Saturday, January 24, 2009

Physician Assistant Concerns

Well, I have been reading some of the blogs here in the blogosphere, and one theme seems to remain constant. That is, PA and NP bashing, on many of the physician blogs, not all of them mind you, but many. This concerns me, I am likely taking a leadership position within our national academy soon, and I am curious as the rationale behind this. So to all physicians reading:

1. HAVE you ever directly worked with and utilized a PA or NP?

2. IF yes, do you feel that the care they provide is substandard, and if so, HOW? and can you provide data to support that assertion?

3. If no, then I am wondering how you can objectively even comment on the situation.
Do you feel threatened by midlevel providers? Do you simply not like the concept? Do you feel that they provide bad care? NOTE IF YOU ANSWER YES, you MUST provide data/studies to support that.

I'm just trying to understand, cause the health system is on the verge of collapse, a recent survey of medical students indicated that only 2% plan on entering primary care. CMS reimbursements are dismal, and the largest generation in the history of our young country is on the verge of retirement.

So, if you want to eliminate midlevel providers, what would be your answer? How would you provide care to all those people?

Basically, I am pretty tired of reading all the bullsh*t PA bashing without a shred of credible data to back up those concerns. If you have studies and or data to show poor care, then let's see it......

Thought so.


Anonymous said...

I agree with you 100%. I think it's an ego thing.

B. said...

From a 20 year EM PA: I'm not sure how long you've been doing this, but it's all about the money...and the egos.

I am fortunate to practice in a state and in a hospital where PAs (and NPs) enjoy a long history of successful practice, and probably less resistance than other areas.

But when I see the negative, unsupported BS on the blogs (yes, you, Happy Hospitalist, Scalpel and plenty of others) I remind myself of what my friend Dave Mittman has long said: it's all about the money. And that, sadly, will probably never change.

The Happy Hospitalist said...

B. Nice flame. When I say that PAs or MDs who would like to practice independently of any oversight should undergo the same credential process and meet the same certification standards as I, I am not being negative. I am not being arrogant.

I am pointing out that two fields practicing in the same scope of practice should be credentialed the same.

Perhaps if a registered nurse started practicing independently in the same scope as you you would understand my beef.

If you believe you can practice independently in the same scope as a physician, then you should be required to undergo the same credential process.

That's what I am saying. And if you want to call that negative, so be it.

Since my stance has nothing to do with PAs and NPs practicing within a structure of MD support, this discussion doesn't concern most of this population.

My beef is with the independent practitioners not undergoing the same credential requirements yet practicing in the same scope.

physasst said...

Well, then your beef does not lie with PA's at all then. We cannot, in any of the 50 states practice without a supervising physician.

B. said...

Happy, I did not advocate for independent practice for PAs without physician involvement. It is illogical to suggest that even an experienced PA is equivalent to a residency trained, board certified physician. I have no argument with your assertions regarding credentialing requirements for independent practice.

However, any regular readers of your blog know full well that you don't go more than a few days without posting a diatribe against PAs and NPs. And the majority of your assertions of substandard care are nothing more than unsupported personal opinions.

In particular, your frequent claim that PAs and NPs are dangerous because "they don't know what they don't know" is absurd. A basic tenant of professional practice is knowing the limits of your knowledge base. Is the fund of knowledge of a residency trained, boarded physician greater than that of a PA or NP in the same specialty? Undoubtedly. But to assert that PAs/NPs do not recognize when they need assistance just does not reflect the reality of any of the practice environments in which I've found myself.

I get that you don't care for referrals from PAs/NPs. I get that you think we miss the "zebras" left and right. Maybe that's your experience. I just don't think it's the norm, based on decades of PA practice experience in the United States.

PAs are, at this moment, providing front line emergency and trauma care to our soldiers in the Middle East, in many cases (gasp!) with no physician in sight. PAs have been assigned to the White House medical staff for years, providing direct care to the president and vice president of the United States. In fact, when Dick Cheney shot his friend a few years ago, immediate care to the patient was provided by a PA accompanying the vice president -- with no physician anywhere around. If our care is as limited and substandard as you frequently imply, would PAs be allowed anywhere near our troops and our national leaders?

