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Physician Assistants: Is it Time for Independent Practice?

pa_independent1In a recent discussion with a fellow physician assistant about the PA profession, the topic of independent vs. dependent practice came up. 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.

Upon making that statement, my fellow PA (retired from family practice) said, “Your surgeon cannot operate without you. He’s dependent upon you.”

That statement, as it relates to modern-day PA practice, was an epiphany for me. To have a successful surgical outcome, my surgeon is not only dependent upon me as his first assistant, but also dependent upon the scrub nurse, the circulating nurse, the CRNA, the lab tech, the CT ICU nurse and many other clinicians and hospital employees.

Are PAs Really the Only “Dependent Providers?”

That clinical reality draws me to ask the following questions: Why don’t other hospital employees carry the same title of “dependent provider,” and why are they not “supervised” in the same legal manner as a PA? I realize that most of them do not carry the same clinical responsibility of a PA, but they do have important roles in the care of patients.

For example: If a CT ICU RN accidently gives an open-heart surgery patient too much potassium replacement, a lethal cardiac arrest could occur. With that said, why can that same RN place orders and write notes in the patient’s medical care that do not require a co-signature by my surgeon?

A CRNA can put a patient to sleep in the operating room and place an endotracheal tube for general anesthesia. Both of those practices carry a high degree of clinical responsibility and risk. The CRNA will document those procedures in the medical record that also do not require my surgeon’s signatures — nor will those procedures be “supervised” by my surgeon.

While it is true that CRNAs are supervised by anesthesiologists, it is equally true that if an open-heart surgery patient has a negative outcome from a procedure that is performed by a CRNA, it is often the surgeon’s responsibility to relay that complication to the patient. But if that same open-heart surgery patient requires a procedure post-op, say a chest tube insertion performed by a PA, “supervision” by a surgeon is required and, in some states, the surgeon’s co-signature of that procedure note is also required.

pa_independent2“Supervision” is a Dated Term

Despite that, 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.

The term “supervision” is a dated term, as it is simply does not reflect modern-day clinical reality. Therefore, more up-to-date and clinically realistic terms like collaboration are now being used by the PA profession.

Now, as with other clinical practices, I know that my surgeon is a phone call or page away to review changes in patient conditions or to discuss treatment plans. In addition, we round on the patients on a daily basis, sometimes twice a day. We are dependent upon each other. As a team, my surgeon and I, along with the other hospital employees, work together to care for our patients. PAs that work in other clinical practices, both medical and surgical, work with similar degrees of autonomy and team-oriented approaches.

Is it Time for Independent PA Practice?

With this all said, the following question does naturally arise: Is it time for independent PA practice? I am not advocating for “true” independent practice, as that type of clinical practice is becoming less of a reality in modern-day medicine. More and more physicians are leaving independent and small group practices to join larger and economically more stable larger group practices or health systems.

In addition, the specialization of medicine and surgery requires that all providers work together more than ever to care for our older and more medically complex patient populations.

What I am advocating for is a leveling of the practice field, from a regulatory standpoint for the PA profession.

Whether it is writing a prescription, performing a well-baby exam, dictating a discharge summary or inserting a central line, a PA carries a significant legal risk for those types of everyday medical and surgical tasks.

Dated Practices are Holding the PA Profession Back

When performing any clinical task, PAs are expected to have the exact same clinical proficiency and outcome as physicians. When the PA profession was “born” in 1967, the concepts of supervision and co-signatures were required in order to gain acceptance by the medical committee to the then newborn profession. Now almost 50 years later, the PA profession is fully grown and accepted by all fields of both medicine and surgery, so much so that the Affordable Care Act identified PAs as one of the three clinicians who can provide primary care.

Yet, many dated practice barriers still exist that hold the profession back.

I believe that once a PA has demonstrated proficiency, there should be an acceptable set of standards of care that are specific to the practice and specialty and that a PA can perform without restrictions. Such changes will reflect how PAs clinical practice today, not how they started out in 1967.

I truly believe that these dated restrictions are holding the modern-day PA profession back, and until those restrictions are eliminated, PAs will not be permitted to give their patients timely, efficient and effective care.

About Michael Doll

Michael C. Doll, MPAS, PA-C, has more than 20 years of cardiac surgery experience and is the chief PA for Cardiac Surgery at the Geisinger Medical Center in Danville, Pennsylvania. He is on the board of directors for the American Academy of Physician Assistants as director-at-large and is a 2014 candidate for president-elect.

