Harsh Criticism from some doctors on the PA profession

[detman]

I was talking with several doctors recently who I interact with on ocassion. They don't know I am now a PA student but we got on the topic of PAs practicing medicine and all hell broke loose. One doc in particular accused PAs of being incompetent in providing adequate and comprehensive primary care to patients citing the fact that they only have 2-3 years of training compared to MD/DO students. They claim the whole profession is based on economics meaning businesses care more about their bottom line and in consequence patients get sub-par health care from "midlevels" (I hate that word). 

 

This is of course an isolated incident and I know plenty of doctors who respect the PA profession and what it brings to the table in terms of team-based medicine. However, this is the first time I have seen such an enraged doctor over another health care provider and it threw me for a loop.

 

Have any of you seen this before? Is this kind of toxic thinking still very much a part of current medical education?

[dream2pa]

I have had an ENT surgeon once belittle me for pursuing PA school. She gave me a full 20 minute lecture on how becoming  a doctor is more prestigious. :/ 

[rev ronin]

(shrug) You don't need an MD to do MOST of what primary care does.  If I were going to invest another 2-3 years of training on top of my PA training to optimize my primary care skillset... would I take embryology? My own cadaver lab?  Heck no!  I'd do a masters' degree in counseling and make myself an ersatz psychiatrist, because that's FAR more needed than a doc who is admittedly superior to PAs in isolating the correct diagnosis in an undifferentiated new disease state.  Fact is, the world doesn't need a ton of House MD's, certainly not in primary care where 90-95% of what we see is obvious and our boards beat the other 5-10% to death.

[bike mike]

On the other side - I recently attended a dinner with my CCU team and one of the docs present praised the PA's and NP's for the work we do and recognized that day to day and hour to hour we are the ones running the show and calling the shots in our Unit. I have run across docs that think anyone less than an MD shouldn't make any medical decisions, but there are many docs that recognize that we can work independently in high acuity situations.

[nubienne]

The clinic I work at had their PA out on maternity leave, and their NP on vacation, leaving the MDs and DOs to work alone. They were SO GLAD when they returned. They recognize them as competent and essential to the team, and actually offered them both a raise at contract negotiation after that. 

 

It sounds like that doctor has had a bad experience (or no experience at all) with physician extenders. The majority of those that have tend to have a positive opinion. 

[Reality Check 2]

Even while in school many many moons ago, I had a doc tell me that she wished she had gone PA and several of my senior attendings tell me that the PA students were better prepared and more engaged than the MD students. 

 

Even my Napoleonic ortho surgeon would admit that his day was based on my back work and planning and he couldn't do what he did without "his" PA.

 

So, my brief take would be than an ENT who berated has had - 1. a bad experience seeing a PA as a patient, 2. Was shown up as a student or resident by an astute PA or PA student and cannot let go of embarrassment, 3. has a relative who is a successful PA and can't handle it, 4. Can't handle anyone having success or smarts other than an MD

 

Move on, rock on, educate and shine

[south]

Well, regardless of my opinion (which is always correct), the entire landscape is totally different now than it was a generation ago and even further from the generation before that.  Some of those changes aren't good for everyone, who may have grown up around the old paradigm and have those expectations.  

A form of nostalgic sour grapes, if you will.  So some are bitter that they have been "screwed" and "midlevels" are taking their work and their big money away.  

 

Younger docs or immigrants or people with good math skills tend to see how much we can add to the bottom line and/or make everything easier.

 

Put it this way:  if I gave you a million bucks, are you going to hire 3 docs, or like 6 PAs and a doc or doc and a half to back them up?  

 

Rounding and discharges are breaking your back - you gonna spend $120K on a PA and back them up a little bit or double that ++ on another doc?

 

No brainer.  The old guard doesn't like it, but there it is.  Personally, stuff like this doesn't bother me at all.  I wouldn't go to medical school for free. The PA life for me, thanks.  

[roger777]

Magnanimity is an unusual quality in our species; downright rare in some circles.

[MainerRD12]

I am in my FM rotation with a DO who precepts med students year-round but we had a cancellation in my original site and he agreed to take me. He has a private practice, just him and 2 MAs. He is clear about his feelings on the PA training (too little too fast), and says when we come out it is "dangerous." NPs he thinks are even worse. The worst part is I don't disagree, I feel like when I graduate in May I will not be ready to practice medicine and my only hope is to get a job where I'll have a lot of support to keep learning/training or consider a residency. I am doing everything I can every day to prepare and am hoping for the best - I still would choose this route vs becoming a doc when I'm 40, though I have definitely considered it.

