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Lessons Canada can learn from the American PA Journey

Lessons Canada can learn from the American PA Journey

What Canada can learn from the American PA Journey

When I approached Dave about writing a guest post for the blog, he requested an audio interview – which I thought was a fantastic idea! I spoke with Maureen Taylor, a Canadian PA who is also a former CBC journalist who agreed to interview Dave.

We cover everything from “Physician Associate” instead of “Physician Assistant”, working with other health care groups, PA reimbursement in the United States, PA supervision, and other American PA trends such as PA residency PA Doctorate Degrees and “Optimal Team Practice”

Note: Although they mention the word “podcast”, I did correct them afterwards to let them know that we do not have a Podcast. 

Listen to the Interview:

About Dave Mittman, PA-C:

Dave MittmanDave Mittman, P.A. has been a PA leader for over 40 years. Dave co-founded the LIU PA Program student society in 1973, was President of the New York State Society of PAs in 1979 and served on the American Academy of Physician Assistants (AAPA) Board of Directors from 1981-1983. Dave is now back on the AAPA Board of Directors serving his second term, as he was elected in 2015. Dave has also won the AAPA Public Education award for leading the march in Trenton NJ to establish PA practice in 1989. Dave has been honored with a Lifetime Achievement Award from both the New York State and New Jersey State Society of PAs for his work as a PA leader, one of the few PAs in the nation to be honored in this way. Dave is a founder and Past-President of PAs for Tomorrow the national PA advocacy group. He also recently served as the Treasurer for the Association of PAs in Family Practice as he spent years practicing primary care and feels that it is a prime specialty for the for the PA profession. Dave is now serving his second year on the Board of Directors of he AAPA, a position he also held thirty years ago in the mid-1980s. Dave was introduced to medicine as a medic in the USAF. He later had the distinction of becoming the first PA in the USAF Reserves permitted to practice as a PA.

Dave did much work for PAs in the AF to gain commissioning as officers for a number of years. Dave spent almost 9 years in a primary care group practice in Brooklyn, N.Y. practicing family practice. He provided medical care to patients from two years to almost one hundred and two years, providing a full scope of medical care. Dave left in late 1983 to begin a career in medical publishing with Physician Assistant Journal. Dave left PA Journal to co-found Clinicians Publishing Group in 1990 and Clinician Reviews Journal in 1991. This was the first journal written for both NPs and PAs. In 2001, Clinicians Group was acquired by Jobson Publishing.

In 2005, Dave became a Life Coach through NYU/Results Coaching. He has done postgraduate work in Executive and Leadership Coaching. In 2008, Dave co-founded Clinician1 (www.clinician1.com) which is the largest NP and PA informational/clinical/social community on the web. Dave has authored papers in over 100 publications as diverse as “Chicken Soup for the Expectant Mothers Soul”, “U.S. Pharmacist”, “The British Medical Journal” and many, many others. Dave is a noted expert in NP and PA practice both in the U.S. and around the world. He has published papers on both NP and PA prescribing. He has consulted for many companies on PA practice and has spoken at numerous PA and NP meetings with audiences ranging from 5 to 1,500. Dave is married to his high school sweetheart Bonnie for 42 years and is Dad to two wonderful young adults who will always be his finest achievement. Dave’s mom is from Lac La Biche, Alberta. He has over 35 first cousins who are Canadian and spent many summers in the fields of Alberta.

About Maureen Taylor, CCPA:

Maureen Taylor is a Physician Assistant in Infectious Diseases at Michael Garron Hospital in Toronto. She is a graduate of the inaugural class of Physician Assistants at McMaster University in2010, and is currently an Associate Clinical Professor in that program. Prior to her studies as a PA, Maureen was an award-winning broadcast journalist for 25 years, including 7 years as the National Medical/Health Reporter for the Canadian Broadcasting Corporation. Maureen has also worked at Sunnybrook Health Sciences Centre as a PA in Emergency Medicine, and she was named PA of the Year by the Canadian Association of Physician Assistants in 2016.

Interview Notes

Be sure to read the full transcript, here are some brief notes from the interview.

Canada should learn from the mistakes and strides American Physician Assistants have undergone.

Don’t rely on organizations or health care professionals (i.e. physicians) alone to push the PA profession forward. Certainly collaborate and make alliances with other organizations and health care providers, but as PAs we need to advocate for ourselves.

The term “Assistant” in “Physician Assistant” does not do the PA profession justice. The term may be confusing and is not reflective of who we are, what we do, and the level of education of PAs. ‘Assistant’ is a technical level person who does not have the ability to diagnose, treat, prescribe and do the things that PAs are doing all over the world. Read Dave’s Post on PAs Connect, “Why I Decided to go with “PA”

PAs in the US have billing numbers and bill at 85% of the physician fee, if there is full physician involvement (called “Incident to” billing) then the practice gets remibursed at 100% physician fee. However, if the practice bills “Incident to”, this does not reflect that the PA was involved with the patient encounter, and PAs are ‘invisible’ to the health care system.

