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| The Reality of PA Practice at the Conclusion of the First Decade of the 21st Century: Reality 2 - Our Image is Supported by Our Standards. |
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by Bob Blumm, MA, PA-C, DFAAPA - June 14, 2010
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Standards; it seems as if everyone is talking about them today. We are either creating a standard, improving standards, setting standards or raising a standard. Ultimately, as each decade passes, we are adding to standards, and this seems appropriate considering the needs concerning health care in the United States and our world standing in health care. I always assumed that we were just number one and was disheartened to discover that my assumptions were grounded in my patriotism instead of evidence based studies that were meant to cause us to reflect on our “standard of care.”
What does the word “standard “connote to the average PA or perhaps, NP? It may be interpreted as an entry level degree or appropriation of a Master’s degree or the pursuit of a doctoral degree. Some of these considerations were never on the landscape in the past and many would never have expected them to surface beyond the horizon but they did and they are confronting the NP world in 2015. What seems like impossibility may also surface on the PA universe in the future as many administrators may seem this to be an appropriate endpoint. One of the lessons I learned from attending the NCNP conference in Chicago last month was that if we as a profession do not set our own standards, someone else or another profession will surely try to do it for us. If ever we needed cohesive futuristic leadership, it is now!
What do I personally think of standards? Personally, I believe that standards are a positive modifier of our practice protocols and approaches to medical problems. I see the patient as the ultimate winner when a profession has high standards. Standards lead to increased study and increased competence. Standards are set with the support of a solid academic environment, education secured at conferences and CME provided by associations on the Internet, they are enhanced by experience and certified by procedural book attestation such as residents became familiar with through rotations. There will, in the near future, be a mandated procedural attestation required within institutions of medical care. As we look at specialty areas in medicine we note that either a residency or a specialized track of education and experience define what the institution requires for an NP or a PA to fill a slot. Using Critical care Medicine as an example, the critical care physician has passed two boards, Internal Medicine and Critical Care Medicine. Ten years ago I saw this specialty as a new niche for PAs and wrote two articles encouraging PAs to enter the field. They did not respond in large numbers but the NP counterparts did and have proven themselves able to competently perform the responsibilities that were set in place by the incorporation of standards and protocols. There are a moderate percentage of PAs entering and working in this field and they are doing an outstanding job. Many of these differ from their NP and physician counterparts as they were former CT or Neurosurgical PAs. A colleague that I have known for years, Bruce, started a group and is supplying by contract, the critical care needs of an entire health care system in New York.
Many of the specialty areas have a need for highly experienced, highly motivated and extremely well educated PAs and NPs to enter their sub-specialty and are willing to provide a mini-residency. Some of these specialties require additional education, CME, preceptorship, a specialized curriculum and an advanced degree. I will repeat a sentence that I wrote ten years ago;” the time is quickly coming upon us that will no longer place on a resume” PA seeking a hospitalist role----willing to learn, seeking physician willing to teach.” Physicians are engaged in their own fight for survival and are focusing on internal issues that affect their profession and are no longer demonstrating the altruism that they have in the past where they sought to be the “teacher” of a non physician. The economy, the new health care laws, the insurance mandated reimbursements, malpractice issues and huge financial debt incurred while becoming better doctors have caused them to protect their own turf or area of responsibility.
What will be the standard for the 21st century PA for the next decade? The PA will be a graduate of a Master’s Program , will be highly intelligent, have an interest to further their education by means of residencies of various length to better prepare them for the arduous task of caring for an additional 31 million patients in a decade with decreasing numbers of physicians. The PA will be a “team member that possesses a team attitude and team spirit” as the care of patients will be delivered by highly trained and functional teams. Personally, I see this as a positive move and will be comforted as a patient to realize that all of the medical personnel with whom I have a relationship will share a unified approach and have a defined attitude of caring that will enhance my care or my wellness. I think that the Nursing profession will continue to grow in this same direction as they are recognized experts in so many specialties today. Appreciating each other and being respectful of each other’s knowledge and contribution to patient care will become an expected standard for all health care members.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| Bob Blumm (Amityville, NY) |
on 20 Jun 2010 at 8:37 pm |
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Thanks for yoiur thoughts Greta. The Matser's will be an endpoint but this will not effect those already practicing as they are covered by the Grandfather laws. As far as training prior to becoming a student, this was a core requirement years ago when most of us were Medics, Corpsmen, EMTs and Nurses. Experience has always been the best teacher although quite a few of our new PAs are hitting the mark with their zeal, intellect and aggressive study.