As an emergency medicine PA, I practice in an ED in a 40 bed hospital in a rural town. My ED sees 12,000 patients annually. Do you honestly believe any EM residency trained, boarded physician would be happy practicing here? Of course they wouldn't. Nor could the hospital and community afford them. If not for the ED -- staffed 24/7 with PAs -- patients would have to travel a minimum of one hour for emergency care. For which life-threatening emergency conditions would that be acceptable? Perhaps you would prefer your child or loved one to travel an hour for treatment of their appendicitis, tension pneumothorax, fracture, CVA, AMI or respiratory arrest. Personally, I'd take an experienced EM PA any day over a moonlighting urologist or retired general surgeon...which even today, is often the choice in the rural EDs out of sight of the academic ivory towers.

I realize I've headed off on a tangent here, but darn it, I feel better for having said it!

The Happy Hospitalist said...

B. Don't know what you don't know applies to physicians as well. There are many things I don't know. And there are many things that I don't know that I don't know.

However, within my scope of practice, I can assure you, that these situations are rare. I can assure you that I would be able to connect the dots for the unknown far better than someone who has not been trained as well as me. To believe otherwise would be to believe that our medical schools and residencies are unnecessary. How do you create a study to test for situations that you don't know exist? You can't. I don't even know how you would measure it. I do know that there are many situations that I personally would not have recognized had it not been for very specific learning situations in my residency.

One more thing. You and others keep referring to "experienced PA". What the heck does that mean? What does that mean for the first 10 or 20 years of a PAs practice? When do you define experienced? Not until they are experienced do you feel a sense of capability near that of an attending MD?

The last time I checked when a physician is done with their training, they are experienced for all situations, all the time. From day one

The thought that only "experienced" PAs are capable of great care scares me.

What about the inexperienced ones? Is the PA track one of on the job training? When do you think it's OK to cut the cord for 80% of your practice? And who makes that decision?

I suppose the difference between your thoughts on great care by a PA and an MD is that it takes a PA experience (which you need to define for me) to provide it. It takes an MD board certification.

Am I off base here? Is a licensed PA only able to provide good care after years of experience?

Anonymous said...

Experienced PA is a clinically practicing PA who has recertified the PA license.

Anonymous said...

It is about money, by way of fear. You don't see flames about LPNs or medical assistants; no one is worried that they may take over physician jobs. You also don't see flames by specialists and sub-specialists. The cardio-vascular docs do not feel threatened by their PAs nor do they want to give them up. We are flamed by those whose jobs most overlap ours.

Motherhood for the Weak said...

Hmmm. I don't have an official horse in the race, but I have to say there's been a lot of asshat behavior lately in some of the medblogs I've been reading. And not just the docs. What is in the electrons lately? A huge passive-aggressive proton?

So I'm not sure your survey respondents are going to make the best cohort. It may be weighted in favor of asshat-ishness.


TJK PA-S said...

As a PA student, I hate to say it but a cursory read of the Happy Hospitalist's blog seems to be pretty fair minded with respect to PAs and NPs. Just like the Happy Hospitalist isn't a cardiologist and can't be expected to act as one, so too we cannot expect PAs or NPs to act as physicians.

Midlevels shouldn't have the same scope of practice as physicians, and most PAs agree. Unfortunately, PAs are frequently grouped with NPs who DO seem to be attempting to expand their scope of practice without proper training. If I wanted to have the scope of practice of a physician I would have gone to medical school. I hope that this expanded scope is never expected of PAs.

Some "experienced" PAs are certainly as capable as some physicians, but there are also experienced PAs and MDs who I wouldn't let anywhere near a goldfish let alone a human.

The point?

No one can make generalizations about what either group of practitioners "can" do, only what we "should" do. Maybe some PAs can out-diagnose/treat/manage their MD colleagues, doesn't mean they should free-reign to do so.

Anonymous said...

"Maybe some PAs can out-diagnose/treat/manage their MD colleagues, doesn't mean they should free-reign to do so."

The greater the experience, the greater the autonomy within scope of practice. A new graduate does not practice with the autonomy as a more experienced PA would. Whether you are member of the AAPA, a member of the Student Academy, or our colleagues, seeking the expertise not within our scope of practice is the right direction in providing outstanding care to our patients.