PAs in the United States work under physician “supervision”, however the term ‘supervision’ is different and broad. In New York State for instance, which has the largest number of PAs practicing in the United States, PAs do not have to report who their supervising physician is as per state legislation. And with “physician supervision’, the supervising physician does not have to be physically present. For instance, a PA may work in a rural clinic, and the physician could be 90 miles away. There is a transition away from ‘supervision’ and more towards ‘Collaborative Practice’.

An increasing number of physicians are being employed by hospitals, and as a result have relied less on hiring PAs. Due to legislative problems and hearing from PAs across America, the AAPA house of delegates made the concept of Optimal Team Practice (OTP) a high priority. 

OTP means PAs collaborate with other health care providers and supervision is determined at a practice level. Just as brand new nurse graduates are not running an ICU, or a brand new pharmacist is mixing ingredients to go in an IV for critically ill patients – a new PA grad will not be seeing patients without supervision. However, the level of supervision of a new PA grad versus a PA who has been practicing for 25+ years will differ – and this will be determined by the skills, education and experience of the individual PAs.

There are PA doctorates available in the United States. Other health care providers have doctorate degrees, this includes naturopaths, chiropractors, physical therapists, and now there are nursing doctorates available. There are 5 schools in the United States that offer this degree. This is an add on, where in addition to clinical curriculum, you can do leadership. education and administration.

There are 140 PA Post-graduate Residency programs. These are post-graduate programs give specialty training available for PAs in various specialties, include an Emergency medicine Post-graduate Fellowship, Surgery, Orthopaedics, and Critical Care. See the Association of Postgraduate PA Programs website for more details.

At present Canadian PAs cannot practice in the US. There is no international reciprocity. See our post on Canadian PAs practicing in the US.

PAs need to get on social media. Both Dave and Maureen agreed that social media (Twitter, Facebook, LinkedIn, etc.) is now how they obtain their health care and PA profession news. Read Why PAs Need to get on Twitter.

Maureen: Why don’t you start off by telling us a little bit about you?

Dave: Let me thank you for the hospitality in allowing me to speak to everyone. I became a PA because of the Draft Lottery in the United States. During the Vietnam War, on television the host would pick your birthday, and then your draft lottery number. You could be either #1 to 365, and I was #2, which meant I was going to be drafted sooner or later, and go somewhere where I didn’t want to go. I decided not to do that, and I joined the Air Force Reserves,  at the end of the day they told me I’d be a good medic and I went for Medic training and while I was on active duty for 7 months I met some people who were as good as physicians who were not physicians. Not knowing a lot about medicine I was intrigued, and it scared the heck out of me, because I was like, “What is that about?” I got to be friends with them, and they were called PAs.  They were wonderful, so I said I want to be that when I grow up. I was 21 or 22 at the time. The next year I was at PA school in Brooklyn, NY at Long Island University I was from Brooklyn, I only applied to one program and Thank God they let me in or I probably would have been a lawyer or something, and that is how I discovered the profession.

Maureen: Obviously not unlike the development of the PA profession in Canada, where it started as you know, a mostly military profession – these were medics that had enormous skillset.

You witnessed the growth and development of the PA profession in the US, where it went from a military profession to a civilian profession. What can we learn in Canada, about utilizing PAs in civilian life?  Its taken us a little longer to get there.

Dave: It sure has, and I’m not sure why, but it is another discussion for another time. I thought about this question, it’s a hard one to answer however I answer it, some people aren’t going to like the answer, but I’m going to answer this just for me. I am only speaking for me, not as a board member or any organization, or an employee of any organization, or owner of any company. I am just little old me – to put that on record.

Canada has to do what is best for Canada. That being said, Canada should learn from the mistakes that the PAs here made. If I had all the Canadian PAs in one room, and I could speak to them, I would tell them where in my mind, some things I would do differently. I don’t want to say mistakes, because I think you live through things and you learn as you live through things, that you might have done them differently, faster, or better.

Number one for me was PAs thought the physician’s organizations were on their side, and I think it took us 20 years to learn that they were not on our side and we are generally not a member of their family. They look at our education and still have not basically given us for any credit for what we know. I mean, in any school, or any place, no physician organization has said, “you know these guys/ladies are really great”. They don’t. They basically in the United States, at least organized medicine comes out every so often and says about us, “they don’t know what they don’t know, and they are good for some things but they are going to wind up getting into trouble.” And it took us 20 years, what I think was wasted political time to realize that we needed to advocate for ourselves, and no one was ever going to do it for us. If we showed up on Thanksgiving with a beautiful cake and we knocked on their door, they would probably say “who the heck are you?”, and we would say, “well, we’re your illegitimate kids or something that you don’t want to recognize” And they would say, “Sorry we’re closing the door” and that would be it. That’s really, for the most part, how we’ve been treated and so I would just pass that on. Make all the alliances and make all the friends that you can, and clearly advocate for yourselves with anyone, including physicians, who have been wonderful (don’t get me wrong – I’m really talking about organized medicine, not physicians –

Maureen: Not individual physicians who may be supportive

Dave: Always have been. There have always been wonderful, beautiful people who supported PAs, who employed PAs, who advocated for PAs. I am not talking about those people. Now with social media, you can go on social media, we find physicians, PAs, or NPs that feel the whole spectrum of feelings about anything. Generally physicians have loved us, and their organizations have not and still fail to recognize many times our feelings, and where we’re coming from – we’ll leave it at that.

