One of the most common questions I get asked by people considering the PA profession is if I feel that I have enough "autonomy" as a PA. I take that to mean that they are seeking to better understand the relationship that exists between a PA and the Supervising Physician, so I wanted to share my experience and unique insight of the nitty-gritty of my physician relationships in surgery, so that there can be a better understanding of the kind of relationships PAs have and have had with physicians, as well as how our relationship is evolving, legislatively speaking.
When asked whether I believe I am satisfied with the amount of "autonomy", My answer is always an emphatic YES.
Personally, I am most happy providing exceptional patient care as being a part of a high-performance medical team with physician/surgeon leadership. I truly enjoy the permanent mentorship with my supervising docs, and over the years have come to really value the trust that my supervising docs place upon me. It's an honor to be one of the select few people they trust to handle delicate patient care scenarios on their behalf, as a part of their team.
Because I'm a PA, I have the freedom and flexibility to practice across all specialties. In my case, I have the unique opportunity to operate with multiple surgeons, across several surgical subspecialties, which not even many surgeons get to do after they graduate from residency and/or fellowship! I think this is one of the coolest things for me.
This freedom has given me the unique opportunity to work with multiple surgeons across many specialties. Because of that, I've had the privilege of learning how things get done at the programs where they trained, which to me is a bit like having those famous academic centers come to me, and for a surgery nerd like me, it's a dream!
Quite a few of my attending surgeons have trained in some of the top surgical training programs in the country and as a perpetual surgery aficionado, I absolutely love absorbing all they have to teach.
I love hearing stories about them working with some of history's most famous and decorated surgeons. Sometimes I can even distinguish where the surgeon has trained, just by recognizing their surgical techniques!
I enjoy being the eternal pupil and I truly love being their trusted copilot in the OR.
So before we delve into the specifics of physician supervision, autonomy, and the governing laws in place, I want you to understand that there are different types of ways in which PAs are supervised.
Types of PA Supervision
Knowing how doctors supervise PAs can help you understand our relationship a bit better. There are two main types of PA supervision: Direct and Indirect. Both types are determined by federal, state, individual hospital by-laws, specialty, PA experience, and trust between the Physician and PA.
In direct supervision, legally the physician must physically be in attendance with the PA, in order for the PA to perform a certain task.
For instance, in a hospital setting like in the operating room, PAs must perform all surgery with an attending surgeon.
Another example of direct supervision is in an office setting. In an office, PAs can see patients independently, often even carrying their own separate, patient schedule. But there are certain services, that medicare requires that the PA must be directly supervised by the physician, which means the supervising Doc just has to be in the building.
As a surgical PA here are some of the duties I have performed under direct supervision:
Emergency Open Chest Codes
Complete End to End Distal Anastomosis of Sigmoidectomy
Deliver uterus transvaginally in Robotic Hysterectomy
Suture and tie-down mitral ring for Mitral Repair in Robotic Mitral Surgery
Drill, screw, and remove bone in Orthopedic surgeries
Limb amputation for gangrene
Proximal vein graft anastomosis in coronary artery bypass grafting
Assisting in Aortic and Venous cannulation and decannulation
Hand Tying purse-string sutures in Cardiac surgery
Open Cardiac massage on the way to the OR
Hand Clamping abdominal Aorta in AAA rupture
Under indirect supervision, the law says PAs can perform the task alone, but the physician has to be readily available by phone or by electronic means via a secure internet network, or EMR messaging, to review patient cases and answer PA questions.
The exact distance and how often the supervising physician has to co-sign charts varies and it is more clearly defined by federal, state, and individual hospital laws and guidelines.
For instance, A PA in family practice, urgent care, or aesthetic medicine can see patients under indirect supervision, meaning the doctor can be available by phone or electronically.
The meaning of indirect supervision can also vary by specialty. For instance, in surgery at least where I've worked in South FL, indirect supervision means the surgeon must be readily available and is in the building.
Most hospitals do not allow the operation to begin unless the surgeon is in the room, however, I do work at one hospital where I can lead the time out and I am allowed to start harvesting the saphenous vein for CABG without the surgeon in the room.
As a surgical PA, these are some of the duties I have performed under indirect supervision:
Insertion and removal of Central venous lines
Insertion and removal of temporary dialysis catheters
Removal of tunneled dialysis catheters
Insertion and removal of radial and femoral arterial lines
Insertion and removal of Chest Tubes
Insertion and removal of urinary catheters
Time out in Cardiac OR and start conduit harvesting for CABG, without the surgeon in the room, Chemical Pleurodesis
Application and changing of sterile wound vac dressing
Removal of temporary pacing wires
Removal of Intra-Aortic Balloon Pump
Writing prescriptions, including narcotics
Rounding on patients in ICU and floor
Discharging and transferring of a patient through different levels of care
Seeing patients in the office
Performing & dictating consults
So Can PA's own their own Practice?
You might have heard that one of the "pitfalls" of the PA professions is the fact that we cannot own our own practice. This is untrue.
Under Medicare rule, a PA can own up to 99% of practice so long as the other 1% is owned by any non-pa, and this person does not have to be a physician!
However, a corporation owned entirely by PAs cannot bill Medicare at the time of writing this post. But this is changing- more on that later.
Also, in the case of cosmetic and aesthetic medicine at the time of writing this post to my knowledge neurotoxin and fillers cannot be legally sold directly to PAs- they need to get a physician sponsor to do it.
What is funny to me, is that medicare will allow PA practices to bill, as long as the 1% is owned by somebody, anybody, who is not a PA.
Like I can literally ask one of my cousins who is a stunt man to own the 1% and then Bam! I can then legally direct bill Medicare. LOL
Click Here to Read an Issue Brief by the AAPA about PA practice ownership. It's very, very, interesting!
