Let physician assistants be part of the primary care answer

There has been so much change in medicine, physicians are leaving primary care, and new ideas are being bantered about such as patient centered medical homes (PCMH) and accountable care organizations (ACO), in an attempt to try to address the problem.   To add to this strain, is the knowledge that medicine is going to have to be ready to absorb thousands of additional patients in the near future with the passage of the health care bill in 2010.  Who’s going to take care of all of these patients, those who are coming into the medical system as well as those who are losing their primary care physician who have left?

In all of these numerous conversations regarding the changes in medicine, one of the available answers to help address patient care has been brushed over.  What about us, those physician assistants (PA) out there?  Can we not be a part of the answer, can we not see primary care patients?  We are well trained, we have the clinical skills, we have the knowledge base, so let us be a part of the solution.

A recent survey has shown that 50% of all physicians have worked with a PA, what about the other 50%?  Why haven’t they worked with a PA and seen what we can do for their practice?

We bring a lot of skills to the table which can help address the impending avalanche of patients.  Not only are we cost effective (our overall labor costs are less than a physician), but we can take the stress off of a physician needing to see a certain amount of patients per day, so as to keep the clinic productive.  Through our cooperatively working as a team member, alongside our physician, we can allow you, the physician, that much sought after balance between your personal life and work.

We can also bring to the table a different set of clinical expertise and experience.  Every physician who has gone through medical school, and then residency, knows that they leave this training with certain skills and interests.   Well PAs do the same, we have certain interests in medicine (such as skills and experience in woman’s health issues, athletic injuries, etc) that the physician we are working for, may not have.  So we can complement each other in our seeing patients.

Yet another area that we are good at, is in our patient communications skills.  I remember being told by my first supervising physician that he would never see a patient without my being present, due to the fact that I spoke the patient’s language and he didn’t.  I did a lot of the patient education and spoke in English with them using words they could understand.  My supervising physician only spoke in scientific terms, which was easily lost on his patients.  Physicians sometimes tend to use medical terms, whereas we as PAs use English terms with patients when we are explaining their health conditions with them.

By us being the communicator, patients are less likely to misunderstand and therefore more likely to comply with their medical regimens.  If patients understand what they are supposed to do, they then feel they are a part of their own medical care and can then cooperate with us, their providers.

So with all of this in mind, let us, the PAs come alongside you, the physician.  Let us work together, see patients in the clinic together, work using our clinical strengths and experience together.  Let us work as a team, and then in the environment of respect and colleagiality, we can address together the health care needs of our nation.

Sharon Bahrych is a physician assistant who blogs at A PA View on Medicine.

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  • Doc BestDeal

    To tell the truth, I have no idea what you are talking about, as all the arguments you have made in terms of communication, experience in certain areas etc are completely baseless. But, and its a big one and good luck with it, I think its time all PCP’s should be taken over by Nurses and PA’s. Its high time Family Medicine should be scrapped from the residency program list. I think it will be for the higher good of all and don’t get me wrong residents, with the Medicare reimbursement and other issues like social security in the future you guys will be better off doing something else !

    • http://twitter.com/RebeccaCoelius Rebecca Coelius

      Doc BestDeal, I tire of nonsensical arguments like yours. The only reason mid level providers have become so prevalent in primary care is that the AMA’s RUC destroyed reimbursement for primary care (and most other non procedural care) and local hospital politics have taken away a meaningful scope of practice in most settings not due to any identifiable outcomes data, but because they need patients to fill their subspecialty clinics. If we had any semblance of a market in medicine right now primary care reimbursement would be skyrocketing and med students returning to it given the unmet demand. Too bad our AMA reps on the RUC care more about how much tape is used in a procedure than the impact of the service on patient outcomes or the unmet demand for the service in our country. Another example; my anesthesiologist friends would do anything to be able to stay and practice in the San Francisco Bay Area, there is such a glut of professionals who went to our country’s best medical schools trying to live here. Its absurd that such regional overabundance and competition for these positions has not dropped their salaries to the basement level required to attract competent talent within our county hospital system, and shifting the money saved to attract PCPs given the shadow panels of hundreds of patients waiting to establish care in each of our community clinics despite having insurance, or Dermatologists given how difficult it is to attract them out of private practice where they can make much more money providing bs cosmetic services in our rich community.  Or god forbid we give this money back to the city or taxpayers. 