Number 2, I would clearly point out we still have a problem in the USA and most if not all PAs, I don’t mean 100%, or 90% or 85%, that will recognize and tell you – and that is that of our title. You guys being part of the British, and I know you’re not part of Britain knowing some Canadian history, being part Canadian in a way, I used to hang out in my summers in Canada – but being part of that system, or closer to the British Health Care System than the American Health Care System might want to look at using “Physician Associate” for now. But clearly, our title in the US does not represent who we are, what we do, the level of education we have. It’s really misleading, it’s confusing, and I almost think it’s been a yolk that we bore, that we succeeded in spite of. Had we had another title, it would have been a lot easier. Without going into too many horror stories, that would be my second.

Maureen: Just to be clear to those listening, and this is something that you have written and talked about at a great length, you think that the title should be “Physician Associate” not “Physician Assistant”?

Dave: I think if I were in Canada I would do that now. Because all of the British health care system has done that. I don’t anymore. Maybe Canada wants to think about the way that I’m thinking, so let me tell you where I’m sitting at. I was behind “Associate” for many years, and we’ll get into this later, we’re really changing our paradigm here in the States, and the way that we think, because we have to. Physician associate to me, is like all my life, I didn’t have a name, and I’ve been married to Bonnie for many years. So you just called me Bonnie’s husband, and it’s the “Apostrophe ‘s’”, and thats who I was. And then you said, “You know what? That’s not really fair anymore, we’re going to call you ‘Bonnie’s Partner’, or maybe even ‘Bonnie’s Associate’”. Well that’s still not me, and I think we need to be ‘me’, whatever ‘me’ means to us. I’m not sure what that is yet, honestly,

Maureen: You haven’t figured out the title you want.

Dave: No, I have not. But I would go to the associate for default, I would say it’s not the title we probably will wind up with in the United States and I’m not sure where we are going with it. I would speak to not using “Assistant” because if Canada is anything like the US, and I’m sure it is on this level, ‘Assistant’ is a technical level person who does not have the ability to diagnose, treat, prescribe and do all the things that PAs do all over the world. It’s confusing. I would limit that.

My number 3 would be to use our studies, and don’t start 25 years behind us. The studies are going to be coming out fast and furiously, I’m going to do a plug, come onto Clinician1.com, we are always posting new studies about PAs and Nurse Practitioners. I wouldn’t want to duplicate what we’ve already done, I don’t think the human body is any different in Canada than it is in the US and our studies, if they’re done well, and most of them are, we are going to have many many more NP/PA studies and many more of us working together, they will show that we’re excellent as they’ve been showing. You can use those, you can walk into the legislators and other people in the provinces and say, “Listen, here is great studies”. If I were looking at them, they’re really irrefutable, why not do that?

Maureen: Let me just ask though, on that point Dave. What I hear from government officials a lot is the studies they want to see is that we can save the system money. And because our two health care systems are different in the way that we’re a single tier system and supposedly universal health care and yours is insurance driven – can we really use your studies to show that we can save the Canadian health care system money?

Dave: Well I think you can use our studies to show that the care you give and the quality of it, is as good as any other practitioner’s care and quality. That’s a big one – for me. And then its how you fit yourself into the system. It certainly costs less to educate PAs than it does physicians, number 1. Number 2 I’m sure that PAs in the Canadian health care system don’t make as much salary as physicians do. Number 3, and in fact, I’ll be posting it probably tomorrow, there was a letter that was in JAMA Internal Medicine about a study, they’re starting to look at PAs and NPs in specialty medicine and saying, “Wow, they do the same level of work that people who went to residencies and specialties are doing, basically”. We may not be doing the surgery, but in many of the cases we are doing the same level of work (not the surgeries) in terms of care and quality. Even in the United States, they haven’t been looking at specialties as much as they were looking into primary care. And so, specialists it has to be that we cost less, both in education, and once you know your stuff, and going out there and providing care I would have to believe.

Work with other health care groups, earlier than we did. So make alliances with the pharmacists, and I know the NPs have been a little harder in some of the States here, but with the NPs, the physical therapists, not just with the physicians. Not saying that the physicians are bad, but to spread our chips around the table a little bit. Keeping them all in one place doesn’t serve us as much as making friends and alliances where ever we can.

