The Kentucky Battle - - - What's Your Thoughts?

[jmj11]

I have a sore spot in my heart for Kentucky. I graduated from UK and the state laws then were horrible and the medical culture in the early 1980s were bad. After 9 months I was the third person in my class to get a real PA job and I had to go out of state to do it.

 

Now there is a big battle to overturn a law that says a new PA graduate must work on the same site as the SP for the first 18 months. As I read this law I question if that is where we need to focus our energy. In my honest opinion, I didn't know crap when I finished PA school. I think a new PA needs at least 12 months of working side by side with the MD before sprouting their wings. What do you think?

[LT_Oneal_PAC]

I think a appropriately trained PA should not need 12 months. Does this mean no new grad needs it, no. I really think it should be up to the SP. I would think the best way to make this decision is to look at KY compared to other states and see if their is any change is lawsuits or MM. I bet there isn't.

[akdEM]

I think you're right, jmj, to say that any new grad needs extra supervision for the first few months. I think the problem lies in the fact that they completely overrule the SP by having this strict 18 month rule. Like Oneal said, I think the goal is more to let the SP decide how much and how quickly he or she wants to let the PA do. It makes PAs almost unemployable when the alternative is for the doc to just hire an NP who can do just about anything they want in this state. The only other state that has something similar, I believe, is Colorado with a 6 month rule. That's much more reasonable than a year and a half.

 

As for having bigger fish to fry... you aren't kidding. There is such a long way to go in this state, but they had to start somewhere. They had been trying to get bills passed for several years now that included things like the chart co-signature rules, narc rxs, SP to PA ratios, etc... and they always failed. The plan now is to just go for 1 thing each year, and I think they saw this as one of the easiest targets since no other state has a law this severe. It's going to take a major change in the culture and ideas that people have about PAs in this state. The KMA is populated with old school docs who hate PAs, the NPs are entrenched, and most people don't even know what a PA is.

 

As a UK student, I've had the opportunity to be involved in a lot of this first hand, and I can tell you that there are some very passionate and well organized people heading this effort. I get the impression that that has not always been the case. Things are changing, but just like everything in this state, it takes way too long.

 

There is a lot I love about this state (I just moved here for school 2 years ago), but I don't blame you for having to get out. Even if this law passes, the general attitude toward PAs is pretty bad. I don't see myself finding the kind of job that I want here, unfortunately.

[rev ronin]

As a new grad, I love the fact that in my first job I'm never without at least 5-6 MDs and 0-2 other PAs in my office at any given time, as well as 20+ other ARNPs, MDs, DOs, and PAs elsewhere in primary care in the same building and probably another 40+ in specialty practice.

[EMEDPA]

Rev- I had a similar setup. my first job was at a place with an md residency. my sp was the residency director. he treated me like an intern, then a pgy-2 the next yr, etc

[andersenpa]

Supervision should be determined at the practice level.

[rcdavis]

Rev- I had a similar setup. my first job was at a place with an md residency. my sp was the residency director. he treated me like an intern, then a pgy-2 the next yr, etc

 

Eric,

 

Same here.

 

When I got out of school, my mentor, Jim Stewart ( who lives in your neck of the woods), felt that there is a huge difference between student and independent practice...

So he set up a system where I would rotate through Surgery, OBGYN, Peds, and IM for three months, as a practicing clinician... Taking call, working side by side with the attendings, attending conferences, seeing and carrying my own patients in the OP clinics, and rounding and partaking in the care of inpatients... Just as if I were to be a permanent member of the department ( this was a hospital based practice, where all departments also had outpatient clinics)

 

He figured that this year would "round out the rough edges" .. And fill (what were larger than I thought possible) knowledge gaps.

 

Also( and this was key), would inculcate the attendings with a more direct impression of PAs in general, and me specifically. So that when I called them from the ED, they had a known commodity on the phone.

 

Doing this took from being what I had thought was pretty good to "acceptable" in the staff's opinion.. And truly set me up for sucess in the ED.

 

I am forever grateful to him for that, and count whatever sucess I have had in my career as a direct result of his vision.

[ventana]

Supervision should be determined at the practice level.

 

 

I share a different opinion and probably not a popular one

 

As new grads you don't realize what you don't know, you can get a good hx and PE but really are no where near being independent on daily routine stuff.

