How are PAs better than Physicians?

[rev ronin]

So, let's start a positive, if perhaps contentious, thread. How are PAs better than Physicians?  We all know how US and Canadian physician training is the best in the world. They get more science, more gross anatomy, more hours in clerkships, internship, residencies, and fellowships. Our PA education is an abbreviated version of this; even with years of experience we will never have had the benefits that a real U.S. physician education conveys.

But at the same time, there are other things that are important to our patients besides being the best able to diagnose and treat undiagnosed illnesses.  Surely I'm not the only one who hears "I like PAs better than doctors" or "I don't care if you're a PA, you're my doctor." Obviously, something prompts our patients to prefer us... but what? Is there something systemically preferable about PAs?

Here's my thoughts so far:

- Life experience builds rapport.  I have the uncomfortably vivid memory, even though it's been more than 25 years, of being asked to make a medical decision for my wife while she was under general anesthesia, when I had nothing in the way of biological education beyond 7th grade life sciences (I don't count a community college summer intensive elective on mushrooms as helping to prepare me to make an informed decision). I like to think that that entire fiasco helped me prioritize communicating to people at a different level of medical education than I currently have. While this may not be true of the young PA aspirants who think there is such a thing as a "gap year" before PA school, I'd like to think that those of us who pursued PA school as adults (I graduated at age 41) bring a lot to the table that a physician who hasn't done anything meaningful besides school lacks.

- PAs generally lack positional authority. We gain power and influence by being right, not by being in charge. Physicians often experience the latter, which subtly influences how they communicate expectations. "Because I said so" simply isn't a part of most PA's vocabularies, unless they're dealing with their own children.

What other situational, educational, positional, or other factors make PAs preferred by some patients?

[UGoLong]

I think you're on to something there. I sometimes feel that -- perhaps because of the nature of our education -- we might have ended up being the "engineers" of medicine rather than its "scientists,"  as physicians often seem to be. Accordingly, we may have an easier time simplifying complexities and explaining things to our patients. Sometimes we need scientists and it's great that we work with physicians who can bring that horsepower.

I was older when I became a PA as well -- the same age as many of our patients -- but I see this same communication trait in some of the younger PA students and graduates that I work with. I also agree with your comments about lacking positional authority and how that may influence our behavior.

[EMEDPA]

We are taller, in better shape, better looking, more charismatic, and have better breath

In all seriousness, I think you nailed it , Rev. I have never heard it explained that way, but your idea about positional authority rings true for me. Life experience is certainly a part of being right more often than not. After all, an expert is someone who has made every possible mistake in a very narrow field and learned from them. 

[SedRate]

When co-rounding or co-seeing a pt in clinic, I can tell when a pt doesn't quite understand what is being said by the physician despite the pt saying they do. So I often find myself staying behind to help further explain what has been said and answer questions the pt didn't think to ask or were embarrassed to/felt they shouldn't bother asking the physician since the physician is "busy" and can't stay behind to talk about such details. Although I don't usually have more time to spend with pts than the physician, pts and their families respond well to my involvement and appreciate the extra time and thorough dialogue. I also find that pts and staff respond well to my accessibility since surgeons are often elusive/evasive creatures. And for these reasons, some pts and staff tell me they prefer PAs over physicians or they appreciate having me as their go-to person rather than the physician. 

[jmj11]

PAs are more cost-effective, which renders care vs no care in some situations. Three years ago I spent almost a month in the hospital undergoing a bone marrow transplant. The team highly utilized PAs in the inpatient setting, where there was a PA on the floor 24-7. I rarely saw them except during rounds in the morning, and when they stopped by socially, but there were patients on the floor doing poorly, indeed a couple died, and the PAs were intimately involved with their and the other patients' care. I suspect, but do not know, that before they discovered PAs, the transplant team could not afford to have a full time physician on the floor, 24-7, except for possibly a generalist-hospitalist who covered multiple floors. As mentioned above, I also suspect that the PA plays a key role in translation of what was discussed during rounds, plus staying around to answer question, for which the physician would not have time for, or the institution could not afford to provide that level of attention. 