Maureen: It’s tough, because even the other groups you mentioned, aside from the Nurse Practitioners, when in Ontario we applied to become a ‘regulated’ health profession, those other groups stood up to say ‘we prefer you didn’t regulate them’. It’s almost still the turf protection runs pretty deep. Even among professions where we don’t pretend to be able to provide any services. And I guess, its just because it’s all brand new, and people feel their jobs are threatened with cut backs, I don’t know.

Dave: I would agree.

Maureen: Let’s talk about the way PAs are paid in the US, can you tell us a little bit about the way PAs bill for the work that they do?

Dave: Well, obviously there’s a number of ways. Insurance companies pay PAs, you would have to be credentialled by the company. They would pay us sometimes the rate that a physician gets and sometimes 80%. I’m not an expert in payment by the way. Obviously, if you are working for a private group, they would pay you a salary, you would elect to bill or they would bill for you. I’m saying they would bill, and you could bill under your name, or the physician sticks their head (so its not fraud) under the physician’s name.

What we found in Medicare, is that we’ve been able to bill for many years, I think its like 25 years and our federal system for the elderly, and Medicaid which is the State system. If the physician sticks their head in, we can bill at 100% and if they don’t, we can bill at 85%. What happens is, either someone will stick their head in, or the biller will just say they stuck their head in because the biller wasn’t there. It’s done two things. The PA doesn’t know that its happening, and number 2, which is even more important even with the insurance companies the service was provided by PA, and it keeps us invisible. We have become, very much so, even with 120,000 of us in the US, both a visible and also an invisible profession. So many of our patient encounters are billed under the physician’s name, so the hospital/clinic can get more money. We know that’s a problem, and that’s called “Incident to”. We are now saying, we would like to do away with that, and so are the NPs by the way. We will have an argument about what level we should bill, should it be 80, 85, 90, 95, or 100% or should you just pay for the service that rendered. In the end it’s going to be, we don’t want to be invisible anymore. We’ll get to the optimal team practice, one of the pillars of OTP is that the PA always bills under their own name. Because I really think, Maureen, that 50, 60% and I don’t know the exact number, and by the way I’m not speaking on behalf of the AAPA, its a huge number of people we see are totally invisible and our entire system thinks physicians are seeing them. And again, if you get into specialty care, home care, God only knows what some agencies are thinking or the insurance companies. We have to take a real look at that, and the way you start, is to bill on your own.

Maureen: So if I understand it, you advocating for this billing on your own not so that PAs can earn more money but more because it would make PAs more legitimate, more visible to the public and patients that they serve. Is that your point?

Dave: Yes, its exactly the point. Undoubtedly, I think PAs would make more money, undoubtedly, when you know your worth, when any of us know our worth you’re more powerful in the way you negotiate, but I think that would be a by product. I think the reason we would want to bill in our own name would be so we become visible instead of invisible in our system.

Maureen: And I appreciate you talking about how it works with medicare and medicaid because those are more similar to our health care system in Canada. On the other hand, in Canada, our governments are wanting to move away from a fee for service model  of physician payment. So they are unlikely to ever give PAs a billing code and the ability to bill on our own. I can’t see that happening here, they want everybody on salaries eventually. What do you think?

Dave: I understand you are saying there is value-based care, but at the end of the day people still want to know, who is doing what, who is responsible for what and how productive a person is and how each class of porvardo would be. There has to be a way in Canada where people care about that. That is what I am advocating for.

Maureen: Interesting. I have certainly been following you over the years and your advocacy for evolving role of the PA and I want  you to talk a little bit more about the role in the US has changed over the last 10 years.

Dave: Sure and thank you. First of all, its changed very quickly. As you know we in many States have to be supervised. What people don’t know it “supervision” is a word that PAs define very differently than everyone else defines it. And so, in New York if I read you our PA legislation and New York is the largest PA state in the country . We don’t have to tell the state who our supervising physician is. We don’t have to be physically near them in anyway. We can run a clinic and basically bill, and do whatever we need to do, pronounce people dead, the physician can be 20, 30, 50, 70, and 90 miles away. And again the state, there is no paper and no form. The PA is basically practicing legally and fine.  And I’m not saying that everybody should be going out and doing that but that’s the law. And so, supervision has always been very broad and very lenient if that;s the right word. You didn’t always want to strictly define it because it was hamper PAs going into the places that they needed us.

