Are More Physician Assistants Good or Bad for America's Health?

 

Over the past forty years, a quiet revolution has been unfolding in the health care sector. Physician Assistants, or PAs, are becoming more popular than doctors. And with the current shortage of doctors, especially in primary care, people are counting more and more on PAs that are more likely to work in primary care clinics.

The American Academy of Physician Assistants (AAPA) wrapped up their national conference this week in Washington, D.C., where PAs from around the country convened to learn more about a still nascent position. The biggest concern for PAs is that when new legislation affects the way a doctor practices medicine, they want to make sure that the legislation also applies to them. PAs are allowed to do many of the same things a doctor can from prescribing medications, to diagnosing illnesses to performing surgery. But they are such a new class of health care professionals that they often get left behind when lawmakers sit down to amend the laws.

The PA profession was a byproduct of the war in Vietnam. Medics were coming back the United States with years of experience and no medical license. Duke University Medical Center graduated its first class of PAs in 1965. Most were Navy corpsman and Army medics.

Today, the profession proves useful in an economy that is choking on education costs. PAs spend less time and money on their education than do doctors at a time when tuition costs and student loan interest has burdened students with an unprecedented amount of debt. PAs can start practicing medicine after 6 to 8 years of schooling. For doctors it takes up to 12.

Ann Davis, the senior director at the Constituent Organization Outreach and Advocacy Department at AAPA, says that PAs are a blessing to the health care system in America.

“They’re young,” she says, “they’ve got lots of energy and it’s a refreshing experience to work with them.”

Since they are trained quicker than physicians, she says, they’re a “good return for the investment.” They’re also twice as likely as physicians to work in rural areas that are seeing a lot of the family practices disappear or get bought up by hospitals. In the next couple of years, the number of PAs in the U.S. is slated to jump from 85,000 to more than 100,000 with a job outlook of about 30 percent according to the Bureau of Labor Statistics. Teachers, by contrast, are at 7 percent.

But Dr. Matt Hahn, a primary care physician at Hahn and Nelson Family Medicine in Maryland, is wary of all the good news.

“I’m extraordinarily concerned that while it is cheap to have Physician Assistants,” Hahn says, “they do not have the breadth and depth of training to handle many of the scenarios that come from a primary care setting.”

Hahn hosted a PA program at his practice in association with the George Washington University School of Medicine before cutting his ties with the school. The students, he says, had not been trained adequately enough to be able to properly take care of his patients.

“I cut my association with GWU because the students were so bad,” he says. “I had no faith them. . . I had 7 years of training and then started seeing patients. I still felt like I had a lot to learn.”

Hahn’s got a healthy number of personal horror stories in dealing with PAs. One involves an elderly patient of Hahn’s who was struggling with gout and a shoulder injury. Hahn referred him to a nearby orthopedic doctor. The patient instead saw a PA, who prescribed him Indocin, a common drug for gout. The patient, a cautious man, wanted the PA to run it by a physician before leaving the office, which he refused to do.

It turns out that Indocin poses a serious danger to patients with high blood pressure, which the patient had a history of. He’d had a stroke recently.

“That’s not an uncommon experience,” Hahn says about his interactions with PAs. “We shouldn’t assume that their care is that good.”

Under the right circumstances, Hahn says, a growing number of PAs could be a good thing. The problem is when they’re unsupervised. Hahn employs a nurse practitioner in his office who reports directly to him. He thinks that PAs need the same kind of supervision. 

Hahn doesn’t think that PAs will eventually replace doctors. But he does think that the trend threatens the quality of care in America. The rosiness of their marketability should be coupled with the understanding that they need experienced professionals to oversee how PAs practice medicine. Right now, he says, PAs are being given many liberties they haven’t yet earned.

“Everything in this country we argue for short-term savings,” he says. “But you won’t get the same type of care. I’ve observed that, over time, a lot of chronic diseases are poorly controlled. There’s the potential for a lot more mistakes being made.”

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