Category Archives: Mid-Level Madness

Ask Yer’ Uncle Panda: More on Mid-Level Providers and other Topics

(In which I answer several random questions submitted to me by readers. -PB)

Hey, Panda, I’m not sure what specialty I would like to do and am considering going to PA school because Physician Assistants can easily move between specialties.  Your thoughts?

I often hear the ease of movement between specialties touted as a benefit of being a Physician Assistant or other mid-level provider. The theory is that if you find yourself bored in, say, primary care you can easily find a job in a different, more interesting, or more lucrative specialty.  By contrast, changing specialties as a physician is a long, incredibly arduous undertaking. The only way, for example, an internist can credibly practice as a cardiologist is to complete an additional three year fellowship on top of his first three years of residency.  If, as another example, I wanted to practice as a surgeon I would have to apply for and complete an additional four years of residency training assuming any surgery residency program would take me which, because of the way medical training is funded, they probably wouldn’t.   A Physician Assistant, on the other hand, can get a job with a cardiology group and a few days later, mutatis mutandis, he is a cardiology PA.

Nothing wrong with this of course. The role of a Physician Assistant in many specialties does not require the depth of knowledge of a physician and I repeat, as many Physician Assistants are hired to do the relatively low-skilled grunt work of a practice this depth of knowledge is not required. But unless we’re going to revisit that magical world where two is bigger than four, five years of residency is no different than a little on-the-job-training, and superior knowledge can be had without learning all of that useless stuff, the ease of moving into different specialties should only indicate that a certain…how can I put it…comprehensiveness is not required of a Physician Assistant.

Which is not exactly a ringing endorsement of the depth of Physician Assistant training although if that’s your thing, go for it.

But Panda, can’t Physicians Assistants do 90 percent of what a doctor does?

No.  Although to be fair they can do 90 percent of the paperwork so, since fifty percent of my job consists of useless bureaucratic tasks, ipso facto they can do a large part of my job.  The conceptual difficulty many of you have is your lack of understanding about the structure of the goat-rodeo-cum-cluster-fuck known as American medicine in which there are three broad specialties.  The first is actual, honest-to-Jehovah Medicine of the kind we all imagined we would be practicing long ago before we actually started wrestling the proverbial pig.  You know, things like diagnosing and treating diseases using good clinical judgment and appropriate testing and consults.

The second specialty is Tort Medicine which is something we do continuously in an effort to minimize the perceived risk of being named in a lawsuit for a bad outcome that may or may not have been our fault.  As this primarily involves throwing vast quantities of money at our patients in the form of useless, unnecessary, or only marginally helpful studies and procedures in an attempt to uncover every single thing that could possibly be wrong with the patient (no matter how unlikely), I see no reason to doubt that Physician Assistants can handle these tasks admirably, the number of boxes you check on the order sheet being often inversely proportional to your knowledge of real medicine.

The third and largest specialty is Boilerplate Medicine in whose service we devote countless hours charting, documenting, and filling out reams of redundant forms, the main purposes of which are to legitimize billing and keep millions of low-level administrators gainfully employed.  It is in this specialty where mid-level providers particularly excel and for which most are hired.  What are most History and Physicals for routine admissions and procedures, after all, but loads of useless information, grimly documented for the insurance company, surrounding a kernel of important facts?  Unfortunately, since you can’t bill insurance companies or the government with a concise paragraph describing everything important about the patient, we have developed check boxes and forms that codify useless information and organize it for easier parsing by bureaucrats; even though for strictly medical communication all most doctors need and would prefer is a brief paragraph.

Or, to look at it another way, I am now after eight years of medical training capable of writing a brief, elegant, and succinct paragraph describing everything you need to know about the patient as well as my assessment and plan which any other doctor can read and understand completely.  If this was all I had to do I could probably see twice as many patients but unfortunately, the government and private insurance companies (not to mention the lawyers as there is considerable overlap between Tort and Boilerplate Medicine) need their medical prose like a sailor needs a happy ending and if I can hire a relatively cheap mid-level to crank it out then so much the better.

The real question should be whether someone needs a two-year Masters degree (in the case of Physician Assistants) or one year of fluffy smugness (in the case of Nurse Practitioners or Doctor Nurses or whatever the hell they want to be called) to essentially fill out a bunch of mostly useless paperwork?  Surely if clinical skills are not that important, and that’s exactly what a mid-level is really telling you when he insists that his two years of training is equivalent to your seven or more, then we could probably save a heap o’ wampum by training motivated Community College students for an exciting career that we can call “Physician Assistant Assistant” (or PAA) and eliminate the expensive mid-level middleman.

But what about Primary Care?  Surely mid-level providers are suited for primary care?

