Military creates new "doctoral" residency program for PAs

[Chronic Student]

I just have to laugh at some of this crap. There are so many points I want to make here is just a random smattering.

All of this vitriol, hate and fear are rarely encountered by me on a day to day basis (I'm a PA).

My state (Texas) specifically prohibits me from representing myself as an MD/Physician in any way. We are also required by state law to wear a name tag that specificaly says that we are a PA.

Out of the hundreds of doctors that I have worked with in the last couple of years I have encountered 2 that really did not like midlevels. One of them I rotated with and finally earned enough respect that he told me that some of us might know our stuff.

All of this talk of follow the decision tree/look for the red flag/do what you have seen before might work for some folks but not for me. When I examine a patient/take a history I think in terms of anatomy/physiology, constellations of symptoms, try and consider every body system that could possibly cause that symptom and ask questions/perform tests in my PE to rule in or rule out what may be causing this particular thing. I usually take my top three or what could be really bad/somewhat probable and try and rule those out with further testing/imaging/labs. I don't shotgun, I know what the hell I'm looking for. Do I remember every single disease process. No, absolutely not and any provider who tells you they do is lying. If I see something strange or that rings an alarm bell do I look it up or grab the Harrison's/Abistons, etc and get reading? You bet I do.

I love these blanket statements about how all PA's want autonomy, to be called doctor, etc. I could give a crap about being called doctor. If I help my patients and don't hurt anybody I'm happy. Autonomy, are you kidding me? I choose to be a PA and knew that I would be the equivalent of a junior resident for life.

The point has already been made that we are the last or close to the last group that has given in to degree inflation.

MacGyver, your rants are flaccid as usual. You are so obsessed and worried by us that it is humorous to me. If we really are so inferior, so dangerous and so incompetent then market forces will take care of us. We have already been around for 30 or 40 years and we have not left a trail of bodies behind us, there are not thousands of lawsuits against PA's and our pay is on the rise. Would that be the case if we did not at least moderately well represent ourselves.

A lot of you young uns that are in an uproar are not operating in the real world. Things will change a lot from med school to residency and into private practice.

Years ago I took a philosophy class and we were taught about the three components of openmindedness: 1. Listen to what others have to say and get information. 2. Critically examine that information. 3. If the evidence warrants, change your opinion. Work with PA's and don't form your opinion based on a few experiences in one hospital. Have you come across bad doctors? You will come across bad PA's, no question. Some of us are actually competent, know our limitations and have no desire to practice independently.

I also think that it is quite funny that the people who scream the loudest about protecting the MD degree are the ones who disparage us about protecting our degree. The PA curriculum is standardized with some small variation, as is the MD degree. There is a standardized test to pass and licensing (granted, not nearly as extensive or involved as with an MD).

Do you think I should be able to just pass steps 1,2 and 3 and then I can get an MD? Then why should you expect us to let someone practice as a PA if they just pass the exam. Did they pass through the standardized curriculums and get the training on knowing their limitations? If they have and it can be verified and they can pass the test then I have no problem with it.

OK, rant over. I'm really too tired to address this any longer. I just spent 12 hours assisting on an occipital brain tumor on a nice, kind, grateful old man. It turned out to be a GBM. So much for that 8-5, no weekends, no call lifestly that apparently all imaginary PA's work.

-Mike

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[MacGyver]

I also think that it is quite funny that the people who scream the loudest about protecting the MD degree are the ones who disparage us about protecting our degree.

Thats a load of ****in bull****. "Protecting" the degree my ass. If you like analogies, its similar to calling a raise in a poker game.

PAs already have "residencies" and they sure as hell dont grant doctoral degrees.

This is a change in the status quo, designed for a specific purpose.

 

[Chronic Student]

Have you ever taken an MMPI. It would be very intresting to see the results of that.

Was that a black chopper?

For someone who does not like us, you sure our giving us a lot of credit for organizing a huge conspiracy behind the scenes in which we will take over the medical profession.

Get real, thats like saying the government is responsible for a good economy. They may have some hand in it, but there are so many factors and the government is only a part of it.

Dude, I was talking about not letting FMG's practice as PA's. Actually reading the post would help, DOCTOR!

The PA residencies are mainly hands on, OJT type stuff and have no business granting doctoral degrees. On this you and I agree, did I just say that. The program you are talking about is something different at least from what my pea-brained, protocol following, autonomy seeking self can tell.

-Mike

 

[kamehame]

Autonomy, are you kidding me? I choose to be a PA and knew that I would be the equivalent of a junior resident for life.

Then that's commendable. Because a number, not all but a substantial percentage, of PAs I've met are the type that basically think that once they've worked for five years or so then they're essentially the equivalent of attendings.

 

[deleted6669]

"Dude, I was talking about not letting FMG's practice as PA's. Actually reading the post would help, DOCTOR!"

actually he's not a doctor yet, he's a med student. he may fail his boards and spare the medical world from being exposed to him.

 

[ForbiddenComma]

MacGuyver, I am not sure why you are focusing on the PAs -- not one of whom here who says they want PA to be the same thing as MD -- when the head of the nation's premier NP school has written little short of a declaration of war on physicians in Forbes magazine.

She doesn't just want NPs to be equal to MDs, although that's crazy enough. She flatly states that they are superior to MDs, as they are doctors and nurses combined into one super-clinician.

"These clinicians are peerless prevention specialists and coordinators of complex care. In other words, as a patient, you get the medical knowledge of a physician, with the added skills of a nursing professional."

