A Cynical Viewpoint From A Long-Time PA

    Although the comments Paul has made are one individual's frustration . We should not overlook some of the talking points that have validity. I have a successful Podiatric practice  that is only two years old. I see 135 patients aweek,25 new patients and net approx.$195,000. I will be the first to tell you Podiatry has hit a major impasse. Insurance companies are having their way with us. It is abusive. The profession has only itself to blame. It has stuck to the restrictive professional ideology of "FOOT" only.  Podiatry was smart enough to make itself a recognize independent Doctoral degree, allowing most of us to survive the onslaught with reasonabe incomes. Because of our restrictive scope I fear the worst is yet to come.

    I am also a practicing P.A.  and earn a good part-time salary.

But it is clear that N.P.'s are going to overtake the profession.

I had my DPM degree and went back to get the PA certificate.

But if I did not have the DPM to fall back on financially I would have gone for the NURSING degree. Lets all face it, its about the money. The insurance companies run the show. Those who can bill independently are going to grow stronger, while those who cannot will have their incomes dwindle as scut doers of those who can.

Right now I have an administrative position at a major hospital system, so I get to see what goes on at the corporate level. N.P's can practice independently and are therefore more desirable than a PA. If P.A.'s think your training is better or clinically more advanced, your wrong.

    Chiropractors refused to see the truth in that they were not satisfying the needs of the nation ( or insurance co.'s)with their restrictive ideology and they have been left behind. Not so with Osteopaths who historically were cut from the same manipulation cloth as the chiro's. Osteopaths refused to be pigeonholed and have flurished.

     The individuals within the Physician Assistant profession

need to shrug off the restrictive views of the NATIONAL PA AGENCIES and demand a second tier of professional degree.

An independent Doctorate of Physician Practice has a nice sound.

Although many will not want to do the additional  educatonal time( like many nurses who choose to stay with the basic nursing degree) others should have the chance to advance themselves. This will only make every P.A. stronger.

Daniel D. Mathews MS, R-PA, DPM

Personally I found Paul's honest, unvarnished opinion refreshing.  I also found some people's responses to be immature.  Its fine to state your objection to his viewpoint, however, the comments stating how its good he is retired is an example of people getting personal.  Being defensive if you don't agree is natural but getting personal and insulting is unwarranted.  The Physicians do not have to recertify every couple of years as we have to do.  If your con-ed is up to par I don't see why we have to pay to take an exam to prove our continued worth.  I work for the government where reimbursement for exams is not allowed.  The Nurse Practicioners make more money for the same work, at my facility a salary review was to take place to even the financial playing field.  After it was done the results were not made available for anyone except administration.  Shortly after it was done and before our incomes could be adjusted it was put on hold for 6 months for "facility financial reasons".  After 6 months they declared that the information on which that review was done had changed therefore the findings were null and void.  No repeat review has been done or is on the horizon.  The Veterans Administration Pa's forum shows widespread discontent across the United States in regard to the pay desparity.  The Nurses are better organized, represented, paid in many circumstances and at this point credentialed.  While I agree that a keeping up with the Jones approach is in some ways childish as we keep paying for degree after degree it seems that in time we will have fallen to the wayside as long as the dependant part of our description is at the forefront of it.  As the NP's hang out their shingle and the Minute Clinics take a bite into Family Practice using only NP's the role of the Physician Assistant will most likely narrow.  Its a Darwinian environment under the surface or our competing professions and we are losing ground.  I understand many of my colleagues are happy where they are and who they work with and for them I am happy.  That does not mean practicioners should stand idly by and watch the future of the profession dwindle.  The nurses have shown powerful solidarity and they have been rewarded over and over for it.  I obtained my Bachelors degree as a P.A. before the masters became the rule of thumb.  Why did the profession change to a masters degree at all?  That change was accepted but now the thought of another change to stay competative with nursing is unreasonable?  Down the road when asked under what model we are trained I suspect some P.A.'s will be telling people they were trained in the model of a physician but working under someone trained in the model of a nurse.  Incidentally, my respect to Paul for serving his country.  Sgt. Pete, Emergency Medicine, Mpas, PA-C, Emt-P and Veteran.

Dr. Block,

I say things like the comedians on TV...Things people really want to say but are afraid to say. Since I don't practice in either profession any longer, I'm really not afraid to say these things that I observe.