This is a different slant, but once in my career I had a physician (SP alternative) tell me that he wished he were a PA. Why? Because he had been a nephrologist for 30 years and he has no choice but to stay in the field or quit. He was envious of the mobility of a PA, changing specialty lanes at a whim, changing jobs without much-a-do, as compared to him. "Sure, I make more money than you," he said. "But money can't by happiness ... only toys."

[LT_Oneal_PAC]

The positional authority is absolutely true. It is also the most frustrating thing about being a PA. I’ve always wanted in my career to be just given respect rather than fight and claw for it everyday in perpetuity. Not saying physicians have never worked for it, but at a certain point they can easily stop. I have to read everyday, listen to hours of education every week, always be perfect, because one slip and I’m that dumbass PA that doesn’t know better and a physician could have swooped in and saved me. Now that you have highlighted for me why it makes me better though, perhaps I don’t ever want it the other way. Diamonds through pressure and all that.

I think a large part of my success is my variety of experience. I was a critical care nurse before, spending 3 years in general practice, having an excellent EM residency to attend. While not necessarily a strength of every PA, it is a strength that I was able to do that. It’s what has allowed me to be successful at a critical access hospital where you truly have to do a little of everything. 
 

[SedRate]

1 hour ago, LT_Oneal_PAC said:

The positional authority is absolutely true. It is also the most frustrating thing about being a PA. I’ve always wanted in my career to be just given respect rather than fight and claw for it everyday in perpetuity. Not saying physicians have never worked for it, but at a certain point they can easily stop. I have to read everyday, listen to hours of education every week, always be perfect, because one slip and I’m that dumbass PA that doesn’t know better and a physician could have swooped in and saved me.

I agree and feel very much the same. And sadly, it's one of the driving forces for me to want to leave altogether. I'm tired of feeling like that when all I'm trying to do is my job and help people.

[CAAdmission]

I'm not sure whether training to become a physician causes people to become arrogant, or the profession simply attracts people with a lot of hubris. The percentage of physicians that are terrible people is significantly greater that what I would expect in the general population. 

There are not a lot of egomaniacs going into a profession with "assistant" in its title. 

[jmj11]

How does all of this translate to the future? How will the PA profession define itself to be of more value than a MD or DO in certain situations as healthcare changes. I always felt like we were behind the curve with adapting to healthcare changes, while the NPs did a better job positioning themselves for what was coming.

While I don't want a full time job again and would not consider hospital administration if I did, I have decided that I will run for the local hospital board as soon as a position opens up. I think we need more PAs in admin and other leadership roles to help advocate for what we bring to the table and to show our value to a organization. Last time I searched (a couple of years ago), I didn't see a PA-doctorate degree in healthcare admin, but maybe I missed it. 

[rev ronin]

1 hour ago, jmj11 said:

How does all of this translate to the future? How will the PA profession define itself to be of more value than a MD or DO in certain situations as healthcare changes. I always felt like we were behind the curve with adapting to healthcare changes, while the NPs did a better job positioning themselves for what was coming.

While I don't want a full time job again and would not consider hospital administration if I did, I have decided that I will run for the local hospital board as soon as a position opens up. I think we need more PAs in admin and other leadership roles to help advocate for what we bring to the table and to show our value to a organization. Last time I searched (a couple of years ago), I didn't see a PA-doctorate degree in healthcare admin, but maybe I missed it. 

First off, a DMSc with a leadership concentration, which is what I'm doing at ATSU, is as close as anything to a PA-specific clinical leadership doctorate.

