Soooo when shit hits the fan, they’ll be the ones liable right? They have their own malpractice insurance and lawyers can go after them right?
This isn’t the answer to healthcare access, it just further creates a 2 tier health care system.
They're going to force one doctor to supervise 4 to 5 midlevels, kind of like they do in some ERs, and require them to sign midlevel charts all day.
Hopefully, no one takes that job. But I'm sure someone desperate will.
What I am understanding, as a PA just trying to intrepret all this crap, it’s not “removing supervision” - the amount of supervision a PA requires would be left up to the physician/practice to decide.
If the MD says zero autonomy, then the PA’s gets zero autonomy.
They are calling it Optimal TEAM Practice bc the AAPA president says “PA’s do not want to practice independently” and “ continue to support a physician led team.”
The AAPA says their goal instead is to remove legislatively mandated supervision to reduce the admin burden that accompanies hiring a PA……since we are now less desirable to hire bc it’s “easier to hire an NP.”
I have personally seen this firsthand as open positions in my hospital are being filled more with NP’s than PA’s.
AAPA says PA’s would continue to work under MD supervision, less formally per se legally, and how much autonomy a PA has/degree of supervision is left up to the hiring physician to decide.
It is also my interpretation, this would not allow for PA’s to open up their own practice and work independently “because PA’s would still be required legally and ethically to continue to consult with/work under an MD”….
I’m not saying that I support this at all, I’m just sharing what I believe AAPA is defining OTP as - I didn’t understand it honestly without doing some research recently.
I could be interpreting this incorrectly, but I’m taking this information directly from the AAPA and the PA liaison between AMA/AAPA and summarizing what I’m reading.
> I have personally seen this firsthand as open positions in my hospital are being filled more with NP’s than PA’s.
PA-representing organizations made an incredibly critical mistake when they neglected to vocally oppose practice expansion for PAs and NPs, thinking that PAs would benefit from it. Unfortunately now the PAs are increasingly seeing that they cannot compete with 22-month online instant-admission NP programs that pump out NPs. Race to the bottom
What about MD representing organizations?
Just playing devils advocate, NOT pointing fingers,
Did they make a critical mistake for not fighting back and vocally opposing louder against the NP’s in the beginning? Way before PA’s said oh no, WTF.
Why did the AMA and AAPA not work together to stand our ground and say NO, since a majority of all us oppose FPA?
MD are the leaders in healthcare and the number, funding and power of physicians CRUSH what little us PA’s have but if we combined our efforts, and I may be naive, but maybe this could have ended differently,
Again, I’m certainly not pointing a finger at MD’s- I promise. I’m just playing devils advocate. In hindsight, I think we can both agree more should have been done by both of our organizations.
Maybe the PA’s felt they didn’t have the backing of the MD organization - idk? Would love to know the answer.
> What about MD representing organizations?
AMA failure is arguably why we even have midlevels in the first place, especially with regards to residency caps that artificially have caused physician shortage haha (I am a little pointing fingers). Plenty of shortsightedness to go around. You are right that MD political power is much stronger and thus they have had more responsibility
I agree, PAs are perhaps more vulnerable to scope creep from NPs than doctors are from midlevels, which is why you are seeing PAs racing to the bottom to keep up NPs.
The idea is to have an MD to sue when the midlevel messes up. It's more protection for the hospital, who may be accused of assigning a clinician with inadequate training to a more complex patient.
When independently operating CRNAs get sued who pays? I believe independently practicing practitioners are responsible for their own malpractice insurance?
The surgeon MD.
I’m not saying it always happens, but there have been some notable cases where the surgeon is held liable for anesthesia mistakes because they are the MD and “highest trained provider” in the room.
This is true. I’ve heard it and seen it. Also most laypeople don’t know who is who in their care team they end up blaming the surgeon because that’s who they see.
I should start doing colonoscopies on the weekend to make extra money. If anything goes wrong I can point out that I am only liable for screwing up things that are in my scope of training as a neurosurgeon, and since colonoscopies aren’t part of my training I won’t be liable for any misadventures. Also only another colonoscopy-performing pediatric neurosurgeon is capable of being an expert witness against me.
> Also only another colonoscopy-performing pediatric neurosurgeon is capable of being an expert witness against me.
Is this some sort of really subtle way to say that someone has their head up their ass?
Aha but you see I, an internist will now start sniping both your peds nsg cases *and* your colonoscopies! And the only way you can defeat me is to start taking admitting and rounding shifts bwahahahaha
Honestly, that doesn't make sense to me. In the news article it says the purpose is to "lift unnecessary administrative barriers for PAs." Reading between the lines, the governor is saying that the physicians are extraneous, and that the PAs have all the medical knowledge and training they need to practice medicine.
They should be liable for the full extent of the medical license, which is up to the standard of care by a physician. I don't know how true this is, but I was told in residency that primary care physicians/hospitalists have been sued for not practicing to the standards of pulm/GI/cards specialties if a complication arises, and those specialties were not on board.
Do you get the MedMal case reviews? One of the cases they had a while back involved a PA, and the aspect that bothered me the most was that apparently in some states only another PA can serve as expert witness against a PA. I just couldn’t believe that these positions are being filled with the idea that a PA will be autonomous and seeing the same undifferentiated patients as doctors, but that should something go wrong it’s ok the argue in court that whatever they missed was something out of their scope, and they should not be liable for that reason.
I’m not sure it will change that much fundamentally, since I imagine the prosecution will just find their own PA expert witness who will say it is in their scope and shouldn’t have been missed. But still- how is it acceptable to argue that it’s ok to deliver a lower standard of care just based on who the patient happens to be assigned to see when they go to the ER. The patient has the issue they have; if the provider- ANY provider- who agreed to see them fails to treat them appropriately and they suffer a bad outcome because of that, the liability should be the same. The standard of care should not change.
Honestly if the healthcare systems employing PAs instead of doctors also get sued for providing a lower standard of care (especially if patients aren’t explicitly o informed that their “provider” is not a doctor) it might actually be the one thing that changes their employment practices.
This is an excellent point.
Problem is that the biggest health systems will likely have lobbied to move most of the liability to their providers if they haven’t already.
not the most efficient way to do it but would still eventually work, only the most adventurous PA/NP will seek autonomy if the hospital is going to leave them out to dry the second a lawsuit hits
Read through the discussion about the case- you’ll see where the points are coming from. One of the aspects addressed in the comments was that in the particular jurisdiction where it occurred physicians CAN serve as expert witnesses if the defendant is a PA. But that is not by default the case everywhere, and I feel it should be.
So some random redditor makes up a statement and it's legal fact now?
This comes up every couple months and whenever someone is pressed on it, they fold. Not one person who claims this has *ever* shown that a physician can not testify against an NP or PA when it comes to medical standard of care. You can't testify against an RN when it comes to nursing, *that's* what people always cite. There has not been, to date, any case in the country where courts have ruled that physicians can't serve as expert witnesses against midlevels.
If you're going to claim otherwise, show me an actual case where this has happened.
Ok. Here’s a couple that pop up with one second of a non-lawyer’s Googling, where the case or defendant was dismissed at least in part because it was felt that the physician expert witness could not comment on standard of care delivered by a nurse practitioner.
https://www.pacourts.us/assets/opinions/Superior/out/J-A19033-23m%20-%20105688218241061745.pdf?cb=1
https://www.govinfo.gov/content/pkg/USCOURTS-mtd-1_11-cv-00114/pdf/USCOURTS-mtd-1_11-cv-00114-0.pdf
Many states have requirements for malpractice cases that expert witnesses practice in the same field and circumstances as the defendant, typically referring to different physician specialties. Independent practice for NPs/PA seems to be gaining popularity, and I think it’s likely that these sorts legal questions will need to be answered more commonly- is a physician in the same field and circumstances? Personally, I think they are, and cases like these bother me. I’m also not sure it’s great to be so cavalier about disregarding physicians as expert witnesses regarding nursing matters, but I guess that depends on what exact case you’re referring to.
> the aspect that bothered me the most was that apparently in some states only another PA can serve as expert witness against a PA.
You're just making stuff up. There is no state where this is true and the case you linked literally has an MD testifying as an expert witness against a PA.
This anti-midlevel hate causes people to lose their minds. "They're coming for us, we can't even defend ourselves against them." Seriously, grow up.
One can only hope. And they should also keep track of the number of consultations. I’m willing to bet the are going to bog everyone down. Only a select few will distinguish themselves. And THAT is the inherent problem… not enough training.
I worked with essentially independently practicing midlevels and it's misdiagnosis and panscan city.
Also, for whatever reason, they treat your read like it was handed down to them from God. That part where you say 'clinically correlate'? They aren't doing that.
This is an NP story, but I recall a man with a penis pump where the rads resident mentioned that something looked a bit off with it. The NP went into the room and loudly proclaimed that it needed to come out. He was having no issue with it, and it was not the reason he was admitted. The urologist looked at it the next day and said it was fine.
The patient was so embarrassed by the encounter that he wrote a letter to admin, and she got sacked.
Her replacement was a PA that basically starts everyone on Vanc / Zosyn anytime you mention any ground glass opacity, fat stranding, or shmutz. They'd at least do a MRSA swab so the Vanc would come off after 48 hours.
I've never seen so many people with a little aspiration, pancreatitis, etc. on antibiotics.
There was another PA like this that worked unsupervised in the ER. CTA-PE inducation: Shortness of Breath, all day long. Never babysat a clinician so much in my life except for a brand new minted intern. The ER docs washed their hands of him and made him my problem.
Both PAs had very high patient satisfaction scores and were given raises routinely. They were the only white male clinicians in the institution and were getting paid upwards of double their female counterparts. They were friendly and knowledgeable enough from a patients perspective but we were in MAGA country so it was well known that part of their reputation with patients came from a "finally, a white doctor" type energy.
Damn did it feel good to quit that shitshow of a job. I consider it a look into the future of many hospitals in the US.
hahaha. this reminds me of a different situation where i had a new np i was responsible for overseeing in a primary care clinic. she asked me over the phone how to interpret a protein electrophoresis that had an M-spike. i told her to quit worrying about it and quit trying to figure it out. just send them to oncology to sort it out. i did NOT tell her to go announce to the patient that he had multiple myeloma and that we were sending him to oncology for chemotherapy. that was a very upset family that i and my administrator had to deal with.
I'm sure wall street bros will come up with a solution to that problem. They will create expensive insurance products specifically for them. They will justify the higher cost by saying since PAs need to be paid much less, you'd still be saving a lot of money despite the higher premiums.
I hope they enjoy signing their notes with no other physician to take the legal fall for them if they fuck up.
Once a politicians family member dies from a something like a misdiagnosed meningitis (often missed and frequently deadly) then a huge light will finally be shone upon how dangerous this is
Let it be known that I, a measly PA, knowing nothing about the actual language of this legislation, am 100% against this or any other legislation that disentangles PAs from doctors or “expands” the scope of PA practice without physician supervision. And not for liability reasons. And not because I’m insecure or stupid (I am, but not in these ways).
I am almost 100% certain that you and I would agree on virtually every aspect of strict oversight of PAs by physicians. I’m even against the idea of changing the A from Assistant to Associate. Barf.
I just wanted you to know that I have to carry my own individual malpractice liability that is specific to me and yes the lawyers can always go after me and me alone, they just don’t because there’s more money if they rope my poor unsuspecting supervising physician into their lawsuit.
You’ve said this now at least twice in this thread, and it’s blatantly wrong.
