"When in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation."
Thomas Jefferson

“Dependence” is an interesting concept.  While it is widely accepted that “no man is an island”, there are few examples of laws which bind one person in dependence to another.  However, one example does exist—physician assistants are forever dependent to one or more physicians.

In the 1960’s when the concept of non-physician medical providers developed there were a lot of concerns about how someone not trained as a physician could do the things that physicians did.  There was no history, no record of performance, no data to support such an idea.  Necessarily concessions had to be made.

We still live with these concessions.  I am about to take the recertification examination for the 6th time.  I can only practice medicine in the office of my supervising physician.

A lot has changed since the 60’s.

I typed the above sentence yesterday, July 4th, at 9:15AM.  Now, a day later, I return.

At 9:15AM yesterday my house was rocked by a loud boom.  I thought it was a sonic boom, but the sound and shaking continued for several seconds.  I thought a branch had fallen from a tree and rolled down the incline of my roof.  But I knew.  Somehow you know these things.  I called to my wife in the other room.  She knew, too.  We both said, “The fireworks….”

Like everyone else in the village we went outside and looked toward the harbor where smoke and flame shot into the air.  Like everyone else in the village we walked towards the smoke, knowing, not yet believing, what had happened.

Things like this always happen someplace else.  They are sad stories carried at the front of the news for a day or two.  They always involve another place, other people.  This day they were here, right in front of us, possibly, probably involving people we knew, friends.

We rode our bikes to an area across the harbor, knowing that the fireworks for the evenings 22 minute pyrotechnics show had exploded on the ground in 4 or 5 seconds.  We saw flames in the brush around the harbor and listened to the many sirens just a few hundred yards away.

I went to the health center where I had worked when I was the only PA on this remote island.  I was prepared to help in what was sure to be a mass casualty situation.  Many other medical personnel showed up.  Physicians and nurses here on holiday and vacation came to provide what help they could.  Some went to the scene where the physician and NP who now staff the clinic had all ready reported.  The island paramedics rolled all the ambulances and went to the scene.  The volunteer fire department, the National Park Service, the local police, and officers of the Marine Fisheries were all on scene.

Two physicians, the health center nurse, and I got out supplies and prepared to receive casualties.

Fortunately there were only 5 casualties.  Unfortunately their injuries were serious enough for helicopter evacuation from the scene.  No casualties came to the health center.

We put our supplies away, turned off the machines we had warmed up and checked and I went home.

Eventually the details of the story unfolded.  Five members of the crew employed by the fireworks company were involved in a blast that involved the 18 wheeler filled with fireworks.  One died on the scene, 4 were transported by helicopter—2 to the regional burn center and 2 to the level one trauma hospital, both on the mainland.

This morning we got the news that 2 more victims died, one at each hospital.

I am a physician assistant, a dependent practitioner.  My license to work is tied to the physician and the office where I work off-island.  I have no legal authority to work here on the island where I live.  I was prepared to violate the letter of the law to help in the tragedy yesterday.  This is my community and these are my people but my status as a dependent practitioner ties me to the urgent care 75 miles away where I still work.

Where was I?  “A lot has changed since the 60’s.”

In the 60’s most medicine was practiced from single physician offices.  Physicians delivered their pregnant patients, admitted and cared for their own patients.  Some still did their own appendectomies.  When one of their patients showed up in the emergency room, the physician left the office and went to the ER to provide care.  The idea of an interdependent system of specialists and sub-specialists and the technology we now take for granted was years away.

Considering the mindset of the 60’s it is easy to understand why a provider who did not attend medical school was a frightening idea.  How could someone who had not gone to medical school do all the things that doctors did?

The decision was made to try this “physician’s assistant concept” with certain stipulations.  The first was that the PA would be tied to the physician—dependent—and would only perform those tasks that the physician delegated.  These PAs would not run off and practice medicine alone.

Oh yes and to assure competence they would take a standardized entry level exam.  If that’s not enough, we’ll take another exam every six years to assure continued competency.

It is not the 60’s anymore.  No one practices alone.  Surgeons refer rashes to dermatologists.  Internists refer diabetics to endocrinologists.  Family practice refers to everyone, and they all refer back to the primary-medical-doctor.  No one group or specialty is independent.  The US health care system has evolved into a complex network of interdependence.

So who sees the patient when I refer?  Most of the time, the first contact in the specialist’s office is a PA or NP.

The system has evolved.  My profession has not.  After 31 years of experience and countless thousands of patient contacts, I am still defined by the concessions made in the 60’s to birth my profession.

Today I am defined by a vocabulary that is outdated.  PAs are “dependent”.  NPs “collaborate”.  But in today’s system who does not collaborate?  Who is not dependent?

All medical providers are trusted with a huge body of evolving knowledge.  Maybe it was possible in the 60’s for one doctor to provide all the care that his/her patient’s needed, but it is simply impossible today.  Each medical provider must know his or her limits and competencies and stay current with new developments.

So my questions are these:
How many years of clinical experience does it take to know one’s area of work?
How long will my profession be defined by words and concepts that by now are quaint pieces of history?
When will the concept of “independent” practice give way to the reality that we all collaborate, we are all interdependent?

When will my associations realize this is something they have to tackle for us to become full professionals?

And when can I respond to an emergency and provide my hard earned expertise and high quality treatment in a crisis when I am not in contact with my supervising physician’s practice?