      Understandably MDs have thus fled the field, and out of desperation we’ve started looking at what other professionals can take their place. I actually do think PAs and NPs are a fantastic team member in the primary care clinic. If they are working at the top of their license, it means I can work at the top of mine diagnosing more complex conditions, performing office-based procedures (in many residency training programs we perform just as many colonoscopies, colposcopies/LEEPs, vaginal deliveries, etc as our subspecialty counterparts and often alongside them in the very same training environment and come out just as competent), develop clinical protocols and outreach plans for our particular patient panel, etc. Look at other countries with significantly better outcomes for less cost, they are all built on a robust backbone of generalist MDs who CONSULT sub-specialists only when its something genuinely out of their area of expertise. Look at the data in the US. The places with the best outcomes and lowest cost are those with robust primary care systems- not those with a scant network that operate as glorified referral centers to more expensive fragmented care like New York City. That doesn’t mean we think we can do everything, as another person here mentioned most FPs develop an area of focus such as women’s health, geriatrics, adolescent medicine, sports medicine, etc. We just don’t drink the academia Kool Aid that just because you publish obscure papers on the subject you are a better clinician that somebody who also keeps up on the literature and treats people with these diseases every day of their career. When will medicine be about actual outcomes and individual competence, rather than a degree you received twenty years ago?  
      A rational person designing a system would not put professionals with the least amount of training in primary care, where a correct differential diagnosis is vital to not missing something seriously wrong, delaying diagnosis, or inappropriately referring and wasting resources. Where you have to balance the care plans of four different sub specialists AND explain their disease again since the subspecialist did such a crap job of it AND preventive care AND a address a new acute problem in a socially complicated patient as efficiently as possible. SOMEBODY needs to be individually or as a leader of a team looking at the whole picture rather than just one organ system. If I had a nickle for every time I was in a subspecialist setting in medical school, and heard “that is the primary care doctors problem”. Be careful wishing that primary care providers disappear or are entirely replaced by those with less training. Many of the patient care activities you consider yourself so above because it falls outside the five medications and three procedures you are comfortable with will suddenly become your responsibility again. How about a more rational proposal: Instead of replacing FPs or any PCPs with all midlevel providers- lets replace some of the extremely expensive subspecialists with exceptionally narrow scopes of practice? Does that not make more intuitive sense, given the more limited amount of information and procedural skills midlevels would need to master, and the potential for more money saved? Oh wait– this is already happening. I’ve seen it in Derm, obviously in Anesthesia (where many are not even NPs or PAs), neonatal pediatrics, etc. 

      • Lance McAdams

        Agreed. Agreed. Agreed.

        • Doug Capra

          Agree with the value of PA’s, but unfortunately, in our current culture of for profit health care in this country, it always comes down primarily to a money issue. The wealthy will always get the doctors, the uninsured and poor will always get the PA’s and the NP’s. That’s the way it will be set up in most cases. Follow the money.

  • http://makethislookawesome.blogspot.com/ PamC

    I think one of the big reasons 50% haven’t worked with a PA is simply cost. I know my dad would *love* to have an associate. But he’s in a small practice. The increase in clients he’s able to handle isn’t enough to cover the overhead of bringing on an another employee. The office staff is already expensive enough and it’s impossible to go without a secretary, etc. Once a practice gets to a certain size, then the cost ratios change. But until then… it’s not personal. It’s business. 

    • Anonymous

      We’ve had a PA off and on in this office over the last 3-4 years.  Not once have they “broken even.”  In other words, they end up costing us more than the income they bring in.  And the documentation we have to do to oversee the PA is ridiculous.  We still have one, but I’m going to put up a stink at our next provider meeting about the losses.