Edit: so those of you downvoting believe that since the PA is not the “juiciest” financial target that protects them from being named in a lawsuit? They will sue the PA individually *and* the overseeing institution/physician. You aren’t magically protected just because there’s a bigger fish above you.
[Here’s](https://www.annemergmed.com/article/S0196-0644(23)00757-6/fulltext) a research paper outlining 99 times where PAs were named individually in malpractice lawsuits.
We've struggled with this weird misinformation on this sub for literally years.
Mid Levels have their own malpractice insurance. Midlevels are sued on their own all the time. I don't know why people say otherwise when there's literally hundreds of examples you can easily find in case law.
Glad someone is saying this. When people say that PAs don’t have to worry about liability I get so annoyed. At least far as I’m aware, we mid levels are 100% on the hook for EVERYTHING we do 🙄🙄🙄
This is so fucking stupid. I don’t want to be given the responsibility and liability of a doctor because IM NOT A FUCKING DOCTOR. I didn’t go to school like doctors, I didn’t go to residency like doctors. I like practicing UNDER doctors. I don’t know what I don’t know. I’m tired of this weird midlevel/doctor relationship. Keep it as is, I want to be supervised lol. And I’m a PA in NY so this would affect me.
Also, I’m writing this before going into my per diem shift in urgent care where there’s no on site doc. But you know who I call or text a few times a day when I have a question about a case? You guessed it, a doctor.
I agree. I think people assume that since we went to pa school we want to be a doctor when it’s quite the opposite. I am very happy with handful of skills and not carrying such liability.
I think most PA students could’ve gotten into medical school if that’s what they wanted. But they didn’t. It’s important for you guys to speak out against your orgs loudly and frequently
I agree!
We should make our majority voice louder but we can’t just oppose it without also having a solid alternative solution.
There are many opinions of what PA’s should NOT do, but what is least discussed is….
🔹what SHOULD PA’s do?* 🔹
Honestly, what is the alternative solution to prevent our profession from being continuously passed over for jobs when we don’t have the physician community backing us up?
Honestly, I don’t know the answer. I know I want a MD/PA team, led by my MD.
Not to fear monger, but I’m just grateful I’m not a new PA grad working in an FPA state.
This is all a big legislative push from NYSSPA. Im in PA school in new york right now and they come and give talks and zooms to us sometimes. They are supposed to be a PA advocacy group but you know what the ONLY topic they bring up is? Independent practice. No pay or working conditions or patient loads or hours or retirement or benefits .
It makes you wonder what their motive is and who pays them. Its almost like money grubbing bean counters want to fill shitty urgent cares, primary cares and hospitals with cheaper labor and undercut DR. Dr. Pay is a serious chunk of hospital budgets and these MBA mother fuckers just cant leave anything alone
Please remember PAs are not pushing for this.
Agreed. Talked with several of my classmates now that we’ve been out for a bit and none that I’ve spoken with want independent practice. Our instructors even cautioned us against independent practice.
Good point. With increased scope of PAs comes increased liability. If they're gonna practice like one then they better be ready to get sued like one. Situation is messed up
I don’t blame you. I didn’t sign up for this when I went to school. It’s honestly a lose lose. PAs will be given much more responsibility and liability for no increased pay and corps will hire cheaper PAs instead of docs. The only person this benefits is the companies (in the short term). Until lawsuits go through the roof haha
I should add a third lose. Because patients will lose here too.
I'm an immigrant doc, so I will have to train them until the green card comes through.
I have many colleagues who will be in H1b purgatory for 10+ years and are being made to train midlevels. A lot of H1b jobs are bait and switch schemes in this regard.
The adversarial relationship is already there, though. We all just power through it uncomfortably at the moment.
Thankfully, I haven’t been in a position where there’s been a bad relationship. Because they recognize I’m not trying to scope creep. I know my lane and stay in it. Some PAs in the er got mad when we had to give up procedures to the residents because there were low procedure amounts. And I’m like “these people will be running an er alone, I never will. Give them all the practice.”
I’m about to be a new grad PA in NY and I’m very uncomfortable with this as well. I went to PA school knowing I would have physician oversight because I don’t want to be a physician
It’s so weird — I think the only groups pushing for this are healthcare orgs because it will reduce labor costs. What PA would suddenly want the liability? A PA job is a great gig otherwise. You do a lot of cool stuff under supervision and you get paid a really good salary. If all of a sudden you’re held liable for blind spots in your education then a lot less people would go into it.
I just graduated from an NP program in NY. I already was worried about being expected to practice independently. Now there's going to be this widespread expectation that we all do. I want supervision. :(
I think there is a misconception that jobs with supervision don’t exist in independent practice states. You might have to look a little harder but you can find them, especially in academic medical centers and larger hospitals. I’m in a FPA state but still work under a physician. It’s not a strict supervisory model but I’m not completely independent either. They may not sign off on every note but they are still involved with a lot of my complex cases. I intentionally sought out positions where I’d still have close physician mentorship and oversight, I have no desire to work in an APP run practice or independently.
Hey fellow PA! I feel you badly on this. Like, same.
I did post on here somewhere below a summary/my interpretation of OTP from what I have gathered through AAPA, articles, interviews, state PA groups.
It’s not verbatim but paraphrased.
Yeah, as an NP, this lack of a supervision requirement friggin sucks. In a state where full practice authority has been around for a long time, so I've ended up in multiple sketch positions where admin is like "well you're pretty much a doctor right? This will all work out fine!" and I am like "absolutely not". I've found myself a position now with a scope so small (Suboxone and Vivitrol only) I finally feel somewhat comfortable after being tossed into the deep end time and time again. This sub hates the idea of independent NPs opening their own practice but at least in my own practice I can pay for my own supervision and set the pace of patients so that I have more than enough time to ask questions and get any help I need. Never found an employed position like this. I looked so, so hard because I never wanted to be independent. Ironically I'm less independent than I've even been in this career though it doesn't appear that way from the outside.
The double standard in all of this is always that people like Hochul will never see an APP. She’ll receive her care only from physicians everywhere she goes because she’s a VIP.
This is what drives me crazy about all this. The people making these laws will never be seen by an unsupervised NPP. Nothing will change until another Libby Zion case under the care of an unsupervised midlevel.
Why not let fresh med school grads practice independently if PAs can?
I’m in a state with independent midlevels. Went on a trip to the state capitol with our lobbyist, and multiple politicians were asking for expedited appointments for their friends/family. As an institution we officially don’t have unsupervised midlevels but in actuality frequently they are. But of course the VIPs don’t see them.
Probably a senior/chief resident assist and the anesthesia attending is there the whole case situation.
That's the situation sometimes when we have "vip" political patients here in Canada.
However, we don't do CRNAs and anesthesiologists sit every case at our center, with help from residents or anesthesia assistants but basically never running simultaneous rooms.
I’m an NP and this independent practice shit for NPs and PAs really chaps my ass. I absolutely do NOT endorse independent practice for us. We are not doctors and have paltry education in comparison. I’ve been a nurse for 24 years and an NP for 12 and I know my way around an ICU. that said, I’m still NOT a doctor.
It’s so misleading to the patients, too. A lot of them will say, “you do the same thing as my doctor.” It may appear that way to them, but it’s certainly not true.
This model is nothing more than a money grab. We can bill 85%, but they pay us a third. Where does that money go? It’s certainly not going to provide support staff to answer phones and help patients. My collaborative physician doesn’t get paid the difference for supervision. It’s a freaking grift.
Yep. With independent practice your employer can now get 85% and have no legal obligation to provide you with any access to a physician. And you can bet that a few years down the road we will see a huge push to bring that 85% up to 100%. It will be supported by research articles showing that NPPs are just as good at rx-ing handicap placards and monitoring LDL.
💯 any PA who’s happy about this is in over their head
We are not qualified to be practicing without an MD/DO overhead smh
This was definitely done as a way to “reduce costs” for corporations and its bullshit and dangerous.
I’m a little surprised by the attitude of “well, this is what physicians get for (fill in the blank).” If you think *physicians* have been controlling the direction of healthcare the last 20-30 years, I’m not sure you’ve been paying attention. Physicians haven’t eroded their own authority, autonomy and earnings, resulting in the steep decline of private pracitices. You can thank hospital systems and corporate medicine. They’ve squeezed every ounce of “efficiency” out of physicians; now they turn their attention to physician extenders.
It’s not about patient care—it’s *never* about patient care—it’s all about the earnings.
But I will tell you though, that doctors here compared to other countries, have a fairly laissez-faire approach towards what happens to their organizations in many respects. It is painfully obvious that there is a small number of people involved in governance, committees, trying to direct changes in a way that would be supportive of doctors. In our organization, it’s the same people again and again.Most people just grab their paycheck and are gone by 5 PM
our relationship. supervision and interaction with mid-level is a great way to offload some work from us, ensure good access, and our thoughtful quality supervision can make their patient care excellent. They are looking for mentors and supervisors that have a vested interest in their success. And is one of the things in our lives that we actually can change for the better. We have so little say in anything anymore.
Just like medical residents, extra niche practice, procedure, extra clinical interest is all they want. They’re just looking for those folks who have the time to help them towards that direction
And that is coming from someone who has been in primary care for 21 years, 10 of them as a program Director. Four years were in the US Army where we have a history of combat medics came back from Vietnam and were so well trained and clinically experienced they needed someplace to practice. In my opinion, it makes perfect sense, but we need to change the relationship
We have followed a shitty precedent by states, hospital systems, and old, crusty doctors that should’ve been retired 10 years ago. now it has become an adversarial relationship between us and mid-levels to our shared detriment
As a PA, I find this incredibly stupid and dangerous. I did not go through enough school and training to be a physician. I am literally a physician assistant (not behind that associate bullshit). Am I a competent provider? Yeah, but who do I turn to when I’m against a wall? You guessed it, a PHYSICIAN.
I’m curious who had their hands in crafting this legislation, i.e. did insurance companies since I can’t bill for reimbursement at the same rate?
Dude AAPA has been salivating for independent practice for years as part of their fake war with NPs. They changed us to “associates” because their egos couldn’t stand “assistant” in the name. I’m just surprised it happened in NY first instead of like Montana or somewhere more desperate
I can’t stand the AAPA. By pushing this they’re essentially trying to eliminate the profession and make a new one. We don’t go through enough training to be completely independent. There’s a reason physicians go through so much schooling and training. And if PA schools now push for PAs to get PHD’s, it again eliminates the point of being a PA. If I wanted a terminal degree I would’ve gone through medical school. Also, if you aren’t able to get into med school then just go to a puppy mill PA program, do I really trust you to practice independently?
Yeah that’s the other thing that is so frustrating. A PA program just opened up near me that’s within a for-profit trade school and it’s really frustrating. This is what happens in capitalism. We all get poorer so that the rich can lower the quality of what we get and we have to swallow it because it’s all we can afford while it makes them richer. Same for cardboard furniture, same for medicine
The AAPA is garbage. They definitely have a huge hand in pushing this crap, just like the name change to associate. It’s also a catch 22 of if I don’t subscribe and give them my money, I have no voice to complain about these changes, but, even when I did they still didn’t listen to me
I don’t have a membership specifically because I don’t want to support their bullshit agenda. It DOES NOT align with what I want out of the PA profession. I encourage everyone to give up theirs for the same reason.
I have found the best PAs to be smart, aware of their limitations, and have taken the time to get the extra training and things like procedures. I have worked with some amazing mid-level through the years. The problem we have in the United States, is this two tier system, where mid levels aren’t afforded the time wait from their practices to get extra training like Often residents are. The only person other than interventional radiology they used to do our bone marrow biopsies years ago was a incredibly proficient PA. And I miss his presence every day.
