A physician assistant writes to the doctors of America

I’m a physician assistant, having graduated from PA school over thirty-six years ago. There is angst in my profession, but many PAs don’t openly voice it. I felt compelled to write to you because I still believe in my profession, and I believe in yours, as well. Sometimes I think it might be time to embrace a new belief system. I’d like to share a few “facts” as I see them about the American medical care system from a view you may not have considered before today.

Fact No. 1. There are 200,000 PAs and nurse practitioners practicing “medicine” today, all of who prescribe and all of whom diagnose and treat. I have been prescribing as a PA for over thirty-six years. I say that to give you perspective. Like much of what we do, we have proven ourselves. This innovation of a non-physician clinician has been successful. The jury is no longer out. While PAs and NPs may somewhat differ on philosophy, in my humble opinion we all practice medicine. I think you would agree, there’s only one way to diagnose hypertension, asthma, tinea and depression.

All three professions need to know that one way. We use the same textbooks as physicians do to learn. We use the same language, write the same prescriptions, use the same instruments. Chiropractors don’t, optometrists don’t, podiatrists don’t, naturopaths don’t, opticians don’t and psychologists don’t. I feel you have never really realized or recognized that. You certainly have not embraced that. While many individual physicians have been wonderful in their support, organized medicine has a long record of opposition to both professions. That hurts the people who are closest to you in the medical world.

Fact No. 2. Many physicians love the PAs and NPs they work with. When it is legal, many have made us partners in their practices. Others only like us, and some barely put up with us. Truth is, every day we interact with a majority of America’s physicians. We practice in almost every medical specialty. I believe we’re all part of the same team but I sometimes doubt you do. Your organizations often can’t wait to tell TV reporters that we can’t treat simple problems. The medical society continually says, “They don’t know what they don’t know”. Yet we run satellite clinics, we are in charge of the healthcare of hundreds of troops, we run your offices, some of us run our own.

Having been a national organizational board member and president of the PA society in the state with the largest PA population, I have generally seen the medical society of my state and other states committed to time and time again putting out a negative spin about us. That, my colleagues, is a crucial mistake. If you keep telling us we’re not good enough, sooner or later you’ll lose our profession. It shows you are not captain of the team but instead are committed to not even being being part of it; or at best, not having the team be all that it can be. Team members should there for each other. Negative rhetoric does not help anyone. What would help is each of us recognizing and embracing what all professions bring to the table.

Fact No. 3. You cannot keep any profession from evolving. Organized medicine has refused to “officially” see PAs as more than “assistants.” Years ago they refused to advocate for our use until no one was left to hire. Even today, any move for PAs to evolve and grow as a profession is met with a negative knee-jerk reaction from the state medical society or national organized medicine. Even to say we provide medical care is met with physician sneers. If I went to Duke University Medical School, or Yale Medical School, or Stanford Medical School, or Emory Medical School to become a PA, did I not go to a medical school to learn my profession?

I say this not because I want people to think I am a physician (please realize that is not the goal) but simply because it is the school I went to. I studied medicine there. It may be just my personal feelings but I feel the physicians of America have never realized this. If you realized this, you might also realize that although I did not get an MD, in many cases I did get a great medical education. I am sorry but your own schools decided to create this profession and train us. Now that we are here, “medicine” is not just owned by you to parcel out as you please. It is now owned and practiced by many of us who have given our lives to it and each and every one of us has a stake in it.

Fact No. 4. As a PA I am not a technician or an assistant level profession. One cannot be trained to do much of what a physician can do, and then do it well for 10, 20 or 30 years, and still be an “assistant,” still need “supervision,” which is a word that was picked for us by organized medicine. Supervision to the public means “they need to be watched.” It means they’ll NEVER really get “good enough” to do it alone. That is not the basis of a profession. These words hurt and are confusing to patients.

How about “collaboration” for PAs? Why are NPs are trained well enough to “collaborate” but not us PAs? Better word, and much more accurate. The people who are now becoming PAs are entering programs that are as competitive to enter as MD and DO programs are. We are good enough to provide much of primary care. If you don’t agree, do some good studies on us. Take experienced PAs and test our outcomes. Let’s look at the evidence. I realize we do not have the same medical education as physicians, but what we do, we generally do very well. We may even do some things better than some physicians do. That should also be fine, because patients are benefiting. It’s not just about egos.

Fact No. 5. Once you are good enough, you need to be recognized for it and allowed to do it. I have a friend who is a professor at a medical school. He was a PA in the Army and did some pretty high-level trauma care. He pointed out to me that when he retires he could not get a part time job at Costco giving flu shots (although he said he would not see himself doing that). An LPN could, an RN could, but he needs to be “supervised” to give shots. Can he give life insurance physicals? Not without a supervising physician. That is counterproductive and overly restrictive. It puts my profession in a place where we are really unrecognized for what we know, and worse, prevents us from providing care that we could easily provide to people that need this care. Physicians don’t want to do it. Let’s figure out a way to decrease some of these barriers.

Medicine needs to see PAs as partners, not medical assistants. Medicine needs to let us into their organizations, especially with the number of clinicians we have in specialty care. Medicine needs to recognize a PA with 10 years experience is able to do many things with more autonomy than a new graduate. Medicine needs to let us evolve, just as any captain of the ship would train his executive officer to one day do what he does. PAs should be allowed to enter residencies, not to automatically become physicians but to increase their knowledge. To teach residents and to show that medicine is best delivered by teams. One-year residencies should be created in primary care that would allow PAs to practice with much more autonomy. Not because “everybody wants to be a doctor” but because professions evolve. This is something I feel you are missing. We have been here since 1965 and have paid our dues.

In summary, organized medicine and you the individual physician can read this and say, “we will do all we can to not listen to what this PA is saying”, and just who does this guy Dave think he is anyway?” Or you may misunderstand what I am trying to say. Or as I have read on some physician blogs when other PAs comment you can say, “Just what part of assistant do you not understand?” or “If you want to do what we do, go to medical school.”

Any of those answers will work short term but all are short sighted. Or you can step back and put yourselves in our place. All of us who treat patients need to come together and try to understand each other. I ask for less opposition to PAs’ evolving as a profession, especially when it makes sense. We are not the enemy. We are not medical assistants, nor are we chiropractors or naturopaths. Please stop thinking of us as such. We are a real part of the solution. I worry that you will only realize this when it is too late and that would be unfortunate for all concerned, especially the patients we all serve.  Can we begin the discussion?

David Mittman is a physician assistant and has practiced family medicine in Brooklyn, NY and served as President of the New York State Society of Physician Assistants.  He is also the founder of Clinician 1.


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  • Jonquelle

    I am going to school to become a PA and think things like this should be heard by students trying to enter the profession. I totally agree.

  • pheski

    Great points, nicely expressed. I’mm happy to be part of the same clinical team with colleagues like you. It’s good for me. It’s good for you. It’s good for patients. And it’s good for society.

  • Tom

    If you want to practice medicine, there is a way to do it. PA school is not it. Nor is a one year residency. Tell you what, how about you do what we require of physicians from other countries? Pass all licensing steps, then do a full residency. We don’t care about their past experience either.

    • ER PA-C

      But I do practice medicine. I diagnose, treat, write prescriptions, then discharge or admit my own patients from the ED where I work. Few of them ever see my attending. What part of that is not practicing medicine?

      • stitch

        Who bears the responsibility for the patients you admit? If there is an error (and I’m not saying that this occurs only with PAs, it also occurs with MDs) who is legally liable? Like it or not that is also a huge part of the practice of medicine.

        • Dan V

          The PA does. If the collaborating physician is meeting the state standard for supervision/collaboration and well documentation, then the PA is legally responsible for the error. This is why PAs have to also pay malpractice insurance (like MDs)

    • Frank

      Dave predicted the comments like this would be added. Like Dave, I am a long time PA–approaching 30 years. I have my bachelor’s degree as a physician associate from University of Oklahoma Health Science Center and a masters of physician assistant studies from the University of Nebraska Medical Center.

      If I were interested in being a physician, I would take you up on your recommendation. I’m not interested in that, I am interested in practicing medicine. I am licenses to do so by my state medical board!

      Education wise for physicians you mention in foreign countries, hmm, let’s talk about that for a second. In the UK (I practiced for the National HEalth Service for 2 years) starts after high school. They go for 4 years–9 months out of the year. A total of 36 months of medical school (probably the same as your “basic” medical training). Not much different in time than the typical PA masters level training.

      I have served in the military, and in 3 of my positions, all of the physicians on the staff worked for me. The President and Vice President and their families both are regularly seen and evaluated and treated by PA’s.

