Physician Assistants Try to Gain Leverage with Legislators

Proposed legislation would change the licensing process, placing more responsibility in the hands of the supervising physician
January 13, 2011 -- The Oregon Society of Physician Assistants has prepared legislation to change the licensure process by placing more responsibility in the hands of the PA’s supervising physician and less on the judgment of the Oregon Medical Board.
 
While the OSPA and physicians claim it’s essential for PAs to work at their full capacity, the Board fears for patient safety if its power to judge a PA’s qualifications is diminished.
 
A legislative draft (Senate Bill 224), printed on Monday, is “very much a work in progress,” said Tom Holt, OSPA’s lobbyist, but already has bipartisan support in the House and Senate.
 
Testifying before the Senate’s Interim Committee on Health Care last month, Ted Ruback, head of the PA training program at Oregon Health & Science University, said the legislation’s primary goal was “to allow the supervising physician to determine the practice description and competency of the PA.” Currently, the Board is responsible for this, which OSPA lobbyist Scott Beyer sees as problematic.
 
The difficulty with the Board is that they have turnover in their membership,” said Beyer. “Some PAs have been doing procedures for years, but a new Board member comes on and says, ‘I didn’t know they could do that, that concerns me,’ and they end up prohibiting PAs from doing certain procedures.”
 
Longtime PA Edwin Weih has felt the impact of the Board’s decisions firsthand. As the sole medical provider in the rural community of Oakridge, an hour southeast of Eugene, he attends to a wide range of medical needs for the town’s 3,500 residents. But over the years, the Board has ruled that PAs cannot perform certain procedures that Weih once did routinely. He used one such procedure, an endometrial biopsy, to diagnose cancer in an elderly patient and refer her to the nearest surgeon, an action that helped save her life.
 
“A few years after that, the Board said that PAs must submit a practice description listing anything they did outside the ‘core competencies,’” said Weih.
“I listed everything I did, and all the procedures were denied me,” including endometrial biopsies. He claimed, and other sources confirmed, that his predicament was shared by numerous PAs in Oregon.
 
The Board’s limitation of PAs’ duties to certain ‘core competencies’ in 2002 was part of a multi-state effort to more explicitly define a PA’s scope of practice. However, Ruback said, “It was proven to be ineffective, and the vast majority of states … have moved to a physician-delegated scope of practice for PAs.” Why? According to Ruback, “The person best suited to determine a PA’s qualifications and competencies is the doctor who works with them on a daily basis.”
 
Ruback served on the Board’s PA committee for a decade before resigning last year to become more involved in advocating for PA licensure legislation. He characterized the Board’s decision-making process regarding PA qualifications during his tenure as “nothing more than guesswork. We were trying to make decisions about PAs in a global way when we had no context for their daily practice.”
 
Not surprisingly, the Board sees things differently. “The Board plays a critical role in terms of patient safety, including [PA] practice descriptions,” said Kathleen Haley, the Board’s executive director, who noted that, “We’re working with the OSPA and the Oregon Medical Association to problem-solve, keeping patient safety foremost while balancing that with patient access.”
 
Access to healthcare is a longstanding issue in Oregon that will only intensify as provisions of federal healthcare reform are enacted. By 2014, health insurance will be extended to hundreds of thousands of previously uncovered Oregonians. Some observers contend that curtailing the responsibilities of PAs over unwarranted safety fears will impede access to care when and where it’s most needed.
 
“In all of the healthcare legislation, you see the [words], ‘using people to the fullest extent of their education,’” said Ruback. “We can’t afford to restrict responsibilities and access.”
 
At a Senate hearing in December, Sen. Jeff Kruse (R-Roseburg) described the legislation as a “no-brainer,” while Sen. Alan Bates (D-Ashland) assured those testifying that the Committee was “very supportive of your request [for legislation].” Now it’s up to the stakeholders to find common ground.
 