I know , that you know, that Podiatric Surgery is way down now...are you in touch with what it's like in a small practice in Pennsylvania?If you are or were a Podiatric surgeon, if you are honest ...you are doing many fewer cases per year.  Most of my colleagues have been forced to drop surgical privileges due to high malpractice insurance costs and astounding office overheads. Who are you kidding. How many have taken to endorsing orthotics, other equipment and medications like Dr. Scholls, and Deep depth shoes for Diabetics...Wound Care and other gimmicks like selling foot care products in the office as a supplement to income...., just to make their practices survive. I left Podiatry because I didn't want to have to fudge diagnostic codes , and sell shoes and products to accommodate insurances and patients that felt they should be treated for free. I left Podiatry because I could. I was a P.A. with other avenues of income. I have colleagues that would quit in a minute if they were able financially or had another profession as I did...I am told that all the time by colleagues. How fortunate I am that I can do something else. I'm certain Podiatrists were making much more and then got hit bad....Many I know , left the profession.

I tried to open a practice in Hollywood Florida . I had 4 offers to enter into associate practice. I moved there with my wife...and when I got there the doctors sai they were not serious about hiring as things were not so good.The Broward County Association gave me grief when I tried to supplement my now devastated income with house calls, because my ad in the paper was 1/8 of an inch too large and I hadn't asked them if I could do it? They didn't even offer to help one of their own. You Florida practitioners were among the worst offenders and abusers of the profession. You guys were "Livin' Large" in they 70's and 80's..guys that were in practice since the 50's and 60's , former

Doctors Of Chiropody...a two year college , were now grandfathered Podiatrists and had all the benefits of the new grads and Medicare reimbursement was started. Zip surgery was in it's heyday...billing was crazy...they cleaned up in Florida...It was abusive .How is it now?  I don't think it can compare. No offense , if a Podiatrist is makin' big bucks now, there is something going on other than Podiatry...Maybe somewhere in Kansas where there are 3 Podiatrists for 100 miles but in Philly where there are Podiatrists on every other block....but you guys were not my idea of who to look up to in that profession.

Some  Podiatrists drove Mercedes and Porsches...lived in lavish homes and had extravagant offices. They had other outlets for income too...like owning Orthotics labs, treating at nursing homes. Owner interests in Clubs, Retirement facilities, medical facilities, restaurants....I think you've been up in your tower too long and need a reality check...I notice you signed your name with , "EDITOR"...after it....I don't know any Cancer Surgeons that are editors...maybe writers of articles in the journals....I met a Podiatrist the other night that wears custom made suits, and clothes...livin' large, hates surgery but runs a residency at a local hospital. Prefers routine care...he seems to do well...His wife is a Medical Professional and owns 5 offices...DUH ! Gimme a break. As far as $116,000 a year...that wouldn't be enough to pay for most people's expenses here as a practicing doc. I know PA's that make almost as much without the aggravation and overhead.  Oncologic surgeons malpractice bill alone is over $200,000 a year easily..thank heaven the hospital pays the bill. Don't kid the kidder.....