You only say that because you don’t understand primary care or are confusing it with something else.  Primary care physicians should and ought to have the highest level of medical knowledge and clinical instincts because they are not specialists and therefore have to be fluent or at least conversant in all of the medical specialties.  To the extent that they aren’t is only a reflection on the nature of American Goat Rodeodery where reimbursement and the predatory legal environment makes referring to specialists a de facto requirement for a primary care physician’s financial survival.   With this in mind, most specialists are used not in their intended role as sage consultants for particularly difficult cases but as extenders for over-worked primary care physicians, meaning that they primarily see nothing but fairly routine patients with bread-and-butter conditions that the patient’s family doctor simply did not have the time or the legal gonads to address.  In this respect mid-level providers are probably better suited to the specialist trade, and the more specialized the better, because it is easier to acquire a superficial knowledge of a highly specialized field than of a broad, non-specialized one.  I know, for example, a Pulmonary Medicine Nurse Practitioner whose entire job is to set patients up for bronchoscopy, the pulmonologist’s signature procedure and biggest money-maker.  Realistically, however, I could train a high school student to do most of her job.

Now, it is true that primary care physicians see a lot of minor complaints.  Hell, I’m an Emergency Physician and I see plenty of them too, some so trivial that it would drive one crazy if it weren’t for a sense of humor or plentiful, cheap whiskey.  In fact, a substantial subset of the patients I see have complaints that are not only minor but only twenty years ago wouldn’t even have been considered the kind of medical problem for which someone would legitimately seek medical attention.  Can a mid-level provider handle these?  Of course.  But are they sure they want to make the motto of their profession, “Mid-Level Providers: Wrangling Patients that Don’t Really Need to Be Seen So You Don’t have To?”

Primary Care, in other words, is not just about minor complaints and it is not urgent care either.

What About Urgent Care?

Urgent Care is mostly a scam, at least in cities that have functioning Emergency Departments and I would advise most of my patients to avoid them as an unnecessary and costly middleman.  With a few exceptions, if your complaint is minor enough where it can be addressed in an Urgent Care Clinic you probably didn’t need to be seen at all and whatever treatment was prescribed is just a placebo, something to show that we care or to keep you amused while nature takes it course.  If your complaint is legitimate or even the slightest bit threatening the practitioner running the place will default to his legal protection mode and refer you to the Emergency Department, off-site Emergency Department triage actually being the only legitimate medical function of Urgent Care clinics.

Can you get a school sports physical at an Urgent Care or a note from your doctor as an excuse when you miss work?  Sure you can.  But these things are worth what they are worth.  The work note is worth nothing medically and the cursory sports physical as it will never pick up any but the most obvious reasons why you might drop dead while playing basketball, fulfills what is mostly a bureaucratic requirement and not a medical one.   This is why, by the way, residents love moonlighting at Urgent Care Clinics.  Namely because it pays pretty well, the stakes are low, nobody is really sick, and if they are you can easily punt to a higher level of care.

What about Complementary and Alternative Medicine?  Can’t I go to Chiropractic School or something like that if all I want to do is primary care?  My Chiropractor advertises himself as “Primary Care” so I was just wondering.

Complementary and Alternative Medicine is mostly modern superstitious drivel marketed to people who are, in their knowledge of science and reason, no better than seventh century peasants except that Dark Age peasants had an excuse to be ignorant as they had marauding Norsemen competing for their attention.   On the other hand most people don’t think about medicine that much and have no reason to distrust their chiropractor so allow me clear something up for you: Chiropractors, naturopaths and other Alternative Medicine practitioners do not have the same training and education as medical doctors, not in quality and not in quantity, not by a long shot, and therefore they are not qualified to serve as primary care physicians, a job that requires more than some haphazard study of herb lore or a cursory knowledge of the spine. If they had the same training including residency training they would be qualified…but they don’t so they’re not.

Take your typical chiropractor, for example.  He has a four-year degree at an institution that was probably nothing but a federal student loan processing mill in which the odds are he never saw a really sick patient, at least not one that wasn’t immediately taken to the nearest Emergency Department.  Unlike your Family Physician who has four years of medical school followed by an intensive three year residency, your chiropractor has never rotated on a pediatric ward, in the Intensive Care Unit, on an internal medicine service, a surgery service, or any other of the medical services in which the core knowledge of every physician is developed.  He has done no call, been responsible for exactly nothing during his brief pseudo-medical training and has never had to make a decision that mattered to anybody.  More than likely he slithered through chiropractic school making a mental list of the many, many things he would never have to worry about (I mean, assuming he was introspective enough for this) and that he would defer to real doctors.  He is, therefore along with his naturopath cousins eminently unsuited to recognize, diagnose, and treat general medical complaints.

The funny thing is that I would never try to pass myself off as a surgeon, an obstetrician, an internist, or a neurologists because I lack the training and knowledge to honestly represent myself to the public as something I am not…and yet naturopaths, chiropractors, and the whole pack of Snake Oil Salesmen with a fraction of the training required for the job lack the humility, the self-awareness that comes with an appreciation of their own limitations, to consider that maybe, just maybe, they don’t know enough to be primary care physicians.

