I know that Physician Assistant (PA) can do roughly 85% of the same task as MD physicians, but I have yet to come across anyone talk about the other 15% that PAs can't do that MDs can. Could someone give me some specific examples of what MDs can do that PAs can't?
PA limitation compared to MD
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Do an unassisted OR surgery (to the best of my knowledge)
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deleted6669
^^ This ^^
run an independent clinic without a physician partner.
gain reciprocity to practice overseas in many(most) other nations.
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Many physicians lack this as well.
correct. They can assist in surgery. Closing, parallel procedures, ect...
They also need all Rx and assessments signed off on.
Approximately 15% of the time 😉. Not really, but that is the idea.
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Any complex procedure/surgery, managing a medicine/surgery team, making the obscure diagnosis. Physicians don't get paid the extra money because of the routine signing of prescriptions for head colds. They get the extra money for the responsibility if the PA effs up and to make the calls that the PA doesn't have the skill to make.
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deleted6669
case in point....pa's care for complex pts with minimal to no physician input in er's and icu's all over the country every day.....
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Make the first incision during an operation.
PA's are at the mercy of their supervising phywician. It comes down the what the physician feels comfortable delegating to the PA. It's a process, a relationship of sorts, that evolves with trust.
PA's are at the mercy of their supervising phywician. It comes down the what the physician feels comfortable delegating to the PA. It's a process, a relationship of sorts, that evolves with trust.
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Practice independently.
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deleted6669
actually lots of CT surgical pa's open and close the chest and harvest vein without the surgeon present in the room. this allows the surgeon to work on 2-3 procedures at a time and concentrate on the part they do best which requires their unique expertise.
http://www.apacvs.org/TheCardiovascularandThoracicPA.html#3
Do you believe honestly that this is ideal or appropriate? Why is less training a good thing? Can experience substitute for closely standardized and intense training?
My uncle was recently seen by a PA in an ED. The PA missed sepsis and bacteremia, calling it a viral infection. Thankfully an ID physician got involved later that night and personally had him admitted.
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deleted6669
I can also come up with numerous ANECDOTES of docs sending patients home and pa's making the correct dx and admitting them hours later when they bounce back.
I recently admitted a STEMI that had been sent home 2 hrs earlier by a PHYSICIAN with a dx of chest wall strain....no ekg done at original visit because the PHYSICIAN thought the pt was too young to have cardiac dz....in 2012 many pa's do structured/intense postgrad programs in em, ct surgery, or critical care. see
www.appap.org
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Oh, this thread has gotten it started now.
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This story doesn't provide evidence to conclude that you acted correctly, btw. As the evidence stands you may have admitted a patient with chest wall strain (although... that's weird) as a stemi
this is why anecdotes are worthless. Sent from my DROID RAZR using SDN Mobile
Of course it was an anecdote, but at least physicians have rigorous training and standards designed to prevent mistakes, all of which are significantly watered down for PAs or nonexistent. Mistakes will always be made because no one is perfect, but they are much more likely to happen with less training and less evaluation.
The existence of these structured programs is an admission that the two year training for PAs is not sufficient in many specialties. Many feel that some MD residencies are not long enough to provide adequate mastery, especially with the new work hour restrictions. A much shorter PA 'residency' is thus still too short to be a meaningful replacement for a physician. No other developed country uses 2+1.5 years of training as the standard for clinicians. They all have training of comparable length to US physicians. I don't think the wheel is being reinvented here.
Never said they don't care for complex patients, just said they don't direct the overall care of it. I work with plenty, and 95% of the time they don't need input from me, or just need a "yes, that's an appropriate workup you just ordered.". But every few shifts there is a patient that is very ill and has a convergence of 5 comorbidities that are spinning out of control because of a new disease process, or some rare masquerading disease entity like a salicylate poisoning. My PA's are still able to handle the majority of the necessary actions in those cases, but don't end up directing the overall care.
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I heart you. I heart you because you are in the position to make this point. In so tired of people on this side making this (irrelevant) point. But yet they try..... those who are unsatisfied with their choices. To be honest I consider them insults towards my PA friends. Also insulting towards intelligence on general. You sign up for a job, and then bitch that your voluntary position should be more like someone else's? Really? I wish I was that "smart". Life would be simpler.
