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| A Look at our Profession, Past, Present, and Future? |
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by Edward A. Ranzenbach, PA-C, MPAS, FAPACVS, DFAAPA - February 21, 2011
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 Provided by Clinician 1
Last night I was flying from Denver the San Diego. I was on my way to the APACVS/STS meeting and was carrying my STS briefcase. For those unfamiliar, this is a nice leather bag embroidered with the Society of Thoracic Surgeons logo. As an associate member of the STS, I am proud to display my affiliation with the prestigious organization. The flight attendant, upon seeing the bag, asked “Are you a doctor”. My answer was the same as it always is when asked. “No, but I am a surgical PA”. I was pleased when she said “Well that’s as good as a doctor. My PA seems to clean up after the doctor.” I took my seat and the flight got underway.
This exchange got me to thinking. How would I (or others) have answered if I possessed a clinical doctorate? Before you answer, think about the question being asked and the context under which it was being asked. The question was “Are you a doctor?” (i.e. a physician). The answer, of course, is “no”. The word “doctor” has been synonymous with physicians for centuries. Her assumption, seeing the STS logo, was that I was a physician and I (as I am required to do by California law) was honest and forthright in my response. Moreover, if an in-flight emergency occurred, I would have misrepresented myself as a physician. Not that I couldn’t handle (and have) the in-flight emergency but imagine the ramifications to the profession if such misrepresentation had been discovered and acted upon in a public forum. You can never predict how these things play out.
There are many questions swirling around in the blogiverse. Should we revert back to the Physician “Associate” title? Should we follow our NP colleagues down the clinical doctorate road? Do we need residencies to be effective and competent providers? Should there be a bridge program that recognizes the educational commitment we have already made in pursuit of a full-fledged MD degree. And, should we be seeking independent practice? Each of these questions in and of itself can become a wedge between us and our physician supervisors (yes, as of this writing we are a supervised provider). Put them together and they have the potential to become a black hole that could drain every last resource of our profession and leave us as just a blip in the brief history of time. They also have the potential to mold our profession into something much more than it is now. We would be a true alternative to our patients and our profession would come of age. But, can these things be reasonably accomplished? Will they be accepted by our patients, our certifying bodies and our colleagues? And perhaps the biggest question, would we still be PAs?
What Does it Take to be a Physician?
There was a time when physicians were not required an undergraduate degree in a medically related field to enter medical school. When medical school was only two years, not four, and when there were no residencies. There was a time when specialty practice did not require any additional training after medical school. A doctor, was a doctor, was a doctor… This was the 1800’s. In 1893 Johns Hopkins Medical School (JHMS) was founded and quickly became the de-facto standard for medical education. They accepted only those with an undergraduate degree. At a time when becoming a doctor was considered entering a trade school, JHMS expanded the curriculum from two to four years, requiring bedside learning and establishing the “MD” as a post-graduate degree. Moreover, they were the first to recognize that graduating from medical school was only the start of life-long learning process for physicians and that additional, formal residencies were necessary to train physicians in specialties. Urology, endocrinology, general surgery, neurosurgery, these specialties and many more were all created at JHMS.
A New Hope
Fast-forward about seventy years to Duke University and Dr. Eugene Stead. Dr. Stead saw a way to address a shortage of primary care providers while preserving the talents of highly trained and experienced combat medics. He reasoned that these medics, who would otherwise return from Viet Nam only to lose their skills in the civilian world with no equivalent practitioner position, could, with two years of additional training, function as primary care providers under supervision of a physician. Thus was born the PA profession as dependent practitioners whose foundational medical training and experience was augmented allowing them to fulfill many of the responsibilities of physicians with little direct supervision and without attending full medical school. Initially, we were called “Physician Associates”, until the AMA used the leverage of recognition of our talents to bargain our “Assistant” title.
Perhaps when trying to debate these questions before us it is prudent to look at our foundations. Certainly, the desire to be titled “Associate” is reasonable. In fact many of us graduated from “Associate” programs. Indeed, the program designed by Eugene Stead was a “Physician Associate” program, and kept that name after the AMA demoted us to assistants. But, are the other questions before us reasonable? Should we really expect to be recognized and respected by our physician colleagues as their peers given that our training is about the same length and overall structure than that provided to physicians in the 1800’s? Let’s be honest, our parent organization prides itself on the notion of lateral mobility… a PA, is a PA, is a PA.