No doubt your Chiropractor can fill out forms with the best of them and correctly bill your insurance company but if you have a medical problem serious enough to warrant treatment you should see a real doctor and eliminate the useless middleman.   Likewise if you really care about your long-term health.

Not to mention that the primary treatment modalities of practioners of Complementary and Alternative Medicine are extremely ridiculous on a fifth grade biology level.  To believe in them, things like subluxations and Reiki, is to place yourself in the company of drooling cretins.

From Excessive Knowledge, Good Lord Deliver Us

(Writing this blog can be difficult. While I am interested in many subjects, developing coherent ideas and putting them down in a logical and entertaining manner does not always come easy. In other words, most of my articles do not just fall effortlessly from my brain. On the other hand, there are some subjects about which I am so interested and have such well-developed ideas that I almost want to avoid writing about them because it feels too much like “phoning it in.” Some run home to their mommies at the first sign of trouble. When I have trouble coming up with anything new I, too, metaphorically run home to the comforting bosom of my mother, revisiting subjects like futile care and the abuse of residents. Precisely because these things are easy to write about and I take great pleasure in doing it, sometimes I feel like a fraud, one who is just repeating himself with only slight variation, and throwing to you, my loyal readers, easy-to-obtain red meat instead of coming up with something original.

With this in mind, please accept the following article as more red meat. I hadn’t planned on writing it but I received so many private emails about what was really just a throwaway line in my last article that I felt compelled to fire up the old easy-writing machine to shoot ducks in a barrel and pluck the low-hanging fruit. You get my drift. I’m not proud of it but there it is. -PB)

Cry Me a Friggin’ River, Why Dontcha’?

It seems that I can’t mention mid-level providers, even in an offhand way as I did in my previous article where I compared Physician Assistants to brand-new interns, without the usual scolding from assorted mid-levels who are quick to rehash the usual half-truths and agitprop about their profession vis-a-vis physicians. It is not enough, apparently, for me to be generally highly complementary to mid-levels in many of my articles but I must instead roll over and submissively urinate, crying Uncle and admitting that the only difference between a physician and mid-level is some inconsequential and medically irrelevant minutia that we had forced on us in medical school and residency but from whose wasteful tyranny the mid-levels have been spared.

This is not the case however and the credence one gives to the theory that Less is Better depends on how much knowledge, the currency of medicine, one has in their possession. Since it is, barring some warping of space-time, impossible to cram the same amount of teaching into a typical two-year-and-change Physician Assistant or Nurse Practitioner curriculum as is crammed into a four-year medical degree, a graduating medical student on his first day of intern year starts out with an advantage in medical knowledge and it’s not an inconsequential one either despite the usual protestation from mid-levels that their shortened curriculum is just as rigorous as the medical school curriculum (but it’s not ’cause they don’t learn any of the useless stuff…see?). Is this extra knowledge important? Of course it is. I am not exactly medical training’s biggest fan but there is not a single thing I learned in medical school, from the structure of cardiac ion channels to neurolation in the embryo that does not, in some way, make me a better physician strictly by virtue of being a more knowledgeable one. It’s easy to stand on the low ground and insist that all of this knowledge is useless but, and maybe I’m missing something, we have not yet arrived at a time where we admire and seek to emulate those physicians who make an effort to limit their knowledge, judiciously deciding that they can do without this or that, and adopting the attitude of one of my fellow students in a now-distant pre-med anatomy class who, exasperated by the depth of the subject matter, said, “This would be a much better class if their weren’t so many word.”

It also should be noted that upon graduation, a mid-level’s mandatory education is at an end while an intern’s is just beginning. Strictly speaking, medical school is a minimum of seven years for all physicians as residency training, although not legally necessary, is a de facto requirement to practice medicine. I will have had eight years of medical training before I feel barely comfortable to practice on my own which is typical. Residency training lasts anywhere from three to seven years (and even more if we count fellowships) which is something that many mid-levels forget or ignore when they assert the equivalence of their training. Additionally, training is not the same thing as punching the clock. In other words, a mid-level can graduate from his program, secure a position, say as an extender for a busy cardiology group, and after a little on-the-job training get into his groove as a paid professional, keeping up with his continuing education requirements of course, but essentially having arrived at a point in his career where he can decide to sit around watching American Idol after he punches out. This is not the case with residency training. Every rotation is training and every day is an exploration of the dark continent of our ignorance, a vast territory whose boundaries no man can see and in which no sooner is one hill crested than we are presented with the prospect of still more hills in the distance. So it goes for eight years and it is the background acquired in medical school and residency, the useless minutia, that provides the foundation for understanding and the ability to synthesize original thinking on medical problems and not to just regurgitate contextless facts.