 

The world is a changing, and I honestly believe we should ALL have to do an internship - just like the doc's have the intern year to burn in the knowledge and see what healthly and sick is, we should have the same thing. Not sure how long this would be or what the requirements would be, but certainly rotating through ICU, Ortho/Med floors, ER and out patients only makes sense - 9 months in a set rotation then 3 months in an elective where you want to work....

 

 

This is my logic

 

As a new grad you really have book knowledge and no practical knowledge, the ever increasing specialization of medicine means that the general public rightfully expects a certain level of competence from their provider, we are trying to advance PA's towards a more independent collaborative agreement at the same time as the average age of PA new grads is decreasing along with the number of hours HCE.

 

A one year internship would very effectively raise the experience bar a significant amount (how many doc's have been burned by hiring a new grad not realizing how much training they will take) as well as provide a one year, get your feet wet and try some different jobs with out having to actually get different jobs. It also would put big pressure on the NP's to up their game (so to speak) as we would then have formal additional training.

 

The medical world is changing and we need to lead the changes - we are not going to do that in the DNP realm or the doctorate level, but lets do it from the true "I have better training level" and help grease the wheels of change for future generations of PA's by allowing a year of practicing clinical medicine to be part of their training.

 

 

 

Just so everyone is aware - it used to be some of the doc's did not have to do an internal medicine year - ie radiology and pathology and I think even psych, but that has all changed and my understanding is that just about everyone now has to do an Internship....... why not ride this wave?

 

 

 

 

Proposal:

 

1 year Internship

Rotate through different areas to gain basic working knowledge - is surgery, ortho, medicine, peds, then shorter rotations at radiology(who can really read a ct or MRI as a new grad?), psych, pain management with the final 3 months to e done in the speciality of the PA's choice.

Pay would be about $50k/year

CAQ testing would be offered and encouraged in the field you are entering (that means CAQ's needed for more specialities)

 

 

 

 

 

 

 

Advantages to the PA:

structured on the job learning for a year

networking to get a job

experience in the sub specialties (which by the way if you don't get in school you will never ever get again)

time to grow (average age of the new grads is getting younger and younger) in a supervised environment

 

Advantages to the system:

steady flow of cheap labor in the local hospitals

smaller non teaching hospitals will LOVE it- and provides a huge foot in the door

"raises the bar" on the experience level of PA's

Advances PA's in the future by mirroring "medical education" - 'hey we do an intern year too"

Allows for CAQ testing and this is what insurance companies are going to mandate (cats out of the bag on that one)

Places us clearly above the skill set of the new grad DNP

 

Disadvantages:

Pay - $50k for first year instead of $80-90k (heck just 10 years ago I made only $57k my first year)

Longer hours of work - no cushy 35 hour derm job till > 1 yr after graduation (still on 28 month school + 12 m = 40 months till you get a real job)

creates a whole new level of AAPA/NCCPA/ARC-PA politics - and we have enough of that already

Would be a more difficult year for a non-traditional student then just going to work - FYI the 35yr old Army medic going to PA school is a disappearing breed already anyways

Does add one year of training onto the us.

[rcdavis]

Ventana,

 

I think we are saying the same thing. I can tell you from personal experience and by comparing the level of competence I was able to demonstrate, pretty much across that board, after that year, that doing a year "internship" was, is, will be a career changing event.

[Medic207]

Supervision should be determined at the practice level.

 

I agree

Once again why do we want to regulate ourselves into oblivion?

[Just Steve]

We want to lessen restrictions for PA supervision, we cast our votes in efforts to be more competitive with other advance practice providers, but then restrict ourselves in the very thing that we crave?

 

I understand I don't know squat. A good mentor is critical. But I bet dollars to donuts that there are senior PAs who could mentor as well as a doc for most cases.

 

Here is what I worry about... We try to push an agenda for more independent practice rights but then resist the movement in Kentucky. This sends a message of disorganized, competing views to congress, like we, as an organization, still can't figure out what we want.

 

A MD wants another provider. They can hire a PA and see a dip in productivity or uptick in work hours as they train this person, or they can hire a NP and let them practice on their own license. Not that tough of a choice.

 

I hope to God that I don't get stuck with 18 months of hand holding. Sure, I appreciate an ear to chew on once in awhile but a year and a half of microscope work conditions? Oooph

[akdEM]

To me, this is not even about having the supervision or not. I absolutely want someone there to help me out anytime I need it, especially as a new grad. Whether supervision should be there or not isn't in question.

