Associate Physician"

[PAMEDIC]

I trained with some med students. At no time were their expectations and standards lower than those for PA students. There was no "you'll get to do this in residency, so step aside and let the PA student do it."

I have never experienced a clinical setting where the expectations of the PA student were higher than the MS3 or MS4. Maybe this happens. I've never seen it.

If anything, I would say most doctors when teaching/pimping expect more from the medical students than the PAs.

 

 

So, from my anecdotal experience, I see no reason to think that these doctors who are medical school graduates who have taken Steps 1 & 2 are somehow less prepared to work in a primary care clinic under constant direct supervision than a brand new PA.

[Acebecker]

I trained with some med students. At no time was their expectations and standards lower than mine.

I have never experienced a clinical setting where the expectations of the PA student were higher than the MS3 or MS4.

 

Bummer. ;)

[db_pavnp]

You can always grab a step 2 review text and see how it compares to PA didactic training, I suppose.  Primadonna recommended Master the Boards USMLE Step 2 CK to me to peruse.  Or watch some onlinemeded.org vids, they are pleasant.

[EMEDPA]

seems like things have changed a lot in pa vs md training. as a 2nd yr pa student I was teaching practical skills to the med students on my rotations and to my intern...

[db_pavnp]

I have read on this a bit and the 4 year MD does change focus over time.  There was a change in the 2000's I think towards a more clinically relevant curriculum.  There is continued interest in reducing the factoid based delivery of MS1 as so much of it is irrelevant and our knowledge of cell biology, etc is expanding exponentially.

[rev ronin]

I dunno, on my very first rotation, general surgery, I was de facto in charge of one of the DPM graduates who was supposed to be an intern equivalent. This gentleman didn't have a lot of enthusiasm, and so I split up our team work for us.  When the junior resident figured out what I was doing, he got a real funny look for a sec, and then shrugged and went with what I had planned. :-)

[Soulfari]

Reading through some of these 2nd year clinical experiences -- carrying entire patient loads, putting in radiologic and laboratory orders (how do you even do that as a student? As students in my program we can 'suggest' orders and the MD must confirm, usually they are working so fast that our suggestions get overlooked anyways), -- has me questioning my clinical year experience. 

 

I am no slacker by any means, but I have yet to see an opportunity to be this independent on clinical rotations thus far (except for my Primary Care rotation, I felt like if I was there for another week the doc was gonna have to start paying me). Our student access to EMR and our highly indigent/very sick patient populations have left me wondering what life and practice will be like on the other side of the student-real world fence. Speaking with a few veteran EMPAs at a large academic hospital who told me to "avoid EM straight out of school at all costs, go learn how to be a PA before trying to do EM" is a bit discouraging.

 

Sometimes I feel like didactic year is insufficient training for emulating a provider on rotations. But my HCE prior to PA school was in Derm, so I've been learning systemic medicine from the ground up since day 1 of didactic year. This past year has opened my eyes to the benefits of a 4 year medical degree + residency before getting at the head of the bed during a code. 

[EMEDPA]

a good medic can run a code from the head of the bed before pa school....
 

[Reality Check 2]

I think I have weedled down my basic issue with this idea.

 

I went to PA school to become a PA and I am required in 99% of places to pass the NCCPA and be certified.

 

If I don't pass the PANCE or PANRE - I don't get to become a nurse or a medic or a respiratory therapist or a whatever. That was not my training and I don't qualify for that job either necessarily. I don't have an OUT or alternative based on my prior education. 

 

So, my gut felt disappointment is that folks are being given an OUT for failure. Failure to pursue the standard avenue of training, licensure and certification and will impinge on my livelihood by being given special privileges. 

 

If a physician cannot match to a residency or, frankly, becomes lazy and doesn't want to - sorry, you graduated from med school but didn't FINISH. Hope you have another skill and can find a job. P.S. you can't call yourself "doctor" or board certified.

 

So, I think this is my most basic issue with this. Do it right or don't do it at all. But, don't impinge on my profession where I FINISHED.

 

My old cranky 2 cents......

[Soulfari]

a good medic can run a code from the head of the bed before pa school....

 

Fair enough. I should use a different example to express the knowledge gap that I am referring to. After all, ACLS is just an algorithm on a laminated card. 

 

Disclaimer: I have never been a medic/EMT, but I am ACLS certified. 

 

Replace HOB during code with being the ED provider of a 36yo female with multiple comorbidities (DM2, HIV, HepC), no PCP for followup,  and wacky vitals who's only CC is "weakness". 

 

Veteran EMPAs would probably see a vignette like this and think, "Okay no worries. Just do X, Y, Z" 

 

As a PA-S2, these scenarios still overwhelm me. Obviously practice makes perfect, but I'm wondering where in a new grads career do they walk into that room and go, "alright, easy. Lets go.", rather than cherry picking for Fast Track. 