Now, as to the assertion that because most of medicine is fairly routine a mid-level can handle 90 percent or some arbitrarily high percentage of a physician’s job, the first thing you have to realize is that for those of us in the generalist specialties, even Emergency Medicine, it should surprise no one that fifty percent of what we see is absolute bullshit (if I may be allowed to create statistics from whole cloth, I mean). Far from requiring the skill of an expensive mid-level, most of these presentations could be easily sorted and sent home by a reasonably competent school nurse who has learned even less of that bothersome and useless knowledge. We don’t even need a well-trained registered nurse either because although their focus is patient care and not diagnosis and treatment, registered nurses particularly Emergency Department and ICU nurses, are extremely sharp cookies and they are probably over-trained to assess and send home many of the patients we see.

In other words, in their zeal to devalue medical knowledge, mid-levels are, perhaps unwittingly, bringing into the question not only the justification for having physicians but also for spending money training so many mid-levels to the extent they are trained today. Far better to just allow reasonably motivated high school graduates to take a year or two of basic coursework at their local junior college, give them a white coat and a stethoscope, and let ’em at all of those routine patients. Why not? My undergraduate degree is in Civil Engineering, for example, and any sharp witted, smooth-talking village idiot could make a good case that this contributes nothing to my ability to diagnose and treat disease. The same fellow could also make the case that eight years of medical school and residency training is not necessary to recognize the flu, treat garden-variety diabetes, or write a couple of prescriptions for blood pressure medications. Hell, as long everything goes smoothly and all we expects is low-level primary care then everything is going to be fine. Unfortunately, as we push the boundaries of medicine and reap a bumper crop of increasingly elderly and multiply comorbid patients, most of whom expect to survive their visit to the doctor, the trend nowadays is towards more complex patients, albeit mixed in with some undetermined proportion of sublimely ridiculous chief complaints or cookie-cutter cases that can be handled by our intrepid Junior college graduate.

Mid-levels are quick to note however that the trend even in their professions is towards more, not less education. Obviously some of that useless minutia is of value.

Let me relate a parable. As many of you know I was once an engineer and after graduating with my engineering degree found myself in an engineering firm where I was in charge of a stable of young design-draftsmen, the “mid-level” providers of the engineering world. Most of these design-draftsmen had Associate degrees in Engineering Technology from reputable junior colleges where their curriculum was heavy on drafting with a smattering of low-level engineering design courses. Good guys, for the most part, and I picked their brains for tips on computer-aided design and drafting as many of them had been using AutoCAD for years and were fairly good at it. (Junior engineers nowadays are expected to do a lot of their own drafting, probably because it is easier to do it yourself than prepare a sketch for a draftsman to translate into a finished drawing). The useful thing about well-trained design-draftstmen is that you can send them, for example, the design drawing for a piece of process equipment (a roll cage, conveyor, etc.) and they have the knowledge to produce detail drawings and parts lists without having to bug you all day about it. Same with detail drawings for structural or foundation work. Very few structural engineers, for example, produce detailed drawings of structural steel connections but instead pass the design drawings to a “mid-level” steel detailer who produces cut lists and all of the drawings need to fabricate and assemble the structure. The details are based on the engineers specifications and if, for example, I were to specify a shear-only connection to resist a certain load the detailer would produce the drawings from which the actual pieces could be fabricated. It’s not rocket science and, as a structural engineer, I am quite capable of designing and drawing my own connections but didn’t, habitually, except for the difficult ones that did not fit the cookie-cutter examples in the two major steel design manuals (that would be the AISC ASD and LRFD manuals for those of you who are interested and still following along).

Naturally, when I finished my five years as an “Engineer in Training” (interestingly enough also called an “intern” in the Civil Engineering world) and passed the licensing exam to become a Registered Professional Engineer I was completely responsible for all aspects of the design, drafting, and detailing of everything that passed through my hands including the detail drawing produced by the detailer, himself usually an independent contractor. Did I check every single connection on a large structure, burning the proverbial midnight oil for weeks at a time with a red pen in hand? Of course not. My detailer had been in the business since before I was born and knew a thing or two about steel fabrication. But that was his thing, you see. My thing was design and management and I don’t recall ever taking a detailer or a design-draftsman aside and asking their help for a particularly thorny foundation design problem. That was my thing.

One day, one of the more crusty design-draftsmen let on to me that he didn’t think it was fair that engineers made more money, especially as he believed he could do ninety percent of what an engineer did.

“Well,” I replied, “seeing as ninety percent of my job involves standing around drinking coffee making sure that you’re doing your job I don’t doubt it.”

But you see, the devil is in that left-over ten percent (or fifteen or twenty or whatever percentage makes you comfortable with your career choice). Most of every career is routine, repetitive, and can be handled on autopilot. The difference between medicine and other careers is that one never knows what patient is suddenly going to become one of the ten percent. Consequently we want to avoid the autopilot as much as possible. Emergency Medicine in particular is all about not just treating the ten percent but accurately determining who is part of this dangerous minority and until such a time as we can determine which of the ninety percent only need the school nurse and which need an attending physician, prudence dictates that we have the physician standing by even if many of his cases turn out to be nothing…keeping in mind of course that your definition of “nothing” depends on your training. Many of what I once thought were incredibly complicated patients are now just another boring case of sepsis or meningitis.