      • stitch

        Frank: re: physicians in the UK: the medical degree is something entered right after college, and it is, in fact, a bachelors degree (MBBS – bachelor of medicine, bachelor of surgery.) To actually reach the level of Doctor, they have to have much, much more extensive post graduate training and education and go through a rigorous credentialing process. The MBBS is, in fact, more like the training of a PA than a fully licensed, boarded MD in this country. So, in a way, you proved why doctors from other countries are required to go through a full residency and licensing process in the US to be considered to be, and to be called, Doctors.

        • anon1

          the MBBS is 100% equivalent to the MD. America just has degree inflation like crazy, but in most parts of the world, the MBBS is a FULL DOCTOR. An MD is a doctor who has gone through EXTENSIVE (much more then american MD’s) research and contributes something NEW to medicine, unlike american MD’s who aren’t required that research step

          • stitch

            Most residencies require some form of research experience, particularly university based research programs. Almost all subspecialty fellowships require some research experience. These are also often required for specialty and subspecialty board certification.


    Mr. Mittman,
    As someone who supervises (I prefer that to collaborate) a PA and an NP in my own practice, I feel qualified to respond. I see that you have clearly outlined the many ways that “experienced” Mid-level providers have come to mimic a physician’s role. I am in fact grateful that my 2 employees can do just that for me and my patients…it allows more patients to be seen in a timely manner, and gives me confidence to leave town for a few days and to know that my patients are in good hands. That being said, I should state clearly that my midlevel providers have 12 and 28 years of experience each, and have proven themselves trustworthy to bear that responsibility.

    What I don’t see is your recognition that obtaining the “experience” of 10 or 20 years or more, is ABSOLUTELY what gives you the competence level you have obtained. So if you would like to compare apples to apples, then feel free to make suggestions implying as such. If you ONLY mean to say that a PA with 7 or 10 or 15 years of experience ought to be able to sit for a Medical License exam, then make the case. I suspect that many PA’s who are as experienced as yourself could do well on all 3 steps of the USMLE, and then once you have completed at least a 1 year internship, you could very well have a license to practice medicine. You will then have all the legal responsibilities associated with prescribing and treating, and you can hang your shingle out and see who comes in the door. I can’t say you’ll be board certified without an additional set of hoops to jump through, like another 2-5 year residency of some kind, but hey, it’s a start.

    If that is what you are advocating, then by all means, let’s begin the discussion. Pardon me for stating the obvious, but surely you are not suggesting that any patient would want to receive his medical care from someone who has just completed a 2 year PA school, instead of from someone who has completed 4 years of medical school and (at least) a 1 year internship, passing 3 steps of the USMLE along the way?

    If much of your rhetoric above was pointed at those who do not believe you could “ever” become worthy enough to practice medicine, then I can see your need to make those points. If however, you do believe that your experience is what brings your competence level close to that of a physician, then it’s important to keep in mind that the experience itself comes from teaching along the way…usually by physicians. This sounds vaguely like an apprenticeship model, so if you are suggesting this, perhaps an approach might be to ask for an “apprenticeship” track for PA’s and NP’s? This would allow the medical profession to identify which midlevels have obtained the aforementioned experience, without alienating the very physicians from whom that teaching/instruction/experience is obtained.

    • http://futureoffamilymedicine.blogspot.com mdstudent31

      PCPMD, that’s probably the best explanation I have seen in regards to this subject. How often do any studies or any arguments standardize for experience?

      After graduating from medical school next month and rotating with PA students along the way, I am very happy with the investment I made, not in respect to money, but for the knowledge and experience gained. I would argue that a traditional medical student compared to a mid-level has more opportunity to gain the proper foundation to practice medicine, standardized for experience. I would also argue that many of these mid-level students would make great physicians and probably should have initiated an effort or continued an effort to attend medical school.

      Comparing apples to apples is really the only objective way to have this conversation. Standardize for a physician just completing internship and a mid-level student just graduating from their respective programs, all going straight through high school, undergraduate education, and completion of professional training.

      When throwing experience in the mix, it definitely is a different ballgame. As stated above by PCPMD, it is a discussion worth having, especially if it means bringing more physician providers to HPSAs.

    • IMFL

      Great explanation PCPMD. I agree with you.

  • Leslie

    From a patient’s perspective, I would like to see a clearer line drawn or thorough explanation given for when I should see a PA versus an MD. In my personal experience, there is truth to the saying that you don’t know what you don’t know. While I have seen some fine PAs, I have also suffered the consequences of three PAs in my lifetime whose major errors were later caught by doctors. I’ve certainly had doctors make errors, but the errors by the PAs involved education and rights that doctors get and PAs don’t.

    • Mark

      I think the general rule of thumb is, if it is other people’s children then a PA or NP is great, because they’ll probably do a pretty good job and they save the healthcare system money. When it is you own kids, you send them to see a doctor because you want to be sure it’s not something serious.

  • http://www.nontradmd.com/ Nontrad

    As someone who will be attending medical school this upcoming fall, it’s hard seeing the diminished value society places on the services provided by physicians. It’s even harder when I read this kind of stuff.

    I will be putting the best years of my life into becoming a doctor and paying through the nose for the privilege of practicing medicine someday. To put it curtly, it sucks to know that there are mid-levels out there with “angst” over this differentiation.

    • GenInternist

      I agree as the “angst” should be more appropriately the experience of the soon-to-be displaced primary care physicians!

      • PA in WA State

        With the number of physicians choosing specialties instead of primary care, I’m afraid it will be a very long time before there will be many “displaced primary care physicians,” at least in Washington State where all but one county is medically underserved (you guessed it-King County- around Seattle). PAs are not out there to take jobs away from physicians but to help provide care to patients who might not get any otherwise.

        Here in Washington State it is “all men to the oars” to try to provide access to medical care and our state medical society values us as members of the health care team. I’m sorry it is not that way everywhere.

  • jenga

    I would agree with PCPMD. Where is the value in experience? Did someone just show up for 10 years and cash a check and never really learn anything? But hey, they have 10 years of experience, or have they truly demonstrated they can be independent and PROVE it objectively, not anecdotally. You have to be able to quantify that for the added responsibility and deal with the liability. You can’t just demand it. Passing part 3 USMLE and a 1 year intership meets that requirement as PCPMD suggests.

  • GenInternist

    Yes, before I closed my general internal medicine practice to become a hospitalist, I would not mind to entrust the care of my patients to a mid-level provider if that person had passed part 3 USMLE and a 1 year internship which meets that requirement as PCPMD suggests. The privilege can only be granted with quantifying verification and not be demanded.

  • ElleCB

    I worked for four years as an ICU nurse and experienced a great deal of autonomy, and most certainly furthered my knowledge from nursing school. Any competent person that does or witnesses something day in and day out for any significant amount of time, will become more proficient at identifying and acting on that pattern. Yes I’ve seen competent and incompetent RNs, MDs, DOs, NPs, PAs, Respiratory Therapists, . The same goes for how each professional treated the other; MDs were rude to RNs, and vice versa ad nauseum. But overall those were the outliers. Overall we all behaved like the professionals we were.

    This argument regarding clinicians is getting as obnoxious as the birthers requesting Obama’s birth certificate. I believe that NPs and PAs have a place in healthcare, and used correctly I believe they deliver quality care and can help deliver basic care to the masses. But if your gripe with your profession is regarding MDs not handing you over the keys to medicine…then go. to. medical. school. No one forced you into PA school, or to be an accountant, or whatever other career someone wants to complain about. If you don’t like your career, then change.

    I discovered that clinical care wasn’t for me (PTSD helped with that disovery) and went back to school to get my Masters in administration. I now work 32 hrs a week, can modify my schedule according my children’s school functions, carry no stress, and although I’m not still on the “frontlines” I feel the reward of helping people as I run our health system’s community health department.

    • stitch

      Thank you, well put. (This coming from an MD who, de riguer, “hates” administrative nurses, of course.)

      • ElleCB

        I would expect no less, ha!

  • Bob Blumm

    Too bad that many of us lack the ability to play in the same sandbox together. I’ve seen wonderful physicians and Surgeons who are not threatened by PAs and NPs but look at them as a feather in their cap as they had a part in their ongoing education and training and will even ask for their assistance in working on a complicated case. We work better as a team as no civilized individuals eat with their steak knife only but utilize all the utensils. After a while it’s like chef’s stating that their cusine is far better because of their training. Cooks learn in the kitchen and so do doctors. the more experience the better we all become so don’t throw out the baby with the bat water because of ignorance or arragance. congratulations on your comments Mr. Mittman. I for one agree with them.

  • soloFP

    Experienced docs and PAs are valuable to the system. That said, insurance companies could care less if the patient sees a PA or doctor with 20 years experience. The payment is the same to the PA or doctor who is a new graduate or a professional with 20 years of experience. Society does not value experience, and insurance companies/patients are not willing to pay more for knowledge.