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How about.... be physicians...pass three USMLE's , get a physicians liscence , think like a physician...in most states have a dr. To turn to when things get hairy and they have questions. There is a lot. Mid levels are not doctors will never be doctors and will never replace them. Yes there is always the story of the doctor who sent the stemi home and thank god for the mid level that was there to save the day but that story has been told and will always occur bc doctors aren't perfect. And for the thoracic PA's yes they can open and close bc you can teach people how to do safe procedures ... This is a very big difference than decision making.
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deleted6669
Thank you for clarifying your position.
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deleted6669
sorry, didn't mention the trop of 6.0 and the cath report of 95% LAD occlusion...in a 26 yr old female cocaine user with terrible family hx....the doc who saw the pt before me didn't ask about cocaine use or family hx.....This story doesn't provide evidence to conclude that you acted correctly, btw. As the evidence stands you may have admitted a patient with chest wall strain (although... that's weird) as a stemi
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PAs cannot do 85% of the same work as a physician. A PA is trained to do a specific job and see/assess certain types of patients. They can go directly from PA school into most any field. They leave school at the level of a 3rd year med student. It isn't hard to do an H&P and get to learn what a doc wants them to do. Also, they work through algorithms which physicians do not do quite as much. Yes, over 10-15 years of doing the same basic thing PAs become good at what they do. But the advantages of a physician are more intangible and learned in med school/residency. PAs work at the level of 2nd year residents. Once you work with PAs more directly you'll see their limitations.
Everybody makes mistakes. No one really knows how this presented initially but I'm fairly certain most docs wouldn't order an EKG on a young otherwise healthy individual presenting with some vague complaint of CP. You work in an ER I assume. You get EKGs on everyone. It's not the same outside of your situation. And if you are not in an ER you are the second person to see the patient so obviously something else is going on. Now, if the doc would have asked about recent cocaine use he may have changed his mind... Also the patient may have reluctant to go to the ER, or any number of things could have been the case... but that is neither here nor there and you were not the first to initially see the patient. It's easy to be the monday morning qb.
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deleted6669
this was the pts second visit to the ER. the physician who sent them home worked there also.
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Thank you, emed. I enjoy reading your posts. You are very knowledgeable about your profession.
Can you recommend any good PA blogs? I was reading one a while back by the guy who authored A Kernel in the Pod who owns and operates a headache clinic in Washington state, but I think he deleted it because I can't find it anymore.
Also, I'm Hear My Silence on the PA forums. Lots of good info there too.
Can you recommend any good PA blogs? I was reading one a while back by the guy who authored A Kernel in the Pod who owns and operates a headache clinic in Washington state, but I think he deleted it because I can't find it anymore.
Also, I'm Hear My Silence on the PA forums. Lots of good info there too.
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deleted6669
get with the program. this thread is about PA bashing, it's sdn. you can't say anything nice here......🙂
post a thread on the pa forum about blogs. several folks over there have them from students to people in postgrad programs to working pa's.
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Heh, yeah. I get the SDN culture.
Will do. Thanks. 🙂
Will do. Thanks. 🙂
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Acknowledging that their scope of practice is more limited doesn't have to be bashing, it is fact. This doesn't make PAs incompetent or any less essential in many settings.
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It amazes me how this fact is always missed around here
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well regardless my point still stands. You were the second one to see the patient. And I am certain there are cases where you would have done things differently as well.
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No one ever implied the opposite. You guys just tend to go a bit overboard with making your elitism known to those you deem below you.
All emed is saying is that everyone has something to teach you should you allow yourself the privilege of learning from them.
I've personally met some great PA's and NP's who do their professions a service by representing their fields skillfully and with great pride. As a pre med, I know these professionals have worlds of wisdom and knowledge to lend me and I am doing myself a favor by truly listening to what they have to offer.
Everyone should be so inclined to do the same.
All emed is saying is that everyone has something to teach you should you allow yourself the privilege of learning from them.
I've personally met some great PA's and NP's who do their professions a service by representing their fields skillfully and with great pride. As a pre med, I know these professionals have worlds of wisdom and knowledge to lend me and I am doing myself a favor by truly listening to what they have to offer.
Everyone should be so inclined to do the same.