In reality the practice of medicine is a team effort, not unlike a symphony orchestra where everyone has a part and an instrument they are expected to play. If any individual from the conductor to the third flute doesn’t do his job well the entire ensemble is going to sound like a high school marching band. While it is true that a good symphony can produce ethereal musical magic from the great composers, they also spend a lot of their time sawing out The Nutcracker to keep the proles interested.
On another note, many of the critical emails I receive about the difference between mid-level providers and residents start out with some variation of, “I have been a PA for twenty years,” and then proceed to expound on the uselessness of an intern. Well, God bless you. I’m willing to allow that a new Emergency Medicine intern on his first day in the department can probably have circles run around him by a Physician Assistant who has been practicing for twenty years. But we’re comparing apples to oranges here. There is a steep learning curve for a resident and I would not presume to say I am even near to cresting it. That’s why we call it it “training.” On the other hand, a typical Emergency Medicine attending with twenty years of experience can run circles around a twenty-year mid-level and their little dog too. They didn’t get that way by stopping their ears against useless medical knowledge.

Other Medical Careers Part Three: Physician Assistants

Inspired By Actual Events

(House DO, one of our good blogfriends, has taken a hard look at the requirments of medical training and decided to divert to PA school. To him is this article dedicated-PB)

As an intern, I once rotated on a service that had a lot of Physician Assistants. One night on call I was paged by one of them to come up to the floor and help him with some paperwork. Naturally I refused. It was late, I was tired, I wanted to get a few hours of sleep, and I told him so.

“Well,” came the peevish reply, “I’m here and you don’t see me getting any sleep.”

“Well,” I replied politely, “You’re not on call, you’re working a shift, you got here at six PM and while you will go home at six AM, I will be here into the afternoon. Not to mention that I got here yesterday morning and have been here ever since while you will work your three shifts this week and I will probably never see you again. Call me if I can help you with anything important.”

That’s about all you really need to know, philosophically, about Physician Assistants. They’re kind of like doctors and can and do perform many of the same functions but they have limitations. Hell, we all have limitations. Medical school and residency sometimes seems primarily about teaching us what they are. As a PA, your limitations will just be lot closer than those of a physician, kind of like the difference between a dog with the full run of the backyard and one who is brought up short by his chain while chasing a squirrel.

Physician Assistants were invented at Duke University in the mid 1960s to address the shortage of primary care in rural North Carolina. Their inventor, Dr. Eugene Stead, studied the training methods used to produce doctors quickly during World War II and created a training program based partly on these methods. His first students were former United States Navy hospital corpsmen (what the Army calls “medics”) who then, as now received extensive medical training far beyond that of paramedics, their closest civilian counterparts. An important thing to keep in mind is that medicine was not nearly as complicated in World War II (or even as late as the 1960s) as it is today when there were, for example, only sixty or so medications in common use and most of those were of the crapshoot variety. You could probably train a doctor to mid-twentieth century standards in a couple of years if you got right down to it.

True to the original ethos of Dr. Stead, most PA training programs heavily favor those with prior careers in allied health such as nursing or paramedicine but this requirement is not universal and my sources tell me that not every program necessarily looks for this.

There are now 130 Physician Assistant training programs in the United States. Most are Master’s level programs although a few still offer an undergraduate degree. The curriculum in the Master’s level programs is typically two years with the first spent on didactics and the second on clinical training after which you may become certified and begin to practice. There are opportunities for further training but this training is not required, de facto or otherwise, to start working and earning a living which is the principle appeal of PA training versus medical school. While a typical physician will train for a decade before he even starts his career, a PA can start earning an income after two years.

