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UNDERSTANDING THE PHYSICIAN-PA RELATIONSHIP

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!


Squeee!



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.


Direct Supervision

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


Indirect Supervision

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

Hot Trend Alert Physician Assistants Opening Their Own Practices


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