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  • Physician Assistants Considering Lobby For Independence



    Michael C. Doll, MPAS, PA-C and incoming President of the American Academy of Physician Assistants recently wrote an article found HERE. In which he made some interesting points about Physician Assistants (PAs).

    Mr Doll states in the article that

    Physicians are seen as independent providers, and PAs are seen as dependent providers. In cardiac surgery (my specialty) I cannot do open heart surgery by myself; I need my surgeon.
    He further goes on to explain that a very experienced family practice PA made the statement which turned around his thinking. He said
    “Your surgeon cannot operate without you. He’s dependent upon you.”
    He goes on to express how he feels that really no one is a 'dependent' provider since everyone is truly interdependent.

    He makes an excellent point when he talks about performing procedures.

    ..if a PA has a complication from that chest tube insertion, she carries the same degree of legal responsibility as the surgeon and can get sued independent of the surgeon. As a well-seasoned PA, I cannot remember the last time a surgeon “supervised” or was physically present at the bedside of one of my procedures. When I work in the CT ICU overnight, my surgeon (who is asleep at home) is not “supervising” my work.
    Mr Doll makes an excellent point when he talks about the reality of modern day practice and makes it clear that true teams are "dependent on each other" and it is much more realistic to consider this a collaboration in the same way all practitioners collaborate with each others regardless of initials.

    Mr Doll also makes another great point when he says
    What I am advocating for is a leveling of the practice field, from a regulatory standpoint for the PA profession.
    . I think all APRNs (including CRNAs) feel the exact same way.

    He further states that
    When performing any clinical task, PAs are expected to have the exact same clinical proficiency and outcome as physicians.
    This is true of all APRNs, PAs, CRNAs but the physician lobby does not want to recognize it even in the face of volumes of case law backing it.

    He makes a final comment that clarifies all the legislative hurdles the Physician Lobby tries to impose in order to maintain control and limit competition with other providers and access to care for patients. It brings home the point all of us are always making.

    ..until restrictions are eliminated, PAs will not be permitted to give their patients timely, efficient and effective care.
    This underscores the fact that for the physician lobby it is about incomes and not outcomes or access regardless of the evidence against their position and lack of evidence for it. Physicians create significant research for medical science for the benefit of patients and yet when it comes to APRNs, CRNAs and PAs their lobby ignores all the evidence in favor of restriction which keeps revenue generated by these professionals always tied to (and streaming to) their members.
    Comments 22 Comments
    1. AnesRes2014's Avatar
      AnesRes2014 -
      Aw hell, let's just let every group do whatever they want, it obviously doesn't matter to outcomes. I'm going to slap a code pack on the nearest CNA I can find and let them have at...
    1. Esper's Avatar
      Esper -
      I take it you disagree? No one is advocating the new grad PA be independent. Those PAs with significant experience however shouldn't be bound by arbitrary rules. Now we've tried to have these rules lifted, like the stupid fact I can't order a cpap machine for OSA but can place a subclavian, and the physician lobby has been an obstacle every step of the way. So now enough PAs are seeing the light that

      physicians, as a organized group, are never going to be supportive of our profession. So instead of being regulated into extinction despite more training than independent NPs, time to cut the umbilical cord.

      How it will be done is being explored now with attempts by multiple groups independent of each other.
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by Esper View Post
      I take it you disagree? No one is advocating the new grad PA be independent. Those PAs with significant experience however shouldn't be bound by arbitrary rules. Now we've tried to have these rules lifted, like the stupid fact I can't order a cpap machine for OSA but can place a subclavian, and the physician lobby has been an obstacle every step of the way. So now enough PAs are seeing the light that

      physicians, as a organized group, are never going to be supportive of our profession. So instead of being regulated into extinction despite more training than independent NPs, time to cut the umbilical cord.

      How it will be done is being explored now with attempts by multiple groups independent of each other.