      • http://www.facebook.com/people/Patricia-Kelly/56303697 Patricia Kelly

        PAs bill at either 100% of the MD rate or 85% (Medicare).  If your practice hires a PA, typically they will collect at least twice their salary in primary care and more than that in a specialty practice.  Most PAs bill and collect as much as their (non-surgical) physician supervisors.   PAs have Medicare and NPI numbers, and DEA numbers in over 45 states.

         Many practices bill incorrectly.  Many physicians do not understand what they can delegate and how PAs practice.  A good consultant, which you can find through the AAPA, can optimize how you use and bill for your PAs.   And, most states do not require any real additional documentation.  Michigan, for example, eliminated co-signature requirements and lets any physician or group hire a PA if they are licensed……no additional paperwork, or at least no more than adding a physician if you include the insurance companies and Medicare.  

  • Anonymous

    I think if more PA’s had this kind of attitude, that would be a great solution.  A couple of points though.  

    As I understand it, a PA should not be offering services that the supervising physician does not (e.g., if you haven’t kept up on Pap smears and refer all of this to a gynecologist, you shouldn’t be hiring a PA to start doing them for you.)  While I certainly think all members of health care team can learn from each other, PA’s should not be doing what the doctor doesn’t do.  One piece of advise – if PA’s want more respect and more acceptance by physicians, please stop insulting our communication skills.  I see this as an argument over and over again.  I like to think I’m a pretty good communicator and patients will confirm this for me.  There are bad physician communicators, and for those individuals hiring someone with more finesse is a great idea.  But I have my “doctor speak” and my “regular people speak.”  Remember, we’re all in this together.  The more civil we can be towards each other, the better off we will all be.

    • Anonymous

      likewise i too am insulted by the frequent attacks on physician communication skills.  i work with several mid-levels in a nursing home, and i find that generally their skills (and efforts to talk to families) are far behind those of the supervising physician. Maybe some of this is due to lack of education etc., permitting them to stand behind the “superiority” of their everyday jargon.

    • http://pulse.yahoo.com/_ZSHLQKNVEBMCTGTA75AYHGZZRY Ed

      Communication.

      I now work in a sub sub-speiality.  We have several physicians with heavy accents who are often misunderstood by their patients.  I find myself re-explaining many things “in plain English” for them. 

      I know a lot of INternists and FPs who are great communicators.  They are able to recognize and speak with their patients on a level consistent with that patient’s ability to understand.

      I know several physicians who cannot.

      The same is true for many professions.

      But I gotta tell ya, “regular people speak” works and is appreciated by most patients. 

  • Anonymous

    “We are well trained, we have the clinical skills, we have the knowledge base, so let us be a part of the solution”Really?  
    4 years of Medical School; 2 of which includes 36 hour clinical work in hospitals with massive workloads; and 3 years of Residency (in the case of Internal Medicine) in which you eat, sleep, breathe, monumental exposure to real sick people, must be prepared to present Patient Cases in the morning after being up for 36 hours, must Supervise Residents below you as you move up the ladder, must admit 20 Patients overnight, etc., etc., as you leave your normal life behind???

    “Communication skills”
    Really?
    If I had the “benefit” of seeing 2 or 3 Patients an hour instead of 4-6, I could spend more time “Communicating” as well.  One of the biggest reasons I have left.  Wait until you PA’s have to see 4-6 Patients an hour and then we’ll see how well your communication “skills” are.

    Sorry, there is certainly a place for PA’s but not at the forefront of Primary Care.  However that is where this ignorant Country we live in is heading, why I have taken my Board-Certification in Internal Medicine and left Primary Care, and why in ten years the “Mortality Curve” and “Average Lifespan” of a citizen will begin to decline.

    By the way; I have already authored a book foretelling all of this.  

    • Anonymous

      I’m sorry to read logicaldoc that you have left medicine after all of your training in it.  I’m trying to be a part of the solution regarding healthcare in this nation of ours.  There are many problems with it and we all need to work together to find some solutions.  I believe by our working together (PAs and MDs) being team members we will be able to do more for healthcare than if we did alone.  I recognize your extensive medical training and applaud you for it.  That’s one of the reasons I believe that PAs need to work alonside a MD who has more extensive training than ourselves, and together we can see and take care of patients. 

