Is Time to allow Physician Associates to practice w/o restrictions in Puerto Rico

        

        For the past 7 years, Puerto Rico has had a very critical shortage of practicing Physicians, yet their highly trained counterparts, Physician Associates/Assistants are severely restricted from practicing to the fullest scope of practice allowed by law in the island. Many studies have shown Physician Assistants can provide accessible life-saving care across all medical specialties and subspecialties, but arbitrary partisan laws prevent them from providing cost-efficient patient-centered care to those in most need: the 3.2 million disenfranchised Puerto Ricans from a broken politicized healthcare infrastructure system. 

        Today, nearly all Puerto Rican citizens lack the basic medical care services they need for the management of their chronic medical illnesses/conditions. Unfortunately, worsening a bad situation, the U.S. government declared a public healthcare emergency back in August 2016 due to an alarming rate of Zika infections followed shortly by the devastating effects of hurricanes Maria and Irma back to back in 2017. To this day, many other socioeconomic infrastructures have yet to recover fully from this.

        Those who have been following this Public Health crisis closely ( much like this author has), know that the root causes of The Puerto Rican healthcare crisis are complex, stemming from a myriad of many problems; ranging from economic shortfalls (budget constraints, etc.) to the duopoly of warring partisan factions when it comes to legislation as seen with the passage of “LEY #71”( law 71) in 2017. 

        Puerto Rican policymakers, along with other industry stakeholders as well as opposing nursing groups, and ultimately The Collegio the Medicos Cirujanos of Puerto Rico have all failed collectively to become aware of the benefits of the PA profession by failing to recognize the one method of alleviating PR’s strained healthcare system: the utilization of PAs to assist the depleted corps of physicians on the island. PAs have well over 50 years proven their ability as competent & empathetic providers not only in the US but around the globe. Especially in more recent times, including with the Veterans Administration Hospital in Puerto Rico. 

    

        Physician Assistants are highly trained in general medicine and are part of a patient-centered healthcare team. PAs improve access to care for underserved populations by diagnosing, treating, and preventing disease. PAs are trusted health care providers, licensed to practice and authorized to prescribe medication in all 50 states, the District of Columbia, and all U.S. territories with the exception of Puerto Rico. 

   

        Please urge your fellow colleagues to support us in changing this draconian practice setting/law so that the people of Puerto Rico can have increased access to medical services. Shouldn’t it be time PAs are allowed to make a difference during this time of extreme need in Puerto Rico? 

My Occupational PA Reality

 When someone asks what I do, it often feels like an oversimplification to say that I'm a PA. Perhaps, I'm a PA by trade, however, I feel that would be an inaccurate statement for a lot of reasons, granted not technically incorrect. And as true as that may be, that’s barely only the surface. Because in reality, and beyond a quick look, I feel I am at times more than just an advanced practice clinician. The other times I am a liaison, a “Psych attendant”, a colleague counselor, at many other times a student mentor, etc. I guess the list could go on, but I think you get the point. 

        The reality is this, saying simply that "I'm a PA" is not descriptive enough, it (personally) can feel as if I'm leaving out something really important–the parts that make the sum total that are just as important if not more so. In other words, yes, I am an Orthopedic PA who spends a great degree of my time not practicing solely as a PA, but also helping other people & other healthcare peers & professionals figure out how we can all be the best patient advocate at the end of the day. 

        While it can take some explaining to share in detail how I go about wearing these many hats simultaneously, I can say, after all these years, the blending of all these parts feels very integral to my workflow and/or workday. In 2 words, more like my professional identity. And while certainly, these might come at times a personal price, via work-related stress or at times some unexpected transactional frustrations, and operational patient-care related delays, etc., just to name a few. It is all part of trying to be the professional we were all called to be when we selected this professional path and career choice. 

        Personally, I know of many PA friends involved in other clinical subspecialties, various healthcare organizations, and work settings, who feel similarly about their professional lives and roles. Their inner compasses are in sync with mine even though we might see things differently at times based on the circumstances we are part of. Yet, the bottom line is the same: patient-centered care is number one…nothing less than that, even in the austere landscape of reimbursement. However, if you are a PA student you don't have to wait until you're a practicing PA to see if this is truly your calling in life. Or if it bodes well with your value system. Because even during your PA training, there will be times you will see and experience these demands placed on you. No one is immune. So, the question becomes: can you withstand these career expectations & or demands daily? Are you willing to go beyond what you envisioned & signed up for? 

