Sunday, August 23, 2009

Mandatory PA Residencies...

Now, for something not so popular with some of my colleagues. PA residencies. They've been around for years, and I believe there are now 48 or 49 programs. The Baylor/Army EM residency program is 18 months and awards a doctoral of science degree, or a DSc at it's completion. I think someone mentioned that it contains 5600 clinical residency hours, and 516 didactic hours.

The point of this discussion, is that the PA profession is changing. Our roots were based in experienced health care workers, at the beginning, military medics, who could recieve additional training and be a complement to the physician. Medicine, and PA training have changed however. Physicians, healthcare policy wonks, and even the market itself is starting to see more and more PA's practicing with more indirect physician supervision. PA's are increasingly becoming practice owners, and hiring supervising docs to work with them. We have branched far from our initial purpose, which was to provide primary care in rural and underserved areas, and are now working in almost every single specialty, including interventional radiology.

Concomitantly, programs have transitioned from a certificate or associates based training, to the majority being held at a Master's degree level. This has meant more and more younger students coming straight from undergraduate into PA school with nominal, if any prior healthcare experience.

Should we mandate mandatory residency training? I am thinking this is an idea whose time may be upon us. Not all of them need to, or should offer a Doctoral degree. But I think any PA who wishes to practice outside of primary care, should complete a residency.

BTW-this is not a very popular idea with a lot of PA's

Here's a link to an article about the Baylor/Army program.


Here's another that needed to be resurrected.

20 comments:

The Happy Hospitalist said...

When you say:

"But I think any PA who wishes to practice outside of primary care, should complete a residency."

I beg to differ. I think any PA who wishes to practice period should complete a residency. Primary care is, on many levels far more difficult than subspecialty care.

I live that experience every day.

physasst said...

True, but our initial board certification is modeled on the family practice boards, and we are "supposed" to able to practice primary care, at least outpatient primary care, hospital medicine is a little bit of a different animal, without additional certifications. That, coupled with massive primary care provider shortages which are looming, mean that mandating primary care residencies is not probably a great idea initially. I think we will eventually see that, but it will take time.

MLP said...

If I had to complete a residency I would have went to med school...

The Medicated said...

If a primary care/family practice residency were available, I would jump on it in a heartbeat.

You're right - we newer grads have less experience before PA school. I would feel much better about my abilities (and maybe respectability) if I had a year or two of hard-core clinical experience after PA school before entering practice for real.

But that's just me.

physasst said...

MLP, we are only talking 12 month residencies. Comparing that to the 3-9 year residencies that MD's complete is still vastly different. I am talking about 3 years total for education. 2 years of PA school, and then completion of a one year residency. Economically, and from a provider supply standpoint, we are going to have to assume more independence and autonomy in our roles. It just has to happen that way. That coupled with younger, more inexperienced students means, at least to me that residencies have to assume a greater role to ensure optimal patient care.

Anonymous said...

I agree with residencies for new grads outside of primary care. I posted a poll about this topic a few months ago at the pa forum and met great resistance.
with the declining quality of the pa school applicant pool I think this change will be forced upon us by hospital credentialing policies.I have already started to see jobs advertised as "10 yrs of experience or completion of an approved residency program".
15 yrs ago no one(me included) thought this was necessary. today the typical pa school applicant has never worked in a health care setting and has no foundation in medicine of any kind. pa is becoming another direct entry profession and that is a damn shame.
-emedpa

Anonymous said...

After pa school, i was able to work as a mid level hospitalist and soon realized how much i had to learn-and that's an understatement. I believe every pa graduate should have a mandatory internal medicine 1.5-2 years training after pa school (and i mean in an inpatient hospital setting), where a pa learns how to manage a patient in the ER for admission, round on the different floors-medicine, surgery, cardiac step down, telemetry, and yes..you know it-ICU!!!-i mean c'mon; what if the icu nurse calls you at 2am and tells you that the obese pt with s/p lap chole-and a hx of copd, htn, dm, cvd, previous mi, and possible chf now has a blood pressure of 70/40!
I also now work in a family practice and urgent care setting, and believe you me, i have met pas with 10-12 yrs experience who are freaking clueless on a lot of significant clinical presentations. I believe our profession need to wake up to the reality that a new pa graduate is a walking time bomb!

MLP said...

If you have a solid PA-Physician relationship you should be able to have that "on the job training" that your residency would fill. I agree that many new graduates with limited health care experience (that was me) have a long way to go until they are "autonomous". However one year of residency is different from one year of paid employment with strong physician oversight in what ways?

Also there are varying degress of PA skills and job descriptions. There are plenty of PA's and NP's that soley follow their docs around and write SOAP notes and do not have or need(or want)that autonomy. TO say that ALL PA's or NP's must have those skills that an ICU PA would have is ludicrous.

I just am afraid that the more alphabet soup you put on the end of PA's names, the job description stays the same and the cost and time of education will go way up.
Which kind of disincentivizes PA's to become a PA...

MLP

Bad Medicine, Good Solutions said...

Superfluous.

Better yet, would be to continue expansion of medical schools to meet the real physician demand, and then expand PA schools.

Use the PA for their true role - an assistant. With a saturated market their salaries will decrease and their roles will align with their education/experience levels. Instead of an 'autonomous' provider bumbling through a legal mine field waiting to go off.

One issue you will face is the nature of the PA applicant. On numerous times of talking with students they frequently mutter how they wanted to practice medicine but didn't want to be in school long enough to be a physician. With such a base mentality of education (or perhaps hard work?) why would the newly minted PA be excited about pursuing more training? It most likely won't net them any more pay. If your argument is for more knowledge and experience then the answer is simple...

physasst said...