  • weakanddizzy

    It seems to me that if a PA education is equivalent to an MD education, then all of the MD’s out there have wasted their time and effort. If they are equivalent society should shut down all the allopathic programs ( and osteopathic programs for that matter) and we should use the PA and NP model for all of our future healthcare needs. If they are equivalent why are we wasting such vast human resources and treasure on all of this MD/DO nonsense? I sure feel like a chump wasting my twenties in the library, lab, clinic and hospital.

  • Bob Blumm

    Dear Weak and dizzy:
    Your name says it alas you think and feel that you are a physician but you are still on training wheels and need to get your butt bailed out by a nurse or NP or PA. those that have been in medicine for any length of time can admit to their lack of judgment in certain scenarios and were grateful the there were other “inferior” professionals next to them to cover their mistakes and with their permission, supervise the treatment.
    Your choice of medicine is admirable but your ignorant statements speak volumes about your immaturity, your lack of humility and your small depth of experience. Fortunately, you will have a residency and with it, an opportunity to develop humility and understand the complexities of the field that we are in and the patients that we are under oath to protect and heal.
    Sorry for the spanking but you need it.

    • weakand dizzy

      Dear Bob,
      Are you serious? I finished residency over 10 years ago. Get my butt bailed out by NP’s and PA’s??? Surely you jest. I did not say PA’s have nothing to contribute. I said if we are going to provide care on a large scale delivered by mid levels, then let’s get with it. Why would any sane person spend their life obtaining a medical degree if you could spend much less effort getting the PA degree for a similar return on investment. You know the next step is to allow independent practice for PA’s, then MD and PA salaries can start to approach one another ( I suspect MD’s down much more than PA’s up). That is what the insurer’s want, cheap healthcare for the masses. I stand by my point that as this country moves forward to a mid level system it is a complete waste of time to become a primary care MD, unless you like to manage mid levels. I have taken an oath to protect and heal, but that does not mean I have taken an oath to be a chump for some insurance company MBA.

      • Dan Forsberg, PA

        You are correct Weak and Dizzy,

        Unfortunately the payers drive the policy. Physician’s specialize because that is where they maximize the return on investment. It is shameful that these drivers have invested less and less in Primary care and prevention. Undermining the role of the primary care physician. I do believe that most primary care can be managed by well-trained non-physicians but these individuals should work in concert with primary care physicians. Extending the reach of the primary care physician not competing with it.

  • Zenfire

    None of the 12 MDs or the 2 PAs and 1 ARNP in the clinic I work in go to a non-MD/DO for their own care. Funny how it’s good enough for the patients but not good enough for the providers.

  • http://www.picumd.com PICU MD

    I think PCPMD hit the nail on the head with the comment about experience. I’ve worked alongside some pretty top notch NPS in PICUs and worked with PAs from other services. I think the big difference between PAs and NPs vs. MDs is the variability of experience. For example, if you walk through the PICU doors and see Pediatric Critical Care Medicine MD on my badge you know you are dealing with a professional who has done 8 years of schooling, 3 years of residency, 3 years of fellowship and is board and subboard certified.

    If you see an NP in a PICU they could be anything from a nurse with 10 years of experience who did a peds critical care NP program who can function at a fellow level to a nurse who has never worked in the PICU who received a primary care NP degree and now took a PICU job.

    That to me is the biggest issue.

    • Jo

      Perfectly stated. The very experienced NPs/PAs who have gone to medical school are shocked to learn “what they did not know”. I was shocked at one NP who did externship at our clinic who could not do a medical note and this was a nuse who was trainer of other nurses with many years of experience that had gone to an “online” NP program. Like as said above, the physicians are providing the residencies for the mid-levels in very busy practices. Even 30 years experience “mimicing” does not replace the medical school, residency training and ongoing board certification. There should be more than “apprenticeships”, the mid-levels should then have to go through medical residencies of 3-4 years and pass board exams before being called “doctor” and/or practicing on their own without supervision or getting paid more than a solo physician.

      • Dan Forsberg, PA

        You are correct the variability in experience is a huge issue but, to be clear, I don’t believe Mr Mittman is advocating calling non-physicians “physicians” nor is he advocating cutting ties with physicians, I believe he is trying to encourage physicians to advocate for the profession by helping to eliminate potentially confusing terms like “supervising” rather than “collaborating”. A small gesture but one that more aptly describes the relationship of most NPPs with their physicians. The idea is that it would improve the utility of these providers in physician’s practices

  • Wendy Macey

    As a practing PA for 10 years within an excellent academic healthcare system, I can say without reservation that I have never been made to feel like “just a PA” or “mid-level provider” or “a physician subsitute or wanna be.” I am a second generation PA, my father has been a PA for 36 years, I have had a unique front row seat to the evolution of the PA profession. I appreciate the view points expressed above and can relate to how the struggle for every professional role to be recognized for excellence in the practice of medicine. I am proud to work on a team with my MD, DO, NP and PA colleagues along with RNs, CNMW, RTs, and all of the support staff as members of that team. It is our collective experiences, training, and expertise that makes us all valuable and necessary to deliver the highest quality of care that we can for our patients at every opprotunity. Instead of focusing on our differences in a negative way, I would suggest that we focus on the ways that we are similar and the common goal of excellent evidenced based compassionate patient care. The key to operating as an effective team is knowing when to lead, when to follow, and when to call in outside help. If our goal is to be our best at all times for our patients, then we should behave as partners, not rivals. These are real people with real issues that we are dealing with. They deserve the best care that we as a healthcare team can give them, irreguardless of degree, that should be our focus. I thank my physician, PA, and NP partners as count on them as they do me to be the absolute best that I can be and I wouldn’t have it any other way.

  • Dave Mittman, PA

    Hi Everyone:
    As I suspected many of you did not read fully what I said and I would ask that you do. I never asked to be a physician. I never asked for the right to practice medicine, PAs already have that. I have a license to prove it but I am not sure Tom likes that.
    I never asked to take medical boards to become a physician, I asked for a way for the profession to evolve within the confines and together as a part of medicine. I never asked about who to take my children to when they are sick, I have a wonderful internist, my kids see an NP as does my wife for women’s health. I trust them and they are excellent at what they do.
    As for PCP MD, you desire to use the word supervision when I asked you consider the alternative shows me that you need to realize others have feelings, and words sometimes can be misleading and sometimes leave the wrong impression. They are also misleading to patients. The word supervision is to many of us a put down word and we wonder why NPs have collaboration and we PAs do not. That was my question. I wrote this commentary NOT to say make me a physician. I wrote this to say that there are PAs and others that already have a profession have some problems and need our physician colleagues to ADVOCATE with us. Seems a few of you have stepped up. Thank you so much for beginning to understand.
    Lastly, Medicine has already lost the ability to “supervise” or collaborate” with NPs in many states. If you think this is wrong, then don’t ask me “why you went to medical school and have such debt?” or tell me “how wrong I am to think I am a physician” (I do not). Come up with some fresh ideas and stop opposing everything we do.
    I would have thought one of my ideas was good?
    I look forward to more constructive dialogue.


    When I was a resident in training, I acted as a “Provider of Medicine,” often with the patient never seeing or even realizing I had an Attending Physician who was technically “supervising” me. Heck by the time I was a 3rd year Resident I almost never called my attendings…the interns were the ones asking me for advice. I had a state medical license and wrote my own scripts, etc. But the reason I was OK with the idea of supervision was that I always knew the buck did not stop with me. If I had a question or was not sure how to proceed, I always had a fallback. Someone to call or often, someone to call in and ask to help me evalaute some unusual clinical presentation. From a legal standpoint, I was insured for my own actions, and legally liable for malpractice, and I could have lost my license for an egregious error…but my supervising attending would also be held liable, at least to a large degree.

    To me that sounds similar to how my PA and my NP currently act, and they often utilize me in a way I would have utilized my Attendings back when I was training. I am not sure how this could be considered anything other than a “supervisory” role…although due to my excellent Mid-levels’ abilities, experience and confidence, it is minimal supervision 95% of the time.

    To be clear, I am not in opposition to you or your role; as mentioned, I need 2 providers in your role just to run my own practice. My perception from your original article was that you want to be seen as a “partner” to docs, rather than an “assistant.” Sorry. I happen to think of a partnership as implying equal responsibility among the members, and that is just simply not the case. Neither was I considered a partner to my attendings in Residency, but the difference is that I was happy to fill my role and Practice Medicine all the same.

