Are we a profession?

I'm sure you answered yes, and I believe many of you are generally surprised at the question. I will suggest that we are not fully engaged as a profession yet, although we are one. Our patients deserve the strongest, most valuable professionals we can become, and while we are on our way, I am asking you to consider that we still have some work to do.

According to Ernest Greenwood in “Attributes of a Profession,” an occupation becomes a profession through the development of a body of theory having the knowledge to perform a particular skill; formal qualifications based upon education, apprenticeship, and examinations; a professional culture; the emergence of regulatory or professional bodies with powers to admit and discipline members; and some degree of monopoly rights.1

According to this definition, we are working toward this but have gaps. Allow me to explain.

I believe we would all agree that a profession has a defined scope of practice. We do. It also has an understood title that describes to the public what the profession does, and we are almost there also. It controls who attends its educational programs, who can take its examinations, and ultimately who gets licensed, which is the “monopoly” part of the equation. Our profession is only partly in control regarding some of these areas, because in medicine, many professions are involved in providing care and they overlap in scope and practice. Every profession regulates what is done in its own field. An engineer regulates engineering, a dentist regulates matters dealing with teeth. Unfortunately, while we also practice medicine, we are left as the only licensed profession I know of unable to regulate ourselves. I hope you realize the implications it has for us all. We know we are licensed to provide medical care and have had the knowledge to provide this care since the 1960s. But only in the “full practice” states do we in any significant way own professionally the care we provide. No other profession providing our level of care has another profession administratively supervising them, regulating them, disciplining them, and virtually controlling them. None. If the medical board in any state decided PAs could no longer prescribe, we would have to stop and ultimately challenge that ruling. That should not be our worry anymore.

We lag behind in our professional understanding in this area for two reasons. One is we were born from, and subject to, the will of organized medicine for so long it became normalized to consider ourselves an unofficial part of physicians. Except we never actually were members of their profession and they consistently let us know that. When we did ask for the same rights other professions enjoy, especially the ability to take full responsibility for what we do, our physician colleagues balked. The old system worked well for them. Understandable. Many of you reading this still say, “I am Dr. Smith's PA.” Professionals do not look at themselves in this manner. When we began to realize that being unable to control our own destinies was not in our best long-term interest, we requested changes. Organized medicine decided it was better to push back and tell us they would not be in favor of us taking our own responsibility. They said we would be a danger. This hurts us professionally and hurts our ability to effectively provide patient care. It hurts our ability to grow and evolve.

Secondly, full professional responsibility was never explained to us or taught to us. No blame being thrown out here, as none of us realized it. We all did our best with what was given to us at the time. Our professors did not know. Our leaders never realized it, as it was above our collective pay grade. But we do now. This realization must lead to change.

Had PAs understood from the beginning that it was our responsibility to advocate for and run our own profession, we would have had to establish a much stronger identity. That is another part of professionalism in which we are weak. Our members need to understand our profession's full place in the healthcare system. We need to understand medicine is always changing and our profession must be ready to change with it. We need to understand professional advocacy. We need to support our associations. Being an appendage of another profession never allowed that growth or understanding. We were looking over our shoulder. Professionals need to understand the healthcare needs of their patients and their communities and collectively work to meet them. We failed to fully own our profession's social commitment to patients, as we looked to others to direct us. They never did. When we succeeded, as in going to rural and underserved areas in numbers that surprised all, we succeeded despite the barriers placed in front of us.

We were never told every other profession besides ours had a board made up of colleagues who decide what their profession does and regulates their practice. We never learned that all professions decide at the practice level how they will practice and build in safeguards to protect the public. Some worry we can't. Over the last 27 months, I have seen New York State and its 19,000 PAs practicing with no need for legislative supervision or collaboration and its 27 PA programs graduating students in a full-practice environment because of the governor's COVID-19 executive order. No significant problems were encountered as they adjusted for these changes at the practice level. Other states had similar executive orders, where the PAs also provided superior patient care, doing the same, adjusting and changing. We also have three states—Utah, Wyoming, and North Dakota—with optimal team practice (OTP), all doing very well. It seems every profession has found their way through this. It seems clear to me that we will also.

The final steps in our decision to finishing the task of becoming a profession were answered when our House of Delegates and profession embraced the passage of OTP in 2017. That was the beginning we needed to become a full legislatively independent profession. We are learning as we go. We need to look at other professions to understand how they developed, how they practice in their area of competence, and how they regulate their day-to-day practice at the practice level. How they fully understand that credentialing committees, insurance companies, and the people who hire and work with you will all have a say in how you practice. That they constantly refer when needed. Understanding that your clinical experience, life experience, formal postgraduate education, and on-the-job education all dictate how you practice. We need to integrate how all other professions developed the same understanding that they needed to be in control of their own profession.

It is time to stop thinking we cannot be the profession most of us dream of being. It does not mean we can't rely on the expertise of others. Physicians are part of that mix. Seasoned PAs are. NPs are. Nurses have things to teach us, all healthcare professionals do. It is time to realize that understanding what a profession is, which is really what OTP is all about, is paramount to our future success. It is time to understand advocacy and professionalism must be taught to every PA early on; not because it is novel or in vogue, but because it is vital to the life of every profession, especially ours.

It is time to no longer make up excuses for wanting to control our own destinies.

It is time for us to realize we own a wonderful profession, and we can and must control its future.

It is simply time.