Thoughts on the future of a Supervision and PA Education

[ventana]

Reading the recent KY post got me thinking and I wanted to put some ideas/thoughts out there about our training and the future as well as the past.

 

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 healthy 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.

[Just Steve]

Might as well go to med school. This proposal is synonymous with degree creep. Passing such a motion would simply give the NP folks more fuel to say that PA is inadequate.

 

Can you compile data showing a prospective view that such a program will enhance overall medical care and lower morbidity/mortality?

[cinntsp]

Have there been demonstrated improved outcomes for PAs that have attended a residency/fellowship vs. those that received additional OTJ training? That would be a first step.

[Contrarian]

The first yr in the first job already IS a "internship"...

[True Anomaly]

To wutthechris- I'm not aware of any objective study of "post-grad training vs new grad PA's out of school" in certain specialties....mostly because the numbers just aren't there to do a real comparison. Those who do a post-grad program are still a very small percentage of the overall PA population that the comparisons made are still only going to be anecdotal. Even if you could compare them, what would you compare? The number of patients seen per hour? The average level of acuity of patients seen? The revenue generated? Morbidity/mortality differences?

 

Sorry Ventana- I don't support something mandatory like this. It ultimately does a disservice to our profession that pigeonholes us to a degree that, as Just Steve pointed out, makes becoming a PA over an MD pretty much a moot point. As a residency grad myself, I absolutely support any and all additional education programs out there PA's want to pursue for whatever specialty they wish to work in, but on an optional basis. Advancing our profession in the medical world is best done through other means- advertising, political advocacy and movements such as PAFT.

[andersenpa]

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.

 

Basically you are repeating the 2nd yr of PA school.

[SocialMedicine]

I do not agree that first year of practice is basically an internship. My first year was in a busy private practice .... I worked with a physician and 2 nurse practitioners that were all very senior, kind, and helpful. However, there was no formal education opportunities. I was not tested on my knowledge .... "pimped" as we call it. I spent many hours reading / studying independent. I purchased text books in my specialty ... found CME programs ... surrounded myself by colleagues and peers who could enhance my abilities. I am not so sure everyone approaches their work with similar ambition .. an internship could force that. I think an internship has some utility in areas outside of internal medicine and general surgery. Not sure how post grad programs help PAs later on .. would be interesting to learn more about this before giving an opinion.

[benny32311]

I don't know if I would necessarily support an internship in the way that the OP phrased it, but would certainly be in favor of what SocialMedicine is talking about, but in a more academic setting. I think that with the changing demographics, myself included, where you have applicants with much less HCE than past PA applicants, having a year of extra training in a particular field would be a good thing. I think you would make the profession overall better as it would given an extra year to learn the skills and information needed for that particular field, which would help if one decided to change disciplines. I think the residency also models after the MD model, which we do follow.

[Timon]

I've seen a few times here regarding posts where we already heading towards a 1 year residency + CAQ for jobs. However you label it internship, fellowship, residency aren't we there already since that seems to be a trend? Just don't know how it's any different than what KY is already doing.

[True Anomaly]

I've seen a few times here regarding posts where we already heading towards a 1 year residency + CAQ for jobs. However you label it internship, fellowship, residency aren't we there already since that seems to be a trend? Just don't know how it's any different than what KY is already doing.

 

It's still not the norm of PA practice. PA's who choose to do post-grad/residency/fellowship/what-have-you are still a very small percentage of new grads, let alone the profession as a whole. It may be trending more than in the past, but it's not guaranteed. We're certainly not there in it being "the norm" or even halfway there.

[EMEDPA]

The first yr in the first job already IS a "internship"...

depends on the first job. if you have a great teacher/sp/senior pa to work with, sure. if it's a mill where you see a pt every 15 min and they all have colds and uti's you won't learn as much as someone doing a yr of structured learning.

[EMEDPA]

I think a required postgrad training period and required specialty boards are coming for pa's.

docs went through the same evolution over the past century.

an example:

my great grandfather was a country doc. he learned medicine via the apprenticeship model as did his father. he never went to med school.

my grandfather went to medschool, practiced for a few yrs as a gp then did 2 yrs of training to be a general surgeon. never took a board exam.

my father went to medschool, did a 3 yr residency, and never took boards but practiced his entire career identified as a specialist.

today docs have to be residency trained and board certified to practice in most situations.

