AAEM Position on APPs

[Psai]

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Friends, ACEP published similar statements TWENTY YEARS AGO. Glad AAEM could catch up.

Twenty years ago the AMA cared more about their physicians as well

 

[lemurcatta]

I never sat in on a PA class, but the attitude is so prevalent that they must get it from someone. Are they getting it from professors, peers, or online?

Weird. it’s not at all “prevalent” from my perspective. And this is from knowing personally faculty from multiple programs in two (very) different states, and having PA student and practicing PA friends across the country. It’s not an exaggeration to say every single PA I know will either roll their eyes or literally get upset when NP full practice authority is brought up. I’m an older non-traditional student who was a paramedic for 10 years prior to entering PA school so I have some fairly non-superficial relationships I’m basing this on. Most of us have mad respect for the depth and rigid of physician training. By the way, our training isn’t a walk in the park either though.

 

[NicMouse64]

Weird. it’s not at all “prevalent” from my perspective. And this is from knowing personally faculty from multiple programs in two (very) different states, and having PA student and practicing PA friends across the country. It’s not an exaggeration to say every single PA I know will either roll their eyes or literally get upset when NP full practice authority is brought up. I’m an older non-traditional student who was a paramedic for 10 years prior to entering PA school so I have some fairly non-superficial relationships I’m basing this on. Most of us have mad respect for the depth and rigid of physician training. By the way, our training isn’t a walk in the park either though.

I never said this was true everywhere, but it is being more common as the barrage of "equality" with these BS studies come out. It may not be prevalent now, but it is becoming moreso.

 

[lemurcatta]

I never said this was true everywhere, but it is being more common as the barrage of "equality" with these BS studies come out. It may not be prevalent now, but it is becoming moreso.

Those non-inferiority studies are from departments of nursing and are bull****. Maybe this isn’t everyone’s view but it should be

 

[Matthew9Thirtyfive]

FWIW, the PA program I initially was accepted to way back in the day had that “med school in 2.5 years” attitude as well. That was 15 years ago.

And I know at least one PA school in TX puts out that attitude. My friend is in PA school there and told me the same crap.

 

[LeroyJenkinsMD]

If only that society’s position changed anything...

 

[NicMouse64]

Those non-inferiority studies are from departments of nursing and are bull****. Maybe this isn’t everyone’s view but it should be

right, and the fact that you are a PA and understand makes me hopeful that there will continue to be PAs that understand their limitations. I will make sure to have PAs such as yourself in the future to help provide good care. That doesn't change the fact that there is a very sizeable (minority???) of PAs that think that independence is reasonable.

 

[Adventurer753]

AAEM joined

 

[jw3600]

EMPA society or whatever their name is put out a nasty gram.

This is the move most of us had seen coming from all the PAs who claimed for years and even as recently as last year that they had no desire to ever be independent. Whelp. Guess that’s over.

Response to AAEM

Also I love when PAs get petty about the “physician’S” vs “physician” assistant thing. Like yeah I agree that traditionally the possessive S isn’t used. But look at the name lol! How do you think the name was derived??

 

[NicMouse64]

EMPA society or whatever their name is put out a nasty gram.

This is the move most of us had seen coming from all the PAs who claimed for years and even as recently as last year that they had no desire to ever be independent. Whelp. Guess that’s over.

Response to AAEM

Also I love when PAs get petty about the “physician’S” vs “physician” assistant thing. Like yeah I agree that traditionally the possessive S isn’t used. But look at the name lol! How do you think the name was derived??

Jimmys rustled lol. Good for the AAEM. Their response is basically like "WHY DIDN'T YOU TELL US YOU DON'T WANT US TO BE INDEPENDENT. That's so mean. Doctors are mean. boo hoo."

 

[lemurcatta]

EMPA society or whatever their name is put out a nasty gram.

This is the move most of us had seen coming from all the PAs who claimed for years and even as recently as last year that they had no desire to ever be independent. Whelp. Guess that’s over.

Response to AAEM

Also I love when PAs get petty about the “physician’S” vs “physician” assistant thing. Like yeah I agree that traditionally the possessive S isn’t used. But look at the name lol! How do you think the name was derived??

How do you get that impression from the SEMPA position statement? I think you are seeing what you want to see. The whole SEMPA statement took pains to say PAs still want physician involvement in their care.

“Proud of the team-based approach” PAs utilize. Supports “physician collaboration.” Want supervision decisions in the hands of the docs and PAs at “the site level”. “Not looking to replace EM physicians”

This is not the language you’re going to get from the NP orgs. And if you and the AAEM treat them the same, it’s far easier to band together in future legislative endeavors.

 

[doctalaughs]

How do you get that impression from the SEMPA position statement? I think you are seeing what you want to see. The whole SEMPA statement took pains to say PAs still want physician involvement in their care.

“Proud of the team-based approach” PAs utilize. Supports “physician collaboration.” Want supervision decisions in the hands of the docs and PAs at “the site level”. “Not looking to replace EM physicians”

This is not the language you’re going to get from the NP orgs. And if you and the AAEM treat them the same, it’s far easier to band together in future legislative endeavors.

The AAPA is openly arguing for independent practice while societies such as SEMPA argue for deferring decisions at the “site level” knowing full well that doctors have less and less control over site policies (controlled almost wholly now by corporate overlords willing to hire the cheapest labor that law will allow with little regard to patient safety).

Do you think physicians are stupid (and blind)?

 

[NicMouse64]

How do you get that impression from the SEMPA position statement? I think you are seeing what you want to see. The whole SEMPA statement took pains to say PAs still want physician involvement in their care.