 

And since medicine is ever evolving and we are forever-learners, I am interested in what makes the veteran EMPAs look at a chart or talk to a patient and go "Woah, I'm probably gonna need some help." 

[Guest Paula]

^^^^  Experience. 

[Gordon, PA-C]

It depends on the program, I think.  I would bet that MS4s have 2000-3000 hours of clinicals under their belt, similar to most PA programs.  However, they are training differently than we do - they are not preparing to hit the ground running upon graduation.  They are prepared to hit the ground with 2 levels of residents checking up on them *and* and attending physician.  We are preparing to hit the ground running essentially as a senior resident with only our attending as backup.  We are designed by training to be the decision makers, they are designed by training to continue learning to become decision makers.  I'm not saying MS4s lack good judgment, but the training and goals are different and they are not designed to be what we are designed to be. 

 

I'm sorry but this is nonsense.

 

I've worked in 5 different academic institutions from east coast to west coast with med students, PA students, residents, fellows, attendings of all stripes. 

 

NEVER EVER EVER did I see a situation where PA students received training "different" in a systematic way than med students that allows them to "hit the ground running" while med students deferred everything to residency.  Not even once.  In over 20 years of experience.

 

It might be true that you have an aggressive PA student with lots of prior HCE and clinical skills who takes the initiative to do something that a med student doesn't do -- but that is NOT built in systematically into the training.

[Gordon, PA-C]

seems like things have changed a lot in pa vs md training. as a 2nd yr pa student I was teaching practical skills to the med students on my rotations and to my intern...

 

Yes but you are an outlier with outside experience prior to PA school and that is not representative of PA vs MD training as a whole.  I know RN students with 5+ years of LPN experience who run circles around fresh PA students with no HCE.  I've seen those RN students save the PA students from making dumb mistakes with patients.  So does that mean that RN students "train" PA students?  No.

[Evolute]

Fair enough. I should use a different example to express the knowledge gap that I am referring to. After all, ACLS is just an algorithm on a laminated card. 

 

Disclaimer: I have never been a medic/EMT, but I am ACLS certified. 

 

Replace HOB during code with being the ED provider of a 36yo female with multiple comorbidities (DM2, HIV, HepC), no PCP for followup,  and wacky vitals who's only CC is "weakness". 

 

Veteran EMPAs would probably see a vignette like this and think, "Okay no worries. Just do X, Y, Z" 

 

As a PA-S2, these scenarios still overwhelm me. Obviously practice makes perfect, but I'm wondering where in a new grads career do they walk into that room and go, "alright, easy. Lets go.", rather than cherry picking for Fast Track. 

 

And since medicine is ever evolving and we are forever-learners, I am interested in what makes the veteran EMPAs look at a chart or talk to a patient and go "Woah, I'm probably gonna need some help." 

You are correct, ACLS "is just an algorithm on a laminated card".

 

Your card must be a little bigger then mine. Because my card doesn't  have an algorithm for running a code secondary to hypothermia, hypovolemia, trauma. Nor does mine have an algorithm for treatment of a pt with a sine wave. I haven't seen anything printed on my card about airway management either. OA vs rescue airway vs intubation vs crich. Post resuscitation care? cant find it, maybe that's the fine print at the bottom. Oh yeah, the other thing I cant find on my card is the "how to break the news to the family" algorithm. If you have that, by all means please sent it my way, because the way I'm doing it now sucks.   

 

My point is there's an enormous difference between being certified in ACLS and being competent to run a code.

 

I work as the solo provider in two different ED's so I don't have the ability to "cherry pick" anything, I have to treat all comer's, so I cant speak to that. However, my experience has been that experienced EMPA's do not "cherry pick", nor is their first thought "woah, I'm probably gonna need some help". the first thought (after seeing the pt) is something along the lines of sick vs not sick?   

 

Being a PA-S2 you should be overwhelmed. Think of it this way, you have been tasked with getting a drink of water..... from a fire hose. Sure there's a lot of water coming form the hose but how much are you able to drink? All PA school does is prepare you to learn how to become a PA. Which cant happen until you start your practice.   

[Acebecker]

I'm sorry but this is nonsense.

 

I've worked in 5 different academic institutions from east coast to west coast with med students, PA students, residents, fellows, attendings of all stripes. 

 

NEVER EVER EVER did I see a situation where PA students received training "different" in a systematic way than med students that allows them to "hit the ground running" while med students deferred everything to residency.  Not even once.  In over 20 years of experience.

 

It might be true that you have an aggressive PA student with lots of prior HCE and clinical skills who takes the initiative to do something that a med student doesn't do -- but that is NOT built in systematically into the training.

 

Nonsense might be the wrong word for it.  It does make sense, in fact.  It's a very cogent paragraph. 