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Comments

  1. Terry Kinney says:

    i totally agree. After 5 years as a PA we should be deemed independent practitioners!!

  2. Dave Mittman, PA says:

    I agree Michael!!
    I have coined the term for PAs “full practice responsibility”. This simply means that the PA, like all other professionals, will be responsible for what they do. After 50 years of practiceit’s time for PAs to say I know what I know and I can sign my own name and it will be on my shoulders. That in itself will level the playing field. No more cosignatures, chart review, and other things administrators and even physicians are saying no longer makes the PA as marketable as we once were.

  3. Shirley Svorny says:

    The bigger picture is that all state regulation of medical professions should be curtailed. The actions of the state agencies restrict access to care and preclude innovation in how care is provided, making medical care less accessible and more expensive than it need be.

  4. Jeff Brasfield PA-C says:

    I’m truly blessed to work with a group of physicians that allow me to virtually autonomously. A month into this job, the owner of the group told me “If you need to do something, especially urgently, just do it, there is no need to complicate the time issue trying find someone to help”
    That, my friend, is a breath of fresh air.

  5. Rena Godfrey says:

    Hi Michael,
    I’m intrigued with your discussion, and feel it’s very valid and relevant. It would be helpful if you could offer some specific examples of changes you envision.
    Thank you,
    Rena

  6. Michael says:

    This is actually becoming a real issue as PAs continue to be considered dependent practitioners by Medicare and make a strong distinction in what a “dependent practitioner” can do and what a “licensed independent practitioner” can do. Nurse practitioners are rapidly gaining independent status.
    We need to at least take over the now old NP term of collaborative practice and emphasize that responsibilities are delegated to us to perform independently. That is at least language that can maintain our close relationship with physicians while giving us the legal freedom to avoid getting bound up in technicalities. We need to modernize before we are left behind.

  7. Barry Campbell says:

    I think that after almost 50 years of being around, and my 36 years of practice it is time that we be recognized as offering quality medical practice. And that, as said, the playing field be leveled. It is time we have our own state boards and not have to be supervised by Doctors.

  8. What do PA’s have in common with Prunes? A lot actually, and it all comes down to marketing. The prune industry asked the FDA to relabel prunes as “dried plums” because “prunes” weren’t selling. Overnight dried plum sales took off. It’s the exact same product; the only difference is people’s perceptions.

    Change the name and you will change the way doctors and patients view you. A name informs expectations. The name doesn’t have to be “PhysicianAssociate”, it could be anything so long as ‘assistant’ is not in the title.

  9. Unfortunately because the P.A.s are licensed under Board of Medicine,doubt that true independence will be possible.

  10. As a current medical student, the only issue I see with this, is that MD/DO are required to go directly into residency programs following graduation, which is not something the PAs I have workeed with previously are required to do (it may vary in other states, I’m not sure). But in regards to practicing independently, I believe that PAs and physicians need to be held to the same requirements and standards regarding training. I will also state that my medical school recently opened a Doctorate of Medical Sciences for PAs who have worked, to come back and earn a doctorate degree in order to help with the physician shortage. I know many of my classmates are concerned, as they WANT to practice family medicine/rural medicine and are afraid that hospitals will be more likely to hire those PAs who are just as qualified, yet might not receive as much pay. I agree it’s time for things to change, but I’m not sure to what extent.

  11. Mike MacKinnon says:

    Great article

    Just as a side note CRNAs do not require anesthesiologist supervision anywhere in the country. Crnas work independently all over the country as well.

  12. jared wong says:

    I fully agree, we should be responsible for our actions and also get full reimbursement.

  13. Tracy Ray says:

    I could not agree more. I did not always hold this belief, as I have matured in our profession I have had increasing autonomy. Additionally as NPs have pushed for this it now is also impacting the employment world. The term dependent is archaic at best. I practice in several areas of medicine, as I have my CAQ in EM I cover many small ED and do not have a physician around. Yes one is available by phone but is not used or needed. I have been fortunate over the years to have MDs who have placed me through an OJT residency and have the expectations that I am them when they are not there. I have 5 degrees, 25 years in medicine, and CAQ. Why do we not pursue this area of independent licensure, we still collaborate with other physicians and specialists however the need to the legal “signoff” is ridiculous even to my supervising physicians.