 

Having the state mandate a 1.5 year period where you can't so much as refill a blood pressure prescription while the doc is at lunch is the problem. If they want to ensure safety, there are more subtle ways to do it than this blanket approach. It also needs to involve the NPs if PAs aren't to get completely pushed out of the market here.

[cinntsp]

I think you're right, jmj, to say that any new grad needs extra supervision for the first few months. I think the problem lies in the fact that they completely overrule the SP by having this strict 18 month rule. Like Oneal said, I think the goal is more to let the SP decide how much and how quickly he or she wants to let the PA do. It makes PAs almost unemployable when the alternative is for the doc to just hire an NP who can do just about anything they want in this state. The only other state that has something similar, I believe, is Colorado with a 6 month rule. That's much more reasonable than a year and a half.

 

It's totally unreasonable if not required for NPs as well. I think andersen's comment that supervision should be determined at the practice level is the correct one. If we're worried about "you don't know what you don't know" then perhaps there should be more emphasis in PA school on the 'when' to ask for help. Several in this thread seem bent on providing even more unnecessary regulation to this profession--something many are working to break free from.

[jmj11]

I certaintly understand the concern about regulations or over regulations. I'm not sure state laws are the way to go either, however, I'm not sure I would spend a lot of resources over-turning the law when, I think there are more important fish to fry. From what I understand, it is simply a requirement against PAs working in an independent setting. Twelve months would be more reasonable.

 

With that said, here is my point. I think our approach should be rational in all areas if we are to be taken seriously. I hear NP (and sometimes PA) chatter about how they come out of PA/NP school "better" prepared than MDs/DOs. That is just silly. PA school gives a good foundation and that is all it is meant to do. The real learning comes when you see patients daily with a great mentor for a signficant period of time. Even MDs go through a powerful learning curve despite having a residency under their belts and we have all witinessed that (new physicians who lacked in clinical skills and judgement).

 

So, as this rational approache continues to the other end, there is no reason that a well-seasoned PA can't perform at the same level as a physican with years under their belts and the regulations should reflect that. But if they believe our arugements on the experience end, we have to rational on the new PA end.

[andersenpa]

Let's get real- the KY law as it stands is a straitjacket applied by the state medical society. The evidence of safe PA practice with supervision applied when needed by the SP is abundant. It works. PAs are safe providers.

 

We all need mentorship in our formative yrs. The average BC/fellowed MD leans on his/her physician partners in the early years. Anyone can be smart, but experience takes time. PAs are the same.

 

A mandatory postgraduate training period is a restriction that is not unversally necessary. As contrarian said, the first yr IS residency....some are just better than ohters, depending on the doc you work with.

 

Perhaps instead of mandating more training we should be building stronger collegial ties with physicians at the student/postgrad level. This means keeping PA programs housed in SOMs so MSs are exposed to PAs from the beginning and learn how to have a productive symbiotic relationship. Incorporate PA students into more intense, QUALITY clinical rotations. Some rotations are garbage and don't serve ANYONE (the student, the program, the profession).

Better early training and physician relationships will reap more benefit than requiring duplicative training that doesn't pay well.

 

I completed a residency and support it 100%....and they should be encouraged for the specialty focus that is absent in general PA education. But repeating the PAS-II year seems a bit much.

[Contrarian]

At my FIRST job out of PA school, during interviews (6 with this practice in total), I made it clear that I didn't know schitte... and expected a structured learning period during the first yr.

 

They agreed and it started out that way but we soon fell into the productivity trap.

 

At my 6 month eval conference, I re-iterated OUR agreement for structured mentorship and threatened to quit...!!!

 

A week later, this group of 7 cardiologists assigned me a single inteventional cardiologist as my primary supervisor, then he and I agreed to cover the bible of Cardiology (Mayo Clinic Cardiology Review) from front cover to back cover.

 

From that point on... for the next year... EVERY friday from 0730-->0830... both our schedules was blocked and we would discuss/debate my under/overstanding of the weekly assigned chapters in that Cardiology Board Review Treatise.

 

THAT was MY "internship"...

 

I got it because I "knew what I didn't know" and threatened to quit if they didn't invest the effort in me and my education.''

