Are PAs "Experts"?

[andersenpa]

Herein lays the Catch-22 of the PA profession. Although, in our clinical practice we are expected to provide service on par with our physician colleagues, legally we cannot be held culpable in the event of an unto wart patient outcome if we practice within our role as a dependent provider. As much as many of us would not like to admit, in the medical legal world there is a PA scope of practice. And to be quite honest it, in large part, is defined and developed for our protection. If it was not then there would not have been a need to pass enabling legislation in all 50 states, the District of Columbia, Guam and the American Virgin Islands. In my over 30 years of practice I have been extensively involved in drafting PA laws, rules and regulations, medical staff bylaws and served as an expert witness (for both the defense and the plaintiff) in over 20 medical malpractice suits. And I can tell you without a shadow of doubt that PA’s who believe that their scope of practice is the same as their supervising physician are those who unfortunately run the risk of ending up on the wrong side of a medical malpractice suit or a medical boards professional inquiry panel.

 

I am sure we all recall one of the most important things we were taught as students was to always remember to know one's limitations, and to recognize when it was time to step back and involve our supervising physicians in the care we are providing to the patients. And until the day comes when we are considered independent practitioners involvement of the supervising physician whether they are in the building or 60 miles away, consulted after-the-fact or just required to review a certain percentage of your caseload, will always be a factor in any PA’s scope of practice. Now I could go on site examples of how a PA’s breech of not knowing their limitations placed their license in jeopardy or knowing their limitations prevented catastrophic events from occurring and saved them and their supervising physician millions of dollars in lawsuits, however that would be the basis for writing a book and not answering your question simply enough for you to understand what I meant when I said there is a PA scope of practice.

 

As I always tell my students, younger PA colleagues and yes even some of my physician colleagues, when we have step out of our normal scope of practice and into that of the recognized “experts" scope of practice and something goes wrong, you lose.

 

It's interesting that you bring that up. I've had the opportunity to do some expert witness testimony. My experiences are more limited than yours, but the cases involved PAs where there were errors of omission, not cases of being cavalier or not respecting limits as a PA. While I was asked to evaluate how the PA performed relative to the accepted standard of a PA in that role, their failing (in these cases) was no different than if a doc had seen them and failed to do the same thing. So while there may be a true definition of PA scope (somehow in a different box than physician scope), the Venn Diagram crossover of those two is significant. The cases I have reviewed were not simply "PA failed to notify the physician", but "PA failed to order X diagnostic test" (just as a doc would be expected to) or "PA failed to admit pt" (just as a doc would be expected to.

 

So while the descriptors that are in place may try to define what PAs do, it seems the reality in many cases still expects us to act identical to how a physician would.

 

It seems to state that we are expected to provide service on par with our physician colleagues, and we legally can be held culpable in the event of an untoward patient outcome when practicing within our role as a dependent provider. Dependent, yes, but still practicing gold standard medicine.

[Joelseff]

I vote yes with a footnote. I am only a 2nd year PA so in some areas of my practice I feel i hold a level of proficiency to effectively carry out medical care in those areas at a high level but of course there are areas I am not as proficient. Having said that, I dont consider myself an expert although I am a "specialist." Although, in the general sense of the word "Expert" I can certainly say I have met my share of expert PAs. Our inpatient coordinator at my school was an old timer PA who worked in the organ tx service and was well revered and respected and have been known to school some of the attendings. As far as legal expert witness, we discussed this in my Masters PA practice issues class. I felt that knowing the SOC and procedures etc does not necessarily equate to expertise. Anyone can regurgitate information but I think expertise comes with experience in the specific arena in question.

[Joelseff]

I vote yes with a footnote. I am only a 2nd year PA so in some areas of my practice I feel i hold a level of proficiency to effectively carry out medical care in those areas at a high level but of course there are areas I am not as proficient. Having said that, I dont consider myself an expert although I am a "specialist." Although, in the general sense of the word "Expert" I can certainly say I have met my share of expert PAs. Our inpatient coordinator at my school was an old timer PA who worked in the organ tx service and was well revered and respected and have been known to school some of the attendings. As far as legal expert witness, we discussed this in my Masters PA practice issues class. I felt that knowing the SOC and procedures etc does not necessarily equate to expertise. Anyone can regurgitate information but I think expertise comes with experience in the specific arena in question.

[andersenpa]

thanks I should qualify that the intent of the question was "Are PAs clinical experts", not including expert witness work which is somewhat different.

[andersenpa]

thanks I should qualify that the intent of the question was "Are PAs clinical experts", not including expert witness work which is somewhat different.

