Jan

14

Ask the Panda: More on Physician Assistants

January 14, 2007 |

Hey Panda. I’m a PA and I don’t like you much even though I inflict your blog on myself religiously. What do you think about Physician Assistants and Nurse Practitioners taking over from doctors? They might even replace you, Mister Emergency-Medicine-Smarty-Panda-Pants.

Another excellent question and a source of great angst among those who are contemplating primary care. As some of you know, Physician Assistants and their sinister cousins, Nurse Practitioners, practice pretty much independently as primary care clinicians in much of the United States, especially the rural and so-called medically underserved areas. Ostensibly they practice under the supervision of a physicians but this supervision is often pro forma and might involve an infrequent cursory review of a handful of charts by a retired physician not concerned about liability and just looking for an easy gig to make a little extra income.

Let’s get a few thing straight at the outset. First, we live in an egalitarian society that delights in thumbing its nose at authority. With this in mind, you are never going to convince the public that physicians should monopolize health care through anything equivalent to the divine right of kings. The public will turn against any group of uppity physicians oppressing the little guy to protect their ill-gotten six-figure salary. You know what is involved in medical training but I guarantee that the bulk of the sturdy and not-so-sturdy yeomanry don’t have a clue and don’t care about your sacrifices. I may think you deserve the six-figures but it’s going to be a hard-sell to the voter working down at the plywood plant for a small fraction of your salary.

Second, we should be against monopolies. A good or service of reasonable quality should be provided to the public at the lowest possible price which is determined by competition in the free market. I’ve been anti-union and for free trade for my whole life and I’d be a hypocrite to change my position simply because it’s my ox being gored.

The question then becomes, as was implied in the previous post, are the services of a residency-trained physician of greater value than those of a less well-trained physician assistant? I believe they are but let’s not get silly about it. Physician Assistants and Nurse Practitioners are not stupid and are more than qualified to handle the majority of primary care. I think it would be criminally insane to send your aging mother with twenty competing comorbidities to a PA but does it take a doctorate level degree to treat a kid with an ear infection?

Of course not, and this is the hook that mid-level providers have with the legislature. They are cheaper than physicians, they can reasonably demonstrate that they can do some of the same work, and since giving away other people’s services is the epitome of compassion, the mid-levels provide the trapping of political compassion at fire sale prices. Whether the public is being well-served is immaterial. It’s just primary care, after all, and the mistakes are slow to evolve and can be ascribed to half a dozen causes other than clinician error.

So what’s the drawback? As you know I’m an Emergency Medicine resident. Forget what you’ve heard about Family Practice or Internal Medicine, the Emergency Physician is the true generalist. From Pediatrics to Obstetrics to Internal Medicine, the Emergency physician has to be able to make intelligent decisions involving almost every specialty and the amount of medical knowledge and skill required to do this is immense and humbling. Not a day goes by where I don’t come against the limits of my knowledge and I have been hard at it for almost six years. And I still have two more years of training before I can practice independently of skilled supervision. If you think that some guy straight out of a two-year masters program is equal to the task then God love you, you’re a true man of the people, but you are crazier than a shithouse rat.

Also consider the training required for by an internist, the basic foot-soldier of the medical profession, not to mention that required for surgical or subspecialty training. To say that a mid-level is equivalent to a trained physician is the same as saying that we are all wasting our time in residency. And that, my friends, is the question which leads us too…

Will Physician Assistants and Nurse Practitioner take over primary care?

Yes. No. It doesn’t matter.

Yes, because American medical school graduates are not exactly flooding the zone protecting their territory from the rapacious inroads of the mid-level providers. Family Medicine, the paragon of primary care is, for several reasons, the least popular career path. It takes a special person to want to do family medicine as you must not only run between the Scylla and Charybdis of your peer’s ridicule but you must also lash yourself to the mast of primary care against the siren call of more lucrative specialties.

It is no wonder then that mid-level providers can move effortlessly into the vast, unpopulated territory of primary care. They may not be residency trained and a typical graduating family practice resident may have three times the skill and knowledge but (to paraphrase the popular World War II joke) they may not have have more than the doctor but what they have they have over here.