It’s a pretty good income too. The average PA salary is close to the mythical “six figures” and some, particularly those in the more lucrative specialties, can earn even more. It is not hard to get into a lucrative specialty either as the demand for PAs in all fields currently far outstrips the supply. That’s one of the beauties of PA training. It is versatile and a PA can move relatively easily (compared to a physician) between specialties. A PA, for example, who is interested in surgery can work for a surgeon and by “first assisting” in his cases can get a pretty good practical grasp of it. If, on the other hand, he has a hankering for primary care (although even PAs run screaming away from it…they are highly intelligent profesisonals after all) he can work as an essentially unsupervised primary care clinician in most states especially in the rural areas which have a shortage of doctors.
The conventional wisdom is that PAs are the equivalent of physicans and this is certainly the mantra you will hear repeated so often during your medical training that it will become a reflex action, kind of like your catechism, to reassure those around you that except for the two extra years of medical school and all of that residency stuff, it’s all the same. But that’s kind of the issue. You either believe that extensive training is required to produce a doctor or you do not. Because our society is highly over-doctored to begin with and most of medicine is fairly routine, those who do not will correctly point out that not every patient is either complicated or critically ill and that it doesn’t take an advanced degree to diagnose an ear infection or treat routine hypertension. Since it it currently takes a minimum of seven years to produce a primary care physician versus two for a primary care PA, the advantages of PAs are obvious. It is also easy to see how in a narrow medical specialty many of the routine tasks can be performed by PAs. If you first assist a general surgeon who concentrates on a narrow repertoire of abdominal procedures, eventually you will have a very good grasp of what is involved and excellent procedural skills without having been through the bottleneck of medical school and a six year surgical residency.
On the other hand, a lot of medicine isn’t routine, some patients are complicated, and if there’s one thing I’ve noticed about cookbook medicine it’s that most of the patients didn’t read the book and don’t follow the recipes. I’m sort of old school about this. I am perfectly willing to concede that PAs can and should take over many medical duties if they are more cost-effective. At the same time the more I learn about my own specialty the more I appreciate the need for a broad and lengthy period of training before we are released upon a trusting and unsuspecting public. I have been hard at it for six years and I am still humbled on a daily basis by my relative ignorance compared to my attendings. And I don’t think I’m in the minority when it comes to an honest assement of my skills and knowledge as a resident either. There is a lot to know, some of it highly nuanced and much of it requiring pretty good clinical judgement that you cannot learn in a couple of years and especially not without the background in medicine that even those lazy bastards in PM&R can’t help but acquire.

Unfortunately, PAs (and other midlevels) have found themselves at the cutting edge of efforts to dumb down medicine in the name of economic efficiency. If I were a PA I would be deeply offended to be associated with this effort, first because PAs are not dumb in the slightest and increasing their scope of practice will require more, not less, resources. Second, and most importantly, if we buy into the premise that medicine is nothing more than an algorithm that we can read from a card and apply to every patient not only do we not need physicians but PAs themselves are probably over-trained for their jobs and eventually they will be replaced by motivated junior college graduates.
I mean, there’s nothing to it, right?

Advantages: Practice as a licensed clinician after minimal training. Good salary, can exceed physician salaries in some specialties. Variety. Mobility. You can wear a white coat and many of your patients will think you are a doctor. The training is not as rigorous from either an intellectual point of view during didactics or from a “fuck with your head” point of view during clinicals as physician training. Nobody will ever insist you have a “passion” for physician assisting as a prerequisite for the job. No residency required although you can get further training if you want it. Only two years worth of debt before you start making money.
Disadvantages: Very few, actually. The training is not as rigorous as physician training and, despite the propaganda, you may keenly feel your lack of skill and knowledge compared to your boss. On a specialty by specialty basis, you will never make as much as a physician for the same amount of work. And your salary will also decrease under any socialized system currently gathering its strength behind the mountains of Mordor before it is loosed upon us all. But other than that it’s not too shabby.

More here and here.

Ask the Panda: More on Physician Assistants

Hey Panda. I’m a PA and I don’t like you much even though I inflict your blog on myself religiously. What do you think about Physician Assistants and Nurse Practitioners taking over from doctors? They might even replace you, Mister Emergency-Medicine-Smarty-Panda-Pants.

Another excellent question and a source of great angst among those who are contemplating primary care. As some of you know, Physician Assistants and their sinister cousins, Nurse Practitioners, practice pretty much independently as primary care clinicians in much of the United States, especially the rural and so-called medically underserved areas. Ostensibly they practice under the supervision of a physicians but this supervision is often pro forma and might involve an infrequent cursory review of a handful of charts by a retired physician not concerned about liability and just looking for an easy gig to make a little extra income.

Let’s get a few thing straight at the outset. First, we live in an egalitarian society that delights in thumbing its nose at authority. With this in mind, you are never going to convince the public that physicians should monopolize health care through anything equivalent to the divine right of kings. The public will turn against any group of uppity physicians oppressing the little guy to protect their ill-gotten six-figure salary. You know what is involved in medical training but I guarantee that the bulk of the sturdy and not-so-sturdy yeomanry don’t have a clue and don’t care about your sacrifices. I may think you deserve the six-figures but it’s going to be a hard-sell to the voter working down at the plywood plant for a small fraction of your salary.

Second, we should be against monopolies. A good or service of reasonable quality should be provided to the public at the lowest possible price which is determined by competition in the free market. I’ve been anti-union and for free trade for my whole life and I’d be a hypocrite to change my position simply because it’s my ox being gored.

The question then becomes, as was implied in the previous post, are the services of a residency-trained physician of greater value than those of a less well-trained physician assistant? I believe they are but let’s not get silly about it. Physician Assistants and Nurse Practitioners are not stupid and are more than qualified to handle the majority of primary care. I think it would be criminally insane to send your aging mother with twenty competing comorbidities to a PA but does it take a doctorate level degree to treat a kid with an ear infection?

