the PA problem

I have received a number of questions from PA students and prospective PA students regarding what it’s like to be: a PA, an emergency medicine PA and a remote PA; enough that a blog post seemed more sensible than replying individually, this is my overly wrought answer.

Part of the daily reality of being a PA or PA student is the necessity to answer time and again two questions: what the heck is a PA and what do PAs do anyway? This occurrence is frequent enough to be a well established internet meme with a host of requisite youtube videos. Every PA develops their own 30 second spiel to answer both these questions in one fell swoop, some good and some not so good. I can attest to having heard explanations that have sounded to my ears like finger nails on a chalkboard and on one occasion, just in the past week alone, which literally, I think, caused something to go pop in my head.

So, please if you are already a PA/ PA student and your patients seem confused or ill at ease with your explanation or your colleagues cringe and leave the room when you begin your exposé please do us all a favor, work on it. Likewise if you are headed to your PA school interview be prepared to answer those questions, they will be asked.

It is not my intention here to correctly define the PA profession or answer those questions; there are plenty of places you can find those answers and part of the practice of medicine is life long learning so you just might as well get used to it. I intend instead to offer a point of view that you perhaps have yet to consider and hopefully will.

This is a post for those students who already are seriously and earnestly considering a career as a PA and already know more than roughly what it entails. They may already be PA students and/or have worked in healthcare with PAs or have done some shadowing. These students have a small n, if you will, of PAs they have been exposed to and are looking to increase their sample size. One of the difficulties I had throughout school and training was the feigned hierarchal and dogmatic idea of deference disguised as professionalism that affects medicine and medical training and with that being said maybe I am a good person to ask for advice, maybe not.

Typically the questions I am asked relate to autonomy, scope of practice and job satisfaction, I will try to summarize the factors that I feel strongly affect these professional attributes, it may not come as any surprise that they are dependently interrelated. I began writing this as a reply email and got carried away, I think it easy enough to follow without too much difficulty. So without further prologue the truth or as I like to put it the PA problem.

Quite frankly there isn’t one simple one size fits all truth; at best I can only serve as an anecdotal bias in one direction or another. The answer is of course, it depends; it depends on a host of factors that would be impossible to enumerate here but I will cover the perhaps not so basics.

The only truly definite answer I can give regarding the variable autonomy and the scope or “level” of practice bestowed upon PAs is that no two PAs practice precisely the same medicine and there is a reason for this that is unique to PAs.

When you examine the practice model you will find that while MD and DO practice varies by training, experience, practice environment/culture and intellect, PAs have an additional yet overwhelmingly important variable, that being, their relationship with their supervising physician.

This fact cannot be understated and it exists anywhere there are PAs. I would not say that the differences between the practice of EM by any two PAs is entirely different from that of differences between PAs in any other sub-specialty. Firstly, as in any hospital based specialty emergency medicine (EM) PAs and MDs for that matter do not practice in a bubble, they are beholden to the culture of the institution.

Regarding institutions, you mentioned academic and non-academic, you could also throw in for profit and not for profit as well as community hospital and tertiary care center. All institutions will approach the “PA problem” differently and grant privileges as they see fit. This is one external factor.

By the letter of the law a PA may practice within the scope of his/ her supervising physician, but you must realize that physicians have set limits as well. Physicians too must be privileged, typically by the same credentialing process, to perform procedures or even admit patients to the hospital and these privileges vary from institution to institution.

These prescriptions, while ostensibly in place for patient protection can at times be non-sensical and/ or be maintained for other reasons entirely. For example the use of a particular drug or the performance of a certain procedure may be the providence of another specialty such as anesthesia, orthopedics or cardiology and the emergency department provider (EDP) may be effectively barred from its utilization.

Another example is that of antibiotic stewardship; it has become a hot topic and at many institutions, rightfully so I believe, powerful antibiotics are non-formulary and must be approved by infectious disease physicians regardless of who the ordering clinician is.

As a singular PA example, as EDP at one institution I was credentialed to place an endotracheal tube (ETT), but not administer the sedatives and paralytic agents that would facilitate its passage other examples abound.

What does any of this have to do with PA practice or autonomy? So far I have mentioned a few external factors to the MD/ PA relationship, but there are also internal factors beginning with interpersonal dynamics, mutual respect and professional confidence/ trust. Additionally you must take into account the training and experience of a supervising physician.

One of the criticisms of the PA profession is lack of a standardized skill set amongst providers, this is an inevitable reality of the apprentice system and medical training in general and it is folly to think physicians or other providers are exempt.