      Sorry, but that is a slippery slope that, as a CRNA, I want NO part. In fact, it would be hypocritical of the CRNA profession to endorse PA independence while still wanting to keep AAs dependent, which of course, both groups are.
    1. Esper's Avatar
      Esper -
      Hypocritical how? We are completely different professions and governed by entirely different laws. What's hypocritical is not supporting people with proven outcomes. I practice solo EVERY DAY. Please tell me specifically why you should oppose PA independence and I'll show you why it's hypocritical.
    1. Teillard's Avatar
      Teillard -
      This provocative question aside, on a related note, it has always occurred to me that the almost venomous support of AA's by some MDA's as a solution to the CRNA "problem" is a bit naïve to say the least. Only a matter of time until AA's get "upitty" too.

      As far as "mid level" groups (spare me the finger waving, I use the term for expediency) supporting each other in their respective bids for independence, whatever that may mean, I too am cautious.

      The quid pro quo may get a little awkward. Will PA organizations rally behind AA's when AA's decide they don't need an anesthesiologist?
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by Teillard View Post
      This provocative question aside, on a related note, it has always occurred to me that the almost venomous support of AA's by some MDA's as a solution to the CRNA "problem" is a bit naïve to say the least. Only a matter of time until AA's get "upitty" too.

      As far as "mid level" groups (spare me the finger waving, I use the term for expediency) supporting each other in their respective bids for independence, whatever that may mean, I too am cautious.

      The quid pro quo may get a little awkward. Will PA organizations rally behind AA's when AA's decide they don't need an anesthesiologist?


      Yep!! This exactly. Once again, far too slippery of a slope, IMHO, for CRNA's to take up this cause.
    1. gaspass3's Avatar
      gaspass3 -
      No one is advocating the new grad PA be independent. Those PAs with significant experience however shouldn't be bound by arbitrary rules.

      How would this happen? Who would decide? What kind of "significant experience" would be required? At what point in the experience continuum does a PA become just as good as? These are all questions that pop into my head when I read your resonse. While highly program specific as to what skills and training a new CRNA possesses, theoretically they come out of school able to hit the ground running from day 1. I do not think the profession would ever consider making an arbitrary line for experience that one must cross before they are considered able to be independent.
    1. Esper's Avatar
      Esper -
      Well the fortunate thing is we do not need CRNA support. You have you hands full blocking AA practice and since nothing we do affects CRNA, I doubt a single cent would be spent on anything to do with it.

      Likewise I doubt we would care about anything that AAs do. Not our pig, not our farm.

      There are multiple tracks in the works. A PA in New Mexico is currently working on PA autonomy after 3 years experience for primary care only. This is the same model that NPs have in Maine, except they only require 2.

      LMU COM recently started a 2 year Doctorate of Medical Science, that can only be applied for after 3 years experience, that will possible lead to expanded scope. They are currently working on the legislative process as well. Doesn't sound anymore arbitrary than CRNAs rallying for 3 years RN experience before they are capable of going into anesthesia.
    1. nomadcrna's Avatar
      nomadcrna -
      I agree with Esper. In the real world, PAs and Nps are interchangeable. Guess what? PA/NPs are also interchangeable with physicians. I've found the initials mean squat. It's the person. good and bad in all 3 professions. The PAs already function independently as do the NPs. The NPs have it codified in law (22 states) while the PAs have to have a "relationship" with a physician who may do a chart review or even just a phone call once a month. Some states you don't talk to your physician "collaborator" for months unless you are late with their check. I see no reason why the PAs can't cut the string just as we NPs/CRNAs are doing.

      Ron
      Quote Originally Posted by Esper View Post
      Well the fortunate thing is we do not need CRNA support. You have you hands full blocking AA practice and since nothing we do affects CRNA, I doubt a single cent would be spent on anything to do with it.

      Likewise I doubt we would care about anything that AAs do. Not our pig, not our farm.

      There are multiple tracks in the works. A PA in New Mexico is currently working on PA autonomy after 3 years experience for primary care only. This is the same model that NPs have in Maine, except they only require 2.

      LMU COM recently started a 2 year Doctorate of Medical Science, that can only be applied for after 3 years experience, that will possible lead to expanded scope. They are currently working on the legislative process as well. Doesn't sound anymore arbitrary than CRNAs rallying for 3 years RN experience before they are capable of going into anesthesia.
    1. nomadcrna's Avatar
      nomadcrna -
      And here is the kicker. The PA doctorate is actually made up of clinical education. Not fluff crap like APRNs have. This will hurt us (APRNs).