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deleted6669
it's the fact that our ACTUAL scope of practice is minimized around here that is the issue.
there are lots of threads here about "pa's only do h+p's" and very little acknowledgement that senior pa's run rural er's and ICU's solo, manage primary care practices without physicians on site, provide the only medical staff for US embassies around the world, staff the white house medical clinic, work as peace corps medical officers without on site physicians, work in all branches of the military and federal services in all specialties with a large degree of autonomy, etc.
the #2 guy at the US public health service under the surgeon general is a PA.
http://www.usphs.gov/profession/healthservices/healtheducation/cpo.aspx
the army flight surgeon of the yr this year was a PA.
http://www.daily-tribune.com/view/f...rdsman-named-Army-flight-surgeon--of-the-year
PA's serve as county coroners:
http://www.jameslkramer.com/coroner.html
when dick cheney shot his friend it was the pa with the vp who saved the guys life:
http://www.foxnews.com/story/0,2933,184957,00.html
when President Clinton first had heart surgery a PA was 1st assist on the procedure at columbia medical ctr in NYC:
http://www.columbiasurgery.org/news/clinton_surgery.html
the first PA to physician 3 yr bridge program opened 2 years ago. pa's get credit for an entire clinical year of school.:
http://lecom.edu/college-medicine.php/Accelerated-Physician-Assistant-Pathway-APAP/49/2205/612/2395
the current class is doing as well or better than the traditional students.
the average med student here on sdn probably thinks pa's are only good for suturing once an all powerful md makes the decision that it is required and tells them how many sutures to put in and then has to check on their work to make sure they did it right.....they think we use "algorithms" for everything. we don't. we practice MEDICINE. we practice under our own licenses and dea #s. as a senior em pa when I don't know the answer to something and ask an em doc ( maybe with 1-2% of my patients) the vast majority of the time they don't know the answer either and I end up consulting a specialist. with some docs I just skip over them from the start because I know they won't have a clue. the brighter ones I still ask.
many senior pa's work with minimal to no physician oversight. many pa's train junior md residents. I have at 2 of my prior jobs. at one I was the only preceptor for the interns rotation. I wrote the eval and submitted it to the residency director.
we are the rodney dangerfields of medicine(for those of you old enough to get the reference)...we can't get no respect....
there are lots of threads here about "pa's only do h+p's" and very little acknowledgement that senior pa's run rural er's and ICU's solo, manage primary care practices without physicians on site, provide the only medical staff for US embassies around the world, staff the white house medical clinic, work as peace corps medical officers without on site physicians, work in all branches of the military and federal services in all specialties with a large degree of autonomy, etc.
the #2 guy at the US public health service under the surgeon general is a PA.
http://www.usphs.gov/profession/healthservices/healtheducation/cpo.aspx
the army flight surgeon of the yr this year was a PA.
http://www.daily-tribune.com/view/f...rdsman-named-Army-flight-surgeon--of-the-year
PA's serve as county coroners:
http://www.jameslkramer.com/coroner.html
when dick cheney shot his friend it was the pa with the vp who saved the guys life:
http://www.foxnews.com/story/0,2933,184957,00.html
when President Clinton first had heart surgery a PA was 1st assist on the procedure at columbia medical ctr in NYC:
http://www.columbiasurgery.org/news/clinton_surgery.html
the first PA to physician 3 yr bridge program opened 2 years ago. pa's get credit for an entire clinical year of school.:
http://lecom.edu/college-medicine.php/Accelerated-Physician-Assistant-Pathway-APAP/49/2205/612/2395
the current class is doing as well or better than the traditional students.
the average med student here on sdn probably thinks pa's are only good for suturing once an all powerful md makes the decision that it is required and tells them how many sutures to put in and then has to check on their work to make sure they did it right.....they think we use "algorithms" for everything. we don't. we practice MEDICINE. we practice under our own licenses and dea #s. as a senior em pa when I don't know the answer to something and ask an em doc ( maybe with 1-2% of my patients) the vast majority of the time they don't know the answer either and I end up consulting a specialist. with some docs I just skip over them from the start because I know they won't have a clue. the brighter ones I still ask.
many senior pa's work with minimal to no physician oversight. many pa's train junior md residents. I have at 2 of my prior jobs. at one I was the only preceptor for the interns rotation. I wrote the eval and submitted it to the residency director.
we are the rodney dangerfields of medicine(for those of you old enough to get the reference)...we can't get no respect....
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Duckie- As a MEDICAL student I don't think you are in any place to judge what a PA can/cannot do. When you become a resident(at the least) then start to form your opinion of the profession
Also we are trained in an abridged version of the medical model. I can tell you how much biochemistry, histology and embroy I have used on wards....take a guess.......
Also don't be so quick to bash doing a good H&P's because a good history and physical will save your butt while a poor one can burn you.......