Now, before you take issue, consider this. When Eugene Stead, MD defined our profession he took highly trained and experienced combat medics and trained them for two years before considering them competent to function as dependent practitioners. He did not consider his training program an alternative to medical school as he planned that his new protégées’ be supervised by a physician. Moreover, we need to examine how things have changed over the course of the PA profession.
Are PAs Today the Same as PAs of Yesterday?
Originally, the educational goal of the PA profession was competency, it still is. Many early PA programs did not offer degrees but simply provided proof of course completion, which allowed you to sit for the board. In the late 1990’s this started to change as NPs touted their Master’s degrees and PAs felt the need to keep up to remain marketable. Here we are at the same crossroads again. Our NP colleagues are now extolling the virtues of clinical doctorates, and we feel the necessity to establish parody. To answer these challenges, we have changed the design of PA schools and most schools now offer a Master’s degree at graduation. But with these changes have come changes in the types of students entering PA school. A quick check of the ARC-PA web site shows that as many PA programs opened in the five years from 1995 through 2000 than in the 25+ years prior to 1995. Indeed, two-thirds of the PA schools in operation today have less than 15 years in operation. Moreover, although the average age of new PAs has remained relatively constant since 1995, the average number of months of pre-PA clinical experience has dropped dramatically in the last 15 years. These statistics are graphed below.
Figure 1. Accredited PA Programs
Source: ARC-PA
Figure 2. Age versus Experience in Months
Source: NCCPA
One cannot deny the importance of clinical experience in the selection of students to PA school. This was a foundational principle of Dr. Stead’s design of our profession. Yet in fifteen years we have reduced the average amount of pre-PA clinical experience form more than five years to two years while at the same time producing three times the PAs annually than we used to. The collective clinical experience of our profession is being significantly diluted.
Of course Dr. Stead himself believed that major changes are possible in medical education. Today’s undergraduate education is far removed from that of the 1800’s when medical school was expanded from two to four years. Dr. Stead stated that in today’s modern educational environment the four year paradigm of medical school was unnecessary. In an October, 2002 speech he gave, on his 93rd birthday, he proposed that much of the first two years of medical school could be accomplished as an undergraduate. He predicted that the future will include on-line medical schools, and considered the rest of medical school to be an “apprenticeship”. That being said by one of the premier medical educators of the 20th century, doctors don’t just start practicing medicine independently the day they graduate from school. They go through years of mentored practice in the form of residencies. Should we not do the same?
Independent Practice?
I have been a PA for almost 15 years and the vast majority of that is a cardiothoracic surgery practice. I am embarking on the NCCPA’s new “Certificate of Additional Qualification (CAQ)” to further demonstrate my competence. Would you send you mother, your spouse, your child to me to operate on, independent of a board certified cardiothoracic surgeon? I wouldn’t. Would I take my child to see a PA or NP in well-established, independent, primary care practice for an otitis media? Absolutely. The difference? I was, like most of us are, trained as a primary care PA. One could argue that there are a handful of programs that have a surgical track for the clinical year. But the bottom line is that I am not, and will never be, a board-certified cardiothoracic surgeon capable of doing an off-pump CABG, followed by a valve-sparing aortic root replacement, and then a Blalock-Taussig shunt, all in the same day. Indeed, the only way for the average PA, graduating from a primary care program, to become competent to first assist at these very complex and demanding procedures is to build your skills over years of practice. A residency in cardiothoracic surgery would provide the foundations and a fair amount of experience that would bring this individual to a competent practice level quickly. But what happens once I become efficient, and my supervising surgeon trusts me to perform procedures normally performed only by seasoned surgeons? PAs open the chest, harvest the IMA, radial artery, veins, place the cannulas for bypass, decannulate the patient and close the chest. But, some states still require that these procedures be done under personal supervision. When will we be trusted as professionals who, like physicians, know when something is outside our comfort zone and ask for a consult?