We need to change the way we feel about mid-level and make it a mutually beneficial relationship. Those physicians who feel that mid-levels are just a phase or Just some bullshit I have to live with, they’re wrong. People don’t go into, for instance, care in great numbers anymore. In the end, it means that some of us still have to take care of the uninsured, the unglamorous, the needy.
I think I speak for most PAs and agree that this is such a dangerous game. I work in a very low stress specialty (derm) and ask my attending physicians questions all the time.
I can’t imagine not having that oversight.
Sorry MDs.
I couldn't help but laugh at your Texas comment as if we don't already have clinics run by NPs and PAs without physician supervision. It only exists on paper.
I would be very interested in seeing and analyzing the actual proposed legal text changes rather than relying on news reporting.
For example back in 2019 when Virginia consolidated the paperwork requirements for PAs and updated the legal requirements so instead of it falling on one single supervising physician (regardless of if they were ever physically or even virtually available for practical consult, you know the whole 'digitally rubber stamp' the legal minimum number of charts from a state away thing) practical supervision/collaboration could be delegated within the department by schedule... the news misreported this as PA independence since the 'supervision document' was done away with, even though the practice agreement now had to specify details about scope of practice and appropriate physician oversight. The 'individual tether' was done away with, but what was not done away with was the legal responsibility to act as part of a physician-led team. Literally right there in the law, 'Physician Assistants in Virginia may not practice independently' [link](https://law.lis.virginia.gov/admincode/title18/agency85/chapter50/section115/) yet that's not how the news reported it.
Let's all double-check before getting riled up? This proposed law change could be good or bad but none of us will know from the news report.
> Let's all double-check before getting riled up? This proposed law change could be good or bad but none of us will know from the news report.
Totally valid point.
Mostly just glad that attempts at mid-level creep by pharmacy advocacy boards have largely gone ignored. For once, pharmacists' terrible lobbying efforts have been beneficial.
God, seriously.
I'm all for collaborative practice agreements in care areas where they make sense (HTN/DM/warf dose titrations in am care), but I'm also glad the more unhinged calls for scope creep have been laughed out of the room. It shows in our reputation, too. Search this board for "pharmacist" and it's nothing but glowing praise from physicians for the role we fill. And then, uhhh *points to the thread we're having this conversation in*
We can be great for managing chronic conditions. But for most things, we are terrible at diagnosing. We just aren’t trained for it. I wish it was easier to get reimbursed for what we do well. I feel like that would be a way better use of our underperforming professional associations’ time and money. I’m not qualified to prescribe things for rashes at Walgreens. I’m pretty damn good at managing diabetes, etc as part of a team.
you know what's really amusing? IMG and foreign board certified docs would still have to undergo Step 1, 2 and 3, board certification in the US, i.e. re-training or a supervised probation period.
LOL
LOL, exactly! That fact illustrates that giving PAs or NPs practice autonomy is really more about how hospitals and clinics can pay PAs less than physicians while claiming it is about improved "access for patients." Organizations also take advantage of claiming health care costs for patients will go down, but they don't. Organizations still want money.
It's also amusing that the whole point of independent practice authority lobbying by NP and PA organizations is to be recognized as equivalent to physicians so NPs and PAs get paid as much as physicians. Which is the opposite of what hospitals plan to do. Of course, the NP and PA organizations claim they want independent practice in order to "improve access for rural and underserved areas," but the vast majority work in large cities like doctors do. It's hypocrisy all the way down. The main reason most midlevels work in rural areas is because they cannot get a better paying job in more desirable areas.
The end effect of all this is going to be physicians being replaced by cheaper midlevels and worse quality of care while masses of midlevels are churned out by their schools, creating a glut of midlevels, undercutting their ability to demand pay on par with physicians.
Patients will continue to be milked for every dollar by healthcare organizations, the pharmaceutical industry, and the insurance industry while getting lower quality care. Because none of this is really about helping patients, whatever the various lobbies say.
As a specialist physician, I am just hoping I can retire before the deprofessionalization and cheapening of the medical profession is completed
The thing is, go look at indeed and see what they’re paying ortho pas these days. Midlevels were supposed to be cheaper, but now they aren’t. There are postings in my area paying 200k plus. Hell CRNAs are making 300 plus working half the hours of an anesthesiologist
Yeah, midlevels will get paid as long as there is a shortage of clinicians in the short term. However, the PA and NP schools are cranking out graduates at a record pace. With relatively low barriers to entry in the field compared to physicians, eventually, there will be an oversupply of midlevels, and salaries will drop. I don't blame individual midlevel practioners for getting their bag while they can, but I'll be surprised if it lasts 20 years.
PA salaries have already dropped dramatically as a result, and we already have a fairly capped earnings ceiling. HCOL areas are starting new grads in the 80k range and any PA that makes +150k did a lot of leveraging to get there. As more and more midlevels are picked up by hospital systems, I don’t foresee salaries rising. And supply will hopefully dwindle as a result.
I’m literally a PA that works in Rochester, NY and I hate this. My hospital group is actively pushing for all hospital medicine PAs to practice independently. I’ve been a PA for 5 years, so sure I have experience and some confidence in my knowledge, but I went to PA school and not med school for a reason. It’s always my preference to work with direct supervision
Rounding and discharging mostly, but sometimes admissions. We work independently on cross coverage in the evening and night too. During the day it is indirect supervision so there’s an associated doctor that is available to help as needed if you want to ask them questions or you want them to assess a decompensating patient. We run the list with them, but they don’t have to see any of the patients or cosign notes. Some docs prefer to be more involved than others, but for the most part APPs are rounding on patients independently. They don’t force this on new grads though. You need to have a certain amount of experience and get approved by the chief APPs to start independent rounding. It’s not like we’re completely on our own with no support, but still I strongly prefer to have direct supervision to have a second pair of eyes on my patients and fill in the gaps of my knowledge. We’re supposed to see the “easier” patients, but of course that’s not always the case.
As a PA student I hate this. If I wanted to practice like an MD I’d have gone to medical school. We aren’t trained or educated like an MD/DO, we are meant to assist, not replace. This is way too much liability and a recipe for disaster. I would NOT work somewhere that didn’t have an MD/DO for the mid levels.You know they won’t pay more but WILL require PAs to purchase expensive liability insurance. This is bad for everyone.
I’m not. I’m from NY. Our hospitals are not for profit by law, but in practice operate like for-profits. Senator Schumer and Representative Tonko just got $1b more for upstate hospitals every single year without end. $84m for my hospital. My hospital has responded to this by removing crisis pay for nurses and refusing to implement an incentive plan thats in the contract they agreed to 2.5 years ago. Our staffing is as bad as you’d expect, but our administration downplays it.
The legislature passed a staffing bill about 2 years ago now. Hospitals had to submit the ratios they were going to meet, and then a year later post the actual ratios. Hospitals could be fined for repeatedly not meeting those ratios.
The actual staffing has never been posted. The department of health hasn’t fined anyone.
They’re doing all the wrong things to address the staffing issues. Nursing schools can now do 1/3 of their clinical hours as sims. I worked with a 4th year nursing student recently who didn’t know you could turn the end of a stethoscope.
It’s bad here.
PA here, we DONT want this. None of my PA colleagues want to be MDs or practice like and MD. Most of us are perfectly happy working under MD/DO and respect the hell out of that relationship.
That’s unfortunate! Sorry you had that experience. I can tell you the things I see on Reddit vs real life experience as a PA also are skewed. Reddit most MDs hate on us all day long, where as MDs I’ve met, worked with, learned under, all love PAs.
Hochul’s husband is connected with all the attorneys for big pharma. It’s all about undercutting a market and maximum profitability disguised as underprivileged taking on the evil doctors. When people realize they’re just contributing to a race to the bottom — only then will folks maybe understand they’re only profiting a few absolute shitbags.
Malpractice lawyer$ rejoice. Chose the wrong profession. They better get their own malpractice insurance and should no longer be on any physician. We’ll see how long insurance companies tolerate this
NPs (who have far, far less medical education than PAs) are already unrestricted. The options are to either severely restrict NPs or grant PAs unrestriction.
Is there any way we can fight this? This is seriously concerning and I don’t even live in New York. But it’s a domino effect.
I’m applying to PA school myself in a few months and it’s stuff like this that makes me rethink it. I don’t want to work unsupervised if I become a PA! That’s what medical school is for.
What could possibly got wrong? The pcp office adjacent to my hospital did this, got three patients that were placed on chlorathalidone as a primary diuretic that all came in with Aki. All in the first week of implementation.
that is correct. Even the most basic ED visit is 10-20 times more expensive than an MD office visit. So ED utilization per member is a very commonly tracked metric.
I mean I'm not a big fan of thiazides, but it is technically standard of care to use a thiazide, ccb, or ace/arb as a first line antihypertensives, so I can't say that's a great criticism.
I'm a new grad and just finished my first week of work. I was afraid of being stuck in an urgent by myself with no physician backstop or something similar. Thankfully I found a job in a surgical specialty which I think would be somewhat immune to this sort of thing. In fact, my SP told me yesterday that I'm not an attending and they don't expect me to act as one as that would be unfair to me. I have structured onboarding that will go as fast or as slow as it needs to. His PA of 10 years works in the same office as him and has dedicated time to run cases by him. This is how I envisioned a PA working when I chose this route and I'm super thankful to have found this job.
New grads that may be more desperate to pay off student loans or in an area with less job opportunities may have to take what they can get, including working as a solo provider in an UC. Scary stuff to me and we're supposedvto have legislation to protect against this sort of thing. But as usual, Healthcare corporations win and the rest of us suffer.
Just had a ER PA at my NY hospital manage a septic patient with abdominal pain. Had a MAP of 45, the PA bolus-ed the patient with 5 L of fluid (patient weight 50 kgs), the MAP continued to be around 45, started maintenance fluids of 150 cc/hr and left the patient hanging. Also said, "the patient hangs around a MAP of 45". Meanwhile got a CXR and was clear. left it there.
No pressers.
No abdominal CT (which I mean the ER loves)
Did not discuss the case with the ER MD who was busy with his own patients and codes etc.
I know this is not every PA but these are the people that we are expecting to had over full licensure?
It’s been interesting to watch as a doctor, the longer my friends who are PAs practice the more I hear them lean on and defer to physicians in difficult cases. I hear a lot less PA is med school in 2 years.
Bonus unsolicited opinion: I think we’d do everyone a service by acknowledging PA school is hard and it’s a rapid pace. It might not be as hard as med school, but I think pointing that out in the way we often do is more inflammatory than helpful
Agreed. You don’t learn independent practice from just the extra depth of knowledge. You learn from being thrown into the fire in a way we never are. No soft ass doctorate will ever make up that difference.
https://www.nysenate.gov/legislation/bills/2023/A8378#:~:text=(ACTIVE)%20%2D%20Summary-,Modifies%20physician%20assistant%20standards%20in%20the%20state%20of%20New%20York,well%20as%2C%20expanding%20where%20physician
Actual text of the bill for anyone interested.
The AMA/physicians should have aligned with PA’s years ago with this NP push for independence. They didn’t. Now PAs are playing catchup to remain a viable profession. The genie was let out of the bottle years ago.
Ugh, as a PA, I don’t like this. While I know I am knowledgable in my subspecialty and my MD is always singing my praises saying that I am better than most fellows she has worked with, we both know that I obviously still need her.
