood Johnson Health Policy Fellowship in DC. We have had ONE PA do it....back in the 70's.

 

I hope people are starting to see the problem. The AHRQ steering council? Has a PharmD, a PT, and 2 nurses (one of whom is an NP).....but not a single PA.

 

THIS IS NOT solely because of the AAPA, although they have made their own mistakes over the years as well, for they are the ones that helped to get the one PA we have working with the IOM, they helped to sponsor the one PA who has done the RWJF fellowship....it's all of us......it is because we haven't had PAs completing PhDs and competing for these positions. We've done this to ourselves as a profession. We graduate a bunch of highly qualified clincians, who then go and excel clinically.....but we have ignored these other parts of the healthcare profession. We do have PAs completing PhDs....but almost all go into education.....

 

Is the name an issue? For sure....but I can think of a bunch of bigger problems that precede the name change. YMMV.

[Guest Paula]

@physst: I am looking forward to your research. Examining terminology is important and if you get a grant for the study it will be helpful (hopefully) and may change the whole picture of PA practice. I have often wondered if "supervision" matters, do PAs need to stay "dependent" and if so, why? NPs new terminology is Full Practice Authority..meaning they have full practice rights and authority over their profession with no physician boards intruding into their profession. Their terminology is now changing because of misunderstanding of the term "independent practice" and the move to "team based care" with the changes in our health care laws.

 

@Acromion: PAS indeed need to play their cards right. What strategy would you propose?

 

Words have meaning and consequences.

[jsfelder0417]

At the risk of oversimplification, Acromion, here is how I see it. Associate=Colleague giving comparable care. Assistant=Employee that finished a certificate program after high school and files charts. When I explained my educational goals to family members, they were floored that I needed to go to grad school to be the 'doctor's helper.'

[benny32311]

So, as a student, all I am getting out of this is that Assistant is demeaning and Associate indicates that we are at a level that we shouldn't be. Is there any other term?

[True Anomaly]

So, as a student, all I am getting out of this is that Assistant is demeaning and Associate indicates that we are at a level that we shouldn't be. Is there any other term?

 

How does "associate" indicate a level that we shouldn't be at?

 

Do you not see yourself as a future provider of care that is comparable to a physician?

 

If you don't see yourself as practicing medicine that is comparable to a physician, just what do you think you're going to be doing once you're a PA?

 

When you're listed in a malpractice suit, do you think they're going to compare you to just a PA or the "standard of care" that EVERYONE is expected to practice at?

[pct2010]

As a pre-PA student looking to apply this coming fall, I can't help but feel that sinking feeling in my stomach that the profession will not be able to keep up with the nursing lobby! It is the quintessential political problem thrown into medicine; the governing body fails to represent the will of its constituents. What keeps me up at night is the following:

1.) Will PAs eventually face competition from a hypothetical "NPA" (nurse practitioner's assistant).

2.) Will enough PAs (and MDs/DOs) get the courage and fortitute to launch an alternative to the AAPA; nobody likes a monopoly.

3.) How will the increasingly competitive PA model compare to the nursing model for future students. Go to PA school out of state, rack up debt, and slave to pay it off, or go to community college nursing school, work while doing NP school online, get same family practice job as PA for same pay.

 

I hope the profession I'm entering into will stand up and dust itself off, lest it become a doormat for everyone else in the medical field.

[LT_Oneal_PAC]

As a pre-PA student looking to apply this coming fall, I can't help but feel that sinking feeling in my stomach that the profession will not be able to keep up with the nursing lobby! It is the quintessential political problem thrown into medicine; the governing body fails to represent the will of its constituents. What keeps me up at night is the following:

1.) Will PAs eventually face competition from a hypothetical "NPA" (nurse practitioner's assistant).

2.) Will enough PAs (and MDs/DOs) get the courage and fortitute to launch an alternative to the AAPA; nobody likes a monopoly.

3.) How will the increasingly competitive PA model compare to the nursing model for future students. Go to PA school out of state, rack up debt, and slave to pay it off, or go to community college nursing school, work while doing NP school online, get same family practice job as PA for same pay.

 

I hope the profession I'm entering into will stand up and dust itself off, lest it become a doormat for everyone else in the medical field.

As a RN

 

1) The NPs themselves would have to create NPAs and they have far more pressing matters. Remember, NPs own their own business at the same percentage PAs do. Besides, they already have an NPA, it's called an RN.

 

2)we have an alternative called PAs for tomorrow (PAFT), join and tell others.

 

3) many will always prefer a science based curriculum. The real problem we have is people see "assistant" and think they can practice medicine without any real responsibility or liability.

 

The bigger problem is PAs competing in a market with NPs who will be hired by docs who THINK they have less liability collaborating with them and certainly have less paperwork to work collaborating with them than supervising us.

[benny32311]

How does "associate" indicate a level that we shouldn't be at?