Of course not, and this is the hook that mid-level providers have with the legislature. They are cheaper than physicians, they can reasonably demonstrate that they can do some of the same work, and since giving away other people’s services is the epitome of compassion, the mid-levels provide the trapping of political compassion at fire sale prices. Whether the public is being well-served is immaterial. It’s just primary care, after all, and the mistakes are slow to evolve and can be ascribed to half a dozen causes other than clinician error.

So what’s the drawback? As you know I’m an Emergency Medicine resident. Forget what you’ve heard about Family Practice or Internal Medicine, the Emergency Physician is the true generalist. From Pediatrics to Obstetrics to Internal Medicine, the Emergency physician has to be able to make intelligent decisions involving almost every specialty and the amount of medical knowledge and skill required to do this is immense and humbling. Not a day goes by where I don’t come against the limits of my knowledge and I have been hard at it for almost six years. And I still have two more years of training before I can practice independently of skilled supervision. If you think that some guy straight out of a two-year masters program is equal to the task then God love you, you’re a true man of the people, but you are crazier than a shithouse rat.

Also consider the training required for by an internist, the basic foot-soldier of the medical profession, not to mention that required for surgical or subspecialty training. To say that a mid-level is equivalent to a trained physician is the same as saying that we are all wasting our time in residency. And that, my friends, is the question which leads us too…

Will Physician Assistants and Nurse Practitioner take over primary care?

Yes. No. It doesn’t matter.

Yes, because American medical school graduates are not exactly flooding the zone protecting their territory from the rapacious inroads of the mid-level providers. Family Medicine, the paragon of primary care is, for several reasons, the least popular career path. It takes a special person to want to do family medicine as you must not only run between the Scylla and Charybdis of your peer’s ridicule but you must also lash yourself to the mast of primary care against the siren call of more lucrative specialties.

It is no wonder then that mid-level providers can move effortlessly into the vast, unpopulated territory of primary care. They may not be residency trained and a typical graduating family practice resident may have three times the skill and knowledge but (to paraphrase the popular World War II joke) they may not have have more than the doctor but what they have they have over here.

For its part, the family medicine establishment has done everything in it’s power to ease the transition towards primary care by mid-levels. First it was the “gatekeeper” paradigm where the primary care doctor was the traffic cop directing most of his patients to the appropriate specialist for definitive treatment. Many things need to be referred, of course, but it doesn’t take an expensive degree to decide which specialist should see a patient. When you surrender your ability to diagnose and treat complicated patients, or lose your nerve, all that you have left is low-level primary care which really could be done by a motivated high-school student much less a Physician Assistant.

The current paradigm is “community medicine” where the traditional diagnostic and treatment function of the physician, the medical skill for which he is sought, is subordinated to the needs of society, “well-being,” and half a dozen other cockamamie functions which dilute the only advantage a residency trained Family Practitioner has over a social worker, much less a lean and hungry PA stalking wolf-like along the periphery of the sickly primary care herd.

Not to mention that those in the avant garde of Family Practice have fallen so deeply in love with team-based medicine where the physician is just an equal player in one of those goofy, non-competitive games where nobody loses and everybody wins that change will never come from that direction.

On the other hand, even many PAs don’t want to go into primary care preferring to subspecialize as physicians extenders. It seems every specialty group has it’s cadre of PAs and NPs rounding on stable patients, assisting in the operating room, or clearing out the backlog of routine clinic patients. In fact, as one of my readers once pointed out, Physician Assistants perform many of the same functions in private practice as residents do in academic medicine.

So no, despite the snowballing numbers of midlevel providers, physicians will not vanish from primary care. They may just have to practice at a higher level, eschewing the current trend to water down their medical knowledge with all of that creepy social work stuff but there are plenty of sick people out there. Not to mention that there is huge bolus of baby-boomers about to start getting really, really sick and they are going to want to see a doctor, not a school nurse.

But you can probably kiss the typical low-acuity practice goodbye.

Ask the Panda: Physician Assistants

Hey, Panda, what’s up with Physician Assistants? There are a bunch of them rotating with me and they say that they are just as well trained as doctors and can make more money. To tell you the truth, they are kind of a pain in the ass.

Excellent question. For those of you who don’t know, Physician Assistants are non-physician clinicians who are licensed to practice medicine under the supervision of a physician. Ideally, they are used in the role of “extenders” and might, for example, round on a surgeon’s patients in the hospital leaving him free to spend more time doing cases. Almost all specialties have a definite need for PAs. In Emergency Medicine, for example, PAs often handle the urgent care or less acute cases. Some rural Emergency Departments, however, are staffed by PAs who have received extra training in Emergency Medicine. This is a direct result of both a shortage of physicians in underserved areas and financial pressures on hospitals, private practices, and municipalities as PAs are generally cheaper to hire than a residency-trained physicians.

Many PAs working in lucrative specialties can, in fact, make more money than physicians working in primary care. I know a PA who has been working for a local neurosurgeon for the last twenty years and without going into the specifics, most Family Practice physicians would be envious of his compensation. But generally, a PA will make considerably less than the residency-trained physician in that specailty. I mention this because you will hear many PAs bragging that they can make more than doctors. This is true, but in any given specialty PAs are hired because they are more economical than physicians for the level of work they do. If the cost is the same or more there is no advantage.

