What is a physician assistant's scope of practice?

I know it has been a few weeks since I updated. I appreciate all the feedback!!

1lovingmom - Thank you for asking what a DON is. So many times I do not know what the responder is talking about because they use acronyms so much. I would not know what CHF meant if my husband didn't have congestive heart failure - but then again it could mean "chronic heart failure". Who knows these days with texting being so prevalent.

Even if this medical professional is a "PA-C," e.g. "Physician's Assistant-Certified" her judgement call was very wrong. Your mother absolutely needs the care of a specialist, the cardiologist!

There's another reason why I feel that the cardiologist who's treated a patient before that patient came to rehab or AL shouldn't be shut out. And that's if the cardio has been treating the patient for several years, knows which meds have been tried and used or changed, what tests have been performed, and just as importantly, knows whether the cardiac conditions have improved or worsened.

Practices on a consulting basis to an AL facility, or practices that work out of rehab facilities, do NOT have access to that kind of history, and in my experience have NEVER asked me to provide it. They draw their own conclusions, on a short term basis and based on data from the hospital. That doesn't always reflect a longer term condition, which should be factored in.

The only thing I can say not knowing your sister's qualifications is good for the PA for being so honest! We never know what places are really there to help and which ones are just in it for the money. I'm so proud of the PA for opening up and being so honest, good for her!

I have a couple of friends who are PA's. One I would trust with my life, and the other, I gave him the decency of listening to him, but it's a case where a little bit of authority went too far.....

The 2nd PA was in my back surgeon's office. New to the job, and I asked for a refill of pain pills, 5 days post op. Totally normal, since I was discharged with a very strong pain reliever and needed something less sedating. He said "After 5 days, you shouldn't have ANY pain". I reminded him that after my first surgery I was on Vicodin for 6 weeks. This was 5 days. Said, "The dr fixed what hurt. Just take Tylenol". Wasn't going to fight him. I left, talked to the front office and made a complaint and went straight to my PCP who treated my pain with the lower dose of Norco.

Good thing I went with my gut feeling. PA's can be very, very good at dxing the regular small stuff, and this PA should have been more in tune and sensitive, but sometimes they just aren't very good. Just like drs. They do take a great load off the drs backs as they are all overwhelmed and a good PA can lighten that load.

Also, PA's work is ALL reviewed by the dr in charge. The dr will catch the "heat" first, for the PA's decisions.

You have to speak up, though. If you are unhappy with the care, tell someone, or fill out the survey forms online that they're always pushing.

There probably is a reason why the PA cannot "work with the cardiologist". PA's usually work within a medical practice that has MDs that have ultimate medical licensing & prescription writing authority. Most states have PAs licensing & liability structured this way unless they are employee of a huge health science center.

In another thread you wrote that the place your mom is in - which seems to be an AL - has an outside medical group under contract to provide care & this PA works for this group. So PA not staff at the facility, right? If so, he's under umbrella of the medical group. Not employee of the AL so not actually under purview of the DON. And absolutely not under purview of the cardiologist.

It's obvious that your unhappy with moms care & theres communication issues all around and to add to this you & your 2? siblings are coDPOAs...... But it could well be that mom is way way WAY beyond the level of care that an AL should provide. ALs expect them to be fully functioning on their own with their ADLs with somewhat minimal assistance. If mom cannot dress, walk, eat, do basic hygiene & meds on her own, either she needs to pay for aides, have medication management added or move to a facility that provides for a higher level of care as she cannot do on her own.

I'd suggest that asap whomever is the main dpoa of you 3 for finances & medical schedule a care plan meeting for next week at the AL. If it's that mom now needs a higher level of care, then all need to know what level of care asap and if this AL cannot do it then you go & find a new facility. Ask that cardiologist where he would place his mother at based on what he wrote in your moms chart. If mom needs Medicaid to pay, then find one that takes Medicaid & determine which dpoa will take the lead in the application & documentation gathering and let them do it.

If a change to skilled or specialty nursing facility provides the level of care she needs, then it's the route to go. Hopefully mom has the $$$ for private pay.

As update, we went to cardio appointment. My moms ankles and feet were so swollen my sister had to buy new shoes! My sister told the office when she cancelled appointment in the first place mom was doing better which it was obvious she wasn't. Moms return visit to cardiologist was to return if swelling was worse or not gotten better. I am so thankful we got the appointment because cardiologist took mom off of Amlodipine which causes swelling!!! PA put her on this in May. In fact, in my research it says if you experience this or other side effects to call doctor immediately. Nothing at all had been done!!! She also had other side effects including fatigue, she would sleep from 8pm - 11am. Dizziness is another side effect which you have to be careful with the elderly. I am sending info to sister as well as in letter to DON. Breaks my heart that this happened but thankful she is off it. There is no reason this PA cannot work with moms specialist as well as the facility. This should be moms best interest and best care.

Report the PA - Immediately!

This is not proper procedure, under Any circumstances!

1Loving - so what is the position on moms care by the MD who is the medical director of the Facility she is in? And is she in a NH? or AL?

If she's in a NH, usually all care plan determinations to go through the medical director of the NH with staff (PA, nursing) carrying out plan with DON running herd. DON in my experience is goddess & ruler at NH & AL as DON there every day & with a direct underling RN for each wing or floor. DON power center.