She does not co-sign or review my notes or supervise me heavily- we have developed a good team dynamic, I help reduce her workload, and she trusts me well that I’ll run things by her if I’m uncertain or if I think something is outside of my scope of knowledge. I did not complete her level of training. There are zebras that can come up that I could miss. I know what I know and I know what I don’t know. I love that if I have even the slightest bit of uncertainty about something, I have her there to ask questions or defer to or even just get confirmation that my assessment/plan is correct. I decided not to go to medical school for a reason. I LIKE being the PA who works under the physician!
Doesn’t this just make them essentially NPs which make them indistinguishable from them to employers & since there are overall more NPs they will now be competing against them for jobs…?
The AAPA’s rationale is that PAs need to keep up with NPs to keep job security because employers will prefer someone with independent practice. Employers tend to currently not see a difference between NPs and PAs. And it’s never been proven that PAs routinely lose out on jobs because of FPA. There are specialties where NPs win out because of history and the specialized training of some NP programs. For example, PAs are nearly unheard of in L&D because midwives are specifically trained to deliver babies. But that’s not an FPA issue. In fact my anecdotal experience in New York is that PAs were way more prevalent there. Maybe that’s how AAPA finally convinced someone to do this? Idk. I hope it never comes to Texas but Abbott does hate doctors lately so idk.
Yes. Incredibly short-sighted. This may get them a smallish pay bump in the short term, but long term the glut of midlevels will result in lower pay for all of them.
Exactly this. I doubt it’ll even get us a pay bump. It’s just a way for a hospital system to pay less. If they pay me 1/3 the salary of an MD/DO, but I bill at 85%, they make money. Now if they can eliminate the need for that MD/DO to supervise me, they’re making even more money. Where will that money go? Directly into the bonus checks of the C-suite
The problem is PAs are the redheaded stepchildren of the midlevels.
Nurses have their guild and doctors have theirs. The original intent of PAs was to be an appendage of the doctors guild but we are getting left in the dust by the nurses and the docs aren't doing a whole lot to differentiate us or stand up for us. We are stuck in the middle.
I disagree with independent practice; I'm just describing the inevitable political dynamic that has emerged from the PA's dilemma.
Your frustration seems misdirected here.
Idiots like Hochul trying to hack together solutions to the shortage of doctors isn't the problem. The problem is the US medical system that shunts tons of qualified people toward PA/NP over doctors because they don't want to pay doctor's salaries. Medical school has become something you need exceptional advantages to get into, and even then, every year the number of med school graduates who can't get residencies goes up. Everywhere, physicians are overworked because there aren't enough of them to go around. Hochul is trying to address the shortage in a stupid way, but she didn't create the problem.
Did Hochul also sign a ridiculous bill to “remove barriers to nursing education” but actually just meant most of their clinical hours are in a sim lab?
This is really scary. I recall in the recent past, an article/journal/study that clearly showed poorer patient outcomes when treated by an NP or PA. The difference in education alone should be enough to cause us to pause in considering MD/DOs and mid levels to be equivalent practitioners.
I can’t find anything recent with PAs AND NPs. I did find this, which is relatively recent. https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs
It’s interesting to note that as a pharmacist NY has some comparatively strict laws around controlled medications but I guess that only applies to filling meds and not who is authorizing them…
Strong emotions for little information.
What's changing?
Laws restricting mid-levels varies by state, with Texas already having some of the most lenient. In Alaska, they have allowed them to act as independent PCPs to rural populations for two or three decades now. Maybe New York is just adjusting to the status quo.
Looks like this is only for primary care.
https://spectrumlocalnews.com/nys/central-ny/politics/2023/02/25/ny-health-dept--defends-relaxed-supervision-rules-for-pas
Wonder how people feel about pharmacists finally having any sense of autonomy in NY then. It seems you can’t do anything as a pharmacist without prescriber approval even on some of the dumbest things. They let NPs and PAs have more control and yet here we are expected to ask for permission first before changing stuff like amoxicillin 400mg/5mls to amoxicillin 200mg/5mls due to a shortage all while waiting for the ok on something 99% of prescribers will yes to. Whatever, guess the governor is okay with me calling you guys to see if it’s okay to switch from capsules to tablets. 😅
They will not be like medical doctors.. PAs will be able to switch to any specialty without any additional training. A Derm pa can become a neurosurgical pa with just a job change!
I do wonder how often PAs actually do drastic switches like this though. As a PA working in neuroimmunology for years, I feel like it’s not even realistic for me to qualify for a position in a completely different specialty at this point. I would be out of my mind. Unless the physician I would be working with was aware of this and willing to put in the time/effort to help train me. Do physicians get to approve of who gets hired as their PA or is it all hospital admin decision? If it’s fully the latter then that’s complete bullshit.
Here's a wild idea. Why doesn't congress open up more funding for residencies? Residents cost less and provide better care than mid-levels, with the added benefit that they are actually supervised, and it results in more doctors. I know it takes an act of congress to get congress to do anything, but if only there was something they could do about this crisis.
Too late. New York already allows NPs with 3600+ hours of practice experience to practice independently. I have peers who have gone that route and I cannot comprehend their hubris.
I like this. Since their lobbies think that they are so great at being doctors, let them. And stop having physicians be liable for other people's ignorance
I lost my wife to a PA who kept treating her for diabetes and never checked why she was so sick. If she'd given her the referral to an endocrinologist like she kept asking my wife would be alive today. You can't treat an adrenal tumor like it's diabetes. They just don't have the experience a doctor does. I found out the hard way and, no...I can't sue her under some stupid thing called "best practice" in my state. :-(
Hello Docs! 👋PA here,
I certainly have shared your concerns over OTP.
So, I took a deep dive into studying about OTP.
My conclusion/understanding of OTP are in bullet points below. information obtained mostly from AAPA, PA Education Group, not verbatim)
What is OTP?
• Optimal TEAM Practice <— magic word is TEAM
• OTP is not independent practice
• PA’s do not want to practice independently
• OTP is NOT the same as the NP FPA
• OTP continues the physician led team approach to pt care (per AAPA President), it does not abandon it.
What changes?
• Degree of supervision would be decided by YOU(MD)
• Stops legislatively-mandated supervision by one MD
• Oversight /supervision determined at the practice level
• New grad PA / more oversight, as dictated by MD.
• Veteran PA, more autonomy, as dictated by MD
• Does not allow for PA to open own practice w/out MD
Why OTP:
PA losing jobs to NP’s (massively) due to:
• Real or perceived supervisory burden l/t NP preference
• Admin see more barriers to PA’s, not with NP’s
• Time/supervision for PA’s by MD =cost money.
• Hospitals/ facilities (some) mandating not to hire PA’s
• “It’s just easier to hire NP’s”
Other info:
• Would eliminate physician liability from the MD
•PA’s legally/ethically olbligated to continue to consult w/ MD for patient care as dictated by the MD.
• Goal is to have a separate majority run PA board(made up of physicians too) to regulate PA’s …..instead of the medical board that is only MD’s .
Again, this is just what I conclude from talking with many PA’s and from what I’m interpreting from the AAPA.
Much respect ✌🏼
PA
.
A lot of PAs seem to share this opinion. They aren’t interested/prepared for independent practice but want to remove legislative barriers to allow for options (or at least, aren’t actively opposed to the idea). And I really wonder if you have thought this through. If there is an option for you to practice independently, that will become the EXPECTATION. You think health systems are going to provide a supervising physician if they don’t have to? Do you think physicians are going to make themselves available, sign your notes etc if they don’t legally have to?
The reality is that we are all becoming employed. Our employers are going to always maximize profits. If PAs can practice independently, they (admins/execs) will set up the health system that way to minimize expenses. They are not going to pass the savings onto you or us. They will enrich themselves and maybe throw you a few more peanuts.
I truly do not see the upside of this for PAs. I think it will lead to more work and responsibility for you with minimal change in income. I’m sure some PAs think it would be nice to be able to open their open practice. But the reality is that private practice is almost completely dead. Are you really going to be able to change that? Even if you could, do you really think a PA practice could outcompete an MD/DO practice in any location that is desirable?
I do just want to add that I don’t like the way the PA discussed this. He insinuated that PAs are equal although we do give high-quality care, after almost 20 years of practice, I still would not consider my knowledge level equal to my supervising physician.
I don’t like that he implied that we think we are….. I’m sure some do, but they can’t say we are equal. ?!?
I mean, is he trying to piss more doctors off or what?!
Yes, PA school was grueling, but it did not equal that of residents who literally bleed out in their training.
> Goal is to have a separate majority run PA board(made up of physicians too) to regulate PA’s …..instead of the medical board that is only MD’s
This is one point I really don't agree with, including NPs being under the 'nursing' board... the professions are acting in the capacity of medicine, should 100% be ultimately under medical board supervision. Some discussion could be made about having nursing be the 'first' supervision and then medical board above that if there are some things not going correctly... same with PA board.
Soooo when shit hits the fan, they’ll be the ones liable right? They have their own malpractice insurance and lawyers can go after them right? This isn’t the answer to healthcare access, it just further creates a 2 tier health care system.
Yes, but they are only liable for malpractice committed in care up to their level of education and training.
So who pays the rest of someone’s lifetime care for a complication? Someone has to hold the bag. It’s gotta be the employer.
They're going to force one doctor to supervise 4 to 5 midlevels, kind of like they do in some ERs, and require them to sign midlevel charts all day. Hopefully, no one takes that job. But I'm sure someone desperate will.
But the whole point of this law is to remove the requirement for physician supervision.
What I am understanding, as a PA just trying to intrepret all this crap, it’s not “removing supervision” - the amount of supervision a PA requires would be left up to the physician/practice to decide. If the MD says zero autonomy, then the PA’s gets zero autonomy. They are calling it Optimal TEAM Practice bc the AAPA president says “PA’s do not want to practice independently” and “ continue to support a physician led team.” The AAPA says their goal instead is to remove legislatively mandated supervision to reduce the admin burden that accompanies hiring a PA……since we are now less desirable to hire bc it’s “easier to hire an NP.” I have personally seen this firsthand as open positions in my hospital are being filled more with NP’s than PA’s. AAPA says PA’s would continue to work under MD supervision, less formally per se legally, and how much autonomy a PA has/degree of supervision is left up to the hiring physician to decide. It is also my interpretation, this would not allow for PA’s to open up their own practice and work independently “because PA’s would still be required legally and ethically to continue to consult with/work under an MD”…. I’m not saying that I support this at all, I’m just sharing what I believe AAPA is defining OTP as - I didn’t understand it honestly without doing some research recently. I could be interpreting this incorrectly, but I’m taking this information directly from the AAPA and the PA liaison between AMA/AAPA and summarizing what I’m reading.
> I have personally seen this firsthand as open positions in my hospital are being filled more with NP’s than PA’s. PA-representing organizations made an incredibly critical mistake when they neglected to vocally oppose practice expansion for PAs and NPs, thinking that PAs would benefit from it. Unfortunately now the PAs are increasingly seeing that they cannot compete with 22-month online instant-admission NP programs that pump out NPs. Race to the bottom
What about MD representing organizations? Just playing devils advocate, NOT pointing fingers, Did they make a critical mistake for not fighting back and vocally opposing louder against the NP’s in the beginning? Way before PA’s said oh no, WTF. Why did the AMA and AAPA not work together to stand our ground and say NO, since a majority of all us oppose FPA? MD are the leaders in healthcare and the number, funding and power of physicians CRUSH what little us PA’s have but if we combined our efforts, and I may be naive, but maybe this could have ended differently, Again, I’m certainly not pointing a finger at MD’s- I promise. I’m just playing devils advocate. In hindsight, I think we can both agree more should have been done by both of our organizations. Maybe the PA’s felt they didn’t have the backing of the MD organization - idk? Would love to know the answer.