TJK PA-S said...


I may be wrong but you seem to be implying that the scope of MDs and PAs is the same with varying levels of autonomy within this scope by the PA based on experience.

If this is the case, I disagree and would assert that while there is overlap, the scope of the MD is much more broad. Correct me if I'm wrong, and please explain if I've misunderstood your comment.

Anonymous said...

As a member of the Student Academy, I would assert "generalist" training is more broad, unless you are trained in a subspecialty.

S. Meier, PA-C - Vascular Surgery said...

The demand of some practitioners - Independent practice whether you agree or you disagree. Practitioners should recognize the limitations and not practice beyond our scope of practice as the law states. Neither handcuffing the qualified's autonomy nor forcing the qualified overdiagnose/overtreat/overmanage yield quality patient outcomes.

PAs recognize uncurrent recertification as an obstacle towards employment. We are the only providers which these requirements are needed to practice.

As much as some practitioners demand we "yessir", no practitioner is superior to our troops and national leaders. And no troop and national leader is above the law.

Anonymous said...

TJK, can you outline what exactly is the scope of practice of a physician? You seem to refer to scope of practice of a physician as some sort of standard not within the limits of jurisdiction.

PAs are qualified by the State Boards of Medicine to practice medicine - the same licensure regulation which physicians are licensed to practice.

Anonymous said...

PAs working in a subspecialty need to draft a practice agreement. In the case of a vascular surgery PA, a vascular surgeon would draft a practice agreement for the PA to manage pre-operative/post-operative patients, as well as first-assist. First-assist is not outlined as the PA replacing the job of the surgeon. First-assist is outlined as the PA being directly across from the surgeon in the OR, performing the duties also outlined in the practice agreement -- reviewing the operations prior to the procedures, ligation, suture, managing tubes, lines, and wires, EBL, IV fluids, implants, and the estimated risks of the operation for the patient.

TJK PA-S said...


When I am comparing the scope of a PA to an MD, I'm not comparing a subspecialist MD to a family practice PA. Perhaps "scope" is not the most useful word, let me use "depth." For example, an EM PA may operate within the same scope as an attending EM MD, but I would argue that the "depth" of the MD's practice is more significant. If this is not the case, and you disagree, the entire concept of the MD/PA relationship is in question.

This isn't a knock against PAs, just a recognition of the position that we're in. And yes, I know there are exceptions (PAs who are more skilled than their attendings, etc.) but I'm referring to the general situation.

If you disagree, I'd be interested to hear your take on the PA/MD relationship...

Anonymous said...

"I would argue that the "depth" of the MD's practice is more significant. If this is not the case, and you disagree, the entire concept of the MD/PA relationship is in question."

We are not questioning who is more "skilled." Depth of practice evens out with experience.

EM PA said...

The ER MD/PA relationship must be based a working knowledge of trust as well as capability. In the ER, PA students generally has more collaboration with the ER attendings and the senior ER residents than any other inpatient facility.

The PA student may work collaboratively with an attending and split up the patients depending on the patients' case severity, or the PA student may be required to examine most patients and present the cases to an attending whose only function is to consult. Residents in the ER adds another function to an EM PA. The EM PA who has been employed in an academia ER for for a period of time, then functions as a preceptor.

As a PA student gains experience in the EM, experience may benefit the PA to sort out house staff EM PA and the attendings who encourage and back the evolvement of the PAs decision-making in a clinical setting, and who would also endorse the expansion of the PA's role in the ER.

carlos said...

"We are not questioning who is more "skilled." Depth of practice evens out with experience."

I am a PA. One with much autonomy.
And, sir or madame, I think you think too highly of yourself and of our field. I've said this on another blog "JUST BECAUSE WE CAN HANDLE IT, DOESN"T MEAN WE SHOULD!!" the patient, who is dying, critical, unstable, etc. DESERVES the level of training and ART that a doctor brings to his case. Just because I understand what to do, what drugs to give, and how to diagnose, doesn't mean I have the experience to do it! If that were the case then any idiot with a PDA and epocrates/up-to-date could practice medicine on ANYONE!