"...these skilled clinicians have the ability to provide comprehensive care indistinguishable from physicians."

I mean, she is basically confirming every one of your worst nightmares about NPs.

And yet, you focus on PAs, why exactly?

I assure you, when your practice or hospital dumps you for a midlevel for half the pay, your replacement will have the letters "ARNP" and not "PA-C."

 

[MacGyver]

MacGuyver, I am not sure why you are focusing on the PAs -- not one of whom here who says they want PA to be the same thing as MD -- when the head of the nation's premier NP school has written little short of a declaration of war on physicians in Forbes magazine.

She doesn't just want NPs to be equal to MDs, although that's crazy enough. She flatly states that they are superior to MDs, as they are doctors and nurses combined into one super-clinician.

"These clinicians are peerless prevention specialists and coordinators of complex care. In other words, as a patient, you get the medical knowledge of a physician, with the added skills of a nursing professional."

"...these skilled clinicians have the ability to provide comprehensive care indistinguishable from physicians."

I mean, she is basically confirming every one of your worst nightmares about NPs.

And yet, you focus on PAs, why exactly?

I assure you, when your practice or hospital dumps you for a midlevel for half the pay, your replacement will have the letters "ARNP" and not "PA-C."

You got me all wrong, I'm an equal opportunity midlevel-hater. But this residency program I linked in the first post was for PAs, not NPs. I've already engaged the NPs multiple times on this stupid DNP crap.

NPs pose more of a threat, to be sure, and I'll deal with them separately. But you guys are fools if you think that the PAs are sitting happy wtih the status quo.

Go read the PA forums and you'll find a thread started there arguing that PA grads should be eligible for the same residencies as MD grads and get independent/unrestricted license to practice medicine as a result. Emedpa sure likes that idea, so I dont understand why he's playing coy on this board.

 

[primadonna22274]

Oh, be honest. We shot that idea to hell on the PA forum and we haven't heard from the OP which implies it was bait to begin with. Could be you started the ridiculous thread....

Go read the PA forums and you'll find a thread started there arguing that PA grads should be eligible for the same residencies as MD grads and get independent/unrestricted license to practice medicine as a result. Emedpa sure likes that idea, so I dont understand why he's playing coy on this board.

 

[core0]

Oh, be honest. We shot that idea to hell on the PA forum and we haven't heard from the OP which implies it was bait to begin with. Could be you started the ridiculous thread....

Hmm you may have a point. Comes out with a ridiculous thread that no one who ever has been a PA believes. Other threads are also consistent with someone who has never been a PA (remember the "everyone knows that specialty PAs make twice what primary care PAs make" thread). I could buy docmartin = McGyver. I was willing to give them the benefit of the doubt despite the trollish nature of the original thread. However, I may have been too generous.

David Carpenter, PA-C

 

[kamehame]

I'm not trying to get into a battle but I do want to point out that saying that you guys "don't want to be doctors or viewed as doctors" doesn't mean squat. It's easy for everyone to say that. That's why we have the old adage that actions speak louder than words. Every PA/NP in the world can say "we just want to be PAs and nurses" but clearly we can all see where they are trying to be able to increase what they can do and therefore how much they get paid and how they are viewed by the laypublic. It happens everywhere (CRNAs vs Anes, opticians vs optho, etc), which is why a bunch of us are saying you guys are insulting our intelligence.

 

[Taurus]

Once the DrScPA is out of the bottle, you can't put it back.

Any reasonable person can see that this degree will proliferate in the non-military sector. I doubt that the governing body of PA's will try to kill it. Schools love it because it means more tuition money. PA's like it because they can finally call themselves "doctor".

I think that the best response by physicians is through supply and demand. Ramp up the number of PA's graduating every year. Keep the supply high relative to demand.

One of the problems with CRNA's is that there is currently a tight supply of them. This is driving up their salaries. With high salaries, they misconstrue this as meaning they are just as good as physicians, except paid lower. I get a sense from a lot of them that they somehow deserve what they are making and that they want more. I believe that this is what is really driving their political ambitions. If you keep salaries low and let them know that they are replaceable, their political ambitions will be severely undermined. Afterall, you're less likely to rock the boat if you're worried about putting food on the table.

It'll be interesting to see how physicians respond to these challenges in the future.

I think that this degree creep is only serving the schools and not the individuals. The holy grail of all of these groups (DNP, DrScPA, PharmD, DPT, etc) is higher reimbursement. But Medicare reimburses for the service provided and not the degree level. That's why the DPT's and PharmD's have not seen the bump in salaries that they have been hoping for. They have been unable to convince Medicare and the insurers to give them higher reimbursements. Will DNP's and DrScPA's be able to convince Medicare to reimburse them like physicians? I doubt a Medicare that is going broke and that tries to cut physicians reimbursements every year would want to pay out more for more groups.

 

[MacGyver]

Oh, be honest. We shot that idea to hell on the PA forum and we haven't heard from the OP which implies it was bait to begin with. Could be you started the ridiculous thread....

Did you read the same thread I did? Most of the posters opinions were something along the lines of "it will never happen, but I like the idea" kind of thing.

Emedpa certainly loves the idea, which is why I brought it up; somebody posted above that none of the PAs who posted on this thread want independence. I can quote him directly if you want me to.

 

[OnPump]

Oh, be honest. We shot that idea to hell on the PA forum and we haven't heard from the OP which implies it was bait to begin with. Could be you started the ridiculous thread....