  • Dave Mittman, PA

    Dear PCP: A partnership is a business agreement. Many PAs and NPs are partners and have equity in the practice. They can have 25 % and not be equal. They can be “junior partnership” constructed in different ways, and not be equal. The point is I am asking that you re-think the paradigm a bit. Many physicians have on many levels. Question would you fire an NP that you hired in a state where they do not need collaboration if the law changed? I do not think so and I am sure you would re-adjust your business agreement and thinking around the contract you have with him/her.
    On the point of you not being in opposition, thank you.
    The fact that you rely on NPs and PAs to run your practice with you is wonderful.

  • pheski

    This conversation has made me truly sad.

    “I happen to think of a partnership as implying equal responsibility among the members, and that is just simply not the case.”

    Differentiating between ‘equal’ and ‘identical’ is neither trivial nor only of semantic interest. I see and treat the rest of my office team as part of a partnership: front staff, nurses, NPs, brand new inexperienced and long standing mature providers. We are all collaborating with equal commitment to the same goal: patient care.

    I could not do the jobs done by others on the team as well as they do. There are things I do, that they cannot do, or cannot do as well. I frequently ask for consultative help or review on certain issues from two of the NPs in our office. Oral contraceptives and vaginal symptoms are examples. One of my colleagues does vasectomies but I do not. I do colposcopies and he does not. I have an interest in sports medicine and dermatology and get asked by my colleagues for help. One of our providers (MD) has an interest in osteoporosis and I routinely ask him for advice about that. Another (DO) is consistently sought out by the rest of us for help with certain musculoskeletal issues. One of our NPs has a strong family history of breast cancer and is as current in that literature as the oncologists in our community and she can be more helpful to some of my patients in this area than I.

    The fact that we have incompletely overlapping and non-identical areas and degrees of expertise (i.e., we are not clones) does not preclude working as partners and treating each other as having equal (but not identical) responsibility for contributing to patient care.

    Methinks some here doth protest too much, suggesting a sad mix of poor self image and fear of status loss. It’s not about us. It’s about our patients.

    A football team that fails to see the 11 players on the field as partners and that has a star running back or franchise safety or QB who claims to be more equal than the others and is more interested in talking about their special position and responsibility is a football team that is destined to suboptimal performance. Even though the 11 do not have the same job or the same specific tool kits, and even though they are not interchangeable, they need to be – indeed – partners.

    Practicing medicine means taking care of patients: assessing health and illness and intervening where appropriate to maximize health and function and minimize suffering and disability. If a PA is not practicing medicine because their training and competence is different (smaller) than mine, it will be equally true that I am not practicing medicine when I take care of a cancer patient because my FP training in cancer is less than that of the oncologist, and my wife’s local oncologist is not practicing medicine because her training and expertise is less than the guru she saw for consultative purposes at the MGH. Etc.

    Here is how the OP ended his post:

    “All of us who treat patients need to come together and try to understand each other. I ask for less opposition to PAs’ evolving as a profession, especially when it makes sense. We are not the enemy. We are not medical assistants, nor are we chiropractors or naturopaths.”

    He is simply and quite articulately asking that we focus on our similarities in order to benefit our patients, rather than focus on our individual ‘specialnesses’ (real or imagined) in order to preserve our egos or bolster our self images.

    Peter Elias, MD

    • Bob Blumm

      This discussion has certainly hit the ulna nerve as there are many varied opinions , some reflective , like your Peter and some a justification of the license on our walls. I especially appreciated your comments as they reflect the realities of medical practice. Five years ago I went to three different endocrinogists for type ll DM and none of the three asked me to remove my socks during an exam to check my sensation. I went to one NP who worked with an endocrinologist and it was like being back on the Ginza Strip in 1966, I was asked to leave the shoes and socks at the bottom of the table rather than outside the door. She examined my feet early in the PE and I chose her based upon her thoroughness. Going for a DM exam with shoes on is somewhat like going to your Gynecologist and keeping your panties on.
      We all have areas of specialty, we can and usually do work well together and I would hope through this blog that we come to understand our differences and work together to be creative in our aapproach to patients. Well done Kevin, M.D.

  • http://npview.blogspot.com/ Stephen Ferrara, NP

    Dr. Elias,

    I could not have stated that better. Thank you for your comments.

    I thought a definition of collaborate would really capture the issue here (from Merriam-Webster on-line):

    Main Entry: col·lab·o·rate
    Function: intransitive verb
    Inflected Form(s): col·lab·o·rat·ed; col·lab·o·rat·ing
    Etymology: Late Latin collaboratus, past participle of collaborare to labor together, from Latin com- + laborare to labor
    Date: 1871
    1 : to work jointly with others or together especially in an intellectual endeavor

    That is what all providers have a professional responsibility to do for the sake of our patients.

    If one is into hierarchical titles, then call it whatever you want while I attempt to care for my patient in the best evidence-based culturally competent way that I can.

    Stephen Ferrara, NP


    I guess, based on Dr. Elias’ comments, that I may be missing the point. I was under the perception that we had a pretty good system of how PAs and NPs are used, as evidenced by my own practice and many others. I see that my patients benefit all the time, and I never stop to think that I need to chase them down in the parking lot and remind them who their Physician is and that the caring, competent, and proficient provider they just saw was “only” a PA.

    So, my point is this: what is broken here that Dave wants to fix? If I read his article, it indicates that he is not happy with his standing in relation to physicians. So I am wondering why? He is providing care, I am providing care, we are all providing care. Patients are not suffering with this little argument we are having…in fact, they are probably just amused.

    Dr Elias, the reason I responded is that he asked the qeustion of me (and other physicians who have an opinion about Mid-levels), as to why he and his colleagues are not considered to be more equal to physicians. I tried to explain from my perspective as to why I strongly value his role, but simply don’t see it as an equal footing.

  • Dan Forsberg, PA

    It is a shame that so much of the discussion is imbued with a belief that there is “turf” infringement. I am a PA and have enjoyed a long and prosperous relationship with each of my physician “supervisors”. These physicans have seen our profession as a very useful and expensive tool for their practices. It would behoove every physician to ensure they don’t limit the ability to use this tool to their every advantage. I don’t want to be a physician and I already practice medicine but, the term supervision is ill-understood by the public. The semantics of our legal authority often constrain the ability to use my skills for the maximal benefit of my practice. Absent these constraints, I would be even more beneficial to my physician colleagues and the patients we serve. Mr Mittman’s comments, I believe, should be seen in this light.

    To comment on the issue experience I agree that there is currently no economic benefit to experience. Insurers don’t have an “experience pay scale”, this is true. Physician salaries in the market place are not often linked to experience either. Yet most would agree that experience is what makes practitioners better. Perhaps we should substitute the term outcomes and perhaps in future models this will be the surrogate for good experience and reimbursed accordingly.


    Dr Elias,
    I also agree with your football analogy…I think the QB and the offensive linemen would and should consider themselves “partners,” in a sense. There is still a definite disparity in responsibilities, and there is only one leader in the huddle, but all are unified toward that common goal. If that is all that Dave is asking for, and I don’t think it is, then in my practice and most others I am aware of this is already occurring.

    To continue your analogy, I see this as the QBs getting together and asking the league to recognize them as coaches. Or on the field, it’s like the linemen asking to be listed in the press guide as QB or RB. Why? To what end? More autonomy? More money? How does that benefit the team approach?

    Other than prestige and standing in society, I cannot understand the impetus behind this movement. I am a “lowly” PCP, and I can see that many put a higher value on the skills and knoweldge of the specialists, both in money and in esteem. So? I feel pretty good about my role, and I don’t mind deferring to the specialist when I am over my head in a specific category. I have no desire to have entry into the Specialty Societies and to be called a Surgeon or an Oncologist or a Dermatologist, nor do I really care if the public sees me as “less than” when I choose to refer them out of my office. I know I am filling my role and I am providing essential care, and I feel great about that. I wish that all Midlevels might seek the same.

  • Dave Mittman, PA

    PCPMD: With all due respect, nothing is working.
    NPs are splitting off from physicians in most states. Are you OK with that, because it will happen. So I as a PA request you LISTEN that things could be better, there are holes in the road thatneed repair and you defend. PAs are not assistants as assistants can not diagnose, treat and prescribe in our society. I also never said I wanted to be a physician. I want to work with physicians and others to allow my profession to grow. I only ask for an open mind, not to be put in my “place”.
    Pheski and others are spot on.

    • ElleCB

      I guess I’m confused regarding this issue as well. I view it similarly to PCPMD’s sentiments; NPs and PAs are absolutely valuable to the healthcare model, but irregardless of years on the job, they can’t (and shouldn’t) be “promoted” to physician. Every member of the team serves an integral role and should be cognizant of the scope of that role.

      My experience working in an ICU, ER, and cath-lab never left me feeling like a “lowly nurse”. I felt valued and it was quite apparent the difference that a competent nurse made. The physicians I worked with never made me feel that they weren’t aware of my capabilities either.