      • http://pulse.yahoo.com/_ZSHLQKNVEBMCTGTA75AYHGZZRY Ed

        I have been a PA in both the military and civilian sector for 30+ years.

        My position before my current one was 10 years in a private suburban internal medicine practice.  I say 20+ patients a day, no triaging for “complexity”.  In flu season, I saw 30+/day.

        I took call every 4th night. and every 4th weekend.

        In my last year, I generated $379K in billings, collected $290K, was paid a salary of $56k, plus another $20K or so in benefits.

        I was meticulous in reviewing my charges each month.  Things I could bill for was ansd still is reimbursed at 85% the physician rate.

        Added benefit to the practice, when I started, all 3 MDs took turns taking vacations for the first time in 5 years.  There average patient load was slightly decreased, there call time definately was, and thier lifestyple improved.

        If any physician here has a PA who isn’t at least paying for themselves, I suggest reviewing the who, what, where, when and whys of your billing practices. 

        • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

          You were underpaid my friend.

          • http://pulse.yahoo.com/_ZSHLQKNVEBMCTGTA75AYHGZZRY Ed

            That’s why (surprise!) I left for a more lucrative position at the University hospital.  I loved my 10 years in the internal medicine practice.  The physicians were great, the patients thankful (for the most part), and the work professionally rewarding.  However, after 5 years of no raises and one $50.00 (yes, fifty dollar) bonus, it was time to go.

          • Anonymous

            Just realize that at the University hospital, with their ability to negociate contracts and collect facility fees, your collections are probably 3x what they were for the same amount of work.

      • Anonymous

        Thank you sbahrych for acknowledging my post and your empathetic words.  I completely agree with the approach you outline.  Physician Assistants certainly have a role but they are called “Assistants” because ideally they should be “assisting”.  Unfortunately, with reimbursement the way it is for Primary Care/Internal Medicine, and the path this Nation continues to take (all outlined in my book I referred to), Physician Assistants (and N.P.’s) in the real World have slid into the role of the M.D.  How many times as a Hospitalist (what I did after leaving Primary Care) covering urgent situations for other Patients have I entered the room (10 minutes after a P.A. or N.P. left) and was told by the Patient himself/herself:  “My DOCTOR was just here”?
        This same sort of thing also occurs in the Outpatient setting.  Most Patients are clueless that their “Provider” that they actually saw (never followed up by the M.D.) is not a Physician.  They will even continue to refer to them as “My Doctor”.        

        Respectfully; 

        logicaldoc

  • Anonymous

    An FNP adds more clinical capacity and competence … along with higher revenue potential for the primary care practice than does a PA. 

    • Anonymous

      windingmywatch: please show me the data that backs up your claim of a FNP adding more revenues, clinical capacity and competence to a PCP office if you are there instead of a PA, I’m totally unaware of it. 

      • http://pulse.yahoo.com/_ZSHLQKNVEBMCTGTA75AYHGZZRY Ed

        I too would like to see the data.  The MGMA has a plethora of this type of data.  As I recall, there was little difference in cost, billing and receivables, PA vs. NP in prmary care.
         
        Suggest seeing Ron Nelson’s presentation: http://hsagroup.net/UnderstandingtheValueofNon-PhysicianProviders.ppt

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      Have to second sbahrych.  I have seen no such data.  And in six years of practice I have found that the PA’s I work with generally (although not always) show more competence than the FNP’s.

