PAs vote for no supervision, own medical boards

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
I think we are agreeing and I think your approach is admirable + the correct way to do things.

All I'm saying is your approach to dealing with midlevels will be harder for a new grad in a tight job market in 10 years if PAs get what they want. You can always say "my way or the highway" but it's not as easy when your job is less stable, the midlevels have more political clout, and there are docs lining up to replace you and let them do whatever they please.


Sent from my iPhone using SDN mobile


That is a huge problem that I see with EM physicians, we don't support one another.

Your situation is correct if one EM doc will just trample over another, but if we actually put up a united front, then we can get whatever we want.

If EM physicians could ever get together and collectively bargain we could be done away with this nonsense in a matter of weeks.

Members don't see this ad.
 
  • Like
Reactions: 2 users
My wife is in PA school and she says this is about being equal to NPs in terms of employment. Apparently in some states being a PA can make it harder to get hired in some practices. At least this is what the AAPA is telling students.

Ask your wife why PAs need independent boards separate from the board of medicine to be equal in the employment search. Why change names to "physician associate.?"

No one is buying the horses*it AAPA is making up (and you gotta be pretty stupid not to see through it).


Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 3 users
My SO is a PA that has been practicing in the ED since graduating. She demonstrates a valuable reminder that while the AAPA might push agendas, it doesn't represent the stance of all in their profession.

20170520_184932.png
 
  • Like
Reactions: 1 user
Members don't see this ad :)
My SO is a PA that has been practicing in the ED since graduating. She demonstrates a valuable reminder that while the AAPA might push agendas, it doesn't represent the stance of all in their profession.

View attachment 219209


Yeah, my wife would definitely agree with that. She was a very good med school applicant but decided she did not want the weight of being 100% responsible (among other reasons) so she went to PA school.

Her classmates and faculty are a real mixed bag though... definitely a few have a chip or two on their shoulders and would be the kind to rub docs the wrong way. Unfortunately the annoying ones are probably more likely to be overzealous and involved in politics/AAPA stuff.
 
Last edited:
  • Like
Reactions: 2 users
You know, they do have 1 year "residencies"
just ask that empa or whatever guy
 
This is why I don't train them. Sure if they're on my team and ask me a question, I will answer but I won't go out of my way to teach them like I do for my medical students. If they want independence and don't want to play on my team, they can teach themselves. Not wasting my hard work and knowledge on people who don't deserve it.

I'm officially adopting this stance.
 
  • Like
Reactions: 1 user
I teach my midlevels because I sign their charts, we're a team, and I care about our patients.

I want competent APPs.

None of the nps/pas I work with have any interest evaluating high risk chest pain, septic patients, anyone who is unstable, or sick kids, etc. If they see a patient who ends up being more complicated than initially appear, I truly appreciate being aware, am usually already aware due to overseeing the chart/pt, and happy to help in anyway possible. If the patient needs an intervention or complicated disposition, I just take over care and the np/pa is basically grateful not to have to deal with that patient anymore.

On SDN there's an "Us vs them" concept of a militant midlevel who wants something more but this is something I genuinely have never seen in actual practice outside of CRNAs in residency...
 
  • Like
Reactions: 10 users
I teach my midlevels because I sign their charts, we're a team, and I care about our patients.

I want competent APPs.

None of the nps/pas I work with have any interest evaluating high risk chest pain, septic patients, anyone who is unstable, or sick kids, etc. If they see a patient who ends up being more complicated than initially appear, I truly appreciate being aware, am usually already aware due to overseeing the chart/pt, and happy to help in anyway possible. If the patient needs an intervention or complicated disposition, I just take over care and the np/pa is basically grateful not to have to deal with that patient anymore.

On SDN there's an "Us vs them" concept of a militant midlevel who wants something more but this is something I genuinely have never seen in actual practice outside of CRNAs in residency...

"I teach my midlevels because I sign their charts, we're a team, and I care about our patients. I want competent APPs."

I think you put that very well, thank you. I'm sure patients and their families want the same thing.

To those who advocate for the "us versus them" mentality...good luck covering all those shifts. Somebody's gotta see the hand weakness that turns out to be the lacunar stroke. I'm sure you'll pick that up as you're juggling 15 patients at a time. Because after all....you wouldn't POSSIBLY want to listen to your APP teammate as they bounce an idea off of you (and therefore learn from you).

I consider myself extremely lucky that, at the one part-time job where I work with EPs, I am fortunate to work with GREAT EPs who give me appropriate supervision as I burn through 2 patients/hour, including the STEMI/NSTEMI, sepsis, and the rare sick kid. I also consider YOU lucky that YOU are making about $20-$50/hour off of my work.
 
