Define primary care. Over at Are You A Doctor, the increasing need for PAs to provide care in rural America with indirect (code word for no) supervision is addressed. A noble undertaking for the PA field. But then the question is posed:
Should PA programs have mandatory residencies if PAs practice outside of primary care?
The question you ask is deeply flawed. The basis of your question assumes that PA school can train PAs to provide primary care services with indirect (code word for no) physician over site. When you conclude that PAs should be required to complete a residency for all practice styles except primary care, you make the assumption, in my mind, that somehow PA school can train one adequately to provide the entire scope of primary care services with minimal oversite.
I hear specialists say all the time how much easier their roles in care are than primary care. As a subspecialist, it's often far easier to answer the question being asked than it is to figure out what the question even is. Often I admit patients in which the question isn't even defined. That's internal medicine for you.
I'm here to tell you that your logic of primary care being easier is all backwards. This assumption has been perpetuated by government, insurance and patients by a lack of understanding of what the scope of primary care actually is. The practice of primary care is far more complicated than a focused specialty such as cardiology or gastroenterology. The scope and breadth of information required to practice competent primary care without reliance on subspecialists for basic problems of internal medicine is far more complicated to master than you give credit to. Every medical subspecialist has finished a residency in internal medicine. Ask any of them and most would agree that the practice of general internal medicine is far more complicated than their focused specialty.
I can tell you categorically, without a doubt that it would be impossible for any scientifically honest extender, whether it is a PA or a NP, to wake up in the morning, look themselves in the face and tell themselves that they are competent to practice in the same scope of primary care as a board certified, residency trained, internal medicine physician, with indirect (code word no) over site.
I can assure you that a graduate of PA school (or even a NP residency) would be incapable of evaluating and managing patients in a scope of practice which meets the expectations of an independent physician provider of internal medicine. Why? Because they aren't trained to do so. You don't just wake up one day and practice internal medicine. No matter how hard you bang the gavel about experience as an EMT or a PA or 40 years of nursing experience. Experience in other fields does not equate to experience as a minimally supervised provider of internal medicine. I could never claim to be competent as an ICU nurse simply because I worked as a hospitalist for 15 years with ICU experience. The training I received as a physician trained me to be a physician, not an ICU nurse.
And my education allowed me to practice from day one with no over site. Are you a doctor, I'm concerned that you believe PAs, who you stated are more frequently trained with little to no prior experience in anything, could magically finish their 2 1/2 years of training and get shipped out to rural America to practice with indirect supervision (code word no supervision). I am concerned that you don't get it.
I can only assume that you feel a body is better than no body in rural America. Which is fine, as long as we accept access as your driving force in determining policy, not competency. That's not to say that those providers who have not received the training that physicians have are incompetent. But they are less competent in matters of patient care. Can you measure competency? Of course. My competency is certified by my status as board certified in my field of expertise. Based on a physician level standard of care.
One has to assume that indirect care of patients in rural America by PAs with no residency training (or even an NP with with the current NP residency standards) must be easier than I am lead to believe. My definition of primary care must be far different than yours.
It appears you make an assumption, by excluding residencies for primary care tracks, that you believe primary care to be a field in which PA school would adequately train one to practice with indirect supervision (code word no).
So I have to ask the question: What exactly do you think primary care is? If it is capable of being practiced with indirect (code word no) supervision, without any type of physician level residency, without the medical school experience, I can only assume that your definition of primary care is vastly different from mine. In which case this whole argument is moot. What I do is provide primary care in the hospitalist setting. I take care of everything. This PA explains my position well (in the comments section).
- After pa school, i was able to work as a mid level hospitalist and soon realized how much i had to learn-and that's an understatement. I believe every pa graduate should have a mandatory internal medicine 1.5-2 years training after pa school (and i mean in an inpatient hospital setting), where a pa learns how to manage a patient in the ER for admission, round on the different floors-medicine, surgery, cardiac step down, telemetry, and yes..you know it-ICU!!!-i mean c'mon; what if the icu nurse calls you at 2am and tells you that the obese pt with s/p lap chole-and a hx of copd, htn, dm, cvd, previous mi, and possible chf now has a blood pressure of 70/40! I also now work in a family practice and urgent care setting, and believe you me, i have met pas with 10-12 yrs experience who are freaking clueless on a lot of significant clinical presentations. I believe our profession need to wake up to the reality that a new pa graduate is a walking time bomb!
The only thing I would add is that 1 1/2 - 2 years is not enough. Not even close. Not without the medical school experience, if you want to practice with indirect (code word no) medical supervision.
The real question you should be asking is not whether or not PAs should be doing residencies on non primary care tracks, but rather the question should be exactly what is your definition of primary care. I think that is the real question that should be asked. So what is your definition? And America, how do you define primary care?
By the way, I heard a surgical PA once explain to a nursing student what they do:
"They've trained me well. I operate. I do everything that the surgeon does. I'm like a second surgeon. Almost, but not quite."
Huh. Addendum: I just found Dr Centor over at DB's Medical Rants discussing the same thing.
One point I would make Happy is that most non-procedural medical subspecialties such as Endocine, Rheum, Hem/Onc, to do their jobs well need to keep a very good handle on their general medicine knowledge. Why? Because of the overlap of general medicine with being a good, comprehensive consultant in their chosen field. I wish I could say the same about cards and GI but in many cases it's about doing procedures not actually thinking about complex patients. I find it EXTREMELY frustrating to get a consult back from a cards or GI PA/NP who after reading the consult clearly doesn't even have the knowledge base that I do in their "subspecialty" practice. I will and have immediately stopped sending further consults to those docs. I have no interest in wasting my patient's time or money with such stupidity.
ReplyDeleteInteresting take Happy. I actually support primary care residencies, however, the same general trend that has been noticed within the physician community regarding providers entering primary care, has also been noticed within the physician assistant community. We have the largest generation in the history of our country ready to retire, and we are already facing massive primary care shortages. Therefore, I think that with proper supervision, PA's should be able to enter primary care without residency. Requiring residencies for other specialties would accomplish two separate, but important goals:
ReplyDelete1. It would encourage more graduates to enter primary care, by requiring residencies for other specialties, and it would raise the level of care of specialty PA's.
2. It would set a precedent for the future development of primary care, maybe even hospitalist, residencies for PA's. Who knows Happy, perhaps you could create one?
I have never suggested, unlike my NP (with their DNP title) brethren that midlevel providers can provide the same exact care as a board certified physician. Not once. I have many of the same concerns as you regarding PA's practicing with little oversight immediately after graduation. However, your kind (physicians) are avoiding primary care like the plaque. Recent surveys have suggested that only 2% of current medical students plan on entering primary care. Who's going to do it? You can continue to bemoan the lack of respect, the lack of financing (Look at my blog for an update on that-it ain't going to get better for ANY of us, OR, you can help by trying to ensure that their is SOME supervision, and perhaps help by training, and imparting some of your wisdom. My offer still stands to have some PA students rotate with you. And please, don't compare PA's to NP's, the differences in training are staggering. But I don't think you are aware of all of them.
SOMEONE HAS TO PROVIDE primary care. Docs don't want it. Therefore, we have to do it. My best friend from PA school, and my best man at my wedding, owns his own family practice setup in Florida. He hired his supervising MD, who visits, once a week for a half day on Fridays. He does chart review, and my friend will have complicated patients, or patients that he is a little unsure of return on those mornings for the physician to see. After over ten years in practice, they are few and far between, but he also knows his limit. Why can't this practice example be applied in other areas?
You offer much in the way of criticism, but little in the way of true dialogue or answers.
Nice post.
ReplyDelete