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A Must-Read blog entry on Clinician1

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If you don't subscribe to Clinician1, you should just to read Dave Mittman's blog entry on our profession's need to change with the times. Maybe, just maybe, we can rally ourselves to make some changes.




KODAK has been a part of many of our lives as much as any company I can think of. If you are of a certain age group, you grew up with KODAK. So much so, that for many of us, our first camera almost always was a KODAK. Paul Simon wrote a song in praise of KODACHROME film. Years ago we all excitedly bought a few rolls of KODAK film before every vacation and as we took our pictures we kept our small finished film containers in a safe place. Then we took them to the drug store for processing on KODAK paper with KODAK processing machines. If KODAK was so important to the lives of so many, how is it that today KODAK is now close to bankruptcy? KODAK stock that sold for about nine dollars a year ago is worth fifty cents today and it may be bankrupt as you read this. Why? And what can it teach PAs more than any other health profession?

If you ask KODAK what it did as a business, I am sure they would say they made film and later cameras and they made them better than anyone else in the world. What KODAK never realized was it was never in the film or camera or photo processing business. Never was, not even for a day. They did not know their strength was that KODAK was in the business of creating memories, the business of self expression and the business of catching people’s dreams on film. Our prom, our babies, our cars, our vacations all were captured by KODAK.

They never got that message and the inability to understand what their market really was, where it was going and that it needed to drastically shift its corporate identity from a film company took down one of the best businesses America ever produced.

So, let’s look at the PA profession. Forty, thirty and twenty years ago the fact that we stressed that we were “dependent” worked for us. We work “under the supervision of a physician” was our mantra. It helped us gain the trust of our patients and the healthcare community. The fact that we did not need advanced degrees was also a plus as many of us entered the profession loaded with life experience and began to practice and show just how good we could be. The fact that we needed chart review or ratios or countersignatures on our orders worked to satisfy those that questioned our ability and training. So did designing a recertification system that treated us as if we were all in the same specialty, that believed that twenty years out we would still all need to know the same information. We took great people with medical experience and trained them in exceptional programs and created a very, very successful profession.

Today the PA profession must recognize that things have changed. We must fully embrace the fact we are in a new medical world. We have to realize that what worked to promote us in the past, won’t work into the future. We have to realize that we are in a country where physicians are not entering primary care. Hard to work as part of a “medical care team” when the other team mate is not even on the playing field, nor will they ever be. Or when the other team mate leaves after being with you for 30 years because the hospital bought their practice.Teamwork only goes so far you know. I believe we are all part of a team; NPs, PAs and physicians but we have to realize that most physicians don’t want to be saddled with anyone who will slow them down with restrictions. This has been felt by many PAs as most of us will agree employers will hire the profession with the least requirements they have to deal with, not the most. It is time to admit that few of us ever acted as “assistants” to physicians and for the most part have been competent healthcare providers, no different from most other providers who work in a group practice. Time to realize that when we tell people we “assist” or need “supervision” that these words no longer promote us, but make us seem unable to do the job our country needs. Time to realize that almost every other professional group that is even near our professional level is autonomous and producing students at the doctorate level. Time to realize that America needs primary care providers with a proven track record of caring for people that can be backed up by research. Time to set up federally funded post graduate residencies in primary care that could (with further work) provide a doctorate and much more autonomous practice. Time to say we are excellent clinicians who can take their earned place as providers (read that as much more autonomous) and not worry about a town losing their medical care because there is no one to sign the PAs charts or because the doc retired. Time to think far out of the box. Time to plan for our place in the future as medical care providers/associates and not anything less.

If we don’t, we risk the chance of waking up one morning and finding out we were too busy making ourselves dependent partners who were good clinicians while the need was clearly for autonomous clinicians who could also be good partners.