  • Anonymous

    I’d have to agree with logicaldoc. Growing up a medical doctor or surgeon takes a lot, to say the very least. Unless one has actually gone through that process, one doesn’t know how challenging it is to go through. In addition, it is also very hard to let go of all the things one must give up when becomes a medical doctor. I have watched some very dear friends, students, and even my husband go through it. In my opinion, the very worst part of being a medical doctor is that the “buck stops with you”. This is called ultimate responsibility. That is the difference between medical doctors and their helpers, the nurse practitioners and the Physician Assistants (PA)’s. And speaking of nurse practitioners, I will never be quite comfortable being lumped together with PA’s. PA’s are great, but they are not nurse practitioners. Most nurse practitioners start school as nurses with Bachelor of Science in Nursing (or should) and years of clinical experience in at least some level of nursing. I also agree that medical doctors are currently overworked and underpaid, as we all are these days. Many physicians I know have excellent ideas about areas of research, but there simply just aren’t enough hours in the day. Working together with knowledgeable colleagues, such as nurse practitioners and PA’s, I am certain that more medical doctors will come to understand, utilize, and perhaps even teach their “mid-level” helpers.

  • http://www.facebook.com/rfdbbb Robert Bowman

    Physician assistants are indeed a workforce solution. The PAs that are most important for most Americans (160 million) in most need of care are the PAs that enter and remain in family practice. The AAPA data notes that family practice PAs are 30 times more likely to be found in a rural health clinic, are 6 – 7 times more likely to be found in a CHC, and are 2 – 4 times more likely to be found where workforce is needed as compared to other PAs not in family practice.

    But only 25% of PAs are found in family practice and only 20% of new PA graduates enter family practice.

    From 1998 – 2008 the PA annual gradutes doubled to 6500 but the number of new entrants to primary care increased only 30% – a number that will vanish as PAs steadily depart primary care in the years after graduation (as noted by Larsen and Hart). The 200% gain in new entrants was in non-primary care. PA primary care will remain the same over the years for the same reason that US primary care is in decline. Lower health spending involving primary care prevents primary care entry and retention. The impact is most important to understand in flexible PA, NP, and IM program graduates that can make 10% or more by departing primary care. Employers also benefit a number of ways by converting NP and PA primary care to non-primary care as in tens of thousands converted to teaching hospital duties due to resident work hours restrictions.

    Cuts in Medicaid, freezes in Medicare, and fast rising costs of delivering primary care also make it difficult to support primary care personnel – including PAs.

  • http://www.facebook.com/profile.php?id=762893788 Dave Miller

    I’m a 3rd year osteopathic medical student on rotations. One of my classmates and good friends is a highly-experienced PA who chose to go to medical school, which gives me a unique perspective into the profession. One of the first things that struck me as I started working alongside PAs is that, as a 3rd year, I’m on the level of a colleague with a new PA. Everyone likes to point to the 15, 25 and 30 year veteran PAs and say, “See, PAs can run primary care.” However, a new PA has the same training and experience as a 3rd year medical student. And I’m less than half-way through my training.

    Do PAs have a role in primary care? You betcha! An important role. They do indeed “come alongside” the docs, who have ultimate responsibility for the patients, and help shoulder the load. Are they capable of running the show by themselves? In some cases but that is not what they are trained to do.

    Many folks want the prestige and respect (and pay?) of the doctor role but few are willing to go through the ardure required to achieve that level of training. It is no disrespect to PAs to suggest that they aren’t doctors and, for the most part, shouldn’t be functioning as doctors. If they wanted to be doctors, they should have done like my classmate and went to medical school. They should be proud of the role for which they have trained and work hard in it. It is indeed an honorable charge and worthy of respect in its own right.

  • Anonymous

    I agree many Patients present with the “usual stuff”.  But will a case of Lupus, or Wegener’s Granulomatosis, or Goodpasture’s Syndrome. or “Referred” pain from something hidden, or Pulmonary Fibrosis, or etc., etc. be caught (or even entertained in the Differential) the first time around by Mid-Level Providers?  Or will it be seen and “passed on” as one of the “usual stuff”? 

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    PA’s leave primary care for the same reason physicians leave primary care. Give PA’s unrestricted practice rights…….set aside any safety or competence issues. Real simple. In a heartbeat, they will want payment parity, eliminating any cost savings. Then they will see the raise in pay and improved lifestyle to become a specialty PA.

    Then there will be two classes of healthcare providers walking away from primary care.