 

So TO ME... the first job out of school IS the "internship."

 

Making some un-enforceable law to try to ensure this is folly and only restrictive to PAs as a whole... as a profession.

 

Internships are in the best interest of New Grad and Experienced PAs changing Fields but should remain optional and practice centric and based upon the assessment of the PA and SPs ...

 

NOT some arbitrarily dictated standard that does not take ino account the proficiency of individual PA-Cs and the assessment of their SPs.

 

Just My experience and NSHO...

 

YMMV

 

Contrarian

[EMEDPA]

the problem is the vast majority of sp's don't want to invest that much time and effort in a new pa. they want someone to move the meat and make them money so although you and I had great first jobs (long ago) this is not that common anymore.

[Contrarian]

So then the answer seems to be to STOP admitting and graduating inexperienced KIDS...

Who have NO experience providing care in positions of responsibility... and therefore have NO grounding in what is required and needed to know.

 

NOT... place restrictive laws on our WHOLE profession that will affect us ALL....!!!!

[rcdavis]

So then the answer seems to be to STOP admitting and graduating inexperienced KIDS...

Who have NO experience providing care in positions of responsibility... and therefore have NO grounding in what is required and needed to know....!!!!

 

bravo Zulu!

[EMEDPA]

So then the answer seems to be to STOP admitting and graduating inexperienced KIDS...

Who have NO experience providing care in positions of responsibility... and therefore have NO grounding in what is required and needed to know.

 

NOT... place restrictive laws on our WHOLE profession that will affect us ALL....!!!!

no argument from me.

[Teasip]

Who says that they have to be "KIDS" (look at the number of second career adults who go into medicine with they're only medical background having been in watching the delivery of, or having given birth to their kids)? Heck, I was one of the younger students in my class back in '81 yet I would argue that I had the second or third most medical experience in my initial class size of 25 students. I, and one of my classmates, both of us having had prior EMS experience, were the first PA's "allowed" to take ACLS at a major medical teaching institution in Texas and even that took some pulling of strings. Over a decade later I can remember having taken ATLS and heaven forbid I should even think about asking for a card showing successful completion of the course! I think I was able to claim it as cat II CME as I recall.

 

With regard to responsibility, I think my generation doesn't have any room to talk when most are in debt up to their arses and can't plan worth a flip for retirement but still continue to spend and dream.

[Contrarian]

Who says that they have to be "KIDS"?

 

Its mostly a function of "time on planet" x "exposure to life's little problems" x gradual responsibility looking after the healh and welfare of other humans.

 

The inexperienced middle aged/elderly attending a Program IS NOT the norm...!!!!

Even if it was... they still have 2 if the three above to help them "fake it until they Make/become it"...

 

As for the uncontrolled spending and debt... how is that relevent to THIS discussion....???

[CAdamsPAC]

no argument from me.

 

E , C & RC sounds about right for me!

[Teasip]

The point being that the assumption was being made that young individuals were not "wise to the ways of the world" and I was pointing out that age alone is not a good indicator of same. As you point out, the older the individual the greater the likelihood that one has hopefully learned from experience which in my opinion, as readily seen in society today, is not always the case. With regard to older students "not being the norm"; I wouldn't know. All I can go by are the comments made here by some stating that they went back to school later in life.

[Contrarian]

With regard to older students "not being the norm"; I wouldn't know. All I can go by are the comments made here by some stating that they went back to school later in life.

 

Yeah... your right... YOU don't know.

 

MANY of us went to school "later in life"... and when we arrived we also had EXTENSIVE DPHCE under our belts.

 

We were NOT "inexperienced middle aged/elderly attending a Program."

 

Therefore, we had the benefit of both LIFE experience AND direct professional healthcare experience on our side when we finished our program and set ou as "New Grads"...

 

We tended to overstand the seriousness of our endeavors, that healthcare IS a business, and a few other notions concerning professionalism and parity (due to having the benefit of both LIFE experience AND direct professional healthcare experience) and therefore sought positions that would help us develop into capable clinicians/providers versus simply looking for positions that paid a lot.

 

TODAY (last 10yrs)... the older student IS NOT the norm. The demo has shifted to young (20-24 yr old), cute, bouncy, females with little to NO life or Healthcare experience... but LOTS of shadowing.

 

What people are doing with their mortgages is irrelevent to THIS discussion.