“Proud of the team-based approach” PAs utilize. Supports “physician collaboration.” Want supervision decisions in the hands of the docs and PAs at “the site level”. “Not looking to replace EM physicians”

This is not the language you’re going to get from the NP orgs. And if you and the AAEM treat them the same, it’s far easier to band together in future legislative endeavors.

collaboration indicates an equal level of training and knowledge. Double speak, ever heard of it? They are just using buzzwords that have no meaning to hide their true intentions. Independent practice. That's the goal and they are slowly moving goalposts. This was never the intention of those who started the PA profession. The idea was to be closely supervised in the medical model. Not "collaborating" or whatever words you decide to come up with today or tomorrow to mean "equivalent" and "independent" or "evil doctors" etc. etc.

 

[lemurcatta]

The AAPA is openly arguing for independent practice while societies such as SEMPA argue for deferring decisions at the “site level” knowing full well that doctors have less and less control over site policies (controlled almost wholly now by corporate overlords willing to hire the cheapest labor that law will move the patients with little regard for safety).

Do you think physicians are stupid (and blind)?

You are misrepresenting the AAPA and you probably know very little about the context and history that led up to their policy position on state regulation of PA Practice. Did you know that there was a time when they were debating calling for full practice authority? There were *very* heated discussions and ultimately the profession decided against it. What was agreed on was what is called optimal team practice. And unequivocally, legislation that is crafted from OTP will NOT allow PAs to hang out their own shingle or work for an employer without physician involvement in their practice. Again, this is different than what the NPs want. This policy even informs the conversations PA advocacy groups have with outside non-physician stakeholders. They told the California state commissioned health care task force that just came out in support of granting NPs full independent practice in CA that we did not want that, and so the recommendation for independent practice was not made for us. This was a behind the scenes conversation that I happen to know about.

And it actually matters when physicians like yourself and your leadership organizations do not make these important distinctions. If therethis develops into a pattern, PAs no longer have the incentive to very carefully craft policy and sponsor legislation that is agreeable to the docs, if you don’t agree with anything we do anyways.

I gotta say, the way you guys handle yourselves, with all your privilege as physicians, (AAEM and here on this forum) lacks the poise and grace of even the SEMPA response which was by its nature defensive.

 

[lemurcatta]

collaboration indicates an equal level of training and knowledge. Double speak, ever heard of it? They are just using buzzwords that have no meaning to hide their true intentions. Independent practice. That's the goal and they are slowly moving goalposts. This was never the intention of those who started the PA profession. The idea was to be closely supervised in the medical model. Not "collaborating" or whatever words you decide to come up with today or tomorrow to mean "equivalent" and "independent" or "evil doctors" etc. etc.

You can believe what you want re: collaboration. This is language is the direction things are headed. Talking about double speak isn’t going to convince policy types who want to increase access for the people in their states, and collobaration and practice level decision making makes it easier to hire PAs. Also, collaboration doesn’t imply equality. Social workers collaborate with physicians in ED dispo. Etc.

Another thing: it doesn’t matter what the creators of the PA profession wanted. We have every right to push and evolve the concept. There is no reason to think what was the right choice in the 60s is what is right today.

Finally, the choice here is change practice led or die off. We face an existential threat from NPs. There is actual data that supports this I can find if you want. Without changing our practice laws, we are more difficult to hire and onboard then they are. You already know that admin types don’t care about clinical staff and want whatever is easiest and cheapest.

 

[enalli]

I’m not here to bend the knee at the physician alter by the way. I’m interested and involved In Health professions policy and just want to do what’s right, and I think independent practice is not the way forward for PAs or NPs. But I gotta say, the way you guys handle yourselves, with all your privilege as physicians, (AAEM and here on this forum) lacks the poise and grace of even the SEMPA response which was by its nature defensive.

You seem to have the roles mixed up here. Midlevels are not the poor innocent victims of an unwarranted attack by physicians--physicians are defending their profession from an intrusion by midlevels. What in the world makes you think we need to act with "poise and grace" when we have a knife sticking out of our back?

 

[NicMouse64]

You can believe what you want re: collaboration. This is language is the direction things are headed. Talking about double speak isn’t going to convince policy types who want to increase access for the people in their states, and collobaration and practice level decision making makes it easier to hire PAs. Also, collaboration doesn’t imply equality. Social workers collaborate with physicians in ED dispo. Etc.

Another thing: it doesn’t matter what the creators of the PA profession wanted. We have every right to push and evolve the concept. There is no reason to think what was the right choice in the 60s is what is right today.

Finally, the choice here is change practice led or die off. We face an existential threat from NPs. There is actual data that supports this I can find if you want. Without changing our practice laws, we are more difficult to hire and onboard then they are. You already know that admin types don’t care about clinical staff and want whatever is easiest and cheapest.

So now that you've admitted it.....what's wrong with the AAEM stance? They are just looking out for patient safety. It's nothing personal.

 

[NicMouse64]

You are misrepresenting the AAPA and you probably know very little about the context and history that led up to their policy position on state regulation of PA Practice. Did you know that there was a time when they were debating calling for full practice authority? There were *very* heated discussions and ultimately the profession decided against it. What was agreed on was what is called optimal team practice. And unequivocally, legislation that is crafted from OTP will NOT allow PAs to hang out their own shingle or work for an employer without physician involvement in their practice. Again, this is different than what the NPs want. This policy even informs the conversations PA advocacy groups have with outside non-physician stakeholders. They told the California state commissioned health care task force that just came out in support of granting NPs full independent practice in CA that we did not want that, and so the recommendation for independent practice was not made for us. This was a behind the scenes conversation that I happen to know about.

And it actually matters when physicians like yourself and your leadership organizations do not make these important distinctions. If therethis develops into a pattern, PAs no longer have the incentive to very carefully craft policy and sponsor legislation that is agreeable to the docs, if you don’t agree with anything we do anyways.

I gotta say, the way you guys handle yourselves, with all your privilege as physicians, (AAEM and here on this forum) lacks the poise and grace of even the SEMPA response which was by its nature defensive.