  • http://twitter.com/RebeccaCoelius Rebecca Coelius

    Question to PAs out there: A few PAs I know socially have argued that MDs should in fact be much more supportive of PAs in practice than DNPs, because your training though less long or in depth than an MDs is otherwise similar to ours with a strong basic science background and focus on complex differential diagnosis. I have also heard from older MDs in practice that they prefer working with and training PAs for this reason. Do others have more information that is not all circumstantial? 

    • Anonymous

      Rebecca, thanks for your comments below (your lengthy post).  In regards to your question above re: MDs needing to be more supportive of PAs than DNPs, I believe your PA colleagues have a very good point.  If you look at the AMA 10/09 consensus report on NPs and their training programs (to acquire a MSN) NP programs have minimal requirements for clinical experience (500-750 typically), some lack pharmacology classes or have only 3-5 semester hours in it, and they continue to be trained in the nursing model.  A DNP program on top of this just adds research hours, some clinical hours and nursing theory. 
      Compare this to a PA who is trained in the medical model, has 2000-2500 hours of clinical experience during their PA schooling, acquires 10 semester hours in pharmacology, and has a strong background in A& P, pathophysiology, biochemistry, clinical medicine, etc.  We generally have to come into our program having taken microbiology and organic chemistry. 
      Then when you look at a MD training they have a strong background in A & P, pathology, pathophysiology, clinical medicine, microbiology, histology, biochemistry, etc.  You then acquire about 3500 clinical hours during yrs 3 and 4.  Then when you’ve finished your residency (3 yrs) you’ve acquired another 6500 hours of clinical training, for a total of about 10,000 hours. 
      So yes, PAs are trained in the medical model and have the strong science background needed. 
      To give a personal perspective, I used to work in the retail health clinic environment.  My market manager (over 36 clinicians) told me that she preferred hiring PAs due to our medical model training, we were much more suited to seeing patients than a NP was.  She said she had more problems with the NPs in the market who couldn’t come up with differential dx on patients.  And this market manager was a PhD trained FNP herself. 
      In being a PA I’m trying to open a dialogue between MDs and PAs re: the future of our nation’s healthcare.  We all have our place at the table, but until we find out what the issues are (for PAs and for MDs) we will never be able to find workable solutions. 

      • http://pulse.yahoo.com/_ZSHLQKNVEBMCTGTA75AYHGZZRY Ed

        Remember too, the original PA education model was patterned after the fast-track physician training program in WW2.  It has undergone several refinements over the past 40 years to meet the demands of a short-course medical education.

      • Kimberly Spering

        All due respect, Sharon…

        I agree with your commentary about PA education.

        However, the average NP going back for education has at least 10 years of nursing PRACTICE under his/her belt prior to graduate school.  So…four years of undergraduate school, plus 10 years of work experience while getting a Masters (or now, DNP degree in some cases).

        Apples vs. oranges in the background education.

        However…if you fast-forward to comparing an NP vs. PA after each is out of school for 2 – 3 yeras, I’d daresay we’re all on even turf when it comes to experience with treating patients.  (smile)

        Kim Spering, CRNP

        • Anonymous

          Kim, I don’t agree with you.  RNs going into their MSN NP program can have as few as two yrs of being an RN to be admitted to the MSN programs.  They certainly don’t have to have 10 yrs.  In addition, using your argument about being a RN counts as part of your NP training, is moot.  Being a RN is totally different than being a medical provider.  When you are a RN you are looking for the nursing assessments and plans, when you are a MD you are looking for the medical assessment and plans.  You’re trained to treat 2 different arenas, one nursing, one medical. 
          If I were to use your argument that my prior health care experience counted towards my PA training, and therefore I didn’t need to be in my school program for 2.5 years after my BS degree, I would have been thrown out of my program. 
          The only thing that the usual 2 yrs prior health care experience does (whether as a RN or for a PA as a surg tech, or LPN or whatever) is it gives the student exposure to the health care field and real knowledge as to whether they wish to complete their NP or PA programs.  Nothing else.
          These days PAs leave their programs with a master’s degree as does the NP, so as far as degrees go, we are on even ground. 
          Thanks for letting me clarify this, Kim.   