While physicians have many more years in school and residency to acquire skills and experience PAs have less opportunity and once graduated are expected to “hit the ground running” it is my feeling that it is the notion that a PA is ready for practice that has perhaps left more than one PA disenfranchised and more than one physician feeling burned. But to say all physicians by conference of their degree are more knowledgable or more skilled than all PAs would be a blatant falsehood.

Apply the above to your notions of fast track. “Fast Track” is not a noun as you might presume, it is not a place, it is instead a verb describing the disposition of a patient whom does not require intensive emergency department work-up or treatment and you are not alone in this misconception. A patient doesn’t GO TO “Fast Track”, a patient GETS fast tracked.

With that in mind a common question I receive is: as a PA will I be stuck in Fast Track or how do I keep out of Fast Track?
While there does seem to be a prevalence of PAs flying solo in emergency department “Fast Tracks”, you will almost never see a resident placed in this position. I will express the reasoning behind this fact two different ways that when combined you will find illogical and in fact a Catch-22.

You may have the preconceived notion that all fast track patients are low-acuity and/or suffering from some self-limited condition that will get better on its own anyway; that for a resident there is nothing to learn and for an attending physician fast track would be sheer boredom and time wasted. Perhaps, but I have personally caught surgical abdomens, heart attacks, blood clots, strokes and open fracture dislocations in “Fast Track”, in other words real emergencies that without proper and timely intervention would have had bad outcomes and I’m just one PA.

So why put a PA in a position where he/she could miss a heart attack? As a PA I can see, treat and discharge a patient without an attending physician laying eyes on the patient, a resident may not and that is the reason PAs are placed in “Fast Track” if the attending had to come and lay eyes on every fast track patient the ED would grind to a halt. Now, I am not claiming to be the reincarnation of Osler’s ghost but I am making the point for argument’s sake that a green PA is not any better suited to being left alone in “Fast Track” than is a PGY-2. It is simply the compounding of two cultural biases: PAs have less training and therefore should see lower acuity patients and PAs as a deliverable product are fully formed the moment they pass the PANCE. So naturally lets stick the untested undertrained providers where they will only see low-acuity patients and they can’t hurt anybody. The truth is that in many EDs patients are triaged to main ED or “Fast Track” prior to being seen by an EDP and naturally sickies fall through the cracks. The truth is that good emergency medicine is the differentiation of the sick from the not sick most pitfalls lie in the missed diagnosis not in failed treatment.

I mentioned earlier endotracheal intubation, a means of definitively controlling a patient’s airway by placement of an ETT. Imagine if you will the dramatic example of two providers: a PA who prior to PA school worked as a paramedic and has placed a thousand of out of hospital non-elective ETTs and has performed a hundred emergent surgical airways and his supervising ED physician who is family practice trained and has placed a handful of ETTs outside the OR and has never performed a cricothyrotomy outside of cadaver lab. Who is best able to handle the next airway emergency? Should the PA be “trusted” when the physician is the less experienced “back-up” provider? I am not that PA and I will not conjecture an answer, my hope is that it elicits thought on the matter.

Another, less dramatic example: a double coverage, MD/ PA practice the PAs do much of the minor procedures whether it be suturing or incision and drainage due to the fact that the procedures are time-consuming in addition to other factors. In this hypothetical practice the MD picks the next chart off the rack and examines the patient, a handsome young female with a complex facial laceration. The PA is perfectly comfortable closing the wound, because he has repaired three similar lacerations this week and it’s only Tuesday. The MD rarely sutures any longer and is ready to call plastics. Who should sew up the child?

In the above examples to the correct answer of course lies in what is best for the patient, I am assuming a favorable outcome in either case. However, as a final Gedanken I offer for your consideration an extension of the previous. Obviously we bill for services, within an EM group PAs may be eligible for RVUs or relative value units these units are directly tied to reimbursement and compensation, in the above examples both “critical care time” and procedures, such as suturing are high RVU generators and would net the PA more income for services rendered as opposed to going to another consulting service.

Hopefully if I’ve done what I intended I have raised more questions than I have answered and the reason for this these are very personal as well as professional questions, there is no simple or one size fits all answer. Some PAs might not be satisfied in a professional relationship in which the felt under utilized while others might enjoy the comfort of making lower risk clinical decisions. It has to do with personality and aptitude more than it does the rules per se, the question is: how do we modify the rules to best utilize highly trained healthcare providers in the most befitting manner without sacrificing patient safety? I’m not advocating independent practice for PAs but better cooperative practice with physicians. It has been shown over and over that PAs improve patient safety and satisfaction, PAs are here to stay, the question remains how do PA provide the greatest good and in turn realize the greatest career satisfaction?