Although I have used my own specialty here as an example, I find it difficult to believe that there are not other specialties that are just as demanding, just as vertical. We are kidding ourselves and doing a great dis-service to our patients and our profession if we promote that the average PA graduate is capable of practicing independently without additional training and examination. I also doubt that new NP graduates are any more qualified for independent practice than PAs. But at some point in their careers, and in some specialties (yes, primary care is a specialty), they are capable of functioning independently and we should identify those benchmarks that must be met for independent practice in a team-based approach to health care. I have no problem with the physician acting as team-lead recognizing that it is the patient’s right to select the provider that they feel the most competent as their primary contact in the health care system.
Of course, the way to avoid all of these issues is to become an MD. Although the bridge programs being considered address the overwhelming need for primary care providers, one can envision (probably not within my remaining career) medical schools jumping on board and admitting PA or NP students that do not desire to remain in primary care. I believe that until of top-tier medical schools institute these programs though, physicians will continue to look down their noses at even these newly minted MDs.
In Summary
So, back to our questions floating in the ether. Reclaim our title as “Physician Associates”? Absolutely! This is worth the political capital and should not result in public confusion. It may take decades to make this legal across the nation however as some states have regulations requiring the use of the “Assistant” title. My state requires it appear on my name badge. It doesn’t cost a thing however to use “Associate” in discussions, at meetings, within organizations, etc.
Obtain a clinical doctorate? If you’ve got the money and time, it couldn’t hurt. That being said, do not misrepresent yourself (or the profession) as a physician either actively or passively. Want to be an MD, bridge programs would seem a reasonable approach. In the interim, wear the PA name proudly.
I lump independent practice and post graduate residency together, because I honestly believe that the clinical quality of our students has significantly declined in the past 15 years. During this same period, the roles and responsibilities that have been delegated our profession have become increasingly more technically demanding. Our physician colleagues dealt with this issue 150 years ago. They recognized that to be a doctor was more about mentored practice than about graduating from school. I view myself as the eternal resident. My supervising surgeon admits that I function at a PGY4 level. In a surgical specialty, I will always be the eternal resident. In family practice, perhaps several years of mentored practice should allow one to sit for the same family practice board that physicians take. Pass the board, hang out your shingle. Given this option to prove I am as good as my physician colleagues, and knowing the prize is peer recognition as an independent practitioner, I’d study my ass off. Wouldn’t you?
Edward A. Ranzenbach, PA-C, MPAS, FAPACVS, DFAAPA
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| Burned out PA (SC) |
on 26 Mar 2011 at 11:37 pm |
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| Let me study for and earn the Clinical Doctorate. Then let me sit for the Medical Boards. When I pass all of them, call me Doctor. I will have proven that I deserved the title. |
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| TP PA-C/SA,CUPA, MPAS (Texas) |
on 08 Mar 2011 at 3:36 pm |
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| Amen. As a surgical PA for over 30 years, being on faculty at a major PA program for 4 years, authoring or co-authoring over 50 peer reviewed publications, obtaining 3 board certifications to show that at least minimum standards for those specilities had been met, I can agree with all premises offered in your presentation. Enough chest beating here. The cirriculum used at the inception of the PA profession was molded after the 2 year curriculum used to bestow an MD degree during W W II. All our classes in the late 70's and early 80's were at the graduate level with the medical students. We took the same tests and rotations but given a BS degree. This is all academic as our MD mentors look at our individual abilities and motivations in order to determine how much responsibility and independence will be offered in their practice. I've found that performing within the medical model of training, which is the main differerence between the PA and NP professions, and excelling within that genre we've been invited into offers the greatest chance of earning respect rather than what letters are pasted at the end of your name or how many "political numbers" our association has. Competence is what our patients and partner MD's demand. Higher education is certainly not going to hinder that process. |
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| Rick Evans (hfhs / mi ) |
on 26 Feb 2011 at 12:19 pm |
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| great article , agree all said , I am a grass roots Pa from AB college , Bachelors 35 yrs experience . I too would study my ass off for my independance . Should AAPA be working on this yesterday . |
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