 

Perhaps, "not my experience" (and you have a lot of it which I would defer to up to a point).  Perhaps, "not what I have seen" (and you have seen a lot).  But it has been *my* experience and it was the way I was instructed at my program.  Not all of us were ready to "hit the ground running," I'll grant you.  But it was expected that if we took a solo rural primary care job, we'd be able to take care of our patients and not hurt them.  It was not the recommended first job, but it was acknowledged by all of us that it may be the case so we'd better be ready for it. 

 

Do you firmly believe that an MS4 would be fine to be solo?  Because I can't see it. 

[Acebecker]

Gordon - it also necessitates the question:

 

If MS4s are ready to practice after their 4th year, then why do they have a residency? 

 

Which necessitates the other question:

 

If PAs are not ready to "hit the ground running" after PA school, then why let us practice medicine at all? 

 

I'm saying this: there are differences in the preparatory mindset between MS4s and PAS2s.  Is that not inherent to the systems of training?  I do not recall once being told, "You shouldn't study this because you'll be referring these patients on to the MDs."  Nope.  What I remember was, "You need to know this and recognize warning signs of bad outcomes so that you can get the patient to the proper level of care *if you can't handle it yourself,* because it's very possible that you'll be the only one available."  Do MS4s have that instilled in them?  Not in my experience and not likely in other programs *because they are expected to do a residency.* 

 

I think the other thing that we're not addressing between the two of us is that we're also talking about MS4s who didn't match.  I think of these as the bottom of the barrel of the MS4s.  Perhaps there are MS4s who, like me, were motivated and wanted to be ready to shine their intern year (as I wanted to be excellent on day one of employment).  But I would bet that these are not the MS4s we're talking about with regard to this "associate physician" idea. 

[PACdan]

Don't disagree with you in principle here, but I still fail to see how the AP privileges are fundamentally any different than PA-C privileges. You are taking a student who has completed didactics, clinicals, and passed boards and saying here you go, you can work, under supervision, with limited prescriptive rights, until you match. I doubt this is a destination position for any medical student. They want to match, not be a PA with a different title.

 

My counter to this idea is that as new medical schools open in the US and FMGs continue to come here, with relatively static residency positions available, the "associate physician" may evolve into a more permanent position overtime. If they can command 80, 90, or 100k salaries, they may satisfied to practice in said role. And of course, since they are still doctors, they'll see themselves as superior to PAs. Even with a lack of residency training. They could push for the right to supervise PAs, own clinics, and employ other providers. Each step will be possible, because at the end of the day "they're doctors" and "we're not". This will stunt our evolution.

 

I see it as allowing them to take a "step down" the ladder, without allowing us to take a step up. I'm sorry, but the pathway of medical school in the US requires residency training. I know it's expensive, I know space is limited, but creating a provider type which mirrors one that already exists is not the answer. Now if you want to afford us the option to similarly "step-up" into their privilege bracket, then that may change the discussion. But I cannot support a work-around that devalues us for the benefit of providers that accepted a pathway with a known hazard. 

 

 

NEVER EVER EVER did I see a situation where PA students received training "different" in a systematic way than med students that allows them to "hit the ground running" while med students deferred everything to residency.  Not even once.  In over 20 years of experience.

 

I do, every day. Preceptors know that PAs have no "residency safety net". They say you'll need to know this/do this/see this now, because you'll be practicing sooner. I see med students slink off to the library to "study" while I'm still seeing pts. or writing notes. If I miss two days, I fail rotation...for any reason. Med students seem to have many "half-days" around here. The attitude is different from my observation. More focused on boards and tainted with a little resentment that "I'll have to do this for 80 hrs/week for 3+ years anyway...so I'm not going to bust my butt now."

 

I think we're geared a bit different, from didactic to clinicals, our time is precious. That focuses the attention differently. So yes, I think that the entire process of 2.33 years of PA school focuses more on practicing general medicine from day 1 of graduation while medical school focuses more on preparing a student to match into a residency program and then master that speciality.

[rev ronin]

My counter to this idea is that as new medical schools open in the US and FMGs continue to come here, with relatively static residency positions available, the "associate physician" may evolve into a more permanent position overtime. 

My experience in Costa Rica was that most physicians never had had a residency, which were coveted, and functioned as GPs instead.  Everything points to that sort of solution being more likely to fill our current provider gap than a wholesale expansion of residency slots for MDs.

[Reality Check 2]

Rev, I think our patients deserve more than an untrained physician to fill our healthcare gaps.

Before allowing non-residency trained physicians to become GPs - allow PAs to certify as advanced GPs based on experience and some sort of test.

We ARE certified and trained.

 

My experience with medical students is that they, by and large, have gone a straight track from high school to college to med school to residency (maybe in this context) and have ZERO work experience or life experience. They are career students who are in debt up to their butts and have never so much as waited a table or tossed a newspaper. 