          • http://ems12lead.com/ Tom Bouthillet

            That’s just a ridiculous comment. Nurses are medical providers. In fact they are the largest group of medical providers and the most trusted by patients. No one owns the so-called “medical model” and my significant other was taught how to formulate a differential diagnosis both as a CCNS and ACNP. She also has many years of emergency and critical care experience as an RN. To suggest that counts for nothing is an insult. I taught a group of PA students ACLS and none of them had much clinical experience and it showed. I’m sure there are many talented PAs in the world but to be dismissive of NPs makes you look foolish.

  • http://warmsocks.wordpress.com/ WarmSocks

    With all due respect, while communication is important, I believe getting the right diagnosis is more important.  Having a PA communicate clearly about diagnosis A and its treatment plan is useless when the PA was wrong and the patient really has diagnosis B.  This happened to me.  I was referred to an MD who shuffled all new patients off to his PA instead of seeing them himself. The PA settled almost immediately on a diagnosis, and thereafter discounted symptoms that didn’t support his theory.  He did not do the appropriate physical exam and did not order appropriate testing, so I suffered needlessly until I finally took myself back to my family physician who had no trouble diagnosing and treating the real problem.

    Not all doctors are poor communicators. My doctor explains things very well. If I ask, “What are the ramifications of that?” he is crystal clear in answering my question.

    If I could make one more comment regarding your post, I don’t understand how having a PA tag along with an MD, both seeing the same patient at the same time, is cost effective.  If one believes that a PA can diagnose and treat patients well, the person’s skills are wasted shadowing the doctor instead of seeing his/her own set of patients.  Or perhaps I misunderstood your description of the doctor who said he wanted you there to interpret for him?

  • Anonymous

    I am in south Africa  and this approach is being contemplated for the sopport of Physicians in the primary health care sector.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      I spent a little time in Malawi as a doctor, back when Banda was still
      in power. We trained….I forget the name, I think it was “clinical
      officer” or some term like that. They were sort of like our physician
      assistants. Most went to the wards or clinics. Some were “subspecialized” if you want to call it that.
      Some went into orthopaedics and just learned to set fractures. Some did
      anaesthesia. Some did obstetrics. They learned the very basics of how to
      do the job…….obstetrics, you should feel a head, if you feel a
      buttock or a limb, call for help, that sort of thing. This is how you set a fracture,
      this is how you set it, how you apply a cast, if you see bone sticking
      out the skin, call for help.

      The training program had to get trainees from each village or tribe, the
      tribalism could be…..well, you know. I found it interesting, some
      tribes the trainees seemed to barely understand English. Other tribes,
      the trainees, with a high school education, they soaked up everything in
      the books we donated, they sounded like a University registrar.
      That way, the village might have one doctor, but a lot of people who might be the equivalent of our physician assistants.
      Then again, Malawi is a dirt-poor country. A beautiful land, I hope they survived the transition from Banda.

  • Anonymous

    My PCP has been doing primary care for 30 years. He tells me that in all his years as a PCP, he will admit that 85 percent of what he does on a regular basis is routine medical care that a trained nurse practitioner (NP) or a trained physicians assistant (PA) could easily do. He says that the other 15 percent of the more serious cases get referred to specialists. Other than check my BP and listen to my heart and lungs, the only other tests my PCP does is routine blood work and I’m even referred out to a lab to get that done. It’s time we stopped the insanity and started to realize that you don’t need a doctor for a flu shot or to remove a splinter. Imagine if 85 percent of primary care was done routinely by NPs and PAs. Imagine the cost savings and imagine the number of jobs that would be created for the middle-class. Also, if seniors were given the choice to see an NP or a PA, we wouldn’t be constantly hearing doctors crying about how little Medicare pays for senior citizens. Seniors need to be encouraged to experience lower costs by having the “choice” to opt to receive their care at a neighborhood clinic instead of at the expensive doctor’s office. If there’s anything the makes me angry, it’s a whining doctor threatening to not accept Medicare patients just because they don’t get paid enough. I say, take all that Medicare work away from them! Prima donnas!