Agree......once again the rest of the ratioanlly thinking world will have to look past Macgyver's B.S.....regular PA Forum contributors quickly dismissed that concept as ridiculous.

MacGyver be a man (if you are one) and respond to criticisms of your babble instead of ducking in the shadows of other comments that suit your need to talk nonsense.

Good lord I pray for your future patients.....

 

[OnPump]

I'm not trying to get into a battle but I do want to point out that saying that you guys "don't want to be doctors or viewed as doctors" doesn't mean squat. It's easy for everyone to say that. That's why we have the old adage that actions speak louder than words. Every PA/NP in the world can say "we just want to be PAs and nurses" but clearly we can all see where they are trying to be able to increase what they can do and therefore how much they get paid and how they are viewed by the laypublic. It happens everywhere (CRNAs vs Anes, opticians vs optho, etc), which is why a bunch of us are saying you guys are insulting our intelligence.

Right, it's ridiculous for a relatively young profession to promote their quality/cost effectiveness and ensure a fair and positive perception by the public.

Evidence based, sir......evidence based. Show us. Show us how how PAs seeking uniform, fair practice acts is harmful to the patients you seem to want to protect from midlevels.

If you weren't so tied up in the idea that no NPP should be granted a doctorate, you may learn a thing or two about a profession that you obviously know very little about.

Thank goodness folks like you are in the minority....you'll learn about that when you get into the real world of medical practice.

 

[OnPump]

Did you read the same thread I did? Most of the posters opinions were something along the lines of "it will never happen, but I like the idea" kind of thing.

Emedpa certainly loves the idea, which is why I brought it up; somebody posted above that none of the PAs who posted on this thread want independence. I can quote him directly if you want me to.

He said that if this crazed hypothetical notion of PAs completing physician residencies were to occur, that 1) there are certainly many PAs who could do it successfully, and 2) the only incentive to such a committment would be if there were some increase in scope or practice freedom afterwards.

What did you think would be the response- "Well golly gee theres no way we could do that, we're not smart enough!"

Many of us on the PA forum have been in practice many years, and have seen residents of all caliber come through the door. It is THAT prespective that enables us to know our abilites.

I was the one who said that PAs don't seek independence, as this is the NATIONAL STANDARD in concordance with the stance of the AAPA and state chapters. No one is speaking for every individual PA, as obviously there are those who desire maximal practice freedom. There are many who have quasi-independence in various ways- practice ownership, limited chart review, remote supervision, solo coverage. PAs like this who have proven their mettle would be the best candidates.

But no PAs are going into practice with the notion that they will have independent practice. If clinical/academic ability and recognition of such permit some to advance to a higher degree of autonomy, so be it. THAT'S a free market at work.

 

[MacGyver]

He said that if this crazed hypothetical notion of PAs completing physician residencies were to occur, that 1) there are certainly many PAs who could do it successfully, and 2) the only incentive to such a committment would be if there were some increase in scope or practice freedom afterwards.

Quit being obtuse. He said that if it grants them independence (which was the whole point of that thread) that he wanted it.

What did you think would be the response- "Well golly gee theres no way we could do that, we're not smart enough!"

No I expected them to say "we are PAs and supposed to work under a doctor's supervision." NOBODY on that thread said that. The consensus was that the MDs wouldnt allow that to happen, but if they did, they were in favor of it.

Many of us on the PA forum have been in practice many years, and have seen residents of all caliber come through the door. It is THAT prespective that enables us to know our abilites.

Oh right. Let me guess, 5 years of practicing as a PA is the same thing as residency training, right? I've heard that before too.

I was the one who said that PAs don't seek independence, as this is the NATIONAL STANDARD in concordance with the stance of the AAPA and state chapters. No one is speaking for every individual PA, as obviously there are those who desire maximal practice freedom.

Do you want me to quote directly? Above, a poster said this: "none of the PAs who posted on this thread want independence." I called that out for hte crap that it is, provided a link to PROVE that it was crap based on one of ht PA's specific comments on that thread, and now I've got you backing into corners and obfuscating the issue and trying to explain to everybody that "he didnt really mean" exactly what he said.

There are many who have quasi-independence in various ways- practice ownership, limited chart review, remote supervision, solo coverage. PAs like this who have proven their mettle would be the best candidates.

I thought PA's didnt want independence or increased autonomy? Now all of a sudden you are changing your tune, revealing your true colors. Take off the mask, everybody can see that monster hiding underneath it.

But no PAs are going into practice with the notion that they will have independent practice. If clinical/academic ability and recognition of such permit some to advance to a higher degree of autonomy, so be it. THAT'S a free market at work.

Does the "free market" also consist of FMGs being locked out of PA practice, even if they pass the exams? Quit being such hypocrites. All the midlevels do this, they try to increase scope/independence at hte expense of physicians while denying that same privilege to the people working below them.

 

[kamehame]

If clinical/academic ability and recognition of such permit some to advance to a higher degree of autonomy, so be it.

Whoops, you got off-point and disclosed the truth at the end of your post.

 

[deleted6669]

higher degree of autonomy does not= independent practice. it means reasonable oversight.

 

[Taurus]

Whoops, you got off-point and disclosed the truth at the end of your post.

Freudian slip.

 

[Taurus]

higher degree of autonomy does not= independent practice. it means reasonable oversight.

What's reasonable? Some physician who stops by to review your charts 1x month like how you have it now?