Last edited:
Excuse you. He's a doctor.
He has a Doctorate. And has repeatedly said he never refers to himself as a Doctor to patients. Would you rather him be a DNP (Doctor of Pepper) and refer to himself as Doctor??

Such pettiness should be above you...
 
Last edited:
"I want competent APPs." I think you put that very well, thank you.

I'm sure patients and their families want the same thing.

To those who advocate for the "us versus them" mentality...good luck covering all those shifts. Somebody's gotta see the hand weakness that turns out to be the lacunar stroke. I'm sure you'll pick that up as you're juggling 15 patients at a time. Because after all....you wouldn't POSSIBLY want to listen to your APP teammate as they bounce an idea off of you (and therefore learn from you).

Everyone wants competent midlevels. That is not a question.

But having their national organization now backstab us after teaching and hiring them for decades.... and try to pretend we can't see through the motivations is... insulting to say the least.

"Us versus them" is a mentality wholly self-inflicted. Physicians are not to blame for the attitudes that are emerging.


Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 1 user
Everyone wants competent midlevels. That is not a question.

But having their national organization now backstab us after teaching and hiring them for decades.... and try to pretend we can't see through the motivations is... insulting to say the least.

"Us versus them" is a mentality wholly self-inflicted. Physicians are not to blame for the attitudes that are emerging.


Sent from my iPhone using SDN mobile
I've edited my response slightly since you responded.

Politics is a bitch. The NP/nursing mafia has the PA organizations by the scrotum. The MBAs/C-suits often prefer hiring NPs because of the supposed "independence" of the nurses. Worse yet, some physician would rather have an "independent" APP that they feel they would be less responsible for (arguably an understandably good reason for APP independence).

Yes, we have been pushed over the slippery slope, but the real limitations of this will come in the state-by-state fights. My (albeit limited) understanding of the AAPA (I'm not a member) position on OTP is that the Physician/PA TEAM should determine the level of supervision necessary. That makes some sense to me. If I'm practicing EM, and I'm much better at EM than the rural FP who is my "collaborating physician"....do they really need to sign my charts? However, if I'm working alongside an EP in a busy ED...yes, they are the expert and can reasonably supervise me.

But I disagree that physicians are not to blame. I have written for years that PHYSICIANS should DEFINE the practice of MEDICINE, and work to limit such practice to those who are under the BOARD OF MEDICINE. Diagnosing and treating diabetes, CHF, pneumonia, or the million other medical diagnoses should be under the purview of PHYSICIANS, and not NURSES. Unfortunately you PHYSICIANS have UTTERLY dropped the ball on this, and now we have nurses, naturopaths, and others diagnosing and treating such diseases without ANY involvement of physicians.

You don't get a pass on this. You practice medicine. What....EXACTLY.....does that mean and how does that separate you from the shamans??
 
I also consider YOU lucky that YOU are making about $20-$50/hour off of my work.

To be fair, that 20-50 an hour is not for free. It is in exchange for lending their expertise and years of training, helping you out when you need it, and taking on the vast majority of the medicolegal liability for the patients you see.
 
  • Like
Reactions: 8 users
Members don't see this ad :)
I've edited my response slightly since you responded.

Politics is a bitch. The NP/nursing mafia has the PA organizations by the scrotum. The MBAs/C-suits often prefer hiring NPs because of the supposed "independence" of the nurses. Worse yet, some physician would rather have an "independent" APP that they feel they would be less responsible for (arguably an understandably good reason for APP independence).

Yes, we have been pushed over the slippery slope, but the real limitations of this will come in the state-by-state fights. My (albeit limited) understanding of the AAPA (I'm not a member) position on OTP is that the Physician/PA TEAM should determine the level of supervision necessary. That makes some sense to me. If I'm practicing EM, and I'm much better at EM than the rural FP who is my "collaborating physician"....do they really need to sign my charts? However, if I'm working alongside an EP in a busy ED...yes, they are the expert and can reasonably supervise me.

But I disagree that physicians are not to blame. I have written for years that PHYSICIANS should DEFINE the practice of MEDICINE, and work to limit such practice to those who are under the BOARD OF MEDICINE. Diagnosing and treating diabetes, CHF, pneumonia, or the million other medical diagnoses should be under the purview of PHYSICIANS, and not NURSES. Unfortunately you PHYSICIANS have UTTERLY dropped the ball on this, and now we have nurses, naturopaths, and others diagnosing and treating such diseases without ANY involvement of physicians.

You don't get a pass on this. You practice medicine. What....EXACTLY.....does that mean and how does that separate you from the shamans??


The issue at hand is one of minimum competence, or at least some assurance of it.