      You say that PAs are not assistants, yet also state that you don’t want to be a physician…so exactly what is it that you want to be? I say this without ill-intent, and with genuine curiosity.

      • Dave Mittman, PA

        We have a catch 22. If PAs want to grow, you say go to med school or that we want to be physicians. After thinking about it, no other profession is “supervised” for life.
        What I want is recognition that we are in the same discipline. I did not create that fact.
        That is where we are stuck. We, like you, need to grow and learn. We need to be recognized for what we know. We PAs need a better professional blueprint. We will figure it out, maybe together or maybe apart.

        • Jo

          All professionals are supervised by someone. From professors to basketball players, QBs and RBs and even attorneys in large legal practices are “supervised”. Physicians just happen to be supervised by third party payors and the government and PAs by physicians. You want a better professional bluprint, not want “assistant” attached to your title then pay the price (the big bucks) and spend a large portion of your life and go to medical school.

  • Cantor

    You sound very insincere when you say, “I don’t want to be a physician, but I already practice medicine” implying that it doesn’t really matter anyway. What do you think the definition of a physician is anyway since you don’t want to be one as you have said so many times.

    What do you want! I cannot understand what you want! Are you not happy with “practicing medicine” for your patients? Do you want a different title? Why do people enter careers knowing full well what they are and what they contain, but then expect that it should be something else that it is not when they entered!

    I think the issue is that the PA wants to a financial partner in the practice so that he can make more money. He wants to be able to say, “You make me a partner or else I am going to open up shop down the street and steal your practice because I am just as good.” You see NPs breaking off and doing there own thing because they are under nursing laws and feel a twinge of jealously that you are under the medical boards.

    It is so easy these days to say that the big bad physician is trying to limit everyone else’s potential because he is soooo greedy and wants money. The truth is though that the faster NPs and PAs get autonomy is the faster that we will have a two tier system in this country. One for the rich and one for the poor. Guess where the poor will be shuttled. This is how it will be eventually because there are powerful business interests at play here such as United Healthcare. Don’t worry, you will win. NPs and PAs will probably have autonomy. The problem is that the payments will be so low you will be wishing for the old system. Physicians will step out and advertise on credentials, but once again you will be stuck because you are a PA. Do you not see this two tier system coming!!!

    You are driven by pure self interest because as you have already stated you are doing the job of doctor. What more do you want… I think it is evident.

    • Tako O.

      Well said.

      • Dave Mittman, PA

        Cantor: Do PAs practice medicine?
        Another disconnect is you believe that only physicians practice medicine. If PAs say we practice medicine, you hear we want to be physicians. I don’t know how to get around that?
        If not, what do we practice? And I’d love to hear what you think NPs practice?
        I am also sorry that you feel your profession is in a hopeless situation, but I am not the cause. It might not be as hopeless if we cared about each other and worked together.
        Trying to stay positive and figure it all out.

    • Hseved

      David – While I don’t think this was phrased in the best way, I have the same fundamental question. What is the difference between practicing medicine and being a physician? As a medical student, I have a great interest in primary care because I would like to be able to serve where there is such a great need in this country. However, if as you say PAs (and I assume this also includes NPs) provide the exact same care, but have substantially less educational debt and time in training, and as such have fewer costs to deal with, they can provide this “same level of care” for a lower cost, and thus outcompete physicians.
      In that situation, what is the possible reason for any medical student to ever go into primary care? My area of practice, or at least the vast majority of it, will be taken over my people with fewer costs to deal with.

      But wait – even if I go into subspecialty practice, it does not seem like anything is firmly the realm of the physician. If anything, it’s easier to train a PA to do colonoscopies or cardiac caths (or anesthesia as with CRNAs?). Doing the same thing over and over will make them just as qualified in terms of the procedural aspects in the typical case. And PAs can be found in any subspecialty (and are often seen by patients in the office setting) so there will not really be a solid footing for me there either. Should I just be a surgeon? Will that even remain untouched? I could see a world where PAs are trusted to do cholecystectomies, appendectomies, hernia repairs, etc.

      If we take this approach, where is the value of my medical education? I take issue with your statement that PA programs are just as competitive as MD programs (I have several friends who did PA programs specifically because they weren’t competitive enough for MD programs). Are we just diverting individuals who are (at least marginally) more qualified/ambitious, and saddling them with extra years of training and debt even though their scope of practice will be the same?

      And where do we see the scope of the PA taking us?

      • Dave Mittman, PA

        All I can say is that PAs learn medicine and practice medicine. We do not practice nursing, or pharmacy or PT.
        We are licensed by the medical board.

        The other questions I can not answer?

  • Wendy Macey

    I appreciate your commentary Dave and your willingness to ask questions that provoke thought. I am respectful of your position and the energy that you bring to the table. I am in agreement that semantics can be a challenge.

    I agree with Dr Elias,PA Frosberg and NP Ferrera. It truly “takes a village” and the roles we all play are critical. In my experience, it is teamwork that suceeds. I appreciate the dialouge. I would be dishonest if I did not state that it concerns me that creating division further is counter productive to the goal of caring for paitents with a goal of consistently providing the best care we can as team members. Supervision, collaboration, quarterbacks, linemen, crew chiefs, drivers…… all of this….. is for OUR patients… not ourselves.

  • Amgen

    One of the major sticking points that the OP is missing is that within his system of “evolution”, there is no standardization of care.

    The whole point of our current medical education system for MDs is to attempt to provide the public with some guarantee of basic quality of care. Medical schools are evaluated for quality by the LCME. Residency programs are monitored for quality by the ACGME. State medical boards require the completion of series of standardized exams for licensure. Specialty boards monitor quality with standardized exams and routine recertification. These systems are put into place to protect patients and provide the public with some guarantee of quality of care. And despite all of these fail safe systems, I think everyone would agree that there are still sub par physicians in practice.

    The reason we don’t allow PAs to apply for independent practice after 10 yrs or 20yr or 30yrs is that there is no standardization for what they did during that time period. You can’t equate variable “experience” with standardized, monitored, and supervised education and training.

    You may have learned alot over a 10 year period and become a very knowledgeable practitioner. However, I have no way of telling the difference between you and someone that sat by a pool drinking beer for the past 10yrs. Taking a single watered down version of step 3 will not filter that out either

    • Dave Mittman, PA

      PAs have a very standardized education.We also do a year of internship and at many institutions PAs do residencies where we will learn exactly what the residents learn. We have boards modeled after what physicians did. We have specialty boards and more are being developed. We also recertify every six years by EXAM, not in one specialty but in general medicine. Every PA has to.
      Tell me that there is standardization regarding medical degrees worldwide. We were importing physicians from many third world countries some where we know the education was inferior to US schools because we needed bodies. We have “wanna bee” physicians go to the tropics and to other continents for physician school and you say they are all the same educationally as Yale and Stamford? C’Mon.

      • Jman

        We have exams (USMLE Steps) to evaluate if internation students are the same educationally as those at Yale & Stanford…

      • Amgen

        The PA educational system is designed to train a supervised PA. I am not arguing that PAs are not of value in their current role. Frankly PA education is light years ahead of nursing education in terms of standardization of curriculum and standard board test for PA licensure

        I am addressing the premiss of your article that PA experience should some how entitle you to a higher level of function and autonomy. You need to address the point that there is too wide of a disparity in the “experience” level of these PAs to come up with any way to guarantee the public that they will not be harmed by that person.

        So is your 10 yrs of experience equal to someone who has 10 yrs of experience of a cardiothoracic PA or 10 yrs of experience as a dermatology PA? Do all three of you get to go provide primary care some where? You may be functional after spending 10 yrs in a PCPs office, however, your colleagues in the other fields likely are not.

        The whole structure of post graduate medical education and board certification is designed to tackle these issues.

        Btw you really mean to tell me that you think a 24yr new PA grad who went to yale is ready to tackle the world better than say a board certified internal medicine doctor who did his medical school india but an internal medicine residency at say medical college of georgia

      • Primary Care Internist

        I am one of those “wanna bee” physicians who went to the tropics for med school after an ivy league undergrad and an MPH at a top-tier major university. Then i came back, kicked ass on my USMLEs (all 3) and endured a rigorous internal medicine residency, then aced my internal med boards. And many of my colleagues from med school and residency have the same story. Even at a school that gets laughed at by people like you, other students represented all the ivies, competitive west coast schools etc. The process after med school of becoming a boarded-MD is VERY standardized. So even the guy from India who you think doesn’t speak English or doesn’t talk to his patients, or went to a substandard school, actually went through hell to get where he is, and probably could’ve gone to harvard for residency & fellowship in his choice of specialties if not on a visa.

        But seemingly your agenda blinds you to this. And i echo the sentiments above – what IS your agenda exactly? You don’t want to be a doctor, but you’re practicing medicine. So i’m really not clear on your wishes, from organized medicine anyway. This whole thing just sounds like a rant of insecurity.