As a PA practice owner myself, I have some first-hand experience.
I have owned my own private surgical first assisting practice since 2012, and I personally know 4 PA Practice owners, all thriving by the way!
One owns a good number of Urgent Care Clinics, 2 own anesthetics practices and another owns a surgical subcontracting company.
If you want more info, here are 2 more interesting articles about PA practice ownership
Barriers to PA Owned Practices
As far as the future is concerned for PA Practice ownership, it's a bit more precarious, due to insurance reimbursement rates getting lower and the cost to run a practice staying the same or getting higher. The same trend can be seen in physician-owned practices.
Because of this, depending on the area in the country, private practices for physicians seem to be falling out of favor, and it seems that fewer and fewer physicians are graduating and starting their own practices. I have no data to back this up, this is purely anecdotal in nature and the trend that I've seen since 2007 in south Florida. When speaking to PA colleagues in other areas of the country they seem to be experiencing similar things, but it is also very area specific.
In our country right now, hospital systems seem to be absorbing physicians and their private practices, in some parts of the country more than others. The trend seems to be increasing in my opinion.
Where I am in South Florida, more and more physicians and PAs are becoming hospital-employed versus owning or working in private practice.
With Medicare and Medicaid reimbursements get lower and lower, and other insurance companies following suit, the overhead costs to stay in private practice are getting higher and higher.
Will we all eventually be hospital-employed?
Will all doctors be forced to refer their patients to only physicians within their network and not necessarily who is best qualified?
Will our country shift into a single payor insurance system and shift into socialized medicine?
I'm not sure yet, but I do project that any practice that makes most of their revenue off insurance reimbursement is at the mercy of what insurances want to pay, which more often than not is nothing lol.
In my experience in surgical billing for my cases, insurances will do whatever they can to figure out a way not to pay you.
The truth is that that the death of health insurance revenue-based private practices for Physicians, probably means that the trend will extend to PAs eventually as well.
Unless another private practice model is birthed, for instance, one supervising doc with multiple pas in one practice or something like that, but it will have to be proven to be more efficient and inexpensive than in a hospital setting.
Cash-Based Medical Practices
I have also seen an increase in PA and/or Physician private practice owners who choose to opt-out of all the insurance stuff and offer their services for cash only. If done well, these can be lucrative as is the case for Independent aesthetic injectors.
I have also seen in-demand surgeons switch to cash only and do very well, as well as Family Practice PAs.
This shift into new private practice models has also given rise to VIP practice models like MDVIP and hybrids like that where patients pay a yearly fee for minimal wait times and more access to the physician as well as using their insurance when they come in for billable medical services.
Autonomy and Job Satisfaction
Is there a correlation between the degree of autonomy and PA job satisfaction?
Well, typically individual job satisfaction is multi-factorial, and it would be hard to isolate autonomy as a single factor in job satisfaction, but I would venture to guess that there is a correlation there seeing as micromanagement is a good predictor of job dissatisfaction.
Research in job satisfaction among Physician Assistants is very underdeveloped, however, there was one study published in 2015 on PA job Satisfaction that said concluded that " PAs seem to experience job satisfaction supported by low attrition rates and competitive wages. Contributing factors are autonomy, experienced responsibility, pay, and supportive supervising physician". Read more about it here.
Overall, I'm very satisfied with my degree of autonomy as a PA. Should I ever become dissatisfied, I'm just the kind of person who will go back to school, no matter how old I am, and find whatever else is next, because loving my job is that important to me.
I project that eventually all the outdated laws currently in place on the PA profession will be phased out over time.
The hypothesis that patients get a lower level of care from PAs or that Physicians need to oversee our every move in order to ensure patient safety has long been disproven by exhaustive studies we just need the law to catch up with the truth so that we can take care of more patients that need us.
Here are just two international studies on PAs if you want to know more about how PA care compares to Physician care in terms of patient safety and satisfaction.
Since the Pandemic PA legislation has made some really favorable progress. Administrative burdens have been relaxed in some places, allowing PAs to penetrate more spaces in the country to serve on the front lines and in underserved areas.
Also starting in 2022 PAs will be allowed to direct bill Medicare which literally brought tears to my eyes since ever since I've been in independent practice, I've had to assign payment to a physician and pay him a percentage of the medicare cases that he wasn't even present for, just so I can get paid something.
Optimal Team Practice
Now, when it comes to recent PA legislation- I need you to understand the following really well:
The push for Optimal Team Practice in PA legislation cannot be confused with the false premise of a Physician-Free PA practice. It is paramount that there is a clear distinction in the verbiage because one is professionally unifying and of benefit to patients, and the other is professionally divisive and damaging to both sides and patients. We simply want multi-provider teams to work better together for the benefit of our patients.
In my career, I have been really fortunate to have beautiful relationships with my attending physicians, many of whom I consider to be close friends + like family.
To err is human and it's a great thing to have partners in the mission to provide exceptional care to our patients. We look out for each other, serving as each other's sounding board, support system when either becomes weary, clinical consultant, friend, and an extra pair of eyes for quality control yes, but also to learn from, admire and get feedback from to always keep growing. My attending docs and I have the kind of relationship where we get each other coffee or food when we know that the other needs it. That level of caring is what you want in anyone you work with, but in the business of taking care of patients, I've come to understand that that having these innate qualities in professional collaborative relationships makes for patients that feel that you truly care for them. Professionally speaking I can tell you that the relationships with my attendings is for me, one of the reasons why I really enjoy what I do most of the time.
I hope after reading this you have a better understanding of the relationship between PAs + Physicians. I believe that maintaining an excellent relationship with physicians and all other members of the healthcare team is of the highest benefit to our patients. If you have any questions for me email me! firstname.lastname@example.org