[Joelseff]

probably so but that is just semantics. if the pa really is on top of the condition and knows as much or more about it than a doc practicing in that field they are in fact an expert, regardless of what " a jury of our peers " might be convinced of. a lot of generalist specialists(say gi) know common modalities regarding disease processes in their field(say hep c) but might not be up on the most current research and tx like a pa might who only deals with that issue. if most of the docs practice relates to doing colonoscopies and dealing with colon ca. they probably only know the basics regarding hep c management. that is why they hire a pa to deal with all of their hep c pts.....that and colonoscopies pay much better than medical management of hep c....

 

Thats funny you brought this up. at a check up with my pcp he asked me about a UC/Chrohns pt and we talked biologics and fecal transplants, prebiotics vs probiotics etc. just the other day after he filled out my paperwork I needed for a flight refund. I shoulda charged him a consult fee. lol:smile:

 

on a side note and way off this thread topic, Scopes pay the bills and my doc has relegated himself to scoping all morning while i see all the medical cases all day long. HCV is no joke too and it requires a support system in the clinic for the family and the patient. My GI doc did not want to tx HCV but I kinda stepped into it. I found a local Hepatologist willing to take my patients as I am leaving the GI practice soon and will be focusing on HIV and Int Med/FP which is where i originaly wanted to practice.

[Joelseff]

probably so but that is just semantics. if the pa really is on top of the condition and knows as much or more about it than a doc practicing in that field they are in fact an expert, regardless of what " a jury of our peers " might be convinced of. a lot of generalist specialists(say gi) know common modalities regarding disease processes in their field(say hep c) but might not be up on the most current research and tx like a pa might who only deals with that issue. if most of the docs practice relates to doing colonoscopies and dealing with colon ca. they probably only know the basics regarding hep c management. that is why they hire a pa to deal with all of their hep c pts.....that and colonoscopies pay much better than medical management of hep c....

 

Thats funny you brought this up. at a check up with my pcp he asked me about a UC/Chrohns pt and we talked biologics and fecal transplants, prebiotics vs probiotics etc. just the other day after he filled out my paperwork I needed for a flight refund. I shoulda charged him a consult fee. lol:smile:

 

on a side note and way off this thread topic, Scopes pay the bills and my doc has relegated himself to scoping all morning while i see all the medical cases all day long. HCV is no joke too and it requires a support system in the clinic for the family and the patient. My GI doc did not want to tx HCV but I kinda stepped into it. I found a local Hepatologist willing to take my patients as I am leaving the GI practice soon and will be focusing on HIV and Int Med/FP which is where i originaly wanted to practice.

[vaston]

For what it's worth, we had a lecture from a medical legal firm during my clinical year. The lawyer brought up this exact point. They had a PA involved in a trial once that was asked "would you consider yourself an expert on _______". After pausing, they replied by saying "No". They were dismissed as a witness from the trial. The lawyer then pulled them aside, somewhat angry, and told them in no uncertain terms that, according to law, if you have more knowledge/training on a subject then the average person on the street then you ARE considered an expert in their eyes. He proceeded to tell us that, even though we are not physicians, we have knowledge and training well beyond that of the average person. So we are absolutely considered 'experts' in the eyes of the law when it comes to medical topics.

 

The caveat here is that I am still new to the field and have very little experience as a PA. My knowledge comes only from that one experience in lecture. So, take it with a grain of salt? Most of the people on here have much more experience than I do. Not sure if my anecdote has much pertinence.

[vaston]

For what it's worth, we had a lecture from a medical legal firm during my clinical year. The lawyer brought up this exact point. They had a PA involved in a trial once that was asked "would you consider yourself an expert on _______". After pausing, they replied by saying "No". They were dismissed as a witness from the trial. The lawyer then pulled them aside, somewhat angry, and told them in no uncertain terms that, according to law, if you have more knowledge/training on a subject then the average person on the street then you ARE considered an expert in their eyes. He proceeded to tell us that, even though we are not physicians, we have knowledge and training well beyond that of the average person. So we are absolutely considered 'experts' in the eyes of the law when it comes to medical topics.

 

The caveat here is that I am still new to the field and have very little experience as a PA. My knowledge comes only from that one experience in lecture. So, take it with a grain of salt? Most of the people on here have much more experience than I do. Not sure if my anecdote has much pertinence.

[andersenpa]

For what it's worth, we had a lecture from a medical legal firm during my clinical year. The lawyer brought up this exact point. They had a PA involved in a trial once that was asked "would you consider yourself an expert on _______". After pausing, they replied by saying "No". They were dismissed as a witness from the trial. The lawyer then pulled them aside, somewhat angry, and told them in no uncertain terms that, according to law, if you have more knowledge/training on a subject then the average person on the street then you ARE considered an expert in their eyes. He proceeded to tell us that, even though we are not physicians, we have knowledge and training well beyond that of the average person. So we are absolutely considered 'experts' in the eyes of the law when it comes to medical topics.