For its part, the family medicine establishment has done everything in it’s power to ease the transition towards primary care by mid-levels. First it was the “gatekeeper” paradigm where the primary care doctor was the traffic cop directing most of his patients to the appropriate specialist for definitive treatment. Many things need to be referred, of course, but it doesn’t take an expensive degree to decide which specialist should see a patient. When you surrender your ability to diagnose and treat complicated patients, or lose your nerve, all that you have left is low-level primary care which really could be done by a motivated high-school student much less a Physician Assistant.

The current paradigm is “community medicine” where the traditional diagnostic and treatment function of the physician, the medical skill for which he is sought, is subordinated to the needs of society, “well-being,” and half a dozen other cockamamie functions which dilute the only advantage a residency trained Family Practitioner has over a social worker, much less a lean and hungry PA stalking wolf-like along the periphery of the sickly primary care herd.

Not to mention that those in the avant garde of Family Practice have fallen so deeply in love with team-based medicine where the physician is just an equal player in one of those goofy, non-competitive games where nobody loses and everybody wins that change will never come from that direction.

On the other hand, even many PAs don’t want to go into primary care preferring to subspecialize as physicians extenders. It seems every specialty group has it’s cadre of PAs and NPs rounding on stable patients, assisting in the operating room, or clearing out the backlog of routine clinic patients. In fact, as one of my readers once pointed out, Physician Assistants perform many of the same functions in private practice as residents do in academic medicine.

So no, despite the snowballing numbers of midlevel providers, physicians will not vanish from primary care. They may just have to practice at a higher level, eschewing the current trend to water down their medical knowledge with all of that creepy social work stuff but there are plenty of sick people out there. Not to mention that there is huge bolus of baby-boomers about to start getting really, really sick and they are going to want to see a doctor, not a school nurse.

But you can probably kiss the typical low-acuity practice goodbye.


Comments

2 Comments so far

  1. Other Medical Careers Part Three: Physician Assistants : PANDA BEAR, MD on May 23, 2007 10:18 pm

    […] More here and here. […]

  2. johanna stuart PhD, PAC on June 18, 2008 11:14 pm

    I was linked to your postings by a relative applying for her NP. I agree with some of what you say. Other items I do not. However, this is not the place for me to debate the PA practice in depth. I will say one thing. You keep lumping PAs into one category. Just as we cannot adequately converse about physicinas in this manner, you cannot with PAs. In a physician discussion I will specify which group I am talking about. For instance you are either a resident or attending. You either practice in surgery or medicine.And so on. I think you need to recognize that a PA who has been in practice for thirty years has picked up a great deal of knowledge on the wards and reading/conferences outside the hospital setting. It would be ignorant to assume ones knowledge is limited to what they encountered in a formal setting towards the initial degree. Just as there is a difference between Junior and Senior faculty so to a Junior and Senior PA. I would be comfortable with my grandma “with 20 comorbidities” being seen by a few of my PA friends. I admit I would not allow her to be seen by myself. I am a PA with only around 7 years of practice who primarily focuses on her PhD life and practices on the side. I defer all my complicated patients to a senior PA or one of the physicians with a clinical interest in that patients most salient issue (HIV, IDDM etc).

    I love how you hold yourself to high as to now ever take orders from a PA. If you came to the ivy league university where I did my doctoral work you would find a hospital system with PAs serving as administraotrs and fellows. You would be reporting to these very experienced fellows. However, you would also be sharing scut work with some of the junior PAs with only a few years experience.

    For the most part, I find your blog postings interesting and articulate. I think you honestly I try to represent the PA profession as it is. I find some error with your message but not necessarily with you. However, I will say the responses you gave to some of the posters on your original thread in the bold lettering were ignorant and childish. You insulted PA’s and yourself through them.

    Good luck in your career!

    (I repeat:  In a medical capacity, I will never take orders or work under a PA, an NP, or any other mid-level provider and I will rapidly quit any position that expects me to.  I will take advice from anybody but as long as I am responsible and liable I will always make the final decision and if you don’t like it that’s your own personal problem.  So sorry.  And I repeat also: Eight years of formal training is better than two.  Period.  You just don’t kow enough to know what you don’t know.  -PB)

Name (required)

Email (required)

Website

Speak your mind