Having said that, I think the PA advantage is very situational and individualized.  We have some very sharp PAs with excellent exposure in different pre-PA worlds... but you can't guarantee that any particular PA has any particular background.  I learned to translate arbitrary jargon to English because my original undergraduate studies were in systems analysis. This is the business end of computing, not the engineering or scientific end, and so classes were focused on figuring out what the customer wanted, and then doing it.  The idea that two sets of smart people without a common language would muck it all up without someone on the lookout for assumptions and pitfalls in their communication is kind of a default professional outlook. I would not trade either my upbringing in Alaska nor my undergraduate training in information systems for anything--they were great foundational perspectives from which to grow and mature.

[ventana]

My honest thoughts

 

Physician training is so rigorous that it gets the humanity beat out of them......

They just look for and manage pathology, not people

 

Yes their are exceptions to this but I think this is the case

 

 

PA seems to strike the perfect comprise between knowledge and compassion 

[rev ronin]

2 hours ago, ventana said:

Physician training is so rigorous that it gets the humanity beat out of them......

I've said that residency ends up beating the milk of human kindness out of most of them.  Residency is a place where you have to decide between taking 5 minutes to make someone's life better... or sleeping 5 extra minutes when you're chronically and seriously sleep deprived. In all seriousness, who thinks that's a good idea? In what sane profession would the establishment push back against limiting work weeks to 80 hours... averaged over 3 weeks!

[ohiovolffemtp]

From the EM point of view, I've seen:

• PA's tend to be better at many procedures: laceration repairs, especially complex ones, I&D, FB removals, because unless the doc is doing solo coverage, the PA or NP is doing almost all of those procedures.  From experience  comes proficiency and knowledge of the tricks of the trade.
• PA's tend to be better at symptom management, especially of the lower acuity complaints, again because from managing volume comes proficiency.
• As mentioned above, PA's tend to be better at explaining things in human terms.  For example, I've NEVER heard an orthopod describe a joint as a tie-rod end or the ball swivel on an office chair, but, patients understand those analogies.

[UGoLong]

2 hours ago, ohiovolffemtp said:

From the EM point of view, I've seen:

• PA's tend to be better at many procedures: laceration repairs, especially complex ones, I&D, FB removals, because unless the doc is doing solo coverage, the PA or NP is doing almost all of those procedures.  From experience  comes proficiency and knowledge of the tricks of the trade.
• PA's tend to be better at symptom management, especially of the lower acuity complaints, again because from managing volume comes proficiency.
• As mentioned above, PA's tend to be better at explaining things in human terms.  For example, I've NEVER heard an orthopod describe a joint as a tie-rod end or the ball swivel on an office chair, but, patients understand those analogies.

I think real-world analogies are everything when it comes to explaining. It's also how I try to teach.

[BirdDogPA]

From a clinical standpoint, we are all individuals and have strengths/weakness. For example last shift I had to manage a number of patients for an internal medicine physician because she/he “ doesn’t intubate” and apparently can’t do central and A lines. 
 

Personally being a PA allowed me to practice two distinct specialties, be on faculty at a PA program, and have a leadership role within my hospital all before I was 30. This would be impossible for a physician, so I’d say the right PA hands down wins on career advancement. 

[LT_Oneal_PAC]

20 hours ago, UGoLong said:

I think real-world analogies are everything when it comes to explaining. It's also how I try to teach.

I just do it because I’m from the south.

 

”oh boy, you’re sweating like a hooker in church!”

 

 

[FiremedicMike]

On 10/2/2022 at 4:17 PM, CAAdmission said:

I'm not sure whether training to become a physician causes people to become arrogant, or the profession simply attracts people with a lot of hubris. The percentage of physicians that are terrible people is significantly greater that what I would expect in the general population. 

There are not a lot of egomaniacs going into a profession with "assistant" in its title. 

But they're out there.  My absolute least favorite provider in our ED and the one who is the most arrogant by far is a PA.  He treats all of the nurses like trash and doesn't even make an effort to be professional.