They didn't decide against full practice authority. They decided to push for it in a more politically acceptable way...... physicians are waking up to what is happening. Don't be surprised when more groups come out with statements like this.

 

[lemurcatta]

You seem to have the roles mixed up here. Midlevels are not the poor innocent victims of an unwarranted attack by physicians--physicians are defending their profession from an intrusion by midlevels. What in the world makes you think we need to act with "poise and grace" when we have a knife sticking out of our back?

I think I came here because I was a medic and a lot of my mentors were docs. And I was upset to see the EM community here make blanket statements about PAs when my personal experiences have differed starkly from the representations here. And how some of you here chose to pick the most uncharitable interpretations of some of our policy initiatives. But I’m limited by my experience and I don’t know what’s happening everywhere.

Not sure anyone from this side is trying to knofe your profession in the back. But actually it’s good to hear this. It’s a reality check for me on what some of you guys are going to think no matter what we do.

 

[doctalaughs]

You are misrepresenting the AAPA and you probably know very little about the context and history that led up to their policy position on state regulation of PA Practice. Did you know that there was a time when they were debating calling for full practice authority? There were *very* heated discussions and ultimately the profession decided against it. What was agreed on was what is called optimal team practice. And unequivocally, legislation that is crafted from OTP will NOT allow PAs to hang out their own shingle or work for an employer without physician involvement in their practice. Again, this is different than what the NPs want. This policy even informs the conversations PA advocacy groups have with outside non-physician stakeholders. They told the California state commissioned health care task force that just came out in support of granting NPs full independent practice in CA that we did not want that, and so the recommendation for independent practice was not made for us. This was a behind the scenes conversation that I happen to know about.

And it actually matters when physicians like yourself and your leadership organizations do not make these important distinctions. If therethis develops into a pattern, PAs no longer have the incentive to very carefully craft policy and sponsor legislation that is agreeable to the docs, if you don’t agree with anything we do anyways.

I gotta say, the way you guys handle yourselves, with all your privilege as physicians, (AAEM and here on this forum) lacks the poise and grace of even the SEMPA response which was by its nature defensive.

Whatever. You can drink the kool aid of your various silver-tongued societies all you want and argue you guys are doing docs a HUGE favor because you arent *as* bad as the NPs.

Why argue for independent PA boards not regulated by the boards of medicine? If independent practice isn’t the end-goal, why not abolish supervisory agreements but specifically state that the team should *always* be led by a physician while PAs are medico-legally fully responsible for their own patients primarily seen by them.... cant have it both ways.

PAs and NPs used to be EXACTLY like paralegals are to lawyers. Paralegals ASSIST lawyers in practicing law - allowing them to get more done then they could do alone. Somehow, midlevels through sheer propaganda and massive lobbying over the years morphed using this “patient team model” jargon into practicing medicine (albeit usually poorly) on their own, instead of assisting doctors in doing so. Cut it any way you want - that is what happened historically in this country. And its one of several reasons why medicine is in such as sorry state here.

 

[jw3600]

Full disclosure PA person. I’m not reading your posts.

“We disagree with the notion that EMPAs must only be supervised by a physician who is board certified in emergency medicine.”

Game over brah.

 

[lemurcatta]

They didn't decide against full practice authority. They decided to push for it in a more politically acceptable way...... physicians are waking up to what is happening. Don't be surprised when more groups come out with statements like this.

That’s a factual claim you are making. It’s probably fine to say “in my opinion it’s a ruse.” Cant argue with that other then to say “I think it’s not a ruse.” But again, factually, I don’t think there is good evidence to support your claim. The motivation is almost entirely to enhance our employability in the face of the seemingly inevitable 50 state NP independent practice campaign. The method is to simply reduce paperwork filed at the state regulatory level and shift supervision decisions to the doctor and PA. But that the last time I’ll say that because honestly it’s probably not helping here.

 

[enalli]

I think I came here because I was a medic and a lot of my mentors were docs. And I was upset to see the EM community here make blanket statements about PAs when my personal experiences have differed starkly from the representations here. And how some of you here chose to pick the most uncharitable interpretations of some of our policy initiatives. But I’m limited by my experience and I don’t know what’s happening everywhere.

Not sure anyone from this side is trying to knofe your profession in the back. But actually it’s good to hear this. It’s a reality check for me on what some of you guys are going to think no matter what we do.

Here's a handy map of what's happening everywhere: State Practice Environment

I know, I know, you don't want to be lumped in with NPs. I actually agree with you: I would rather have a PA by my side rather than an NP. PAs (for now) have fairly standardized in-person training programs with actual rotations. If NPs cared about their knowledge as much as they care about prestige and money, they would be clamoring to have half the training you have.

But we can't exactly go out and say "NPs need to be supervised by physicians; PAs are cool, they already know this." No; we need to have a clear standard for all midlevels: NPs, PAs, or whatever new degree program gets invented in the future. Like it or not, you have to be lumped together for clarity's sake.

 

[lemurcatta]

Whatever. You can drink the kool aid of your various silver-tongued societies all you want and argue you guys are doing docs a HUGE favor because you arent *as* bad as the NPs.

Why argue for independent PA boards not regulated by the boards of medicine? If independent practice isn’t the end-goal, why not abolish supervisory agreements but specifically state that the team should *always* be led by a physician while PAs are medico-legally fully responsible for their own patients primarily seen by them.... cant have it both ways.

PAs and NPs used to be EXACTLY like paralegals are to lawyers. Paralegals ASSIST lawyers in practicing law - allowing them to get more done then they could do alone. Somehow, midlevels through sheer propaganda and massive lobbying over the years morphed using this “patient team model” jargon into practicing medicine (albeit usually poorly) on their own, instead of assisting doctors in doing so. Cut it any way you want - that is what happened historically in this country. And its one of several reasons why medicine is in such as sorry state here.

