Provided by Clinician 1

Hey you know the old “S” word. The one all PAs and some NPs have to work with in their practices. The one that is hardly done and almost never done well. The one we all roll our eyes about because we can be running a clinic 400 miles away from our “supervisor” and we both know all is fine. The one whose culture is stuck in the 1960s when it evolved from a management style rooted well before that.

We need a paradigm shift in how we all work together. Those that do not need total independence must still look at the words and concepts we use and what they mean to the rest of the world that hears them.

Which leads me to question one. Can you ever become an “expert” and still have a law that requires you to be closely watched by someone else your ENTIRE career?

I have had an epiphany about the word supervision, it was NEVER meant to really work. We were all set up. The physicians never bought into it. To those that would say they did, where are the mandatory classes they should have been mandated to attend to show them how to do it effectively? And supervision to what ends? What were the results supposed to look like? How could you measure it’s success? Any manager knows those are the benchmarks of corporate evaluation systems. Most physicians still don’t even understand what supervision is and what it was meant to achieve (nor do PAs and NPs). Although I truly believe the original PAs and NPs and needed it, supervision has never really worked the way it was supposed to. Supervision is a term the AMA placed into legislative language (see not only us but CRNAs, midwives and even PTs) when it wanted the public to think the person “supervised” needed to be closely scrutinized. Why? Look at the word. To the public, it means very closely watched, but it really means more. To many, having to be supervised means you are not capable of handling your duties on your own. If you were capable would you have to be watched? We have to realize that people use this word very differently than we use it. The word has no bearing on how competent we are, never has. It does feed a perception that our professions need watching. Exactly what the AMA wanted, even today, 40 years after it was chosen. I agree that when you are just out of school you should be “supervised”. With benchmarks, with agreed upon measurements, with a way to keep moving up. Possibly with 360 degree evaluations so you can also evaluate your “supervisor” and that evaluation would count. Imagine that, NPs and PAs evaluating physicians or at least how well they mentor. I hate to tell you but this is done in most businesses. Everyone gets evaluated and if done well everyone gets better. Many occupations and professions have that. Physicians closely evaluate residents, but sooner or later the “supervision,” the close scrutiny ends, as they move up the ladder of competency. All professionals and non-professionals do. That’s called vertical mobility. Something we don’t really have. Another evolution needed.

Question two is more interesting and requires more common sense. In the business world you are supervised (or a nicer word, mentored) by people who have a real stake in your future. quite significantly, many physicians do not want to supervise as it takes valuable time away from their too busy schedules and they don’t know what they are supposed to be achieving anyway. If there was a real plan, a course to take, a different more autonomous level of NP or PA you would get to by being supervised, it would be different. Again, in the corporate world, in the military, in almost every profession, the goal is for you is to replace your supervisor and for them to keep being promoted. These supervisors are almost always formally trained in HOW to supervise, how to raise morale, how to mentor. Always with the end result of seeing the employee/soldier/trainee move up and accept more responsibility. Then the supervisee becomes the supervisor. Logical. Physicians have never taken a course on how to “supervise” or how to collaborate or how to mentor well. I would question whether many of them, even if they did, have a direction they want you to grow towards anyway. Take over the practice, NO. Be more autonomous, too threatening. Independence, don’t bring that up. So what is the preparation for? If there is no place for us to go, what are the means to the end? Even being a better clinician should someday lead to the lessening of the supervision requirements. Common sense.

Lastly, and of equal significance is possibly the most interesting question; have any evidence based studies shown that closer supervision (or collaboration) makes us better clinicians? Not that I know of. What does make one better is motivated teaching. Leaders who want to take you and mentor you. Many of us owe much to physicians, PAs and NPs who have taken us under their wings and really made us learn, made us better clinicians. None of us would be here without them. No one would question mandatory teaching if the teacher wants to teach, the student is open to learning and there are objectives that are measurable. No one would question guidelines that were evidence based and showed that the way people learn and progress is best done with a combination of A B and C. After all, the better we get, the more high quality patient care we can give. But this is not today’s supervision and it never will be. Please show me some studies that show that NPs and PAs who practice in their clinics without much collaboration or supervision practice worse quality medicine than those who practice with physicians all around them. I bet we would find it does not matter. And now we all know why, we don’t know what we are doing or where it is supposed to lead us. Supervision, which may have been needed when PAs and NP first came on the scene has never grown with the professions. It was become a nuisance and a barrier to care as PAs and NPs need it so they can practice. It has become a way for physicians to gain a side income but not something that is thought of positively.

I feel it is time to take this pejorative word out of our lexicon. Personally not so I can practice independently, but because supervision is a political word and a poorly thought out concept which is misleading to our professions, the public and our fine education. Let’s define that place we are to go and get there. Time to call supervision what it should be called MENTORING and require real learning objectives for all health professionals who will mentor. It would actually be nice to have a mentoring PA, NP or physician and know there is a place they will take me where I will grow with my personal goals and our patients best interests at heart.

Does the term mentoring physician sound nice?

Until next week,

Dave

Dave has been a PA, and later NP, leader for thirty years. He strongly believes that NPs and PAs must work together to insure a better future for both professions. Most recently Dave has been busy launching another dream; Clinician 1, the first internet community for PAs and NPs. In October 2008, Dave was honored by the New Jersey State society of PAs with its “Lifetime Achievement Award”.

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