        And i have worked with plenty of mid-levels who love to tout their training from yale, columbia, and other university health systems that constantly announce their resume to everyone they meet.

        And the foreign-grads i trained with in residency? Much much more brilliant than myself or anyone who’d ever dream of limiting themselves to being a PA or NP. Any one of us could’ve gotten into a PA or NP program. Can you really confidently say that you or the NPs and PAs you know CHOSE that route, and that going to med school was even an option?

        From what i can tell there’s almost no standardization to NP training. I’m sorry, i tried to keep an open mind in reading your post and the responses, but it all just seems so hypocritical, and nonsensical.

        • stitch

          Excellent comments as far as the standardization of what it means to be a practicing physician, even coming from an off-shore or a foreign medical school.

          As someone who worked for years in community based residency training programs, I can certainly say in my experience that just because someone has gone to an off-shore school or to a foreign medical school that does not guarantee they will be able to become licensed and practice medicine in this country. I have seen many, many applicants from these programs who could not get residency positions. There are any of a number of people in this country who are either graduates of international medical programs who could not pass the licensing exams or who could not get a residency position. Similarly for graduates of off-shore schools.

          Moreover, students from off-shore schools usually have to jump multiple hoops just to get their clinical rotations done. I have seen these students bounce literally all over the country so that they could pick up their core rotations in pediatrics, psychiatry, ob-gyn. As one such student once told me, you have to be a very motivated person to pursue this track.

          Keep in mind that in this country, where you live is a big determinant of how easy or difficult it is to get into medical school, because many medical schools get some form of state subsidy. Ohio, for example, has 6 allopathic and 1 osteopathic medical schools, and the one private one still gets extensive state funding (or did.) To the east, Pennsylvania also has a high number of schools, although fewer state schools. Indiana, to the west, to the best of my knowledge only has one (with two campuses.) This can be a big determinant of whether or not someone pursues an off-shore education.

          The bottom line is, the final common pathway to USMLE licensure and to board certification is highly standardized. There is certainly still a high degree of variation in individual competency and experience, certainly.

  • http://physasst.blogspot.com Michael Halasy

    Well, as usual, there are some good comments, some bad ones, and a lot in between.

    PA’s can be partners in practices, they can own their own practices, and roughly 2% of PA’s nationally do. The best man at my wedding owns his own FM practice, and employs his supervising physician. We now have PA’s that are flag officers in the military and have physicians under their command. The physician of course retains medical decision making power, but the PA may be in charge of them militarily.

    Many of the physicians on here are being kind, and their comments are appreciated. Besides practicing as an EM PA for over a decade, I have developed a second career and a reputation as a health policy analyst and workforce researcher. It is interesting to see the reaction of different physicians when I attend many of the high profile policy meetings/symposia across the country.

    Some are impressed (not that that matters), some are happy with a collegial discussion as well as my input, others however, will almost seem incredulous that a PA is attending these meetings and discussing how to change physician reimbursement models, ACO constructs, etc.etc.etc. as if the fact that they are an MD somehow automatically confers advanced knowledge of policy and legislative affairs, and especially economics. Most are thankfully not like that, but some are. Before anyone asks, I have an education as an economist, and am just about finished with my doctoral in policy and organizational leadership.

    Most of the physicians I know and work with are outstanding colleagues, and treat me as a true colleague. I worked in Ortho for 7 years prior to switching to EM, so the EM attendings will often ask my opinion on Orthopedic problems. Likewise, I ask them when I need assistance. I also work at one of the most prestigious medical centers in the entire world.

    This is what needs to happen more. A true collegial respect, and I think this is what Dave was asking for.

    • Primary Care Internist

      my graduate degree program in public health, alongside doctoral degree students was one thing. But nothing teaches you about healthcare economics like setting up your own individual practice and billing medicare, medicaid, and private insurers for your services. That is a very very quick education on where money is spent well and where it’s spent stupidly. And where cuts make sense, and where it makes sense to spend more.

      A doctoral in economics or health policy without this perspective is useless in my opinion.

      There are plenty of examples of bureaucrats making decisions that sound good but prove to be costly mistakes:

      medicare part D

      medicare RVU committee

      DME reimbursement rates (think of wilford brimley & scooter store etc.)

      incentives & dis-incentives for e-prescribing and HIT

      the list goes on and on. And many many middlemen have gotten rich off politicians’ idiotic ideas at the expense of the doctors actually caring for our frail elderly population, e.g.


      • http://physasst.blogspot.com Michael Halasy

        Of course. My issue is not with them, and I would never belittle your education and contribution to the debate. I would only ask the exact same in return.

        BTW, it’s not usually Private Group physicians, or true physician administrators that do this. It’s usually a physician from some academic institution that thinks that because they have been an internist for 20 years that somehow they have a better understanding than everyone else.

        • Primary Care Internist

          i did not mean to belittle your education – my point is that i have BOTH – the MPH and the perspective of practicing MD, and as far as policy-making and spending OPM (other people’s money) the latter is far more valuable in my opinion. And i think academic doctors are perhaps more detached than ANYONE from real issues of practice. even more detached than those outside medicine altogether, compounded by their generally liberally-brainwashed and shielded university professor mindset.

  • buzzkillersmith

    2 points: 1. The MD is a stamp of quality–not a perfect one, but a stamp nonetheless. If you don’t have that particular ticket punched, you will be thought less of. Sorry, but that is your lot.
    2. Scratch the surface of this debate and you will find it is about money. And you can never convince someone to believe something if his income depends on his not believing it.

  • Joe

    Reading your post, I get the feeling that you are quite disgruntled. However, I’m left with more of a vague ambivalence than a meaningful list of specific problems you wish to identify and associated corrective proposals you endorse. It is certainly easier to write a vague criticism, preemptively defend yourself, and selectively respond to commenters than it is to make your own proposals available to such critique.

    The main points I take away from your post are that 1) you are sensitive to perceived slights from physicians and dislike like the term “assistant”, and 2) you want more autonomy and more opportunity for advancement for PAs.

    In response:
    1) Semantics will always be argued. It is impossible to succinctly, differentially, and completely describe the roles of all the ever-increasing different types of providers in the medical field. – What do you propose instead of “physician assistant?”
    2) Sensible increases in autonomy are understandable, but, at some point, MD/DOs and PAs are either working as a team, with different roles being filled, or MD/DOs and PAs are directly competing for the provision of the same services. From your suggestions, I don’t get the feeling that there would ever come a stopping point in the “evolution” of the PA profession that would be to your satisfaction – the personal situation argument, based on experience, would always prevail. How, then, do you defend the inherent inefficiency of potentially having a piece-meal, highly varied, “separate yet equal” career tract?

  • http://www.nontradmd.com/ Nontrad

    I don’t think that anyone here is advocating PA’s get less respect. It’s confusing to try and parse out what’s being asked for here. Do PA’s just want to be able to say “yes, we practice the same discipline that physicians practice.” If that is the case, are PA’s trying to say that all doctors just go to medical school for the privilege of putting “MD” behind their name?

    Why should people even bother going to medical school if you don’t even need to in order to practice medicine?

  • http://physasst.blogspot.com Michael Halasy

    What this really deals with is “status”, and the concept thereof of status in medicine. That’s what this discussion is all about. Many physicians are far too wrapped up in their status as physicians.

    For example. One PA I know very well, is rather high up in the Coast Guard. He was the CFO for Quest Diagnostics at one point, has completed an MBA, his PA, a DHA, and a PhD. He is a base commander now, and is in charge of physicians daily. He sees patients a few hours each week, but is primarily an administrator. When he goes to administrative meetings, his findings seem to mirror mine in the policy realm.

    He will introduce himself, and not even mention that he is a PA, he will talk about his MBA, history at Quest, his DHA, even his PhD. Inevitably, at some point, one of the physicians will bemoan how hard it is to be an administrator will maintaining clinical competence and time for patient care.

    At this point, he will agree, and note that he is a PA as well. Of course, this is the light bulb moment. The business types, and health administrators will be interested and will ask questions with a very open mind. The physician administrators will instantly change. He states that you can note a change in the inflection in their speech, the statements made, the attitude, ALL of it. For in one moment, he was instantly transformed from an equal with an impressive administrative resume, to a subordinate.

    THIS is what needs to change.

    Perhaps someone should write a paper on the concept of status in healthcare. Perhaps someone should write a paper on physician perception of status, and what their status really is.

    Hmmmm…..maybe I should write that.

    • abxpro

      Nice post. I want a copy when you write that article. I’m especially interested in the discordance between our impression of our status and our “real” status in the eyes of different groups.