I'm so sorry that you guys responded in thinking my situation is sad...I'm very happy producing music and singing with bands and other projects. I notice the responses come from those in states that obviously don't  have the problems that ours does. ...As far as my own personal feeling here, It's more of a disappointment and anger directed at what the profession has turned into here in my area. It didn't begin that way in 1973 when only one PA program existed in Philadelphia.....I'm certain that had I moved to another state where P.A.'s were valued I would have loved working. I loved doing the job itself and the whole idea of the profession...but the agenda has changed....  I didn't appreciate the treatment by other practitioners, by administrators  and the way PA's were generally accepted. After the first 20 years in the medical profession, at any level, that kind of treatment takes the wind out of your sails. I cannot tell you how many times the people around me ,that run things, have caused me to re-evaluate my decision to be a Healthcare Provider..I went to school in Brooklyn, lived in Philly and took 3 trains six hours a day to get my Associate degree as a PA. That, after 4 years in the Air Force as an O.R . Assistant during the Viet Nam conflict..Then , after I worked a bit, when there were no jobs that actually knew what a PA did, I went back to college  and then  to Podiatry school and practiced 15 years after that....Remember , you were not in private practice as the doctor owning and running a practice. Dealing with insurance companies, payments and hiring and interviewing office personnel, overhead percentages and the like, on that level. If you are doing that , and are a P.A., you are more than what you were trained to be. If you own a building and rent to doctors etc, and are in business...You are NOT a regular P.A. I think a PA that makes over $100,000 a year is right where he or she wants to be and should appreciate it. My first PA job paid $12,000. and they had no idea what I could do for them. ...Many years later , after Podiatry, I worked in Oklahoma at an Indian Reservation clinic and was treated like a king and a respected colleague. What  I was doing was needed .There was a shortage of trained , caring professionals. That would not happen in Pennsylvania. Pennsylvania is a state inundated with medical schools and PA's ,NP's and Doctors , a million different highly specialized docs, PA's and NP's with so much training you could get crazy from reading the initials.... A dime a dozen....How many Physicians do you work with that are MD PhD's...I have many where I worked...and two Nobel Prize winners. Here,they hire you with a different attitude. It's hard to explain. I am looking at the PA profession through the eyes of a PA that became a doctor that became a PA  again. I left Podiatry Medicine and Surgery because in my heart I felt I was not doing enough to help patients. I needed more than what I ultimately was doing, worrying about running a business. Do you ever go home at night and worry about the patient that you did a procedure on today...worry that your assistant didn't give them the treatments you wanted them to have, the Prescriptions, appointments...call them to check up on them...? Worry about how they will perceive you after they see the charges to insurance? Call them and ask them to pay the bill?  Did you worry about having to pay the office bills and what will happen if they are not happy because it didn't go the way they wanted it to ? Worry about getting an assistant or another secretary...Have to fire someone ? I've been in both places and i'm sorry , but I guess I knew I'd ruffle some feathers here ...Seriously , I seldom  think about it now when I'm doing a show or on vacation. Just when I read some of the political propaganda and bulletins. The educational level of today's PA's is far more advanced than what we were offered in 1971. When I was in school we didn't know if we would have a classroom to go to or what the next day would bring. Nobody knew what a PA was and we had to explain ourselves , tell our training and what we do, to every doctor , nurse and patient. There were no licenses, Certifications or other documents. Many times they laughed, or didn't like the whole idea. . The acceptance in most places is great . When I hear stories from Gung Ho youngsters at dinner meetings and conferences and see these political types pushing for some elected post in a State association...and hear about how much money they make and what degrees they possess and what they've done in the 6 or 7 years they've worked , I have to laugh....I think we need to worry about getting the health care delivered, not our "Certification" as prescribed by a bureaucratic association that does it for the MONEY. I'm sure the NCCPA genuinely cares about each and every PA in the nation...as long as you cough up the money each year. In my experience, really sick people don't give a hoot about your degree , your certificate. (I wasn't even allowed to hang up my diplomas in my office with 2 secretaries and 4 nurses.) If you are a sensitive, caring , compassionate professional trying to help them, that's what counts. It's that smile, that trust , that thank you letter to the hospital Medical Director, that makes your life worth while. When they bring you a candy bar or give you a hug. That appreciation you received from them...Not the fact that you are Board Certified in Orthopedics by NCCPA. That doesn't make you the person you are...YOU DO THAT ! That's what  it's all about... and you thought it was The Hokey Pokey !

Dr. Fogel writes "I predicted the downfall of podiatric surgery years ago, knowing that the economy would drive the orthopods to take foot surgery back..."%0d%0a%0d%0aAlthough Dr. Fogel (in his own words) failed as a podiatrist, the profession has prospered. According to Podiatry Management's Annual Income Survey, Podiatrists average over $116,00 per year, which is slightly above the average of lawyers in America . Podiatric surgeons earn significantly more.%0d%0a

Glad you are retired.

Having practiced as a PA-C for 33 years, my experiences are totally opposite from sad Mr. Fogel's.

I agree that specialty Certification by NCCPA is a huge mistake, and would urge every PA in the US to avoid falling into the specialty certification web that NCCPA is weaving. NCCPA has, for years, been out of control and out of touch with the profession, and exists only for NCCPAs benefit, but these issues are unrelated to Mr. Fogel's sad story.

It is a good thing that he is now retired and can hopefully find some measure of joy in life.

I was very saddened to read Paul Fogel's blog.  I have to admit that I have not practiced in any state other than Illinois, and have been only doing this for 4 years, but his viewpoint could not be further from my experiences.  I practice nearly autonomously in a 12,000/per census rural ED with no direct physician supervision.  There are local FP docs on call, but I otherwise run the show.  Everyone that I come in contact with knows the role I play.  We have had a few NPs hired into our ED, but they never lasted long:  no direct supervision was too overwhelming for them I was told. I made $75,000/year the first year out of school and now make ` $100,000.  I couldn't be more happier.

I love my job, would not trade it for the world.  It is sad that Paul Fogel spent his life in a profession that did not meet his expectations nor made him happy.  I thank God that I am not in a similar situation.

Dale T. McKinney, PA-C