Medical Maximalism

[EMEDPA]

posted by request of a friend:

Medical Maximalism

Medical politics has always been maximal.  What I mean is that organized medicine never saw the PA or NP as an equal or even a deserving team member. It has always been extreme.  No - you can’t sit in the “doctor’s lounge”, even if you are on call. No - you can’t call yourself “doctor”, even if you have a doctorate level degree.  Other team members would be proud of people on their team being highly educated, but not in the medical field.  No - you can’t join our organizations, even if your educational needs are the same and you practice the same specialty.  No - you can’t join our web sites, even if you do take call alone for the entire service.  Our web sites are restricted to “members”, and you can’t join, so in effect you won’t get the information.  
Despite the past 50 years of our presence and despite that we are at least partly a physician creation, leaders of organized medicine still seem to view both NPs and PAs as outsiders and interlopers, rather than part of the medical team.  We’ve just been renting a spot.  Or perhaps we’re like an unexpected guest at the door that one wouldn’t want to be impolite to, but isn’t truly welcome either.  Actually, as a PA leader I can’t ever remember being welcomed by organized medicine. Only if it was for their own needs and never when we disagreed. 
Recognition that NPs and PAs are true professionals that deserve a place in diagnosing and treating patients historically has been considered a weakness by organized medicine and the ability to say so is still severely frowned upon. A position of inclusion of any PA or NP by physician peers is most often viewed as a negative, as if somehow it diminishes the organization instead of strengthens it. Despite so many advances in medicine, regarding PAs and NPs, extremism still rules. 
For almost fifty years, the mantra has been if you did not go to “medical school” you can never be as good as a physician. “You don’t know what you don’t know.” It is impossible for you to gain medical experience on the job, and even if you could, it is impossible for you as a PA or NP to learn it or comprehend it. Even if you do exactly what we do, you can’t be as good. How many times have we heard, “If you are not a physician you are inherently dangerous.” Yes, a physician can leave their practice for two weeks with an NP covering and yes, we have PAs at the hospital for 25 years who started out as residents and now function at the level of a staff physicians teaching residents and doing everything physicians do; but please don’t tell me you might know more than any physician, including a newly minted graduate MD/DO. Don’t tell me you could run a retail clinic. Of course, my PA just might be the exception to that rule, but generally most of you folks are the most dangerous, as most don’t know when to call for help. 
And we will never stop reminding the world that if you practice you need “supervision”.  No ifs, ands, or buts. Even though we know that to most Americans supervision means someone needs to watch you until you get competent. Regardless of competence, you will never be truly competent. That’s part of the maximalism. Even if someone went to “medical school” in a third world country which did not even require them to go to college or have prior healthcare experience and they had less class and clinical hours than a PA program; they will not be second guessed. Even if they can’t pass the Boards, they can move to Missouri and become an “Assistant Physician” with a better law than a PA or NP has in that state. Why do you think they call you an ASSISTANT? 
I guess we would all agree that we NPs and PAs have a different world view. Coming from 2 different professions, with 2 different paradigms, we acknowledge that although we take different paths and climb different ladders, we generally wind up standing on the same roof. A pediatric PA has much in common with a pediatric NP, an NP running a rural health clinic would understand a PA doing the same and see her as a colleague. We look at each other as colleagues. We realize life experience counts. We realize that a great education coupled with great clinical experience is another way to create excellent clinicians. We are lifelong learners. Most of us want to do well.

We will someday be members of the medical care team when team members drop words like superior and inferior. Concepts like automatic captain, instead of earned captain. In looking at ways to form teams of the future, part of our work must be to show physician groups (not individual physicians who generally know this) that medical maximalism will never work. That if PAs and NPs are truly welcomed as teammates on the patient centered team, physicians who oppose our memberships into professional organizations won’t fly.  Physicians who cannot comprehend PAs and NPs as professional colleagues and partners won’t fly.  Physicians pushing us away won’t fly. Physicians participating in verbal rhetoric about us won’t fly.  Physicians who minimize our professional value won’t fly. Medical extremism won’t fly – not anymore. Why would good people who consider themselves members of a team working for the greater good want to do that? 
Viewing PAs and NPs as professional colleagues will be what unites us. Truly ascribing to patient centered care with the focus on the good FOR the patient will be what brings us together.  It’s long-overdue that medical maximalism go away.  It only distracts from an already broken healthcare system.  
Dave 
Dave Mittman, PA, DFAAPA 

P.S. Please feel free to reprint this in your state or specialty newsletter or to send to any group of your choice.

 

[Guest Paula]

I'm manning my clinic solo in September when my collaborating physician is in Italy for 2 weeks.  We may have the retired NP come in to help on the busiest days.  She and I will handle everything.  He trusts us.  Individual physicians tend to appreciate our education and knowledge.  

 

Someday  medical maximalism will bite the physician groups in the rear end. 

[rev ronin]

Reminds me of a joke that starts "What's the difference between God and a doctor?"...

[Guest Paula]

God is the Great Physician.  Doctors just think they are. 

[LT_Oneal_PAC]

Reminds me of a joke that starts "What's the difference between God and a doctor?"...

God doesn't think he's a doctor. I always heard it with surgeon though

[jmj11]

I'm manning my clinic solo in September when my collaborating physician is in Italy for 2 weeks.  We may have the retired NP come in to help on the busiest days.  She and I will handle everything.  He trusts us.  Individual physicians tend to appreciate our education and knowledge.  

 

Someday  medical maximalism will bite the physician groups in the rear end. 

This is strange as my SP will be in Italy for two weeks in Sept. Maybe they are going together.

[Guest Paula]

We can supervise each other.  ^^^^^^

[Gordon, PA-C]

 "we have PAs at the hospital for 25 years who started out as residents and now function at the level of a staff physicians teaching residents and doing everything physicians do"

 

 

If this is true, then it means doing a residency is unnecessary.  So why are we trying to push PAs into doing residencies when by all accounts it DOENST MEAN A THING in long term practice?  If the PA who has been practicing for 25 years doesnt need a residency, then neither does a fresh grad PA.

[Guest Paula]

Because life has changed and PAs don't get the "residency"-type OTJ training like they once did.  Physicians don't have time or interest anymore.  Systems are not set up like they once were for mentoring and even for clinical rotations.  I hear (anecdotally) that PAs/NPs in some cases do more shadowing and not as much hands on in clinical training.   Preceptors are not paid.  

 

PAs who have an interest and opportunity to do a residency should do one.  Even if it is 1 -1/2 more years at least they are paid positions and the residencies are formally set up to provide (hopefully) a great learning environment and will help the PA be competent in the SOP the residency provides. It will also prepare the PA to take the CAQ test if one is available.