  • Doug

    One erroneous point in the original note. Podiatrists have the rights & privileges to prescribe and perform surgery. Like dentists, we have anatomical limits to how far we practice but full medical and surgical responsibility for what we do. The other professions mentioned, optometry, psychology, etc. have differing modes of practice with fairly limited, if any, prescription privileges.

  • abxpro

    Seems like turf wars are immortal. Organized medicine protects its turf vigorously. But has anybody noticed that the policy models that are being handed down all rely on Teamwork?

    I’m fond of the 80/20 rule. In this case, 80% of an internist’s training is what qualifies him to care for the toughest 20% of his patients. It is highly cost effective to use professionals with shorter training as team members to manage the others.

    I am an internist with 30 years of experience. I have taught PA’s at Yale, and now employ primary care PA’s. Some of my students have become key members of advanced neurosurgical teams, of surgical teams, of hospitalist teams. Some of my co-worker PA’s are better clinicians than some doctors; and some, not so much. And of course there are some doctors I wouldn’t be willing to practice with, either.

    At the end of the day, the responsibility for the patient rests with the physician. A PA always has the option of handing over the complicated mess or the cancer diagnosis discussion or the intransigent drug seeker to the doc. But with the PA to decompress his schedule and his stress, the doc then has time to take care of that. And in fact, some of our PA’s do very well and can take the necessary time to cope with these messy situations.

    I anticipate that most of us will work out our pattern of teamwork and ofmrecognition of excellence among each other, long before the fossilized structure of Organized Medicine catches up with us.

    • Primary Care Internist

      so what you’re saying is that PA’s are an assistant to a physician within a specifically defined role or specific subset of patients? Now i get it.

      For all the talk about PA’s practicing medicine, i find in my practice that the vast majority of mid-levels i come into contact with are involved in subspecialty care.

      This makes much more sense to me, assisting to manage a small handful of conditions with oversight by a specialist physician, rather than juggling the multiply-comorbid elderly resident on 7 meds who presents with confusion, or SOB, or dizziness, or nausea.

      It’s much easier to train a PA to manage the groin access site after cardiac cath for 24 hrs prior to hospital discharge, than to judge whether medical management or revascularization is appropriate on someone with CAD. Or to assist in craniotomy than to decide on the proper management of a glioblastoma multiforme. Or to harvest a vein graft rather than to decide on a BKA vs fem-pop bypass.

      These situations require both judgment and manual skill/labor. The former is what requires years of formal training AND experience, whereas the latter primarily requires experience, and is where mid-levels are more appropriately used than in primary care. And for all the talk, i think most busy practicing primary care docs would agree that they very commonly see mid-levels choosing specialty care over primary care.

      • Dan Forsberg, PA

        Practitioners of all levels of training tend to choose specialty care because there is an economic incentive to do so. Frankly, payers pay more for specialty care. Still about a third of all PA graduates go into primary care (only 17% for physicians) I’m sorry you don’t see the utility of these providers, they are a value added addition to most practices when utilized appropriately.

      • abxpro

        Thank you for recognizing the complexity of primary care. I agree that PA’s are well suited for procedural and repetitive duties. Most of our primary care PA’s manage acute office visits or focused disease managment followups. The best of them can juggle the more complex patients, particularly because they are allowed longer appointment times.

      • CJ PA-C

        Many of us “mid-levels” (what does that make nurses? “Low-levels”?) are forced away from primary care due to the actions of our physician colleagues. As an example, in the original poster’s state of residence, PAs did not gain prescriptive authority until the mid 1990s. They did not gain prescriptive authority for CDS until a couple of years ago. These absurd delays were due almost entirely to the extensive lobbying of the state medical society. The actions of this this society arose soley out of concern for physician financial well-being and not the health of the citizens of the state.

        You will agree that it is pretty impractical to work in primary care if you can’t write someone a script for Bactrim when their pee-pee burns or for penicillin for their sore throat.

        As another aside (and as a lowly PA) you will probably be surprised to learn:

        - I do not write patients scripts for antibiotics when they are not indicated. I practice good medicine (or “assistanting” as you would prefer to call it) and I don’t care much what the Press-Ganey surveys say.

        -Since my profession was founded by a physician and I was trained to think in the same manner a physician does, I develop a differential diagnosis, concern myself with ruling out bad things (in the example above, peritonsillar and retropharyngeal abscess), and develop a treatment plan for which patient compliance can be maximized in terms of education and socioecomic constraints.

    • Primary Care Internist

      and i don’t see this as a “turf war”. On the contrary, I am happy to see the patients who had an incomplete or inappropriate workup for anemia, or weight loss, or whatever by a mid-level (especially a NEW midlevel) – this is just free business for me. But this situation isn’t exactly good for the patient or taxpayers.

      And what is “teamwork” when ultimately the physician is responsible for everything? when things get difficult who gets to talk to the family? who gets sued? who is on call and the only one directly reachable after hours? maybe in academia you are shielded from all that because of residents, but the vast majority of us in private practice aren’t blinded by that luxury.

      • abxpro

        My perspective is private practice primary care. Our PA’s are “physician extenders”, i.e. they may do the initial visit for fatigue or weight loss, begin the lab/imaging workup, and make the followup appointment with the primary physician. That is what I meant by “teamwork”. Just like the secretary and the nurse, the PA decompresses some of my less complex duties. As I noted in my post, the physician has the ultimate responsibility, just as you point out.

        • Dave Mittman, PA

          Sorry, you are practicing in the 1970s.
          And you my friend are making my point I hope the other physicians note it. “Just like the secretary or the nurse” again is what I wrote about. Maybe it is me but
          I think you do not hold your PAs (or NPs) in high professional regard?
          Your PAs should be doing much more. Unless you are hiring the bottom of the barrel clinicians who are glad to do anything. Seriously, you need to take a look at that. But if you are paying them a good living PA wise, maybe they are really happy not to think much. I would not be.

      • Dave Mittman, PA

        I find the comments above to be unproductive and sad. Every PA can tell you the same stories about missed diagnosis, poor prescribing and more about some physicians they have worked with. That is not what we are talking about and if everything comes to this, we will not have the communication we need. This is not the spirit of why my commentary was written and I think you know that.
        As far as taking to the family, we do. As far as being on call, more than half the PAs take call. As far as who gets sued-we do also. It seems to me you feel PAs are not pulling their load. Do you work with a PA in your practice?
        We would not be here if we were not good. The majority of us are hired by physicians in private practice, not academic institutions and they the rave about us.

  • CJ PA-C

    Wow, are you docs engaged in a hubris competition with attorneys? Just as a reality check on the great and noble practice of medicine:

    -Organized medicine has an illustrious history of ridiculing essentially every great advance ever proposed – even those proposed by physicians. Handwashing? Antisepsis? Anesthesia? Organized medicine suffers from terrible inertia. The prevailing attitude among most practitioners is that this is the way we have always done things, so it is therefore the best and only way to do things, QED. You should take some time to reflect upon your own history.

    -I read my state medical board’s disciplinary minutes every month, and have done so for years. It is with mixed emotions that I regularly observe dozens of physicians (the very paragon of virtue and intelligence in our society) committing insurance fraud, abusing and selling drugs, and having trouble keeping their collective fly zipped. In these years I have seen exactly one issue involving a PA. You folks make lawyers look like angels.

    -”Organized medicine” has run the show in American healthcare since our founding. Where exactly has that gotten us? It was on your watch that our healthcare system collapsed. You will of course blame our crushing expenses on regulatory issues, but frankly many of those regulations were put in place due to the above-referenced poor behavior of your predecessors and colleagues. If so many docs had not spent so much time worrying about prestige and fat wallets maybe the practice environment would be a little more hospitible today. Healthcare has run aground with physicians at the helm. If this alone is not grounds for a paradigm shift, I’m not sure what is. Do you change your patient’s treatment when it is not working?

    People love to talk about competence issues and what is “left out” of a PAs education. In short, a physician is trained to be a scientist and a clinician, while a PA is trained to be a clinician. I work in Emergency Medicine and I can tell you with confidence that my “lack” of knowledge in histology, biochemistry and embryology has never had an adverse effect on my patients. But if you want to compare patient outcomes, let’s do it – let’s rigorously and scientifically approach the issue. I’m inclined to think that many docs would be afraid to have patient outcomes compared to PAs and NPs. What happens if you come in second? In my experience, PAs and NPs are much more likely to follow guidelines like JNC and ATP in treating patients. For some reason (probably ego and not liking being told what to do) many docs have a hard time doing likewise.

    In the final analysis, simple things are costing our country a ton of money. A great deal of our medical expenditures are related to complications arising from issues like untreated diabetes and hypertension. If you gave me high school students of average intelligence, BP cuffs and a truckload of HCTZ I could do a lot of good in my city. Sure, they would miss a renal artery stenosis here and there, but their other 20,000 patients would be better off for the encounter.