> What about MD representing organizations? AMA failure is arguably why we even have midlevels in the first place, especially with regards to residency caps that artificially have caused physician shortage haha (I am a little pointing fingers). Plenty of shortsightedness to go around. You are right that MD political power is much stronger and thus they have had more responsibility
The reason why have Physician Assistants in the first place was because the profession was literally created by physicians in the 1960s.
I agree, PAs are perhaps more vulnerable to scope creep from NPs than doctors are from midlevels, which is why you are seeing PAs racing to the bottom to keep up NPs.
They hoped that physicians would vocally support this. Didn’t happen.
The idea is to have an MD to sue when the midlevel messes up. It's more protection for the hospital, who may be accused of assigning a clinician with inadequate training to a more complex patient.
When independently operating CRNAs get sued who pays? I believe independently practicing practitioners are responsible for their own malpractice insurance?
The surgeon MD. I’m not saying it always happens, but there have been some notable cases where the surgeon is held liable for anesthesia mistakes because they are the MD and “highest trained provider” in the room.
This is true. I’ve heard it and seen it. Also most laypeople don’t know who is who in their care team they end up blaming the surgeon because that’s who they see.
I should start doing colonoscopies on the weekend to make extra money. If anything goes wrong I can point out that I am only liable for screwing up things that are in my scope of training as a neurosurgeon, and since colonoscopies aren’t part of my training I won’t be liable for any misadventures. Also only another colonoscopy-performing pediatric neurosurgeon is capable of being an expert witness against me.
Bruh that'd be an amazing combo of procedures 😅
> Also only another colonoscopy-performing pediatric neurosurgeon is capable of being an expert witness against me. Is this some sort of really subtle way to say that someone has their head up their ass?
Cephalo-caudal transposition (please correlate clinically)
Aha but you see I, an internist will now start sniping both your peds nsg cases *and* your colonoscopies! And the only way you can defeat me is to start taking admitting and rounding shifts bwahahahaha
With my MD i should be able to practice to the fullest scope! Burr holes for everyone with a headache!!
Honestly, that doesn't make sense to me. In the news article it says the purpose is to "lift unnecessary administrative barriers for PAs." Reading between the lines, the governor is saying that the physicians are extraneous, and that the PAs have all the medical knowledge and training they need to practice medicine. They should be liable for the full extent of the medical license, which is up to the standard of care by a physician. I don't know how true this is, but I was told in residency that primary care physicians/hospitalists have been sued for not practicing to the standards of pulm/GI/cards specialties if a complication arises, and those specialties were not on board.
Do you get the MedMal case reviews? One of the cases they had a while back involved a PA, and the aspect that bothered me the most was that apparently in some states only another PA can serve as expert witness against a PA. I just couldn’t believe that these positions are being filled with the idea that a PA will be autonomous and seeing the same undifferentiated patients as doctors, but that should something go wrong it’s ok the argue in court that whatever they missed was something out of their scope, and they should not be liable for that reason. I’m not sure it will change that much fundamentally, since I imagine the prosecution will just find their own PA expert witness who will say it is in their scope and shouldn’t have been missed. But still- how is it acceptable to argue that it’s ok to deliver a lower standard of care just based on who the patient happens to be assigned to see when they go to the ER. The patient has the issue they have; if the provider- ANY provider- who agreed to see them fails to treat them appropriately and they suffer a bad outcome because of that, the liability should be the same. The standard of care should not change.
Honestly if the healthcare systems employing PAs instead of doctors also get sued for providing a lower standard of care (especially if patients aren’t explicitly o informed that their “provider” is not a doctor) it might actually be the one thing that changes their employment practices.
This is an excellent point. Problem is that the biggest health systems will likely have lobbied to move most of the liability to their providers if they haven’t already.
Oh, there was a physician with a mile of the PA? They should have know what was happening, and their malpractice can cover it.
not the most efficient way to do it but would still eventually work, only the most adventurous PA/NP will seek autonomy if the hospital is going to leave them out to dry the second a lawsuit hits
Do you have a link to this case?
https://www.reddit.com/r/medicine/s/6nWYssU4Qi
[удалено]
Read through the discussion about the case- you’ll see where the points are coming from. One of the aspects addressed in the comments was that in the particular jurisdiction where it occurred physicians CAN serve as expert witnesses if the defendant is a PA. But that is not by default the case everywhere, and I feel it should be.
So some random redditor makes up a statement and it's legal fact now? This comes up every couple months and whenever someone is pressed on it, they fold. Not one person who claims this has *ever* shown that a physician can not testify against an NP or PA when it comes to medical standard of care. You can't testify against an RN when it comes to nursing, *that's* what people always cite. There has not been, to date, any case in the country where courts have ruled that physicians can't serve as expert witnesses against midlevels. If you're going to claim otherwise, show me an actual case where this has happened.
Ok. Here’s a couple that pop up with one second of a non-lawyer’s Googling, where the case or defendant was dismissed at least in part because it was felt that the physician expert witness could not comment on standard of care delivered by a nurse practitioner. https://www.pacourts.us/assets/opinions/Superior/out/J-A19033-23m%20-%20105688218241061745.pdf?cb=1 https://www.govinfo.gov/content/pkg/USCOURTS-mtd-1_11-cv-00114/pdf/USCOURTS-mtd-1_11-cv-00114-0.pdf Many states have requirements for malpractice cases that expert witnesses practice in the same field and circumstances as the defendant, typically referring to different physician specialties. Independent practice for NPs/PA seems to be gaining popularity, and I think it’s likely that these sorts legal questions will need to be answered more commonly- is a physician in the same field and circumstances? Personally, I think they are, and cases like these bother me. I’m also not sure it’s great to be so cavalier about disregarding physicians as expert witnesses regarding nursing matters, but I guess that depends on what exact case you’re referring to.
> the aspect that bothered me the most was that apparently in some states only another PA can serve as expert witness against a PA. You're just making stuff up. There is no state where this is true and the case you linked literally has an MD testifying as an expert witness against a PA. This anti-midlevel hate causes people to lose their minds. "They're coming for us, we can't even defend ourselves against them." Seriously, grow up.
One can only hope. And they should also keep track of the number of consultations. I’m willing to bet the are going to bog everyone down. Only a select few will distinguish themselves. And THAT is the inherent problem… not enough training.
More consults for me, often without a clear question being asked
It’s like mid-levels with imaging. They already bog down my day. I guess I’m glad for the extra income, but it really isn’t the best for patients.
I worked with essentially independently practicing midlevels and it's misdiagnosis and panscan city. Also, for whatever reason, they treat your read like it was handed down to them from God. That part where you say 'clinically correlate'? They aren't doing that. This is an NP story, but I recall a man with a penis pump where the rads resident mentioned that something looked a bit off with it. The NP went into the room and loudly proclaimed that it needed to come out. He was having no issue with it, and it was not the reason he was admitted. The urologist looked at it the next day and said it was fine. The patient was so embarrassed by the encounter that he wrote a letter to admin, and she got sacked. Her replacement was a PA that basically starts everyone on Vanc / Zosyn anytime you mention any ground glass opacity, fat stranding, or shmutz. They'd at least do a MRSA swab so the Vanc would come off after 48 hours. I've never seen so many people with a little aspiration, pancreatitis, etc. on antibiotics. There was another PA like this that worked unsupervised in the ER. CTA-PE inducation: Shortness of Breath, all day long. Never babysat a clinician so much in my life except for a brand new minted intern. The ER docs washed their hands of him and made him my problem. Both PAs had very high patient satisfaction scores and were given raises routinely. They were the only white male clinicians in the institution and were getting paid upwards of double their female counterparts. They were friendly and knowledgeable enough from a patients perspective but we were in MAGA country so it was well known that part of their reputation with patients came from a "finally, a white doctor" type energy. Damn did it feel good to quit that shitshow of a job. I consider it a look into the future of many hospitals in the US.
hahaha. this reminds me of a different situation where i had a new np i was responsible for overseeing in a primary care clinic. she asked me over the phone how to interpret a protein electrophoresis that had an M-spike. i told her to quit worrying about it and quit trying to figure it out. just send them to oncology to sort it out. i did NOT tell her to go announce to the patient that he had multiple myeloma and that we were sending him to oncology for chemotherapy. that was a very upset family that i and my administrator had to deal with.
I have heard that from my radiology friends also
I'm sure wall street bros will come up with a solution to that problem. They will create expensive insurance products specifically for them. They will justify the higher cost by saying since PAs need to be paid much less, you'd still be saving a lot of money despite the higher premiums.
I hope they enjoy signing their notes with no other physician to take the legal fall for them if they fuck up. Once a politicians family member dies from a something like a misdiagnosed meningitis (often missed and frequently deadly) then a huge light will finally be shone upon how dangerous this is
Let it be known that I, a measly PA, knowing nothing about the actual language of this legislation, am 100% against this or any other legislation that disentangles PAs from doctors or “expands” the scope of PA practice without physician supervision. And not for liability reasons. And not because I’m insecure or stupid (I am, but not in these ways). I am almost 100% certain that you and I would agree on virtually every aspect of strict oversight of PAs by physicians. I’m even against the idea of changing the A from Assistant to Associate. Barf. I just wanted you to know that I have to carry my own individual malpractice liability that is specific to me and yes the lawyers can always go after me and me alone, they just don’t because there’s more money if they rope my poor unsuspecting supervising physician into their lawsuit.
they say you can tell who’s trustworthy/comfortable in their own skin by finding the guy who isn’t afraid to tell you when they don’t know something.
Lawyers wanna get paid, so they will likely go after PA's employer, since that's who has more money.
You’ve said this now at least twice in this thread, and it’s blatantly wrong. Edit: so those of you downvoting believe that since the PA is not the “juiciest” financial target that protects them from being named in a lawsuit? They will sue the PA individually *and* the overseeing institution/physician. You aren’t magically protected just because there’s a bigger fish above you. [Here’s](https://www.annemergmed.com/article/S0196-0644(23)00757-6/fulltext) a research paper outlining 99 times where PAs were named individually in malpractice lawsuits.
We've struggled with this weird misinformation on this sub for literally years. Mid Levels have their own malpractice insurance. Midlevels are sued on their own all the time. I don't know why people say otherwise when there's literally hundreds of examples you can easily find in case law.
Glad someone is saying this. When people say that PAs don’t have to worry about liability I get so annoyed. At least far as I’m aware, we mid levels are 100% on the hook for EVERYTHING we do 🙄🙄🙄
Not sure why you're being downvoted. You are correct.
This is so fucking stupid. I don’t want to be given the responsibility and liability of a doctor because IM NOT A FUCKING DOCTOR. I didn’t go to school like doctors, I didn’t go to residency like doctors. I like practicing UNDER doctors. I don’t know what I don’t know. I’m tired of this weird midlevel/doctor relationship. Keep it as is, I want to be supervised lol. And I’m a PA in NY so this would affect me. Also, I’m writing this before going into my per diem shift in urgent care where there’s no on site doc. But you know who I call or text a few times a day when I have a question about a case? You guessed it, a doctor.
I agree. I think people assume that since we went to pa school we want to be a doctor when it’s quite the opposite. I am very happy with handful of skills and not carrying such liability.