      Quote Originally Posted by nomadcrna View Post
      I agree with Esper. In the real world, PAs and Nps are interchangeable. Guess what? PA/NPs are also interchangeable with physicians. I've found the initials mean squat. It's the person. good and bad in all 3 professions. The PAs already function independently as do the NPs. The NPs have it codified in law (22 states) while the PAs have to have a "relationship" with a physician who may do a chart review or even just a phone call once a month. Some states you don't talk to your physician "collaborator" for months unless you are late with their check. I see no reason why the PAs can't cut the string just as we NPs/CRNAs are doing.

      Ron
    1. Esper's Avatar
      Esper -
      Quote Originally Posted by nomadcrna View Post
      I agree with Esper. In the real world, PAs and Nps are interchangeable. Guess what? PA/NPs are also interchangeable with physicians. I've found the initials mean squat. It's the person. good and bad in all 3 professions. The PAs already function independently as do the NPs. The NPs have it codified in law (22 states) while the PAs have to have a "relationship" with a physician who may do a chart review or even just a phone call once a month. Some states you don't talk to your physician "collaborator" for months unless you are late with their check. I see no reason why the PAs can't cut the string just as we NPs/CRNAs are doing.

      Ron
      Thanks for being the voice of reason, Ron.
    1. icudropout's Avatar
      icudropout -
      As a CRNA who is also a NP and PA, I often tell nurses interested in anesthesia because of the independence, that it is not so black and white. As a PA i worked in urgent care and saw and treated patients all weekend long as the only provider in the facility. If i had a question of what to do, they more than likely needed an emergency room with more resources, so I would send them there. I had a physician who was supervising me on paper, nothing more. Some CRNAs wait for a physician to prescribe an anesthetic plan, induce the patient, and call for orders if there is any change in plan. Who is more independent? I say the PA. The problem for the PA profession is that, Physicians control it, if they move from dependence to independence the physician organizations that support the PA profession will become enemies. I doubt the current PA organization would support a strong move for independence.
    1. Esper's Avatar
      Esper -
      Quote Originally Posted by icudropout View Post
      As a CRNA who is also a NP and PA, I often tell nurses interested in anesthesia because of the independence, that it is not so black and white. As a PA i worked in urgent care and saw and treated patients all weekend long as the only provider in the facility. If i had a question of what to do, they more than likely needed an emergency room with more resources, so I would send them there. I had a physician who was supervising me on paper, nothing more. Some CRNAs wait for a physician to prescribe an anesthetic plan, induce the patient, and call for orders if there is any change in plan. Who is more independent? I say the PA. The problem for the PA profession is that, Physicians control it, if they move from dependence to independence the physician organizations that support the PA profession will become enemies. I doubt the current PA organization would support a strong move for independence.
      They already fight us on everything. From schedule 2 rx rights to eliminating co-signature. The leadership is slowly realizing this, so they have stopped the multiple grass root campaigns that have cropped up. In short, physicians, as a group, never had our back in all of history.
    1. MmacFN's Avatar
      MmacFN -
      And esper, they never will.
    1. AnesRes2014's Avatar
      AnesRes2014 -
      Quote Originally Posted by MmacFN View Post
      And esper, they never will.
      I think this is the perfect thread for this conversation. My earlier post was mostly snark out of frustration, and maybe I should verbalize my thoughts more clearly.

      To set the background: I'm going to argue that medicine, like every natural and unnatural system, has a hierarchy. Like a company, like the military, like a pack of wolves, like a drug ring. Somebody has to be in charge and someone has to take orders. Not everybody gets to be a special snowflake. Otherwise there is complete anarchy. In medicine, the hierarchy is typically based on level of education (and secondarily the level of experience).