 

[deleted6669]

What's reasonable? Some physician who stops by to review your charts 1x month like how you have it now?

depends on the pa. reasonable for a new grad or pa resident is every chart.
reasonable for a pa in the same practice with the same doc for 25 yrs? I guess that's up to the supervising doc but certainly doesn't need to be every chart.....
Many progressive states define supervision as " an ongoing and regular assessment " which seems reasonable. certainly if there was a problem and it was shown that the doc had no involvement whatsoever in care than there would be grounds for disciplinary action both to the pa and the doc.

 

[Frijolero]

depends on the pa. reasonable for a new grad or pa resident is every chart.
reasonable for a pa in the same practice with the same doc for 25 yrs? I guess that's up to the supervising doc but certainly doesn't need to be every chart.....
Many progressive states define supervision as " an ongoing and regular assessment " which seems reasonable. certainly if there was a problem and it was shown that the doc had no involvement whatsoever in care than there would be grounds for disciplinary action both to the pa and the doc.

Except that PA's supposedly already have lots of training which allows them to know their scope and thus makes them more culpable for said offense. If you're talking about private practice in which the doc hired the PA, then fine. A hospital setting in which the MD's have little to no say about with whom they work is a different beast entirely.

This whole debate in meaningless (to me, anyway) until someone, like a poster suggested a thousand posts ago, has some evidence regarding outcomes or even cost comparing MD's to DNP's to PA's to burger flippers, whatever. Anybody have any evidence?

BTW, what's your view on "reasonable"? "Solo nights covering the ED"? No thanks, I'll pass...

 

[Coastie]

Yeah, seriously.

That Forbes article..sheesh. How could they print such rubbish?

Physician envy at its worst. How could the AMA not respond to this load? It's like me saying I can fly commercial jets without a license; After all, I can fly on Microsoft Simulator, why not on the real thing? Or, I can gain admission to the Special Forces because I'm ranked #4 in the world with > 3000 playing hours on SOCOM 2 over xbox live.

Docs have to fight this junk or else we're ALL in trouble.

MacGuyver, I am not sure why you are focusing on the PAs -- not one of whom here who says they want PA to be the same thing as MD -- when the head of the nation's premier NP school has written little short of a declaration of war on physicians in Forbes magazine.

She doesn't just want NPs to be equal to MDs, although that's crazy enough. She flatly states that they are superior to MDs, as they are doctors and nurses combined into one super-clinician.

"These clinicians are peerless prevention specialists and coordinators of complex care. In other words, as a patient, you get the medical knowledge of a physician, with the added skills of a nursing professional."

"...these skilled clinicians have the ability to provide comprehensive care indistinguishable from physicians."

I mean, she is basically confirming every one of your worst nightmares about NPs.

And yet, you focus on PAs, why exactly?

I assure you, when your practice or hospital dumps you for a midlevel for half the pay, your replacement will have the letters "ARNP" and not "PA-C."

 

[deleted6669]

Except that PA's supposedly already have lots of training which allows them to know their scope and thus makes them more culpable for said offense. If you're talking about private practice in which the doc hired the PA, then fine. A hospital setting in which the MD's have little to no say about with whom they work is a different beast entirely.

This whole debate in meaningless (to me, anyway) until someone, like a poster suggested a thousand posts ago, has some evidence regarding outcomes or even cost comparing MD's to DNP's to PA's to burger flippers, whatever. Anybody have any evidence?

BTW, what's your view on "reasonable"? "Solo nights covering the ED"? No thanks, I'll pass...

IF I was a physician who worked with pa's I would make my supervision criteria based. for example pts with abnl vitals and/or certain complaints(chest pain, aloc, worst h/a ever, abd pain, joint pain or rash with fever, etc) I would want to be more involved with. lower acuity complaints(minor procedural, minor ortho, dysuria, etc) I would be less concerned about. I think that would be a much better system than a random % of charts. I tend to submit admissions, interesting cases, cases with significantly abnl labs, etc as charts for review as I think this is of more value to my sponsoring physician( as in he might read them and give me feedback) as opposed to giving him every uti, ankle sprain, uri, and minor lac I see(which he would just stamp and sign without reading). hard to see a dx of "cardiac arrest" and not feel the need to review the chart....

as a side note the position in which I work solo nights( one of 4 places I work at) has 100% md chart review within 12 hrs.
my sponsoring physician actually asked the state without my input if he could review none of my charts(or those of other senior pa's who work there) and just do "ongoing assessment" and the state ok'd it but the hospital said they get a better malpractice rate(and I'm guessing billing) with 100% chart review so that's how it stayed.

 

[OnPump]

Quit being obtuse......(brevity edit)

You're blurring two issues. The premise of PA education and practice is the place of the PA within the PA-SP team. All PAs enter the career under that model. That is the position of the AAPA, and has been backed up by the actions of it and the state chapters.

"Docmartin"'s post posed whether or not PAs should be eligible to enter physician residencies based on the content of their education/clinical rotations. It was clearly disagreed that the content is not equal between MD/DO and PA education. Based on that thinking, PAs should not be eligible.

Now, could a PA do it? Without a doubt, there are many...EMEDPA certainly being one of them. I can't change your mind if you are too provincial to see that. It is absoultely certain that there are PAs who, after obtaining significant clinical experience and further didactic education, would excel in physician residencies.

The gradual improvement in PA practice laws has been a process of recognition of skill, competence, and efficacy. What we are talking about lies at the extreme of that continuum.