For an outside MD to place orders for care poses problems for a facility. Like say there's edema & an outside MD writes orders for XY&Z to be done 3x a day and ABC every other day..... so who is going to do this? Resident has a care plan in place already..... medical director has their own orders in place... staffing schedules set.
Outside MD now making moms NH care a la carte. Now if you, mom, your family can pay $$$$ totally on your own to have outside nursing staff (with approval of facility) come in and do whatever, then fabulous. But that's not the situation now is it..... your expecting facility to do whatever this cardiologist orders. For facilities, it's not feasible to do unless this is a very high end private pay place. Be careful in wanting this, facility can determine that the level of care is beyond their capability and mom is issued a 30 day notice which means she now has to find a a la carte private pay facility. Very very expensive so I hope she has funds to afford 20k a mo.

For us, the yr before mom moved from IL into a NH she had out patient eye surgery - retinal specialist - 1 eye and with plan to evaluate other eye following year. Now post surgery care involved lots of monitoring so she stayed evenly elevated, special diet so no straining..... basically 24/7 continuous oversight for about 10 days done by me, a cousin & with Home Instead coming in 3 times a week for their minimum. Mom was a good Pt & still very competent at the time so all good. When I brought up doing other eye at moms initial care plan NH meeting, nursing was quite direct as to what would need to happen..... either she was hospitalized & stayed for post care then back to NH or moved to 1 of the isolette single bed rooms at NH & I hired private duty care from a list they provided & paid the up charge for single bed. Fortunately retinal guy gave mom the all ok so no surgery. But it did make me realize that NH have to have bright lines as to who is in charge of determination of care plan. If they are on Medicaid or LTC insurance, the medical director needs to be it. If their private pay then you have the $$$$ to do a la carte care. 

I personally intend to stop taking all of my preventive drugs at age 85, maybe sooner if I should lose mobility. That includes statins and blood pressure meds. I am more afraid of dementia than of stroke and heart attack, and I do carry a gene for Alzheimer's, although both my parents died (64, 80) before it became apparent in either of them. I think my great grandmother had Alzheimer's.

A PA is almost as qualified as a physician. The only part of the PA's statement that sounds unprofessional is "they just want the money", even if it is true. I prefer working with PAs over physicians because they tend to give more quality time. If you trust the PA and find him/her to be competent, then follow the advice.

1Lov, let us know how this turns out. We really do all learn from each other here and it's nice to know what kind of feedback you get from the DON, as well as your mom's progress with controlling her edema, which many of us struggle with.

I agree that mom needs to continue with the cardiologist. Her edema has improved and the cardiologist wants to work with the family and has my moms best interests in mind. He was my dad in-laws cardiologist and I personally have a history with him. He is very good and hate to lose him to lesser care.

I have decided to speak to the Director of Nursing with my concerns about this PA. I appreciate ALL the good counsel!

LovingMom, cardiologists "keep having you in" for follow-ups so they can monitor a cardiac condition, with EKGs, and an ultrasound test for which I can't recall the name now. Sometimes they'll do what's known as a MUGA, a more extensive exam. Each of these tests has specific purposes, to monitor various aspects of cardiac conditions. That's what they're supposed to do.

I still think that kind of comment by a PA is inappropriate and wonder if this person wasn't fired or encouraged to find employment elsewhere.

The PAs in our cardio's office could easily be mistaken for doctors; they're that knowledgeable. They've gathered information, asked insightful questions, then discussed with a cardiologist who then made recommendations.

Other doctors "keep having" people come back for similar reasons, especially pulmonary doctors. They monitor through tests and determine whether there have been changes, positive or negative, and act appropriately.

I still question a PA who feels this is inappropriate; there are some doctors who do abuse the "return in 3 months" approach, but cardiologists especially need to monitor on a regular basis.

I would have a talk with the Director of Nusing and get his/her opinion about the management of mom's cardiac issues.

What is the cardiologist's plan of action and is THAT what the PA is unhappy about?

When I moved my mom from her home to Ind Living, we ditched most of her doctors for a lovely Geriatrician. He took mom off all of her cardiac drugs. Nothing terrible happened. She had CHF and it progressed very slowly.

If a doc is going to prescribe meds, there needs to be followup. 

It seems to me what wants examining here are the courses of treatment each of these medical professionals is recommending.

Found out today that indeed, the PA did make these statements. I talked with my sister telling her that when she told me this I had red flags. She said that he did say this because he used to work in a cardiologist office and knows the overhead of running an office. They just keep having you in for follow ups. I, quite honestly, am shocked!!

thank you

LovingMom, DON stands for Director of Nursing.

I also am not sure what a DON is :)

Thank all of you for giving me your insight. My sister is the one who told me this. After I took mom to her cardiology appointment (both my sister and brother were also at the appointment) my sister again told me that this PA was not happy that we went to the appointment and the plan of action the cardiologist gave to mom to relieve her of the edema. You are right, I need to make sure this PA is saying these things. I just needed to get some counsel from others if indeed these statements were made to my sister. Thank you so much!!!

Did you hear that from the PA yourself, or is that what your sister is telling you?

1Lov; Did you hear the PA say those words, or is that what your sister is reporting he said?

I absolutely agree with GA that if the PA told you the cardiologist is just looking for money, that should be reported to the DON and the director of the facility.

But....is there any possibility that what the PA said was interpreted by your sis, or embroidered a little? Just make sure before you go charging off.

This PA is absolutely, totally overstepping his authority, as well as being unprofessional. She should be reported to the DON.

I don't know of any legitimate, responsible, reliable and professional PA who would give the advice of which you wrote.

Adding, after thinking a few more minutes, that this PA is probably in violation of professional standards of the AMA.

Dad has a PA on his medical team, & to date, I trust her completely to tell me what she can & can't treat. Alas, they're surely not all the same, though, so I would follow my gut instincts if I were you.