 

Do you not see yourself as a future provider of care that is comparable to a physician?

 

If you don't see yourself as practicing medicine that is comparable to a physician, just what do you think you're going to be doing once you're a PA?

 

When you're listed in a malpractice suit, do you think they're going to compare you to just a PA or the "standard of care" that EVERYONE is expected to practice at?

 

In some ways yes and some ways no. I mean I can practice to what degree my supervising physician allows me. In that way I will never be "on their level" as they will be my supervisor, even if they give me free reign to do whatever I want/can. At least that is the way I see it. You have practiced, I haven't though, so you know more about it than I do.

 

To be honest the name thing doesn't really bother me, at all, assistant or associate. Will the name keep me from practicing medicine that is comparable to a physician? Probably not. The profession is already doing that with the title of physician assistant.

 

Just my $0.02

[jsfelder0417]

It won't stop you from practicing good medicine, but it can certainly hinder your upward progression. Another member, when opening a clinic of their own, as a Physician Assistant, was referred to the Medical Assistant board to seek approval. That is a stupid problem to have, but it is a problem, nonetheless. Supervised does not mean we are doormats. Don't sell yourself short. You've worked hard to get where you are and have an incredibly valuable skillset. You should be recognized for the same.

[physasst]

Well, we have to be careful here. As a PAFT Board of Advisors member, I see the organization not in competition with the AAPA, or as an "alternative" to the AAPA, but as a complement to the AAPA. In fact, we applied for, and received SIG status exactly for that reason.

 

The AAPA has done a lot of good for the profession over the decades. They respond to almost every issue, but they do so behind the scenes. One very legitimate criticism of the AAPA, is that they do not let the membership know about their advocacy work. Sometimes they cannot, policy issues sometimes dictate that deals or discussions with other groups remain confidential as not to inflame tensions further, but they still need to do more.

 

One suggestion I have made, and the leadership at the AAPA is aware, is why not develop a quarterly advocacy newsletter. Simple, could even be electronic to save on costs, and could be distributed to the members with a list of legislative issues and solutions, as well as advocacy efforts that the Academy is engaged in....

 

One of the reasons that we as a profession need to work together, is that in the policy arena, we are vastly outnumbered, and numbers count.

 

185k physical therapists, 225k pharmacists, 850k physicians, and finally, 2.5 million nurses. We just certified our 100k PA. We may think we have a great product, but we do not have the influence these other groups have.....

 

Two things, and ONLY two things influence legislative policy......1. Money...and 2. Votes. Physicians have the money and nurses have the votes....We have neither. Which means we must be as united as possible...Has the AAPA been perfect....nope, and I have several issues with them, but rather than simply turning our back on the Academy, a better solution is to try and change it from within.......That's my opinion at least.

 

Mike Halasy

[burnpac]

Well said Michael, and right on the money (no pun intended.... :-) ).

[andersenpa]

As a pre-PA student looking to apply this coming fall, I can't help but feel that sinking feeling in my stomach that the profession will not be able to keep up with the nursing lobby! It is the quintessential political problem thrown into medicine; the governing body fails to represent the will of its constituents. What keeps me up at night is the following:

1.) Will PAs eventually face competition from a hypothetical "NPA" (nurse practitioner's assistant).

2.) Will enough PAs (and MDs/DOs) get the courage and fortitute to launch an alternative to the AAPA; nobody likes a monopoly.

3.) How will the increasingly competitive PA model compare to the nursing model for future students. Go to PA school out of state, rack up debt, and slave to pay it off, or go to community college nursing school, work while doing NP school online, get same family practice job as PA for same pay.

 

I hope the profession I'm entering into will stand up and dust itself off, lest it become a doormat for everyone else in the medical field.

 

1. Not likely.

2. PAFT is an AAPA SIG, but in the case of the title change they are working in opposition to the AAPA HODs stance that the issue is not worthy of investigation. Suprisingly they have taken a philosophical view and not a representative one. After the last HOD result, I found that the delegates votes 1) are not strictly counted (a "aye/nay" vote takes place) and thus, 2) there is no record each delegate's vote. My delegate. Or yours. You have to contact them directly to ask how they voted. Again, no OFFICIAL RECORD. No accountability to see if they are representing the interests of their member PAs (as Dave said in his blog post on vote percentages). Oh, and they are only concerned with representing AAPA member PAs, not ALL PAs. The response to my questions about these issues with the HOD? "Vote them out, or run yourself" if you are unhappy. The system is flawed, and that burden is placed on the constituents. Diasappointing.

I am on the BOD of PAFT and encourage you to look at the website and mission/vision. We work to hear and represent ALL PAs.

 

3. While PA and NP share many similarities we are still miles apart in other ways. There will be progression towards standardized 4 year nursing degrees and doctorate PA programs. I wouldn't think that the longview of the DNP wil be an overall cheaper education.