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PA History Was Transformed Last Week: I'm Proud, Amazed, and Ready

Posted on: May 23, 2017

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The AAPA House of Delegates had debated the Optimal Team Practice (OTP) resolution long enough. It was time to vote. Before we talk about that, though, some background … 

The OTP resolution was huge. It would give the AAPA’s blessing for the physician assistant (PA) profession to have responsibility to practice, and to ultimately be accountable for our own profession. This is something that all professions have. Yes, all professions. It’s something that our nursing colleagues have as RNs, but not as NPs in many states. It’s also something that worried some.

Independence is a foolish word. We don’t want to leave the team, but we so want to be fully responsible members of that team. No one practices alone anymore, but people are responsible for what they do. PAs (and NPs) have always had the option to practice alone, with their collaborating physicians 20 or 100 miles away. This was different. All I (we) wanted was responsibility for what I did every day. All I wanted was to own my own profession and career. Sign my name, say goodbye to everyone at work, and go home. End the barriers. Permission to end a part of history that has placed unfair obstacles on myself and my profession.

Why the OTP Resolution Matters

Our House of Delegates (HOD) is a sight to see. We were in Mandalay Bay in Las Vegas. More than 7,000 PAs attended the 2017 AAPA Conference, and only a select few represented the entire profession at the House. I am sure most delegates would have preferred to be at the pool, but there they were anyway, in this huge room, committed to debating and voting on all the resolutions. Many of them gave testimony, all very politely, all very transparently.

This was the issue. There was no one pushing against us except history. Ghosts of PAs past and ghosts of PAs future hovered all around us. History was in the room. You hardly see that anymore, but I saw all the ghosts. That's what happens when you are a PA leader for 40-plus years. All of us were trying very hard to represent our views. Some were totally ready, some were ready but worried about what “other stakeholders" or those ghosts would think, and some were open to hearing both sides.

“Optimal Team Practice” is what the AAPA task force decided to call the changes that would set up the new modernization of PA practice. It keeps PAs as part of the team with our NP and MD colleagues. It started out as “Full Practice Authority and Responsibility” (FPAR), and in theory, it did not change much. OTP focuses on full practice (i.e., no regulatory supervision/collaboration), PA regulatory state boards (we currently have medical boards that, in some cases, don't know much about us), and universal insurance reimbursement to the PA, among other issues.

If passed, this would be as large a shift as the PA profession had ever undertaken, but it was wasn’t going to be easy and couldn’t be done haphazardly. A very well-led task force came up with guidelines they hoped would be endorsed by the HOD so states that wanted to modernize could use them to change their state practice acts. The need for OTP was brought on by so many factors, such as the maturation of the PA profession itself and the ability to compete with other healthcare professionals who had taken responsibility for what they did in the marketplace. I’m not just talking about NPs, but also others like pharmacists and physical therapists who now own a scope of practice that PAs (and many NPs) still do not. Time was passing us by. This had less to do with owning our own practices and more to do with maturation. Let’s face it: PAs could always practice autonomously. This had more to do with just plain taking full responsibility for what we did. You do something and you sign your name. Period. It was about not needing a “collaborative” or “supervising” physician years after we started to practice.

It also had so much to do with how medicine is changing. Physicians want to work with clinicians who give them the least liability and be colleagues with people whose regulations do not hinder them. This responsibility and the fact that so many more physicians are working as employees gives administrators a reason to stop an increasing number of PAs from being hired. The changes we sought were not born out of a need to leave the team — hence the "Optimal Team” part  — but would allow the PA to practice without mandatory regulatory supervision or collaboration. How we all practiced would be dictated by clinical knowledge shown at the practice level, just as it is for all other professionals. Basically, OTP would give us access to the same regulations every other healthcare profession has for itself.

The AAPA put together a task force with a chair who was as fair and balanced as anyone could want. After many months, they came back with well-thought-out recommendations. Some PAs were worried. A survey was done of the entire profession, and OTP/FPAR was preferred in each state. Still people were worried. Change is hard. It is also scary. PA culture, is, by our very nature, not used to sudden change. At a minimum, change would have to be explained to all stakeholders, including physicians, and some of them would not be happy. Still, in our last elections, every candidate who ran — every single one — endorsed the task force’s recommendations. We were ready.

Taking the Vote

So, back to the top. Our HOD had been debating these changes for parts of two days. Some wanted a particular sentence or word struck, and some felt that other changes were in order. The clock was ticking. All of a sudden, on day two, compromise happened quite quickly. Just when it looked like the process would be drawn out, possibly with an individual roll-call vote for each delegate, the PA Educational Association (PAEA) announced that if a few changes were made, they could compromise and support the resolution. Most of us “progressives” gasped. Could it be that the inevitable would happen? Seriously? I, for one, was shocked.