        Remember, being a PA oftentimes is not just the easy part of medicine. It is about wearing the “many hats” you might be called to wear in your practice and workplace, but more importantly, can you wear them well, proudly, and diligently too? Therefore, if you one day or ever get asked what you do, you should be able to respond affirmatively that you’re PA…in the truest sense of the word. Think beyond the oversimplification tag or label others may feel inclined to label you with by (possibly) and indirectly diminishing your professional value or role. You know your reality because you live or have lived that PA reality yourself many times over while embracing it day in and out!

How well does state-regulated Compulsory Implicit Bias Training serve practicing Healthcare Professionals?

The answer to this question is debatable in the mind of this writer and many other observers regardless of how well-intentioned the proponents of this workforce movement see this. Obviously, this concept and/or idea have gained traction in the minds and views of those seeking ethical & societal reparations for all the past aggrieved parties. I would admit & be the first one to say that we as a society have woefully fallen short of establishing accountable and equitable transparency in this regard not only for decades but centuries as well and for a host of a lot of reasons.

But frankly, as imperfect the world and our country have been, can be, and will be, we must realize that Tokenism & Presentism can not atone for our past transgressions. Let’s not be naive and delude ourselves about this reality. Let me explain, while I am not advocating for moral collective social inertia or collective denial, I think (feel & believe) most healthcare providers don't provide professional care services from this space. This is not to say there aren’t any “bad apples” in our community or the world, because, the truth is they will always be those folks amongst us…like the poor as Jesus said to his apostles when Mary Magdalene was openly chastised by the Apostles when they felt the spent perfume used to wash his feet was a waste of money in their eyes.

My main point of contention is not that I am flat-out objecting to this practice in raising national or industry awareness to the forefront of our flawed transactional dealings but rather eliminating over-regulating the practice of medicine under some ideological pretense. In other words, eliminate these legislating virtue-signaling governmental practices disguised under Public Health codes by law as seen in 4 states since 2019. 

But more importantly, keep in mind that creating equitable healthcare outcomes for the patient community is inherently our calling. That's exactly how we, the PA community whether consciously or unconsciously have met our patients' needs for half a century. Simply stated, it is in our professional DNA. not to mention, why would we sacrifice & give so much of ourselves, our families, etc. to make a living in a very well-known “thankless stressful industry”? 

 Moreover, there’s minimal scientific evidence showing these desirable training courses enhance healthcare outcomes. However, at a closer look, they will ultimately line up corporate executives' pocketbooks–no surprise there (right)? This unilateral alignment is nothing more than political identity rationalizations that are flawed given the push for adding another partisan metric into the equation. 

Basically, we can do without this monetary infringement for which the healthcare ecosystem would not be any worse given the lack of hard and/or robust evidence of implicit bias training implementation improving transactional medical patient-provider outcomes. I call for all providers to measure their blind endorsement of Implicit Bias, by being grounded and putting things in perspective by examining more closely Tokenism & Presentism as the other side of the coin.

Unveiling Medical Heuristics: Beyond Clicking the Boxes

            I think and feel I have a lot to say about how detrimentally medicine is practiced in our fast-paced business of ours these days. I've seen it in my own career and in many other colleagues' careers too. In this commentary, I'm going to do something I've never done before or at least didn’t think about it on a deeper level. I'm going to pull back the curtain, and, I'm going to show you where we have erred and continue to do so in our daily practices. More specifically, what we have become--Robotic box checkers-- as modern-day clinicians. 

Moreover, why what we or you're doing isn't working as well as you'd like to admit, and what to do instead? I'll show you not one, but 2 root causes where we have unconsciously abdicated our very own thinking selves. As medicine pushes for profits, we too have been pushed to become super “fast thinkers” when providing medical services to the patient community. In many respects, we have become too automated, even protocolized in many instances. Do not misunderstand me, I am not against abiding by following practice or clinical guidelines, or even abiding by organizational protocols. Obviously, they have a role in standardizing medical care. However, be that as it may, be, I feel, we have relinquished our clinical thinking to a robotic mode, or simply to the activity of “checking boxes” in our minds. Luckily, Psychologists have looked into this phenomenon.

Interestingly enough, Cognitive Psychology proves this very clearly. This is when we all practice Medical Heuristics (aka, rules of thumb applied as they say it). Unfortunately, this mindset–although very convenient–oftentimes leads us astray in our medical decision-making activities. Sadly and tragically, this leads us to medically misdiagnose, or delay the appropriate treatment, therefore the increasing plethora of potential medical errors and adverse outcomes we see occurring across the continuum of medical care. See, this is where we are all doing it all WRONG! Not slowing down to pause & think and look beyond the immediacy or even look at the big picture when making clinical decisions in our daily busy practices. In essence and sadly that has become our Achilles heel in many legal instances.