Cool, man. I mean, that is certainly one way to feel about how medicine should be practiced and I respect it in a way. I happen to disagree and am trying to make a case, but no need to make it personal. Not drinking to Kool aid so much as given you my read of it.

 

[jw3600]

Cool, man. I mean, that is certainly one way to feel about how medicine should be practiced and I respect it in a way. I happen to disagree and am trying to make a case, but no need to make it personal. Not drinking to Kool aid so much as given you my read of it.

Dude I just glanced at your last 50 posts. Literally 95%+ are about midlevel creep, supervising midlevels, comparisons to NP/senior medical students and PA independence. Your intentions are clear as day.

 

[NicMouse64]

Dude I just glanced at your last 50 posts. Literally 95%+ are about midlevel creep, supervising midlevels, comparisons to NP/senior medical students and PA independence. Your intentions are clear as day.

He's doing that one thing that PAs and NPs like to do where they say one thing (ie we don't want independence) then does the other (lobbies legislators for independence). I say let them. Let PAs run their profession into the ground and be lumped in with NPs. I already have family asking me where to find a physician because they are sick of seeing MLPs. If PAs knew what was good for them, they would see the current NP degree mill and being lumped into their profession is a bad long term solution. Physicians will always be there, and PAs can either be a part of the medical model or leave it and face the consequences.

 

[lemurcatta]

Here's a handy map of what's happening everywhere: State Practice Environment

I know, I know, you don't want to be lumped in with NPs. I actually agree with you: I would rather have a PA by my side rather than an NP. PAs (for now) have fairly standardized in-person training programs with actual rotations. If NPs cared about their knowledge as much as they care about prestige and money, they would be clamoring to have half the training you have.

I don't think most would mind being lumped in on a practical level, we are basically interchangeable clinically. Politically we aren't the same though. I understand that there is going to be accusations of OTP being a Trojan horse for independence and expect that as bills are introduced, things will get heated. Change is hard for everyone but the bills *are* going to be introduced and will be passed in at least some states. From a pragmatic perspective, it is helpful to separate out PAs and NPs and deal with them separately at the legislative level because there will be differences in language and sponsors/supporters.

But we can't exactly go out and say "NPs need to be supervised by physicians; PAs are cool, they already know this." No; we need to have a clear standard for all midlevels: NPs, PAs, or whatever new degree program gets invented in the future. Like it or not, you have to be lumped together for clarity's sake.

I don't think anyone is saying there shouldn't be a clear standard in the clinical environment that applies to both NPs and PAs. again, mostly used interchangeably and there should be similar standards. This is how that works out under proposed changes with OTP:

Without OTP: Hospital system A wants to use APPs to help do inpatient admissions overnight. NPs are able to write H&Ps and review patient case with physician at handoff in the morning. PAs have to have arbitrary amount co-signatures on x% of charts because of state-level regulation and discuss y amount of patients with SP at state-mandated weekly or monthly meeting.

With OTP: Hospital system A is able to set policy from the medical committee that treats NPs and PAs exactly the same: neither has to have arbitrary amount of co-sig and both can review admitted patients with doc at practice-designated time and place. The state no longer sets policy from a top down approach but hands decision making to the employer and PA (PA can decide not to work at practice with supervisory requirements they don't agree with).

 

[NicMouse64]

I don't think most would mind being lumped in on a practical level, we are basically interchangeable clinically. Politically we aren't the same though. I understand that there is going to be accusations of OTP being a Trojan horse for independence and expect that as bills are introduced, things will get heated. Change is hard for everyone but the bills *are* going to be introduced and will be passed in at least some states. From a pragmatic perspective, it is helpful to separate out PAs and NPs and deal with them separately at the legislative level because there will be differences in language and sponsors/supporters.


I don't think anyone is saying there shouldn't be a clear standard in the clinical environment that applies to both NPs and PAs. again, mostly used interchangeably and there should be similar standards. This is how that works out under proposed changes with OTP:

Without OTP: Hospital system A wants to use APPs to help do inpatient admissions overnight. NPs are able to write H&Ps and review patient case with physician at handoff in the morning. PAs have to have arbitrary amount co-signatures on x% of charts because of state-level regulation and discuss y amount of patients with SP at state-mandated weekly or monthly meeting.

With OTP: Hospital system A is able to set policy from the medical committee that treats NPs and PAs exactly the same: neither has to have arbitrary amount of co-sig and both can review admitted patients with doc at practice-designated time and place. The state no longer sets policy from a top down approach but hands decision making to the employer and PA (PA can decide not to work at practice with supervisory requirements they don't agree with).

how about no NPs/PAs inpatient alone overnight because they are supposed to be going to rural Primary care clinics anyways.

 

[lemurcatta]

Dude I just glanced at your last 50 posts. Literally 95%+ are about midlevel creep, supervising midlevels, comparisons to NP/senior medical students and PA independence. Your intentions are clear as day.

Yup. Thats why I am here. What intentions did you think I was belying or obscuring?

The problem I see with things going unchallenged on this forum is that it is a massive and publicly accessible space (probably largest of its kind on the internet) where pre-med, pre-pa, patients, and working clinicians will end up at via google searches. If there isn't someone challenging some of the views and occasional misinformation here, it will stand as a sort of prevailing opinion.

 

[doctalaughs]

Cool, man. I mean, that is certainly one way to feel about how medicine should be practiced and I respect it in a way. I happen to disagree and am trying to make a case, but no need to make it personal. Not drinking to Kool aid so much as given you my read of it.

Happy to disagree respectfully.