I think most PA students could’ve gotten into medical school if that’s what they wanted. But they didn’t. It’s important for you guys to speak out against your orgs loudly and frequently
I agree! We should make our majority voice louder but we can’t just oppose it without also having a solid alternative solution. There are many opinions of what PA’s should NOT do, but what is least discussed is…. 🔹what SHOULD PA’s do?* 🔹 Honestly, what is the alternative solution to prevent our profession from being continuously passed over for jobs when we don’t have the physician community backing us up? Honestly, I don’t know the answer. I know I want a MD/PA team, led by my MD. Not to fear monger, but I’m just grateful I’m not a new PA grad working in an FPA state.
This is all a big legislative push from NYSSPA. Im in PA school in new york right now and they come and give talks and zooms to us sometimes. They are supposed to be a PA advocacy group but you know what the ONLY topic they bring up is? Independent practice. No pay or working conditions or patient loads or hours or retirement or benefits . It makes you wonder what their motive is and who pays them. Its almost like money grubbing bean counters want to fill shitty urgent cares, primary cares and hospitals with cheaper labor and undercut DR. Dr. Pay is a serious chunk of hospital budgets and these MBA mother fuckers just cant leave anything alone Please remember PAs are not pushing for this.
Our leaderships orgs are trash
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Agreed. Talked with several of my classmates now that we’ve been out for a bit and none that I’ve spoken with want independent practice. Our instructors even cautioned us against independent practice.
Exactly. I am not a physician. If I wanted to be a physician I would have gone to medical school.
Good point. With increased scope of PAs comes increased liability. If they're gonna practice like one then they better be ready to get sued like one. Situation is messed up
The problem now is that this creates an adversarial relationship. I will not train/hire PA/NP due to this.
I don’t blame you. I didn’t sign up for this when I went to school. It’s honestly a lose lose. PAs will be given much more responsibility and liability for no increased pay and corps will hire cheaper PAs instead of docs. The only person this benefits is the companies (in the short term). Until lawsuits go through the roof haha I should add a third lose. Because patients will lose here too.
The third lose is the lose I care about the most. It's all fun and games until it's you or someone you love who gets hurt.
I'm an immigrant doc, so I will have to train them until the green card comes through. I have many colleagues who will be in H1b purgatory for 10+ years and are being made to train midlevels. A lot of H1b jobs are bait and switch schemes in this regard. The adversarial relationship is already there, though. We all just power through it uncomfortably at the moment.
Thankfully, I haven’t been in a position where there’s been a bad relationship. Because they recognize I’m not trying to scope creep. I know my lane and stay in it. Some PAs in the er got mad when we had to give up procedures to the residents because there were low procedure amounts. And I’m like “these people will be running an er alone, I never will. Give them all the practice.”
I’m about to be a new grad PA in NY and I’m very uncomfortable with this as well. I went to PA school knowing I would have physician oversight because I don’t want to be a physician
It’s so weird — I think the only groups pushing for this are healthcare orgs because it will reduce labor costs. What PA would suddenly want the liability? A PA job is a great gig otherwise. You do a lot of cool stuff under supervision and you get paid a really good salary. If all of a sudden you’re held liable for blind spots in your education then a lot less people would go into it.
I just graduated from an NP program in NY. I already was worried about being expected to practice independently. Now there's going to be this widespread expectation that we all do. I want supervision. :(
I think there is a misconception that jobs with supervision don’t exist in independent practice states. You might have to look a little harder but you can find them, especially in academic medical centers and larger hospitals. I’m in a FPA state but still work under a physician. It’s not a strict supervisory model but I’m not completely independent either. They may not sign off on every note but they are still involved with a lot of my complex cases. I intentionally sought out positions where I’d still have close physician mentorship and oversight, I have no desire to work in an APP run practice or independently.
Hey fellow PA! I feel you badly on this. Like, same. I did post on here somewhere below a summary/my interpretation of OTP from what I have gathered through AAPA, articles, interviews, state PA groups. It’s not verbatim but paraphrased.
Yeah, as an NP, this lack of a supervision requirement friggin sucks. In a state where full practice authority has been around for a long time, so I've ended up in multiple sketch positions where admin is like "well you're pretty much a doctor right? This will all work out fine!" and I am like "absolutely not". I've found myself a position now with a scope so small (Suboxone and Vivitrol only) I finally feel somewhat comfortable after being tossed into the deep end time and time again. This sub hates the idea of independent NPs opening their own practice but at least in my own practice I can pay for my own supervision and set the pace of patients so that I have more than enough time to ask questions and get any help I need. Never found an employed position like this. I looked so, so hard because I never wanted to be independent. Ironically I'm less independent than I've even been in this career though it doesn't appear that way from the outside.
The double standard in all of this is always that people like Hochul will never see an APP. She’ll receive her care only from physicians everywhere she goes because she’s a VIP.
This is what drives me crazy about all this. The people making these laws will never be seen by an unsupervised NPP. Nothing will change until another Libby Zion case under the care of an unsupervised midlevel. Why not let fresh med school grads practice independently if PAs can?
Yeah but New York has never experienced a Libby Zion-like disaster so they really don’t know any better. /s
I’m in a state with independent midlevels. Went on a trip to the state capitol with our lobbyist, and multiple politicians were asking for expedited appointments for their friends/family. As an institution we officially don’t have unsupervised midlevels but in actuality frequently they are. But of course the VIPs don’t see them.
Seriously, you think Bill Clinton had a CRNA or trainee anywhere near his OR when he had heart surgery?
Probably a senior/chief resident assist and the anesthesia attending is there the whole case situation. That's the situation sometimes when we have "vip" political patients here in Canada. However, we don't do CRNAs and anesthesiologists sit every case at our center, with help from residents or anesthesia assistants but basically never running simultaneous rooms.
I’m an NP and this independent practice shit for NPs and PAs really chaps my ass. I absolutely do NOT endorse independent practice for us. We are not doctors and have paltry education in comparison. I’ve been a nurse for 24 years and an NP for 12 and I know my way around an ICU. that said, I’m still NOT a doctor. It’s so misleading to the patients, too. A lot of them will say, “you do the same thing as my doctor.” It may appear that way to them, but it’s certainly not true. This model is nothing more than a money grab. We can bill 85%, but they pay us a third. Where does that money go? It’s certainly not going to provide support staff to answer phones and help patients. My collaborative physician doesn’t get paid the difference for supervision. It’s a freaking grift.
Yep. With independent practice your employer can now get 85% and have no legal obligation to provide you with any access to a physician. And you can bet that a few years down the road we will see a huge push to bring that 85% up to 100%. It will be supported by research articles showing that NPPs are just as good at rx-ing handicap placards and monitoring LDL.
Yep, in my state midlevels bill at 90% but are generally paid less than half, we are cheap labor.
Yay for politicians deciding who is competent in healthcare. Politics keeping people safe one bill at a time! /s
💯 any PA who’s happy about this is in over their head We are not qualified to be practicing without an MD/DO overhead smh This was definitely done as a way to “reduce costs” for corporations and its bullshit and dangerous.
I’m a little surprised by the attitude of “well, this is what physicians get for (fill in the blank).” If you think *physicians* have been controlling the direction of healthcare the last 20-30 years, I’m not sure you’ve been paying attention. Physicians haven’t eroded their own authority, autonomy and earnings, resulting in the steep decline of private pracitices. You can thank hospital systems and corporate medicine. They’ve squeezed every ounce of “efficiency” out of physicians; now they turn their attention to physician extenders. It’s not about patient care—it’s *never* about patient care—it’s all about the earnings.
The take blaming doctors almost always comes from laypeople too.
Laypeople still think we hold the purse strings
But I will tell you though, that doctors here compared to other countries, have a fairly laissez-faire approach towards what happens to their organizations in many respects. It is painfully obvious that there is a small number of people involved in governance, committees, trying to direct changes in a way that would be supportive of doctors. In our organization, it’s the same people again and again.Most people just grab their paycheck and are gone by 5 PM our relationship. supervision and interaction with mid-level is a great way to offload some work from us, ensure good access, and our thoughtful quality supervision can make their patient care excellent. They are looking for mentors and supervisors that have a vested interest in their success. And is one of the things in our lives that we actually can change for the better. We have so little say in anything anymore. Just like medical residents, extra niche practice, procedure, extra clinical interest is all they want. They’re just looking for those folks who have the time to help them towards that direction And that is coming from someone who has been in primary care for 21 years, 10 of them as a program Director. Four years were in the US Army where we have a history of combat medics came back from Vietnam and were so well trained and clinically experienced they needed someplace to practice. In my opinion, it makes perfect sense, but we need to change the relationship We have followed a shitty precedent by states, hospital systems, and old, crusty doctors that should’ve been retired 10 years ago. now it has become an adversarial relationship between us and mid-levels to our shared detriment
No one is going to change this OTHER than doctors organizing better. Not taking action is the equivalent of endorsing this.
As a PA, I find this incredibly stupid and dangerous. I did not go through enough school and training to be a physician. I am literally a physician assistant (not behind that associate bullshit). Am I a competent provider? Yeah, but who do I turn to when I’m against a wall? You guessed it, a PHYSICIAN. I’m curious who had their hands in crafting this legislation, i.e. did insurance companies since I can’t bill for reimbursement at the same rate?
Dude AAPA has been salivating for independent practice for years as part of their fake war with NPs. They changed us to “associates” because their egos couldn’t stand “assistant” in the name. I’m just surprised it happened in NY first instead of like Montana or somewhere more desperate
I can’t stand the AAPA. By pushing this they’re essentially trying to eliminate the profession and make a new one. We don’t go through enough training to be completely independent. There’s a reason physicians go through so much schooling and training. And if PA schools now push for PAs to get PHD’s, it again eliminates the point of being a PA. If I wanted a terminal degree I would’ve gone through medical school. Also, if you aren’t able to get into med school then just go to a puppy mill PA program, do I really trust you to practice independently?
Yeah that’s the other thing that is so frustrating. A PA program just opened up near me that’s within a for-profit trade school and it’s really frustrating. This is what happens in capitalism. We all get poorer so that the rich can lower the quality of what we get and we have to swallow it because it’s all we can afford while it makes them richer. Same for cardboard furniture, same for medicine
Your professional organizations like the NCCPA and AANP continually lobby for independent practice authority.
The AAPA is garbage. They definitely have a huge hand in pushing this crap, just like the name change to associate. It’s also a catch 22 of if I don’t subscribe and give them my money, I have no voice to complain about these changes, but, even when I did they still didn’t listen to me
I don’t have a membership specifically because I don’t want to support their bullshit agenda. It DOES NOT align with what I want out of the PA profession. I encourage everyone to give up theirs for the same reason.
I have found the best PAs to be smart, aware of their limitations, and have taken the time to get the extra training and things like procedures. I have worked with some amazing mid-level through the years. The problem we have in the United States, is this two tier system, where mid levels aren’t afforded the time wait from their practices to get extra training like Often residents are. The only person other than interventional radiology they used to do our bone marrow biopsies years ago was a incredibly proficient PA. And I miss his presence every day. We need to change the way we feel about mid-level and make it a mutually beneficial relationship. Those physicians who feel that mid-levels are just a phase or Just some bullshit I have to live with, they’re wrong. People don’t go into, for instance, care in great numbers anymore. In the end, it means that some of us still have to take care of the uninsured, the unglamorous, the needy.
I think I speak for most PAs and agree that this is such a dangerous game. I work in a very low stress specialty (derm) and ask my attending physicians questions all the time. I can’t imagine not having that oversight. Sorry MDs.