Autnomous providers bumbling through a legal minefield?

Really, you do of course have evidence to support such an assertion. You do have studies that show an increased rate of malpractice among PA's? Don't you? You do have data that shows that PA's provide inferior care right? Cause that's what your post implies. Without data, which you don't have btw, that is completely useless and merely meant to be inflammatory.

PA's are dependent providers, we are NOT completely autonomous. Even practicing in small office on our own, their is ALWAYS a physician we can confer with, even if only by phone.

NP's on the other hand, as Happy wil attest to, want to be completely independent with NO physician oversight. PA's do not wish for that.

If you want support that PA's cannot provide good care, well, back it up. Let's see some studies demonstrating that.

Bad Medicine, Good Solutions said...

We both know I'm going to have a heck of a hard time finding such studies. Mostly because of the difficulty to tease out true head to head outcome based studies, and with the limitations of the degree requiring over sight, it is unlikely. Also recognizing any current issues are often attributed to the oversigner and deeper pocket when it comes to litigation. We can agree to disagree here, but in the end there is an acceptable harmony between the two professions.

However, I believe you, like many PAs, do offer double speak about autonomy. I quote you in your most recent blog post, "In most specialties, PA's function with a HIGH level of independence, and autonomy. In one of the ED's I work in, specifically, Waseca Medical Center, the ED is solely staffed by PA's. There are NO MD's in the ED. Overnight, we cover the floors as well."

But yes, you are also right the real mine field will be the truly autonomous NPs, which the future will clearly elucidate.

physasst said...

While there are no MD's in the ED specifically, there is ALWAYS a physician (family practice) on back up call if needed. I have not yet, needed to call them in. I have called a few times to tell them that someone was really sick, and this is what I am doing. There is some supervision, albeit, not much. It's good and bad for me. I have to really pull my thinking cap on for some patients which is good, but some patients can scare me a bit.

As one of the consultants at my primary job at Mayo said. "You know, to be honest, I'd rather have an experienced EM PA out there that knows how to intubate a patient, and knows their way around a trauma, rather than some family practice doc that hasn't done any of that in years"

I agree with some of your other points however.

Anonymous said...

Why would I want to spend all that time,effort and cost in DSc program and still not be able to work independently? Apply to Medical school. Secondly, I think our basic PA school should be more indepth than they are now and "residencies" program manadatory for a specialty. The NPs have solid backgrounds in nursing before they go on to their specialties, thats a big advantage over PAs.

Anonymous said...

Why bother. Resiendency are helpful but not needed.

Alison said...

"with the declining quality of the pa school applicant pool I think this change will be forced upon us by hospital credentialing policies."
"today the typical pa school applicant has never worked in a health care setting and has no foundation in medicine of any kind. pa is becoming another direct entry profession and that is a damn shame. -emedpa"


I really don't agree with this post. I don't think the quality of PA applicants is dwindling, I think its increasing. This year, I interviewed at 8 schools. The average number of applicants was around 1300 for an average of around 50 seats. Its becoming more and more competitive every year. I would expect that many of these applicants were qualified for any of these programs, but they do have to get down to a manageable size, even if that means rejecting fully qualified applicants. And I was quite surprised when you said that "today the typical pa school applicant has never worked in a health care setting" since, I believe, you are a moderator on the PA forum, you would know that healthcare experience is required for the majority of programs. We may not have years and years of experience like the first PAs had, but 2 years (which seems to be about average) of full time experience in, for example, an emergency dept where the chief complaints vary constantly, seems adequate if you are academically prepared for a rigorous program. But I do feel like completing a residency is an invaluable way to strengthen your skills before practicing solo (with your SP, of course).

Anonymous said...

Today's applicants are highly qualified, just as yesterday's were - there is just a change in the mix.
One which has changed the WRONG way is PA education - accreditation has mandated so much NON-clinical content at the same time that clinical information is expanding. For the PA model to work, we need to go back to pure clinical education. If you want to research, if you want to do something else, then pick that up elsewhere. Otherwise, the 27 mo avg of education will continue to decline in actual clinical content.

Anonymous said...

Phyasst, you've stated that the Baylor Residency program has 5600 clinical hours and 516 didactic hours. That equals 6116 hours over 18 months or 72 weeks. At 40 hours a week times 72 weeks that would equal 2880 hours. At 80 hours a week = 5184 hours over 72 weeks. So, again, you've over stated the educational requirements that PA receieve.

Anonymous said...

5760 hours at 80 hours a week for 72 weeks. It would appear that sleeping during the program is not encouraged. I apology for my math error in the above comment.

Anonymous said...

Residency program should be required to make the newly graduated PA competent in that particular specialty he/she might enters into. I am quite concern by the lack of uniform educational standards that PAs have and patient safety issues that it raises.

Michael Halasy, MS, PA-C, DHSc(c) said...

Well, PA schools have uniform standards. ALL programs are accredited by ARC-PA. ALL must teach the same curriculum. A PA student should be able to go to a school in Oregon, or one in Florida, and the core education will be the same. ALL PA's must then pass the PANCE certification exam, which is a primary care based exam. We have to re-take that same exam EVERY six years, regardless of what specialty you might be in. There is actually quite a bit of contiguity, and uniformity in PA education, the problem is not in the education, but in the younger applicant pool, less previous HCE, and expanding scope of practice/independence. These are the reasons I question a mandatory residency.