Seriously, unless you are talking about EXTREME cases (40 years experience PA in critical care medicine handling an ICU case vs a 1st year attending certified in psychiatry). I think you should stop posting before you make the rest of us look bad.
Thank you for your insight PA student!

carlos said...

I'd like to clarify, when I say "we CAN handle it" I mean, at a book knowledge level the information is there for us to use, yes, if you are good you have probably studied how to handle "x" critical patient. but Medicine is an art and someone who has spent 4 years training day and night to treat patient "x" and has seen patient "x" more times than you definitely better be at the helm of that ship!

physasst said...

Carlos, I disagree to some degree. In an ideal world, sure, but we are facing massive physician shortage forecasts, especially in primary care. I moonlight at a small ER in Minnesota, where there is NO physician in the ER, and NO physician anywhere in the hospital in the evenings. The PA in the ED is responsible for every patient in the ED, and even for managing the patients inhouse, should they start to crash. As one of my attendings at my main job at Mayo said recently. "To be perfectly honest, I'd rather have those small ER's staffed by PA's with solid emergency medicine credentials and experience, than some family practice doc who doesn't know his way around a code or trauma to save his life". I agree with this.

Randall Sexton said...

Happy Hospitalist, I disagree with this:

"The last time I checked when a physician is done with their training, they are experienced for all situations, all the time. From day one"

Some physicians have told me about during residencies they were not allowed to do much, only shadow. In some cases I understood why that happened (dork). Experience after training is more important, I think. I showed one physician how to remove a great toe nail for Christ's sake...

Anonymous said...

phyasst, if your so concerned about the health care system collapsing because of lack primary care, why don't you do what PAs were originally designed to fill...primary care.

Anonymous said...

The male-centic mind always seeing its logic as absolutely correct and infallible. Medicine is a generic term that describes a number of things. It does not belong to any specific group but can be use to define one. The term can be used by anyone without liability or penalty. Its knowledge is not the exclusive property of one group. It is integral to many disciplines in health care. It is the "holy grail" of self important groups who see this as their own and believe they are the guardian of it. Discussions here certainly make my point. It will be interesting to see your responses but they're likely to be expected.

PRPA said...

I think most of us are in primary care? isn't that the realm of family practice? internal medicine? and Emergency medicine? am I wrong? or does this guy have no idea what he's talking about?

The Happy Hospitalist said...

anon922: I actually agree with you. That medical knowledge is is not exclusive to any one group. And that is my point. Many others can learn medicine and how to take care of patients They just don't learn as much as doctors do in their training.

Which makes the clinical application of their knowledge limited in scope, compared with physicians. There are certainly many roles non physicians can provide for patients and many roles they do very well and for which I rely on for my patient care in the hospital.

physasst said...

Anon 8:58

This is what I do.

Emergency Medicine is FAR more primary care oriented than most people ever realize. I have thought long and hard about primary care, and if the right opportunity presented itself, I may make that transition.

We all have our niche, we all have our likes/dislikes, I love Emergency Medicine. It began when I was a corpsman in the Navy, and it has never stopped.

Adam Miller said...

I actually do agree that it can be about the ego, but at the same time I don't think that all doctors look down on PAs and that all doctors do it for the money. There is too much generalizing in that statement. Anyways, I'm graduating college as a Business major, but have recently decided that I want to be a PA. Any info on physician assistant programs would be appreciated!

medjobplanet- the start of a new business website said...

Ugh. The dreaded relationship issue. I have not been practicing for a great length of time, but I have faced issues with some physicians, PAs and NPs. I have to earn the respect of most of the physicians I have worked with. They will still from time to time try and educate me on things. Other PAs and NPs I have worked with have also gotten a power trip because of length of time they have been practicing and will think they know better than I do. I am not perfect and I try to make as little mistakes as possible (or no mistakes). I will still ask questions and have my patients seen by a fellow physician, PA or NP if I want another idea of what may be going on. Complicated cases are always brought to the attention of my physicians (and/or 911 called).
I do not like grouping individuals. There are physicians that think highly of PAs and NPs. There are physicians that could careless for a PA or NP. Just have to do your best and make sure if the physician, NP or well seasoned PA gives you a chance; you need to take it and prove your worth.
--Right now, I am working on a project for Healthcare providers to find a job without filtering through a lot of crap on the screen. I like something straight forward and to the point when it comes to job search. Most of what we are dealing with has tons of other needless things on the screen that we have to look through in order to find a job. Posting and searching for jobs are free at the moment. Searching will always be free. Test it out medical jobs, a physician assistant job