Are they as well-trained as you will be after you finish medical school and residency? Of course not. No doubt a PA who has been in practice for ten years probably knows more practical medicine than a freshly minted intern. But we’re not comparing apples on apples. If you compare, let’s say, the training of a brand new PA who has just finished his two-and-a-half year program with the training of a brand new internal medicine attending who has just finished his seven year training program there is no contest. I am going to get a lot of hate mail for pointing out this simple and obvious fact but a PA, by and large, can practice after he completes PA school. A physician can only practice after both medical school and an extensive period of residency training.

Do the math.

The question then becomes, do you need seven years or more of training to function as a physician? This is the 64-dollar question. As many of you will find out, apart from the legal requirements, a lot of medicine is fairly bread-and-butter and could be handled by a school nurse much less a PA. I have done several out-patient pediatric rotations and with the exception of a few interesting cases, it was nothing but viral gastroenteritis (the craps), viral upper respiratory infections (the coughs), or eczema (the itches). Not to mention “Well Child Checks” that could be done by a trained monkey which is why they have interns do them. Likewise, an otherwise healthy man with hypertension probably does not need your medical degree from Johns Hopkin and your residency training from Duke to have a couple of prescription written every six months.

On the other hand a lot of medicine is not bread and butter. Part of your training is learning to know your limitations and the scary thing about PAs and other mid-levels is that, having only sipped sparingly from the well of knowledge, their little knowledge can be a dangerous thing. Things can get out of hand easily in medicine, either quickly because of mistakes made in acute interventions, or slowly as the result of bad judgement or mismanagement of chronic conditions. Physicians, for their part, are not immune from errors and bad decisions but imagine the danger from someone with a third of the formal training who gets in over his head and doesn’t know enough to realize it except when it is too late.

I had a patient with a Pulmonary Embolus, for example, who despite a history of obesity, oral contraceptives, and smoking was diagnosed with “Viral Upper Respiratory Infection” by a PA in an urgent care clinic only hours before she was brought in by ambulance for severe shortness of breath. This is a pretty simple example and most PAs would pick up the not-so-subtle clues in the patient’s history but there are thousands of permutations and combinations of symptoms and long formal training which includes didactics is definitely a major advantage. Whether this is recognized politically is another story. To a politician or anybody making public policy, “health care providors” are interchangeable components and one is as good as another to demonstrate a compassionate concern for univeral access to health care. It is also easy to make scapegoats out of “rich doctors,” most of who are not actually rich, especially as the public by-and-large has no idea how much low-paid and no-paid training is required to make a doctor. My neighbors sneer at the state of my lawn and opine that a guy like me pulling in the proverbial six-figures could pay to have it mowed more often.

The other thing you’re going to hear a lot from PAs is that they get better clinical training in PA school than you get in medical school. As evidence of this they will point to their greater facility with physical exams, blood draws, and other basic medical skills than you have as a third year medical student. Again, this is not comparing apples with apples. PA students learn practical clinical skills almost from the start of their training so they show up on the wards with a slight advantage. Medical students, on the other hand, learn practically no clinical skills during first and second year as these years are dedicated to basic science and general medical knowledge. By the end of fourth year your practical skills will be far beyond those of a PA student who only acutally does one year of clincal work compared to your two and, at least at the three medical centers where I have rotated with PAs, don’t do call and work substantuially fewer hours than the medical students.

“Oh yeah,” some PAs say, “But most of what you learn in first and second year of medical school is of no practical value and besides, you forget most of it.”

As you know, I am not the biggest fan of medical training. And it is true that a knowledge of some esoteric topics like embryology is rarely, if ever, needed by the majority of physicians. But I have never regreted the many hours I spent learning these topics and I think it is the height of arrogance for both medical students and PAs to decide, based on their limited experience, what is necessary knowledge and what is not. Medical knowlege forms part of your deep medical personality and besides serving as a platform on which to build the knowledge that you should be acquiring for your whole medical career, also allows you to speak intelligently and authoritatively to an increasingly medically sophisticated public.

Besides, this particular sword cuts deeply both ways. Why stop at medical school if we want to eradicate useless knowledge? I’m sure I can ride aggresvely through the curriculum of PA school, nursing school, paramedic school, and any school you care to mention, slashing, burning, raping, and pillaging innocent knowledge from the curriculum with the abandon of a deranged mongol and the bread-and-butter patient would still get his prescription for Glucophage. Let’s just do away with the whole deceptive edifice and recruit motivated and reasonably intelligent high school students to staff highly specialized low-level clinics in much the same way we fill positions in the fast food industry.

In short, while it is reasonable to worry about the encroachment of mid-levels into the practice of medicine, this is a political thing and not a reflection on the intensive and necessary training you are recieving.