 

[sas5814]

7 hours ago, LT_Oneal_PAC said:

I just do it because I’m from the south.

 

”oh boy, you’re sweating like a hooker in church!”

 

 

sitting in the front row...

 

[jmj11]

6 minutes ago, sas5814 said:

sitting in the front row...

 

And recognizes the preacher from the previous night, so he's sweating too.

[LT_Oneal_PAC]

1 hour ago, sas5814 said:

sitting in the front row...

 

If I tell you that chicken dips snuff, don’t go lookin under his wing

 

(took me a while to understand my granddad on that one)

[Reality Check 2]

For some reason, my organization believes that being an MD/DO makes you leadership material out of the shoot - no extra training or education - makes you a Chief of Department or Chief of Staff. And the rest of us suffer for that choice too often. 

PA - meh, do you have a Masters in Health Administration?????? Seriously - no advancement without more letters behind one's name. It sucks.

Certainly not an all or never situation but my observations over 30 years:

* Many MDs have never had a job before MD - high school > college > Med School > Residency. Most have not flipped burgers or worked retail or even delivered newspapers - they were destined to go to school. ZERO life experience and too often brain over social intelligence.  

* More DOs have had a life. Went to school later in life perhaps. Had real jobs. Had kids, changed careers. My experience has been more positive on an interpersonal and leadership level. 

* Many PAs have previous lives - RN, EMT, Medic, Professor, etc. More PAs have flipped burgers and worked retail and held jobs of many levels. One guy in my class owned a restaurant - Vietnam Vet - wanted to go into Medicine at 44. 

Life experience makes PAs generally better communicators and empathizers. We have been up late at night with our own croupy, colicky kids rather than a spouse or nanny. We have flipped burgers and lived on smaller salaries. We made choices between getting the car fixed and paying rent. We are more relatable. We express our intelligence in a more personable way instead of perhaps dictating what "should be done".

Maybe MDs are taught in school to be haughty and superior - maybe they are geared that way. 

NPs have herd strength and that damn Doctorate BS pushing their identity without substance. We will always struggle against the numbers and the Executive Nurse positions. 

PAs deserve to be at the table, in the boardroom and guiding healthcare towards a public that generally likes us and trusts us. 

It won't go anywhere until we have LIP status though - we are dependent and lesser.

And I am tired of it.

[sas5814]

I worked with a great doc who said "somewhere in our training there is a class called Arrogance 101. Some people take the advanced course as an elective."

As always it is easy to paint with a broad brush but I have found the younger physicians more open to us than the older ones. I find less hubris in the newer physicians.

As always your mileage may vary.

[JessT]

On 10/2/2022 at 1:17 PM, CAAdmission said:

I'm not sure whether training to become a physician causes people to become arrogant, or the profession simply attracts people with a lot of hubris. The percentage of physicians that are terrible people is significantly greater that what I would expect in the general population. 

There are not a lot of egomaniacs going into a profession with "assistant" in its title. 

I think many of them are completely out of touch with others outside of their own income bracket. When you look at the statistics for med school applicants, most are coming from the top income quintiles. That is straight from AAMC. I think that has a lot to do with it. Keep physicians in high demand by making the path to becoming one almost impossible to achieve for those who don’t have the same privileges. Some examples of that privilege are access to better resources, higher parental income and education, volunteer/shadow/mission opportunities, the ability to study without having to worry about work, and a parent or family member who is a physician and has connections. It’s like this vicious cycle of elitism. Does it apply to all med school applicants, students, or physicians? No, but I bet it applies to a majority of them. 

In my experience talking to people applying to PA school, many of them are older than the typical med school applicant. They have more HCE and life experience. A lot of them have had previous careers. They have also faced adversity and are more well rounded. I think this allows them to better relate to patients who can sense that. I also think that many patients consider a “doc” to be anyone who is capable of successfully treating their ailments in a way that fosters a connection and builds trust.