And once again, granting clinical doctorates to PAs does not equal independent practice! Do you get it yet? Remember, you learn more by listening. Write that down, it may pay off in the future.

I see that you want to bundle this all into "all midlevels are power hungry and want true independent practice" (after all, you are an admitted midlevel hater), however it is simply not true.

OK kids, let's review:

Not all PAs desire independent practice.
Clinical doctorates do not grant independent practice.
PAs desire maximal autonomy within the scope of their abilites and the practice arrangement with their SP.
"Higher degree of autonomy" does not equal independent practice.
"PAs entering physician residencies" is a troll post dropped in the PA forum to stir up nonsense like this.
Despite the topic's trollish nature, the fact remains that there are PAs who can excel in physician residencies.
There are PAs who, after establishing certain clinical and academic standards, would be successful clinicians with even more limited degrees of supervision.
The regulations for what states have deemed reasonable oversight have led to safe, efficient care delivered to a broad segement of the patient population. (Even solo coverage! Heaven forbid! )
Five years practice as a PA does not equal residency (nice try, straw man).
....Repeat QD and PRN.

Sorry that it doesn't fit into your world view, but those are the facts.


...and no, Taurus, a Freudian Slip is an inadvertent expression of a subconscious belief. What I said above I consciously believe in.

 

[Taurus]

certainly if there was a problem and it was shown that the doc had no involvement whatsoever in care than there would be grounds for disciplinary action both to the pa and the doc.

If the midlevel screws up and the doc doesn't know about it, then both should be culpable. Hmmm. The doc should be culpable for being stupid enough to give the midlevel such a long leash.

I recognize that midlevels are an important part of modern medicine. I've worked with them and when I finish training the group I join may even employ some of them.

I believe that the appropriate level of supervision with midlevels is the same that you would give to residents. You let them do the H&P and rounding. Then you look at their documentation. An attending can keep good track of patients just by reading the notes, talking to the resident or midlevel, and checking up on the patients himself nearly everyday.

When its your license on the line, you can't just trust that the midlevel or resident knows what their limitations are and have the appropriate knowledge base and skills. As emedpa says, it's both your and the midlevel's butts on the line when the midlevel screws up.

 

[Pinkertinkle]

Slippery slope!

 

[MacGyver]

Ahh yes, here comes the "we just want the next step in our natural progression, not the whole enchilada" stuff from the PAs.

Hmmmm I think I've heard that before.

There has NEVER been a midlevel/allied health group that just simply stopped their agenda after being granted the "next step." The "next step" is always a progression to greater freedoms down the road.

Take a look at the history of NP development and you'll see that the "next step" is NEVER the last step.

 

[MacGyver]

Just to make sure I'm not beating up on the PAs too much, let me give you a nice refreshing update on what the pharmacists are up to. This is a primer by a pharmacist on how to copy the NP model to achieve "independent provider" status

http://www.medscape.com/viewarticle/464663_1

Read this article very very carefully, and pay special attention to what the pharmacist lobby ultimately wants:

The history of nurse practitioners, their efforts to achieve provider status, and lessons learned from their activism are discussed.

The nurse practitioner profession arose out of a need to meet a rising demand for primary care services, especially in rural areas. Some nurses and physicians vehemently opposed the nurse practitioner model, but studies documented the value of nurse practitioner services, and the utilization of these practitioners continued to grow. Compensation was provided via salary or per-member-per-month agreements. Nurse practitioners recognized that direct federal reimbursement (provider status) was needed to recognize them as independent health care providers and assign specific monetary values to their services, so they undertook an aggressive lobbying campaign. Contacts on Capitol Hill were exploited, and nursing organizations encouraged nurse practitioners to get involved in grass-roots activism. Nurse practitioners discussed their patients during meetings with their representatives in Congress, and legislators were invited to make site visits. In 1993, the American College of Nurse Practitioners was formed to unite the profession and move the campaign forward. Ultimately, the Balanced Budget Act of 1997 granted nurse practitioners provider status and authorized them to bill Medicare directly for services furnished in any setting. The key strategies that contributed to this victory were (1) gaining recognition that nursing had the potential to expand its role, (2) documenting nurse practitioners value, (3) establishing standards in education and credentialing, (4) using professional organizations to empower individuals, and (5) being willing to accept small, incremental gains over time.

The experience of nurse practitioners in obtaining Medicare provider status offers valuable lessons for pharmacists as they pursue the same goal.

As I said before, there is no allied health/midlevel group that has been satisfied with the status quo. Every single one of them wants what we got.

So who's next up for telling me I'm just paranoid and that there's really nothing to this at all?

 

[kamehame]

Despite the topic's trollish nature, the fact remains that there are PAs who can excel in physician residencies.
There are PAs who, after establishing certain clinical and academic standards, would be successful clinicians with even more limited degrees of supervision.

Notice how all of OnPump's posts started out with "you guys are crazy!! Quit exaggerating in order to inflame people!! PAs know their role and do not desire independence! We've settled that. Period!!" And then as time progressed (i.e., one day), suddenly the message changed to "this may lead to more autonomy for PAs, but that's life and there are PAs who could work with even more limited supervision." Makes you think, eh?

 

[kamehame]

Also, while there probably are PAs who could excel in residency, the fact remains that they haven't and therefore it's irrelevant what you think they "could" do. That's like when people decide to go into business instead of pursuing medical school, which is of course a legitimate choice. But then they say "of course, if I wanted to go to medical school, I could do it, but I chose not to." If everyone who thinks they could do something could actually do it, we'd all be flying around like superheroes. If a PA wants me to believe they can do medical school, they should do it first and then get back to me.