  • Lance McAdams

    I speak English very well, and I speak English to my patients, in non-scientific terms. And because of my much more extensive training, I tell them the correct medical diagnosis more often than not (and much more often than the PA with whom I work) and I explain the treatment for that condition better because I understand better what is going on. All in English. That’s a really poor argument in favor of PAs working in primary care – “we speak English.” I can’t tell you how many times I’ve seen people with some medical knowledge explain things horribly wrong because they try to use big scientific words that they know how to say, but don’t really know what they mean.

    As I said, I work with a PA – share an office with him. We’re in the Air Force where PAs are allowed to practice full spectrum care without direct supervision. He’s a nice guy, so this is nothing personal. But, he messes up a lot: way overprescribes antibiotics (although admittedly that’s not a problem unique to PAs), orders CT scans for everything, refers everything on to specialists when that doesn’t need to happen. In the grand scheme of it, the system as a whole probably doesn’t save all that much money after you factor in the excess tests, referrals, prescriptions, and medical errors. (And yes, I know physicians over-order those to some degree, too)

    I think back to my first year in residency – after a year in a family medicine program – and at the end of that first year, I would not have felt comfortable allowing my then-self to diagnose and treat members of my own family for anything more serious than a common cold and maybe a nonacute UTI. As mentioned in other posts, a new PA is maybe the equivalent of a MS3 or MS4, which is kind of scary. Sure, experience really matters, so a PA who’s been out for 15 years might be pretty good, but until then …

    One comment mentioned elderly patients being seen by an NP or PA, and that’s where things get scary because of the complexity of many of them: DM2, HTN, HLP, to screen or not to screen for cancer, etc. My parents are in their 60s, and while my mother does not take any medications or have any serious medical issues, my father has had an MI with stent placement, though is otherwise still very active and in good shape. Nevertheless, there’s no way I’d feel comfortable letting him see a PA or NP. Sorry. That’s just how it is.

    I think if you asked most doctors the same - Would you let your family members, particularly the older ones with chronic illnesses, be managed by an NP or PA? – the vast majority would not feel very comfortable with that. And that’s not being a prima donna; that’s being a buon figlio (good son).

  • Anonymous

    Doc Fix? I have a doc fix for you…

    Medicare should sit down with the WalMart types all across America and see if these big box stores will accept the current payment structure and try to set up a big box primary care system. I say, to hell with private practice prima donnas that want to milk the system dry. 

  • Anonymous

    I find interesting that responses that are dismissive of a PA’s potential contribution to our health care crisis generally focus on what training and experience a PA has less of than an MD or what a PA does less well than an MD or DO. Where is the bigger picture perspective in these responses? The bigger picture of the tremendous unmet need for providers of all levels, especially among low income and uninsured populations. The bigger picture of the coming tsunami of chronic conditions, largely stemming from poor diet and lifestyle options, that will increasingly overwhelm whatever health care system we have in the coming years and decades. In times of crisis a healthy response is for folks of all skill and experience levels to come together and maximize effectiveness and impact by working as a team. What is it about the organizational culture in medicine that tends to hinder movement towards greater interdependence among health professionals working, ostensibly, for the common greater good?  

  • http://www.facebook.com/lshandikin Liek Sari Handikin

    Whatever we name the person,we need them as the extended arms of a physician position function.
    In our country (Indonesia) the person maybe dukun,(dukun beranak,dukun bayi,dukun patah tulang),pemijat,pengobat tradisional(batra)etc. or a long history of barefoot doctors,shinshe in China.
    Their existence do not eliminate physician position in the primary care setting.
    On the contrary there is positive cooperative teamwork between these persons to serve and educate people in health matters because health is a personal and community (in large ) responsiblity.President Obama understand it very well  while he spent part of his forming years  in Indonesia ,where tradition and cultural heritage had a long story and had been implemented in the health delivery system of this (island) country.

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