A reader objects to the growing physician assistant autonomy in the real world of clinical medicine.
Dear HH,
Have a comment about the growing autonomy of PAs. Frankly, after checking out a PA blog, they scare me. Not much training, lots of ego. Yet, we are allowing people with sometimes as little as 2 years of training to order tests, diagnose, and prescribe. A PA at the Cleveland Clinic has listed as her undergraduate degree: a BA in art. Gee, that will come in handy when my loved one is seriously ill or injured. Physicians need to wake up and protect patients from people who don't know what they don't know. If I'm every 8 and need a soccer physical, they'll be the first one I call. More horror stories, but later.
Here's my opinion. There are lots of great physician assistants who are competent to care for patients in a manner consistent with their education and who know their own limitations. And there are a lot that aren't. Many primary care and subspecialty offices utilize physician assistants in a focused, defined and understood clinical role. I rarely have contact with outpatient physician assistants, but I suspect they can do a fine job in a clinical role that is structured and defined.
From the point of view as a hospitalist taking care of hospital type illness, I can tell right from the beginning whether a physician assistant's medical decision trees are incomplete or even dangerously lacking.
The problems, I believe, arise when the population of patients being treated by those without a medical school education is expanded to include a higher degree of complexity including the ever important process of differential diagnosis. It's easier for a physician assistant to get in over their heads when they haven't been exposed to hundreds of different variations of the same pathology and aren't aware of the possible atypical presentations of both common and uncommon pathology.
That's not a personal knock on their capabilities, but it is a reality of their training. Without years of exposure during medical school and residency training, one cannot safely go out and provide competent independent care of the unknown.
I'm not aware of anywhere in this country where physician assistants can get a license to practice medicine independently without a physician over seeing their medical care. While PAs are supposed to have physician backing, that's now how it works in the real world. Not a night shift goes by where I'm not accepting critically ill patients from small town emergency departments staffed on site by a physician assistant only and an MD soundly sleeping in bed 20 miles away.
If that's the definition of supervised medical care, then I guess all physician assistants are being adequately supervised by their sponsoring physician. Although all of us in the medical field who work with PAs day in and day out know that they practice independently every day. It's just a matter of semantics, where the doctor who is supervising them is accepting responsibility for their actions. Which is fine with me. Except when it harms my patients. I once heard a PA telling the patient's family.
"I do everything that the surgeon does. I'm like a second surgeon. Almost, but not quite."
The thing is, I would never claim to be something I'm not. I'm an internist. I'm a hospitalist. That's what I do. I'm not kind of anything. If you're going to be a physician assistant, be proud you're a physician assistant. If you want to be a surgeon, go to medical school and complete a residency in bloodless surgery.