pa's are going through this same evolution. we are now at the must go to school phase. I think it might work backwards for pa's. first it will be must pass a test(CAQ) for the better jobs then later a residency will be required to be eligible to take the test. the caq has been out for 2 years. already some of the better jobs(in em at least) are being advertised as "preference to those with caq and/or residency". a great job near me now REQUIRES pa's to have the caq to do any kind of advanced procedures without an md immediately present supervising them. I am getting cold calls/emails/mailings on a regular basis from recruiters specifically because my name is on the nccpa list as having passed the caq. I recently got a job from a lawyer unsolicited to read through pending cases to see if pa's exercised appropriate judgement, etc as I am one of the few "expert em pa's" in my area. the cases I have reviewed fortunately showed pa's exercising good judgement and doing appropriate work ups.

my point was, required postgrad training and specialty boards are coming like the tide. it's going to happen. hospital credentialing boards will probably hop on the bandwagon next. they are already making it harder and harder every year to practice, especially for new grads. you must demonstrate you have done a procedure to be able to do the procedure. catch 22 without a procedures log. best place to get a good one is in a residency. my regular hospital requires 800 u/s studies to be credentialed. I don't have that but someone who has done a residency would. my rural job requires 25. that I have.

if I graduated from pa school today I would do a postgrad program without hesitation. the folks I know who have done them are much better pa's than those who have not.

true anomaly (above) is way ahead of the vast majority of pa's working in emergency medicine even though he is only a few years out of training due to attending an excellent residency. he probably knows more about critical care/ em than I do due to his exposure to multiple different rotations like icu medicine, u/s, etc. I have seen more patients but he has seen a lot of "high yield patients". many of my patients have been low acuity bs that never needed to go to the er in the first place. it's only in the past 5-6 years that I have begun to work in a place that gives me the leeway to perform advanced procedures on a regular basis and evaluate truly critically ill patients. for the first 10 years of my career I saw mostly fast track and "intermediate quality" patients (abd pain, pelvic pain, etc) because that is how facilities around here use pa's. I used a glide scope for the first time 2 weeks ago on a difficult airway(and not well, ended up intubating with a miller blade after not getting good visualization with the glide scope). I'm guessing T.A. probably has 25+ successful intubations with a glide scope.

almost 20 years out of pa school I am still thinking about going back to do a residency when done with my doctorate.

[rpackelly]

Change is a given. Nothing stands still. What is expected of PAs now is about 3times what was expected when I graduated in 1980. I did two years of a grant funded clinical and didactic experience in family medicine after I graduated (with a MD residency cohort), and then 10 months in an EM residency. The expectations are so much higher now. We are the PCPs of the future. Additional training can never hurt us or our patients. We can meet this challenge but not by refusing to adapt.

[EMEDPA]

Agree with Dr. Kelly, above. The future for pa's is more responsibility. With that responsibility will come more requirements for training and testing to verify that training.

Someday all pa's will be residency trained and specialty board certified. They will probably all have doctorates too as that is also coming, just not as soon.

[Bryce83]

Could you imagine the bottle neck this would create for certifying future PAs? Requiring a mandatory one-year internship for PAs would in essence create the same problem we have now with MDs getting into their residencies. Like it or not the reason this will not happen is because PAs are needed to save money... It is estimated that the government will be allocating 25 Percent of the national budget to health care by the end if this decade. The affordable care act's individual mandate will flood the system with an estimated 40 million newly insured patients next year in an attempt to help pay for rising and unsustainable costs. Who is going to take care of these patients?? The only answer is to have more PAs taking up the slack. This is why you are seeing so many new PA programs being approved! I agree that a residency should be optional but in my opinion, it will never be required.

[EMEDPA]

the problem is that hospitals are requiring more and more to become credentialed every year. without a residency pa's will only have access to entry level outpatient jobs(you know the ones the np's are dominating right now....)

there is a "legal requirement" and a "defacto requirement". the truth of the matter is that it will probably be a long while before pa's are legally required to do a residency but long before that all the good jobs will start going to folks with residencies and caq's.

know how many em residencies there were when I graduated? one.

today there are 19 with more starting all the time. the er docs are pushing for them because they want to use pa's but they want them trained to a standard they recognize and they want them to pass a test. several of the folks who designed the caq for em were current or past members of the board of acep(american college of em physicians).

[Contrarian]

I LOVE the way you folks are pushing for the mandating of the options you individually chose... to validate your personal choices...

 

Its really a interesting study/demonstration of abberant human behavior...

 

The silly part of this is that as soon as post GRAD residencies and internships become MANDATORY...

 

Our profesion WILL become moot...

[Gordon, PA-C]

Basically you are repeating the 2nd yr of PA school.