      I'm sure you all appreciate that. You must feel like going to CRNA school has provided you with knowledge and a skill set you didn't have as ICU nurses, just like your ICU skill set put you a step above floor nurses. I know this because there are endless threads on here bemoaning all the grads who interview after 6 months in the ICU and start after 14 months. Likewise, most of you probably feel like your education allows you to be better than AAs (or else you wouldn't fight them so hard, because it's definitely not about the money ;-) ).

      I assure you, physician attitudes towards mid-levels (whether PAs, NPs, or CRNAs), comes from the same place. Granted, it's more complicated because the education is not linear (like it is from RN to CCRN to CRNA), but the idea behind more education/experience = better decision-making remains the same.

      And I know some people might argue, well maybe MDs have too much training. This is where the slope gets tricky, because where does it stop? What's to stop someone from arguing that maybe CRNAs also have too much training? Why do you need all that schooling to take care of a healthy ASA1 lap chole? An RT can intubate and extubate, and any ICU nurse could handle sedation and hemodynamic titration of an intubated patient. So where does it end?

      Ideally, it would end with data, but it's just not there. I won't belabor this point because I've gone over it ad nauseum in other threads, but I doubt we will ever know the answer, there are just too many variables. So in the absence of data, I'm just going to fall back and argue that more education (and experience) are never a bad thing.
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by AnesRes2014 View Post
      I think this is the perfect thread for this conversation. My earlier post was mostly snark out of frustration, and maybe I should verbalize my thoughts more clearly.

      To set the background: I'm going to argue that medicine, like every natural and unnatural system, has a hierarchy. Like a company, like the military, like a pack of wolves, like a drug ring. Somebody has to be in charge and someone has to take orders. Not everybody gets to be a special snowflake. Otherwise there is complete anarchy. In medicine, the hierarchy is typically based on level of education (and secondarily the level of experience).

      I'm sure you all appreciate that. You must feel like going to CRNA school has provided you with knowledge and a skill set you didn't have as ICU nurses, just like your ICU skill set put you a step above floor nurses. I know this because there are endless threads on here bemoaning all the grads who interview after 6 months in the ICU and start after 14 months. Likewise, most of you probably feel like your education allows you to be better than AAs (or else you wouldn't fight them so hard, because it's definitely not about the money ;-) ).

      I assure you, physician attitudes towards mid-levels (whether PAs, NPs, or CRNAs), comes from the same place. Granted, it's more complicated because the education is not linear (like it is from RN to CCRN to CRNA), but the idea behind more education/experience = better decision-making remains the same.

      And I know some people might argue, well maybe MDs have too much training. This is where the slope gets tricky, because where does it stop? What's to stop someone from arguing that maybe CRNAs also have too much training? Why do you need all that schooling to take care of a healthy ASA1 lap chole? An RT can intubate and extubate, and any ICU nurse could handle sedation and hemodynamic titration of an intubated patient. So where does it end?

      Ideally, it would end with data, but it's just not there. I won't belabor this point because I've gone over it ad nauseum in other threads, but I doubt we will ever know the answer, there are just too many variables. So in the absence of data, I'm just going to fall back and argue that more education (and experience) are never a bad thing.
      For the most part, you hit all the key points. One little gripe, though..

      Somehow, with the (historical) use of 'mid-level', we (meaning our physician counterparts) got to the assumption that all APRNs/PAs (can only) provide a nice, comfortable, mid-level-type care, while our esteemed physician colleagues provide high-level-only care. Granted, not shown for PS-4/5s, data is clear that in routine care, 'mid-levels' provide just as equally effective/safe/efficient care as physicians. And if that's true, then physicians can also be mid-levels. No?

      Anyway, using mid-level or advanced provider or CRNA or PA or whatever, will probably be going on well after I've moved on to the next life. Good discussion, though.
    1. AnesRes2014's Avatar
      AnesRes2014 -
      Quote Originally Posted by ethernaut View Post
      For the most part, you hit all the key points. One little gripe, though..

      Somehow, with the (historical) use of 'mid-level', we (meaning our physician counterparts) got to the assumption that all APRNs/PAs (can only) provide a nice, comfortable, mid-level-type care, while our esteemed physician colleagues provide high-level-only care. Granted, not shown for PS-4/5s, data is clear that in routine care, 'mid-levels' provide just as equally effective/safe/efficient care as physicians. And if that's true, then physicians can also be mid-levels. No?