Seriously though- why is AAPA advocating for a separate board to govern PAs if their “only” motivation is to increase employability compared to NPs? Surely even you can see through that? I can see the argument about abolishing supervisory agreements if the purpose is decrease regulation (although it’s a tenuous argument- signing the paperwork for this takes literally 5 minutes). Believe me, I have no interest in taking liability for a patient I never have seen, but somehow we are *still* on the hook even for the nurses that “practice” under their own licenses (look at the whole CRNA anesthesiologist debacle).

 

[EctopicFetus]

Own your practice and then you have say over your MLPs. Seems simple. Screw the CMGs.

 

[TheComebacKid]

I don't know if any of you are active on Twitter, but here is a response from Swami of EMRAP fame regarding AAEM's statement:


This is why physicians lose. Every. Single. Time.

We live in a society where we are so politically correct that we can't say "NP training is inadequate." This is not a personal attack on the individual NP or their character. But if you are talking about patients, it's a fair point to bring up.

As a physician, I know my limitations, within my own profession. If a patient needs a crich and I have a trauma surgeon/ENT standing next to me, I am going to defer to them ever single time to do it, because I fully concede that they are more experienced than I am, and they have better training when it comes to a surgical airway than I do. They have done more hours of surgical airway training than I have. I don't go around saying, "We should be allowed to do crich's independently without trauma surgery supervision".

If midlevels truly cared about patient care, they would own up to the fact that experience matters. Medical school is the most competitive specialized schooling to get into in the country for a reason. Just like I give it up to the surgeon who has given up their careers to practice the surgical airway, I don't see why midlevels can't do the same for physicians.

I know midlevels will play it as the physicians who have the fragile ego's, but in reality, it's them. I am confident that my training is solid because medical school and a medical residency is literally the gold standard. If midlevels want to create something similar and put in MORE time training than physicians, be my guest and I will gladly support them in their quest for independent practice.

 

[Boatswain2PA]

Do you think physicians are stupid (and blind)?

No. But they have ACTED stupid, blind, and utterly impotent as NPs (who compete with PAs for jobs) have established legal independent rights in most states.

collaboration indicates an equal level of training and knowledge.

no, it doesn't.

What in the world makes you think we need to act with "poise and grace" when we have a knife sticking out of our back?

Grow up and quit playing the victim. Anyone can play the victim if they need to. For example: "Those poor pa'S have been abandoned by their master's who have allowed the NPs to establish independent practice!"

So now that you've admitted it.....what's wrong with the AAEM stance?

The biggest thing I see wrong in the AAEM stance is their push for every EM midlevel (or whateverthehellyouwannacallus) to work for a BC EP. I think the majority of EDs in the country don't have an EP working in them.

Why argue for independent PA boards not regulated by the boards of medicine? If independent practice isn’t the end-goal, why not abolish supervisory agreements but specifically state that the team should *always* be led by a physician while PAs are medico-legally fully responsible for their own patients primarily seen by them.... cant have it both ways.

I would be fine with that. Unfortunately the lawyer's (and judge's are lawyers) wouldn't be. Back to reality now....

PAs and NPs used to be EXACTLY like paralegals are to lawyers. Paralegals ASSIST lawyers in practicing law - allowing them to get more done then they could do alone.

I think that's a great analogy, let's flesh this out a little more.

About 50 years ago the Paralegal was born to ASSIST the lawyers. Back then, lawyers were lawyers. But at about the same time that Paralegals were born, lawyers began to specialize into EMERGENCY lawyering, starting of course in the big cities. As this specialization movement continued, some paralegals also specialized into EMERGENCY paralegaling, and some of these worked in rural areas where there were just typical lawyers who didn't specialize in EMERGENCY lawyering. After all, those EMERGENCY lawyers earned about twice as much as the regular lawyers, and them rural folks just couldn't afford that.

Full disclosure PA person. I’m not reading your posts.

“We disagree with the notion that EMPAs must only be supervised by a physician who is board certified in emergency medicine.”

Game over brah.

Great...you willing to come pull duty in a rural EDs so you can supervise all of us EMPAs out there? Yeah...I didn't think so.

Game's not over kid....

 

[Boatswain2PA]

But we can't exactly go out and say "NPs need to be supervised by physicians; PAs are cool, they already know this." No; we need to have a clear standard for all midlevels: NPs, PAs, or whatever new degree program gets invented in the future. Like it or not, you have to be lumped together for clarity's sake.

I don't think anyone is saying that. However we unfortunately are in a position where the much less-trained NPs are achieving legislative independence, leaving PAs in the dirt.

He's doing that one thing that PAs and NPs like to do where they say one thing (ie we don't want independence) then does the other (lobbies legislators for independence).

Meanwhile there are docs who scream that PAs can't possibly see patient's on their own, yet other doc's who say they don't want to have to sign off.

Physicians will always be there, and PAs can either be a part of the medical model or leave it and face the consequences.

And yet we are facing the consequences of being part of that medical model team....and being left in the dust by the lesser-trained NPs because the physicians no longer control the administration of healthcare.

how about no NPs/PAs inpatient alone overnight

You want more night shifts? Most of the Doc's I work for like it I pull night shift...let's them sleep.

Seriously though- why is AAPA advocating for a separate board to govern PAs if their “only” motivation is to increase employability compared to NPs? Surely even you can see through that? I can see the argument about abolishing supervisory agreements if the purpose is decrease regulation (although it’s a tenuous argument- signing the paperwork for this takes literally 5 minutes).

I am personally against a separate board. I think physicians and PAs need to stick together as we all practice medicine (vice "advanced" nursing, whatever that is), but I understand that I'm at the losing end of that argument. Here's why: If I am working at a single job, with a single physician as my SP....and s/he up and quits/dies/gets arrested/etc....I'm up $hit creek without a paddle as suddenly I can't see patients anymore. This has happened to many PAs, especially rural PAs. Furthermore, some medical boards are unabashedly anti-PA, all the while the NPs (who fall under the "nursing board") continue to grow in independence.

