I have been a PA for more than 20 years. In that time, I have worked in multiple fields with various levels of autonomous practice, and have worked in several states with differing levels of restriction to my practice. I have rarely felt that I am a “dependent” practitioner. I have proven my value to my team throughout my career, and have not felt overly restricted in my role. However, there have been times when I felt that seemingly needless restrictions constrained me. I can’t send that prescription in without my supervising physician’s approval? My patient cannot be seen because my supervising physician didn’t sign off on my insurance application? Why are there holdups?
Times have changed. PAs are no longer preferred for some jobs and for valid reasons. Why hire a “dependent” PA when an “independent” NP is less of a liability? There is a mountain that we need to climb as PAs to gain parity with other APPs and ensure our future and relevance in the health care system.
PAs are educated on the physician model. It is an abridged version; however, most programs offer approximately 75% of the didactic commonly offered by medical schools. If we consider only the metrics of time spent or hours in a clinical setting, we are closer than further away from each other. Is time the only qualifier for independent practice?
To be clear, most of the PAs that I have spoken to over the years are not looking for competition, nor to replace their physician colleagues. They respect their role, look to them for consults or guidance, and seek them out for referrals. Not once have I ever been told that they feel “better” than their supervising physicians, or that they should hang their own shingle outside their office. They are looking for a collaborative agreement, without the restrictions that negatively impact their practice, or a patient’s access to care.
Since my graduation in 2003 and passing my board exams, I have taught, learned, and have been an essential part of the health care team. I have rarely felt limited. However, I have lost possible employment/career opportunities to clinicians with less experience, but the ability to practice independently.
Independent practice, or the perception of this, is subjective. Every one of us requires a team to effectively treat our patients. We rely on lab technicians, pharmacologists, transporters, physical therapists, and nurses to get our jobs done.
I had the great honor of starting my career in a system that trained all clinicians to a high standard. If I knew how to change a wound vac, then I was expected not only to be good at it, but to teach others to be proficient as well. If a surgical fellow wished to learn endoscopic vein harvesting, we would work to find the time and access to provide that training. It was never a hierarchy — knowledge was readily shared, and with this, our team grew stronger. I never felt as if I was “overstepping” my scope, or that teaching someone would lead them to become my replacement. Unfortunately, there is more than enough “sick” in this world to make space for all who wish to become a part of the solution.
As my experience grew, so did my responsibilities. And with those responsibilities came more exposure and risk. If I was trusted to evaluate a step-down unit patient for discharge, I had better make sure that I’d checked all labs, X-rays, vitals, and surgical incisions prior to letting them leave. While I always felt like I was part of a team, as I grew more confident in my role, I became more of a leader and resource to those newer members. I didn’t want to be the PA who called consults on every issue that arose, but the clinician that worked out what he could, and asked for help when it was needed. I felt like the kid trying to ride a bike; at a certain point, the true learning began when my father’s hand stopped holding on.
Currently, independent practice for PAs is not the rule, but rather the exception. There are a handful of states that have allowed “supervision” to be replaced by “collaboration” in their rules. Thus far, we have not seen any increases in malpractice claims or a drop in the quality of the standard of care in those regions. However, “independent practice” does NOT equate to any degree of “equivalency” with MDs or DOs. Some areas of medicine require more training, specialized education, and graduated supervision before a physician can operate independently. These specialties, for example, would likely never see independent PAs/NPs in practice.
However, independence also does not mean solo practice. For PAs, this would simply mean parity with our NP colleagues, access to the same jobs, and relief from a more restrictive practice. Supervision means that PAs need to be “attached” to their supervising physician’s license and operate under the scope of that supervising physician's practice. If we come to them with years of experience in psychiatry, for example, we cannot treat psychiatric symptoms if that falls outside our supervising physician's scope, despite our confidence, and our supervising physician's confidence, in our abilities. We are unable to expand our supervising physician's practice with any training or education that we bring into their clinic if that would not be covered by their scope.
Restrictions on our practice vary by state, but the majority of states require a supervisory agreement. To practice, we need to find a physician who will agree to our requirements, including the “tether” to their license, their requirement to oversee our charting, and signing off on Schedule 2-5 medications, among other things. The hiring process can be laborious, without the ability of the PA to apply for and finish the process of getting their state license before being hired. Compare that with NPs in many states, who might move to an area, get licensing done, and start working without this restriction. From an employer standpoint, hiring someone in a needed position who can start immediately, with less liability attached to any one physician could be far more attractive than the alternative.
There are many approaches we might take toward filling our nation’s health care needs. Independent practice for APPs could be modeled on a gradual release of restrictions in a given field, such that a PA might have dependent practice for 2-5 years, then a provisional period, ending in a release of restrictions such as chart oversight, cosigning of prescriptions, etc. Physicians go through residencies, fellowships, additional training, and education to become experts in their fields and to have the ability to practice independently. PAs should be no different in the requirement to show over time that they are ready for more independent practice. While one advantage to being a PA/NP is that we can switch specialties, with that should come a requirement to show proficiency in a new specialty before there would be a less restrictive license agreement. We need to uphold the standards of care that the U.S. health system is known for.
Obviously, this is a very simplistic overview of what independence could be for PAs. There are many details that would need to be addressed, and many approaches that we might take on this journey. However, I do think that while some progress has been made, there is a longer road ahead and a rather glaring disparity in the restrictions experienced by PAs versus their NP colleagues. We need to work out reasonable, thoughtful, and progressive means to reach a solution. It may not be pretty, or easy, but it will also not be the first time that a profession has ventured into the territory of independence — DOs were not considered equivalent to MDs nationwide until the late 1980s. NPs much more recently started their climb toward less-restrictive practice. PAs have gotten a later start, and while some of the ropes have been set, there are still uncharted peaks to conquer.
What are your thoughts on the status PAs have for independent practice? Share in the comments.
Chris van Eyck, DMSc, PA-C, MSHS is a psychiatric physician associate working in psychiatry in Northern Virginia. He was a 2023–2024 Doximity Op-Med Fellow and continues as a 2024-2025 Doximity Fellow.
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