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.

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.