In my perfect world, the physicians would declare what it means to practice medicine, then require anyone who does so to fall under the jurisdiction of the BOM (including PAs, NPs, naturopaths, chiropractors, podiatrists, etc). But I think that horse has left the barn....

As a physician, I know my limitations, within my own profession.

And as a PA, I know mine. You're not that special kid...you're really not.

If midlevels want to create something similar and put in MORE time training than physicians,

I don't disagree with your premise here. The reason the BC physician is at the top of their profession is because of the dedication it took to get into med school right through the completion of residency.

But playing devils advocate...what if that wasn't necessary for xx% of patients. What is xx% was 99%? What if it is 99.9% of patients?

What if I could learn, by investing in the insane amount of training/education that you have, to give the EXACT SAME level of care to 99% of the ED patients that you do?

Scary thought, huh. Especially with the growth of socialized/government controlled medicine.

The "Gold Standard" to detect a PE is a CTA. How many clinically irrelevant subsegmental PEs are we treating with xarelto only to have grandma fall, hit her head, and bleed out.....

 

[Zebra Hunter]

I don't know if any of you are active on Twitter, but here is a response from Swami of EMRAP fame regarding AAEM's statement:


This is why physicians lose. Every. Single. Time.

We live in a society where we are so politically correct that we can't say "NP training is inadequate." This is not a personal attack on the individual NP or their character. But if you are talking about patients, it's a fair point to bring up.

As a physician, I know my limitations, within my own profession. If a patient needs a crich and I have a trauma surgeon/ENT standing next to me, I am going to defer to them ever single time to do it, because I fully concede that they are more experienced than I am, and they have better training when it comes to a surgical airway than I do. They have done more hours of surgical airway training than I have. I don't go around saying, "We should be allowed to do crich's independently without trauma surgery supervision".

If midlevels truly cared about patient care, they would own up to the fact that experience matters. Medical school is the most competitive specialized schooling to get into in the country for a reason. Just like I give it up to the surgeon who has given up their careers to practice the surgical airway, I don't see why midlevels can't do the same for physicians.

I know midlevels will play it as the physicians who have the fragile ego's, but in reality, it's them. I am confident that my training is solid because medical school and a medical residency is literally the gold standard. If midlevels want to create something similar and put in MORE time training than physicians, be my guest and I will gladly support them in their quest for independent practice.

Holy ****. I knew Swami wasnt the sharpest tool in the shed, but that post is ridiculous. The “MD/DO” next to our names means that we have better training than a mid-level. So yes, MD/DO is better than DPA/DNP. To argue otherwise is absurdity.

 

[d2305]

During WW2 medical school was shortened to 2 years, thus Stead got his idea for PAs.

 

[GonnaBeADoc2222]

Own your practice and then you have say over your MLPs. Seems simple. Screw the CMGs.

Not that easy

I don't know if any of you are active on Twitter, but here is a response from Swami of EMRAP fame regarding AAEM's statement:


This is why physicians lose. Every. Single. Time.

We live in a society where we are so politically correct that we can't say "NP training is inadequate." This is not a personal attack on the individual NP or their character. But if you are talking about patients, it's a fair point to bring up.

As a physician, I know my limitations, within my own profession. If a patient needs a crich and I have a trauma surgeon/ENT standing next to me, I am going to defer to them ever single time to do it, because I fully concede that they are more experienced than I am, and they have better training when it comes to a surgical airway than I do. They have done more hours of surgical airway training than I have. I don't go around saying, "We should be allowed to do crich's independently without trauma surgery supervision".

If midlevels truly cared about patient care, they would own up to the fact that experience matters. Medical school is the most competitive specialized schooling to get into in the country for a reason. Just like I give it up to the surgeon who has given up their careers to practice the surgical airway, I don't see why midlevels can't do the same for physicians.

I know midlevels will play it as the physicians who have the fragile ego's, but in reality, it's them. I am confident that my training is solid because medical school and a medical residency is literally the gold standard. If midlevels want to create something similar and put in MORE time training than physicians, be my guest and I will gladly support them in their quest for independent practice.

Easy to tweet this out when you work 2 shifts a month in academic lala land.

 

[NicMouse64]

During WW2 medical school was shortened to 2 years, thus Stead got his idea for PAs.

You mean before we had safe surgery, antibiotics, cancer drugs, and a lot of effective medical treatments? Genius.

On another note I think the point of this PA trolling SDN is to convince EM doctors that there's nothing to fight against with MLP independence. I am not EM, rather just a medical student, but please look out for the profession. Do what is right by patients. Don't sign charts and don't prioritize MLP education over Medical Student education.

 

[GonnaBeADoc2222]

Amazing lobbying + marketing + corrupted corporate pressures have led to our current state.

Anecdotally, I've worked with mostly terrible ERPAs (a handful of truly excellent ones who were a pleasure to be around) and all terrible ERNPs.

I spend probably a total of 30-40 minutes each shift cleaning up their orders, seeing their bouncebacks, seeing patients they are "uncomfortable" seeing.

I see higher numbers of patients, that are more complex, with a faster overall LOS.

You get what you pay for.

 

[enalli]

Grow up and quit playing the victim. Anyone can play the victim if they need to. For example: "Those poor pa'S have been abandoned by their master's who have allowed the NPs to establish independent practice!"

This is rich. Do you honestly think "quit playing the victim" is a "win the argument instantly" card? If you're afraid of pointing out wrongs because you feel emasculated at being called a "victim" then you're the one who has some growing up to do. For what it's worth, both PAs and MDs can be the victims of NP lobbying. If you ever get over your hang-ups of having to pretend you're a tough guy then maybe you will realize this.

 

[Cryc_to_the_point]

no, it doesn't.