 

[MacGyver]

Notice how all of OnPump's posts started out with "you guys are crazy!! Quit exaggerating in order to inflame people!! PAs know their role and do not desire independence! We've settled that. Period!!" And then as time progressed (i.e., one day), suddenly the message changed to "this may lead to more autonomy for PAs, but that's life and there are PAs who could work with even more limited supervision." Makes you think, eh?

yes they love trying to hide their true intentions.

all you MDs who hire midlevels, bear in mind that what they tell you in clinic is NOT the same as what they will say in an anonymous internet forum. They are subtle and compliant by day, and then turn into vampires by night, and every time a new legislative session comes up.

You have been warned.

 

[alpha62]

Relax everybody, who really cares about this?

this thing was hatched by the army. They're running out of ways to keep us PAs on the hook for this freaken Iraq jive that's going to bleed over into the next century.

They're just looking for ways to lure people into a longer ADSO. that's all.

Those of us that have been around the block have already told them where to put it.

 

[kamehame]

Weakest attempt ever at linking an issue to Iraq. Try again.

 

[MacGyver]

Relax everybody, who really cares about this?

this thing was hatched by the army. They're running out of ways to keep us PAs on the hook for this freaken Iraq jive that's going to bleed over into the next century.

They're just looking for ways to lure people into a longer ADSO. that's all.

Those of us that have been around the block have already told them where to put it.

I dont buy for one second that this is just a "military" thing and that it wont spread elsewhere.

I'll bet every penny that I own that the civilian world will copy this within the next 5 years. You want to give me some action on that? I'm dead serious.

 

[deleted6669]

"Also, while there probably are PAs who could excel in residency, the fact remains that they haven't and therefore it's irrelevant what you think they "could" do"

actually there are...pa's have been doing residencies for > 20 yrs. many(not all) of these are taught as the pa filling a pgy-1 md spot.
see www.appap.org for a list of residencies. look at montefiore and the other surgical residencies. look at norwalk where pa's are the only in house residency staff for the entire hospital.....

 

[deleted6669]

I dont buy for one second that this is just a "military" thing and that it wont spread elsewhere.

I'll bet every penny that I own that the civilian world will copy this within the next 5 years. You want to give me some action on that? I'm dead serious.

I'm sure they will but at 30k the only ones that will bite will be pas's who want to be directors of pa programs. I have looked into doing a dhsc and all the current ones are too expensive without any real practice advantage so why bother? I could do a dhsc right now but it wouldn't get me anywhere...and I would be just as much "DR" as a grad of this new military program

 

[brightness]

Here is my question:
For all of you who dislike or are afraid of the advance of midlevels, what do you suggest the medical community do about it? Should all midlevels be eliminated (not going to happen...)? Should there be a cap on midlevel degrees saying they can't possess doctorates? Should there be legislation that forces all midlevels to work under physician supervision?
I hear a lot of fear and a lot of noise, but what is the solution?

 

[ForbiddenComma]

but what is the solution?

Midlevel-to-MD bridge program.

Why doesn't such a program exist already? It makes perfect sense.

Those who have what it takes can step up, beat their peers who are applying for the same spots, take the USMLEs, go through residency, and prove they are able to handle patients on their own -- on an equal footing.

No watered-down admission requirements. No wussie USMLE-lite pseudotest. I'm talking about the same boards that every med student takes.

Because the patient doesn't care which route you took to become a doctor -- traditional or bridge. All they care about is whether you are competent. And the boards, plus clinical evals, are the best tool we got to measure such a thing.

Such a program would immediately obviate the DNP or proposed D-PA degree.

My biggest problem with the whole midlevels-going-independent thing is that we are going to wind up with underqualified people, who could have never gotten into med school or passed the USMLEs, taking care of patients. They want to circumvent this not for the benefit of the patients, but for the benefit of themselves... so they can call themselves "doctor" without being qualified.

The historical barriers to practice of medicine, as imperfect as they are, exist for a reason. They exist to protect patients. Let's impose the exact same standards on midlevels who wish to practice independently as we do on other physicians. And if they meet these standards, they deserve the designation of "M.D.".

 

[kamehame]

Midlevel-to-MD bridge program.

Why doesn't such a program exist already? It makes perfect sense.

How wrong you are. In a sense, the PAs aren't lying, they really do want to remain PAs. That's because as PAs they get a good salary, no liability, and often can determine their hours. For example, the PAs I've seen only work during the day, no holidays, and no call. Try doing that as an attending. However, if they can finesse it so they can be recognized as doctors and increase their pay to equivalency by horning in on physician-level procedures, even better. That's prestige and pay and title without liability or call. And you wonder why they do what they do? That's why they're sitting around lying about this whole thing.

Add to that being able to basically start working in your early- to mid-20s and not have a load of debt and you can see there's no advantage for them to go to medical school, so long as they can just intrude on physician turf. In order to do so, all they need to do is convince you that anyone who is upset by this is just "biased" against mid-levels for irrational reasons. It's very underhanded.

 

[deleted6669]

"That's because as PAs they get a good salary, no liability, and often can determine their hours."