[newton9686]

Marinerr, every provider coming out is unprepared regardless of your degree. However what makes MD/DOs more dangerous is many actually believe they are fully prepared fresh out of residency.

[delco714]

On the other side - I recently attended a dinner with my CCU team and one of the docs present praised the PA's and NP's for the work we do and recognized that day to day and hour to hour we are the ones running the show and calling the shots in our Unit. I have run across docs that think anyone less than an MD shouldn't make any medical decisions, but there are many docs that recognize that we can work independently in high acuity situations.

"You reap what you sow"

 

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[Badgers]

I find this tends to be an opinion more so of older physicians. Younger physicians are well acquainted with how competitive PA school has become, have friends that are PAs, and are more willing to experiment with how they can utilize us. 

 

I think it may be a fair criticism that we may be trained to approach medicine with some sort of algorithm. But in many circumstances, that's fine. Doctors are around to fill in the rest. 

[sk732]

Insecure people act insecurely and take it out on everyone around them.  I had an attending on one of my worst rotations in school actually look at my senior resident (PA's being new to many of them and him being an arsehole generally) and say "get used to it...they're not here to take your job, but to make your job easier". 

 

Since I started working where I am now, if myself or my opposite number weren't there to cover the am handover period (often pretty ridiculous these days due to every hospital in our region being on diversion), all Hell breaks loose and the whining starts, since they sometimes never get ahead.

 

SK

[newton9686]

Badgers, medicine is one big algorithm. This isn't House. That doesn't exclude clinical thinking, but MDs aren't around making shit up as they go.

[Badgers]

Badgers, medicine is one big algorithm. This isn't House. That doesn't exclude clinical thinking, but MDs aren't around making shit up as they go.

 

Surely. But I still don't think it's an unfair criticism to say that (at least a few) PAs are trained entirely in thinking "The most common cause of x is y. The most common treatment of y is z." without much preparation for what happens when it isn't y. When you hear hoof beats, thinks horses, not zebras. So yes, generally that is sufficient. In a setting like family practice, this is fine. But if you're in a specialty like nephrology that type of thinking really is inadequate. 

 

Not saying medicine isn't algorithmic (which worries me actually, btw. It won't be long until machine learning allows computers to supplant human providers for diagnostics?), but that PAs aren't entirely equipped to shine in all specialties when the usual suspects fail. 

[Croooz]

Experiences vary both for physicians with PAs as well as for students who become PAs.  The learning curve for the younger PAs now is huge because many do not have the patient care experience.  Some of those then fall into the algorithm model of care, which is more NP than PA, and its a recipe for disaster.  So while there are great PAs there are PAs that are no better than MAs, just like there are MD/DO who are complete idiots and lazy.  If a particular place is used to hiring PAs from a particular school and they continue to get the same quality of PA then whose fault is it for doing the same thing and expecting a different outcome. Why not take condescend from the medical heavens and take these alleged deficient PAs under their all knowledgeable wing and share with them the nectar of the MD/DO deities?

A few lab techs from my program went and became PAs years ago.  They all lacked real patient care experience.  They each were terrified what would happen after graduation.  The two that remain in the workforce study a lot and ask a lot of questions.  So they didn't hit the ground running but got up to speed.  Then there's the few Navy friends I know who became PAs... One is a complete dirtbag as a PA just like he was as a corspman.

In the end it's not the profession but the individual.  A smart person would not condemn an entire profession based on some bad experiences.  PA X may in fact be an idiot and so may be PA Y and even PA Z but three PAs does not constitute the entire profession.  Besides it might be more a matter of they are "idiots" to that particular physician because he's earned their distrust and disrespect...

[sk732]

 

 

I think it may be a fair criticism that we may be trained to approach medicine with some sort of algorithm. But in many circumstances, that's fine. Doctors are around to fill in the rest. 

 

One of the best study guides I've seen comes out of the University of Toronto called "The Toronto Notes" and it breaks down everything into approach algorhythms for pretty much any major problems you can think of.  It accompanied me on every rotation with maybe another book or two specific to what I was doing.  This book is a study manual for the Medical Council of Canada licensing exams...and it's written by current residents/fellows.  If I got stuck on something, I'd check the approach pathways out to see where the next fork would take me...I still get my updated book each year.