Collaborate in this context most certainly implies a level footing and a lack of hierarchy betwixt the parties. Also, maybe elaborate instead of using what is essentially, "no, you."

 

[KeikoTanaka]

When I scribed in the ED before medical school (in a state where there was no PA independence, NY) there was only one PA who ever worked completely independently, and this was the PA who had the most experience in the ED. That PA worked in triage and was the only PA who received a scribe (I loved working with her, she was amazing). There occasionally was another MD/DO in the triage area as well, but typically there was a 3-4 hour period in which there was no overlap so she was completely alone. We saw all sorts of things together and it was a super efficient system. The moment an MI, acute abdomen, severe respiratory complication, etc, was detected by her, she would send them to the back to see a Doctor in the "real ED". The other PAs roamed the ED picking up patients and every shift I would see 1-3 patients from the PA who asked their MD/DO counterpart to see the patient for them, so I had to go into the PA chart and write in an Attestation for the doc. Just given the frequency in which this happened, I don't understand how they could realistically replace EM physicians, or how hospital administration could think it is actually a good return on investment, the physicians could see so many more patients. The PAs saw 12-14 patients in 8 hours while the docs would see 27-32 (on a super busy day, scribing also really helps). They have their place, I never saw an NP in this ED however, it seemed to be very PA friendly.

Just another note too: It is in this same city in NY that I went to undergrad. 5 people from my high school and I went to the same school (way more but those are the people I was friends with). Those 5 people/friends went into the direct-PA route and I went for Biotechnology and Bioscience. Their PA program was a 5 year program (1 year extra for rotations). Our biology courses were the same intensity, mine even higher up in many cases. And, having now gone to medical school, I just realize just how little I learned about biology compared to now. So, my PA counterpart friends definitely can't have that high of an understanding of the pathophysiology of much of what they treat. Which is fine, they have been working now for 3-4 years and I'm sure all the on-the-job training has afforded them to be great PAs and clinicians, but, when **** hits the fan and the presentation of a disease is off.. I worry about their ability to think of a novel treatments on the fly given their lack of biological knowledge.

 

[NicMouse64]

When I scribed in the ED before medical school (in a state where there was no PA independence, NY) there was only one PA who ever worked completely independently, and this was the PA who had the most experience in the ED. That PA worked in triage and was the only PA who received a scribe (I loved working with her, she was amazing). There occasionally was another MD/DO in the triage area as well, but typically there was a 3-4 hour period in which there was no overlap so she was completely alone. We saw all sorts of things together and it was a super efficient system. The moment an MI, acute abdomen, severe respiratory complication, etc, was detected by her, she would send them to the back to see a Doctor in the "real ED". The other PAs roamed the ED picking up patients and every shift I would see 1-3 patients from the PA who asked their MD/DO counterpart to see the patient for them, so I had to go into the PA chart and write in an Attestation for the doc. Just given the frequency in which this happened, I don't understand how they could realistically replace EM physicians, or how hospital administration could think it is actually a good return on investment, the physicians could see so many more patients. The PAs saw 12-14 patients in 8 hours while the docs would see 27-32 (on a super busy day, scribing also really helps). They have their place, I never saw an NP in this ED however, it seemed to be very PA friendly.

Just another note too: It is in this same city in NY that I went to undergrad. 5 people from my high school and I went to the same school (way more but those are the people I was friends with). Those 5 people/friends went into the direct-PA route and I went for Biotechnology and Bioscience. Their PA program was a 5 year program (1 year extra for rotations). Our biology courses were the same intensity, mine even higher up in many cases. And, having now gone to medical school, I just realize just how little I learned about biology compared to now. So, my PA counterpart friends definitely can't have that high of an understanding of the pathophysiology of much of what they treat. Which is fine, they have been working now for 3-4 years and I'm sure all the on-the-job training has afforded them to be great PAs and clinicians, but, when **** hits the fan and the presentation of a disease is off.. I worry about their ability to think of a novel treatments on the fly given their lack of biological knowledge.

How can you diagnose and treat an illness that you don't know exists?

 

[KeikoTanaka]

How can you diagnose and treat an illness that you don't know exists?

Are you talking about the PA in triage? If so, then, to answer your question: You don't, and she didn't. If someone comes in and it's not a very obvious complaint, she would defer to the physicians in the back. The majority of what we saw were: Lac repairs, UTIs, STDs, URIs, drug seekers, back pain, etc. A lot of BS she took care of in triage were PCP complaints for individuals who don't have insurance. The hospital is in a very urban and very poor area. In fact the doctors always let her take the lac repairs over themselves because they knew she loved them. Idk, I think it's very person-to-person dependent (which is the problem with independence, and why I'm not sitting here saying PAs should be able to practice independently, but there is definitely cases where they probably could use lighter supervision when the complaint is very well within the control and they've proven they are competent). Also, to work as a PA Triage in this particular ED, you had to have worked in the ED for 3 years minimum, which I suppose was a way to prove her competence.

 

[NicMouse64]

Are you talking about the PA in triage? If so, then, to answer your question: You don't, and she didn't. If someone comes in and it's not a very obvious complaint, she would defer to the physicians in the back. The majority of what we saw were: Lac repairs, UTIs, STDs, URIs, drug seekers, back pain, etc. A lot of BS she took care of in triage were PCP complaints for individuals who don't have insurance. The hospital is in a very urban and very poor area. In fact the doctors always let her take the lac repairs over themselves because they knew she loved them. Idk, I think it's very person-to-person dependent (which is the problem with independence, and why I'm not sitting here saying PAs should be able to practice independently, but there is definitely cases where they probably could use lighter supervision when the complaint is very well within the control and they've proven they are competent). Also, to work as a PA Triage in this particular ED, you had to have worked in the ED for 3 years minimum, which I suppose was a way to prove her competence.