GOOD SALARY: CHECK

NO LIABILITY: ARE YOU ON MARS? HERE'S WHAT ACTUALLY HAPPENS WHEN A PA BLOWS IT BIG TIME:
PA GETS FIRED AND CAN ONLY WORK AT FEDERAL PRISONS FOR THE REST OF HIS CAREER.
PA, MD, AND HOSPITAL GET SUED
MALPRACTICE COMPANY PAYS OFF SUIT
DOC KEEPS JOB AND HAS TO DO 2 HRS CME ON APPROPRIATE PA SUPERVISION....BLAMES IT ALL ON PA(AS HE SHOULD) AND GOES ON WITH HIS CAREER....

DETERMINE THEIR OWN HRS: ONCE AGAIN: DUDE, YOU HAVE GOT TO BE KIDDING: I HAVE BEEN AT WORK SINCE NOON TODAY AND WILL BE HERE UNTIL 0700....THAT'S A 19 HR SHIFT...AND I AM ON THE NEXT 2 NIGHTS AS WELL(NOT 19'S BUT STILL OVERNIGHTS).
THE DOCS IN MY GROUP WORK 12-14 EIGHT HR SHIFTS/MO(NO DOUBLES EVER AND ONLY 1-2 NIGHTS)
THE PA'S WORK 16-20 TENS AND FREQUENTLY ARE ASSIGNED DOUBLES(2-4/MO) WITH 5+ NIGHTS.THIS MONTH I WORK 230 HRS WITH 9 NIGHTS INCLUDING A RUN OF 16 DAYS IN A ROW, NEXT MONTH I WORK 190 WITH 6 NIGHTS.
and no holidays...who are you kidding...I have xmas off this yr for the 1st time in 6 yrs.....
pa's in most settings work the same schedule as the docs they work with(or in the case of em typically more) including taking call, working weekends/nights/holidays. sure there are cush jobs out there but the docs in those practices have a cush schedule as well.

 

[Coastie]

Yes, the bridge program is a 4 year MD/DO degree.

Why is that too hard for some people to swallow?

My buddies from Australia and Europe read this thread and laughed their collective butts off at how lame (in a bureaucratic sense) the American system has become. That Forbes article remains one of the worst hit pieces I have ever seen: AMA, please respond!

Midlevel-to-MD bridge program.

Why doesn't such a program exist already? It makes perfect sense.

Those who have what it takes can step up, beat their peers who are applying for the same spots, take the USMLEs, go through residency, and prove they are able to handle patients on their own -- on an equal footing.

No watered-down admission requirements. No wussie USMLE-lite pseudotest. I'm talking about the same boards that every med student takes.

Because the patient doesn't care which route you took to become a doctor -- traditional or bridge. All they care about is whether you are competent. And the boards, plus clinical evals, are the best tool we got to measure such a thing.

Such a program would immediately obviate the DNP or proposed D-PA degree.

My biggest problem with the whole midlevels-going-independent thing is that we are going to wind up with underqualified people, who could have never gotten into med school or passed the USMLEs, taking care of patients. They want to circumvent this not for the benefit of the patients, but for the benefit of themselves... so they can call themselves "doctor" without being qualified.

The historical barriers to practice of medicine, as imperfect as they are, exist for a reason. They exist to protect patients. Let's impose the exact same standards on midlevels who wish to practice independently as we do on other physicians. And if they meet these standards, they deserve the designation of "M.D.".

 

[alpha62]

Weakest attempt ever at linking an issue to Iraq. Try again.

The time to " try again " is when you're on month 18 of an Iraq rotation that was supposed to last 6 months. You obviously don't understand how the army works.

 

[Miami_med]

He said that if this crazed hypothetical notion of PAs completing physician residencies were to occur, that 1) there are certainly many PAs who could do it successfully, and 2) the only incentive to such a committment would be if there were some increase in scope or practice freedom afterwards.

What did you think would be the response- "Well golly gee theres no way we could do that, we're not smart enough!"

Many of us on the PA forum have been in practice many years, and have seen residents of all caliber come through the door. It is THAT prespective that enables us to know our abilites.

I was the one who said that PAs don't seek independence, as this is the NATIONAL STANDARD in concordance with the stance of the AAPA and state chapters. No one is speaking for every individual PA, as obviously there are those who desire maximal practice freedom. There are many who have quasi-independence in various ways- practice ownership, limited chart review, remote supervision, solo coverage. PAs like this who have proven their mettle would be the best candidates.

But no PAs are going into practice with the notion that they will have independent practice. If clinical/academic ability and recognition of such permit some to advance to a higher degree of autonomy, so be it. THAT'S a free market at work.

I've tried by and large to stay out of this thread, because these things mostly degenerate. However, I have to say here that this is NOT the free market. All of these schools and their students are funded by the Federal Government. There is a shortage of nurses and midlevel providers (who function as midlevels), but the government continues to fund DNP and now PA doctoral programs, driving people away from where there is actually a need, creating artificial shortages in one sector (which is why even the most incompetent nurses that can't take a BP are now making >$50k/year down here) and creating competition in another.

After all of this, they will then control the payment in 50% of the medical market. Most people don't know what a PA or DNP are. They don't understand medical training. They see a white coat and say doctor. Someone else then pays, and as the payer progressively becomes the government, cost control and politics will become the thing du jour, and the government will happily funnel money to well connected political lobbies that claim lower expenditures.

None of this has to do with the free market.

