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Changes to Scope of Practice

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Hi there! Has anyone seen the recommendations for changes made to the PA scope of practice for Louisiana by the LSBME??? If so, what are your thoughts? I am personally not happy about them and feel frustrated that they will further limit our ability to act as competent providers and will likely cost some people their jobs as physicians will not be able to utilize us as they currently are.


Also, if you are not from Louisiana and would like to comment on how your state's scope of practice mimics or varies from these recommendations, please feel free!


Here is a copy of the proposed changes for those of you who have not seen them:


2.1.1.B Exh. 1.B

Oct. 18, 2010 Regulatory Report

- 1 -

Title 46


Part XLV. Medical Professions

Subpart 3. Practice

Chapter 45. Physician Assistants

§4507. Authority and Limitations of Supervising Physician

A. The supervising physician ("SP") is responsible for the responsible supervision, control, and direction of the

physician assistant ("PA") and retains responsibility to the patient for the competence and performance of the

physician assistant PA.

B. An SP may delegate medical services identified as core competencies by the National Commission on

Certification of Physician Assistants ("core competencies"), under supervision as defined in Section 1503A of these


C. An SP may delegate certain medical services beyond core competencies to a PA provided the SP:

1. is trained and qualified in and performs the service in the course and scope of his or her practice. If the

service is provided in a hospital the SP shall be credentialed to provide the service;

2. delegates the service to a PA who has obtained additional training and has documented the ability to

perform the service safely and effectively; and

3. provides a level of supervision appropriate to the risk to the patient and the potential for complications

requiring the physician's personal attention. The level of supervision and examples of the types of services that may

be delegated are:

a. direct supervision—an SP may delegate certain medical services to a PA to be performed under direct

supervision provided the SP has first examined the patient and determined that the service is indicated. Direct

supervision exists where the SP is personally in the office or procedure suite where the service in question is being

provided, immediately available to furnish assistance and direction during the performance of the service and his or

her presence is documented in the patient's chart. Examples of these services include:

i. placement of a peripheral arterial line;

ii. placement of a peripherally inserted central catheter;

iii. removal of a central venous catheter, chest tube or drain;

iv. performance of bone marrow aspiration and biopsy from the hip bone or posterior iliac crest;

v. performance of a punch biopsy of the skin or cervix not to include wide excisional biopsies;

vi. manipulation of a closed (simple) fracture and/or dislocation not involving a crush injury or the use of

conscious sedation;

vii. performance of a lumbar puncture for diagnostic purposes;

viii. suture of an open wound under local anesthesia, not including a puncture or gunshot wound; and

ix. performance of an ultrasound-guided paracentesis or thorancentesis.

b. personal supervision—an SP may delegate certain medical services to a PA to be performed under

personal supervision. Personal supervision exists where the SP is personally at the bedside during the performance

of the service and his or her presence is documented in the patient's chart. Examples of these services include:

i. placement of a central venous catheter;

ii. placement of a Swan-Ganz (right heart) catheter, not including a coronary or left heart catheter;

iii. placement of an arterial catheter;

Board Agenda October 2010 2 Legal


2.1.1.B Exh. 1.B

Oct. 18, 2010 Regulatory Report

- 2 -

iv. placement of a chest tube;

v. management and removal of an intraaortic balloon pump;

vi harvesting saphenous veins and exposing femoral or popliteal vessels; and

vii. assisting in all other surgical procedures.

4. Credentials file. A primary SP ("PSP") shall maintain a credentials file for each PA for whom he or she

serves as a PSP and at least annually assess and document therein the PA's performance as evidenced by the PSP's

dated signature. The credentials file shall include a list of services beyond core competencies the PA may perform

and with respect to each shall also document:

a. the PA's training in the service;

b. the PAs ability to provide or perform the service safely and effectively; and

c. the protocols to be followed for the service.

5. A PSP who is employed or under contract with a hospital is not required to maintain a credentials file for a

PA, who is also employed or under contract with the same hospital provided:

a. the PA is credentialed individually by the medical staff organization of the hospital based on his or her

training and experience;

b. the PA's credentials file at a minimum addresses each of the items listed in 4507C.4. of this Section; and

c. the primary PSP annually reviews, dates and signs the PA's credentials file.

BD. The supervising physicianAn SP;

1. may not serve as the primary supervising physician a PSP for more than two physician assistants

PA’s;provided, however, that a physician may be approved to act as a locum tenens physician for any number of

physician assistants in addition to the physician assistants for whom he or she is the primary supervising physician,

provided that suchphysician:

2. shall not act as supervising physician an SP for more than four physician assistants PAs at any one the

same time; and

3. an SP employed or under contract with a hospital may only supervise PAs who are also employed or

under contract with the hospital, who are assigned to the same department and work in the same facility as the


AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270(B)(6), R.S. 37:1360.23(D) and (F), R.S.


HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Board of Medical Examiners, LR 4:112

(April 1978), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:1106 (November 1991),

LR 22:205 (March 1996), LR 25:32 (January 1999), LR 34:246 (February 2008); LR

Board Agenda October 2010 2 Legal


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Oops hit post too soon :)


That is precisely what I say. I work in an urgent care setting and it is ridiculous to think that there has to be direct supervision of abscess I&D or suturing or wound debridement (simple debridement for the most part). This is a total waste of time for something that all PA's that work with us are fully capable of performing themselves! Unfortunately, this does not apply to NP's. The NP's in our state are governed by the board of nursing and we are governed by the board of medicine. The NP's essentially have free reign as long as they have a "collaborating physician"....they do not have he 100% chart cosignature requirement or one year of clinical practice wait period to get prescriptive privileges. It is like they want PA's to be the physician puppet and the physician should see the pt and then give orders for the PA to carry out in each and every situation. Wouldnt this then place us in the role of nurses???? (Nothing agains nurses, just see us as having clearly different roles) We are taught to have critical thinking skills and ask for help when needed. Ugh. So frustrating. Wish I could move........

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It is no coincidence that LA ranks 49th in standard of healthcare in the US. It is the protect the ole-boys-club at all cost. Patient care is only a token reason for such "quality assurance" concerns. Reminds me of Kentucky when I was in PA school there (early 80s). The KMA and KNA (nurses) kept promoting these bizarre bills such as the PA could not touch a patient unless the MD was in the room.

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Do you know what I think about PA's? I think you know just enough to be dangerous


The hothead in me wants to punch someone in the mouth for saying that;

the little diplomat in me wants to say: "Well articulated- though I would might say I've encountered numerous residents and physicians suffering a similar prognosis..."



...such a pity, really

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Sounds like there's a doc with clout that just doesn't like PAs or maybe midlevel in general. Feeling maybe a little threatened or just trying to protect her own, whatever is sounds like there's going to be a drastic change in LA. Is this for midlevel or just PAs? There was a nurse who b/c a congresswoman in MS. She put up all sorts of blocks to the PA profession in that state, she was just simply protecting the nursing profession in the process elevating NPs. Thus the state of MS was virtually last when it came to how it ranked medically in the US. Looks as if LA wants to compete for that title now. Kbarro I see PAs leaving the state, I see PAs not wanting to go to that state, and I see docs not wanting to hire PAs b/c of their limitations and the ones that have jobs will have a difficult time keeping that job. NPs will be more than happy to take those jobs, build up their part of the practice, and then go out on their own. This is already happening in IL, remember no one comes to IL anymore for their medical care. Sad ending....

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Well here is is for AZ.


Notice: Legislative Changes Regarding Physician Assistants

Arizona Regulatory Board of Physician Assistants (ARBoPA)

Effective January 1, 2011

Diligent care has been taken to avoid any contradiction between this Notice and the actual enacted legislation. Any

inconsistency or conflict is unintentional. To the extent that there is an appearance of conflict or inconsistency, the actual

legislation shall take precedence.

Effective January 1, 2011, there will no longer be a requirement to file a “Notice of Supervision” (NOS) with the ARBoPA,

nor to wait for approval before the PA can begin working under the physician’s supervision. Each PA must, however,

have a Prescribing Authority Form on file with the ARBoPA in order to prescribe. Supervising Physicians are still

responsible for the health care services provided by all PAs under their supervision.

Effective January 1, 2011:

• There will be no requirement to file a “Notice of Supervision” (NOS) with the Board.

• A Delegation Agreement shall be signed by the PA and each Supervising Physician, filed in the practice’s office,

and be available for inspection by the ARBoPA. Although there is no specific format required, the required

elements of the Delegation appear in statute.

• Each PA must have a Prescribing Authority Form on file with the ARBoPA in order to prescribe. There will be no

fee for filing this form. A PA can check his/her the profile at http://www.azpa.gov to verify that prescribing authority is

on file before prescribing. (See A.R.S. 32-2532) (See sample below)

• There is no limit to the number of PA’s with whom a physician may have a delegation agreement. However, the

physician may only engage in supervising four PA’s at one time, regardless of where they are geographically


• There is no longer a category of Supervising Physician “agent.” Any qualified physician who has completed a

Delegation Agreement can act as a Supervising Physician for a PA.

• There will be no requirement for temporary or student licensing.

Effective June 1, 2011:

• The fee for PA license renewal will increase from $100.00 to $185.00.

32-2532. Prescribing, administering and dispensing drugs; limits and requirements; notice

A. Except as provided in subsection F of this section, a physician assistant shall not prescribe, dispense or


1. A schedule II or schedule III controlled substance as defined in the federal controlled substances act of 1970

(P.L. 91-513; 84 Stat. 1242; 21 United States Code section 802) without delegation by the supervising physician,

board approval and drug enforcement administration registration.

2. A schedule IV or schedule V controlled substance as defined in the federal controlled substances act of 1970

without drug enforcement administration registration and delegation by the supervising physician.