Well over the last two years, in the AAPA house of delegates, the  HOD passed a resolution, a very brave one, saying that “PAs will no longer be supervised”. For those Canadian PAs that don’t understand our house of delegates. HOD is a PA branch of the AAPA and we just come up with resolutions which could best be interpreted as the statements from something for our profession. So they have no legal weight, no reality, so you would still have to go back to your state and change the law, but at the end of the day they are what our professions feels “on record”. So we went to 2 years ago, we are going to collaborate, which is the word that Nurse Practitioners that they use in the 28 states, where they need to collaborate. They do have a couple of states where they use the term ‘supervision’, but its a less confusing, much nicer sweeter word for pretty much doing the same thing. In the last two years, I think the number of States have passed “Collaborative Practice”, PAs clearly collaborate in the States, and the VA has full collaborative practice. Michigan, 6-8 months ago, changed everything, PAs need a “participating physician” which only meant they needed a practice agreement, but it was very ineresting as it was interpreted as broader than collaboration. It was another step towards full practice.

Maureen: What does that mean “practice agreement”? That a physician agrees that once in a while they are there once in a while for the PA to call if you do need some need help?

Dave: I’m actually not sure, but I think it’s an agreement. Its an agreement that spells out who you go to, and the chain of command if you need help. What you can and can’t do, depending on where you are working. I don’t mean, ‘you can do a physical exam’ or not, but more like I am not sure but I know that is where you go, the physician and you have an agreement that he or she will participate with you and will be a PA and provide care, it was certainly was looser than ‘supervision’ but it was a step in the right direction. And this year, a number of organizations backed a resolution to say that actually a task force was formed to look into what the nurse practitioners and we were calling ‘Full Practice Authority” or Responsibility. And this meant, PAs would not need supervision at all. And, really, I’ll tell you what that meant after the house of delegates but it meant we would have laws not like the NPs for many reasons, and we’ll get to the reasons after. There’s clearly variation number 1, and I think both PAs and NPs have been looked at medical providers, where 10 years ago, we were looked more at as “adjunct” providers. There’s PAs doing absolutely amazing things. There’s PAs doing things surgically, PAs doing everything, anything you can almost imagine we are doing now, and we’re holding our we’re good. That is still evolving. Where we got to back in the house of delegates was, actually before the HOD, the AAPA put together a task force chaired by a wonderful PA named Jeff Katz past president of the AAPA, they looked at full practice authority, and meaningful practice responsibility for a reason. Let me go into this a little bit, I hope that people who listen find it interesting.

More and more physicians in the States are becoming employees of large hospital systems. And these large private practices and small groups. Years ago, where 3-4 physicians would be together, the local hospitals would say to we’ll give you “X” money, sell us your group and becoming employees. This has gone on for a number of years, it will go on way in to the future where very few physicians will open up private practices. And yes, there is called “concierge medicine” where people give you a lot of money. We are not going into that.

[29:30]

What we found was that the more physicians became employees, the less economic incentive there was for them to employ a PA. If a PA and NP both were doing the same thing, they seemed to prefer the NP regardless of what they thought about how our education was, or that we went to school in a different way under the medical model and whatever you might think. They wanted to employ the NP, because the NP was legislatively and legally less of a hassle. And in 20-23 states, NPs have full practice. They don’t require any supervision. So they don’t need co-signatures, they don’t need meetings. These physicians once there was no economic variable, listen, “We don’t need this anymore,” and so did the hospitals or the institution where they said “We don’t want to hire 5 physicians, just to be “collaborating physiciyou bringans, we can hire NPs who don’t need these extra physicians” Of course NPs need physicians, but they don’t need them legally, they don’t’ need them by law. PAs did. “We don’t need PAs, we don’t want the responsibility for another profession” and that’s what we were hearing more and more from regular PAs that were out across America. So the task force got together they came out with a report and the house of delegates looked at their recommendations, and it was really about taking responsibility for what we do. That was really the hallmark of the report. I have written previously to that for years, to be a real profession, one has to be responsible for what you do. In America, I hope you call them the same thing, we have “licensed practical nurses” [Note: In Canada, we called then RPNs, registered practical nurses] and they can go to Costco and give flu shots and get paid $200 for the day, or whatever they get paid for the day. They sign their name and they give shots and they go home. They do whatever, and they can make a nursing diagnosis and whatever they do. Here in the states, physical therapists have full practice in every State right now. And people can walk into their offices, I think it is every State, and people can walk in without a referral from a physician and they can diagnose and treat them, sign their name and they can go home.

[32:40]

Audiologists sign their name and go home.

Because of legislative problems, hearing from the PAs of America the system was not working for them anymore. The house of delegates got together and they passed “Optimum Team Practice” (OTP). We wanted to keep “team” in there because we feel we are members of a team, not because NPs aren’t, they are also, we just thought we wanted to stress that and so let me tell you the four pillars of OTP:

[33:20]
  1. Full PA responsibility – No supervision (not saying that you don’t work as a part of a team and I’ll go into that a little bit later because that is the fourth pillar). We are responsible for what we do, just like every other professional in the world.
  2. Reimbursement to the PA directly. If you are working in a large group you do what all the other providers do. You sign your waiver and they will bill in your name, and the group gets the proceed, at least you would know what you were bringing in, you would know what you were worth and you would know your value, and we wouldn’t be invisible anymore which was the biggest thing for us – to stop that invisibility because again all the other providers were being recognized in the healthcare system,
  3. We asked for PA boards of the medicine to be either split out or at least the boards that have authority have PAs, even if it’s from the board of medicine (ND board of medicine), to allow the majority of people to sit on it to be PAs. Because we need to regulate our own profession, our own practice. And that would go along with being responsible. If you are being responsible for what you do, then you should be clearly responsible for your own profession.
  4. Lastly, we said we want to collaborate. Collaboration is good amongst all health care providers and clearly within what we do and within our paradigm. We want it. We want it determined at the practice level. So you go get a job, and they look at what you’ve done before, and they look at all the things you bring to your practice. This is determined legislatively. No other profession requires supervision after 30 years of practice. We want that collaborative relationship to be determined at the practice level. So if you’re in a satellite clinic, and you need it once a month, fine you’ll get it once a month. If you need supervision everyday, then you’ll need it everyday. That’s not the point, to be determined on your education, your experience, and how good you are, not because legislation says supervision.
[35:50]

Maureen: That answered one of my questions because some of the people listening to this podcast will be brand new grads who will be frightened at the thought of being left on their own to just start practicing with no supervision, that is not what is your saying, you are saying that will be determined when you apply for the job, the people hiring you will determine your level of supervision in accordance with your education and your experience.

Dave: Right, and it might be other PAs that determine it. Its shifting the paradigm to recognize that we are a real profession. Keep going back to this, we take our responsibility for what we do. You are going to diagnose, Otitis Media, and you will listen to people’s lungs, you can do physicals, and you can do this and do that, you will also treat hypertension, but you might not treat really complicated case of Diabetes at onset. You are going to take that, you will determine that because you are a profession. In the same way a brand new RN doesn’t run an ICU, the first day. A brand new pharmacist isn’t mixing ingredients in the IVs that the second it goes in your arm it could potentially kill you if it’s mixed wrong. You gain experience and your education, and you get to do what you are able to, but that’s determined for all professions, even physicians what you do is determined at the level of the practice, “practice level”.

Maureen: Moving it along here, you’ve been talking about the goals of this the wing of the AAPA. What is the reality in most States.

Dave: I’m not sure about the question, the reality is that most PAs …

[38:40]

Maureen: Do PAs need supervision? Or do they practice collaboratively all those nice things in the language that you use use.

Dave: No the reality is that it just passed two months ago, this optimal team practice. There again, Michigan needs participating physicians. There’s a number of States that need collaborating physicians. Every state’s legislation is different. In real practice, PAs see patients as any other medical care provider does, diagnose, treat and prescribe in all 50 states, we can write all controlled drugs in 49 States now, and in one state we cannot. And that is what we would call class drugs. The addictive drugs, benzodiazepines etc. I think we function as, I don’t want to compare us to anyone else, as PAs. We function as medical care providers who are professional by education and clinical training, and can provide clinical care. The supervision is generally again, determined at the practice level.

What I’m saying that the House of Delegates did, what’s really going on in reality. Again I told you New York State Law, I never have to physically meet the physician. Not saying that happens, but you can be in a rural clinic in a month, and maybe you talk , maybe you don’t, maybe you have as much experience as many of the physicians you work with. Now if you are just out of school, you are not taking on jobs. There are PAs in and out of the military that are Chief of Family Practice Clinics. There are PAs doing great things in every specialty. I don’t even want to say one or the other. In a collaborative way, but clearly not using their education and experience is the best way I can put it.

Maureen: To work at the top of their scope of practice. Another trend that I have been watching, and these things start in the US and then it comes to Canada, is this what I like to “Degree creep” in the medical professions. So that I now that entry to practice for physiotherapists is now a Master’s Degree. NPs are getting Doctors, “Doctor Nurse so and so”. I think that in the States you have a couple of PhD programs for PAs. What role do you think that will play in PA education in the future?

Dave:I think its there now. Let me go back, I grew up really believing in that you don’t need to be a doctor to provide high quality health care. My life was dedicated seriously, dedicated to showing the world that this was possible. Here’s what happened along the way. I got converted. I’m not saying you need a Doctorate at all, to provide good health care. I’m saying in the future, we will probably have that. So let me tell you why, in the States every physical therapist who goes to school goes to a Doctorate in Physical Therapy program. Occupational therapists the same thing. Audiologists the same thing. Psychologists same thing. Naturopaths same things. Chiropractors same thing. Dentists same thing. Now we can all argue PA training by hours is three months less in the Master’s program by hours than the traditional US/Canadian physician education (medical school). It’s not really that much less in hours. Where we are limited in our education is in residencies and structured post-graduate education. Not saying you can’t learn after you graduate, because we’ve all 10,000 people who have shown you can. And you can. But looking into the future, I really believe in we will have to along the way, many of us will get Doctorates. Let me go into that a little bit.