 

Docs don't always fill in the rest - they too have to call 911 sometimes as well, hence the reason we have specialists.  Docs think in algorhythms too - usually x+y=z, but if it ends up as e, go to a, b, c, or d and reset based on that result.  We all use critical thinking because we know that not everything fits nicely into a symptom package - part of the process is also looking at and listening to what we're being told and experiential learning so that we're seeing all the different presentations of given diseases, in their different stages.  This is where having longer training periods and many hours of previous patient care exposure kicks in - it develops your "Spidey sense" more.

 

$0.02

 

SK

[runforhotdogs]

Geez, why do people have such inferiority or superiority complexes. Yes, the doctor is more prestigious and should know more. They went to school 3x as much as a PA. Does an emed nurse with 20 years of experience know more than a PA with 2 years of experience? Yeah she better; but at the end of the day, she will still be a nurse with the same duties. If some doc said that to me, I'll just smile and say yup you better be. So what? I admire friends and family who were dedicated and put their effort into being a doc. They were summa cum laudes and valedictorians too. I have no doubt many are much smarter than me. But I don't worship them.

[runforhotdogs]

One of the best study guides I've seen comes out of the University of Toronto called "The Toronto Notes" and it breaks down everything into approach algorhythms for pretty much any major problems you can think of.  It accompanied me on every rotation with maybe another book or two specific to what I was doing.  This book is a study manual for the Medical Council of Canada licensing exams...and it's written by current residents/fellows.  If I got stuck on something, I'd check the approach pathways out to see where the next fork would take me...I still get my updated book each year.

 

Docs don't always fill in the rest - they too have to call 911 sometimes as well, hence the reason we have specialists.  Docs think in algorhythms too - usually x+y=z, but if it ends up as e, go to a, b, c, or d and reset based on that result.  We all use critical thinking because we know that not everything fits nicely into a symptom package - part of the process is also looking at and listening to what we're being told and experiential learning so that we're seeing all the different presentations of given diseases, in their different stages.  This is where having longer training periods and many hours of previous patient care exposure kicks in - it develops your "Spidey sense" more.

 

$0.02

 

SK

You know they've taught apes to sign too? They have been shown to have critical thought too. I guess they are equivalent too according to your 0.02. That's a facetious comment btw. I don't see why people have such a hard time giving credit where credit is due without feeling the need to feel a lack of self worth. Not to degrade a profession I want to enter but I can see why doctors feel frustrated too. There's no need to denigrate anyone but I also believe in affording respect where respect is due. Everyone has a place. It's like an ER doc denigrating a nurse or tech working on a code with them. Are they going to lecture either one how worthless they are too?

[delco714]

Surely. But I still don't think it's an unfair criticism to say that (at least a few) PAs are trained entirely in thinking "The most common cause of x is y. The most common treatment of y is z." without much preparation for what happens when it isn't y. When you hear hoof beats, thinks horses, not zebras. So yes, generally that is sufficient. In a setting like family practice, this is fine. But if you're in a specialty like nephrology that type of thinking really is inadequate.

 

Not saying medicine isn't algorithmic (which worries me actually, btw. It won't be long until machine learning allows computers to supplant human providers for diagnostics?), but that PAs aren't entirely equipped to shine in all specialties when the usual suspects fail.

Most of my job is outside the box urology. It's fun. I function or replace my md's often when they arent free..usually all day every day unless they need higher care (surgery) I can't do myself alone. Not sure why some of you don't think we can learn to "be" specialists..the knowledge comes from somewhere for them too.. In time..volume..etc. I'll never be a surgeon, but Damn if I can't get close bc they made me this way as a group on purpose over 4 years almost.

 

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[cg02186]

I've been kind of noticing this in general too.  Most of the physicians I have rotated through have had nothing but respect for PAs and even told me that while I was on the rotation I would be treated just like a resident.  It was a great experience.  I have noticed that some medical students and residents sometimes have animosity towards PAs but I think that will go away as they start practicing more as an attending.  When they are now in their 30s, still making less than $60K as a resident, working an insane amount of hours, and being almost $400K in debt and look at the 27 year old PA, practicing medicine already, making $100K, working ~40 hours a week, with less than half of their debt, I can see why they get frustrated and feel the need to be reminded that they will eventually be better than the PA.  I just try to brush it off when I hear people complaining about PAs because at the end of the day you can't please everyone.  Just put your head down, work hard, and earn the respect you want. 

[Lauren R]

You'll have that. Haters gonna hate. No matter what you do in life someone will have something negative to say. Most patients and other providers love PAs.