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Past perfection

Jennifer M. Coombs, PhD, PA-C

The wi-fi password at the AAPA conference in Las Vegas last month was, aptly, “Beyond50,” or
past perfection, as the joke goes about those beyond the ripe age of Ȓ years. The debates on the House of Delegates (HOD) floor were excellent, and after conversations with students, PAs, and fellow PA faculty, I felt both buoyant and ambivalent about the future. The debate was heated and historic representing the uncertainty and the optimism that the next 50 years will be as bright and successful as the last 50. I want to sum up
what I gleaned from the final vote in the HOD. The AAPA leadership implored that we not quote from the HOD document as it needs to be cleaned up and spelling and synaptic errors removed. But I will sum up what it means to me, with the caveat on accuracy. I like the term
optimal team practice (OTP), although I know it sounds like a euphemism, akin to calling a prison camp a relocation center.

According to the HOD final report from the conference, Reference Committee A, “Optimal team practice is when PAs have the ability to consult with a physician or other qualified medical professional, as indicated by the patient’s condition and the standard of care, and in accordance with the PA’s training, experience, and current competencies.” Furthermore, the report states, “the evolving medical practice environment requires flexibility in the composition of teams and the roles of team members to meet the diverse needs of patients. Therefore, the manner in which PAs and physicians work together should be determined at the practice level.” This very important point is that the physician-PA partnership should be decided at the practice level. As well, chart cosignatures should be decided at the practice level and not prescribed in law or statue. A PA should be able to receive a license from a medical board made up by PAs, nor should PA licenses be tied in any way to physicians. PAs also should not have to obtain letters of recommendation from physicians (who may not be involved in their training) to receive a license. The phrase
supervising physician has evolved to
collaboration and beyond, to be removed altogether from state laws. PAs should be included in all legislation in all states that list providers, NPs, physicians, and PAs. A complete and total uncoupling from the language of
supervising physician but with this proviso: only in states that can and wish to do so. Already, model legislation has been passed in some states that removes the word
supervision from the PA practice law.

Now we can let the handwringing begin. Will we as PAs be able to move from specialty to specialty or to primary care? Will PAs lose the support of their physician partners? Will all PAs be required to obtain doctorates? Does this mean independent practice and why did I become a PA anyway? Isn’t the dependent (but autonomous) relationship with physicians the definition of our profession, our very raison d’etre? What about PA programs? Will programs in schools of medicine be asked to leave? Will physicians read the news and think the worst, that PAs no longer wish to be team players, in spite of the term optimal team practice? What will happen if rural PA providers lose their supervision?

Other issues were discussed in the testimony of many participants in the HOD. The most important is the loss of job share to NPs. There was compelling data that office managers consider hiring a PA to be complicated, technical, and with onerous paperwork. The perceived ease of hiring someone who doesn’t need supervision (and the completely assumed lack of front-end paperwork) makes it hard for even experienced PAs to get hired. The loss of job share to NPs solely due to licensing issues is a problem overdue for a fix. The Veterans Administration (VA) has notoriously struggled to maintain job share to the NPs who have often been paid better. The lack of parity in the treatment of NPs and PAs in the VA has frustrated those inside and outside the system. PA leadership in the VA moved to use the word
collaboration, pushing and pulling the language from the NPs’ own rules.

Not only the administrators but the physicians themselves have told PAs they don™t want to supervise any longer. When the PA profession began, PAs made physicians’ lives easier by letting them see more patients and letting money flow back into the practice. Now physicians are being hired by large healthcare organizations. Supervision adds to their workload instead of reducing it. They are saying, “You’re not getting us home earlier, so why do it?” It is like they are making a choice: “Do you want me to produce or supervise?” They do the same amount of collaboration at the end of the day, even if they hire a NP over a PA, but it is the perception that supervision will take more time than collaboration. The other perception is legal. Who is responsible? If the PA makes a mistake, and the physician is the supervisor, ensuing litigation may involve the physician.

As we move into our next decade of practice, past perfection, the 60-year celebration should be even more interesting and significant than this 50th year. As I write this, the questions asked of me by a group of non-medical students are, “What is the difference between a PA and a doctor?” and “What can’t you do?” The answer may appear in the future.

Jennifer M. Coombs is an assistant professor in the Division of Physician Assistant Studies, Department of Family and Preventive Medicine at the University of Utah School of Medicine in Salt Lake City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


 


 

Published: 6/12/2017 7:57:00 AM

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