Tyler said...

i can't really say much because i lack any form of experience as an md or pa or np (im still an undergrad at umass), but im having trouble seeing what anyone gets out of writing these negative posts? it seems like some of you are just venting, but i think everyone needs to recognize the severity of what is said within these blogs. someone like myself thats interested in the medical field could read some of these posts and already have a negative outlook on the help from pa's and np's before they even reach their first day of med school -- how would that affect the quality of patient care? i know i probably sound like some liberal from amherst, and i know i really don't have a lot of room to talk considering my lack of experience, but it seems like quality patient care not only in the present but in the future is going to be dependent on all of the different role players in the medical field (lpn,pa,np,md, etc etc) coming together to help the patient in the best way possible and i think this starts by establishing an equal and positive respect for one another, even on these blogs

Sarah said...

I think part of the problem is the duality of professions, and the overlapping of jobs (which is why it's so hard to explain why PAs work a lot like doctors but are not doctors). I also think people are so clingy to the idea that only doctors practice medicine, and this is not helpful to anyone.

Imagine this situation: a world where primary care doesn't exist. If you have hypertension, you see a cardiologist. If you have diabetes, you see an endocrinologist. If you get pregnant, you see an OBGYN. If you have a headache, you see a neurologist. Every doctor works very neatly and specifically in his/her area of practice. One day, a patient named Susie has a headache. She is appalled to learn that she will not go to see Dr. Brain, her neurologist, but instead she will see a new type of doctor, Dr. General, who is a "family practice doctor."
"What is a family practice doctor??" Susie asks, indignantly, at her appointment. "What the heck is family practice? I want to see a real brain doctor."
"A family practice doctor is a generalist, which means that I can see many different diseases, but when a disease is out of my scope of practice, I refer to specialists," respons Dr. General.
"You mean you haven't done a residency in neurology?" Susie asks.
"That is correct," replies Dr. General. "However, I am trained to see some neurological conditions and I can always refer to Dr. Brain if I am unsure how best to handle a situation."
"But how can you know what you don't know?" replies Susie, appalled. "If you haven't done a neurology residency, how do I know that you can treat my headache? How do I know that you have the experience to differentiate a brain tumor from a tension headache? After all, you haven't done a residency in neurology and Dr. Brain has!"
"I know enough to treat simple causes of headaches," replies Dr. General.
"How do I know that?" asks Susie. "Are you telling me that it doesn't matter whether you do a residencey in neurology? Are you telling me that you know just as much as Dr. Brain? Are you telling me that Dr. Brain's expertise means nothing? Is this some half-baked idea by insurance companies designed to save money? After all, I know that your training is shorter, has less competetive admissions, and that you make 1/2 the salary that Dr. Brain does. I don't want to see some "family practice" doctor who wasn't smart enough to become a neurologist like Dr. Brain!"
Dr. General has difficulty arguing with this. There is some truth to what Susie is saying, after all, it's impossible to argue that Dr. Brain may catch some zebras that she won't catch. Dr. General can't argue that neurology training is useless.

Dr. General closes down shop, is depressed, and gets no sympathy from the neurologists, tell her that if she "wanted to treat headaches, she should have done a neurology residency." Dr. Brain sees Susie, who diagnoses a tension headahce and prescribes an analgesic. The healthcare system runs out of money in 1 year, funding collapses, and the Thelma, who desperately needed Dr. Brain's formindable experience, has to wait for 6 months to see Dr. Brain, at which point her brain tumor has spread and she is given a few months to live.

The END.

JROD said...

this is funny.. I'm a fairly green PA with < 5 yrs experience in Urgent care and Family Practice.. and I just got an operative report back from a patient I sent to the nearest city with a CT for suspected acute abdomen/appendicitis.. Looks like even I can diagnose acute abdomen from history and physical exam, and order appropriate labs and diagnostics, and mind you, my supervising physician was never in the room, nor saw this patient. (this is not arrogance either, just stating a point that there are competent PAs out there)