Whenever these debates rage, there is always someone who provides anecdotal evidence of their individual capability as an APP, and I have no doubt your and many others like you are very good at your job. I personally have worked with several PA's who I would trust to evaluate my family. There are excellent PA's out there. However....deep down you know it's true that there is a lot of PA who "need a lot of supervision" would be the tactful way to put it.

There is no standardization of minimum competence. The path of becoming a fully BC EM physician is full of requirements where each must prove they have a baseline capability. Some are better than others, but the bar exists, and it is set pretty high. There is no bar for PA's, there is no bar for NP's. You graduate, the vast majority green as the spring grass, and you can enter into practice the next day.

There is NO discussion that a fresh physician who graduated medical school yesterday should be capable of independent practice, it seems odd that there is a discussion that APP's are capable of such feats.

The question then becomes, if not right out of practice....when? How much experience should an APP have before this independent practice? How can we certify that each person has attained such minimum competence? How can we assure the public that we are meeting the needs of the sharply growing numbers of patients, while ensuring we are not putting out practitioners in the field too early who are truly not ready for the awesome responsibility of being the only name on the chart.

These questions MUST be answered, and simple stating it is up each TEAM to determine the level of supervision is not satisfactory. Until they are, the AAPA is just playing "keeping up with the Jones'"
 
  • Like
Reactions: 5 users
The issue at hand is one of minimum competence, or at least some assurance of it.

Whenever these debates rage, there is always someone who provides anecdotal evidence of their individual capability as an APP, and I have no doubt your and many others like you are very good at your job. I personally have worked with several PA's who I would trust to evaluate my family. There are excellent PA's out there. However....deep down you know it's true that there is a lot of PA who "need a lot of supervision" would be the tactful way to put it.

There is no standardization of minimum competence. The path of becoming a fully BC EM physician is full of requirements where each must prove they have a baseline capability. Some are better than others, but the bar exists, and it is set pretty high. There is no bar for PA's, there is no bar for NP's. You graduate, the vast majority green as the spring grass, and you can enter into practice the next day.

There is NO discussion that a fresh physician who graduated medical school yesterday should be capable of independent practice, it seems odd that there is a discussion that APP's are capable of such feats.

The question then becomes, if not right out of practice....when? How much experience should an APP have before this independent practice? How can we certify that each person has attained such minimum competence? How can we assure the public that we are meeting the needs of the sharply growing numbers of patients, while ensuring we are not putting out practitioners in the field too early who are truly not ready for the awesome responsibility of being the only name on the chart.

These questions MUST be answered, and simple stating it is up each TEAM to determine the level of supervision is not satisfactory. Until they are, the AAPA is just playing "keeping up with the Jones'"

How much experience should an APP have before independent practice? Graduate from medical school and complete residency...that's how much experience should be required.
 
  • Like
Reactions: 7 users
To be fair, that 20-50 an hour is not for free. It is in exchange for lending their expertise and years of training, helping you out when you need it, and taking on the vast majority of the medicolegal liability for the patients you see.

Agree, did not intend to imply it is "free" money.

The question then becomes, if not right out of practice....when? How much experience should an APP have before this independent practice? How can we certify that each person has attained such minimum competence? How can we assure the public that we are meeting the needs of the sharply growing numbers of patients, while ensuring we are not putting out practitioners in the field too early who are truly not ready for the awesome responsibility of being the only name on the chart.

These questions MUST be answered, and simple stating it is up each TEAM to determine the level of supervision is not satisfactory. Until they are, the AAPA is just playing "keeping up with the Jones'"

I agree completely, and would like to add 2 points.

1) Physicians should have demanded answers to these questions when the NPs first started the push for independent practice. Now that cat is out of the bag and can't be put back... so NPs, with grossly inferior training to PAs, have a significant hiring advantage over us due to the reduced administrative burden to the practice.

2) I believe the Optimal Team Practice (OTP) pushes for the supervisory agreement to be between the doc and the PA, and not set by some bureaucrat at the state capital. THAT is a good thing as it allows physicians to manage their team.
 
I've edited my response slightly since you responded.

Politics is a bitch. The NP/nursing mafia has the PA organizations by the scrotum. The MBAs/C-suits often prefer hiring NPs because of the supposed "independence" of the nurses. Worse yet, some physician would rather have an "independent" APP that they feel they would be less responsible for (arguably an understandably good reason for APP independence).

Yes, we have been pushed over the slippery slope, but the real limitations of this will come in the state-by-state fights. My (albeit limited) understanding of the AAPA (I'm not a member) position on OTP is that the Physician/PA TEAM should determine the level of supervision necessary. That makes some sense to me. If I'm practicing EM, and I'm much better at EM than the rural FP who is my "collaborating physician"....do they really need to sign my charts? However, if I'm working alongside an EP in a busy ED...yes, they are the expert and can reasonably supervise me.