From your friend
Makati PA-C, OMS-3
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Just for giggles, be glad these docs weren't taking care of your family then:
http://www.dailymail.co.uk/news/art...octors-fail-spot-infection-ravaging-body.html
I honestly don't mean anything bad about those doctors because it goes to show you that ANYONE can make a mistake whether it is a doc or mlp. Also I agree residency is VERY VERY VERY important.
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deleted6669
I think in the future pa's will be required to do specialty postgraduate training equivalent to the first year of a physician residency. there are more of these programs springing up every year.
see www.appap.org there are now 19 em pa postgrad programs and many more surgical programs.
there are now specialty exams ( CAQ's) for pa's in em, ortho, CT surgery, nephrology, and psych. to take the exam you have to show competence in a list of skills as signed off by a physician, log 3000 hrs in that specialty and have specific education to your field above and beyond pa school. I took and passed the em caq the first yr it was offered. someone who does not work in em would not have passed that exam. I think many fp docs would have failed that exam. there was a lot of critical care, trauma, and tox on it and very little of the acls type material I was expecting(arrhythmia management, etc).
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I'd love to see how a PA residency program works in comparison to a medical residency program. I find these kind of things fascinating.
I'm graduating medical school in may so I have worked with many PAs and NPs and so I have seen when they are good and when they are not so good. I know the value of good h&ps. I think PAs perform necessary functions in healthcare but they are not comparable to MDs in knowledge base. PAs treat what they are trained to treat and don't know what they don't know.
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deleted6669
many are set up to be equivalent to a physician pgy-1 internship in the same specialty
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deleted6669
hmm, kind of like physicians then.....I am very aware of "what I don't know" and when to get a specialty consult. don't discount years of on the job training side by side with physicians. pa's don't stop learning the day we graduate. I run circles around the vast majority of residents who moonlight in our dept.
they don't know what they don't know either.
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So, the PA residents average 80 work weeks?
Has a PA ever been allowed in a full medical residency program? I'd be interested to see how well they'd do.
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As in full you mean an entire residency if so,then No. It defeats the purpose of having a PA instead of just training more Physician's in that field. Also funding limitations would prevent that I assume
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It would raise a lot of questions, though, if a PA was able to function as an equal to a physician.
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I'll bite. What questions?
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deleted6669
yes, the pa's have the same call and responsibilities as physician residents. for example see this pa critical care residency info:
http://www.montefiore.org/critical-care-professional-training-programs-residency
"Our PA residents function as house staff members. They must meet the same coverage and call requirements as the surgery or medical residents completing the same rotation".
I don't know of any pa's completing full residencies. I think if it was allowed they would do fine if they were allowed access to exactly the same learning opportunities as the physician residents. it is residency that makes a physician a stronger clinician than a pa for the most part, not the year of basic medical sciences which only apply to a limited set of circumstances and specialties and is forgotten to a large extent by most physicians by the time they are 5 years out of residency. a lot of it just doesn't apply in the day to day practice of medicine. the medical model in other countries eliminates a significant portion of this material and yet those grads function at the same level as american medical grads. the basic sciences needed for each specialty are learned by those in the specialty as they practice, both pa's and md's.
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It would also raise a lot of questions if purple gophers started playing gagnam style on harmonicas. Life is full of questions. Best to not to worry about the trivialities and risk extracting meaning from something that has none.
The fact is that there are some PAs who function as well as or even better than some doctors. However on average the level of skill is related to the level of training and physicians have more of both. PAs are less likely to function as well ad physicians outside of primary care settings because their training becomes more and more support based rather than abbreviated training of the same flavor. PAs in surgery would be an example.
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deleted6669
is all of the medical school basic science curriculum really needed to practice medicine.
Makati, as you know at this point having done both pa and do, the big difference between pa school and medschool is the ms1 year. the question is do you really need to have a strong grasp of embryology and histology to be a primary care provider? do you think most fp docs 10 years out of residency could pass the same basic sci. tests they did as ms1's?
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deleted6669
wow, never seen that sentence on sdn before....thanks, I guess.....
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deleted6669
I would agree if you said primary care and emergency medicine. many em pa's practice essentially independently. I work solo nights. there is no other clinician in house after midnight. I am also responsible for emergency coverage for a small number of inpatients during this time.
I never work with my sponsoring physician. our communication is an email or a note in my box maybe once/mo saying "did you consider this?" or (more often) "this pt is bogus, I know her, don't write her for any more narcs, ok?
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