      Anyway, using mid-level or advanced provider or CRNA or PA or whatever, will probably be going on well after I've moved on to the next life. Good discussion, though.
      We will stop using the term "mid-level" when y'all stop using the term "MDA." ;-)
    1. AnesRes2014's Avatar
      AnesRes2014 -
      Anyway, I just always assumed mid-level referred to the amount of education (between RN and MD), not as a descriptor for quality of care. You can provide quality care whatever the initials are behind your name.
    1. ethernaut's Avatar
      ethernaut -
      I agree. I was half-ribbing.
      I do think it's pretty prevalent in the entire physician community to utilize the term mid-level. To what definition, is the variable. As many of us have read (gleaned) from many, many SDN posts, CRNAs are half-care/half-good, and MDs are full care/best-good.
    1. neopusher's Avatar
      neopusher -
      Quote Originally Posted by AnesRes2014 View Post
      I'm going to argue that medicine, like every natural and unnatural system, has a hierarchy. Like a company, like the military, like a pack of wolves, like a drug ring. Somebody has to be in charge and someone has to take orders. Not everybody gets to be a special snowflake. Otherwise there is complete anarchy. In medicine, the hierarchy is typically based on level of education (and secondarily the level of experience).
      I think this is a good point and I'd like to address it, because I think it has a lot of relevance both to this topic and to many others that we go back and forth about here.

      In many settings - though not all - it does make sense to have someone "in charge". It is kind of the natural order. Bosses and hierarchies are prolific for a reason. And I think lots of ML's would agree that if you are going to have someone in charge of a group of clinicians, it makes sense for several reasons that that person be a physician. Not because the ML's need to be closely directed by a MD at every turn, but for other reasons.

      I personally have no problem having a boss. No doubt that is in part because I am a new CRNA and I not only don't mind, but actually welcome input from people who have been doing it much longer than me. But being new isn't the only reason - I learned long ago was that I am a worker bee and have no interest in running any show. I have no desire to be in charge of or responsible for anything other than my own performance. I think there are lots and lots of people out there that feel similarly. I suspect that most midlevels don't mind reporting to and taking guidance from a physician who respects their expertise and doesn't take every opportunity to assert their authority and micromanage.

      Why the constant pushes for independence from physicians than? It has nothing to do with not wanting a boss. It has nothing to do with needing to be at the top of the hierarchy. Not for most of us, anyway.

      What it does have to do with more than anything, is pragmatism. The reality that the ASA and other physician groups refuse to acknowledge is that most midlevels already work with little or no effective "supervision" anyway. Many if not most primary care NP's and PA's only see their supervising MD once a month or less. That MD doesn't help or direct or teach or guide the NP or PA in any way, shape, or form. Literally all they do is collect a fee and provide a signature that satisfies a legal requirement. In anesthesia it's the same way. Many CRNA's have no MDA supervision at all. And many that are "supervised" on paper aren't in reality. Removing that facade has practical and economic value.

      And really, to many of us, that facade is actually well and good and tolerable, because we like what we do and we don't need to be the boss and we're more concerned with living our lives and doing our jobs than being political and rocking the boat. But then every time we turn around we see an article or a position statement put out by the professional associations that our physician bosses belong to warning the public about how undereducated we are compared to physicians and how important it is to patient safety that we are supervised by MD's. It is untrue and it is insulting. If you want to turn a CRNA who just does their job and goes home into a "militant" CRNA who gives money to their PAC and starts calling their legislators about medical supervisory issues, what do you think is the best way to do it?

      So I don't think there is any problem with a hierarchy. I don't think most of us object too strongly to having a MD as a boss. But be a boss, then. Be around, provide useful guidance and helpful input and assistance. Don't be sipping coffee in the lounge or playing golf in the sun or sitting in an office 50 miles away while you bill for the work we are doing and then turn around and lie to the public and the lawmakers about how important your "presence and direction" is. It is a lie and it is economically wasteful and it is insulting.
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