But I disagree that physicians are not to blame. I have written for years that PHYSICIANS should DEFINE the practice of MEDICINE, and work to limit such practice to those who are under the BOARD OF MEDICINE. Diagnosing and treating diabetes, CHF, pneumonia, or the million other medical diagnoses should be under the purview of PHYSICIANS, and not NURSES. Unfortunately you PHYSICIANS have UTTERLY dropped the ball on this, and now we have nurses, naturopaths, and others diagnosing and treating such diseases without ANY involvement of physicians.

You don't get a pass on this. You practice medicine. What....EXACTLY.....does that mean and how does that separate you from the shamans??

So why do PAs need a board, separate from the board of medicine in order to compete with NPs?

How about they design a mission statement creating a separate PA license governed by the BOM, but explicitly state that it's inappropriate for PAs to run or operate independent practice not under physician leadership? This would allow them to release their leadership from perceived "supervision liability," but make it clear the expert in their respective field still is shaping/setting the practice expectations and readily available to provide care for any patient beyond their scope.

I concede physicians should have fought NPs more vigorously, but the notion that any newly minted PA just graduated might have the legal right to be completely independent is sickening. Just cause the NPs are endangering patient care doesn't make it right for other midlevel groups to jump on board.


Sent from my iPhone using SDN mobile
 
Physicians should have demanded answers to these questions when the NPs first started the push for independent practice. Now that cat is out of the bag and can't be put back... so NPs, with grossly inferior training to PAs, have a significant hiring advantage over us due to the reduced administrative burden to the practice.

That's a fair point, but I hope you're not trying to say that one bad turn deserves another?
 
If I were king, PAs and NPs would both fall under the BOM, and would not have independent practice rights. However there would not be stupid/useless regulations/requirements such as mandated chart review, co-signatures, etc. It would be much like what the OTP is apparently pushing for...the Doc and the PA agree on the level of supervision required.

With regards to the two wrongs: In a perfect world we could fix the initial wrong, NP independence would go away, and then PAs wouldn't have to fight against the greater administrative burden. But I don't see a way to turn back the clock on that, so many PAs feel that the only way to protect their jobs is to push for independence.

It's a damn mess.
 
  • Like
Reactions: 3 users
If this happens, would it not be a direct challenge to NP's and threaten their security of handling the bread and butter cases of medicine? Since NP's already have wedged their way into independent practice maybe their influence could stop this movement in a sort of,but less dramatic, "the enemy of my enemy is my friend" situation.


Sent from my iPhone using SDN mobile app
 
If this happens, would it not be a direct challenge to NP's and threaten their security of handling the bread and butter cases of medicine? Since NP's already have wedged their way into independent practice maybe their influence could stop this movement in a sort of,but less dramatic, "the enemy of my enemy is my friend" situation.


Sent from my iPhone using SDN mobile app

Welcome to the thread.
 
  • Like
Reactions: 1 user
If I were king, PAs and NPs would both fall under the BOM, and would not have independent practice rights. However there would not be stupid/useless regulations/requirements such as mandated chart review, co-signatures, etc. It would be much like what the OTP is apparently pushing for...the Doc and the PA agree on the level of supervision required.

With regards to the two wrongs: In a perfect world we could fix the initial wrong, NP independence would go away, and then PAs wouldn't have to fight against the greater administrative burden. But I don't see a way to turn back the clock on that, so many PAs feel that the only way to protect their jobs is to push for independence.

It's a damn mess.

While some places might prefer NPs due to a separate license others prefer PAs as they are less militant, scope-pushing and better trained.

If this change happens I'm guessing it will be a wash on their employability as they will now be lumped with the chip-on-shoulder NPs. I know my group prefers PAs now but that could definitely change.


Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 1 user
While some places might prefer NPs due to a separate license others prefer PAs as they are less militant, scope-pushing and better trained.

If this change happens I'm guessing it will be a wash on their employability as they will now be lumped with the chip-on-shoulder NPs. I know my group prefers PAs now but that could definitely change.


Sent from my iPhone using SDN mobile


I agree completely.

In my experience the PA's tend to accept and want the supervisory relationship with a physician. NP's seem a little bit...........cantankerous
 
  • Like
Reactions: 1 user
I wish this were the case... unfortunately there really are programs now for doctor PAs. The school claims that this will somehow relieve the primary care shortage.

Can you imagine a conversation like this:

PA: Hi, I'm doctor Smith, your physician assistant.
Patient: So are you the doctor or the PA?
PA: Yes, I'm the doctor physician assistant

LMU ANNOUNCES A NEW MEDICAL DEGREE: DOCTOR OF MEDICAL SCIENCE - Lincoln Memorial University

http://www.lynchburg.edu/graduate/physician-assistant-medicine/doctor-of-medical-science/
I about choked when I saw this so I googled the link. here's an excerpt from the last paragraph:
“The program’s curriculum is designed to fill the educational gaps between the foundational physician and physician assistant curricula,” Serrell said.

that's called medical school and residency mother****er
 
  • Like
Reactions: 9 users
I agree completely.