I know to some that statement might come across as a bit sanctimonious. But know this, and rest assured I know this firsthand & better than most. Why? Because I have seen this issue occur over and over. Furthermore, from a different lens than yours: that of a medical-legal consultant perspective. Mostly when I have served as an expert reviewer in alleged PA med-mal claims, but sadly…there it is--the elephant in the middle of the room. Perhaps we should start being more open about this problem.

            However, in the spirit of sharing, I just had to remind you of this. And from a Risk Management perspective, I'm telling you, that knowing this body of knowledge helps mitigate your clinical risks. In other words, this stuff works if you familiarize yourself with these inherent biases (Medical Heuristics) and understand how to consciously sidestep them in your everyday patient encounters, whether it is in the office, ED or urgent care settings, or hospital. At the very least, it's worth taking a few minutes more of your time to see for yourself what I'm talking about when you put these techniques into practice. It will give you a better understanding of the legal landmines lurking in the background. 

Start practicing safely and confidently...don’t take chances by being or becoming an automated provider. Better yet, don't sabotage your own career. Stay present, become an engaged provider, and allow your fast (unconscious) and slow thinking (conscious) to coexist harmoniously when making your final clinical decisions. Your patients will be less inclined to raise any potential medical malpractice claims knowing that you balanced your options before making a rash decision. You owe it to them...you owe it to yourself.

Will I ever get over The Impostor Syndrome?

        As a PA, as you mature and grow professionally you will eventually come to a point where you stop seeking professional validation from your colleagues or supervising physician(s). Moreover, many mid-career or senior PAs can’t recall exactly when this occurred in their career, but suffice it to say that level of clinical comfort comes to fruition around your 3rd or even 5th year of clinical practice--maybe a little sooner or a little bit later. Everyone learns and assimilates differently. Just ask your peers.

        You may still feel like a fraud ( aka The Impostor Syndrome ) even with many years of experience under your belt. In fact, even despite the years of CMEs, conferences, and practice skillset refinement & continual enhancement of your knowledge base, it is not uncommon to still feel that you don't measure up in the eyes of others including yourself.

        But rest assured,  as you grow and continue your professional development in your career journey, you will find out you no longer feel like you're a clinical fraud and know nothing at all! In fact, it will all come together and those insecure professional emotions and self-felt insecurities will vanish away. I have precepted numerous PA students during their second-year rotations over the years. All of my students have gone on and done well and I am proud to call them colleagues. While working with these students for 8-week rotations, I have made great friendships. Many have shared their concerns and uncertainty in their readiness to practice. I have also seen their triumphs and watched many grow in their skills and become great PAs. I have also heard their fears. 

        Eventually, you will realize that little nervousness and apprehension you felt and experienced almost daily immediately post-PA school during your early career while going it "alone” or without any mentoring will come to pass too. This is not to say you will never have your fair share of trying times, or difficult patients, nor toxic colleagues/workplaces,  or changing employers several times early on, etc.

        Remember, as the old saying goes: pace yourself; is not a sprint! I now find myself approaching my retirement after 35 years as a surgical PA. Naturally, I feel more comfortable in many areas of medicine than I ever did before; but truth be told, I still feel like I don’t know enough at times. Why? Because medicine is always evolving at a dizzying pace--we all know that. And among the PAs or physicians who have practiced longer than myself, I am sure they would attest to that or feel the same way.

        So, will you ever get over the Impostor Syndrome? Yes, and no. You might not feel any longer nervous or apprehensive about your knowledge base or skill set; rather, more self-aware of what you need to continue learning, and know that learning is a life-long endeavor. Yet, we must recognize and accept many of us in practice tend to see other experienced providers as “experts” in their careers. And in my view that’s okay! Again, Medicine is too vast to be an expert in everything. A PA wanting to be successful (and sane) knows when to ask for help or where to look for the answers.

      Reflecting back at my career thus far, I have concluded that we never really get over The Impostor Syndrome,  but instead, we slowly can become better providers by self-validating our clinical selves knowing that your “training” to be a PA did not end at graduation. The first several years in practice and thereafter will help mold you into the PA you will become thus giving you your very own and unique PA identity.