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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