In my experience the PA's tend to accept and want the supervisory relationship with a physician. NP's seem a little bit...........cantankerous

Ok, so I'm going to call BS on cantankerous -- I prefer poorly trained, arrogant and clueless about what they don't know.
 
  • Like
Reactions: 1 user
I about choked when I saw this so I googled the link. here's an excerpt from the last paragraph:
“The program’s curriculum is designed to fill the educational gaps between the foundational physician and physician assistant curricula,” Serrell said.

that's called medical school and residency mother****er

Everyone wants to be a doctor but no one wants to go to medical school/residency.
 
  • Like
Reactions: 9 users
Whether they can or can't do everything you can as well as you can will be totally immaterial. They will (like the AANP) publish their garbage observational studies "proving" that their care is equal to yours. They will use that "proof" to replace you or drive your salary down.

Patients won't complain because 80-plus percent of the time they have no idea why they are even in the hospital let alone who is treating them. And in case you haven't heard, medical malpractice suits are very rarely about medical outcomes (at least according to Dr. Greg Henry). They could have worse outcomes all over the place, but if they are nicer/better-looking/sweeter-talking than you, they probably won't be sued any more than you.

I'm very sweet talking. This is my only hope.
 
Does this vote by the PAs actually mean anything? Me and my buddies can get together and vote to anoint ourselves Leaders of the Golden Horde but nothing will change for anybody in any way as a result of said vote because there is no Golden Horde, and if there was, we wouldn't simply be able to declare ourselves its leaders.

When all is said and done, can the PAs really do anything without the cooperation of the medical board? And if they vote to create their own independent board, who is going to recognize it and give it authority to regulate healthcare delivery in the real world? At least the Nursing Board has been a real, recognized thing for decades so its push to expand practice rights benefits from said fact that it actually exists and is recognized by government bodies.

So am I understanding this improperly, or is this PA vote literally nothing more than a bunch of PAs getting together and expressing a desire for independent practice with no real world impact resulting from it?
 
Does this vote by the PAs actually mean anything? Me and my buddies can get together and vote to anoint ourselves Leaders of the Golden Horde but nothing will change for anybody in any way as a result of said vote because there is no Golden Horde, and if there was, we wouldn't simply be able to declare ourselves its leaders.

When all is said and done, can the PAs really do anything without the cooperation of the medical board? And if they vote to create their own independent board, who is going to recognize it and give it authority to regulate healthcare delivery in the real world? At least the Nursing Board has been a real, recognized thing for decades so its push to expand practice rights benefits from said fact that it actually exists and is recognized by government bodies.

So am I understanding this improperly, or is this PA vote literally nothing more than a bunch of PAs getting together and expressing a desire for independent practice with no real world impact resulting from it?

Personally I think it should be squashed before it has time to proliferate. Look at the NPs independence.....it probably started off with a few folks wanting autonomy and look what we have now.....


Sent from my iPhone using SDN mobile app
 
I am a PA in ER and I have to say I have NEVER heard one of my colleagues pushing for independent practice. Additionally my classmates working in all sorts of different specialties wouldn't push for this either. Generally, we know what we don't know, and therefore, we are grateful for the guidance of our attending physicians. They are grateful for us, too - I've had many of the docs in the ER tell me that I take a huge load of work off them. I've been doing this for about 18 months... I can manage most of the patients I take on by myself (asthma exacerbation, abdominal pain, lacerations, fractures, headaches, chest pain, whatever) with minimal involvement. Most of the time my questions are brief and they are more than happy to help because they know I've got a sizeable chunk of the ER taken care of. I've developed pretty good instincts when it comes to the patients I need them to take a look at, and then they supervise heavily if they need to. And if they do, I use the moment as a learning opportunity so I can manage it next time. There's a strong anti-PA movement on this board but the reality is we are here to stay, and the vast majority of doctors I know are grateful for that because we are all part of a team whose mission is to take care of patients. I think the independence this is stupid because that's not how our career was designed and we don't have the training for that (although physician assistants with years and years and years of experience working pretty independently may feel differently). I think there's a movement going on because we want to keep up with the nurse practitioners.
 
  • Like
Reactions: 1 user
I understand why the PA factions are pushing for doctoral degrees and more independence. Its because of the Noctors and their agendas. They don't want to get pushed out or left behind.

EM is different than other specialties because we don't have any/much say in who our midlevels are. Its different than a surgical PA that a surgeon can train 1 on 1 and escalate their level of competency, say similar to a PGY2 resident or something. We don't have that luxury.