 

The PA students I went to school with and the ones I teach show far more life experience - they have flipped burgers, been nurses, been RTs, been farmers or were in the military - The overwhelming majority of PA students I have seen through graduation bring to the table a working knowledge of life, paying bills, having more common sense and intuition with their patients and a true respect for the situations that some patients are in. 

 

I see this in more DOs too, but that is a different story.

 

So, why should the US public be subjected to GPs who aren't really trained when Primary Care and Family Practice have to KNOW A LOT ABOUT A LOT ALL THE TIME? Primary Care is the gateway to everything. If we don't recognize the problem early on - the patient suffers and is delayed to getting to the specialist. 

 

The idea of allowing MS4-plus-one-day to become a shingle-hanging GP in a town in need makes me wince. 

 

Also, can these uncertified physicians supervise a PA on paper or in reality? Should they be allowed to? How will that effect the ability of a PA to provide GP services with a doc who isn't qualified?

 

So, back to the idea that a PA with "x" years of experience be tested for their knowledge base and prowess as THE Primary Care Provider and allowed to practice independently.

 

My very old 2 cents.................................

[PACdan]

My experience in Costa Rica was that most physicians never had had a residency, which were coveted, and functioned as GPs instead.  Everything points to that sort of solution being more likely to fill our current provider gap than a wholesale expansion of residency slots for MDs.

 

I like the GP model. It's not very supported in the modern era by the insurance industry or medical institutions. But my point is that if we allow MS4 graduates to become GPs, PAs should be allowed to become GPs as well. I always hear how a new grad PA is very similar to a MS4 or doc without a residency. But I'm sure if the AP model takes off, and evolves, the conversation will go something like this:

 

"These associate physicians have really proved themselves here in X state. As such, we feel that after 36-months of continuous, supervised primary care practice, they should be promoted to independent practitioners in the field. Oh PAs? No, they need to remain dependent for the entirety of their careers. The training that the med school grad received is just so much more than the PA school graduate...."

[delco714]

Gordon - it also begs the question:

 

If MS4s are ready to practice after their 4th year, then why do they have a residency?

 

Which begs the other question:

 

If PAs are not ready to "hit the ground running" after PA school, then why let us practice medicine at all?

 

I'm saying this: there are differences in the preparatory mindset between MS4s and PAS2s. Is that not inherent to the systems of training? I do not recall once being told, "You shouldn't study this because you'll be referring these patients on to the MDs." Nope. What I remember was, "You need to know this and recognize warning signs of bad outcomes so that you can get the patient to the proper level of care *if you can't handle it yourself,* because it's very possible that you'll be the only one available." Do MS4s have that instilled in them? Not in my experience and not likely in other programs *because they are expected to do a residency.*

 

I think the other thing that we're not addressing between the two of us is that we're also talking about MS4s who didn't match. I think of these as the bottom of the barrel of the MS4s. Perhaps there are MS4s who, like me, were motivated and wanted to be ready to shine their intern year (as I wanted to be excellent on day one of employment). But I would bet that these are not the MS4s we're talking about with regard to this "associate physician" idea.

I don't want to be that guy, but don't use "beg the question" wrong like That over and over.

 

Having said that, I'm another in the ms4 can't be a practitioner out of school crowd

[Acebecker]

Changed it for you.  I didn't intend to point out logical fallacies.  I will state that Gordon's assumption does beg the question regarding MS4s being capable of practicing right out of school, but perhaps does not necessitate the second question about PAs.  I was truly asking what his assumption was based upon.  

 

At any rate...

[rev ronin]

Rev, I think our patients deserve more than an untrained physician to fill our healthcare gaps.

I don't disagree.  I just was commenting that the economic pressures seem to be firmly against treating our entire population with nothing other than residency trained, board-certified physicians.  Everywhere else in the world gets along just fine, more or less, without the universal expectations of residencies and board certification.

[Acebecker]

I don't disagree.  I just was commenting that the economic pressures seem to be firmly against treating our entire population with nothing other than residency trained, board-certified physicians.  Everywhere else in the world gets along just fine, more or less, without the universal expectations of residencies and board certification.

 

Rev - are these FMG who practice as GPs trained in the same model our US physicians are trained?  Are they trained through the traditional 2 years hardcore sciences, 2 years clinical clerkship model?  I'm curious if the response would instead be to take the PAs who are already churning through our schools and giving them additional scope.  Is the training comparable between the FMGs you're referencing and ourselves?

[NLRP3]

Oops maybe you got lost on the internet, this isn't SDN. I was actually enjoying this conversation. So please make sure what you say is substantive and not attacking. You made almost exclusively ad hominem attacks, and those that weren't, were not elaborated on. Maybe you could try again?