 

Interesting............

[andersenpa]

For what it's worth, we had a lecture from a medical legal firm during my clinical year. The lawyer brought up this exact point. They had a PA involved in a trial once that was asked "would you consider yourself an expert on _______". After pausing, they replied by saying "No". They were dismissed as a witness from the trial. The lawyer then pulled them aside, somewhat angry, and told them in no uncertain terms that, according to law, if you have more knowledge/training on a subject then the average person on the street then you ARE considered an expert in their eyes. He proceeded to tell us that, even though we are not physicians, we have knowledge and training well beyond that of the average person. So we are absolutely considered 'experts' in the eyes of the law when it comes to medical topics.

 

Interesting............

[kargiver]

Yes, we are experts.

 

In the realm of medicine, there are many fields for comparison... On its face, compared with the public, we are considered experts. This is why they seek our care. Within the realm of medicine, particularly the specialties, we are experts by comparison to our "primary care" colleagues and those in other fields. For example, an orthopedist PA can come into my ER and reduce XYZ fracture whereas myself AND the doc on duty cannot. That certainly qualifies as expertise in my view.

 

Additionally, there are experts BEYOND the docs regarding medicine. Try comparing the knowledge base of an immunologist PhD to your average, run of the mill, MD. Apples and oranges, folks. When the MD screws up the vaccination given to a patient and there are serious consequences, it will be the PhD on the stand bringing them down (along with other MDs as well). Expertise is a scale of relativistic knowledge and understanding within a certain field and how you, as a provider, fit into it.

 

G

[kargiver]

Yes, we are experts.

 

In the realm of medicine, there are many fields for comparison... On its face, compared with the public, we are considered experts. This is why they seek our care. Within the realm of medicine, particularly the specialties, we are experts by comparison to our "primary care" colleagues and those in other fields. For example, an orthopedist PA can come into my ER and reduce XYZ fracture whereas myself AND the doc on duty cannot. That certainly qualifies as expertise in my view.

 

Additionally, there are experts BEYOND the docs regarding medicine. Try comparing the knowledge base of an immunologist PhD to your average, run of the mill, MD. Apples and oranges, folks. When the MD screws up the vaccination given to a patient and there are serious consequences, it will be the PhD on the stand bringing them down (along with other MDs as well). Expertise is a scale of relativistic knowledge and understanding within a certain field and how you, as a provider, fit into it.

 

G

[GeneValgene]

That's just it...PA's can develop a certain expertise in their field of practice, but they cannot ever really be considered experts....I mean, how would you measure that expertise? For physicians we have a rigorous (for some specialties at least) specialty board exam process. To claim that you are an expert, would mean that you have equivalent knowledge to other experts in that field of study. But how do you know? How do you measure it? I might be the only one that voted no...but we have to remember, despite ALL of our education, high standards of practice, etc.etc.etc.....we are still dependent providers who must practice under the supervision (I prefer collaboration) of a physician. By that very standard, we are not experts. I would argue instead that the greatest value of the PA profession is just that...

 

that we ARE NOT experts. We are the modern day GP's....the modern day general practitioner who handles just about everything, including minor surgeries etc.

 

SO, I would argue that while a PA can develop a certain expertise, and certainly can practice with a high level of autonomy, they cannot, nor were they ever designed or educated as "Experts". I know that many will disagree with me, and that is fine.

 

well said...

[GeneValgene]

That's just it...PA's can develop a certain expertise in their field of practice, but they cannot ever really be considered experts....I mean, how would you measure that expertise? For physicians we have a rigorous (for some specialties at least) specialty board exam process. To claim that you are an expert, would mean that you have equivalent knowledge to other experts in that field of study. But how do you know? How do you measure it? I might be the only one that voted no...but we have to remember, despite ALL of our education, high standards of practice, etc.etc.etc.....we are still dependent providers who must practice under the supervision (I prefer collaboration) of a physician. By that very standard, we are not experts. I would argue instead that the greatest value of the PA profession is just that...

 

that we ARE NOT experts. We are the modern day GP's....the modern day general practitioner who handles just about everything, including minor surgeries etc.

 

SO, I would argue that while a PA can develop a certain expertise, and certainly can practice with a high level of autonomy, they cannot, nor were they ever designed or educated as "Experts". I know that many will disagree with me, and that is fine.

 

well said...