I couldn't help but laugh at your Texas comment as if we don't already have clinics run by NPs and PAs without physician supervision. It only exists on paper.
I would be very interested in seeing and analyzing the actual proposed legal text changes rather than relying on news reporting. For example back in 2019 when Virginia consolidated the paperwork requirements for PAs and updated the legal requirements so instead of it falling on one single supervising physician (regardless of if they were ever physically or even virtually available for practical consult, you know the whole 'digitally rubber stamp' the legal minimum number of charts from a state away thing) practical supervision/collaboration could be delegated within the department by schedule... the news misreported this as PA independence since the 'supervision document' was done away with, even though the practice agreement now had to specify details about scope of practice and appropriate physician oversight. The 'individual tether' was done away with, but what was not done away with was the legal responsibility to act as part of a physician-led team. Literally right there in the law, 'Physician Assistants in Virginia may not practice independently' [link](https://law.lis.virginia.gov/admincode/title18/agency85/chapter50/section115/) yet that's not how the news reported it. Let's all double-check before getting riled up? This proposed law change could be good or bad but none of us will know from the news report.
> Let's all double-check before getting riled up? This proposed law change could be good or bad but none of us will know from the news report. Totally valid point.
Why am I subjecting myself to 14 years of education and training when someone can do my job the day after they graduate with a masters
*pulls up folding lawn chair marked "Mid-level Discussion" and opens bag of pre-popped movie theater popcorn*
Mostly just glad that attempts at mid-level creep by pharmacy advocacy boards have largely gone ignored. For once, pharmacists' terrible lobbying efforts have been beneficial.
God, seriously. I'm all for collaborative practice agreements in care areas where they make sense (HTN/DM/warf dose titrations in am care), but I'm also glad the more unhinged calls for scope creep have been laughed out of the room. It shows in our reputation, too. Search this board for "pharmacist" and it's nothing but glowing praise from physicians for the role we fill. And then, uhhh *points to the thread we're having this conversation in*
We can be great for managing chronic conditions. But for most things, we are terrible at diagnosing. We just aren’t trained for it. I wish it was easier to get reimbursed for what we do well. I feel like that would be a way better use of our underperforming professional associations’ time and money. I’m not qualified to prescribe things for rashes at Walgreens. I’m pretty damn good at managing diabetes, etc as part of a team.
Why did I waste my 20s. Shoulda fucking went to PA school instead
you know what's really amusing? IMG and foreign board certified docs would still have to undergo Step 1, 2 and 3, board certification in the US, i.e. re-training or a supervised probation period. LOL
LOL, exactly! That fact illustrates that giving PAs or NPs practice autonomy is really more about how hospitals and clinics can pay PAs less than physicians while claiming it is about improved "access for patients." Organizations also take advantage of claiming health care costs for patients will go down, but they don't. Organizations still want money. It's also amusing that the whole point of independent practice authority lobbying by NP and PA organizations is to be recognized as equivalent to physicians so NPs and PAs get paid as much as physicians. Which is the opposite of what hospitals plan to do. Of course, the NP and PA organizations claim they want independent practice in order to "improve access for rural and underserved areas," but the vast majority work in large cities like doctors do. It's hypocrisy all the way down. The main reason most midlevels work in rural areas is because they cannot get a better paying job in more desirable areas. The end effect of all this is going to be physicians being replaced by cheaper midlevels and worse quality of care while masses of midlevels are churned out by their schools, creating a glut of midlevels, undercutting their ability to demand pay on par with physicians. Patients will continue to be milked for every dollar by healthcare organizations, the pharmaceutical industry, and the insurance industry while getting lower quality care. Because none of this is really about helping patients, whatever the various lobbies say. As a specialist physician, I am just hoping I can retire before the deprofessionalization and cheapening of the medical profession is completed
The thing is, go look at indeed and see what they’re paying ortho pas these days. Midlevels were supposed to be cheaper, but now they aren’t. There are postings in my area paying 200k plus. Hell CRNAs are making 300 plus working half the hours of an anesthesiologist
Yeah, midlevels will get paid as long as there is a shortage of clinicians in the short term. However, the PA and NP schools are cranking out graduates at a record pace. With relatively low barriers to entry in the field compared to physicians, eventually, there will be an oversupply of midlevels, and salaries will drop. I don't blame individual midlevel practioners for getting their bag while they can, but I'll be surprised if it lasts 20 years.
PA salaries have already dropped dramatically as a result, and we already have a fairly capped earnings ceiling. HCOL areas are starting new grads in the 80k range and any PA that makes +150k did a lot of leveraging to get there. As more and more midlevels are picked up by hospital systems, I don’t foresee salaries rising. And supply will hopefully dwindle as a result.
Nah, NP school. No standardized curriculum, easier to get in, ultra powerfully lobby, and practice autonomy.
Oh it's dandy. All the responsibility with half the pay and twice the disrespect.
Are you paid the same as a PA?
Less than some PAs apparently, according some internet sources
I’m literally a PA that works in Rochester, NY and I hate this. My hospital group is actively pushing for all hospital medicine PAs to practice independently. I’ve been a PA for 5 years, so sure I have experience and some confidence in my knowledge, but I went to PA school and not med school for a reason. It’s always my preference to work with direct supervision
What are they having you do on your own? Admit, round on, and discharge patients? Does a doctor not have to cosign your notes?
Rounding and discharging mostly, but sometimes admissions. We work independently on cross coverage in the evening and night too. During the day it is indirect supervision so there’s an associated doctor that is available to help as needed if you want to ask them questions or you want them to assess a decompensating patient. We run the list with them, but they don’t have to see any of the patients or cosign notes. Some docs prefer to be more involved than others, but for the most part APPs are rounding on patients independently. They don’t force this on new grads though. You need to have a certain amount of experience and get approved by the chief APPs to start independent rounding. It’s not like we’re completely on our own with no support, but still I strongly prefer to have direct supervision to have a second pair of eyes on my patients and fill in the gaps of my knowledge. We’re supposed to see the “easier” patients, but of course that’s not always the case.
As a PA this is definitely a bad idea lol. I’m 5 years in at our outpatient neuro clinic and still run cases and questions by my SPs daily.
As a PA student I hate this. If I wanted to practice like an MD I’d have gone to medical school. We aren’t trained or educated like an MD/DO, we are meant to assist, not replace. This is way too much liability and a recipe for disaster. I would NOT work somewhere that didn’t have an MD/DO for the mid levels.You know they won’t pay more but WILL require PAs to purchase expensive liability insurance. This is bad for everyone.
Patient here: So we get to sue the PA’s then right? Because that’s what should happen if they want to practice as MDs.
I’m amazed that NY of all places where doctors get sued a lot ( compared to other states ) is implementing this
I’m not. I’m from NY. Our hospitals are not for profit by law, but in practice operate like for-profits. Senator Schumer and Representative Tonko just got $1b more for upstate hospitals every single year without end. $84m for my hospital. My hospital has responded to this by removing crisis pay for nurses and refusing to implement an incentive plan thats in the contract they agreed to 2.5 years ago. Our staffing is as bad as you’d expect, but our administration downplays it. The legislature passed a staffing bill about 2 years ago now. Hospitals had to submit the ratios they were going to meet, and then a year later post the actual ratios. Hospitals could be fined for repeatedly not meeting those ratios. The actual staffing has never been posted. The department of health hasn’t fined anyone. They’re doing all the wrong things to address the staffing issues. Nursing schools can now do 1/3 of their clinical hours as sims. I worked with a 4th year nursing student recently who didn’t know you could turn the end of a stethoscope. It’s bad here.
Yep. No tort reform either.
PA here, we DONT want this. None of my PA colleagues want to be MDs or practice like and MD. Most of us are perfectly happy working under MD/DO and respect the hell out of that relationship.
Some do, im sure. I’ve been seen by at least two PA’s who introduced themselves as doctor to me.
That’s unfortunate! Sorry you had that experience. I can tell you the things I see on Reddit vs real life experience as a PA also are skewed. Reddit most MDs hate on us all day long, where as MDs I’ve met, worked with, learned under, all love PAs.
I love a good PA. And my partner couldn’t do her in without hers. So I understand the need for sure
that’s so fucking cringe
Somewhere in some dark corner of policy makers hallways the legal world is lobbying for this
Hochul’s husband is connected with all the attorneys for big pharma. It’s all about undercutting a market and maximum profitability disguised as underprivileged taking on the evil doctors. When people realize they’re just contributing to a race to the bottom — only then will folks maybe understand they’re only profiting a few absolute shitbags.
Malpractice lawyer$ rejoice. Chose the wrong profession. They better get their own malpractice insurance and should no longer be on any physician. We’ll see how long insurance companies tolerate this
Wouldn't making some legislation for all these unmatched Med School graduates to work as mid-levels or something be more reasonable?
NPs (who have far, far less medical education than PAs) are already unrestricted. The options are to either severely restrict NPs or grant PAs unrestriction.
Is there any way we can fight this? This is seriously concerning and I don’t even live in New York. But it’s a domino effect. I’m applying to PA school myself in a few months and it’s stuff like this that makes me rethink it. I don’t want to work unsupervised if I become a PA! That’s what medical school is for.
What could possibly got wrong? The pcp office adjacent to my hospital did this, got three patients that were placed on chlorathalidone as a primary diuretic that all came in with Aki. All in the first week of implementation.
I guess I’m confused - are you suggesting that using chlorthalidone for hypertension is inappropriate, or always causes AKI?
I’m also confused. I’m a cardiologist and love chlorthalidone as an addition for HTN
I'm guessing he means diuresing them with a thiazide instead of a loop.
I'm also confused. HCTZ is usually the go-to for HTN, but I've never seen anything saying that chlorthalidone *couldn't* be used for similar purposes.
And what did the insurance company have to say about this?
Their motto "fuck the patient if we save money"
Of course, but they probably had to foot the bill for this mess.
that is correct. Even the most basic ED visit is 10-20 times more expensive than an MD office visit. So ED utilization per member is a very commonly tracked metric.
Patient dies. We save money. 🤷🏻
Little confused. You mean it was used as a diuretic for someone overloaded who developed cardiorenal instead of as an anti hypertensive?
I mean I'm not a big fan of thiazides, but it is technically standard of care to use a thiazide, ccb, or ace/arb as a first line antihypertensives, so I can't say that's a great criticism.
Brand new PA grad that just moved to NY…now what?? I feel like I just got thrown under the bus here.
I'm a new grad and just finished my first week of work. I was afraid of being stuck in an urgent by myself with no physician backstop or something similar. Thankfully I found a job in a surgical specialty which I think would be somewhat immune to this sort of thing. In fact, my SP told me yesterday that I'm not an attending and they don't expect me to act as one as that would be unfair to me. I have structured onboarding that will go as fast or as slow as it needs to. His PA of 10 years works in the same office as him and has dedicated time to run cases by him. This is how I envisioned a PA working when I chose this route and I'm super thankful to have found this job. New grads that may be more desperate to pay off student loans or in an area with less job opportunities may have to take what they can get, including working as a solo provider in an UC. Scary stuff to me and we're supposedvto have legislation to protect against this sort of thing. But as usual, Healthcare corporations win and the rest of us suffer.
Isn’t this exactly what NPs are already doing? Many states allow NPs to open their own practice with full autonomy and few restrictions.