3. Prescription-only medication without delegation by the supervising physician.

J. The board shall advise the state board of pharmacy and the United States drug enforcement administration of all

physician assistants who are authorized to prescribe or dispense drugs and any modification of their authority.



Well, I was right about it being more money. But it doesn't seem much different?

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I knew Louisiana was not exactly a PA-friendly state. I'm currently a PA student outside Louisiana, but I can't imagine not returning to New Orleans when I graduate (every day I'm away from New Orleans sucks a little bit of my will to live). This post has me somewhat freaked out, but I'm not sure in what ways this is going to change things on the ground for PAs. Any PAs from Louisiana who can shed some light? I just went to the LAPA website and they provide very little info. Here is the letter from the president of the LAPA: http://www.ourlapa.org/images/presidents%20address.pdf

Not exactly informative. She does say they are working on it, and the AAPA is supporting, but why not more info? Is this just politics that I'm not getting?

It seems to me like no other state is "going back." All other states are moving forward and increasing scope. Leave it to Louisiana. Sigh.

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Joanna.Nola, I am freaking out too! I start PA school in January and hope to end up practicing in Baton Rouge. this is CRAZY! what's the point of being a PA in Louisiana if these suggested changes go into effect? looks like I will be commuting across state lines to practice. I am especially curious how these changes would fit into the whole healthcare reform deal? it seems so contradictory! what can we do???

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Elvis, I think all we can do is join the state group and support the work they are doing, which I hope is enough. They are really putting pressure on doctors who work w/ PAs. We might have to contact our legislators, too.

I've been emailing back and forth with the pres of the LAPA (while I should have been listening to that Patho lecture). She's responded very quickly. Here is what she said when I asked her to break it down (info on teleconference is on website):

In a nutshell, the LSBME is trying to create a list of what PAs can and cannot do. On the list now, which we do not want to see is, a SP must be physically present for suturing a laceration, performing a punch biopsy, or pulling a chest tube (see rule change for list on the website). As you can see, the list only affects certain people working in surgical subspecialties, dermatology, etc. But if this were to pass, where does the list stop? Some primary care physicians have said, I am not affected by this. Maybe not now, but if a list is started at all, it will continue to be added to. Most physician would say, this it too much trouble, I am hiring an NP, so obviously this will have a financial impact as well. Continue to watch the website for updates. Again, we are having a statewide teleconference Nov 27th. We will post the number for the teleconference, but are encouraging PAs to meet in regions with a spokesperson, so we do not have 500 PAs speaking at once.

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Im about to start my third year of PA school and will be graduating in May, so now instead of worrying about WHERE I can get a job, I'm now worrying about IF I can get a job!!!


I can't believe the LSBME is gonna make me move my family out of state, and take my two young children away from their grandparents, just so I can find a job!!


Dec. 6th will be a very happy (or very sad) day to be a PA in the state of Louisiana!!!

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I just got another email from the Pres of Louisiana PA Assoc:


November 30, 2010


Greetings Louisiana PAs!


On behalf of the Louisiana Academy of Physician Assistants, thank you for your interest concerning the Louisiana State Board of Medical Examiners regulatory proposal. As previously reported, these proposed rules have the potential to restrict physician-PA team practice in the state. LAPA held a state-wide informational teleconference this past Saturday, and were pleased that nearly all regions of the state participated, along with AAPA staff.


As you are probably aware, the next LSBME meeting will be held on December 6. LAPA representatives will attend this meeting to oppose the current proposal and offer alternatives which would not be punitive towards physician-PA teams. We are currently working with AAPA staff to draft alternative language for the board to consider. Rest assured that any proposed alternative language LAPA offers will reflect the PA professions commitment to supervised practice within physician-led teams.


Heres what we need every PA to do right now:

1. Join LAPA today. There is strength in numbers, and we need every PA in the state to be a LAPA member in order to assure that our voices are heard. Your dues dollars also help pay for the cost of our continued advocacy efforts on this and other issues. You can join online today www.ourlapa.org.

2. Have your supervising physician call the Louisiana State Medical Society today. Physician support is critical to this issue, so please have your supervising physician(s) call the Louisiana State Medical Society today at (225) 763-8500 to express their opposition to these regulations. Even if supervising physicians are not members of the medical society, it is very important that they call to make their voice heard.

3. Let us know who you know. If you have key contacts within the legislature, state government, physician organization leadership, or hospital/clinic system leadership please contact LAPA Legislative Chair Jennifer Angelo at lclapajangelo@gmail.com or me at kmarla@yahoo.com as soon as possible with this information.


Thanks to everyone for your continued assistance on this issue. We cant do this alone! If you have additional questions or comments, please contact me kamarla@yahoo.com or Jennifer Angelo jangel1@lsuhsc.edu with any questions you have.



Marla Moore, MPAS, PA-C Jennifer Angelo, MPAS, PA-C

LAPA President LAPA Legislative Chair


This alert is being sent to you via the AAPA Legislative Action Center at the request of your state chapter.

LAPA and AAPA: Partners in Advocacy

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