The "question" was called and within a five-minute period, the future of the PA profession and its paradigm was changed forever. A shift many never thought they would see for years came to pass. And it was passed. Yes, we had it. Yes, we did it. ALL OF US. OK, again … ALL OF US. A profession that hardly agrees on anything knew the time had come. Most of all, the rank-and-file delegates sent to represent their fellow PAs from every part of the U.S. took their commitment to further the profession as seriously as I had ever seen it taken. I was totally and seriously impressed.

The course of PA history has changed forever. Yes, me, Dave — the PA who has written more about “full practice" for PAs than almost anyone else in our profession’s history — was speechless. One who was a leader and who pleaded with my colleagues that these changes were needed to successfully evolve ... speechless. Yes, that Dave. All my arguments had vanished. "We” were validated. Us and “you” had become one. The people who did not understand suddenly understood. The magic of compromise had won them over. I doubted my reality.

Everyone turned to hug each other. Not ten, not twenty, but hundreds. The task force, the House, the board, each and every delegate, the educators, staff, others … we knew and felt at that moment that we had made history. It was palpable. It would become a “Where were you when you heard?” moment. I could not process much that went on. All I did was cry and hug anyone I saw who responded to my outstretched arms. I was in shock. I still am. I can compare my feelings only to something else that happened to me 27 years ago, and then again three years later: I felt the same way when I held my son and later my daughter in my arms for the first time. I was exhilarated. I was scared. I was amazed. I was immobile. I was filled with emotion. I was totally at peace. I knew my life had changed for the better and would never be the same again. I knew there would be changes that I could not predict, but I knew that this was the way we needed to go. That at the end of the day, this felt so right, so good, so good for our patients, so good for access, cost, everything. I know we are up to the task.

Interestingly, I awoke two days later with another realization. This will empower us in a way we never knew before. I am a PA leader who is “aging.” Most of my colleagues had never felt this way before. I had felt this feeling a number of times in the distant past, but not recently. My NP colleagues had. I am sure my physician colleagues had. We PAs, or at least this PA, had not for almost three decades. Not like this. Not this deep. I was at Woodstock, and this beat it. This date was history. I might be overreacting, but I don’t think so. My two other past recollections — New York passing the prescribing law in 1976 (yes, we could not prescribe legally before that) and being a former medic, a PA commissioning in the Air Force in 1990 — were close, but still not this good. Both changed my life, but this is even more than that.

I salute the AAPA and every delegate who knew it was time. Every delegate who would not take “no” for an answer is now my hero. Every grassroots PA who supported them, I owe you one. The task force who came up with the recommendations that led to this historic vote — your pictures are on my wall. The AAPA staff, our state leaders, PAFT, AFPPA, and all our colleagues who led us down this path: thank you. And yes, that also includes the NP profession, which showed us it could be done, and some of our our physician colleagues, who have always supported us being more. It takes a profession and a village.

So where am I now? Still making no footprints (walking on air). Wow, just wow. I need more time to process. I am holding my profession in my arms, scared to let go, but knowing that I have to,  just as I have so many times before. Time to give the kid the car keys and let her go. Just call me every 15 minutes or so to check in. There are 50 states to drive through.

I am so proud of us all.

I am amazed. I am ready.

Wow.

—Dave

This article originally appeared on Clinician1, the largest online community of NPs and PAs.

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The views and opinions expressed by the author(s) of this blog and those providing comments hereto are theirs alone and do not reflect the views or opinions of Barton Associates, Clinician1, LLC, any of its affiliates, or any employee, director, officer, staff member, or consultant thereof, or those of any group or professional organization, or board or governing body of any such professional organization, in which the author(s) may serve or be a member. The individual author(s) is responsible for the accuracy of all information provided herein by such author(s).

Dave Mittman, PA, DFAAPA
About Dave Mittman, PA, DFAAPA

Dave Mittman, PA, DFAAPA, has been a PA (and NP) leader for more than 39 years. He 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 to 1983. Dave has also won the AAPA Public Education award for leading the march in Trenton, NJ, to establish PA practice. 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. In 2008, Dave co-founded Clinician1, which is the largest NP and PA informational/clinical/social community on the web. 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 NP and PA practice and has spoken at numerous PA and NP meetings with audiences ranging from 5 to 1,500. He honestly considers himself both a PA and an NP at heart. Dave is married to his high school sweetheart Bonnie and has two wonderful children.

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