We are going to do what physicians do, and we are going to look towards having optimal team practice (OTP) and those four pillars. I as a patient would expect that level of education. There are for me, not in any order:

Other professions with a much lesser scope of practice than what PAs can do in the States for sure, are graduating with Doctorates. If we’re going to write orders and write other things expecting other professions to listen, I don’t like the word “order”because it’s a word from the last century. If we give suggestions, and other people need to listen to our suggestions more and more, it’s going to be expected that reimbursement in the States is a big issue, and I think all those other professions went to the Doctorate, because they found reimbursement at Master’s degree level in the States was a problem and will be a problem in the future again. I agree that there is a Degree Creep, I also threw out number 4: We spend more graduate hours in school than any other profession in PA studies than MDs or DOs. Why would we not want to reward ourselves for what we earned. Just clearly an interesting question and it’s part of  evolution. I agree with the degree creep, but I also think that there is a part of me sometimes we just need more critical thing skills around other parts – administration, leadership and clinical skills that wouldn’t hurt us to have add on doctorates, and it’s just in a more structured environment. As you know we have (I’m not sure of the numbers) but we have 140 post graduate degree residencies now across the States, and maybe it will be that if you do those residencies that we will add on many more graduate hours, if you are working 80-100 hours per week, clearly you will come to realize that there’s no reason you don’t deserve a clinical Doctorate. For me, I think we have to look toward the future and not towards the past.

Maureen: I hear all that and I think you are being a realist. This may not be the way we choose to go, but this is the way things are going anyway. But that’s going to be a hard sell to some people trying to decide, “Do I go to medical school? Or PA school?”If you are making the PA program longer and more expensive, you know, I think people choose the PA route because they want to get it over with and get out there and look for patients.

[48:20]

Dave: I totally agree, if you noticed there was a word that I didn’t use and you didn’t use “mandatory” doctorate. I think these are going ot be “add on”. I think you will go back to school, Lynchberg College, one of my friends is program director in Virginia, AT stills in Arizona, one of my good friends is program director. There are 5 now announced in the States. They’re “add on” and you can do leadership, education, administration – they’re all clinical, but youc an also take other courses and you will be given hours and projects in either leadership, education or administration. They are going to get us board rooms and other places where we need  to compete  in these big health care systems. We are not going to get in in many cases without it.

[40:01]

Maureen: Now I want to throw something at you that wasn’t in the questions, i have to ask you. Canadian PAs feel that our options are somewhat limited compared to your options in the US. You guys seem more excited because you have these PA residency programs and PA Doctorates. Do you ever see a world in which Canadian or even European trained PAs will be allows to practice in the US?

Dave: I don’t know, its a fascinating question, and thanks for asking it! One of the things I’d like to go back to do, is to find out what good reasons are, especially for Canadian PAs, not even, if you’re following the same model of education and you’re as good, and you can pass our boards, I’m not saying anything again, I’m not representing anyone but me – I don’t see a problem with that. I would love it that the legislation in Canada got so good, we PAs would be clamouring to do the opposite, and I think that’ll happen. I don’t know if you’re listeners know, but PAs in the Netherlands, are independent practitioners. Now, there are experiments in all of Africa with PA-like people, and many of them are. If we all look at, I think if we look at the best practices, clinical training. This is one thing I would like listeners to sleep on.

I want to make it so that I can say, I am 100% PA and everybody understands that, and that’s cool. Getting back to your question, yes I I think that will happen, I’m not sure how we get there, obviously that’s tied up with NCCPA, PA programs, just saying “yes”, we would be okay to allow, whatever mechanisms we have to allow for that to happen. Not sure.

Maureen: A good topic for an interview with the licensing, regulatory board in the US, find out why we can’t write that exam.

Dave: I would be all for it. There are the British PA programs, that echo both of our PA country’s programs, and there are a number of countries that are doing excellent work, there should be no reason why I can’t go to London, England for a year and sample what they do there however they are not licensed there and it’s currently a weird pilot thing. Why not?

Maureen:  Let’s wrap up by talking about social media. You and are I great, but we’re pretty active in social media. Why do you think PAs should be involved in social media.? For those PAs who don’t know, how I got into medical communications expert I was in journals, and with two of my partners, the publisher of the number 1 journal for the PA and NP profession, for 10 years. When I looked at what I wanted to do for our future after we sold our company and I was left at the doorstep crying, “Omg what am I going to to do now?” I realized the future was not as much on paper anymore as it was on my computer, as it was through the internet, as it was through social media. I put my money where my mouth was, and I started a site which Canadian PAs can join also, although I’m not sure how we can get around an NPI number, Clinician1.com is the site. I started and put up money and I had a partner who put it money, I think social media is the future, obviously. You can’t beat the speed that you can both learn new things, new developments, that you can’t beat consulting with 5 or 6 other friends at the same day at the same time. You can’t beat taking classes, looking at pictures of rashes, with which rash you get from visiting Africa, and things like professional and health care news. If you’re not on social media, I’m not saying that people need a big mouth like I do and get on it, and tell you what they ate every morning, because I don’t even want to do that.