FOR MORE INFORMATION:
 
Current Oregon Medical Board licensure process for Physician Assistants:
State-by-state laws for Physician Assistants:

http://www.aapa.org/component/content/article/26/517

 

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Comments

When I finished my internal medicine residency 25 years ago, I was hired as a staff physician at the Albuquerque VA Hospital where I trained. I supervised some incredible physician assistants then and became deeply aware that my traditional allopathic training left me shortchanged in the diagnosis and treatment of the ordinary stuff that these P.A.s routinely cared for. The old dogs taught me some new tricks! As so-called "physician extenders," P.A.s are more than competent in routine care. The key is knowing limitations. But this is true for ANY care provider. OHSU's program (http://tinyurl.com/4k6zc7t) is 26 months long. This is concentrated learning! Their tuition is nearly the same as that for in-state medical students! (see p. 32 http://tinyurl.com/4ptr8u5) Certainly, their career requires support from physicians. That said, the "supervision" of the P.A. can be very lax even when their skills are expanding far beyond their original training. P.A.s independently see patients and do procedures (cardiac catheterizations, cystoscopies, sigmoidoscopies, etc.)--which requires on-the-job special training. I have understood that patients are getting billed as though an MD does the care. One must ask if expanding their scope of practice is just to generate more income for the supervising physician under these circumstances... Obviously, a P.A. will not be able to do procedures that could be risky without having immediate physician back-up. There are certain procedures that the Board of Medical Examiners cannot allow under these circumstances--cardiac catheterization being one of them. Shortages in rural areas will be met with more P.A.s, nurse practitioners and visiting nurses who need physician support when they independently treat patients. The supervising physician must trust the work of the providers who will extend their services in their own clinics and in surrounding communities. That relationship is extremely important as liability could extend to the supervising physician when care goes wrong. This relationship could be virtual, but it does require meaningful time allotted between the MD and allied health care provider. This relationship has far more bearing than an inflexible top-down policy--especially since we face a crisis of insufficient primary care provers. Strengthened relationships with supervising physician mentors is essential.

Nice comment from the Above physician. PAs need to practice and be able to grow, evolve, learn and treat. We are not "assistants" but truly associates in the best sense of the word. This legislation has to pass as having to worry about the whims of a new Board member to be able to earn a living will drive, yes, drive new PAs from seeking employment in Oregon. In NY we can do anything a physician can do. No one is dying and many people are getting the care they deserve. We are trained to ask for help when we need it. Our 40 year track record is excellent, Take the chains off a bit........ Dave

A individual can attend a PA program with nothing more than a high school education. To leave the standard of practice up to ' supervising' physician is ridiculous, somebody who is in another place collecting a check . I am a physician with 6 yrs of residency training and former ICU nurse, I am constantly amazed out how little insight PAs have about what they don't know. I would never attempt a procedure that I had not done multiple ( 100s ) times in my residency. If you want to do everything a physician does , finish college with a degree in science , do the 4 years of medical school and the 3-8 yrs of residency. Or just take the 26mo course in how to fake it or wing it , an endometrial bx or cardiac cath ?Come on get real. Rural medicine should involve non invasive screening and health maintenance. Otherwise patient should be seen by physicians. At least nurse practitioners have been through a longer training pipeline with much more scrutiny. This legislation scares me and should scare potential patients. A bunch of cowboy paramedics and greedy supervising physicians. This legislation should be promoting programs where someone can work as PA , then enter a NP program with advanced standing or medical school with advance standing so PAs can grow and learn. JMM

Wow. The above comment is truly offensive and off base. I think you should reacquaint yourself with the actual PA education. Most PA programs require a Bachelors degree and a minimum of 2000 hours of health care experience involving direct patient contact prior to entry. The prerequisite courses are, in fact, almost identical for medical school and PA school. The majority are Masters programs which receive between 600-1000 applicants annually for an average of 30 seats. This is just the formal portion of a PA's education, but training continues on the job and autonomy is gained with demonstration of an expanding knowledge base and skill set. Yes, you, as a physician have received more formal education in your area of medicine than a PA and I doubt any PA would dispute that, but to suggest that the PA education is inferior to that of an NP is ludicrous.