Sorry, didn't mean to point that towards you, I meant more of how can a PA in a rural hospital treat and diagnose something they don't know exists. I get that this particular PA filled the role of being a physician extender perfectly.

 

[KeikoTanaka]

Sorry, didn't mean to point that towards you, I meant more of how can a PA in a rural hospital treat and diagnose something they don't know exists. I get that this particular PA filled the role of being a physician extender perfectly.

I see. Well, I've said it in other capacities on various topics regarding NP and PA encroachment: I think Physicians need to "Get with the times" and we need to create Telemedicine-Remote-Supervisors for rural NP/PAs who work in areas with little-to-no physician presence. Midlevel providers could utilize a camera along with a "medication queue system". They would in direct contact with a remote provider at all times who can in real time ask patients and the APPs questions if need be. The MLPs/APPS/NPs/PAs (Runs out of breath) could "Queue" up a medication which was recommended by the physician, or if it is a higher tier medication in general that the APP is not normally able to prescribe at their discretion.

I feel the irony of all this MLP-independence is the fact that they're using very rural areas/states as a reason why they need to practice independently. However, just like millennial physicians, millennial MLPs have no intention of actually going to rural areas either. They're just exploiting an intrinsic weakness in our healthcare system: Disparity between rural/suburban/urban healthcare (I see this more-so with NPs, I think PAs only tried doing this in South Dakota). If this was truly the case, then sure, I'm all for independence, but only if you petition/prove that your COUNTY (There are hella rural counties even in major east coast states) is truly physician-scarce and you would truly make an impact on a population who is not receiving any treatment whatsoever. PA-independent practice in the middle of Appalachia is hell of a lot better than those rural elderly individuals going to buy "their dog antibiotics from the nearest Petco 75 minutes away because their dog has a tooth infection" when it's actually for their own health cuz they self diagnosed themselves with strep lol.

 

[Boatswain2PA]

This is rich. Do you honestly think "quit playing the victim" is a "win the argument instantly" card? If you're afraid of pointing out wrongs because you feel emasculated at being called a "victim" then you're the one who has some growing up to do. For what it's worth, both PAs and MDs can be the victims of NP lobbying. If you ever get over your hang-ups of having to pretend you're a tough guy then maybe you will realize this.

You were talking about having the proverbial knife in your back, kinda makes you out to be a victim with that proverbial scenario.

Okay, you got me...you're tougher than me. congrats.

Collaborate in this context most certainly implies a level footing and a lack of hierarchy betwixt the parties.

I guess if that's what is important to you. I collaborate with docs all the time. I also have a supervising physician, and I'm perfectly fine with that. Of course, he's the medical director, so he supervises physicians as well. He just has more paperwork, and more liability, with supervising me.

To be clear, I think we SHOULD maintain a hierarchical system with supervising physicians. 20 years in military operations (not as a provider) has given me a clear understanding of the benefits of a hierarchical system. But I think it's too late to maintain it. As our society has moved more toward "everyone gets a trophy" mentality, it is no longer politically expedient to mention that you are "better" than someone else (that hierarchical "uneven footing" you mention). And while the physician groups were asleep, the nurses established independence.

So what should PAs do? Perfect world we extend the reach of the physicians who run healthcare, but in real world adminiscritters run health care and often would rather hire an NP who doesn't need hassle of supervision.

I meant more of how can a PA in a rural hospital treat and diagnose something they don't know exists.

Same way you treat and diagnose something you don't know exists.

I think Physicians need to "Get with the times" and we need to create Telemedicine-Remote-Supervisors for rural NP/PAs who work in areas with little-to-no physician presence. Midlevel providers could utilize a camera along with a "medication queue system"

Already happening in some places, even in some places with BC EPs calling for tele-neuro for stroke.

 

[BoardEligibleEventually]

Friends, ACEP published similar statements TWENTY YEARS AGO. Glad AAEM could catch up.

A warranty is only as good as the paper it's written on. AAEM was established by a secession of membership from ACEP because ACEP was not delivering on its promises to EPs. This statement is part and parcel for AAEM's mission for the past 25 years, but the climate today has warranted this firm statement from the organization.

 

[Fox800]

A warranty is only as good as the paper it's written on. AAEM was established by a secession of membership from ACEP because ACEP was not delivering on its promises to EPs. This statement is part and parcel for AAEM's mission for the past 25 years, but the climate today has warranted this firm statement from the organization.

ACEP’s continued close relationships with CMGs speaks volumes, they aren’t putting their money where their mouth was 25 years ago.

 

[NicMouse64]

If

You were talking about having the proverbial knife in your back, kinda makes you out to be a victim with that proverbial scenario.

Okay, you got me...you're tougher than me. congrats.



I guess if that's what is important to you. I collaborate with docs all the time. I also have a supervising physician, and I'm perfectly fine with that. Of course, he's the medical director, so he supervises physicians as well. He just has more paperwork, and more liability, with supervising me.

To be clear, I think we SHOULD maintain a hierarchical system with supervising physicians. 20 years in military operations (not as a provider) has given me a clear understanding of the benefits of a hierarchical system. But I think it's too late to maintain it. As our society has moved more toward "everyone gets a trophy" mentality, it is no longer politically expedient to mention that you are "better" than someone else (that hierarchical "uneven footing" you mention). And while the physician groups were asleep, the nurses established independence.

So what should PAs do? Perfect world we extend the reach of the physicians who run healthcare, but in real world adminiscritters run health care and often would rather hire an NP who doesn't need hassle of supervision.


Same way you treat and diagnose something you don't know exists.


Already happening in some places, even in some places with BC EPs calling for tele-neuro for stroke.

all you say is true then what's so bad about the AAEM position? Seems like it perfectly aligns with your beliefs. /endthread