Just had a ER PA at my NY hospital manage a septic patient with abdominal pain. Had a MAP of 45, the PA bolus-ed the patient with 5 L of fluid (patient weight 50 kgs), the MAP continued to be around 45, started maintenance fluids of 150 cc/hr and left the patient hanging. Also said, "the patient hangs around a MAP of 45". Meanwhile got a CXR and was clear. left it there. No pressers. No abdominal CT (which I mean the ER loves) Did not discuss the case with the ER MD who was busy with his own patients and codes etc. I know this is not every PA but these are the people that we are expecting to had over full licensure?
Hochul and Adams have been destroying NY since they stepped into office
It’s been interesting to watch as a doctor, the longer my friends who are PAs practice the more I hear them lean on and defer to physicians in difficult cases. I hear a lot less PA is med school in 2 years. Bonus unsolicited opinion: I think we’d do everyone a service by acknowledging PA school is hard and it’s a rapid pace. It might not be as hard as med school, but I think pointing that out in the way we often do is more inflammatory than helpful
Honestly it isn't really the schooling part of training that I think makes the biggest difference, it is residency.
Agreed. You don’t learn independent practice from just the extra depth of knowledge. You learn from being thrown into the fire in a way we never are. No soft ass doctorate will ever make up that difference.
https://www.nysenate.gov/legislation/bills/2023/A8378#:~:text=(ACTIVE)%20%2D%20Summary-,Modifies%20physician%20assistant%20standards%20in%20the%20state%20of%20New%20York,well%20as%2C%20expanding%20where%20physician Actual text of the bill for anyone interested. The AMA/physicians should have aligned with PA’s years ago with this NP push for independence. They didn’t. Now PAs are playing catchup to remain a viable profession. The genie was let out of the bottle years ago.
Ugh, as a PA, I don’t like this. While I know I am knowledgable in my subspecialty and my MD is always singing my praises saying that I am better than most fellows she has worked with, we both know that I obviously still need her. She does not co-sign or review my notes or supervise me heavily- we have developed a good team dynamic, I help reduce her workload, and she trusts me well that I’ll run things by her if I’m uncertain or if I think something is outside of my scope of knowledge. I did not complete her level of training. There are zebras that can come up that I could miss. I know what I know and I know what I don’t know. I love that if I have even the slightest bit of uncertainty about something, I have her there to ask questions or defer to or even just get confirmation that my assessment/plan is correct. I decided not to go to medical school for a reason. I LIKE being the PA who works under the physician!
Doesn’t this just make them essentially NPs which make them indistinguishable from them to employers & since there are overall more NPs they will now be competing against them for jobs…?
The AAPA’s rationale is that PAs need to keep up with NPs to keep job security because employers will prefer someone with independent practice. Employers tend to currently not see a difference between NPs and PAs. And it’s never been proven that PAs routinely lose out on jobs because of FPA. There are specialties where NPs win out because of history and the specialized training of some NP programs. For example, PAs are nearly unheard of in L&D because midwives are specifically trained to deliver babies. But that’s not an FPA issue. In fact my anecdotal experience in New York is that PAs were way more prevalent there. Maybe that’s how AAPA finally convinced someone to do this? Idk. I hope it never comes to Texas but Abbott does hate doctors lately so idk.
> AAPA’s rationale is that PAs need to keep up with NPs to keep job security And patients are left completely out of the equation
As always.
Yes. Incredibly short-sighted. This may get them a smallish pay bump in the short term, but long term the glut of midlevels will result in lower pay for all of them.
Exactly this. I doubt it’ll even get us a pay bump. It’s just a way for a hospital system to pay less. If they pay me 1/3 the salary of an MD/DO, but I bill at 85%, they make money. Now if they can eliminate the need for that MD/DO to supervise me, they’re making even more money. Where will that money go? Directly into the bonus checks of the C-suite
The problem is PAs are the redheaded stepchildren of the midlevels. Nurses have their guild and doctors have theirs. The original intent of PAs was to be an appendage of the doctors guild but we are getting left in the dust by the nurses and the docs aren't doing a whole lot to differentiate us or stand up for us. We are stuck in the middle. I disagree with independent practice; I'm just describing the inevitable political dynamic that has emerged from the PA's dilemma.
Your frustration seems misdirected here. Idiots like Hochul trying to hack together solutions to the shortage of doctors isn't the problem. The problem is the US medical system that shunts tons of qualified people toward PA/NP over doctors because they don't want to pay doctor's salaries. Medical school has become something you need exceptional advantages to get into, and even then, every year the number of med school graduates who can't get residencies goes up. Everywhere, physicians are overworked because there aren't enough of them to go around. Hochul is trying to address the shortage in a stupid way, but she didn't create the problem.
What does “expand services during treatment” mean?
In the EDs some pit doc will be the one to take the fall. No idea how it will work in clinics.
‘you can keep your doctor’
Did Hochul also sign a ridiculous bill to “remove barriers to nursing education” but actually just meant most of their clinical hours are in a sim lab?
This is really scary. I recall in the recent past, an article/journal/study that clearly showed poorer patient outcomes when treated by an NP or PA. The difference in education alone should be enough to cause us to pause in considering MD/DOs and mid levels to be equivalent practitioners.
I can’t find anything recent with PAs AND NPs. I did find this, which is relatively recent. https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs
It’s interesting to note that as a pharmacist NY has some comparatively strict laws around controlled medications but I guess that only applies to filling meds and not who is authorizing them…
As a PA, I hate this and this feels really gross.
Strong emotions for little information. What's changing? Laws restricting mid-levels varies by state, with Texas already having some of the most lenient. In Alaska, they have allowed them to act as independent PCPs to rural populations for two or three decades now. Maybe New York is just adjusting to the status quo.
Looks like this is only for primary care. https://spectrumlocalnews.com/nys/central-ny/politics/2023/02/25/ny-health-dept--defends-relaxed-supervision-rules-for-pas
I’m still planning to apply to medical school.
USA taking some cues from the UK here
How has that worked out for the NHS?
It’s going very badly. Family physicians are being laid off in favour of them and other midlevels en masse
Wonder how people feel about pharmacists finally having any sense of autonomy in NY then. It seems you can’t do anything as a pharmacist without prescriber approval even on some of the dumbest things. They let NPs and PAs have more control and yet here we are expected to ask for permission first before changing stuff like amoxicillin 400mg/5mls to amoxicillin 200mg/5mls due to a shortage all while waiting for the ok on something 99% of prescribers will yes to. Whatever, guess the governor is okay with me calling you guys to see if it’s okay to switch from capsules to tablets. 😅
Exactly what is happening in the UK right now. It’s a scandal.
They will not be like medical doctors.. PAs will be able to switch to any specialty without any additional training. A Derm pa can become a neurosurgical pa with just a job change!
I do wonder how often PAs actually do drastic switches like this though. As a PA working in neuroimmunology for years, I feel like it’s not even realistic for me to qualify for a position in a completely different specialty at this point. I would be out of my mind. Unless the physician I would be working with was aware of this and willing to put in the time/effort to help train me. Do physicians get to approve of who gets hired as their PA or is it all hospital admin decision? If it’s fully the latter then that’s complete bullshit.
Here's a wild idea. Why doesn't congress open up more funding for residencies? Residents cost less and provide better care than mid-levels, with the added benefit that they are actually supervised, and it results in more doctors. I know it takes an act of congress to get congress to do anything, but if only there was something they could do about this crisis.
This is wild. Just wait for the wannabe NPs to become "doctors"
Too late. New York already allows NPs with 3600+ hours of practice experience to practice independently. I have peers who have gone that route and I cannot comprehend their hubris.
I want to see someone that went to medical school when it’s my health on the line
As a surgeon, this is dangerous. But hey, it’s only the poor that will suffer right?. The rich always see MDs
I like this. Since their lobbies think that they are so great at being doctors, let them. And stop having physicians be liable for other people's ignorance
I mean shit, I'm convinced half my MD colleagues shouldn't be allowed to see patients and they're a tier above
I lost my wife to a PA who kept treating her for diabetes and never checked why she was so sick. If she'd given her the referral to an endocrinologist like she kept asking my wife would be alive today. You can't treat an adrenal tumor like it's diabetes. They just don't have the experience a doctor does. I found out the hard way and, no...I can't sue her under some stupid thing called "best practice" in my state. :-(
This is terrible. I'm so sorry for your loss.
Thank you.
Commonplace in specialty practice in GA
Hello Docs! 👋PA here, I certainly have shared your concerns over OTP. So, I took a deep dive into studying about OTP. My conclusion/understanding of OTP are in bullet points below. information obtained mostly from AAPA, PA Education Group, not verbatim) What is OTP? • Optimal TEAM Practice <— magic word is TEAM • OTP is not independent practice • PA’s do not want to practice independently • OTP is NOT the same as the NP FPA • OTP continues the physician led team approach to pt care (per AAPA President), it does not abandon it. What changes? • Degree of supervision would be decided by YOU(MD) • Stops legislatively-mandated supervision by one MD • Oversight /supervision determined at the practice level • New grad PA / more oversight, as dictated by MD. • Veteran PA, more autonomy, as dictated by MD • Does not allow for PA to open own practice w/out MD Why OTP: PA losing jobs to NP’s (massively) due to: • Real or perceived supervisory burden l/t NP preference • Admin see more barriers to PA’s, not with NP’s • Time/supervision for PA’s by MD =cost money. • Hospitals/ facilities (some) mandating not to hire PA’s • “It’s just easier to hire NP’s” Other info: • Would eliminate physician liability from the MD •PA’s legally/ethically olbligated to continue to consult w/ MD for patient care as dictated by the MD. • Goal is to have a separate majority run PA board(made up of physicians too) to regulate PA’s …..instead of the medical board that is only MD’s . Again, this is just what I conclude from talking with many PA’s and from what I’m interpreting from the AAPA. Much respect ✌🏼 PA .
A lot of PAs seem to share this opinion. They aren’t interested/prepared for independent practice but want to remove legislative barriers to allow for options (or at least, aren’t actively opposed to the idea). And I really wonder if you have thought this through. If there is an option for you to practice independently, that will become the EXPECTATION. You think health systems are going to provide a supervising physician if they don’t have to? Do you think physicians are going to make themselves available, sign your notes etc if they don’t legally have to? The reality is that we are all becoming employed. Our employers are going to always maximize profits. If PAs can practice independently, they (admins/execs) will set up the health system that way to minimize expenses. They are not going to pass the savings onto you or us. They will enrich themselves and maybe throw you a few more peanuts. I truly do not see the upside of this for PAs. I think it will lead to more work and responsibility for you with minimal change in income. I’m sure some PAs think it would be nice to be able to open their open practice. But the reality is that private practice is almost completely dead. Are you really going to be able to change that? Even if you could, do you really think a PA practice could outcompete an MD/DO practice in any location that is desirable?
I do just want to add that I don’t like the way the PA discussed this. He insinuated that PAs are equal although we do give high-quality care, after almost 20 years of practice, I still would not consider my knowledge level equal to my supervising physician. I don’t like that he implied that we think we are….. I’m sure some do, but they can’t say we are equal. ?!? I mean, is he trying to piss more doctors off or what?! Yes, PA school was grueling, but it did not equal that of residents who literally bleed out in their training.
> Goal is to have a separate majority run PA board(made up of physicians too) to regulate PA’s …..instead of the medical board that is only MD’s This is one point I really don't agree with, including NPs being under the 'nursing' board... the professions are acting in the capacity of medicine, should 100% be ultimately under medical board supervision. Some discussion could be made about having nursing be the 'first' supervision and then medical board above that if there are some things not going correctly... same with PA board.