Many on here feel midlevels increase their liability, especially new grads or poorly trained ones. For the most part I unfortunately agree. The best PA's I have worked with finished an EM 'residency' (I hate to use that word but thats what they call it) that are about 1-2 years. I wish it was mandated to have that sort of training to work in the ED.

Given the corporate aspect of medicine, I feel that likely in several years they will increase the number of midlevels we supervise because it decreases their bottom line. They are here to stay. I try to train and help my midlevels as much as I can. Some have chips on their shoulders and are resistant to this. Others do well and try to learn. Most of the time I am busy with med students and residents to help the midlevels much.

The further I go along this road, the more I realize that there is so much outside of my control. I just try to do the best I can, and hope for the best. Try to keep your outlook positive for the most part, which I know is very hard.

I wish the midlevels the best of luck. I want you to be knowledgeable, train and work hard, and be a good part of the team. I want to help you and I think intrinsically most of us on here want the same. please be different than the Noctors, work with us, not against us.

- ThrockMorton
 
  • Like
Reactions: 2 users
I understand why the PA factions are pushing for doctoral degrees and more independence. Its because of the Noctors and their agendas. They don't want to get pushed out or left behind.

EM is different than other specialties because we don't have any/much say in who our midlevels are. Its different than a surgical PA that a surgeon can train 1 on 1 and escalate their level of competency, say similar to a PGY2 resident or something. We don't have that luxury.

Given the corporate aspect of medicine,

The further I go along this road, the more I realize that there is so much outside of my control. I just try to do the best I can, and hope for the best. Try to keep your outlook positive for the most part, which I know is very hard.


- ThrockMorton

I believe this is the only opinion worth adopting in order to maintain sanity.

The train had already left the station fellas!
 
  • Like
Reactions: 1 user
I am a PA in ER and I have to say I have NEVER heard one of my colleagues pushing for independent practice. Additionally my classmates working in all sorts of different specialties wouldn't push for this either. Generally, we know what we don't know, and therefore, we are grateful for the guidance of our attending physicians. They are grateful for us, too - I've had many of the docs in the ER tell me that I take a huge load of work off them. I've been doing this for about 18 months... I can manage most of the patients I take on by myself (asthma exacerbation, abdominal pain, lacerations, fractures, headaches, chest pain, whatever) with minimal involvement. Most of the time my questions are brief and they are more than happy to help because they know I've got a sizeable chunk of the ER taken care of. I've developed pretty good instincts when it comes to the patients I need them to take a look at, and then they supervise heavily if they need to. And if they do, I use the moment as a learning opportunity so I can manage it next time. There's a strong anti-PA movement on this board but the reality is we are here to stay, and the vast majority of doctors I know are grateful for that because we are all part of a team whose mission is to take care of patients. I think the independence this is stupid because that's not how our career was designed and we don't have the training for that (although physician assistants with years and years and years of experience working pretty independently may feel differently). I think there's a movement going on because we want to keep up with the nurse practitioners.

you're absolutely right. I have never heard my colleagues want or push for indep. funny enough I have had NP patients that demand to be called "doctor" or request to have that title placed in their chart. umm. no. The best chuckle was this one NP refused to be seen by other than a physician for something very simple. I have no doubt the ANA is all behind this, driving up the "education" requirements, legislature which is causing the pa lobby to do the same. unfortunately they have used their historic trust from the public, sheer numbers to push their agenda, but have not increased their medical education only a facade of one. I can't say I ever recall a PhD in "energy requirements of bedpan vs bedside commode" doing much in the clinical setting. it's not that we're anti PA its the commercialism that 2 yrs of education/clinical training plus a "masters" will provide a comparable knowledge base to 4 yrs of education+3-7 yrs of residency/fellowship. here's the other issue: with the rise of the midlevel, higher expectations of seeing more complex patients, and supposedly comparable knowledge, we as physicians are still on the hook for any of your malpractice. we're getting more charts to co sign, taking on more liability, without any real benefit.

its' only natural of increase of Independence. PA programs are designed to supplement undeserved areas and to address the physician shortage, started back in the 60's when vietnam battlefield medics came back to the states. the theory was they've got the hands on skill already and first hand experience of rural medicine. that's basically any rural area USA. let's toss in 2 years of just what you need to get by medical knowledge. History of the Profession > Physician Associate Program | Medical Education | Yale School of Medicine. the biggest diff is the legality today, the wide range of specialties and the brainwashing of the NP.

and it's "you don't know what you don't know".
 
  • Like
Reactions: 1 user
And in case you haven't heard, medical malpractice suits are very rarely about medical outcomes (at least according to Dr. Greg Henry).