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There are other reasons that “dependency” was necessary forty years ago but not now. First, as medicine advances its understanding of disease, there is diffusion of knowledge. When the doctor and his craft were once a mystery, time has made the practice of much of primary care medicine to be a widely understood and quickly mastered knowledge. The second factor that accelerates the diffusion of knowledge is the internet. Students of medicine today, whether in medical school, PA school or NP school, have access to tools and knowledge shortly after it was originally developed.


I believe the PA profession’s lack of advanced degrees was a benefit to supervising physicians forty years ago. Without education, there were diminished opportunities for PAs and they were less able to negotiate. The profession was originally characterized by the model of the slave owner and slave who was permitted to work in the house. Slaves were not to be educated. The quality of the master’s goods and services derived from the master alone. It was no accident that many if not most of the original PAs were enlisted men from the Vietnam era. During that period, the elite avoided service by remaining in college. If one was in Vietnam he or she either had a unique sense of patriotism or a severe absence of academic and financially wherewithal to circumvent service. So, while I know this is offensive to some, the original cohort of PA who now are well entrenched (and retiring) have shaped this dependency model. Today, the vast majority of PA students have equal undergraduate preparation as their medical school counterparts. Today’s PA student has a four year degree from a University or college in a science field. Today’s PA graduate has a Masters degree. The resistance that new PAs are feeling from older PAs about eliminating dependency stems from the master-slave model.


Residencies should lead to the same outcome as our medical student/resident counterparts. That is, PAs who complete residencies should be identified as doctor though the M.D. credential should remain distinct and separate to represent their training pathway. A PA who completes a residency should not remain a house slave. PAs must refuse residency training that does not offer a terminal doctorate degree and the legal right to be identified as doctor in the clinic. Remember, first year residents travel throughout the year identifying themselves as doctors yet many experienced Pas are more knowledgeable. Nobody asks the resident to say to patients “I’m Doctor A, I’m not independently practicing and all of my work is reviewed by my attending. Basically I am assisting the attending. Please understand that my license is restricted” On the other hand, experienced and competent PAs enter a room and say “I’m Bob (or Sara etc), I am a Physician Assistant.” It’s all about keeping PAs in a lower caste.


The answers to our future probably won’t come from posting on this forum. Remember that most of the moderators are the original cohorts. They react harshly to calls for independent practice and a pathway through residency to a terminal doctorate (with clinical title as well). It reminds me of parents of children during the Civil Rights movement who told their kids, “don’t rock the boat.”

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Quite frankly, I find the above posting to be offensive and lacks the compassion and understanding of the past and current history of the physician assistant profession. It makes me wonder if the poster displays the same lack of compassion to their patients. I am one of your so-called “co-horts" who has been in this profession since 1972 I consider myself one of the pioneers of our glorious profession. I can quite honestly say that the biggest reason why we remain “dependent practitioners” is rooted in the fact that there is a disparity in the skills and knowledge of the PAs depended upon the programs they attended. In the early years the training varied in length and degree awarded, associates versus baccalaureate versus certificate of completion. Even today, not all PAs graduate from masters levels program, as you infer.


I graduated from George Washington University and can quite honestly say that my early supervising physicians would allow me to practice with much greater autonomy than some of my colleagues who graduated from an associate degree program. My supervising physicians(as did I) noted that my base of knowledge as a new graduate from a baccalaureate degree program far exceeded that of my colleagues. Granted over time (approximately 2 to 3 years) with closer supervision and on-the-job training all our skill sets were noticeably equal. And I do not believe we acted as much as a dependent practitioner and more as autonomous providers collaborating with our physician colleagues.


I will give you this, you are correct in stating that the answers to our future do not lie in postings on forums like this. Nor will they come from articles and blogs like Mr. Mittman's that are long in the tooth in pointing out perceived problems with the profession yet our short sighted and offered no solutions other than constantly referring to changing the title of the profession. Any changes to our role in the health care system and our scope of practice will only come through intelligent exchange of ideas between our Academy and the physician organizations that we partner with.

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