All of that being said, I really have no problem with people competing at a higher level. If the DNP or PA really is functioning at the MD level, and the people they are treating want them to treat them, I really don't see why they shouldn't be able to do so. This just has nothing to do with whether they will be allowed to or not. Sometimes they will be kept from doing what they can do. Sometimes they will be allowed to do what they shouldn't do. Politics, not competence, will win, and this works both for and against them ALL THE TIME.

 

[kamehame]

"That's because as PAs they get a good salary, no liability, and often can determine their hours."

GOOD SALARY: CHECK

NO LIABILITY: ARE YOU ON MARS? HERE'S WHAT ACTUALLY HAPPENS WHEN A PA BLOWS IT BIG TIME:
PA GETS FIRED AND CAN ONLY WORK AT FEDERAL PRISONS FOR THE REST OF HIS CAREER.
PA, MD, AND HOSPITAL GET SUED
MALPRACTICE COMPANY PAYS OFF SUIT
DOC KEEPS JOB AND HAS TO DO 2 HRS CME ON APPROPRIATE PA SUPERVISION....BLAMES IT ALL ON PA(AS HE SHOULD) AND GOES ON WITH HIS CAREER....

DETERMINE THEIR OWN HRS: ONCE AGAIN: DUDE, YOU HAVE GOT TO BE KIDDING: I HAVE BEEN AT WORK SINCE NOON TODAY AND WILL BE HERE UNTIL 0700....THAT'S A 19 HR SHIFT...AND I AM ON THE NEXT 2 NIGHTS AS WELL(NOT 19'S BUT STILL OVERNIGHTS).
THE DOCS IN MY GROUP WORK 12-14 EIGHT HR SHIFTS/MO(NO DOUBLES EVER AND ONLY 1-2 NIGHTS)
THE PA'S WORK 16-20 TENS AND FREQUENTLY ARE ASSIGNED DOUBLES(2-4/MO) WITH 5+ NIGHTS.THIS MONTH I WORK 230 HRS WITH 9 NIGHTS INCLUDING A RUN OF 16 DAYS IN A ROW, NEXT MONTH I WORK 190 WITH 6 NIGHTS.
and no holidays...who are you kidding...I have xmas off this yr for the 1st time in 6 yrs.....
pa's in most settings work the same schedule as the docs they work with(or in the case of em typically more) including taking call, working weekends/nights/holidays. sure there are cush jobs out there but the docs in those practices have a cush schedule as well.

I didn't bother reading that post, all I know is that all capital letters = correct, apparently. I think they learned that in PA school.

 

[alpha62]

I see all these posts from self appointed defenders of the faith. I gotta wonder is the faith worth defending ?

I routinely see mentally ill pts in my office that have had multiple cosmetic procedures performed on them by B/C fully cred. U.S. Trained Plastic Surgeons. I watch 'Celebrity Rehab With Dr. Drew' exploit wasteoids on camera.

I think the PAs should be the ones that are worried here. Is this what we're aspiring to become?

 

[NDESTRUKT]

I see all these posts from self appointed defenders of the faith. I gotta wonder is the faith worth defending ?

I routinely see mentally ill pts in my office that have had multiple cosmetic procedures performed on them by B/C fully cred. U.S. Trained Plastic Surgeons. I watch 'Celebrity Rehab With Dr. Drew' exploit wasteoids on camera.

I think the PAs should be the ones that are worried here. Is this what we're aspiring to become?

Pointless argument.

I work with some PA's in the Emergency Room and let me tell ya, they all want to be doctors and every one of them were pre-med but didn't have the academic ability to get into medical school (applied and didn't get in). They all b!tch about how the state I am in won't give them independent prescription rights and they always act like they know just as much as the MD's (one of them insisted the respiratory tech to use nebs because the patient was wheezing - yeah he had CHF exacerbation, genius). We MD and MD students are "nice" to the PA's mostly because we should be - it would be immature to be mean to people we work with but deep inside, most of us know you want our turf and the ones we love to be with and respect are few and far between.

I know my n=only a few but that's what I know.

 

[brightness]

Pointless argument.

I work with some PA's in the Emergency Room and let me tell ya, they all want to be doctors and every one of them were pre-med but didn't have the academic ability to get into medical school (applied and didn't get in). They all b!tch about how the state I am in won't give them independent prescription rights and they always act like they know just as much as the MD's (one of them insisted the respiratory tech to use nebs because the patient was wheezing - yeah he had CHF exacerbation, genius). We MD and MD students are "nice" to the PA's mostly because we should be - it would be immature to be mean to people we work with but deep inside, most of us know you want our turf and the ones we love to be with and respect are few and far between.

I know my n=only a few but that's what I know.

This is somewhat confusing to me. A great deal of the PA programs I have looked at - and the one at my school - are just as difficult to get into as medical school, with the added requirement that one have hands on medical experience. Many of the programs require a lot of the same classes, if not all of the same classes, as medical school. Most of the undergrads I know want to go to PA school because they don't want to take on the years of education, but for the most part they are academically able.

 

[brianmartin]

I've got an idea. Want an MD? Pass the boards and do a residency.

 

[Faebinder]

Okay correct me if I'm wrong.. Didn't the DO programs started the same way sorta? Chiropractor style... expanded to become almost like an MD... then became the same as an MD when world war happened and they needed more MDs? Now I might not know my medical history that well but I believe that's the sequence right?

Will we see DNP allowed to take step 1-3 and attend allopathic residency just like DOs? mmm... Not that I would mind.. but then I would argue against the independant license be given before residency.

Random thoughts here.