[winterallsummer]

Would we say Bill Gates is not an expert in computers because he never graduated college? No. Expertise comes down to two things: ability and knowledge. A PA with many years of experience has both. It's a simple argument. "Expert" does not come down to a title. If you have a bomb strapped to you and are approached by someone who has been disarming bombs for years successfully, including the same type of bomb you have on you, but has the title "Bomb Squad Assistant" and a second person who has only half the experience but has the title "Bomb Squad Disarmer", who would you trust? The first guy. Why? Simply put, he's the expert.

 

*I am not arguing that PAs are experts and MDs are not. I think either a PA or MD with enough experience can be an expert on their given subject.

[winterallsummer]

Would we say Bill Gates is not an expert in computers because he never graduated college? No. Expertise comes down to two things: ability and knowledge. A PA with many years of experience has both. It's a simple argument. "Expert" does not come down to a title. If you have a bomb strapped to you and are approached by someone who has been disarming bombs for years successfully, including the same type of bomb you have on you, but has the title "Bomb Squad Assistant" and a second person who has only half the experience but has the title "Bomb Squad Disarmer", who would you trust? The first guy. Why? Simply put, he's the expert.

 

*I am not arguing that PAs are experts and MDs are not. I think either a PA or MD with enough experience can be an expert on their given subject.

[CAAdmission]

Anytime you have a job title that says "something" and there is another title that says "something assistant" you already know who the superior expert is.

 

I'm certainly not saying it is right or logical, but I can easily see a jury believing a physician one year out of residency over a PA with 30 years experience. That is the life we have chosen...

[CAAdmission]

Anytime you have a job title that says "something" and there is another title that says "something assistant" you already know who the superior expert is.

 

I'm certainly not saying it is right or logical, but I can easily see a jury believing a physician one year out of residency over a PA with 30 years experience. That is the life we have chosen...

[andersenpa]

I frequently get these online surveys in my email and saw this on one today:

 

Which of the following positions, if any, do you currently hold? (SELECT ONE)

 

[TABLE]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Family Practice, General Practice, Primary Care Physician[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Cardiologist[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Doctor of Internal Medicine[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Endocrinologist[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Diabetologist[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Other type of Physician/Doctor[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Nurse Practitioner (not Registered Nurse)[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Physician Assistant[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Registered Nurse (not Nurse Practitioner)[/TD]

[/TR]

[TR]

[TD=class: input][/TD]

[TD=class: answerlabel]Other (please specify)Other (please specify)[/TD]

[/TR]

[/TABLE]

 

 

 

This reinforces my issue with our "expert" status as it is perceived within our medical community. We are not considered practitioners within a specialty but rather practitioners of our title...."physician assisting"....

[winterallsummer]

So what happens when/if the title is changed to physician associate? Then PAs can be considered experts? Even though the body of knowledge and ability remains the same?

 

Bill Gates holds no title, he dropped out of college. Would anyone not consider him an expert in computers or business because he doesn't have a license or title with a name that implies so? And what about the MDs that are not even fit to practice medicine, are they considered experts just because of their title?

[LT_Oneal_PAC]

"Are PA experts?" and "are they considered experts?" are two VERY different questions. They can be experts in their field, certainly, but are not ever considered such by the public at large and I would imagine rarely by those they associate with.

[physasst]

"Are PA experts?" and "are they considered experts?" are two VERY different questions. They can be experts in their field, certainly, but are not ever considered such by the public at large and I would imagine rarely by those they associate with.

 

Exactly, I think of Rod's study from last year, where he examined a patients WILLINGNESS to be seen by a PA in an ED. Patients, regardless of complaint, overwhelmingly wanted to see an attending physician.

 

Hell, he repeated it in Australia, and they were MORE willing to see a PA and they don't even have them there yet.

 

I don't think there is any chance that the US public sees PA's as experts when compared to their physician colleagues. It might make an interesting study though.

[LT_Oneal_PAC]

Exactly, I think of Rod's study from last year, where he examined a patients WILLINGNESS to be seen by a PA in an ED. Patients, regardless of complaint, overwhelmingly wanted to see an attending physician.

 

Hell, he repeated it in Australia, and they were MORE willing to see a PA and they don't even have them there yet.

 

I don't think there is any chance that the US public sees PA's as experts when compared to their physician colleagues. It might make an interesting study though.

 

Could you link that study for me? Or possible more info so that I can search for it easier?

[physasst]

Could you link that study for me? Or possible more info so that I can search for it easier?

 

Here:

 

http://www.ncbi.nlm.nih.gov/pubmed/20694894

 

I have the whole article here. Not sure if I have the Australian one, but it was interesting.

 

I would argue that we are not considered experts by these results.

 

NOW, there are some weaknesses in this study...(academic centers, limited geographic representation, etc.) but the results are not encouraging.