If you’re not on social media, you’re missing a lot. As the years go on, and it gets that much more both acceptable and professional in our nature, we’re going to be missing a large part of postgraduate education by not being on social media. I think we need to share information. We’re not doing it by places like this and other places like Skype, Facebook, the AAPA has the huddle for AAPA members, and our excellent conversations that go on there now on all of these sites. I have learned so much. Just from my colleagues that I would have never met, we have put together, there’s a group, a sort of “Progressive PA” group called “PAs for tomorrow”, some people would say more than Progressive but I started the group with a number of other PAs and all of us only met on the internet. Many of us had never physically met each other. We met each other amazingly at our first board meeting.

Maureen: It’s really utilizing the power of the internet, the distance between us, and bringing everyone together instantly. I have students I teach at McMaster on this issue and they’re all amazed that I have over 1600 followers on twitter, their image of Twitter is “what I had for breakfast this morning” and “What I’m doing with my friends this weekend.” It’s where I get my medical, health information professional information. It’s a community out there it’s a replacing newspapers in ways for me.

[58:12]

Dave: And newspapers are never going to let you know that Alberta passed legislation allowing PAs to exist or do “X” or do “Y” or have full practice. That’ll come around 7 days after because somebody got angry about something, and if you’re online, and you’re clued into the right places, you’ll know that before it happened you really well. You’ll know the way the vote is going to go before the vote is taken.

Maureen: I would encourage the listeners to check out Clinician1.com, I have been following it for many years, it’s a pleasure to talk to you like this with this extended period of time that we’ve been given. Thanks so much for taking the time to do this.

Dave: “you’re welcome, thanks for inviting me. It’s a dream come true to speak to my colleagues from Canada.”

Maureen: “Perfect, thanks again.”

Dave: “You’re welcome.”

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2017-08-30T18:26:07+00:00 1 Comment

About the Author:

Dave Mittman, P.A. has been a PA leader for over 40 years.

Dave co-founded the LIU PA Program student society in 1973, was President of the New York State Society of PAs in 1979 and served on the American Academy of Physician Assistants (AAPA) Board of Directors from 1981-1983. Dave is now back on the AAPA Board of Directors serving his second term, as he was elected in 2015. Dave has also won the AAPA Public Education award for leading the march in Trenton NJ to establish PA practice in 1989. Dave has been honored with a Lifetime Achievement Award from both the New York State and New Jersey State Society of PAs for his work as a PA leader, one of the few PAs in the nation to be honored in this way. Dave is a founder and Past-President of PAs for Tomorrow the national PA advocacy group. He also recently served as the Treasurer for the Association of PAs in Family Practice as he spent years practicing primary care and feels that it is a prime specialty for the for the PA profession. Dave is now serving his second year on the Board of Directors of he AAPA, a position he also held thirty years ago in the mid-1980s.

Dave was introduced to medicine as a medic in the USAF. He later had the distinction of becoming the first PA in the USAF Reserves permitted to practice as a PA. Dave did much work for PAs in the AF to gain commissioning as officers for a number of years. Dave spent almost 9 years in a primary care group practice in Brooklyn, N.Y. practicing family practice. He provided medical care to patients from two years to almost one hundred and two years, providing a full scope of medical care. Dave left in late 1983 to begin a career in medical publishing with Physician Assistant Journal.

Dave left PA Journal to co-found Clinicians Publishing Group in 1990 and Clinician Reviews Journal in 1991. This was the first journal written for both NPs and PAs. In 2001, Clinicians Group was acquired by Jobson Publishing.

In 2005, Dave became a Life Coach through NYU/Results Coaching. He has done postgraduate work in Executive and Leadership Coaching.
In 2008, Dave co-founded Clinician1 (www.clinician1.com) which is the largest NP and PA informational/clinical/social community on the web.

Dave has authored papers in over 100 publications as diverse as “Chicken Soup for the Expectant Mothers Soul”, “U.S. Pharmacist”, “The British Medical Journal” and many, many others.

Dave is a noted expert in NP and PA practice both in the U.S. and around the world. He has published papers on both NP and PA prescribing. He has consulted for many companies on PA practice and has spoken at numerous PA and NP meetings with audiences ranging from 5 to 1,500.
Dave is married to his high school sweetheart Bonnie for 42 years and is
Dad to two wonderful young adults who will always be his finest achievement.

Dave’s mom is from Lac La Biche, Alberta. He has over 35 first cousins who are Canadian and spent many summers in the fields of Alberta.

  • Sahand Ensafi

    What an amazing discussion between two very well known, well respected and seasoned PAs. I think we need to definitely share this podcast with our colleagues and use it as a stepping stone in discussions with different stakeholders across the province/the country. Great work!