 

I dont agree. 2nd year PA students are not the primary caretaker of the patient and have almost zero real responsibilities. They function like med students, which is to say they dont contribute anything to the patient's care other than making comments/reports to the physician who actually makes the decision. They generally dont write orders (or if they do, they are trivial orders), they arent the primary guys calling the shots on the patient. 2nd year PA students dont see patients on their own.

 

An intern on the other hand, is the one who writes pretty much all the orders on the patient, sees the patient alone without the MD always coming to see them.

[Contrarian]

An intern on the other hand, is the one who writes pretty much all the orders on the patient, sees the patient alone without the MD always coming to see them.

 

That's laughable...

 

As I have NEVER seen a physician "Intern" NOT micromanaged by their 2nd yr residents, 3rd yr residents AND Attending...

 

Maybe YOU have seen differently... but somehow I doubt it...

[Guest JMPA]

How is it that 51 percent say no and 52 percent say yes?????????????????????? trollsssssssssssssss

[Teasip]

It's called "new math". :wink:

[MedicinePower]

I would support it for new grad PAs, but not for new grad PA's. :;-):

[Gordon, PA-C]

That's laughable...

 

As I have NEVER seen a physician "Intern" NOT micromanaged by their 2nd yr residents, 3rd yr residents AND Attending...

 

Maybe YOU have seen differently... but somehow I doubt it...

 

 

Even being micromanaged is still a lot more responsibility for an intern than what med students and PA students get.

 

A physician intern HAS a **** load more responsibility in patient care than a 2nd year PA student or a 3rd-4th year med student. I know you know the difference between them.

 

Interns make decisions on patients all the time without getting a formal OK from the attending -- it is usually little stuff like adjusting IV fluids, changing diet orders, starting NA/K replacement, but a PA student would NEVER do that unless they talk to the attending first. In most places PA students and med students CANT write orders even if they have the OK from the attending. PA students and med students also dont get calls to deal with patient situations from the nurses. It is a night and day difference.

 

Intern level responsibility >>>>>> PA student or med student responsibility. It's not even close.

[drholmes]

A mandatory anything beyond initial training is problematic. It is the regulators that own the position of deciding who plays the game at what particular level. Let them sort those things out - they will anyway. They are the power brokers. We are the healers. However, limiting PA practice to general medicine is even more horrifying. We start our training in the medical model. This approach defines the remainder of our professional lives. We are constantly learning, constantly training; developing new strategies to heal and to deliver said approaches to healing. Stifling that approach will kill the medical profession and PA's specifically quicker than a tax hike kills an economy.

 

We are (or will be) generalists. That is our basic role. To formally step away from that and suggest our initial training is somehow inadequate fuels the regulatory and lobbyist fires. Being a generalist is where our greatest value lies. We need to be able to step back and say: "Doc, did you notice...?" We need our physicians to be super focused. That's why they are reimbursed differently. However, for an experienced PA who wishes to further their learning or feels their professional contribution can have a greater impact with more specific formal training; let them have a go at residency's/internships what-have-you. I support PA to MD bridge programs for the same reason.

 

Let's pretend the Affordable Care Act doesn't exist for a minute and we actually let the marketplace determine which practitioners are best for which patients. If the marketplace (read: patient) finds they can obtain basic medical advice cheaper - will they not flock to it? We all need or will need specialized medical care. But then we have specialists for that - don't we. PA's are functioning and can function in both arenas quite well - with and without extra training. Keep extra training optional. I have seen physicians with lots of smarts (training) who make a patient feel like just another petri dish.

 

Now, with a hugely respectful nod to my NP friends: My observation of how NP's and PAs practice has left me scratching my head. Aren't we just doing basically the same things with the basically same practice constraints? (I know this particular point is very state dependent!) However, if we construct a future where a patient is seen by a properly trained Physician or a properly trained Physician Associate; don't we eliminate much confusion. I am in no way suggesting that Nurses give up any future as advanced practitioners by limiting themselves either. That would be just as counter-productive as limiting a current Physician Assistant's educational/practice pursuits. Anyway, my point is that all future PAs would be trained to the appropriate and same focus - to make medical evaluations and advise our patients what the better courses of action would be to resolve their medical concerns. Yes, this would require some major revamping of current educational models. Ultimately, it would be us - as medical professionals - saying to the marketplace (read: patient); "We have made this much easier for you to understand." "You need medical advice... come and talk to us." This might just be a sensible marketplace friendly solution on a host of levels.

 

Just my humble, and non-authoritative thoughts...

[CAdamsPAC]

Gee a discussion of "KY Rule" , wouldn't the discussed mandate ,reqiure KY for what it would do to the profession? ;-)!!