I have a lot of experience representing physicians in malpractice cases, and with due respect to Dr. Henry (whom I've had the pleasure of meeting--interesting guy), it's always about the outcome, because without the bad outcome they're not going to sue. What would be more accurate to say is that it's not always about negligence--in my experience, in fact, it's USUALLY not about negligence. But that's a topic for another post.

But what part of what makes MLPs cheaper is that they don't need to pay exorbitant malpractice premiums because they're often not found to be negligent--if everything you do has to be reviewed and signed off on by someone else, it considerably narrows the liability. PAs can get million-dollar policies for peanuts as a result. But if they start practicing independently, the liability is all on them. And suddenly they (or their employers) are going to have to pay more for malpractice coverage. And when they're paying what you're paying for coverage, they're not going to be as happy taking so much less money. And their employers are not going to view someone with equal liability and much less training/skill/knowledge as much of a bargain. Because plaintiffs' lawyers, who are among the most innovative people on the planet, WILL NOT HESITATE to play the "not adequately trained" card in front of a jury. Not so much against the mid level, I'd guess, but more likely against the hospital/clinic/whatever entity employed them. I can almost picture the "this never would have happened if they hadn't been to cheap to hire doctors!" argument now.






Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 3 users
I understand why the PA factions are pushing for doctoral degrees and more independence. Its because of the Noctors and their agendas. They don't want to get pushed out or left behind.

EM is different than other specialties because we don't have any/much say in who our midlevels are. Its different than a surgical PA that a surgeon can train 1 on 1 and escalate their level of competency, say similar to a PGY2 resident or something. We don't have that luxury.

Many on here feel midlevels increase their liability, especially new grads or poorly trained ones. For the most part I unfortunately agree. The best PA's I have worked with finished an EM 'residency' (I hate to use that word but thats what they call it) that are about 1-2 years. I wish it was mandated to have that sort of training to work in the ED.

Given the corporate aspect of medicine, I feel that likely in several years they will increase the number of midlevels we supervise because it decreases their bottom line. They are here to stay. I try to train and help my midlevels as much as I can. Some have chips on their shoulders and are resistant to this. Others do well and try to learn. Most of the time I am busy with med students and residents to help the midlevels much.

The further I go along this road, the more I realize that there is so much outside of my control. I just try to do the best I can, and hope for the best. Try to keep your outlook positive for the most part, which I know is very hard.

I wish the midlevels the best of luck. I want you to be knowledgeable, train and work hard, and be a good part of the team. I want to help you and I think intrinsically most of us on here want the same. please be different than the Noctors, work with us, not against us.

- ThrockMorton

Great name. Saw one of these a couple months back for the first time.


Sent from my iPhone using SDN mobile app
 
I am a PA in ER and I have to say I have NEVER heard one of my colleagues pushing for independent practice. Additionally my classmates working in all sorts of different specialties wouldn't push for this either. Generally, we know what we don't know, and therefore, we are grateful for the guidance of our attending physicians. They are grateful for us, too - I've had many of the docs in the ER tell me that I take a huge load of work off them. I've been doing this for about 18 months... I can manage most of the patients I take on by myself (asthma exacerbation, abdominal pain, lacerations, fractures, headaches, chest pain, whatever) with minimal involvement. Most of the time my questions are brief and they are more than happy to help because they know I've got a sizeable chunk of the ER taken care of. I've developed pretty good instincts when it comes to the patients I need them to take a look at, and then they supervise heavily if they need to. And if they do, I use the moment as a learning opportunity so I can manage it next time. There's a strong anti-PA movement on this board but the reality is we are here to stay, and the vast majority of doctors I know are grateful for that because we are all part of a team whose mission is to take care of patients. I think the independence this is stupid because that's not how our career was designed and we don't have the training for that (although physician assistants with years and years and years of experience working pretty independently may feel differently). I think there's a movement going on because we want to keep up with the nurse practitioners.

Thats great you arent pushing to be independent. So stop paying dues to the AAPA and write them you don't support their agenda.

Obviously there are plenty that "say" they don't support this misguided policy but their silence allows the militant leadership to keep pushing it.