    Finally, for what is is worth, I got accepted to med school (an allopathic school in the continental US) and did not go. I agonized over the decision, but I ultimately decided that I really don’t like many doctors. Compared to most other professions, a disproportionate number of you are arrogant, petty and miserable. Since you must have gone into medicine with the purest motives, I am forced to conclude that your precious medical education mutated you into your current form. Not for me…

    • Primary Care Internist

      why on earth would you decline an MD to become a PA. I find it hard to believe…

  • Dave Mittman, PA

    A few more thoughts.
    On the “practice medicine” question:
    What if I told you that a PA was appointed as Chairman of the Board of Medicine in your state. It has already happened in North Carolina.
    What if I told you a PA was named THE “Flight Surgeon of the Year” by the US Army. Impossible as we are PAs but that too has already happened.
    Not to mention the Assistant Surgeon General.
    Things are changing. I want to work together on the change. That is all I have been saying.

  • Kate

    It is unfortunate that you have experienced disrespect from certain physicians, but I say that is a personality issue, not an issue with physicians as a whole. But because you sometimes disrespected, you want your entire profession to change to allow you increased practice rights in order to notify everyone else of the clinical knowledge you have. I guess I have a hard time understanding why it is not enough for you to feel comfortable with what you know and what you can do and be okay within your profession. You did voluntarily join this profession, right? Did you consider if you would be okay with remaining in a mid-level position throughout your career when you applied to PA school? When I was deciding between applying to medical and PA school, I considered this and realized I would want to be a leader of a team and that PA would not be for me.

    I don’t mean to sound like I’m talking down, but I think some physicians have difficulty understanding why the mid-levels want laws/governing bodies to simply advance them into a higher position instead of going through the path that others took to get there. I agree with the people who said there would need to be some kind of standardized bridge or apprenticeship program in place to go this route, because there is no way to judge how active a PA (or NP… especially NPs) has been in learning and developing his diagnostic skills as he has been in practice. We have general standardized medical education in place in the form of MD/DO schools for a reason, right? No one is saying physicians are somehow better/special individuals, but that that is the standard model on which we all depend.

    I have plenty of colleagues who might talk down to me because they are crass individuals, but what can I do to prove myself to them? Do I need to prove myself to them? Are we just going to keep creating more advanced education to make us feel better about ourselves? Again, I apologize if I am offending anyone, but I’m just trying to understand where the push is coming from.

  • Kristin

    This reminds me of the conflicts in psychology–psychologists wanting prescriptive privileges, PsyDs wanting more respect–and it’s interesting to me because in the psychology debates I have lots and lots of opinions (nobody knows enough to be prescribing psychoactive drugs! nobody pays enough attention to research! psychiatrists are still working from a psychoanalytic model, PsyDs aren’t taught research methods and therefore aren’t able to incorporate new research findings into their work, and psychologists have to lie and say they want to research if they want to get a clinical Ph.D.! plus people with a master’s in Counseling Psychology are getting edged out of the field by the rampant overproduction of Ph.Ds and PsyDs–but maybe they should be, because God knows psychological counseling is REALLY HARD and it’s difficult to feel comforted by people having one year of internship, especially after watching them being aggressively ill-informed during my experimental psych graduate classes!), but when it comes to medicine, there’s such a vast dearth of empirical evidence to back up anybody’s claims that it devolves into a pissing contest half the time.

    Of course PAs want more respect and more money. You know who else wants more respect and more money? Literally everyone.

    But the studies to demonstrate who deserves it don’t exist. They would hinge on large-scale tracking of patient outcome across a wide range of practices, and that doesn’t exist. With the advent of mandatory EHRs, maybe that will happen, eventually, once health care as a field realizes what amazing potential this has for allowing researchers to track what works and what doesn’t, instead of grouching about how much longer it takes to type information up (why isn’t anyone making better voice-recognition or touchscreen-based technology?) and how awful the interfaces are (why don’t government regulations favor open platforms? oh, right, the government is inevitably run by rich corporate puppets).

    Are there good PAs? Yes. Are there bad PAs? Yes. There are good doctors and bad doctors. And right now, we don’t KNOW how useful these people are relative to each other. We have ideas–we all have lots of brightly colored and conflicting ideas (I, for instance, think that it’s really difficult to work around the benefits of a background in hard science, no matter how much experience someone accumulates)–but we don’t have conclusive evidence. I could be wrong, you could be wrong.

    Until we know, until we have hard data to indicate whether patients with X complaint and Y additional issues can be seen by a PA with the same quality of outcome as when they’re seen by an MD, we’re just flapping our jaws.

  • Anonymous

    As a health care professional who deals with PAs and MDs, and as a patient, I have to say that my faith and trust is with the physician.  I don’t intend to insult or put down PAs, but it is an absolute fact that the physician has more education and training. That can not be argued.  Again, not to insult PAs or put down PAs, but medical schools educate the brightest of the bright, not the guys who could not get in.  PA programs like so many programs out there are without a doubt competitive, no argument there.  However, few programs (if any) are as selective as medical school programs.  With that said I want to be treated by the individual who was smart enough to get accepted to medical school, completed residency training (under the supervision of attending physicians) and fellowship training when I need a specialist.  I am truly sorry to offend, as I know that this will hurt all the good PAs out there that are great at what they do.  Fact is, you’re not physicians, and I can’t make apples and oranges the same thing in my mind, no matter how hard I try. 

  • Vincent Schultz

    I applaud you Dave for being a pioneer in the P.A. profession.

  • http://www.facebook.com/profile.php?id=1361370265 Alexis France

    Eva1234, No one is saying that PA’s are expecting to be physicians. His point is that it’s supposed to be a collaborative team effort. If you go on rounds, you will see that there are various people in the circle, attending, residents, NP or PA, OT and PT. It is a team effort to get the patient healthy. A Physician Assistant has much more training than to be treated like an ‘assistant.’ If a PA wanted to be an MD, they would go to medical school. Most PA’s become PA’s because they want more patient contact and team work. This letter is a little bit far fetched in that a lot of physicians actually respect and appreciate a PA on their team. Many patients prefer PA’s for exams and evaluations. That is not to say that the patient does not see the doctor also, but the doctor’s time is split up as well. Medicine is evolving into a career in which all members of a health care team are extremely important. It’s time to recognize that it’s changing. Again, no one is asking a PA to be an MD, but the PA profession is growing rapidly and it’s time to realize the rigorous training that they too have to go through.

    P.s., most PA’s could get into medical school but choose not to. PA isn’t a path that people decide to do after a rejection letter. The biggest hospitals (Rush University, Northwestern University) are opening up Master’s programs for PA’s, why invest the money if it is not rigorous or important in the health care system? Just want to clear up your misconception.

  • Vincent Schultz

    Alexis – I completely agree with you. Well said. Also, thank you for clearing up the misconceptions. My wife practices medicine in a specialty as a P.A. She had/has the grades, intelligence and work ethic to get into med school, but she chose to become a P.A. It was the better choice for her when she weighed all of her options.

  • http://pulse.yahoo.com/_SPLYLUKFAMTTLUZIDJXWHO7TKE William Ingram

    There is a PA in New York, who is credentialled as a procurement surgeon.  Fellows go out with him, but he is ultimately responsible for performing the operation and teaching fellows.  I had the pleasure of operating side by side with him and was amazed when he told me he was not a fellow, but a PA.  My hat is off to him, because clearly he is an exception and a “great surgeon.”  I have seen him teach and his skills are unsurpassed.  As a matter of fact when I know he is the “thoracic surgeon” on the procurement, I’m at ease knowing there is a top notch “surgeon” at the table who will  be able to fix any screw up by the training fellow and not place organs in jeopardy.  I believe he is based out of Columbia University or Cornell.  This guy is really top notch and I would put him up against many of my surgical colleagues.  Just goes to prove, that you should never judge a book by its cover until you have read it.

  • http://pulse.yahoo.com/_T24C7TBI6MDAWVYN4RKAZN63SY britt

    It actually is not true that PA schools are not as competitive as
    medical schools. Take a look at this article which lists the lowest
    acceptance rates of the medical schools in the US   
    ….keeping in mind these are the LOWEST, so many schools have much
    higher rates.  Now take a look at this website  
    which shows statistics which work out to be a 4% acceptance rate, in
    range with some of those medical schools with the lowest acceptance
    rates; and this is just an example of one PA school.  Also you should
    not make an assumption that all people who go to medical school are
    brighter than those who to go PA school or that PA students are just
    those who did not make it into med school. This is not true at all.
    There is not a single person in my class who wanted to go to med school
    or even tried to go to med school. They chose PA as a career because
    they love the practice and the time with patients.

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