Bob |
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| TP (Texas) |
on 16 Jun 2010 at 4:02 pm |
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Well put, Bob. Are the expected changes for both inpatient and outpatient care venues? Will the MD role remain only as a "collaborator" once the gatekeeper feels the patient is not improving? At what point should this collaboration be manadated and by who? The State Medical Board? The State Nursing Board? Managed Care? The patients themselves? Who should the providers be held accountable to? The State Medical Board? The State Nursing Board? Should PA's and NP's join into one title as midlevel provider (MLP's)? As an MLP, does this label infer that we are not the final answer for patient management?
Patient "ownership" is an extremely important concept is it defines responsibility from both a medical, legal and financial standpoint. Will management be by protocol or intuition and medical logic based on evidence based double blinded studies or even cost?
These are just a few hard questions which come to mind as these are issues are ones we deal with on a daily basis. As seems to be the standard, it's extremely difficult to get 2 providers to agree on a management technique let alone 5 or ten providers. If things go badly, will it be the ER MD's that handle these patients or the collaberation of admitting providers involved in the events prompting admission?
Much to do it seems. |
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| Greta Peck PA-C (Kalkaska, Mi ) |
on 16 Jun 2010 at 8:26 am |
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I think if the PA profession requires a masters degree it will do two things:
1. tip those who may be trying to decide medical school versus physician assistant program toward medical school. And why not? The debt will be approximately the same and the length of schooling. I could never have afforded the time or the financial commitment as a fifty year old single mother with 15 years experience as a registered nurse. I would not have attempted to move on under those circumstances but am so grateful that I took the chance and many of my patients are grateful as well. I took the non-traditional route. That would no longer be possible under what you are proposing. Like medical school, this profession would be beyond the reach of many more.
2. It makes me think about the long term viability of our profession to raise the stakes so high. I would rather see pre-program requirements raised........require at least some kind of experience in medicine before letting loose totally in-experienced PAs on the population. And we still would be requiring doctor supervision so no independent practise. |
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| Bob Blumm (Amityville, NY) |
on 15 Jun 2010 at 8:41 pm |
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That was perhaps the most intellectual response that I have ever encountered. I was obliged to read slowly and I cannot disagree. Yes, there will be a "gatekeeper" who most likely will be a physician but with medicine changing as it is, those gatekeepers are very likely to be NPs. Whoever has the responsibility, they will need the sense of commitment to the patient and the ability to dance between the specialists and other team members to gather ideas, reports and tests so that an ultimate game plan can be devised.
In some cases I see this as slowing down a process with some unwieldy delays however, this can also be a catalyst for fresh thoughts and suggestions on management which will enhance the diagnostic acumen of all of the team members.
Not unlike other changes in medicine, there will be bumps as we try to navigate this new territory but I believe the final results may be better and certainly, the liability will be shared evenly.
Bob |
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| TP (Texas) |
on 15 Jun 2010 at 5:16 pm |
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| Having experienced 30 years of acute quaternary care and ongoing primary care for the neonate to geriatric patient populations, I can attest to seeing these purported changes occuring over the years. The multidisciplinary approach to patient management certainly is the trend of the future, however, it is not wtihout its caveats. Medical and surgical management of a patient usually has one \"attending\" MD who is ultimately responsible from both a medical and legal perspective. Management by committee is very time consuming and often delays urgent treatment. Also, there are well documented differences in the medical model of patient management and other less evidenced based management genres. I anticipate continued \"turf battles\" before the any utopic patient management team manages the patient. |
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