Sent from my iPhone using SDN mobile
 
  • Like
Reactions: 1 users
it's always about the outcome, because without the bad outcome they're not going to sue.
Ostensibly it's about the outcome, but wouldn't you agree that when you dig deeper into the majority of these complaints, the real reason they are suing you has to do with the fact that the family felt they were mistreated/lied to/given the run-around in some way? I'd also be willing to bet many cases are simply legalized extortion, with the plaintiff seeking to make a windfall but knowing full-well the physicians or "PRovider" did nothing wrong.
 
ike to add 2 points.
Ostensibly it's about the outcome, but wouldn't you agree that when you dig deeper into the majority of these complaints, the real reason they are suing you has to do with the fact that the family felt they were mistreated/lied to/given the run-around in some way? I'd also be willing to bet many cases are simply legalized extortion, with the plaintiff seeking to make a windfall but knowing full-well the physicians or "PRovider" did nothing wrong.

nope..disagree with first comment. Bad outcome. The rest of stuff is from hospital RM...Unfortunately no good way to conduct real action/look into problem b/c lawyers run this country
 
I have a lot of experience representing physicians in malpractice cases, and with due respect to Dr. Henry (whom I've had the pleasure of meeting--interesting guy), it's always about the outcome, because without the bad outcome they're not going to sue. What would be more accurate to say is that it's not always about negligence--in my experience, in fact, it's USUALLY not about negligence. But that's a topic for another post.

But what part of what makes MLPs cheaper is that they don't need to pay exorbitant malpractice premiums because they're often not found to be negligent--if everything you do has to be reviewed and signed off on by someone else, it considerably narrows the liability. PAs can get million-dollar policies for peanuts as a result. But if they start practicing independently, the liability is all on them. And suddenly they (or their employers) are going to have to pay more for malpractice coverage. And when they're paying what you're paying for coverage, they're not going to be as happy taking so much less money. And their employers are not going to view someone with equal liability and much less training/skill/knowledge as much of a bargain. Because plaintiffs' lawyers, who are among the most innovative people on the planet, WILL NOT HESITATE to play the "not adequately trained" card in front of a jury. Not so much against the mid level, I'd guess, but more likely against the hospital/clinic/whatever entity employed them. I can almost picture the "this never would have happened if they hadn't been to cheap to hire doctors!" argument now.


Not if they're independent. And if the rewards get passed on to the cross-signing MD, then they're really not cheaper then, just under-trained doctor surrogates.
 
We are arguing semantics here.
Without the negative outcome, there's no lawsuit, period. You don't see doctors getting sued because the patient had back surgery, is now pain free, but "was treated mean".
It's because they still have back pain. Or they got an infection. Or whatever.

Same thing in EM. People die. We can't stop it. People lose function/limbs/consortium. It's rarely our fault. But we are the ones that get sued if the patient doesn't like the demeanor.
You can be mean and right, or you can be nice and wrong. You can never always be right though.
 
  • Like
Reactions: 1 user
I find this hard to believe for PAs. They have to pass an ACLS course before they graduate.

This statement quite literally epitomizes the midlevels don't know what they don't know concept. Pattern recognition and following an algorithm of too fast, too slow, shockable or not shockable, and maybe give some mag does not equate to being able to read an EKG.
 
  • Like
Reactions: 10 users
The future of medicine quite honestly scares the crap out of me. Physicians are getting more and more specialized, we are lengthening subspecialty training, adding subspecialty board exams, and hospitals are starting to require these increasing credentials for physicians. Yet, at the same time less trained "providers" (I hate that word as it's used to make us equal, or interchangeable to the MBAs in admin) are simply getting legislated into equivalency. Why will anyone spend 7+ years in medical school plus residency to be seen as an interchangeable "provider"? An NP can graduate and open up a clinic of their choosing while if I wanted to go open a medicine clinic I'd never get a dime from insurance and the first bad outcome that came along I'd get annihilated for practicing outside my scope of expertise, but the nurses are ok practicing "to the full scope of their license". It's maddening.

If physicians don't rally aggressively in the coming years we will be equals, if at the very least in salary.
 
  • Like
Reactions: 3 users
I find this hard to believe for PAs. They have to pass an ACLS course before they graduate.

I should be able to do trauma surgery in the OR, I took and passed ATLS....

In serious though, ACLS is hardly an ability to read EKGs or do procedures.
 
  • Like
Reactions: 2 users
There are ekg(s) that are straightforward, then there are ekg(s) that a gaggle of cardiology residents can't agree on.
 
  • Like
Reactions: 1 user
PAs who do EM should be competent reading EKGs. Every PA gets the broad basics on reading EKGs during their PA education (think Dubins). If a PA goes into EM it is incumbent on them to learn how to read them better (think Amal Mattu). An EMPA should understand the inappropriate concordance of Sgarbossa's in a chest pain patient with a LBBB or pacer, and know how to look for Brugada's/WPW in a syncope patient.

That being said, many shops require the EP to read all EKGs. One busy shop I'm PRN at, where I work alongside EPs, has that requirement. It's easy in that busy environment to simply let the EP read the EKG and make the chart entry.

NPs however often do not have ANY standardized "provider-level" education on reading EKGs. Just worked a shift with a new-grad NP who told me she got ZERO education on EKGs in her NP program. The last time she had "learned" EKGs was in nursing school 10 years ago.
 
Top